BMC Public Health

Background: Alcohol affordability is a determinant of consumption and alcohol-related harm. In many low- and middle-income countries (LMICs), informal production, variable alcohol strength, and non-standard packaging complicate conventional affordability measures, limiting evidence on the economic accessibility of alcohol and the cost of intoxication. Objective: To assess the affordability of intoxication in Uganda by estimating the cost of obtaining ethanol to reach intoxication across alcohol products, packaging types, and retail contexts. Methods: Data were collected on 824 alcoholic beverages from urban, rural, and urban-slum retail markets. Ethanol-standardized pricing (price per gram of alcohol) was calculated, and the cost of consuming 60 g of ethanol was estimated. Multivariate regression identified determinants of ethanol affordability. Results: Affordability varied by product type and packaging. Opaque beers and illicit spirits provided the cheapest pathways to intoxication, with median costs of UGX 1,200-1,500 per 60 g of ethanol. Plastic packaging was associated with lower ethanol costs than glass packaging. Ethanol prices differed across formal and informal markets (p < 0.01), while rural areas and urban informal settlements had 20-25% lower costs than urban areas. Regulatory status alone did not predict affordability. Conclusions: In Ugandas diverse alcohol market, affordability is driven by access to ethanol rather than beverage price alone. Low-cost, high-strength alcohol sold through informal channels enables intoxication at minimal expense, among disadvantaged populations. Implications: Alcohol policies should target ethanol content through minimum unit pricing, alcohol-content-based taxation, and regulation of informal markets and packaging practices to reduce harmful consumption and inequities.

Background YouTube highlights packages are a major and growing route to football consumption, particularly among children and young people, but brand exposure within them has not been quantified. We measured unhealthy commodity brand exposure in English Premier League (EPL) and FIFA World Cup (WC) highlights. Methods We coded brand appearances lasting two or more seconds in 10 Sky Sports EPL highlights (final 10 games of the 2025/26 season) and 19 official FIFA 2026 WC highlights, recording commodity category, placement, and match moment, alongside pre-roll YouTube adverts. Data were collected between 4 June and 27 July 2026. Five highlights were double-coded (Cohen's kappa 0.85). Results Overall brand density was similar across competitions (13.1 vs 13.9 references per minute), but composition differed markedly. Unhealthy commodity branding occupied 38.0% of EPL screen time versus 18.7% at the WC, a difference driven almost entirely by gambling (32.6% vs 1.5%). Gambling appeared in every EPL package, mainly on pitchside boards and LED screens (50.4%), with front-of-shirt accounting for 27.1%. WC exposure was more evenly spread across HFSS food (13%), alcohol (4%) and trading/crypto/prediction markets (3.7%), and appeared almost exclusively pitchside. Gambling brands accounted for ten of twelve pre-roll EPL adverts (123 of 153 seconds); no gambling adverts preceded WC highlights. Conclusions Gambling dominates unhealthy commodity exposure in EPL highlights, both in-video and in pre-roll advertising. Because most appearances occur away from the front of shirt, the voluntary front-of-shirt sponsorship withdrawal will leave the majority of this exposure intact. The WC comparison shows that tighter central control of the advertising environment produces lower and more diffuse exposure, and that governments and governing bodies with such control could restrict unhealthy categories altogether.

