International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050645

Authors: Emily Eddy Stuart Beatty David Nau Karen L. Kier Michelle Musser Michael Rush

Objective: Describe a mobile health clinic program led by pharmacists to provide services in a primary care shortage area. Methods: ONU HealthWise is a comprehensive pharmacy service offered by Ohio Northern University Raabe College of Pharmacy with a mobile clinic initiated in 2015. ONU HealthWise is located in an HRSA-designated medically underserved and primary care shortage area and the mobile health clinic visits 11–18 locations monthly plus additional sites for screening or vaccinations. Medical residents from a health-system attend some locations and collaborative practice agreements allow pharmacists to initiate and adjust medications. Student pharmacists rotate through the mobile clinic to gain experiential training toward their Doctor of Pharmacy. The mobile clinic is an integral part of the learning and precepting for ONU HealthWise PGY-1 residents. Results: Over a 12-month period (July 2024–June 2025), the mobile clinic held 148 clinics across 7 rural counties in northwest Ohio. A total of 1265 screenings were conducted at 713 patient encounters (604 unique patients). Of the screenings, 38.1% of blood glucose, 21.6% of cholesterol, and 60.1% of blood pressures were abnormal. All abnormal tests resulted in either a medication adjustment, scheduled follow-up at future mobile clinic, or referral to a provider. Student pharmacists spent more than 3670 h on the mobile health clinic in experiential education. Conclusion: Pharmacists can be an integral healthcare provider by increasing access to primary care services through a mobile health clinic in a medically underserved area. The service provides learners with vital patient experiences.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050644

Authors: Marie Lluberes-Contreras Eduardo Figueroa-Santiago Hamid-Reza Kohan-Ghadr Angel Ortiz-Ortega Abiel Roche-Lima Roche-Lima

Hemoglobin A1c is a central biomarker for long-term glycemic control and a key predictor of diabetes-related complications. The COVID-19 pandemic disrupted routine healthcare delivery and introduced potential metabolic effects of SARS-CoV-2 infection, yet the long-term impact of COVID-19 on glycemic trajectories in individuals with diabetes remains unclear. In this retrospective study, we leveraged harmonized electronic health record data from the National Clinical Cohort Collaborative to evaluate changes in HbA1c before and after documented SARS-CoV-2 infection in adults with diabetes (n = 93,320). Patients were required to have repeated HbA1c measurements pre- and post-infection and stable exposure to key antihyperglycemic medications. A paired statistical analysis was used to identify individuals with statistically significant post-infection changes in HbA1c. We then developed and evaluated multiple supervised machine learning classifiers using an 80/20 train–test split and cross-validation to assess demographic, clinical, and structural factors associated with significant glycemic change. Most patients (71%) did not experience a statistically significant change in average HbA1c following COVID-19 infection, and among those who did, decreases were more common than increases. A random forest classifier achieved the best overall performance, and feature importance and SHAP analyses highlighted body mass index, insulin use, age, and socioeconomic proxies as key contributors. These findings suggest that while COVID-19 infection does not substantially alter long-term glycemic control for most patients with diabetes, individual-level clinical and structural factors influence post-infection glycemic variability.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050643

Authors: Siti Dariyani Budi Utomo Eflita Meiyetriani Sudibyo Alimoeso Maria Gayatri Sukma Rahayu Restu Octasila

Introduction: The increasing use of traditional contraceptive methods in Indonesia may raise the risk of unintended pregnancies, while modern contraceptive use has stagnated and often experiences discontinuation. Nevertheless, contraceptive choice is an individual right and should guide family planning programs. This study aimed to estimate contraceptive effectiveness based on pregnancy risk and dropout rates and to examine the socio-demographic characteristics of users. Methods: This cross-sectional study with a retrospective cohort approach used calendar data from the 2017 Indonesia Demographic and Health Survey (IDHS). The study population included all contraceptive use episodes within five years, resulting in 46,461 episodes. Data were obtained from the 2017 IDHS socio-demographic questionnaire and contraceptive calendar. Multivariate logistic regression was used for analysis. Results: There was no significant difference in dropout rates between traditional and modern contraceptive users (OR = 0.92; 95% CI = 0.79–1.05). However, users of traditional methods had a 2.46-times higher risk of pregnancy compared with modern method users (95% CI = 2.19–2.76). Traditional contraceptive use was more common among women aged 40–49 years, with parity ≥ 5, higher education, and higher economic status, living in urban areas, and residing in Sumatra, Kalimantan, and Sulawesi (p = 0.001). Conclusions: Traditional contraceptive use is associated with a higher risk of pregnancy. Strengthening counseling services through comprehensive, pluralistic, and participatory approaches is essential while respecting individuals’ rights in contraceptive choice.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050641

Authors: Emil Larsson Sölve Elmståhl Henrik Ekström

Fear of crime (FOC) has been shown to be associated with negative physical and mental health effects, and older adults have been identified as a vulnerable group. As an individual as well as a societal problem, it is expected to increase in line with the growth of the older population. Nevertheless, the associations between FOC, life satisfaction (LS), and health-related quality of life (HRQoL) among non-victimized older adults are not well understood. Thus, the aim of the present study was to investigate whether levels of behavioral FOC in a sample of non-victimized older adults aged 60–93 years (mean age 69.6 years) were associated with HRQoL and LS. In this cross-sectional study a total of 5832 participants, representing both urban and rural areas, constituted the study sample. Associations between levels of behavioral FOC and LS as well as physical and mental HRQoL were examined in adjusted linear regression models. The results revealed that in those not previously exposed to violence or threats, FOC was associated with lower LS and poorer physical and mental HRQoL. When deterioration in HRQoL and LS in non-victimized older adults is discussed in a clinical setting, the possible link to FOC as an often unprovoked social stressor should be considered.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050642

Authors: Ketyllem Tayanne da Silva Costa Maria Francisca da Conceição Maciel Targino Pedro Ivo Torquato Ludugerio Gidyenne Christine Bandeira Silva de Medeiros Grasiela Piuvezam Richardson Augusto Rosendo da Silva

Advances in antiretroviral therapy have transformed infection with HIV into a manageable chronic disease, increasing the survival of people living with HIV, who are also undergoing a demographic aging process marked by the emergence of non-communicable chronic diseases. This study aims to map and analyze how the scientific literature addresses the organization and integration of care in the HIV-NCD syndemic, identifying implications for nursing and for health systems. This is a Rapid Scoping Review, using the databases PubMed, Scopus, CINAHL, and LILACS. Data synthesis was conducted using Microsoft Excel. The research was structured using the PCC framework: Population—people living with HIV (≥18 years); Concept—organization and integration of care in the HIV-NCD syndemic, including care models, care coordination, service integration, and the role of nursing; and Context—health services and systems. Twenty-three studies were included, most of which used qualitative methodology, were conducted in sub-Saharan Africa, and had predominantly female samples. This study demonstrated that the organization of care in the HIV-NCD syndemic remains predominantly characterized by fragmented models, which are insufficient to address the complexity of multimorbidity. Integrated care models emerge as a promising strategy; however, their effects remain limited in settings marked by health inequalities.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050639

Authors: Sonia Villagrán Rueda Lisandro José Alvarado-Peña Luis Alfredo Vega Osuna Flor de la Cruz Salaiza Lizárraga Ma. Loecelia Guadalupe Ruvalcaba Sánchez Bertha Lucía Santos-Hernández Rodolfo Valentín Muñóz Castorena Wilfred Fabián Rivera Martínez

The public sector constitutes a complex system of psycho-affective management, where leadership and autonomy are crucial for institutional efficacy. The objective of this study was to analyze the relationship between leadership, autonomy (control over work), and other psychosocial risk factors across six departments of a government agency in Mexico, under the framework of NOM-035-STPS-2018. A quantitative, cross-sectional, and correlational design was utilized with 235 public servants, employing Reference Guide III of the official standard to identify psychosocial risk categories. The results, analyzed through Welch and Games–Howell tests, reveal significant differences based on the operational nature of each unit. Public Safety and Civil Protection present critical risks due to high demand and low control. The Municipal DIF (System for the Integral Development of the Family) stands out as a protective environment thanks to its positive leadership. A statistically significant association was identified between lower leadership quality and a decrease in work autonomy (rho = 0.701), along with a consistently low perception of performance recognition across all evaluated departments (p = 0.056). It is concluded that management style influences the perception of psychosocial risk, suggesting the need for interventions centered on humanistic leadership to mitigate occupational stress.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050640

Authors: Francesca D’Apolito Alessandra Bulbarelli Elena Lonati Paola Palestini Emanuela Cazzaniga

Bodybuilding aims to achieve a muscular physique through intensive resistance training and strict dietary control. Athletes in this sport could be at risk of disordered eating behaviors; however, limited evidence exists regarding its association with ON. Social media use and Weight-Related Self-Monitoring (WRSM) applications may contribute to ON symptoms by reinforcing rigid dietary behaviors. These aspects remain underexplored in the current literature, particularly within the sporting context. This narrative review aimed to synthesize current evidence on the potential association between bodybuilding and ON, and to examine the influence of social media and weight-related self-monitoring (WRSM) applications on its development. Literature searches included the terms “bodybuilding AND orthorexia nervosa”, “bodybuilding AND eating disorders”, “bodybuilding AND social media”, “bodybuilding AND aesthetic pressure”, “orthorexia nervosa”, “orthorexia nervosa AND social media”, “fitness influencers” and “orthorexia nervosa in sport”. Available evidence suggests that bodybuilders may present risk factors for orthorexic tendencies, including dietary rigidity, body image centrality, perfectionism, and compulsive exercise. Social media may contribute by promoting unrealistic aesthetic standards, potentially reinforcing disordered eating patterns. Although direct data in bodybuilding are limited, findings indicate a plausible vulnerability profile. Monitoring and preventive strategies may be warranted to reduce the risk of onset or exacerbation of comorbid eating disorders.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050638

Authors: Riadh Jeljeli Faycal Farhi Faris El-Dahiyat Mohammed Alsbou Zaheer-Ud-Din Babar

Introduction: Self-medication has become a growing concern, especially in the current era of digitalization. The ubiquitous access to social media platforms has been associated with this behaviour due to factors like body image leading to weight loss obsession and seeking solutions to achieve the ideal body image and weight. Aims: This research also examined the relationship between Social Media Usage and Self-Medication, Weight Loss Obsession, and further Intention to Use Ozempic (semaglutide) among university students in the United Arab Emirates. Methods: The researchers used a cross-sectional design and gathered data from students enrolled at Al Ain University, United Arab Emirates. Data were analyzed using SPSS (Version 29) and SmartPLS software (Version 4). Descriptive statistics and Partial Least Squares Structural Equation Modelling (PLS-SEM) were employed to examine relationships among variables based on the Self-Medication Theory by Khantzian. Results: It was found that Social Media Usage was significantly linked with Self-Medication behaviour among the students. Also, this usage makes individuals conscious about weight and body image as important concerns. Finally, Social Media Usage was also significantly linked with Intention to Use Ozempic for weight loss without medical prescriptions and doctor consultations. Conclusions: It is concluded that self-medication for weight loss disregards the significance of maintaining a well-balanced diet and regular exercise, leading to serious health risks, i.e., nutritional deficiencies, metabolic disorders, and negative effects on mental well-being. Educating and informing young individuals about the importance of adopting healthy and sustainable weight loss processes is important, underlining the need for professional guidance, nutrition education, and promoting a positive body image. This approach may help reduce the harmful outcomes associated with self-medication for weight loss.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050637

Authors: Saya Moriyama Minoru Takahashi Aimi Hayashi Takayuki Harada

Problematic internet use among children and adolescents is a major public health concern. In this protocol, it is defined as construct encompassing problematic gaming, social media use, smartphone use, and undifferentiated use, characterized by impaired control, prioritization, and persistence despite harm. It is associated with academic, sleep, and psychosocial difficulties. However, preventive interventions—particularly family-based—remain underexplored despite evidence linking parenting and family functioning to risk. This protocol outlines systematic review and meta-analysis of family-based preventive interventions among children and adolescents (6–18 years). Randomized controlled, quasi-randomized, cluster-randomized, and quasi-experimental studies with parallel comparison groups will be included. Comparators defined as no intervention, waitlist, usual care, or non-family-based prevention. Searches will be conducted in CENTRAL, PubMed, PsycINFO, Web of Science, and CiNii Research, supplemented by reference screening. Risk-of-bias will be assessed using RoB 2 and ROBINS-I. Primary outcomes include changes in overall and subtype-specific severity; secondary outcomes include use time, family functioning, and parental involvement. Random-effects meta-analyses with Hartung–Knapp adjustment will be conducted when ≥3 homogeneous studies are available; otherwise, findings will be synthesized narratively following the Synthesis Without Meta-analysis guideline. This review will synthesize current evidence and clarify role of family-based prevention, informing research and public health strategies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050636

Authors: Rabia Imran Aashka Patel Morgan Snell

Smoking combustible cigarettes causes an enormous health and financial burden in the U.S. Across tobacco and nicotine products, cigarettes are ranked as the most toxic. Any harm reduction efforts rely on smokers understanding nicotine’s absolute and relative health risk potential, but many studies reveal widespread misperceptions. To inform policies focused on reducing the public health burden of smoking, it is essential to understand whether conveying accurate absolute and relative risk information about nicotine and its delivery methods may shift risk perceptions and impact use behaviors. To fill this gap, we conducted a systematic search, using PubMed, PsycINFO, and Google Scholar, for original U.S. studies investigating effects of exposure to educational messages about (1) nicotine’s addictive and health risk properties or (2) relative risk information on participants’ nicotine knowledge, perceptions, behavioral attentions, and/or use behaviors. Across studies of predominantly fair methodological quality, message exposure was consistently associated with improvements in knowledge and risk perceptions; however, findings were mixed regarding behavioral intentions, and the evidence base is limited by short-term experimental designs without longitudinal follow-up. Our results highlight the potential for educational interventions to increase nicotine knowledge more broadly and reveal important considerations for using education to try to shift behavior among individuals who smoke.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050635

Authors: Jea-Yong Jung Gwi-Gon Kim

Firefighters are repeatedly exposed to occupational trauma in high-risk work settings, and PTSD symptoms represent an important occupational and public health concern. This study examined the association between psychological safety and PTSD symptoms among firefighters and tested whether this association is conditioned by occupational identity and peer support within an occupational health framework. A cross-sectional survey was conducted with 314 firefighters in Gyeongsangbuk-do, South Korea. PTSD symptoms were assessed using eight selected items adapted from the PCL-5 representing core symptom domains. Confirmatory factor analysis, correlation analysis, and regression analysis were performed, and moderation analyses were conducted using PROCESS Macro (Model 1). Results indicated that psychological safety was negatively associated with PTSD symptoms. Both occupational identity and peer support significantly conditioned this association. The negative association was consistently observed across all levels of occupational identity, whereas it was significant only at or above the mean level of peer support. These findings suggest that psychological safety may be understood as an organizational resource related to PTSD symptoms in high-risk occupational contexts, while occupational identity and peer support may function as individual and social resources that condition this association. The findings highlight the importance of understanding occupational mental health based on the integrated roles of organizational, individual, and social resources.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050634

Authors: Oriana Binik Debora Ginocchio Clarissa Cricenti Silvia Ferrari Tindara Addabbo Isabella Merzagora Anna Maria Giannini Georgia Zara Giovanna Laura De Fazio

Sexual harassment (SH) in academia constitutes a pervasive form of gender-based violence that undermines individual well-being and academic equity. While existing research has largely investigated risk factors, less attention has been paid to protective factors, coping strategies, and the cumulative burden generated by the reporting process itself. This qualitative study explores how victims of SH in Italian universities mobilize resources when disclosing their experiences informally to peers and colleagues or formally through institutional channels and how this process generates extra-fatigue: the cumulative cognitive, emotional, and practical labor victims have to perform as a direct consequence of inadequate institutional responses. Drawing on semi-structured interviews, we employed thematic and dialogical narrative analyses to examine cognitive, emotional, and behavioral coping dimensions. Findings highlight the central role of informal networks in enabling victims to recognize harassment, validate their narratives, and mobilize coping strategies. Trusted colleagues and supportive professors provided cognitive clarity, emotional relief, and practical protection. However, institutional responses were frequently perceived as inadequate or emotionally detached, reinforcing self-doubt and generating significant extra-fatigue to absorb largely alone or through informal support. Understanding extra-fatigue as structurally produced labor, rather than individual fragility, has implications for designing victim-centered institutional responses and structural reform in universities.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050633

Authors: Stanslaus Mghanga Alan Elias Mtenga Liliane Pasape Ally Olotu

Background: Clinical trials are important for advancing medical knowledge and improving healthcare delivery. However, participants’ knowledge and attitudes towards clinical trials remain a key challenge affecting clinical trial recruitment and participant retention. Therefore, this study aimed to assess the knowledge and attitudes of the Bagamoyo district towards participation in clinical trials. Methods: A convergent parallel mixed-methods study was conducted among adults in the Bagamoyo district. Multistage stratified random sampling was used to select participants. Quantitative data were analysed descriptively and using logistic regression, while qualitative data were analysed thematically using NVivo. Results: Among 394 recruited participants, 293 (74.4%) were female and 101 (25.6%) were male. Most participants had a primary-level education (266, 67.5%), while 128 (32.5%) had secondary or tertiary education. The majority were married (297, 75.4%) and 97 (24.6%) were either separated or unmarried. Regarding economic status, 244 participants (61.9%) earned less than TZS 50,000. General knowledge of clinical trials was low, with most participants scoring below 60%. However, we found a positive attitude towards participation in clinical trials. Logistic regression revealed that poor knowledge was significantly associated with being male (AOR, 22.95 (95% CI: 10.27–51.28, p = 0.001)), age above 55 years (AOR of 2.43 (95% CI: 1.29–4.55, p = 0.006)), and unemployment (AOR of 2.39 (95% CI: 1.27–4.53, p = 0.007)). Positive attitudes towards clinical trial participation were significantly associated with being female (AOR) 7.61 (95% CI: 4.32–13.39, p < 0.001), age 44 years and below, (AOR: 2.22 (95% CI: 1.27–3.86, p = 0.005), and employment (AOR of 1.89 (95% CI: 1.08–3.32, p = 0.03). Conclusions: Despite low levels of knowledge, the general population in the Bagamoyo district demonstrated a high willingness to participate in clinical trials. To address the knowledge gap, targeted educational interventions should focus on older adults and the unemployed. Furthermore, policies supporting community outreach and awareness campaigns may help strengthen public understanding and sustain positive attitudes toward clinical research.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050632

Authors: Lina Homman Lilly Augustine Mats Granlund

Poor mental health (problems and well-being) among children, particularly those with disabilities, represents a significant individual and public health burden, with multifactorial origins including family environment and participation limitations. Family climate also impacts participation, suggesting the three structures may be interlinked. Furthermore, children with disabilities face additional obstacles increasing their vulnerability to poor mental health, such as limitations to participation. Therefore, the present study aimed to (1) investigate whether participation mediated the relationship between family climate and mental health and (2) whether possible relationships differed by disabilities. The Swedish Statistics (SCB) register on the conditions of life for children (barnULF) was utilised. This interview-based registry study employs a repeated cross-sectional design, where children are recruited yearly and invited to participate in the study. The present study used data from 2013–2019, resulting in 3676 children aged 10–18, of whom 510 reported some type of disability. Structural Equation Models (SEMs) mediation analyses were conducted to assess the possible mediating role of participation between family climate and mental health (well-being and problems separately), including models with and without covariates (age and gender). Multigroup analyses were conducted to assess whether children with and without disability differed. Results showed that participation significantly mediated the relationship between family climate and mental well-being but not mental health problems, amongst all children. Models including covariates indicated mediating models for both well-being and problems, but only amongst children without disabilities. However, model fits were poor. Implications of the study direct preventative strategies to focus on family climate as a route to improve mental well-being and highlight the importance of earlier strategies amongst children with disabilities and in particular girls.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050631

Authors: Danleen James Hongoro Andre Pascal Kengne Nasheeta Peer Kim Nguyen Kirsty Bobrow Olufunke A. Alaba

In the original publication [...]

