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Abstract Background As the older population increases, the need for early detection of cognitive decline is also increasing. In this study, we examined whether our paper–pencil type group examination for cognitive assessment (PAPLICA) could detect the effects of years of education and aging. Methods PAPLICA was conducted on 829 older people. The inclusion criteria were age 60 years or older and the ability to come to the event site alone. The exclusion criteria were participants with a medical or psychiatric disorder or dementia.One examiner conducted the test on a group of approximately 10–20 people in approximately 25 min. Participants were instructed on tackling the issues projected on the projector, and their answers were recorded in a response booklet. Results An independent sample t-test was performed for years of education, and ANCOVA was performed for aging. Among the test items included in PAPLICA, the Speed I and Letter fluency tests were unable to detect the effects of aging. Furthermore, the age at which the effect of aging manifests varies depending on the test item. For instance, a decline in scores in the Speed I and Picture ECR Free recall tests was observed in the 70–74 age group; for that of Word DRT, Picture ECR cued recall, and Similarity, in the 75–79 age group; for CFT, in the 80–84 age group, and for CLOX, the decline was observed in the 85 ≤ age group. Conclusions PAPLICA, similar to other neuropsychological tests, was able to detect the effects of years of education and aging. Future testing should be conducted on different demographics to identify the differences in patterns of cognitive decline.

Abstract Background The advent of Personalized Medicine (PM) holds significant promise in revolutionizing healthcare by tailoring treatments to individual patients based on their data. However, its successful implementation requires the seamless integration of innovative technologies and presents formidable challenges in terms of sustainability. To tackle these challenges head-on, the International Consortium for Personalized Medicine (ICPerMed) was established, and the IC2PerMed project, as part of this consortium, seeks to foster collaboration between the European Union (EU) and China in the field of Personalized Medicine. Based on the results collected by the project, the objective of this study is to discern the key priorities for the implementation of Personalised Medicine concerning Information and Communication Technologies (ICT) and Big Data and digital solutions, with a particular emphasis on data management and protection. Methods A Delphi survey was conducted to gather expert’s consensus on the main priorities for actions on Information and Communication Technologies (ICT) and Big Data and digital solutions in the field of Personalized Medicine. Results The survey identified seven priorities in the area of Big Data and digital solutions, including data interoperability, standards, security measures, and international partnerships. Additionally, twelve priorities were identified for the innovation-to-market process, emphasizing cost-effectiveness, need assessment, and value definition in resource allocation. Conclusions The effective implementation of new technologies in Personalized Medicine research and practice is essential for the advancement of healthcare systems in both the European and Chinese contexts. The identified priorities play a pivotal role in promoting the sustainability of health systems and driving innovation in the implementation of Personalized Medicine. Addressing challenges related to data interoperability, standards, security, international collaboration, cost-effectiveness, and value assessment is of utmost importance in order to propel the progress of Personalized Medicine in healthcare systems.

Abstract Background An estimated 11 million individuals are released from U.S. jails and prisons each year. Individuals with a history of incarceration have higher rates of cardiovascular disease (CVD) events and mortality compared to the general population, especially in the weeks following release from carceral facilities. Healthy sleep, associated with cardiovascular health, is an underexplored factor in the epidemiology of CVD in this population. Incarcerated people may have unique individual, environmental, and institutional policy-level reasons for being sleep deficient. The social and physical environment within carceral facilities and post-release housing may synergistically affect sleep, creating disparities in sleep and cardiovascular health. Since carceral facilities disproportionately house poor and minoritized groups, population-specific risk factors that impact sleep may also contribute to inequities in cardiovascular outcomes. Methods This study is ancillary to an ongoing prospective cohort recruiting 500 individuals with known cardiovascular risk factors within three months of release from incarceration, the Justice-Involved Individuals Cardiovascular Disease Epidemiology (JUSTICE) study. The Sleep Justice study will measure sleep health among participants at baseline and six months using three validated surveys: the Pittsburgh Sleep Quality Index (PSQI), the STOP-Bang, and the Brief Index of Sleep Control. In a subsample of 100 individuals, we will assess sleep over the course of one week using wrist actigraphy, a validated objective measure of sleep that collects data on rest-activity patterns, sleep, and ambient light levels. Using this data, we will estimate and compare sleep health and its association with CVD risk factor control in individuals recently released from carceral facilities. Discussion The incarceration of millions of poor and minoritized groups presents an urgent need to understand how incarceration affects CVD epidemiology. This study will improve our understanding of sleep health among people released from carceral facilities and its potential relationship to CVD risk factor control. Using subjective and objective measures of sleep will allow us to identify unique targets to improve sleep health and mitigate cardiovascular risk in an otherwise understudied population.

Abstract Background Work participation is important for health and can be considered as engagement in a major area of life which is of significance for most people, but it can also be thought of as fulfilling or discharging a role. Currently, academic research lacks a comprehensive classification of work participation outcomes. The International Classification of Functioning is the foremost model in defining work functioning and its counterpart work disability, but it does not provide a critical (core) set of outcomes. Standardizing the definitions and nomenclature used in the research of work participation would ensure that the outcomes of studies are comparable, and practitioners and guideline developers can better decide what works best. As work participation is a broad umbrella term including outcome categories which need unambiguous differentiation, a framework needs to be developed first. Aim To propose a framework which can be used to develop a generic core outcome set for work participation. Methods First, we performed a systematic literature search on the concept of (work) participation, views on how to measure it, and on existing classifications for outcome measurements. Next, we derived criteria for the framework and proposed a framework based on the criteria. Last, we applied the framework to six case studies as a proof of concept. Results Our literature search provided 2106 hits and we selected 59 studies for full-text analysis. Based on the literature and the developed criteria we propose four overarching outcome categories: (1) initiating employment, (2) having employment, (3) increasing or maintaining productivity at work, and (4) return to employment. These categories appeared feasible in our proof-of-concept assessment with six different case studies. Conclusion We propose to use the framework for work participation outcomes to develop a core outcome set for intervention studies to improve work participation.

Abstract Background Africa is the global region where modern-slavery is most prevalent, especially among women and girls. Despite the severe health consequences of human trafficking, evidence on the risks and experiences of trafficked adolescents and young women is scarce for the region. This paper addresses this gap by exploring the intersections between violence, migration and exploitation among girls and young women identified as trafficking survivors in Nigeria and Uganda. Methods We conducted secondary analysis of the largest routine dataset on human trafficking survivors. We used descriptive statistics to report the experiences of female survivors younger than 25 years-old from Nigeria and Uganda. We also conducted 16 semi-structured interviews with adolescents identified as trafficked in both countries. We used thematic analysis to explore participants’ perceptions and experiences before, during and after the trafficking situation. Results Young female survivors of human trafficking in Nigeria and Uganda are exposed to a range of experiences of violence before migration, during transit and at destination. The qualitative data revealed that children and adolescents migrated to escape family poverty, violence and neglect. They had very low levels of education and most had their studies interrupted before migrating. Family members and close social contacts were the most common intermediaries for their migration. During transit, sexual violence and hunger were common, especially among Nigerians. Participants in both the quantitative and qualitative studies reported high levels of violence, deception, coercion, withheld wages and poor working conditions at destination. The adolescents interviewed in the qualitative study reported severe mental suffering, including suicide attempts. Only one reported the prosecution of perpetrators. Conclusions Our findings suggest that interventions to prevent or mitigate the negative impact of adverse childhood experiences can contribute to preventing the trafficking of adolescents in Nigeria and Uganda. These interventions include social protection mechanisms, universal access to education, social service referrals and education of parents and carers. Importantly, effective prevention also needs to address the systemic conditions that makes trafficking of female adolescents invisible, profitable and inconsequential for perpetrators.

Abstract Background In the European Union it is mandatory to include paper package leaflets (PPL) with all medicines, including vaccines, to inform the recipient. However, it is difficult to meet the necessity for localized PPLs in each of the 24 official European languages. Replacing PPLs with electronic versions offers many advantages including redistribution across nations, reduced storage space, accessibility by the visually impaired, easily updated information or the addition of video content. We wanted to assess the attitudes of patients (vaccine recipients or their parents) to the potential of replacing PPL with electronic versions. Methods We surveyed vaccinees or their parents in four European countries—Belgium, Italy, Bulgaria and France—for their actual use of vaccine PPLs and their opinions about switching to an electronic package leaflet. Our survey was conducted online because of the COVID-19 pandemic and resulted in 2518 responses to a questionnaire targeted at three specific groups with particular information needs: parents of young children, pregnant women and the elderly (≥ 60 years). Results Our main findings are that currently vaccine PPLs are rarely used and frequently unavailable for the vaccinee. Across the four countries surveyed 55–82% of vaccinees would accept an electronic version, as did 64% when there was an option to request a printout of the leaflet. Conclusions We found that switching to electronic versions of vaccine PPLs is an acceptable alternative for the public, potentially increasing the quality and amount of information reaching vaccinees while eliminating some barriers to redistribution of vaccines between countries.

