Risk Management and Healthcare Policy

Background A small proportion of hospitalized patients generates a disproportionate share of inpatient admissions, bed-day utilization, and associated health expenditure globally. In Saudi Arabia, where Vision 2030 mandates measurable reductions in preventable hospitalizations and hospitals consume approximately 79% of public health expenditure, population-level evidence on inpatient frequent utilization is absent from the published literature. A key methodological limitation of existing studies is reliance on a single threshold that cannot distinguish acute high-frequency episodes from sustained multi-year hospital dependence. Methods A retrospective cross-sectional study analyzed electronic health records from three public hospitals in Jeddah - East Jeddah Hospital (EJH), King Abdul-Aziz Hospital (KAAH), and Thagher Hospital (TH) - for January 2022 to December 2024. Records from two clinical information systems (Oasis at KAAH and TH; Careware at EJH) were harmonized using an eight-stage data quality protocol applied to 258,391 raw encounters, yielding a final cohort of 82,160 unique patients and 100,685 valid inpatient visits. Three complementary definitions were applied: Frequent Utilizer (FU: >=3 admissions within any rolling 365-day window), Persistent Utilizer (PU: >=3 admissions with >=24 months between first and last), and Yearly Utilizer (YU: >=1 admission in each of 2022, 2023, and 2024). Analyses were conducted in JASP 0.95.4. Results FU prevalence was 2.96% (n=2,434), PU 0.60% (n=494), and YU 0.62% (n=507). Overlap analysis identified 177 compound utilizers (0.22%) satisfying all three criteria simultaneously, with a median of 7 admissions and 33.44 bed days - more than thirteen times the standard patient median. Compound utilizers had the youngest median age of any utilizer group (24 years), while Saudi nationality concentration rose progressively from 75.0% in standard patients to 87.6% in compound utilizers, and female predominance was highest in the persistence-defined groups (PU-only 62.9%, YU-only 63.6%). All three ANOVA models confirmed significant utilizer status x hospital interactions (all p<.001). Logistic regression confirmed age, Saudi nationality, and hospital as independent predictors across all definitions. A gender discrepancy - significant for males in FU Model 1 (OR=1.090, p=.039) but not Model 2 (p=.181) - was attributable to age confounding. Conclusions Approximately one in thirty-four inpatients meets the FU criterion in this Jeddah system, with significant between-hospital variation. The three-definition framework reveals clinically distinct utilization phenotypes invisible to any single threshold, including compound utilizers with extraordinary burden and unexpectedly young age, and persistent users entirely missed by annual-window definitions. Saudi nationality is the strongest and most consistent predictor across all definitions. Integrated clinical pathways connecting primary care and community services to hospital care, with shared accountability for quality across levels, are the recommended system response aligned with Vision 2030.

Effective management of biomedical equipment prevents breakdowns, extends equipment lifespan, ensures perioperative safety and cost-efficiency. There are major challenges in managing biomedical equipment, particularly in low- and middle-income countries. This study aimed to assess the availability, functionality, and adherence to maintenance practices of biomedical equipment in operating rooms (ORs) and post-anaesthesia care units (PACUs) across Rwanda. A cross-sectional observational study was conducted at one Level 2 district hospital in each of Rwanda's five provinces (n=5 sites). Data were collected using three main tools: 1) a medical equipment checklist, 2) a checklist for hospital biomedical management, and 3) direct inspections of selected biomedical equipment. All tools underwent pretesting and face validation with support from biomedical experts prior to data collection in May 2024. Key measures, including the availability and functionality of biomedical equipment, and adherence to maintenance and management practices, were summarised using descriptive statistics. The five hospitals had a total of 16 ORs, 4 PACUs, and 226 pieces of equipment. The overall availability of biomedical equipment was 45%, and the functionality of the available equipment was 96%. The mean adherence rate to national management practices was 66%. The Rwandan government, non-governmental organisations, and hospitals were identified as direct funders of the equipment, accounting for 42%, 12%, and 4%, respectively. However, 42% of the equipment surveyed could not be linked to any of the above sources of acquisition. Among non-functional equipment, 75% was due to a lack of spare parts, while 25% was due to a lack of skills to maintain the equipment. In summary, we found low availability of perioperative biomedical equipment across Rwanda, although the available equipment was highly functional. Adherence to national management practice guidelines was relatively low, threatening the sustainability of functional equipment. We recommend that the government and hospital administrators implement robust, regular auditing systems to ensure proper management of biomedical equipment.

