Public Health and Healthcare

Abstract: Suicide attempts, bullying, and insufficient sleep duration are significant public health concerns among US adolescents. While research has identified sleep as a modifiable factor linked to both bullying and suicidality, it remains unclear whether sleep duration influences the relationship between bullying and suicide attempts. This study examined whether sleep duration moderates the association between bullying (school and electronic) and suicide attempts among US adolescents. Data were drawn from the 2021 National Youth Risk Behavior Surveillance System, a nationally representative survey of US students in grades 9–12. Primary exposure was self-reported school/electronic bullying. Suicide attempts were the outcome. Self-reported sleep duration was the moderating variable. Multivariable log-binomial models and interaction effects were examined on both multiplicative and additive scales. Among 17,134 students, bullying was associated with a greater risk of suicide attempts, with the highest risk among those experiencing school and electronic bullying RR = 2.13, 95% CI, 1.75–5.89. Sleep duration moderated this association, with lowest risk observed at 7–8 hours and greater risks at ≤ 4 and ≥ 9 hours. Additive interaction analysis revealed the proportion of suicide attempt risk attributable to the interaction of school bullying with a sleep duration of ≥ 9 hours was 68%. Sleep duration moderates the relationship between bullying and suicide attempts in US adolescents. Reducing bullying and promoting optimal sleep duration in adolescents could substantially lower suicide risk.

Abstract: This study examines the role of leadership support in enhancing employee morale and strengthening Total Quality Management (TQM) implementation within a Sub-Saharan African public hospital context. Public hospitals in the region continue to experience service delivery challenges despite formal commitments to quality improvement, suggesting a persistent gap between quality management policy and operational practice. Guided by the Resource-Based View (RBV), the study conceptualizes leadership capability, employee morale, resources, and process management as strategic organizational resources that influence healthcare service delivery. A deductive, quantitative, cross-sectional survey design was adopted. Structured questionnaires were administered to 150 hospital staff members and 250 clients at the hospital of study, with response rates of 65.3% and 79.6%, respectively. Data were analysed using descriptive statistics, correlation analysis, and multiple regression analysis. The findings indicate that leadership support for TQM, resource adequacy, and managerial task execution were generally perceived as low to moderate. Regression results further revealed that TQM Leadership and TQM Process were the only dimensions that significantly and positively influenced employee morale. These findings suggest that leadership is not merely one dimension of TQM, but the strategic capability that activates other TQM dimensions by mobilizing resources, supporting employees, and aligning processes with quality objectives. The study concludes that leadership-enhanced employee morale represents a critical missing link between TQM implementation and improved healthcare service delivery. It recommends leadership development, stronger resource commitment, employee engagement, process improvement, and institutionalisation of a TQM-oriented culture in public healthcare settings.

Abstract: Background: During the geographically dispersed 2026 Bundibugyo virus disease (BVD) outbreak in the Democratic Republic of the Congo (DRC), 21 days without a newly attributed confirmed case may inform health-zone surveillance and resource-allocation decisions while transmission continues elsewhere. However, the frequency and timing of renewed confirmed-case reporting after this interval have not been quantified. Methods: A retrospective cohort study was conducted among health zones affected by the 2026 BVD outbreak in the DRC. The primary data source was the national situation-report series, triangulated with World Health Organization weekly reports. Health zones that completed 21 days without a newly attributed confirmed case by 2 August 2026 entered the cohort. The observed recurrence proportion, incidence per 100 zone-days and Kaplan-Meier time to recurrence were estimated. Spatial adjacency to zones with reported confirmed-case activity during the 21 days before each focal health zone completed the interval was described. Results: Seventeen of 51 affected health zones completed the 21-day interval. Ten subsequently reported recurrence and seven were right-censored, giving an observed recurrence proportion of 58.8% (95% exact confidence interval 32.9% to 81.6%). The incidence was 2.83 recurrences per 100 zone-days (95% confidence interval 1.36 to 5.21). The estimated cumulative probability of recurrence was 20.0% by day 7, 41.3% by day 14, 48.7% by day 21 and 56.0% by day 28; median recurrence-free time was 22 days. All recurrent health zones and five of seven censored zones shared a boundary with a zone that had reported confirmed-case activity during the 21 days before threshold crossing. Aggregate reports could not distinguish persistent undetected transmission, reintroduction, delayed confirmation or retrospective attribution. Conclusions: Completion of 21 days without a newly attributed confirmed case was frequently followed by reported recurrence. The interval should not be used as a stand-alone trigger for substantial surveillance de-escalation. Decisions should also consider subsequent observation time, nearby case activity, surveillance performance and unresolved laboratory or reporting constraints.

