BackgroundAlthough perceived distance is a key factor in deciding and reaching healthcare, its impact on antenatal care (ANC) utilisation remains underexplored.ObjectiveThis study aims to examine the effect of perceived distance on ANC uptake, stratified by key maternal characteristics.DesignCross-sectional analysis based on demographic and health survey data (DHS).MethodsThis study analysed the demographic and health survey data of 26 sub-Saharan African countries, comprising 186,873 women who had given birth within the five years preceding the surveys. The exposure variable was perceived distance to a healthcare facility, categorised as "a big problem" or "not a big problem." Whereas the outcome variable was the number of ANC contacts, classified as no, one to three, four to seven and eight or more contacts. A Generalised Structural Equation Model (GSEM) with a multinomial logit link was employed to examine the association. Analyses were further stratified by socio-demographic characteristics.ResultsThe analysis revealed that women who perceived the distance as a major problem had 15% higher odds of receiving only 1-3 contacts (aOR = 1.15, 95% CI: 1.05, 1.25, p = 0.002), and 51% higher odds of receiving no ANC (aOR = 1.51, 95% CI: 1.35, 1.66, p < 0.001), compared to those receiving eight or more contacts. These associations were particularly pronounced among women with lower educational status (aOR=1.48, 95%CI: 1.29, 1.64), rural residents (aOR=1.55, 95%CI: 1.37, 1.74), low household income (aOR=1.47, 95%CI: 1.27,1.68), and younger age (aOR=1.55, 95%CI: 1.31, 1.80).ConclusionPerceived distance remains a significant barrier to the utilisation of antenatal care services in resource-limited settings. Strengthening health system responsiveness and addressing structural barriers, such as transportation infrastructures, through innovations like mobile antenatal care is vital to improving maternal health outcomes and advancing global health equity. Ensuring access to high-quality antenatal care (ANC) is essential for improving maternal and newborn health outcomes. However, evidence on the effect of geographical distance on ANC use in sub-Saharan Africa remains limited and inconclusive. This study examined the relationship between perceived distance to a health facility and ANC utilisation across 26 sub-Saharan African countries. We analysed the Demographic and Health Survey (DHS) data from 186,873 women who had given birth in the five years preceding the survey. Women who reported that distance to a health facility was a major problem had 15% higher odds of attending only 1-3 ANC contacts and 51% higher odds of receiving no ANC, compared with women who attended at least eight contacts. These associations were stronger among women with lower levels of education, those living in rural areas, women from low-income households, and younger women. These findings underscore the importance of addressing perceived distance-related barriers to improve uptake of the WHO-recommended number of ANC contacts and to promote equitable access to maternal health services in sub-Saharan Africa.
War and armed conflict profoundly disrupt cancer care systems, with radiation therapy services among the most severely affected due to their static geography, reliance on stable infrastructure, specialized equipment, and a highly trained multidisciplinary workforce. Drawing on intercontinental narratives shared by clinicians and medical physicists from Sudan, Yemen, Syria, Palestine, and Ukraine, this work synthesizes frontline experiences of delivering radiation therapy amid instability, displacement, and resource collapse. Beyond documenting challenges, the manuscript articulates a collective call to action for the global radiation oncology community, outlining priority areas for intervention, including education, workforce development, technology support, research, and advocacy, and proposing practical, ethically grounded pathways for translating awareness into sustained, collaborative resilience planning. Cancer care in conflict settings is framed not as a peripheral humanitarian concern, but as a central issue of patient safety, equity, and professional responsibility, central to today's new challenges.
Youth experiencing homelessness face significant barriers to mental healthcare. To address this gap, the Réseau d'Intervention de Proximité Auprès des Jeunes de la rue (RIPAJ) was established in Montréal in 2003 through collaboration between community and governmental health organizations. In 2016, RIPAJ joined the national Adolescent/Young Adult Connections to Community-driven Early Strengths-based Stigma-free services-Open Minds (ACCESS-OM) initiative, aiming to enhance mental healthcare accessibility for youth experiencing homelessness. This study evaluates the impact of this integrated approach on referral trends and wait times before and during ACCESS-OM RIPAJ implementation. Monthly referrals and wait times for first appointment were recorded for a historical cohort (2014-2015) and the ACCESS-OM RIPAJ period (2016-2020). We used Poisson and Cox regression models to analyze trends in referral rates and wait times, with 2014 as reference period. Seasonality was controlled by incorporating calendar month in the models. Additional Cox regressions examined individual-level sociodemographic and clinical factors associated with post-implementation wait times. We analyzed 158 referrals for 2014 to 2015 and 681 for 2016 to 2020. Monthly referrals increased significantly, peaking at 2.5 times the 2014 level. Wait times remained stable, with 73.5% evaluated within 72 hr. The hazard ratio for wait times during the peak period was 0.87 (95% CI [0.63, 1.20]) indicating no significant change despite the surge in referrals. Older age and self-referral were associated with reduced wait times. This collaborative model successfully increased mental healthcare utilization among youth experiencing homelessness, providing valuable insights for addressing the unmet needs of this vulnerable population and potentially reducing homelessness perpetuation.
