Disaster Medicine and Public Health Preparedness

Background: Academic achievement is crucial for university students, but various factors affect their performance. This study explores the impact of anxiety, sleep quality, social media use, and socioeconomic status on academic performance (CGPA) among public university students in Bangladesh. Data and Methods: Data were collected from 225 students using a structured questionnaire that assessed anxiety (GAD-7), sleep quality (PSQI), social media use (SMUQ), and socioeconomic status (income, parental education). Structural Equation Modeling (SEM) was used to analyze the relationships between these variables. Outcomes: The results showed that socioeconomic status had a strong positive effect on academic performance ({beta} = 0.745, p < 0.001), while anxiety negatively impacted academic outcomes ({beta} = -0.675, p < 0.001). Sleep quality was positively related to academic performance ({beta} = 0.113, p < 0.05), but with a weaker effect. Social media usage is found to have a negative significant effect on academic performance ({beta} = -0.137, p < 0.001). Conclusion: These findings highlight the importance of controlling social media usage and anxiety to enhance academic performance among adult students. Sleep quality and socioeconomic background of the students are also found to be meaningfully associated with their educational progress.

Objective: To assess the efficacy of an executive peer coaching program, Charting Champions Program (CCP), in helping physicians manage their administrative workload, thereby improving time management, workflow and well-being. Findings: In this longitudinal survey study, physicians self-reported significant improvements in completing charting and administrative paperwork during their clinical day. Physicians reported significant improvements in mental, cognitive and emotional states after the program. Meaning: The Charting Champions Program is an effective intervention that supports physicians in problem-solving the administrative burden of their clinical day, improving workflow efficiency, completing administrative requirements during clinical hours, and enhancing work-life balance and personal satisfaction. Background: Physicians are subject to high levels of mental, physical, and emotional stress, partly due to increasing administrative burdens. Online coaching is a proven intervention to help physicians improve workflow efficiency, reduce administrative burden and improve job satisfaction. Design: This voluntary longitudinal survey took place between 2020 and 2023. Physicians were asked to complete a survey at program entry and again 30-90 days after program completion. The survey consisted of 14 Likert scale questions, and a final sample of 280 physicians completed both surveys. Intervention: CCP contains modules that teach workflow improvements for clinical days, including timely charting, administrative task workflow, managing patient consultations and reducing interruptions. Interventions include self-paced modules, live coaching, recordings and an online peer community. Results: Post-CCP physicians reported a significant decrease in hours spent charting (P<0.0001) and completing clinical paperwork outside of clinical hours (P<0.006). Physicians also reported a decrease in work-related dread (P<0.001), feelings of burnout (P<0.001), and thoughts of quitting due to administrative burdens (P<0.001). Physicians felt more focused at work (P<0.001), felt more in control of the clinical day (P<0.001), and rated their mental energy at work higher (P<0.001). The program did not affect the number of patients seen in a full clinical day (P > 0.918). Conclusion and Relevance: The CCP reduces the time physicians spend on tasks outside of clinical hours, increasing free time without decreasing the number of patients seen per day.

Perioperative safety checklists standardize critical actions, but reliable completion depends on the surrounding work system and team behavior. We conducted a prospective observational analytic study from April to May 2026 in the central surgical unit of a high-volume public teaching referral hospital in Indonesia to examine whether patient safety culture and teamwork were associated with directly observed perioperative safety compliance and whether teamwork mediated the culture-compliance relationship. Patient safety culture was measured with the Hospital Survey on Patient Safety Culture 2.0, teamwork with a 35-item TeamSTEPPS Teamwork Perceptions Questionnaire research adaptation, and compliance by direct role-based observation using a 45-item checklist derived from the AORN Comprehensive Surgical Checklist. Eighty of 92 recruited professionals contributed 240 person-operation observations across 50 operations. Overall compliance was 74.75%, with sign-out lowest at 70.68%. Patient safety culture was associated with teamwork ({beta} = 0.590; 95% CI 0.510-0.770) and directly with compliance ({beta} = 0.407; 95% CI 0.187-0.712). The teamwork-compliance coefficient was positive ({beta} = 0.285; p = 0.046), but the prespecified percentile 95% CI included zero (-0.045 to 0.517). The indirect effect through teamwork was not supported ({beta} = 0.168; p = 0.079). These findings support a system-level interpretation of perioperative safety and identify learning-oriented responses to error, situation monitoring, and sign-out fidelity as measurable targets for future improvement efforts.

