Search Results (1,596)

Background: Multimorbidity is a growing global health challenge in aging populations, yet its progression across physical, psychological, and cognitive domains and its contribution to health inequalities remain unclear. We compared longitudinal patterns of multimorbidity in China and the United States (US) and examined the socioeconomic and healthcare-related factors associated with these patterns and their functional consequences. Methods: This longitudinal cohort study included adults aged ≥45 years from China (2011–2020) and the US (2012–2020), matched 1:1 by baseline age and sex. Multimorbidity was classified into eight domains spanning physical, psychological, and cognitive conditions and their combinations. Longitudinal changes across five survey waves were assessed. Multinomial logistic mixed models examined socioeconomic and healthcare-related correlations, and Cox models estimated associations with subsequent limitations in activities of daily living (ADL) limitations and instrumental activities of daily living (IADL) limitations. Results: A total of 7064 participants from China (mean age 60.15 ± 7.93 years; 45.4% male) and 7064 matched participants from the US were included. Multimorbidity patterns were more complex in the US at baseline, but progression toward cross-domain multimorbidity occurred in both countries and was more pronounced in China. Psychological conditions occupied a central position in the development of more complex multimorbidity patterns. Higher educational and household wealth were consistently associated with lower odds of cognitive-related and cross-domain multimorbidity in both countries, whereas associations with healthcare-related factors varied across settings. Cross-domain multimorbidity was more strongly associated with functional limitations than within-domain multimorbidity. In particular, physical–psychological–cognitive multimorbidity was associated with substantially higher risks of ADL limitations (hazard ratio (HR)  =  5.70, 95% confidence interval (CI)  =  4.87–6.67 in China; HR  =  7.72, 95% CI  =  5.90–10.11 in the US) and IADL limitations (HR  =  4.14, 95% CI  =  3.64–4.71; HR  =  5.84, 95% CI  =  4.50–7.59, respectively). Conclusions: Multimorbidity increasingly spans physical, psychological, and cognitive domains in both China and the US. Psychological conditions appeared to bridge physical and cognitive conditions in more complex multimorbidity patterns. Integrated care models incorporating psychological health and strategies addressing socioeconomic inequalities may help reduce the burden of multimorbidity and related functional decline. Full article

Background: Physical activity is a crucial component of diabetes prevention and management, yet participation varies across populations. Differences by country of birth may reflect cultural, socioeconomic, and structural factors that influence health behaviors among individuals with diabetic conditions. Objective: To examine the relationship between country of birth, diabetes status, and physical activity, and to assess whether country of birth is associated with diabetes prevalence. Methods: A cross-sectional analysis was conducted using U.S.-nationally representative data from the National Health and Nutrition Examination Survey (NHANES). Adults were categorized as having diabetes/prediabetes or no diabetes based on self-reported diagnosis. Physical activity was assessed using self-reported levels of moderate and vigorous leisure-time physical activity (LTPA). Sociodemographic characteristics were compared across groups. Stratified analyses were conducted to evaluate differences by country of birth and statistical tests were used to identify significant associations between diabetes status, physical activity, and sociodemographic variables. Results: Significant differences in sociodemographic characteristics were observed across diabetes status groups, particularly by age. There was no significant difference in physical activity levels between adults with diabetes compared to those without. Individuals with diabetes reported higher levels of sedentary time before adjustment for sociodemographic factors. Differences in physical activity behaviors were also observed in unadjusted analyses by country of birth, with foreign-born groups demonstrating lower levels of vigorous activity. Conclusions: Physical activity disparities exist among adults in the United States with diabetes and prediabetes and differ by country of birth, although they can be largely explained by sociodemographic factors. These findings highlight the need for culturally and socioeconomically tailored interventions to promote physical activity and support chronic disease management in diverse populations. Full article

