International Journal of Environmental Research and Public Health

19 pages, 547 KB

Open AccessPerspective

Adverse Drug Reaction Trajectories in Older Adults: From Pharmacological Vulnerability to Clinical Complexity

by Fulvio Lauretani, Crescenzo Testa, Marco Salvi, Irene Zucchini, Aurora Merolla, Patrizia Rovere-Querini and Marcello Maggio

Int. J. Environ. Res. Public Health 2026, 23(7), 849; https://doi.org/10.3390/ijerph23070849 (registering DOI) - 29 Jun 2026

Abstract

Background: Adverse drug reactions (ADRs) represent a major and often underestimated source of morbidity, hospitalization, and functional decline in older adults. The convergence of age-related pharmacokinetic and pharmacodynamic changes, multimorbidity, polypharmacy, and frailty creates a clinical environment in which ADR risk is not [...] Read more.

Background: Adverse drug reactions (ADRs) represent a major and often underestimated source of morbidity, hospitalization, and functional decline in older adults. The convergence of age-related pharmacokinetic and pharmacodynamic changes, multimorbidity, polypharmacy, and frailty creates a clinical environment in which ADR risk is not static but evolves along progressive trajectories—from mild, early manifestations toward severe, potentially irreversible outcomes. Understanding these trajectories is essential for rational geriatric prescribing. Methods: This narrative review synthesizes evidence from epidemiological studies, systematic reviews, Cochrane analyses, and clinical trials published between 2000 and 2025, focusing on adults aged 65 years and older with two or more chronic conditions. Sources were identified through a structured, non-systematic literature search of PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus using the terms ‘adverse drug reactions’, ‘polypharmacy’, ‘multimorbidity’, ‘frailty’, ‘deprescribing’, and ‘pharmacokinetics’ in older adults, alone and in combination. Evidence quality was assessed narratively, distinguishing trial evidence from observational and expert consensus data. Results: ADRs in older adults are best classified using complementary frameworks—the augmented Type A to withdrawal Type E and failure-of-therapy Type F taxonomy (Types A–F), the Dose-Time-Susceptibility (DoTS) classification, and the EIDOS mechanistic scheme—which together capture the heterogeneity of drug-related harm in this population. Age-related pharmacokinetic changes (altered absorption, increased volume of distribution of lipophilic drugs, reduced hepatic and renal clearance) and pharmacodynamic shifts (heightened receptor sensitivity, baroreflex impairment, increased blood–brain barrier permeability) interact with polypharmacy and frailty to amplify ADR trajectories from mild to severe. Anticholinergic burden, prescribing cascades, and inappropriate polypharmacy function as structural accelerators of these trajectories. Medication review and deprescribing improve prescribing quality but evidence for hard outcome benefits remains of low to very low certainty. Emerging AI-enabled digital tools show promising accuracy for identifying frailty and pharmacological vulnerability, but this performance relates to frailty classification and has not yet been shown to prevent ADR trajectories; they require validation for routine clinical use. Conclusions: Recognizing ADRs in older adults as dynamic trajectories rather than isolated events repositions prescribing review and deprescribing from optional to essential clinical acts. An integrated approach combining pharmacological vigilance, comprehensive geriatric assessment, structured deprescribing, and emerging digital decision-support tools offers the most realistic pathway to reduce the trajectory-related burden of drug-related harm in complex older patients. Full article

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15 pages, 3253 KB

Open AccessArticle

Sex Differences in Perceptions and Behavioral Context of Electronic Cigarette Use: A Cross-Sectional Study in Jeddah, Saudi Arabia

by Shada Alodaini, Mohammed Ahmed Alzahrani, Mohammed Awad Algarni, Wajdi Hussain Alamri, Ahmed H. Alasimi, Faisal A. Turkestani, Alaa Bugis and Jameel Hakeem

Int. J. Environ. Res. Public Health 2026, 23(7), 848; https://doi.org/10.3390/ijerph23070848 (registering DOI) - 29 Jun 2026

Abstract

Importance Understanding sex-based differences in vaping-related perceptions and behaviors is critical for informing targeted public health interventions, particularly in regions where e-cigarette use is emerging. Objective To examine sex differences across multiple vaping-related domains, including behavioral context, perceived utility, risk perception, social norms, [...] Read more.

Importance Understanding sex-based differences in vaping-related perceptions and behaviors is critical for informing targeted public health interventions, particularly in regions where e-cigarette use is emerging. Objective To examine sex differences across multiple vaping-related domains, including behavioral context, perceived utility, risk perception, social norms, and media influence among young adults in Saudi Arabia. Design, Setting, and Participants This cross-sectional study was conducted among 388 young adults aged 18–24 years in Jeddah, Saudi Arabia. Data were collected using a structured, theory-informed questionnaire adapted from established tobacco-use instruments. Exposure Sex (male vs. female), monthly income, and marital status. Main Outcomes and Measures Domain-specific scores were derived from 12 vaping-related items grouped into 5 conceptual domains. Scores were categorized into low, medium, and high levels using tertiles. Associations were assessed using ordinal logistic regression. Results Among 388 participants, 228 (58.8%) were male and 160 (41.2%) were female. Males consistently demonstrated higher levels of endorsement across domains. In adjusted models, females had significantly lower odds of higher domain scores across situational use (OR, 0.62; 95% CI, 0.45–0.86), perceived utility (OR, 0.58; 95% CI, 0.41–0.81), risk perception (OR, 0.54; 95% CI, 0.39–0.75), social norms (OR, 0.63; 95% CI, 0.45–0.88), and media influence (OR, 0.49; 95% CI, 0.35–0.69). Lower income was also associated with reduced endorsement across multiple domains. Conclusions and Relevance Significant sex-based differences exist in vaping-related perceptions and behaviors among young adults. These findings highlight the need for sex-specific prevention strategies addressing perceived benefits and marketing exposure in emerging vaping contexts. Full article