Abstract Background People who have been incarcerated have high rates of cardiovascular risk factors, such as hypertension and smoking, and cardiovascular disease (CVD) is a leading cause of hospitalizations and mortality in this population. Despite this, little is known regarding what pathways mediate the association between incarceration exposure and increased rates of CVD morbidity and especially what incarceration specific factors are associated with this risk. The objective of this study is to better understand CVD risk in people exposed to incarceration and the pathways by which accumulate cardiovascular risk over time. Methods and Analysis The Justice-Involved Individuals Cardiovascular Disease Epidemiology (JUSTICE) study is a prospective cohort study of individuals released from incarceration with known cardiovascular risk factors. We are recruiting 500 individuals within three months after release from jail/prison. At baseline we are assessing traditional risk factors for CVD, including diet, exercise, and smoking, and exposure to incarceration-related policies, psychosocial stress, and self-efficacy. Cardiovascular risk factors are measured at baseline through point of care testing. We are following these individuals for the 12 months following the index release from incarceration with re-evaluation of psychosocial factors and clinical risk factors every 6 months. Using these data, we will estimate the direct and indirect latent effects of incarceration on cardiovascular risk factors and the paths via which these effects are mediated. We will also model the anticipated 10-year burden of CVD incidence, health care use, and mortality associated with incarceration. Discussion Our study will identify factors associated with CVD risk factor control among people released from incarceration. Our measurement of incarceration-related exposures, psychosocial factors, and clinical measures of cardiovascular risk will allow for identification of unique targets for intervention to modify CVD risk in this vulnerable population.

Abstract Background Health policy papers disseminate recommendations and guidelines for the development and implementation of health promotion interventions. Such documents have rarely been investigated with regard to their assumed mechanisms of action for changing behaviour. The Theoretical Domains Framework (TDF) and Behaviour Change Techniques (BCT) Taxonomy have been used to code behaviour change intervention descriptions, but to our knowledge such “retrofitting” of policy papers has not previously been reported. This study aims first to identify targets, mediators, and change strategies for physical activity (PA) and nutrition behaviour change in Finnish policy papers on workplace health promotion, and second to assess the suitability of the Behaviour Change Wheel (BCW) approach for this purpose. Method We searched all national-level health policy papers effectual in Finland in August 2016 focusing on the promotion of PA and/or healthy nutrition in the workplace context (n = 6). Policy recommendations targeting employees’ nutrition and PA including sedentary behaviour (SB) were coded using BCW, TDF, and BCT Taxonomy. Results A total of 125 recommendations were coded in the six policy papers, and in two additional documents referenced by them. Psychological capability, physical opportunity, and social opportunity were frequently identified (22%, 31%, and 24%, respectively), whereas physical capability was almost completely absent (1%). Three TDF domains (knowledge, skills, and social influence) were observed in all papers. Multiple intervention functions and BCTs were identified in all papers but several recommendations were too vague to be coded reliably. Influencing individuals (46%) and changing the physical environment (44%) were recommended more frequently than influencing the social environment (10%). Conclusions The BCW approach appeared to be useful for analysing the content of health policy papers. Paying more attention to underlying assumptions regarding behavioural change processes may help to identify neglected aspects in current policy, and to develop interventions based on recommendations, thus helping to increase the impact of policy papers.

Abstract Background Gestational age (GA) is a key determinant of newborn survival and long-term impairment. Accurate estimation of GA facilitates timely provision of essential interventions to improve maternal and newborn outcomes. Menstrual based dating, ultrasound based dating, and neonatal estimates are the primarily used methods for assessing GA; all of which have some strength and weaknesses that require critical consideration. Last menstrual period (LMP) is simple, low-cost self-reported information, recommended by the World Health Organization for estimating GA but has issues of recall mainly among poorer, less educated women and women with irregular menstruation, undiagnosed abortion, and spotting during early pregnancy. Several studies have noted that about 20–50% of women cannot accurately recall the date of LMP. The goal of this study is therefore to improve recall and reporting of LMP and by doing so increase the accuracy of LMP based GA assessment in a rural population of Bangladesh where antenatal care-seeking, availability and utilization of USG is low. Method We propose to conduct a 4- parallel arm, superiority, community based cluster randomized controlled trial comparing three interventions to improve recall of GA with a no intervention arm. The interventions include (i) counselling and a paper based calendar (ii) counselling and a cell phone based SMS alert system (iii) counselling and smart-phone application. The trial is being conducted among 3360 adolescent girls and recently married women in Mirzapur sub-district of Bangladesh. Discussion Enrolment of study participants continued from January 24, 2017 to March 29, 2017. Data collection and intervention implementation is ongoing and will end by February, 2019. Data analysis will measure efficacy of interventions in improving the recall of LMP date among enrolled participants. Results will be reported following CONSORT guideline. The innovative conventional & e-platform based interventions, if successful, can provide substantial evidence to scale-up in a low resource setting where m-Health initiatives are proliferating with active support from all sectors in policy and implementation. Trial registration ClinicalTrials.gov NCT02944747. The trial has been registered before starting enrolment on 24 October 2016.

Abstract Background The transition from childhood into adolescence can be considered as a critical developmental period. Moreover, adolescence is associated with a decreased use of adaptive emotion regulation strategies and an increased use of maladaptive emotion regulation strategies increasing the risk of emotional problems. Targeting emotion regulation is therefore seen as an innovative prevention approach. The present study aims to evaluate the effectiveness of Boost camp, an innovative school-based prevention program targeting ER, on adolescents’ emotion regulation skills and emotional wellbeing. Also secondary outcomes and possible moderators will be included. Methods The aim is to reach 300 adolescents (16 class groups, 6 schools) in their first year of high school. A clustered Randomized Controlled Trial (RCT) with two conditions, intervention (n = 150) and control (n = 150), will be set up. Adolescents in the intervention condition will receive 14 lessons over the course of 2 days, followed by Booster sessions, and will be compared with adolescents in a non-intervention control group. The outcomes will be measured by self-report questionnaires at baseline, immediately after Boost camp, and at three and 6 months follow-up. Discussion Data-collection is planned to be completed in May 2018. Data-analyses will be finished the end of 2018. The presented paper describes the Boost camp program and the clustered RCT design to evaluate its effectiveness. It is expected that Boost camp will have beneficial effects. If found effective, Boost camp will have the potential to increase adolescent’s ER and well-being, and reduce the risk to become adults in need. The trials is registered on the 13th of June 2017 in ISRCTN registry [ISRCTN68235634].

Abstract Background Identifying critical life transitions in people’s physical activity behaviors may illuminate the most opportune intervention apertures for chronic disease prevention. A substantive evidence base now indicates that parenthood is one of these critical transition points for physical activity decline. This study will examine whether a brief theory-based intervention can prevent a decline in physical activity among new parents over 6 months following intervention. This study protocol represents the first dyad-based physical activity initiative in the parenthood literature involving both mothers and fathers; prior research has focused on only mothers or only fathers (albeit limited), and has shown only short-term changes in physical activity. This study will be investigating whether a theory-based physical activity intervention can maintain or improve moderate to vigorous intensity physical activity measured via accelerometry of new parents over a 6 month period following intervention compared to a control group. Methods This study is a 6-month longitudinal randomized controlled trial. Parents are measured at baseline (2 months postpartum) with two assessment points at 6 weeks (3.5 months postpartum) and 3 months (5 months postpartum) and a final follow-up assessment at 6 months (8 months postpartum). The content of the theory-based intervention was derived from the results of our prior longitudinal trial of new parents using an adapted theory of planned behavior framework to predict changes in physical activity. Results A total of 152 couples have been recruited to date. Sixteen couples dropped out after baseline and a total of 88 couples have completed their 6-month measures. Discussion If the intervention proves successful, couple-based physical activity promotion efforts among parents could be a promising avenue to pursue to help mitigate the declines of physical activity levels during parenthood. These findings could inform public health materials and practitioners. Trial registration This trial has been registered with the Clinical Trials Registry maintained by the National Library of Medicine at the National Institutes of Health on April 19, 2014. The registration ID is NCT02290808 .

Abstract Background A growing body of evidence suggest an association between physical activity levels and students psychological well-being. A number of research studies have evaluated playground interventions that aim to increase physical activity levels, decrease conflict and bullying, and improve students behaviour. The HAPPY Study will evaluate the success of an intervention combining environmental modifications, teacher development, and peer support that can culminate in an easy to implement, low cost and effective model for increasing physical activity, and improving psychological well-being for children. Methods/Design Data will be collected at six New South Wales (NSW) primary schools, on physical activity levels, on-task time during classes, and social support for physical activity during a 12 month Cluster Controlled Trial (CT). Three quantitative data collection tools will be used to capture student’s physical activity levels during lunch and recess breaks (the SOPARC tool), student’s on-task behaviour during classes following recess and lunch breaks (the BOSS tool) and where students receive the most encouragement to be physically active from (the Physical Activity Social Support Scale survey). Baseline data will be analysed against follow-up data, collected after an intervention that is rolled out in all schools as part of a stepped wedge CT design. Discussion A review of relevant Australian and New Zealand literature suggests that playground interventions can be successful at increasing physical activity levels, increasing social and conflict resolution skills in students, and decreasing incidences of bullying. This study will investigate any correlation between physical activity levels, and student behaviour during classes following breaks. Trial Registration Australian and New Zealand Clinical Trials Register ACTRN12616000575437 , registered May 2016.

