Healthcare

28 pages, 5025 KB

Open AccessArticle

Factors Associated with Appointment Cancellation on a Commercial Digital Mental Health Platform: A Retrospective Cohort Study in Saudi Arabia

by Abdulmajeed A. Alkhamees

Healthcare 2026, 14(17), 2672; https://doi.org/10.3390/healthcare14172672 (registering DOI) - 22 Aug 2026

Abstract

Background: Commercial digital mental health platforms have expanded across the Gulf since 2020, yet cancellation in this delivery model remains understudied. We aimed to identify factors independently associated with session cancellation on a Saudi Arabic-language commercial platform and to determine whether they describe [...] Read more.

Background: Commercial digital mental health platforms have expanded across the Gulf since 2020, yet cancellation in this delivery model remains understudied. We aimed to identify factors independently associated with session cancellation on a Saudi Arabic-language commercial platform and to determine whether they describe user or provider behaviour. Methods: We conducted a retrospective cohort analysis of 36,544 booked sessions from 21,904 unique users (October 2023–April 2026); the outcome was binary cancellation (cancelled vs. completed). Multivariable logistic regression with cluster-robust standard errors estimated adjusted odds ratios (aORs) for user, provider, and booking characteristics; secondary analyses decomposed cancellation by recorded initiator and modelled age, lead time, and calendar time flexibly. Reporting followed STROBE guidelines. Results: Crude cancellation was 25.6%. Cancellation was strongly patterned by visit type (follow-up aOR 0.26, 95% CI 0.21–0.32), lead time (≥8 days 2.10, 95% CI 1.90–2.33), session type (free 1.19, 95% CI 1.10–1.27), and provider specialty; age reduced odds modestly (aOR 0.90 per decade, p < 0.001) and gender was null (aOR 0.95, p = 0.119). Cause-specific models showed that the lead-time gradient reverses by initiator: at ≥8 days versus same-day, user-initiated cancellation was less likely (aOR 0.62, 95% CI 0.49–0.78), whereas provider-initiated cancellation was far more likely (aOR 4.75, 95% CI 4.23–5.35), and provider-specialty differences were confined almost entirely to provider-initiated cancellation. The very low adjusted odds for emergency sessions (aOR 0.17, 95% CI 0.13–0.23) reflect how emergency bookings are administratively coded on the platform rather than genuine behavioural non-adherence and are regarded as artefactual. Discrimination was moderate (apparent AUC 0.700, development sample). Conclusions: Cancellation reflected operational features of the booking, but its largest correlates—lead time, free-session status, and provider specialty—operate predominantly through provider-side scheduling rather than patient non-adherence. Full article

(This article belongs to the Section Healthcare Organizations, Systems, and Providers)

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15 pages, 726 KB

Open AccessArticle

An Integrated Multidimensional Framework for Hospital Performance Assessment: Design and Application in Romanian Public Hospitals

by Cristina Elena Dobre, Robert Daniel Negru, Doina Clementina Cojocaru, Eliza Maria Fotache, Ioana Rudnic, Liliana Sachelarie, Alina Elena Jehac and Liviu Stafie

Healthcare 2026, 14(17), 2671; https://doi.org/10.3390/healthcare14172671 (registering DOI) - 22 Aug 2026

Abstract

Background/Objectives: Hospital performance is a multidimensional construct that cannot be adequately assessed using isolated financial, clinical, organizational, or patient-reported indicators. This study aimed to develop and evaluate an Integrated Multidimensional Hospital Performance Assessment Framework combining organizational management, healthcare quality, patient satisfaction, and cost [...] Read more.