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12 pages, 262 KB

Open AccessProtocol

Protocol for a Systematic Review of Psychosocial Factors That Predict Mental Health Among Males Living with Type 2 Diabetes

by Mokoena Maepa, Mqemane Tshababa, Nkarenbi Juliette Bih and Sello Mantse

Int. J. Environ. Res. Public Health 2026, 23(7), 847; https://doi.org/10.3390/ijerph23070847 (registering DOI) - 27 Jun 2026

Abstract

Psychosocial factors such as diabetes distress, depression, anxiety, social support, stigma, coping styles, and quality of life play a critical role in shaping mental health outcomes among males living with type 2 diabetes. Despite their importance, systematic evidence on how these factors influence [...] Read more.

Psychosocial factors such as diabetes distress, depression, anxiety, social support, stigma, coping styles, and quality of life play a critical role in shaping mental health outcomes among males living with type 2 diabetes. Despite their importance, systematic evidence on how these factors influence mental health remains limited. Objective: This protocol aims to synthesize existing evidence on psychosocial factors associated with mental health outcomes among males living with type 2 diabetes. Eligibility Criteria: Studies will be included if they focus on males aged 18 years and above diagnosed with type 2 diabetes and examine psychosocial factors in relation to mental health outcomes. Qualitative, quantitative, and mixed-methods designs will be considered. Exclusion criteria include studies focused on females, males under 18, or those with type 1 diabetes; studies exclusively evaluating interventions (e.g., CBT trials, self-management programs); non-English publications; and studies published before 2015. Confounders such as co-morbidities and lifestyle factors will be included if reported alongside psychosocial exposures, but studies focusing solely on these without mental health outcomes will be excluded. Information Sources: The search strategy will be guided by the PICO framework, and such searches will be conducted in Scopus, MEDLINE (PubMed), CINAHL, and Web of Science using Medical Subject Headings (MeSH) for articles published in English between January 2016 and December 2026. Risk of Bias: Two independent reviewers will screen studies, with disagreements resolved by a third reviewer. Risk of bias will be assessed using the JBI Critical Appraisal Checklist. Data Synthesis: Eligible studies will undergo narrative thematic synthesis. Confidence in findings will be evaluated using the JBI ConQual approach. Ethics and Dissemination: Ethical approval is not required. This protocol is registered with PROSPERO (CRD420261299482). Results will be disseminated through peer-reviewed journals and conferences. Conclusion: This protocol outlines a transparent plan to review psychosocial factors influencing mental health in men with type 2 diabetes, guiding gender-sensitive strategies that integrate mental health into diabetes care. Full article

(This article belongs to the Collection Health Behaviors, Risk Factors, NCDs and Health Promotion)

17 pages, 506 KB

Open AccessReview

Psychosocial Risks in Informal Employment: A Scoping Review

by María F. Cuenca-Lozano and Gabriel A. Jaramillo-Ochoa

Int. J. Environ. Res. Public Health 2026, 23(7), 846; https://doi.org/10.3390/ijerph23070846 (registering DOI) - 27 Jun 2026

Abstract

Background: This review examines informal employment—defined here following ILO Recommendation No. 204 as remunerated and unremunerated jobs not effectively covered by formal arrangements—and its association with psychosocial risks. While particularly prevalent in low- and middle-income countries, informal employment is also a structural [...] Read more.

Background: This review examines informal employment—defined here following ILO Recommendation No. 204 as remunerated and unremunerated jobs not effectively covered by formal arrangements—and its association with psychosocial risks. While particularly prevalent in low- and middle-income countries, informal employment is also a structural feature of high-income labor markets, affecting approximately 2 billion workers worldwide who lack regulation, security and social protection. These factors disproportionately affect vulnerable groups such as immigrants and women. Method: A scoping review was conducted across four databases (ScienceDirect, Scopus, Web of Science, PubMed) following the PRISMA-ScR extension. Eligibility was limited to primary studies on psychosocial risk factors in informal employment and their association with mental health (CRD420261280859) Prior systematic reviews were excluded from the evidence units and used only as back-ground literature. Results: The search yielded 257 initial articles, reduced after applying the eligibility criteria and after excluding prior systematic reviews and one out-of-scope study, to a final set of 12 primary studies. The review found a consistent association between informal employment and increased symptoms of stress, depression and anxiety, especially among women and undocumented immigrants. Conclusions: The findings support the extension of labor and social protection to informal workers, including unpaid caregivers, to reduce the adverse mental health effects of precarious employment. Socioeconomic exclusion, lack of labor rights and occupational decline increase vulnerability, underscoring the importance of addressing structural inequalities. Full article

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

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11 pages, 1412 KB

Open AccessArticle

Understanding Community Perspectives on Staphylococcus aureus Disease and Prevention in the White Mountain Apache Tribal Community in Arizona

by Sumayya U. Beekun, Monica Pilewskie, Catherine G. Sutcliffe, Francene Larzelere Sinquah, Shea J. Littlepage, Jennifer R. Richards, Natalie Jones and Laura L. Hammitt

Int. J. Environ. Res. Public Health 2026, 23(7), 845; https://doi.org/10.3390/ijerph23070845 (registering DOI) - 27 Jun 2026

Abstract

Staphylococcus aureus (Staph) infections are a pressing health concern in the White Mountain Apache (WMA) Tribal community, where invasive Staph infection rates far exceed those in the general U.S. population. This study explored community perspectives to guide culturally tailored education and prevention strategies. [...] Read more.

