JMIR Research Protocols

Despite the global prevalence of postpartum depression (PPD), current referral uptake rates are far from satisfactory. While some qualitative studies have investigated factors affecting PPD referrals, a gap in quantitative analysis remains. Addressing this, our study utilized a discrete choice experiment (DCE) to understand the procedural elements influencing PPD referral uptake among diagnosed women. The DCE was conducted via home visits by healthcare providers and a comprehensive mobile app questionnaire. We constructed seven distinct referral attributes to explore participants' preferences, analyzed using mixed logit models and latent class analysis. This analysis identified key determinants and revealed the heterogeneities in referral preferences. A total of 698 individuals completed the DCE questionnaire. All assessed attributes, except for Accompaniment (going to clinic with a family member), were important determinants of preference. Participants generally preferred referrals to psychiatric clinics, face-to-face consultations, lower costs, and shorter waiting times. Significantly, participants' personal and socio-demographic characteristics also played a critical role in their referral preferences. Latent class analysis categorized participants into four distinct groups based on their preferences, with treatment cost and waiting times being the most decisive factors. In conclusion, the preference for PPD referrals is predominantly driven by convenience and access to specialist care. To enhance referral uptake, developing flexible and personalized referral programs that cater to these preferences is crucial.

Background: The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines on nutrition for cancer patients provides evidence based dietary recommendations that is routinely deployed by dieticians in oncology settings. Although these can be culturally adapted, they do not adequately address inter individual variability in treatment related gastrointestinal symptoms and appetite, issues that increase malnutrition risk in cancer patients. Ayurveda, on the other hand, lacks nutrient based guidelines but offers a well grounded dietary framework to assess digestive function and personalise diets. This study investigated the feasibility of combining the two approaches in a clinical setting. Methods: Consenting adult cancer patients diagnosed with any type and stage of cancer were recruited. At baseline, digestive strength, dietary intake, quality and frequency and Patient Generated Subjective Global Assessment (PGSGA) score were recorded. Based on this, personalised meal plans (MPs) that combine nutrient guidelines from ESPEN and traditional food concepts to support digestive strength were provided to participants. Follow ups ranged from 4 weeks to 6 months, at which digestive strength and PGSGA was noted. To evaluate against a benchmark, meal plans were theoretically constructed using Ayurveda concepts (traditional MP) or ESPEN guidelines (Standard MP) alone. Results: Data is presented for 33 participants, of which 52% had weak digestive strength. Baseline intake averaged 879 kcal/day, well below the recommended 1400 to 1600 kcal/ day level. Traditional MPs improved energy intake but were protein insufficient, aspects that were addressed in the standard MPs. Diet quantity (1417 kcal/day), quality and frequency improved on the integrated MP, with 3 patients achieving optimal digestive strength. Personalised counselling reduced malnutrition risk, as reported by PGSGA score. Conclusion: Customising dietary advice by overlaying nutrient guidelines with Ayurveda dietary concepts is feasible. The evaluation of digestive strength holds promise for personalising nutrition therapy. Trial Registration: CTRI/2023/07/055657

Background The Precision rEsearCh pArticipatioN (PECAN) study aims to explore factors that influence perceptions of precision health research participation, focusing on diverse communities in South Carolina. The objective is to identify both positive and negative factors affecting participation, enabling the development of strategies to enhance understanding and reduce barriers, particularly within a population facing significant health disparities. Methods To ensure the effectiveness of the survey instrument for the PECAN study, researchers conducted a cognitive study through guided group discussions with community members. These discussions were designed to pinpoint survey questions that participants found difficult to understand, hard to answer, or unclear. The insights gained from this cognitive evaluation were used to refine and improve the survey, ensuring it is clear, uniform, and effective for gathering meaningful data. Results The cognitive interview study identified several survey items that participants found challenging or ambiguous, particularly due to complex wording, culturally irrelevant content, and questions requiring extensive recall. Participants emphasized the need for clearer language, reassurance about anonymity, and the use of biological terms, as well as greater cultural representation. Based on this feedback, researchers revised the survey to simplify language, provide contextual disclaimers about specimen collection, depersonalize genetic testing questions, and restructure redundant items. Conclusions The cognitive interview study was instrumental in enhancing the PECAN survey's clarity and effectiveness. By addressing participants' feedback, the researchers were able to create a more accessible survey instrument. These improvements are expected to facilitate better data collection, ultimately contributing to a deeper understanding of factors influencing precision health research participation among diverse populations. This methodology highlights the importance of participant feedback in developing research tools that are both inclusive and effective.

