International Journal of Environmental Research and Public Health

13 pages, 3835 KB

Open AccessArticle

Lessons Learned from a Pilot Study of the Relationship Between Rainfall and Levels of 1,4-Dioxane and Metals in Water Bodies Adjacent to Superfund Sites on Long Island, New York, USA

by Sarah Grace Frueh, Jessica Alfano, Wil Cruz-Ruiz, Lissa Fortes Soares, Sheryl Jeanty, Janroy Caraan, Dimitrios E. Bakatsias, Brian Haldenwang, Roxanne Karimi, Xiayan Ye, Sudheera Yaparatne, Arjun K. Venkatesan, Carrie A. McDonough, Henry J. Bokuniewicz, Christopher J. Gobler, Kevin A. Reed and Jaymie R. Meliker

Int. J. Environ. Res. Public Health 2026, 23(9), 1173; https://doi.org/10.3390/ijerph23091173 - 7 Sep 2026

Abstract

Rainfall and groundwater fluctuations may influence the migration or dilution of contaminants from US Superfund sites. This pilot study was designed to provide empirical data on relationships between rainfall and contaminant concentrations in water near Superfund sites. Four heterogeneous Superfund sites on Long [...] Read more.

Rainfall and groundwater fluctuations may influence the migration or dilution of contaminants from US Superfund sites. This pilot study was designed to provide empirical data on relationships between rainfall and contaminant concentrations in water near Superfund sites. Four heterogeneous Superfund sites on Long Island, New York, were selected to represent a range of contaminant profiles and hydrogeologic conditions. Baseline samples were collected in December 2022, with subsequent samples obtained following major storms through September 2023. Samples were collected on 11–24 different days across the sites and measured for 18 metals and 1,4-dioxane. Overall, we observed few consistent associations between rainfall and contaminant concentrations across sites. Two trends, however, were noted: (1) at Gowanus Canal, a surface water site, there was a negative association between rainfall and contaminant concentrations using same-day or prior-day rainfall; and (2) in effluent from a treatment well near Lawrence Aviation, negative associations were observed between prior month’s rainfall and contaminant concentrations. Rainfall appeared to dilute contaminant concentrations using different hydrogeological processes at two of the four Superfund sites in this pilot study with a small sample size and study site heterogeneity. Given the increased frequency and intensity of extreme rainfall events, it is important to continue probing links between rainfall and contaminants near Superfund sites with intensive monitoring campaigns. Full article

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13 pages, 1169 KB

Open AccessPerspective

Addressing Heat Stress in Arid, High-Visitor Cities with a Focus on Makkah

by Osman Ulvi, Saiful Momen, Iftikhar Sikder and Ubydul Haque

Int. J. Environ. Res. Public Health 2026, 23(9), 1172; https://doi.org/10.3390/ijerph23091172 - 7 Sep 2026

Abstract

Makkah faces substantial heat-stress challenges associated with extreme temperatures, dense urban form, and the large numbers of pilgrims present during Hajj and Umrah, creating important public health concerns. Recent heat-related fatalities highlight the need for complementary strategies that address outdoor as well as [...] Read more.

Makkah faces substantial heat-stress challenges associated with extreme temperatures, dense urban form, and the large numbers of pilgrims present during Hajj and Umrah, creating important public health concerns. Recent heat-related fatalities highlight the need for complementary strategies that address outdoor as well as indoor heat exposure, alongside conventional cooling approaches such as air conditioning. This article examines the potential role of nature-based and complementary engineered interventions in mitigating urban heat stress in Makkah, focusing on afforestation, urban greening, and the possible use of artificial water bodies, contingent on sustainable water management. Drawing on case studies and published evidence from arid and heat-prone regions, including China, Pakistan, Saudi Arabia, and the wider Middle East, we summarize reported cooling effects, implementation experience, and feasibility considerations and assess their potential relevance to Makkah. The perspective highlights critical challenges related to water scarcity, spatial constraints, ecological impacts, and governance, while proposing phased implementation pathways that could be evaluated incrementally. If carefully designed and integrated with urban planning and climate-adaptation strategies, nature-based and complementary interventions could potentially reduce human heat stress, reduce cooling demand, and strengthen climate resilience in Makkah. However, their effectiveness, water requirements, environmental impacts, and scalability require evaluation under Makkah-specific environmental and operational conditions. Full article

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23 pages, 1791 KB

Open AccessArticle

Using Conditional Random Forest and Feature Ranking Algorithms to Determine the Relative Importance of the Nicotine Metabolite Ratio (NMR) and Demographic and Behavioral Factors on Nicotine Dependence Severity

by Michael Machiorlatti, Nicolle M. Krebs and Joshua E. Muscat

Int. J. Environ. Res. Public Health 2026, 23(9), 1171; https://doi.org/10.3390/ijerph23091171 - 7 Sep 2026

Abstract

Cigarette smokers have different levels of nicotine dependence, which affect their daily cigarette consumption and ability to quit. Genetic factors play a role, and there is interest in tailored nicotine therapy based on an individual’s rate of nicotine metabolism, which can be measured [...] Read more.

