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The aim of this study was to examine attitudes and behaviors related to hand hygiene among hospital cleaning staff and to identify promoting and inhibiting factors influencing hand hygiene behavior. In addition, existing worldwide target group-specific interventions for this occupational group were mapped. A comprehensive literature search was conducted for publications from 2009 to 2025 in MEDLINE (via PubMed®), the Cochrane Library, CINAHL (via EBSCO), Embase, and Scopus. Additional research was carried out in WHO IRIS, BASE, and Science.gov, and internationally applicable guidelines were identified using the TRIP Database. Included were studies from worldwide somatic acute care hospitals examining hand hygiene compliance, knowledge, attitudes, practices, influencing factors, or interventions among cleaning staff. Texts limited to other hygiene domains, airborne infections, non-acute-care settings, or study populations consisting of mixed occupational groups and not limited to cleaning staff exclusively were excluded. Literature screening was performed in two stages (title/abstract and full-text screening), and data extraction was conducted by one reviewer using a standardized extraction table. In total, 33 sources met the inclusion criteria, comprising five guidelines, 25 full-text studies, and three conference abstracts, which formed the primary basis of this review. The conference abstracts identified during the research for which corresponding full texts were not provided were documented for the sake of completeness, but not included in the main analysis and qualitative synthesis, as relevant information may not be available due to the lack of full texts. The base of evidence was heterogeneous and predominantly descriptive, addressing knowledge, attitudes, practices, as well as promoting and inhibiting factors. Identified interventions related to infection prevention and control and hand hygiene among cleaning staff were based on the provision of target group-oriented training materials, simulation-based training, and multimodal approaches and training programs. The findings indicate overall limited and predominantly descriptive evidence regarding hand hygiene among hospital cleaning staff. This underscores the need for methodologically diverse research as well as the development of target group-specific interventions and guidelines to strengthen infection prevention, particularly hand hygiene, in acute care hospital settings.
India's evolving public health challenges emphasize the need for a competent, multidisciplinary public health workforce, emphasizing the importance of strengthening public health education. Since 1995, the Master of Public Health (MPH) programs in India have expanded rapidly; however, in the absence of a regulatory body, consolidated details regarding these programs remain not readily available. This study aimed at landscaping MPH programs in India and understand its key components in terms of geographical distribution, admission criteria, fee structure, electives, program delivery modes, internships, and dissertation requirements. To compile a comprehensive overview of MPH programs across India a multi-step desk review was undertaken. The study identified 177 institutions offering MPH programs with intake capacity of 4,228 seats (data available from 136 institutes) across 23 states and three Union Territories. Variations were seen across institutions in program eligibility criteria, admission processes, program electives, program fees, credit requirements, the structure and duration of internships and dissertations. The expansion of MPH programs during last three decades, highlights growing recognition of public health as a multidisciplinary field; however, the variations in program offerings and admission criteria highlight the lack of standardized structure in MPH programs across India. Introducing a standardized admission test for MPH in India, multi-disciplinarity in the program admission criteria and eligibility, developing a competency-based MPH curriculum aligning with the evolving employment market, and a national accreditation body could significantly strengthen MPH education, leading to workforce preparedness to address India's emerging public health priorities.
Equitable approaches to public and global health require grounding in diverse ontologies of wellbeing and decolonial theory. Indigenous wellbeing models and frameworks embed holistic values that support ecological thriving. In contrast, Western approaches often individualize and compartmentalize wellbeing, narrowing public and global health practice and contributing to persistent disparities. Despite the proliferation of Indigenous-developed frameworks, no scoping review has synthesized contributions in this area. This review aimed to identify models, frameworks, and theories of wellbeing developed by Indigenous communities and scholars from Turtle Island (North America) and Moananuiākea (the Pacific) to inform more culturally safe and decolonial approaches to public and global health. Guided by the PRISMA-ScR framework, both peer-reviewed publications and grey literature were sourced from five databases (PubMed, Web of Science, EBSCO Academic Search Complete, CINAHL, and ProQuest). Additional articles were hand-sourced. Included articles posed an original model, framework, or theory of wellbeing, developed for Indigenous people, families, or communities, by Indigenous authors from those respective lands in Turtle Island or Moananuiākea. A total of 1,473 database references and 89 additional references were identified for screening. After 61 full-text reviews, 33 manuscripts were included for analysis. Twenty-one publications originated from Moananuiākea (64%) and 12 originated from Turtle Island (36%). The most common method used to develop the models and frameworks was qualitative (52%). Synthesis of the data yielded seven themes: (1) holistic integration of all life domains; (2) spirituality and the ongoing presence of ancestors; (3) culture and preservation of tradition; (4) collective wellbeing and relationality; (5) reciprocal relationship with land as a source of identity, health, and responsibility; (6) use of place-specific Indigenous metaphors and language; and (7) empowerment and self-determination. Indigenous communities globally are calling for a shift from conceptual discussion of wellbeing toward tangible application in public and global health systems. These findings hold several implications for decolonial theory-development and more equitable health systems. Future research should build on work which moves Indigenous wellbeing frameworks from theory to action.