Introduction: The preconception period (i.e. the weeks and months before pregnancy) is a critical window during which parental health behaviours can influence pregnancy outcomes and the childs long-term health. Modifiable factors such as nutrition, physical activity, substance use, and environmental exposures play a key role, yet womens ability to adopt and sustain healthy behaviours is shaped by complex psychological, social and environmental influences. This study applies the Theory of Planned Behaviour to identify the beliefs underpinning womens preconception behaviours, with the aim of informing support for effective and sustained health behaviour change. Methods: An Australian national retrospective cross-sectional survey of pregnant women (18-49 years), recruited through social media platforms. The 92-item survey captured respondent socio-demographics, pregnancy status and health conditions, health behaviours, and beliefs regarding preconception health behaviours. Respondents level of pregnancy planning was categorised using the London Measure of Unplanned Pregnancy (LMUP). Items regarding preconception beliefs were structured in accordance with the Theory of Planned Behaviour, with a focus on regular exercise, healthy diet, and alcohol avoidance. These beliefs variables were analysed using structured equation modelling to identify paths between latent variables and the items used to estimate each concept. Results: The study was completed by 430 pregnant women of whom 72.7% had a planned pregnancy. Most had a partner, were university educated and in good health. Structural equation modelling showed intention strongly predicted exercise ({beta}=0.65), healthy diet ({beta}=0.54) and alcohol avoidance ({beta}=0.64). Perceived control and partner norms influenced intentions, whereas health professional norms had limited effect. Positive beliefs were associated with folate supplement use and smoking cessation. Conclusion: These findings highlight intention as a key driver of preconception health behaviours, with perceived control and partner influences playing a more significant role than individual beliefs or health professional input. Effective interventions should therefore address structural barriers and actively involve partners, while respecting womens autonomy. Overall, couples-focused, multi-level strategies are likely essential to support meaningful and sustained preconception health behaviour change.

This study aimed to examine factors associated with behavioural difficulties among school-aged children (aged 7 -11) using self-reported survey data linked with education data from a national cohort study of over 50,000 children (the HAPPEN national cohort) in Wales, UK between 2014 and 2024. Data include self-reported health and wellbeing linked to additional learning needs (ALN) status collected from education data in Wales. Measures included self-reported time spent on screens, frequency of sugary snack, fizzy drink and takeaway food consumption, physical activity levels, sleep duration and behavioural difficulties (as measured by the Me and My Feelings Survey). Associations were analysed using descriptive trends, K-means cluster analysis and multivariate regression modelling. Findings showed a rise in behavioural difficulties during and post Covid, which are now improving in Wales. Cluster analysis identified that children with poor sleep and high takeaway and fizzy drinks dietary habits had the highest levels of behavioural difficulties, a trend that remained significant after adjusting for all potential confounders. Physical activity associated with reduced behavioural difficulty, with 5-6 days of activity associated with the lowest difficulty scores. These findings suggest that behavioural difficulty is driven by health behaviours especially sleep and diet rather than single factors. The results highlight the need for integrated public health approaches that address dietary quality and sleep hygiene rather than focusing on single factors in isolation. Promoting more balanced daily activity patterns, promoting good sleep routines, improving food environments and building movement into the school day may have important benefits for childrens behaviour.

Despite having received increasing attention over the past decade, little is known about the factors that can increase or decrease symptoms of problematic gaming (PG) in individuals with different video gaming (VG) habits (e.g., occasional use gamers vs heavy use gamers). Here, we apply a specification curve analysis to assess the impact of changes in two key risk factors, gaming consumption and impulsivity, as well as one protective factor, family environment, on changes in PG symptoms over 2 years in a large sample of Singaporean adolescents between 2007 and 2009. By considering individual differences in baseline video game habits, we show that changes in VG consumption influenced changes in PG in adolescents who reported not usually playing games at study inception (i.e., occasional use gamers), whereas changes in impulsivity influenced PG symptoms in those who reported being the most heavy use gamers at study inception. These findings highlight the importance of designing preventive measures that differ as a function of current video game habits. Possible measures may involve introducing gaming progressively (e.g., through setting age-appropriate limits or structured scaffolding with parents) to improve symptoms of tolerance and preoccupation in occasional use gamers while promoting self-control early in development before gaming can become a problematic habit.