Bacterial contamination of Surgical sites could lead to Surgical Site infections (SSI) which may prolong hospital stay, increased treatment costs and increased mortality. This study determined the prevalence of bacterial contamination of surgical sites among post-operative wounds and theatre surfaces together with their resistance to commonly prescribed antibiotics. A cross-sectional study design was used where a total of 290 and 74 swabs were collected from patients and theatre surfaces respectively. Swabs were cultured on duplicate plates of Blood Agar, Chocolate Agar and MacConkey Agar. Gram-staining and Biochemical tests were performed to identify the isolates. Resistance to commonly prescribed antibiotics was determined using the Kirby Bauer (KB) method. Data were analyzed using SPSS version 23, and descriptive statistics, Chi square and student T- tests were used to describe the results. The prevalence of bacterial contamination in wounds was 30.7% and was significantly higher in women of child bearing age ({chi}2= 10.79, df=1, P=0.0010). Microbial growth increased with an increase in duration of antibiotic therapy ({chi}2=12.73, df=2, P=0.007). E. coli was responsible for the highest cases of wound contamination (34.9%). All microorganisms isolated from post-operative wounds showed considerable resistance to antimicrobials. All isolates from wounds were resitant to Trimethoprin Sulfamexathone and 76.9% showed resistance to Ciprofloxacin. Other than E.coli and Acinetobacter, the rest of the isolates were susceptible to imipinem. Fourty nine gram positive isolates were grown from theatre surfaces and a significant majority (86%) were from air. There was high resistance to Erythromycin in Coagulase Negative Staphylococcus (CNS) isolates (56.0%). Overall, our study demonstrated that wound contamination at the Hoima Regional Referral Hospital is high but not associated with theatre surface contamination.

Background Severe Clostridioides difficile infection (CDI) morbidity and mortality disproportionately affect Black and Hispanic patients in the United States. Antibiotic exposure is the primary modifiable risk factor for CDI, and clindamycin is among the agents most strongly associated with related harm. Characterizing inequities in prescribing is critical. Dentistry is a major source of clindamycin prescriptions. Academic dental clinics serve diverse patient populations and provide an ideal setting to evaluate prescribing across racial and ethnic groups. We therefore examined antibiotic use and cumulative clindamycin exposure as measures of CDI-associated risk. Methods We conducted a retrospective study of electronic health records from 5 US academic dental institutions from 2021 through 2023. We analyzed 552,428 encounters among 132,770 patients with documented race/ethnicity to estimate adjusted odds of receiving any oral antibiotic and clindamycin by race/ethnicity. Secondary outcomes evaluated total antibiotic exposure among dental provider-prescribed antibiotics, focusing on higher-than-standard cumulative dosing of clindamycin (>8400 mg) and amoxicillin (>10,500 mg). Results Oral antibiotic prescribing occurred in 1.9% of encounters. Compared with White patients, Black, Hispanic, and Other race patients had slightly lower adjusted odds of receiving any oral antibiotic, while Black patients had greater odds of receiving a higher-than-standard cumulative clindamycin dose when clindamycin was prescribed (adjusted odds ratio, 2.19; 95% confidence interval, 1.25-3.82). Conclusion Racial and ethnic inequities in dental antibiotic prescribing extended beyond antibiotic receipt to cumulative clindamycin exposure. Although CDI outcomes were not directly measured, these prescribing differences may have implications for disparities in CDI-associated harm and warrant further investigation.

Introduction: Primary care clinicians (PCC) commonly make decisions in the context of time delay and uncertainty. Delay discounting (DD) and probability discounting (PD) are cognitive biases related to delay and uncertainty that are minimally explored in PCC. We assessed DD and PD in PCC and evaluated their association with low-value care (LVC) decision-making. Methods: We administered a survey to PCC in a Southeastern U.S health system and within the American Academy of Family Physicians networks. The survey comprised standardized psychometric assessments of DD and PD and four LVC clinical vignettes. Outcomes included DD and PD discounting rates for two monetary rewards ($100 and $10,000) and ratings of LVC likelihood (0-100). We used regression analysis with model selection to evaluate the relationship between variables. Results: 225 PCC (89% physicians, 11% advanced practice providers) participated. Heterogeneity in DD and PD rates was observed. For the $10,000 reward, ln k(DD)= -6.80, IQR:-7.60--6.10) and ln h(PD)= 1.75, IQR:1.75-2.36). The reward amount impacted DD and PD in opposing directions (i.e., lower DD/higher PD rates for $10,000 vs. $100). LVC likelihood was highest for low-value antibiotics and lowest for low-value cervical cancer screening (median 20, IQR:10-40 and 0, IQR:0-10, respectively). Model selection revealed demographic associations with LVC likelihood, but no association with DD or PD. Conclusions: Consistent with effects previously reported in non-clinicians, PCC exhibited a range of DD and PD, which ranged by reward magnitude. Neither DD nor PD predicted vignette-based LVC likelihood. Further research should investigate actual clinical practice patterns and other LVC scenarios.