Abstract Background Pregnant women are a vulnerable population to COVID-19 given an increased susceptibility to severe SARS-CoV-2 infection and pregnancy complications. However, few SARS-CoV-2 serological surveys have been performed among this population to assess the extent of the infection in sub-Saharan countries. The objectives of this study were to determine SARS-CoV-2 seroprevalence among Beninese pregnant women, to identify spatial seropositivity clusters and to analyse factors associated with the infection. Methods A cross-sectional study including women in their third trimester of pregnancy attending the antenatal care (ANC) clinics at Allada (south Benin) and Natitingou (north Benin) was conducted. Rapid diagnostic tests (RDT) for detection of IgG/IgM against the SARS-CoV-2 spike protein were performed using capillary blood. Seroprevalence of SARS-CoV-2 antibodies and associations between SARS-CoV-2 serostatus and maternal characteristics were analyzed by multivariate logistic regression. Spatial analyses were performed using the spatial scan statistics to identify spatial clusters of SARS-CoV-2 infection. Results A total of 861 pregnant women were enrolled between May 4 and June 29, 2022. 58/861 (6.7%) participants reported having received COVID-19 vaccine. None of the participants had been diagnosed with COVID-19 during their pregnancy. SARS-CoV-2 antibodies were detected in 607/802 (75.7%; 95% CI 72.56%–78.62%) of unvaccinated participants. Several urban and rural spatial clusters of SARS-CoV-2 cases were identified in Allada and one urban spatial cluster was identified in Natitingou. Unvaccinated participants from Allada with at least one previous morbidity were at a three-times higher risk of presenting SARS-CoV-2 antibodies (OR = 2.89; 95%CI 1.19%-7.00%). Conclusion Three out of four pregnant women had SARS-CoV-2 antibodies, suggesting a high virus circulation among pregnant women in Benin, while COVID-19 vaccination coverage was low. Pregnant women with comorbidities may be at increased risk of SARS-CoV-2 infection. This population should be prioritized for COVID-19 diagnosis and vaccination in order to prevent its deleterious effects. Trial registration NCT06170320 (retrospectively registered on December 21, 2023).

Abstract Background The primary aim of the present study was to investigate if exposure to dust from absorbent hygiene products containing superabsorbent polymer is related to symptoms from the airways and from the eyes. The secondary aim was to estimate the current exposure to superabsorbent polymer among production and maintenance workers in a plant producing hygiene products. Methods The cohort comprised 1043 workers of whom 689 were exposed to super absorbent polymer and 804 were exposed to paper dust (overlapping groups). There was 186 workers not exposed to either superabsorbent polymer or to paper dust They were investigated with a comprehensive questionnaire about exposure, asthma, rhinitis and symptoms from eyes and airways. The results were analyzed with logistic regression models adjusting for sex, age, atopy and smoking habits. An aerosol sampler equipped with a polytetrafluoroethylene filter with 1 μm pore size was used for personal samplings in order to measure inhalable dust and superabsorbent polymer. Results The prevalence of nasal crusts (OR 1.4, 95% CI 1.01-2.0) and nose-bleeding (OR 1.7, 95% CI 1.2-2.4) was increased among the paper dust exposed workers (adjusted for superabsorbent polymer exposure). There were no significant effects associated with exposure to superabsorbent polymer (adjusted for paper dust exposure). The average exposure to inhalable levels of total dust (paper dust) varied between 0.40 and 1.37 mg/m3. For superabsorbent polymer dust the average exposure varied between 0.02 and 0.81 mg/m3. Conclusions In conclusion, our study shows that workers manufacturing diapers in the hygiene industry have an increased prevalence of symptoms from the nose, especially nose-bleeding. There was no relation between exposure to superabsorbent polymer and symptoms from eyes, nose or respiratory tract, but exposure to paper dust was associated with nose-bleeding and nasal crusts. This group of workers had also a considerable exposure to superabsorbent polymer dust.

Abstract Background The World Health Organisation, WHO, recommends that most countries should vaccinate all children against hepatitis B. Sweden has chosen not to do so, but the issue is reassessed regularly. The objective of this survey was to assess knowledge and attitudes towards hepatitis B vaccine for children among parents living in Sweden, and to compare distribution of responses and response rate between parents answering a postal questionnaire and those responding via the Internet. Methods A population-based cross-sectional survey, where the sampling frame consisted of all parents to a child born 2002 living in Sweden. Two independent samples of 1001 parents in each sample were drawn. All parents were contacted by postal mail. The parents in the first sample were invited to participate by answering a paper questionnaire. The parents in the second sample were given an individual user name along with a password, and asked to log on to the Internet to answer an identical electronic questionnaire. Results A total of 1229 questionnaires were analysed. The overall response rate for paper questionnaires was 55%, and 15% for the web version. Knowledge of the disease hepatitis B was overall high (90%). A higher degree of knowledge was seen among parents with education beyond high school (p = 0.001). This group of parents also had a higher tendency to reply via the Internet (p = 0.001). The willingness to accept hepatitis B vaccine for their child was correlated to the acceptance of the present childhood vaccination programme (p = 0.001). Conclusion The results reveal a high level of knowledge of the disease and a positive attitude to having their children vaccinated. This study also displays that the conventional postal method of surveying still delivers a higher response rate than a web-based survey.

Abstract Background This study sought to ascertain whether there might be excess lung cancer mortality among the population residing in the vicinity of Spanish paper and board industries which report their emissions to the European Pollutant Emission Register (EPER). Methods This was an ecological study that modelled the Standardised Mortality Ratio (SMR) for lung cancer in 8073 Spanish towns over the period 1994–2003. Population exposure to industrial pollution was estimated on the basis of distance from town of residence to pollution source. An exploratory, near-versus-far analysis was conducted, using mixed Poisson regression models and an analysis of the effect of municipal proximity within a 50-kilometre radius of each of the 18 installations. Results Results varied for the different facilities. In two instances there was an increasing mortality gradient with proximity to the installation, though this was exclusively observed among men. Conclusion The study of cancer mortality in areas surrounding pollutant foci is a useful tool for environmental surveillance, and serves to highlight areas of interest susceptible to being investigated by ad hoc studies. Despite present limitations, recognition is therefore due to the advance represented by publication of the EPER and the study of pollutant foci.

Abstract Background Housing insecurity can be understood as experiencing or being at risk of multiple house moves that are not through choice and related to poverty. Many aspects of housing have all been shown to impact children/young people’s health and wellbeing. However, the pathways linking housing and childhood health and wellbeing are complex and poorly understood. Methods We undertook a systematic review synthesising qualitative data on the perspectives of children/young people and those close to them, from the United Kingdom (UK). We searched databases, reference lists, and UK grey literature. We extracted and tabulated key data from the included papers, and appraised study quality. We used best fit framework synthesis combined with thematic synthesis, and generated diagrams to illustrate hypothesised causal pathways. Results We included 59 studies and identified four populations: those experiencing housing insecurity in general (40 papers); associated with domestic violence (nine papers); associated with migration status (13 papers); and due to demolition-related forced relocation (two papers). Housing insecurity took many forms and resulted from several interrelated situations, including eviction or a forced move, temporary accommodation, exposure to problematic behaviour, overcrowded/poor-condition/unsuitable property, and making multiple moves. Impacts included school-related, psychological, financial and family wellbeing impacts, daily long-distance travel, and poor living conditions, all of which could further exacerbate housing insecurity. People perceived that these experiences led to mental and physical health problems, tiredness and delayed development. The impact of housing insecurity was lessened by friendship and support, staying at the same school, having hope for the future, and parenting practices. The negative impacts of housing insecurity on child/adolescent health and wellbeing may be compounded by specific life circumstances, such as escaping domestic violence, migration status, or demolition-related relocation. Conclusion Housing insecurity has a profound impact on children and young people. Policies should focus on reducing housing insecurity among families, particularly in relation to reducing eviction; improving, and reducing the need for, temporary accommodation; minimum requirements for property condition; and support to reduce multiple and long-distance moves. Those working with children/young people and families experiencing housing insecurity should prioritise giving them optimal choice and control over situations that affect them.

Abstract Background Disasters can cause casualties and significant financial loss. In accordance with the Sendai Framework for Disaster Risk Reduction, areas affected by disasters must be built back better. Accurate post-disaster damage and loss assessments are critical for the success of recovery programs. This scoping review aimed to identify the components and entities of the healthcare sector’s post-disaster damage and loss assessment program. Methods An comprehensive search for relevant literature was performed using several databases, including the Web of Science, PubMed, Scopus, ProQuest, and Magiran. The search was limited to papers published between 2010 and 2022. In addition, we searched the grey literature for resources related to post-disaster damage and loss assessments. Study selection and data extraction were evaluated by a third reviewer. The main themes were determined through a consensus process and agreement among team members. Results A total of 845 papers were identified, 41 of which were included in the review. The grey literature search yielded 1015 documents, 23 of which were associated with the study’s purpose. The findings were classified into five main themes, 20 subthemes, and 876 codes. The main-themes include the following: Concepts and Definitions; Post-Disaster Damage and Loss Assessment Procedures; Healthcare sector procedures; Assessments Tools, and Methods; Intra-sectoral, Inter-sectoral, and cross-cutting issues. Conclusions The existing corpus of literature on post-disaster damage and loss assessment programs within the healthcare sector offers only limited insights into the entities and components involved. It is of great importance that stakeholders have an extensive grasp of these pivotal concepts and principles, as they are fundamental in enabling effective responses to disasters, informed decision-making, and facilitating rehabilitation and reconstruction efforts. Consequently, there is a considerable scope for further investigation in this area. Scoping review registration number https://osf.io/nj3fk .

Abstract Background Burn injuries are a significant public health concern, closely linked to housing conditions and socioeconomic status. Residents in socioeconomically deprived neighbourhoods are at increased risk of exposure to hazards due to older and poorer housing conditions and limited access to fire protection measures. Individual behaviours such as substance use, smoking, and hoarding are often highlighted as primary causes of residential fires, overshadowing the broader socioeconomic and structural factors that also play a significant role in housing safety. This paper explores the correlation between inadequate housing conditions and heightened fire risks leading to burn injuries, focusing on the contextual factors shaping everyday urban fire risks, experiences, and responses of residents living in Single-Room Occupancy (SRO) housing in Vancouver’s Downtown East Side (DTES) and staff working in the fire, health, housing (social and private), and non-profit sectors. Methods As part of an ongoing ethnographic study, we partnered with the Vancouver Fire Rescue Services (VFRS) to conduct participant observations in private, non-profit, and government-owned SROs, modular homes, and a temporary shelter. This paper synthesizes insights from participant observations from the first author’s self-reflexive journals, including informal conversations with approximately fifty-nine individuals such as SRO tenants, SRO managers/caretakers, health workers, burn survivors, municipal staff, not-for-profit staff, and firefighters. Results Urgent housing-related issues contributing to inequitable everyday urban fire risks were identified, such as structural deficiencies in SRO buildings and systems, inadequate waste management and storage, and inequitable approaches to addressing hoarding. Additionally, disparities in access to information and the interaction between interpersonal and structural stigmas were significant factors, underscoring the pressing need for intervention. Conclusion Communities like DTES, facing precarious housing conditions, disadvantaged neighbourhoods, and complex health and social challenges, necessitate a comprehensive and holistic approach to fire prevention and safety. Recognizing the interplay between housing instability, mental and physical health issues, unregulated toxic drug supply, drug criminalization, and structural inequities allows practitioners from various sectors to develop contextually driven fire prevention strategies. This multifaceted approach transcends individual-level behaviour change and is crucial for addressing the complex issues contributing to fire risks in underserved communities.

