International Journal of Environmental Research and Public Health

15 pages, 287 KB

Open AccessArticle

Sustained Telehealth Engagement in Chronic Disease Management in Jordan: A Qualitative Study of Patient Experiences

by Ahmad Rajeh Saifan, Ahmed Yahya Ayoub, Ibtisam A. Alarabyat, Zyad Saleh, Dana Anwer Abujaber, Nabeel Al-Yateem, Khulud Ahmad Rezq, Noor Hafiz Saleem, Eman Mohammed Amin, Osama Al-Kouri and Mohammad Naser Abunasrah

Int. J. Environ. Res. Public Health 2026, 23(10), 1243; https://doi.org/10.3390/ijerph23101243 (registering DOI) - 23 Sep 2026

Abstract

Background: Telehealth can improve access to chronic disease care, but how patients maintain engagement beyond initial adoption remains insufficiently understood in Middle Eastern settings. Methods: This exploratory qualitative study interviewed 24 adults with chronic conditions receiving telehealth-supported care across three military/private hospitals in [...] Read more.

Background: Telehealth can improve access to chronic disease care, but how patients maintain engagement beyond initial adoption remains insufficiently understood in Middle Eastern settings. Methods: This exploratory qualitative study interviewed 24 adults with chronic conditions receiving telehealth-supported care across three military/private hospitals in Jordan. Participants had used telehealth for at least three months. Interviews were conducted in Arabic, transcribed verbatim, translated into English with back-translation quality checks, and analyzed using Braun and Clarke’s six-phase reflexive thematic analysis; NVivo 15 supported data organization. Results: Five interrelated interpretive patterns were identified: reduced physical access work alongside new connection and financial burdens; family-supported autonomy; reconfigured self-monitoring and preparation; relational reassurance alongside limits when physical examination was needed; and trust shaped by system reliability and coordination. Conclusions: The findings suggest that continued telehealth engagement in this Jordanian sample was associated with the balance between convenience and digital burden, family-mediated support, relational continuity, and reliable, coordinated services. Hybrid models may be appropriate but require evaluation in other settings and populations. Full article

(This article belongs to the Topic Advances in Chronic Disease Management)

41 pages, 502 KB

Open AccessReview

From Measurement to Health: A Synthesis of EMF Exposure, Biological Evidence, and Safety Guidelines in Electric Vehicles

by Peng-Hung Tsai and Xin Chen

Int. J. Environ. Res. Public Health 2026, 23(10), 1242; https://doi.org/10.3390/ijerph23101242 - 22 Sep 2026

Abstract

The expanding global adoption of electric vehicles (EVs) has raised an understudied public health concern regarding extended occupant exposure to complex electromagnetic fields (EMFs) from high-voltage components such as battery packs, electric motors, and power electronics within the enclosed vehicle cabin. This study [...] Read more.

The expanding global adoption of electric vehicles (EVs) has raised an understudied public health concern regarding extended occupant exposure to complex electromagnetic fields (EMFs) from high-voltage components such as battery packs, electric motors, and power electronics within the enclosed vehicle cabin. This study provides a risk assessment by integrating a review of international safety guidelines, recent in-cabin EMF measurements from battery electric vehicles, and current evidence on the biological and health effects of comparable EMF exposure. The synthesized data reveal that while EV magnetic fields remain well below the established safety limits, certain biological and adverse health outcomes may occur at levels measured in EV cabins. Notably, rear seat exposures frequently exceed the 0.4 µT level associated with an increased risk of childhood central nervous system tumors, while similarly weak magnetic fields can displace magnetic particles in human brain tissue, which may in turn contribute to cellular damage. Additionally, field levels near the EV footwell approach intensities reported to induce pro-inflammatory immune responses in human cells, and comparable occupational exposures are linked to higher blood pressure and poorer sleep quality. In addition, field levels tend to peak during acceleration and at higher speeds, creating conditions where maximum field exposure and driving-related stress may occur simultaneously. This dynamic closely parallels recent occupational findings showing that higher magnetic field exposure combined with mental stress significantly increases cardiovascular risks. This compounding effect represents an unexamined vulnerability for drivers that current safety frameworks do not address. Overall, the evidence suggests that magnetic field exposure during routine EV use should not be presumed harmless and highlights the need for targeted research priorities, including health tracking of frequent users, dedicated analysis of children as a vulnerable subgroup, and laboratory investigations using exposure patterns representative of real EV environments. Adopting standardized measurement protocols (e.g., IEC 62764-1:2022) and integrating new findings into future safety guidelines would further strengthen research comparability and regulatory adequacy, ultimately benefiting human health. Full article

11 pages, 1247 KB

Open AccessArticle

Serum Polychlorinated Biphenyl Burden and Prevalent Cardiovascular Disease in U.S. Adults: A Cross-Sectional Analysis Using Evidence from NHANES 1999–2002

by Ese Freeman Oghaghare and David O. Carpenter

Int. J. Environ. Res. Public Health 2026, 23(10), 1241; https://doi.org/10.3390/ijerph23101241 - 22 Sep 2026

Abstract

Background: Polychlorinated biphenyls (PCBs) persist in the environment and have been associated with cardiovascular disease (CVD). We examined whether routine cardiometabolic biomarkers statistically accounted for this association. Methods: This cross-sectional analysis used NHANES 1999–2002 data for 2815 adults aged 20 years or older. [...] Read more.