The objective of this study is to combine morbidity in terms of various levels of growth faltering or malnutrition among surviving children with mortality to better understand the determinants of infant and child health. This study uses data from the latest National Family Health Survey (NFHS)-5 of India conducted during 2019-21 to provide a framework that integrates both mortality and morbidity as a measure of infant and child health to investigate their association with maternal and other socio-economic determinants of health. The outcome variable representing health status of a child is defined as a categorical variable with four progressively worsening levels- no malnutrition, moderate malnutrition, severe malnutrition, and not alive. The levels of morbidity in terms of growth faltering or malnutrition are defined in line with the World Health Organization (WHO) guidelines. Cumulative Link Mixed Model (CLMM) with partial proportional odds framework has been used to assess the association of risk factors with the outcome variable. Multivariate Imputations by Chained Equation has been employed to address high amount of missingness in three risk factors. Parameter estimates from CLMMs fitted to each of the 20 multiply imputed datasets were combined using Rubin's rules to obtain pooled estimates. Among the examined determinants, maternal education and household wealth index demonstrated the strongest associations with child health outcomes. Notably, low birth weight and non-institutional delivery are consistently strong risk factors across all thresholds of child health status, from moderate malnutrition till mortality. Antenatal care incompleteness does not associate with whether a child enters moderate malnutrition, but it strongly associates (14-19% higher odds) with severe malnutrition and with death, confirming its role in preventing the worse child health outcomes. Combining child mortality and morbidity allows better indication of child health status with added sensitivity through progressive health status levels, ranging from best scenario (no malnutrition) to worst scenario (death). Consequently, it enables a more comprehensive assessment of maternal and socioeconomic determinants of child health. In addition, using such combined outcome ensures complete utilization of information available in a survey dataset, irrespective of the mortality status of the child.
Fragmentation of health information systems remains a major barrier to effective health system performance across Europe, particularly in decentralized settings. Federated data infrastructures have been proposed as a scalable solution, but evidence on their implementation at population level remains limited. We aimed to describe the implementation of a federated information infrastructure at regional level and assess the completeness and variability of linked data across participating centers, discussing implications of scaling up the approach within the European Health Data Space. We carried out a population-based cohort study linking administrative, clinical, and patient-reported data across three healthcare organizations in Emilia-Romagna, Italy, covering over 2.1 million residents. Data were analyzed using a federated architecture without sharing individual-level information. Baseline characteristics were assessed at 1 January 2019, with longitudinal follow-up over 6 years. We identified 116,552 individuals with diabetes (prevalence 5.6%). Among individuals with available classification, 90.8% had type 2 diabetes. Clinical data were available for 43.5% of patients in charge of diabetes clinics, with substantial heterogeneity across centers (12.8-80.6%). Among those with clinical data, 27.5% had baseline HbA1c levels below 48 mmol/mol, while 69% had elevated systolic pressure (≥130 mmHg) and 56.6% had high diastolic pressure (≥80 mmHg). Sociodemographic variables were largely missing. Patient-reported outcomes were collected in 521 individuals, demonstrating feasibility but limited scalability. Federated linkage of administrative, clinical, and patient-reported data is feasible at regional scale and enables population-level monitoring of diabetes care. However, variability in data completeness was primarily driven by organizational and governance factors rather than technical capacity. These findings provide empirical evidence that strengthening health data systems requires alignment of healthcare organization and service delivery models, beyond technical solutions alone. The REWINDER project built a collaborative information infrastructure using federated linkage of different data sources and person-reported outcomes, independently managed by local healthcare organizations. The project has made available a large database to inform policy and planning of diabetes care across the region. The system may be used as a model that can be conveniently scaled up to other geographical areas and chronic diseases.
