Public Health and Healthcare

Abstract: The Family Management Measure (FaMM) is a theory-based instrument for assessing how families manage childhood chronic conditions; however, evidence supporting its cross-cultural structural validity remains limited, and no validated Thai version is available. This methodological study translated, cross-culturally adapted, and psychometrically evaluated the Thai FaMM among 350 primary family caregivers of children with chronic conditions. Translation followed the International Society for Pharmacoeconomics and Outcomes Research Task Force guidelines, and psychometric evaluation was guided by the Consensus-based Standards for the Selection of Health Measurement Instruments framework. Structural validity was examined using exploratory and confirmatory factor analyses with independent split-half samples, followed by second-order confirmatory factor analysis where appropriate. The Child’s Daily Life scale retained its original unidimensional structure, whereas Condition Management Ability, Family Life Difficulty, View of Condition Impact, and Parental (Caregiver) Mutuality were more accurately represented by multidimensional hierarchical measurement models. Five of the six scales demonstrated satisfactory structural validity, internal consistency, item discrimination, and excellent test–retest and interobserver reliability. In contrast, the Condition Management Effort scale demonstrated inadequate structural validity and internal consistency. The Thai FaMM is a culturally appropriate and psychometrically robust instrument that extends cross-cultural measurement of the Family Management Style Framework by demonstrating that several family management constructs are better represented as multidimensional hierarchical constructs within the Thai sociocultural context.

Abstract: Background/Objectives: Beginning in mid-life, audiology patients may experience symptoms of age-related cognitive decline that may negatively impact their overall hearing health; thus, understanding the relationship between hearing and cognition is of critical importance. Although the relationship has received considerable attention [1,2] , and numerous theories have been posited to explain it, questions remain. Research indicates that 50% of older adults grapple with severe hearing loss, affecting their daily communication, while Alzheimer’s disease, a prevailing cause of dementia, affects approximately 11% of individuals aged 65 or older. The Lancet Commission underscores hearing loss as a leading modifiable risk factor for dementia, attributing up to 7% of the risk. The purpose of this study was to advance our understanding of the specific domains of hearing and cognition that are related, thus informing theory and clinical practice. Methods: Participants were 99 older adults (mean age = 73 years) recruited from the 10-year Indicators of Cognitive Change study. Two measures of peripheral hearing sensitivity (pure tone average [PTA], high-frequency pure tone average [HF-PTA]) and one measure of auditory processing (Dichotic Sentence Identification [DSI]) were used to predict performance on multiple measures from the Montreal Cognitive Assessment (MoCA) and Cogstate Brief Battery (CBB). Results: DSI emerged as a significant predictor across both MoCA and CBB, surpassing the predictive power of both types of PTAs. Surprisingly, relationships between hearing and cognitive measures differed for MoCA domains versus CBB subtests, highlighting the complexity of this association. Conclusions: The ability to separate and identify competing auditory information may be necessary components of healthy cognitive function.

Abstract: Individuals with chronic kidney disease (CKD) are at high risk of depression and mortality. This study investigated the prevalence and predictors of depression and its impact on all-cause and CKD-specific mortality in American adults with CKD. Data from the National Health and Nutrition Examination Survey, linked to publicly avail-able National Death Index data, was analyzed. Descriptive statistics were utilized to determine the prevalence of depression among adults with CKD. Logistic regression and Cox proportional hazard regression are used for association and mortality analysis. This cross-sectional study included 19032 participants, grouped into healthy (n=13141), T2D (n=3474), CKD (n=1083), and non-T2D related CKD(n=1334). Depression was prevalent in 13.68% of individuals with CKD compared to T2D alone. De-pression was associated with having CKD, being female gender, being a smoker, being obese, and having a low income. Depression was also associated with increased risk of all-cause mortality in participants with CKD compared to T2D alone (adjusted HR 3.58 [2.92 - 4.37] vs 1.17 [0.94-1.47]). Comorbid depression is prevalent and significantly increases all-cause mortality risk in T2D individuals with CKD, particularly in women and younger individuals. These findings highlight the importance of screening for and managing depression in this high-risk population to improve outcomes in healthcare settings.

