IntroductionForensic psychiatry is characterized by highly complex case presentations, where co-morbidity, fluctuating symptoms, and elevated risk of disruptive behavior are central concerns. Traditional categorical diagnostic models, such as the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), often fail to capture this clinical complexity. This article introduces an integrated framework that synthesizes three perspectives: complexity theory, transdiagnostic models, and network analysis.MethodsUsing a hypothetical yet realistically constructed case (Mark), we demonstrate how these approaches can collectively lead to a richer clinical conceptualization and a more effective treatment strategy.ResultsComplexity theory offers a dynamic lens through which symptoms are understood as emergent patterns within a feedback-sensitive system. The transdiagnostic approach shifts the focus toward cross-cutting psychological processes, such as emotion regulation and impulsivity, that often constitute the core of psychopathological issues. Network analysis further elucidates the interrelations between symptoms and processes and highlights central or “bridge” symptoms as potential focal points for intervention. Two conceptual network models of Mark’s symptoms and underlying mechanisms illustrate how this integrated approach can enhance both diagnostic clarity and therapeutic precision. Instead of a fragmented treatment plan based on multiple discrete diagnoses, a coherent systemic perspective is established, guiding prioritization and clinical monitoring.DiscussionThe discussion addresses the added value, practical applications, ethical considerations, and implementation challenges of this approach, particularly in forensic psychiatric contexts. This integrated conceptualization holds promise for renewing forensic diagnostics and treatment paradigms, shifting from static disorder classification to dynamic, person-centered networks.

Virtual Communities of Practice (vCoPs) provide collaborative spaces where healthcare professionals and patients can exchange knowledge, experiences, and support. Gamification—the application of game design elements in non-game contexts—is increasingly being integrated into digital health platforms to improve engagement. However, the effectiveness of gamification within healthcare-focused virtual communities of practice (vCoPs) remains unclear. To evaluate how gamification has been implemented within healthcare vCoPs. A systematic search of eight databases (Medline, CINAHL, Embase, Scopus, Web of Science, PsycInfo, ERIC, Global Health) identified studies published from 2000 onwards. Eligible studies reported empirical evaluations of healthcare-related vCoPs incorporating at least one gamification feature. Titles, abstracts, and full texts were screened independently by four reviewers . Data extraction and risk-of-bias assessment followed PRISMA 2020 guidance . Due to heterogeneity in study designs and outcomes, results were synthesised narratively. Of 890 records identified, 269 duplicates were moved, and 621 unique studies were screened and four studies met inclusion criteria. Designs included one quasi-experimental study, two mixed-methods studies, and one cluster randomised controlled trial. Gamification elements across studies included badges, levels, points, challenge-based tasks, and interactive simulations. Educational and professional-development vCoPs reported improvements in engagement, participation, and self-reported learning. The patient-facing intervention demonstrated improved adherence to the Mediterranean diet but no changes in activation, mental health, quality of life, physical activity, or medication adherence. Gamification within healthcare vCoPs shows potential to enhance engagement and perceived value, particularly in educational and professional settings. Evidence for broader behaviour change or clinical impact remains limited. Further rigorous trials with standardised gamification components and longer follow-up are required to assess effectiveness and scalability. This review was registered on PROSPERO, an international prospective register of systematic review (February 2025, reference CRD420251242967).

We investigated the association between unclean cooking fuel use and sleep problems in a nationally representative sample of adults aged ≥65 years from 6 low- and middle-income countries (China, Ghana, India, Mexico, Russia, and South Africa). Cross-sectional, community-based data from the WHO Study on global AGEing and adult health (SAGE) were analyzed. Unclean cooking fuel referred to kerosene/paraffin, coal/charcoal, wood, agriculture/crop, animal dung, and shrubs/grass. Outcomes related to sleep included self-reported nocturnal sleep problems, lethargy, poor sleep quality, and sleep duration. Multivariable logistic regression analysis was conducted. Data on 14 585 individuals aged ≥65 years were analyzed (mean [SD] age: 72.6 [11.5] years; 55.0% females). After adjustment for potential confounders, unclean cooking fuel use was associated with significant 1.51 (95% CI, 1.03-2.22) times higher odds for nocturnal sleep problems, while it was also associated with 1.64 (95% CI, 1.20-2.26) times higher odds for long sleep duration (ie, >9 vs >6 to 9 h), but not with other sleep-related outcomes. These findings suggest that the implementation of the United Nations Sustainable Development Goal 7, which advocates affordable, reliable, sustainable, and modern energy for all, may also have a positive impact on sleep problems, as well as a plethora of other health and environmental impacts. This article is part of a Special Collection on Cross-National Gerontology.

