Public Health and Healthcare

Abstract: Decision-making in dementia presents ethical, clinical, legal and social challenges, particularly where personal autonomy, perceived risk and protective intervention come into conflict. A diagnosis of dementia is sometimes treated as evidence of diminished decision-making capacity, potentially contributing to unnecessary restrictions on choice, independence and self-determination. Yet an unwise decision, refusal of assistance, disagreement with family members or professionals, and impaired capacity are distinct circumstances and should not be treated as interchangeable. This conceptual paper examines the relationship between autonomy, decision-making capacity, dignity of risk and protection in dementia. It draws on interdisciplinary scholarship, international human rights principles, Australian aged-care policy and relevant legal frameworks, with Western Australia used as a jurisdictional example. It considers the importance of presuming capacity, providing decision-making support, recognising changing preferences, and ensuring that protective and substitute decision-making arrangements are legally authorised, proportionate and appropriately safeguarded. The paper develops a preliminary framework for reconciling autonomy and protection. It argues that dementia care should preserve individual agency, identity and participation wherever possible, while responding appropriately to serious harm, coercion and exploitation. The framework is intended to inform clinical practice, aged-care policy, legal decision-making and future empirical research.

Abstract: Anemia is one of the most common disorders identified in the children, representing a significant global health concern. Delays in diagnosis and treatment may put anemic patients at risk of developing rare and serious complications, including chronic and irreversible cognitive impairment. Risk factors that contribute to the development of anemia in children include eating disorders, chronic comorbidities, inflammation and infection as well as congenital disorders. Pediatricians play a crucial role in identifying these risk factors, which is essential for developing appropriate and timely therapeutic interventions and prevention strategies. Biological sex or gender may influence the risk of anemia, the presentation of symptoms, and the response to therapy, but these are often underexplored in clinical practice and research.

Abstract: Background. Immune checkpoint inhibitors changed cancer treatment, and the patents behind them shape who can develop the next generation of these drugs. China’s role in checkpoint drug development and licensing has grown quickly, but its share of checkpoint patenting, where Chinese applicants seek protection and what they protect have not been measured systematically.Methods. We analysed 3,320 patent documents on immune checkpoint therapy exported from Lens.org in January 2024 (application years 1997–2023). We measured the share of documents with Chinese and US applicants over time, the patent office where each document was filed, the size of its patent family, and what each country protects, using keyword labels for checkpoint targets and therapeutic strategies checked against 200 hand-coded documents. We tested the main result with five robustness checks. Results. The share of documents with a Chinese applicant rose from 21.6% (95% CI 16.8–27.3) in 2015–16 to 39.1% (36.2–41.9) in 2020–21, while the US share fell from 50.8% to 35.4%; China overtook the United States in 2020. China’s share also nearly doubled outside the Chinese patent office (9.1% to 17.7%; p = 0.004). Yet in 2010–2021, 70.1% of Chinese documents were filed in the Chinese office, Chinese applicants used the international PCT route half as often as US applicants (13.5% vs 26.9%), and Chinese patent families were smaller (median 2 vs 7 documents). Chinese documents more often named PD-1 (55.5% vs 42.9%) and PD-L1 (44.6% vs 30.5%) and more often described bispecific molecules (10.6% vs 4.2%), including 19 of the 21 PD-1/PD-L1 × VEGF bispecific documents. US documents more often described combination therapies (53.8% vs 33.5%) and CTLA-4 (14.6% vs 8.7%). Conclusions. China became the largest source of immune checkpoint patent filings in 2020. Most of its filings protect the home market and focus on the PD-1 axis and bispecific formats, the same formats that later drove large international licensing deals. An open interactive explorer with all data is available at cognosx.ca/dashboards/immune-checkpoint.