Abstract Background Subjective wellbeing (SWB) and health are important facets of any person’s life, and they tend to influence each other. This importance is reflected in the vastness of literature aiming to explore this association. However, most of this literature is based on sampling national population which may present different population characteristics to those of a province. Thus, the paper aims to investigate if the association between perceived health and SWB is moderated by population characteristics at a provincial level. We intend to add value to subjective wellbeing and health literature by reviewing the relationship between SWB and health in the Eastern Cape stratified by age, gender, rural and urban and different income classifications. Methods Different population characteristics tend to associate to subjective wellbeing and health differently, therefore influencing how these two variables influence each other. Thus, the paper aims to investigate if the association between perceived health and SWB is moderated by population characteristics at a provincial level. Utilising the South African National Income Dynamics Survey from 2008 to 2017, this study examined the relationship between subjective wellbeing and health using a random effects model stratified according to aforementioned population characteristics. Results A better perceived health status is associated with higher subjective wellbeing. A better subjective wellbeing is also associated with a higher health status. Determinants of subjective wellbeing and health associate with these variables differently besides income and employment which led to higher subjective wellbeing and health. Health associates to subjective wellbeing different across populations characteristics. Conclusion Subjective wellbeing and health are interdependent as reflected in the World Health Organisation (WHO) and United Nation (UN) statements. Higher income and level of education and being employed is associated with both higher SWB and health. Therefore, improving these economic outcomes maybe associated with an improvement in well-being and health as desired by WHO and UN. Provinces differ, and different population characteristics tend to associate with subjective wellbeing and health differently, therefore influencing how these two variables influence each other. Health improvement policies must consider subjective wellbeing. Well-being improvement policies need to be cognisant of the differences in provincial and population characteristics.

Abstract Background Limited research has been conducted on the forms, manifestations and effects of intersectional stigma among young HIV-positive men who have sex with men (MSM) and transgender women (TGW) in Zambia. In this study, we aimed to address this gap by elucidating the experiences of these in a small group of young, HIV + MSM and TGW in Zambia. Methods We applied a mixed-methods design. Data were collected from January 2022 to May 2022. Qualitative data were collected using in-depth interviews while quantitative data were collected using a questionnaire. Qualitative transcripts were coded using thematic analysis while paper-based questionnaire data were entered into Kobo Connect. Descriptive statistics, using chi-squared tests were calculated using Excel. In this paper, we provide a descriptive profile of the sample and then focus on the qualitative findings on intersectional stigma, depression, and contemplation of suicide. Results We recruited 56 participants from three sites: Lusaka, Chipata, and Solwezi districts. Participants’ mean age was 23 years. The study found that 36% of all participants had moderate to significant symptoms of depression, 7% had major depression, 30% had moderate signs of anxiety, 11% had high signs of anxiety, 4% had very high signs of anxiety and 36% had contemplated suicide at least once. A greater proportion of TGW had moderate to significant symptoms of depression (40%) or major depression (10%) compared to MSM, at 33% and 6%, respectively (X 2 = 0.65; p = 0.42). Similarly, more TGW (55%) had contemplated suicide than MSM peers (36%, X 2=1.87; p = 0.17). In the qualitative data, four emergent themes about the forms, manifestations, and effects of intersectional stigma were (1) HIV, sexual orientation, and gender identity disclosure; (2) Dual identity; (3) Challenges of finding and maintaining sexual partners; (4) Coping and resilience. Overall, having to hide both one’s sexuality and HIV status had a compounding effect and was described as living “a private lie.” Conclusion Effectively addressing stigmas and poor mental health outcomes among young HIV-positive MSM and TGW will require adopting a socio-ecological approach that focuses on structural interventions, more trauma-informed and identity-supportive care for young people with HIV, as well as strengthening of authentic community-informed public health efforts.

Abstract Background Cardiovascular diseases (CVDs) are the primary cause of mortality globally. The prevalence of obesity is rising worldwide; there seems to be a significant positive association between obesity and CVDs. The distribution of fat in the abdominal area in the form of visceral (VAT) or subcutaneous adipose tissue (SAT) affects the risk of CVDs. The aim of the present study was to conduct a systematic review of the available literature regarding the association between the VAT-to-SAT ratio and CVDs. Methods A comprehensive search strategy was used to retrieve all human observational studies indexed in PubMed, Scopus and Google Scholar databases/search engines (from Jan 2000 up to Oct 2023). The VAT-to-SAT or SAT-to-VAT ratio was an independent variable and various cardiovascular diseases, including hypertension, atherosclerosis, coronary heart disease, cerebrovascular disease and heart failure, were considered as outcomes of interest. Results Out of 1173 initial studies, 910 papers were screened. Based on the inclusion criteria, 883 papers were excluded. Finally, 27 papers (18 cross-sectional and 9 cohort studies) published between 2010 and 2023 which met the inclusion criteria were reviewed. Conclusions The distribution of abdominal fat seems to be associated with the risk of CVDs; the majority of the evidence suggests that a higher abdominal VAT-to-SAT ratio is associated with the development of CVDs. Therefore, this ratio can be used as a prognostic indicator for CVDs. Trial registration Not applicable.

Abstract Background Although exclusive breastfeeding is recommended for the first six months of life, research suggests that breastfeeding initiation rates and duration among Indigenous communities differ from this recommendation. Qualitative studies point to a variety of factors influencing infant feeding decisions; however, there has been no collective review of this literature published to date. Therefore, the objective of this scoping review was to identify and summarize the qualitative literature regarding Indigenous infant feeding experiences within Canada, the United States, Australia, and Aotearoa. Methods Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses- Scoping Reviews and the Joanna Briggs Institute Guidelines, in October 2020, Medline, Embase, CINAHL, PsycINFO, and Scopus were searched for relevant papers focusing on Indigenous infant feeding experiences. Screening and full-text review was completed by two independent reviewers. A grey literature search was also conducted using country-specific Google searches and targeted website searching. The protocol is registered with the Open Science Framework and published in BMJ Open. Results Forty-six papers from the five databases and grey literature searches were included in the final review and extraction. There were 18 papers from Canada, 11 papers in the US, 9 studies in Australia and 8 studies conducted in Aotearoa. We identified the following themes describing infant feeding experiences through qualitative analysis: colonization, culture and traditionality, social perceptions, family, professional influences, environment, cultural safety, survivance, establishing breastfeeding, autonomy, infant feeding knowledge, and milk substitutes, with family and culture having the most influence on infant feeding experiences based on frequency of themes. Conclusions This review highlights key influencers of Indigenous caregivers’ infant feeding experiences, which are often situated within complex social and environmental contexts with the role of family and culture as essential in supporting caregivers. There is a need for long-term follow-up studies that partner with communities to support sustainable policy and program changes that support infant and maternal health.

Abstract Background One in five people living in Ireland is a migrant. Understanding the distinctive health needs of this diverse population is essential to provide evidence-based, culturally sensitive primary care services. The aim of this review is to systematically examine changes in migrant health research in Ireland and to inform research, policy and practice in the field. Methods To update a 2017 scoping review of migrant health research in Ireland, we used Arksey and O’Malley’s framework, updates by Colquhoun and Peters and the PRISMA-ScR from the Joanna Briggs Institute to search 10 databases covering May 2017 - March 2023. Findings were analysed using the World Health Organisation Strategy and Action Plan for Refugee and Migrant Health 2016–2023, which identifies 9 priority strategic areas (SA). Findings were compared with the 2017 review. Results 62 papers were identified. There has been an increase in studies over time from an average of five per year in the previous review to an average of 10 per year in this review. There is growing interest in research about SA1: Collaborative action on migrant health issues and SA2: Advocacy for the right to health of refugees and migrants – evidenced by an increase of 13% in this review. Similarly to 2017, the majority of papers align with three of the nine WHO Strategic Areas; SA3: Addressing the social determinants of health (24%), SA4: Achieving public health preparedness (29%) and SA5: Strengthening health systems (26%). The volume of research on SA6: Communicable diseases (11%) and SA7: Noncommunicable diseases (19%) remains stable however research on SA8: Health screening and assessment (5%) and SA9: Improving health information and communication (2%) remains low. Conclusions The increase in the volume of research on migrant health in Ireland is notable. The analysis over time illuminates changes in the focus of research studies. Gaps in research about screening, assessment and health information warrant particular attention. It is also necessary to continue paying attention to areas of recent growth and stagnation for a balanced and comprehensive evidence base. Mobilising resources to continue this increase is needed for evidence-based policy and practice.

