International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070843

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

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070842

Authors: Simone Ejstrup Niels-Peter Brøchner Nygaard Gert Frank Thomsen Inge Brosbøl Iversen David Høyrup Christiansen Bibi Gram

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070841

Authors: Joan Efua Edua Hanson Selassie Tagoh Ernest Korang Asamoah Susarah Maria Richter Michael Agyemang Kwarteng

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070840

Authors: Kelly Chacon-Acevedo Ana María Castillo John Alexander Castro-Muñoz Yonatan Ferney Rojas Andrea Bermudez-Rodriguez Ana María Rojas-Gómez

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070839

Authors: Bryson Carrier James W. Navalta

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070838

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

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070836

Authors: Alessandro Germani Antonella Lopez Claudia Mirenghi Manuela Nicoletta Di Masi Andrea Bosco

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070837

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

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070835

Authors: Gang Xu

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070834

Authors: Kelly L. L’Engle Julianna Sahoo Gwendolyn M. Hoff Anderson Elise Brown Lexi Nutkewicz

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070833

Authors: Lucrezia Tomberli Fausto Barlocco Annariina Koivu Jari Hyttinen Iacopo Olivotto Enrica Ciucci

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070832

Authors: Christiane Stock Ulrike Grittner Jennifer Lehnchen Zita Deptolla Julia Burian Katherina Heinrichs

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070831

Authors: Lisa K. Zottarelli Robyn Stassen Yejin Heo Madeline Navarrete Shamshad Khan Thankam Sunil Andrea Shields

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

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070830

Authors: Pedro Melo Renata Silva Flávio Vieira Susana Barbeitos Susana Figueiredo Sandra Silva

This study assessed community process and empowerment in a Primary Healthcare Island Unit in the Azores to support the implementation of Epidemiological Surveillance of Nursing Diagnoses (ESND), focusing on three priority areas: tobacco use, drug dependence, and adolescent decision-making related to sexuality and life planning. Strengthening the visibility of nursing-sensitive phenomena requires integrating nursing diagnoses into epidemiological surveillance systems. A multimethod descriptive study was conducted between September and November 2025, combining document analysis, a community empowerment assessment, and a structured questionnaire. The total population included 328 nurses, with 172 participants (response rate: 52.4%) using a non-probabilistic sampling approach. Data were analyzed using descriptive statistics (frequencies, percentages, means, and standard deviations). Priority nursing foci were identified according to the ICNP® 2019 classification: tobacco use, drug dependence, and decision-making process related to sexuality and life planning. Results showed that all three dimensions of the MAIEC were weak: community leadership was limited, particularly in knowledge indicators; participation was constrained by unclear organizational structures and insufficient communication; and coping capacity was insufficient due to limited training and experience. Empowerment assessment confirmed structural weaknesses in leadership, organizational support, and resource mobilization. Overall, the community process and empowerment profile indicate that the conditions required to sustain ESND are not yet sufficiently developed. Strengthening leadership, improving communication, and expanding training in ESND and ICNP® documentation are essential to support nurse-centered surveillance and enhance the visibility of nursing contributions to population health.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070829

Authors: Gabriel Souza-Silva Maria I. G. A. Silva Anna C. B. Miranda Mariângela Domingos Alcântara Cléssius R. Souza Micheline Rosa Silveira

Ketoprofen (KET) is a non-steroidal anti-inflammatory drug frequently detected in surface waters and effluents, with the potential to impact trophic base organisms. This study evaluated the toxicity of KET, in its active pharmaceutical ingredient (API) form and in four commercial formulations (KET-1, KET-2, KET-3, and KET-4), on two freshwater species: the cyanobacterium Microcystis novacekii and the microalga Chlorella vulgaris. Cell growth assays, performed under acute (4 days) and chronic (14 days) conditions, showed that the API KET was the most toxic compound, especially for M. novacekii, with a chronic EC50 of 1.35 mg/L. The commercial formulations presented distinct toxicity profiles, suggesting the influence of excipients and synergistic or antagonistic interactions. For C. vulgaris, low acute toxicity was observed, with increased chronic effects at high concentrations and possible hormetic response at low doses. Risk quotient (RQ) calculations, based on environmental concentrations of KET, indicated low risk in surface and drinking water, but high risk in untreated hospital and wastewater treatment plant effluents, especially for M. novacekii. The results show that the complete formulation, exposure time, and target species are critical factors in the ecotoxicological risk assessment of pharmaceuticals in freshwater environments.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070828

Authors: Franziska Zecha Lena-Marie Hupperich Tobias Viere

Life cycle assessment is increasingly applied in healthcare, yet the healthcare-specific standardisation landscape and its relation to current practice remain unclear. This study maps existing frameworks and analyses their alignment with published healthcare LCA to identify standardisation gaps. Healthcare-specific standards and product category rules were identified through grey literature searches. Published healthcare LCA studies were quantitatively analysed and compared with the identified frameworks to assess methodological convergence and divergence. Six healthcare-specific frameworks were identified: five address medical products, one addresses services, and none cover organisational assessment. Product-level applications showed strong alignment in structural modelling elements including system boundaries and life cycle stages, while substantial heterogeneity persisted in functional unit definitions and impact assessment approaches. Service and organisational assessments showed broader variability in modelling approaches, functional units, and system boundary conceptualisations, indicating distinct modelling logics of healthcare delivery across assessment levels. Healthcare LCA practice is consistent with ISO-based principles but lacks a shared conceptual modelling logic for healthcare delivery systems. Rather than reflecting a single methodological paradigm, healthcare LCA combines product-, intervention-, pathway-, and organisational-oriented approaches. Standardisation efforts should therefore focus not only on harmonising calculation methods but also on developing healthcare-specific modelling conventions for products, services, and organisational structures.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070827

Authors: Onyedikachi Uchechi Bliss Edene Osemudiamen Anao Paul Promise Chibuike Ugorji Chizoba Agatha Peter Chinedu Agu Emmanuel Anuoluwapo Oke

Slaughterhouse wastewater introduces potentially toxic elements into aquatic ecosystems, yet bioaccumulation patterns in commercial fish species and associated human health risks remain underexplored in West Africa. This study quantified zinc (Zn), lead (Pb), iron (Fe), magnesium (Mg), chromium (Cr), and cadmium (Cd) in three ecologically distinct fish species—Oreochromis niloticus (Nile tilapia), Clarias gariepinus (African sharptooth catfish), and Mugil cephalus (Flathead grey mullet)—from two slaughterhouse-impacted rivers (Transamadi and Mgbuosimini) and a control site (Iwofe) in Rivers State, Nigeria. Metal concentrations were measured using atomic absorption spectrophotometry. Two-way ANOVA assessed species and location effects. Principal component analysis (PCA) was performed, with Mg used as a potential geogenic tracer, as its loading pattern was independent of Pb and Cd and consistent with the natural background. A Water Quality Index (WQI) classified Mgboshimini and Iwofe as having poor water quality (WQI > 75), while Transamadi had medium quality. Health risks were evaluated using estimated daily intake (EDI), target hazard quotients (THQ), and hazard indices (HI) following USEPA guidelines. Metal levels varied significantly by species and location (p < 0.001). Flathead grey mullet from Mgbuosimini had the highest Pb (1.50 ± 0.05 mg/kg) and Cd (0.41 ± 0.02 mg/kg), exceeding EU maximum levels for fish muscle (Pb 0.30 mg/kg, Cd 0.05 mg/kg) by 500% and 800%, respectively. PCA explained 77.5% of the variance, with Pb and Cd clustering as anthropogenic sources, while Mg loaded independently. THQ for Pb approached unity in Flathead grey mullet (0.88), and THQ for Cd reached 0.97. HI exceeded 1.0 in all species from Mgbuosimini, peaking at 2.07 in Flathead grey mullet. Uncertainty analysis (using ±SD) gave a HI range of 1.89–2.25 for this species, all above the safety threshold. Carcinogenic risk for Flathead grey mullet (3.97 × 10−4) approached the upper acceptable limit. Slaughterhouse effluent appears to elevate Pb and Cd burdens in fish, with detritivorous Flathead grey mullet posing the highest health risk. Exceedance of safety thresholds and HI > 1.0 indicate potential non-carcinogenic and carcinogenic risks. We recommend improved wastewater treatment and species-specific consumption advisories.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070826

Authors: Potjana Jitjamnong Chakkrit Ponrachom Nannapat Ketkosan

Low health literacy is associated with risky alcohol use among young people, particularly those exposed to social and environmental factors that normalize drinking. In digital contexts, innovative and engaging interventions are needed to strengthen alcohol-preventive competencies among hazardous drinkers. This study evaluated the effectiveness of an online health literacy promotion program integrating artificial intelligence (AI) and gamification in improving health literacy and alcohol-preventive behaviors among hazardous-drinking vocational students. A quasi-experimental two-group pre-test–post-test design with a 1-month follow-up was conducted among 114 first-year Higher Vocational Certificate students aged 18–20 years in Bangkok, Thailand. Participants were assigned to an intervention group (n = 57) or a comparison group (n = 57). The intervention group received the ALC Literacy Program, while the comparison group received standard educational materials on alcohol prevention. Data were analyzed using descriptive statistics, chi-square tests, independent t-tests, and two-way mixed-design repeated-measures ANOVA with Bonferroni post hoc comparisons. At baseline, no significant between-group differences were observed. After the intervention and at 1-month follow-up, the intervention group showed significantly greater improvements in both health literacy and alcohol-preventive behaviors than the comparison group (p < 0.001). Large interaction effect sizes were observed for health literacy (partial η2 = 0.623) and alcohol-preventive behaviors (partial η2 = 0.622). These findings indicate that the ALC Literacy Program was effective in enhancing health literacy and strengthening alcohol-preventive behaviors among hazardous-drinking vocational students. This intervention may represent a potentially useful digital health promotion approach for alcohol prevention in educational settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070825

Authors: Lei Chen Joanne Spetz

During the COVID-19 pandemic, family support for older adults living with disabilities was disrupted due to “Shelter-in-Place (SIP)” orders. This study examined the impact of SIP policies on caregiving changes for people with disabilities who were not married. We used the National Health and Aging Trends Survey (NHATS) round 10 data and previously published data regarding SIP policies. The study sample included NHATS community-dwelling respondents who needed assistance with activities of daily living (ADLs) or instrumental activities of daily living (IADLs) and who were not married (n = 512). More than half of people (55.1%) reported no change in receiving help, approximately one-third (36.7%) reported receiving less help, and 8.2% reported receiving more help during COVID-19 than before. Compared with people who lived in areas that had fewer than 30%, people living in areas with 30–59% and with 60% or more of SIP days had 12 percentage points lower probability of reporting they received more help during COVID-19 (p = 0.02 for 30–59% and p = 0.03 for ≥60%). It is crucial to address caregiving needs during public health emergencies and to examine how policy disruptions impact support for individuals reliant on family assistance.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070824

Authors: Roshanak Mehdipanah Leanna Delhey Fatema Shafie Khorassani Sehee Kim Xu Shi Lewis B. Morgenstern Erin Case Lynda D. Lisabeth

Limited research on the impacts of housing conditions on post-stroke outcomes exists, particularly in minoritized neighborhoods that face greater housing disparities than non-Hispanic White neighborhoods. This is largely due to the unavailability of data that combines residential conditions and post-stroke outcomes in diverse communities. This brief report explored whether neighborhood housing values, a proxy of housing conditions, mediate the association between neighborhood ethnic composition (%Hispanic) and post-stroke outcomes in Nueces County, a bi-ethnic community in south Texas. Linear regression models were used to assess associations adjusted for socio-demographics, pre-stroke factors and stroke severity. A total of 782 ischemic stroke cases in 78 neighborhoods were included. Greater %Hispanic was associated with worse post-stroke outcomes and lower housing values. Higher housing values did not change the association between %Hispanic and post-stroke outcomes. Future studies should consider including individual-level data on housing conditions and the capacity to make modifications in research related to post-stroke recovery.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070823

Authors: Nia Imani Bailey Jenna Bucolo Katelyn Bucolo Brittnee Cannon Samuel Elenwo Monique Gary Trudean Haye Rebecca Kusters

Cancer incidence among adolescents is increasing, yet cancer risk reduction education remains largely absent from school-based curricula. This pilot study assessed whether a small-scale early, developmentally appropriate intervention could improve cancer literacy to support long-term risk reduction. This pilot study used a convergent parallel mixed-methods pre–post design to evaluate two separate, 45 min, school-based cancer education interventions delivered to 24 middle-school students in Pennsylvania. The intervention delivered developmentally appropriate content on cancer biology, modifiable risk factors, genetics, HPV vaccination, and self-advocacy using a low-resource, low-investment model easy for schools to implement. Pre- and post-intervention surveys assessed student knowledge, awareness, and health-related perceptions. Survey data were analyzed both descriptively using frequencies and percentages and thematically. Post-intervention results demonstrated substantial improvements across all domains. Correct definition of cancer increased from 16% to 100%. Awareness of modifiable risk factors increased to 96%, sunscreen knowledge to 90%, genetic testing awareness to 83%, and HPV vaccine understanding from 21% to 57%. Students also reported increased confidence in recognizing symptoms and engaging in health-seeking behaviors. Findings suggest that small-scale, school-based cancer education interventions are feasible and effective in improving adolescent cancer literacy. These results support the need for larger, controlled studies to evaluate long-term knowledge retention and behavioral outcomes.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23070822

Authors: Xuewei Chen Emily Roberts

Rural adolescents face persistent health inequities driven by limited access to preventive health education, intergenerational engagement, and resources that support lifelong wellness. This study evaluated the effectiveness of Active Aging for L.I.F.E., a school-based intergenerational health literacy program, in improving adolescents’ attitudes toward aging and health. The four-session program, delivered through a train-the-trainer model involving older adults and undergraduate students, was implemented in three rural schools during the 2024–2025 academic year. A total of 86 junior high and high school students participated, with 77 completing pre- and post-program surveys assessing attitudes toward aging, health consciousness, and intergenerational engagement. Paired t-tests and multiple regression analyses examined overall program effects and differences by sex/gender and age group. Students demonstrated significant improvements in aging attitudes, perceived relevance of aging topics, enjoyment of intergenerational interaction, and awareness of health-promoting behaviors across the lifespan. Several baseline sex/gender and age-based gaps in health-related perceptions were reduced following participation, with stronger future-oriented attitude shifts observed among younger adolescents. These findings suggest that brief, scalable intergenerational interventions embedded in rural school settings can support early prevention, health literacy, and community capacity building, offering a promising strategy for advancing rural public health outcomes across the life course.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060821

Authors: Elvis Kichana Solomon A. Minyila Braimah Apambire Collins Gbeti Abukari Wumbei Fati Alhassan

Background: Access to safe drinking water remains a critical public health concern in rural Ghana, particularly in climatically vulnerable and underserved settings. This study assessed the microbiological and chemical quality of drinking water and evaluated nitrate-related health risks in the North Gonja and North-East Gonja Districts of the Savannah Region. Methods: A cross-sectional study was conducted between January and March 2025. A total of 460 water samples were collected from groundwater sources and household storage containers. Microbial analyses targeted total coliforms and Escherichia coli. Physicochemical and chemical parameters included nitrate-nitrogen, pH, residual chlorine, major ions, and trace metals. Data was analyzed using descriptive statistics, chi-square tests, spatial interpolation, and non-carcinogenic health risk assessment based on the hazard quotient (HQ) approach. Results: Widespread microbial contamination was observed, with 91.5% of household water samples positive for total coliforms and 46.6% for E. coli. Contamination of source water was significantly higher in North Gonja than in North-East Gonja. Overall, 49.1% (n = 55) of groundwater sources exceeded the World Health Organization guideline value for nitrate-nitrogen, with exceedances predominantly occurring in North Gonja. Additionally, 67.0% (n = 75) of samples were outside the acceptable pH range (6.5–8.5), including 74 samples below 6.5 and one above 8.5. Residual chlorine was not detected in any of the samples. Health risk assessment indicated potential non-carcinogenic risks associated with nitrate exposure, particularly among infants and children. Conclusions: The study demonstrates significant microbial contamination and nitrate-related health risks in the study area, particularly in North Gonja. Interventions such as improved source protection, routine water quality monitoring, chlorination, household water treatment, and implementation of Water Safety Plans are recommended to enhance drinking water safety and reduce associated public health risks.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060820

