OBJECTIVES:Sexual violence has been reported to correlate with HIV infection among Sexual and gender minorities, yet evidence regarding the association between sexual violence and HIV infection within this population in low-resource settings remains limited. This meta-analysis aimed to quantify the pooled association and explore subgroup disparities. STUDY DESIGN:Systematic review and meta-analysis of observational studies following PRISMA 2020. METHODS:Registered on PROSPERO (CRD420261398499). We searched eight databases up to April 7, 2026. Random-effects models were used to pool odds ratios; subgroup analyses, univariate meta-regression, sensitivity analyses, trim-and-fill, Egger's and Begg's tests were performed. The AHRQ/NOS tool was applied to assess study quality. RESULTS:A total of 21 eligible observational studies were included. Only one small-sample study enrolled women who have sex with women (WSW), and the majority of evidence came from transgender women (TW) and cis-gender men who have sex with men (MSM).Sexual violence was significantly associated with elevated odds of HIV infection (pooled OR = 2.05, 95% CI: 1.71-2.47, I2 = 57.4%). The magnitude of this observed association was stronger among TW (OR = 3.14) compared with cisgender MSM (OR = 1.84). Univariate meta-regression identified gender identity as the primary detectable source of between-study heterogeneity. Significant publication bias was detected; the trim-and-fill adjusted pooled OR was 1.73. CONCLUSIONS:We observed a significant association between sexual violence and elevated odds of HIV infection among Sexual and gender minorities in low-resource contexts, with TW showing the strongest association. These findings underscore the need for trauma-informed multi-level strategies targeting sexual violence and HIV-related health disparities in this population. Notably, evidence was predominantly generated from TW and cis-MSM, with only one small study among WSW; our findings cannot be generalized to WSW.
OBJECTIVES:The Hub-and-Spoke model has long provided a credible architecture for healthcare networks by concentrating high-complexity care within tertiary centers while organizing lower-intensity services around them. This article examines why its rigid interpretation is increasingly inadequate and proposes the Territorial Hub as the missing organizational layer between tertiary expertise and community-based care. STUDY DESIGN:Conceptual policy analysis. METHODS:Hub-and-Spoke arrangements were critically examined alongside district and place-based systems, integrated delivery networks, accountable care organizations and primary-care-led models, focusing on clinical governance, territorial coordination, inter-hub relationships, public health functions, community participation, workforce capacity and transferability. RESULTS:The Territorial Hub is defined as the organizational evolution of the first-level hospital. It assumes vertical responsibility for coordinating Community Houses, Community Hospitals, district services, home care, outpatient services and territorial professionals, while maintaining a horizontal, structured and bidirectional relationship with the Hospital Hub. The Hospital Hub concentrates on high-complexity care, research, education, innovation and the production and updating of clinical standards; the Territorial Hub translates these competencies into locally governed pathways, ensures continuity, manages complexity compatible with local resources and activates timely escalation towards advanced specialist care. CONCLUSIONS:The Hospital Hub-Territorial Hub architecture preserves necessary centralization while overcoming the passive notion of the spoke. Its implementation requires shared governance, explicit safety boundaries, adequate workforce capacity, community participation and evaluation through clinical, organizational and public health outcomes.
Objectives Influenza, pneumonia, and respiratory syncytial virus are the leading causes of respiratory morbidity and mortality globally. Environmental factors influence the spread of these diseases, yet considerable variation remains in how these relationships are modelled across different climates and geographic scales. This systematic review evaluates the use of spatiotemporal frameworks to investigate the relationship between environmental factors and these diseases. Study design Systematic review. Methods A systematic search of PubMed, Embase, and Scopus identified peer-reviewed studies investigating the relationship between environmental factors and influenza, pneumonia, and respiratory syncytial virus using spatiotemporal modelling approaches. Methodological quality was assessed using the Spatial Methodology Appraisal of Research Tool. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and was registered with PROSPERO. Results Twelve studies met the inclusion criteria. Temperature and humidity were the most identified environmental determinants. Bayesian hierarchical models were the leading analytical framework for handling spatial and temporal dependencies. The interaction between environmental factors and area-level socioeconomic conditions significantly influenced local infection risk. Overall, the findings indicate that these relationships are often nonlinear and vary across locations, with threshold effects and geographical heterogeneity frequently reported. Conclusions Spatiotemporal modelling is a valuable tool for investigating the associations between environmental factors and respiratory infection risk. The reviewed evidence suggests that these relationships are often complex, delayed, and, in some cases, nonlinear. This study highlights temperature and humidity as the main environmental factors influencing respiratory infections, noting that local socioeconomic conditions strongly shape their impact. Effective public health surveillance should incorporate localised environmental characteristics and socioeconomic vulnerabilities to better address disease risk across diverse areas.
