Disaster Medicine and Public Health Preparedness

Introduction Louisiana ranks last in the United States of America in terms of maternal health outcomes. Previous works have highlighted the impact of some social determinants of health on the incidence of adverse birth outcomes. These works have subjectively selected specific social determinants of health from larger datasets. Here, we attempt to replicate their results with objective variable selection techniques. Methods By deriving principal components from the Agency of Healthcare Research and Quality's parish-level social determinants of health dataset, we were able to objectively find social determinants of health associations instead of the conventional subjective variable selection approach. Then, we applied Bayesian linear mixed-effects models to calculate more conservative parameter estimates about the effects of social determinants of health on adverse birth outcome incidence. Then, we used local Moran's I to identify clusters of spatially autocorrelated parishes. Finally, we combined the results of these two methods and inspected the relationship between important predictors and clusters of spatial autocorrelation. Results We identified several significant effects on the incidence of adverse birth outcomes, including populational composition and economic attainment, and several clusters of high and low incidences of adverse birth outcomes in Louisiana. There was also a concordant relationship between important predictors from our predictive models and the cluster assignments of Local Moran's I. Conclusion Our results validate previous works in the subject area and hold implications for precision development of maternal health interventions in Louisiana.

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

PurposeTo characterize maternal transport patterns in Iowa, a state with levels of maternal care and without formal perinatal regions, and assess whether transport decisions reflect efficient, risk-appropriate coordination. MethodsWe analyzed 2010-2023 Iowa birth records, which included 2,251 maternal transports between obstetric facilities across 106 unique routes. We characterized transport patterns and applied a community detection algorithm to identify "communities" of obstetric facilities that disproportionately transport among themselves. FindingsSuburban and rural counties have elevated transport rates compared to urban counties. 2,189 transports (97%) were from lower-to higher-level facilities. Among these, 2,037 (93%) were to Level III tertiary care centers. 567 transports (25.2%) bypassed a closer facility offering an equivalent or higher level of care than its destination facility. Health system affiliation was associated with bypassing transport, indicating potential organizational rather than purely geographic drivers of transport decisions. Three "communities" of obstetric facilities largely shaped by geographic proximity were identified. ConclusionsAlthough Iowa does not have formal perinatal regions, patterns of maternal transport are mostly in line with three de facto regions. Some potential inefficiencies were identified, such as obstetric facilities transporting to a farther facility when a closer facility offered the same level of care or higher. These findings may help identify opportunities to enhance care coordination among obstetric facilities, optimize maternal transport networks, and improve regionalization of maternal care.

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.

Scorpionism is a public health concern in warm regions, particularly affecting children under 10 years old. Timely treatment with antivenom, provided free by the Brazilian Unified Health System, at strategic care points (PEs) is crucial to prevent avoidable deaths. Our study focused on the Sao Paulo state (SP), which has the largest population in Brazil. The objectives were to adapt a network analysis method suited to SPs context; to assess the efficiency of the SP PE network coverage, considering the 90-minute response time; and to determine the ideal number of vials to be stored at each PE. After adapting the healthcare network analysis, we applied spatial coverage models to evaluate the adequacy of PE response times. We also estimated the demand for antivenom vials at each PE based on Notifiable Diseases Information System data from 2021 to 2023, which is currently limited to the state level. We identified 12 areas lacking coverage, of which only one was suitable for a new PE. The estimated serum requirements aligned with SP's current distributions. However, the estimation carried out according to the PEs has the advantage of reducing the risk of antivenom shortages, especially in emergencies, thus ensuring timely care to prevent avoidable deaths. Our adapted method and PE serum estimates can enhance the scorpion sting care system by supporting geographic planning and optimizing resource allocation. Moreover, these findings and methodologies have potential applicability to other Brazilian regions and warm countries facing similar challenges, contributing to improved access and outcomes for scorpionism victims.

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.