Authors: Piotr Gabryjończyk Anna Jęczmyk Monika Wojcieszak-Zbierska Jarosław Uglis Jan Zawadka

This study aims to empirically analyze the patterns, intensity, and perceived barriers to physical activity among Polish university students during the COVID-19 pandemic. The research utilized a diagnostic survey method, employing a questionnaire. The online survey was conducted from December 2020 to May 2022 via the Webankieta.pl platform. The minimum sample size, calculated using the standard formula for estimating a proportion in a large population, was set at 1100 participants and was exceeded, with 1260 students providing valid responses. The results show that over half (55.8%, mainly women) of the respondents did not participate in regular physical activity during the pandemic. Participants cited lack of desire, fatigue, and low motivation—not pandemic restrictions—as primary reasons. Conversely, 44.2% of respondents, mostly men, reported engaging in regular physical activity. Most engaged in moderate-intensity activities two to five times a week, with vigorous activities performed slightly less often. Women were more likely to do both types, while men favored strength training. The most common activities included walking (61.6%), simple gymnastic exercises (43.1%), strength training with equipment (35.0%), cycling (34.5%), and calisthenics (30.2%). The majority (81.3%) exercised at home or nearby (33.4%). Reported barriers, especially among those who exercised regularly, were pandemic-related, such as limited or closed access to gyms, fitness centers, and pools (59.1%), along with time constraints (44.7%) and low motivation or determination (32.0%). The findings emphasize the importance of targeted interventions to boost physical activity among university students, particularly women and those with fewer financial resources. Universities should consider implementing programs that promote accessible, regular activity and initiatives to enhance motivation and foster long-term, health-promoting habits.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060819

Authors: Naina Sharma Bastakoti Stephanie L. Richards Avian White Jo Anne Balanay

Mosquito control personnel work within health departments, public works, private companies, and other agencies. These essential outdoor workers have highly specialized training and are faced with a variety of potential health and safety hazards (e.g., arthropod bites and stings, exposure to insecticides and other chemicals, working with heavy equipment, noise, heat, solar ultraviolet radiation, slips, trips, and/or falls). Mosquito control personnel undergo employer-provided and other types of training on a variety of topics from regulatory updates to new surveillance and control techniques that are required for safety purposes and to maintain their applicator license. Here, an exploratory baseline survey was conducted among members of the North Carolina Mosquito and Vector Control Association (NCMVCA) and the Virginia Mosquito Control Association (VMCA). There was a 28% response rate so results should be interpreted with caution in this pilot study. Most respondents reported utilizing ultra-low volume insecticide application equipment for controlling adult mosquitoes. Backpack sprayers were utilized by less than half of respondents. Those who reported using respirators showed higher concern about insecticide-related health effects than those who did not use respirators. Outdoor workers encounter various potential hazards and utilize several forms of personal protective equipment to reduce risks. This baseline work can be considered a starting point for implementing and strengthening occupational safety and health awareness and preventive measures for mosquito control workers. Knowledge of health and safety hazards can reduce workplace risk.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060818

Authors: Daisuke Takahara Misuzu Takahara Noudéhouénou Credo Adelphe Ahissou Daisuke Nonaka

The growing prevalence of gaming disorder (GD) in adolescents is a global concern. Despite parents’ critical role in addressing GD, how dysfunctional parenting practices are associated with adolescent GD remains understudied. This study assessed the association between dysfunctional parenting practices and adolescent GD among Japanese male junior high school students. Data were collected in 2024 via web-based, self-administered questionnaires from 300 parents (183 fathers and 117 mothers), each reporting on one male junior high school student. Suspected GD was assessed using a validated parent report measure (i.e., the Gaming Disorder Scale for Parents). Dysfunctional parenting practices were measured using the Parenting Scale, comprising two dimensions: Overreactivity and Laxness. Mean factor scores of Overreactivity and Laxness were compared between the suspected and non-suspected GD groups using a t-test. Logistic regression models assessed the association of Overreactivity and Laxness with suspected GD, controlling for covariates. The mean score of Overreactivity was significantly higher in the suspected GD group than in the non-suspected group, whereas that of Laxness was not. After adjustment, overreactive parenting was significantly associated with suspected GD (adjusted odds ratio: 1.89, 95% CI [1.31, 2.74]). This study showed that overreactive parenting was independently and significantly associated with increased odds of suspected GD.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060817

Authors: Jenny K. Cohen Kara Zamora-Rogoski Caitlin L. McLean Mariam E. Jacob Evana Mack Haley Moss Aimee Kroll-Desrosiers

Within the Veteran’s Health Administration (VHA), peer support specialists (PSSs) have traditionally worked in mental health and behavioral health settings. PSS-facilitated cancer support groups are less common and underused in this setting. The purpose of this study was to understand the acceptability, feasibility, and perceived benefits of a PSS-facilitated peer support group for women veterans with breast cancer. Semi-structured interviews were conducted among veteran participants and health system leaders (HSLs) and were recorded, transcribed, and analyzed using rapid qualitative analysis. Key findings from interviews with veterans and HSLs emerged across several domains: The value of shared experiences, peer status and “matching”, virtual aspect, group structure, beneficial topics, and desired outcomes. Veteran participants greatly valued the ability to share experiences and connect with other women veterans with breast cancer and shared a desire for the facilitator to be a peer with an overlapping shared lived experience as they described benefits from peer interactions including supportive coping and instrumental coping. Veterans also reflected on the acceptability of the group being virtual, and uncovered attitudes and preferences regarding group structure, beneficial topics, and desired outcomes. HSLs noted that target outcomes might be linked to feeling connected with community and having an increased feeling of support. Findings suggest that cancer support groups, unlike more traditional mental health support groups at the VHA, may require greater specificity regarding programmatic content and PSS-cancer-experience-matching for group experience to feel authentic and meaningful.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060816

Authors: Celestin Banamwana David Musoke Theoneste Ntakirutimana Esther Buregyeya John Ssempebwa Gakenia Wamuyu Maina Charles Drago Kato Lordrick Alinaitwe Patrick Albert Ipola Nazarius Mbona Tumwesigye

Reuse of human excreta and derivatives is becoming a common practice in areas with agricultural predominance. While in situ treated faeces through ecological sanitation (Ecosan), known as “faecal by-products” are being used to sustain soil nutrients and improve on-site sanitation, the concern remains about the health risks related to the survival of pathogens in these by-products in the community of farmers. This study assessed the survival of faecal pathogens and estimated microbial risks associated with the use of Ecosan faecal by-products in agriculture. The quantitative microbial risks assessment (QMRA) framework was used to estimate the risks posed by each faecal pathogen in solid and semi-solid faecal by-products under the probabilistic model of Monte Carlo simulation. Ascaris lumbricoides (6.5 eggs/gr), Taenia species (0.3 egg/gr), Schistosoma species (9.3 cercariae/gr), Entamoeba species (4.4 cysts/gr), and Escherichia coli (451 Cfu/gr) were detected in semi-solid faecal products. Exposure scenarios were observed throughout four critical points: vault faecal by-products removal/unloading, transport, collection, and application of faecal by-products in the gardens. Due to the presence of eggs and cysts, an estimated annual risk of infections was found in semi-solid faecal by-products with Schistosoma species (88%) and Ascaris lumbricoides (90%). Both concentrations were above World Health organisation (WHO) standards of associated infective risks of 0–10% of helminths in faecal sludge applied in the gardens. The users of faecal by-products, particularly farmers are exposed not only to high concentrations of helminth eggs but also to protozoa and bacteria with infective risks of Entamoeba species (99%) and E. coli species (62%). A stepwise implementation of faecal pathogens die-off during treatment of faecal by-products in compliance with the WHO’s 2018 guidelines can prevent the use of unsanitary faecal by-products. According to these findings, the proper control of intestinal protozoa and soil-transmitted helminths (STHs) should be enforced through personal protective measures in Burera district, Rwanda.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060815

Authors: Uraiporn Booranasuksakul Mario Siervo Alongkote Singhato Narisa Rueangsri Tepparit Samrit Wichukorn Suriyawongpaisal Piyapong Prasertsri

Background: Nutritional biomarkers are linked to body composition changes, but limited evidence has studied how nutritional biomarkers relate to low muscle mass, excess adiposity, and both coexisting conditions across different physical activity levels. This study aims to investigate associations between low muscle mass, obesity, and low muscle mass with obesity and nutritional biomarkers across physical activity levels among U.S. adults across physical activity levels. Methods: This cross-sectional study analyzed data from adults aged 20–59 years from the 2015–2018 cycles of the National Health and Nutrition Examination Survey (NHANES) 2015–2018. Low muscle mass was defined by low appendicular lean mass relative to body weight (LALM/W). Obesity was classified using body mass index (BMI1), waist circumference (WC2), and body fat percentage (FM%3), and low muscle mass with obesity was defined using three coexisting phenotypes (LALM/W-O1, LALM/W-O2, LALM/W-O3). Nutritional biomarkers included serum albumin, vitamin D, triglyceride, cholesterol, LDL cholesterol, iron, insulin resistance (HOMA IR), and high-sensitivity C-reactive protein (hs-CRP). Physical activity was categorized as inactive, insufficiently active, or sufficiently active based on MET minutes per week. Multivariable regression models accounted for the complex survey design and relevant covariates. Results: After adjustment, LALM/W was significantly associated with low serum albumin, low vitamin D, high triglyceride, high HOMA-IR, and high CRP. Obesity was significantly associated with low serum albumin, low vitamin D, high triglyceride, high LDL cholesterol, high HOMA-IR, and high CRP. LALM/W-O in all phenotypes were significantly associated with low serum albumin, low vitamin D, high triglyceride, high LDL cholesterol, high HOMA-IR, and high CRP. LALM/W-O phenotypes demonstrated the strongest associations, particularly with high HOMA-IR and hs-CRP. Although the associations varied by physical activity level, sufficiently active group was associated with lower odds of adverse nutritional biomarkers compared with insufficient activity. Conclusions: Nutritional biomarkers are associated with LALM/W and obesity. Sufficient physical activity was associated with fewer adverse outcomes. This suggests that adequate physical activity may be associated with better nutritional status and body composition.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060814

Authors: José Adevalton Feitosa Gomes Anthony Rodrigues de Vasconcelos José Roberto Andrade do Nascimento Júnior Ysadora Verena Ribeiro de Souza Fabiana Oliveira dos Santos Camatari Bruno Bavaresco Gambassi Manoel da Cunha Costa Paulo Adriano Schwingel Jorge Luiz de Brito Gomes

Adults with type 1 diabetes mellitus (T1DM) face elevated cardiovascular risk, and regular exercise is a key non-pharmacological mitigation strategy. However, safe prescription requires cardiovascular and glycemic monitoring, often unfeasible in real-world gyms. Low-cost psychophysiological tools (ratings of perceived exertion—RPE and enjoyment) may offer practical alternatives. This exploratory randomized crossover trial examined whether post-session RPE and enjoyment are associated with acute heart rate (HR) and capillary blood glucose (BG) responses to gym-based aerobic and resistance training. Twelve adults with T1DM (29.8 ± 7.8 years; HbA1c 7.7 ± 1.6%; LDL-c 119.5 ± 24.4 mg/dL) completed three ~30 min sessions: aerobic interval training (AE) and two resistance protocols (STA, STB). HR and BG were measured pre-, immediately post-, and 20 min post-exercise; RPE and enjoyment, post-session. Multiple linear regression, controlling for exercise session type, examined associations of RPE and enjoyment with resting HR, BG, and percentage of heart rate reserve (%HR). RPE was higher after STA and STB than AE (p < 0.001; η2p = 0.529), while enjoyment and %HR were similar across sessions. Neither variable was associated with resting HR or BG (all adjusted R2 < 0; all p > 0.05). Controlling for exercise session type, RPE was a significant positive predictor of %HR (β = 0.44, p = 0.044), whereas enjoyment was not (β = −0.06, p = 0.719); however, the overall %HR model did not reach statistical significance (adjusted R2 =0.119; F(4,31) = 2.183; p = 0.094). These exploratory findings suggest that RPE, but not enjoyment, may serve as a low-cost adjunct intensity marker to inform exercise prescription in adults with T1DM at elevated cardiovascular risk; however, replication in larger samples is needed before clinical recommendations can be drawn. Direct BG monitoring remains essential for safety.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060813

Authors: Najibah Galadanci Calia Torres Terrika Johnson Julie Kanter

Data in sickle cell disease (SCD) shows that 30–50% of adults have chronic pain. Chronic pain is a life-shaping condition that is often inadequately managed with chronic opioid therapy (COT). Buprenorphine–naloxone (bup-nal) is an alternative (to COT), yet patient perspectives on its use remain limited. This is a phenomenological qualitative study exploring how adults with SCD experience chronic pain and consider treatment options including COT and bup-nal. Semi-structured interviews were conducted with 26 adults with SCD and chronic pain who were offered pain management with bup-nal, including individuals who declined or discontinued treatment. Participants described pain as a constant, embodied experience around which they structured their daily functioning, relationships, well-being, and treatment. Those receiving bup-nal consistently reported improved daily functioning, greater independence, enhanced mood, and reduced healthcare utilization. In contrast, participants not receiving bup-nal described ongoing pain interference, reduced daily functioning, and continued reliance on acute care services. Importantly, participants emphasized functional improvement and stability, rather than pain elimination, as the most meaningful outcomes. These findings suggest that buprenorphine–naloxone may shift pain from a dominant, disabling experience to a more manageable condition that improves participation in work, relationships, and daily activities. To optimize management of chronic pain in SCD, it is necessary to align treatment with patient priorities.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060812

Authors: Thaís Borges Evellyn Grilo Thais Alves Cunha Luana Lima Karina Vermeulen-Serpa Mário Dourado-Júnior Marília Lopes Núbia Torres Breno Bezerra José Brandão-Neto Sancha Vale

Individuals with Duchenne muscular dystrophy (DMD) are prone to nutritional imbalances, and zinc deficiency may contribute to impaired bone health. This study evaluated serum zinc status and the effects of oral supplementation on bone parameters in DMD. In this quasi-experimental before-and-after study, 34 patients were assessed at three time points over eight months. Eligible participants who met the inclusion criteria and agreed to participate received the proposed interventions during routine follow-up at the Neurology outpatient clinic. Anthropometry, dietary intake, bone mineral density (BMD), bone mineral content (BMC), and serum zinc were measured; supplementation (5–15 mg/day) was provided for four months. Baseline zinc deficiency was observed in 36.7% of participants. No significant overall changes were detected. Stratified analyses revealed a modest increase in total body BMD among individuals with adequate baseline BMD (p = 0.02). As this finding emerged from a subgroup analysis, it should be interpreted cautiously, and the potential contribution of physiological growth to the observed change cannot be excluded. In addition, zinc-deficient participants showed a significant rise in serum zinc levels (p = 0.008). These findings suggest that the response to zinc supplementation may vary according to baseline nutritional and skeletal status and underscore the relevance of micronutrient monitoring in individuals with DMD. Trial registration: The trial was also registered in the Brazilian Registry of Clinical Trials under the code RBR-7cfdxm, approved on 14 June 2018.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060811

Authors: Leily Montoya-Alvarez Edgar Rodriguez-Sepúlveda Claudia Galeano-Páez Osnamir Elias Bru-Cordero Noelba Alcala-Tafur