Abstract: Background. Dementia research spans prevention, public health education, digital interventions, lived experience, care relationships, policy and end-of-life questions. These domains are connected but require distinct explanatory approaches. Carey (2026a–s) is an emerging programme of scholarship focused on translating dementia prevention evidence into public understanding, personal relevance and possible action. Objective. To critically synthesise Carey (2026a–s), examine the programme’s theoretical parsimony, distinguish candidate constructs from established behavioural models, and outline an empirically grounded research agenda. Method. A reflexive, document-based critical conceptual synthesis of the author’s programme portfolio, supplemented by publicly accessible publication records and selected external literature. It is a self-synthesis, not an independent systematic review, peer evaluation or empirical validation. Findings. The programme comprises nineteen numbered outputs, including conceptual papers, an educational infographic, a policy-oriented futures framework and later conceptual manuscripts, with a coherent prevention-education core: a proposed translation pathway from information exposure to engagement, interpretation, personal relevance, emotional appraisal and behavioural readiness. Dementia Prevention Literacy, Midlife Preventive Capacity and Dementia Preventive Agency are potentially useful candidate constructs, but their boundaries need tightening to avoid overlap with established models such as health literacy, COM-B and Burden of Treatment Theory. The help-refusal and terminal-lucidity work addresses related but distinct domains. Carey (2026e) is a proposed study design, not completed evidence. Empirical validation, co-production and realist evaluation remain priorities. Conclusion. The programme is best represented as an evolving four-domain architecture anchored by a digital prevention-education core, not a single validated theory. Its contribution depends on rigorous empirical testing, co-production, transparent evidence-status reporting and incremental explanatory value over existing frameworks.

Abstract: Urban arboviral diseases represent a persistent epidemiological challenge for the Brazilian Unified Health System (SUS), requiring institutional resilience and health compliance from local governments. Objective: To analyze the resilience of municipal health systems in responding to urban arboviruses in a health region of Espírito Santo, Brazil, using secondary data from the Integrated Instrument for the Assessment of the Response to Arboviruses (IIARA 2026), while preserving the anonymity of the federated entities. Methods: Observational, descriptive and analytical ecological study based on aggregated secondary data from 23 municipalities. Forty-eight criteria distributed across six thematic axes were assessed. The Resilience Index (IR%) was calculated per axis and globally, applying the "Deal Breaker" (Critical Cut-off) rule to the risk classification criteria in primary and hospital care. Results: The mean regional global IR was 67.15% (range 40.3%–89.6%). The Epidemiological Surveillance axis showed the best performance (87.7%), whereas Management and Governance showed the greatest fragility (41.4%). Only six municipalities achieved the Silver Seal; four municipalities with global scores above 70% were withheld by the Deal Breaker due to failures in care risk classification, preventing certification. Conclusion: The IIARA proved to be an effective health compliance tool, revealing significant regional heterogeneity. The Deal Breaker rule fulfilled its role by preventing the certification of municipalities with critical care fragilities, pointing to the need for priority interventions in local governance and in risk-classified reception.

Abstract: Objectives. To test whether product characteristics available in public Food and Drug Administration (FDA) data, measured before a fixed date, identify prescription drugs that are added to the FDA shortage list after that date.Study Design. Temporal validation at two cutoff dates, applying a previously developed cross-sectional risk screen.Methods. Drugs marketed as of each cutoff were identified from National Drug Code directory marketing dates. Drugs already on the shortage list at the cutoff were excluded. Features were computed only from products marketed at the cutoff; the outcome was first shortage listing after it. L2-penalized logistic regression, a random forest and a fixed-weight three-item rule were compared under repeated stratified cross-validation. Because the rule has no fitted parameters, its score is a fully out-of-time prediction; the two fitted models are not, and are interpreted accordingly.Results. At a January 2025 cutoff, 125 of 2,779 eligible drugs (4.5%) were newly listed. Area under the receiver operating characteristic curve (AUC) was 0.732 for the random forest, 0.692 for logistic regression and 0.655 for the rule, with average precision (AP) of 0.143, 0.117 and 0.116 against a chance value of 0.045. At a January 2023 cutoff, 137 of 2,577 drugs (5.3%) were newly listed, with AUCs of 0.705, 0.675 and 0.649 and AP of 0.119, 0.133 and 0.125 against chance of 0.053. Discrimination was higher among injectables on both measures, but the two measures ranked the approaches differently: the rule achieved the highest AUC at both cutoffs (0.806 and 0.742) while logistic regression achieved the highest average precision at both (0.266 and 0.224). All between-approach differences were smaller than the fold-to-fold standard deviations.Conclusions. Public product characteristics carry modest forward signal for shortage listing, concentrated in injectables. A three-item rule with no fitted parameters discriminates comparably to fitted models out of time, though which approach ranks highest depends on the measure used and no approach leads on both. Absolute precision remains low, so the ranking is a screening aid rather than a forecast.

