Healthcare doi: 10.3390/healthcare14091133

Authors: Saar Baert Mariska Meersschaut Kristien Roelens Sara Van Belle Paul Gemmel Iva Bicanic Ines Keygnaert

Background: Sexual Assault Care Centres (SACCs) in Belgium provide integrated medical and psychological care, a forensic examination and the option to report to the police to victims of sexual assault (SA). Understanding victims’ acceptability of these services is essential for improving SACC’s effectiveness and informing policy. Methods: In-depth interviews were conducted with 19 victims and 14 support persons to explore victims’ experiences with SACCs. The victims represented diverse characteristics (gender, age, SACC site and police reporting status). Data were analysed using thematic framework analysis, guided by Sekhon’s “Theoretical Framework of Acceptability”. Results: Participants viewed SACCs as a highly acceptable integrated model of specialised care for victims of recent SA. They expressed strong appreciation for the care provided at the SACC and its set-up (affective attitude), and they identified key professional qualities of SACC professionals (ethicality). Participants demonstrated good understanding of the functioning of the SACCs (intervention coherence). The model was perceived as effective in providing medical care, mental health support, and facilitating police reporting, though gaps were noted in linking victims with other actors in the criminal justice system (perceived effectiveness). Organisational strengths included the holistic, long-term, proactive, affordable and accessible nature of the care offered (perceived effectiveness, burden and opportunity cost). Victims faced challenges in linking to, engaging with and remaining in care due to distress post-SA, with support persons playing a crucial role in helping them navigate these challenges (self-efficacy). Conclusions: The study highlights the acceptability of an integrated, multidisciplinary approach to specialised SA care. Key elements include embedded psychological support, the option for forensic examination without mandatory reporting, and the possibility of police reporting at the SACC. These findings may inform the development of specialised SA services in other settings.

Healthcare doi: 10.3390/healthcare14091132

Authors: Woo-Hyuk Kim Eunhye Park

Background: This study examines how medical consumption is discussed in online communities among individuals who are blind or visually impaired using the Social Ecological Model (SEM) to capture multilevel healthcare experiences within digital discourse. Methods: A total of 428 posts and comments were collected from Reddit’s r/Blind community. Term frequency–inverse document frequency keyword extraction and a theory-driven LLM-based classification approach were applied to categorize texts into five SEM levels: intrapersonal, interpersonal, institutional, community, and public policy. Results: The findings show that intrapersonal (44.4%) and public policy (29.8%) levels were the most prominent, indicating a strong emphasis on personal coping experiences alongside structural constraints in healthcare access. Institutional-level discourse accounted for 15.8%, whereas interpersonal (6.2%) and community (3.8%) discourse were relatively limited. Keywords and qualitative analyses revealed themes related to emotional adaptation, social support, service accessibility, mobility constraints, and welfare policy barriers. The Jaccard similarity analysis indicated stronger associations between institutional and policy levels, whereas community-level discourse remained relatively distinct. Conclusions: These findings highlight the importance of understanding healthcare experiences, both individually and structurally, in online environments. This study also demonstrated the potential of integrating LLM-based classification with theory-driven frameworks to enable an interpretable and scalable analysis of complex health-related discourse.

Healthcare doi: 10.3390/healthcare14091131

Authors: Zepeda-Lugo Insfran-Rivarola Sanchez-Lizarraga Macias-Velasquez Arevalos Baez-Lopez Tlapa

Background/Objectives: Efficient management of intensive care unit (ICU) resources is a critical challenge for modern healthcare systems, which must balance high-quality patient care with operational and financial performance. ICU length of stay (LOS) is a key metric of clinical complexity and hospital efficiency. However, traditional methods for predicting LOS often fail to capture the complex, nonlinear interactions among physiological, demographic, and treatment-related variables. Machine learning (ML) and deep learning (DL) models have emerged as promising tools for enhancing predictive accuracy and supporting data-driven decision-making. Methods: This study presents a systematic review and meta-analysis of ML and DL approaches for predicting ICU LOS in adult patients. Following PRISMA guidelines, eight scientific databases were searched, yielding 33 eligible studies published between 2015 and 2025. Results: Mixed medical–surgical ICUs were the most common setting (51.5%), and 45.5% of datasets were sourced from public repositories. Most studies (19/33) focused on binary classification of prolonged stays, although thresholds ranged from >48 h to ≥14 days. The pooled results from ten studies yielded an AUROC of 0.9005 (95% CI: 0.8890–0.9121), indicating strong predictive capability across diverse clinical contexts. Subgroup analyses showed comparable performance between specialized surgical and general ICUs. Conclusions: These findings suggest that AI-driven LOS prediction models exhibit strong discriminatory power for ICU LOS prediction, supporting hospital capacity planning. However, to translate this into reliable clinical support, the methodological heterogeneity, scarcity of external validation, and near absence of calibration reporting identified in this review need to be addressed.

Healthcare doi: 10.3390/healthcare14091130

Authors: Jui-Kun Chiang Po-Chen Chiang Malcolm Koo

Background/Objectives: Zinc deficiency has been associated with increased cancer-related mortality, yet its prognostic relevance in patients with breast cancer and comorbid diabetes remains unclear. This study evaluated the association between zinc deficiency and adverse 5-year clinical outcomes in this population. Methods: This retrospective cohort study used the TriNetX database to identify women aged ≥20 years with breast cancer and type 2 diabetes who had recorded serum zinc levels within 3 months before the index date during the period from 1 January 2013 to 4 April 2026. Patients were categorized into zinc-deficiency, normal-zinc, or high-zinc groups. Outcomes included all-cause mortality, hospitalization, intensive care unit admission, and emergency department visits at the 1-, 3-, and 5-year follow-ups. Cox proportional hazards regression models were applied after 1:1 propensity score matching across 12 demographic and clinical variables. Results: Among 648 eligible patients, 282 had zinc deficiency, 311 had normal zinc levels, and 55 had high zinc levels. After matching, 218 remained in each of the zinc-deficient and control groups. Zinc deficiency was associated with higher all-cause mortality at 1 year (hazard ratio [HR], 2.45; 95% CI, 1.41, 4.28), 3 years (hazard ratio [HR], 2.09; 95% CI, 1.34, 3.28), and 5 years (HR, 1.92; 95% CI, 1.27, 2.92), as well as increased risks of emergency department visits, hospitalization, and ICU admission across follow-up periods. No significant differences were observed between the high-zinc and zinc-normal groups, possibly due to limited sample size. Subgroup analyses identified several exploratory subgroup-specific associations. Conclusions: Zinc deficiency was associated with poorer clinical outcomes in women with breast cancer and type 2 diabetes. However, because low serum zinc may also reflect malnutrition, systemic inflammation, frailty, or disease burden, these findings should be interpreted as hypothesis-generating rather than causal.

Healthcare doi: 10.3390/healthcare14091129

Authors: Mehmet Salık Elif Pınar Bakır Şeyhmus Bakır

Background/Objectives: This study aimed to evaluate the self-reported knowledge levels of evidence-based practice among actively practicing dentists in Türkiye in relation to restorative material selection, and to identify the demographic and professional factors associated with this knowledge. Materials and Methods: This cross-sectional descriptive survey included 341 dentists and was conducted using an online questionnaire. Descriptive statistics were expressed as frequencies, percentages, means, and standard deviations. Factors associated with self-reported knowledge levels of evidence-based dentistry were initially assessed using ordinal logistic regression. As the proportional odds assumption was violated, multinomial logistic regression analysis was employed as the final model. Statistical significance was set at p < 0.05. Results: Aesthetic expectations and durability were identified as the primary factors influencing restorative material selection. Approximately half of the participants reported low-to-moderate levels of knowledge regarding evidence-based dentistry. Multinomial logistic regression analysis demonstrated that professional experience, professional status, and type of institution were significant predictors of knowledge level (p < 0.05). General dental practitioners were significantly less likely to have high knowledge levels compared to specialists. Certain experience groups also showed a lower likelihood of achieving higher knowledge levels relative to the reference group. Although the type of institution was statistically significant, its overall effect was limited. Conclusions: The findings indicate that knowledge of evidence-based approaches in restorative material selection among dentists in Türkiye remains suboptimal. While professional status and experience play a significant role in shaping knowledge levels, institutional factors appear to have a comparatively minor impact. These results underscore the need for structured continuing education programmes—particularly for general dental practitioners—and highlight the importance of strengthening evidence-based decision-making in clinical practice.

Healthcare doi: 10.3390/healthcare14091128

Authors: Shin-Young Lee

Background/Objectives: Despite the availability of the National Cancer Screening Program in Korea, participation rates remain suboptimal. The literature demonstrates that cancer screening participation extends beyond individual-level knowledge and attitudes and is largely associated with trust. This study examines the role of trust—across cancer screening tests, health care providers, and health care organizations—as a central determinant of cancer screening participation among Koreans. Methods: A cross-sectional study was conducted with 369 Korean adults aged 40 years and older, recruited through convenience sampling from community centers in a metropolitan city. Data were collected using structured, paper-based questionnaires assessing socio-demographic factors and multilevel trust across specific screening tests, doctors, and health care organizations. Following descriptive statistics, bivariate and multivariate logistic regression analyses were performed to identify significant predictors of cancer screening utilization. Results: Koreans had relatively high trust in doctors and cancer screening tests. On an 11-point numeric rating scale ranging from 0 (not at all) to 10 (completely), the mean scores were 7.47 for the trust in doctors; colonoscopy had the highest trust score (M = 7.71), whereas the fecal occult blood test had the lowest (M = 7.14). Multivariate logistic regression revealed that trust and distrust were associated with the utilization of Pap smear, gastroscopy, upper gastrointestinal series, and colonoscopy in complex and sometimes paradoxical ways, and having a usual source of care was a consistent facilitator of cancer screening. Conclusions: These findings suggest that future research is needed to examine the complex interplay among trust, access to health care, and national policy in shaping cancer screening utilization in the Republic of Korea.

Healthcare doi: 10.3390/healthcare14091127

Authors: Yile Li Yingying Tao Luyu Mo Dan Wu Chengcheng Li Xuehui Meng

Background: Chronic Obstructive Pulmonary Disease (COPD) poses a substantial public health challenge in China owing to its increasing prevalence and substantial economic burden. In response, the diagnosis–intervention packet (DIP) payment reform was implemented to control healthcare costs and enhance service efficiency. Methods: To evaluate the effect of the DIP reform on medical costs, hospitalization days, and individual out-of-pocket payments for COPD inpatients in M City, a pilot city in central China, we conducted an interrupted time series (ITS) analysis using monthly reimbursement records from January 2020 to December 2023. The study included 84,410 hospitalized patients from a city-wide database of 3,241,233 inpatient records with COPD who met the inclusion criteria. The analysis focused on the total healthcare costs, length of stay, and individual out-of-pocket costs. Results: The DIP reform resulted in a 3.7% reduction (95% CI: 0.9% to 6.5%) in the total hospitalization costs in the first month post-reform, with a sustained monthly decline of 0.8% (95% CI: 0.5% to 1.1%). The length of stay decreased from 9.53 (95% CI: 9.31 to 9.75) to 8.74 days (95% CI: 8.62 to 8.86). Conversely, the proportion of out-of-pocket payments relative to total costs increased. Conclusions: While the DIP reform effectively reduced hospitalization costs and days, it led to an increase in individual out-of-pocket payments. Future research should focus on optimizing payment rules, enhancing the supervision of medical services, and refining health insurance policies to achieve the reform’s objectives better and alleviate the financial burden on patients.

Healthcare doi: 10.3390/healthcare14091125

Authors: Jiahao Li Yang Chu Shan Liu Yanfang Liu Jie Xu

Background: Nomophobia, the fear of being without a mobile phone, has become an increasing public health concern. While existing theories suggest that smartphones often serve as tools for emotional regulation, the situational mechanisms driving these compensatory behaviors remain under-explored. This study investigated how nomophobia levels interact with daily emotional fluctuations and busyness to influence smartphone-based coping patterns. Methods: We employed an intensive longitudinal approach combining objective smartphone tracking with a 4-week daily diary design. Thirty-seven participants were monitored, yielding 837 daily observations. Smartphone use was categorized into Instant Messaging (IM), Social Media Use (SMU), and Non-social Use (NSU). Multilevel linear regression analyzed the interaction effects on usage metrics. Results: Nomophobia significantly correlated with the duration and frequency of SMU, but not IM or NSU. A significant three-way interaction was observed: individuals with high levels of nomophobia exhibited a significantly increased frequency of overall usage, SMU and NSU when experiencing negative emotions during periods of low busyness. In contrast, low-nomophobia individuals maintained stable usage patterns regardless of situational stressors. Conclusions: By conceptualizing smartphone usage as a behavioral proxy for the coping process, this study provides preliminary evidence that nomophobia is associated with a situation-dependent coping pattern, primarily involving increased social media usage. These findings underscore the importance of integrating situational contexts and underlying coping processes to better understand and manage problematic smartphone use.

Healthcare doi: 10.3390/healthcare14091126

Authors: Steliyana Valeva Nazife Bekir Katya Mollova Andriana Kozareva Ivelina Stoyanova Pavlina Teneva

Background: Obesity represents a major public health challenge worldwide and contributes substantially to the burden of type 2 diabetes and hypertension. While body mass index (BMI) is widely used in clinical practice, indices reflecting central adiposity may provide additional prognostic value. This study aimed to assess the prevalence of general and central obesity in an adult population across different age groups from Stara Zagora, Bulgaria, and to examine their associations with cardiometabolic outcomes and lifestyle factors. Methods: A quasi-representative cross-sectional study was conducted among 3512 adults (mean age 53.7 ± 14.9 years). Anthropometric indices, including BMI, waist circumference, waist-to-hip ratio, and waist-to-height ratio were measured. Cardiometabolic outcomes included diabetes, hypertension, and their combined presence. Multicollinearity was assessed using the Variance Inflation Factor (VIF), and the discriminatory ability of indices was evaluated using Receiver Operating Characteristic (ROC) analysis and DeLong’s test. Results: The prevalence of overweight/obesity (BMI ≥25) was 68.4%, while central obesity (WHtR ≥0.5) affected 66.9% of participants. BMI demonstrated the highest discriminatory ability in this dataset for hypertension (AUC = 0.852) and diabetes (AUC = 0.796), significantly outperforming WC and WHR (p < 0.05). However, 24.4% of individuals with normal BMI exhibited high-risk central adiposity. Significant sex-specific differences were observed: short sleep duration (<6 h) was a strong predictor of obesity in women (aOR = 2.98), whereas smoking showed stronger associations in men. Age-stratified analyses revealed that while BMI stabilizes in the oldest age group (75–89 years), WHtR continues to increase, reflecting age-related redistribution of visceral fat. A strong protective effect of physical activity was observed, supported by quasi-complete separation in active subgroups. Conclusions: General and central obesity represent a substantial health burden in this urban population. While BMI remains a robust screening tool, the integration of WHtR enhances the identification of “hidden” cardiometabolic risk particularly in older adults and individuals with normal BMI. Given the quasi-representative nature of the sample, these findings are primarily generalizable to similar urban populations and may inform targeted regional public health strategies.

Healthcare doi: 10.3390/healthcare14091124

Authors: Ana Suárez-Carrasco Álvaro León-Campos Maria José Peláez-Cantero Silvia García-Mayor Bibiana Pérez-Ardanaz

Background: Families caring for children with medical complexity (CMC) face sustained psychosocial demands that may impair health-related quality of life (HRQoL) and mental health. A clear map of how these outcomes are assessed and which factors shape them is needed to guide family-centered care. Methods: We conducted a scoping review following the Joanna Briggs Institute guidelines, and reports were prepared according to the PRISMA guidelines. Searches were conducted in PubMed, CINAHL, and EMBASE (January 2011 to December 2023) to find studies reporting on health-related quality of life (HRQoL) and/or mental health outcomes (anxiety, depression, burden) of family members and/or caregivers of CMC, including operationalization based on complex chronic condition (CCC) classifications, technology dependency, or the Pediatric Medical Complexity Algorithm (PMCA). Two reviewers independently screened records and recorded data, and the findings were synthesized narratively and thematically. Results: Sixty-seven studies met the inclusion criteria and spanned cross-sectional, cohort, case–control, pre–post and qualitative designs across conditions such as epilepsy, congenital heart disease, cerebral palsy, technology dependence and cancer. Common measures were PedsQL™ Family Impact Module, SF-36/12, HADS, Beck inventories and Zarit burden scales. Across the included studies, caregivers, predominantly mothers, frequently reported poorer HRQoL and higher levels of anxiety, depressive symptoms, or burden than comparison groups when these were available. Six recurrent themes emerged: (1) gendered caregiving with disproportionate maternal burden; (2) socio-economic gradients and financing models shaping outcomes; (3) culture, religion and spirituality as coping resources; (4) family and social support buffering distress; (5) school participation and coordinated services potentially reducing burden; and (6) interdependence between caregiver and child outcomes. Conclusions: Heterogeneous CMC definitions, outcome measures, and study designs limited comparability across studies. The mapped evidence suggests that family HRQoL and mental health outcomes are shaped by interacting clinical, social, and contextual factors. These findings may inform more family-centered and equity-oriented approaches to care. Future research should harmonize CMC definitions, standardize outcome measures, and prospectively evaluate multicomponent interventions.

Healthcare doi: 10.3390/healthcare14091123

Authors: Dorothy Day Huntsman Desiree Jenkinson Grzegorz Bulaj

Home has been recognized as a health infrastructure through hospital-at-home, home care, and direct-to-consumer wellness and fitness products. However, the patient home environment has been largely overlooked by healthcare as a means to improve therapy outcomes for difficult-to-treat chronic conditions, such as migraine; high-impact pain; and treatment-resistant depression, anxiety, or insomnia. Growing research evidence enables the formulation of a therapeutic home environment standard consisting of three pillars: biophilic design, indoor environmental quality, and intentional self-care spaces that serve as habit cues and foster sleep hygiene, stress management, relaxation, physical activity, and social interactions. Together, these environmental and behavioral interventions can transform real-world inputs into clinical benefits through autonomic, circadian, and emotional regulation. We also highlight the converging roles of self-management, self-efficacy, self-regulation, and self-compassion in sustaining patient engagement and healing at home. The applicability of the therapeutic home environment as an adjunct is illustrated in the case of chronic migraine, a debilitating neurological condition commonly associated with comorbidities. Current challenges in achieving migraine freedom with FDA-approved pharmacotherapies, neuromodulation devices, and digital health technologies are underscored by the high prevalence of refractory, chronic, episodic, and pediatric migraine. Perspectives on developing a personalized, multimodal cure for migraine are illustrated through a hypothetical drug + digital combination therapy comprising anti-CGRP drugs and an AI-powered digital health platform that promotes daily self-care practices within the therapeutic home environments. In conclusion, achieving sustained freedom from high-morbidity conditions requires end-to-end care ecosystems that integrate pharmacological, cognitive, behavioral, and environmental interventions into real-world settings.

Healthcare doi: 10.3390/healthcare14091122

Authors: Eleftheria Morela Evgenia Kouli Evangelos Galanis Nerantzoula Koufou Konstantinos Astrapellos

Background: Hatha yoga has gained increasing popularity worldwide and has been associated with benefits for mental health and short-term emotional functioning. Objective: The present study examined pre–post changes in mood states following a single Hatha yoga session in adult women participating in community-based exercise programs. Methods: A total of 253 adult women participated in the study. Participants completed the Profile of Mood States (POMS) questionnaire immediately before and after a single 60 min Hatha yoga session. The questionnaire assesses anxiety–tension, depression, anger, fatigue, confusion, and vigor. Repeated measures ANOVA was used to examine the changes in mood states and the potential differences between the age groups. Results: Significant improvements in mood states were observed following the session. Anxiety–tension, depression, anger, fatigue, and confusion decreased, while vigor increased. No significant time × age group interaction was observed for most mood variables. However, a significant interaction was found for vigor, indicating that women aged 41 and older showed a greater increase following the session. Conclusions: Participation in a single Hatha yoga session was associated with short-term changes in mood states among adult women, suggesting that yoga may represent a potentially beneficial community-based activity for supporting short-term mood regulation.