Information regarding risk factors among service member families for different child maltreatment types is needed to improve prevention efforts. To identify factors associated with first occurrences of 4 child maltreatment types and examine child age-related changes in risk for each type among active duty service member families. This population-based retrospective cohort study used data from the Child Maltreatment in Military Families Life Course Study on active duty service member families with a first occurrence of child maltreatment in fiscal years 2009 through 2018 and a representative sample of active duty families without child maltreatment incidents. Data were analyzed from August 2023 to February 2026. One or more parents serving as an active duty service member. First documented occurrences of neglect, physical abuse, emotional abuse, and sexual abuse, identified using Family Advocacy Program data. Associations between sociodemographic, family, and military-related characteristics and first occurrences of maltreatment types were examined in univariable and multivariable logistic regressions. The study included 618 101 active duty service member families (28 684 [4.64%] with a first occurrence of child maltreatment and 589 417 [95.36%] without child maltreatment incidents), consisting of 1 070 510 family-months (FM); the total weighted sample was 65 142 809 FM (59 031 293 male service member FM [90.62%]; mean [SD] age, 32.74 [6.97] years). Crude rates of child maltreatment were highest for child neglect (22.16 per 100 000 FM) followed by physical abuse (10.97 per 100 000 FM), emotional abuse (4.23 per 100 000 FM), and sexual abuse (2.66 per 100 000 FM). Factors associated with higher odds of all child maltreatment types in multivariable models were female service member families (eg, sexual abuse: odds ratio [OR], 1.39 [95% CI, 1.18-1.64]; physical abuse: OR, 1.82 [95% CI, 1.70-1.95]), early parenting (age <21 years) (eg, neglect: OR, 1.32 [95% CI, 1.22-1.41]; sexual abuse: OR, 2.12 [95% CI, 1.75-2.56]), larger number of dependent children (≥3) (eg, emotional abuse: OR, 1.63 [95% CI, 1.48-1.79]; sexual abuse: OR, 2.32 [95% CI, 2.06-2.61]), and never-deployed status (eg, sexual abuse: OR, 1.90 [95% CI, 1.55-2.32]; emotional abuse: OR, 3.76 [95% CI, 3.09-4.57]). Risk rates peaked at 3 months of age for neglect (48.61 per 100 000 FM) and physical abuse (25.49 per 100 000 FM). Risk of emotional and sexual abuse peaked in middle childhood (age 5-12 years) and adolescence but was generally lower (<6 per 100 000 FM) than risk of other child maltreatment types across all ages. In this cohort study, families with female service members, never-deployed service members, 3 or more children, and young parents had higher risk of child maltreatment. Dynamic prevention approaches appear to be needed to address evolving risk factors across the family life course.
Healthcare systems in transitional economies frequently fail to translate formally adopted strategies into consistent patient-centered care. This persistent disconnect between strategic intent and frontline execution is conceptualized in this study as the Strategic Implementation Fidelity Gap. This paper introduces the concept of whether differences in strategic implementation fidelity are associated with measurable variations in patient-perceived service quality in public healthcare organizations. A comparative cross-sectional study was conducted in two state-owned healthcare institutions in Almaty, Kazakhstan: a hospital characterized by higher implementation fidelity and a polyclinic with lower fidelity. Service quality was assessed using the SERVQUAL model, reconceptualized here as a behavioral indicator of strategic execution. Non-parametric analysis was applied to compare service quality gaps across five dimensions. The findings reveal significant negative service quality gaps in both institutions, with the largest deficiencies consistently observed in empathy and responsiveness. Crucially, the institution with higher implementation fidelity demonstrated a significantly smaller overall SERVQUAL gap (p = 0.003), indicating that differences in execution capacity translate directly into measurable differences in patient experience. This study provides compelling evidence; however, its findings should be interpreted in light of the following limitations. Cross-Sectional Design: The study employed a cross-sectional design, collecting data at a single point in time. While this allows for statistical comparison between institutions, it limits the ability to establish definitive cause-and-effect relationships or track the dynamic evolution of the Strategic Implementation Fidelity Gap over time. Future research should utilize longitudinal designs to assess the impact of implemented managerial protocols. Perceptual Data Dependency: The research relies primarily on patient-perceived quality data (SERVQUAL), which is inherently subjective. Although this is a crucial measure of service quality, the scope does not include the perspectives of healthcare providers or objective clinical outcome data. Generalizability: The sample was restricted to two public healthcare institutions in a single large city (Almaty, Kazakhstan). Therefore, the generalizability of the results to diverse regional healthcare settings or other transitional economies should be approached with caution. Strategic Resource Rebalancing: The results offer a clear rationale for healthcare decision-makers to strategically rebalance investments. Priorities must shift from sole reliance on structural assets to rigorous development and control of managerial and staff protocols, placing a specific focus on the identified areas of weakness: Empathy and Responsiveness. Management Monitoring Tool: The statistically significant differences between institutions demonstrate that the SERVQUAL gap score can serve as a quantifiable management monitoring tool for supervisory bodies to audit the quality of strategic execution and compliance. Applicability in Transitional Systems: The findings provide an actionable governance model for all transitional and emerging economies seeking to modernize their health systems, demonstrating that reform success is predicated on the quality of Behavioral Governance. Restoring Public Trust: The identified gaps in Empathy and Responsiveness are primary drivers of eroded public trust in the healthcare system and government-led reforms. Addressing the Strategic Implementation Fidelity Gap through mandatory behavioral governance directly contributes to restoring citizens' trust in public institutions. Promoting Social Equity: Inconsistent service quality (low Implementation Fidelity) creates barriers to equitable access to effective care. Ensuring every facility adheres to standardized protocols (especially in behavioral aspects) promotes social equity and guarantees consistent quality of service for all population segments. Enhancing Patient Well-being: Directly addressing failures in Empathy and Responsiveness not only improves the clinical experience but also significantly enhances the psychological and emotional well-being of patients, increasing their adherence to treatment plans and overall satisfaction with state interaction. The study provides the first empirical quantification of a Strategic Implementation Fidelity Gap in a transitional healthcare system and demonstrates that service quality deficits are not solely driven by resource constraints, but by failures in behavioral execution. By repositioning SERVQUAL as a diagnostic tool for strategic implementation, the study offers a novel framework for assessing how governance and execution shape frontline outcomes. The findings suggest that healthcare reforms should move beyond structural investment and prioritize behavioral governance, performance monitoring, and the standardization of frontline practices to ensure effective strategy implementation.