Abstract: Kidney transplantation offers a route beyond long-term dialysis, yet access depends on a sequence of clinical, organizational, and biological decisions. This analytical essay combines a patient coauthor's lived experience with a narrative synthesis of published studies, registry reports, and public policy documents. It examines dialysis-market concentration, referral and waitlisting, organ-offer transparency, kidney nonuse, and the limits imposed by ischemic injury. Observational associations between facility ownership and transplant access are distinguished from evidence of intentional conduct. Established evidence for hypothermic machine perfusion is separated from investigational oxygen-carrier applications, including Biological Hemoglobin Oxygen Carriers (BHOC), for which product-specific benefit must be demonstrated. A patient-centered quality framework links referral timelines, allocation decisions, organ support, graft outcomes, and patient-reported experience. The central proposal is to assess economic reform and biomedical innovation together rather than as competing explanations for limited transplantation. This is not a systematic review, original clinical study, or demonstration of BHOC efficacy; it proposes an evidence-generation and quality-improvement agenda.

Abstract: Background/Objectives: Lateral ankle sprain (LAS) is one of the most common musculoskeletal injuries, and a large proportion of patients go on to develop chronic ankle instability (CAI). Neuromodulation, ranging from transcutaneous to percutaneous techniques, has been proposed as a conservative adjunct for both conditions. This review examined its efficacy in LAS and CAI and compared the available modalities. Methods: We carried out a narrative review with a structured search of PubMed, Scopus, Web of Science and Embase (January–March 2026), reported following PRISMA 2020. Studies published between 2015 and 2026 with levels of evidence 1 to 3 were eligible. Of 511 records identified, 19 studies were included: three systematic reviews, eleven randomized trials, two non-randomized controlled studies, one cohort study and two case series or case-control studies. Results: In LAS (nine studies), results were heterogeneous. Low-frequency stimulation combined with proprioceptive training improved pain, range of motion, strength and joint position sense in one cohort and one randomized trial, and a trial of non-invasive neurostimulation reported less pain and faster return to sport. Two reviews, however, found no added benefit of electrical stimulation in acute sprains. Neuromuscular electrical stimulation (NMES) reduced edema in one pilot trial but not in another study. In CAI (ten studies), six-week NMES programs combined with exercise improved balance, muscle morphology, frontal-plane motor control and patient-reported outcomes, whereas single sessions and two-week programs did not. Percutaneous techniques showed rapid effects in one non-randomized LAS report but only limited acute effects on postural control in CAI. Conclusions: Neuromodulation appears useful as an adjunct to exercise-based rehabilitation rather than as a stand-alone treatment. The evidence is most consistent for NMES combined with exercise in CAI. Standardized protocols and more rigorous trials are required.