Background: Young women in Ghana (18-35 years) remain disproportionately affected by HIV due to intersecting structural and social challenges, including stigma, gendered power dynamics, and limited access to women-centered prevention services. Although HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP) are effective biomedical prevention strategies, uptake among young Ghanaian women remains low. Barriers include limited awareness, persistent stigma, and a lack of culturally relevant, youth-responsive prevention approaches. The WISE WOMAN study aims to address these gaps by developing and piloting a women-centered HIV prevention intervention co-created with young women in Ghana. Methods: This protocol describes a pilot implementation study of a women-centered HIV prevention intervention that will be delivered via WhatsApp. The intervention is informed by community-based participatory research and human-centered design approaches to enhance cultural relevance and responsiveness to young womens lived experiences. The study will enroll 50 young women aged 18-35 years who will participate in a four-week WhatsApp-based intervention designed to increase HIV prevention knowledge, reduce stigma, and support engagement with HIVST and PrEP. Implementation outcomes, including feasibility, acceptability, and appropriateness, will be assessed using mixed methods. Quantitative data will be collected through baseline and post-intervention surveys, including the PIERS-22 engagement scale, and will be analyzed using descriptive statistics and paired comparisons. Qualitative data from group interactions and post-intervention interviews will be analyzed using thematic analysis. The study has received ethical approval from the University at Buffalo Institutional Review Board (STUDY00009328) and the Ensign Global College Ethics Committee (IRB/EL/AF-02/2025) and is registered at ClinicalTrials.gov (NCT07003789). Discussion: This protocol outlines the design and methods for a digitally delivered, women-centered HIV prevention intervention grounded in participatory approaches. The planned pilot study will generate critical implementation evidence on the feasibility, acceptability, and appropriateness of a WhatsApp-based, co-designed intervention, informing future adaptation, scale-up, and integration of culturally grounded HIV prevention strategies for young women in Ghana and similar settings.

Background: With an aging population and increasing comorbidities, supporting people to remain at home for as long as possible is essential. A major challenge in home care is ensuring coordinated, interprofessional collaboration among all actors involved: patients and their close ones, health and social care professionals, and the broader health and social network. To address this challenge, a new organizational model promoting reinforced interprofessional collaboration, the "Reseau Interprofessionnel Ambulatoire de Proximite" (Local Interprofessional Outpatient Network; RIAP) has recently been developed in the canton of Geneva. The aim of this paper is to present the protocol for a research project evaluating both the effectiveness and implementation of this model. Methods: This is a type-2 hybrid effectiveness implementation study guided by the RE-AIM framework, aiming to evaluate the RIAP organizational model and its implementation, context, and outcomes. This multi-method study will examine the RIAP model under real-world conditions. Routinely collected data on patient outcomes and institutional processes will be used to compare the RIAP model with usual care. Questionnaires will assess patients' perceptions of continuity of care, professionals' perceptions of interprofessional collaboration, and stakeholders' views on the acceptability of the model. Open-ended questions will be included to explore experiences and insights in greater depth, complemented by qualitative data on barriers and facilitators to implementation. Financial indicators will also be analyzed to contextualize the model within the institutional setting. Results: The EFFI-RIAP project began in October 2025 and has a planned duration of 22 months. The project will primarily rely on the reuse of institutional routine data, complemented by questionnaires and interviews scheduled for September 2026. At the time of submission, study preparation and institutional data processing are ongoing. Discussion: This research will provide insights into the clinical, organizational, and implementation-related effects of the RIAP model compared with usual care. The natural deployment of new RIAP teams will enable investigation of the organizational model under real-world conditions. The combined evaluation of the effectiveness and implementation of RIAP will assess the model's added value, inform refinement, and identify potential barriers and facilitators relevant to implementation in other teams.

