Disaster Medicine and Public Health Preparedness

Objectives To explore the prevalence, spatial aggregation, and demographic correlates of climate change awareness among adults in Nigeria, as well as impacts on humanitarian health preparedness. Design Nationally representative cross-sectional survey with multivariate logistic regression and Global Moran's I and LISA techniques of spatial autocorrelation analyses was applied. Setting All 36 states and the Federal Capital Territory, Nigeria. Participants 1,600 adults drawn from the Afrobarometer Round 9 nationally representative survey. Interventions None. Main Outcome Measures Prevalence, spatial aggregation, and demographic correlates of climate change awareness among adults in Nigeria, and impacts on humanitarian health preparedness. Results Less than one in three Nigerians (30.1%) was aware of climate change, significantly lower than the 65% found in the continent, and education is the most predictive factor, with tertiary-educated Nigerians more than ten times more likely to be aware of climate change than those with no formal education. Most critically, the poor performance in government climate policies is not found in low-awareness states, but in two geographically distinct risk corridors based on a different mechanism and requiring a different policy response. Conclusions The finding shows that the gap in climate awareness is not a communication problem, it is a structural problem - one that requires a national intervention to reduce and close, but that might not be enough because of educational inequality, gender disparity and geographic marginalization. To prepare the country for humanitarian needs, targeted state-level, gender-responsive programming based on Nigeria's Climate Change Act 2021 is required, and effective intervention to make adaptation to the health impacts of climate change happen will need to start with triggering awareness into adaptive health action before climate hazards surpass the country's humanitarian response capacity. Registration Not applicable. Keywords: Climate change awareness; spatial autocorrelation; humanitarian health preparedness; educational inequality; Nigeria

Background: Statewide immunization data are essential for monitoring vaccination trends and evaluating immunization program impact. In the United States, Immunization Information Systems (IIS) were established in the early 1990s to collect these data; however, operational, legal, and procedural details vary across states and over time. This study summarized differences in IIS characteristics, such as legal requirements and reporting procedures, across U.S. states and jurisdictions over time. Methods: We analyzed survey data from previous work in 2000 and the Centers for Disease Control and Prevention (CDC) in 2012, 2018, and 2024. Our review focused on legislation and reporting requirements for immunization registries across 50 states and 14 jurisdictions, including U.S. territories and Freely Associated States. Results: Between 2000 and 2024, legal frameworks and reporting practices for immunization registries expanded across U.S. states and jurisdictions. The number of states with laws or administrative rules authorizing immunization registries increased from 24 states in 2000 to all 50 states, the District of Columbia, five metropolitan areas, five U.S. territories, and three Freely Associated States in 2024. Over the same period, reporting requirements also became more widespread. The number of states and jurisdictions mandating providers to report immunization records increased from 12 in 2000 to 54 in 2024. Consent policies also changed over time. By 2024, most states and jurisdictions had adopted implicit consent for reporting children's immunization records (41; 64%), while a smaller proportion required explicit parental consent (7; 11%) or implemented mandatory reporting without consent (14; 22%). Discussion: IIS infrastructure and reporting requirements have expanded across U.S. states and jurisdictions over the past two decades, while heterogeneity in consent policies and reporting practices persists. These temporal changes may need to be considered when interpreting IIS data, particularly in longitudinal and cross-jurisdictional analyses.

