BMC Public Health

BackgroundSex workers struggled to adhere to isolation guidelines following COVID-19 diagnosis because of financial pressure to keep working. We co-developed and evaluated for feasibility, acceptability, and cost an intervention for promoting isolation and community-based self-monitoring for COVID-19. MethodsSex workers testing positive for COVID-19 received the following co-developed intervention: i) risk-differentiated support, including immediate hospitalization and/or treatment for serious illness, and community-based self-monitoring for those at risk of progressing to severe illness, ii) food packs lasting two weeks. Using Proctors Framework, we interviewed purposively selected health-workers and sex workers before intervention implementation (26 sex workers and 24 health workers) and during implementation (8 sex workers of whom 5 tested positive, and 5 health workers) to evaluate the intervention. We determined intervention development and implementation costs using program data. ResultsThe intervention was implemented between March-June 2023. Sex workers and health workers reported that the intervention was highly acceptable and was implemented with fidelity. Food packs were highly appreciated; participants said they promoted isolation although vulnerability to non-food financial pressures persisted. Unanticipated impacts were increased testing uptake following introduction of food packs. Self-monitoring at home was acceptable although fear of stigma prevented some participants from seeking the needed support. The cost per sex worker testing positive was $49 and $54 respectively excluding/including intervention co-development costs. ConclusionA co-developed intervention for promoting isolation and community-based self-monitoring for COVID-19 was feasible and acceptable, with costs comparing favorably with similar interventions. Addressing stigma could optimise implementation and potential for future pandemics.

BackgroundSecondhand smoke (SHS) exposure remains a major public health concern among adolescents, particularly in low- and middle-income countries. Evidence from Zambia is limited, despite increasing tobacco use and existing tobacco control policies. This study examined the prevalence and correlates of SHS exposure among adolescents in Zambia. MethodsWe analyzed data from the 2021 Zambia Global Youth Tobacco Survey (GYTS), a nationally representative, school-based survey. The sample included 6,499 adolescents aged 11-17 years enrolled in grades 7-9. The primary outcome was any SHS exposure, defined as exposure to tobacco smoke at home, school, enclosed public places, or outdoor public places. Weighted prevalence estimates were calculated, and multivariable logistic regression was used to identify factors associated with SHS exposure, adjusting for demographic, social, environmental, and socioeconomic variables. ResultsOverall, 66.0% of adolescents reported exposure to SHS. Adolescents living with a parent or guardian who smoked had nearly three times higher odds of SHS exposure (adjusted odds ratio [AOR] = 2.76; 95% CI: 2.12-3.62; p < 0.001). Having friends who smoked tobacco (AOR = 1.86; 95% CI: 1.52-2.30; p < 0.001) and seeing teachers smoking at school (AOR = 1.88; 95% CI: 1.40-2.56; p < 0.001) were also significant predictors. Media exposure was important: seeing people use tobacco on television (AOR = 1.88; 95% CI: 1.63-2.17; p < 0.001) and exposure to tobacco advertisements (AOR = 1.38; 95% CI: 1.14-1.67; p = 0.001) increased odds of SHS exposure. Adolescents who had smoked cigarettes had higher odds of exposure (AOR = 2.80; 95% CI: 1.70-4.67; p < 0.001), as did those intending to use tobacco in the next five years (AOR = 1.64; 95% CI: 1.21-2.24; p = 0.002). Age, sex, and grade level were not independently associated with SHS exposure. ConclusionsSHS exposure among adolescents in Zambia is widespread and is largely driven by household smoking, peer influence, school environments, and media exposure. Strengthening enforcement of smoke-free policies, promoting smoke-free homes, and addressing social and media influences are critical to reducing adolescent SHS exposure.