People with Borderline Personality Disorder (PBPD) have been historically excluded from Assertive Community Treatment (ACT) teams. The 'gold standard' ACT service model in community psychiatry aims to serve people with serious mental illness (SMI), typically diagnosed with psychotic and mood disorders. For various clinical, administrative, and model innovation reasons, PBPD are notably present on ACT teams, presenting unique clinical challenges; yet clinician perspectives and experiences are little known. Qualitative study using semi-structured interviews and thematic analysis on experiences and perspectives of clinicians from a well-established ACT team in an academic setting that transitioned to a Flexible ACT team in Toronto, Canada. Clinicians reported working with PBPD presents unique training, skills, clinical, team, system, and personal level challenges Five main themes included: (1) Lack of specific training among clinicians in serving people with BPD; (2) Diverse views of suitability of ACT for PBPD; (3) Specific challenges for clinicians working with PBPD on ACT; (4) Positive aspects of using ACT to serve PBPD; (5) Potential adaptive changes to ACT teams working with PBPD. Conclusion: Having PBPD on ACT teams is a little acknowledged and less known area of ACT and has significant impact on ACT services. Further attention to training and skill building, service adaptation, and research that improve care and therapeutic relationships with PBPD on ACT are warranted. Having PBPD on ACT teams is a little acknowledged and less known area of ACT and has significant impact on ACT services. Further attention to training and skill building, service adaptation, and research that improve care and therapeutic relationships with PBPD on ACT are warranted.
Medicare home health is a critical postacute care source for individuals with Alzheimer disease and related dementias (ADRD). The Home Health Value-Based Purchasing (HHVBP) program has substantially reshaped financial incentives in home health, but its implications for patients with ADRD are unclear. To assess the association between residence in a state with an HHVBP program and home health service volume within 30 days of home health initiation among Medicare beneficiaries with ADRD, and how this varies by patient race and/or ethnicity, dual eligibility, and home health agency (HHA) racial composition. This cohort study linked 2021 to 2022 Medicare claims data with Home Health Focus and Provider of Services files for Medicare fee-for-service beneficiaries with ADRD older than 65 years who initiated home health care within 14 days of hospital discharge in the 9 states in which an HHVBP program was piloted compared with non-HHVBP states. The analysis was conducted from November 2024 to June 2025. Residence in an HHVBP pilot state vs a non-HHVBP state. Number of nursing and therapy visits received within 30 days (main analysis) and 14 days (sensitivity analysis) of home health initiation. Negative binomial regression models with HHA random effects were estimated, and average marginal effects were reported. The analytic cohort included 264 601 Medicare beneficiaries with ADRD (median [IQR] age, 83 [77-89] years; 160 947 males [60.8%]), of whom 68 765 (26.0%) resided in HHVBP states. The overall racial and ethnic composition included Asian (3.1%; n = 8099), non-Hispanic Black (8.9%; n = 23 634), Hispanic (6.3%; n = 16 562), and non-Hispanic White (81.7%; n = 216 306) individuals, as determined by Research Triangle Institute race codes from the Master Beneficiary Summary File. Adjusted 30-day outcomes showed HHVBP state residence vs non-HHVBP state residence was associated with 0.46 fewer nursing visits (3.94 vs 4.40 visits; average marginal effect [AME] = -0.46; 95% CI, -0.52 to -0.41; P < .001) and 0.32 more therapy visits (6.37 vs 6.05 visits; AME = 0.32; 95% CI, 0.24-0.39; P < .001). In non-HHVBP states, dual-eligible beneficiaries and those receiving care from HHAs primarily serving a racial and ethnic minority population received more nursing but fewer therapy visits compared with non-dual-eligible beneficiaries and those receiving care from HHAs serving a predominantly White population. These differences became smaller in HHVBP states. For example, therapy visit gaps between patients receiving care from HHAs primarily serving a racial and ethnic minority population and those receiving care from HHAs serving a predominantly White patient population narrowed from -0.81 (95% CI, -0.90 to -0.73) to -0.27 (95% CI, -0.44 to -0.09) visits in non-HHVBP vs HHVBP states (P < .001). The findings of increasing use of therapy visits and smaller group differences were consistent within a 14-day window. In this cohort study of Medicare beneficiaries with ADRD, residence in an HHVBP state was associated with increased therapy use and smaller differences in home health service patterns between racial and/or ethnic minority and White patients, dual-eligible and non-dual-eligible beneficiaries, and patients receiving care from minority-serving HHAs and those receiving care from HHAs serving a predominantly White patient population compared with residence in a non-HHVBP state. These findings suggest that VBP models could reduce differences in postacute care.