Background/Objectives: Hospital performance is a multidimensional construct that cannot be adequately assessed using isolated financial, clinical, organizational, or patient-reported indicators. This study aimed to develop and evaluate an Integrated Multidimensional Hospital Performance Assessment Framework combining organizational management, healthcare quality, patient satisfaction, and cost efficiency. Methods: An observational, descriptive, comparative study was conducted using data collected during 2018–2019 from two Romanian public hospitals with different organizational profiles: a multidisciplinary general hospital and a monospecialty hospital. Organizational, operational, financial, and clinical indicators were analyzed comparatively. Patient satisfaction was assessed in 184 hospitalized patients, including 130 from the general hospital and 54 from the monospecialty hospital, using a structured questionnaire with excellent internal consistency (Cronbach’s α = 0.92). Cost efficiency was estimated using Stochastic Frontier Analysis based on hospital expenditure, activity, resource utilization, case complexity, and quality-related variables. Results: Significant differences were identified between the hospitals in staff composition, bed occupancy, outpatient activity, case-mix complexity, surgical activity, healthcare quality, and financial performance. Patient satisfaction was generally high in both institutions, although several dimensions differed significantly, particularly overall satisfaction, waiting time, physician consultation, treatment received, and adherence to the prescribed medication schedule. The general hospital had a lower mean cost-inefficiency score than the monospecialty hospital (0.253 vs. 0.395), corresponding to higher estimated cost efficiency (0.747 vs. 0.605; p < 0.001). Conclusions: The proposed framework offers a comprehensive and practical approach to hospital performance assessment, and its application in two public hospitals provides a proof-of-concept demonstration of feasibility. Further multicenter studies are required for external validation and assessment of its generalizability across different hospital settings. Full article

(This article belongs to the Special Issue Healthcare Economics, Management, and Innovation for Health Systems)

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14 pages, 2362 KB

Open AccessReview

Factors Associated with Treatment Burden in Older Adults with Multimorbidity and Implications for Potential Reduction Strategies: A Scoping Review

by Leandro Amato, Gianluca Ciccaglione, Noemi Giannetta, Emanuele Di Simone, Nicolò Panattoni, Sara Dionisi, Alessandra Improta, Sofia Taborri and Marco Di Muzio

Healthcare 2026, 14(17), 2670; https://doi.org/10.3390/healthcare14172670 (registering DOI) - 22 Aug 2026

Abstract

Background: Treatment Burden (TB) refers to the workload imposed on patients by healthcare-related tasks involved in the management of chronic conditions. Despite increasing evidence on this phenomenon, strategies for its reduction in older adults with multimorbidity remain poorly explored. Aim: To map the [...] Read more.

Background: Treatment Burden (TB) refers to the workload imposed on patients by healthcare-related tasks involved in the management of chronic conditions. Despite increasing evidence on this phenomenon, strategies for its reduction in older adults with multimorbidity remain poorly explored. Aim: To map the factors associated with treatment burden reported for older patients with multimorbidity and to derive implications for potential reduction strategies, regardless of the care setting. Methods: A scoping review was conducted applying the JBI methodology for scoping reviews and reported in accordance with the PRISMA-ScR checklist. The literature search was performed on PubMed, Scopus, and CINAHL; no restrictions on publication year or language were applied. All study designs were eligible if they reported factors associated with TB from which reduction strategies could be derived, in patients aged ≥65 years, or with a mean age ≥ 65 years, with multimorbidity or associated geriatric conditions. Results: Six studies met the eligibility criteria, all of which were observational in design, conducted between 2021 and 2025. Eleven potential strategies for TB reduction, inferred from observational findings, were identified and grouped into three areas: healthcare system and access to care, therapeutic regimen, and patient and psychosocial context. Conclusions: To our knowledge, this review provides the first structured mapping of potential TB reduction strategies specifically in the older population with multimorbidity. The identified strategies, derived by the authors rather than empirically tested, may exclusively inform the design of future interventional studies and offer healthcare professionals preliminary guidance for TB management in this population. Full article

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22 pages, 343 KB

Open AccessArticle

Intention to Leave Among Quality Nurses in Public Hospitals in Kuwait: A Sequential Explanatory Mixed-Methods Study

by Talal ALFadhalah, Shaimaa Ali, Marjan Lari, Hamad Al Kharji and Hossam Elamir

Healthcare 2026, 14(17), 2669; https://doi.org/10.3390/healthcare14172669 (registering DOI) - 22 Aug 2026

Abstract

Background/Objectives: In Kuwait, a marked decline in the number of quality nurses has been observed; however, the factors underpinning their intention to leave have never been investigated. This study aimed to determine the prevalence of turnover intention among quality nurses in Kuwait, [...] Read more.