Healthcare doi: 10.3390/healthcare14091121

Authors: Antonio Brugos-Larumbe Alba Equiza-Vaquero Carmen Hugo-Vizcardo Laura Guillen-Aguinaga Francisco Guillen-Grima Ines Aguinaga-Ontoso

Background: Food bank users experience food insecurity, a social determinant of health linked to poorer physical and mental health. However, evidence on the health-related quality of life (HRQoL) of food bank users in Spain is scarce. Objectives: This study sought to assess HRQoL among users of the Navarra Food Bank and identify associated sociodemographic factors. Methods: We performed a cross-sectional study of heads of household using the Navarra Food Bank. A simple random sample of 350 participants was selected from a population of 2749 families. HRQoL was assessed by telephone using the EQ-5D-5L. We described the prevalence of problems in the five EQ-5D-5L dimensions, calculated the EQ-5D-5L utility index using the Spanish value set, and analyzed EuroQol Visual Analogue Scale (EQ-VAS) scores. Associations with sociodemographic characteristics were examined using multivariable general linear models. Results: Mean EQ-VAS was 73.56 (95% CI: 71.62–75.50), and mean EQ-5D-5L utility index was 0.815 (95% CI: 0.800–0.831). The most frequently reported problems were anxiety/depression (62.9%) and pain/discomfort (55.7%), while mobility (25.5%), usual activities (19.7%), and self-care (8.7%) were less commonly affected. Older age was significantly associated with both EQ-VAS and EQ-5D-5L utility index. Employment status and nationality were significantly associated with EQ-VAS, whereas sex was significantly associated with the EQ-5D-5L utility index. Conclusions: HRQoL was impaired among users of the Navarra Food Bank, with the greatest burden observed in the anxiety/depression and pain/discomfort dimensions. Older age and selected sociodemographic characteristics were associated with poorer HRQoL. Given the cross-sectional design, the findings should be interpreted as associative rather than causal.

Healthcare doi: 10.3390/healthcare14091120

Authors: Yih-Ming Weng Gia-Wei Chang Meng-Siew Hii Hsiu-Chun Chien Jong-Long Guo

Background/Objectives: Sarcopenia and age-related muscle weakness pose significant global health challenges, highlighting the need for innovative and sustainable exercise interventions for older adults. This study developed and evaluated an Interactive Smart Mirror Exercise Program and investigated the factors associated with older adults’ usage intention toward the program based on the Decomposed Theory of Planned Behavior (DTPB). Methods: A cross-sectional survey was conducted with 92 community-dwelling older adults in northern Taiwan. Structural equation modeling was applied to test the proposed framework and examine the relationships among the study variables. Results: The results showed a satisfactory model fit (SRMR = 0.071). Attitude, subjective norms, and perceived behavioral control together explained 41.6% of the variance in usage intention. In addition, perceived usefulness, perceived compatibility, interpersonal influence, and self-efficacy were identified as factors significantly associated with usage intention, both directly and indirectly. Conclusions: These findings might support the applicability of the DTPB framework in explaining older adults’ usage intention toward technology-assisted exercise programs and provide insights for the design and implementation of digital exercise interventions in community settings.

Healthcare doi: 10.3390/healthcare14091119

Authors: Carmen García-Gomariz Sonia Andrés-Reig María-José Chiva-Miralles Roi Painceira-Villar José-María Blasco

Introduction: Although gait alterations associated with excess body weight have been widely studied, most available evidence comes from laboratory-based analyses, which limit ecological validity and the translation of findings into clinical practice. This study addresses this gap by examining gait biomechanics across BMI categories using portable sensor-based insoles that allow gait assessment in real-world conditions. Methods: A cross-sectional study including 96 adults categorized as normal weight (NW), overweight (OW), or obese (OB) was conducted. Gait biomechanics were recorded using PODOSmart® intelligent insoles, which capture spatiotemporal and angular parameters during natural walking. Foot health, quality of life and comorbildities were evaluated throught valeted questionnarires. Differences between groups were analyzed using ANOVA and chi-square tests. Age and sex, known to influence gait, were comparable across BMI groups and were considered in the interpretation of the results. Results: Overall, the participants in the OB group exhibited reduced stride length, gait speed, and swing time, increased double-support time, and greater pronation–supination and progression angles than OW and NW participants. Partial eta-squared values (η2p) were predominantly medium to large, reinforcing the robustness of these between-group differences (e.g., double-support time, p > 0.001; η2p = 0.19). Individuals with obesity reported poorer general and foot health and more difficulty finding suitable footwear. BMI was also significantly associated with hypertension, dyslipidemia, arthritis, and depression (all p <0.05), whereas diabetes, cardiopathies, knee pain, and fatigue andwalking or social activity limitations showed no significant differences. Conclusions: By using portable gait analysis technology in ecological conditions, this study provides novel evidence of clinically meaningful gait impairments across BMI groups. Higher BMI is associated with clinically relevant gait impairments, poorer perceptions of foot and general health, and a higher prevalence of several comorbidities.

Healthcare doi: 10.3390/healthcare14091118

Authors: Ahmad Rajeh Saifan Murad Sawalha Ibtisam A. Alarabyat Hanan F. Alharbi Zyad Saleh Osama Alkouri Rani Shatnawi Dana Anwer Abujaber Rami Eid Samarah Nabeel Al-Yateem

Background: Telehealth has expanded access to care for people with chronic diseases, but little is known about how patients in Jordan become activated, motivated, and ready to use these services, particularly during early adoption. Aim: To explore how patients with chronic diseases in Jordan describe their initial activation, readiness, and experiences with telehealth services. Methods: This exploratory qualitative study used interviews with 14 purposively selected adults with chronic diseases from three hospitals in Jordan. Data was analyzed using Braun and Clarke’s six-step thematic analysis. Results: Four interrelated themes emerged. First, patients valued telehealth for preserving independence and ensuring continuity of care, particularly by reducing reliance on family members for transportation to health facilities. Second, readiness was shaped by geography, mobility, and finances. Although telehealth reduced transport costs and lost wages, patients still had to pay for devices and internet access, creating an economic paradox for poorer patients. Third, participation was supported by families but hindered by low digital literacy, platform changes, and unstable internet connectivity. Fourth, trust in telehealth was conditional and depended on patients’ perceptions of convenience and responsiveness. Conclusions: Readiness to use telehealth was relational, structural, experiential, and conditional rather than purely individual. Patients with chronic diseases in Jordan need hybrid care models that engage families and leverage affordable digital technologies to support sustained telehealth use for disease management.

Healthcare doi: 10.3390/healthcare14091117

Authors: Adil M. Hazara Maureen Twiddy Victoria Allgar Sunil Bhandari

Background: The optimal method of starting maintenance haemodialysis (HD) in patients with kidney failure is not known. We have compared early treatment characteristics, blood pressure trajectories, and selected dialysis-related safety events in patients who started HD using a stepped and phased approach, with those who received conventional care. Method: A single-centre cohort feasibility study was conducted. Participants with kidney failure, about to start maintenance HD, were enrolled prospectively (intervention arm). They started treatment on a novel regime comprising four pre-specified incremental steps (Phases 1 to 4) over 14 weeks. They were matched using propensity scores with historical controls: patients who had previously started HD on a three-times weekly basis from the outset (control arm). Results: The final cohort comprised 15 and 29 participants in the intervention and control arms respectively (1:2 ratio; one control excluded after matching). Intervention group participants were slightly older with a higher proportion of men. The rate of decline in blood pressure was slower in the intervention group. There were also signals for fewer events of intra-dialytic hypotension (211 vs. 379 per 100 person-year), infections not requiring admission (56 vs. 114 per 100 person-year) and loss of vascular access (56 vs. 79 per 100 person-year) in intervention group. There was a signal for higher incidence of severe hypertension (systolic BP ≥ 180 or diastolic BP ≥ 110 mmHg) in the intervention group. Hospitalisation rates were similar; there were no deaths and one non-fatal major cardiac event (MACE) in the intervention group, and one death and no MACE in the control group. Conclusions: Implementing a short transitional regime of incremental HD may be possible in clinical settings, potentially helping to reduce the gradient of physiological change and burden of early treatment. The findings of this feasibility study are exploratory, and fully powered randomised controlled trials are needed to establish the efficacy and safety of such a programme.

Healthcare doi: 10.3390/healthcare14091116

Authors: Seoyoon Heo Taeseok Choi Wansuk Choi

There was an error in the funding statement of the original publication [...]

Healthcare doi: 10.3390/healthcare14081115

Authors: Alexandra Herlaș-Pop Andrei-Flavius Radu Ada Radu Gabriela S. Bungau Delia Mirela Tit Cristiana Bustea Elena Emilia Babes

Background/Objectives: The intersection of mental health and acute coronary syndromes has become an increasingly prominent area of cardiovascular and psychosomatic research, yet its temporal dynamics and intellectual structure remain incompletely characterized. Methods: This study analyzed 13,646 peer-reviewed documents spanning five decades, employing advanced changepoint detection (PELT) algorithms, network visualization (VOSviewer), and bibliometric performance metrics (Bibliometrix) to quantify the evolution of the mental health–ACS intersection. Results: Statistical analysis identified two robust inflection points at 1990 and 2005 that demarcate distinct developmental periods. The 1990 breakpoint marked an important transition, although additional metadata-completeness analysis indicated that part of the increase from 72 to 142 publications may reflect improved availability of non-title Topic-field metadata in WoSCC around 1990–1991. The 2005 breakpoint represented the most critical transition (Cohen’s d = 4.05, p < 0.000001), initiating exponential growth from 349 to over 600 annual publications by 2022 and coinciding with growing research attention to psychiatric comorbidity within ACS literature. Keyword co-occurrence networks revealed a shift in research focus: early publications predominantly addressed mental health as a psychological reaction to cardiac events, whereas more recent publications increasingly frame depression, anxiety, and PTSD alongside mechanistic constructs such as inflammatory pathways, autonomic dysfunction, and platelet reactivity. Although seminal intervention trials (i.e., ENRICHD, SADHART) established pharmacological safety and symptom improvement, keyword analyses indicate that following these trials, research attention increasingly shifted toward precision psychiatry concepts and mechanistic pathway elucidation. Conclusions: These findings provide a quantitative map of how publication activity at the mental health–ACS intersection has evolved, offering a structured basis for identifying under-researched areas and informing future research agendas.

Healthcare doi: 10.3390/healthcare14081114

Authors: Eleonora Colella Hans-Christoph Pape Ladislav Mica

Background/Objectives: The purpose of this study was to examine the sex-specific distribution of traumatic spinal fractures and potential predictive clinical factors for a more well-founded treatment evaluation. Methods: This study is a retrospective cohort study. Data from electronic medical records were analyzed and compiled in a database. Demographic information, trauma-specific characteristics, and radiological measurements, as well as laboratory values and surgical treatments, were collected. Only surgical cases were included in this study. Statistical analyses were performed using the IBM SPSS Statistics program. Chi-square tests, effect sizes, and 95 confidence intervals were used for comparison of categorical variables, and means and standard deviations were calculated, as well as Levene’s test for equality and t-tests for analyzing continuous variables. The statistical significance was set at a two-tailed p < 0.05. Results: A total of 164 patients were included, with a mean age of 58.03 years. Statistically significant differences between sexes were found in age (p = 0.04), GCS (p = 0.03), hemoglobin (p = 0.03), hematocrit (p = 0.007), and the one-year post-surgical intervertebral angle (p = 0.004). AIS score showed statistically significant differences in the cervical and lumbar sections (p < 0.015; p = 0.022) and the overall spine (p = 0.049). No statistically significant difference in the HU values in the vertebra above the fracture was found between men and women. Women showed significantly larger one-year postoperative intervertebral angles than men. Conclusion: Vertebrae with lower HU values tend to collapse despite stable surgical treatment; therefore, additional bone quality assessment should be contemplated. These findings highlight sex-specific considerations for future clinical decision-making.

Healthcare doi: 10.3390/healthcare14081113

Authors: Nuha Mahdi Hashim A. Mahdi

Background: The present study aimed to assess the caregiving burden among family caregivers of adult patients with various cancer types and stages in the Kingdom of Saudi Arabia (KSA), and to examine the associations with caregiver and patient characteristics. Materials and Methods: A cross-sectional study involving 212 family caregivers of cancer patients was conducted between March and April 2024 at King Abdullah Medical City in Makkah, KSA. The Arabic version of the Zarit Burden Interview (ZBI) scale was used to assess overall and specific burdens. Associations between overall burden and sociodemographic variables were analyzed using significance tests. Results: Over half (55%) of participants experienced burden, with a mean ZBI score of 26.33 ± 16.86, indicating a mild to moderate level. Low levels of psychological (7.34 ± 5.41), social (2.27 ± 2.93), physical (1.96 ± 2.22), and financial (1.22 ± 1.41) burdens were found. Financial difficulties and patient immobility significantly contributed to higher burden scores. Caregivers with financial hardships scored higher (31 ± 14.8 vs. 24 ± 17.3, p = 0.01), and those caring for bedridden patients experienced greater burdens (38 ± 21.8 vs. 18 ± 12.5, p = 0.001). Conclusions: Although financial difficulties and patient immobility significantly contribute to caregiver burden, the overall burden in the Makkah region remains relatively moderate. Strong cultural and familial support systems in KSA may alleviate challenges, yet coping strategies targeting financial and physical burdens are necessary.

Healthcare doi: 10.3390/healthcare14081111

Authors: Bandar S. Alharbi Majed M. Aljabri Endale Alemayehu Ali

Background: Psychological stress is a common concern among university students, which is also pronounced among nursing students due to the academic and clinical demands of their training. Persistent stress can negatively affect students’ mental well-being, academic performance, and professional development. Social support has been identified as an important protective factor. However, evidence on the relationship between perceived social support and stress among nursing students in Middle Eastern educational contexts remains limited. Methods: A cross-sectional survey was conducted among nursing students. The survey included the Multidimensional Scale of Perceived Social Support (MSPSS) and the 10-item Perceived Stress Scale (PSS-10), along with sociodemographic and academic characteristics. Multivariable linear regression was used to examine the association between perceived social support and perceived stress after adjusting for age group, sex, program type, living arrangement, and employment status. Differences in stress across levels of social support were also examined using analysis of variance (ANOVA). Results: A total of 182 nursing students participated in the study. The mean perceived social support score was 4.95 (SD = 1.42), while the mean perceived stress score was 15.49 (SD = 2.82). We found that higher perceived social support was significantly associated with lower perceived stress (β = −1.9, 95% CI: −3.4 to −0.44), indicating that a one-point increase in the MSPSS score was associated with a 1.9-point decrease in perceived stress. Other sociodemographic factors were not significantly associated with stress. ANOVA indicated significant differences in stress across social support levels (F(2,179) = 6.91, p = 0.001). Conclusions: Perceived social support was significantly associated with lower levels of perceived stress among nursing students. These findings highlight the potential importance of strengthening supportive social environments to promote psychological well-being in nursing education.

Healthcare doi: 10.3390/healthcare14081112

Authors: Mitar Saveljic Milovan Roganovic Emir Muzurovic Nikica Sutalo Marin Mamic Sanja Plestina

Background: Psychological distress, including anxiety, stress, and depression, is common and expected in women with newly diagnosed metastatic breast (MBC) or lung (MLC) cancer. This study examined short-term changes in depression, anxiety, and stress and the associations of such changes with demographic, lifestyle, and religiosity factors. Methods: This prospective longitudinal study included 121 women (66 with MBC and 55 with MLC) who attended two oncology clinics in Montenegro between July 2024 and February 2025. Psychological symptoms were assessed at baseline (T1) and three months after treatment initiation (T2) using the Depression Anxiety Stress Scale-21 (DASS-21) and the Anxiety Sensitivity Index (ASI). Due to the non-normal distribution of residuals, multivariable quantile regression models (median regression, tau = 0.5) were used to examine independent predictors of psychological outcomes at T2, adjusting for baseline symptom severity, demographics, and clinical factors. Results: Baseline DASS-21 and ASI scores were comparable between the MBC and MLC patients. At three-month follow-up, depressive symptoms decreased in the overall cohort, driven by improvement among patients with MLC. Patients with MBC showed increased anxiety and stress over time, whereas patients with MLC showed reductions in depression and stress. At follow-up, anxiety was significantly higher in the MBC group than in the MLC group. The perceived importance of faith showed weak negative correlations with distress (ρ ranging from −0.227 to −0.242; all p = 0.01), while younger age was strongly associated with higher baseline distress in the MLC group (ρ = −0.431 to −0.688; all p < 0.001). In the multivariable median regression models, baseline symptom severity was the strongest predictor of psychological outcomes at T2 (p < 0.001). Additionally, cancer type was a significant independent predictor of depression at follow-up (B = −1.258; p < 0.001), with MLC associated with lower scores compared to MBC. Conclusions: Psychological distress is a common phenomenon during the first months after the diagnosis of metastatic cancer. Our results support the importance of early psychological assessment and tailored support in routine oncology practice.

Healthcare doi: 10.3390/healthcare14081110

Authors: Anders Valentin Johansen Christine Elise Swane Lotte Evron Laila Twisttmann Bay Sinthuja Vasantharajan Dorthe Susanne Nielsen

Background/Objectives: Older adults with an LGBT+ identity represent an under-researched population within healthcare systems. Existing evidence suggests that they experience distinct health challenges compared to their heterosexual counterparts, partly shaped by lifelong experiences of stigma and discrimination. Such experiences may contribute to minority stress, which is associated with adverse mental health outcomes and lifestyle-related health issues. This review aims to synthesise the existing literature on how older adults with an LGBT+ identity experience encounters with healthcare. Methods: An integrative literature review was conducted following PRISMA guidelines. A systematic search of multiple databases was performed, and studies were screened using predefined inclusion and exclusion criteria. Data were analysed using systematic text condensation. Results: A total of 18 studies were included, comprising approximately 450 participants. All studies contained a qualitative component. Three overarching themes were identified: (1) double-edged discrimination—experiences of stigma and anticipated fear in healthcare; (2) relational networks as essential yet fragile sources of support in later life; and (3) healthcare practices as shaping inclusion or invisibility—the need for competence and recognition. Conclusions: The findings highlight significant barriers faced by older adults with an LGBT+ identity in healthcare, including fear of discrimination and challenges related to disclosure. Social networks play a crucial role as sources of support, while healthcare professionals’ competencies and practices are central to ensuring inclusive and equitable care.

Healthcare doi: 10.3390/healthcare14081108

Authors: Yuting Lu Wenliang Guo Yanlin Zou Ailing Wei Jianwen Xu

Background: Autism Spectrum Disorder (ASD) is a heterogeneous neurodevelopmental condition for which non-pharmacological interventions remain the primary therapeutic approach. Although research output in this field has increased substantially, a comprehensive synthesis of its developmental trajectory and emerging directions is still lacking. Methods: We conducted a bibliometric analysis of publications on non-pharmacological interventions for ASD indexed in the Web of Science Core Collection between 2001 and 2025. Knowledge structures, research hotspots, and temporal trends were visualized and analyzed using CiteSpace. Results: The field has transitioned from an early focus on behavioral interventions in children to a diversified and interdisciplinary research ecosystem spanning the lifespan. Recent growth has been driven by the integration of neuroscience-based approaches, particularly neuromodulation techniques, alongside continued refinement of behavioral, sensorimotor, and complementary therapies. Increasing attention has been paid to individual heterogeneity, methodological rigor, and mechanism-oriented research. Current frontiers emphasize multimodal intervention strategies, neural plasticity-based mechanisms, and the development of personalized precision intervention frameworks. Conclusions: This bibliometric analysis delineates the intellectual evolution of non-pharmacological intervention research for ASD and identifies key research gaps, particularly the need for longitudinal and pragmatic studies targeting individualized treatment response. The findings provide an evidence-informed overview of current concepts and emerging research directions in non-pharmacological care for ASD, with important implications for future clinical research, intervention design, and strategic research planning.

Healthcare doi: 10.3390/healthcare14081109

Authors: Anwar Alhashem Norah Aldarwish Rahaf Almoqbel Reem Alsaeed Sabba Alanazi Mohammed S. Khusheim

Background/Objectives: Falls are a significant public health issue and the second most common cause of injury and death worldwide. The risk is exceptionally high for older adults, and fall-related injuries can significantly affect their well-being and lead to pain, disability, and loss of independence, necessitating urgent redressal of this issue. This study assesses the fall risk among older patients at a referral hospital in Riyadh, Saudi Arabia. Methods: This cross-sectional study included 246 older adults aged 65 years and older from the Internal Medicine Department. Data were gathered through a survey addressing sociodemographic characteristics, fall risk assessment, prevention knowledge, behaviors, and social support. Results: A high fall risk and good knowledge of fall prevention were observed in older adults. A weak-to-moderate positive correlation was found between behavior and fall risk. Correlations were observed among age, fall prevention behavior, educational level, and fall prevention knowledge. Conclusions: While a weak-to-moderate positive association was found between fall risk and positive behaviors, no statistically significant association was observed between fall risk and fall prevention knowledge or social support. This indicates that factors other than knowledge and social support may play a critical role in influencing fall risk. Behavioral interventions alone may not reduce fall incidence sufficiently unless other underlying factors are addressed.