Background: Access to dental care remains a significant challenge for many children in Canada, particularly among low-income and underserved populations. The Interim Canada Dental Benefit (CDB), introduced in October 2022, aimed to reduce financial barriers to oral health care for children under 12 years of age while the Canadian Dental Care Plan (CDCP) was being developed. While emerging evidence has examined program uptake, limited qualitative research has explored parents and caregivers experiences with the Interim CDB. Objective: This study aimed to explore parents and caregivers experiences with the Interim CDB in Manitoba, Canada, including awareness, access, perceived benefits, challenges, and recommendations for program improvement. Methods: A qualitative descriptive study was conducted using semi-structured interviews with 30 parents and caregivers of children under 12 years of age. Participants were recruited primarily through community dental clinics. Interviews were conducted between July 2023 and February 2024, audio-recorded, and transcribed verbatim. Data were analyzed using inductive thematic analysis to identify key themes and subthemes. Results: Seven interconnected themes were identified: (1) limited and uneven awareness of the Interim CDB; (2) inadequate and inequitable communication strategies; (3) barriers to accessing the benefit, including misconceptions about eligibility and complex application processes; (4) dental providers as key facilitators of access; (5) financial relief and improved access to care; (6) gaps in coverage and ongoing financial strain; and (7) participant-driven recommendations for improvement. While the benefit was widely perceived as reducing financial barriers and enabling access to care, challenges related to awareness, communication, and adequacy of coverage limited its overall effectiveness. Participants emphasized the need for improved communication from government, simplified application processes, expanded eligibility, and increased financial support. Conclusion: The Interim CDB represents an important step toward improving access to dental care for children in Canada. However, this study highlights critical implementation gaps related to awareness, accessibility, and coverage. Addressing these challenges will be essential to ensuring the success of the new CDCP and advancing equitable access to oral health care.

Background: Health-related social needs (HRSNs), particularly housing instability, are significant drivers of poor health outcomes among Medicaid populations. New York State's Social Care Networks (SCNs) aim to systematically connect members to housing services through coordinated referral systems. However, limited systematic analysis of referral patterns hinders quality improvement efforts. We analyzed housing referral outcomes and workflows to identify barriers to successful service connections. Methods: We conducted a mixed-methods quality improvement study at Public Health Solutions' WholeYouNYC SCN Coordination Center. Quantitative analysis examined 4,258 housing referrals submitted between June 2025 and January 2026, extracted from the Unite Us platform via Power BI dashboard. We calculated acceptance rates, analyzed time metrics, and examined outcomes by receiving organization. Qualitative data were collected through structured consultations with 7 staff members (5 navigators, 2 supervisors) and review of internal workflow documentation. Process mapping identified workflow bottlenecks. Results: Of 4,258 housing referrals, only 45% (n=1,936) were accepted by receiving organizations, while 19% (n=815) were rejected and 32% (n=1,382) remained awaiting response with no recorded action. Average time to acceptance was 8 days for accepted referrals. Acceptance rates were consistent across top receiving organizations (44-46%), suggesting systemic rather than partner-specific barriers. Analysis of unresolved referrals revealed prolonged cases, with the longest pending 271 days. Three critical workflow bottlenecks were identified: CBO response delays, missing housing documentation, and challenges with client engagement. Conclusions: Low housing connection rates (45%) and prolonged unresolved referrals (up to 271 days) indicate systemic barriers requiring interventions at multiple levels. Recommendations include establishing CBO response time benchmarks, implementing automated follow-up protocols, standardizing documentation requirements, and enhancing real-time data monitoring. These findings provide an evidence-based framework for quality improvement in social care coordination programs.

Introduction: Stroke care is time-sensitive, yet patients in low-resource settings may reach tertiary services only after passing through multiple formal and informal care options. This study examined documented care-seeking pathways and time to presentation among stroke cases recorded at the University of Medical Sciences Teaching Hospital (UNIMEDTH), Ondo State, Nigeria. Methods: A retrospective hospital record review was conducted using secondary data from the Stroke Registry, radiology department records, referral notes, and ambulance records at UNIMEDTH. The analysis included 371 stroke cases with documented time from symptom onset to UNIMEDTH presentation and reconstructable care pathways. First-contact routes were classified as hospital/biomedical, self/informal or traditional/faith-based care, and the number of documented steps defined pathway complexity before and including tertiary presentation. Frequencies and percentages described pathway patterns; median presentation times were compared using Mann-Whitney U and Kruskal-Wallis tests. Results: The median time to tertiary presentation was 24 hours (interquartile range [IQR] 9-72), and 317 patients (85.4%) presented after four hours. Only 30 patients (8.1%) presented directly to UNIMEDTH; 44 distinct care-pathway sequences were recorded. Hospital-facility first contact was documented for 81 patients (21.8%). It was associated with a median presentation time of 3 hours (IQR 2-6), compared with 48 hours (IQR 24-72) among patients whose initial contact was outside a hospital facility (U = 699.50, p < 0.001). The median time also differed across grouped first-contact categories and pathway complexity levels (both p < 0.001). Conclusion: Non-hospital or multi-step care-seeking pathways commonly preceded tertiary stroke presentations in this setting. The findings indicate that delayed tertiary arrival is partly embedded in the pathway followed after symptom onset. Interventions should combine public recognition of stroke warning signs with urgent referral linkages involving hospitals, patent medicine vendors, traditional and faith-based providers, and emergency transport systems.

