International Journal of Environmental Research and Public Health

32 pages, 2197 KB

Open AccessArticle

Developing and Validating a Global Governance Framework for Health: A Delphi Consensus Study

by Kadria Ali Abdel-Motaal and Sungsoo Chun

Int. J. Environ. Res. Public Health 2026, 23(1), 138; https://doi.org/10.3390/ijerph23010138 (registering DOI) - 22 Jan 2026

Abstract

Background: The COVID-19 pandemic exposed major deficiencies in global health governance, including fragmented authority, inequitable resource distribution, and weak compliance mechanisms. Although the WHO Pandemic Agreement (2025) addresses several of these gaps, significant operational and institutional challenges remain. This study aims to develop [...] Read more.

Background: The COVID-19 pandemic exposed major deficiencies in global health governance, including fragmented authority, inequitable resource distribution, and weak compliance mechanisms. Although the WHO Pandemic Agreement (2025) addresses several of these gaps, significant operational and institutional challenges remain. This study aims to develop and empirically validate a Global Governance for Health (GGFH) Framework that strengthens leadership, financing, equity, and legal accountability across global, regional, and national levels. Methods: A three-round Delphi study was conducted. Thirty-one experts from diverse sectors, including public health, international law, economics, environment, and diplomacy, evaluated 32 structured governance statements across seven domains. Experts rated all statements using a 7-point Likert scale. Consensus was determined using a strict threshold median ≥ 6; SD ≤ 1.35; ≥75% agreement. Open-text comments were systematically reviewed through thematic analysis. All statements were systematically mapped to the WHO Pandemic Agreement articles to identify areas lacking operational clarity or enforceability. Results: All seven governance domains achieved consensus by Round 3. High agreement emerged on strengthening WHO leadership, implementing sustainable and equitable financing mechanisms, embedding LMIC representation, establishing legal preparedness and capacity-building, and integrating independent accountability tools. Correlation and interdependence analyses demonstrated that governance goals form an integrated, mutually reinforcing system, with financing, equity, and legal frameworks identified as core enablers of effective treaty implementation. Conclusions: The Delphi process validated a comprehensive and operational Global Governance for Health Framework. The GGFH complements the WHO Pandemic Agreement by addressing its unresolved governance, financing, and equity limitations and offers a structured roadmap to guide global pandemic preparedness and treaty implementation. Full article

(This article belongs to the Section Global Health)

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22 pages, 1286 KB

Open AccessArticle

Alberta Family Caregiver Strategy and Action Plan: Enhancing Integration Across Health and Social Care Systems

by Jasneet Parmar, Vivian Ewa, Andrew Karesa, Angie Grewal, Lesley Charles, Linda Powell, Josephine Amelio, Ginger Bitzer, Shannon Saunders, Darlene Schindel, Kimberly Shapkin, Charlotte Pooler, Frances Ross, Leeca Sonnema, Sanah Jowhari, Michelle N. Grinman, Cheryl Cameron, Arlene Huhn, Paige Murphy, Johnna Lowther, Cindy Sim, Suzette Brémault-Phillips and Sharon Anderson Show full author list Hide full author list

Int. J. Environ. Res. Public Health 2026, 23(1), 137; https://doi.org/10.3390/ijerph23010137 (registering DOI) - 22 Jan 2026

Abstract

Family caregivers provide up to 90% of care in Alberta’s communities and play an essential role in sustaining the province’s health and social care systems, yet they remain under-recognized and insufficiently supported. To address this gap, we co-designed the Alberta Family Caregiver Strategy [...] Read more.

Family caregivers provide up to 90% of care in Alberta’s communities and play an essential role in sustaining the province’s health and social care systems, yet they remain under-recognized and insufficiently supported. To address this gap, we co-designed the Alberta Family Caregiver Strategy and Action Plan (2024–2025), a provincial framework developed through participatory research and collective impact methods. Guided by principles of co-production, equity, and lived experience, the project engaged over 500 stakeholders, including caregivers, healthcare providers, educators, employers, and policymakers, through Phase 1 interviews (health/community leaders, n = 44; Family and Community Support Services (FCSS), n = 47; navigation experts, n = 9), Phase 2 co-design team consultations, and Phase 3 sector roundtables (n = 52). Using reflexive thematic analysis, we identified four foundational caregiver strategies, Recognition, Partnership, Needs Assessment, and Navigation, and four enabling conditions: Education, Workplace Supports, Policy and Research and Data Infrastructure. These elements were synthesized into an eight-priority Alberta Caregiver Strategy and Action Plan Framework, a practical way to connect validated priorities with coordinated, measurable implementation across settings. Participants emphasized four key enablers essential to making caregiver inclusion more feasible and sustainable: education, workplace supports, policy infrastructure, and research and evaluation. Findings highlight strong cross-sector consensus that caregiver inclusion must be embedded into routine practice, supported by consistent policy, and reinforced through provincial coordination with local adaptation. The Alberta Family Caregiver Strategy provides a practical, evidence-informed plan for transforming fragmented supports into a coherent, caregiver-inclusive ecosystem that strengthens both caregiver well-being and system sustainability. Full article

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16 pages, 326 KB

Open AccessArticle

Metabolically Guided Walking and Plant-Based Nutrition Enhance Body Composition and Weight Loss

by Harold C. Mayer, Lucas G. Valenca, Gregory W. Heath, Chris S. Hansen, Kristina Nelson Hall and Cassie J. White

Int. J. Environ. Res. Public Health 2026, 23(1), 136; https://doi.org/10.3390/ijerph23010136 (registering DOI) - 22 Jan 2026

Abstract

Sedentary behavior contributes to obesity and metabolic dysfunction, yet few interventions individualize exercise intensity using fuel-based metrics such as the respiratory exchange ratio (RER; VCO₂/VO₂). This study investigated the effects of metabolically guided walking combined with whole-food, plant-based nutrition [...] Read more.