Healthcare doi: 10.3390/healthcare14081107

Authors: Micaela Di Consiglio Francesca D’Olimpio Alessandro Couyoumdjian

Background: Self-criticism is a transdiagnostic factor associated with psychological distress and poorer outcomes in traditional psychotherapy, yet recent evidence suggests it may facilitate change in preventive and low-intensity interventions. This study examined the role of self-criticism in adherence, working alliance, and outcomes within NoiBene, a guided self-help program designed to promote well-being and prevent psychological distress among non-clinical university students. Methods: A total of 455 participants (82% female; M = 23.5 years) completed measures of internalized and comparative self-criticism, and key psychological processes (e.g., emotional awareness, rumination, worry, perfectionism, psychological inflexibility, and assertiveness) were assessed before and after the intervention. Adherence and working alliance were measured only after the intervention. Results: Contrary to evidence from clinical settings, severe self-criticism was not associated with increased dropout or weaker alliance. Instead, individuals with severe self-criticism exhibited the greatest improvements across multiple domains, suggesting a higher potential for therapeutic gain. Moreover, participants with moderate levels of both internalized and comparative self-criticism showed higher dropout and lower adherence. Conclusions: These findings indicate that, in preventive guided self-help contexts, self-criticism does not necessarily hinder engagement and outcomes and may, under certain conditions, function as a catalyst for change. Implications for tailoring digital preventive interventions and addressing dropout risk are discussed.

Healthcare doi: 10.3390/healthcare14081106

Authors: Chiara Bianchi Laura Rotondo Claudio Bersani Rita Pavasini Federico Marchini Serena Caglioni Andrea Raisi Gianluca Campo Elisabetta Tonet

Background: Psychological distress, autonomic dysregulation, and unhealthy lifestyle behaviors are common after myocardial infarction (MI) and negatively affect cardiovascular outcomes. In recent years, integrative mind–body interventions, such as yoga and mindfulness-based approaches, have gained increasing attention as adjuncts to conventional cardiac rehabilitation (CR) programs. However, evidence regarding their effectiveness in post-MI populations remains fragmented. Objective: This systematic review aimed to synthesize the available evidence on the effects of yoga- and mindfulness-based interventions in patients following myocardial infarction. Methods: A systematic literature search was conducted across major electronic databases to identify randomized controlled trials and observational studies evaluating yoga- or mindfulness-based interventions in post-MI patients. Eligible studies included adult MI populations. Study selection and quality assessment were performed according to predefined criteria. Results: The 10 included studies suggest that yoga-based cardiac rehabilitation programs may provide benefits beyond standard care, particularly in terms of self-rated health, psychological well-being, and return to pre-infarction daily activities. Mindfulness-based interventions were associated with reductions in anxiety and perceived stress, improvements in blood pressure control, enhanced social support, and better health-related quality of life. Several studies also reported favorable effects on autonomic balance and stress-related physiological markers. Finally, a study reported benefits in terms of MACE (p = 0.032). However, heterogeneity in intervention protocols, outcome measures, and study designs limited direct comparisons across studies. Conclusions: Yoga and mindfulness-based interventions appear to be promising complementary strategies in post-MI care.

Healthcare doi: 10.3390/healthcare14081105

Authors: Mahmud Sehwail Khader Rasras Wisam Sehwail Pau Pérez-Sales Andrea Galan-Santamarina Raluca Cosmina Budian

Background: Torture, as a fundamental violation of human rights, is unequivocally condemned by all international organizations. Sexual torture is one of the most severe forms of torture, encompassing forced nudity, various forms of humiliation, and physical abuse, including rape. Despite testimonial evidence indicating the incidental use of sexual torture by Israeli authorities, there is a lack of epidemiological research providing a comprehensive understanding of this issue. This study aims to analyze the prevalence and characteristics of ill treatment and sexual torture among Palestinian male detainees and the subsequent impacts. Methods: This cross-sectional study analyzed a database of 517 former male detainees. The interview protocol included items related to psychological and physical methods of sexual torture, medical impacts, subjective psychological impacts, clinical medical and psychological measures, and psychosocial and community impacts. Results: The findings indicate that the majority of detainees experienced some form of sexual torture, with humiliation being the most common type. The impact of sexual torture are severe, affecting both clinical and social domains. The impacts of sexual torture persist over time and, in some cases, worsen, particularly regarding physical health outcomes. Socially, the consequences extend to the detainees’ families and communities. Conclusions: The prevalence of such torture tactics calls for urgent responses from both the authorities and civil society. These findings highlight the need for proactive measures to address and mitigate the impacts of sexual torture, including independent investigations, robust monitoring, secure reporting mechanisms, the prosecution of perpetrators and comprehensive reparation for victims.

Healthcare doi: 10.3390/healthcare14081104

Authors: Carol Moussa Marion Mégly Jeremy Glomet Maha H. Daou Céline Clement Frédéric Denis

Oral diseases affect an estimated 3.5 billion people globally and remain among the most prevalent noncommunicable conditions. Despite recent global policy commitments under the WHO Global Oral Health Strategy and Action Plan (2023–2030), substantial variation persists in how countries structurally embed oral health within national health systems. A structural classification of all 194 WHO Member States was conducted using WHO 2022 oral health country profiles and official policy documentation. Countries were categorized according to financing architecture and entitlement design into four integration models: Structural UHC Integration, Partial or Targeted Integration, Predominantly Private or Insurance-Driven Systems, and Minimal or Emerging Integration. Regional and global distributions were calculated using RStudio (version 2025.09.0, Posit Software, PBC, Boston, MA, USA). Globally, Partial or Targeted Integration represents the most common configuration (44%), followed by Predominantly Private systems (17%) and Minimal or Emerging Integration (15%), while Structural UHC Integration accounts for approximately 10% of countries. Marked regional heterogeneity was observed, with Structural UHC Integration concentrated in selected regions and Minimal or Emerging models more prevalent in parts of Africa and South-East Asia. Findings suggest that integration is primarily determined by financing architecture and legally defined entitlements rather than national income level alone. Structural embedding of oral health within pooled universal coverage mechanisms appears to be an important structural feature associated with higher levels of integration.

Healthcare doi: 10.3390/healthcare14081103

Authors: Tobias Hübner Oliver Schöffski

Background: Sepsis remains a major global health challenge, associated with high mortality, prolonged intensive care unit (ICU) stays, and disproportionate healthcare costs. CytoSorb hemoadsorption offers a potential adjunct in septic shock, but real-world cost-effectiveness data in Diagnosis-Related Group (DRG)-based systems are limited. This study aimed to evaluate the clinical and economic impact of CytoSorb therapy in ICU patients with septic shock at a high-volume Swiss tertiary care center. Methods: A retrospective observational cohort study (2020–2023) was conducted at Kantonsspital Münsterlingen. Among 246 septic shock patients, 142 received CytoSorb therapy and 104 standard care. Patients were grouped according to treatment exposure. Baseline characteristics as well as ICU course variables, including sepsis origin, Simplified Acute Physiology Score (SAPS) II, and the Nine Equivalents of Nursing Manpower Use Score (NEMS), were compared between groups. Clinical outcomes included ICU/hospital length of stay (LOS) and duration of mechanical ventilation. Economic analysis included DRG-based revenue, direct case-related hospital costs, and net financial results. Results: CytoSorb-treated patients had significantly higher SAPS II scores at baseline. Despite higher initial acuity, this group showed a significantly shorter ICU LOS (median 408.5 vs. 554.5 h; p = 0.001), reduced hospital LOS (23.5 vs. 30.0 days; p = 0.008), and lower nursing workload (>20% NEMS point reduction; p = 0.015). Survivors treated with CytoSorb had significantly shorter ventilation durations (164.0 vs. 336.0 h; p = 0.014). Total hospital costs were not significantly different between groups; however, CytoSorb patients achieved a significantly better net financial result (CHF 17,125 vs. –1930; p = 0.025), particularly in the abdominal and pneumogenic sepsis subgroups. Conclusions: This study provides the first real-world evidence for the cost-effectiveness of CytoSorb hemoadsorption in septic shock, showing reduced ICU length of stay and improved financial outcomes, without increasing treatment costs or nursing workload. These findings challenge the perception of hemoadsorption as a cost driver and highlight its potential to optimize resource use in critical care. Further multicenter studies are needed to inform reimbursement strategies and integration into sepsis treatment protocols.

Healthcare doi: 10.3390/healthcare14081102

Authors: Meighan Mary Sarah Clifford Andreea A. Creanga

Background/Objectives: Hypertensive disorders of pregnancy (HDPs) affect approximately one in seven hospital deliveries in the United States and increase the risk of pregnancy-associated mortality. Home blood pressure monitoring (HBPM) for patients with HDPs has emerged as a model of care poised to improve ascertainment of blood pressure and triage of care during pregnancy and postpartum periods. However, the strength of evidence supporting HBPM approaches has been variable. This rapid review aimed to understand how HBPM approaches for pregnant and postpartum populations with HDPs have been evaluated in order to strengthen future research. Methods: Search criteria included peer-reviewed literature in English and French published during 2018–2024 that assessed HBPM approaches for pregnant and postpartum populations in high-income countries. A total of 370 records were screened and reviewed to identify 52 eligible articles. Key study characteristics, methodologies, and outcome measures were extracted. Identified outcome measures were mapped by outcome type (implementation, health service, and client) to assess gaps in evaluation of HBPM approaches. Results: A range of study designs were employed to evaluate HBPM approaches: experimental (17%), observational (52%), qualitative (10%), mixed method (10%), and economic (11%) designs. Over a third employed a comparison group, most of which compared HBPM approaches to usual antepartum or postpartum care. Only 11 studies reported on impact outcomes (long-term blood pressure control, adverse maternal and perinatal outcomes). Significant gaps were identified among the implementation outcomes examined. While patient engagement measures were common, assessment of provider adherence and engagement was limited. Hospital admissions and emergency department visits were often employed as proxies to measure HBPM effectiveness, efficiency, and safety. However, no studies adequately reported effectiveness measures for remote patient triage. Conclusions: Our results call for improved HBPM metrics to ensure patients are receiving high-quality care responsive to their clinical condition. Future studies on HBPM approaches should prioritize more transparent reporting on health actor engagement. A composite measure including both patient and provider adherence to monitoring and triage processes will provide stronger evidence on the effectiveness of HBPM for pregnant and postpartum patients and share impactful learning for health systems interested in adopting HBPM approaches.

Healthcare doi: 10.3390/healthcare14081101

Authors: Ahmed M. Alhuwaydi Oqab Ahmed F. Alsharari Abdulelah Faisal A. Alfandi Ahmed Meshal H. Alorayyidh Abdulrahman Yousef A. Alfayyadh Ashokkumar Thirunavukkarasu Aliyah Muteb Al-Ruwaili

Background and objectives: Mental health assessment of healthcare workers (HCWs) is essential to inform prevention-oriented policies and interdisciplinary support strategies to strengthen HCWs’ mental health and optimize patient care. Therefore, the present study assessed mental health status and associated factors of HCWs using the DASS-21. Methods: Using a cross-sectional study design and the standardized DASS-21 questionnaire, we assessed the mental health status of HCWs of different categories from various healthcare settings of northern Saudi Arabia. A binomial logistic regression analysis was performed to examine the factors associated with each DASS-21 domain. Finally, Spearman’s correlation test was done to find the correlation across the domains. Results: Of the 385 participants, some forms of depression, anxiety, and stress were found in 49.6%, 49.4%, and 39.0% of the participants, respectively. Extremely severe symptoms were observed in depression and anxiety (9.6% each), and the lowest were observed for stress (3.9%). Depression was significantly associated with female gender (p = 0.017) and being single (p = 0.043), while anxiety was associated with nurses (p = 0.002) and non-Saudi nationality (p = 0.037). Stress was higher among HCWs working in specialty hospitals (p = 0.045) and lower among those aged > 40 years (p = 0.003). Furthermore, a positive correlation was noted within each DASS-21 domain (p < 0.001). Conclusions: Given the high prevalence of mental health issues, the relevant authorities should consider implementing preventative measures, including regular screening, psychoeducation workshops, interdisciplinary care, and proper referral pathways for the HCWs who screen positive for any of the mental health domains.

Healthcare doi: 10.3390/healthcare14081094

Authors: Yeeun Park Jin-hyoung Jeong

Background: Early screening of cognitive impairment is essential for timely clinical intervention; however, conventional cognitive tests such as the Mini-Mental State Examination (MMSE) rely on fixed thresholds that may not be optimal in real-world screening settings. Methods: This study developed a threshold-aware multimodal screening framework integrating MMSE item-level scores with wearable-derived sleep and physical activity lifelog data. A dataset of 174 adults was analyzed and categorized into cognitively normal (CN), mild cognitive impairment (MCI), and dementia, with MCI and dementia combined as an impaired group. A CatBoost-based binary classification model was trained using five-fold cross-validation. The optimal decision threshold was determined by maximizing balanced accuracy using out-of-fold predictions. Results: The optimized threshold (0.49) achieved an accuracy of 0.818 and a balanced accuracy of 0.728 on the validation set. The recall values were 0.885 for CN and 0.571 for the impaired group, with an area under the ROC curve of 0.676. Feature importance and stability analyses showed that variability-related sleep and activity features were consistently selected across folds. Conclusions: These findings suggest that threshold optimization combined with multimodal lifelog integration may improve the interpretability of screening decisions. Variability-based lifelog features may provide complementary information alongside MMSE, although their role remains exploratory and requires further validation in larger and longitudinal cohorts.

Healthcare doi: 10.3390/healthcare14081100

Authors: Claudia Vinciguerra Ignazio Leale Nicasio Rini Fabio Tiziano Orlando Liliana Bevilacqua Paolo Barone Filippo Brighina Vincenzo Di Stefano Giuseppe Battaglia

Background: Myasthenia gravis (MG) is a chronic autoimmune disorder characterized by fluctuating skeletal muscle weakness and fatigue, leading to reduced functional independence and impaired quality of life (QoL). Although exercise has historically been discouraged due to concerns about symptom exacerbation, emerging evidence suggest that structured exercise programs may be safe and beneficial in clinically stable patients. This systematic review critically evaluates current evidence on exercise and physical activity interventions in MG, focusing on effectiveness, safety, and impact on functional outcomes, fatigue, and QoL. Materials and Methods: A systematic review was conducted following PRISMA guidelines. Searches were performed in PubMed, Web of Science, Google Scholar, Scopus and ScienceDirect for studies published between 2015 and 2025. Keywords included MG, physical activity, aerobic training, resistance training, and respiratory muscle training. Methodological quality was assessed using the Downs and Black checklist. Results: Eight controlled studies met the inclusion criteria, encompassing aerobic, resistance, combined, and respiratory muscle training interventions. Sample sizes ranged from small pilot studies to moderate-size randomized controlled trials. Overall, exercise interventions were well tolerated, with no evidence of sustained symptoms exacerbation. Aerobic and combined programs consistently improved functional capacity, muscle strength, and activities of daily living. Respiratory muscle training demonstrated improvements in pulmonary function and inspiratory muscle strength, although findings were more heterogeneous. Study quality ranged from poor to excellent, with common limitations including small sample size, short follow-up duration, and heterogeneity in exercise programs. Conclusions: Current evidence supports the safety and potential efficacy of individualized, symptom-guided exercise interventions in clinically stable MG. Regular physical activity exercise may reduce secondary deconditioning, improve functional outcomes, and enhance QoL. However, larger, high-quality randomized controlled trials with standardized programs and longer follow-up periods are required to strengthen clinical recommendations and clarify long-term effects.

Healthcare doi: 10.3390/healthcare14081099

Authors: Kyungman Cha Youngjin Kim Sohee Lee Jaekwang Shin Jee Yong Lim

Background/Objectives: Emergency department (ED) overcrowding burdens rural and remote areas where geographic isolation limits timely care. The Compact Emergency Unit (CEU)—a 24 h facility with remote physician oversight—has been proposed but lacks an empirical foundation. We aimed to (1) quantify CEU-eligible (final KTAS 4–5) patients in a multicenter ED cohort; (2) compare their operational metrics with non-eligible patients; (3) characterize hourly demand for facility planning; and (4) develop machine-learning models for non-discharge prediction within this low-acuity stratum. Methods: Retrospective analysis of 12 months (January–December 2025) of NEDIS data from two Korean university-affiliated EDs. Effect sizes (Cliff’s δ, Cramér’s V) were reported alongside p-values. Three classifiers (logistic regression, random forest, and XGBoost) were developed with patient-level cross-validation, comparing a 16-feature baseline and a 22-feature set augmented with arrival vital signs. Calibration and decision curve analysis were performed. Results: Of 34,544 valid triage visits (27,743 unique patients), 9871 (28.6%) were CEU-eligible. They had shorter LOS (92 vs. 171 min; Cliff’s δ = −0.51), 98.8% symptomatic home discharge, and a median of 0 specialty consultations. Nighttime visits comprised 43.7% of CEU-eligible encounters, peaking at 20:00 (1.76 visits/h/day). The non-discharge rate was 1.20% (118/9871). The vital-augmented random forest reached AUROC 0.794 (95% CI 0.758–0.829); XGBoost calibration was near-perfect (ECE 0.020). A combined ML-or-vital-sign screening rule raised non-discharge sensitivity to 94.1%. Conclusions: Approximately 29% of ED visits could be CEU-suitable. Single-modality machine learning is insufficient for safety-critical triage, but a layered ML-plus-vitals screening approach achieves operationally relevant sensitivity. Prospective implementation studies are required before clinical deployment.

Healthcare doi: 10.3390/healthcare14081097

Authors: Roberto Zegarra-Chapoñan Jhon Alex Zeladita-Huaman Rosa Castro-Murillo Flor De Jeanette Blas Bergara Eduardo Franco-Chalco Nataly Julissa Membrillo-Pillpe Henry Castillo-Parra Gabriela Samillán-Yncio Laryn Smith

Background: This study aims to psychometrically validate the abbreviated version of the Connor–Davidson Resilience Scale (CD-RISC-10) in Peruvian nurses, evaluating its convergent validity through its association with perceived stress and empathy. Methods: A cross-sectional psychometric study was conducted in 374 Peruvian nurses to evaluate the psychometric properties of CD-RISC-10 through confirmatory factor analysis (CFA). Furthermore, concurrent validity was assessed through correlational analysis using Spearman’s rho coefficient to evaluate the relationships among resilience, perceived stress, and empathy. Results: The CFA supported the predominantly one-dimensional model showing an adequate fit when the residual covariance between Items 4 and 7 was specified after correlating the residuals of Items 4 and 7 (CFI = 0.978, TLI = 0.971, RMSEA = 0.080, and SRMR = 0.044). Ordinal Cronbach’s alpha of 0.89 and McDonald’s omega of 0.81 were obtained. Concurrent validity showed significant correlations with perceived stress (rho = −0.53, p < 0.001) and empathy (rho = 0.31, p < 0.001). Conclusions: The CD-RISC-10 has adequate psychometric properties in Peruvian nurses. Future studies are needed to evaluate its factorial invariance between clinical specialties and establish normative thresholds.

Healthcare doi: 10.3390/healthcare14081098

Authors: Fatma Eren Akgün Metin Akgün

Background/Objectives: Large language models (LLMs) such as ChatGPT are rapidly being integrated into healthcare for tasks ranging from clinical documentation to diagnostic support. Current ethical discussions focus predominantly on bias, privacy, and accuracy, leaving three critical governance questions unresolved: What kind of knowledge does an LLM output represent in clinical reasoning? When is a clinician’s or patient’s trust in that output justified? Who bears responsibility when an AI-informed decision leads to patient harm? This study proposes the Epistemic Authority–Trust–Responsibility (ETR) Architecture, a normative conceptual framework that addresses these three questions as an integrated governance challenge. Methods: The framework was developed through normative conceptual analysis—a method that constructs governance proposals by synthesising philosophical principles, ethical theories, and empirical evidence. The literature was identified through structured searches of PubMed, PhilPapers, and EUR-Lex (January 2020–March 2026), drawing on the philosophy of medical knowledge, the ethics of trust and testimony, and the moral philosophy of responsibility. Results: The ETR Architecture produces four outputs: (i) a four-tier classification system that distinguishes LLM outputs—from administrative drafts to clinical evidence claims—and matches each tier to appropriate verification requirements; (ii) the concept of the ‘epistemic placebo’, formally defined as a governance measure that creates a documented appearance of compliance while lacking at least one operative element of genuine oversight; (iii) a model specifying four conditions under which trust in healthcare AI is justified; (iv) four testable hypotheses with associated research designs connecting governance design to trust calibration and patient safety. Conclusions: The 2025–2027 regulatory transition period offers a critical window for shaping how healthcare institutions govern AI. We argue that deploying LLMs without explicitly classifying their outputs and building appropriate oversight risks allows governance norms to be set by technology vendors rather than by evidence-informed, patient-centred policy.