Cigarette smokers have different levels of nicotine dependence, which affect their daily cigarette consumption and ability to quit. Genetic factors play a role, and there is interest in tailored nicotine therapy based on an individual’s rate of nicotine metabolism, which can be measured by the ratio of 3′hydroxycotinine [3HC]-to-cotinine, e.g., the nicotine metabolite ratio [NMR]. However, many other behavioral factors or symptoms are considered important indicators of nicotine dependence. The current study uses machine learning (ML) and traditional statistical methods to rank the importance of NMR and non-NMR factors that contribute to nicotine addiction. Using data from the Pennsylvania Adult Smoking Study (PASS), we found that salivary NMR is a predictor of nicotine dependence in the most commonly used nicotine dependence scales, including the Fagerstrom Test for Nicotine Dependence, Heaviness of Smoking Index, and the Hooked On Nicotine Checklist. However, other predictor variables, such as waking urges, showed higher rankings than NMR, with findings dependent on the modeling approach. These results indicate that other factors besides NMR may be clinically useful for understanding the extent of dependence and approaches to quitting. Full article

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18 pages, 447 KB

Open AccessArticle

Agreement Between Six-Minute Walk Test-Based Equations and Bruce-Derived Aerobic-Fitness Estimates in Adults with Metabolic Syndrome: A Single-City Cross-Sectional Method-Comparison Study

by Anahy Ordóñez-Zea, Alberto Urzúa, Jorge Méndez-Cornejo, Edgardo Rojas-Mancilla, Carmen Zambrano-Bravo, Esteban Oñate-Henríquez, Trinidad Parada and Cristian Vidal-Silva

Int. J. Environ. Res. Public Health 2026, 23(9), 1170; https://doi.org/10.3390/ijerph23091170 - 7 Sep 2026

Abstract

Accessible assessment of aerobic fitness is important for adults with metabolic syndrome when cardiopulmonary exercise testing is unavailable. This study aimed to evaluate participant-level agreement between Six-Minute Walk Test (6MWT)-based equations and estimates derived from total Bruce treadmill duration. Using a single-city cross-sectional [...] Read more.

Accessible assessment of aerobic fitness is important for adults with metabolic syndrome when cardiopulmonary exercise testing is unavailable. This study aimed to evaluate participant-level agreement between Six-Minute Walk Test (6MWT)-based equations and estimates derived from total Bruce treadmill duration. Using a single-city cross-sectional method-comparison design, 105 newly recruited adults, comprising 67 women and 38 men, completed standardized 6MWT and graded treadmill assessments. Agreement was evaluated using mean bias, mean absolute error (MAE), root mean square error (RMSE), Pearson correlation, calibration, proportional-bias regression, and Bland–Altman limits of agreement. Mean Bruce-derived estimated peak oxygen uptake (

{VO}_{2 p e a k}

) was

23.42 \pm 1.87

mL·kg⁻¹

\cdot

min⁻¹. Model 1 produced

15.90 \pm 1.72

, with a mean bias of

- 7.53

, an RMSE of 7.77, and limits of agreement from

- 11.29

to

- 3.76

. Model 3 produced

16.78 \pm 3.28

, with a mean bias of

- 6.65

, an RMSE of 7.11, and limits from

- 11.60

to

- 1.70

. Both models systematically underestimated Bruce-derived values, and Model 3 showed proportional bias. Model 2 produced

99.31 \pm 4.82 %

on its original age- and sex-adjusted percentage-predicted scale. It was not converted to mass-specific units because the participant-specific reference values required for a valid back-conversion were unavailable. The observed bias and limits of agreement indicated that Models 1 and 3 did not achieve close participant-level agreement with the Bruce-derived approach. Validation against directly measured oxygen uptake remains necessary before clinical or public-health use. Full article

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10 pages, 323 KB

Open AccessArticle

Philanthropic Hospitals and Geographic Access to Health Care in Brazil: Impact Evaluation of a Tax Relief Programme

by Aléssio Tony Cavalcanti de Almeida, Luciana Mendes Santos Servo and Edvaldo Batista de Sá

Int. J. Environ. Res. Public Health 2026, 23(9), 1169; https://doi.org/10.3390/ijerph23091169 - 7 Sep 2026

Abstract

Philanthropic hospitals are key providers within Brazil’s public healthcare system and benefit from the Certification of Beneficent Social Assistance Entities in Health (CEBAS-Saúde), a tax relief program designed to incentivize service provision in underserved areas. We analyze a balanced panel of 1641 philanthropic [...] Read more.

