Introduction More than half of older adults living with Alzheimer’s disease and related dementias (ADRD) never receive a formal diagnosis, and when a diagnosis occurs, it is often years after symptom onset. Primary care clinicians are ideally positioned to detect ADRD early; however, current workflows lack scalable tools that support systematic identification and follow-up. The Passive Digital Marker (PDM), a machine learning model that uses structured electronic health record (EHR) data, can identify patients at elevated risk for ADRD without adding burden to clinicians. This protocol outlines a feasibility study to develop and evaluate a patient-informed secure messaging intervention paired with PDM-based risk stratification to enhance patient engagement in cognitive assessment in primary care settings. Methods and analysis This will be a non-randomised pilot study conducted across 12 single health system primary care clinics. The PDM will be applied to EHR data to identify patients aged ≥65 years who are at high risk for ADRD. High-risk patients will receive a co-designed secure message prior to and after upcoming primary care visits encouraging follow-up evaluation with a trained nurse, the Brain Health Navigator (BHN). The primary objectives are to: (1) determine the feasibility of applying the PDM to EHR data across 12 primary care clinics; (2) assess the feasibility of engaging patients identified as positive on the PDM through secure text messaging prior to a primary care encounter and (3) evaluate engagement with the BHN following secure text messaging. Study outcomes will assess the feasibility of implementing the PDM and secure messaging workflow, including identification of high-risk patients using the PDM, message delivery and patient engagement measured through message open rates, completion of cognitive concern questions and appointments scheduled with the BHN. Quantitative data will be analysed using descriptive statistics. Ethics and dissemination This study was deemed exempt as part of enhanced patient care. The findings will be disseminated through peer-reviewed publications, professional conferences, health system reports and public-facing communications. Trial registration number NCT07016178 .
Objectives We investigated the magnitude and correlates of modern contraceptive non-use among women of reproductive age (15–49 years) in Eswatini (formerly Swaziland). Design Secondary analysis of a cross-sectional, nationally representative, population-based, household survey Setting Eswatini Participants Women of reproductive age in the Swaziland HIV Incidence Measurement Survey 3 2021 dataset Primary outcome measure The primary outcome was non-use of modern contraceptive methods. Results Of 3080 reproductive age women whose data were analysed in this study, 53% were aged 20–34 years, and the majority were from rural areas (66.8%). The weighted prevalence of non-use of modern contraceptives was 33%. The risk of non-use of modern contraceptives was lower among women: aged 20–34 (adjusted risk ratio (ARR)=0.85, 95% CI 0.75 to 0.97); from households of middle wealth quintile (ARR=0.82, 95% CI 0.68 to 0.97); who had given birth at least once (ARR=0.84, 95% CI 0.73 to 0.96); who were living with HIV (ARR=0.79, 95% CI 0.70 to 0.89); and among those who reported being sexually active in the past 12 months (ARR=0.54, 95% CI 0.48 to 0.61). On the other hand, adolescent girls aged 15–19 years (ARR=1.31, 95% CI 1.04 to 1.67) and women who lived in the Manzini (ARR=1.21, 95% CI 1.01 to 1.46) and Shiselweni regions (ARR=1.21, 95% CI 1.00 to 1.45) had a higher risk of not using modern contraceptives. Conclusion Given that a third of women in Eswatini did not use modern contraceptive methods, there is a need to promote modern contraceptive methods in Eswatini, particularly long-acting methods. The Eswatini Sexual and Reproductive Health Program should strengthen initiatives aimed at promoting modern contraceptive use among adolescent girls and those living in the Manzini and Shiselweni regions, who showed a higher risk of not using modern contraceptives.
