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Physiotherapists are frontline providers in supporting the return-to-work process of individuals with musculoskeletal disorders. However, many report feeling unprepared for work rehabilitation following entry-level training. This study explored recent physiotherapy graduates in Quebec, Canada, perceived preparedness to practice in work rehabilitation and its influencing factors. A convergent mixed methods design grounded in a competency-based framework was used. Recent graduates from physiotherapy programs completed a cross-sectional survey rating their perceived preparedness across seven work rehabilitation competencies. Semi-structured individual interviews explored how their training prepared them for work rehabilitation practice. Quantitative data were analyzed descriptively, and interviews were thematically analyzed. Findings were integrated through a joint display to contextualize preparedness ratings with qualitative insights. Twenty-five recent graduates from five physiotherapy programs across the province of Quebec completed both the survey and the interview. Perceived preparedness was highest for competencies on person-centered care and collaborative treatment planning, and lowest for psychosocial factors management, collaboration with involved actors, compensation system navigation, and return-to-work support. Three overarching themes influenced perceived preparedness: (1) role perceptions in work rehabilitation, (2) enablers such as supportive curriculum elements, and (3) challenges including stigma toward injured workers and limited work rehabilitation-specific training. A fourth theme described strategies to improve work rehabilitation training. Recent physiotherapy graduates reported varying levels of perceived preparedness for work rehabilitation, with the lowest ratings associated with managing psychosocial factors, collaborating with involved actors, navigating compensation systems, and supporting return to work. These gaps were linked to limited work rehabilitation training, perceived role ambiguity, and exposure to stigma. Future research should develop strategies to improve work rehabilitation training in physiotherapy programs.

Alternative meat products, including plant-based, insect-based products, and cultured meat, are gaining momentum as sustainable food innovations. Yet, the perceptions of political and institutional actors, key players in shaping regulation, legitimacy, and public discourse, remain poorly understood. This study fills this gap by examining how Romanian policymakers and public institutional actors understand sustainable protein transition using the SPECT framework (Social, Policy, Environmental, Commercial, Technological dimensions). Using qualitative thematic analysis of semi-structured interviews with 18 political and institutional actors, the research provides the first in-depth account of how governance elites in an Eastern European context interpret the sustainability, risks, and legitimacy of meat alternatives. The originality of this research lies in reframing political and institutional actors as active co-authors, rather than passive implementers, of sustainable food transition. The findings reveal a cautious but structured hierarchy of acceptance: plant-based products are perceived as "palatable bridges" to sustainability, whereas insect-based and cultured meat products provoke reactions ranging from curiosity to strong symbolic rejection. Concerns extend beyond health or naturalness to include food sovereignty, fairness for domestic producers, and the preservation of culinary identity. Findings highlight the concept of trust as the "currency of transition," showing that acceptance depends on credible institutions, transparent certification, and communication strategies grounded in local food traditions rather than globalist or "eco-elitist" narratives. Within the SPECT framework, social and policy dimensions proved more influential than technological or commercial ones, highlighting the primacy of cultural identity and institutional trust in shaping actors' perceptions. By situating Romania's case within the broader debate on just and inclusive food transition, the research provides new empirical evidence on how national identity, smallholder farming structures, and policy skepticism influence the political feasibility of adopting meat alternatives. The study concludes that aligning innovation with national food priorities through trust-based, inclusive policy design is essential for enabling a culturally embedded protein transition. Although the findings offer insights relevant to broader debates on sustainable protein transitions, their transferability to other national contexts is limited by Romania's specific cultural, institutional, and agri-food structures.