BackgroundDisparities in injury and death indicate that Latinos and Hispanics are disproportionately affected by firearm violence. Understanding the factors that impact Latino and Hispanic engagement with firearm safety is integral to developing nuanced interventions, yet these factors remain largely understudied. This study explores the social ecological factors related to firearm safety engagement among Latino and Hispanic adults residing in New Mexico. MethodsThe study used a convergent mixed-methods design with quantitative and qualitative components. Data were collected from a predominantly Latino-Hispanic community experiencing high rates of firearm violence near Albuquerque, New Mexico. Quantitative data (n=303) were collected using a community-based survey with a non-random sample on firearm safety engagement, collective efficacy, and sociodemographic characteristics. Qualitative data (n=18) included semi-structured interviews from a subset of the survey population who expressed interest in participating. Quantitative data was used to explore descriptive statistics and correlations between reported levels of collective efficacy and firearm safety engagement. Qualitative data were used to explore the firearm safety experiences of Latino and Hispanic participants. AnalysesMultivariate regression analyses examined associations between collective efficacy (exposure) and engagement with firearm safety (outcome). I also explored associations across key domains: collective efficacy, neighborhood characteristics, individual characteristics, and sociodemographic factors. Interviews were analyzed using framework analysis to generate a cohesive thematic structure informed by a social ecological model. The results from the quantitative and qualitative data were then integrated to develop a robust understanding of social ecological factors related to firearm safety engagement using a mixed methods joint display. ResultsThere were 303 survey participants (40.6% male; 55.1% female; 4.3% other gender identity) and 18 interview participants in this study. 57.1% of survey participants reported engaging with at least one firearm safety practice or initiative. Results from multivariate regression indicated that higher collective efficacy ({beta} = 0.082, p = 0.002), higher informal social control ({beta} = 0.174, p = 0.001), stronger endorsement of gun safety principles ({beta} = 0.079, p < 0.001), being married vs. unmarried ({beta} = -0.334, p < 0.001), speaking Spanish in the home vs. English ({beta} = 1.048, p < 0.001), and not owning a gun ({beta} = - 0.638, p = 0.006) were significantly and positively associated with firearm safety engagement. Themes from the qualitative data included barriers (insecure environment; lack of meaningful engagement) and facilitators (location-specific contributors to safety; collective identity and pride) to firearm safety engagement, organized by social ecological domain. Mixed methods findings indicate factors associated with participants individual firearm safety engagement, while providing insights into the perceived barriers and facilitators across social ecological domains. DiscussionFindings from this mixed-methods study suggest that processes of empowerment and collective efficacy may contribute to greater firearm safety engagement within Latino and Hispanic communities. Findings expand injury prevention research by exploring the factors influencing firearm safety engagement among a marginalized and hard-to-reach population who have disproportionate experiences with firearm victimization, perpetration, and injury. ConclusionThis study offers unique methodological approaches by using concurrent mixed methods and collecting complementary data sources to understand firearm safety engagement among Latinos and Hispanics. Findings highlight the need for culturally specific and community-engaged interventions that address social ecological disparities to strengthen safety practices and reduce firearm-related harms.

Misinformation circulating through digital platforms and community networks increasingly challenges public health communication, particularly in low-and middle-income countries. Frontline health educators play a critical role in addressing misinformation and promoting accurate health information within primary health care systems; however, empirical evidence on their preparedness to manage infodemics remains limited. This study assessed the training needs and response capacity of primary health care health educators in Lagos State, Nigeria. A convergent mixed-methods design was employed across three districts. Quantitative data were collected from 95 health educators using the 30-item Health Educators Infodemic Management Training Needs Assessment Questionnaire (HEIM-TNAQ). Qualitative data were obtained through six focus group discussions involving 56 educators and 25 key informant interviews with supervisors and programme managers. Quantitative data were analysed using descriptive statistics and t-tests, while qualitative data were analysed thematically. Participants demonstrated relatively strong knowledge of health misinformation (mean = 71.5), but only moderate decision-response skills (48.6) and low confidence in addressing misinformation (42.5). Integration of misinformation response into routine practice was also limited (46.3), and no significant differences were observed between respondents with or without prior training. Qualitative findings revealed frequent exposure to vaccine rumours, spiritual explanations for illness, and misinformation circulating through social media and community networks. Strengthening infodemic management within primary health care requires practical training, behavioural communication skills, and institutional mechanisms for systematic rumour monitoring and response.