Background The proliferation of Child Sexual Abuse Material (CSAM) on digital platforms poses a critical challenge for online safety, especially for children. Despite global efforts to combat CSAM, opportunities for exposure remain widespread, with limited research on its developmental and psychosocial impacts. Objective This study investigates the prevalence and circumstances of early CSAM exposure and examines associations between age of first exposure and psychosocial functioning among self-reported CSAM users. Method The study analysed survey data from 5642 respondents who have searched for CSAM on the dark web. Descriptive statistics were used to quantify the age and circumstances of first exposure, while chi-square tests assessed whether the context of exposure differed across age groups. Psychosocial functioning (stress regulation, social withdrawal, daily routine management) was compared across age-of-first-exposure groups using one-way ANOVA and MANOVA, with effect sizes assessed for practical significance. Sensitivity analyses addressed missing data. All analyses were carried out using SPSS (version 29). Results Results show that 65.1% reported first exposure before the age of 18 years, with over one-third exposed at age 13 years or younger. Younger exposure was significantly linked to greater difficulties coping with stress and social withdrawal, although daily routines were unaffected. Moreover, half (50.2%) of younger respondents (under 18 years) reported accidental exposure. Conclusion These findings demonstrate the necessity for enhanced online safeguarding to prevent early, unintentional exposure and highlight the psychosocial impacts that may contribute to offending pathways.

BACKGROUND:Strong evidence highlights that sufficient physical activity (PA) has multiple benefits for people living with and beyond cancer. However, many are not meeting PA recommendations. APPROACH is a trial of a theory-driven, app-based behavioral support intervention to promote brisk walking after breast, prostate, or colorectal cancer. OBJECTIVE:The aim of this trial is to evaluate the efficacy and cost-effectiveness of the intervention. METHODS:APPROACH is a multicenter, phase III, 2-armed, individually randomized controlled trial (N=472). We will recruit patients with localized breast, prostate, or colorectal cancer from hospitals in Yorkshire and surrounding areas in the North of England, United Kingdom, and randomize them 1:1 between the intervention and control arm (usual care). The intervention consists of an app designed for the general population to encourage brisk walking (NHS Active 10), supplemented with habit-based behavioral support, including 2 brief telephone or video calls, a leaflet, website, and walking planners. The primary endpoint is the difference between trial arms in the changes from baseline in activPAL-assessed average minutes of brisk walking (≥100 steps per minute) after 3 months. Demographic and medical characteristics will be collected through self-report and hospital records. Secondary outcomes (assessed at 0, 3, and 6 months) will be the other activPAL-assessed outcomes (brisk walking at 6 months, total steps, light PA, standing time, and sitting times, weekly metabolic equivalent of task), self-reported PA, and self-reported BMI and waist circumference. Patient-reported outcome measures of quality of life, fatigue, sleep, anxiety, depression, self-efficacy, habit strength for walking, and social support will also be collected. Interviews will explore experiences of receiving the intervention. We will use health economic modeling to estimate the cost-effectiveness of the intervention over a lifetime horizon. RESULTS:The study was funded in June 2019. Trial recruitment commenced in November 2023 and is planned to be completed in 2025. As of December 2025, a total of 473 participants have been randomized. The publication of the main results is expected in autumn 2027 after all follow-up data collection and analysis are complete. CONCLUSIONS:Overall findings will determine the clinical and cost-effectiveness of the intervention for patients diagnosed with breast, prostate, or colorectal cancer. If successful, APPROACH provides a potential model of supportive care to increase PA among people living with and beyond cancer. TRIAL REGISTRATION:ISRCTN Registry ISRCTN14149329; https://www.isrctn.com/ISRCTN14149329. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/77096.