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050630

Authors: Amelia Sullivan Bryn Kubinsky Jade McNamara

Helping Early Adolescents Live Their Healthiest Youth (HEALTHY) is a theory-driven, school-based nutrition education program grounded in frozen-fruit smoothie taste tests that has been shown to improve fruit intake and promote nutrition security among rural adolescents. To support broader dissemination, a comprehensive implementation toolkit and website were developed. This study conducted an expert review to evaluate the feasibility, clarity, and acceptability of the HEALTHY Toolkit. A survey collected quantitative (Likert-scale) and qualitative (open-ended) data, which were analyzed using descriptive statistics and content analysis. Experts (N = 15) primarily included Registered Dietitians (40%, n = 6) and school nutrition professionals (33%, n = 5). Experts reported high agreement that the HEALTHY Toolkit provided sufficient detail and guidance for implementation, indicating strong feasibility, clarity, and acceptability. Mean scores across Toolkit sections were high: Part I. Foundations (4.70 ± 0.26), Part II. Program Design and Implementation (4.64 ± 0.41), and Part III. Tools and Resources (4.14 ± 0.17). These findings support the use of formative evaluation approaches, such as expert review, to optimize implementation resources and strengthen readiness before dissemination. Overall, the HEALTHY Toolkit was perceived as a promising resource for supporting the implementation of the HEALTHY program.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050629

Authors: Şermin Önem

Nutritional supplement use has emerged as an important health-related consumption behavior in digitalized environments, with implications for both public health and individual well-being. While prior research has largely focused on general populations, limited attention has been paid to how occupational pressures and digital information contexts jointly shape supplement-related decision-making among highly educated professionals. Addressing this gap, this study examines the behavioral determinants of nutritional supplement use among academics within an intention–behavior framework. Using survey data collected from academic professionals, the proposed model was tested through confirmatory factor analysis and structural equation modeling. The findings reveal that health motivation and academic work stress significantly predict supplement use intention, which, in turn, strongly influences actual consumption behavior. In contrast, digital health literacy and digital marketing exposure do not exert significant direct effects on usage intention. These results provide theoretical insight into the boundary conditions of informational determinants in consumer behavior models, suggesting that intrinsic motivation and contextual stressors may play a more dominant role than digital influences among highly educated consumers. From a practical perspective, the findings highlight the importance of addressing stress-related health coping mechanisms and motivation-driven behaviors in promoting informed supplement use.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050628

Authors: Ruth Lin Campbell Smita Ekka Dewan

Increasing opiate use and mental health problems among younger and older Latinos in urban US contexts prompted this investigation into the organizational resources that facilitate help-seeking efforts of Latinos in New York State (NYS). Guided by a Vulnerability Model and a framework of organizational enabling resources, this study used complementary longitudinal and cross-sectional designs. The longitudinal component examined changes in levels of organizational facilitators for Latino substance use disorder (SUD) help-seeking in Downstate NYS across three time periods, while the cross-sectional component compared post-pandemic facilitator levels across service types and regions. A convenience sample of 241 SUD clinicians participated in the longitudinal analysis. A sample of 150 clinicians whose practice information varied by location and service type participated in the post-pandemic cross-sectional comparisons. The findings revealed that the proportion of clinicians reporting organizational facilitation of Latino SUD help-seeking in Downstate NYS has diminished significantly from pre-pandemic levels, with little recovery. Cross-sectional analyses revealed no significant differences in clinician estimation of post-pandemic organizational resources by region or service type. The findings suggest that the organizational bulwarks against SUD and mental health problems are not sufficient to mitigate public health risk for NYS Latinos in the post-pandemic period. Recommendations informed by provider perspectives are discussed.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050627

Authors: Petra Norlund Jamal Jokar Arsanjani Jesper M. Paasch

The COVID-19 pandemic generated an unprecedented volume of spatially and temporally resolved data, enabling rapid development of spatio-temporal models for surveillance, forecasting, and policy support. However, the evolution, geographic distribution, and equity implications of these models remain insufficiently synthesized. This study presents a global systematic review of 363 peer-reviewed studies published between January 2020 and August 2025 using publicly available data. Following PRISMA 2020 guidelines, studies were classified by geographic scale, modeling approach, data streams, and analytical purpose. The results indicate that Bayesian and compartmental models remained dominant throughout the pandemic, although methodological diversity increased over time with the growing use of machine learning and hybrid frameworks integrating mobility, environmental, and socio-demographic data. Data integration was more common than previously reported. Approximately 30% of studies relied on a single data stream, while 70% incorporated multiple sources, although most multi-source approaches combined only two data types and relatively few studies integrated three or more. Geographic coverage was uneven, with a strong concentration of studies in high-income regions and persistent underrepresentation of low- and middle-income contexts. Models incorporating finer spatial scales and socio-demographic variables more frequently supported geographically targeted interpretation of risk, vulnerability, testing access, and intervention needs. Overall, the findings highlight the importance of multi-source data integration, improved geographic representativeness, and transparent uncertainty communication, alongside the need for FAIR-aligned and equity-aware data infrastructures to strengthen future pandemic preparedness.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050626

Authors: Rafael Baena Neto Vicente Idalberto Becerra Sablón

The digital transformation of health systems and the increasing adoption of data-driven public health strategies have intensified the need for methods capable of capturing, structuring, and analyzing information derived from clinical interactions. In the Brazilian Unified Health System (SUS), orthopedic rehabilitation and therapeutic exercise prescription rely heavily on communication between healthcare professionals and patients, particularly with regard to understanding instructions, reporting symptoms, and identifying barriers to treatment continuity. However, much of this information remains embedded in unstructured spoken interactions, limiting its use for monitoring and evaluation purposes. This study presents a prospective methodological protocol for the future development and validation of a speech analytics architecture designed to analyze verbal interactions in orthopedic rehabilitation within the SUS. The proposed framework integrates automatic speech recognition, speaker diarization, semantic processing with large language models (LLMs), biomedical entity extraction, and retrieval-grounded analytical components to generate structured indicators from clinical speech. In addition, the manuscript includes an illustrative simulation based on administrative proxy data converted into synthetic narratives in order to exemplify the expected structure of downstream analytical outputs. This simulation does not constitute validation of the full audio-based pipeline, but rather serves to clarify the proposed analytical workflow. Overall, the protocol establishes a structured methodological basis for future empirical studies aimed at evaluating the technical performance, semantic validity, and potential public health utility of speech analytics in rehabilitation monitoring, under appropriate ethical, regulatory, and data protection safeguards.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050625

Authors: Nedim Durmus Ziyue Wang Alan A. Arslan Emre Goren Ramazan Alptekin Yujia Lou Andrew Shao Nida Athar Yibeltal A. Ashebir Yidan Shi Leigh Wilson Joan Reibman Yongzhao Shao

Local community populations (“survivors”) exposed to the World Trade Center (WTC) disaster experienced complex exposures to mixtures of dust and combustion products with potential carcinogenic effects. Survivors with certifiable WTC-related conditions are eligible for inclusion in the federally funded WTC Health Program. We provide an updated description of cancers in the WTC Environmental Health Center (EHC), a program for WTC survivors, through 31 December 2024. Using data from the WTC EHC Pan Cancer Database, we summarized demographics, exposure history, and tumor characteristics among enrollees with pathologically confirmed primary cancers meeting WTC Health Program certification criteria. Among 17,449 members, 7274 had a certifiable cancer diagnosis; excluding non-melanoma skin cancers, 6588 patients with 7643 eligible cancers were analyzed. Women comprised 50.3% of the cohort and 47.5% of diagnoses. Solid tumors accounted for 87% of certifications, with breast (22%) and prostate (19%) cancers most frequent, followed by lung (8%), thyroid (6%), colorectal (6%), and melanoma (4.5%). Lymphoproliferative and hematopoietic malignancies represented 13% of cases. Fourteen percent developed multiple primary cancers, and median latency clustered around 14–16 years. Compared with our previous report in 2020, the enrolled number of cancers increased 2.5-fold. These findings support the need for sustained surveillance and additional epidemiologic studies to improve cancer prevention and survivorship in this uniquely exposed population.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050623

Authors: Palesa Sokazi Zelda Janse van Rensburg Wanda Jacobs

This study aimed to explore and describe the barriers to Antiretroviral Therapy (ART) adherence among children in Ekurhuleni, Gauteng. A quantitative, cross-sectional design using a survey method was employed. Convenience sampling was used to recruit 157 parents, guardians, and caregivers (PGCs) who consented to participate in the study. Data was collected using self-report questionnaires and analysed using descriptive statistics and frequency distributions. The study was not designed or statistically powered to formally test associations between variables; therefore, only descriptive statistical analyses were conducted. The reliability and validity of the instrument were ensured, and ethical clearance was obtained from the relevant authorities prior to data collection. The study was conducted in accordance with established ethical principles and in compliance with the Declaration of Helsinki. The findings revealed that there were multiple barriers to children’s adherence to ART. Approximately one-third of PGCs reported being fully informed about the importance of ART adherence, while the majority indicated being only partially informed. Missed doses emerged as a significant challenge, with a substantial proportion reporting missed medication on one or more days, and only 31.2% administering ART consistently on time. Difficulties in understanding blood test results were also reported. In addition, a notable proportion of PGCs admitted to missing clinic appointments. These findings emphasize the need for strengthened caregiver education, ongoing support, and tailored interventions directed at primary health care nurses to promote consistent ART adherence among children.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050624

Authors: Viviane Dasilva Diana Poli Olimpia Pino

This paper proposes a high-precision theoretical and computational neurorehabilitation framework for Mild Cognitive Impairment (MCI), connecting computational neuroscience and clinical practice through qEEG-guided neurofeedback training (NFT). By employing sLORETA to identify putative pathological nodes within the Default Mode Network (DMN)—specifically the Precuneus and the Posterior Cingulate—the model utilizes spectral decomposition to isolate the aperiodic 1/f component, reducing background noise bias and allowing the calculation of a pure individual alpha frequency (IAF) to inform recalibration of Weber’s Cognitive Threshold. The core architecture uses Bayesian algorithms and stochastic modeling to drive a Dynamic Weight Change mechanism. To support Long-Term Potentiation (LTP) and Hebbian learning, reward thresholds are modulated in real time to target a 70% success rate, as a strategic rationale to anticipate neural fatigue while maintaining the Reward Prediction Error required for synaptic strengthening. As a prospective validation pathway, future studies may assess clinical value through changes in MoCA and RAVLT scores, as well as by examining normalization of cortical coherence in the Default Mode Network (DMN). By merging computational neuroscience with biological models of synaptic plasticity, this work outlines how individual biology can be mapped into an explicit mathematical model. The proposed framework may inform an individualized protocol that provides an objective model-based measure of cognitive recovery, suggesting a replicable and robust strategy for neurorehabilitation during the prodromal phase of dementia, and providing a new approach to neuroscience-based cognitive rehabilitation. This work is intended as a theoretical and computational framework; no complete empirical dataset is reported in the present manuscript.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050622

Authors: Sarah H. Nash Rachael Adcock Chi Wang Mindy C. Hebert-DeRouen Natalie S. Joe Dornell Pete Tyler B. Kratzer Charles L. Wiggins Lihua Liu Bradley D. McDowell

Purpose: Purchased/Referred Care Delivery Area (PRCDA) counties are those where resident American Indian and Alaska Native (AIAN) people are eligible for Indian Health Service care. Due to concerns about racial misclassification, cancer statistics for AIAN people are often restricted to PRCDA counties. Differences in sociodemographic characteristics may exist between PRCDA and non-PRCDA counties, but have not been described; therefore, the potential selection bias associated with the restriction to PRCDA counties remains unknown. Methods: We used data from the University of California, San Francisco Health Atlas to explore ecological differences in county-level demographic, socioeconomic, healthcare access, and health outcomes data between PRCDA and non-PRCDA counties (n = 3152 counties). We tested for statistical differences in mean levels of demographics between PRCDA and non-PRCDA counties using Pooled or Welch t-tests. Results: We observed small, but statistically significant differences between PRCDA and non-PRCDA counties in county-level demographic and socioeconomic characteristics (age, poverty, utility services threat, unemployment, educational attainment, computer access, and median income), neighborhood and environment characteristics (overcrowding, severe mortgage/rent burden), healthcare access and utilization (uninsured, annual checkup, annual dental visit, mammography, binge drinking, smoking, physical inactivity, social isolation), and health outcomes (poor mental health, arthritis, poor self-rated health, high blood pressure, diabetes, high cholesterol, and obesity). Conclusions: These results indicate variability in county-level measures between PRCDA and non-PRCDA counties. While these data do not speak specifically to AIAN peoples’ experiences, they provide critical contextual information to understand how exclusion of AIAN people residing in non-PRCDA counties from cancer statistics may bias risk estimates.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050621

Authors: Younoh Kim Vlad Radoias

Hypertension is a serious public health concern in developing countries, where the lack of resources and the poor infrastructure often lead to a high incidence of disease and also to high rates of underdiagnosis. We study the linkages between hypertension and social capital in Indonesia. Indonesia is a large developing economy, where social capital is encouraged and plays a significant role. We use participation in community programs as a proxy for social capital, specifically capturing the structural dimension of social networks. By engaging in these programs, individuals create the social ties that facilitate resource sharing and gain access to socially embedded resources. We find significant associations between participating in community programs and having lower blood pressure and lower likelihood of hypertension. These results underscore the public health significance of social capital as a potential non-clinical determinant of health. From a policy perspective, the findings suggest that strengthening community-based social infrastructure could offer an alternative strategy to mitigate hypertension in resource-constrained economies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050620

Authors: Roy McConkey Fiona Murray

Background: Children and adults with disabilities are widely acknowledged to have poorer health and emotional wellbeing than their non-disabled peers, which is further compounded by less access to health services and health-promoting activities. A relatively untried solution is to mobilize community initiatives such as sports to promote better health. Method: Special Olympics (SO) is an international sports organization present in over 200 countries and jurisdictions, engaging with just under four million athletes with intellectual disabilities annually. Research on the perceptions of sports coaches around incorporating health promotion within their sports training has been scarce. Likewise, little attention has been paid to identifying athletes’ understanding of what health means to them and actions that would make them healthier. A qualitative, descriptive study was conducted with eight national SO programs involving 62 coaches and 47 athletes. Group interviews were conducted via Zoom and a thematic content analysis was made of their responses. Results: In all countries, coaches and athletes agreed that the most common needs were healthy eating, healthy weight and exercise. Good mental wellbeing and sleeping well were also named. Ideas were sought from both sets of participants regarding how coaches could assist their athletes to attain better health and the barriers they might face in doing so. Conclusions: Three main conclusions emerged. Athletes and coaches were aware of health deficits and knew of ways to reduce them. Both appreciated the contribution that coaches could make through motivating athletes and providing training activities but were dependent on suitable resources being available to them. Engagement with families and available health and social care services was essential. Health-oriented, sporting activities offer promise in improving the health and wellbeing of persons with developmental disabilities, particularly in less affluent countries with fewer health professionals and poorly developed primary care services.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050619

Authors: Anna Khalemsky Moshe Z. Abramowitz Roman Sonkin Haim Y. Knobler Eli Jaffe

