Journal of Occupational & Environmental Medicine

Background Meat processing plants in Alberta, Canada experienced among North America's largest COVID-19 outbreaks. We examined health impacts among workers by occupational hierarchy and equity-relevant characteristics. Methods This exploratory sequential mixed-methods study was guided by community-based participatory research and the PROGRESS-Plus framework. Multilingual qualitative interviews and surveys using validated instruments were conducted among meat plant workers who experienced outbreaks. Interviews were analysed using inductive-deductive thematic analysis. Multivariable logistic regression and linear regression estimated associations between occupational group, racialization, facility, and self-reported COVID-19 diagnosis, physical and mental health, and mean Everyday Discrimination Scale score. We integrated findings using joint displays. Findings Qualitative and integrated analysis of thirty-six interviews described occupational hierarchy shaping unequal protection, limited communication, constrained agency, and psychosocial harms, amplified by income insecurity and family separation. Among 187 survey respondents, compared with general labour, skilled labour (aOR 0.38; 95% CI 0.15-0.89) and management (aOR 0.13; 95% CI 0.01-0.75) had lower odds of reported COVID-19 diagnosis. Compared with Black workers, other racialized workers had lower odds of reporting fair or poor mental (aOR 0.24; 95% CI 0.09-0.58) and physical health (aOR 0.20; 95% CI 0.06-0.54). Compared with workers from the primary facility, others reported lower mean everyday discrimination scores ({beta} = -0.54; 95% CI -0.96 to -0.12). Interpretation COVID-19 harms followed workplace social hierarchies. Pandemic preparedness should combine infection-control measures with paid sick leave and income protection, multilingual communication, enforceable anti-discrimination standards, and independent reporting mechanisms. Funding Canadian Institutes for Health Research (CIHR Application no. 469206). Keywords COVID-19, immigrant workers, migrants, essential workers, health equity, occupational health, PROGRESS Plus

Background Occupational exoskeletons are used to reduce physical workload and prevent work-related musculoskeletal disorders in physically demanding jobs. Although laboratory studies demonstrate reduced muscle load during simulated manual work tasks, evidence from long-term, real-world implementations remains very limited. The RELAX project aims to investigate the long-term effects of a passive back-support exoskeleton (BSE) during manual order-picking work in a Danish warehouse, focusing on health and socio-economic outcomes. Methods This 18-month controlled in-field intervention study compares outcomes at two warehouse departments: one where workers use a passive BSE and a control group where workers perform work tasks as usual. Approximately 90 full-time workers will be followed during the intervention period with questionnaires, interviews and company-registered performance indicators. Primary outcomes include perceived work intensity and musculoskeletal discomfort, while secondary outcomes include sickness absence, employee turnover, productivity and cost effectiveness. Furthermore, a process evaluation will be conducted based on questionnaires, focus-group interviews, and reported exoskeleton use. Quantitative effects will be analysed using difference-in-difference analysis with generalized linear mixed models to account for repeated measures over time. Employee turnover will be analysed using time-to-event analysis, and qualitative focus-group interviews will be analysed using reflexive thematic analysis to explore implementation processes and contextual factors. Cost-effectiveness and return on investment will be assessed by comparing the investment with potential savings in costs and resource use. Discussion By combining longitudinal quantitative outcomes with qualitative process evaluation, the study seeks to provide ecologically valid evidence on the effectiveness, feasibility and sustainability of occupational exoskeleton implementation. This approach will help clarify whether long-term exoskeleton use improves worker health without compromising productivity and may inform future workplace guidelines and large-scale adoption strategies.

