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National guidelines (e.g., the U.S. Preventive Services Task Force) and public health organizations (e.g., the Centers for Disease Control and Prevention) recommend population-level family cancer history screening to enhance hereditary cancer risk assessment. Despite over a decade of statewide implementation in Georgia, participation in and the impact of family cancer history screening in rural public health clinics remains limited, highlighting the need for systematic adaptation of existing program delivery approaches. Furthermore, the application of implementation frameworks to the documentation and evaluation of adaptations in genomic service delivery is infrequent. In this report, we apply the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to systematically document multilevel adaptations aimed to increase access to Georgia's statewide family cancer history screening program for BRCA-associated cancers among women in rural Georgia. We conducted a 14-month adaptation process in the Southwest Public Health District of Georgia from November 2023 to January 2025. Using the FRAME, we systematically documented adaptations in five steps: (1) stakeholder identification, (2) multilevel needs assessment, (3) development of prototype adaptations, (4) adaptation validation and prioritization through stakeholder deliberation, and (5) pilot testing. We convened a stakeholder committee (n = 15) representing multiple levels of healthcare delivery, including patients, internal stakeholders from 14 public health clinics in the district, and external stakeholders from regional cancer coalitions and healthcare systems. A total of 15 adaptations were prioritized across individual (n = 2), provider (n = 1), clinic (n = 7), organization (n = 3), and community (n = 2) levels. Most adaptations focused on implementation and scale-up activities (n = 10), followed by changes to contextual modifications (n = 4) and communication content (n = 1). Key adaptations included new outreach (e.g., posters, phone scripts, social media), streamlined screening workflow (e.g., simplified data entry, automated referrals), and integration of theory-based, risk-stratified communications about screening results. Strong partnerships between public health agencies, community organizations, and academic institutions were essential to guiding our adaptation process. By combining implementation frameworks, multilevel stakeholder engagement, and proactive pre-implementation adaptation, our study offers a replicable, stepwise approach for adapting, scaling up, and sustaining other hereditary cancer screening programs in underserved public health settings.

Child survival is a critical indicator for a nation's health and its progress is important in attaining the Sustainable Development Goals. Understanding the regional and country-specific dynamic and interplay of various determinants of under-five child mortality is vital for the African continent, which remains one of the most vulnerable regions for child mortality globally. This study investigates the association of economic, health-related, social and demographic, environmental, and infrastructure-related factors with under-five child mortality. It integrates generalisable regional associations using a standard fixed-effects panel model and examines illustrative country-specific associations of the selected determinants through multiple linear regression, based on a balanced panel dataset of 45 countries over a 22-year period. Fixed-effect analysis reveals that the diphtheria-tetanus-pertussis (DTP) immunisation and total fertility rate (TFR) are robust regional determinants of under-five mortality across specifications. While health expenditure, sanitation services, and malaria incidence show significant associations in the baseline model, these findings are sensitive to the inclusion of year fixed effects, suggesting they are influenced by broader temporal trends or common regional shocks rather than serving as stable independent factors within the study period. Regional analysis, which controls for unobserved country-specific heterogeneity over an extended period and is complemented by country-specific analysis, facilitates the formulation of policy implications at both national and international levels. Recommended policy measures include increasing immunisation coverage, implementing malaria control programmes, strengthening community health infrastructure, enhancing girls' education, promoting widespread access to modern family planning, and improving sanitation services. These strategies are expected to contribute to the progress toward Sustainable Development Goal 3.2 in the African region.

