Occupational and Environmental Medicine

BackgroundWork-related stress (WRS) accounts for 52% of self-reported work-related ill-health. In 2004, the Health and Safety Executive (HSE) developed the Management Standards (MS), aimed at helping organisations reduce WRS. This work investigates WRS post implementation, with reference to six MS risk factor domains: control, support, relationships, demand, change, and role. MethodCases of WRS were extracted from The Health and Occupation Research (THOR) database and mapped to the six domains. Trends in WRS incidence rates attributed to each of the domains were split at 2004 and compared with the overall WRS trend using mixed generalised regression models. ResultsBefore 2004, annual incidence in WRS increased by 1.4%(-0.5%,3.1%), whereas after 2004, there was a decrease of -0.9%(-1.5%,-0.2%), based on 10,815 WRS cases reported between 1996 and 2019. Three of the six MS domains (demands, relationships, and change) were reported in [~]82% of cases. Pre-2004, four of the six domains were observed to be increasing per year. Post 2004, cases increasingly contained multiple precipitating events e.g. demands + another (+2.6% per year) and relationships + another (6.1%). Reports of the two most common domains decreased post 2004 (demands -0.46%, relationships -0.55% per year), whereas incidence in less common domains increased (change 1.1%, support 2.4%, control 4.8%, role 4.7%). ConclusionTrends in WRS, and their common risk factors appear to be decreasing gradually, since introduction of MS in 2004. However, less common risk factors are becoming more prominent, contributing to reporting of WRS with multiple risk factors.

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.

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 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.

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.

Structured AbstractO_ST_ABSBackgroundC_ST_ABSPost-Traumatic Stress Disorder (PTSD) is a mental health condition affecting people who experience traumatic events. Trauma-exposed occupational groups report higher rates of PTSD than the general population. Current treatments, and access, often take months and may cause distress when people are required to talk about the trauma. ObjectiveTo determine the proof of concept of FIRST, a brief, non-trauma focussed therapy, in two separate populations with employment-associated PTSD. MethodTwo independent, single-arm, experimental therapy pilot trials were conducted. Trial one recruited 20 military veterans who received FIRST therapy via trained third-sector therapists. Trial two recruited 16 health and social care workers with FIRST therapy delivered by healthcare provider therapists. All participants were adults with PTSD (confirmed via CAPS-5 in trial one, and symptom score of [&ge;]33 on the PCL5 in trial two). Primary outcomes were recruitment feasibility, retention, data quality and reduction in PTSD symptoms. Secondary outcomes were anxiety and depression symptoms, daily life functioning and perceived health status. Veterans were followed up at 12 weeks post-enrolment and healthcare workers at 8 weeks. ResultsThe veteran trial progression criteria to main trial were met. Seventy-nine people screened eligible, 43 attended a CAPS-5 assessment; 20 had confirmed PTSD and were enrolled. Seventeen completed therapy and 12-week outcome measures. Mean PCL-5 scores decreased from 48.7 (SD = 13.02, n=20) at baseline to 23.5 (SD = 15.30, n=17) at 12-weeks. The healthcare worker trial obtained informed consent from 16 participants, 10 commenced therapy and were included in analysis with eight completing therapy. Mean PCL-5 scores decreased from 42.60 (12.23, (n=10) at baseline to 22.00 (19.92, n=8) at 8-weeks. ConclusionsProof of concept of FIRST was established. PTSD symptom reductions exceeded the PCL-5 minimal clinically important difference. Undertaking a fully powered randomised controlled trial of FIRST therapy is feasible within both healthcare and third sectors. HighlightsO_LIPost-traumatic stress disorder (PTSD) is more common in military veterans and health workers than the general population C_LIO_LITherapy can be challenging to commence and complete when it requires a focus on the trauma incident C_LIO_LIFIRST offers a promising, brief, non-trauma focused therapy for the treatment of PTSD C_LI