The use of digital health technologies holds potential benefits for palliative care. Their implementation is fundamentally shifting routines and care practices. These shifts entail social implications that are complex, may emerge gradually and are challenging to identify. However, the social implications of digital health technologies are not conceptualized yet. This study addresses this gap by developing a framework on the social implications of digital technologies in palliative care, where the importance of social inclusion and interpersonal connection is particularly evident. We assessed the potential social implications of digital health technologies’ use in palliative care through a sequential research design using qualitative empirical methods of social research. Alongside conducting an iterative narrative literature review, we held multidisciplinary expert consultations using a conceptual mapping method and focus groups involving researchers, clinicians, and a patient and public involvement group, analyzed with qualitative structured content analysis. Participants as well as the literature review identified key areas to the understanding and analysis of the social implications of digital health technologies in palliative care: principles and objectives of palliative care (patient-centered care, Total care, multiprofessional collaboration, relieving suffering, improving quality of life); the various actors involved in a specific care practice; the different roles they might have; the interactions among different actors; the tasks individual actors might carry out; the processes they are involved in; and the contexts they are embedded in. These factors were summarized and set out in the CARE-HOUSE Framework to conceptualize the social implications of digital health technologies’ use in palliative care and to support researchers in assessing the impacts of these technologies. The CARE-HOUSE Framework provides guidance for analyzing the social implications of digital health technologies in palliative care. It will be for future studies to evaluate the framework’s adaptability and scalability to diverse technologies and settings. The online version contains supplementary material available at 10.1186/s12904-026-02114-z.

Previous studies found that online communities are critical in supporting stroke survivors and caregivers for stroke recovery. However, it is unclear how such online communities are designed, or could be designed. This review aims to identify the key design elements of an online community to support stroke survivors and caregivers, that is, the actors, types of community support, and supporting technologies. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. We included journal articles related to online community support for stroke. Editorials, registers, opinion pieces, letters, and conference papers were excluded. Online databases PubMed/MEDLINE, Scopus, Web of Science, ScienceDirect, and ProQuest were searched for articles published from January 2015 to June 2025. Articles were screened based on the title, abstract, and full text using Covidence software. After screening and full-text review, we read the selected articles in detail to analyze and synthesize information on key actors, types of support, and technologies used to support stroke survivors and caregivers. A total of 77 articles were included. These articles discussed digital support technologies (52 articles), community functions and roles (18 articles), online stroke community systems (6 articles), and the stroke ecosystem (1 article). Our review found that the online community of support for stroke survivors and caregivers includes the caregivers themselves (46 articles), health workers (24 articles), and the local community/society (14 articles). Online communities mainly provide informational support, including giving advice (28 articles) and tangible aids (29 articles), followed by social support to create a sense of belonging (26 articles). Technologies discussed included mobile health (25 articles), web-based systems (12 articles), virtual/augmented reality (8 articles), sensors/wearable technology (8 articles), video-guided exercise apps (4 articles), and telehealth/telerehabilitation/teleconsultation/telestroke (4 articles). Only one examined how cultural differences influence technology. Although technologies are essential in online communities of support for stroke survivors and caregivers, this review shows a lack of studies that analyze the use and role of technologies in such online communities. This could be because the key actors of the online communities are the caregivers, who mainly seek social support and therefore do not require sophisticated technology. Nevertheless, technologies such as telerehabilitation and video-guided exercise apps could be important for other actors, including the local community and health workers, to enable them to support stroke survivors and their caregivers.

The pressure on publicly financed healthcare systems may necessitate decisions to not (or no longer) reimburse health technologies. Such decisions remain politically sensitive and often evoke public opposition, pressuring decision-makers to revoke or revise them. However, the elements that constitute public opposition remain unclear. This study addresses this gap by systematically reviewing the scientific literature. We searched Embase, Google Scholar, Google, and Startpage, and supplemented these with a hand search in 2021, updated in 2022 and 2024. Based on 81 articles, we developed a thematic framework of 21 categories grouped under the Five Ws-'Who, What, When, Where, and Why'-of public opposition to negative reimbursement decisions. Citizens, patients (and representatives), physicians, pharmaceutical companies, and politicians emerged as key actors. Opposition typically targets the outcomes and justifications of decisions, driven by high expectations, claims about effectiveness, or perceptions that decision-makers prioritize cost containment. Distrust in decision-makers and evidence-based decision-making may leave some actors-particularly citizens and patients-vulnerable to commercial driven information and misinformation. Other actors-including pharmaceutical companies, patient representatives, and politicians-may strategically use the media to shape opinion and amplify opposition. Public opposition is multifaceted. Understanding its dynamics may help align decision-making with public values and support efforts to address misconceptions and counter misinformation, thereby enhancing the acceptability of such decisions in healthcare.