Philanthropic hospitals are key providers within Brazil’s public healthcare system and benefit from the Certification of Beneficent Social Assistance Entities in Health (CEBAS-Saúde), a tax relief program designed to incentivize service provision in underserved areas. We analyze a balanced panel of 1641 philanthropic general hospitals from 2005 to 2019, employing a conditional Difference-in-Differences (DiD) model with heterogeneous treatment exposure and entropy balancing to ensure comparability between certified and non-certified hospitals. The results show that certification significantly improved geographic access, mainly by reducing macro-regional patient evasion—the outflow of patients seeking care outside their designated health regions. This effect, most pronounced after ten years of certification, translated into an average annual reduction of approximately 8700 avoided hospitalizations between 2015 and 2019. The reduction was particularly concentrated in small hospitals and in the Northeast region, where access barriers are historically greater. These findings suggest that CEBAS-Saúde is an effective policy instrument for strengthening the regionalization of healthcare provision, reducing geographic inequities, and addressing service gaps in areas with limited healthcare supply. Full article

(This article belongs to the Special Issue The Effects of Public Policies on Health)

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1 pages, 176 KB

Open AccessRetraction

RETRACTED: Lucas et al. Health Impact and Psychosocial Perceptions Among French Medical Residents During the SARS-CoV-2 Outbreak: A Cross-Sectional Survey. Int. J. Environ. Res. Public Health 2021, 18, 8413

by David Lucas, Sandrine Brient, Bisi Moriamo Eveillard, Annabelle Gressier, Tanguy Le Grand, Richard Pougnet, Jean-Dominique Dewitte and Brice Loddé

Int. J. Environ. Res. Public Health 2026, 23(9), 1168; https://doi.org/10.3390/ijerph23091168 - 7 Sep 2026

Abstract

The journal retracts the article titled “Health Impact and Psychosocial Perceptions among French Medical Residents during the SARS-CoV-2 Outbreak: A Cross-Sectional Survey” [...] Full article

15 pages, 1640 KB

Open AccessArticle

Using Generative AI to Improve Readability, Actionability, and Health Literacy of COPD Caregiver Materials

by Michael L. Stellefson, Gracie Avery, Sarah Flora, Ansley Boles, Olivia Henry, Rakshan Sivalingam and Savanna Williams

Int. J. Environ. Res. Public Health 2026, 23(9), 1167; https://doi.org/10.3390/ijerph23091167 - 7 Sep 2026

Abstract

Informal caregiving for individuals with chronic obstructive pulmonary disease (COPD) places substantial emotional and physical demands on caregivers. However, many educational resources remain difficult to use due to high reading levels, dense medical language, and limited accessibility. Given that a large proportion of [...] Read more.

Informal caregiving for individuals with chronic obstructive pulmonary disease (COPD) places substantial emotional and physical demands on caregivers. However, many educational resources remain difficult to use due to high reading levels, dense medical language, and limited accessibility. Given that a large proportion of U.S. adults experience challenges with health literacy, existing caregiver toolkits may not provide the clear, actionable guidance needed to support caregiver self-efficacy or improve patient outcomes. This study introduces a reproducible, three-phase workflow that uses generative artificial intelligence (AI) to simplify and refine caregiver education materials, with application to the COPD Caregiver’s Toolkit. Four AI tools were used to simplify text, followed by human-guided refinement using the Sydney Health Literacy Lab (SHeLL) health literacy editor to ensure conceptual accuracy and usability. Readability indices and blinded assessments were used to evaluate changes in understandability and actionability across versions. AI-assisted simplification improved readability and clarity while maintaining high levels of actionability and preserving key instructional content. This scalable, adaptable approach may help public health researchers and practitioners improve the accessibility of educational resources across settings. Multi-phase, human-in-the-loop AI workflows may reduce linguistic complexity and improve the dissemination of essential health information to caregiving populations. Full article

(This article belongs to the Topic Health Literacy and eHealth: New Challenges and Developments)

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17 pages, 304 KB

Open AccessArticle

Rational Risk or Cultural Resistance: Co-Produced Findings on Structural Barriers to Drug and Alcohol Recovery Among South Asian Muslim Communities in England

by Zeibeda Sattar, Aneeta Shajan, Sheinaz Stansfield, Michael Cave, Humaira Khan, Mushtaq Dakri and William McGovern

Int. J. Environ. Res. Public Health 2026, 23(9), 1166; https://doi.org/10.3390/ijerph23091166 - 7 Sep 2026

Abstract

Background: South Asian Muslim (SAM) communities remain significantly underserved by mainstream drug and alcohol (D&A) recovery services in England. Cultural and religious misalignment in service design creates structural barriers to engagement. Family members from SAM communities who support individuals with substance use [...] Read more.