Primary healthcare (PHC) managers are central to the functioning of South Africas healthcare system, yet many assume leadership roles without formal management training. To address this gap, the Aurum Institute developed the Management Development Programme (MDP), a structured leadership and management training intervention aimed at strengthening PHC management competencies. This study evaluated the impact of the MDP on leadership practices, organisational readiness for change, and workplace stress among PHC managers in the Western Cape Province. A non-randomised matched cluster trial was conducted across 20 PHC facilities. Intervention facilities were purposively selected based on participation in the MDP, while matched control facilities were randomly selected. Data were collected using structured and semi-structured surveys administered to facility managers and clinic staff. Leadership competency was assessed using the Leadership Practices Inventory (LPI), which measures five dimensions of exemplary leadership: Model the Way, Inspire a Shared Vision, Challenge the Process, Enable Others to Act, and Encourage the Heart. Organisational readiness for change was measured using Kotters 8-Step Framework, while workplace stress was assessed using a 13-item version of the Brief Job Stress Questionnaire focusing on Job Meaning, Environmental Quality, Autonomy, and Control. Intervention effects were estimated using generalised linear models adjusted for manager age, years in role, matched-pair fixed effects, and cluster-robust standard errors. Outcomes were reported as adjusted risk differences with 95% confidence intervals and two-sided p-values. A total of 20 facility managers (median age 51 years; IQR 42-55; 90% female) and 105 clinic staff members (median age 42 years; IQR 35-50) participated in the study. Managers in both intervention and control facilities reported consistently high self-rated leadership competency scores across all LPI domains, with no statistically significant differences between groups. Similarly, clinic staff rated managers highly across the standard LPI domains, and no significant differences were observed between intervention and control facilities. Despite the absence of significant differences in overall leadership competency scores, staff in intervention facilities reported significantly stronger relational and communication practices among managers compared with staff in control facilities (72.7% vs. 64.0%; adjusted risk difference 22.0%, 95% CI 6.1-37.8; p=.007). After adjustment for age and tenure imbalances, intervention facilities also demonstrated significantly higher scores for institutionalised capability and learning culture (adjusted risk difference 21.3%, 95% CI 0.6-42.0; p=.043). Managers who participated in the MDP further reported stronger perceptions of district support, including improved internal leadership and cultural readiness (adjusted risk difference 22.1%, 95% CI 14.0-30.3; p<.001) and greater district leadership and resource availability (adjusted risk difference 28.1%, 95% CI 15.6-40.6; p<.001). No statistically significant differences were observed in workplace stress across any domain. Although the MDP did not produce measurable short-term improvements in managers self-rated leadership competencies or standard LPI domains as assessed by staff, it was associated with important gains in relational leadership practices, organisational readiness for change, and perceived district support. These findings suggest that structured management training programmes may strengthen critical organisational and interpersonal foundations necessary for sustained performance improvement within PHC settings.

Aims Moral distress has been studied across many health arenas; however, public health has often been overlooked. Canada is facing a healthcare crisis with a significant number of staff leaving the healthcare field. This study explores the experiences of moral distress in public healthcare practitioners across Canada. Better understanding these experiences can provide insights into how to support staff and prevent attrition in public health. Methods This was a cross-sectional qualitative study. Fifteen in-depth interviews were conducted between May and July 2023, through remote and in person methods. Participants were from nursing, social work, medicine, and dietetics, all working in public health across Canada. Iterative thematic analysis was used. Emergent themes were compared within and across data sets and by participant age and years of experience. Results/Findings Experiences that contributed to moral distress included systemic powerlessness, political and ideological overreach, unethical work environments and undervalued expertise. Years of experience and diversity in gender and ethnicity impacted how practitioners navigated moral distress. Experiences where practitioners felt actions went against their values increased during the pandemic, contributing to moral injury. Conclusions This study situates the unique position of public health within the health system and explores experiences of moral distress both during and outside the COVID-19 pandemic. While the pandemic brought the concept of moral distress to the forefront of many peoples minds, these experiences existed prior. Addressing the underlying causes will contribute to establishing approaches to support public health practitioners suffering from moral distress and injury.

