Healthcare doi: 10.3390/healthcare14121715

Authors: Miguel A. Arce-Huamani Williams Carrascal-Astola Brissa C. Haro-Vásquez Brishel Navarro-Ochoa Karin M. Chuquihuara-Guerrero Amir M. Pineda-Chuquiyauri Lesly C. Paucar-Sanchez Maritza M. Ortiz-Arica

Background/Objectives: Dengue prevention in rural Amazonian communities is shaped by knowledge, household feasibility, sociocultural dynamics, institutional continuity, and trusted communication. This study explored behavioral, sociocultural, and institutional barriers to dengue prevention and control in rural communities of the Peruvian Amazon. Methods: An exploratory qualitative study with an ethnographic orientation, informed by the Communication for Behavioural Impact (COMBI) framework, was conducted in three anonymized rural settlements in San Martín, Peru. The qualitative corpus included 120 adults, 84 in-depth interviews, six focus group discussions with 36 participants, 22 household and community observation records, 13 institutional communication materials, and seven local operational documents. Data were analyzed using an inductive thematic approach and triangulated across participant profiles, settlements, and sources. Results: Dengue was widely recognized as a mosquito-borne disease, but the central finding was a gap between general awareness and practical, routine application. Participants’ understanding of breeding sites, warning signs, and feasible source reduction was uneven. Prevention was mainly reactive, increasing after nearby cases, alerts, or fumigation, but weakening when risk was not visible. Irregular water supply, water storage, waste accumulation, gendered domestic labor, competing household priorities, reluctance to confront neighbors, and intermittent institutional action limited sustained prevention. Fumigation was perceived as the most visible institutional response, while communication was more credible when mediated by trusted local actors. Conclusions: Dengue prevention requires locally feasible household practices, safe water-storage guidance, trusted communicators, neighborhood coordination, continuous pre-outbreak engagement, and intersectoral support.

Healthcare doi: 10.3390/healthcare14121714

Authors: Veronica Madalina Boruga Melania Lavinia Bratu George Puenea Daniel Popa Cristina Annemari Popa Iulia Georgiana Bogdan Cristina Elena Savencu

Background and Objectives: Artificial intelligence (AI) is increasingly integrated into healthcare management and pharmaceutical marketing workflows, yet determinants of AI adoption intention among non-clinical professionals remain under-studied in Central and Eastern Europe. This cross-sectional study quantified AI adoption intention (AAI) across three professional groups and examined its organizational, cognitive, attitudinal, and regulatory correlates. Methods: We surveyed 127 Romanian professionals (43 hospital administrators, 42 pharmaceutical marketing professionals, 42 community pharmacy managers) using a 46-item structured instrument. The instrument combined items adapted from UTAUT/TAM and organizational-readiness measures with study-specific AI-marketing, AI-literacy, and regulatory-literacy items; Analyses included ANOVA with Tukey HSD, Spearman correlations, age-adjusted OLS regression with HC3 robust standard errors, bootstrap indirect-effect analysis, moderation, exploratory k-means clustering, and exploratory logistic/ROC analysis. Results: AAI differed across groups: pharmaceutical marketing 4.33 ± 0.50, hospital administrators 3.39 ± 0.47, and pharmacy managers 2.88 ± 0.54; all pairwise Tukey contrasts p < 0.001. In the multivariable model (R2 = 0.833)—interpreted cautiously because conceptually related adoption constructs may overlap despite acceptable collinearity diagnostics—perceived usefulness, organizational readiness, and perceived ease of use were the strongest associated factors, while data governance concern was the main negative correlate. Perceived usefulness statistically accounted for 61.7% of the AI literacy–AAI indirect association, and regulatory literacy moderated the AI literacy–AAI association. An exploratory age-adjusted logistic model showed high within-sample discrimination for top-tertile AAI but should be interpreted as convergent validity among survey constructs rather than as a validated screening tool. Conclusions: AI adoption intention in Romanian medical management and pharmaceutical marketing is associated mainly with perceived usefulness and organizational readiness, tempered by data governance concern and regulatory knowledge. Longitudinal, multi-site, real-world implementation studies with external validation are needed.

Healthcare doi: 10.3390/healthcare14121713

Authors: Minghe Xu Hairong Zhou Erya Wen Jian Yang Chuanan Wu Weiqing Chen

Background/Objectives: General practitioners (GPs) face critical workforce shortages and high turnover globally. While external factors are known to influence turnover intention (TI), the role of individual psychological traits is less well understood. This study examines the association between Type D personality (TDP) and TI among GPs and the co-occurring statistical associations of perceived occupational stress (POS) and job satisfaction (JS). Methods: A cross-sectional survey was conducted from September to October 2024 among 383 GPs in Longhua District, Shenzhen, China. Participants completed a structured questionnaire assessing socio-demographic characteristics, TDP, POS, JS, and TI. After controlling potential confounders, correlation and regression analyses were performed to assess associations between TDP, POS, JS, and TI. Structural equation modeling (SEM) was conducted to examine the specific indirect associative components within the covariance between TDP and TI. Results: After adjusting for confounding factors, TDP was significantly positively associated with TI (B = 0.71) and POS (B = 0.30), and significantly negatively associated with JS (B = −0.24). In the hypothesized structural model, the proportions of total standardized covariance attributable to the indirect associative paths involving POS alone, JS alone, and the serial combination of POS and JS were 17.28%, 9.90%, and 3.50%, respectively, summing to 30.68% of the model-implied association. Conclusions: GPs with TDP reported a higher level of turnover intention, and this association was statistically accompanied by elevated occupational stress and diminished job satisfaction. Healthcare managers may consider implementing targeted interventions aimed at reducing stress and enhancing satisfaction, particularly among GPs with TDP, although the effectiveness of such strategies requires confirmation in future longitudinal or intervention studies.

Healthcare doi: 10.3390/healthcare14121712

Authors: Xiyun Ren Shuaishuai Zhou Yao Li

Objective: The aim of this study was to evaluate associations between flavonoid intake at dinner versus breakfast and the odds of non-alcoholic fatty liver disease (NAFLD) using data from the National Health and Nutrition Examination Survey (NHANES). Methods: According to total flavonoids, flavonoids intake at breakfast and dinner, or flavonoids intake differences at dinner and breakfast (Δ = dinner-breakfast), we divided 3240 participants from the NHANES (2007–2010) into five groups. Logistic regression analyses were performed to examine associations between total flavonoids, flavonoid intake at breakfast and dinner or Δ flavonoids and NAFLD after the adjustment of several confounding factors. Dietary substitution models were used to estimate the association between replacing 5% of flavonoid intake at dinner with that at breakfast and the odds of NAFLD. Results: For total flavonoids intake and flavonoids intake at breakfast, when compared to the lowest quintile (Q1), participants in the highest quintile of total flavonoids intake had lower odds of NAFLD, with an adjusted odds ratio (OR) for NAFLD of 0.78 (95% confidence interval (CI): 0.61–0.98) and a p-trend of 0.076. Participants in the highest quintile of flavonoid intake at breakfast had an adjusted OR for NAFLD of 0.87 (95% CI: 0.69–1.09) and a p-trend of 0.035, also showing a trend toward lower odds of NAFLD. Conversely, for Δ flavonoids, participants in the highest quintile had higher odds of NAFLD, with an adjusted OR for NAFLD of 1.27 (95% CI: 1.01–1.60) and a p-trend of 0.093. When total flavonoid intake in participants remained constant, replacing 5% of dietary flavonoid intake at dinner with that at breakfast was associated with 7% lower odds of NAFLD. Conclusions: Higher flavonoid intake at breakfast than at dinner may be associated with lower odds of NAFLD. Future research should focus on the potential role of breakfast-timed flavonoid intake in preventing the onset of NAFLD.

Healthcare doi: 10.3390/healthcare14121711

Authors: Fatima Al-Ghadban Ahmad Salman Ahmad Abbas

Background/Objectives: Despite the availability of free national mammography services, participation in breast cancer screening remains suboptimal in Kuwait. This study aimed to assess breast cancer screening beliefs and barriers among women in Kuwait using the Breast Cancer Screening Beliefs Questionnaire (BCSBQ) and to examine their associations with sociodemographic characteristics. Methods: This study is a secondary analysis of a cross-sectional dataset collected among 458 women aged ≥20 years across all six governorates of Kuwait. Data were collected using a structured questionnaire including the BCSBQ, breast cancer knowledge measures, and a general help-seeking barrier scale. Internal consistency was assessed using Cronbach’s alpha, and exploratory factor analysis was performed to evaluate construct validity. Group differences were examined using t-tests and one-way analysis of variance with post hoc correction, while adjusted associations were assessed using general linear models and linear regression. Results: The BCSBQ demonstrated good internal consistency (Cronbach’s α = 0.808) and a clear three-factor structure (Kaiser–Meyer–Olkin = 0.790; Bartlett’s test p < 0.001), explaining 50.26% of the total variance. Nearly half of participants (48.7%) reported positive attitudes toward screening, while 16.4% exhibited firmer fatalistic beliefs and 18.8% reported elevated mammography-related barriers. A substantial proportion believed that screening is only necessary when symptoms are present (57.2%). Lower education and younger age were significantly associated with higher barriers and less favorable screening beliefs (p < 0.05). In regression analysis, higher mammography-related barriers were associated with greater general help-seeking barriers, whereas more positive attitudes were associated with lower barriers, explaining 11.5% of the variance (R2 = 0.115, p < 0.001). Conclusions: Breast cancer screening beliefs among women in Kuwait are shaped by sociodemographic factors, particularly education level and age, with persistent misconceptions and perceived barriers influencing screening perceptions. Targeted, culturally appropriate interventions are needed to address these gaps and promote participation in Kuwait’s free-access screening program.

Healthcare doi: 10.3390/healthcare14121708

Authors: Nazym Zhumagulova Alla Mireeva Sholpan Akhelova Gaukhar Koshkimbayeva Aizada Askarova Mariam Taipova Akerke Amirkhanova Elmira Kartbayeva Balzhan Kudaibergenova Yerbol Kosherbekov Zukhra Davletgildeyeva Kenzhebek Bizhanov Anara Daniyarova Zhanara Buribayeva

Background/Objectives: Mental health problems among university students represent a growing public health concern and are shaped by both psychological and socioeconomic determinants that may act independently and interactively. This systematic review aimed to evaluate the separate and combined effects of these determinants on depression, anxiety, stress, and psychological distress in higher education students. Methods: A structured and targeted search strategy using predefined keyword groups and Boolean combinations across PubMed, Scopus, Web of Science, and Google Scholar identified 99 records, of which 19 duplicates were removed. After screening 80 titles and 52 abstracts, 34 full-text articles were assessed for eligibility, and 30 studies were ultimately included in the final review. Data were extracted on study characteristics, mental health outcomes, psychological determinants, socioeconomic factors, and their interactions. Results: The included studies consistently showed that psychological factors, including resilience, coping strategies, loneliness, self-efficacy, and perceived control, were associated with mental health outcomes, with higher resilience and self-efficacy linked to lower levels of depression and anxiety, and maladaptive coping and loneliness associated with increased psychological distress. Socioeconomic determinants, including financial stress, low socioeconomic status, parental education, housing insecurity, and food insecurity also independently contributed to elevated risks of depression, anxiety, and stress. Importantly, several studies demonstrated an interaction between these domains, where socioeconomic disadvantage amplified the adverse effects of poor coping capacity, low resilience, and social isolation, whereas social support and adaptive coping mitigated these effects. Conclusions: Student mental health is influenced by both distinct and interacting psychological and socioeconomic mechanisms, emphasizing the need for integrated institutional strategies that address structural vulnerabilities alongside individual psychological resilience.

Healthcare doi: 10.3390/healthcare14121710

Authors: Neşe Bülbül Rukiye Çiftçi İpek Atik Özgür Eken Nuriye Efe Ertürk Monira I. Aldhahi

Background/Objectives: Type 2 diabetes mellitus (T2DM) is a prevalent metabolic disorder associated with substantial long-term morbidity and mortality. Routinely collected anthropometric, biochemical, and hematological variables may contain useful discriminatory information for data-driven classification. This study aimed to compare the apparent classification performance of multiple machine learning algorithms for distinguishing individuals with and without T2DM using routinely obtained clinical parameters in a single-center dataset. Methods: This single-center observational study included 160 adults (95 females, 65 males) evaluated at the Endocrinology Outpatient Clinic of Gaziantep Islam Science and Technology University, Faculty of Medicine, Ersin Arslan Training and Research Hospital. The dataset comprised anthropometric measurements, biochemical markers, and complete blood count parameters. SMOTE was applied only within the training folds to address class imbalance and to avoid information leakage. Following fold-internal data preprocessing, which included imputing missing values and feature standardization where appropriate, the dataset was evaluated using stratified 5-fold cross-validation. SHAP analysis was performed to interpret the model predictions. A calibration curve was used to assess the model’s reliability. Eight supervised machine learning models were evaluated with and without HbA1c: Logistic Regression, Linear Discriminant Analysis, Quadratic Discriminant Analysis, Decision Tree, Random Forest, Extra Trees, Gaussian Naive Bayes, and k-Nearest Neighbors. Model performance was evaluated using accuracy, sensitivity, specificity, and F1 score, and ROC curves were used as a diagnostic tool. Results: The models were evaluated in two different ways: with and without HbA1c. Random Forest demonstrated the best classification performance in the cross-validated evaluation; without HbA1c, it achieved 92.2% accuracy, 93.9% sensitivity, 97.9% specificity, and a 95.9% F1 score. When HbA1c was included, it achieved 98.0% accuracy, 97.9% sensitivity, 98.8% specificity, and a 99.0% F1 score. Decision Tree and Extra Trees demonstrated strong performance with accuracy rates of 87.6% and 92.8%, respectively, without HbA1c, and 90% and 93.5% when HbA1c was included; in contrast, KNN yielded the lowest accuracy rate (70.6%). Overall, tree-based models performed better than linear classifiers on this dataset. Conclusions: Machine learning models based on routine clinical and anthropometric variables demonstrated promising performance for T2DM classification in this single-center dataset; tree-based approaches yielded the most promising results. Including HbA1c improved the models’ ability to classify individuals with and without T2DM. However, since HbA1c was included both as a predictor and as part of the operational definition of the diabetes group, the findings should be interpreted with caution due to the risk of target leakage. Therefore, these results should be considered exploratory rather than evidence of clinically applicable predictive performance, and an independent external validation study should be conducted prior to clinical application.

Healthcare doi: 10.3390/healthcare14121709

Authors: Jeong Sil Choi Kyung Mi Kim

Background: The number of long-term care hospitals (LTCHs) in Korea has been increasing. Because LTCHs primarily care for older adults who are vulnerable to infection, strict infection control (IC) practices are essential. This study aimed to assess the IC core competency of infection control nurses (ICNs) and IC physicians in LTCHs and to identify the individual and organizational factors associated with IC core competency. Methods: A descriptive cross-sectional survey was conducted among 348 participants (273 ICNs and 75 IC physicians) working in LTCHs across Korea in December 2022. Data were analyzed to assess levels of IC core competency, IC knowledge, and organizational support for patient safety. Results: The overall scores for IC core competency, IC knowledge, and organizational support for patient safety were 3.2 ± 0.7, 3.3 ± 0.7, and 3.4 ± 0.7 (out of 5), respectively. For ICNs, factors associated with IC core competency included IC nurse specialist certification, pre-employment IC training, attendance at IC-related academic conferences or training courses, IC knowledge, and organizational support for patient safety. For IC physicians, attending IC-related academic conferences or training courses, IC knowledge, and organizational support for patient safety were identified as significant factors associated with competency levels. Conclusions: This study found that IC knowledge, IC core competency, and organizational support for patient safety were insufficient among ICNs and IC physicians in LTCHs. IC Knowledge was the factor most strongly associated with IC core competency, and organizational support for patient safety also emerged as an important associated factor.

Healthcare doi: 10.3390/healthcare14121707

Authors: Yi-Lang Chen Chun-Yu Chan Yun-Pei Fan Tzu-Ting Wei

Background/Objectives: Smartphone use during public transit is widespread, yet the combined effects of posture, viewing duration, and sex on visual fatigue and visually induced motion sickness (VIMS) under real commuting conditions remain insufficiently understood. This study examined these factors during smartphone video viewing aboard Taipei MRT carriages. Methods: Forty healthy young adults (20 males, 20 females) completed four randomized conditions crossing two postures (sitting, standing) and two viewing durations (15 min, 30 min). Conditions were administered in a randomized order. Critical flicker fusion frequency (CFF), visual fatigue scale (VFS) scores, viewing distance, and VIMSSQ-short change scores were assessed as primary outcomes and analyzed using three-way mixed ANOVA. Results: Viewing duration produced the largest and most consistent effects across all outcomes (η2p = 0.658–0.969): 30 min viewing yielded greater CFF reduction, higher VFS scores, shorter viewing distance, and elevated VIMS compared with 15 min viewing. Standing posture significantly increased VFS scores, shortened viewing distance, and raised VIMS relative to sitting, though its effect on CFF reduction was not statistically significant. A significant sex × viewing duration interaction emerged with regard to VFS scores, with females showing a steeper increase in subjective fatigue over time, despite no significant sex main effect for any outcome. A significant posture × viewing duration interaction for VIMS indicated that standing was associated with greater VIMS responses during prolonged viewing. Conclusions: Prolonged viewing duration and standing posture are key contributors to smartphone-related visual and motion discomfort in metro environments. Limiting continuous viewing time and preferring a seated posture when using smartphones during commuting are recommended strategies to reduce both visual fatigue and VIMS among healthy young adults; generalizability to broader commuter populations warrants further investigation.

Healthcare doi: 10.3390/healthcare14121706

Authors: María Ángeles Caballero-Mora Virginia Mazoteras-Muñoz Irene Bartolomé-Martín Luis Saucedo-Mora Leocadio Rodríguez-Mañas Ángel Rodríguez-Laso

Background/Objectives: The relationship between psychotropic medication use, prescribing appropriateness, and fall-related risk factors remains incompletely characterised. Gait speed is a key predictor of falls. We aimed to examine whether gait speed is associated with appropriately versus inappropriately prescribed psychotropic medication use among relatively healthy older adults. Methods: We conducted an observational cross-sectional study of 119 community-dwelling adults aged ≥ 70 years with low comorbidity burden (Charlson Comorbidity Index < 2) and preserved functional status (Barthel Index > 85). Gait speed was assessed over 6 metres. Psychotropic medication use was recorded and prescribing appropriateness was evaluated using STOPP/START and Beers criteria, supplemented by geriatric pharmacological considerations. Multivariable linear regression analyses adjusted for age, sex, waist-to-height ratio, and frailty status. Results: In the fully adjusted model, inappropriate psychotropic medication use was associated with significantly slower gait speed compared with no use (B = −0.109 m/s; p = 0.026). In contrast, appropriately prescribed psychotropic medication use was not associated with gait speed (B = −0.018 m/s; p = 0.699). Conclusions: In this cross-sectional sample of relatively healthy older adults, appropriate psychotropic medication use was not associated with gait speed impairment, whereas inappropriate use was associated with slower gait. Although causal inference is not supported, these findings may inform prescribing quality and fall-risk assessment in older populations.

Healthcare doi: 10.3390/healthcare14121705

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

Background: Diabetes-related stigma is an underrecognized psychosocial factor that may contribute to emotional burden among individuals with diabetes. In Saudi Arabia, where the prevalence of diabetes is among the highest globally, limited evidence exists on how stigma across different social contexts influences interpersonal diabetes distress. We aimed to assess the association between diabetes-related stigma and interpersonal diabetes distress and to determine whether these associations differed across family, workplace, and healthcare stigma domains among adults with diabetes in Saudi Arabia. Methods: This cross-sectional study analyzed survey data collected from 438 patients with diabetes. Diabetes-related stigma was measured using an adapted 12-item diabetes stigma scale covering family, workplace, and healthcare domains, while interpersonal diabetes distress was assessed using the Interpersonal Distress subscale of the Diabetes Distress Scale (DDS). The relationships between stigma and distress were estimated using multiple linear regression analysis adjusted for age, gender, education level, years since diagnosis, and presence of complications. Results: Participants reported moderate levels of stigma (mean: 2.50, SD: 1.08) and interpersonal distress (mean: 2.31, SD: 1.23). Higher stigma scores were strongly associated with greater interpersonal distress (β = 0.57, 95% CI: 0.48 to 0.66). Domain-specific analysis showed that workplace (β = 0.26, 95% CI: 0.10 to 0.42) and healthcare stigma (β = 0.23, 95% CI: 0.07 to 0.38) were significantly associated with distress, while family stigma was not. Individuals with diabetes complications had higher distress (β = 0.49, 95% CI: 0.25 to 0.73). No evidence of effect modification by gender or education was observed. Spline models confirmed a positive and strengthening association at higher levels of stigma. Conclusions: Diabetes-related stigma is a strong and consistent factor associated with interpersonal diabetes distress in Saudi Arabia, with workplace and healthcare stigma demonstrating the strongest associations. These findings highlight the importance of addressing stigma within both social and healthcare environments and suggest that stigma reduction strategies may help alleviate the psychosocial burden associated with diabetes.

Healthcare doi: 10.3390/healthcare14121704

Authors: Chaxiraxi Bacallado-Rodríguez Francisco Javier Castro-Molina Jesús Manuel García-Acosta Silvia Elisa Razetto-Ramos Federico David Bacallado-Rodríguez José Ángel Rodríguez-Gómez

Background: Violence against healthcare professionals constitutes a global and persistent problem, with significant consequences for professionals’ physical and mental health, organisational climate, and the quality of care provided to patients. Objective: To evaluate the impact of a training activity on the prevention and management of aggression in healthcare settings among fourth-year undergraduate nursing students. Materials and Methods: The study was conducted at the Nuestra Señora de Candelaria School of Nursing, University of La Laguna. An intervention study with a quasi-experimental design without a control group was conducted through the implementation of a training workshop. A pre- and post-intervention questionnaire was administered to a sample of 59 fourth-year nursing students. In addition, two questionnaires were distributed at the end of the session to assess satisfaction with the training received and students’ self-perceived acquisition of knowledge. This research complied with the TREND statement. Results: Descriptive analysis showed higher post-test scores than pre-test scores. The Wilcoxon test indicated a statistically significant difference between the pre-test and post-test scores. Mean knowledge scores increased from 3.16 to 7.58 following the intervention, with a statistically significant difference (p < 0.001) and a very large effect size (r = 0.87). Conclusions: The training workshop was associated with a significant immediate improvement in knowledge, high levels of satisfaction, and enhanced self-perceived learning.