Background: Lifestyle interventions incorporating medically-tailored meal delivery may support rapid behavior change among pregnant individuals with gestational diabetes (GDM). Purpose: To examine the feasibility and acceptability of a multicomponent lifestyle intervention for pregnant individuals with GDM. Primary outcomes included recruitment, retention, intervention receipt, and acceptability. Methods: We conducted a pilot randomized feasibility trial among pregnant individuals with GDM recruited from maternal fetal medicine clinics in the Hartford, Connecticut area. Participants were randomized to usual GDM care or the Meals4Moms intervention plus usual care. The intervention included medically-tailored meal delivery, personalized physical activity support, and multimodal education with digital tools. Participants completed a survey and three 24-hour dietary recalls at baseline and post-intervention. Meals4Moms participants also completed a semi-structured interview at follow-up. Intervention receipt was tracked by study staff. Results: Of 30 individuals approached, we screened 80% (n=24), of whom 75% (n=18/24) were eligible; we randomized 8 participants. Seventy-five percent (n=6/8) completed at least one component of the follow-up assessment (100%, n=4/4 Meals4Moms, 50%, n=2/4 Usual Care). One participant spent [≥]80% of her total food budget (n=1/4, 25%), and no participants completed [≥]80% of prescribed exercise sessions (range: 0-50%). All (n=4) Meals4Moms participants reported they would be very likely to participate in the program if they had GDM again, and 100% (n=4) would be very likely to recommend the program to a friend with GDM. Conclusions: While the Meals4Moms intervention was highly acceptable to participants, procedural refinements are needed prior to conducting a full-scale efficacy trial.

Abstract The ISBAR framework is used to standardize clinical handovers and enhance patient safety. Observational tools based on ISBAR have been developed to assess the completeness of information transfer. However, these instruments have primarily been developed in non-Chinese contexts, and validated Chinese-language observational tools suitable for clinical practice remain limited. In this study, a cross-cultural adaptation and psychometric validation of the ISBAR Structured Handover Observation Tool was conducted, examining its reliability and discriminant validity in Chinese clinical settings. The study was conducted in two phases: cross-cultural adaptation and psychometric evaluation in real-world clinical settings. Content validity was assessed using the Content Validity Index (CVI), and inter-rater reliability was evaluated using the Intraclass Correlation Coefficient (ICC) based on a two-way mixed-effects model with absolute agreement. Discriminant validity was examined using the Mann-Whitney U test to compare scores across nurses with varying levels of clinical experience. A total of 233 handover cases involving patient transfers from the intensive care unit (ICU) to general wards were collected, involving 84 nurses. The scale demonstrated good content validity, with item-level content validity indices (CVI) ranging from 0.88 to 1.00 and a scale-level CVI/Ave of 0.98. The inter-rater reliability, assessed using fifty randomly selected cases, was high, with an intraclass correlation coefficient (ICC) of 0.885 for single-rater assessments and 0.939 for average-rater assessments. Discriminant validity analysis showed that nurses with more clinical experience had significantly higher total scores than those with less experience (Z = -4.772, p < 0.001). The Chinese version of the ISBAR Structured Handover Observation Tool demonstrates good content validity, high inter-rater reliability, and acceptable discriminant validity. This tool provides a standardized and practical method for assessing the completeness of information transfer and is expected to support quality improvement in patient handover from the ICU to general wards in Chinese clinical settings.

