Heart failure is a chronic condition that significantly impacts patients' quality of life and increases health care burden. Effective self-monitoring and lifestyle modification are essential components of heart failure management and can support improved health outcomes. Mobile health technologies, such as smartphone apps, are increasingly used to assist patients with heart failure in self-management. However, evidence regarding patient engagement, user experience, and the effectiveness of these mobile health tools remains limited and continues to evolve. This study aimed to explore the feasibility of a mobile health platform, MoTER-HF, which incorporates a smartphone app and a web-based clinical portal to support self-management in patients with heart failure. The feasibility study used a single-group pretest-posttest mixed methods design. A total of 23 participants diagnosed with heart failure were recruited to use the app and 2 Bluetooth-enabled measurement devices (a blood pressure monitor and a digital weight scale) over a 12-week period. Participants' engagement and acceptance were assessed using a satisfaction questionnaire, semistructured interviews, and platform usage logs. Potential health and behavioral outcomes were explored using validated instruments administered at baseline and week 12. Most participants found the MoTER-HF app easy to use and aligned with their routine self-monitoring practices. Daily monitoring features such as blood pressure and weight tracking were used frequently. However, features such as symptom tracking and exercise logging were used less often, reflecting individual preferences and perceived relevance. Participants reported improved self-monitoring practices and valued the ability to visualize and track their data, and the reassurance provided through nurses' oversight in the satisfaction questionnaire and interviews. Changes in health and behavioral outcome measures were not statistically significant, although exploratory changes were observed in the scores of self-care, quality of life, and psychological well-being. The MoTER-HF platform has demonstrated potential in supporting self-management among individuals with heart failure, particularly when it incorporates features that participants find engaging. Further research is needed to better understand the platform's impact on health outcomes and the implementation challenges, and to involve clinicians in developing a scalable digital model of care.
Smartphone-based digital phenotyping has emerged as a promising approach for monitoring mental health using passive behavioral data. Prior studies have linked smartphone-derived features to depression and anxiety severity; however, knowledge regarding whether short-term changes in symptoms can be captured using passive smartphone data in general population samples remains limited, as does the understanding of how such findings should be interpreted vis-à-vis behavioral patterns and demographic variability. This study aimed to model short-term changes in depression and anxiety severity using passive smartphone data, examine model performance across demographic subgroups, and identify behavioral patterns associated with symptom changes. We collected 2 weeks of smartphone usage data from 95 adults in the general population and assessed depressive and anxiety symptoms using the clinician-rated Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale, respectively. Behavioral features-including physical activity, app use, and screen usage metrics-were extracted and compressed using an autoencoder and principal component analysis. The resulting features-along with age, sex, and baseline Hamilton scores-were used to train random forest classifiers predicting symptom score changes (increase, decrease, or unchanged). Additionally, we examined whether model performance differed across demographic subgroups and whether models excluding baseline scores retained predictive performance, as baseline severity was expected to be a strong predictor. To add explanatory value beyond prediction, behavioral subtypes associated with symptom changes were identified by applying unsupervised clustering. The model exhibited moderate performance in predicting changes in the Hamilton Depression Rating Scale (mean accuracy=0.70, mean area under the receiver operating characteristic curve=0.74) and Hamilton Anxiety Rating Scale (mean accuracy=0.65, mean area under the receiver operating characteristic curve=0.69) scores. Performance varied according to demographics, with reduced accuracy among younger adults and females, although these differences were not significant in permutation tests. Excluding baseline Hamilton scores diminished performance substantially, suggesting that baseline symptom severity accounted for a substantial proportion of the predictive performance. Clustering revealed 4 distinct behavioral subtypes according to smartphone usage patterns. A cluster characterized by structured, daytime-focused smartphone use and lower temporal entropy demonstrated greater improvement in depressive symptoms, whereas clusters with lower and irregular usage patterns exhibited minimal improvement or worsening. Passive smartphone-derived behavioral data demonstrated moderate ability to model short-term symptom changes in this predominantly nonclinical sample. However, a substantial proportion of the predictive performance was attributable to baseline symptom severity, underscoring that passive smartphone data may provide modest supplementary information rather than robust stand-alone predictive value. Nevertheless, clustering analyses indicated that passive data may still assist in identifying behaviorally distinct subtypes associated with different depressive symptom trajectories. These findings reflect a practical contribution to digital phenotyping research by elucidating both the potential and constraints of passive smartphone data for short-term symptom monitoring in small general population samples.