Sub-Saharan Africa has a critical shortage of paediatric surgical resources. Specialists are concentrated in urban centres, leaving rural areas underserved; peripheral hospitals lack trained providers, contributing to suboptimal care. Underdiagnosis and limited surveillance conceal the true disease burden. Short-term outreach has not produced sustainable improvements. Consistent with the Global Surgery 2030 framework, this study holds that sustainable paediatric surgical access requires a deliberate transition from episodic, vertical outreach to a horizontal, locally governed system that is embedded within existing health services and referral networks. This retrospective programme evaluation investigates how a participatory approach at a secondary hospital in Tanzania's rural context can strengthen local providers' capacity and enable the facility to serve as a paediatric surgical hub. A 404-bed charitable secondary-level hospital in the Southern Tanzanian Highlands, 800 km from the nearest tertiary centre, hosted the programme from 2016 to 2026. It evolved from short-term outreach into ongoing training, mentorship, and joint goal-setting, through which local staff acquired skills to manage paediatric cases via surgical tutoring, anaesthesia upgrading, nurse empowerment, and remote consultation. Paediatric procedures rose from 7.2% to 11.9% of total surgical activity (two-sided p<10-16), with a 102.4% increase in general surgical and urological procedures. Local surgeons are now performing all procedures autonomously. The most recent caseload includes many major conditions, with generally favourable outcomes; however, neonatal mortality remains high, mainly due to late referrals and the absence of dedicated postoperative facilities. A participatory approach identified previously unrecognised needs and supported the development of sustainable local capacity. Ongoing training, structured mentorship, and a gradual transfer of responsibility enhanced autonomous practice and increased patient recruitment. Context-sensitive partnerships and sustained educational investment supported skill retention, institutional learning, and the integration of new practices into routine care. These elements are essential to expanding paediatric surgical services in under-resourced settings.
Employed informal caregivers in Iran navigate caregiving responsibilities within a context of absent formal support infrastructure, rigid cultural expectations, and economic constraints. This study explored their lived experiences, focusing on work-care balance, stress management, and interactions with support structures. A qualitative descriptive study was conducted using semi-structured in-depth interviews with five employed female informal caregivers of older persons (aged 65 and above) in urban Iran. Interviews were conducted in Persian via Zoom between January and March 2025, lasting 60 to 120 min. Data were analyzed using Reflexive Thematic Analysis, informed by Role Theory and Lazarus and Folkman's Stress and Coping Theory. Six themes emerged: (1) onset and context of caregiving, (2) work-care role balance, (3) stress and coping strategies, (4) social and workplace support, (5) personal and cultural experiences, and (6) advice and future perspectives. Findings reveal a distinctive "triple burden" where structural barriers (absent caregiver leave policies, inadequate insurance coverage, limited respite services), cultural expectations (filial piety norms, gendered care obligations), and economic pressures (inability to reduce work hours, high caregiving costs) converge to create unsustainable caregiving conditions. Participants sacrificed sleep, personal relationships, and career advancement while experiencing chronic exhaustion, workplace discrimination, and social isolation. Coping strategies proved insufficient without formal support structures. Unlike developed countries with established support systems, Iranian caregivers operate within institutional silence where caregiving remains an exclusively private burden. Urgent policy reforms are needed: caregiver leave policies, subsidized respite services, insurance coverage for home care, workplace accommodations, and culturally sensitive counseling programs.
Public health organizations in Canada play a central role in chronic disease prevention (CDP) but face persistent challenges, including system restructuring, persistent underfunding and shifting policy priorities. The growing complexity of these issues warrants qualitative insight to complement quantitative reports capturing CDP organizations' perspectives. The Public Health Organizational Capacity Study (PHORCAST) is a repeat Canada-wide census of public health organizations engaged in primary CDP at national, provincial, territorial and regional population levels. In 2023, senior managers and staff with in-depth knowledge of their organizations' CDP activities completed a questionnaire that requested optional comments via an open-ended question. The responses were analyzed using qualitative descriptive methods and inductive content analysis to identify and organize recurring issues. Theme frequencies are reported descriptively to indicate prominence across organizations and not to quantify meaning. Across the 55 organizations, 125 coded references to barriers to CDP were synthesized into five key themes: organizational capacity and program delivery challenges (n = 38), including chronic underfunding, workforce shortages and limited infrastructure; COVID-19 pandemic disruptions causing staff redeployment and prolonged service interruptions (n = 30); policy and systemic barriers (n = 28), including political interference and poor interjurisdictional coordination; fragile partnerships and the need for stronger intersectoral collaboration (n = 16); and difficulties engaging diverse communities, digital access issues and lack of culturally responsive programming (n = 13). CDP efforts in Canada are constrained by structural, operational and contextual barriers. Addressing these challenges requires sustained investment, coherent policies and stronger cross-sector partnerships. Alors que les organismes de santé publique au Canada jouent un rôle central dans la prévention des maladies chroniques, ils sont confrontés à des défis persistants, notamment à la restructuration des systèmes, à un sous-financement chronique et à des changements de priorités en matière de politique. La complexité croissante de ces enjeux justifie l’apport de données qualitatives en complément des rapports quantitatifs, qui présentent le point de vue des organismes de prévention des maladies chroniques. L’étude sur les capacités organisationnelles de santé publique (PHORCAST) est un recensement itératif à l’échelle du Canada des organismes de santé publique mobilisés dans la prévention primaire des maladies chroniques à l’échelle de la population