Non-profit product development partnerships (PDPs) have succeeded in bringing nearly 80 new drugs, vaccines and diagnostics for neglected diseases through regulatory approval, but arrangements to ensure they reach patients are unclear since the usual commercial incentives do not apply. We conducted a case study of how unusually fast access was achieved to a new treatment regimen for drug-resistant tuberculosis (DR-TB) developed by the TB Alliance (TBA). Over 100 countries procured the regimen in quantities to reach 67% of global demand by 2024, 5 years after first regulatory approval and 2 years after the WHO recommended it for routine use. What interventions contributed to this rapid rollout, and what role did the PDP play? We analysed the academic and grey literature, internal documents from TBA, and conducted interviews with 21 key informants from 16 organisations. We identified relevant interventions and actors, constructed a timeline and analysed the role TBA played. We found TBA orchestrated a complex set of interventions implemented by dozens of actors over an 8-year time period across three categories: regulatory and normative guidance; market shaping for affordability and availability; and supporting country-level implementation through knowledge generation, knowledge sharing, stakeholder engagement and advocacy. Five attributes enabled TBA to do so: ability to generate and share knowledge about the product and regimen; non-profit status; ability to mobilise material resources for access interventions; pre-existing relationships and/or ability to develop new collaborative relationships; and intrinsic motivation to see the product reaching people with DR-TB. An orchestrator able to steer many actors towards the shared goal of reaching patients is critical in a complex ecosystem where no single organisation can realise access alone. Non-profit product developers can play this role well, including managing actual or perceived conflicts of interest, but require clearer mandates and financial support to do so.

Shared decision-making (SDM) is central to person-centred care, and particularly critical in oncology. Yet, its clinical implementation remains inconsistent. A strong theoretical foundation is essential for developing and sustaining effective SDM practices. Formal representation of theories enhances clarity and testability, enabling the accumulation of reliable evidence to support implementation. We systematically reviewed SDM models in oncology and formally mapped the constructs proposed, their definitions and operationalization, and the hypothesized relationships among them. Peer-reviewed articles describing SDM models in oncology were searched in PubMed, Embase, Web of Science, PsycINFO, CINAHL, and the Cochrane library. Constructs, definitions, and interrelationships were extracted and visualised using an ontology-based modelling system. Study quality was assessed using a modified QuADS tool. Findings were synthesised narratively. Twenty studies were included, spanning diverse methodologies and cancer localisations. A total of 225 constructs were identified. The models varied in focus, terminology, and detail. Nine models focused on the SDM process only, describing diverse sequences of steps using different terms, among which four common steps could be identified: exchange information; discuss alternatives; elicit patient values and preferences; and make a decision. Ten models included SDM determinants at patient-, clinician-, healthcare system- and treatment-level, and interpersonal and social factors. Six models included SDM outcomes such as satisfaction with care, decision or relationship, health and quality of life. Three models specified other components, i.e. SDM actors, goals or assumptions. Ambiguity in construct definitions and interrelationships was common, and several models lacked explicit theoretical propositions. Beyond the commonalities identified across models, the diversity and lack of formal specification of oncology-specific SDM models pose challenges for the development, evaluation and implementation of SDM interventions in practice. Given the theoretical fragmentation and current challenges in SDM implementation, advancing theory remains crucial to inform practice and improve patient outcomes.

Although universities worldwide are increasingly adopting health promotion strategies, there remains limited longitudinal evidence on how these initiatives are institutionally integrated and sustained over time, especially in Latin American contexts. This study explores the 24-year trajectory (1999-2023) of the first Health Promotion Policy implemented at a Chilean university, providing rare insights into a long-term bottom-up institutional process. In analytical terms, the VIVE UCN Evaluation Model was applied using the milestones (M), actors (A), processes (P), and challenges (C) (MAPC) framework, a convergent mixed-methods design that combined a qualitative documentary analysis of 47 official and unofficial sources with quantitative analysis using descriptive statistics. The MAPC framework was applied to documents from 1999 to 2023, including policy texts, management reports, and evaluation records, to systematically identify milestones, actors, processes, and challenges shaping the policy trajectory. Findings reveal that community participation and collective ownership were key to the policy's institutionalization, shifting health promotion from isolated initiatives into an educational and organizational commitment. By documenting a sustained, bottom-up experience from the Global South, this study contributes new longitudinal evidence to the field of health-promoting universities. Ultimately, integrating the health promotion policy into the educational mission demonstrates a long-term commitment to creating healthy settings and empowering the academic community to address the social determinants of health-both goals recommended by the World Health Organization for higher education institutions.