The United States continues to see significant issues with gun violence, resulting in significant public health concerns. Behavioral medicine is often involved in addressing the psychological aftermath of gun violence, as survivors experience higher rates of post-traumatic stress disorder, depression, and suicidal ideation. Black and Latino communities are disproportionately affected by gun violence due to structural inequities, with gun violence furthering the structural and health inequities experienced in these communities. While the Bipartisan Safer Communities Act of 2022 helped to improve gun control laws, federal policies are still needed to help close loopholes. The STOP School Violence Act of 2018 focuses on violence prevention education in schools but lacks information on behavioral health services and early psychological risk identification. To address future gun violence, we urge members of Congress to co-sponsor the Break the Cycle of Violence Act, which focuses on community building, including counseling services, financial, legal, and housing support for those at high risk for exposure to violence, and job training and digital literacy education for youth. Additionally, we ask them to support stronger measures to ensure safe transfer and responsible handling of firearms, including supporting legislation to close the "Charleston loophole" by requiring completion of background checks before transfers and the Protecting Extreme Risk Protection Orders, allowing courts to temporarily remove firearms from individuals showing warning signs of violence and connect them with crisis and behavioral health support. Gun violence continues to be an important public and behavioral health issue in the United States. In addition to the fatalities resulting from gun violence, survivors and their communities often experience post-traumatic stress disorder and depression. Gun violence also disproportionately affects communities of color, intensifying the structural inequities they face. While there has been legislation passed to help strengthen gun control laws, there are still gaps that need to be addressed. In order to address gun violence, we ask members of Congress to support gun violence legislation focusing on community building, complete background checks before transfers, and temporary removal of firearms from owners showing warning signs of violence.
Community college (CC) students face significant mental health concerns but are unlikely to receive treatment. Barriers to mental health service uptake among CC students have been delineated, but few studies have identified strategies to improve uptake. Text messaging has been used to address engagement barriers to mental health services among adolescents and adults, but little research has explored this strategy for CC students. The goal of this study was to partner with CC students to co-design and conduct pilot usability testing of a text messaging intervention to address barriers and increase uptake of a mental health screening and treatment program, called Screening and Treatment for Anxiety and Depression (STAND), offered to CC students. We conducted 2 parallel sets of 4 co-design focus groups with CC students who had varying levels of engagement with STAND. We used rapid qualitative analysis to extract key themes, create text message prototypes and refine them, and present updated prototypes to gather feedback across workshops. We also assessed six usability factors on a 5-point Likert scale: satisfaction, helpfulness, attractiveness, readability, comprehension, and likelihood of getting started with STAND after receiving texts. Key themes emerged about perceptions of texting, barriers to STAND, a basic framework for the text message intervention, feedback about the format of messages, and feedback about the content of messages. Students expressed positive regard for text messaging and general agreement on key barriers to STAND. Students codeveloped a framework for the intervention, including (1) delivering introductory texts to engage students in the text messages, (2) providing a personalized approach for students to select barriers most salient for them, and (3) delivering tailored content designed by students to address each barrier. Across workshops, several themes emerged with regard to how messages should be formatted and delivered, including the following: use short messages; use not too many messages; use relevant language; use images, memes, and short videos; and make messages "human-like." Themes related to the content of messages included the following: reminders that you are not alone, knowledge that STAND has worked for other students, expressing understanding of student context and stressors, and providing an option to speak to a team member. Mean ratings on usability factors ranged from 3.88 (SD 0.64) to 4.25 (SD 0.46). This study describes a process for co-designing a text messaging mental health engagement intervention with CC students that is grounded in a human-centered design approach. Further research is needed to rigorously test this intervention and make iterative refinements to improve response and effectiveness.
Climate change has emerged as a growing psychosocial stressor that shapes individuals' perceptions of the future, including decisions related to childbearing. However, the lack of standardized measurement tools limits the systematic assessment of eco-reproductive concerns within public health and nursing research. This study aims to develop a measurement tool that assesses individuals' reproductive concerns and intentions in the context of climate change and environmental crises. This cross-sectional methodological study was conducted with 617 adults aged 18-45 years between September and December 2025. Data were collected using the Personal Information Form and the Eco-Reproductive Concern Scale (ERCS). Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed on independent samples. Reliability was assessed using Cronbach's alpha, McDonald's omega, and split-half methods. Convergent, discriminant, and construct validity, as well as measurement invariance across gender, were evaluated. Data analyses were conducted using SPSS Statistics 29 and AMOS. Participants' mean age was 26.37 ± 8.28 years in the EFA phase (74.3% women, 25.7% men) and 26.97 ± 8.65 years in the CFA phase (72.1% women, 27.9% men). EFA yielded a 28-item, four-factor structure, accounting for 70.12% of the total variance. CFA confirmed the factor structure, demonstrating acceptable model fit (χ²/df = 2.35, CFI = 0.909, TLI = 0.900, RMSEA = 0.074, SRMR = 0.064). Convergent and discriminant validity were supported by AVE, CR, and Fornell-Larcker criteria. The scale's internal consistency was excellent (Cronbach's α = 0.946). Measurement invariance across women and men was established at configural, metric, and scalar levels. The study found that the ERCS is a valid and reliable instrument for assessing reproductive concerns associated with climate change. The ERCS can be used across a broad range of health research and clinical settings, including public health, nursing, medicine, psychology, and other behavioral and allied health disciplines, to better understand how environmental crises influence reproductive attitudes and intentions.