Abstract: Hospital pharmacy replenishment decisions are made under demand uncertainty, where stockouts may compromise service continuity and overstock may immobilize scarce resources. This study proposes a demand-profile-informed framework for selecting probabilistic inventory models for medication supply decisions. Monthly demand records and consolidated operational cost parameters for 13 medicines over 48 months were analyzed to characterize high-, medium-, low-, and intermittent-demand profiles. Candidate models included normal, gamma, negative binomial type II, and zero-inflated negative binomial distributions. Each fitted distribution was embedded in a two-stage stochastic inventory-cost model, where distribution-specific scenarios determined first-stage replenishment quantities and binary ordering decisions, and second-stage shortage and overstock outcomes were evaluated. A Monte Carlo simulation study assessed model behavior under controlled levels of demand, variability, zero-demand frequency, trend, and shortage-cost exposure. Empirical results showed substantial demand heterogeneity across medicines. Normal and gamma models provided the best statistical fit for most recurrent-demand medicines, whereas zero-inflated negative binomial models dominated several intermittent-demand cases. Model-based replenishment reduced realized costs for 11 of the 13 medicines, with percentage savings ranging from 15.4% to 99.3% among improved cases; however, one medicine showed a negative saving, confirming that statistical fit and operational cost performance may diverge. Simulation results identified zero-demand frequency as the main driver of model selection, with zero-inflated models becoming dominant once zero-demand months were introduced. The proposed framework provides interpretable decision rules to support differentiated, data-driven replenishment decisions in hospital pharmacy management.

Abstract: Background/Objectives: Migrants often experience health inequities resulting from administrative insecurity, precarious employment, and barriers to healthcare access. Although non-metropolitan areas are increasingly important destinations for migrant populations, evidence on their health experiences in these settings remains limited. This study aimed to examine how migrants living in non-metropolitan areas of Spain expe-rience health throughout the migration process and to identify implications for nursing practice and health policy. Methods: A descriptive phenomenological study was con-ducted using Giorgi’s method. Twenty-two adult migrants living in the Spanish prov-inces of Zamora and León participated in semi-structured, in-depth interviews. Data were analyzed following Giorgi’s phenomenological approach, and the study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ). Results: Five in-terconnected themes emerged: migration process, health perceptions, social networks, work conditions, and adaptation and integration. The central finding, “Health as Work”, revealed that participants primarily understood health as the ability to work and maintain economic stability rather than as a state of physical or mental well-being. This perspective reflected broader structural vulnerability arising from administrative insecurity, pre-carious employment, and limited social support. Nurses and third-sector organizations were identified as essential in facilitating healthcare navigation, promoting health lit-eracy, and providing psychosocial support. Conclusions: Migrants’ health experiences in non-metropolitan Spain are shaped by structural vulnerability, with employment and legal status strongly influencing health and access to care. Nursing practice should in-tegrate culturally responsive and structurally informed care, while health policies should reduce administrative and employment barriers and strengthen collaboration between healthcare services and community organizations to promote health equity.