Universities provide a key opportunity to deliver social prescribing, a care pathway that aims to connect people with non-medical forms of support within the community to address their social, emotional, and practical needs. However, it is unclear whether students in the UK are aware of social prescribing and whether it would be an acceptable form of support. We surveyed 775 university students across the UK who completed a questionnaire measuring awareness and perceptions of social prescribing. We described awareness and attitudes and used logistic regression to explore how they differed according to individual characteristics. We found an awareness-attitude paradox. Only 25% of students were aware of social prescribing, but attitudes were overwhelmingly positive once explained: 97% thought it could support mental health and wellbeing; 95% believed universities should offer it; and 89% would accept social prescribing if offered by a healthcare professional. Students who were older, postgraduates, and had English as their first language were among those with higher odds of being aware of social prescribing, but positive attitudes were more evenly reported across the sample. Our findings indicate that implementation efforts should prioritise awareness-raising and clear referral pathways, rather than increasing students' willingness to engage with social prescribing.

Ethnic minority and migrant populations experienced disproportionately severe COVID-19 outcomes across Europe, yet the mechanisms underlying these disparities, particularly inequities in healthcare access, remain insufficiently understood at the patient level. This qualitative study examines healthcare-seeking behaviours and access to care among ethnically diverse patients hospitalised with COVID-19 in Amsterdam between 2020 and 2022, and the contextual factors shaping their pathways to care. Twenty adults of Turkish, Moroccan, Surinamese, Ghanaian, and Dutch ethnic backgrounds, all hospitalised with COVID-19, were interviewed using a semi-structured retrospective approach to reconstruct individual care pathways from symptom onset to hospitalisation. Data were analysed thematically, guided by the Candidacy Framework and the Health Belief Model. Pandemic-induced structural disruptions, including healthcare system strain, capacity shortages, absent care protocols, and fragmented referral pathways, constituted the primary barriers to care across all ethnic groups. Participants with longer hospital stays tended to be older, less educated, and with more comorbidities, yet reported fewer barriers once hospitalised, as disease severity triggered prioritisation. Those with shorter stays or emergency department visits without admission encountered greater difficulties, including repeated discharge despite worsening symptoms. Language barriers and prior negative experiences with healthcare services compounded access challenges for some participants with migrant backgrounds, though pandemic phase and disease severity were the dominant determinants across the sample. Inequities in access to care were driven primarily by pandemic-induced structural factors rather than ethnic background. Pre-existing vulnerabilities among migrant groups, including reduced institutional trust and language barriers, intensified these structural barriers for some. These findings are directly relevant for equity-sensitive pandemic preparedness: crisis response frameworks must explicitly address structural accessibility alongside targeted support for groups facing compounding disadvantage.

Background: Hemorrhoids are among the most common anorectal disorders, yet traditional treatment practices remain widespread in Ethiopia. These remedies often involve corrosive chemicals, herbal preparations, or invasive procedures, and are associated with severe complications. Despite their prevalence, systematic evidence on outcomes and community perceptions is limited. Methods: A hospital?based cross?sectional study was conducted from December 30, 2024 to December 29, 2025 in Sidama, Ethiopia. A total of 450 patients diagnosed with hemorrhoids and managed across five government hospitals were enrolled. Structured questionnaires and medical record review were used to collect socio?demographic characteristics, clinical presentation, hospital management, traditional treatment practices, complications, and community perceptions. Descriptive statistics and independent sample t?tests were applied. Results: The mean age of participants was 35.2 years, with a predominance of males (63.1%) and urban residents (72%). Perianal pain (84%) and rectal bleeding (50%) were the most frequent symptoms. Independent samples t?test analysis demonstrated that patients who visited traditional healers were significantly older than those who did not (mean age 48.2 vs. 34.4 years; mean difference = 13.8 years, 95% CI: 8.8-18.8; p < 0.001). Hospital management, primarily hemorrhoidectomy (31.8%), achieved favorable outcomes, with 97.3% of patients improving. Twenty-eight patients (6.2%) reported using traditional healers, most commonly involving topical chemical applications (71.4%). Complications were frequent among traditional users, with 85.7% experiencing adverse outcomes such as persistent pain, anal stenosis, and perianal discharge. Despite these complications, community perceptions remained largely positive or neutral, influenced by family and peers. Conclusion: Traditional hemorrhoid treatment in Southern Ethiopia is associated with high complication rates, yet community perceptions remain favorable due to sociocultural influences. Hospital management demonstrates superior outcomes. Bridging the gap between biomedical care and community beliefs is essential to reduce morbidity and promote safe treatment .