IntroductionColorectal cancer (CRC) remains a leading cause of cancer-related morbidity and mortality worldwide, despite advances in conventional oncological therapies. In recent years, various studies have made advances in integrative oncology, such as investigating the use of Chinese Herbal Medicine (CHM) as a complementary therapy alongside conventional oncological therapies to alleviate treatment-related adverse effects, improve quality of life, and potentially enhance therapeutic outcomes. Despite this, clinical practice in this area remains highly heterogeneous, with limited standardized guidelines on key areas of concern such as (1) optimal intervention, (2) recommended stage and duration of intervention, (3) safety considerations, and (4) possible herb-drug interactions. Hence, this study aims to establish expert consensus on the usage of CHM as a complementary therapy in the management of CRC, to support safe, consistent, and evidence-informed clinical practice. Methods and AnalysisWe will employ a modified Delphi technique to achieve consensus amongst a panel of international experts in various fields related to integrative oncology. Prior to the study, a list of questionnaire items was developed based on a systematic review of existing clinical practice guidelines on CRC. An international panel will be invited based on established international profile in integrative oncology research and clinical practice, and by peer referral. Two rounds of Delphi will be conducted using anonymous online questionnaires. Consensus will be considered reached if at least 50% of the panel strongly agree/disagree that an item should be included or excluded while strong consensus will be set at 76%. Items which achieve strong consensus after Round 1 will be removed, before being sent out for Round 2 with a summary of Round 1 responses for a final consensus. Ethics and DisseminationEthics approval has been obtained from the Institutional Review Board of Nanyang Technological University (IRB-2025-1222). Our findings will be disseminated through peer-reviewed publications and conference presentations. Strengths and limitations of this studyO_LIThis study will develop an expert consensus which aims to guide future integration of Chinese Herbal Medicine (CHM) as a complementary therapy into colorectal cancer (CRC) management. C_LIO_LIKey concerns in areas such as determining the (1) optimal intervention, (2) recommended stage and duration of intervention, (3) safety considerations, and (4) possible herb-drug interactions, thereby laying the groundwork for potential future incorporation of CHM into CRC treatment protocols alongside conventional oncology approaches has been identified, thus limiting implementation in clinical practice. C_LIO_LIDesigning a study e-guide, followed by the consensus rounds study online will facilitate participants responses and the dissemination of information from previous rounds. C_LI

BackgroundHwa-byung (HB) is a Korean culture-bound syndrome characterised by prolonged suppression of anger and somatic complaints. No evidence-based digital therapeutic (DTx) has been developed for HB. We evaluated the feasibility, user experience (UX), and preliminary clinical effect of an acceptance and commitment therapy (ACT)-based DTx application, Hwa-free, for HB. MethodsAdults aged 19-80 years diagnosed with HB were enrolled in a four-week app-based intervention with assessment at baseline (Week 0), Week 2, Week 4, and Week 8 follow-up. The primary outcome was UX assessed via a 22-item survey at Week 4. Secondary outcomes included HB-related symptom and personality scales, depression, anxiety, anger expression, psychological flexibility, health-related quality of life, and heart rate variability. ResultsOf 45 screened, 30 were enrolled and 28 constituted the modified intention-to-treat population. Mean app use was 19.9 {+/-} 7.9 days (71.2% adherence over 28 days). Adverse events were infrequent and unrelated to the intervention. Positive response rates exceeded 80% for video content (items 2-4: 82.8-89.7%), HB self-assessment (86.2%), meditation therapy (86.2%), and in-app guidance (85.7%). Pre-post improvements from baseline to Week 4 were observed in 11 of 18 clinical scales, including HB Symptom Scale ({Delta} = -9.8, Cohens d = -0.92), Beck Depression Inventory-II ({Delta} = -13.3, d = -1.11), and state anger ({Delta} = -7.8, d = -0.96). The HB screening-positive rate declined from 100% at baseline to 55.6% at Week 8. ConclusionsHwa-free demonstrated adequate feasibility, acceptable UX, and preliminary evidence of clinically meaningful improvement in HB-related symptoms. Future randomised controlled trial is warranted. Trial registrationCRIS, KCT0011105