Abstract: Background: The Mano River Union (MRU) countries (Liberia, Sierra Leone, and Guinea) face persistent health-system constraints related to conflict, epidemics, underinvestment, and weak institutional capacity. Progress toward universal health coverage (UHC) requires evidence on how financing and system-strengthening strategies affect service access, equity, and resilience. This review synthesized evidence on health financing and health-system strengthening in Liberia and the wider MRU, including their implications for health outcomes, equity, and community health systems. Methods: This PRISMA 2020-compliant review was registered in PROSPERO (CRD420251243931). PubMed and African Journals Online were searched for English-language sources published from 1 January 2015 to 31 December 2025, and gray literature was sought from the World Health Organization, World Bank, UNICEF, African Development Bank, and Liberia Ministry of Health. Two reviewers independently screened records and extracted data, and primary empirical studies were appraised using the Mixed Methods Appraisal Tool 2018. Findings were integrated using narrative thematic synthesis within a health-systems framework informed by PECOS. Results: Database searches identified 1,254 records, and organizational sources identified six additional records. After 312 database duplicates were removed, 942 database records were screened; 934 were excluded, and eight reports were retrieved and assessed. All six organizational records were retrieved and assessed. No reports were excluded after full-text assessment, and all 14 reports were included, comprising six journal articles (including two reviews) and eight institutional or technical reports. Five themes emerged: chronic underfunding and low government prioritization of health; mixed, mechanism-dependent performance of financing reforms; geographic and socioeconomic disparities in maternal and child health access; central but donor-dependent community health systems; and Ebola-related disruption with uneven recovery. Governance fragmentation and donor coordination were cross-cutting concerns. Liberia's average health-budget allocation of 3.46% from 2010 to 2018 illustrates the financing gap. Conclusions: Although the evidence base is limited by heterogeneous designs, reliance on policy and technical sources, and the absence of Guinea-specific studies, evidence from the MRU indicates that underinvestment, inequity, and governance weaknesses continue to constrain health-system performance. More predictable domestic financing, equity-oriented reforms, and sustained support for integrated community health systems are priorities for advancing UHC in fragile and post-conflict settings.

Abstract: The economic value of artificial intelligence (AI)-supported cancer detection in the Philippines remains uncertain. This study evaluated opportunistic AI reading and AI-supported screening programmes for breast, lung, colorectal and cervical cancer from the public-payer perspective. A decision-analytic model integrated stage shift, precursor-lesion prevention, budget impact and value-of-information analyses using published inputs, 7% discounting and 10,000 probabilistic draws. At PHP 250 per read, opportunistic AI reading would avert approximately 270 deaths per annual cohort at a net cost of PHP 0.93 billion and PHP 628,000 per quality-adjusted life-year (QALY). Only computer-aided colonoscopy approached the benchmark of one gross domestic product per capita (PHP 220,000 per QALY). Combined opportunistic reading met this benchmark at AI prices of PHP 50 or less. Increasing screening uptake from 1% to 20% would avert approximately 4750 deaths per annual cohort at PHP 14.0 billion annually, with a five-year budget impact of PHP 56 billion. Further research had greatest value for lung and breast screening programmes and opportunistic colonoscopy. Auto-contouring could expand annual radiotherapy capacity to 19,100–23,900 courses. Cost-effectiveness depends on software pricing, prevention benefits and affordable acquisition; conditional reimbursement should prioritise Philippine evidence on incremental detection and prevalence. AI-supported cancer detection offers substantial health gains but requires affordable implementation to achieve cost-effectiveness. This study identifies actionable pricing thresholds and research priorities to guide evidence-based reimbursement and equitable cancer screening in the Philippines.

Abstract: Late-stage dementia, chiefly Alzheimer’s disease, is usually regarded as a permanent decline caused by the gradual destruction of brain tissue. Long-standing clinical and family accounts nevertheless describe people with severe dementia who briefly speak clearly, know where they are and recognise their relatives, typically close to the end of life. Known as terminal lucidity when it falls close to death, and as paradoxical lucidity in the broader sense, the phenomenon has seldom been studied in a systematic way. This narrative review, which did not use a systematic search, synthesises the existing case reports, retrospective surveys and related neurophysiological evidence, and evaluates candidate mechanisms, including terminal neurophysiological surges, retrieval-based accounts of memory loss, and inflammatory or neuromodulatory change. It argues that, if confirmed in prospective studies, terminal lucidity would indicate that some late-stage deficits reflect reversible, network-level dysfunction rather than permanent loss of stored information. It proposes, as a hypothesis, a two-factor model in which lucidity arises when a transient permissive brain state coincides with a salient relational retrieval cue, derives testable predictions from that model, and concludes with ethical considerations and a research agenda for standardised, prospective investigation.