Type 2 diabetes mellitus (T2DM) represents a growing public health concern in Indigenous populations, where early risk identification remains limited. This study aimed to analyze the association between estimated T2DM risk and cardiorespiratory endurance in a Zenú Indigenous community in northern Colombia. A cross-sectional study was conducted among adults aged 18–70 years belonging to the Momil Urban Minor Indigenous Cabildo (Córdoba, Colombia). T2DM risk was assessed using the Finnish Diabetes Risk Score (FINDRISC), and cardiorespiratory endurance was evaluated through the Ruffier index. Associations were examined using a multivariable ordinal logistic regression model, and discriminative performance was evaluated using receiver operating characteristic (ROC) curve analysis. A total of 95 participants were included, most of whom were classified as low risk according to FINDRISC, while cardiorespiratory endurance assessed by the Ruffier index was predominantly classified as moderate to good. Age was significantly associated with higher risk categories in the adjusted model, whereas cardiorespiratory endurance was not significantly associated with estimated T2DM risk. The model demonstrated excellent discriminative capacity (AUC = 0.912; 95% CI: 0.850–0.973). In this population, age and family history were key determinants of estimated T2DM risk. Findings regarding cardiorespiratory endurance should be interpreted cautiously given sample size limitations.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060810

Authors: Sigit D. Arifwidodo Nattanon Ubontip Natsiporn Sangyuan Orana Chandrasiri Panitat Ratanawichit Putthipanya Rueangsom

Background. First-mile walking to mass rapid transit (MRT) has two methodological problems. Composite walkability scores blur which features drive walking. And because walking to transit is itself transport physical activity (PA), linking it to total PA is circular. Both issues are sharper in tropical Asian cities. Methods. We surveyed 378 adults within a 1 km network distance of 20 stations on Bangkok’s Pink Line MRT. Walkability was measured with NEWS-A (aggregate and eight subscales); PA with the GPAQ. Binary logistic regression with station-cluster-robust standard errors tested which NEWS-A subscales predict first-mile walking and whether walkers meet the WHO PA guideline (≥150 min/week MVPA). A tautology sensitivity test removed transport PA from the outcome. Results. Walkers were 71.7% of the sample. Disaggregating NEWS-A improved fit; two subscales were the dominant predictors: pedestrian infrastructure and traffic safety. Walkers were 30.6 percentage points more likely to meet the overall PA guideline; with transport PA removed, the gap was 17.5 points and still significant. The pedestrian infrastructure effect was strongest 201–1000 m from a station, not at the immediate frontage. Conclusions. Perceived pedestrian infrastructure quality and perceived traffic safety drive first-mile walking in suburban Bangkok. The walking–PA link is not entirely a measurement artefact. The 201–1000 m ring is a plausible priority for pedestrian investment.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060809

Authors: Reberth Magalhães Da Silva Ariane Viana Fernanda Monma Fernando Alves Santa Rosa José Robertto Zaffalon Kátia De Angelis

Sex differences and lifestyle factors such as physical activity play an important role in cardiovascular autonomic regulation. Heart rate variability (HRV) is a widely used marker of cardiac autonomic modulation and cardiovascular health. However, the combined influence of sex and physical activity levels on HRV in young, healthy adults has not been sufficiently explored. Therefore, this study investigated the effects of sex and a physically active lifestyle on HRV in men and women. A cross-sectional study was conducted on a cohort of young, healthy adults aged 18–30 and categorized into four groups based on: physically active men (AM; n = 37), sedentary men (SM; n = 44), and physically active women (AW; n = 31) and sedentary women (SW; n = 40). Regarding the impact of lifestyle, the AM group exhibited 41% higher total variance (VAR-RR) and 34% higher RMSSD (a parasympathetic index) than the SM group. The AW exhibited 74% and 78% higher VAR-RR and RMSSD, respectively, compared to the SW. Furthermore, the physically active groups (AM and AW) displayed a 75% and 50% lower LF/HF ratio, respectively, compared to their sedentary counterparts. Interestingly, the LF/HF ratio was 66% higher, and the RMSSD was 20% lower in the AM group than in the AW group. HRV indices demonstrated large to very large effect sizes. In conclusion, these findings demonstrate significantly advantage in cardiac autonomic modulation among physically active individuals and women. Together, these results reinforce the roles of female sex and an active lifestyle as important protective factors for cardiovascular health.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060808

Authors: Masilu Daniel Masekameni Joinet Sitapata Phoka Caphus Rathebe Themba Titus Sigudu

Male circumcision (MC) has been shown in studies from South Africa, Kenya, and Uganda to reduce heterosexual Human Immunodeficiency Virus (HIV) transmission among men by approximately 50–60%. Despite Namibia’s adoption of voluntary medical male circumcision (VMMC) as part of national HIV prevention strategies, uptake remains suboptimal in some communities. This study assessed the knowledge, attitudes, and perceptions (KAP) of male circumcision among men aged 20–40 years in Otjiwarongo, Namibia, and examined socio-demographic factors associated with these outcomes. A community-based cross-sectional survey was conducted between March and May 2024, involving 359 participants selected through multistage sampling. Data were collected using structured, pre-tested questionnaires and analysed using STATA version 19. Descriptive statistics, chi-square tests, and binary logistic regression were used to summarise data and identify predictors of favourable KAP outcomes. Overall, 69.1% of respondents demonstrated good knowledge of male circumcision, 72.7% had positive attitudes, and 69.9% reported positive perceptions. Awareness of male circumcision was high (91.9%); however, only 69.4% of participants recognised its role in reducing HIV infection risk, and notable misconceptions persisted regarding its protective effects and procedural aspects. Multivariable analysis showed that urban residence (AOR = 1.58; 95% CI: 1.03–2.42; p = 0.035) and higher education (AOR = 4.12; 95% CI: 1.21–14.02; p = 0.024) were significant predictors of favourable KAP outcomes. In addition, good knowledge was strongly associated with positive attitudes (AOR = 3.25; 95% CI: 2.01–5.26; p < 0.001) and perceptions (AOR = 2.87; 95% CI: 1.79–4.60; p < 0.001). In conclusion, while knowledge, attitudes, and perceptions towards male circumcision were generally favourable, important gaps and misconceptions remain. Targeted, culturally appropriate health education interventions are needed, particularly among rural and less-educated populations, to improve understanding and acceptance of VMMC as part of comprehensive HIV prevention strategies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060807

Authors: Soraia Poloni Laura de Azevedo Pesce Viviane de Cássia Kanufre Lilia Ramos Farret Camila Pugliese José Araújo de Oliveira Silva Monique Poubel Maria Efigênia de Queiroz Leite Renata Bernardes de Oliveira

Aim: To evaluate the status of the nutritional management of diet-treated IEM in Brazil from the perspectives of healthcare professionals, patients, and families. Methods: Data were collected through two nationwide digital questionnaires administered to healthcare professionals involved in dietary management (n = 37) and to patients and caregivers (n = 278), addressing professional training, workload, access to resources, treatment adherence, and socioeconomic factors. Results: Healthcare professionals from 20 out of the 26 Brazilian states participated, most of them female (81%) and dietitians (81%). Although more than half had over 10 years of experience, 59% considered their training insufficient to work with IEM. Only 19% reported exclusive dedication to the field, and 54% were the sole professional responsible for dietary prescriptions at their center. Weekly workload dedicated to IEM varied widely. Among the patients and families, phenylketonuria (60.4%) and glycogen storage disease (25.9%) were the most frequent conditions. Higher educational level and longer time since diagnosis were associated with a better understanding of dietary management (p < 0.05). Among patients on protein-restricted diets, most reported regular use of protein substitutes, although 92% reported poor palatability and 36% reported supply problems. Access to special low-protein foods was limited, and over half of the families reported some level of food insecurity. Conclusions: Significant systemic, logistical, and socioeconomic barriers to optimal dietary management of IEM persist in Brazil, highlighting the need for strengthened public policies, professional training, and equitable access to dietary resources.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060806

Authors: Fabian Sepúlveda Ana Peñata-Taborda Osnamir Bru-Cordero Leily Montoya-Álvarez Alicia Humanez-Álvarez

Adolescence is a critical window for health behavior consolidation, yet the combined influence of physical activity level (PAL) and the body mass index (BMI) on aerobic capacity remains understudied, especially in transitioning periurban environments. This study examined the association between PAL, BMI, and aerobic capacity in adolescents from Montería, Colombia. A cross-sectional study was conducted among 112 adolescents (aged 12–17 years). Aerobic capacity was assessed using the 20 m shuttle run test (Course Navette), and PAL was measured via the validated Assessment of Physical Activity Levels Questionnaire (APALQ), following standard fitness assessment protocols. Multivariable linear regression models were utilized to estimate independent associations, adjusting for age and sex. The multivariable model was significant (F = 8.45; p < 0.001), explaining 21% of the variance in aerobic capacity (adjusted R2 = 0.21). PAL was positively and independently associated with aerobic capacity (B = 0.22; 95% CI: 0.05–0.38; p = 0.010), regardless of BMI. While age showed a positive association (B = 0.09; p = 0.032) and sex was inversely associated (B = −0.39; p < 0.001), BMI did not emerge as an independent predictor in the adjusted model (B = −0.04; p = 0.080). Aerobic capacity in adolescents is more consistently explained by behavioral factors (what they “do”) than by anthropometric status (what they “weigh”). These findings support a paradigm shift in pediatric public health, prioritizing high-intensity movement overweight control to improve cardiorespiratory fitness in transitioning urban territories.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060805

Authors: Masilu Daniel Masekameni Thokozane Patrick Mbonane Khathutshelo Vincent Mphaga Themba Titus Sigudu Phoka Caiphus Rathebe

Occupational lung diseases remain a significant public health concern in mining populations, particularly in high-exposure environments. This study examined occupational exposure profiles and respiratory health outcomes among surface and underground miners in Mpumalanga Province. A cross-sectional analytical design was employed among 239 mine workers. Data on socio-demographic characteristics, occupational exposures, behavioural factors, and respiratory outcomes were analysed using descriptive statistics, chi-square tests, and logistic regression models. Underground miners were significantly more likely to report high dust exposure (44.9% vs. 24.1%), poor ventilation (60.6% vs. 39.3%), and longer working hours (>8 h: 68.5% vs. 50.0%) compared to surface miners. They also reported a higher prevalence of respiratory symptoms, including chronic cough (45.7% vs. 25.9%), shortness of breath (41.7% vs. 23.2%), wheezing (34.6% vs. 18.8%), and diagnosed lung disease (23.6% vs. 9.8%). Multivariable analysis showed that underground mining (AOR = 1.92; 95% CI: 1.08–3.41), smoking (AOR = 1.78; 95% CI: 1.02–3.11), and high dust exposure (AOR = 2.89; 95% CI: 1.45–5.76) were independent predictors of chronic cough. A significant interaction between smoking and underground mining (AOR = 2.74; 95% CI: 1.32–5.68) further amplified respiratory risk. Additionally, underground miners demonstrated lower levels of knowledge (48.8% vs. 66.1%) and poorer preventive practices (44.1% vs. 64.3%). These findings highlight the combined influence of occupational and behavioural factors on respiratory health and highlight the need for integrated interventions to reduce the burden of occupational lung diseases.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060804

Authors: Nanna W. Christiansen Thora G. Thomsen Elizabeth E. Rosted Marianne Krogsgaard Marian C. Petersen Anja Geisler

Background: Patients’ preoperative expectations may influence postoperative quality of life and satisfaction. Aim: To provide an overview of the evidence regarding the association between patients’ preoperative expectations and postoperative quality of life as the primary outcome, with postoperative satisfaction included as a secondary outcome. Methods: A systematic review was conducted in accordance with the PRISMA guidelines and Cochrane Handbook of Systematic Reviews guidelines. A comprehensive search was conducted across five databases for all study types. Results: Ten cohort studies met the inclusion criteria, encompassing 1013 patients undergoing various surgical procedures. Most studies exhibited a high risk of bias, and several employed unvalidated instruments to assess preoperative expectations. Only one study found a significant association between preoperative expectations and quality of life. One study reported significantly better perceived health among patients with high preoperative expectations, and four studies identified a significant relationship between preoperative expectations and post-operative satisfaction. Overall, the findings were inconsistent, and the included studies demonstrated substantial methodological heterogeneity. Conclusions: Only individual studies identified significant associations with quality of life, perceived health, or postoperative satisfaction; overall, the findings were inconsistent. The evidence is limited by high risk of bias, heterogeneous methodologies, and use of non-validated measurement tools. Further research is needed to clarify the role preoperative expectations have in postoperative outcomes.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060803

Authors: Simran Grewal James Wildish Catherine Chalmers Christine Dedding Jeanine Suurmond Charles Agyemang Nimrat Grewal

Missing Conflict of Interest [...]

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060802

Authors: Áron Szandi Zsombor Balog Krisztián Sándor Zaka Gergely Zoltán Macher

Although asbestos has been banned in the European Union since 2005, asbestos-containing materials, such as brake pads and clutch linings, may still occur in waste streams due to the long service life of vehicles, legacy equipment, and international trade in spare parts. The persistence of these materials raises environmental and occupational health concerns, particularly in waste management systems. This study aims to assess the presence, temporal trends, and sectoral distribution of asbestos-containing friction materials in the Hungarian waste management system two decades after the EU ban, and to evaluate the associated regulatory and occupational risk implications. The analysis is based on national hazardous waste datasets classified under EWC code 16 01 11* (asbestos-containing brake pads), with a specific focus on this waste category rather than on the full range of asbestos-related waste streams recorded in the national database. The results indicate that asbestos-containing friction materials are still present in the waste stream, with measurable quantities recorded annually. Despite regulatory control, identification challenges and potential misclassification may contribute to underreporting. The continued occurrence of asbestos-containing materials highlights the persistence of legacy hazardous materials within circular economy systems. Strengthened monitoring, improved identification protocols, and enhanced occupational safety measures are necessary to mitigate residual exposure risks. The findings underline that asbestos is not merely a historical issue but remains a contemporary environmental and public health challenge.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060801

Authors: Luiz Gonzaga Ribeiro Silva-Neto Risia Cristina Egito de Menezes Vanessa Sá Leal Thays Lane Ferreira dos Santos Telma Maria de Menezes Toledo Florêncio

Background: The food environment plays a significant role in determining children’s nutritional status, especially in socially vulnerable settings, where the high availability of ultra-processed beverages can contribute to both overweight and nutritional deficiencies, such as anemia. Thus, this study aimed to assess the association between the availability of fruits, vegetables, and ultra-processed beverages in the food environment and the occurrence of overweight and anemia in children living in socially vulnerable areas. Methods: This is a cross-sectional study with an ecological component, conducted between 2020 and 2021, involving 665 children residing in 40 favelas and urban communities in Maceió, Alagoas, Brazil. Socioeconomic, anthropometric, and hematological data were collected, along with a characterization of the food environment in 624 establishments using the AUDITNOVA tool, focusing on the availability of fruits, vegetables, and ultra-processed beverages. The outcomes investigated were overweight (BMI-for-age z-score > +2) and anemia (hemoglobin < 11 g/dL). Multilevel models were used to assess the associations between the food environment and the outcomes of interest. Results: The prevalence of overweight was 19.7%, while anemia affected 50.4% of the children assessed. Greater availability of fruits and vegetables was associated with a lower chance of being overweight (OR: 0.82; 95% CI: 0.79–0.98). In contrast, high availability of ultra-processed beverages was associated with a higher chance of being overweight (OR: 1.35; 95% CI: 1.07–1.84) and anemia (OR: 1.53; 95% CI: 1.04–2.29). Conclusion: Food environments characterized by widespread availability of ultra-processed beverages were associated with a higher prevalence of overweight and anemia among children. In comparison, greater availability of fresh or minimally processed foods was associated with a lower prevalence of overweight. These findings highlight the importance of public policies that promote healthier food environments in socially vulnerable areas.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060800

Authors: Christine Samuel-Nakamura Abdul-Mehdi S. Ali

More than 500 unreclaimed mines and about 1100 associated waste sites remain on the Navajo Nation as a result of uranium (U) mining. This study evaluated the impact of U-mining water contamination in a region of Northwestern New Mexico. The goal of this study was to determine historical baseline concentrations of selected metal(loid)s: those found to be highly associated with cancer (arsenic (As), cadmium (Cd), lead (Pb)) and other associated metals: cesium (Cs), molybdenum (Mo), selenium (Se), thorium (Th), U, and vanadium (V), using inductively coupled plasma-mass spectrometry. Cadmium drinking water concentrations (10.64 μg/L) exceeded the United States Environmental Protection Agency Maximum Contaminant Levels (MCLs) of 5 μg/L. Overall, water mean concentration levels were 11.04 μg/L of Pb, 4.21 μg/L of As, 3.53 μg/L of U, 278.67 μg/L for Mo, 21.70 μg/L for V, 2.39 μg/L for Cs, and 7.75 μg/L for Se. These findings underscore the importance of improving access to safer water sources and highlight the need for continued environmental monitoring and research on exposure pathways associated with carcinogenicity and other negative health outcomes.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060799