ObjectiveTo explore the interpretation of unexpected results from a randomized controlled trial (RCT). Study Design and SettingAdjunctive frequentist (power and type{square}M error) and Bayesian analyses were performed on a recently published RCT reporting a statistically significant relative risk reduction (p <0.01) for caffeinated coffee drinkers compared with abstinence on atrial fibrillation (AF) recurrence. Individual patient data for the Bayesian survival models were reconstructed from the RCT published material and priors informed by the RCT power calculations. ResultsThe original RCT design had limited power for realistic effect sizes, increasing susceptibility to type{square}M (magnitude) error. Bayesian analyses also tempered the benefit for caffeinated coffee implied by standard statistical analysis resulting in only modest probabilities of clinically meaningful risk reductions (e.g., hazard ratio < 0.9 of 88% or a risk difference > 2% of 82%). ConclusionsSupplemental frequentist and Bayesian approaches can provide robustness checks for unexpected RCT findings, providing contextualization, clarifying distinctions between statistical and clinical significance, and guiding replication needs. HighlightsO_LIRandomized controlled trial (RCT) results may be unexpected and challenge prior beliefs C_LIO_LISupplemental frequentist and Bayesian analyses can clarify interpretation of surprising findings C_LIO_LIPower and type{square}M error assessments help evaluate design adequacy for realistic effects C_LIO_LIBayesian posterior probabilities provide additional nuanced insights into contextulaization and clinical significance C_LI

Objective: A questionnaire survey was conducted on the willingness and demand for acupuncture treatment in patients with malignant tumors, and the possible factors affecting patients' willingness and demand for acupuncture treatment were explored. Methods: A voluntary, anonymous survey was conducted between February and May 2025 among patients with malignant tumors aged 18 years and older who visited Beijing Cancer Hospital. The questionnaire included 16 questions addressing three dimensions:current medical purposes,Traditional Chinese Medicine(TCM) literacy, and acupuncture treatment needs.The questionnaire was posted online and completed by respondents using a smartphone interface. Results: A total of 511 valid questionnaires were retrieved in the survey, and 481 patients(94.1%) are willing to receive acupuncture treatment. Among the 481 patients willing to receive acupuncture treatment, the top five symptoms they hoped to improve with acupuncture were: disturbed sleep (245 participants, 50.9%); pain (229 participants, 47.6%); fatigue (177 participants, 36.8%); numbness (165 participants, 34.3%); and poor appetite (144 participants, 29.9%). Among patients who chose to "explicitly accept" acupuncture treatment and those who "accepted acupuncture treatment upon doctor's recommendation", 55% and 56% respectively had good knowledge of traditional Chinese medicine (TCM) culture. In contrast, this proportion was only 36.7% among patients who refused acupuncture treatment, and the difference was statistically significant (P<0.05). The survey results also show that Female patients reported significantly higher demands for pain relief and improved sleep than male patients, with statistically significant differences (P<0.05). Furthermore, those aged 18-45 and with better TCM literacy were more likely to desire acupuncture to improve sleep, with statistically significant differences (P<0.05). Conclusion: Differences in TCM literacy can influence patients' willingness to choose acupuncture treatment. Strengthening patient health education and improving TCM literacy will help increase cancer patients' willingness to choose TCM acupuncture treatment, thereby enabling them to benefit from acupuncture. For patients aged 18-45, those with good TCM literacy female with high acupuncture needs, acupuncture treatment may be recommended as a priority.

Objectives: Introducing a new covariate adjustment method for hierarchical outcomes using ordinal logistic regression, comparing it with existing approaches, and assessing whether adjustment improves power in randomized trials with hierarchical outcomes. Methods: We developed an ordinal regression-based method for covariate adjustment of the win ratio and compared it with three alternatives: probability index models, inverse probability weighting, and a randomization-based estimator. Methods were applied to the EMPEROR-Preserved rial and tested through extensive simulations involving two common hierarchical outcome structures: time-to-event composites, and composites combining time-to-event with quantitative measures. Simulations assessed impacts on estimates, standard errors, and power across prognostic and non-prognostic settings. Results: In RCT data and simulations, covariate adjustment consistently increased power when adjusting for prognostic baseline variables. Gains were comparable to or greater than those in conventional Cox models, with no power loss for non-prognostic covariates. Our ordinal approach performed similarly to existing methods while providing interpretable covariate effect estimates. Adjusting for baseline values of quantitative components yielded power gains according to the baseline-to-follow-up correlation. Conclusions: Covariate adjustment for prognostic variables meaningfully improves efficiency in win ratio analyses for hierarchical outcomes. Our ordinal method is easily implemented and facilitates covariate effect interpretation. We recommend the broader adoption of covariate adjustment and our ordinal method in randomized trials using hierarchical outcomes.