Abstract Background Residents’ adoption of preventive behaviours proved beneficial in preventing the large-scale transmission of the virus during the early stages of the COVID-19 outbreak. It is critical to investigate how social media triggers residents' preventive behaviour decisions during the COVID-19 outbreak. Methods This paper selected online shopping as a specific preventive behaviour for empirical investigation. An online cross-sectional survey was conducted through the Sojump website from 1 to 15 March 2020, and a total of 1,289 valid questionnaires were collected from China. This paper uses multiple regression analysis to investigate the heterogeneous impacts of different information sources on residents' online shopping willingness and online shopping behaviour and the heterogeneous impacts of different information content in social media on the transformation of residents' online shopping willingness and online shopping behaviour. Results The findings indicate that both official-media and self-media positively promote residents' online shopping willingness and behaviour, with official-media having a stronger promotional effect than self-media. Furthermore, official-media and self-media can collaboratively promote residents' online shopping willingness and online shopping behaviour. The ease-of-use and usefulness of information significantly promoted the transformation of residents' online shopping willingness. Conclusions This study analyses the heterogeneous impacts of social media on residents' preventive behaviours from the perspectives of information source differentiation and information content differentiation, which enriches related studies and provides feasible paths for promoting residents' preventive behaviours.

Abstract Introduction Problematic usage of the internet (PUI) is perhaps one of the most frequently studied phenomena of the 21st century receiving increasing attention in both scientific literature and the media. Despite intensive research there have been relatively few meaningful studies among elementary school students in Hungary and worldwide, who may be considered as a high-risk population with regard to problematic internet use. The aim of our study was to carry out a complex research focusing on the prevalence and risk factors of PUI among elementary school children aged 10–15 years (Grade 5–8). Methods Demographics included were gender, age, place of stay, type of residence, family type, parental education, start of internet use, used devices, daily internet use, purpose of internet use, internet accounts, ways of keeping in touch with friends and sporting activities. PUI was evaluated using the paper-based version of the Potentially Problematic Use of the Internet Questionnaire. Results Overall, 2000 paper-based questionnaires were successfully delivered and the final analysis included 1168 responses (overall response rate 58.4%). Mean age was 12.55 ± 1.24 years. Female gender (OR = 2.760, p = 0,006, CI 95% 0.065 to 0.384), younger age (11–12 years) (OR = 3.812, p

Abstract Background Knowledge of changes in the domains of physical activity (PA) during the transition period from primary to secondary education and the factors associated with these changes, are prerequisites for the design of effective PA promotion strategies. Therefore, the first aim of this study was to systematically review changes in general, leisure-time, school, transport, work, and home PA across the transition from primary to secondary education. The second aim was to systematically review the individual, social, and physical environmental factors that were associated with these changes. Methods Records published up until September 2023 were retrieved from five electronic databases. We included longitudinal and cross-sectional studies that investigated general or domain-specific PA from 2 years before to 2 years after the transition from primary to secondary education. Information on source, study characteristics, sample characteristics, PA, and factors were extracted from the papers included. We reported the direction of change in general and domain-specific PA and the direction of association of the factors with change in general and domain-specific PA. Results Forty-eight papers were included in the study. The evidence on changes in PA and associated factors was greatest for general PA. A limited number of the studies investigated the separate domains of leisure-time, school, and transport. Most studies on general and school PA reported a decline in PA, but there were no consistent results for the domains of leisure-time and transport. With respect to the associated factors, evidence was predominantly found for individual factors and to a lesser degree for physical environmental and social environmental factors. None of the factors were consistently associated with changes in general or domain-specific PA during the school transition. Conclusions For the design of targeted PA promotion strategies, further studies are warranted to explore changes in the specific domains of PA across the transition from primary to secondary education, especially in the domains of leisure-time, transport, home, and work PA. In addition, the interactions between factors at different socioecological levels to influence changes in PA need to be addressed more in the future. Trial registration PROSPERO CRD42020190204.

Abstract Background With the development of the economy, public health has become increasingly important. Therefore, it is important to establish a comprehensive and scientific the public health level index (PHL) system to measure public health level as a research priority. The current research has limitations in exploring the PHL system; therefore, the field still lacks a comprehensive indicator system to measure the level of public health. Therefore, this paper aims to develop a multi-level public health index system and utilizes China as a case study to evaluate its public health status. The objective is to offer insights and recommendations for the improvement of public health initiatives in China and other regions. Methods Utilizing data from 2011 to 2020, a comprehensive PHL was developed to encompass three vital indices: the Public Health Service Index (PHS), the Public Health Resource Index (PHR), and the Population Health Level Index (PHL). Subsequently, the PHL, PHS, PHR, and PH were meticulously calculated using a comprehensive evaluation method. Amid the current disparity between public health and economic progress, both the spatial Durbin model and the spatial lag model were finally employed to examine the influence of economic level (EL) on PHL, thus affirming the consistent reliability and accuracy of PHS. Results Our findings revealed the following: (i) the PHL, PHS, and PHR indices show increasing trends in China; (ii) both EL and PHL exhibit high-high clustering and low-low clustering states; (iii) the PHL in the area has a positive spatial spillover effect on the surrounding area; (iv) EL will result in the siphoning effect of PHL; and (v) EL can enhance PHL through urbanization, PH, and PHS. Conclusions The PHL system constructed in this paper demonstrates multiple levels, pluralism, spatio-temporal comparability, and robustness. It can reflect not only the input and output of public health initiatives but also the interconnectedness and autonomy within the public health system. Therefore, it can be widely utilized in other areas of public health research.

Abstract Background The infodemic accompanying the COVID-19 pandemic has led to an overwhelming amount of information, including questions, concerns and misinformation. Pandemic fatigue has been identified as a concern from early in the pandemic. With new and ongoing health emergencies in 2022, it is important to understand how pandemic fatigue is being discussed and expressed by users on digital channels. This study aims to explore and report on key narrative themes associated with expressions of pandemic fatigue by users on digital platforms. Methods This paper describes the collection of publicly available data over a 3-month period from multiple online sources using the Meltwater and CrowdTangle platforms to source data from Twitter, Facebook, Instagram, YouTube, TikTok, Pinterest, Product Reviews, Twitch, blogs & forums. A comprehensive search strategy was developed and tested. A total of 1,484,042 social media posts were identified during the time-period that included the defined search terms for pandemic fatigue. These data were initially sorted by highest levels of engagement and from this dataset, analysts reviewed the identified posts to isolate and remove irrelevant content and identify dominant narratives. A thematic analysis was carried out on these narratives to identify themes related to expression of pandemic fatigue. Two researchers reviewed the data and themes. Results The thematic analysis of narratives identified six main themes relating to expression of pandemic fatigue, and one theme of counter narratives against pandemic fatigue. Data volume increased concurrent with the time of the mpox emergency announcement. Emergent themes showed the different ways users expressed pandemic fatigue and how it was interlaced with issues of trust, preventative measure acceptance and uptake, misinformation, and being overwhelmed with multiple or sustained emergencies. Conclusions This paper has identified the different ways users express pandemic fatigue on digital channels over a 3-month period. Better understanding the implications of the information environment on user’s perceptions, questions, and concerns regarding pandemic and more broadly emergency fatigue is vital in identifying relevant interventions and, in the longer term, strengthening the global architecture for health emergency preparedness, prevention, readiness and resilience, as evidenced in this paper. There are clear pathways for further research, including incorporating additional languages and reviewing these themes over longer time periods.

Abstract Background With the rapid development of China’s chemical industry, although researchers have developed many methods in the field of chemical safety, the situation of chemical safety in China is still not optimistic. How to prevent accidents has always been the focus of scholars’ attention. Methods Based on the characteristics of chemical enterprises and the Heinrich accident triangle, this paper developed the organizational-level accident triangle, which divides accidents into group-level, unit-level, and workshop-level accidents. Based on 484 accident records of a large chemical enterprise in China, the Spearman correlation coefficient was used to analyze the rationality of accident classification and the occurrence rules of accidents at different levels. In addition, this paper used TF-IDF and K-means algorithms to extract keywords and perform text clustering analysis for accidents at different levels based on accident classification. The risk factors of each accident cluster were further analyzed, and improvement measures were proposed for the sample enterprises. Results The results show that reducing unit-level accidents can prevent group-level accidents. The accidents of the sample enterprises are mainly personal injury accidents, production accidents, environmental pollution accidents, and quality accidents. The leading causes of personal injury accidents are employees’ unsafe behaviors, such as poor safety awareness, non-standard operation, illegal operation, untimely communication, etc. The leading causes of production accidents, environmental pollution accidents, and quality accidents include the unsafe state of materials, such as equipment damage, pipeline leakage, short-circuiting, excessive fluctuation of process parameters, etc. Conclusion Compared with the traditional accident classification method, the accident triangle proposed in this paper based on the organizational level dramatically reduces the differences between accidents, helps enterprises quickly identify risk factors, and prevents accidents. This method can effectively prevent accidents and provide helpful guidance for the safety management of chemical enterprises.