OBJECTIVES:Maternal alcohol consumption during pregnancy is a major, yet preventable, risk factor for fetal alcohol spectrum disorders (FASD), which can lead to lifelong neurodevelopmental, educational, and social challenges. The economic burden of FASD in Germany remains poorly quantified. In this study, we aimed to estimate the direct and indirect lifetime costs associated with FASD in Germany. STUDY DESIGN:Static cohort-based cost-of-illness study. METHODS:We conducted a cost-of-illness analysis from the perspectives of the German healthcare (e.g., psychiatric care) and social (e.g., alternative housing, special education) systems. Data from German and international studies were used to derive age-specific annual costs, which were applied to a modeled cohort of 12,600 and 13,500 individuals with FASD in Baden-Württemberg. Lifetime costs were calculated from birth to the German retirement age (67 years), adjusted to inflation in 2024, and discounted at 0%, 3%, and 5% per annum. RESULTS:The estimated undiscounted lifetime cost per affected individual was EUR 3.9 million, corresponding to EUR 49.6-53.1 billion for a single birth cohort, depending on the assumed prevalence. Applying a 3% discount rate reduced the present value to EUR 1.5 million per individual and EUR 18.4-19.8 billion for the birth cohort, while a 5% discount rate further decreased these estimates to EUR 0.9 million per individual and EUR 11.1-11.9 billion. CONCLUSIONS:FASD represents a significant lifetime economic burden in Germany. Both undiscounted and discounted estimates underscore the importance of early preventive interventions, improved screening, and targeted support to reduce long-term costs for healthcare, social services, and society.
OBJECTIVES:To examine association of private health insurance (PHI) with preventive care utilisation, and the influences of chronic conditions in Australia. STUDY DESIGN:Longitudinal study. METHODS:Data were drawn from three waves (2009, 2013 and 2017) of the Household, Income and Labour Dynamics in Australia Survey. Preventive healthcare utilisation was measured as the number of six reported preventive services: cervical screening, prostate screening, breast screening, bowel cancer screening, blood pressure checks and cholesterol testing. PHI coverage included extras PHI, hospital PHI, or combined hospital and extras PHI. Associations between PHI and preventive care were estimated using Poisson regression with augmented inverse probability weighting, adjusting for chronic conditions, demographic, and socioeconomic factors. RESULTS:The cohort included 9674 individuals followed over three waves. Chronic conditions became more prevalent over time, particularly hypertension, arthritis/osteoporosis, depression or anxiety, cardiovascular disease and diabetes. Individuals with chronic conditions reported higher preventive service utilisation than those without such conditions. After adjustment, PHI was significantly associated with greater preventive care use compared with Medicare alone. Among women, hospital PHI and combined PHI were associated with a 14% higher utilisation rate (incidence rate ratio IRR 1.14, 95% confidence interval CI 1.09-1.18). Among men, hospital PHI was associated with a 12% higher rate (IRR 1.12, 95% CI 1.00-1.23), while combined PHI was associated with an 18% higher rate (IRR 1.18, 95% CI 1.11-1.25). CONCLUSIONS:PHI was associated with higher preventive care utilisation. Strengthening coordination between PHI and Medicare may improve preventive care delivery and chronic disease management in Australia.
Objectives Male preconception exposures are associated with adverse pregnancy and offspring outcomes, yet few studies have reported prevalence of these risk factors in men of reproductive age. We aimed to estimate preconception risk factor prevalence and concurrent risk counts, and to identify risk levels within population subgroups. Study design Descriptive, cross-sectional analyses of a national cohort study. Methods Data were from four waves across the Australian Longitudinal Study on Male Health (2012-2022). Included were fertile men aged 18-44 years at each wave (nw1 = 8727; nw2 = 5854; nw3 = 3267; nw4 = 2705). Eleven pre-established risk factors were assessed: eight were available at all waves and used to derive a concurrent risk score (harmful alcohol use, cigarette use, cannabis use, illicit drug use, occupational exposure to harmful substances, type 2 diabetes, depression, and high body mass); three were assessed at between one and three waves (anxiety, intimate partner violence perpetration, and low fruit or vegetable intake). Proportions were estimated at each wave and weighted to be population representative. Subgroup differences were examined in regression analyses. Results 82-84% of men had one or more preconception risk factors, 48-53% had two or more. The most common risk was low fruit or vegetable intake (76-77%). Relative to counterparts, men under financial stress reported 45-50% more risk factors, men with lower education reported 18-30% more, unemployed men 19-32% more, and men residing in regional or remote locations 12-22% more. Conclusions Results present compelling evidence of high preconception health needs in men and underscore the importance of supporting men prior to reproduction.
