International Journal of Environmental Research and Public Health

Purpose: This study aimed to examine the effects of formative and summative assessments on college students tennis performance and basic psychological needs. Methods: A total of 128 undergraduate students (64 males, 64 females; Mage = 19.22, SD = 0.91) participated in this study. Participants were cluster-randomized to either a formative assessment group (n = 64) or a summative assessment group (n = 64). The formative assessment intervention involved setting personalized learning goals and success criteria, administering periodic tests, and providing process-oriented and individualized feedback. The summative assessment intervention involved setting uniform goals for all students, offering instructor feedback only on common problems, and requiring students to practice independently after class without personalized guidance. Both interventions were implemented over 10 weeks, with one 90-minute session each week. Tennis skills and basic psychological needs (i.e., autonomy, competence, and relatedness) were assessed before and after the intervention. Tennis skills were reassessed 1 week after the intervention. Two-way mixed-effects analysis of variance (ANOVA) was used to examine the impact of group, time, and their interaction on tennis skills and basic psychological needs. Results: The results showed that the interaction between group and time was significant for all of the outcome variables. Simple effects analyses indicated that, at pre-test, the two groups did not differ significantly in tennis performance or in satisfaction of autonomy, competence, and relatedness (p > 0.05). At post-intervention, the formative assessment group demonstrated significantly better performance than the summative assessment group in tennis skills (MD = 3.50, 95% CI = [1.303, 5.697], p = 0.002), autonomy (MD = 2.44, 95% CI = [1.816, 3.059], p < 0.001), relatedness (MD = 1.33, 95% CI = [0.679, 1.977], p < 0.001), and competence (MD = 1.75, 95% CI = [1.046, 2.454], p < 0.001). At the 1-week follow-up session, the formative assessment group also showed significantly better tennis performance than the summative assessment group (MD = 6.81, 95% CI = [4.667, 8.958], p < 0.001). Conclusion: Formative assessment was more effective than summative assessment in improving college students tennis performance and satisfying their basic psychological needs. These findings suggest that incorporating personalized goals, process-oriented evaluation, and individualized feedback into tennis instruction could promote both skill development and psychological outcomes in college physical education.

Background: China has implemented policies to strengthen its pharmacist workforce since the 2009 healthcare reform, yet a comprehensive evaluation of their long-term systemic effects is lacking. Objective: To systematically analyze the evolution of Chinas pharmacist workforce in healthcare institutions from 2007 to 2023 across four dimensions: quantity, quality, structure, and distribution, providing an empirical foundation for policy optimization. Methods: A retrospective analysis was conducted using longitudinal data from the China Health Statistics Yearbooks. Trends were delineated via descriptive statistics. Equity and spatial evolution were assessed using the Gini coefficient, Theil index decomposition, and spatial autocorrelation analyses (Global Morans I and hotspot analysis). Results: From 2007 to 2023, the total number of pharmacists increased from 357,700 to 569,500 (average annual growth: 2.2%). This growth lagged behind physicians (4.6%) and nurses (7.4%), causing the pharmacist-to-physician ratio to decline from 1:5.15 to 1:8.39. The workforce showed trends of feminization (female proportion rose from 59.7% to 70.8%) and aging. While quality improved, 51.1% still held an associate degree or below, and only 6.6% held senior titles. Equity analysis revealed the provincial Gini coefficient improved from 0.145 to 0.093. Theil index decomposition confirmed intra-provincial disparities as the primary inequality driver. Spatial analysis showed a non-significant global Morans I by 2023 (0.154, P*>0.05), down from 0.254 (P<0.01) in 2007. Hotspot analysis confirmed this transition, revealing a contraction of high-confidence clusters and a trend toward balanced distribution. Conclusions: China has made measurable progress in expanding pharmacist workforce size and improving inter-provincial equity since 2007. However, persistent structural challenges remain: relative workforce contraction compared to other health professions, an aging demographic, a shortage of senior talent, and significant intra-provincial inequity. Future policies must prioritize optimizing workforce structure and enhancing clinical service capabilities to catalyze a shift toward patient-centered pharmaceutical care.