The COVID-19 pandemic introduced unprecedented societal disruptions that may have altered patterns of acute substance-related harm. Despite extensive research on overdose mortality, there remains limited real-time, population-level evidence based on Emergency Medical Services (EMS) data. This study provides a national, multi-year characterization of temporal trends in alcohol- and drug-related overdose incidents in Israel across thirteen defined pandemic phases. A total of 18,348 overdose cases recorded between 1 January 2019 and 31 December 2022 were analyzed. Descriptive statistics were calculated, event frequencies were normalized by period length, and loglinear Poisson models were applied to compare occurrences across periods. Cluster analysis was used to explore joint age- and gender-related patterns. Alcohol-related overdoses demonstrated marked fluctuations across pandemic phases, whereas drug-related overdoses showed comparatively moderate variation and a gradual increase over time. Age- and gender-specific heterogeneity was observed across periods. As an observational study based on EMS records, causal inference cannot be established. These findings provide population-level surveillance evidence of dynamic overdose patterns during prolonged societal disruption and highlight the importance of integrating EMS-based monitoring into public health preparedness strategies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050618

Authors: Deeyana Binhayeekonoh Pussadee Laor Nutnaree Nimsiri Sujittra Hinwiset Safeena Tohranee Rohmatul Fajriyah Wanvisa Saisanan Na Ayudhaya

Village Health Volunteers (VHVs) play an important role in Thailand’s community-based public health system, yet limited evidence is available on how their digital engagement relates to their own health behaviors. This cross-sectional study examined associations between sociodemographic characteristics, digital use frequency, digital literacy, and health behavior scores among 426 VHVs in southern Thailand. Data were collected using an online questionnaire that included the Mobile Device Proficiency Questionnaire (MDPQ-16) and a 23-item health behavior measure based on the Thai 3A2S framework. The median health behavior score was 61.0 (IQR 13.25). After adjustment, rural residence was associated with higher health behavior scores (β = 1.97, p = 0.043), whereas frequent digital use was associated with lower scores than infrequent use (β = −2.72, p = 0.010). Digital literacy was not independently associated with health behavior scores. The final model explained 4% of the variance, suggesting that additional factors may influence VHVs’ health behaviors. Overall, the findings indicate that digital literacy alone may not explain differences in health behaviors and that context may also play a role. Future research should examine these relationships using broader and more context-sensitive measures.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050617

Authors: Maja Cvek Emina Pustijanac Marko Vucelja Dean Girotto Josip Margaletić Linda Bjedov

Tick-borne diseases are a growing public health concern in the Mediterranean. Brijuni National Park (BNP), a unique, highly visited island ecosystem characterized by increased large game host density and diverse Mediterranean habitats, presents an elevated risk for pathogen co-circulation. This study addresses the lack of spatial and epidemiological data to accurately assess human exposure risk in this environment. We performed a detailed geospatial and epidemiological risk mapping of pathogen co-circulation in BNP. A total of 587 hard ticks were collected across 26 georeferenced micro-locations (2020–2022). Ticks were morphologically identified and subsequently screened for six key zoonotic bacterial pathogens using qPCR. The Minimal Infection Rate (MIR) and a Co-infection Rate (CR) were calculated. Geographic Information System (GIS) mapping was utilized to map ecological determinants of risk. Ixodes ricinus was the overwhelmingly dominant vector (94.0%), peaking in spring, with activity absent in summer. Recorded diverse tick fauna also included Hyalomma marginatum (3%), Haemaphysalis punctata (2%), Ixodes frontalis (0.8%) and Rhipicephalus sanguineus (0.2%). Active circulation of Borrelia burgdorferi s.l. (Bbsl), Anaplasma phagocytophilum, and Ehrlichia canis were confirmed. Bbsl presented the highest MIR (3.05). The Co-infection Rate (CR) was notably high at 29.41%, with triple co-infections (Bbsl, A. phagocytophilum, E. canis) concentrated in cultivated mosaics and holm oak forests (Quercus ilex L.). The highest number of ticks was recovered from ecotone zones, accounting for 50.0% of the total catch, confirming them as high-risk interfaces. The absence of Rickettsia conorii may be attributed to the strict control/absence of its primary host (domestic dogs). The presence of the exotic vector H. marginatum was also confirmed. The high rate of co-infection and the spatial concentration of risk in specific habitats underscore an elevated and complex public health risk in BNP, closely linked to habitat structure and increased game host density. This research provides an essential geospatial framework for targeted ‘One Health’ management, prioritizing vector control in ecotone zones and dense forest refugia. Urgent surveillance for the exotic H. marginatum is warranted to monitor the potential risk of Crimean-Congo Hemorrhagic Fever.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050616

Authors: Beatriz Minghelli Vera Lúcia Ramos Guerreiro Rodrigo Miguel Coelho Luz Bruna Raquel Ferreira Rodrigues Miguel Tomé Carminho

Frisbee has gained increasing popularity and is characterized by high-intensity running, rapid changes in direction, jumping, and indirect physical contact, exposing players to a risk of injury. This study aimed to determine the epidemiology of musculoskeletal injuries in frisbee athletes who participated in the World Beach Ultimate Championship in Portugal, and the risk factors associated with these injuries. The sample included 484 athletes aged 18–64 years, of whom 275 (56.8%) were male. Data was collected using a digital questionnaire. Across their frisbee practice, 391 (80.8%) athletes reported at least one injury, totalling 1685 injuries. A total of 49 (10.1%) athletes reported an injury in the last 7 days. Over the past 12 months, 211 (43.6%) athletes sustained injuries, totalling 358 cases. The injury proportion was 0.44 (95% CI: 39.2–48.0), and the injury rate was 0.67 injuries per 1000 h of training. The most frequent injuries were muscle strains (18.86%) and sprains (13.43%), mainly affecting the ankle (62; 17.71%) and knee (54; 15.43%). Repetitive movements (84; 22.11%) and changes in direction (62; 16.32%) were the most common mechanisms. Athletes with equal or more than 11 years of practice had a higher injury risk (OR = 1.84; 95% CI: 1.16–2.91; p = 0.009). Frisbee athletes present a considerable risk of injuries. Preventive strategies are recommended.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050615

Authors: Monika Norberg Elisabet Bohlin Ann Dolling Benno Krachler Julia Elfving Martin Gärdemalm Kristina Lämås

This study explores experiences of spending time in immersive virtual reality with a natural environment among individuals with type 2 diabetes, aiming to enhance perceived wellbeing and reduce perceived stress. Seventeen participants with type 2 diabetes took part in a multimodal lifestyle education program and used immersive virtual reality with natural environment over a six-month period, selecting from a number of 30 min serene natural environments. Semi-structured interviews were conducted and analyzed using qualitative content analysis. Participants described immersive virtual reality with a natural environment experience as providing tranquility, inspiration, and a sense of transcending time and space (A). Feelings of calm and mental withdrawal from everyday demands were often reported (A2), and memories were evoked (A2). Some participants experienced these effects as extending beyond the immersive virtual reality with natural environment sessions themselves (A3–4). At the same time, several factors were identified that could disrupt the restorative experience (A5), including technical issues, individual preferences for specific environments, health- or situation-related constraints, and difficulties establishing a regular routine for headset use. Immersive virtual reality with natural environment was generally viewed as a valuable complement to real-world nature experiences, particularly for individuals with limited access to outdoor environments (B1–2). Overall, the findings suggest that immersive virtual reality with natural environment experiences may offer a supportive resource for enhancing emotional wellbeing and managing stress in people with type 2 diabetes, while not replacing the benefits of actual nature exposure.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050614

Authors: Siji Thomas Shafer G. Tharrington Aditya Patel Mevelyn Kaalla Adarsh Thomas Nikhil Madala Younghoon Kwon William J. Healy

Background: Sleep apnea is identified and treated less frequently among racial and ethnic minorities. Objective: The purpose of this systematic review was to examine disparities among racial and ethnic minorities and to understand the reasons for poor sleep health. Methods: The authors conducted a literature search using PubMed and Cochrane Library databases, last accessed in September 2025, using regular and MeSH keywords. A total of 123 articles were identified. PRISMA guidelines were followed, the PICO framework was applied, and the inclusion criteria were based on studies conducted in the past 10 years. After quality assessment, 18 studies were included for in-depth analysis. Results: The 18 studies included meta-analyses and observational cohort studies. In total, 51,489 patients were represented. Studies revealed that sleep apnea is underdiagnosed and undertreated in ethnic minority populations. Resident location, gender, economic status, and marital status also play an important role. One study noted clinically insignificant differences in positive airway pressure requirements between black and white populations. Nocturnal hypertension and increased left ventricle size are also observed in untreated sleep apnea. Given the heterogenous nature of the studies, quality risk assessment was not possible, which is a limitation of this study. Conclusions: Sleep apnea is underdiagnosed and undertreated among ethnic minorities. Factors such as ancestry, comorbidities, social determinants, geography, and healthcare access drive global inequities. Further sleep apnea phenotyping may be of value in planning treatment strategies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050613

Authors: Jeel Moya-Salazar Eliane A. Goicochea-Palomino María Jesús S. Moya-Salazar Magaly M. Medina-Rojas Gloria Cruz-Gonzales

Adolescents are prone to unwanted pregnancies and sexually transmitted infections. It is key that they receive reproductive sexual education during secondary education, which can be important for the prevention of these events. This study aims to compare knowledge of reproductive health between adolescents with and without STI history. A cross-sectional study was carried out on 164 schoolchildren from a national school in Lima (Peru). The AA-20 short questionnaire and the t-test were used to demonstrate differences between students with and without a history of sexually transmitted infections (STIs). Twenty-six (15.9%) students had STIs (mean age 16.6 ± 2.3 years). The average knowledge in students with and without STIs was 15.4 ± 3.7 points and 14.7 ± 3.9 points, respectively (p = 0.417). Among students with and without a previous STI, it was found that the majority used some form of contraception (61.5% vs. 31.9%, p = 0.004) and had received talks on the topic (92.3% vs. 72.5%, p = 0.031). Condom use was the most commonly used method to prevent STIs in both groups. In conclusion, students with a previous STI had slightly better knowledge about pregnancy and infections than students without a history.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050611

Authors: Kanphatson Kerdkaew Phisut Rattanathamma Wannaporn Tongtako Timothy Mickleborough Bulin Jirapongsatorn

Allergic Rhinitis (AR) is an IgE-mediated inflammatory disorder that impairs quality of life and systemic function. Following the ‘one airway, one disease’ paradigm, AR-related inflammation often extends to the lower respiratory tract. This randomized controlled trial investigated the effects of an 8-week moderate-intensity aerobic exercise (MOA) program on clinical symptoms, nasal airflow, airway inflammation, pulmonary function, and cardiorespiratory parameters in young adults with physician-confirmed persistent AR. To isolate the exercise effects, all participants discontinued antihistamines, corticosteroids, and leukotriene antagonists before and during the study period. Eighteen participants were allocated to either the MOA group (n = 9), which performed treadmill walking or jogging at 50–60% heart rate reserve three times per week for eight weeks, or a control group (CON, n = 9) that maintained usual daily activities. Clinical symptoms, peak nasal inspiratory flow, fractional exhaled nitric oxide, pulmonary function, heart rate, blood pressure, aerobic fitness, and perceived exertion were assessed at baseline, week 4, and week 8 using standardized procedures. Compared with baseline and the CON group, the exercise intervention resulted in significant reductions in nasal congestion, itching, sneezing, and rhinorrhea, accompanied by increased nasal airflow and reduced airway inflammation. Pulmonary function indices and cardiorespiratory parameters also improved following training. These findings suggest that moderate-intensity aerobic exercise may offer a valuable non-pharmacological approach to support conventional care, potentially enhancing respiratory and physiological outcomes in young adults with persistent AR.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050612

Authors: Juma Orach Aysha Afzaal Aman Bathla Zhenxiao Yang Lauren Lapointe-Shaw Ceara Cunningham Valeria E. Rac Shoshana Hahn-Goldberg Melissa Chang Christopher Chan Carolyn Gosse Emily Hay Thomas E. MacMillan Michelle Grinman Karen Okrainec

Integrated care programs (ICPs) are associated with positive patient experiences, but provider experiences remain understudied. We examined burnout in healthcare providers working in an ICP that facilitates hospital-to-home care transitions for patients. We conducted a mixed-methods evaluation comprising a cross-sectional survey of burnout and provider experience using the Maslach Burnout Inventory, open-ended questions, and semi-structured interviews. Twenty-eight participants completed the surveys (31% response rate). Respondents were 75% female, and, on average, were 42 ± 10 years old, had spent 19 ± 11 months as providers in the ICP and had cared for a median of 170 (IQR = 245) patients. Twenty staff, who were 38 ± 8 years old on average and 95% women, were interviewed. Emotional exhaustion was low (average total score = 14 ± 7 out of 42), depersonalization was moderate (9 ± 6 out of 42), and personal achievement was high (40 ± 5 out of 48), corresponding to low-to-moderate burnout. Respondents cited teamwork as the leading protective factor against emotional exhaustion and positive impact on patients as the leading factor underlying high personal achievement. Perceived under-appreciation was the leading factor for depersonalization, likely moderated by team support and rapport. Burnout was low to moderate in our sample of ICP healthcare providers, who cited several important contextual factors requiring further study.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050610

Authors: Alberto Grossi Francesca Campoli Giuseppe Messina Giuseppe Caminiti Matteo Vitarelli Gabriele Morganti Elvira Padua Bruno Ruscello

Background: This study aims to map the temporal evolution of light-based therapies and identify emerging technological trends in wearable photobiomodulation (PBM) devices. Materials and Methods: A bibliometric analysis (1970–2025) was conducted using three major databases: Scopus, PubMed, and Web of Science. The initial dataset, consisting of 117 articles, was processed using the Bibliometrix package in R (version 4.5.0), resulting in a final set of 110 articles. The analysis followed the TALL model (Tracking, Analysis, Layout, and Learning). Results: Scientific production on phototherapeutic devices began in the early 2000s, peaking in 2024, showing a productivity pattern typical of emerging or highly specialized fields. The period 2010–2023 represents a central thematic hub in research. During this time, new light sources (OLED and QLED) enabled the development of flexible, wearable, and implantable photonic devices. In the recent period (2024–2025), light-based therapies are increasingly integrated with network-connected biosensing systems for tissues or accessories, allowing adaptive treatments and remote monitoring. However, these next-generation devices are still undergoing consolidation and scientific maturation. Conclusions: The results highlight the rapid evolution of research on light-based therapies toward more integrated and clinically validated approaches, indicating growing scientific interest in personalized wearable PBM devices.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050609

Authors: Jennifer A. Poon David G. Zelaya Vedhalakshmi Rajasankar Matthew J. Murphy Riley A. Russell Shufang Sun

Background: Young adult sexual minority men (SMM) disproportionately experience childhood interpersonal trauma. The Dimensional Model of Adversity and Psychopathology (DMAP) framework proposes that exposure to threat (i.e., emotional, physical, and sexual abuse) and deprivation (e.g., physical and emotional neglect) are differentially linked to adult psychopathology. Studies of predominantly heterosexual samples have revealed emotion regulation and mindfulness as mechanisms linking childhood trauma to mental health and health risk behaviors in adulthood. However, the influence of emotion regulation (ER) or mindfulness as associated with exposure to threat vs. deprivation has not been examined among SMM in adulthood. Objective: This study explored the relationships between childhood threat/deprivation and mental health and health risk behaviors among SMM with ER and mindfulness as mediators. Participants and Setting: The sample consisted of 317 SMM (Mage = 26.70; SD = 3.87; ages 18–35; 59.3% White) recruited from the community. Methods: Childhood experiences of threat and deprivation were assessed via the Childhood Trauma Questionnaire; ER difficulties and dispositional mindfulness were assessed using self-report. Mental health behaviors were assessed using a composite score consisting of self-reported depressive, anxiety, PTSD symptoms, and suicidality. Health risk behavior score included the Sexual Compulsivity Scale, Alcohol Use Disorders Identification Test, and smoking history (Y/N). Results: Threat and deprivation were both positively correlated with mental health and health risk behaviors. Threat was associated with both mental health and health risk behaviors via emotion regulation (ER) difficulties. Deprivation was associated with these outcomes through both ER difficulties and mindfulness. Conclusions: Treatment aimed at bolstering ER and mindfulness skills among those with histories of abuse and deprivation, respectively, may help reduce psychopathology risk among SMM.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050608

Authors: Barbara Loera Federica Graziano Giorgia Molinengo Daniela Converso Giulia Bacci

Background: University students’ mental health represents an increasing public health concern, particularly in STEM contexts characterized by high academic demands. Students living away from home, including international students, may face additional stressors related to relocation, social integration, and adaptation. This study examined how narrated academic experiences are associated with psychological and academic functioning among relocated STEM students. Methods: A cross-sectional convergent parallel mixed-methods study was conducted at an Italian STEM university (May–June 2024). An online survey was distributed to the entire accessible student population (33,336 invitations; 12,538 accesses; response rate = 37.6%). Analyses focused on relocated students who completed all relevant sections (N = 776; M age = 22.96). Quantitative measures assessed academic self-efficacy, burnout (Emotional Exhaustion; Cynicism), engagement (Vigor; Dedication), study program satisfaction, and perceived academic goal attainment. Open-ended responses underwent thematic analysis with a codebook approach and transformed into category count variables. Hierarchical regression models examined associations controlling for age, gender, and academic level. Results: Organizational and learning-related difficulties were the most frequent categories. Content categories explained additional variance across outcomes (ΔR2 = 0.054–0.107). Teaching-related narratives were associated with higher burnout and lower engagement and satisfaction, whereas Positive narratives showed the opposite pattern. Conclusions: Institutional and pedagogical experiences are systematically associated with student well-being among relocated STEM students, highlighting modifiable targets for university-level mental health promotion strategies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050607