Staphylococcus aureus (Staph) infections are a pressing health concern in the White Mountain Apache (WMA) Tribal community, where invasive Staph infection rates far exceed those in the general U.S. population. This study explored community perspectives to guide culturally tailored education and prevention strategies. We conducted 42 in-depth interviews and focus group discussions with healthcare providers, traditional practitioners, and community members. Thematic analysis showed that participants had familiarity with the term “MRSA” (methicillin-resistant Staph), although many did not recognize it as a form of Staph, per se. Barriers to timely care-seeking included lack of transportation, stigma, and misconceptions about infection causes. With regard to biomedical approaches to prevention, participants preferred products like antiseptic nasal sprays and antimicrobial skin cleansers due to ease of use. Community members emphasized the need for simple, bilingual educational materials grounded in Apache culture and delivered by trusted figures. The findings underscore the importance of culturally grounded education and prevention approaches. Implementation and scaling of these strategies may enhance health literacy, reduce infection rates, and promote holistic wellness in Indigenous communities. Full article

(This article belongs to the Special Issue Improving Health and Mental Wellness in Indigenous Communities)

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30 pages, 2171 KB

Open AccessArticle

The Community–Environment–Health Nexus: Connecting Community-Led Climate Action to Health Co-Benefits

by Charlotte Wendelboe-Nelson, Kaz Lyon, Erica Alex, Stephen Malden, Andrew J. Williams and Catharine Ward Thompson

Int. J. Environ. Res. Public Health 2026, 23(7), 844; https://doi.org/10.3390/ijerph23070844 (registering DOI) - 27 Jun 2026

Abstract

Background: Climate action initiatives primarily target environmental outcomes, but their potential for health co-benefits through green and blue space contact remains understudied. Understanding these secondary outcomes could inform dual-purpose programming addressing climate and health challenges. Methods: This retrospective analysis examined 32 community-led climate [...] Read more.

Background: Climate action initiatives primarily target environmental outcomes, but their potential for health co-benefits through green and blue space contact remains understudied. Understanding these secondary outcomes could inform dual-purpose programming addressing climate and health challenges. Methods: This retrospective analysis examined 32 community-led climate action projects funded through Edinburgh Communities Climate Action Network (ECCAN) and their GreenLight programme (2024–2025). Projects spanned energy, transport, food, circular economy, and green space themes, with no formal health evaluation framework. Data were extracted from final reports covering 3195 direct participants. Results: Despite health not being a primary objective, 21 of 32 projects (66%) reported secondary health and wellbeing outcomes. Projects involving direct nature contact showed the strongest co-benefits: nine of ten high-nature-contact projects reported health benefits, compared to two of eight low-nature-contact projects. Notable outcomes included 94% of participants reporting increased willingness to engage in future community activities and 76% reporting mental wellbeing improvement following community garden workshops. Blue space engagement demonstrated particular significance for mental health and social cohesion. Conclusions: Green and blue space engagement in climate action projects consistently produces secondary health outcomes. We propose the Community–Environment–Health Nexus (CEHN) framework to understand how community-led environmental action generates synergistic health co-benefits. Full article

(This article belongs to the Special Issue Advancing Environmental Health in Urban Areas)

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13 pages, 495 KB

Open AccessArticle

Development and Pilot Evaluation of a Training-of-Trainers Model for School-Based Sexuality Education Within the ESPRIT Project

by Alessandra Casuccio, Nicolò Piazza, Giada Cordova, Patrizia Ferro, Nazareno Inzerillo, Alessio Castiglione, Manola Comar, Barbara Suligoi, Maria Cristina Salfa, Daniele Gianfrilli, Franz Sesti, Silvia Gazzetta, Laura Brunelli, Palmira Immordino, Vincenzo Restivo and ESPRIT Study Collaboration Group

Int. J. Environ. Res. Public Health 2026, 23(7), 843; https://doi.org/10.3390/ijerph23070843 (registering DOI) - 26 Jun 2026

Abstract

Background: Sexuality education is essential for adolescent health and well-being, yet in Italy it is not included in a mandatory national curriculum, resulting in heterogeneous implementation across regions. Within the ESPRIT project, a multidisciplinary training-of-trainers (ToT) model was developed to prepare professionals to [...] Read more.