Background: South Asian Muslim (SAM) communities remain significantly underserved by mainstream drug and alcohol (D&A) recovery services in England. Cultural and religious misalignment in service design creates structural barriers to engagement. Family members from SAM communities who support individuals with substance use disorders have identified structural, cultural, and religious barriers that hinder engagement with mainstream treatment services. This study builds on this body of evidence by working with service providers, commissioners and community stakeholders through participatory co-production to examine how these barriers can be addressed. Methods: Three participatory co-production workshops were held over a 12-week period. Data were also generated from a field visit to a culturally adapted recovery service and a content analysis of an Islamically adapted 12-step recovery workbook. Participants included commissioners, service providers, community ambassadors and service users (total n = 42 across three workshops; some participants attended more than one workshop). Results: Four interconnected themes that shaped recovery engagement were identified: (1) stigma and izzat operating as a collective structural risk management system; (2) confidentiality functioning as a precondition for engagement rather than a by-product of it; (3) service design, space and visibility as determinants of access; and (4) co-construction of religiously coherent recovery pathways. Low engagement among participants reflected rational risk management, in response to real social consequences, rather than cultural resistance. Conclusions: Findings suggest that inclusive recovery systems may benefit from the adaptation of mainstream services rather than the creation of parallel provision. Six evidence-based design principles are proposed for commissioners and service providers. Findings contribute to the evidence base for equitable health, culturally responsive D&A intervention design and have relevance beyond SAM communities to other marginalised faith communities across England. Full article

(This article belongs to the Special Issue Alcohol Use in Disadvantaged Populations: Health Equalities and Appropriate Intervention)

24 pages, 565 KB

Open AccessArticle

Bridging the Knowledge–Practice Gap in Hypertension Management: A Community-Engaged Systems Approach in Disadvantaged Rural Community

by Aphiwe Khaya Yekani, Lindiwe Modest Faye, Ncomeka Sineke and Monwabisi Faleni

Int. J. Environ. Res. Public Health 2026, 23(9), 1165; https://doi.org/10.3390/ijerph23091165 - 7 Sep 2026

Abstract

Background: Hypertension is a major contributor to cardiovascular morbidity and mortality globally, with particularly poor control in disadvantaged communities. Although awareness is generally high, sustaining lifestyle changes and treatment adherence remains difficult. This study examined socioeconomic, behavioural, and health system factors associated with [...] Read more.

Background: Hypertension is a major contributor to cardiovascular morbidity and mortality globally, with particularly poor control in disadvantaged communities. Although awareness is generally high, sustaining lifestyle changes and treatment adherence remains difficult. This study examined socioeconomic, behavioural, and health system factors associated with hypertension management and explored the role of community-engaged health education in strengthening primary health care. Methods: A cross-sectional descriptive study was conducted among 107 adults with hypertension attending public primary health care facilities. Data were collected using structured questionnaires covering socioeconomic status, health system access, medication adherence, lifestyle practices, and knowledge and attitudes. Descriptive statistics summarized participant characteristics, while chi-square tests and multivariable logistic regression identified factors associated with clinic attendance, dietary adherence, lifestyle practices, and self-management. Results: Awareness of hypertension (86.9%) and trust in clinic care (91.6%) were high; however, a clear knowledge practice gap was evident. Although 79.4% acknowledged the importance of lifestyle changes, only 45.8% followed a hypertension-specific diet. Structural barriers included low income (39.3% earning <R3 000/month) and long distances to clinics (46.7% living ≥5 km away). Health worker advice strongly predicted dietary adherence (OR = 6.36, p = 0.001), lifestyle adherence (OR = 4.24, p = 0.006), and overall self-management (OR = 12.46, p = 0.024), whereas knowledge alone did not. Conclusions: Hypertension management is constrained more by structural and health system factors than by lack of awareness. Strengthening primary health care counselling and community-based health education may improve sustained lifestyle change and outcomes. Full article

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17 pages, 611 KB

Open AccessArticle

Income Inequality and Mortality from Diabetes Mellitus and Hypertensive Diseases Among Adults Aged 30–69 Years in Brazilian Federative Units: A Longitudinal Analysis, 2012–2024

by Miguel Medeiros da Silva, Luiz Alves Morais Filho, Janmilli da Costa Dantas Santiago, Isaque Augusto Rosendo Costa, Richardson Augusto Rosendo da Silva and Cristiane da Silva Ramos Marinho

Int. J. Environ. Res. Public Health 2026, 23(9), 1164; https://doi.org/10.3390/ijerph23091164 - 6 Sep 2026

Abstract

Objective: To analyze the association between income inequality and age-standardized mortality from diabetes mellitus and hypertensive diseases among adults aged 30–69 across Brazilian Federative Units (2012–2024). Methods: Ecological longitudinal study using balanced panel data from the 27 Federative Units. Data were retrieved from [...] Read more.