Authors: Jennifer Fenwick Olga Aleshin Jennifer Green Vanessa Scarf Heike Roth Kathleen Baird Helen Barrett Deborah Fox

The adoption of Virtual Maternity Care (VMC) in antenatal settings is increasing, propelled by technological advancements that facilitate remote communication and telemonitoring. A spectrum of care models exists globally, ranging from fully virtual to hybrid approaches. This review seeks to synthesise the qualitative evidence on women’s experiences of antenatal VMC in high-income countries, developing a conceptually rich understanding of factors that facilitate or hinder engagement and perceived safety. In June 2025, four databases were searched for peer-reviewed literature published in English between January 2010 and June 2025. After screening for quality and eligibility, 21 articles were included. Four core themes were identified: Virtual Care Worked Well, Seeking Good Connections, Empowerment and Safety Through Virtual Care Monitoring, and Feeling Disconnected and Unsafe. Women described feeling empowered through active participation and shared responsibility in their care (Empowerment and Safety Through Virtual Care Monitoring), particularly when relational care and continuity were present (Seeking Good Connections). Flexibility, convenience, and access to daily telehealth and reliable technologies were highly valued (Virtual Care Worked Well). Hybrid models were generally preferred; in contrast, exclusively remote models sometimes inhibited quality care and heightened feelings of insecurity (Feeling Disconnected and Unsafe), particularly for women with previous pregnancy loss, experiences of intimate partner violence, mental health concerns, or those facing language barriers, digital poverty, financial hardship, or low health literacy. In conclusion, women’s perspectives underscore priorities for designing and scaling high-quality, accessible virtual midwifery care: relational continuity, technological reliability, flexible delivery, and hybrid models integrating virtual and in-person care.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050606

Authors: Mirosława Huflejt-Łukasik Anna Szuster Maciej Pastwa Adrianna Wielgopolan Dorota Karwowska Inna Haletska Maryna Klimanska Kamil Imbir

This study examines how individuals adapt to situations of danger and change arising from the COVID-19 pandemic by testing a model based on self-regulatory mechanisms. The model includes three key elements: (1) the intensity of negative emotions as a manifestation of affective reaction to situations of danger and change and, at the same time, as a signal activating self-regulatory processes; (2) protective mechanisms in change, that is, the perception of goal congruence and a positive future self; and (3) the individual sense of danger and the overall sense of danger at various physical distances to the self. The study was conducted online. Participants completed a set of standardized questionnaires assessing negative emotions, perceived danger, and protective mechanisms across three measurement waves corresponding to successive stages of the COVID-19 pandemic. The model was validated in three waves of the pandemic in Poland and one in Ukraine. To verify the relationships between the measured variables, a structural equation model was constructed using the RStudio software (version 1.2, 2019) with the Lavaan package. The results were consistent with the prediction model, which considers the relationships between the intensity of negative emotions and the intensity of protective mechanisms in change and perceived danger. Two factors within negative emotions were identified, each interacting differently with self-regulation. Negative emotions were related to the intensity of perceived danger, while protective mechanisms were linked to the reduction in danger. The results confirm the complex nature of self-regulation mechanisms both affectively and cognitively and also their orientation toward the future, which constitutes a protective resource. The study’s limitations include the online method, which limits standardization, control, and the sample’s limited randomness and inequivalence of measurements and sampling in Ukraine and Poland.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050605

Authors: Ethan H. Yu Chelsea Olson Megan A. Moreno

(1) Background: Previous studies have shown that increased Problematic Internet Use (PIU) is associated with higher Fear of Missing Out (FoMO). However, the role of gender in this association remains unclear. Evidence suggests that males and females may experience PIU and FoMO differently, warranting further examination of gender differences. (2) Methods: In this cross-sectional study, a total of 4370 U.S. adolescents aged 12–17 years (47% female) were recruited through Qualtrics research panels and completed a national online survey on adolescent health and technology. Demographic information collected included age, race, and gender. PIU was measured using the validated three-item Problematic and Risky Internet Use Screening Scale (PRIUSS-3), while FoMO was measured using a validated 10-item FoMO scale. Multiple linear regression analysis examined the relationship between PIU and FoMO, including an interaction term between PIU and gender to assess the potential gender moderation effect while adjusting for age and race. (3) Results: Gender significantly moderated the relationship between PIU and FoMO, indicating that males experience a stronger association between PIU and FoMO compared to females. While higher PIU scores were significantly associated with higher FoMO for both males and females, each unit increase in PIU corresponded to a 0.15 point increase in FoMO for females (SE = 0.01, p < 0.01), and an additional 0.03 point increase for males (SE = 0.01, p < 0.01). (4) Conclusion: These findings illustrate the complex relationship between PIU and FoMO, highlighting the importance of gender-specific strategies and targeted interventions for promoting healthy Internet use.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050604

Authors: Andrew Schembri Doris Yuet Lan Leung Aaida Mamuji Mac Osa Osazuwa-Peters Charlotte T. Lee

Organizations ought to demonstrate a responsibility for conditions that reduce moral stress and enhance moral resilience for their employees. No literature to date has explored how Emergency Management Personnel (EMP) experience both moral stress and distress [(di)stress], building up to stigma during health crises, given their role in emergency management operations. This study draws from a primary study of EMP, including frontline and first responders and those in leadership, who reported structural stigma during the COVID-19 pandemic. Our research question was, In what ways did structural stigma shape the moral landscape of emergency management practice during COVID-19? This qualitative study draws on the paradigm of critical realism to conduct thematic analysis. Interviews and focus groups were collected in 2024 from a total of 23 participants in the Greater Toronto Area, Canada. Participants represented EMP across emergency and public service sectors. System-level stressors revealed disruptions or “cracks” from an overwhelmed public services system. In sum, systemic “cracks” gave rise to organizational mechanisms designed to compensate for system failures, inadvertently propagating structural stigma. At times these mechanisms generated moral distress and/or resilience, through simultaneously expanding and limiting EMP’s responsibility and agency. The authors suggest that EMP build their leadership capacity to enhance skills of structural competency.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050603

Authors: Shannon L. Stewart Abigail Withers Jeffrey W. Poss

Timely access to children’s mental health services depends on accurate identification of service urgency; however, triage practices in Ontario, Canada vary widely, contributing to prolonged wait times and inconsistent pathways to care. This study aimed to develop and validate an empirically based decision-support algorithm to support standardized triaging and prioritization in Ontario based children’s mental health agencies. Data were drawn from 17,564 children and youth aged 4–18 years assessed with the interRAI Child and Youth Mental Health Screener (ChYMH-S) as part of routine clinical practice. Interactive decision tree modelling was used to identify combinations of clinical indicators associated with high service urgency, with age-stratified models for children 7 years and younger, 8–11 years, and 12 years and older. The resulting interRAI Children’s Algorithm for Mental Health and Psychiatric Services (ChAMhPS) classified individuals into seven urgency levels. The algorithm demonstrated good discrimination for services required within seven days (c-statistic = 0.70) and for the urgency of a comprehensive assessment (c-statistic = 0.73), with stable performance across derivation and testing samples. Higher algorithm levels were associated with an increased likelihood of urgent assessment or service need. The ChAMhPS algorithm offers a standardized, empirically derived tool to support clinical decision-making and improve consistency in triage and prioritization of children and youth with urgent mental health needs.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050602

Authors: Marilene Gonçalves Queiroz Karen Dennise Lozada Tobar Amílcar Sabino Damazo Lucieli Teresa Cambri

This randomized crossover study aimed to evaluate the effect of a single session of aerobic exercise on 24 h ambulatory blood pressure (BP) and heart rate variability (HRV) in young adults with a family history of hypertension, FHH+ (participant with at least one hypertensive parent). Twenty non-hypertensive individuals (four females, sixteen males, 24.84 ± 4.15 years, 23.97 ± 3.28 kg·m−2) underwent a control (non-exercise) and an experimental (aerobic exercise) session in a randomized order, with a minimum interval of 72 h between them. Baseline anthropometric and metabolic parameters included body fat percentage, abdominal circumference, and blood glucose. The aerobic session consisted of 30 min cycling at 50–60% of heart rate reserve (142 ± 5 bpm; 68 ± 23 W). Twenty-four-hour BP and HRV were assessed by ambulatory monitoring. Two-way repeated-measures ANOVA showed a significant main effect of session (exercise vs. control) for systolic (p = 0.026, η2 = 0.084) and diastolic (p = 0.022, η2 = 0.088) BP, with no session × time (awake vs. asleep) interaction. For HRV indices, there were no significant (p > 0.05) main effects of session, nor any interaction between session and time. In summary, aerobic exercise induced 24 h ambulatory hypotension during both awake and sleep periods in non-hypertensive individuals with FHH+, without altering ambulatory HRV.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050601

Authors: George Antônio dos Santos Lucas Hoffmann Dias Tamara Tomitan Richter Jeferson Luis Lima da Silva Tânia Maria Gomes da Silva

The Street Clinic (Consultório na Rua—CnR) is a strategic component of Primary Health Care in Brazil, aimed at populations experiencing homelessness, a group characterized by high levels of social and health vulnerability. This study critically analyzes the experiences of healthcare professionals working within a CnR team, identifying the meanings attributed to their work, the challenges encountered, and the strategies developed within the territory. This is an exploratory study with a qualitative approach, grounded in health narratives and the philosophical hermeneutics of Hans-Georg Gadamer. Four professionals participated, representing the totality of eligible members of a team in a medium-sized municipality in Southern Brazil, with between one and eleven years of experience in the service. Hermeneutic analysis revealed that the CnR functions as an entry point to Primary Health Care and Psychosocial Care, with the bond between team and users serving as the primary mechanism for overcoming barriers to access. Professionals report ethical suffering arising from the tension between their commitment to comprehensive care and the structural limitations of the service, including shortages of supplies, institutional instability, and precarious employment arrangements. It is concluded that strengthening the CnR requires not only investment in infrastructure and expansion of the teams, but also policies that recognize and support the complexity of street-based work, including care for the caregivers themselves.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050600

Authors: Katrina Fyfe Samantha Bay Emma V. Taylor Ha Hoang Lisa Hall Annette McVicar Emma Walke Carolyn Lethborg Bahram Sangelaji Sandra C. Thompson

The Australian University Departments of Rural Health (UDRHs) promote the health and wellbeing of people in rural and remote Australia through health education, research, and advocacy. This narrative review evaluated the extent to which Indigenous health intervention research conducted by UDRHs over a 12-year period (2010–2021) aligned with the Principles and Priorities of the National Aboriginal and Torres Strait Islander Health Plan 2021–2031. The purpose was to reflect on past UDRH research contributions to identify existing strengths and areas for improvement in line with current policy. Thirty-three relevant UDRH publications were identified from a broader database of UDRH research outputs. Each paper was independently coded by at least two authors as demonstrating “yes”, “partial”, or “not evident” alignment with the twelve priorities of the Health Plan. UDRH intervention research demonstrated strengths in genuine shared decision making and partnerships with Indigenous communities, workforce development, health promotion, and identifying and addressing racism. However, gaps were evident in research addressing social and emotional wellbeing, mental health and suicide prevention, promotion of healthy environments, sustainability and preparedness, and transparency regarding shared access to data and information. UDRHs play a key role in building research capacity among staff and communities in rural settings and often maintain long-standing, respectful relationships with local Indigenous communities. While UDRH research aligns with many domains of the national Health Plan, future efforts should prioritise social and emotional wellbeing and mental health. Improved reporting of shared data access represents an immediate opportunity for enhancement.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050599

Authors: Thiago Ferreira de Sousa Karine Moraes Pereira Ysamara dos Santos Conceição Cristiane dos Santos Matos Djalma Pereira Santana Aline de Jesus Santos Chandra Lima Maciel Grasiely Faccin Borges

Leisure-time physical activity (LTPA) is associated with positive self-rated health (SRH); however, evidence regarding different practice patterns and potential racial differences among university students remains limited. The objective of this study was to estimate the association between LTPA patterns and positive SRH among university students who entered higher education in 2025 at a public university in Brazil. This cross-sectional study analyzed data from 1143 first-year undergraduates. Positive SRH (defined as reporting “good” or “very good” health) was used as the outcome. LTPA (walking and activities of moderate and vigorous intensity) was classified as inactive, insufficiently active, weekend warrior, or regularly active based on the World Health Organization (WHO) guidelines on physical activity. The analyses were stratified by self-reported race/skin color (White students vs. students from other racial/ethnic groups). Prevalence ratios (PRs) and 95% confidence intervals (95% CIs) were estimated using Poisson regression. The prevalence of positive SRH was 44.6% among White students and 41.1% among other racial/ethnic group students. Among White students, positive SRH was associated with walking performed at weekend warrior (PR = 2.08; 95% CI: 1.33–3.24) and regular levels (PR = 1.51; 95% CI: 1.06–2.14), as well as with vigorous-intensity activity in a weekend warrior pattern. Among other racial/ethnic group students, positive SRH was associated with regular walking (PR = 1.34; 95% CI:1.05–1.71) and with vigorous-intensity activity at both insufficient and regular levels. LTPA was positively associated with SRH, with variations according to intensity, practice patterns, and race/skin color, indicating that benefits are not homogeneous across groups.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050598

Authors: Mlandeli Tsibiyane Lindiwe Modest Faye Kululwa Ndayi Ncomeka Sineke Londele Tyeshani Monwabisi Faleni

Background: Tuberculosis (TB) remains a major public health challenge globally, particularly in high-burden countries such as South Africa. Treatment interruption is a critical barrier to effective TB control, contributing to poor treatment outcomes, increased risk of multidrug-resistant tuberculosis (MDR-TB), and continued community transmission. Understanding the determinants of treatment interruption in rural healthcare settings is essential for strengthening TB programme implementation. Methods: This qualitative study explored the factors influencing TB treatment interruption from the perspectives of professional nurses working in primary healthcare facilities in the Nyandeni Subdistrict, Eastern Cape, South Africa. Semi-structured interviews were conducted with nurses involved in TB programme implementation. Data were analysed using thematic analysis following the six-phase approach described by Braun and Clarke. Descriptive statistical analyses were also used to summarize participant characteristics, including age and years of nursing experience. Conceptual frameworks were developed to illustrate the multilevel determinants of TB treatment interruption. Results: Participants had a mean age of 40.6 years and an average of 14.2 years of nursing experience, reflecting a workforce with substantial clinical exposure to TB management. Thematic analysis identified multiple interconnected determinants of treatment interruption. Key barriers included poverty, food insecurity, transport costs, long distances to healthcare facilities, limited family support, and challenges related to patient tracing. These factors interact across structural, community, health system, and interpersonal levels to influence patient adherence behaviour. Conceptual models developed from the findings illustrate the complex pathways through which these determinants contribute to treatment interruption and programme-level consequences such as reduced treatment success and increased risk of MDR-TB. Conclusions: TB treatment interruption in rural settings is driven by multilevel socioeconomic and health system determinants rather than individual patient behaviour alone. Strengthening community health worker programmes, improving patient tracing systems, addressing socioeconomic barriers, and enhancing community-based support mechanisms are essential for improving treatment adherence. Integrated, multisectoral interventions are required to strengthen TB programme outcomes in rural high-burden settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050597

Authors: Mirfat Mohamed Labib Elkashif Mohamed Sayed Abdellatif Darelglal Ahmed Gassmelseed Abdalla Ashraf Ragab Ibrahim Mohamed Ali Nemt-allah

Despite growing recognition that organizational culture shapes nursing practice, the linking of ethical climate to sustainable environmental health literacy (SEHL) remains poorly understood. This study examined whether moral courage statistically mediates the relationship between perceived ethical climate and self-reported environmental health literacy among Egyptian nurses, rather than observed competencies or clinical actions. A cross-sectional correlational design was employed with 743 nurses recruited from government, private, and university-affiliated hospitals. Participants completed the Hospital Ethical Climate Survey, the Nurses’ Moral Courage Scale, and the Environmental Health Literacy Scale. Mediation analysis used Hayes’ PROCESS macro with 5000 bootstrap samples. Ethical climate demonstrated strong positive associations with moral courage (r = 0.81) and SEHL (r = 0.86), while moral courage and SEHL were also strongly correlated (r = 0.82). Ethical climate explained 74% of variance in SEHL and 66% of variance in moral courage. Moral courage was associated with partial statistical mediation of the ethical climate–SEHL relationship, accounting for 33.4% of the total effect (β = 0.31, 95% CI [0.26, 0.37]), while the direct effect remained substantial (66.6%). These findings suggest that supportive ethical climates may be associated with nurses’ environmental health literacy via two statistical pathways: one directly linked to environmental learning and another indirectly linked to moral courage. Healthcare organizations should prioritize ethical climate development alongside moral courage training as potentially promising approaches to advance climate-responsive nursing practice.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050596

Authors: Ilaria Corazza Niyat Aregawi Gebremichael Paolo Belardi Fabio Manenti Milena Vainieri

The efficacy of healthcare performance evaluation systems depends on their design and implementation, as well as on their perceived value and integration into daily practice. This study explores the acceptability of a healthcare performance evaluation system, used by health and administrative professionals in four rural healthcare settings in Ethiopia, Tanzania, and Uganda, three years after its implementation. In-depth semi-structured interviews were conducted, either in person or via video conference, with 17 professionals involved in system design and implementation. The analysis of qualitative data drew on Sekhon’s Theoretical Framework of Acceptability, using content analysis to identify themes across seven dimensions of acceptability. Key findings show that participants’ perceptions of acceptability of the performance evaluation system are influenced by data disclosure and reputational effect, the system’s understandability, alignment with their mission to improve quality of care, perceived usefulness, experienced opportunity costs, and intervention burden. The key features of the performance evaluation system are the most critical factors contributing to its acceptability, but the administrative burden, which includes professionals’ need to invest more time and change work habits to use the new system, poses some challenges and may hinder the medium- to long-term effectiveness of the intervention.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050595

