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Abstract Background Veterans with substance use disorder (SUD) are at high risk for cognitive problems due to neurotoxic effects of chronic drug and alcohol use coupled in many cases with histories of traumatic brain injury (TBI). These problems may in turn result in proneness to SUD relapse and reduced adherence to medical self-care regimens and therefore reliance on health care systems. However, the direct relationship between cognitive function and utilization of Veterans Health Administration (VHA) SUD and other VHA health care services has not been evaluated. We sought initial evidence as to whether neurocognitive performance relates to repeated health care engagement in Veterans as indexed by estimated VHA care costs. Methods Neurocognitive performance in 76 Veterans being treated for SUD was assessed using CNS-Vital Signs, a commercial computerized cognitive testing battery, and related to histories of outpatient and inpatient/residential care costs as estimated by the VHA Health Economics Resource Center. Results After controlling for age, an aggregate metric of overall neurocognitive performance (Neurocognition Index) correlated negatively with total VHA health care costs, particularly with SUD-related outpatient care costs but also with non-mental health-related care costs. Barratt Impulsiveness Scale scores also correlated positively with total VHA care costs. Conclusions In Veterans receiving SUD care, higher impulsivity and lower cognitive performance were associated with greater health care utilization within the VHA system. This suggests that veterans with SUD who show lower neurocognitive performance are at greater risk for continued health problems that require healthcare engagement. Cognitive rehabilitation programs developed for brain injury and other neurological conditions could be tried in Veterans with SUD to improve their health outcomes.

Abstract Background Immigrant populations, especially women, continue facing challenges in accessing quality healthcare, particularly sexual and reproductive health services (SRH). Poor cultural competent health systems contribute to communication challenges between immigrant women and healthcare providers perpetuating health disparities. This exploratory study describes these communication barriers from the perspective of Moroccan and Pakistani immigrant women and healthcare providers within the Catalan health system and its implications to ensure an equitable provision of SRH services. Methods An exploratory-descriptive qualitative study was conducted in various municipalities of Barcelona with high concentration of immigrants. Eight focus groups (N = 51) and semi-structured interviews (N = 22) with Moroccan and Pakistani immigrant women were combined with key informant interviews (N = 13) with healthcare professionals. Thematic analysis and data triangulation were performed primarily using an inductive approach. Results Language barriers and cultural differences in health needs, expectations, care-seeking behaviours and understanding of quality healthcare provision hindered the ability of immigrant women and providers to interact effectively. Limited availability of intercultural mediators and inadequate cultural competence training opportunities for health staff were also identified. Findings suggest a lack of minority representation in the Catalan health workforce and leadership roles. Conclusion This study reinforces the evidence of persistent inequities in accessing healthcare among immigrant populations by focusing on the cultural competence barriers of the Catalan health system in the provision and access to SRH services. The regularization of adequately trained intercultural mediators, quality training in cultural competence for health staff and a commitment to increase workforce diversity would contribute to improve intercultural communication between immigrant patients and providers. An urgent call to action in this direction is needed to ensure an equitable access to SRH services among immigrant women.

Abstract Background While digital health and social services offer promising solutions, they often overlook the perspectives and needs of older adults. This study aims to comprehensively investigate the preferences of older adults regarding the use and development of digital health and social services. Methods The survey spanned from 19 March to 31 March 2023. The study population comprised 1100 Finnish individuals aged 75 and over from across Finland. The study used qualitative inductive content analysis to examine the open-ended responses obtained in the survey. Results We identified eight main categories for the older adults’ preferences: usability, service design, and security; training, support, instructions, and information; flexibility of compatible devices; understandable language and interpretation of laboratory results; available and accessible services; desired functionalities; delivery of information for viewing, and personalization. Conclusions Older adults’ involvement in digital services’ strategy development is crucial, emphasizing value co-creation and segmentation while avoiding value co-destruction. Segmenting users and understanding their needs aids in customizing services, improving healthcare provision. Further research should assess the impact of segmentation-based training and digital device provision on older adults’ adoption of digital health and social services.

Abstract Background The integration of patient-centered care (PCC) and value-based healthcare (VBHC) principles, emphasizing personalized, responsive care and cost efficiency, is crucial in modern healthcare. Despite advocation from the International Consortium for Health Outcomes Measurement (ICHOM) for the global adoption of these principles through patient-reported measures (PRMs), their implementation, especially the pregnancy and childbirth (PCB) set, remains limited in maternity care. This study focuses on understanding the optimal organizational entity for integrating standard ICHOM-PCB-PRMs into routine maternity care in Finland. It aims to clarify the distribution of tasks among stakeholders and gather Finnish maternity healthcare professionals’ perspectives on organizational responsibility in PRM collection. The emphasis was on identifying the optimal organizational framework for managing PRMs in maternity care. Results A total of 66 maternity healthcare professionals participated in the study, reaching a consensus that public maternity care centers in Finland should be the primary entity responsible for managing PRMs in the maternity sector. Key aspects such as confidence with the role as a mother, maternal confidence with breastfeeding, and satisfaction with the result of care were identified as crucial and should be inquired about in both public maternity care centers and hospital maternity wards. The findings highlight the importance of comprehensive and consistent attention to these PRMs across public maternity care centers and hospital maternity settings to ensure holistic and effective maternal care. Conclusions The study highlights the central role of public maternity care centers in the collection and management of PRMs within Finnish maternity care, as agreed upon by the professional consensus. It underscores the importance of a consistent and holistic approach to PRM inquiry across different care settings to enhance the quality and effectiveness of maternity care. This finding is crucial for policymakers and healthcare practitioners, suggesting that reinforcing the collaborative efforts between public maternity care centers and hospital maternity wards is vital for a patient-centric, efficient healthcare system. Aligning with PCC and VBHC principles, this approach aims to improve healthcare outcomes for pregnant and postpartum women in Finland, emphasizing the need for a unified strategy in managing maternity care.

Abstract Background The path of a complaint and patient satisfaction with complaint resolution is often dependent on the responses of healthcare professionals (HCPs). It is therefore important to understand the influences shaping HCP behaviour. This systematic review aimed to (1) identify the key actors, behaviours and factors influencing HCPs’ responses to complaints, and (2) apply behavioural science frameworks to classify these influences and provide recommendations for more effective complaints handling behaviours. Methods A systematic literature review of UK published and unpublished (so-called grey literature) studies was conducted (PROSPERO registration: CRD42022301980). Five electronic databases [Scopus, MEDLINE/Ovid, Embase, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Health Management Information Consortium (HMIC)] were searched up to September 2021. Eligibility criteria included studies reporting primary data, conducted in secondary and tertiary care, written in English and published between 2001 and 2021 (studies from primary care, mental health, forensic, paediatric or dental care services were excluded). Extracted data included study characteristics, participant quotations from qualitative studies, results from questionnaire and survey studies, case studies reported in commentaries and descriptions, and summaries of results from reports. Data were synthesized narratively using inductive thematic analysis, followed by deductive mapping to the Theoretical Domains Framework (TDF). Results In all, 22 articles and three reports met the inclusion criteria. A total of 8 actors, 22 behaviours and 24 influences on behaviour were found. Key factors influencing effective handling of complaints included HCPs’ knowledge of procedures, communication skills and training, available time and resources, inherent contradictions within the role, role authority, HCPs’ beliefs about their ability to handle complaints, beliefs about the value of complaints, managerial and peer support and organizational culture and emotions. Themes mapped onto nine TDF domains: knowledge, skills, environmental context and resources, social/professional role and identity, social influences, beliefs about capability, intentions and beliefs about consequences and emotions. Recommendations were generated using the Behaviour Change Wheel approach. Conclusions Through the application of behavioural science, we identified a wide range of individual, social/organizational and environmental influences on complaints handling. Our behavioural analysis informed recommendations for future intervention strategies, with particular emphasis on reframing and building on the positive aspects of complaints as an underutilized source of feedback at an individual and organizational level.

Background: COVID-19 has been troublesome for families due to its socio-economic changes worldwide. Therefore, the present study aimed to investigate the socio-economic burden of COVID-19 on children’s health in Iran.Methods: In the present cross-sectional study, the target population was 500 parents of children aged 5 to 18 years from 5 provinces of Iran in 2021. The samples were randomly selected from different geographical regions of Iran. The questionnaires on the socioeconomic burden of COVID-19, general health, child health, and place of residence landscape were employed to collect the data. For data analysis, t-test, structural equation modeling (SEM) were used in SPSS version 26 and AMOS version 26, respectively.Results: The results indicated that based on determination coefficients of socio-economic burden of COVID-19, the socioeconomic status of the parents and the settlement external perspective variable account for nearly 25% of the mental changes in parents. Furthermore, the combined effects of COVID-19’s socioeconomic burden and parents’ mental health accounted for 26% of the health changes observed in children. The socio-economic burden had a negative correlation with parents’ mental health (β=-0.383, P