Objective: To analyze the association between income inequality and age-standardized mortality from diabetes mellitus and hypertensive diseases among adults aged 30–69 across Brazilian Federative Units (2012–2024). Methods: Ecological longitudinal study using balanced panel data from the 27 Federative Units. Data were retrieved from the Mortality Information System and IBGE/IPEA databases. Mortality rates were standardized using the direct method (WHO population). Trends were evaluated via Joinpoint regression, and associations were analyzed using mixed linear models with random intercepts and first-order autoregressive covariance structure. Results: Inequality decreased in 25 Federative Units, accompanied by rising income and declining poverty, whereas national aggregated analysis showed a linear increase in inequality (APC = 0.514%; p < 0.001). Overall mortality trends were stationary for diabetes (AAPC = −1.507%; p = 0.102) and hypertension (AAPC = −0.881%; p = 0.524), despite significant declines from 2021 to 2024. In adjusted mixed models, higher per capita household income was independently associated with lower diabetes mortality (β = −0.012; p = 0.031), while hypertension displayed an upward adjusted linear trend (β = 0.289; p = 0.001). Neither the Gini Index nor poverty rates maintained significant independent associations with mortality. Conclusions: After structural adjustment, only absolute per capita household income maintained an independent protective association with diabetes mortality, highlighting the relevance of material living conditions beyond inequality measures alone. Full article

(This article belongs to the Section Health Care Sciences)

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18 pages, 387 KB

Open AccessArticle

Forgiveness of Family Offenses and Psychological Well-Being in Youth and Emerging Adults: A Cross-Sectional Study on the Mediating Role of Desire for Reconciliation

by Agata Kasprzak and Karla Gabriela Gallo-Giunzioni

Int. J. Environ. Res. Public Health 2026, 23(9), 1163; https://doi.org/10.3390/ijerph23091163 - 6 Sep 2026

Abstract

Family offenses constitute relational experiences that can have a profound impact on the psychological well-being of sons and daughters. Although forgiveness has been consistently associated with higher levels of well-being, the relational processes that account for this association remain underexplored, particularly from the [...] Read more.

Family offenses constitute relational experiences that can have a profound impact on the psychological well-being of sons and daughters. Although forgiveness has been consistently associated with higher levels of well-being, the relational processes that account for this association remain underexplored, particularly from the perspective of adolescent and emerging adult sons and daughters. The present study used a cross-sectional design to examine whether the desire for reconciliation mediates the relationship between the positive and negative dimensions of forgiveness (affective, behavioral, and cognitive) and psychological well-being following a family offense. A non-probability convenience sample of 419 Spanish young people and emerging adults from the general population, aged between 16 and 25 years (M = 20.54, SD = 2.69), was recruited across Spain through university channels, social media and snowball sampling, and an online survey was completed. Participants completed the Enright Forgiveness Inventory (EFI-30), the Desire for Reconciliation Scale (DRS) and the Psychological Well-Being Scales for Youths–Short Form (PWB-YS-SF). Results indicated a pattern of associations consistent with the desire for reconciliation, mediating the relationship between all forgiveness dimensions and psychological well-being. These associations remained significant after adjusting for sociodemographic and offense-related covariates. However, the distinction between partial and full mediation across dimensions was not robust enough to correct for multiple testing, and when the overlap among the six highly intercorrelated dimensions was controlled, only positive affect and positive cognition retained a unique association with the desire for reconciliation. Overall, the findings suggest that the link between forgiveness and well-being in young people is partly accounted for by the desire to repair the family relationship. Full article

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

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18 pages, 481 KB

Open AccessArticle

Population-Adjusted Survival: A Real-World, Epidemiologic Approach for Analyzing Time-to-Event Clinical Trial Data

by Jimmy T. Efird, Genevieve N. Dupuis, Yuk Ming Choi, Cynthia Hau, Sonia T. Anand, Michael J. Davenport, Maria Androsenko, Kaitlin J. Cassidy, Robert A. Lew and Hongsheng Wu

Int. J. Environ. Res. Public Health 2026, 23(9), 1162; https://doi.org/10.3390/ijerph23091162 - 6 Sep 2026

Abstract

Results of a clinical trial may misrepresent the target population. Inappropriate inclusion/exclusion criteria, selective recruitment, and differential participation may restrict the number of patients who consent to join the study. Frequently, they differ from the real-world population in terms of key outcome-related characteristics. [...] Read more.

Results of a clinical trial may misrepresent the target population. Inappropriate inclusion/exclusion criteria, selective recruitment, and differential participation may restrict the number of patients who consent to join the study. Frequently, they differ from the real-world population in terms of key outcome-related characteristics. Such biased selection may make the therapeutic agent seem more or less effective within a certain stratum. While block randomization and an intent-to-treat design can help to minimize confounding within the trial sample, differences may still exist with respect to the distribution of these variables in the population. To mitigate misleading conclusions, the current manuscript illustrates how to ‘population-adjust’ survival estimates in a clinical trial using the Beckett–Bayes expansion method. In contrast to other population adjustment methods, this novel approach involves substituting the probability of belonging to a specific sample stratum with the corresponding population data (i.e., population borrowing). As a regression-free technique, the method is not susceptible to model misspecification. A large clinical trial focusing on cardiovascular-related deaths in patients with hypertension is used as an example to illustrate the method. The proposed framework is promising and easy to implement when reliable population-level information is available. Full article

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

14 pages, 455 KB

Open AccessArticle

by Olga Malas, Marwa Khan and Aisha Zubair

Int. J. Environ. Res. Public Health 2026, 23(9), 1161; https://doi.org/10.3390/ijerph23091161 - 6 Sep 2026

Abstract

Background: Needle fear (NF), vaccination fear (VF), and conspiracy beliefs (CB) have been negatively associated with vaccination intention (VI), although the mechanisms linking these variables remain unclear. The aim of this cross-sectional exploratory study was to shed light on these relationships. Methods: The [...] Read more.

