International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081043

Authors: Juliana Maria Altavista Sagretti Gallo Amanda Rafaelly Honório Mandetta Ana Paula Taboada Sobral Marcela Letícia Leal Gonçalves Mayumi Oshiro Costa Caroline Diniz Pagani Vieira Ribeiro Mariana Moreira Machado Abigail Malavasi Elaine Marcílio Santos Cinthya Cosme Gutierrez Duran Sandra Kalil Bussadori

Introduction: Halitosis is a common oral condition that may negatively affect social interactions, psychological well-being, and quality of life. However, evidence regarding its association with mental health and sleep quality remains inconsistent, particularly among university students. Aim: This cross-sectional study investigated the prevalence of objectively measured halitosis and its association with tongue coating, sleep quality, and symptoms of anxiety, depression, and stress among university students from the metropolitan region of Santos, Brazil. Methods: Sixty-two Brazilian university students enrolled in health-related undergraduate programs participated in the study; most were in the first academic year (61.3%) and resided in the municipality of Santos (59.7%). Halitosis was assessed using a portable breath detector, tongue coating was evaluated using the Coated Tongue Index, sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), and symptoms of depression, anxiety, and stress were measured using the Depression, Anxiety and Stress Scale (DASS-21). Results: Objectively measured halitosis was identified in 25 participants (40.3%; 95% CI: 29.0–52.7%). The analyses did not provide statistically significant evidence of associations between objectively measured halitosis and tongue coating, sleep quality, or symptoms of anxiety, depression, and stress. Significant positive correlations were identified between stress and sleep disturbance, anxiety and sleep disturbance, and depression and sleep latency, daytime dysfunction, and overall sleep quality. Tongue-cleaning habits were significantly associated with the presence of halitosis, whereas oral mucosal desquamation was less frequent among participants with halitosis. Conclusion: The study did not provide statistically significant evidence of associations between objectively measured halitosis and tongue coating, sleep quality, or psychological symptoms in this population. Significant positive correlations were identified between stress and sleep disturbance, anxiety and sleep disturbance, and depression and sleep latency, daytime dysfunction, and overall sleep quality. These findings highlight the importance of objectively assessing oral malodor in epidemiological studies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081042

Authors: Lindokuhle Mokoena Teboho Abram Moloi Tanusha Singh

Background: Vaccine hesitancy is a global challenge affecting workplaces and academic institutions. Despite efforts, low vaccination rates persist in South Africa, increasing the risks associated with pathogen exposure. This study assessed the knowledge, attitudes, and perceptions (KAPs) of healthcare workers (HCWs) and students at a Nursing College regarding voluntary and mandatory COVID-19 vaccination. Methods: A quantitative cross-sectional study was conducted using a structured, self-administered electronic questionnaire. All eligible nursing students and staff at the participating Nursing College were invited to participate. Of the 504 eligible individuals, 372 completed the questionnaire, corresponding to a response rate of 73.8%. Data were analyzed using IBM SPSS Statistics version 30.0. Logistic regression and Mann–Whitney U tests were used to assess associations and differences between groups, with statistical significance set at p < 0.05. Results: Most respondents were female (302, 81.0%) and single (252, 67.9%). The age group 26 to 40 was most prominent (144, 38.8%). Only 42.2% of respondents (n = 157) were fully immunized with no boosters. Student nurses dominated (344, 92.5%), with 226 (60.9%) having no COVID-19 infections and 198 (72.0%) voluntarily receiving the vaccine. Occupation (p = 0.030) and age group (p = 0.027) were independently associated with reporting voluntary COVID-19 vaccination. Age was also associated with respondents’ attitudes and perceptions of the COVID-19 vaccine (p < 0.001) as well as their understanding of the vaccine (p = 0.002). Conclusions: Occupation and age group were independently associated with the reported basis on which COVID-19 vaccination was received (voluntary versus mandatory). Targeted communication and educational strategies addressing these factors may improve vaccine acceptance and preparedness for future outbreaks.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081041

Authors: Chedsada Saisombut Pheerasak Assavanopakun Pevra Kanta Jinjuta Panumasvivat

This study investigated the complex interfaces between knowledge, attitude and practice (KAP); biomechanical risks; and musculoskeletal disorders (MSDs) among heavy manual handling workers. A cross-sectional study surveyed 99 industrial manual lifting workers within manufacturing factories (mean age: 33.4 ± 7.7 years; mean job experience: 7.95 ± 6.5 years) using a validated online questionnaire assessing demographics, occupational conditions, biomechanical risk, lifting KAP, and MSD prevalence via the Extended Nordic Musculoskeletal Questionnaire. Associations with 12-month and active 7-day MSD prevalence were analyzed using multinomial logistic regression. The 12-month prevalence of MSDs was 56.6%, predominantly affecting the lower back (51.0%). The MSD group reported significantly higher biomechanical risks. Chi-square analysis revealed significant differences in safety practices (p = 0.025), particularly regarding pre-work stretching, load-weight assessment, and overhead lifting. Higher biomechanical risk was significantly associated with 12-month MSDs without 7-day pain (RRR = 1.54, 95% CI: 1.10 to 2.16, p = 0.012). Conversely, greater knowledge demonstrated a significant protective association against 12-month MSDs without 7-day pain (RRR = 0.74, 95% CI: 0.56 to 0.99, p = 0.045). Age-related vulnerability significantly increased active 7-day MSDs. MSD prevalence is driven by cumulative biomechanical hazards. Although knowledge is associated with lower long-term risk, a critical knowledge-to-practice gap exists. Interventions must prioritize workplace ergonomic risk reduction with age-tailored adjustments. These should be integrated with active, practice-based training to foster behavioral modification.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081040

Authors: Ratchaya Supalak Naparat Doungchan Arisa Sespheng Kornanong Yuenyongchaiwat Stephen J. Scholand Chuchard Punsawad

Background: There is limited evidence regarding sarcopenia in Thailand, especially in southern provinces when applying the AWGS-2019 criteria. Objective: The present study aimed to determine the prevalence and independent risk factors of sarcopenia among community-dwelling older adults in Nakhon Si Thammarat. Methods: A cross-sectional study was conducted involving 246 adults aged 60 years or older. Sarcopenia was defined using the AWGS-2019 criteria. Data collection comprised the Mini Nutritional Assessment-Short Form (MNA-SF), Abbreviated Mental Test (AMT), and physical performance assessments. Multivariable logistic regression analysis was performed to identify independent predictors, incorporating both categorical and continuous variables. Results: The prevalence of sarcopenia was 27.64%. Multivariable analysis identified age of ≥80 years or older (AOR = 4.25, 95% CI: 1.12–16.14; p = 0.033) and body mass index (BMI) below 18.5 kg/m2 (AOR = 3.58, 95% CI: 1.20–10.65; p = 0.022) as significant risk factors. Protective factors included attainment of secondary education or higher (AOR = 0.12, 95% CI: 0.02–0.78; p = 0.025), BMI of 23.0 kg/m2 or greater (AOR = 0.19, 95% CI: 0.09–0.40; p < 0.001), engagement in regular physical activity (AOR = 0.21, 95% CI: 0.08–0.54; p = 0.001), and normal nutritional status (AOR = 0.24, 95% CI: 0.08–0.71; p = 0.010). Further continuous analysis confirmed that each 5-year increase in age significantly increased the risk of sarcopenia (AOR = 1.52, 95% CI: 1.14–2.03; p = 0.005), while each 1 kg/m2 increase in BMI was associated with a protective effect (AOR = 0.78, 95% CI: 0.69–0.88; p < 0.001). Conclusions: Sarcopenia is common among older adults in Southern Thailand. Both categorical and continuous analyses identify advanced age as a primary risk factor. In contrast, higher education, optimal body mass index, regular physical activity, and adequate nutrition serve as important protective factors. These results highlight the importance of community-based screening and targeted interventions that address nutritional adequacy and structured exercise to enhance quality of life in this population.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081039

Authors: Natasha Crooks Nyssa Snow Hill Abigail Bushnell Rabiatu Barrie Stephanie Castelin Gina Sissoko

The adultification of Black adolescent girls, viewing them as less innocent and more adult-like, has implications for their sexual and psychological well-being. Adultification creates bias, which hyper-sexualizes Black girls, increasing vulnerability to early sexual activity, sexual abuse, and lack of support, while hindering their ability to seek protection. However, protection from parents, peers, and communities may play a critical role in mitigating this risk for Black girls. The current study examined the role of maternal, paternal, peer friendships, and communal protective factors in mediating the association between adultification and sexual risk among Black girls. Girls’ responses (N = 575), 9–18 years old, were analyzed. Multiple linear regression analyses were conducted to estimate the mediating effects of protective factors (mother, father, friendship, and communal) on adultification and sexual risk. In separate mediation models, paternal relationships and friendship partially mediated the association between adultification and sexual risk. However, in a parallel mediation model that simultaneously examined maternal and paternal relationships, friendship, and community protection, friendship emerged as the only significant indirect pathway. Greater adultification was associated with stronger peer friendship, which in turn was associated with greater sexual risk. Programs, policies, and interventions addressing the sexual health of Black girls should consider how peer relationships shape responses to adultification and promote peer environments that support healthy sexual development.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081038

Authors: Ferrarello Susi

It is becoming harder to feel at home. As wildfires, floods, drought, and heat become recurrent rather than exceptional, and as everyday life fills with weather alerts, evacuation warnings, and preparedness drills, many people experience a particular kind of distress: the pain of remaining in a place that is still physically present but no longer feels safe, familiar, or trustworthy. This paper examines that experience through the concept of solastalgia—homesickness felt while still at home—and argues that it is not a private mood or a distortion of thinking, but a meaningful disturbance in the very conditions of dwelling. Bringing together phenomenology, emotional geography, and emotion-regulation theory, it shows how a pervasive “culture of emergency” reshapes the way we inhabit space, time, our bodies, and our relationships with others, narrowing the room we feel we have to live and act. Rather than treating climate-related anxiety as something to be corrected, the paper understands it as an honest response to a world whose stability has genuinely been compromised. It then asks how home might become livable again, arguing that repair must happen at several levels at once—personal, communal, and institutional—and that a workable sense of belonging can be rebuilt without denying what has been lost.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081037

Authors: Altay Dyussupov Rauan Kissina Nailya Chaizhunussova Dariya Shabdarbayeva Andrey Orekhov Zhanargul Smailova Meruyert Massabayeva Assel Baibussinova Alexandra Lipikhina Yulia Brait Alexey Klivenko Saulesh Apbassova Gulnara Batenova Murat Lepesbayev Saule Kozhanova Asset Izdenov Raushan Dosmagambetova Lyudmila Pivina

Introduction. Mortality rates from malignant neoplasms can be considered a key marker of adverse environmental impacts. The aim of this study was to assess the association between exposure to ionizing radiation and the risk of mortality from malignant neoplasms among the population of Kazakhstan living in areas adjacent to the Semipalatinsk Nuclear Test Site (SNTS). Materials and Methods. The main source of data used in this study was the mortality sub-register of the population living in territories adjacent to the Semipalatinsk Nuclear Test Site (SNTS). The main study group included residents of the Abay District (n = 1300) and Beskaragay District (n = 414). In total, 478 residents of the Kokpekty District, where the radiation dose was minimal, were included in the control group. The median effective radiation dose was 864 mSv for the population of the exposed group, whereas in the control group, it was 67 mSv. Results. The highest RR values were observed in the periods 1965–1969 (RR = 6.14; 95% CI: 4.04–9.34) and 1970–1974 (RR = 6.14; 95% CI: 4.19–8.99). Age-standardized mortality rates (ASMR) in the study group were significantly higher than those in the control group. A dose–response relationship was established: with each 10.0 mSv increase in radiation dose, the risk of cancer mortality increased by 0.9% (OR = 1.009; 95% CI: 1.008–1.010; p < 0.001). Conclusions. The obtained results indicate a significant association between long-term exposure to ionizing radiation due to testing at the Semipalatinsk Nuclear Test Site and increased cancer mortality among the population of adjacent territories.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081036

Authors: Prasert Makkaew Apirak Bumyut Ni Luh Ayu Megasari Nopadol Precha

Kindergarten environments combine high microbial exposure with increased immunological vulnerability, yet antibiotic resistance genes (ARGs) in kindergarten dust remain poorly characterized. This systematic review synthesized evidence on the occurrence and potential health relevance of ARGs in kindergarten dust. Following PRISMA 2020 guidelines, PubMed, Scopus, and Web of Science were searched. Four studies from China, Hong Kong, and Norway (2018–2024) met the inclusion criteria. ARGs were detected in all kindergarten dust samples, indicating that dust is a consistent reservoir of antibiotic resistance determinants. A consensus resistome (classes detected in ≥2 studies) encompassed sulfonamide, macrolide–lincosamide–streptogramin B (MLSB), tetracycline, beta-lactam, aminoglycoside, and multidrug resistance genes; beta-lactam resistance genes were the only class reported in all four studies. Clinically important ARGs associated with last-resort antibiotics, including mecA, vanA, blaNDM, and mcr-5, were reported in three studies. Class 1 integron-integrase genes (intI1) frequently co-occurred with ARGs, suggesting potential horizontal gene transfer. Limited evidence indicated higher ARG abundance in urban and winter samples. One study reported antibiotic-resistant bacteria carrying resistance markers concordant with those in kindergarten dust in the urine of children attending the same facilities; however, this cross-sectional, single-site evidence is consistent with, but not sufficient to establish, a dust-to-child exposure pathway. The available evidence supports the plausibility that kindergarten dust may contribute to children’s exposure to ARGs and ARG-carrying bacteria, but current studies do not establish causal transmission from dust to child colonization or infection. Standardized monitoring and longitudinal studies are needed to assess health risks and guide mitigation strategies in early childhood educational settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081035

Authors: Md. Sabbir Hossain Khan Mohammad Javad Koohsari Jiuling Li Jing Zhao Yufeng Luo Akitomo Yasunaga Koichiro Oka Andrew T. Kaczynski

Park audits can inform neighbourhood-scale urban design strategies that support health. However, interpreting park audit data is time-consuming and requires specialised expertise. Recent advances in large language models suggest potential for assisting with structured data interpretation, but their application to park audits remains unexplored. This study examined whether a large language model (ChatGPT-5) can assist in interpreting park audit data from public parks in Dhaka City, Bangladesh. Using a modified park audit tool, 59 parks were audited, of which 26 met the predefined completeness threshold and were included in the analysis. ChatGPT-5 and human experts received identical park audit datasets and instructions for interpretation. Outputs were evaluated using content analysis and a pre-defined scoring framework to assess accuracy and comprehensiveness. Paired t-tests compared ChatGPT-5 outputs with the expert benchmark. ChatGPT-5 showed no statistically significant difference from the expert benchmark in overall accuracy in this sample (p = 0.13). The unadjusted analysis showed a higher recommendation-match count for ChatGPT-5 (p < 0.05), but this result should be interpreted as exploratory because multiple criteria were tested. No statistically significant differences were detected across accuracy domains or other comprehensiveness criteria. These findings suggest that ChatGPT-5 may assist with preliminary interpretation of structured park audit data. However, the results do not establish equivalence with expert assessment. Expert review remains necessary to assess feasibility, contextual relevance, and alignment with local planning standards.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081034

Authors: Rihab Khalid Agnes Naluwagga Jimmy Agaba Adrian Okorio Charles Kayemba

Institutional and commercial cooks may experience sustained heat exposure from combustion-based cooking, yet field evidence on thermal conditions following the introduction of electric cooking remains limited. This exploratory before-and-after case study examined three purposively selected kitchens in Kampala, Uganda, combining five-minute temperature and relative humidity monitoring at three spatial positions with cooking diaries, repeated thermal comfort and sensation votes, and enumerator observations. Heat Index (HI) was used as a temperature–humidity screening proxy, and Kampala weather data were used to calculate weather-adjusted differences. On documented active e-cooking days, mean hourly near-stove HI fell from 33.26 °C to 26.00 °C at Site A, 31.35 °C to 29.55 °C at Site B, and 31.71 °C to 27.50 °C at Site C. Time in the Safe HI category increased from 23.5% to 67.8%, 17.0% to 33.3%, and 25.4% to 53.0%, respectively. Day-level tests and a sensitivity analysis using all weather-matched intervention period logger days showed the same overall direction. Raw cooking durations declined for several meals, although, after normalisation by the number of people served, the reductions remained statistically detectable only for Site B breakfast and lunch. The results provide exploratory evidence of lower environmental thermal exposure under documented active e-cooking conditions. Sequential timing, purposive sampling, workload differences, incomplete intervention records and the absence of radiant, air speed and physiological measurements prevent causal interpretation as reduced occupational heat strain.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081033

Authors: Jaime Cesar Prieto-Luna Luis Alberto Holgado-Apaza Mixel Luigui Corrido-Ninahuaman Nestor Antonio Gallegos Ramos Nelly Jacqueline Ulloa-Gallardo Dany Dorian Isuiza-Perez Roxana Madueño-Portilla Pierre Vidaurre-Rojas Miguel Angel Valles-Coral

The coexistence of undernutrition and excess weight is an important child public health challenge. This study described temporal trends and departmental spatial configurations of wasting, stunting, overweight, and obesity among children under five years of age in Peru during 2014–2024. Analyses used anthropometric assessment records from the Nutritional Status Information System (SIEN), collected in public healthcare facilities and aggregated by department and year. Annual Percentage Change summarized average temporal trends, while observed prevalence maps, Global Moran’s I, Local Indicators of Spatial Association (LISA), and a median-based bivariate classification were applied independently to 2014, 2019, and 2024. Queen contiguity was the primary spatial specification, along with KNN-4 sensitivity analysis. Wasting and obesity increased on average, stunting decreased, and overweight showed no significant long-term trend. Global autocorrelation was most consistent for wasting, whereas findings for excess-weight indicators were sensitive to the weights matrix. LISA identified local spatial classifications at nominal p < 0.05; however, these findings were exploratory because no multiple-testing correction was applied. The bivariate classification identified two, four, and three departments with concurrent high relative undernutrition and excess-weight scores in 2014, 2019, and 2024, respectively. These record-based findings show territorial heterogeneity within SIEN but do not represent population prevalence, causal geographic effects, or an integrated spatiotemporal process.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081032