Sedentary behavior contributes to obesity and metabolic dysfunction, yet few interventions individualize exercise intensity using fuel-based metrics such as the respiratory exchange ratio (RER; VCO₂/VO₂). This study investigated the effects of metabolically guided walking combined with whole-food, plant-based nutrition on body composition and metabolic outcomes in sedentary overweight and obese women. Forty-four women mean age 43 years; BMI 30.1 kg·m⁻²) were randomized to low-intensity continuous training (LICT; RER ≈ 0.75), moderate-intensity intermittent training (MIIT; RER ≈ 0.85), or high-intensity continuous training (HICT; RER ≈ 0.95). Following a 2-week dietary lead-in with an individualized ~200 kcal·day⁻¹ energy deficit, participants completed an 8-week RER-guided walking program (5 sessions·week⁻¹; 15–50 min·session⁻¹). Assessments included air-displacement plethysmography (BodPod) body composition, resting metabolic rate and substrate utilization, and oxygen uptake at the first ventilatory threshold (VT1). Data were analyzed using ANCOVA, mixed-factorial ANOVA, and Pearson correlations. Percent body fat decreased significantly across participants (p < 0.0001, η² = 0.827), with MIIT demonstrating the most favorable integrated outcomes. MIIT elicited the largest reductions in total body mass (−11.2%), fat mass (−25.9%), and percent body fat (−17.1%), alongside improvements in VT1 VO₂ (Δ = 1.487 ± 0.895 L·min⁻¹; p = 0.038). Resting respiratory quotient (RQ) declined in LICT and MIIT but increased in HICT, corresponding with increased fat oxidation in LICT and MIIT and reduced fat oxidation in HICT. Changes in RQ were significantly associated with changes in percent body fat (r = 0.316, p = 0.039). Metabolically guided moderate-intensity intermittent walking combined with whole-food, plant-based nutrition produced the most consistent improvements in adiposity, substrate utilization, and submaximal fitness, supporting the public-health feasibility of a community-deliverable, substrate-informed walking prescription. Full article

(This article belongs to the Section Exercise and Health-Related Quality of Life)

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16 pages, 826 KB

Open AccessReview

Racket Sports-Related Injuries in Youth Athletes: A Narrative Review

by Mahesh Shrestha, Asra Usmani, Serena Karlov, Ann Harris and Dilip R. Patel

Int. J. Environ. Res. Public Health 2026, 23(1), 135; https://doi.org/10.3390/ijerph23010135 (registering DOI) - 22 Jan 2026

Abstract

Objectives: The popularity of racket sports has been increasing globally in recent years, with tennis remaining the most played sport worldwide and pickleball gaining popularity in the United States. While many studies have addressed injuries associated with racket sports in adult athletes, minimal [...] Read more.

Objectives: The popularity of racket sports has been increasing globally in recent years, with tennis remaining the most played sport worldwide and pickleball gaining popularity in the United States. While many studies have addressed injuries associated with racket sports in adult athletes, minimal data are available focusing on young athletes in pediatric and adolescent populations. This study aimed to review the various injuries associated with racket sports in pediatric and adolescent populations. Methods: Using the PubMed database, we searched for studies completed in the last 10 years that addressed injuries due to racket sports in age groups up to 18 years old, as well as adult studies that included pediatric and adolescent populations. Results: In total, 60 studies met our inclusion criteria, of which 18 were descriptive studies. The most common injuries reported in the studies were lower extremity injuries, specifically knee and ankle injury. Upper extremity injuries were the next most common, specifically shoulder injuries. Most of the studies reported multiple musculoskeletal injuries as opposed to just one. Tennis was found to be the racket sport that caused the highest number of injuries, as well as the most severe injuries. Conclusions: There are few studies on musculoskeletal injuries from racket sports in pediatric and adolescent populations. This review found that tennis had the highest number of studies, and different types and severities of injuries were well-described. Lower extremity overuse injuries were the most common, followed by upper extremity injuries. Eye injuries were less common but serious. Injuries cause pain, time loss in school, and increased healthcare burden, so there is public health relevance to conducting more racket sport studies. There is a significant amount of physical and mental growth occurring during childhood and adolescence; therefore, more kinematic studies and systematic reviews should be conducted pertaining to racket sports, which will hopefully help with injury prevention in these age groups. Full article

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20 pages, 464 KB

Open AccessArticle

Information-Seeking Behaviours of CALD Women with Endometriosis in Australia: A Qualitative Study

by Deniz Senyel, James H. Boyd and Melissa Graham

Int. J. Environ. Res. Public Health 2026, 23(1), 134; https://doi.org/10.3390/ijerph23010134 (registering DOI) - 22 Jan 2026

Abstract

Endometriosis affects one in seven women in Australia and is a significant public health concern. Access to appropriate health information is essential for informed decision-making and quality of life, especially for culturally and linguistically diverse (CALD) women who may face additional communication and [...] Read more.

