Schools are a key setting for child health promotion, yet implementing school-based programs, particularly those involving parents, remains challenging. Organizational readiness and early implementation outcomes, acceptability (ACC), appropriateness (APP), and feasibility (FEAS), capture how stakeholders perceive the implementability of new interventions and engage with them. These perceptions may evolve during implementation, but evidence on how they change over time and relate to one another in real-world school settings is limited. This study examined these changes among school staff during the first year of implementing the Healthy School Start program in schools in three Swedish municipalities (M). Validated questionnaires were used to assess readiness, ACC, APP, and FEAS pre- and post-intervention to examine how these implementation variables varied with direct experience of the intervention. Data were collected from 39 school principals, 72 teachers, and 40 school nurses between September 2021 and June 2023. Multilevel linear regression models with random intercepts for school and individual examined pre-post changes and interactions by municipality and professional group. Readiness, ACC, and APP declined significantly from pre- to post-intervention in the total sample (readiness: β = −2.54, p = 0.032; ACC: β = −1.31, p = 0.004; APP: β = −1.12, p = 0.022), while FEAS remained stable (β = −0.30, p = 0.501). M2 schools reported lower baseline scores than M1 schools on ACC, APP, and FEAS. M1 schools showed significant declines across all four outcomes, while M3 schools remained stable. FEAS was the only outcome for which pre-post change differed significantly across municipalities (time × municipality interaction: χ²(2) = 9.56, p = 0.008), driven by a decline in M1. No significant differences were observed between professional groups, although school nurses reported the lowest readiness and feasibility scores. Baseline readiness was strongly correlated with ACC (ρ = 0.66), APP (ρ = 0.67), and FEAS (ρ = 0.73; all p < 0.001). Perceptions of implementability generally declined with feasibility remaining stable overall except for one municipality showing a significant decline. These findings run counter to assumptions that exposure alone improves implementation outcomes, and suggest that perceptions are shaped by organizational context, underscoring the importance of addressing contextual barriers both before and during implementation. Registered prospectively at ClinicalTrials.gov ID: NCT04984421, registered July 30, 2021.
Food security is a key social determinant of health and well-being. This study examines the association of self-reported ill-treatment, perceived age discrimination, and unsafe neighbourhood environment with food insecurity among older adults in India. Nationally representative data from the first wave of the Longitudinal Ageing Study in India (LASI) was analysed for 30,017 older adults aged 60 and above. Univariate, bivariate and multivariate analyses were used to examine the associations. Further, Karlson–Holm–Breen (KHB) method was used to assess the mediating role of ill-treatment and perceived age discrimination on individual, household and unsafe neighbourhood environment on food insecurity. Compared with those who did not experience age discrimination, older adults who experienced one type (OR = 1.77, 95
People with HIV (PWH) are disproportionately impacted by the criminal legal system. While carceral settings can provide transient stability for HIV and other chronic conditions, incarceration frequently disrupts continuity of care. HIV care engagement and antiretroviral therapy (ART) concordance are impacted after incarceration by multiple factors including substance use disorder (SUD), limited social support, and structural factors such as housing and economic instability. Peer navigators can improve linkage to and retention in HIV care during the reentry period, and technology-enhancements may increase engagement in existing peer navigation services. We conducted a qualitative study with criminal legal-involved (CLSI) PWH who had recently been released from incarceration and were enrolled in a pilot study that integrated mobile directly observed therapy (mDOT) with peer navigation. The interview guide and thematic analysis were informed by Social Cognitive Theory. Semi-structured interviews focused on understanding barriers to and facilitators of ART concordance and engagement in HIV care among CLSI PWH, and experiences with this peer navigator-led intervention. Fifteen of 18 pilot study participants completed qualitative interviews. Their mean age was 50.3 (SD 10.92), 14 identified as cisgender men and 1 identified as a transgender woman. Just over half of participants identified as Black (n = 8), one third identified as Hispanic (n = 5), one individual as White (n = 1), and one as Biracial (n = 1). Greater than half reported currently experiencing homelessness (n = 8), and two-thirds reported living in a group setting such as a shelter (n = 10). There were 4 overarching themes: (1) Structural barriers complicated engagement in HIV care; (2) Social support was important for engagement in HIV care; (3) Participants highly valued peer navigation; and (4) mDOT assisted with ART concordance for some participants while others had challenges with smartphone and application use. Participants faced several barriers to care in the post-incarceration period. Participants valued social support and expressed appreciation for both the peer navigator and mDOT application; however, the intervention was not “one-size-fits-all” as some participants found it challenging to use the smartphone and mDOT application. Overall, the intervention appears acceptable, but some participants may need technological support and structural barriers will continue to complicate post-incarceration linkage to HIV care.