In this secondary cross-sectional analysis of 847 Spanish adolescents (aged 12-17 years) from the Eating Healthy and Daily Life Activities (EHDLA) study, we investigated whether frequency of helping with dinner preparation and grocery shopping (<3 or ≥3 times/week) were associated with ultra-processed food (UPF) consumption. Generalised linear models, adjusted for covariates, revealed that adolescents who helped prepare meals ≥3 times/week consumed significantly lower UPFs (B = -3.52 servings/week; 95% confidence interval (CI) -5.54 to -1.51, p = 0.001) compared to those helping less frequently. Grocery shopping frequency showed no significant association. Among specific UPF categories, only UPF beverage intake was significantly lower (B = -1.20 servings/week; 95% CI -2.17 to -0.24, p = 0.015); associations for sweets, fast food and other categories were not statistically significant. These findings suggest that regular involvement in home meal preparation, but not grocery shopping, is associated with lower UPF consumption among adolescents.

Eating disorders (EDs) substantially impair physical health, psychological well-being, and social functioning. Shorter untreated illness duration has been proposed to be associated with better outcomes, though evidence for this relationship remains mixed. Nonetheless, delays in accessing treatment remain common and contribute to prolonged suffering and risk of lasting harm. This study aimed to estimate the duration of untreated eating disorder (DUED) and examine potential moderators. A PRISMA 2020-compliant systematic review and meta-analysis was conducted. Searches were performed from inception to March 2026 in PubMed, Embase, PsycINFO, and CINAHL. Random-effects models were used to estimate pooled DUED of available studies, with subgroup and meta-regression analyses to explore moderators. Study quality and risk of bias were assessed using National Institutes of Health (NIH) tools. Of 2,776 records identified, 29 studies (n = 17,433) were included. The pooled DUED of available studies was 21.9 months (95

BACKGROUND:Adults with intellectual disabilities (IDs), particularly those who reside in community living arrangements (CLAs), are at high risk for these chronic diseases. Sedentary behaviour (SB) is an emergent, independent risk factor for several chronic diseases including cardiovascular and metabolic conditions. SB may represent a potent behavioural target to mitigate chronic disease risk in adults with ID who live in CLAs. Limiting the development of interventions to address SB is a lack of understanding of device-estimated SB patterns. Also not clear are the individual-level determinants of SB in this high-risk group of CLA residents with ID. The current study sought to address these knowledge gaps. METHODS:A cross-sectional observational study design was used to characterize SB patterns and individual-level determinants of SB in adults with ID living in CLAs. Thirty-eight adults from 24 different CLAs wore activPAL devices for 1 week to enable device estimates of SB. activPAL data were processed, and the study outcomes of daily time spent in SB, SB bout lengths, sedentary breaks and prolonged SB were generated. Participants also completed an online survey to assess individual factors, which included demographics, independence, programming and health status. Univariate statistics were used to describe SB patterns and logistic regression models were used to ascertain the association between individual factors and SB variables. RESULTS:On average, the sample were aged 44.79 years (SD = 14.9), and 60.53% were male. The sample were highly sedentary: 47.37% engaged in prolonged SB, the daily average time in SB was 7.46 h (SD = 2.18), and an average of 32.4 daily SB bouts (95% CI = 28.9, 35.9) lasted 17.7 min (95% CI = 13.8, 21.7). Participants requiring more assistance with ADLs were more likely to have longer uninterrupted sedentary bouts (95% CI = 0.169, 1.721; β = 0.945; p = 0.018) and total daily duration of SB (95% CI = 4.58, 20.21; β = 12.394; p = 0.003). Those with less than a high school education had sedentary bouts that were ~15 min longer (95% CI = 3.21, 25.69; p = 0.013). CONCLUSIONS:Adults with ID living in CLAs spent almost 8 h of their waking day in SB. Those with lower levels of independence and education were more likely to have higher levels of SB. CLAs may represent a critical opportunity for targeted, place-based interventions to reduce time spent in SB.