Authors: Christopher Delali Amegah Gloria Adobea Odei Obeng-Amoako Shu Wen Ng Monica Lambon-Quayefio Seth Adu-Afarwuah

Background: In May 2023, Ghana implemented a 20% ad valorem tax on bottled water and sweet beverages (SBs), replacing a 17.5% tax; sachet water remained untaxed. The effect on low-income consumers’ purchasing decisions and consumption patterns remains poorly understood. Objective: We aimed to explore factors influencing water and SB purchasing behaviours among low-income households in four peri-urban Accra communities. Methods: This study employed a convergent parallel mixed-methods design. Four focus group discussions (n = 36) and a cross-sectional survey (n = 43) were conducted among purposively sampled household primary shoppers in early 2025 across Oyarifa, Teiman, Kweiman, and Danfa. Data were analysed thematically and descriptively. Results: Of 43 participants, 67% were female and 65% had junior high school education. Water insecurity was common (60%), and sachet water was the main drinking source (77%). SB purchasing was driven by taste and convenience, while sachet water choices were linked to perceived safety, price, and availability. Tax awareness was moderate (56%); many perceived bottled water taxation as unfair and reported intentions to switch to cheaper local alternatives. Conclusions: Limited tax awareness and perceived inequities suggest the need for policy refinements to better align fiscal measures with public health objectives.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060798

Authors: Nguyen Dinh Phuong Thao Le Thi Thanh Tuyen Dao Trong Quan Duong Thi Kim Hoa

The absence of a culturally adapted instrument to assess menopause-specific quality of life in Vietnamese women limits both clinical practice and research in this population. This study aimed to translate, culturally adapt, and psychometrically validate the Vietnamese version of the Utian Quality of Life (VN-UQOL) Scale. A cross-sectional design was employed with 384 community-dwelling postmenopausal women aged 46–65 years. The UQOL was translated and adapted following established guidelines, including forward-back translation, expert review, and pilot testing. Internal consistency was evaluated using Cronbach’s alpha, construct validity through confirmatory factor analysis (CFA), and concurrent validity via Pearson correlations with the Vietnamese Menopause Rating Scale (VN-MRS). The VN-UQOL demonstrated excellent internal consistency, with a total scale Cronbach’s alpha of 0.87 and sub-scale alphas ranging from 0.81 to 0.93. Content validity indices (I-CVI, S-CVI) were 1.0. CFA confirmed the original four-factor structure, with all factor loadings exceeding 0.50 and good model fit indices (CFI = 0.921, RMSEA = 0.072). Concurrent validity was supported by significant negative correlations between the VN-UQOL sub-scales and corresponding VN-MRS domains (p < 0.01). The VN-UQOL is a reliable and valid instrument for assessing menopause-specific quality of life in Vietnamese women, providing a valuable tool for clinical practice and research in this underserved population.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060797

Authors: Burcu Aksoy Şükrü Can Akmansoy Yasemin Özkan Gonca Mumcu

Oral health problems among older adults represent a growing public health concern due to increasing life expectancy and treatment needs. This study aimed to assess dental treatment needs and cost burden within the context of oral health policies. This retrospective study included anonymized data from 250 patients aged ≥65 years (F/M: 121/129; 65–89 years). Sociodemographic characteristics, treatment needs, and costs were obtained from the Hospital Information Management System (HIMS). Costs were adjusted to 2025 Turkish lira values using the Consumer Price Index and converted to international dollars using purchasing power parity (PPP). Patients were classified by total treatment costs using K-means cluster analysis. Periodontal (61.2%), restorative (36.0%), and endodontic (41.2%) treatment needs, which are largely preventable through oral hygiene practices, were more frequent among patients with a lower mean age, whereas tooth loss and prosthodontic treatment needs (89.6%) increased with mean age. Cluster analysis identified two groups: a low-cost group (67.6%) and a high-cost group (32.4%). The high-cost group had a lower mean age (68.84 ± 4.27 years) compared to the low-cost group (70.73 ± 5.18 years), indicating that relatively younger patients needed more complex and costly treatments. Out-of-pocket payments were notable for prosthodontic and surgical treatments, although Social Security Institution (SSI) payments constituted most of the costs. Preventive and early dental care strategies are essential to reduce treatment complexity and cost burden among older adults within the framework of oral health policy.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060796

Authors: Inke Nadia Diniyanti Lubis Nelli Khalilah Sari Siregar Gema Nazri Yanni Isti Ilmiati Fujiati Lenni Evalina Sihotang

Background: Dengue infection is an expanding public health threat in Indonesia, increasingly reported in semi-urban areas undergoing rapid demographic and environmental change, where household-level determinants remain poorly characterised. Methods: We conducted a case–control study in the Deli Serdang district, North Sumatra, evaluating sociodemographic and environmental risk factors for dengue. Patients admitted to the district referral hospital (July–September 2024) were screened via medical records. Laboratory-confirmed dengue cases were compared with non-dengue febrile controls. Housing conditions and sociodemographic characteristics were assessed using a validated electronic questionnaire with photographic documentation. Multivariable logistic regression identified independent risk factors. Results: Of 238 individuals screened, 39 dengue cases and 78 controls were enrolled. Male sex (aOR 6.7, 95% CI 1.3–33.7), student status (aOR 7.8, 95% CI 1.1–56.5), absence of window screens (aOR 12.9, 95% CI 3.1–53.8), and surrounding vegetation (aOR 7.3, 95% CI 1.7–31.9) were independently associated with dengue infection. Rural residence was overrepresented among cases, suggesting expansion beyond traditional urban boundaries. Conclusions: Dengue risk in a transitional setting is shaped by demographic exposure and modifiable structural vulnerabilities. Integrated prevention strategies, including window screening, covered water storage, environmental management, and school-based vector control, are needed in rapidly urbanising districts.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060795

Authors: Diksha Gautam Anuj Kumar Pandey Benson Thomas M Sutapa Bandyopadhyay Neogi

India exhibits substantial variation in neonatal mortality across regions and socioeconomic groups. This study used nationally representative survey data (2019–2021) to examine wealth-based inequalities in neonatal mortality. Socioeconomic disparities were assessed using Erreygers’ Normalized Concentration Index (ECI) and concentration curves, with subgroup analyses by residence, state development status (Empowered Action Group (EAG) vs. non-EAG), district typology, and region. Inequality was further decomposed using the Wagstaff method. Analysis of 176,843 most recent live births revealed marked rural–urban disparities, with neonatal mortality in rural areas (18.3 per 1000 live births) 1.6 times higher than in urban areas (11.5). Neonatal mortality was significantly concentrated among poorer households (ECI: −0.0123; p < 0.001), with greater inequality in urban areas, EAG states, and non-aspirational districts. Regional variation was evident, with the highest inequality in the Western and Central regions. Decomposition analysis showed that inequality was primarily driven by adverse household conditions and maternal risk factors concentrated among poorer populations. Key contributors included unclean cooking fuel, higher parity, large family size, normal delivery and inadequate antenatal care. These findings highlight the need for equality-focused strategies addressing both social determinants and gaps in access to quality maternal and newborn care.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060794

Authors: Celine-Chantal Elster-Kann Beate Muschalla

Emotional exhaustion has been discussed as a major contributor to work ability problems, with substantial economic, individual, and social consequences. Research largely focuses on specific professions and sometimes overlooks that exhaustion and work overload problems are partly distinct. This study uses a differential analysis to explore working conditions and individual characteristics in employees with emotional exhaustion or perceived work overload, aiming to identify potential common risk factors. A representative German cross-sectional sample of 2289 employees aged 15–67, working at least 10 h per week, was analyzed. Employees with and without treatment for exhaustion, and with and without perceived work overload, were compared using variance analysis. Overloaded employees reported more work demands, while exhausted employees appear to be more often female and not in their preferred occupation. Several psychosocial work factors (e.g., responsibility) were more consistently associated with the overload and exhaustion groups than many of the physical work conditions. Employee characteristics such as openness and internal locus of control appeared to be similarly distributed across groups. Overload without exhaustion can be distinguished from combined exhaustion and overload, suggesting that work overload may occur with or without exhaustion, in relation to individual psychosocial resources. Preventive interventions for work ability may benefit from addressing overload as a distinct risk factor, besides illness-related exhaustion.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060793

Authors: Mayara Calixto da Silva Paulo Cesar Basta Bruna Duarte Pinto Daniel Escorsim Machado Felipe Oliveira Pessoa-Silva Rogério Adas Ayres de Oliveira Ana Claudia Santiago de Vasconcellos Jamila Alessandra Perini

Mercury (Hg) is a major neurotoxicant and public health concern and gold mining is a significant source of Hg contamination in the Amazon. There, Indigenous peoples are vulnerable to this exposure. Individual susceptibility influences both internal mercury levels and related clinical outcomes. In this context, the GSTP1 gene stands out due to its role in detoxification of xenobiotics. The objectives were to assess the associations between: (1) Hg levels and neurotoxicity signs; (2) the GSTP1 rs1695 polymorphism and Hg levels; and (3) whether the GSTP1 rs1695 polymorphism modifies the effect of mercury on neurotoxicity signs. A cross-sectional study was conducted between April and May 2023, with 113 Paiter-Suruí Indigenous people. Sociodemographic and clinical data were collected using a validated methodology. Hair and oral mucosa cells were collected to assess Hg levels and the GSTP1 rs1695 polymorphism. Hg levels ranged from 0.1 μg/g to 6.5 μg/g (median = 1 μg/g, IQR = 1.43). Individuals with impaired memory and muscle strength had significantly higher mercury levels (β = 4.39 and β = 1.24). Carriers of the GSTP1AA genotype showed a 0.46-point reduction for each 1 μg/g increase in mean Hg levels, compared to individuals with the GSTP1GG genotype (β = −0.46). These results may support public policies by identifying priority groups for intervention based on genetic profiles.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060792

Authors: Nandini Khatter Sapna Chotai Giouliana Kadra-Scalzo

Returning to work (RTW) following sickness absence due to common mental disorder (CMD) symptoms, such as anxiety, depression and stress, is increasingly recognised as a critical yet complex phase of recovery. Despite this, individuals do not always experience the process as supportive or straightforward. This study explored the factors shaping RTW by examining the perspectives of service users, employment advisors (EAs) and human resource (HR) professionals. In a qualitative study, using purposive sampling, we recruited 17 participants across the three stakeholder groups. Data were collected through semi-structured interviews and analysed using thematic analysis. The findings suggest that RTW is shaped by a dynamic interplay between individual experiences, workplace relationships and organisational structures. Participants described returning to work as an ongoing and often uncertain process, influenced by shifts in confidence, expectations of support and the extent to which workplaces were able to respond flexibly to individual needs. While some accounts reflected collaborative and supportive environments, others highlighted disconnection, misalignment and unmet expectations across stakeholders. Overall, the findings point to RTW as a negotiated process, requiring alignment between employees, managers and organisational systems. The study highlights the importance of consistent, flexible and context-sensitive approaches to support sustainable RTW following CMD-related absence.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060791

Authors: Ivana Marcinko Ana Kurtovic Ana Babic Cikes

The majority of somatic symptoms have unexplained medical causes, and it is claimed that psychological factors are important in the initiation and exacerbation of somatic complaints. This study, cross-sectional and correlational in nature, investigated the mediating role of eudaimonic well-being on the relationship between self-determination and somatic symptoms. Mediations were examined at both the whole-construct and component levels to better understand these relationships. A total of 486 participants took part in this study, comprising 403 females (82.9%) and 83 males (17.1%), with an age range of 18 to 36 years (M = 22, SD = 2.27). Self-determination, eudaimonic well-being, and somatic symptoms were measured using questionnaires. Mediations were tested at the construct and component levels using the PROCESS macro. The results show that eudaimonic well-being mediates the relationship between self-determination and somatic symptoms (b = −0.21, SE = 0.03, 95% CI = [−0.32, −0.10]). Component-level analyses reveal that the relationship between controlling motives and somatic symptoms is mediated by negative affect (b = 0.39, SE = 0.08, 95% CI [0.23, 0.56]). These findings identify the variables that may explain the origin of somatic symptoms, emphasising self-determination as a starting point and eudaimonic well-being as a mechanism by which motivational factors affect health outcomes.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060790

Authors: David John Hallford Emily J. Wallman Ryan A. Kaplan Glenn A. Melvin

Suicide is a substantial contributor to global mortality, with suicidal ideation (SI) a significant predictor of suicide. Research has demonstrated relationships between dispositional coping styles and SI. This study aimed to advance this research by examining the specific coping strategies people use when experiencing SI. Further, it assessed predicted use of coping strategies of people with a history of SI would differ from the actual coping strategies employed by people have experienced SI. Seventy-seven help-seeking adults (Mage = 31.6, SD = 10.4) with (n = 49) or without (n = 28) history of SI completed the Brief Coping Orientations to Problems Experienced (Brief COPE) adapted to SI-related coping and current emotional distress measured by the 21-item version of the Depression Anxiety Stress Scale (DASS-21). An ANCOVA, while controlling for current emotional distress levels, showed a greater predicted Problem-Focused coping use than actual use reported by participants with SI history. Facet-level ANCOVAs attributed this to differences in Active Coping, Use of Informational Support, and Planning strategies. There were no group differences in emotion-focused or avoidant coping. The preliminary findings suggest individuals without a history of SI may prognosticate more frequent use adaptive coping strategies, relative to how frequently people actually employ them during these times. Future research may examine the factors explaining these differences to help inform programs related to SI and coping.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060789

Authors: Mirza Ali Anser Beg Yahya Dawood Scott Burton Patten

This study evaluated the effectiveness of a youth-developed vaping intervention created by the Airdrie Board of Youth Affairs (ABYA) in changing Grade 7 and 8 students’ knowledge, attitudes, and harm perceptions regarding e-cigarette use. The vaping video trial followed a preceding local education program on smoking harms. A total of 107 students were randomly assigned to either the intervention group (ABYA video) or the control group (expert-developed video). Four instruments were used: the Video Survey, Personal Information Questionnaire, Knowledge and Attitudes Regarding E-cigarette Ingredients, Safety, and Addictive Properties (KAS), and the E-cigarette Harm Perception and Reduction (EHI). Pre- and post-intervention data were analyzed using t-tests and Mann–Whitney U tests. Compared with controls, the intervention group showed a significantly larger mean decrease in total EHI scores (mean change 9.05 vs. 2.06; t(105) = 3.34, p = 0.001; Cohen’s d = 0.65), indicating that the youth-developed video increased the perceived risk of vaping relative to cigarettes to a greater extent than the expert-developed video. Students also rated the ABYA video significantly higher on a 5-point scale for overall enjoyment (3.13 vs. 2.33; p < 0.001; Cohen’s d = 0.81) and for perceived increase in knowledge about vaping (3.34 vs. 2.84; p = 0.023; Cohen’s d = 0.44). The KAS instrument showed low internal consistency in this sample, so item-level KAS findings were treated as exploratory. Notably, unlike the expert-developed video, which explicitly acknowledged uncertainty, the ABYA video conveyed a clearer and more direct message, which may have contributed to its greater appeal while also carrying a risk of overstating absolute risk of e-cigarettes relative to cigarettes. Overall, these findings suggest that grassroots, youth-led interventions may be an effective approach for adolescent vaping education and may offer advantages over traditional expert-developed messaging in some contexts.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060788

Authors: José Antonio Guerrero Serrano Samuel Lozano Martín Julia Sánchez García Marta Arroyo Hernández Pedro Caba Doussoux