Sub-Saharan Africa has the highest maternal death rate worldwide. Access to quality healthcare for pregnant women can significantly reduce the number of maternal deaths. There is limited evidence on barriers to healthcare access, particularly among pregnant women in countries with a high burden of maternal mortality. Therefore, this study intended to examine the magnitude of barriers to healthcare access among pregnant women in high and very high maternal mortality countries in sub-Saharan Africa. This study employed a population-based cross-sectional study design. Data was gathered from the latest Demographic and Health Surveys data of the top 15 high and very high maternal mortality sub-Saharan African countries. A total weighted sample of 21,079 pregnant women were participated. A multilevel modified poison regression analysis model was fitted. Adjusted Prevalence Ratio (APR) with a 95% confidence interval and a P-value of less than 0.05 was used to declare statistical significance. This study revealed that 65.08% (95% CI: 64.43-65.72) of pregnant women in high and very high maternal mortality sub-Saharan African countries have barriers to healthcare access. In this study, age 15-24 (adjusted prevalence ratio [APR] = 1.12, 95%CI: 1.06-1.18), no education (APR = 1.53, 95%CI: 1.37-1.73), primary education (APR = 1.35, 95%CI: 1.49-1.82), secondary educational (APR = 1.48, 95%CI: 1.36-1.62), poor wealth quantile (APR = 1.76, 95%CI: 1.65-1.88), middle wealth quantile (APR = 1.30, 95%CI: 1.23-1.41), partner's no education (APR = 1.18, 95%CI: 1.06-1.30), partner's primary education (APR = 1.16, 95%CI: 1.04-1.34), unmarried (APR = 1.13, 95%CI: 1.08-1.21), no health insurance (APR = 1.59, 95%CI: 1.24-1.94), not autonomous in household decision making (APR = 2.12, 95%CI: 1.32-2.88), unwanted pregnancy (APR = 1.20, 95%CI: 1.06-1.40), rural resident (APR = 1.25, 95%CI: 1.17-1.33), community level of women's education (APR = 1.31, 95%CI: 1.16-1.51), low poverty status (APR = 1.86, 95%CI:1.20-2.52) were significantly associated with barriers to healthcare access. Our findings concluded that two-thirds of women in high and very high maternal mortality sub-Saharan African countries have barriers to healthcare access. Women's barrier to healthcare access was affected by individual and community-level factors. Our findings recommend that empowering women by enhancing their education and reducing poverty can help mitigate women's barriers to healthcare access. Moreover, healthcare policymakers and stakeholders should improve healthcare infrastructure and the availability of healthcare services in rural areas.

Community-based medical education and research services (COBMERS) place medical students in primary health care facilities to strengthen their skills in community health service delivery, teamwork, leadership and professional ethics within limited-resource settings. Beyond training, COBMERS enables universities to generate evidence on local disease epidemiology, transmission dynamics, and control practices, resulting in a tangible, contextualized impact on the communities. There is however limited data on disease profile in Teso subregion, with limited epidemiological research in the area. This prospective study aims to profile the disease burden in the Teso subregion through COBMERS, thereby informing community-level interventions and health policy. The study will employ convergent parallel mixed-methods design, integrating quantitative and qualitative approaches. Quantitative components will include cross-sectional surveys to determine prevalence of non-communicable diseases (NCDs), neglected tropical diseases (NTDs), and infectious diseases, complemented by prospective cohort studies to assess temporal trends. Qualitative data will be gathered through focus group discussions and key informant interviews to explore community perceptions, health system capacity, and effectiveness of preventive measures. A community-based participatory research (CBPR) approach will guide all phases, ensuring that research is co-designed with community members, health practitioners, and local authorities. Medical students, under the supervision of faculty and site mentors, will serve as primary data collectors, integrating research with their COBMERS training. The study is expected to provide evidence on the prevalence, trends, and risk factors of major diseases in the Teso subregion, alongside community perspectives on health priorities and barriers to care. Findings will stir up debates to inform tailored interventions, strengthen primary health care, and guide policy formulation. Additionally, embedding research within COBMERS is expected to build local research capacity among site mentors and students, fostering sustainability and continued community-university collaboration. This protocol therefore provides an integrated framework that combines epidemiological surveillance, community engagement, and capacity building. By leveraging COBMERS and CBPR, the study seeks to provide actionable evidence to reduce the burden of NCDs, infectious diseases, and NTDs while promoting health system resilience in Eastern Uganda.