Background: Healthcare-associated infections (HAIs) remain a major patient safety challenge in sub-Saharan Africa, where gaps in infection prevention and control (IPC) practices persist. Nursing and midwifery students are particularly vulnerable during clinical training, yet evidence on their IPC knowledge and compliance in Ghana remains limited. Objective: To assess knowledge of nosocomial infections and compliance with standard precautions among third-year nursing and midwifery students at Kwame Nkrumah University of Science and Technology (KNUST), Ghana. Methods: A descriptive cross-sectional study was conducted among 150 third-year nursing and midwifery students at KNUST, Kumasi, Ghana, between 28 June and 9 July 2021. Data were collected using a structured questionnaire adapted from WHO and CDC guidelines. Knowledge was assessed using a 19-item scale and compliance using a 17-item Likert-type scale. Chi-square tests, Fisher's exact test, and Spearman's rank correlation were used to examine associations between knowledge and compliance. Results: Overall, 143 respondents (95.3%) demonstrated high knowledge of nosocomial infections and standard precautions (mean score: 16.44/19; SD: 1.59). High compliance with standard precautions was reported by 112 respondents (74.7%; mean score: 59.13/68; SD: 5.89). Compliance was strongest for hand hygiene and glove use but lower for PPE use during splash-risk procedures and safe needle-handling practices. No statistically significant association was found between categorized knowledge and compliance levels (df = 1, p = 0.491; Fisher's exact p = 0.679). However, a modest positive correlation was observed between continuous knowledge and compliance scores (Spearman's rho = 0.326, p < 0.001). Conclusion: Although knowledge of nosocomial infections was high, compliance varied across standard precaution domains, with notable gaps in PPE use and safe needle-handling practices. Practical training, simulation-based learning, and supervised clinical reinforcement are needed to bridge the knowledge practice gap in nursing and midwifery education in Ghana.

Health workforce performance is central to service quality, yet little empirical work has examined how performance management systems operate for physiotherapists in rehabilitation services in low- and middle-income settings. This cross-sectional study assessed the current state, perceived effectiveness, and process gaps of performance management systems among physiotherapists working in public rehabilitation centers in Dhaka, Bangladesh. A pretested semi-structured questionnaire was administered to 105 physiotherapists between September and October 2025. Descriptive statistics were used to summarize participant characteristics and performance management indicators. Wilson 95% confidence intervals were estimated for key proportions. A nine-item exploratory performance management system maturity score was constructed from process indicators. Fisher exact tests with Cramer's V were used to examine associations with perceived system effectiveness, and exploratory logistic regression estimated odds ratios for effective or moderately effective performance management. The mean age of respondents was 31.6 years, 56 of 105 were male, and 85 of 105 had graduate or postgraduate qualifications. Formal performance management systems were reported by 102 of 105 respondents (97.1%, 95% CI 91.9-99.0). Standardized appraisal timing and method, assessment form use, performance planning, and formal evaluation systems were each reported by about 60-70% of participants. Reward-performance linkage was perceived as motivating by 97 of 105 respondents (92.4%, 95% CI 85.7-96.1). Overall, 81 of 105 respondents (77.1%, 95% CI 68.2-84.1) rated the system as effective or moderately effective. Training recipient category was associated with perceived effectiveness (Fisher exact p=0.0035; Cramer's V=0.363), as was perceived appropriateness of the process (p=0.0323; Cramer's V=0.258). The maturity score was not independently associated with perceived effectiveness in exploratory regression. Public rehabilitation centers in Dhaka appear to have formal performance management systems, but the systems are only moderately developed. Strengthening training coverage, transparent evaluation criteria, routine feedback, and formal system review may improve staff confidence in performance management processes.