Abstract: Background/Objectives: Generative artificial intelligence (GenAI) presents immense potential to advance flipped learning approach. Yet, it is under-explored. This study presents the integration of GenAI into a nursing leadership course, guided by Bloom’s taxonomy, and explores the learning experiences of postgraduate nursing students in this GenAI-integrated flipped learning approach. Methods: A descriptive qualitative design was employed, and individual semi-structured interviews were conducted with 9 postgraduate nursing students who had completed a nursing leadership course delivered via a GenAI-integrated flipped-learning approach. Results: Three interconnected themes emerged: (1) GenAI supplements in-person learning, (2) Direct and Socratic questioning, and (3) Factors contributing to GenAI learning experience. Students appreciated that GenAI helped them summarize and understand the learning material, thereby promoting meaningful in-class activities. Students highlighted direct and Socratic questioning as the major approaches in using GenAI. Notably, Socratic questioning, AI-driven thought-provoking dialogue, helped develop higher-order thinking. However, suboptimal prompting techniques was the barrier, while channels for learning prompting and integrating it into the curriculum were facilitators. Conclusions: This study provides evidence on integrating GenAI into higher education. It also provides insights into the potential use of Socratic questioning to develop higher-order thinking in postgraduate nursing education.

Abstract: Background and aims According to the World Health Organization chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and the seventh leading cause of poor health worldwide. Our aim was to evaluate the effectiveness of COPD screening strategy in Romanian primary care, comparing the diagnostic utility of the COPD Assessment Test (CAT) and the Modified Medical Research Council (mMRC) dyspnea scale and post-bronchodilator (post-BD) spirometry. Methods A cross-sectional screening study was conducted among 220 consecutive patients aged over 40 years. The study enrolled patients from the General Practitioner (GP) office. Demographics, clinical history, tobacco exposure, and validated screening questionnaires (CAT and mMRC) were recorded. All participants underwent diagnostic post-BD spirometry. Airflow limitation was defined as a post-BD FEV₁/FVC < 0.70. Results Spirometry confirmed a positive COPD diagnosis in 48.2% (n = 106) of the screened cohort. Severity staging revealed that 34.9% met criteria for GOLD 1, 49.1% for GOLD 2, 15.1% for GOLD 3, and 0.9% for GOLD 4. Smoking history (p < 0.001) was significantly higher in the COPD group. While the mMRC scale at a cut-off of ≥ 2 demonstrated excellent diagnostic specificity (82.5%) the CAT score ≥ 17 had 64.2% sensitivity and 74.8% specificity. Discussion The findings of this screening shows the clinical utility of primary care screening questionnaires. A comprehensive evaluation of symptoms—incorporating cough, sputum production, and sleep impact—provides a much more reliable clinical trigger for diagnostic spirometry than dyspnea alone. Conclusion A targeted screening protocol utilizing CAT score (≥ 17) has high diagnostic utility in Romanian primary care. Screening algorithms in primary care should be focused on individuals over 40 who present with a CAT score ≥ 17, or a tobacco history exceeding 20 pack-years.

Abstract: Background: Human papillomavirus (HPV) persistence drives malignant transformation, yet the systemic role of gut microbiota in HPV clearance remains elusive. Methods: 16S rRNA gene sequencing was performed on fecal samples from condyloma acuminatum (CA) patients and healthy controls. A two-year follow-up stratified patients into HPV turn-negative (HPV_TN) and persistent-positive (HPV_PP) groups. Alpha/beta diversity, LDA Effect Size (LEfSe), PICRUSt2, and Receiver operating characteristic (ROC) analyses were employed. Results: CA patients showed increased alpha diversity and distinct beta diversity versus controls. HPV_PP was characterized by elevated Bacteroides vulgatus and Bacteroides stercoris, while Lactobacillus gasseri was enriched in HPV_TN (p < 0.05). B. vulgatus and B. stercoris formed a co-occurring consortium with other Bacteroides species (r > 0.50, p < 0.05), yielding a combined predictive AUC of 0.756. Functional profiling revealed enrichment in folate one-carbon pool and cobalamin transport pathways in HPV_PP, with reduced ABC transporter activity. Conclusions: This study identifies gut dysbiosis and metabolic alterations associated with HPV persistence in CA, suggesting the gut-reproductive axis modulates viral clearance. These findings highlight non-invasive microbial biomarkers and propose microbiota modulation as a therapeutic strategy, warranting validation in larger cohorts.