Gifted students often encounter challenges in receiving the education that they need. To enhance adequate educational interventions for gifted students, it is important to explicitly consider the involvement of and interactions between key actors, such as parents, teachers, and policy makers. This systematic review study sought to explore the involvement of these key actors in educational interventions for gifted students, and to illuminate the current understanding of the mechanisms and conditions underlying the involvement and interactions. Results showed that studies investigating teachers, and studies focusing on participants' attitudes, perspective, or view were most prevalent in the literature. Additionally, research focusing on all three actor groups (i.e., parents, teachers, and policy makers) was scarce, varied in quality, and was mainly focused on evaluation of diverse educational interventions. Content analysis of these three-actor studies revealed the following requirements for successful gifted education: clear policies, effective communication and collaboration between the school and the home environment, awareness among teachers and parents on the impact of their views on the students, professional development of teachers, and support for parents. Further research is needed to uncover the underlying mechanisms and conditions forming the effectiveness of these requirements.

The proliferation and pervasive use of artificial intelligence (AI) pose significant challenges to our democracies. In particular, AI leverages microtargeting political campaigns by constructing detailed user profiles and inferring people's individual susceptibilities from their data. This capability enables highly targeted political messaging that can substantially influence voting decisions, potentially undermining citizens' ability to make deliberative decisions in elections. While existing research has proposed interventions to mitigate the negative impacts of political micro-targeting, many of these interventions may become less effective as AI continually yields more powerful and subliminal forms of micro-targeting. Assuming that technologies can play a role in mitigating these negative impacts of AI, we conducted an explorative study to identify the design principles of technological tools that could facilitate citizens' deliberative decision-making in elections in the continuously levelaged AI-based political campaigns. Using Indonesia's 2024 elections as a case study, we interviewed twenty citizens and four political actors to gain critical insights into how such technologies might be developed. Initially, we anticipated that privacy-enhancing AI, used to counterattack profiling AI used by political actors, might suffice to facilitate election deliberation. However, our findings reveal a more complex reality: addressing societal issues through technology is inherently challenging; no single solution can serve as a silver bullet. Instead, facilitating election deliberation requires integrating privacy with other conditions, including self-reflection, education, access to diverse information, critical thinking, and openness to others. These design principles might serve as concrete, actionable design principles to guide the development of technologies to enhance election deliberation.

Self-rated health (SRH) is a widely used indicator of overall health and a robust predictor of morbidity and mortality. Although metabolic health and obesity are well-established determinants of SRH, most previous studies have examined these factors at the individual level. This study investigated how spousal metabolic phenotypes, defined by metabolic and weight status, are jointly associated with SRH among Korean adults. We analyzed nationally representative data from 1817 heterosexual couples. Participants were classified into four phenotypes: metabolically healthy normal weight (MHNW), metabolically healthy obesity (MHO), metabolically unhealthy normal weight (MUNW), and metabolically unhealthy obesity (MUO). We applied actor-partner interdependence models (APIM) and couple-level analyses to assess associations with worse SRH, adjusting for sociodemographic factors, health behaviors, perceived stress, and comorbidities. Among husbands, the MUNW phenotype was significantly associated with worse SRH, with marginal partner effects were observed when wives were MUNW. Among wives, both MUNW and MUO were significant predictors of worse SRH, whereas partner effects were not significant. At the couple level, husbands had higher odds of worse SRH across all non-MHNW couple combinations, whereas wives had higher odds only in discordant couples in which the wife was non-MHNW and the husband was MHNW. Sensitivity analyses among older couples confirmed these findings. These findings highlight gender-specific actor and partner effects and suggest that couple-level metabolic profiles may shape SRH, underscoring the importance of considering spousal metabolic status in its assessment.