Defensive medicine involves clinical practices—either through overuse of interventions (positive) or avoidance of high-risk procedures (negative)—driven by liability concerns rather than patient care. In Egypt, rising medico-legal issues and workplace violence may exacerbate these behaviors. This study assessed the prevalence and drivers of defensive medicine among physicians at a tertiary academic hospital, comparing medical and surgical specialties and examining the impact of prior litigation experience. A cross-sectional study was conducted at Zagazig University Hospitals using a two-stage sampling design, involving stratified random selection of departments followed by voluntary response sampling of physicians through an online questionnaire. Data were collected between 1 November 2024 and 30 April 2025 through a self-administered questionnaire covering: (1) socio-demographic and occupational characteristics; (2) positive and negative defensive medicine practices during physicians’ entire career; and (3) perceived causes of defensive practices and involvement in medical litigation. Data were analyzed using Chi-square and Fisher’s exact tests. Binary logistic regression analysis was performed to detect the associations of age, sex, years in profession, working hours/day, and exposure to workplace violence with defensive medicine practice. Statistical significance was set at p < 0.05. The study included 340 physicians, of whom 323 (95
Canada legalized recreational cannabis in 2018, and one of the primary objectives was to protect youth. Leading up to legalization, the government emphasized a public health approach aimed at delaying initiation, reducing frequency, preventing problematic use and dependence, increasing access to services and prevention programs, and prioritizing early and ongoing public education. Since legalization, cannabis use has increased across all age groups, particularly among youth and young adults aged 16–24. Youth are especially vulnerable to cannabis-related harms due to ongoing neurobiological development, with risks compounded by increases in cannabis potency. Cannabis use among youth has been associated with several adverse effects, including psychosis, depression, anxiety, and suicidal behaviours. To better understand diverse perspectives on reducing the risks and harms associated with youth cannabis use, this study examined recommendations from three key stakeholder groups: youth, parents, and service providers. This qualitative study used a community-based participatory research approach in partnership with Families for Addiction Recovery (FAR), a national charity founded by parents. Participants were eligible if they were Ontario residents and included: youth aged 16–24 who used cannabis regularly, parents/caregivers of youth aged 16–24 who used cannabis regularly, and service providers working with youth aged 16–24 in mental health or addiction services. Using a qualitative descriptive design, we conducted virtual semi-structured interviews and analyzed the data using reflexive thematic analysis. The study included 88 participants (n = 31 youth, n = 26 parents, n = 31 service providers). Participants identified six recommendations to reduce the risks and harms of cannabis use among youth: (1) reduce cannabis access and availability; (2) increase public education on risks and harms of cannabis use; (3) enhance training and education for service providers; (4) expand mental health and addiction services for youth and families; (5) strengthen family support and involvement; and (6) reduce the stigmatization and normalization of cannabis use. The findings underscore the need to strengthen a comprehensive public health approach to cannabis and to address the influence of commercial determinants of health (CDoH), which are profit-driven and can have serious impacts on health outcomes.