Background: Research consistently shows that colorectal cancer (CRC) screening uptake is socially patterned; however, sociodemographic determinants are usually analysed separately, overlooking how multiple social conditions jointly shape inequalities. This also applies to policy research, where heterogeneity in screening programme effects remains underexplored. Methods: Using data from the European Health Interview Survey (2014 and 2019; n=201,214; 24 countries), we applied Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to analyse CRC screening uptake across 72 subgroups defined by sex, education, living arrangement and employment. To assess heterogeneity in screening programme effects, we combined MAIHDA with difference-in-differences (MAIHDA-DiD). Results: MAIHDA revealed inequalities in uptake: lower- and middle-educated men, whether employed or unemployed, had the lowest uptake, whereas men and women not living alone, retired or living with disability, had the highest uptake. Lower-educated homemaker women were the only female group with below-average uptake. MAIHDA-DiD showed that programmes increased overall uptake but did not produce larger gains among groups with lower pre-intervention uptake, and therefore did not reduce inequalities. Instead, programmes generated above-average increases among groups with higher pre-intervention uptake, particularly lower- and middle-educated men and women not living alone and retired. Living arrangement explained more variation in programme effects than other factors, with individuals living alone benefiting less from the programmes. Conclusion: CRC programmes did not reduce (and may have widened) inequalities, underscoring the need for equity-focused strategies in population-based screening. By extending MAIHDA with difference-in-differences, this study introduces a novel approach for evaluating heterogeneous policy effects in public health.

Food contamination contributes to 40% of childhood diarrhoea cases globally. It occurs when pathogens are transmitted from faecal matter to food through the faecal oral route. Food hygiene can prevent food contamination and improve the microbial quality of weaning foods in domestic settings. However, context specific evidence is needed to identify risk factors associated with food contamination, especially in complex low-income communities. Our study used a modified Hazard Analysis Critical Control Point approach to assess the quality of weaning foods and identify associated risk factors in a low income setting of Lusaka, Zambia. We enrolled 60 caregivers of children aged <1 year who had begun complementary feeding and collected data on household characteristics and food hygiene behaviours using surveys and structured observations. We collected samples of complimentary foods prepared for the child and tested them for Escherichia coli (E. coli) using the IDEXX Colilert-18 method. Multivariable logistic regression was performed to determine risk factors associated with food contamination. Of 59 food samples, 17 (29%) were contaminated with E. coli. Porridge (AOR = 0.04; 95% CI: 0.01, 0.28; p = 0.001) and non-animal source foods (AOR = 0.11; 95% CI: 0.02, 0.69; p = 0.019) were associated with lower odds of contamination compared with animal source foods. Heating of food was also associated with lower odds of contamination but was not significant. Food hygiene behaviours including utensil and surface cleaning were low (17% and 15%, respectively), and handwashing with soap before food preparation was not practiced. Our study identifies the microbiological risk associated with animal source foods and the potential health risk posed to weaning children. Nutrition guidelines should take into consideration this risk as programs promote an increased uptake of animal source foods in child diets.

Background: The retail food environment is a widely used exposure in behavioural-nutrition and obesity research, on the premise that nearby food retailers shape diet and obesity risk. Over the past quarter-century, grocery stores have declined across rural and small-town America while limited-assortment discount ("dollar") stores have proliferated. Standard food-environment indices classify retailers as healthy or less-healthy but typically exclude dollar stores, now the fastest-growing food-retail format. As a result, a single classification decision may alter how the food environment is measured and the conclusions drawn from it. We develop a dollar-aware index, quantify how counting dollar stores changes the measured exposure, and derive a longitudinal trajectory typology. Methods: Using establishment-level data from Data Axle for all 878 Mississippi census tracts (1997-2024), we classified food retailers into five mutually exclusive categories using a previously validated approach and calculated the modified Retail Food Environment Index (mRFEI) in both its standard and dollar-aware forms, with the latter counting dollar stores as less-healthy outlets. We fitted Nagin-style group-based trajectory models to the tract-level dollar-aware index, related class membership to the Social Vulnerability Index (SVI) and urbanicity with multinomial regression, and characterised spatial clustering (Getis-Ord Gi*, join-counts) and grocery access. Results: Grocery stores fell from 1,616 to 716 while dollar stores rose from 315 to 1,005, intersecting in 2018. Counting dollar stores lowered the index by a margin that widened over time, and a growing number of tracts had only dollar-store retail, undefined under the standard index. Six trajectory classes emerged: stable adequate (5.6% of tracts), steady decline (13.1%), early collapse (11.1%), late collapse (6.7%), persistently constrained (34.1%) and chronic desert (29.3%); only the stable-adequate class (5.2% of children) stayed adequate throughout. Constrained and steady-decline membership rose steeply with vulnerability (RRR 11.7 and 9.9); chronic desert was urban (RRR 5.2, a food-swamp pattern); collapse classes had no cross-sectional social signature. Conclusions: In the US state with the highest adult obesity prevalence, a single retailer-classification decision substantially changes the measured food environment. The dollar-aware index and trajectory typology offer a transferable, time-varying exposure for behavioural-nutrition and obesity research and establish a foundation for future childhood-obesity studies.