Background: Sexuality education is essential for adolescent health and well-being, yet in Italy it is not included in a mandatory national curriculum, resulting in heterogeneous implementation across regions. Within the ESPRIT project, a multidisciplinary training-of-trainers (ToT) model was developed to prepare professionals to support school-based peer-education pathways. This study aimed to describe the training model and perform a pilot evaluation of short-term knowledge outcomes among trained participants. Methods: A pilot non-randomized controlled comparative study was conducted within the ESPRIT project framework. A multidisciplinary Training Team developed a structured ToT pathway based on WHO guidance, national recommendations, and peer-education models. Ten advanced public health residents in Hygiene and Preventive Medicine attended a three-day residential training course. One month later, a 10-item knowledge questionnaire was administered to trained participants (n = 10) and untrained advanced public health residents (n = 10). Results: Trained participants achieved higher questionnaire scores than the comparator group (median score 8 [IQR 2] vs. 3.5 [IQR 2]; p < 0.0005). Conclusions: Structured ToT programmes may represent a promising approach for strengthening professional preparation in sexuality education. Larger studies with longer follow-up are needed to evaluate sustainability and real-world implementation. Full article

23 pages, 868 KB

Open AccessArticle

Decline in Work Ability over Time and Its Association with Physical Performance Among Senior Workers: A Prospective Cohort Study

by Simone Ejstrup, Niels-Peter Brøchner Nygaard, Gert Frank Thomsen, Inge Brosbøl Iversen, David Høyrup Christiansen and Bibi Gram

Int. J. Environ. Res. Public Health 2026, 23(7), 842; https://doi.org/10.3390/ijerph23070842 (registering DOI) - 26 Jun 2026

Abstract

Background: Work ability (WA) decreases with age. This cohort study investigated changes in WA over time among senior workers and explored associations between WA and objectively measured physical performance. Methods: A questionnaire regarding WA (0–100 points), work status and general health was sent [...] Read more.

Background: Work ability (WA) decreases with age. This cohort study investigated changes in WA over time among senior workers and explored associations between WA and objectively measured physical performance. Methods: A questionnaire regarding WA (0–100 points), work status and general health was sent out to individuals aged 50–65 years (n = 23,463) with a 6.5-year follow-up. A subgroup participated in a clinical substudy testing physical performance. Results: A total of 13,404 participants responded to the baseline questionnaire (56%) and 8474 (63%) responded at follow-up. Overall, WA decreased by –8.3 points over time (95% CI: –8.9 to –7.7). The decline was similar between genders and among senior workers with high or low physical work demands. The steepest decline in WA was among those aged 56–59 years at baseline (–10.3 points, 95% CI: –11.5 to –9.1). Clinical examination showed that WA was positively associated with higher isokinetic muscle strength, handgrip strength and functional capacity after adjusting for confounders (all p < 0.05). Conclusion: Work ability decreased over time among all senior workers. Clinical subgroup analyses revealed positive associations between physical performance and WA. Future longitudinal studies are needed to determine whether improving physical performance can reduce age-related decline in work ability. Full article

13 pages, 293 KB

Open AccessArticle

Visual Difficulties and Uptake of Optical Correction Among Malawians: Insights from the 2024 Demographic and Health Survey

by Joan Efua Edua Hanson, Selassie Tagoh, Ernest Korang Asamoah, Susarah Maria Richter and Michael Agyemang Kwarteng

Int. J. Environ. Res. Public Health 2026, 23(7), 841; https://doi.org/10.3390/ijerph23070841 (registering DOI) - 26 Jun 2026

Abstract

Background: Uncorrected visual impairment, primarily due to refractive errors, is a persistent public health concern in low- and middle-income countries. In Malawi, national data on the prevalence of visual difficulty and uptake of optical correction remain scarce, hindering targeted health interventions. This study [...] Read more.

Background: Uncorrected visual impairment, primarily due to refractive errors, is a persistent public health concern in low- and middle-income countries. In Malawi, national data on the prevalence of visual difficulty and uptake of optical correction remain scarce, hindering targeted health interventions. This study examines the prevalence of self-reported visual difficulties, the uptake of refractive correction, and the sociodemographic determinants of optical correction in Malawi using 2024 national survey data. Methods: We conducted a secondary analysis of data from the 2024 Malawi Demographic and Health Survey (MDHS), a nationally representative, cross-sectional survey encompassing 23,095 participants across urban and rural regions. Self-reported visual difficulties and optical correction (spectacle/contact lens use) were assessed alongside key sociodemographic factors. Associations were examined using chi-square tests and multinomial logistic regression. Results: Among 23,095 participants, visual difficulty was significantly associated with age, education, marital status, region, and residence (all p < 0.001). The prevalence of visual difficulty increased markedly with age, from 2.3% in the youngest group to 15.5% in those over 74 years. Women, individuals with lower education, widowed participants, and residents of the Northern region experienced higher rates of visual difficulty. Spectacle or contact lens use was low overall (6.4%), with uptake increasing with age, education, and urban residence but remaining below 20% even among the most educated. Most individuals reporting visual difficulty were not using optical correction, including 70% of those with “some difficulty” and 67% of those with “a lot of difficulty” indicating substantial unmet need. Multivariable analysis identified advancing age, higher education, urban residence, and Northern region as key independent predictors of both visual difficulty and refractive correction uptake. Conclusions: The unmet need for refractive correction in Malawi is substantial, disproportionately affecting older, less educated, rural, and widowed individuals. Expanding access to affordable and equitable refractive services is essential to reducing avoidable visual impairment and addressing social and geographic health disparities. Full article

(This article belongs to the Special Issue Health Inequalities in Primary Care)

19 pages, 1895 KB

Open AccessReview

Implicit Bias in Health Professionals: A Scoping Review

by Kelly Chacon-Acevedo, Ana María Castillo, John Alexander Castro-Muñoz, Yonatan Ferney Rojas, Andrea Bermudez-Rodriguez and Ana María Rojas-Gómez

Int. J. Environ. Res. Public Health 2026, 23(7), 840; https://doi.org/10.3390/ijerph23070840 (registering DOI) - 26 Jun 2026

Abstract

Implicit bias, automatic attitudes or stereotypes outside conscious awareness, may influence clinicians’ communication, diagnosis, and treatment decisions, contributing to inequities in care. We conducted a scoping review to map measurement strategies used to assess implicit bias among health professionals and students in healthcare [...] Read more.