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/Objectives: Women+ (e.g., women and individuals assigned female at birth) experience disproportionate health risks and persistent gaps in access to care, despite regionally coordinated health systems. Women+ health research remains significantly underfunded and understudied, contributing to inequities in diagnosis, treatment, and outcomes. This study aims to collaboratively identify and prioritize the most pressing unanswered research questions related to women+ health in the Maritime provinces of Canada. Methods: This study will use a modified Priority Setting Partnership (PSP) methodology based on the James Lind Alliance framework. A mixed-methods participatory approach will be used, including bilingual online surveys (French, English) and a one-day consensus workshop. Participants will include women+, healthcare professionals, researchers, policymakers, and the public residing in the Maritime provinces (Nova Scotia, New Brunswick, and Prince Edward Island). An initial survey will collect research uncertainties through open-ended questions. A second interim survey will rank verified uncertainties, followed by a facilitated workshop to achieve consensus on the Top 10 research priorities. Qualitative data will be analyzed using content analysis, and descriptive statistics will summarize participant demographics. Anticipated Results: This project is expected to generate a collaboratively developed, evidence-informed Top 10 list of research priorities for women+ health in the Maritimes. The process will also identify thematic gaps in existing research and assess feasibility considerations to inform future study design and implementation. Conclusions: By centering women+ voices and engaging diverse interest holders, this study will establish a shared regional research agenda to guide future research, funding, and policy initiatives for women+ health research.

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.

This study evaluates the feasibility of implementing artificial intelligence (AI)-driven disease surveillance systems at Julius Nyerere International Airport (JNIA) in Tanzania, a key hub for regional and international travel. Through a mixed-methods approach combining qualitative interviews and quantitative surveys, the research assesses the infrastructure, human resource capacity, and regulatory frameworks necessary for AI integration. Findings indicate that while Port Health Officers are strongly optimistic about AIs potential to enhance disease detection, the airport faces significant barriers, including outdated infrastructure, insufficient technical resources, and a lack of trained personnel. Ethical and privacy concerns, particularly surrounding data security, also emerged as key challenges, compounded by limited public awareness and the socio-cultural acceptability of AI systems. Furthermore, the study identifies gaps in national policies and inter-agency coordination that hinder the effective implementation of AI technologies. The research concludes that while current conditions render AI adoption infeasible, strategic investments in infrastructure, workforce training, and policy development could pave the way for future integration, enhancing public health surveillance at JNIA and potentially other airports in low- and middle-income countries. This study contributes critical insights into the barriers and opportunities for AI-driven disease surveillance in low-resource settings, specifically focusing on a high-priority transit point, international airports. It emphasizes the importance of region-specific solutions to enhance health security in East Africa and supports the broader global health agenda by advocating for international collaboration and the development of scalable disease surveillance systems. Future research should explore pilot AI implementations at other airports to evaluate real-world challenges and refine AI systems for broader applicability, including cost-effectiveness analyses and integration of public perspectives on AI.

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.

BackgroundImplementing proven vehicle safety standards recommended by the UN World Forum for Harmonization of Vehicle Regulations is among the most cost-effective strategies to reduce road traffic deaths. In 2022, Mexico approved updated vehicle safety standards, including side pole testing, electronic stability control, seatbelts, airbags, side structures, and anchorage child restraint systems. However, pedestrian protection and advanced driver-assistance technologies, such as autonomous emergency braking systems (AEBS), were excluded. These exclusions are critical, given that more than half of road traffic deaths involve vulnerable road users. Local evidence on the expected benefits of implementing comprehensive vehicle safety standards is needed to guide policy decision-making. ObjectiveTo estimate the potential public health impact of increasing the availability of recommended vehicle safety technologies in Mexico. MethodsWe conducted a comparative risk assessment analysis to estimate the impact of improving vehicle safety standards on road traffic deaths, injuries, and disability-adjusted life years. Counterfactual analyses were defined using traffic statistics for 2019 as baseline, relative risk estimates associated with each safety technology, and technology penetration within Mexicos vehicle fleet. Three scenarios were modeled: (1) full implementation of Mexicos 2022 standards; (2) addition of crashworthiness, AEBS, and motorcycle ABS/ESC; and (3) inclusion of expanded AEBS crash configurations, lane departure warning (LDW), and lane keeping assistance (LKA) systems. ResultsScenario 1 reduced deaths by 18%, injuries by 16%, and DALYs by 18%, with the greatest benefits for car occupants. Scenario 2 reduced deaths by 29%, injuries by 27%, and DALYs by 30%, benefiting motorcyclists and pedestrians the most. Scenario 3 reduced deaths, injuries, and DALYs by 41%, 38%, and 41%, respectively, benefiting car occupants and motorcyclists. ConclusionsCurrent vehicle safety standards in Mexico are expected to reduce deaths, injuries, and disabilities, yet existing guidelines focus largely on protecting car occupants. Mexico should strive to update and strengthen its current legislation by adding technologies that protect vulnerable road users, such as pedestrians and cyclists, and to focus on technologies for motorcycle users to further reduce the burden of road traffic injuries.