Authors: Chuchard Punsawad Prasit Na-ek Udomsak Narkkul Chanakan Rattanaburi Aunchisa Kongsuk Tharathep Plub-on Stephen J. Scholand Nonthapan Phasuk

Background: Soil-transmitted helminth (STH) infections are a recognized public health challenge, particularly in rural and island settings. Despite the implementation of national control programs, epidemiological data from geographically isolated communities remain limited. In this study, we aimed to determine the prevalence of STH infections and identify associated risk factors among adults in Koh Yao Islands, southern Thailand. Methods: A community-based cross-sectional survey was conducted in three subdistricts of Koh Yao, Phang Nga Province, from January to September 2024. Demographic data and information on potential risk factors were collected using structured questionnaires. Stool specimens were analyzed using the formalin–ethyl acetate concentration technique and the modified Kato–Katz method. Associations were assessed using univariate and multivariate logistic regression analyses. Results: A total of 241 adults participated in the study, with females accounting for 68.9% and males for 31.1%. The overall prevalence of STH infections was 2.49%, with hookworms and Trichuris trichiura identified as the predominant species. All infected individuals had an educational level lower than a bachelor’s degree. Univariate analysis showed that participants who did not use hygienic toilets at home had a significantly higher likelihood of developing STH than those who did (crude odds ratio = 46.80; 95% confidence interval [CI]: 2.55–859.00; p = 0.010). Multivariable logistic regression analysis confirmed that the absence of hygienic toilet use at home was independently associated with STH infection (adjusted odds ratio = 30.69; 95% CI: 1.17–804.65; p = 0.040). Conclusions: This study documents low overall prevalence of STH infections in the study area, with hookworms and T. trichiura as the predominant organisms. These findings support continued targeted public health measures, including periodic deworming and health education initiatives, to strengthen hygiene practices, particularly in high-risk populations. Future investigations should incorporate environmental assessments and longitudinal monitoring to evaluate the durability of current control strategies.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050594

Authors: Ryan Dumais Emmett Suckow Ibrahim Ainab Francis Zirille Lindsay M. Forbes Justin S. Lawley William K. Cornwell

Aerobic exercise capacity, best quantified by maximal oxygen uptake (VO2max), varies between individuals and is dependent on cardiac output (CO) and oxygen uptake in the periphery (a-vO2 diff). Environmental stressors like hypoxia, microgravity, and heat negatively impact these parameters, thereby reducing aerobic exercise capacity. However, in response to acute and chronic exposures to these environments, compensatory processes serve to counteract reductions in VO2max. In hypoxic environments, reduced oxygen partial pressure (PO2) leads to hypoxic pulmonary vasoconstriction (HPV) and a diffusion limitation at the level of the lungs and skeletal muscle, resulting in a reduction in VO2max. Microgravity environments reduce VO2max through cardiac and skeletal muscle deconditioning, as well as reductions in plasma volume (PV), resulting in an increase in sympathetic nerve activity through baroreceptor-mediated pathways. In heat stress environments, increases in skin perfusion upon acute exposure hinder exercise performance, whereas compensatory PV expansion mitigates further decreases in VO2max. As humans are increasingly exposed to austere environments and environmental extremes, it is critical to understand how these environments impact cardiovascular exercise physiology so that effective strategies and protocols ensuring proper aerobic functioning may be implemented.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050593

Authors: Ingrid M. E. Johansen Darcey K. McCampbell Luke M. Leners

Mpox is a rare but potentially serious vaccine-preventable disease. The 2022 United States outbreak disproportionately impacted gay, bisexual, and other men who have sex with men, people living with HIV, and people of transgender experience. Early vaccination efforts revealed substantial racial and geographic inequities, with lower uptake among Black and Hispanic cisgender men, transgender women, and residents of rural areas. To address these challenges, Fairview’s Minnesota Immunization Networking Initiative (MINI), a 20-year-old mobile health collaborative, partnered with state and local public health agencies and community-based organizations to expand mpox vaccine access. With support from governmental outbreak response funding and stockpiled vaccine, mobile clinics were deployed in trusted community settings, including Pride events and recurring community sites. Targeted outreach, education, and coordination with local providers supported stigma reduction and second-dose series completion. Program data were collected from October 2022 through December 2024. MINI hosted 125 community-based mpox vaccination events, administered 2259 doses to individuals from 220 cities across the United States, including 195 cities in the Midwest. Pride events were key entry points for first-dose vaccination, particularly in rural areas; urban non-Pride clinics played a complementary role in facilitating second-dose completion. Program-level vaccination-to-case ratios were highest among populations experiencing disproportionate mpox burden, including Black, Hispanic, and American Indian/Alaska Native male participants, suggesting alignment of preventive resources with community need. MINI’s mobile, partnership-driven approach demonstrates the value of pairing large-scale community events with recurring clinics to address barriers to both vaccine access and series completion. These findings underscore the importance of flexible, community-centered infrastructure in advancing health equity and strengthening outbreak preparedness.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050592

Authors: Ana Clara F. Paiva Jéssica M. Bittencourt Daniela Rabelo-Costa Jennifer E. Gallagher Saul M. Paiva Cristiane B. Bendo

Dental fear and anxiety (DFA) are common among children, and their occurrence needs to be assessed in population-based studies. This study aimed to evaluate a structural model for the association of DFA in children with individual and family-related factors. A representative cross-sectional study was conducted in Carmópolis de Minas, Brazil, with 272 children aged 4–6 years. Children’s DFA was self-reported using the Children’s Fear Survey Scale—Dental Subscale, and caregivers' DFA using the Dental Fear Survey. Caregivers provided sociodemographic information on the family and children’s health. Two calibrated dentists examined the children for dental caries using the DMFT index. Structural equation modelling was performed. Dental caries showed a direct association with greater DFA in children (β = 0.145; p = 0.036). Toothache showed an indirect association with children’s DFA through the variable “dental visit”, as children with toothache had visited the dentist more recently (β = 0.401; p < 0.001), and a more recent dental visit was associated with DFA (β = −0.158; p = 0.037). Maternal depression was associated with greater caregiver DFA (β = 0.124; p = 0.006), but no association was found between children’s DFA and caregiver’s DFA (p > 0.05). Children with caries-related toothache who visited the dentist within six months before data collection—and more recently—had higher DFA.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050591

Authors: Nicola Magnavita

Over the course of just a few decades, health sciences have developed and expanded at an ever-increasing pace [...]

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050590

Authors: Saja Alnahar Mahmoud Alquraan Austen El-Osta

Background: Regulatory restrictions and mandates typically offer short-term behaviour guidance, whereas interventions to improve knowledge and attitudes could result in more sustainable behavioural changes. Health authorities implemented awareness campaigns to enhance public knowledge and attitudes regarding COVID-19. This study explored the interplay between knowledge, attitudes and behaviours related to COVID-19 among university undergraduate students in Jordan, aiming to inform public health initiatives and educational programmes. Methods: A cross-sectional survey targeting undergraduate students enrolled at Yarmouk University in Jordan was conducted between January and May 2021. Participants consented to complete an anonymised validated self-administered questionnaire to evaluate their understanding of COVID-19 symptoms, treatment and transmission and attitudes and behaviours towards preventive measures. Data were analysed using descriptive and inferential statistics and structural equation modelling to investigate the associations between knowledge, attitudes and behaviours. Results: A total of 1375 undergraduate students participated in the survey. Knowledge of COVID-19 was low among most participants, with only 1.3% demonstrating high knowledge. Conversely, 58.5% exhibited good behaviour, and 31.4% reported full compliance with recommended behaviours. Significant differences were found in knowledge, attitudes and behaviours across different faculty clusters, with health faculties showing superior knowledge and more positive attitudes. Female participants (66.3%) were more likely to engage in positive behaviours than males (p-value = 0.02). Structural equation model (SEM) analysis showed that knowledge significantly influenced attitudes, which affected behaviours, confirming the model’s validity. Conclusions: The study highlights the critical role of knowledge and attitudes in shaping COVID-19-related behaviours among university students. Significant variations in knowledge and attitudes across different academic disciplines highlight the need for tailored educational interventions. The analysis supports the theoretical model linking knowledge, attitudes and behaviours, emphasising the importance of improving knowledge and attitudes to drive behaviour change. The findings suggest that comprehensive health education programmes targeting cognitive and affective aspects are essential for effective public health responses during pandemics.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050589

Authors: Puleng Lydia Ramphalla Mantji Juliah Modula Mutshidzi Mulondo

Adolescents and young people (AYP) experience a disproportionate burden of both mental health conditions and HIV, particularly in low- and middle-income countries (LMICs)-nations classified by the World Bank as having lower or middle economies. Mental health problems such as depression, anxiety, and substance use increase HIV (Human Immunodeficiency Virus that attacks the human immune system and leads to various illnesses when untreated) risk, and negatively affect treatment adherence and outcomes. However, mental health remains insufficiently integrated into HIV research and programming. Evidence on how mental health services are operationally integrated into HIV prevention and treatment for this population is limited and fragmented. This scoping review mapped existing evidence on the integration of mental health services into HIV treatment programs for AYP in LMICs, guided by PRISMA-ScR (a guideline used for reporting scoping reviews in research) and the Person–Concept–Context framework, a framework used to define specific research question in research. In this case, the population was adolescents and young people (10–24 years) receiving HIV prevention or treatment services, the concept referring to the integration of mental health interventions such as screening, assessment and counseling within HIV services, and the context focused on low- and middle-income countries (LMICs). PubMed, MEDLINE, Scopus and PsycINFO databases were searched for studies published between 2014 and 2024. Eligible studies reported mental health screening, assessment, treatment, or referral within HIV services for AYP in LMICs. Two reviewers independently screened studies, assessed full texts, and extracted data. Of 634 records identified, ten (10) studies met the inclusion criteria. All were conducted in Sub-Saharan Africa and primarily used qualitative or pilot designs. Four integration approaches were identified: routine mental health screening within HIV services, task-shifting to trained lay providers, peer-led and community-based psychosocial support, and culturally adapted, youth-centered psychological interventions. Common barriers included stigma, low mental health literacy, limited training and supervision, staffing constraints, and weak referral systems. Existing evidence is limited, remains exploratory, preliminary, and largely focused on feasibility and implementation experiences, suggesting that integrating mental health services within adolescent HIV care in LMICs may be feasible and acceptable when approaches are contextually adapted and participatory.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050588

Authors: Tumisang Ramodipa Maasago Mercy Sepadi Daniel Mmereki Ingrid Mokgobu

Background: Effective treatment of healthcare risk waste (HCRW) is essential for preventing pathogen transmission, reducing toxic emissions, and protecting public and environmental health. South Africa faces a growing burden of HCRW driven by expanding healthcare services, population growth, and increased use of medical technologies. Methods: This systematic review critically examines governance frameworks, treatment technologies, and sustainability gaps in healthcare risk waste management in South Africa. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Searches were conducted in PubMed, Scopus, and Web of Science for studies published between 2014 and 2025. Eighteen studies met the inclusion criteria and were analysed using a qualitative and semi-quantitative synthesis approach. Results: The findings indicate persistent systemic weaknesses in healthcare risk waste management. Incineration remains the dominant treatment method, reported in 72% of the included studies, and is often associated with ageing infrastructure and environmental compliance concerns. Policy fragmentation and weak regulatory enforcement were identified in 67% of studies, while 61% reported training gaps among healthcare workers and waste handlers. Poor segregation practices and illegal dumping were also frequently documented. Only 22% of studies explicitly addressed sustainability or circular economy principles, highlighting a significant policy–practice gap. Conclusions: Healthcare risk waste management in South Africa is therefore constrained by fragmented governance, limited infrastructure, and insufficient integration of sustainable treatment technologies. Strengthening regulatory coordination, expanding non-burn treatment technologies, and embedding circular economy principles are critical to improving environmental performance and advancing Sustainable Development Goals 3 and 12.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050587

Authors: Evelien van Gelderen Rebecca Marquard Olivia E. Nasef Robert L. Bogue Paul S. Nestadt

Suicide is a global and public health crisis that impacts people of all ages and backgrounds. The literature supports that individuals with serious mental illness are at a higher risk of suicide compared with those without a serious mental illness. It is also well-documented that individuals are at particularly high risk of suicide immediately post-hospitalization for a psychiatric illness. Our narrative review synthesizes and analyzes the existing literature on this phenomenon, the rates of suicide post-hospitalization, the risk factors for suicide during that time, and the interventions and strategies developed to reduce the rates. Current risk assessments struggle to identify individual patients who are at the highest risk of suicide post-discharge. Research has shifted towards focusing on brief crisis interventions to target this high-risk period. Other interventions in the literature include those that attempt to increase engagement with mental health services and increase institutional resources. We also synthesize literature on the iatrogenic risk of hospitalization, the impact hospitalization itself can have on patients, and their risk of suicide once discharged. Future directions could include further exploration of the impact these interventions have on specific populations, such as those with comorbid psychiatric and substance use conditions.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050585

Authors: Chadayu Udom Chatkaew Pongmala Phatcharawadee Srirug

Undergraduate students often engage in nighttime activities and electronic device usage that may adversely affect sleep quality and academic performance; therefore, factors associated with sleep quality are important. The objective of this study was to investigate the prevalence and associated factors of poor sleep quality in undergraduate students. Four hundred and five undergraduate students participated in a cross-sectional study and had no history of psychological disorders or use of medications affecting sleep. Data was collected using the Pittsburgh Sleep Quality Index (PSQI), musculoskeletal discomfort questionnaire, electronic device usage questionnaire and Depression Anxiety Stress Scales (DASS-21). Multivariate logistic regression was employed to analyze the factors associated with poor sleep quality. Among the undergraduate students in this study, 65.93% reported having poor sleep quality. The factors associated with poor sleep quality were stress (OR, 1.03; 95% CI, 1.01–1.06) and musculoskeletal discomfort (OR, 1.92; 95% CI, 1.23–2.99) after controlling for other variables. Undergraduate students frequently experience poor sleep quality, with stress and musculoskeletal discomfort being major contributors. These findings highlight the importance of mental health support and stress management programs in improving sleep quality and overall well-being, as well as in preventing long-term detrimental consequences for undergraduate students’ mental health, physical health and academic performance.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050586

Authors: Khalifa Al Kuwari Izzeldin Ibrahim Abdulaziz Farooq James England Perla ElMoujabber Rama Kamal Karim Chamari Vidya Mohamed-Ali Mohammad Al-Maadheed

Background: Mega-events like the FIFA World Cup (FWC) present unique and substantial challenges for individuals in recovery from substance use disorders (SUDs), primarily by increasing the risk of relapse. We employed a qualitative design using reflexive thematic analysis to explore the behavior of patients with SUDs during the 2022 FWC and to evaluate institutional strategies for mitigating related risks. Methods: We purposively sampled 32 participants who were present at the Naufar Center during the 2022 FWC: (i) thirteen adult patients with SUDs who were receiving treatment, and (ii) nineteen healthcare practitioners. Semi-structured patient interviews were conducted, and focus group discussions were held with a multidisciplinary team, including psychologists, nurses, and physicians. Individuals’ experiences regarding patterns in substance use behavior, environmental triggers, and the effects of institutional interventions were examined. Thematic analysis was employed to identify patterns, risks, and effective strategies. Results: Most patients maintained abstinence and only had cravings for alcohol. Triggers included public celebrations, emotional excitement, and the increased availability of addictive substances. Psychologists and physicians reported signs of behavioral destabilization; nurses observed some behavioral changes and noted logistical challenges. The participants acknowledged the supportive measures provided by Naufar, including the accessibility of clinical services, individualized therapy, social and recreational programming, and protective fan zones, which enabled them to participate in various activities during the event. Conclusions: The 2022 FWC created considerable psychological and environmental triggers for high exposure to alcohol and other substances. The supportive structured activities and tailored interventions were helpful in mitigating the risk of relapse, maintaining treatment engagement and ensuring recovery. Further research is required to explore the implications for recovery-oriented practices during culturally and socially high-risk events.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050584

Authors: Kamel Mouloudj Sarah Ali Saeed Alameri Marian A. Evans Alaa Abdulkareem Ghaleb Almado Basheer Ismail Mahmoud Dachel Martínez Asanza

Preventive health behaviors play a critical role in reducing disease risks and improving public health outcomes, particularly among vulnerable populations such as women in rural communities. However, limited research has explored the determinants of intentions to adopt preventive health behaviors in developing contexts among women in rural communities. This study applies and extends the Theory of Planned Behavior (TPB) to examine these determinants in Algeria. A cross-sectional study was conducted using convenience sampling among 205 women in rural communities aged 20–60 years across five Algerian cities. Data were collected through a self-administered questionnaire and analyzed using hierarchical multiple regression. The results indicate that attitude, subjective norms, and perceived behavioral control have significant positive effects on behavioral intention. The inclusion of health literacy significantly enhances the model’s explanatory power, with higher literacy associated with stronger intentions. In contrast, perceived healthcare discrimination does not have a statistically significant effect. The extended model explains 57.5% of the variance in behavioral intention. These findings underscore the importance of psychosocial and informational factors in shaping preventive health intentions and support the extension of TPB in this context. They also provide practical implications for policymakers and healthcare practitioners to design targeted social marketing interventions aimed at improving preventive health behaviors and reducing health disparities among women in rural communities.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050583

Authors: Cesar Ivan Aviles Gonzalez Massimo Tusconi Sergio Machado Haidy Rocio Oviedo Cordoba Doriam Esperanza Camacho Rodriguez Rober Romero Ramirez Francesco Pegreffi Michela Atzeni Dhurata Ivziku Marzia Lommi Vanessa Barrui

Background: Disruptions in social and circadian rhythms are increasingly recognized as key contributors to depressive symptomatology and impaired quality of life, particularly in older adults, for whom daily regularity represents a crucial determinant of psychological and functional stability. Understanding the interplay between rhythm dysregulation, mood disturbances, and perceived well-being may inform preventive strategies in aging populations. Objective: This study aimed to examine the association between social rhythm dysregulation, depressive symptoms, and perceived quality of life in a sample of community-dwelling older adults. Methods: A cross-sectional observational study was conducted among 119 older adults (mean age 72.26 ± 4.72 years) enrolled in an active aging program. Social rhythms were assessed using the Brief Social Rhythm Scale (BSRS), depressive symptoms with the Patient Health Questionnaire-9 (PHQ-9), and health-related quality of life with the SF-12 Health Survey. Pearson correlation analyses and multiple linear regression models were applied. Results: Greater social rhythm dysregulation was significantly associated with higher depressive symptom levels (r = 0.41, p < 0.001) and lower perceived quality of life (r = −0.39, p < 0.001). In multivariate analyses, both rhythm dysregulation (β = −0.1863, p < 0.001) and depressive symptoms (β = −0.2885, p = 0.037) independently predicted poorer quality of life. Conclusions: In community-dwelling older adults, irregular social rhythms and depressive symptoms are independently and jointly associated with reduced quality of life. These findings highlight social rhythm regulation as a relevant and potentially modifiable target for preventive and supportive interventions aimed at promoting mental well-being and resilience in later life.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050582

Authors: Hasan Ejaz Hafiz Muhammad Zeeshan Fahad Ahmad Syed Nasir Abbas Bukhari Naeem Anwar Awadh Alanazi Ashina Sadiq Kashaf Junaid Muhammad Atif Khalid Omer Abdalla Abosalif Abid Iqbal Manhal Ahmed Hamza Sonia Younas

We sincerely thank the authors of the comment for their interest in our study and for highlighting the issue of author name ambiguity in bibliometric research [...]