Healthcare doi: 10.3390/healthcare14121703

Authors: Saw Ye Win Thu Sneha Patnaik Yin-Hwa Shih

Background/Objectives: Exercise is pivotal for glycemic control in type 2 diabetes mellitus (T2DM), yet the relative efficacy of various exercise modalities remains inconclusive. This network meta-analysis aimed to evaluate and provide a preliminary ranking of exercise interventions on HbA1c levels in adults with type 2 diabetes mellitus, to facilitate clinically relevant network comparisons and to generate evidence for future large-scale comparative trials. Methods: A systematic review and network meta-analysis were conducted in accordance with PRISMA guidelines. Electronic databases (PubMed, MEDLINE, Cochrane Library, CINAHL, and ProQuest) were searched from inception to Dec 2024. Randomized controlled trials evaluating exercise interventions in adults with T2DM were included. Risk of bias was assessed independently by two reviewers using the JBI critical appraisal tool. The primary outcome was the change in HbA1c level. Results: Six randomized controlled trials involving a total of 511 participants (256 in the treatment group and 255 in the control group) were included in the final analysis. Both high-intensity interval training (MD = −0.322; 95% CI: −0.559 to −0.084; p = 0.008) and yoga (MD = −0.366; 95% CI: −0.534 to −0.198; p < 0.001) significantly reduced HbA1c compared with the active control. Although the preliminary ranking analysis suggested a higher probability of effectiveness for yoga (SUCRA 1) than for HIIT (SUCRA 0.5), the indirect comparison revealed no statistically significant difference in HbA1c reduction between the two interventions (MD = −0.044; 95% CI: −0.335 to 0.247; p = 0.766). Conclusions: These findings provide preliminary, evidence-generating; however, given the sparse network and absence of head-to-head trials, the treatment hierarchy should be interpreted with extreme caution and selected based on patients’ preferences and tolerance. Registration: PROSPERO [CRD42025650162].

Healthcare doi: 10.3390/healthcare14121702

Authors: Sidonia Maria Săndulescu Virginia Maria Rădulescu Sidonia Cătălina Vrabie Anca Vulcănescu Andreea Velișcu Carp Mirela Anișoara Siminel George Lucian Zorilă Ioana Victoria Camen Laurențiu Dîră Bogdan Ivănuș Claudia Monica Danilescu Maria-Magdalena Manolea

Background: Digital health technologies have expanded access to home fetal heart rate (FHR) monitoring devices, enabling fetal surveillance outside clinical settings. However, evidence on women’s awareness, acceptance, and experiences with these devices remains limited. Objective: To assess awareness, adoption, user experience, perceived reassurance, and attitudes toward home FHR monitoring among pregnant and postpartum women. Methods: A cross-sectional online survey was conducted using a structured questionnaire distributed via Google Forms. Eligible participants were women aged ≥18 years who were currently pregnant or had been pregnant within the previous two years. The survey evaluated awareness and use of home FHR monitoring devices, usage patterns, sources of recommendation and instruction, emotional responses, perceived reassurance, mobile application integration, and overall attitudes. Descriptive statistics and exploratory subgroup analyses were performed. Results: A total of 225 women completed the survey; 166 (73.8%) reported using a home FHR monitoring device during pregnancy. Most users reported positive emotional experiences, with calmness as the most common response. Home monitoring was generally perceived as reassuring, and many participants felt calmer on days of device use. Gynecologists were the primary source of device recommendations and usage instructions. Participants highlighted the importance of professional guidance, clear instructions, and mobile application support. Primiparous women had significantly higher adoption rates than multiparous women (p < 0.001). Conclusions: Home FHR monitoring was widely accepted and commonly perceived as reassuring. These devices may support patient-centered prenatal care when accompanied by appropriate professional guidance. Further prospective studies are needed to assess their clinical utility, safety, and integration into prenatal care pathways.

Healthcare doi: 10.3390/healthcare14121701

Authors: Mateusz Grajek Teresa Wagner-Tomaszewska Tomasz Jurys

Digital isolation represents a contemporary paradox in which increased connectivity through social media and digital technologies does not necessarily translate into improved social integration or psychological well-being. This review synthesizes current evidence on the relationship between digital environments and mental health, with a focus on mechanisms underlying loneliness, anxiety, depression, and related outcomes. The findings indicate that problematic and passive use of social media—particularly when associated with social comparison processes and Fear of Missing Out (FoMO)—is consistently linked to increased levels of depressive symptoms, anxiety, sleep disturbances, and reduced well-being. At the same time, the evidence highlights substantial heterogeneity, suggesting that the impact of digital technologies is moderated by user characteristics, age, patterns of engagement, and psychosocial context. Importantly, digital technologies may also serve compensatory and protective functions by facilitating social support, especially in conditions of objective isolation. Key mediating mechanisms include cyberbullying, social exclusion, emotional contagion, and internalization of body image standards. The concept of “digital loneliness” emerges as a useful framework for understanding the discrepancy between constant connectivity and perceived relational insufficiency. Practical implications emphasize the need for targeted interventions focusing on digital literacy, healthy usage patterns, and psychosocial support rather than simplistic reduction in screen time. Overall, digital isolation should be conceptualized as a qualitative dysfunction of mediated social interaction rather than a purely quantitative effect of technology exposure.

Healthcare doi: 10.3390/healthcare14121699

Authors: Mario Giordano Gianpiero Gaio Raffaella Marzullo Ippolita Altobelli Raffaele Barbato Raffaella Esposito Giancarlo Scognamiglio Gabriella Gaudieri Michela Palma Maurizio Cappelli Bigazzi Giuseppe Limongelli Berardo Sarubbi Maria Giovanna Russo

Introduction: The Melody transcatheter pulmonary valve (TPV) was the first percutaneous bioprosthetic valve approved for transcatheter pulmonary valve implantation (TPVI). We report our single-centre experience with Melody TPV implantation in patients with congenital heart disease (CHD). Methods: This retrospective observational single-centre study included all patients evaluated in the catheterization laboratory for Melody TPV implantation. Early outcomes included procedural failure, life-threatening adverse events, and mortality. Long-term outcomes assessed during follow-up included infective endocarditis, transcatheter reintervention, and surgical reintervention. Results: Between 2015 and 2025, 50 consecutive patients were evaluated for TPVI with the Melody TPV at our institution. In four patients (8%), the procedure was aborted because of coronary artery compression detected during balloon interrogation of the right ventricular outflow tract (RVOT). One patient (2%) died of septic shock following acute pulmonary oedema in the immediate post-procedural period. The remaining 45 patients (90%) underwent successful Melody TPV implantation and were discharged from hospital. In six patients, the Melody TPV was implanted off-label: in the tricuspid position (n = 2) and in small conduits (<16 mm) (n = 4). Mean follow-up duration was 5.8 ± 3.6 years. One patient was lost to follow-up. Among the remaining 44 patients, seven (15.9%; 2.7% per patient-year) developed infective endocarditis, seven (15.9%; 2.7% per patient-year) underwent transcatheter reintervention (six balloon dilatations of the Melody valve and one valve-in-valve implantation), and four (9.1%; 1.5% per patient-year) required surgical replacement of the Melody TPV. Conclusions: Transcatheter implantation of the Melody TPV is an effective treatment for RVOT dysfunction. At mid-term follow-up, the majority of implanted Melody valves demonstrated satisfactory function, and only a minority of patients required surgical valve replacement.

Healthcare doi: 10.3390/healthcare14121700

Authors: Raquel Gracia Rodríguez Esperanza Romero-Rodríguez Ignacio Jimena Medina Fernando Leiva-Cepas

Background: Sarcomas are rare malignant tumors for which diagnostic delay is associated with poorer clinical outcomes. Primary care clinicians (PCCs) are often the first physicians to evaluate patients with suspicious soft tissue masses. This study aimed to assess training exposure, self-reported knowledge of soft tissue tumors/sarcoma (STT/S) alarm signs, and diagnostic practices among PCCs in Spain. Methods: We conducted a nationwide descriptive cross-sectional survey between January 2024 and May 2025. A structured questionnaire was distributed through scientific societies, in-person dissemination at healthcare centers, and direct professional contact. Participants included Primary Care physicians (PCPs), and medical intern residents (MIRs). The primary outcome was self-reported knowledge of STT/S alarm signs, assessed as a dichotomous variable. Results: A total of 642 clinicians participated, of whom 67% were female. Most respondents were Primary Care general practitioners (64%) or MIRs (31%), and 64% worked in urban settings. Overall, 38% of participants reported being aware of STT/S alarm signs. Undergraduate exposure to oncology- or sarcoma-related content was limited: 36% reported no training, 17% reported fewer than 10 h, and data were missing for 35%. Self-reported knowledge of sarcoma alarm signs was higher among younger participants, residents, and those with prior oncology training. Conclusions: Undergraduate exposure to sarcoma-related content and self-reported knowledge of STT/S alarm signs were suboptimal among PCCs in Spain. Targeted educational interventions and simplified referral pathways aligned with national recommendations may help improve earlier recognition and referral of suspected sarcoma.

Healthcare doi: 10.3390/healthcare14121698

Authors: Temitope S. Ajagbe

Remote patient monitoring (RPM) is widely framed as a foundational technology for the next generation of chronic-disease care. Specific applications—pacemaker follow-up, hypertension cohorts, structured heart-failure programmes, post-surgical biosensor protocols, and virtual wards—now generate measurable clinical and economic value. Yet a decade of evaluations and implementation studies suggests that the surrounding ecosystem has matured unevenly: working applications coexist with persistent cross-cutting fragility. In this Perspective we argue that four structural gaps continue to constrain RPM’s promise at scale: (i) economic models that do not credibly compensate the asynchronous clinical work that RPM generates; (ii) ambiguous frameworks for professional liability and accountability for continuous data streams, intensified by artificial-intelligence (AI)-mediated decision support; (iii) privacy, equity, and benefit-sharing arrangements that do not yet make patients unambiguous net beneficiaries—a gap visible across very different health systems internationally; and (iv) engagement and adherence dynamics that determine whether programmes deliver value at all, but are still treated as secondary outcomes. The COVID-19 emergency briefly suspended much of the friction in this ecosystem and produced a useful natural experiment: what scaled rapidly under emergency conditions, and what subsequently atrophied, illuminates which gaps are technical, which are economic, and which are institutional. We close with a six-point research and policy agenda intended to move RPM from localised successes to a trustworthy, generalisable standard of care.

Healthcare doi: 10.3390/healthcare14121697

Authors: Braveheart Gillani Rem Martin Kate Freeman Brenda Mathias Augustus Klein

Background: Telehealth is increasingly positioned as a solution for healthcare access among older adults; yet for transgender older adults, its application remains undertheorized, inconsistently implemented, and frequently reductive. Structural barriers, including provider incompetence, administrative misgendering, insurance precarity, and the clinical invisibility of aging transmasculine bodies, shape this population’s relationship to telehealth in ways that existing frameworks have not adequately addressed. Objective: This study examines the structural conditions shaping transmasculine and gender-nonconforming older adults’ engagement with healthcare and telehealth, and centers their visions for transformed, justice-oriented virtual care. Methods: Four semi-structured focus groups (n = 14 transmasculine and gender-nonconforming older adults, ages 40–67) were conducted via Zoom in June 2024 and analyzed using Braun and Clarke’s reflexive thematic analysis. The study was designed according to community-based participatory research (CBPR) principles. This study followed the Consolidated Criteria for Reporting Qualitative Research guidelines to ensure methodological transparency in reporting. Results: Analysis yielded five themes: (1) the provider competency crisis; (2) administrative violence and the architecture of misgendering; (3) insurance, politics, and the precarity of access; (4) the aging transmasculine body as uncharted clinical territory; and (5) participants’ collective vision for relational, community-centered care. Conclusions: We introduce the Campfire Model of Relational Telehealth, a conceptual framework comprising five empirically derived pillars: gathering, warmth, collective knowledge, safety, and accountability. The model argues that telehealth must move beyond transactional encounters toward a relational ecosystem of care grounded in justice, belonging, and structural transformation. We conclude with a call to action for providers, policymakers, and researchers to dismantle structural barriers and advance telehealth that cultivates dignity, belonging, and equity.

Healthcare doi: 10.3390/healthcare14121696

Authors: Stanka Uzunova Rumyana Stoyanova Marin Atanassov Angel Atanasov Kristina Kilova

Background: Over the past two decades, teleophthalmology has become an effective approach for glaucoma screening and follow-up, with its adoption markedly accelerated by the COVID-19 pandemic. Objectives: The aim of the present study was to explore and analyze the attitudes of ophthalmologists in Bulgaria toward the application of teleglaucoma, digital communication, and artificial intelligence in clinical practice. Methods: A cross-sectional survey study was conducted among 113 ophthalmologists between September 2024 and March 2025, representing 10.5% of all licensed ophthalmologists in Bulgaria (n = 1074). Results: Age, professional experience, and specialization influenced the level of involvement in managing glaucoma patients. The level of awareness regarding the term ‘teleophthalmology’ was higher among respondents with a specialization in ophthalmology and those holding a doctoral degree (p = 0.001). Among the ophthalmologists surveyed, 35.4% (n = 40) provided teleophthalmology services, while an additional 19.5% (n = 22) reported no prior provision of such services but planned to do so in the future. The most preferred method for conducting teleophthalmology consultations was telephone communication (n = 27; 67.5%), followed by communication via Skype, Viber, or Messenger (n = 23; 57.5%). Physicians with longer professional experience more frequently conducted remote consultations with patients they already knew (p = 0.006). A substantial proportion of respondents (85.0%, n = 96) expressed willingness to participate in training related to contemporary trends and the provision of remote medical services. More than half of respondents expressed positive attitudes toward the use of artificial intelligence in ophthalmology, although practical implementation remained limited. Conclusions: The present study outlined the current landscape of attitudes among ophthalmologists in Bulgaria toward teleglaucoma, digital communication, and the use of artificial intelligence in clinical practice. The findings indicated a moderately positive yet cautious stance—remote services were perceived primarily as complementary tools, particularly for the follow-up of previously known patients and for real-time collaboration between specialists.

Healthcare doi: 10.3390/healthcare14121695

Authors: Shahul Hameed Pakkir Mohamed Abdulaziz A. Albalwi Mohamed Taher Mahmoud Eldesoky Hamad S. Al Amer Ahmad A. Alharbi Jana Alhmeed Emtenan Alhakami Shahad Battal Alanazi Maha Alrashedi Ghala Dakhilallah

Background and Objectives: Cervicogenic headaches (CGH) are increasingly common among college students and may negatively affect academic performance and sleep quality. This study aimed to identify the self-reported prevalence of cervicogenic-type head and neck pain in a convenience sample of Saudi college students and to examine its associations with electronic device use, physical activity, and sleep quality among college students in Saudi Arabia. Materials and Methods: A cross-sectional study was conducted among 313 college students from various Saudi university colleges using an online self-administered questionnaire. The questionnaire gathered information on sociodemographic characteristics, electronic device usage, neck pain awareness, physical activity levels, and sleep quality. Descriptive statistics were used to summarize the data, and chi-square tests were used to explore associations between potential predictors and the prevalence of self-reported cervicogenic-type head and neck pain consistent with possible CGH. Results: Most participants were female (84.3%) and aged 18–25 years (95.2%). Cervicogenic-type head and neck pain were reported by 65.2% (n = 204/313), while 56.5% experienced moderate to severe stress. A significant association was found with perceived stress (p = 0.002). Prolonged electronic device use (>4 h/day: 77.9%; p < 0.01), lower physical activity (p = 0.056), medication use (p < 0.01), headache exacerbation with inactivity (p = 0.006), and poor sleep quality (95.1% with PSQI > 10; p = 0.044) were significantly associated. Conclusions: These findings highlight associations between excessive electronic device use, low physical activity, and poor sleep quality with self-reported cervicogenic-type head and neck pain among Saudi college students. Future longitudinal studies and randomized controlled trials are needed to determine whether targeting these factors reduces the prevalence of CGH.

Healthcare doi: 10.3390/healthcare14121694

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

Background/Objectives: Teachers in educational institutions are continuously exposed to high occupational demands, which may contribute to the development of increased adiposity and comparatively unfavorable health-related quality of life (HRQoL) scores. However, there is limited evidence regarding how years of professional experience is associated with these indicators in teachers. The objective of this study is to examine the association between years of professional experience, adiposity indicators, and HRQoL among teachers in educational institutions. Methods: An observational, relational, exploratory cross-sectional study was conducted in 175 teachers from educational institutions in the city of Temuco, Chile. Body mass index (BMI), waist-to-height ratio (WHtR), and waist-to-hip ratio (WHR) were assessed as adiposity indicators, and health-related quality of life (HRQoL) was measured using the SF-12. Age, sex, and years of professional experience were recorded. Simple and multivariable linear regression models were used to analyze the association between years of experience and the study variables, adjusting for age and sex. Additionally, experience tertiles were compared using ANOVA and ANCOVA. Results: In the unadjusted analyses, greater years of professional experience were associated with higher adiposity indicators, including BMI (β = 0.071; 95% CI: 0.020 to 0.129). However, after adjustment for age and sex, these associations were attenuated and no longer statistically significant (adjusted BMI: β = −0.172; 95% CI: −0.434 to 0.053). Associations with PCS and MCS scores were also not statistically significant after adjustment. Conclusions: Teachers exhibited high levels of adiposity and HRQoL scores suggesting an unfavorable perceived health profile. The observed associations between years of professional experience and adiposity or HRQoL appear to be largely explained by age rather than by professional experience itself. Future longitudinal studies are needed to more precisely distinguish between the effects of aging and prolonged occupational exposure. However, the findings should be interpreted cautiously given the convenience sampling design and the inclusion of teachers from a single city.

Healthcare doi: 10.3390/healthcare14121693

Authors: Vid Duplančić Ana Bobinac Luka Vončina Katarina Hraste Ana Tečić Vuger Robert Šeparović Eduard Vrdoljak

Background/Objectives: Breast cancer affects working-age women not only through treatment and survival but also through health-related quality of life (HRQoL), work capacity and informal caregiving needs. Evidence from Central and Eastern Europe remains limited. This study estimated the indirect societal burden of breast cancer among working-age women in Croatia and reported economic indirect costs separately from monetised HRQoL/welfare loss. Methods: A multicentre cross-sectional study conducted in 2024 included women aged 18–65 years receiving outpatient oncology care at two tertiary centres in Croatia. HRQoL was assessed with the EuroQol five-dimension five-level instrument (EQ-5D-5L) and compared with Croatian general-population norms. Utility decrements were annualised and monetised using a national willingness-to-pay threshold of €17,000 per quality-adjusted life year (QALY). Work productivity impairment was measured using the Work Productivity and Activity Impairment: General Health (WPAI:GH) questionnaire and valued, together with informal care, using the human-capital approach. Deterministic sensitivity analyses and approximate 95% confidence intervals were used to show how the estimates changed under key assumptions. Results: A total of 271 women participated (mean age 51.3 years among age-eligible records). Mean EQ-5D-5L utility was 0.76 versus 0.91 in the general population, corresponding to an annual QALY loss of 0.15 and a monetised HRQoL/welfare loss of €2550 per patient-year (95% CI €2083–€3017). Among employed participants, mean overall work productivity loss was 43.9% (842.9 h/year), equivalent to €7333 annually (95% CI €6311–€8355). Informal caregiving was reported by 54.7% of participants, with mean annual costs of €1566 (95% CI €1269–€1863). Economic indirect costs were €8899 per patient-year (95% CI €7835–€9963). In an extended welfare-inclusive scenario, the estimated burden was €11,449 per patient-year (95% CI €10,287–€12,611), corresponding to an illustrative national estimate of €86 million (95% CI €77–€95 million; 0.11% of gross domestic product). Conclusions: Breast cancer in working-age women imposes a substantial societal burden in Croatia, driven by reduced HRQoL, productivity losses and informal caregiving needs. These findings support taking societal burden into account in public health planning, survivorship care and health policy decision-making.

Healthcare doi: 10.3390/healthcare14121692

Authors: Samuhaer Azhati Shuning Liu Ruizhe Song Mingchen Li Yan Wei Chang Liu Huaichuan Zhang

Background: Low back pain (LBP) is a major cause of disability in later life. We aimed to assess the population-level burden, demographic and epidemiological drivers, GBD-defined risk attribution, and future trajectory of LBP among Chinese adults aged 45 years and older. Methods: Using population-level estimates from the Global Burden of Disease Study 2023 (GBD 2023), we analyzed incidence, prevalence, and years lived with disability (YLDs) among Chinese adults aged 45 years and older from 1990 to 2023. We assessed temporal trends, decomposed changes in burden, evaluated age–period–cohort patterns, quantified YLDs attributable to three GBD-defined risk factors—high body mass index, occupational ergonomic factors, and smoking—and projected burden to 2040 using Bayesian age–period–cohort models. Results: In 2023, population-level GBD estimates indicated that LBP accounted for 30.29 million incident cases, 71.54 million prevalent cases, and 7.90 million YLDs among Chinese adults aged 45 years and older. Compared with 1990, these numbers increased by 101.54%, 97.08%, and 96.11%, respectively, despite declining age-restricted age-standardized incidence, prevalence, and YLD rates. Expansion of the population aged 45 years and older was the main driver of the increasing absolute burden, whereas favorable epidemiological change offset part of this increase. High body-mass index showed the largest increase in attributable burden and was the only risk factor with rising age-standardized attributable YLD rates. Model-based projections suggested that age-restricted age-standardized burden would continue to decline through 2040. Conclusions: LBP remains a growing absolute burden among middle-aged and older adults in China despite declining age-restricted age-standardized rates. Future disability reduction will require integrated strategies combining risk-factor control, rehabilitation, functional support, and age-sensitive care.