Authors: Anna Foxcroft Craig Allen Julia Dray Amelia Gulliver Dianna Smith Grenville Rose Bridget Berry Michelle Banfield

The language used to describe and discuss mental ill-health continues to evolve and improve, driven by advocacy and commitment to reducing the harmful effects of stigma. However, from a lived experience perspective, room for improvement remains. This project aimed to explore the use of language and labels within the mental health sector and its impact on people with lived experience of mental ill-health. Interviews were conducted with mental health consumers and/or carers (n = 15), and co-researchers with lived experience of mental ill-health contributed researcher positionality to the research. Six themes were generated using reflexive thematic analysis; they accented how participants expressed complex and nuanced experiences of language and labels, and the overlapping themes highlight the ‘blurry edges’ when people with lived experience discuss language, with the individual at the centre. Responses reflected the nature of inclusive and exclusive language in the medical system and the community. Central to experiences of exclusion were times when people felt dismissed and misunderstood due to the language and labels others use and how the words are delivered. These negative experiences reflect the influence of stigma. Positive language provides validation, understanding and a sense of hope. Health professionals may have opportunities to apply more personalised communication approaches, which could improve outcomes for the people they support.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081031

Authors: I Gede Juanamasta Rapin Polsook Bootan Ahmed Yupin Aungsuroch Ni Made Ratih Comala Dewi I Gede Griya Suparta Ferry Efendi

Background: Dementia is a global health priority affecting more than 55 million people worldwide, with projections indicating this figure will rise to 139 million by 2050. People living with dementia (PLWD) face profound difficulties accessing primary care services—the critical gateway to dementia diagnosis, ongoing management, and coordinated specialist referral. Despite growing evidence on individual barriers, a comprehensive synthesis integrating patient, caregiver, and system-level perspectives is lacking. Objectives: This systematic review and meta-synthesis aimed to identify, appraise, and synthesize evidence on the barriers and facilitators experienced by PLWD and their caregivers when accessing primary care services, and to propose evidence-based recommendations to address inequities. Methods: A systematic search was conducted to identify relevant articles in six electronic databases: PubMed, MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Library, and Web of Science from January 2000 to December 2024, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Qualitative, quantitative, and mixed-methods studies reporting barriers or facilitators to primary care access for PLWD were included. A convergent integrated synthesis and thematic meta-synthesis approach was applied. Quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Results: Forty-three studies from 18 countries met inclusion criteria. Barriers were categorized across five domains: (1) patient-level factors (stigma, denial, symptom normalization, and limited health literacy); (2) caregiver-level factors (burden, late symptom recognition, and cultural barriers); (3) provider-level factors (insufficient training, therapeutic nihilism, and time constraints); (4) system-level factors (fragmented care pathways, long waiting times, and poor care coordination); and (5) structural and societal factors (rurality, poverty, and ethnic minority status). Facilitators included caregiver advocacy, strong patient–GP relationships, dementia literacy campaigns, availability of memory clinics, and integrated care models. Disparities were consistently greater for ethnic minority groups, rural populations, and those with lower socioeconomic status. Conclusions: Barriers to primary care access in dementia are complex, overlapping, and mutually reinforcing. Effective strategies require multi-level interventions addressing individual, relational, provider, and system dimensions simultaneously.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081030

Authors: Fehmidah Munir Alice Sinclair Oliver Davis Jeremy Dawson Lizzie Degerdon Jaime Delgadillo Umesh Kadam Joanna Yarker

Long-term sickness absence is a growing public health issue, reducing workforce participation and widening health inequalities. Effective interventions must address both health and workplace factors to enable not only return-to-work but sustained employment. This study evaluated the feasibility of a multi-level workplace intervention to support sustainable RTW in large organizations. A two-arm cluster randomised feasibility trial was conducted in nine UK organizations (≥600 employees). Participants included senior leaders and HR professionals (n = 91), workers on long-term sick leave (n = 112), and line managers (n = 83). The IGLOo intervention combined e-learning for leaders/HR with structured toolkits for workers and managers to support RTW before and after return. Feasibility outcomes included recruitment, retention, engagement, acceptability, and usability. Secondary outcomes included RTW timing, sustained participation, mental health, and workplace factors. A mixed methods process evaluation explored implementation and context. Retention, acceptability, and usability met targets, but recruitment and engagement were lower than expected. Potential mechanisms included improved confidence, communication, and self-management. Organizational systems and pressures affected delivery. Exploratory analyses suggested different patterns of return-to-work trajectories across trial arms. Overall, the intervention was acceptable to participants who engaged with it, but recruitment barriers and organizational constraints require substantial modification before any future efficacy trial.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081028

Authors: Hubert Tuyishime Carole Lin Amandeep Chawla Bryan Khoo Kevin G. Shea

Healthcare services account for approximately 4–5% of global greenhouse gas emissions worldwide, and nearly 10% of emissions in the United States are primarily from general hospital operations, surgical and anesthetic care, and pharmaceutical and medical device supply chains. Healthcare services and operations also generate substantial plastic and chemical waste that pollute the environment and disproportionately affect vulnerable communities. Although global and national organizations have introduced decarbonization frameworks, adoption remains hindered by limited leadership engagement, competing institutional priorities, and insufficient regulatory accountability. This article synthesizes the published literature on the current landscape of healthcare sustainability, summarizes key policy frameworks, and identifies major barriers to implementation; these findings are then illustrated through sustainability initiatives at Stanford Medicine, a quaternary hospital system. These efforts are presented as implementation examples that other institutions may adapt to their own resources and contexts, to reduce emissions and ensure more sustainable healthcare delivery.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081029

Authors: Ángel Radamés Rábago-Monzón Karyme Mylenia Alemán-Villa Emiliano Terán Javier Abednego Magaña-Gómez Verónica Judith Picos-Cárdenas Beatriz Kazuko De la Herrán-Arita Loranda Calderón-Zamora Alberto Kousuke De la Herrán-Arita

This study examined how residents of Culiacán, México, adapted over time to prolonged community violence and perceived insecurity. We evaluated a two-speed adaptation theory, which proposes that indicators of acute psychological distress and economic strain decline over time, whereas protective behavioral responses persist as a state of chronic vigilance. A mixed-longitudinal design was employed, consisting of a baseline survey of 1163 residents conducted in October 2024 and a longitudinal cohort of 100 participants followed in February and June 2025. Longitudinal changes were evaluated using Cochran’s Q tests with exact McNemar post hoc comparisons, proportions were reported with 95% Clopper–Pearson confidence intervals, and multivariable logistic regression was used to examine predictors of migration intent. Pharmacologic treatment utilization declined significantly from 36% to 20%, and reported economic strain decreased from 62% to 35% over the study period. In contrast, behavioral routine modifications remained persistently high, decreasing only from 95% to 88%, with no statistically significant longitudinal change. These findings are consistent with the proposed theory, suggesting that while acute psychosocial and economic impacts may diminish over time, protective behavioral adaptations remain comparatively stable. Regarding migration intent, individual economic strain was not significantly associated with the intention to leave the city. Instead, participants who attributed insecurity primarily to social contract collapse, conceptualized as the perceived erosion of community trust, institutional legitimacy, social polarization, and the breakdown of social order, had substantially greater odds of reporting migration intent than those primarily concerned with economic factors (OR = 11.56, 95% CI 1.55–85.98). Overall, these findings suggest that prolonged community violence produces distinct trajectories of psychosocial adaptation, in which acute distress decreases while chronic vigilance persists. Furthermore, migration intentions appear to be more strongly associated with perceived deterioration of the social environment than with individual economic hardship, highlighting the importance of restoring community trust and institutional legitimacy alongside traditional public health and economic interventions.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081027

Authors: Vanessa Wright Katy Fisher-Cunningham Brayton Amidon Shari Clifton

American Indian and Alaska Native (AI/AN) communities experience disproportionate rates of HPV-associated cancers, yet vaccination uptake remains low. This scoping review mapped research on HPV vaccination among AI/AN college students aged 18–26, including vaccine uptake, knowledge, perceptions, and barriers. Using Joanna Briggs Institute scoping review methodology and the PRISMA-ScR checklist, MEDLINE (Ovid), CINAHL Ultimate, Embase (Ovid), ERIC (Ovid), Scopus, and Web of Science Core Collection were searched with no restrictions on publication year. Eligible studies included AI/AN college students aged 18–26 and examined factors influencing HPV vaccine uptake; studies that did not disaggregate AI/AN data were excluded. Of 911 abstracts identified, three publications met inclusion criteria; all included studies drew exclusively on American Indian samples and did not include Alaska Native participants. The findings reveal low HPV knowledge, limited perceived risk, gender differences in attitudes, and barriers including stigma, access challenges, and mistrust of healthcare systems. The near absence of contemporary research reflects ongoing data invisibility and structural factors affecting AI/AN young adults. AI/AN college students represent a critical yet overlooked population for catch-up HPV vaccination, requiring community-engaged strategies to advance cancer equity.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081026

Authors: Morgan A. Valley Katie McMahon Aurora Koren Lorann Stallones

Background: Public housing employees work in challenging conditions with many stressors. A Colorado housing authority requested an evaluation of its voluntary reduced work schedule pilot program and its association with employee wellbeing. Previous research has shown promising short-term improvements in employee productivity and morale from reduced schedule programs, but researchers have questioned whether impacts on wellbeing could be sustained. The study aimed to evaluate if program participants and non-participants reported differences in wellbeing measures over 18 months post-implementation. Methods: A longitudinal survey based on the NIOSH WellBQ over three timepoints and a series of four focus groups were conducted with program participants and non-participants. Linear mixed modeling was used to test for differences between participant and non-participant wellbeing outcomes over time. Deductive thematic analysis was used to analyze focus group data. Results: Program participants reported significantly lower work overload than non-participants; differences in work stress and work-to-non-work conflict were smaller and did not reach statistical significance. There was no evidence that the magnitude of these differences changed across timepoints, although limited statistical power constrains interpretation of this finding. Qualitative findings demonstrated that participants perceived benefits for work–life integration and decreased work stress and work overload, which participants attributed to the program. Conclusions: Findings suggest that reduced work schedules may be associated with differences in employee wellbeing over the study period, particularly reduced work overload.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081025

Authors: Urai Jaraeprapal Pornchanuch Chumpunuch Arthit Boonrodchu Uraiwan Pantong Ladda Thiamwong

Geriatric nutritional problems are increasingly characterized by the co-existence of undernutrition and obesity, yet community-level evidence from Southern Thailand remains limited. Grounded in the social determinants of health (SDH) framework, this cross-sectional study examines the prevalence and independent predictors of BMI categories and abdominal obesity among 13,458 community-dwelling older adults across 20 sub-districts in Southern Thailand. Anthropometric measurements and structured interview data were analyzed using chi-square tests and multinomial logistic regression, with normal weight as the reference category. Overall, 50.3% of participants were overweight or obese, 40.5% had abdominal obesity, and 7.7% were underweight. Advancing age, continued employment, and asthma were independently associated with higher odds of underweight, whereas abdominal obesity was the strongest predictor of elevated BMI categories, increasing the odds of overweight, obesity Class I, and obesity Class II. Female sex, literacy, dyslipidemia, hypertension, and diabetes were also associated with excess BMI categories. Moderate, regular physical activity was a protective factor. These findings support risk-stratified community interventions that integrate BMI with WC screening and address regional occupational, behavioral, clinical, and food culture determinants of nutritional health in older adults.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081024

Authors: Ester Villalonga-Olives Abdolvahab Khademi Alisha A. Crump Christopher M. Amissah Inez Adams Candace Hall Yun-Yi Pan Yusuf Ransome

Volunteering is a key component of social capital associated with improved health outcomes. However, it remains unclear how volunteer patterns differ by race and education and whether standard measures adequately capture racial and contextual differences in how volunteering is understood and reported. This mixed-methods study examined racial and educational differences in volunteer activities over time and evaluated how individuals from different racial backgrounds define, engage in, and value volunteering. This study used a mixed-methods longitudinal design combining secondary analysis of the Midlife in the United States (MIDUS) study (1995–2016; n = 5921) with qualitative interviews (n = 47) in the United States. The quantitative outcome was the number of self-reported volunteer hours per month across four domains: healthcare, youth-related, political, and other organizations. Linear mixed-effects models were used to examine differences by race, volunteer context, and time, adjusting for age, gender, and educational attainment. Qualitative interviews used MIDUS item probes and open-ended questions to examine participants’ interpretations of volunteer work, unpaid activities, and forms of engagement. Black participants reported significantly higher volunteer hours than White participants (β = 0.97, p = 0.007). Volunteering varied by context, with higher engagement in school and youth-related (β = 1.12, p < 0.001) and other organizational activities (β = 2.80, p < 0.001) and lower engagement in political contexts (β = −0.45, p < 0.001), relative to healthcare settings. Volunteering increased modestly over time (Wave 2: β = 0.45, p < 0.001; Wave 3: β = 0.39, p < 0.001). Interaction analyses indicated that racial differences varied across contexts, with a significantly smaller increase in volunteering within “other” organizations among Black participants relative to White participants (β = −1.29, p = 0.006). Qualitative findings indicated that Black participants more often engaged in community-based and informal activities, including work within community organizations, whereas White participants more frequently participated in formal volunteering. Urban residents reported more flexible engagement compared with suburban residents’ structured participation. Volunteering is shaped by structural and contextual factors. Public health research and interventions should adopt more inclusive measures to better capture diverse forms of civic engagement.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081023

Authors: Lisa Roque Lorelei Van Hees Bebiana Leonardo Teresa Santos Paulo Ferrajão

Background: Inflammatory bowel disease (IBD) affects millions worldwide, imposing substantial clinical consequences and mental health implications. This burden leads to reduced quality of life (QoL) and growing pressure on healthcare systems and economies. This cross-sectional study examined the effects of childhood trauma on subjective symptoms of IBD health-related QoL, focusing on the mediating roles of emotional suppression and cognitive control, providing an integrative model for the general population. Methods: A sample of 402 Portuguese adults completed self-report measures, including the Childhood Trauma Questionnaire, the Emotion Regulation Questionnaire, the Cognitive Control and Flexibility Questionnaire, and the Short IBD Questionnaire. Multiple-step mediation analyses with bootstrapped confidence intervals tested indirect effects. Results: The two-step mediation effects indicated that childhood trauma was associated with subjective symptoms of IBD health-related QoL through both expressive suppression and cognitive control. Conclusions: These findings highlight the pivotal role of developmental, emotional and cognitive factors in understanding IBD health-related QoL in the general population, offering an opportunity to capture undiagnosed, mild, atypical, or intermittent cases, often discarded from most clinical studies. General-population-based data collection on IBD, beyond clinical settings, is vital for informed resource allocation and the design of effective screening, prevention and public health interventions that capture both diagnosed and undiagnosed cases.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081022

Authors: Miluska Vega-Guevara Felipe Aguirre-Chávez Rosa Millones Rivalles Vicenta Irene Tafur Anzualdo

Health care empowerment is essential for self-care, informed decision-making, and appropriate use of health services among university students. This cross-sectional pilot study examined the association between selected social determinants of health and health care empowerment among university students in Peru. A sample of 336 undergraduate and graduate students from six universities completed an online survey that included the Empowerment Scale for Health Care Empowerment in University Students (ECSU). The instrument demonstrated adequate psychometric properties (Cronbach’s α = 0.859; McDonald’s ω = 0.835). Descriptive analyses and ordinal logistic regression were conducted to identify factors associated with health care empowerment and its dimensions. Income level, family type, and housing situation were associated with overall empowerment. Lower income levels and extended family structures were associated with lower empowerment levels, while university type and educational level were associated with specific dimensions related to decision-making and the ability to empower others. The explanatory capacity of the models was modest (pseudo-R2 = 5.0–12.8%). These findings provide preliminary evidence on the relationship between social determinants and health care empowerment in university students. However, results should be interpreted with caution due to the cross-sectional design and convenience sampling. Future studies using probabilistic sampling and longitudinal designs are needed to confirm these associations.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081021

Authors: Andreas Müller Eitan Bronschtein Ferdinand Sasváry

(1) Background: Ambulatory services are the main interface between populations and health systems, yet their benefits are unevenly distributed due to structural inequalities—systemic differences rooted in the social, economic, and political organisation of society. Inequities in access and quality are well documented, but patient safety remains the least examined. (2) Methods: Following Joanna Briggs Institute methodology and PRISMA-ScR guidelines, PubMed/MEDLINE and Scopus were searched for studies published from 2010 to 2026. In total, 44 studies were included, predominantly from the USA (n = 31), and synthesised narratively. (3) Results: Inequalities operated through geographic maldistribution, financial barriers, exclusionary institutional cultures, and market-driven practices. Access and quality were each addressed by 17 studies, whereas only four examined patient safety directly; the limited safety evidence indicated disproportionate diagnostic errors, medication-safety failures, and care-coordination breakdowns among vulnerable groups. Evidence was concentrated in the USA. (4) Conclusions: Structural inequalities are well documented for access and quality but are markedly under-studied for patient safety—the principal evidence gap identified. Patient safety warrants treatment as an equity outcome, measured with stratification by structural disadvantage and addressed through system-level interventions.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081020

Authors: Emi Morita Sayo Kawai Tae Sasakabe Rieko Okada Yoko Kubo Yoko Mitsuda Yasufumi Kato Takashi Matsunaga Mako Nagayoshi Takashi Tamura Kenji Wakai