Background: Polychlorinated biphenyls (PCBs) persist in the environment and have been associated with cardiovascular disease (CVD). We examined whether routine cardiometabolic biomarkers statistically accounted for this association. Methods: This cross-sectional analysis used NHANES 1999–2002 data for 2815 adults aged 20 years or older. Lipid-adjusted total PCB burden was the sum of 21 congeners. Survey-weighted logistic regression estimated odds ratios for prevalent CVD, restricted cubic splines examined the exposure–response shape, and mediator-specific structural equation models evaluated indirect and residual pathways through CRP, HbA1c, waist circumference, central obesity, the total cholesterol/HDL ratio, and a binary high-ratio measure. Results: Weighted mean total PCB burden was 234.6 ng/g lipid, and weighted CVD prevalence was 8.9%. A 1-unit increase in the natural log of total PCB burden was associated with higher odds of prevalent CVD after full adjustment (aOR = 1.36, 95% CI: 1.01–1.84). Coronary heart disease and angina showed the clearest subtype associations. The spline analysis did not detect nonlinearity. Indirect estimates through CRP, waist circumference, and the TC/HDL ratio were negative, which is consistent with statistical suppression; estimates through the other biomarkers were small and imprecise. Conclusions: Higher serum PCB burden was associated with prevalent CVD after adjustment for major demographic and cardiometabolic factors. In cross-sectional pathway models, routine biomarkers did not account for most of this association. Longitudinal studies are needed before these statistical pathways can be interpreted as causal mechanisms. Full article

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32 pages, 1134 KB

Open AccessReview

Patient Safety in Primary Health Care: A Scoping Review of Characteristics, Thematic Dimensions, and Gaps in the Literature

by Luciano Garcia Lourenção, Luciano Silveira Pacheco de Medeiros, Daiani Modernel Xavier, Valéria Slongo de Souza, Adriana Kitajima, Adriene dos Santos Sá and Lara Helk de Souza

Int. J. Environ. Res. Public Health 2026, 23(10), 1240; https://doi.org/10.3390/ijerph23101240 - 22 Sep 2026

Abstract

Patient safety in primary health care (PHC) is a multidimensional and systemic phenomenon, although the literature retrieved under the specified search and eligibility criteria was heterogeneous and unevenly distributed across geographic contexts. This scoping review aimed to map, analyze, and synthesize how patient [...] Read more.

Patient safety in primary health care (PHC) is a multidimensional and systemic phenomenon, although the literature retrieved under the specified search and eligibility criteria was heterogeneous and unevenly distributed across geographic contexts. This scoping review aimed to map, analyze, and synthesize how patient safety is addressed in PHC by identifying the characteristics, thematic dimensions, reported or evaluated strategies, and gaps in the retrieved literature. The review followed the Joanna Briggs Institute methodological guidance and was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Searches were conducted between 1 and 15 June 2026 in PubMed/MEDLINE, Scopus, Web of Science, CINAHL, LILACS, and SciELO for original empirical publications issued from January 2016 up to the search period in Portuguese, English, or Spanish. Of 497 records identified, 107 publications met the eligibility criteria. Publications were concentrated in Europe (48.6%) and the Americas (37.4%), whereas Asia and Africa accounted for 10.3% and 3.7%, respectively. Among single-country publications, Brazil had the highest frequency (29.0% of the corpus). Quantitative studies predominated (60.7%), and 72.9% of the publications were issued between 2019 and 2024. The thematic synthesis identified seven recurring dimensions: patient safety culture; adverse events and reporting systems; medication safety and polypharmacy; assessment tools and indicators; continuing education and professional training; user participation and person-centered care; and organizational strategies and risk management. Research gaps and future directions were synthesized as a cross-cutting component. The mapped literature addresses patient safety in PHC through clinical, organizational, technological, methodological, and relational perspectives. However, heterogeneity among the publications and the absence of formal critical appraisal preclude conclusions regarding effectiveness, causal effects, comparative superiority, certainty of evidence, or applicability of the mapped strategies across different PHC contexts. Full article

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21 pages, 1163 KB

Open AccessStudy Protocol

Development of a Pandemic-Resilient Framework to Optimise Childhood Routine Immunisation and Maternal Health Services Post-COVID-19 Pandemic in Sokoto State, Nigeria: A Mixed Method Study Protocol

by Clovis Nchinjoh Sangwe, Sibusiso Frank Nkosi, Kelebogile Leah Manjinja and Wilfred Njabulo Nunu

Int. J. Environ. Res. Public Health 2026, 23(10), 1239; https://doi.org/10.3390/ijerph23101239 - 22 Sep 2026

Abstract

The COVID-19 pandemic reduced access to childhood immunisation and maternal health services in Nigeria, which already reports some of the highest maternal and child mortality rates globally. This study seeks to develop a pandemic-resilient framework to optimise these services post-pandemic. An explanatory sequential [...] Read more.