The current paper examines how individual/personality factors are associated with the political legitimacy of government restrictions at the onset of the COVID-19 pandemic. A total of 1262 US-based participants completed an online survey comprising several scales (predictor factors), such as the Just World Scale, the Police Legitimacy Scale, and the Authoritarianism Scale measuring aggression, submission, and conventionalism. In addition, they completed scales measuring their Fear of COVID and Perceptions of Government (outcome factors). The results suggest that those who viewed the president or federal government as most responsible had lower legitimacy scores than those who reported their governor, state government, or local official or government to be responsible. Also, those who aligned with the Republican party had the lowest mean for fear of COVID, while the highest was in the "Other" political affiliation, followed by the Democrats, who had the second highest. It also turned out that whereas one's relationships with those who have been hospitalized or died as a result of COVID and individual risk factors for COVID were not significant variables in predicting perceptions of the federal government's handling of the pandemic, the most significant factors were Authoritarianism, Fear of COVID-19, (older) Age, Change in Federal Trust and Political Ideology. Fear of COVID-19 was the only significant factor predicting government legitimacy and individual decisions to engage in protection measures during the pandemic. Theoretical and practical implications are discussed.

Objective: The purpose of this qualitative study is to explore and identify elements used in bowel cancer screening visuals that promote health literacy and participation in screening tests in the United Kingdom and India. Methods: A total of 17 participants from the United Kingdom and India took part in a thematic analysis study. Individuals were eligible for this study, if they were within the National Health Service bowel cancer screening target between ages 50 and 74 years. A total of 58 bowel cancer screening promotional images were presented to the participants, and they had to indicate whether they believed the image effectively encouraged participation in bowel cancer screening. Then, participants were invited for a remote interview to explore their verbal constructions of the bowel cancer screening images. The interview questions were designed to explore participants' preferences and aversions toward the visual elements used in promoting health literacy around bowel cancer screening. Key Results: The findings highlight key visual features that resonate with the target audience and those that may hinder the effectiveness of screening messages. Encouraging elements include images of happy families, the portrayal of screening consequences, clear details about the screening process, and the inclusion of health care professionals. The study also underscores the importance of using both gain-framed and loss-framed messages. In contrast, discouraging elements, such as ambiguous images, such as pictures of toilets, and visuals evoking negative emotions, such as pictures showing internal organs, were identified as barriers to engagement. These visuals may confuse audiences or evoke feelings of disgust, which can deter individuals from participating in screening. The findings suggest that screening promotion materials should incorporate clear, informative visuals that directly relate to the screening process, such as test kits and health care professionals. Conclusions: The study provides practical recommendations for designing effective, culturally relevant promotional materials that balance informational content with emotional appeal, improving the likelihood of increasing bowel cancer screening uptake.

IntroductionEmployment is not merely a means of financial security. It is a key social determinant of health. The Connect to Work (CtW) programme aims to support people with disabilities, long-term health conditions, and other barriers to find, secure, and sustain meaningful employment. The CtW was launched in November 2024 as the commitment and investment in England and Wales to support the Get Britain Working Again white paper. The CtW programme in Greater Essex commenced in August 2025 and has since engaged several hundred individuals across the region. The primary aim of this study is to assess the employment-related changes, including progression into work, sustaining employment, and preventing job loss, during the programme's first year. The findings will inform subsequent years of the programme delivery and development, while contributing to the evidence base on supporting people with barriers to employment.Methods and analysisThis project will use a pre-post single arm study design and utilize a mixed-methods approach. Eligible participants are aged 18 or over and willing to engage in the CtW programme activities. The CtW programme in Greater Essex is delivered by Essex County Council in partnership with three expert providers: Essex Cares Ltd, Essex Partnership University NHS Foundation Trust, and Shaw Trust. The evaluation design includes an online survey, qualitative interviews, participant workshops, and economic evaluation. The survey is administered at baseline, with follow-up points at 3 and 12 months, and explores participants' current housing and financial situations, general health, motivation to seek employment, readiness to enter the workforce, and barriers to employment. Exit interviews with participants, programme facilitators, and wider stakeholders will capture their experiences of the programme, including barriers and facilitators encountered during implementation. Workshops with participants will map their journeys and generate better understanding of their experiences of the programme. Additionally, the economic evaluation will calculate the value of the CtW programme to the Greater Essex economy.Ethics and disseminationThe results of this study will be disseminated through peer- review publications, scientific presentations, and local dissemination activities. Ethical approval was obtained through the Anglia Ruskin University Research Ethics Committee (Reference number: ETH2526-0259).