Abstract Background Previous initiatives concerning adolescent sexual and reproductive health (SRH) education in Low-or-Middle Income Countries (LMICs) have been limited by cultural norms and misinformation perpetuated within families. Responding to the paucity of research on the implementation of SRH interventions in LMICs and limited knowledge regarding their mechanisms, this study undertakes a process evaluation of a parent-focused intervention to promote parent-adolescent communication about SRH in Uganda. Methods This paper explores the implementation, contextual factors and mechanisms of impact of the intervention, using the Medical Research Council (MRC) guidelines for process evaluations. Implementation was evaluated through indicators of dose, fidelity and adaptations, acceptability and feasibility. The contextual factors and mechanisms of impact were evaluated to refine the intervention’s causal assumptions. Data was collected during April - October 2021 in South-Western Uganda using a mixed-methods approach, including document analysis, intervention observations, interviews, focus group discussions and most significant change stories. Results The acceptability of the intervention was related to its community engagement, the strong rapport with delivery agents, and individual characteristics of participants. Five contextual factors influencing implementation were highlighted; (i) cultural norms, (ii) perceptions about youth SRH, (iii) poverty, (iv) Covid-19 pandemic, and (v) prior research projects in the community. When considering the intervention’s mechanisms of impact, four causal pathways were identified; (i) Awareness of SRH needs helped parents overcome stigma, (ii) Parenting skills training improved SRH communication, (iii) Group learning stimulated shared parenting, and (iv) Group learning improved co-parenting. Conclusion The paper presented three key learnings and corresponding recommendations for future research. Firstly, implementation success was credited to meaningful community engagement which improved acceptability and uptake. Secondly, the complex influences of contextual factors highlighted the need for contextual analysis in research studies to inform intervention design. Finally, this evaluation recognised the interplay between mechanisms of impact and suggested further research consider such combined impacts when designing intervention content.

Abstract The ability of the public to remain psychologically resilient in the face of public health emergencies and disasters (such as the COVID-19 pandemic) is a key factor in the effectiveness of a national response to such events. Community resilience and social capital are often perceived as beneficial and ensuring that a community is socially and psychologically resilient may aid emergency response and recovery. This review presents a synthesis of literature which answers the following research questions: How are community resilience and social capital quantified in research?; What is the impact of community resilience on mental wellbeing?; What is the impact of infectious disease outbreaks, disasters and emergencies on community resilience and social capital?; and, What types of interventions enhance community resilience and social capital? A scoping review procedure was followed. Searches were run across Medline, PsycInfo, and EMBASE, with search terms covering both community resilience and social capital, public health emergencies, and mental health. 26 papers met the inclusion criteria. The majority of retained papers originated in the USA, used a survey methodology to collect data, and involved a natural disaster. There was no common method for measuring community resilience or social capital. The association between community resilience and social capital with mental health was regarded as positive in most cases. However, we found that community resilience, and social capital, were initially negatively impacted by public health emergencies and enhanced by social group activities. Several key recommendations are proposed based on the outcomes from the review, which include: the need for a standardised and validated approach to measuring both community resilience and social capital; that there should be enhanced effort to improve preparedness to public health emergencies in communities by gauging current levels of community resilience and social capital; that community resilience and social capital should be bolstered if areas are at risk of disasters or public health emergencies; the need to ensure that suitable short-term support is provided to communities with high resilience in the immediate aftermath of a public health emergency or disaster; the importance of conducting robust evaluation of community resilience initiatives deployed during the COVID-19 pandemic.

Abstract Background Maternal smoking in pregnancy is associated with several adverse maternal and infant health outcomes including increased risk of miscarriage, stillbirth, low birth weight, preterm birth, and asthma. Progress to reduce rates of smoking at time of delivery in England have been slow and over the last decade, less than half of pregnant women who accessed services went onto report having quit. This realist review was undertaken to improve the understanding of how smoking cessation services in pregnancy work and to understand the heterogeneity of outcomes observed. Methods The initial programme theory was developed using the National Centre for Smoking Cession and Training Standard Treatment Programme for Pregnant Women and the National Institute for Health and Care Excellence guidance on treating tobacco dependency. A search strategy and inclusion criteria were developed. Four databases were searched to identify published papers and four websites were hand searched to identify any unpublished literature that could contribute to theory building. Realist logic was applied to the analysis of papers to identify the contexts in which the intended behaviour change mechanism(s) were triggered, or not, and towards what outcomes to develop context mechanism outcome configurations. Results The review included 33 papers. The analysis produced 19 context mechanism outcome configurations structured under five closely interconnected domains (i) articulating harm, (ii) promoting support, (iii) managing cravings, (iv) maintaining commitment and (v) building self-efficacy. This review identifies two key processes involved in how services achieve their effects: how material resources are implemented and relationships. Of the two key processes identified, more existing literature was available evidencing how material resources are implemented. However, the review provides some evidence that non-judgemental and supportive relationships with healthcare workers where regular contact is provided can play an important role in interrupting the social cues and social practice of smoking, even where those around women continue to smoke. Conclusions This review clarifies the range of interconnected and bi-directional relationships between services and the personal and social factors in women’s lives. It underscores the importance of aligning efforts across the models five domains to strengthen services’ ability to achieve smoking cessation.

Abstract Background Intervention planners use logic models to design evidence-based health behavior interventions. Logic models that capture the complexity of health behavior necessitate additional computational techniques to inform decisions with respect to the design of interventions. Objective Using empirical data from a real intervention, the present paper demonstrates how machine learning can be used together with fuzzy cognitive maps to assist in designing health behavior change interventions. Methods A modified Real Coded Genetic algorithm was applied on longitudinal data from a real intervention study. The dataset contained information about 15 determinants of fruit intake among 257 adults in the Netherlands. Fuzzy cognitive maps were used to analyze the effect of two hypothetical intervention scenarios designed by domain experts. Results Simulations showed that the specified hypothetical interventions would have small impact on fruit intake. The results are consistent with the empirical evidence used in this paper. Conclusions Machine learning together with fuzzy cognitive maps can assist in building health behavior interventions with complex logic models. The testing of hypothetical scenarios may help interventionists finetune the intervention components thus increasing their potential effectiveness.

Abstract Background Many researchers have examined the impact of social insurance on health in elderly. However, in most cases, they have only demonstrated correlational results and have not been able to determine causal effects, possibly because confounding biases have not been fully addressed. In this study, we investigated the health effects of the New Rural Pension Scheme (NRPS) on the elderly (age≥60 years old) with chronic diseases in rural areas, and to explore the causal relationship and effects of NRPS and health status. Methods This paper used data from the 2018 China Health and Retirement Longitudinal Study (CHARLS) and applied Bayesian networks and fuzzy regression discontinuity design to conduct causal analysis. Bayesian networks were used to explore the causal directed acyclic graphs of factors related to NRPS and health status. Based on the results of Bayesian network, a fuzzy regression discontinuity design was employed to estimate the causal effect of NRPS on health status. Results Among rural elderly with chronic diseases, Bayesian network mapping of causal relationships among NRPS, health status and covariates showed that age was a common cause of NRPS receipt and satisfaction with health. The results of the fuzzy regression discontinuity analysis showed that the effect of receiving NRPS on the health status was positive, but there was no statistically significant difference concerning the interval estimates. The results of the subgroup analysis with chronic obstructive pulmonary disease (COPD) and asthma indicated that the effect of NRPS receipt on the health status of elderly people with COPD was positive. There was a statistically significant effect of receiving NRPS on self-rated health description ( $${\beta }_{1}=3.653,P=0.032$$ β 1 = 3.653 , P = 0.032 ) and health satisfaction ( $${\beta }_{1}=4.204,P=0.033$$ β 1 = 4.204 , P = 0.033 ) in COPD population and a statistically significant effect of receiving NRPS on health satisfaction in asthma population ( $${\beta }_{1}=9.844,P=0.008$$ β 1 = 9.844 , P = 0.008 ). Conclusion This paper has confirmed the contribution and positive causal effect of NRPS on health status in a subgroup of older adults with COPD and asthma, using the CHARLS database as evidence. Thus, Chinese government should increase the take-up rate of the NRPS to enhance their positive impact on health status of elderly people with chronic diseases in rural areas.

Abstract Background Ambient air pollution can be harmful to the fetus even in countries with relatively low levels of pollution. Most of the established literature estimates the association between air pollution and health rather than causality. In this paper, I examine the causal effects of ambient air pollution on birth outcomes in Norway. Methods With the large sample size and geographic division of sub-postal codes in Norway, I can control for a rich set of spatio-temporal fixed effects to overcome most of the endogeneity problems caused by the choice of residential area and date of delivery. After controlling for a rich set of spatio-temporal fixed effects, my paper uses the variance in ambient air pollutant concentrations over narrow time intervals and in a small geographic area of Norway to determine how prenatal air pollution exposure affects birth outcomes. My data contain extensive information about parents as well as meteorological conditions that can be used to control for potential confounding factors. Results I find that prenatal exposure to ambient nitric oxide in the last trimester causes significant birth weight and birth length loss under the same sub-postcode fixed effects and calendar month fixed effects, whereas other ambient air pollutants such as nitrogen dioxide and sulfur dioxide appear to be at safe levels for the fetus in Norway. In addition, the marginal adverse effect of ambient nitric oxide is larger for newborns with disadvantaged parents. Both average concentrations of nitric oxide and occasional high concentration events can adversely affect birth outcomes. Conclusions Prenatal exposure to NO pollution has an adverse effect on birth outcomes. This suggests that government and researchers should pay more attention to examining NO pollution and that health care providers need to advise pregnant women about the risks of air pollution during pregnancy.