Background Although cycling has definite health benefits, it is certainly not a risk-free activity; its increasing use is associated with a rise in accidents. This study aims to characterize cycling injuries and their associated factors in a tertiary trauma center, including injury severity, accident circumstances, and in-hospital costs. Methods: A retrospective observational study was conducted on patients over 15 years of age hospitalized after a cycling accident. Collected variables included the characteristics of the accident, the epidemiology of musculoskeletal injuries, helmet use, injury severity as assessed using the Abbreviated Injury Scale (AIS), the Injury Severity Score (ISS), and costs. Results: A total of 131 patients were included, of whom 90.8% were male, with a mean age of 43.2 ± 14.1 years. Most accidents were due to falls (83.7%). Accidents occurred in urban areas (56.3%), inter-urban roads (28.1%), and rural areas (15.6%). Upper limb fractures, particularly clavicle fractures (13.7%), were the most frequent injuries (31.0%). Traumatic brain injury (TBI) was present in 30.0% of patients, and 17.6% were polytraumatized. Injury severity was higher in males (p = 0.009) and in collisions compared with falls (p = 0.033). It was also correlated with length of hospital stay (r = 0.376). Patients with TBI exhibited significantly higher ISSs (p < 0.001). Helmet use was reported in 71.1% of patients and was more frequent in rural areas (p < 0.001) and associated with lower neurological AIS scores (p = 0.031). The mean cost per patient was €8545 ± 15,298, increasing with severity of injury (p < 0.001), and was higher in polytraumatized patients (p < 0.001) and in those with TBI. Conclusions: Cycling accidents most frequently resulted in upper limb fractures. Helmet use was more common where mandatory and was associated with less severe neurological injuries but not with a lower incidence of TBI. Costs increased with injury severity, particularly in patients with TBI and longer hospital stays.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060787

Authors: Ghazal S. Fazli Jane Polsky Ashley Johns Peter Gozdyra Jin Luo Gillian L. Booth

Background: We examined whether higher access to parks and greenspace is independently associated with an increase in physical activity and lower rates of obesity when neighbourhood walkability is accounted for and whether neighbourhood walkability and park access have synergistic effects on these outcomes. Materials and Methods: We used cross-sectional data from the Canadian Community Health Survey between 2007 and 2014 for adults aged 20 to 74 in Ontario, Canada. Neighbourhood-level park access exposures included size of parks and number of parks within 800 m of residential areas, and neighbourhood walkability was based on a validated index. The main outcomes were physical activity during leisure time (LPA), both leisure and transportation physical activity (LTPA), and obesity. Descriptive and multivariate logistic regression analyses were conducted, stratified by age groups, accounting for sex, income, ethnicity, and season. Results: Among 41,945 respondents, park access was associated with higher LPA and LTPA, with effects modified by neighbourhood walkability (p < 0.001). Physical activity was highest in neighbourhoods with high walkability and park access and lowest in low walkability areas without parks. In highly walkable neighbourhoods, ≥1 small- or medium-sized park was associated with 29% higher odds of LPA (OR: 1.29, 95%CI: 1.21–1.37) and 48% higher odds of LTPA (OR: 1.48, 95%CI: 1.38–1.57) than low walkability/no park access. In contrast, associations were modest in low-walkability neighbourhoods (4–7%). High walkability was also associated with lower obesity and marked reductions when combined with very high access to large parks (OR: 0.72, 95%CI: 0.55–0.94). Findings were consistent across age groups. Conclusions: High neighbourhood walkability was the strongest predictor of physical activity and lower obesity risk, with park access providing additional benefits primarily in already walkable environments. These findings suggest that population health interventions targeting urban design need to consider the combined benefits of neighbourhood walkability and park access on health.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060786

Authors: Monica R. Lininger Michael Anastario

Background: Traumatic brain injury (TBI) and substance use disorder (SUD) frequently co-occur due to shared risk factors and a potentially bidirectional relationship. However, epidemiological patterns in rural populations remain understudied despite known disparities in access and outcomes. This study aimed to characterize the relationship between TBI and SUD in a rural Southwestern population, including demographic and clinical patterns of diagnostic sequencing. Methods: A retrospective observational study was conducted using electronic health records and trauma registry data (2022–2023) from a rural trauma center. Cohort one included 24,389 emergency department encounters with ICD-10 codes for TBI or SUD. Cohort two included 248 trauma registry patients with TBI and SUD diagnoses. Descriptive statistics and multinomial logistic regression models were used to evaluate diagnostic patterns and associated demographic factors. Results: Males were more likely to have co-occurring TBI and SUD (Relative Risk Ratio [RRR] = 1.35), while increasing age was associated with TBI-only diagnoses. Among patients with multiple visits and diagnoses, 16% had co-diagnoses, while 9% had sequential diagnoses. American Indian/Alaska Native patients had higher co-diagnosis risk compared to White patients (RRR = 2.21, p < 0.001). Higher blood alcohol concentration was associated with lower Glasgow Coma Scale scores (r = −0.15, p = 0.022), indicating greater severity. Conclusions: TBI and SUD frequently co-occur in rural populations, with notable disparities by sex and race/ethnicity. Emergency Departments are critical points of care for interventions such as screening for both substance use and head injury when either is suspected, and employing culturally responsive education and referral pathways upon discharge.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060784

Authors: Ashley Jarrett Oscar Fleming Jacob Shomali William Romani

In Burke County, North Carolina, a Hepatitis A outbreak among unsheltered residents exposed gaps in access to clinic-based care and prompted early, ad hoc “backpack medicine” outreach efforts to deliver care directly in nontraditional settings. While this approach addressed immediate needs, it highlighted the inadequacy of isolated interventions, prompting local partners to pursue more structured, coordinated, and community-driven approaches to homeless health system design. This project report describes how Burke County Public Health, in partnership with the University of North Carolina at Chapel Hill, applied systems thinking, community coalition building, and human-centered design to transition from reactive outreach to a structured, sustainable mobile health delivery model for people experiencing homelessness. Guided by Community Coalition Action Theory (CCAT), partners used human-centered design methods to engage over 40 community stakeholders and 10 individuals with lived experience of homelessness or housing instability. Through empathy mapping, iterative prototyping, and thematic analysis, the team identified priority service gaps, defined operational requirements, and developed prototype service models, while building cross-agency readiness for implementation.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060785

Authors: Gulnaz Sadykanova Sanat Kumarbekuly Ayauzhan Yessimbekova Gulfat Kalelova

Industrial settlements of the East Kazakhstan Region face a persistent technogenic burden driven by the dense concentration of non-ferrous metallurgy and heat-and-power enterprises, further compounded by unfavorable pollutant dispersion conditions inherent to the region’s mountain–basin topography. This study evaluated spatiotemporal associations between annual mean concentrations of NO2, SO2, H2S, and CO, the integrated air pollution index (API5), and primary neoplasm morbidity across five settlements over the period 2014–2024. A retrospective ecological analysis was carried out for Ust-Kamenogorsk, Ridder, Altai, Shemonaikha, and the settlement of Glubokoe, incorporating Spearman’s rank correlation, lag analysis (1–3 years), and the Mann–Kendall trend test. Throughout the study period, neoplasm morbidity in the region consistently exceeded the national average by a factor of 1.3 to 2.0. In Ust-Kamenogorsk—where metallurgical SO2 and NO2 emissions are most heavily concentrated—strong positive associations were found in children for SO2 (ρ = 0.791, p < 0.05) and in adolescents for NO2 and CO, reflecting elevated inhalation exposure under conditions of chronic pollution. The negative associations with API5 observed in Ridder and Altai, where the index showed a statistically significant downward trend, are interpreted as evidence of the inertial character of oncological processes and the lasting influence of cumulative past exposure. Across all studied settlements, SO2 emerged as the most consistent predictor of morbidity variation. These findings support prioritizing stricter emission controls for SO2 and NO2 from metallurgical and energy facilities, establishing oncological screening programs for children and adolescents in chronically polluted areas, and strengthening ambient air monitoring—measures whose effective implementation will require coordinated action between public health authorities and environmental regulators.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060783

Authors: Toni Wright Michelle England Thomas Thompson Sabina Hulbert Theofanis Fotis Eleni Hatzidimitriadou

Population ageing presents growing challenges for health and social care systems, particularly in supporting older adults to remain independent and involved in decisions concerning their own health and wellbeing. The EMPOWERing individuals and communities to manage their own CARE (EMPOWERCARE) project evaluated asset-based initiatives designed to support older adults in managing their health and wellbeing across seven pilot sites in Belgium, France, the Netherlands and the United Kingdom. Initiatives were categorised as caring technologies, which focused on digital tools and assistive technologies to improve autonomy, promote self-management, and support independent living, and social mobilisation initiatives aimed at building stronger community networks, reducing loneliness, and fostering engagement. A multi-site, embedded case study design combined quantitative and qualitative methods. Survey data were collected at baseline (T0; n = 187) and endpoint (T2; n = 105) between July 2021 and January 2023. Outcomes included self-efficacy, mental wellbeing, loneliness and digital literacy. Descriptive statistics and repeated-measures t-tests were conducted, while Photovoice and focus group data were analysed using summative content analysis. Findings indicated improvements in self-efficacy and mental health among some participants, alongside positive trends in digital literacy and internet-based health-seeking behaviour. Qualitative findings further highlighted increased confidence, social connectedness and empowerment among participants.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060782

Authors: Hilde Skjerve Lars Erik Braaum Ursula Småland Goth Anette Sørensen

We sincerely thank the authors of the comment [...]

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060781

Authors: Rochele Villafuerte Aaron Funa

Skjerve et al [...]

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060780

Authors: Sinentlahla Mamane Monwabisi Faleni Guillermo Alfredo Pulido Estrada Ziphelele Ncane Laston Gonah

Background: While caregiver and health system factors are known to influence paediatric ART outcomes, their roles within routine rural South African settings remain insufficiently characterised. Aim: The aim of this study is to assess the association between caregiver-mediated ART adherence, perceived healthcare access and service quality with viral suppression among children receiving ART in a rural South African province. Methods: A cross-sectional study was conducted among 86 children aged <15 years receiving ART in routine paediatric HIV care. Viral load suppression was defined as <1000 copies/mL. Predictor variables included caregiver-reported adherence (30-day recall; adherent vs. non-adherent), perceived healthcare access and perceived service quality. Associations were assessed using Chi-square or Fisher’s exact tests, where appropriate. Effect sizes were estimated using risk differences. Results: Overall, 77.9% of the child participants were virally suppressed. Caregiver-reported adherence was significantly associated with VLS (p = 0.034). The probability of viral suppression was 100% among adherent children compared to 73.2% among non-adherent children (risk difference: 26.8 percentage points). Caregiver-reported adherence demonstrated high specificity (100%) and positive predictive value (100%) but low sensitivity (22.4%) and negative predictive value (26.8%), indicating that while reported adherence reliably identified children who were suppressed, non-adherence did not consistently predict virological failure. Perceived healthcare access (p = 0.372) and service quality (p = 0.267) were not significantly associated with viral suppression. Conclusions: Caregiver-mediated adherence was strongly associated with viral suppression, whereas perceived health system factors were not independently associated with treatment outcomes in this cohort. These findings should be interpreted cautiously given the cross-sectional design and reliance on short-term adherence measures. Strengthening household-level adherence support is critical for improving paediatric HIV outcomes in rural settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060779

Authors: Stefania Fantinelli Michela Cortini Morena Santoriello Leonardo Pagano Teresa Galanti

Seasonal workers in the tourism sector are exposed to significant psychosocial risks, such as work overload, emotional exhaustion, and precarious employment conditions. Despite growing interest in positive organizational psychology, little is known about how organizational culture impacts perceptions and experiences of seasonal workers in Italy. This study explores the role of positive organizational culture in promoting well-being among seasonal workers in the tourism sector, examining their direct perspectives on organizational climate, work challenges, and individual and organizational resources. Eight semi-structured interviews were conducted with seasonal workers employed in the hospitality industry in Italy. Data were analyzed through an integrated mixed-method approach combining Grounded Theory methodology with quantitative lexical analysis using T-LAB software, ensuring both analytical rigor and interpretive depth. Five macro-categories emerged inductively from the data: trust and relations, coping strategies and emotions, perceived justice, teamwork, and meaning of work. These were integrated into a core category defined as flourishing at work, interpreted through the lens of Seligman’s PERMA model. These findings suggest that well-being in seasonal work is an active and relational achievement, sustained by emotional self-regulation, perceived fairness, and collective identity. The results carry direct implications for organizational policies and psychosocial risk prevention strategies in precarious work contexts. In particular, positive organizational culture and environments can act as protective factors against psychosocial risks, with direct implications for organizational policies, psychosocial risk prevention, and evidence-based workplace interventions. The specificity of the analysis method offers an original contribution by integrating qualitative and quantitative textual analysis to investigate psychosocial well-being in an under-explored population: Italian seasonal workers.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060778

Authors: TyWanda L. McLaurin-Jones Shannon M. Hughley Joi J. Wright

Research examining risk and protective factors of suicidality among Black students remains limited. This study assessed the effects of psychological inflexibility and emotional resilience on suicidal behaviors among Black college students. We conducted a secondary data analysis of the 2022–2024 Healthy Minds Study. Black students (aged 18–24) who completed the suicidality matrix, psychological inflexibility (Acceptance & Action Questionnaire II) and emotional resilience (Brief Resilience Scale) measures were included in the analysis. Logistic regressions were performed to examine the effect of psychological inflexibility and resilience on suicidal ideation, plans for suicide, and suicide attempts. The students (N = 4557) represented diverse backgrounds, with 61% being African American, 12.2% African, 13.8% Caribbean, and 7% Afro-Latinx. Further, 18.7% endorsed suicidal ideation, 9.2% endorsed suicide plans, and 3.2% reported a suicidal attempt within the past 12 months. Psychological inflexibility was associated with increased risk of suicidal ideation (OR = 1.04, p < 0.001), suicidal plan (OR = 1.05, p < 0.001) and suicide attempt (OR = 1.03, p = 0.011). Emotional resilience was not associated with any suicidal behaviors as a protective or risk factor. The findings support previous research identifying psychological inflexibility as a suicidal risk factor. Prevention and intervention strategies may warrant a focus on promoting psychological flexibility.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060777

Authors: Veisinia Pulu Emma V. Taylor Phuntsho Om Sandra C. Thompson

Aboriginal people in Western Australia (WA) experience poorer cancer outcomes compared to non-Aboriginal Australians, with significant disparities in cancer screening participation, later-stage diagnosis, and lower survival rates. This narrative review, informed by selected scoping methods, examined 69 peer-reviewed studies contributed by WA researchers from 2000 to 2024 to inform understanding of and address these inequities. Recurring issues requiring attention included promoting cultural safety in healthcare, addressing barriers to and disparities in cancer care, boosting cancer screening and awareness, enhancing education and communication, strengthening support systems and care navigation, improving treatment access and outcomes, and building workforce capacity. Recommendations to address the above challenges and improve cancer care and outcomes for Aboriginal people in WA included addressing barriers and disparities in cancer care; promoting effective education, communication, and culturally appropriate support; enhancing cancer screening participation and awareness initiatives; improving access to cancer treatment and outcomes; strengthening policy and system-level interventions; supporting families and communities throughout their cancer journey; building research capacity and data collection to guide Aboriginal and community-led initiatives. These recommendations highlighted that multi-level interventions are needed, from empowering Aboriginal people and strengthening communities to improving service delivery and driving systematic reforms. Overall, this narrative review informs future research, policy, and practice focused on equity to improve cancer outcomes for Aboriginal people in WA and beyond.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060776

Authors: Tolulope M. Okuneye Andrew J. Godley Elaine C. Russell Lisa L. Lindley Kenneth W. Griffin

Experiences of discrimination and/or microaggressions may negatively affect mental health among university students. We assessed the association between experiences of discrimination, microaggressions, and combined exposure on poor behavioral health (PBH) among university students in Spring 2023 (N = 45,386) using cross-sectional data from the American College Health Association’s National College Health Assessment III. PBH (an index of severe psychological distress and substance use risk) was reported by 42.9% of students. More than half of sexual and gender minority (SGM) youth reported PBH, and had a high prevalence of discrimination and microaggressions. Among racial/ethnic groups, Black/African American students had the highest prevalence of experiences of discrimination and microaggressions. Minoritized groups who experienced discrimination or microaggressions consistently reported a higher prevalence of PBH compared to their counterparts not reporting these experiences; the opposite pattern was observed among cisgender, heterosexual, and White participants. In the logistic regression models, experiences of both discrimination and microaggressions were associated with an over 2-fold increase in odds of PBH, controlling for demographic variables, compared to those experiencing neither. Interaction effects revealed that experiences of microaggressions did not consistently and differentially predict PBH across subgroups of minority youth. Efforts to increase resilience on university campuses may improve behavioral health.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060775