Road traffic accidents represent a global public safety crisis, necessitating advanced computational tools for accurate injury severity prediction and effective decision support. This study evaluates high-performing ensemble machine learning models, including AdaBoost, XGBoost, LightGBM, HistGBRT, CatBoost, Gradient Boosting, NGBoost, and Random Forest, using a comprehensive National Highway Traffic Safety Administration (NHTSA) dataset from 2018 to 2022. While all models demonstrated exceptional predictive accuracy, with HistGBRT achieving the highest overall accuracy of 92.26%, a defining achievement of this work is the perfect classification (100% precision and recall) of fatal injuries across all ensemble architectures. To bridge the gap between predictive performance and actionable intelligence, this research integrates SHapley Additive exPlanations (SHAP) to provide both global insights into dataset-wide risk factors and local, instance-specific rationales for individual crash events. The global analysis identified ethnicity, airbag deployment, and harmful event type as primary drivers of injury severity, while local force and waterfall plots revealed the precise "push and pull" of variables for specific incidents. The results offer a robust, interpretable framework for stakeholders tasked with improving traffic safety and mitigating crash-related harm.

ObjectivesRising temperatures are a major climate-related hazard for U.S. workers, increasing heat-related illness and a broad range of occupational injuries through indirect pathways often overlooked in economic evaluations. We examined the association between temperature and occupational injury and illness and quantified heat-attributable injuries (including illnesses) and costs in New York State. MethodsWe conducted a time-stratified case-crossover study of 591,257 workers compensation (WC) claims during the warm season (2016-2024). Daily maximum temperature was linked to injury date and county and modeled using natural cubic splines, with effect modification by industry and worker characteristics. ResultsInjury risk increased with temperature, becoming statistically significant at approximately 78{degrees}F. Relative to 65{degrees}F, injury odds increased to 1.06 (95% CI: 1.01-1.10) at 80{degrees}F, 1.12 (1.07-1.18) at 90{degrees}F, and 1.17 (1.11-1.23) at 95{degrees}F. Overall, 5.0% of claims (2,322 annually) were attributable to heat. At temperatures [&ge;]80{degrees}F, an estimated 1,729 excess injuries occurred annually, generating approximately $46 million in WC costs. An estimated $3.2 million to $36.1 million in medical expenditures were associated with incomplete claims, likely borne outside the WC system. ConclusionsThese findings demonstrate substantial economic costs not fully captured within WC and support workplace heat protections as a cost-containment strategy that can reduce health care spending and strengthen workforce resilience.

With Japans rapidly aging population, demand for home healthcare is projected to increase by 62% by 2040. This study quantitatively evaluated accessibility to 24-hour home healthcare and regional disparities across all 335 secondary medical areas (SMAs) in Japan using the Enhanced Two-Step Floating Catchment Area (E2SFCA) method. We conducted a nationwide cross-sectional study analyzing approximately 430,000 population points at 500-meter mesh resolution. The E2SFCA integrated demand (age-adjusted population), supply (24-hour home care support clinics and hospitals), and transportation (road networks). Accessibility scores (ASs) and Gini coefficients were calculated for each SMA. Wards hierarchical cluster analysis classified regional types, and multiple regression based on the Penchansky and Thomas five-dimensional access framework identified factors associated with the median AS (ASM) and Gini coefficient. The median ASM was 45.71 (0.00-153.49), and the median Gini coefficient was 0.33 (0.06-0.93). Cluster analysis identified six types ranked by descending ASM, from C1 (high access, equitable; n = 48) to C6 (access desert; n = 23). C6 had a median ASM of 0.00 and Gini coefficient of 0.74, indicating virtually no access within a 30-minute catchment. Home-visit standardized claim ratios, used as external validation, declined monotonically from C1 (125.6) to C6 (17.6). For ASM, 24-hour visiting nursing stations ({beta} = +0.369) and clinic physicians ({beta} = +0.342) showed the strongest positive associations, with non-residential area negatively associated ({beta} = -0.273). For the Gini coefficient, non-residential area showed the strongest positive association ({beta} = +0.523). Taxable income per taxpayer was not significantly associated with either outcome. Non-residential area was associated with both lower accessibility and greater intra-regional inequality, suggesting that geographic constraints may limit the effectiveness of resource investment alone. Uniform nationwide implementation of policies shifting care from long-term care beds to home healthcare may not be feasible; region-specific approaches considering geographic characteristics are necessary.

