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Chronic heart failure (CHF) is a progressive and recurrent condition associated with high hospitalization rates, substantial healthcare burden, and impaired quality of life. Health-promoting behaviors are essential for long-term disease management in patients with CHF, yet their formation and maintenance are often constrained by individual capability, external support, and motivational factors. This study aimed to examine the current status and associated factors of health-promoting behaviors among patients with chronic heart failure and to clarify the pathways among related factors. A cross-sectional design was used to investigate health-promoting behaviors and their associated factors among patients with CHF. The study was conducted from December 2024 to November 2025 in two tertiary Grade A hospitals in Shanghai. Convenience sampling was used, and 320 questionnaires were distributed; 302 valid questionnaires were included, yielding a valid response rate of 94.38%. The instruments included a general information questionnaire, the Health-Promoting Lifestyle Profile, the Perceived Social Support Scale, the Heart Failure-Specific Health Literacy Scale, and the Health Activation Scale. SPSS version 26.0 was used for descriptive statistics, univariate analysis, and multiple linear regression. AMOS version 23.0 was used for path analysis, and Python version 3.9 was used for random forest-based feature importance ranking. The total health-promoting behavior score was 126.00 (116.00, 137.00), and the mean item score was 2.42 (2.23, 2.63), indicating an overall moderate level; the largest proportion of patients was classified as moderate (52.32%). Among the dimensions, self-actualization had the highest score, whereas physical activity had the lowest score. Health literacy was at a moderate level, perceived social support was at a high level, and health activation was at a low level. Univariate analysis showed significant differences in health-promoting behavior scores by age, educational level, employment status, marital status, living arrangement, monthly per capita household income, type of medical insurance, disease duration, number of comorbidities, and number of hospitalizations in the past year (p < 0.05). Health-promoting behaviors were positively correlated with health literacy, perceived social support, and health activation (p < 0.01). Multiple linear regression analysis showed that monthly per capita household income, type of medical insurance, number of comorbidities, number of hospitalizations in the past year, employment status, health activation, perceived social support, and health literacy were independently associated with health-promoting behaviors, jointly explaining 68.7% of the variance. Mediation analysis showed that health activation partially mediated the associations of health literacy and perceived social support with health-promoting behaviors. Nonlinear analysis further suggested that number of hospitalizations in the past year, health activation, perceived social support, and health literacy were key features associated with health-promoting behaviors. Health literacy, perceived social support, and health activation were key factors associated with health-promoting behaviors among patients with CHF. Health activation served as a significant mediator linking health literacy and perceived social support with health-promoting behaviors. Future interventions should focus on improving health literacy, strengthening social support systems, and enhancing health activation to promote the development and maintenance of health-promoting behaviors among patients with CHF.
Males, who disproportionately account for 83% of oropharyngeal cancer cases, are underrepresented in health promotion research, including human papillomavirus (HPV) vaccination studies. The initial exclusion of males in HPV vaccine research, policies, and interventions has negatively affected male vaccine uptake. Furthermore, stigma, a well-documented barrier to healthcare engagement, has been overlooked in HPV vaccination behaviors. This study aimed to provide a more contextualized understanding of HPV vaccine disparities among adult males by applying the Health Stigma and Discrimination Framework (HSDF) to examine how stigma is produced, enacted, and sustained across social systems, which may impact male vaccine uptake. This qualitative study analyzed previously collected data from virtual group interviews conducted in 2021 with a convenience sample of 13 vaccine-eligible males aged 18-35 residing in El Paso, Texas, United States. Participants completed a demographic survey and participated in semi-structured discussions about their knowledge, attitudes, and experiences with HPV and vaccination. Data were analyzed by employing the Critical Discourse Analysis (CDA) method and the Health Stigma and Discrimination Framework (HSDF) to guide the methodological and analytical processes, helping to map stigma processes and mechanisms across individual, interpersonal, and structural levels to identify multi-level influences on male HPV vaccine behavior. Analysis identified four overarching themes reflecting the discursive construction of stigma processes and mechanisms, spanning proximal to distal levels of influence. At the individual level, (1) male sexual health and manhood reflects how internalized sex-specific beliefs and masculine norms fostered shame and discomfort around male sexual health, often framing males as unaffected by HPV rather than vulnerable or in need of vaccination. At the interpersonal level, (2) cultural and familial forces captures how discourses of intergenerational silence, religious morality, and sexual health taboos perpetuated stigma processes and mechanisms, constraining open discussion about HPV and vaccination. At the systemic level, (3) structural barriers to vaccination reflects how policy environments, institutional practices, and health system norms perpetuate systemic-level obstacles restricting vaccine access. Finally, at the multi-level, (4) stigma resistance reflects counter-narratives that highlight affirming, peer-informed, perspectives and reframed male vaccination as legitimate and necessary. Findings provide an in-depth examination of how stigma processes and mechanisms-rooted in masculine norms, sexual health taboos, intergenerational silence, misinformation, and institutional exclusion-shape HPV vaccination access, beliefs, and behaviors among vaccine-eligible adult males. In contrast, participants expressed resistance to these stigmatizing narratives by reframing male vaccination as a necessary and achievable health behavior when supported by peer-informed, culturally resonant messaging. These findings highlight the need for multi-level interventions that replace stigmatizing discourses and practices with affirming male narratives in HPV and broader sexual and reproductive health prevention efforts.