Background: Needle fear (NF), vaccination fear (VF), and conspiracy beliefs (CB) have been negatively associated with vaccination intention (VI), although the mechanisms linking these variables remain unclear. The aim of this cross-sectional exploratory study was to shed light on these relationships. Methods: The sample comprised 777 adults from the educational community in Pakistan (M = 23.39 years, SD = 6.83; 72.6% female), including students, academic/research staff, and administrative/support personnel. Descriptive and correlational analyses were conducted, followed by structural equation modelling (SEM) to examine the direct and indirect relationships among the study variables. Results: NF was not directly associated with VI. The best-fitting SEM model was the sequential model NF → VF → CB → VI. These findings suggest that the relationship between NF and VI is indirect through VF and CB. However, due to the cross-sectional design, the temporal direction of the associations cannot be established, and alternative explanations remain possible. Conclusions: These findings suggest that the relationship between NF and VI is indirect and is manifested through VF and CB. However, given the exploratory nature of this study and the use of ad hoc measures, further research is needed to determine whether VF and CB stem from NF or, alternatively, may serve as cognitive justifications for it. Full article

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15 pages, 293 KB

Open AccessArticle

Intergenerational Strategies to Reduce Dementia-Related Stigma in Rural Communities: Stakeholder Perspectives from a Community-Based World Café Study

by Juanita-Dawne R. Bacsu, Marc Viger, Alixe Ménard, Maya Kluch-Morrell, Anila Virani, Claudia Gonzalez, Wendy Hulko, Jim Mann, Melba Sheila D’Souza, Matthew Lee Smith, Myrna Norman, Sheila Blackstock and Mark Rakobowchuk

Int. J. Environ. Res. Public Health 2026, 23(9), 1160; https://doi.org/10.3390/ijerph23091160 - 6 Sep 2026

Abstract

Although dementia-related stigma is well-documented, there is a paucity of research examining intergenerational activities to reduce stigma within rural settings. Using a World Café approach, the objective of this paper was to explore rural stakeholders’ ideas and perspectives on intergenerational strategies to reduce [...] Read more.

Although dementia-related stigma is well-documented, there is a paucity of research examining intergenerational activities to reduce stigma within rural settings. Using a World Café approach, the objective of this paper was to explore rural stakeholders’ ideas and perspectives on intergenerational strategies to reduce dementia-related stigma in rural communities. Seventy-five participants engaged in a facilitated workshop held in Kamloops, British Columbia, Canada, on 14 May 2025. Discussions were transcribed and analyzed using Braun and Clarke’s thematic analysis framework. The findings highlighted three themes for reducing dementia-related stigma in rural communities: (1) contact activities that promote meaningful interactions (e.g., shared hobbies, arts programs, and reminiscence activities) between people living with dementia and others across age groups; (2) educational interventions that enhance dementia knowledge and awareness (e.g., dementia information integrated into educational institutions across the life course); and (3) mixed interventions that combine contact-based and educational approaches. Moving forward, further research is needed to co-design, implement, and evaluate the impact of specific interventions. This study provides critical insights to inform the development of dementia stigma-reduction programs, policies, and interventions in rural settings. Full article

(This article belongs to the Section Health Care Sciences)

26 pages, 381 KB

Open AccessReview

A Conceptual Framework and Narrative Review of Current and Emerging Posttraumatic Stress Disorder Treatments

by Trevor J. Murphy, Megan Jung, An-Fu Hsiao, Nichole M. Martin, Alec J. Jimenez, Andrea Munoz, Jennifer Lai-Trzebiatowski, Tyler Smith and Michael Hollifield

Int. J. Environ. Res. Public Health 2026, 23(9), 1159; https://doi.org/10.3390/ijerph23091159 - 5 Sep 2026

Abstract

Background: This narrative concept-generating review proposes a theoretical and heuristic framework for conceptualizing established and emerging interventions for posttraumatic stress disorder (PTSD) including three categories: top-down/conscious (e.g., cognitive processing therapy, CPT), bottom-up/non-conscious (e.g., pharmacotherapy) and hybrid/conscious and non-conscious integration (e.g., eye movement desensitization [...] Read more.