Introduction: Physical inactivity and sedentary behaviour are significant risk factors for noncommunicable diseases. Engaging in regular physical activity (PA) during childhood is crucial for preventing long-term health burdens. This study examined PA levels and associated factors among upper primary school children in Lusaka, Zambia. Methodology: A cross-sectional survey was conducted from August to October 2022 among 638 children aged 9-18 years from six public and six private schools. Data were collected using the Physical Activity Questionnaire for Children (PAQ-C), Youth Risk Behaviour Survey (YRBS), Model of Youth Physical Activity Questionnaire (MYPA), and 3-Day Physical Activity Recall Questionnaire (3DPAR). Analyses included descriptive statistics, Chi-square, Fishers exact tests and multivariable binary logistic regression at a 0.05 significance level and 95% confidence interval. Results: Most participants (82%) were insufficiently active, with only 18% achieving sufficient PA. Reported barriers included lack of playgrounds or parks near home (p=0.012), neighbourhood safety concerns (p=0.041), and limited parental supervision (p=0.006). Watching television reduced the odds of PA by 69% (aOR=0.31; 95% CI: 0.13-0.75). Conversely, peer support increased activity by 15% (aOR=1.15, 95% CI: 0.67-1.97), while not being concerned about showering or fixing hair after PA increased activity by 94% (aOR=1.94; 95% CI: 1.21-3.11). Conclusion: The majority of school children in this study did not meet recommended PA levels. Barriers to activity included personal, parental, and environmental factors. Interventions should prioritise safe play spaces, increased parental and peer support, and reduced screen time to curb future non-communicable disease risks.

Ambulatory Care Sensitive Conditions (ACSCs) are conditions for which effective and timely primary health care (PHC) can prevent hospitalizations. They are widely used as a proxy indicator of access to and quality of PHC. Despite their relevance, evidence from Central America remains scarce. This study aimed to quantify the burden, describe the epidemiological profile, and assess temporal trends of ACSCs hospitalizations in Honduras from 2014 to 2024. We conducted a retrospective observational study using national administrative hospital discharge data from all Ministry of Health hospitals. ACSCs were defined using a standardized list of 20 diagnostic groups based on ICD-10 codes. We estimated percentages and sex-age-standardized hospitalization rates per 10,000 inhabitants. Clinical indicators included length of stay (LOS) and in-hospital fatality rates. Temporal trends were evaluated using joinpoint regression models to estimate annual percent changes (APC). Analyses included stratification by age, sex, and disease category. A total of 4,023,944 hospitalizations were analyzed, of which 547,486 (13.6%) were classified as ACSCs. The overall sex-age-standardized rate was 54.1 per 10,000 inhabitants. ACSCs' standardized rates increased between 2014 and 2018 (APC: 2.7%; 95% CI: -2.4; 15.2), declined sharply between 2018 and 2021 (APC: -17.8%; 95% CI: -30.6; -10.3), and increased again between 2021 and 2024 (APC: 15.9%; 95% CI: 4.6; 37.6). Despite this rebound, rates remained below pre-pandemic levels. ACSCs were concentrated among children under 5 years (27.7%) and adults aged 60 years and older (29.9%). Noncommunicable diseases accounted for 56.8% of cases, with diabetes mellitus as the leading cause. Compared with non-ACSCs hospitalizations, ACSCs were associated with longer LOS (4.9 vs. 3.9 days; p <0.001) and higher in-hospital fatality rates (2.4% vs. 1.7%; p <0.001). ACSCs hospitalizations constitute a substantial burden in Honduras and reflect persistent gaps in PHC performance. Strengthening PHC resilience and capacity, particularly for chronic disease management and vulnerable populations, is essential to reduce avoidable hospitalizations and improve health system efficiency and equity.

Cardiovascular disease (CVD) remains the leading cause of mortality in the United States, despite being largely preventable through effective management of risk factors. This study evaluates the impact of Phase II cardiac rehabilitation (CR) on functional capacity and quality of life, using data from the Montana Outcomes Project Cardiac Rehabilitation Registry. Functional capacity improvements were assessed via the six-minute walk test (6MWT) and Dartmouth COOP questionnaire, with statistical analyses exploring the influence of CR session attendance, demographic factors, and referring diagnoses. Results demonstrated significant gains in 6MWT, with a mean improvement of 330.73 feet (p < .0001), and quality of life scores across all subgroups. A dose-response relationship was observed, indicating greater improvements with increased CR sessions (p < .0001), though diminishing returns were observed beyond 24-35 visits. Demographic factors and complex conditions influenced outcomes, underscoring the need for tailored strategies to enhance CR access and effectiveness. These findings highlight the critical role of CR in improving patient outcomes and emphasize the importance of addressing barriers to participation in underserved populations.