Background/Objectives: In Kuwait, a marked decline in the number of quality nurses has been observed; however, the factors underpinning their intention to leave have never been investigated. This study aimed to determine the prevalence of turnover intention among quality nurses in Kuwait, describe the reported reasons for leaving, and explore the organizational and personal experiences underlying their intentions. Methods: A sequential explanatory mixed-methods design was used. The quantitative phase involved a total population survey of all eligible quality nurses working in public hospitals (n = 65), using a structured questionnaire that included demographic characteristics, the Turnover Intention Scale (TIS-6), and literature-informed reasons for leaving. Descriptive analyses and non-parametric group comparisons (Mann–Whitney U and Kruskal–Wallis H tests) were conducted. The qualitative phase comprised in-depth semi-structured interviews with seven nurses who voluntarily reported an intention to leave and agreed to explain and contextualize the quantitative findings. Interview data were analysed using inductive thematic analysis informed by phenomenological principles. Results: The mean turnover-intention score was 21.7 (SD = 3.9), exceeding the TIS-6 scale midpoint of 18. Overall, 54 of 65 participants (83.1%; 95% CI: 72.2–90.3%) scored above the TIS-6 midpoint of 18, consistent with the original developer’s scoring guidance for a desire to leave. The most frequently reported reasons for leaving were low salary (60.0%), stressful or unsupportive work environments (49.2%), and lack of recognition (44.6%). The qualitative findings expanded these results by illustrating how organizational factors were manifested in practice through poor communication, lack of managerial support, role ambiguity, blame culture, verbal mistreatment, emotional exhaustion, and perceived inequity. Three overarching themes were identified: organizational and workplace factors, compensation and benefits, and personal reasons. Predictable morning duty also emerged as a factor that participants perceived as supporting their willingness to remain in their roles. Conclusions: Turnover intention among quality nurses in Kuwait was reported primarily in relation to organizational and work-related factors rather than demographic characteristics. The qualitative findings contextualized the high turnover-intention scores by illustrating participants’ workplace experiences. These findings suggest that strengthening organizational support, clarifying professional roles, promoting equitable management practices, and reviewing remuneration structures might contribute to improving retention among quality nurses. Full article

(This article belongs to the Special Issue Burnout, Perceived Efficacy and Job Satisfaction of Nurses: Leadership, Management and Organizational Perspectives)

14 pages, 547 KB

Open AccessArticle

Comparison and Agreement of Criteria for Classifying Improvement in Walking Ability During Inpatient Rehabilitation After Spinal Cord Injury

by Urška Puh, Tea Čuk, Bojan Čeru and Gaj Vidmar

Healthcare 2026, 14(16), 2668; https://doi.org/10.3390/healthcare14162668 - 21 Aug 2026

Abstract

Background/Objectives: To evaluate classification of improvement and agreement of walking-ability improvement criteria derived from outcome measures of walking capacity and performance among inpatients with spinal cord injury (SCI). Methods: Retrospective analysis of admission and discharge data from adults with SCI in the [...] Read more.

Background/Objectives: To evaluate classification of improvement and agreement of walking-ability improvement criteria derived from outcome measures of walking capacity and performance among inpatients with spinal cord injury (SCI). Methods: Retrospective analysis of admission and discharge data from adults with SCI in the single-centre database from years 2020 to 2023: Six-minute Walk Test (6MWT), Ten-metre Walk Test (10MWT), Walking Index for Spinal Cord Injury; selected items of Spinal Cord Independence Measure (SCIM-III), and Functional Independence Measure; Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI) Walking Mobility subscale. Twenty-three criteria for assessing walking-ability improvement including distribution-based change threshold (DBCT) and provisional milestones for in-home or in-the-community walking (derived from stroke population) and/or related independence were evaluated. Proportion of patients who progressed according to each criterion and agreement between criteria were calculated. Results: Data from 281 individuals were analysed (median 2 months since SCI). Improvement in SCIM-III Mobility Categories was achieved in 47%. Estimated DBCT of 6MWT (69 m) was exceeded in 46%, and DBCT of 10MWT at comfortable speed (CS) in 42% of participants. Forty-two percent of participants improved in provisional Walking Ability Categories (WACs) based on 6MWT or 10MWT_CS, 39% on SCIM-III-Stairs criterion, and 36% on the SCI-FAI criterion. Conclusions: The estimated DBCT and the WACs for 6MWT and 10MWT_CS are promising criteria to assess improvement in walking capacity after rehabilitation in patients with SCI; however, they require prospective validation against patient-centred and real-world mobility anchors. SCIM-III Mobility Categories and Stairs are recommended for assessing improvement in walking-related independence, and the SCI-FAI criterion for walking performance in everyday life. Full article