Abstract: The presence of indicator microorganisms and foodborne pathogens in prepared foods remains a safety concern, particularly in establishments with inadequate hygienic and sanitary conditions. This study analyzed microbiological non-compliance involving Escherichia coli and Salmonella spp. in prepared foods according to the hygienic and sanitary conditions of restaurants in Independencia, Lima, Peru. A quantitative, observational, non-experimental study was conducted in 170 restaurants evaluated on two occasions between 2022 and 2024. One prepared-food sample was collected from each establishment during each assessment and analyzed according to national microbiological criteria. During the first assessment, 23 of 170 samples (13.53%) exceeded the microbiological criterion for E. coli, while five samples (2.94%) tested positive for Salmonella spp. In the second assessment, one sample (0.59%) exceeded the criterion for E. coli, and no samples tested positive for Salmonella spp. Of the 23 samples non-compliant for E. coli, 22 came from restaurants classified as unhealthy and one from an establishment classified as in process. All five samples positive for Salmonella spp. were obtained from unhealthy establishments. An inverse, statistically significant association was observed between hygienic and sanitary classification and E. coli non-compliance during the first assessment (Spearman’s ρ = −0.296; p < 0.001). This association was not statistically significant during the second assessment (ρ = −0.104; p = 0.177). Microbiological non-compliance was concentrated in restaurants with unfavorable sanitary conditions. Integrating sanitary inspections with microbiological testing may help prioritize surveillance. However, the observational design does not establish causality, and the findings should be interpreted within the study context.

Abstract: India’s healthcare challenge is no longer simply to build institutions, but to ensure that clinical expertise reaches every citizen reliably. As a physician, I see the consequences when accurate diagnosis is separated from timely treatment by workforce shortages, fragmented referrals and unclear institutional responsibility. This editorial examines whether an Indian Medical Service (IMS) could address a gap that existing administrative structures do not consistently bridge: sustained, clinically informed coordination across district, State and national health systems. Such a service must complement, not displace, State medical services and multidisciplinary public-health cadres, while respecting constitutional responsibilities. Its legitimacy would depend on transparent recruitment, rigorous administrative training and independently measured improvements in specialist access, diagnostic turnaround, referral completion, continuity of care and financial protection. An IMS should not be established for professional prestige or bureaucratic expansion. It merits consideration only if it demonstrably converts medical capacity into genuinely accessible, equitable and accountable care.

Abstract: Cardiovascular disease remains the leading cause of death worldwide, and much of its burden is driven by modifiable behaviours. Diet, physical activity and sleep are central to cardiovascular health as they influence common biological pathways, including glucose regulation, endothelial function, blood pressure, inflammation and adiposity. This is increasingly reflected in prevention frameworks. In 2022, the American Heart Association added sleep to Life's Essential 8, recognising it alongside diet and physical activity as a core component of cardiovascular health. In addition, emerging large-scale evidence indicates that the combined pattern of higher diet quality, greater physical activity and healthier sleep across the 24-hour day is associated with greater cardiovascular benefit than any single behaviour alone. Even modest simultaneous improvements across all three behaviours, without a large change in any single behaviour, have been linked to meaningful risk reduction. Yet prevention continues to address these behaviours largely in isolation, relying heavily on individual behaviour change while sleep remains frequently omitted from research and policy. Drawing on previous public health successes, this review argues that individualised prevention messages should be complemented by behavioural infrastructure. Behavioural infrastructure refers to the everyday systems that shape diet, physical activity and sleep as a single 24-hour behavioural exposure, making healthier routines easier, more sustained and equitable. We propose five design principles that transfer a validated structural prevention logic to diet, physical activity and sleep as a practical route to primordial cardiovascular prevention.