This scoping review mapped evidence on whether school health education using active learning with peer-to-peer health communication is associated with behavior change among elementary and junior high school students and identified challenges to sustaining change. Following PRISMA-ScR, we searched Ichushi Web, PubMed, and ERIC (February 14, 2024) for studies (2014-2024) evaluating peer-communication-based active learning in school health education with behavioral outcomes. Seventeen studies were included; 14 reported behavioral change, 2 partial change, and 1 emotional change without clear behavioral outcomes. Nine studies used behavioral or learning theories, and in this small set of studies, theory-informed interventions were reported to show overall or partial behavioral change, most often with Social Cognitive Theory (5 studies). These findings should be interpreted cautiously given the heterogeneity of study designs and outcome measures. Key limitations were limited long-term follow-up assessing sustainability of behavior change (5 studies) and concerns about measurement reliability (4 studies). The included studies were heterogeneous in terms of interventions and outcome measures, and many relied on self-reported behavioral indicators. As this was a scoping review, no formal risk-of-bias assessment was conducted. Schools may strengthen primary prevention by embedding structured peer interaction and theory-informed techniques, while ensuring inclusive participation and supports that do not depend on family resources. Peer-to-peer health communication-based active learning may support short-term behavior change, but sustainability and measurement quality remain major evidence gaps.
While molded puree is marketed as a dignified alternative to traditional texture-modified diets for older adults and patients with dementia, the clinical implications of their rapid commercialization remain under-examined. To investigate the knowledge, clinical expectations, and psychosocial drivers regarding molded puree for older adults among community carers and aged-care professionals. This concurrent mixed-methods study recruited 164 community carers (public cohort) and 60 aged-care professionals (staff cohort) who work in non-governmental residential aged-care networks in Hong Kong SAR. Quantitative data were collected via cross-sectional surveys evaluating self-rated knowledge, swallow safety perceptions, and clinical expectations on consumption of molded puree in older adults. Qualitative data were obtained through semi-structured, in-depth interviews with a purposive sub-sample of 12 community carers to explore underlying behavioral drivers. Quantitative differences were analyzed using Mann-Whitney U and Chi-Square tests, while qualitative data underwent thematic analysis. Self-rated knowledge about molded puree was significantly lower in the public cohort compared to professional staff (p < 0.001). A puree equivalence fallacy was prevalent; 23.8% of the public believed molded puree shares the exact texture of conventional puree, and 39.3% assumed it requires no chewing. Staff were significantly more aware of biomechanical differences (65.0% disagreed with equivalence). The public held significantly higher expectations regarding improvements in feeding behaviors (50.6% agreement) and nutritional value (26.2%) compared to professionals (p< 0.05). Qualitatively, thematic analysis revealed twohigher-order themes: psychosocial motivations centered on restoringdining dignity and avoiding dietary stigma, and structural hurdlesinvolving procedural ambiguity. A significant knowledge-perception gap exists between the general public and healthcare professionals. While molded puree offers substantial psychosocial benefits, the prevalence of the puree equivalence fallacy underscores a potential risk for vulnerable older adults. Clinical interventions should prioritize evidence-based swallow safety and standardized screening over aesthetic appeal. Why was this Study Done? Age-related swallowing difficulties, known as dysphagia, often require foods to be blended into a smooth puree. Molded purees are a newer option where blended food is reshaped using gelling agents to look like standard meals, improving visual appeal and dining dignity. This study investigated whether the general public and healthcare professionals understand how to utilize these products safely. How was the Study Conducted? We surveyed 164 community members and 60 professional staff from residential aged-care facilities to compare their understanding. We also conducted in-depth interviews with 12 public respondents to explore their underlying motivations. What did the Study Find? A significant knowledge gap exists between the public and professional staff. Many community members mistakenly believed that molded purees share the exact texture of standard pureed food and require no chewing. In reality, gelling agents alter food behavior, requiring oral processing to swallow safely. Public respondents held highly optimistic expectations regarding nutritional and behavioral improvements. Interviews revealed that the public is heavily motivated by the desire to restore dining dignity and avoid dietary stigma, an aesthetic focus that often overrides essential swallow safety considerations. What does this Mean for the Future? Molded puree effectively enhance mealtimes. However, public education must emphasize that a speech-language pathologist should evaluate individuals before introducing these meals, ensuring physical safety is maintained alongside visual appeal.
