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.

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.

Objective: To verify the association between perceived social & emotional support and self-reported food insecurity in the United States Design: Cross-sectional secondary data analysis Setting: Behavioral Risk Factor Surveillance System (BRFSS) data from 2024, collected via a nationwide telephone survey. Food insecurity was defined as responding always, usually, or sometimes to "During the past 12 months how often did the food that you bought not last, and you didn't have money to buy more?" Social support was measured using a BRFSS item assessing the frequency with which respondents received the social and emotional support they needed. Adjusted logistic regression models were used to assess the relationship between these variables while controlling for a wide variety of demographic, socioeconomic, and health status factors. Participants: Adults (n = 190,577) aged 18-80 years old (72.3% non-Hispanic White) Results: Individuals who reported only "sometimes" receiving the social and emotional support they need were more likely to report food insecurity as compared to those who "always" receive such support (aOR = 1.75; 95% CI 1.56, 1.96). Conclusions: These findings indicate that decreased social support may put individuals at higher risk of food insecurity. Future work should seek to understand the mechanisms of this association to inform targeted policy and other interventional programs.

BackgroundWhile 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. MethodsPatient 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. ResultsAmong 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. ConclusionsWe 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.

AimsYouth loneliness is a prevalent global health concern with lifelong health ramifications. Schools, as childrens 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. MethodsA 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. ResultsThirty-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. ConclusionsFindings 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.

While SARS-CoV-2 and influenza continue to place a significant burden on population health, within-household differences in decisions towards vaccination and seeking care across these two pathogens, and across sociodemographic groups, remain largely unexplored. By conducting a household-level survey in Illinois, we found that many individuals made inconsistent decisions about vaccination: among all adults, 29% were vaccinated for only one of COVID-19 or influenza, and among those with children in the home, 39% lived with a child whose influenza or COVID-19 vaccination status differed from their own. A higher proportion of adults were vaccinated against COVID-19 compared to influenza, while the opposite was true for those younger than 18 years old. These differences hold even when accounting for disparities in coverage by age, race/ethnicity, political affiliation, and socioeconomic status. While vaccinated individuals consistently reported wanting to protect themselves or others, those who declined vaccination reported highly heterogeneous reasons ranging from resource constraints to distrust or misconceptions about vaccination. These differences are even more pronounced for COVID-19, with larger partisan gaps and higher refusal driven by safety concerns, lack of trust, or religious reasons than those who decide not to get the influenza vaccine. In contrast to vaccination, the decision to seek medical care when sick showed opposite sociodemographic trends, that are likely attributable to illness severity. Our findings highlight that closing gaps in COVID-19 and influenza vaccination coverage will require an integrative strategy that accounts for diverse motivations, fears, and barriers to access, while addressing social inequalities common to both diseases.

Introduction Access to quality early childhood development (ECD) services remains limited for families working in economic settings in many low-and middle-income countries. This study examined the associations between participation in integrated ECD centres of integrated ECD centres located in market and cross-border communities in Rwanda and childcare access, child nutrition, caregiving practices, and developmental outcomes. Methods A repeated cross-sectional pre-post evaluation without a comparison group was conducted between 2023 and 2025 across eight markets and cross-border ECD centres in Rwanda. Quantitative data were analyzed with logistic regression models adjusted for socio-demographic characteristics, while qualitative data were analysed thematically. University of Rwanda College of Medicine and Health Sciences Institution review board approved the study (No.366/CMHS IRB/2023). Results The proportion of children aged 6-23 months who achieved minimum meal frequency increased from 26.6% to 57% (AOR=2.35; 95% CI: 1.01-5.49), and those meeting minimum acceptable diet increased from 15.4% to 51.4% (AOR=4.51; 95% CI: 1.77-11.45). Stunting declined from 32.6% to 15.7% (AOR=0.45; 95% CI: 0.32-0.63) and underweight from 9.3% to 4.3% (AOR=0.55; 95% CI: 0.32-0.97). The proportion of children aged 24-59 months who were developmentally on track increased from 77.9% to 93.8% (AOR=3.85; 95% CI: 2.23-6.65). Households reported higher income at endline, and the centres generated strong demand for childcare services. However, reports of scolding and physical punishment increased between surveys. Conclusions Integrated ECD centres in market and cross-border settings were associated with improved child feeding practices, nutritional status, and developmental outcomes among children from vulnerable working families in Rwanda. Place-based childcare models may represent a promising strategy for expanding access to integrated ECD services while supporting womens economic participation in economic settings.