We performed a latent profile analysis (LPA) to identify subgroups in the population undergoing metabolic bariatric surgery (MBS), based on various behavioral and psychosocial characteristics. Gaining deeper insights into the variability among preoperative MBS patients may be helpful in facilitating tailored care that addresses the specific needs of each profile, in relation to physical, emotional, and psychological functioning. Within a prospective cohort study, demographics and questionnaires regarding general health, quality of life, social support, problematic eating behavior (i.e., emotional eating, external eating, restrained eating, disordered eating) and depressive symptoms were collected preoperatively. LPA was performed to identify homogeneous subgroups. Out of 272 patients, four distinctive profiles were derived. The profiles were: (1) 'higher psychosocial and physical functioning profile' (n = 122, 45%): no deficits on all domains; (2) 'higher psychosocial and lower physical functioning' (n = 53, 20%): moderate impairments in physical functioning and problematic eating behavior, with no to mild impairments in emotional wellbeing and high scores on social support; (3) 'lower psychosocial functioning and stable physical health' (n = 36, 13%): mild impairments in physical functioning, with moderate levels of depressive symptoms and problematic eating behavior; (4) 'lower psychosocial and physical functioning profile' (n = 61, 22%): moderate deficits in general health, problematic eating behavior, depressive symptoms, social support, and quality of life. These findings suggest that subgroups can be identified, differing in behavioral and psychosocial characteristics, including psychological well-being, eating behavior, social support, and physical and emotional functioning among patients prior to MBS. Future longitudinal studies are necessary to establish the prognostic validity of these subgroups.
Leisure-time physical activity (LTPA) participation among Chinese college students remains insufficient despite growing public health concerns regarding sedentary lifestyles and obesity. Social media platforms have increasingly become important channels for delivering social support related to physical activity (PA); however, different dimensions of social support on social media may exert distinct psychological influences on exercise intentions. Guided by the theory of planned behavior, this study aimed to examine the direct and indirect relationships between different dimensions of social support on social media and Chinese college students' intentions to engage in LTPA. A cross-sectional online survey was conducted among undergraduate and graduate students from a comprehensive university in East China between February and June 2022. A total of 310 valid responses were analyzed using structural equation modeling in R. Three dimensions of social support on social media, including companionship support, informational support, and self-esteem support, were examined as predictors of LTPA intention, with the theory of planned behavior constructs (attitude, subjective norms, and perceived behavioral control) modeled as mediators. Demographic characteristics, BMI, social media use, and prior PA behaviors were included as covariates. Companionship support demonstrated the strongest positive association with LTPA intention, including both a direct effect (β=.348; P=.005) and an indirect effect through attitudes toward PA (β=.286; P=.002). Self-esteem support also showed a significant positive indirect association with LTPA intention via attitude (β=.138; P=.02). In contrast, informational support demonstrated a significant negative indirect effect on LTPA intention through attitude (β=-.291; P<.001). Subjective norms and perceived behavioral control did not significantly mediate the relationships between social support dimensions and LTPA intention. The findings suggest that companionship-oriented interactions on social media may strengthen positive exercise attitudes, whereas excessive or low-credibility informational content may undermine exercise motivation. Different dimensions of social support on social media play distinct roles in shaping Chinese college students' intentions to engage in LTPA. Social media-based PA interventions should prioritize companionship and esteem support while improving the credibility, personalization, and quality of informational support to reduce potential negative effects associated with misinformation and information overload.
The Developmental Origins of Health and Disease (DOHaD) hypothesis suggests that early life environmental exposures, especially during pregnancy, can impact long-term health. Research has largely relied on correlational evidence and has focussed on maternal factors, with less attention given to paternal, postnatal, and broader social determinants. This focus could complicate efforts to determine the most effective strategies for improving population health. Using harmonised data across four population-based longitudinal cohort studies from the UK and Norway (births between 1991 and 2008), we took a systematic approach to explore associations of parental prenatal health behaviours (smoking, alcohol, and caffeine consumption) and low socioeconomic position (SEP) with 72 child health-related outcomes (e.g., related to body size and composition, cognitive function, mental health, blood pressure, allergy, etc.) from birth up to age 11. Where possible, cohort estimates were meta-analysed, yielding a maximum sample size of 232,139. We triangulated evidence of causality using different analytical approaches, including a Mendelian randomisation-informed approach using genetic risk scores, negative controls (maternal versus paternal and during versus post-pregnancy comparisons), and dose-response analyses. This comprehensive set of analyses generated more than 594,000 effect estimates. We developed a web app, 'EPoCH Explorer' to visualise and share our results in an accessible format. We did not find strong evidence for widespread or large effects of parental health behaviours on child health and wellbeing. Only 6% of analyses had a Cohen's D value >0.2 and FDR-adjusted P < 0.05. In most analyses, the effect estimate was similar for mothers and partners, with 51% showing a larger effect for mothers and 49% for partners. Despite the lack of widespread associations, we found consistent evidence of association between maternal smoking and small for gestational age, higher childhood body mass index (BMI), depressive symptoms, and behavioural issues, while partner smoking was consistently associated with childhood BMI and social communication difficulties. Overall, we found stronger evidence of child outcomes being associated with low SEP than with health behaviours: 15% of results for low SEP had a Cohen's D value >0.2 and FDR-P < 0.05, compared to 6% for parental smoking, 3% for alcohol, and 0.4% for caffeine. Sample sizes and statistical power varied across outcomes and there was limited ethnic diversity in our study samples. Our findings suggest that wider familial socioeconomic conditions may be a more important determinant of child health than specific parental health behaviours prenatally. Interventions to improve population health may be most effective if they target wider social inequalities, rather than individual behaviours and mothers specifically. We encourage researchers to use EPoCH Explorer to prioritise associations for exploration in their own datasets, thus enabling replication and cross-context comparison to validate and extend the generalisability of our findings.