IntroductionThe volume of Child Sexual Abuse Material (CSAM) available online and the global demand for it has reached unprecedented levels. Increasing numbers of individuals concerned about their online behaviour are contacting therapeutic providers for help and support outside of the criminal justice system. Previous research asking individuals what would help them to stop viewing CSAM suggests that the availability of a technological solution to voluntarily self-manage access to CSAM could be an effective tool.AimTo explore the findings from the user-centered design (UCD) of the ‘Salus’ prototype - a technological prevention tool to support effective self-management of individuals at risk of committing a first or further CSAM offence(s).Materials and methodsIn this two-year, European Commission funded project we conducted research in four European countries: Belgium, Germany, the Netherlands, and the United Kingdom (UK). For the UCD phase of the project we conducted semi-structured interviews with 31 at-risk individuals in Belgium (n=10), Germany (n=10) and the UK (n=11), to explore the specific needs, design features, deployment methods, and concerns and barriers for the design, functionality and deployment of Salus. Additionally, four focus group discussions (FGDs) were held in Belgium, the Netherlands, and the UK with service providers (primarily therapists and managers) with extensive experience of supporting individuals at risk of committing CSAM offences to explore the same questions at the service level.ResultsIn terms of privacy and security, the potential discovery of apps such as Salus, data security and legal consequences of app usage are the main concerns of potential app users. There was consensus on the value of blocking CSAM, but opinions on the inclusion of an optional adult sexual content (pornography) filter in Salus design were not unanimous. Users should be able to switch a pornography filter on and off at their convenience. Blocking notifications should be quiet and subtle. Interactivity features are welcomed by potential users – these may include a diary function; a personal CSAM statistics page; a resources section; and a function to allow users to provide feedback to the app developers. Such features should be optional for users in order to prevent any unintended consequences of app usage. Finally, app deployment must be safe and secure.ConclusionBased on these findings, we propose seven evidence-based design principles for user-centered harm-reduction technology: privacy-by-default architecture; discretion through design ambiguity; adaptive notification systems; optional interactivity with user control; trusted-channel deployment; progressive trust building; and fail-safe harm prevention. These principles provide a framework for app developers and researchers working on similar technologies to develop interventions that reduce harmful behaviours.

The global rise in obesity increasingly includes extreme forms, notably BMI ≥ 50 kg/m², which present disproportionate health risks, especially among older adults. Despite this, most epidemiological research aggregates all obesity (BMI ≥ 30 kg/m²), potentially underestimating the burden of extreme obesity. Understanding trends in this subgroup is critical for targeted public health and clinical responses. We analyzed data from the English Longitudinal Study of Ageing (ELSA) across four waves (2004–2005 to 2016–2017). Data were analysed on the entire population and also for those aged ≥ 65 years. BMI was calculated from measured or self-reported height and weight and classified using WHO standards. Poisson regression with robust error variance was used to assess trends across BMI categories, adjusting for age and sex. Extreme obesity (BMI 50–59.9 kg/m²) increased by 50

Although pesticide exposure occurs through multiple pathways and has been linked to diverse health outcomes, the overall evidence remains unclear. We systematically searched PubMed/MEDLINE, Embase, CINAHL, and Google Scholar up to November 20, 2025, for meta-analyses examining pesticide exposure and adverse health outcomes. We recalculated pooled estimates using random-effects models and converted all effect metrics to equivalent odds ratios with 95% confidence intervals. The quality of included reviews was assessed using AMSTAR 2, and the credibility of evidence was graded using predefined criteria (Class I to IV). A total of 53 meta-analyses covering 235 associations were included. Among the 77 main associations, 48.1% achieved statistical significance, of which 51.4% were supported by highly suggestive or suggestive evidence. Significant associations with pesticide exposure were observed across several health domains, particularly oncological, metabolic, neurological, and respiratory outcomes, with additional signals emerging in subgroup analyses. Particularly, exposures to organochlorine pesticides had increased odds of non-Hodgkin lymphoma. Exposure to dichlorodiphenyldichloroethylenes was associated with diabetes mellitus and non-Hodgkin lymphoma, while exposure to organochlorine insecticides was associated with hypothyroidism. Pesticide exposure was associated with childhood lower respiratory infections among respiratory outcomes. These findings identify priorities for prevention and highlight the need for better exposure assessment.