Endometriosis affects one in seven women in Australia and is a significant public health concern. Access to appropriate health information is essential for informed decision-making and quality of life, especially for culturally and linguistically diverse (CALD) women who may face additional communication and health literacy barriers. This study explored the information-seeking behaviours and experiences of CALD women living with endometriosis using semi-structured interviews. Through convenience and snowball sampling via social media, eleven women were recruited. Data were analysed using thematic analysis. The results showed that although women often did not view their cultural background as influential, taboos and stigma can shape information-seeking behaviours. Women primarily relied on healthcare professionals, online resources, and other women with endometriosis as information resources. Healthcare professionals were appreciated for providing tailored information, but some were perceived to have limited knowledge of endometriosis, reducing their usefulness. Online information was abundant and easily accessible but often overwhelming and difficult to navigate. Information from other women with lived experience provided both practical insights and validation, though participants recognised its limited transferability to their own circumstances. These findings highlight the need for information pathways, including better patient education through healthcare providers, as well as accessible and evidence-based online resources. Full article

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11 pages, 259 KB

Open AccessArticle

The Role of Socio-Structural Factors in Influencing Feeding Intentions and Practices Among Mothers with Infants in Mthatha, South Africa

by Luviwe Lutotswana, Guillermo Alfredo Pulido-Estrada, Eric Maimela and Sibusiso Cyprian Nomatshila

Int. J. Environ. Res. Public Health 2026, 23(1), 133; https://doi.org/10.3390/ijerph23010133 - 21 Jan 2026

Abstract

Breastfeeding is universally regarded as the cornerstone of infant feeding, as it is the ideal infant feeding choice for optimal nutrition and development. Socio-structural factors of breastfeeding in child health play an important role in guiding women’s decisions on options to feed their [...] Read more.

Breastfeeding is universally regarded as the cornerstone of infant feeding, as it is the ideal infant feeding choice for optimal nutrition and development. Socio-structural factors of breastfeeding in child health play an important role in guiding women’s decisions on options to feed their babies. A cross-sectional study was conducted among mothers with infants aged 0–6 months in Mthatha, Eastern Cape, with the aim of assessing the role of socio-structural factors in shaping feeding intentions and practices among mothers with infants. Written Informed consent was obtained in accordance with the Declaration of Helsinki from the participants prior to data collection. Data was gathered with a validated designed questionnaire as well as analyzed using Social Sciences (SPSS) version 29. A total of 181 mothers were enrolled. Only 45.9% reported that they exclusively breastfed their babies, of which the highest proportion of exclusive breastfeeding (EBF) was observed among the 21–29 age group at 51.8%, and the lowest among those aged 20 years and below (3.6%). Marital status (p = 0.005) and employment status (p < 0.001) were significantly associated with exclusive breastfeeding, with higher EBF rates observed among married mothers and those who were self-employed. Both the EBF mothers and non-EBF mothers shared a common belief that colostrum was not beneficial for infants (p = 0.854), whereas their views differed significantly on the amount of water given to infants before they reached six months (p = 0.001). There was no significant relationship between EBF status and having a family member who had breastfed in the past six months (p = 0.815); also, a weak association was noted for having a friend who had breastfed recently (p = 0.057). The difference in EBF practice between those receiving antenatal care (ANC) breastfeeding education and those not receiving it was not statistically significant (p = 0.591). A statistically significant association was found between the support level and exclusive breastfeeding status (p < 0.001). This study highlights that the successful practice of exclusive breastfeeding (EBF) is strongly associated with high levels of social support. Interventions are needed to engage active partners, family members, and community members in creating a supportive environment for breastfeeding mothers. Full article

17 pages, 1838 KB

Open AccessArticle

Responsiveness to City Service Requests, Life Satisfaction, and Horizontal Inequality: Does Good Local Governance Improve Subjective Well-Being for All?

by Danyel P. L. Tharakan and Tiffany N. Ford

Int. J. Environ. Res. Public Health 2026, 23(1), 132; https://doi.org/10.3390/ijerph23010132 - 21 Jan 2026

Abstract

Local governance has been found to be an important determinant of individuals’ subjective well-being (SWB) in cross-municipality studies in Europe and Asia. In addition, previous literature suggests that increasing access to determinants of SWB provides lesser SWB benefit to racial minorities compared to [...] Read more.

Local governance has been found to be an important determinant of individuals’ subjective well-being (SWB) in cross-municipality studies in Europe and Asia. In addition, previous literature suggests that increasing access to determinants of SWB provides lesser SWB benefit to racial minorities compared to white people in the United States (U.S.). Given this context, we ask the following: (1) does good local governance improve SWB in the U.S.? and (2) does good local governance improve SWB for Black and Hispanic people equally compared to white people? To answer these questions, we examine Chicago, Illinois, the third-largest city in the U.S. with substantial Black and Hispanic populations. We model local governance, our independent variable, as the number of weeks for the municipality to respond to pothole service requests reported to the city’s non-emergency services system. Our dependent variable was life satisfaction, measured by the Cantril Ladder. Covariates included self-reported health problems, lack of money for food, sex, age, age-squared, and marital status. Neighborhood race/ethnicity was tested as a moderator of the primary relationships. We estimated linear regression models with and without race × governance interactions. Our findings demonstrate that local governance is an important determinant of SWB, but that it benefits SWB in white neighborhoods more than in Black/Hispanic neighborhoods. Full article