Cervical cancer is a common cancer among women worldwide. While preventable and treatable, its incidence is high in Ethiopia, where only 1 out of every 7 age-eligible women have been screened in their lifetime. Systemic barriers to healthcare and inequities in social determinants of health must be addressed to achieve screening coverage. Understanding the specific factors affecting women’s access and decision to be screened can inform healthcare service delivery that is responsive to the local context and population needs to increase reach, feasibility, and appropriateness of cervical cancer screening. This study aims to identify, rank, and qualitatively describe self-reported factors that influence Ethiopian women’s cervical cancer decision-making and care-seeking behaviors. Focus group discussions were conducted with women living with and without HIV (n = 25 each) in Adama, Ethiopia. Embedded within the discussions, an item ranking activity generated dialogue about how various factors influenced screening behavior and participant-driven suggestions for overcoming barriers. Composite salience values (csv) were calculated (range 0 to 1) to determine top-rank factors from most (csv = 1) to least important (csv = 0) across discussions. Qualitative analysis used these factors to perform deductive coding of the interview transcripts and to contextualize the findings with narrative synthesis and direct participant quotes. Participants were 18 to 60 years old (mean age: 34 years) with varied lived experiences in terms of education, religion, marital status, and health status. Participants listed 14–19 different factors related to cervical cancer screening decision and behavior in each of four focus groups (mean: 16.25). Nine determinants emerged as the most salient between groups: socioeconomic status (csv = 0.825); awareness (csv = 0.75); commitment/motivation (csv = 0.55); distance to screening (csv = 0.475); age (csv = 0.475); fear of results/cancer (csv = 0.475); addiction (csv = 0.425); service availability (csv = 0.40); and fear of the screening procedure (csv = 0.325). This study described what women perceived as influential barriers and facilitators to receipt of preventive cervical cancer screening. Addressing low cervical cancer awareness through community-centered education, with a focus on fears, misconceptions, stigma, and self-efficacy to screen while simultaneously addressing structural barriers like transportation, cost, and clinic hours are concurrently needed to increase uptake of preventive screening.
Increasing food insecurity worldwide prompts more reliance on emergency food aid. Little is known about the factors associated with this reliance among populations facing extremely precarious conditions of living and how this aid may influence their dietary habits. This study aimed to define socio-ecological factors associated with the use of food parcels among families experiencing homelessness in France and compare children’s dietary patterns between users and non-users. The ENFAMS survey was conducted by the Observatoire du Samu social de Paris in 2013 with a random sample of 801 families using shelters in the Greater Paris area. Data on food parcel use, family socio-ecological factors, and children dietarry intake (15-item food frequency questionnaire for 6–12 years-olds, n = 235) were collected during face-to-face interviews in 17 languages with parents (mostly migrants). Five dietary patterns were previously derived with principal component analysis and named "Diversified", "Vegetables-And-Dairy-Products" (relatively healthy), "Ready-To-Consume", "Starchy", "Fast-Food" (relatively unhealthy). Multivariable modified hierarchical Poisson and linear regressions were used to assess associations. About 60
Individual differences exist in foot self-care behaviors among patients with high-risk diabetic foot (HRDF), yet classification studies based on population heterogeneity remain limited. This study aims to identify latent profiles of foot self-care behaviors in HRDF patients and to explore their influencing factors. A cross-sectional study was conducted. From May 2025 to January 2026, 402 HRDF patients admitted to the Endocrinology Department of a tertiary hospital in Shanghai were recruited. Data were collected using the General Information, the Foot Care Behavior Questionnaire for Diabetic Patients, the Diabetes Self-Efficacy Scale, the Diabetes Attitude Scale-3, the Diabetic Foot Care Knowledge Questionnaire, and the Social Support Rating Scale. The structure of the Foot Care Behavior Questionnaire for Diabetic Patients was optimized using confirmatory factor analysis (CFA); latent profile analysis (LPA) was employed to identify behavioral subtypes, and multinomial logistic regression was used to analyze the influencing factors. Confirmatory factor analysis (CFA) optimized the 17 items into four dimensions (cleaning and changing socks, inspection and care, footwear and sock selection, and risky behaviors) and six single items. LPA identified four behavioral profiles: “Basic Deficit” (15.7
Sedentary behavior among university students is a growing public health concern. This study describes the development and planned randomized controlled evaluation of Let’s Move, a Transtheoretical Model–based mobile software program designed to promote physical activity among sedentary university students. This randomized controlled trial will be conducted among students aged 18–25 at a university in Istanbul (N = 290). Participants identified as inactive or minimally active by the International Physical Activity Questionnaire will be randomly assigned to experimental and control groups. The sample size (n = 194) was calculated using G*Power (effect size = 0.5; α = 0.05; power = 0.95). Primary outcomes will be physical activity level (MET-min/week) and daily step count. Secondary outcomes will include BMI, body fat-to-muscle ratio, and TTM sedentary behavior scales. Let’s Move is a mobile software program developed within this study for iOS/Android. All participants will use pedometers and wristbands, while only the intervention group will use Let’s Move, which includes short animated videos, motivational messages, step tracking, and data recording. Analyses will include descriptive, parametric/non-parametric, and Chi-square/Fisher tests (p < 0.05). The intervention is expected to enhance physical activity and self-efficacy while reducing sedentary time, body fat, and body mass index. Let’s Move may serve as an effective tool to modify sedentary behavior among university students. If effective, this theory-based mobile program could provide a scalable public health strategy to address sedentary lifestyles in young adults. Clinical Trial Number: NCT05883930, Registration Date: 29.05.2023.