Lymphocytes, long regarded as central actors of adaptive immunity, are increasingly recognized as key regulators of the foreign body response (FBR) to biomaterials. Their presence shapes the chronic phases of inflammation, fibrosis, angiogenesis, and regenerative outcomes after implantation. This review summarizes the roles of T cells, B cells, and natural killer (NK) cells in biomaterial-associated immune responses, with a particular focus on protein adsorption, antigen recognition, cytokine secretion, and downstream interactions with macrophages, fibroblasts, and endothelial cells. Evidence indicates that T-cell polarization into Th1/Th17 subsets promotes pro-inflammatory reactions, while Th2 and regulatory T cells (Tregs) support constructive remodeling and resolution. B cells contribute through antibody production and cytokine release, which may foster fibrosis or support debris clearance. NK cells serve as early stress sensors, releasing cytotoxic mediators and pro-angiogenic factors that influence vascularization and tissue repair. Collectively, lymphocytes are pivotal but underexplored players in biomaterial integration. Incorporating lymphocyte biology into material design and surface modification strategies offers promising avenues to guide immune cascades toward predictable and regenerative outcomes.

Forest disturbances are increasingly understood as social-ecological phenomena involving diverse actors. Here, we focused on one of the Europe's largest recent disturbances-the drought-triggered bark beetle outbreak in Central Europe (2017-2022). Based on a survey of 165 respondents, we examined perceived disturbance drivers, response actions, and the alignment between them as an indicator of a value-action gap that is often present in social-ecological and governance systems. Climatic and forest structure-related factors were identified as the dominant drivers, aligning with current scientific understanding, whereas socio-economic and management constraints were perceived as less influential. Reported responses reflected awareness of climate-change risks and involved workforce training, adaptive change in species composition, and water-retention measures. Cause-action alignment was observed in nearly half of respondents, particularly among managers and legal entities. We found a relatively sound understanding of disturbance causes and corresponding responses, likely shaped by recent experience with an unprecedented disturbance impact.

China's Rural Toilet Revolution, despite strong central support, reveals persistent challenges in sustaining policy integration within a complex, multi-level governance system. This study, based on process-tracing and fieldwork in Shaoguan, emphasizes the strategic agency of local governments in managing integration and develops a typology of integration fluctuations along two dimensions: vertical cross-level versus horizontal cross-departmental integration, and political authority versus social network drivers. Four patterns emerge-Bureaucratic Pressure-Driven, Differential Penetration-Driven, Institutional Regulation-Driven, and Network-Embedded Integration-demonstrating that fluctuations are not policy failures but adaptive responses to institutional tensions. Local governments actively reshape policy frames to align objectives, coordinate subsystems, and mitigate accountability risks. These frames serve a dual function: as tools for consensus-building and as sources of institutional legitimacy that shield actors from blame in cross-jurisdictional collaboration. The study advances policy theory by revealing how subnational actors navigate governance complexity and offers practical insights for designing resilient policy architectures in hierarchical systems where integration must be continuously renegotiated.

Insect resistance management (IRM) for Bt corn (Zea mays L.) has traditionally emphasized grower compliance with non-Bt refuge requirements. However, this framing overlooks the broader agricultural system that shapes refuge outcomes, including the US Environmental Protection Agency, seed companies, trait providers, seed dealers and agricultural retailers, and Cooperative Extension. As a result, refuge outcomes are often treated as individual behavioral failures rather than system-level design challenges. We argue that sustaining Bt susceptibility requires shifting from a grower-centric compliance model to a systems perspective in which refuge outcomes are co-produced by multiple actors. Within this sociological context, we then situate a recent US Environmental Protection Agency proposal requiring growers to purchase non-Bt corn seed with Bt corn seed as an example of how policy can reshape responsibility for refuge implementation. While this approach moves refuge planning earlier in the decision process, it does not fully address the economic, logistical, and institutional constraints that influence how refuge is ultimately implemented. We identify opportunities to improve IRM through coordinated system-level interventions, including integrating social science into policy design, improving transparency of non-Bt hybrid performance, aligning non-Bt seed offerings around a smaller set of hybrids with flexible management traits, and exploring system-level design options, such as track-and-trace mechanisms, to ensure that non-Bt seed is sold and distributed in appropriate quantities. Together, these approaches emphasize shared stewardship to sustain Bt susceptibility as a common-pool resource, rather than reliance on individual grower compliance.