Background The prevalence of chronic heart failure is increasing in Singapore and is associated with frequent hospitalisations, high costs, and impaired quality of life. Patient empowerment interventions for chronic diseases, which are structured approaches that enable patients to actively engage in and influence their care, have demonstrated promising effects on health-related outcomes. In chronic heart failure, however, many interventions focus on selected aspects of empowerment, and there remains limited synthesis of which approaches are most acceptable, preferred, and effective as comprehensive intervention packages. This protocol describes the methods for a study to identify an empowerment-based intervention for adults with chronic heart failure that is both contextually suitable and cost-effective in Singapore. Methods We will use a staged, sequential design comprising three objectives. Objective one is to conduct a systematic review (PROSPERO registration number CRD420251249957) and meta-analysis to synthesise international evidence of the effectiveness of empowerment-based interventions for adults with chronic heart failure. Objective two is to complete a mixed-methods study, including semi-structured interviews with chronic heart failure patients, as well as their caregivers, to identify empowerment-related needs, barriers and facilitators in local chronic heart failure care. This will be followed by a discrete choice experiment to elicit patients preferences for features of an empowerment-based intervention. Objective three is to conduct a cost-effectiveness analysis of the proposed intervention from the perspective of the Singapore health system. Discussion This series of studies integrates international evidence with local stakeholder perspectives and patient preferences to inform a feasible, patient-centred empowerment intervention for chronic heart failure in Singapore. The findings will inform intervention design and provide policy-relevant evidence on costs, health outcomes, and implementation decisions for empowerment-based chronic heart failure care in Singapore.

Background: Transition timing to post-acute rehabilitation after ischemic stroke is heavily influenced by non-clinical factors, introducing potential systemic disparities in care access. We evaluated the association between insurance payor status and acute hospital length of stay (LOS) prior to inpatient rehabilitation discharge among critically ill stroke patients. Methods: Using the MIMIC-IV database, we identified ICU-admitted adults with ischemic stroke discharged to inpatient rehabilitation (n=1,285). The primary outcome was hospital LOS prior to rehab transfer. Multivariable log-transformed linear regression evaluated the association with insurance payor (Medicare, private, other/unknown; reference: Medicaid), adjusting for demographics, diagnostic-code counts (medical complexity), and ICU LOS (acute illness severity). Results: Median hospital LOS before rehab discharge was longest for Medicaid patients (13.2 days) compared with private insurance (11.0 days) and Medicare (9.5 days). In the adjusted model, Medicare insurance was associated with a significantly shorter transition time to inpatient rehabilitation, corresponding to a 13.5% shorter acute hospital stay (adjusted LOS ratio 0.87; 95% CI: 0.79-0.96; p=0.005) relative to Medicaid. Private insurance demonstrated a descriptive trend toward shorter LOS that did not achieve statistical significance (adjusted LOS ratio 0.93; 95% CI: 0.84-1.02; p=0.122). Other and unknown payor categories showed no significant differences. Conclusions: Insurance payor status serves as an independent predictor of acute care transition timing for stroke patients requiring inpatient rehabilitation. The prolonged acute stays observed among Medicaid beneficiaries suggest significant non-clinical, administrative bottlenecks in post-acute placement, underscoring the critical need for standardized, streamlined insurance approval pathways to ensure equitable neurological recovery.

Caregivers increasingly act as proxies, managing patients digital accounts and making complex end-of-life decisions. Greater dyadic engagement in advance care planning (ACP) improves patient and caregiver outcomes, yet empirical evidence linking formal digital proxy roles to ACP engagement remains limited. The study aims to quantify patterns of ACP engagement, digital proxy roles, and how these caregivers behaviors are associated among caregivers in Singapore. We conducted a cross-sectional survey among an online panel of nationally representative adults in Singapore to identify caregivers and assessed their lifetime engagement in formal proxy roles across legal, financial, and medical digital domains, along with ACP proxy behaviors. Formal digital proxies had institutional or joint access to digital financial accounts (for financial digital proxies) or digital patient health/caregiver accounts (for medical digital proxies). ACP engagement was measured using 13 proxy-related behaviors, such as discussing end-of-life care preferences. Multivariable regressions were performed. In total, we identified 276 caregivers, who assisted with instrumental activities daily living to another adult from 311 completed responses. Among caregivers (age 41.0{+/-}13.8, 46.2% female), 28.9% were legal proxies and 40.2% were formal digital proxies (31.5% financial; 29.0% medical). Overall engagement was modest (mean 3.97{+/-}4.54) despite most reported completing at least one behavior. Compared to non-proxies, medical (AME=3.722, 95%CI: 2.143-5.301) and financial digital proxies (AME=1.515, 95%CI: 0.121-2.910) reported significantly higher ACP engagement while legal proxy status did not. High-stakes discussions on life-sustaining treatment and health-state preferences showed low engagement. Formal digital proxy roles are positively associated with ACP engagement and may provide a strategic entry point for interventions. Persistent deficits in high-stakes ACP highlight limited readiness for complex end-of-life decisions and the need for targeted decision-support tools.