Abstract: This article offers a critical exploration of the concept of Sati within Buddhist psychology and its translation into contemporary clinical practice through mindfulness-based interventions. Rooted in over 2,500 years of contemplative tradition, Sati denotes an embodied mode of awareness that integrates attention, memory, and discernment within the immediacy of lived experience. While historically embedded in a spiritual framework, its clinical adaptation in Western psychology has reframed mindfulness as a secular therapeutic construct centred on cultivating non-judgmental, present-moment awareness. The analysis first examines the phenomenological foundations of Sati, outlining its classical dimensions of embodied awareness, affective sensitivity, cognitive vigilance, and recognition of hindrances. It then considers the reconceptualisation of mindfulness within third-wave cognitive-behavioural therapies, where it functions not as an ancillary technique but as a central mechanism of therapeutic change. Programmes such as Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), and Dialectical Behaviour Therapy (DBT) exemplify this translation, applying mindfulness to diverse clinical populations ranging from stress-related disorders and recurrent depression to borderline personality disorder. Across these modalities, mindfulness disrupts habitual reactivity, reduces cognitive and affective rigidity, and fosters psychological flexibility, resilience, and values-consistent living. Taken together, the article argues that mindfulness-based therapies represent a paradigmatic innovation within contemporary psychotherapy. By shifting the focus from first-order symptom change to process-oriented transformation, they expand the horizons of clinical practice and reaffirm mindfulness as both an ancient phenomenological framework and a modern mechanism of psychological healing.

Abstract: Medical nutrition therapy is a cornerstone of the prevention and management of type 2 diabetes mellitus (T2DM). Current international guidelines recommend several dietary patterns, including Mediterranean, vegetarian, low-carbohydrate, and Nordic diets, while emphasizing individualized nutrition therapy rather than a single universal die-tary approach. Among these strategies, carbohydrate restriction has consistently demonstrated favorable effects on glycemic control, although concerns remain regard-ing long-term adherence, safety, and applicability across diverse populations. Moderate carbohydrate restriction has emerged as a practical approach that seeks to balance metabolic efficacy with long-term sustainability. LOCABO®, a moderately low-carbohydrate dietary approach developed in Japan, incorporates three key design principles: meal-based carbohydrate targets (20–40 g per meal), daily carbohydrate targets (70–130 g per day), and dietary flexibility through discretionary carbohydrate intake. These features are intended to reduce postprandial glycemic excursions while maintaining nutritional adequacy and facilitating long-term adherence. This narrative review summarizes current evidence regarding dietary strategies for T2DM, discusses the rationale for moderate carbohydrate restriction, and reviews the clinical evidence supporting LOCABO®, including randomized controlled trials, long-term observational studies, implementation research, and safety evaluations. We also address current controversies related to saturated fat intake, non-sugar sweeteners, long-term clinical outcomes, generalizability, and personalized nutrition. Rather than proposing a single optimal dietary pattern, current evidence supports in-dividualized medical nutrition therapy tailored to patients' metabolic characteristics, nutri-tional status, cultural background, and personal preferences. Within this framework, moder-ate carbohydrate restriction represents a practical, evidence-informed, and sustainable op-tion for the management of T2DM and metabolic health. By integrating clinical evidence with pathophysiological mechanisms underlying postprandial glycemic regulation, this review provides a conceptual framework for positioning moderate carbohydrate restriction within contempo-rary personalized nutrition therapy.