Healthcare doi: 10.3390/healthcare14081092

Authors: Carmen Pantis Mihaela Simona Popoviciu Timea Claudia Ghitea Alina Manuela Pop Roxana Daniela Brata

Background: Length of stay (LOS) reflects healthcare utilization but may also capture patient clinical trajectories. We investigated the relationship between LOS categories, organ support requirements, and in-hospital mortality. Methods: This retrospective observational study included 1332 consecutive adult ICU patients in a tertiary-care center. ICU LOS patterns were categorized using median-based and predefined cutoffs. Multivariable logistic regression was used to identify independent predictors of in-hospital mortality. Results: Prolonged ICU LOS was associated with higher crude mortality (61.0% vs. 43.5%, p < 0.001). However, in LOS-adjusted models, mortality was independently associated with mechanical ventilation (aOR 29.89, 95% CI 17.92–49.86), inotropic support (aOR 4.94, 95% CI 3.50–6.97), hemodialysis (aOR 5.43, 95% CI 2.52–11.72), older age, and diabetes mellitus. Prolonged LOS was not independently associated with mortality (aOR 0.93, p = 0.630). Conclusions: LOS reflects underlying disease severity rather than acting as an independent driver of mortality. Integrating LOS pattern assessment with markers of organ dysfunction may improve risk stratification and resource planning in hospitalized populations.

Healthcare doi: 10.3390/healthcare14081096

Authors: Runping Zhu Zunbin Huo Yue Li Banlinxin Gao Richard Krever

Background: Doctors have made increasing use of artificial intelligence-based clinical decision support systems in recent years in eastern China, but far less so in poorer western China, where hospitals with less access to specialized expert services might be expected to make greater use of such aids. Methods: This study of the reasons for lower uptake in the western hospitals focused on a tertiary referral hospital in the capital city of the poorest province in China. Drawing on UTAUT (unified theory of acceptance and use of technology) theoretical literature and previous studies, seven variables most likely to explain the limited adoption of the technology were identified and tested by means of an explanatory sequential mixed-methods study. Results: Initial bivariate tests revealed no significant differences across variables; however, multivariate logistic regression identified social influence as the sole statistically significant predictor of adoption willingness. Follow-up structured interviews revealed a surprisingly low awareness of the technology by medical personnel, with very limited deployment. Conclusions: The failure to adopt AI diagnosis technology is attributable not to the variables usually cited as factors inhibiting technology adoption but rather the failure of hospital and medical faculty administrators to acquire the technology and train doctors and medical students.

Healthcare doi: 10.3390/healthcare14081093

Authors: Kristína Doležalová Ricardo Massmann Ľubomír Soják Lucia Kročková Matej Bendžala Eliška Marešová Peter Mihalov Soňa Kašická Mária Borsányiová Jakub Vallo Peter Sabaka

Background: The full-scale Russian invasion of Ukraine in 2022 triggered the largest displacement crisis in Europe in recent decades. Displacement may affect both clinical outcomes and mental health among people living with HIV (PLHIV). Evidence comparing displaced PLHIV with host-country patients within the same healthcare system remains limited. This study aimed to compare epidemiological characteristics, clinical staging, and mental health outcomes between war-displaced Ukrainian PLHIV and Slovak PLHIV receiving care in the same clinical setting, with particular attention to sex-specific differences. Methods: This cross-sectional study included 137 PLHIV receiving care at the HIV/AIDS Centre, University Hospital Bratislava, Slovakia (69 from Ukraine and 68 from Slovakia). Anxiety and depressive symptoms were assessed using the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) scales. Scores were categorized into three severity groups (0–4, 5–9, ≥10). Results: Age distribution was comparable between cohorts (p = 0.2438). Transmission patterns differed substantially: heterosexual transmission predominated among Ukrainian participants, whereas men who have sex with men (MSM) transmission predominated among Slovak men (p < 0.001). Ukrainian patients were more frequently classified in CDC stage C, while Slovak patients more often presented in stage A. The combined antiretroviral therapy coverage was 100% in both cohorts and viral suppression rates were high (HIV RNA < 200 copies/mL: 91.3% in Ukraine vs. 94.1% in Slovakia). Overall anxiety and depressive symptom severity did not differ significantly between cohorts (GAD-7 p = 0.4145; PHQ-9 p = 0.7661). However, within the Ukrainian cohort, women demonstrated higher depressive symptom severity compared with men (p = 0.0478). Conclusions: War-displaced Ukrainian PLHIV achieved comparable biomedical outcomes to host-country patients within a structured healthcare system. However, depressive vulnerability emerged at the intersection of gender and displacement. These findings highlight the importance of integrating gender-sensitive mental health screening and psychosocial support into routine HIV care for displaced populations.

Healthcare doi: 10.3390/healthcare14081095

Authors: Fatma Ayşin Kurak Ersin Taşatan Hayriye Deniz Şelimen

Background/Objectives: Culturally responsive care requires both intercultural communication competence (ICC) and empathy; however, these constructs are often examined separately in nursing research. This study aimed to (i) describe nurses’ ICC and empathy levels, (ii) test the association between ICC and empathy, and (iii) examine group differences by selected demographic and professional variables. Methods: A quantitative, cross-sectional correlational design was conducted with 300 nurses recruited from state and private hospitals. ICC was measured using the Arasaratnam Intercultural Communication Competence Scale (cognitive, affective, and total), and empathy was assessed using the 18-item Jefferson Scale of Empathy (compassionate care, perspective taking, standing in the patient’s shoes, and total). Data were analyzed with descriptive statistics, Pearson correlations, independent-samples t-tests, and one-way ANOVAs with Scheffé post hoc tests (α = 0.05). Results: Both ICC and empathy were above the scale midpoint. Cognitive ICC (M = 4.71, SD = 1.42) exceeded affective ICC (M = 4.35, SD = 1.34), and total empathy was high (M = 4.50, SD = 0.90), with compassionate care as the highest subscale (M = 4.60, SD = 1.10). ICC total was moderately correlated with total empathy (r = 0.607, p < 0.05); affective ICC correlated with compassionate care (r = 0.455) and perspective taking (r = 0.493). Male nurses reported higher ICC than female nurses (p < 0.05), while empathy did not differ by gender. Younger nurses (20–29) scored higher in ICC and empathy than older groups, and nurses with ≥28 years of experience also showed elevated levels. Nurses who willingly chose nursing had higher ICC and empathy across dimensions (all p < 0.001). Hospital type showed minimal differences except for “standing in the patient’s shoes” (private > state, p = 0.04). Conclusions: ICC and empathy were generally high and interrelated among nurses, with meaningful variation across workforce characteristics. Training should emphasize experiential and reflective approaches to strengthen affective ICC and perspective taking, while organizational strategies should foster intrinsic motivation and support professional development across career stages.

Healthcare doi: 10.3390/healthcare14081091

Authors: Akef Obeidat Abdal Ahmad Akhtar Hussain Saeed Ahmad Hidayat Ullah Mahmood Ul Hassan Muhammad Abrar Sadia Qazi

Background: Long-bone non-unions complicated by osteomyelitis remain a major reconstructive and healthcare challenge, particularly in resource-limited settings with a high prevalence of multidrug-resistant (MDR) pathogens. Conventional staged management is associated with a prolonged treatment burden, repeated procedures, and delayed functional recovery. This study evaluated the clinical, radiological, functional, and short-term safety outcomes of a single-stage approach using custom-threaded antibiotic-coated locking nails (TACLNs) in a high-resistance cohort. Methods: This prospective single-center cohort study enrolled 30 adults with osteomyelitis-associated femoral or tibial nonunion at a tertiary hospital in Peshawar, Pakistan. All patients underwent radical debridement and single-stage stabilization with a chest tube mold TACLN loaded with vancomycin and gentamicin, with culture-directed adjunctive antibiotics for resistant organisms. Outcomes were assessed at baseline, Weeks 3 and 6, and Month 6 using inflammatory markers, RUST score, VAS pain, EQ-5D-5L, ASAMI criteria, and return to work or usual activity. No formal sample size calculation was performed, and this study was exploratory in nature. Results: The cohort (mean age 44.9 ± 9.9 years) had a challenging microbiological profile, with 40.0% MDR and 13.3% extensively drug-resistant (XDR) infections. By Month 6, short-term infection control was achieved in 96.7% of patients, with significant reductions in ESR and CRP (both p < 0.001). Radiographic union was achieved in 90.0% of cases at a mean of 18.6 weeks, and the mean RUST score improved from 4.87 to 10.43 at the final follow-up. The VAS pain decreased from 5.23 at week 3 to 0.73 at month 6, EQ-5D-5L improved from 0.39 to 0.84, and 90.0% returned to work or usual activity by month 6. No cement debonding, implant failure, or nephrotoxicity was noted. Conclusions: In this single-arm exploratory cohort, TACLNs were associated with favorable short-term infection control, radiographic union, and functional recovery in osteomyelitis-associated long-bone nonunion, including in an MDR/XDR setting. The independent contribution of the threaded core design cannot be established. Larger multicenter comparative studies with longer follow-ups are needed to confirm the durability and implementation feasibility.

Healthcare doi: 10.3390/healthcare14081090

Authors: Hiromi Moriwaki Mihoko Ishizawa

Objectives: We aimed to explore foot condition and toe strength in older adults undergoing heart valve surgery. Materials and Methods: This exploratory pilot study included nine older adults undergoing heart valve surgery. Subjective data on foot-related symptoms, self-care status, nail care, footwear, exercise habits, and fall history were collected. Preoperative foot and nail conditions were assessed using observation and photography. Toe strength was measured preoperatively in all participants and postoperatively in a subset of participants when feasible. Descriptive analyses were primarily conducted, with exploratory group comparisons. Results: Participants frequently reported foot-related symptoms and difficulties with foot self-care prior to hospitalization. Lower toe strength appeared to be related to greater difficulties in foot self-care, whereas higher toe strength was more commonly observed in those reporting regular exercise habits. Postoperative toe strength was reassessed in six participants. In a participant with prolonged intensive care unit (ICU) stay, delayed recovery of toe strength was observed. Conclusions: These preliminary findings suggest that foot condition and toe strength may be relevant to physical function and fall prevention-related factors in older a dults undergoing cardiac surgery. Reduced toe strength may be related to self-care difficulties, and prolonged ICU stay may influence the recovery of toe strength. However, due to the small sample size, these findings should be interpreted as exploratory and hypothesis-generating.

Healthcare doi: 10.3390/healthcare14081089

Authors: João Miguel Alves Ferreira Vaitsa Giannouli Sergii Tukaiev

Disinformation, amplified by digital platforms and algorithmic distribution systems, represents a growing challenge for media trust, public health communication, and societal stability. This narrative literature review examines disinformation through an integrative psychosocial perspective, focusing on how patterns of exposure interact with individual vulnerability factors—including education, political beliefs, social identity, personality traits, and emotional responses to uncertainty—to influence the processing and acceptance of misleading information. The review synthesises interdisciplinary evidence on how algorithmic amplification and emotionally salient content increase susceptibility to disinformation and shape risk perception, health-related decision-making, and preventive behaviours. Findings indicate that repeated exposure to false or misleading information reinforces perceived credibility through familiarity effects, contributes to declining trust in institutional sources, and intensifies social and political polarisation. Disinformation is therefore conceptualised not only as an informational problem but also as a psychosocial process affecting emotional regulation, cognitive evaluation, and collective responses to crises, particularly in public health contexts. The analysis further highlights a recursive feedback loop in which reduced media trust increases vulnerability to subsequent disinformation, with broader implications for democratic participation and social cohesion. Mitigation strategies discussed include media literacy initiatives, critical thinking education, platform governance, regulatory approaches, and interventions targeting psychosocial drivers of susceptibility.

Healthcare doi: 10.3390/healthcare14081088

Authors: Elisabete da Luz

Background/Objectives: Single-parent families represent a growing and particularly vulnerable family structure within community and primary health care contexts. These families often experience cumulative burdens related to caregiving overload, socioeconomic constraints, social isolation, and fragmented support networks, which directly affect health and well-being. This integrative review aimed to synthesize and critically analyse direct and conceptually transferable evidence relevant to Family Health Nursing interventions supporting single-parent families in community and primary health care contexts, identify existing knowledge gaps, and inform the development of a relational empowerment model. Methods: An integrative literature review was conducted following PRISMA 2020 guidelines. A comprehensive search was performed across three electronic databases (PubMed, CINAHL, and Scopus) covering publications from 2020 to 2025. Inclusion criteria comprised peer-reviewed empirical studies and reviews addressing nursing or health interventions relevant to single-parent families in community or primary health care contexts. Data were extracted and synthesized thematically, with attention to theoretical frameworks, intervention characteristics, and reported outcomes. Results: Twenty-nine studies met the inclusion criteria. The synthesis revealed four main thematic domains: (1) caregiving burden and psychosocial vulnerability, (2) access to and coordination of community-based resources, (3) nurse–family relational processes, and (4) empowerment-oriented nursing interventions. Theoretical underpinnings frequently included family systems perspectives, the Calgary Family Assessment and Intervention Models, and empowerment-oriented frameworks. Conclusions: Nursing interventions for single-parent families in community health settings should prioritise relational empowerment approaches that acknowledge family diversity, contextual vulnerability, and dynamic caregiving demands. The proposed relational empowerment model offers a practice-informed framework to guide Family Health Nursing interventions, education, and policy development, supporting more responsive and equitable care for single-parent families.

Healthcare doi: 10.3390/healthcare14081087

Authors: Muhammad Hizri bin Hatta Farah Deena Abdul Samad Siew Koon Chong Suriati Mohamed Saini

Objective: This study aimed to compare the efficacy of immersive 360-degree Virtual Reality (VR) videos depicting local (Malaysian) versus overseas (Western European) natural environments on the mental health of medical students. The primary outcome was overall mental well-being (WHO-5), and the co-secondary outcomes were changes in anxiety, stress, and depression symptoms (DASS-21). Methods: A two-arm parallel randomized trial was conducted with 84 fourth-year and fifth-year medical students. Participants were randomized into two groups (n = 42 each) using a custom, gender-balancing minimization algorithm: Group 1 viewed local environments, and Group 2 viewed overseas environments. Each participant underwent two 15-min VR sessions spaced two weeks apart. Outcomes were measured at baseline (T0), after the first intervention (T1), and at the primary time point after the second intervention (T2). Data were analyzed using a repeated-measures ANOVA with Greenhouse–Geisser and Bonferroni corrections. Results: The VR intervention demonstrated a statistically significant improvement in well-being (p < 0.001, ηp2 = 0.380) and a significant reduction in anxiety (p < 0.001, ηp2 = 0.255) and stress (p < 0.001, ηp2 = 0.311) across all participants over time. No significant change was observed in depression scores (p = 0.122, ηp2 = 0.028). Notably, there were no statistically significant differences between the local and overseas groups for well-being (p = 0.399, ηp2 = 0.011), anxiety (p = 0.593, ηp2 = 0.005), stress (p = 0.945, ηp2 < 0.001), or depression (p = 0.546, ηp2 = 0.006). Conclusions: A two-session immersive VR nature intervention is effective for improving well-being and reducing anxiety and stress in medical students. The geographical familiarity of the environment did not significantly impact therapeutic effectiveness, suggesting that the restorative effects of virtual nature may generalize across different environmental and cultural contexts. Trial Registration: NCT07447310; retrospectively registered on 25 February 2026.

Healthcare doi: 10.3390/healthcare14081086

Authors: Theunis Jacobus De Wet Tessa De Wet

Background: Human wellbeing consists of dynamic interactions and feedback loops across multiple life domains, a perspective increasingly emphasised within positive psychology’s systemic and strengths-based approach to flourishing. This study develops a systemic framework to model these interdependencies and examines how cross-domain investment can optimise both domain-specific and integrated wellbeing across the lifespan. Methods: Using a Cobb–Douglas functional form with associated growth and resource constraints, we formalise the interaction between physical and financial wellbeing as an example and analyse their joint contribution to overall wellbeing. Results: The model demonstrates that improvements in one domain of wellbeing can enhance wellbeing in another, thereby shifting the optimisation frontier. While narrow domain-specific wellbeing strategies are subject to larger diminishing marginal returns, cross-domain investment generates reinforcing effects that elevate both domains simultaneously and increase integrated wellbeing. Conclusions: In line with positive psychology’s focus on leveraging strengths to support areas of relative weakness, the findings show how developing one domain of wellbeing can mitigate constraints in another. These findings align with positive psychology’s emphasis on multidimensional flourishing and resource-building processes, highlighting the importance of systemic resource allocation and suggesting that wellbeing optimisation requires coordinated, contextualised multi-domain strategies rather than siloed approaches.

Healthcare doi: 10.3390/healthcare14081085

Authors: Mariana Moya-García Wendy Campos-Pérez Mariana Pérez-Robles Sissi Godínez-Mora Sarai Citlalic Rodríguez-Reyes Liliana Estefanía Ramos-Villalobos Erika Martínez-López

Background/Objectives: Cardiovascular diseases are the leading cause of mortality worldwide, with coronary artery disease (CAD) being the most prevalent. An atherogenic diet contributes to oxidative stress by promoting lipid peroxidation in lipoproteins and cellular membranes, thereby compromising membrane integrity, which is reflected in lower phase angle (PhA) values. Dietary antioxidants play a crucial role in cellular health and in reducing atherosclerotic risk; therefore, the Dietary Antioxidant Index (DAI) is an important measure, as dietary antioxidants may counteract oxidative damage. This study aimed to assess the association between anthropometric, PhA, and biochemical variables across groups classified according to DAI. Methods: This was an analytical cross-sectional study. A total of 107 subjects, with and without CAD, were included. Oxidized LDL (oxLDL) and oxidized HDL (oxHDL) were determined using the ELISA technique. PhA was measured by bioelectrical impedance analysis, and DAI was calculated using the formula proposed by Wright et al. Results: DAI was positively associated with HDL concentrations in women with CAD, indicating that HDL levels increased by 5.8 mg/dL for each unit increase in DAI (R2 = 0.625, p = 0.001). Furthermore, for each unit increase in DAI, the TC/HDL ratio decreased by 0.3 (R2 = 0.625, p = 0.006), and the LDL/HDL ratio decreased by 0.2 (R2 = 0.506, p = 0.012). Conclusions: A higher DAI is associated with a more favorable lipid profile in women with CAD, particularly with higher HDL concentrations and lower TC/HDL and LDL/HDL ratios.

Healthcare doi: 10.3390/healthcare14081084

Authors: Yusuf Adnan Güçlü Nil Tekin Şerafettin Ceylan

Objective: This study aimed to evaluate the health-related quality of life (HRQoL) of informal caregivers providing primary care to elderly chronically ill patients receiving home health care services in Türkiye and to identify patient and caregiver characteristics independently associated with HRQoL. Methods: This cross-sectional study included 499 patient–caregiver dyads enrolled in home health care services at a training and research hospital in İzmir, Türkiye. Data were collected through face-to-face interviews using a sociodemographic questionnaire, the Palliative Performance Scale (PPS), and the Short Form 36 (SF-36). One-sample t-tests compared SF-36 scores with Turkish normative values. Multivariate linear regression identified independent predictors of the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Results: Caregivers scored significantly lower than population norms across all SF-36 subdimensions (p < 0.001), with the largest impairments in Role Physical (mean difference: −53.0) and Role Emotional (−42.9). In multivariate analyses, independent predictors of poorer physical health (PCS) were severe patient functional dependence (PPS ≤ 30: β = −0.260, p < 0.001), older caregiver age (≥65 years: β = −0.089, p = 0.044), unemployment (β = −0.118, p = 0.014), additional care recipients (β = −0.095, p = 0.026), and caregiver’s own chronic illness (β = −0.169, p < 0.001). Poorer mental health (MCS) was independently associated with caregiver’s own chronic illness (β = −0.138, p = 0.002), receipt of caregiving payment (β = −0.137, p = 0.004), and university-level education (β = −0.108, p = 0.040), whereas the presence of a support person was protective (β = 0.096, p = 0.038). Conclusions: Informal caregivers of home health care-dependent elderly patients experience significantly reduced quality of life across all health domains compared with the general population. The independent determinants of caregiver health are multidimensional, encompassing patient-related factors, socioeconomic characteristics, and psychosocial resources. These findings underscore the urgent need for health systems to implement tailored interventions that address the distinct physical and mental health needs of caregivers, with particular attention to those who are elderly, chronically ill, socioeconomically disadvantaged, or highly educated.