Climate change has increased the frequency and severity of heat waves, leading to a relatively high risk of heat-related illness. This study explores the heat-related illness risk in Bangladesh, focusing on the connection between perception of health risks, adaptation behaviors, and heat-related illness. Using face-to-face surveys, data were gathered from 491 participants through multi-stage sampling techniques across six areas in Dhaka in 2024. The survey examined demographic factors, heat-related illness, perception of health risk, and adaptive behaviors. Binary logistic regression examined factors associated with heat-related illness, ordinal logistic regression assessed determinants of perception of health risk, and Poisson regression identified factors associated with adaptation behaviors. A significance value of p < 0.05 was considered for all analyses. Results showed that participants perceived heat waves as posing low (34
Despite being a curable disease, tuberculosis (TB) remains a major public health problem in low-resource settings, including Uganda, which is among the World Health Organization’s high TB/HIV burden countries. Suboptimal treatment success rates persist, largely driven by treatment interruption and loss to follow-up. While existing evidence has focused largely on programmatic and provider perspectives, limited data exist on patient-reported reasons for TB treatment interruption in Uganda. This study explored patients’ perspectives on factors contributing to TB treatment interruption and identified patient-suggested strategies to improve adherence. A qualitative descriptive study was conducted among TB patients who missed at least one clinic appointment or treatment refill between January and March 2021 at nine purposively selected high-volume public health facilities in central Uganda. Participants were purposively sampled from TB clinic registers to ensure inclusion of individuals with lived experience of treatment interruption. Face-to-face interviews were conducted using structured guides to elicit experiences, perceptions, and contextual factors influencing adherence. Interviews were audio-recorded, transcribed verbatim, and analyzed using inductive (data-driven) thematic analysis, with themes derived through iterative coding following the approach described by Braun and Clarke. Thirty-four TB patients (61.8
Functional disability is a critical public health challenge in aging populations. While lifestyle factors have been extensively studied, the protective role of hobby engagement against functional decline remains underexplored. Thus, this study aimed to examine the association between hobby engagement and functional disability, as well as the potential mediating effects of depressive symptoms across three large international longitudinal cohort studies. We analyzed data from the China Health and Retirement Longitudinal Study (CHARLS), the Survey of Health, Ageing and Retirement in Europe (SHARE), and the Mexican Health and Aging Study (MHAS). Hobby engagement and depressive symptoms were self-reported by participants. Functional disability was assessed using standardized Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) measures. Cox proportional hazards models and General linear mixed models were employed to examine the associations between hobby engagement and functional disability incidence and progression. Mediation analysis was used to explore the role of depressive symptoms. Across all three cohorts, hobby engagement demonstrated consistent negative associations with both ADL and IADL disability. In the fully adjusted models, hobby engagement was associated with a reduced risk of ADL disability (CHARLS: HR = 0.77, 95
Although comorbidity burden and polypharmacy are increasingly prevalent among middle-aged and older adults and may contribute to depressive symptoms, evidence on their joint associations remains scarce. Furthermore, the combined impact of comorbidity burden, polypharmacy, and depressive symptoms on all-cause mortality has not been well characterized. This study aimed to evaluate the joint associations of comorbidity burden and polypharmacy with depressive symptoms, and the joint associations of comorbidity burden, polypharmacy, and depressive symptoms with all-cause mortality among adults aged ≥ 45 years. This dual cross-sectional and cohort study used data from the NHANES 2005–2018, with follow-up until December 31, 2019. Comorbidity burden was quantified using the Charlson Comorbidity Index (low: 0–1; high: ≥ 2), and polypharmacy was defined as the concurrent use of ≥ 5 prescription medications. Depressive symptoms were defined as a Patient Health Questionnaire-9 score of ≥ 10. Weighted logistic regression was used for cross-sectional analyses, and weighted Cox proportional hazards models were applied for mortality analyses. Restricted cubic splines and subgroup analyses were performed. High comorbidity burden and polypharmacy were associated with depressive symptoms. High comorbidity burden with polypharmacy showed higher odds compared with the unexposed group (OR = 3.21, 2.34–4.39) and high comorbidity burden without polypharmacy (OR = 1.53, 1.09–2.15), but no difference compared with low comorbidity burden with polypharmacy (OR = 1.13, 0.76–1.67). High comorbidity burden, polypharmacy, and depressive symptoms were associated with higher mortality. High comorbidity burden with polypharmacy or depressive symptoms showed higher mortality risk than unexposed or single-exposure patterns. Polypharmacy with depressive symptoms showed higher risk compared with the unexposed group (HR = 2.56, 1.87–3.51) and non-polypharmacy with depressive symptoms (HR = 1.46, 1.01–2.12), but no difference compared with polypharmacy without depressive symptoms (HR = 1.25, 0.92–1.70). Among adults aged ≥ 45 years, high comorbidity burden and polypharmacy were associated with depressive symptoms, and the coexistence of comorbidity burden, polypharmacy, and depressive symptoms was associated with increased all-cause mortality risk. These findings underscore the importance of early recognition and integrated management of multimorbidity, medication burden, and depressive symptoms, particularly among middle-aged adults.