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: Background: Respiratory syncytial virus (RSV) is a leading cause of acute respiratory tract infec-tion and a major contributor to lower respiratory tract disease, hospitalization, and intensive care admission in young infants. The burden of severe disease is greatest during the first months of life, when active infant immunization is not yet feasible or may not provide sufficiently rapid protec-tion. The recent availability of prefusion F protein–based vaccines and long-acting monoclonal antibodies has transformed the RSV prevention landscape, making protection during early in-fancy an achievable public health objective. Methods: This consensus document summarizes and critically appraises updated evidence on RSV epidemiology, disease burden, seasonality, pre-ventive strategies, and implementation challenges, with a specific focus on maternal immuniza-tion. Evidence was reviewed in relation to infant protection, transplacental antibody transfer, optimal timing of vaccination during pregnancy, integration into antenatal care, and the posi-tioning of maternal vaccination alongside infant monoclonal antibody prophylaxis. Results: RSV imposes a substantial clinical and economic burden in infancy, including among previously healthy term infants, with the most severe outcomes concentrated in the first months after birth. Post-pandemic changes in RSV circulation have reduced the predictability of seasonal patterns, challenging prevention strategies based solely on traditional RSV seasons. Maternal RSV vac-cination provides passive protection to newborns through transplacental transfer of neutralizing antibodies and has demonstrated efficacy in reducing medically attended RSV-associated lower respiratory tract infection, severe disease, and hospitalization in early infancy. However, re-al-world effectiveness depends on several factors, including gestational age at vaccination, the interval between vaccination and delivery, prematurity, maternal immune response, vaccine uptake, and local RSV epidemiology. The coexistence of maternal vaccination and infant mono-clonal antibody prophylaxis requires clear, coordinated recommendations to prevent gaps in protection and support efficient resource allocation. Conclusions: Maternal immunization is a clinically relevant strategy to protect infants against RSV during their period of greatest vulner-ability. Successful implementation will require integration into routine antenatal care, adaptation to local epidemiology, coordination with monoclonal antibody programs, and continued sur-veillance of effectiveness, safety, uptake, and equity. A flexible prevention framework combining maternal vaccination and infant monoclonal antibody prophylaxis, according to local needs and individual risk, has the potential to substantially reduce RSV-associated morbidity, hospitaliza-tions, and healthcare burden in early infancy.

Abstract: Background/Objectives: Substance use disorders are common in the prison population and are associated with relapse and criminal recidivism, yet qualitative evidence on recovery capital and family support within Eastern European penitentiary systems remains limited. This study explored how incarcerated men with a history of substance use perceive initiation, withdrawal, recovery, and the role of family support as a recovery capital resource. Methods: A qualitative descriptive study was conducted in a Romanian penitentiary with 50 definitively sentenced men with self-reported substance use history, selected through purposive sampling. Data were collected through semi-structured interviews and analyzed using inductive thematic analysis, with independent coding by two researchers, until thematic saturation was reached. Results: Six themes were identified: initiation of use influenced by peer groups, socioeconomic vulnerability, and criminogenic environments; effects initially perceived as beneficial, followed by progressive deterioration; severe withdrawal and frequent denial of dependence; cognitive mechanisms sustaining use, including externalization of responsibility; the dual role of the family as both risk and protective factor; and a recovery process marked by ambivalence toward abstinence, in which family support, employment, and prosocial relationships were central. Abstinence during incarceration was frequently perceived as externally imposed rather than as authentic recovery. Conclusions: In this single-prison sample, recovery extended beyond abstinence, suggesting the need to strengthen personal, social, and family recovery capital. The findings, which require confirmation in larger samples, support exploring integrated prison–community continuum-of-care interventions centered on addiction treatment, family involvement, and post-release support.