Training healthcare professionals to recognize and respond to intimate partner violence (IPV) is an important component of health system responses to violence. However, little research has explored how healthcare professionals prefer such training to be delivered. This study explored healthcare professionals' preferences for training modalities on mandatory reporting of IPV and the associations between participant characteristics and preferred training modalities. A cross-sectional survey was conducted between May and September 2025 (N = 266) among healthcare professionals working in Norway. The questionnaire assessed demographic and professional characteristics, previous training on mandatory reporting of IPV, perceived competence, and preferences for training delivery formats. Descriptive statistics were used to summarize participant characteristics and teaching preferences. Logistic regression analyses explore associations between participant characteristics and preferred training modalities. In-person meetings, courses, and workshops were the most frequently preferred training formats (62%), followed by e-learning (54%) and digital meetings and webinars (44%). Greater perceived time constraints were associated with a stronger preference for digital training formats. Less experienced professionals were more likely to prefer video-based and e-learning formats. Physicians and healthcare workers were less likely to prefer in-person training. Healthcare professionals' preferences for training modalities on mandatory reporting of IPV vary across professional and contextual factors. Flexible and multimodal training strategies may increase participation and engagement in such training.
This study aimed to evaluate the effect of targeted Carbapenem-resistant Klebsiella pneumoniae (CR-Kpn) phage aerosol combined with routine disinfection on the decontamination of CR-Kpn in the ICU environment, as well as its incidence rate, drug resistance rate, and antibiotic use. A prospective two-phase study design was adopted. During the baseline phase (P1), routine terminal disinfection with chlorine-containing agents was performed. In the intervention phase (P2), targeted phage aerosol spray was added to the isolation rooms of CR-Kpn patients. Multivariable models were fitted to isolate the intervention effect, adjusting for patient-days, imipenem use intensity, and carbapenem-resistant Acinetobacter baumannii (CRAB) incidence density. Outcomes including environmental CR-Kpn detection rate, incidence density, carbapenem resistance rate of K. pneumoniae, and antibiotic use intensity were compared between the two phases. Following the combined intervention, the overall detection rate of CR-Kpn in the ICU environment decreased from 17.28% (47/272) to 0.96% (1/104), with the detection rate in sink drains dropping from 85.29% (29/34) to 7.69% (1/13). Clinical data showed that the incidence density of CR-Kpn significantly decreased from 10.16 cases/1,000 patient-days to 4.71 cases/1,000 patient-days (p = 0.007), whereas the incidence density of carbapenem-resistant A. baumannii (CRAB) increased significantly, suggesting the species-specificity of the intervention. Concurrently, the carbapenem resistance rate of K. pneumoniae decreased from 62.50 to 53.80%, and the use intensity of key antibiotics (tigecycline, polymyxin B, meropenem) significantly declined (reductions of 52.6, 58.5, and 36.6%, respectively; p < 0.01 for all). The combination of phage aerosol and routine disinfection showed potential in controlling CR-Kpn contamination in the ICU environment, reducing its incidence and carbapenem resistance rate, and decreasing the use of related antibiotics. This approach may provide a safe and effective biological disinfection strategy for controlling the spread of CR-Kpn.