Background: Dengue is a major public health problem in Brazil, and Minas Gerais is one of the states with the highest burden. In January 2019, the Brumadinho dam collapse released about 12 million cubic meters of iron ore tailings into the Paraopeba River basin, causing environmental disturbance that could plausibly affect vector habitats and dengue transmission. We evaluated the spatiotemporal dynamics of dengue in Minas Gerais from 2014 to 2023 and tested whether the disaster was associated with changes in affected municipalities. Methods: We performed an ecological spatiotemporal analysis using dengue notifications from SINAN for all municipalities in Minas Gerais (2014-2023). Municipalities were classified as Paraopeba basin, regional controls, or state controls. Temporal similarity was assessed using Pearson correlation-based hierarchical clustering and non-metric multidimensional scaling (NMDS). Sources of variation were examined with PERMANOVA and principal component analysis (PCA). A linear mixed-effects model with municipality as a random effect was used to test changes after 2019, with pre/post contrasts estimated from marginal means. Results: Dengue showed strong temporal synchrony across the state, with major epidemic peaks in 2015-2016, 2019, and 2023. Health region explained 31.5% of the variation in temporal incidence profiles (p = 0.001), whereas Paraopeba basin status explained no significant variation (p = 0.998). No temporal cluster was enriched for municipalities in the Paraopeba basin. PCA identified 2023, 2019, and 2016 as the main years driving variability. In the mixed model, year was significant (p < 0.001), but Paraopeba basin status and its interaction with time were not. Incidence increased significantly after 2019 in non-exposed municipalities (p < 0.001), but not in basin municipalities (p = 0.088). Conclusions: Dengue dynamics in Minas Gerais were driven mainly by regional and state-wide epidemic processes, with no significant independent effect of the Brumadinho dam collapse on notified dengue patterns.

Introduction: Early hospital presentation after stroke onset is necessary for rapid assessment and access to time-dependent acute management. This study examined the correlates of late presentation for stroke care among patients recorded at a tertiary hospital in Ondo State, Nigeria. Methods: A retrospective records review was conducted using secondary data from the Stroke Registry of the University of Medical Sciences Teaching Hospital, radiology department records, referral notes, and ambulance records. Records of stroke cases documented within the preceding 24 months were reviewed. Late presentation was defined as hospital presentation more than four hours after symptom onset. Frequencies, chi-square tests, and modified Poisson regression with robust standard errors were used to estimate adjusted prevalence ratios. Results: The analysis included 371 stroke cases. Of these, 317 (85.4%) presented after four hours, and the median time to presentation was 24 hours (interquartile range: 9-72 hours). Late presentation differed significantly by employment status, first-contact route, and pathway complexity at bivariate analysis. After adjustment, non-hospital first contact remained strongly associated with late presentation: patients whose first documented contact was non-hospital-based had almost 3 times the prevalence of delay compared with those whose first contact was hospital-based (adjusted prevalence ratio = 2.89; 95% confidence interval: 2.15-3.90; p < 0.001). Conclusion: Late presentation was pervasive in this tertiary hospital record cohort and was primarily associated with the initial direction of care-seeking. Stroke response interventions should emphasise immediate hospital presentation and strengthen urgent referral from non-hospital first-contact points.