Objectives Lung ultrasound (LUS) is accurate for diagnosing pneumonia in the emergency department (ED), but standard training is time-intensive, limiting its widespread implementation. We evaluated LUS proficiency for pneumonia diagnosis and perceived adoption barriers after a short training programme. Setting This study was conducted in the frame of the PLUS-IS-LESS trial (Procalcitonin and Lung UltraSonography-based antibiotherapy in patients with Lower rESpiratory tract infection in Swiss Emergency Departments) ( NCT05463406 ), a pragmatic stepped-wedge cluster-randomised clinical trial evaluating a clinical management algorithm combining LUS and procalcitonin to guide antibiotic use for lower respiratory tract infections (LRTIs) in 10 Swiss EDs. Participants All medical supervisors (senior registrars and senior physicians) from the participating EDs were invited to go through the PLUS-IS-LESS LUS training programme and all those who completed the training programme were included in this study. Methods The training programme included an e-learning course, followed by a half-day on-site training session with theory and hands-on practice. For proficiency evaluation, a validated structured assessment of LUS skills (LUS-OSAUS) was adapted into a 32-question online quiz and five bedside LUS examinations. Success was defined as achieving a score ≥80% on both the online quiz and supervised practical assessment. Success rates were compared between physicians according to their characteristics (age, sex, medical experience, previous use of ultrasound or LUS, linguistic region of work and type of hospital) using a χ² test. A 6-month follow-up survey identified factors associated with non-certification and barriers to the clinical use of LUS for managing LRTIs. Results Of 122 trained physicians, 83 (68 %) completed both quiz and supervised LUS and 61 (50%) achieved certification. The most challenging items were pleural line assessment (83% success), recognition of consolidations (83%) and decision-making based on LUS findings (72%). Physicians <40 years had a higher success rate (p=0.009). Among those without complete certification, limited access to an ultrasound machine and low perceived added value of LUS were the main identified reasons. Lack of time was the most frequently reported barrier overall to LUS integration into ED workflows (77%). Conclusion After receiving short training and focused proficiency testing, only half of physicians achieved certification, underscoring the challenges of broad LUS implementation. Limited time, equipment access and low perceived clinical value were key barriers, and integrating LUS findings into decision-making remained difficult. Ongoing support, supervision and protected time may be needed to enhance LUS adoption in EDs. Trial registration number NCT05463406 .
Objectives To describe stress, coping behaviours, anxiety, psychological support and benzodiazepine use among French final-year medical students sitting a high-stakes national ranking examination and to explore how these patterns relate to exam ranking when interpreted through transactional stress and coping and ‘coping reservoir’ models. Design Cross-sectional questionnaire survey. Setting Single university medical faculty in France; final-year students sitting the national Épreuves Dématérialisées Nationales (EDN) and ‘national Objective Structured Clinical Examination (nOSCE)’ clinical examination. Participants All 387 sixth-year students present for the 2025 nOSCE were invited; 192 (50%) completed the questionnaire (69% women; median age 25 years). Inclusion: registered for the national exam and attending nOSCE; exclusion: non-attendance or incomplete questionnaire. Interventions None. Primary and secondary outcome measures Primary outcomes were self-rated stress for EDN and nOSCE and State-Trait Anxiety Inventory-Y (STAI-Y) state and trait anxiety scores. Secondary outcomes included stress management behaviours, psychological/psychiatric follow-up, benzodiazepine and other psychotropic use and final national ranking. Results 92% of respondents reported that stress impacted their daily life, particularly attention (83%), sleep (79%) and learning capacity (64%). Overall, 32% had consulted a psychologist/psychiatrist and 15% used benzodiazepines. Most reported regular sport (86%; ≥2 sports 69%) and breathing exercises (61%). Median nOSCE stress was 8/10; median STAI-Y state and trait scores were 45 and 46. Comparing very low versus high/very high trait-anxiety subgroups, ranking did not differ significantly, but low-anxiety students reported more sport (p=0.04), less benzodiazepine use (1/24 vs 10/37; p=0.003) and far less psychological follow-up (1/24 vs 19/46; p<0.0001). Self-reported coping strategies were not associated with better ranking. Conclusions Final-year medical students preparing for a high-stakes national ranking examination report pervasive stress, substantial functional impairment and frequent professional and pharmacological coping, with only limited linkage between anxiety and performance. Within transactional and coping reservoir frameworks, these results highlight the need for reflection on structural assessment practices and for longitudinal institutional strategies to protect learner well-being.
Introduction Motor skills are integral to numerous developmental domains throughout infancy and childhood. In autism, motor impairments are prevalent and pervasive, often appearing before core symptoms. These motor difficulties have a cascading effect on a child’s broader physical and psychological health, including social, cognitive, emotional and behavioural functioning. Accordingly, researchers are increasingly interested in interventions that improve motor functioning, as these may have a downstream effect on broader developmental domains. One intervention that could address motor difficulties is the AllPlay Dance programme, which provides inclusive dance classes to children in community settings, with pilot data demonstrating acceptability and feasibility among parents and their children with autism and cerebral palsy. This pragmatic randomised controlled trial (pRCT) is thus designed to evaluate whether the AllPlay Dance programme creates the conditions for motor, cognitive and social abilities to thrive in children with autism. Method and analysis This pRCT intends to enrol 70 families of children with autism, aged 7–12 years, living in Victoria, Australia. We will also enrol up to 60 participants with previous dance experience, called buddies, to support the participation of our dancers with autism. We will use our clinical, research, university and community networks to recruit participants. Interested families will complete an online screening survey, followed by questionnaires that parents complete and assessments of the motor functioning in the children. Interested buddies will also complete an online screening survey followed by a baseline questionnaire. Families will be randomly allocated to the intervention group or the treatment-as-usual waitlist control group. The intervention group will attend 9 weeks of community-based dance classes led by disability and dance experts and supported by buddies. The primary outcome is change in motor functioning, as assessed through performance-based measures, with parent reports providing complementary information about everyday motor functioning. Secondary outcomes include improvements in the executive, social, emotional and behavioural functioning of the children, as well as decreases in the stress of parents. We will also evaluate the acceptability and feasibility of this programme, as well as whether families decide to enrol and engage with other dance programmes in the community following the intervention. Ethics and dissemination The study has received approval from the Monash University Human Research Ethics Committee and the Deakin University Human Research Ethics Committee. Findings will be disseminated through a PhD thesis, peer-reviewed publications, presentations at scientific conferences and reports to participants, community organisations and the wider community. Trial registration number Australian New Zealand Clinical Trials Registry (ANZCTR); ACTRN12625000600448; registered on 11 June 2025; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=389672 .