Accurate identification of modifiable risk factors for child malnutrition is of great importance in the formulation of policies to protect children's health in South Asia. Current research has developed an innovative analytical system that uses deep learning algorithms to accurately assess the nutritional status of children and its relevance to indoor parental smoking pollution, at threshold level in South Asia. Data on 219,168 under-five children were analyzed from recent (2016-2022) nationally representative Demographic and Health Survey (DHS) for five South Asian countries: Bangladesh, India, Maldives, Nepal, and Pakistan. Our method first applied a comprehensive pre-processing and feature engineering pipeline to detect key risk patterns. By conducting a thorough benchmark of 16 deep learning models, the Bayesian Neural Network (BNN) was identified as the optimal model for predictive inference and risk quantification. The BNN analysis, supported by Mesh query graphs, showed strong co-association of parental exposure (tobacco smoking) and child undernutrition. Moreover, the association was dose-dependent in that predicted risk for child malnutrition increased substantially when the frequency of cigarette smoking exceeded ten cigarettes per day. This study importantly found that the marginal risk of malnutrition increases by 3.2 times with additional consumption of cigarette after threshold. There is a strong joint association between child malnutrition and parental smoking. Additionally, less than equal to 10 cigarettes considered the threshold smoking level, greater than 10 cigarettes per day higher the risk of malnutrition by 3.2% with additional cigarette consumption. This evidence provides considerable leverage for policymakers as our results suggest that modern AI methods can effectively inform interventions targeted at increasing the prevalence of smoke-free homes and improving child nutrition in South Asia. Not applicable. This study is a secondary analysis of publicly available, de-identified data from the Demographic and Health Survey, and does not report the results of a prospective health care intervention.

Hospital morbidity data are used for hospital reimbursement in many countries and are also critical for epidemiological profiling and health planning, both of which depend on data quality. Exploring the clinical coders' perspective is crucial for implementing targeted interventions in this field. To identify the main factors influencing the quality of health registries, the coding process and data quality, from the perspective of clinical coders in Portugal. We conducted a nationwide online survey of clinical coders, informed by prior focus groups and a literature review, to assess their perspectives on the quality of health records, the clinical coding process, and coded data. A total of 162 responses were obtained. Respondents primarily used electronic health records, including discharge notes, clinical diaries, and surgical reports. Common problems in health records included "copy-paste" practices (67%) and the use of unspecified acronyms (52%). Incomplete records, inconsistent information, and the lack of support affected coding quality. Half agreed that a reduction in the number of coders contributed to delays. Financial incentives for quality, software availability, and frequent internal audits were identified as priority measures to improve data quality. This study highlights the importance of clinical documentation for coding accuracy. Despite the use of electronic health records and the transition to ICD-10-CM/PCS, difficulties such as "copy-paste" practices and the use of unspecified acronyms persist. Continuous training, standardisation of documentation practices, and collaboration between clinical coders and other health professionals are essential to ensure coding accuracy. These problems and potential improvements may affect national policymaking and initiatives such as the European Health Data Space and international health prioritisation.

Food environments influence dietary behaviors and nutritional health outcomes. Food deserts, areas characterized by limited spatial access to healthy foods, and food swamps, areas where unhealthy outlets predominate, present challenges to the adoption and maintenance of a healthy diet. This study analyzed trends in access to healthy and unhealthy food environments in neighborhoods and around schools in Wallonia, Belgium, over the period 2008-2024. The region remains understudied and offers a particularly insightful case due to its mix of urban and rural areas. We combined data on geocoded food outlets (Locatus database), short chain initiatives (LogCiCa), schools, road networks, residential addresses and area socio-demographic characteristics to identify and quantify food deserts, food swamps and the food environment within 1000m around schools across the study region. Potential food deserts were defined as areas lacking a supermarket within 1000 m road distance and a bus stop within 500 m, while actual food deserts additionally required high proportions of low-income households or elderly (65 years and older). Food swamps were quantified using the modified Retail Food Environment Index (mRFEI). Food environments around 4,696 schools were assessed using 1000 m road-network buffers. Temporal trends were evaluated using linear regression. Between 2008 and 2024, approximately 11% of households lived in potential food deserts, with fewer than 2% residing in actual food deserts. In contrast, food swamps were widespread: in 2024, 52.2% of households were located in sectors where unhealthy outlets outnumbered healthy ones. Sectors with high proportions of elderly residents or children were disproportionately affected. Around secondary schools, traditional fresh food retailers declined substantially (fruit and vegetable stores - 60%), while takeaway and delivery outlets increased threefold. By 2024, over 90% of secondary schools were located in predominantly unhealthy food environments within walking distance. In Wallonia, exposure to unhealthy food environments is widespread and persistent, particularly around schools and in socio-demographically vulnerable areas, while food deserts remain relatively rare. Policy efforts addressing the density and spatial distribution of unhealthy outlets may contribute to reducing dietary inequalities and improving population health.