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

Objectives: The primary aim of this study was to assess the feasibility of delivering an adapted problem-solving skills (PSS) intervention by quantifying the recruitment, follow-up and completion rates using a brief problem-solving intervention for people with a mental health diagnosis in two Polish prisons. Design: IAPPS is an open, multi-centred, parallel group feasibility randomised controlled trial (RCT). Setting: Two prisons in Poland. Participants: Men in custody aged 18 years and older, having a mental illness and living within the prison therapeutic unit. Interventions: The intervention consisted of an adapted PSS skills intervention plus care as usual (CAU) or care as usual only. Delivered in groups of up to five people in 1.5-hour sessions over the course of two weeks. Main outcome measures: Primary outcomes - rate of recruitment, follow-up, and feasibility to deliver the intervention. Secondary outcomes included measures of depression, general mental health, and coping strategies. Results: 129 male prisoners were screened, 64 were randomly allocated, with a mean age of 53.5 years (SD 14, range 23-84). 59 (95%) prisoners were of Polish origin. Our recruitment rate was 48%. There was differential follow up with those in the intervention group less likely to complete the post-test battery versus those who received care as usual. Outcome measures were successfully collected at both time points. Conclusions We were able to recruit, retain and deliver the intervention within the prison setting; some logistical challenges limited our assessment of intervention engagement. Our data helps to demonstrate how use of the RCT study design can be implemented and delivered within the complex prison environment. Trial registration number ISRCTN 70138247, protocol registration date May 2021

BackgroundPatients who have undergone Anterior Cruciate Ligament Reconstruction (ACLR) have a 6-24% chance of either re-tearing or having subsequent knee surgery. To date there have been no practical validated risk prediction models that can be easily implemented into clinical workflow for re-injury risk. Micro-Doppler radar (MDR) provides a promising solution. ObjectiveThe purpose of this study was to investigate the predictive ability of MDR to identify persons with a previous ACLR relative to an age and sex matched healthy control. MethodsACLR patients (n=81) and controls (n=100) performed drop box jump, sit to stand (STS), and walking trials as MDR signatures were collected. A 1D Convolutional Neural Network was developed to evaluate each activity individually followed by the development of a fusion model validation using all three activities. ResultsThe STS model individually achieved the highest overall accuracy of 82.3%, with a sensitivity of 71.6% and specificity of 91.0%. The fusion model using all activities achieved a peak overall accuracy to detect ACLR of 86.2%, 80.3% sensitivity, and 91% specificity. ConclusionsCurrently, there is no clinically validated, efficient approach to objectively evaluate human motion at the point of care. When coupled with machine learning, MDR accurately differentiates ACLR from control groups by identifying complex biomechanical asymmetries, with classification performance comparable to or exceeding that of motion capture. Future research is needed to determine if MDR can be used in conjunction with risk prediction modeling. Key pointsMicro-Doppler radar provides a promising new solution to identify important human motion asymmetries in clinical settings. Here we evaluated a group of patients who have a history of Anterior Cruciate Ligament reconstruction versus a control group. Simple movements performed in the presence of the micro-Doppler radar system were used to identify the 2 groups with accuracy comparable or superior to motion capture systems.