Abstract: Background: During a rapidly expanding outbreak, changes in confirmed case counts and test positivity may reflect transmission, testing selectivity, geographic expansion of surveillance, or delayed processing of accumulated samples. This study reconstructed laboratory indicators reported during the 2026 Bundibugyo virus disease (BVD) outbreak in the Democratic Republic of the Congo (DRC) and examined how testing volume and sample backlog influenced their interpretation. Methods: This retrospective descriptive analysis included 68 of 77 expected daily situation reports through 30 July 2026, with 11 WHO weekly BVD reports through 26 July used for triangulation. Province-level laboratory indicators, pending-sample counts, operational events, and selected cumulative case and death outcomes were extracted. Interval and cumulative observations were analysed separately. An operational interpretation framework classified consecutive comparable observations using prespecified thresholds of a 5-percentage-point change in positivity and a 20% change in testing volume. Comparisons with cumulative crude case fatality ratio (CFR) were exploratory and descriptive. Results: Of 82 positivity records, 75 interval observations were eligible for the primary analysis. Volume-weighted positivity was 32.1% (95% exact CI 30.9–33.3%) in Ituri and 7.3% (6.4–8.3%) in North Kivu. In North Kivu, same-day pending results increased from 42 on 2 June to 193 on 6 June and remained elevated through 11 June; reagent shortages were reported from 5 June. Despite lower positivity, cumulative crude CFR in North Kivu increased from 5.3% on 31 May to 60.0% on 11 June and was 58.2% on 13 July. In Ituri, cumulative crude CFR increased from 15.4% to 17.6% over 31 May–11 June and was 34.9% on 13 July. These cumulative values were not interpreted as period-specific fatality risks, and unresolved outcomes were not estimable by province. WHO weekly triangulation showed that the same national positivity-range statement was carried forward in reports dated 12, 19, and 26 July, while daily positivity in Ituri varied from 13.3% to 51.3% during the corresponding period. Across 72 province-level transitions, the operational framework showed that changes in positivity and testing volume required contextual corroboration to distinguish selective testing, surveillance expansion, and laboratory constraints. Conclusions: Test positivity and cumulative crude CFR provided distinct and sometimes discordant surveillance signals. High positivity did not consistently indicate higher cumulative mortality, while low positivity could coexist with substantial mortality and laboratory backlog. The operational framework supports joint assessment of positivity, testing volume, pending-sample burden, geographic coverage, cumulative outcomes, and laboratory context. Situation reports should provide current numerators and denominators, distinguish samples awaiting transport from those awaiting analysis, and report backlog age, turnaround times, and outcome completeness.

Abstract: Background/Objectives: Dental caries is the most prevalent chronic disease of childhood, and untreated caries in the primary dentition affects an estimated 514 million children worldwide. Children are the principal target of oral health outreach, through school dental screening, community camps, and charitable events for children with special healthcare needs, yet these programmes are evaluated largely by what is most visible: the number of children examined and the photographs disseminated. This measurement substitution dissociates activity from impact, so that children are screened but not treated, counted but not cared for. The objective was to determine what works, for whom, in what contexts, and through what mechanisms in converting children’s oral health screening contacts into sustained care. Methods: A realist synthesis was conducted and reported in accordance with the RAMESES publication standards. An initial programme theory was developed and refined through purposive iterative searching, appraisal of relevance and rigour, and the extraction of Context, Mechanism and Outcome (CMO) configurations across diverse literature. Results: Eight configurations were derived, six enabling and two antagonist, organised around three thematic constellations, Prevent, Promote and Promulgate, and navigated by a compass of competency-based education. The refined theory holds that the intervention is not the camp, but the configuration of conditions that allows it to convert into care for the child. Conclusions: Children’s oral health outreach should be evaluated as a multi-level, health-systems configuration rather than a discrete event; competency-based education is the generative lever that reorients practice from optics to outcomes.

Abstract: Background: Dementia prevention has emerged as a global public health priority, with growing evidence indicating that a substantial proportion of dementia cases may be delayed or prevented through modification of life-course risk factors. Despite this expanding epidemiological evidence base, translating knowledge into sustained behavioural change remains a persistent challenge. Digital dementia risk-reduction education offers unprecedented opportunities to increase public access to evidence-based prevention information; however, existing approaches frequently emphasise information delivery rather than explaining the processes through which individuals interpret, internalise, and act upon that information. Objective: This paper examines the theoretical foundations of Context–Mechanism–Outcome (CMO) reasoning within realist evaluation and proposes a domain-specific realist-informed conceptual framework to strengthen explanation of how digital dementia risk-reduction education may influence behavioural readiness and preventive action. Methods: A conceptual synthesis was undertaken drawing upon critical realism, realist evaluation, health literacy, behaviour change theory, implementation science, and contemporary dementia prevention literature. The paper also synthesises an emerging programme of conceptual scholarship on dementia prevention literacy and digital dementia education (Carey, 2026a–e) to develop a coherent programme theory for future empirical investigation. Results: The proposed framework extends established CMO reasoning by distinguishing broader contextual influences, digital intervention characteristics, resource availability, and user engagement while proposing interpretative engagement as a potential generative mechanism through which individuals construct meaning from dementia prevention information. Behavioural readiness is positioned as an intermediate outcome linking interpretation with sustained dementia risk-reduction behaviours. The framework integrates complementary theoretical traditions into a single explanatory model capable of informing future realist evaluation of digital dementia interventions. Conclusions: Rather than replacing established realist evaluation, the proposed framework provides a domain-specific refinement designed to improve theoretical explanation within digital dementia risk-reduction education. By emphasising interpretation, meaning-making, and behavioural readiness, the framework offers a foundation for future empirical testing and contributes to ongoing theory development within realist-informed digital health research.