régionale, territoriale, provinciale et nationale. En 2023, les gestionnaires principaux et le personnel ayant une connaissance approfondie des activités de prévention des maladies chroniques de leur organisme ont répondu à un questionnaire suscitant des commentaires facultatifs par l’entremise d’une question ouverte. Les réponses ont été analysées à l’aide de méthodes qualitatives descriptives et d’une analyse inductive du contenu afin d’identifier et d’organiser les enjeux récurrents. Les fréquences des thèmes sont présentées de manière descriptive afin d’indiquer leur importance au sein des organismes et non pour quantifier leur signification. Portant sur 55 organismes, 125 références codées aux obstacles à la prévention des maladies chroniques ont été synthétisées autour de 5 thèmes clés : les défis liés aux capacités organisationnelles et à la mise en oeuvre des programmes (n = 38), notamment le sous-financement chronique, la pénurie de main-d’oeuvre et des infrastructures limitées; les perturbations causées par la pandémie de COVID-19, qui ont entraîné un redéploiement du personnel et des interruptions de service prolongées (n = 30); les obstacles politiques et systémiques (n = 28), notamment l’ingérence politique et la mauvaise coordination entre administrations; les partenariats fragiles et la nécessité d’une collaboration intersectorielle plus forte (n = 16) et enfin les difficultés à mobiliser des collectivités diverses, les problèmes d’accès au numérique et le manque de programmes adaptés culturellement (n = 13). Les efforts en matière de prévention des maladies chroniques au Canada sont limités par des obstacles structurels, opérationnels et contextuels. Pour relever ces défis, il faut des investissements soutenus, des politiques cohérentes et des partenariats intersectoriels plus solides. Chronic underfunding and workforce shortages are major barriers to primary chronic disease prevention (CDP) across Canada. Policy fragmentation, political interference and weak interjurisdictional coordination continue to undermine long-term CDP capacity. The COVID-19 pandemic intensified existing challenges through staff redeployment and disruptions to CDP programs. Reaching diverse communities is hindered by digital inequities and a lack of culturally responsive approaches. Partnerships are essential but remain fragile, which emphasizes the need for more stable, crosssector collaboration frameworks. Le sous-financement chronique et la pénurie de main-d’oeuvre sont des obstacles majeurs à la prévention primaire des maladies chroniques à l’échelle du Canada. La fragmentation des politiques, l’ingérence politique et la faible coordination entre administrations continuent d’affaiblir les capacités en matière de prévention des maladies chroniques à long terme. La pandémie de COVID-19 a entraîné l’intensification des défis déjà présents en raison du redéploiement du personnel et des perturbations des programmes de prévention des maladies chroniques. Les inégalités numériques et le manque d’approches adaptées culturellement empêchent d’atteindre les collectivités dans leur ensemble. Les partenariats sont essentiels, mais demeurent fragiles, ce qui fait ressortir le besoin de mettre en place des cadres de collaboration intersectoriels plus stables.
This rapid review mapped how information and communication technologies (ICTs), particularly digital health applications, are being used within healthcare services for adults aged 55 years and older. Following the Joanna Briggs Institute methodology and guided by the Population-Concept-Context framework, studies published between 2016 and 2024 were identified and reported in accordance with the PRISMA extension for scoping reviews, based on a previously published protocol registered on the Open Science Framework. Nineteen studies were included after critical appraisal. The findings indicate that ICT use is most frequently associated with improved accessibility and coordination of healthcare services, support for health professionals' training and care management practices, and positive health-related outcomes for older adults, particularly in the domains of mental health, social participation, and self-care. However, the evidence remains heterogeneous and often limited in its reporting of design and implementation processes, highlighting the need for further context-sensitive research that addresses ethical, equity, and implementation considerations in the use of digital health technologies for older populations.
BackgroundSepsis affects an estimated 166 million people annually. Short-term survival has been the primary focus of research to date, yet individuals who survive acute sepsis face substantial long-term challenges, including chronic illness, physical disability, cognitive impairment, chronic organ dysfunction, cardiovascular events, and psychological disorders. These complications contribute to personal economic hardship, high healthcare utilization, frequent rehospitalization, and significant mortality rates.ObjectivesWe aimed to identify and summarize key interventions for sepsis survivors' post-hospital discharge - including physical rehabilitation, psychological care, provider assessments, monitoring, medication, and education - and to identify gaps in current evidence to elucidate future research priorities.MethodsA systematic scoping review was completed across five databases, supplemented with hand searching. Two reviewers independently screened and extracted data. Eligible studies focused on adult survivors of sepsis, where interventions were implemented after discharge from acute care, and included any research design.ResultsThirteen studies with four follow-up papers were included. Five reported on the impact of simultaneous intervention protocols, four on physical rehabilitation alone, and two on provider assessment and follow-up. The final two focused on psychological care, and pharmacotherapy. Mortality and readmission rates were the most common outcomes measured; satisfaction with care services, mental health outcomes, and cardiovascular event incidence were also evaluated. Qualitative study data was limited. Four studies mentioned intervention costs, but none completed a cost-benefit analysis. Based on a limited pool of evidence, protocolized multi-intervention approaches, provider assessment and follow-up, and physical rehabilitation show some promise in reducing hospital readmissions and improving long-term survival from sepsis. No interventions positively impacted sepsis survivors' mental health. Further, no studies evaluating educational interventions alone were identified.ConclusionsThis review highlights the need for more comprehensive, multidisciplinary post-sepsis care interventions. Future research should focus on patient education, mental health support, and cost-effectiveness analyses to inform evidence-based post-sepsis care strategies.