Indiana still faces significant health challenges, ranking among the least healthy U.S. states due to high obesity rates, mental health issues, and other chronic conditions. These disparities are closely linked to inequities in healthcare access, which are largely shaped by social determinants of health. Using data from the Social Vulnerability Index and County Health Rankings and Roadmaps, this study analyzes trends in obesity, mental health, and premature death across Indiana counties before, during, and after the COVID-19 pandemic. Descriptive statistics, correlation analyses, and Negative Binomial regression models were used to evaluate county-level disparities. In 2018, higher rates of uninsured, obese, and physically inactive populations were associated with increased premature death. In 2020, diabetes, smoking, and alcohol consumption were significant factors. By 2022, unemployment, education, obesity, insurance, exercise access, and mental health provider availability were associated with premature death. Findings indicate that socially vulnerable counties experienced amplified health impacts, with obesity rising most sharply where exercise infrastructure was limited and poor mental health days increasing across all counties. These results highlight persistent service gaps and the critical need for targeted investments in recreational infrastructure and mental healthcare. Future research should examine policy influences and causal relationships to inform equity-focused interventions.

Background Although often perceived as a technical tool, a data bank is fundamental for district performance management, facilitating integrated coordination, data consolidation, and routine information use for decision-making. However, implementation unfolds within hierarchical bureaucratic systems shaping authority distribution, workload allocation, coordination, and resource use. This study examines the political economy of institutionalizing a district-level health data bank in West Sumbawa District, Indonesia. Method A longitudinal qualitative case study was conducted in West Sumbawa District, West Nusa Tenggara Province, Indonesia, from November 2025 to March 2026 across three evaluation phases (baseline, midline, endline), involving 25 District Health Office (DHO) officers appointed to the Health Data Bank team, representing five organizational units, including the Secretariat, General and Human Resources Unit, and Public Health Division. Data were collected through participatory workshops, focus group discussions, in-depth interviews, observation, and document review, including official decrees, SOPs, meeting minutes, and implementation records, and analysed using Bossert's Decision Space Framework combined with a problem-driven political economy analysis examining how power relations, institutional norms, workload, resource support, and perceived incentives influenced whether technical reforms became operationalized in routine practice. Results The Health Data Bank progressed from strong institutional acceptance to structural formalization. Decision-making authority remained centralized within the Secretariat, enabling coordination but limiting distributed ownership. Resource constraints increased workload, concentrated in the Secretariat and division coordinators responsible for data consolidation and validation, without dedicated financing or staffing, despite improved analytical capacity. Accountability mechanisms were established through governance instruments, though enforcement and feedback loops remained underdeveloped. Data submission, validation, and use were not yet fully institutionalized, resulting in a gap between structural readiness and functional use. Conclusion Data institutionalization involves both technical and organizational processes, requiring collaborative negotiation of authority, workload, and resources. Continued attention to these factors will help structural formalization translate into sustainable operational outcomes.

