Search Results (1,583)

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

Housing financialization has transformed residential property from a basic social necessity into a speculative asset, intensifying socio-spatial inequalities in the Global South. In Iran, a bank-dominated financial regime and high spatial inequality severely restrict access to housing finance, particularly for low-income households and climate-induced migrants in mid-sized cities. While the spatial consequences of financialization have been extensively studied in major metropolises, neighborhood-scale exclusion mechanisms in secondary cities remain significantly understudied. This study addresses this gap by employing a hybrid methodology that integrates the Bayesian Best–Worst Method (BWM) with Geographic Information Systems (GISs) and Fuzzy Overlay analysis to quantify and spatially visualize barriers to housing finance in Birjand, Iran. Eleven indicators were weighted through probabilistic expert elicitation (n = 10) using Markov Chain Monte Carlo (MCMC) sampling, with excellent convergence confirmed by Gelman–Rubin diagnostics (R-hat ≈ 1.00). Results identify land use as the dominant barrier (posterior mean = 0.256; 95% CrI [0.244, 0.270]), followed by homeownership rate and education level (≈0.132 each). Spatial modeling reveals a pronounced north–south monetary–spatial divide: southern districts concentrate financial services and formal tenure, while northern peripheries, predominantly inhabited by low-income and climate-migrant populations, constitute financial deserts. These findings demonstrate that spatial barriers to housing finance are structurally embedded in land-use classification and asset-based gatekeeping. The study offers a replicable probabilistic–spatial framework for diagnosing financial exclusion in Global South mid-sized cities and provides evidence-based guidance for spatially targeted policy interventions aligned with SDGs 1, 10, and 11. Full article

Against the backdrop of stock-space urban renewal, green-space governance in megacity cores increasingly requires a shift from expansion-oriented supply to the optimisation of existing spatial resources. This study examines the spatial equity of green-space provision in the central districts of seven Chinese megacities using high-resolution remote-sensing data from 2015, 2020, and 2025. We combined semantic segmentation, nested-buffer measurement, the Gini coefficient, Extreme Gradient Boosting (XGBoost), and Shapley Additive Explanations (SHAP) to evaluate the relationships between urban morphology and green-space provision. We first derived a pixel-level cumulative green-space provision index from nested-buffer measurements and calculated city-year Gini coefficients to quantify distributional inequality. XGBoost models were then used to predict the cumulative green-space provision index from urban morphology, and SHAP was applied to interpret the resulting nonlinear, model-derived associations. The results show that changes in the green-space provision index and its distributional inequality were not synchronous across cities. Beijing showed the largest increase in inequality, whereas Chengdu showed the strongest improvement; Tianjin recorded the fastest increase in the green-space provision index, while Beijing experienced a marked decline. Urban form showed nonlinear associations with the unit-level green-space provision index, helping to explain the spatial differentiation underlying the city-year Gini coefficients. Building density was the primary contributor in most city-year models, whereas compactness showed threshold-like associations, with positive effects at lower levels and inhibitory effects at higher levels. Statistical testing and clustering further indicated substantial heterogeneity among cities, which were categorised into three spatial patterns: centripetal agglomeration, peripheral expansion, and clustering/ring-shaped fluctuation. These findings provide morphology-based evidence for differentiated green-space governance in high-density megacity cores, though they should not be interpreted as a complete socioeconomic assessment of green-space equity. 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