This study aimed to develop and evaluate a hypothetical model of health-promoting behaviors among middle-aged women with hypertension, guided by the Information-Motivation-Behavioral Skills (IMB) framework. The endogenous variables were self-efficacy in chronic disease management and health-promoting behaviors, and the exogenous variables were hypertension-related knowledge, eHealth literacy, health attitudes, and social support. This cross-sectional study used an online structured questionnaire. A total of 331 middle-aged women diagnosed with hypertension participated. Data were analyzed using IBM SPSS ver. 25.0 and IBM SPSS AMOS ver. 25.0 to test the hypothesized model and evaluate model fit. The proposed model showed satisfactory fit to the data. Of the nine hypothesized pathways, six were statistically significant. Hypertension-related knowledge, social support, and self-efficacy in chronic disease management had significant direct effects on health-promoting behaviors. In contrast, eHealth literacy and health attitudes did not have statistically significant direct effects on health-promoting behaviors. Health attitudes and social support had significant indirect and total effects on health-promoting behaviors. The model explained 60.4% of the variance in health-promoting behaviors, indicating the importance of hypertension-related knowledge, health attitudes, social support, and self-efficacy in chronic disease management. The findings suggest that the proposed IMB-based model may help explain health-promoting behaviors among middle-aged women with hypertension. The results indicate that self-efficacy in chronic disease management may link motivational factors to behavioral outcomes and may inform future intervention research aimed at promoting health behavior change in this population.
Developmental delay affects daily living, social functioning, and mental health. Maternal cardiovascular health (CVH) during pregnancy may indicate an adverse intrauterine environment, but its association with developmental delay is unclear. To examine the association between maternal CVH during pregnancy and developmental delay in offspring at 4 years of age. This cohort study enrolled patients between July 19, 2013, and March 31, 2017, with 5 years of follow-up, at obstetric hospitals and clinics in Miyagi Prefecture, Japan. Participants included eligible mother and offspring pairs enrolled in the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study. Offspring were followed up until age 4 years. Data analyses were conducted from November 12, 2024, to March 24, 2026. Maternal CVH during pregnancy, which was assessed using Life's Essential 8 metrics (diet, physical activity, nicotine exposure, sleep health, body mass index, blood lipids, blood glucose, and blood pressure). Each metric was scored on a scale of 0 (least favorable) to 100 (most favorable), and these scores were used to categorize mothers as having high (80-100), moderate (50-79), or low (0-49) CVH. Developmental delay at age 4 years, which was evaluated by the mother using the validated Japanese version of Ages and Stages Questionnaire, Third Edition. This instrument has 5 domains: communication, gross motor, fine motor, problem solving, and personal-social skills. Domain-specific delay was defined as 2 or more SDs below the mean score, and developmental delay in total was defined as delay in 1 or more of the 5 domains. Among 19 160 eligible mother and offspring pairs, 8238 (43.0%) were analyzed. Offspring were assessed at a mean (SD) age of 4.1 (0.2) years and included 4299 males (52.2%). Among mothers with high, moderate, and low CVH, 154 (8.8%), 763 (12.1%), and 33 (16.8%), respectively, had offspring with developmental delay in total. Compared with high CVH, moderate (risk ratio [RR], 1.30; 95% CI, 1.09-1.54) and low (RR, 1.62; 95% CI, 1.11-2.36) CVH during pregnancy were associated with developmental delay in total. Low CVH was associated with higher prevalence of developmental delay across all 5 domains, with personal-social domain having the largest effect size (RR, 2.23; 95% CI, 1.23-4.07; P for trend = .002) and communication domain having the smallest effect size (RR, 1.40; 95% CI, 0.69-2.85; P for trend = .03). In this cohort study of mother and offspring pairs in Japan, better maternal CVH during pregnancy was associated with a lower risk of offspring developmental delay at age 4 years.