Despite policy-level progress, implementation of oral HIV preexposure prophylaxis (PrEP) remains limited in Latin America. In Peru, men who have sex with men (MSM) account for most new HIV diagnoses, yet uptake remains low. Widespread smartphone ownership and the use of digital platforms present an opportunity to expand access through mobile health (mHealth) interventions. However, limited data exist on user preferences to guide the design of mHealth tools in Spanish-speaking Latin American settings. This study aimed to assess preferences for mHealth features to support PrEP engagement among Peruvian MSM and their association with PrEP cascade stages. We conducted a cross-sectional online survey (June-August 2023) among 600 HIV-negative MSM residing in Peru (median age 29, IQR 24-35 years), recruited via Facebook, Instagram, WhatsApp (Meta Platforms, Inc), and Grindr (Grindr LLC). The survey assessed communication platform use, interest in mHealth features measured on a 4-point Likert scale, and PrEP cascade stages. Exploratory factor analysis (principal axis factoring with Promax rotation) identified domains of mHealth preferences, from which median domain scores were calculated. Bivariate analyses used chi-square tests and Wilcoxon rank sum tests. Multivariable logistic regression models (α=.05), with covariates selected using stepwise procedures from candidate sociodemographic and behavioral variables, estimated associations between each domain score and PrEP cascade stages, each modeled as a separate binary outcome. Nearly all participants (589/600, 98.2%) reported owning a smartphone. WhatsApp was the most frequently used and preferred platform for PrEP support, with 547 (91.2%) reporting frequent use and 302 (50.3%) ranking it first. Exploratory factor analysis identified three mHealth preference domains: informational support (Cronbach α=0.94), self-management tools (Cronbach α=0.94), and interactive communication (Cronbach α=0.91). Among participants, 483 (80.5%) had decided to use PrEP, 190 (31.7%) had sought PrEP, and 109 (18.2%) had initiated PrEP. Higher informational support was associated with the decision to use PrEP (adjusted odds ratio [aOR] 4.54, 95% CI 3.36-6.28; P<.001), seeking PrEP (aOR 1.43, 95% CI 1.10-1.89; P=.001), and PrEP initiation (aOR 1.64, 95% CI 1.16-2.44; P=.009). Self-management tools showed similar associations with the decision to use PrEP (aOR 3.23, 95% CI 2.51-4.22; P<.001), seeking PrEP (aOR 1.34, 95% CI 1.06-1.70; P=.02), and PrEP initiation (aOR 1.49, 95% CI 1.11-2.05; P=.01). Interactive communication was associated with the decision to use PrEP (aOR 2.74, 95% CI 2.15-3.53; P<.001) but not with initiation. Preferences for mHealth features were associated with engagement at multiple stages of the PrEP cascade among MSM in Peru. Informational support features demonstrated the most consistent associations with cascade engagement. These findings provide empirical evidence on user-prioritized digital functions that could support early engagement in HIV prevention services in a Latin American implementation context. Integrating culturally tailored mHealth tools within widely used platforms such as WhatsApp may strengthen early PrEP cascade engagement and support scalable digital strategies for HIV prevention in Peru and similar settings.
Approximately 1.6 million Americans identify as transgender and gender diverse (TGD), yet health outcomes research focused on TGD patients is lacking. This gap persists despite significant health disparities experienced by TGD patients, including high rates of depression and suicidality. In clinical settings, patient-reported outcomes surveys (PROS) can pinpoint immediate clinical needs for individual patients while also generating health outcomes data. This project describes early outcomes and the implementation of PROS for TGD patients being seen at a gender health clinic (GHC) in Birmingham, Alabama. A REDCap-based PROS was implemented at a GHC in Birmingham, Alabama from June 2023 to May 2024, including validated tools for depression (Patient Health Questionnaire-2 and -9), gender dysphoria (Utrecht Gender Dysphoria Scale), alcohol use (Alcohol Use Disorders Identification Test-C), and substance use (Alcohol, Smoking, and Substance Involvement Screening Test). Acceptability, appropriateness, and feasibility metrics also were collected. In total, 51 patients completed the PROS, including transwomen (n = 21), transmen (n = 21), nonbinary (n = 10), genderqueer (n = 3), and gender nonconforming (n = 3) patients. Among those patients, 40% screened positive for depressive symptoms and 45% reported tobacco use. The mean gender dysphoria score was 56.81 (standard deviation 9.91) out of 70, and the mean gender affirmation score was 18.13 (standard deviation 2.22) out of 20. Patients found the PROS highly acceptable (86%), appropriate (98%), and feasible (94%). Several challenges were encountered during implementation, including REDCap technical issues, staffing and workflow complexities, and occasional patient difficulty with independent PROS completion. This project demonstrates the feasibility and value of implementing a PROS in a GHC, particularly in a medically underserved region like the southeastern United States. Addressing implementation challenges is critical, however.
Serious games are increasingly used in professional health education and maternal health promotion. However, most pregnancy-related digital interventions target specific behaviors and do not provide a comprehensive, longitudinal simulation of the pregnancy journey that incorporates psychosocial and administrative aspects. This study aimed to develop and evaluate a narrative-based serious game that simulates the chronological course of pregnancy and to assess its perceived educational usefulness, accessibility, and user acceptance across multiple platforms. We developed a 9-chapter interactive serious game covering pregnancy recognition, partner communication, public health consultation, mid-pregnancy and late-pregnancy checkups, and home preparation for childbirth. The game was collaboratively created by a pediatrician, 6 medical students, and a student illustrator using a low-cost visual novel engine (TyranoBuilder). It was released in April 2025 on iOS, Android, and Steam. A voluntary, anonymous postgame survey was conducted between April 2025 and January 2026. Descriptive statistics were used to summarize survey responses and platform analytics. This study was approved by the Ethics Committee of Shinshu University Hospital. A total of 65 users completed the postgame questionnaire. Most respondents were aged 10 to 19 years (38/65, 58.5%) and female (55/65, 84.6%). Nearly half of the participants (30/65, 46.2%) completed the game within 1 hour. Gameplay evaluation scores (5-point Likert scale; 3=neutral or appropriate) were balanced: game length (mean 3.37, SD 0.96), difficulty (mean 2.84, SD 0.85), and interactivity (mean 3.31, SD 1.10). Educational outcomes were rated highly (5-point Likert scale; higher=more favorable): reduced anxiety (mean 3.84, SD 0.96), perceived educational usefulness (mean 3.98, SD 1.02), perceived knowledge acquisition (mean 4.06, SD 1.06), story empathy (mean 3.80, SD 1.11), and overall satisfaction (mean 4.05, SD 1.04). Across all platforms, the game achieved 925 cumulative downloads. iOS and Android downloads were predominantly from Japan, whereas Steam downloads were geographically diverse. Of the 21 Steam reviews, 20 (95.2%) were positive. A serious pregnancy education game developed through a low-cost clinician-student collaborative model demonstrated high perceived educational usefulness, balanced gameplay characteristics, and broad user acceptance, including substantial engagement among teenagers and international users. Narrative-based serious games represent an accessible and scalable approach to maternal health education. Further research using more rigorous evaluation designs is warranted to assess long-term educational and behavioral impacts.