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

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13 pages, 1055 KB

Open AccessArticle

Understanding the Lived Experience of Family Caregivers of Loved Ones in Long-Term Care During COVID-19 Through Art

by Tracy M. Christianson, Evans Appiah-Kusi and Jordan Bremner

Int. J. Environ. Res. Public Health 2026, 23(1), 131; https://doi.org/10.3390/ijerph23010131 (registering DOI) - 21 Jan 2026

Abstract

Public health restrictions during COVID-19 disproportionately affected older adults, especially those in long-term care (LTC) and their families. Family caregivers (FCs) are essential care partners in LTC settings, yet pandemic policies largely excluded them, creating emotional and systemic consequences. This study explored FCs’ [...] Read more.

Public health restrictions during COVID-19 disproportionately affected older adults, especially those in long-term care (LTC) and their families. Family caregivers (FCs) are essential care partners in LTC settings, yet pandemic policies largely excluded them, creating emotional and systemic consequences. This study explored FCs’ experiences of visitation restrictions in British Columbia, Canada, using an arts-based qualitative approach within a larger mixed-methods project. Eight FCs participated in completing a total of twelve artworks, including photographs, collages, and creative writing that reflected their experiences. Virtual talking circles were used to facilitate the sharing and description of their experiences. Findings revealed three interconnected theme categories with eleven sub-themes. These themes suggest a plausible pathway: infection-control rules may lead to caregiver exclusion, disrupting relational continuity and oversight and contributing to distress and task-centered care. While context-specific and exploratory, results underscore the need for trauma-informed, family-inclusive policies and cultural safety in LTC. Arts-based research methods provided a powerful lens for capturing emotional realities often missed by conventional research. Full article

(This article belongs to the Special Issue Family Caregiving, Nursing and Health Promotion)

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12 pages, 915 KB

Open AccessArticle

Locus of Control and Its Association with Depression, Anxiety, and Stress Among Mexican University Students: A Cross-Sectional Study

by Magnolia Guerrero Castillo, Maria Fernanda Martinez Gonzalez, Andrea Alejandra Escalera Jasso, Luis Adrian Alvarez Lozada, Arcelia Lizbeth Torres Pérez, Alejandro Quiroga Garza, Rosa Ivett Guzman Avilan, Diego Escamilla Magaña, Rodrigo Bravo Garcia, Martha Lilia Pérez Sosa, Yelyann Magory Márquez González, Rodrigo Enrique Elizondo Omaña and Guillermo Jacobo Baca

Int. J. Environ. Res. Public Health 2026, 23(1), 130; https://doi.org/10.3390/ijerph23010130 - 21 Jan 2026

Abstract

Locus of control is a psychological construct that influences how individuals perceive their ability to manage life events. Although its relationship with mental health has been widely studied, limited evidence exists among Latin-American university student populations. To assess the association between locus of [...] Read more.

Locus of control is a psychological construct that influences how individuals perceive their ability to manage life events. Although its relationship with mental health has been widely studied, limited evidence exists among Latin-American university student populations. To assess the association between locus of control and symptoms of depression, anxiety, and stress among university students in Nuevo León, Mexico. A cross-sectional, analytical study was conducted using data from the Healthy Lifestyle Promotion Program at the Universidad Autónoma de Nuevo León. A total of 815 students completed a digital survey assessing sociodemographic variables, DASS-21, and Burger’s Locus of Control Scale. Participants had a mean age of 19.8 ± 3.4, 57.1% were women. The prevalence of symptoms was 64.4% for depression, 55.8% for stress, and 74.1% for anxiety. Women exhibited higher severity across all dimensions (p < 0.001). Locus of control scores decreased significantly as the severity of depression, stress, and anxiety increased, particularly in moderate to extremely severe categories. An external locus of control was consistently associated with higher frequency of severe psychological symptoms. An external locus of control was strongly associated with poorer mental health outcomes. Strengthening internal locus of control may enhance resilience, reduce psychological distress, and improve academic performance. Full article

(This article belongs to the Special Issue Health Behaviors and Mental Health Among College Students)

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13 pages, 318 KB

Open AccessArticle

Comparison of Mental Illness Comorbidity Pre-Pandemic vs. Pandemic-Era and Associations with Clinical and Demographic Characteristics for Virginia Public Hospital Inpatient Discharges with a Substance Use Disorder

by Marilyn Bartholmae and Tharidu Gunawardena

Int. J. Environ. Res. Public Health 2026, 23(1), 129; https://doi.org/10.3390/ijerph23010129 - 21 Jan 2026

Abstract

The rise in mental illnesses after the COVID-19 pandemic is well documented. However, it is not known whether the rates of mental illness comorbidity increased. The objectives of this study were to compare mental illness comorbidity rates before and after the pandemic among [...] Read more.