Regional development disparities remain a persistent global challenge, yet existing assessment approaches often face a trade-off between spatial detail and temporal coverage. Conventional socioeconomic statistics provide relatively reliable information but are typically limited by coarse spatial representation and low update frequency, whereas high-resolution remote sensing-based studies often focus on individual time points, making it difficult to capture the temporal evolution of regional development. Remote sensing observations provide valuable opportunities for regional development assessment by offering extensive spatial coverage and repeated observations over time. To address this gap, this study proposes a multisource remote sensing framework for characterizing the spatiotemporal dynamics of regional development in Chongqing Municipality across four temporal nodes (2014, 2016, 2018, and 2020). We first construct a county-level Development Intensity Index (DII) using socioeconomic indicators derived from statistical data. Subsequently, we integrate nighttime light, DEM, NDVI, and POI data to generate a 500 m gridded Comprehensive Spatial Development Index (CSDI), which captures spatial heterogeneity at a fine spatial scale. The CSDI exhibits strong correspondence with the DII, and its spatial validity is further corroborated through visual interpretation of Google Earth imagery. Results indicate that areas with higher development levels are predominantly concentrated in Chongqing’s central urban core, while less-developed counties are concentrated in the northeastern and southeastern peripheries. Although a general upward trend in development is observed across the study period, notable spatial disparities persist. Overall, the proposed CSDI-based framework offers an effective and replicable approach for gridded regional development assessment, with implications for targeted regional planning and differentiated policy design. Full article

Mild traumatic brain injury (mTBI) is a common cause for pediatric emergency department visits and can impose substantial burdens on families, including missed work and childcare needs. Socioeconomic context may influence both healthcare use and these downstream impacts. This study examined the association between Child Opportunity Index (COI), a neighborhood-level measure of socioeconomic status, and healthcare utilization and indirect costs following pediatric concussion. In a secondary analysis of a multisite randomized controlled trial of patients with acute (<72 h) concussion, participants were categorized into high, middle, and low COI groups. Outcomes included follow-up care, caregiver missed workdays, childcare needs, and indirect costs, analyzed using multivariable regression models. Participants from lower COI neighborhoods were more likely to present to the emergency department, with 93.02% compared to 71.43% in higher COI groups (p = 0.005); had higher symptom scores at 14 days, 28.69 versus 16.64 (p = 0.03); and were less likely to be seen by concussion specialists, 6.98% versus 28.57% (p = 0.005). They also had lower odds of attending follow-up within 14 days (OR = 0.36, p = 0.015) and higher caregiver burden, including more missed workdays and childcare needs. Although total indirect costs did not differ significantly for low COI groups after adjustment, middle COI participants had lower costs than high COI ones. Overall, disparities were observed in care patterns and caregiver burden despite similar recovery outcomes. These findings suggest that expanding access to affordable concussion follow-up through school-based programs, telehealth services, transportation assistance, and flexible scheduling may help reduce caregiver burden and improve continuity of care for children from lower COI neighborhoods following pediatric mTBI. Full article

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

Background: Diabetic ketoacidosis (DKA) remains a preventable yet frequent complication at the onset of type 1 diabetes (T1D) in children, driven by delayed symptom recognition, socioeconomic disparities, and inconsistent access to care. Early identification of presymptomatic T1D through autoantibody-based screening, together with emerging disease-modifying therapies, may reduce the incidence of DKA. This review synthesizes evidence on epidemiology, risk determinants, screening strategies, and immunological interventions relevant to DKA prevention. Methods: A narrative review was conducted using PubMed, EMBASE, Scopus, Web of Science, and Google Scholar (2011–2026). Eligible sources included clinical studies, guidelines, systematic reviews, meta-analyses, and prevention trials addressing staging, screening, epidemiology, and disease-modifying treatments in pediatric T1D. Landmark publications outside this timeframe were included when essential. Evidence was integrated to identify determinants of DKA and strategies to reduce its occurrence. Results: DKA risk is influenced by younger age, socioeconomic disadvantage, rural residence, misdiagnosis, and limited access to specialized care. Sustained public awareness and community-based education reduce DKA incidence, whereas short-term campaigns show transient effects. Structured screening programs, including TrialNet and TEDDY, demonstrate near-elimination of DKA among monitored children. Teplizumab delayed progression from stage 2 to stage 3 T1D by a median of approximately 24 months in the original TN-10 trial, with extended follow-up demonstrating a median delay of 32.5 months. It is approved for individuals with stage 2 T1D aged ≥ 1 year and has recently gained approval for selected patients with newly diagnosed T1D, expanding opportunities for early disease modification. Global networks such as INNODIA strengthen prevention through coordinated biomarker-driven research. Conclusions: Reducing DKA at T1D onset requires integrated, sustained strategies combining public awareness, systematic autoantibody screening, structured follow-up, and access to emerging immunotherapies. Coordinated care across primary providers, pediatric endocrinologists, and research networks is essential to advance a proactive, prevention-oriented model of pediatric T1D care. Full article