Background: This narrative concept-generating review proposes a theoretical and heuristic framework for conceptualizing established and emerging interventions for posttraumatic stress disorder (PTSD) including three categories: top-down/conscious (e.g., cognitive processing therapy, CPT), bottom-up/non-conscious (e.g., pharmacotherapy) and hybrid/conscious and non-conscious integration (e.g., eye movement desensitization and reprocessing, EMDR). The categorization offers a preliminary novel classification of well established and emerging interventions, while highlighting gaps in current treatment approaches. Methods: Clinical guidelines and review articles from 2008 through 2026 were used to create the framework; PubMed and Google Scholar databases were searched for relevant meta-analyses, systematic reviews, narrative reviews, and randomized clinical trials. A total of 27 treatment modalities were included presenting effect size data from 43 published articles. Results: Treatments across categories present mixed results for efficacy. While guideline recommended treatments offer more robust evidence, many understudied emerging interventions exhibit preliminary efficacy. At the intersection of conscious and non-conscious approaches, hybrid modalities may present unique potential benefits. However, superiority determinations between modalities cannot be made and further empirical validation of categorization is needed. Conclusions: The proposed framework highlights the need for increased investigation of treatments that address PTSD as an interconnected whole-body disorder to potentially expand care options. Full article

(This article belongs to the Special Issue Prevention and Treatment of Trauma-Related Mental Illness)

22 pages, 655 KB

Open AccessSystematic Review

Climate Change and Suicidal Behavior in Older Adults: Determinants, Associated Factors, and Risk Factors: A Systematic Literature Review

by Diego De Leo, Josephine Zammarrelli, Elena Zamò, Fausto Carlo De Rossi, Francesca Lippi, Martina Andrea Viecelli, Luca Vannucci and Cristina Bordignon

Int. J. Environ. Res. Public Health 2026, 23(9), 1158; https://doi.org/10.3390/ijerph23091158 - 5 Sep 2026

Abstract

Background: Climate change is being recognized as a factor associated with increased suicidal behavior, especially in the older adult population. Extreme temperatures, thermal anomalies, and intense weather events can amplify pre-existing physical, psychological, and social vulnerabilities, increasing the risk of suicidal ideation and [...] Read more.

Background: Climate change is being recognized as a factor associated with increased suicidal behavior, especially in the older adult population. Extreme temperatures, thermal anomalies, and intense weather events can amplify pre-existing physical, psychological, and social vulnerabilities, increasing the risk of suicidal ideation and behavior in older adults. Objectives: This systematic review aims to map the literature on the relationship between climate change and suicidal behavior in older people, identifying risk and protective factors, as well as the prevention and intervention strategies aimed at this age group. Methods: A systematic review was conducted according to PRISMA guidelines. The literature search was performed in the EBSCO PsycINFO, Scopus and MEDLINE (PubMed) databases in the period 2007–2025, using combinations of the keywords “climate change”, “global warming”, “older adults”, “elderly”, “suicide”, “suicidal ideation” and related terms. Out of 35 studies, 16 articles were included in the final analysis. Results: Five thematic areas emerged from the analysis of the studies: (1) risk factors, (2) protective factors, (3) sociodemographic factors, (4) prevention and intervention strategies and (5) variables associated with suicidal behavior. Across the included studies, suicidal ideation, non-fatal attempts, and suicide mortality were examined with differing frequency and are reported separately in the thematic synthesis rather than pooled, reflecting the heterogeneity of outcome definitions and study designs. Significant limitations in the literature remain, including the paucity of longitudinal studies, the widespread use of aggregate data and the limited integration of environmental, social, and psychological factors. Conclusions: Climate change and extreme weather events may contribute to suicidal behavior in older adults. It is therefore necessary to develop multidimensional approaches that address structural vulnerabilities and promote the active role of older adults in climate resilience and social cohesion. Full article

36 pages, 3317 KB

Open AccessSystematic Review

Nature-Based Solutions, Climate, and Health in Chinese Cities: A Secondary Analysis of an English-Language Systematic Review with Implications for Urban Policy and Practice

by Yirong Jia and Catalina Turcu

Int. J. Environ. Res. Public Health 2026, 23(9), 1157; https://doi.org/10.3390/ijerph23091157 - 5 Sep 2026

Abstract

Urban nature-based solutions (NbSs) are increasingly deployed to address climate risks, yet their health co-benefits remain poorly understood. This paper presents a secondary analysis of 90 peer-reviewed, English-language China-specific studies drawn from a registered systematic review covering January 2015 to April 2025. Evidence [...] Read more.

Urban nature-based solutions (NbSs) are increasingly deployed to address climate risks, yet their health co-benefits remain poorly understood. This paper presents a secondary analysis of 90 peer-reviewed, English-language China-specific studies drawn from a registered systematic review covering January 2015 to April 2025. Evidence was analyzed by geographical distribution, NbS category, climate-adaptation pathway, health outcome, and greenness measurement, with complementary comparison against 88 non-China-specific studies. Air-quality pathways and physical-health outcomes predominated, whereas heat received less attention, and only one study examined flood-related health. Thirty studies (33.3%) were located wholly in eastern China, while 9 of the 31 mainland provincial-level jurisdictions lacked dedicated or separately reported evidence. Setting-based greenery dominated the five-category NbS classification. Of 126 association units, 100 (79.4%) were favorable; null or adverse findings were confined to specific exposures or contexts, including allergenic or low-diversity vegetation and reduced visibility. Although the two subsets covered broadly similar topics, China-specific studies relied more heavily on aggregate greenness indices (e.g., NDVI: 73.3% versus 45.5%), less often distinguished vegetation types or strata (14.4% versus 36.4%), and included no studies treating urban trees or community gardens as distinct exposures. These findings support five China-specific policy priorities and adapt four international policy themes to Chinese governance contexts. Full article