To investigate the heterogeneity of oral health self-efficacy among patients undergoing maintenance hemodialysis (MHD) and its influencing factors, and to compare the discrepancies in oral health-related quality of life (OHRQoL) across different patient subgroups, thereby furnishing evidence for the formulation of targeted interventions. A convenience sampling approach was adopted to recruit 352 MHD patients from three tertiary hospitals in Guangzhou from June 2023 to April 2024. Data were collected using a general information questionnaire, the Self-Efficacy Scale for Oral health (SESS), and the Oral Health Impact Profile-14 (OHIP-14). Latent profile analysis (LPA) was employed to identify latent classes of oral health self-efficacy. Univariate analysis and multivariate logistic regression analysis were performed to explore the influencing factors of class membership, and differences in OHRQoL among the classes were compared. The total score of SESS was 49.60 ± 11.91, and that of the OHIP-14 was 12.61 ± 9.51. LPA identified three latent classes: C1 "low self-efficacy group" (17.3%), C2 "moderate self-efficacy group" (44.9%), and C3 "high self-efficacy group" (37.8%). The three-class model demonstrated optimal comprehensive fit indices and practical interpretability (Entropy = 0.966). Multivariate logistic regression analysis indicated that age, place of residence, monthly household income, number of comorbidities, daily tooth brushing frequency, and self-rated oral health status were significant influencing factors of oral health self-efficacy levels in MHD patients (all p < 0.05). There were statistically significant differences in OHRQoL scores among the different classes of MHD patients (p < 0.001). Improving oral health self-efficacy could effectively ameliorate patients' OHRQoL. Oral health self-efficacy in MHD patients exhibits significant heterogeneity and can be categorized into three latent classes, with notable differences in OHRQoL across classes. Healthcare providers ought to develop class-specific stratified intervention strategies: focusing on improving basic oral care skills in the low self-efficacy group, correcting cognitive biases in the moderate self-efficacy group, and facilitating dental visit behaviors in the high self-efficacy group, so as to improve patients' overall oral health-related quality of life.
Substantial yet preventable maternal and neonatal mortality persists across low- and middle-income countries (LMICs), where shortages of skilled maternal and child health (MCH) nurses, inadequate infrastructure and socioeconomic inequalities continue to limit access to quality care. Artificial intelligence (AI), particularly machine-learning-driven decision-support and predictive systems, is increasingly proposed to strengthen MCH services through risk stratification, early diagnosis and clinical decision-making. However, evidence supporting its equitable, contextually appropriate and sustainable implementation in resource-constrained settings remains limited. Existing literature has inadequately addressed the structural, ethical and relational dimensions of AI adoption from a nursing perspective, and there is a lack of frameworks integrating equity, nurse-led governance and contextual adaptation for LMICs. Drawing on a purposive narrative review, this Perspective proposes an equity-centred, nurse-led framework for AI-assisted MCH nursing in low-resource settings. The framework comprises six interdependent domains: contextual algorithm validation, humanised and relational nursing care, community co-design and engagement, digital equity and inclusion, transparent data governance, and longitudinal monitoring and evaluation. Its novelty lies in positioning equity as a prerequisite for deployment, identifying the nurse-patient relationship as the principal mechanism through which AI influences outcomes, and assigning governance authority to nurses and communities. A phased implementation pathway is proposed to guide responsible deployment. The framework remains conceptual and requires prospective empirical validation. Responsible AI integration in MCH nursing demands equity-centred governance, investment in nursing capacity, community participation and locally grounded validation strategies.
Workplace ostracism is a negative workplace experience. It can affect nurses' psychological wellbeing and work-related behaviors. However, this issue has not been fully discussed in nursing, a profession characterized by intensive interpersonal interaction and complex social contexts. This scoping review aimed to examine studies on workplace ostracism in nursing. It summarized the current research status, variable roles, potential mechanisms, and major outcomes. This study followed the scoping review guidance of the Joanna Briggs Institute. PubMed, Embase, Web of Science, APA PsycInfo, The Cochrane Library, Scopus, CINAHL, and MEDLINE Ultimate were searched. The search covered the period from database inception to April 19, 2026. Two Reviewers independently screened the studies, reviewed the full texts, and extracted the data. A total of 21 studies from nine countries were included. Most studies were conducted in China, Egypt, and Pakistan, indicating a degree of geographical concentration in the current evidence base. The included studies were predominantly cross-sectional quantitative surveys, with only a small number using time-lagged designs, multilevel nested analyses, or qualitative interviews, suggesting limited methodological diversity. In the field of nursing, workplace exclusion is mainly studied as an independent variable, mediating variable, or outcome variable. The correlates of workplace ostracism among nurses involved individual and organizational factors. Potential mechanisms included psychological resource depletion, reduced organizational identification, and impaired communication. Associated outcomes covered multiple levels, including individual psychological health, professional behavior, and organizational functioning. Current evidence suggests that workplace ostracism is a complex and context-dependent phenomenon in nursing organizations. Given the predominance of cross-sectional designs, future research should strengthen theoretical integration and methodological development, including longitudinal studies, intervention studies, mixed-methods research, and cross-cultural comparisons, to further clarify its pathways and effective intervention strategies. Nursing managers should address leadership behaviors, team culture, communication safety, and organizational support to reduce workplace ostracism and its potential adverse consequences.