Abstract: Objective: First update of the global transgender oral health LSR (Kumar et al. 2025), covering September 2021 to May 2026. Basic research design: LSR update, PRISMA 2020. Six databases plus grey literature. Random-effects DerSimonian-Laird meta-analysis on Freeman-Tukey transformed proportions matching the baseline LSR and Mehta et al. (2024). Risk-of-bias: JBI, Newcastle-Ottawa, CASP, AMSTAR-2, MMAT. Clinical setting: Global; community, hospital, NGO outreach, surveys, population analysis. Participants: Transgender and gender-diverse populations including third-gender identities. Eleven quantitative studies (n=1,766) in meta-analysis; four qualitative, five provider-side, one population analysis (US BRFSS, n≈290 million) in narrative synthesis. Interventions: Not applicable (descriptive prevalence synthesis). Main outcome measures: Pooled prevalence of caries, periodontal disease, calculus, bleeding, tobacco use, toothbrush use; heterogeneity; publication bias; HIV subgroup and leave-one-out sensitivity; GRADE. Results: Pooled prevalence: toothbrush 82.9% (73.4-90.6); smoking 12.5% (5.2-22.5); smokeless tobacco 53.2% (38.1-68.0); caries 73.8% (62.5-83.6); calculus 64.4% (43.1-83.1); bleeding 16.5% (7.6-27.9); periodontal 90.8% (87.5-93.7). Estimates reproduced Mehta et al. (2024) within ≤5 points. HIV subgroup collapsed heterogeneity for toothbrush use (I² 91%→0%). Suleman et al. (2023) reported mean DMFT 6.86 (Lahore) — highest globally. Indian dentists: 46-point gap between willingness (71.3%) and training (25.2%). Conclusions: Global transgender populations face elevated oral disease burden and a workforce-preparedness gap. This first LSR update extends geography, design diversity, and analytic depth. A four-tier policy roadmap aligned with WHO Global Oral Health Action Plan 2023-2030 supports transgender-inclusive Universal Health Coverage.

Abstract: Objectives: To determine whether Democratic Republic of the Congo (DRC) health zones with the same operational-priority score required different effective ring reach to achieve the same simulated benefit, and how surveillance reconstruction and modelling assumptions affected estimates. Effective ring reach was the proportion of eligible contacts and contacts of contacts identified, reached, accepting vaccination and vaccinated in time. Design: Health-zone-stratified preparedness modelling using routine aggregate outbreak data. Current transmission (Rt) was estimated from reconstructed reporting intervals, and paired branching-process simulations compared hypothetical ring vaccination with no vaccination. Setting: Five affected DRC provinces; data lock 24 July 2026. Units of analysis: Forty-nine affected health zones identified from 64 official situation reports. Interventions: Scenarios varied vaccine efficacy across five levels, operational timing across three scenarios, additional transmission reduction from non-vaccine measures across four levels, and effective ring reach from 5% to 100%. Main outcome measures: Current Rt; C*25, the lowest effective ring reach producing at least a 25% mean case reduction over 42 days; and C*50, defined similarly for a 50% reduction. Results: Twenty-one health zones met minimum data requirements and 13 had a usable current Rt, producing 18 simulated states because five zones required two plausible reconstructions. Among health zones with priority scoring 14/16, C*25 was 64% in Bunia, 71%-74% in Mongbwalu and 83% in Rwampara. Among zones scoring 11/16, it was 55%-56% in Nizi, 57% in Bambu, 60% in Katwa and 62% in Butembo. Nyankunde did not achieve the 25% target at 100% reach, and no state achieved 50%. Using WHO infection-timing assumptions did not usually change whether transmission was increasing or decreasing, but it made the vaccination target harder to achieve. The model’s short-term predictions were also less reliable than expected. Conclusions: Operational priority and modelled vaccination opportunity differed across health zones. Even zones with the same priority score could require different levels of effective ring reach to achieve the same simulated benefit. These findings are most useful for comparing preparedness demands across zones and scenarios when interpreted alongside recent transmission, surveillance quality and field constraints. They should not be used as forecasts, allocation rules or vaccination-coverage targets.