Rheumatoid arthritis (RA) is a systemic autoimmune inflammatory disease affecting synovial joints and extra-articular systems. Public recognition of early symptoms, complications, and misconceptions is important for timely help-seeking. To assess public awareness of RA articular symptoms and extra-articular complications in Jordan, identify misconceptions, evaluate intended healthcare-seeking behavior, determine predictors of awareness, and examine questionnaire psychometric performance. A cross-sectional online survey using nonprobability, quota-based recruitment through social media and messaging-application advertisements was conducted among adults across all Jordanian governorates between February 10 and March 24, 2026. The cleaned analytic sample included 2332 respondents. Awareness was assessed using six symptom items and five complication items, with scores transformed to a 0-100 scale. Adequate awareness was defined as correct identification of at least 6 of 11 awareness items. Misconception burden was calculated from four items. Multivariable regression identified predictors of awareness and appropriate intended action. Internal consistency and exploratory factor analysis evaluated questionnaire performance. The mean total awareness score was 54.4 (SD, 33.5), and 56.3% of respondents had adequate awareness. Symptom awareness was slightly higher than complication awareness (mean scores, 56.9 vs. 51.4). Joint pain (73.1%), subcutaneous nodules (68.2%), and joint deformity (64.3%) were most recognized, whereas eye inflammation (29.7%), morning stiffness (45.5%), and small-joint swelling (46.5%) were less frequently identified. Misconceptions were common: 46.7% believed RA is not serious, 34.9% endorsed herbal cure beliefs, and 30.5% confused RA with osteoarthritis. Only 40.4% selected an appropriate intended action. Prior awareness of RA, knowing someone with RA, and higher education were the strongest predictors of awareness. Symptom and complication subscales showed good internal consistency (Cronbach's alpha, 0.806 and 0.799), and exploratory factor analysis supported a dominant general awareness factor. RA awareness in Jordan was moderate but uneven, with better recognition of visible joint manifestations than early inflammatory symptoms and extra-articular complications. Misconceptions were frequent, and appropriate intended help-seeking was reported by fewer than half of respondents. Interventions should frame RA as a serious, treatable systemic autoimmune disease and emphasize early warning signs, extra-articular complications, misconception correction, and medical consultation. Key Points • Overall, RA awareness was moderate, with a mean total awareness score of 54.4%, and 56.3% of participants meeting the predefined threshold for adequate awareness. • Participants recognized visible or general joint manifestations better than early inflammatory features; joint pain was most recognized, while morning stiffness and small-joint swelling were identified by fewer than half of respondents. • Awareness of extra-articular complications was incomplete, especially for eye inflammation and lung involvement, supporting the need to frame RA as a systemic autoimmune disease rather than only a joint disorder. • Misconceptions were frequent, and only 40.4% selected appropriate intended medical consultation, indicating a need for public health awareness campaigns targeting early symptoms, systemic complications, misconception correction, and timely referral.
Unemployment is a persistent socioeconomic phenomenon with profound psychological and community-level consequences. Despite extensive evidence on its adverse effects, an integrated construct capturing both psychosocial and spatial dimensions remains underdeveloped. To develop and validate the Psychosocial Impact of Unemployment Scale (PSIUS) and to examine the spatial distribution of the psychosocial impact of unemployment in an urban Chilean community. A cross-sectional psychometric validation study was conducted in Cauquenes, Chile. The PSIUS, a 30-item Likert-type scale, was developed in a pilot sample of 200 adults selected through a two-stage stratified random sampling procedure based on urban households from central and peripheral sectors of the borough. Its factorial structure was validated in an independent sample of 202 participants using exploratory factor analysis and exploratory structural equation modeling (ESEM). Latent class analysis (LCA) identified psychosocial response typologies, while spatial techniques (Global Moran's I, Getis-Ord Gi*) examined their geographic distribution. ESEM supported a six-factor structure (financial pressure, work values and commitment, perceived well-being, self-devaluation, dysfunctional affectivity, and perceived social support), explaining 72% of the variance and showing adequate model fit (RMSEA = 0.06, SRMR = 0.04, CFI = 0.98, TLI = 0.96) and satisfactory reliability (ω = 0.86). LCA identified four psychosocial response typologies: resilient, paradoxical, traumatic, and witness. Spatial analysis revealed significant clustering, with hot and cold spots associated with each typology, reflecting territorial inequalities in psychosocial vulnerability. The PSIUS showed preliminary evidence of reliability and construct validity in this community sample and effectively detected spatial patterns in the psychosocial impact of unemployment. These findings highlight the potential value of integrating psychosocial and spatial perspectives in public health research. However, further validation in independent and more diverse populations is required before broader implementation of the PSIUS.
Adolescent obesity is increasing worldwide, and a minority of adolescents are meeting recommended physical activity (PA) and dietary guidelines, particularly among adolescents from low socioeconomic areas. There are limited studies qualitatively investigating the engagement in healthy lifestyle behaviours in this population. Therefore, this study aimed to gain a greater understanding of perceived barriers and facilitators of healthy lifestyle behaviours, specifically PA and dietary behaviours, in this under-represented population. Eight semistructured qualitative focus groups with 35 adolescents aged 13-15 years old were conducted across four European countries (Spain, the Netherlands, Greece, UK) following the Theory of Planned Behaviour framework which states that individual behavioural intentions are grounded on attitudes, subjective norms and perceived behavioural control. Discussions were centred on adolescents' PA and healthy eating behaviours and were thematically analysed. Regarding attitudes, adolescents understood the importance of healthy lifestyle behaviours but often failed to engage in them. Concerning subjective norms, friends and peers were perceived as barriers to PA, except during physical education (PE) classes. Positive relationships between pupils and teachers facilitated PA, and family influence primarily affected dietary behaviours. Regarding perceived behavioural control, the school structures including lack of space and time, as well as limited healthy food options in canteens and the COVID-19 pandemic were barriers to healthy lifestyle behaviours, while mandatory PE classes and school clubs facilitated PA. In conclusion, despite adolescents recognising the significance of healthy lifestyle behaviours they often fail to engage in them. Their healthy lifestyle behaviours were influenced by their friends, families and teachers. The school structure and the COVID-19 pandemic were considered barriers to healthy lifestyle behaviours among adolescents. NCT05002049.