A number of studies have examined the acute effects of shinrin-yoku (forest bathing), or forest walking; however, only a limited number of epidemiological studies have examined the association between habitual forest walking and daily health. The aim of this study was to examine the association of daily happiness, the Japanese concept of ikigai, and enjoyment of daily life with the frequency of forest walking. We used data from the secondary survey of the Japan Multi-Institutional Collaborative Cohort (J-MICC) Daiko study for this cross-sectional study. A total of 3472 participants (2518 women) were included in the analysis. Logistic regression analysis showed that the aORs for frequency of feeling happy, degree of happiness, ikigai, and daily life enjoyment were 1.72 (95% confidence interval [CI]: 1.29–2.28), 1.54 (95% CI: 1.14–2.09), 1.65 (95% CI: 1.25–2.20), and 2.38 (95% CI: 1.60–3.35), respectively, for those who reported going for forest walks at least once per month when those who reported rarely engaging in this practice served as the reference. This study found that the frequency of forest walking was associated with daily happiness, ikigai, and enjoyment of daily life, suggesting that occasional forest bathing may lead to improved well-being and quality of life.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081019

Authors: Sajay Arthanat Jing Wang Dain LaRoche Heather Fritz Rosanne DiZazzo-Miller Mostafa Hussein Ola Ghattas Moniruzzaman Akash Momotaz Begum

Artificial intelligence-enabled technologies offer new opportunities to support healthy aging and the long-term care needs of older adults. However, inclusive practices are paramount to ensuring that accessibility, usability, privacy, and equitable use are factored into the design and deployment of these emerging technologies. This article explores the role of co-design in health technology development and highlights the application of three methodological tools—the NIH Stage Model for Behavioral Intervention Development, the Unified Theory of Acceptance and Use of Technology, and Goal Attainment Scaling—to create a smart-home-based socially assistive robot (SAR) for the care of individuals living with Alzheimer’s disease and related dementias (ADRD). Ten participants (five caregiver–care recipient dyads) from an ongoing mixed-methods pilot feasibility study trialed the SAR in their homes for 1–6 months, with the robot personalized to their daily functioning, home layout, and caregiving needs. Qualitative analysis of monthly interviews derived themes pertaining to technical design, care protocol design, training management, and complementary care. These themes, combined with goal attainment analysis, offered several insights that allowed us to iteratively scale and refine the technology tailored to ADRD care. The study offers a practical framework for future co-design efforts aimed at enhancing the adoption of AI-enabled health technologies among older adults.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081018

Authors: Nithinan Mahawan Rachadaporn Jantasuwan Hasanah Pairoh

Workplace violence (WPV) is a major occupational hazard for nurses in Thailand, negatively affecting psychological well-being, professional confidence, and patient care. In this quantitative cross-sectional analytic study involving 415 nurses, 43.61% reported experiencing at least one incident of WPV during the previous 12 months. Verbal abuse (41.20%) and physical violence (13.25%) were the most frequently reported forms, with a higher prevalence observed in urban hospitals than in rural hospitals (53.66% vs. 33.81%). Higher WPV risk was associated with working in medical wards (adjusted incidence rate ratio [Adj IRR] 3.33) and emergency departments (Adj IRR 2.47), caring for male-only patients (Adj IRR 1.87), younger age (Adj IRR 3.31), divorced or separated status (Adj IRR 3.05), rotating day and night shifts (Adj IRR 2.03), and extreme concern about WPV (Adj IRR 4.57). The psychological impact was considerable. Hypervigilance was the most common response (66.30%), especially following physical violence (76.36%). More than 41% of affected nurses reported intentions to resign or transfer and reduced professional confidence. Reporting incidents was often perceived as ineffective, contributing to underreporting. Nurses identified clear disciplinary measures, increased staffing, improved workplace environments, stronger security systems, and organizational support as key prevention priorities. These findings highlight the urgent need for context-specific interventions, targeted staff training, and organizational strategies to protect nurse well-being, strengthen workforce resilience, and maintain quality patient care.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081017

Authors: Lisa Avery Marcie Snyder Monica Cyr Della Herrera Leona Star Stephanie Sinclair Janet Smylie Michael Rotondi

Background: Evidence of systematic under-counting of First Nations, Inuit, and Métis (FNIM) populations living in urban centres in Canada has been documented for the previous three census rounds (2012, 2016, 2021). Methods: In partnership with Aboriginal Health and Wellness Centre of Winnipeg, Inc. and the First Nations Health and Social Secretariat of Manitoba, a respondent-driven sampling survey of First Nations and Métis peoples living in Winnipeg was conducted and the population living in Winnipeg was estimated using the multiplier method in conjunction with participants’ responses to census participation. Results: We estimated a population of 300,000 (95% CI 248,000 to 379,000) First Nations and Métis people living in Winnipeg, three times higher than the 2021 Census count of 90,535. Interpretation: The Canadian census continues to systematically undercount Indigenous peoples living in urban centres. Improving the accuracy and precision of Indigenous population enumeration is required for equitable health services funding and delivery. Partnerships with FNIM governing and health service organizations, addition of Indigenous identity to the short form-census participation and coverage, and improved collection methods for people living in collective dwellings or experiencing housing insecurity are recommended.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081016

Authors: Dominic Gregory Vertue Nicole Thomas Therese Fish Charles Takalana Kevin Govender Sally Ann Macfarlane Lynn Hendricks

Depression, anxiety, and stress-related disorders continue to rise globally, with South Africa’s burden intensified by structural inequalities and a 91% mental health treatment gap, making accessible complementary interventions urgently needed. This exploratory mixed-methods pilot study examined the feasibility and acceptability of astronomy-based mental health support grounded in Attention Restoration Theory and awe research and sought a preliminary signal of change in psychological well-being. Two sequential retreat iterations combined guided naked-eye and telescope-based stargazing with nature immersion: a proof-of-concept peer camp (n = 19, Glencairn) and a family-focused retreat (n = 22 across nine family groups, Sutherland). The Depression Anxiety Stress Scale (DASS-21) was administered before (T1) and after (T2) the Glencairn retreat; qualitative data comprised the Most Significant Change focus groups (Glencairn) and asynchronous text-based interviews (Sutherland). Mean depression, anxiety and stress scores were lower at T2 than at T1. Because questionnaires were completed anonymously, individual T1 and T2 responses could not be linked. A valid paired analysis was therefore not possible, and inferential significance testing was not undertaken. These results represent descriptive cohort level patterns and should not be interpreted as evidence of within person change. Qualitative findings across both settings indicated calm, perspective shifts, and relational connection, while environmental novelty and family dynamics introduced competing cognitive demands at Sutherland. These preliminary findings suggest that astronomy-based interventions may support short-term psychological well-being and highlight three design considerations for implementation in African contexts, offered as provisional insights rather than established implementation principles with the design considerations being: cognitive spaciousness, contextual onboarding and relational anchoring.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081015

Authors: Indika Koralegedera Felicity A. Braithwaite G. Lorimer Moseley Gemma Skaczkowski Kate M. Gunn

Persistent pain is a major health issue that interferes with farmers’ ability to work more commonly than for the general working population. Farmers also like to self-manage pain but evidence-based pain management educational resources that are relevant to their way of life are limited. This study utilised a participatory co-design approach with farmers, pain clinicians and pain researchers to develop a tailored persistent pain management education resource for farmers. Key, transferable learnings include: the value of information provision in both printed and digital formats, the use of straightforward language, farmer-themed metaphors, imagery, humour and case studies/quotes, as well as reflection and goal-setting activities that focus on function. Co-designers highlighted the importance of materials being easily accessible, sharable and distributed by those who can demonstrate an understanding of farming, to reassure farmers of the resources’ relevance. Including information that is applicable across farmers’ typical pain journeys (pain onset, frustration and resignation stages as described in the paper) is another important consideration. Findings have informed the development of a pain management education resource that was considered relevant, relatable and accessible by co-designers. Lessons are applicable to the development of future health-related educational resources for this unique and at-risk group.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081014

Authors: Hwanseok Winston Choi Michelle Brazeal Joohee Lee

This study examined the relationship between loneliness and sleep disturbances and explored the roles of community resilience and psychosocial factors (social support, anxiety, and substance use coping) in shaping this relationship. A spatially stratified random sampling approach was applied to select households between Interstate 10 and the Gulf of Mexico coastline across three Mississippi counties: Hancock, Harrison, and Jackson. Amos version 30 was used to analyze the proposed structural equation model (SEM) based on responses from 310 participants (mean age = 50.47 years, SD = 17.57; 53.3% female). Data were collected using validated self-report instruments, including the Communities Advancing Resilience Toolkit (CART), the Multidimensional Scale of Perceived Social Support (MSPSS), the UCLA 3-item Loneliness Scale, the GAD-2, and the Brief COPE. Results revealed that initially, a significant association was observed between loneliness and sleep disturbances. However, this direct association was non-significant upon the inclusion of anxiety and substance use coping, showing instead a statistically significant indirect association operating through anxiety symptoms. Higher levels of loneliness were associated with increased anxiety symptoms, which in turn were associated with higher sleep disturbances. No indirect relationship between loneliness and sleep disturbances through substance use coping was found. The results also found that higher levels of community resilience and social support were associated with lower levels of loneliness. These findings highlight the need for multilevel strategies to improve sleep quality, which creates a nested system in which community strengths and individual support systems are jointly positioned as upstream correlates of lower individual isolation.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081013

Authors: Nan Ei Moh Moh Kyi Muhammad Naeem Rashid Shun Lae Lae Aung Tipsuda Pintakham Anurak Wongta

Flooding is the most devastating natural disaster in Southeast Asia, disproportionately affecting vulnerable communities and posing substantial public health challenges. This PRISMA 2020 systematic review, registered with PROSPERO, aimed to synthesize the determinants influencing community flood resilience among flood-affected communities in Southeast Asia. Five electronic databases and Google Scholar were searched for empirical peer-reviewed studies published between January 2015 and January 2026. Methodological quality was independently assessed using the Kmet standard quality assessment tool, and a convergent integrated synthesis design was applied for the synthesis. Eighteen studies (nine quantitative, six qualitative, and three mixed methods) from Indonesia, Thailand, Malaysia, Cambodia, Myanmar, and Vietnam met acceptable quality thresholds. Seven determinant domains were identified: (1) sociodemographic, (2) flood exposure, (3) socioeconomic, (4) socio-cultural, (5) environmental, (6) physical, and (7) psychological factors. Synthesized evidence revealed that community flood resilience is shaped by dynamic interactions among structural, social, environmental, and psychological determinants that collectively influence resilience capacities. Psychological factors, particularly risk perception and anxiety, served as cross-cutting influences on adaptive behavior, while vulnerability remained concentrated among older adults, women, low-income households, informal settlements, and rural agricultural communities. These findings highlight the importance of integrated and equity-oriented resilience strategies that strengthen community adaptation and improve public health outcomes in the region.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081012

Authors: Aikaterini Mastoraki Maximos Frountzas Foivos-Konstantinos Stamatis Maria Batagianni Emmanouil I. Kapetanakis Panagiotis Sakarellos Paraskevas Stamopoulos Napoleon Moulavasilis Evangelos Fragkiadis Dimitrios Schizas

Climate change has been identified by the World Health Organization (WHO) as “the single greatest health threat to humanity”. To investigate this subject, we conducted a narrative review of the literature about sustainability in the OR, with the aim of exploring the existing knowledge and identifying prevailing challenges in the field. A combined automated and manual database search of the literature was performed using Medline (PubMed), Scopus, Ovid, and the Cochrane Library, covering publications available up to and including 21 May 2025. The significance of environmental sustainability is recognized across all healthcare systems. To fulfil the United Nations Sustainable Development Goals, the healthcare sector must undergo a transformation towards more eco-friendly practices, which will also affect clinical decision-making. Net-zero is an internationally agreed goal for avoiding worsening global heating in the second half of the 21st century, as it aims to balance the quantities of greenhouse gases released into and removed from the atmosphere, achieving carbon neutrality. Nevertheless, the operating room (OR) is among the most significant contributors to environmental pollution, with the major carbon hotspots determined by the use of energy, procurement and disposal of consumables and the waste of water. In response to this challenge, leading medical societies, surgical teams, government bodies, and industry stakeholders endorse Green Surgery (GS) by taking steps to address healthcare sustainability and its impact on climate change. Therefore, a movement toward “greening” healthcare, or improving the environmental footprint of healthcare has been built.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081011

Authors: Kimberly Mary Jackson

Globally, school meals have formed a social safety net for improving children’s nutrition, health, and educational attainment. In Aotearoa New Zealand, government funded lunches for children attending schools in low-income neighbourhoods were introduced in 2020, amidst rising poverty levels and consequent household food insecurity. The aspirations encapsulated within the scheme’s indigenous Māori name, ‘Ka Ora, Ka Ako’ (‘to be well, healthy and safe; to be ready to learn’) have lost focus since reforms to the lunches in 2024 prioritised cost savings, resulting in widely publicised quality issues. This present study draws from a critical multi-level investigation into the issue of hungry children in New Zealand schools, prior to the introduction of ‘Ka Ora, Ka Ako’. Narrative analysis identified how food in schools has been conceptualised within the context of a settler colonial charity model and neoliberal austerity. Applying a critical community psychology lens highlights how burnt and meagre lunches offered to children from food insecure households are a concrete product of historically grounded, unequal relations between groups. A community psychology approach reimagines state-funded food in schools as a public good, arguing for equitable rights to nutrition, including recognition of Māori rights to food sovereignty.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081010

Authors: Csaba Bálint Ali Abbas Rahi Al-Murshedi Ammar Mahmood Jaber Annamária Pakai Zsófia Verzár

Background: Although extreme heat is associated with adverse cardiovascular outcomes, the relationship between heat-alert-threshold days, acute myocardial infarction (AMI) admissions, and post-AMI mortality remains uncertain. We aimed to evaluate the association between temperature-defined heat-alert-threshold days and (i) daily AMI admissions and (ii) cumulative all-cause mortality after hospitalized AMI in Hungary. Methods: We conducted a nationwide registry-based study using data from the Hungarian Myocardial Infarction Registry (HMR). All AMI admissions between 1 January 2018 and 31 December 2019 were eligible, with mortality follow-up through 16 June 2021. Heat-alert-threshold days were defined using the temperature criterion applied in the Hungarian national heat-health action plan (daily mean temperature ≥25 °C). AMI admissions were analyzed using adjusted quasi-Poisson regression models and cumulative mortality using stratified Cox proportional hazards models. This operational temperature threshold was used as the exposure definition and does not represent linkage to administrative heat-alert declarations. Results: The cohort included 30,883 AMI events from 29,596 unique patients (mean age, 67.2 [SD 12.8] years; 60.3% male). Patients admitted on heat-alert-threshold days had baseline clinical characteristics similar to those admitted on non-alert days (all standardized mean differences <0.10). Heat-alert-threshold days were associated with fewer recorded AMI admissions during summer (adjusted incidence rate ratio [aIRR] 0.93, 95% CI 0.90–0.97). In contrast, no association was observed between heat-alert-threshold exposure and subsequent all-cause mortality after AMI hospitalization (adjusted hazard ratio [aHR] 0.96, 95% CI 0.87–1.05). These findings remained consistent across sensitivity analyses. Conclusions: In this nationwide Hungarian registry-based study, temperature-defined heat-alert-threshold days were associated with fewer recorded AMI admissions during summer but not with differences in post-AMI mortality among hospitalized patients. The observed inverse association should not be interpreted as evidence of a protective effect of heat exposure. Alternative explanations include behavioral adaptation, delayed care-seeking, exposure misclassification, residual confounding, and the possibility of unmeasured out-of-hospital cardiovascular events, which were not captured by the registry. Because administrative heat-alert declarations were not linked to the analytic dataset, the findings should be interpreted as associations with temperature-defined heat-alert-threshold days rather than evaluations of the effectiveness of the Hungarian heat-alert system.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081009

Authors: Irma Aidé García Villegas Silvia Lizette Ramos de Robles Claudia Alvarado Osuna

Dietary pesticide exposure is a growing public health concern, particularly for children in agricultural regions. This study assessed the occurrence and concentration of neonicotinoids and other pesticide residues in foods frequently consumed by preschool children (4–5 years) in an agroindustrial zone of Jalisco, Mexico, and estimated their weekly dietary exposure (DE). Thirty-one food samples representing 18 items were collected from retail sites identified through seven-day dietary records completed by 23 families. Samples were analyzed by LC/ESI-MS/MS covering 236 compounds; exposure was estimated considering raw and cooked consumption patterns and processing factors. Residues were detected in 87% of samples, yielding 34 distinct compounds, including 5 neonicotinoids; imidacloprid was the most frequently detected. Strawberry, raspberry, apple, grape, and tomato showed the highest residue loads; seven samples exceeded MRLs set by the EU, USA, or Mexico. Raw food consumption accounted for 96% of total estimated exposure, with pyrimethanil, boscalid, propamocarb, and imidacloprid as principal contributors. These findings confirm that children in this population face repeated, simultaneous exposure to multiple pesticides through diet, underscoring the need for stronger food safety monitoring, harmonized regulatory limits, and cumulative risk assessment frameworks for vulnerable populations.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081008

Authors: Tania Santina Marwa Alahmed Aiysha Faraj Asma Arif Jawaher Muhammed Shayma Haidar Wedad Almuaini Nour Kawam Abdallah Saab

Secondhand smoke exposure (SHSE) remains a major environmental health risk among university students, particularly in socially shared settings. In the United Arab Emirates, culturally embedded practices such as shisha and midwakh use, combined with variable policy enforcement, sustain persistent exposure. This cross-sectional study examined SHSE-related knowledge and protective health behaviors among 360 university students and their sociodemographic correlates, using a self-report questionnaire with documented internal consistency in comparable populations. Data were analyzed using SPSS version 28. SHSE was highly prevalent, occurring mainly in public and university settings; knowledge was moderate and protective behavior varied. Knowledge emerged as a moderate-to-strong correlate of protective behavior (r = 0.70, p < 0.001, R2 = 0.49). Age, employment, marital status, and number of children were associated with knowledge; age, gender, marital status, and income, but not employment, remained associated with behavior after adjusting for knowledge. Confirmatory factor analysis showed poor absolute fit for both the one- and two-factor solutions, and the behavioral-response factor did not satisfy the Fornell–Larcker criterion (√AVE = 0.750 < latent r = 0.836), providing only partial support for the empirical distinctiveness of the two constructs. Bootstrapped mediation analysis shows that knowledge partially mediated the employment–behavior association (~62% of the total effect); employment status was not, however, independently associated with behavior once knowledge was included, so this pathway is reported as hypothesis-generating. Still, more than a quarter of participants reported poor protective behavior, suggesting that unmeasured social and environmental factors, and possible overlap between the two constructs, may influence this relationship. Findings support integrated interventions combining health education, policy enforcement, and culturally tailored strategies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081007