Abstract Background Global policy and guidelines for low back pain (LBP) management promote physical activity and self-management yet adherence is poor and a decline in outcomes is common following discharge from treatment. Health coaching is effective at improving exercise adherence, self-efficacy, and social support in individuals with chronic conditions, and may be an acceptable, cost-effective way to support people in the community following discharge from treatment for LBP. Aim This qualitative study aimed to understand which aspects of a community over-the-phone health-coaching program, were liked and disliked by patients as well as their perceived outcomes of the service after being discharged from LBP treatment. Methods A purposive sampling approach was used to recruit 12 participants with chronic LBP, from a large randomised controlled trial, who were randomly allocated to receive a health coaching program from the Get Healthy Service® in Australia. Semi-structured interviews were conducted, and a general inductive thematic analysis approach was taken. Results The main themes uncovered regarding the intervention included the positive and negative aspects of the health coaching service and the relationship between the participant and health coach. Specifically, the participants spoke of the importance of the health coach, the value of goal setting, the quality of the advice received, the benefits of feeling supported, the format of the coaching service, and LBP-specific knowledge. They also reported the health coach and the coaching relationship to be the primary factors influencing the program outcomes and the qualities of the coaching relationship they valued most were connection, communication, care, and competence. The sub-themes uncovered regarding the outcomes of the intervention included positive impacts (a greater capacity to cope, increased confidence, increased motivation and increased satisfaction) and negative impacts (receiving no personal benefit). Clinical implications In an environment where self-management and self-care are becoming increasingly important, understanding the patient’s experience as part of a coaching program is likely to lead to improved quality of health coaching care, more tailored service delivery and potentially more effective and cost-effective community-based care for individuals with chronic LBP in the community after being discharged from treatment. Trial Registration The GBTH trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000889954) on 10/9/2020. Ethical approval was prospectively granted by the Western Sydney Local Health District Human Research and Ethics Committee (2020/ETH00115). Written informed consent was obtained from all participants. The relevant sponsor has reviewed the study protocol and consent form.

Abstract Background The COVID-19 pandemic significantly increased the demand for remote healthcare services delivery, including remote access to medications. This study explored the practices and challenges associated with remote provision of pharmaceutical products and services in Kampala, Uganda. Methods A cross-sectional study was conducted from July to September 2022, enrolling 174 out of 198 sampled retail pharmacies. Data was collected using a pre-tested questionnaire on remote service provision, platforms used, products offered, delivery methods, and challenges faced. Results Over 58% of pharmacies provided remote services, primarily through social media (especially WhatsApp) and phone calls. OTCs and POMs were the most commonly dispensed products remotely. Key challenges identified included high internet costs, labor shortages, poor internet quality, and a lack of specific regulations for remote provision of pharmaceutical products and services. Conclusion The proportion of retail pharmacies providing pharmaceutical products and services remotely is significant in Kampala, but they face challenges that need to be addressed. Regulations are crucial to ensure responsible dispensing practices and rational medicine use. Addressing internet affordability and quality, staffing issues, and delivery logistics is essential for sustainable and effective remote pharmaceutical products and services.

Abstract Background Virtual Reality in mental health treatment has potential to address a wide spectrum of psychological and neurocognitive disorders. Despite the proven benefits, integration into clinical practice faces significant challenges. There is a critical need for research into clinicians’ perceptions of virtual reality due to the gap between rapid technological advancements and their adoption in mental health services. Method A scoping review was conducted to comprehensively understand clinicians’ perspectives on the application of immersive virtual reality technologies within mental health settings. 4 data bases were searched, from inception, with the search areas of clinicians’, technology, perspectives and mental health. The scoping review followed the PRISMA-ScR checklist. All results were thematically analysed to identify and categorise themes with a focus on qualitative analyses of clinicians’ experiences and perceptions of VR applications in therapeutic contexts. Results 17 articles were selected, encompassing a range of mental health settings. The findings indicate that the integration of VR in clinical environments is heavily influenced by clinicians’ knowledge and experience, with unfamiliarity often leading to scepticism. Positive attitudes towards VR, bolstered by direct experience and training, were found to drive acceptance, as clinicians’ acknowledged its potential to complement traditional therapies. However, there are still gaps in understanding VR’s therapeutic applications, particularly concerning its impact on human interaction and its suitability for specific patient groups. Balancing VR’s clinical benefits with ethical and safety concerns is crucial, especially when working with vulnerable populations. Furthermore, structural and administrative support is essential to overcoming the financial and logistical challenges of VR implementation, ensuring its safe and effective integration into mental health care. Conclusion While VR holds significant potential for enhancing mental health care, its successful integration into clinical practice necessitates addressing existing gaps in knowledge, training, and structural support. By carefully balancing its clinical benefits with ethical, practical, and safety considerations, VR can be effectively utilised as a valuable tool in mental health treatment, providing innovative solutions while ensuring that patient care remains paramount.

Abstract Background To make the best use of health resources, it is crucial to understand the healthcare needs of a population—including how needs will evolve and respond to changing epidemiological context and patient behaviour—and how this compares to the capabilities to deliver healthcare with the existing workforce. Existing approaches to planning either rely on using observed healthcare demand from a fixed historical period or using models to estimate healthcare needs within a narrow domain (e.g., a specific disease area or health programme). A new data-grounded modelling method is proposed by which healthcare needs and the capabilities of the healthcare workforce can be compared and analysed under a range of scenarios: in particular, when there is much greater propensity for healthcare seeking. Methods A model representation of the healthcare workforce, one that formalises how the time of the different cadres is drawn into the provision of units of healthcare, was integrated with an individual-based epidemiological model—the Thanzi La Onse model—that represents mechanistically the development of disease and ill-health and patients’ healthcare seeking behaviour. The model was applied in Malawi using routinely available data and the estimates of the volume of health service delivered were tested against officially recorded data. Model estimates of the “time needed” and “time available” for each cadre were compared under different assumptions for whether vacant (or established) posts are filled and healthcare seeking behaviour. Results The model estimates of volume of each type of service delivered were in good agreement with the available data. The “time needed” for the healthcare workforce greatly exceeded the “time available” (overall by 1.82-fold), especially for pharmacists (6.37-fold) and clinicians (2.83-fold). This discrepancy would be largely mitigated if all vacant posts were filled, but the large discrepancy would remain for pharmacists (2.49-fold). However, if all of those becoming ill did seek care immediately, the “time needed” would increase dramatically and exceed “time supply” (2.11-fold for nurses and midwives, 5.60-fold for clinicians, 9.98-fold for pharmacists) even when there were no vacant positions. Conclusions The results suggest that services are being delivered in less time on average than they should be, or that healthcare workers are working more time than contracted, or a combination of the two. Moreover, the analysis shows that the healthcare system could become overwhelmed if patients were more likely to seek care. It is not yet known what the health consequences of such changes would be but this new model provides—for the first time—a means to examine such questions.

Abstract Background Family factors, sleep, and physical activity have previously been associated with risk of sick leave and disability benefits due to musculoskeletal disorders. However, how these factors act during adolescence and young adulthood is unclear. The aim of this study was to (i) examine if chronic pain, disability benefits and education in parents influence the risk of long-term sick leave due to musculoskeletal disorders in young adulthood, and (ii) to explore if offspring sleep problems and physical activity modify these effects. Methods A population-based prospective study of 18,552 adolescents and young adults (≤ 30 years) in the Norwegian HUNT Study. Survey data was linked to national registry data on sick leave, disability benefits, family relations and educational attainment. We used Cox regression to estimate hazard ratio (HR) with 95% confidence interval (CI) for long-term (≥ 31 days) sick leave due to a musculoskeletal disorder in offspring associated with parental factors and the joint effect of parental factors and offspring lifestyle factors. Results Parental chronic pain (HR 1.36, 95% CI 1.27–1.45), disability benefits (HR 1.41, 95% CI 1.33–1.48) and low educational attainment (HR 1.78, 95% CI 1.67–1.90) increased the risk of long-term sick leave due to musculoskeletal disorders among offspring. There was no strong evidence that sleep and physical activity modified these effects. Conclusion Chronic pain, disability benefit and low education in parents increased the risk of long-term sick leave due to musculoskeletal disorders among offspring, but these effects were not modified by offspring sleep problems or physical activity level. The findings suggest that efforts beyond individual lifestyle factors might be important as preventive measures.

Abstract Background The Aboriginal health workforce has unique insights given their healthcare experience and interactions with their communities. The aims of this project were to explore their perceptions of hepatitis B related shame and ways to improve hepatitis B care in Aboriginal and Torres Strait Islander communities of Northern Territory’s Top End, Australia. Methods We conducted a qualitative study with guidance from the Menzies School of Health Research Infectious Diseases Indigenous Reference Group. The Aboriginal health workforce was asked to participate in semi-structured interviews exploring hepatitis B related shame and ways to improve hepatitis B care. Qualitative data were evaluated using reflexive thematic analysis. Results There were fifteen semi-structured interviews with participants representing eight different communities. The experience of shame was reported by the Aboriginal health workforce to be common for individuals diagnosed with hepatitis B and comprised feelings of fear related to transmitting the virus, to being isolated, and to being at fault. Shame was mediated by poor health literacy, communication, the lack of culturally safe spaces and was perpetuated by intersecting stereotypes. Improvements in care can be achieved by utilising the Aboriginal health workforce more effectively, improving communication and the availability of culturally safe spaces, emphasising community connection, and reframing hepatitis B as a chronic condition. Conclusions Hepatitis B related shame was an important issue and impactful in Aboriginal and Torres Strait Islander communities in the Top End of the Northern Territory. There were many facets to shame in these communities and it was mediated by several factors. The Aboriginal health workforce has emphasised several pathways to improve care and diminish the impact of shame, such as improving communication and the availability of culturally safe spaces.