The rise in mental illnesses after the COVID-19 pandemic is well documented. However, it is not known whether the rates of mental illness comorbidity increased. The objectives of this study were to compare mental illness comorbidity rates before and after the pandemic among inpatients with SUD and to test associations between mental illness comorbidity, physical illness, and demographics. We used a retrospective cross-sectional design in a sample of inpatient discharges (N = 233,017) at Virginia public hospitals from January 2018 to December 2022. We used Z tests to compare rates of mental illness comorbidity pre- and post-pandemic and Chi-square tests to examine associations of mental illness comorbidity with physical illness and demographics. Single and comorbid mental illness significantly increased from pre- to post-pandemic, p < 0.0001. Mental illness comorbidity was significantly associated with sex, age, race, insurance, COVID-19/Long COVID, HIV/AIDS, COPD, hypertension, obesity, CVD, cancer, and diabetes (p < 0.0001). There was a significant increase in mental illness comorbidity, which was significantly associated with age, race, sex, and physical illnesses. Children/adolescents, females, American Indians, and individuals with HIV/AIDS had the highest rates of mental illness comorbidity. Public health action is needed to address the increase in complex medical needs among people with SUD. Full article

16 pages, 1690 KB

Open AccessArticle

Sociodemographic Factors and Childhood Growth: Associations with Environmental Sanitation Phases

by Yadira Morejón-Terán, Ana Clara P. Campos, Juan Marcos Parise-Vasco, Leila Denise A. F. Amorim, Laura C. Rodrigues, Mauricio L. Barreto and Sheila Maria Alvim de Matos

Int. J. Environ. Res. Public Health 2026, 23(1), 128; https://doi.org/10.3390/ijerph23010128 - 20 Jan 2026

Abstract

Background: Early childhood growth trajectories can influence the risk of chronic diseases in adulthood. Improvements in environmental sanitation may affect child development in low-resource settings. Objective: to examine the associations among socioeconomic factors with nutrition indicators, and trajectories of anthropometric indicators across three [...] Read more.

Background: Early childhood growth trajectories can influence the risk of chronic diseases in adulthood. Improvements in environmental sanitation may affect child development in low-resource settings. Objective: to examine the associations among socioeconomic factors with nutrition indicators, and trajectories of anthropometric indicators across three epidemiological cohorts that reflect different phases of environmental sanitation implementation. Methods: A longitudinal study was conducted in Salvador, Brazil, from 1997 to 2013. A total of 1429 children were recruited across three epidemiological cohorts, corresponding to the phases of a sanitation program: pre-intervention (n = 299), intervention (n = 1007), and post-intervention (n = 123). Height-for-age (HAZ) and BMI-for-age (BAZ) z-scores were assessed at four time points. Multilevel linear models were used to adjust for socioeconomic factors. Results: A total of 992 children (68.7%) completed follow-up. Post-intervention children showed improved HAZ trajectories, with sex-specific patterns that varied across cohorts. Birth weight is positively associated with HAZ across all cohorts (0.34–0.49 kg increase per z-score). Household overcrowding (>2 persons/room) is consistently associated with lower HAZ (−0.34 to −0.63 z-score reduction). Children who were never exclusively breastfed in the post-intervention phase had a higher BAZ (0.76 z-score increase). Caesarean delivery is associated with higher BAZ in the pre-intervention (0.23) and intervention (0.27) cohorts. Conclusions: Children born in later time periods showed better growth trajectories, which may reflect the combined effects of sanitation improvements, economic development, and other societal changes in Brazil during this period. Further research using experimental or quasi-experimental designs is needed to isolate the specific contribution of sanitation to child growth. Full article

(This article belongs to the Section Environmental Health)

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18 pages, 314 KB

Open AccessFeature PaperArticle

Building Capacity in Crisis: Evaluating a Health Assistant Training Program for Young Rohingya Refugee Women

by Nada Alnaji, Bree Akesson, Ashley Stewart-Tufescu, Md Golam Hafiz, Shahidul Hoque, Farhana Ul Hoque, Rayyan A. Alyahya, Carine Naim, Sulafa Zainalabden Alrkabi, Wael ElRayes and Iftikher Mahmood

Int. J. Environ. Res. Public Health 2026, 23(1), 127; https://doi.org/10.3390/ijerph23010127 - 20 Jan 2026

Abstract

Background: The Rohingya refugee crisis is one of the largest humanitarian emergencies of the 21st century, with nearly one million Rohingya residing in overcrowded camps in southern Bangladesh. Women and children face the greatest vulnerabilities, including inadequate access to education and healthcare, which [...] Read more.

Background: The Rohingya refugee crisis is one of the largest humanitarian emergencies of the 21st century, with nearly one million Rohingya residing in overcrowded camps in southern Bangladesh. Women and children face the greatest vulnerabilities, including inadequate access to education and healthcare, which exacerbates their risks and limits opportunities for personal and community development. While international organizations continue to provide aid, resources remain insufficient, particularly in maternal and child healthcare, highlighting the urgent need for sustainable interventions. Objectives: The Hope Foundation for Women and Children in Bangladesh launched a pilot project for the Health Assistant Training (HAT) program to address critical gaps in healthcare and education for the Rohingya community. This nine-month training program equips young Rohingya women with essential knowledge and skills to support maternal health services in both clinical and community settings. Design: We conducted a qualitative evaluation of the HAT Program to explore its acceptance and anticipated benefits for both participants and the community. Methods: The research team used semi-structured interviews, focus groups, and field observations to explore the HAT Program’s impact on young Rohingya women and their community. They analyzed data through thematic analysis, developing a coding framework and identifying key themes to uncover patterns and insights. Results: The results were categorized into four themes: (1) community acceptance of the HAT Program, (2) the HAT Program’s impact on the health assistant trainees, (3) the impact of the HAT Program on the community, and (4) the potential ways to expand the HAT Program. Conclusions: This research underscores the program’s impact on improving healthcare access, enhancing women’s empowerment, and promoting community resilience. By situating this initiative within the broader context of refugee health, education, and capacity-building, this research highlights the HAT program’s potential as a replicable model in Bangladesh and in other humanitarian settings. Full article