Authors: Alex Asakitikpi

While South Africa’s Constitution guarantees the right to healthcare for all who live in the country, there are still inequities that affect vulnerable groups. Based on migration status, this paper examines how discrimination intersects with structural and institutional practices to produce unequal access to healthcare services for black foreign migrants and asylum seekers in South Africa. Desk reviews of policy frameworks, relevant academic literature, and documented case reports were used to analyze the disconnect that exists in South Africa’s rights-based legal commitments and the lived realities of foreigners in the country. Adopting a theoretical framework that integrates structural violence, intersectionality, and bureaucratic discretion, the findings are discussed by conceptualizing discrimination as a structural and interpersonal determinant of health. The findings suggest that the experiences of foreign nationals regarding access to healthcare services are not incidental but embedded within complex socio-political dynamics of scarce resources, institutional practices, and institutional ambiguity. The consequences of these inequities involve delayed care-seeking and increased vulnerability to preventable diseases among black immigrants, with a broader public health risk. Drawing from the study, policy clarity is recommended, and the strengthening of accountability mechanisms to ensure equitable access to healthcare in the country.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060774

Authors: Pongjan Yoopat Nisakorn Julraksa Weerawat Liemmanee Karn Yongsiriwit Thannob Aribarg

Retail service workers face complex occupational demands across psychosocial, environmental, and physical domains; however, integrated multidomain workload assessments remain limited. A cross-sectional study among 253 retail workers used the Find My Stress Progressive Web Application (PWA)—a digital tool assessing subjective workload (Subjective Workload Index; SWI), psychosocial factors, environmental discomfort, musculoskeletal symptoms, and handgrip strength. Hierarchical multiple regression identified four significant SWI predictors: postural difficulty (β = 0.176, p = 0.012), workplace bullying (β = 0.175, p = 0.008), task duration (β = −0.179, p = 0.004), and air quality (β = 0.171, p = 0.011; Adjusted R2 = 0.199, ΔR2 = 0.227, p < 0.001; VIF: 1.03–1.57). Grip strength was retained as a functional capacity indicator. Sex-stratified analyses revealed distinct risk profiles: postural difficulty and task duration predicted SWI in men (Adjusted R2 = 0.224); workplace bullying was the sole predictor in women (Adjusted R2 = 0.170). The PWA demonstrated excellent reliability (α = 0.97) and usability (87%; n = 359). The Find My Stress PWA provides a scalable platform for multidomain stress screening. Integrated ergonomic, organisational, and environmental interventions guided by digital screening offer targeted strategies for reducing occupational workload burden in retail settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060773

Authors: Samara Nickel Rodrigues Bruno Veiga Guterres Maurício Tatsch Ximenes Carvalho Rodrigo Sudatti Delevatti Cristine Lima Alberton

Individuals with type 2 diabetes mellitus (T2D) are at increased cardiovascular risk. Although exercise is an important strategy for reducing cardiometabolic risk, accessible and scalable intervention delivery strategies, such as synchronous telehealth programs, remain underexplored. This randomized clinical trial (RED Study; NCT05362071) investigated the effects of a 12-week synchronous telehealth exercise program on clinical, functional, and psychosocial outcomes in adults with T2D. Thirty-three participants (55.8 ± 10.1 years) were randomized to an intervention group (INT; n = 17), which performed supervised combined aerobic and resistance exercise via video calls (2–3 sessions/week), or a control group (CON; n = 16). Glycated hemoglobin (HbA1c) was the primary outcome. Secondary outcomes included capillary blood glucose, blood pressure, functional performance, and psychosocial parameters. Assessments were conducted at baseline and post-intervention by blinded evaluators, and analyses were conducted using linear mixed-effects models in an intention-to-treat analysis. No significant interaction effect was observed for HbA1c (p > 0.05). However, significant group × time interactions favored the INT for functional performance outcomes, including the 30 s Chair Stand (p = 0.02), Arm Curl (p < 0.001), Timed Up and Go (p = 0.01), and 2-Minute Step Test (p = 0.01), as well as sleep quality (p < 0.001). Depressive symptoms decreased over time (p = 0.03) in both groups. Additionally, the INT showed reductions in post-session capillary blood glucose across mesocycles 1, 2, and 4 (p = 0.03). The synchronous telehealth exercise program was not superior to the control condition in reducing HbA1c; however, it improved functional performance, enhanced sleep quality, and promoted acute reductions in glycemic levels in individuals with T2D.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060772

Authors: Paz Kelmer Shachar Zion Shemesh Jose Asprilla Omri Cohen Zvi R. Cohen Lior Ungar

Objective: On 28 February 2026, Israel entered direct large-scale hostilities with Iran under Operation Roaring Lion. The opening phase was characterized by repeated missile alerts, civilian protected-space instructions, and rapid reorganization of hospital activity into protected areas. We observed an apparent increase in strict spontaneous intracerebral hemorrhage admissions during March 2026 within our linked neurology/neurosurgery services dataset. The aim of this preliminary single-center study was to determine whether March 2026 was temporally associated with a higher proportional burden of strict spontaneous intracerebral hemorrhage admissions compared with March cohorts from the preceding decade and whether this pattern was also observed for acute ischemic stroke or non-traumatic subarachnoid hemorrhage. Methods: We performed a retrospective observational cohort study of all unique March admissions captured within a linked neurology/neurosurgery services dataset from 2016 through 2026. Hospitalizations were deduplicated by admission number. March 2026 was treated as the first full March occurring after the onset of direct Israel–Iran hostilities on 28 February 2026. Strict spontaneous ICH was defined using diagnosis-text phenotyping that included intraparenchymal or intracerebral hemorrhage terminology while excluding trauma, subarachnoid hemorrhage, subdural hematoma, aneurysm, arteriovenous malformation, tumor-related hemorrhage, cavernoma, venous sinus thrombosis, dissection, and other clearly secondary etiologies. Comparator phenotypes included acute ischemic stroke and non-traumatic subarachnoid hemorrhage (SAH). Results: Across 3855 unique March admissions, 68 met criteria for strict spontaneous ICH. In March 2026, 9 of 223 admissions (4.0%) were classified as strict spontaneous ICH, compared with 59 of 3632 admissions (1.6%) across March 2016–2025, yielding a rate ratio of 2.48 (95% CI 1.25–4.94; p = 0.015). Patients with strict spontaneous ICH in March 2026 were older (mean age 72.3 vs. 65.8 years), and 7 of 9 cases (77.8%) occurred in patients aged ≥70 years compared with 25 of 59 (42.4%) historically (p = 0.073). Acute ischemic stroke did not increase in March 2026 (7.6% vs. 9.4%; p = 0.475), and non-traumatic SAH showed only a non-significant numerical increase (2.7% vs. 1.4%; p = 0.147). Sensitivity analyses showed a directionally consistent but statistically non-significant increase when March 2026 was compared with March 2025 alone (4.0% vs. 1.2%; rate ratio 3.36, 95% CI 0.92–12.27; p = 0.076) and with a rolling 3-year March baseline from 2023 through 2025 (4.0% vs. 2.1%; rate ratio 1.93, 95% CI 0.88–4.23; p = 0.143). In-hospital mortality among strict spontaneous ICH patients was 1 of 9 (11.1%) in March 2026 versus 4 of 59 (6.8%) in March 2016–2025. Conclusions: In this preliminary single-center neurology/neurosurgery services cohort, March 2026 showed a higher proportional burden of strict spontaneous intracerebral hemorrhage admissions than March cohorts from the preceding decade, while acute ischemic stroke did not increase. Sensitivity analyses using March 2025 alone and a rolling 3-year March baseline were directionally consistent but did not reach statistical significance. These findings should therefore be interpreted as a hypothesis-generating temporal association rather than evidence of causality or population-level incidence. Wartime-related psychological stress, sleep disruption, altered healthcare access, blood pressure dysregulation, and medication nonadherence are biologically plausible contributors, but individual-level blood pressure, medication exposure, body mass index, time-to-admission, direct stress exposure, and detailed outcome data were not available in the present dataset. Multicenter, hospital-wide, and registry-based validation with seasonal and systems-level sensitivity analyses is required.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060771

Authors: Emmanuel Irimaso Concorde Rwibutso Therese Nyirahabimana Cynthia Curl Stephanie Mitchell Liberata Mukamana Dawn Zimmerman Sabrina B. Sholts

Growing pesticide use is linked to increased health risks for farmers across Africa, due to factors such as improper handling, insufficient knowledge, and lack of resources. To better understand these risk factors in Rwanda, where the majority of the population and most women are farmers, we held focus group discussions (FGDs) with 31 Sector Agricultural Officers (SAOs) and Sector Animal Resources Officers (SAROs) in five districts of Eastern Province. Among their views on this topic, we identified four core themes among the FGDs of (1) interconnected challenges, (2) shared exposure and health risks, (3) gender differences in risk behavior, and (4) transmission of knowledge, in addition to six pesticides—abamectin, cypermethrin, lambda-cyhalothrin, profenofos, mancozeb, and metalaxyl—most commonly used across all districts. Our findings suggest that Rwandan farmers may overestimate variety in the pesticides that they use and thus potentially contribute to problems such as pest resistance, underlining a critical need for integrated, locally informed approaches to pesticide management. This study also demonstrates the valuable role of extension officers in highlighting challenges related to pesticide use in farming communities and advancing research that engages with them.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060770

Authors: Ping Tang Qin Fan Jingmin Sun Jianlin Ji Liling Yang Wenjuan Tang Qunfeng Lu

The journal retracts the article titled “The Hidden Danger of Unintentional Child Injuries in an Urban Domestic Environment: Considering Unintentional Injuries from Another Angle” [...]

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060769

Authors: Tanvir Fittin Abir Rakibul Islam Kazi Fayzus Salahin Kaniz Kakon Kingsley Emwinyore Agho Sandy Francis Peris Khan Sarfaraz Ali

Chronic kidney disease (CKD) is a rising public health concern in low- and middle-income countries (LMICs), with urban populations disproportionately affected. In Bangladesh, particularly in Dhaka, dialysis services have become essential for CKD management. This study investigates the determinants of revisit intention among adult attendants of dialysis patients in Dhaka, using partial least squares structural equation modeling. A cross-sectional survey was conducted across four major dialysis centers totaling 399 valid responses. A purposive sampling technique was employed to ensure the inclusion of respondents with relevant experience and engagement in dialysis service utilization. Among respondents, over half were male, 43% had primary to higher secondary education, and one-third reported household incomes between BDT 40,001 and 60,000. The largest age group was 45–49 years (32.3%), and nearly 60% selected the facility due to nearness. Reliability and validity metrics met recommended thresholds, and multivariate normality was not assumed (Mardia’s test, p < 0.05). The structural model revealed significant direct effects of cost (β = 0.167, p = 0.003), Perceived trust in healthcare providers (β = 0.252, p < 0.001), and Perceived patient satisfaction (β = 0.422, p < 0.001) on Perceived revisit intention. Dialysis Delivery Service and word of mouth influenced revisit behavior indirectly through Perceived patient satisfaction. All mediation paths were statistically significant and classified as complementary. To improve patient retention, the policymaker should prioritize affordability, perceived trust in healthcare providers, and overall service quality, which together enhance perceived patients’ satisfaction and revisit intention.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060768

Authors: Clay Collins

This paper revisits the famous Card and Dahl study on emotional cues on intimate partner violence (IPV). This paper was one of the first to explore the effects of seemingly irrelevant outcomes—in this case, local National Football League (NFL) game outcomes—on incidents of IPV, finding that upset NFL losses are associated with a 10% increase in IPV. This paper briefly describes the current state of the “emotional cue” literature, specifically further extensions related to IPV, and then applies the Card–Dahl model to an updated 25-year crime dataset. Results suggest a deviation from the previous literature. NFL upset losses seem to have a considerably reduced effect on IPV than initially found, but some restricted samples find relationships between unexpected game outcomes and IPV.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060767

Authors: Tânia Russo João Pereira

Socioeconomic inequities are associated with longer length of hospital stay (LOS) and clinical severity in children. This retrospective cross-sectional study analyzes health inequalities and area-level deprivation, focusing on hospitalization indicators, in a suburban pediatric population in Portugal. Pediatric admissions to a local general hospital were analyzed for LOS and admission to intensive care unit (ICU), as well as their relation to socioeconomic factors, over an 8-year period (2014 to 2021), using population-averaged models. Area-level inequalities were measured for the population ranked by civil parishes’ European Deprivation Index. 8016 admissions were included. Health inequalities associated with socioeconomic deprivation were observed, with concentration curves above the diagonal for LOS and admission to ICU and located in urban and densely populated civil parishes. Neonatal age showed the highest mean LOS ratio (MR = 2.29, 95% CI 1.96; 2.67, p < 0.001) and ICU admission odds (OR = 9.25, 95% CI 4.84; 17.68, p < 0.001). Mean LOS ratio was significantly higher for Black ethnicity (MR = 1.19; 95% CI 1.10; 1.28, p < 0.001) and lower maternal education. Odds of admission to ICU was significantly higher for male gender (OR = 1.25, 95% CI 1.01; 1.55, p = 0.048) and mother’s unskilled occupation (OR = 1.66, 95% CI 1.09; 2.53, p = 0.019). Paternal manual skilled occupation demonstrated 17% higher mean LOS ratio (p < 0.001) and 51% higher odds of admission to ICU (p = 0.019). Public policies must be culturally competent and target socioeconomic and geographical deprivation.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060766

Authors: Megan M. Patton-Lopez Mariana Pinto-Alvarez Elisa Rivero Julia Ma Ileana Carrión Eric Toole Daniel F. López-Cevallos

Commercial determinants of health (CDoHs) describe how corporate practices influence population health. This scoping review aimed to characterize the extant evidence base regarding how CDoH in the sugar-sweetened beverage (SSB) industry affects health and health-related outcomes among Latinx populations in the United States of America (USA). The present study was conducted in accordance with the JBI methodology for scoping reviews. Overall, 1236 references were identified and imported for screening. After duplicate removal, screening, and full-text eligibility assessment, 33 studies met all inclusion criteria. SSB marketing and advertising was the most frequently examined CDoH (61%), including advertising exposure, messaging strategies, and warning label interventions. SSB taxation studies projected reductions in consumption and obesity prevalence. Outcomes associated with health focused primarily on perceptions of marketing and purchasing intentions (94%). Additional studies examined the impact on knowledge, attitudes, beliefs, and behaviors (e.g., purchasing and consumption of SSBs) (66%), while a few studies included chronic disease (27%) or healthcare outcomes (6%). Evidence highlights several gaps in CDoH research associated with SSBs, with 94% of the included studies focused on understanding marketing exposure, signaling a need to examine other domains of CDoH, SSB industry practices, and impacts on health disparities. Findings suggest that structural policy interventions such as taxation and stronger regulation of commercial practices are necessary to address higher exposure to marketing and consumption of SSBs among Latinx populations in the USA.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060765

Authors: Kellie McLean Stefani Wiloejo Zoya N. Rehman Pasquale E. Rummo Angela C. B. Trude

Inadequate fruit and vegetable consumption is associated with increased risk of chronic disease. Yet, many individuals consume below the recommended intake according to the Dietary Guidelines for Americans (DGA). This study aimed to examine the association of adherence to the DGA (2020–2025) recommendations for fruit and vegetable (FV) intake of 1.5–2 cups of fruits and 2–3 cups of vegetables daily for adults among caretakers with a child(ren) living in households eligible for a Supplemental Nutrition Assistance Program (SNAP). We conducted a cross-sectional analysis of 85 caretakers with children in an urban neighborhood of low-income in the Bronx, New York (NY). Log-binomial regressions demonstrated that having more children (RR 1.36; 95% CI 1.15–1.59), younger children (RR 1.22; 95% CI 1.07–1.39), or children participating in a school lunch program (RR 1.47; 95% CI 1.16–1.85) was positively associated with caretakers’ probability of adhering to the DGA recommendations for FV intake. Our study highlights the eating behaviors of families living with children ≤ 10 years of age, many of whom were participating in a school lunch program, and underscores the dietary benefits associated with these characteristics.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060764