Importance: Loneliness is associated with premature mortality and poor mental health and was declared an epidemic by the US Surgeon General in 2023, but national surveillance has relied on state-based or experimental online surveys. In 2024, the National Health Interview Survey measured loneliness directly for the first time. Objective: To estimate the national prevalence of loneliness among US adults, identify the sociodemographic groups with the highest burden, and quantify associations with mental health, health status, and health care use. Design: Cross-sectional analysis of the 2024 National Health Interview Survey, a nationally representative household survey conducted continuously from January to December 2024. Setting: US households; face-to-face and telephone interviews. Participants: 32 629 sampled civilian noninstitutionalized adults aged 18 years or older (response rate, 47.9%); 31 470 (96.4%) had valid loneliness data. Exposures: Frequent loneliness, defined as feeling lonely always or usually on a 5-category item (always, usually, sometimes, rarely, never). Main Outcomes and Measures: Survey-weighted prevalence of loneliness overall and by sociodemographic characteristics, and associations of frequent loneliness with serious psychological distress (Kessler 6 scale score 13 or higher), frequent feelings of depression and anxiety, life dissatisfaction, fair or poor self-rated health, receipt of counseling or therapy, cost-related unmet mental health care need, and emergency department use. Results: In 2024, 4.9% (95% CI, 4.6%-5.2%) of US adults, an estimated 12.2 million people, felt lonely always or usually, and 23.7% (95% CI, 23.1%-24.3%), an estimated 59.3 million, felt lonely at least sometimes. Prevalence of frequent loneliness was highest among adults with family income below the federal poverty level (10.3%), adults with disability (13.6%), adults living alone (9.0%), and American Indian or Alaska Native adults (12.2%). Adults aged 65 years or older had the lowest prevalence of any age group (4.0%) and adults aged 18 to 29 years the highest (6.3%). After adjustment for sociodemographic characteristics, frequent loneliness was associated with serious psychological distress (adjusted odds ratio, 14.5; 95% CI, 12.1-17.3), life dissatisfaction (9.0; 95% CI, 7.6-10.8), cost-related unmet mental health care need (4.3; 95% CI, 3.5-5.2), and emergency department use (1.8; 95% CI, 1.5-2.0). Conclusions and Relevance: Loneliness among US adults was patterned by poverty, disability, and household structure rather than older age. These estimates from the nation's principal household health survey provide a benchmark for monitoring loneliness and suggest that strategies for social connection should address material hardship and access to mental health care.

Background: Chronic illness is a major public health concern in Europe, the United States, and other high-income countries, limiting individuals capacity for self-management and health promotion. Empowerment interventions improve health outcomes while reducing healthcare utilization. Aim: This study assessed the feasibility of implementing the Bodyknowledging Program, a broadly applicable health promotion intervention developed in Norway, at the community level in the US to evaluate participants experiences, program components, and self-management outcomes among adults living with chronic illness, and to identify the programs strengths and areas for cultural adaptation to inform its cross-national transferability. Methods: A multi-method feasibility design was used, including a group of participants living with various chronic illnesses. Reflexive thematic analysis was applied to analyze focus group data, examining participants experiences, program components, and outcomes. Facilitators field notes and post-intervention survey data were additional data sources. Results: Three themes emerged through the thematic analysis: (1) acceptability of the BKPs health promotion content and approaches among US participants, (2) implementation of the BKP intervention in a US community context, and (3) demand and ideas for continued implementation. Facilitator field notes identified challenges in implementing the hybrid format. Survey data confirmed that participants strongly agreed that the program enhanced their ability to recognize bodily signs and tolerance limits, manage symptoms, prevent deterioration, and promote their health. Participants reached consensus on the value of the programs content, materials, organization, and communication strategies. Conclusion: The Bodyknowledging Program is feasible and well-suited for implementation in the US. This community-based empowerment intervention leverages existing but unutilized human resources to strengthen self-management and health promotion among people with chronic illnesses across diagnostic categories. Further research across diverse settings is recommended to support broader dissemination.