Shifts in the demographic composition of US military veterans underscore the need for updated population-based estimates of suicidal thoughts and behaviors (STBs) to accurately characterize suicide risk in this population. To update prevalence estimates of and factors associated with STBs among US military veterans and to examine mental health treatment utilization among veterans with a history of STBs, stratified by use of the Veterans Health Administration as a primary source of health care. Population-based cross-sectional study of US military veterans drawn from the 2025 to 2026 National Health and Resilience in Veterans Study. Past 2-week and past-year suicidal ideation (SI), lifetime planning, and lifetime suicide attempt(s). Among 2636 veterans (mean [SD] age, 62.4 [16.2] years; 2349 [88.5%] male), the prevalence of past 2-week SI was 13.4% and past-year SI was 14.0%, with past 2-week SI significantly higher in 2025 to 2026 than in 2019 to 2020 (13.4% vs 9.0%; z = 5.69; P < .001). In contrast, prevalence estimates of lifetime suicide planning (8.0% vs 7.3%; z = 1.06; P = .29) and suicide attempts (4.9% vs 3.9%; z = 1.97; P = .048) were similar to those observed in 2019 to 2020. After adjustment for sociodemographic and military characteristics, factors most strongly associated with past 2-week SI based on relative importance analyses included functional disability (odds ratio [OR], 1.10; 95% CI, 1.04-1.16), lifetime major depressive disorder (OR, 2.22; 95% CI, 1.63-3.02), and lifetime posttraumatic stress disorder (OR, 1.53; 95% CI, 1.09-2.13). Factors most strongly associated with past-year SI included functional disability (OR, 1.09; 95% CI, 1.07-1.11), lifetime major depressive disorder (OR, 2.33; 95% CI, 1.72-3.16), and lifetime posttraumatic stress disorder (OR, 1.62; 95% CI, 1.17-2.25). Factors most strongly associated with lifetime suicide planning included lifetime posttraumatic stress disorder (OR, 2.61; 95% CI, 1.82-3.76), lifetime major depressive disorder (OR, 2.61; 95% CI, 1.84-3.71), and younger age (OR, 2.11; 95% CI, 1.36-3.28). Factors most strongly associated with lifetime suicide attempts included greater adverse childhood experiences (OR, 1.39; 95% CI, 1.29-1.51), lifetime major depressive disorder (OR, 3.76; 95% CI, 2.31-6.10), and functional disability (OR, 1.04; 95% CI, 1.02-1.07). In this cross-sectional study of US military veterans, results suggest that SI was more prevalent in 2025 to 2026 relative to estimates from 2019 to 2020, whereas the prevalence of suicide planning and attempts remained stable. Younger and female veterans appear to carry disproportionate risk for STBs. Targeting key risk factors in vulnerable subpopulations may help mitigate suicide risk.
Insomnia during adolescence impairs mood and cognitive functioning, yet access to effective behavioral sleep treatment is limited. Although CBTi is considered the first-line therapy, the relative value of different delivery formats has remained unclear. This study systematically evaluated and compared the efficacy of various cognitive behavioral therapy for insomnia (CBTi) delivery formats in improving sleep outcomes among adolescents using a network meta-analysis (NMA). A comprehensive search of five databases, namely PubMed, Embase, PsycINFO, CINAHL, and the Cochrane Library, was conducted through September 28, 2025. Eligible studies were randomized controlled trials (RCTs) involving adolescents with insomnia that examined at least one CBTi modality, including web-based, face-to-face, group-based, mobile-app-based, self-help, brief CBTi, and sleep hygiene. Both pairwise and network meta-analyses were conducted using a frequentist random-effects model. Risk of bias was evaluated using the Cochrane Risk of Bias 2.0 tool, and confidence in evidence was examined using the Confidence in NMA framework. Sleep outcomes included total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), sleep efficiency (SE), and insomnia severity. Twenty-two RCTs evaluating seven CBTi modalities were analyzed. Web-based CBTi consistently outperformed other delivery formats across most outcomes, significantly improving TST by 33 min, reducing SOL by 23 min, increasing SE by 7%, and reducing insomnia severity by 5 points compared with usual care. P score analysis identified web-based CBTi as the most effective modality for TST (86%), SOL (79%), SE (74%), and insomnia severity (99%). No significant differences were observed for WASO. Web-based CBTi is the most effective delivery format for improving sleep outcomes among adolescents. These findings support integrating CBTi into adolescent-focused sleep care pathways. Implementation of web-based CBTi as a first-line option in school and primary-care pathways could expand access and improve outcomes. PROSPERO: CRD420251128688.
