Healthcare doi: 10.3390/healthcare14182993

Authors: Olga Cerela-Boltunova

Background/Objectives: Prolonged working shifts may adversely affect healthcare workers’ health, well-being, cognitive performance, and patient safety. Nevertheless, 24-h shifts remain commonly used in Latvian healthcare. This study aimed to examine healthcare workers’ experiences of 24-h shift work, their attitudes toward revising this work schedule, and the main reported reasons underlying their preferences. Methods: A cross-sectional survey was conducted in Latvia between October 2025 and February 2026. A structured 64-item questionnaire assessed sociodemographic and professional characteristics, workload, shift patterns, health and emotional well-being, perceived patient-safety concerns, professional motivation, and attitudes toward alternative work schedules. Of 1524 submitted questionnaires, 1318 were included in the analysis. Quantitative data were summarized using descriptive statistics, while open-ended responses were examined using qualitative content analysis. Results: Most respondents regularly worked extended shifts, and 40.5% worked at more than one institution. More than half reported health changes that they perceived as potentially related to extended shift work, with 61.1% reporting emotional exhaustion and 49.2% reporting persistent fatigue. Fatigue during extended shift work had contributed to a self-reported error or perceived decline in care quality among 34.9% of respondents. Despite these concerns, a substantial proportion of participants preferred to retain 24-h shifts. Frequently reported reasons included schedule convenience, consecutive days off, financial considerations, and the ability to combine employment across multiple workplaces. Open-ended responses further highlighted preferences for flexibility, employee choice, adequate staffing, opportunities for rest, and consideration of financial consequences when revising work schedules. Conclusions: The findings demonstrate a tension between healthcare workers’ perceived health and patient-safety concerns associated with extended shift work and the practical and financial advantages associated with retaining 24-h shifts.

Healthcare doi: 10.3390/healthcare14182992

Authors: Akshay Soni Marcel Chua Warren M. Rozen Lisa Ellis

Background: Fragmented healthcare systems require patients and informal carers to collect, organise, transfer, and interpret personal health information across providers. This review examined the burdens of this work, its management methods, and the evidence for digital tools intended to reduce it. Methods: MEDLINE, Embase, CINAHL, and the Cochrane Library were searched for English-language primary studies published from January 2000 to 25 June 2026. Eligible studies examined patient- or carer-led management of personal health information in community, outpatient, or longitudinal care. Two reviewers independently screened records. The findings were synthesised narratively because of study heterogeneity. Results: Eleven studies published between 2005 and 2021 were included: seven from the United States, two from Italy, and one from Canada and Israel each. Ten used qualitative methods and one used mixed methods. Patients and carers managed medications, appointments, test results, correspondence, medical histories, and insurance information using folders, binders, handwritten notes, calendars, spreadsheets, memory, and, less commonly, digital portals. Reported burdens included time, administrative effort, cognitive demand, emotional distress, and responsibility for maintaining continuity between services. Burdens were greatest when information demands increased while illness reduced a patient’s capacity to manage them. Paper-based systems remained common because they were visible, portable, and easy to annotate. No study directly tested whether a digital intervention reduced information management burden, and none were conducted in Australia. Conclusions: Personal health information management (PHIM) is substantial but largely unrecognised patient and carer work arising partly from fragmented information exchange. The available evidence identifies design considerations for information management, but it does not establish that digital interventions can reduce burden.

Healthcare doi: 10.3390/healthcare14182991

Authors: Rehab Yusuf Al-Ansari Safa Hamdan Kamal Saleh Al Al Zahrani Arifa Jamal Assim Osman Nayef Al Ahmadi Walaa Abouelenien Mona Al Twayan Nada Rajab Al Al Zahrani

Background: Geriatric patients represent a growing proportion of the population, accounting for more than 9% globally. At our study center, admissions to general medical services comprise over 30% of geriatric patients. This study investigated the reasons for 30-day readmissions among geriatric patients and the impact of a multidisciplinary approach on reducing readmission rates. Methods: A retrospective, observational study was conducted at a tertiary care center in the Eastern Province of Saudi Arabia. Data was collected on patients aged ≥60 years admitted under the general medicine unit between October 2022 and August 2023 (October–December 2022 for baseline, and January 2023–August 2024 for action, intervention and result). Information was extracted from the hospital’s health informatics system (HIS), including demographics, comorbidities, reasons for readmission, post-discharge care, and outcomes. The multidisciplinary approach included nutritional support (nutritional assessment by referral to dietitian), wound care, virtual post-discharge clinics, family meetings, home healthcare, involvement of social services and psychiatry when indicated. The 30-day readmission rate was calculated by dividing the number of geriatric patients readmitted within 30 days of their last admission by the total number of geriatric patients admitted to internal medicine each month, with a benchmark of 11–23% from previous studies. Results: Of 650 geriatric patients, N = 100 required 30-day readmission. Among those 100 geriatric patients (mean age 78), 48% were over 80 years old, 41% had dementia, and 67% were bedridden (defined as the patient’s inability to get out of bed, ambulate, or sit upright without assistance). Hypertension (90%), type 2 diabetes mellitus (78%), and renal impairment (50%) were the top comorbidities. Urinary tract infections (24%) and pneumonia (17%) were the leading causes of readmission. Post-discharge interventions included virtual clinics within 1–2 weeks (49%), home healthcare referrals (27%), and regular outpatient follow-up (87%). Despite a mortality rate of 16% during the study period, the 30-day readmission rate was reduced to less than 23% from 40% in the fourth quarter of 2022 (baseline). Conclusions: The observed reduction in 30-day readmissions coincided with multidisciplinary care, yet SPC (Statistical Process Control) analysis confirmed process stability, supporting an observational rather than causal interpretation.

Healthcare doi: 10.3390/healthcare14182990

Authors: Marilia Baquerizo-Sedano Miguel Lancho Pedrazo María Merino Martínez Álvaro Taype-Rondan José Luis Cuesta Gómez María Consuelo Sáiz-Manzanares

Background/Objectives: Wearable biometric sensors may help characterize autonomic arousal in everyday settings among autistic people with high support needs, a population underrepresented in naturalistic research. This study aimed to describe patterns of autonomic arousal measured using electrodermal activity (EDA) and to explore their relationship with behavioral and contextual records compatible with distress or maladaptive stress. Methods: We retrospectively analyzed routine-care data from 57 autistic people with high support needs attending two specialized services. EDA was recorded for up to 10 days and integrated with behavioral and contextual records collected through a mobile application and stored in ABmonitor. Phase 1 retrospectively analyzed these data using principles derived from Ecological Momentary Assessment. Phase 2 descriptively compared pre- and post-adjustment EDAmax values in five cases with documented contextual adjustments, drawing on principles of Ecological Momentary Intervention, without causal inference. Results: In Phase 1, 19.3% of participants remained within the same arousal category across days, whereas 80.7% showed variable levels. Overall, 22 of 57 participants (38.6%) showed high autonomic arousal on at least one day; among them, 12 had behavioral records compatible with distress, and 5 had a specific contextual factor documented. In Phase 2, descriptive reductions in EDAmax ranging from 4 to 23 µS were observed after contextual adjustments. Conclusions: EDA provides relevant information about autonomic arousal but should not be interpreted as a direct marker of stress. Multimodal ecological monitoring may help generate person-centered clinical hypotheses and inform individualized support in real-world settings.

Healthcare doi: 10.3390/healthcare14182989

Authors: Fernando Muñoz-Hinrichsen Diana Camargo Rojas Luís Torres Paz Marco Kokaly Farah Noemi Ortega Díaz Juan López Jofré Sophie Pombet Ortiz Martín Lanas Araos Jorge Pérez-Contreras Alan Martínez Aros Felipe Herrera Miranda

Background: Participation in physical and sports activities is essential for the overall health of persons with disabilities (PWD). However, these individuals encounter multiple environmental and contextual barriers limiting sports engagement. Objective: This study aimed to analyze the perceived barriers to sports participation among PWD in Chile using a socio-ecological framework, evaluating differences by sex and sports practice status while adjusting for potential demographic confounders. Methods: A quantitative, cross-sectional design was conducted with a convenience sample of 245 PWD. Perceptions across four socio-ecological dimensions (intrapersonal, interpersonal, organizational, and community) were measured using the short Spanish version of the Barriers to Physical Activity Questionnaire for People with Mobility Impairments (BPAQ-MI). Non-parametric Mann–Whitney U tests were performed as primary bivariate analyses due to non-normal data distribution, followed by Analysis of Covariance (ANCOVA) models controlling for age and sex. Results: Bivariate analyses showed no significant differences by sex. When comparing sports participants versus non-participants, athletes perceived significantly lower barriers in the organizational (U=5357, p<0.001, r=0.286) and community (U=6216, p=0.020, r=0.172) dimensions. After adjusting for age and sex via ANCOVA, sports practice remained a significant independent predictor of lower organizational barriers (F=7.814, p=0.006, ηp2=0.032), and a significant interaction between sports practice and sex was identified in the community dimension (F=4.671, p=0.032, ηp2=0.019). Community-level barriers were rated highest across all groups. Conclusions: Sports participation is associated with a lower perception of organizational barriers, even when controlling for age. The prominent community-level obstacles underscore the need for targeted, context-specific public policies that enhance accessibility and inclusive infrastructure.

Healthcare doi: 10.3390/healthcare14182988

Authors: Zhiyi Luo Biao Fan Hongyuan Wu Shenqi Han Zihao Bian Ning Zhao Zongjiu Zhang Shuyuan Cheng

Background/Objectives: We aimed to evaluate the temporal associations and heterogeneous patterns between the Beijing Diagnosis-Related Group (DRG) 2.0 payment reform and hospitalization costs and resource utilization among patients receiving major colorectal cancer (CRC) surgery and to explore hospital adaptive cost adjustment behaviors under bundled payment constraints. Methods: Utilizing inpatient data of 1232 colorectal cancer surgical patients from a Beijing hospital spanning January 2021 to October 2024, we adopted segmented regression interrupted time-series analysis (ITSA), with April 2022 defined as the policy intervention point. The analysis used total hospitalization expenses, itemized costs, cost composition proportions, and length of stay (LOS) as outcome indicators, conducted heterogeneity analysis, and applied seasonal autoregressive integrated moving average (SARIMA) counterfactual forecasting as a supplementary sensitivity check. All medical expenditures were inflation-adjusted based on Beijing’s medical consumer price index (CPI), with 2024 as the base year. Results: After DRG implementation, total hospitalization costs showed an immediate decrease of 13,111.73 CNY and a sustained monthly downward trend of 1312.60 CNY. Medical consumable fees were the main component associated with total-cost reduction, and their proportion declined immediately by 4.1 percentage points. LOS showed no abrupt immediate decline but shortened by 0.22 days per month over the post-reform period. Heterogeneous association patterns were observed across selected clinical and treatment subgroups. SARIMA counterfactual forecasting provided supplementary, directional sensitivity evidence for the primary outcomes and was interpreted cautiously for volatile sub-item expenditures. Conclusions: DRG 2.0 reform was associated with lower hospitalization costs and improved bed-turnover efficiency among CRC surgical patients, mainly through reductions in consumable expenditures.

Healthcare doi: 10.3390/healthcare14182984

Authors: Zülal Soylu Karaca Miray Akkuş Hande Başak

Objective: To determine healthcare professionals’ attitudes toward migrant patients and explore the sociodemographic and migration-related factors associated with these attitudes. Methods: This descriptive, cross-sectional, exploratory study was conducted with 390 healthcare professionals reached through a Facebook-based professional community and subsequently via other social media platforms using snowball sampling. Data were collected using a Demographic Information Form and the Healthcare Professionals’ Attitudes Toward Migrants Scale. Data Analysis involved the use of independent-samples t-tests or one-way ANOVAs, or Mann–Whitney U or Kruskal–Wallis tests, based on distribution characteristics; effect sizes and 95% confidence intervals were calculated for each comparison, and the Benjamini–Hochberg false discovery rate (FDR) correction was applied to all 96 comparisons reported. Additionally, a multiple linear regression analysis was performed using conceptually justified predictors to identify independent and interrelated factors. Results: The mean total attitude score was 38.47 ± 10.71 (the total score was calculated by reversing the scores on the positive attitude subscale; thus, a higher score indicates a more negative overall attitude; see Methods). In pairwise comparisons, attitude scores differed according to marital status, job satisfaction, the number of migrant patients encountered, language barriers, cultural differences, access to interpreters, perceived competence in providing care, perceptions of migrants’ attitudes, perceived social prejudice, workload, and willingness to receive training on migrant health (raw p < 0.05 in 42 of 96 comparisons; 39 after FDR correction; 22 of these 42 also met a stricter α = 0.001 threshold applied given the large number of repeated comparisons). Multivariable regression (R2 = 0.398) showed that perceived social prejudice (standardized β = 0.300), reluctance to pursue education (β = 0.287), and increased workload (β = 0.181) were independently associated with higher total attitude scores. Inaccessibility of interpreters (p = 0.010) and negative perception of migrants’ attitudes (p = 0.029) showed associations at the conventional p < 0.05 level but did not meet the stricter α = 0.001 threshold. Conclusions: In this exploratory sample, healthcare professionals’ attitudes toward migrant patients were associated not only with individual characteristics but also with communication barriers, cultural competence, and working conditions. Given that the study design was cross-sectional and based on non-probability sampling, these associations should be interpreted with caution and not assumed to be causal. Strengthening professional interpreter services, expanding cultural competence training, and evaluating institutional support strategies through future controlled or longitudinal studies may help improve healthcare professionals’ attitudes and promote migrant-friendly, equitable healthcare services.

Healthcare doi: 10.3390/healthcare14182985

Authors: Letícia Figueirinha Crespo Eduarda Guiné Sidarth Pernencar Ana Querido Feten Fekih-Romdhane Carlos Laranjeira

Background/Objectives: Advanced chronic diseases significantly compromise the quality of life of patients and their family caregivers due to the high symptom burden, psychosocial distress, and increasing care dependency. Despite recommendations for the early integration of these individuals into Palliative Care (PC), understanding hope as a resource for adaptation to the illness trajectory remains limited. This study aimed to describe the lived experience of hope among dyads consisting of individuals with advanced chronic disease and their family caregivers. Methods: A qualitative descriptive phenomenological design, grounded in Amedeo Giorgi’s methodology, was used. Data were collected through semi-structured interviews with 13 patient–caregiver dyads living with advanced chronic obstructive pulmonary disease or advanced heart failure. Data were analysed following the procedures of descriptive phenomenological analysis, and the study was reported in accordance with the Standards for Reporting Qualitative Research (SRQR) guidelines. Results: The lived experience of hope was organized into four essential constituents: (1) hope as a horizon of possibilities; (2) everyday anchors of hope; (3) challenges to sustaining hope; and (4) cultivating hope in the face of adversity. Findings revealed that hope was experienced as a dynamic, multidimensional, and relational phenomenon. Participants described hope as being repeatedly reshaped in response to changing illness-related circumstances. Dyads identified multiple sources of hope, including family relationships, legacy, spirituality, and short-term goals, alongside challenges such as disease progression, caregiver burden, significant losses, and social isolation. Conclusions: Within this sample, hope emerged as a fundamental resource for adaptation to advanced chronic illness, enabling dyads to find meaning in the illness experience, cope with uncertainty, and preserve quality of life. As a phenomenon shared between the patient and the family caregiver, hope highlights the importance of dyad-centred approaches and its integration into palliative care to promote more humanized, relational, and responsive care that addresses the emotional, social, and spiritual needs of families.

Healthcare doi: 10.3390/healthcare14182987

Authors: Carina Domingues Antunes Alcinda Reis Maria Celeste Godinho Nogueira Ana Cristina Spinola Madeira

Background/Objectives: Informal caregivers support home care while having health, information and self-care needs. This study assessed general and domain-specific health literacy among informal caregivers registered with a Portuguese Family Health Unit and explored, with QUAL interpretive priority for the nursing-practice objective, perceptions of nursing practices supportive of health literacy. Methods: A sequential mixed-methods design (quan → QUAL) was used. The quantitative phase included 30 informal caregivers who completed a sociodemographic questionnaire and the Portuguese European Health Literacy Survey (HLS-EU-PT). The QUAL phase included five informal caregivers selected from the highest recorded caregiving-intensity category and interviewed at home. Quantitative data were analysed descriptively; 95% confidence intervals were calculated for principal means and proportions. Qualitative data were analysed using Bardin’s content analysis. Integration occurred through connection and aggregate interpretation; individual HLS-EU-PT scores were not linked to interviews. Results: Informal caregivers were mostly women (83.3%), older than 55 years (80.0%) and cohabiting with the dependent person (83.3%). The mean general HLS-EU-PT score was 26.64 ± 8.40 (95% CI 23.50–29.78); 22/30 informal caregivers had limited health literacy (73.3%; 95% CI 55.6–85.8). Health promotion was the lowest-scoring domain (25.34 ± 8.31; 95% CI 22.24–28.44), with 28/30 informal caregivers showing limited health literacy (93.3%; 95% CI 78.7–98.2). QUAL findings highlighted personalised information, checking understanding, caregiver experience, decision support and resource guidance. Conclusions: Limited health literacy was frequent. The QUAL phase deepened understanding of perceived nursing support, but findings indicate perceived needs rather than effects.

Healthcare doi: 10.3390/healthcare14182986

Authors: Latefa Ali Dardas Anne Marijn de Graaff Amjad Al-Khayat Ammar Ali Rayan Saleh Rand Habashneh Dharani Keyan Sarah Fanatseh Aemal Akhtar Adnan Abualhaija Muhannad Faroun Ibrahim Said Aqel Hadeel Alfar Chiara Servili Richard Bryant Kenneth Carswell

Background: Adolescents and young adults in Jordan experience high levels of psychological distress amid persistent stigma, limited mental health literacy, and shortages of specialist services. Although task-shared interventions have expanded access, their dependence on in-person delivery and sustained human resources constrains scalability. Guided digital interventions may extend reach, but evidence regarding their system integration and sustainability in low- and middle-income countries remains limited. Purpose: This study explored how the WHO-developed Scalable Technology for Adolescents and youth to Reduce Stress (STARS), a non-generative, rule-based chatbot intervention supported by trained e-helpers, was experienced and implemented in Jordan. It also examined the system-level tensions shaping its potential for sustainable scale-up. Methods: We conducted a qualitative multiple-case study nested within a randomized controlled trial of STARS in Jordan. Semi-structured interviews were conducted with 21 individuals, including STARS completers and non-completers, trained non-specialist e-helpers, a clinical supervisor, and policy and implementation stakeholders. Data were analyzed using a hybrid approach combining inductive thematic analysis with deductive coding informed by a system-innovation perspective and the culture–structure–practice framework. Results: Participants described STARS as culturally resonant, accessible, and adaptable to everyday life. Four recurring system-level tensions emerged: individualized support versus standardized protocols; privacy and anonymity versus institutional and parental trust; non-specialist support versus expectations for professionally qualified providers; and innovation within research settings versus integration into routine service systems. These tensions reflected competing priorities shaping implementation and perceptions of sustainable scale-up. Conclusions: STARS shows promise as a scalable guided digital mental health intervention for young people in Jordan. However, scale-up will require navigating recurring tensions across cultural, structural, and practice domains rather than addressing implementation barriers in isolation. This will require policy alignment, sustained investment in digital infrastructure and supervision, and cross-sector collaboration.

Healthcare doi: 10.3390/healthcare14182983

Authors: Abdulmajeed Hassan Jaafari Abdulaziz Sami Al-Shwairkh Miteb A. Alanazi Abdullah M. Alhammad Yazed Alruthia

Background: Dyslipidemia is becoming an increasingly important issue from a public health point of view and is generally treated with statins. However, as generic versions of these drugs are now widely available, doubts have emerged about their effectiveness. The current study examines the clinical effectiveness and impact on the national budget of using generic atorvastatin compared to the branded version. Methods: A retrospective comparative study was conducted at King Khalid University Hospital between 2015 and 2025, involving 286 patients (142 receiving the generic form and 144 receiving the branded form). Changes in lipid panel values were assessed using a Generalized Linear Model (GLM) to account for multiple factors. The economic outcomes were estimated using probabilistic (10,000 Monte Carlo iterations) and deterministic scenario analyses. Results: The mean adjusted decrease in low-density lipoprotein (LDL) was 26.11% in the generic group and 19.34% in the branded group. After adjusting for multiple variables, the branded group showed a non-significant lower reduction in LDL (β-estimate: −0.255, 95% CI: −0.119 to 0.391, p = 0.3318). The Monte Carlo simulations showed large projected mean annual savings when using the generic formulation: $29,717,778 based on tender pricing and $295,432,159 based on retail pricing. The deterministic sensitivity analyses consistently found positive projected savings across all population and market-share scenarios tested. Conclusions: Generic atorvastatin was found to have similar clinical effectiveness to the branded version in terms of reducing atherogenic lipids, with no statistically significant difference between the two groups. Furthermore, the economic modeling shows that using generic atorvastatin yields considerable national-level cost savings.

Healthcare doi: 10.3390/healthcare14182982

Authors: Sudharani B. Banappagoudar Nader Alnomasy Shimaa Ramadan Ahmed Ahmed Ali Hafez

Background: Smartphones are ubiquitous among young adults today. However, many young adults exhibit characteristics of problematic or dependent phone use. These individuals often have sleep disturbances and difficulties with emotional regulation. Currently, the research on the connection between these three variables is scarce, with particular gaps in studies of nursing professionals in this population. Objective: The study aimed to identify the prevalence of problematic phone use among young adults and the relationship between these three variables: problematic phone use, sleep disturbances, and difficulties with emotion regulation. The study will also investigate the potential of sleep disturbances to mediate the relationship between problematic phone use and difficulties with emotion regulation. Methods: Data was collected from participants aged 18 years or older through a self-administered, anonymous web survey. The web survey was disseminated via social media and used snowball sampling to collect responses from individuals from various regions. There were no investigators involved in data collection from any particular institution or to reduce researcher bias. A power analysis was performed to determine the ideal sample size; the results from the 167 participants exceeded the ideal sample size requirement. The Smartphone Addiction Scale–Short Version (SAS-SV), a sleep disruption score derived from the Pittsburgh Sleep Quality Index (PSQI), and the Difficulties in Emotion Regulation Scale–Short Form (DERS-SF) were used to collect data. Data were analyzed using descriptive and inferential statistics, including Cronbach’s alpha, Pearson correlations, independent-samples t tests, one-way ANOVA, multiple linear regression, and bootstrapped mediation (n = 5000 resamples). The CHERRIES guidelines were adhered to throughout the research study. Results: The participants were aged a mean of 21.6 years old (SD = 4.6). The majority of the participants (n = 117, 70.1%) identified as female. The internal consistency reliability for the SAS-SV and DERS-SF was high (SAS-SV α = 0.94; DERS-SF α = 0.88). Based upon the sex-specific cutoffs for the SAS-SV, a total of 63 participants (37.7%) screened positive for problematic phone use. There were significant positive correlations between problematic phone use and sleep disturbances (r = 0.41, p < 0.001) as well as problematic phone use and difficulties with emotion regulation (r = 0.54, p < 0.001). There was a significant positive correlation between sleep disturbances and difficulties with emotion regulation (r = 0.37, p < 0.001). The amount of time each individual spent on their smartphone on an average daily basis differed significantly across self-reported daily use bands (F2,164 = 6.26, p = 0.002), with dependency highest among those reporting more than 5 h of daily use. There were no significant differences in this relationship based upon sex. Multiple linear regression analysis revealed that problematic phone use was a significant predictor of difficulties with emotion regulation (β = 0.47, p < 0.001); once the effects of problematic phone use were accounted for, sleep disturbances also significantly predicted difficulties with emotion regulation (β = 0.18, p = 0.01). In a complete-case analysis excluding 12 participants with uninterpretable sleep-duration data (n = 155), the bootstrapped indirect effect of sleep disturbances on the relationship between problematic phone use and difficulties with emotion regulation was statistically significant (ab = 0.081, 95% CI = 0.015 to 0.174, adjusting for age and sex); an earlier analysis that had scored these 12 cases as zero rather than excluding them found a smaller, non-significant indirect effect (ab = 0.060, 95% CI = −0.014 to 0.140). Conclusions: Problematic phone use is common among young adults today. The use of problematic phone behavior is positively associated with sleep disturbances and difficulties with emotion regulation. In a corrected complete-case analysis, sleep disturbances significantly mediated part of this relationship, though this cross-sectional association should not be interpreted as demonstrating a causal mechanism, and it should be weighed against a smaller, non-significant estimate obtained before this missing-data correction. These findings suggest that both problematic phone use and, cautiously, sleep health may be relevant targets for nursing-led digital-wellness interventions, though the effectiveness of such interventions would need to be established in prospective studies before implementation.