Background: Socioeconomic deprivation is a well-established determinant of participation in colorectal cancer (CRC) screening. However, less is known about the geographic clustering of screening adherence and whether spatial inequalities mirror regional patterns of socioeconomic disadvantage. This study investigated the association between socioeconomic deprivation and adherence to CRC screening across Italian regions and explored the presence of spatial autocorrelation using geographic analytical methods. Methods: We conducted a nationwide ecological cross-sectional study including 21 Italian regional units. Pearson correlation analysis was performed to explore associations between colorectal cancer (CRC) screening adherence, primary care physician (PCP) workload and socioeconomic deprivation. Multivariable linear regression was used after assessment of multicollinearity using variance inflation factors (VIFs). Sensitivity analyses included alternative deprivation indicators and leave-one-region-out analyses. Spatial dependence was evaluated using Global Moran’s I and Local Indicators of Spatial Association (LISA). Results: CRC screening adherence showed substantial geographic variability across Italy, with higher participation in northern regions and lower participation in southern areas. Screening adherence was inversely associated with socioeconomic deprivation. Sensitivity analyses confirmed the robustness of the association across alternative deprivation measures and sequential exclusion of each regional unit. Spatial analysis demonstrated significant positive spatial autocorrelation (Moran’s I = 0.275; p = 0.039), indicating that neighbouring regions tended to exhibit similar screening behaviours. LISA analysis identified significant High–High clusters in northern Italy, Low–Low clusters in southern and insular regions, and isolated spatial outliers, highlighting persistent territorial inequalities in preventive healthcare utilisation. Conclusions: Regional disparities in CRC screening participation were associated with socioeconomic deprivation and modest but significant spatial clustering. These findings provide a regional-level description of inequalities in screening participation and may help inform future public health strategies aimed at reducing disparities in organised colorectal cancer screening. Full article

Tuberculosis (TB) continues to be a significant public health challenge in Europe, despite a sustained decline in disease incidence over recent decades. This narrative review briefly traces the historical development of TB diagnosis and focuses on the evolution of TB control protocols from the early twentieth century to the present across Europe, through a longitudinal comparative analysis of its geographical regions. A literature search was conducted using publications, guidelines, and surveillance reports from the World Health Organization (WHO), the European Centre for Disease Prevention and Control (ECDC), and national public health authorities. The analysis follows a geographical framework encompassing Eastern, Western, Northern, and Southern Europe, reflecting historical, socioeconomic, and healthcare system differences. This study presents the transition from traditional diagnostic approaches based on clinical assessment, chest radiography, and smear microscopy to modern molecular and immunological techniques, including Xpert MTB/RIF assays and interferon-gamma release assays (IGRAs). Similarly, treatment strategies have evolved from sanatorium-based supportive care to standardized, evidence-based short-course regimens employing first- and second-line anti-TB drugs. However, marked regional differences remain in the implementation of contemporary protocols. Western and Northern European countries have largely adopted advanced diagnostic technologies and comprehensive surveillance systems and are approaching TB elimination targets. In contrast, Eastern Europe continues to bear a disproportionate disease burden, driven by multidrug-resistant TB, HIV co-infection, and socioeconomic disparities. TB control protocols in Southern Europe are progressively converging with those of Western Europe through the adoption of modern diagnostic approaches, standardized treatment regimens, and WHO-endorsed guidelines. The findings of this study underscore the need for greater harmonization of TB control protocols across Europe through an initiative coordinated by the ECDC/WHO. Accelerating progress toward TB elimination in the European Region will depend on expanding access to modern diagnostic technologies, implementing targeted interventions in high-burden settings, and strengthening cross-border collaboration through coordinated public health policies. Full article