Against the backdrop of the deep integration of the Digital China initiative and the Rural Revitalization Strategy, the use of digital technology to empower primary healthcare services has become an inevitable trend. However, the paradox between precision and warmth needs to be resolved, and the scientific design and implementation of public health policies are key to addressing this challenge. Taking Tianjin's Primary Digital Health Community as a case study, this paper constructs a dual embedding analysis framework of "Process-Relational" to systematically explore the underlying mechanisms and practical pathways of digital technology empowerment, thereby providing theoretical support for public health policy formulation. The study finds that the core of digital empowerment lies in the synergistic interaction between process embedding and relational embedding: process embedding achieves precision across the entire service chain through standardized systems, integrated platforms, and AI algorithms, thereby establishing a foundation for enhanced efficiency; Relational embedding conveys human warmth by empowering frontline staff, connecting diverse stakeholders, and creating emotional spaces. Together, these form a virtuous cycle that drives primary healthcare services to achieve a triple leap in efficiency, governance, and value. The dual-embedding mechanism revealed in this paper offers practical insights for optimizing public health policies. It aids in formulating grassroots healthcare development policies that balance efficiency with equity, and technology with humanistic values, thereby promoting the high-quality development of grassroots public health services.
Occupational stress among clinical nurses is a long-standing quality-of-care concern associated with burnout, attrition, lapses in patient safety, and erosion of workforce wellbeing. Continuous, nurse-centered monitoring of within-shift physiological stress states is therefore an emerging priority for nursing innovation and quality improvement (QI), yet routine clinical adoption of wearable monitoring is constrained by accuracy, response time, communication load, alert fatigue, and physiological differences across individual nurses. This study proposes the Nurse-centered Edge-Server Technology (NEST), a wearable edge-server framework for real-time occupational-stress monitoring designed to support QI-oriented screening and workflow awareness. Physiological and motion signals from wearable devices are processed locally with a compact feature set for rapid screening, while a richer feature set confirms suspected high-stress events through cascade alerting. A central server collects brief summaries from each device and returns small updates that personalize the model to each nurse over time. The framework was evaluated on the public Wearable Stress and Affect Detection (WESAD) dataset and on a continuous nurse-monitoring dataset collected in clinical wards, using subject-wise evaluation, out-of-fold supplementary event analysis, ablation experiments, and edge-equivalent runtime tests. Lightweight screening preserved accuracy comparable to that of a richer feature set while reducing the feature dimension from 48D to 15D. In a held-out event-level test set of 24 positive events, the selected cascade preserved the 14/24 event hit count observed with Single48 while reducing false alerts from 9.68 to 1.88 per hour and total alerts from 10.65 to 2.10 per hour. Confidence intervals remained wide because the strict held-out stream protocol yielded 24 positive test events; supplementary all-subject and multi-split analyses were used as robustness checks for the primary held-out evaluation. In the edge-equivalent software setting, P95 latency remained in the millisecond range, the P95 CPU duty cycle was 6.77%, and 15D feature-summary upload was 4.69% of raw-stream upload. Chronological personalized updating increased sensitivity when feedback updates were available, but it did not improve overall F1 and lowered specificity; no-update controls showed no artificial gain. The retrospective evaluation supports the technical feasibility and alert-control value of a wearable edge-server pipeline that combines compact inference, cascade event confirmation, and personalized updating as an assistive QI-oriented monitoring approach. The study evaluates prediction behavior, alert burden, latency, and communication load; direct effects on burnout, nurse retention, workload reduction, patient-safety outcomes, or occupational-health improvement require prospective workflow studies. NEST is intended to augment clinical judgement and the relational role of nurses in occupational-health management and workforce sustainability.