Firearms are the leading cause of death among children in the United States (US). As of 2023, half of US states had enacted laws allowing permitless concealed carry of firearms. Our cross-sectional study evaluated the association between permitless concealed carry laws and child general health using data from the nationwide Environmental influences on Child Health Outcomes (ECHO) Cohort collected between 2003 and 2023. Children aged 1-21 years with caregiver- or self-reported general health status were included. Secondary outcomes included child internalizing and externalizing behaviors and child stress. Regression models estimated the association of exposure to state-level permitless concealed carry laws six months prior to each outcome, adjusted for individual- and area-level covariates. One-fifth (20.9%) of the sample (n = 11,325) lived in states allowing permitless concealed carry of a handgun. Children living in these states were 25% less likely (OR: 0.75, 95% CI: 0.60, 0.95) to report excellent/very good general health and had psychological stress scores 0.21 standard deviations higher (β = 0.21, 95% CI: 0.10, 0.31) than children in other states. There was no statistically significant association with internalizing or externalizing behavior scores. Our study found that children living in states that allow permitless concealed carry of firearms had worse general health and higher stress, suggesting the need for policy changes to address gun violence as a public health and human rights crisis.
Evening smartphone use disrupts circadian rhythms and recovery through exposure to blue light and cognitive hyperarousal. Nomophobia: fear of smartphone separation: may limit the effectiveness of digital restriction interventions. To determine the effects of a five-day evening smartphone restriction on objectively measured sleep, cognitive, and physical performance, and to assess whether outcomes differ by nomophobia level. Twenty-eight physically active university students (20.4 ± 1.8 years) were stratified into high (n = 14) and low (n = 14) nomophobia groups using the validated Nomophobia Questionnaire. Participants avoided using smartphones and other blue-light-emitting devices after 6:00 pm for 5 consecutive days. Sleep was monitored using wrist-worn actigraphy (ActiGraph wGT3X-BT); cognitive performance was assessed via Simple and lower-limb reaction time tests; and physical performance via squat jump, Countermovement Jump, and Modified Agility t Test (Optojump) tests. Stress and anxiety were measured at baseline and on Days 1, 3, and 5. Mixed-effects analysis of variance assessed group × time interactions. All participants completed the intervention with 100% compliance. Individuals with low nomophobia showed large to very large improvements in total sleep time (+45 minutes, d = 0.80, P < .001), sleep efficiency (+12%, d = 2.99, P < .001), and wake after sleep onset (-18 minutes, d = 4.60, P < .001). Morning reaction time (d = 0.40, P < .001) and lower-limb reaction speed (d = 1.07, P < .001) improved significantly. Physical performance increased across all tests: squat jump (d = 1.30), Countermovement Jump (d = 1.25), and agility (d = 1.40), with changes exceeding typical short-term training gains. Stress (d = 2.16, P < .001) and anxiety (d = 2.63, P < .001) declined progressively over time. High nomophobia participants exhibited no meaningful improvements and experienced acute stress/anxiety elevations on Day 1. A short-term, technology-based behavioral intervention: complete evening smartphone restriction can significantly enhance sleep quality, cognitive readiness, and physical performance in young adults with low digital dependency. Nomophobia significantly moderates these benefits, highlighting the need for psychological screening and tailored telehealth approaches when designing digital wellness and sleep optimization programs.
Health sciences students have a higher incidence of mental health disorders; however, stigma and barriers have complicated help-seeking. Telepsychiatry may be a solution, but acceptance, satisfaction, and stigma in this population, especially in Egypt, remain unclear. This study aimed to evaluate the levels of satisfaction regarding telepsychiatry, stigma perceived with respect to mental illness, among health sciences students towards mental health services. It also aims to assess sociodemographic factors associated with these outcomes. This was a questionnaire-based cross-sectional study conducted among 799 students from various universities in Egypt. It was conducted between August and November 2025, and the questionnaire involved sociodemographic data, the telepsychiatry satisfaction scale (21 items), and the STIG-9 stigma scale. Data were analyzed using descriptive statistics, chi-square and t-tests, and linear regression, with significance set at p < 0.05. Overall, participants had a mean age of 21.4 years, while 66.8% of participants were female. In total, 24.0% agreed, and 18.4% strongly agreed to being satisfied with telepsychiatry, with a mean total satisfaction score of 67.84/105. The mean STIG‑9 stigma score was 14.44/27. Linear regression identified sociodemographic variables independently associated with satisfaction and stigma; higher stigma was also positively associated with higher satisfaction. In this cohort of Egyptian health sciences students with prior telepsychiatry experience, satisfaction with telepsychiatry was positively associated with perceived stigma. These findings suggest that addressing socio-cultural stigma may support the acceptability of telepsychiatry and improve engagement with digital mental health services in similar student populations.