Abstract: Background: How spontaneously breathing individuals modulate inspiratory pressure and peak inspiratory flow (PIF) during incremental positive end-expiratory pressure (PEEP) loading, and whether this differs across respiratory phenotypes, are incompletely characterised. Methods: In a secondary analysis of a public dataset, 78 volunteers (Normal, Asthmatic, Smoker, Vaper) underwent PEEP titration from 4.0 to 12.0 cmH₂O in 0.5 cmH₂O steps. Per-breath mask inspiratory pressure swing (MIPS), PIF, and an exploratory flow-effort ratio (FER = PIF/MIPS) were analysed with PEEP-random-slope mixed-effects models; three electrical impedance tomography (EIT) metrics (pendelluft, Center of Ventilation, Global Inhomogeneity) provided a mechanistic assessment. Results: PIF increased with PEEP across all cohorts (β= +0.068 L·s⁻¹·cmH₂O⁻¹, 95% CI 0.064–0.072, p < 0.001; +68% over the range) and persisted after adjustment for respiratory rate and duty cycle (Ti/Ttot), whereas MIPS increased modestly (β= +0.026, p= 0.004). Asthmatic and Vaper subjects showed significantly steeper PIF responses than Normal subjects (interaction p=0.005 and 0.002, respectively). FER rose uniformly (β= +0.023, p < 0.001), and all EIT metrics were phenotype-independent (no cohort × PEEP interaction, p ≥ 0.35). Conclusions: Progressive PEEP loading raises PIF disproportionately to mask pressure swing, with phenotype-independent regional ventilation, supporting a global mechanism, though regional contributions cannot be excluded.

Abstract: The Global Burden of Disease study quantifies health loss through disability-adjusted life years (DALYs) but captures only the outcome dimension of health capability. The paper argues that adding a structurally defined Health Resource Constraint component to DALYs would reveal a health capability deficit beyond what DALYs alone capture and distinguish realised outcome losses from the structural conditions that produce or precede them. The resulting Health Capability Gap constitutes a GBD+ metric: an extension of burden measurement into capability measurement. This reframing would align global health monitoring with the capability-based and rights-based commitments of the Sustainable Development Goals, Universal Health Coverage, and the WHO Constitution.

Abstract: Global health and development monitoring relies on a narrow set of outcome-based indicators. While these metrics enable cross-country comparisons, facilitate public policy debates, enrich academic enquiry, and guide investment decisions, they are anchored in achieved states and, by design, capture only a limited set of outcomes rather than whether individuals have the freedom to live the lives they value. By shifting the focus from outcomes alone to both functioning and capabilities, this paper proposes a Human Capability Metric (HCM) comprising four interrelated pillars: life-span, productive, reproductive, and agency capabilities. All four pillars are expressed using a common life-course accounting architecture comprising a capability gap, a decomposable loss metric, and a capability-adjusted life expectancy, thereby extending the logic of the Global Burden of Disease (GBD) into a multidimensional capability framework. This provides a more comprehensive and policy-relevant metric for monitoring global health and development.

Abstract: How guests are guided to notice a destination may be as important as the natural features themselves. This article reports a distinct set of outcomes from three facilitator-led arms of a four-condition randomised field experiment whose service-evaluation findings have been published separately. The parent experiment allocated 120 adult resort guests equally, by individual manual lottery, to sky-focused cloud observation, forest-therapy elements, an active control session, or an ordinary stay. The present complete-case dataset comprised 84 participants with linked measurements immediately before and after an organised activity: cloud observation (n = 29), forest-therapy elements (n = 28), and active control (n = 27). The ordinary-stay group was outside the analytical scope because no additional session, and therefore no matched session-level measurement interval, was available. Outcomes in this paper were state anxiety, positive and negative affect, subjective restoration, perceived stress, connectedness with nature, six activity-specific experiential ratings, resting pulse, and blood pressure. Relative to active control, both nature-focused sessions showed more favourable short-term patterns on the central psychological measures. The sky-focused arm was especially associated with awe, widened mental perspective, and distance from immediate concerns; the forest-focused arm showed stronger sensory absorption, bodily awareness, grounding, and the greatest increase in nature connectedness. Cardiovascular changes were small and interpreted only as supportive field observations. The earlier companion publication examined a different module—experience quality, satisfaction, novelty, added value, and recommendation intention—and none of those endpoints is reanalysed here. The present results therefore concern immediate restorative response rather than perceived service performance. Their applicability is limited by the single-resort setting, lack of blinding, complete-case analysis, and absence of follow-up.