Background: Whether corrective actions documented in medical safety incident reports rely on individual vigilance ("Safety-I") or on structural, system-level intervention ("Safety-II") has not been quantitatively evaluated on a national scale in Japan. We developed an automated classification pipeline to assign corrective-action free-text to a 7-level maturity scale (L0-L6) and computed two summary indices: the Safety Measure Quality Profile (SMQP), the full L0-L6 distribution, and the System-based Safety Measure Rate (SSMR), the proportion of non-L0 records classified L3-L6. Methods: We analyzed all 11,507 corrective-action free-text entries from the 2010 release of Japan's national medical accident and near-miss reporting database (Japan Council for Quality Health Care, JCQHC), comprising 8,804 near-miss (Hiyari-Hatto) and 2,703 accident (Jiko) reports. Records were classified using a five-stage hybrid pipeline: an expert-developed rule dictionary, TF-IDF + k-nearest-neighbor matching, cosine-similarity matching, a two-tier large-language-model (LLM) classifier, and a conservative priority-cascade fallback. SSMR was compared between near-miss and accident reports using a chi-square test, Wilson 95% confidence intervals, Cramer's V, and the risk difference (RD), against pre-specified minimal clinically important difference (MCID) criteria of RD >= 2 percentage points and Cramer's V >= 0.10. Results: Every record received a definitive L0-L6 label (0% unresolved). Overall, 16.6% of records were unclassifiable (L0); among the 9,599 classifiable (non-L0) records, individual-vigilance actions (L1) predominated (54.6% of all records), and only 11.82% (95% CI, 11.19-12.49%) met the SSMR criterion (L3-L6). SSMR was higher for accident reports than for near-miss reports (18.12% [95% CI, 16.69-19.64%] vs. 9.[95% CI,46% [95% CI, 8.80-10.17%]; RD = 8.66 percentage points; Cramer's V = 0.120; chi-square(1) = 136.97001), exceeding both pre-specified MCID thresholds. Conclusions: In this interim single-year analysis, the large majority of documented corrective actions in Japanese medical safety reports remained individual-vigilance-based rather than system-based, with accident reports showing a substantively, rather than merely statistically, higher proportion of system-based actions than near-miss reports. These findings support the feasibility of large-scale automated assessment of corrective-action quality and provide the rationale for the planned 16-year longitudinal analysis.

Cancer prevalence is distributed unevenly across regions and caused by the interaction of multiple risk factors. Previous studies focused on the use of global modeling techniques to predict cancer at the county level that overlooks important spatial differences. This study aims to develop geographically weighted machine learning models to predict cancer prevalence at the census tract level in the United States and identify local determinants of cancer burden. First, a scoping review was conducted to find a list of measurable drivers of cancer in the United States. Using this list, the data of these variables for 84415 census tracts were obtained from the Center for Disease Control and Prevention PLACES dataset and other publicly accessible resources. Then, several predictive models, including Ordinary Least Squares (OLS) and Geographically Weighted Regression (GWR), as well as Random Forest, XGBoost, and Deep Neural Network and their geographically weighted counterparts, were developed and compared using the Coefficient of Determination, Root Mean Square Error, and Absolute Error. Results presented that geographically weighted models outperformed other methods, and geographically weighted XGBoost achieved the strongest and most consistent overall performance with pseudo-R2 ranging between 0.89 and 0.98. Feature importance analysis of this model illustrated that most important cancer drivers changed location by location. Aged people, racial composition, preventative behaviors, and metabolic conditions such as diabetes, hypertension, and high cholesterol were determined as influential predictors, although their relative importance varied across regions. These findings revealed the value of localized models at a small geographic scale to identify regional cancer risk patterns and help the allocation of proper resources to hotspot areas. Keywords: Cancer prevalence, Census tracts, geographically weighted machine learning models, Deep neural network, XGBoost, Random Forest, Ordinary Least Squares, risk factor, determinant