IntroductionOccupational stress among rescue workers is a major global public health concern. Rescue workers, including paramedics, firefighters, and disaster response teams, are consistently exposed to traumatic events, long working hours, physical hazards, and emotionally charged situations. These chronic stressors make them one of the most vulnerable groups to psychological distress, burnout, anxiety, depression, and post-traumatic stress disorders. In the local context of Pakistan, workplace mental health remains a neglected area. Despite stress and burnout being widely reported in these sectors, limited evidence-based interventions are available. Therefore, the study aims to develop and evaluate a locally tailored intervention to improve the mental health and psychosocial well-being of rescue workers. ObjectivesO_LITo develop a culturally appropriate stress management intervention to promote mental health for rescue workers in Rawalpindi. C_LIO_LITo validate the content and structure of stress management intervention for rescue workers C_LIO_LITo evaluate the effectiveness of stress management intervention for rescue workers in Rawalpindi C_LI MethodThe ethical approval of the study has already been obtained from the ethical review board of Health Services Academy (00013/HSA/PhD-2022) and Rescue 1122 District Headquarters, Rawalpindi. Data will be collected after obtaining informed written consent from relevant stakeholders. Data collection will start from April 2026 and will be completed in six months. Data compilation and results are expected by December 2026. Data collection will involve a scoping review to explore stress determinants and intervention components, and then a qualitative phase in which data will be collected through focus group discussions from potential Stakeholders (rescue workers, mental health experts, and program managers) to identify and validate stress determinants. Triangulation of data will be done to integrate qualitative findings with findings from the review. In the second phase, validation will be done by intervention development experts. The third phase aims to evaluate the effectiveness of the developed intervention using a quasi-experimental pre-post design. A total of 154 participants evaluated with the Perceived Stress Scale Score will be employed through a stratified sampling technique. The primary outcome is defined as remission from stress at 3 months, measured with the PSS. DiscussionIt is anticipated that the study will result in the development of a culturally appropriate and evidence-based stress management intervention for rescue workers, thus contributing to sustainable improvement in rescuers mental health and job performance.

Strengthening the resilience and inclusivity of primary health care (PHC) systems during crises is critical to achieving equitable access to health care in low-income countries. The COVID-19 pandemic exposed significant weaknesses in PHC systems, highlighting gaps in inclusivity and resilience, particularly for persons with disabilities (PWDs). Although studies have examined PWDs, few have applied systems thinking approaches such as Group Model Building (GMB). This study aimed to develop a resilient and inclusive PHC system to improve access to services and vaccine uptake among PWDs during pandemics. A mixed-methods design incorporating GMB was employed in three phases. First, quantitative and qualitative data were collected to identify barriers and facilitators to PHC access and vaccine uptake. Second, a stakeholder GMB workshop was conducted in Monze to map system dynamics and develop causal loop diagrams. Third, validation and refinement meetings were held, including a final workshop in Lusaka. Findings identified key endogenous system drivers influencing vaccine uptake and access to PHC services and consumables, including financing mechanisms, human resources, outreach services, transport, staff commitment, and availability of accessible information such as Braille materials. These interact through reinforcing and balancing feedback mechanisms. In addition, critical contextual (exogenous) drivers such as political will, health insurance, community gatekeepers, and road networks shape system performance and influence access and service delivery. Strengthening both endogenous system drivers and contextual factors through inclusive strategies, coordinated financing, and supportive governance is essential for building resilient PHC systems that improve equitable access and vaccine uptake among PWDs during health crises. These findings contribute to Universal Health Coverage and equity by showing that strengthening both health systems drivers and contextual drivers is essential to ensure inclusive, accessible, and fair delivery of PHC services for all populations, including persons with disabilities.

Background: Mass gathering events (MGEs) are associated with several public health challenges and may cause a strain on healthcare services. Literature findings on the impact of MGEs on emergency departments (EDs) are heterogeneous. Objectives: To examine shifts in ED attendance characteristics during a major sporting tournament, namely the UEFA European Football Championship 2024 held in Germany. Methods: We conducted a retrospective observational study using ED data from the Emergency Department Data Registry. We compared baseline ED attendance characteristics between the tournament and the reference period, defined as two weeks before and two weeks after the tournament, and between Germany game days and non-Germany game days. Hourly attendance patterns were analysed for all Germany games using a reference range. Results: We included data from 41 EDs, totalling 253,493 attendances during the study period. A 1.57% increase in attendance was observed during the tournament compared to the reference period, with baseline characteristics remaining similar. The median daily attendance within all EDs was slightly lower on Germany game days (4066) compared to non-Germany game days (4128). Modest changes were observed in the hourly attendance on Germany game days, most notable during the last Germany game where a decrease in attendance below the reference range extended over three hours. Conclusions: The observed shifts in ED attendance were minimal, suggesting that no major changes of public health relevance occurred in ED attendance during the tournament. We highlight the utility of using ED data for monitoring and for enhancing the understanding of the public health risks and challenges associated with MGEs.