The COVID-19 pandemic reduced access to childhood immunisation and maternal health services in Nigeria, which already reports some of the highest maternal and child mortality rates globally. This study seeks to develop a pandemic-resilient framework to optimise these services post-pandemic. An explanatory sequential mixed method study design will be used, consisting of three distinct but interconnected phases. In phase 1, an analytical retrospective cohort study using administrative data from Sokoto State from 2015 to 2023 will be analysed to inform the qualitative study design. Microsoft Excel 2013 worksheets will be used to collect and export secondary data into R Statistical Software (version 4.1.2) for analysis using descriptive statistics and dynamic time-series regression. In phase 2, qualitative data collection tools will be developed based on the socio-ecological model and the Health Belief Model and refined based on the outcome of the quantitative analysis. The data will be collected using key informant interviews and focus group discussions with purposively selected participants. Thematic analysis involving deductive coding will be employed. In the final phase, the pandemic-resilient framework will be developed using Strength, Weakness, Opportunity, and Threat (SWOT) analysis; the Threat, Opportunity, Weakness, and Strength (TOWS) model; and the Build, Overcome, Explore, and Minimise (BOEM) model. The resulting framework will be validated using the Delphi technique and used to inform policy on building resilience of childhood immunisation and maternal health services during public health emergencies, which is critical for future pandemic preparedness. Full article

(This article belongs to the Section Global Health)

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23 pages, 405 KB

Open AccessArticle

Beyond the Classroom: Factors Associated with Job-Related Suicide Among Educators

by Leanne M. Confer, Beth L. McGee, Katie M. Mercer, Edward B. Mondor, Jessica S. Schwind, Hadeer Hegazy and Jacquelyn Mesenbrink-Sainz

Int. J. Environ. Res. Public Health 2026, 23(10), 1238; https://doi.org/10.3390/ijerph23101238 - 22 Sep 2026

Abstract

Going beyond the classroom, this study emphasized the well-being and support of educators, shifting focus from the traditional emphasis on students. Leveraging the National Violent Death Reporting System (NVDRS) dataset, this study identified preceding factors and salient qualitative themes based on available coroner/medical [...] Read more.

Going beyond the classroom, this study emphasized the well-being and support of educators, shifting focus from the traditional emphasis on students. Leveraging the National Violent Death Reporting System (NVDRS) dataset, this study identified preceding factors and salient qualitative themes based on available coroner/medical examiner and police reports of primary and secondary educator suicides in the United States. Factors related to having a job-related problem among educators who died by suicide included the COVID-19 pandemic, age, being male, being married, teaching special education, experiencing depressed mood, financial problems, and/or the presence of criminal-legal problems (n = 1655). Additionally, qualitative themes extracted among those with a job-related problem preceding suicide (n = 136) included conduct-related issues or related investigations, the COVID-19 pandemic, financial strain, teaching-related issues, employment changes, and mental health problems. The findings of this study are connected to self-efficacy theory and teacher identity, and to broader global challenges among educators. We provide policy recommendations based on our findings for this important occupational group. Full article

(This article belongs to the Special Issue Research on Suicide Assessment, Prevention and Management)

22 pages, 1025 KB

Open AccessArticle

Associations of Cardiometabolic Risk Burden, Metabolic Syndrome, and Functional Exercise Capacity in Thai Older Adults: A Cross-Sectional Study

by Orachorn Boonla, Nutsupa Singhasoot, Sudarat Boonpitak, Oranat Sukkho, Puttipong Poncumhak, Promtpong Anuchitchanchai and Piyapong Prasertsri

Int. J. Environ. Res. Public Health 2026, 23(9), 1237; https://doi.org/10.3390/ijerph23091237 - 18 Sep 2026

Abstract

Metabolic syndrome (MetS) is highly prevalent among older adults and has been associated with impaired physical function and reduced exercise capacity. However, the relationships of binary MetS status and cumulative MetS component burden with different dimensions of functional capacity remain unclear. This cross-sectional [...] Read more.

Metabolic syndrome (MetS) is highly prevalent among older adults and has been associated with impaired physical function and reduced exercise capacity. However, the relationships of binary MetS status and cumulative MetS component burden with different dimensions of functional capacity remain unclear. This cross-sectional study examined these associations and evaluated whether they were attenuated after adjustment for body mass index (BMI) among community-dwelling Thai older adults. A total of 182 participants aged ≥ 60 years were included. The outcomes represented complementary dimensions of functional capacity: lower-extremity functional performance assessed using the Five-Times Sit-to-Stand Test (5TSTS), stepping endurance assessed using the 2-Minute Step Test (2MST), cadence-derived estimated oxygen uptake, and externally paced walking capacity assessed using the Incremental Shuttle Walk Test (ISWT). Overall, 55 participants (30.2%) had MetS. Functional outcomes did not differ significantly between participants with and without MetS. After false-discovery-rate (FDR) correction, BMI was inversely correlated with ISWT distance, waist circumference was correlated with slower 5TSTS performance and shorter ISWT distance, and cumulative MetS component burden was inversely correlated with ISWT distance. Binary MetS status was not independently associated with any outcome after FDR correction. In Model 1, each additional MetS component was associated with a 0.27-s longer 5TSTS completion time (95% CI: 0.07 to 0.46; p = 0.008; q = 0.030) and a 27.80-m shorter ISWT distance (95% CI: −45.01 to −10.59; p = 0.002; q = 0.014). Both associations were attenuated and no longer statistically significant after additional adjustment for BMI. These findings suggest that cumulative MetS burden was associated with sit-to-stand and walking performance before BMI adjustment. Both associations were attenuated and no longer statistically significant after additional adjustment for BMI. Full article