Australia's increasingly diverse population includes a nearly one third from Culturally and Linguistically Diverse (CALD) backgrounds, who often face significant challenges in accessing and utilizing healthcare services, particularly for non-communicable diseases (NCDs). These challenges stem from various factors including understanding and communication barriers in English, cultural differences, limited health literacy and healthcare system related limitations. This project aims to co-develop and test a culturally responsive community-based, multi-packaged model of care to enhance access to and utilization of health services for common NCDs (screening of hypertension and diabetes mellitus, and initiation of treatment for those diagnosed) among CALD communities in Australia. This project will follow a four-phased approach, based on the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Other complementary frameworks including the consolidated framework for implementation research will also be utilized depending on contextual requirements. In Phase I, formative research will be conducted through a scoping review, quantitative survey, and qualitative interviews with service users and healthcare providers to identify successful care models, service preferences, and key facilitators and/or barriers to service access and utilization. Phase II of the project will focus on co-developing a culturally responsive care model informed by the findings of the first phase, which will then be reviewed and standardized with input from stakeholders, including healthcare providers and CALD community members. The Phase III activities will involve capacity building and collecting baseline data and implementing the care model. Finally, in Phase IV, implementation outcomes will be assessed by collecting follow‑up data using the same tools from Phase III, but not necessarily from the same individuals. The quantitative follow up window for outcome assessment is 6 to 12 months after site activation, with any longer activity focused on qualitative work, sustainment assessments, and dissemination. Overall, this project may play a pivotal role in enhancing the accessibility, quality, and cultural responsiveness of healthcare for CALD communities and reducing health disparities. We believe the lessons learned and the model developed through this process will be useful not only in Australia but also in other countries with similar multicultural communities.

Phthalates, parabens, benzophenone-3, bisphenols and triclosan are among the contaminants suspected of being involved in several hormone-related pathologies. In developing countries, weak regulations and lack of a precise monitoring plan lead to exposures that could be much worse than in developed countries. The objectives of this study were to evaluate the level of exposure of the adult population of Kinshasa in the Democratic Republic of the Congo to these compounds and to assess the health risk induced by these pollutants. Concentrations of four parabens, nine phthalate metabolites, two non-phthalate plasticizers, benzophenone-3, three bisphenols and triclosan were assessed in the urine of 145 volunteers recruited between November 2022 and January 2023 in Kinshasa. Measurements were performed using a liquid or a gas chromatography coupled to a mass spectrometer. Methylparaben (MeP: 62.6 μg/L), mono-n-butyl phthalate (MnBP: 78.1 μg/L) and bisphenol A (BPA: 1.54 μg/L) were detected in over 95% of urine samples, with exposure levels exceeding those observed in Western populations. For BPA and MnBP, 100% and 15% of the study samples, respectively, exceeded human biomonitoring guidance values (HBM-GV) proposed by the European Human Biomonitoring Initiative (HBM4EU) consortium, meaning that their exposure levels are associated with health concerns. The exposure of the population of Kinshasa to these pollutants merits consideration, as it constitutes a serious public health concern. To enhance protection, regulatory measures must be implemented and large-scale studies and awareness campaigns must be conducted.