Implicit bias, automatic attitudes or stereotypes outside conscious awareness, may influence clinicians’ communication, diagnosis, and treatment decisions, contributing to inequities in care. We conducted a scoping review to map measurement strategies used to assess implicit bias among health professionals and students in healthcare and training settings. Using Joanna Briggs Institute guidance and PRISMA-ScR, we searched PubMed, Embase, BVS, Google Scholar, and institutional repositories for studies to November 2025; two reviewers independently screened and charted data (protocol was developed a priori but submitted internal in organization, and then uploaded in OSF. Of 1864 records, 93 studies from 28 countries were included. We identified 57 bias domains, most often race/ethnicity, weight, and sexual orientation. Across studies, 42 unique instruments were reported; the Implicit Association Test was most common, while psychometric validation and administration details were frequently limited, constraining comparability and interpretation. Evidence gap mapping showed concentration in academic and hospital settings, with fewer studies in primary care or community contexts and limited attention to age, disability, and intersectionality-related biases. The evidence base is growing but fragmented; future work should prioritize standardized administration and reporting, stronger validation, and tools that better capture automatic responding across diverse identities and care settings to support education and equity-oriented interventions. Full article

(This article belongs to the Section Global Health)

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15 pages, 292 KB

Open AccessArticle

Demographic and Socioeconomic Factors Associated with Fitbit Ownership in the NIH All of Us Cohort

by Bryson Carrier and James W. Navalta

Int. J. Environ. Res. Public Health 2026, 23(7), 839; https://doi.org/10.3390/ijerph23070839 - 26 Jun 2026

Abstract

Wearable fitness trackers are increasingly popular for monitoring health-related metrics, yet their ownership patterns across socioeconomic, demographic, and gender-diverse populations remain underexplored at a population level. This study utilized data from the NIH All of Us Research Program to investigate how area-level socioeconomic [...] Read more.

Wearable fitness trackers are increasingly popular for monitoring health-related metrics, yet their ownership patterns across socioeconomic, demographic, and gender-diverse populations remain underexplored at a population level. This study utilized data from the NIH All of Us Research Program to investigate how area-level socioeconomic status, race, and gender identity influence wearable device ownership. Methods. Data were analyzed from 633,547 participants from the All of Us Dataset. Fitbit ownership was modeled with four binary logistic regression models: a demographics-only model, a ZIP3-level socioeconomic indicators model, and a combined model incorporating four demographic × median household income interactions (race, gender, age, and Hispanic/Latino ethnicity), and an intersectional model adding a race x gender interaction. Continuous socioeconomic predictors were rescaled for interpretability (median income per USD 10,000; area-level fractions per 10 percentage points). Socioeconomic-adjusted models were restricted to 606,414 participants with available ZIP3-linked data. Fitbit ownership was defined as having a Fitbit record in the database. Results. Fitbit ownership was observed in 8.34% of the study population. Logistic regression analyses revealed significant demographic disparities: female participants and gender-diverse identities had significantly higher odds of ownership than males (OR = 1.25–2.2). Black or African American (OR = 0.38) and NHPI/MENA (OR = 0.82) participants had lower odds compared to White participants, while Asian (OR = 1.13), more than one race (OR = 1.25), and Hispanic or Latino (OR = 1.25) participants had higher odds. Each USD 10,000 increase in ZIP3 median household income was associated with 12.5% lower odds of ownership overall (OR = 0.875), but this gradient varied significantly by race. For Black or African American participants, the relationship reversed direction (OR = 1.08 per $10,000). A race x gender interaction further showed that female ownership was not uniform across race, being the largest among Black or African American participants (OR = 2.27) and reversed among Asian participants (OR = 0.87). ZIP3 socioeconomic data were structurally unavailable for all American Indian or Alaska Native participants due to the All of Us program’s small-population ZIP3 aggregation policy, precluding their inclusion in socioeconomic-adjusted models. Conclusions. This analysis demonstrates significant gender, racial, and socioeconomic disparities in wearable fitness tracker ownership, showing significantly higher device usage among females and gender-diverse individuals, but lower usage among certain racial groups and a seemingly contradictory negative ownership rates among higher socioeconomic levels. Ownership patterns nonetheless appear more equitable than in consumer cohorts, likely reflecting the device-provision programs undertaken by the NIH. Full article

(This article belongs to the Special Issue Advancing Public and Occupational Health Through Physical Activity and Injury Prevention)

28 pages, 890 KB

Open AccessReview

Incorporating a Screening-Level Risk Quotient (RQ_screen) for Assessing Human Health Risk of Pharmaceutical Residues in Consumption Water

by Gabriel Souza-Silva, Igor F. C. Santos, Inês B. Gomes, Manuel Simões, Micheline R. Silveira, Vítor J. P. Vilar and Ana I. Gomes

Int. J. Environ. Res. Public Health 2026, 23(7), 838; https://doi.org/10.3390/ijerph23070838 - 25 Jun 2026

Abstract

Pharmaceutical residues are increasingly detected in aquatic environments and are recognized as contaminants of emerging concern. This systematic literature review compiled and evaluated published concentrations of pharmaceutical residues in bottled water, tap water, and surface water in Portugal, applying risk quotient (RQ) and [...] Read more.