Healthcare doi: 10.3390/healthcare14182981

Authors: Nurgül Kılıçaslan Esra Yurtsev

Background/Objectives: Effective labor pain management and labor comfort are essential for a positive birth experience. Evidence regarding the effects of foot reflexology on labor pain and labor comfort remains limited. Therefore, this randomized controlled trial investigated the effects of foot reflexology on labor pain as the primary outcome and labor comfort as the secondary outcome. Methods: This prospective randomized controlled trial was conducted between February 2024 and February 2025 in the obstetrics and gynecology unit of a tertiary training and research hospital and was reported in accordance with the CONSORT 2025 guidelines. Seventy pregnant women were randomly assigned to the reflexology (n = 35) and control (n = 35) groups. Data were collected using structured forms, the Visual Analog Scale (VAS), and the Childbirth Comfort Questionnaire (CCQ) and analyzed using appropriate statistical procedures, with statistical significance set at p < 0.05. Results: Post-intervention pain scores were significantly lower in the reflexology group during the active (p = 0.009) and transition phases (p < 0.001). Complementary linear mixed-effects analyses showed significant group × time interactions for pain across the latent, active, and transition phases (all p < 0.001), indicating greater pre-to-post reductions in the reflexology group. The standardized post-intervention between-group differences were small, moderate, and large in the latent, active, and transition phases, respectively. Labor comfort was significantly higher in the reflexology group during the latent (p = 0.008) and active phases (p = 0.044), and calm and controlled behavior was observed more frequently in the reflexology group (p = 0.03). Conclusions: Foot reflexology was associated with reduced labor pain and improved comfort during the first stage of labor. Repeated application across the latent, active, and transition phases showed differential reductions in pain across labor phases, suggesting that foot reflexology may be a feasible supportive non-pharmacological intervention during labor.

Healthcare doi: 10.3390/healthcare14182980

Authors: Jamal M. Alzahrani Abdulaziz M. Alodhailah Abdullah Alharbi Bandar S. Alharbi Monirah Albloushi Mohammed Almutairi

Background: Physical inactivity is common among people living with chronic non-communicable disease, and nurses are frequently the professionals with the most sustained patient contact. How nursing support for physical activity is experienced by patients, and how nurses understand their own role in providing it, remain poorly described. Objective: To explore how patients with chronic diseases and nursing professionals describe nursing support for physical activity and exercise adherence, and where their accounts converge or diverge. Methods: A qualitative descriptive study using individual semi-structured interviews and reflexive thematic analysis. Seventeen participants (nine patients with chronic diseases and eight nursing professionals) were purposively recruited from five healthcare institutions in the Riyadh region of Saudi Arabia. Interviews lasted 30 to 60 min (mean 45 min) and were conducted between December 2025 and February 2026. No quantitative measures of exercise frequency, intensity, duration, or session regularity were collected, so the study reports perceptions and experiences rather than measured adherence, and no causal relationships were examined. Rigor was addressed through researcher reflexivity, member checking, peer debriefing, and an audit trail; reporting follows COREQ. Results: Five themes were constructed: (1) Nursing-Facilitated Empowerment Through Education and Guidance; (2) Personalized Support and Accountability Mechanisms; (3) Barriers and Facilitators to Exercise Adherence; (4) Perceived Health Benefits and Motivation Enhancement; and (5) Gaps in Current Nursing Practice and Opportunities for Enhancement. Participants identified individualized explanation, graduated goal-setting, correction of fear-based misconceptions, scheduled exercise-specific review, and family involvement as the components of support they valued most, and lapsed follow-up, generic advice, limited interdisciplinary coordination, and scarce patient resources as the principal shortfalls. Conclusions: Patients and nurses in this setting described sustained, individualized nursing support as central to how patients engage with exercise, while both groups identified structural constraints that limit it. These accounts indicate targets that intervention studies with objective activity measurement could test; they do not establish that nursing support changes exercise behavior.

Healthcare doi: 10.3390/healthcare14182979

Authors: Siriporn Jantharuechai Pairot Khusakul Wannee Chaichalermpong Chaiyasith Wongvipaporn Verawan Uchaipichat

Background/Objectives: Adequate patient knowledge of non-vitamin K antagonist oral anticoagulants (NOACs) is important for their safe and effective use in atrial fibrillation (AF), yet knowledge deficits remain widely reported. This study assessed NOAC knowledge and identified factors associated with knowledge level among Thai AF outpatients at a tertiary cardiac center. Methods: A cross-sectional study was conducted between January and March 2023 using the KAQNAF-Thai, a validated 23-item instrument covering six domains, classified as high (≥60%) or low (<60%). Factors associated with low knowledge were identified using multivariable logistic regression. Results: A total of 250 participants were enrolled (mean age 71.9 ± 9.13 years; 53.2% male). The mean total knowledge score was 15.4 ± 3.04 out of 23 points (67% correct responses), with 178 (71.2%) having high knowledge and 72 (28.8%) having low knowledge. The most critical gaps were in laboratory monitoring (correct response rate 36.0%) and dose management; accidental double dosing (13.2%), NOAC effectiveness after vomiting (30.4%), and missed dose management (34.4%). Three variables were independently associated with low knowledge: age ≥75 years (aOR = 2.11 [95% CI 1.10–4.05]), education below tertiary level (aOR = 17.38 [95% CI 5.03–60.01]), and lack of awareness of NOAC indications (aOR = 3.22 [95% CI 1.25–8.29]). Conclusions: Although most Thai AF patients met the threshold for high NOAC knowledge, critical gaps in laboratory monitoring and dose management persisted even in this group. Educational interventions should prioritise elderly patients, those with lower educational attainment, and those unaware of their NOAC indication.

Healthcare doi: 10.3390/healthcare14182977

Authors: Paweł Pędrasik Bartosz Wilczyński Monika Kontowt Katarzyna Zorena

Background: Angling-related injuries include acute trauma and chronic overuse conditions, but detailed clinical descriptions of different injury mechanisms remain limited. This retrospective case series presents four clinically distinct injuries associated with recreational and sport angling. Methods: Four purposively selected patients were recruited between 6 November 2025 and 30 April 2026 through questionnaires, angling forums, events, and regional angling associations. All provided written informed consent and sufficient medical documentation. Clinical data were obtained from participant-provided medical documentation, imaging reports, and interviews, with follow-up varying according to the clinical course. Results: Cases included high-velocity open-globe ocular trauma, a penetrating palmar injury caused by a baiting needle, a penetrating finger injury caused by a large barbed double hook, and rotator-cuff tendinopathy with lateral epicondylitis in the context of high angling exposure. Management included surgery, antimicrobial treatment, rehabilitation, and load modification. Outcomes ranged from substantial visual recovery to persistent scar-related hand limitation and improvement in overuse symptoms. Conclusions: These cases illustrate projectile, penetrating, and repetitive-load injury mechanisms associated with angling and support clinical awareness, careful assessment of equipment-related trauma, and activity modification and rehabilitation in overuse conditions. Preventive measures discussed should be regarded as clinical considerations and hypotheses for further study rather than interventions of established effectiveness.

Healthcare doi: 10.3390/healthcare14182978

Authors: Fahad Abdulaziz Alrashed Tauseef Ahmad Syed Irfan Karim Jennesse John

Background: Diabetes mellitus is a chronic metabolic disorder often accompanied by psychological distress, including stress, anxiety, and depression. Such emotional symptoms can influence self-care behaviours and metabolic control. In Saudi Arabia, cultural and religious practices may mitigate the effects of psychological distress on glycaemic regulation. Limited evidence exists regarding the simultaneous assessment of depression, anxiety, and stress in relation to objective glycaemic indicators such as HbA1c among adults with diabetes in Saudi Arabia. This study aimed to determine the association between psychological distress and glycaemic control among adults with diabetes, while exploring the influence of demographic and biochemical factors. Methods: A cross-sectional study was conducted from 21 January 2026 to 19 April 2026 among 546 adults diagnosed with diabetes in multiple healthcare settings in Riyadh, Saudi Arabia. Psychological distress was assessed using the DASS-21 questionnaire, while glycaemic control was measured using HbA1c, categorised as controlled (<7%) or uncontrolled (≥7%). Demographic, anthropometric, and biochemical parameters including BMI, blood pressure, and lipid profile were collected from medical records and standardized assessments. Associations were examined using chi-square tests and multiple linear regression analysis was performed including psychological distress scores, BMI, blood pressure measurements, and lipid profile parameters to identify factors associated with HbA1c variation. Results Psychological distress was prevalent; however, stress (6.2–10.7%), anxiety, and depression were significantly associated with variation in HbA1c levels. In contrast, nationality, total cholesterol, LDL, triglycerides, and systolic blood pressure were significantly associated with HbA1c. Multiple regression showed that stress (B = 0.09, p = 0.015), systolic blood pressure (B = 0.146, p = 0.006), and total cholesterol (B = 0.229, p < 0.001) were independent predictors, collectively explaining 14.8% of HbA1c variance. Multiple regression analysis identified stress, systolic blood pressure, and total cholesterol as significant factors associated with variation in HbA1c levels. Conclusions: While psychological distress is common among adults with diabetes, its direct impact on HbA1c may be attenuated in populations with strong religious and cultural coping practices. Conversely, metabolic factors, particularly total cholesterol and systolic blood pressure, alongside stress, showed stronger associations with HbA1c levels in this study population. These findings underscore the importance of integrating physiological, psychological, and culturally contextualised strategies in diabetes management to optimize outcomes.

Healthcare doi: 10.3390/healthcare14182976

Authors: Enrique Monsalvo-San Macario Andrea Sierra-Ortega Rosa Fernández-Fernández Verónica Sánchez-Niño Almudena del Puerto-Claros Juan Antonio Sarrión-Bravo Alexandra González-Aguña Jose María Santamaría-García

Background: Population ageing, multimorbidity, and chronic conditions have increased the demand for person-centred care in Primary Health Care. Current stratification systems rely on diagnoses or resource utilization and fail to capture the multidimensional nature of care complexity, which also depends on functional, social, environmental factors. Objective: To develop a HealthCare Complexity Index using routinely collected electronic health record (EHR) data and the Person-Centred Care Knowledge Model. Methodology: A retrospective, cross-sectional observational study was conducted in Primary Health Care in the Community of Madrid (Spain). Deductive Care Methodology was used to identify functional assessment variables associated with four care dimensions: vulnerability, risk, etiology, and signs/symptoms. A multidisciplinary expert panel selected and validated the variables through iterative consensus rounds. A weighted scoring algorithm, the Care Complexity Index, was designed to quantify care complexity on a 0–100 scale. Relationships between the selected variables and NANDA-I nursing diagnoses were established and validated by an expert in standardized nursing languages. Results: 27 assessment variables were identified and classified into the 4 dimensions of the care model. These variables were integrated into a weighted complexity index with five severity levels ranging from low to critical complexity. Furthermore, 48 NANDA-I nursing diagnoses were linked to the selected variables. Conclusions: The HealthCare Complexity Index provides a standardized, person-centred approach for estimating care complexity using routinely available (EHR) data. It may support early identification of individuals with complex care needs, facilitate individualized care planning, and strengthen clinical decision-making. Future studies should validate its predictive performance and implementation in other clinical practice.

Healthcare doi: 10.3390/healthcare14182973

Authors: Angel Yordanov Tsvetan Yordanov Eva Tsoneva Ivaylo Petrov Ihsan Hasan Dimo Manov Stoyan Kostov Assia Konsoulova

Cervical cancer is one of the most preventable malignancies, yet disparities in survival remain a significant public health burden across Eastern Europe and the Balkans. Bulgaria illustrates this paradox: HPV vaccination coverage is very low, and prevention continues to rely substantially on opportunistic screening, although recent national initiatives have introduced HPV-based testing and self-sampling. This article argues that the primary barrier to cervical cancer control in Bulgaria is not the lack of medical technology, but the absence of a structured, organized screening system. A modern national cervical cancer screening program should be recognized as a structured clinical and organizational pathway rather than a single diagnostic test. Such a programme requires population identification, active invitation and recall, reg-istry-based tracking, standardized referral and follow-up pathways, and continuous quality assurance. Primary high-risk HPV (hrHPV) testing provides high sensitivity and excellent negative predictive value, supporting longer screening intervals; however, screening for HPV positivity alone is insufficient as a sole referral criterion because many infections are transient and clinically insignificant. We propose a rational framework for cervical cancer screening in Bulgaria and comparable health systems: invitation-based screening for women aged 25–65 years built on primary hrHPV testing with genotyping, reflex cytology, and selective use of p16/Ki-67 dual staining. Drawing on a regional comparison of HPV vaccination and screening programs and on Bulgarian cost-of-illness data, we argue that transitioning from opportunistic testing to an integrated, registry-based screening cascade is essential for effective and equitable cervical cancer prevention in the region.

Healthcare doi: 10.3390/healthcare14182975

Authors: Chen Yang Zelin Guo Fan Cheng Yonghui Wan Yan Liu

Background: Racial and socioeconomic differences in prostate cancer outcomes are often described as survival disparities, but observed differences may also reflect healthcare access, treatment delivery, and resource allocation. Methods: NCDB and SEER–Medicare were treated as independent, complementary retrospective data sources without individual-level linkage. The analytic material comprised 111,396 database records from 2010 to 2020 across two independent source files; this is a cross-source record count, not a deduplicated count of unique persons. Harmonized descriptive analyses characterized stage, treatment, and treatment timing, while multivariable Cox proportional hazards modeling evaluated prostate cancer-specific survival (CSS) in outcome-eligible SEER–Medicare records. The CSS model denominator is therefore substantially smaller than the total record count, and the two should not be confused. Results: Records for non-Hispanic Black (NHB) men more often showed stage III–IV disease than records for non-Hispanic White (NHW) men (26.9% vs. 18.7%) and lower receipt of guideline-concordant first-course management initiated within 90 days, particularly in the low-SES subgroup (51.4% vs. 84.3% among high-SES NHW men). In the adjusted CSS model, NHB race was associated with higher mortality (HR = 1.32; 95% CI: 1.24–1.41). Uninsured status (HR = 1.47; 95% CI: 1.33–1.62), low income (HR = 1.28; 95% CI: 1.19–1.37), and rural residence (HR = 1.14; 95% CI: 1.06–1.22) were also associated with higher mortality. Conclusions: The findings support a healthcare-system interpretation of prostate cancer disparities and identify measurable targets for prospective evaluation, including EHR-enabled monitoring, nurse navigation, telehealth-supported follow-up, and facility-level treatment-concordance review.

Healthcare doi: 10.3390/healthcare14182974

Authors: Jingwen Hu Qiaoling Lin Chunping Du Jianmei Zhang Tao Gao Hongying Jiang

Background: Guidance on catheter removal addresses passive balloon deflation and cuffing, but the comparative effect of small-volume reinjection after complete aspiration remains uncertain. This review evaluated reinjection versus conventional complete aspiration in adult men and women. Methods: The review was registered in PROSPERO (CRD420261451421) after the initial search and preliminary analyses had begun. Eight English- and Chinese-language databases were formally searched from inception to 9 July 2026. Randomized and quasi-randomized controlled trials of routine transurethral catheter removal were eligible. The primary outcome was pain experienced during withdrawal of the deflated balloon through the urethra, measured during removal or at the earliest immediate post-removal assessment. Pain was pooled as Hedges’ g; a harmonized 0–10 mean difference was examined for interpretability. Secondary outcomes were pooled as risk ratios. Risk of bias was assessed with Risk of Bias 2 and certainty with GRADE. Results: Forty-six Chinese trials (6395 participants; both sexes represented) were included: 35 were reported as randomized and 11 used predictable quasi-random allocation. Sex-stratified outcome data were not available. Reinjection was associated with less pain (26 trials; SMD −1.14, 95% CI −1.35 to −0.92; I2 = 89.8%; 95% prediction interval −2.25 to −0.03); the harmonized 0–10 mean difference was −1.73 points (95% CI −2.11 to −1.35). Associations also favored reinjection for urinary retention (RR 0.22; low certainty), successful spontaneous voiding (RR 1.29; very low certainty), any hematuria (RR 0.21; very low certainty), macroscopic hematuria (RR 0.28; low certainty), microscopic hematuria (RR 0.34; very low certainty), and catheter reinsertion (RR 0.44; low certainty). Infection-related adverse events were not reported in extractable comparative form. Conclusions: Reinjection was associated with lower pain and fewer removal-related events compared with active complete aspiration, but certainty is low or very low, heterogeneity is substantial, all evidence is from one country, and sex-specific effects and the influence of prostatic hyperplasia or catheter diameter could not be assessed. The findings do not establish superiority over passive balloon deflation or support routine international implementation.

Healthcare doi: 10.3390/healthcare14182972

Authors: Danielle Kristen Nadorff Margaret Ralston Laura A. Shillingsburg Amara L. Mason

Background/Objectives: Grandparent caregiving is a common and demanding role, and perceived economic strain is among the more consistent correlates of caregiver well-being. Guided by Hill’s ABC-X family stress model, this study examined whether perceived economic strain was associated with quality of life (QoL) among U.S. caregiving grandparents through two caregiving appraisals, caregiver burden and caregiver ambivalence, and whether perceived residential area type (a single self-classification item, with higher scores indicating a more urban perception) moderated the ambivalence–QoL relation. Methods: Participants included 424 caregiving grandparents recruited through an opt-in online panel. QoL was measured with the two-item WHOQOL-BREF general facet. Storage codes for the health-satisfaction item were verified against the survey instrument; a scoring error affecting them was corrected, and all results reflect the corrected scoring. A serial mediation model (PROCESS Model 6) and a moderated serial mediation model (PROCESS Model 87) were tested, controlling for age, sex, and marital status entered as categorical indicators, with percentile bootstrap confidence intervals (5000 samples). Results: Perceived economic strain was strongly and negatively associated with QoL (total effect B = −4.64, p < 0.001; the full QoL regression model explained 38% of the variance, R2 = 0.38). Greater strain was associated with greater burden, and burden with greater ambivalence, but the hypothesized negative serial pathway was not supported, and the serial indirect relation was positive and small (effect = 0.20, 95% CI [0.04, 0.41]). Perceived area type moderated the ambivalence–QoL relation (interaction B = 0.63, p = 0.002). Ambivalence was associated with lower QoL among grandparents who perceived their communities as small towns (B = −3.97) and with higher QoL among those with urban (B = 0.93) or major metropolitan (B = 1.09) perceptions. The moderation held across robustness checks, including an ordinal specification of the outcome, but did not replicate with an objective metropolitan versus nonmetropolitan indicator. Conclusions: The findings are cross-sectional, come from a relatively advantaged and nonrepresentative sample, and rest on brief measures, so causal conclusions are not warranted, and practice implications remain preliminary. Even so, the results support the idea that the meaning of caregiving ambivalence for well-being may depend on the kind of community caregivers believe they live in, and the strong relation between perceived economic strain and QoL supports continued attention to financial hardship in policies and programs serving caregiving grandparents.

Healthcare doi: 10.3390/healthcare14182971

Authors: Michelle Ndiulor Hao Wang Rolake Neba Rafia Rasu Bo Zhou Usha Sambamoorthi

Background/Objectives: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly prescribed for type 2 diabetes mellitus (T2DM). However, its mental health safety profile in routine care, particularly among Medicaid beneficiaries, remains uncertain. We aim to examine the association between glucagon-like peptide-1 receptor agonist (GLP-1 RA) use and newly documented depression diagnosis among adults with type 2 diabetes mellitus (T2DM) enrolled in Medicaid. Methods: We conducted a retrospective longitudinal cohort study using the 2022–2023 Merative™ MarketScan® Multi-State Medicaid Database. Adults aged 18–64 years with T2DM, continuous Medicaid enrollment, and no documented depression during the 2022 baseline period were included. Baseline GLP-1 RA use was assessed in 2022, and newly diagnosed depression was identified in 2023. Associations were estimated using multivariable logistic regression, inverse probability weighting (IPW), and a doubly robust estimator. Results: Among 74,760 eligible adults, 14,953 (20.0%) were GLP-1 RA users. Incident depression occurred in 12.9% of users and 11.1% of non-users (absolute difference, 1.8 percentage points; p < 0.001). GLP-1 RA use was associated with higher odds of newly documented depression diagnosis in multivariable analysis (adjusted OR 1.10, 95% CI 1.04–1.16), IPW analysis (OR 1.09, 95% CI 1.03–1.15), and doubly robust analysis (OR 1.09, 95% CI 1.03–1.15). Conclusions: Baseline GLP-1 RA use was associated with modestly higher odds of a newly documented depression diagnosis during the subsequent year. Prospective studies are needed to determine whether this association is causal.

Healthcare doi: 10.3390/healthcare14182970

Authors: Burak Manay Mustafa İbas Özcan Sönmez Mehmet Nuri Elgörmüş Mehmet Şerif Önen Gizem İbas Hakan Parlak Murat Ünsel Alperen Şentürk Ramazan Güven Ramazan Ocal

Background/Objectives: Oral health is important for safe oral feeding after stroke. However, the relationships among oral health-related quality of life, functional oral intake, and eating-related quality of life remain unclear. This study examined these associations in older adults with stroke. Methods: This cross-sectional observational study included 100 adults aged ≥65 years with stroke receiving oral feeding (FOIS ≥ 4). Oral health-related quality of life was assessed using the Geriatric Oral Health Assessment Index (GOHAI) and Oral Health Impact Profile-14 (OHIP-14), and eating-related quality of life using selected Swallowing Quality of Life Questionnaire (SWAL-QOL) domains. Correlation, multiple linear regression, and exploratory parallel indirect-effect analyses were performed. Results: GOHAI was most strongly correlated with Desire to Eat (r = 0.632, p < 0.001), whereas OHIP-14 showed the strongest negative correlation with Desire to Eat (r = −0.603, p < 0.001). FOIS was positively associated with GOHAI (ρ = 0.487, p < 0.001) and negatively associated with OHIP-14 (ρ = −0.571, p < 0.001). Desire to Eat, Food Selection, and Eating Time were independently associated with GOHAI. The exploratory parallel analysis showed a statistically supported total indirect association between FOIS and GOHAI through these eating-related domains collectively (indirect effect = 2.7496, 95% bootstrap CI 0.6070 to 4.9102), while no specific indirect effect was individually supported. Conclusions: Functional oral intake, eating-related experiences, and oral health-related quality of life were significantly interrelated. The exploratory findings suggest a collective statistical indirect association through eating-related domains without establishing temporal or causal mediation.