Abstract Background:Sickle cell disease (SCD) is concentrated in sub-Saharan Africa, where delivery of guideline-referenced care remains challenging. Current evaluation approaches rely largely on access indicators and clinical outcomes, which do not directly measure care delivery. We developed the Care Delivery Gap (CDG) framework, a patient-reported approach for identifying care-process omissions, and conducted a proof-of-concept study to assess feasibility and explore variation across income strata. Methods: We conducted a cross-sectional framework-development study involving a proof-of-concept sample of 52 individuals with SCD or caregivers recruited through clinics and moderated SCD communities across Africa, North America, and Europe between June 2025 and March 2026. The CDG framework assessed patient-reported omissions in specialist involvement, follow-up continuity, cardiovascular screening, and biochemical surveillance. Analyses were descriptive. Results: Substantial multi-domain care-process omissions were identified despite high reported healthcare engagement. Across geographic income strata, cardiovascular screening was reported by 4/35 (11%) LMIC versus 16/17 (94%) HIC participants, and regular follow-up within the preceding 12 months by 14/35 (40%) versus 16/17 (94%), respectively. High CDG scores, representing 1 omissions across three or four domains, occurred in 20/35 (57%) LMIC compared with 1/17 (6%) HIC participants. Similar disparities were observed across specialist review and vitamin B12 surveillance domains. Conclusion: A structured patient-reported framework identified multi-domain omissions in guideline-referenced SCD care, including among individuals reporting healthcare access. The divergence between access indicators and reported care delivery suggests that service contact alone may not reflect care quality. The framework provides a feasible foundation for future process-level quality measurement in high-burden settings.

Preventive health is a crucial health systems component for managing disease burden and achieving health promotion policy goals. However, effective prevention relies on the modification of relevant risks, often requiring systemic health behaviour change. Australia's National Preventive Health Strategy (NPHS) prioritises seven focus areas: tobacco and nicotine, healthy diet, physical activity, cancer screening, immunisation, alcohol and other drugs, and mental health. The readiness of community members in Australia to address health behaviours relating to these areas has not been fully examined. In response, six focus groups were conducted with 27 adults from the Australian general population to explore their perspectives and experiences of preventive health information and behaviours relating to the seven NPHS focus areas. Themes and sub-themes were identified using an applied descriptive framework. Participants described motivations, barriers and experiences surrounding preventive health through the themes of 'Making informed health choices', 'Facilitating behaviour change and the role of support systems' and 'Spreading the preventive health word'. Sub-themes detailed processes of prioritisation, risk-benefit assessment, critical appraisal, sociocultural influence and support-seeking to understand and personalise preventive health information, implement behavioural change, and share information with others. The focus areas participants engaged with most strongly were healthy eating and physical activity, while cancer screening was discussed less often. These findings indicate high preventive health engagement in the Australian community, alongside challenges navigating and adapting relevant information to personal needs. These insights can support policymakers, healthcare providers and others to effectively enact the NPHS through more targeted preventive health information and care delivery.