Background Health inequalities between occupational or social class groups are pervasive and persistent. Healthcare professionals have better health outcomes compared to the general population. Whether this is a result of healthcare education, favourable socio-demographic characteristics among professionals or other effects is not certain and the extent to which single healthcare occupational groups exhibit inequalities is unknown. We have described self-rated health and quantified geographic health inequalities among a single occupational group of Registered Nurses compared to the general population. Methods We analysed nationally representative samples from the 2011 UK Censuses across England, Wales and Scotland in the Office for National Statistics Longitudinal Study and Scottish Longitudinal Study. Self-rated health and socio-demographic characteristics for the study population are described. Inequalities in health by area deprivation among Registered Nurses and the General Population are quantified. Logistic regression analysis was used to assess the association between Nurse status and self-rated health, adjusting for socio-demographic variables. Results Among economically active, working age adults (n = 478,802), we identified 9,180 Registered Nurses resident in England, Wales and Scotland. 59% of Registered Nurses reported very good self-rated health, with only 1% reporting poor or very poor health. A smaller proportion of Registered Nurses reported less than good health than the General Population at every level of area deprivation and had smaller absolute (4.1 percentage points vs. 9.1) and relative (RR: 1.5 vs. 2.0) inequalities between residents in the most and least deprived areas. Registered Nurses have an increased likelihood of reporting good or better health compared to the general population (Scotland OR: 1.3, 95% CI: 1.2 - 1.5, England & Wales OR: 1.4, 95% CI: 1.3 - 1.5) after adjusting for socio-demographic factors. Discussion Registered Nurses report better health compared to the general population and have smaller inequalities in health by area deprivation. However, unfair and avoidable geographical differences in health are present even in this socioeconomically privileged professional group. After adjusting for socioeconomic and demographic factors, the positive association between being a Registered Nurse and having good self-rated health remained.

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

Given the growing crisis in youth mental health, there is a critical need to rebuild and sustain healthy social environments. Cooperative experiences (e.g., sports, clubs) may promote mental health but we lack rigorously tested measures to drive research and evaluation. This study sought to develop a measure of cooperative experiences and test associations with health. We developed and revised a measure of cooperative experiences based on interdisciplinary literature and 20 cognitive interviews. We recruited youth aged 13-25 years (N = 262) through youth-serving organizations and snowball sampling to complete an investigator-administered (n = 50) or self-administered (n = 212) survey assessing cooperative experiences (48 items), mental and physical health, and demographics. We assessed item characteristics, dimensionality, reliability, and construct validity. Multivariable linear regressions were used to estimate the association between the total score and self-reported health. Participants were 57% female, 69% Latino, 55% high school students, and 25% college students. The measure was reduced to 35 items (alpha = 0.90) with six subscales: sense of a unified group (7 items, alpha = 0.83), goal alignment (3 items, alpha = 0.80), inclusion and shared purpose (10 items, alpha = 0.88), social exclusion (2 items, alpha = 0.91), positive interdependence (7 items, alpha = 0.77), and negative interdependence (6 items, alpha = 0.87). A higher total score was associated with better self-reported mental health (beta = 0.25 standard deviation change in health score for each standard deviation change in cooperation scale, 95% CI [0.108, 0.394], p = 0.001) and self-reported general health (beta = 0.25, 95% CI [0.107, 0.395], p = 0.001). The study provides preliminary support for the reliability and validity of a new measure of exposure to cooperative experiences among youth. The measure holds promise as a tool to examine the relationship between social environments and health outcomes in real-world settings.