This scoping review investigates peer-led programs as a strategy to promote physical activity (PA) among older adults, addressing a gap in the literature concerning in-depth assessment of the characteristics, components, and effectiveness of such programs. Seven databases were searched for articles published in English, Portuguese, or Spanish on peer-led initiatives aimed at encouraging PA in older adults. A total of 53 studies were included, with a notable increase in publications since 2018, primarily focusing on randomized clinical trials involving participants of both sexes. The findings highlight that peer leaders typically have an average age of 65.2 years, with a minority having prior training in PA, although over half received specific training for leading PA programs. These programs, which predominantly span 1 to 4 months, often involve resistance exercises, walking, and flexibility/stretching/mobility activities, conducted in homes and community spaces. Despite the substantial number of studies utilizing peer-led approaches, a consistent lack of detailed reporting on the specific characteristics of peer leaders was observed, underscoringa need for more comprehensive documentation to enhance the understanding and implementation of these programs for older adults.

Abstract Background The effectiveness of eLearning in enhancing healthcare professionals’ capacity has received substantial attention globally. This review sought to synthesis evidence on the effectiveness of various types of eLearning programmes, and the facilitators and barriers to its use. Methods The review was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Four main databases (PubMed, Web of Science, JSTOR, and Scopus) in July 2023 and 44 articles met the eligibility criteria and were included in the review. The JBI critical appraisal checklist was used to appraise the methodological quality of the studies. The data were examined using narrative review to determine the effectiveness of the intervention as well as the barriers and facilitators to its use. Results This review found that asynchronous, synchronous, blended, and self-learning methodologies are effective eLearning approaches for continuous professional development. Previous positive experiences, user-friendly interfaces and relevance of the eLearning content to daily practice are critical elements that facilitate eLearning usage. Poor computer competence and literacy, lack of personal computers and high family duties were the main personal factors that hindered eLearning use. Some systemic barriers included; heavy workloads, shortage of specialised eLearning facilitators poor management involvement, and technical inadequacies within the ICT departments. Environmental issues such as poor infrastructure, including limited internet and frequent power outages acted as barriers. Conclusion The review highlights the effectiveness of various eLearning approaches among health professionals and presents the disparities between developing and developed economies in relation to the facilitators and barriers.

Abstract Background While genetic, hormonal, and lifestyle factors partially elucidate the incidence of breast cancer, emerging research has underscored the potential contribution of air pollution. Polychlorinated biphenyls (PCBs) and benzo[a]pyrene (BaP) are of particular concern due to endocrine-disrupting properties and their carcinogenetic effect. Objective To identify distinct long term trajectories of exposure to PCB153 and BaP, and estimate their associations with breast cancer risk. Methods We used data from the XENAIR case–control study, nested within the ongoing prospective French E3N cohort which enrolled 98,995 women aged 40–65 years in 1990–1991. Cases were incident cases of primary invasive breast cancer diagnosed from cohort entry to 2011. Controls were randomly selected by incidence density sampling, and individually matched to cases on delay since cohort entry, and date, age, department of residence, and menopausal status at cohort entry. Annual mean outdoor PCB153 and BaP concentrations at residential addresses from 1990 to 2011 were estimated using the CHIMERE chemistry-transport model. Latent class mixed models were used to identify profiles of exposure trajectories from cohort entry to the index date, and conditional logistic regression to estimate their association with the odds of breast cancer. Results 5058 cases and 5059 controls contributed to the analysis. Five profiles of trajectories of PCB153 exposure were identified. The class with the highest PCB153 concentrations had a 69% increased odds of breast cancer compared to the class with the lowest concentrations (95% CI 1.08, 2.64), after adjustment for education and matching factors. The association between identified BaP trajectories and breast cancer was weaker and suffered from large CI. Conclusions Our results support an association between long term exposure to PCB153 and the risk of breast cancer, and encourage further studies to account for lifetime exposure to persistent organic pollutants.

Abstract Background Non-specific low back pain is a common and costly global issue. Many people with low back pain live for years with ongoing symptom recurrence and disability, making it crucial to find effective prevention strategies. Motivational interviewing (MI) is an evidence-based patient-centred counselling style that helps motivate individuals to change their behaviours. In combination, MI and cognitive-behavioural therapy (MI-CBT) has the potential to yield long term improvements in pain and disability and reduce incidence of recurrence. Method This is a two-arm superiority randomised controlled trial comparing MI-CBT and Education (n = 83) with Education only (n = 83). Participants that have recovered from a recent episode of non-specific low back pain (7th consecutive day with pain ≤ 2 on a 0–10 numeric pain rating scale) will be eligible for inclusion into the study. Both groups will receive five 30-min sessions over a 10-week period as well as the Navigating Pain booklet, homework book and a standardised exercise programme. In the intervention group, MI-CBT techniques will be used to provide individualised support, identify beliefs, and increase engagement with the resources provided. Outcomes measures include pain (current and in the last 7 days) as rated on the numeric pain rating scale. This will be used to determine recurrence (number of participants who report back pain ≥ 3 out of 10 on the numeric pain rating scale). Furthermore, self-reported (1) pain intensity; (2) pain catastrophizing; (3) fear-avoidance beliefs; (4) pain self-efficacy; (5) depression and anxiety; (6) disability will be measured. All outcomes will be measured at baseline, and again at 3-, 6-, and 12-months post allocation. Discussion The effective delivery of self-management strategies to prevent recurrence of low back pain is an important aspect that requires urgent attention. This study will provide new information on the effectiveness of using an MI-CBT approach to facilitate self-management through education and exercise to improve low back pain outcomes. Evidence emerging from this trial has the potential to inform clinical practice and healthcare management of non-specific low back pain. Trial registration Prospectively registered with Australian New Zealand Clinical Trials Registry: ACTRN12623000746639 (10/07/2023).

Abstract Objective Evidence from low- and middle-income countries regarding the effect of smoking in people with diabetes is lacking. Here, we report the association of smoking with mortality in a large cohort of Mexican adults with diabetes. Methods Participants with diabetes mellitus (self-reported diagnosis, use of antidiabetic medications or HbA1c ≥ 6.5%) aged 35–74 years when recruited into the Mexico City Prospective Study were included. Cox regression confounder-adjusted mortality rate ratios (RRs) associated with baseline smoking status were estimated. Results Among 15,975 women and 8225 men aged 35–74 years with diabetes but no other comorbidities at recruitment, 2498 (16%) women and 2875 (35%) men reported former smoking and 2753 (17%) women, and 3796 (46%) men reported current smoking. During a median of 17 years of follow-up there were 5087 deaths at ages 35–74 years. Compared with never smoking, all-cause mortality RR was 1.08 (95%CI 1.01–1.17) for former smoking, 1.11 (95%CI 1.03–1.20) for current smoking, 1.09 (95%CI 0.99–1.20) for non-daily smoking, 1.06 (95%CI 0.96–1.16) for smoking

Abstract Background In 2016, large-scale 20 miles per hour speed limits were introduced in the United Kingdom cities of Edinburgh and Belfast. This paper investigates the role that scientific evidence played in the policy decisions to implement lower speed limits in the two cities. Methods Using a qualitative case study design, we undertook content analysis of a range of documents to explore and describe the evolution of the two schemes and the ways in which evidence informed decision-making. In total, we identified 16 documents for Edinburgh, published between 2006 and 2016, and 19 documents for Belfast, published between 2002 and 2016. Findings In both cities, evidence on speed, collisions and casualties was important for initiating discussions on large-scale 20 mph policies. However, the narrative shifted over time to the idea that 20 mph would contribute to a wider range of aspirations, none of which were firmly grounded in evidence, but may have helped to neutralize opposing discourses. Discussion and conclusions The relationship between evidence and decision-making in Edinburgh and Belfast was neither simple nor linear. Widening of the narrative appears to have helped to frame the idea in such a way that it had broad acceptability, without which there would have been no implementation, and probably a lot more push back from vested interests and communities than there was.

Abstract Background Surveys have found concerningly high levels of agreement that the United States will experience civil war soon. This study assesses variation in expectation of and perceived need for civil war with respondent sociopolitical characteristics, beliefs, firearm ownership, and willingness to engage in political violence. Methods Findings are from Wave 2 of a nationally representative annual longitudinal survey of members of the Ipsos KnowledgePanel, conducted May 18–June 8, 2023. All respondents to 2022’s Wave 1 who remained in KnowledgePanel were invited to participate. Outcomes are expressed as weighted proportions and adjusted prevalence differences, with p-values adjusted for the false discovery rate and reported as q-values. Results The completion rate was 84.2%; there were 9385 respondents. After weighting, half the sample was female (50.7%, 95% CI 49.4%, 52.1%); the weighted mean (± standard deviation) age was 48.5 (25.9) years. Approximately 1 respondent in 20 (5.7%, 95% CI 5.1%, 6.4%) agreed strongly or very strongly that “in the next few years, there will be civil war in the United States.” About 1 in 25 (3.8%, 95% CI 3.2%, 4.4%), and nearly 40% (38.4%, 95% CI 32.3%, 44.5%) of those who strongly or very strongly agreed that civil war was coming, also agreed strongly or very strongly that “the United States needs a civil war to set things right.” Expectation of and perceived need for civil war were higher among subsets of respondents who in Wave 1 were more willing than others to commit political violence, including MAGA Republicans, persons in strong agreement with racist beliefs or statements of the potential need for violence to effect social change, persons who strongly approved of specified extreme right-wing political organizations and movements, firearm owners who purchased firearms in 2020 or later, and firearm owners who carried firearms in public all or nearly all the time. Conclusions In 2023, the expectation that civil war was likely and the belief that it was needed were uncommon but were higher among subsets of the population that had previously been associated with greater willingness to commit political violence. These findings can help guide prevention efforts.