Gallbladder cancer (GBC) is highly fatal and, unlike most cancers, is more common in women than in men. Most GBC cases have gallstones, but most people with gallstones do not develop GBC. Thus, a critical question is what drives the risk of GBC in the presence of gallstones. We designed a case-control study to complement the Chile Biliary Longitudinal Study (Chile BiLS) cohort, enriching the number of GBC cases and enhancing our ability to evaluate risk factors for GBC. Starting in July 2022, we began to recruit non-cohort prevalent (diagnosed between January 1, 2016, and July 18, 2022) and incident (diagnosed on or after July 19, 2022) GBC cases, as well as patients with high-grade dysplasia (HGD), in a high-risk area of Chile. Individuals with GBC or HGD are considered cases (HGD +). We are matching gallstone cholecystectomy patients to cases at an approximate 1:1 ratio. We also include unmatched controls (adjudicated) who were initially suspected of having cancer but had benign findings on gallbladder pathology. If a case or control is deceased, we conduct proxy interviews to maximize the potential for detailed epidemiological data collection. Through August 31, 2025, we recruited 196 prevalent and 117 incident HGD + cases. Of these cases, 189 (96%) prevalent and 108 (92%) incident cases were diagnosed with GBC. All prevalent and 98.3% of incident cases have matched controls. Participation rates are 70.8% for HGD + cases and 67.8% for matched controls. The Chile BiLS case-control study is conducted in an area with high risk of GBC and a high proportion of people with Mapuche Amerindian ancestry. This study will provide important insights into the factors associated with GBC among people with gallstones. Here, we provide a thorough description of the design of the study, field procedures, and biological resources, as well as research opportunities, which will enable a more complete picture of the etiology of GBC by combining epidemiological, molecular, digital imaging, and clinical data. This study represents a powerful resource for the identification of new targets for cancer prevention and treatment, which are particularly needed in populations at high risk of GBC.

Fertility rates in Somalia are among the highest globally, posing significant challenges to maternal and child health and sustainable development. However, there is limited evidence regarding the specific drivers of high fertility. This study aimed to identify the factors associated with the number of children ever born among Somali women of reproductive age to inform reproductive health policies and programs. A cross-sectional analysis of a nationally representative household survey was performed. We analyzed the weighted data of 27,352 women aged 15-49 years who participated in the 2020 Somali Health and Demographic Survey. The number of children born was defined as the total number of live births and was modeled as a count outcome. Owing to overdispersion, survey-adjusted negative binomial regression was used to estimate unadjusted and adjusted incidence rate ratios with 95% confidence intervals for demographic, socioeconomic, reproductive, and geographic factors. The mean number of children born was 6.22. Higher education level showed the strongest inverse association (higher vs. none: incidence rate ratio = 0.154; 95% confidence interval: 0.049-0.487). A later age at first birth (> 20 vs. ≤20 years) and literacy were associated with fewer children ever born (incidence rate ratio = 0.913; 95% confidence interval: 0.902-0.923, and incidence rate ratio = 0.965; 95% confidence interval: 0.939-0.991, respectively). Compared with rural residents, urban women had more children ever born (incidence rate ratio = 1.019; 95% confidence interval: 1.003-1.035), whereas nomadic women had fewer (incidence rate ratio = 0.979; 95% confidence interval: 0.965-0.993). Women in the middle wealth quintile had more children ever born than the poorest women (incidence rate ratio = 1.033; 95% confidence interval: 1.021-1.046). Compared with current modern method users, non-users intending future use and non-users with no intention to use had more children ever born. Fertility rates in Somalia remain high and are shaped by structural and behavioral factors. Expanding girls' education, delaying childbearing, improving literacy, and ensuring equitable access to contraception may help reduce fertility and improve population health.