Authors: Prasit Na-Ek Chuchard Punsawad Aulia Rahmi Pawestri Udomsak Narkkul

Toxocara spp. infection is a neglected zoonotic disease associated with exposure to companion animals and contaminated environments. However, information regarding its seroprevalence and associated risk factors among cat owners in Thailand, particularly in remote island communities, remains limited. This cross-sectional study aimed to determine anti-Toxocara spp. IgG seropositivity and identify associated risk factors among cat owners in Koh Yao District, Phang Nga Province, Thailand. A total of 291 cat owners participated in the study. Sociodemographic characteristics, health-related behaviors, serum anti-Toxocara spp. IgG antibodies, and hematological parameters were collected. Univariate and multivariable logistic regression analyses were performed to identify factors associated with seropositivity. The overall prevalence of anti-Toxocara spp. IgG seropositivity was 34.36%. In the univariate analysis, failure to wash hands after cat contact was significantly associated with higher odds of seropositivity (odds ratio [OR] = 1.96, 95% confidence interval [CI]: 1.16–3.33; p = 0.011). This association remained significant in the multivariable logistic regression model. These findings indicate substantial exposure to Toxocara spp. among cat owners in this island community and highlight the importance of personal hygiene, particularly handwashing after cat contact, in reducing exposure to infective Toxocara eggs. Targeted health education programs and preventive interventions should be strengthened to reduce the risk of Toxocara spp. exposure in endemic communities.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081006

Authors: Gabrielle A. Grant Alana Gall

Autism spectrum disorder (hereafter autism) is increasingly recognised as being underdiagnosed in females worldwide, contributing to inequalities in clinical visibility and access to appropriate care. The clinical visibility of autism in females is influenced by diagnostic practices historically developed using predominantly male samples, which may be less sensitive to less overt or more socially camouflaged presentations. Greater levels of autistic camouflaging, including masking, compensations, and assimilation, have been proposed as one factor contributing to differences in the presentation of autism between males and females. However, camouflaging is resource-intensive, associated with significant psychological costs, and varies across contexts. Because camouflaging relies on cognitive–emotional resources, it may also fluctuate under conditions that influence these resources, such as the menstrual cycle. To date, no empirical research has directly investigated this relationship. This opinion article proposes the conceptual hypothesis that menstrual cycle-related fluctuations may influence the cognitive–emotional resources required for autistic camouflaging, with potential implications for clinical visibility, diagnostic recognition, mental health, and equitable access to care. By synthesising indirect evidence from autism, camouflaging, and menstrual health research, this conceptual framework aims to guide future empirical investigation and highlights the urgent need to better understand this overlooked intersection to improve diagnostic equity, clinical recognition, and women’s health outcomes globally.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081005

Authors: Lusine Gigoyan Michelle L. Dossett Kathryn C. Conlon Shuai Chen Sean M. Raffuse Irva Hertz-Picciotto

This longitudinal cohort study examined acute and mid-term mental health impacts among 4346 survivors of the 2018 Camp Fire in Northern California using a retrospective survey that asked participants to report symptoms at one, three, and six months post-wildfire. Forty-one percent of participants reported at least one mental health symptom three weeks after the wildfire. Mental health symptoms declined over the six-month follow-up. The mean number of mental health symptoms was 3.7 (95% CI, 3.3–4.1) at three weeks, 3.3 (3.0–3.7) at one month, 3.1 (2.8–3.4) at three months, and 2.7 (2.5–3.1) at six months. Among survivors reporting one or more symptoms, severe home damage was associated with a 1.6-fold higher number of mental health symptoms, preexisting mental health conditions and job loss due to the wildfire were each associated with 1.2-fold increase, and prior physical disabilities with a 1.1-fold increase. Loss of a family member or friend and living alone were also associated with a higher number of mental health symptoms, whereas both younger age (<18 years) and male sex were associated with fewer symptoms. Wildfire exposure is associated with increased mental health risks, particularly among those with preexisting conditions and significant fire-related losses.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081004

Authors: Golan Shahar Avi Besser Christopher C. Henrich

Terrorism exposure may be longitudinally associated with adolescents’ community violence exposure, but these associations may depend on preexisting externalizing behavior. Guided by ecological–transactional theory and competing stress-diathesis, dual-vulnerability, and rival-vulnerability perspectives, this study examined whether aggression and severe violence commission moderated associations of past terror exposure and cumulative Kassam rocket exposure, referring to exposure to short-range rockets launched from the Gaza Strip toward southern Israel, with Time 2 violence witnessing and victimization. Participants were 362 Israeli adolescents enrolled in a longitudinal study with assessments in 2008 and 2010; cumulative Kassam rocket exposure incorporated exposure reports from 2008, 2009, and 2010. Models controlled for baseline community violence exposure, depressive and anxiety symptoms, sex, grade, and locality. Structural equation modeling (SEM) was used to test the hypothesized models. Under low levels of both aggression and severe violence commission, past terror exposure was prospectively associated with higher Time 2 violence witnessing. Under high levels of severe violence commission, past terror exposure was prospectively associated with lower Time 2 violence victimization. A three-way interaction involving past terror exposure, cumulative Kassam rocket exposure, and aggression was also found and interpreted with caution. Overall, the pattern was consistent with a dual-vulnerability or rival-vulnerability pattern, but not with a stress-diathesis model. This pattern highlights the importance of assessing terrorism exposure, externalizing behavior, and distinct forms of community violence exposure when designing preventive interventions for adolescents living under chronic armed threat.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081003

Authors: Stephanie Rosenberg Tawny Boyce Scott T. Walters Laura Barriga John Torres Vernon Shane Pankratz Bernard Tawfik Sangeetha Prabhakaran Stephanie Fine Acadia W. Buro Ursa Brown Glaberman Cindy Blair Jacklyn Nemunaitis

Young breast cancer survivors often develop post-breast surgery pain syndrome (PBSPS). Despite potential benefit from physical activity, access to in-person programs is often limited by competing work and caregiving responsibilities. We assessed the feasibility and acceptability of a remotely delivered physical activity intervention for young Hispanic breast cancer survivors with PBSPS. Our single-arm, 12-week feasibility study enrolled Hispanic women aged ≤60, at least 3 months post-treatment for invasive breast cancer or ductal carcinoma in situ (DCIS), with PBSPS. Using a Fitbit Inspire 3 activity tracker and health coaching, the program encouraged whole-of-day movement to increase activity. Feasibility outcomes included recruitment, retention, and adherence. Secondary outcomes assessed pain measures, daily steps, and quality of life (QOL). Twenty-five breast cancer survivors enrolled (mean age 47.4 years [SD 6.3]), with 76% selecting Spanish-language health coaching. Retention at 12 weeks was 79% (19/24). Engagement with health coaching was high, with 95% completing at least 4 of 5 pre-planned calls. The mean change in daily step count was 1502 (−348, 3353), with twelve (66.7%) increasing in step count (median 2334.5, range: 14, 13,422). Each additional 1000-step increase was associated with a 2.67-point increase in pain self-efficacy scores (β = 2.669, 95% CI: 0.884 to 4.454, p = 0.006). A remotely delivered, health coaching physical activity intervention was feasible and acceptable for young Hispanic breast cancer survivors with PBSPS. This supports further evaluation in a larger trial. Accessible survivorship interventions for young breast cancer patients in their preferred language are needed.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081002

Authors: Jimmy Jacob Priyanka Malaiyappan Vettrivel Arul Taranjot Kaur Shanthini Vijayaraman Greety Antony Kaviya Ramesh Maria R. Dasari Balasankar Ganesan

Burnout and psychological distress among healthcare workers (HCWs) have become a major workforce challenge, raising an important question: should responsibility for worker wellbeing rest primarily with individuals or with the organization of work itself? This systematic review evaluated workplace mental health programs for HCWs, comparing individual-level psychological interventions with organizational-level approaches. Following PRISMA 2020 guidelines, 54 studies (2016–2026) from more than 18 countries were identified from approximately 7144 records through a PubMed/MEDLINE search. The included studies comprised 29 individually randomized controlled trials (RCTs), 11 cluster-randomized or stepped-wedge trials, and 14 additional non-randomized or contextual studies. ROBINS-I was applied only to the five eligible non-randomized intervention studies—the remaining non-randomized studies contributed contextual evidence and were not included in the ROBINS-I assessment. Here, 41 studies contributed effectiveness evidence, of which 34 (83%) reported a statistically significant improvement in at least 1 primary or key outcome, while 13 studies provided contextual, feasibility, or implementation evidence. Individual-level interventions dominated the evidence base (39/54; 72%). In contrast, organizational interventions were less frequently evaluated, rarely randomized, and showed mixed findings. Observational studies consistently identified workload, organizational trust, and other structural stressors as factors associated with burnout, although causal inferences remain limited. Risk of bias was substantial, with only 7 of 40 randomized trials (17.5%) rated as low risk. All five non-randomized intervention studies assessed using ROBINS-I were judged to have serious risk of bias. Overall, individual-level interventions were evaluated more frequently than organizational interventions and generally reported improvements in mental health outcomes. However, the evidence base was limited by the single-database search, variability in study quality, and methodological limitations. Further well-designed and adequately powered studies, particularly of organizational interventions, are needed to strengthen the evidence base.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081001

Authors: Julia Eigenheer Mühlbauer Ana P. Ribeiro Juliana B. de-Salles Andrade Livi F. Testoni de Faro Maria E. Moreira-de-Oliveira Veronica Hühne Carina Félix-da-Silva Gabriela B. de Menezes Leonardo F. Fontenelle

Background: The COVID-19 pandemic has become a global public health emergency, causing substantial disruptions in societal norms and behaviors. Among the affected population, individuals with mental health disorders are particularly vulnerable, facing heightened infection rates and worse outcomes. These challenges can be linked to factors such as insufficient adherence to vaccination and other preventive measures. Objective: This study aims to investigate the literature on the adherence of individuals with mental disorders to vaccination and other preventive behaviors such as social distancing, use of face masks, and hygiene practices during the COVID-19 pandemic. Methods: This scoping review was performed following the methodological guidelines outlined by the Joanna Briggs Institute and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. A comprehensive search for published research containing original data was conducted in four databases (Embase, Medline, PsycINFO, and Web of Science). Results: The search yielded 2778 records, and 10 additional relevant papers were identified through handsearching, resulting in a total of 50 studies meeting all inclusion criteria. Most of them focused on vaccination adherence, with approximately half reporting lower adherence in the patient group, particularly among individuals with severe mental illnesses (SMIs), compared to the general population or to other control groups. However, some studies reported comparable—or, in specific psychiatric populations, even higher—levels of adherence to preventive behaviors. Out of the fifty selected studies, only four employed an interventional approach aimed at increasing preventative behaviors, but they were effective in most of the studies. Conclusions: This review underscores a noticeable lack of intervention studies employing psychoeducational strategies to mitigate risky behaviors among individuals with mental disorders. This gap emphasizes the urgent need for increased research focus in this area, as it holds promise for reshaping future approaches and strategies to address other crises within this vulnerable population.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080997

Authors: Ulpan Kuandyk Alua Omarova Nailya Delellis

Background: Evidence on adolescents’ knowledge and practices related to healthy eating and food hygiene in Kazakhstan remains limited. This study aimed to assess knowledge and behaviors associated with healthy eating and food hygiene among adolescents in Karaganda, Central Kazakhstan. Methods: A cross-sectional study was conducted among 382 students aged 11–18 years from six schools. Data were collected using a bilingual questionnaire and analyzed using Chi-square tests and multivariable logistic regression. Results: Girls were significantly more likely than boys to demonstrate knowledge of healthy eating and food hygiene practices. According to parental reports, 61.5% of adolescents consumed fruit daily, whereas daily fast-food consumption was reported in 7.7% of boys and 7.5% of girls. Food-outsourcing company reports showed that complete meals and drinking water were available in all participating schools; however, dairy products were available in only half of the school cafeterias. Conclusions: The study identified sex- and age-related differences in adolescents’ knowledge and practices regarding healthy eating and food hygiene. The findings highlight the importance of combining nutrition education with improvements in the school food environment and greater parental involvement to promote healthier dietary behaviors among adolescents.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23081000

Authors: Joel J. Gagnier John P. O’Connor

Glyphosate-based herbicides are widely used agricultural chemicals. Concerns regarding carcinogenicity, particularly non-Hodgkin lymphoma (NHL), persist. We conducted a systematic review and meta-analysis to better evaluate glyphosate exposure and NHL risk. MEDLINE and EMBASE were searched for eligible cohort, case–control, and pooled studies. Risk of bias was assessed using recommended criteria. Random- and fixed-effects meta-analyses were performed, with sensitivity analyses addressing overlapping cohorts, hazard ratio inclusion, exposure definitions, and model overfitting. Evidence certainty was graded using GRADE. Ten primary datasets were analyzed. Ever-exposure was associated with an odds ratio of 1.11. Highest-exposure analyses demonstrated a significant association with NHL. Ever-exposure associations were modest, whereas a higher glyphosate exposure was consistently associated with an increased NHL risk. The findings were robust across sensitivity analyses.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080998

Authors: Ahna Ballonoff Suleiman Claire Cole Selena Regalado

Managing one’s fertility and determining the timing of one’s pregnancies is integral to human flourishing. An emerging body of literature focuses on global measurement of human flourishing. Despite significant debates in the field, the goal of measuring human flourishing is to understand what it means to live life well. We conducted a modified scoping review of quantitative, qualitative, and mixed-method grey and white literature to identify the extent to which evaluations of interventions aiming to increase the use of voluntary family planning include measures of human flourishing. We searched for peer-reviewed articles published from 2007 to 2025 across four databases (PubMed, Google Scholar, Web of Science, and Science Direct). We completed a full-text review of 583 documents and identified 111 that contain both a behavioral measure of contraceptive use and the measurement of at least one flourishing construct. We captured both the flourishing constructs and measures used. The most measured flourishing constructs were self-efficacy, shared decision-making, social support, mental health, and agency. Less frequently, evaluations measured happiness/pleasure/joy, empowerment, emotional intimacy, physical health, meaning/purpose, social capital, autonomy, trust, and wellbeing. Among the 111 articles, 76 (68.5%) of them included both flourishing-related intervention components and evaluation measures. Twenty-three measured flourishing-related outcomes in the evaluation but did not explicitly include flourishing components in the intervention. Collectively, these findings suggest that there is room for growth to fully understand the relationship between voluntary family planning interventions and the construct of human flourishing.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080999

Authors: Mahsa Hadidi Eileen O’Connor Nadia Abu-Zahra Laura Ambrosio Emily Regan Wills

Background: Immigrant working women’s well-being is shaped not only by formal health and settlement services but also by everyday opportunities for rest, social connection, cultural expression, and participation in community life. This study examined how three community-based leisure activities were experienced by Farsi-speaking Iranian immigrant women aged 30 to 55 living in Ottawa, Canada. Methods: Organized in partnership with PAND Settlement Services, the activities included a group walk along the Rideau Canal, a Classical Persian dance workshop, and a group visit to the National Gallery of Canada. Data were drawn from 32 post-activity evaluation surveys, researcher field notes, and two follow-up semi-structured feedback sessions. Structured items were analyzed descriptively; open-ended responses and feedback sessions notes were analyzed thematically following Braun and Clarke’s six-phase approach. Results: Participants rated all three activities positively across enjoyment, accessibility, and social contact. Leisure was experienced as a meaningful break from routine, a source of emotional relief, an opportunity to meet other women, and a setting in which shared language and migration experience made participation easier and more comfortable. Sustained participation remained shaped by time pressure, caregiving demands, weather, transportation, cost, and access to clear and trusted information. Conclusions: Leisure activities contributed to the well-being and sense of belonging for the women who participated in the study.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080996

Authors: Mirliana Ramírez-Pereira

Chronic kidney disease (CKD) is a major public health challenge associated with substantial physical, psychological, social, and economic consequences. Although its clinical outcomes have been extensively investigated, less is known about how individuals progressively reconstruct their lives while living with an irreversible condition requiring long-term dialysis, particularly in contexts characterized by health inequities. This study aimed to develop a substantive theory explaining how adults reconstruct their lives while living with CKD on dialysis. A qualitative study was conducted using Strauss and Corbin’s Grounded Theory methodology. Eighteen adults receiving hemodialysis or peritoneal dialysis in Chile participated in semi-structured interviews. Data collection and analysis were conducted concurrently using theoretical sampling, the constant comparative method, memo writing, and theoretical saturation. The findings identified “Reconstructing Life While Living with Chronic Kidney Disease” as the central phenomenon. Life reconstruction emerged as a dynamic and ongoing process sustained by the interaction between resignation and survival and facilitated by three interrelated conditions: understanding the disease, social support networks, and nursing care. Through this process, participants progressively reorganized their identities, everyday lives, interpersonal relationships, and future life projects while living with an irreversible chronic condition. The resulting substantive theory provides a contextually grounded explanation of life reconstruction that integrates individual, relational, and social dimensions of living with CKD. By demonstrating that opportunities for life reconstruction are shaped not only by individual agency but also by supportive social and healthcare conditions, the findings contribute to nursing knowledge and provide a conceptual foundation for person-centered care, health equity, and future research on chronic illness.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080995