Active navigation involves direct control over movement and decision-making, whereas passive observation entails viewing another individual's exploration. Although active engagement is often assumed to benefit spatial learning, findings in desktop virtual environments remain mixed. This study examined whether active exploration versus passive observation differentially influences spatial knowledge acquisition in a desktop virtual navigation task, and whether exploration quality or individual differences in cognitive ability account for performance variability. Participants either actively navigated a virtual environment using a joystick or passively observed a yoked recording of another participant's navigation, ensuring identical visual input across conditions. Spatial knowledge was assessed using an overhead map drawing task and a route recall task. Across outcomes, actors and observers did not differ significantly in overall map accuracy or route recall, nor did they have any advantage for active navigators on any map drawing components. Exploration quality did not predict spatial learning for either group. In contrast, mental rotation ability consistently predicted better map drawing performance and fewer route recall errors, independent of learning condition. These findings indicate that, under desktop virtual navigation conditions with minimal motor demands, active exploration does not confer a substantial advantage over passive observation, and that individual differences in spatial ability are a more reliable predictor of spatial learning performance.

Artificial turf systems have become increasingly widespread in urban environments, providing durable and weather-independent surfaces for a wide range of sports. Yet, their multi-material composition poses critical challenges for sustainable end-of-life management. A growing number of industrial actors are developing recycling solutions, but these efforts remain fragmented and only partially documented. The present review examines the current state of artificial turf recycling through a systematic literature review complemented by expert interviews with industry stakeholders. The holistic examination of contemporary artificial turf recycling processes reveals that the separation of major components-namely turf carpet, performance infill, and stabilising infill-along with their diverse polymer fractions, is imperative to achieve high-quality secondary materials. Nevertheless, this process remains technologically and economically demanding due to the high complexity and variety of products. Current practices often face limitations in terms of recycling efficiency, transport logistics, and the lack of standardised data, which in turn affects recycling practice, life cycle assessments and policy evaluation. This review makes a significant contribution to the field by providing a detailed mapping of European practices at a level of technological detail not previously published. It highlights challenges and identifies research gaps concerning materials, products, processes and assessment methodologies. It provides a more profound understanding of the environmental implications of artificial turf recycling and outlines pathways for advancing sustainable waste management strategies in the artificial turf sector. Furthermore, it addresses the internal tensions within this highly competitive industry.

Cytotoxic T lymphocytes eliminate infected or malignant cells, safeguarding surrounding tissues. Although experimental and systems-immunology studies have cataloged many molecular and cellular actors involved in an immune response, the design principles governing how the speed and magnitude of T cell responses emerge from cellular decision-making remain elusive. Here, we recast the T cell response as a feedback-controlled program, wherein the rates of activation, proliferation, differentiation, and death are regulated through antigenic, pro- and anti-inflammatory cues. By exploring a broad class of feedback-controller designs as potential immune programs, we demonstrate how the speed and magnitude of T cell responses emerge from optimizing signal-feedback to protect against diverse infection settings. We recover an inherent trade-off: infection clearance at the cost of immunopathology. We show how this trade-off is encoded into the logic of T cell responses by hierarchical sensitivity to different immune signals. Notably, we find the designs that balance harm from acute infections and autoimmunity produce immune responses consistent with the experimentally observed patterns of T cell effector expansion in mice. Extending our model to immune-based T cell therapies for cancer tumors, we quantify the trade-off between the affinity for tumor antigens ("quality") and the abundance ("quantity") of infused T cells necessary for effective treatment. Finally, we show how therapeutic efficacy can be improved by targeted genetic perturbations to T cells. Our findings offer a unified control-logic for cytotoxic T cell responses and point to specific regulatory programs that can be engineered for more robust T cell therapies.