Antimicrobial resistance (AMR) has emerged as one of the most pressing threats to global health and a major challenge for contemporary public health governance. As the drivers of AMR span human, animal, and environmental systems, the One Health framework has become central to the design of effective containment strategies. This study compares AMR governance in China and the United Kingdom (UK), focusing on institutional organization, regulatory frameworks, surveillance systems, and mechanisms for cross-sectoral coordination. The analysis highlights two contrasting governance models within the broader One Health paradigm. China relies on strong state-led coordination and hierarchical administrative mobilization, whereas the UK emphasizes specialized institutional collaboration supported by integrated surveillance infrastructures. Despite these structural differences, both countries continue to face major challenges in environmental surveillance, intersectoral data integration, and long-term coordination across sectors. Future progress in AMR control will depend not only on strengthening multisectoral governance capacity, but also on improving the integration of environmental dimensions into existing surveillance and response systems. The comparative experiences of China and the UK offer broader insights into the development of adaptive and globally coordinated One Health strategies for AMR governance.
Older adults with hearing loss are at increased risk of cognitive impairment, yet tailored risk stratification tools remain limited. In this cross-sectional study, 524 adults aged ≥60 years with hearing loss were enrolled between June 2023 and September 2024. Participants were divided by enrollment period into a development cohort (June 2023 to May 2024, n = 367) and a temporally independent validation cohort (June 2024 to September 2024, n = 157). Cognitive function was assessed using the Montreal Cognitive Assessment, with a score <26 indicating cognitive impairment after correction for education. Candidate predictors were selected based on the Integrated Framework for Population Health Risk Management. Feature selection was performed using LASSO regression, and six machine-learning models were developed and compared. Model performance was evaluated using AUC, F1 score, sensitivity, specificity, Youden index, PPV, NPV, calibration curves, and decision curve analysis. The final candidate model was optimized using grid search with five-fold cross-validation, and SHAP was applied for interpretability. The prevalence of cognitive impairment was 40.8%. LASSO identified five key predictors: age, pure-tone average, depression, hearing-aid use, and social activities. Multivariable analysis showed that depression, older age, and higher pure-tone average were associated with a higher likelihood of cognitive impairment, whereas hearing-aid use and participation in social activities were protective factors. Among the six models, Random Forest showed the best overall performance in the validation cohort. After hyperparameter tuning, the optimized Random Forest model achieved an AUC of 0.952 in the training cohort and 0.871 in the validation cohort. In the validation cohort, the F1 score, sensitivity, Youden index, and NPV increased to 0.737, 0.779, 0.583, and 0.863, respectively. SHAP analysis indicated that pure-tone average, age, and social activities were the most influential predictors in the optimized model. The optimized five-variable Random Forest model demonstrated good predictive performance for cognitive impairment in older adults with hearing loss. This low-cost and interpretable tool may support early screening, risk stratification, and targeted intervention in clinical and community settings.
Low ambient temperature is associated with increased carbon monoxide (CO) poisoning incidents, likely through behavioral pathways such as heating device use and reduced ventilation. This study examines the association between daily mean temperature and CO poisoning emergency medical service (EMS) responses in Chengdu, explores potential population susceptibility, estimates the attributable burden, and proposes exploratory temperature reference points for public health monitoring. CO poisoning EMS records from Chengdu (January 1, 2013-December 31, 2025; 4,352 cases across 1,894 days) were matched with daily meteorological and air pollutant data. A time-stratified case-crossover design combined with distributed lag nonlinear models (DLNMs; max lag = 5 days) was employed. Models adjusted for relative humidity, PM2.5, wind speed, precipitation, day of week, and holidays, using median temperature (10.5 °C) as reference. Stratified analyses covered age, sex, season, and humidity. Attributable fractions were estimated via Monte Carlo simulations. A reverse "J"-shaped association was observed, with a cumulative lag 0-5 days minimum morbidity temperature (MMT) of 14.9 °C. Extreme cold (2.9 °C, 2.5th percentile) vs. reference was associated with a cumulative RR of 5.12 (95% CI: 1.74-15.09), peaking at lag 0 (RR = 1.79, 95% CI: 1.47-2.17). Subgroup analyses suggested potential vulnerability among adults aged 20-39 and ≥60 years. Wind speed stratification indicated a 69% higher extreme cold risk on low-wind days (RR ratio = 1.69), though formal interaction testing was non-significant (p = 0.94). Non-optimal temperatures were statistically coincident with an estimated 32.9% of EMS responses. Nominal exploratory reference points of 7.3 °C and 6.0 °C were derived; bootstrap validation (1,000 resamples) yielded median estimates of 7.0 °C (95% CI: 6.0-8.0 °C) and 6.0 °C (95% CI: 4.3-6.7 °C). Low ambient temperature serves as a measurable proxy indicator for conditions associated with elevated CO poisoning risk in Chengdu. The proposed exploratory temperature reference points (7.3 °C and 6.0 °C) may inform targeted safety messaging during winter, though prospective validation is required before operational implementation in warning systems.
