According to United Nations (UN) Women, a 'shadow pandemic' (or secondary crisis) occurred alongside COVID-19: increased violence against vulnerable populations (women and older adults (UN Research Roadmap)). While COVID-19-related morbidity and mortality were lower than expected in Sub-Saharan Africa, this region reports the highest global levels of violence experienced by these groups. In order to investigate this shadow pandemic, we undertook a cross-sectional survey in three countries at the height of the pandemic in order to explore both the impacts of COVID-19, as well as attitudes towards violence against women and older adults. The results illustrate high levels of reported attitudes justifying violence against women (23% in Uganda, 59% in Ghana, and 80% in Kenya) as well as attitudes of acceptability of violence against older adults (39% in Ghana, 69% in Uganda, and 94% in Kenya). Attitudes supporting violence were associated with resource insecurity, low levels of reported well-being, and high levels of reported emotional distress. Addressing violence against vulnerable populations through policy and practice interventions now could serve to preclude similar future shadow pandemics in the face of anticipated global disruptions, such as those related to climate, conflict, and/or health emergencies.
Gambling is a highly visible and socially embedded activity among young people, with marketing, social practices, and digital platforms shaping perceptions and behaviours. This article presents a narrative review of qualitative studies (2015-25) exploring how gambling is normalized among youth and younger adults (up to 35 years), and how they perceive and respond to these processes. Four themes were constructed from n = 22 articles using a reflexive approach to thematic analysis. First, gambling was socially constructed as a normative activity through early family exposure and peer group practices, where participation could both encourage and discourage engagement. Second, exposure to gambling advertising, particularly through sport, was a pervasive driver of normalization, framing gambling as entertaining, glamorous, and overwhelmingly positive. Third, digital access via smartphones, apps, and online platforms further embedded gambling into daily life, enabling engagement in previously restricted spaces and facilitating peer-to-peer participation. Finally, youth and younger adults articulated strategies to counter the normalization of gambling, emphasizing structural and regulatory approaches, including stricter controls on advertising, counter-marketing campaigns, education, and youth participation in policy development. Policy action is needed to tackle the influence of a range of determinants of gambling normalization, with a particular focus on how commercial drivers and political responses impact youth and younger adults in specific sociocultural settings and contexts.
World Cafés are a method to promote inclusive, constructive dialogue to identify solutions to large scale problems. These attributes make World Cafés a potentially valuable tool for multi-sectoral dialogue to identify solutions to health promotion issues such as addressing social determinants of health inequities. However, there are few accounts of World Cafés being used to bring disparate sector knowledges together to address common problems. We sought to test how the World Café method could aid bringing together multi-disciplinary and multi-sector expertise to identify solutions to reduce increasing health inequities in Australia. We conducted World Cafés in each Australian state and territory (N = 8) with a total of 162 participants from academia, government, and civil society. Participants were drawn from sectors including health, education, housing, urban planning, economics, and employment, and from organizations representing Aboriginal and Torres Strait Islander peoples, people with a disability, multicultural communities, youth, and older people. We found different sector participants readily found common ground and collaborated to identify potential public policy solutions to health inequities, generating deep discussion on structural drivers that would not be possible without bringing together these sector knowledges. This upstream focus is likely to identify opportunities to make meaningful changes to create healthier, more equitable societies. Participants reported valuing participation in the World Cafés, making the research more of an exchange compared to other data collection methods. We would suggest World Cafés are a valuable addition to a research toolkit for seeking structural solutions to health promotion issues.
In many high-income countries, including Australia, intensified political, social, and commercial visibility has been widely described as contributing to a contemporary 'menopause moment'. This moment is propelled by the convergence of varied social, political, and economic drivers, but it is also unfolding within a context shaped by historically gendered assumptions about who experiences menopause and how it is experienced. While the current 'menopause moment' has raised awareness across a range of domains, there is also the risk of the amplification and normalisation of a particular type of person who experiences a particular type of menopause. Drawing on three focus groups conducted with 17 trans men and non-binary people with ovaries, this article attempts to intervene in the universalizing tendencies on which prevailing (and pervasive) discourses on menopause circulate. By paying close attention to how transgender and other gender diverse people defined, applied, and potentially resisted such discourses, we reveal how understandings of menopause among trans people were mediated both by their and others' gender, and by the different contexts in which people experience hormonal change, including their experiences of gender affirmation. The contemporary discourses around menopause may be at a tipping point where paradoxically, in the wake of the heightened visibility of menopause, there is a risk of the increasing narrowness of the conversation. Now is the time to move menopause beyond cisgenderism, heterosexism, and binary-based gender so that trans people can be included in this contemporary 'menopause moment' as a matter of equitable health promotion.