(This article belongs to the Special Issue Novel Exercise and Nutrition Interventions for Better Ageing and Preventing Metabolic Conditions)

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18 pages, 596 KB

Open AccessArticle

Community Perspectives on Multilevel Socioecological Influences on Cancer Prevention Engagement in Houston, Texas: A Qualitative Study

by Veronica Ajewole-Mwema, Erika Figueroa-Solis, Maria C. Mejia, Grace Loudd, Ivy O. Poon, Assata Richards and Uche Ndefo

Int. J. Environ. Res. Public Health 2026, 23(9), 1236; https://doi.org/10.3390/ijerph23091236 - 18 Sep 2026

Abstract

Background: Predominantly African American communities continue to experience challenges in cancer prevention, screening, and outcomes. This study explored perceptions, experiences, and challenges related to cancer prevention and screening among adults recruited through a community engagement initiative in a predominantly African American urban community [...] Read more.

Background: Predominantly African American communities continue to experience challenges in cancer prevention, screening, and outcomes. This study explored perceptions, experiences, and challenges related to cancer prevention and screening among adults recruited through a community engagement initiative in a predominantly African American urban community in Houston, Texas. Methods: Four virtual focus groups were conducted between May 2021 and August 2022 with 35 participants. Sessions addressed prostate cancer, breast cancer, and general cancer prevention. Transcripts were analyzed using thematic analysis, and findings were reported in accordance with COREQ guidelines. Final themes were interpreted using the Socioecological Model. Results: Four interconnected themes reflected individual/interpersonal, healthcare/organizational, community, and structural/policy factors: (1) personal and family experiences and social support; (2) healthcare experiences and trust; (3) structural and financial challenges; and (4) community engagement, education, and advocacy. Family support, trusted providers, community resources, and culturally relevant education facilitated prevention engagement, while negative healthcare experiences, insurance restrictions, costs, and complicated healthcare navigation created challenges. Conclusions: Cancer prevention engagement was shaped by interacting influences across socioecological levels. Multilevel, culturally responsive approaches that strengthen trust and community partnerships while addressing financial, healthcare access, and structural challenges may improve cancer prevention and screening engagement. Full article

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22 pages, 363 KB

Open AccessArticle

Listening to Youth Voices: Student-Generated Recommendations for Suicide Prevention and Mental Wellbeing in Higher Educational Institutions—A Qualitative Round-Table Dialogue from India

by Narcilina Kalita, Abhishek Karishiddimath, Aditya Shetty Jnana, Angelina Francis, Tanvi Agarwal, Jomy T. Jose and Seema Mehrotra

Int. J. Environ. Res. Public Health 2026, 23(9), 1235; https://doi.org/10.3390/ijerph23091235 - 17 Sep 2026

Abstract

Background: Student suicide has emerged as a major public health concern, particularly in India, where rising suicide rates have intensified calls for higher education institutions to play a central role in prevention. Although whole-university and participatory approaches are increasingly advocated, evidence on [...] Read more.

Background: Student suicide has emerged as a major public health concern, particularly in India, where rising suicide rates have intensified calls for higher education institutions to play a central role in prevention. Although whole-university and participatory approaches are increasingly advocated, evidence on students’ priorities for institutional action remains limited. This study explored students’ perspectives on actions that higher education institutions can take to promote mental wellbeing and reduce suicide risk. Methods: An exploratory qualitative study was conducted using document analysis of written group responses generated during a large-scale participatory round-table dialogue on suicide prevention in Bengaluru, India. A total of 212 undergraduate and postgraduate students from 29 higher education institutions participated. Written responses from 19 discussion groups were analysed using reflexive thematic analysis. Results: Four overarching themes and 13 subthemes were identified: strengthening institutional mental health support systems, building mental health capacity across the institutional ecosystem, humanising academic and institutional systems, and creating wellbeing-oriented campus environments and cultures. Students emphasised accessible mental health services, faculty and peer capacity building, compassionate institutional policies, academic reforms, and campus environments that foster belonging and holistic wellbeing. Conclusions: The findings support socio-ecological and whole-university approaches to student mental health and suicide prevention. By centring students’ recommendations, the study provides practical insights to inform participatory, contextually relevant institutional policies and campus-based suicide prevention strategies. Full article

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

20 pages, 313 KB

Open AccessArticle

Knowledge, Attitudes, Beliefs, and Intention to Support Future Legalization of Medical Cannabis Among Vietnamese Nursing Students: A Convergent Parallel Mixed-Methods Study

by Bao Thy Vuong, Uyen Thi To Nguyen, Thanh Thao Trang Le, Nguyen Cong Cuu and Cua Ngoc Le

Int. J. Environ. Res. Public Health 2026, 23(9), 1234; https://doi.org/10.3390/ijerph23091234 - 17 Sep 2026

Abstract

(1) Background: Medical cannabis (MC) is attracting global attention due to its therapeutic potential; however, the preparedness of nursing students in countries where MC remains banned is not well understood. This convergent parallel mixed-methods study aimed to examine the knowledge, attitudes, beliefs and [...] Read more.