Background: Evaluating outbreak detection models is a key component of syndromic surveillance. However, balancing timeliness, predictive performance, and local surveillance constraints remains a major challenge. We developed and assessed whether stacking ensemble approaches, which integrate multiple outbreak detection methods, can improve the timeliness and predictive performance of influenza-like illness (ILI) surge detection. Methods: We developed a two-stage stacking ensemble framework to detect early warning of ILI surges in city-level Primary Health Care encounter time series from Brazil (2022 to 2025). Epidemic thresholds were defined using the Moving Epidemic Method (MEM). In the first stage, multiple outbreak detection models (ODMs) generated warnings of unusual ILI activity. In the second, these warnings were then used as inputs to three supervised meta-classifiers: Logistic Regression, Extreme Gradient Boosting (XGB), and a Multi-layer Perceptron (MLP). For comparison, a Majority Voting (MV) aggregation is also examined. Timeliness, sensitivity, specificity, positive and negative predictive values are evaluated to measure each model's ability to anticipate epidemic periods of varying intensity in 2025. Robustness was further assessed using simulated outbreak scenarios with varying magnitudes and durations. Findings: We identified 5,765 ILI surge onsets across 5,365 Brazilian municipalities in 2025. Compared with individual ODMs and MV, stacking ensemble meta-classifiers anticipated up to 33% of surge onsets three weeks in advance (an average improvement of 15 percentage points) while reducing missed detections to <10%. They achieved sensitivity >90%, while maintaining balanced specificity >80%, PPV >65%, and NPV >99%. Improvements were greatest for very high-intensity surges, with missed detections reduced by more than half compared with individual ODMs. In simulated outbreak scenarios, the MLP and XGB classifiers remained robust despite being trained on fewer than half of all simulated surge events, consistently outperforming individual detection methods and simpler integration approaches. Interpretation: We provide a practical framework for integrating complementary ODMs into a single, robust early warning decision. By improving both timeliness and predictive performance without requiring additional surveillance data or resources, this approach offers a scalable methodological upgrade for syndromic surveillance systems and supports more reliable public health decision-making. Funding: The Rockefeller Foundation (award 2023 PPI 007 to MB-N); Brazilian National Research Council - CNPq (408775/2024-6); MB-N, PIPR, RFSA are CNPq fellows.

Background: Postpartum Medicaid coverage and support are central maternal health policy issues, but county-level tools for identifying where postpartum Medicaid populations may face overlapping administrative, clinical, and contextual access barriers remain limited. Methods: We developed and internally validated a county-level Postpartum Medicaid Access Barrier Index for all 3,144 counties and county equivalents in the 50 states and District of Columbia. Public data sources included geocoded Medicaid office locations from Shafer et al. (2024), U.S. Census county boundaries, American Community Survey 2024 5-year county indicators, the National Center for Health Statistics 2023 Urban-Rural Classification Scheme for Counties, and county-level hospital-based obstetric care status from the University of Minnesota Rural Health Research Center. Medicaid office locations were spatially assigned to counties, then merged with ACS indicators, rurality, and obstetric care status by county FIPS. The theoretical score range was 0-11; the index assigned higher weights to two core infrastructure measures and lower weights to contextual indicators. Internal validation assessed component structure, known-groups validity, geographic clustering, weighting sensitivity, added value over simpler infrastructure screens, and separation across concern levels. Results: Across 3,144 counties, observed scores ranged from 0 to 10 on the theoretical 0-11 score, with a mean of 3.65 and median of 3. High or highest concern counties accounted for 665 counties (21.2%), including 56 counties (1.8%) in the highest concern group. Component correlations were low-to-moderate, with an average absolute phi of 0.176 and no pairwise component correlation at or above 0.50. Known-groups validity was strong: dual administrative and clinical gap counties scored 4.43 points higher than counties with neither gap (Cohen's d = 3.28, p < 0.001). Scores were geographically clustered (Moran's I = 0.375, permutation p = 0.005). A dual-gap-only screen captured 386 of 665 high/highest concern counties (58.0%) but missed 279 high/highest counties; a parsimonious rule requiring one infrastructure gap plus at least four contextual flags recovered 265 of these 279 missed counties (95.0%) with 100.0% precision. Discussion: The Postpartum Medicaid Access Barrier Index provides a transparent county-level screening tool for identifying places where administrative, clinical, and contextual barriers may overlap for postpartum Medicaid populations and should be externally validated against Medicaid enrollment, renewal, churn, coverage continuity, and postpartum care outcomes.

Background Timely assessment, classification, and escalation of public health events are essential for effective outbreak response, yet decision-making after event detection remains challenging because of fragmented guidance and variable interpretation of escalation criteria.To strengthen public health emergency management, Kenya developed the Decision-Making Tool for Public Health Emergencies (DMT-PHE), a framework for event assessment, classification, notification, and escalation. An artificial intelligence (AI)-enabled version, the DMT-PHE AI Agent, was subsequently developed to operationalize the framework through decision support. This study describes the development of the DMT-PHE AI Agent and evaluates its performance, usability, safety, and user acceptability. Methods The DMT-PHE AI Agent was developed using a retrieval-augmented generation architecture supported by a curated knowledge base derived from the validated DMT-PHE framework and related public health guidance. A simulation-based pilot evaluation was conducted among 11 public health professionals who independently assessed three standardized outbreak scenarios. AI-generated recommendations were compared with expert-defined gold standards. Outcomes included concordance, response-action coverage, citation performance, safety, usability, and user acceptability. Results Thirty-three scenario evaluations were completed. The AI Agent achieved an overall weighted concordance score of 0.924, with exact agreement of 90.9% for Public Health Events of Initially Unknown Etiology, 81.8% for Rift Valley fever, and 90.9% for Mpox. Citation support was provided in 78.8% of interactions, with no incorrect citations or major safety concerns identified. The mean System Usability Scale score was 85.2, while participants reported high trust (4.27/5), contextual relevance (4.55/5), and perceived time savings (4.82/5). Conclusions The DMT-PHE AI Agent demonstrated that a nationally validated public health emergency decision framework can be successfully translated into an AI-enabled decision-support system. These findings provide early evidence that AI can augment public health emergency decision-making by delivering structured, transparent, and context-specific recommendations while maintaining human oversight, offering a practical model for operationalizing national public health guidance.