The fulfillment of rights to maternal healthcare is a key factor for the wellbeing of women. However, there is a lack of an instrument to ascertain the experience of women during maternity to enable adequate monitoring. The aim of this study was to validate a new instrument to measure women’s perception of the fulfillment of rights during healthcare in pregnancy and childbirth and immediately postpartum. The initial version of the instrument consists of 50 items and was validated using exploratory factor analysis. Additionally, the final version of the instrument consists of 29 items and was validated by confirmatory factor analysis and known-group validity. The instrument was applied to 185 Spanish women. The global Aiken’s V of the initial instrument proposal was 0.89. The process resulted in an instrument with five factors (information, privacy, consent, support, and participation) that explained the 60% of the total variance. The score of the instrument was correlated with resilience, maternity beliefs, and positive and negative affect. External validation showed relations with age, gravida, and the number of times a woman has been in labor. Additionally, the Cronbach’s α reliability was 0.93 [0.91; 0.94]. In conclusion, the instrument developed is consistent and has appropriate psychometric properties for assessing the fulfillment rights of maternity healthcare.

Abstract Background The English National Health Service has multiple waiting time standards relating to cancer diagnosis and treatment. Targets can have unintended effects, such as prioritisation based on targets instead of clinical need. In this case, a `threshold effect’ will appear as a spike in hospitals just meeting the target. Methods We conducted a retrospective study of publicly available cancer waiting time data, including a 2-week wait for a specialist appointment, a 31-day decision to first treatment and a 62-day referral to treatment standard that attracted a financial penalty. We examined the performance of hospital trusts against these targets by financial year to look for threshold effects, using Cattaneo et al. manipulation density test. Results Trust performance against cancer waiting targets declined over time, and this trend accelerated since the start of the Covid-19 pandemic. Statistical evidence of a threshold effect for the 2-week and 31-day standard was only present in a few years. However, there was strong statistical evidence of a threshold effect for the 62-day standard across all financial years (p

Abstract Background While oral health often takes a backseat to other health domains, it silently affects nearly half of the Worldwide population. The DELIVER project, funded by the EU’s Horizon Europe program, seeks to develop a blueprint model for improving the quality of oral health care for everyone. Methods Applying the Nominal Group Technique (NGT), 17 stakeholders from various backgrounds participated in identifying pressing issues for oral care quality improvement across practice, community, and policy levels. Results The results revealed significant differences at the different levels, with accessibility emerging as a prominent issue, encompassing affordability, availability, and acceptability of oral healthcare services. Conclusions These findings emphasizes the need for policy reforms, increased investments, and a shift towards preventive and patient-centered dental care practices. It highlights the importance of collaborative efforts with multi-stakeholders and prioritizing pressing issues on a multi-level to drive positive change in improving oral care quality.

INTRODUCCIÓN: El entorno escolar juega un rol importante para prevenir la malnutrición en la infancia. El objetivo fue evaluar la disponibilidad de agua potable en la cocina, la oferta durante el almuerzo y la jornada escolar y la presencia de kioscos en escuelas públicas de la provincia de Buenos Aires según prestación alimentaria y necesidades básicas insatisfechas (NBI). MÉTODOS: Se realizó un análisis post hoc de la Encuesta del Servicio Alimentario Escolar 2016-2019 de una muestra de 3342 escuelas iniciales, primarias y secundarias. Se evaluó el suministro de agua en la cocina, las fuentes de agua potable para los alumnos, la bebida en el almuerzo y la disponibilidad de kiosco. Las variables se analizaron por nivel educativo y se estratificaron según la prestación alimentaria. Se realizó un análisis estadístico descriptivo. RESULTADOS: Alrededor del 1% (n=30) de las escuelas no contaban con agua potable en la cocina, y no se observaron diferencias porcentuales por prestación ni tertil de NBI. El 10% de las escuelas no ofrecía bebida en el almuerzo, y 7 de cada 10 no disponía de fuente de agua potable accesible; 4 de cada 10 primarias y secundarias presentaron kiosco. Al evaluar según NBI, la proporción de escuelas con kiosco decrecía a medida que aumentaba el tertil. DISCUSIÓN: Es fundamental generar políticas de regulación del entorno escolar con un enfoque integral y sistémico para prevenir la malnutrición en la población infantil más vulnerable.

Introduction: The World Health Organization (WHO) has proposed to monitor intrinsic capacity (IC) in the older population as a public health strategy through the Integrated Care for Older People (ICOPE) program. Although the program has been developed based on solid concepts, scientific evidence on its practical applicability is still scarce. Objectives: To evaluate IC in Brazilian older adults, its progress over time, and its association with sociodemographic and health factors and outcomes. To evaluate the psychometric properties of the WHO/ICOPE screening tool. Methods: This is a prospective multicenter cohort study with a 36-month follow-up. We will recruit 3838 people aged ≥ 60 years, registered in the health care units included in the study by the participating centers. We will collect sociodemographic and health data and will administer tools to assess IC domains, both those provided for in the ICOPE screening tool and the sequence of confirmatory assessments provided for in the program. Participants will be reassessed every 6 months for 36 months. Expected results: To establish the profile of IC in the study population and to understand its progress and the variables associated with the clinical outcomes of interest. To reveal the diagnostic and psychometric properties of the WHO/ICOPE screening tool. The project is funded by the Brazilian National Council for Scientific and Technological Development (CNPq). Relevance: Understanding the potential use of the ICOPE public health strategy proposed by the WHO within the scope of the Brazilian Unified Health System (SUS) by integrating several research centers in the field of Geriatrics and Gerontology throughout Brazil.

Abstract Background The health system plays a critical role in safeguarding the well-being of communities in the face of health risks associated with climate change. This review maps evidence on health systems' adaptation to climate risk and barriers to effective adaptation. Methods This review followed the recommendations by Arksey and O’Malley for conducting scoping review. Search for records was conducted in PubMed, Central, Web of Science, JSTOR, Google, and Google Scholar. Only peer-reviewed papers published in English language were included in this review. All the 63 included studies were critically appraise d. Results We found that efforts are being made to create resilient health systems by incorporating climate change into health policies. Investments are being made in innovative technologies, climate-resilient health infrastructure, enhancing healthcare delivery, developing the capacity of climate specialists and agencies to provide high-quality evidence for resilient health systems. We also found that several obstacles prevent health system adaptation to climate risk, including poor policy implementation and evaluation. The obstacles are further exacerbated by financial constraints, including poverty, a lack of political commitment, inadequate data, and deficient healthcare systems, especially in developing countries. There is also a lack of integration of climate change into mental health actions and the health and safety of healthcare workers. Conclusion Efforts to develop resilient health systems against climate risks are underway, but persistent obstacles, including inadequate policy implementation, resource limitations, and a lack of integration of climate change into critical health domains, hinder comprehensive adaptation measures, particularly in developing nations.

Abstract Background Proper and complete clerkships for patients have long been shown to contribute to correct diagnosis and improved patient care. All sections for clerkship must be carefully and fully completed to guide the diagnosis and the plan of management; moreover, one section guides the next. Failure to perform a complete clerkship has been shown to lead to misdiagnosis due to its unpleasant outcomes, such as delayed recovery, prolonged inpatient stay, high cost of care and, at worst, death. Objective The objectives of the study were to determine the gap in clerkship, the impact of incomplete clerkship on the length of hospital stay, to explore the causes of the gap in clerkship of the patients and the strategies which can be used to improve clerkship of the patients admitted to, treated and discharged from the gynecological ward in Mbale RRH. Methodology This was a mixed methods study involving the collection of secondary data via the review of patients’ files and the collection of qualitative data via key informant interviews. The files of patients who were admitted from August 2022 to December 2022, treated and discharged were reviewed using a data extraction tool. The descriptive statistics of the data were analyzed using STATA version 15, while the qualitative data were analyzed via deductive thematic analysis using Atlas ti version 9. Results Data were collected from 612 patient files. For qualitative data, a total of 8 key informant interviews were conducted. Social history had the most participants with no information provided at all (83.5% not recorded), with biodata and vital sign examination (20% not recorded) having the least number. For the patients’ biodata, at least one parameter was recorded in all the patients, with the greatest gap noted in terms of recording the nearest health facility of the patient (91% not recorded). In the history, the greatest gap was noted in the history of current pregnancy (37.5% not provided at all); however, there was also a large gap in the past gynecological history (71% not recorded at all), past medical history (71% not recorded at all), past surgical history (73% not recorded at all) and family history (80% not recorded at all). The physical examination revealed the greatest gap in the abdominal examination (43%), with substantial gaps in the general examination (38.5% not recorded at all) and vaginal examination (40.5% not recorded at all), and the vital sign examination revealed the least gap. There was no patient who received a complete clerkship. There was a significant association between clerkships and the length of hospital stay. The causes of the gap in clerkships were multifactorial and included those related to the hospital, those related to the health worker, those related to the health care system and those related to the patient. The strategies to improve the clerkship of patients also included measures taken by health care workers, measures taken by hospitals and measures taken by the government. Conclusion and recommendation There is a gap in the clerkships of patients at the gynecological ward that is recognized by the stakeholders at the ward, with some components of the clerkship being better recorded than others, and no patients who received a complete clerkship. There was a significant association between clerkships and the length of hospital stay. The following is the recommended provision of clerkship tools, such as the standardized clerkship guide and equipment for patient examination, continuous education of health workers on clerkships and training them on how to use the available tools, the development of SOPs for patient clerkships, the promotion of clerkship culture and the supervision of health workers.