IntroductionCommunity engagement is increasingly seen as essential within vaccination programming to improve uptake of vaccines, build trust and foster community ownership. Yet the goals and mechanisms of such interventions are often contested or not explicit. This article aims to address this by examining how those directly involved in implementing community engagement understand its intended aims and outcomes. We use as a case study a risk communication and community engagement (RCCE) intervention implemented by the Nigeria and Ethiopia Red Cross/Red Crescent with support from the IFRC for COVID-19 vaccination. MethodsWe conducted 41 interviews, 12 participatory workshops and citizen ethnography in Dire Dawa, Ethiopia and Kano, Nigeria including with Red Cross/Red Crescent and vaccination staff, vaccine users and community members. We explored how participants understood the RCCE interventions theory of change, including how it was expected to work, for whom, under what circumstances, and why. ResultsParticipants described RCCE activities as a mix of two-way (such as house-to-house visits) and mass approaches (such as media campaigns). These interventions were primarily seen as enhancing vaccine knowledge and countering misinformation. Key mechanisms included vaccine users willingness to act on the information provided, however this was heavily influenced by the credibility and trustworthiness of the bearers of vaccine information. While feedback mechanisms existed, communities were not involved in designing vaccination strategies. Efforts were shaped by a context with unpredictable vaccination campaigns, supply constraints and parallel RCCE efforts by community actors. ConclusionsWe show that in this theory of change messengers are more influential than the messages themselves. By developing a theory of change with our participants, we highlight the lack of clarity within the sector regarding the definition and expected impact of community engagement and reveal a gap between community engagement practice on the ground and normative goals such as co-production and dialogue. Key messagesO_ST_ABSWhat is already known on this topicC_ST_ABSRisk communication and community engagement (RCCE) is widely used to improve vaccination programmes, but there is limited evidence on how such interventions are expected to work, for whom, under what circumstances and why. What this study addsWe examined how those involved in implementing a Red Cross/Red Crescent and IFRC RCCE intervention in Ethiopia and Nigeria understood the aims and outcomes of this intervention. Whilst our study participants believed their main goal was to share correct vaccine information to counter rumours, we found that trust in the people who delivered the information was often more important than the information delivery itself. How this study might affect research, practice or policyOur research highlights tension between normative ideals of community engagement and how it is understood and practiced by implementors in humanitarian contexts, and underscores the need to move beyond knowledge-deficit approaches.

BackgroundThe initiation of tobacco and nicotine product use often occurs in adolescents. This necessitates monitoring of this behaviour in this population, particularly in countries such as the Democratic Republic of the Congo (DRC) where approximately 58% of the population is under 19 years of age. Our study assessed the prevalence of, and factors associated with use in the DRC. MethodsWe conducted a nationally representative, cross-sectional, household survey between March and May 2024 among adolescents aged 10 to 17 years. We estimated the prevalence of use of smoked and smokeless tobacco products, heated tobacco products, and nicotine products (i.e., electronic cigarettes and nicotine pouches). We used logistic regression to identify factors associated with current use of any tobacco product, smoked tobacco, and smokeless tobacco using adjusted odd ratios. All analyses included 95% confidence intervals (CI). ResultsOf the 4,675 adolescents who completed the survey, the prevalence of current use of any tobacco or nicotine product was 11.87% (95% CI: 6.93-19.58). This was 7.98% (95% CI: 4.23-14.55) for smoked tobacco products, 5.86% (95% CI: 3.42-9.87) for smokeless tobacco products, 0.11% (95% CI: 0.11-0.11) for heated tobacco products and 0.60% (95% CI: 0.10-3.40) for nicotine products. Boys were more likely to use tobacco than girls. Being enrolled in school and having both parents alive were protective from tobacco use. Having a male household head, a household head education level of at least secondary school, and exposure to tobacco smoking in public places increased the odds of being a tobacco user. ConclusionsThe DRC should strengthen policies that make tobacco and nicotine products less accessible or appealing to adolescents. This includes raising excise taxes; banning the sale of single cigarette sticks, small packets and flavoured products; and comprehensive smoke-free laws. Policies should account for factors that make adolescents more vulnerable product use. Key messagesO_ST_ABSWhat is already known on the topicC_ST_ABSO_LIThe last survey on tobacco use among adolescents in the DRC was a school-based survey among 13-15-year-olds conducted in 2008, and only covered Kinshasa and Lubumbashi. C_LI What this study addsO_LIThis survey provided national-level estimates that cover adolescents aged 10-17years, includes out-of-school adolescents, and covers both tobacco and nicotine products. C_LIO_LIIt also identifies individual-, household-, and environmental-level factors that are associated with tobacco and nicotine product use among adolescents in the DRC. C_LI How this study might affect research, practice or policyO_LIBy providing current and more comprehensive data, our study enhances policymakers ability to design evidence-based tobacco control interventions that are aimed at preventing the initiation and use of tobacco and nicotine products among adolescents in the DRC and other similar settings. C_LI

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.