To address the structural mismatch between high clinical demand and limited public participation in platelet donation recruitment in megacities, this study constructed a three-dimensional community empowerment model-organizational empowerment, cognitive empowerment, and service empowerment-based on social capital theory, community governance theory, and planned behavior theory. A cross-sectional questionnaire survey was then conducted to examine statistical associations between key factors and attitudes toward platelet donation via machine collection, as well as blood donation intention, thereby providing empirical evidence for subsequent community recruitment strategy design. A multi-stage stratified sampling approach was used to select nine administrative districts and 32 communities in Chongqing according to population size and community type. Permanent residents aged ≥18 years who had lived in the community for at least 6 months were recruited. Of 2,200 distributed questionnaires, 2,004 valid responses were returned (valid response rate: 91.0%). Data were cleaned and analyzed using Excel, SPSS 26.0, and AMOS 26.0. The full sample was used to describe demographic and sociological characteristics, awareness deficits, and recruitment preferences; respondents with prior blood donation history were used to describe blood donation behavior; and 1,964 complete cases were included in confirmatory factor analysis (CFA) and structural equation modeling (SEM). The measurement and structural models were evaluated using Cronbach's α, KMO and Bartlett's test of sphericity, CFA, average variance extracted (AVE), composite reliability (CR), discriminant validity testing, Pearson correlation analysis, and SEM. Among respondents, 9.80% reported prior blood donation, and 59.18% of these donors had donated only once in the past year, suggesting limited sustained participation. Misconceptions remained common: 38.47% believed blood donation could harm health, and 31.34% of potential donors identified lengthy procedures as the primary participation barrier. Short science-popularization videos (penetration rate: 79.49%), government-enterprise collaborative recruitment programs (penetration rate: 68.21%), and leadership by Party members and officials in blood donation activities (penetration rate: 71.71%) showed high acceptance. CFA indicated standardized factor loadings of 0.65-0.85; AVE values were > 0.50 and CR values were > 0.70. Model fit was good [CMIN/DF = 1.583 (1-3), RMSEA = 0.017 < 0.05, and NFI, TLI, and CFI all > 0.90]. SEM results showed that institutional trust, fixed donor loyalty, community philanthropic culture, blood usage transparency, and social support norms were all significantly and positively associated with attitudes toward platelet donation via machine collection and blood donation intention. The community empowerment model developed in this study helps explain variation in residents' attitudes toward platelet donation via machine collection and blood donation intention from the perspectives of institutional trust, community philanthropic culture, blood usage transparency, and service accessibility. Given the cross-sectional study design, the findings indicate correlations rather than causal effects and do not demonstrate direct improvements in recruitment efficiency attributable to specific recruitment measures. Future studies should incorporate longitudinal follow-up, intervention trials, and cost-effectiveness evaluation to further verify the model's validity and generalizability in real-world community recruitment practice.
Latino/a adolescents report worse mental health than other ethnic-racial groups in the United States, including elevated depressive symptoms and anxiety, yet they remain less likely to access mental health services. Negative perception about mental health within Latino/a communities, shaped by negative beliefs about mental illness and limited knowledge of treatment, poses significant obstacles to care. Low mental health literacy, including poor understanding of depression, anxiety, and the role of therapy and medication, further contributes to negative attitudes about mental health. Prior work shows that Latino/a adolescents often avoid disclosing mental health concerns to parents to prevent burdening them, and this lack of communication impacts their help-seeking behaviors. To examine these challenges, we conducted six focus groups (n = 56) with Latino/a parents and adolescents aged 14-17 from Michigan and Texas. Analysis identified negative perceptions about mental health as a central obstacle for both parents and adolescents, limiting open dialogue about mental health. Adolescents reported fears of judgment or symptom minimization, contributing to delayed help-seeking behaviors. Parents expressed a need for greater mental health knowledge, including symptom recognition, treatments, and strategies for discussing mental health with their adolescent children. Adolescents emphasized the importance of trust, confidentiality, and family acceptance in facilitating disclosure and support. Findings underscore the need for interventions that reduce negative perception about mental health, improve mental health literacy, and strengthen parent-adolescent communication to enhance Latino/a adolescents' access to mental health care. Practitioners can support families by providing tools that support dialogue and reduce negative-perceptions about mental health.