IntroductionOver one billion people worldwide have hypertension. In Zimbabwe, prevalence is an estimated 38%, surpassing the global average of 34%, and >50% of hypertensives are undiagnosed. The Community BP groups (Com-BP) study examined whether community groups of people living with hypertension, provided with BP machines and led by trained Facilitators could improve awareness, screening and support for those diagnosed with hypertension, to help blood pressure (BP) control. We present findings from the quantitative evaluation of the Com-BP pilot intervention. MethodsThe acceptability of the Com-BP intervention, its potential effectiveness in improving knowledge, attitudes and practices (KAP) and in reducing BP among hypertensive adults in Zimbabwe, was evaluated. Cross-sectional surveys using standardised questionnaires, and BP and Body Mass Index (BMI) assessments, were done at the start and end of the pilot intervention. Statistical evidence of difference between baseline and follow-up was examined using Wilcoxon signed-rank test for continuous data and McNemars test for categorical data. ResultsFourteen groups (seven urban and seven rural) were formed and 151 participants joined over a median of 5months. Retention in the groups was 97.9% (137/140 recruited at baseline), with approximately equal numbers from the urban and rural sites. Median age at baseline was 54 years (IQR 45-66y; min-max 30-92y) and the majority (79%, n=108) were female. Most participants (82.5%, n=113) rated their experience of the group sessions as excellent. The proportions of participants with changes in KAP from baseline to endline were as follows: 45.3% (n=62) to 81.0% (n=111) (p=0.004) able to identify at least two pre-disposing factors for hypertension; 65.0% (n=89) to 77.4% (n=106) (p=0.02) reporting [&ge;]1day of vigorous physical activity/week; 28.5% (n=39) to 13.9% (n=19) (p=0.001) reporting salt added to meals at the table. There was no statistical evidence of any difference in medication adherence, p=0.06. The proportion of participants with uncontrolled hypertension was 58.1% (n=79) at baseline and reduced to 31.8% (n=43) at follow-up (p<0.001). DiscussionCommunity groups for improving awareness, detection and support are acceptable and led to improvements in self-reported KAP and prevalence of uncontrolled BP. Further research on the sustainability and impact of the intervention is required.

IntroductionIncreasing global prevalence of overweight and obesity underscores the need for context-specific evidence to guide preventive policy implementation. Previous modelling showed that promoting healthy indigenous foods, implementing a 20% tax on sugar-sweetened beverages (SSBs), and introducing mandatory kilojoule menu labelling in formal-sector restaurants in Kenya were health-promoting, cost-saving, and cost-effective. Cost-effectiveness evidence is strengthened when considered alongside broader policy implementation considerations. We engaged stakeholders to assess additional implementation considerations relevant to decision-makers and to evaluate the stakeholder engagement process used in the modelling study. MethodsUsing the Assessing Cost-Effectiveness approach, we conducted a stakeholder-engaged study with national-level Kenya stakeholders recruited through purposive and snowball sampling. Through deliberative dialogue at a hybrid workshop, stakeholders assessed implementation considerations such as equity, feasibility and sustainability using a colour-coded scoring tool. We evaluated the engagement process using an anonymous survey covering seven stakeholder-engaged research domains. We analysed responses thematically. ResultsAcross the three interventions, most implementation considerations for feasibility, reach and impact, affordability, acceptability, and sustainability were assessed as medium or high. Industry acceptability of kilojoule labelling and SSB tax and affordability of kilojoule labelling to industry were rated low. Equity scores varied. Stakeholders proposed complementary measures that could raise low ratings to favorable scores. Clarity on stakeholder roles was identified as a key strength of the engagement process, while competing time commitments limited participation. ConclusionStakeholder insights contextualise prior cost-effectiveness evidence within policy-relevant implementation considerations and inform current fiscal and regulatory debates. Evaluation of the stakeholder engagement process underscores its contribution to strengthening public health research.

Lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+) students continue to face violence, exclusion, and barriers at school, including in STEM education. A key underexamined factor in diversity, equity, and inclusion (DEI) efforts is the content of the life science curriculum, which is uniquely positioned to reinforce or refute bioessentialist, binary, and heteronormative biases. Outdated science curricula not only conflict with current scientific evidence but can also perpetuate beliefs that contribute to sexism and LGBTQIA+ marginalization. To address this, we designed four gender and sexual diversity (GSD)-inclusive biology activities, aligned with NGSS standards, and informed by inclusive curriculum frameworks. Using a mixed-methods approach, we studied 127 high school students who participated in two or more inclusive biology activities. Surveys conducted before and after implementation showed significant reductions in essential, binary beliefs about sex and gender, and increases in affirming attitudes toward sex and gender diversity. Interviews conducted after implementation further revealed differences between LGBTQIA+ and straight students conceptualizations of biological sex. Our findings demonstrate that even brief curriculum interventions can shift student attitudes, although we hope future studies will explore the impact of sustained interventions. Updating life science instruction is essential for educational equity and scientific accuracy.