Abstract Background The implementation of intervention programs in Emergency Departments (EDs) is often fraught with complications due to the inherent complexity of the environment. Hence, the exploration and identification of barriers and facilitators prior to an implementation is imperative to formulate context-specific strategies to ensure the tenability of the intervention. Objectives In assessing the context of four EDs prior to the implementation of SurgeCon, a quality improvement program for ED efficiency and patient satisfaction, this study identifies and explores the barriers and facilitators to successful implementation from the perspective of the healthcare providers, patients, researchers, and decision-makers involved in the implementation. Settings Two rural and two urban Canadian EDs with 24/7 on-site physician support. Methods Data were collected prior to the implementation of SurgeCon, by means of qualitative and quantitative methods consisting of semi-structured interviews with 31 clinicians (e.g., physicians, nurses, and managers), telephone surveys with 341 patients, and structured observations from four EDs. The interpretive description approach was utilized to analyze the data gathered from interviews, open-ended questions of the survey, and structured observations. Results A set of five facilitator-barrier pairs were extracted. These key facilitator-barrier pairs were: (1) management and leadership, (2) available resources, (3) communications and networks across the organization, (4) previous intervention experiences, and (5) need for change. Conclusion Improving our understanding of the barriers and facilitators that may impact the implementation of a healthcare quality improvement intervention is of paramount importance. This study underscores the significance of identifing the barriers and facilitators of implementating an ED quality improvement program and developing strategies to overcome the barriers and enhance the facilitators for a successful implementations. We propose a set of strategies for hospitals when implementing such interventions, these include: staff training, champion selection, communicating the value of the intervention, promoting active engagement of ED staff, assigning data recording responsibilities, and requiring capacity analysis. Trial registration ClinicalTrials.gov. NCT04789902. 10/03/2021.

Objectives This study compares the demographics, diagnoses, re-admission rates, sick leaves, and prescribed medications of patients accessing digital general practitioner (GP) visits with those of patients opting for traditional face-to-face appointments in a primary health care setting.Design The study adopted a retrospective analysis of patient record data collected in 2019, comparing visits to a digital primary health center with traditional health center visits.Setting Primary health care.Participants The data encompassed patients who utilized the digital clinic and those who visited public health centers for primary health care services.Main Outcome Measures The study assessed demographics, health diagnoses, prescribed medications, sick leave recommendations, re-admission rates, and differences in costs between digital clinic and face-to-face visits. Secondary outcomes included a comparative analysis of medication categories, resolution rates for health problems, and potential impacts on health care utilization.Results Digital clinic users were typically younger, more educated, and predominantly female compared with health centre users. Digital visits were well-suited for uncomplicated infections, while health centre appointments were associated with a higher prevalence of chronic conditions. Medication patterns differed between the two modalities, with digital clinic users receiving generic over-the-counter drugs and antibiotics, whereas health centre visits commonly involved cardiac and antihypertensive medications. Sick leave recommendations were slightly higher in the digital clinic, but the difference was not significant. Approximately 70% of health problems addressed in the digital clinic were successfully resolved, and the cost of digital visits was about 50,3% of face-to-face appointments.Conclusion Digital health care services offer a cost-efficient alternative for specific health problems, appealing to younger, educated individuals, when compared to the users of public health center, and may enable improvement of cost-effectiveness combined with acceptable demand management and patient segmentation practices. The results highlight the potential benefits of digital clinics, particularly for uncomplicated cases, while also emphasizing the importance of suitable referral mechanisms for in-person consultations.

Abstract Background Mental health conditions affect one in seven young people and research suggests that current mental health services are not meeting the needs of most children and youth. Learning health systems are an approach to enhancing services through rapid, routinized cycles of continuous learning and improvement. Patient-reported outcome measures provide a key data source for learning health systems. They have also been shown to improve outcomes for patients when integrated into routine clinical care. However, implementing these measures into health systems is a challenging process. This paper describes a protocol for a formative evaluation of the implementation of patient-reported measures in a newly operational child and adolescent mental health centre in Calgary, Canada. The purpose is to optimize the collection and use of patient-reported outcome measures. Our specific objectives are to assess the implementation progress, identify barriers and facilitators to implementation, and explore patient, caregivers and clinician experiences of using these measures in routine clinical care. Methods This study is a mixed-methods, formative evaluation using the Consolidated Framework for Implementation Research. Participants include patients and caregivers who have used the centre’s services, as well as leadership, clinical and support staff at the centre. Focus groups and semi-structured interviews will be conducted to assess barriers and facilitators to the implementation and sustainability of the use of patient-reported outcome measures, as well as individuals’ experiences with using these measures within clinical care. The data generated by the patient-reported measures over the first five months of the centre’s operation will be analyzed to understand implementation progress, as well as validity of the chosen measures for the centres’ population. Discussion The findings of this evaluation will help to identify and address the factors that are affecting the successful implementation of patient-reported measures at the centre. They will inform the co-design of strategies to improve implementation with key stakeholders, which include patients, clinical staff, and leadership at the centre. To our knowledge, this is the first study of the implementation of patient-reported outcome measures in child and adolescent mental health services and our findings can be used to enhance future implementation efforts in similar settings.

Objetivo. Calcular o indicador de consumo de álcool per capita (APC) para o Brasil utilizando dados nacionais (APC Brasil), com vistas a estabelecê-lo como padrão ouro para o país em substituição ao indicador anteriormente calculado pela Organização Mundial da Saúde (OMS) com base em dados internacionais. Métodos. Foram selecionadas, no Brasil, as fontes públicas de dados necessárias para a composição do cálculo do APC registrado e definida a concentração alcoólica por categoria de bebida. Para as variáveis APC turista e APC não registrado, indisponíveis no Brasil, foram usadas as estimativas da Organização das Nações Unidas (ONU) e da OMS. O indicador APC Brasil foi calculado e comparado ao indicador produzido pela OMS por meio de análise das medianas para o período de 2005 a 2020. Resultados. O indicador de consumo de álcool nacional foi de 9,2 litros per capita em 2005, chegando a 9,8 em 2020. Já o indicador da OMS mostrou, para 2005, um consumo de 8,4 litros per capita, com queda até 2016 e leve aumento para 7,8 em 2020. Conclusão. O APC Brasil foi calculado com base em fontes nacionais e mostrou tendência distinta em relação ao indicador da OMS, que se mostrou em queda. A disponibilização transparente e regular desse indicador por canais governamentais permitirá o seu monitoramento, possibilitando a elaboração de políticas para o enfrentamento do consumo do álcool no país.

Abstract Background There is an urgent need to increase colorectal cancer screening (CRCS) uptake in Texas federally qualified health centers (FQHCs), which serve a predominantly vulnerable population with high demands. Empirical support exists for evidence-based interventions (EBIs) that are proven to increase CRCS; however, as with screening, their use remains low in FQHCs. This study aimed to identify barriers to and facilitators of implementing colorectal cancer screening (CRCS) evidence-based interventions (EBIs) in federally qualified health centers (FQHCs), guided by the Consolidated Framework for Implementation Research (CFIR). Methods We recruited employees involved in implementing CRCS EBIs (e.g., physicians) using data from a CDC-funded program to increase the CRCS in Texas FQHCs. Through 23 group interviews, we explored experiences with practice change, CRCS promotion and quality improvement initiatives, organizational readiness, the impact of COVID-19, and the use of CRCS EBIs (e.g., provider reminders). We used directed content analysis with CFIR constructs to identify the critical facilitators and barriers. Results The analysis revealed six primary CFIR constructs that influence implementation: information technology infrastructure, innovation design, work infrastructure, performance measurement pressure, assessing needs, and available resources. Based on experiences with four recommended EBIs, participants described barriers, including data limitations of electronic health records and the design of reminder alerts targeted at deliverers and recipients of patient or provider reminders. Implementation facilitators include incentivized processes to increase provider assessment and feedback, existing clinic processes (e.g., screening referrals), and available resources to address patient needs (e.g., transportation). Staff buy-in emerged as an implementation facilitator, fostering a conducive environment for change within clinics. Conclusions Using CFIR, we identified barriers, such as the burden of technology infrastructure, and facilitators, such as staff buy-in. The results, which enhance our understanding of CRCS EBI implementation in FQHCs, provide insights into designing nuanced, practical implementation strategies to improve cancer control in a critical setting.