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

25 pages, 1343 KB

Open AccessArticle

Nature-Based Health Interventions for People with Mild to Moderate Anxiety, Depression, and/or Stress: Identifying Target Groups, Professionals, Mechanisms, and Outcomes Through a Delphi Study

by Louise S. Madsen, Knud Ryom, Liv J. Nielsen, Dorthe V. Poulsen and Nanna H. Jessen

Int. J. Environ. Res. Public Health 2026, 23(1), 126; https://doi.org/10.3390/ijerph23010126 - 20 Jan 2026

Abstract

Nature-based health interventions (NBHIs) are increasingly used in the healthcare system to support people with anxiety, depression and/or stress, highlighting the need for systematic development and evaluation. This study aims to identify target group, professionals, mechanisms, and outcomes of NBHIs for people with [...] Read more.

Nature-based health interventions (NBHIs) are increasingly used in the healthcare system to support people with anxiety, depression and/or stress, highlighting the need for systematic development and evaluation. This study aims to identify target group, professionals, mechanisms, and outcomes of NBHIs for people with mild to moderate anxiety, depression, and/or stress. A Delphi-based study was conducted to explore core components of NBHIs in healthcare settings. Thirteen vs. eleven researchers with expertise related to the target group responded in two rounds. Respondents rated statements on a 7-point Likert scale and prioritised core components regarding target group, professionals, mechanisms, and outcomes. A thematic analysis was applied to synthesise qualitative responses. Consensus was achieved on 12 of 21 items across the four domains. Highest agreement concerned core mechanisms (nature interaction, social community, and physical activity), outcome priorities (mental wellbeing and quality of life), and professional competencies. Greater variation was observed regarding group composition and team delivery. Analysis of qualitative expert responses highlighted four key themes: (1) Balancing Group Composition, (2) Adapting Competencies to Context, (3) Core Mechanisms for Change, and (4) Weighing Perspectives in Outcome Selection. By setting out guiding principles for a programme theory, the study lays the foundation for the design and implementation of context-adapted NBHIs. The study underscores the need to approach NBHIs as complex interventions, thus contributing to a paradigm shift towards a new era of a bio-psycho-social health perspective. Full article

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

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17 pages, 748 KB

Open AccessArticle

Opportunities and Challenges in the Care of Patients with Somatic Complaints and Patients with Additional Work-Related Anxiety—A Mixed Methods Study

by Lara Kleist, Franziska Weißenstein, Beate Muschalla, Lukas Kühn, Eileen Wengemuth and Kyung-Eun (Anna) Choi

Int. J. Environ. Res. Public Health 2026, 23(1), 125; https://doi.org/10.3390/ijerph23010125 - 20 Jan 2026

Abstract

Background: Work-related anxiety can result in prolonged work incapacity and reduce return-to-work probabilities. Despite the prevalence of work-related anxiety in somatic rehabilitation settings, there has been little research examining the experiences of affected patients from a public health perspective. This research project aims [...] Read more.

Background: Work-related anxiety can result in prolonged work incapacity and reduce return-to-work probabilities. Despite the prevalence of work-related anxiety in somatic rehabilitation settings, there has been little research examining the experiences of affected patients from a public health perspective. This research project aims to address this gap by providing initial insights into the care provided to patients with somatic complaints and patients with additional work-related anxiety. Methods: A sequential mixed methods approach was employed, beginning with semi-structured interviews (2022, n = 18 orthopedic rehabilitation patients), followed by questionnaire distribution (2023, n = 53). Qualitative analysis distinguished between patients with higher (JA) and lower (nJA) Job Anxiety Scale scores (cut-off 2.5). Results: The findings highlight notable differences between JA and nJA patients. JA patients often report that they face unmet psychological needs, limited work-related treatment focus, financial barriers, and inadequate occupational support, relying more on self-initiative for reliable information. In contrast, nJA patients appear to benefit from stronger social networks, stable financial resources, and improved access to healthcare. Both groups report mixed experiences with workplace support. For professionals the findings underline that JA patients are specifically in need of work-related interventions, even patients themselves remind about this. Conclusions: The findings illustrate significant differences between JA and nJA patients in terms of their experiences, challenges, and support needs within healthcare, workplace, and rehabilitation contexts. While qualitatively insightful, these findings are pilot and explorative and warrant further research. Trial registration: DRKS00029004 (25 May 2022). Full article

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23 pages, 986 KB

Open AccessArticle

Exploring Inclusion in Austria’s Breast Cancer Screening:A Dual-Perspective Study of Women with Intellectual Disabilities and Their Caregivers

by Theresa Wagner, Nourhan Makled, Katrina Scior, Laura Maria König, Matthias Unseld and Elisabeth Lucia Zeilinger

Int. J. Environ. Res. Public Health 2026, 23(1), 124; https://doi.org/10.3390/ijerph23010124 - 19 Jan 2026

Abstract

Women with intellectual disabilities (IDs) face persistent health inequities, particularly in preventive services such as breast cancer screening, where participation rates remain disproportionately low. These disparities contribute to higher mortality and poorer survivorship outcomes, often linked to later-stage diagnoses. To better understand these [...] Read more.