(1) Background: Medical cannabis (MC) is attracting global attention due to its therapeutic potential; however, the preparedness of nursing students in countries where MC remains banned is not well understood. This convergent parallel mixed-methods study aimed to examine the knowledge, attitudes, beliefs and intention to support the future legalization of MC among Vietnamese nursing students, as well as to identify factors associated with this intention. (2) Methods: A cross-sectional survey was conducted among 422 nursing students selected via simple random sampling at Dong Thap Medical College, Vietnam, alongside in-depth interviews with 10 purposefully selected participants. Data were analyzed using descriptive statistics, ordinal logistic regression, and thematic analysis. (3) Results: Nursing students achieved 56.5% of the maximum knowledge score, while attitude and belief scores were 73.5% and 68.1% of the respective maximums. Notably, 56.2% of students remained undecided about supporting the future legalization of MC. Greater knowledge and stronger beliefs regarding the therapeutic benefits and safety of MC were independently associated with higher intention to support future legalization, whereas general attitudes were not statistically significant in the multivariable model. Four core qualitative themes emerged—therapeutic value, safety and ethical concerns, professional readiness, and social, legal, and organizational impacts—providing rich contextual explanations for the quantitative findings. (4) Conclusions: Intention to support the future legalization of MC depends not only on individual knowledge and beliefs but also on confidence in evidence-based practice, professional preparedness, and regulatory oversight. Integrating education on MC into nursing curricula can enhance future workforce readiness and support evidence-based healthcare policy. Full article

12 pages, 282 KB

Open AccessArticle

Do Hospice Gardens Need a Guide? Comparing Guided and Unguided Forest Bathing for Wellbeing, Nature Connectedness and Heart Rate Variability: A Pilot Study

by Yangang Xing, Rachel Pitzettu and Kirsten McEwan

Int. J. Environ. Res. Public Health 2026, 23(9), 1233; https://doi.org/10.3390/ijerph23091233 - 17 Sep 2026

Abstract

Nature-based interventions may support health and wellbeing, but evidence directly comparing guided and less-resource-intensive formats in clinical populations remains limited. This non-randomised pilot study examined one-hour guided forest bathing and a matched, lightly facilitated unguided nature walk in hospice gardens. Seventeen adult hospice [...] Read more.

Nature-based interventions may support health and wellbeing, but evidence directly comparing guided and less-resource-intensive formats in clinical populations remains limited. This non-randomised pilot study examined one-hour guided forest bathing and a matched, lightly facilitated unguided nature walk in hospice gardens. Seventeen adult hospice service users selected either the guided (n = 8) or unguided (n = 9) session. The Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS), Inclusion of Nature in Self (INS) scale, and heart rate variability, indexed by the standard deviation of normal-to-normal intervals (SDNN), were assessed before and immediately after the sessions. In 2 × 2 mixed analyses of variance, WEMWBS and INS scores improved significantly over time, but neither outcome showed a significant group-by-time interaction. SDNN showed neither a significant time effect nor a group-by-time interaction; its significant between-group effect was consistent with baseline differences. Exploratory Reliable Change Index analyses identified improvement for some individuals, although these findings require cautious interpretation. Both formats were associated with short-term improvements in self-reported wellbeing and nature connectedness, but the design does not establish causality or equivalence. A lightly facilitated nature walk may warrant evaluation as an accessible, lower-resource addition to palliative-care programmes. Full article

(This article belongs to the Special Issue Nature Immersion, Health, and the Community)

23 pages, 1623 KB

Open AccessReview

Tourism Intensity, Salutogenic Settings, and Population Health in Alpine Destinations: A Scoping Review with Implications for South Tyrol

by Christian J. Wiedermann, Patrick Rina, Giuliano Piccoliori and Doris Hager von Strobele-Prainsack

Int. J. Environ. Res. Public Health 2026, 23(9), 1232; https://doi.org/10.3390/ijerph23091232 - 17 Sep 2026

Abstract

Background/Objectives: Alpine destinations combine high tourism intensity with location-bound natural health resources that position them as potentially salutogenic settings; however, the evidence connecting tourism, public health, and well-being in this context has never been systematically mapped. This scoping review charts the concepts, evidence, [...] Read more.

Background/Objectives: Alpine destinations combine high tourism intensity with location-bound natural health resources that position them as potentially salutogenic settings; however, the evidence connecting tourism, public health, and well-being in this context has never been systematically mapped. This scoping review charts the concepts, evidence, and knowledge gaps at this intersection, focusing on South Tyrol (Italy). Methods: This review followed the Joanna Briggs Institute methodology and PRISMA-ScR. Five databases (PubMed, Embase, CINAHL, Web of Science, and Scopus) were searched, supplemented by Publish or Perish searches of Google Scholar, Crossref, and OpenAlex. Records were screened against a Population–Concept–Context framework, with geographic restrictions applied at screening. Data were synthesized descriptively without aggregating effect estimates. Results: Of 4163 records identified, 3343 were screened, and 128 were assessed in full text; 33 sources were included (22 conceptual, 11 empirical), divided almost evenly between tourism and health science journals. Empirical evidence has concentrated on residents’ quality of life and subjective well-being, with findings differing by outcome, scale, and tourism intensity. None of the included studies measured mental health outcomes. Only four empirical studies originated from the Alpine region, each addressing a different level of the destination system, and none from South Tyrol; evidence on tourism workers and older populations was exclusively conceptual. Conclusions: The field rests mainly on conceptual work distributed across two largely separate studies. The evidence gap map identifies measured resident health outcomes, worker health, and population-specific groups as research priorities for tourism-intensive Alpine regions, for which South Tyrol offers a suitable setting. Full article