Background Despite existing road safety regulations, commercial motorcycle riders commonly referred to as "Boda Bodas" in Uganda continue to experience high rates of injuries due to road traffic accidents resulting from unsafe riding behaviours, contributing significantly to morbidity and mortality among both riders and passengers. Safe riding behaviours are less well documented, as well as factors associated with the observance of those behaviours. This study aimed to determine factors associated with safe riding behaviors for both boda-boda riders and their passengers in Kampala Central Division. Methods A cross-sectional survey study design was conducted using a convergent parallel mixed-methods design guided by the PRECEDE model. Quantitative data were collected from 424 riders through structured questionnaires administered by trained research assistants. Binary Logistic regression was used to determine the independent predictors of safe road riding behaviors, and Adjusted Odds ratios (AORs) have been reported. Data were analyzed using descriptive and inferential statistics, with a p-value <0.05 considered statistically significant. Qualitative data were collected simultaneously with quantitative data through in-depth semi-structured interviews with 10 passengers to capture perceptions of rider behaviors and safety practices. Thematic analysis was applied, and results were triangulated to highlight convergences and divergences between quantitative and qualitative findings, providing a comprehensive understanding of safety determinants for both riders and passengers. Results Of the 424 riders (mean rider age was 29.56 {+/-} 5.71), overall, 276 (65.1%) of riders exhibited unsafe riding behaviors. In the bivariate analysis with Logistic regression, predisposing factors (education, marital status, religion, and willingness to obey traffic regulations), and reinforcing factors (family encouragement) were significantly associated with safe riding behaviors. However, in the adjusted model, secondary (AOR=0.50; 95% CI:0.30-0.85) and post-secondary education (AOR=0.57; 95% CI:0.33-0.98), being married (AOR=0.56; 95% CI:0.34-0.91), Christian religion (AOR=2.98; 95% CI:1.63-5.47), willingness to obey traffic regulations (AOR=0.41; 95% CI:0.24-0.70), union advocacy (AOR=1.76; 95% CI:1.03-3.01), and well-maintained roads (AOR=1.65; 95% CI:1.07-2.55) were significant predictors of safe riding behaviors. Qualitative interviews further highlighted barriers to safety, including a lack of helmets, over-speeding, disregard for traffic regulations, and poor road infrastructure. Conclusions Rider and passenger safety is still low, interdependent, and influenced by multiple factors. Integrated interventions focusing on education, stronger families, religious affiliations, union safety advocacy, and stricter enforcement of traffic regulations are vital for enhancing safety for both riders and passengers.

Introduction: Even though state minimum wage (MW) is a policy lever that affects income and poverty and can prevent of violence, no prior study has comprehensively evaluated its impact in the United States (US). In this study, we estimated the impact of at least a $1 USD increase in state MW above the federal MW on overall, firearm, and non-firearm homicide mortality and examined its impact on racialized inequities. Methods: We conducted a quasi-experimental study using controlled interrupted time series (CITS) and synthetic controlled interrupted time series (SCITS) approaches to examine immediate and sustained impact of state MW increases. We used state-month level homicide victimization mortality data from 2010-2019. Homicide victimization death was identified using International Classification of Disease codes, 10th revision. State MW data was obtained from the Bureau of Labor Statistics. Results: Demographic and social variables from intervention, never-exposed, and always-exposed states were similar to each other and representative of the total US population from all 50 states. The CITS results show that after MW increases in the intervention states, these states experienced a sustained decline of -0.22 (-0.37, -0.07) homicide victimizations/ 100,000 person-years/ year relative to the never-exposed states and -0.39 (-0.59, -0.18) relative to always-exposed states. This resulted in 5,657 fewer homicide victimization deaths in the intervention states over four years of post-MW increase period compared to the never-exposed states. SCITS results were similar to the CITS results, and the majority of sustained declines were observed in firearm-related deaths and among Black population. Conclusion: MW increase was associated with a reduction in homicide victimization rates, which were robust in multiple sensitivity analyses, more pronounced for firearm-related homicide deaths, and reduced homicide victimization inequities for Black Americans.