Abstract Background: Medical residents and physicians face persistently high-demand environments marked by heavy workloads, time pressure, night duties, and emotionally intense clinical encounters. These conditions increase vulnerability to stress-related outcomes, including burnout and impaired mental health, and can affect functioning at work. Personality traits are relatively stable individual differences and might help explain why some doctors experience greater stress vulnerability or use less adaptive coping strategies than others. Evidence linking the Big Five personality traits to stress, coping, and performance outcomes in residents and physicians has grown, but it remains difficult to apply because of inconsistent findings and heterogeneous measures. This systematic review and meta-analysis aim to synthesize the existing literature on how the Big Five personality traits influence these outcomes in medical residents and physicians. Methods: We conducted a PRISMA-aligned systematic review and meta-analysis (PROSPERO CRD42023483408). PubMed, Embase, MEDLINE (Ovid), Cochrane Library, Scopus, and Web of Science were searched from database inception to Nov 15, 2023. Searches were updated periodically through Jan 2026. Eligible studies were primary research in English involving medical residents and/or practicing physicians that assessed at least one Big Five trait using a recognized Five-Factor Model instrument and reported an association with a validated or clearly defined stress, coping, performance, or professional skills/aptitudes related outcome in medical residents or physicians. Studies exclusively involving medical students were excluded. Risk of bias was assessed using the AXIS tool (supplemented by Joanna Briggs Institute items) for cross-sectional studies and the Cochrane Risk of Bias 2 tool for the randomized trial. Where at least three comparable studies were available, effect sizes were pooled using random-effects models with restricted maximum likelihood estimation after Fishers z transformation; remaining studies were synthesized narratively. Results: Of the 4,967 records identified, 34 studies (21,379 participants) met the inclusion criteria; most were cross-sectional (30/34), with three longitudinal studies and one randomized trial. Meta-analyses were restricted to 11 studies reporting Maslach Burnout Inventory subscales and three studies reporting GHQ-12 psychological distress. Neuroticism showed the clearest and most consistent adverse associations: for emotional exhaustion (pooled r=0.418, 95% CI 0.219 to 0.616, p<0.001), for depersonalization (pooled r=0.304, 95% CI 0.166 to 0.442, p<0.001), and for personal accomplishment (pooled r=-0.244, 95% CI -0.393 to -0.094, p=0.005). Conscientiousness, Extraversion, and Agreeableness showed small protective patterns, with lower emotional exhaustion and depersonalization and higher personal accomplishment, although associations with stress were weak and generally non-significant. Openness showed a weaker, selective pattern, with lower depersonalization and higher personal accomplishment, but no clear association with emotional exhaustion or stress. Moderator analyses suggested that associations for Neuroticism, Conscientiousness, and Agreeableness varied more by experience and region than by specialty, whereas Extraversion was moderated mainly by experience; Openness showed little evidence of consistent moderation. Narrative synthesis of studies not included in the main meta-analyses was broadly concordant: Neuroticism was the most consistent vulnerability marker for burnout, distress, maladaptive coping, and poorer work-related outcomes, whereas Conscientiousness and, to a lesser extent, Extraversion were linked to more adaptive coping and more favorable performance-related indicators. Agreeableness showed modest prosocial and attitudinal benefits, and Openness remained the least consistent trait across outcomes. Overall risk of bias was low to moderate for most observational studies, although heterogeneity was substantial across pooled analyses. Conclusions: Big Five personality traits have modest correlation with physicians and residents burnout, distress, coping, and work-related functioning. Neuroticism emerged as the clearest vulnerability marker, whereas Conscientiousness and, to a lesser extent, Extraversion and Agreeableness showed small protective associations. Interpretation is limited by the predominance of cross-sectional designs, reliance on self-report, substantial heterogeneity, and restricted geographic representation. These findings support the use of personality traits as a supportive and formative resource within medical education and workforce well-being, but not for deterministic selection or labelling. Larger longitudinal and intervention studies using multi-method outcomes are needed to clarify mechanisms and causal pathways.

Background/Objectives: Influenza infection is a major trigger of pneumonia and acute exacerbations among patients with chronic obstructive pulmonary disease (COPD). However, national laboratory-confirmed evidence on influenza vaccine effectiveness (VE) in this high-risk population remains limited. This study aimed to estimate the effectiveness of seasonal influenza vaccination against influenza-associated pneumonia and COPD exacerbations among patients with COPD in Thailand.Methods: We conducted a nationwide retrospective test-negative design study using administrative healthcare data from the National Health Security Office linked with laboratory-confirmed influenza surveillance data between June 1, 2013, and May 31, 2025, covering twelve influenza seasons (2013-2024). COPD-related clinical episodes among patients aged [&ge;]40 years who presented with pneumonia or acute exacerbation of COPD and underwent RT-PCR testing for influenza were included. Multilevel Poisson regression models were used to estimate adjusted risk ratios (RRs), and VE was calculated as (1 - adjusted RR) x 100.Results: A total of 606,072 COPD-related clinical episodes were included, of which 192,224 (31.7%) were influenza-positive. The overall adjusted VE against influenza-associated pneumonia was 63.2% (95% CI: 62.5-64.0), while VE against influenza-associated COPD exacerbations was 67.0% (95% CI: 48.8-78.8). VE estimates were broadly similar across age groups and remained substantial across COPD severity strata. Although point estimates were numerically higher in severe and very severe COPD, subgroup differences should be interpreted cautiously.Conclusions: Seasonal influenza vaccination was associated with substantial protection against influenza-associated pneumonia and COPD exacerbations among patients with COPD in Thailand.