As COVID-19 cases increased, organizational changes were implemented in Emergency Departments (EDs) to manage the expected demand. However, the impact of these changes on ED utilization is not understood. This study aims to examine the pattern of hospital-based all-cause ED visits and ED visits for Emergency Care Sensitive Conditions (ECSC) and external causes of morbidity (e.g., falls, traffic accidents) between 2018 and 2021 and assess the effect of the COVID-19 pandemic on ED care utilization by socio-demographic groups. A population-based study including those 18 years and older in region Stockholm (N = 1, 848,271) comparing the utilization of hospital-based ED care obtained from the National Patient Register between 2018 and 2021. The pattern of ED visits was visually assessed, the types of ED visits and socio-demographic composition described, and an interrupted time series analysis was used to assess trend changes between 2018 and 2021. Between 2018 and 2019 the weekly volume of ED visits decreased, followed by a sharp decrease in 2020 and remaining at a reduced level in 2021. ED visits due to external causes followed a similar trend, while the rate of visits for ECSC increased between 2018 and 2019. The trend in ED visits per week decreased by -11.6 (CI: -13.8 to -9.3) between 2018w1-2020w10, a significant level change of -1,175 0.0 ED visits (CI: -1,418.5 to-932.6) compared to 2020w11. ED utilization decreased across socio-demographic groups to various extents although remained lower at the end of 2021 compared to 2018–2019. The reduced utilization of ED care for ECSCs and across socio-demographic groups may indicate that individuals delayed or avoided seeking necessary care during the COVID-19 pandemic. These findings are important in guiding health policy and resource allocation. Moreover, further research is needed to determine whether this decline is due to seeking alternative care sources or forgoing care altogether. Not applicable.
To evaluate public awareness, information sources, treatment preferences, safety perceptions, and common myths regarding tooth whitening and to investigate whether these perceptions differ according to gender and educational level. A cross-sectional survey was conducted among 532 adults recruited via convenience sampling in Türkiye. A 19-item questionnaire, developed through a literature review, expert evaluation, and pilot testing, assessed participants’ demographic characteristics, information sources, treatment preferences, safety perceptions, and beliefs regarding professional and alternative whitening methods. Associations between responses and gender or educational level were analyzed using Pearson chi-square and Rao–Scott chi-square tests (α = 0.05). Associations among the questionnaire items were additionally explored using Pearson chi-square tests with Cramer’s V and Bonferroni adjustment. Dentists were the primary source of tooth-whitening information (58.08
Suspected cardiopulmonary emergencies represent a major component of EMS demand and are highly sensitive to environmental exposures. However, the combined impact of these dual macro-environmental and micro-operational stressors on prehospital treatment effectiveness remains poorly understood. We aimed to evaluate how spatiotemporal, meteorological, and operational factors are jointly associated with EMS demand and immediate on-scene symptom response in a large metropolitan system. This retrospective cohort study analyzed dispatch records from the centralized EMS system of Nanning, southern China (2021–2025). From 38,562 initial activations screened via cardiopulmonary symptom keywords, 15,884 eligible EMS missions recorded from August 24, 2021 to December 31, 2025, were included after excluding non-medical or incomplete records. Objective meteorological data were integrated using generalized additive models (GAM). Multivariable logistic regression incorporating categorical congestion levels and spatial-operational variables was used to identify factors independently associated with unfavorable immediate on-scene symptom response, defined statistically as prehospital treatment failure. Exploratory restricted cubic splines (RCS) evaluated the association between continuous on-scene treatment duration and clinical outcomes. GAM analysis revealed that extreme relative humidity (P = 0.003) and extreme ambient temperatures (P = 0.028) non-linearly were associated with population-level surges in EMS demand. In the integrated multivariable model, severe traffic congestion (CI > 2.0) was associated with unfavorable immediate on-scene symptom response compared with free-flow conditions (aOR 1.19, 95