Introduction Intraductal papillary mucinous neoplasms (IPMNs) are common pancreatic cystic neoplasms with malignant potential. Current evidence on IPMN management is derived largely from retrospective surgical cohorts that over-represent high-risk cases and provide limited insight into the long-term outcomes of conservatively managed lesions. Australia currently lacks a prospective national dataset to evaluate surveillance pathways, practice patterns, guideline adherence and long-term outcomes in individuals with IPMN. Variation between international guideline recommendations may also contribute to differences in surveillance intensity and thresholds for intervention. The Australian Pancreatic Cyst Registry (APCR) was established to address these evidence gaps. Methods and analysis The APCR is a prospective, multicentre clinical quality registry that collects clinical, imaging, management and outcome data for individuals with IPMN across public and private healthcare settings in Australia. Historical information is extracted from existing clinical documentation where available, with prospective data collection continuing during routine follow-up. The registry operates under an opt-out model and aims to enrol up to 10 000 participants over a 5-year recruitment period. Participants are followed through routine clinical care until discharge from surveillance, diagnosis of pancreatic cancer, withdrawal or death. Standardised electronic case report forms capture clinical and imaging variables aligned with risk features described in the 2024 Kyoto guidelines. This analysis will describe participant characteristics, cyst features, management and clinical outcomes, with comparative, time-to-event and multivariable analyses undertaken where appropriate. Guideline adherence and the predictive performance of established risk stratification frameworks will also be evaluated. Ethics and dissemination The study protocol was approved by the Monash Health Human Research Ethics Committee (Project ID: RES-24-0000-634A). Findings will be disseminated through peer-reviewed publications, conference presentations and updates to participating sites.
Introduction Schools are key settings to intervene for the purpose of health promotion in children. However, the effectiveness of school-based interventions remains limited, potentially related to the obesogenic behaviours observed during holidays as posited by the structured days hypothesis. This study aims to evaluate the feasibility, process evaluation and preliminary efficacy of the keep moving in a structured summer (KEMOSS) intervention among Chinese children. Methods and analysis The KEMOSS intervention is an 8-week hybrid programme comprising two digitally supported home-based phases (weeks 1–2 and 7–8) and a structured school-based phase (weeks 3–6). The school-based phase will be a full-day scheduled programme that replicates the routine of regular school days, with a coach-led structured physical activity lesson and a free-play lesson embedded in the morning and afternoon, respectively. During the home-based phases, participants will be encouraged to complete prescribed exercises independently with support from mHealth reminders and instructional materials and to achieve a minimum of 10 000 steps per day. Feasibility, process evaluation and preliminary efficacy outcomes will be assessed using a mixed-methods approach. Quantitative data will be analysed using SPSS, while qualitative data from interviews and focus groups will be analysed thematically using NVivo. Ethics and dissemination Ethical approval has been obtained from the Ningbo University Ethics Committee (TY2026028). Findings will inform the refinement of the intervention and the design of a future definitive trial. Results will be disseminated through peer-reviewed publications and conference presentations. Trial registration number ChiCTR2600126738.
