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11 papers

'He who knows it, feels it.' Stepping stones towards fulfilling a peer-advocate role among people with chronic stigmatising conditions in Liberia.

Berrian H et al. · Jul 1, 2026

Background People affected by skin neglected tropical diseases (NTDs) are often stigmatised, experiencing discrimination in consequence of their condition. Peer advocates can help progress a person-centred agenda for people affected by NTDs, however, evidence gaps in the steps to becoming an advocate persist. Methods We wanted to understand the steps towards a peer advocacy role for skin NTDs. We used the participatory Stepping Stones method to identify steps on the journey to becoming an advocate with 48 participants, followed by three in-depth life histories with peer advocates for other stigmatising chronic conditions (e.g. disability, mental health, Ebola survivors). Results We found study participants frequently experience stigma and discrimination in consequence of their condition. The peer advocate role includes awareness raising and advocacy and providing mutual peer support. Among peer advocates, personal acceptance of their condition, vocational training and family support are important steps along the pathway to becoming a peer advocate. Outcomes of the role include personal determination and increased confidence for peer advocates, provision of help and support for others with similar conditions and broader change in understanding, attitudes and policy within the community and country. Conclusions We find that when appropriately enabled, peer advocates can themselves be empowered and play a key role in person-centred care.

Health Professions

Occupational Burnout, Post-Traumatic Stress Disorder and Intention to Resign Among Nursing Personnel During Public Health Emergencies.

Zhao J et al. · Jul 1, 2026

Aim Studies have shown that nursing staff are prone to post-traumatic stress disorder (PTSD), occupational burnout and turnover tendency in public health emergencies, but the incidence of these three and their influencing factors during the outbreak of COVID-19 have not been clarified. The aim of this study was to explore the mediating mechanism of occupational burnout between PTSD and turnover intention in nursing staff in public health emergencies. Design The study was a cross-sectional survey involving 1087 nursing personnels from 17 provinces in China. Convenience sampling was employed to select nursing personnel from frontline clinical settings in 17 Chinese provinces from March to May 2023. After excluding 13 invalid questionnaires, 1087 valid questionnaires were obtained, resulting in an overall validity rate of 98.8%. Methods Civilian version of Post-traumatic Stress Disorder Questionnaire (PCL-C), Maslach Burnout Inventory-General Survey (MBI-GS) and Turnover Intention Questionnaire (TIQ) were used respectively. Post-traumatic stress symptoms, occupational burnout and turnover tendency were assessed. Ethical review approval: Approval unit: Medical Ethics Committee of Beijing Huilongguan Hospital; Approval number: 2023-23-Science and Technology. Results 15.8% of nursing personnel had PTSD, 71.8% had occupational burnout and 63.7% had turnover intention. The scores of occupational burnout and turnover intention of nursing personnel with PTSD were higher than those without PTSD. Each dimension of PTSD was positively correlated with all dimensions of occupational burnout and nurse resignation (all p Conclusions During public health emergencies, during the COVID-19 pandemic, nursing personnel had PTSD, occupational burnout and turnover intention. PTSD plays a significant direct and indirect role in nurse turnover. Therefore, it should be a standard practice to monitor and manage PTSD among nursing personnel and provide proactive support systems in order to retain personnel and promote the best nursing practice standards during public health emergencies. Patient or public contribution No patient or public contribution.

Health Professions

Producing Mobility, Withholding Authority: Epistemic Drain and Nursing Sovereignty in Nepal.