Authors: Janette DeFelice

Objective: Naegleria fowleri, known as the brain-eating amoeba, is a thermophilic, freshwater amoeba causing primary amoebic meningoencephalitis (PAM), a disease that progresses rapidly from symptom onset to death. Climate change is causing surface water temperatures to increase, providing a hospitable environment for N. fowleri, possibly increasing risk factors for PAM. This review synthesizes the peer-reviewed biomedical literature published between January 2012 and December 2025, examining the risk of N. fowleri infection in the context of a warming climate. Methods: A scoping review was conducted searching PubMed, Scopus, and Environment Complete. Data were extracted using a structured coding framework, and risk dimensions were derived inductively during the coding process. Results: Twenty-seven articles met inclusion criteria. Analysis revealed four dimensions of risk (environmental, behavioral, clinical/biological, and infrastructural). The environmental risk dimension highlighted gaps in understanding geographic range expansion and organism ecology. The behavioral dimension identified recreational water exposure, sinus rinsing, and travel as primary risk drivers. The clinical/biological dimension highlighted the need for standards and capacity in diagnosis and treatment, as well as research into pathogenicity. The infrastructural dimension identified gaps in water distribution system surveillance and disinfectant efficacy at high temperatures. Discussion: This review maps environmental, behavioral, clinical/biological, and infrastructural dimensions of N. fowleri disease risk onto a hazard/exposure/vulnerability framework, highlighting major gaps surrounding exposure and vulnerability. Uncertainties remain in hazard habitat favorability factors, human behavior, and water distribution systems. Emphasis should be placed on characterizing the hazard through environmental testing and determining geographic range, and addressing vulnerability by increasing clinician awareness, which serves double duty in both initiating early empiric treatment and efforts to quantify true disease burden.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060763

Authors: Seshadri S. Vasan Sudarshan Anand Miae Lee Nicholas C. Fluck

Burden of diseases measured as disability-adjusted life years (DALYs) per 100,000 people can be mined from public domain data, when they are made available by population health surveillance systems. This can be analysed to allow insightful comparisons with the national average, and to understand differences in trends between the sexes, age groups, time periods, geographic regions, and sub-regions. In this illustrative case study, we have analysed the Scottish burden of disease database to understand what ailed the population of the Grampian region before the COVID-19 pandemic. We have identified that selected cancers, ischaemic heart disease, Alzheimer’s disease and other dementias are amongst the highest contributors to the burden; that drug use disorders and colorectal cancer are showing worsening trends and require health promotion and disease prevention measures from ages 15 and 25, respectively, especially in Aberdeen City; and that males are more vulnerable to atrial fibrillation and flutter, diabetes mellitus, oesophageal cancer, and self-harm, while females are more vulnerable to cerebrovascular and chronic obstructive pulmonary diseases. We demonstrate the usefulness of our analysis and methodology for the wider health system, allowing targeted medical research investments and coordinated response from public health and health service delivery. We also show the need for up-to-date surveillance data, forecasts, and evidence on the impact of interventions to be made available widely.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060762

Authors: Kwadwo Amoah Gladys Fordjuor Seth Lartey Gilbert Batieka Bonsaana Benjamin Abaidoo John Tetteh Enam Afi Mana Aidam Kwame Asante Darko Kwame Oteng Alhassan Fuseini Amanda Evelyn Forgah Mohammed Alphazaazi Quaye Lahari Salma Abdul-Rahaman Amina Ponaa Mamani Dorcas Baah Boateng Josiah Charinga Ida Mbamah Ansing Lawrence Oppong Kusi-Appiah Collins Adjei Asante Awo Yaa Karikari Oduro Bertha Ellen Wryter Kojo Blankson Nafisatu Odokai Odoi Dora Sam-Brew Mabel Oparebea Krow James Addy Michael Gyamera Oboo-Gyan Shannan Berzack Ashiyana Nariani

Background: Organ donation and transplantation are among the greatest scientific discoveries of our time, which have restored hope and life to many. However, several factors influence the global organ donation rate. It is, therefore, important to understand the Ghanaian context of facilitators and barriers to donation to dispel cultural myths and misconceptions about organ donation. This study aims to qualitatively explore the facilitators and barriers influencing organ donation in Ghana. Methods: This was a qualitative exploratory study conducted among health professionals at four major tertiary hospitals in Ghana. Participants were chosen using the purposive sampling technique. Using a structured interview guide, an in-depth interview was conducted to gather qualitative data, which was then tape-recorded and transcribed. Thematic content analysis was used to manually analyze the data. Results: Of the 25 expert participants, the majority (15, 60.0%) were female. The majority (15, 60.0%) were between 40 and 59 years. The mean age was 42.4 ± 8.0 years. The average number of years of work experience was 15.8 ± 7.1 years. Themes identified for facilitators of organ donation included increased awareness and knowledge campaign, societal influence, and legislative support. Themes for barriers were inadequate knowledge, socio-cultural influence, religious beliefs, and ethical concerns. Conclusions: Increased awareness and knowledge campaigns, societal influence, and legislative support are the significant facilitators of organ donation in Ghana, whereas inadequate knowledge, socio-cultural, and religious influence are important barriers to organ donation in Ghana.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060761

Authors: Vladimír Siska Andrea Sollárová Zuzana Slezáková Lukáš Kober Peter Minárik Tomáš Forgon

Investigating the predictors of moral distress is particularly important for protecting nurses’ mental health and professional satisfaction, thereby preventing burnout and attrition from the profession. The primary aim of this study was to evaluate the predictors of moral distress among nurses. A cross-sectional study design was used. The sample consisted of 412 nurses from 11 hospitals across Slovakia. The mean age of the respondents was 40.48 years (SD = 10.92). Moral distress was assessed using the Modified Moral Distress Scale. Linear regression analysis was used to evaluate predictors of moral distress. Personal accomplishment, the maladaptive coping strategy of self-distraction, continuous shift operation, and emotional burnout emerged as significant predictors of the frequency of moral distress among nurses (AdjR2 = 15.5%; R2 = 0.155). Regarding the intensity of moral distress, significant predictors included personal accomplishment, the maladaptive strategy of self-distraction and the adaptive strategy of religiosity and spirituality (AdjR2 = 14.0%; R2 = 0.140), which appear to function as adaptive coping mechanisms for dealing with the intensity of moral distress. Systematic investigation of predictors of moral distress among nurses may contribute to the development of interventions and programs that support nurses, thereby improving not only their job satisfaction but also the quality of patient care.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060760

Authors: Hanan Abdulghafoor Khaleel Riyadh Abdulameer Alhilfi Sabrina Viele Brown

Background: The elimination of measles is a public health priority for the World Health Organization. During the COVID-19 pandemic from 2020 to 2022, the number of cases in Iraq decreased. However, a surge in cases started in late 2022. The aims of this study are to understand and describe the epidemiology of the surge of measles compared to reported cases in 2018 and 2019. Secondarily, they are to identify high clusters to find possible causes and implement prevention efforts accordingly, and low clusters of measles to identify possible protective factors. Methods: Frequencies were used to describe the univariate characteristics of cases reported each year. The chi-square test of independence was used to test differences by age; p-values less than 0.05 were considered statistically significant. Gi cluster analysis was used to determine where there were high and low clusters of cases in each district. Results: The number of clinically confirmed cases of measles rose dramatically in 2023 (14,301) and early 2024 (33,048) compared to 2018 (1044) and 2019 (4586). Most patients were less than one year to 14 years of age. The percentage of patients aged 5–14 years was higher in 2023 (32.8%) and 2024 (30.0%) than in 2018 (15.9%) and 2019 (22.1%). Males were consistently more prevalent than females throughout all study years. Almost 5% (1545) of patients were vaccinated; the remainder were unvaccinated or had unknown vaccination status. Only 1% reported a history of contact with infected patients. The case fatality ratio was 0.06% in 2023 and 0.2% in early 2024. Despite the recent surge in cases, 27 of the 153 districts (17.4%) had low clustering. Conclusions: The recent surge in measles cases in Iraq was found to be in those below 15 who are commonly associated with the disease. Clusters of high reporting were mainly in the middle of Iraq while clusters of low reporting were mainly in the north. We recommend continuing to study clusters of measles and vaccine coverage to direct prevention efforts.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060759

Authors: Sven Maričić Denis Juraga Tomislav Rukavina Darko Roviš Zlatko Trobonjača Mihaela Marinović Glavić Lovorka Bilajac Vanja Vasiljev

The HORUS project investigates the interface between urban planning and public health, focusing on the reduction in non-communicable diseases through innovative urban planning and technological integration. Using geographic information systems, the project will develop advanced urban mapping and analysis tools to visualize and tackle health inequalities. The participatory approach of technologies will actively engage communities and empower citizens to shape a healthier urban environment. Through multidimensional methodology, including qualitative research and natural experiments, HORUS will align urban planning with public health needs. The project will target modifiable risk factors (physical inactivity, unhealthy diet and substance use) and will promote behavior change and environmental redesign to reduce the prevalence of non-communicable diseases. The integration of digital technologies will not only improve the assessment of urban health but also facilitate evidence-based interventions tailored to vulnerable populations. HORUS will provide practical applications for policy makers and urban planners by providing actionable frameworks for incorporating health-promoting features into urban design. This holistic approach will help create resilient cities that prioritize public health and shape the future urban environment. The project is an example of the transformative potential of aligning technology, policy and community engagement to effectively address the challenges of urbanization, and non-communicable diseases.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060758

Authors: Michael Hollifield Jennifer Lai-Trzebiatowski Michael Alkire Tyler C. Smith Christine J. Eickhoff Nima Fahimian Rostam Khoshsar Rajika Tobey Staci Becker Rossean C. Rossel Sarah Madison Patrick Wu Amy Treadwell Christopher Reist

Background/Objectives: Extant data suggest that the Stellate Ganglion Block (SGB) is effective for posttraumatic stress disorder (PTSD). Clinical data from a large healthcare system are lacking. We report data from a clinical project in the Veterans Health Administration. Methods: Retrospective data of PTSD and anxiety for 579 patients who received one or more SGBs were analyzed on the full sample and on those who had complete data using general linear models. Results: Receiving the first SGB provided a 36% and 30% reduction in PTSD symptom scores at 1-week and 1-month post-SGB, respectively. Those who received 2–4+ SGBs showed lower pre-SGB PTSD symptom scores and trends for lower scores at 1-week and 1-month post-SGB. Overall, 78% and 71% of patients had a reliable (Δ ≥ −5 points) change and 68% and 60% had a clinically meaningful (Δ ≥ −10 points) change in PTSD symptom scores from pre-SGB to 1-week and 1-month post-SGB, respectively. There were clinically meaningful reductions for anxiety in 51.5% and 48.3% at 1-week and 1-month post-SGB, respectively. Conclusions: These data corroborate existing data about the benefit of SGB for PTSD and anxiety and are unique in showing an association between repeat SGBs and lower PTSD symptoms at subsequent baseline.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060757

Authors: Bridget Ndlovu Bernard Hope Taderera

Burnout among intensive care unit (ICU) nurses is an escalating occupational health concern due to the high psychological and physical demands of critical care, with implications for staff well-being, patient safety, and healthcare quality. Despite its importance, limited evidence exists on burnout among ICU nurses in Saudi Arabian tertiary hospitals. This study investigated the prevalence of burnout, associated factors, and potential interventions to reduce stigma and support mental health among ICU nurses at a tertiary healthcare setting, Saudi Arabia. A quantitative cross-sectional design was employed using the Maslach Burnout Inventory–Human Services Survey (MBI-HSS). Simple random sampling selected 250 registered ICU nurses with at least six months of experience. Data was analysed using SPSS v30 with descriptive statistics, and chi-square tests at a significance level of p < 0.05. Findings indicated a high prevalence of burnout, with 52% of nurses reporting elevated emotional exhaustion. Burnout was significantly associated with overtime hours (χ2 = 29.155, df = 12, p = 0.015), nurse-to-patient ratios (χ2 = 36.170, df = 20, p = 0.015), shift patterns (day: χ2 = 4.931, df = 8, p = 0.765; night: χ2 = 263 4.226, df = 8, p = 0.836; rotating: χ2 = 3.739, df = 4, p = 0.442), living arrangements ((χ2 = 13.153, df = 16, p = 0.662), and perceived impact on patient outcomes. Participants identified mental health education, anonymous support programmes, psychological check-ins, and leadership encouragement as helpful coping strategies. The study concludes that burnout among ICU nurses is influenced by workload, work schedules, and organisational support, underscoring the need for systemic interventions to enhance nurse well-being and sustain healthcare quality.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060756

Authors: Cynthia A. Tschampl Jennifer J. Wicks Dominic Hodgkin Craig Regis Jadyn Baptista Brittany P. Chapman Madeline E. Davies Kimberly De La Cruz Karen Peugh Allyson Pinkhover Ben Plant Priya Sarin Gupta Sarah Mackin Catherine E. Urquhart Samantha Walsh Jessie M. Gaeta Constance Horgan Elsie M. Taveras

First launched in Boston, MA in January 2018, Community Care in Reach® is a mobile addiction model that uses mobile clinics to deliver harm reduction and clinical services to people at high risk of drug-related morbidity and mortality and who are unhoused or at risk of losing housing. Through a public/private partnership, the model has grown to include six programs across Massachusetts. Using the RE-AIM framework, this initial, descriptive evaluation for this multisite project included quantitative and qualitative methods to give insight into reach and performance. From 1 January 2022 to 30 June 2024, there were 17,887 harm reduction encounters and 16,117 clinical encounters providing care to 4645 individuals. Buprenorphine-based treatment (a key medication for opioid use disorder) was initiated among 1227 individuals, of whom 15% remained in buprenorphine-based treatment after 180 days. Evaluation across multiple organizations posed unique challenges; however, results demonstrated universal engagement of hard-to-reach individuals.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060755

Authors: Hajir Al Hamrashdi Ismail Al Yahmadi Fatma Al Ma’mari

Background radiation and nuclear applications are deeply embedded in modern life. With the continuous advancement in nuclear techniques, daily radiation exposure is commonplace. The level of knowledge within this field among the general public must therefore be assessed to ensure that fundamental and essential information on radiation and nuclear energy is attained and to prevent the spread of misinformation. The aim of this study is to evaluate the level of knowledge and awareness of this topic among the general public in Oman. The study was performed using a cross-sectional survey specifically designed to measure the knowledge of different aspects in the field of radiation and nuclear applications. We achieved this aim by assessing the level of knowledge among the general public and medical professionals. Overall, 500 individuals participated in the study, 75 of whom were from the medical field. The results demonstrate varying levels of knowledge on this topic. In general, the public and medical professionals show a high level of confidence in basic information; however, the level of knowledge and confidence decreases to intermediate and, in some cases, low levels with questions at fundamental and intermediate levels of knowledge. This decrease was clearly observed among topics related to the nature of radiation, the origin of radiation, radiation protection, and radiation applications. Our findings demonstrate conclusively that the public and medical professionals in Oman have limited knowledge in this field; therefore, appropriate measures must be implemented.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060754

Authors: Emily M. Melnick Francesco Acciai Nicole Vaudrin O’Reilly Mindy Jossefides Punam Ohri-Vachaspati

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides monthly cash-value benefits (CVBs) for fruits and vegetables. In addition to fresh produce, WIC agencies may allow households to purchase frozen and canned produce using CVBs. The use of these options may support benefit redemption for households who face inequitable barriers to accessing fresh produce, such as households living on tribal lands. This study examined (1) associations between frozen/canned food CVB purchases and overall CVB redemption and (2) predictors of frozen/canned food purchasing within a Tribal Organization using administrative data collected between November 2024 and April 2025 and a participant survey. Administrative data analyses included 4787 Inter Tribal Council of Arizona WIC-participating households; survey analyses included 1165 respondents. Mixed-effects models showed that households purchasing frozen and canned foods using CVBs, instead of only fresh, redeemed more of their CVBs. Further, higher frozen/canned purchasing predicted higher redemption rates. Households with multiple WIC participants were more likely to purchase frozen and canned foods using CVBs than single-participant households. The most commonly reported reason for purchasing frozen/canned foods in surveys was longer shelf life. Findings indicate that allowing and promoting frozen and canned food options may improve CVB utilization for American Indian families.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060753