Healthcare doi: 10.3390/healthcare14121691

Authors: Evelina Razheva Georgi Iskrov Tsonka Miteva-Katrandzhieva Rumen Stefanov

Background: Rare diseases are associated with chronic progression, functional impairment, and complex care needs, requiring long-term and coordinated rehabilitation. Physical and Rehabilitation Medicine (PRM) plays a key role in maintaining functional capacity and improving quality of life; however, access to rehabilitation services remains uneven across regions. Aim: This study aims to assess the regional structural availability of PRM services across Bulgaria and to identify territorial differences in the organizational profile of rehabilitation services that may influence the potential availability of rehabilitation care for patients with rare diseases. Methods: A descriptive cross-sectional study was conducted using publicly available aggregated data from the NHIF and the National Statistical Institute as of 31 December 2024. Structural indicators included the number of outpatient and inpatient PRM healthcare facilities and PRM specialists, standardized per 100,000 population, as well as the outpatient-to-inpatient facility ratio (OFs/IFs). Hierarchical cluster analysis (Ward’s method, Euclidean distance) was applied as an exploratory tool to identify similarities in regional service availability profiles. Results: Substantial regional differences in the structural availability of PRM services were identified. Outpatient facilities ranged from 4.46 to 6.74 per 100,000 population, while inpatient facilities ranged from 2.30 to 3.42 per 100,000 population. The OFs/IFs ratio varied between 1.30 and 2.26, indicating different organizational profiles of PRM service provision. Exploratory hierarchical clustering suggested two broad regional service profiles: one characterized by a relatively balanced distribution of outpatient and inpatient structures and another characterized by a predominance of outpatient-oriented rehabilitation services. Conclusion: The findings reveal substantial regional differences in the organization of PRM services in Bulgaria. Regions with a predominance of outpatient structures may demonstrate different capacities for delivering comprehensive rehabilitation services, particularly for patients with complex long-term needs, including rare diseases. The results highlight the need for targeted regional planning, improved integration of rehabilitation services, and policy measures aimed at ensuring equitable access to care.

Healthcare doi: 10.3390/healthcare14121690

Authors: Janina Kulińska Jolanta Grzebieluch

Introduction: Patients are increasingly aware of ways to manage their own health—especially regarding chronic diseases—along with the fundamental factors that should be present in well-organized and patient-oriented healthcare organizations. Due to the fact that the image of healthcare organizations depends on patients’ opinions, healthcare organizations are continuously improving and transforming their processes to increase patient satisfaction. This study aimed to analyze the relationship between patients’ opinions about the public hospitals in which they were treated and selected factors, including socio-demographic characteristics, previous hospital experiences, sources of information, and satisfaction with hospitalization in Poland. Methods: A cross-sectional survey was conducted among patients hospitalized in eight public hospitals in Wrocław. A self-developed questionnaire included two sections: (I) opinions about the hospital (11 items) and (II) expectations and satisfaction (12 items). Questionnaires were distributed in person. Data were analyzed using descriptive and inferential statistics, including correlation and chi-square tests. Results: Hospital image was shaped mainly by interpersonal factors, particularly staff kindness (82.9%), access to specialists (75.4%), and a sense of safety (54.4%). Women were more likely than men to seek information about hospitals before admission (47.6% vs. 39.3%; p = 0.021). A positive correlation was found between patient expectations and satisfaction with hospitalization (ρ = 0.425; p < 0.001). Media exposure played a minor role in shaping hospital image (22.1%), while personal recommendations and previous experience were the dominant sources of influence. Conclusion: Patients’ assessments of hospital image are determined primarily by relational and communication factors rather than infrastructural or technical aspects. Sociodemographic characteristics, such as gender and previous contact with the institution, may moderate these perceptions. The findings highlight the need to strengthen patient-centered care models, improve communication competencies among health professionals, and develop transparent institutional communication strategies.

Healthcare doi: 10.3390/healthcare14121689

Authors: Wiktor Rybicki Katarzyna Kapcia Marek Krzystanek Anna Brzęk Kamil Barański Iwona Schuster Dorota Szydlak Wiktoria Balcerzak Anetta Lasek-Bal

Stroke is a leading cause of morbidity and long-term disability worldwide. This study evaluated the feasibility, safety, and preliminary clinical effects of phonotherapy (PHT) as an adjunct to standard care in patients with acute ischemic stroke. This prospective observational study enrolled 140 patients, who were assigned to receive either phonotherapy in addition to standard care (PHT group, n = 70) or standard care alone (control group, n = 70). Phonotherapy consisted of twice-daily 528 Hz sound stimulation administered for 3 months. Neurological (NIHSS), functional (mRS), and cognitive (MoCA) outcomes were assessed at days 10 and 90. At day 10, patients receiving PHT showed significantly better neurological, functional, and cognitive outcomes compared to the controls. However, these differences were not sustained at 90 days. Phonotherapy was not an independent predictor of favorable functional outcome at 90 days. Recurrent stroke occurred in three patients (4.3%) in the PHT group and nine (12.9%) in the control group (p = 0.07). No intervention-related adverse events were observed. Phonotherapy appears to be a safe adjunct intervention in acute ischemic stroke and may be associated with short-term improvements in selected outcomes. Overall, phonotherapy appeared safe as an adjunctive intervention in patients with acute ischemic stroke and showed possible short-term associations with improvements in selected outcomes, although these preliminary findings require confirmation in randomized controlled trials.

Healthcare doi: 10.3390/healthcare14121688

Authors: Hend A. Algrvi Madhawi M. Aldhwayan Sara Al-Musharaf Tagreed A. Mazi Afshan Masood Hicham Benabdelkamel Ghadeer S. Aljuraiban

Background/Objectives: Obesity is a major public health concern, and accurate diagnosis is essential for effective treatment and prevention strategies. Obesity screening utilizes anthropometric indices, among which body mass index (BMI) has been most widely used; however the comparative performance of alternative indices still needs to be evaluated. Methods: This cross-sectional study included 1042 participants. Anthropometric indices including BMI, waist circumference (WC), waist-to-height ratio (WHtR), waist–hip circumference ratio (WHR), neck circumference (NC), and hip circumference (HC) were measured among Saudi adults. Body fat percentage was measured using bioelectrical impedance analysis and used to define obesity. Correlation analysis was used to assess associations with BF%, and receiver operating characteristic curve analysis was used to compare discriminatory performance and determine optimal obesity-screening cutoffs using the Youden index. Results: The study included 1042 Saudi adults, predominantly women (61.9%), with a mean age of 31.8 ± 12 years. BMI showed the strongest overall correlation with body fat percentage (r = 0.707), followed by hip circumference and waist-to-height ratio. ROC curve analysis revealed excellent discriminatory performance for BMI in the total cohort (AUC = 0.924, 95% CI: 0.908–0.939), followed by HC (AUC = 0.887) and WHtR (AUC = 0.861); the least discriminatory performance was for WHR (AUC = 0.667). Further sex-stratified analysis showed that BMI had the strongest correlation with BF%, in both men (r = 0.837), and women (r = 0.821). On the other hand, ROC analysis showed that WHtR was the best in men (AUC = 0.932), with performance comparable to BMI, whereas BMI remained the strongest discriminator in women (AUC = 0.930). Conclusions: BMI demonstrated the highest discriminatory performance for identifying BF-defined obesity in this cohort, supporting its value as a practical and reliable screening index. Although waist circumference and waist-to-height ratio reflected differences in body fat distribution, they did not outperform BMI. These findings support the continued use of BMI as the primary obesity screening measure, while highlighting the importance of using sex-specific interpretation of complementary anthropometric indices.

Healthcare doi: 10.3390/healthcare14121687

Authors: Ljiljana Cvorovic Ana Jotic Bojana Bukurov Saša Jakovljevic Simona Aleksic Katarina Jovanovic

Background/Objectives: Hearing loss and dementia are highly prevalent conditions in older adults and represent a growing public health challenge. Over the past decade, a substantial body of epidemiological evidence has demonstrated a consistent association between age-related hearing loss and cognitive dysfunction, including incident dementia. However, the nature of this relationship remains incompletely understood. Methods: This narrative review provides a structured overview of current evidence, focusing on epidemiological findings, mechanistic pathways, and clinical implications. Hearing loss has been associated with both accelerated cognitive decline and increased dementia risk, with a clear severity–impact relationship. Results: Several interacting mechanisms have been proposed, including increased cognitive load, structural and functional brain changes, social isolation, and shared vascular and metabolic risk factors. Emerging concepts such as the “auditory brain” and central auditory dysfunction further suggest that hearing impairment may also represent an early manifestation of neurodegenerative processes. Intervention studies have yielded mixed results. While hearing rehabilitation improves communication and quality of life, randomized evidence has not consistently demonstrated a reduction in cognitive decline in the general population, but potential benefits may exist in higher-risk subgroups. Increasing attention has been directed toward the role of neuroplasticity, with evidence suggesting that delayed intervention may limit the effectiveness of rehabilitation due to long-standing auditory deprivation. Conclusions: Taken together, current evidence suggests that hearing loss may represent both a potentially modifiable risk factor and an early marker of cognitive decline. Early identification and timely management of hearing impairment may therefore play an important role in maintaining cognitive and brain health and improving quality of life in older adults.

Healthcare doi: 10.3390/healthcare14121686

Authors: Dain Jeong Youngsil Lee

Objectives: This study used psychological network analysis to examine the interrelationships among smartphone addiction, depression, anxiety, fatigue, sleep quality, and learning engagement in nursing students. Methods: A cross-sectional survey was conducted among 200 nursing students in South Korea using validated self-report instruments. Psychological network analysis was performed using the qgraph and bootnet packages in R. A non-regularized partial correlation network based on Spearman correlations was estimated, and bootstrap was conducted to evaluate the stability and accuracy of network estimates. Results: The strongest positive association was observed between fatigue and depression, whereas smartphone addiction showed the strongest negative association with learning engagement. Depression demonstrated relatively higher centrality within the network, while anxiety showed comparatively lower centrality values. Strength and expected influence estimates demonstrated acceptable stability. Conclusions: The findings suggest meaningful associations among depression, fatigue, sleep quality, smartphone addiction, and learning engagement in nursing students. Learning engagement demonstrated relatively strong connectivity within the network, highlighting its close association with psychological and behavioral factors. These findings support the utility of network analysis for understanding complex interrelationships among psychological variables in nursing students.

Healthcare doi: 10.3390/healthcare14121685

Authors: Myeong-Min Ju Dae-Sung Park

Background/Objectives: Falls among older adults are a major public health concern. Although instrumented posturography provides objective balance and fall-risk assessment, its cost and limited portability restrict widespread use. This study aimed to examine the construct and concurrent validity of center of pressure (COP) path length measured using a Wii Balance Board (WBB) in relation to a clinically established posturographic fall-risk construct in community-dwelling older adults and to explore its discriminatory performance across multiple sensory postural conditions. Methods: Sixty adults aged ≥ 65 years participated in this cross-sectional study. COP path length was measured using a WBB under eight postural conditions and compared with the Fall Index derived from a conventional posturography system (TetraxⓇ). Functional performance was assessed using the Four Square Step Test and the Five Times Sit-to-Stand test. Pearson correlation, receiver operating characteristic (ROC), and exploratory regression analyses were performed. Results: COP path length showed significant positive correlations with the TetraxⓇ Fall Index across all conditions (r = 0.349–0.561, p < 0.01) and with functional performance tests under most postural conditions (p < 0.05), except for the Normal stability, Open eyes (NO) condition. ROC analysis demonstrated acceptable-to-good discriminatory performance for classifying TetraxⓇ Fall Index-based risk status (AUC = 0.783–0.865), with the NO condition showing the highest discriminatory capability (AUC = 0.865). Exploratory regression models based on selected postural conditions explained 12.1–40.7% of the variance in the reference Fall Index. Conclusions: COP path length measured using a WBB demonstrated construct validity and acceptable discriminatory capacity in relation to a conventional posturographic fall-risk construct in community-dwelling older adults. These findings support the exploratory feasibility of simplified WBB-based balance assessment approaches for community and clinical screening contexts. Further longitudinal studies incorporating prospective fall outcomes are required to establish predictive validity and broader clinical applicability.

Healthcare doi: 10.3390/healthcare14121684

Authors: Fernando M. Runzer-Colmenares Walter Mendoza Nelson Luis Cahuapaza-Gutierrez Kiara Camacho-Caballero Jose F. Parodi

Background/Objectives: To analyze the determinants of frailty among older adults residing in the Peruvian Amazon, focusing on four complementary frailty-related outcomes. Methods: A cross-sectional study was conducted using secondary data from the Amazon frail study. Four multivariable Poisson regression models were specified. Associations were estimated using prevalence ratios (PRs) with their corresponding 95% confidence intervals (95% CIs), employing robust variance estimation to account for potential heteroskedasticity. Results: The sample included 429 older adults (≥60 years), predominantly female (64.0%), with most participants aged 60–79 years (85.8%). The prevalence of the main variables of interest was: dynapenia (51.5%), low physical performance (32.2%), social frailty (66.4%), and frailty according to the Fried phenotype (26.3%). In adjusted models, altered muscle mass showed the strongest association with dynapenia (PR = 2.08, 95%CI = 1.74–2.50). Likewise, functional dependence and social frailty were significantly associated with low physical performance (PR = 1.65 and PR = 1.57, respectively). A higher potential support relationship (upper tertile) was associated with a lower prevalence of social frailty (PR = 0.56, 95%CI = 0.41–0.88), whereas low physical performance was strongly associated with frailty defined by the Fried phenotype (PR = 3.71, 95%CI = 2.60–5.34). Conclusions: Frailty among older adults in the Peruvian Amazon is highly prevalent and characterized by a distinctly multidimensional nature. It is associated with muscular, functional, cognitive, and social factors that may reflect interrelated vulnerabilities at both the individual and community levels.

Healthcare doi: 10.3390/healthcare14121683

Authors: So-Hee Lim

Background/Objectives: This study aimed to verify a prediction model identifying the relationships and pathways among factors associated with Korean nursing students’ provision of person-centered care to patients with dementia. Methods: This was a covariance structure analysis study to establish a hypothetical model of 313 Korean nursing students located in a metropolitan area. IBM SPSS version 18.0 (Chicago, IL, USA) and AMOS version 5.0 (Chicago, IL, USA) were used to analyze the data. Structural equation modeling analysis was applied to verify convergent and discriminant validity using higher-order factor analysis in the final model analysis. Results: The model fit indices of the research model were as follows: χ2/df = 1.83 (p < 0.001), GFI = 0.91, AGFI = 0.88, NFI = 0.91, CFI = 0.90, RMR = 0.04, and RMSEA = 0.05. The factors affecting person-centered care, nursing professionalism (γ = 0.45, p = 0.024), and empathy (γ = 0.21, p = 0.036) showed significant associations, whereas clinical practice adaptation (γ = 0.21, p = 0.013) and nursing professionalism (γ = 0.08, p = 0.004) had indirect effects. These factors explained 40% of the variance in person-centered care. Conclusions: This study is significant because it provides basic data for developing an educational program that can improve the person-centered care capacity of domestic nursing students by confirming that clinical practice adaptation, nursing professionalism, and empathy are important factors related to person-centered care.

Healthcare doi: 10.3390/healthcare14121682

Authors: Yuhang Liu Gu Hu Ziyue Zhou Shuaibin Liu

Background: Pelvic inflammatory disease (PID) is a prevalent chronic inflammatory condition among women. The Composite Dietary Antioxidant Index (CDAI), a measure of dietary antioxidant capacity, has been associated with various inflammatory diseases, but evidence concerning its association with PID remains limited. Methods: The final analytic sample included 4539 women. CDAI was calculated from six dietary antioxidant components: vitamin A, vitamin C, vitamin E, carotenoids, zinc, and selenium. Survey-weighted multivariable logistic regression models were used to evaluate the association between CDAI and self-reported history of treated PID, incorporating the sampling weights, strata, and primary sampling units of NHANES. Restricted cubic spline (RCS) analysis was used to assess both linear and non-linear associations. Subgroup analyses and a machine learning model based on random forest, combined with SHapley Additive exPlanations (SHAP) value ranking, were conducted to evaluate the relative importance of individual components of CDAI. Results: In the fully adjusted spline model including smoking status, CDAI was inversely associated with the odds of self-reported history of treated PID, with no statistical evidence of nonlinearity. Compared with the lowest quartile (Q1), the odds ratios (ORs) for self-reported history of treated PID across higher quartiles of CDAI were as follows: Q2 (OR = 0.682, 95% CI: 0.485–0.959, p = 0.036), Q3 (OR = 0.524, 95% CI: 0.334–0.819, p = 0.009), and Q4 (OR = 0.666, 95% CI: 0.380–1.167, p = 0.167). Among the components of CDAI, vitamin E intake showed an independent inverse association with the odds of self-reported history of treated PID. The SHAP value interpretation indicated that vitamin A, vitamin C, and carotenoids were the three components in CDAI with the highest predictive contribution. Furthermore, subgroup analysis demonstrated a significant interaction effect of age on the association between CDAI and PID. Conclusions: This cross-sectional study suggests an inverse association between CDAI and self-reported history of treated PID, particularly in spline analyses; however, the quartile-based fully adjusted results were non-monotonic and attenuated after adjustment for smoking status. These findings provide hypothesis-generating evidence for future longitudinal and mechanistic studies on antioxidant-related dietary patterns and PID-related reproductive health.

Healthcare doi: 10.3390/healthcare14121681

Authors: Jingjing Gong Bing Xie Yuxuan Wei Li Fu Lili Xing Xiaonan Liu Xiaodan Li

Background/Objectives: Pregnancy and childbirth are independent risk factors for pelvic floor injury. The choice of delivery position, as an interventionable factor during labor, has received much attention. This study aimed to assess the impact of sitting delivery on pelvic floor function by observing the outcomes of the perineum, duration of the second stage of labor, integrity of pelvic floor structure, and postpartum pelvic floor function. The goal was to provide scientific evidence for optimizing delivery management and reducing the risk of pelvic floor injury. Methods: This was a non-randomized study (based on patient choice). A total of 222 primiparous women who delivered at our hospital from February to August 2023 were selected and divided into the control group (n = 88) and the sitting group (n = 134). The second stage of labor in the control group was delivered in the traditional bladder lithotomy position, while the sitting group delivered in a sitting position. The duration of the second stage of labor, delivery method, degree of perineal laceration, postpartum 2 h bleeding volume, and the occurrence of urinary incontinence and sexual dysfunction 1 year after delivery were observed in both groups. Results: The rate of perineal lateral incision in the sitting group was lower than that in the control group (24.6% vs. 48.9%, aOR = 0.37, p < 0.001); the adjusted mean difference in second-stage duration was −11.65 min (95% CI: −25.35 to 2.05, p = 0.095), indicating no statistically significant difference after adjustment. In unadjusted subgroup analysis, a larger point estimate for reduction was observed in women aged < 30 years (median difference −16.0 min, p = 0.033), but the interaction test was not significant. For urinary incontinence and sexual dysfunction, there were no statistically significant differences between the two groups. Conclusions: Sitting delivery was associated with a lower episiotomy rate and, in unadjusted analysis, a shorter second stage (although the adjusted difference was not significant), and it did not increase the incidence of urinary incontinence or sexual dysfunction at one year postpartum.

Healthcare doi: 10.3390/healthcare14121680

Authors: Radka Čopková

Background/Objectives: Helplines are an important component of mental health support systems; however, limited research has examined burnout among helpline workers. This exploratory pilot study investigated the relationships between job demands, job and personal resources, and burnout within the Job Demands–Resources (JD-R) framework. Methods: A cross-sectional online study was conducted among 73 helpline workers. Burnout was assessed using the Burnout Assessment Tool (BAT). Job demands were categorized as topic-related, client-related, and service-related. Data were analysed using Spearman correlations and hierarchical regression analyses. Results: Job demands were positively associated with burnout (rs = 0.41, p < 0.001), while job resources were negatively associated with burnout (rs = −0.30, p < 0.01). Regression analyses showed that job demands and resources explained 50% of the variance in overall burnout (R2 = 0.50, p < 0.001). Service-related demands emerged as the strongest predictor of burnout (β = 0.70, p < 0.001) and consistently predicted exhaustion (β = 0.60, p < 0.001), mental distance (β = 0.48, p < 0.001), cognitive impairment (β = 0.52, p < 0.001), and emotional impairment (β = 0.61, p < 0.001). Organizational resources were negatively associated with mental distance (β = −0.31, p < 0.01), whereas topic-related demands were not significant predictors. Conclusions: The findings highlight the importance of differentiating types of job demands in understanding burnout among helpline workers. Service-related demands appeared to be more strongly associated with burnout than topic- or client-related demands, suggesting that structural aspects of helpline work may be particularly relevant for worker well-being.

Healthcare doi: 10.3390/healthcare14121679

Authors: Jenna A. P. Sim Ashley L. Exall Maneka A. Perinpanayagam Debra L. Isaac Kelly W. Burak Stefan Mustata S. Nicole Culos-Reed

Background/Objectives: Caregivers play a critical role in patient care across the pre- and post-transplant periods. However, the demands of caregiving can negatively impact caregivers’ own physical and psychosocial well-being. The Transplant Wellness Program (TWP) is a behavior change intervention that provides exercise support for pre- and post-kidney, pre- and post-liver, and post-lung transplant patients but has not yet included transplant caregivers. Thus, the purpose of this study was to explore the experiences and needs of organ transplant caregivers to inform the development of caregiver-specific support resources for the TWP. Methods: Semi-structured interviews with family caregivers of patients receiving kidney or liver transplant in the TWP were conducted and recorded via Zoom. Interview recordings were transcribed verbatim and analyzed using conventional content analysis. Results: Eight interviews were conducted, with caregivers in both the pre- (n = 4) and post-transplant (n = 4) periods. Four categories resulted from the data: caregiver strain, life changes, individual wellness needs, and caregiving needs. Nine sub-categories further described caregivers’ experiences and opportunities for wellness support. Conclusions: The caregiving experience was characterized by feelings of overwhelm, stress, and uncertainty. This study highlights the need for comprehensive services such as exercise classes, peer support programs, and tangible aide to support transplant caregivers’ well-being. Three caregiver resources were built out of this study and integrated into the TWP.