Pharmaceutical residues are increasingly detected in aquatic environments and are recognized as contaminants of emerging concern. This systematic literature review compiled and evaluated published concentrations of pharmaceutical residues in bottled water, tap water, and surface water in Portugal, applying risk quotient (RQ) and screening-level risk quotient (RQ_screen) approaches to evaluate potential human health risks and prioritize contaminants. Assessment based on the compiled literature data across age groups showed bottled and tap water posed low risk, while surface water presented the highest concern, with compounds spanning the full risk spectrum. Key contributors to potential human health risk included hormones (17-alpha-ethinylestradiol, 17-beta-estradiol, estrone), ramipril, betamethasone, citalopram, and amoxicillin. RQ_screen highlighted compounds relevant for ongoing monitoring even in treated waters, such as carbamazepine, diclofenac, salicylic acid, warfarin, fluoxetine, and erythromycin, due to their persistence and toxicological significance. Both RQ and RQ_screen indicated higher risk values for infants and children, reflecting lower body weight and higher water intake per unit mass, underscoring the need for age-specific evaluations. The RQ_screen method proved useful for contaminant prioritization, identifying substances relevant for monitoring despite low concentrations. Overall, this systematic review highlights pharmaceutical residues as an emerging public and environmental health concern in Portugal and emphasizes the importance of targeted monitoring and risk-based management within a One Health framework. Full article

(This article belongs to the Special Issue Pharmaceutical Pollution in Aquatic Ecosystems: Public Health Risks and Sustainable Solutions)

19 pages, 1521 KB

Open AccessArticle

The CHALO! Study Results of a Randomized Controlled Trial to Reduce Risk of Childhood Dental Caries and Obesity

by Arundhati Debnath, Karen Bonuck, Qi Gao, Usha Ramachandran, Sunanda Gaur, Christie L. Custodio-Lumsden, Dorota T. Kopycka-Kedzierawski, Mimi Kim and Alison Karasz

Int. J. Environ. Res. Public Health 2026, 23(7), 837; https://doi.org/10.3390/ijerph23070837 - 25 Jun 2026

Abstract

(1) Background: Obesity and dental caries disproportionately affect low-income South Asian (SA) immigrant children in the US. This CHALO! study aimed to reduce the risk of obesity and oral health risk in young SA children in the US. (2) Methods: CHALO! is a [...] Read more.

(1) Background: Obesity and dental caries disproportionately affect low-income South Asian (SA) immigrant children in the US. This CHALO! study aimed to reduce the risk of obesity and oral health risk in young SA children in the US. (2) Methods: CHALO! is a randomized controlled trial. A total of 350 low-income Bangladeshi mothers of 6-month-old children were recruited and randomized to intervention or control. Intervention participants received six home visits and six phone calls from trained community health workers who delivered health education and support. The primary outcome was frequency of combined bottle/sippy cup use over 18 months measured via self-report. Secondary outcomes included sugar consumption, maternal feeding practices, oral hygiene practices, and dental utilization measured via self-report. Secondary clinical outcomes included the presence of dental caries at follow-up (12 months post baseline) assessed through intra-oral camera, and obesity risk, measured as weight gain velocity, at each 6-month period. (3) Results: Bottle/sippy-cup use increased less in the intervention group (Poisson rate ratio = 0.36, 95% CI: 0.34–0.39, p < 0.0001) vs. controls (Poisson rate ratio = 0.58, 95% CI: 0.56–0.61), and while consistent results were noted in sugar consumption, oral hygiene practices, dental visits, and other secondary outcomes, no difference was found in caries prevalence or weight gain velocity. (4) Conclusions: The intervention improved self-reported bottle use and child diet in the intervention group. There were no significant changes in caries prevalence or weight gain velocity. Social context, particularly social networks, may act as a barrier to adopting new healthy behaviors, impacting changes in caries and obesity outcomes. Full article

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21 pages, 391 KB

Open AccessArticle

A Pilot Feasibility Study of Mindful Walking in Older Adults: Exploratory Bayesian Estimates of Psychological Distress and Alexithymia

by Alessandro Germani, Antonella Lopez, Claudia Mirenghi, Manuela Nicoletta Di Masi and Andrea Bosco

Int. J. Environ. Res. Public Health 2026, 23(7), 836; https://doi.org/10.3390/ijerph23070836 - 25 Jun 2026

Abstract

Population aging demands accessible interventions for psychological well-being in later life. This work evaluated the feasibility and acceptability of an 8-week mindful walking program in community-dwelling older adults and generated exploratory estimates of within-person change across emotional, psychosomatic, and psychological outcomes. Thirteen community-dwelling [...] Read more.

Population aging demands accessible interventions for psychological well-being in later life. This work evaluated the feasibility and acceptability of an 8-week mindful walking program in community-dwelling older adults and generated exploratory estimates of within-person change across emotional, psychosomatic, and psychological outcomes. Thirteen community-dwelling older adults participated in a pilot human trial with assessments at baseline, post-intervention, and one-month follow-up. Measures included depression, anxiety, somatic symptoms, mindfulness, mind wandering, alexithymia, quality of life, and attachment style. Primary feasibility outcomes indicated high acceptability and participant satisfaction, good physiological tolerance and full adherence. Secondary exploratory analyses suggested within-person reductions in depressive symptoms and alexithymia, while somatic symptoms decreased notably by follow-up. Mindfulness increased and was maintained over time, while mind wandering displayed a probable long-term decrease. Psychological quality of life improved and remained elevated, whereas physical, social, and environmental quality-of-life domains showed uncertain trends. Trait anxiety decreased post-intervention but returned toward baseline at follow-up, while state anxiety and attachment styles remained stable. Within pilot design limits, mindful walking may be a feasible intervention for older adults, associated with exploratory within-person patterns suggesting possible improvements in certain psychological outcomes, which should be interpreted as preliminary and descriptive signals pending confirmation in controlled trials. These preliminary findings support further investigation in controlled trials to determine effectiveness and to formally test hypothesized mechanisms. Full article