(This article belongs to the Section Clinical Care)

14 pages, 510 KB

Open AccessArticle

Changes in Salivary Interleukin-1 Beta Levels Following a Care Worker-Centered Oral Health Care Program Among Residents of Long-Term Care Facilities

by Hee-Jung Lim, Da-Eun Kim, Se-Eun Jang, Ki-Hyun Yoon and Jun-Yeong Kwon

Healthcare 2026, 14(16), 2667; https://doi.org/10.3390/healthcare14162667 - 21 Aug 2026

Abstract

Background/Objectives: Older adults residing in long-term care facilities (LTCFs) are at increased risk of poor oral health because of functional dependence and limited access to professional oral healthcare. Although oral healthcare education programs for care workers improve knowledge and performance, evidence of their [...] Read more.

Background/Objectives: Older adults residing in long-term care facilities (LTCFs) are at increased risk of poor oral health because of functional dependence and limited access to professional oral healthcare. Although oral healthcare education programs for care workers improve knowledge and performance, evidence of their effects on residents’ biological oral health outcomes remains limited. This study evaluated the effects of a care worker-centered oral healthcare program on oral inflammatory status in LTCF residents using salivary interleukin-1 beta (IL-1β) as an objective biomarker. Methods: A single-group pretest–posttest quasi-experimental study was conducted in two LTCFs in the Republic of Korea. Forty care workers completed a structured oral healthcare education program and provided daily oral healthcare to residents for 4 weeks. Saliva samples were collected before and after the intervention, and salivary IL-1β concentrations were measured using enzyme-linked immunosorbent assay. Changes in IL-1β concentrations were analyzed using the Wilcoxon signed-rank, Mann–Whitney U, and Kruskal–Wallis tests. Results: Thirty-seven residents completed the study. Median salivary IL-1β concentrations significantly decreased from 19.33 pg/mL (interquartile range [IQR], 11.49–34.66) at baseline to 10.78 pg/mL (IQR, 0.65–33.64) after the intervention (Z = −3.764, p = 0.001). Greater reductions were observed among residents with greater functional dependence, whereas limited communication ability or oral care refusal was associated with minimal improvement. Conclusions: A care worker-centered oral healthcare program significantly reduced salivary IL-1β concentrations among older adults residing in LTCFs. Findings support care worker training and highlight the use of salivary IL-1β as an objective biomarker for evaluating oral healthcare interventions. Full article

(This article belongs to the Section Public Health and Preventive Medicine)

13 pages, 688 KB

Open AccessArticle

Association of Night Eating Syndrome Risk with Sleep Disturbance in Medical Students: A Cross-Sectional Study

by Volkan Tekin, Sümeyra Delibaş, Eyüp Sina Keten, Mustafa Şahan, Mehmet Koçer and Sinan Yetkin

Healthcare 2026, 14(16), 2666; https://doi.org/10.3390/healthcare14162666 - 21 Aug 2026

Abstract

Background: Medical students are vulnerable to sleep disturbance and nocturnal eating behaviors that may jointly increase psychiatric and metabolic morbidity. Comprehensive sleep-eating evaluations in Turkish medical students remain limited. To determine the prevalence of poor sleep quality and night eating syndrome (NES) risk [...] Read more.