Healthcare doi: 10.3390/healthcare14121678

Authors: Elizabeth Brouwer Fulton Velez Junwei Tan

Background/Objectives: Successful revascularization following extremity arterial injury is critical for survival and limb salvage. Graft repair is required in ~45% of patients, with the autologous vein preferred for its efficacy and safety. When unavailable, synthetic or non-autologous grafts are associated with infection, amputation, and reduced durability. Extremity arterial injury-specific cost data are lacking, with estimates extrapolated from the general trauma literature. This study characterized the costs and post-discharge healthcare resource utilization (HCRU) for U.S. adults with extremity arterial injury undergoing graft repair. Methods: Adults with extremity arterial injury undergoing graft repair (January 2018 to March 2023) were identified from the linked PINC AI Healthcare Database and Inovalon all-payer claims. Hospitalization charges, costs, and 18-month post-discharge HCRU and costs were assessed. Two-part models estimated cost drivers, adjusted for demographics, clinical characteristics, and complications. Results: Among 964 patients, grafts were autologous (74%), synthetic (14%), other (6%), or multiple (6%). Mean initial hospitalization charges and reimbursed costs were $316,600 and $75,947, respectively. Charges/costs increased with orthopedic fracture (+$639,558/+$91,462), graft infection (+$589,921/+$84,598), and amputation (+$492,986/+$116,611) (all p < 0.05). Mean post-discharge costs were $70,222 at 6 months and $93,639 at 18 months. Initial hospitalization complications predicted increased post-discharge costs: orthopedic fracture ($138,683–$145,360) and graft infection ($389,376–$422,224) (both p < 0.01). Post-discharge aneurysm, graft infection, and thrombectomy were also associated with higher costs (all p < 0.05). Post-discharge HCRU was lowest and most stable with the autologous vein. Conclusions: In-hospital and post-discharge complications are major cost drivers following arterial graft repair. Graft infection was associated with significantly increased costs across both periods, and non-autologous graft use was associated with disproportionately higher 18-month HCRU.

Healthcare doi: 10.3390/healthcare14121677

Authors: Mihnea Nicodin Laura Nicodin-Tigoianu Anca Popescu Mariam Dalaty Diana Badiu Lucian Cristian Petcu Ovidiu Nicodin Cristian Delcea Nicolae Suciu

Background: The total vaginal hysterectomy (TVH) technique has been performed for many gynecological surgeries but is less used than total abdominal hysterectomy (TAH). The purpose of this study was to analyze the outcomes in patients who underwent either TVH or TAH for enlarged diffuse uterine adenomyosis (ADS). Methods: In this retrospective study, 160 hysterectomies with bilateral adnexectomy were scheduled for premenopausal women with diffuse ADS between 2020 and 2024 at a tertiary care center in Romania. The diagnosis was established based on clinical symptomatology, color Doppler transvaginal ultrasound, transabdominal ultrasonography and magnetic resonance imaging with histopathological confirmation of diffuse uterine ADS post-operatively from the hysterectomy specimen. All surgical procedures were performed by the same surgeon. The patients were divided into two groups: the TVH group (n = 80) and the TAH group (n = 80). Patient characteristics, including age, uterine weight, body mass index (BMI), parity, operative time, intraoperative blood loss, length of hospital stay, medical history, surgical history, intra- and postoperative complications, and the presence of adhesions, were evaluated. Results: No differences were observed between the two groups with regard to uterine weight, BMI, or parity. However, the TVH group was associated with significantly younger age, shorter operative time, lower intraoperative blood loss, and a reduced length of hospital stay (p < 0.001). Additionally, both medical and surgical histories were more frequently observed in the TAH group than in the TVH group. However, intra- (i.e., 3.75%) and postoperative complications (i.e., 13.75% vs. 3.75%) were slightly more frequent in the TAH group, as well as adhesions (i.e., 17.50% vs. 8.75%). Uterine hemisection, tactical myomectomy, or morcellation were frequently employed in the TVH group, being required in 77.5% of cases. Conclusions: In our cohort of patients with enlarged diffuse uterine ADS, TVH was associated with younger age, shorter operative time, reduced intraoperative blood loss, and a shorter length hospital stay compared with TAH, without an observed increase in perioperative complications. These results support the use of TVH as a feasible surgical approach for selected enlarged diffuse uterine ADS.

Healthcare doi: 10.3390/healthcare14121676

Authors: Diana Pop-Lodromanean Nicolae Grigore Adrian Hasegan Samuel Bogdan Todor Paula Anderco Radu Chicea Cristian Ichim Livia-Mirela Popa

Background: Perioperative outcomes in pelvic organ prolapse (POP) surgery remain difficult to predict due to substantial heterogeneity in both surgical techniques and patient characteristics. Existing studies typically evaluate these factors in isolation, limiting their ability to support individualized risk stratification. This study introduces a stratified analytical framework to disentangle the relative impact of procedural and patient-related determinants across common vaginal reconstructive approaches. Methods: A retrospective cohort of 376 women undergoing POP surgery between 2020 and 2025 was analyzed. Patients were stratified into three procedure groups: sacrospinous fixation with mid-urethral sling (SFM + TOT/TVT), anterior and posterior repair with sling (A&P + TOT/TVT), and isolated anterior and posterior repair (A&P alone). Key outcomes included intraoperative blood loss, length of hospitalization, postoperative hospital stay and catheterization time. Within-group predictors were assessed using stratified odds ratios and synthesized via a random-effects model. Results: Procedure type was consistently associated with recovery-related outcomes, although it explained only a modest proportion of outcome variability. Patients undergoing A&P repair exhibited significantly prolonged hospitalization (8.00 vs. 6.29 and 6.94 days), postoperative recovery (4.99 vs. 3.48 and 4.17 days), and catheterization duration (3.31 vs. 2.33 and 2.86 days) (all p < 0.001). In contrast, intraoperative blood loss was primarily driven by patient-specific factors, including concomitant hysterectomy, prolapse severity, obesity, age, and obstetric history. Prolonged hospitalization was strongly associated with combined procedural complexity and clinical burden, while catheterization duration was influenced by postoperative complications and parity. Conclusions: This study demonstrates that perioperative outcomes in POP surgery arise from distinct and interacting domains: procedural factors predominantly shape recovery trajectories, whereas patient characteristics govern intraoperative risk. The proposed stratified random-effects framework enables integrated evaluation across heterogeneous surgical groups and provides an exploratory basis for identifying domains that may inform future individualized perioperative risk models.

Healthcare doi: 10.3390/healthcare14121675

Authors: Miruna Popovici Nilima Rajpal Kundnani Marius Papurica Anca-Raluca Dinu Victor Buciu Ovidiu Horea Bedreag Elena Sîrbu Dorel Sandesc Simona Ruxanda Dragan

Background: Many patients with heart failure with reduced ejection fraction (HFrEF) remain undertreated in routine practice. Delayed treatment intensification, poor adherence, and fragmented follow-up are common barriers. Low-cost digital support may help reduce this implementation gap. Objective: This study evaluated whether a simple digital support pathway was associated with better 6-month treatment adherence and guideline-directed medical therapy (GDMT) optimization in ambulatory patients with stable HFrEF. Methods: This single-center matched cohort study compared a prospective digital-support cohort with a historical usual-care cohort. The intervention combined smartphone-based telemanagement, home blood pressure and heart-rate reporting, daily weight surveillance, and scheduled video consultations. The co-primary endpoints were treatment adherence at 6 months and GDMT optimization, assessed by change in foundational HFrEF drug classes and by a prespecified exploratory GDMT optimization score. Results: After 1:1 propensity-score matching, 200 patients were included, with 100 patients in each cohort. Treatment adherence at 6 months was higher in the digital-support cohort than in usual care (82.0% vs. 64.0%, p = 0.004). The intervention cohort also had more frequent class addition, more dose escalation, a greater increase in foundational drug classes, and a larger improvement in GDMT optimization score (all p < 0.001). Heart failure hospitalization and the composite of heart failure hospitalization or all-cause death were less frequent in the digital-support cohort, but these clinical outcomes were exploratory. Conclusions: A pragmatic low-cost digital support pathway was associated with better adherence and more complete GDMT optimization in ambulatory patients with HFrEF. The findings support further prospective multicenter evaluation.

Healthcare doi: 10.3390/healthcare14121674

Authors: Anastasia Bothou Angeliki Bolou Konstantinos Dinas Giannoula Kyrkou Deniece Hardy Panagiota Pappou Pinelopi Varela Georgia Margioula-Siarkou Myrsini Balafouta Athina Diamanti

Background: Breast cancer (BC) remains one of the leading causes of cancer-related deaths worldwide, with early detection being essential for improving survival rates, treatment outcomes, and preventive women’s healthcare strategies. Artificial Intelligence (AI), particularly deep learning (DL) and machine learning (ML) algorithms, has emerged as a promising tool for improving the accuracy and efficiency of BC diagnosis. This systematic review explores the role of AI in early BC detection and its implications for preventive and patient-centered women’s healthcare. Methods: A comprehensive search was conducted in PubMed and Scopus for studies published between January 2015 and December 2025, following PRISMA guidelines. The search strategy included combinations of MeSH terms and free-text keywords related to artificial intelligence, machine learning, deep learning, BC screening, mammography, magnetic resonance imaging (MRI), ultrasound, and BC detection. Eleven studies involving approximately 148,170 participants were included. Methodological quality was assessed according to study design. Results: AI-driven diagnostic systems demonstrated improved accuracy, sensitivity, specificity, and efficiency compared with conventional approaches. AI applications in mammography and ultrasound reduced radiologists’ workload and healthcare costs while enhancing cancer detection rates, particularly in women with high breast density. AI models also showed potential in identifying metastases and predicting clinical outcomes, supporting more efficient patient management and follow-up care. Conclusions: AI-based tools represent a promising advancement in BC detection and screening efficiency. Their integration into BC screening programs may strengthen preventive women’s healthcare services and improve patient outcomes. However, further large-scale clinical validation and real-world implementation studies are required before widespread clinical implementation.

Healthcare doi: 10.3390/healthcare14121673

Authors: Željko Krznarić Darija Vranešić Bender Dina Ljubas Kelečić Nikica Daraboš Ivan Radoš Ana Soldo

Background/Objectives: Disease-related malnutrition affects millions of patients worldwide. Nutrition support therapy (NST), namely oral nutritional supplements (ONSs), serve as a cornerstone therapeutic intervention. However, treatment effectiveness depends not only on an appropriate prescription but also on patient acceptance and adherence. This study evaluates the provision pathway of ONSs within a co-payment healthcare system, focusing on patient acceptance patterns, barriers to adherence, and the critical yet underexplored role of pharmacist–patient interactions in determining treatment outcomes. Methods: A cross-sectional observational study was conducted across 100 Croatian community pharmacies during September–October 2025. Pharmacists prospectively documented 973 patient encounters involving ONS prescriptions requiring co-payment using real-time patient record forms. Data captured patient demographics, diagnoses, prescription patterns, prior knowledge of co-payment requirements, acceptance responses, and pharmacist-assessed reasons for refusal. Results: While 65% of all patients knew about co-payment requirements in advance, 51% of first-time users arrived uninformed, leading to dramatically different acceptance patterns (93% immediate acceptance when informed versus 33% when uninformed, p < 0.05). Overall, 8–12% of patients refused or reduced prescribed ONSs. Among refusals, 59% cited the financial burden, but, critically, 23% appeared not to understand why an ONS was prescribed or what benefits to expect, revealing significant communication gaps in the care pathway. Overall, fifteen percent of patients required an explanation from the pharmacist before accepting their prescription, demonstrating pharmacists’ decisive role as gatekeepers of nutritional therapy. Conclusions: These findings suggest that the pharmacy dispensing encounter is an important decision point in the ONS care pathway, where insufficient preparation and coordination may be associated with suboptimal treatment outcomes among vulnerable patient populations. Improved prescriber–patient communication about co-payment and clinical rationale, pharmacist education in disease-specific nutrition and ONS counseling, and structured communication protocols between prescribers and pharmacists represent areas that may warrant further attention and evaluation.

Healthcare doi: 10.3390/healthcare14121672

Authors: Josipa Glavaš Roberta Matković Mirjana Rumboldt Jure Aljinović

Background/Objectives: Adolescent idiopathic scoliosis (AIS) is a multifactorial condition with an unclear etiology. Previous studies have reported associations of scoliosis with female sex, lower body mass index (BMI), and lower physical activity levels. This study examined factors associated with suspected scoliosis identified through school screening, with emphasis on BMI and sports participation. Methods: A cross-sectional study was conducted during the 2019/2020 school year and included 18,216 adolescents. Suspected scoliosis was identified using the forward bend test (FBT). Logistic regression analysis assessed associations between suspected scoliosis and sex, grade, BMI, participation in the seven most frequently reported sports, and training frequency. Results: Higher BMI (odds ratio (OR) = 0.91, p < 0.001), participation in soccer (OR = 0.64, p < 0.001), gymnastics (OR = 0.58, p = 0.05), martial arts (OR = 0.66, p = 0.02), and higher recreational training frequency (OR = 0.92, p < 0.001) were associated with lower odds of suspected scoliosis. Female sex (OR = 2.49, p < 0.001) and higher grade level (6th: OR = 1.54; 8th: OR = 2.98; p < 0.001) were associated with increased odds of suspected scoliosis. Conclusions: Suspected scoliosis identified through school screening was more frequently observed among females and adolescents with lower BMI. Participation in certain sports and greater recreational physical activity were associated with lower prevalence and odds of suspected scoliosis. These findings reflect screening-based associations and do not imply causal relationships. The results support the importance of school-based screening and consideration of body composition and physical activity patterns in the early identification of adolescents with suspected scoliosis.

Healthcare doi: 10.3390/healthcare14121671

Authors: Kristen A. Waters Serena K. Kaul Sritha R. Donepudi Sophia D. Danchine Jennifer M. Hilgeman Gregory M. Eberhart John M. Pascoe

Background/Objectives: Children of families facing unmet social needs experience higher rates of adverse outcomes compared to those not experiencing unmet social needs. This study aimed to identify factors associated with families’ unmet social needs as reported by parents or guardians at their children’s primary care visits. Methods: This cross-sectional study recruited English-speaking primary caregivers of children less than 18 years of age from the Southwestern Ohio Ambulatory Research Network (SOAR-Net) who were surveyed between January 2023 and August 2024. Surveys included the Maternal Social Support Index, Social Capital Scale, RAND Depression Screener, Children with Special Health Care Needs Screener, Medical Expenses of Children Survey, a 10-item social needs screener, and demographics. Data were analyzed with chi-square or Fisher’s exact tests, adjusted logistic regression, and ANOVA. Results: Among 1167 respondents (78% response rate), 1114 provided complete data. Primary caregivers were predominantly mothers (79.9%) or fathers (13.6%), White (72.0%) or Black (16.0%), and had an associate’s degree or less (65.1%). The mean (SD) index child’s age was 6.4 (5.3) years, and 52.4% were female. Underinsurance, positive depression screens, and poor child health were positively associated with unmet social needs. Higher scores for social support and social capital were associated with fewer social needs. Multinomial logistic regression revealed significant relationships with reporting two or more unmet social needs with the following variables: childhood underinsurance, household annual income < $50,000, positive depression screens, raising a child with a chronic health condition, and Black race/ethnicity. Conclusions: Several significant social factors were independently associated with a greater number of unmet social needs. These findings highlight the complex interplay among social factors in children’s healthcare. Future research should explore the putative longitudinal stability of these relationships.

Healthcare doi: 10.3390/healthcare14121670

Authors: Eunjung Kim Boyoung Kim Hae Ran Kim

Background: Unmet healthcare needs are a significant public health concern among older adults, particularly those with chronic conditions such as osteoporosis. This study aimed to identify several key factors associated with unmet healthcare needs among older adults with osteoporosis using Andersen’s behavioral model. Methods: This observational, cross-sectional study examined data from the 2025 Korea Community Health Survey, analyzing responses from 20,988 individuals aged ≥ 65 years with physician-diagnosed osteoporosis. General characteristics were analyzed using descriptive statistics in terms of frequencies and percentages. Variables were categorized into predisposing, enabling, and need factors. Complex sample analyses were performed using the Rao–Scott chi-square test and multivariable logistic regression. Results: In the multivariable analysis, female sex (adjusted odds ratio [aOR] = 1.44, 95% confidence interval [CI]: 1.08–1.91), poor health literacy (aOR = 1.56, 95% CI: 1.31–1.87), and rural residence (aOR = 1.36, 95% CI: 1.18–1.58) were significantly associated with higher odds of unmet healthcare needs. Among the need factors, fall experience (aOR = 1.56, 95% CI: 1.34–1.83), pain or discomfort (aOR = 2.40, 95% CI: 1.93–2.99), and elevated stress (aOR = 2.37, 95% CI: 2.02–2.79) were also significantly associated with unmet healthcare needs. Conclusions: Beyond accessibility, unmet healthcare needs among older adults with osteoporosis in Korea were associated with cognitive, health-related, and regional factors. Interventions should prioritize improving health literacy, managing pain and psychological distress, and strengthening osteoporosis care pathways, specifically focusing on follow-up care and fragility fracture prevention.

Healthcare doi: 10.3390/healthcare14121669

Authors: Sunkyung Cha Miran Jung Geun Myun Kim Seong Kwang Kim

Background/Objectives: Because the numbers of middle-aged and older adults living alone in Korea have substantially increased, which warrants greater attention to their health-related quality of life. Therefore, we aimed to develop a predictive model for the health-related quality of life among community-dwelling middle-aged and older adults living alone. Methods: Using 2022 Korea Health Panel Survey data, 1313 participants with complete EQ-5D component data were analyzed. All candidate predictors were entered into benchmarked models without pre-model feature selection. Preprocessing and 5-fold cross-validated hyperparameter tuning were conducted within the training data. Final performance was evaluated on a held-out test set, and the selected model was interpreted using SHAP. Results: XGBoost had the lowest training cross-validated RMSE and was selected as the final explainable model. On the test set, it showed moderate performance (R2 = 0.373, MAE = 0.070, RMSE = 0.096), outperforming the mean baseline model (RMSE = 0.121) but remaining comparable with other top-performing models. Predictions were within absolute errors of 0.05 and 0.10 for 45.6% and 76.4% of participants, respectively. SHAP ranked subjective health, age, walking time, need for care, and monthly household income as the five highest-ranked predictors. Other highly ranked predictors included unmet medical needs, total annual out-of-pocket expenditure, disability, anxiety, and regular exercise. Conclusions: These findings may inform targeted interventions and support strategies, although external validation and longitudinal studies are needed to confirm generalizability and causal relationships.

Healthcare doi: 10.3390/healthcare14121668

Authors: Shengyan Sun Wenxue Sun Shan Liao Min Wang

Background/Objectives: Adherence to the 24-h movement guidelines is generally low in preschool children, and less is known about how proximal family support for children’s physical activity (family PA support) is associated with physical fitness and 24-h movement behaviors. This study aimed to describe guideline adherence and to examine the associations among family PA support, 24-h movement behaviors, and physical fitness in Chinese preschool children. Methods: This cross-sectional study included 2386 Chinese preschool children (4.50 ± 0.86 years, 46.8% girls). Family PA support and 24-h movement behaviors were assessed using parent-reported questionnaires, and physical fitness was assessed using the Chinese National Physical Fitness Evaluation Standard for preschool children. Path analysis was used to examine the overall association pattern, including direct and indirect association estimates, among family PA support, movement behaviors, and physical fitness. Results: Only 12.7% of preschool children met all three 24-h movement recommendations. Compliance was 24.7% for physical activity, 82.7% for screen time, and 76.8% for sleep, indicating that insufficient physical activity was the main barrier to full guideline adherence. Family PA support was positively associated with physical fitness (β = 0.048, p = 0.021), and the combined indirect association estimate involving the three movement behaviors was also statistically significant (β = 0.024, p < 0.001). Among the three movement behaviors, family PA support was most strongly associated with higher MVPA (β = 0.150, p < 0.001), and MVPA showed the clearest positive association with physical fitness (β = 0.155, p < 0.001). Screen time was negatively associated with family PA support (β = −0.088, p < 0.001) but not significantly associated with physical fitness (p = 0.091), whereas sleep showed a small negative association with physical fitness (β = −0.056, p = 0.005). These findings suggest a comparatively stronger role for MVPA within the observed association pattern. Conclusion: Chinese preschool children showed low adherence to the 24-h movement guidelines, with insufficient physical activity appearing to be the main limiting factor. Family PA support may represent a potentially modifiable family-level correlate of preschool children’s physical fitness, with MVPA appearing to play a comparatively stronger role within the observed association pattern.

Healthcare doi: 10.3390/healthcare14121667

Authors: Guorui Chen Bo Zhang Yicheng Zhang Kun Song

Background/Objectives: College student health has become a global public health concern, with campus environments serving as critical resources for supporting healthy lifestyles. This study aimed to identify heterogeneous associations between health-related lifestyle parameters and health status among university students, as well as the relationships between these parameters and campus environmental factors. Methods: A two-stage analytical approach was applied to 909 student responses from five Chinese universities. Stage One employed hierarchical regression to identify lifestyle parameters significantly associated with health status. Stage Two used EFA-derived factors and LASSO robustness checks to examine campus environmental factors linked to these key parameters. Results: Six lifestyle parameters were significantly associated with student health: physical exercise frequency, physical exercise duration, active commuting frequency, nature contact frequency, healthy diet frequency, and self-rated health literacy. Each parameter exhibited distinct patterns of environmental association. Conclusions: These findings provide empirical evidence for redefining health-promoting campus design through targeted environmental interventions.