(This article belongs to the Topic Healthy, Safe and Active Aging, 3rd Edition)

22 pages, 3525 KB

Open AccessArticle

Islands in an Obesogenic Ocean: A Multiscale Spatial Analysis of School Neighborhood Food Environments in Michigan

by Gang Xu

Int. J. Environ. Res. Public Health 2026, 23(7), 835; https://doi.org/10.3390/ijerph23070835 - 25 Jun 2026

Abstract

This study examines the retail food environment surrounding public schools in Michigan using a multiscale, multidimensional framework. A cross-sectional spatial analysis integrates relative healthfulness (modified Retail Food Environment Index, mRFEI), availability (outlet counts), and accessibility (network-based walking time) across school districts, census tracts, [...] Read more.

This study examines the retail food environment surrounding public schools in Michigan using a multiscale, multidimensional framework. A cross-sectional spatial analysis integrates relative healthfulness (modified Retail Food Environment Index, mRFEI), availability (outlet counts), and accessibility (network-based walking time) across school districts, census tracts, block groups, and school-centered buffers. The analysis includes 3530 public schools, 7680 fast food restaurants, and 2065 convenience stores. Results show pronounced spatial heterogeneity and clustering of unhealthful outlets (Nearest Neighbor Index = 0.284, p < 0.001), with many located near schools. Approximately 34% of schools are within a 10 min walk of a fast food restaurant, increasing to 65% within a 20 min walk. Urban schools face significantly greater exposure—2.27–2.80 times more fast food outlets and shorter walking times than rural schools (p ≤ 0.002)—with consistent gradients across city, suburban, town, and rural contexts. Overall, school neighborhood food environments are highly structured, obesogenic, and inequitable. By integrating multiple spatial scales and complementary measures of food environments, this study advances food environment research and provides policy-relevant evidence for targeted, place-based interventions to improve access to healthier food around schools. Full article

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15 pages, 532 KB

Open AccessArticle

Hope and Fear: A Survey of Eco-Emotions and Climate Anxiety, Activism, and Well-Being Among Older Adolescents in Northern California

by Kelly L. L’Engle, Julianna Sahoo, Gwendolyn M. Hoff Anderson, Elise Brown and Lexi Nutkiewicz

Int. J. Environ. Res. Public Health 2026, 23(7), 834; https://doi.org/10.3390/ijerph23070834 (registering DOI) - 25 Jun 2026

Abstract

The purpose of this study is to examine positive and negative emotions about climate change reported by youth living in northern California and explore how these emotions are linked to climate anxiety, activism, and other measures of well-being. We surveyed ethnically diverse first- [...] Read more.

The purpose of this study is to examine positive and negative emotions about climate change reported by youth living in northern California and explore how these emotions are linked to climate anxiety, activism, and other measures of well-being. We surveyed ethnically diverse first- and second-year students (N = 521, mean age = 19) at a Jesuit, urban university in California in Fall 2022. Survey measures assessed climate-related emotions, eco-anxiety, and eco-impairment, along with activism, optimism, and compassion. Bivariate and multivariate models examined positive and negative eco-emotions, controlling for race, gender, and income. Overall, climate anxiety was linked to greater activism and confidence that actions matter. However, experiencing positive climate-related emotions had a stronger relationship to activism and optimism for the present and future, compared to negative emotions which were linked to higher eco-anxiety and greater compassion for others. Climate education and communication should consider inducing and reinforcing positive emotions to encourage youth activism, especially since negative emotions in response to climate change are linked to worse mental health. More research on a range of climate emotions is needed, and future interventions should test how to induce hope without minimizing the seriousness of climate change to support confidence and youth action. Full article

(This article belongs to the Section Environmental Health)

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21 pages, 873 KB

Open AccessReview

Assessing Quality of Life in Genetic Cardiomyopathies: A Scoping Review

by Lucrezia Tomberli, Fausto Barlocco, Annariina Koivu, Jari Hyttinen, Iacopo Olivotto and Enrica Ciucci

Int. J. Environ. Res. Public Health 2026, 23(7), 833; https://doi.org/10.3390/ijerph23070833 - 25 Jun 2026

Abstract

Genetic cardiomyopathies (GCMs) are chronic heart muscle disorders requiring lifelong monitoring and treatment. Although quality of life (QoL) and health-related quality of life (HRQoL) are increasingly recognized as important outcomes in cardiomyopathy care, their conceptualization and measurement remain inconsistent. This scoping review aims [...] Read more.