Background: Medical and doctoral students in health sciences represent a strategic public health lever as future professionals who will have a lasting influence on healthcare practices and the overall quality of health systems. Impaired quality of life and mental health issues among these students, coupled with scarce prevention programmes, led us to develop PROMESS-Group, an innovative multimodal programme designed to promote healthier lifestyle habits among university students. Methods: We will conduct a 2-arm randomised, controlled, superiority monocentric trial to assess the effect of this programme on medical and doctoral students compared to a control group. The intervention will consist of six sessions covering stress, sleep and physical activity domains. Each session will include group and individual meetings led by trained peer experts, focusing on needs assessment, self-care education, and personalised goals setting. Students' quality of life, academic self-efficacy, and broader health outcomes will be assessed using validated questionnaires and objective tools at baseline, during, and post-intervention. Data will be analysed according to the intention-to-treat principle and presented in accordance with CONSORT guidelines. Ethical approval was obtained from the institutional review board (IRB2025021802). All procedures will be performed in adherence to the Helsinki Declaration. Discussion: This study will enable the generation of high-quality evidence to evaluate the programme's effects on students' quality of life and related psychosocial outcomes, and may inform evidence-based health promotion strategies in university settings. Trial registration: ClinicalTrials.gov: NCT07030751 (https://clinicaltrials.gov/study/NCT07030751?locStr=Lyon,%20France&country=FR&state=Auvergne-Rh%C3%B4ne-Alpes&city=Lyon&cond=promess%20group&rank=1), 06.12.2025 - retrospectively registered. This protocol study follows the SPIRIT guidelines (Appendix 1). Keywords: Doctoral student, health behaviour, medical student, quality of life, physical activity, sleep, stress

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

Background Physical inactivity and sedentary behaviour are major contributors to non-communicable diseases (NCDs) and are unevenly distributed across populations, disproportionately affecting migrants and ethnic minority groups. Somali communities in the UK experience multiple structural and socio-economic disadvantages; however, evidence on physical activity and associated inequities remains limited. This study examined physical activity, sedentary behaviour, and related barriers and facilitators among Somali residents in Sheffield, United Kingdom. Methods A cross-sectional mixed-methods study was conducted among Somali adults (n = 238). Quantitative data were collected using the International Physical Activity Questionnaire Short Form (IPAQ-SF) and analysed using descriptive statistics and ordinal logistic regression. Qualitative data were obtained from two focus group discussions (n = 14) and analysed using inductive thematic analysis to explore socio-cultural, environmental, and structural determinants of physical activity. Results No statistically significant predictors of physical activity were identified in the adjusted analysis; however, consistent trends indicated lower activity levels among older adults and those in employment. Qualitative findings revealed multiple, intersecting barriers rooted in structural inequities, including migration-related lifestyle changes, reduced incidental activity, sedentary occupations, limited health literacy, language barriers, financial constraints, and gendered responsibilities. Cultural norms and environmental conditions further shaped behaviour. Facilitators included community-based, culturally tailored interventions, peer support, gender-sensitive programmes, and adaptation of traditional practices. Conclusion Somali residents in Sheffield face overlapping structural and socio-cultural barriers to physical activity that are not fully captured by quantitative measures alone. Equity-oriented, culturally competent, and community-led interventions addressing both systemic and behavioural determinants are essential to improve access to physical activity and reduce health inequalities and NCD risk.