Maternal disorders remain a critical public health challenge in sub-Saharan Africa, accounting for disproportionate maternal mortality despite global progress. This study examined regional inequalities and temporal trends in maternal disorders across sub-Saharan Africa from 1990 to 2023 using the Global Burden of Disease 2023 data. Age-standardized disability-adjusted life years and death rates per 100,000 population were extracted for 11 maternal disorder causes across 46 sub-Saharan African countries classified into four subregions (Western, Eastern, Central, and Southern Africa). Cause of Death Ensemble modeling and DisMod-MR 2.1 were used to generate mortality and morbidity estimates. Temporal trends were assessed using percentage change calculations, and geographic distributions were mapped using choropleth visualizations. Subregional inequalities were quantified by comparative analyses of absolute and relative disparities. In 2023, maternal disorders accounted for 1,601.9 disability-adjusted life years and 25.8 deaths per 100,000 population region-wide, with substantial subregional variation. Central Africa exhibited the highest burden (2,592.6 disability-adjusted life years; 42.7 deaths per 100,000), followed by Western Africa (1,889.6; 30.9), Eastern Africa (1,204.4; 18.7), and Southern Africa (586.3; 9.4). Maternal hemorrhage, sepsis, and hypertensive disorders were the leading causes. From 1990 to 2023, the overall burden declined by 60%, driven primarily by Eastern Africa's 76.6% reduction in disability-adjusted life years. Central and Western Africa achieved moderate declines (42.8% and 50.2%, respectively), whereas Southern Africa experienced increases in specific causes, including hypertensive disorders (33.5%) and HIV-aggravated maternal deaths (241.5%). Despite remarkable progress, profound regional inequalities persist in the burden of maternal disorders across sub-Saharan Africa. Achieving Sustainable Development Goal 3.1 requires strengthened health systems, universal access to quality obstetric care, expanded reproductive health services, and targeted interventions that address subregion-specific maternal health challenges.

Depression is among the most prevalent mental disorders worldwide and is associated with an increased risk of mortality from all causes and from specific causes (cardiovascular disease or suicide). The aim of this study was to analyze whether depression is a risk factor for all-cause and cardiovascular disease (CVD) mortality in a representative sample of the Spanish population, considering also the competing risk of depression in both CVD mortality and other causes that are not CVD mortality. We used the data of 4,753 individuals from the Edad con Salud study, recruited between 2011 and 2012, and followed up on three occasions. We included sociodemographic, healthy lifestyle, and chronic conditions variables. The association between depression and all-cause mortality was assessed using hazard ratios obtained from Cox regression, and the association between depression with CVD and non-CVD mortality was assessed using sub-hazard ratios from Fine-Gray models for competing risks. A total of 18% of the sample had depression. Of the 279 participants who died during the study and had their causes of death recorded, 57 died from CVD. After adjustment for the main potential confounders, depression was significantly associated with all-cause (HR = 1.81; 95% CI = 1.23-2.65) and CVD mortality (sHR = 2.01; 95% CI = 1.08-3.72), but was not significantly associated with non-CVD mortality (sHR = 1.32; 95% CI = 0.88-1.99). Depression was associated with an increased risk of all-cause and CVD mortality, but was not significantly associated with non-CVD mortality. This may be due to the heterogeneity of the causes of death of the participants comprising this subgroup. One significant limitation is the small number of cases involving CVD mortality and depression (n = 13). One potential implication of this study is the need to adopt a comprehensive approach to treating depression to address not only mental health, but also actively promote healthy behaviors that reduce the risk of chronic disease and mortality. NCT03343886 (Last Public Release: 10/10/2024).

Global burden of cognitive decline is rapidly increasing, yet existing research on modifiable lifestyle factors often relies on static assessments. To address this gap, this study aims to explore the dynamic, joint trajectories of multiple lifestyle behaviors and their association with cognitive health in older adults. This study included 6765 older adults from the Chinese Longitudinal Healthy Longevity Survey. Data on lifestyle, including dietary habits, sleep quality, physical, cognitive, and social activity were self-reported from 2008 to 2014. Cognitive function was measured using the Mini-Mental State Examination from 2014 to 2018. To capture the joint trajectories of these lifestyle behaviors over time, parallel-process latent class growth analysis was used. The identified behavioral trajectory classes were subsequently examined for their associations with cognitive outcomes using cox regression models and linear mixed effects models. Over a mean follow-up period of 5.9 years, 1659 participants (24.5%) developed cognitive impairment. Three distinct lifestyle behavior trajectory classes were identified: "Low- Declining" (n = 4342, 64.2%), "Moderate-Improving" (n = 1777, 26.3%), and "High-Declining" (n = 646, 9.5%). Compared with the Low- Declining group, the Moderate-Improving group was associated with a lower risk of cognitive impairment (HR = 0.368, 95% CI: 0.269-0.396), a longer time to cognitive impairment onset (mean = 6.433 years) and a slower rate of annual cognitive decline (0.806 points per year). Similarly, the High-Declining group showed a reduced risk (HR = 0.629, 95% CI: 0.507-0.779), delayed onset (mean = 4.969 years) and a slower decline rate (0.543 points per year) compared with the Low- Declining group. An upward trajectory of moderate lifestyle engagement, as well as a high but declining class, was associated with better cognitive outcomes compared with persistently low or declining engagement. These findings highlight that the direction of lifestyle change, rather than intensity alone, may be critical for cognitive health, supporting preventive strategies that emphasize gradual and sustainable improvements in lifestyle behaviors.