Objectives Evidence used in NICE guidance has traditionally prioritised randomised controlled trials, but increasing availability of electronic health record (EHR) data has expanded opportunities for real-world evidence. The Clinical Practice Research Datalink (CPRD) is a commonly used UK primary care EHR resource, yet the extent to which CPRD studies have informed NICE guidelines in the past decade is unclear. Study design The systematic review was conducted in accordance with PRISMA guidelines. Methods We conducted a systematic review of CPRD studies in PubMed, MEDLINE, and Embase published between 04/16-09/25. For each eligible CPRD study, targeted searches of NICE guidelines were performed to identify explicit citations in NICE guidelines. Two reviewers screened and extracted data independently, resolving disagreements by consensus or third reviewer. Guideline information, number of guidelines over time, type of guidelines, and disease area guidelines (using British National Formulary (BNF) chapters) were described. Results 7181 records were identified. After de-duplication, 2704 unique CPRD studies were screened against NICE guidelines. Of these, 92 CPRD-based studies met inclusion criteria and were cited across 67 NICE documents. The annual number of NICE guidelines citing CPRD studies increased between 2016 and 2025; 1.5% of identified guidelines published in 2016 and 27.7% in 2025. The guideline citing the most CPRD studies was cancer related. The most common types of guidelines included clinical guidelines (49.3%) and technology appraisals (32.8%). Guidelines made up 12 different BNF categories, most frequently central nervous system related (23.9%; n = 16). Conclusion Observational CPRD studies are increasingly referenced in NICE guidelines across multiple disease areas, supporting the growing role of EHR data in national guideline development.
Objectives To identify/map the nature and extent of the literature on training for non-custodial staff (social workers, healthcare staff and/or their equivalent) working in prisons in England, with a specific focus on social care, to inform the training of individuals delivering the Empowered Together (coordinated social care in prison) intervention. Study design Systematic scoping review. Methods We conducted systematic searches across eight electronic databases. Pairs of reviewers independently screened articles meeting pre-specified criteria. We extracted the following into Excel spreadsheets: study characteristics; training development, content/delivery, evaluation; author recommendations. We tabulated study characteristics and provided narrative summaries. We also considered the grey literature. Results Of 512 records identified through database searches, two met our inclusion criteria. Both focused on training to support people living in prison with dementia. Each embraced stakeholder involvement as part of training development, targeted a range of staff (rather than solely social workers), and aimed to enhance knowledge among staff. However, only one covered practical skills and neither included evaluations of their training programmes. No relevant documents were found within the grey literature. Conclusions This is the first systematic scoping review of social care training in prison. Findings suggest a paucity of evidence regarding training for social workers working in prisons across England. Future training should ideally be co-designed with key stakeholders including people living and working in prison, and future research should focus on robust evaluation of training initiatives not only in terms of knowledge but also the impacts this has on people living in prison.
Despite the long-standing efforts to promote whole-of-government and whole-of-society models, health emergency preparedness is still challenged by siloed institutional or sectoral approaches. In practice, no unified mechanism has existed to systematically bring different sectors, communities, countries or regions to strengthen preparedness capacities. In response to these persistent gaps, World Health Organization (WHO) introduced the Universal Health and Preparedness Review (UHPR) as one of its Post COVID-19 initiatives. This commentary examines the place of UHPR in the sphere of health emergency preparedness in bringing sustained engagement between different sectors at the national level and facilitating cross-country and cross-regional peer learning at the global level.
OBJECTIVES:In July 2022, Australia's National Cervical Screening Program introduced vaginal self-collection for human papillomavirus testing as a screening option. We evaluated the policy impact on cervical screening rates in Victoria, Australia, and compared use of clinician-versus self-collection by practice location. STUDY DESIGN:Interrupted time series. METHODS:Using de-identified electronic medical records of age-eligible women (n = 267,127) from general practices (n = 69) contributing data to the Patron Primary Care Data repository. Interrupted time series analysis using segmented Poisson regression models estimated the slope change in monthly cervical screening rates per 100 women before (December 2017-June 2022) and after policy change (July 2022-June 2023). We described collection method by metropolitan versus regional/rural location. RESULTS:Monthly screening rates per 100 women decreased before policy change (incident rate ratio [IRR]: 0.98; 95% confidence interval [CI]: 0.97, 0.98) and increased after policy change (IRR: 1.10; 95% CI: 1.08, 1.12). Self-collection screening per 100 women increased monthly after policy change (IRR: 1.22; 95% CI: 1.16, 1.29), compared to clinician-collection (IRR: 1.06; 95% CI: 1.08, 1.12). The use of self-collection after policy change was higher amongst regional/rural practices. CONCLUSIONS:Universal access to self-collection resulted in modest increases in cervical screening, though direct attribution to the policy cannot be confirmed. Ongoing implementation challenges may explain variation observed between metropolitan and regional/rural practices.