Healthcare doi: 10.3390/healthcare14081082

Authors: Aikaterini Vasiou Servet Altan Eleni Vasilaki Aristea Mavrogianni Georgios Vleioras Marinos Anastasakis Konstantinos Mastrothanasis

Background: Parental practices that support autonomy, provide structure, and foster warm relationships are associated with greater satisfaction of students’ basic psychological needs for autonomy, competence, and relatedness. In minority educational contexts, however, students’ psychological need satisfaction is also shaped by broader sociocultural conditions that may create additional pressures and sources of chronic stress. Within such environments, parental support may function as a protective factor that helps students cope with educational and cultural demands. Objective: The aim of this study was to explore how parental support contributes to the satisfaction of students’ basic psychological needs within a minority educational context where students from the Greek minority attend a bilingual school operating within a Turkish educational framework. Methods: A qualitative design was employed using three focus groups conducted in a minority school located in Gökçeada, Türkiye: one with parents (N = 5), one with lower secondary school students (N = 6), and one with upper secondary school students (N = 6). Interview questions were developed on the basis of Basic Psychological Needs Theory. Data were analyzed thematically by five members of the research team. Results: Findings indicated that parental support influenced students’ need satisfaction through practices related to autonomy (e.g., trust, space for mistakes), competence (e.g., encouragement, comparison), and relatedness (e.g., emotional presence, empathy). However, these practices were not experienced in a uniform way. Rather, their meaning and impact were shaped by contextual conditions associated with minority status, including bilingual educational demands, limited resources, and close-knit community dynamics. Conclusions: The study suggests that in minority school settings, parental support operates not simply as a general interpersonal resource but as a contextually mediated protective process. By showing how sociocultural and institutional conditions shape the enactment and experience of autonomy, competence, and relatedness, the findings extend existing BPNT research beyond majority settings and offer a more context-sensitive understanding of students’ psychological need satisfaction.

Healthcare doi: 10.3390/healthcare14081083

Authors: Se Young Kim Dong Hyun Lim Dae Ho Kim Ok Ran Jeong

Background/Objectives: Postoperative pulmonary complications (PPCs) following abdominal surgery are associated with prolonged hospitalization, delayed recovery, and increased mortality. Because nursing surveillance is essential for early detection and timely intervention, this study aimed to develop a holistic nursing surveillance decision support system integrating PPC risk prediction with structured nursing action recommendations. Methods: In this retrospective cohort study, electronic medical record (EMR) data from approximately 6900 adult patients who underwent abdominal surgery at a single institution between January 2015 and September 2023 were analyzed. The study protocol was approved by the Institutional Review Board, and the requirement for informed consent was waived because of the retrospective study design. PPC risk was predicted using a tabular multilayer perceptron (MLP) encoder with SHapley Additive exPlanations (SHAP)-based feature weighting and a random forest classification head optimized via Optuna. Class imbalance was addressed using weighted sampling, class weighting in BCE(Binary Cross Entropy) With Logits Loss, and decision-threshold optimization. For clinical decision support, a large language model generated structured nursing surveillance recommendations in an action–evidence–rationale JSON format and was aligned through supervised fine-tuning (SFT) using human-evaluated cases. Results: The prediction model achieved an AUROC of 0.810, with an accuracy of 0.811, precision of 0.547, and recall of 0.545. In expert evaluation, the SFT-aligned model improved recommendation quality, reducing incorrect nursing actions from 19.3% to 8.0%. Conclusions: The proposed system demonstrates the feasibility of an end-to-end nursing surveillance decision support framework linking PPC risk prediction with structured clinical recommendations. The findings suggest its potential to support more accurate risk prediction and more actionable nursing surveillance for patients undergoing abdominal surgery.

Healthcare doi: 10.3390/healthcare14081081

Authors: Aoba Kadono Naohiro Hohashi

Background/Objectives: Stress experienced by families of individuals with illnesses or disabilities is shaped through the interaction of multiple complex influencing factors. This study aimed to elucidate the factors influencing stress in families of young/adult children with illnesses or disabilities, using Family System Unit Stress Theory (FSUST) as the guiding theoretical framework. Methods: Semi-structured interviews were conducted with 10 families of young/adult children with illnesses or disabilities. Data were analyzed using qualitative content analysis following the approach of Graneheim and Lundman. In line with FSUST, the identified influencing factors were categorized into negative factors (risk/causal/promoting) and positive factors (preventive/inhibitory/suppressive). Results: A total of six categories and 18 subcategories were extracted for the risk/causal/promoting factors, including “accumulation of unshared burdens within the family leading to role overload” and “concerns about the future of the young/adult child.” For the preventive/inhibitory/suppressive factors, five categories and 13 subcategories were extracted, including “receiving a diagnosis of the young/adult child’s illness or disability” and “family maintaining a positive attitude.” Conclusions: Family stress in families of young/adult children with illnesses or disabilities varies through the interaction of multilayered influencing factors, including persistent emotions carried over from the past, difficulties faced in the present, and anticipatory concerns regarding the future. Therefore, nursing practice requires a life course-oriented understanding of family stress and an integrated approach that concurrently reduces risk/causal/promoting factors while enhancing preventive/inhibitory/suppressive factors.

Healthcare doi: 10.3390/healthcare14081080

Authors: Danica Vangsgaard Misa Noumi K. Alix Hayden Patricia K. Doyle-Baker

Background/Objectives: Masters athletes are adults aged ≥40 who compete in sport, exhibiting superior physical function and healthier aging than their sedentary peers. However, even highly trained masters athletes experience age-related performance declines. Women masters athletes represent a growing yet understudied population who may face unique physiological challenges. This scoping review synthesizes literature from 1984 to 2024, examining the impact of age and menopause on determinants of endurance performance in women masters athletes. Methods: Following JBI scoping review methodology, six databases were searched (Medline, Embase, Central, CINAHL, SPORTdiscus, Scopus). Studies were evaluated for population characteristics, methodological approaches, and physiological determinants of performance (i.e., aerobic capacity, lactate kinetics, and exercise economy). Results: Twenty-nine studies were included. Most (n = 28) assessed aerobic capacity, reporting declines between 0.36 and 0.84 mL·kg−1·min−1·year−1 (0.5–2.4%·year−1). These reductions were primarily associated with decreased cardiac output followed by changes in body composition. Training volume emerged as a predictor of aerobic capacity, but the effects of menopause were unclear. Findings on lactate kinetics and exercise economy were mixed but preliminary research indicated that lactate threshold relative to VO2max generally increased, peak lactate remained stable and energy cost increased with age. Fitness and health characteristics among women athletes differed from sedentary populations, emphasizing the need for athlete-specific data to support training and health decisions. Conclusions: Aging is associated with decreased aerobic capacity and variable changes in lactate kinetics and exercise economy. While training volume may attenuate performance decrements, the impact of menopause remains uncertain, underscoring the need for longitudinal research to better support this growing segment of the population.

Healthcare doi: 10.3390/healthcare14081079

Authors: Jiayi Zheng Tong Hu Shandan Xu Jing Xiao Change Xiong

Aim: The aim of this study was to explore the distribution and driving factors influencing the disparity of health professionals (HPs) at the Centers for Disease Control and Prevention (CDC) in China and to provide a reference for regional health planning and rational allocation of public health resources. Methods: The Gini coefficient was used to measure the equity of HP distribution at CDC sites at the provincial level during 2012–2023 in China. Moran’s I was used to analyze the spatial agglomeration effect, and the geographic detector model was used to explore the factors driving the allocation of HPs at CDC sites in different provinces. Results: The number of HPs at the CDC showed an increasing trend from 2012 to 2023 in China. The average Gini coefficients at the population and geographical areas were 0.16 and 0.58, respectively. The global Moran’s I statistic indicated a notable decline in spatial clustering for the population dimension, decreasing from 0.503 to 0.238; in contrast, spatial clustering for the geographical dimension remained relatively stable, ranging between 0.13 and 0.16. The local Moran’s I statistic revealed that provinces such as Qinghai in the western China consistently exhibited a “low–low” spatial clustering pattern. Six factors were found to explain the variability in the CDC HP distribution based on the 2020 data. In the context of factor interactions, the synergistic effects between education level and health expenditure share (q = 0.9781), and between population aging and per capita GDP (q = 0.9699), substantially exceed the explanatory power attributable to any single factor alone. Conclusions: A significant regional disparity was observed in the distribution of HPs among 31 provinces, with the distribution based on service area being less equitable than that based on population. The shortage of healthcare professionals in the western region is characterized by notably inadequate geographical distribution. Future policy initiatives should prioritize targeted spatial interventions and integrated, multi-factor collaborative strategies.

Healthcare doi: 10.3390/healthcare14081078

Authors: Gunther Alonso Huaytalla Sanchez Juan Marcelo Zanga Céspedes Zembe Alejandro Saito Roncal Jacksaint Saintila

Background: Adventist spirituality has been identified as a relevant psychosocial resource for emotional well-being; however, evidence on its relationship with self-control and perceived stress in specific religious populations remains limited. Objective: The aim of this study was to examine the associations between Adventist spirituality, self-control, and perceived stress in a sample of adults belonging to the Seventh-day Adventist Church and residing in coastal regions of Peru. Methods: A cross-sectional study was conducted between December 2025 and January 2026 with 506 Seventh-day Adventist adults who completed an online questionnaire. Adventist spirituality was assessed using the Mission Commitment Questionnaire, which captures religious–spiritual commitment through three dimensions: personal devotion, participation, and witnessing. Self-control and perceived stress were measured using standardized scales. Data were analyzed using partial least squares structural equation modeling. Results: The constructs showed adequate internal consistency, with Cronbach’s alpha values ranging from 0.875 to 0.951 and composite reliability values ranging from 0.906 to 0.956. Adventist spirituality was positively associated with self-control (β = 0.479, p < 0.001) and negatively associated with perceived stress (β = −0.457, p < 0.001). Personal devotion showed the strongest contribution to the higher-order spirituality construct. The model explained 22.9% of the variance in self-control and 20.9% of the variance in perceived stress. Conclusions: Adventist spirituality, particularly personal devotion, was associated with higher self-control and lower perceived stress. Although the cross-sectional design does not allow causal inference, the findings support the relevance of Adventist spirituality as a psychosocial resource linked to emotional well-being in this religious population and justify future longitudinal studies.

Healthcare doi: 10.3390/healthcare14081077

Authors: Fatmah Ahmed Alamoudi Mahmoud Abdel Hameed Shahin Maryam Abdullah Bayahya Shouq Mubarak Al Zuabi Rasha Essam Bakhurji Wadha Anbar Aldarbi Hanan Alfahd

Background/Objectives: Nurses and dialysis technicians are primarily responsible for cannulation in in-center and satellite dialysis units. Despite being a core component of hemodialysis care, existing clinical guidelines offer limited standardization, resulting in practice variability across facilities. Therefore, clinical expertise and adherence to consistent standards are essential to ensure safe and effective vascular access management. The study aimed to investigate the variables related to patients and nurses that contribute to unsuccessful vascular access cannulations, as well as the actions taken in response to cannulation failure, in a tertiary dialysis center in the Eastern Region of Saudi Arabia. Methods: This retrospective analytic study reviewed the records of 228 adult hemodialysis patients at King Fahad Military Medical Complex from 2020 to 2024, analyzing demographic, clinical, vascular access, and nursing variables associated with cannulation failure using descriptive statistics, the chi-square test, and t-tests. Ethical approval was obtained, and data were de-identified and manually extracted from nursing and dialysis documentation. Results: Most patients had hypertension and diabetes, with significant comorbidity burdens. Infiltration (61%) and clot formation (30.7%) were the primary complications of cannulation failure. Significant associations emerged with recurrent stroke and peripheral vascular disease, but not with nurse or patient demographics, suggesting vascular factors outweigh staff variables in cannulation risk. Cannulation failures were most common in patients with vascular comorbidities, while staff experience and education had no significant impact. Conclusions: Recommendations include implementing tailored protocols, providing ongoing nurse education, conducting systematic vascular assessments, and holding regular team reviews to enhance access outcomes and patient safety.

Healthcare doi: 10.3390/healthcare14081076

Authors: Walid Al-Qerem Sawsan Khdair Anan Jarab Akram Saleh Mohammad Al-Rawashdeh Judith Eberhardt Walaa Ashran Lama Sawaftah Fawaz Alasmari Alaa Hammad Nouf Alsultan

Objectives: We aimed to evaluate the reliability and validity of the Arabic version of the Chronic Heart Failure Health-Related Quality of Life Questionnaire (CHFQOLQ-20) among patients with heart failure in Jordan. Methods: A cross-sectional study was conducted among 399 adults with heart failure recruited from a tertiary hospital in Jordan (median age 68 years; 55.9% male). The CHFQOLQ-20 was translated using forward–backward procedures. Construct validity was examined using confirmatory factor analysis (CFA) and a multidimensional Partial Credit Model. Differential item functioning by sex and internal consistency were assessed. Results: CFA supported the original four-domain structure (physical, cognitive, mental, and general health), with all items showing significant factor loadings. Item-level analyses demonstrated acceptable model fit, ordered response thresholds, and minimal sex-related bias. Physical health scores were lower than other domains. Conclusions: The Arabic CHFQOLQ-20 is a valid, reliable, and multidimensional measure of HRQoL in patients with heart failure, supporting its use in clinical practice and research.

Healthcare doi: 10.3390/healthcare14081075

Authors: Ahmet Depreli Emre Adıgüzel Burcu Çavdar Fatma Coşkun

Background/Objectives: Children and adolescents exposed to criminal victimization are at increased risk for depression; however, the contribution of nutritional status to depressive symptom severity in this vulnerable population remains poorly understood. Therefore, we aimed to examine the associations between depression severity and nutritional parameters in child and adolescent victims of crime. Methods: This cross-sectional study included 72 children and adolescents (aged 10–16 years) referred to a forensic medicine department in Türkiye. Nutritional status was assessed using anthropometric measurements (body weight, body mass index [BMI], BMI-Z score, and body fat percentage), three-day dietary records, and the Mediterranean Diet Quality Index (KIDMED). Depression severity was evaluated using the Kutcher Adolescent Depression Scale (KADS). The associations were analyzed using Pearson’s rho correlation and forward stepwise linear regression. Potential confounding variables, including age, gender, socioeconomic status, and trauma-related characteristics, were recorded and considered during the analysis; however, due to the limited sample size and to avoid model overparameterization, they were not fully adjusted for in the final model. Results: Depression severity was positively correlated with the body weight, BMI, BMI-Z score, body fat percentage, and dietary energy, carbohydrate, protein, and fat intakes (all p < 0.05). In contrast, the vitamin C and dietary fiber intakes, breastfeeding duration, and KIDMED scores were negatively correlated with the KADS scores (p < 0.05). Regression analysis revealed that the lower KIDMED scores, higher body fat percentage, and greater body weight were significantly associated with depression severity, collectively explaining 82.2% of the variance in the KADS scores. Conclusions: Poor diet quality and adverse body composition are strongly associated with depression severity in child and adolescent victims of crime. These findings suggest that nutritional factors may be associated with depression severity in child and adolescent victims of crime; however, the results should be interpreted as preliminary and hypothesis-generating.

Healthcare doi: 10.3390/healthcare14081074

Authors: Tanjila Nawshin Navneet Kaur Baidwan Hui-Ju Young James Rimmer Tapan Mehta

Background/Objectives: To evaluate construct (convergent and divergent) validity and conduct confirmatory factor analysis (CFA) of the National Center on Health, Physical Activity and Disability (NCHPAD) Wellness Assessment (NWA) tool. Methods: A cross-sectional survey validation study utilizing secondary data. We assessed Spearman correlations between NWA and 36-Item Short Form Health Survey (SF-36), NWA and Godin Leisure-Time Exercise Questionnaire (GLTEQ) and NWA and Modified Fatigue Impact Scale (MFIS) scores to determine construct validity. A CFA was conducted to test the appropriateness of a three-factor model for NWA. Results: Data from 149 participants were used to assess construct validity and from 180 participants for CFA. Both correlations between NWA mental wellness domain and SF-36 mental component scores and between NWA emotional/spiritual wellness domain and SF-36 emotional well-being scores were 0.61 (p < 0.001 for both). The correlation between NWA physical wellness domain and SF-36 physical component score was −0.06 (p = 0.45). The correlations of NWA with GLTEQ overall and with health contribution scores were 0.26 and 0.30, respectively (p < 0.001 for both). The correlations of all NWA domain and MFIS subscale scores ranged between −0.42 and −0.25 (p < 0.05). The CFA model’s comparative fit index was 0.90. Conclusions: The NWA physical wellness domain did not demonstrate strong convergent validity, as mental and emotional/spiritual wellness domains did. All domains showed strong divergent validity, and CFA showed evidence supporting a three-factor model. Future efforts will emphasize refining and reevaluating the physical wellness domain until it achieves strong psychometric properties.

Healthcare doi: 10.3390/healthcare14081073

Authors: Vanessa A. Moore Austin Watkins Michael Ting Ben Seibert Justin Dvorak Katie Keyser Nirmal Choradia Ryan D. Nipp

Introduction: The costs associated with ambulance services are varied and poorly understood, which may contribute to financial burden and barriers to care for patients. Methods: We describe differences in ambulance service costs, comparing public versus private companies, by using the Centers for Medicare and Medicaid Services public use files. We determined the two largest public and two largest private ambulance companies in each state and calculated the average miles traveled per ambulance ride, number of trips by company, adjusted cost, and CPT code usage. We compared these variables between 2019 and 2021, across nine geographic divisions of the US. Results: In both 2019 and 2021, the average costs (adjusted for total service) of public companies were higher than the average costs of private companies. In both years, public companies had fewer average miles traveled compared to private companies. The distribution of CPT codes used was significantly different in public and private companies. The CPT code used most frequently by public companies was more expensive than the CPT code used most often by private companies. Conclusions: Differences in ambulance billing practices may contribute to financial uncertainty for patients. This study underscores the need for further investigation into the factors driving these disparities to inform policy decisions and improve cost transparency for patients.

Healthcare doi: 10.3390/healthcare14081072

Authors: Mu-Yeol Cho Je-Hyun Eom Ji-Won Kim Yun-Woo Kim Seung-Jo Yang Jiyoung Hwang Mi-Hwa No Hye-Sung Kim

Background/Objectives: Forest therapy has demonstrated stress-reducing and immune-enhancing effects, yet its simultaneous impact on cognitive function, stress biomarkers, and oral microbiota in older adults remains unexplored. This study aimed to evaluate the effects of an 8-week community-based village forest experience program on cognitive function, salivary cortisol, and oral pathogenic bacteria in community-dwelling older adults. Methods: A total of 125 older adults (mean age 82.2 ± 5.3 years; 87.2% female) from 17 senior centers participated in a single-arm, pre–post intervention study. Cognitive function was assessed using the Cognitive Impairment Screening Test (CIST), salivary cortisol was measured by ELISA, and seven oral bacterial species were quantified by qPCR. Results: CIST scores improved significantly (p = 0.003, d = 0.27), with the suspected cognitive impairment subgroup showing greater improvement (d = 0.66) and 48.8% transitioning to normal classification. Salivary cortisol decreased significantly (p = 0.002), and total bacterial load, Porphyromonas gingivalis, and Tannerella forsythia were significantly reduced. The 80–84-year age group showed the greatest cognitive gain, whereas participants aged 85 and older showed no significant change. Conclusions: An accessible village forest program may simultaneously benefit cognitive function, stress, and oral health in older adults with early-stage cognitive decline. Controlled studies are needed to confirm causality and elucidate the underlying mechanisms.

Healthcare doi: 10.3390/healthcare14081069

Authors: Alice Yip Wai Ping Cecilia Li Tsang Jeff Yip Chi Kong Calvin Yip Man Ho Tim Li Zoe Tsui Ka Man Rachel Yip Ka Wing Gavin Lee Shuk Yu Maria Hung

Background/Objectives: Globally, rheumatoid arthritis (RA) patients struggle to meet the expectation of being active in their daily lives. The burden on these individuals is twofold, including physical limitations and emotional stress, which make looking after themselves a major challenge. Supporting self-management requires more than just offering strategies; it requires fitness. Whether we are proposing new daily habits or creative outlets like ceramic workshops, it is essential to tap into the patient’s perspective to understand exactly what kind of support will resonate with them. This study explored how ceramic workshops can help people with RA to build resilience and improve their well-being. Methods: Using a phenomenological study design, we interviewed 16 patients with RA in Hong Kong who engaged in ceramic workshops. These participants were selected through purposive sampling, and their insights were gathered via semi-structured interviews. We applied Colaizzi’s seven-step method to analyze the findings. Results: Four key themes emerged: (i) embodied manageability; (ii) clear comprehension of body limits; (iii) the meaningfulness of creating art; and (iv) supporting resilience. Conclusions: This study reveals that effective self-management support should prioritize patient-driven needs, particularly peer interaction and high-demand creative pursuits such as ceramic workshops.