Background: Over half of UK adults eat food prepared out-of-home (OOH) weekly and the poor nutritional profile of OOH food contributes to ill health. Nutri-Score is a form of interpretative labelling which assigns food products a value of A (healthiest) to E (least healthy) based on nutritional quality, and inclusion on menus could be a public health policy option to reduce obesity. This is the first real-world Randomised Control Trial to test the effectiveness of Nutri-Score alongside calorie labelling on food menus in UK OOH settings. Methods: Adult participants (N=672), majority White (80%) female (63%), with a mean age of 47(SD18) years, were recruited from the local community to visit OOH food businesses to order, consume, and pay for meals. Data collection days were randomised to be control (calorie labelling) or Nutri-Score (calorie labelling with Nutri-Score). Linear mixed models assessed impacts of labelling condition on perceived effectiveness of menu labelling and nutritional quality of food orders. Findings: Scores for perceived effectiveness of labelling were significantly greater in the Nutri-Score condition compared to control (B = 0.21, p=0.010; 95% CI 0.05, 0.37) and food orders were significantly better nutritional quality, indicated by lower Nutrient Profiling Model scores in the Nutri-Score vs. control condition (B = -0.89, p=0.003; 95% CI -1.48, -0.31). Interpretation: Compared to providing calorie labelling alone, inclusion of Nutri-Score could be an effective policy approach to improve nutritional quality of diet and reduce diet-related disease.

Atopic dermatitis (AD) is a chronic inflammatory skin condition with a multidimensional burden. This study aimed to estimate the socioeconomic burden of the pediatric and adult population with AD in Argentina and explore the health system's response to their needs. We employed a mixed-methods approach, combining a cross-sectional cost-of-illness analysis with a qualitative component to comprehensively assess the social and economic impact of atopic dermatitis in Argentina. We collected data from a survey, focus group and in-depth interviews conducted in Argentina between May 2023 and September 2023. We recruited adult patients and caregivers of children with AD below 18 years of age. We used multivariable ordinal regression to assess associations between sociodemographic and clinical characteristics and burden associated with AD. 1471 subjects participated in the pediatric analysis, and 1412 in the adult analysis. The average annual per capita cost was USD 2639 for adults with AD and USD 8682 for children with AD. Costs increased significantly with disease severity in both groups and were strongly associated with patients' quality of life. Patients and caregivers highlighted the poor response of the health system in terms of adequate and timely access, as well as comprehensive care of the disease. Patients and caregivers suffer from a significant economic burden and quality of life impact associated with AD, which requires urgent attention and comprehensive support from the healthcare system to improve their lives.

Background: In low- and middle-income countries, laboratory testing to rapidly detect measles outbreaks is limited by infrastructure availability and high costs. This study estimates the potential impact and cost-effectiveness of measles rapid diagnostic tests (RDTs) if implemented nationally in Ethiopia to either replace or expand current testing. Methods: An agent-based model to simulate measles outbreaks was calibrated to Ethiopian measles surveillance data. Modelled outbreak outcomes were aggregated over a 10-year period. Scenarios included using RDTs to (1) replace laboratory testing; (2) replace epidemiological linkage; and (3) increase case detection, in addition to replacing laboratory testing and epidemiological linkage. Testing and outbreak response costs (in 2025 US$) were obtained from Ethiopian Public Health Institute from a government perspective. Total costs and disability-adjusted life years (DALYs) for each scenario were compared to baseline. Results: All scenarios were cost saving compared to baseline. Replacing laboratory testing with RDTs saved US$4.2M (3.2M-4.9M) over 10-years, but due to very low testing rates the benefits of eliminating laboratory testing delays were offset by missed cases from the lower RDT sensitivity, leading to similar outbreak detection times and DALYs. Replacing epidemiological linkage with RDTs had similar DALYs but increased the cost savings to US$9.7M. Using RDTs to double case detection reduced outbreak detection time from 113 to 80 days, averted 17,000 DALYs, and saved US$4.3M. Conclusions: In Ethiopia, use of measles RDTs could be cost saving, and if used to expand testing could prevent measles infections through faster outbreak detection and response.