Background Floods are among the most devastating natural disasters worldwide and are increasingly associated with adverse mental health outcomes, particularly Post-Traumatic Stress Disorder (PTSD). In December 2023, Hanang District in northern Tanzania experienced catastrophic mud floods that resulted in extensive loss of life, destruction of property, displacement of households, and disruption of livelihoods. While emergency humanitarian responses focused primarily on physical needs, limited evidence exists regarding the long-term psychological consequences among survivors. Therefore, this study aimed to determine the patterns of PTSD manifestations and assess cognitive factors associated with PTSD symptoms among flood victims in Hanang District, Tanzania. Methods A community-based cross-sectional study was conducted among 360 flood victims one year after the disaster. PTSD symptoms were assessed using the PTSD Checklist for DSM-5 (PCL-5). Descriptive statistics summarized PTSD severity, while chi-square tests and regression analyses examined associations between socio-demographic characteristics and PTSD manifestations. Cognitive factors were assessed based on participants' exposure to traumatic experiences and perceptions of traumatic events. Results The mean PCL-5 score was 39.2 (SD = 20.6), indicating a high burden of psychological distress. Approximately 45% of respondents had severe PTSD symptoms (PCL-5 [&ge;]45), while another substantial proportion demonstrated moderate symptom severity. PTSD manifestations varied significantly by geographical location (p < 0.001), household income (p = 0.011), and marital status (p = 0.002). Age positively predicted PTSD severity ({beta} = 0.019, p = 0.001), whereas household income negatively predicted symptom severity ({beta} = -0.297, p = 0.001). Exposure to natural disasters constituted the predominant cognitive factor, with 45% directly experiencing the flood and 38.3% witnessing the event. Exposure to secondary traumatic experiences through witnessing or learning about violent events was also common. Cognitive trauma exposure demonstrated a significant association with PTSD symptoms ({chi}2, p < 0.001). Conclusion PTSD remains highly prevalent among flood survivors in Hanang district. Both direct and indirect trauma exposure significantly contributed to PTSD manifestations. Comprehensive disaster recovery programmes should integrate trauma-focused psychological services, cognitive behavioural interventions, routine PTSD screening, and community-based psychosocial support alongside socioeconomic recovery initiatives.

Objectives: To describe age-group differences in inability to afford dental treatment and cost related dental delay, among the US community-dwelling population. Study design: Descriptive analysis of nationally representative survey data. Methods: Using nationally representative Medical Expenditure Panel Survey data (2018-2021), we examined trends in inability to afford dental treatment and cost-related dental treatment delays across four age groups (2-17, 18-39, 40-64, [&ge;]65 years). Weighted analyses accounted for the complex survey design; statistical significance was set at p<0.001. Results: Cost-related delays declined modestly from 2018 to 2021 but remained most prevalent among adults aged 40-64 (4.8% for ages 40-64, 3.4% for ages 18- 64, 2.2% for ages>65 in 2021; p<0.001). Conclusion: Middle-aged adults seem to experience delays due to cost, underscoring the need for dental coverage to expand dental coverage for this group and to reduce their out-of-pocket costs.

Background: Stress research in nursing education has largely focused on distress, stressors, and negative outcomes, although challenging experiences may also support motivation, confidence, learning, and growth when appraised positively. Objective: To develop and evaluate the psychometric properties of the Nursing Student Positive Stress Scale (NSPSS). Design: A methodological instrument development and psychometric evaluation study. Methods: The NSPSS was developed using a deductive, theory-driven approach informed by the transactional theory of stress and coping and positive psychology perspectives. Content validity was assessed by an international nursing expert panel. Psychometric evaluation used national survey data from nursing students in New Zealand. Of 539 responses, 507 were analysed. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted using separate subsamples. Internal consistency was assessed using Cronbach's alpha and McDonald's omega, and convergent validity through correlation with Perceived Stress Scale-10 scores. Results: Content validity was strong (I-CVI = .88-1.00; S-CVI/Ave = .975; S-CVI/UA = .800). EFA identified a dominant factor explaining 41.38% of variance (loadings = .528-.735). CFA supported a two-context Academic and Clinical Positive Stress model with correlated residuals between five parallel item pairs, chi-square(29) = 60.49, CFI = .970, TLI = .954, RMSEA = .063, SRMR = .065. Internal consistency was good (alpha = .839; omega = .843). NSPSS scores correlated negatively with PSS-10 scores (r = -.298, p < .001). Conclusion: The NSPSS demonstrated strong content validity, preliminary evidence of structural and convergent validity, and good internal consistency reliability for assessing positive stress appraisal among nursing students. Further validation in independent samples is warranted.