Background Cholera remains a recurrent public health emergency in Zamfara State, northwestern Nigeria, where communities depend predominantly on untreated and poorly protected water sources. Environmental water bodies serve as reservoirs for Vibrio cholerae, sustaining transmission cycles between outbreaks. Despite the severity of recurrent outbreaks in the region, data on the molecular characteristics and serogroup distribution of V. cholerae across different drinking water source types in Zamfara State remain critically limited. Methodology/Principal Findings A cross-sectional environmental surveillance study was conducted between 13 October and 26 November 2025 across five cholera-affected Local Government Areas (LGAs) of Zamfara State: Gusau, Bungudu, Talata Mafara, Zurmi, and Shinkafi. A total of 142 water samples were collected from five source types -- rivers, boreholes, wells, tap water, and sachet water. Presumptive isolation was performed on Thiosulfate-Citrate-Bile Salts-Sucrose (TCBS) agar following alkaline peptone water enrichment. Fifty-five presumptive isolates underwent PCR-based molecular confirmation and serotyping using three gene targets: ompW (species confirmation, 588 bp), ctxA (O1 toxigenicity marker, 302 bp), and tcpA (O139 colonisation factor, 120 bp). Presumptive V. cholerae was recovered from 55 of 142 samples (38.7%; 95% CI: 30.5-47.3%), with well water recording the highest positivity rate (69.7%; 95% CI: 51.3-83.7%). A statistically significant association was observed between water source type and presumptive V. cholerae occurrence ({chi}2 = 23.11, df = 4, p < 0.001). Molecular analysis confirmed 29 isolates (52.7%; 95% CI: 39.2-66.0%) as V. cholerae, comprising 22 O1 serotypes (75.9%), one O139 serotype (3.4%), and six non-O1/non-O139 serotypes (20.7%). Toxigenic O1 strains were detected across all five LGAs and in all five water source types, including commercially packaged sachet water. The O139 serotype was identified in a single well-water isolate from Zurmi LGA, representing the first environmental detection of this serotype in Zamfara State. Conclusions/Significance The co-circulation of toxigenic O1, O139, and non-toxigenic non-O1/non-O139 V. cholerae serogroups across five distinct drinking water source types confirms that community water environments serve as genetically diverse reservoirs sustaining cholera transmission in Zamfara State. These findings underscore the urgent need for integrated water quality surveillance, sanitation infrastructure investment, and sustained molecular monitoring of environmental V. cholerae populations.

Abstract Objective To evaluate the adherence to guidelines and readability of large language model-generated sexual health information related to female sexual dysfunction following cystectomy, and to determine whether adherence differs across models and prompt formats. A secondary objective was to introduce an analytic strategy using principal component analysis to examine the dimensions of readability metrics. Methods Three large language models (LLMs), ChatGPT, Gemini, and Perplexity were prompted with six clinical questions related to sexual function after cystectomy. Questions were phrased in long-form and short-form language. Responses were independently graded by two reviewers, derived from guideline recommendations. Linear mixed-effects models predicted adherence as functions of LLM, prompt, and reviewer, with clinical questions as a random intercept. Readability was assessed using five metrics, and principal component analysis (PCA) was used to determine latent structure. Results ChatGPT demonstrated the highest (estimated marginal mean [emm] = 0.769), outperforming Gemini (0.499) and Perplexity (0.457). Shorter, less complex prompts elicited higher adherence than more complex, clinical prompts. All models produced content that exceeded recommended reading levels. PCA demonstrated that a single dominant component accounted for 76.7% of variance across readability indices, indicating a shared underlying construct. Conclusion ChatGPT produced the most guideline-concordant information overall. High linguistic complexity was seen across models, highlighting a barrier to patient comprehension. These findings characterize large language models as variable medical information systems whose outputs rely heavily on prompt structure and model type.