Background Making Every Contact Count (MECC) is a person-centred initiative that enables service providers across settings to support behaviour change through conversations about health and wellbeing. MECC has been widely implemented across the UK and internationally, although training approaches vary considerably and do not consistently translate into MECC delivery. Evidence suggests that Healthy Conversation Skills (HCS) training, which supports service users to identify their own solutions, may be an acceptable and effective means of delivering MECC across settings. This realist evaluation aims to understand which elements of HCS training work, for whom, under what circumstances, in what respects, to what extent, and why, to inform the adaptation of HCS across settings to ensure that all recipients are equipped to deliver MECC. MethodsThis mixed-methods realist evaluation will comprise pre- and post-training surveys (at baseline, immediately post-training, and approximately eight weeks post-training) and realist interviews. Two participant groups were selected for comparison: service providers working or volunteering in the voluntary, community, and social enterprise (VCSE) sector, and undergraduate pharmacy students. Initial programme theories were developed through abductive reasoning, literature scoping, and stakeholder engagement. Survey data will assess outcomes of HCS training, while realist interviews will explore how these outcomes are generated by underlying mechanisms within specific contexts. DiscussionA refined programme theory will be produced, explaining how and why HCS training leads to MECC delivery across different settings. Findings will inform how HCS training can be adapted for distinct audiences, identify the core components of MECC training that must be preserved, and guide future evaluations by examining whether HCS training translates into sustained MECC delivery. The findings of this study will inform resource allocation for preventative health interventions outside of healthcare settings and thus have the potential to shape public health policy, empower non-specialist providers, and strengthen strategies for disease prevention.

Introduction: Economic opportunity is a core pillar of the American Dream but is not distributed equally across communities. Substantial evidence has identified economic opportunity as an independent social determinant of health, but relatively little is known about opportunity's relationship with other socioeconomic characteristics such as income. Here we address this gap in the literature to examine how area-level economic opportunity modifies the income-health gradient. Methods: We used multivariable ordinary least squares models to estimate the association between self-reported health and economic opportunity across household income levels for working age adults (ages 25-64). Our measures of income and health come from the 2010-2019 Current Population Survey Annual Social and Economic Supplements. Our measure of economic opportunity was drawn from Opportunity Insights and represents the county-averaged national income percentile rank attained in adulthood for individuals born to parents at the 25th percentile of the income distribution. We adjusted for a wide range of individual- and county-level demographic and socioeconomic characteristics. Results: We find that county-level economic opportunity modified the gradient in self-reported health and household income among working-age adults. Effects were particularly pronounced in the lowest income deciles -- an interdecile increase in economic opportunity was associated with closing almost 33% of the gap in health between the lowest and highest income deciles. The results were robust to sensitivity analyses. Conclusion: We show that local area economic opportunity flattens the relationship between household income and health, with lower-income individuals benefitting the most from living in high opportunity areas.

BackgroundHealth behaviors established during young adulthood significantly shape the long-term risk of non-communicable diseases and mental health disorders. Although behaviors such as diet, physical activity, sleep, and substance use are often targeted individually, growing evidence suggests these behaviors function as an interconnected system. However, the organization of lifestyle behaviors at the system level, and which behaviors exert the greatest structural influence, remains poorly understood, particularly in non-Western populations. PurposeThis study aimed to model the interdependence of lifestyle behaviors among university students in China and identify key behaviors with the greatest structural influence within a lifestyle network. MethodsWe analyzed cross-sectional survey data from 5,652 university students in China, assessing seven lifestyle behaviors (diet, physical activity, sleep quality, social engagement, green and blue space exposure, alcohol use, and tobacco use) as well as symptoms of anxiety and depression. A pairwise Markov random field model was used to construct a lifestyle network and identify behavioral clusters and influential behaviors. Network stability and subgroup invariance were evaluated using bootstrap and permutation procedures. ResultsThree stable behavioral clusters were identified: (1) a positive lifestyle cluster (diet, physical activity, social engagement, and environmental exposure), (2) a distress-sleep cluster (sleep problems, anxiety, and depression), and (3) a substance-use cluster (alcohol and tobacco use). Dietary behavior consistently emerged as the most central behavior in the network, with extensive connections to both behavioral and psychological domains. Physical activity played a more peripheral role. Strong coupling between sleep problems and emotional distress was observed, consistent with systems theories of mental health. ConclusionsThese findings support a systems-based framework for understanding health behaviors in young adulthood. Identifying structurally influential behaviors, particularly dietary behavior, can provide leverage points for targeted health interventions. The study highlights implications for public health policy and intervention design, particularly in non-Western university populations.