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

Free generative AI (GenAI) services appear to democratize access, but freemium platform models can create post-access stratification after basic connectivity and initial use have been achieved. This article conceptualizes paid commitment to GenAI as an emergent outcome of a socio-technical system composed of platform tiers, user capabilities, task environments, economic constraints, affective feedback, and institutional access. Using a cross-sectional 2025 survey of 2000 South Korean adults aged 18–69, the study models the observed states of non-use, free use, and paid commitment through sequential logit models. Descriptive results show that 70.6% of respondents used GenAI in the previous year, yet only 20.6% of users, or 14.6% of the total sample, paid for access. Practical AI literacy is positively associated with both initial use and paid commitment, whereas critical AI awareness is associated with initial use but not payment. Negative emotions are negatively associated with initial use but positively associated with paid commitment among users, a pattern consistent with vigilant and intensive engagement. The premium digital divide is defined not as a fourth level of the digital divide, but as a tier-mediated extension of second-level inequality that may condition access to later educational, occupational, or civic benefits. Because the data are cross-sectional and combine different GenAI platforms, the estimates are ecosystem-level associations and do not establish causal direction or platform-specific effects. Full article

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

Background/Objectives: Socioeconomic inequalities continue to shape health service use in low- and middle-income countries. This study aimed to quantify socioeconomic inequalities in formal health service utilization among Peruvian adults using nationally representative data. Methods: A cross-sectional analytical study was conducted using the 2023 National Household Survey (ENAHO). The sample included 77,793 adults aged 18 years or older. Formal health service utilization was defined as self-reported use of outpatient, emergency, or hospitalization services during the preceding 12 months. Survey-weighted Poisson regression with robust variance was used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs). Results: Overall, 15.94% of adults reported using formal health services in the previous year. In the adjusted model, utilization was higher among women (aPR: 1.47; 95% CI: 1.41–1.55) and adults aged 60 years or older (aPR: 1.74; 95% CI: 1.57–1.92). Compared with uninsured adults, service utilization was higher among those covered by SIS (aPR: 2.59; 95% CI: 2.29–2.93), EsSalud (aPR: 2.90; 95% CI: 2.56–3.29), Armed Forces/Police insurance (aPR: 3.04; 95% CI: 2.36–3.91), and private insurance (aPR: 2.32; 95% CI: 1.77–3.03). Non-extreme poverty (aPR: 0.72; 95% CI: 0.67–0.78) and extreme poverty (aPR: 0.68; 95% CI: 0.59–0.78) were associated with lower utilization. Conclusions: Formal health service utilization remains low and unequal in Peru. Insurance coverage was strongly associated with greater service use, whereas poverty was associated with lower utilization. Full article

Background/Objectives: Sleep health is a key determinant of physical and psychological well-being, yet poor sleep quality remains common, particularly among women. Sociodemographic inequalities and culturally patterned pre-sleep behaviours may contribute to sleep disturbances, but their combined role in Mediterranean populations is still insufficiently understood. This study aimed to examine sleep quality and its associations with sociodemographic characteristics and pre-sleep habits among adult women living in Spain. Methods: A cross-sectional online survey was conducted among 785 Spanish adult women aged 18–64 years. Sleep quality was assessed using the Spanish version of the Pittsburgh Sleep Quality Index (PSQI). Additional questionnaire items collected information on sociodemographic variables and pre-sleep habits, including meal timing, stimulant consumption, physical activity, bedtime routines, screen exposure, and sleeping alone or with company. Data were analysed using chi-square tests, Mann–Whitney U tests, Kruskal–Wallis tests, Spearman’s correlations, and principal component analysis. Results: The mean global PSQI score was 7.5 (SD = 3.01), indicating mildly impaired sleep quality overall. Age showed the largest association with global PSQI score (ε² = 0.052, p < 0.001), followed by income (ε² = 0.010, p = 0.016). Frequent nocturnal awakenings were the most common sleep disturbance, whereas sleep medication use was uncommon. Older age and lower income were associated with poorer sleep outcomes, including shorter sleep duration, lower sleep efficiency, and higher global PSQI scores. Higher education and health-related training were generally associated with more favourable sleep profiles. Pre-sleep habits such as late dinners, stimulant use, and evening screen exposure were highly prevalent but showed weak and non-significant associations with global PSQI scores. Conclusions: In this cross-sectional sample, poorer sleep quality was associated with selected sociodemographic characteristics, whereas isolated pre-sleep behaviours showed weak or non-significant associations with global PSQI scores. Given the study design and non-probability sampling, these findings should be interpreted as associations and generalized with caution. They may inform future studies and support the development of gender-sensitive, non-pharmacological sleep-health strategies that consider socioeconomic and cultural context. 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