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 HIV remains a major public health challenge in South Africa, with gaps in early diagnosis and linkage to care driving onward transmission. Adolescent girls and young women face barriers to timely care, including stigma, privacy concerns, and limited clinic access, while healthcare providers work in resource-constrained settings with high client volumes. We evaluated the Self-Care from Anywhere (SCFA) toolkit, an AI-enabled intervention comprising an AI Companion for AGYW and a provider-facing Clinical Portal to support HIV prevention, testing, and linkage to care. The AI Companion is designed to complement and extend human-delivered services, particularly in resource constrained settings, rather than replace in-person counselling. Methods We conducted an exploratory study to assess the usability, feasibility, and acceptability of the SCFA toolkit in Gauteng Province (November 2024-May 2025). AGYW engaged with the AI Companion, and a subset completed a simulated HIV self-testing activity with AI-delivered counselling. Pre and post-intervention surveys, including the System Usability Scale (SUS), were administered. Usability testing of the Clinical Portal involved healthcare providers using the toolkit without formal training to capture first impressions. A subset of AGYW and healthcare providers participated in separate focus group discussions or in-depth interviews. Quantitative data were analysed using descriptive statistics, and qualitative data were analysed thematically. Results A total of 97 AGYW were enrolled; 75.3% had completed high school and 91.8% were unemployed or full time students. Most participants (85.6%) self-reported HIV-negative status, and 63.9% reported sexual activity in the past 12 months. The AI Companion demonstrated high usability (mean SUS 87.7, SD 12.7) and was perceived as acceptable and useful, particularly for its personalisation and confidentiality features. Healthcare providers had a mean age of 34 years (SD 6.5), with about half serving as HIV testing and screening counsellors. Most providers rated the Clinical Portal ease of use, comprehension, and client support as positive to very positive, though 23% expressed concerns regarding workflow efficiency and their ability to manage additional client volume. Providers also highlighted the Clinical Portal value for case management. Conclusion AI-powered digital health tools, such as the SCFA toolkit, show potential to enhance user engagement and support care delivery, with high usability and acceptability demonstrated among AGYW and healthcare providers. Continued user-centred refinement is essential to ensure these tools remain responsive to the evolving needs and care contexts of diverse user groups.

ABSTRACT Background: Student nurses satisfaction with their academic programme is crucial for measuring the success of nursing training institutions. However, in Ghana, studies on student nurses' satisfaction have mainly focused on clinical learning, neglecting their satisfaction with the academic programme as a whole. This study therefore, assessed the predictors of student nurses satisfaction with their academic programme. Methods: A quantitative cross-sectional study design was used in the study. A systematic random sampling technique was employed to recruit 241 student nurses from two Nursing Training Institutions in the Eastern Region of Ghana. The Nursing Student Satisfaction Scale (NSSS) was used for data collection and data was analyzed using Statistical Package for Social Sciences (SPSS) version 27 software. Results: Correlation analysis revealed significant positive associations between satisfaction with curriculum (r = 0.583, p<0.001), faculty role (r = 0.650, p<0.001), social interaction (r=0.680, p<0.001), and overall satisfaction with the academic programme. After adjusting for the school of the student nurses, the school environment (B=0.354, p =0.000) and social interaction (B=0.291, p=0.001) emerged as significant predictors of student nurses' satisfaction with their academic programme. Conclusion: The study highlights the need for interventions to enhance the school environment and foster positive social interactions to improve student nurses satisfaction with their academic programme.