Abstract: Background: The Adverse Childhood Experiences (ACE) Pyramid has been widely used for more than two decades to illustrate pathways linking childhood adversity to health outcomes across the lifespan. Since its development, substantial advances in the science of toxic stress have expanded understanding of the biological mechanisms through which adversity influences lifelong health. Objective: To describe the development and scien-tific rationale for a revised ACE Pyramid that reflects contemporary evidence on toxic stress, the biological pathways linking childhood adversity to health, and opportunities for prevention and healing. Methods: An interdisciplinary revision process was con-ducted in collaboration with subject matter experts from government, academia, healthcare, professional associations, and community-based organizations. Iterative re-view and refinement were used to align the framework with current scientific evidence and practice. Results: The revision process resulted in a revised ACE Pyramid that preserves the familiar structure of the existing framework while incorporating contem-porary scientific understanding of toxic stress, the biological pathways linking childhood adversity to lifelong health, and opportunities for prevention and healing. Compared with the ACE Pyramid featured on the CDC website during development of the revised framework, the revised framework more explicitly emphasizes prolonged or excessive activation of the stress response as a central mechanistic pathway linking childhood adversity to lifelong health, expands the biological layer to encompass multiple inter-acting biological systems beyond neurodevelopment alone, and integrates prevention and healing opportunities throughout the framework. Discussion: The revised ACE Pyramid provides a contemporary conceptual framework for understanding how childhood adversity influences lifelong health while highlighting opportunities for prevention and healing. By integrating advances in the science of toxic stress with current understanding of the biological pathways through which adversity affects health, the framework offers an updated foundation for understanding, preventing, and treating toxic stress across the life course. Conclusions: The revised ACE Pyramid translates decades of advancing science into an accessible framework that can support trau-ma-informed clinical care, public health action, and multidisciplinary efforts to prevent and treat toxic stress. By providing a shared scientific foundation for prevention and healing, it can help advance health equity and improve outcomes for children and families.

Abstract: Background/Objectives: Despite recommendations that all hospitalized older adults receive tailored fall-prevention education, studies suggest that many patients at risk of falling do not receive such education. Furthermore, some patients may not recognize having received fall-prevention instructions, potentially limiting their effectiveness. This study examined the proportion of older patients who recognized that they had received fall-prevention instructions from nurses and examined the characteristics associated with this perception. Methods: A nationwide online survey was conducted among Japanese adults aged ≥ 60 years who were currently hospitalized or had been discharged within the previous year. Participants reported their fall-risk factors and whether they had received fall-prevention instructions from nurses. Latent class analysis identified two fall-risk profile groups, and logistic regression was used to examine factors associated with reported receipt of these instructions. Results: Among 3608 participants, more than 40% reported not receiving fall-prevention instructions. After excluding 395 participants without identified fall-risk factors, fall-risk profile and age were associated with reported receipt of instructions. Participants with mobility impairment and other risk factors more frequently reported receiving instructions than those with other risk factors but no mobility impairment (90.79% vs. 47.73%). Conclusions: Whether participants’ reports of not receiving instructions reflect a lack of provision or poor recall remains unclear. In either case, not recognizing or receiving fall-prevention instructions may increase fall risk by limiting patients’ ability to implement preventive behaviors. Enhancing nurses’ awareness of fall-risk profiles and providing consistent patient education may improve recognition of fall-prevention instructions and support fall prevention in hospital settings.

Abstract: This study analysed the relationships among physical activity, physical fitness, and motor competence in primary-school children, and examined whether objectively measured physical activity predicts motor competence and physical fitness. A total of 164 children participated (86 boys; aged 6.65–10.38 years). Physical activity was assessed by accelerometry as the daily time spent in moderate-to-vigorous physical activity (MVPA); motor competence was assessed with the Motor Competence Assessment (MCA); physical fitness with the FITescola battery; and body mass index (BMI) was computed. Pearson correlations and two multiple linear regression models (with robust standard errors) were estimated, with physical activity as the predictor and sex, age, and BMI as covariates. Motor competence and physical fitness were strongly associated (r = 0.65; p < 0.001), whereas physical activity was not significantly associated with either (r = 0.13 and r = −0.04; p > 0.05). In the regression models, physical activity predicted neither motor competence (β = 0.13; p = 0.141) nor physical fitness (β = −0.01; p = 0.855); BMI was the strongest, negatively signed predictor in both models. At these ages, the volume of physical activity is weakly associated with motor competence and physical fitness, highlighting the need for structured, motor-development-oriented school interventions.