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.

BackgroundDrowning remains a major global public health challenge. This study examined whether the timing and trajectories of urbanisation--beyond the current built environment--are associated with subnational drowning mortality. MethodsWe linked satellite-derived measures of built-environment change (GHSL), population crowding (WorldPop), surface water exposure (JRC Global Surface Water), and infrastructure proxies (VIIRS/DMSP nighttime lights) to GBD 2021 drowning mortality estimates across 203 ADM1 regions in 12 countries (2006-2021; 3,248 region-year observations). Temporal predictors captured recent expansion, development "newness" ([&le;]10-year built share), acceleration/volatility, and a crowdingxgrowth interaction. We screened predictors using LASSO (10-fold cross-validation) and fitted mixed-effects models with region random intercepts. Distributed-lag models tested temporal precedence and development age, and income-stratified models assessed heterogeneity. ResultsAdding temporal predictors improved fit beyond contemporaneous built-environment measures ({Delta}AIC=177; {Delta}BIC=147). In adjusted models, crowdingxgrowth was strongly positively associated with drowning mortality, and a higher share of recent development was associated with higher mortality. Lag models showed a development age gradient: older built environment was most protective. Associations differed by income group, with several key coefficients reversing sign across strata. DiscussionDrowning mortality appears shaped by development histories as well as present-day conditions, with risk concentrated in rapidly changing, dense settings and the newest built environments. Cross-context heterogeneity suggests mechanisms and prevention priorities are unlikely to be uniform. ConclusionsDevelopment timing and trajectories help explain subnational drowning mortality beyond current built form alone. Prevention and planning should prioritise transition-period safety strategies in newly developing and rapidly densifying areas.

As toxicology shifts towards non-animal testing, quantitative models are essential to predict adverse health effects from molecular or cellular perturbations. Quantitative Adverse Outcome Pathways (qAOPs) represent such models, building on mechanistic knowledge and quantifying the Key Event Relationships (KERs) described in AOPs. Despite the recognized need, the number of qAOPs remains limited. Bayesian-based approaches are often chosen for developing qAOP for their flexibility, but most use discretized variables, limiting their predictive power. In addition, these models are mainly built from newly generated data, underexploiting the large amount of information available. This study successfully leverages data from public literature and presents an innovative framework based on continuous variables to develop a Bayesian-based quantitative model for a central KER towards liver fibrosis. The model predicts the probability of the expression fold change for two key markers of hepatic stellate cell activation (aSMA and COL1A1), given the effects on tissue injury, using in vitro data from 9 chemicals. We propose a newly developed workflow to assist in knowledge identification, organization, and extraction from scientific literature and chemical databases. Based on in vitro data and in vivo information from the Open TG-GATEs (Toxicogenomics Project-Genomics Assisted Toxicity Evaluation System) database, we estimate a biologically relevant range in COL1A1 fold change that indicates an activated state of stellate cells and high liver fibrosis odds ratios. Our study provides a case example of integrating published data and continuous variables to build a Bayesian-based model, which constitutes an essential step for predicting liver fibrosis from in vitro data.