Authors: Juan Pablo Carvajal Fred Gustavo Manrique-Abril

The present study evaluated the association between morning serum cortisol levels and burnout syndrome among healthcare workers in the department of Boyacá, Colombia. An observational, analytical, cross-sectional, and quantitative study was conducted on 69 employees. Total serum cortisol was measured via chemiluminescence in fasting morning samples (reference: 110–692 nmol/L). Burnout was assessed using the Maslach Burnout Inventory–General Survey (MBI-GS). A total of 96.6% of participants fell within the normal range for serum cortisol. MBI-GS dimensions reported mean scores of: exhaustion 1.54 ± 1.17, cynicism 0.93 ± 0.89, and professional efficacy 5.60 ± 0.60. High exhaustion prevalence was 16.9%, high cynicism 6.8%, and low efficacy 3.4%. Profile classification showed 67.8% “engaged,” 13.6% “overextended/worn-out,” and 5.1% with “burnout.” No significant association was found between cortisol and burnout dimensions: exhaustion (r = 0.069, p = 0.605), cynicism (r = −0.135, p = 0.309), and professional efficacy (r = 0.044, p = 0.742). Mean cortisol comparisons between high and low dimension groups showed no statistically significant differences (p > 0.05). The study documented a low prevalence of established burnout and an absence of significant association between morning serum cortisol and MBI-GS dimensions, suggesting a relatively healthy work environment; however, the prevalence of high emotional exhaustion warrants preventive interventions. Multilevel organizational strategies like workload management, job stability, role clarity, and psychosocial support are recommended for worker mental health protection.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080994

Authors: Simran D. Bhakta Tyler S. Peters Alessandra Merenna Debra E. Bramblett

NM averages 450 new cases of melanoma annually. Promotoras are community health workers in NM that provide health education and resources to the community. The project aims to determine if promotora education can improve the recognition of suspicious lesions, encouraging community members to seek care. Current literature focuses on the self-reported confidence of CHWs in recognizing skin cancer. A total of 54 promotoras were sampled through a Qualtrics quiz asking whether skin lesion photos are suspicious. Participants were also asked to rate their confidence in recognizing a suspicious skin lesion and comfort in addressing it from 1 to 5. Participants then read an educational flyer about the “ABCDEs” of melanoma before repeating the quiz/ratings. Wilcoxon signed-rank testing revealed significant increases in quiz scores (W = 220.5, p = 0.045), confidence (W = 44.0, p < 0.001), and comfort (W = 8.5, p < 0.001). Promotoras could be an additional line of defense against melanoma, helping save lives. Healthcare personnel with limited skin lesion knowledge could be an ideal future population for education.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080993

Authors: Cecilia Strand Freddie Lymeus Ann-Sofie Bergman

There is a lack of step-by-step guides for developing evidence-based interventions through close collaboration between researchers and practitioners that emphasize genuine co-creation. The purpose of this paper is to provide a detailed description of the five-year participatory action research- and iterative-design-inspired development process that resulted in a 12-week group-based intervention to support reorientation and post-traumatic growth among intimate partner violence (IPV) survivors. This paper presents a case study based on an analysis of meeting agendas and notes, observations, successive versions of the intervention, and interviews with staff at partnering women’s shelters and female victim-survivor intervention participants, conducted from 2021 to 2025. This study offers future intervention developers three actionable recommendations: (1) invest in relationship building and establish a collaborative project culture characterized by epistemic equality between academic researchers and practitioners, manifested in non-hierarchical decision-making; (2) create a purpose-built framework for genuine collaboration and co-creation, like the one presented in this project, which combines participatory action research and iterative design approaches; and (3) ensure a shared vision and a formalized agreement regarding future uses and rights connected to the intervention. By offering key transferable recommendations, this paper contributes to teams embarking on intervention development alongside end-beneficiaries and community stakeholders in women’s shelters and beyond.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080991

Authors: Lucas Murrins Marques

Urban environments concentrate spatially distributed stressors, including heat, noise, pollution, and biodiversity loss, that are increasingly recognized as determinants of population mental health. However, current approaches rarely integrate environmental structure, lived exposure, and climate-related emotional responses within a unified spatial framework applicable to public health. This article introduces Eco-Affective Health Mapping (EAHM) as a conceptual, spatially explicit framework, grounded in the recently formalized Eco-Affective Health theoretical model, for understanding how environmental conditions may shape climate-related emotional responses, including eco-anxiety, solastalgia, and ecological grief, across urban socio-ecological systems. Drawing on evidence from spatial epidemiology, landscape ecology, environmental mental health, and digital phenotyping, I argue that affective responses to environmental stressors are not randomly distributed but are hypothesized to exhibit spatial clustering in relation to environmental exposures, landscape configuration, and mobility-based interactions. I propose the Eco-Affective Health Mapping (EAHM) framework, which integrates four spatial layers: environmental exposures, landscape configuration, person–place interaction, and affective indicators, together with a companion composite metric, the Eco-Affective Load Index (EALI), for which I provide a formal multi-domain specification and a purely illustrative, non-empirical worked example. EAHM is presented here as a theoretical and methodological proposal rather than as a validated instrument: no primary environmental, mobility, or affective data were collected or analyzed for this article, and the framework’s constituent relationships require prospective empirical testing, for which I outline a companion measurement strategy grounded in the Eco-Affective Health Assessment Protocol (EAHAP). By conceptualizing climate-related emotional responses as candidate measurable public health signals, EAHM is intended to support a future shift toward prevention-oriented, population-level mental health strategies aligned with planetary health and sustainable development agendas.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080990

Authors: Heather Massey Clare Eglin Geoff Long Danielle Obe Ed Accura Seren Jones Alice Dearing Ruth Williamson Shelley Blane Ross D. Pollock Gareth Morrison Michael J. Tipton

Drowning is a largely preventable global public health problem. Many unintended drownings are linked to the initial responses to cold-water immersion (cold shock), which includes a rapid involuntary cardio-respiratory response that increases the risk of aspirating water within the first two minutes of immersion. Floating rather than struggling to swim can help survival in this circumstance. In light of early research and subsequent changes in anthropometry, we are re-examining whether bone mineral density (BMD) in people from African, Caribbean, and Asian communities influences their float. This study examined predictors of float outcome. A total of 101 participants of African, Caribbean, Asian, or mixed heritage were recruited; 96 attempted a two-minute supine float following instruction and practice, of whom 89 were successful. Body fat percentage strongly correlated with buoyancy and floating outcome, while other predictors, including BMD, showed weak or no association. Passive floaters (no movement required) demonstrated greater buoyancy and less exertion than active floaters (purposeful movement required). These findings suggest that body fat percentage is the primary factor influencing float outcome, and that with appropriate instruction and practice, individuals of African, Caribbean and Asian heritage can “find their float”. The results indicate that floating is a learnable competence and highlight the need for integrated drowning prevention strategies combining existing campaigns with accessible, community-based practices and co-produced approaches to improve engagement and equity.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080992

Authors: Cirila Estela Vasquez Guzman Susan J. Rosenkranz Carlos Martinez Kyleigh A. Layman Blair G. Darney

Background: Although cervical cancer is preventable, Latinas are twice as likely to receive a late diagnosis compared with non-Hispanic Whites (NHW). We currently know very little about the experiences of cervical cancer among middle- to older-age Latinas in the U.S. This study aimed to document Latina cervical cancer survivors’ journeys with an emphasis on improving the cervical cancer system of care to address inequities among a rapidly aging Latina population. Methods: We interviewed participants aged ≥ 40 years with a diagnosis of cervical cancer of three months or greater who identify as Latina. Recruitment was multi-pronged, including electronic healthcare records search, community tabling events, and snowball sampling. We conducted a qualitative study using the Database of Individual Patient Experiences (DIPEx) methodology and identified themes using grounded theory constructivist analysis. Results: A total of 20 Latinas (43 to 85 years old) participated, including 16 Spanish-language interviews. We identified three themes: formative experiences driving screening and prevention behaviors, provider communication that was suboptimal throughout the cancer continuum, and survivorship impacts including isolation and stigma with implications for the next generation. Conclusions: A central takeaway was the pervasiveness of Latinas’ feelings of shame, lack of communication, and isolation. Healthcare systems must improve culturally responsive communication, survivorship support, and screening equity for aging Latina populations. Abuelas, tias, and/or primas (grandmothers, aunts, and cousins) could play a critical role in raising awareness and increasing timely and early screening among the wider Latina population.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080989

Authors: Kate Doyle Ruti G. Levtov Lori Rolleri Erin Stern Lori Heise

Curriculum-based programs are one of the most common and effective strategies for preventing intimate partner violence (IPV) in low- and middle-income countries (LMICs). Yet relatively little is known about how curricula and their implementation compare across programs, limiting learning and innovation. This scoping review examined the design, content, and implementation of 55 curricula from 42 programs implemented in 23 LMICs between 2001 and 2024. Curricula were identified through screening systematic reviews, grey literature, donor reports, and professional contacts. Data on program characteristics, subject matter, methodologies, and implementation were extracted, synthesized, and analyzed. We found curricula employed similar participatory methodologies and content, and violence, gender, relationships, power, and communication emerged as core topics. Adaptation of earlier programming was widespread: only five curricula did not cite content adapted from an earlier program. Key gaps included the relatively limited use of evidence-based strategies to build relationship skills and content addressing alcohol use and poor mental health, important IPV risk factors. Implementation varied considerably in terms of intensity, frequency, duration, group size, facilitators and their training, and information on some features was sparse. The findings highlight several opportunities for strengthening and innovation, for which we present six recommendations to guide future IPV prevention programming.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080988

Authors: Xonné Muller Anita E. Pienaar Barry Gerber Colin N. Moran Naomi E. Brooks

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International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080987

Authors: Philip Ogah Abutu Marcia Y. Shade Susan Barnason Chad Abresch Nada Fadul Regina Idoate Keyonna M. King

HIV-tuberculosis (HIV-TB) co-infection remains a leading cause of morbidity and mortality among people living with HIV and disproportionately affects immigrant and refugee communities in the United States. While antiretroviral therapy has improved HIV outcomes, cultural, social, and psychological barriers hinder timely diagnosis and sustained HIV-TB co-infection care in these populations. This integrative review aims to synthesize evidence on cultural, social, and psychological factors influencing access to diagnosis, treatment, and management of HIV, TB, and HIV-TB co-infection among immigrant and refugee populations in the United States. This study is an integrative review guided by Whittemore and Knafl’s framework. We conducted a systematic search of PubMed, Scopus, and CINAHL for peer-reviewed, mixed-methods, quantitative, qualitative, and review articles published in English between 2015 and 2025. After duplications were removed and dual screening of 107 retrieved records, 16 articles met inclusion criteria for this study. Findings were thematically categorized and synthesized. The themes generated were placed into three main categories: cultural factors including stigma and misperceptions about disease transmission; social factors such as limited healthcare access, lack of insurance, and socioeconomic marginalization; and psychological factors including fear of deportation, trauma, and mistrust of healthcare systems. Addressing HIV-TB co-infection in immigrant and refugee populations requires holistic, trauma-informed, and community-engaged strategies that integrate mental health support, culturally and linguistically tailored education, and policy reforms to remove structural obstacles. Future research should employ culturally validated measures to co-create sustainable interventions and advance health equity.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080986

Authors: Andrés Mauricio Garcia-Sierra Mahmud Sheku Luz Adriana Urbina Francisco Becerra-Posada Carlos Espinal Rodrigo DeAntonio Diana Carolina Rivera-Pinzón

Latin America and Africa face complex public health challenges shaped by social, environmental, and epidemiological factors. This study conducts a comparative analysis of publicly available national health strategies and national policy documents from 52 countries in Africa and 12 countries from Latin America, supplemented with data from the World Health Organization (WHO) and Pan American Health Organization (PAHO). The analysis focuses on five domains: social determinants of health, environmental health, infectious diseases, non-communicable diseases (NCDs), and immunization. This study examines how these health priorities are represented in national policy frameworks. Across the reviewed country sample, national policy documents tend to emphasize challenges related to health care access, the growing burden of NCDs, and environmental risks. In selected Latin American countries, migration-related pressures, health system fragmentation, and uneven vaccination coverage are primarily highlighted. In selected African countries, policy priorities tend to focus on communicable diseases, infrastructure limitations, and large zero-dose populations. The study underscores policy priorities and highlights opportunities for cross-regional learning. Strengthening primary health care, improving domestic health financing, and enhancing environmental health governance emerge as key areas for policy development. These findings support the value of comparative policy analysis in informing context-sensitive and equity-oriented health strategies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080985

Authors: Rong Zheng Hussain Ali Yuxiao Hu Mengmeng An

Sugar sweetened beverages (SSBs) are an important source of added sugars and a key target for fiscal policies aimed at preventing obesity, type 2 diabetes and other non-communicable diseases. This study assessed the association of SSB taxes, tax structure and tax-design elements and changes in per capita soft drink sales volume across geographies from 2010 to 2024. Annual Euromonitor International Passport sales data were combined with national SSB tax-policy data from the World Bank and macroeconomic indicators. The final sample includes 74 geographies and 1096 geography-year observations. We use a multi-period difference-in-difference technique with staggered implementation of the policy and event-study estimation. SSB taxes were associated with a reduction of 7.286 L per person (p < 0.01), about 10.4% of the sample mean. Taxes with an explicit health objective were associated with larger reductions than taxes without a health objective. Ad valorem, mixed, and specific taxes were related with lower sales volume, although differences across structures were not significant. Importantly, the results imply policy design matters. This indicates that governments should evaluate not only whether to impose SSB taxes but also how to design, position, and communicate them as health-oriented fiscal policies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080984

Authors: Roberta Lavin Su Zhang Yue Feng Xi Gong Yiliang Zhu Wei Fang Xiaozhong Yu Shuguang Leng Kritim Bastola Bhawana Kafle Daylin Clifton Shawn L. Penman Sandeep Talasila Mary Pat Couig José M. Cerrato

Over the past three decades, the United States has experienced a notable increase in weather-related disasters, including hurricanes, floods, tornadoes, wildfires, and severe storms, posing growing challenges to healthcare preparedness and public health systems. This study analyzes Federal Emergency Management Agency (FEMA) disaster declarations from 1989 to 2019 to characterize temporal and geographic trends in weather-related events. Data after 2019 were excluded to avoid confounding effects associated with the COVID-19 pandemic, which disrupted disaster declarations, resource allocation, and healthcare system demands. Using descriptive statistics, generalized linear mixed models, and spatial clustering techniques, we identified substantial increases and nonlinear patterns in disaster declarations, with variation across hazard types and regions. These trends reflect evolving hazard exposure, regional differences, and policy-driven declaration practices. Although this study does not directly measure health outcomes or social vulnerability, the observed patterns have important implications for healthcare system capacity, workforce preparedness, and populations known to be disproportionately affected by disasters. The findings highlight the need for climate-informed training, data-driven preparedness planning, and integration of disaster trend analysis into nursing education and public health practice. Strengthening the ability of healthcare systems to anticipate and respond to evolving disaster patterns is critical for advancing resilience and promoting equitable health outcomes in the context of climate change.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080983

Authors: Jeanne M. Ward Melissa Perkins John R. Blosnich

Introduction: Suicide rates among individuals working in agriculture remain disproportionately high in the United States. Although farming-related stressors and coping strategies are documented, gaps remain in understanding how farmers sustain themselves psychologically amid chronic stress and why elevated suicide risk persists despite apparent resilience. Purpose: This study sought to explore the major stressors of farming, coping strategies used by farmers, and their barriers to help-seeking, with the goal of informing suicide prevention and mental health interventions. Methods: Fourteen semi-structured interviews were conducted with Kentucky farmers recently receiving a suicide prevention intervention. Participants were purposively sampled and interviewed via telephone or Zoom. Interviews were transcribed, modified verbatim, and then analyzed using reflexive thematic analysis. Results: Farmers described chronic stressors, including financial volatility, time scarcity, uncontrollable weather, loneliness, and feeling misunderstood or undervalued by the general public. Despite these stressors, many participants initially denied being stressed. Their coping strategies centered on meaning-making rather than stress elimination, including faith, gratitude, nature-based reflection, occupational pride, and community ties. However, prominent barriers to help-seeking included stigma, self-reliance, and privacy concerns. Conclusions: The findings suggest that farmer resilience is primarily enacted through their resourcefulness, including enduring stressors and reframing their thoughts, which enabled their continued functioning despite chronic stress. However, their resourcefulness often obscures their distress and delays help-seeking. These findings may help explain why elevated suicide risk persists among farmers even with strong coping narratives. Interventions that leverage existing strengths while addressing stigma, trust, and structural stressors are needed to better support farmer mental health and suicide prevention.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080982

Authors: Morgan A. Valley Ryan Sawyer Megan B. Machmuller Helen D. Silver James Hale

Soil health practices are increasingly promoted through sustainable agricultural programs to improve environmental outcomes, yet little is known about how these practices impact the occupational health of farmers and ranchers who implement them. This qualitative study examined perceived occupational benefits and hazards of soil health practices among Colorado farmers and ranchers. Semi-structured interviews with 15 Colorado farmers and ranchers were conducted between October 2024 and January 2025 and then analyzed using thematic analysis. Six themes were identified: perceived physical benefits, psychosocial benefits, physical hazards, psychosocial hazards, and health and safety practices, and One Health perspectives of the impacts of soil health. Participants described reduced chemical exposure, increased physical activity, and improved mental health, creativity, connection to nature, and community as perceived benefits. Perceived physical hazards included heat stress, respiratory exposure to mold from organic mulching materials, and musculoskeletal strain. Perceived psychosocial hazards included social isolation, financial uncertainty, and a sense of insufficient collective action. Health and safety practices used were largely informal, and personal protective equipment use was limited. Participants described their health as intertwined with the health of the land and living systems around them, reflecting a One Health orientation. Findings suggest that soil health practices may alter occupational health risk in ways that warrant further investigation and tailored safety guidance and programmatic support.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080981