Abstract Background Limited access to specialist medical services is a major barrier to healthcare in rural areas. We compared rural-urban specialist doctor consultations outside hospital by older adults (≥ 60 years) across South Australia. Methods Cross-sectional data were available from the South Australia’s Department of Health. The Modified Monash Model (MM1-7) of remoteness was used to categorize data into rural (MM 3–4), remote (MM5-7), and urban (MM1-MM2) of participants in urban and non-urban South Australia. The analysis was conducted on older adults (n = 20,522), self-reporting chronic physical and common mental health conditions. Results Specialist doctor consultation in the past 4 weeks was 14.6% in our sample. In multivariable analysis, increasing age (odds ratio 1.3, 95% CI: 1.2-1.4), higher education (odds ratio 1.5, 95% CI: 1.3-1.9), physical health conditions [diabetes (odds ratio 1.2, 95% CI: 1.1-1.3); cancer (odds ratio1.8, 95% CI: 1.7-2.0); heart disease (odds ratio 1.9, 95% CI: 1.6-2.1)], and common mental disorders [depression (odds ratio 1.3, 95% CI: 1.1-1.5); anxiety (odds ratio 1.4, 95% CI: 1.1-1.6)] were associated with higher specialist care use. Specialist care use among rural (odds ratio 0.8, 95% CI: 0.6–0.9), and remote (odds ratio 0.8, 95% CI: 0.7–0.9) older people was significantly lower than their urban counterparts after controlling for age, education, and chronic disease. Conclusion Our findings demonstrate a disparity in the use of out of hospital specialist medical services between urban and non-urban areas.

Abstract Background Behaviour change interventions can result in lasting improvements in physical activity (PA). A broad implementation of behaviour change interventions are likely to be associated with considerable additional costs, and the evidence is unclear whether they represent good value for money. The aim of this study was to investigate costs and cost-effectiveness of behaviour change interventions to increase PA in community-dwelling adults. Methods A search for trial-based economic evaluations investigating behaviour change interventions versus usual care or alternative intervention for adults living in the community was conducted (September 2023). Studies that reported intervention costs and incremental cost-effectiveness ratios (ICERs) for PA or quality-adjusted life years (QALYs) were included. Methodological quality was assessed using the Consensus Health Economic Criteria (CHEC-list). A Grading of Recommendations Assessment, Development and Evaluation style approach was used to assess the certainty of evidence (low, moderate or high certainty). Results Sixteen studies were included using a variety of economic perspectives. The behaviour change interventions were heterogeneous with 62% of interventions being informed by a theoretical framework. The median CHEC-list score was 15 (range 11 to 19). Median intervention cost was US$313 per person (range US$83 to US$1,298). In 75% of studies the interventions were reported as cost-effective for changes in PA (moderate certainty of evidence). For cost per QALY/gained, 45% of the interventions were found to be cost-effective (moderate certainty of evidence). No specific type of behaviour change intervention was found to be more effective. Conclusions There is moderate certainty that behaviour change interventions are cost-effective approaches for increasing PA. The heterogeneity in economic perspectives, intervention costs and measurement should be considered when interpreting results. There is a need for increased clarity when reporting the functional components of behaviour change interventions, as well as the costs to implement them.

Abstract Background and aims Waist circumference (WC) is a significant indicator of body adiposity and is associated with increased mortality and morbidity of cardiovascular diseases. Although, single nutrient intake and candidate genes were previously associated with WC. Little is known about WC association with overall diet quality, genetic risk score and gene-nutrient interaction. This study aims to investigate the influence of overall diet quality and multiple WC-associated single nucleotide polymorphisms on WC. In addition to investigating gene-nutrient interaction association with WC. Methods This study explored cross-sectional data from two large sample-size studies, to provide reproducible results. As a representation of the UK population, the Airwave Health Monitoring Study (n = 6,502) and the UK-Biobank Cohort Study (n = 171,129) were explored for factors associated with WC. Diet quality was evaluated based on the Mellen Index for Dietary Approaches to Stop Hypertension (Mellen-DASH). The genetic risk score for WC (GRS-Waist) was calculated by screening the population genotype for WC-associated single nucleotide polymorphisms. Multivariate linear regression models were built to explore WC association with diet quality and genetic risk score. Gene-nutrient interaction was explored by introducing the interaction term (GRS-Waist X Mellen-DASH score) to multivariate linear regression analysis. Results The prevalence of high WC (Female > 80 cm, Male > 94 cm) was 46.5% and 51.7% in both populations. Diet quality and genetic risk score of WC were significantly associated with WC. There was no evidence of interaction between GRS-Waist, DASH diet scores and nutrient intake on WC. Conclusion This study’s findings provided reproducible results on waist circumference association with diet and genetics and tested the possibility of gene-nutrient interaction. These reproducible results are successful in building the foundation for using diet and genetics for early identification of those at risk of having high WC and WC-associated diseases. In addition, evidence on gene-diet interactions on WC is limited and lacks replication, therefore our findings may guide future research in investigating this interaction and investigating its application in precision nutrition.

Abstract Background Public health emergencies of international concern (PHEICs) as the COVID-19 pandemic and others that have occurred since the early 2000s put enormous pressure on health and care systems. This is being a context for protests by health and care workers (HCWs) because of additional workload, working conditions and effects on mental and physical health. In this paper, we intended to analyze the demands of HCWs associated with industrial actions, protests, strikes and lockouts (IAPSLs) which occurred during COVID-19 pandemic and other PHEICs; to identify the impact of these grievances; and describe the relevant interventions to address these IAPSLs. Methods We included studies published between January 2000 and March 2022 in PubMed, Embase, Scopus, BVS/LILACS, WHO’s COVID-19 Research Database, ILO, OECD, HSRM, and Google Scholar for grey literature. Eligibility criteria were HCWs as participants, IAPSLs as phenomenon of interest occurring in the context of COVID-19 and other PHEICs. GRADE CERQual was used to assess risk of bias and confidence of evidence. Results 1656 records were retrieved, and 91 were selected for full-text screening. We included 18 publications. A system-wide approach, rather than a limited approach to institutions on strike, makes it possible to understand the full impact of the strike on health and care services. PHEICs tend to aggravate already adverse working conditions of HCWs, acting as drivers for HCWs strikes, leading to staff shortages, and financial issues, both in the North and in the Global South, particularly evident in Asia and Africa. In addition, issues related to deficiencies in leadership and governance in heath sector and lack of medical products and technologies (e.g., lack of personal protective equipment) were the main drivers of strikes, each contributing 25% of the total drivers identified. Conclusions It is necessary to focus on the preparedness of health and care systems to respond adequately to PHEICs, and this includes being prepared for HCWs’ IAPSLs, talked much in the context of COVID-19 pandemic. Evidence to assist policymakers in defining strategies to respond adequately to the health and care needs of the population during IAPSLs is crucial. The main impact of strikes is on the disruption of health care services’ provision. Gender inequality being a major issue among HCWs, a proper understanding of the full impact of the strike on health and care services will only be possible if gender lens is combined with a systemic approach, rather than gender-undifferentiated approaches limited to the institutions on strike.

Abstract Introduction Interpersonal violence is a phenomenon that can occur with different people and conditions. However, people with intellectual disabilities have increased vulnerability to this problem, with potential risks to their health and well-being. The aim of this study was to identify the sociodemographic characteristics of people with disabilities who have been victims of interpersonal violence, the profile of the perpetrators and the measures taken after the victims have been cared for. Methods This is an exploratory, descriptive, cross-sectional study using the Interpersonal Violence Notification Forms entered into the Brazilian Ministry of Health’s Notifiable Diseases Information System. The city of São Paulo was chosen as the setting because it is the largest city in Latin America and has a faster data processing system than other cities. The period covered notifications made between 2016 and 2022. The information was collected between October and November 2023 and a univariate statistical analysis was carried out. Fisher’s exact test was used, with a significance level of 5% (α = 0.05). Results There were 4,603 notifications against people with intellectual disabilities in the period. The forms of physical violence, neglect/abandonment and psychological/moral violence were more frequent in the 15–19 age group, while sexual violence was more frequent in the 10–14 age group (p

Abstract Background Although physical activity (PA) is associated with significant health benefits, only a small percentage of adolescents meet recommended PA levels. This systematic review with meta-analysis explored the modifiable determinants of adolescents’ device-based PA and/or sedentary behaviour (SB), evaluated in previous interventions and examined the associations between PA/SB and these determinants in settings. Methods A search was conducted on five electronic databases, including papers published from January 2010 to July 2023. Randomized Controlled Trials (RCTs) or Controlled Trials (CTs) measuring adolescents’ device-based PA/SB and their modifiable determinants at least at two time points: pre- and post-intervention were considered eligible. PA/SB and determinants were the main outcomes. Modifiable determinants were classified after data extraction adopting the social-ecological perspective. Robust Bayesian meta-analyses (RoBMA) were performed per each study setting. Outcomes identified in only one study were presented narratively. The risk of bias for each study and the certainty of the evidence for each meta-analysis were evaluated. The publication bias was also checked. PROSPERO ID: CRD42021282874. Results Fourteen RCTs (eight in school, three in school and family, and one in the family setting) and one CT (in the school setting) were included. Fifty-four modifiable determinants were identified and were combined into 33 broader determinants (21 individual–psychological, four individual–behavioural, seven interpersonal, and one institutional). RoBMAs revealed none or negligible pooled intervention effects on PA/SB or determinants in all settings. The certainty of the evidence of the impact of interventions on outcomes ranged from very low to low. Narratively, intervention effects in favour of the experimental group were detected in school setting for the determinants: knowledge of the environment for practicing PA, d = 1.84, 95%CI (1.48, 2.20), behaviour change techniques, d = 0.90, 95%CI (0.09, 1.70), choice provided, d = 0.70, 95%CI (0.36, 1.03), but no corresponding effects on PA or SB were found. Conclusions Weak to minimal evidence regarding the associations between the identified modifiable determinants and adolescents’ device-based PA/SB in settings were found, probably due to intervention ineffectiveness. Well-designed and well-implemented multicomponent interventions should further explore the variety of modifiable determinants of adolescents’ PA/SB, including policy and environmental variables.