OBJECTIVES:Limited information is available on anabolic-androgenic steroids (AAS) use among young people. This study aims to fill this knowledge gap using a large Italian dataset. STUDY DESIGN:Repeated representative cross-sectional study. METHODS:We used data from the ESPAD®Italia surveys annually conducted between 2017 and 2023 (excluding 2020) on 93,437 adolescents aged 15-19 years. Odds ratios (OR) of lifetime AAS use were estimated using unconditional multiple logistic regression models. RESULTS:Lifetime AAS use prevalence was 1.9%, current use was 0.8%. Lifetime use declined from 2.4% (2017) to 1.2% (2021), then rose to 3.3% (2023). AAS use was more frequent among males (OR = 1.94; 95% Confidence Interval, CI: 1.75-2.15), those preferring not to disclose their gender (OR = 4.18; 95% CI: 3.00-5.81), overweight/obese (OR = 1.27; 95% CI: 1.10-1.46), subjects doing daily (OR = 1.21; 95% CI: 1.02-1.45), moderate (OR = 1.22; 95% CI: 1.00-1.49), intense (OR = 1.74; 95% CI: 1.41-2.15), agonistic (OR = 1.29; 95% CI: 1.15-1.45) physical activity, users of slimming substances (OR = 15.61; 95% CI: 13.01-18.73), supplements (OR = 4.59; 95% CI: 4.07-5.19), cigarettes (OR = 2.26; 95% CI: 2.04-2.51), cannabis (OR = 3.16; 95% CI: 2.83-3.52), alcohol (OR = 1.71; 95% CI: 1.53-1.91), energy drinks (OR = 4.25; 95% CI: 3.81-4.74), gamblers (OR = 1.98; 95% CI: 1.72-2.28), with low school performance (OR = 1.49; 95% CI: 1.17-1.90) and self-satisfaction (OR = 1.57; 95% CI: 1.36-1.82), and social problems (OR = 1.61; 95% CI: 1.40-1.84). CONCLUSIONS:After a declining trend until 2021, AAS use subsequently rose among Italian teens, especially in vulnerable groups, including gender minorities, and adolescents with addictive behaviours or compromised social and psychological well-being. Awareness efforts are needed to address this emerging concern.
OBJECTIVES:To identify factors associated with non-participation in health screenings amongst Korean older adults, with a focus on digital engagement, environmental accessibility, and end-of-life values. STUDY DESIGN:Cross-sectional study. METHODS:Data from 9136 community-dwelling adults aged ≥65 years in the 2023 National Survey of Older Koreans were analysed using multivariable survey-weighted logistic regression. RESULTS:Non-participation (20.2%) was associated with older age, male sex, unmarried status, poverty, and urban residence. Smartphone use (OR 1.38), dissatisfaction with public transportation (OR 1.16 per 1-point decrease), and life-sustaining treatment (LST) decline (OR 1.35) were independently associated with non-participation. Depression (OR 1.66) and cognitive impairment (OR 1.71) were the strongest modifiable predictors. Sex- and age-stratified analyses revealed differential patterns. CONCLUSIONS:Improving screening uptake requires a multifaceted approach addressing psychological health, digital-era paradoxes, and structural transportation barriers.