Authors: Teresa Galanti Morena Santoriello Michela Cortini Elisa Di Tullio Angelica Di Febbo Stefania Fantinelli Gabriella Mincione

Pediatric oncology nursing is among the highest-intensity care specialties, exposing nurses to repeated child death and sustained emotional investment in family relationships. This occupational burden is a recognized psychosocial risk factor and a driver of compassion fatigue, burnout, and reported intention to leave, yet the organizational and educational determinants of this risk remain poorly captured by existing assessment approaches. This study investigated the lived experiences of nurses caring for terminally ill children in a pediatric onco-hematology unit and hospice ward in central Italy (N = 15), using a qualitative descriptive design, informed by a phenomenological sensibility to lived experience, supported by computer-assisted textual analysis. Structured face-to-face interviews were analyzed through thematic content analysis with stepwise replication, while quantitative textual analysis was performed using T-Lab software to map co-occurrence patterns among key lemmas, providing a frequency-based, semantically grounded picture of nurses’ representations of occupational risk. Seven themes emerged, including quality of nursing care, parental relationships, coping with a child’s death, and impact on personal and professional life. Findings showed that reported intention to leave was associated, in participants’ accounts, with absent psychological debriefing, cumulative emotional burden, inadequate end-of-life training, and a near-total absence of organizational vocabulary for peer-level support—a gap directly visible in the co-occurrence structure of nurses’ language. As a secondary aim, by combining qualitative depth with complementary lexical analysis of thematic patterns, this study also offers a methodological example of how psychosocial risk in high-intensity care settings can be assessed and translated into actionable indicators for organizational climate and workforce well-being. The findings inform concrete prevention strategies and policy recommendations for nursing education and occupational health, consistent with this Special Issue’s focus on methodological innovation for psychosocial risk assessment and public health policy design.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080980

Authors: Aseel A. Takshe Ayah Abboud Haneen Marwan Youssef Masah Al Zuhairi Dit Amr Marya Al Hosni Xin Wee Chen

Indoor air pollution (IAP) is an important public health issue in urban households, particularly in hot climates where residents spend substantial time indoors. While the health risks of indoor air pollution are increasingly recognised, gender differences in exposure-related behaviours, risk perception, and health communication preferences remain underexplored in Gulf cities. This study examined gender differences in awareness, household practices, and preferred information channels related to IAP among English-speaking adults in Dubai. A cross-sectional survey was conducted among 1014 adults using a structured questionnaire. Descriptive, bivariate, and multivariable regression analyses were used to examine gender-based patterns. Overall, participants showed moderate awareness of IAP; gender differences emerged across each of the four behavioural domains examined, with women more likely to use chemical-based cleaners and to open windows for ventilation. After controlling for age and education, women were significantly more likely than men to use traditional chemical-based cleaners (β = 0.69; p < 0.001) and to open windows for ventilation (β = 0.78; p < 0.001), while men more frequently relied on mechanical methods such as air filters and ceiling fans. Women were more likely to express interest in learning about IAP (adjusted OR = 2.55; 95% CI: 1.71–3.79) and to prefer community-based, informal channels such as awareness campaigns and social media. These gender differences persisted after adjustment for age and education, suggesting that indoor air quality behaviours and communication preferences may vary systematically by gender in this sample. Among this English-speaking convenience sample, gender differences were observed in household practices and preferred communication channels. These findings provide preliminary evidence that may help inform future public health communication strategies in Dubai but should not be interpreted as representative of the wider Dubai population.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080979

Authors: Cataldo Giuliano Gemmano Mirko Pio Petruzzelli Amelia Manuti

Work-related stress and difficulties in managing the work–life interface represent significant challenges for psychological well-being. While research has increasingly examined coping and recovery processes, less attention has been paid to the role of nature-based leisure activities in supporting these dynamics. This qualitative study explores how adult workers who regularly practice surfing use this activity to cope with work-related stress and how it relates to the development of personal resources and the work–life interface. Semi-structured interviews were conducted with 14 Italian workers, and the data were analyzed using thematic analysis. Three main themes emerged. First, surfing was described as a coping strategy that supports emotional regulation, psychological detachment from work, and recovery, particularly through immersion in a natural environment. Second, participants reported that experiences developed in surfing, such as managing uncertainty, risk, and decision making, were transferable to the work context. Third, surfing played a complex role in the work–life interface, contributing to balance but also generating time-based tensions when not adequately integrated into daily routines. Overall, the findings highlight the active role of individuals in using extra-work activities as resources for coping and recovery and underline the importance of considering nature-based experiences within broader models of occupational well-being and work–life dynamics.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080978

Authors: Kellie O’Dare Clint Bowers Deborah C. Beidel Junwei Jiang Steve McCoy

Background: Emergency medical services (EMS) personnel experience high rates of psychological distress yet demonstrate low utilization of mental health services. Factors associated with actual service use—rather than intentions or attitudes—are not well understood. Methods: Using secondary data from 36,697 licensed Florida EMTs and paramedics collected during the 2022 licensure renewal process, logistic regression models evaluated the relative contributions of workplace factors, attitudinal variables, trauma exposure, and mental health symptoms in their association with service utilization. Results: Psychological symptoms, particularly anxiety and depression, were the strongest factors associated with help-seeking. Peer support emerged as one of the few system-level factors associated with increased service use, even after accounting for symptom presence. Stigma-related variables showed weaker and, in some cases, counterintuitive associations. Suicidality and substance use were modestly associated with help-seeking beyond core symptom variables. Findings were consistent among trauma-exposed personnel. Discussion: Results are consistent with the potential value of early identification, routine symptom screening, and integrated, system-level supports such as peer support and access to confidential, occupationally competent care.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080977

Authors: Alina Cernasev Karissa Cliff Emily Nagel Hunter Smith Alex Johnson Tracy M. Hagemann

Background: Human papillomavirus (HPV) continues to cause an estimated 4000 preventable cancer deaths each year in the United States. Given the prevalence of HPV-related disease and suboptimal vaccination rates, this study explores perceptions of HPV vaccination among HIV-negative females and females living with HIV in Tennessee. Methods: This prospective, observational qualitative study consisted of narrative interviews which were conducted with HIV-negative and HIV-positive participants, focusing on their perceptions of HPV and its vaccine. Interviews were conducted by phone, and the verbatim transcripts were inductively coded by three researchers. The inductive codes were then grouped into categories based on similarities which facilitated the emergence of themes. Results: A total of 40 participants were interviewed between July 2024 and December 2024. Narrative analysis revealed three themes: (1) “I had never heard of it until I saw the flier.” Gaps in Understanding of HPV and Its Health Implications, (2) Navigating Adolescent Health Decisions and Emotional Influence, and (3) Barriers to Uptake—Skepticism, Trust, and the Need for Tailored Information. Two subthemes emerged: Cohort-Specific Skepticism, and Parental Influence and Communication Gaps. Conclusions: This study revealed significant gaps in HPV knowledge and vaccination uptake among HIV-negative women and women living with HIV in Tennessee. Provider communication was key to vaccine decisions, but clear recommendations were often missed in clinical encounters.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080976

Authors: Evija Nagle Maksims Zolovs Anna Nyberg Iluta Skrūzkalne Ieva Saukuma Andrejs Ivanovs Ieva Reine

Background: Healthcare professionals work in demanding psychosocial environments that may affect their subjective well-being and, consequently, the performance and sustainability of healthcare systems. Understanding how job demands and job resources are associated with healthcare professionals’ well-being is important for developing organizational strategies that support workforce health and service quality. Methods: A cross-sectional quantitative study was conducted among 566 healthcare professionals in Latvia. Psychosocial work environment factors were assessed using a multidimensional instrument based on the Job Demands–Resources (JD-R) model, while subjective well-being was measured using the WHO-5 Well-Being Index. A comprehensive multiple-predictor mediation SEM was estimated using the WLSMV estimator. The primary covariate-adjusted model was based on 561 complete cases and simultaneously included all four psychosocial predictors, Work Engagement and Vitality as the mediator, subjective well-being as the outcome, and age, work experience, and professional position as covariates. Results: The comprehensive model demonstrated good fit. Job Satisfaction and Reward showed significant positive direct and indirect associations with subjective well-being and the strongest total association. Occupational Distress and Strain showed significant negative indirect and total associations, whereas their direct associations were not statistically significant. Autonomy and Work Control showed a significant positive indirect association and a significant positive total association, while its direct association was not statistically significant. Organizational Trust and Support demonstrated a positive indirect association but a negative direct association, whereas its total association was not statistically significant, indicating inconsistent mediation. Conclusions: The findings suggest that psychosocial work environment factors are meaningfully associated with subjective well-being among healthcare professionals. Job Satisfaction and Reward, Autonomy and Work Control, and Occupational Distress and Strain appear to be particularly relevant factors. Work Engagement and Vitality may serve as an indirect pathway linking selected work environment factors to subjective well-being; however, given the cross-sectional design, these findings should be interpreted as statistical associations rather than evidence of causal mediation.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080975

Authors: Allisa George Jacqueline Nassaka Anna Nabulya Jane Palmier Emeka W. Dumbili Monica H. Swahn

Young women living in urban informal settlements experience intersecting structural and environmental conditions that shape health and well-being. Alcohol environments (the physical, social, and commercial contexts in which alcohol is sold, marketed and consumed) represent an important but understudied social and commercial determinant of health. Young women in these settings face intersecting vulnerabilities, including poverty, unemployment, and gender inequality, that increase their exposure to alcohol-related harm. Although alcohol use and alcohol-related harms are increasingly understood as shaped by social and commercial determinants of health, little is known about how young women experience alcohol environments in low-resource settings. This exploratory, site-specific secondary, qualitative analysis draws on data from a 2022 Photovoice project conducted over several weeks with 15 young women (ages 18–24) living in urban poverty in Kampala. Participants used photography and group discussions to explore how alcohol shapes their lives. Our inductive thematic analysis included all five participants from the Makindye site, where alcohol-related photographs and narratives emerged prominently during the Photovoice discussions. Six key themes were identified from 42 narrative excerpts and two photographs, highlighting alcohol’s dual role as both a source of livelihood and a source of harm. Participants described pervasive exposure to aggressive marketing, unregulated drinking venues, and the normalization of alcohol use, often linked to interpersonal violence, emotional distress, and disruption of household dynamics. Alcohol environments also constrained women’s mobility and safety, limiting their participation in public life. These findings suggest that alcohol environments may shape young women’s exposure to violence, economic precarity, and psychological distress in this setting. They also point to the potential value of gender-responsive policies, stronger regulation, and community-based prevention strategies to address alcohol-related harm and health inequities in low-resource urban settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080974

Authors: Gouwa Dawood Rentia Maart Quinette Abegail Louw

Hearing-functioning problems contribute substantially to disability and rehabilitation needs globally; however, evidence describing the range and interconnected nature of these problems across African populations remains fragmented. This study aimed to describe hearing-functioning problems associated with high-burden adult health conditions across African populations using data from the Rehab4All database. A secondary exploratory analysis was conducted using data extracted from a large Africa-wide scoping review of functioning problems associated with conditions contributing substantially to years lived with disability (YLD). The parent review systematically searched PubMed, Scopus, Web of Science, EBSCOhost, and SABINET and included English-language studies conducted in African adults. Hearing-functioning problems were classified according to the International Classification of Functioning, Disability and Health (ICF). Descriptive analyses, visual mapping techniques, and exploratory random-effects prevalence meta-analyses were performed. Ninety-seven articles published between 2007 and 2022 were included. Most studies originated from Southern Africa, particularly South Africa. Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis (TB), diabetes mellitus (DM), hearing-loss cohorts, and headache-related conditions contributed most frequently to reported hearing-functioning problems. Hearing loss, tinnitus, and vestibular dysfunction were the most commonly reported problems; however, multidimensional co-occurring auditory and vestibular profiles were frequently identified. Distinct functional patterns emerged across conditions, with TB demonstrating predominantly auditory dysfunction, while HIV/AIDS and DM demonstrated broader auditory–vestibular involvement. Hearing-functioning problems within the African evidence base appear multidimensional, interconnected, and unevenly distributed geographically.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080973

Authors: Hanna Vertanen-Greis Sirkku Häkkilä Eliisa Löyttyniemi Juha Vintturi Anthony Maalouf Ahmed Geneid

This study examined associations between perceived indoor air quality (PIAQ) and self-reported voice symptoms in teachers, with exploratory observations on man-made mineral fibers (MMMF). Forty-seven teachers underwent within-day assessments at the beginning (good PIAQ) and end (poor PIAQ) of a workday. Clinical voice status was evaluated with laryngoscopy and the Grade–Roughness–Breathiness–Strain (GRBS) scale. Self-reported symptoms were measured with a 100 mm Visual Analog Scale (VAS) and the 30-item Voice Handicap Index (VHI). Classroom settled dust was collected on gelatin tape and analyzed by light microscopy for MMMF. No significant within-day clinical voice changes were detected, although breathiness showed a non-significant increase. Median VAS scores for voice symptoms showed no meaningful within-day change. Poorer afternoon PIAQ was associated with higher post-VAS, and longer daily exposure time co-varied with greater subjective worsening. Teachers with high VHI scores more often reported symptom worsening and poorer PIAQ ratings. Self-reported voice symptoms correlated positively with poor PIAQ and exposure duration. These findings suggest a symptom-driven pattern without evidence of environmental causality. Longitudinal studies with real-time IAQ monitoring are needed. Occupational health follow-up is recommended for teachers with persistent voice problems, with attention to vocal load.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080972

Authors: Leomar White Christiana Zimmer Jason Jackman Karen Liller Jason L. Salemi

Few national comparisons exist on healthcare utilization among e-scooter users, and prior research was limited by the absence of e-scooter-specific ICD-10-CM codes before 2021. Using newly implemented codes, this cross-sectional study compared emergency department disposition and injury patterns between e-scooter riders and bicyclists using the 2021 Nationwide Emergency Department Sample (n = 239,457 weighted encounters). Multivariable logistic regression adjusted for demographic, geographic, and temporal confounders, with interaction terms for insurance status, substance use, and motor vehicle involvement. E-scooter riders were more often female (46.5% vs. 24.7%) and under age 18 (47.6% vs. 37.4%) than bicyclists. Overall adjusted odds of admission or transfer did not differ significantly between groups (OR = 1.03; 95% CI: 0.86–1.23). Motor vehicle involvement significantly modified this relationship, with e-scooter riders showing higher odds of admission (OR = 1.67; 95% CI: 1.12–2.48). No significant effect modification was detected for insurance status or substance use. E-scooter riders more frequently sustained distal extremity fractures consistent with low-energy falls, while bicyclists experienced more proximal fractures and internal trauma. Updated ICD-10-CM codes improve e-scooter injury surveillance, and motor vehicle involvement represents a priority target for mode-specific prevention and infrastructure investment.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080971

Authors: Takashi Kuwayama Kazuhiko Kotani

Non-communicable diseases (NCDs), including cardiovascular disease, cancer, and chronic respiratory disease, are major causes of death worldwide; addressing NCDs is thus essential. NCDs may contribute to health disparities between rural and urban areas. The COVID-19 pandemic has altered medical and social environments, and NCD management approaches may have changed accordingly. This scoping review aimed to examine themes of reported rural healthcare challenges related to NCD management before and after the COVID-19 pandemic. A literature search of original articles was conducted via PubMed. A thematic analysis was applied to compare the content of studies classified as pre-pandemic and post-pandemic. A total of 23 articles were identified, including 12 studies classified as pre-pandemic and 11 studies classified as post-pandemic. Before the pandemic, commonly reported challenges included low management rates of hypertension and diabetes, instability in pharmaceutical supply, and insufficient training of healthcare personnel. We integrated these into a theme related to “healthcare”. After the pandemic, in addition to the low management rates, studies increasingly addressed mental and nutritional health, multimorbidity, and socioeconomic disparities. We integrated there into a theme related to “society”. Namely, studies classified as pre-pandemic primarily reported healthcare-related aspects, whereas studies classified as post-pandemic more frequently reported broader societal aspects in addition to healthcare-related aspects. These findings may reflect changes in how rural healthcare challenges related to NCDs have been recognized and discussed following the COVID-19 pandemic. Further research is needed to clarify the significance and implications of these reported themes.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080970

Authors: Nargis Sultana Kathryn L. Braun

Regular physical activity (PA) is essential for healthy aging. For older adults residing in urban areas, access to urban green space (UGS) can help increase PA levels. This systematic review examined the association between availability, accessibility, and attractiveness of the UGS on PA among older adults. PubMed, CINAHL, and Web of Science were searched for articles published 2016–2024 that used quantitative methods to explore associations between the qualities of UGS and measures of PA in this demographic. Findings from nine studies from Europe, China, Hong Kong, and Australia were synthesized by availability, accessibility, and attractiveness domains. For availability, the presence and size of UGS were positively associated with older adults’ PA in several studies, whereas UGS proximity was inconsistently associated with PA. For accessibility, infrastructure-related features such as trail length were positively associated with PA, but findings for park features and safety were mixed. Results were also inconsistent for attractiveness; some land-cover and amenity features showed positive associations, while others showed no clear relationship with PA. In addition to variability in associations, there was great heterogeneity across studies in age inclusion criteria (e.g., 45+ vs. 65+), participant inclusion criteria, setting, operationalization of UGS quality, PA measures, and study rigor, reducing the ability to draw conclusions about the association between UGS qualities and PA. Although findings can begin to inform urban planners, public health professionals, and policymakers in designing UGS to promote PA in older adults, the field would benefit from more consistent definitions and measures of UGS qualities and PA.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080969