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

Background and Objectives: Breast cancer is the leading oncological diagnosis among women in Kazakhstan, yet a substantial proportion of cases are still detected beyond the earliest stages, particularly in peripheral regions such as Aktobe. Despite a national mammography screening programme covering women aged 40–70 years since 2018, structural differences in access to early diagnosis—related to geography, socioeconomic circumstances, and the diagnostic pathway—may compromise outcomes. We aimed to identify factors independently associated with early-stage presentation and to characterise the temporal pattern of early-stage presentation without assuming a monotonic trend. Methods and Materials: We conducted a retrospective, population-based analytical study of all confirmed breast cancer cases (ICD-10 C50) registered in the Aktobe regional cancer registry and diagnosed between 1 January 2015 and 31 December 2025 (n = 2232). The outcome was early-stage presentation, defined literally as Stages I–IIa at diagnosis, with Stages IIb–IV as the comparator; this is a stage-at-presentation classification and is not intended to indicate surgical operability or treatment sequence. Multivariable logistic regression estimated adjusted odds ratios (aORs). Two models were used: Model A included age, sex, residence, administrative nationality, employment/social status, and calendar year; Model B additionally included the diagnostic pathway, which may lie on the causal pathway between structural determinants and stage. Calendar year was modelled as a categorical variable, and a complementary phase-based model (2015–2017, 2018–2019, 2020–2022, 2023–2025) was fitted. A residence-by-year interaction; a multinomial sensitivity analysis separating Stages IIb, III, and IV; discrimination (AUC, Brier score); and calibration (Hosmer–Lemeshow test, calibration plot) were also assessed. Results: Of 2232 patients (99.1% female; mean age 57.0 ± 12.5 years), 1323 (59.3%) presented at Stages I–IIa. In Model A, rural residence (aOR 0.77, 95% CI 0.64–0.93; p = 0.006), unemployment relative to employment (aOR 0.69, 95% CI 0.52–0.90; p = 0.007), Russian administrative nationality (aOR 0.64, 95% CI 0.50–0.82; p < 0.001), and other non-Kazakh nationalities (aOR 0.73, 95% CI 0.58–0.94; p = 0.012) were independently associated with lower odds of Stage I–IIa presentation. In Model B, patient-initiated (self-referral) presentation was associated with lower odds relative to clinical examination room detection (aOR 0.46, 95% CI 0.30–0.72; p < 0.001), whereas organised screening was not significantly associated (aOR 1.52, 95% CI 0.95–2.43; p = 0.082). The calendar-year pattern was clearly non-linear (categorical vs. linear year: likelihood-ratio χ² = 76.1, df = 9, p < 0.001): odds of Stage I–IIa presentation peaked in 2018 (aOR 2.49, 95% CI 1.57–3.93 vs. 2015), were lowest in 2022 (aOR 0.64, 95% CI 0.42–0.97), and partially recovered thereafter. In the phase-based model (reference 2015–2017), the aORs were 1.62 (95% CI 1.22–2.15) for 2018–2019, 0.54 (95% CI 0.41–0.69) for 2020–2022, and 0.62 (95% CI 0.46–0.84) for 2023–2025. Model discrimination was limited (AUC 0.648, 95% CI 0.625–0.671; Brier score 0.226) with acceptable calibration (Hosmer–Lemeshow χ² = 8.38, df = 8, p = 0.40). Conclusions: In this registry-based cohort, rural residence, unemployment, non-Kazakh administrative nationality, and patient-initiated presentation were independently associated with lower odds of early-stage breast cancer presentation. The temporal pattern was non-monotonic, with the highest odds around the 2018 screening expansion, a marked reduction during 2020–2022, and only partial recovery thereafter. These are observational associations rather than causal or programme-evaluation findings; they should be interpreted as hypothesis-generating and require confirmation with screening-process, service-capacity, and patient-level access data. Full article

The scarcity of resources is a major challenge for the livability of cities and sustainable urbanization. This study explores the socioeconomic dimensions of water scarcity in four low-income neighborhoods of Amman, the capital of Jordan, using a qualitative approach. The study investigates how water scarcity intersects with socioeconomic vulnerability, spatial injustice, and behavioral adaptation. The main research findings are that income, the quality of the neighborhood, and infrastructure access commonly shape residents’ coping strategies and perceptions of fairness. While households adopt a range of adaptive behaviors, limited affordability and institutional neglect intensify existing inequalities. Temporal shifts in service provision, spatial disparities within and between neighborhoods, and gaps in awareness and governance deepen the sense of water insecurity. The study concludes that water scarcity in Amman is not only a technical or economic challenge but a socially embedded problem that requires equity-oriented policies, participatory planning, and spatially targeted investments. Full article