Healthcare doi: 10.3390/healthcare14182969

Authors: Adina Honoria Sabadoș Daniela Rahotă Teodor Traian Maghiar Timea Claudia Ghitea Laura Gratiela Vicas Lucia Georgeta Daina

Background: Community pharmacy-based influenza vaccination may improve access, but healthcare professionals may evaluate the service differently according to professional role, previous vaccination behaviour, and awareness. This study assessed the association between personal influenza vaccination behaviour and willingness to receive influenza vaccination in a community pharmacy among pharmacists and family physicians in Northwestern Romania. Methods: We analysed a cross-sectional, voluntary, non-probability convenience sample of 700 returned questionnaires from professionals active in six Northwestern Romanian counties. After exclusion of 22 blank records, 678 responses remained (340 pharmacists and 338 family physicians); one out-of-range willingness response was excluded from outcome analyses (n = 677). The study-specific anonymous questionnaire included demographic, professional, vaccination behaviour, awareness, and willingness items. Formal expert-panel content validation, pilot testing, test–retest reliability, construct validation, and a content-validity index were not documented; the primary outcome was a single Likert item, for which internal consistency is not estimable. Between 1 October 2025 and 30 April 2026, 761 questionnaires were distributed, and 700 were returned. After exclusion of 22 blank records, 678 completed questionnaires remained. Because recruitment was non-probability-based and a complete sampling frame was unavailable, the return proportion should not be interpreted as a population response rate. Ordinal comparisons used the Mann–Whitney U and the Kruskal–Wallis tests; high willingness (scores 4–5) was analysed with multivariable logistic regression. A 10-fold internal cross-validation and a sensitivity ordinal-logistic model were also performed. Results: Women comprised 85.5% of respondents. Annual influenza vaccination was more frequent among family physicians than pharmacists (71.9% vs. 32.6%), whereas mean willingness to be vaccinated in a pharmacy was higher among pharmacists (3.41 ± 1.40 vs. 2.08 ± 1.28). High willingness was reported by 201/339 pharmacists (59.3%) and 57/338 family physicians (16.9%). In the adjusted binary model, pharmacist profession (aOR 7.39, 95% CI 4.60–11.89), awareness of pharmacy vaccination (aOR 3.71, 95% CI 2.01–6.85), and annual personal vaccination (aOR 2.07, 95% CI 1.16–3.69) were associated with high willingness. Apparent discrimination was good (AUC 0.804), while mean 10-fold cross-validated AUC was 0.789. The profession × vaccination behaviour interaction was not statistically significant (likelihood-ratio p = 0.472). Conclusions: In this regional, non-probability sample, pharmacists were more willing than family physicians to receive influenza vaccination in a community pharmacy despite lower annual personal uptake. Professional category, service awareness, and annual vaccination were associated with willingness, but measurement validity, causality, and generalisability cannot be established. The findings support profession-specific implementation hypotheses and require confirmation with a formally validated instrument, transparent sampling, and multi-region prospective studies.

Healthcare doi: 10.3390/healthcare14182968

Authors: Safa Özçelik Ünsal Vural

Background: We evaluated factors associated with postoperative hospital length of stay (LOS) after elective isolated coronary artery bypass grafting (CABG), including contemporaneous associations with postoperative complications. Methods: This single-center retrospective cohort included 1493 patients undergoing elective isolated CABG from January 2020 to September 2025. Among 1449 30-day survivors, cumulative postoperative hospital days were modeled using negative binomial regression; LOS > 7 days was the data-derived, center-specific binary outcome. Secondary models assessed postoperative events. Exploratory mortality analysis used Firth logistic regression with bootstrap validation. Results: Median postoperative LOS was 7 days; 406 survivors (28.0%) had LOS > 7 days. Longer LOS was associated with higher body mass index (IRR per 5 kg/m2, 1.05), diabetes (IRR, 1.07), hypertension (IRR, 1.09), chronic obstructive pulmonary disease (IRR, 1.21), lower left ventricular ejection fraction (IRR per 5-percentage-point decrease, 1.04), lower hemoglobin (IRR per 1 g/dL decrease, 1.04), and longer cardiopulmonary bypass (CPB) duration (IRR per 30 min, 1.11). Infection (IRR, 1.46), postoperative atrial fibrillation (IRR, 1.19), and prolonged mechanical ventilation (IRR, 1.54) were contemporaneous correlates. In exploratory mortality analysis, EuroSCORE II (odds ratio per doubling, 2.01) and CPB duration (odds ratio per 30 min, 1.78) were associated with mortality; the optimism-corrected area under the curve was 0.799. EuroSCORE II alone showed moderate discrimination. Conclusions: LOS reflected baseline reserve, operative burden, and postoperative complications. Without event timing, associations with postoperative events are hospitalization-level and neither prospective nor causal.

Healthcare doi: 10.3390/healthcare14182967

Authors: Cristina Gómez-Calero Rebeca Martín-Peralvo Miguel Brea-Rivero Juan C. Pacho-Hernández Olga I. Fernández-Rodríguez

Background/Objectives: Stroke during pregnancy, childbirth, or the postpartum period is uncommon but may substantially affect women’s everyday functioning and maternal roles. This study aimed to characterize functional independence, occupational performance and satisfaction, and quality of life in women who had a stroke during these periods and to explore their lived experiences of motherhood. Methods: An exploratory mixed-methods study used sequential complementary quantitative and qualitative components. Eleven women completed quantitative assessments of functional independence, occupational performance and satisfaction, and quality of life. Six women participated in semi-structured interviews. Qualitative data were analyzed thematically by three researchers, and findings were integrated during interpretation. Results: Participants showed relatively high functional independence, with a median Functional Independence Measure total score of 111 (interquartile range = 8). Qualitative findings revealed disruption and gradual redefinition of the maternal role, difficulties in mother–child bonding and childcare, physical, cognitive, and emotional sequelae, reliance on family support, and perceived gaps between stroke-related care and motherhood-related needs. Integration of the findings showed that relatively preserved basic independence could coexist with substantial difficulties in maternal activities, while occupational priorities frequently related to childcare and family life. Conclusions: Motherhood after stroke involves challenges that may not be adequately captured by general measures of independence. The findings identify meaningful maternal occupations and the integration of stroke-related and motherhood-related needs as areas warranting further investigation within person-centered rehabilitation.

Healthcare doi: 10.3390/healthcare14182966

Authors: Minqi Ma Xueqin Ma Huoling Pan Weibo Lyu Fan Zhang Jinyu Zhang

Introduction: Current clinical guidelines recommend comprehensive management of multiple healthy lifestyles as fundamental to prediabetes care; however, the evidence base regarding the status and clustering of these risk factors remains insufficient. We identified distinct latent classes of healthy lifestyle in individuals with prediabetes and examined their impact on glycemic progression. Methods: This study included 2529 baseline prediabetic participants from the China Health and Retirement Longitudinal Study (CHARLS). We performed latent class analysis (LCA) to stratify participants according to healthy lifestyle factors: physical activity, smoking, alcohol consumption, sleep duration, body mass index (BMI), and blood pressure. Multiple imputation was used for missing covariate data. Multinomial logistic regression was used to examine associations with glycemic transition. Results: Three healthy lifestyle classes were identified: Class 1 (27.6%, the smoking and drinking group), Class 2 (28.2%, the high-BMI group), and Class 3 (44.3%, the healthy lifestyle group). Compared with Class 3, Class 1 (OR, 0.736; 95% CI, 0.554 to 0.978) and Class 2 (OR, 0.628; 95% CI, 0.489 to 0.806) had significantly decreased odds of returning to normoglycemia. Conversely, Class 2 (OR, 2.167; 95% CI, 1.626 to 2.887) had higher odds of progressing to diabetes than Class 3. Conclusions: Prediabetic individuals fall into three distinct healthy lifestyle latent classes. The distinct associations between the three lifestyle latent classes and glycemic progression to diabetes and regression to normoglycemia support the potential value of lifestyle-based risk stratification in prediabetes management, pending validation in prospective cohorts.

Healthcare doi: 10.3390/healthcare14182965

Authors: Namkuk Son

Background/Objectives: The purpose of this study was to investigate the association between physical activity levels and life functioning among Korean older adults using data from the 2024 Korea National Health and Nutrition Examination Survey (KNHANES). Methods: Data from 1418 adults aged ≥65 years were analyzed in this cross-sectional study. Participants were classified into Aerobic-only, Muscle-strengthening-only, Combined, and Inactive groups according to whether their self-reported physical activity met the World Health Organization’s recommendations. Associations with life functioning were examined using complex sample logistic regression analyses adjusting for demographic, lifestyle, and health-related covariates. Results: Compared with the Inactive group, the Aerobic-only (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.11–2.18), Muscle-strengthening-only (OR 1.65, 95% CI 1.06–2.56), and Combined groups (OR 2.19, 95% CI 1.41–3.39) had significantly higher odds of having no limitations in overall life functioning. Similar associations were observed for lower-extremity function, while associations with other functional domains varied across physical activity groups. Conclusions: In this cross-sectional study, meeting the recommended levels of aerobic physical activity, muscle-strengthening exercise, or both was associated with higher odds of having no limitations in overall life functioning and lower-extremity function.

Healthcare doi: 10.3390/healthcare14182964

Authors: Lalesu Geiger Marion Kiechle Heike Jansen

Background: Despite the rapid proliferation of mobile health applications in oncology, real-world uptake, determinants of use, and patient needs among breast cancer patients remain insufficiently described, particularly in the German healthcare context. This study aimed to assess health app use in breast cancer patients and to identify sociodemographic, lifestyle, and psychosocial correlates. Methods: We conducted a non-interventional, cross-sectional, anonymous paper-based survey among adult breast cancer patients receiving outpatient, day-care, or inpatient treatment, or follow-up at a tertiary university hospital (July 2022–January 2023). Descriptive statistics and group comparisons with false discovery rate correction and multivariable logistic regression were used to examine associations between app use and sociodemographic, lifestyle, and psychosocial variables. Results: A total of 202 patients were included (mean age 56.4 ± 13.8 years). Health app users were significantly younger than non-users (51.7 ± 11.0 vs. 64.7 ± 13.8 years, p < 0.001, Cohen’s d = 1.08). Age was the only variable that was independently associated with the use of health apps in the multivariable analysis (adjusted OR 0.43 per 10 years, 95% CI 0.29–0.64). Health app use showed no significant associations with indicators of physical fitness or lifestyle, perceived social support, or emotional burden. Health and fitness apps were the most frequently used app category (77.4%). Physicians were the most frequently consulted source of medical information (77.6%), and only one participant reported having received a digital health application on prescription. Conclusions: In this breast cancer cohort, health app use was common and age-associated. Given patients’ reliance on physicians and the near-absent DiGA prescription rate, age-sensitive implementation strategies and structured clinician guidance are needed to support equitable digital engagement in breast cancer care.

Healthcare doi: 10.3390/healthcare14182963

Authors: Andrés Godoy-Cumillaf Josivaldo de Souza-Lima Maribel Parra-Saldias Daniel Duclos-Bastias Claudio Farias-Valenzuela Eugenio Merellano-Navarro José Bruneau-Chávez Valentina Díaz-Goñi Bruno Bizzozero-Peroni

Background/Objectives: Diet quality is an important determinant of health during young adulthood; however, associations between dietary behaviours and anthropometric outcomes in university students remain insufficiently understood. This study examined the associations between dietary behaviours and anthropometric indicators in Chilean university students. Methods: A cross-sectional study was conducted among university students from southern Chile between June and November 2025. Dietary habits were assessed using a validated Chilean dietary habits questionnaire, from which Healthy Eating, Unhealthy Eating, and Overall Diet scores were derived. Anthropometric measurements included body mass index (BMI), waist circumference, and waist-to-height ratio (WHtR). Age- and sex-adjusted multivariable linear regression models were fitted. Exploratory analyses included psychometric evaluation, principal component analysis, false discovery rate (FDR) correction, and dietary behaviour network analysis. Results: A total of 374 students were included, of whom 40.3% were women. Psychometric analyses provided only partial support for the predefined two-domain structure, with stronger properties for the healthy domain. None of the predefined dietary scores were associated with BMI. The Unhealthy Eating Score was nominally positively associated with waist circumference (β = 0.285 cm per score point, 95% CI: 0.011–0.560), although this association did not remain statistically significant after FDR correction. Exploratory item-level analyses identified positive associations between sugar-sweetened beverage consumption and waist circumference and inverse associations between breakfast consumption and BMI after FDR correction. Conclusions: Predefined dietary behaviour scores showed limited associations with anthropometric outcomes. Psychometric analyses provided only partial support for the predefined scoring structure, particularly for the unhealthy dietary domain. Exploratory item-level analyses suggested that specific dietary behaviours may provide complementary information beyond that obtained by composite dietary scores, although these findings require confirmation in prospective longitudinal studies and further psychometric validation.

Healthcare doi: 10.3390/healthcare14182962

Authors: Devi Das Shukla Mandal Uday Mondal Mihir Bhatta Deepanjan Ray Anoop Velayudhan Bobby Paul Saibal Das Indranil Saha

Objectives: The term “never treated” refers to individuals who self-report having never ingested tablets during any round of Mass Drug Administration (MDA) against Lymphatic Filariasis (LF). This study estimated the pooled prevalence of never-treated individuals with MDA for LF and identified factors associated with persistent non-treatment. Methods: This systematic review and meta-analysis was registered in PROSPERO [CRD420251270067] and conducted in accordance with the PRISMA 2020 guidelines. Relevant literature was identified by searching databases, i.e., PubMed, Scopus, Cochrane Central, Embase, Web of Science, and Epistemonikos from January 2000 to December 2025, and only studies published in English were included. The AXIS tool was used to assess the study quality. A random-effects model with 95% CI was applied to estimate the pooled prevalence. Subgroup, leave-one-out sensitivity, and meta-regression analyses were conducted to explore the heterogeneity. Results: Eighteen studies including 24,940 individuals showed the pooled prevalence of never treatment during all MDA rounds at 26% (95% CI: 16% to 37%, I2 = 99.7%, 95% prediction interval: 0% to 75%). Exploratory subgroup analysis indicated wide regional and MDA round-specific variations. Meta-regression indicated that publication year did not explain the variability. Common reasons for persistent non-treatment included fear of side effects, limited knowledge, difficulty swallowing the pills, and absence during drug distribution. Conclusions: Persistently never-treated populations may represent an important programmatic barrier to LF elimination. Given the very low certainty of evidence, extreme heterogeneity, and potential publication bias, these estimates should be interpreted cautiously. Future research should ensure broader geographical representation, including both urban and rural areas, and explore structural, behavioural, and socio-cultural determinants to better target high-risk groups.

Healthcare doi: 10.3390/healthcare14182960

Authors: Marian Turbatu Alessandro Nota Teresa Laborante Laura Pittari Giulia Deodato Chiara Maria Galati Doina Lucia Ghergic Simona Tecco

Background: The widespread use of portable electronic devices may involve prolonged exposure to altered cranio-cervical postures. This study investigated whether participants classified as HT+ and HT− according to a predefined operational classification differed in masticatory muscles recruitment. Methods: This cross-sectional study included 50 healthy adults (30 F, 20 M; mean age, 27 ± 5 years) classified into two operational groups. The HT+ group (n = 25) was defined by the simultaneous presence of portable electronic device use >8 h/day and habitual marked anterior head flexion, whereas the HT− operational group (n = 25) included participants who did not simultaneously meet both criteria. Participants underwent surface electromyography of the masseter and anterior temporalis muscles during maximum voluntary clenching (MVC) in the neutral head posture and during anterior head flexion (approximately target range 40–60°) using the MyoWise device (MyoWise, Via Gran Sasso 18, 20008 Bareggio, Milan, Italy). Percentage Overlapping Coefficients, Asymmetry Index, Activity Index, Torque Index, and Impact were assessed. Between-group comparisons, within-group posture-related changes, and between-group comparisons of change scores (Δ) were performed using parametric or non-parametric tests according to data distribution. The between-group comparison of the Activity Index in the reference posture was predefined as the primary analysis, whereas secondary analyses were adjusted for multiple comparisons using the Benjamini–Hochberg false discovery rate (FDR) procedure. Statistical significance was set at p < 0.05 for the primary analysis and at FDR-adjusted q < 0.05 for secondary analyses. Results: The Activity Index was significantly more negative in HT+ than in HT− participants in both the reference posture (p < 0.001) and during anterior head flexion (p = 0.003; q = 0.032). The Activity Index decreased significantly from the neutral head posture to anterior head flexion in both groups (HT+: q = 0.025; HT−: q = 0.002), whereas the magnitude of this change did not differ significantly between groups (p = 0.101; q = 0.607). No other sEMG outcome remained significant after FDR correction. Conclusions: The HT+ operational group was associated with a distinct temporalis–masseter recruitment pattern in asymptomatic adults. The Activity Index emerged as the sEMG parameter most strongly associated with operational HT classification, indicating that the observed between-group differences primarily involved the relative recruitment balance between the jaw-elevator muscles.

Healthcare doi: 10.3390/healthcare14182961

Authors: Sayan Sagidullin Gulmira Sagidullina Khussan Umurzakov Gulnar Shalgumbayeva Marzhan Dauletyarova

Background: Fear of cancer progression (FoP) is a well-recognised, clinically significant dimension of quality of life in oncology, yet it remains largely unstudied among men treated for reproductive system malignancies in Central Asia. This study assessed the level and correlates of FoP among such patients across several regions of Kazakhstan, as part of a broader research programme aimed at improving rehabilitation services for this patient group. Methods: A cross-sectional survey was conducted among 1081 men treated for a malignancy of the reproductive system, recruited across seven administrative regions of Kazakhstan (Pavlodar, Karaganda, Astana, Shymkent, Kyzylorda, Taldykorgan and East Kazakhstan). Participants completed a 12-item, 5-point Likert-scale questionnaire covering the same thematic domains as the Fear of Progression Questionnaire–Short Form (FoP-Q-SF), together with a structured sociodemographic and clinical questionnaire. Total FoP scores were calculated, together with two post hoc, exploratory subscales (somatic/health-related and social/occupational-family), reported descriptively only. Associations with sociodemographic and clinical variables were examined using t-tests, one-way ANOVA with Tukey post hoc comparisons, Spearman correlation and multivariable linear regression. Results: Internal consistency of the 12-item instrument was good (Cronbach’s α = 0.864). The mean total FoP score was 38.6 ± 8.2 (observed and possible range, 12–60). Patients who had experienced disease recurrence or had an unclear disease status scored markedly higher than patients with no recurrence and no treatment in the preceding six months (mean difference 4.07 points, p < 0.001), as did patients who had received treatment in the past six months without recurrence (mean difference 2.90 points, p < 0.001). Patients receiving hormonal (androgen-deprivation-type) therapy reported higher fear scores than those who were not (39.4 vs. 37.7, p = 0.001), an association that remained significant after multivariable adjustment (β = 1.19, p = 0.024). Urban residents scored higher than rural residents (38.9 vs. 37.6, p = 0.019). Age, having minor children, and ethnicity were not significantly associated with FoP. In multivariable analysis, disease status and hormonal therapy were the only independent predictors of FoP (model R2 = 0.053, p < 0.001). Conclusions: Fear of cancer progression is common and clinically relevant among Kazakhstani men treated for reproductive system cancers, and was most strongly associated with current disease status and receipt of hormonal therapy rather than with age or family circumstances. These findings support integrating structured psychological screening into routine rehabilitation pathways for this patient group, with universal access to psychosocial support and proactive outreach particularly considered for patients with recurrent or recently treated disease and those receiving hormonal therapy.

Healthcare doi: 10.3390/healthcare14182959

Authors: Tina Lipovec Sebastjan Merlo Ines Cilenšek Nina Kovacevic

Background: Genitourinary syndrome of menopause (GSM) is a common consequence of hypoestrogenism that negatively affects vulvovaginal health, sexual function, and quality of life. Evidence comparing non-hormonal treatment options in women with hormone-dependent malignancies remains limited. This study evaluated patient-reported outcomes following non-ablative Er:YAG laser therapy or hyaluronic acid vaginal gel in women with hormone-dependent cancer and GSM. Methods: In this prospective randomized pilot study, 65 women with hormone-dependent malignancies and GSM were randomized to receive either three sessions of non-ablative Er:YAG vaginal laser therapy (n = 34) or 0.2% hyaluronic acid vaginal gel applied intravaginally every 72 h for two months (n = 31). The primary outcome was change in the total Vulvovaginal Symptom Questionnaire (VSQ) score; change in the total Female Sexual Function Index (FSFI) score was a secondary outcome, and domain-level analyses were exploratory. Outcomes were assessed at baseline and one month after treatment. Wilcoxon signed-rank and Mann–Whitney U tests were used for the principal analyses; adjusted analyses were performed using ANCOVA. The study was retrospectively registered at ClinicalTrials.gov (Identifier: NCT07420647; first posted on 19 February 2026). Results: Within-group improvements were observed under both active interventions. The primary between-group comparison showed no difference in total VSQ change (p = 0.398). Total FSFI change favored laser therapy in the unadjusted between-group comparison (p = 0.034), and the exploratory baseline-adjusted difference was 2.72 points (95% CI, 0.19–5.25; p = 0.036). Domain-level analyses were exploratory and were not adjusted for multiplicity. Conclusions: In this active-comparator pilot study, total VSQ change was comparable between groups and the adjusted total FSFI estimate favored laser therapy. Without a sham or untreated control, within-group changes cannot establish intervention-specific efficacy; these comparative findings require confirmation in larger controlled trials.

Healthcare doi: 10.3390/healthcare14182958

Authors: Huan Xiao Yichun Chai Juan Wen Qiulin Mi Youruo Zhang Junguo Duan

Purpose: We aimed to compare the real-world effectiveness of four myopia-control spectacle lens interventions for childhood myopia control using a doubly robust causal inference framework. Design: This was a retrospective cohort study with multi-treatment augmented inverse probability weighting. Participants: A total of 2764 myopic children (right eyes) aged 3–18 years were included, screened from 13,071 electronic medical records at Ineye Hospital, Chengdu University of Traditional Chinese Medicine, between January 2023 and January 2026. Methods: Participants were allocated to four myopia-control spectacle lens groups and one single-vision spectacle lens group: Higher-Order Aberration Defocus (n = 912), Defocus Incorporated Multiple Segments (n = 800), Highly Aspherical Lenslets (n = 476), Diversified Segmental Defocus Optimization (n = 238), and single-vision lenses (n = 338). A doubly robust estimator combining multinomial propensity-score weighting with outcome regression was applied to adjust for confounding. Outcome Measures: The primary outcomes were one-year changes in axial length and spherical equivalent. The secondary outcomes were the rates of rapid progression. Treatment-effect heterogeneity was explored across prespecified baseline age, refractive error, and axial length subgroups. Results: After adjustment, all four myopia-control designs significantly outperformed single-vision correction (p < 0.05). The design based on Higher-Order Aberration Defocus demonstrated the greatest efficacy, with an axial length change of 0.107 mm and a spherical equivalent change of −0.146 D. Within this group, 25.5% of children exhibited rapid axial elongation (≥0.36 mm/year) and 8.3% exhibited rapid myopic progression (≥−0.50 D/year). The treatment effect was statistically significant in children with low myopia or an axial length no greater than 26 mm (p < 0.05), but not in those with high myopia or pathological axial elongation. Conclusions: All four myopia-control spectacle lens designs demonstrated significant advantages over single-vision correction in real-world clinical practice. Particular emphasis should be placed on the role of myopia-control spectacles during the early stages of myopia. As myopia progresses to high myopia or pathological axial elongation, the efficacy of myopia-control spectacle lenses as a standalone intervention diminishes, and combined approaches incorporating multiple myopia management strategies may be warranted.

Healthcare doi: 10.3390/healthcare14182957

Authors: Thurayya Eid Bader M. Almutairy Abdulaziz M. Alodhailah Mohammed Almutairi Waleed M. Alshehri

Background/Objectives: Nurses may use digital communication channels alongside formal rostering systems to negotiate shift swaps. How these practices are organized, governed, and experienced in Saudi hospitals remains insufficiently understood. This study explored how nurses in one tertiary hospital coordinated shift swaps through digital communication and navigated reciprocity, professional accountability, and access to scheduling flexibility. Methods: A qualitative descriptive study was conducted in a tertiary hospital in the Riyadh region, Saudi Arabia. Twenty-four registered nurses, recruited by purposive maximum-variation sampling from medical–surgical, intensive care, emergency, and specialty units, completed individual semi-structured interviews incorporating digital journey-mapping prompts. Interviews were audio-recorded, transcribed, de-identified, and analyzed using reflexive thematic analysis, reported with reference to the Reflexive Thematic Analysis Reporting Guidelines. Results: Four interrelated themes were developed: (1) digital pathways of negotiation; (2) reciprocity as social currency; (3) managing risk and responsibility; and (4) collective coping and unequal flexibility. Private and group messaging supported initial negotiation, whereas managerial approval and formal roster documentation established legitimacy and accountability. Reciprocal assistance increased flexibility but could also generate obligation and reproduce inequalities associated with seniority, trust, and social integration. Conclusions: In this hospital, digital shift-swap coordination operated alongside, rather than in place of, formal scheduling governance. Transparent procedures connecting peer communication with managerial approval may support flexibility while protecting fairness, documentation, professional boundaries, and appropriate staffing. These findings describe one purposively recruited sample in a single hospital and require evaluation in multi-center research.