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050581

Authors: Zineb Rhazzar Khalid Ennibi Nadia Touil

Ejaz et al [...]

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050580

Authors: Chizimuzo Okoli Sarret Seng Bassema Abu Farsakh Emily Koyagi Heather Beck Audrey Darville

Tobacco use remains disproportionately high among adults living with mental illnesses (MIs), contributing to excess morbidity and mortality, particularly in high-burden states such as Kentucky. Behavioral healthcare providers are well-positioned to address this disparity but often lack formal training in evidence-based tobacco treatment. Tobacco Treatment Specialist (TTS) training provides healthcare providers with skills to deliver evidence-based tobacco treatment; however, traditional TTS training models often rely on synchronous, in-person or live virtual formats, which may limit accessibility for some healthcare workforces. Asynchronous, web-based delivery models may reduce these barriers. This study evaluates a targeted, asynchronous TTS training program designed for providers working in Community Mental Health Centers (CMHCs) across Kentucky between 2020 and 2024. Using a one-group post-test-only design to assess engagement and completion and a one-group pre-test–post-test design among completers, we examined program outcomes and changes in knowledge and attitudes. Eligible participants were nominated by the administrative team at each CMHC. Of 100 registered participants, 70.0% enrolled and 55.0% completed the program. Among completers (n = 55), knowledge scores increased significantly from pre- to post-test (t[51] = 7.6, p < 0.001). Participants also reported significant improvements in perceived skills (t[51] = 7.9, p < 0.001) and knowledge of resources to deliver tobacco treatment (t[51] = 7.8, p < 0.001), while perceived time to deliver services did not change significantly. These findings suggest that asynchronous TTS training is a feasible approach to improving tobacco treatment knowledge and confidence among behavioral health providers, though additional strategies may be needed to enhance completion and assess practice-level impact.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050579

Authors: Alicia Fernández-Parra Juan Martín-Hernández Azael J. Herrero Inmaculada Fierro Ana Domínguez-García María Sol Cobo-Cuadrado Pilar González-Pélaez Carlos Roncero

Gambling disorder (GD) is a behavioral addiction associated with significant psychosocial consequences and high psychiatric comorbidity, including anxiety, depression, and impulsivity; however, the role of physical activity (PA) as a potential modulator of these alterations remains unclear. The aim of this study was to examine the relationship between PA levels and symptoms of anxiety, depression, and impulsivity in patients with GD. An observational study was conducted with 62 adults diagnosed according to DSM-5 criteria, recruited from AJUPAREVA (Valladolid, Spain). PA was assessed using the International Physical Activity Questionnaire (IPAQ), Personality trails where evaluated with CEPER III, impulsivity with the Barratt Impulsiveness Scale (BIS-11) and the Plutchik Impulsivity Scale, and anxiety and depression with the Hamilton Anxiety (HAM-A) and Depression (HAM-D) scales. Participants were predominantly male (91.5%) and reported moderate-to-high PA levels. No significant differences were found in total impulsivity across PA levels; however, motor impulsivity was higher in highly active individuals, while non-planning impulsivity was greater in those with low PA. Anxiety and depression were highly prevalent (~65%) with no significant associations with PA. In conclusion, PA was not significantly associated with psychiatric outcomes in this clinical sample, highlighting the need for larger, longitudinal studies to clarify its potential role within multidisciplinary interventions for GD.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050578

Authors: Angie Wagner Athena D. F. Sherman Sarah Febres-Cordero Sophie Grant John Nemeth Molly Szczech Andrea Cimino Carissa Lawrence Sangmi Kim Moriah Chedekel Arlette Hernandez Elijah Goldberg Meredith Klepper Pranav Gupta Monique S. Balthazar

Background: Transgender and gender expansive (TGE) people experience high rates of interpersonal victimization, which has been linked to high rates of post-traumatic stress disorder (PTSD, a highly disabling and under-studied mental illness among TGE people). This systematic review identifies, classifies, critically appraises, and synthesizes the peer-reviewed literature describing the association between interpersonal victimization and post-traumatic stress among TGE people. This review collates what is known about the associations between victimization and PTSD among TGE people and makes recommendations to guide future research and intervention development. Methods: Searches were conducted across five databases (PubMed, Embase, Web of Science, PsycInfo, and CINAHL) following PRISMA guidelines. Inclusion criteria were: English language; peer-reviewed original research; articles describing the association between victimization and PTSD among TGE youth or adults; reporting TGE-specific data. Exclusion criteria were: reviews, commentaries without original data, dissertations or theses, conference abstracts, animal studies, studies without TGE-specific findings, and case studies. Quality appraisal was completed for all studies, which included a discussion of bias. Data extraction was completed by two independent authors, and conflicts were resolved by a third. Data were stratified by gender identity, race or ethnicity, and type of violence for further synthesis. Results: 25 studies were evaluated for design, measure quality, and key findings. Findings were highly consistent across studies: multiple forms of interpersonal violence (e.g., childhood maltreatment, sexual violence, intimate partner violence, and transgender-specific victimization) were significantly associated with PTSD symptom severity or diagnosis across diverse identities and geographic contexts. All studies examining childhood sexual abuse reported significant associations with PTSD outcomes, highlighting early life as a critical period of vulnerability. Samples were disproportionately White and adult, with limited examination of intersectional experiences shaped by race, ethnicity, and socioeconomic status. Discussion: Interpersonal violence-related PTSD among TGE populations reflects a pervasive and systemic pattern of trauma rooted in structural discrimination rather than isolated individual risk. Addressing this inequity requires multilevel prevention and intervention strategies. Future research should prioritize longitudinal designs, culturally responsive measurement tools, and intersectional analyses to inform prevention, clinical care, and policy responses. The majority of studies were cross-sectional designs, so causality cannot be inferred. Additionally, the samples were disproportionately White and adult, which may bias the magnitude of associations reported and limit generalizability to racially and ethnically diverse TGE populations. Although many studies reported race and ethnicity descriptively, none disaggregated violence-related PTSD outcomes by racial or ethnic group within TGE samples, representing a critical limitation for intersectional analysis.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050577

Authors: Avi Besser Virgil Zeigler-Hill

Everyday public parenting encounters may influence immediate stress-relevant appraisal processes. Guided by interactionist and narcissistic self-regulation frameworks, the present study examined how recognition-based versus status-challenging norm framing in a standardized playground interaction influences young parents’ immediate responses, and whether narcissistic admiration and rivalry shape these processes. A community sample of 776 Israeli parents aged 25 to 41 was randomly assigned to view one of two ultra-realistic video vignettes depicting an identical turn-taking situation framed either in recognition-based terms that emphasized fairness, shared legitimacy, and respectful coordination, or in status-challenging terms that emphasized priority claims, non-negotiability, and implied hierarchy. Participants responded from the perspective of the focal parent (i.e., a parent from the family being spoken to in the interaction). Narcissistic admiration and rivalry were assessed using the Narcissistic Admiration and Rivalry Questionnaire. Parallel moderated mediation analyses revealed that condition was strongly associated with both perceived recognition and perceived freedom threat. These appraisals, in turn, predicted state reactance, negative affect, evaluations of the initiating parent, and behavioral preferences. Recognition-based framing indirectly reduced reactance and negative affect and increased favorable evaluations through higher perceived recognition and lower perceived freedom threat. Contrary to moderated mediation predictions, narcissistic admiration and rivalry did not moderate the indirect effects. However, narcissistic rivalry, and to a lesser extent narcissistic admiration, showed consistent direct associations with reactance-related and entitlement-oriented responding. These findings identify proximal appraisal mechanisms linking subtle norm framing in public parenting contexts to immediate affective, evaluative, and behavioral reactions. More broadly, the results highlight an immediate appraisal-based process that may inform future longitudinal and intervention-focused research on parenting stress in shared community settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050576

Authors: Patrick Mbullo Owuor Doreen Obondo Wicklife Orero Silvia Odhiambo Eyram Agbe Godfred Boateng Elizabeth Onyango

Introduction: HIV remains a public health concern despite several decades of effort. In sub-Saharan Africa, where political, environmental, and economic challenges persist, progress toward “Getting to Zero,” including zero new infections and zero HIV-related deaths, has been significantly slow. Although sub-Saharan Africa has seen the successful implementation of HIV/AIDS interventions across behavioral, biomedical, and structural approaches, there has been limited focus on housing insecurity—the inability to access safe, affordable, and stable housing—and mental health among people living with HIV, despite the critical role of housing insecurity in overall health and well-being. Therefore, this study explores how housing insecurity shapes mental health experiences among PLHIV in Kisumu. Methods: Using a qualitative approach, we purposively recruited 70 individuals from households participating in the Pamoja community-based organization’s Orphans and Vulnerable Children (OVC) project. We then conducted in-depth interviews (IDIs) with 30 participants and 4 focus group discussions (FGDs) with 40 adult participants living with HIV (ALHIV). Audio-recorded interviews were transcribed verbatim, translated from Luo into English, and uploaded to Atlas.TI v.23, a qualitative data analysis software. We then performed thematic analysis guided by grounded theory. Results: Our findings showed that housing insecurity was a significant issue for individuals living with HIV. The majority of participants experienced heightened feelings of worry, shame, fear, anxiety, stress, and depression, which negatively impacted their adherence to HIV treatment and care. While some participants showed resilience through acceptance and disclosure, limited resources and ongoing insecurity heightened vulnerability to mental health issues. Discussions: These findings underscore the importance of housing in HIV care programs and offer valuable insights for practitioners and policymakers. The findings highlight the need to incorporate housing stability and mental health support into HIV programs.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050575

Authors: Silvia Achieng Odhiambo Patrick Mbullo Owuor Doreen Obondo Janet Anyango Onyango Elizabeth Onyango

While substantial literature exists on COVID-19’s effects on businesses, long-term recovery strategies and support systems for informal female-owned enterprises in secondary cities are underexplored. The study sought to qualitatively examine the gendered impacts of COVID-19 on informal food businesses owned by women in Kenya. Qualitative interviews with 80 participants, including key informant interviews, in-depth interviews, and focus group discussions in Kisumu, Kenya, were conducted. The study found that the pandemic significantly disrupted the livelihoods of female vendors, leading to changes in the market and household organization, including gender specific transformations. The women adopted some individual and collective strategies as part of the post-pandemic recovery strategies to enhance their resilience in business. The study findings shed light on the vulnerabilities of informal food businesses in secondary cities to emergencies and the need for targeted policies to support informal economies during crises.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050574

Authors: Maria V. Aslam Cherie Rooks-Peck Curtis Florence Sarah Beth L. Barnett Claudia Gaffney Elizabeth A. Swedo

Non-medical use of cannabis (NmC) and/or opioids (NmO) can lead to adverse health effects (AHEs), yet the proportion of these harms attributable to adverse childhood experiences (ACEs) remains unclear. This study estimated the contribution of ACEs to AHEs from NmC and/or NmO among adults aged ≥18 years using 2019–2020 Behavioral Risk Factor Surveillance System data from Arizona and Massachusetts. We conducted a retrospective cohort analysis of 24,739 respondents, linking past ACE exposure to self-reported NmC/NmO/NmC&NmO and related AHEs. Generalized linear models with a log link and binomial distribution adjusted for socio-demographic, healthcare access, and geographic factors were used to estimate associations and population-attributable fractions (PAFs). Propensity score methods matched respondents with and without ACEs on demographic and location characteristics. Among all the adults, 17.9% reported NmC, 5.8% reported NmO, and 2.4% reported NmC&NmO; among users of NmC/NmO/NmC&NmO, 5.0%/13.2%/36.0% reported AHEs. Among the respondents reporting AHEs from non-medical substance use, exposure to ≥2 ACEs was common (NmC: 89%; NmO: 82%; NmC&NmO: 84%). Compared to adults without ACEs, those with ≥2 ACEs had a higher likelihood of AHEs for NmC (adjusted relative risk [aRR] = 3.54, 95% CI: 1.65–7.59) and NmO (aRR = 3.64, 95% CI: 1.99–6.66) but not NmC&NmO (aRR: 1.86, 95% CI: 0.84–4.09). PAFs indicated that 63% (NmC) to 64% (NmO) of AHEs among the adults reporting NmC or NmO were attributable to ≥2 ACEs. Preventing childhood adversity may substantially reduce substance-related harms in adulthood.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050573

Authors: Stefano Cataloni Darryl Forsyth David Brougham Kaye Thorn

The purpose of this study is to examine how the leadership competence of school leaders supports the implementation of psychosocial safety climate (PSC) within an educational workplace. While recent studies have considered how various leadership styles influence PSC, the processes through which school leaders at different levels enact and develop PSC in practice continue to receive limited attention. This study addresses this gap through a qualitative case study at a school in Aotearoa, New Zealand, which employed a sequential data collection process comprising 26 interviews and three focus groups. This investigation found that exemplary leadership, overcoming complexity, and multiskilled leadership are pivotal competencies that enable PSC implementation within a school setting. More broadly, we discuss how these key leadership competencies facilitate the development of policies, practices, and procedures that promote teachers’ psychological health and the four domains of the PSC framework. Finally, we propose a Leader Competence–PSC Framework as a practical tool for investigating and evaluating school leader competence across specific PSC domains.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050572

Authors: Jeri M. Antilla Linda M. DiClemente Amy C. Buckenmeyer Aubree Villarreal Nicole Rek

Black women in the United States experience inequities in perinatal and neonatal mortality, contributing to psychological stress during and after perinatal loss. This analysis drew on a subset of interviews from a larger qualitative dataset and explored the experiences of 22 Black women who experienced perinatal loss and were pregnant or had given birth after a loss, focusing on feeling unheard by healthcare providers. Semi-structured interviews were conducted, and data were analyzed using descriptive coding and inductive thematic analysis. Three themes emerged: unheard and dismissed concerns, biased and stratified care, and perinatal loss follow-up gaps driving self-advocacy. Women described how systemic racism intensified psychological distress, expressed as heightened anxiety and uncertainty in subsequent pregnancies after perinatal loss. Findings underscore the need for maternity settings to confront racial bias and strengthen cultural safety. Care environments that validate Black women’s concerns and act on them may help rebuild trust and improve maternal and newborn outcomes. The study calls for changes in maternity and mental healthcare aimed at addressing systemic racism and strengthening culturally responsive, equitable care. These findings have implications for perinatal public health practice and policy, including surveillance, prevention, and community-responsive approaches to maternity care during and after perinatal loss.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050571

Authors: Amber I. Sophus Alex Dubov Aaliyah Gray Chika C. Chuku Mandy J. Hill Jamila K. Stockman Jason W. Mitchell

Existing research has identified multi-level barriers and facilitators associated with pre-exposure prophylaxis (PrEP) uptake among Black women (BW); little is known about how BW prioritize these factors. In this study, Nominal Group Technique (NGT) was used to identify and prioritize key barriers and facilitators influencing BW’s potential use of PrEP. NGT sessions were conducted in two online focus groups with adult BW without HIV (N = 14). Participants ranked 16 barriers and 16 facilitators related to PrEP, by importance from 1 to 16, followed by a group discussion to review rankings, clarify reasons, and consolidate options. Participants also offered suggestions to enhance PrEP uptake for BW. Top concerns about PrEP were (1) side effects; (2) potential interactions with other medications; and (3) lack of health insurance coverage for PrEP. Key factors influencing PrEP use included: (1) discussing PrEP with a doctor of the same race; (2) discussing PrEP with a doctor of the same gender; and (3) receiving regular text or email reminders to take PrEP. Participants emphasized the importance of having race- and gender-concordant providers, which significantly influenced their consideration of PrEP. Using NGT as a qualitative exploratory method, this study underscores the importance of addressing key barriers and facilitators to PrEP uptake among BW.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050570

Authors: Grace Mabiala-Maye Keyonna M. King Marisa S. Rosen Regina Idoate Michelle Strong Chad Abresch