Healthcare doi: 10.3390/healthcare14121666

Authors: Enos M. Rampamba Stephen M. Campbell Brian Godman Johanna C. Meyer

Background/Objectives: Hypertension contributes to almost 5 million deaths annually, exacerbated by poor quality of care. Currently in South Africa, the quality of care for patients with hypertension is unknown, and there have been no agreed-upon quality indicators to measure this at the primary healthcare (PHC) level. Quality indicators have previously been developed to address this although their acceptability in PHC facilities in South Africa has not been established. Consequently, we aimed to explore the acceptability of these indicators, and their subsequent use for monitoring adherence to hypertension guidelines, as well as assess their availability and accessibility. Subsequently, identify recommendations for service-delivery changes to improve the uptake of evidence-based indicators into routine practice and the quality of hypertension care in South Africa. Methods: Questionnaire survey during semi-structured interviews with one key informant from 12 PHC clinics where the indicators had previously been tested. Results: Most facilities accepted hypertension quality indicators to improve hypertension management and patient outcomes. Ten clinics had assessed the facility’s quality of care, and all had access to hypertension guidelines. However, only two clinics had a hypertension-specific patient register. Concerns also included a manual data management system and nurse shortages. Conclusions: Large-scale application of quality indicators would facilitate evidence-based decisions for future use at PHC clinics to improve monitoring of adherence to hypertension guidelines and patient outcomes. However, this needs investing in electronic information management to improve data accuracy and management alongside a nursing workforce strategy. Replicating this study in other LMICs can provide comparable preliminary data within the region.

Healthcare doi: 10.3390/healthcare14121665

Authors: Gulsum Ozturk Emiral Pakize Gozde Gok Alaettin Unsal Didem Arslantas Engin Ozakin Nurdan Acar

Aim: This study aimed to assess the health literacy (HL) levels of patients visiting the emergency department of a university hospital and identify related factors. Methods: This cross-sectional study aimed to assess the health literacy levels of patients visiting the emergency department of a university hospital, and to identify related factors. The re-quired sample size was at least 384 individuals, assuming an inadequate HL level of 50%, with 95% confidence interval and 5% margin of error. Data were collected through a two-part questionnaire designed by the researchers. The first part covered the patients’ socio-demographic characteristics and details regarding their emergency department visits. Meanwhile, the second part included the widely used Chew’s short questions to assess inadequate HL. The analysis was conducted using IBM SPSS version 27.0. Descriptive sta-tistics, including frequency, percentage, and mean, were used to summarize the charac-teristics of the study group. The Chi-square test was applied for data analysis. Results: The study group included 58% (n = 250) female and 42% (n = 181) male. Their ages ranged from 18 to 64 years, with a mean (SD) of 29.6 (10.8) and a median of 26.0. In terms of HL levels, 197 individuals (45.7%) had inadequate HL. The frequency of inadequate HL was higher in individuals over the age of 40 years and those with an education level of ≤8 years (p < 0.05 for each). A total of 39.2% (n = 169) of the patients had visited the emergency department multiple times for their current complaints, whereas 243 participants (56.4%) visited the emergency department for a different reason within the past six months. Conclusions: In our study, four out of ten individuals had inadequate HL, and the frequency of repeated emergency department visits was quite high. No statistically significant association was found between emergency department usage characteristics and health literacy levels in the present sample, highlighting the need for larger longitudinal studies with adjusted analyses.

Healthcare doi: 10.3390/healthcare14121664

Authors: Jun Norkaew Rattanathorn Intarak Ranee Wongkongdech

Background: The increasing use of e-cigarettes among adolescents is a growing public health concern in Thailand, where they are prohibited but remain accessible. This study aimed to examine the psychosocial correlates of preventive behaviors regarding e-cigarettes among adolescents in central Thailand. Methods: A cross-sectional correlational study was conducted with 383 secondary school students (Grades 7–12) selected through proportionate stratified random sampling from two government schools in Ongkharak District, Thailand. Data were collected using a validated self-administered online questionnaire assessing attitudes toward e-cigarettes, peer influence, family attachment, and preventive behaviors. Item analysis, confirmatory factor analysis (CFA), and factor-score regression with bootstrapped indirect-association analysis (k = 5000) were performed to examine direct and indirect associations. Results: The four-factor measurement model demonstrated acceptable absolute fit (SRMR = 0.069) but weaker incremental fit (CFI = 0.70), expected given the large number of ordinal indicators estimated via maximum likelihood, with standardized factor loadings ranging from 0.621 to 0.926 (p < 0.001). The structural model explained 44.2% of the variance in preventive behaviors (R2 = 0.442). Family attachment showed the strongest total association (β = 0.456), including both direct and indirect associations through attitudes (β = 0.116) and peer influence (β = 0.162), consistent with a pattern of statistically significant indirect associations. Conclusions: Family attachment was associated with self-reported e-cigarette preventive behavior, with statistically significant indirect associations through attitudes and peer influence. Given the cross-sectional design, these findings should be interpreted as model-consistent associations rather than causal mediation, and may inform future family- and peer-oriented prevention research in comparable settings.

Healthcare doi: 10.3390/healthcare14121663

Authors: Carmine Cristiano Di Gioia Daniele Orso Alice Alame Jessica Vella Michela D’Apolito Gianmarco Sicuranza Eli Ollari Lorenzo Bianchi Marcello Boccardi

Background: Renal colic is a common emergency department (ED) presentation requiring rapid and accurate diagnosis. Point-of-care ultrasound (POCUS) is a fast, radiation-free alternative to CT. The Copetti sign—a rhythmic anteroposterior oscillation of the affected kidney—has been proposed as a dynamic sonographic marker of distal ureteral stones. Methods: In this prospective observational study (June–September 2025), 44 adult patients with suspected renal colic were enrolled at a single-center ED in Baggiovara, Modena, Italy. All underwent standardized POCUS to detect the Copetti sign prior to confirmatory imaging. Clinical, laboratory, and sonographic variables were collected. Associations between the Copetti sign, stone location, stone size, hydronephrosis, urinoma, and management strategy were explored. Associations with conservative management were considered exploratory. Results: The Copetti sign was identified in 70.5% of patients and was significantly associated with distal ureteral stones (74.2% vs. 25.8%, p = 0.005). Copetti-positive patients were more often managed conservatively (77.4% vs. 38.5%, p = 0.019), although this likely reflects the underlying clinical-imaging phenotype and local treatment decisions rather than a validated prognostic endpoint. Conclusions: In this prospective pilot cohort, the Copetti sign was frequently observed and was strongly associated with distal ureteral stone location. Copetti-positive patients were also more often managed conservatively, although this should be interpreted as an exploratory association reflecting clinical decision-making rather than a validated prognostic endpoint.

Healthcare doi: 10.3390/healthcare14121662

Authors: Mingzhu Wu Hongfei Zhang Kunpeng Li Mariusz Lipowski Wenjun Hu

Artificial intelligence (AI), virtual reality (VR), and exergame technologies have been increasingly used in dance and movement activities. However, this literature remains dispersed across different areas, making it difficult to determine how the field has developed. This study mapped the research landscape and thematic development of AI-, VR-, and exergame-based dance and movement research on psychological outcomes using bibliometric analysis and latent Dirichlet allocation (LDA) topic modeling. A total of 252 records indexed in the Web of Science Core Collection from 2011 to 2025 were included. Five related thematic strands were identified: immersive dance interaction and technology-supported teaching; rehabilitation-oriented dance or rhythm training; school-based exergaming and psychophysiological assessment; behavioral program design and intervention implementation; and AI-based motion or emotion recognition. These strands indicate that the field has developed into a multi-layered research space shaped by technology functions, movement contexts, intervention formats, and psychological constructs, rather than a single dance-intervention or technology-application domain. At the same time, psychological outcomes were not represented with equal clarity across these strands. Participation-related and psychosocial constructs, including enjoyment, motivation, engagement, self-efficacy, social interaction, emotional expression, and quality of life, were more frequently represented, whereas mental-health-related outcomes such as anxiety, depression, stress, loneliness, and psychological well-being were less consistently connected to technology-supported dance or movement interventions. These findings clarify where evidence is concentrated, how major themes are organized, and where psychological outcome measurement requires clearer theoretical and methodological specification. Future studies should use comparative and longitudinal designs to examine whether VR/AI-based feedback-supported movement training offers added value over conventional dance or movement programs for psychological outcomes, participation, exercise experience, and longer-term behavior change.

Healthcare doi: 10.3390/healthcare14121661

Authors: Jiayi Li Fulong Shang Moran Lyu Qingyi Wang Xiaohan Wang Yuliu Tao

Background/Objectives: Sleep disturbance is common in older adults and is associated with impaired daily functioning and poorer health-related outcomes. This study examined whether a 12-week Health Qigong program could improve subjective and objective sleep quality in older adults with self-reported sleep disturbance. Methods: Sixty adults aged 55 years or older who reported poor sleep and had Pittsburgh Sleep Quality Index total scores above 5 were randomly allocated to an intervention group or a control group (30 participants per group; 10 men and 20 women in each group). Both groups received health education and lifestyle guidance, and the intervention group completed supervised Health Qigong sessions twice weekly. Sleep quality was assessed before and after the intervention using the Pittsburgh Sleep Quality Index and wrist actigraphy. Results: Baseline characteristics were comparable between groups. In adjusted post-intervention comparisons, the intervention group showed lower Pittsburgh Sleep Quality Index scores, higher sleep efficiency, less wake after sleep onset, fewer awakenings, shorter average awake time, and longer total sleep time than the control group. The adjusted group difference for sleep onset latency was not significant. Conclusions: These preliminary findings suggest that Health Qigong may be a feasible community-based practice for improving sleep quality in older adults with self-reported sleep disturbance. The overall pattern was more consistent with improvement in sleep continuity than in sleep onset latency, although this interpretation should remain cautious because no direct contrast between sleep maintenance and sleep initiation was tested.

Healthcare doi: 10.3390/healthcare14121660

Authors: João Miguel Alves Ferreira Sergii Tukaiev Vaitsa Giannouli

Background/Objectives: Large language models (LLMs) and generative AI are rapidly being integrated into healthy ageing initiatives for tasks ranging from companionship and cognitive support to personalised health advice and reduction in social isolation among older adults. Current ethical discussions predominantly address bias, privacy, and accuracy, leaving unresolved three critical governance questions: How do LLM sentiments towards transformative technologies diverge from human values in ageing contexts? What epistemic status do LLM outputs hold when applied to geriatric care? When is trust in those outputs justified for older adults? And who bears responsibility when AI-informed decisions affect functional ability or well-being? Methods: The framework was developed through normative conceptual analysis, synthesizing philosophical principles of medical knowledge and trust, ethical theories of responsibility, empirical evidence on LLM sentiment divergence, digital ageism, and applications of AI in geriatric care (structured searches in PubMed, PhilPapers, and relevant databases, January 2020–March 2026). Results: The integrated framework produces (i) adaptation of SAIA for multidimensional evaluation of human–machine value convergence specific to healthy ageing values (functional ability, autonomy, dignity, equity); (ii) a four-tier classification of LLM outputs tailored to geriatric scenarios; (iii) conditions for warranted trust calibrated to age-related vulnerabilities such as cognitive decline and digital divide; and (iv) responsibility allocation via RACI models with testable hypotheses linking governance design to trust calibration and patient safety outcomes. Conclusions: Without explicit societal alignment and epistemic governance, generative AI risks reinforcing benevolent ageism, automation bias, and responsibility gaps in healthy ageing. The 2025–2027 period offers a decisive window to shape institutional norms that place functional capacity, human dignity, and value convergence at the centre of AI deployment in geriatric care.

Healthcare doi: 10.3390/healthcare14121657

Authors: Jeonghye Yun Hyunjung Lee

Background: Korean registered nurses face substantial cumulative occupational stress. Telomere length, a biomarker of cellular aging, is increasingly used in occupational stress research, but evidence on early-career Korean nurses is scarce. This study examined the association between occupational characteristics and telomere length in female nurses aged 20–39 years. Methods: Sixty-eight female nurses from a tertiary hospital in South Korea completed the questionnaires. We assessed demographics, occupational factors, burnout (Maslach Burnout Inventory), and sleep quality (Pittsburgh Sleep Quality Index—Korean [PSQI-K]). Salivary telomere length was measured using quantitative polymerase chain reaction (qPCR). Data were analyzed using t-tests, ANOVA with a Bonferroni post hoc test, Pearson correlations, and multivariable linear regression. Results: Participants showed moderate to high burnout levels (Emotional Exhaustion [EE] = 24.78 ± 10.96), with 41.2% exceeding the high EE threshold. Sleep quality was poor (PSQI-K = 7.90 ± 3.07), with 82.4% exceeding the cut-off. Univariable analyses revealed that younger age, unmarried status, shorter work experience, and higher personal accomplishment were associated with longer telomeres (all p < 0.05); multivariable analysis identified only age group as a significant predictor (B = −2.055 kb for nurses aged ≥30 years compared to those <30 years, p < 0.001). The model explained 83% of the variance in telomere length. Shift work, burnout, and sleep quality were not significantly associated with telomere length after controlling for age. Conclusions: Age was the main factor associated with telomere length in young female nurses, suggesting that biological manifestation of occupational effects may require longer exposure. The high prevalence of burnout and sleep disturbances warrants immediate organizational intervention. Saliva-based qPCR demonstrated reliable precision as a non-invasive method for biological monitoring in occupational health research. These findings provide a basis for future longitudinal studies examining the cumulative effects of occupational stress and inform targeted wellness interventions for early-career nurses.

Healthcare doi: 10.3390/healthcare14121659

Authors: Juan Aristegui-Mondaca Gabriel Rodríguez Sepúlveda Eduardo Guzmán-Muñoz Jordan Hernandez-Martínez Joaquín Perez-Carcamo Edgar Vásquez-Carrasco Eugenio Merellano-Navarro Braulio Henrique Magnani Branco Eduardo Carmine-Peña Cristian Sandoval-Vásquez Francisca Peña Pablo Valdés-Badilla

Objective: This study aimed to examine the associations of morphological variables, maximal isometric handgrip strength (MIHS), and static postural balance with self-esteem, motivational climate, school climate, and health-related quality of life (HRQoL) in early adolescents. Methods: A cross-sectional study was conducted in 235 Chilean adolescents, in whom morphological variables, MIHS, and static postural balance were assessed using center-of-pressure (CoP) parameters under eyes-open (EO) and eyes-closed (EC) conditions. Psychosocial variables, including self-esteem, motivational climate, school climate, and HRQoL, were evaluated via validated questionnaires. Multiple linear regression analyses were performed to determine associations between physical and psychosocial variables. Results: Reduced CoP sway area and lower CoP velocity under eyes-closed conditions were significantly associated with higher self-esteem (R2 = 0.168; p < 0.001). Greater non-dominant MIHS and younger age were associated with more favorable perceptions of a task-involving motivational climate (R2 = 0.438; p < 0.001). Higher HRQoL scores were associated with male sex and better postural balance performance. Conclusions: Better static postural balance and greater muscle strength were associated with more favorable psychosocial outcomes, particularly self-esteem and HRQoL. However, these findings should be interpreted as associative rather than causal relationships due to the cross-sectional design.

Healthcare doi: 10.3390/healthcare14121658

Authors: Şehma Şen Şeyma Demiralay

Background/Objectives: This systematic review aims to synthesize existing evidence on the impact of nursing interventions based on Watson’s Theory of Human Caring (THC) on women’s mental health and to provide an evidence-based framework for clinical practice. Methods: The review followed the PRISMA guidelines and was registered in the PROSPERO database (Registration No: CRD420251111577). A comprehensive literature search was conducted across databases, including PubMed, CINAHL, and Google Scholar. Ten studies (nine randomized controlled trials and one quasi-experimental study), involving 869 participants, met the eligibility criteria. Data were analyzed using a narrative synthesis approach due to methodological and clinical heterogeneity. Results: A total of 10 studies involving 894 women met the inclusion criteria. Geographically, nine studies were conducted in Türkiye and one in Iran. The included studies spanned various clinical contexts directly associated with significant mental health challenges for women, including medical abortion, infertility, gynecological oncology, and the postpartum period. The synthesized findings demonstrated that nursing interventions based on Watson’s Human Caring Theory led to statistically significant reductions in anxiety, depression, stress, postpartum depression risk, and infertility-related distress. Furthermore, these caritas-based frameworks significantly enhanced positive psychological assets, including self-efficacy, hope, meaning in life, prenatal attachment, and social support perception. Conclusions: Watson’s Theory of Human Caring provides a transformative framework for women’s health nursing that extends beyond symptom management to strengthen the individual’s internal resources and spiritual integrity. Integrating this theory into clinical protocols and nursing curricula is essential for humanizing care and protecting women’s mental health during challenging life transitions, particularly within the examined sociocultural contexts.

Healthcare doi: 10.3390/healthcare14121654

Authors: Igor Goričan Andrej Šorgo Matej Strnad

Background and Objectives: Slovenia, like many other European nations, has introduced voluntary first responders to enhance survival rates in out-of-hospital cardiac arrests. In currently published research, no conclusive data exists on the optimal retraining interval, categorizing recommendations as expert opinion with limited reliability. Materials and Methods: Between 2019 and 2024, observational longitudinal research and a cross-sectional comparison was conducted in accordance with national guidelines on Slovenian newly certified (N = 342; 227 males, 112 females and three participants with missing or undetermined gender; mean age, 31.3 ± 12.2 years) and senior (N = 140; 105 males, 35 females; mean age, 38.0 ± 11.9 years) licensed first responders (LFRs) with 5–10 years of experience (median = 6.5, IQR 6–7). LFRs were reassessed for retention of skills and knowledge one year after previous certification. Additionally, each cohort was classified into groups according to the number of interventions they engaged in over the past year, and their retention of skills and knowledge was assessed. Results: During the initial year of service, no statistically significant decline in practical skills (median 53 [52–54] vs. 53 [50–54]; p = 0.059) or theoretical knowledge (median 10 [9–10] vs. 9 [9–10]; p = 0.458) was observed among newly certified LFRs. In contrast, senior LFRs demonstrated significantly lower practical skill scores prior to recertification compared with newly certified LFRs (median 51 [49–54] vs. 54 [52–55]; p < 0.001), whereas theoretical knowledge remained stable (median 9 [8.5–10] vs. 10 [9–10]; p = 0.091). Intervention frequency did not affect skill or knowledge retention among newly certified LFRs. However, senior LFRs who did not participate in any interventions during the certification period demonstrated significantly lower practical skill scores comparable to newly certified LFRs (median 49 [47–51] vs. 54 [52–55]; p < 0.001), whereas those who participated in at least one intervention showed no significantly lower scores (median 52 [50–54] vs. 54 [52–55]; p = 0.117). No significant reduction in theoretical knowledge was observed. Linear regression analysis demonstrated that participation in at least one intervention significantly predicted higher practical skill scores among senior LFRs (β = −1.11, p = 0.001), whereas no significant association was observed for theoretical knowledge retention or among newly certified LFRs. Conclusions: The initial training for Slovenian LFRs was found to be adequate. However, senior LFRs who did not participate in interventions demonstrated lower practical skill performance compared with newly certified LFRs. Further evaluation and different strategies for recertifying senior LFRs should be adopted, considering the number of interventions they have been involved in after last certification.

Healthcare doi: 10.3390/healthcare14121656

Authors: Punipuao Mariner Samuela ‘Ofanoa Seita Meneua Malakai ‘Ofanoa Felicity Goodyear-Smith Siobhan Tu’akoi

Background/Objectives: Despite the potential use of social media for health promotion and education among Pacific communities, there is a lack of understanding regarding how it is used and how interventions can best utilize it. This scoping review aims to explore how social media is used for health purposes within Pacific communities and the potential benefits, challenges and opportunities. Methods: This review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews. Databases and grey literature sources were searched for health-related primary research studies that focused on Pacific communities and included social media. Thematic analysis was used to synthesize the included studies and create codes that reflected the text. Results: A total of 37 studies were included, with most mentioning social media as a key finding (35%), while others approached social media as a recruitment strategy (30%), research topic (22%), intervention tool (14%) or recommendation for use in future approaches (11%). The benefits of social media mentioned in health-related studies for Pacific people include access to health information and services and providing a safe and familiar space. Challenges and risks included misinformation, lack of digital literacy, a disconnect with Pacific cultural norms and the negative impacts of prolonged time on social media. Conclusions: Our findings highlight the potential of culturally grounded social media approaches for health promotion among Pacific communities. To support health promotion in the modern world, there are clear opportunities for developing digital literacy, preserving cultural knowledge, identifying trusted voices to disseminate health knowledge and ensuring social media approaches are evaluated for impact and effectiveness.

Healthcare doi: 10.3390/healthcare14121655

Authors: Liqing Li Jiashan Teng Haifeng Ding

Background: Population ageing and the gradual implementation of delayed retirement policies have drawn increasing attention to the lives of older adults after retirement age. Although previous studies have examined the relationship between retirement and health outcomes, limited evidence is available on whether continued workforce participation after retirement age affects healthcare utilization. Methods: Using nationally representative data from the 2018 China Health and Retirement Longitudinal Study (CHARLS), we employ negative binomial regression as the baseline model and use an instrumental variable two-stage least squares (IV-2SLS) to address endogeneity. We further conduct heterogeneity and mechanism analyses. Results: The findings reveal that workforce participation after retirement age significantly reduces healthcare utilization: post-retirement workers have 42.1% fewer outpatient visits and 49.2% fewer inpatient admissions than their fully retired counterparts. Mechanism analyses indicate that the negative effect operates primarily through tighter time constraints that crowd out care-seeking time and income fluctuations that alter health investment behaviors. Heterogeneity analyses further show that the reduction in outpatient utilization is more pronounced among males and highly educated individuals, whereas the reduction in inpatient utilization is stronger for females and those with good self-rated health. Conclusions: Workforce participation after retirement age may hinder healthcare utilization among older adults. These findings reveal an unintended consequence of delayed retirement policies and call for flexible, targeted arrangements to balance labor participation and healthcare access for older workers.