Healthcare doi: 10.3390/healthcare14182955

Authors: Mert Demircioğlu Hazal Ezgi Mutlu

Background/Objectives: Operating room nurse scheduling is a complex healthcare optimization problem. Operating room settings are particularly challenging because permanent and subcontracted nurses operate under complex 16 h and 24 h shift structures, with continuous surgical coverage requirements and recovery-period requirements. To our knowledge, few existing models simultaneously integrate nurse preferences, recovery-period requirements, and heterogeneous shift structures within a unified goal programming framework. This study aims to develop and implement a goal programming model that incorporates nurses’ needs and preferences as flexible constraints to optimize shift scheduling in an operating room department. Methods: This single-center case study combined a qualitative component, an analysis of scheduling records, and mathematical optimization modeling. It was conducted at the operating room department of a public hospital in Türkiye employing 37 permanent and 7 subcontracted nurses in the shift rotation, together with a head nurse responsible for the roster. The hospital was selected purposively as a high-volume public center with a dual-tier staffing model and a fully manual scheduling process; semi-structured interviews were then conducted with all 37 permanent nurses and the head nurse (n = 38). The seven subcontracted nurses were not interviewed; the constraints applying to them were derived from national regulatory guidance and operational information provided by the head nurse. Scheduling requirements were formalized as five flexible constraints informed by nurses’ preferences and institutional requirements and incorporated into a goal programming model alongside obligatory coverage and staffing constraints. Penalty weights were calibrated through structured consultation with the head nurse. The model was solved to proven optimality using Python with the OR-Tools CP-SAT solver. Results: The optimized 28-day schedule eliminated direct night-to-day shift transitions, which, under the manual schedule, affected approximately three nurse assignments per week. Weekly night shifts were limited to a maximum of two per nurse in every planning block, a limit that individual nurses exceeded under the manual system. Monthly working days were standardized to a range of 18–20 days (mean = 19.84, SD = 0.49) from an irregular 14–26-day range (mean = 20.57, SD = 3.51), an 86% reduction in the standard deviation. All identified rest-period violations for subcontracted nurses on 16 h and 24 h duties were eliminated in the optimized schedule. Conclusions: A goal programming model integrating flexible constraints informed by nurses’ preferences and institutional requirements generated a schedule with greater equality in the distribution of monthly working days and improved compliance with the predefined scheduling objectives compared with the historical manual schedule. The model offers nurse managers a potentially adaptable decision-support tool that requires prospective validation in other settings. Future work should extend the model to incorporate dynamic patient demand, cost optimization, and multi-department scheduling scenarios.

Healthcare doi: 10.3390/healthcare14182956

Authors: Cihat Özgüncü

Objective: Informed consent documents often prioritize institutional liability over patient comprehension, and conventional readability metrics are inadequate to assess their ethical and cognitive complexities. This study aims to develop and demonstrate the preliminary feasibility of the Universal Health Communication Index (UHCI), an AI-driven Health Technology Assessment (HTA) framework utilizing large language models (LLMs) to objectively evaluate the multidimensional quality and operational impact of medical consent forms. Methods: The UHCI employs a hybrid natural language processing architecture to evaluate clinical texts across five dimensions: Accessibility, Transparency, Autonomy, System Burden, and Medical Adequacy. The pipeline deploys an ‘AI Persona’ to simulate patient cognitive load and an ‘AI Gold Standard’ utilizing clinical guidelines (UpToDate) to identify omitted risks. The framework was benchmarked in an exploratory proof-of-concept against a fifty-eight-member multidisciplinary human baseline and subsequently tested in a cross-lingual proof-of-concept by comparing standardized lumbar puncture consent forms across three distinct healthcare jurisdictions (Turkey, the UK, and the USA). Results: The algorithm effectively quantified abstract bioethical concepts into an objective HTA metric, demonstrating preliminary numerical agreement with the human baseline across five pilot forms (mean difference: 2.73, SD: 5.94). The framework effectively penalized the ‘illusion of transparency’ and defensive medical terminology. In the cross-lingual case study, although the global scores were comparable, the algorithm successfully discerned between forms prioritizing patient-centered autonomy and those reflecting directive institutional discourse. Conclusions: Transcending conventional readability formulas, the UHCI provides healthcare administrators and policymakers with a scalable, practical methodology to optimize clinical documentation. By identifying institutional bias and communicational barriers, this AI-assisted screening tool promotes equitable patient engagement and supports evidence-based health policies, demonstrating the responsible integration of AI into clinical workflows without replacing human clinical judgment.

Healthcare doi: 10.3390/healthcare14182953

Authors: Ye Chan Park So-Yun Kim Green Hong Jang Hee Hong Dongil Park Jung Sunwoo

Introduction: Home-based spirometry has emerged as a potential component of decentralized clinical trials (DCTs) in respiratory medicine, but its real-world feasibility in patients with chronic obstructive pulmonary disease (COPD) and other respiratory diseases remains insufficiently characterized. This study evaluated the feasibility of remote pulmonary function monitoring using a portable spirometer and mobile application in adults with COPD or other respiratory diseases. Methods: This exploratory single-arm study enrolled adults aged 19 years or older with COPD or other respiratory diseases. Participants were asked to perform home-based spirometry at six prespecified time points (Days 15, 29, 43, 57, 71, and 85). Feasibility was assessed using visit-level and participant-level adherence, spirometry quality grades, and patient-reported usability and satisfaction. Participants completing at least 5 of 6 scheduled measurements were classified as the high-adherence group; this cut-off was an operational, study-specific definition. Results: A total of 30 participants were enrolled (19 with chronic obstructive pulmonary disease, 5 with asthma, 2 with asthma–COPD overlap, and 4 with other respiratory conditions), and 23 completed the study. Visit-level completion rates declined over time, from 88.5% on Day 15 to 47.8% on Day 71 and 56.5% on Day 85. Nine participants completed all six measurements, while 13 completed at least five. Portable spirometry quality showed variability across visits, with both high-quality and low-quality measurements observed. Compared with the low-adherence group, the high-adherence group reported significantly higher scores for convenience, communication with the research team, overall satisfaction, willingness to participate in future telemedicine-based trials, device training adequacy, ease of device use, and application usability. Conclusions: Home-based spirometry may be a useful decentralized trial component in patients with COPD and other respiratory diseases; however, the decline in adherence over time and the variability in measurement quality indicate that substantial operational refinement is needed before broader implementation. Because no feasibility threshold was prespecified, no concurrent laboratory spirometry comparison was performed, and the study population was diagnostically heterogeneous, these findings are exploratory and address operational feasibility rather than measurement validity.

Healthcare doi: 10.3390/healthcare14182954

Authors: Marija Arapović Marina Ćurlin Marin Senčar Željka Kanižaj Rogina Alen Pajtak

Background: Obesity is associated with impaired health-related quality of life, including reduced sexual satisfaction. Metabolic and bariatric surgery leads to substantial weight loss and favorable changes in body composition; however, its association with sexual satisfaction as a health-related outcome remains insufficiently explored. The aim of this study was to examine changes in body composition and sexual satisfaction six months following metabolic and bariatric surgery. Methods: This prospective study included 40 women with obesity who underwent metabolic and bariatric surgery performed according to standard clinical indications and multidisciplinary team recommendations. Body composition parameters were assessed using bioelectrical impedance analysis, and sexual satisfaction was evaluated using the New Sexual Satisfaction Scale at baseline and six months postoperatively. Changes in anthropometric, body composition, and sexual satisfaction measures were analyzed using nonparametric statistical tests. Results: Six months after surgery, significant changes were observed in body composition and sexual satisfaction. Median body weight decreased from 119.55 to 100.80 kg, BMI from 42.15 to 35.65 kg/m2, and visceral fat level from 14.50 to 11.00 (all p < 0.001). Although absolute skeletal muscle mass decreased significantly (28.40 to 26.30 kg, p < 0.001), its relative proportion increased (25.35% to 25.90%, p = 0.002). Median total NSSS score increased from 62.50 to 69.50, with significant improvements in both NSSS subscales (all p < 0.001). Conclusions: Metabolic and bariatric surgery was associated with significant improvements in body composition and sexual satisfaction six months postoperatively. These findings suggest that improvements in physical health following metabolic and bariatric surgery may be accompanied by enhancements in sexual well-being.

Healthcare doi: 10.3390/healthcare14182952

Authors: Aashiq Khan Irum Zeb Shuanghu Fang

Background: Mental health is important in higher education because university students often face academic stress and social adjustment challenges. Objective: We examined the direct and indirect associations among self-efficacy, perceived social support, and mental health among students at H university in central China. Methods: A stratified convenience sample of 581 undergraduate, master’s, and doctoral students completed online or face-to-face self-report questionnaires. Shortened measures were used to reduce respondent burden. Self-efficacy was assessed using six items from the Self-Efficacy Scale, perceived social support using three items from the Multidimensional Scale of Perceived Social Support, and mental health using six items from the 12-item General Health Questionnaire. The measures showed acceptable reliability and validity overall (α = 0.848–0.876; CR = 0.886–0.924; AVE = 0.564–0.801; HTMT < 0.85). SPSS 26 and SmartPLS v4.0 were used to examine the proposed associations with 5000 bootstrap resamples. Results: Self-efficacy had a significant positive association with mental health (β = 0.293, p < 0.001) and perceived social support (β = 0.721, p < 0.001). Perceived social support had a significant positive association with mental health (β = 0.145, p = 0.025). The indirect association between self-efficacy and mental health through perceived social support was significant (β = 0.105, p = 0.026). The model explained 16.8% of the variance in mental health and 52.0% of the variance in perceived social support. Conclusions: In this single-university sample, self-efficacy and perceived social support were positively associated with mental health. The cross-sectional self-report design and convenience sampling prevent causal conclusions and limit generalizability. The findings should also be interpreted cautiously because the shortened measures were not independently validated.

Healthcare doi: 10.3390/healthcare14182951

Authors: Hanlong Li Hongyu Tan

Background: Lung function and sleep are each prospectively associated with late-life depressive symptoms, but whether their co-occurrence carries risk beyond the sum of the two components has not been tested across national populations. Methods: We quantified the joint association of low peak expiratory flow (PEF) and sleep disturbance with incident depressive symptoms in four ageing cohorts and formally tested additive and multiplicative interaction. We analysed 49,201 at-risk participants aged 50 to 100 years from the Health and Retirement Study (US), the English Longitudinal Study of Ageing, the China Health and Retirement Longitudinal Study and the Survey of Health, Ageing and Retirement in Europe (16 countries). Low PEF was defined as the lowest quartile within sex and age bands; sleep disturbance used each cohort’s established measure. Incident elevated depressive symptoms were modelled with Poisson generalized estimating equations with robust variance and random-effects meta-analysis. Results: The joint-exposure group had a higher adjusted rate of incident elevated symptoms in every cohort (pooled aRR 1.40, 95% CI 1.28 to 1.52; I2 = 41%), corresponding to 7 to 25 additional events per 1000 person-years; component associations were smaller (low PEF only aRR 1.14; sleep disturbance only 1.27). No evidence of interaction was found on either scale, with complete cross-cohort consistency (multiplicative interaction RR 0.95, 0.89 to 1.02; additive RERI −0.03, −0.11 to 0.06; both I2 = 0%). Findings persisted in zero-symptom-baseline, sex-stratified, attrition-weighted and competing-risk analyses and were replicated in ELSA when low lung function was defined by spirometric FEV1 (aRR 1.33) or FVC (aRR 1.23) instead of PEF. Conclusions: Co-occurring low PEF and sleep disturbance mark a consistent, additive burden of incident depressive symptoms in later life; combined assessment should be read as simple risk addition, not as a synergistic high-risk phenotype.

Healthcare doi: 10.3390/healthcare14182950

Authors: Fahad S. Alshehri Nasser M. Alorfi Nouf M. Alourfi Wajid Syed

Background: People with disabilities may face medication-safety challenges when functional limitations interfere with medication handling, administration, communication, self-management, or continuity of treatment. This study examined pharmacists’ experiences and perceptions of safe medication use among people with disabilities in Saudi Arabia and identified adaptations that may support safer, more independent medication management. Methods: A qualitative descriptive study was conducted using a self-administered electronic survey that included structured items on participant characteristics and 15 open-ended questions. Eighteen pharmacists from different practice settings participated, and 17 provided substantive qualitative responses for analysis. Data were analyzed using a codebook thematic analysis approach within a qualitative descriptive orientation, informed by Braun and Clarke’s phases of thematic analysis. Two researchers initially coded the responses independently and subsequently compared and refined the coding framework through discussion. Results: Four major themes were identified: (1) functional limitations shape perceived medication-use challenges; (2) pharmacists perceive safety concerns at multiple points in medication use; (3) proposed function-adapted strategies for medication management; and (4) organizational conditions perceived to support function-adapted care. Participants reported challenges with medication packaging, dosage forms, administration devices, medication information, self-management, caregiver dependence, refills, and treatment continuity. They also proposed strategies, including functional assessment, personalized counseling, caregiver education, adapted packaging and dosage forms, medication review, assistive tools, alternative access services, and standardized institutional procedures. Conclusions: Pharmacists identified several ways disability-related functional limitations could complicate medication use and proposed potential adaptations at the patient, pharmacist, and organizational levels. These strategies should be viewed as hypotheses and considerations for practice rather than proven medication-safety interventions. Further research that incorporates patient and caregiver perspectives and directly measures medication-use outcomes is needed.

Healthcare doi: 10.3390/healthcare14182949

Authors: Young Suk Yoon Jinyong Choi Seok Yoon Doori Kim

Background: Herniated intervertebral disc (HIVD) with radiculopathy and foot drop can lead to substantial functional impairment. Although both pharmacopuncture and motion-style acupuncture treatment (MSAT) have demonstrated therapeutic potential individually, evidence on their combined use remains limited. In this single-case report, we described the clinical course of a patient with HIVD with radiculopathy and foot drop who underwent a novel approach combining ultrasound (US)-guided Shinbaro 2 pharmacopuncture targeting multiple nerve roots with tibialis anterior muscle motion-style acupuncture treatment (TA MSAT). Case Presentation: A 40-year-old man with lower back pain (LBP), radiculopathy, and foot drop attributed to acute HIVD was treated with high-dose US-guided Shinbaro 2 pharmacopuncture and TA MSAT. Outcomes were measured using the Numeric Rating Scale (NRS) for LBP, L5, and S1 radiculopathy; Manual Muscle Testing (MMT) for dorsiflexion and great toe extension; the Oswestry Disability Index (ODI) for lumbar function; the EuroQol Five-Dimension (EQ-5D) Index for quality of life; and the Patient Global Impression of Change (PGIC) for satisfaction. After 14 weeks of treatment, NRS scores for LBP, L5, and S1 radiculopathy decreased from 5 to 1, 8 to 1, and 8 to 1, respectively. MMT grades for dorsiflexion and great toe extension improved from 3 to 5 and 2 to 5, respectively, indicating full functional recovery. ODI and EQ-5D scores improved from 62.22 to 6.67 and 0.344 to 1.0, respectively. The PGIC score was 1, indicating clinical improvement. Conclusions: Our integrative approach involving US-guided pharmacopuncture and TA MSAT demonstrates therapeutic potential for the management of acute HIVD.

Healthcare doi: 10.3390/healthcare14182944

Authors: Patricia Rojas Carolina Rojas Aída Rojas-Castañeda Margarita Martínez Gómez María Esther Ocharan-Hernández Judith Pacheco-Yépez

Background/Objectives: Population aging represents a major social and public health challenge in Latin America. Mexico has made significant advances in regulatory and policy frameworks. Notable progress includes accession to the Inter-American Convention on Protecting the Human Rights of Older Persons (IACPHROP). It also includes the enactment of the Law on the Rights of Older Persons, and institutional reforms for social and cultural inclusion. This review evaluates Mexico’s alignment of aging policies with IACPHROP standards using an integrated framework of social determinants, policies, and legal obligations. This approach has not been previously reported for Mexico. Methods: Searches were conducted in electronic databases and official repositories. These included the World Health Organization, the Organization of American States, the Inter-American Human Rights System, and Mexican government regulations. Additional searches were performed in PubMed, Redalyc, SciELO, and Google Scholar. Results: Advances include universal non-contributory pensions, the expansion of healthcare coverage, and social inclusion programs. Important policy areas remain to be addressed, including the establishment of a national long-term care system, and the reduction of regional disparities in health coverage. In addition, the evidence linking specific policies to improve health outcomes remains heterogeneous. Conclusions: Mexico has built a solid foundation for the protection of older adults’ rights. The development of a long-term care system and the adoption of place-based approaches are also essential. Regional cooperation and community traditions play a pivotal role in achieving dignified, inclusive, and sustainable aging.

Healthcare doi: 10.3390/healthcare14182946

Authors: Jae Hee Kim

Background/Objectives: Mental health service utilization remains considerably lower than the level of mental health need, and the factors related to utilization may differ across the life cycle. Applications of the Andersen Behavioral Model often underrepresent service availability and responsiveness. Based on the Andersen Behavioral Model, this study aimed to identify factors related to professional mental health counseling among Korean adults within three age strata. Methods: Using nationally representative, cross-sectional data from the 2021 National Mental Health Survey of Korea, this secondary analysis included 5511 participants: 1135 young adults aged 18–34 years, 3339 middle-aged adults aged 35–64 years, and 1037 older adults aged 65–79 years. Rao-Scott chi-square tests and survey-weighted logistic regression were used. The outcome was counseling for a mental health problem by a physician, nurse, clinical psychologist, or doctor of Korean medicine during the previous five years. Results: Female sex was associated with higher odds of counseling among young adults (odds ratio [OR] = 1.99, 95% confidence interval [CI] 1.01–3.95) and middle-aged adults (OR = 1.75, 95% CI 1.06–2.87), as was greater satisfaction with health status (OR = 2.67, 95% CI 1.46–4.91 and OR = 1.93, 95% CI 1.28–2.91, respectively). Higher loneliness was inversely associated with counseling in all three strata (OR = 0.70, 95% CI 0.55–0.89; OR = 0.69, 95% CI 0.58–0.83; OR = 0.64, 95% CI 0.52–0.80). Conclusions: Loneliness was the only factor associated with counseling in every stratum. These within-stratum estimates are not formal tests of between-group differences, and temporal order is uncertain. Loneliness may reflect a disruption in the pathway from need to help-seeking, change following prior care, or residual confounding; longitudinal evaluation is required.

Healthcare doi: 10.3390/healthcare14182948

Authors: İsmail Çapar Utku Cem Hasırcı Didem Dumanlı Kusay Edanur Altın Gediz Geduk

Background/Objectives: This study aimed to compare the diagnostic performance of multimodal (image-capable) large language models (LLMs) and oral and maxillofacial radiologists in detecting nine predefined incidental findings on panoramic radiographs, using a cone-beam computed tomography (CBCT)-derived reference standard. Methods: This retrospective diagnostic performance study included 500 purposively assembled, finding-enriched panoramic radiographs paired with CBCT images. CBCT images were evaluated by three radiologists to establish the reference standard. Two experts and three LLMs, the latter accessed through their consumer web interfaces, independently assessed the presence or absence of the nine findings; 4500 finding-level decisions were analyzed for each reader. Sensitivity, specificity, accuracy, and error rates were calculated. Within-patient clustering was accounted for using generalized estimating equations and a cluster bootstrap procedure with 5000 resamples. Finding-specific comparisons used Cochran’s Q test with Benjamini–Hochberg correction. Results: Agreement between the two experts was very good (κ = 0.86). Expert sensitivity, specificity, and accuracy ranged from 89.5 to 91.6%, 92.0–93.0%, and 91.8–92.9%, respectively, compared with 75.1–83.1%, 88.0–90.0%, and 86.8–89.0% for the LLMs. The overall reader effect was significant for all three performance metrics (all p < 0.001). In the exploratory high-risk group, expert sensitivity ranged from 90.9 to 93.2% versus 62.9–78.0% for the LLMs. After correction for multiple comparisons, the difference between readers remained significant only for carotid artery calcification (q < 0.001) and extensive maxillary sinus pathology (q = 0.005). Conclusions: Under the consumer-interface conditions and access period tested, the LLMs performed below the experts, particularly for high-risk findings, and should not be used independently to evaluate panoramic radiographs. Because the dataset was finding-enriched and single-center, the absolute estimates cannot be transferred directly to routine clinical populations, and any future role for these models, more plausibly as an expert-supervised adjunct or screening aid than as a replacement for expert interpretation, remains to be tested prospectively.

Healthcare doi: 10.3390/healthcare14182947

Authors: Sky Wei Chee Koh Yixuan Chuah Si Hui Low Alicia Ying Ying Boo Thomas Soo Yii Jen Lew Howard Bauchner Lynette Mei Lim Goh

Background: Healthcare professionals in Singapore’s primary care face sustained workload pressures and increasing complexity. Grounded in the Job Demands–Resources model, this study identifies demographic, clinical, and lifestyle factors associated with psychological distress among staff across two independent windows spanning the pre- and post-pandemic periods. Methods: The study was conducted among staff in National University Polyclinics (NUP) Singapore. De-identified health screening data included demographics, occupation, clinical measures, medical history, and lifestyle behaviours. Primary outcome was psychological distress, assessed across 2 distinct observation windows: the Hospital Anxiety and Depression Scale (HADS) from 2018–2022 (abnormal ≥ 8) and the General Health Questionnaire-12 (GHQ-12) from 2023–2025 (abnormal ≥ 2). Multivariate mixed-effects logistic regression identified factors associated with psychological distress while accounting for within-person clustering. Results: We analysed 3307 screening visits from 1260 staff. Within the HADS observation window (2018–2022), abnormal scores were significantly higher in 2022 compared with 2018 (OR 2.28, 95% CI 1.64–3.17). Within the GHQ-12 observation window (2023–2025), a non-significant decline in abnormal scores was observed. Older age (2018–2022: OR 0.967, 95% CI 0.948–0.987; 2023–2025: OR 0.955, 95% CI 0.928–0.983) and regular exercise (2018–2022: OR 0.724, 95% CI 0.529–0.991; 2023–2025: OR 0.357, 95% CI 0.231–0.551) were consistently associated with lower odds of distress. Medical staff had significantly lower odds of distress compared to ancillary staff in 2018–2022 (OR 0.391, 95% CI 0.207–0.739). Regular alcohol use was associated with higher distress in 2018–2022 (OR 1.56, 95% CI 1.05–2.31), while active smoking (OR 5.79, 95% CI 1.75–19.10) and family history of chronic disease (OR 2.22, 95% CI 1.28–3.87) were significant in 2023–2025. Conclusions: Older age and regular exercise were consistently associated with lower odds of psychological distress across both windows, while ancillary staff and alcohol use (HADS window), and smoking and family history of chronic disease (GHQ-12 window) were period-specific determinants. These findings support the implementation of proactive, targeted wellness initiatives alongside the routine mental health surveillance among primary care staff.

Healthcare doi: 10.3390/healthcare14182945

Authors: Carmen Pena-Díaz Fe Amalia García Santiago

Background/Objectives: Early recognition of psychological distress is an important component of integrated healthcare, particularly among patients experiencing social and linguistic vulnerability. This hypothesis-generating study examined how observable expressions of distress were conveyed and addressed in multilingual hospital encounters. Methods: An exploratory qualitative analysis was conducted using fifteen interpreter-mediated consultations purposively selected from the Intercomsalud corpus because verified transcripts were available. The sample included consultations in Arabic (n = 6), Chinese (n = 2), English (n = 5), Russian (n = 1) and Ukrainian (n = 1). Coding distinguished (1) explicit verbal distress, (2) observable emotional cues, and (3) researcher-inferred distress; it also described full, partial or non-relay and the healthcare professional’s observable response within the recording. Results: In the analysed consultations, biomedical and procedural information was generally conveyed in recognisable form. Some explicit distress expressions and observable cues were reduced, reformulated or not explored, whereas other encounters showed sustained acknowledgement. The psychology consultation provided a suggestive, uncontrolled contrast and cannot establish a department effect. Conclusions: The cases illustrate that clinical-content relay and affective recognition can be examined as related dimensions, but the present sample primarily documents accurate clinical-content relay with variable affective recognition and does not empirically validate their full independence. Larger, independently coded studies with follow-up data are needed.