Objective: We examined the link between cohabitation with a partner and nighttime smartphone use through the social control of health behavior theory. Background: Nighttime smartphone use is a behavioral risk factor for sleep problems. While previous research has predominantly focused on individual-level risks of sleep disturbances, the role of social context remains underexplored. Theoretical frameworks, specifically the Social Control of Health Behavior, suggest that social relationships regulate health-related behaviors; however, it is unclear how far this regulation extends to modern digital behaviors among couples. Method: We analyzed survey data from three waves of the SmartSleep Study (2018, 2020, and 2023; total N = 25,028), including a longitudinal follow-up subset (N = 1,003). We tested multivariate associations between living with a partner, changes in cohabitation status and frequent nighttime smartphone use by fitting generalized linear mixed-effects models. Additionally, we mapped the complex interplay between indicators of social integration, social support, smartphone use, and sleep quality using hierarchical clustering of non-linear correlations. Results: Cohabiting participants had lower odds of frequent nighttime smartphone use compared to those living alone (OR = 0.66; 95% CI: 0.61, 0.72). This lower risk was driven primarily by cohabitation with a partner (OR = 0.49; 95% CI: 0.36, 0.66). Longitudinal analysis supported these findings, showing that sustained cohabitation was associated with less frequent nighttime use (OR = 0.56; 95% CI: 0.38, 0.82). Clustering analysis revealed that indicators of social integration and support clustered with favorable sleep quality. Conclusion: Our findings suggest that the health-protective effects of cohabitation with a partner extend to digital behaviors. Consistent with social control of health behavior theory, the presence of a partner appears to reduce frequent nighttime smartphone use, highlighting the critical importance of considering social context when addressing digital health hygiene and promoting sleep.

Background. The emergency department in the United States of America functions as a residual access point for healthcare and social services for populations including rural communities, the uninsured, mental health and addiction patients, and the unhoused. The workforce variable that determines unit function (experience density, the concentration of accumulated clinical judgment within a unit workforce) is not measured in hospital accounting systems. Objective. To document workforce composition changes in U.S. emergency nursing across the 2018 and 2022 cycles of the National Sample Survey of Registered Nurses (NSSRN), and to specify falsifiable predictions for the 2026 cycle. Methods. We analyzed NSSRN public-use files using a four-way ED definition extending Castner et al. (2024) and a hospital-bedside-restricted comparator. Variance estimation used jackknife replicate weights for 2018 and Successive Differences Replication for 2022. Burnout was operationalized using the Norful et al. (2023) leaving-reasons proxy across cycles, with sensitivity analysis using the 2022 direct burnout item. Results. A 15-year trajectory (2008-2022) documents progressive experience-density compression: the ED's 15+ year veteran cohort fell from 41.9% to 28.0% over the decade preceding the pandemic, a loss of nearly a third of the senior cohort and a 19.6% decline in mean experience density, before recovering modestly to 33.3% as veteran nurses remained through the pandemic acute phase, leaving the ED as the youngest hospital setting throughout. Hospital non-ED bedside nurses lost senior tenure between cycles (mean 15.65[-&gt;]14.06 years since first licensure; 15+ year share 43.5%[-&gt;]38.7%), while ED nurses retained their senior tail (mean 11.60[-&gt;]12.58). Burnout endorsement rose sharply in both populations (non-ED 27.3%[-&gt;]46.0%; ED 34.2%[-&gt;]61.2%), with the ED-vs-non-ED gap more than doubling. Controlling for tenure, ED status was not independently associated with burnout in 2018 (OR 1.15, 95% CI 0.83-1.59) but was strongly associated in 2022 (OR 1.92, 95% CI 1.44-2.55; p<.001). The direct burnout item showed a parallel pattern (OR 2.92, 95% CI 1.62-5.28). Conclusions. A pandemic-era setting-specific burnout effect emerged in emergency nursing that workforce-composition controls cannot explain. The 2022 cycle establishes a pre-exit baseline against which the 2026 NSSRN will serve as the falsifiable test of post-Omicron veteran exit. Nursing pipeline replacement lag exceeds the interval before 2026 data arrives; the consequences of inaction fall on populations dependent on ED-based residual access.