Ghimire A. · Jul 1, 2026

Global discussions of nursing in low- and middle-income countries (LMICs) are dominated by the language of shortage, staffing, retention, and migration. Although useful, this technocratic vocabulary obscures a deeper philosophical crisis: nurses may be numerically produced yet institutionally denied authority over knowledge, care, and professional futures. Using Nepal as a theory-generating case, this conceptual article employs critical interpretive synthesis and philosophical analysis of nursing, policy, migration, and interdisciplinary scholarship to argue that the central problem is not workforce scarcity alone but a crisis of 'nursing sovereignty'. The paper introduces three concepts. First, epistemic drain extends the idea of brain drain by naming the erosion of mentorship, pedagogical continuity, professional memory, policy voice, research capacity, and the public credibility of nursing knowledge. Second, professionalised for exit captures a paradox of production in which nursing education expands global mobility more readily than local authority, making migration a morally justified reaction to constrained socioeconomic prospects, rather than a lack of professional dedication. Third, nursing sovereignty names the collective capacity of nurses to shape the ends, authority, knowledge, and institutional conditions of their profession. Drawing together social epistemology, feminist ethics, decolonial lens, political economy, sociology of professions, spatial theory, and digital pedagogy, the article argues that Nepal illuminates a wider LMIC condition in which nurses are essential yet disposable, mobile yet institutionally voiceless, and professionalised yet epistemically diminished. It concludes with a six-domain normative framework for institutional redesign: epistemic authority, educational integrity, governance voice, material justice, spatial and digital parity, and mobility justice. Reframing nursing in this way shifts debate from retention to justice, from labour supply to institutional re-design, and from workforce management to the political philosophy underpinning nursing practice.

Health Professions

Lessons from the field: implementing an electronic clinical decision support app for acute febrile illness in rural Cambodia.

Mishra A et al. · Jul 1, 2026

To improve the management of acute febrile illness in rural low- and middle-income country (LMIC) primary care settings, we developed the Electronic clinical Decision support for Acute fever Management (EDAM) app and evaluated it through a cluster-randomised trial in rural Cambodian primary health centres (PHCs). In parallel, we conducted structured, mixed methods observations at a subset of participating PHCs to document key challenges in screening, enrolling and managing patients. A key lesson was the critical importance of user-centred design to align digital tools with health worker workflows and capabilities. The lessons from these observations may help guide researchers and policymakers developing novel digital health solutions for low- and semi-skilled health workers in rural LMIC settings. Our experiences could offer valuable insights, as there are few documented digital health interventions designed for these contexts. Furthermore, navigating the challenges of implementation and subsequent evaluation remains a significant hurdle for the field.

Health Professions

Food Insecurity and Mental Health Among High School Students: Evidence From National and Virginia Youth Risk Behavior Surveillance Data.

James N et al. · Jul 1, 2026

Background Youth mental health problems are rising nationally. Virginia ranks among the lowest states in youth mental health access and has concentrated pockets of food insecurity (FI), underscoring the urgency of policy responses. FI is a known risk factor, yet surveillance often relies on single-item measures. We introduce a multidimensional Food Insecurity Index (FII) to examine associations with adolescent mental health. Methods We analyzed 2023 Youth Risk Behavior Surveillance System data from Virginia (n = 1866) and the United States (n = 10,724). The FII combined five indicators capturing acute scarcity and chronic dietary compromise. Survey-weighted logistic regression estimated adjusted odds ratios (AORs) for persistent sadness or hopelessness. Results Each 1-point increase in FII was associated with higher odds of persistent sadness or hopelessness in Virginia (AOR = 1.066, 95% CI: 1.005-1.130) and nationally (AOR = 1.087, 95% CI: 1.062-1.112). Female students had higher odds than males, and bullying was a strong correlate. A dose-response pattern was observed. Implications for school health policy, practice, and equity Integrating FI screening with nutrition and behavioral health supports may help identify and address overlapping risks. Conclusions Multidimensional FI is consistently associated with poorer mental health among high school students.

Health Professions

Knowledge, Attitude and Practices of Swallowing and Dysphagia: A Cross-Sectional Survey Among the Community Dwelling Adults of South India.