BackgroundPre-exposure prophylaxis (PrEP) is highly effective in preventing human immunodeficiency virus (HIV) transmission, particularly for individuals at increased risk. However, uptake and long-term adherence remain challenging, with limited data on pharmacies beyond pilot studies. This study explored how psychological, social, and structural factors shape perceptions of HIV risk and influence PrEP adherence, using the Tripartite Risk Perception (TRIRISK) model, Protection Motivation Theory, and the Theory of Planned Behavior.MethodsA qualitative design using in-depth interviews (IDIs) was conducted pre-implementation (May 2023) and during implementation (April-July 2024) of pharmacy-based PrEP services. Participants were adults (18+years) accessing pharmacy-based PrEP services in Gauteng and the Western Cape, South Africa. Data were analyzed thematically using Excel and MAXQDA, guided by the integrated behavioral frameworks.ResultsA total of 99 IDIs were conducted, 30 in 2023, 69 in 2024. Through the TRIRISK model, this study found that decisions to start or continue PrEP were shaped by perceived vulnerability to HIV, awareness of risky sexual behaviors, mistrust of partners, and emotional experiences like fear and trauma. The PMT further highlighted how emotional triggers, along with perceived severity and coping efficacy, affected motivation to initiate or continue PrEP. The TPB helped explain how subjective norms, such as stigma and social judgment, and perceived behavioral control, shaped by access, convenience, and privacy, impacted adherence.ConclusionIntegrated behavioral frameworks offer critical insights into PrEP-related decision making. Interventions, including pharmacy-based PrEP models, should address emotional barriers, such as stigma-sensitive messaging, strengthening social support, and reducing structural inequalities. HIV Risk Perception and PrEP UsePre-exposure prophylaxis (PrEP) is a highly effective medicine that helps prevent human immunodeficiency virus (HIV). However, not everyone who needs PrEP uses it effectively. In South Africa, PrEP is being offered in some pharmacies to make it easier to access compared to most public clinic settings. This study looked at what people think and feel about their risk of getting HIV, and how those thoughts shape their decision to take PrEP. We interviewed 2 groups of pharmacy clients at different stages of implementation: one group before pharmacy-based PrEP was rolled out, and another group during implementation after PrEP had been initiated. We used 3 behavioral theories to understand how people assess their risk and make decisions about PrEP use. We found that people were more likely to start PrEP when they felt personally at risk of HIV, for example due to a partner's unfaithfulness or past traumatic experiences. Support from peers, privacy at the pharmacy, and easy access made it easier to keep using PrEP. However, stigma, travel, and life challenges like family responsibilities often made it harder to continue. This study shows that providing PrEP through pharmacies can work well, but emotional, social, and structural barriers must be addressed. PrEP programs should include supportive messaging, flexible access options, and tools that help people stay on PrEP even when life gets difficult.
The working fields of general practitioners (GPs) and occupational health physicians (OHPs) overlap manifoldly. Yet, cooperation between both groups is often scarce as has been revealed by studies from several countries. During the COVID-19 pandemic, GPs dealt with many work-related counselling topics. We conducted a trend study surveying German GPs and OHPs in 2014/2015 (GPOP-0 study) and 2023/2024 (GPOP-Trend) to analyse trends regarding a potential change of attitudes towards interdisciplinary cooperation over time, before and after the COVID-19 pandemic. The trend study used repeated cross-sectional surveys and an identical questionnaire for GPs and OHPs, which was sent by postal mail to both groups. The questionnaire covered topics regarding cooperation and attitudes towards both professional groups, as well as questions to assess the perceived quality of cooperation with regard to counselling purposes specific for the COVID-19 pandemic (only in GPOP-Trend). The statistical analysis followed a prior published analysis plan, and comprised an exploratory factor analysis, Mann-Whitney U tests, and regression analyses. More than 1,000 physicians took part in both surveys (GPOP-0: 585 GPs and 473 OHPs, response rate 35%; GPOP-Trend: 482 GPs and 532 OHPs, response rate: 30%). We identified hardly any cooperation between these two groups during the COVID-19 pandemic. In cases where cooperation took place, it was rated more positively by OHPs than by GPs in retrospect. Comparing the total survey data of both time points revealed that attitudes among GPs and OHPs changed only little over time. The strongest predictor for the attitudes surveyed was the variable "professional group" in all regression models. This predictor was also the most relevant, when investigating the influence of different variables during the COVID-19 pandemic on attitudes towards cooperation of GPs and OHPs. Socialization within a professional group seems to be the determining factor, and therefore attitudes remain stable as described by Social Identity Theory. We assume that interventions that focus solely on strengthening cooperation between GPs and OHPs therefore have only a very limited effect. We therefore suggest another approach with interventions targeting primarily on patient outcomes and the design of clear interfaces or clinical pathways.