Authors: Sari Castrén Johanna Järvinen-Tassopoulos Kirsimarja Raitasalo

Adolescent gambling is a growing public health concern as opportunities expand across both physical and digital environments. This study examined gender differences in on-site and online gambling among Finnish adolescents and assessed associations with school engagement, family context, peer activities, and co-occurring risk behaviors. Data were obtained from the European School Survey Project on Alcohol and Other Drugs (ESPAD), collected from Finnish adolescents aged 15–16 in 2024 (boys: n = 1706; girls: n = 1588). Associations with past-12-month gambling were analyzed using Rao–Scott’s chi-square tests, F tests, and multinomial logistic regression, examining gender interactions. Gambling was more common among boys than girls: 7% of boys had gambled on-site only, 3% online only, and 11% both during the past 12 months. Among girls, the corresponding proportions were 0–2%. Skipping school, spending leisure time with friends, risky sexual behavior, and problematic substance use were associated with increased odds of both gambling types, whereas parental control was associated with decreased odds. Problematic social media increased the odds of on-site gambling, while problematic gaming decreased the odds. Several associations with online gambling differed by gender. These findings support multi-level prevention targeting family, school, peer, and behavioral risk factors.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060752

Authors: Uratcha Sadjapong Nattapon Harnsamut Patipat Vongruang Sakesun Thongtip

Health literacy (HL) is an important factor associated with individuals’ capacity to manage their health effectively. This cross-sectional study assessed HL and its associated factors among 327 community-dwelling individuals in Northern Thailand. Data were collected through face-to-face interviews using the 47-item European Health Literacy Questionnaire (HLS-EU-Q47). The participants were predominantly female (59.9%), with a mean age of 59.0 ± 11.7 years. Overall, 60.2% of the participants exhibited problematic HL across all domains. In bivariate analyses, overall HL was significantly associated with sex, age, body mass index (BMI), education, marital status, and hypertension. Age was negatively correlated with overall HL (r = −0.250, p < 0.001), whereas BMI was positively correlated with overall HL (r = 0.130, p = 0.019). In the multivariable linear regression model, higher education (β = 4.251, p < 0.001), female sex (β = 2.310, p = 0.002), and alcohol consumption (β = 1.411, p = 0.047) were independently associated with higher HL scores. Conversely, marital status (β = −1.747, p = 0.033) was associated with lower HL scores. Problematic HL was highly prevalent in this population and was associated with sociodemographic and health-related factors. These findings highlight the need for targeted, context-specific health communication and education strategies to improve HL among vulnerable community-dwelling populations, particularly older adults and individuals with lower educational attainment.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060751

Authors: Zhandos Kurban Sholpan Bulekbayeva Natalia Slivkina Elena Titskaya Yersin Ussin Galym Zorgulov Farkhad Adylkhanov Dana Aldakuatova

Total hip arthroplasty (THA) is among the most effective orthopedic interventions for osteoarthritis, yet post-operative rehabilitation is frequently delayed due to informational and organizational barriers. Geographic information system (GIS) technology offers a promising approach to improving rehabilitation access coordination, though its integration into patient-facing mobile platforms remains insufficiently studied. This two-arm, parallel-group, superiority randomized controlled trial enrolled 142 adult patients (≥18 years) within seven days of primary THA at the National Research Oncology Center LLC, Astana, Kazakhstan. Participants were randomized 1:1 to the GIS-integrated Health-GIS mobile coordination platform (experimental group) or standard general practitioner (GP)-mediated referral (control group). Key exclusion criteria included severe cognitive or visual impairment, absence of smartphone access or digital literacy, and medical contraindications to rehabilitation. The primary outcomes were time to second-stage rehabilitation initiation and health-related quality of life assessed by the SF-12 (Physical and Mental Component Summaries). Secondary outcomes included the Harris Hip Score (HHS), Visual Analogue Scale (VAS) for pain, System Usability Scale (SUS), and quality-adjusted life years (QALYs) over a 12-month follow-up. Of 142 randomized participants (61% male, 39% female), 131 completed follow-up and were included in the modified intention-to-treat analysis (experimental: n = 66; control: n = 65). The experimental group initiated second-stage rehabilitation significantly earlier (median 43 vs. 59 days; p = 0.021). At 12 months, the experimental group demonstrated superior SF-12 Physical Component Summary scores (48.21 vs. 42.84; p < 0.001), while Mental Component Summary scores did not differ significantly between groups (46.96 vs. 47.05; p = 0.669). Quality-adjusted life years were significantly higher in the experimental group (0.74 ± 0.04 vs. 0.72 ± 0.04; p = 0.008). Harris Hip Scores were significantly better in the experimental group at 6 weeks (p < 0.001) and 6 months (p = 0.009), converging by 12 months (p = 0.068). No statistically significant between-group differences in pain intensity (VAS) were observed at any time point (baseline: p = 0.814; 6 weeks: p = 0.336; 6 months: p = 0.066; 12 months: p = 0.105). Platform usability was rated as good-to-excellent by clinicians (SUS: 86.9 at 6 months) and acceptable by patients (mean SUS: 71.4). A GIS-integrated mobile coordination platform significantly reduced time to rehabilitation initiation and improved physical health-related quality of life and health utility following THA compared to standard referral practice. These findings support platform-based care coordination as an effective complement to surgical care, with important implications for rehabilitation access policy. Future multi-center studies and formal cost-effectiveness analyses are warranted to establish generalizability. Trial Registration: ClinicalTrials.gov, NCT07201116, registered 23 September 2025.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060750

Authors: Ihsen Abid

Life expectancy is a key indicator of public health and sustainable development in Gulf Cooperation Council (GCC) countries, where rapid economic growth, urbanization, and fossil-fuel dependence create environmental and health challenges. This study examines the determinants of life expectancy in six Gulf Cooperation Council countries from 2000 to 2023, focusing on death rates, renewable energy consumption, gross domestic product (GDP) per capita growth, government health expenditure, and carbon dioxide (CO2) emissions. The empirical strategy combines cross-sectional dependence and slope heterogeneity tests, second-generation panel unit root tests, panel cointegration analysis, and a dynamic System Generalized Method of Moments (System GMM) estimator, with Driscoll–Kraay fixed-effects estimates used for robustness. The results show that higher death rates significantly reduce life expectancy, whereas renewable energy consumption and government health expenditure improve longevity. GDP per capita growth has a modest positive effect, while CO2 emissions negatively affect life expectancy, confirming the adverse public health consequences of environmental degradation. Robustness checks support the reliability of the main findings. Overall, the evidence highlights the need for integrated policies that combine clean energy transition, stronger environmental regulation, preventive healthcare investment, and sustainable urban development to improve long-term health outcomes in resource-dependent economies in the region.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060749

Authors: Kayla Blackburn Mina Silberberg Sandra Stinnett Donna Biederman

Homelessness is a major public health concern, and successful rehousing is an important outcome for people experiencing homelessness (PEH). However, limited evidence exists on which individual factors are associated with rehousing after transitional care; this study examined characteristics associated with being rehoused at discharge from Durham Homeless Care Transitions (DHCT). We analyzed data from DHCT, a transitional care program serving PEH. Independent variables included demographic characteristics, self-efficacy, mental healthcare status, and unmet identity and communication access (ICA) needs, including lack of personal identification documentation and technology access. We performed bivariate analyses and multivariable regression to assess associations with being rehoused at discharge. In both bivariate and multivariable analyses, non-White PEH were less likely to be rehoused at discharge than White PEH. Greater unmet ICA needs were also significantly associated with lower likelihood of rehousing. These findings add to the mixed prior literature regarding racial inequities in rehousing among PEH. The concept of ICA needs has not previously been studied and may offer an actionable target for transitional care programs seeking to improve rehousing outcomes and advance equity.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060748

Authors: Shaher H. Hamaideh Abdallah Abu Khait Sawsan Abuhammad Hanan Al-Modallal Ayman Hamdan-Mansour Rami Masa’deh Mohammed ALBashtawy

Background: Alexithymia and Internet addiction are emerging concerns among university students, and perceived social support may help explain how difficulties in identifying and expressing emotions relate to problematic Internet use. This study examined the mediating role of perceived social support in the relationship between alexithymia and Internet addiction among Jordanian university students. Methods: A descriptive cross-sectional online survey was conducted among 300 university students in Jordan during the 2022/2023 academic year using Google Forms distributed through Facebook and Microsoft Teams. Participants completed the Toronto Alexithymia Scale (TAS-20), Internet Addiction Test (IAT), Multidimensional Scale of Perceived Social Support (MSPSS), and demographic questions. Data were analyzed using descriptive statistics, Pearson correlations, multiple regression, and Hayes PROCESS macro Model 4 with 5000 bootstrap samples. Results: The overall mean scores for alexithymia, Internet addiction, and social support were 62.57, 46.05, and 55.13, respectively. Alexithymia was positively correlated with Internet addiction and negatively correlated with social support. Social support partially mediated the relationship between alexithymia and Internet addiction, indicating that higher alexithymia was associated with lower perceived social support, which in turn was associated with higher Internet addiction. Conclusions: The findings support the need for university-based screening and prevention programs that address emotional awareness, healthy Internet use, and social support. Theoretically, the results suggest that social support is a meaningful psychosocial pathway linking alexithymia with problematic Internet use among university students.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060747

Authors: Kelly A. Laurila Suzanne M. Randolph Cunningham Lakesha Stevenson Melissa Tarasenko Lauren M. Ramsey Carlamarie Noboa-Ramos Katherine Matos Akash Dania Angela Sy

In 2020, evaluators within the Research Centers in Minority Institutions (RCMIs) program proposed a conceptual framework identifying four primary evaluation targets: scientific productivity, scientific collaboration, professional growth, and research resources. This study extends prior work by capturing the contextual and process-oriented dimensions of program impact. This reflective practice-based project examines how non-quantitative approaches complement traditional metrics to better characterize RCMI outcomes. Evaluators representing ten RCMI sites participated in a multi-site case study guided by three questions addressing: (1) qualitative evidence of impact beyond metrics; (2) challenges and successes in implementation of non-quantitative methods; and (3) potential expansion of evaluation targets. Evaluators provided descriptive responses, generating a 22-page dataset that was analyzed thematically. Thirteen non-quantitative evaluation domains emerged: investigator consultations, investigator productivity, investigator success, community partnerships, intra-RCMI collaborations, implementation of team science, career progression, programmatic support, mentoring support, impact on RCMI affiliates, intellectual resources, physical resources, and faculty hires. Key challenges included inconsistent data capture and limited evaluation resources, while successes highlighted improved cross-site learning and visibility of program impact. Findings support retaining the original evaluation targets while expanding the framework to include institutional transformation, equitable research environments, and longitudinal societal impact. A conceptual map was developed to depict how mixed methods that include non-quantitative approaches can yield RCMI evaluations that expand upon the current approach, which relies primarily on quantitative data. The authors recommend quantitative targets and non-quantitative strategies to provide context, communicate evidence of success, and inform programmatic changes to deepen the findings and strengthen the rigor of RCMI evaluation practices.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060746

Authors: Cecilia Castiello Kai W. Wheeler Judith Ann Dean Federica Barzi

Indigenous women experience a disproportionate burden of adverse perinatal health outcomes, yet the extent and nature of health promotion interventions addressing modifiable behavioural and social determinants remain poorly synthesised. This scoping review mapped smoking, nutrition, alcohol, physical exercise, and social and emotional wellbeing (SNAPS(o))-related perinatal health promotion programs delivered through Australian Aboriginal Community Controlled Health Organisations (ACCHOs), supplemented by relevant peer-reviewed evidence identified across Australia, Aotearoa New Zealand, Canada, and the United States. A two-phase design looked at peer-reviewed literature from January 2010 to January 2025 across PubMed, CINAHL, and the Cochrane Library, followed by a structured review of Aboriginal Community Controlled Health Organisation (ACCHO) websites in Australia (n = 145). Data were extracted on program characteristics, SNAPS(o) components, implementation models, and evaluation outcomes. Findings were synthesised using content analysis. Thirty-four programs were identified in total, most delivered through ACCHOs (n = 26) and predominantly implemented in Australia (n = 29). Smoking was the most frequently addressed component (n = 18, 55%), while nutrition and social and emotional wellbeing were each included in 27% of programs (n = 9), physical exercise in 18% (n = 6), and alcohol in 15% (n = 5). Grey-literature programs more commonly reflected multi-component, holistic models compared with peer-reviewed studies and formal evaluations. Only 10 programs had identifiable formal evaluation evidence, including published or publicly reported evaluations, almost all of which were identified through academic sources. Evaluations focused primarily on tobacco-related behavioural outcomes, with limited reporting of sustained maternal or infant health endpoints. The perinatal SNAPS(o) intervention landscape for Indigenous women is characterised by strong community-controlled delivery but limited published evaluation, particularly of integrated models implemented within ACCHOs. The concentration of evidence on smoking cessation highlights a need to expand evaluation across broader domains of maternal wellbeing. Strengthening Indigenous-led evaluation frameworks and outcome measures that reflect holistic models of care is essential to advancing equitable and culturally grounded perinatal health systems.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060745

Authors: Akanksha Anand Ian Lindong Sharon Barrett

Background: Immigrant communities and first-generation immigrants in the United States face persistent disparities in maternal health outcomes. These inequities are shaped by intersecting structural conditions, including socioeconomic exclusion, language barriers, cultural differences, and institutional constraints documented in prior research. Methods: This narrative review examined 28 peer-reviewed studies published between 2010 and 2024 that applied an intersectional framework to maternal health research focused on immigrant communities in the United States. Studies were identified through PubMed, Scopus, Web of Science, and Google Scholar. The review analyzed how each study conceptualized, designed, and interpreted maternal health in these populations. Results: Seven recurring themes were identified: barriers to and access to care; gaps in clinical guidance; limitations in health data and surveillance; immigration-related policy context; health system influences; intersectional vulnerability across subgroups; and the role of individual- and community-level supports. Conclusions: The literature highlights the importance of community-based strategies, Medicaid policy considerations, and culturally responsive care in addressing maternal health disparities among immigrant communities. Advancing birth equity will require coordinated efforts across healthcare systems, public health programs, and policy environments.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23060744

Authors: Monde Magadla Mojisola Clara Hosu Linda Sobekwa Mirabel Kah-Keh Nanjoh

Background: Prostate cancer remains a major cause of cancer-related morbidity and mortality among men worldwide. Limited access to oncology services contributes to late presentation, delayed diagnosis, and treatment. This study describes the clinicopathological profile of prostate cancer and identifies factors associated with disease severity at presentation in an Eastern Cape population. Methods: A retrospective cross-sectional study was conducted among men diagnosed with prostate cancer at a tertiary hospital between 2014 and 2024. Demographic, clinical, and pathological data were extracted. Descriptive analyses were performed, and multivariable logistic regression was used to identify independent predictors of advanced disease. Results: The study included 202 patients with a mean age of 67.2 years. Thirty-four (16.8%) reported a family history of prostate cancer, and 62.4% had never undergone PSA screening before diagnosis. Elevated PSA levels were common (60.4%), and more than half of patients presented with advanced disease (54.5%). High-risk and very high-risk disease were identified in 44.1% and 21.3% of patients, respectively. Lack of prior PSA screening was independently associated with high-risk disease (aOR 2.4, 95% CI 1.1–5.0), advanced stage at presentation (aOR 2.4, 95% CI 1.2–4.8), and PSA > 20 ng/mL. Conclusions: There is a high burden of late-stage, high-risk prostate cancer at presentation. These findings highlight ongoing challenges in early detection and emphasize the need for improved awareness, screening, and referral pathways to improve outcomes.