Background: Medical students are vulnerable to sleep disturbance and nocturnal eating behaviors that may jointly increase psychiatric and metabolic morbidity. Comprehensive sleep-eating evaluations in Turkish medical students remain limited. To determine the prevalence of poor sleep quality and night eating syndrome (NES) risk and to examine their cross-sectional associations with insomnia, anxiety, emotional eating, restless legs symptoms, chronotype, and lifestyle factors. Methods: This cross-sectional study, conducted from March to December 2023, included 265 medical students who completed validated instruments assessing sleep quality (Pittsburgh Sleep Quality Index [PSQI]), night eating syndrome (NES) risk (a score of ≥25 indicating high risk), insomnia severity, daytime sleepiness (Epworth Sleepiness Scale [ESS]), anxiety, emotional eating, Restless Legs Syndrome (RLS) symptoms, and chronotype. Group comparisons, Spearman’s correlation analyses, and multiple linear regression were conducted. Results: Poor sleep quality (PSQI > 5) affected 50.2% of participants, and high NES risk affected 14.7%. PSQI correlated with NEQ (r = 0.301; p < 0.001), insomnia severity (r = 0.538), anxiety, and emotional eating. Mean NEQ was higher in the poor-sleep group (18.67 ± 8.00 vs. 15.38 ± 6.36; p < 0.001; Cohen’s d = 0.455). Females had higher PSQI and ESS scores, anxiety, and emotional eating scores; high NES risk was numerically more frequent in males (18.6% vs. 11.8%; p = 0.175). RLS symptoms (score > 0) were present in 34.7% (mild 22.6%; moderate 7.9%; severe 4.2%). In the primary multivariable model (PSQI and sex), PSQI was the strongest independent correlate of NEQ (standardized β = 0.325; p < 0.001); sensitivity analyses showed stable PSQI estimates after additional covariate adjustment, whereas sex coefficients were non-significant and unstable across models. A secondary model excluding PSQI identified alcohol use as a significant lifestyle correlate (standardized β = 0.167; p = 0.014). R² = 0.148 for the full covariate model and R² = 0.108 for the primary model. Conclusions: Sleep disturbance and NES risk are prevalent and cross-sectionally associated in Turkish medical students. Poor sleep quality was the strongest independent correlate of night eating scores. Integrated campus screening targeting sleep, eating behavior, anxiety, and comorbid sleep symptoms may facilitate prevention and referral. Full article

15 pages, 585 KB

Open AccessArticle

Fear of Cancer Recurrence and Psychological Symptom Burden in Breast Cancer Survivors Without Evidence of Active Disease: A Cross-Sectional Real-World Study

by Salih Karatlı, Safiye Kübra Çetindağ Karatlı, Selahattin Çelik, Tülay Eren and Doğan Yazılıtaş

Healthcare 2026, 14(16), 2665; https://doi.org/10.3390/healthcare14162665 - 21 Aug 2026

Abstract

Objective: This study assessed the prevalence of fear of cancer recurrence (FCR) and its clinical, treatment-related, and psychological correlates in breast cancer survivors without active disease. Materials and Methods: This cross-sectional study included 200 breast cancer survivors after curative treatment. FCR [...] Read more.

Objective: This study assessed the prevalence of fear of cancer recurrence (FCR) and its clinical, treatment-related, and psychological correlates in breast cancer survivors without active disease. Materials and Methods: This cross-sectional study included 200 breast cancer survivors after curative treatment. FCR was assessed using the Fear of Cancer Recurrence Inventory–Short Form (FCRI-SF), with scores ≥ 13 indicating clinically significant FCR. Hospital Anxiety and Depression Scale-Anxiety (HADS-A) and Depression (HADS-D) scores ≥ 8 indicated clinically significant symptoms. Associations with FCR were analyzed using logistic regression, with HADS-A and HADS-D evaluated in separate multivariable models because of their potential overlap. Results: The mean age was 55.6 ± 9.5 years; clinically significant FCR, anxiety, and depression occurred in 38.0%, 32.5%, and 38.0%, respectively. In univariable analysis, younger age, stage III disease, mastectomy, chemotherapy history, and high HADS-A and HADS-D were associated with FCR. In the HADS-A model, chemotherapy history (adjusted OR: 5.841; p = 0.006) and high HADS-A (adjusted OR: 7.828; p < 0.001) were independently associated with FCR, whereas increasing age was protective (adjusted OR: 0.855; p < 0.001). In the HADS-D model, mastectomy (adjusted OR: 6.265; p = 0.002), chemotherapy history (adjusted OR: 6.941; p = 0.001), and high HADS-D (adjusted OR: 14.343; p < 0.001) were independently associated with FCR, whereas increasing age was protective (adjusted OR: 0.836; p < 0.001). Conclusions: FCR is a major psychosocial concern among breast cancer survivors, particularly in younger patients, those with chemotherapy history, and those with greater psychological symptom burden. The association with mastectomy should also be considered, particularly in patients with depressive symptoms. Full article

(This article belongs to the Special Issue Cancer Prognosis and Survivorship: Integrating Nursing, Medicine, and Psychosocial Care)