OBJECTIVES:To identify risk and protective factors associated with lifetime marijuana use among male high school students through an interpretable machine learning model, providing evidence to support early and targeted public health interventions. STUDY DESIGN:Cross-sectional analysis of 2023 Youth Risk Behavior Surveillance System (YRBS) data for boys in grades 9-12 across the United States. METHODS:The final analytical sample included 8285 boys after excluding missing outcomes. Thirty-six predictors spanning demographics, substance use behaviors, lifestyle, psychosocial stressors, mental health, and household environment were retained following optimization of missing data thresholds. Ensemble feature importance was determined using Logistic Regression, Linear Discriminant Analysis, and Extra Trees classifiers. Seventeen machine learning algorithms were benchmarked, with Logistic Regression selected for its combination of predictive performance and interpretability. Model performance was evaluated using accuracy, F1-score, specificity, and area under the receiver operating characteristic curve (AUC). Explainable AI methods, SHAP and LIME, provided global and individual-level feature interpretations. RESULTS:Lifetime marijuana use was reported by 28.4% of participants. The optimized Logistic Regression model achieved strong performance (AUC = 0.9034; Accuracy = 0.8582; F1 = 0.8928). The most predictive factors included electronic vapor product use, cigarette smoking, alcohol consumption, frequent social media use, age, bullying and sexual violence exposure, lifetime cocaine use, academic achievement, and grade level. High academic achievement was protective. SHAP and LIME analyses confirmed the robustness and interpretability of these predictors. The optimized model was also well calibrated (Brier score = 0.104; expected-to-observed ratio = 1.01). CONCLUSIONS:This study applies an interpretable machine learning approach, grounded in systematic algorithm benchmarking, that provides actionable insights to identify high school boys with patterns associated with marijuana use, supporting early, focused prevention in schools and communities.
OBJECTIVES:Deaths of despair - suicide, drug overdose, and alcohol-related mortality - have been widely studied in the U.S., where rising midlife mortality has been linked to institutional decline and cohort disadvantage. Far less is known about these dynamics in countries with stronger welfare regimes, particularly when disaggregated by cause, age, and socioeconomic position, and few studies examine these causes jointly. This study examines trends in despair-related and homicide mortality and associated socioeconomic factors in the Netherlands, expecting patterns that differ from those documented elsewhere and reflect context-specific institutional arrangements. STUDY DESIGN:Retrospective population-based observational study. METHODS:Using national mortality data (2013-2023) obtained from Statistics Netherlands, we analysed cause- and age-specific despair-related mortality alongside socioeconomic indicators to assess structural and socioeconomic influences. We uniquely examine these causes together - and explicitly include homicide alongside suicide, drug overdose, and alcohol-related mortality - on the premise that they represent different expressions of a shared set of despair-related processes. RESULTS:Suicide remains the leading cause of external mortality across the life course among the studied variables, with rates declining among middle-aged adults, but remaining stable among youth. In contrast, drug- and alcohol-related deaths have risen steadily, particularly among working-age and older adults. These patterns indicate a partial convergence with U.S. trajectories, while persistently low homicide rates and the absence of a midlife suicide surge differentiate the Dutch case. CONCLUSION:Despair-related mortality in the Netherlands reflects overlapping but distinct processes across the life course. The results suggest that the Netherlands' welfare institutions may buffer some of these dynamics compared with countries where social protections are weaker. These findings underscore the need for integrative, life-course models that combine epidemiological, socioeconomic, and ecological factors, and for policies that strengthen prevention, reduce inequalities, and foster resilience. Deaths of despair are not merely individual tragedies, but indicators of systemic vulnerability and institutional limits.
OBJECTIVES:To examine sugar-sweetened beverage (SSB) taxation through a health planning and governance lens, identifying structural gaps in fiscal design, policy integration, and alignment with contemporary evidence on diet-related chronic disease prevention. STUDY DESIGN:Structured narrative review combined with a systems-based policy analysis. METHODS:A structured narrative review was conducted following the Scale for the Assessment of Narrative Review Articles (SANRA). Evidence was identified through targeted searches of PubMed, Scopus, and Web of Science, complemented by international policy documents, including the World Health Organization Global Report on the Use of Sugar-Sweetened Beverage Taxes (2025). Thematic synthesis was guided by a conceptual framework integrating fiscal policy design, governance arrangements, food environments, and evidence-based prevention models. RESULTS:The analysis identified persistent governance and planning gaps that may limit the preventive impact of SSB taxation. These included low and heterogeneous tax levels, limited adoption of sugar-content-based taxation, absence of inflation-adjustment mechanisms, weak earmarking of revenues, and poor integration with food environment regulation and institutional health policies. The review also highlighted the influence of governance fragmentation and the limited incorporation of contemporary prevention evidence into fiscal policy design. Overall, SSB taxes frequently function as isolated fiscal measures rather than as components of comprehensive chronic disease prevention strategies. CONCLUSIONS:The preventive limitations of SSB taxation appear to reflect governance and planning misalignment rather than insufficient policy adoption. Reframing SSB taxation as a health planning function, integrated with food environment regulation, institutional policies, and evidence-based prevention frameworks, may strengthen its contribution to long-term population health and chronic disease prevention.