Introduction Antibiotic use drives antimicrobial resistance, and optimizing prescribing in skilled nursing facilities (SNFs) - which care for medically complex residents in congregate settings characterized by frequent care transitions and diagnostic uncertainty - presents unique challenges. Antimicrobial stewardship (AMS) in SNFs has therefore become a focus of quality improvement efforts by federal and state health agencies. We aimed to identify factors that facilitate and hinder AMS implementation in SNFs. Methods A qualitative study of AMS implementation was conducted in Southern Arizona SNFs randomly sampled to represent urban/suburban, border, and rural regions. Semi-structured interviews were conducted with administrators, clinicians, and nonclinical staff within participating facilities. Interview transcripts were analyzed using constant comparative analysis, with both directed and emergent coding, facilitated by NVivo 12 software. Findings From 04/13/2019 through 12/13/2019, 57 interviews were conducted with 9 administrators, 38 clinical providers, and 10 nonclinical staff across 6 urban/suburban, 2 border, and 2 rural facilities. Analysis identified two thematic categories: "influencer themes," which describe specific barriers and facilitators to AMS implementation, and "system themes," which characterize SNFs as complex adaptive systems shaped by interacting staff roles, care transition challenges, and differing perceptions of AMS practices within the same facility. Key facilitators included effective internal communication, ongoing AMS education, and clinician AMS champions. Primary barriers included poor interfacility communication during care transitions, limited access to diagnostic resources, enculturated prescribing norms, and tension between immediate infection control priorities and long-term AMS goals. Conclusions Findings suggest that AMS implementation in Arizona SNFs is best understood as a systems-level process emerging from interactions among staff roles, organizational workflows, and care transitions, rather than solely from individual prescribing decisions. Recognizing SNFs as complex adaptive systems highlights the importance of communication structures, local champions, and feedback mechanisms. It underscores the need for coordination strategies within and across SNFs to sustain AMS interventions.

BACKGROUND: Integrated WASH interventions are essential for improving public health by increasing access to safe water, sanitation, and hygiene services. This study evaluates their impact on water access and household knowledge, attitudes, and practices (KAP) in rural communities by comparing intervention and non-intervention areas. METHODS: A cross-sectional survey was conducted in May 2025 across six kebele administrations (three intervention and three control). Data were collected from 396 households with children under five using structured questionnaires, with equal representation from both groups. Descriptive analysis was applied to compare outcomes. RESULTS: Children in intervention areas experienced significantly lower diarrhea rates (2.5% vs. 34.9%). Households also showed improved health behaviors, including higher rates of facility births (88.9% vs. 63.6%), breastfeeding (98% vs. 89.9%), and vaccination (78.8% vs. 59.1%). Access to safe water improved markedly: all intervention households used protected sources, spent less time collecting water (13.9 vs. 55.8 minutes), and consumed more water daily (20.6 vs. 10.5 liters). Safely managed water services reached 59.6% compared to just 1% in control areas. Sanitation and hygiene practices were also better, with higher latrine access (95% vs. 78.3%), reduced open defecation (23.2% vs. 52%), and increased handwashing with soap (48.5% vs. 12.1%). Knowledge, attitudes, and practices were significantly stronger in intervention communities. CONCLUSION: Integrated WASH interventions significantly improve water access, hygiene practices, and child health outcomes. Sustaining these benefits requires continued investment in infrastructure, community awareness, and behavior change programs. KEY WORDS: Water, sanitation and hygiene, KAP, rural Ethiopia

IntroductionDuring the COVID-19 pandemic, incarcerated populations faced heightened risk of exposure due to healthcare barriers, restrictive environments, and pre-existing health conditions. Consequently, Correctional Officers (COs) faced increased risk of COVID-19 exposure. Given the health benefits of COVID-19 vaccination and the rise in vaccine hesitancy, this study examined the relationship between COs health beliefs and COVID-19 vaccine uptake. MethodsA health beliefs survey was administered to Massachusetts-based COs (n=118). Chi-squared Automatic Interaction Detection modeling and logistic regression was utilized to analyze the survey data. ResultsCOs with higher trust in vaccines and a prior positive COVID-19 test were most likely to get vaccinated voluntarily. Those with low trust in vaccines and no previous positive COVID-19 test were least likely to receive the vaccine. ConclusionDespite the severe impact of COVID-19 in correctional settings, and the evidence of vaccine efficacy against hospitalization and death, vaccine uptake among COs remains low.

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.