Genetic cardiomyopathies (GCMs) are chronic heart muscle disorders requiring lifelong monitoring and treatment. Although quality of life (QoL) and health-related quality of life (HRQoL) are increasingly recognized as important outcomes in cardiomyopathy care, their conceptualization and measurement remain inconsistent. This scoping review aims to (a) identify the tools most commonly used to assess QoL and HRQoL in adults with genetic cardiomyopathies and (b) map the thematic areas of existing studies, including symptom burden, psychological distress, diagnostic challenges, and the impact of medical and psychological interventions. PubMed, Scopus, and PsycINFO were systematically searched, and the final search was completed in November 2025. Seventeen peer-reviewed studies met the inclusion criteria and were included in this scoping review. The review followed the PRISMA extension for Scoping Reviews and included both quantitative, qualitative and mixed-methods designs. Most studies employed standardized tools such as EQ-5D (N = 5), SF-36/SF36v2 (N = 5), and the Kansas City Cardiomyopathy Questionnaire (N = 3), while others included the Minnesota Living with Heart Failure Questionnaire (N = 2) and disease-specific or ad hoc measures. The most frequently investigated themes included impairments in physical functioning, emotional well-being, symptom burden, psychological distress, and social participation. Several studies showed that patients’ perceived QoL was more closely associated with symptom burden and psychological adjustment than with objective clinical indicators alone. Clinical interventions showed mixed or limited effects on QoL and HRQoL outcomes, even when clinical parameters improved. Qualitative research further emphasized the lived experiences of patients and families, highlighting unmet needs in care. Less commonly addressed findings concerned caregiver perspectives, patient–provider communication, treatment adherence, socioeconomic disadvantage, healthcare costs, productivity loss, and the experiences of patients with rarer cardiomyopathy-related conditions. The results highlight how QoL and HRQoL are central but still inconsistently assessed outcomes in cardiomyopathy research. This review calls for greater conceptual clarity between QoL and HRQoL, greater standardization in measurement tools, broader inclusion of psychosocial variables, and more patient-centred research approaches to better support individuals living with cardiomyopathies. Full article

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

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17 pages, 290 KB

Open AccessArticle

Institution-Level and Individual Factors Associated with Student Mental Health in Germany: A Multilevel Analysis of StudiBiFra Data

by Christiane Stock, Ulrike Grittner, Jennifer Lehnchen, Zita Deptolla, Julia Burian and Katherina Heinrichs

Int. J. Environ. Res. Public Health 2026, 23(7), 832; https://doi.org/10.3390/ijerph23070832 - 24 Jun 2026

Abstract

While individual determinants of students’ well-being are well established, less is known about the association with the institutional context. This study evaluates institutional-level factors associated with students’ mental health while controlling for individual characteristics. The cross-sectional analysis used data from 12 German institutions [...] Read more.

While individual determinants of students’ well-being are well established, less is known about the association with the institutional context. This study evaluates institutional-level factors associated with students’ mental health while controlling for individual characteristics. The cross-sectional analysis used data from 12 German institutions (n = 13,715) collected in the StudiBiFra survey on study conditions and student mental health. Individual-level variables included gender, age, study subject group, and four mental health variables (general well-being, depressiveness, cognitive stress, and exhaustion). Institution-level variables comprised institution type, excellence status, multi-campus structure, size, and satisfaction with the quality of health promotion services. Multilevel binary logistic regression models were applied to examine associations between institutional characteristics and mental health outcomes, adjusting for individual factors. Students enrolled at universities of applied sciences showed a lower likelihood of reporting depressiveness and exhaustion. Higher levels of depressiveness and cognitive stress were observed among students at medium-sized institutions compared to small ones. Students not enrolled at institutions with excellence status had lower risks of depressiveness, stress, and exhaustion. Additionally, higher satisfaction with institutional health promotion services was associated with reduced odds of depressiveness. Institutional factors are related to students’ mental health beyond individual characteristics, highlighting the need for a holistic, setting-based approach. Full article

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

19 pages, 493 KB

Open AccessArticle

Weather Information Seeking and Heat-Health Protective Actions During Pregnancy: An Exploratory Study

by Lisa K. Zottarelli, Robyn Stassen, Yejin Heo, Madeline Navarrete, Shamshad Khan, Thankam Sunil and Andrea Shields

Int. J. Environ. Res. Public Health 2026, 23(7), 831; https://doi.org/10.3390/ijerph23070831 - 24 Jun 2026

Abstract

Extreme heat poses health risks during pregnancy, but little is known about how pregnant individuals seek weather information to engage in heat-health protective actions. This study examined associations between routine and event-driven weather information seeking and both routine physiological heat-health protective actions (i.e., [...] Read more.

Extreme heat poses health risks during pregnancy, but little is known about how pregnant individuals seek weather information to engage in heat-health protective actions. This study examined associations between routine and event-driven weather information seeking and both routine physiological heat-health protective actions (i.e., limiting sun exposure, staying hydrated, and spending time in air conditioning) and higher-threshold adaptive behaviors (i.e., changing plans due to heat). A cross-sectional survey of 195 pregnant individuals in Bexar County, TX, USA, was conducted during the summer and fall of 2024. Descriptive and nonparametric analyses explored relationships across trimesters. Participants demonstrated high routine weather information seeking and greater weather information needs since becoming pregnant. Over half (51.3%) reported increased weather information seeking during excessive heat, with lower increases during the first trimester. During extreme heat, most respondents increased heat-health protective actions. Increased information needs during pregnancy were significantly related to heat-health protective actions. Routine weather checking showed weak or inverse relationships with changing plans, suggesting that routine weather awareness alone may not prompt changing plans. Trimester patterns indicated heightened information seeking and protective actions later in pregnancy. Findings highlight the importance of pregnancy-specific heat risk communication with trimester-specific guidance provided in clinical counseling, public health messaging, and meteorological communication. Full article

(This article belongs to the Section Environmental Health)

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