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27 pages, 4890 KB

Open AccessSystematic Review

Effects of Traditional Chinese Mind–Body Exercise on Physical Function in Older Adults with Sarcopenia and Frailty: A Meta-Analysis of Randomized Controlled Trials

by Jingtao Zhou, Wi-Young So and Minhye Shin

Healthcare 2026, 14(16), 2664; https://doi.org/10.3390/healthcare14162664 - 21 Aug 2026

Abstract

Background and Objectives: Sarcopenia and frailty are associated with falls, disability, and functional decline in older adults. This review evaluated traditional Chinese mind–body exercise (TCMBE), including Tai Chi and Health Qigong, in adults aged 60 years or older with clinically defined sarcopenia or [...] Read more.

Background and Objectives: Sarcopenia and frailty are associated with falls, disability, and functional decline in older adults. This review evaluated traditional Chinese mind–body exercise (TCMBE), including Tai Chi and Health Qigong, in adults aged 60 years or older with clinically defined sarcopenia or frailty. Materials and Methods: Randomized controlled trials identified through December 2024 from six English- and Chinese-language databases were synthesized. The analyses included physical performance and secondary outcomes and explored sarcopenia and frailty as study-level subgroups. Results: Twenty-two trials involving 1660 participants were included. TCMBE was associated with a shorter Timed Up and Go Test time (mean difference [MD], −1.17 s; 95% CI, −1.80 to −0.54; p < 0.01; I² = 74%), a higher Short Physical Performance Battery score (MD, 0.99 points; 95% CI, 0.58 to 1.40; p < 0.01; I² = 24%), and greater grip strength (MD, 2.02 kg; 95% CI, 0.58 to 3.47; p = 0.006; I² = 89%). The 6 min walk test estimate was borderline and imprecise (MD, 11.76 m; 95% CI, 0.10 to 23.43; p = 0.05; I² = 0%), and no clear overall effects were observed for gait speed, the 30 s chair stand test, sit-to-stand time, Berg Balance Scale score, muscle mass, depressive symptoms, or quality of life. Several analyses showed substantial heterogeneity, and some subgroup estimates were based on only one or two studies. Conclusions: Low-certainty evidence suggests that TCMBE may produce small improvements in TUGT performance, SPPB scores, and grip strength. Very-low-certainty evidence leaves its effects on gait speed and quality of life uncertain. Risk-of-bias concerns, heterogeneity, imprecision, and uncertain clinical significance limit confidence in the current estimates. The available evidence is insufficient to support routine implementation, and larger, rigorously conducted randomized controlled trials are needed. Full article

15 pages, 276 KB

Open AccessArticle

Independent Associations of Appendicular Skeletal Muscle Mass Index and Waist Circumference with Site-Specific Bone Mineral Density in Postmenopausal Women: A Real-World Cross-Sectional Study

by Pattama Tongdee, Sajeera Kupittayanant, Khanidtha Marungrueng, Sayah Ongsricharoenbhorn and Porntip Nimkuntod

Healthcare 2026, 14(16), 2663; https://doi.org/10.3390/healthcare14162663 - 21 Aug 2026

Abstract

Background/Objectives: Postmenopausal aging is accompanied by progressive loss of skeletal muscle mass and increased abdominal adiposity, both of which may influence bone health through distinct mechanical and metabolic pathways. However, their independent associations with bone mineral density (BMD) at different skeletal sites [...] Read more.