Healthcare doi: 10.3390/healthcare14121653

Authors: Christopher K. Haddock Luther Elliott Andrew Kolodny Christopher M. Kaipust Walker S. C. Poston Jennifer D. Oliva Eleanor T. Lewis Elizabeth M. Oliva Nattinee Jitnarin Chunki Fong

Error in Conflicts of Interest Statement [...]

Healthcare doi: 10.3390/healthcare14121652

Authors: Kelsey Lee Julia Yates Andrew M. Johnson Liliana Alvarez Jeffrey D. Holmes

Background/Objectives: Individuals living with Parkinson’s disease often rely on informal caregivers for daily support. Existing research on caregiving has largely been framed from a predominantly female perspective. However, caregiving roles are evolving, with an increasing number of men assuming these responsibilities. Despite this shift, the experiences of male caregivers remain underexplored. A deeper understanding of their perspectives is essential to inform more inclusive and effective caregiver support in Parkinson’s disease care. This study aimed to explore the lived experience of male caregivers supporting individuals with Parkinson’s disease. Methods: A secondary qualitative analysis was conducted using interviews with seven male caregivers supporting individuals with Parkinson’s disease. Data were analyzed using thematic analysis within a descriptive phenomenological framework. Results: Three overarching themes emerged. (1) Economic and employment challenges, including difficulties balancing work and caregiving, structural barriers to accessing services during working hours, and the financial burden of Parkinsons-related expenses, with financial stability acting as a buffer against stress; (2) Psychological and emotional dynamics, including self-doubt linked to gender norms, the influence of personal and partner attitudes on coping, and ongoing experiences of loss; and (3) Adaptation and coping, involving renegotiation of roles, maintenance of routines, and information seeking that was experienced as both empowering and anxiety-provoking. Conclusions: Male caregiving experiences were shaped by financial stability, personal beliefs and perspectives, and the ability to adapt to changing roles and responsibilities. These findings highlight the importance of recognizing gender-specific caregiving needs and incorporating targeted support for male caregivers into Parkinson’s disease care.

Healthcare doi: 10.3390/healthcare14121651

Authors: Christos Ntais Michael A. Talias

Background/Objectives: Free riding in healthcare occurs when actors benefit from health-related public goods, risk-pooling arrangements, common resources, or cooperative institutions while contributing less than is socially optimal. This review clarifies how free-rider dynamics differ across vaccination, health insurance and universal health coverage, antimicrobial resistance, organ donation and transplant allocation, and global health cooperation. Methods: A narrative review with conceptual synthesis was conducted. Searches of PubMed and Scopus were complemented by citation tracking and targeted inclusion of foundational economics, game theory, public-health ethics, and market-design sources. Sources were mapped by domain, actors, strategies, payoff structure, information conditions, time horizon, enforcement mechanism and policy relevance. Results: Across domains, free riding arises when private payoffs diverge from collective welfare, but the underlying game differs: threshold public-good and coordination games in vaccination, adverse-selection and participation games in insurance, common-pool-resource dilemmas in antimicrobial use, donor-registration and matching-market problems in transplantation, and repeated public-goods games in global health. The review identifies three policy functions: altering payoffs, altering information and beliefs, and changing the structure, repetition, or enforceability of the game. Conclusions: Game theory is most useful as a mechanism-based framework rather than a stand-alone policy prescription. Its policy value depends on empirical calibration, institutional context, ethical legitimacy, and attention to equity, incomplete information, behavioral responses, and enforcement capacity. The synthesis also emphasizes boundary conditions: game-theoretic prescriptions can fail when political economy, asymmetric power, implementation capacity, access barriers, or trust-related drivers are ignored.

Healthcare doi: 10.3390/healthcare14121650

Authors: Jungmi Kwon Yoonjoo Kim

Background/Objectives: Alarm fatigue is common in clinical settings and can impair nursing performance. Guided by the job demands–resources framework, this cross-sectional study examined the associations among alarm fatigue, nursing performance, perceived stress, and patient safety culture, including an indirect association through perceived stress and moderation by patient safety culture. Methods: Self-report questionnaires completed by 218 registered nurses from two general hospitals in South Korea were used to assess alarm fatigue, perceived stress, patient safety culture, and nursing performance. Data were analyzed using descriptive statistics, Pearson’s correlations, and Hayes’ PROCESS macro with 5000 bootstrap samples controlling for covariates. Results: Alarm fatigue was positively correlated with perceived stress and negatively correlated with nursing performance. Patient safety culture was positively correlated with nursing performance. Alarm fatigue was positively associated with perceived stress, and perceived stress was negatively associated with nursing performance. The indirect association through perceived stress was significant. Patient safety culture moderated the association between perceived stress and nursing performance. The index of the moderated indirect association was significant. Conclusions: These findings suggest that alarm-related problems should be addressed in clinical and assistive nursing practice by integrating strategies aimed at reducing unnecessary alarms, strengthening training in alarm prioritization and interruption management, supporting nurses’ stress responses, and promoting a patient safety culture characterized by open communication and teamwork. Considering the cross-sectional design of this study, the findings should be interpreted as associations, rather than causal evidence.

Healthcare doi: 10.3390/healthcare14121649

Authors: María-Raquel Huerta-Franco Solange Ivette Rivera-Manrique Isabel Delgadillo-Holtfort Svetlana Kashina Carlos Eduardo Molina-Guerrero José Marco Balleza-Ordaz Francisco Miguel Vargas-Luna

Background/Objectives: The climacteric transition is a critical stage in women’s health characterized by significant endocrine, metabolic, cardiovascular, and autonomic changes that increase cardiometabolic vulnerability during midlife. This narrative review aimed to synthesize current evidence on body composition, heart rate variability and autonomic function, phytoestrogens & estrobolome interactions, and exercise-based lifestyle approaches during the climacteric transition. Methods: A structured literature search was conducted across four domains (body composition, heart rate variability, phytoestrogens, and exercise) using PubMed/MEDLINE, Web of Science, Scopus, Google Scholar, and the Cochrane Library. Studies were selected based on relevance, study design, and methodological rigor, and synthesized using a narrative approach. Additional thematic components, including dietary patterns and gut microbiota estrobolome interactions, were incorporated through targeted searches. Results: The climacteric transition is associated with increased visceral adiposity, reduced lean mass, insulin resistance, dyslipidemia, and a higher prevalence of metabolic syndrome, while body mass index may underestimate metabolically relevant adiposity. Altered autonomic regulation, reflected by reduced heart rate variability and sympathetic predominance, is linked to increased cardiovascular risk, although its independent contribution is influenced by aging and comorbidities. Mediterranean and plant-based dietary patterns may improve metabolic and inflammatory profiles and modulate estrogen metabolism through gut microbiota mechanisms. Phytoestrogens show potential benefits for vasomotor symptoms and selected metabolic markers, although evidence remains heterogeneous. Exercise interventions consistently improve body composition, cardiometabolic parameters, and autonomic function. Conclusions: A multidimensional lifestyle-based approach integrating exercise, dietary strategies, and modulation of estrogen-related pathways may help mitigate cardiometabolic risk and support healthier aging during the climacteric transition.

Healthcare doi: 10.3390/healthcare14121648

Authors: Maha Alhajeri Elham Aldousari Dennis Kithinji

Background/Objectives: Strategies to improve the Social Health Authority (SHA)’s equity can be identified by analyzing the Kenya Demographic and Health Survey (KDHS) 2022. This study reports evidence of determinants of health insurance coverage in Kenya. Methods: Household- and individual-level datasets from the Kenya Demographic and Health Survey conducted between February and July 2022 were combined to form the analyzed dataset. Proportions of individuals with and without health insurance were estimated. The associations between potential determinants and health insurance status were calculated using the Rao–Scott chi-square. Logistic regression was used to analyze the determinants of health insurance coverage. Results: Most of the 14,232 participants were literate (75%), relatively poor (56%), in good health (79%), connected to electricity (55%), and radio listeners (61%). About 34% had health insurance, with 93% of the insured covered by the NHIF. Twenty predictors (Adjusted F = 4.2–434.1, p < 0.0001) were included in the complex sample logistic regression model, but only nine were statistically significant predictors of health insurance coverage. The key predictors were education level; wealth index; ownership of a solar panel, television, smartphone, and computer; age; and recent outpatient care (11–80% differences in odds). Conclusions: Health insurance coverage remains low in Kenya due to low education levels, poor economic status, and disparities in access to media. The SHA can emphasize media campaigns in the informal sector to increase premium payments. Accelerating socioeconomic advancement and adopting tax-based funding could speed up Kenya’s progress towards UHC.

Healthcare doi: 10.3390/healthcare14121647

Authors: Elena Violeta Iborra-Palau Elena García-Redondo Carlos Blasco-García Raquel Alabau-Dasi

Background: Psoriasis is a chronic systemic disease affecting over 60 million people. While phototherapy is effective, its demanding schedule imposes a significant treatment burden. This study explores the lived experiences and healthcare expectations of patients in specialized nursing-led phototherapy units. Methods: A descriptive phenomenological study was conducted (2019–2022) with 72 participants at a Spanish tertiary hospital. Data from semi-structured interviews were analyzed using inductive thematic content analysis. Results: Nine subtopics emerged within four main thematic areas: (1) a gap between psychological awareness and low knowledge of systemic comorbidities; (2) psychological stress as the primary disease trigger; (3) an adherence-stress cycle causing biographical disruption; and (4) a collective demand for a permanent nursing referent to overcome systemic barriers. Conclusions: Phototherapy’s clinical efficacy is often undermined by its logistical rigor. Achieving skin clearance is insufficient if biographical and systemic gaps remain. Integrated care models, led by specialized dermatology nurses, are essential to provide clinical navigation and support beyond conventional skin treatment.

Healthcare doi: 10.3390/healthcare14121646

Authors: Xin Deng Zhihong Ni Xinxin Wang Jiani Hu

Background: Hypertension and diabetes often coexist in older adults, causing complex overlapping symptoms. However, systematic research on their symptom clusters and core symptoms is insufficient, necessitating this study. Objective: To explore the composition characteristics of symptom clusters in older adults with HDC, construct symptom networks and identify core symptoms, so as to provide a reference for the development of symptom management programs. Design: A cross-sectional study. Setting: Patients were continuously recruited from community populations in northern Xinjiang, China, between June 2024 and September 2024. Participants: 766 hypertension–diabetes comorbidity patients aged 60 years and older. Methods: The symptoms were evaluated using a general information questionnaire and the memory symptom assessment scale (MSAS). The symptom clusters were extracted by systematic cluster analysis, and the symptom network was constructed by R (version 4.4.3) to analyze the central indicators. Results: The most common symptom was fatigue (73.5%), followed by dry mouth (64.9%), pain (55.8%), and dizziness (47.5%). Regarding the burden level of symptoms, fatigue was the most burdensome symptom, followed by pain, dry mouth, fatigue, and numbness/tingling in hands/feet. Three clusters were identified: circulatory metabolic disorder symptom cluster, endocrine neurological disorder symptom cluster, and general physical symptom cluster. Network analysis showed that fatigue was the core symptom of the population. Conclusions: Community nursing staff should focus on the symptom changes in older adults with HDC, implement precise interventions based on their symptom clusters and core symptoms, and develop personalized symptom management plans to improve the quality of life for patients.

Healthcare doi: 10.3390/healthcare14121645

Authors: Qingteng Wei Yubo Zhou Zhen Qin Siu Shing Man Yao Li Alan Hoi Shou Chan

Background: In an era of sedentary lifestyles and multifaceted health challenges, adopting health behavior (HB) is essential to address the health problems threatening the physical health of university students. This study aimed to explore the factors associated with HB among university students. The University Student Health Behavior Model (USHBM) was developed based on the theory of planned behavior and incorporated health consciousness (HC), health knowledge (HK), and risk perception (RP). Methods: Using a cross-sectional survey design, data were collected from 384 university students in China. Structural equation modeling was employed to evaluate the hypothesized relationships of the USHBM. Results: HK significantly and directly predicted behavioral intention (BI) (β = 0.421, p < 0.001). Perceived behavioral control (PBC) emerged as the strongest associated factor of BI (β = 0.417, p < 0.001). HC was significantly and positively related to attitude toward behavior (ATT) (β = 0.451, p < 0.001), subjective norm (SN) (β = 0.332, p < 0.001), and PBC (β = 0.357, p < 0.001). Furthermore, RP functioned as an associated factor of HB (β = 0.411, p < 0.001). Additionally, RP was significantly and positively associated with the adoption of HB. Conclusions: The findings provided an in-depth understanding of university students’ HB. According to the findings, practical implications for enhancing university students’ HB were discussed.

Healthcare doi: 10.3390/healthcare14121644

Authors: Ushna Shameen Elavarasi Kuppusamy Farinawati Yazid Haslina Rani Muneer Gohar Babar Muhammad Khan Asif

Background: Parents play a pivotal role in influencing children’s oral health; thus, effective oral health education (OHE) is essential to equip them with the knowledge needed to support their children’s oral health care. In countries such as Pakistan, apart from limited access to dental care and socioeconomic barriers, the widespread lack of OHE is also an important factor contributing to the high prevalence of oral diseases. Conventional OHE approaches are often limited by passive delivery, lack of tailored content and poor accessibility. Social media platforms such as Facebook offer an accessible platform for health education; however, structured, validated, and tailored content is required. Aim: This study aims to develop and validate an online OHE module for Pakistani parents using the ADDIE instructional design model. Materials and Methods: The study was conducted in two phases using the ADDIE model. Parental OHE needs were identified through a questionnaire. An Urdu-language module was developed based on these needs and expert recommendations. Content validation was performed by six experts, followed by face validation with 15 parents. Results: Needs assessment guided the development of a culturally appropriate module covering six main topics. Item-level Content Validity Index ranged from 0.83 to 1.00, with a Scale-level Content Validity Index of 0.94 and a Scale-level Face Validity Index of 0.97. Conclusions: The developed Facebook-delivered OHE module demonstrated high content and face validity and may serve as an accessible and practical strategy for improving parental OHE. Further studies are required to evaluate its effectiveness in improving oral health-related behaviours and outcomes.

Healthcare doi: 10.3390/healthcare14121642

Authors: Astrid Van Damme Florence Talrich Deborah L. Billings Christine McCourt Ashley Gresh Crystal L. Patil Matty Crone Marlies Rijnders Ilir Hoxha Sharon Schindler Rising Katrien Beeckman

Background: Group Care (GC) is an antenatal/postnatal care model comprised of a stable group of pregnant people or parent–child dyads receiving care in two-hour group sessions that combine clinical care with interactive discussion and learning. Integrating GC into healthcare systems organised for individual care poses challenges at both site and system levels. This study identified scheduling-related modifications across contexts to understand modification processes. Methods: We used an explanatory sequential design with mixed qualitative methods across seven GC implementation sites in Belgium, Kosovo, and the United Kingdom. A qualitative survey based on the Framework for Reporting Adaptations and Modifications to Evidence-based interventions (FRAME) was completed at each site by multiple stakeholders. Subsequently, in-depth interviews were conducted to further explore modification processes and examine whether changes were sustained or discontinued up to three years post-implementation initiation. Results: Two modifications were identified across countries: (1) combining GC sessions with individual consultations, and (2) integrating GC into digital booking and medical record systems. Guided by FRAME, we identified similarities and differences in the goals, drivers, and impact of these modifications. The dominant one-to-one antenatal care model strongly influenced modifications, making it more difficult to implement GC as a stand-alone model in obstetrician-led systems (Belgium and Kosovo) compared to a midwifery-led system (UK). In both contexts, the dominant model negatively influenced the perceived value of GC, with GC sessions viewed only as education and individual consultations seen as the actual care. Integration in the booking system appeared essential for payment and scheduling arrangements. Conclusions: Integrating GC scheduling into existing care pathways is challenging in systems where one-to-one care is the predominant model. Sustainable integration of GC requires early coordination and shared ownership across areas, including clinical, administrative, and IT.

Healthcare doi: 10.3390/healthcare14121643

Authors: Romina Georgiana Bita Otilia Cornelia Boloș Edida Maghet Adrian Boloș Raluca Briceag Bogdan Andrei Bumbu

Background and Objectives: Halitosis is a prevalent oral concern that meaningfully affects oral health-related quality of life (OHRQoL), yet how active dental treatment is associated with short-term changes in the objective–subjective halitosis–QoL nexus remains poorly quantified. Interpretation is complicated by the multifactorial nature of malodor and by baseline differences between patients selected for different dental procedures. We compared changes in volatile sulfur compound (VSC) emissions, organoleptic ratings, tongue-coating burden, and OHIP-14 across three contrasting treatment modalities and explored whether VSC change statistically accounted for OHRQoL change. Methods: In a non-randomized prospective comparative study, 119 adults (18–67 y) commencing one of three procedures were assessed at baseline and at 8 weeks: scaling and root planing (Group A, n = 42), fixed prosthodontic rehabilitation (Group B, n = 38), or fixed orthodontic appliance bonding (Group C, n = 39). Outcomes included Halimeter® VSC (ppb), Rosenberg organoleptic score (0–5), Winkel tongue-coating index (TCI), self-perceived halitosis, and OHIP-14 total and seven-domain scores. Mixed-design ANOVA, ANCOVA, prespecified multivariable regression, mediation (5000 bootstrap resamples), receiver operating characteristic analysis, and four-class latent class analysis were performed. A sensitivity-analysis framework including expanded covariate adjustment, propensity-score overlap weighting, and baseline-severity strata was also applied to address residual baseline imbalance. Secondary mediation, ROC, and latent-class analyses were considered exploratory. Results: At 8 weeks, VSCs fell by 116.4 ± 38.7 ppb in Group A and 35.4 ± 29.1 ppb in Group B but rose by 34.3 ± 28.6 ppb in Group C (p < 0.001). OHIP-14 improved by 10.3 and 4.9 points in A and B and worsened by 3.7 in C (p < 0.001). ΔVSC correlated with ΔOHIP-14 (ρ = 0.51, p < 0.001) and most strongly with the psychological discomfort domain (ρ = 0.58). VSC change mediated 35.1% of the periodontal-versus-orthodontic association on QoL (indirect β = −4.7; 95% CI −6.3 to −3.1). Because VSC and OHIP-14 changes were measured over the same interval, mediation was interpreted cautiously. A ΔVSC threshold of −63 ppb predicted clinically meaningful OHIP-14 improvement (AUC = 0.81). Latent class analysis identified four distinct responder phenotypes. The cutoff and responder classes were internally derived and require external validation. Sensitivity analyses preserved the direction of the primary contrasts, but residual confounding remains possible. Conclusions: Treatment modality was associated with the direction and magnitude of halitosis and QoL change, with orthodontic patients constituting a vulnerable subgroup. Targeted oral-hygiene reinforcement during fixed-appliance therapy is warranted.

Healthcare doi: 10.3390/healthcare14121641

Authors: Mateus Klein Roman Luan Zanatta Jeangrei Emanoelli Veiga Ericles Andrei Bellei Ana Carolina Bertoletti De Marchi

Objectives: This study proposes an implementation-oriented design framework for multimodal conversational agents handling patient-generated health data and reports an exploratory experiment evaluating its instantiation in hypertension self-monitoring, focusing on user experience of conversational data-entry workflows. Methods: The framework operationalizes four complementary dimensions (social intelligence, communication style, anthropomorphic characteristics, and technological mapping) and was instantiated in two agents integrated into an eHealth platform. Each agent supports users by providing prompts, interpreting responses, checking data plausibility, and confirming submission. A three-arm, single-session feasibility experiment (n=18, n=6 per group) compared a conventional app interface with text-based and voice-based conversational agents. Evaluation triangulated three sources of evidence: open-ended qualitative responses analyzed through descriptive content analysis, session-level researcher observation notes, and the User Experience Questionnaire (UEQ) reported descriptively with one-way ANOVA and η2 effect sizes. Results: All three modalities were acceptable to participants and produced UEQ scores in the positive range. Hesitation was observed in 2 of 6 Control participants, 1 of 6 Text participants, and 3 of 6 Voice participants, with self-reports indicating that voice-related difficulties were modality-specific (diction, command phrasing) and resolved within the session. Qualitative themes of acceptability and innovation, perceived effort, and modality-specific facilitators emerged across the corpus. Between-group ANOVAs did not reach statistical significance (p>0.05), as expected for an underpowered design, yet η2 values were medium for Attractiveness, Efficiency, Dependability, and Pragmatic Quality and large for Stimulation and Hedonic Quality, converging with the qualitative innovation and engagement signal in the conversational conditions. Conclusions: The framework and feasibility experiment provide preliminary, hypothesis-generating evidence on the potential of multimodal conversational interfaces in healthcare. However, no clinical, behavioral, or longitudinal outcomes were assessed. The four design dimensions can be tentatively associated with themes recognizable in user discourse, and the observed effect-size pattern motivates adequately powered longitudinal studies that incorporate behavioral and clinical endpoints alongside user experience measures.