Abstract: Background/Objectives: Occupational justice has expanded conceptually and empirically over the past two decades, addressing inequalities related to health, participation, and rights. However, there has been no comprehensive bibliometric analysis of its global scientific output. The objective of this study was to analyze evolution, distribution, editorial structure, collaboration networks, and thematic domains of the literature on occupational justice, using classical bibliometric laws and scientific mapping techniques. Methods: A bibliometric study was conducted on 238 articles and reviews indexed in the Web of Science Core Collection (1982–2026), retrieved using the subject equation TS=(occupational NEAR/0 justice). The laws of Price (growth), Lotka (prolific authors), Bradford (journal dispersion), and Zipf (semantic concentration) were applied. Scientific mapping was performed using co-authorship and co-occurrence analysis from Keywords Plus^® via VOSviewer. Results: Scientific output showed exponential growth (R² = 87.29%), with an acceleration beginning in 2015 and thematic diversification between 2021 and 2026. The geographic distribution revealed a marked centrality of the Global North, along with the emergence of research hubs in the Global South. Just ten journals accounted for 75% of the output, forming a robust editorial nucleus. Co-authorship networks revealed three transnational clusters and bridge authors who facilitate the circulation of knowledge. The thematic map identified three interdependent macro-clusters: health and well-being, occupational practice and science, and justice and rights. Conclusions: Bibliometrics highlights the rapid expansion and editorial concentration of occupational justice, identifies geographic and thematic gaps, and proposes new agendas in digital, environmental, and decolonial fields. Although limited by its sources and methods, it helps guide priorities for more inclusive research, policies, training, and interventions.

Abstract: Regional HPV genotype data for the Yangtze River Delta remain scarce, limiting evidence-based vaccine and screening policy. We retrospectively analysed all 8,515 cervical HPV genotyping records from Xishan People’s Hospital of Wuxi City (January 2024–June 2025) using a 23-type fluorescent PCR panel classified by IARC criteria. Overall HPV prevalence was 22.83% (1,944/8,515; 95% CI 21.9–23.8%). The five leading types were HPV52 (4.82%), HPV58 (3.14%), HPV16 (2.96%), HPV53 (2.50%), and HPV42 (2.08%); HPV18 (0.74%) ranked below two unvaccinated carcinogens, HPV51 (1.76%, IARC Group 1) and HPV68 (1.68%, Group 2A). Age-stratified prevalence was U-shaped (χ² = 123.27, P < 0.001), with peaks at ≤20 years (52.94%; exploratory, n = 51) and ≥61 years (34.66%). Among 1,944 positive women, 43.0% were completely unprotected by the nonavalent vaccine (all types absent from 9vHPV), and 60.4% harboured ≥1 non-9vHPV type. HPV51 and HPV68 together accounted for 15.08% of positive cases. In the co-infection network (n = 585 multiple-type infections), HPV52 achieved the highest degree centrality (281 co-infection events; normalised degree 0.0218) and was present in 8 of the 15 most frequent dual-type pairs, with observed/expected ratios of 6.5–14.8×. These findings reveal a clinically substantial protection gap and support HPV51/68 prioritisation in next-generation vaccine design.