Commercial gambling is increasingly recognized as a public health issue, with local government playing a critical role in mitigating its harms. The challenges that public health teams in local government face when there are applications for new gambling premises licences include no mandatory regulatory role; lack of evidence to draw upon and an 'aim to permit' principal entrenched in legislation. This case study examines a city council's refusal to grant a gambling premises licence, and the subsequent legal appeal, which was dismissed in February 2025. Despite the Gambling Act 2005's 'aim to permit' principle, the council denied the application for an Adult Gaming Centre (AGC) due to its proximity to vulnerable populations and sensitive locations. Objections came from public health officials, local residents, and community organizations, citing risks of hidden and invisible gambling harms. The gambling operator appealed, but the court upheld the council's decision, emphasizing the importance of local knowledge, public health evidence, and the limitations of licencing conditions. The Judge criticized the appellant's lack of local knowledge and affirmed that authorities are not required to prove direct harm from a yet-to-open venue. The case sets a precedent for integrating public health into licencing decisions and highlights the legitimacy of using ecological data to assess risk. Success was underpinned by a robust policy framework and strategic preparation. The judgement empowers local authorities to prioritize community wellbeing over commercial interests and challenges industry narratives that downplay gambling harms.
High health literacy (HL) is associated with improved health behaviours and outcomes. Schools are an ideal environment to improve adolescents' HL levels. This study assessed the feasibility of LifeLab Dublin, a co-designed HL intervention, for socioeconomically disadvantaged schools. Students (N = 356) and teachers (N = 15) from four Dublin schools participated in this study. A pre-post follow-up, single-arm feasibility, mixed methods study design was adopted, guided by the Orsmond and Cohn (2015) feasibility objectives. Data sources included research records, semistructured interviews and focus groups, and student and teacher surveys. A combined inductive-deductive reflexive thematic analysis was conducted on the interview and focus group data. Descriptive statistics were run on survey data. Student surveys measured HL, wellbeing, and health-related quality of life at baseline, postintervention, and follow-up. Data sources were analysed independently and integrated during write up. Interviews and focus group data indicated positive experiences with the LifeLab programme among students and teachers. School-level recruitment rates were low (6% participated), but the individual level was strong (91% participated). Attrition rates were 13.8% postintervention and 16.8% at follow-up. Including additional content for each health topic, flexibility in delivery, and the inclusion of structured teacher training may improve the programme. Moderate HL levels and good wellbeing was observed at baseline. Mean increases were observed from baseline to follow-up in students' HL, wellbeing, and health-related quality of life. Evidence supports the feasibility and acceptability of LifeLab for young adolescents and teachers, with progression to a definitive trial as a logical next step.
Online food delivery (OFD) platforms account for a growing share of out-of-home meals, but their often poor nutritional quality may worsen diets and related health inequalities. Furthermore, pricing structures within this sector may be systematically incentivizing the selection of higher-calorie items. Using menu data collected in June 2023 from two major UK OFD platforms, this study examined 7392 unique adult menu items from large restaurant chains. The price-calorie relationship (per 100 kcal) was modelled using restaurant-chain fixed-effects regressions controlling for menu categories. Results indicated a significant nonlinear relationship: while price initially increased with calorie content (101.14 pence per additional 100 kcal, 95% CI [87.98, 114.29]), the rate of increase diminished by 2.19 pence per (100 kcal)2 (95% CI [1.50, 2.87]), suggesting a relative discount for higher-calorie options. Furthermore, menu items classified as 'healthier' (<600 kcal, consistent with recommendation on calorie content per meal in England) were priced relatively higher, costing 70.3 pence more per 100 kcal than items containing ≥600 kcal (95% CI [61.9, 78.8]) after controlling for menu categories. These findings suggest that pricing structures within the UK OFD sector financially favour higher-calorie options. Policy makers should consider strategies addressing pricing mechanisms to ensure healthier options are equally accessible.