(This article belongs to the Special Issue Healthy Spaces, Healthy Lives: Analyzing the Role of Built Environment on Human Health)

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12 pages, 313 KB

Open AccessArticle

Changes in Aerobic and Muscle-Strengthening Physical Activity and Self-Reported Morbidity Among University Students During the COVID-19 Pandemic: A Cross-Sectional Study

by Juliana de Souza Soares, Maria Isabel Martins Mourão-Carvalhal and Sandra Celina Fernandes Fonseca

Int. J. Environ. Res. Public Health 2026, 23(9), 1231; https://doi.org/10.3390/ijerph23091231 - 17 Sep 2026

Abstract

The COVID-19 pandemic substantially affected lifestyle behaviors among university students, potentially increasing their vulnerability to chronic noncommunicable diseases (NCDs). This cross-sectional study investigated associations between self-reported changes in the frequency of moderate-intensity aerobic physical activity (MPA) and muscle-strengthening physical activity (MSPA) and self-reported [...] Read more.

The COVID-19 pandemic substantially affected lifestyle behaviors among university students, potentially increasing their vulnerability to chronic noncommunicable diseases (NCDs). This cross-sectional study investigated associations between self-reported changes in the frequency of moderate-intensity aerobic physical activity (MPA) and muscle-strengthening physical activity (MSPA) and self-reported morbidity among university students. Data were collected through an online questionnaire from 1150 students at a private university in Rio de Janeiro, Brazil, between August 2021 and April 2022. Morbidity was defined as a self-reported medical diagnosis of hypertension, type 2 diabetes mellitus, and/or cardiovascular disease. Separate and mutually adjusted binary logistic regression models were controlled for sex, age, smoking, sugar consumption, and fat consumption. Morbidity prevalence was 9.4%. In separate adjusted models, MPA (global p = 0.046) and MSPA (global p = 0.016) were associated with morbidity. Compared with no engagement, all MPA engagement categories were linked to lower odds of morbidity (ORs = 0.41–0.42), as were increased (OR = 0.41; 95% CI: 0.22–0.75) and maintained MSPA (OR = 0.44; 95% CI: 0.24–0.81). In the mutually adjusted model, the overall associations were attenuated for MPA (p = 0.442) and MSPA (p = 0.127), although increased MSPA remained individually associated with lower odds of morbidity (OR = 0.42; 95% CI: 0.19–0.93; p = 0.032). These findings should be interpreted cautiously, as the cross-sectional design precludes establishing temporal direction and reverse causality is possible. Full article

(This article belongs to the Special Issue Physical Activity and Its Association with Health in University Students)

10 pages, 452 KB

Open AccessArticle

Validity of EHR-Derived Phenotypes for Outcome Ascertainment in the PRESERVE Trial: Implications for Embedding RCTs in Healthcare Systems

by Sarah M. Leatherman, Sonia T. Anand, Michael J. Davenport, Jade Fiotto, Paul A. Monach, Steven D. Weisbord and Ryan E. Ferguson

Int. J. Environ. Res. Public Health 2026, 23(9), 1230; https://doi.org/10.3390/ijerph23091230 - 17 Sep 2026

Abstract

Randomized controlled trials (RCTs) are crucial for determining effective interventions but are costly, time-consuming, and complex. Electronic health records (EHRs) offer the potential to enhance research using clinical data, reducing costs and improving efficiency. We evaluated the accuracy of EHR-derived phenotypes for endpoint [...] Read more.

Randomized controlled trials (RCTs) are crucial for determining effective interventions but are costly, time-consuming, and complex. Electronic health records (EHRs) offer the potential to enhance research using clinical data, reducing costs and improving efficiency. We evaluated the accuracy of EHR-derived phenotypes for endpoint identification versus RCT-outcome ascertainment in the PRESERVE trial (NCT01467466), comparing sodium bicarbonate vs. sodium chloride and oral acetylcysteine vs. placebo in preventing serious adverse outcomes and contrast-associated acute kidney injury (CIAKI) after angiography. PRESERVE outcomes were compared with EHR data from the Veterans Affairs Corporate Data Warehouse. Real-world data (RWD) phenotypes captured serious adverse events within 90 days post-angiography, including death, dialysis need, and persistent kidney decline. Sensitivity, specificity, and percent agreement were calculated using trial outcomes as the gold standard. Among 4,196 PRESERVE patients, 95% had outcomes assessed. RWD outcomes showed mixed accuracy: 100% sensitivity/specificity for death; high sensitivity for primary composite events (71.2%), dialysis (75.0%), and hospitalization (78.1%); and low sensitivity for CIAKI (45.8%) and persistent kidney decline (40.5%). Substituting RWD outcomes into primary analysis produced conclusions matching the RCT conclusions. EHR phenotypes can substitute for traditional outcome collection, given adequate planning and validation. Despite variable accuracy, RWD outcomes yielded similar conclusions to RCTs, supporting their use for trial efficiency and reducing costs. Full article