Background: Mental health difficulties increase risk of justice system contacts, and justice involvement increases risk of and exacerbates existing mental health difficulties. However, discrimination influences both whether children's needs are supported and the likelihood of justice system contacts. Examining patterning in Special Educational Needs and Disability (SEND) provision for Social, Emotional and Mental Health (SEMH) needs and youth justice contacts may identify escalation pathways and opportunities for equitable support. Methods: In partnership with young people and community stakeholders, we analysed population-level linked school and police administrative data for 3.7m children (born 1997-2003) who attended state schools in England. We examined rates, timing and risk ratios for the sequencing of SEND-for-SEMH and youth justice contacts. Results: Children ever recorded with SEND-for-SEMH had markedly elevated rates of youth justice contact, and vice versa. First justice contacts clustered between ages 14-16, though Black Caribbean, Mixed White-Black Caribbean, Romani, and Irish Traveller boys experienced steeper increases from age 12. Most racially and ethnically minoritised boys, alongside Romani and Irish Traveller girls, were significantly more likely than White British boys to have youth justice contacts before/without SEND-for-SEMH. Following SEND-for-SEMH, racially and ethnically minoritised boys and Irish Traveller girls were at greater risk of contacts. Conclusions: Findings reveal intersectional discrimination in criminalisation of children and shed light on the complex bi-directional relationship between identified mental health need and youth justice contacts. A healing-centred, public health, multi-agency approach is urgently required to break the vicious cycle between unmet mental health need and youth justice system contacts.

Background A persistent gap between motivation and action threatens voluntary blood supply. This study examined the publics knowledge, attitudes, and practices (KAP) regarding blood donation, with a particular focus on identifying the different determinants of past blood donation behavior and future willingness to donate. Methods Convenience sampling was used to conduct a cross-sectional survey among 1,058 eligible people in Qingdao, China, between July and November 2025. Data were collected via a self-designed KAP questionnaire. To find independent characteristics linked to previous behavior and future intention, respectively, multivariable binary logistic regression was used. Results Overall, 37.0% of participants (n=391) had a lifetime donation history, while 39.2% (n=415) intended to donate in the next 12 months. Past behavior was positively associated with older age (36-45 years: OR=6.84; 95% CI: 3.21-14.58), higher education (OR=2.06; 95% CI: 1.33-3.17), and interpersonal interaction channels (OR=1.45; 95% CI: 1.01-2.09) but hindered by safety concerns (OR=0.23; 95% CI: 0.16-0.34). Conversely, future intention was positively correlated with male sex (OR=1.69; 95% CI: 1.24-2.29), prior donation history (OR=2.69; 95% CI: 1.87-3.86), having family members or friends in need of blood (OR=2.75; 95% CI: 1.96-3.85), and traditional media exposure (OR=3.33; 95% CI: 2.18-5.10). Higher education was adversely correlated with future intention (OR=0.55; 95% CI: 0.38-0.79). Conclusion There is a substantial disparity between donation motivation and action. The determinants of past behavior and future intention are asymmetric, suggesting that stage-specific interventions are required, using social mobilization for initiating first-time donations, while employing family reciprocity and authoritative communication to sustain long-term engagement.

Background In November 2023, the Joint Committee on Vaccination and Immunisation advised the UK government that a targeted, opportunistic vaccination programme using 4CMenB to prevent gonorrhoea primarily in gay, bisexual and other men who have sex with men (GBMSM) at higher risk of infection should be introduced in sexual health services (SHSs). Data on the acceptability of 4CMenB vaccination and factors influencing uptake were needed. Methods Three focus group discussions (FGDs) were conducted with 17 GBMSM aged [&ge;]18 years, resident in England, who self-reported bacterial sexually transmitted infection or [&ge;]5 sexual partners in the previous 12 months. One FGD with five sexual healthcare professionals (HCPs) was conducted. Data were analysed using reflexive thematic analysis. Themes were organised using the Vaccine Uptake Continuum and interpreted using the Social Ecological Model. Results Acceptability of 4CMenB vaccination was high among GBMSM and HCP participants. GBMSM described vaccination as supporting sexual wellbeing and reducing anxiety about gonorrhoea, particularly when positioned alongside existing prevention strategies like HIV pre-exposure prophylaxis and Doxycycline post-exposure prophylaxis. While the estimated effectiveness of ~30-35% was perceived as modest, it did not deter acceptability, but reduced willingness to actively seek vaccination. Structural constraints, including limited SHS capacity, appointment availability, and restrictive eligibility criteria, were identified as barriers to equitable uptake. Community-based and outreach delivery models were widely supported as strategies to improve access. HCPs drew on experience from mpox vaccination to anticipate implementation challenges, emphasising the need for clear guidance, staff training, and sustainable resourcing. Mixed views were expressed regarding additional protection against meningitis, which was generally considered a secondary influence on decision-making. Conclusions 4CMenB vaccination for gonorrhoea was acceptable for both GBMSM and HCPs; however, uptake is likely to depend on ease of access, clear communication, and system-level support. Addressing structural constraints and supporting community-based delivery may help achieve equitable delivery of 4CMenB.