The aim of this study was to identify subgroups with similar health states based on health-related quality of life (HRQoL) profile (i.e. differences in affected dimensions and severity of problems per dimension) among PCC patients, to examine transitions between these subgroups over time, and to examine the association with sociodemographic and medical characteristics. In this longitudinal cohort study, data from 5,737 PCC patients, collected through two online surveys, were analysed using a latent Markov model. Dichotomized HRQoL scores per EQ-5D-5L dimension were used as indicators to determine latent states and covariates were added into the model. A model with six latent states was selected. The largest state, consisting of 31% of respondents, was characterized by a high probability of problems on all dimensions, whereas the smallest state (7%) was characterized by a low probability of problems on all dimensions, except usual activities. The remaining four states were all characterized by a high probability of problems on usual activities and pain/discomfort, but differed based on the probability of problems on the dimensions mobility, self-care and anxiety/depression. The probability of transitioning to a different state was low, with states with fewer affected dimensions being most stable. Women, younger respondents, those with a lower educational level, and those with comorbidity were more likely to be in states with more affected dimensions. The identification of different HRQoL profiles shows that there is substantial heterogeneity in the HRQoL dimensions that are affected and in observed changes between two measurement points.

Self-management empowers non-communicable disease (NCDs) patients to improve health, enhance quality of life (QoL), and reduce adverse outcomes. This study aims to synthesize empirical evidence on the effectiveness of self-management interventions in improving QoL and health outcomes among patients with NCDs. Following the PRISMA guidelines, a systematic search of PubMed/MEDLINE, Scopus, CINAHL, Web of Science, ScienceDirect, and OVID databases was conducted to identify relevant studies published between 2019 and 2024. Studies were included if they evaluated the impact of self-management interventions on QoL among adults with NCDs using randomized controlled trials or experimental designs. Risk of bias was assessed using the RoB 2 and ROBINS-I tools. A random-effects meta-analysis was performed to calculate pooled standardized mean differences using Hedges' g. Heterogeneity was assessed using Cochran's Q test and the I² statistic. Sensitivity analyses and publication bias assessments were also conducted. Eleven studies involving 1,591 participants were included in the systematic review, and 10 studies were eligible for the meta-analysis. The pooled analysis demonstrated that self-management interventions significantly improved QoL compared with standard care (Hedges' g = 0.58; 95% CI: 0.34-0.81). Moderate-to-substantial heterogeneity was observed across studies (I² = 69.3%). Subgroup analysis indicated that intervention effects varied by country income level, with larger effect sizes observed in upper-middle-income countries. Sensitivity analysis confirmed the robustness of the findings. Funnel plot inspection and Egger's test indicated no statistically significant evidence of publication bias. Self-management interventions are associated with significant improvements in QoL among individuals with NCDs. These findings highlight the importance of integrating structured self-management programs into chronic disease care. Given the observed heterogeneity across studies, future research should focus on standardized intervention components, rigorous study designs, and evaluation across diverse healthcare settings to better understand the long-term effectiveness of self-management strategies. Not applicable.