Against the backdrop of nationwide inclusive education promotion, children with autism spectrum disorder, intellectual disabilities and other special educational needs (SEN) in Jiangxi Province have raised growing demands for equitable schooling. Paraeducators serve as a critical on-site support mechanism enabling SEN children to access mainstream classrooms; the adequacy of shadow teacher service provision and the maturity of corresponding multi-stakeholder support systems jointly determine the overall quality of local inclusive education. This study adopted mixed quantitative-qualified methods, including questionnaire surveys and semi-structured interviews, to investigate SEN children, paraeducators, general and special education teachers, as well as SEN caregivers across multiple prefecture-level cities in Jiangxi. Grounded in provincial special education policies and local frontline inclusive education practices, we systematically unpacked multidimensional service demands from four core stakeholder groups, diagnosed prominent practical bottlenecks restricting the sustainable operation of shadow teacher services, and constructed regionally tailored multi-layered support strategies aligned with Jiangxi's educational realities. The findings of this research offer empirical evidence and actionable policy references to advance high-quality inclusive education for SEN children across central China's Jiangxi Province.

Background Waterlogging, a form of chronic, stagnant flooding, is increasing in the Ganges-Brahmaputra delta in Bangladesh due to the compounding effects of land-use change, including the expansion of brackish shrimp farming, poor water management, and changing rainfall regimes. Its effects are negatively impacting livelihoods and health; its association with mental wellbeing is less known. Methods We hypothesised that 1-recent waterlogging, 2-social disadvantage (women, older individuals, the poorest, the least educated, those with chronic illness, and religious minorities) would be associated with lower wellbeing, and 3-chronic illness would modify the association between waterlogging and mental wellbeing. 1260 respondents from 595 households in Tala upazila, southwest Bangladesh, were interviewed about their mental wellbeing, chronic illness, and exposure to waterlogging in the 12 months prior to data collection, in August and September 2022. Associations between WHO-5 wellbeing scores and waterlogging and covariates were assessed using multi-level linear mixed-effects models with household random effects and cluster fixed effects. Results Our results confirm our hypotheses: wellbeing was lower among disadvantaged groups and chronic health vulnerability modifies the association between waterlogging and wellbeing: waterlogging exposure was associated with 18.31-point lower WHO-5 scores among individuals with chronic illness (95% CI -26.45 to -10.17), an association markedly attenuated among those without chronic illness (interaction {beta}=14.21, 95% CI 5.48 to 22.95, p=0.001). Conclusion These results suggest that chronic illness may increase vulnerability to the mental health burden associated with waterlogging. As waterlogging is increasing, policies addressing both its environmental drivers and the needs of vulnerable populations should be considered.

Communities exposed to flooding can experience markedly different mental health outcomes, yet conventional resilience indicators capture only part of the social and contextual conditions that may explain this variation. This study develops a multilevel and predictive framework for examining community resilience and depressive symptoms following flood exposure in Indonesia. Data were drawn from 20,303 respondents aged 15 years and older nested within 312 communities in the Indonesia Family Life Survey (IFLS-5). Depressive symptoms were assessed using the 10-item Centre for Epidemiologic Studies Depression Scale (CES-D-10), with Rasch Partial Credit Model calibration used to examine measurement properties. Bayesian multilevel models quantified between-community heterogeneity and assessed how far observable structural resources accounted for this variation. Community resilience was represented through two complementary constructs: structural resilience, based on observable socioeconomic and social-capital resources, and Latent Community Protective Capacity (LCPC), a model-derived proxy for residual contextual variation in depressive-symptom risk. Approximately 6 percent of variation was attributable to between-community differences, while observable structural resources explained only part of this heterogeneity. Structural resilience and LCPC were weakly correlated (r = 0.155). Moderation analyses provided no clear evidence that structural resilience altered the flood-depression association, while LCPC showed a directionally consistent but uncertain buffering pattern. Predictive models incorporating community-level information improved discrimination, with the best-performing model reaching an ROC-AUC of approximately 0.71. The findings suggest that observable resource-based indices provide an incomplete account of community-level mental health vulnerability and that residual contextual measures may provide complementary information, while requiring cautious interpretation and independent validation.