Background Engagement with the arts is advocated to reduce stigma and to increase the social inclusion of people living with dementia since the arts powerfully support non-verbal communication, affect and the opportunity to participate in activities that are meaningful to self and others. An example is Sharing Dance Older Adults (SDOA), an innovative, community dance programme that is offered by Canada’s National Ballet School (NBS) intended to support social inclusion by making dance accessible to older adults with a range of physical and cognitive abilities, including people living with dementia. Despite the benefits that SDOA offers people living with dementia and their carers, individuals from historically excluded populations, and more specifically those from racialised groups, have had only limited engagement with the programme. This study thus aims to co-develop with dance artists in the three largest racialised communities in Canada (Black, Chinese and South Asian) culturally relevant SDOA-informed dance opportunities for people living with dementia. Methods and analysis This 3-year study (2024–2027) is a multiple-case and intrinsic-case study design informed by critical participatory action research and the Critical Realism and the Arts Research Utilisation Model. For each of the three racialised communities, implementation and data collection will develop across five phases (preimplementation of professional development for dance artists; implementation of professional development for dance artists; postimplementation of professional development for dance artists; implementation of dance programming; and postimplementation of dance programming). Drawing on organisational partnerships in two Canadian provinces for three racialised communities, we plan to recruit older adults living with/without dementia who will attend the dance programming (n=90), formal/informal carers such as nurses and family (n=30), site managers such as directors of care (n=15), dance artists from the case communities (n=15) and NBS dance trainers who teach SDOA (n=2). Data collection strategies include: semistructured e-diary entries; active interviews; and video recordings of dance classes. All e-diary entries, transcriptions of interviews and video clips selected for full verbatim transcription will be analysed concurrently and recursively, using standard thematic analysis techniques. Ethics and dissemination All five phases of this study have been approved by the Clinical Trials Ontario (CTO Project ID: 4997, 11 June 2026), which is a streamlined ethics review system for multisite studies. All participants will provide written informed consent before taking part in the study. The outcomes will be shared through articles published in journals, presentations at academic and professional conferences, arts-based community events and other knowledge mobilisation forums that include all partners and collaborators.
Objective Sickle cell disease places a significant burden on health systems in sub-Saharan Africa, including Ghana, where access to high-quality, patient-centred care remains limited. This study evaluated patient-perceived quality of sickle cell disease care at a tertiary-level facility in Ghana and explored process factors influencing perceived quality of care. Design Cross-sectional, questionnaire-based study. Setting A tertiary-level healthcare facility in Accra, Ghana. Participants A total of 424 individuals with sickle cell disease were recruited using convenience sampling. Data were collected between 4 September and 16 October 2023 using pretested, interviewer-administered questionnaires. First-time clinic attendees and those requiring urgent medical intervention were excluded. Primary and secondary outcome measures Primary outcome was patient-perceived quality of care. Secondary outcome measures included socio-demographic and process-related factors influencing patient-perceived care quality. Results Participants’ ages ranged from 15 to 66 years, with a median (IQR) age of 32 (27–42) years. Most were female (67.4%), had the SS genotype (51.9%) and 68.6% were on hydroxyurea. Overall, 81.8% of respondents reported receiving good-quality care. Predictors of higher perceived care quality included age (adjusted OR (AOR)=8.9, (95% CI 3.3 to 24.3), p=0.001), hydroxyurea use (AOR=2.3, (95% CI 1.2 to 4.2), p=0.008), good health worker-patient communication (AOR=3.2, (95% CI 1.7 to 6.0), p=0.001), positive provider attitudes (AOR=3.1, (95% CI 1.7 to 5.7), p=0.001), receipt of health education (AOR=2.1, (95% CI 1.1 to 3.9), p=0.030) and shorter waiting times for emergency care (AOR=0.2, (95% CI 0.1 to 0.6), p=0.001). Conclusion This study provides context-specific evidence on process-level determinants of quality of sickle cell disease care in Ghana. Interventions to improve provider communication, enhance provider attitudes, strengthen patient education and reduce waiting times may improve patient experience and contribute to progress towards Universal Health Coverage in resource-limited settings.
Objectives To estimate the annual and overall incidence rates (IRs) of herpes zoster (HZ) in adults with selected immunocompromising or chronic conditions by age and condition and to estimate HZ complications and recurrence in adults with immunocompromising or chronic conditions by age.Design and setting Retrospective observational cohort study using data from the UK Clinical Practice Research Database Aurum, with linkage to Hospital Episode Statistics and the Office for National Statistics data in England (January 2012–December 2019).Participants Adults ≥18 years with no record of HZ or HZ vaccination prior to the index date. Four study populations were identified and included individuals with: selected immunocompromising conditions (immunocompromised (IC) population, N=1 764 900), none of the selected immunocompromising conditions (IC-free population, N=12 867 750), selected chronic conditions (chronic disease (CD) population, N=6 423 633) and none of the selected immunocompromising or chronic conditions (IC-free/CD-free, N=8 235 858).Primary and secondary measures HZ IRs estimated per 1000 person-years (PY) with 95% CIs; percentage (with 95% CIs) of individuals with HZ who developed HZ complications; rate of HZ recurrence per 1000 PY with 95% CIs stratified by age group.Results HZ IRs were higher in the IC and CD populations than in the IC-free and IC-free/CD-free populations and increased with age in all populations (eg, from 3.34 per 1000 PY (95% CI 3.26 to 3.42) in the 18–49 years group to 12.58 per 1000 PY (12.34 to 12.81) in the ≥80 years group in the IC population and from 2.45 per 1000 PY (2.42 to 2.48) in the 18–49 years group to 11.54 per 1000 PY (11.40 to 11.68) in the ≥80 years group in the CD population). A similar pattern was seen across individual immunocompromising and chronic conditions. The proportion of HZ complications increased with age and was higher in the IC and CD populations versus the IC-free and IC-free/CD-free populations. HZ recurrence rates were higher in the IC than IC-free population.Conclusions This very large, up-to-date, real-world study highlights the higher HZ IRs in adults with immunocompromising or chronic conditions in England compared with those without such conditions. This study reinforces the need for the current UK HZ vaccination programme in adults with immunocompromising conditions and can inform further research, clinical guidelines and immunisation policy discussions.