Women with intellectual disabilities (IDs) face persistent health inequities, particularly in preventive services such as breast cancer screening, where participation rates remain disproportionately low. These disparities contribute to higher mortality and poorer survivorship outcomes, often linked to later-stage diagnoses. To better understand these challenges and inform the development of inclusive screening programs, this qualitative study conducted in Austria explored barriers, facilitators, and needs related to breast cancer screening from the dual perspectives of 17 women with mild-to-moderate IDs aged 45 and older and 10 caregivers. Semi-structured focus groups and interviews were analyzed thematically within a constructivist framework, integrating perspectives from both groups. Barriers included social taboos around sexuality, psychological distress, exclusion through standardized procedures, and unclear responsibility among stakeholders. Facilitators involved person-centered communication, accessible information, emotional and practical support, and familiar healthcare environments. Women with IDs expressed a strong desire for education, autonomy, and inclusion, while caregivers played a pivotal role in enabling access. These findings demonstrate that low screening participation among women with IDs is driven by systemic and organizational barriers rather than lack of health awareness or willingness to participate. Without structurally inclusive design, organized screening programs risk perpetuating preventable inequities in early detection. Embedding accessibility, clear accountability, and person-centered communication as standard features of breast cancer screening is therefore a public health priority to reduce avoidable late-stage diagnoses and narrow survival disparities for women with IDs. Full article

(This article belongs to the Special Issue Breast Health and Cancer Awareness: Addressing Breast Cancer Disparities from Etiology to Survivorship)

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18 pages, 1034 KB

Open AccessArticle

Unmet Needs and Service Priorities for ADHD in Australia: AI-Assisted Analysis of Senate Inquiry Submissions

by Blair Hudson, Sam Connell, Anie Kurumlian, Anjali Fernandes, Habib Bhurawala and Alison Poulton

Int. J. Environ. Res. Public Health 2026, 23(1), 123; https://doi.org/10.3390/ijerph23010123 - 19 Jan 2026

Abstract

Objective: To analyse written submissions from individuals and families with lived experience of attention-deficit hyperactivity disorder (ADHD) to the 2023 Australian Senate Inquiry, using artificial intelligence (AI)-assisted thematic analysis. The aim was to identify priority concerns, service needs, and community-proposed solutions. Methods: A [...] Read more.

Objective: To analyse written submissions from individuals and families with lived experience of attention-deficit hyperactivity disorder (ADHD) to the 2023 Australian Senate Inquiry, using artificial intelligence (AI)-assisted thematic analysis. The aim was to identify priority concerns, service needs, and community-proposed solutions. Methods: A mixed-methods study of 505 publicly available submissions from individuals with ADHD and their families. Submissions were analysed using large language model (LLM)-assisted data extraction and thematic clustering, with human validation and review. Main Outcome Measures: Frequency and thematic distribution of (1) problems experienced; (2) services wanted; and (3) solutions suggested. Results: Thematic analysis of 480 eligible submissions revealed high costs and long wait times for assessment and treatment (each cited by 46%), lack of specialised care (39%), diagnostic delays (36%), and gender bias (27%). The most common service request was for affordable and accessible ADHD-specific care (71%), followed by services tailored to diverse populations and life stages. Proposed solutions focused on Medicare-funded access to psychological and psychiatric services (68%), expanded roles for general practitioners, improved provider training (39%), and recognition of ADHD under the National Disability Insurance Scheme. Submissions also highlighted misalignment between current clinical guidelines and public expectations. Conclusions: The findings highlight substantial unmet needs and systemic barriers in ADHD diagnosis and care in Australia. The AI-assisted analysis of consumer submissions offers a scalable method for integrating lived experience into policy development, providing numerical weighting to the individuals’ responses. Coordinated reforms in access, funding, and workforce training are needed to align services with both clinical evidence and community expectations. Full article

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18 pages, 347 KB

Open AccessArticle

Lean Six Sigma for Sharps Waste Management and Occupational Biosafety in Emergency Care Units

by Marcos Aurélio Cavalcante Ayres, Andre Luis Korzenowski, Fernando Elemar Vicente dos Anjos, Taisson Toigo and Márcia Helena Borges Notarjacomo

Int. J. Environ. Res. Public Health 2026, 23(1), 122; https://doi.org/10.3390/ijerph23010122 - 19 Jan 2026

Abstract

Occupational exposure to sharps waste represents a critical challenge for public health systems, directly affecting healthcare workers’ safety, institutional costs, and environmental sustainability. This study aimed to analyze sharps waste management practices and to structure improvement actions for biosafety governance in Brazilian Emergency [...] Read more.