School reopening during an Ebola outbreak is often framed as a binary question of whether schools are safe. For Ebola, however, the immediate operational question is where an infected school-age child may reach the school system before recognition and isolation, and whether local systems can detect and respond rapidly. We developed an exploratory, scenario-based health-zone framework for the September 2026 rentree during the ongoing Bundibugyo virus disease outbreak in eastern Democratic Republic of the Congo. The primary estimand was scenario-based expected introduction pressure, expressed on an expected-count scale, for infected school-age children reaching school in each health zone during a one-week window. The framework combined recent reported transmission, estimated school-age exposure and attendance, a surveillance/interception probability, and directed mobility-based importation. Case-fatality patterns were analysed separately and did not determine introduction pressure. A 10,000-draw probabilistic sensitivity analysis examined uncertainty in the school-age case share, attendance, pre-isolation school-entry probability and mobility scaling. Geographic components were retrospectively evaluated at eight non-overlapping weekly origins from 1 June to 20 July 2026, using subsequent reported seven-day health-zone activity and first reported cases in previously unaffected zones as outcomes. Seven-day local epidemic pressure discriminated health zones with subsequent reported activity with pooled ROC-AUC 0.848; the 14-day local measure increased this to 0.885. Adding directed mobility increased ROC-AUC to 0.952. In the base scenario, the six-province combined scenario-based expected introduction pressure was 10.97; the probabilistic sensitivity median was 11.17, with a 2.5-97.5% sensitivity range of 5.56-20.97. Bunia, Rwampara and Nizi had the highest base introduction pressures, followed by Katwa and Nia Nia. Among 24 previously unaffected health zones that subsequently reported a first confirmed case, 13 (54.2%) were in the top 10 and 18 (75.0%) in the top 20 mobility-ranked zones; random selection would have been expected to capture approximately 2.05 and 4.10 events, respectively. In a separate six-origin exploratory nested-specification sensitivity, surveillance/access modifiers did not improve geographic discrimination over local epidemic pressure alone, whereas mobility did. The dominant structural uncertainty remained the probability that an infected child reaches school before being identified. The framework supports targeted geographic prioritisation and minimum school-health readiness, but its probabilities are model-implied scenario probabilities rather than calibrated forecasts or evidence for a single national open/close decision.

Infectious disease modelling has become an increasingly prominent tool in public health decision-making, with its use accelerating markedly during the COVID-19 pandemic. This growth calls for an understanding of how modelling evidence is received, interpreted, and used or not used by decision-makers. There is a recognised need for evaluations of modelling-to-policy systems to understand how to best integrate modelling evidence into decision-making. So far, no comprehensive evaluation framework exists that maps modelling-to-policy pathways. This study addresses that gap by developing a theory of change for modelling-to-policy systems that could serve as a foundation for future evaluations. A qualitative study design was employed, comprising semi-structured interviews with 35 modellers, knowledge brokers, and decision-makers across five continents and diverse institutional settings, spanning high-income and low- and middle-income countries, as well as national and international modelling-to-policy contexts. Thematic analysis was combined with a backward-mapping-informed approach to develop a multi-level evaluative framework. The protocol for this study has been published on March 20, 2025, at OSF (https://doi.org/10.17605/OSF.IO/J9QXV). Participants diverged in their conceptualisations of successful modelling evidence use, ranging from instrumental use to accurate understanding and consideration of modelling outputs, yet converged on shared risks: decisions informed by inadequately specified models or by evidence that is misinterpreted due to communication failures. The resulting three-level framework identifies factors directly influencing modelling evidence use across three domains (policy relevance, model quality, and communication and interaction), traces these to enabling conditions, and maps them to systemic enablers, including local and embedded modelling capacity, data infrastructure, knowledge brokering capacity, formal knowledge translation structures, established networks, and funding. The proposed framework represents a first theory of change for modelling-to-policy systems. While it requires further testing and application across diverse decision-making contexts, it offers a structured basis for evaluating existing systems and informing the design of new ones.