Objectives To explore how participants in the UK’s Targeted Lung Health Check (TLHC) programme understand and respond to incidental findings of coronary artery calcification (CAC) and to identify patient preferences for communication that might enhance engagement with cardiovascular prevention such as lipid-lowering therapy (LLT).Design Qualitative study using semi-structured interviews and thematic analysis.Setting One general practice participating in the National Health Service TLHC programme in North-East England, an area of high social deprivation.Participants Ten adults aged 59–71 years with CAC detected on TLHC CT scans and a calculated QRISK >10%.Primary outcome To explore patient understanding of incidental CAC findings and how this influences engagement with cardiovascular prevention.Secondary outcomes To identify patient preferences for receiving and discussing CAC results, including preferred communication methods, terminology and the role of the clinician in shaping preventive treatment decisions.Results Patients initially reported understanding their findings but deeper exploration revealed misconceptions about personal cardiovascular disease risk. A lack of trust in doctors and reliance on non-clinical information sources (social media, family and friends) were barriers to LLT uptake. Trust in the medical professional giving the advice also shaped acceptance of LLT.Conclusion Enhancing patient education on CAC findings, fostering doctor-patient trust and tailoring communication strategies may improve LLT uptake. Personalised follow-up and clearer risk explanations could reduce hesitancy and improve engagement with preventive care.
Objectives Catastrophic health expenditure (CHE) and impoverishment due to out-of-pocket (OOP) expenditure are the most widely used metrics to assess financial protection in health. This study aimed to investigate the impact of OOP expenditure on CHE and impoverishment in Bangladesh and identify their determinants.Design A national cross-sectional survey.Setting We used data from the latest Household Income and Expenditure Survey 2022 in Bangladesh.Participants 14 395 households from eight administrative divisions in Bangladesh.Primary and secondary outcome measures The well-known methodology developed by Wagstaff and Doorslaer was used in this study to estimate the prevalence of CHE and the effect of OOP spending on impoverishment. We used a generalised linear model with a log link and a gam ma distribution to assess the association between the explanatory variables and annual OOP expenditure.Results The prevalence of CHE was estimated to be 17.72% (95% CI 17.71% to 17.73%) and 7.07% (95% CI 7.06% to 7.08%) using 10% and 25% of the total consumption expenditure as thresholds, respectively. Given the 40% of non-food expenditure threshold level, about 9.46% (95% CI 9.45% to 9.47%) of households faced CHE due to OOP expenditure in Bangladesh. In 2022, approximately 3.7% (95% CI 3.7% to 3.71%) of the population (6.13 million people) fell into poverty in Bangladesh. The prevalence of CHE was higher among male-headed households, larger families, households with elderly members, households with members suffering from chronic illnesses, those using hospital care and individuals in the poorest wealth quintiles.Conclusions Our study indicated that the financial burden due to OOP expenditure was substantial in Bangladesh. Findings stress the need for prepayment schemes such as national health insurance for safeguarding households against falling into poverty.
Introduction Keratinocyte cancers (KCs) are increasing in incidence in the UK, with over 234 000 cases annually, largely due to demographic changes and sun exposure. Skin cancers, including malignant melanoma and KCs, are projected to cost the NHS over £180 million annually and impose healthcare demands. Although KCs have high cure rates following surgical excision and primary closure, wounds healing by secondary intention (HBSI) particularly on the lower leg present clinical challenges. Compression therapy (CT) known to improve venous insufficiency and venous ulcer healing may also benefit HBSI following lower limb KC excision but current evidence is sparse. Methods and analysis H ealing of E xcision A l wounds on L ower legs by S econdary intention (HEALS2) is a multicentre, prospective, Phase III, parallel group, open-label, randomised controlled trial with embedded internal pilot and blinded endpoint assessment. A total of 396 participants (≥18 years) from UK skin cancer surgery centres will be randomised 1:1 to assess the clinical and cost-effectiveness of standard care (SC) alone or with CT (SC+CT) for surgical wounds HBSI following excision of lower limb KCs. The primary outcome is time to healing from randomisation (maximum 52-week follow-up). Secondary outcomes include incidence of infection, antibiotic usage, scar quality, safety (including complications and hospitalisations), quality of life, cost-effectiveness and relationship between post-partial closure wound area, type of partial closure method and time to healing. Exploratory objectives include association between short-term wound area reduction and time to HBSI, patient acceptability, adherence and associations between wound breakdown post-healing and CT use. A qualitative sub-study will explore patients’ experiences and decision-making during CT use. Primary endpoint analysis will be conducted on the intention-to-treat population using a multivariable Cox Proportional Hazards modelling. Secondary outcomes and safety will be evaluated using other regression models and descriptive statistics, respectively. Cost-effectiveness will be evaluated using within-trial analysis and decision-analytic modelling. Patient and public involvement representatives are contributing to trial design and oversight. The study protocol complies with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) Statement. Ethics and dissemination Ethics approval has been granted by the Yorkshire & The Humber – Leeds East Research Ethics Committee (ref 23/YH/0247). Findings will be published in high-impact peer-reviewed journals. Trial registration number ISRCTN12417689 .