Despite expanded access to antiretroviral therapy (ART), HIV-related mortality remains a concern in resource-limited settings. We assessed all-cause mortality and the factors associated with death among adults receiving ART in the Sughd region of Tajikistan. We conducted a retrospective cohort study of adults (aged ≥ 18 years) diagnosed with HIV between 2013 and 2022 in the Sughd region who had received ART for ≥ 6 months. Data were obtained from the national electronic HIV case-tracking system. Mortality rates were calculated per 1,000 person-years (PY) and patients were followed from the date of diagnosis until death or censoring at the date of the last available clinical record or HIV viral load measurement. Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) and 95
Black individuals who are currently or formerly incarcerated have experienced disproportionate risk of COVID-19 infection and mortality. Yet, COVID-19 vaccine uptake within this population remains shaped by complex multilevel factors. Guided by the Health Belief Model and Social Ecological Model, this study examined how formerly incarcerated Black adults’ perceptions of their incarceration and reentry experiences influence their COVID-19 vaccine-related beliefs and behaviors. Between March 2021 and August 2022, 12 semi-structured interviews were conducted with formerly incarcerated Black adults recruited from a reentry program affiliated with a local health department in the South-Central region of the United States. The study used an Interpretative Phenomenological Analysis (IPA) design, and an interview guide informed by theoretical frameworks guided each interview. Interviews were audio-recorded, transcribed verbatim, and analyzed using IPA procedures. Findings are organized around six Health Belief Model constructs: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. Participants' perceptions of susceptibility and severity were shaped by their health status, racial identity, and religious or spiritual beliefs, social networks, and experiences with incarceration. Vaccine acceptance was influenced by underlying health conditions, employment needs, family responsibilities, prior vaccine experiences, and perceived benefits to the Black community. Barriers included limited access to trusted information, concerns about vaccine safety and effectiveness, challenging community conditions, and inconsistent messages from trusted leaders. Findings underscore the need for multilevel, culturally informed, and community-engaged health promotion and prevention reentry strategies that address mistrust, improve access to trusted information, and include individuals with lived experience of incarceration as credible messengers.
Current epidemiological data on cancer incidence attributable to human papillomavirus (HPV) infection in China remain unclear. This study provides an updated assessment of the magnitude of and geographic variability in the incidence of HPV-attributable cancer in China in 2013–2017, temporal trends from 1988 to 2017 and projections to 2032. Data were extracted from the Cancer Incidence in Five Continents Volumes VII–XII. The population-attributable fraction was calculated by multiplying the high-risk HPV prevalence at each anatomical site by the specific biomarker positivity rate in HPV-positive cases. Joinpoint regression and age-period-cohort models were used to quantify temporal age-standardized incidence rate (ASR) trends and age and birth cohort effects, respectively. Bayesian age-period-cohort models were constructed to project the HPV-attributable cancer incidence through 2032. An estimated 68,955 and 3463 HPV-attributable cancer cases were observed among females and males in China in 2013–2017, respectively, with ASRs of 11.20 (95
Based on national mortality surveillance data (2004–2021), this study analyzed breast cancer mortality trends in China using Joinpoint regression. Among 110,224 recorded deaths, female crude mortality (7.26/10⁵) far exceeded male (0.14/10⁵), with significant urban-rural disparities. Age-standardized rates highlighted a widened gender gap (female ASMR: 8.10/10⁵; male: 0.17/10⁵). Female crude mortality rose steadily (AAPC = 2.21