Undocumented immigrants are more than 5 times as likely as US citizens to be uninsured. Before 2020, undocumented young adults aged 19 to 25 years in California were eligible for restricted-scope Medi-Cal, which only covers emergency services. To examine the association of the California 2020 full-scope Medi-Cal expansion to young adults aged 19 to 25 years regardless of immigration status with coverage outcomes and to assess subgroup differences by race and ethnicity, sex, and age. This cross sectional study included American Community Survey respondents who were noncitizens aged 19 to 25 years before (2016-2019) and after (2021-2022) the policy's implementation in California; the treatment group was compared with California noncitizens aged 26 to 32 years and young adults aged 19 to 25 and 26 to 32 years from 6 comparison states (Arizona, Florida, Illinois, Nevada, New York, and Texas). Analysis was conducted from January 2024 to August 2025. California's 2020 Medi-Cal expansion. Triple difference analysis was used to estimate the association of the California Medi-Cal expansion with health insurance coverage (any, Medicaid, and private coverage) among noncitizens aged 19 to 25 years relative to California noncitizens aged 26 to 32 years and young adults in the 6 comparison states. The sample included 19 773 and 32 515 noncitizen American Community Survey respondents in California aged 19 to 25 years and 26 to 32 years, respectively, and 28 535 and 43 213 individuals aged 19 to 25 years and 26 to 32 years, respectively, residing in comparison states. Baseline weighted percentages for the 19- to 25-year treatment group included 52.1% (95% CI, 51.0%-53.2%) male, 31.9% (95% CI, 30.7%-33.0%) Asian non-Hispanic, 1.8% (95% CI, 1.5%-2.2%) Black non-Hispanic, 54.6% (95% CI, 53.4%-55.9%) Hispanic, 9.7% (95% CI, 8.9%-10.5%) White non-Hispanic, and 2.0% (95% CI, 1.6%-2.3%) other race non-Hispanic. Medi-Cal expansion was associated with a 4.2 (95% CI, 1.3-7.1)-percentage-point increase in Medicaid and a 3.5 (95% CI, 0.2-6.8)-percentage-point increase in any coverage. In subgroup analyses, percentage-point increases in Medicaid were statistically significant for Hispanic young adults (6.7 [95% CI, 2.6-10.9] percentage points), males (3.6 [95% CI, 0.1-7.1] percentage points), females (5.0 [95% CI, 0.7-9.3] percentage points), those aged 19 to 22 years (4.4 [95% CI, 0.7-8.1] percentage points), and those aged 23 to 25 years (4.0 [95% CI, 0.7-7.3] percentage points). In post hoc analyses, the estimates translated to increases in Medi-Cal and any coverage of 24.4 and 20.3 percentage points, or 30 665 and 25 554 young adults, respectively. In this cross-sectional study, the California 2020 Medi-Cal expansion was associated with significant coverage gains. Because the American Community Survey did not distinguish between restricted- and full-scope Medi-Cal, the analysis may have underestimated coverage increases, and further research is warranted to understand the health care and economic costs and benefits of California's expansion.
Methamphetamine use is prevalent among people with HIV (PWH) and complicates HIV care. Integrated substance use and HIV care services are recommended, yet rarely available. Contingency management (CM) is an evidence-based treatment for methamphetamine use, but its implementation within HIV primary care is limited. This study identified determinants and strategies to support CM implementation in HIV care. Key informants from an HIV clinic at an academic medical center (n = 15 patients; n = 15 providers) completed semi-structured interviews and a survey. A rapid qualitative analysis guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework identified implementation determinants, and potential strategies were classified using the Expert Recommendations for Implementing Change (ERIC) compilation. Both patient and provider participants rated CM as acceptable (M = 3.72 and 4.55/5) and appropriate (M = 3.85 and 4.54/5). Providers also rated CM as feasible (M = 4.08/5) and reported strong support for integrating CM into HIV care, citing the high priority of addressing methamphetamine use. Facilitators included the clinic's person-centered culture and providers' familiarity with substance use treatment. Barriers included perceptions that reinforcer values in standard CM protocols were low, limited staffing, and competing provider demands. Suggested implementation strategies included adapting CM (e.g., increasing reinforcer value), patient-directed outreach/advertisements, and provider education and support (e.g., reminders about CM availability and referral processes). Findings indicate strong support for integrating CM into HIV primary care, while noting challenges to implementation. Addressing these determinants through targeted multi-level implementation strategies may enhance CM adoption and sustainment in HIV care settings. El uso de metanfetamina es frecuente entre las personas con VIH (PCV) y complica su tratamiento. Aunque se recomiendan servicios integrados para el tratamiento de sustancias y el VIH, rara vez están disponibles. La gestión de contingencias (CM) es un tratamiento con evidencia para la metanfetamina, pero su implementación en la atención primaria del VIH es limitada. Este estudio identificó determinantes y estrategias para apoyar la implementación de CM en entornos de atención del VIH. Informantes clave de una clínica de VIH en un centro médico académico (n = 15 pacientes; n = 15 proveedores) completaron entrevistas semiestructuradas y una encuesta cuantitativa. Un análisis cualitativo rápido guiado por el marco Exploration, Preparation, Implementation, Sustainment (EPIS) identificó determinantes de la implementación, y las estrategias se clasificaron utilizando la compilación Expert Recommendations for Implementing Change (ERIC). Pacientes y proveedores calificaron la CM como aceptable (M = 3.72 y 4.55/5) y apropiado (M = 3.85 y 4.54/5); los proveedores también lo consideraron factible (M = 4.08/5) y apoyaron su integración en la atención del VIH, citando la alta prioridad de abordar el consumo de metanfetamina. Los facilitadores incluyeron la cultura clínica centrada en la persona y la experiencia previa de los proveedores en tratamiento de adicciones. Las barreras principales incluyeron el bajo valor percibido de los incentivos en los protocolos estándar de CM, la escasez de personal y las demandas concurrentes de los proveedores. Se propusieron estrategias como adaptar la CM (p. ej., aumentar los incentivos), divulgación dirigida a pacientes (p. ej., anuncios publicitarios) y formación y apoyo a proveedores (p. ej., recordatorios sobre la CM y aclaración de procesos de derivación). Los resultados muestran fuerte apoyo para integrar la CM en la atención primaria del VIH, aunque existen desafíos de implementación. Abordar estos factores determinantes mediante estrategias de implementación dirigidas y multinivel puede favorecer la adopción y sostenibilidad de la CM en entornos de atención del VIH.