Introduction Child and adolescent tuberculosis (CATB) poses a significant global burden with an estimated 1.25 million diagnoses and 191 000 deaths annually, disproportionately higher than adult rates. Over half of CATB cases remain unreported, and burden increases are expected following the USA’s tuberculosis (TB) aid withdrawal, particularly affecting high-burden countries including Namibia. Namibian children under the age of 15 years account for 10% of notified TB cases, with under-reporting suggesting higher actual morbidity and mortality. Through a multistakeholder process in 2024, Namibia’s National Tuberculosis and Leprosy Programme (NTLP) updated its National Clinical Guidelines for CATB management. We aim to (1) assess baseline levels of CATB diagnosis and management knowledge and (2) evaluate post-training knowledge, attitudes and practices (KAP) with updated guidelines to identify gaps informing targeted interventions and policy refinement. Methods and analysis We plan to conduct a two-phase evaluation of healthcare workers’ (HCWs) KAP regarding CATB diagnosis and management across Namibia. A collaborative team from Dartmouth, the University of Namibia (UNAM) and NTLP developed, piloted and refined a standardised assessment tool. 256 HCWs involved in all TB care levels are selected at three facilities per district across 16 districts stratified by TB burden (high, medium and low). Baseline data (KAP1) were collected before national training on updated guidelines, with follow-up assessment (KAP2) planned at 6 months post-training using the same procedures on a secure Research Electronic Data Capture (REDCap) platform. Descriptive analyses and regression models will summarise baseline KAP, while McNemar tests and paired t-tests will evaluate changes over time for participants who completed both KAP assessments. Ethics and dissemination Ethics approval was obtained from the UNAM and the Ministry of Health and Social Services (MoHSS). Written informed consent is obtained from all participants, protecting confidentiality and using secure data storage. Findings will be disseminated through Namibian MoHSS reports, conference presentations, peer-reviewed publications and policy briefs.
Objectives This study aimed to explore healthcare workers’ lived experiences of job satisfaction and examine the multilevel factors perceived to shape these experiences at Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia. Design A descriptive phenomenological qualitative study was conducted using in-depth interviews and focus group discussions (FGDs). Setting Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia. Participants A total of 24 in-depth interviews and 12 FGDs were conducted with purposively selected hospital staff. Methods Data were collected using semistructured interview guides informed by the Social Ecological Model to explore experiences and factors across individual, interpersonal, organisational, community and policy levels. All interviews and discussions were audio-recorded, transcribed verbatim and thematically analysed using ATLAS.ti V.9 Findings Job satisfaction emerged as a multidimensional experience formed by interconnected factors across individual, interpersonal, organisational, community and policy levels. At the individual level, high workload, burn-out and low salary were key challenges. Interpersonal factors included strained patient–provider relationships and lack of recognition. Organisational barriers such as staff shortages, inadequate infrastructure and limited training opportunities contributed to difficult working conditions and dissatisfaction. At the community level, limited or changing public respect for health workers was reported. At the policy level, delays in procurement systems and inconsistencies in benefit distribution contributed to demotivation. Despite these challenges, many participants expressed a strong sense of professional commitment and purpose. Conclusion Hospital staff’s job satisfaction was experienced as a multidimensional phenomenon formed by interconnected conditions across multiple levels of the work and broader health-system environment. The findings suggest that efforts to improve healthcare workers’ experiences should consider these interconnected levels, including fair compensation, supportive leadership, adequate staffing and infrastructure, equitable access to opportunities, and responsive institutional and policy support. Such contextually responsive approaches may contribute to a more supportive working environment and strengthen healthcare workforce well-being and retention in Ethiopia.