The Health-Promoting School (HPS) is a holistic approach that addresses not only the curriculum but also policies, the physical and social school environment, and the school's external environment. Given its complexity in implementation, evidence on effectiveness is mixed. Adequately measuring the implementation of the approach is therefore essential for research and practice. This paper presents the results of a scoping review of instruments that measure the implementation of the HPS approach at the school level. The review was conducted using databases (Scopus, Web of Science, and EBSCO Global Health) and a survey targeting experts and stakeholders in school health promotion to collect unpublished instruments. The instruments were analysed with respect to the HPS components and health topics addressed, and implementation indicators. In total, 28 instruments were retrieved. Heterogeneity in instrument length, recipients, data collection methods, theoretical orientations, and methodological quality in the development and validation was observed. In relation to the HPS model, 'Healthy school policies' was the most frequent component, while 'School Social Environment' was the least addressed. Implementation indicators (implementation outcomes and steps in the implementation process) were present but were mostly not grounded in theoretical frameworks. Among the health topics, 'nutrition' and 'physical activity' were most frequently addressed for students, while 'relationships' was most often found for school staff. For the first time, the study provides an overview of existing instruments to capture the implementation of different components/indicators of HPS. Its results offer room for consolidation and further development of this emerging field.
The commercial determinants of health (CDoH) are increasingly recognized as major drivers of non-communicable disease and health inequities. However, the extent to which CDoH concepts are translated into policy action remains unclear. This study examined the extent to which Australian public health and health promotion policies recognize and respond to the CDoH. We conducted a critical qualitative content analysis of 94 Australian Commonwealth, state and territory public health and health promotion policy documents published between 2015 and 2025. Using a theory-informed a priori coding framework, we examined explicit recognition of CDoH and the nature of proposed policy responses. Eighteen policies explicitly referred to the CDoH or related concepts, all published from 2021 onwards, indicating recent but uneven policy uptake. Legislative and regulatory measures were concentrated in a small number of Commonwealth-led strategies and focused primarily on tobacco, with more limited attention to unhealthy food and alcohol. State and territory strategies relied more heavily on public awareness campaigns and administrative tools rather than direct regulation of the commercial sector. Governance protections against industry interference were largely confined to tobacco control, with no measures targeting the gambling and fossil fuels industries. Australian public health and health promotion policies demonstrate emerging but uneven recognition of the CDoH, with limited institutionalization through regulatory and governance measures. These findings highlight ongoing challenges in translating health promotion and CDoH frameworks into coherent, whole-of-government policy responses to address the commercial drivers of health and health inequity.
Racism in peer review is a common, structurally embedded, and systemic problem. However, it is often framed as isolated acts of individual-level bias. Racism in peer review manifests across interconnected societal, system, and process levels, shaping who participates in knowledge production, what is deemed credible evidence, and whose work is published. This Indigenous-led Perspective examines racism in peer review through a three-layer framework: (1) societal, (2) system, and (3) process (decision-making and interpersonal), situating peer review as one domain within the broader problem of anti-Indigenous publication bias. Grounded in the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), Indigenous Data Sovereignty, and lived experience, we integrate conceptual analysis with illustrative examples to identify intervention points. At the societal level, colonial structures and socio-political forces determine whose knowledges count. At the system level, editorial governance, publishing models, and reward structures reproduce inequities. At the process (decision-making and interpersonal) level, racism cuts across reviewer selection and feedback, editorial decision-making, and dissemination through racialized assumptions, assessment and evaluative practices. We propose concrete, systemic reforms to dismantle racism in peer review, including structural policy reform, diversification of reviewer and editorial pools, anti-racism and cultural safety training, and explicit guidelines. We also outline (co)author responsibilities to act in solidarity when racism occurs. Equity, justice, and fairness in peer review demand more than goodwill. They require enforceable structural change, accountability, and culturally safe practice. Confronting racism is both an ethical imperative and a prerequisite for research excellence, integrity, and health promotion that serves all communities.