Abstract Weight-related discussions during childhood may have long-lasting effects on children’s body image and well-being. However, little is known about how parents frame these discussions with children who have undergone treatment for obesity. Our study aimed to explore how parents perceive weight-related discussions, several years after their children started obesity treatment. This qualitative study is part of the 4-year follow-up of the More and Less study, a randomized controlled trial examining the effectiveness of a parental support program as part of obesity treatment for preschool-aged children in Stockholm, Sweden. Semi-structured interviews were conducted with 33 parents (79% mothers, 48% with a university degree, 47% with foreign background) of 33 children (mean age 9.3 years (SD 0.7), 46% girls), transcribed and analyzed using realist informed thematic analysis. Three main themes, encompassing three subthemes were developed. Under the first theme, Parental attitudes and concerns, parents emphasized the importance of discussing weight and health behaviors with their children, yet found it challenging due to uncertainties about how to approach it safely and sensitively. A few parents found the conversation manageable, citing their own experiences of having overweight or their style of communication with the child as facilitating the conversation. Under the second theme, The significance of time and context, parents said they engaged in weight-related conversations with their children more frequently as the children matured, driven by their growing self-awareness. Parents also expressed how contextual factors, such as gender and the presence of others, shaped conversations. Parents perceived boys as more resilient, thus exposing them to more negative weight talk. The third theme, Navigating weight stigma, revealed how parents employed strategies such as nurturing their children’s self-confidence, downplaying the significance of appearance and emphasizing health when discussing weight to shield their children from weight stigma. Taken together, we found that many parents need support to navigate weight-related discussions. Addressing weight stigma is part of children’s obesity management process, as children may be bullied, teased, or experience discrimination in different social settings. More research is needed to explore how young children undergoing obesity treatment experience weight stigma and to understand gendered differences in these experiences.

The role of anxiety is unknown in relation to postpartum bonding, unlike the well-known detrimental effect that postpartum depression has on the relationship between a mother and child. This study investigates how anxiety affects mother–infant bonding after childbirth, comparing the Italian version of the Postpartum Specific Anxiety Scale (PSAS-IT) with generalized measures of anxiety. Examining 324 non-randomly-selected participants responding to various scales, including the Edinburgh postnatal depression scale (EPDS), generalized anxiety disorder (GAD), postpartum-specific anxiety scale (PSAS-IT), postpartum bonding questionnaire (PBQ), and baby care questionnaire (BCQ-2), initial results suggest a link between certain postpartum anxiety symptoms and attachment problems. Surprisingly, anxiety measured with the PSAS has no direct influence on attachment; however, it is a strong predictor of bonding, even when maternal age, general anxiety, and depression are taken into account, explaining 3% of the variance in scores (β = 0.26, p < 0.001). This emphasizes the importance of early identification and intervention of postpartum anxiety in promoting bonding between mother and child.

In this study, we systematically examined the importance of human rights standards and principles for rights-based pre-exposure prophylaxis (PrEP) provision for marginalized adolescents. Nested within a demonstration study of PrEP provision to adolescent men who have sex with men, travestis, and transgender women, we carried out interviews in São Paulo, Brazil with 25 adolescents, eight health providers, and six workers involved in community-based demand creation. Analysis focused on participants’ narratives about aspects of human rights within service delivery, including the availability, accessibility, acceptability, and quality of services; informed decision-making; nondiscrimination; and privacy and confidentiality. Clients and service providers highlighted the importance of availing a range of services beyond PrEP and described how community outreach and social media helped promote accessibility. Acceptability centered around clients feeling heard and respected. Health workers appreciated having time to build trusting relationships with clients to ensure quality of care and support informed decision-making. Nondiscrimination was valued by all, including using clients’ chosen pronouns. Privacy and confidentiality were primary concerns for clients who were not “out” about their sexuality or PrEP use; to mitigate this, health workers sought to accommodate clients’ preferred channels of communication. Rights-based PrEP services can help promote engagement and retention in PrEP services, particularly for marginalized populations.

Abstract Background Interprofessional collaborative care such as a split-shared care model involving family physicians and community pharmacists can reduce the economic burden of diabetes management. This study aimed to evaluate the economic outcome of a split-shared care model between family physicians and community pharmacists within a pharmacy chain in managing people with uncontrolled type 2 diabetes and polypharmacy. Method This was a multi-center, parallel arm, open label, randomized controlled trial comparing the direct and indirect economic outcomes of people who received collaborative care involving community pharmacists (intervention) versus those who received usual care without community pharmacist involvement (control). People with uncontrolled type 2 diabetes, defined as HbA1c > 7.0% and taking ≥ 5 chronic medications were included while people with missing baseline economic data (such as consultation costs, medication costs) were excluded. Direct medical costs were extracted from the institution’s financial database while indirect costs were calculated from self-reported gross income and productivity loss, using Work Productivity Activity Impairment Global Health questionnaire. Separate generalized linear models with log link function and gamma distribution were used to analyze changes in direct and indirect medical costs. Results A total of 175 patients (intervention = 70, control = 105) completed the trial and were included for analysis. The mean age of the participants was 66.9 (9.2) years, with majority being male and Chinese. The direct medical costs were significantly lower in the intervention than the control group over 6 months (intervention: -US$70.51, control: -US$47.66, p

Abstract Background Gambling and gambling-related harm attract significant researcher and policy attention. The liberalisation of gambling in most western countries is strongly associated with a marked rise in gambling activity and increases in gambling-related harm experienced at the population level. Programs to address gambling-related harm have traditionally focused on individuals who demonstrate problematic gambling behaviour, despite clear evidence of the effectiveness of a public health approach to high-risk activities like gambling. Little is known about the availability or efficacy of programs to address gambling-related harm at a population level. Methods The Victorian Responsible Gambling Foundation commissioned a rapid evidence review of the available evidence on programs designed to reduce gambling-related harm at a population level. The review was conducted using a public health and harm reduction lens. MEDLINE, ProQuest Central and PsychInfo databases were searched systematically. Included studies were published in English between 2017 – 2023 from all countries with gambling policy contexts and public health systems comparable to Australia’s; included primary data; and focused on primary and/or secondary prevention of gambling-related harm or problems. Results One hundred and sixty-seven articles were eligible for inclusion. Themes identified in the literature included: risk and protective factors; primary prevention; secondary prevention; tertiary prevention; target population group; and public health approach. The evidence review revealed a gap in empirical evidence around effective interventions to reduce gambling-related harm at the population level, particularly from a public health perspective. Conclusions Addressing gambling-related harm requires a nuanced, multi-layered approach that acknowledges the complex social, environmental, and commercial nature of gambling and associated harms. Moreover, evidence demonstrates community programs to reduce gambling-related harm are more successful in reducing harm when based on sound theory of co-design and address the social aspects that contribute to harm.

There is strong evidence that the implicit biases of health care professionals affect the treatment of patients, and that minority and other marginalized patients are disproportionately harmed. Assumptions made about patient knowledge or lack thereof function as judgments that are prone to bias, which then affect the education and advice imposed upon patients. We review how the motivational interviewing (MI) approach to patient engagement includes components of evidence-based bias-mitigating strategies, such as understanding circumstances from the patient?s point of view, and therefore we propose that the MI approach can reduce the impact of bias in patient care.

Abstract Background Hepatitis B is endemic amongst the Australian Aboriginal population in the Northern Territory. A participatory action research project identified the lack of culturally appropriate education tools and led to the development of the “Hep B Story” app in the Aboriginal language Yolŋu Matha. This paper describes a formal evaluation of the app’s first version, which informed improvements and translation into a further ten Aboriginal languages. Methods The evaluation employed Participatory Action Research (PAR) principles to work within Indigenous research methodologies and prioritise Indigenous knowledge to improve the app iteratively. Semi-structured interviews and focus groups were conducted across the Northern Territory with 11 different language groups. Local Community Based Researchers and Aboriginal Research team members coordinated sessions. The recorded, translated conversations were transcribed verbatim and thematically analysed using an inductive and deductive approach. Results Between November 2018 and September 2020, 94 individuals from 11 language groups participated in 25 semi-structured interviews and 10 focus groups. All participants identified as Aboriginal. Most participants felt the app would be culturally appropriate for Aboriginal communities in the Northern Territory and improve knowledge surrounding hepatitis B. The information gathered from these interviews allowed for identifying five main themes: support for app, relationships, concept versus language, shame, and perceptions of images, along with errors that required modification. Conclusions A “real-life” evaluation of the app was comprehensively completed using a PAR approach blended with Indigenous research methods. This evaluation allowed us to develop an updated and enhanced version of the app before creating the additional ten language versions. An iterative approach alongside strong community engagement was pivotal in ensuring the app’s cultural safety and appropriateness. We recommend avoiding the use of knowledge-based evaluations in an Aboriginal setting to ensure relevant and culturally appropriate feedback is obtained.