Background: Evaluation of public health surveillance systems is a programmatic obligation but has largely been conducted as a periodic, externally commissioned activity requiring dedicated resources and additional data collection. India's Integrated Disease Surveillance Program (IDSP) generates continuous outbreak data through weekly reports but lacks a routine, embedded performance evaluation mechanism. This study assessed the quality of IDSP outbreak detection and response across multiple surveillance attributes and developed a weighted composite performance scoring framework using only routine program data. Methods: A cross-sectional evaluation study was conducted across 38 districts of Bihar using secondary data from IDSP Central Surveillance Unit weekly outbreak reports for 2016 - 2018 (n=559 outbreaks). Six surveillance quality attributes were assessed - timeliness, completeness, representativeness, relative sensitivity, acceptability and flexibility. A weighted composite performance scoring scale was developed using expert opinion-derived attribute weightages (n=25 experts). District-level scores were computed and scaled to 100. Results: Timeliness was the poorest-performing attribute, with fewer than 15% of outbreaks notified within 48 hours across all three years. Private sector participation was entirely absent - the acceptability score was 0 across all 38 districts for all three years. Completeness was the strongest attribute, exceeding 95% in all years. The mean composite score remained consistently low (23 - 27 out of 100) with widening inter-district disparity over time. Four districts (10.5%) scored 0 in all three years. Conclusions: This study presents a dynamic, routine-data-based composite performance evaluation framework for IDSP outbreak detection and response. The modular, configurable framework functions at any administrative level (from block to national) and is compatible with digital health information platforms, enabling continuous, embedded performance monitoring without additional data collection. The framework has been registered as an Intellectual Property with the Government of India. Keywords: Disease surveillance; IDSP; IDSR; performance evaluation; composite score; outbreak detection; timeliness; completeness; relative sensitivity; digital health

Health facilities (HFs) routinely administer medicines and are expected to ensure patient safety by detecting, reporting, investigating, and analysing adverse events following exposure to drugs (AEFED). This study aimed to assess the implementation of pharmacovigilance activities in referral and regional health facilities in Cameroon and to identify pharmacovigilance training needs among healthcare personnel (HP). This was a cross-sectional descriptive study targeting referral and regional health facilities and healthcare personnel involved in patient care and pharmacovigilance activities in Cameroon. Health facilities were selected using stratified purposive sampling, while healthcare personnel were selected through exhaustive sampling. Data were collected using semi-structured electronic questionnaires administered face-to-face by trained enumerators. The questionnaires assessed the organization, resources, and implementation of pharmacovigilance activities at health facilities, as well as healthcare personnel knowledge of pharmacovigilance concepts, previous training, and perceived training needs. Of the 14 eligible health facilities, 10 (71.4%) consented to participate in the study. Of the 10 health facilities, 4 (40.0%) had an established pharmacovigilance unit, while 3 (30.0%) reported conducting neither detection nor notification activities. Among the 261 healthcare personnel approached, 214 (81.9%) participated. Only 41.6% had needed knowledge to detect an adverse event, while 72.9% were aware of adverse event notification procedures. Previous exposure to pharmacovigilance training was reported by 37.9% of healthcare personnel, and all participants expressed a need for additional training, particularly on national pharmacovigilance regulations (69.2%), organization of the pharmacovigilance system (67.3%), and adverse event detection (67.3%). The main reported challenges by healthcare personnel in the implementation of pharmacovigilance activities included insufficient budget allocation, limited access to pharmacovigilance training, lack of pharmacovigilance guidelines and insufficient qualified human resources. Pharmacovigilance implementation in referral and regional health facilities in Cameroon remains limited, with gaps in organizational structures, resources, healthcare personnel knowledge, and training. Strengthening pharmacovigilance systems through improved facility capacity, availability of essential tools, and targeted healthcare personnel training is needed to enhance drug safety surveillance.