BackgroundArticle 5.3 of the WHO Framework Convention on Tobacco Control requires Parties to protect policies from tobacco industry interference, yet implementation remains weak internationally. Aotearoa New Zealands (Aotearoa NZ) is seen as a leader in tobacco control, yet little is known about its implementation of Article 5.3 protections. This study examines these protections as well as existing transparency measures in light of the 2024 repeal of world-leading tobacco control policies. MethodsInterviews with current and former: public health experts, politicians, officials and political journalists, and analysis of key texts. ResultsAotearoa NZs Article 5.3 implementation and scope is constrained, leaving invisible and exploitable paths of influence. Public health experts argued protections have been neglected from the start. Politicians were unaware of Article 5.3 obligations, and reported limited guidance on industry interactions. These gaps are compounded by non-existent lobbying laws and ill-equipped transparency measures. ConclusionDespite the countrys reputation for strong tobacco controls, structural policy and implementation failures leave Aotearoa NZs health policies vulnerable to industry interference. Aotearoa NZ and other Parties should consider institutionally embedding comprehensive Article 5.3 protections to safeguard policy decisions from tobacco industry influence. WHAT THIS PAPER ADDSO_ST_ABSWhat is already known on this topicC_ST_ABSTobacco industry interference remains the biggest barrier to tobacco control policies, with evidence consistently identifying gaps in Parties implementation of Framework Convention on Tobacco Control Article 5.3 protections. Parties often rely on pre-existing measures such as lobbying laws. What this study addsThis is the first study examing Aotearoa NZs implementation of Article 5.3. It shows that despite its reputation as a tobacco control leader, implementation is severely limited and pre-existing measures are inadequate, enabling a system in which industry interference can go on unseen. How this study might affect research, practice or policyBy identifying how structural policy gaps enable industry interference, this study highlights the need for comprehensive institutional embedding of Article 5.3 protections across government, and consideration of its codification into law.

Background: The COVID-19 pandemic disrupted childhood immunization programmes in many countries worldwide. However, evidence on its impact in low and middle-income countries remains limited. This study examined the impact of the COVID-19 pandemic on childhood immunization coverage across 514 districts in Indonesia and identified district-level associated factors. Methods: We conducted a nationwide longitudinal analysis of the Expanded Programme on Immunization to compare immunization coverage before and after the pandemic. The outcome variable was the annual childhood immunization coverage (proportion of children aged 0-12 months who have received all recommended doses of childhood immunization as per the national immunization schedule). The explanatory variables include COVID-19 burden and vaccination rates, health system and human development indicators. Mixed-effect logistic regression was done to assess association between the explanatory and outcome variables. Results: At the national level, the coverage was 83.2% in pre-pandemic, 75.0% in the first year of pandemic, and 88.6%, in the second. In the first year, 69.3% of districts experienced significant decline, with a lower national coverage ratio of 0.92 (95% confidence interval 0.89-0.94). In the second year, 36.2% districts were still affected. The multivariable analysis showed that a significant decline in coverage during the first pandemic year was associated with high COVID-19 incidence (adjusted odds ratio 2.19, 95%CI 1.01-4.73 for the highest vs. lowest group), low midwife adequacy (5.84, 2.40-14.16 for the lowest vs. the highest group, 2.61, 1.26-5.40 for low-middle vs. the highest group), and a high proportion of health facility-based births (2.98, 1.49-5.98 for middle-high vs. the lowest group). Conclusions: The COVID-19 pandemic negatively and unevenly impacted childhood immunization in Indonesia, with greatest impacts in districts facing a higher COVID-19 burden and weaker health system capacity. These findings underscore the need for targeted efforts to strengthen the local health system for future health crises. Keywords: COVID-19, pandemic, immunization, vaccine preventable diseases

BackgroundAlthough health mediation is widely studied in the U.S. through community health worker programs, evidence on their effectiveness in promoting cancer screening in Europe is limited. Since 2022, the "13 en Sante" program has implemented a multicomponent health mediation intervention -- combining educational activities, outreach strategies, and navigation support -- in socioeconomically disadvantaged neighbourhoods of Marseille, France. This study evaluates the effectiveness of this program in promoting breast, colorectal, and cervical cancer screening. MethodsA controlled before-after design based on two cross-sectional surveys was conducted in 2022 and 2024 in intervention or control neighbourhoods. Individuals aged 18-74 were randomly selected and interviewed via door-to-door questionnaires. Weighting was applied to account for stratified sampling and to align age and sex distributions with census data. Weighted logistic regression models were fitted for each cancer screening to estimate the interventions effects on uptake and awareness at both individual and population levels. FindingsOverall, 4,523 individuals were included across the two cross-sectional surveys. The program successfully reached individuals facing cumulative socioeconomic barriers to healthcare access. No significant population-level effect was observed. At the individual level, declared exposure to health mediation was associated with significantly higher uptakes of breast and colorectal cancer screenings (breast: 54% vs. 74%, OR=2.3 [1.1-4.5]; colorectal: 30% vs. 50%, OR=2.8 [1.3-5.8]). In addition, colorectal cancer screening awareness was significantly higher among exposed participants (83% vs. 93%, OR=8.1 [2.1-31]). InterpretationThis study provides the first evidence that a multicomponent health mediation intervention could effectively promote breast and colorectal cancer screening in disadvantaged French neighbourhoods. The study highlights screening-specific mechanisms of action that should be considered to further optimize intervention effectiveness. FundingThe survey was funded by the Regional Health Agency of Provence-Alpes-Cote dAzur and Sante publique France.