Abstract Background With millions of unscheduled patient contacts every year and increasing call outs clustered around the most deprived communities, it is clear the ambulance sector could have a role to play in improving population health. However, the application and value of a public health approach within the ambulance sector has not been comprehensively explored. A scoping review was undertaken to explore the role of the ambulance sector in the delivery of public health interventions and what impact this has on population health and ambulance sector outcomes. Methods A search strategy was developed on MEDLINE and translated to other major medical and health related bibliographic databases (Embase; CINAHL; HMIC; Science and Social Sciences Citation Index; Cochrane Library) to identify literature published since 2000 in OECD countries. Targeted grey literature, reference list, and citation searching was also carried out. Search results were downloaded to Microsoft Excel and screened by three reviewers according to pre-determined inclusion / exclusion criteria. Data from included studies, such as the type of activity noted within the paper, the population involved and the public health approach that was utilised, was extracted from within the paper using a data extraction form and narratively synthesised. Results Fifty-two references were included in the final review (37 database searching; 9 reference list searching; 6 grey literature). Included articles were categorised according to the relevant public health domains and subdomains as articulated by the UK Faculty of Public Health: 1. Health improvement domain: Public health education and advice (Health promotion sub-domain) (n=13) Emergency Services personnel providing vaccines (Disease prevention sub-domain) (n=1) 2. Health care public health domain Paramedicine (Service delivery sub-domain) (n=30) Screening tools and referral pathways used by the ambulance sector (Service delivery sub-domain) (n=28) Health intelligence using ambulance sector data (population health management sub-domain) (n=26) Of note, some domains (e.g. health protection) returned nil results. Discussion The scoping review demonstrates the breadth of public health related activities in which the ambulance sector is involved. However, an overemphasis on demand management outcomes precludes definitive conclusions on the impact of ambulance sector-led public health initiatives on public health outcomes. Future evaluations of public health initiatives should incorporate wider health system perspectives beyond the immediately apparent remit of the ambulance sector.

Abstract Background The ethnicity data gap pertains to 3 major challenges to address ethnic health inequality: 1) Under-representation of ethnic minorities in research; 2) Poor data quality on ethnicity; 3) Ethnicity data not being meaningfully analysed. These challenges are especially relevant for research involving under-served migrant populations in the UK. We aimed to review how ethnicity is captured, reported, analysed and theorised within policy-relevant research on ethnic health inequities. Methods We reviewed a selection of the 1% most highly cited population health papers that reported UK data on ethnicity, and extracted how ethnicity was recorded and analysed in relation to health outcomes. We focused on how ethnicity was obtained (i.e. self reported or not), how ethnic groups were categorised, whether justification was provided for any categorisation, and how ethnicity was theorised to be related to health. We held three 1-h-long guided focus groups with 10 young people from Nigeria, Turkistan, Syria, Yemen and Iran. This engagement helped us shape and interpret our findings, and reflect on. 1) How should ethnicity be asked inclusively, and better recorded? 2) Does self-defined ethnicity change over time or context? If so, why? Results Of the 44 included papers, most (19; 43%) used self-reported ethnicity, categorised in a variety of ways. Of the 27 papers that aggregated ethnicity, 13 (48%) provided justification. Only 8 of 33 papers explicitly theorised how ethnicity related to health. The focus groups agreed that 1) Ethnicity should not be prescribed by others; individuals could be asked to describe their ethnicity in free-text which researchers could synthesise to extract relevant dimensions of ethnicity for their research; 2) Ethnicity changes over time and context according to personal experience, social pressure, and nationality change; 3) Migrants and non-migrants’ lived experience of ethnicity is not fully inter-changeable, even if they share the same ethnic category. Conclusions Ethnicity is a multi-dimensional construct, but this is not currently reflected in UK health research studies, where ethnicity is often aggregated and analysed without justification. Researchers should communicate clearly how ethnicity is operationalised for their study, with appropriate justification for clustering and analysis that is meaningfully theorised. We can only start to tackle ethnic health inequity by treating ethnicity as rigorously as any other variables in our research.

Abstract Background Optimum adherence to antiretroviral therapy (ART) is crucial in managing HIV. However, some people’s religious beliefs can influence how they deal with HIV and the psychosocial factors influencing their adherence to ART, such as disclosure, acceptance of HIV status, belief in ART, and depression. In sub-Saharan Africa (SSA), the role of religious beliefs in ART adherence is underexplored. We aimed to identify and conceptualize the literature on religious beliefs concerning ART adherence among Pentecostal Christians living with HIV in SSA. Methods We conducted a scoping review of the literature on religious beliefs and ART adherence. We searched papers from PubMed, Web of Science, Medline, Sabinet, Academic Search Complete, CINAHL Plus, Health Source/Nursing Academic, Scopus, and Google Scholar and published papers from conference proceedings and dissertations. Data were extracted according to a predetermined population, concept, context framework, and eligibility criteria for selecting or rejecting studies. We used a narrative synthesis to summarize the data on evidence and the impact of religious beliefs on ART adherence. Results Seven papers published between January 2010 and February 2022 met the inclusion criteria. Nineteen aspects of religious beliefs were identified as negatively influencing ART adherence, while eight aspects facilitated optimal adherence. “Being saved” or “born again” enhanced coping strategies for optimal adherence through actions such as less alcohol use, fidelity to a sexual partner(s), disclosure, acceptance of HIV status, reduced depression, and facilitated PLHIV to access social support from church members or other institutions. Conclusion Religious beliefs are integral to Pentecostal Christians living with HIV and affect their adherence to ART. While some Pentecostal Christians living with HIV on ART use their religious beliefs and practices to access psychosocial support from other church members or organizations and achieve good clinical outcomes, others apply their religious beliefs and practices differently and compromise their commitments to taking ART as prescribed, thus experiencing poor viral suppression and clinical outcomes. However, more research is required to understand and theorize how religious beliefs impact ART adherence among Pentecostals living with HIV to inform guidelines for practitioners.

Abstract Background Suicidal ideation, or thinking about death and suicide, is common across all layers of society. The aim of this paper is to add to the understanding of suicidal ideation in the general population, as well as help-seeking behaviors and perceived unmet mental health needs among those who report suicidal thoughts. Methods The research is part of a representative population-based survey study of mental wellbeing in Antwerp (Flanders, Belgium) carried out in 2021. A total of 1202 participants between 15 and 80 years old answered the Ask Suicide-Screening Questions (ASQ), and an additional question about suicide plans. Participation was by invitation only and possible online or via a postal paper questionnaire. Univariate and multivariate logistic regression analyses were used to explore the association between both current suicidal ideation and self-reported lifetime suicide attempt with the sociodemographic factors age, gender, educational level, origin and financial distress. Moreover, formal care use for mental health was examined among those experiencing suicidal ideation, and logistic regression analyses were used to assess associated sociodemographic factors. Finally, perceived unmet mental health needs were assessed among suicide ideators. Results The point-prevalence of suicidal ideation was 8.6% and was higher among younger age groups and individuals reporting financial distress. The lifetime-prevalence of suicide attempts is 6.5% and was higher in younger people and individuals with a primary educational level and with financial distress. About half (45.6%) of those with suicidal ideation consulted a professional for mental health problems in the past twelve months. Men and those with a primary educational level were less likely to seek help. Half of suicide ideators without care use perceived some need for mental health care, and a third of suicide ideators who used care perceived the obtained help as insufficient, resulting in a population prevalence of 3.6% suicide ideators with a fully or partially perceived unmet need. Conclusions The prevalence of suicide attempts, suicidal ideation and unmet needs among suicide-ideators is high in this Belgian sample. Mental health care need perception in suicide ideators needs further investigation.

Abstract Background There is a lack of reliable data on the size, characteristics, and experiences of sexual and gender minority (SGM) young people (ages 10–24) in low- and lower-middle- income countries (LMICs). This review examines the research conducted in the last thirteen years with and about SGM young people living in low-income settings and seeks to answer the question: What is known about the mental and physical health needs, safety, and wellbeing of SGM young people living in LMICs? Methods We conducted a scoping review informed by the methodological frameworks put forth by Arksey and O’Malley and the Joanna Briggs Institute. We systematically searched two general social science databases and one topic-specific database for peer-reviewed papers, of any research design, that included SGM young people or explored attitudes toward SGM young people in LMICs. We included papers that reported on factors influencing the health and wellbeing of SGM populations, including physical and mental health, healthcare-seeking behaviors, substance use, experiences of discrimination and/or stigma, experiences of violence and abuse (emotional, physical, and/or sexual), economically motivated paid sex practices, housing or economic security, and attitudes of others toward SGM populations. Results Of the 5,409 unique records identified, 79 papers drawing from data collected from 74 unique studies met the inclusion criteria. Only 50 of the 79 papers included SGM young people as participants, with just 13 focusing exclusively on SGM young people ages 10–24. The included papers were classified into three thematic groupings: attitudes toward SGM populations (n = 26), risks to health (n = 40), and experiences of stigma and discrimination (n = 13). Conclusion The findings indicate that the health and wellbeing of SGM young people in LMICs has been historically under-researched. While SGM young people have received more attention from researchers in recent years, the body of literature as a whole is disjointed and sparse, and often studies are about SGM young people, rather than with and for them. Our review highlights the need for more and better research, more accurate and disaggregated demographic data, and leadership and participation of SGM-led community-based organizations in the co-design of studies that focus on SGM young people.

Abstract Background The resilience of democracy is tested under exogenous shocks such as crises. The COVID-19 pandemic has recently tested the resilience of democratic institutions and practices around the world. Aim The purpose of this article is to scope the early research literature that discusses democracy and the COVID-19 pandemic. We review scientific journal articles published during the first two years of the pandemic. We ask three research questions in scoping this body of literature: (1) what are the key topic areas of all published research that associates itself with both democracy and COVID-19, (2) what kinds of conceptual and theoretical contributions has research literature that more specifically discusses democracy under the pandemic produced, and (3) what are the impacts of democracy to the pandemic and vice versa according to empirical research? Methods The scoping review methodology draws on systematic literature search strategies, computational methods, and manual coding. The systematic Web of Science search produced 586 articles for which we conducted a Correlated Topic Model. After technical and manual screening, we identified 94 journal articles that were manually coded. Results The early research on democracy and the COVID-19 pandemic offers a versatile body of scholarship. The topic modeling shows that the scholarship discusses issues of crises, governance, rights, society, epidemiology, politics, electorate, technology, and media. The body of papers with conceptual and theoretical contributions has offered new insights on the difficulties, possibilities, and means to maintain democracy under a pandemic. Empirical research on democracy’s impact on the COVID-19 pandemic and vice versa varies in terms of methodology, geographical scope, and scientific contributions according to the direction of influence studied. Democracy appears to have a significant impact on some aspects of policy responses and epidemiological characteristics of the pandemic. In most parts of the world, the scope, franchise, and authenticity of democracy narrowed down due to the pandemic, albeit in most cases only temporarily. Conclusions A significant number of papers show that the pandemic has accentuated democratic backsliding but is unlikely to have undermined established democracies that have proved resilient in face of the pandemic. But empirical research has also made visible some weak signals of antidemocratic tendencies that may become more accentuated in the longer run.