Health literacy is one of the most influential concepts in contemporary health promotion. However, its success has created an explanatory shadow. Specifically, complex problems of communication, participation, and engagement are often reduced to deficits in individual health literacy, while relational, organizational, and structural explanations are backgrounded. This paper conceptualized this repetitive explanatory pattern as "health literacy reductionism," the tendency to preferentially translate complex health communication and health promotion problems into a lack of individual health literacy among patients or the public. Drawing on and distinguishing this concept from adjacent critical discussions, including deficit framing, victim blaming, stigma, epistemic injustice, structural approaches, and medicalization, we argued that health literacy reductionism operates as a cross-cutting explanatory logic that can facilitate the reproduction of each of these phenomena. We presented a spectrum that distinguishes valid health literacy explanations from reductionist overextension, together with diagnostic questions for their identification. Four preliminary analytical codes (deficit attribution, presumed incomprehension, omitted alternatives, and design invisibilization) were proposed and applied to the published literature on medication adherence, clinical silence, shared decision-making, and vaccine hesitancy. This study highlighted the implications for research, health promotion, clinical practice, and institutional design.
Physical inactivity among older adults remains a significant public health issue. Age-friendly active spaces with the Seniors Exercise Park equipment in local parks offer an accessible, low-cost opportunity to promote health through physical activity. The ENJOY IMP-ACT project was a multi-site implementation initiative aimed at scaling up the use of the Seniors Exercise Park across six sites in Victoria, Australia. This paper examines factors influencing implementation and uptake. A descriptive practice-based implementation insights approach was used to evaluate the ENJOY IMP-ACT project. Data sources included staff field notes, meeting minutes and park-based activity tracking. Insights were categorized using the TERM framework: training, engagement, resource development, and marketing. Additional analysis considered environmental and organizational factors affecting delivery and uptake. Coordinated planning with local government staff, flexible timelines, and tailored training delivery supported effective program implementation. Local governments with dedicated project officers, clear internal processes, and targeted community engagement strategies demonstrated higher levels of participation. Site visibility, access to amenities, and proactive promotion influenced park usage. Organizational factors, such as changes in staff or limited resources, created barriers to continuity. Efforts to adapt to local contexts, such as modifying training models or leveraging community events, were also important for success. The ENJOY IMP-ACT project highlights the value of a flexible, multi-components implementation framework supported by local partnerships. Consideration of both environmental and organizational factors is essential for sustained delivery of age-friendly health promotion initiatives. These findings offer actionable insights to guide future scale-up efforts in community settings. Trial registration This trial is prospectively registered with the Australian New Zealand Clinical Trials Registry. Trial registration number ACTRN12622001256763. Date registered 20/09/2022. https://www.anzctr.org.au/ACTRN12622001256763.aspx.
Vaccine hesitancy is a persistent global health challenge. This project explored attitudes towards and utilization of COVID-19 vaccination, as well as suggestions to improve utilization within Indigenous communities in Northwest Territories, Canada. Utilizing a cross-sectional design, this project spanned two phases: 10 communities in Phase 1 (April to November 2021), and 11 in Phase 2 (August 2022-January 2023). Self-identifying Indigenous adults (≥18 years) were invited. Quantitative and qualitative data were collected via a semi-structured interviewer-administered questionnaire. In Phase 1 (n = 124; mean age = 41.6 years; 63.7% women) and Phase 2 (n = 221; mean age = 43.6 years; 66.21% women), 78.2% and 87.2% of participants had received at least one dose, respectively. In Phase 1, 67.2% reported not being concerned about the vaccine, and 61.2% believed the benefits outweighed the risks. In Phase 2, 56.2% of participants agreed all eligible individuals should be vaccinated, and 59.2% agreed the vaccine prevented serious outcomes. Bivariate analyses revealed that negative attitudes towards COVID-19 severity, vaccine safety, and effectiveness were significantly associated with lower intention to receive a COVID-19 vaccine in the future. Qualitative insights revealed factors of vaccination hesitancy, including: concerns about safety, efficacy, and necessity; a need for information; and distrust in government. Reasons for utilization included: trust in vaccine safety; perceived necessity; and employment and travel requirements. COVID-19 vaccine utilization in Indigenous communities is high, yet hesitancy persists due to safety and efficacy concerns, and distrust in government. Culturally safe strategies, improved communication, and equitable access are essential to sustaining confidence and future pandemic preparedness.