Authors: Muhammad Aljukhadar

Major societal stressors such as pandemics and economic crises can significantly disrupt individual well-being through altered sleep patterns. This study uses a mixed-methods approach to explore the underlying causes and consumption expressions of sleep disturbance during the COVID-19 lockdown. Based on qualitative responses from 59 participants, the findings reveal three core disturbance patterns: delayed sleep schedules, increased sleep duration, and sleep restriction. These shifts were associated with a combination of emotional arousal, cognitive overload, and disrupted routines. Two dominant types of pre-sleep thought processes—pressing and comforting—appear to influence sleep outcomes. Despite the availability of mindfulness and guided-meditation technologies, most participants did not adopt these tools, citing either skepticism or inertia. The proposed model highlights the interplay between personal traits, pre-sleep behavior, and stress responses in shaping sleep. The study offers implications for public health initiatives, suggesting that targeted and accessible interventions are needed to support sleep health during a major stressor.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080968

Authors: Jingwen Yang Li Yao Zhouyuan Peng Kumiko Kuroda

Background/Objectives: As population ageing accelerates, integrated care has become an important strategy for addressing the complex care needs of older adults. Although gerontological nurse specialists (GNSs) are expected to contribute to integrated care, their roles remain inconsistently defined and insufficiently synthesized across healthcare systems and professional role titles. This scoping review aims to systematically map the roles of GNSs in supporting integrated care for older adults within hospital-based settings. Methods: This scoping review protocol will follow the JBI methodology for scoping reviews and will be reported in accordance with the PRISMA-ScR guidelines. Searches will be conducted in PubMed, CINAHL, Web of Science, China National Knowledge Infrastructure, and Ichushi-Web, with no date restrictions. Studies published in English, Chinese, and Japanese will be included. The review will consider studies involving nurses with recognized specialist or advanced nursing practice competence in gerontological or older-adult care and will focus on their roles in supporting integrated care for older adults within hospital-based settings and hospital-linked transitional care services. Two independent reviewers will conduct study selection and data extraction. The findings will be synthesized descriptively and presented using tabular, narrative, and diagrammatic formats. Conclusions: This review is expected to contribute to a clearer understanding of the roles of GNSs in integrated care for older adults and provide evidence to inform future nursing practice, workforce development, education, and research in gerontological integrated care. Registration: This protocol was registered within the OSF database on 19 May 2026.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080967

Authors: Daniela Muntele-Hendreș Georgiana-Mary Clapon Clementina Doina Cojocaru

Physician burnout represents a major occupational health concern associated with impaired wellbeing, reduced job satisfaction, and decreased quality of patient care. Although burnout is frequently examined using variable-centered approaches, less is known about distinct burnout profiles among physicians and their associations with professional identification and intellectual humility. The present study investigated relationships between burnout, job satisfaction, professional social identification, and intellectual humility among physicians using both variable-centered and person-centered approaches. A sample of 100 physicians completed measures assessing burnout dimensions, job satisfaction, professional identification, and intellectual humility. Cluster analysis identified four distinct burnout profiles characterized by different combinations of exhaustion, distancing, cognitive dysfunction, and emotional dysfunction. Significant differences between profiles emerged regarding job satisfaction and professional identification, with higher burnout generally associated with lower occupational wellbeing and weaker professional identification. Correlational analyses also indicated negative associations between burnout, job satisfaction, and professional identification. Although global intellectual humility was not significantly associated with burnout severity, exploratory analyses revealed that openness to correction and engagement in debate were negatively associated with cognitive and emotional dysfunction. These findings support the heterogeneous nature of physician burnout and suggest that professional identification and humility-related cognitive openness represent relevant psychological resources in demanding healthcare environments.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080966

Authors: Dirk Schreckenberg Sarah Leona Benz Julia Kuhlmann Jonas Bilik Christian Popp Frank Heidebrunn Wolfgang Wack Ferenc Marki

Motorcycle noise along leisure routes constitutes a distinct environmental health burden poorly captured by standard road traffic noise indicators. This study derives source-specific exposure–response functions and examines non-acoustic predictors of residential motorcycle noise annoyance. A mixed-methods socio-acoustic design was applied in five study areas in Baden-Wuerttemberg, Germany. A community survey (N = 493) assessed long-term annoyance (12-month recall); a smartphone-based experience-sampling study (MotoApp; N = 213; ten days in summer 2022) collected hourly ratings. Acoustic measurements provided vehicle-specific LAeq,1h, LAFmax,1h, and N60; exposure–response functions were estimated using logistic regression and generalised estimating equations. In the long-term survey, 46.5% were highly annoyed by motorcycle noise, compared with 18.4% for passenger cars. Motorcycle exposure–response curves were markedly shifted; the 25–highly-annoyed threshold was reached approximately 16 dB lower in LAeq,1h than for passenger cars on weekends. Negative attitudes towards motorcycle riders, low coping capacity, and noise sensitivity were significant independent predictors. Source-specific assessment is necessary for motorcycle leisure routes. The 25–highly-annoyed criterion maps to approximately 52 dB LAeq,1h and 78 dB LAFmax,1h on weekends, and to 25 N60 events per hour—substantially below current road traffic guideline values—providing actionable thresholds for noise action planning.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080965

Authors: Martin S. Lipsky Lucia Romero Owen Cohen Sajjan Dhasi Lily Overman Man Hung

Dental caries is one of the most prevalent chronic diseases affecting older adults and remains an important, underrecognized contributor to pain, impaired nutrition, systemic illness, and reduced quality of life. Older adults access medical care more often than dental care, positioning non-dental clinicians to identify risk, initiate prevention, and facilitate timely referral. A narrative review of English-language literature was conducted using PubMed and Google Scholar. Search terms included “dental caries,” “root caries,” and “older adults.” Sources included original studies, clinical guidelines, consensus statements, and high-quality reviews, with an emphasis on relevance to older adults and applicability to non-dental clinicians. Dental caries in older adults commonly presents as root and recurrent decay and isstrongly associated with xerostomia, polypharmacy, chronic disease, functional impairment, cognitive decline, and limited access to dental care. The literature supports fluoride-based prevention, management of salivary dysfunction, dietary counseling, minimally invasive therapies such as silver diamine fluoride, and interprofessional care models. Non-dental providers play a critical role in screening, risk assessment, preventive counseling, symptom triage, and referral. Integrating oral health into routine medical care is an essential and achievable strategy to reduce morbidity and improve health outcomes in older adults.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080964

Authors: Rachadaporn Jantasuwan Suda Jaihow Sumoltip Sontimuang Kanyapak Pluemjai Hasni Embong Salwismawati Badrin

Maternal anemia during pregnancy may adversely affect fetal growth, including neonatal head circumference (HC). This retrospective cohort study aimed to identify predictors of small HC among infants born to women with third-trimester anemia. Secondary data were obtained from the HosXP electronic medical database and delivery records of pregnant women who delivered between October 2020 and September 2023. A total of 934 women met the eligibility criteria and were included in the analysis. Maternal characteristics were summarized using descriptive statistics. Associations between maternal factors and neonatal HC were examined using the Chi-square test, Fisher’s exact test or Mann–Whitney U test, and independent predictors were identified using binary logistic regression analysis. The mean neonatal HC was 32.76 ± 1.50 cm, and 43.90% of infants were classified as having a small HC. Gravidity, pre-pregnancy body mass index (BMI), and gestational weight gain (GWG) were significantly associated with neonatal HC. Multivariable analysis revealed that women with two pregnancies (aOR = 0.51, 95% CI: 0.352–0.734) and those with three or more pregnancies (aOR = 0.54, 95% CI: 0.373–0.773) had lower odds of delivering infants with small HC than primigravida women. Pre-pregnancy overweight or obesity was associated with lower odds of small HC (aOR = 0.59, 95% CI: 0.426–0.805), whereas inadequate GWG increased the likelihood of this outcome (aOR = 1.38, 95% CI: 1.010–1.894). Maternal gravidity, pre-pregnancy BMI, and GWG may influence neonatal HC. These findings may support nurses in identifying women at risk, monitoring GWG, and providing targeted nutritional counseling during antenatal care.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080963

Authors: Molly J. Taylor Tait D. Shanafelt Lisa G. Williams

Biomedical scientists/researchers are critical to advancing human health, but their experiences of occupational stress, burnout, and subsequent consequences are surmised but understudied. The current narrative review aimed to search and summarize existing literature and scientific discourse specific to biomedical scientist burnout to better understand the prevalence and unique drivers of stress in this population and highlight critical areas that require further research and intervention efforts. The authors searched six primary databases from August 2024 to December 2025 using defined search terms to identify peer-reviewed articles and scientific discourse related to occupational burnout of academic medicine biomedical faculty researchers, postdoctoral researchers, or lab personnel. Prevalence and primary drivers of burnout, stress mediators, and mitigation/intervention recommendations were extracted from the included works. A total of 16 empirical articles and 4 non-empirical works were included. Over 30% of biomedical scientists exhibit high occupational burnout, nearly 45% report high distress, and just over 34% experience high emotional exhaustion. Seven primary drivers of biomedical scientist distress were identified including intense workloads/expectations, funding pressures, and lack of perceived organizational support/recognition. Biomedical scientist burnout prevalence appears comparable to clinical faculty but is driven, in part, by distinct stressors. The attributable organization and societal cost of biomedical scientist burnout remain unquantified. The current review establishes a significant need for further research and tailored efforts to address the distinct needs of biomedical scientists across academic medical centers.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080962

Authors: Mi Phan Thanh Tra Xuan Thanh Phan

Psychosocial job characteristics are important components of the work environment and are closely associated with occupational health, particularly among nurses working in demanding healthcare settings. However, evidence from primary healthcare settings in low- and middle-income countries remains limited. This study aimed to describe psychosocial job characteristics and job strain among nurses in urban primary healthcare centers in Vietnam and to examine factors associated with psychosocial job characteristics and job strain. A multicenter cross-sectional study was conducted among 768 nurses across four district-level healthcare centers in Ho Chi Minh City, Vietnam, using a structured questionnaire including the validated Vietnamese Job Content Questionnaire. Nurses reported moderate-to-high job demands, high social support, and limited decision latitude. Most participants reported low strain (45.6%) or active jobs (42.4%), while fewer were in the high-strain (6.3%) and passive (5.7%) categories. Sociodemographic and work-related factors were significantly associated with job strain (p < 0.001). Although the prevalence of high strain was relatively low, differences between perceived job demands and specific dimensions of decision latitude were observed. These findings highlight the importance of job control, workload, and workplace support as factors associated with psychosocial job characteristics and job strain and may help inform future workplace interventions and longitudinal research.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080961

Authors: Bovornpot Choompunuch Emanyah Sani Jutatip Sillabutra Jatuporn Ounprasertsuk

Burnout among nurses is an important occupational and public health concern because it is associated with nurses’ well-being, workforce retention, and the quality and safety of patient care. This explanatory sequential mixed-methods study examined levels of work stress, quality of work life, and burnout among registered nurses in public hospitals in Samut Songkhram Province, Thailand, and explored nurses’ experiences regarding workplace factors related to burnout. The target quantitative sample was 217 registered nurses, and 186 completed questionnaires were included in the final analysis. Structured questionnaires assessed work stress, quality of work life, and burnout. Multiple regression analysis was used to identify factors associated with burnout. Qualitative data were collected through in-depth interviews with 10 registered nurses and analyzed using content analysis. Most nurses were classified as having high work stress and being at risk of burnout. Work stress and quality of work life jointly explained 35.0% of the variance in burnout. Work–life balance, fair and adequate compensation, professional development, workplace safety, organizational justice, and social integration in the workplace were associated with lower burnout scores. Organizational structure, policy, and climate showed a positive coefficient in relation to burnout and should be interpreted cautiously because the p-value was close to the conventional threshold for statistical significance. Qualitative findings supported the quantitative results and highlighted workload, staffing shortages, limited resources, insufficient recovery time, and workplace support as important workplace concerns.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080960

Authors: Fabricio González-Andrade Fausto Coello Henry Vásconez

Background: Microtia is a congenital anomaly of the external ear that is frequently associated with conductive or mixed hearing impairment and potential developmental consequences. Although genetic factors may contribute to some cases, social and economic conditions can influence access to diagnosis, hearing rehabilitation, and specialized care. This study examined clinical severity, hearing disability, and socioeconomic characteristics among patients with isolated and familial microtia evaluated in Ecuador. Methods: A cross-sectional study was conducted at a tertiary referral center in Quito, Ecuador. A total of 143 patients with microtia were included. Clinical variables included hearing impairment, hearing device use, microtia severity, associated risk factors, and family history. Sociodemographic variables included age, sex, residence, economic level, and healthcare access. Categorical variables were summarized as frequencies and percentages, and continuous variables as medians with interquartile ranges. Group comparisons were performed using the chi-square test and the Mann–Whitney test. Multivariable logistic regression was used to assess factors associated with hearing device use. Statistical significance was set at p < 0.05. Results: Hearing impairment was present in 41.78% of patients, with similar prevalence in isolated and familial cases. Hearing device use was reported by 19.86% of the sample. Familial microtia showed a significantly different distribution of right-ear severity, with higher frequencies of grade 1 and grade 4 anomalies, whereas isolated microtia was more commonly grade 3. Significant differences were also observed in sex distribution and economic level. Isolated cases were more frequent among males, whereas familial cases showed a higher proportion of females. Familial microtia was concentrated mainly in the low-middle economic stratum. In multivariable analysis, no factor was independently associated with hearing device use, and confidence intervals were wide, indicating limited precision. Conclusions: In this tertiary referral sample, microtia-related disability and access to care appeared to reflect the combined influence of clinical vulnerability, familial aggregation, and socioeconomic disadvantage. The low use of hearing devices despite frequent hearing impairment indicates an important gap between clinical need and rehabilitation. Equity-oriented strategies, including early hearing screening, timely referral, financial protection for assistive devices, and improved access to specialized care, may help reduce unmet needs among patients with microtia.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080959

Authors: Togzhan Serbatyrova Gulnar Shalgumbayeva Assel Tukinova Gulnara Sarsebayeva Laura Danyarova

Background/Objectives: Gestational diabetes mellitus (GDM) is a common metabolic complication of pregnancy associated with adverse maternal and neonatal outcomes. Data on GDM in Central Asian populations remain limited. This study aimed to identify factors associated with GDM and evaluate selected obstetric outcomes among pregnant women in Kazakhstan. Methods: A retrospective case–control study based on medical record data was conducted among 256 pregnant women, including 106 women with GDM and 150 women with normal glucose tolerance. GDM was diagnosed using a 75 g oral glucose tolerance test according to the International Association of Diabetes and Pregnancy Study Groups criteria. Demographic, clinical, anthropometric, laboratory, and obstetric data were obtained from medical records. Multivariable logistic regression was used to identify factors statistically associated with GDM. Obstetric outcomes were compared using unadjusted analyses. Results: Women with GDM were older than controls (31.6 ± 5.8 vs. 28.6 ± 5.3 years, p < 0.001) and had a higher pre-pregnancy body mass index (BMI) (29 [25–33] vs. 26 [23–29] kg/m2, p < 0.001). Thyroid-stimulating hormone levels were also higher in the GDM group (p = 0.026). In multivariable analysis, pre-pregnancy obesity (adjusted OR 4.54, 95% CI 2.08–9.91; p < 0.001) and educational level (overall p = 0.001) remained associated with GDM, whereas maternal age was not independently associated after adjustment. Hypertension (24.5% vs. 2.0%; p < 0.001), eclampsia (3.8% vs. 0%; p = 0.028), cesarean delivery (52.8% vs. 28.0%; p < 0.001), and fetal macrosomia (21.7% vs. 12.0%; p = 0.037) were more frequent among women with GDM. No significant difference was observed in neonatal birth weight. Conclusions: Pre-pregnancy obesity and educational level were independently associated with GDM. Women with GDM more frequently experienced hypertensive complications, cesarean delivery, and fetal macrosomia; however, these findings were based on unadjusted analyses and should be interpreted cautiously. Further multicenter prospective studies are needed to confirm these findings in Central Asian populations.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080958

Authors: Khutso Lekgothoane Selekane Ananias Motadi Osia Livhuwani Munyangane

In low- and middle-income countries, the burden of hypertension and hyperglycaemia is alarming. These conditions remain major, recurring public health concerns that demand alternative healthcare strategies. This systematic review critiques and synthesises the existing evidence on the roles of recreational activities and dietary management in treating hypertension and hyperglycaemia in adults in low- and middle-income countries. The aim is to create awareness for hypertensive and hyperglycaemic patients. A systematic search was conducted using the PRISMA guidelines across six online databases: PubMed, Scopus, Google Scholar, Cochrane Library, Web of Science, and CINAHL. The search included peer-reviewed articles published between 2015 and 2025. Of the 12,500 identified articles, only 35 met the inclusion criteria. The evidence suggests that active recreational activities and dietary interventions are the most effective strategies for managing hypertension and hyperglycaemia when implemented properly. Current studies demonstrate that aerobic recreational activity improves vascular function, lowers blood pressure, and enhances insulin sensitivity. DASH and Mediterranean diets support cardiometabolic health in hypertensive and hyperglycaemic patients. These diets help reduce hypertension, control blood sugar levels, and lower cardiovascular risk. If sustained, these intervention strategies can effectively prevent and manage hypertension and hyperglycaemia. This review recommends that healthcare systems integrate therapeutic recreational activities with the DASH and Mediterranean diets as alternative interventions for adults with hypertension and hyperglycaemia.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080957

Authors: Aaron Chigona Farai Mapanda Chakare Benhura Justice Nyamangara Phillip Nyamugafata Menas Wuta Ntandokamlimu Nondo Sessely Mavunga Takudzwa Nota

Background: Wild foods and geophagic material are important in the nutrition of communities along Zimbabwe’s Great Dyke, a serpentinic ultramafic (SUG) and surrounding granitic geological (GG) environment. However, the health risks associated with consumption of these in terms of toxic geogenic contaminants (TGC) is largely unknown. The study objective was to evaluate the health risks associated with consuming wild foods and geophagic materials from these environments. Methods: Health risk assessments were determined using the hazard quotient, hazard index (HI) and life cancer risk (LCR) for 10 TGCs in wild foods and geophagic material. Results: High human health risks (HI ≥ 1) were found in six wild foods and geophagic material under the SUG environment compared with five wild foods and geophagic material under the GG environment. Wild foods and geophagic materials exceeded the tolerable risk level of 1 × 10−4. Their LCR values ranged from 2.11 × 10−1 to 6.83 × 10−7. All TGCs had high LCR values above the tolerable risk level, except for Cu, Fe, Mn and Zn. Conclusions: Infusion reduced the LCR values for TGCs, with only Pb in the GG environment decreasing to below tolerable risk level. Communities should apply selective consumption and avoid F. sycomorus and geophagic materials with cancer risks.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080956