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.

Objective: The study aimed to describe the challenges, best practices, and lessons learned during meningitis vaccination campaigns conducted in the context of COVID-19 in Cameroon in 2020. Results: During the prevention campaigns, 3,460 individuals were selected. All were tested before the campaign (100%). Eight cases were positive, representing a positivity rate of 0.23% (8/3,460). The campaign was carried out using a fixed strategy in health facilities and prisons and a fixed-temporary strategy in communities. Most health areas received sufficient quantities of COVID-19 equipment for some items and insufficient quantities for others. No screening was done during or after the campaign. The main difficulties encountered were compliance with social distancing and the continuous wearing of gowns. The challenges faced were the screening of actors and the use of personal protective equipment. Lessons learned: aspects related to COVID-19 impacted the speed of the campaign. Vaccination coverage ranged from 91% to 140% in prisons on the one hand, and from 35% to 112% in the health areas surrounding prisons on the other. The campaign in the context of COVID-19 was effective. Compliance with barrier measures was not optimal due to difficulties encountered with aspects such as social distancing, continuous wearing of gowns, screening of participants during and after the campaign, and insufficient personal protective equipment.

Background People with severe mental health conditions (SMHC) and caregivers in South Africa experience high rates of poverty. The PRIZE feasibility trial found that recovery groups were broadly acceptable and feasible and potentially effective in reducing relapse. Addressing economic needs was identified as a means to increase impact. This study aimed to understand experiences of financial insecurity and acceptability of poverty alleviation interventions as an adjunct to psychosocial interventions amongst people with SMHC and caregivers. Methods We conducted two focus group discussions and 12 in-depth interviews in isiXhosa with a total of 14 people with SMHC and 13 caregivers who had participated in PRIZE in Eastern Cape Province, South Africa. An inductive thematic analysis was conducted. Results We identified four major themes. Theme 1: Financial insecurity as a defining influence on life. We found that financial security was crucial to recovery, through bringing status and dignity. However, participants experienced substantial financial insecurity, which impacted on social and mental wellbeing. Financial insecurity was entrenched due to fractured and violent communities, cycles of debt and stigma amongst employers. Theme 2: Government disability grants are not a panacea. Difficulties accessing disability grants included problems attending assessments and rejection of applications. Whilst they were generally welcomed, receipt of disability grants sometimes caused problems such as increased stigma and family disagreements about how the money should be spent. Theme 3: Group savings offer conditional hope if carefully managed. Several caregivers had longstanding experiences of stokvels (community-based credit unions). However, some were fearful of group members absconding with funds. Participants emphasised that trust, safety and fairness are essential for successful group savings. Theme 4: Income-generating activities are desired but need capital and come with safety concerns. Many had ideas and motivation for small businesses but stressed the need for financial capital, skills training and financial literacy support. There were serious concerns that owning a business or gaining wealth could make one a target of crime. Conclusion Poverty alleviation interventions could positively impact on the wellbeing of people with SMHC and caregivers in South Africa as an adjunct to psychosocial interventions and psychiatric care. Approaches could include supporting access to social protection or existing savings groups, and nesting new savings groups or income generation initiatives into psychosocial interventions. Any model would need to incorporate robust mechanisms to ensure the safety of participants. All approaches would be enhanced by parallel social and public health interventions to build social capital and reduce violence in neighbourhoods.

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.

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.

Introduction: Socioeconomic deprivation is often associated with poorer health outcomes, but some studies suggest the opposite for Lyme disease. Here we test two hypotheses to explain this: differences in (i) local landcover of high risk habitats such as woodlands (landscape hypothesis) and (ii) outdoor recreation in such habitats (behaviour hypothesis). Methods: We analysed reported Lyme disease incidence data for 824 data zones in the city of Glasgow, UK, against deprivation rank (based on indicators relating to income, employment, health, education, crime and housing). We then tested how these relate to woodland cover and indices of urban greenspace usage (per capita and per ha of greenspace). Additionally, we measured Lyme disease hazard (density of infected ticks) in 32 greenspaces and tested relationships with deprivation, woodland and greenspace usage. Results: More advantaged data zones (data zones with low deprivation rank) had higher Lyme disease incidence. These areas had more woodland and woodland cover was positively correlated with both Lyme disease incidence and hazard. Deprivation did not correlate with greenspace usage, nor did greenspace usage correlate with Lyme disease incidence. Intensely used greenspaces had lower infected tick densities, consistent with a human disturbance effect on wildlife that carry ticks. Conclusions: Differences in woodland cover, but not outdoor recreation behaviour, can help explain our finding of higher Lyme disease incidence in more advantaged areas. However, to further test the behaviour hypothesis, we need more detailed data on outdoor recreation activity per capita both locally and in rural areas, as well data on mitigation behaviours.