The United States faces a maternal health crisis marked by stark racial disparities. Although doula support has emerged as an evidence-based intervention to improve perinatal outcomes by addressing social determinants of health, its integration into healthcare systems remains limited. This qualitative study, informed by phenomenological principles, examined multi-level experiences, perceived barriers, and perceived facilitators of integrating doula services into perinatal care systems and their intersection with health equity goals. We conducted 17 semi-structured interviews with 20 participants across Nebraska and Tennessee, including doulas, midwives, physicians, Medicaid administrators, and public health professionals, and analyzed data using reflexive thematic analysis guided by the Socio-Ecological Model. Three themes emerged: the integration paradox, an overarching theme capturing tensions between doula independence and healthcare system demands for standardization, including divergent views on practice models, provider dynamics, and certification; sustainable financing as the prevailing barrier, encompassing grant limitations, private pay inequities, absent Medicaid reimbursement, and the need for cost-effectiveness evidence; and cultural concordance as the prevailing facilitator, including cultural matching, addressing social determinants, and lived experience as motivation. Sustainable doula integration requires reconciling system demands for standardization with the relational, culturally responsive characteristics that define effective care, through Medicaid reimbursement pathways and policy reforms developed in partnership with doula communities.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050569

Authors: Washington Luiz Félix Correia Filho José Francisco de Oliveira-Júnior Dimas de Barros Santiago

The Maceió Metropolitan Region (MMR) has undergone significant changes due to public policies that promote urban growth. This has intensified environmental impacts, adversely affecting local communities. The Remote Sensing Ecological Index (RSEI), a remote sensing-based metric, was used to evaluate ecosystem quality. The study assessed annual ecosystem quality in the MMR, Alagoas, using RSEI values from MODIS data spanning 2000 to March 2024/2025. To ensure data quality and reliable results, all MODIS data underwent rigorous quality control, including the exclusion of pixels affected by cloud cover, shadows, and missing values. Only data points meeting established MODIS quality assurance standards were used. Annual RSEI values varied considerably, from 0.449 in 2005 to 0.636 in 2014. Most areas in the MMR are classified as moderate quality (0.4 < RSEI < 0.6), particularly in central and eastern sectors. The lowest-quality regions (0 < RSEI < 0.4) are concentrated in the east—including Maceió, the hub city—and the west, largely due to high population density. The Sen-Slope Estimator and trend analysis revealed significant trends in the hub city, with positive trends in the northeast. Urban expansion has led to the loss of native vegetation, including sugarcane fields and remnants of the Atlantic Forest. The Pettitt test identified a structural change in 2018, likely linked to environmental violations related to the Braskem petrochemical industry and salt extraction in Maceió.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050568

Authors: Aisling Sealy Phelan Arnulf Hartl Christina Pichler René Zechner Elena Pisani Laura Secco

This study presents a pilot cost–benefit analysis of a nature-based therapy (NBT) for Chronic Obstructive Pulmonary Disease (COPD) in Austria. Within the framework of a randomised controlled trial, we identify cost categories, quantify the costs and benefits, and synthesise findings through a partial economic evaluation. Costs were estimated for two scenarios: the trial setting and a hypothetical roll out. Benefits were valued using contingent valuation to estimate willingness to pay (WTP). The trial scenario costs were €326.27 per patient per day, while the roll out scenario estimated was €171.84 per patient per day. Cost component analysis revealed accommodation and staff as the highest contributors in both scenarios. Marginal WTP was estimated at between €25–€35 per day, indicating patients’ perceived added value of NBT over standard clinic-based rehabilitation. These exploratory findings suggest NBT could be financially viable if marginal costs are lower than the estimated WTP. This study provides important preliminary evidence on the economic aspects of NBT, highlighting its potential as a sustainable alternative to standard COPD therapy. We recommend that future research expand upon our initial findings and incorporate economic assessments from the early trial design stage to enable more comprehensive cost–benefit analyses, thus facilitating informed decision-making on the implementation of such programmes.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050567

Authors: Charlotte Georgia Anderson Sarabjit Mastana

Background: Blood flow restriction training (BFRT) is a low-load resistance training modality capable of inducing muscle hypertrophy and strength adaptations that are comparable to traditional high-load resistance training. Beyond athletic performance settings, BFRT has growing relevance for musculoskeletal health, rehabilitation and populations unable to tolerate high mechanical loads. However, substantial inter-individual variability in adaptive responses has been reported. Genetic and molecular factors may partly contribute to this variability and inform more individualised exercise strategies. Other intrinsic and extrinsic factors, including age, sex, training status, nutrition, and protocol-related differences, may also influence adaptive responses. Objective: This scoping review aimed to map available evidence on molecular modulators of adaptation to BFRT and to identify gaps in the literature regarding genetic influences on BFRT responses. Methods: A structured search of PubMed, Web of Science and Google Scholar was conducted till 1 February 2026. Experimental and quasi-experimental studies examining BFRT in relation to genetic polymorphisms, gene expression, and molecular signalling pathways associated with strength and hypertrophy outcomes were included. Primary outcomes were genetic and molecular factors relevant to BFRT adaptation, including genetic polymorphisms, gene expression, and molecular signalling markers. Secondary outcomes included muscle strength, hypertrophy, vascular responses, and related functional outcomes where reported. Study selection and data extraction were conducted according to PRISMA-ScR guidelines. The methodological quality of randomised controlled trials was assessed using the PEDro scale. This scoping review was registered retrospectively in the Open Science Framework on 17 March 2026, after completion of the literature search. Results: From an initial 47 records, only three studies (n = 3) met the inclusion criteria. The included studies reported molecular responses associated with BFRT, including downregulation of proteolytic genes, suppression of myostatin expression, and upregulation of angiogenic markers. Notably, no studies directly examined genetic polymorphism or genotype–BFRT interactions, highlighting a clear need for these studies in this field. Conclusions: This scoping review therefore identifies a critical evidence gap, with genotype-informed BFRT prescription remaining unsupported by the current literature. Limited evidence supports the possible role of BFRT in molecular responses associated with muscle adaptation. Future research should prioritise well-designed studies integrating both genetic and molecular analyses to better understand inter-individual variability in BFRT adaptations.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050566

Authors: Seongwon Kim Seunghui Nina Jeong Minye Jung Yunjeong Eom Jungran Kim Meng-en Yang Junghun Aj Kim

(1) Background: Driving enables participation and independence for persons with disabilities; however, Korea lacks standardized driver rehabilitation guidelines and clearly defined occupational therapy roles. Current evaluations at the National Rehabilitation Center (NRC) rely heavily on instructors’ experiential judgment, resulting in inconsistent fitness-to-drive decisions. This study developed and field-tested a comprehensive driving evaluation (CDE) tailored to the Korean service context, integrating structured off-road functional assessment with on-road driving evaluation through a collaborative occupational therapist–driving instructor model. (2) Methods: The off-road assessment was refined through a literature review, an analysis of the ICF Core Set for driving rehabilitation, expert surveys, and a workshop with 10 occupational therapists. The on-road assessment was adapted from international tools and validated by NRC driving instructors and an expert committee. The CDE was field-tested with 30 persons with physical disabilities, cerebral palsy, or auditory disabilities enrolled in the NRC Driving Education Program. Eligibility for independent driving was classified as “eligible” or “doubtful.” (3) Results: The CDE was feasible within existing workflows. Off-road deficits predicted on-road difficulties, and cases with discordant judgments benefited from combined assessment. (4) Conclusions: The CDE offers a structured alternative to experience-based evaluations and supports interprofessional collaboration, providing foundational evidence for standardized driver rehabilitation in Korea.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050565

Authors: Juan Cesario Salas-Rosario Yanelba Elisa Abreu-Rojas Antonio Torres-Valle Ulises Javier Jauregui-Haza

Sustainable development results from the harmonious integration of economic growth, social equity, and environmental sustainability. Building on available risk analysis capacities, this study employs risk perception as a diagnostic tool to evaluate the adequacy of decision-making regarding environmental sustainability in vulnerable human settlements under a changing climate in the Dominican Republic. Using the perceived risk profile approach and a specially designed questionnaire, the research explores issues related to climate change and sustainability, targeting a population composed of decision-makers and professionals engaged in risk assessment. The findings reveal a systematic underestimation of risk across most perception variables, as well as a generally low collective risk perception. The study’s methodological framework enables the identification of proactive measures to strengthen knowledge and performance among decision-makers and stakeholders involved in advancing sustainable development in Dominican human settlements.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050563

Authors: Imran Zafar Shaista Shafiq Muhammad Sohail Khan

Wastewater is a complex and dynamic issue, particularly at the human–animal–environment interface, bearing biological and chemical hazards that may serve as a resource for transmission pathways for pathogens, antimicrobial resistance (AMR) determinants, heavy metals, pharmaceutical residues, per- and polyfluoroalkyl substances (PFAS), and microplastics. Rising global health issues necessitate effective wastewater treatment and advanced research to support risk-informed circular management within a one health framework, incorporating wastewater-based epidemiology (WBE), multi-omics approaches, nanobiotechnology, and green technologies. Inadequate wastewater treatment and uncontrolled discharge result in the generation of more than 380 billion cubic meters of wastewater annually worldwide, contributing to ecological degradation, the spread of AMR, and long-term toxicological risks. Despite significant advances in wastewater treatment, several challenges remain, including complex contaminant mixtures, limited detection and monitoring technologies, variable treatment efficiency, and weak regulatory and governance frameworks. This review highlights key wastewater treatment issues and presents recent advances in WBE and multi-omics approaches, such as metagenomics, resistome profiling, virome analysis, and chemical fingerprinting for contaminant monitoring and public health risk assessment. This review also examines circular reuse strategies focused on water reclamation, nutrient recovery, bioenergy production, and resource recovery, with particular emphasis on nature-based systems, hybrid biological–physicochemical treatment platforms, and green nanobiotechnology as promising approaches to improve treatment performance while minimizing environmental impacts. In conclusion, this review highlights the importance of integrated and sustainable wastewater management approaches within the One Health framework to address emerging challenges and promote environmental resilience, public health protection, and circular resource recovery.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050564

Authors: Michelle C. E. McCarron Sandra Jasinoski Marilyn Cox Yan Song Joy C. MacDermid Gregory S. Anderson

Public Safety Personnel (PSP) face numerous potentially psychologically traumatic events in the line of duty. Resilience courses intended to mitigate the effects of operational stress injuries in this population—many of which are available online—have proliferated in recent years. An environmental scan yielded 15 courses that met all inclusion criteria. Courses were required to be offered for $250 or less and had to be created and/or hosted in Canada. Courses focused on individual (n = 7), family (n = 2), or workplace (n = 6) resilience. A qualitative content analysis was conducted. Data were extracted from public-facing documents and course materials, and supplemented by additional text materials and contacting program staff for clarification, when necessary. Coding and synthesis were completed in iterative team meetings. Courses were compared across numerous dimensions, including focus, intended audience, cost, enrollment details, length, instructional style, customization for PSP, and completion requirements. Nearly half of the courses (46.7%) were available free of charge. Outcome data were available for four of the courses, with most studies showing initial gains in resilience, skills, knowledge, attitudes, intentions, and/or behaviors, but with evidence of skill decay over time. The potential benefit of short refresher sessions warrants further investigation.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050562

Authors: Lauren Callaghan Anushree Dwivedi Cathal Óg O’Sullivan Saim Ghafoor Michelle Queally Robert Mooney

(1) Background: Childhood obesity is one of the greatest challenges facing public health in the 21st century. Currently, there is a great deal of interest in the concept of physical literacy due to its comprehensive nature on the development of physical activity. Physical literacy can be described as the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life. The aim of this paper is to provide a systematic review of the literature examining the relationship between physical literacy and risk of obesity in children. This paper also focuses on providing an evaluation of the availability and effectiveness of current physical literacy assessment tools. (2) Methods: This review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. (3) Results: A total of 3267 papers were identified from five major databases. Twelve studies met the inclusion criteria, with nine studies included in the final review following quality appraisal. (4) Conclusions: This review identified significant gaps in our understanding of physical literacy emphasising the need for a consistent framework, standardised assessment tools and more experimental research.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050561

Authors: Sarah Halleluyah Adeyemi Roshan Paudel

Antimicrobial resistance in Escherichia coli (E. coli) is a major public health concern globally, driven by increased resistance to commonly used antimicrobial agents such as β-lactams and fluoroquinolones. The main goal of our research is to develop a machine learning framework to predict antimicrobial resistance in E. coli by integrating antimicrobial susceptibility testing data with genomic biomarker analysis. A dataset comprising 17,122 E. coli clinical isolates was obtained from the Bacterial and Viral Bioinformatics Resource Center (BV-BRC). After preprocessing, fivefold cross-validation was used to train and test five machine learning models: Random Forest, XGBoost, Support Vector Machine, Logistic Regression, and k-Nearest Neighbors. The highest-performing model was XGBoost, with 0.86 accuracy and 0.932 ROC-AUC, followed by Random Forest, with 0.82 accuracy and 0.89 ROC-AUC. Phylogenetic analysis revealed that resistant isolates clustered together relative to the reference genome of E. coli K-12 MG1655. Genomic biomarkers such as gyrA, parC, CTX-M-15, OXA-1, and various multidrug efflux pumps were identified by the Comprehensive Antibiotic Resistance Database (CARD) and ResFinder as significant resistance determinants in this study. In conclusion, this study demonstrates that combining antimicrobial susceptibility testing with machine learning and genomic biomarkers is a powerful framework for predicting antimicrobial resistance in E. coli.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050560

Authors: Željka Dujmić Štefica Mikšić Željko Mudri Marija Barišić Ivana Barać Jasenka Vujanić Maja Čebohin Zvjezdana Gvozdanović Stana Pačarić Valentina Grnja Josip Samardžić Ivica Mihaljević Nikolina Farčić

Rotating shift work is a common occupational stressor among healthcare professionals. This study aimed to examine the impact of shift work on sleep quality and cortisol levels among nurses. A prospective observational study was conducted in Croatia in 2025, involving 140 nurses. Sleep quality was assessed using the Fitbit Charge 3 smartwatch over eight consecutive days, and blood cortisol was measured at two time points. Most nurses (98.6%) had a neutral chronotype. Nurses who work day shifts (DSN) achieved significantly higher sleep scores compared with rotating-shift nurses (RSN) (77, IQR 75–80 vs. 73, IQR 68–76; Mann–Whitney U test, p < 0.001). RSN also had significantly higher morning cortisol levels at the first measurement (median 431.6, IQR 351.3–496.2 vs. 355.15, IQR 254.9–434.2) nmol/L; p < 0.001). In the RSN group, morning cortisol levels at the first measurement were positively correlated with age and years of service, and negatively correlated with circadian rhythm. Smartwatch-based assessments demonstrated that rotating shift work is associated with poorer sleep quality and transient disruption of cortisol regulation. Notably, cortisol levels in rotating-shift nurses returned to levels comparable to those of DSN after two nights of rest, indicating substantial reversibility of the hormonal response. These findings highlight the short-term physiological impact of shift work and underscore the importance of optimizing work schedules and implementing strategies to reduce long-term health risks.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050559

Authors: Bridgette Masters-Awatere Rachel McClintock Utiku Potaka Luke Enoka Stacey Ruru Amohia Boulton

This systematic review synthesises the qualitative literature on Māori leadership to examine how leadership is conceptualised, enacted, and constrained, and what this implies for Aotearoa New Zealand’s health system. Across included studies, Māori leadership is grounded in whakapapa-based legitimacy, tikanga and mātauranga Māori, and collective responsibility for relational, cultural, and intergenerational wellbeing; these foundations persist across “traditional” and “contemporary” settings, with differences reflecting institutional conditions rather than shifts in core values. Interpreting the literature through a Māori cultural lens, the review shows that leadership is often exercised within Crown-dominated organisations where Māori authority is not the default, requiring leaders to navigate multiple accountabilities to iwi and communities, organisational mandates, and statutory obligations. Hybridity emerges as a structurally produced feature of practice, integrating Māori relational ethics with bureaucratic, professional, and governance requirements and ongoing translation work to make Māori priorities legible within institutional systems. Health-sector evidence illustrates how commissioning, funding, and accountability arrangements can limit Māori decision-making, increase leadership burden, and constrain sustainability and leadership pipelines. The review concludes that strengthening Māori leadership in health requires organisational and system change—such as clearer Māori decision rights, resourced Māori-led priority setting, and accountability mechanisms that operationalise equity and anti-racism—alongside targeted research on governance, commissioning, and system design.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050558

Authors: Katherine Simmonds Madison Evans Nancy Nguyen Niharika Putta Alexis Thom

Rural communities face significant healthcare access barriers that contribute to persistent health disparities. Mobile health clinics (MHCs) have emerged as a promising strategy for expanding healthcare access, yet their effectiveness in rural settings remains understudied. The aim of this review was to examine the literature to determine what is known about access, health outcomes, and the cost-effectiveness of rural MHCs, specifically with regard to their impact on patient access and outcomes, return on investment (ROI)/financial, and program sustainability. We conducted a comprehensive search of peer-reviewed and grey literature sources. Systematic screening yielded 34 documents for full analysis. Thematic analysis was conducted across three domains: patient access, patient outcomes, and ROI/sustainability. All 34 documents provided data on patient access, with common themes including expanded service utilization, multi-service integration, overcoming geographic and transportation barriers, and improved healthcare affordability. Thirty-two documents addressed patient outcomes, reporting improvements in preventive care delivery, chronic disease management, and high patient satisfaction. Twenty-eight documents included ROI/sustainability information, with evidence suggesting cost-effectiveness particularly through emergency department visit avoidance and multi-service integration. Across the literature reviewed, the quality of evidence varied considerably, yet we concluded mobile health clinics demonstrate promise for expanding healthcare access and improving outcomes in rural populations. Key success factors include multi-service integration, diverse funding partnerships, technological integration, and strong community engagement. More rigorous research with longitudinal clinical outcome measures and robust economic analyses is needed.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050557