Abstract: Federal policy has made standardized application programming interfaces (APIs) the backbone of health information exchange (HIE), and pharmacy is increasingly a full participant through electronic prescribing, the pharmacist electronic care plan, and emerging FHIR-based clinical documentation. Proposals for artificial-intelligence (AI) systems capable of querying electronic health records and pharmacy management systems through such interfaces raise pressing questions about patient autonomy and privacy. This paper argues that those questions are best understood as questions of governance rather than of transport technology. The effect of API-mediated HIE on autonomy is bimodal: a patient-mediated architecture, in which the individual authorizes access, functions as an instrument of data portability and exit and is strongly autonomy-enhancing, whereas an institution-mediated architecture, in which the patient is the object rather than the principal of exchange, tends to erode the interests it nominally serves. Drawing on the political economy of pharmacy intermediation, the semantics of medication data, and the law-and-economics of entitlements, the analysis explains why institutional incentives favor the second path absent deliberate design, and proposes six governance principles: (1) first-class individual access; (2) regulation of inferences as protected health information; (3) query visibility; (4) judicial authorization for state access; (5) provenance; and (6) prevention of single-point choke points. These principles are directed at keeping the pharmacist and the patient the principals of an exchange conducted in the patient's name.

Abstract: Background: The global healthcare landscape is increasingly shaped by two pivotal trends: the adoption of international quality frameworks, such as Joint Commission International (JCI) accreditation, and the strategic shift towards resource-efficient models like outpatient surgery. While JCI is the gold standard for hospital risk management and outpatient surgery is a key driver of efficiency, a critical disconnect exists in both research and policy. The applicability and impact of hospital-centric JCI standards within the unique operational context of ambulatory surgery remain a critical blind spot. The present scoping review aims to systematically map the evidence regarding the association between JCI accreditation and outpatient surgery, identify critical knowledge gaps, and highlight implications for healthcare contexts. Methods: The scoping review was performed in accordance with the PRISMA-ScR guidelines. A comprehensive search of major databases (i.e., PubMed/MEDLINE, Scopus, and Web of Science) was conducted for the period 2000–2025. Data extraction was centered on study design, interventions, and key findings related to quality and risk management. Results: Our analysis of 80 included publications revealed a key finding: the literature on JCI accreditation and outpatient surgery exists in two separate, non-overlapping silos. A complete absence of empirical studies directly evaluating the implementation or effectiveness of JCI accreditation within outpatient surgery centers was identified. Conclusions: The review revealed a critical evidence gap concerning integrated risk management in ambulatory settings. This finding highlights an urgent need for further research to inform evidence-based healthcare policy and ensure patient safety in the growing field of outpatient surgery.