Healthcare waste (HCW) management is a critical determinant of occupational safety, infection control, and environmental protection, particularly in low- and middle-income settings. Using the knowledge-attitude-practice (KAP) framework, this study assessed cognitive, behavioral, and institutional dimensions of HCW management among healthcare workers in urban Bangladesh. A cross-sectional survey was conducted among 342 cleaners and nurses in hospitals in the Chattogram Metropolitan Area (CMA) and Cumilla City Corporation (CuCC). Marked disparities were observed across professional groups. Training coverage was significantly lower among nurses than cleaners in CMA (22.5% vs. 48.7%; p = 0.002), whereas in CuCC nurses showed higher coverage (69.0% vs. 52.3%; p < 0.01). Knowledge of color-coded waste segregation was generally inadequate, with only 39.3% of CMA cleaners correctly identifying pharmaceutical waste bins compared with 60.0% of nurses (p < 0.01); CuCC nurses demonstrated substantially higher awareness (82.8%). Attitudinal indicators favored nurses, with strong hygiene and environmental risk awareness (95-100%) compared with cleaners (66-87.3%; p < 0.001). Despite this, compliance with segregation practices remained low across both sites (<30%). Several institutional support indicators were more favorable among nurses, particularly in CuCC. These findings indicate a significant knowledge-practice gap, emphasizing that effective HCW management requires not only training but also strengthened institutional structures and enforcement mechanisms to reduce public health and environmental risks.

BackgroundHealthcare workers are at increased risk of post-traumatic stress disorder (PTSD) due to prolonged exposure to high-stress clinical environments. Although the Health Belief Model (HBM) has been widely used to explain health behaviors, its application to psychological outcomes such as PTSD remains limited. The role of cognitive-emotional processes, particularly experiential avoidance, in linking health beliefs to trauma symptoms is not well understood. MethodsThis study adopted a quantitative cross-sectional design to collect data from 475 healthcare workers in Ekiti State, Nigeria. Participants completed standardized measures assessing Health Belief Model constructs, experiential avoidance, and PTSD symptoms. Data were analyzed using Partial Least Squares Structural Equation Modeling (PLS-SEM), with bootstrapping used to test direct, indirect (mediation), and moderation effects. Cluster analysis was also conducted using SPSS to validate differences in PTSD symptom severity across psychological constructs and demographic variables. ResultsExperiential avoidance significantly predicted PTSD symptoms ({beta} = 0.395, 95% CI [0.231, 0.565]). HBM constructs were negatively associated with experiential avoidance ({beta} = - 0.198, 95% CI [-0.270, -0.108]) and PTSD symptoms ({beta} = -0.119, 95% CI [-0.216, -0.006]). Mediation analysis indicated that experiential avoidance partially mediated the relationship between HBM constructs and PTSD ({beta} = -0.078, 95% CI [-0.132, -0.037]), with a total effect of - 0.197. Age moderated the relationship between HBM and experiential avoidance ({beta} = -0.114, 95% CI [-0.207, -0.025]) as well as the indirect pathway to PTSD. Sex significantly predicted PTSD symptoms ({beta} = 0.358, 95% CI [0.214, 0.501]). Cluster analysis showed that experiential avoidance and perceived barriers significantly differentiated high and low PTSD symptom groups. ConclusionThe findings support a conditional cognitive-emotional model in which Health Belief Model constructs influence PTSD symptoms both directly and indirectly through experiential avoidance. Demographic factors shape the strength of these relationships, while perceived barriers and experiential avoidance emerge as key determinants of trauma-related distress among healthcare workers.