Background Migraine prevalence is higher among individuals with attention deficit hyperactivity disorder (ADHD). However, most research has focused on single-disease studies. This study used Global Burden of Disease (GBD) data to analyze co-occurrence patterns and related risk factors. Methods This study extracted the incidence and age-standardized incidence rate (ASIR) of migraine and ADHD among individuals across 204 countries and territories in GBD 2021, as well as exposure values for risk factors. To explore the co-occurrence patterns of migraine and ADHD and their spatial heterogeneity in global distribution, the incidence of both diseases was classified into quartiles, and countries and territories were categorized into three regional types: consistent regions, migraine-dominant regions, and ADHD-dominant regions. Global groupings by economy and risk factors were analyzed separately for co-occurrence patterns, and disease burden projections were made for 2050. Results In 2021, countries and regions were categorized into three distinct groups based on disease prevalence patterns: the majority exhibited an ADHD-dominant profile, predominantly found in high-SDI regions; a consistent pattern, where both diseases occurred at comparable levels, was primarily observed across South Africa and the Middle East, while a migraine-dominant pattern was identified in North Africa. Co-occurrence patterns were generally less prevalent in areas with lower socioeconomic development. Across all three patterns, high temperature exposure, iron deficiency, and metabolic risks emerged as the primary contributing factors. Looking ahead to 2050, the global burden of migraine was projected to stabilize, whereas the prevalence of ADHD was expected to experience a slight yet consistent increase. Conclusion This study systematically identifies the co-occurrence patterns of ADHD and migraine, along with their socioeconomic and environmental drivers, offering evidence-based insights for early prevention and targeted intervention in disease populations globally. Keywords GBD, migraine, ADHD, incidence, disease burden

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. Lifetime exposure to trauma is associated with chronic pain. Separate studies of chronic pain and trauma report overlapping alterations in white matter microstructure, yet their distinct and cumulative effects remain unclear. Methods. White matter microstructure (fractional anisotropy [FA] and mean diffusivity [MD]) from the UK Biobank (N = 21,995) were analysed using linear mixed-effects models. First, group effects (chronic pain versus control) on white matter integrity within this cohort were established. To investigate distinct and cumulative impacts of trauma exposure at different developmental stages, main and interactive effects of group and trauma severity on FA and MD were examined in separate groups exposed to childhood maltreatment only, adulthood trauma only, and both. Sex-stratified analyses were conducted. Results. Chronic pain was associated with widespread alterations and was spatially refined to brainstem tracts and cingulum when accounting for maltreatment/trauma severity. Accounting for chronic pain, cumulative trauma severity was associated with alterations in brainstem, frontal and parietal tracts, whereas adulthood trauma showed comparable but attenuated patterns. Childhood maltreatment severity was associated with localised FA and MD reductions in brainstem tracts, sagittal stratum and superior longitudinal fasciculus. These effects were more pronounced in females than males. A chronic pain-by-maltreatment/trauma severity interaction was observed for FA in the superior cerebellar peduncle in females exposed to childhood maltreatment only. Conclusions. Distinct and interactive effects of chronic pain and maltreatment/trauma severity on white matter microstructure were evident. The findings suggest that trauma-informed care should be tailored by timing of exposure and sex in this population.

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

BACKGROUND: The UK National Institute for Health and Care Excellence recommends routine enquiry about domestic violence and abuse (DVA) in maternity care. We aimed to explore patterns and predictors of DVA enquiry during routine first antenatal care ( booking) appointments with midwives in South East London. METHODS: We conducted an observational cohort study using cross-sectional data collected through the St Thomas Hospital midwifery service between 1st January 2019 and 31st March 2023. Pseudonymised data were extracted from maternity records, comprising demographics, mental and physical health information, social factors, and DVA enquiry. We used linear mixed modelling to test associations between predictors and DVA enquiry. RESULTS: The dataset comprised 7,932 booking appointments with 7,007 women (median age: 32 years; ethnicity: 52% White, 27% Black, 7% Asian, and 15% other). Enquiry was made about current experiences of DVA in 79.4% of appointments. Black-identifying women (OR=1.28, 95% CI [1.11,1.46]) and those born in Sub-Saharan Africa (OR=1.37 [1.14,1.64]) were more likely to be asked than white-identifying and UK-born women. Single women were more likely to be asked than married or cohabiting women (OR=1.22 [1.08,1.38]). Those living in more deprived neighbourhoods were more likely to be asked (OR=1.07 [1.01,1.14]). Multivariable modelling found that being born in Sub-Saharan Africa or Southern Europe, and living alone but with additional support were all associated with increased DVA enquiry, while being born in North America or requiring an interpreter were associated with decreased enquiry CONCLUSIONS: Despite recommendations for routine DVA enquiry during all booking appointments, a substantial proportion of pregnant individuals were not asked between 2019 to 2023. Predictors of DVA enquiry reflected practical barriers (e.g. language), and known or perceived predictors of DVA risk (e.g. deprivation). Our findings suggest that midwives consciously or unconsciously prioritise DVA enquiry for women they believe are at greatest risk, against national guidelines.