Abstract Background Consumers have difficulty understanding alcoholic units and low risk drinking guidelines (LRDG). Labelling may improve comprehension. The aims of this rapid evidence review were to establish the effectiveness of on-bottle labelling for (i) improving comprehension of health risks; (ii) improving comprehension of unit and/or standard drink information and/or LRDG, and (iii) reducing self-reported intentions to drink/actual drinking. Methods Electronic database searches were carried out (January 2008-November 2018 inclusive). Papers were included if they were: published in English; from an Organization for Economic Co-operation and Development country; an experimental/quasi-experimental design. Papers were assessed for quality using the Effective Public Health Practice Project Quality Assessment tool. Ten papers were included. Most studies were moderate quality (n = 7). Results Five themes emerged: comprehension of health risks; self-reported drinking intentions; comprehension of unit/standard drink information and/or LRDG; outcome expectancies; and label attention. Labelling can improve awareness, particularly of health harms, but is unlikely to change behaviour. Improved comprehension was greatest for labels with unit information and LRDG. Conclusions Alcohol labelling can be effective in improving people’s comprehension of the health risks involved in drinking alcohol enabling them to make informed consumption decisions, and perhaps thereby provide a route to changing behaviour. Thus, effective alcohol labelling is an intervention that can be added to the broader suite of policy options. That being said, the literature reviewed here suggests that the specific format of the label matters, so careful consideration must be given to the design and placement of labels.

Abstract Background Creating a healthy, decent and safe workplace and designing quality jobs are ways to eliminate precarious work in organisations and industries. This review aimed at mapping evidence on how psychosocial safety climate (PSC) influence health, safety and performance of workers. Methods A literature search was conducted in four main databases (PubMed, Scopus, Central and Web of Science) and other online sources like Google Scholar. A reference list of eligible studies was also checked for additional papers. Only full-text peer-reviewed papers published in English were eligible for this review. Results A search in the databases produced 13,711 records, and through a rigorous screening process, 93 papers were included in this review. PSC is found to directly affect job demands, job insecurity, effort-reward imbalance, work-family conflict, job resources, job control and quality leadership. Moreover, PSC directly affects social relations at work, including workplace abuse, violence, discrimination and harassment. Again, PSC has a direct effect on health, safety and performance outcomes because it moderates the impact of excessive job demands on workers’ health and safety. Finally, PSC boosts job resources’ effect on improving workers’ well-being, safety and performance. Conclusion Managers’ efforts directed towards designing quality jobs, prioritising the well-being of workers, and fostering a bottom-up communication through robust organisational policies, practices, and procedures may help create a high organisational PSC that, in turn, promotes a healthy and decent work environment.

Abstract Background Against the grim background of declining intention to have children, the ravages of COVID-19 have pushed China and the world into a more complex social environment. To adapt to the new situation, the Chinese government implemented the three-child policy in 2021. Objective COVID-19 pandemic indirectly affects the country's internal economic development, employment, fertility plans or intention, and other major issues related to the people's livelihood, while undermining the stable operation of society. This paper explores the question that will COVID-19 pandemic affect Chinese people's intention to have a third child. And What are the relevant factors inside? Method The data in this paper are from the Survey released by the Population Policy and Development Research Center of Chongqing Technology and Business University (PDPR-CTBU), including 10,323 samples from mainland China. This paper uses the logit regression model and KHB mediated effect model (a binary response model given by Karlson, Holm, and Breen) to investigate the impact of the COVID-19 pandemic and other factors on Chinese residents' intention to have a third child. Results The results suggest that the COVID-19 pandemic has a negative effect on Chinese residents' intention to have a third child. In-depth research on the mediating effect of KHB shows that COVID-19 pandemic will further inhibit residents' intention to have a third child by affecting their childcare arrangements, increasing their childcare costs, and increasing their exposure to occupational hazards. Contribution This paper is more pioneering in focusing on the impact of the COVID-19 epidemic on the intention to have three children in China. The study provides empirical evidence for understanding the impact of COVID-19 epidemic on fertility intentions, albeit in the context of policy support.

Abstract Background Amref Health Africa, with support from Global Affairs Canada, examines if women's access to reproductive health services in Tanzania is affected by Gender social norms, decision-making power, roles and responsibility, and access to resources in relation to the utilization of reproductive Health Services in Tanzania. A Gender Need Assessment (GNA) was conducted in five districts in ' 'Tanzania Simiyu Region to improve the infrastructure, supply, quality, and demand for integrated Reproductive, Maternal, Newborn, and Child and Adolescent Health (RMNCAH), Nutrition, and Water, Sanitation, and Hygiene (WASH) services. The analysis identifies gender as a fundamental maternal and child health driver through existing gender inequality at the household and community levels that dictates women's status. Methods The qualitative assessment involved data collected from gender- and age-desegregated focus group discussions (FGDs) and in-depth interviews (IDIs) of key informants in three districts; Bariadi, Busega, and Meatu, in Simiyu region, Tanzania. Participants comprised 8-10 married women and men, unmarried women and men, and adolescent boys and girls. A total of 129 participants were involved in the FGDs. Results This paper reports the critical drivers influencing gender inequality in Simiyu by detailing how Gender inequality affected women's access to reproductive health care in relation to; gender social norms, decision-making power, access to resources at the household and community level, roles and responsibilities, including men's and 'boys' roles are more valued than the roles and responsibilities of women and girls resulted to limited free time to do things for themselves, such as visiting the health facilities for RMNCAH. Conclusions This paper explored gender-based enablers and/or barriers influencing women and girls' realization of their sexual and reproductive health and rights. It was found that social norms, decision-making powers, and lack of access to and control over resources presented as key barriers. In contrast, continuous community sensitization and increased scope of women's participation in decision-making served as enabling environment to overcome gender inequities that influence woman's use of RMNCAH services in Tanzania. Such insights will shape interventions geared towards valuing differences in a manner that overcome gender inequities that influence woman's use of RMNCAH services in Tanzania.

Abstract Background The digital economy based on the internet and IT is developing rapidly in China, which makes a profound impact on urban environmental quality and residents’ health activities. Thus, this study introduces environmental pollution as a mediating variable based on Grossman’s health production function to explore the impact of digital economic development on the health of the population and its influence path. Methods Based on the panel data of 279 prefecture-level cities in China from 2011 to 2017, this paper investigates the acting mechanism of digital economic development on residents’ health by employing a combination of mediating effects model and spatial Durbin model. Results The development of digital economy makes direct improvement on residents’ health condition, which is also obtained indirectly by means of environmental pollution mitigation. Besides, from the perspective of spatial spillover effect, the development of digital economy also has a significant promoting effect on the health of adjacent urban residents, and further analysis reveals that the promoting effect in the central and western regions of China is more pronounced than that in the eastern region. Conclusions Digital economy can have a direct promoting effect on the health of residents, and environmental pollution has an intermediary effect between digital economy and residents’ health; At the same time, there is also a regional heterogeneity among the three relationships. Therefore, this paper believes that the government should continue to formulate and implement scientific digital economy development policies at the macro and micro levels to narrow the regional digital divide, improve environmental quality and enhance the health level of residents.

Abstract Background In South Africa, the prevalence of gestational diabetes (GDM) is growing, concomitant with the dramatically increasing prevalence of overweight/obesity among women. There is an urgent need to develop tailored interventions to support women with GDM to mitigate pregnancy risks and to prevent progression to type 2 diabetes post-partum. The IINDIAGO study aims to develop and evaluate an intervention for disadvantaged GDM women attending three large, public-sector hospitals for antenatal care in Cape Town and Soweto, SA. This paper offers a detailed description of the development of a theory-based behaviour change intervention, prior to its preliminary testing for feasibility and efficacy in the health system. Methods The Behaviour Change Wheel (BCW) and the COM-B model of behaviour change were used to guide the development of the IINDIAGO intervention. This framework provides a systematic, step-by-step process, starting with a behavioural analysis of the problem and making a diagnosis of what needs to change, and then linking this to intervention functions and behaviour change techniques to bring about the desired result. Findings from primary formative research with women with GDM and healthcare providers were a key source of information for this process. Results Key objectives of our planned intervention were 1) to address women’s evident need for information and psychosocial support by positioning peer counsellors and a diabetes nurse in the GDM antenatal clinic, and 2) to offer accessible and convenient post-partum screening and counselling for sustained behaviour change among women with GDM by integrating follow-up into the routine immunisation programme at the Well Baby clinic. The peer counsellors and the diabetes nurse were trained in patient-centred, motivational counselling methods. Conclusions This paper offers a rich description and analysis of designing a complex intervention tailored to the challenging contexts of urban South Africa. The BCW was a valuable tool to use in designing our intervention and tailoring its content and format to our target population and local setting. It provided a robust and transparent theoretical foundation on which to develop our intervention, assisted us in making the hypothesised pathways for behaviour change explicit and enabled us to describe the intervention in standardised, precisely defined terms. Using such tools can contribute to improving rigour in the design of behavioural change interventions. Trial registration First registered on 20/04/2018, Pan African Clinical Trials Registry (PACTR): PACTR201805003336174.