Fear of cancer recurrence is one of the most frequent concerns among breast cancer survivors and can significantly affect health-related quality of life. However, it remains insufficiently explored in routine clinical practice. The aim of this study is to describe the frequency of fear of cancer recurrence and quality of life in patients with early breast cancer, to analyze their association with clinical and sociodemographic characteristics. As a complementary descriptive exploration, communication between patients and the healthcare team regarding fear of cancer recurrence was also assessed. Cross-sectional observational study conducted in two public centers. A total of 301 women with stage I-III breast cancer, disease-free and at least 12 months post-treatment, were included. Fear of cancer recurrence was assessed using the Cancer Worry Scale, and quality of life was evaluated using the PROMIS Global 10 questionnaire. High fear of cancer recurrence was observed in 34.9% of participants, and moderate fear of cancer recurrence in 20.9%. This concern was significantly associated with ≤5 years since diagnosis, age <50 years, education level, chemotherapy, and endocrine therapy. No associations were found with tumor stage, type of breast surgery, axillary surgery, or radiotherapy. Nearly half of the patients had not discussed fear of cancer recurrence with their medical team, mainly because they did not consider it a serious issue or were unaware that it could be addressed during consultations. PROMIS scores showed median values of 37.4 for physical health and 43.5 for mental health. Quality of life did not vary according to clinical characteristics or treatments but was associated with age and education. Patients with higher fear of cancer recurrence consistently showed poorer quality of life across all domains (p < 0.001). Fear of cancer recurrence is highly frequent and strongly associated with poorer quality of life, independently of clinical variables. Its identification and management should be systematically integrated into survivorship care for women with breast cancer. El temor a la recurrencia es una de las principales preocupaciones de las sobrevivientes de cáncer de mama, lo que puede afectar de forma significativa su calidad de vida. Sin embargo, sigue siendo poco explorado en la práctica clínica. El objetivo de este trabajo es describir la frecuencia del temor a la recurrencia y la calidad de vida en pacientes con cáncer de mama precoz, junto con analizar su asociación con características clínicas y sociodemográficas. De forma complementaria y descriptiva, se exploró la comunicación entre las pacientes y el equipo de salud en relación con el temor a la recurrencia. Estudio observacional de corte transversal realizado en dos centros públicos. Se incluyeron 301 mujeres con cáncer de mama en estadios I a III, libres de enfermedad y con al menos 12 meses desde la finalización del tratamiento. El temor a la recurrencia se evaluó con la y la calidad de vida mediante el cuestionario PROMIS Global 10. Un 34,9% presentó temor a la recurrencia alto y un 20,9% moderado. El temor a la recurrencia se asoció significativamente con un tiempo inferior o igual a cinco años desde el diagnóstico, edad menor de 50 años, nivel educativo, quimioterapia y hormonoterapia. No se observaron asociaciones con el estadio, el tipo de cirugía ni la radioterapia. Casi la mitad de las pacientes no habló del temor a la recurrencia con su equipo médico, principalmente por no considerarlo un problema grave o por no saber que podía abordarlo en la consulta. Los puntajes del cuestionario PROMIS mostraron una mediana de 37,4 en salud física y 43,5 en salud mental. La calidad de vida no varió según las características clínicas ni los tratamientos, pero sí según la edad y el nivel educativo. Las pacientes con mayor temor a la recurrencia tuvieron peor calidad de vida en todos los dominios (p < 0,001). El temor a la recurrencia es altamente frecuente y se asocia con peor calidad de vida, independientemente de las variables clínicas. Su identificación y abordaje deben integrarse de forma sistemática en el seguimiento de las sobrevivientes de cáncer de mama.
Health-seeking behaviors directly affect migrant adolescents' access to healthcare, health outcomes, and social integration. The aim of this study is determine the effect of acculturation on health-seeking behaviors in adolescent migrants aged 16-18 years. This descriptive and correlational cross-sectional study was conducted with 272 migrant adolescents, selected using convenience sampling, who completed the Individual Identity Form, the Health-Seeking Behavior Scale (HSBS) and the Vancouver Index of Acculturation (VIA). Data were collected between April 2023-April 2024 and analyzed using IBM SPSS Statistics 27. Traditional health-seeking behavior and VIA core culture orientation had higher mean scores. mainstream culture orientation had positive and significant effect on health seeking behavior (p = 0.044). Educated, socially secure, living mostly in cities with their nuclear families, and with income equal to expenditure, adolescent migrants scored significantly higher on the health-seeking behavior scale. These relationships revealed that cultural orientations have a significant effect on health seeking behaviors. Future studies with larger, diverse samples are recommended.
Despite strong evidence of benefit, in the UK only 40% of eligible patients are referred to Pulmonary Rehabilitation (PR) and there are poor levels of uptake and completion globally. Understanding how current interventions address reported barriers to PR referral and engagement can help understand intervention effectiveness and highlight opportunities for future policy and intervention. Two systematic reviews were conducted: 1) Review of studies reporting barriers/enablers to PR delivery and engagement behaviours, with extracted barriers/enablers inductively synthesized into themes and coded to the domains of the Theoretical Domains Framework (TDF). 2) Review of existing interventions to improve PR uptake/engagement, specifying component Behaviour Change Techniques (BCTs) using established taxonomies. Interventions were categorised for promise according to evidence of change in behaviour for one or more outcomes. Findings from both reviews were triangulated using the Theories and Techniques tool (TaTT), to assess the extent to which components in current interventions targeted key barriers/enablers. Sixty-three studies were included in the analysis. Barriers and enablers to PR mainly fell under the TDF domains Environment, context and resources; Knowledge; Social Influences; Professional role and identity; and Memory, attention and decision making. There are opportunities to further support referral by considering interventions targeted at memory and decision making and by streamlining referral processes. For patient engagement with PR, the highly represented TDF domains were Environment, context and resources; Social influences; Emotions; Knowledge; and Beliefs about capabilities. Fifty-four percent of referral interventions and 15% of engagement interventions were considered very promising. BCTs in promising interventions targeting patient engagement included provision of social support and guidance on planning and goal setting. Opportunities for improving engagement include consideration of the emotional burden associated with COPD and attending PR. These findings can inform development of new, or refinement of existing, interventions targeting PR for people with COPD.