Authors: Maria Domenica Sauta Giulia Raimondi Giulia Tomaselli Claudia Lanza Cristiana Maria Avalle Isabella Giulia Franzoi Antonella Granieri

Mentalization is a core psychological function underlying emotional regulation and vulnerability to psychopathology. This pre–post naturalistic study examined whether baseline mentalization predicts depressive symptoms and alexithymia in university students undergoing brief psychoanalytic psychotherapy. A sample of 104 students was assessed at baseline (T0) and post-treatment (T1). Longitudinal path analysis showed that baseline mentalization significantly predicted both depressive symptoms and alexithymia at follow-up, controlling for their temporal stability. Lower mentalization at intake was associated with poorer outcomes at treatment. completion The model demonstrated good fit and explained a substantial proportion of variance in both outcomes. These findings suggest that mentalization functions as a transdiagnostic vulnerability factor influencing psychotherapy outcomes and highlight the clinical importance of assessing and targeting mentalization from the early stages of treatment.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080955

Authors: Guillermo Medina-Santos Alberto Urzúa Jorge Méndez-Cornejo Edgardo Rojas-Mancilla Carmen Zambrano-Bravo Esteban Oñate-Henríquez Trinidad Parada Cristian Vidal-Silva

Metabolic syndrome is a major public health concern, yet evidence from structured community-based interventions in Latin America remains limited. This study conducted a comparative reanalysis of an 18-week program implemented in Talca, Chile, that combined supervised aerobic exercise, health education, and clinical monitoring. The analysis included archived data from 80 adults with metabolic syndrome who had originally been randomly allocated using SPSS to an intervention group (n=33) or a usual-care comparison group (n=47). Anthropometric, biochemical, cardiovascular, body-composition, functional-capacity, and estimated cardiorespiratory-fitness outcomes were assessed at baseline and after 18 weeks. At the post-intervention assessment, the intervention group showed greater Six-Minute Walk Test (6MWT) distance, higher 6MWT-based estimates of cardiorespiratory fitness, lower waist circumference, systolic and diastolic blood pressure, fasting glucose, triglycerides, body weight, body fat percentage, and fat mass, and higher high-density lipoprotein (HDL) cholesterol and muscle mass percentage than the comparison group. Within the intervention group, body weight, body fat percentage, and fat mass decreased, whereas muscle mass and 6MWT distance increased. These findings indicate that participation in the integrated program was associated with favorable cardiometabolic, body-composition, and functional outcomes. The results support further prospective evaluation of this community-based model within primary healthcare and public health settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080954

Authors: Najjuwah Walden Lora Iannotti Gifty Aboagye-Mensah Rachel G. Tabak

Understanding how sensory preferences shape the acceptance of nutrient-dense foods is essential for improving prenatal nutrition. This exploratory study examined taste, smell, texture, appearance, and enjoyment factors influencing food acceptability among (n = 21) African American pregnant women, examining how determinants must be met for consumption. We administered surveys to identify preferred foods and analyzed the nutrient quantity of vitamin A, B vitamins, vitamin D, iodine, iron, calcium, magnesium, selenium, and omega-3 fatty acids in each food, given their influence on prenatal health. Nutrient-dense, anti-inflammatory foods were identified by ranking preferred foods by nutrients and selecting those that consistently ranked as top contributors. Focus groups further explored conditions that promote or hinder intake, and content analysis was conducted using NVivo. Preferred nutrient-dense, anti-inflammatory foods included cashews, peanuts, almonds, pistachios, black-eyed peas, pinto beans, salmon, carrots, red bell peppers, and spinach. Participants cited low acceptance due to allergies, undesirable textures (“dry” or “slimy”), unpleasant taste or appearance, a lack of cravings, preference for alternatives, unenjoyable preparation methods, and foods perceived as “display-only.” High acceptance was linked to appealing taste and texture, flexible preparation options, and perceived health benefits. These considerations suggest that taste, texture, appearance, and enjoyment are important considerations for prenatal food intake.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080953

Authors: Sus Sola Corazon Maria Stoltze Fray Gitte Saldern Schroeder Carina Wedell Andersen Stine Bekke-Hansen

Background/Objectives: Young adults living with advanced cancer often experience substantial psychological and existential health challenges, while frequently being underserved by existing rehabilitative and palliative services. This mixed-methods study evaluated the effects and experiences of a nature-based intervention designed to ease the burden of distress and support coping in the context of an incurable illness. Methods: Four consecutive intervention groups participated in a six-week program consisting of one overnight nature camp and three outdoor sessions. Quantitative data on quality of life (FACT-G) were collected before and after each intervention cycle. At the session level, pre–post measures assessed distress, vitality, resilience, and perceived connectedness. Qualitative data consisted of post-intervention semi-structured group interviews. Results: Twenty-four participants completed the intervention. No significant change was observed in overall quality of life which is in line with expectations for palliative interventions for individuals with incurable illness. In contrast, session-level analyses showed consistent reductions in distress and increases in vitality, resilience, and connectedness across multiple domains. The qualitative findings indicated that the intervention provided a supportive context for emotional regulation, coping, social belonging and existential orientation. Conclusions: Together, the findings support that nature-based rehabilitative palliation may offer meaningful support for young adults living with advanced cancer. The study underscores the importance of multi-level mixed-methods evaluation for capturing the value of palliative interventions where temporality and situational benefit constitute central outcomes.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080952

Authors: Leshata Winter Mokhwelepa Gsakani Olivia Sumbane

Family-centred approaches are being increasingly recognized as integral to inclusive mental health care. Although substantial evidence-based exists for specific interventions particularly family intervention for psychosis, there is no synthesis that maps how family-centred approaches are conceptualized, implemented, and linked to inclusivity across diagnoses, service contexts, and levels of evidence. Existing reviews are largely disorder-specific or outcome-focused and do not examine family-centred care as a system-level strategy for inclusive practice. This scoping review aimed to map and synthesize the existing literature on family-centred approaches used to promote inclusive mental health care for individuals with psychiatric disorders. This review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews and the PRISMA-ScR reporting guidelines. Searches were conducted in PubMed, PsycINFO, CINAHL, Scopus, Embase, and Web of Science for English-language empirical studies published between 2000 and 2025. Studies involving individuals with psychiatric disorders and any form of family-centred, family-focused, or family-inclusive approach were eligible. Data were charted and analyzed thematically to map intervention types, reported outcomes, and implementation influences; the review did not evaluate intervention effectiveness. Twenty-four studies met the inclusion criteria. Only five themes emerged from this study. Across the literature, family involvement was associated with improved engagement, enhanced communication, and increased caregiver competence. Psychoeducation featured prominently in evidence-based interventions, while newer models emphasized shared decision-making and service co-production. Family-centred approaches are conceptualized in diverse ways across mental health services and are commonly linked to more inclusive and collaborative care. However, the strength of evidence varies substantially between intervention types. This review clarified how family-centred practices are situated across levels of evidence and service contexts, highlighting the need for greater precision in distinguishing established interventions from emerging practices and for system-level strategies to support consistent, culturally responsive family inclusion.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080951

Authors: Siphelele Thamsanqa Ngubane Dumile Gumede

Community-based organisations (CBOs) play a critical role in implementing HIV programmes, many of which have historically relied on United States (U.S.) donor funding. Recent U.S. funding cuts have disrupted community-based HIV programmes, underscoring the need to understand implementers’ experiences to support sustainable service delivery. This study explored how funding instability affected community-based HIV programmes in rural KwaZulu-Natal, South Africa. A qualitative, exploratory design was employed using interviews and focus group discussions with purposively selected youth frontline workers and programme managers (n = 26). The Health Systems Building Blocks framework guided thematic analysis. Participants described disruptions in outreach and prevention services, contract terminations and reduced working hours among frontline personnel, weakened data and follow-up systems, shortages or reduced local availability of HIV prevention commodities, lack of transition planning, and abrupt program closure without sustainability measures. U.S. funding cuts disrupted essential community-based HIV services in rural KwaZulu-Natal, exposing vulnerabilities in prevention, outreach, workforce, and monitoring systems. Sustainable financing and stronger integration of community organisations into health systems are needed to protect HIV service continuity.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080949

Authors: Susan Gonya Julie Brunkhorst Michael Laviolette

Foodborne mycotoxins are toxic secondary metabolites produced by filamentous fungi. At sufficient concentrations, ingested mycotoxins have been found to disrupt the microbiome and exert toxic effects on gastrointestinal, hepatic, renal, and other tissues. Toddlers are particularly vulnerable to ill effects due to increased intake relative to lower body weight and immature detoxification, metabolic, and immune function. Despite this susceptibility, their adverse health effects remain under-recognized in public health sectors, and data on mycotoxin contamination in foods marketed to young children in North America remain sparse. To investigate this, 118 food products, including cereals, snacks, pasta, first foods, juices, and staple ingredients, were purchased at retail and analyzed for 34 mycotoxins using liquid chromatography–tandem mass spectrometry. The results were compared with the United States Food and Drug Administration (FDA) regulatory thresholds and European tolerable daily intake (TDI) limits. Of the 34 analytes, 32 were detected, and 25 were quantified. At least one mycotoxin was quantified in 87 percent of products, with a mean of 3.7 per item and a maximum of 13. Multi-toxin contamination was common; many products exceeded the FDA and TDI limits, and many remain unregulated. These findings highlight regulatory gaps in food safety and underscore the need for stronger child-focused oversight, particularly regarding emerging mycotoxins and multi-toxin contamination.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080950

Authors: Linh My Duong Nghia Quang Bui Lam Phuc Duong Ry Thi Khao Duong

Digital technologies are central to student life, but evidence is limited on whether digital-use scales can provide useful thresholds for identifying psychological distress among medical students. This single-center cross-sectional study analyzed complete data from 600 undergraduates at a medical university in southern Vietnam. Stress, depression, and anxiety symptoms were classified using the DASS-21, while problematic smartphone use, social media use, and gaming-related problems were assessed using the SABAS, BSMAS, and a six-item GAS adaptation, respectively. Receiver operating characteristic analyses and the Youden index were used to estimate discrimination and candidate cut-offs. Non-normal DASS-21 scores were observed for stress (30.4%), depression (37.8%), and anxiety (39.0%), predominantly within the mild range. For stress, the AUCs and cut-offs were 0.75 (95% CI 0.70–0.80; ≥23.5) for SABAS, 0.67 (0.62–0.71; ≥17.5) for BSMAS, and 0.64 (0.60–0.70; ≥15.5) for GAS. For depression, the corresponding values were 0.62 (0.57–0.66; ≥21.5), 0.68 (0.63–0.73; ≥18.5), and 0.60 (0.55–0.65; ≥14.5). For anxiety, they were 0.60 (0.55–0.64; ≥20.5), 0.62 (0.57–0.67; ≥17.5) and 0.55 (0.51–0.60; ≥15.5). Sensitivity was low across thresholds (35.0–59.0%). These candidate cut-offs showed modest discrimination and should be considered only as preliminary behavioral flags prompting validated mental health assessment, not as stand-alone screening or diagnostic criteria.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080948

Authors: Naphat Wuttaphan Hisako Matsuo Bovornpot Choompunuch

Fear of missing out (FOMO) has become an important digital mental health concern among Generation Z, a population highly engaged with social media and online interaction. This study examined the associations among digital intelligence, emotional intelligence, self-disclosure, and FOMO among Generation Z individuals in Thailand. A cross-sectional quantitative study was conducted from December 2025 to January 2026. Data were collected from 322 participants using self-administered questionnaires and analyzed using descriptive statistics and partial least squares structural equation modeling. The results showed that digital intelligence was positively associated with FOMO, whereas emotional intelligence and self-disclosure were not significantly associated with FOMO. Self-disclosure did not mediate the associations between emotional intelligence, digital intelligence, and FOMO. However, the measurement model showed acceptable internal consistency but limited convergent validity, as average variance extracted values were below the conventional threshold for all constructs. Therefore, the structural findings should be interpreted as preliminary and exploratory. The positive association between digital intelligence and FOMO may reflect greater exposure to online social activity, social comparison, or possible overlap between the constructs, rather than a harmful effect of digital intelligence itself. These findings contribute initial evidence from Thailand but should not be used alone to guide public health practice or policy. Future studies should refine the measurement instruments, examine individual dimensions of digital intelligence, and confirm the observed relationships using stronger psychometric and longitudinal designs.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080947

Authors: Carlo Maccheroni Roberta Pace Giuseppe Venere

This paper examines the geography of frail ageing in Italy by analysing how longevity, health conditions, non-self-sufficiency and assistance needs intersect across territories. Its distinctive contribution lies in moving beyond a purely demographic reading of population ageing, linking the extension of life to the quality of later-life survival and to the uneven territorial distribution of public assistance. Drawing on official data from Istat, Eurostat and INPS, this study adopts a regional comparative approach, with evidence disaggregated by sex, age group and macro-area. The analysis combines indicators of demographic structure, residual life expectancy at age 65, healthy life expectancy, severe limitations in daily activities, multimorbidity and assistance benefits. This framework makes it possible to distinguish between ageing as a numerical increase in the older population and ageing as a differentiated condition of vulnerability, dependency and welfare need. The findings show that Italy’s high longevity conceals marked territorial and gender inequalities. While the centre–north displays more favourable survival and health profiles, the south and the islands have higher levels of frailty, functional limitations and reliance on public assistance. Women appear to be particularly exposed to this imbalance, living longer but spending more years in conditions of disability and dependency.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080946

Authors: Luana Alves Silva Ana Clara de Brito Cintra Ivan Gustavo Masselli dos Reis

Exposure to physical inactivity (PI) may be a risk factor for the development of one or more noncommunicable chronic diseases (NCDs). The present study examined the prevalence of diabetes, hypertension, and obesity, as well as their various combinations, among the Brazilian population exposed to PI. A total of 323,448 Brazilian men and women aged 18 to 59 years from the 26 state capitals and the Federal District were contacted by telephone and answered questions regarding their physical activity (PA) and health conditions, including medical diagnoses of NCDs. Participants who reported not engaging in any type of PA at home, at work, during commuting, or during leisure time were assigned to the PI group, whereas the remaining participants comprised the control group. Physical inactivity was associated (p < 0.05) with a 16% and 28% higher prevalence of obesity among middle-aged female and male participants, respectively. It was also associated (p < 0.05) with a higher prevalence of combined diabetes and hypertension, diabetes and obesity, and hypertension and obesity, ranging from 49–273%, 60–113%, and 20–71%, respectively. Additionally, physical inactivity was associated (p < 0.05) with a 73–106% higher prevalence of the coexistence of diabetes, hypertension, and obesity.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080945

Authors: Adam Neufeld Savannah Roy

Mental health concerns are increasingly encountered in primary care, yet clinical approaches often focus on symptom management rather than underlying psychological processes. Self-Determination Theory (SDT) proposes that psychological well-being depends on the satisfaction of three basic psychological needs—autonomy, competence, and relatedness—while their chronic frustration contributes to psychological distress. Despite extensive evidence linking these needs to mental health outcomes, their relevance in primary care remains underexplored. This single-center cross-sectional study examined associations between psychological need satisfaction and frustration and indicators of well-being and ill-being among adult primary care patients. A total of 380 patients (Mage = 47.81, SDage = 15.42) completed validated measures of need satisfaction and frustration, resilience, vitality, coping strategies, anxiety, and depression. A dual-process model was examined, with hypotheses informed by SDT: higher need satisfaction associated with greater resilience, vitality, and adaptive coping (well-being), and higher need frustration associated with greater anxiety, depression, and maladaptive coping (ill-being). Although results revealed several significant cross-paths, need satisfaction was most strongly associated with positive outcomes and need frustration was most strongly associated with negative outcomes. The dual-process model did appear clear for coping outcomes, with need satisfaction uniquely predicting adaptive coping and need frustration uniquely predicting maladaptive coping. Findings highlight the potential value of incorporating psychological need-based perspectives into primary care mental health approaches. By recognizing autonomy, competence, and relatedness as foundational psychological resources, healthcare systems may develop more scalable strategies to promote mental well-being and prevent psychological distress in everyday clinical practice.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23080944

Authors: Wallace Pereira Silva Giovanna Camargo Mello Deborah Madeu Pereira Cid André Fidelis De Paula Gomes Carla Malaguti Luciana Maria Malosa Sampaio Soraia Micaela Silva

Telehealth has the potential to improve access to healthcare, but teleassessment usability may be influenced by contextual factors beyond technology access alone. This study investigated factors associated with teleassessment usability among individuals with interstitial lung disease (ILD) in Brazil using a convergent mixed methods design with 31 adults from four Brazilian regions. Usability was assessed with the Telehealth Usability Questionnaire (TUQ-Brazil); associations with contextual variables were examined using Spearman’s correlation. Qualitative data were obtained through semi-structured interviews and analyzed using thematic analysis. Participants generally reported acceptable usability perceptions with predominance of agreement responses; greater dispersion was observed for items related to equivalence with in-person care and video quality. Usability was significantly associated with income (rho = 0.437; p = 0.014), perceived clinical feasibility (rho = −0.397; p = 0.027), and perceived intensity of access barriers (rho = −0.428; p = 0.016). Qualitative findings identified financial constraints, digital literacy, internet stability, third-party support dependence, and absence of physical examination as key experiential factors. Teleassessment was perceived as a complement for follow-up and triage rather than a substitute for face-to-face assessment. Usability in ILD is shaped by socioeconomic, clinical, and structural factors, underscoring the need to address digital inequalities in telehealth implementation.