Background: Population-based cohort studies are increasingly expected to demonstrate benefits for public health and wider society. However, there is limited systematic evidence on what such impact entails or how it is generated and sustained. To address this gap, we examined researcher perspectives on the impact of cohort studies. Methods: We conducted, to our knowledge, the first quantitative study of researcher views on cohort impact, recruiting active cohort researchers through national and international networks between August and December 2025. The anonymous cross-sectional survey captured researcher characteristics, perceived contributions, impact processes, challenges, and open-ended reflections. Results: A total of 163 cohort researchers participated, primarily from Australia (42%) and the UK (23%). Participants perceived their work as informing a wide range of societal issues and reported investing an average of 24% of their work time in impact-related activities. While most respondents (73%) believed their research leads to tangible policy or practice change, two thirds indicated that impact is rarely or never demonstrable shortly after study completion (67%) and seldom attributable to a single study (67%). Key concerns included pressure to overstate contributions (80%), perceived disadvantages for cohort studies in impact assessments (78%), and inadequate skills or resources to achieve impact (65%). Conclusions: Cohort researchers perceive their work as generating broad societal contributions and invest substantial effort in supporting impact. However, they face systemic challenges in both achieving and demonstrating impact. These findings highlight the need for impact frameworks that better capture complexity, long-term influence, and cumulative contributions, while mitigating unintended consequences.

BackgroundCarrier screening for inherited genetic disorders can reduce the burden of conditions that lead to childhood morbidity and mortality, including thalassaemia, cystic fibrosis, and spinal muscular atrophy. To be successful, national carrier screening programs should aim to maximise uptake, which may depend on population preferences for screening characteristics. In this study, we aimed to determine how expanded carrier screening in Singapore should be designed based on operational factors including suggested copayments, wait times, and disorders included in screening panels. MethodsWe elicited stated preferences for the design of a hypothetical national carrier screening program with seven attributes from 500 Singaporeans of reproductive age (18 to 54). A discrete choice experiment was applied using 30 choice tasks with 3 alternatives per task, divided between 3 blocks. The mixed multinomial logit model was used to estimate willingness-to-pay for each attribute level. Predicted uptake for three plausible screening programs was assessed, with copayment amounts from $0 to $1,200 in increments of $30. Impact on the annual national budget was calculated as a function of 25,000 expected eligible couples per year. All costs were reported in 2026 SGD. ResultsRespondents showed the strongest preferences for cost, followed by the number of diseases included in the panel, then wait times, with limited impact of remaining attributes. With no copayments, predicted uptake ranged from 85% [95% CI: 83% to 87%] to 90% [88% to 92%] for the basic and utility-maximising screening programs, respectively. This declined to 61% [56% to 66%] and 69% [65% to 73%] and, respectively, at a copayment of $1,200 per test. The model predicted higher uptake if a selection of screening alternatives were available, compared to a single program. The budget impact was highly dependent on population eligibility, copayments, and couples decision-making processes, but was unlikely to exceed $22.5m [$19.0m to $26.6m] per year unless expanded beyond married couples. ConclusionsThere was high predicted demand for carrier screening even as copayments increased. Successful strategies to improve uptake may include reducing copays and wait times, increasing the number of screening options available to prospective parents, and increasing program eligibility beyond pre-conception married couples.