Rural green development is essential for coordinating ecological protection, rural revitalisation and spatial governance in ecological spaces within urban agglomerations. Taking the Chang-Zhu-Tan Ecological Green Heart region in China as a case study, this study evaluates rural green development in 10 counties, county-level cities and districts from 2013 to 2022. A combined weighting–TOPSIS model is used to measure development levels, while Global Moran’s I, the Theil index and XGBoost–SHAP are applied to examine spatial patterns, regional disparities and key associated factors. The results show that rural green development improved overall, with the regional average index increasing from 0.315 in 2013 to 0.378 in 2022. High-value areas gradually expanded, and the Changsha group formed the main high-value core, but no statistically significant global spatial clustering was identified. Regional disparities narrowed during the study period, although intra-group disparities, especially within the Zhuzhou group, remained the main source of imbalance. Human capital, medical resources, income level, urbanisation level, PM_2.5 concentration and pesticide use intensity were closely associated with rural green development, with socioeconomic factors generally contributing positively and environmental pressures acting as constraints. These findings suggest that rural green development in ecological green heart regions is a spatially differentiated and multi-factor process, providing empirical evidence for differentiated county-level governance, coordinated ecological protection and rural green transformation in urban agglomerations. Full article

Recent studies indicate that regional disparities and differences in policy effectiveness have increased the importance of behavioural factors, including awareness, social norms, motivation, and cultural practices, in shaping energy transition outcomes. This study adopts an interdisciplinary framework that integrates behavioural, socio-technical, and regional development perspectives to explain household energy consumption behaviour and to translate behavioural evidence into policy recommendations. The study aims to identify and empirically assess the profiles of household energy consumption behaviour during the energy transition, examine how these profiles shape behavioural patterns, and develop differentiated policy recommendations. The empirical analysis is based on a survey of 997 household representatives from different regions of Ukraine. Exploratory factor analysis was applied to identify the main behavioural dimensions, K-means cluster analysis was used to classify respondents into behavioural profiles, and Pearson’s χ² test was employed to examine the association between categorical characteristics and cluster membership. The findings reveal three distinct behavioural clusters characterized by different levels of awareness, engagement, and readiness to adopt energy-efficient practices. The identified clusters represent individual-level behavioural profiles rather than territorial categories. Although the region of residence was significantly associated with cluster membership, regional characteristics should be interpreted as associated with the socio-economic, climatic, and infrastructural context in which different behavioural profiles emerge rather than determining individual behaviour directly. The findings provide evidence for integrating behavioural segmentation with regional characteristics when designing energy efficiency and demand-side management policies, thereby supporting more targeted and effective energy transition strategies in Ukraine. Full article

How SME development affects poverty reduction and income inequality remains a contested issue, particularly in transition economies characterized by structural and regional disparities. Existing studies often treat SMEs as a homogeneous phenomenon. As a result, evidence on the relationship between SME development, multidimensional poverty, and income inequality remains limited. This study examines the relationship between SME development, multidimensional poverty, and income inequality across 15 regions of Kazakhstan during 2005–2024 using panel data and Driscoll–Kraay estimators. Poverty is assessed using incidence, depth, and severity. SME development is measured using indicators capturing quantitative expansion and qualitative contribution. The findings identify unemployment and income inequality as the most robust drivers of poverty. Income growth reduces poverty depth and severity but is also associated with higher income inequality. SME development exhibits heterogeneous socioeconomic effects. Indicators reflecting SME value added are associated with lower poverty and inequality, whereas increases in the number of enterprises or SME output do not necessarily improve social outcomes and may be linked to higher poverty intensity. The results indicate that the developmental impact of SMEs depends on productivity, value creation, and structural transformation rather than enterprise quantity, highlighting the importance of quality-oriented SME policies for inclusive growth. Full article

Child malnutrition remains a critical global health challenge, yet most existing studies rely on static risk estimates and overlook the spatial–temporal nature of environmental exposures and localized socioeconomic disparities. To address this gap, we integrated Earth observation-derived environmental indicators, geolocated conflict events, socioeconomic variables, and child health outcomes, and applied a Fixed Effects Two-Stage Least Squares Spatial Durbin Error Model (FE-2SLS-SDEM). We found distinct hotspots of joint vulnerability, where areas experiencing both high conflict intensity and recurrent droughts show significantly higher rates of childhood stunting. High conflict intensity, drought severity, diarrheal prevalence, and inadequate sanitation significantly increase stunting, while maternal and paternal education, improved sanitation, economic development (proxied by nighttime light intensity), and agricultural productivity reduce it. Among these determinants, female education demonstrated the most pronounced inverse relationship with childhood stunting. Additionally, exposure to both drought severity and high conflict intensity independently and in combination worsens childhood stunting not only within affected regions but also in nearby localities. Our results underscore the urgency of geographically targeted, multisectoral, and action-oriented policies aimed at strengthening community and health system capacities to mitigate the converging risks of climate change and conflict on child malnutrition. Full article