Background/Objectives: Postmenopausal aging is accompanied by progressive loss of skeletal muscle mass and increased abdominal adiposity, both of which may influence bone health through distinct mechanical and metabolic pathways. However, their independent associations with bone mineral density (BMD) at different skeletal sites remain incompletely characterized. This study investigated the independent associations of appendicular skeletal muscle mass index (ASMI) and waist circumference (WC) with site-specific BMD in postmenopausal women. Methods: This cross-sectional study included 345 postmenopausal women who attended a university hospital menopause clinic in Thailand. Body composition was assessed using multi-frequency bioelectrical impedance analysis, and ASMI was calculated according to the Asian Working Group for Sarcopenia (AWGS) 2019 consensus criteria. WC was measured using standardized anthropometric procedures. BMD at the lumbar spine (L1–L4), total hip, and femoral neck was determined by dual-energy X-ray absorptiometry. Multivariable linear regression analyses were performed to evaluate the independent associations of ASMI and WC with site-specific BMD after adjustment for age, years since menopause, hormone replacement therapy use, osteoporosis medication use, calcium supplementation, vitamin D supplementation, and fracture history. Robust standard errors were used in the final models. Results: Higher ASMI was independently associated with higher BMD at the lumbar spine (standardized β = 0.362, p < 0.001), total hip (standardized β = 0.371, p < 0.001), and femoral neck (standardized β = 0.353, p < 0.001). WC was positively associated with total hip BMD (standardized β = 0.158, p = 0.006), whereas no statistically significant associations were observed at the lumbar spine (standardized β = 0.009, p = 0.899) or femoral neck (standardized β = 0.105, p = 0.092). Conclusions: ASMI was consistently associated with BMD across all measured skeletal sites, whereas the association between WC and BMD varied according to skeletal region. These findings support the complementary assessment of skeletal muscle mass and central adiposity for characterizing body composition and skeletal health in postmenopausal women. Full article

(This article belongs to the Section Clinical Care)

26 pages, 324 KB

Open AccessArticle

Barriers and Facilitators to the Implementation and Scale-Up of the Baby-Friendly Hospital Initiative: A Qualitative Study in Saskatchewan, Canada

by Shela Akbar Ali Hirani and Natasha C. Taylor

Healthcare 2026, 14(16), 2662; https://doi.org/10.3390/healthcare14162662 - 21 Aug 2026

Abstract

Background: The Baby-Friendly Hospital Initiative (BFHI), developed by the World Health Organization (WHO) and UNICEF, provides an evidence-based framework to protect, promote, and support breastfeeding through implementation of the Ten Steps to Successful Breastfeeding. Despite its global adoption, implementation and scale-up of BFHI [...] Read more.

Background: The Baby-Friendly Hospital Initiative (BFHI), developed by the World Health Organization (WHO) and UNICEF, provides an evidence-based framework to protect, promote, and support breastfeeding through implementation of the Ten Steps to Successful Breastfeeding. Despite its global adoption, implementation and scale-up of BFHI remain inconsistent across healthcare systems. In Saskatchewan, Canada, only one healthcare facility currently holds BFHI designation, highlighting the need to understand the health system factors influencing implementation. This study aimed to explore the barriers and facilitators influencing the implementation and scale-up of BFHI within Saskatchewan healthcare settings. Methods: A qualitative descriptive study was conducted using Bronfenbrenner’s socioecological model as a guiding theoretical framework. Semi-structured interviews were conducted with 26 mothers and healthcare professionals with breastfeeding-related experiences in Saskatchewan, including 11 mothers (42.3%), 6 mothers who were also healthcare professionals (23.1%), and 9 healthcare professionals without maternal experience (34.6%). Participants were recruited using purposive and maximum variation sampling. Guided by a socioecological framework, interview data were manually analyzed using an iterative thematic analysis approach. Themes were interpreted across individual, interpersonal, organizational, community, and health system levels. Results: Five interrelated themes characterized BFHI implementation and scale-up in Saskatchewan, including (1) leadership and governance as foundations for BFHI implementation; (2) workforce capacity, competency, and practice consistency as determinants of care delivery; (3) continuity of breastfeeding support across care settings; (4) breastfeeding as a psychosocially embedded maternal experience; and (5) structural and societal factors shaping BFHI scale-up. While supportive leadership, provincial breastfeeding guidelines, skilled healthcare providers, interdisciplinary collaboration, and community-based services facilitated BFHI-aligned care, implementation was challenged by workforce shortages, inconsistent clinical practices, limited access to specialized breastfeeding support, early postpartum discharge, geographic inequities, fragmented care pathways, and inadequate system-level monitoring. Conclusions: In Saskatchewan, BFHI implementation and scale-up are shaped by interconnected organizational, workforce, maternal, and structural factors. The findings provide context-specific qualitative evidence to inform future BFHI planning and implementation. Further research is needed to assess the feasibility, sustainability, and effectiveness of strategies to support BFHI scale-up across diverse healthcare and geographic settings. Full article

(This article belongs to the Special Issue Educating and Strengthening the Workforce for Maternal and Neonatal Health)