Background: Nursing education in conflict-affected settings faces significant disruptions that compromise the preparation of a competent and resilient workforce. In regions such as Iraq, prolonged instability, resource constraints, and fragmented health systems challenge traditional educational models, necessitating innovative and context-responsive approaches to ensure continuity, quality, and equity in nursing training. Purpose: This study aimed to explore innovative strategies in nursing education within conflict-affected settings and to examine their implications for leadership development, health policy reform, and the advancement of health equity. Methods: A cross-sectional descriptive study was conducted among undergraduate nursing students across selected universities in the Nineveh Governorate, Iraq, during the 2025-2026 academic year. Data were collected using a structured, self-administered questionnaire designed to assess students educational experiences, engagement with digital learning approaches, perceived barriers, and attitudes toward innovation in nursing education. The instrument captured multiple dimensions of the learning environment, including access to educational resources, institutional support, and exposure to blended and technology-enhanced learning. Descriptive and inferential statistical analyses were performed using SPSS (version 28), including frequency distributions, chi-square tests, and binary logistic regression modeling to identify key predictors of positive educational outcomes, such as engagement, satisfaction, and perceived clinical readiness. Results: The findings indicate that, although students demonstrated a high level of motivation to engage with innovative learning approaches, notable gaps remained in access to digital resources, faculty preparedness, and institutional support. A majority of participants reported engagement with blended and technology-enhanced learning, which was significantly associated with higher levels of engagement, improved critical thinking, and greater perceived clinical readiness (p < 0.001). Multivariable analysis identified institutional support, digital learning access, and learner-centered teaching strategies as significant predictors of positive educational outcomes. Students with access to digital learning resources and supportive educational environments were more likely to report higher levels of satisfaction and competence. Conclusions: Innovating nursing education in conflict-affected settings is essential to building a resilient and future-ready nursing workforce. Integrating digital technologies, flexible learning models, and competency-based approaches can enhance educational outcomes despite contextual constraints. Implications for Nursing Practice and Policy: Strategic investment in nursing education infrastructure, faculty development, and digital transformation is critical to strengthening health systems in fragile contexts. Policymakers and academic leaders must prioritize inclusive, scalable, and sustainable educational reforms to promote health equity and empower nurses as key agents of system-level change.

Background. People with lived/living experience of health conditions, as well as caregivers, are increasingly engaged in research. This study aimed to develop and pilot test a new tool measuring the impact of lived/living experience engagement on the research. The measure is called the Measure of Engagement Tool for Research and lived Experience (METRE). Method. We conducted a qualitative descriptive study among 28 people with lived/living experience and caregivers and 12 academic researchers to understand the impacts of engagement. Using the findings, we drafted the METRE. We pilot tested the METRE among 13 people with lived/living experience and caregivers and 10 academic researchers. Insights were used to refine the scale. Results. Qualitatively, participants identified multiple domains of impact of engagement on research, which guided scale development. Pilot testing of the draft METRE revealed it being straightforward to complete, providing a thorough evaluation of the impact of engagement. However, some areas of improvement were recommended. The draft items showed acceptable preliminary performance. Conclusions. An assessment tool is now available to assess the impact of lived/living experience engagement on the research. Additional research is required to evaluate its psychometric properties. Tools to evaluate the impact of engagement on research will help advance the science of engagement and support engaged research teams in their work.

Culture plays a crucial role in health; family, community, culture, and social conventions all have a significant impact on how an infant with jaundice is treated. Written or unwritten rules govern what parents and the community are allowed to do, which may have a detrimental effect on the neonates care. ObjectivesThe study explored how social expectations affect midwives management of neonatal jaundice at the St Patricks hospital in Maase-Offinso, in the Ashanti region of Ghana. MethodA total of seventeen midwives were sampled purposively using an exploratory descriptive design. Participants were engaged in interviews and focus group discussion after ethical approval was obtained. A semi-structured focus group discussion guide and interview guide was used to collect data. ResultsThe study discovered that the treatment of neonatal jaundice was adversely affected by social pressures, misconceptions, maternal choices, and spiritual views. Mothers and midwives socially approved sunbathing, and there were indications that grandmothers disapproved hospital care for their grandchildren. ConclusionCulture, family and social norms cannot be separated from health especially for the neonate whose means of identification is to belong to a family. Consequently, it is essential to respond to social influences, cultural conventions, and the various cultures of families with a culturally sensitive approach.