Background. Tobacco smoke exposure, quantified by serum cotinine, is associated with cardiovascular, metabolic, and sleep-related health risks. The relationship between biomarker-verified tobacco smoke exposure and objectively measured, free-living wrist-worn ambient light patterns has not been examined in a nationally representative U.S. adult sample. Methods. We analyzed NHANES 2011-2014 cross-sectional data from 6,937 adults aged >20 years with valid serum cotinine and wrist-worn Physical Activity Monitor (PAM) ambient light data. Seven light outcomes were modeled using survey-weighted linear regression with log2(cotinine+1) as the continuous exposure across four covariate adjustment levels. Benjamini-Hochberg false discovery rate (FDR) correction was applied across the 7 outcomes within each model. Results. In Model 2 (adjusted for age, sex, race/ethnicity, education, poverty-income ratio, BMI, and survey cycle; N = 6,350), higher serum cotinine was associated with significantly higher nighttime light (beta = +0.024, 95% CI: 0.010, 0.038; p-FDR = 0.014) and lower evening light (beta = -0.031, 95% CI: -0.055, -0.008; p-FDR = 0.042). In exploratory behavioral models without alcohol (Model 3a; N = 5,766), both nighttime and evening associations remained FDR-significant. After additional adjustment for alcohol, which substantially reduced the sample due to 37.6% missingness (Model 3b; N = 3,866), the nighttime association attenuated below the FDR threshold, while the evening association remained FDR-significant. Categorical analyses showed progressively higher nighttime light across cotinine groups, and a hypothesis-generating sex interaction was identified (p-interaction = 0.001). Conclusions. Higher serum cotinine concentrations were associated with higher nighttime and lower evening ambient light after sociodemographic adjustment. Attenuation after behavioral adjustment and the cross-sectional design preclude causal inference. Longitudinal studies with formal mediation analyses are needed to clarify the temporal ordering and mechanisms linking tobacco smoke exposure, smoking-related behaviors, and personal light-dark cycle patterns.

Objective: The study aimed to describe the challenges, best practices, and lessons learned during meningitis vaccination campaigns conducted in the context of COVID-19 in Cameroon in 2020. Results: During the prevention campaigns, 3,460 individuals were selected. All were tested before the campaign (100%). Eight cases were positive, representing a positivity rate of 0.23% (8/3,460). The campaign was carried out using a fixed strategy in health facilities and prisons and a fixed-temporary strategy in communities. Most health areas received sufficient quantities of COVID-19 equipment for some items and insufficient quantities for others. No screening was done during or after the campaign. The main difficulties encountered were compliance with social distancing and the continuous wearing of gowns. The challenges faced were the screening of actors and the use of personal protective equipment. Lessons learned: aspects related to COVID-19 impacted the speed of the campaign. Vaccination coverage ranged from 91% to 140% in prisons on the one hand, and from 35% to 112% in the health areas surrounding prisons on the other. The campaign in the context of COVID-19 was effective. Compliance with barrier measures was not optimal due to difficulties encountered with aspects such as social distancing, continuous wearing of gowns, screening of participants during and after the campaign, and insufficient personal protective equipment.

Introduction Menopause is a central marker of reproductive ageing, but national evidence on menstrual cessation among Nigerian women in the late reproductive ages remains limited. This study examined the prevalence and socio-demographic correlates of prolonged amenorrhea/possible menopausal transition among Nigerian women aged 30-49 years. Methods The study used the women's individual recode file from the 2024 Nigeria Demographic and Health Survey. The analytic sample was restricted to women aged 30-49 years, excluding women who were currently pregnant, currently or postpartum amenorrheic, and those with invalid or special responses on time since last menstrual period. The final sample comprised 14,223 women. The outcome combined women whose last menstrual period occurred 12 or more months before the survey, and women reported as being in menopause. Weighted descriptive statistics, design-adjusted bivariate tests and survey-weighted binary logistic regression were used. Results The weighted prevalence of prolonged amenorrhea/possible menopausal transition was 7.6%. Prevalence rose from 1.2% among women aged 30-34 years to 23.6% among women aged 45-49 years. In the adjusted model, women aged 35-39 years (OR=1.64; p=0.030), 40-44 years (OR=6.20; p<0.001) and 45-49 years (OR=24.51; p<0.001) had higher odds than women aged 30-34 years. Primary education (OR=1.65; p=0.004), middle wealth status (OR=1.37; p=0.043) and poorest wealth status (OR=1.60; p=0.024) were associated with higher odds. Muslim affiliation (OR=0.72; p=0.024) and traditional contraceptive use (OR=0.24; p<0.001) were associated with lower odds. Conclusion Prolonged amenorrhea/possible menopausal transition among Nigerian women aged 30-49 is strongly age-patterned and socially differentiated. The findings support the need to make midlife menstrual health more visible within reproductive, family planning and primary healthcare services. Because the measure is based on survey-reported menstrual recency, it should not be interpreted as clinically confirmed natural menopause.