(This article belongs to the Special Issue Real-World Data Analytics and Evidence Generation for Chronic Disease and Health Systems)

11 pages, 288 KB

Open AccessEssay

Menstrual Hygiene as a Human Rights and Health Equity Issue: Inequality, Access, and Human Dignity Among Women

by Hazrina Adelia, Nur’aini Nur’aini, Feni Betriana, Firnaliza Rizona and Gil P. Soriano

Int. J. Environ. Res. Public Health 2026, 23(9), 1229; https://doi.org/10.3390/ijerph23091229 - 16 Sep 2026

Abstract

Lack of health awareness and access to menstrual hygiene goods is a challenging issue in some parts of the world, creating a situation where menstrual hygiene becomes a privilege. This issue reflects the broader social determinants of health and gender-based inequities affecting women. [...] Read more.

Lack of health awareness and access to menstrual hygiene goods is a challenging issue in some parts of the world, creating a situation where menstrual hygiene becomes a privilege. This issue reflects the broader social determinants of health and gender-based inequities affecting women. This essay discusses why hygiene access remains unequal for women and outlines ways to address the disparity. The sources of this essay draw on the relevant literature in healthcare focusing on women’s hygiene practices. Various factors, including socio-economic-cultural factors and hygiene education, were identified to trigger hygiene behaviors. Strategies to enhance menstrual hygiene include structured and targeted education, school-based programs and menstrual hygiene management, and community-led and WASH approaches. Inadequate access to hygiene products and sanitation facilities is linked to poverty, educational disparities, stigma, and structural inequities that compromise women’s health, dignity, and social participation. Menstrual hygiene should be recognized as a fundamental human right and a public health necessity. Multisectoral interventions involving healthcare providers, educators, communities, and policymakers are essential to reduce hygiene inequities and promote women’s dignity and health equity. Full article

28 pages, 792 KB

Open AccessEssay

Identifying the Primary Driver of Rising Cancer Incidence—A Path to Prevention

by Jian Gao

Int. J. Environ. Res. Public Health 2026, 23(9), 1228; https://doi.org/10.3390/ijerph23091228 - 16 Sep 2026

Abstract

Cancer incidence has risen sharply over the past century. Despite enormous investments in cancer research and treatment, cancer continues to inflict immense human suffering and premature mortality. If current trends continue, nearly half of the populations in developed countries will develop cancer during [...] Read more.

Cancer incidence has risen sharply over the past century. Despite enormous investments in cancer research and treatment, cancer continues to inflict immense human suffering and premature mortality. If current trends continue, nearly half of the populations in developed countries will develop cancer during their lifetime by 2040. Given the persistent challenges in treating solid tumors that cannot be surgically removed, primary prevention has become more imperative than ever. Effective prevention, however, requires a clear understanding of the primary driver behind the dramatic rise in cancer incidence. Identifying this driver has been difficult because numerous risk factors may contribute to carcinogenesis directly or indirectly. To overcome this challenge, this study focuses on what has primarily driven the increase in cancer incidence rate over the past eight decades, rather than what causes cancer. To achieve this objective, the present study classified all potential root causes into six categories—genetics, aging, lifestyle, nutrition, psychological stress, and environmental exposures—and evaluated their biological mechanisms, exposure scales, and probabilistic dependencies (temporal correlations) in relation to the increase in cancer incidence rate. Based on established criteria for causal inference, this study finds that the chronic accumulation of toxic chemicals in the human body through food, water, air, and consumer products applied to the skin is most likely the principal driver of the escalating incidence of cancer over the past century. Therefore, reversing this upward trend will require public health policies that prioritize reducing exposure to these ubiquitous toxic chemicals. Full article

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22 pages, 534 KB

Open AccessArticle

Gender-Based Discrimination and Its Associations with Mental Wellbeing, Self-Efficacy and Career Choice Among Medical Students in Latvia: A Cross-Sectional Study

by Ērika Markina and Laura Valaine

Int. J. Environ. Res. Public Health 2026, 23(9), 1227; https://doi.org/10.3390/ijerph23091227 - 16 Sep 2026

Abstract

Gender-based discrimination in medical education remains a critical yet overlooked issue that may adversely affect the mental health and professional development of future physicians. This study investigated the prevalence of such experiences and their association with mental wellbeing, self-esteem, self-efficacy and career choices [...] Read more.