Autistic adults are significantly more likely than non-autistic peers to have many physical and mental health conditions and unmet health care needs. One major barrier to meeting their needs is the scarcity of adult primary care physicians who are prepared to care for them. We partnered with autistic adults to develop "Promoting Residents' Excellence in Patient-centered cARE (PREPARE) for Autistic Adults," a 5-hour training. It includes 6 asynchronous lectures, 6 synchronous case studies, and 2 virtual standardized patient experiences. Residents (N = 29) at a large midwestern US academic medical center completed a pre- and postcourse evaluation and qualitative interviews to report their self-efficacy, attitudes, perceived behavioral control, intention to treat in the future, and knowledge about caring for autistic adult patients. The training had medium to very large effects on improving residents' self-efficacy (d = 2.98), perceived behavioral control (d = 1.08), and knowledge (d = 0.44), but did not improve attitudes toward or intention to care for autistic adults, likely due to ceiling effects. Resident feedback indicated an appreciation for the active learning elements of the training, insights from faculty facilitators and other residents, and the growth they experienced as practitioners. This multifaceted training provides active learning opportunities in a low-stakes environment to increase residents' confidence in providing primary care for autistic adults. Future efforts include integration of this training into residency curricula at our institution and others.
Social Cognitive Theory and the Theory of Planned Behavior suggest that self-efficacy influences physical activity through behavioral intention; however, evidence in vocational students is scarce. This study examined whether exercise behavioral intention mediates the association between exercise self-efficacy and physical activity levels among vocational education students in Shanghai. A cross sectional survey was conducted with 992 students from four vocational colleges. Participants completed validated measures of exercise self-efficacy (nine items, 1-10 scale), exercise behavioral intention (five items, 5-point Likert scale), and physical activity (IPAQ-SF). Data were analyzed using SPSS 25.0 (IBM Corporation, Armonk, New York, USA) and AMOS 26.0 (IBM Corporation, Armonk, New York, USA), adjusting for gender, age, and education level. Exercise self-efficacy was positively associated with exercise behavioral intention (r = 0.612, p < 0.001) and physical activity (r = 0.322, p < 0.001). Mediation analysis showed that behavioral intention partially mediated this relationship (indirect effect = 0.122, 95% CI [0.085, 0.163]), accounting for 45.19% of the total effect. Exercise self-efficacy is associated with physical activity both directly and indirectly via behavioral intention in vocational students. Interventions enhancing self-efficacy and behavioral intention may support higher activity levels, though longitudinal studies are needed to confirm directionality.
Despite the high prevalence of depressive disorders, access to effective treatment remains limited due to financial, geographic, and social barriers. Online self-help groups offer a promising and scalable form of peer-based support beyond traditional clinical settings. Integrating cognitive behavioral therapy (CBT) techniques such as cognitive restructuring and behavioral activation into self-help groups may enhance their effectiveness. This study evaluated the efficacy of a cognitive behavioral therapy-based online self-help group (COS) that integrates structured CBT techniques with peer-led group support as a low-intensity intervention for individuals with depressive symptoms. A randomized controlled trial (RCT) comparing COS with a CBT-based mobile application was conducted. Additionally, a separately recruited waitlist control group was included as a supplementary comparison condition. Participants were recruited online. After eligibility screening via a structured clinical interview, participants were randomly assigned to a COS group (n=79) or a CBT-based mobile application group (n=39). An additional waitlist control group (n=48) was recruited separately during the second phase of the study. The COS intervention involved 7 videoconferencing sessions that incorporated peer-led group discussions, sharing lived experiences, and core CBT techniques such as cognitive restructuring. The primary outcome measure was depressive symptoms, assessed using the Beck Depression Inventory-II, and the secondary outcome was suicidal ideation, estimated using the Beck Scale for Suicide Ideation, measured at baseline, postintervention, and 3-month follow-up. Linear mixed models were used to evaluate group × time interaction effects. Reliable change indices were also calculated to assess clinical significance. All statistical tests were 2-tailed. Among participants assigned to the COS group, 61% (48/79) completed all 7 sessions, and 84% (66/79) attended 5 or more sessions. A significant time × group interaction was observed for depressive symptoms (F4,288.47=7.23, P<.001). The COS group exhibited a substantial reduction in depressive symptoms from baseline to postintervention (t285.76=10.77, two-tailed; P<.001), with a large within-group effect size (d=1.38); this improvement was maintained at the 3-month follow-up. Suicidal ideation also significantly decreased in the COS group (t277.11=4.55, two-tailed; P<.001), with sustained effects at follow-up. Clinically meaningful improvement in depressive symptoms, as defined by the reliable change index, was observed in 75% (56/75) of COS participants. While both the COS and app-based CBT groups achieved comparable reductions in depressive symptoms, only the COS group demonstrated a significant reduction in suicidal ideation. This RCT provides evidence that a structured, CBT-informed online self-help group can reduce depressive symptoms and suicidal ideation. The COS program offers a scalable, accessible alternative to traditional therapy, particularly in settings with limited access to mental health professionals.