Abstract: Background: The “fridge cigarette” is a social-media phenomenon in which a chilled diet carbonated soft drink (CSD) is ritualised as an adolescent stress-relief practice using the symbolic grammar of cigarette consumption. It presents an analytic problem for conventional prevention because its flagship product is sugar-free: harm is mediated not by sucrose but by acidity, non-nutritive sweetener exposure, and a transplanted dependency ritual. Linear exposure–outcome models do not account for the phenomenon’s propagation, its resistance to information-based correction, or the limited traction of existing regulation. Objective: To analyse the phenomenon as an instrumental case of a commercial determinant of health operating as a complex adaptive system, and to derive an implementable, theory-grounded intervention sited at high-leverage points in that system. Methods: A systems thinking review structured as a single instrumental case study. Evidence was assembled across five predefined system domains and synthesised using three established instruments: qualitative causal loop mapping with explicit link-polarity coding and evidence grading; systems-archetype analysis expressed as falsifiable propositions; and leverage-point classification following Meadows, in the shallow-to-deep formulation of Abson et al. Results: The case system comprises three reinforcing loops (R1 algorithmic amplification; R2 identity–affect reward; R3 commercial reinvestment) and one balancing loop (B1 clinical–regulatory correction). Loop-dominance analysis indicates that R1–R3 operate on cycle times of hours to months, whereas B1 carries a multi-year exposure-to-detection delay and low gain at two of three links, rendering it structurally incapable of stabilising the system. Four archetypes (Fixes that Fail, Shifting the Burden, Success to the Successful, Tragedy of the Commons) each predict that symptom-directed interventions will strengthen the reinforcing loops. Leverage classification shows the current policy repertoire concentrated in shallow tiers (L12–L6); no current instrument addresses the paradigm tier (L2–L1) at which the phenomenon operates. Conclusion: The analysis specifies CHAMP (Child-led Health Advocacy for Misinformation and Prevention), a peer-delivered counter-system of five sequenced levers mapped to deep leverage points, designed to re-aim the amplification loop rather than oppose it. The dental encounter is identified as the system’s earliest observable sensor, positioning pediatric dentistry to close the corrective feedback that currently fails. Recommendations are ranked by leverage depth, and an explicit falsification condition is stated.

Abstract: The imposition of Structural Adjustment Programmes on some developing countries in the 1980s, which necessitated cuts in social spending, contributed to the current healthcare challenges in these countries. The introduction of health insurance was intended to improve access to affordable healthcare; however, many people in the informal sector are not covered by the commonly adopted health insurance models. Community-based health insurance was recommended as a better alternative. This study was conducted to assess the awareness and interest in community-based health insurance in 11 selected rural communities in Kwara State, Nigeria. A mixed methods approach was adopted to obtain data for the study. Focus group discussions, questionnaires, and key informant and in-depth interviews were the methods of data collection. The respondents in this study are members of the selected communities, including religious and community leaders. The study found that awareness about community-based health insurance was high among the respondents. It also found that the involvement of community members and leaders in creating awareness is essential for the success of health policy programmes. Thus, to attain universal health coverage, it is recommended that policymakers secure buy-in from the people and work closely with community members who have already earned the people’s trust.

Abstract: Background: Dengue has expanded rapidly beyond traditional tropical and subtropical regions, driven by climate change, urbanization, population mobility, and the spread of competent Aedes vectors. Vaccination is an increasingly important component of dengue prevention, but development has been complicated by four viral serotypes, antibody-dependent enhancement, variable baseline serostatus, and the need for balanced and durable tetravalent immunity. Methods: We conducted a narrative review of PubMed/MEDLINE, Google Scholar, ClinicalTrials.gov, and relevant public health and regulatory sources. Evidence on dengue epidemiology, immunopathogenesis, licensed vaccines, advanced candidates, efficacy, immunogenicity, safety, durability, and implementation was critically evaluated. Priority was given to randomized trials, long-term follow-up studies, regulatory assessments, and surveillance data. Evidence was synthesized descriptively without formal meta-analysis or risk-of-bias assessment. Results: CYD-TDV was the first licensed dengue vaccine but is restricted to individuals with documented previous infection because seronegative recipients may experience an increased risk of severe dengue. TAK-003 provides protection against symptomatic dengue and hospitalization in both seropositive and seronegative individuals and can be administered without mandatory prevaccination screening, although efficacy varies by serotype. Butantan-DV offers a promising single-dose strategy, but broader use requires additional long-term safety, effectiveness, and serotype-specific data. Inactivated, DNA, viral-vectored, virus-like particle, and mRNA vaccines remain investigational. Conclusion: Dengue vaccination should be integrated with surveillance, vector control, clinical preparedness, and risk communication. Population-based vaccination is most appropriate in high-transmission settings, whereas selective, risk-based strategies are preferable in temperate regions. Continued pharmacovigilance and effectiveness monitoring are essential to guide safe and equitable implementation.