Abstract: Background: Controversy remains about the optimal age at which screening mammography should be started. Methods: Cost-effectiveness analysis was based on a British Columbia birth cohort of 40,000 individuals, including 19,661 women alive at age 40. Ten screening scenarios were modeled: no screening versus best-in-the-world screening rates for ages 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75-79, 50-74, 40-74. The main outcomes included breast cancers treated by stage at diagnosis, deaths attributable to breast cancer averted, and quality-adjusted life years (QALY) gained or lost associated with ruling out false-positive results, receiving treatment, the metastatic phase, and living in remission. Results: Screening in women aged 50-74 would result in 92.9 deaths avoided and 889 QALYs gained, at a cost of $ 38,242 per QALY. Screening in women aged 40-74 would result in 99.6 deaths avoided and 744 QALYs gained, at a cost of $ 71,155 per QALY gained. Excluding patient time costs reduced the cost per QALY to $ 2,086 and $ 13,622, respectively. The only scenario in which benefits outweighed harms in women aged 40–49 was when harms attributable to false-positive results were excluded in the model, resulting in a cost per QALY of $ 138,594 and $ 83,210 in women aged 40-44 and 45-49, respectively. Conclusion(s): Our model results are highly sensitive to assumptions regarding utility losses associated with false-positive screening results and inclusion/exclusion of patient time costs, especially in younger women. Subsequent modeling investigations and policymakers who may utilize these investigations should be aware of the impact of these assumptions on model results.

Abstract: The EU Health Technology Assessment Regulation makes the joint clinical assessment dossier the foundation of a single European appraisal of the relative effectiveness and safety of new medicines, and Article 9 conditions that foundation on the completeness of the evidence a developer submits. Drawing only on the first publicly observable outputs of the new system — two completeness reviews and one completed assessment — this article asks how the European Commission and the HTA Coordination Group are giving operational meaning to “completeness”. It argues that an exacting interpretation is emerging, closer to the logic of systematic review than of regulatory submission, but that the evidentiary base remains too thin to call it a settled doctrine. Two structural tensions follow: a certainty paradox, in which uncertainty is catalogued exhaustively yet never converted into a graded judgment of certainty; and an evidence-generation paradox, in which developers of orphan and highly innovative therapies may face analytical demands whose outcome is largely foreseeable. The article situates these tensions within the principle of proportionality, the duty to give reasons and the limits of judicial review, and sets out a research agenda for the Regulation’s scheduled 2028 evaluation.

Abstract: Background/Objectives: Treat-to-target strategies have made clinical remission an achievable goal in rheumatoid arthritis (RA). Yet many patients still report foot pain and difficulty walking. This narrative review asks whether disease control, as captured by standard activity indices, translates into resolution of foot symptoms and function, and what foot orthoses can offer when it does not. Methods: The review builds on a structured search (PubMed, Scopus, Web of Science, CINAHL; March–May 2026; PRISMA 2020; PROSPERO CRD420261338225) that identified 18 observational and randomized studies published between 2016 and 2026. This was supplemented by key complementary literature on remission definitions and pain mechanisms. Study quality was appraised with RoB 2, MINORS and the JBI checklist. Results: Foot pain and disability persisted across cohort and cross-sectional studies in patients with low disease activity or remission. Forefoot deformity, mid- and hindfoot involvement, residual synovitis, kinesiophobia, anxiety, depression and physical inactivity were each associated with worse outcomes. In patients in remission with metatarsal pain, perceived disability was related mainly to pain and forefoot stiffness. Gait performance was related to age, body mass index and graded structural severity. Three randomized trials of foot orthoses suggested benefits for pain and, in one trial, for balance, mobility and foot function. Effects on function and quality of life were inconsistent, and designs were heterogeneous. Conclusions: Controlling systemic inflammation does not guarantee a healthy foot. Foot pain and disability in RA arise from inflammatory, structural, mechanical and psychosocial mechanisms that act together. Routine foot assessment, early podiatric care including foot orthoses, and attention to psychological factors should complement pharmacological control. Larger, methodologically homogeneous trials are needed.