Background: Perceived characteristics of the food environment may influence individuals’ dietary practices and health outcomes. This study analyzed associations between social and housing conditions, food environment perception, and food security, and their associations with maternal and child nutritional status. Methods: A cross-sectional study conducted between 2022 and 2023 with 314 participants in Vitória de Santo Antão, Pernambuco, Brazil. Socioeconomic variables, housing conditions, perceptions of domestic and community food environments, food security, and anthropometric indicators were assessed using generalized structural equation modeling (GSEM, p < 0.05). Results: Better social and housing conditions were associated with a more favorable perception of the domestic food environment (β = 0.79; 95% CI: 0.23–1.34) and lower food insecurity severity (β = −1.05; 95% CI: −1.62 to −0.48). No significant associations were observed between the domestic food environment and food insecurity, nor between the community food environment and the remaining model variables. No significant indirect associations were identified, indicating no mediation through food environment perceptions. Greater food insecurity severity was positively associated with maternal BMI (β = 0.19 95% CI: 0.002–0.37), and maternal BMI was positively associated with child BMI-for-age (β = 0.25 95% CI: 0.09–0.39). Conclusions: Social and housing conditions play a central role in shaping food security and nutritional outcomes, while food environment perception showed limited relevance. These findings reinforce the need for intersectoral public policies addressing social inequalities and promoting healthy eating. Full article

Background/Objectives: Dental caries remains a major public health problem in childhood and disproportionately affects socioeconomically disadvantaged populations. Although toothbrushing and oral hygiene are commonly promoted as key preventive behaviours, their protective effect may be limited by structural factors such as access to dental care, fluoride exposure, and preventive services. This study aimed to compare dental caries experience, oral hygiene status, toothbrushing frequency, and sugar consumption among disadvantaged children from the Peruvian Amazon and Valencia, Spain, and to explore whether differences in hygiene behaviours were reflected in caries outcomes. Methods: An exploratory cross-sectional school-based study was conducted among 291 children aged 5–12 years attending three purposively selected schools serving socioeconomically disadvantaged communities: one rural school in the Peruvian Amazon (n = 162) and two urban schools in Valencia, Spain (n = 129). Dental caries experience was assessed using a combined global caries score derived from the dmft and DMFT (CAOD/cod) indices according to dentition type, and oral hygiene status was evaluated using the Simplified Oral Hygiene Index (OHI-S). Toothbrushing frequency and sugar consumption were collected through structured questionnaires. Group comparisons, Spearman correlation analyses, and exploratory multiple linear regression models were performed. Results: Mean global caries scores did not differ significantly between Peruvian and Spanish children (3.71 ± 2.86 vs. 4.07 ± 3.44; p = 0.596). However, severe caries experience (score ≥ 8) was more frequent among Valencian children (21.7% vs. 10.5%; p = 0.014). Peruvian children showed significantly better oral hygiene status (OHI-S-derived score: 1.25 ± 0.79 vs. 1.49 ± 0.84; p = 0.014) and higher toothbrushing frequency (p < 0.001). Frequent sugar consumption was similarly high in both groups. Within each population, poorer oral hygiene and lower toothbrushing frequency were associated with higher caries experience in bivariate analyses, although the exploratory multivariable models showed a more limited pattern of association. Conclusions: Among the participating schools, children from the Peruvian Amazon showed better oral hygiene indicators and more frequent toothbrushing than Spanish children, while no statistically significant difference in caries experience was detected. Because structural variables such as fluoride exposure, dental attendance, and access to restorative care were not directly measured, explanations involving healthcare infrastructure should be considered as candidate hypotheses to be tested in future, adequately powered and adjusted studies, rather than as confirmed mechanisms. Findings should not be generalised beyond the participating schools. Full article