Healthcare doi: 10.3390/healthcare14182941

Authors: Aigerim T. Kushtekova Maral G. Nogayeva Lyudmila S. Yermukhanova Vyacheslav N. Lokshin Ardak N. Nurbakyt Aigul Y. Tazhiyeva Aiman A. Musina Akmaral K. Mussakhanova Alireza Afshar

Background: Patient-centered care is particularly important in assisted reproductive technology, where treatment is clinically demanding and emotionally intensive. This study documented a preliminary cultural and linguistic adaptation of a fertility-care survey for Kazakhstan and evaluated patient–staff perception gaps, item-level priorities, preliminary reliability, and exploratory associations with global care ratings. Methods: A cross-sectional survey was conducted in two assisted-reproduction clinics in Almaty. The analytic workbook contained 273 patient and 74 staff records; 173 patient response patterns were unique and 100 records matched an earlier exact pattern. Group-level patient–staff comparisons between independent respondent samples used prespecified harmonized indices, Welch tests, false-discovery-rate correction, clinic-stratified analyses, and one-pattern-per-record sensitivity analyses. Importance–experience differences were calculated within respondents with both values available. Global-rating regressions used HC3 robust inference and were treated as exploratory. Results: Staff rated cost, attitude and communication, information and education, and participation more favorably, whereas patients rated privacy, emotional support, and continuity more favorably. Accessibility and competence showed little difference. Clinic-stratified and one-pattern-per-record analyses preserved the principal contrast directions, although the Physical Comfort proxy was not robust. Several indices showed weak or negative internal consistency. Global ratings had a marked ceiling, with 79.1% at 10/10, and the HC3 joint test for the added care-index block was not significant (p = 0.080). Conclusions: This exploratory survey identified substantial, bidirectional group-level patient–staff differences and concrete item-level priorities, but the scoring and psychometric evidence are insufficient to interpret the domain indices as established measurement scales. Source-codebook verification and broader structural validation are required.

Healthcare doi: 10.3390/healthcare14182942

Authors: Martina Kancheva Mariana Dimitrova-Haruil Desislava Voynikova Sevda Rimalovska

Background/Objectives: Dentists are uniquely positioned to detect child abuse and neglect (CAN), including dental neglect, yet reporting rates remain low and Bulgarian data are scarce. This study assessed the knowledge, attitudes, and self-reported intention to report CAN, including dental neglect, among clinical dental students in Plovdiv, Bulgaria, and their views on further education. We additionally tested whether recognition and attitudes differed by sex, stage of training, and prior CAN education, and identified independent correlates of the intention to report. Methods: A single-centre, analytical cross-sectional survey (Microsoft Forms) was conducted among 4th-, 5th-, and 6th-year (intern) dental students at the Medical University of Plovdiv (March–May 2025). The 17-item questionnaire covered demographics, knowledge, attitudes, the perceived role of the dentist, and interest in further training. An indicator-recognition score (0–24) was derived from four “select-all-that-apply” items. Group differences were examined with Mann–Whitney U and χ2/Fisher tests; independent correlates were identified with a general linear model (recognition score) and binary logistic regression (reporting intention; dentist’s role), with effect sizes reported. Results: Of 200 invited students, 115 responded (57.5%; 74 female, 41 male). Physical abuse was recognised by all participants (100%) but neglect by only ~75%. Female students scored higher than males (adjusted means 19.97 vs. 18.08; p = 0.005; partial η2 = 0.07), with no difference by year of study. Overall recognition scores were similar in students with and without prior CAN education (p = 0.713), but trained students more often endorsed the dentist’s safeguarding role (88.3% vs. 57.9%; p = 0.001) and intended to report suspected cases (66.2% vs. 39.5%; p = 0.011). In multivariable models, prior education (adjusted OR 3.31) and the recognition score (adjusted OR 1.32 per point) were each independently associated with the intention to report (both p ≤ 0.012). Over half (51%) considered their training insufficient and 94.8% wanted further education, preferring case-based seminars (71.3%). Conclusions: A clear gap exists between awareness of CAN and readiness to act; prior education related to readiness to act rather than to broader recognition. Structured, practice-oriented training with clear local reporting pathways and interprofessional learning is needed.

Healthcare doi: 10.3390/healthcare14182943

Authors: Zhansaya Torgauytova Ardak Ayazbekov Gulzhakhan Omarova Almagul Kurmanova Damilya Salimbayeva Altynay Nurmakova Natalya Kravtsova Makhambet Smailov Rinaliya Usmanova

Background: The Turkestan region is one of the regions with a high birth rate; therefore, analysis of the effectiveness of an early detection system for chromosomal abnormalities in this region is important for practical healthcare. Objective: To evaluate the diagnostic potential of first-trimester prenatal screening markers for identifying Down syndrome in the Turkestan region. Methods: A retrospective analytical study was conducted based on the analysis of medical records of pregnancies registered at perinatal centers in the Turkestan region between 2020 and 2025. The final analytical sample included 143 cases, comprising 71 pregnancies affected by Down syndrome and 72 randomly selected pregnancy cases included for comparative analysis. Maternal age, nuchal translucency (NT) thickness, pregnancy-associated plasma protein A (PAPP-A), free beta-human chorionic gonadotropin (free β-hCG), and fetal nasal bone hypoplasia/aplasia were assessed. Multivariable logistic regression and receiver operating characteristic (ROC) curve analysis were used. Results: In the multivariable analysis, maternal age (odds ratio [OR] = 1.16; p < 0.001) and NT (OR = 3.01; p = 0.001) showed statistically significant independent associations with Down syndrome. PAPP-A and free β-hCG did not demonstrate statistically significant independent associations in the multivariable model. The area under the ROC curve (AUC) was 0.855 for Model 1 and 0.903 for Model 2, which additionally included fetal nasal bone status. Conclusions: The exploratory models demonstrated good discriminatory performance within the present retrospective analytical sample. Maternal age and ultrasound markers showed the strongest associations with Down syndrome in the multivariable analysis. These models are not intended for direct clinical application at this stage and require external validation in independent and representative prenatal screening populations before their potential clinical utility can be assessed.

Healthcare doi: 10.3390/healthcare14182940

Authors: Shoichi Kimura Naoki Terada Michikazu Nakai Toyoharu Nagata Toshio Kamimura Toyoharu Kamibeppu Hiromasa Tsukino Hironobu Wakeda Katsuhisa Mori Takeshi Yamasaki Masafumi Nagano Soichiro Fukuda Yasuhiro Yamashita Toshiyuki Takehara Kentaro Kuroiwa Takahiro Shitamura Chie Onizuka Atsuro Sawada Toshiyuki Kamoto

Background/Objectives: Healthcare resources are unevenly distributed across Miyazaki Prefecture, Japan. We examined regional differences in the clinical presentation of renal cell carcinoma (RCC) recorded in the Miyazaki Urological Cancer Database (MUCD), together with area-level healthcare resource indicators. Methods: We performed a retrospective descriptive observational analysis of prospectively collected data from the multicenter MUCD registry. After deduplication and rechecking eligibility, 540 patients with a documented diagnosis date within the study period (1 April 2019–31 March 2024) were included (Central/Southern, n = 333; Western, n = 116; Northern, n = 91). The three main clinical outcomes were adjusted for age and sex, with clustering by registering facility taken into account. Results: Presentation with predefined local symptoms occurred in 18.6%, 19.0%, and 34.1% of patients in the Central/Southern, Western, and Northern areas, respectively. Compared with Central/Southern, the adjusted odds ratio for predefined local symptoms in the Northern area was 2.30 (95% CI, 1.39–3.81). Median tumor size was 3.8, 4.4, and 5.0 cm, respectively; the adjusted mean difference for Northern versus Central/Southern was 1.24 cm (95% CI, 0.65–1.82). Clinical M1 disease was recorded in 10.2%, 12.1%, and 19.8%, respectively; the global test accounting for facility clustering yielded p = 0.076, and the Holm-adjusted p value for Northern versus Central/Southern was 0.082. Urologist density in 2024 was 8.7, 8.0, and 5.3 per 100,000 population, respectively. Conclusions: Regional differences were observed in the clinical presentation of MUCD-recorded RCC and in area-level healthcare resource availability. These findings are descriptive and hypothesis-generating and do not show that differences in resource availability caused the observed clinical patterns.

Healthcare doi: 10.3390/healthcare14182939

Authors: Manuela Lalu Marius Sorin Pop Dana Carmen Zaha

Background/Objectives: Temporomandibular disorders (TMDs) affect the masticatory muscles, temporomandibular joints, and related tissues and are frequently associated with pain and functional limitation. Patients with chronic TMD may present multiple comorbidities that complicate clinical management and contribute to symptom persistence. This study aimed to identify comorbid conditions associated with chronic TMD, compare their distribution between chronic and acute TMD presentations, and propose a conceptual interdisciplinary assessment framework. Methods: A retrospective observational study included 82 patients with TMD and at least one symptomatic or documented comorbidity identified during interdisciplinary clinical assessment or within the previous three months. Of these, 58 patients had chronic TMD and 24 had acute TMD. Categorical variables were compared using Fisher’s exact test, with odds ratios and 95% confidence intervals calculated for each comparison. False discovery rate (FDR) correction was applied, and age- and sex-adjusted Firth-penalized logistic regression models were also fitted. Results: In direct group comparisons, chronic TMD was associated with higher frequencies of primary headache, secondary headache, neck pain, lower back pain, endocrine/hormonal disorders, Axis II findings, and kinesiophobia. After age- and sex-adjusted Firth-penalized logistic regression analyses and FDR correction, primary headache, secondary headache, neck pain, lower back pain, endocrine/hormonal disorders, and kinesiophobia remained significantly associated with chronic TMD. No significant differences were observed for sleep bruxism, awake bruxism, or poor sleep quality. Conclusions: Given the retrospective design and limited sample size, the results should be interpreted as exploratory associations rather than causal relationships. Further prospective studies are needed to evaluate and validate the proposed framework and assess its clinical applicability.

Healthcare doi: 10.3390/healthcare14182938

Authors: Diego Gómez-Costa Pablo Lastra-Prados Marta Olmos Valverde Lorena Camarero Aizpurua

Background/Objectives: Routine administrative dental data can quantify specialty activity and reconstruct sequential patient movement when operational definitions and analytical provenance are explicit. To reconcile institutional activity through 30 June 2026, describe the derivation of all treatment records, and reconstruct patient transitions across 18 dental services. Methods: The official institutional report was the source of truth for descriptive totals. Patient-level workbooks were used for deduplication and transition analysis after excluding dates later than 30 June 2026. A treatment record was a coded administrative row; appointments and first visits followed the official report definitions. Directed transitions linked different services in consecutive dated patient stages. PageRank, betweenness and modularity were recalculated from the resulting matrix. Results: The official report comprised 98,685 treatment records represented by 476 treatment codes, 24,327 unique appointments and 1351 first visits. There were 7260 unique anonymized patient codes; 13,026 was the non-additive sum of service-specific patient counts. The cutoff-restricted chronology included 3947 multiservice patients and 16,347 dated stages. The network contained 253 directed service pairs and 8777 transitions (density 0.827). The leading PageRank values were RX (0.202), CIRUGÍA BUCAL (0.149), MEA (0.101), MIA (0.088), and MPSI (0.062). Modularity was low (Q = 0.042). Conclusions: The descriptive results are fully reconciled to the official report, while network estimates are restricted to reproducible individual trajectories from 1 January 2025 to 30 June 2026. The observed network characterizes sequential service use and should not be interpreted as proof of formal referral.

Healthcare doi: 10.3390/healthcare14182936

Authors: Mehmet Kadir Bartın Müge Kara

Background/Objectives: Curative-intent surgery for early-stage upper gastrointestinal (GI) cancer causes substantial nutritional, functional, and psychological morbidity; whether an integrated post-treatment nutrition and rehabilitation pathway improves distress and survival is unclear. Methods: We conducted a retrospective cohort study of 130 patients undergoing curative-intent esophagectomy or gastrectomy for early-stage esophagogastric cancer: 65 received a structured post-treatment nutrition and rehabilitation support program (Group A), and 65 received standard care (Group B). The primary outcome was psychological distress trajectory over 12 months (Distress Thermometer; secondarily HADS); overall survival was secondary. Propensity-score matching assessed covariate balance; a multivariable Cox model estimated the adjusted mortality association. Results: Distress scores were similar at 1 month (7.2 vs. 7.4; p = 0.43) and diverged progressively (group × time interaction p < 0.001; 4.9 vs. 6.1 at 12 months; p < 0.001, Cohen’s d ≈ 0.8; 95% CI for the 12-month between-group difference 0.65–1.75 points); HADS-A and HADS-D followed a concordant trajectory (8.4 vs. 10.1; 7.7 vs. 9.3; both p ≤ 0.003). Baseline covariates were reasonably balanced before matching (all standardized mean differences [SMDs] < 0.16) and met the prespecified <0.10 balance threshold for most covariates after matching. Fourteen deaths occurred (3 vs. 11); log-rank testing showed a significant survival difference (p = 0.021), consistent after matching (p = 0.037), and in the adjusted Cox model, support-program receipt was associated with lower mortality (hazard ratio 0.25, 95% CI 0.07–0.90; p = 0.034), though underpowered (14 vs. ~37 events required) and hypothesis-generating. Conclusions: Structured post-treatment nutrition and rehabilitation support was associated with markedly lower psychological distress, the prespecified primary outcome, with the achieved sample exceeding the a priori requirement for the assumed effect size; a secondary, exploratory survival association requires prospective confirmation. These findings support prospective, multicenter evaluation of integrated psycho-oncology and nutrition-rehabilitation care pathways after upper GI cancer surgery and should not be interpreted as demonstrating a causal treatment effect.

Healthcare doi: 10.3390/healthcare14182937

Authors: Hannah Husby Jacqueline Liu Alexandra Scott Jiang Li Qiwen Huang James Brian Jones Xiaowei Yan

Background/Objectives: National guidelines include recommendations for cardiovascular disease (CVD) prevention, but gaps in prevention still exist. Clinical decision support (CDS) tools may be an avenue for delivering preventive care. The goal of this project was to understand how clinicians approach primary prevention of CVD and to determine barriers and facilitators in delivery of primary preventive care with and beyond a CDS tool. Methods: A user-centered design approach including a cross-sectional survey and qualitative interviews was deployed in a health system in Central and Northern California. Clinician responses to the survey in addition to clinician interviews about perspectives on CVD were analyzed. Results: A total of 62 primary care physicians, advanced practice clinicians, and nurse practitioners completed surveys, and 7 primary care clinicians participated in interviews. Primary care clinicians generally agree that preventive care would be more efficient with team-based care. Physician-centered care and CVD preventive care were constricted by limited time, the highly varied nature of primary care, and a lack of standardized and personalized CDS tools. Once patients at risk of CVD are identified, there is also a lack of clarity around resources available to support downstream care for patients. Conclusions: The results highlight the challenges in providing CVD prevention for primary care clinicians. A team-based approach, supported by digital CDS tools, can be more effective for ensuring the necessary CVD prevention communication and coordination takes place.

Healthcare doi: 10.3390/healthcare14182935

Authors: Aviraj Soin Charles A. Odonkor Massab Bashir Jose R. Rodriguez

Background/Objectives: Artificial intelligence (AI) is increasingly applied across spinal pain care, by improving diagnostic accuracy, optimizing clinical workflow, and advancing translational research. However, AI’s role and its integration into rural spine care face challenges. Therefore, the current narrative review synthesizes the role of AI in rural spine care, spanning diagnosis, clinical decision support, imaging, natural-language processing, and remote monitoring. Methods: We searched the peer-reviewed literature on AI in spinal pain care across six databases from inception to June 2026. Results: In the United States, AI models have shown promise in strengthening clinical decision support that assists clinicians in identifying spinal pain disorders and providing evidence-based treatment recommendations; however, most were developed and validated in urban healthcare settings. Additionally, evidence on external validation, dataset representativeness, robustness to incomplete or low-quality data, interoperability, prospective clinical utility, and implementation feasibility in rural spine care remains limited. Therefore, we propose a translational framework in which de-identified data from rural and urban healthcare settings are aggregated, harmonized, and used to develop a multimodal AI model. AI models further require rigorous technical and external validation, prospective validation in rural settings, explainability, and continuous post-implementation monitoring. Despite its benefits, key limitations, including data scarcity and algorithmic bias, are also highlighted. Conclusions: AI has emerged as a promising tool for strengthening clinical decision support in spinal pain disorders in rural settings. The most realistic role of AI in rural settings is not to replace specialist expertise, but to act as one component of a multidisciplinary care team.

Healthcare doi: 10.3390/healthcare14182934

Authors: Hatice Ozcaliskan Ilkay Zuleyha Cihan Ozdamar Karaca

Aims: Although the Mediterranean diet (MD) is widely recognized as a sustainability-aligned dietary model, its relationship with sustainable eating behaviors and its cross-sectional associations with adiposity, cooking and food skills, and macrovascular complications in type 2 diabetes mellitus (T2DM) remain insufficiently characterized. Methods: This cross-sectional study included 120 adults with T2DM (median age, 60 years) consecutively recruited from an endocrinology outpatient clinic. Mediterranean diet adherence (MDA), Sustainable and Healthy Eating Behaviors (SHEB), and Cooking Skills and Food Skills (CSFS) were assessed using validated scales. Dietary intake was evaluated using a single 24-h dietary recall, and anthropometric and body composition measures were obtained using standardized procedures. Adjusted group differences were examined using ANCOVA. To account for multiplicity across prespecified families of exploratory outcomes, nominal p-values were corrected using the Benjamini–Hochberg false discovery rate (FDR) procedure. Results: Higher MDA was associated with a higher total SHEB score (primary outcome; p < 0.001) and with higher scores for quality labels, seasonal foods and food waste avoidance, local food, and reduced meat consumption, after FDR correction (all q < 0.05). Across SHEB tertiles, waist-to-hip ratio differed significantly after FDR correction (p = 0.001, q = 0.010), whereas the nominal difference in neck circumference did not remain significant (p = 0.046, q = 0.230). In analyses according to macrovascular complication status, lower adjusted protein intake remained significant after FDR correction (p = 0.002, q = 0.032). Nominal differences in food skills, total CSFS, MDA, total and saturated fat intake, monounsaturated fat intake, and dietary total antioxidant capacity did not remain significant after multiplicity correction (all q > 0.05). Conclusions: Greater adherence to the Mediterranean diet was cross-sectionally associated with more sustainable and healthier eating behaviors, whereas higher SHEB scores were associated with a lower waist-to-hip ratio. Most exploratory differences according to macrovascular complication status did not remain significant after correction for multiple testing, underscoring the need for cautious interpretation. Prospective studies are needed to establish temporal relationships, and intervention studies are required to determine whether modifying adherence to the Mediterranean diet, sustainable eating behaviors, or cooking and food skills affect subsequent cardiometabolic and vascular outcomes in T2DM.

Healthcare doi: 10.3390/healthcare14182933

Authors: Predrag Duric Smiljana Rajcevic Jelena Djekic Malbasa Dunja Prokic Ljiljana Milosevic

Background/Objectives: Contemporary health systems continue to face persistent challenges in financing, equity, and governance, particularly under conditions of limited resources, workforce shortages, and demographic pressures. While the World Health Organization calls for strengthening social participation to achieve universal health coverage, evidence suggests that such participation often remains largely symbolic. Existing global examples of social participation in health are limited either by their short duration of implementation or by their limited scope. In contrast, the experience of former Yugoslavia (1945–1991) represents a distinctive case. In the early post-war period, health reforms were directed towards the development of a decentralised, self-managed health system that emphasised universal coverage, participatory governance, social solidarity, and local autonomy. The trajectory of these reforms was further shaped by global economic and political pressures, including neoliberal trends, international debt, and the oil crises, which constrained resources and exposed systemic vulnerabilities. The so-called Yugoslav Experiment may offer an alternative to existing market-oriented and, at times, inefficient health systems. This review aims to synthesise evidence on the governance, financing, organisation, and outcomes of Yugoslavia’s self-managed health system and to evaluate its relevance to contemporary debates on health system resilience, decentralisation, participatory governance, equity, and sustainability. It examines power relations, stakeholder interests, and resource allocation, and assesses the lessons that the Yugoslav experience offers for contemporary debates on participatory governance and the sustainability of healthcare systems, while identifying areas of convergence, debate, and gaps in the existing scholarship. Methods: We conducted a systematic narrative review of peer-reviewed articles, book chapters, conference papers, and commentaries published in English or Bosnian–Croatian–Montenegrin–Serbian that covered the period 1945–1991. Scopus, PubMed, and EBSCOhost (including CINAHL Plus with full text, Medline and PsychInfo) were searched on 19 January 2026. Studies were included if they addressed health system reform, self-management, governance, financing, or institutional continuity. Contextual studies of selected services—primary care, mental health, reproductive health, and vaccination—were included only if they illuminated reform trajectories. Data synthesis focused on reform phases, institutional transformations, financing arrangements, governance mechanisms, and power relations, with particular attention to continuity, path dependence, and critical junctures. Given the heterogeneous and predominantly historical, analytical, and policy-oriented nature of the literature, we did not apply conventional study-design-specific risk-of-bias tools. Instead, we used an overarching framework to classify and contextualise the included evidence according to five dimensions: source type, nature of contribution, evidentiary role, temporal context, and health-system domain. The protocol was not registered. The study was financed by the Provincial Secretariat for Higher Education and Scientific Research, Autonomous Province of Vojvodina, Republic of Serbia. Results: The database searches yielded 265 records, of which 193 were selected for title and abstract screening after removing 72 duplicates. At this stage, 133 publications were excluded because they did not meet the eligibility criteria and 60 publications were selected for full-text review. Application of the predefined inclusion and exclusion criteria resulted in 22 eligible publications. An additional 18 studies were identified through citation chaining and targeted Google Scholar searches. Twenty-two publications were coded as primary studies, directly examining health system reform, governance, or self-management, while 18 were classified as contextual studies addressing specialty areas. The analysis identified key reforms that followed the social participation, i.e., ‘self-management’, approach, which expanded primary care, preventive services, and local participation. It revealed institutional changes, as well as the role of power and health financing in health reforms aimed at strengthening social participation. Nonetheless, challenges—including bureaucratic and managerial elitism, unequal professional authority, resource scarcity, and tensions between market-oriented policies and social solidarity—were amplified by global economic forces and neoliberal trends, ultimately contributing to the system’s collapse by the late 1980s. This review was limited by its search strategy, the exclusion of grey literature, the potential omission or inaccessibility of relevant studies, and its focus on selected aspects of health reform, namely post-war recovery and self-management. Conclusions: The Yugoslav experience illustrates both the promise and the fragility of socially oriented, participatory health systems, demonstrating how international political alignments and global economic pressures can profoundly shape domestic health reform trajectories. Lessons from this case remain relevant to contemporary efforts to strengthen social participation for universal health coverage through designing sustainable, resilient, equitable, and socially accountable health systems under complex global conditions.