Cyberbullying affects approximately one-third of Thai secondary school students and has been linked to adverse emotional outcomes and mental health vulnerabilities. Strengthening digital resilience, along with critical thinking, empathy, and help-seeking skills, is essential to empower youth to cope with online risks and promote safer digital behavior. Despite growing recognition of cyberbullying as a critical youth mental health issue, few studies have explored how digital resilience interventions can be co-designed with youth and relevant stakeholders to address the contextual and emotional challenges experienced by affected adolescents. This study aimed to develop a youth-centered, theory-informed intervention using a design thinking framework to support digital resilience in addressing cyberbullying. The research repositioned youth with lived cyberbullying experiences from passive persons who experienced abuse to active co-creators of the intervention. Grounded in empowerment principles, nudge theory, and the concept of digital resilience, this approach reimagined cyberbullying prevention through empathy-driven innovation and participatory engagement, generating a contextually grounded model for designing cyberbullying interventions in a Global South context. We applied a 5-phase design thinking framework: empathize, define, ideate, prototype, and test. Twelve participants were purposively selected as extreme and lead users and key stakeholders. This group engaged in participatory design workshops and included a psychologist, experts, teacher counselors, and LGBTQI+ (lesbian, gay, bisexual, transgender, queer, and intersex) students aged 15 to 17 years with lived experience of cyberbullying. Youth participants were recruited in collaboration with school counselors to ensure diversity of experiences and perspectives. Qualitative data from the workshops were analyzed using reflexive thematic analysis to identify user needs, guide problem framing, and inform prototype development. A low-fidelity mobile-based prototype in the form of screen mockups was iteratively refined through user testing and expert consultation to ensure theoretical alignment and contextual relevance. The co-creation process identified key challenges, including emotional distress, lack of support, and the rapid spread of harmful content. Youth participants collaboratively designed a virtual community platform featuring peer support spaces, confidential expert consultation, skill-building workshops, a knowledge hub, gamified engagement tools, and artificial intelligence-assisted support. The intervention design was informed by the study's theoretical framework, which guided the development of engagement strategies, supportive communication features, and youth-centered interaction pathways. Iterative refinement contributed to improvements in perceived usability, personalization, and theoretical coherence. Importantly, the process supported youth agency by positioning participants as active co-designers who shaped solutions grounded in their lived experiences. This study illustrates how a theory-driven, participatory design thinking approach can be used to develop digital prevention and intervention for cyberbullying. By integrating behavioral theory with youth co-creation, the findings provide insights into how youth-centered co-design can inform the development of interventions addressing cyberbullying, highlighting the role of empowerment-oriented and theoretically grounded design processes in engaging youth as active contributors to solution development.
Child maltreatment is a major global public health concern with well-documented psychological consequences, but its associations with long-term physical health conditions remain less well understood. To examine the associations between childhood maltreatment and adult multimorbidity using electronic health records in Hong Kong. This population-based cohort study used electronic health record data from Hong Kong, comprising 7473 individuals with a first recorded episode of maltreatment between ages 0 and 19 years from 2001 to 2010 and 26 834 matched individuals without documented maltreatment. Individuals who reached adulthood (ie, after age 19 years) by December 31, 2024, were included. History of childhood maltreatment vs none. The primary outcome was the occurrence of multimorbidity during adulthood as documented in participants' diagnostic records through December 31, 2024. Cox proportional hazards models were used to estimate the risks of 16 disease categories and multimorbidity patterns diagnosed after age 19 years, both overall and stratified by preexisting physical, mental, or neurodevelopmental conditions in childhood. After exclusions, the final cohort comprised 32 674 individuals (16 986 female [52%]), including 7137 who were exposed to childhood maltreatment and 25 537 unexposed individuals. Their median (IQR) age was 9.0 (6.0-13.0) years at inclusion and 28.1 (24.2-31.6) years at the end of follow-up. The median (IQR) follow-up duration was 19.0 (16.6-21.3) years. Childhood maltreatment was associated with increased risks across 13 adult diagnostic categories. The highest risks were observed with mental and behavioral disorders (hazard ratio [HR], 2.78; 95% CI, 2.49-3.09), ear diseases (HR, 1.88; 95% CI, 1.27-2.78), injuries (HR, 1.81; 95% CI, 1.65-1.98), and blood diseases (HR, 1.67; 95% CI, 1.41-1.97). Maltreatment was also associated with a higher risk and earlier onset of complex multimorbidity (HR, 1.96; 95% CI, 1.68-2.27). The associations between childhood maltreatment and adult diagnoses were attenuated among individuals with mental health or neurodevelopmental conditions diagnosed in childhood. In this 19-year cohort study of 32 674 individuals, childhood maltreatment was associated with elevated risks for multiple health conditions in adulthood. These findings underscore the need for early prevention and sustained, trauma-informed health care support to reduce the risk of lifelong multimorbidity among children who have experienced maltreatment.