Mental health nurses now work with growing volumes of measures, documentation screens, alerts and automated scores. More information does not always mean better decisions. When key cues are hard to find, nurses may spend more time searching, checking and reconciling, with less time available for judgement, continuity and therapeutic work. How can digital information be organised so that the most important cues are easier to see and use at the point of care without adding burden? This structured debates essay draws on literature on sociotechnical safety, measurement-based care, electronic record workload and burnout, and governance for clinical decision support. A five-gate Cognitive Firewall is proposed to shape what is shown at the point of decision: Relevance, Prioritisation, Trust, Context and Actionability. Together, these gates produce a task-specific Minimum Viable Data decision view. The aim is to reduce low-value noise, searching and verification work while keeping the full record available. Cognitive safety is framed as a practical mental health nursing concern, not only a technical design issue. The framework treats information overload as a safety problem that can be reduced through clear local rules and governance that do not add further burden. The framework can support safer, clearer work in triage, handover, discharge and follow-up by making recent change, current risk and next steps easier to see. Local services should pilot the gate rules in one high-burden workflow, co-design the decision view with frontline nurses and lived-experience perspectives, and evaluate workload, usability and safety before wider adoption.
Thailand's rapidly aging population highlights the urgent need for sustainable strategies to support older adults' independence in activities of daily living (ADLs). Occupational therapists (OTs) play a vital role; however, their limited availability restricts community-based service delivery. Village Health Volunteers (VHVs), embedded within local communities, provide ongoing support but lack structured guidance in ADL-focused care. This study is aimed at developing occupational therapy-informed practice guidelines that translate professional expertise into culturally relevant recommendations for community-based eldercare. A qualitative design using semistructured interviews was employed with 10 OTs in Chiang Mai, Northern Thailand. Participants were recruited through stratified and purposive sampling across urban, semiurban, and suburban settings. The inclusion criteria required a minimum of 5 years of clinical experience with older adults and direct involvement in ADL training. Data were collected between April and June 2024, transcribed verbatim, and analyzed thematically. Guiding questions were interpreted using the Occupational Therapy Practice Framework: Domain and Process, 4th Edition (OTPF-4), while additional inquiry explored broader community and cultural themes. Credibility was ensured through rapport building, audio recording, and member checking. OTs recommended adaptive techniques, environmental modifications, caregiver education, and assistive device integration. Culturally adapted solutions, such as Thai garments, bamboo ramps, and gradual modification of bathing practices, were emphasized to enhance acceptance and sustainability. This study provides structured, occupational therapy-informed guidelines to support ADLs among community-dwelling Thai older adults. Empowering VHVs through these recommendations may strengthen community-based eldercare, reduce caregiver burden, and promote active, dignified aging in place.
Camel production plays a crucial role in supporting the livelihoods and food security of pastoral and agro-pastoral communities across Ethiopia, Kenya, Somalia, and Djibouti in the Horn of Africa. This review systematically synthesizes peer-reviewed studies and regional reports published between 2000 and 2026, identified through structured database searches and screened using defined inclusion criteria, to evaluate camel milk production systems, traditional utilization, physicochemical and nutritional quality, safety, and value chain dynamics across the region. Camel milk is widely consumed raw or fermented and serves as a key dietary resource. Traditional practices across the region involve spontaneous fermentation for product formation, the production of sour milk products and camel milk tea, and the incorporation of camel milk into various local dishes; however, systematic documentation of these practices remains limited. Compared with bovine and caprine milk, camel milk generally contains lower fat and lactose levels, higher vitamin C and mineral concentrations, and distinct protein characteristics, including lower κ-casein content and the absence of β-lactoglobulin, which influence digestibility and processing properties. Reported fat content ranges from approximately 2.5 to 4.5% and protein from 2.5 to 3.9%, while vitamin C levels substantially exceed those of bovine milk. These features confer nutritional advantages but also create technological challenges, such as weak coagulation and extended fermentation time. Despite increasing urban and cross-border demand, the sector remains constrained by feed shortages, limited veterinary services, inadequate processing facilities, informal marketing systems, and hygiene limitations that contribute to microbial contamination. Key gaps include a lack of harmonized quality standards, limited comparative data on milk composition and microbiological safety, weak cold-chain infrastructure, and poor value-chain coordination. Strengthened hygiene, standardized quality protocols, improved processing and cold-chain systems, and coordinated institutional support are essential to enhance commercialization, safety, and regional integration.