IntroductionTobacco smoking is especially high among males in the Kingdom of Saudi Arabia (KSA). In 2019, 27.5% of males ages 15+ reported smoking. Despite a minimum age requirement of 18 years, data indicate that 6.8% of youth ages 13-15 currently smoke tobacco products. To reduce youth smoking, countries have raised the minimum purchase age to 21, also referred to as Tobacco 21. Except for Kuwait, no other Middle Eastern country has done so. We develop a tobacco smoking simulation model to project the potential impact of a national Tobacco 21 policy in Saudi Arabia. MethodsWe used data from three nationally representative health surveys in Saudi Arabia to develop the KSA Tobacco Control Policy (TCP) model, estimating smoking initiation and cessation rates for males, as smoking rates are low among females. A national Tobacco 21 policy was operationalized as a 34% (15%-53%) reduction to smoking initiation for ages 18-20. Economic impact was evaluated using the 2024 KSA value of a statistical life which ranges from $1.65 million to $5.15 million USD. ResultsUnder a status quo scenario, tobacco smoking prevalence in males would decrease to 10.2% by 2100. Implementation of Tobacco 21 in 2026 would decrease smoking prevalence to 9.4% (8.9%, 9.8%) by 2100. While modest, these reductions would eventually translate into nearly 5000 (2200, 7800) premature deaths averted with up to 155000 (69000, 241000) life years gained from 2026-2100, respectively. The total expected economic benefit ranges from $1.67 to $5.19 billion USD, equivalent to 6.25 to 19.45 billion SAR. DiscussionTimely implementation would support the KSA in its goals to reduce non-communicable disease and death; however, even under best-case conditions, a Tobacco 21 alone would not achieve the Vision 2030 smoking prevalence target of 9%. Additional policies that substantially increase smoking cessation are needed. What is already known on this topicThe leading causes of death in Saudi Arabia are all linked to tobacco smoking. Tobacco 21 policies have been pursued by numerous governments to reduce youth smoking, but such policies are lacking in Middle Eastern nations. What this study addsA nationwide Tobacco 21 policy in Saudi Arabia would reduce smoking initiation, smoking prevalence, and smoking-related mortality. Overall smoking prevalence among males ages 15+ would decline, and nearly 5000 premature deaths would be averted with up to 155,000 life years gained from 2026-2100, valued at 6.25 to 19.45 billion SAR. How this study might affect research, practice or policyThis study quantified for the first time the potential long-term benefits of a Tobacco 21 policy in Saudi Arabia for the male population. A Tobacco 21 policy would benefit future generations of young people by reducing their risk for heart disease, stroke, and cancer, currently the leading causes of death in the nation. However, additional efforts are needed in addition to Tobacco 21 policies to achieve tobacco smoking reduction goals.

BackgroundAvian Influenza (AI) is a potential pandemic threat, specifically when human-to-human transmission occurs. For outbreak management testing is essential. Current knowledge on testing behaviour is mostly derived from other infectious diseases such as COVID-19. It is necessary to identify determinants of testing behaviour for AI in an early phase. Therefore, this interview study aims to identify a wide range of behavioural determinants of testing during a hypothetical human-to-human transmissible AI outbreak. MethodsSemi-structured in-depth interviews, based on the Theoretical Domains Framework, were carried out between May 2024 and February 2025. Participants were included through purposive and convenience sampling. During the interviews an animation was shown illustrating a hypothetical AI outbreak. Verbatim transcripts were thematically analysed. ResultsWe included seventeen participants (median age 44, range 20-81; 71% women) with diverse backgrounds in terms of age, gender, educational level and country of birth. We found that having the freedom to decide to test would make testing more acceptable, whereas a decreased sense of autonomy would discourage testing. Most themes included individual rather than population-level benefits as drivers of testing behaviour. These included protecting loved ones, ones own health and gaining psychological reassurance. External conditions like being unable to go to work or an event would generally encourage testing behaviour. Lower trust in governmental authorities could hamper testing behaviour. Previous experiences from the COVID-19 pandemic shaped participants answers about AI testing behaviour. ConclusionKey considerations include balancing peoples need for autonomy with the external measures imposed by employers or the government, rebuilding trust in institutions and acknowledging how prior experiences with testing may shape testing behaviour in future AI outbreaks. Further research is needed to determine how these findings can be translated into effective communication and how trust in authorities can be build.