Healthcare doi: 10.3390/healthcare14182932

Authors: Katerina Kloumpa Eleni Lahana Eleni Albani Christos Kleisiaris Georgios Manomenidis Georgios Dentsikas Stiliani Kotrotsiou Nikolaos Bakalis

Background: Health-related quality of life (HRQoL) and job satisfaction are important indicators of nurses and physicians’ wellbeing and system sustainability, particularly under conditions of high clinical demand. Although organizational determinants of nurses and physicians’ wellbeing have received increasing attention, evidence regarding protocol-based work as a specific organizational characteristic remains limited. Methods: A multicenter cross-sectional study was conducted in 11 Greek public hospitals between September 2022 and March 2023. The study included 405 nurses and physicians (214 nurses and 191 physicians). HRQoL was assessed with the SF-36 and job satisfaction with the MSQ-Short Form. Protocol-based work was assessed using a single self-reported dichotomous item referring to the use of standardized clinical protocols during the pandemic. Associations between workplace characteristics and outcomes were examined using multivariable linear regression models. Results: Vitality (57.24 ± 17.61 among nurses and 53.92 ± 16.93 among physicians) and general health (56.58 ± 19.81 and 53.42 ± 16.32, respectively) were the lowest-scoring HRQoL dimensions in both professional groups. Compared with physicians, nurses reported higher mental health (62.52 vs. 58.11, p < 0.05), social functioning (67.17 vs. 58.96, p < 0.05), and overall job satisfaction (3.23 vs. 2.98, p < 0.01), whereas physicians scored higher in physical functioning (83.47, p < 0.05) and bodily pain (72.87, p < 0.05). Conclusions: Several organizational characteristics were associated with wellbeing among nurses and physicians. Protocol-based work showed consistent associations with better HRQoL and job satisfaction across multiple outcomes. However, longitudinal studies are needed to determine whether these associations reflect causal relationships.

Healthcare doi: 10.3390/healthcare14182931

Authors: Waleed M. Alshehri Mohammed Almutairi Faihan F. Alshaibany Thurayya Eid Bader M. Almutairy Abdulaziz M. Alodhailah

Background/Objectives: Supporting families during end-of-life care in intensive care units is clinically, emotionally, and ethically demanding, and nurses’ experiences of this work in Saudi Arabian intensive care settings remain underexplored. This study explored nurses’ experiences of providing psychosocial and emotional support to families during end-of-life care, including their role in treatment-limitation and goals-of-care discussions. Methods: A qualitative descriptive study, analyzed using reflexive thematic analysis from a contextualist position, was conducted with 15 intensive care nurses across three healthcare facilities in Riyadh. Ten were Saudi nationals and five internationally recruited; eleven had Arabic as a first language. Semi-structured interviews were conducted in Arabic (n = 11) or English (n = 4) between December 2025 and February 2026 and coded in the language of collection. Results: Three themes were developed: doing relational work inside a system organized for clinical throughput; carrying what the work leaves behind; and standing between, brokering understanding for families. Nurses described having no formal decision-making authority while shaping what families understood and what the clinical team heard. Conclusions: Nurses positioned themselves as intermediaries between families and clinical teams. This relational work was shaped by staffing, formal preparation, access to palliative care, and physician recognition of the nursing role. Strengthening these organizational conditions may support more consistent family care.

Healthcare doi: 10.3390/healthcare14182930

Authors: Tina Tomić Mahečić Vedran Premužić Robert Baronica Marija Trbojević Lucija Biličić Ivana Janja Bošnjak Antonia Vukšić Iva Tucić

Idiopathic Capillary Leak Syndrome (ICLS), also known as Clarkson’s disease, is a rare yet potentially life-threatening disorder of unknown etiology. It is a clinical condition that is frequently overlooked, but represents a severe and potentially fatal illness, characterized by fluid extravasation into the interstitial space, resulting in hemoconcentration, generalized edema, effusions, and hypotension. Owing to the similarity of its symptoms to those of other conditions, ICLS is often underdiagnosed, thereby posing a challenge for patient management. We report a complex case of a 69-year-old patient who presented with shock secondary to a necrotic cecal tumor and was ultimately diagnosed with ICLS. This case underscores the diagnostic challenges, the need for awareness and need for precision monitoring in differentiating ICLS from other causes of shock and emphasizes the critical importance of early recognition and appropriate therapeutic intervention. Additionally, a review of the current understanding of ICLS pathophysiology, diagnostic criteria, and treatment strategies, based on existing evidence, is provided.

Healthcare doi: 10.3390/healthcare14182928

Authors: Eduard Moreno Gabriel Faranak Nooriankafshgari Rosa García-Sierra Candela Sancho Vallvé Daina Parellada-Moreno Victoria Ardiles Ruesjas Immaculada Herrero-Fresneda Pere Torán-Monserrat

Background/Objectives: Irritable bowel syndrome (IBS) is one of the most common disorders of gut–brain interaction and one of the most frequent functional bowel disorders encountered in clinical practice. The lack of reliable biomarkers, coupled with inconsistent clinical presentations and variable therapeutic outcomes, creates a landscape of ongoing uncertainty for clinicians. Against this background, non-pharmacological and technological developments—such as digital health interfaces, sensor technologies, and medical devices—emerge as potential support tools for clinical management. This qualitative study explored how healthcare professionals manage diagnostic and therapeutic uncertainty in IBS across care settings while evaluating the potential role and value of integrating these technological and non-pharmacological innovations into routine practice. Methods: Fifteen semi-structured interviews were conducted with healthcare professionals involved in IBS care across primary and specialized settings and one expert patient with lived experience in the Barcelona metropolitan area. Data were analyzed using principles of grounded theory. Results: The notion of “catch-all category” articulates four interrelated themes that characterize IBS in clinical practice: persistent clinical uncertainty, pragmatic diagnostic strategies, patient engagement in biopsychosocial and longitudinal management, and the implementation and interpretability of digital and non-pharmacological support. Participants described IBS management as shifting from exclusionary, symptom-based diagnostics toward holistic biopsychosocial and gut–brain-axis models. This transition underscores the necessity for resources that empower patients through education, support clinicians through longitudinal monitoring, and facilitate shared management strategies. Conclusions: The findings suggest that IBS management is not a single diagnostic act but a longitudinal process of uncertainty management. Future digital or non-pharmacological support tools for IBS should prioritize longitudinal monitoring, clinically interpretable information, and low burden for professionals and patient–professional communication.

Healthcare doi: 10.3390/healthcare14182929

Authors: Katrine Holen Mia Karabeg Ellen Steffenssen Sauesund Dag Sigurd Fosmark Marius Dalby Beata Eva Petrovski Goran Petrovski

Background: Diabetic retinopathy (DR) is a major cause of visual impairment. Its clinical determinants are well-established, whereas socioeconomic associations vary across settings. Objective: To estimate the observed proportion of DR and examine associations between clinical, demographic, and socioeconomic factors and DR among adults attending a hospital-based screening program in Oslo, Norway. Methods: This cross-sectional study analyzed 118 adults with diabetes. DR was graded from wide-field retinal images. A complete-case multivariable logistic regression model included age, diabetes duration, HbA1c, BMI, diabetes type, education level, and economic activity. Results: DR was present in 67 participants (56.8%). The adjusted model included 93 participants (53 with DR and 40 without DR). Longer diabetes duration was associated with higher odds of DR (adjusted odds ratio [aOR] 1.27 per year, 95% CI 1.14–1.41; p < 0.001), whereas age showed an inverse association (aOR 0.89 per year, 95% CI 0.82–0.97; p = 0.006). HbA1c, BMI, diabetes type, education, and economic activity were not statistically significant after adjustment. Conclusions: No statistically significant associations between the measured socioeconomic factors and DR were identified in this study sample. Clinically relevant associations and causal inference cannot be assumed because of possible selection bias and cross-sectional study design.

Healthcare doi: 10.3390/healthcare14182926

Authors: Iva Zdravkova-Aneva Tihomir Dermendzhiev Kostadin Kostadinov Angel Prodanov Rositsa Dimova Ralitsa Raycheva

Background/Objectives: Despite major advances in precision medicine, equitable and timely access to innovative oncology therapies remains challenging because of differences in reimbursement systems, health technology assessment (HTA), and healthcare organization. Physicians are well positioned to identify barriers affecting the implementation of these therapies in routine practice. This study evaluated Bulgarian physicians’ perceptions of innovative oncology therapies, assessed patient access, identified barriers to timely availability, and examined factors perceived as associated with these perceptions. Methods: A cross-sectional web-based survey was conducted between March and May 2025 among physicians involved in oncology care in Bulgaria. The questionnaire comprised six domains addressing professional characteristics, self-perceived knowledge, clinical implementation, perceptions of patient access, barriers to implementation, and policy priorities. Descriptive statistics, Pearson’s chi-square tests, Cramér’s V, and multivariable ordinal logistic regression were used to analyze the data. Results: A total of 114 physicians participated. Respondents generally reported moderate-to-high levels of self-perceived knowledge regarding innovative oncology therapies. Self-perceived knowledge was higher among medical oncologists (adjusted p < 0.001) and physicians treating at least 100 patients with cancer per month (adjusted p = 0.003). Overall, 57.9% of respondents (95% CI: 48.7–66.6%) rated the perceived timeliness of access as good or very good, while 68.4% (95% CI: 59.4–76.2%) reported encountering patients who sought treatment abroad because innovative therapies were perceived as unavailable or insufficiently accessible in Bulgaria. Professional experience (aOR = 0.68, 95% CI: 0.50–0.93; p = 0.014) and higher monthly patient volume (aOR = 0.45, 95% CI: 0.21–0.96; p = 0.039) were independently associated with more favorable perceptions of access. Financial constraints, regulatory and HTA-related delays, and perceived delays in pharmaceutical-company submissions were the principal perceived barriers. Conclusions: Bulgarian oncology specialists demonstrate high self-reported professional readiness for innovative oncology therapies; however, the perceived timely patient access remains constrained primarily by financial, organizational, and reimbursement-related factors. Although, these findings reflect physicians’ perceptions and do not establish causal determinants of access, strengthening reimbursement pathways, HTA implementation, molecular diagnostic capacity, and clinical research infrastructure may improve equitable access to innovative oncology therapies within the evolving European HTA framework.

Healthcare doi: 10.3390/healthcare14182927

Authors: Adel S. Alhlayl Haitham Alzghaibi

Background: People living with multiple sclerosis (MS) are increasingly turning to the Internet for information about their condition and its treatment. However, online health information varies widely in quality, and patients often lack the eHealth literacy needed to distinguish reliable from unreliable sources. Objective: This study examined how people with MS in the United Kingdom seek, evaluate, and judge the quality of online health information, with particular attention to information about medicines, and explored the features that they would value in a curated, quality-assessed information resource. Methods: A cross-sectional online survey was distributed via the MS Trust to adults with MS or their carers in the United Kingdom. The 55-item instrument, adapted from a previously validated questionnaire, captured demographic characteristics, Internet use, eHealth confidence, perceived quality indicators, assessment difficulties, and preferences for a curated information resource. Descriptive statistics summarised the sample, and Spearman’s rank-order correlation tested associations between confidence, perceived importance of quality, and information-checking behaviours. Results: One hundred and fifty-two participants completed the survey. Because the number of individuals reached through the MS Trust’s distribution channels was not recorded, a true response rate could not be calculated; the achieved sample represented approximately 38–40% of the a priori target of 400. Almost all participants (99%) used the Internet to find MS-related information, and 84% sought information about their medicines online. Recommendation by a healthcare professional was the strongest indicator of perceived information quality (17.8%), and MS specialists were the most trusted source overall (32.9%). However, 54.4% of participants expressed concerns about online information quality, and only 47.9% believed that search engines reliably returned high-quality websites. Confidence in evaluating online medicine information correlated strongly and positively with the perceived importance of information quality (ρ = 0.869, p < 0.001, n = 73) and with active checking behaviour (ρ = 0.677, p < 0.001, n = 73). Eighty-eight percent of participants endorsed the development of a single, quality-assessed website for MS-related medicine information, and 80% wished for visible details of how each source had been assessed. Conclusions: Despite high engagement with online information, people with MS remain uncertain about its quality and find independent assessment time-consuming and complex. A curated, transparently assessed information resource, ideally with clinician endorsement and visible quality indicators, was endorsed by the subset of participants who reached these items and represents a candidate direction for future digital health interventions in MS care. Because several preference items were answered by small subgroups (n = 35–79) drawn from an engaged charity membership, these findings are exploratory and require confirmation in more representative samples.

Healthcare doi: 10.3390/healthcare14182924

Authors: Rania Maher Alhalawany Rahaf Fahad AlNufaie Yahya Mubark Khatatbeh

Background: Psychological flourishing is a key indicator of optimal mental health and professional well-being, particularly among psychologists who are routinely exposed to emotionally demanding clinical environments. Although self-compassion has consistently been associated with positive psychological outcomes, few studies have integrated traditional statistical methods with machine learning approaches to predict psychological flourishing among psychologists. Objective: This study aimed to examine the relationship between self-compassion and psychological flourishing among psychologists in Saudi Arabia, identify the unique contribution of self-compassion dimensions, evaluate the predictive performance of supervised machine learning models, and compare their performance with traditional multiple linear regression. Methods: A cross-sectional correlational design was employed, involving 224 psychologists practicing in Saudi Arabia. Participants completed the Self-Compassion Scale and the Flourishing Scale. Descriptive statistics, Pearson’s correlation, and multiple linear regression analyses were performed using IBM SPSS Statistics version 29.0. In addition, Random Forest Regression and Support Vector Regression (SVR) models were implemented in Python using scikit-learn version 1.8.0 to predict psychological flourishing based on self-compassion dimensions together with demographic and professional characteristics. Model performance was evaluated using the coefficient of determination (R2), root mean square error (RMSE), and mean absolute error (MAE). Results: Overall, self-compassion was positively associated with psychological flourishing (r = 0.627, p < 0.001). Multiple linear regression showed that self-kindness had a significant positive independent association with psychological flourishing (β = 0.292, p = 0.001), whereas over-identification had a significant negative independent association (β = −0.206, p = 0.009). The regression model explained 40.5% of the variance in psychological flourishing (R2 = 0.405, p < 0.001). In the held-out test-set comparison using the same predictor set, predictive performance was similar across multiple linear regression (R2 = 0.273; RMSE = 3.583; MAE = 2.849), Random Forest Regression (R2 = 0.282; RMSE = 3.562; MAE = 2.771), and Support Vector Regression (R2 = 0.272; RMSE = 3.587; MAE = 2.768), with no substantial predictive advantage of the machine-learning models over the linear benchmark. Conclusions: Self-compassion, particularly self-kindness and over-identification, was significantly correlated with psychological flourishing among psychologists. Machine-learning models demonstrated predictive performance comparable to traditional regression, with no substantial predictive advantage over the linear benchmark, indicating that increased model complexity did not improve out-of-sample prediction in the present sample.

Healthcare doi: 10.3390/healthcare14182925

Authors: Lucas Carrera-Villar Julia López-Canay Jaime Álvarez-Vázquez Manuel Casal-Guisande María Torres-Durán Alberto Fernández-Villar

Background and Objectives: Non-invasive mechanical ventilation is the first-line treatment for managing acute respiratory failure. However, patient variability and complex pulmonary mechanics complicate therapy adjustments, frequently leading to ventilator-induced lung injuries. This study aims to propose and define a simulation platform and decision support prototype, named VENTILA2, to optimize pressure-controlled ventilation strategies. Methods: The system integrates a bicompartmental series model of the respiratory system incorporating severity-stratified physiological profiles of chronic obstructive pulmonary disease and acute respiratory distress syndrome, and it is coupled with a Mamdani fuzzy inference system. This architecture maps inspiratory time adjustments based on pressure errors and their derivatives across predefined clinical profiles within a scenario-based feedforward parameter-mapping framework. Results: Evaluated through quantitative operational verification across all profiles and proof-of-concept case studies, the platform successfully recreates complex clinical scenarios, accurately simulating phenomena such as accelerated lung emptying in severe acute respiratory distress syndrome and air trapping in moderate chronic obstructive pulmonary disease. Conclusions: VENTILA2 provides a controlled simulation environment for evaluating pathology-specific ventilatory configurations across simulated profiles prior to clinical implementation, though it remains an early-stage prototype whose clinical effectiveness, safety, and robustness remain to be rigorously evaluated.

Healthcare doi: 10.3390/healthcare14182923

Authors: Mohamad Adam Bujang Wei Hong Lai Xun Ting Tiong Sing Yee Khoo Fazalena Johari Alex Ren Jye Kim Yvonne Yih Huan Jee Clare Hui Hong Tan Nurul Fatma Diyana Ahmad

Background: Chronic diseases are widely recognized to negatively affect individuals’ quality of life and well-being. Therefore, this study aimed to evaluate the quality of life and well-being among patients with chronic diseases. Methods: This cross-sectional study using a self-administered survey was conducted from May 2022 to May 2023 in Sarawak General Hospital, Kuching, Malaysia. Data were collected based on a consecutive sampling technique from patients diagnosed with chronic diseases, including end-stage renal disease, cancer, heart disease, and depressive disorder. During the recruitment process, all patients were in stable condition (stable here refers only to care setting rather than clinical severity) and were recruited from four specialist clinics. All participants completed the Significant Quality of Life Measure (SigQOLM), a comprehensive instrument comprising 69 items that assess 18 domains and four dimensions of quality of life and well-being. Descriptive analysis and General Linear Model Analysis of Covariance (ANCOVA) were applied in the analysis. Results: A total of 168 patients were included in the study. Of these, 41 (24.4%) had end-stage renal disease (ESRD), 48 (28.6%) had cancer, 39 (23.2%) had heart disease, and the remaining 40 (23.8%) had depressive disorder. Statistical analysis demonstrated significant differences (p < 0.001) in quality of life and well-being among the four chronic disease groups. Despite being in stable condition, patients with depressive disorder reported the poorest quality of life and well-being, whereas patients with cancer and heart disease demonstrated the highest quality of life and well-being (adjusted mean score of 71.6 and 69.6, respectively). Conclusions: Under stable condition, differences in quality of life and well-being were observed among patients with chronic diseases. These findings provide valuable insights for medical practitioners and policymakers in designing and tailoring interventions to improve the quality of life and well-being of patients with chronic diseases.

Healthcare doi: 10.3390/healthcare14182922

Authors: Mohammad Saleem Mahdieh Zare Bidoki Wafa Alsuraihi Mohammed Ali Al-Garadi Abdulaziz Ahmed

Background/Objectives: Emergency departments (EDs) are high-pressure environments where time-sensitive decisions, fragmented data, and operational strain create strong demand for AI-driven clinical decision-support systems (AI-CDSSs). These systems have shown promise in triage, diagnosis, risk stratification, and workflow optimization, yet real-world implementation in emergency medicine remains uneven. This systematic review aimed to synthesize the technical characteristics, clinical applications, implementation dimensions, organizational and ethical considerations, and real-world impact of AI-CDSSs in ED settings. Methods: This systematic review followed PRISMA guidance and searched PubMed, Scopus, and Embase for English-language studies published between January 2015 and February 2025. Eligible studies described AI-CDSS implementation, clinical integration, or performance evaluation in ED settings. Twenty-three studies met the inclusion criteria and were synthesized across five domains: technical characteristics, clinical applications, implementation dimensions, organizational and ethical considerations, and real-world impact. Results: Among the 23 included studies, 20 contributed to the real-world evaluation synthesis. Of these 20 studies, 8 (40%) achieved live or prospective evaluation, seven (35%) relied only on retrospective validation, four (20%) used human-centered or perception-based evaluation, two (10%) used post-implementation assessment, and one (5%) used simulation-based evaluation; categories were not mutually exclusive because some studies employed more than one evaluation approach. In the separate clinical-application synthesis of 20 studies, AI-CDSS were most frequently applied to diagnosis and immediate intervention (45%), followed by prediction and risk stratification (35%) and operational improvement (20%). Successful adoption was more consistently associated with EHR integration, workflow-sensitive design, and clinician engagement than with algorithmic performance alone. Persistent barriers included limited external validation, weak drift-monitoring plans, inconsistent usability testing, regulatory ambiguity, and insufficient equity mitigation. Conclusions: Sustainable implementation of AI-CDSSs in emergency medicine will require prospective multi-site evaluation, sociotechnical integration, adaptive governance, and greater attention to equity. Technical performance alone is insufficient to establish clinical readiness; successful implementation also depends on integration with clinical workflows, clinician engagement, ongoing monitoring, and appropriate governance.

Healthcare doi: 10.3390/healthcare14182921

Authors: Xiu Huang Xiya Ren Yajie Hao Limei Zhao Zhibo Zhao Rongrong Wang Xiaoshuang Zhou

Background: Sleep-related problems are common among patients receiving dialysis for end-stage renal disease (ESRD), while pharmacological management may be complicated by comorbidities, polypharmacy, and altered drug clearance. This systematic review and meta-analysis evaluated the effects of non-pharmacological interventions on sleep-related outcomes, anxiety symptoms, depressive symptoms, and fatigue symptoms in this population. Methods: PubMed, Embase, the Cochrane Library, and Web of Science were searched from inception to February 2026. The prespecified eligibility criterion was restricted to randomized controlled trials (RCTs) involving adults with ESRD receiving hemodialysis or peritoneal dialysis and reporting an eligible sleep-related outcome. One quasi-cluster randomized trial was retained as a documented protocol deviation. Standardized mean differences (SMDs) calculated using Hedges’ g and 95% confidence intervals (CIs) were pooled using random-effects models with restricted maximum-likelihood estimation and the Hartung–Knapp–Sidik–Jonkman adjustment (REML–HKSJ). Risk of bias was assessed using the revised Cochrane Risk of Bias tool for randomized trials (RoB 2), and evidence certainty was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. PROSPERO: CRD420251123449. Results: The 19 RCTs and one quasi-cluster randomized trial contributed an effective sample size of 1294 participants. The pooled estimate favored non-pharmacological interventions for sleep-related outcomes (Hedges’ g = −0.820, 95% CI −1.188 to −0.451; p = 0.0002), with substantial heterogeneity (I2 = 83.1%; τ2 = 0.4879). The 95% prediction interval (PI) ranged from −2.325 to 0.685. The pooled effects on anxiety symptoms (Hedges’ g = −0.29, 95% CI −0.99 to 0.41; p = 0.219), depressive symptoms (Hedges’ g = −0.64, 95% CI −2.32 to 1.04; p = 0.313), and fatigue symptoms (Hedges’ g = −0.41, 95% CI −0.93 to 0.11; p = 0.087) were not statistically significant. Effect estimates differed significantly by comparator type (Q-between = 11.28, df = 2; p = 0.0036). Conclusions: Non-pharmacological interventions may improve sleep-related outcomes in patients receiving dialysis for ESRD. However, substantial heterogeneity and a prediction interval crossing the null value limit confidence in the pooled estimate. Current evidence does not demonstrate clear benefits for anxiety symptoms, depressive symptoms, or fatigue symptoms.

Healthcare doi: 10.3390/healthcare14182920

Authors: Haonan Tian Aozhe Wang Lin Yan Longhao Xiao Jun Wang

Background/Objectives: Tactical populations must maintain high physical capacity and operational readiness despite substantial occupational demands and musculoskeletal injury risk. Blood flow restriction training (BFRT) has potential applications in injury rehabilitation and the restoration or maintenance of physical capacity. However, BFRT research in tactical populations has not been systematically mapped. This review aimed to characterize the existing evidence. Methods: This scoping review followed JBI methodology and PRISMA-ScR guidance. Seven databases and two clinical trial registries were searched. Two reviewers independently conducted study screening and data extraction. Evidence was summarized descriptively and graphically. Results: Thirty reports representing 21 studies were included, comprising 17 completed studies and 4 protocol- or registry-only studies. All completed studies involved military populations, and all planned studies targeted military populations. No eligible studies involving other tactical occupations were identified. Completed studies generally had small BFRT-exposed samples and short intervention durations, with male representation more common than female representation across studies. They mainly examined rehabilitation and fitness/performance. Individualized occlusion-pressure prescription and low-load resistance exercise were common. Strength/power was the most frequently assessed observed outcome, whereas occupational performance was rarely assessed. Safety and implementation reporting in completed studies remained incomplete. Conclusions: Completed BFRT studies in tactical populations have increased in recent years, but the evidence remains limited to military populations and exploratory in nature. Future studies should include non-military tactical occupations and more women, use larger samples and longer interventions, assess occupationally relevant outcomes, and improve the completeness and consistency of BFRT prescription, implementation, and safety reporting.