Problematic Internet Use (PIU)--marked by compulsive or maladaptive online behavior--is an emerging public health issue among adolescents and is associated with psychological distress, social difficulties, and academic problems. In Finnmark County, Norways northernmost and ethnically diverse region, limited research has examined the underlying mechanisms of PIU among Sami and non-Sami youth, despite increasing levels of digital engagement. This study protocol outlines a population-based cross-sectional survey investigating the associations between social norms (descriptive and injunctive), ethnic identity, and ethnicity-based discrimination in relation to PIU among Sami and non-Sami adolescents in Finnmark. Guided by Social Norm Theory and Ethnic Identity Theory, the study aims to examine risk and resilience factors associated with adolescents digital behavior in a geographically sparsely populated, multiethnic region. A population-based, cross-sectional school survey will include all upper secondary school students in Finnmark County (N {approx} 2,230). A culturally adapted, bilingual questionnaire (Northern Sami - Norwegian) will measure problematic internet use, perceived social norms in family, peer, and school contexts, ethnic identity, ethnicity-based discrimination, positive internet use, and key covariates. Ethnicity will be classified based on indicators of Sami language use and self-identification. Data will be prepared using prespecified quality procedures and analyzed with partial least squares structural equation modeling (PLS-SEM) to examine associations between social norms, ethnic identity, ethnicity-based discrimination, and internet use outcomes, including mediation and moderation. Group differences between Sami and non-Sami adolescents will be assessed using PLS Multi-Group Analysis. The findings may inform the development of culturally appropriate approaches to screening, prevention, and early intervention, and are relevant for mental health services, school-based programs, and public health strategies targeting Indigenous youth in rural and semi-rural regions.

Tropical cyclones are among the deadliest and costliest natural disasters in the United States, and the most intense storms are expected to become more frequent as the climate warms. Anticipating where deaths are most likely to occur is therefore central to preparedness, evacuation planning, and public health response. We modeled block-level mortality risk for twenty-four of the deadliest and costliest tropical cyclones to strike the U.S. Gulf and East Coasts, Puerto Rico, and the U.S. Virgin Islands between 1992 and 2024. For each storm, we combined NOAA hazard data (wind swaths, rainfall, and storm-surge inundation) with 2020 U.S. Census demographic and socioeconomic characteristics and the CDC/ATSDR Social Vulnerability Index for all Census blocks within 25 miles of the coast, and trained storm-specific boosted-tree models with population-standardized mortality as the outcome. Averaging block-level predictions within Saffir-Simpson categories yielded risk maps spanning tropical storms through Category 5 hurricanes. Predicted mortality risk rose with storm severity and concentrated in urban coastal communities of Puerto Rico, Louisiana, Florida, North Carolina, Virginia, Maryland, New Jersey, and New York, as well as in low-lying inlet, peninsula, and sound geographies. Large block population, non-Hispanic composition, male-dominated blocks, predominantly white blocks, and males aged 20 to 34 years ranked among the strongest predictors of mortality; patterns that likely reflect structural factors shaping exposure rather than individual susceptibility. The category-specific risk maps and an accompanying interactive dashboard provide a practical decision-support tool for emergency managers, planners, and coastal residents preparing for future storms.

Objectives: To evaluate the sustainability of Lean Healthcare practices after the implementation phase of a national quality improvement programme and to identify organisational factors associated with maintaining results over time. Design: Multicentre cross-sectional study with a mixed-methods approach. Setting: Twelve public and philanthropic hospitals in Brazil participating in Phase 2 of the Lean in Emergency Departments Project. Participants: Key respondents in managerial or leadership roles from participating hospitals (response rate: 75.0%). Outcome measures: Sustainability of Lean practices and organisational readiness, assessed through a structured survey and triangulated with operational indicators collected across successive implementation cycles at hospital level. Results: During one year of structured follow-up, 66.7% of respondents reported maintenance of Lean practices; this decreased to 33.3% after the end of structured follow-up. Although 66.7% considered professionals capable of maintaining results, only 58.3% positively evaluated institutional structure, indicating a discrepancy between individual capacity and organisational readiness. Operational indicators showed heterogeneous behaviour across hospitals, with no consistent pattern of sustained improvement. Qualitative analysis identified professional and managerial turnover, formal governance structures, and continuous monitoring as key factors associated with sustainability. Conclusions: The sustainability of Lean Healthcare practices is more strongly associated with institutional capacity to embed and sustain changes over time than with isolated individual training. Quality improvement programmes should incorporate structured strategies for the post-implementation phase. Keywords: Lean Healthcare; Sustainability; Quality improvement; Hospital flow; Health systems; Organisational factors