Occupational exposure to sharps waste represents a critical challenge for public health systems, directly affecting healthcare workers’ safety, institutional costs, and environmental sustainability. This study aimed to analyze sharps waste management practices and to structure improvement actions for biosafety governance in Brazilian Emergency Care Units (ECUs) through the application of the Lean Six Sigma (LSS) and DMAIC method (Define, Measure, Analyze, Improve, and Control). A single multiple-case study was conducted across three public units in different regions of Brazil, combining direct observation, regulatory checklists based on ANVISA Resolution No. 222/2018 (RDC), and cause–and–effect (5M) analysis. The diagnostic phase identified recurrent nonconformities in labeling, documentation, and internal transport routes, primarily due to managerial and behavioral gaps. Based on these findings, the DMAIC framework supported the development of a low-cost, evidence-based action plan that outlined proposed interventions, including visual checklists, standardized internal routes, and key performance indicators (KPIs), intended to strengthen biosafety traceability and occupational safety. The se proposed actions are expected to support continuous learning, staff engagement, and a culture of shared responsibility for safe practices. Overall, the study provides a structured basis for future implementation and empirical validation of continuous improvement initiatives, aimed at enhancing public health governance and occupational safety in resource-constrained healthcare environments. Full article

(This article belongs to the Section Environmental Health)

21 pages, 1423 KB

Open AccessSystematic Review

Diagnosis-Specific Links Between Physical Activity and Sleep Duration in Youth with Disabilities: A Systematic Review with Quantitative Synthesis

by Janette M. Watkins, Martin E. Block, Janelle M. Goss, Emily M. Munn and Devan X. Antczak

Int. J. Environ. Res. Public Health 2026, 23(1), 121; https://doi.org/10.3390/ijerph23010121 - 19 Jan 2026

Abstract

Children and adolescents with disabilities experience disproportionate challenges in achieving recommended levels of physical activity (PA) and adequate sleep, two core determinants of health and functional well-being. This systematic review examined associations between meeting PA guidelines and sleep duration among youth with disabilities. [...] Read more.

Children and adolescents with disabilities experience disproportionate challenges in achieving recommended levels of physical activity (PA) and adequate sleep, two core determinants of health and functional well-being. This systematic review examined associations between meeting PA guidelines and sleep duration among youth with disabilities. Following PRISMA guidelines, MEDLINE, PsycARTICLES, and SPORTDiscus were searched through Spring 2024 for studies assessing PA and sleep in children and adolescents (<18 years) with disabilities using subjective or objective measures. Data were extracted from 28 studies (N = 138,016) and synthesized using qualitative methods and regression-based quantitative analyses to examine the effects of diagnosis category and PA guideline adherence on sleep duration. The diagnosis type was associated with sleep duration, with youth with autism spectrum disorder (ASD) exhibiting shorter sleep than those with physical disabilities. Meeting PA guidelines (≥60 min/day) was associated with longer sleep duration among youth with ASD, but not consistently across other diagnostic groups. Qualitative findings further indicated diagnosis-specific variability, with PA positively associated with sleep outcomes in ASD, attention deficit/hyperactivity disorder, and epilepsy, and mixed associations observed for cerebral palsy and intellectual disability. These findings suggest that PA may support sleep health in specific disability groups. Given persistently low PA participation among youth with disabilities, integrating accessible, diagnosis-specific PA opportunities within school, community, and clinical settings may represent a feasible strategy to improve sleep and overall health. Full article

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19 pages, 1537 KB

Open AccessReview

Upper Crossed Syndrome in the Workplace: A Narrative Review with Clinical Recommendations for Non-Pharmacologic Management

by Nina Hanenson Russin, Carson Robertson and Alicia Montalvo

Int. J. Environ. Res. Public Health 2026, 23(1), 120; https://doi.org/10.3390/ijerph23010120 - 19 Jan 2026

Abstract

Problem Statement: Upper crossed syndrome (UCS), as first described by Janda, refers to a group of muscle imbalances in which tightness in the upper trapezius and levator scapulae dorsally cross with tightness in the pectoralis major and minor muscles, and weakness of deep [...] Read more.

Problem Statement: Upper crossed syndrome (UCS), as first described by Janda, refers to a group of muscle imbalances in which tightness in the upper trapezius and levator scapulae dorsally cross with tightness in the pectoralis major and minor muscles, and weakness of deep cervical flexors cross ventrally with weakness of the middle and lower trapezius. Postural alterations from this dysfunction, including forward head, rounded shoulders, and scapular dyskinesis, contribute to upper-back and shoulder pain, particularly among office workers who spend long periods of the workday on a computer. Upper crossed syndrome is a significant contributor to both neck pain and shoulder pain among computer users, which have been rated at 55–69%, and 15–52%, respectively. Despite its prevalence, knowledge about UCS and its treatment remains spotty among primary care physicians. In addition, improvements in workstation ergonomics along with hourly work breaks may be considered as primary prevention strategies for UCS. Objectives: This narrative review examines and synthesizes evidence about the epidemiology and diagnosis of UCS, along with clinical recommendations for physiotherapeutic approaches to treatment. Ergonomic measures in the workplace, including changes in the design of computer workstations so that both the keyboard and monitor are at the proper heights to minimize the risk of long-term musculoskeletal disorders, are also critical. Methods: The first author, a Doctor of Behavioral Health, performed the initial literature search, which was reviewed by the second author, a PhD in sports injury epidemiology. The third author, a chiropractor and practice owner, provided clinical recommendations for stretching and strengthening exercises, which were also described in the literature. Discussion: While easily treatable when caught early, UCS may become resistant to noninvasive approaches over time, and more severe pathologies of the neck and shoulder, including impingement, thoracic outlet syndrome, and cervicogenic headaches may result. Because there is no specific ICD code for UCS, it is important for physicians to recognize the early signs, consider them in the context of workplace-related injuries, and understand physiotherapeutic strategies for symptom resolution. Full article

(This article belongs to the Special Issue New Trends in Work-Related Musculoskeletal Disorders and Health-Related Quality of Life)

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