Healthcare doi: 10.3390/healthcare14121640

Authors: Nikhil Sriram Rishi Jain Mehul Mittal Ravi A. Patel Benjamin J. Fredeen Anitesh Bajaj Rebecca Du Karl Habashy Hanna Kemeny Sachin Govind Kevin Swong Christopher S. Ahuja Najib El Tecle

Objective: Online patient education materials (OPEMs) are important resources for patients seeking health information. While the National Institutes of Health (NIH) and American Medical Association (AMA) recommend a sixth-grade readability level for OPEMs, commonly available material often exceeds such criteria. Large language models (LLMs), such as ChatGPT and Gemini, have emerged as tools for health education with potential applications in simplification of health material. This study assesses the utility of ChatGPT and Gemini in enhancing the readability of OPEMs for peripheral nerve surgeries. Methods: Eleven common peripheral nerve surgeries were used as online search terms. The first 20 unique search results were assessed; results were excluded if they did not include patient-facing material. ChatGPT and Gemini were instructed to rewrite the text of the OPEM at or below a sixth-grade reading level. Readability metrics were calculated for original OPEMs, alongside ChatGPT and Gemini rewrites. LLM responses were reviewed for accuracy/quality (five-point scale) and comprehensiveness (three-point scale) using predefined criteria. Results: A total of 220 websites were assessed. In total, 155 OPEMs met the inclusion criteria; 65 websites were excluded because they were academic journal articles or other provider-facing materials. The average Flesch–Kincaid grade level (FKGL) of OPEMs was 11.3, significantly greater than the NIH/AMA-sixth grade recommendations (p < 0.001). The average FKGL of ChatGPT rewrites was significantly lower than that of OPEMs (11.3 vs. 7.5, p < 0.001), as was the average FKGL of Gemini rewrites (11.3 vs. 5.6, p < 0.001). ChatGPT rewrites were of higher accuracy/quality (4.5/5.0 vs. 4.0/5.0, p < 0.001) and comprehensiveness (2.0/3.0 vs. 1.0/3.0, p < 0.001) relative to Gemini rewrites. Conclusions: The readability of online patient education materials for peripheral nerve surgery significantly exceeded NIH/AMA recommendations. ChatGPT and Gemini were able to significantly simplify the reading level of these OPEMs. LLMs may serve as tools to improve the readability of peripheral nerve surgery OPEMs.

Healthcare doi: 10.3390/healthcare14121639

Authors: Melda Tas Gungor Dilek Kahvecioglu

Objective: Maternal substance use during pregnancy is an increasing public health concern worldwide. However, data on neonatal abstinence syndrome (NAS) remain limited in many regions, including Turkey. This study aimed to evaluate the clinical and laboratory characteristics of neonates exposed to maternal substance use and to assess the association between Finnegan score severity and laboratory findings. Methods: This retrospective study was conducted in a tertiary neonatal intensive care unit. Neonates with prenatal substance exposure were divided into two groups according to their Modified Finnegan scores (<8 and ≥8). Demographic characteristics, clinical outcomes, and laboratory parameters, including acute phase reactants and liver enzymes, were compared between the groups. Maternal substance exposure was mainly determined by maternal self-report, with toxicological confirmation available in only two infants. Results: A total of 25 neonates were included. Higher Finnegan scores were associated with increased white blood cell counts, plateletcrit and liver enzyme levels (AST and ALT), although only the ALT association remained significant after correction for multiple comparisons. Infants placed under state care had longer hospital stays than those discharged to their families (p = 0.02). No mortality was observed. Conclusions: In this small retrospective cohort, greater withdrawal severity was associated with higher aminotransferase levels, particularly ALT, and longer hospitalization was observed among infants placed under state care. These findings should be regarded as preliminary and require confirmation in larger prospective multicenter studies.

Healthcare doi: 10.3390/healthcare14121638

Authors: Aleksej Omeljančiuk Eimantas Peičius Aušra Urbonienė Gvidas Urbonas

Background/Objectives: Artificial intelligence reshapes clinical practice, and its effect on the clinician–patient relationship requires reconsideration of the frameworks that have shaped modern medical ethics. When clinicians delegate expertise to algorithms they cannot verify, it becomes unclear who bears clinical responsibility. Methods: This article applies a theoretically grounded normative approach to explore the ethical conditions under which artificial intelligence can be integrated into clinical practice without compromising the moral foundations of medicine. The analysis is primarily based on Pellegrino and Thomasma’s concept of the internal morality of medicine and the clinician’s act of profession. It further draws on Kantian ethics of human dignity, Levinasian relational ethics, virtue ethics, and Vallor’s concept of technomoral wisdom. Results: AI systems do not satisfy the conditions under which moral responsibility can be ascribed to them. Clinical moral agency lies in the capacity to bear three distinct responsibilities—epistemic, relational, and phronetic—none of which can be fulfilled by AI. The implementation of AI in healthcare, therefore, must occur strictly under the condition of Meaningful Human Control, rather than as a technical function of human oversight over algorithmic outputs. To ensure that MHC can function as an effective and ethically grounded safeguard, we propose five normative requirements: primacy of clinical judgement, prohibition of forced automation, traceability and explainability, transparency towards patients, and retaining clinical authority. Dialogue between clinicians and patients should remain the foundation of clinical decision-making. The proposed normative requirements aim to preserve the internal morality of medicine in a form that harmoniously combines both technological progress and established medical ethics.

Healthcare doi: 10.3390/healthcare14121637

Authors: Bojana Milekić Marko Štaka Sara Koprivica Đorđe Pržulj

Background/Objectives: The lateral symmetry of dental disease and treatment patterns reflects underlying biological, behavioral, and systemic factors. Although clinical experience suggests asymmetric treatment frequencies, large-scale quantitative evidence remains limited. This study aimed to analyze the symmetry and asymmetry of dental interventions—encompassing restorations, extractions, endodontic treatments, and prosthetic procedures—in relation to tooth position, jaw, patient sex, and age group. Methods: A retrospective analysis was conducted on 30,063 dental intervention records from 2738 patients treated at a single private practice between 1999 and 2025. Tooth identification was based on FDI two-digit notation. Chi-square goodness-of-fit tests were applied to assess left–right and upper–lower symmetry, stratified by sex, age group, and tooth position. Bonferroni correction was applied to account for multiple comparisons (adjusted α = 0.0033). Results: Overall left–right symmetry was maintained across the full dataset (χ2 = 0.17, p = 0.682). After Bonferroni correction, only the right-side excess at the first premolar position remained statistically robust (p = 0.002), driven predominantly by the lower jaw (tooth 44 vs. 34; p = 0.011). The upper jaw received significantly more interventions than the lower jaw (56.3% vs. 43.7%, p < 0.001). Additional asymmetries observed at the uncorrected threshold—in the lower jaw (p = 0.026), in the 18–30 age group (p = 0.009), and a sex × jaw interaction (p = 0.047)—did not survive correction. Conclusions: Dental treatment patterns are predominantly symmetric at the population level. The most robust site-specific finding was a right-side excess of first premolar interventions, particularly in the lower jaw. These results may inform targeted preventive strategies and population-level oral health planning, with caution warranted in generalizing findings beyond the single-practice setting.

Healthcare doi: 10.3390/healthcare14121636

Authors: Birgitta Kerstis Peter Jönsson Alyx Taylor Kent W. Nilsson Björn Hofvander Christine Rubertsson Sara Lindeberg

Background/Objectives: Valid and time-efficient measurement instruments for the assessment of perinatal distress beyond depressive symptoms are yet to be determined. The main objective was to analyse the psychometric measurement properties of the Depression Anxiety Stress Scales (DASS) short forms in Swedish pregnant women during the third trimester. The secondary objective was to analyse the measurement properties of DASS short forms for the postnatal period. Methods: Data from the Scania Birth Cohort study including 78 women followed prospectively from the third pregnancy trimester to one year postpartum were used. The DASS-21, DASS-12, DASS-9 (two versions), and the 12-item Mini-DASS were analysed using confirmatory factor analysis (CFA), inter-item analysis, and Spearman’s rho subscale cross-correlations. Postnatal analysis at infant ages 1, 6, and 12 months was performed using CFA and inter-item analysis. Results: When used with third-trimester pregnant women, the DASS-9 version 1 and the Mini-DASS exhibited overall acceptable psychometric properties in terms of internal consistency (McDonald’s ω ≥ 0.77) and structural and discriminant validity (e.g., CFI > 0.90 and SRMR < 0.08 for all DASS-9 two- and three-factor models; and CFI > 0.95 and SRMR < 0.08 for one-factor models of the Mini-DASS subscales - including a modified anxiety scale - and for the Mini-DASS depression and anxiety two-factor model). Support for these DASS short forms postpartum was also indicated. Conclusions: Although preliminary, the current results support the DASS-9 and the Mini-DASS as parsimonious tools for the assessment of perinatal distress and its subtypes. Further validation in the perinatal context is warranted.

Healthcare doi: 10.3390/healthcare14121635

Authors: Altuğ Güner

Background and Objectives: Familial Mediterranean fever (FMF) is a chronic autoinflammatory disease characterized by recurrent inflammatory attacks and a persistent psychosocial burden. Although generalized anxiety symptoms have been investigated in FMF, disease-specific anticipatory concerns related to recurrent attacks remain insufficiently understood. This study aimed to investigate the associations of attack-related anticipatory anxiety symptoms with clinical characteristics, quality of life, and composite inflammatory indices in FMF. Materials and Methods: This exploratory cross-sectional study included 38 adult patients with FMF. Attack-related anticipatory anxiety symptoms were assessed using an exploratory six-item questionnaire. Generalized anxiety and quality of life were evaluated using the Generalized Anxiety Disorder-7 (GAD-7) and Short-Form–12 (SF-12), respectively. Composite inflammatory indices including the C-reactive protein–albumin–lymphocyte (CALLY) index, log-CALLY, hemoglobin–albumin–lymphocyte–platelet (HALP) score, and systemic immune-inflammation index (SII) were calculated from routine laboratory parameters. Results: Attack-related anticipatory anxiety scores demonstrated a significant positive correlation with GAD-7 scores (r = 0.581, p < 0.001) and an inverse correlation with SF-12 mental component scores (r = −0.380, p = 0.019). Direct correlations between attack-related anticipatory anxiety scores and composite inflammatory indices were weak and not statistically significant. In subgroup analysis, a higher annual attack burden was associated with higher GAD-7 scores, higher CRP and serum amyloid A values, and lower CALLY, log-CALLY, and HALP values. Differences in attack-related anticipatory anxiety, SF-12 MCS, and SII between attack burden groups did not reach statistical significance. In multivariable linear regression analysis, GAD-7 score remained independently associated with attack-related anticipatory anxiety symptoms (β = 0.438, p = 0.010). Conclusions: Attack-related anticipatory anxiety symptoms may represent an exploratory psychosocial dimension of FMF associated mainly with generalized anxiety symptoms and impaired mental well-being. Composite inflammatory indices appeared more closely related to annual attack burden than to attack-related anticipatory anxiety. These findings should be interpreted cautiously and considered hypothesis-generating.

Healthcare doi: 10.3390/healthcare14121634

Authors: Yuqian Sun Siyu Chen Zhongliang Li Qiqi Peng Xuan Li Yijia Zhao Tingxi Zhou Wenchi Zou Xu Hong

Background/Objectives: Spiritual care is core to holistic patient care, yet a persistent implementation gap exists in Chinese hospitals. This study examines the association between spiritual leadership and nurses’ spiritual care behavior, with career calling as mediator and empathy as moderator. Methods: A cross-sectional design was adopted. Data were collected from 323 frontline nurses in 10 public hospitals across five provinces in China from June to September 2025 using validated Likert scales. Analyses included confirmatory factor analysis, hierarchical regression, and a second-stage moderated mediation model with 5000 bootstrap resamples using SPSS 26.0 and Mplus 8.3. Results: Spiritual leadership was positively associated with both nurses’ spiritual care behavior and career calling. Career calling partially mediated the relationship between spiritual leadership and nurses’ spiritual care behavior. Furthermore, empathy significantly strengthened the positive association between career calling and spiritual care behavior, and amplified the indirect effect of spiritual leadership on nurses’ spiritual care behavior via career calling. Conclusions: Spiritual leadership, career calling, and empathy are key factors associated with nurses’ spiritual care delivery. Targeted interventions for these factors can bridge the spiritual care implementation gap and enhance holistic patient care.

Healthcare doi: 10.3390/healthcare14121633

Authors: Carmen Rajer David Bogataj Marija Bogataj Samo Drobne

Background/Objectives: This study examines the relationship between user preferences, spatial accessibility, and the financial sustainability of long-term care (LTC) systems, with a focus on Slovenia and the Posavje region. The analysis compares different care models, including long-term home care (LTHC), institutional care, and community-based housing solutions such as sheltered housing and “silver villages”. Methods: A mixed-methods approach was applied, combining qualitative interviews, survey data, spatial analysis, mobility-related operational assessment, and cost estimation. The survey included 1005 individuals, of whom 475 provided valid responses. Statistical analysis was conducted using chi-square tests and the Agresti–Caffo method to examine differences in care preferences and selected proportions across respondent groups. Results: Statistically significant differences in LTC preferences across age groups were identified. Most respondents preferred care options located close to their homes, with the majority unwilling to relocate more than 10 km and a substantial share preferring distances below 5 km. The findings further indicate that travel-related costs for care providers in rural areas are considerable and, in the Municipality of Krško, comparable to the estimated monthly housing costs in specialized community-based units. Cost comparisons suggest that reductions in travel-related operational costs could offset a substantial share of the estimated housing-related costs. Conclusions: The results indicate that sustainable LTC systems require not only adequate service capacity and funding but also spatially coordinated care models aligned with user preferences and long-term sustainability. The findings contribute to strategic LTC planning and support the development of integrated, community-based care systems in geographically dispersed regions.

Healthcare doi: 10.3390/healthcare14121632

Authors: Jie Bai Jinxia Zheng Ke Wang Yueyan Dong Ying Liu Hui Jiang

Background: Women undergoing in vitro fertilization (IVF) often experience poor well-being. Social support and family resilience are considered protective factors, but their combined roles in the anxiety–fertility-related quality of life (FertiQoL) relationship remain unclear. Design: A cross-sectional study was conducted with women undergoing IVF at the reproductive medicine department of a tertiary hospital in Shanghai, China, between March and December 2024. Methods: Participants completed validated measures of anxiety, social support, family resilience, and QoL. Associations and indirect effects were examined using mediation analysis, and sensitivity analyses were conducted. Results: A total of 419 women participated in the study (response rate = 98.6%; mean age = 33.3 ± 4.7 years). Anxiety was negatively associated with social support, family resilience, and FertiQoL (all p < 0.001). The total indirect association between anxiety and FertiQoL involving social support and family resilience was statistically significant (B = −0.15, p = 0.03). However, the specific indirect effects, including the hypothesized sequential pathway through social support and family resilience, were not statistically significant. The total association between anxiety and FertiQoL was significant (β = −0.32, p < 0.001). Conclusions: Anxiety was associated with poorer FertiQoL among women undergoing IVF. Although the findings suggest an overall indirect association involving social support and family resilience, the hypothesized sequential mediation pathway was not supported. Therefore, the results should be interpreted cautiously, and longitudinal studies are needed to clarify the temporal and causal relationships among these psychosocial factors.

Healthcare doi: 10.3390/healthcare14121631

Authors: Jia Yin Ruan Sha Li Fen Xu Fiona Yan Yee Ho Teris Cheung Janice Yuen Shan Ho Wai Chi Chan Hai Yong Chen Dennis Cheuk Wing Au Rebecca Wing Yan Lee Yim Wah Mak Wing Fai Yeung

Introduction: Evidence supports using multicomponent lifestyle medicine programs to alleviate depression, yet few studies detail the program development process. This study aimed to systematically develop a complex lifestyle medicine program for depression based on Traditional Chinese Medicine theory. Methods: A stepwise, multi-method study was conducted. The preparation phase involved understanding the public health issue, identifying resources, and reviewing published evidence. Based on these results, a Delphi survey was performed, followed by an analysis of the context understanding as well as design and refinement of the program. Subsequently, the program was modeled, and a program theory was developed, incorporating explanations and assumptions in a relevant conceptual framework and logic model. Results: A complex lifestyle medicine program and program manual were established. The program involves three major themes, each with six 120 min weekly consecutive sessions: nourishing the heart (two sessions), nourishing according to the time (two sessions), and nourishing the Qi (two sessions). The program covered TCM theory and practice to promote healthy sleep, diet, stress management, and self-administered acupressure and TCM exercise. Teaching materials were created accordingly. Conclusions: This study reports the development of a complex multicomponent TCM lifestyle medicine program to relieve depression thoroughly and transparently, with a specific focus on the Hong Kong context and a particular focus on TCM theory. The developed program will be examined for feasibility, acceptability, and preliminary efficacy in alleviating depression in a mixed-methods clinical study.

Healthcare doi: 10.3390/healthcare14121630

Authors: Yao-Hsiang Chen Chia-Huei Lin Ju-Han Liu Hsin-An Lin Yu-Shan Hsieh

Background: Inspiratory training using an incentive spirometer (IS) improves respiratory symptoms and functional status in Long COVID. In Taiwan, NRICM101 is commonly used during the acute phase; however, its impact on rehabilitation outcomes remains unclear. Objective: This study evaluated the effects of IS-based respiratory training and the potential influence of prior NRICM101 use. Methods: Participants were grouped by time since recovery, and pre-post changes after six weeks of IS training were compared between those with and without self-reported prior NRICM101 use. Primary outcomes were dyspnea and functional status; secondary outcomes included six-minute walk distance and arterial oxygen content. Results: IS training significantly improved dyspnea (p < 0.0001), functional status (p < 0.0001), and exercise endurance (NRICM101 group: p = 0.002; no NRICM101 group: p < 0.0001). Stratified analysis showed that when initiated within three months of recovery, participants without prior NRICM101 use had greater improvements in dyspnea (p < 0.0001), functional status (p = 0.001), and exercise endurance (p < 0.0001). Conclusions: Prior NRICM101 use may be associated with different rehabilitation patterns, likely reflecting differences in recovery trajectory or patient behavior rather than purely pharmacological effects.

Healthcare doi: 10.3390/healthcare14121622

Authors: Kara M. Schneider Dodie Limberg Krista M. Schneider Claire Balane Jessica Barnes Brittany Sandonato Ashley J. Blount

Background/Objectives: Trauma and chronic pain frequently co-occur and mutually reinforce functional impairment, yet few counseling interventions integrate somatic and psychological approaches. This study had two primary objectives: (1) to evaluate the feasibility and acceptability of an interdisciplinary trauma–chronic pain group intervention, and (2) to explore preliminary clinical outcomes related to trauma symptoms, fear of movement, and pain through an interdisciplinary group intervention combining trauma-informed counseling with physical therapy grounded in Postural Restoration Institute (PRI) principles. Methods: A convergent mixed-methods design was used, wherein quantitative and qualitative data were collected concurrently, analyzed separately, and integrated during interpretation to provide a comprehensive understanding of intervention outcomes. Fifteen adults with chronic pain (≥3 months) and clinically significant trauma symptoms (PCL-5 ≥ 31) completed a six-week, 90 min group program co-facilitated by a counselor and a physical therapist. Quantitative measures included weekly pain (BPI), pre/post trauma symptoms (PCL-5), fear of movement (TSK), group climate (GCQ), and postural neutrality. Qualitative data included weekly journals, photographs, open-ended post-surveys, and focus groups, analyzed using inductive thematic analysis. Results: Participants attended most sessions (96.7% overall attendance) with no dropouts and high fidelity (mean 2.89/3). Pre/post analyses indicated statistically significant within-group reductions in trauma symptoms and fear of movement and improvements in pain and postural neutrality; however, findings should be interpreted as preliminary given the pilot design and small sample size. Qualitative themes highlighted the persistent burden of pain/trauma, increased mind–body awareness, emotional regulation, and validation through group support. Conclusions: An interdisciplinary, PRI-informed, trauma-informed group model was obtained. This model demonstrates preliminary feasibility and acceptability and suggests potential benefit; however, findings are derived from a small, non-controlled pilot study and require further validation. Future research should employ larger, controlled, and longitudinal designs.

Healthcare doi: 10.3390/healthcare14121629

Authors: Norah M. Alyahya Abdulaziz M. Alodhailah Alya Alghamdi Faihan F. Alshaibany Majed M. Aljabri Bandar S. Alharbi Bader M. Almutairy Safiya Salem Bakarman Waleed M. Alshehri

Background: Nursing faculty shortages, burnout, and high turnover represent an escalating workforce crisis in Saudi governmental colleges of nursing. The Job Demands–Resources (JD-R) model offers a theoretically grounded framework for examining how occupational demands are associated with reduced well-being and how resources moderate these effects. Objective: This study aimed to examine the direct associations between job demands and stress outcomes and the moderating roles of job and personal resources among nursing faculty in Saudi Arabia, accounting for gender and nationality as structural covariates. Methods: A quantitative cross-sectional survey was conducted with 268 nursing faculty members from five governmental colleges using a voluntary survey of all eligible faculty (response rate: 51.1%). Theory-driven hierarchical regression analyses examined direct and moderating effects within the health-impairment pathway of the JD-R model. Results: Job demands significantly predicted all three burnout dimensions, reduced mental well-being, and job dissatisfaction. Trait emotional intelligence moderated the demand–exhaustion (delta-R2 = 0.031, p = 0.006) and demand–job satisfaction (delta-R2 = 0.028, p = 0.009) relationships. Job resources moderated the demand–mental well-being (delta-R2 = 0.024, p = 0.018) and demand–professional efficacy links (delta-R2 = 0.021, p = 0.029). Conclusions: Job demands are the primary predictor of burnout and occupational stress. Gender and nationality were associated with systematic differences in stress outcomes, suggesting that interventions should be culturally responsive and account for structural inequities.

Healthcare doi: 10.3390/healthcare14121628

Authors: Bandar Alwadani

Purpose: Variation in knee MRI diagnostic yield is often interpreted as reflecting imaging effectiveness. However, in real-world healthcare systems, diagnostic yield may instead be driven by referral behavior and patient selection. Understanding this distinction is essential for evaluating imaging utilization, healthcare efficiency, and potential overuse of advanced imaging. This study examines whether differences in MRI yield reflect imaging pathways or underlying referral patterns in routine clinical practice. Materials and Methods: This retrospective cohort study included consecutive patients undergoing knee MRI between January 2020 and December 2024. Patients with red flag indications were excluded to focus on discretionary imaging. The primary outcome was clinically relevant MRI findings based on final report impressions. The primary exposure was prior X-ray before MRI. Multivariable logistic regression was used for adjusted analysis, including age, sex, trauma status, mechanical symptoms, and symptom duration. Results: Among 486 patients, 59.5% had prior X-ray. Clinically relevant MRI findings were less frequent among patients with prior X-ray (40.1%) than among those without (49.7%), corresponding to an absolute difference of 9.6%. After adjustment for sex and clinical covariates, prior X-ray showed lower odds of clinically relevant findings, although this association was attenuated and no longer statistically significant (aOR 0.74, 95% CI 0.50–1.10; p = 0.138). Male sex was independently associated with higher odds of clinically relevant MRI findings (aOR 2.48, 95% CI 1.61–3.83; p < 0.001). Formal interaction testing did not demonstrate significant effect modification by trauma status (p = 0.317). These findings suggest that variation in MRI yield may reflect differences in referral pathways, patient selection, and healthcare utilization patterns. Conclusions: MRI yield in routine practice may be influenced by differences in clinical context and referral-related patient selection. Further studies are needed to better understand the contribution of imaging pathways to observed variation in diagnostic yield.