Healthcare doi: 10.3390/healthcare14081071

Authors: Jing Xu Na Li Yu Jian Xin Yang Xianwen Li

Background/Objectives: This study aimed to explore the association between internet use and executive function among older adults and the mediating role of social participation and loneliness in internet use and executive function. Methods: A cross-sectional study was conducted among 439 community-dwelling older adults (≥60 years) in Nanjing, China, from September to December 2022. Participants were selected using simple random sampling and assessed with four standardized instruments: the Internet Use Questionnaire, the Social Participation Capacity Assessment, the six-item UCLA Loneliness Scale (ULS-6), and the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A). Data were analyzed with the SPSS 21.0 software for descriptive statistics and correlation analysis and the AMOS 23.0 software for structural equation modeling to test the chain mediation effects. Model fit was evaluated using Root Mean Square Error of Approximation (RMSEA), Comparative Fit Index (CFI), Tucker–Lewis Index (TLI), and Weighted Root Mean Square (WRMR), with bootstrap resampling for indirect effect estimation. Results: The results showed that internet use was positively correlated with loneliness (r = 0.203, p < 0.01), social participation impairment (r = 0.193, p < 0.01), and executive function (r = 0.420, p < 0.01). Structural equation modeling showed that greater internet use was significantly associated with poorer executive function (β = 0.306, p < 0.01). These associations were partially explained by pathways involving social participation and loneliness through three indirect pathways: internet use via social participation (indirect effect = 0.087, 18.3% of the total effect); internet use via loneliness (indirect effect = 0.049, 10.3%); and internet use via social participation and then loneliness in sequence (indirect effect = 0.035, 7.1%). Conclusions: In community-dwelling older adults, more frequent internet use was associated with greater executive function impairment through mechanisms involving reduced social participation and increased loneliness. Therefore, there is a need to limit excessive internet use while promoting social participation and reducing isolation, which can have the greatest benefits for executive functioning in older adults.

Healthcare doi: 10.3390/healthcare14081070

Authors: Georgios S. Chatzopoulos Larry F. Wolff

Background/Objectives: The aim of this study was to analyze and quantify the independent effects of tooth mobility and furcation involvement on the probability of tooth loss in a large patient cohort, after controlling for patient-level confounding factors. Methods: This retrospective cohort study utilized data from 16,756 patients. Primary predictors were tooth mobility and furcation involvement. The primary outcome was tooth loss. A multivariable logistic regression model, adjusting for confounders (age, gender, smoking, diabetes), was developed to calculate Odds Ratios (OR) and 95% confidence intervals (CI). Results: A significant dose–response relationship was observed between the severity of both mobility and furcation involvement and the rate of tooth loss (p < 0.001). After multivariable adjustment, both remained statistically significant predictors (p < 0.001). Compared to no mobility, the odds of tooth loss for Class 3 mobility were 3.99 times higher (OR = 3.99; 95% CI: 3.58–4.45). Compared to no furcation involvement, the odds for Grade 3 involvement were 2.50 times higher (OR = 2.50; 95% CI: 2.19–2.85). Diabetes, smoking, male gender, and increasing age were also significant risk factors. Conclusions: Tooth mobility and furcation involvement are independent predictors of future tooth loss. These findings highlight the critical importance of thoroughly assessing mobility and furcation defects for patient risk assessment, prognosis, and treatment planning.

Healthcare doi: 10.3390/healthcare14081068

Authors: Pai-Yueh Chen Ying-Hua Chao Yao-Ching Huang Shi-Hao Huang Ren-Jei Chung Pi-Ching Yu Bing-Long Wang Hsiu-Ju Chang Pi-Chen Chang Shu-Min Huang Chao-Hsi Huang

Background: Family caregivers remain closely involved in communication, care planning, and shared decision-making in long-term care (LTC) facilities. In this context, the quality of the relationship between family caregivers and professional staff may influence trust, collaboration, and satisfaction with care. However, few instruments have been specifically adapted to assess caregiver–staff relationship quality in Taiwanese LTC settings. Objectives: This study aimed to culturally adapt and preliminarily validate the Family Caregiver Relationship Quality (FCRQ) Scale for use in Taiwanese LTC facilities. Methods: A cross-sectional psychometric validation study was conducted with 205 primary family caregivers recruited from 20 LTC facilities in Taiwan. The original Relationship Quality Scale was adapted to the LTC context through contextual revision, expert review, bilingual verification, and pilot testing. Psychometric evaluation included confirmatory factor analysis, internal consistency assessment, convergent validity, and structural equation modelling with Bollen–Stine bootstrap correction to address potential non-normality. Results: The initial 16-item model required refinement, and three items with low standardized factor loadings were removed. The revised 13-item model met the prespecified fit criteria and showed acceptable internal consistency and convergent validity. The retained items reflected three conceptually related domains of relationship quality: trust, commitment, and satisfaction. Overall, the findings provided preliminary psychometric support for the adapted scale in Taiwanese LTC settings. Conclusions: The adapted FCRQ Scale may be a useful tool for assessing caregiver–staff relationship quality in Taiwanese long-term care facilities, particularly in the context of shared decision-making and family-centred care. Nevertheless, the findings should be interpreted as preliminary, and further validation in larger and more diverse samples is needed before broader clinical or research application.

Healthcare doi: 10.3390/healthcare14081067

Authors: Hongfei Zhang Wenjun Hu Qing Zhang Man Jiang Jakub Kortas

Virtual reality (VR) has been increasingly adopted as a digital tool in rehabilitation for balance training, coordination improvement, and motor recovery, yet the literature remains dispersed across clinical rehabilitation, exercise-based interventions, and broader motor-related applications. This fragmentation makes it difficult to determine how the field has evolved and where research emphasis has shifted. This study mapped the research landscape and thematic evolution of VR for balance, coordination, and motor rehabilitation using bibliometric analysis and topic modeling. A total of 1258 articles indexed in the Web of Science Core Collection from 2011 to 2025 were analyzed. Only English language articles and reviews relevant to VR-based balance, coordination, or motor rehabilitation research were included, yielding a final dataset of 1258 publications. CiteSpace and VOSviewer were used to examine keyword co-occurrence, clustering patterns, and temporal trends, while Latent Dirichlet Allocation (LDA) was applied to identify latent themes and their temporal dynamics. The field has moved beyond early feasibility testing toward a more differentiated landscape shaped by distinct clinical targets, population groups, and training purposes. Seven recurring themes were identified, including vestibular rehabilitation and immersive training, post-stroke upper-limb rehabilitation, efficacy and adverse-effect assessment, balance and gait training interventions, evidence synthesis and review-based evaluation, elderly exercise and cognitive interventions, and skill-oriented virtual task training with recent expansion toward broader population groups and task-specific applications beyond traditional rehabilitation settings. VR research on balance, coordination, and motor rehabilitation has evolved into a more thematically differentiated field rather than remaining a single rehabilitation-oriented domain. By combining bibliometric mapping with topic modeling, this study clarifies where evidence is concentrated and which thematic directions are gaining visibility, providing a clearer basis for future evidence synthesis and more comparable intervention reporting.

Healthcare doi: 10.3390/healthcare14081066

Authors: Marijus Leketas Inesa Stonkutė Miglė Miškinytė Dominykas Afanasjevas

Background: Magnetic resonance imaging (MRI) is the reference standard for evaluating temporomandibular joint (TMJ) disorders, particularly for assessing disc position, joint effusion, and degenerative changes. With increasing imaging demands and advances in deep learning, artificial intelligence (AI) has emerged as a potential adjunct to expert interpretation. This systematic review aimed to compare the diagnostic performance of AI-based models with that of human experts in TMJ MRI analysis. Methods: This review was conducted in accordance with the PRISMA 2020 guidelines and prospectively registered in PROSPERO (CRD420251174127). A systematic search of PubMed/MEDLINE, ScienceDirect, Wiley Online Library, and Springer Nature Link was performed for studies published between 2020 and 2026. Eligible studies included human participants undergoing TMJ MRI and evaluated AI, machine learning, or deep learning models against human expert interpretation. Extracted outcomes included sensitivity, specificity, accuracy, area under the receiver operating characteristic curve (AUC), and agreement metrics. Risk of bias was assessed using QUADAS-2. Due to substantial heterogeneity, a narrative synthesis was conducted. Results: Five retrospective diagnostic accuracy studies were included, comprising sample sizes ranging from 118 to 1474 patients. Target conditions included anterior disc displacement, joint effusion, osteoarthritis, and disc perforation. AI models demonstrated strong discriminative performance, with reported AUC values ranging from 0.79 to 0.98. In direct comparisons, AI achieved diagnostic accuracy comparable to experienced radiologists. AI systems frequently demonstrated higher specificity and similar overall accuracy, whereas human experts often showed higher sensitivity. In osteoarthritis assessment, AI performance approached expert level and exceeded that of less experienced readers. All studies were retrospective and predominantly single-center, with heterogeneous reference standards and limited external validation. Conclusions: AI achieves diagnostic performance comparable to experienced clinicians in TMJ MRI interpretation and shows promise as a decision-support tool. Nevertheless, it should be regarded as complementary to, rather than a replacement for, expert radiological assessment pending further rigorous validation.

Healthcare doi: 10.3390/healthcare14081064

Authors: Joseph P. Anlacan Veeda Michelle M. Anlacan Harold Joshua D. de Guzman Beatrice M. Anlacan Roland Dominic G. Jamora

Background: In the Philippines, studies have shown that availability and access to healthcare varies widely. Although the shortage of psychiatrists in the country has been recognized for many years, no published study to date has described their distribution across the regions. This study aimed to describe the distribution of psychiatrists in the country using publicly available data on the Internet. Methods: This was a cross-sectional study, analyzing publicly available data from the Philippine Psychiatric Association (PPA) web directory, the Philippine Health Insurance Corporation (PhilHealth) web database of accredited psychiatrists, and the Philippine Statistics Authority. Information on location of practice, sex, PPA membership, PhilHealth accreditation, regional gross domestic product (GDP), and regional population were collated. Results: Information on 409 psychiatrists was available online, with 68% being female and 53% holding PhilHealth accreditation. There were a total of 417 declared locations of practice, with six psychiatrists practicing in more than one location. The National Capital Region accounted for 53.5% of the declared practice locations, while no psychiatrist declared practicing in the Bangsamoro region. Conclusions: This study highlights the maldistribution of psychiatrists across the Philippines. Policies to incentivize and encourage practice in low-access regions and investment in technology, such as telemedicine, may help reduce the access gap.

Healthcare doi: 10.3390/healthcare14081065

Authors: Negin Mirzaei Damabi Patience Castleton Bridgit McAteer Zohra S. Lassi

Background: Sexual health research with migrant and refugee communities presents unique challenges, shaped by cultural sensitivities, stigma, and the under-representation of these populations in health research. However, lived experiences insights are essential for the development of appropriate and useful research and health initiatives. It is important to learn from researchers’ experiences to expand the representation of migrant and refugee community voices. Method: This paper draws on two qualitative studies conducted in South Australia: one exploring the sexual and reproductive health perspectives of refugee and migrant women, and the other of men. We reflect upon the methodological and ethical considerations in conducting research in this sensitive field and provide recommendations for future researchers and healthcare providers when working with migrant and refugee communities. Results: Both studies encountered difficulties in relation to participant recruitment, cross-cultural communication, and addressing taboos surrounding sexual health. At the same time, they highlighted opportunities for generating meaningful insights through culturally safe, gender-sensitive approaches and collaboration with community stakeholders. Conclusions: By synthesising experiences from both projects, we identify practical strategies for building trust, overcoming linguistic and cultural barriers, and creating supportive environments for discussing sensitive topics. These reflections offer guidance for researchers and clinicians aiming to advance culturally responsive sexual health research and strengthen healthcare provision for migrant and refugee populations.

Healthcare doi: 10.3390/healthcare14081063

Authors: Pedro Ramalho António Nunes Fernanda M. Silva André Ramalho Gonçalo Flores Diogo Monteiro Pedro Duarte-Mendes

Background/Objectives: Radiologic technologists are frequently exposed to occupational stressors that heighten the risk of burnout, compromising well-being and job performance. Workplace exercise programs have been identified as promising strategies to enhance physical and mental health across occupational groups; however, robust experimental evidence among radiologic technologists remains limited. This study aimed to evaluate the effects of a structured workplace exercise program on perceived stress, burnout, and quality of life among radiologic technologists. Methods: A small-scale randomized controlled experimental study was conducted with 19 radiologic technologists from the Local Health Unit of Castelo Branco, Portugal. Participants were randomly assigned to an experimental group (n = 10, age mean = 43.8 ± 9.92 years old) or a control group (n = 9, age mean = 48.2 ± 7.86 years old). The intervention consisted of a six-week workplace exercise program conducted during work hours, comprising sessions three times per week, twice per day. Each session lasted approximately 15–20 min and included balance, stretching, and light resistance exercises. Outcomes were assessed pre- and post-intervention using the Perceived Stress Scale, the Copenhagen Burnout Inventory, and the WHOQOL-BREF. Results: The experimental group showed significant reductions in perceived stress (p = 0.013, d = −0.697 (−1.6–0.206) [moderate]) and in personal (p = 0.004, d = −0.834 (−1.748–0.08) [moderate]) and work-related burnout (p = 0.026, d = −0.756 (−1.664–0.151) [moderate]), as well as improvements in the physical (p = 0.046, d = 0.592 (−0.303–1.488) [small]) and environmental (p = 0.032, d = 0.991 (0.062–1.92) [moderate]) domains of quality of life. No significant changes occurred in the control group. Conclusions: These preliminary findings suggest that a brief, low-cost workplace exercise program may reduce stress and burnout and improve quality of life among radiologic technologists. These findings support the integration of structured physical activity into healthcare work settings as a feasible, preventive, and health-promoting strategy.

Healthcare doi: 10.3390/healthcare14081062

Authors: Seohyeon Cho Keon Woo Yoonsoo Choy

Background: In the context of global population aging, nutritional risk has emerged as an important factor associated with both physical and mental health among older adults. This study aimed to examine the associations between nutritional risk, depression, and cognitive function in older adults and to explore potential variations across residential area, educational attainment, employment status, frailty status, and activities of daily living (ADL). Methods: Data were obtained from 9955 community-dwelling older adults aged 65 years and older who participated in the 2023 National Survey of Older Koreans. Nutritional risk was assessed using the DETERMINE checklist (21-point scale), a multidimensional screening tool reflecting dietary, functional, and social risk factors. Depression was measured using the Short-form Geriatric Depression Scale (15-point scale), and cognitive function was assessed using the Korean version of the Mini-Mental State Examination-2 (K-MMSE-2; 30-point scale). Hierarchical multiple linear regression, correlation, subgroup, and sensitivity analyses were conducted, adjusting for sociodemographic characteristics, health behaviors, and geriatric factors. Results: Correlation analyses showed significant associations between nutritional risk and cognitive function (r = −0.191, p < 0.05), nutritional risk and depression (r = 0.440, p < 0.05), and depression and cognitive function (r = −0.259, p < 0.05). Higher nutritional risk scores were significantly associated with greater depressive symptoms (B = 0.314, p < 0.001) and lower cognitive function (B = −0.051, p < 0.05). While some subgroup differences were observed, not all interaction effects reached statistical significance, and these findings should be interpreted with caution. Conclusions: These findings suggest that nutritional risk is associated with depressive symptoms and cognitive function in older adults. Given that the DETERMINE checklist reflects multidimensional vulnerability, the results should be interpreted as indicating broader risk contexts rather than direct nutritional status alone. These findings highlight the importance of integrated, multidimensional approaches to support older adults at nutritional risk in community settings.

Healthcare doi: 10.3390/healthcare14081061

Authors: Neil G. Barr Glen E. Randall

Background/Objectives: The use of personal smartphones by healthcare professionals in clinical settings has become a growing area of concern as practice may not consistently align with policy guidance. This study enhances our understanding of how and why medical residents are using smartphones to communicate patient healthcare information with other physicians in daily practice and provides insights into the role that institutional governance, policies, and structures play in the use of smartphones. Methods: This study used qualitative techniques to examine medical residents’ use of smartphones to communicate healthcare-related information with colleagues. Additionally, a neo-institutional theory lens was applied to assess the role that regulative (guidelines/policies), normative (what peers/staff are doing), and cultural-cognitive (beliefs/perceptions) factors play in smartphone use by medical residents. Results: The results suggest that behaviour related to smartphone use is based primarily on normative and cultural-cognitive factors rather than regulative factors. Regulative elements around smartphone use play a smaller role in shaping behaviour, particularly when they: (1) lack clarity; (2) are not seen as credible/legitimate; or (3) are viewed as cumbersome and do not align with workflow needs. Conclusions: The implementation of future guidelines/policies should consider the use of mentorships throughout postgraduate medical training whereby staff physicians educate, model, and promote behaviour in accordance with the associated policies/guidelines.

Healthcare doi: 10.3390/healthcare14081060

Authors: Mika Miyaoka Kosuke Muraoka Shuji Awano Wataru Fujii

Background/Objectives: Japan, the world’s first super-aged society, has confronted rapid population aging and increasing healthcare demands earlier than any other country. In this context, dysphagia rehabilitation has become a critical issue affecting quality of life and survival. With nearly 30% of the population aged ≥65 years, Japan has developed a distinctive dysphagia rehabilitation model characterized by interprofessional collaboration and dental involvement. This narrative review describes its historical evolution and structural characteristics. Methods: This narrative review employed a structured literature search of PubMed and Ichushi-Web, supplemented by manual searches of policy documents and professional guidelines. Publications from 1980 to January 2026 were included if they addressed dysphagia rehabilitation systems or dental involvement in Japan. Both English- and Japanese-language sources were analyzed using thematic synthesis. Results: Japan’s dysphagia rehabilitation model evolved alongside population aging and is embedded within the universal health insurance and long-term care insurance systems. A prominent characteristic is the sustained involvement of dental professionals, who contributed to the foundational development of the field and remain actively involved across care settings, particularly within community- and home-based care. The system is further supported by certification frameworks, a triadic model integrating rehabilitation, nutrition, and oral health, and institutionalized interprofessional education. Conclusions: Previous studies have examined specific aspects of dysphagia care in Japan, but few have examined the overall structure of the system. This review maps the fundamental structure of Japan’s dysphagia rehabilitation model within its historical and policy context, offering insights relevant to dysphagia care in other aging societies.

Healthcare doi: 10.3390/healthcare14081059

Authors: Christine Kirby Julie A. Baldwin Kristan Elwell Michelle Anne Parsons

Background: The literature shows inconclusive results from utilizing motivational interviewing (MI) in indigenous populations to address early childhood caries (ECC). Great Beginnings for Healthy Native Smiles (GBHNS) (NIDCR U01DE028508), a community focused oral health (OH) intervention, was utilized alongside adapted MI techniques to promote OH care and education at home. Methods: The intervention was conducted by local Community Health Representatives (CHRs) from the two partnered indigenous communities. Reflecting on the years-long MI training and CHRs’ concerns, GBHNS conducted post-intervention semi-structured interviews with all MI staff regarding their experiences with MI. This paper uses participant observation, semi-structured interviewing, and inductive and deductive qualitative coding and analysis. Results: Thematic analysis was used to explore lessons learned and future research recommendations for interventions considering the use of MI. Generally considered a person-centered approach, MI reinforces Western psychological frameworks and practices which may disrupt local communicative practices and values. Conclusions: Specifically, interdisciplinary pre-intervention community assessments are recommended to ensure acceptability, relevance and appropriateness through attention to local communicative practices.

Healthcare doi: 10.3390/healthcare14081058

Authors: Bernadett Szilágyi János Sándor Zoltán Ónodi-Szűcs Karolina Kósa

Background: Hungary operated a public health-focused primary care model programme with expanded preventive and community-based services between 2013 and 2017 in four disadvantaged regions. This study aimed at assessing the association of this programme in one region with the patterns of emergency ambulance care before (2012) the programme and 3 years later when all services were available (2016). Methods: Patients in the selected region who received emergency ambulance care in the hospital catchment area were included. De-identified demographic data, reason for emergency service, on-site and hospital diagnosis, and treatment outcomes were entered into an electronic database from paper-based records. Diagnoses were assigned separate codes at GBD 1 and 3 levels. Results: The proportion of patients in emergency ambulance care showed a significant, 0.85% increase (p = 0.013) from 2012 to 2016. The proportion of female/male patients was roughly equal, but males needed emergency ambulance care significantly, 7 years younger than females in both years. Among patients with GPs in the model programme, 3.41% fewer needed emergency ambulance care due to non-communicable diseases, and 1.98% fewer were referred to other institutions from the hospital A&ED compared to those whose GPs did not participate (p < 0.001 for all). Conclusions: Utilisation of emergency ambulance services rose in the region in line with global trends suggesting that expanding primary care services alone may not be sufficient to reduce demand for emergency ambulance services. Further research is warranted to identify individual and systemic factors with major influence on emergency care use, including patient-level differences in the use of acute and preventive primary care services, and the availability of primary care after work hours.