Introduction Nature-based interventions aimed at promoting health, enhancing well-being and supporting medical treatment have long been a focus of public health research. In particular, forest therapy and forest bathing are well established in Asia as evidence-informed approaches to stress reduction. In Europe, research on forest therapy is expanding although the field remains comparatively young. Existing studies have mainly focused on the short-term effects of single forest visits while evidence on multiweek interventions and potential medium-term to long-term effects remains limited. The project Forest|Health ( Wald|Gesund ), embedded within the research consortium T!Raum-Initiative One-Health-Region Pomerania located in northern Germany, aims to address this gap by developing a structured forest therapy intervention tailored to three different target groups. Methods and analysis The study protocol describes a pilot study to evaluate a modular forest therapy intervention with regard to feasibility indicators as well as stress-related and symptom-related exploratory outcomes. A total of 120 participants will be recruited across three target groups: community-dwelling adults aged 65 years and older, adults with arterial hypertension and adults with depressive symptoms recruited from treatment waiting lists. Using a multimethod approach, two preliminary studies were conducted: a survey of community-dwelling individuals in the region and focus groups with regional stakeholders. Additionally, a 2-week pilot study of the intervention was conducted. Based on these findings, a 4-week modular forest therapy intervention will be implemented. Participants will be assigned to intervention modules with distinct content using a quasi-randomised procedure. The intervention will follow a pre–post design with follow-up assessments. Feasibility indicators will be assessed as key process outcomes. The primary exploratory outcome will be stress while secondary exploratory outcomes will include psychological and physiological health-related measures. Ethics and dissemination The study was approved by the Ethics Committee of the University Medicine Greifswald. Participants will provide informed consent, receive information about potential risks and support options. The results will be disseminated through scientific publications, conferences and public outreach. Trial registration This study protocol is preregistered on the Open Science Framework (OSF; Registration DOI: 10.17605/OSF.IO/C2D5P; last update 16 December 2025).
Objectives To assess HIV knowledge, stigma and perceived adequacy of HIV curricular coverage among medical students in Egypt and to identify factors associated with HIV stigma.Design An online-based cross-sectional study.Setting Medical schools across Egypt. Data were collected in August 2025 using a bilingual (Arabic/English) online questionnaire using convenience sampling.Participants First- through fifth-year students enrolled in Egyptian medical schools.Primary and secondary outcome measures HIV knowledge was assessed using the Brief HIV Knowledge Questionnaire (HIV-KQ-18); HIV-related stigma was assessed using the Healthcare Providers HIV/AIDS Stigma Scale (HPASS) and perceived adequacy of HIV curricular coverage.Results A total of 1503 students participated (mean age 20.6 years; 57.4% female), half of whom (48.9%) rated curricular coverage of stigma and psychosocial aspects of HIV as inadequate. The mean HIV-KQ-18 score was 8.96/18 (SD 4.26). Only 39.9% recognised that HIV cannot be transmitted through kissing, 47% believed washing after sex is protective and just 41.3% knew that not all infants born to mothers with HIV will have AIDS. The mean HPASS score was 60.1/108 (SD 17.6). Most students (76.8%) worried about contracting HIV from patients, 52% believed patients acquired HIV through risky behaviours and 43.6% endorsed a right to refuse providing care. Knowledge and stigma were inversely but weakly correlated (r = −0.17, p<0.001), and higher knowledge was independently associated with lower stigma on multivariable regression (B=−0.16, p<0.001). Despite higher knowledge, males reported significantly higher stigma (B=0.25, p<0.001) compared with their female counterparts. Similarly, participants who completed the Arabic form had significantly lower knowledge and higher stigma (B=0.24, p<0.001).Conclusions HIV stigma is prevalent among medical students in Egypt, with significant variations observed across gender, survey language and levels of HIV knowledge. These findings call for multifaceted interventions and curriculum reform to reduce stigma among future clinicians.
Objective To examine the association between sleep quality and psychological resilience in a Chinese community-based cohort and assess the consistency of this association across two sleep measures.Design Cross-sectional analysis of baseline data.Setting Community-based cohort in Hangzhou, China (2016–2019).Participants 10 268 adults aged 18–80 years enrolled via quota sampling stratified by sex and age group. After excluding participants with missing data, analytic samples were 9781 (single-item measure) and 9780 (Pittsburgh Sleep Quality Index (PSQI)), owing to one additional missing response.Primary outcome measure Low psychological resilience, defined by a median split on a 9-item scale adapted from the Brief Resilience Scale and Connor–Davidson Resilience Scale.Results Poor sleep quality was associated with higher odds of low resilience across both measures (single-item measure, adjusted OR=1.5, 95% CI 1.3 to 1.6; PSQI, adjusted OR=1.5, 95% CI 1.4 to 1.7), after adjustment for demographic factors, socio-economic factors, mental health indicators and health behaviours. Interaction tests showed no evidence of effect modification by sex, age group, loneliness or depression history for the single-item measure (p>0.05). For the PSQI, the association differed by loneliness (p<0.05), with a larger magnitude of association among lonely participants (adjusted OR=2.1, 95% CI 1.6 to 2.7) than non-lonely participants (adjusted OR=1.5, 95% CI 1.3 to 1.6).Conclusions Poor sleep quality was consistently associated with low resilience across both measures. Because the design was cross-sectional, temporal direction cannot be established. Longitudinal and interventional studies are needed to establish temporal ordering, and intervention studies are needed to determine whether improving sleep increases resilience.