Essential medicines are one of the cornerstones of financial protection and health equity. The REMEDIAR Program is an initiative of the Argentine Ministry of Health aimed at ensuring free access to essential medicines for the uninsured at the point of care in primary healthcare centers (PHC). This study analyzes the financing, procurement, and distribution of this program over two decades (2002 to 2024). It evaluates how the program's capacity to navigate economic and political challenges ensured an uninterrupted supply of essential drugs at the primary healthcare level in a federal country where health services are devolved to provinces. We adopted a mixed-methods approach to examine the duality between international concessional loans and domestic treasury funding. Findings reveal that while international financing enhanced predictability and efficiency, reducing procurement timelines from 458 to 235 days, it also constrained domestic planning through external conditionalities. Conversely, while national centralized procurement achieved superior price efficiency and lower dispersion, it faced rigidities in adapting to local needs. Territorial distribution analysis confirms that REMEDIAR reduced access barriers for vulnerable households without formal insurance. However, the program entered a stabilization phase, failing to consolidate robust coordination with subnational policies, becoming entrenched in its own operational logic. The study concludes that program effectiveness depends not only on resource volume but on management quality. To guarantee long-term sustainability, transition to national financing requires profound institutional redesign. This must integrate operational capacities with federal coordination and domestic regulations, ensuring that the primary healthcare supply chain remains resilient to macroeconomic volatility and political shifts, aligned with sub-national strategies.

Resuscitation in the oldest old at the end of life is associated with potential harm, raising concerns about misalignment with patients goals of care. This study aimed to elucidate changes in the use of resuscitation among the oldest old in Japan following the revision of the national guideline on end-of-life care which explicitly incorporates the concept of advance care planning. We conducted a repeated cross-sectional study using the National Database of Health Insurance Claims Open Data, including adults aged [&ge;]85 years, from April 2014 to March 2024. The annual number of resuscitation procedures per 100,000 individuals aged [&ge;]85 years was used as the measure of frequency. Resuscitation included closed-chest cardiopulmonary resuscitation (CPR) and endotracheal intubation. Interrupted time series analysis was used to examine changes following the 2018 revision of the national end-of-life care guideline. The frequencies of CPR and endotracheal intubation declined before 2018 (CPR: age 85-89, -68.4 [-87.9 to -48.8]; age [&ge;]90, -106.7 [-131.5 to -82.0]; intubation: age 85-89, -57.5 [-71.8 to -43.2]; age [&ge;]90, -69.5 [-80.7 to -58.3]), but the decline attenuated thereafter (CPR: age 85-89, +56.2 [28.0 to 84.5]; age [&ge;]90, +84.1 [50.7 to 117.6]; intubation: age 85-89, +36.6 [8.5 to 64.7]; age [&ge;]90, +38.3 [23.8 to 52.8]). These findings provide insight into the changes in resuscitation trends following policy interventions supporting end-of-life decision-making. Further studies are needed to better understand the mechanisms underlying this change.

Background Cancer is a growing public health challenge in low- and middle-income countries, where urbanization, nutritional transition and lifestyle changes contribute to modifiable risk factors. In Mauritania, population-based data on cancer-related nutritional, behavioral and anthropometric risk factors remain limited. Objective To describe the frequency of the main nutritional, behavioral and anthropometric cancer-related risk factors among adults living in the three wilayas of Nouakchott. Methods A cross-sectional study was conducted among 1,000 adults aged 18 years and older in Nouakchott. Data were collected using a standardized questionnaire covering sociodemographic characteristics, dietary habits, physical activity and selected health behaviors. Anthropometric measurements were performed to assess body mass index and abdominal adiposity. Abdominal obesity was defined using sex-specific waist circumference cut-off points recommended by the World Health Organization: [&ge;] 88 cm in women and [&ge;] 102 cm in men. Results were presented as frequencies and proportions, with comparisons by sex, age group and wilaya of residence. Results Women represented 52.0% of participants, and 53.5% were aged 18-34 years. Excess body weight was frequent, with 38.6% overweight and 28.0% obese. Abdominal adiposity was also common, with 58.0% having increased or substantially increased waist circumference and 48.3% having an elevated waist-to-hip ratio. Physical inactivity was reported by 64.7% of participants, and 15.7% were current smokers. Dietary exposures included high red meat consumption in 66.8%, daily refined cereal intake in 67.5%, daily sugar-sweetened beverage consumption in 14.9%, and limited daily fresh fruit consumption in 13.8%. Significant differences were observed by sex for anthropometric indicators, by age for selected dietary habits, and by wilaya for physical activity, smoking and selected dietary behaviors. Conclusion This study shows a high frequency of modifiable cancer-related risk factors among adults in Nouakchott, particularly excess body weight, abdominal adiposity, physical inactivity and unfavorable dietary habits. These findings support the need to strengthen primary prevention strategies targeting nutrition, physical activity and tobacco control in Mauritania.