ObjectiveTo examine adherence to COVID-19 public health measures among culturally and linguistically diverse (CALD) and low socio-economic status (SES) populations in Victoria using a unique longitudinal cohort. Study DesignThe Optimise Study was a mixed-methods longitudinal cohort and social networks study (September 2020 - December 2023) assessing the impact of COVID-19 and related public health measures in Victoria, Australia. We used a serial cross-sectional design to analyse adherence to public health recommendations, restrictions, and requirements. Settings, participantsThe study examines two 28-day periods during the COVID-19 pandemic in Victoria: April 23- May 20, 2021 ( non-lockdown), and September 13-October 10, 2021 ( lockdown). We explored adherence to three categories of COVID-19 public health measures -- Recommendations (non-enforced, longer-term), Restrictions (mandated during lockdown periods), and Requirements (mandated, longer-term) -- among participants who completed questionnaires during these periods. Participants were grouped as: 1) non-CALD high SES (did not meet CALD or low-SES criteria), 2) CALD, or 3) non-CALD low-SES. Main outcome measuresPrimary outcomes were adherence to Recommendations, Restrictions, and Requirements during the two study periods. ResultsOf 782 participants recruited, 579 (75%) completed a survey or diary during at least one study period and were included in the analysis. Of these, 275 (47%) were in the non-CALD high-SES group, 114 (20%) in the CALD group, and 190 (33%) in the non-CALD low-SES group. Across all groups, risk-reduction behaviours increased during the lockdown. CALD participants showed higher adherence to some Recommendations and Restrictions compared to the other groups. Overall, 28% left home while awaiting a COVID-19 test result, commonly due to work. ConclusionsHigh adherence among CALD and non-CALD low-SES groups suggest structural barriers, rather than behavioural non-compliance, contributed to higher COVID-19 impacts, highlighting the need for tailored support. During future public health emergencies, better supports are needed for individuals working outside of home to remain in isolation while awaiting a test result. Summary box O_TEXTBOXWhat is already known about this subject? In Australia, priority populations such as culturally and linguistically diverse (CALD) and low socio-economic status (SES) groups experienced higher COVID-19 infection, mortality and a disproportionate impact from public health restrictions. What does this study add? CALD populations had an overall higher level of adherence to public health behavioural measures during both lockdown and non-lockdown periods compared to non-CALD populations. Over 25% of participants did not comply with stay-at-home requirements while awaiting a COVID-19 test result, largely due to work responsibilities. How might this impact on clinical practice? Pandemic preparedness efforts should focus on understanding the reasons for non-adherence with isolation requirements and considering tailored support during future pandemics to address the diverse C_TEXTBOX

BackgroundPopulation ageing is accelerating, with the fastest growth occurring in low-and middle-income countries. Adequate nutrition is central to healthy ageing, yet little is known about the factors shaping dietary behaviours among older adults in rural African settings, where structural constraints may strongly influence dietary choice. This study explored the facilitators and barriers influencing the dietary choices among older adults aged 60 years and above living in rural communities of Edo Central, Nigeria. MethodsThis exploratory qualitative study was guided by the Socio-Ecological Model (SEM). Semi-structured, in-depth interviews were conducted with 22 older adults. Interview transcripts were analysed thematically using NVivo 14, with findings mapped across individual, environmental, community, and policy/system levels of the SEM. ResultsFourteen subthemes were identified and organised into four overacting SEM domains. Individual drivers identified included a deep knowledge of nutrient-rich diets and a preference for natural, minimally processed foods, as well as community drivers, including cultural and traditional norms and market access, which were the facilitators. Environmental drivers, including physical and economic access, and policy/system drivers, including government policies/subsidies, food prices and inflation, were identified as the main barriers. ConclusionDietary choices among older adults in rural Nigeria are shaped predominantly by structural and food-system constraints rather than by individual knowledge alone. Policies aimed at improving nutrition in ageing populations should prioritise strengthening rural food systems, supporting smallholder agriculture, stabilising food prices, and developing targeted social protection programmes for older adults.

Aims: Youth loneliness is a prevalent global health concern with lifelong health ramifications. Schools, as children's primary peer environments, are promising settings for loneliness interventions. However, school-based interventions are highly heterogeneous and no review to date has evaluated their effect on loneliness specifically. Methods: A systematic review was conducted to identify studies of school-based interventions measuring loneliness as an outcome in children and young people aged up to 18. Meta-analyses were conducted using a random-effects model to pool effect sizes and examine the significance of intervention characteristics and study design. Reported implementation factors were extracted and narratively synthesised. Results: Thirty-eight studies were included in meta-analysis, of which 19 were randomized controlled trials, ten were non-randomized controlled, and nine were single group studies. A small-to-moderate effect estimate was found, Hedges' g = -0.42 [95% CI: -0.71, -0.13], p = .006, and sub-group analyses indicated that differences in study design and quality did not result in significantly different effect estimates. Psychological interventions, followed by social and emotional skills training, produced significantly higher effects estimates compared with other intervention types. Conclusions: Findings indicate that school-based interventions are effective in reducing youth loneliness. However, study heterogeneity, reporting inconsistencies, and a wide prediction interval indicates this finding should be interpreted with caution. Future research may benefit from improved measurement and reporting of implementation factors, particularly dosage and fidelity.