Healthcare doi: 10.3390/healthcare14121627

Authors: Yulia Treister-Goltzman Lior Zadok-Fridman

Background: This study aimed to examine the association between the three subscales of the Transgender Attitudes and Beliefs Scale and professional commitment to treat transgender patients, and to test whether these associations were related to the physician’s level of religiosity. Methods: A cross-sectional study of 109 family physicians was conducted using a self-administered questionnaire between October 2021 and July 2023 in the southern district of Clalit Healthcare Services. Confirmatory factor analysis and multi-group structural equation modeling were carried out. Main measures included TABS subscales, level of religiosity, and physicians’ commitment to treat transgender patients. Results: Only the ‘Human value’ subscale was a statistically significant positive predictor of professional commitment to treat transgender patients among the whole population of physicians and among the subgroup of physicians with high religiosity at β = 0.36 (95% Confidence interval (CI) 0.11 to 0.61, p = 0.005), and β = 0.57 (95% CI 0.20 to 0.95, p = 0.003), respectively. Among physicians with a low level of religiosity there was a significant positive effect of the ‘Interpersonal comfort’ subscale on the professional commitment to treat transgender patients at β = 3.31 (95% CI 1.66 to 4.95, p < 0.001). Although the ‘Sex/gender beliefs’ subscale showed a significant negative association in the primary model (β = −2.91, 95% CI −4.64 to −1.17, p = 0.001), sensitivity analyses suggested that this finding should be interpreted with caution because of the strong correlation between TABS domains. Conclusions: Different TABS domains were associated with physicians’ professional commitment to treat transgender patients across levels of religiosity. These findings can help tailor interventions more effectively to specific religiosity subgroups.

Healthcare doi: 10.3390/healthcare14121626

Authors: Shahid Akhtar Akhund Shahmina Naz Ahmed Yaqinuddin Paul Ganguly Shoukat Ali Arain

Background: Cardiovascular disease (CVD) is the leading cause of global mortality, necessitating its early detection. Carotid intima-media thickness (CIMT) is a validated biomarker of CVD. In Saudi Arabia (SA), population-specific CIMT data for young adults are lacking. This pilot study aimed to generate single-institution preliminary CIMT data using the Butterfly iQ+ handheld ultrasound device (HHUD) and identify CVD risks. Methods: A cross-sectional observational study was conducted on 63 medical students. CIMT was measured bilaterally on common carotid artery (CCA), using the Butterfly iQ+ HHUD. Data on sex, age, ethnicity, BMI, mean arterial pressure (MAP), family history, and dietary habits were collected and analysed using t-tests, one-way ANOVA, Chi-square tests, Spearman’s rho (ρ) correlation, and stepwise multiple linear regression. Results: Mean age was 19.19 ± 1.89 years, and mean BMI was 24.93 ± 4.72 kg/m2. Mean CIMT was 0.053 ± 0.006 cm. Males demonstrated thicker right CIMT (0.055 cm; 95% CI: 0.053–0.058 cm) than females (0.051 cm; 95% CI: 0.048–0.053 cm; mean difference: 0.005 cm, 95% CI: 0.001–0.008 cm; p = 0.012) and higher mean CIMT (0.0548 vs. 0.0513 cm; mean difference: 0.004 cm, 95% CI: 0.000–0.007 cm; p = 0.031). Height (ρ = 0.266; p = 0.035) and weight (ρ = 0.320; p = 0.011) correlated with right CIMT. Stepwise regression identified sex as the sole independent predictor (R2 = 0.105; F = 6.541; p = 0.013). Conclusions: This pilot study establishes preliminary single-institution CIMT data for young healthy medical students at a single university in Riyadh, Saudi Arabia. Sex, height, and body weight are key early determinants of carotid wall thickness. The Butterfly iQ+ HHUD is a feasible point-of-care tool for CIMT measurement, supporting community-based CVD screening in the region.

Healthcare doi: 10.3390/healthcare14121625

Authors: Victor Abiola Adepoju Abdulrakib Abdulrahim Qorinah Estiningtyas Sakilah Adnani Shankar Biswas Safayet Jamil Uthman Okikiola Adebayo

Background and Objectives: Despite global commitment to the World Health Organization triple elimination initiative, evidence on integrated antenatal service delivery models that simultaneously address human immunodeficiency virus (HIV), syphilis, and hepatitis B virus (HBV) remains fragmented, particularly across diverse health-system contexts. Eliminating vertical transmission of HIV, syphilis, and HBV is a global priority. Pregnant women are disproportionately affected by these infections, and untreated maternal disease leads to significant infant morbidity. Integrating antenatal screening and treatment provides an opportunity to address all three conditions simultaneously. Purpose: This systematic review and meta-analysis aimed to identify and synthesise evidence on integrated antenatal service delivery models addressing HIV, syphilis, and HBV simultaneously within maternal health services. It specifically examined model characteristics, screening uptake, treatment and follow-up outcomes, implementation barriers and facilitators, and evidence on cost-effectiveness. Methods: This systematic review and meta-analysis followed PRISMA 2020 guidelines and was registered in PROSPERO (CRD420261342186). We searched Scopus, PubMed, Web of Science, and Dimensions for studies published between January 2007 and January 2026. Of 423 records identified, 11 met the inclusion criteria after excluding two studies that did not provide empirical results for an integrated service model addressing all three target infections simultaneously. Data on study characteristics, service delivery, diagnostics, outcomes, and implementation factors were extracted. A random-effects meta-analysis of proportions was conducted using the DerSimonian–Laird estimator with logit transformation. Results: Eleven studies covered Asia, Africa, Europe, and Latin America, mostly in low- and lower-middle-income countries. Integration ranged from rapid test packages in community clinics to comprehensive programmes including STI treatment, malaria testing, and HBV birth-dose vaccination. Pooled triple testing uptake was 97% (95% CI 92 to 100%). Large programmes achieved over 99% coverage and reduced HIV vertical transmission to below 3%. Pilot studies showed feasibility but noted stockouts, data gaps, and weak treatment linkage. Economic analyses supported cost-effectiveness. Conclusions: Integrated antenatal services appear feasible and can achieve high testing uptake, particularly in well-supported programmes. However, evidence remains uneven regarding treatment completion, infant follow-up, HBV prophylaxis, long-term transmission outcomes, and sustainability in resource-constrained settings. Key challenges include supply constraints, workforce limitations, and follow-up gaps. Future research should evaluate the full care cascade, not screening uptake alone.

Healthcare doi: 10.3390/healthcare14121624

Authors: Shiqi Liu Yanli Tan Liuhong Zang

Background/Objectives: Climate change worry is an emerging concern in youth mental health, but little is known about how it is associated with positive psychological functioning among university students. This study examined whether climate change worry was associated with flourishing and whether this association showed a cross-sectional statistical indirect effect through anxiety and depressive symptoms, with physical activity specified as a first-stage boundary condition. Methods: A cross-sectional anonymous survey was conducted in 2026 using convenience sampling among students from four universities located in three provincial-level regions of China, covering southern, western, and central areas. After predefined quality control procedures, 2826 valid responses were included. Climate change worry, anxiety and depressive symptoms, flourishing, and physical activity were assessed using the Climate Change Worry Scale (CCWS), the Patient Health Questionnaire-4 (PHQ-4), the Flourishing Scale (FS), and the Physical Activity Rating Scale-3 (PARS-3), respectively. Pearson correlations and conditional process analyses were conducted using the PROCESS macro, with 5000 bootstrap samples. Results: Climate change worry was positively associated with anxiety and depressive symptoms (r = 0.331, p < 0.001) and negatively associated with flourishing (r = −0.193, p < 0.001). Anxiety and depressive symptoms were negatively associated with flourishing (r = −0.486, p < 0.001). The cross-sectional statistical indirect effect through anxiety and depressive symptoms was significant (indirect effect = −0.1277, 95% bootstrap CI: [−0.1441, −0.1123]). Physical activity was statistically associated with a weaker first-stage association between climate change worry and anxiety/depressive symptoms (B = −0.0014, p < 0.001; ΔR2 = 0.0064). The index of moderated mediation was significant (0.0014, 95% bootstrap CI: [0.0008, 0.0020]). Conclusions: Climate change worry was statistically associated with lower flourishing, primarily through higher anxiety and depressive symptoms. Physical activity was associated with a weaker first-stage association, but the moderation effect was small in practical magnitude. Given the cross-sectional and self-report design, these findings should be interpreted as conditional statistical associations rather than causal or protective effects.

Healthcare doi: 10.3390/healthcare14121623

Authors: António Lista Lara Guedes de Pinho Elisabete Alves César Fonseca

Background/Objectives: Person-centred psychosocial and rehabilitation interventions are increasingly relevant in long-term care (LTC) for older people with multimorbidity. Existing classifications describe the technical nature of these interventions rather than the LTC needs addressed by their delivered components. This study aimed to map delivered or reported components from a published parent review onto the World Health Organization long-term care framework. Methods: We conducted a framework-guided secondary analysis of 18 randomised controlled trials, including 9132 participants, from the parent review. Trials were conducted in LTC or settings relevant to LTC. Components were deductively mapped at study level to five framework domains: health care needs, palliative care needs, social care and support needs, person-centred integrated care, and education and training. Mapping followed predefined operational rules, a codebook, and a decision log. Planned-only components were excluded. Results were synthesised descriptively, without reassessing intervention efficacy. Results: Health care needs were identified in 17 of 18 trials, social care and support needs in 14, person-centred integrated care in all 18, and education and training in 17. Palliative care needs were less frequently represented, appearing in four trials. Psychosocial and Rehabilitation components were interpreted as mainly representing the technical-therapeutic core of interventions, while Complementary components were interpreted as supporting the operational infrastructure of care, including assessment, planning, coordination, monitoring, referral, training, documentation, and continuity. Conclusions: This framework-guided secondary analysis suggests broad but uneven coverage of WHO long-term care domains across the included trials. Future trials should more explicitly align targeted needs, delivered components, and outcome assessment, including social, caregiver, palliative, continuity, and person-centred care experience outcomes.

Healthcare doi: 10.3390/healthcare14121621

Authors: Els Roorda Marc Bruijnzeels Jeroen Struijs Marco Spruit

Background: Health disparities in individuals with type 2 diabetes result in an enormous amount of healthcare usage and are difficult to address. We examine how Dutch private, not-for profit health insurers, responsible for accessibility of care, use their claims data in the commissioning process to reduce health disparities. Objective: To identify factors influencing the possibility to reduce health disparities in commissioning based on data-driven insights. Methods: Key informant group interview data was analyzed using a hybrid deductive–inductive approach following the 6SQIuD framework to identify factors, their relationships, and potential for change, with results validated using a saturation, member and expert check. Results: From the 79 factors found, three were data capability-related and 76 were decision context-related. Fifteen main factors were found on socio-cultural, system, organizational and interpersonal levels. The factors in the decision context can be divided into the themes equality, quality and organizational sustainability. Conclusions: This study explored the factors influencing commissioners’ ability to reduce disparities and the role of data. Interestingly, no main factors related to data capabilities were identified. Three paradoxes were seen after interpreting our data: equal access leads to unfavorable unequal outcomes; a focus on evidence-based healthcare interventions limits effectiveness in reducing health disparities; and conservative organizational behavior threatens long-term viability. Further policy analyses are needed to better understand which systemic and organizational conditions facilitate commissioners in addressing health disparities.

Healthcare doi: 10.3390/healthcare14121620

Authors: Filiz Mercan Sarıdaş Erhan Hocaoğlu Müge Yaşar Kadircan Karatoprak Güven Özkaya Soner Cander Erdinç Ertürk Canan Ersoy Özen Öz Gül

Objective: This study aimed to assess health-related quality of life (HRQoL) and fatigue in patients with osteogenesis imperfecta (OI) and to compare these outcomes with those of healthy controls. In addition, the associations between fatigue and the physical and mental components of HRQoL, as well as related clinical factors, were examined. Method: Between June 2024 and June 2025, 27 adults with OI were enrolled and compared with 27 healthy controls. Fatigue was assessed with the FSS and HRQoL with the SF-36, including PCS and MCS scores. We evaluated factors associated with the PCS and MCS and examined the associations between the PCS/MCS and fatigue. Results: PCS scores were significantly lower in patients with OI types III and IV compared with controls, whereas no difference was observed between type I and controls. No significant differences were found in MCS scores or mental health domains among the groups. Fatigue levels did not differ significantly among the groups. Height was positively correlated with the PCS, while the number of fractures showed a moderate negative correlation. Lower PCS scores were observed in patients with lower extremity deformities and a history of orthopedic surgery. Alendronate use and longer treatment duration showed associations with higher PCS scores. In addition, a significant negative correlation was found between the MCS and fatigue severity. Conclusions: Adults with OI showed impaired physical functioning compared with controls, with relatively preserved mental functioning and similar fatigue levels. Physical functioning was associated with height, fracture burden, orthopedic surgery, and alendronate use, while fatigue was associated with mental functioning, underscoring the need for patient-centered care addressing both skeletal and psychosocial outcomes.

Healthcare doi: 10.3390/healthcare14121619

Authors: Chanatthee Kitsiripant Wilasinee Jitpakdee Maliwan Oofuvong Pannawit Benjawaleemas Nussara Dilokrattanaphichit Wipharat Juthasantikul Pannipa Phakam Qistina Yunuswangsa Polathep Vichitkunakorn

Background/Objectives: Unanticipated difficult airway remains a critical patient safety concern in perioperative care. Despite routine preoperative assessment, difficult intubation may still occur in patients without obvious high-risk findings. This study aimed to evaluate perioperative factors associated with unanticipated difficult intubation and to examine the relationship between preoperative assessment and intraoperative intubation difficulty in routine clinical practice. Methods: This retrospective case–control study included adult patients undergoing general anesthesia with tracheal intubation between 2015 and 2020 at a tertiary care hospital. Unanticipated difficult intubation was defined as requiring ≥3 intubation attempts without documented preoperative suspicion of difficult airway. Patients with anticipated difficult airway or preoperative mechanical ventilation were excluded. A total of 95 cases and 429 controls were analyzed. Associations were explored using multivariable logistic regression. Results: Among 524 patients, cases more frequently had ASA physical status III and airway/neck/oral deformity. Notably, intubation difficulty became evident only at laryngoscopy, characterized by poorer visualization, increased intubation attempts (median 4 vs. 1), and frequent escalation to video laryngoscopy. Severe laryngoscopic views (Cormack–Lehane grade III–IV: 74.8% vs. 3.0%) were markedly overrepresented among cases. In multivariable analysis, ASA III and airway deformity remained independently associated with unanticipated difficult intubation. The model demonstrated modest discrimination (AUC 0.685). Conclusions: Unanticipated difficult intubation was uncommon but clinically important and frequently became apparent only during airway management. Although several associated factors were identified, routine bedside airway assessment alone may not reliably predict all cases of intraoperative difficult intubation. These findings highlight the limitations of routine bedside airway assessment in identifying all patients who subsequently experience difficult intubation and support the need for improved strategies to identify patients at risk.

Healthcare doi: 10.3390/healthcare14121618

Authors: Sara Morais Pires Idalina Gomes

Background/Objectives: Older adults with cancer in the postoperative environment face complex vulnerability, exacerbated by the frailty of ageing and the aggressiveness of surgical treatment. In this highly demanding context, nurses play a crucial role as patient advocates. However, there is a knowledge gap regarding how advocacy is perceived and experienced by the nurse-patient dyad. This qualitative study aims to explain the practice of advocacy by comparing the perspectives of nurses and patients in order to construct part of a substantive theory on the subject. Methods: The Grounded Theory methodological approach was adopted. The sample included 6 specialist nurses and 10 older cancer patients from the ICU. Data collection consisted of participant observation and semi-structured interviews with both groups of participants. The analysis followed the constant comparison method, using MAXQDA software (version 24.10.0; VERBI Software; Berlin, Germany), allowing for the systematic and comparative identification of codes and categories from the two data sources. Results: The core process, defined as The Advocacy-Adjustment Dyad, reveals how older adult cancer patients navigate critical care through a symbiotic interplay of coping and support. Patients autonomously deploy Internal Adjustment mechanisms namely, Shielding the Emotional Self, to mitigate disease stress. Concurrently, the nurse operationalizes the Dynamic Expert Nurse Advocacy Cycle through a Therapeutic Alliance that prioritizes the patient’s best interest, integrates the Family as an anchor, and ensures a meaningful understanding of information. This dyadic interaction transforms the ICU from a purely technological setting into a therapeutic space, ensuring the Preservation of Personhood and the safeguarding of the patient’s self-determination. Conclusions: This study is pioneering in integrating the patient’s voice into the construction of a theory on advocacy in critical care, demonstrating that its effectiveness is a process of mutual interaction and not merely a unilateral function of the nurse. The findings emphasise the need to actively include the patient’s perspective in training and policy, offering valuable implications for optimizing older adult-centered care.

Healthcare doi: 10.3390/healthcare14121617

Authors: Hang Yang Xi Wang Tao Zhang Rongjiang Cai Shufang Zhao

Background/Objectives: Cross-border meteorological disaster medical rescue policies in the Guangdong–Hong Kong–Macao Greater Bay Area face challenges in coordination, completeness, and effectiveness. Existing policy systems lack systematic quantitative evaluation. This study aims to assess the current policy landscape and provide evidence-based recommendations for optimizing cross-border medical rescue policy supply and enhancing regional emergency coordination. Methods: We reviewed policy documents on cross-border meteorological disaster medical rescue issued from 2005 to 2025 and used a combination of text mining and the PMC index model to quantitatively analyze and evaluate selected policy texts. The PMC scoring criteria (0–10 scale) define scores ≥ 7 as “excellent” and 5–6.99 as “good”. Results: Policy word frequency analysis showed that “emergency,” “disaster,” “meteorology,” and “management,” were core high-frequency words; semantic network clustering revealed five major thematic modules: monitoring and early warning, emergency rescue, medical treatment, material support, cross-border coordination. The PMC indices of the 26 policies ranged from 5.65 to 9.42, with an average score of 6.95, which corresponds to the “good” level. Policy 14 scored 9.42, reaching the “perfect” level; eight policies received an “excellent” rating, indicating generally high policy quality. From a dimensional perspective, X9 (policy evaluation), X1 (Nature of policy), and X8 (policy guarantee) scored relatively high, while X4 (policy type) and X2 (policy timeliness) scored relatively low. Conclusions: The overall performance of the cross-border meteorological disaster medical rescue policy system is good, with relatively sound policy transparency and institutional guarantees. However, the policy system has the following shortcomings: insufficient cross-border coordination mechanisms, shallow integration of medical rescue professional content into comprehensive policies, and an emphasis on short-term emergency response with inadequate medium- and long-term strategic planning. It is recommended to strengthen medium- and long-term top-level strategic planning, enhance the functional allocation of health departments in meteorological disaster emergency plans, and establish a cross-regional joint policy evaluation and dynamic revision mechanism.

Healthcare doi: 10.3390/healthcare14121616

Authors: José P. Traña-Serrano Cristina Orts-Ruiz Sergio Montero-Navarro Andrés Zamora-Streber María José Ramírez Rivera Oscar Garita Redondo Francisco J. Molina-Payá Laura Fluxa-Juan Jesús Sánchez-Más Cristina Salar-Andreu

Background: Stress urinary incontinence (SUI) is defined as involuntary urine loss during activities that increase intra-abdominal pressure. It is highly prevalent among women and significantly affects physical, emotional, and social well-being. Pelvic floor muscle training (PFMT) is the gold-standard conservative therapy. Second-generation radiofrequency (RF) therapy has shown promise as an alternative. It stimulates collagen synthesis and promotes tissue remodeling. This study will compare the effects of PFMT, RF, and their combination on pelvic floor function, urethral stability, and health-related quality of life (HRQoL) in women with SUI due to urethral hypermobility. Methods/Design: This will be a single-blinded, three-arm, randomized controlled trial conducted at Clínica Traña (San José, Costa Rica). Women aged ≥18 years with clinically confirmed SUI and a retrovesical (β) angle ≥ 140° during the Valsalva maneuver on functional transperineal ultrasound will be randomized (1:1:1) to PFMT (16 weeks, twice-weekly supervised sessions), RF (5 weekly sessions using Capenergy® C500 Urogyne), or combined RF + PFMT (39 per arm; total N = 117 accounting for 30% attrition). The primary outcome is the change from baseline in pelvic floor muscle strength at 12 months post-intervention, measured by the modified Oxford scale and vaginal manometry. Secondary outcomes will include urethral stability (retrovesical β angle and bladder neck descent on ultrasound), incontinence severity (Sandvik Severity Index), and HRQoL (ICIQ-UI SF and King’s Health Questionnaire). All outcomes will be assessed at baseline, immediately post-intervention, 15 days, 3 months, 6 months, and 12 months follow-up. Assessments will be performed by blinded evaluators. Analysis will follow intention-to-treat principles using repeated-measures ANOVA or non-parametric equivalents (SPSS v.29; p < 0.05). The trial was prospectively registered on ClinicalTrials.gov (NCT07095283, registered on 24 July 2025), prior to the recruitment of the first participant. Expected outcomes: This study will provide comparative effectiveness data on whether the addition of RF to PFMT offers additional benefits over PFMT alone in the management of SUI.