Background Quality of life is a key outcome in schizophrenia, requiring valid patient-reported outcome measures. We evaluated Schizophrenia Quality of Life (S-QoL) instruments. Methods We searched PubMed, PsycINFO, and Web of Science from inception to Dec 10, 2025. Measurement properties were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines and Risk of Bias checklist, and evidence quality was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Heterogeneity was addressed through COSMIN-based best-evidence synthesis. Neuroimaging studies were reviewed to contextualise the neurobiological basis of S-QoL domains. This review is registered with PROSPERO, CRD420261287006. Findings Fourteen studies demonstrated sufficient validity (content, structural, and construct), internal consistency, and responsiveness of S-QoL instruments. Reliability was supported for S-QoL41 and S-QoL18, but limited for S-QoL-MCAT. Evidence for cross-cultural validity and measurement invariance ranged from very low to moderate certainty, while evidence for measurement error was scarce. Neuroimaging findings supported the construct coherence of S-QoL domains. Interpretation S-QoL41, S-QoL18, and S-QoL-MCAT demonstrate robust psychometric properties and are suitable for clinical research and practice. S-QoL18 offers the best balance between psychometric performance and feasibility. Further research should address cross-cultural validity, measurement error, and thresholds for individual-level change. Funding There was no specific funding source for this research.

BACKGROUND:Numerous studies support the association of exercise training, physical activity (PA) and sedentary behaviour (SB) with both mortality and morbidity outcomes. The results across studies have been inconsistent, and no umbrella reviews have yet been conducted on this topic. METHODS:We conducted an umbrella review of meta-analyses of observational studies by screening articles in PubMed/MEDLINE, EMBASE and Web of Science databases from inception to 30 April 2024. Quality appraisal of each included meta-analysis was done using the AMSTAR 2 tool, with evidence certainty evaluated based on statistical significance, study size, heterogeneity, small-study effects, prediction intervals (PI) and potential biases. RESULTS:Frothy-eight meta-analyses were included (AMSTAR 2 ratings: high 25, moderate 10, low 2 and critically low 11). No evidence was highly suggestive or convincing. Suggestive evidence linked any PA and SB to lower and higher risks of all-cause, cardiovascular and cancer mortality. Suggestive evidence indicated a significant association between self-reported and device-measured total PA (equivalent odds ratio [eOR] 0.78 [0.70-0.86] and eHR = 0.50 [0.38-0.65], respectively), self-reported leisure time PA (eHR = 0.73 [0.66-0.80]), device-measured daily steps (eHR = 0.44 [0.35-0.56]) and aerobic plus resistance training (eHR = 0.60 [0.56-0.64]) with lower all-cause mortality. Weak evidence supported links between self-reported and device-measured SB and higher mortality (eHR = 1.3 [1.22-1.38] and eHR = 2.16 [1.09-4.28], respectively). Suggestive evidence was noted for the association between self-reported leisure time PA (eHR = 0.74 [0.69-0.80]) and resistance training (eHR = 0.82 [0.81-0.84]) with cardiovascular mortality. Suggestive evidence was also found for the association between self-reported leisure time PA (eHR = 0.87 [0.83-0.91]) with cancer mortality. Associations between self-reported running time and mortality from all causes, cardiovascular diseases (CVD) and cancer did not reach statistical significance nor did the association between low skeletal muscle mass and all-cause mortality. Meta-regression analyses showed that physical activity reduces mortality risk, with age reducing the protective effects against all-cause, CVD and cancer mortality. We also found that combined exercise training (aerobic plus resistance) most effectively reduces all-cause and CVD mortality. CONCLUSIONS:Converging evidence supports that physical activity and sedentary behaviour are associated with lower and higher rates of all-cause, cardiovascular and cancer mortality. More high-quality prospective studies are needed for a better understanding of the associations between running time and also TV-viewing time and health-related outcomes.