Frailty state is dynamic and reversible, but there is a lack of clarity about the patterns of frailty transition and its influencing factors. This study aimed to investigate frailty transitions and the impact of sociodemographic and behavioral factors on these transitions in Chinese middle-aged and older adults. We used five-wave data from the China Health and Retirement Longitudinal Study (CHARLS), and 20,140 Chinese adults aged&#x2009;&#x2265;&#x2009;45 years were included. Frailty was assessed using a 35-item frailty index. A multi-state Markov model was used to systematically analyze the transition patterns of frailty states (robust, prefrail, frail) and death, and to explore the associations of sociodemographic and behavioral factors with frailty transitions. Among the 20,140 participants at baseline, the proportions of robust, prefrailty, and frailty were 30.4%, 51.8%, and 17.8%, respectively. In the short term, participants tended to remain in their original state, while over time, the probability of deterioration and recovery increased significantly. Increasing age [HR (hazard ratio): 1.02; 95% CI (confidence interval): 1.02-1.02], being female (1.39, 1.27-1.53), living in a rural area (1.34, 1.26-1.42), being illiterate (1.21, 1.12-1.30), current smoking (1.11, 1.01-1.21), and sleep < 6 or > 8 h (1.23, 1.16-1.30) increased the risk of frailty deterioration. While current drinking (0.92, 0.86-0.99) reduced the risk of frailty deterioration. Stratified analyses by age and gender showed consistent results with the main analysis. Targeted interventions should be developed for at-risk populations and intervenable behavioral factors should be taken to slow or reverse the progression of frailty.

Equity in maternal health is critical to achieving Sustainable Development Goals and Universal Health Coverage. Unequal distribution of maternal health resources threatens access and outcomes, particularly in Low- and Middle-Income Countries (LMICs) like Iran. This study assesses spatial and socioeconomic inequalities in the availability of human and physical maternal health resources across Iranian provinces in 2023. This cross-sectional study analyzed data from 20 maternal health resource indicators collected in 2023 across all 31 provinces of Iran. Among these, 7 variables represented human resources and 13 represented physical resources. Data aggregation was performed at multiple levels, including provincial boundaries, geographic regions, deprivation categories, and classification of provinces as border or central, to comprehensively assess spatial and socioeconomic disparities. Composite indices for human and physical resources were constructed using min-max normalization followed by averaging relevant variables. Inequality was quantified using the Gini coefficient across provinces and data processing and statistical computations were performed using R software. Findings reveal generally moderate inequalities in maternal health resource distribution (Gini mostly below 0.5) with advantaged and border provinces showing higher resource availability. Specialized facilities and supervisory staff remain concentrated in select regions, while frontline workers show more equitable distribution. The concentration of border&#x2011;specific facilities in a limited number of provinces explains part of the observed regional disparities. While important progress has been made in expanding maternal health services, spatial and socioeconomic inequities in the distribution of resources persist across provinces in Iran. Policy efforts should prioritize equity-oriented resource allocation, strengthen services in deprived provinces, and implement continuous inequality monitoring to support more equitable maternal health outcomes.

Family health is an important variable that links internal and external resources at the family level, exerting significant effects on individual health. However, there remains a lack of empirical evidence regarding its potential to mitigate health disparities. Therefore, the present study aimed to explore the effect of family health on income-related health disparity in China and analyze the heterogeneous effects of different dimensions of family health across different sub-populations. Using nationally representative data from the 2023-2024 Psychology and Behavior Investigation of Chinese Residents [n&#x2009;=&#x2009;49,885], we employed health-related quality of life (HRQoL) as a proxy variable for individual health and applied the recentered influence function-index-ordinary least squares model to explore the contributions of family health and its four dimensions to the disparity in HRQoL. Our findings showed that family health had a significantly negative association with the concentration index of health utility index (UI; &#x3b2; = -0.0002, P&#x2009;<&#x2009;0.05) and EuroQol Visual Analogue Scale (EQ-VAS; &#x3b2; = -0.0006, P&#x2009;<&#x2009;0.01). Family social or emotional support was negatively associated with EQ-VAS disparity, and family external social support significantly contributed to lower UI disparity. However, family health resources were positively associated with the disparity in UI and EQ-VAS. Heterogeneity analysis revealed more pronounced effects of family health in mitigating health disparity among females, young populations, and urban residents. This study emphasizes the importance of alleviating health disparities through family health improvement. In addition, the study findings demonstrate the necessity of reshaping resource allocation at the family level-balancing external supply and internal equity of families among different subgroups-and accelerating the distribution of high-quality medical resources to economically disadvantaged areas.