Polypharmacy is closely linked to multimorbidity in older adults, but its distribution may also reflect social inequalities in health. We aimed to describe pharmacological burden and multimorbidity among individuals with polypharmacy in La Rioja, Spain, and to examine their relationship with age, sex, and socioeconomic conditions. This retrospective cross-sectional study included all individuals in La Rioja, Spain, who met the operational definition of polypharmacy between January 1 and December 31, 2024. Polypharmacy was defined as the dispensing of five or more distinct ATC4 medication groups, each dispensed at least six times during the study period. Only publicly funded prescriptions dispensed in community pharmacies were considered. Sociodemographic and clinical data were obtained from electronic health records. Pharmacological burden was quantified as the number of distinct ATC4 groups dispensed per individual and categorized as 5, 6-9, and ≥10 groups. Among 33,534 individuals with polypharmacy, 54.7% were women and the mean age was 73.9 years. The mean pharmacological burden was 7.07 ATC4 groups (SD 2.17), with 58.4% of participants receiving 6-9 groups. Burden increased with age and was higher among individuals with chronic conditions, particularly congestive heart failure, renal disease, peripheral vascular disease, myocardial infarction, and chronic pulmonary disease. Sex differences were modest. In contrast, socioeconomic differences were marked: 71.8% of participants belonged to the low socioeconomic group, which also showed the highest proportion of individuals receiving ≥10 ATC4 groups (14.9%), compared with the middle (9.2%) and high (8.0%) socioeconomic groups. The highest burdens were observed in very low-income individuals and lower-income pensioners. In this population-based study, pharmacological burden among individuals with polypharmacy was concentrated on older adults, those with multimorbidity, and socioeconomically disadvantaged groups. These findings support interpreting polypharmacy not only as an indicator of clinical complexity, but also as a socially patterned health phenomenon. Efforts to optimize medication use should therefore integrate both clinical and socioeconomic vulnerability.
Implementation of Food Service Guidelines (FSG) can improve nutritious offerings and individual health behaviors. This case study demonstrates how a state health department supported hospitals to improve their nutrition environments. The Colorado Healthy Hospital Compact (the Compact) is a statewide initiative designed to implement FSG to improve hospital nutrition environments by increasing the availability of healthier foods and beverages and reducing or eliminating unhealthy items. Developed and implemented by the Colorado Department of Public Health and Environment (CDPHE), hospitals voluntarily participated and completed assessments to monitor changes in the cafeteria nutrition and marketing environments. Of the n = 10 participating hospitals that submitted quantitative data in 2021 and 2023, one staff member (eg, food service directors, registered dietitians, wellness coordinators) from 8 of these hospitals completed interviews with CDPHE staff in March 2023 on facilitators and barriers, attitudes and feedback on changes by implementers and clients, maintenance, and experiences with implementation of the Compact. From 2021 to 2023, hospitals showed improvements in meeting standards for healthy sides, entrees, snacks, desserts, and beverages. Hospitals also showed improvements in their pricing strategies and healthy product offerings. The primary barrier to implementation was customer desire for specific foods; facilitators included existing priorities around healthy food environments and buy-in from staff. Common themes of intervention maintenance included having a nutrition policy or contracts, good communication/culture about the Compact, leadership support, and using food service vendor healthy food program(s). The Compact appears to be a feasible approach for implementing healthier nutrition standards in the hospital setting and spreading implementation across hospital settings.