This study examines spatial inequalities in job accessibility in Porto Alegre, Brazil, through a multimodal perspective that incorporates walking, cycling, and public transport within the 15-minute city framework. Accessibility was assessed using cumulative opportunity measures with a 15-minute travel threshold, combining open data on employment, transport networks, and demographics into hexagonal grids. Travel-time matrices were generated using the R5 routing engine via the r5r package in R, accounting for realistic multimodal routing conditions, including transfers and waiting times. The resulting accessibility measures were then integrated with socioeconomic and racial indicators for subsequent analysis. The analysis identified four accessibility profiles structured by a center–periphery divide: a low-accessibility southern periphery, a transitional northern belt with strong transit but limited active mobility, a central corridor with consistently high multimodal access, and a hyper-accessible core with exceptional walking and cycling opportunities. Income-elasticity analysis revealed stronger associations between income and active mobility accessibility than with public transport, highlighting how proximity to jobs privileges wealthier, centrally located households. High-skilled employment was concentrated in central areas, reinforcing cumulative advantages and deepening inequalities for low-income and racially marginalized populations. The findings underscore the urgency of integrated mobility and land-use policies to expand active and public transport infrastructure and decentralize employment opportunities, ensuring equitable access to jobs. Full article

Digital dependence and substance use may co-occur in post-digital cohorts when platform design, peer norms, stress exposure, and individual vulnerabilities converge to reinforce dysregulated patterns of reward seeking, self-regulation failure, and affective coping. This Entry defines their co-occurrence as a multidetermined phenomenon in which digital environments, including algorithmic feeds, notifications, social comparison, and variable rewards, interact with developmental vulnerabilities such as identity formation, impulsivity, reward sensitivity, and emotional dysregulation. Psychiatric comorbidities, particularly depression, anxiety, Attention-Deficit/Hyperactivity Disorder, and personality pathology, may increase susceptibility, while socioeconomic disadvantage and unequal access to care can intensify harm. Current evidence suggests that problematic digital use and substance use are more strongly related to functional impairment, coping motives, peer norms, and contextual stressors than to screen time alone. This Entry therefore organizes the available evidence around structural determinants, individual mechanisms, mental-health mediators, and prevention strategies, with emphasis on proportionate regulation, digital literacy, culturally adapted interventions, and integrated clinical pathways. Full article

Climate adaptation in high-density cities requires equitable access to cooling and habitat benefits from blue–green infrastructure (BGI). However, the critical thresholds where human activity overwhelms these services remain unknown. Taking Shenzhen as a case study, we quantified habitat quality using the InVEST model and divided the urban landscape into low-, medium-, and high-quality zones. After screening significant drivers via multiple linear regression, we compared six machine learning algorithms and selected XGBoost (for low- and medium-quality zones) and LightGBM (for high-quality zones) with Optuna-tuned hyperparameters, then applied SHAP dependence analysis to identify nonlinear, threshold-driven responses. We identify a systemic thermal threshold of 23.7 °C. Above this temperature, BGI cooling efficiency decouples from habitat quality. We also quantify actionable intervention windows. Low-quality habitats—dominated by dense residential areas—collapse when building density exceeds 0.7 or road density exceeds 0.009. Medium-quality habitats offer a balance window (core area > 2844 m², building density < 0.361) that enables incidental nature contact during daily travel. High-quality refugia require a core area > 8600 m² with near-zero disturbance. These thresholds expose a stark green inequity: socioeconomically vulnerable groups in low-quality zones are systematically disconnected from cooling services. We translate these findings into a tiered spatial intervention framework—restoration, accessibility enhancement, and strict protection—to advance climate-resilient and socially equitable urban planning. Full article