Healthcare doi: 10.3390/healthcare14182919

Authors: Tatjana Gavrancic Igor Dumic Jessica Laenger Brittany S. Jackson Khanyisile N. Tshabalala Michele D. Lewis Margaret R. Paulson Michael J. Maniaci Wendelyn Bosch

Background/Objectives: Hospital-at-home (HaH) programs have emerged as an alternative model to brick-and-mortar (BaM) hospital management of acute conditions such as heart failure, pneumonia, pyelonephritis, and chronic obstructive pulmonary disease exacerbation among the others. However, the clinical management of acute pancreatitis in the HaH setting has never been described in the literature. The primary objective of this study was to describe the demographic and clinical characteristics of patients with acute pancreatitis managed in a Mayo Clinic Advanced Care at home (ACH) program. The secondary objective was to describe feasibility and short-term clinical outcomes. Methods: This multistate, multicenter, retrospective descriptive study included 40 unique patients with acute pancreatitis managed at ACH between 13 October 2020 and 1 June 2024. Repeat admissions were excluded from the primary analysis. Results: The most common etiologies were idiopathic (42.5%), gallstone-related (22.5%), and alcohol-related (12.5%). Peripancreatic fluid collections occurred in 17.5%, necrotizing pancreatitis in 10.0%, pleural effusion in 12.5%, and infected pancreatitis in 7.5%. Intravenous antiemetics were administered to 22.5%, intravenous fluids to 62.5%, and intravenous opioids to 7.5%. Median total hospital length of stay was 5.0 days (IQR, 3.0–8.25), including a median of 3.0 days (IQR, 2.0–4.0) in ACH. Four patients (10.0%; exact 95% CI, 2.8–23.7%) were transferred from ACH to BaM care. Seven-day and 30-day readmission rates were 10% (95% CI: 2.8%, 23.7%) and 5% (95%CI: 0.6%, 16.9%), respectively. The 30-day emergency department visit was 0%. Although 30-day mortality was 2.5% (95% CI: 0.0%, 13.2%), in-program mortality was 0%. Conclusions: Among a highly selected group of clinically stable patients meeting the program’s eligibility criteria, management of acute pancreatitis in ACH was feasible and was associated with low observed rates of unplanned escalations and short-term adverse outcomes.

Healthcare doi: 10.3390/healthcare14182918

Authors: Ardak Ayazbekov Aigul Terlikbayeva Saken Khaidarov Gulzhan Baigazieva Zhaysan Imanbaeva Aliya Aimbetova Almagul Kurmanova Damilya Salimbayeva

Background/Objectives: Menstrual health in adolescence is influenced by nutritional, developmental, and psychosocial factors, yet integrated school-based evidence from Central Asia is limited. We assessed recorded anthropometric, menstrual/reproductive, and psychosocial indicators among adolescent girls in southern Kazakhstan and evaluated factors associated with a prespecified composite menstrual/reproductive outcome. Methods: We conducted a cross-sectional secondary analysis of a non-public school health screening database containing 5197 participant records from 2025. After removal of 946 exact duplicate copies, 4251 unique records of girls aged 12–18 years remained. We present prevalence estimates with Wilson 95% confidence intervals (CIs). We estimated adjusted prevalence ratios (aPRs) using modified Poisson regression with robust standard errors clustered by recorded school field. Results: Mean age was 15.03 ± 1.23 years and mean BMI was 20.36 ± 3.36 kg/m2. The source form used fixed adult BMI categories; these are reported descriptively and are not interpreted as pediatric nutritional diagnoses. At least one non-reference menstrual or reproductive indicator was recorded in 24.1% of participants; severe menstrual pain and stress were each recorded in 6.9%. Stress was associated with any menstrual/reproductive abnormality (aPR 2.05, 95% CI 1.65–2.54) and with severe menstrual pain (aPR 3.27, 95% CI 2.39–4.46). Unsatisfactory nutrition was also associated with the composite outcome (aPR 1.64, 95% CI 1.35–2.00). Conclusions: Recorded menstrual/reproductive concerns were frequent in this screened sample, and stress showed consistent associations with menstrual outcomes. Because anthropometric categories were based on adult cut points and several screening items were not validated instruments, interpret the findings as descriptive and hypothesis-generating rather than as population prevalence or causal estimates.

Healthcare doi: 10.3390/healthcare14182917

Authors: Nozomu Takada Seiko Tsuruta Shoko Sugiyama Kyoko Asakura

Background: Turnover among hospital nurses remains a major challenge for healthcare systems. Although various factors have been linked to turnover intention, few studies have examined them together. Therefore, we examined these factors within a single analytical model. Methods: In 2025, a cross-sectional survey was distributed through 70 hospitals randomly selected from the Tohoku and Kanto regions of Japan; individual nurses were selected at the discretion of each hospital, and data from 411 nurses were analysed. Turnover intention and affective organizational commitment were measured using previously validated scales, and intrinsic job satisfaction and satisfaction with financial rewards using scales developed for this study. The measurement model was examined using confirmatory factor analysis, which provided preliminary support for the two scales developed for this study. Multiple regression was performed, and relative weight analysis estimated each factor’s proportional contribution to the explained variance. Results: All three factors were significantly negatively associated with turnover intention. Relative weight analysis indicated that intrinsic job satisfaction accounted for the largest proportion of explained variance (44.49%), followed by affective organizational commitment (31.98%) and satisfaction with financial rewards (13.50%). Conclusions: Different job-related attitudes among nurses may contribute differently to turnover intention. The quality of work experiences and supportive organizational environments warrant evaluation as potential targets for future intervention research.

Healthcare doi: 10.3390/healthcare14182916

Authors: Abdulqadir J. Nashwan Jibin Kunjavara Rebecca George Mahmoud A. Khedr Yasmine M. Osman Anas H. Khalifeh Fadwa Al-halaiqa

Background: Digital innovations have transformed health professions education, with podcasting emerging as a flexible, learner-centered educational modality. Podcasts support asynchronous, mobile, and self-directed learning, enabling access to educational content beyond traditional classroom environments. However, evidence regarding their effectiveness, integration strategies, and impact on educational and practice outcomes remains fragmented. Aim/Objective: This review aimed to map the existing literature on the use of podcasting in nursing and midwifery education and continuing professional development (CPD), identify how podcasts are used, summarize reported benefits and limitations, and highlight gaps for future research. Design: Scoping review. Methods: A scoping review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Eligibility criteria were developed using the Population–Concept–Context (PCC) framework to define the review scope. A comprehensive literature search was performed across PubMed/MEDLINE, Scopus, Embase, CINAHL, Google Scholar, ProQuest, and OpenGrey to identify studies published in English between January 2005 and December 2024. Two reviewers independently screened titles, abstracts, and full-text articles against the predefined eligibility criteria. Data were extracted using a standardized charting form, and the included studies were synthesized using descriptive statistics and thematic analysis to map the characteristics and educational applications. They reported outcomes of podcasting in nursing and midwifery education. Results: Twenty-four studies were included. Podcasting was associated with enhanced learning flexibility, learner engagement, and knowledge retention in both academic and CPD contexts. It supported asynchronous and self-directed learning while reinforcing key concepts. Challenges included variable content quality, limited integration of assessment, and scarce evidence linking podcast use to clinical outcomes. Conclusions: Podcasting is a promising adjunct to nursing and midwifery education and CPD. Formal integration into curricula and professional development frameworks is recommended. Further research should focus on longitudinal outcomes, low- and middle-income settings, and impacts on clinical practice and interprofessional learning.

Healthcare doi: 10.3390/healthcare14182915

Authors: Gaku Watanabe Yukiyo Shimizu Kei Takehara Yuki Mataki Shigeki Kubota Yasushi Hada

Background/Objectives: The Synchronized Hand Interface for Neurorehabilitation and Innovation (SHINI) is a mechanical device that uses voluntary movement of the unaffected or less affected upper limb to generate synchronized bilateral hand and finger movements without biological signal detection or electronic control. This exploratory study evaluated SHINI’s technical operability and practical limitations during a single supervised session. Methods: Seven participants with hand dysfunction of varied etiologies attempted one 10 min session. Completion status was categorized as completed without therapist intervention, completed with therapist intervention, or not completed; no quantitative acceptability threshold was prespecified. Secondary outcomes were adverse events, overall perceived exertion and upper-limb fatigue assessed using the modified Borg Scale, exploratory pre- and post-session modified Ashworth Scale scores, and participant and therapist feedback. Results: Three participants (42.9%) completed the session without therapist intervention, three (42.9%) completed it with therapist intervention, and one (14.3%) did not complete it. Hand or forearm displacement affected four participants (57.1%), including the participant who discontinued. No adverse events occurred. Perceived exertion and upper-limb fatigue were generally low, no consistent direction of change in modified Ashworth Scale scores was observed, and feedback emphasized the need for improved fixation and adjustability. Conclusions: SHINI showed preliminary technical operability during a single supervised session, but the findings do not establish feasibility for independent or semi-supervised use. With improved fixation and adaptability, SHINI may offer a simple mechanical approach to repetitive bilateral hand training. Repeated-use studies are required to evaluate usability, safety, and clinical effectiveness.

Healthcare doi: 10.3390/healthcare14182914

Authors: Funda Işık Yaşar Nuri Şahin

Background/Objectives: Food exclusions in vegan and vegetarian diets may complicate the assessment of disordered eating and orthorexia. This study compared eating disorder risk, healthy orthorexia, and orthorexia nervosa across vegan, vegetarian, and omnivorous women and examined their adjusted associations with dietary pattern. Methods: This cross-sectional study used convenience sampling to recruit 305 women in Türkiye who self-identified as vegan (n = 64), vegetarian (n = 71), or omnivorous (n = 170). Participants completed the Eating Attitudes Test-26, Teruel Orthorexia Scale, and Food Choice Questionnaire. Associations with vegan and vegetarian patterns were examined using multinomial logistic regression, with omnivorous women as the reference group. Potential nonlinearity in the association between orthorexia nervosa and the vegan versus omnivorous contrast was examined using restricted cubic splines. Secondary exploratory food choice models were corrected for multiple testing. Results: Elevated eating disorder risk was not significantly associated with either the vegan or vegetarian pattern in the adjusted model. Higher healthy orthorexia scores were associated with greater odds of following a vegan pattern (adjusted odds ratio (aOR) = 1.177, 95% confidence interval (CI): 1.090–1.270), whereas the association between orthorexia nervosa and the vegan pattern was nonlinear (p for nonlinearity = 0.006), with the adjusted probability declining across low-to-moderate scores and the estimates becoming imprecise at higher scores. Neither orthorexia dimension was associated with the vegetarian pattern. In secondary exploratory analyses, weight control motivation was associated with lower odds of vegan (aOR = 0.424, 95% CI: 0.249–0.723) and vegetarian patterns (aOR = 0.610, 95% CI: 0.382–0.975), while familiarity was associated with lower odds of the vegan pattern (aOR = 0.466, 95% CI: 0.296–0.735). Conclusions: Healthy orthorexia and orthorexia nervosa showed distinct associations with the vegan pattern. Dietitians and healthcare professionals should not infer eating pathology from dietary pattern labels alone but should consider motivations for food exclusions, weight- and shape-related concerns, dietary rigidity, distress, and functional impairment.

Healthcare doi: 10.3390/healthcare14182913

Authors: Mishal M. Aldaihan Abdulrahman M. Alsubiheen Ali H. Alnahdi

Background/Objective: The measurement properties of the Arabic Fear-Avoidance Beliefs Questionnaire (FABQ) have not been examined using the Rasch measurement model. This study evaluated the Physical Activity (FABQ-PA) and Work (FABQ-W) subscales of the Arabic FABQ in individuals with low back pain (LBP). Methods: This cross-sectional study included 113 individuals with LBP who completed the Arabic FABQ. The FABQ-PA and FABQ-W were evaluated separately using RUMM2030. Likelihood-ratio tests supported use of the partial credit model for both subscales. Rasch analysis examined overall and individual item fit, person misfit, response-category threshold ordering, local item dependency, differential item functioning (DIF), person separation, unidimensionality, and targeting. DIF was investigated by sex, age, and LBP duration. Unidimensionality was evaluated by comparing person estimates derived from item subsets defined by principal component analysis of residuals. Targeting was examined using person–item threshold distributions. A previously proposed four-category rescoring structure was additionally explored because of disordered thresholds. Results: Following removal of participants with substantial person misfit, both FABQ-PA (n = 105) and FABQ-W (n = 106) demonstrated satisfactory overall Rasch model fit, and all individual items showed satisfactory fit. Both subscales supported unidimensionality, with no evidence of local item dependency or DIF by sex, age, or LBP duration. Targeting was generally adequate, although coverage was less optimal at the higher end of FABQ-PA and lower end of FABQ-W. Person separation was limited for FABQ-PA (PSI = 0.60) but good for FABQ-W (PSI = 0.80). All items demonstrated disordered thresholds using the original seven-category response scale. A previously proposed four-category rescoring structure improved, but did not completely resolve, threshold disordering. Conclusions: The Arabic FABQ-PA and FABQ-W demonstrated satisfactory final model and item fit and supported unidimensional measurement; however, important limitations were identified. Limited person separation for FABQ-PA and persistent threshold disordering across both subscales indicate that scores should be interpreted cautiously and that further refinement of the FABQ response format is warranted.

Healthcare doi: 10.3390/healthcare14182912

Authors: Myeong-Hwa Park Jae-Hyun Kim Jong-Hwa Jang

Background/Objectives: Evidence from repeated-measures studies examining denture use, subjective chewing difficulty, and depressive symptoms remains limited. This study examined the population-averaged associations of denture use and subjective chewing difficulty with depressive symptoms across nine waves of the Korean Longitudinal Study of Aging (KLoSA). Methods: Data from 10,137 participants contributing 68,937 person-wave observations across nine KLoSA waves (2006–2022) were analyzed. Depressive symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10). Generalized estimating equations (GEEs) were used to account for repeated observations within participants. Sex-stratified analyses and formal interaction tests were additionally performed. Results: In adjusted sex-stratified analyses, denture use was associated with a higher expected mean CESD-10 score among women [exp(B) = 1.068, 95% CI: 1.044–1.092] but not among men. Greater subjective chewing difficulty was consistently associated with higher expected mean CESD-10 scores among both men and women and among both denture users and non-denture users. The sex × denture use interaction was significant [exp(B) = 1.064, 95% CI: 1.043–1.085, p < 0.001], and sex × subjective chewing difficulty interactions were also significant among both denture users and non-denture users (all p ≤ 0.001). Conclusions: Greater subjective chewing difficulty was consistently associated with higher depressive symptom levels across repeated observations among both denture users and non-denture users. Sex modified the associations of denture use and subjective chewing difficulty with depressive symptoms. Perceived chewing function may provide additional information beyond denture status when assessing oral health-related vulnerability associated with depressive symptoms; however, temporal direction and causality cannot be inferred from these analyses.

Healthcare doi: 10.3390/healthcare14182911

Authors: Nouf H. Alkhamees Marilyn Gilyana Sameer Badri Al-Mhanna Alexios Batrakoulis

Adherence to home-based exercise programs is central to rehabilitation, yet adherence to prescribed rest intervals remains largely unexplored. This narrative review synthesized relevant literature identified through targeted, purposive searches of PubMed, Scopus, Web of Science, and Google Scholar for publications from 2000 to 20 July 2026, supplemented by reference-list screening. Direct evidence is extremely limited: no study identified prospectively quantified adherence to prescribed rest intervals in a home-based rehabilitation setting. Accordingly, most interpretation is extrapolated from broader literature on general exercise adherence, resistance training, telerehabilitation, and digital monitoring. Rest duration can influence neuromuscular recovery, fatigue, and performance, providing a physiological rationale for studying recovery timing, but these effects do not establish the clinical consequences of rest-interval non-adherence. We distinguish participant adherence from intervention fidelity and propose temporal fidelity as a hypothesis-generating framework describing concordance between the intended and implemented timing structure of exercise. Explicit prescriptions, patient education, simplified timing cues, supervised familiarization, and digital monitoring are presented as candidate strategies rather than established rest-specific interventions. Prospective studies should objectively measure prescribed and actual recovery periods and determine whether temporal fidelity predicts or improves rehabilitation outcomes.

Healthcare doi: 10.3390/healthcare14182910

Authors: Yousra Nomier Yaqeen Al-Aamri Rawan AL-Toqi Abdallah Al-Nofli Ibrahim Al-Sibayi Yahya Al-Farsi Ibrahim Al-Zakwani

Objectives: Epilepsy is a chronic neurological disorder associated with substantial morbidity, reduced quality of life, and a considerable global healthcare burden. We aimed to assess anti-seizure medication (ASMS) utilization patterns, adherence levels, and factors influencing seizure control and adverse effects among pediatric patients with epilepsy in Oman. Methods: A retrospective cross-sectional study was conducted at Sultan Qaboos University Hospital (SQUH) between January 2023 and November 2024. A total of 305 pediatric patients aged 2–12 years receiving at least one ASMS with a minimum of two years of follow-up were included. Data were extracted from electronic medical records. Adherence was assessed using the Medication Possession Ratio (MPR). Statistical analysis was performed using SPSS. Results: Levetiracetam (68.52%) was the most prescribed ASMS, followed by sodium valproate (22.62%) and topiramate (8.52%). Adherence was observed in 54.68% of patients. Mean seizure duration decreased progressively across follow-up visits. Seizure control was achieved in 43% of patients. Patients without adverse effects had significantly better seizure control (56.2% vs. 10.2%, p < 0.001). Dose increases were associated with higher rates of adverse effects. Conclusions: Levetiracetam was the most commonly prescribed ASMS. Seizure type influenced drug selection. Adverse effects had a strong negative impact on seizure control, while adherence showed a limited association, indicating that managing side effects is crucial for effective treatment. Optimizing ASMS dosing and minimizing adverse effects are essential to improving outcomes in pediatric epilepsy. Dose adjustments, particularly dose increases, were associated with a higher frequency of adverse effects. Careful dose optimization may therefore be important to balance tolerability and seizure management. In this study, just over half of the patients evaluated (54.68%) were classified as adherent based on Medication Possession Ratio.

Healthcare doi: 10.3390/healthcare14182909

Authors: Maria Smitmanis Lyle Alexander Rozental Trine Ellegaard Laursen Lena Flyckt Inger Elise Opheim Moljord Dag Øivind Antonsen Merete Nordentoft Sofie Westling Rose-Marie Lindkvist

Background/Objectives: Psychiatric inpatient care is characterised by power asymmetries between care providers and care receivers. Despite international guidelines and policies promoting autonomy, involvement, and empowerment, these ideals remain challenging to implement in clinical practice. Psychiatric self-admission has been developed to strengthen autonomy; however, its implementation may challenge established power structures, professional roles, and responsibilities within mental healthcare settings. This study aimed to explore stakeholder perspectives on power transfer during the implementation of psychiatric self-admission in Scandinavia. Methods: A qualitative multi-source study was conducted using semi-structured interviews, focus group interviews, and document collection. Interviews were conducted with 36 participants involved in the development and implementation of self-admission in Denmark, Norway, and Sweden. Additionally, approximately 250 documents were gathered. The documentary material was analysed alongside the interviews and focus groups to provide an understanding of the implementation of self-admission models and how power transfer was represented within these processes. The analyses were inspired by methods in qualitative content analysis and document analysis. Results: Findings on stakeholder perspectives on power transfer during implementation revealed a tension reflected in two subthemes: ‘Responsive and Responsible’, where self-admission was viewed as a necessary response to needs that the healthcare system was unable to address, and ‘Unsafe and Unsound’, where self-admission was associated with uncertainties and risks related to losing control. Conclusions: Implementing psychiatric self-admission, which involved challenging traditional power relations in healthcare, was permeated by trust, distrust, and fear. The findings highlight the need to address stakeholders’ concerns related to safety and professional responsibility.

Healthcare doi: 10.3390/healthcare14182908

Authors: Sumaya O. Basudan

Background: This study aimed to investigate the prevalence and levels of depressive, anxiety, and stress symptoms among dentists at an academic institution, and to identify demographic and work-related factors correlated with these psychological conditions. Methods: A cross-sectional study was conducted among full-time dentists teaching at King Saud University (Riyadh, Saudi Arabia). Data were collected using a self-administered questionnaire that captured demographic and work-related variables, alongside the validated 21-item Depression, Anxiety, and Stress Scale (DASS-21). Data were analyzed using descriptive statistics, Chi-square tests, and multiple linear regression to determine significant associations. Results: A total of 114 participants completed the questionnaire, of which 86.8% were faculty and the rest non-faculty. The prevalence of depressive, anxiety, and stress symptoms was 21.9%, 32.5%, and 34.2%, respectively, predominantly at moderate levels. The prevalence of at least one subscale was 44.7%, and a significant correlation was found for the co-occurrence of the three subscales (p < 0.001). Regression analysis indicated three correlates of stress: dissatisfaction, female sex, and choosing a career in academia were significantly associated with the stress scores (p < 0.05). No significant factors were correlated with the anxiety or depression subscales. While females and dissatisfied participants reported higher scores for stress, intending to work in academia as a primary career choice was significantly correlated with lower levels of stress, highlighting the potential importance of intrinsic motivation for academia. Conclusions: A considerable proportion of participants experience depression, anxiety, and stress symptoms, suggesting the need for targeted institutional strategies to support mental well-being, particularly among vulnerable groups.

Healthcare doi: 10.3390/healthcare14182907

Authors: Shirong Wu Man Ling Ng Yan Yi Fong Fiona Yan Yee Ho Jia Yin Ruan Na Zhang Ka Ying Heidi Lo Hai Yong Chen Dennis Chak Fai Ma Danny Jucheng Yu Wing Fai Yeung

Background: Insomnia requires long-term self-management, prompting many patients to turn to Traditional Chinese Medicine-based lifestyle (TCM-L) practices for health preservation. However, a consensus-based TCM-L content framework is lacking. This study aims to develop a consensus-based TCM-L content framework using a modified Delphi method. Methods: A modified Delphi study was conducted in two phases. In phase 1, a preliminary content framework was developed based on a systematic review, TCM textbooks, and clinical guidelines, consisting of 10 initial domains and 82 subordinate items. In phase 2, 18 local Chinese medicine practitioners were purposively recruited to evaluate the framework over four iterative rounds. Items were rated on a 5-point Likert scale, with consensus defined as a mean ≥ 4.0, a coefficient of variation < 0.25, and a consensus level of agreement ≥ 80%. Iterative modifications, deletions, and additions were informed by both these numerical thresholds and qualitative expert feedback. Kendall’s W was calculated to assess the coordination of consensus. Results: All 18 experts completed four rounds (100% response rate) with high authority (Cr = 0.864–0.883). The initial 10 domains and 82 subordinate items were refined to six domains and 49 subordinate items. Expert consensus was statistically significant across rounds (p < 0.01), with Kendall’s W demonstrating a high concordance of 0.717 for domain importance in the final round. The prioritized sequence of the six domains in the final TCM-L framework was: (1) Domain 1: introduction to TCM-L, (2) Domain 4: sleep–wake routines, (3) Domain 3: dietary regulation, (4) Domain 2: emotional regulation, and tied at (5) Domain 5: mind–body exercise and Domain 6: acupoint massage. Conclusions: This study established a consensus-based TCM-L content framework for insomnia, providing a culturally relevant foundational structure for future lifestyle interventions, clinical education, and self-management support.