Background: AI powered cognitive behavioral therapy CBT chatbots represent a scalable approach to addressing the global mental health treatment gap However causal evidence on their population level effectiveness in low and middle income countries LMICs remains limited and patient perspectives on acceptability and engagement are critical determinants of sustained use Brazils Estrategia de Saude da Familia ESF deployed an AI powered CBT chatbot Saude Mental Digital SMD to registered patients aged 18 and older at participating primary care units with eligibility determined by a composite vulnerability score exceeding a predetermined threshold Objective: To estimate the causal effect of AI powered CBT chatbot access on anxiety and depressive symptoms among primary care patients in Minas Gerais Brazil leveraging the eligibility score threshold as an exogenous source of variation Methods: We conducted a fuzzy regression discontinuity design fuzzy RDD study using linked administrative and clinical data from 312 ESF primary care units across Minas Gerais N 43287 patients January 2022 December 2024 The running variable was the composite vulnerability score with a threshold of 60 points determining chatbot eligibility The primary outcome was the 12 week change in the Patient Health Questionnaire Anxiety and Depression Scale PHQ ADS composite score Two stage least squares 2SLS estimation was used with local polynomial regression and triangular kernel weighting Bandwidth selection followed the Calonico Cattaneo Titiunik CCT optimal procedure Results: The fuzzy RDD estimated a local average treatment effect LATE of 473 points 95 CI 691 to 255 p 0001 on the PHQ ADS composite score at the eligibility threshold indicating clinically meaningful symptom reduction among compliers First stage estimates confirmed a strong 312 percentage point jump in chatbot uptake at the threshold F statistic 1274 Subgroup analyses revealed larger treatment effects among patients in rural municipalities 618 95 CI 902 to 334 those with lower educational attainment 582 95 CI 844 to 320 and women 537 95 CI 761 to 313 McCrary density tests confirmed no evidence of running variable manipulation p 067 Results were robust across alternative bandwidths polynomial orders and kernel specifications Conclusions: AI powered CBT chatbot access causally reduces anxiety and depressive symptoms among primary care patients near the eligibility threshold in Brazil with particularly pronounced benefits for rural less educated and female populations These findings provide quasi experimental evidence supporting the scalable deployment of AI powered CBT tools within public primary care systems in LMICs while underscoring the importance of incorporating patient perspectives on acceptability to maximize engagement and sustained therapeutic benefit

BackgroundProspective studies of pregnant adolescents are essencial to effectively address this global health priority. They help answer vital questions about their health, but such studies are uncommon due to the difficulty in retaining adolescents. This paper describes the successes and challenges of the research strategies used to ensure sufficient recruitment and retention of pregnant adolescents in a longitudinal study about adolescent childbearing in an under-resourced setting. MethodsThe Adolescence and Motherhood Research project was conducted in a rural region of Northeast Brazil in 2017-2019 and assessed 50 primigravids between 13-18 years (adolescents) and 50 primigravids between 23-28 years (young adults) during the first 16 weeks of pregnancy with two follow-ups (third trimester of pregnancy, and 4-6 weeks postpartum). Recruitment strategies involved engagement of health sector and community, as well as referrals from health care professionals and dissemination of the project in different locations. Retention strategies included maintaining contact with the participants between assessments and providing transportation for them to attend the follow-up procedures. ResultsRecruitment took 10 months to complete. A total of 78% of the participants were recruited from the primary health care units, mainly after referral from a health care provider. Retention reached 95% of the sample throughout the study (90%: adolescents; 98%: adults). ConclusionA combination of approaches is necessary to successfully recruit and retain youth in longitudinal studies and engaging local stakeholders may help to increase community-perceived legitimacy of the research. Working closely with front-line staff is essential when conducting research in rural low-income communities.