Introduction. Climate change is increasing the frequency and intensity of heatwaves, creating critical challenges for social care settings where both staff and residents face heightened heat related vulnerability. This study examined the impact of heatwaves on UK care homes using a national survey of staff experiences, challenges, and adaptation strategies. Methods. Care home staff (N = 225) in managerial (N = 88) and caregiving roles (N = 137) completed an online survey investigating staff perceptions of heatwaves impact on thermal comfort, health and vulnerability of themselves and residents, alongside current heat resilience strategies and the barriers to their implementation. Results. Two thirds (66%) of the surveyed staff complained of being too hot three or more times per day resulting in a perceived impact on their ability to perform tasks (90%) and on residents' comfort and health (92%). Staff demonstrated strong awareness of older adults' heightened heat vulnerability (95%) and signs of heat illness (87%). Thematic analysis identified five key barriers to providing effective cooling: funding limitations, inadequate equipment, building constraints, staffing pressures, and individual resident needs; and four priority improvement areas: increased access to cooling equipment, improved temperature control, strengthened strategy and policy, and support for staff needs. Conclusions. Heatwaves place considerable strain on care homes, challenging staff capacity to maintain comfortable thermal conditions, despite good knowledge of heat risks. Financial, infrastructural, and staffing constraints limit effective heat resilience practices. Evaluating and implementing affordable, accessible, and context appropriate cooling strategies will be essential to protect both residents and staff as extreme heat events become more frequent.

IntroductionAdolescence is a vulnerable period for tobacco initiation, yet evidence on exposure to anti-tobacco messaging in Zambia is limited. Understanding who is reached by media and school-based campaigns is fundamental to designing effective strategies for preventing tobacco initiation and reducing use, in line with tobacco control goals. MethodsWe analyzed data from 6,499 in-school adolescents (11-17 years) in the 2021 Zambia Global Youth Tobacco Survey. Exposure was defined as having seen or heard anti-tobacco messages via television, radio, newspapers, or magazines. Weighted prevalence estimates were calculated, and multivariable logistic regression examined associations with sociodemographic, behavioral, and household factors. ResultsOverall, 61.6% of adolescents reported exposure to anti-tobacco messages, predominantly through television and radio rather than print media. Exposure was greater among adolescents who had ever tried smoking (OR = 1.37, 95% CI: 1.15-1.63), had friends who smoke (OR = 1.50, 95% CI: 1.27-1.76), lived with a parent/guardian who smokes (OR = 1.58, 95% CI: 1.31-1.93), or received school-based tobacco education (OR = 1.81, 95% CI: 1.60-2.04). Male adolescents had lower odds of exposure (OR = 0.83, 95% CI: 0.73-0.94). Age, grade, current smoking, and observing teachers smoking were not significant predictors. ConclusionAnti-tobacco messages reached almost two-thirds of Zambian adolescents through schools and mass media, but exposure is strongly influenced by social and household environments. Gender- and context-sensitive strategies targeting male adolescents and peer/family networks could strengthen preventive impact, supporting Zambias tobacco control goals and compliance with the WHO Framework Convention on Tobacco Control.

Background While a mobile lung cancer screening (mLCS) program can mitigate barriers to access, this study conducted a survey study to assess barriers and facilitators to mLCS which could inform the implementation of new mLCS programs or inform modifications to existing programs. Methods Patient eligibility included current age of 50 to 80 and had undergone any cancer screening at Moffitt Cancer Center (MCC) between January 1, 2023 and December 1, 2024. A web-based survey was administered from May 2025 to June 2025 which collected data on health behaviors, barriers, facilitators, screening preferences, and demographics. Descriptive statistics were used to quantify survey responses. Results Among participants who completed the survey, 73.4% reported no concerns about getting screened in a mobile screening unit, 67.9% reported concerned about the cost or if insurance covered mobile lung cancer screening, and 82.4% reported they would be screened if a voucher or insurance would pay for it. For preferences, 54.1% reported no preference for the time of year for a mobile screening event, 59.6% reported they will be willing to wait up to 30 minutes to get screened, and 44% would travel more than 20 minutes to get screened. There were no statistically significant differences in barriers and facilitators when the analyses were stratified by LCS eligibility. Conclusions We found acceptability of mobile lung cancer screening and preferences that are actionable including daytime weekday events, indoor waiting, short waits, proximity to home, clear cost coverage, and streamlined clinician recommendation.