Gender-based discrimination in medical education remains a critical yet overlooked issue that may adversely affect the mental health and professional development of future physicians. This study investigated the prevalence of such experiences and their association with mental wellbeing, self-esteem, self-efficacy and career choices among the medical students at Rīga Stradiņš University in Latvia. Using a cross-sectional design, 294 medical students completed a survey incorporating the gender discrimination questionnaire, Rosenberg Self-Esteem Scale, General Self-Efficacy Scale, PHQ-9 and GAD-7. Overall, 36.05% (n = 106) of respondents self-identified as personally having experienced gender-based discrimination. The most encountered or witnessed discriminatory behaviours were inappropriate gender-related jokes or comments and patronizing pet names. After adjustment for age, self-reported gender, and study year, self-reported discrimination was associated with higher odds of clinically significant depressive symptoms and anxiety, as well as lower self-esteem and self-efficacy. It was also associated with a higher relative likelihood of having no current specialty option, uncertainty about pursuing residency, or no intention to pursue residency. These findings indicate the need to address gender-based discrimination within academic and clinical training environments to support student wellbeing and professional development. Full article

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

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21 pages, 1416 KB

Open AccessSystematic Review

The Organization of Home Palliative Cancer Care by Primary Health Care: A Systematic Review

by Marcelle Miranda da Silva, Thayna de Assis Barros S. Thiago, Maria da Conceição Albernaz Crespo, Audrei Castro Telles, Cristina Lavareda Baixinho, Andreia Costa and Eunice Sá

Int. J. Environ. Res. Public Health 2026, 23(9), 1226; https://doi.org/10.3390/ijerph23091226 - 16 Sep 2026

Abstract

Background: Home-based palliative cancer care coordinated by primary care has been proposed as a strategy to improve access, continuity, and alignment with patient preferences, but its organizational characteristics and effects remain insufficiently synthesized. Aim: The aim was to characterize the organizational components of [...] Read more.

Background: Home-based palliative cancer care coordinated by primary care has been proposed as a strategy to improve access, continuity, and alignment with patient preferences, but its organizational characteristics and effects remain insufficiently synthesized. Aim: The aim was to characterize the organizational components of home-based palliative care models for patients with advanced cancer coordinated by primary care and to evaluate the effects of these models on patient-related and health system outcomes. Methods: Following a Cochrane review protocol, primary studies were searched in MEDLINE, Scopus, LILACS, Web of Science, the Cochrane Library, and CINAHL to identify randomized controlled trials and analytical observational studies published between January 2018 and May 2026. Results: The narrative synthesis included seven analytical observational studies conducted in high-income countries, most classified as 4b—settings with advanced and integrated palliative care. Across these studies, recurrent organizational components included case management, structured care pathways prioritizing home-based care, and mechanisms linking primary care with specialized palliative care teams. Reported outcomes were associated with potential system-level benefits, such as fewer emergency department visits and higher proportions of home death, but these findings are subject to residual confounding, heterogeneity, and indirectness, which limit confidence in the evidence. Conclusion: The available evidence, which was restricted to seven observational studies conducted in countries with highly developed palliative care systems, suggests that certain organizational components may support home-based palliative cancer care coordinated by primary care. However, substantial methodological limitations, the absence of patient-centred outcomes, and the lack of studies from low- and middle-income countries indicate that further research is needed before drawing practice or policy recommendations. Full article

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31 pages, 1306 KB

Open AccessReview

A Scoping Review of Psychological Distress Outcomes in NICU Healthcare Providers

by Pamela A. Geller, Andrea L. Nelson, Leah Sodowick, Hisham Nsier, Shannon G. Hanson, Sage N. Saxton, Chavis A. Patterson, Miller Shivers, Rochelle Steinwurtzel and Melissa Maye

Int. J. Environ. Res. Public Health 2026, 23(9), 1225; https://doi.org/10.3390/ijerph23091225 - 16 Sep 2026

Abstract

The Neonatal Intensive Care Unit (NICU) is a demanding work environment that provides medical care for acutely ill and premature infants while supporting parents experiencing significant stress and psychological distress. This scoping review is the first to examine quantitative research across a broad [...] Read more.

The Neonatal Intensive Care Unit (NICU) is a demanding work environment that provides medical care for acutely ill and premature infants while supporting parents experiencing significant stress and psychological distress. This scoping review is the first to examine quantitative research across a broad range of psychological constructs, including burnout, traumatic stress, moral distress, and other distress outcomes such as mental health, somatic symptoms and physiological indicators, among NICU healthcare providers. Following PRISMA-ScR guidelines, PsycINFO, Ovid via MEDLINE, Embase, and CINAHL were searched. Two searches (2021 and 2024) identified 1889 unique records, with 76 publications from 34 countries meeting inclusion criteria (i.e., original quantitative research assessing work-related psychological consequences with NICU healthcare providers) and exclusion criteria (i.e., intervention studies; qualitative studies; NICU provider data inseparable from aggregate results). Most participants were White, female NICU nurses. Across studies, psychological distress was most often reported in the low-to-moderate range, with considerable variability within and across studies making it difficult to clearly summarize the average levels of distress and associations that best predict psychological distress outcomes. Consistent differences by healthcare profession or sociodemographic characteristics were not identified, largely because these factors were infrequently assessed, or findings were inconsistent. Environmental factors were more frequently assessed and reported to be associated with psychological distress in NICU providers. The current evidence base is constrained by cross-sectional designs, inconsistent practices, and conceptual overlap across psychological constructs. Future research should prioritize longitudinal designs, standardized methodologies, and more representative samples across professions. In the interim, unit-level assessment and targeted interventions may help address modifiable work-related stressors, individual responses to stressors, and support NICU healthcare providers’ well-being. Full article

(This article belongs to the Special Issue Psychosocial Risk Factors and Mental Health Outcomes Among Healthcare Workers: An Occupational Health Perspective)

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International Journal of Environmental Research and Public Health

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