Abstract: Background: Long-acting monoclonal antibodies have become an important strategy for pre-venting respiratory syncytial virus (RSV) disease in infants. Nirsevimab is the first product for which substantial post-licensure implementation data are available, whereas real-world evidence on clesrovimab remains limited. Although nirsevimab has demonstrated high efficacy, its uptake varies considerably across countries, healthcare systems, delivery settings, and population subgroups. This WAidid consensus document examines the policy, organizational, economic, and equity-related determinants that shape real-world implementation of long-acting monoclonal antibodies for infant RSV prevention. Methods: A structured literature search was conducted in PubMed and Embase for studies published between January 1, 2000, and March 31, 2026. Only English-language publications were considered. The search was complemented by manual review of surveillance reports, policy documents, and public health guidance from the ECDC, UKHSA, and CDC, as well as reference lists of selected publications. Eligible sources included clinical trials, observational studies, real-world effectiveness studies, systematic reviews, meta-analyses, economic evaluations, guidelines, policy statements, and relevant narrative reviews. Evidence was synthesized qualitatively, with attention to policy frameworks, financing, reimbursement, delivery pathways, demographic and socioeconomic determinants, and healthcare-system factors influencing uptake. Results: Nirsevimab uptake was strongly influenced by national RSV prevention policies, particularly whether countries adopted universal infant monoclonal antibody programs, maternal RSV vaccination strategies, dual maternal–infant approaches, or targeted risk-based models. Universal, publicly funded programs inte-grated into neonatal care achieved the highest and most homogeneous coverage, especially when administration occurred before hospital discharge and was supported by registry-based recall systems for infants born outside the RSV season. In contrast, fragmented, outpatient-only, insurance-dependent, or partially reimbursed models were associated with lower, delayed, or more variable uptake. Additional determinants included product cost, reimbursement path-ways, provider practices, caregiver awareness and health literacy, insurance status, income, race and ethnicity, geographic deprivation, and access to primary pediatric care. Most available evidence comes from high-income countries, limiting generalizability to low- and middle-income settings, where RSV burden is greatest and implementation constraints may differ. Conclusion: Successful implementation of long-acting monoclonal antibodies for infant RSV prevention requires more than regulatory approval and demonstrated efficacy. Equitable up-take depends on clear national recommendations, sustainable public financing, reliable product supply, integration into neonatal and primary pediatric care, proactive identification and recall of eligible infants, and targeted strategies to reduce socioeconomic and geographic disparities. Although many determinants identified in high-income settings are likely relevant globally, their feasibility, relative importance, and impact require dedicated evaluation in low- and middle-income countries.

Abstract: Background: Respiratory syncytial virus (RSV) is a leading cause of lower respiratory tract infection and hospitalization in infants. Nirsevimab, a long-acting monoclonal antibody, provides single-dose protection during the RSV season, but the effectiveness of prophylaxis programs depends on sustained parental acceptance and high uptake. This study evaluated changes in parental knowledge, perceptions, and willingness to accept nirsevimab across two consecutive RSV seasons in Emilia-Romagna, Italy. Methods: A prospective, multicenter, observational survey was conducted during the 2024–2025 and 2025–2026 RSV seasons. Parents or legal guardians of infants eligible for nirsevimab completed a semi-structured questionnaire during routine counseling in neonatal units. Survey 1 included 1042 respondents and survey 2 included 867 respondents. Sociodemographic characteristics, RSV awareness, knowledge and perception of nirsevimab, willingness to accept prophylaxis, trust in healthcare providers and the healthcare system, preferred information sources, and willingness to pay were compared between seasons. Results: Willingness to administer nirsevimab remained high and stable, 87.04% in survey 1 and 88.00% in survey 2. Awareness of RSV-related risks increased from 68.23% to 73.47% (p < 0.05), and correct identification of nirsevimab as an antibody increased from 65.93% to 71.74% (p < 0.01). Explicit refusal rose slightly from 2.21% to 3.81% (p < 0.05). In survey 2, acceptance was associated with higher education, awareness of RSV risks, perceived child susceptibility, confidence in efficacy, lower concern about side effects, trust in pediatricians and the healthcare system, and willingness to pay. Notably, acceptance in 2025–2026 was higher among infants born in September–December than among those born in January–March, indicating a late-season decline. Conclusion: Parental acceptance of nirsevimab remained high across two seasons. Future campaigns should address residual knowledge gaps, reinforce communication on safety and efficacy, and sustain high coverage throughout the entire RSV season, particularly among infants born in its final months.