Climate change draws attention to the planetary health perspective in sport and exercise sciences, that is, to physical activity that supports both human wellbeing and environmental sustainability. Active commuting is a sustainable form of physical activity with well-established somatic health benefits. However, more knowledge is needed on its relationship with mental health. We examined dose-response associations between active commuting, anxiety symptoms, and mental wellbeing among Finnish adults, and whether green commuting environment moderates these relationships. We used data from the cross-sectional Environment and Health Survey collected in June-September 2023 in the ten largest cities in Finland. Employed participants with data on anxiety symptoms (Generalized Anxiety Disorder-7, GAD-7), mental wellbeing (World Health Organization-Five Well-Being Index, WHO-5), commuting profile over a year (mode, frequency, distance, and perceived greenness along the commute route), and sociodemographic and lifestyle factors were included (n=1,672; mean age 45.3 years; 53.8% women). Active commuting was defined as travelling the entire commute by walking or cycling (including e-biking) that was converted into approximated annual km/week and MET-h/week. We used linear and logistic regression with restricted cubic splines to evaluate dose-response associations, adjusted for key covariates. The role of perceived greenness was tested using an active commuting x commute greenness interaction term. We found no dose-response relationships between active commuting and anxiety symptoms or mental wellbeing in any of the models. No effect modification by commute greenness was observed. More research on how active commuting may support planetary health from a mental health perspective is needed.

Background: Stunting affects approximately 32% of children under five years in Benin. While birth intervals shorter than 33 months are a recognized risk factor for childhood malnutrition, the optimal birth interval for preventing stunting in the Beninese context is still unclear. Objective: This study examined the association between preceding birth interval (PBI) and stunting among children aged 6 to 59 months in Benin. Methods: This study used a cross sectional design to analyze data from the 2017 to 2018 Benin Demographic and Health Survey. We included 10,153 children aged 6 to 59 months. Stunting was defined as height for age z score below 2 standard deviations from World Health Organization standards. Preceding birth interval was categorized as <24, 24 to 32, 33 to 44, 45 to 56, and >56 months. Survey adjusted multivariable logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals for the association between PBI and stunting, controlling for child, maternal, and household level covariates. Potential effect modification by child age group (6 to 23 vs. 24 to 59 months) was assessed through a multiplicative interaction term and evaluated using information criteria, a likelihood ratio test, and the statistical significance of individual interaction terms. Results: Compared with children born after an interval of <24 months, those born after 45 to 56 months (AOR: 0.63; 95% CI: 0.51 to 0.78) and >56 months (AOR: 0.67; 95% CI: 0.54 to 0.82) had significantly lower odds of stunting (both p<0.001). Intervals of 24 to 32 months and 33 to 44 months were not significantly associated with stunting, nor was firstborn status. No evidence of effect modification by child age group was found (likelihood ratio test p=0.336), and stratified analyses conducted separately for children aged 6 to 23 months and 24 to 59 months yielded results consistent with those from the pooled model. Conclusion: The lack of protective effect for intervals shorter than 45 months indicates a threshold specific to this context above which nutritional benefits become manifest. Integrating family planning messages emphasizing birth intervals longer than 45 months into child nutrition programs, coupled with strengthened access to modern contraception, could contribute to stunting reduction in Benin among other factors. Alongside this, nutritional support for pregnant and breastfeeding women, including adequate dietary supplementation and counselling, may further contribute to improved child growth outcomes. Keywords: Birth interval; stunting; family planning; Benin; childhood morbidity; nutrition