Introduction Testosterone deficiency in middle-aged men is associated with a wide range of adverse health outcomes, including metabolic disorders, reduced physical performance, sarcopenia, impaired sexual function, psychological distress and decreased quality of life. Despite its growing clinical and public health importance, early identification of men at increased risk remains challenging. Current diagnostic approaches rely primarily on laboratory assessment of testosterone levels, which may not adequately reflect symptom burden and are often inaccessible in resource-limited settings. There is therefore a need for comprehensive and practical approaches that integrate anthropometric, functional and lifestyle-related factors associated with serum total testosterone levels.Methods and analysis This population-based analytical cross-sectional study will be conducted among middle-aged men aged 35–59 years residing in the Andijan region of Uzbekistan. Approximately 600 participants will be recruited through community-based screening programmes, primary healthcare institutions, workplace outreach and public announcements. Data collection will include anthropometric measurements, assessment of muscle strength and physical performance, lifestyle characteristics, dietary habits, sleep quality, symptoms suggestive of testosterone deficiency, lower urinary tract symptoms, muscle function and laboratory evaluation of serum total testosterone concentrations. Standardised questionnaires and validated clinical assessment tools will be used. The primary outcome is serum total testosterone concentration. Secondary outcomes include identification of anthropometric, functional and lifestyle-related factors associated with serum total testosterone levels and development of a multivariable predictive model for the early identification of testosterone deficiency. Statistical analyses will include correlation analyses, multivariable linear and logistic regression models and receiver operating characteristic curve analysis to evaluate model performance.Ethics and dissemination The study was approved by the Ethics Committee of the Ministry of Health of the Republic of Uzbekistan (Approval No. 4/26-2380, 13 May 2026) and registered at ClinicalTrials.gov (NCT07476222). Written informed consent will be obtained from all participants before enrolment. Study findings will be disseminated through peer-reviewed publications, scientific conferences and academic networks. The results are expected to contribute to the development of accessible screening strategies for the early identification of testosterone deficiency among middle-aged men.Trial registration number NCT07476222.
Objectives To examine the predictive contributions of clinical, non-clinical and policy-related factors to cesarean section (C-section) utilisation under Indonesia’s National Health Insurance (JKN) and to assess whether the predictive relationships differed between the periods before and after the 2023 Indonesia Case-Based Groups (INA-CBG) tariff reform. We developed and temporally evaluated machine learning models to determine whether non-clinical and tariff-related variables provided additional predictive information beyond clinical risk factors.Design Retrospective observational study using Random Forest and Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression models applied to national hospital claims data from 2022 and 2023. Models were developed separately by year and evaluated within and across years to assess discrimination, calibration, predictor selection and temporal transportability.Setting Under JKN, coverage is limited to medically indicated C-sections, reimbursed through the INA-CBG payment system. In 2023, INA-CBG tariffs were recalibrated nationwide, increasing payment levels and introducing regional payment reclassification.Participants A total of 39 049 delivery episodes involving 38 535 women with recorded mode of delivery in JKN-affiliated referral hospitals between January 2022 and December 2023.Primary and secondary outcome measures The primary outcome was mode of delivery (C-section vs vaginal birth). Model discrimination was evaluated using the area under the receiver operating characteristic curve, with bootstrap CIs. Calibration was evaluated using decile-based calibration plots. Secondary analytical measures included Random Forest variable-importance rankings, predictors retained by LASSO logistic regression and differences in model performance across within-year and cross-year evaluations.Results C-section rates remained high and stable at approximately 66% across the study period. Models demonstrated consistent discriminatory performance across years. Clinical risk factors remained the strongest predictors of C-section use. However, non-clinical characteristics—including subsidised insurance status, inpatient class, referral pathways and private facility ownership—gained greater predictive prominence following the 2023 tariff reform. Cross-year evaluation showed reduced discrimination when models were applied to data from the alternate year.Conclusions Clinical risk remained the dominant predictor of C-section utilisation under JKN, while non-clinical, health-system and tariff-related variables provided additional predictive information. Cross-year analyses indicated modest temporal differences in predictive relationships and limited model transportability across the two study years. Future studies should use longitudinal and quasi-experimental designs incorporating procedure-specific tariff changes to evaluate causal mechanisms.