(This article belongs to the Section Environmental Health)

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31 pages, 420 KB

Open AccessArticle

Co-Creating Healthy Ageing: A Mixed-Methods Pilot Study of a Community-Based Intergenerational Programme

by Adelinda Araújo Candeias and Adriana Simões Félix

Int. J. Environ. Res. Public Health 2026, 23(9), 1156; https://doi.org/10.3390/ijerph23091156 - 5 Sep 2026

Abstract

Population ageing, social isolation, and limited opportunities for meaningful contact between generations pose important challenges to healthy ageing and community well-being. This mixed-methods pilot study examined the feasibility, acceptability, co-creation process, and preliminary outcomes of the P-IN Programme, a community-based intergenerational intervention involving [...] Read more.

Population ageing, social isolation, and limited opportunities for meaningful contact between generations pose important challenges to healthy ageing and community well-being. This mixed-methods pilot study examined the feasibility, acceptability, co-creation process, and preliminary outcomes of the P-IN Programme, a community-based intergenerational intervention involving preschool children and older adults living in residential care. The programme was developed and implemented in partnership with a preschool and a residential care facility in Portugal and comprised ten intergenerational sessions shaped through an iterative co-creation process involving participants, professionals, and researchers. Twenty-three children, eighteen older adults, and five professionals contributed to the study. Quantitative pre–post assessment explored fluency in both generations and cognitive functioning, quality of life, subjective well-being, and social participation in older adults. Qualitative data examined intergenerational beliefs, participants’ experiences, relationships, and reciprocal learning, while also informing the co-creation process. Most quantitative outcomes remained stable, although cognitive functioning showed a moderate, non-significant effect. Perceived quality of life changed significantly in an unfavourable direction. In contrast, qualitative findings revealed broader and more relational representations of the other generation, alongside shared experiences and clearer recognition of reciprocal learning. The integration of both components showed that positive relational and experiential changes were not necessarily accompanied by changes in broader standardised outcomes. Overall, the P-IN Programme was feasible to implement and generally well received within the two participating community settings. These findings support further evaluation of co-created intergenerational programmes using larger samples, controlled designs, and longer-term follow-up. Full article

(This article belongs to the Special Issue Health and Vulnerability in Societal Emotional Environments: Community-Based Interventions, Public Policy, and Environmental Determinants)

17 pages, 294 KB

Open AccessArticle

Beyond Belief: Immigrant Youths’ Socially Constructed Climate Change Risk Perceptions and Implications for Climate Communication and Public Health

by Md Badrul Hyder, Ranjan Datta, Didem Erman, Mozharul Islam, Mustahseem Chowdhury, Ruksana Rashid and Tanvir C. Turin

Int. J. Environ. Res. Public Health 2026, 23(9), 1155; https://doi.org/10.3390/ijerph23091155 - 5 Sep 2026

Abstract

Climate change perception among youth has gained increasing scholarly attention; however, immigrant youth remain underrepresented in empirical research despite navigating climate change impacts across multiple sociocultural and geopolitical contexts. This study investigates (1) immigrant youths’ beliefs about climate change, (2) how climate risks [...] Read more.

Climate change perception among youth has gained increasing scholarly attention; however, immigrant youth remain underrepresented in empirical research despite navigating climate change impacts across multiple sociocultural and geopolitical contexts. This study investigates (1) immigrant youths’ beliefs about climate change, (2) how climate risks are perceived across space and time, and (3) how they construct their climate change beliefs and associated risks. Drawing on Social Constructivism, and Risk Perception Theory, the study employs a qualitative descriptive design using eight focus group discussions with 41 immigrant youth aged 14–18 in Calgary, Canada. Reflexive thematic analysis reveals that immigrant youth widely recognise climate change as real and intensifying, with beliefs shaped through lived and observed environmental experiences, social interaction, family narratives, and transnational comparisons rather than abstract scientific reasoning alone. Climate risk perception emerges as complex and relational. Participants associated climate change with impacts on health, wellbeing, food security, and everyday life; however, they often perceived its most severe consequences as temporally and spatially distant. This produces a notable “belief–risk gap,” where acceptance of climate change does not translate into a strong sense of personal vulnerability or urgency. Risk perceptions are mediated by everyday experiences, institutional trust in the host country, and comparisons with other global crises. The findings highlight the critical role of transnational experiences in shaping climate understanding and advance an integrated interpretation linking socially constructed climate knowledge with perceptions of risk and psychological distance, with implications for climate communication and public health communication strategies for immigrant youth. Full article

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