Sex work is diverse and includes a broad range of people and settings. Over the last thirty years, a large proportion of public health emergencies of international concern (PHEIC) have involved infections transmitted through sexual or close contact and in sexual networks (WHO 2024). Sex workers can face increased disadvantage in relation to these public health emergencies. Given the significant health inequalities sex workers can face, they should be eligible to receive targeted and tailored health support to reduce health protection risks (Hester 2019; Jeal and Salisbury 2004a). However, they are often not explicitly eligible for targeted and tailored support due to a lack of information on incidence, prevalence of disease, and even more basic data such as reliable estimates of the number of sex workers in the UK. Accordingly, the aim of this paper is to determine a population size estimate, with uncertainty, that is more robust than those currently available. In this study, we apply Bayesian Evidence Synthesis to bring together historic estimation efforts with recent ONS National Population Estimates and Genito-Urinary Medicine Clinics Attendance Data (GUMCAD) from the UK Health Security Agency (UKHSA). A key feature of our model is the embedding of uncertainty from each input study in model priors, hence propagating it through to our final estimate. The Bayesian evidence synthesis model estimated a total of 84,000 sex workers in the United Kingdom (95% credible interval: 49,000-130,000), representing 0.121% of the current UK population.

Background: Sexual and gender minorities (SGM), including men who have sex with men (MSM) and transgender women, often face stigma, legal constraints, and limited access to sexual and reproductive health services. These conditions restrict prevention and care, increasing vulnerability to HIV and human papillomavirus (HPV) infections. While strong HIV-HPV interaction is documented in high-income settings, evidence from low- and middle-income countries remains limited. This study examines the burden, co-infection dynamics, and progression of HPV infection and anal dysplasia among MSM and transgender women in Pakistan. Methods: A cross-sectional study was conducted between September 2015 and October 2016 among men who have sex with men (MSM) and transgender women recruited from sexual health and antiretroviral therapy centers in Karachi. Eligible participants were aged [&ge;]18 years and self-reported anal sex within the past 6 months (N=298). Two anal specimens were collected for HPV DNA detection and genotyping using PCR, and anal squamous intraepithelial lesions (ASIL) were assessed cytologically using the Bethesda classification. Associations were estimated using Cox proportional hazards regression algorithms to derive prevalence ratios (PRs). Results: Among participants, 44% (n=133) were living with HIV. Overall HPV prevalence was 65.1%, rising to 87% among HIV-positive individuals compared to 48% among those without HIV ({chi}{superscript 2}p[&le;]0.001). Likewise 28.9% of participants living with HIV were infected with two or more than two types of HPV as compared with 18.8% participants without HIV ({chi}{superscript 2}p[&le;]0.001). HIV infection was strongly associated with HPV acquisition (adjusted PR 2.81, 95% CI 2.16-3.82). Among HPV-positive participants (n=194), 58.8% were co-infected with HIV. High-risk HPV was highly prevalent among those living with HIV (83.2% vs. 35.3% ({chi}{superscript 2}p[&le;]0.001)), with HPV16 as the dominant oncogenic type. Multiple HPV infections were more common among HIV-positive individuals ({chi}{superscript 2}p[&le;]0.001), and HIV seropositivity was 3.43 (95% CI: 2.55-3.51) times higher among those with high-risk HPV. Co-infected participants demonstrated prolonged smoking, longer duration of sex work, high-intensity sex work with limited condom negotiation, and higher prevalence of anal warts (all p<0.05). Anal dysplasia (ASIL) was present in 35% of participants and was higher among HIV-positive individuals (42.4% vs. 28.1%, p<0.001). HIV-HPV co-infection was independently associated with ASIL (adjusted PR 1.75, 95% CI 1.07-2.88), while high-risk HPV further amplified this risk (PR 3.04, 95% CI 1.75-5.26). Conclusion: These findings demonstrate a biological continuum in HIV-positive MSM and transgender women, where HIV increases HPV acquisition, persistence, and multiplicity, accelerating progression to anal dysplasia. This reflects a syndemic shaped by biological interaction and structural vulnerability. Integrating HPV screening and vaccination within HIV services is essential to interrupt progression to cancer in this high-risk population.