Healthcare doi: 10.3390/healthcare14081057

Authors: Massimo Guasconi Federico Dibennardo Chiara Cosentino Giovanna Artioli Angela Andriollo Sara Pressi Michela Rocchi Sarah Santona Galli Giulia Valente Antonio Bonacaro

Background: Healthcare professionals are exposed to high emotional demands, including repeated contact with suffering, death, moral distress, and organizational pressure. These factors are associated with psychological distress, burnout, and secondary traumatic stress. Expressive Writing (EW) has been proposed as a psychological intervention, but evidence of its effectiveness among healthcare professionals remains heterogeneous. Objectives: To examine the effects of EW on psychological health, psychophysical well-being, and professional satisfaction among healthcare professionals. Methods: A systematic review was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA 2020 guidelines. Searches were performed in PubMed, CINAHL, CENRAL, CENTRAL Scopus, Embase, and PsycINFO from database inception to January 2025. Quantitative studies involving healthcare professionals and evaluating structured expressive writing interventions were considered for inclusion, including randomized and non-randomized, controlled and uncontrolled designs. Studies reporting psychological, psychophysical, or work-related outcomes were eligible. Only full-text articles published in English or Italian were considered. The review protocol was registered and archived in the Open Science Framework. Methodological quality was assessed using CASP checklists, the RoB 2 tool, and the Newcastle–Ottawa Scale. Results: Seven studies published between 2017 and 2023 were included. EW interventions were associated with reductions in psychological distress, particularly perceived stress, depressive symptoms, and post-traumatic stress symptoms. Findings regarding burnout and compassion fatigue were mixed. Organizational and job-related outcomes, such as job satisfaction and organizational commitment, showed limited and heterogeneous improvements. No consistent effects were observed for resilience or social support. Overall, the methodological quality of the included studies was generally good. Conclusions: EW appears to be a promising, low-cost intervention for reducing psychological distress among healthcare professionals. However, heterogeneity in study designs, intervention protocols, and outcome measures limits the strength of the evidence. Further high-quality, controlled studies using standardized EW protocols are needed.

Healthcare doi: 10.3390/healthcare14081056

Authors: Marian Rybář Gleb Donin Vojtěch Kamenský Martina Holá

Background: Stroke remains a significant health and economic challenge both globally and in the Czech Republic. Although a structured network of specialized stroke centres exists, comparative data on patient outcomes and healthcare costs across hospital types are still lacking in the Czech context. This study analyzed real-world administrative data to assess 90-day mortality and healthcare costs after ischemic stroke, categorized by intervention and provider type. Methods: Claims data from six Czech health insurance companies, covering approximately 44% of the population, were used for the years 2017–2020. Patients aged 18 and older with a primary diagnosis of ischemic stroke (ICD-10 code I63) were included. Interventions were categorized as thrombectomy, thrombolysis, or other treatment, and providers were classified as comprehensive stroke centres (CSCs), primary stroke centres (PSCs), secondary referral hospitals (SRHs), or others. Costs were calculated from the payer perspective using administrative claims data, and standardized 90-day mortality and effective cost per survivor (ECPS) were computed. Funnel plots were used to evaluate provider variability in outcomes and costs. The analysis included 23,568 patients (47% female; mean age 70.6). Results: Thrombectomy was associated with the highest mean costs (€13,385), the highest 90-day mortality (29.3%), and the highest ECPS (€18,880). Patients receiving other treatments had the lowest costs (€2725) and lower mortality (14.4%). CSCs recorded the highest average costs (€5087) and mortality (16.7%), while SRHs had the lowest costs (€2204) and mortality (13.7%). Funnel plots revealed greater variability in costs, mainly driven by primary hospitalization, while mortality rates showed less variation. Conclusions: These findings suggest that while stroke outcomes are relatively consistent across providers, costs differ, possibly reflecting efficiency differences and case-mix severity. The study is limited by the lack of clinical severity data, highlighting the need to link administrative data with clinical registries for more comprehensive future evaluations.

Healthcare doi: 10.3390/healthcare14081055

Authors: Eleni N. Sertaridou Emmanouela Tsouvala Vasilios E. Papaioannou Christina Alexopoulou

Background: The care and management of a pregnant woman suffering from end-stage brain cancer is surrounded by medical, legal, and ethical controversies. When this brain pathology leads to brain death (BD), continuation of life-sustaining treatments has been considered futile and unethical. An exception could be the case of pregnancy, in order to deliver a healthy neonate. Aim: The presentation of a pregnant woman with a terminal stage brain astrocytoma, admitted in the intensive care unit (ICU) to support the pregnancy, until optimal fetal viability, after she had neurological deterioration and confirmed BD, and a brief literature review of previously relevant published cases. Case Presentation: A 36-year-old woman with a medical history of brain astrocytoma in the last 2 years was admitted in ICU for the first time due to status epilepticus, six months after she stopped anticonvulsant therapy. Her epilepsy was controlled, and a pregnancy of 14 weeks was confirmed. Two weeks later, she deteriorated. After a multidisciplinary approach, it was decided to mechanically ventilate the patient and support the pregnancy. Brain death was determined after a couple of days. Results: A cesarean section was performed 11 weeks after BD diagnosis (at 27 weeks of gestational age) resulting in the delivery of a live, premature infant, weighing 549 gr. Conclusions: Maternal corporeal support can maximize the chances for survival in the neonate by prolonging the pregnancy of a brain-dead woman.

Healthcare doi: 10.3390/healthcare14081054

Authors: Mira Naguib Abdelrazek Heba Mahmoud Mahmoud Mohamed Ahmed Hashem El-Monshed Omima Mohamed Ibrahim Morsy Mahmoud Abdelwahab Khedr Wafa Hamad Almegewly Shadaid Alanezi Laila Saad Mahmoud

Background: Preoperative anxiety is a common and clinically significant response among surgical patients, with prevalence estimates ranging from 30% to over 80% depending on measurement method and surgical context. Early maladaptive schemas (EMSs)—deeply rooted, negative cognitive patterns formed in early life—have been theorized to amplify anxiety vulnerability. This study aimed to examine whether EMSs independently predict preoperative anxiety in a surgical population and to explore the role of demographic factors. Methods: A descriptive cross-sectional correlational study was conducted with 310 patients scheduled for elective surgery. Data were collected using a sociodemographic questionnaire, the Amsterdam Preoperative Anxiety and Information Scale (APAIS), and the Young Schema Questionnaire-Short Form, Second Edition (YSQ-S2). Internal consistency of both instruments was computed for this sample. Analyses included Pearson’s correlations and multiple regression. Results: Participants reported preoperative anxiety scores near the clinically meaningful threshold (M = 11.06, SD = 3.80). Small but statistically significant negative bivariate correlations were observed between APAIS scores and several EMS subscales (rs = −0.12 to −0.17). However, in multiple regression analysis, none of the EMS subscales was an independent predictor of preoperative anxiety (all ps > 0.18). Gender was the only significant independent predictor, with females reporting higher anxiety than males (B = 1.27, p = 0.012). The overall model explained 5.6% of variance (R2 = 0.06). Conclusions: This study did not support the hypothesis that EMSs independently predict preoperative anxiety, representing a null result with respect to EMS prediction. The primary finding was a significant gender difference, with females reporting higher preoperative anxiety. Clinicians should prioritize gender-sensitive preoperative screening. Future research should explore potential moderating factors and use prospective, multicenter designs.

Healthcare doi: 10.3390/healthcare14081053

Authors: Yahia Aldhamri Waleed M. Alshehri Sara M. Alahmari Amirah S. Alharbi Abdullah M. Alanazi Layla A. Alqahtani Samya Alshehri Salman Aloufi Raeed Alanazi Ali Kerari

Background: Mental health problems are highly prevalent among university students in Saudi Arabia; however, help-seeking behaviors remain low despite the availability of mental health services. There is limited evidence regarding students’ intentions to seek help and preferred sources of support, especially formal or informal sources. This study examined help-seeking intentions for mental health problems among university students. Methods: This cross-sectional descriptive study was conducted using an online self-administered questionnaire. Participants were 248 undergraduate students from various Riyadh universities. Help-seeking intentions were assessed using the General Help-Seeking Questionnaire. SPSS software was used to perform independent t-tests to assess differences in preferred sources across demographic groups, and Pearson’s correlation analyses were conducted to examine relationships between preferred sources and demographic variables. Multiple linear regression analyses were conducted to examine demographic and academic predictors of intentions to seek help from formal and informal sources. Results: Students demonstrated a low overall propensity to seek help. Online sources were the most preferred help-seeking option, followed by mothers, friends, and general physicians, whereas faculty, relatives, and religious persons were the least preferred. Preferred help-seeking sources differed by gender. Seeking help from mental health specialists was positively correlated with age and grade point average. Additionally, the regression analysis for formal help-seeking was significant, explaining 8.4% of the variance, with gender as the only significant predictor. Conclusions: These findings suggest the need for targeted interventions to improve students’ help-seeking behaviors. Universities should prioritize mental health literacy initiatives, stigma reduction strategies, and accessible support pathways, particularly by integrating digital and hybrid services and enhancing the role of faculty and institutional support systems in promoting timely and appropriate help-seeking.

Healthcare doi: 10.3390/healthcare14081051

Authors: Jin-Hee Na Hyo-Eun Park Seok-Hwan Kim

Background: The incidence and mortality rates of cancer among females aged 65 years or older in the Republic of Korea are increasing; however, the national cancer screening rate (50.4%) remains low. Therefore, this study aimed to identify predictors of participation in the National Cancer Screening Program (NCSP) among women aged 65 years or older using data from the 8th Korea National Health and Nutrition Examination Survey (KNHANES VIII, 2019–2021). Methods: This cross-sectional study utilized data from the 8th Korea National Health and Nutrition Examination Survey (KNHANES VIII, 2019–2021). Study variables were selected based on Andersen’s healthcare utilization model. Participation in the National Cancer Screening Program (NCSP) was defined as the dependent variable, and independent variables included predisposing, enabling, and need factors. Descriptive analyses were conducted to examine participants’ characteristics. Chi-square tests were used to assess differences in NCSP participation according to participant characteristics. Multivariable logistic regression analysis was conducted to identify factors associated with participation, with all independent variables simultaneously included in the model to adjust for potential confounding. A p-value of <0.05 was considered statistically significant. Results: A total of 2105 women aged 65 years or older were included in the analysis. Of the 2105 women aged 65 years or older, 1429 (67.9%) reported participation in cancer screening within the past two years. NCSP participation was significantly associated with being married (OR = 1.540; 95% CI: 1.263–1.879), being a middle school (OR = 1.357; 95% CI: 1.022–1.801) or college graduate or higher (OR = 2.012; 95% CI: 1.199–3.378), having private insurance (OR = 1.930; 95% CI: 1.573–2.368), average subjective health (OR = 1.332; 95% CI: 1.004–1.766), dyslipidemia (OR = 1.347; 95% CI: 1.110–1.636), and physical activity participation (OR = 1.252; 95% CI: 1.029–1.524). In contrast, urban residence, income level, being employed, medical coverage type, hypertension, diabetes, monthly drinking status and current smoking status were not statistically significantly correlated with NCSP participation. Conclusions: These findings highlight the need for tailored outreach strategies and health education programs targeting women aged 65 years and older to enhance participation in the NCSP and ultimately improve public health outcomes.

Healthcare doi: 10.3390/healthcare14081052

Authors: Sieun Park Seung Kyum Kim

Background/Objectives: Down syndrome (DS), the most common chromosomal disorder, is associated with obesity and related metabolic complications. Although physical activity (PA) improves health outcomes in individuals with DS, global research trends in this field have not been systematically synthesized, and evidence regarding the effects of aerobic training (AT) on obesity-related parameters in individuals with DS remains inconsistent. This study incorporated a dual bibliometric and meta-analytical approach. Methods: First, the bibliometric analysis included 321 original research articles published between 2001 and 2024, retrieved from Scopus, Web of Science, and PubMed. Second, a meta-analysis of 15 randomized controlled trials (n = 477) was conducted to examine the effects of AT on obesity-related parameters, including body weight (BW), body mass index (BMI), fat mass (FM), waist circumference (WC), and waist-to-hip ratio (WHR) in individuals with DS. Results: Keyword co-occurrence and collaboration network analyses revealed a notable increase in research output since 2018, with “adolescent,” “obesity,” and “intellectual disability” the most co-occurring keywords associated with DS and PA. “Obesity” emerged as the most prominently growing keyword associated with DS and PA. A meta-analysis concluded that AT reduced FM (standardized mean differences [SMD] = −0.44; p < 0.001) and WC (SMD = −0.39; p < 0.01), while subtle changes in BW, BMI, and WHR were found. These findings suggest that AT improves body composition, particularly reducing central adiposity, even without changes in traditional weight-based metrics. Conclusions: Our findings demonstrate that AT can be an effective non-pharmacological strategy for improving body composition in individuals with DS and obesity and highlight the urgent need to shift clinical and research paradigms toward multidimensional, individualized health strategies that support PA and healthy body composition throughout the lifespan.

Healthcare doi: 10.3390/healthcare14081050

Authors: Neylan Kaya Aslıhan Ersoy Bozcuk Güler Ferhan Ünal Uyar Eylül Türkay Mehtap Türkay

Background/Objectives: The comparative evaluation of health system performance is becoming increasingly critical for policy makers in the context of rising health expenditures, demographic ageing, and the deepening of health inequalities between countries. In the existing literature, a substantial proportion of studies addressing health performance either examine causal relationships based on single health outcomes or rely on a single multi criteria decision making (MCDM) method based on equal or subjective weighting. This situation may lead to limitations in terms of method sensitivity and the reliability of the resulting rankings. This study addresses an important gap in the literature by directly tackling method sensitivity through the integrated use of objective weighting and multiple ranking methods. The aim of this study is to evaluate the health system performance of OECD countries within an integrated MCDM framework based on objective weighting. Methods: The analysis covers 27 OECD countries and is based on key indicators representing health performance, such as life expectancy, avoidable mortality, infant mortality rate, and maternal mortality rate. Criterion weights are determined objectively using the CRITIC method, and country performance rankings are obtained using the MAIRCA and MARCOS methods. Results: The findings indicate that there are substantial differences in health system performance among OECD countries. The high level of consistency between the results obtained from different ranking methods supports the methodological robustness of the findings. Conclusions: In this respect, the study contributes to the literature on health system performance evaluation at both methodological and applied levels and provides policy makers with a more reliable framework for comparative analysis.

Healthcare doi: 10.3390/healthcare14081049

Authors: Ali M. Bahathig Ayedh H. Alghamdi Mohammed A. Aljaffer Mohammed A. Alblowi Metib S. Alotaibi Deena N. AlNouwaiser Asma’a M. Alshehri Abdullah M. Alhejji Wejdan S. Alruwaili Ghassan A. Abuseif Ahmad H. Almadani

Background: Depression and anxiety are prevalent mental health disorders that substantially impact quality of life. The association of incretin mimetics, including glucagon-like peptide-1 (GLP-1) receptor agonists, with symptoms of depression and anxiety remain underexplored in Saudi Arabia. This study was conducted to assess the association between GLP-1 receptor agonist use and symptoms of depression and anxiety and to identify related factors. Methods: A cross-sectional study using convenience sampling was conducted among adults (≥18 years) treated with GLP-1 receptor agonists at King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia. Data were collected using a questionnaire developed by the research team, in addition to the Arabic versions of the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7). Results: A total of 235 participants were included, of whom 48.5% used GLP-1 receptor agonists for both glycemic control and weight loss. Only 31.9% had undergone psychiatric evaluation prior to initiating therapy, and 14.9% had a diagnosed psychiatric disorder. The mean anxiety score (GAD-7) was 4.82 ± 5, and the mean depression score (PHQ-9) was 6.13 ± 4.95. Multivariable analysis showed that higher odds of more severe depression were associated with using diabetes medications for weight loss in addition to diabetes treatment, a history of psychiatric disorders, and holding a bachelor’s degree. Exercising for 101–150 min per week was associated with lower odds of depression. Regarding anxiety, participants who exercised 101–150 min per week had significantly lower odds of anxiety compared with those who did not exercise, while a history of psychiatric disorders was associated with higher odds of more severe anxiety. Conclusions: This study’s findings highlight the importance of integrating both routine psychiatric screening and follow-up into diabetes and obesity management to enhance both psychological well-being and metabolic outcomes. They also reflect the benefit of physical activity for mental health, emphasizing the need to encourage exercise among individuals with diabetes or obesity.

Healthcare doi: 10.3390/healthcare14081048

Authors: Adrijana Svenšek Lucija Gosak Tamara Trajbarič Luka Šajher Gregor Štiglic Mateja Lorber

Background/Objectives: Digital health interventions are increasingly used to support person-centered care (PCC) in chronic disease management, yet it remains unclear which PCC components are most consistently enabled by digital tools and how these relate to outcomes. This study synthesized evidence on digitally supported PCC for adults with chronic conditions, examining how interventions operationalize PCC and which clinical, patient-reported, and implementation outcomes are reported. Methods: A structured literature synthesis was conducted according to PRISMA guidelines across a heterogeneous evidence base, including randomized and pragmatic trials, observational studies, qualitative studies, and systematic reviews. The review protocol was pre-registered in the Open Science Framework (OSF) Registries. Results: Across 16 included studies, digital solutions most consistently supported PCC through enhanced situational awareness via self-monitoring, strengthened partnership through two-way communication and coaching, and reinforced shared documentation through co-created health plans. Benefits were reported most consistently for process and experience outcomes, such as perceived access to support, engagement, and empowerment. Evidence for sustained long-term clinical improvements, such as glycemic control, was mixed and frequently limited by short follow-up periods and variation in intervention integration. Conclusions: Digitalization can strengthen PCC when embedded within relational care models and organizational workflows that translate patient-generated data into meaningful action. Future work should utilize clearer PCC operationalization, longer follow-up, and routine reporting of equity outcomes, alongside targeted training for healthcare professionals delivering PCC in digital encounters.

Healthcare doi: 10.3390/healthcare14081047

Authors: Evdoxia Tsigkaropoulou Fragiskos Gonidakis Ioannis Michopoulos

Anorexia nervosa is a clinically complex and ethically challenging psychiatric disorder. Clinicians are frequently confronted with ethical dilemmas arising from conflicts between core ethical principles in everyday clinical practice. Professional codes of ethics and legal frameworks often fail to provide a stable basis for resolving these dilemmas due to the fluctuating medical risk and the ego-syntonic nature of anorexia nervosa. Under conditions of heightened responsibility and medical risk, clinicians’ cognitive and emotional responses may be activated and may mediate ethical decision-making. Although such internal processes have been described in the literature, limited attention has been paid to their role in shaping ethical judgment in routine clinical care. The aim of this article is to conceptualize the decision-making processes that unfold in response to ethical dilemmas in the clinical context of anorexia nervosa and propose a sequential multi-level framework. A focused conceptual literature review was conducted to develop a reflective framework for clinical practice, drawing on selected studies in clinical ethics, healthcare law, anorexia nervosa care, and cognitive theory. Clinicians’ internal cognitive and emotional processes play a significant role in ethical decision-making in complex clinical contexts such as anorexia nervosa and should be explicitly recognized and brought into reflective awareness through supervision and reflective practice. Ethical decision-making is therefore conceptualized as a dynamic process linking clinical events, clinicians’ internal responses, ethical and legal considerations, and reflective clinical judgment. Incorporating structured reflection into clinical, educational, and supervisory settings may support more ethically informed and context-sensitive clinical judgment within multidisciplinary eating disorder services.

Healthcare doi: 10.3390/healthcare14081046

Authors: Azzah S. Alharbi

Objectives: Given the limitations of body mass index (BMI) as a metric and the lack of data on the relationship between various anthropometric indices of obesity and immune fitness (IF), this study aimed at exploring the possible association between various anthropometric indicators and the immune fitness among an adult sample of the Saudi population residing in Makkah. Methods: A structured self-reported questionnaire, with questions covering age, sex, anthropometric and immune fitness assessment data, was distributed online to a convenience sample of target population. The Immune Status Questionnaire (ISQ) was utilized to assess respondents’ IF over the past 12 months, while perceived momentary immune fitness (PMIF) was measured using a single-item scale. A total of 1135 responses were included in the study. Results: Overall, 530 male (46.7%) and 605 female (53.3%) respondents were included in the analysis. Of these, 478 (42.1%) had a normal BMI, and 343 (30.2%) were classified as overweight, 184 (16.2%) as obese, and 130 (11.5%) as underweight. Participants with reduced ISQ score (<6) were more likely to be underweight (p < 0.001), have a high weight-adjusted waist index (WWI) (p = 0.035), and exhibit an increased conicity index (C index) (p = 0.037) compared to those with an ISQ score ≥ 6. After controlling for age and sex, weight (p = 0.003), height (p < 0.001), and WWI (p = 0.01) were found to have significant correlations with past-year IF, while only height (p = 0.004) showed a significant positive correlation with PMIF. A multiple linear regression analysis revealed that sex and height and waist circumference (WC) were significant predictors of IF. Specifically, males and those who were taller had higher IF scores. Whereas individuals with high-risk WC values reported lower IF scores than those with low-risk WC. Conclusions: Sex (male) and anthropometric measures (lower WC, and taller height) were the most informative predictors of higher IF scores. The findings highlight the association between anthropometric measures and IF. A deeper understanding of these associations can inform the development of targeted interventions aimed at improving IF and overall health outcomes.