Abstract Background Decentralization of a health system is a complex and multidimensional phenomenon that demands thorough investigation of its process logistics, predisposing factors and implementation mechanisms, within the broader socio-political environment of each nation. Despite its wide adoption across both high-income countries (HICs) and low-and-middle-income countries (LMICs), empirical evidence of whether decentralization actually translates into improved health system performance remains inconclusive and controversial. This paper aims to provide a comprehensive description of the decentralization processes in three countries at different stages of their decentralization strategies – Pakistan, Brazil and Portugal. Main body This study employed a systematic analysis of peer-reviewed academic journals, official government reports, policy documents and publications from international organizations related to health system decentralization. A comprehensive search was conducted using reputable databases such as PubMed, Google Scholar, the WHO repository and other relevant databases, covering the period up to the knowledge cutoff date in June 2023. Information was systematically extracted and organized into the determinants, process mechanics and challenges encountered during the planning, implementation and post-decentralization phases. Although decentralization reforms have achieved some success, challenges persist in their implementation. Comparing all three countries, it was evident that all three have prioritized health in their decentralization reforms and aimed to enhance local decision-making power. Brazil has made significant progress in implementing decentralization reforms, while Portugal and Pakistan are still in the process. Pakistan has faced significant implementation challenges, including capacity-building, resource allocation, resistance to change and inequity in access to care. Brazil and Portugal have also faced challenges, but to a lesser extent. The extent, progress and challenges in the decentralization processes vary among the three countries, each requiring ongoing evaluation and improvement to achieve the desired outcomes. Conclusion Notable differences exist in the extent of decentralization, the challenges faced during implementation and inequality in access to care between the three countries. It is important for Portugal, Brazil and Pakistan to address these through reinforcing implementation strategies, tackling inequalities in access to care and enhancing monitoring and evaluation mechanism. Additionally, fostering knowledge sharing among these different countries will be instrumental in facilitating mutual learning.

Abstract Background A 2022 survey in the USA found concerningly high prevalences of support for and personal willingness to engage in political violence, of beliefs associated with such violence, and of belief that civil war was likely in the near future. It is important to determine the durability of those findings. Methods Wave 2 of a nationally representative cohort survey was conducted May 18-June 8, 2023; the sample comprised all respondents to 2022’s Wave 1. Outcomes are expressed as weighted proportions; changes from 2022 to 2023 are for respondents who participated in both surveys, based on aggregated individual change scores. Results The completion rate was 84.2%; there were 9385 respondents. After weighting, 50.7% (95% confidence interval (CI) 49.4%, 52.1%) were female; weighted mean (SD) age was 48.5 (25.9) years. About 1 in 20 respondents (5.7%, 95% CI 5.1%, 6.4%) agreed strongly/very strongly that “in the next few years, there will be civil war in the United States,” a 7.7% decrease. In 2023, fewer respondents considered violence to be usually/always justified to advance at least 1 of 17 specific political objectives [25.3% (95% CI 24.7%, 26.5%), a 6.8% decrease]. However, more respondents thought it very/extremely likely that within the next few years, in a situation where they consider political violence justified, “I will be armed with a gun” [9.0% (95% CI 8.3%, 9.8%), a 2.2% increase] and “I will shoot someone with a gun” [1.8% (95% CI 1.4%, 2.2%), a 0.6% increase]. Among respondents who considered violence usually/always justified to advance at least 1 political objective, about 1 in 20 also thought it very/extremely likely that they would threaten someone with a gun (5.4%, 95% CI 4.0%, 7.0%) or shoot someone (5.7%, 95% CI 4.3%, 7.1%) to advance such an objective. Conclusions In this cohort, support for political violence declined from 2022 to 2023, but predictions of firearm use in political violence increased. These findings can help guide prevention efforts, which are urgently needed.

Abstract Background Social prescribing (SP) is a non-clinical approach, most commonly based in healthcare units, that aims to address non-medical health-related social needs by connecting individuals with community-based services. This qualitative study explores the perception of Portuguese older adults regarding the benefits of SP and their willingness to participate in SP initiatives. Methods Three face-to-face focus group sessions were conducted with 23 participants in different cities in Portugal. Open and semi-open questions were used to guide the discussions and thematic analysis was used to analyze the data. Results The participants recognized the potential benefits of SP for older adults, including diversifying leisure activities, improving mental health, and complementing existing support systems. They highlighted the need for external support, usually in the form of link workers, to facilitate personalized referrals and consider individual characteristics and preferences. While some participants expressed reluctance to engage in SP due to their existing busy schedules and a perceived sense of imposition, others showed openness to having new experiences and recognized the potential value of SP in promoting activity. Barriers to participation, including resistance to change, mobility issues, and family responsibilities, were identified. Conclusions The study emphasizes the importance of a person-centered and co-designed approach to SP, involving older adults in the planning and implementation of interventions. The findings provide valuable insights for the development of SP programs tailored to the unique needs and aspirations of older adults in Portugal, ultimately promoting active and healthy aging. Future research should consider the perspectives of family doctors and include a broader representation of older adults from diverse geographic areas.

Dyskinesia affects the limbs, trunk, and head and is more prevalent in people with Parkinson’s disease (PD) and a history of falls. More evidence about the effects of dyskinesia on postural control, balance, gait, and fall risk could help improve the quality of life of individuals with PD. This review aims to examine associations between dyskinesia and postural control, balance, gait, and fall risk in individuals with PD. Such information could lead to new approaches to quality of life improvement among individuals with PD. PubMed, CINAHL, PsycInfo, Scopus, and SciELO will be searched for longitudinal, cohort, and case-control studies published in English or Portuguese in any year that investigated the association between dyskinesia and postural control, balance, gait, and fall risk in individuals with PD. Two reviewers will independently evaluate the titles, abstracts, and full texts according to PRISMA guidelines to select eligible studies for the review. Data on participants, dyskinesia, postural control, balance, gait, and fall risk will be extracted and summarized in tables. Two reviewers will independently assess the methodological quality of each study using the Newcastle Ottawa quality assessment scale. Meta-analysis will not be performed. The results of this systematic review will offer insight into the effects of dyskinesia on postural control, balance, gait, and fall risk. Such information could significantly contribute to informed decisions about early motor intervention in individuals with PD.

Objective: Adapt functional mobility and muscle strength tests for older people with dementia to be performed remotely in the home environment; determine intra-rater and inter-rater reliability of functional mobility and strength tests for older people with dementia; and correlate the performance on the physical tests executed remotely and the Timed Up and Go (TUG) test, which was validated remotely in healthy older people. Methods: We included 43 people with dementia. The Short Physical Performance Battery (SPPB), TUG, TUG Dual Task (TUG-DT), and 30-Second Sit-to-Stand Test (SST30s) were performed through videocalls. Test performance was documented to facilitate the subsequent determination of inter- and intra-rater reliability. The intra-rater reliability was determined at a 2-week interval from the real-time videocall to analysis of the recording. Results: Intra-rater reliability ranged from good to excellent for all tests performed (ICC 0.862–1.000). Inter-rater reliability values were fair for gait speed (ICC = 0.223), moderate for some of the SPPB items (ICC = 0.706–0.801), good for the SPPB two-foot balance (ICC = 0.860) and the SPPB total score (ICC = 0.831), and excellent for the rest of the tests. Conclusion: Functional mobility and muscle strength tests proved reliable and feasible for remote, at-home assessments of older people with dementia when assisted by their respective caregivers, providing an additional alternative for assessment of this patient population.

Abstract Aim Customer discovery, an entrepreneurial and iterative process to understand the context and needs of potential adoption agencies, may be an innovative strategy to improve broader dissemination of evidence-based interventions. This paper describes the customer discovery process for the Building Healthy Families (BHF) Online Training Resources and Program Package (BHF Resource Package) to support rural community adoption of an evidence-based, family healthy weight program. Methods The customer discovery process was completed as part of a SPeeding Research-tested INTerventions (SPRINT) training supported by the U.S. Centers for Disease Control and Prevention. Customer discovery interviews (n=47) were conducted with people that could be potential resource users, economic buyers, and BHF adoption influencers to capture multiple contextual and needs-based factors related to adopting new evidence-based interventions. Qualitative analyses were completed in an iterative fashion as each interview was completed. Results The BHF Resource Package was designed to be accessible to a variety of implementation organizations. However, due to different resources being available in different rural communities, customer discovery interviews suggested that focusing on rural health departments may be a consistent setting for intervention adoption. We found that local health departments prioritize childhood obesity but lacked the training and resources necessary to implement effective programming. Several intervention funding approaches were also identified including (1) program grants from local and national foundations, (2) healthcare community benefit initiatives, and (3) regional employer groups. Payment plans recommended in the customer discovery interviews included a mix of licensing and technical support fees for BHF delivery organizations, potential insurance reimbursement, and family fees based on ability to pay. Marketing a range of BHF non-weight related outcomes was also recommended during the customer discovery process to increase the likelihood of BHF scale-up and sustainability. Conclusions Engaging in customer discovery provided practical directions for the potential adoption, implementation, and sustainability of the BHF Resource Package. However, the inconsistent finding that health departments are both the ideal implementation organization, but also see childhood obesity treatment as a clinical service, is concerning.