Abstract Importance Stigma and discrimination against transgender and gender-diverse people are prevalent across many settings and may contribute to substantial health disparities. Objective To synthesize global evidence on the prevalence of stigma, discrimination, and resilience among transgender (trans) and gender-diverse adults. Data Sources A systematic search was conducted in PubMed, Embase, CINAHL, Cochrane Central, LILACS, and PsycInfo for articles published between January 1, 2010 and January 2, 2023. This database search was supplemented by grey literature and secondary reference searches. Article Selection Studies were eligible if they presented primary quantitative data on prevalence of stigma, discrimination, and/or resilience among trans and gender-diverse adults (aged 18 and over), with no restrictions on study design, language, or geographic region. Data Extraction and Synthesis Two independent reviewers extracted data using standardized forms, with discrepancies resolved by consensus. The JBI Critical Appraisal Checklist for Prevalence Articles was used to assess risk of bias. Random effects meta-analysis was conducted for dichotomous prevalence measures using inverse variance weighting and logit transformation; non-dichotomous prevalence data were summarized descriptively. Main Outcomes and Measures Outcomes included prevalence estimates for various forms of stigma (anticipated, perceived, internalized, and experienced), discrimination in legal/institutional settings (housing, healthcare, employment, police/prison), and resilience. Results A total of 97 articles, with data from 72,158 unique trans and gender-diverse participants across 26 countries, met inclusion criteria. Studies showed moderate levels of anticipated stigma, perceived stigma, and internalized stigma. Meta-analyses of 36 studies provided pooled estimates of discrimination prevalence across multiple domains: 21.4% in housing (e.g., eviction, rental denial), 24.6% in healthcare (e.g., denial of care, mistreatment), 32.8% in employment (e.g., hiring bias, workplace harassment), and 39.1% in police/prison settings (e.g., profiling, mistreatment). High heterogeneity was observed across studies, reflecting regional and methodological differences. Resilience scores ranged from moderate to high, indicating variation within trans and gender-diverse communities. Conclusions and Relevance This systematic review and meta-analysis found that stigma and discrimination against trans and gender-diverse adults are pervasive globally. Variation in stigma and discrimination across settings and regions underscores the need for targeted interventions and policy reforms. Funding World Health Organization through a grant from the Elton John AIDS Foundation and the Bill and Melinda Gates Foundation.

Purpose To evaluate patient satisfaction and preferences for portable versus table-mounted visual field (VF) devices in a rural telemedicine setting and identify influencing factors. Methods We conducted a sequential explanatory mixed methods study at three Federally Qualified Health Centers (FQHCs) within the Alabama Screening and Intervention for Glaucoma and eye Health through Telemedicine (AL-SIGHT) study. Participants completed VF testing with table-mounted Humphrey Field Analyzer (HFA), tablet-based Melbourne Rapid Fields (MRF), and virtual reality (VR)-based VisuALL perimeters. Participants rated satisfaction, comfort, ease of use, and future testing preference. Chi-square tests assessed differences in device preferences. Twelve participants completed semi-structured interviews to explore reasons underlying preferences. Qualitative data were analyzed in NVivo 14 using reflexive thematic analysis. Results Among 271 respondents (mean age 60.4 years; 62.4% women), 50.6% preferred VR-based, 35.1% tablet-based, and 14.4% table-mounted for future testing ({chi}2 (2) = 53.52, p<0.001, Cramers V = 0.31). Satisfaction was highest for VR-based (56.9% very satisfied), followed by tablet-based (49.4%), and HFA (38.0%). VR-based perimeter was most frequently selected as the most comfortable (55.7%; {chi}2 (2) = 63.33, p<0.001, V = 0.34) and easiest to use (54.6%; {chi}2 (2) = 71.96, p<0.001, V = 0.36). Preferences did not vary significantly across demographic variables (all p>0.05). Qualitative themes identified four key drivers: comfort and physical experience, visual experience, ease of use and interaction, and psychological and motivational factors. Portability and community suitability were valued. Conclusion Rural underserved patients strongly preferred portable visual field devices, particularly VR-based, over table-mounted HFA. Comfort, ergonomic flexibility, immersive visual experience, and simplicity of interaction were central determinants of preference. Portable perimetry may enhance patient-centered glaucoma monitoring within telemedicine programs and access in resource-limited settings.

We are pleased to submit our Original article entitled "Assessing medication-related burden and medication adherence among older patients from Central Nepal: A machine learning approach" for consideration in your esteemed journal. In this paper, we assessed medication burden using validated Living with medicines Questionnaire (LMQ-3) and medication adherence using Adherence to Medication refills (ARMS) Scale. In this paper we analysed our result through machine learning approach in spite of traditional statistical approach to identify the complex factors influencing both. Six ML architectures (Ordinary Least Square, LightGBM, Random Forest, XGBoost, SVM, and Penalized linear regression) were employed to predict ARMS and LMQ scores using various socio-demographic, clinical and medication-related predictive features. Model explainability was provided through SHAP (Shapley Additive exPlanations). Our study identified the moderate medication burden with moderate non-adherence among older adults. Requiring assistance for medication and polypharmacy were the strongest drivers for the medication burden and non-adherence. The high predictive accuracy by ML suggests the appropriate clinical intervention like deprescribing to cope with the high prevalent medication burden and non-adherence among older adults in Nepal.