Women shoulder the majority of water collection labor globally, yet how their water collection and water-related work experiences may change over time or by water source type remains insufficiently understood. We conducted a longitudinal, mixed-methods study in rural Kenya and Honduras to understand how women's experiences collecting water and performing water-related work varied between (a) two time points, (b) improved and unimproved water source types, and (c) water source location. Data were collected in 2023 and 2024 using interviews, observation, GPS-enabled watches, and scales to measure time and distance traveled, water weight and volume carried, and calories expended. 133 women participated in data collection (66 Kenya, 67 Honduras). We compared women's experience data by time point (2023 vs. 2024), source type (improved vs. unimproved), and source location (off-premises vs. on-premises) (t-test, Mann-Whitney U test). We also mapped participants' routes and activities to show which sources were visited, when, and for what activities. In Kenya, mean water collection time, distance, and caloric expenditure were significantly lower and water volume was significantly higher in 2024 when there were unexpected rains compared to 2023 when there was a persistent drought. When comparing source types during the 2023 drought, journeys to improved sources took significantly less time and energy and covered less distance than journeys to unimproved sources. These differences were not observed during the rainy conditions of 2024 when unimproved sources were closer and more accessible. In Honduras, water collection and water work burdens did not differ significantly by time point or source type. We found women with on-premises water access to still expend considerable time and caloric expenditure engaging in water work within their household compounds. Findings from Kenya suggest that water infrastructure improvements can reduce women's water collection burdens, though benefits may depend on and vary by season and source location. Findings from Honduras show that water labor does not end once water is in the household. Rather, substantial time and energy are expended carrying out water-related work even when sources are on premises, suggesting that efforts to assess water labor need to extend beyond collection alone. To meaningfully reduce burdens and ensure improved water sources are utilized during all seasons, initiatives need to consider source location, seasonal variability, and work beyond collection. Evaluations to assess infrastructure impacts on women's labor and well-being are needed and long overdue.

Introduction Gender norms and roles are important determinants of physical and mental health in the key period of adolescence. Yet, the gendered pathways to mental health in adolescents are not fully understood. Using a conceptual framework for global adolescent mental health that we developed based on a Delphi process, we empirically investigated the associations between six gender-related constructs and adolescent mental health. Methods We used cross-sectional Gender and Adolescence: Global Evidence (GAGE) data from Ethiopia (2020) to explore the associations between sex, gender norms, psychological competencies, gender attitudes, gender roles, with the latter two also serving as mediators, and psychological distress (GHQ-12), using Structural Equation Modelling (SEM). Results The SEM model contained measurements from 1,584 adolescents, including 843 girls and 741 boys, with a median age of 13 years. Out of 14 pathways tested, we found statistically significant associations between psychological competencies and psychological distress; sex and gender attitudes; and between gender norms and psychological competencies, gender attitudes, and gender roles. Hence, the gender-related constructs were mostly associated with each other, rather than with psychological distress. Conclusion The gender-related constructs are strongly interrelated, thereby attenuating their individual effects on psychological distress. The interplay of gender-related constructs should be considered when developing interventions to promote mental health in adolescents.

Youth in the United States are experiencing growing mental health challenges, yet many face barriers to accessing timely, affordable, and stigma-free support. At the same time, artificial intelligence (AI) chatbots have become widely available and are increasingly being used by young people as tools for information seeking, coping, and self-reflection. This brief report explores how youth are engaging with AI chatbots for mental health support, drawing from qualitative interviews conducted in New Jersey. Nine semi-structured interviews were completed with participants ages 19-22. Thematic analysis revealed five core themes: (1) generational change, peer communication, and humor as coping and normalization tools; (2) internal and external barriers to self-recognition and help-seeking; (3) AI chatbots as a safe and accessible first step; (4) AI chatbots as a tool for filling information gaps; and (5) limits of AI chatbots and the preference for human connection. These findings indicate that young people see AI chatbots as private, judgment-free starting points for exploring their emotions and seeking early support. However, they also recognize that these tools cannot replace human connection or professional care. For public health, this presents both challenges and opportunities in utilizing the accessibility of AI chatbots while ensuring ethical design, cultural responsiveness, and protections that safeguard youth privacy and equity.