The forced displacement of medical students due to armed conflict presents a profound disruption to the global medical education continuum. Existing research predominantly evaluates individual psychological trauma, leaving a critical gap in measuring the structural and institutional friction displaced learners face when transitioning into host medical schools. This study details the development, structural refinement, and psychometric validation of the Displaced Medical Student Scale (DMSS), a novel 38-item instrument theoretically grounded in Pierre Bourdieus Theory of Practice. Utilising an exploratory sequential mixed-methods design adhering to COSMIN guidelines, initial qualitative items generated from a transnational cohort underwent content validation by an expert panel (Scale-Level Content Validity Index Average = 0.96) and pilot face validation (N = 29) to eliminate linguistic barriers. Subsequent psychometric testing with 156 displaced Gazan medical students confirmed a robust six-factor latent structure: Mechanisms of Conflict, Hysteresis and Dislocation, Agential Coping, The Agents Toolkit, The Institutional Field, and Transition Outcomes. Confirmatory factor analysis using diagonally weighted least squares demonstrated excellent model fit (, Comparative Fit Index = 0.925, Tucker-Lewis Index = 0.918, Root Mean Square Error of Approximation = 0.058, Standardised Root Mean Square Residual = 0.064) and exceptional internal consistency (Cronbachs , McDonalds ). Structural equation modelling proved that institutional symbolic violence negatively impacts transposed clinical capital () and that structural hysteresis mathematically mediates the path between symbolic violence and professional attrition fatigue (). Furthermore, agential coping significantly moderates identity crisis outcomes (). The DMSS provides medical faculties with an evidence-based metric to transition from deficit frameworks to targeted structural interventions that preserve displaced clinical capital.

Introduction: Clinical students are a future health workforce, yet their roles during outbreaks of highly infectious diseases remain uncertain because of safety, training, supervision and welfare concerns. Ugandas 2022 outbreak of Ebola disease caused by Sudan ebolavirus highlighted the need to understand how clinical students perceive outbreak-related care. Aim: This study explored willingness to care for patients with Ebola virus disease among clinical students at a Ugandan medical school and examined how perceived risks, perceived benefits and support needs shaped that willingness. Methods: An exploratory descriptive qualitative study was conducted among clinical students of Makerere University in Kampala, Uganda. Fifteen undergraduate medical and nursing students in the later years of training were purposively selected. Data were collected through in-depth interviews, audio-recorded with consent, transcribed verbatim, de-identified and analysed using latent content analysis. The Health Belief Model sensitised interpretation, and reporting was strengthened using the COREQ guidance. Results: Five interrelated themes emerged, showing that willingness to care was conditional rather than simply present or absent. Students described an initial willingness grounded in professional duty, devotion to patients and the desire to save life. This willingness was restrained by perceived risks of contracting Ebola virus disease, dying, transmitting infection to family members or colleagues, emotional distress, lack of epidemic-readiness in the curriculum, inadequate preparedness and weak welfare support. Perceived benefits, including patient survival, professional learning, outbreak experience and personal fulfilment, strengthened willingness but did not override safety concerns. Students identified reliable personal protective equipment, epidemic-ready curricula, practical infection-prevention and control training, simulation, clear protocols, close supervision, psychosocial support, insurance and fair compensation as cues to action that could convert willingness into safe participation. Conclusions: Clinical students in this Ugandan teaching hospital expressed a strong sense of professional responsibility, but their willingness to participate in Ebola care was conditional upon preparedness, protection, epidemic-ready education and institutional trust. Professional duty and learning opportunities promoted participation, whereas perceived risks and inadequate support limited it. Medical education programmes and outbreak-response systems should develop ethical, supervised, competency-based student roles supported by practical curricula, reliable protective equipment and psychosocial and welfare safeguards.