Healthcare doi: 10.3390/healthcare14081045

Authors: Kulweena Sisayanarane Suchira Chaiviboontham Piyawan Pokpalagon Nutsiri Kittitirapong Chutirat Sonpee

Background: Chronic venous insufficiency (CVI) is characterized by venous dysfunction in the lower extremities, leading to increased venous pressure, edema, and reduced quality of life. Objectives: This study aimed to evaluate the additional effect of a structured home-based calf muscle strengthening exercise program when combined with standard compression therapy, by comparing disease severity, musculoskeletal function, and quality of life over time between patients receiving compression therapy alone and those receiving combined intervention. Methods: A randomized controlled trial was conducted in 50 patients with CVI (CEAP C3–C5), who were assigned to an experimental group (n = 25) and a control group (n = 25). Outcomes were assessed at baseline, week 6, and week 12. Disease severity was measured using the Revised Venous Clinical Severity Score (rVCSS), and swelling, muscle, and joint function were assessed using calf muscle strength and ankle range of motion. Quality of life outcomes were assessed using the chronic venous disease quality of life questionnaire (CIVIQ-20). Data were analyzed using two-way repeated measures ANOVA. This trial was registered retrospectively at the Thai Clinical Trials Registry (registration number: TCTR20260307002). Results: Significant group × time interaction effects were observed for disease severity (right leg: F = 81.562, p < 0.001, η2p = 0.630; left leg: F = 73.765, p < 0.001, η2p = 0.606), indicating greater improvement in the experimental group over time. Calf muscle strength significantly increased in the experimental group (right leg: F = 395.246, p < 0.001, η2p = 0.892; left leg: F = 87.278, p < 0.001, η2p = 0.645). Ankle range of motion also improved significantly (p < 0.001). Quality of life showed significant improvement with a group × time interaction effect (F = 66.104, p < 0.001, η2p = 0.579). Conclusions: A structured home-based calf muscle strengthening exercise program combined with compression therapy produced significant improvements in disease severity, musculoskeletal function, and quality of life over time, demonstrating an additive therapeutic effect in patients with CVI.

Healthcare doi: 10.3390/healthcare14081044

Authors: Marija Burceva Vineta Viktorija Vinogradova Elmars Rancans

Background/Objectives: Previous research has shown that mental disorders are common in the general population in Latvia, while access to specialised psychiatric services is limited, particularly in rural areas. General practitioners, therefore, have a crucial role in the early detection and management of these conditions. Previous studies and national initiatives have highlighted an unmet need for continuing education in psychiatry tailored to the Latvian primary care context. In response, the first Latvian telementoring programme, the “ECHO School of Psychiatry” (Extension for Community Healthcare Outcomes, ECHO), was launched in 2023 to enhance general practitioners’ competencies and decision-making in mental healthcare. This study explored general practitioners’ experiences and perceptions of participation in the programme and its perceived impact on their practice, using a qualitative approach. Methods: Thirteen women general practitioners who had participated in the programme between October 2023 and February 2025 were recruited using voluntary response sampling, via email invitations from programme coordinators. Individual semi-structured interviews were conducted remotely between May and September 2025, audio-recorded, transcribed verbatim, and the resulting transcripts were analysed thematically using an inductive approach, supported by NVivo software. Data collection continued until no new themes emerged. Results: Four main themes emerged from the thematic analysis: (1) participants’ perceptions of the structure and educational value of the programme; (2) perceived impact of the programme on clinical practice and decision-making; (3) programme limitations in addressing professional isolation and fostering collaboration; (4) suggestions for programme improvement. Themes illustrate participants’ perceptions of the programme’s value, its impact on practice, and recommendations for further development. Conclusions: This study provides insights into the strengths and areas for improvement of the “ECHO School of Psychiatry” as perceived by general practitioners. It also acknowledges current challenges in primary care, such as limited access to specialists and professional isolation.

Healthcare doi: 10.3390/healthcare14081043

Authors: Almudena Castaño Reguillo Raquel Sánchez Ruano Jaime Barrio Cortés Elena Polentinos-Castro ESAPD Espronceda Collaborative Group ESAPD Espronceda Collaborative Group

Background: Dying in the preferred place is considered an indicator of the quality of end-of-life care. Advance care planning and home palliative care may increase the likelihood of dying at home, but it remains unclear whether the documentation of these preferences in clinical records is associated with the actual place of death. This study assessed whether the recording of patients’ preferred place of care or death was associated with the actual place of death among patients followed by home palliative care teams. Methods: We conducted a retrospective observational study with an exploratory approach that included adult patients who died in 2022 and were followed by a home palliative care team in Madrid, Spain. Data were extracted from electronic health records and analysed using bivariate tests and multivariable logistic regression. Results: A total of 464 patients were included (53% women; mean age 80.8 years). Overall, 82.5% of the patients died at home. Preferences were recorded for 64% of the patients; 97.6% preferred to die at home, and 89% died there. Documentation of preferences was not significantly associated with the place of death. Conclusions: Documentation alone was not independently associated with the place of death. These findings should be interpreted cautiously given the observational and exploratory design of the study and the limited explanatory power of the regression model. Notably, most patients expressed a preference to die at home, and most deaths also occurred at home. Recording preferences may still support advance care planning and patient-centred decision-making, but documentation should not be interpreted as sufficient in itself to influence place of death.

Healthcare doi: 10.3390/healthcare14081042

Authors: Adolfo Romero-Arana Nerea Romero-Sibajas Juan Gómez-Salgado María Isabel Ruiz-Moreno Víctor Manuel Cotta-Luque Lucía Rojas-Suárez Luis El Khoury-Moreno Julio Torrejón-Martínez Adolfo Romero-Ruiz

Background: In Spain, the number of patients anticoagulated with vitamin K antagonists (VKAs) is high. Among them, poor adherence is common, which may be justified by a low level of knowledge, and could affect their quality of life. We analyzed treatment adherence, health-related quality of life, and knowledge level about treatment, and evaluated the possible influence of these factors on patients’ time in the therapeutic range while also studying potential differences between patients under routine monitoring or self-monitoring. Methodology: A cross-sectional descriptive study was conducted using three validated and cross-culturally adapted questionnaires to study therapeutic adherence, health-related quality of life, and knowledge level about VKA treatment in a sample of anticoagulated patients. Additionally, it was assessed whether they were self-monitoring or not; the Rosendaal Time in Therapeutic Range (TTRr) was also administered for each patient at the time of recruitment. Descriptive analysis of all variables was performed, and a logistic regression model was constructed to evaluate the possible interaction of variables. Results: Ninety-eight patients participated and were selected sequentially from those attending the oral anticoagulation clinic at Hospital Universitario Virgen de la Victoria in Malaga. Of these, 39 were men and 59 were women. The mean age of these participants was 60.62 years (SD 11.67). Sixty-six were under conventional monitoring and thirty-two followed the self-monitoring program. The DecaMIRT had a mean score of 39.22 (SD 8.57), the SF-12 mean score was 31.73 (SD 6.21), and the knowledge questionnaire’s was 14.2 (SD 2.6). The mean TTRr value was 63.88 (SD 22.99). Self-monitored patients showed better results in DECAMirt and knowledge. Discussion: Overall, patients included in the sample presented satisfactory values in these three questionnaires, which seems to indicate that this was a treatment-compliant group with a correct quality of life, and adequately informed about their treatment. Conclusions: The work of nurses responsible for these aspects appears crucial in achieving these results. We aim to extend this study by focusing on groups with poorer results to design specific activities that allow for improvement in care and, as much as possible, homogenize outcomes. For this purpose, we intend to use all available tools, including those derived from the use of health-oriented artificial intelligence.

Healthcare doi: 10.3390/healthcare14081041

Authors: Muhammet Fatih Şahin Ali Erol

Background/Objectives: In-hospital critical outcome among palliative inpatients remains high, often driven by acute physiological instability rather than chronic comorbidities. Although diabetes mellitus (DM) is common in this population, its independent impact on critical outcome is unclear. This study aimed to determine whether acute metabolic and inflammatory markers—specifically glucose, C-reactive protein (CRP), albumin, and oxygen requirement—better predict short-term outcomes, defined as in-hospital critical outcome or ICU transfer during the same hospitalization period, than DM status alone. Methods: This retrospective study included 200 palliative inpatients admitted to the Internal Medicine Clinic of Kestel State Hospital, Bursa, Turkey, between January 2024 and January 2025. Demographic, clinical, and laboratory data were obtained from electronic records. The primary outcome was in-hospital critical outcome or ICU transfer (“critical outcome”). Logistic regression and receiver-operating characteristic (ROC) analyses identified independent predictors. The study was approved by the Bursa Yüksek İhtisas Training and Research Hospital Ethics Committee (ethics approval: protocol code 2024-TBEK 2025/05-12). Results: The mean age was 77.7 ± 12.3 years, and 47% were male. DM was present in 30.5% but did not independently predict critical outcome (p = 0.904). In contrast, oxygen requirement (OR = 4.08, p = 0.002), mean glucose (OR = 1.01, p = 0.001), and cancer (OR = 3.28, p = 0.016) were significant predictors. ROC analysis identified CRP > 64.1 mg/L and albumin < 25 g/L as optimal thresholds, and these two markers formed the basis of the low-, intermediate-, and high-risk stratification, with critical-outcome rates of 39.0%, 45.1%, and 85.4% (p < 0.001). Conclusions: Acute metabolic and inflammatory disturbances—particularly hyperglycemia, elevated CRP, hypoalbuminemia, and oxygen requirement—are stronger prognostic indicators than DM. A simple bedside model incorporating these parameters may improve prognostic accuracy and communication in palliative care.

Healthcare doi: 10.3390/healthcare14081040

Authors: Deepa Fernandes Prabhu Varadraj Gurupur Alexa Stone Elizabeth Trader

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Healthcare doi: 10.3390/healthcare14081039

Authors: Evanthia Asimakopoulou Kyriakos Alexandrou Maria Foka Anna Vavlitou Petroula M. Mavrikiou

Background: Delirium is a frequent and serious complication in intensive care units (ICUs), associated with increased mortality, prolonged mechanical ventilation, extended length of stay, and long-term cognitive impairment. This study aimed to assess ICU nurses’ knowledge and practices regarding delirium management in Cyprus and to identify predictors of knowledge. Methods: A cross-sectional study was conducted among nurses working in adult ICUs in Cyprus. Data were collected using a structured self-administered questionnaire that included demographic characteristics, sedation and analgesia practices, and an adapted Delirium Knowledge Questionnaire incorporating ICU-specific items. Results: A total of 70 ICU nurses participated, most of whom were female (60%) with a mean ICU experience of 5.1 years. Only 27.1% reported daily delirium screening, although 65.2% perceived delirium as frequent. Sedation protocols were reported by 34.3%, sedation scales were used by 44.3%, and daily sedation interruption by 61.4%. Only 15.7% had received formal delirium training, while 87.1% expressed the need for further education. Knowledge scores were moderate to high (68.5–84.0%), with higher scores among nurses with prior training and female nurses (p = 0.003). Hospital type was associated with sedation practices, with greater use of sedation scales in public ICUs (p < 0.001) and propofol more commonly used as first-line sedation compared with midazolam in private ICUs (p = 0.018). Conclusions: Although ICU nurses demonstrated moderate knowledge of delirium, systematic screening and protocolized management remain suboptimal. Structured education and standardized implementation strategies are required to strengthen patient safety in critical care settings.

Healthcare doi: 10.3390/healthcare14081038

Authors: Sadia Qazi Hafsa Fayyaz Bilal Ahmad Abdal Ahmad Syeda Sama Bilal Aiman Ajmeer Humna Aziz

Background: Acute lymphoblastic leukemia (ALL) requires intensive induction, but implementation of pediatric-inspired regimens in low- and middle-income countries is constrained by diagnostic gaps, procurement instability, and limited supportive-care capacity. We evaluated the feasibility, safety, and affordability of a pragmatically adapted pediatric-inspired induction regimen for adults with Philadelphia chromosome-negative Ph(−) ALL in a Pakistani tertiary hospital. Methods: In this prospective single-center cohort study at the Pakistan Institute of Medical Sciences (December 2024–June 2025), consecutive adults aged 18–50 years with newly diagnosed Ph(−)ALL received an adapted pediatric-inspired induction regimen. The primary outcome was complete remission (CR) after induction, with or without extended induction. Secondary outcomes were early mortality, treatment abandonment, grade 3–4 toxicities, and service delivery feasibility indicators. Affordability was assessed against household income. Results: Among 200 adults (mean age 30.3 ± 8.8 years; 65.5% male), 39.5% presented with WBC ≥ 30 × 109/L and 88.0% with platelets < 50 × 103/µL. CR was achieved in 83.0% of patients. Early mortality was 2.0%, and treatment abandonment was 1.5%. Grade 3–4 toxicities included febrile neutropenia (15.0%) and sepsis (7.5%). The Day-30 evaluability was high (96.5%). Observed out-of-pocket diagnostic costs were USD 119, whereas a guideline-complete diagnostic package would cost USD 929, equivalent to 3–6 months of income for households in the poorest quintile. Conclusions: This adapted pediatric-inspired induction regimen was operationally deliverable in a resource-restricted hospital and produced favorable induction-phase outcomes. Limited diagnostic capacity and a lack of financial protection for testing remain barriers to risk-adapted care. Expanding subsidies for essential diagnostics and stabilizing the procurement of critical agents may yield the greatest implementation gains.

Healthcare doi: 10.3390/healthcare14081037

Authors: Sabine Pawellek Isabell Estorff Hagen Wulff Thomas Wendeborn

Background/Objectives: Digital obesity therapy requires exercise therapists with adequate digital competences, yet training opportunities remain limited. This study provides the first application of the DigCompThExO questionnaire to assess exercise therapists’ digital competences and their predictors in obesity therapy, addressing digital sovereignty as an educational outcome and informing future training programs. Methods: A cross-sectional online survey assessed self-perceived digital competences among German-speaking exercise therapists in obesity care using the validated DigCompThExO questionnaire (14 items). Descriptive and regression analyses examined personal (age, gender, qualification) and contextual (type of therapy, therapeutic targets) predictors of overall digital competence, with correction for multiple testing. Results: Of 203 therapists (mean age 33.3 ± 5.9 years), ‘Teaching Strategies’ yielded the highest scores, ‘Selection Criteria’ the lowest. Regression analysis (n = 202) accounted for a substantial proportion of variance in overall digital competence (R2 = 0.801, adjusted R2 = 0.790, p < 0.001), with the digitally pursued therapeutic target body awareness emerging as significant predictor (B = 0.18, p_FDR = 0.003). Conclusions: This study provides initial insights into the digital competence profiles of exercise therapists in obesity therapy. In exploratory analysis, the therapeutic target of digitally fostering body awareness was the only predictor that remained significant after correction. The findings suggest that targeted education in data protection, media reflection, and the communication of exercise-related therapeutic targets may be relevant to support digital competence development.

Healthcare doi: 10.3390/healthcare14081036

Authors: Ji-Hun Kang Min-Seok Choi Eun-Kyung Jung Sung-Soo Choi Seong-Ju Kim Yun-Deok Jang

Background/Objectives: Injury mechanism and intent are key determinants of patient outcomes in the emergency department, yet their combined effects remain insufficiently understood. Emergency department disposition after injury may differ according to mechanism and intent and may be further influenced by specific mechanism–intent combinations. This study aimed to evaluate the associations of injury mechanism, intent, and their interaction with emergency department disposition and injury severity measured using the International Classification of Diseases-based Injury Severity Score (ICISS). Methods: We conducted a retrospective analysis of injury-related emergency department visits recorded between 1 January 2019 and 31 December 2023. Eligible visits included those with valid arrival and departure timestamps and complete disposition data; records with missing key variables or implausible length of stay were excluded. A total of 1,029,875 visits were analyzed. The primary outcome was emergency department disposition, categorized as discharge, admission, or transfer. Multinomial logistic regression was used to estimate relative risk ratios, with discharge as the reference category, and to derive predicted probabilities for selected mechanism–intent combinations. Injury severity was assessed using ICISS and modeled with injury mechanism, intent, their interaction, and prespecified covariates. Results: Of all visits, 69.9% resulted in discharge, 24.3% in admission, and 5.8% in transfer. Compared with traffic accidents, the highest likelihood of admission was observed in suffocation, drowning, and poisoning injuries. Transfer was more frequent in drowning, suffocation, penetrating injuries, and poisoning. Self-harm was associated with increased risks of both admission and transfer compared with unintentional injuries. Interaction analyses showed that certain combinations, particularly poisoning with self-harm and suffocation with self-harm, were associated with substantially higher risks than either factor alone. Predicted probabilities further highlighted high-risk combinations, including markedly elevated admission probabilities in self-harm-related poisoning and suffocation, and increased transfer probability in unintentional drowning. Injury mechanism, intent, and selected interactions were also significantly associated with ICISS-based injury severity. Conclusions: Injury mechanism and intent are independently associated with emergency department disposition and injury severity, with additional risk amplification observed for specific combinations. These findings suggest that mechanism–intent combinations may serve as clinically useful risk indicators in emergency department triage and decision-making, supporting improved risk stratification and system-level coordination.

Healthcare doi: 10.3390/healthcare14081035

Authors: Wenjing Luo Haishan Wei Kaili Zhang Dehui Wang Hong Lu Yinchu Hu Chunying Li Junrong Zhang Xiu Zhu

Background: While combined diet and physical activity interventions are recommended, evidence specific to low-risk pregnant women remains limited. As responses to combined interventions may vary by pre-pregnancy BMI, maternal health status and pregnancy outcomes, targeted evaluation in low-risk pregnant women is needed. Inconsistencies across studies, along with the lack of a comprehensive synthesis of both effects and intervention components, further limit their implementation. Objective: Our aims were to assess the effects of combined diet and physical activity interventions on gestational weight gain among low-risk women and to systematically characterize the intervention components. Design: We conducted a systematic review and meta-analysis following the Cochrane Handbook guidelines and PRISMA 2020. Methods: Eight databases and trial registries were searched from inception to 16 March 2026. Two reviewers independently conducted study selection, data extraction and risk of bias assessment. Intervention components were coded using the TIDieR checklist. The quality of included studies was assessed using the updated Cochrane risk of bias 2.0 tool. Meta-analyses were performed using Review Manager 5.4, and certainty of evidence was assessed using the GRADEpro online tool. Results: A total of 10 studies involving 3977 pregnant women were included. Combined diet and physical activity interventions significantly reduced total gestational weight gain (GWG) (MD = −0.78 kg, 95% CI: −1.12 to −0.44, p < 0.00001) and the risk of excessive gestational weight gain (EGWG) (OR = 0.63, 95% CI: 0.49–0.81, p = 0.0003). Additionally, individually delivered physical activity components and those implemented in healthcare facilities appeared to be associated with lower total GWG (MD = −0.76 kg, 95% CI: −0.98 to −0.53, p < 0.00001). For EGWG, lower risk was observed in interventions using combined face-to-face and remote formats (OR = 0.54, 95% CI: 0.41–0.72, p < 0.0001) and moderate frequency (diet: OR = 0.64, 95% CI: 0.51–0.81, p = 0.0002, physical activity: OR = 0.65, 95% CI: 0.52–0.83, p = 0.0004). Conclusions: Combined diet and physical activity interventions were associated with reduced total GWG and lower EGWG risk in low-risk pregnant women. Intervention characteristics, such as individual delivery formats, combined face-to-face and remote formats, moderate frequency and implementation in healthcare facilities, may be related to intervention effectiveness. Registration number: CRD420251013116 (PROSPERO).

Healthcare doi: 10.3390/healthcare14081034

Authors: Atta Ur Rehman Rubeena Zakar Gulzar H. Shah Ume Hani Muhammad Zakria Zakar Tran Nguyen

Introduction: Health literacy enables refugees to assess, understand, and utilize health information effectively. This investigation aims to identify factors influencing health literacy levels among Afghan refugees in Pakistan. Methods: A cross-sectional survey using a multistage sampling approach was conducted to collect data from 1185 refugees. Health literacy levels were measured using the pre-validated All Aspects of Health Literacy tool in five districts of Punjab and Khyber Pakhtunkhwa provinces that met the inclusion criteria. We used logistic regression models to analyze the dichotomous dependent variables. Results: A significant proportion of Afghan refugees demonstrated low functional health literacy and required assistance with reading and completing health documentation. Afghan refugees in the younger age group, male gender, higher monthly income, and access to healthcare information and clean water were more functionally literate in health. More than two thirds of the Afghan refugee population had adequate communicative health literacy with health care professionals in Pakistan. Most refugees believed that healthy lifestyles information and encouragement were more crucial for health than housing, employment, education, and local infrastructure. Conclusions: Afghan refugees in Pakistan lacked functional health literacy, critical health literacy, and overall health literacy. However, they have adequate communicative health literacy. This initial survey added new data on Afghans’ health literacy levels, which could help stakeholders strengthen health promotion initiatives within the healthcare system to improve health outcomes.