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

Background: Physical activity is a well-established modifiable risk factor for depression and anxiety. However, whether vigorous intermittent lifestyle physical activity (VILPA), defined as short, sporadic bouts embedded in daily life, confers mental health benefits remains unclear. We aimed to examine the associations of accelerometer-measured VILPA with risks of incident depression and anxiety among non-exercising adults. Methods: This prospective cohort study included 19,962 non-exercising adults (mean age 62.3 years) from the UK Biobank, free of depression and anxiety at baseline (2013-2015), with 7-day wrist-worn accelerometry data. Cox proportional hazards models and restricted cubic splines were used to examine associations between average daily duration of VILPA bouts lasting up to 1 or 2 minutes and these outcomes. Findings: Over an average follow-up of 7.8 years, 469 participants developed depression and 536 developed anxiety. Approximately 94.6% of participants engaged in VILPA bouts lasting up to 1 minute. Daily VILPA duration exhibited L-shaped associations with both depression and anxiety. Compared with participants who accumulated no VILPA, the whole-sample median daily VILPA duration for bouts lasting up to 1 minute, 4.1 minutes, was associated with a hazard ratio of 0.70 (95% confidence interval [CI]: 0.56-0.88) for depression and 0.79 (95% CI: 0.64-0.97) for anxiety. Findings were similar for VILPA bouts lasting up to 2 minutes. Interpretation: Among non-exercisers, even small amounts of VILPA were associated with substantially lower risks of depression and anxiety, highlighting the potential of high-intensity incidental physical activity as a feasible strategy for preventing depression and anxiety, particularly among individuals unable or unwilling to engage in structured exercise.

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

ObjectiveTo assess the prevalence, determinants, and health associations of vitamin D deficiency among workers in Cikarang, Indonesia. MethodsCross-sectional study of 107 workers. Serum 25(OH)D was measured by ECLIA; deficiency was <20 ng/mL. Data included demographics, occupation, sun exposure, diet, anthropometry, laboratory parameters, and self-reported health. Analyses used t-test/Mann-Whitney U, chi-square, and multivariable regression. ResultsDeficiency was prevalent (57.9%; median 18.6 ng/mL). Males had higher levels (+7.60 ng/mL) and lower risk (OR 8.56), while younger age (<38.5 years) showed lower levels (-5.60 ng/mL) and higher risk (OR 4.73; all p<0.0001). Greater sun exposure increased levels, whereas sunscreen use and greater clothing coverage reduced them. Only sex and age remained significant. ConclusionVitamin D deficiency is common, especially among female and younger workers, with modifiable sun-avoidance behaviors contributing. LEARNING OUTCOMESO_LISummarize the prevalence and key determinants of vitamin D deficiency among industrial workers in equatorial Indonesia, contributing to limited occupational health data in this setting. C_LIO_LIHighlight the role of modifiable behaviors--particularly sun exposure and sun-avoidance practices--in influencing vitamin D status among workers. C_LIO_LIEmphasize the need for targeted workplace interventions, including safe sun exposure strategies and nutritional support, especially for high-risk groups such as female and younger workers. C_LI

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.

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.