Dodderi T et al. · Jul 1, 2026

Background Community awareness of swallowing and dysphagia plays a significant role in improving early-referral behavior. Literature reports that community awareness of swallowing and dysphagia in the Western countries to be low. Conversely, India has a diverse cultural, linguistic and healthcare-related factors which may influence the health-seeking behavior and early-referral of dysphagia. Hence, it becomes difficult to generalize the findings of existing literature. Aim The primary objective of this study was to analyze the knowledge, attitudes and practices (KAP) related to swallowing and dysphagia among the community dwelling adults of South India. The secondary objective was to evaluate if age, sex and education levels were associated with these factors. Methods and procedures Community dwelling adults were recruited from Mangalore city, India for a cross-sectional survey using a convenience sampling design. A purposive built content validated 27-item questionnaire was distributed using Google Form and/or hard copies to the participants for data collection. Participant's responses were independently analyzed by two Speech Language Pathologists using open content analysis. The responses were summarized as percentages and categories and chi square test was administered to examine the association between age, sex and education levels and KAP enquiries at 0.05 level. Outcomes and results A total of 372 participants aged 20-79 years (mean age = 46.26; SD = 15.63) participated in the study. Participants demonstrated limited knowledge of signs, causes, complications and professional management of dysphagia. Aspiration was widely recognized as unsafe, yet only one-tenth correctly identified pneumonia as a complication of dysphagia. Less than one-fifth knew the treatment options for dysphagia. Attitudes reflected fear of choking, discomfort towards nasogastric-tube feeding and moderate willingness to seek help from healthcare professionals. Practices suggested low awareness of Heimlich maneuver, inconsistent food-texture modification and reliance on water to manage dry mouth. Age, sex and education levels were significantly associated with knowledge (saliva is important for chewing, avoid eating in public space to overcome stigma, early intervention helps regain swallowing abilities, age range frequently associated with dysphagia), attitude (fear of choking, preference to non-oral feeds), practices (using internet to find solutions for dysphagia, drinking water before meals or moistening food using water, changing food consistencies, using straw over cup) at p > 0.05 level. Conclusions and implications Community dwellers demonstrated insufficient knowledge, predominantly negative attitudes and unsafe self-management practices related to swallowing and dysphagia. Strengthened public education, early-referral pathways and inclusion of basic life-support skills are highly warranted to improve community awareness on swallowing and dysphagia. What this paper adds What is already known on this subject Community awareness of dysphagia is low in Western countries. Cultural beliefs, literacy, superstition and access to healthcare influence what people know, how they respond and when they seek help. Understanding knowledge, attitude and practices (KAP) of swallowing and dysphagia in India is critical for reducing self-management risks and improving early-referral behavior. What this study adds to existing knowledge The study provides the first structured KAP analysis on swallowing and dysphagia in an Indian community . Participants recognized aspiration as dangerous, yet lacked awareness of critical signs, causes, treatment options and responsible team members. Fear of choking was high, and most were uncomfortable with tube-based feeding. The public seldom employed safe compensatory strategies and very few were familiar with Heimlich maneuver or food-texture modification. Age, sex and education levels were significantly associated with multiple KAP variables. What are the clinical implications of this work? There is an urgent need to conduct more public awareness programs on prevention, early identification and intervention of dysphagia by healthcare professionals involved in dysphagia care. Efforts must be scaled to provide basic life support (BLS) skills training programs, including training in Heimlich maneuver, to the public.

Health Professions

Differences in Physical Fitness and Health-Related Variables Between Older Adults With Versus Without Self-Reported Impairments in Activities of Daily Living: A Population-Based Study.

Bergmann M et al. · Jul 1, 2026

Activities of daily living (ADL) are associated with declines in physical fitness and subjective health. However, it remains unclear as to whether ADL impairments are related to specific components of physical fitness and health variables. Therefore, we examined differences between community-dwelling older persons with versus without ADL impairments with regard to various physical fitness components, physical complaints as well as subjective and objective health outcomes. Cross-sectional study among 254 participants aged ≥ 55 years [51% female; 84 with ADL impairments; mean (SD) age 62.1 (6.6) years] enrolled in the population-based "Gesundheit zum Mitmachen" study in Southwestern Germany. ADL, physical complaints and subjective health status were assessed using a self-report questionnaire, physical fitness (cardiorespiratory fitness, strength, gross motor coordination, flexibility, and functional mobility) was assessed using a fitness test battery, and objective health status was derived from health exam performed by a physician. We ran analyses of covariance, adjusted for age, sex, body mass index and education. Participants with ADL impairments had statistically significantly worse subjective (p < 0.001) and objective (p < 0.001) health and reported more physical complaints (p < 0.001) compared to those without ADL impairments. Regarding physical fitness, ADL-impaired participants performed worse in 10 out of 12 variables. The findings provide additional evidence that ADL impairments are related to decreased objective and subjective health and physical fitness in older community-dwelling adults. Future studies employing more comprehensive, preferably objective, ADL assessments and considering cognitive impairments, which may also impact ADL performance, are warranted.

Health Professions

Childhood Material Hardship Linked to Adolescent Neurocognition: A Computational Modeling Approach.