The Active School Flag (ASF) is a peer-led whole-of-school physical activity (PA) programme in Irish secondary schools. This study assessed the feasibility of implementing the COMMUNICATE toolkit for ASF programme implementers (peer leaders and coordinating teachers). A pre-post, quasi-experimental, mixed-methods design was employed and guided by the Orsmond and Cohn feasibility objectives. Online surveys, semi-structured interviews, and focus groups were collected from six secondary schools (40% recruitment rate), 170 peer leaders, and three coordinating teachers. Survey data were analysed using descriptive statistics and independent and paired samples t-tests. Interview and focus group data were analysed using a combined inductive-deductive reflexive thematic analysis. Data were integrated during the writing-up stage. The toolkit was acceptable and appropriate; however, full implementation was hindered by time constraints within the busy school schedule and short implementation period. Methodological refinements regarding data collection timing and instrument validity and reliability were identified as necessary. Despite no differences between the intervention and control groups' communication skills or health knowledge at follow-up, the toolkit positively impacted peer leaders' personal development and knowledge and the PA and knowledge levels of their peers. While a real-world implementation design, led by programme implementers, may improve intervention sustainability and cost efficiency, implementation support and flexibility in delivery are essential. The COMMUNICATE toolkit was a valuable resource for whole-of-school programme implementers. Nevertheless, changes to the intervention and study procedures are required before proceeding to a definitive trial. Future research should consider an internal pilot within a definitive trial to ensure the changes are sufficient.
Critical health literacy (CHL) is regarded essential for critically appraising health information and making informed decisions. However, evidence on CHL-promoting interventions is low, leaving unclear how such interventions are implemented and evaluated, and which conceptualizations of CHL they draw on. This scoping review systematically identified and characterized CHL interventions, including target populations and settings, theoretical and methodological underpinnings, CHL dimensions addressed, evaluation approaches and reported implementation barriers and facilitators. We searched MEDLINE, CINAHL, APA PsycInfo, PSYNDEXplus and ERIC to September 2025 and supplemented this with backward citation searching. Publications reporting interventions with a stated or implicit CHL focus were included and synthesized narratively. Database searches yielded 3715 records and citation searching identified 117 additional records. After screening, 81 publications describing 53 distinct interventions were included. Publication activity increased from 2016 onwards, peaking between 2021 and 2025. Interventions were conducted in 19 countries and were concentrated in educational settings, mostly targeting school and university students. Most interventions focused on appraisal skills and individual action (e.g. informed decision-making), while broader CHL dimensions such as understanding social determinants of health and collective action were rarely addressed. Barriers included limited time and resources, technical infrastructure constraints and high demands on teachers, while facilitators included leadership support, training or coaching and high-quality learning materials. To strengthen CHL's preventive potential in health promotion, future interventions should prioritize large-scale effectiveness and follow-up studies, while accounting for context-sensitive adaptation, implementation conditions and broader operationalizations of all CHL dimensions across settings.