ObjectiveTo investigate in the National School Feeding Program (PNAE) the local-level drivers and barriers to the implementation of four guidelines: the banning of sugary drinks; restrictions on the procurement of processed and ultra-processed foods; the mandatory increase in weekly servings of fruits and vegetables offered to students; and mandatory direct procurement from family farmers. DesignQualitative study that used semi-structured interviews. Street-level bureaucracy theory informed the theoretical framework and thematic analysis. SettingBrazilian municipalities, across the countrys five geographic regions (North, Northeast, Southeast, South, and Midwest). ParticipantsStakeholders (e.g. nutritionists, school cooks, and food procurement managers) involved in the local implementation of the PNAE program across the country. ResultsNinety stakeholders were interviewed. Stakeholders reported having autonomy to perform their activities, collaboration and support from other members within the local government and food providers, adequate infrastructure such as a well-equipped kitchens, the availability of trained personnel, and political commitment as drivers for optimum program implementation. Reported barriers included lack of support and resistance to change among cooks, teachers and parents; insufficient physical and human resources; and limited political commitment. When barriers outweighed drivers, interviewees reported adapting their practices, often in restrictive ways that could compromise the implementation of the program. ConclusionsDrivers and barriers to local PNAE implementation were generally similar across studied municipalities, although their magnitude varied. In contexts of greater economic vulnerability and fiscal constraint, additional support and targeted actions from the federal government may be required to strengthen local implementation.

BackgroundLung cancer screening can reduce lung cancer mortality through early detection, but uptake of the NHS Targeted Lung Health Check (TLHC) programme remains low. Behaviourally informed invitation messages have been proposed as a low-cost approach to increase attendance, but evidence of their effectiveness in lung cancer screening is mixed. Few intervention studies used evidence-based behaviour change frameworks, and rarely tailored invitation strategies to empirically identified barriers and enablers. MethodsIn an online experiment, 3,274 adults aged 55-74 years and with a history of smoking were randomised to see one of four behaviourally informed invitation messages or a control message. Participants then rated their intention to attend a TLHC appointment, and selected barriers and enablers to attending from a pre-defined list, which were classified according to the Theoretical Domains Framework. Invitation messages were mapped to Behaviour Change Techniques using the Theory and Techniques Tool. Message conditions were compared on intention to attend TLHC using bootstrapped ANOVA followed by pairwise comparisons. Exploratory counterfactual mediation analyses examined the role of fear in intention to attend. ResultsBehaviourally informed invitation messages did not meaningfully increase intention to attend TLHC compared with the control message. While a GP-endorsed message showed a small potential benefit relative to the other conditions, this finding was not robust after adjustment for multiple comparisons. Participants most frequently reported barriers related to Emotion (particularly fear), Social Influence, and Knowledge, while Beliefs about Consequences emerged as the primary enabler of attendance. Only around half of reported barriers and enablers were addressed by the invitation messages. Exploratory analyses found that fear was associated with lower intention to attend a TLHC appointment, yet none of the behaviourally informed messages appeared to reduce fear compared to the control message. ConclusionsImproving lung cancer screening uptake will likely require invitation messages that directly address emotional concerns, particularly fear, alongside credible recommendations. These findings highlight the importance of systematically aligning invitation message content with empirically identified behavioural influences when designing scalable interventions to improve lung cancer screening uptake. Contributions to the literatureO_LIAttendance at the NHS Targeted Lung Health Check remains low despite being a UK policy priority. This study provides evidence to inform invitation strategies for ongoing and future screening programmes. C_LIO_LIBehavioural economics frameworks are widely used in health messaging but lack systematic methods for linking behavioural influences with intervention content and evaluation. C_LIO_LIThis study demonstrates how Behaviour Change frameworks can diagnose why behaviourally informed messages may fail, by assessing alignment between intervention content and population-specific barriers and enablers. C_LIO_LIFindings suggest that messaging interventions targeting lung cancer screening attendance may have limited impact when they do not address emotional and social influences. C_LI