Mental health stigma remains prevalent in clinical practice, affecting even family physicians. Despite serving as frontline mental health providers, family physicians also face stigma and barriers to seeking care. Drawing on 2024 Council of Academic Family Medicine Educational Research Alliance study data, this study investigates family physician educators' perceptions of stigma, their help-seeking intentions, and the obstacles they encounter when pursuing mental health support. This cross-sectional study drew responses from a 2024 survey of family medicine educators and practicing physicians between October 15 and November 22, 2024. Out of the initial pool of 4,844 participants completing the survey, our sample included 1,195 respondents. One-way analysis of variance and simple linear regression were performed in Stata 14.0 to test our hypotheses rigorously. Bivariate analyses identified statistically significant associations across five key relationships: years since degree completion and stigma score, age and stigma score, race and barriers to care, underrepresented in medicine status and barriers to care, and gender and barriers to care. Furthermore, linear regression models demonstrated that all three stigma categories (personal, perceived, and stigma of others) were significantly linked to higher barrier scores. These findings underscore the pervasive nature of mental health stigma among family physicians, highlighting its detrimental impact on help-seeking and well-being. Targeted interventions are crucial for reducing stigma, addressing barriers to care, and protecting physicians' mental health, ultimately improving patient outcomes.
Malaria remains one of the most persistent public health challenges in Ethiopia, where its meaning and treatment are shaped not only by biological causes but also by cultural beliefs and social inequalities. Despite increased awareness and government-led control efforts, the disease continues to affect communities in endemic areas. This study examined how communities in Jimma City understand and manage malaria, specifically focusing on how local beliefs, gender roles, and economic barriers shape treatment choices. An ethnographic study was conducted in Jimma City, southwest Ethiopia. Data were collected through in-depth interviews (n = 32), key informant interviews (n = 8), two focus group discussions, participant observation, and document review. Participants included household members affected by malaria, traditional healers, religious leaders, community elders, and health professionals. Interviews were conducted in Afaan Oromo and Amharic, transcribed verbatim, translated into English, and analyzed using thematic analysis. Malaria was understood through overlapping cultural and biomedical explanatory models. Local terms such as buda (evil eye), busa (seasonal fever), and sekera (killer disease) shaped how symptoms were recognized and interpreted. Treatment-seeking followed a pluralistic pathway, commonly beginning with home remedies, herbal treatments, and prayer, followed by biomedical care when symptoms worsened or persisted. Gender dynamics strongly influenced care-seeking: females were typically the first to recognize illness and provide care but often lacked decision-making authority and financial control, contributing to delays in accessing treatment. Males' occupational and social activities increased their exposure to malaria risk. Structural barriers including poverty, drug stockouts, transport constraints, inadequate housing, and weak health infrastructure further constrained timely and effective care. In Jimma City, malaria is experienced as a social as well as biomedical condition, embedded in local belief systems, gender relations, and structural inequalities. Malaria control efforts that focus solely on biomedical interventions risk overlooking the social realities that shape treatment-seeking behavior. Effective and sustainable malaria control requires engagement with local explanatory models, strengthening women's decision-making power, and addressing systemic barriers that perpetuate vulnerability.
Poststroke depression (PSD) affects approximately 33% of stroke survivors and is associated with worse outcomes, poor quality of life (QOL) and mortality. Despite its prevalence and consequences, there is no consensus on the most effective strategy for PSD prevention. Behavioural activation (BA) is an effective intervention for depression across diverse populations and is considered safer, better tolerated and a longer-lasting alternative to antidepressant medications. This study aims to test the effectiveness of a remotely delivered BA intervention to prevent PSD (Tele-BA-S). We will conduct a randomised effectiveness trial of 350 low-income adults (≥ 55 years) within 3 months of ischaemic or haemorrhagic stroke and with subthreshold depression (Patient Health Questionnaire-9 score <9 and 24-item Hamilton Depression Rating Scale (HDRS) score <15). Eligible and consented adults will be randomly assigned to Tele-BA-S or treatment-as-usual. Tele-BA-S will be comprised of an orientation session, 5 weekly BA sessions and 2 follow-up monthly booster calls delivered by trained community health workers. We will conduct assessments at 1 month, 2 months, 4 months, 6 months and 9 months after baseline. The primary outcome (PSD) will be measured by the 24-item HDRS. Secondary outcomes will include anxiety (Generalised Anxiety Disorder-7 Scale), psychological well-being (Ryff Scale of Psychological Well-being), QOL (Stroke Specific QOL Scale), medication adherence (Medication Adherence Report Scale-5), rehabilitation adherence (Rehabilitation Adherence Inventory), number of emergency department visits and hospitalisations, functional outcome (Barthel Index) and degree of disability (Modified Rankin Scale). Mediating variables will include self-efficacy (Stroke Self-Efficacy Questionnaire), motivation (Motivation in Stroke Patients for Rehabilitation Scale) and activity engagement (Neuro-QOL Participation in Roles and Activities). Exploratory implementation measures will also be collected. Primary analysis will follow the intention-to-treat principle and evaluate intervention effects over time using mixed-effects models. Ethical approval was obtained by the University of Texas Health Science Center at Houston's (UTHealth Houston) Committee for the Protection of Human Subjects Institutional Review Board. The trial protocol, statistical analysis plan and code, and deidentified participant data will be made available via the National Institute of Mental Health Data Archive. The results will be presented at academic conferences and submitted for publication. The authors declare that they have no conflicts of interest relevant to the content of this manuscript. NCT06864715.