Zhang YL et al. · Jul 1, 2026

Childhood material hardship, including insecurity in housing, utilities, food, and medical care, is a critical factor influencing cognitive functioning and mental health outcomes. However, past research on material hardship is limited by cross-sectional data and reliance on conventional behavioral measures of cognitive functioning that suffer from poor reliability and lack of specificity. To address these gaps, this study used a well-validated computational model of cognition to examine individuals' drift rate, which is hypothesized to be driven by the efficiency of evidence accumulation (EEA) for decision-relevant information, a key process that supports higher-order cognitive functioning. Here, we examined how material hardship during childhood was associated with adolescent drift rate, and whether drift rate was linked with attention difficulties. 187 adolescents recruited from the Future of Families and Child Wellbeing Study were included in the analyses. Adolescents exposed to greater material hardship showed lower drift rate, suggesting less effective processing. Growth curve modeling revealed that initial exposure to material hardship, but not changes across childhood, was associated with drift rate in adolescence. Lower drift rate was also associated with concurrent attentional problems and served as a significant indirect pathway linking material hardship to adolescent attention. This is the first longitudinal study that examined the associations among childhood material hardship exposure, adolescent drift rate, and attentional difficulties. Our results suggest that challenges to essential living conditions in childhood may impact cognitive processes underlying goal-directed behavior in adolescents. These findings highlight the application of computational models to reveal specific cognitive processes impacted by adversity. SUMMARY: Existing research on material hardship and cognitive functioning is limited by reliance on cross-sectional task-based performance, resulting in inconsistent findings. We applied the diffusion-decision model to decompose trial-wise performance into underlying cognitive processes, including drift rate, a key evidence accumulation process underlying goal-directed behavior. Greater cumulative childhood material hardship, beyond exposure to other adversity, is associated with lower drift rate, which is linked with greater attentional problems in adolescents. Findings were specific to drift rate, not average response time or accuracy, emphasizing the value of computational methods in capturing cognitive changes associated with material hardship.

Health Professions

Moral Distress as Subordination by Design: Silence, Containment and the Ethical Erosion of Nursing.

Ramsay A et al. · Jul 1, 2026

Moral distress has become one of the most prominent ethical constructs in contemporary nursing, widely used to describe nurses' experiences of constraint, frustration and ethical unease. While moral distress scholarship continues to retain important ethical and structural dimensions, the broader operationalisation of moral distress within healthcare organisations and professional discourse may influence how ethical conflict is understood and managed within healthcare organisations. This paper argues that such framings can have unintended consequences for nursing's moral authority and professional standing. Adopting a critical theoretical and conceptual synthesis, and drawing on feminist theory, Foucauldian analyses of power and contemporary nursing scholarship, this paper reconceptualises moral distress as functioning within conditions of subordination by design, understood as organisational, discursive and material arrangements that may systematically constrain nursing authority while influencing the conditions under which ethical dissent is manageable and non-disruptive. Within this framework, this paper advances three related concepts: moral containment, referring to organisational responses that absorb and redirect ethical dissent; ethical erosion, describing the cumulative diminishment of nurses' moral agency over time, and ethical laundering, naming the institutional process through which ethical harm may be acknowledged yet rendered politically inert. Rather than rejecting moral distress scholarship, the paper situates moral distress within a broader architecture of organisational power, contributing to contemporary debates regarding nursing voice, professional authority and the structural conditions under which nursing ethics can be meaningfully enacted.

Health Professions

Advancing health equity for Roma people in Romania.

Matache M et al. · Jun 25, 2026

Over the past few decades, scholars in the humanities and social sciences have increasingly interrogated the histories and legacies of violence against Romani people through critical, decolonial, feminist, and anti-racist lenses. Building on this body of research, this article examines continuities of anti-Roma racism in a specific place, Romania, and how they can help reproduce and shape health outcomes and inequities today. Using a critical analysis of Romanian laws, policies, literature, and public discourse, we propose the right to a remedy for past collective injustices faced by historically oppressed and racialized populations as a pathway to the full realization of the right to health in places marked by continuous collective injustices. We argue that the realization of the right to health must be understood and addressed beyond equal access and protections against violations of the right to health; it also requires addressing the legacies and persistence of anti-Roma racism and its long-term impacts on health, well-being, and quality of life, as well as addressing other enduring oppressions.

Health Professions