Healthcare doi: 10.3390/healthcare14182905

Authors: Gloria Carvajal-Carrascal Alejandra Fuentes-Ramírez Ricardo Sotaquirá-Gutiérrez Mayerly Andrea Medina-Jutinico Alejandra Rojas-Rivera Beatriz Sánchez-Herrera

Background/Objective: The H-HT represents a critical vulnerability for patient–family caregiver dyads. This study developed and content-validated a middle-range nursing theory, the Adaptarte Model, designed to guide dyadic adaptation during the H-HT within the Latin American healthcare context. Methods: A sequential exploratory multimethod design was executed in two phases. Phase 1 integrated three evidence streams: clinical practice insights, a JBI-guided scoping review, and two focus groups with transitional care professionals. Qualitative content analysis and iterative consensus refined the model’s core concepts, assumptions, and propositions. Phase 2 evaluated the model’s content, structure, functionality, and projection using an international panel of eleven Latin American experts meeting strict eligibility criteria. Data were analyzed using Lawshe’s Content Validity Ratio (CVR) modified by Tristán (cutoff = 0.58) and the overall Content Validity Index (CVI). Reporting followed PRISMA-ScR and GRAMMS guidelines. Results: Expert consensus confirmed the essential model components. Item-level CVR values ranged from 0.90 to 0.99, yielding an overall CVI of 0.96, while external functionality and conceptual projection achieved an average rating of 0.88. Conclusions: The Adaptarte Model demonstrates high content validity and structural clarity, establishing a rigorous theoretical foundation for subsequent empirical research. Rather than being ready for immediate clinical implementation, it provides a structured blueprint for prospective protocol development. Systematic empirical testing and longitudinal studies are now imperative to evaluate its clinical utility and drive future healthcare transformations. The scoping review protocol was prospectively registered on the Open Science Framework (OSF) URL (accessed on 23 September 2024).

Healthcare doi: 10.3390/healthcare14182906

Authors: Magda-Ecaterina Antohe Monica Silvia Tatarciuc Cristina Gena Dascalu Cristina Iordache Irina Gradinaru Arina Alice Ciocan Pendefunda Cezar Ilie Foia Roxana Ionela Vasluianu

The quality of dental care is determined not only by the dentist’s technical competence but also by their ability to communicate effectively, listen actively, and establish a relationship of trust with the patient. Patients’ perceptions of dentists’ soft skills represent an essential component of patient-centered care; however, evidence from Romania remains limited. Aim: To evaluate patients’ perceptions of the importance of dentists’ non-technical (soft) skills in private dental practices and to analyze the influence of socio-demographic characteristics on these perceptions. Materials and Methods: The study included 297 patients attending private dental practices in Iași, Romania, who anonymously completed a questionnaire consisting of 20 items rated on a five-point Likert scale. Statistical analysis was performed using SPSS Statistics version 31.0. The Chi-square test and Fisher’s exact test were applied where appropriate. Results: Communication and interpersonal skills were considered the most important competencies by patients (91.3%), followed by cognitive skills (84.2%) and personal characteristics (80.2%), whereas artistic skills received the lowest level of appreciation (49.9%). Communication and interpersonal skills were the most highly valued domain (91.3%), followed by cognitive skills (84.2%) and personal characteristics (80.2%), whereas artistic skills received the lowest ratings (49.9%). Younger patients, urban residents, individuals with higher educational attainment, and those attending regular dental check-ups tended to assign greater importance to several of the non-technical competency domains assessed. The most pronounced age-related difference concerned digital technologies, with acceptance of telemedicine and digital communication decreasing markedly with increasing age. Conclusions: Communication and interpersonal skills were the non-technical competencies most highly valued by patients. The observed differences according to socio-demographic characteristics support the need for an individualized communication approach in dental practice.

Healthcare doi: 10.3390/healthcare14182904

Authors: Zikang Yang Chuchuan Wan Xiaoyu Xi Yuankai Huang

Objectives: Exchange characteristics describe and evaluate the state of collaboration and the collaborative counterpart from the perspectives of both parties. They reflect the interaction tendencies between collaborators and are important factors influencing the effectiveness of interprofessional teamwork. This study aimed to assess the current exchange characteristics between clinical pharmacists and physicians and identify between-group differences. It also explored approaches to enhancing professional respect, trust, and clarity of Role Recognition among physicians and clinical pharmacists. Method: Separate questionnaire versions were developed for clinical pharmacists and physicians, and a nationwide cross-sectional survey was conducted among both groups. First, descriptive statistics were used to characterize the current status of exchange characteristics in interprofessional collaboration. Second, paired-samples t-tests were conducted to compare clinical pharmacists and physicians across 774 matched pairs. Finally, subgroup analyses were performed using data from 448 clinical pharmacist questionnaires and 446 physician questionnaires. Kruskal–Wallis tests, Mann–Whitney U tests, and chi-square tests were used to examine differences in exchange characteristics across healthcare professionals with different characteristics. Results: A total of 448 clinical pharmacist and 446 physician questionnaires were analyzed. Compared with clinical pharmacists, physicians reported greater professional respect (p < 0.001), clearer role recognition (p < 0.001), better team communication ability (p < 0.001), and a stronger sense of fairness (p < 0.001) in interprofessional collaboration. In subgroup analyses, clinical pharmacists who graduated from universities and those with higher educational attainment reported greater professional respect. Younger clinical pharmacists reported lower levels of fairness and trust, while physicians in central regions and those in non-permanent employment experienced more severe job burnout. Conclusions: Exchange characteristics differed significantly across healthcare professionals by training pathway, region, hospital grade, employment status, gender, age, and education. To strengthen interprofessional collaboration, efforts should focus on optimizing training models, enhancing early-career professional education, improving remuneration systems, and clarifying role boundaries.

Healthcare doi: 10.3390/healthcare14182903

Authors: Yunji Lee Eunjoo Lee Myo-Sung Kim

Background: Hypertension requires lifelong antihypertensive medication to reduce cardiovascular risk. While most studies have focused on individual determinants of adherence, the role of perceived environmental and social characteristics remains unclear. This study examined the associations of depressive symptoms, satisfaction with the community environment, social participation, and social contact with antihypertensive medication non-adherence among older adults with hypertension in South Korea. Methods: A cross-sectional secondary analysis was conducted using the 2023 Korea Community Health Survey, including 44,822 adults aged 65 years and older with physician-diagnosed hypertension who were currently taking antihypertensive medication. Medication non-adherence was defined as taking medication on fewer than 24 of the previous 30 days, and associated factors were identified using complex sample multivariable logistic regression. Results: The prevalence of medication non-adherence was 0.4%. Higher satisfaction with the community environment was associated with lower odds of medication non-adherence (OR = 0.83, 95% CI = 0.72–0.95), whereas greater social participation was associated with higher odds (OR = 1.39, 95% CI = 1.09–1.78). Social contact, depressive symptoms, and the remaining characteristics were not significantly associated with medication non-adherence. Conclusions: Antihypertensive medication non-adherence among older adults is associated with perceived environmental characteristics as well as individual factors. Whether community-based approaches addressing these conditions can improve medication adherence requires evaluation in longitudinal or interventional studies.

Healthcare doi: 10.3390/healthcare14182902

Authors: Xia Li Heng Yin Zhiqiang Li Yiying Wang Yi Yuan Ran Chen Jun Fang Jianping Liu

Objectives: Multimorbidity is a growing global health challenge, yet the role of mind–body therapies in addressing its complex health burdens remains insufficiently characterised. This study aimed to map the research landscape and clinical evidence structure of mind–body therapies for multimorbidity. Methods: Bibliometric analysis integrated with evidence mapping was conducted using English-language publications indexed in the Web of Science Core Collection, PubMed, and Embase from January 2004 to July 2026. CiteSpace and R were used to construct knowledge networks, visualise temporal, geographical, collaborative, and thematic patterns, and generate evidence maps. Clinical studies were coded according to intervention type, comparator, comorbidity pattern, outcome domain, and reported outcome direction. Results: Of 6441 records identified, 119 publications were retained for bibliometric analysis and 77 clinical studies for evidence mapping. Publication activity increased after 2017 but remained geographically concentrated, with limited international collaboration. Keyword, clustering, timeline, and co-citation analyses showed sustained research attention to chronic pain, post-traumatic stress disorder, substance use disorders, anxiety disorders, mindfulness-based approaches, and biofeedback or neurofeedback. The evidence map covered 53 condition combinations, most of which were represented by only one clinical study. Mindfulness-based interventions were the most frequently studied approach (31.2%), followed by multicomponent mind–body interventions. Randomised controlled designs represented only a minority of the clinical evidence, and many studies had no comparator. Psychological outcomes and clinical symptoms were commonly assessed, although outcome categories were not mutually exclusive and findings varied across studies. Conclusions: Research on mind–body therapies for multimorbidity is expanding, but the evidence remains heterogeneous across condition combinations, interventions, comparators, and outcomes. Publication frequency and bibliometric prominence do not establish comparative effectiveness. Future studies should include broader condition combinations, use robust comparative designs, and report standardised outcomes and safety data.

Healthcare doi: 10.3390/healthcare14182901

Authors: Hanifi Demir

Background/Objectives: Medical secretaries, who serve as patients’ first point of contact and are frequently exposed to stress arising from illness, waiting, and the hospital environment, remain under-examined in health-workforce research. Previous studies have positioned emotional intelligence in different roles within job-attitude and performance models, including as an antecedent of job satisfaction. Because cross-sectional self-report data cannot establish temporal ordering or causal mediation, the present study examined whether emotional intelligence statistically accounts for part of the cross-sectional association between medical secretaries’ job satisfaction and self-reported job performance. Methods: A cross-sectional study was conducted with medical secretaries from two public hospitals in Bitlis Province, Türkiye (April–May 2025). Of 176 eligible employees invited, 134 complete questionnaires were analyzed (response rate: 76.1%). Emotional intelligence was assessed with the Wong and Law Emotional Intelligence Scale, job satisfaction with the five-item short form of the Brayfield–Rothe scale, and self-reported job performance with a four-item scale. Group comparisons, Pearson correlations, linear regression, a 10,000-resample bootstrap indirect-association analysis, a reverse-model sensitivity analysis, and a Harman single-factor diagnostic were performed. Results: Job satisfaction was positively associated with self-reported job performance (r = 0.275; p = 0.001) and emotional intelligence (r = 0.341; p < 0.001), while emotional intelligence showed a stronger association with performance (r = 0.539; p < 0.001). The conditional direct association of job satisfaction with performance was not statistically significant after emotional intelligence entered the model (β = 0.103; p = 0.187); the cross-sectional indirect association through emotional intelligence was 0.114 (95% bootstrap CI: 0.042–0.204). Explained variance increased from 7.6% to 30.0%, leaving 70.0% unexplained. In the reverse specification (emotional intelligence → job satisfaction → performance), the indirect association was not statistically supported (ab = 0.009; 95% bootstrap CI: −0.005 to 0.025). Harman’s first unrotated component accounted for 38.7% of item variance. Conclusions: Emotional intelligence accounted statistically for a meaningful but incomplete portion of the job satisfaction–performance association in this sample. The results are compatible with the proposed indirect pathway but do not establish temporal order or causality. Replication using longitudinal designs, multiple data sources, objective performance indicators, and additional occupational factors such as emotional labor, burnout, workload, and organizational support is warranted.

Healthcare doi: 10.3390/healthcare14182900

Authors: Mabel Giraldo Fabio Sacchi

Background/Objectives: The increasing integration of artificial intelligence (AI) into assistive technologies challenges evaluation models traditionally centred on usability, satisfaction and device-related outcomes. Because AI-enabled systems are probabilistic, data-dependent and adaptive, their evaluation must also address algorithmic behaviour, user agency and consequences in everyday life. This critical review aimed to identify and compare standardised instruments, frameworks and structured procedures for evaluating AI-enabled assistive technologies and to determine the extent to which they connect AI-specific properties with the goals of persons with disabilities, activities, participation and environmental conditions. Methods: MEDLINE/PubMed, Scopus and IEEE Xplore were searched without publication-date restrictions, with final searches completed on 30 June 2026 and complemented by backward and forward citation searching. Data were extracted on approach type, purpose, stage of application, target populations and technologies, methodological evidence, evaluated dimensions and outcomes. Evidence was classified as documented, partially documented, not documented or not applicable, while dimensional coverage was coded as explicit, partial or absent. Results: Of the 2299 records screened by title and abstract, 478 publications underwent full-text assessment and 45 were retained in the documentary corpus. These publications supported 16 evaluation approaches: four frameworks, three structured procedures and nine measurement instruments published between 2001 and 2026. The person-related dimension was explicitly operationalised in 15 approaches and activity in nine, whereas participation was explicit in only one and environmental factors in six. AI-specific properties were explicitly evaluated in three approaches, and everyday-life outcomes over time in two. Among the approaches included in this review, none combined comprehensive coverage of person, activity, participation and environment with AI-specific evaluation and longitudinal monitoring. Conclusions: Evaluation remains fragmented across assistive technology, human–computer interaction, human–robot interaction and AI assessment traditions. The review proposes assistive validity as a higher-order criterion linking technical performance, agency and meaningful outcomes for persons with disabilities. It also identifies a modular and longitudinal evaluation architecture as a priority for future empirical development and validation.

Healthcare doi: 10.3390/healthcare14182899

Authors: Nafih Cherappurath Halil İbrahim Ceylan E. Anakha Saranya T. Satheesan Deniz Öztürk Muhammed Ali Thoompenthodi Masilamani Elayaraja Rinsa Raj Raul Ioan Muntean P. C Firdousiya

Background/Objectives: Mindfulness-based interventions (MBIs) have gained increasing attention in sport psychology due to their potential to enhance psychological well-being and performance-related outcomes among athletes. Despite various systematic reviews and meta-analyses examining mindfulness in athletic contexts, broader scoping evidence mapping randomised controlled trials (RCTs) of MBIs targeting psychological well-being among athletes remains limited. This scoping review aims to map and synthesise empirical evidence from RCTs examining MBIs and psychological outcomes among athletes, identify methodological and conceptual gaps, and guide future systematic reviews and meta-analytic investigations. Methods: The review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews and was reported according to the PRISMA-ScR guidelines. Searches were conducted across Scopus, Web of Science, and PubMed, initially in March 2026 and updated in April 2026. Data were extracted on study characteristics, participant demographics, intervention features, comparator conditions, outcome measures, and key findings. Results: A total of 17 studies met the inclusion criteria and were included in the review. The included studies generally reported beneficial effects of MBIs across psychological well-being, emotion regulation, cognitive functioning, and sport-related psychological outcomes among athletes. Beneficial effects were reported for several outcomes, including mindfulness, mental toughness, emotional intelligence, mental well-being, flow state, self-compassion, psychological flexibility, emotional regulation, attention, life satisfaction, and grit. Reductions in psychological distress, particularly anxiety and stress, were also reported in several studies, although findings for anxiety were not consistent across trials. Findings were mixed for some other outcomes, including self-esteem, acceptance, and depression. Improvements were additionally reported in social relationships, pleasure regulation, and overall psychological functioning. Conclusions: The findings suggest that MBIs may offer beneficial effects across multiple dimensions of psychological functioning among athletes, although effects were not uniform across outcomes or interventions. These findings indicate the potential utility of structured MBI programmes within athlete support settings, particularly when delivered by or in collaboration with sport psychologists and mental performance consultants, while highlighting the need for further well-designed RCTs to clarify intervention-specific effects and longer-term outcomes.

Healthcare doi: 10.3390/healthcare14182898

Authors: Walid Al-Qerem Ruba Zumot Anan Jarab Judith Eberhardt Alaa Hammad Fawaz Alasmari Nouf Alsultan

Background: Growth standards and growth references serve different purposes. The WHO Child Growth Standards for ages 0–5 years describe growth under specified optimal conditions, whereas the WHO 5–19-year curves are a reference reconstructed from historical NCHS data. This study aimed to develop sex-specific growth reference curves for Jordanian children and adolescents and compare selected centiles descriptively with WHO growth standards and references. Methods: Retrospective anthropometric records collected between 2019 and 2025 through the Ministry of Health’s Hakeem National E-Health Program were used. Following medical eligibility screening, 63,187 measurement records were selected before analytical cleaning using proportionate stratified random sampling by sex and governorate, with age balancing across four broad age groups. Analytical cleaning excluded 506 boys’ and 1084 girls’ records, producing a final height-for-age and BMI-for-age sample of 61,597 measurement occasions from 33,170 Jordanian children and adolescents (27,933 occasions from 14,594 boys and 33,664 occasions from 18,576 girls). Weight-for-age used 16,071 occasions from 9537 boys and 16,185 occasions from 10,214 girls aged 2–10 years. LMS/BCPE-based centile modeling was conducted within GAMLSS, and the 3rd, 15th, 50th, 85th, and 97th centiles were compared with WHO values. Results: Separate sex-specific models were developed, and the Jordanian curves differed descriptively from WHO curves at several ages and centiles. Conclusions: The population-proportionately stratified Jordanian curves provide direct local context for describing attained anthropometric distributions. Future studies should compare both the Jordanian and WHO curves against Jordan-specific outcomes and classification decisions to determine their respective clinical roles.

Healthcare doi: 10.3390/healthcare14182897

Authors: Hyun Namgung Moon-June Oh

Background/Objectives: Digital inequalities are increasingly recognized as a health-equity issue, yet self-reported practical digital competence and psychosocial well-being among adults with severe disabilities remain understudied. This study examined their cross-sectional association and indirect associations through perceived self-determination in daily life and subjective social isolation in a parallel model. Methods: Cross-sectional data from 1519 adults in a 2023 Seoul survey were analyzed. Self-reported practical digital competence was assessed with six task-ability items, perceived self-determination in daily life with one item, and subjective social isolation with two items. Adjusted product-of-coefficients models used 2000 bootstrap replications to calculate bias-corrected confidence intervals. Results: Self-reported practical digital competence was positively associated with psychosocial well-being (b = 0.085, p < 0.001). The indirect association through perceived self-determination in daily life was significant in the main analysis (estimate = 0.076, BC 95% CI [0.050, 0.106]) and remained significant across all sensitivity analyses. Self-reported practical digital competence was not significantly associated with subjective social isolation (b = −0.026, p = 0.203), and the corresponding indirect association was nonsignificant (estimate = 0.006, BC 95% CI [−0.003, 0.016]) and inconsistent across specifications. The direct association was near zero and nonsignificant after both psychosocial variables were included. Conclusions: The indirect association through perceived self-determination in daily life was consistent across analyses, but this single-item measure should be interpreted as a narrow indicator of perceived autonomy or control rather than the broader multidimensional construct of self-determination. Evidence for subjective social isolation was limited and specification-sensitive, and simultaneous measurement precludes temporal or causal interpretation. Digital inclusion efforts may benefit from combining practical digital skills with opportunities to support meaningful goals and everyday choices. Broader relational and environmental supports may also be needed for subjective social disconnection, and longitudinal and intervention research is warranted.

Healthcare doi: 10.3390/healthcare14182896

Authors: Özlem Karagöz Uğur Karagöz Büşra Tozduman Melih Kaan Sözmen

Background/Objectives: This study aims to determine the indirect costs associated with the disease process in patients hospitalized for acute coronary syndrome and to analyze the sociodemographic and clinical factors influencing these costs. Methods: This prospective, single-center, observational cost-of-illness study evaluated 146 ACS patients at a tertiary cardiology clinic over an index episode extending from admission to 30 days after discharge, from a patient and household perspective that excludes direct medical costs. Excluding six patients (one death, five early retirements), 140 patients were analyzed. Productivity losses were measured with the iMTA Productivity Cost Questionnaire and valued using the Human Capital Approach; SCORE2, GRACE and MIDAS scores were also recorded. Costs are reported in 2025 international dollars (Int$, OECD PPP factor 16.20). Factors associated with total indirect cost were examined with a Gamma generalized linear model with a log link, containing five prespecified covariates: sex, occupational group, age, GRACE and MIDAS. Results: The mean age was 61 ± 12 years, and 69.9% of the cohort were male. The median total indirect cost per patient was 1007 Int$. In the actively employed subgroup, the median absenteeism cost was 1450 Int$, while the median household production loss for the entire cohort was 340 Int$. The multivariate Gamma GLM identified occupational status (p < 0.001) and female sex (p = 0.004) as variables independently associated with total indirect costs, whereas age and clinical/prognostic scores (GRACE, MIDAS) lacked statistical significance. Compared to patients outside the labor force, total costs were 4.8 and 4.1 times higher for white-collar and blue-collar workers, respectively. Conclusions: ACS imposes a significant short-term indirect cost burden at the patient and household levels, driven by absenteeism among actively employed patients and by household production losses among those outside the labor force. These findings indicate that the early post-discharge economic burden is patterned primarily by labor force position and by the distribution of unpaid domestic work rather than by clinical severity.

Healthcare doi: 10.3390/healthcare14182895

Authors: Warantron Potarin Thidarat Somdee Kemika Sombateyotha Chitkamon Srichompoo Benchaphon Aengwanich Santisith Khiewkhern

Background: Pressure injuries are a major patient safety concern, particularly among hospitalized patients at high risk. Identifying factors associated with pressure injuries is essential for effective prevention. Therefore, this study aimed to identify factors associated with pressure injuries among high-risk hospitalized patients. Methods: A case–control study was conducted among 80 inpatients, including 40 with hospital-acquired pressure injuries (HAPIs) and 40 without HAPIs, admitted to the Department of Medicine, Mahasarakham Hospital, between April 2023 and December 2025. Data were obtained from medical records and structured data collection forms. Descriptive statistics and bivariable analyses using chi-square or Fisher’s exact tests were performed. Variables with p < 0.25 were considered for multivariable logistic regression. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported. Results: Patients with HAPIs had higher proportions of edema, incontinence, hypoalbuminemia, and nil per os (NPO) status. Bivariable analysis identified associations with Braden score ≤17, impaired level of consciousness, mechanical ventilation, inotropic/vasopressor use, physical restraint, edema, incontinence, low serum albumin, and NPO status (p < 0.05). In the final multivariable model, endocrine and metabolic diseases (AOR = 25.92; 95% CI: 1.06–633.10; p = 0.046), mechanical ventilator use (AOR = 104.79; 95% CI: 11.78–932.05; p < 0.001), inotropic/vasopressor use (AOR = 17.26; 95% CI: 1.15–258.41; p = 0.039), and diarrhea (AOR = 24.34; 95% CI: 1.88–315.36; p = 0.015) were statistically associated with HAPIs. Cardiovascular diseases showed a borderline association (AOR = 18.78; 95% CI: 1.00–354.36; p = 0.050), while physical restraint was not statistically significant (AOR = 5.40; 95% CI: 0.80–36.66; p = 0.084). Conclusions: Several clinical factors were associated with HAPIs. However, large AORs and wide CIs indicate substantial uncertainty in the magnitude of these associations. Findings should be interpreted cautiously and confirmed in larger prospective studies. Prevention should emphasize early risk identification, management of critically ill patients, and appropriate moisture and pressure injury prevention.

Healthcare doi: 10.3390/healthcare14182894

Authors: Simona Steliana Tudor Ancuta Elena Tupu Alice Elena Munteanu Claudia Simona Stefan Ionela Daniela Ferțu

Cardiovascular diseases remain the leading cause of global mortality, yet conventional diagnostics are episodic and clinic-centered, missing the dynamic physiological events that unfold between encounters. Wearable devices offer continuous, real-world monitoring and, together with artificial intelligence, digital biomarkers, and telecardiology, increasingly support a shift toward predictive, preventive, personalized, and participatory (P4) cardiovascular care. This narrative review synthesizes the contemporary evidence base for wearable cardiovascular technology and organizes it around the four pillars of P4 medicine, with the explicit aim of distinguishing what is clinically proven from what remains aspirational. The wearable ecosystem now spans consumer smartwatches, medical-grade ECG patches, smart textiles, and emerging soft bioelectronics, generating an expanding repertoire of digital biomarkers. Evidence is strongest where validation is most mature: atrial fibrillation screening, supported by large-scale studies, and structured heart-failure telemonitoring, associated with reductions in heart-failure hospitalization of 18–32% in structured programs. For acute coronary syndrome triage, cuffless blood pressure, cardiac rehabilitation, and AI-derived prognostic markers, the supporting evidence is growing but rests largely on analytical and early clinical validation rather than on demonstrated improvements in hard cardiovascular outcomes. Across all four pillars, translation is constrained by accuracy variability across demographic subgroups, regulatory fragmentation, data privacy concerns, interoperability deficits, and inequitable access for elderly, low-income, and low- and middle-income populations. Realizing the P4 promise will require harmonized validation standards, demographic-stratified accuracy reporting, equitable access strategies, and a clinical infrastructure capable of converting continuous wearable data into actionable decisions.