BackgroundNon-communicable diseases (NCDs) are the leading cause of mortality in Iran, driven largely by modifiable lifestyle risk factors. Healthcare providers play a pivotal role in delivering preventive lifestyle recommendations, yet the extent and effectiveness of these efforts remain unclear. This study aimed to assess the distribution of lifestyle counseling across sociodemographic and clinical subgroups and its association with health behavior status in Iran using data from the 2021 WHO STEPS survey. MethodsWe conducted a cross-sectional analysis of 27,704 included adults participating in the nationally representative 2021 STEPS survey in Iran. Data on delivery of ten specific lifestyle recommendations within the past 12 months, covering diet, physical activity, weight management, and tobacco non-initiation/cessation, were collected. Associations between recommendation delivery and health behaviors were analyzed using logistic regression models. ResultsOnly 33.4% (95% Confidence Interval (CI): 32.8-34.0) of participants received all ten lifestyle recommendations, while 10.7% (10.2-11.1) received no recommendations. Recommendations were more frequently delivered to females, rural residents, and individuals with multiple comorbidities, indicating a risk-based response by healthcare providers. Notably, tobacco non-initiation/cessation advice was not more commonly offered to patients with multiple chronic conditions. Delivery of lifestyle counseling was associated with positive behavior status: individuals who received weight loss/ maintaining normal weight and physical activity advice were more likely to engage in sufficient physical activity (adjusted odds ratio 1.21(1.13-1.29)), and among current smokers, receiving tobacco cessation recommendation was associated with higher tobacco quitting attempt (aOR: 1.83(1.49-2.24)). A dose-response relationship was observed between the number of nutritional recommendations received and better diet quality (aOR for 6 vs. [&le;]2 recommendations: 1.32 (1.24-1.41)). Geographical disparities were evident, with eastern provinces receiving the least comprehensive counseling. ConclusionDelivery of lifestyle recommendations by healthcare providers in Iran shows variation by sociodemographic and clinical factors and is positively associated with behavior status. These findings highlight the effectiveness of provider-delivered lifestyle counseling and the need for more consistent, equitable, and targeted delivery, particularly for high-risk individuals and underserved regions, to strengthen national NCD prevention efforts.

IntroductionTobacco smoking among school-going adolescents poses a major global public health challenge, contributing significantly to future disease burden. Understanding the prevalence and determinants of cigarette smoking in this group is critical for effective interventions. MethodsThis study analyzed data from the Global Youth Tobacco Surveys collected between 2001 and 2021, covering 439, 322 school-going adolescents aged 11 to 19 across 45 African countries. Descriptive statistics estimated smoking prevalence by age, sex, school grade, country, and survey year. Predictive modelling identified independent correlates of current cigarette smoking under complex two-stage cluster sampling. ResultsOverall, 23.8% (95% CI: 20.20-27.57) of adolescents reported cigarette smoking. Prevalence increased with age, rising from 9.5% at 12 years to 22.4% at 18 years. Boys smoked more than girls (14.0% vs. 7.3%). Smoking varied widely across countries, with the highest rates in Burkina Faso 48.9%, and South Africa (18.9%), and the lowest in Angola (1.5%, 95% CI: 0.86-2.13), Eritrea (2.1%). Use of other tobacco products strongly increased the prevalence of cigarette smoking for smokeless chew (35%, 95% CI: 29.6-40.3). Being taught in school about the effects of smoking showed protective effects, while ownership of tobacco-branded items increased smoking likelihood (17.8%, 95% CI: 17.52-18.13). Smoking prevalence declined over time, with lowest rates in recent years (3.5% in 2020). ConclusionCigarette smoking among school-going adolescents in Africa is a growing public health concern influenced by factors such as age, gender, country, behavior, and media exposure. Urgent, youth-focused tobacco control strategies especially targeting males and older teens are needed. Strengthening school-based education and implementing tobacco control policies among students can help reduce smoking rates. These findings offer vital evidence to inform global tobacco control efforts within the African context