This article presents a practice-based case study illustrating how the action areas and strategies outlined in the Ottawa Charter can be put into practice and reduces neighbourhood-level health inequalities. The Priority Neighbourhood Development (PND) programme in Worcestershire focused on small, high-need geographical areas identified through analyses of emergency hospital admissions and socio-economic data. Work in the socio-economically deprived Westlands housing area is described in detail. Community development workers mapped local assets and deficits, enabling residents to challenge stigmatizing narratives and build positive place identity. A resident-led working group was established and supported with a devolved budget, facilitating locally determined actions such as expanding counselling provision, enhancing community facilities, developing arts and nature-based projects, and improving skills through training and youth-led initiatives. Co-location and outreach by health, housing, voluntary sector, and policing partners reoriented services towards prevention and accessibility. Evaluation after 18 months showed reductions in emergency hospital admissions and children's social care referrals, improved wellbeing, and reduced social isolation. Qualitative feedback highlighted increased empowerment, strengthened community action, and improved access to support. The model has since been scaled across the County and embedded into local policy and commissioning frameworks. The PND Programme demonstrates how neighbourhood-level investment, resident leadership, and cross-sector mediation can meaningfully reduce health inequalities and build healthier, more resilient communities.
Critical Health Literacy (CHL) emphasizes that health-related action is shaped by power, inequality and structural conditions, not by individual skills alone. This study examines a more specific and under-theorized link in that process: how negative and ambivalent social ties affect whether health-related competencies are enacted as concrete action in everyday healthcare. Drawing on 12 semi-structured interviews with adults living with multimorbidity in contexts of social vulnerability, the study explores how health-related knowledge, intentions, and professional advice are converted, delayed, redirected, or blocked in concrete health-related episodes. Analysis was abductive and used Compensatory Network Capital (CNC) as a sensitizing framework. Participants often described knowledge, motivation, and awareness of recommended care, but action appeared to be constrained when support was difficult to mobilize, poorly matched to the task, insufficiently recognized in institutional encounters, or when no helper was available to act on the person's behalf. These patterns were analysed through four tie-level mechanisms: Activation, Function-specific Help, Recognition and Substitution. Negative and ambivalent ties appeared to operate not only as psychosocial stressors but also as practical barriers affecting help-seeking, follow-up, care coordination and digital navigation. The study contributes to CHL research by specifying a micro-meso relational layer through which health-related competencies may become actionable, partial or blocked in practice. It suggests that equity-oriented health promotion may need to address not only individual skills, but also the relational and organizational conditions that enable, constrain or block health-related action.
Gauteng province was at the epicentre of the COVID-19 pandemic in South Africa. An understanding of the experiences of survivors in this setting has the potential to inform South Africa's preparedness and response in future pandemics. We aimed to explore the experiences of survivors via a qualitative study conducted in Tshwane and Sedibeng districts, Gauteng. One-on-one interviews were conducted on 20 purposefully sampled survivors and carers. Analysis was guided by the framework methods. An explanatory model was developed using the social ecological model. As a result, eight major themes emerged from the study and included participants' awareness and diagnosis of their illness, personal attitudes, quarantine and home care, in-hospital care, psychosocial support, illness outcomes, COVID-19 aftermath, and returning to normal life. The study findings revealed experiences that were intense and filled with morbid thoughts, fraught with physical and emotional challenges, highlighted the need for psychosocial support, and exposed the vulnerabilities and inadequacies of the current South African health system. These experiences implicate several individual, family/communal, health systems, and policy/government level gaps that warrant strengthening for better preparedness for future pandemics.
Digitalization is shaping the environments, behaviours, and systems through which people access, choose, and produce food, yet nutrition has received limited attention within growing scholarly and policy debates on the digital determinants of health. This perspective argues that the digital transformation is shaping nutrition through pathways that are sufficiently distinct and far-reaching to warrant dedicated attention. We propose that there must be a concerted focus on addressing the digital determinants of nutrition (DDoN), defined as structural conditions that influence nutrition through shaping the characteristics, features, uses, and governance of digital technologies and ecosystems, in future research and policy action. Drawing on a narrative review of literature at the intersection of digital transformations and nutrition, we identify five major pathways through which digital technologies are currently shaping nutrition outcomes: precision nutrition solutions; digital nutrition education and information; digital food environments; digital marketing and content; and digitally transformed agriculture and food systems. Across these pathways, digital transformations present both significant opportunities and serious risks for nutrition, with structural risks often disproportionately affecting vulnerable populations. Establishing DDoN as a recognized domain within health promotion would enable a more coordinated, multi-sectoral response and help ensure that digital governance agendas account for their nutritional consequences.