Childhood and adolescent obesity is increasingly understood as a heterogeneous condition in which excess adiposity may be accompanied by distinct cardiometabolic phenotypes. Metabolically healthy obesity and metabolically unhealthy obesity have become important concepts for risk stratification, but the overall knowledge structure and emerging research directions in this field remain insufficiently mapped. Records on metabolic phenotypes in childhood and adolescent obesity published between 1 January 2000 and 20 February 2026 were retrieved from the Web of Science Core Collection and PubMed on 20 February 2026. English-language articles and reviews were independently screened by two researchers. After database merging, deduplication and data cleaning, 4,963 records were retained for bibliometric analysis, including 4,384 WoSCC-retained records and 579 PubMed-only records. CiteSpace 6.4. R1, VOSviewer 1.6.20, R 4.5.2 and bibliometrix 5.4.1 were used to analyze annual publication trends, country and institutional collaboration, author and reference co-citation, keyword co-occurrence, clustering and burst terms. Citation-dependent analyses were based on WoSCC-retained records with complete cited-reference metadata. Publication output increased overall and showed three broad phases: an initial phase centered on BMI criteria, obesity prevalence and metabolic syndrome recognition; a rapid growth phase associated with insulin resistance, glucose-lipid abnormalities and metabolic heterogeneity; and a recent consolidation phase emphasizing phenotype transition, gut microbiota, non-alcoholic fatty liver disease, physical activity, cardiometabolic health and precision intervention. The United States, Spain, China and England were leading contributors, although cross-regional collaboration remained uneven. Co-cited references, author networks and keyword clusters indicated that the field has moved from weight-based classification toward integrated cardiometabolic risk identification, with emerging attention to central adiposity, visceral fat, microbiome-related mechanisms and phenotype-guided management. Research on metabolic phenotypes in childhood and adolescent obesity is shifting from BMI-centered description toward risk-stratified interpretation of metabolic heterogeneity. Future studies should harmonize pediatric phenotype definitions, strengthen multicenter longitudinal cohorts and integrate body composition, fat distribution, insulin sensitivity, liver fat, inflammatory markers, lifestyle exposure and gut microbiota to support early identification and precision prevention of cardiometabolic risk.
The aim of this study was to develop a set of quality indicators for hemodialysis vascular access nursing. A two-round Delphi study was conducted from August to September 2025. Based on the Donabedian structure-process-outcome theory model, this study retrieved, evaluated, and synthesized the best evidence on quality indicators for hemodialysis vascular access nursing. A questionnaire was developed through evidence-based analysis and semistructured interviews. An indicator system was established using the Delphi method, and an analytic hierarchy process (AHP) was employed to determine the weights of each indicator. A total of 16 experts from 14 hospitals across nine provinces in China completed two rounds of Delphi surveys. After two rounds of consultation, the experts reached a consensus on the definitions of the indicators, calculation formulas, and data collection methods. They established a quality indicator system for hemodialysis vascular access nursing, which includes 3 primary indicators and 15 secondary indicators. The developed nursing quality-sensitive indicator system for hemodialysis vascular access was constructed through a rigorous Delphi process and aligns with the practical features of hemodialysis vascular access nursing management. It may serve as a reference basis for evaluating the quality of vascular access nursing, pending further clinical validation. This framework offers a structured approach to monitoring vascular access nursing quality. Its potential to reduce complications and improve patient outcomes requires confirmation through future clinical implementation studies. The indicators identified in this study are highly consistent with those in clinical practice, demonstrating sensitivity and practicality. The hemodialysis centers of relevant medical institutions may consider using this quality indicator system for routine data collection. Its utility for quality improvement should be further evaluated in clinical practice. This study was reported in line with the Conducting and Reporting of Delphi studies (CREDE) guidance on Delphi studies.
Oral disease is the most prevalent noncommunicable disease globally, affecting an estimated 3.7 billion people and imposing an annual economic burden of roughly US$710 billion-even though preventive recommendations for oral health are clear and widely known. This striking gap between knowledge and behavior points to a need for complementary approaches that help people translate awareness into action. Despite this need, behavioral science is an underexamined approach in oral health: Our bibliometric review found only 360 behavioral science publications addressing oral health compared with thousands in other domains, and most oral health studies were non-experimental. We argue that boosting, an approach from behavioral science that builds competences and respects autonomy, is a practical complement to traditional oral health education. We introduce the Toothbrushing Boost Toolbox: a set of simple, memorable strategies that map onto common behavioral barriers. These boosts are low-cost, adaptable across age groups and literacy levels, and could be integrated into clinical practice, public health programs, and digital tools. We further argue that boosting should be embedded within a broader agenda of system-level reform, including universal access and subsidized preventive care, and propose practical steps for implementing, evaluating, and co-designing boost interventions. An oral health agenda that is informed by behavioral science can help shift oral health promotion from providing information to fostering competence and sustained daily practice.