Abstract: Background: Geriatric Medicine is a medical specialty concerned with the health and wellbeing of older adults. Despite the rapid increase in the geriatric population in Ethiopia, the access to specialized care among older patients is limited. There are significant gaps in integrating geriatric competencies across the medical curriculum and the interdisciplinary team for geriatric medicine in Ethiopia. Methods: A narrative review was conducted via PubMed and Google Scholar to identify studies on Geriatric Medicine in Ethiopia. The literature search was supplemented by targeted web searches and reference snowballing. Results: No directly related literature was identified during the initial search. Furthermore, implementation of the Geriatrics framework in Ethiopia is critically limited by a severe lack of specialized training and curricula. This lack of knowledge leads to various clinical misdiagnoses and service gaps. On the other hand, an international academic partnership in 2024 successfully initiated the integration of core geriatric topics into medical training. Conclusion: Strengthening the geriatric workforce requires formal recognition, structured training, and the active integration of multidisciplinary care teams across Ethiopia.

Abstract: Background: Lifestyle medicine (LM) is defined as the discipline of studying how daily habits and practices impact both the prevention and treatment of disease, often in conjunction with pharmaceutical or surgical therapy, to provide an important adjunct to overall health. The pillars of LM comprise nutrition, physical activity, sleep, stress management, avoidance of harmful substances and social connections. Materials and Methods: We conducted a narrative review of the existing literature by searching for literature in PubMed and google scholar. Snowballing of references was also used to identify relevant articles from the articles that came out of the search. We included other studies evaluating Ethiopian dietary habits, staple diets, and EOTC or Islamic (Ramadan) fasting practices. Result: Ethiopian staples like teff injera exhibit low glycemic profiles, aligning with traditional practices that protect against Western-diet-induced metabolic and inflammatory risks. Adherence to Orthodox Christian and Islamic (Ramadan) fasting practices significantly improves mainly cardiometabolic markers, lowering blood pressure, optimizing lipid profiles and injury markers. In addition, these culturally and religious integrated non-pharmacological interventions consistently lower anthropometric measurements, weight, and long-term chronic disease risk profiles. Conclusions: Aligning the nutritional pillar of lifestyle medicine with Ethiopia’s traditional cuisine and religious fasting cycles offers clear health benefits.

Abstract: Delayed or refused help-seeking is a common and consequential feature of dementia. Families often report that a relative with suspected or diagnosed dementia declines assessment, treatment, or support, leaving caregivers uncertain how to act. Refusal is frequently interpreted as stubbornness or denial, which can strain relationships and delay care. This article focuses on the refusal of the person living with dementia to seek or accept help, whether that is a first assessment or later assistance with every day and personal care, and treats denial by relatives as a contributing influence rather than the central problem. This narrative review synthesises published literature on why people living with dementia may refuse or delay help and proposes a practical, ethically grounded framework to guide family members and informal caregivers in encouraging professional assessment and in responding to refusal of care. The review draws on published systematic reviews, a scoping review, a meta-ethnography, a realist synthesis and selected assessment and primary-care literature; it did not involve a new database search, and review-level figures are attributed to the reviews that reported them. Four interacting explanations recur in the literature: (1) anosognosia, a neurologically based lack of awareness that differs from psychological denial; (2) stigma, fear, and fear of losing independence; (3) relational, communication and contextual factors, including trust and safety, how and by whom help is offered, pain, and the care environment; and (4) system barriers such as delayed recognition and fragmented pathways. A further distinction runs through the paper: denial implies an interpretation of what a person understands or accepts, whereas refusal is an observable response whose meaning must be established. Evidence for interventions that reduce refusal is strongest for music during personal care and modified bathing methods, with some support for positive communication and person-centred approaches, though quality is generally low and few studies involve family caregivers in community settings. Help-refusal should be understood as a symptom and a relational challenge rather than a character flaw, and as something to understand rather than merely to manage. This article proposes a staged, non-coercive framework (Understand, Check, Frame, Partner, Plan, Escalate, Sustain) that keeps professional assessment central, protects dignity and autonomy, and supports caregiver well-being. The framework is a conceptual synthesis and has not been empirically tested. A plain-language guide for families is provided in Appendix A.