Adequate blood supply remains a challenge in sub-Saharan Africa (SSA). Malawi has a 13% shortfall in required blood supplies. Innovative recruitment and retention strategies are crucial to ensuring a sufficient number of donors and blood supply. We explored alternative approaches to enhance blood donation in Malawi to bridge the gap. A qualitative exploratory design was utilised with a sample of 135 participants purposively selected in eight districts, in the Northern, Central, Southern and Eastern regions of Malawi. Data were collected using in-depth interviews with 20 participants (first-time and repeat donors, lapsed and non-donors), 20 key informant interviews with community, policy-level stakeholders, Malawi Blood Transfusion Service (MBTS) staff and 16 focus group discussions (involving 95 participants). Thematic content analysis was used to categorise the strategies, and a qualitative software data package (NVivo version 12) was used to organise the qualitative data. Donor education emerged as a key strategy for donor recruitment and retention. Other strategies included the formation of blood donor clubs in secondary schools and for post-secondary students, accountability mechanisms related to blood: its collection and management of blood and blood products, the provision of incentives and youth-friendly motivation strategies, including school competitions (quizzes and sports) and entertainment. The study emphasised the significance of blood donor education in encouraging blood donation. Participants' views suggest that developing innovative approaches for education to increase awareness and understanding of blood-donation processes may help motivate more individuals to donate. In addition, participants suggested other youth-friendly approaches to support blood donor recruitment, including providing incentives preferred by young people, introducing intra-school competitions and incorporating entertainment activities. These insights point to the potential value of developing innovative strategies to support blood donor recruitment efforts.
Physical activity is critical for health, yet many adolescents do not engage in regular activity. Youth with autism spectrum disorder (ASD) and intellectual disability (ID) may be at heightened risk due to motor, sensory, and social barriers, but less is known about complete disengagement. Using nationally representative data from the 2021-2023 National Survey of Children's Health, this study examined disparities in (1) any weekly physical activity and (2) participation in organized sport among transition-age youth (14-17 years) with ASD only, ID only, or ASD + ID, compared with youth without ASD or ID. Survey-weighted multiple logistic regression models estimated adjusted odds ratios (aORs) for each outcome, controlling for sex, race, household poverty ratio, metropolitan residence, and age. Compared to youth without ASD or ID, all diagnostic groups had significantly lower odds of engaging in any weekly physical activity (ASD only: aOR = 0.32, 95% CI: 0.24-0.44; ID only: aOR = 0.49, 95% CI: 0.31-0.76; ASD + ID: aOR = 0.51, 95% CI: 0.30-0.88; all p ≤ 0.02) and organized sport (ASD only: aOR = 0.20, 95% CI: 0.15-0.27; ID only: aOR = 0.31, 95% CI: 0.19-0.51; ASD + ID: aOR = 0.24, 95% CI: 0.14-0.41; all p < 0.001). Across both models and diagnostic groups, female sex, lower household income, and increased age were associated with lower physical activity and sport participation (all p ≤ 0.02), whereas non-metropolitan residence was associated with higher odds of sport participation-only (p = 0.005). These findings identify substantial disengagement among youth with ASD and/or ID and highlight the need for accessible, adapted physical activity and sport opportunities during adolescence to reduce risk of long-term inactivity. Adolescents with autism and/or intellectual disability are less likely to take part in weekly physical activity and sports than their peers without these conditions. Lower engagement was most pronounced for autistic youth without intellectual disability. The findings point to a need for more inclusive and sustainable physical activity and organized sport opportunities before support services decline in adulthood.
Mobility-related disabilities are the most prevalent disabilities in Saudi Arabia, significantly affecting quality of life. While mobility-assistive technologies (MATs) help mitigate impairments, unmet needs persist with a critical knowledge gap regarding barriers to their provision. This study investigated the barriers to the provision of MAT in the healthcare system of Saudi Arabia. This mixed methods study combined a cross-sectional survey with a qualitative embedded multiple case study across three public hospitals in two Saudi regions. The survey assessed MAT availability among 67 stakeholders and facilitated recruitment for the qualitative investigation. Semi-structured interviews were conducted with 33 participants (healthcare professionals [HCPs], managers and leaders), and six policy documents were analysed. The Consolidated Framework for Implementation Research (CFIR) guided data collection and analysis. The survey demonstrated that, while basic MATs were generally accessible, advanced devices were not and there were substantial regional disparities. The qualitative analysis identified 52 barriers across all CFIR domains, including dependence on imported devices, high costs and procurement delays, restrictive policies and regulatory ambiguities, insufficient professional healthcare training, inadequate strategic planning and clinical leadership, infrastructural constraints and sociocultural factors that influence patient acceptance. This study is the first comprehensive investigation of barriers to MAT provision in Saudi Arabia. These findings provide policymakers and practitioners with an evidence-based foundation for designing contextually relevant implementation strategies to enhance equitable MAT provision. Rehabilitation professionals require targeted education on MAT assessment and prescription to address identified knowledge gaps.Culturally sensitive education strategies are needed to address stigma regarding device use.Clear protocols defining roles and responsibilities across rehabilitation, administrative and procurement departments are essential to reduce coordination delays in MAT provision.Comprehensive services encompassing assessment, environmental evaluation, patient training and maintenance support are needed.