Authors: Giovanni Schettino Maria Francesca Trocino Ilaria Poderico Vincenza Capone

In the current labor market, perceived employability is a key resource for university students approaching the transition from university to work, which is often marked by heightened stress, vulnerability, and unhealthy behaviors, particularly in contexts with high youth unemployment rates. Despite prior research documenting the buffering role of perceived employability in the relationships between career-related stressors and well-being, limited evidence exists regarding the roles of faculty support and self-compassion, a fundamental factor for effective emotional regulation, during university years. Consequently, this study aimed to examine the relationships between faculty support, self-compassion, career self-efficacy, career planning, and perceived employability through a self-report questionnaire completed by 186 Italian university students, mainly female, with a mean age of 21.24 (SD = 2.57). Results from a partial least squares model indicated that faculty support was indirectly associated with perceived employability through self-compassion, career self-efficacy, and career planning. These findings could support higher education organizations by suggesting the design of interventions to promote supportive learning environments and to develop training in emotional regulation skills. Such an approach could empower students to effectively cope with career-related stressors and, in turn, engage in adaptive behaviors associated with employability.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050556

Authors: Diana Araújo Ana Bártolo Cláudia Fernandes Anabela Pereira Sara Monteiro

Background: Burnout is an occupational phenomenon that has adverse effects on the health and work outcomes of employees. In this sense, there is greater emphasis on understanding and addressing this problem. In this regard, organizations play a significant role in preventing burnout, and organizational interventions have been shown to be more effective at reducing burnout than individual-focused interventions. This study aims to systematically review organizational interventions to prevent burnout in the workplace. Methods: A search was conducted in three databases: Scopus, Web of Science, and PubMed, reviewing studies published from 2013 to 2025. Following the PRISMA model, 11 studies meeting eligibility criteria were selected. The methodological quality of included studies was assessed using the Joanna Briggs Institute (JBI) checklist. Results: Of the eligible articles, 1669 participants were identified, predominantly female healthcare professionals. Some strategies that proved to be effective in preventing burnout in the workplace were workshops, discussion groups, psychoeducation and training programs. Concerning psychotherapeutic interventions, third-generation therapies are the most used, such as ACT or mindfulness. Conclusions: These findings suggest that organizational-level interventions, particularly those combining psychoeducational strategies with third-generation therapeutic approaches, represent promising avenues for burnout prevention in the workplace, although effectiveness varies across interventions and contexts, and the most positive effects were limited to the short term. Future research should focus on evaluating long-term outcomes, exploring understudied occupational sectors beyond healthcare, and examining the role of organizational culture and leadership in sustaining intervention effects.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050555

Authors: Caroline Sindisa Baloyi Cairo Bruce Ntimana Eric Maimela

Despite the availability of clinical guidelines aimed at managing pregnancy complications, maternal deaths related to obstetric emergencies remain unacceptably high in South Africa, especially in rural provinces like Limpopo. These preventable deaths are often linked to delayed response to complications, poor adherence to protocols, and lack of essential resources. The study aimed to explore the experiences of health professionals regarding the implementation of maternal guidelines used to manage obstetric emergencies. The study adopted a qualitative, descriptive, and explorative design. Data were analysed thematically, and trustworthiness was maintained throughout the research process. Sixteen participants from four selected hospitals in a rural area of South Africa (Vhembe District, Limpopo Province) were purposively sampled and interviewed using semi-structured interviews; data were analysed thematically. The findings highlighted multiple critical barriers to guideline implementation, including shortages of printed clinical protocols, inconsistent patient follow-up, poor referral systems, infrastructure deficits, medication stock-outs, and negative staff attitudes. Most doctors and midwives working in maternity units lacked training on the Essential Steps in the Management of Obstetric Emergencies (ESMOE), resulting in insufficient knowledge and skills to manage obstetric emergencies. Therefore, there is an urgent need for comprehensive ESMOE training for all doctors and midwives in maternity units.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050554

Authors: Maurice J. Chery Eric C. Brown Arsham Alamian Jovanka Ravix Sandy St. Hilaire Aisha Severe Lauren Smith Reginald Fils-Aime Mary Clisbee Rimsky Denis Samara Perez Justin J. Sanders Donaldson Conserve Judite Blanc Joseph Bernard Patricia Moreno Matthew P. Schlumbrecht Sophia H. L. George

Background: Haitian immigrants in the United States face health literacy challenges related to recent migration, language discordance, and unfamiliar healthcare systems, yet no general health literacy instrument has been psychometrically validated in Haitian Creole. This study translated, culturally adapted, and evaluated the Haitian Creole HLS19-Q12 (HLS19-Q12-HC). Methods: Haitian Creole-speaking adults without cancer diagnoses in South Florida (n = 168) completed the HLS19-Q12-HC and the Haitian Creole Brief Health Literacy Screen. Translation included forward–backward procedures, expert review, and cognitive interviews (n = 7). Psychometric evaluation used confirmatory factor analysis, reliability testing, and assessment of convergent and known-groups validity. Results: Cognitive interviews supported clarity and cultural appropriateness with minor refinements. Reliability was excellent (ω = 0.949; α = 0.944; AVE = 0.584). The unidimensional model showed good fit (CFI = 0.951; TLI = 0.944; RMSEA = 0.065; SRMR = 0.048), whereas multi-factor models showed limited discriminant validity. Convergent and known-groups validity were supported. Using provisional European-derived cutpoints, 70.2% of participants were classified as having inadequate or problematic health literacy. Conclusions: The HLS19-Q12-HC showed evidence of reliability and validity as a unidimensional measure of general health literacy and may support research, needs assessment, and culturally responsive interventions for Haitian Creole-speaking populations. Findings should be interpreted in light of the convenience sample from South Florida and the predominantly female composition of the cohort.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050553

Authors: Parichart Boueroy Nattamol Phetburom Birabongse Hardthakwong Ratanee Kammoolkon Panchamapohn Rattanahon Peechanika Chopjitt Narita Fakkaew Pathanan Suwannaboon Chavanakorn Krueakaew Patiwat Yasaka Janjira Hantakhu Kulthida Y. Kopolrat

Opisthorchis viverrini infection remains a significant public health concern in Southeast Asia, particularly in rural communities of Northeast Thailand, where persistent environmental and behavioral factors sustain transmission. A quasi-experimental study aimed to identify environmental and behavioral risk factors for infection and to evaluate the effectiveness of a community-based intervention program. The intervention program study was conducted over 10 months and comprised three phases: baseline survey‚ health education intervention program implementation‚ and follow-up evaluation. The results were analyzed for the prevalence of parasitic infections, and multivariable logistic regression was performed to identify associated factors. The majority of study participants were female (67.94%)‚ aged 55 to 64 years (48.09%)‚ and farmers (89.31%). Parasitic infections‚ especially O. viverrini‚ substantially decreased during the follow-up period‚ and independent risk factors predicting infection included lower education‚ previous infection‚ raw fish consumption‚ and pesticide use‚ according to multivariable logistic regression analysis. This intervention considerably improved knowledge; mean knowledge score increased by 6.29 points (p < 0.001). Analysis of fecal sludge after treatment with the sand-drying system identified S. stercoralis larvae (20 eggs/L) and Taenia spp. eggs (12.4 eggs/g). These findings indicated that, despite treatment, integrated behavioral and environmental interventions can be effective in interrupting parasite transmission in rural endemic settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050552

Authors: Motlatso Elias Letshokgohla Reneilwe Given Mashaba Cairo Bruce Ntimana Eric Maimela

The prevalence of chronic conditions such as hypertension, diabetes, and Human Immunodeficiency Virus (HIV) is rising globally, yet access to continuous care remains limited, particularly in rural low- and middle-income countries. This study evaluated the acceptability and psychosocial predictors of retention in a linkage-to-care (LTC) intervention for patients with chronic conditions in rural South Africa. We conducted a cross-sectional analytical study with a retrospective cohort component among 1673 patients diagnosed with hypertension, diabetes, and/or HIV in Limpopo Province, South Africa. Acceptability and psychosocial factors were assessed cross-sectionally using a theory-informed, interviewer-administered questionnaire between January and June 2024. Retention in care over the preceding six months (July–December 2023) was extracted from routine clinic records and classified as consistent (no gaps > 6 months between visits) or inconsistent (≥1 gap > 6 months. Logistic regression examined associations between psychosocial factors and retention outcomes, adjusting for age, gender, marital status, and diagnostic category. Overall, 25.1% of participants maintained consistent retention over six months, while 74.9% were retained inconsistently. Acceptability of the LTC intervention varied significantly by diagnosis (p < 0.001): 79.5% of participants with multimorbidity rated the intervention as acceptable compared to 54.9% with hypertension, 64.5% with diabetes, and 46.8% with HIV. However, only 12.8% of multimorbid participants agreed that intervention activities fit well with their daily lives. In adjusted analyses, participants who were not happy to participate had 85% lower odds of consistent retention (adjusted odds ratio [AOR] = 0.15, 95% CI: 0.09–0.22) and 7.2 times higher odds of inconsistent retention (AOR = 7.2, 95% CI: 4.8–10.9). Most participants supported de-identified data sharing, though privacy concerns were elevated among those with multimorbidity. Acceptability of LTC interventions differs by diagnosis, with multimorbid patients reporting poorer alignment with daily routines. Retention is strongly associated with emotional engagement and self-efficacy, suggesting that LTC interventions should integrate psychosocial support and be contextually adapted for multimorbid patients in rural settings.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050551

Authors: Costanza Vecchio Chiara Copat Paola Rapisarda Gea Oliveri Conti Margherita Ferrante

Background: Human health is closely interconnected to our ecosystem. Several studies found evidence that nature-based interventions improve mental health. Very recently, these approaches have started including mindfulness practices. Nature-based mindfulness interventions (NBMIs) combine contemplative practices with exposure to natural environments and are increasingly recognised as promising tools for supporting mental health and resilience within a One Health perspective, fostering physio-psychological wellbeing whilst promoting nature awareness and a sense of connection with our planet—“biofilia”, as defined by American biologist Edward Wilson. Given the growing psychological impacts of climate-related stressors, NBMIs may offer particular value for regions with high climate-risk and ecological vulnerability. Methods: A narrative literature review was conducted following established principles for high-quality non-systematic reviews. A non-systematic but structured search of PubMed, Scopus, Web of Science and Cochrane Library (January 2018–November 2025), complemented by grey literature, identified studies involving adolescents and adults participating in interventions integrating mindfulness practices with natural environments. Extracted data included study context, participant characteristics, intervention type, mental health and resilience outcomes. Results: Across heterogeneous designs, NBMIs consistently reduced stress, anxiety, depressive symptoms and rumination, while improving sleep, vitality, attention and self-regulation. Most studies reported enhanced nature connectedness—an important mediator of wellbeing and pro-environmental behaviour. Programmes delivered to disaster-affected populations showed reductions in distress. Conclusions: NBMIs are feasible, low-cost and adaptable interventions with dual benefits for mental health and ecological awareness. They offer promising One Health-aligned strategies for strengthening psychological resilience in climate-vulnerable regions, warranting further research and context-specific adaptation.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050550

Authors: Margaret Henning Magdalynn Graul Kate McAvoy

This research, funded by the National Science Foundation (Award #2412054) as part of the NH-LIFT project, provides a critical analysis of a successful public health initiative addressing food insecurity in New Hampshire, which affects nearly 10% of residents and 13.4% of children. The study’s primary objective was to analyze the effectiveness, unique characteristics, and replicability of The Community Kitchen’s Mobile Food Pantry program in collaboration with the Healthy Monadnock Alliance and Cheshire Medical Center. Methods: A survey design was employed over a four-week period (July–August 2025) to collect qualitative data from n = 97 voluntary participants attending mobile pantry events in four rural southwest New Hampshire towns, Gilsum, Richmond, Winchester, and Fitzwilliam, during the period of May-June of 2025. The anonymous, 25-question instrument gathered information on program benefits and needed improvements. Results indicate the model is highly effective in mitigating increased financial stressors and overcoming transportation barriers, which are critical challenges for families and aging adults in this rural region. While demonstrating success in promoting local health and well-being, the research also highlights factors crucial for long-term sustainability. This study contributes to an evidence-based public health model suitable for replication in other food-insecure rural communities.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050549

Authors: Christopher Benny Jakob Hanschu Roger G. Aby Serap Gorucu Bryan P. Weichelt

In the U.S., extreme heat is the leading cause of weather-related fatalities. Farmers, ranchers and other outdoor workers who are exposed to the elements and engaged in strenuous physical activity are disproportionately impacted. This manuscript summarizes the number and severity of heat-related illnesses and injuries collected through the AgInjuryNews.org system, highlights their characteristics, provides recommendations for farmworkers and employers, and calls for future research. Heat-related illness cases from 2016–2024 were analyzed. Fourteen agricultural heat-related incidents covered by U.S. media were identified. Most incidents took place in June and July. A content analysis was conducted to identify news articles that included mention of prevention strategies, laws and regulations related to working conditions, or OSHA. Over half of the cases were from southern states. Eleven of the incidents involved male farmworkers, one involved a male farmer, and two involved first responders (gender unspecified). All of the farmer/farmworker incidents were single-victim fatalities. Seven articles mentioned prevention strategies, ten mentioned laws or regulations, and nine mentioned OSHA, often cursory. These findings suggest that media reports provide a limited and selective image of agricultural heat-related injuries, with coverage emphasizing fatalities and investigation information more often than prevention.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050548

Authors: Bartira Pereira Palma Carine Collet Evandro Morais Peixoto Riller Silva Reverdito Larissa Rafaela Galatti

The aim of this study was to investigate older adults’ engagement in sport through the lens of the Positive Development in Sport (PDS), a framework aimed at fostering human growth in sport environments. This qualitative study involved 80 older athletes (M = 71.91 years, SD = 7.91; 45 women) engaged in regular sport practice and four experienced coaches (37–57-years-old). Data was collected across multiple contexts: brief in-person individual or small-group interviews during a competitive event; five in-person focus groups; and individual interviews. Data was analyzed using reflexive thematic analysis. Findings revealed a central theme, autonomy to engage in sport, supported by three subthemes: competence and confidence, health, and setting priorities. Participants described sport as a meaningful component of their identity, with sustained engagement driven by intrinsic motivation and harmonious passion. They reported increased self-awareness, intentional health management, and the ability to balance sport participation with other life domains, highlighting positive implications for mental health. Coaches who actively supported athletes’ psychological needs played a key role in fostering autonomy and personal development. Participants also emphasized the importance of inclusive relationships and pedagogical strategies tailored to older athletes’ goals and lived experiences. The findings suggest that sport in older adulthood can be a context for personal growth and mental health development.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050547

Authors: Alex Leong Erich C. Fein Kirstie Daken Judith A. Dean Sara F. E. Bell Joseph Debattista Armin Ariana Kathryn Elizabeth Wenham Joanne Durham Charles F. Gilks Zhihong Gu Amy B. Mullens

Alcohol use has been linked to sexual risk-taking behaviour, particularly among young people in Australia, who are also substantially represented in sexually transmissible infection (STI). While research on alcohol use and sexual risk-taking among university students in Australia exists, no studies outside recent Tertiary Students Sexual and Reproductive Health Survey (TSSHS) publications have distinguished between Australian-born and overseas-born domestic students, despite evidence that migrant populations may show different alcohol use and sexual behaviour patterns. Using data from the TSSHS and a cross-sectional anonymous online survey of university-enrolled students, this study is the first to compare sexually active Australian-born domestic, overseas-born domestic, and international students on alcohol use and sexual risk-taking. Findings align with past research, with Australian-born domestic students being more likely to consume alcohol at high-risk levels than international and overseas-born domestic students. Differences in sexual risk-taking behaviours between the three enrolment groups were fully mediated by harmful alcohol use, indicating an indirect effect between group membership and sexual risk-taking. Age moderated this mediation, with the association between harmful drinking and sexual risk-taking strongest among students aged 20–24, compared with younger and older groups.

International Journal of Environmental Research and Public Health doi: 10.3390/ijerph23050546

Authors: Gira J. Ravelo Michelle Robinson Gladys Ibañez Mariana Sanchez Arnaldo Gonzalez Beatriz Macias Gomez-Estern Patria Rojas Mario De La Rosa Victoria Behar-Zusman

Background: Miami-Dade County ranks first in Florida for HIV cases, yet broad epidemiological data often masks the “on-the-ground” reality of its most vulnerable residents. While standard reports suggest declining domestic violence, these statistics fail to account for community-defined health crises—the “SAVA” syndemic (substance use, violence, and HIV/AIDS)—occurring within localized micro-communities. Methods: Leveraging five years of Community-Based Participatory Research (CBPR) and Grounded Theory, this study engaged 97 community members and leaders to unmask these hidden burdens. We employed a multi-level sequential design and methodological triangulation, incorporating community forums, focus groups, and interviews with farm-workers, inner-city residents, and LGBTQ+ individuals. Results: Findings reveal a disconnect between official data and community reporting, including “Party and Play” methamphetamine/sex-trafficking networks in the LGBTQ+ scene, rampant youth vaping in inner cities, and child sexual abuse and opioids in farm-working communities. Mental health emerged as a pervasive need, masked by substance use and suppressed by cultural stigmas and institutional fears. Conclusions: Findings from this study highlight the value of community-level approaches in generating localized, culturally grounded insights that may not be fully captured in more aggregated geographic analyses (e.g., zip code, county, or state levels). We propose a collaborative, multi-sectoral model to address the systemic factors underlying the SAVA syndemic in these communities.