Abstract: Background: Accreditation has become a central mechanism for strengthening healthcare quality systems globally. However, despite the proliferation of accreditation programs, limited empirical literature describes structured methodologies for developing national accreditation standards, particularly in low- and middle-income countries (LMICs). Objective: To describe and analyze the systemic methodology employed by the General Authority for Healthcare Accreditation and Regulation (GAHAR) in Egypt for the development and revision of accreditation standards, and to examine the role of hospital participation in this process. Approach: A descriptive policy analysis was conducted outlining GAHAR’s structured framework for standards development. The process includes stakeholder needs assessment, multidisciplinary drafting committees, external expert review, field testing, pilot surveys assessing inter-rater reliability, editorial harmonization, formal approval mechanisms, and continuous post-publication feedback integration. Key Findings: GAHAR’s methodology aligns with recognized international accreditation paradigms, including committee-based drafting, evidence-informed review, structured pilot validation, and iterative refinement. The inclusion of healthcare facilities and frontline professionals enhances contextual relevance, feasibility, and system ownership. Conclusion: A structured, participatory, and evidence-informed approach to accreditation standards development strengthens national quality governance frameworks. Hospital engagement is not merely consultative but foundational to ensuring implementable, contextually appropriate, and sustainable accreditation systems within LMIC settings.

Abstract: Gait symmetry in children is increasingly understood as a development-dependent continuum rather than a fixed endpoint of perfect bilateral equivalence, a framework that this review extends into a developmental systems model of divergence in cerebral palsy. Typically developing children retain small but measurable inter-limb asymmetries that progressively decrease from early childhood to adolescence. This narrative review asks whether gait asymmetry in hemiplegic and diplegic CP simply fails to reach this normative curve or diverges from it in phenotype- and construct-specific ways that a single asymmetry index cannot capture. Synthesizing longitudinal, cross-sectional, and intervention-based evidence across four interacting domains — direct interlimb symmetry, global and joint-level kinematic deviation, neuromuscular and coordination control, and functional balance — we show that hemiplegic CP is characterized by lateralized divergence involving compensatory changes in the nominally unaffected limb, with partial improvement in directly measured asymmetry over time. Diplegic CP, by contrast, frequently presents with preserved or near-normal left–right symmetry that coexists with progressive, growth-linked deterioration in specific sagittal-plane impairments concealed beneath a stable global gait score, and with a more coupled, less variable coordination strategy that does not correspond to comparable neuromuscular maturation. The recurring finding across both phenotypes is that these domains do not move in parallel, such that reliance on any single metric risks masking clinically important divergences. Building on this evidence, we propose a provisional, non-summative, phenotype-conditioned Trajectory Divergence Index as a hypothesis-generating framework for multi-domain monitoring and identify the absence of longitudinal, multi-domain, multi-phenotype cohorts as the principal evidence gap in the field.

Abstract: Background: Vaccine hesitancy, cost of vaccination and vaccine access are three major barriers to receiving vaccines. Clinica Esperanza/Hope Clinic (CEHC) is a free clinic serving uninsured adults in Providence, Rhode Island. CEHC clinic staff and volunteers hypothesized that mobile vaccine clinics providing free vaccines at multiple community sites might improve vaccine uptake by members of a local uninsured, low-income, and immigrant community living on the West Side of Providence. Methods: This intervention established vaccine uptake baselines by conducting pre- intervention chart reviews of existing patients to compare with participants at the mobile vaccine clinics. Mobile vaccine clinics were scheduled at community sites in targeted zip code areas in Providence and community members were invited to walk-in and receive vaccines at the outreach clinics. Event attendees were asked to participate in an anonymous survey where they were asked about their vaccine habits and beliefs, barriers to accessing vaccines, in addition to demographics questions. Additionally, event attendees’ charts were checked for vaccine completion and to ensure that multidose vaccines were being received in a timely manner. Results: Post-intervention chart reviews of clinic patients during the study period showed a modest increase in routine vaccinations carried out at clinic visits. 545 individuals received vaccines at one or more community vaccine clinics during the intervention period, with 58 individuals attending more than one clinic. Survey results from event attendees showed that being able to access no-cost vaccines in community settings was an important factor in their decision to get vaccinated. Most mobile clinic participants were motivated to get vaccinated to protect their immediate family and the wider community. Conclusion: Access to routine immunizations was increased by partnering with trusted community sites to create mobile clinics. This increase was likely mediated by reducing or eliminating cost and transportation as major barriers to vaccination. Cost and transportation are major barriers to accessing healthcare, including vaccines, and this intervention greatly reduced or eliminated those barriers for individuals.