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

Background: With rising concerns about health impacts from climate change and environmental exposures, planetary health approaches are increasingly prominent, considering connections between human health and that of the natural environment. Naturopathy is an holistic traditional medicine system characterised by philosophies and practices rooted in nature that theoretically align with planetary health. However, it is unknown to what extent these philosophies translate into consideration of relevant factors during patient care. This study describes the perceptions and clinical behaviours of the global naturopathic workforce in addressing the health impacts of climate change and environmental pollutants. Methods: A cross-sectional online survey was administered to an international sample of naturopathic practitioners, recruited through communications from World Naturopathic Federation member organisations. The survey utilised the Climate Change Perceptions Scale, and asked participants about their perceptions of the health impacts of climate change and environmental pollutants. The survey also examined participant considerations of factors relating to climate change and environmental pollutants during clinical case assessment and prescribing of treatments. Data were descriptively analysed. Results: Of n=363 naturopathic practitioners who completed the survey, 88.7% agreed climate change is real, of whom the majority were concerned about impacts of climate change on their patients' health (89.1%). Almost all participants agreed that environmental pollutants harm human health (99.7%) and were concerned about impacts on their patients (99.5%). Climate-related health factors such as water intake (74.2%) and food security (72.9%) were frequently considered during patient assessment, while impacts of severe weather events (41.4%) were less commonly considered. Consideration of factors relating to environmental pollutants was more commonly reported, particularly for food quality (83.8%) and domestic/indoor sources of pollutants (73%). When formulating prescriptions, participants reported highly frequent consideration of all climate-related factors (73%-86.8%) and varied consideration of environmental pollutant exposures (54.4%-83.4%). Conclusions: The global naturopathic workforce demonstrates a high level of awareness and engagement with factors relating to health impacts of climate change and environmental pollutants, suggesting alignment with planetary health. While this engagement is evident in clinical behaviour, some gaps between awareness and application suggest a need for greater support to strengthen the naturopathic application of planetary and environmental health.

Background: Spinal pain, including neck pain and low back pain (LBP), is a common musculoskeletal condition and major contributor to disability worldwide. Evidence comparing disability, fatigue and mental health across acute and chronic stages remains limited, particularly in conflict-affected and low-resource settings. This study assessed these outcomes among patients with acute and chronic neck pain and LBP in the Gaza Strip. Methods: A comparative cross-sectional study was conducted among 410 adults attending outpatient physical therapy at Nasser Medical Complex, Khan Younis, Gaza Strip. Participants included 204 with neck pain and 206 with LBP, classified as acute neck pain (n=101), chronic neck pain (n=103), acute LBP (n=102) and chronic LBP (n=104). Disability, fatigue, psychological distress and sleep disturbance were assessed using the Neck Disability Index (NDI)/Oswestry Disability Index (ODI), Fatigue Severity Scale (FSS), Patient Health Questionnaire-4 (PHQ-4) and PROMIS Sleep Disturbance Short Form 8a. Independent t-tests, adjusted linear regression, correlation analyses, clinical-threshold analyses and binary logistic regression were performed. Results: Chronic neck pain and chronic LBP were associated with significantly higher disability, fatigue and psychological distress than acute pain. Chronic neck pain patients had higher NDI, FSS and PHQ-4 scores than acute neck pain patients; chronic LBP patients had higher ODI, FSS and PHQ-4 scores than acute LBP patients (all p<0.001). Sleep disturbance did not differ significantly between groups. Female participants reported higher psychological distress in both pain groups, with higher fatigue in neck pain and higher disability in LBP. Adjusted analyses confirmed that chronic pain status remained associated with higher disability, fatigue and psychological distress. Fatigue was the most consistent factor independently associated with chronic pain status. Conclusions: Chronic spinal pain was associated with greater disability, fatigue and psychological distress than acute spinal pain, while sleep disturbance was common across groups. These findings support early multidimensional assessment, including screening for fatigue and psychological distress. Longitudinal studies are needed to clarify whether these factors contribute to transition from acute to chronic spinal pain.