20 pages, 2709 KB

Open AccessArticle

Thematic Structure of Clinical Rehabilitation Research in the Early Post-Pandemic Period: An LDA-Based Analysis of Publications from 2022 to 2025

by Alina Alshevskaya, Ivan Khutornoy, Natalia Sivitskaya, Marat Fatkhullin and Elena Aksenova

Healthcare 2026, 14(16), 2661; https://doi.org/10.3390/healthcare14162661 - 21 Aug 2026

Abstract

Background/Objective: Recent advances in scientometric topic modeling have enhanced the capacity to rapidly assess evolving research priorities. This study aimed to characterize the thematic reorganization of clinical rehabilitation research during the early post-pandemic period and to compare how an Latent Dirichlet Allocation (LDA)-derived [...] Read more.

Background/Objective: Recent advances in scientometric topic modeling have enhanced the capacity to rapidly assess evolving research priorities. This study aimed to characterize the thematic reorganization of clinical rehabilitation research during the early post-pandemic period and to compare how an Latent Dirichlet Allocation (LDA)-derived topic structure, SciVal, and OpenAlex represent this interdisciplinary research domain. Methods: Titles of 55,711 publications on clinical rehabilitation (2022–2025) were analyzed using an LDA-based topic modeling pipeline to identify predominant thematic directions. For comparison, topics automatically generated by Scopus and OpenAlex were examined. Results: The analysis revealed ten major thematic clusters encompassing the entire publication corpus. These clusters represented both medical and non-medical dimensions of rehabilitation research. The principal directions included post-COVID-19 recovery, psychological and quality-of-life outcomes, technological innovations such as virtual reality and telemedicine, and the growing emphasis on multidisciplinary and integrative rehabilitation frameworks. Conclusions: The proposed approach provided a field-wide, two-level representation of rehabilitation research and enabled a direct structural comparison of alternative topic-classification systems. The analysis showed systematic differences in aggregation, fragmentation, and corpus coverage across the compared approaches, without implying the universal superiority of any single method. Full article

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19 pages, 687 KB

Open AccessArticle

Perceived Barriers to Home-Based Telemedicine and Facilitators of Public Health Center-Based Telemedicine Among Digitally Capable Community-Dwelling Older Adults: A Cross-Sectional Scenario-Based Survey

by Seung-Kwon Ji and Wonseuk Jang

Healthcare 2026, 14(16), 2660; https://doi.org/10.3390/healthcare14162660 - 21 Aug 2026

Abstract

Background/Objectives: Home-based telemedicine requires patients to perform technical tasks independently, whereas assisted public health center (PHC)-based telemedicine transfers some of these tasks to on-site personnel. This study describes model-specific perceptions and estimates the difference in intention to use between the two scenarios among [...] Read more.

Background/Objectives: Home-based telemedicine requires patients to perform technical tasks independently, whereas assisted public health center (PHC)-based telemedicine transfers some of these tasks to on-site personnel. This study describes model-specific perceptions and estimates the difference in intention to use between the two scenarios among relatively digitally capable, community-dwelling older adults. Methods: A cross-sectional, fixed-order, scenario-based online survey was completed by 300 adults aged 65 years or older in South Korea. Home-based barriers and PHC-based facilitators were analyzed as non-equivalent descriptive domains. The primary paired comparison used three conceptually matched intention items. Internal consistency, exploratory factor evidence, 95% confidence intervals (CIs), Pearson and Spearman correlations, and multivariable linear regressions with HC3 robust standard errors were reported. Results: The seven-item home-based barrier score was 2.80 (SD 0.76; 95% CI 2.71–2.89), and the seven-item PHC facilitator score was 3.58 (SD 0.58; 95% CI 3.52–3.65). Intention scores were 3.91 (SD 0.64) for home-based and 3.88 (SD 0.66) for PHC-based telemedicine. The paired mean difference (PHC minus home) was −0.030 (95% CI −0.107 to 0.047; p = 0.441; Cohen’s dz = −0.045, bootstrap 95% CI −0.155 to 0.071). Preferences were home-based 42.7% (95% CI 37.2–48.3%), PHC-based 41.3% (95% CI 35.9–47.0%), and unsure 16.0% (95% CI 12.3–20.6%). After adjustment, digital literacy remained positively associated with both intention outcomes. Conclusions: No statistically detectable difference in intention to use was observed between the two hypothetical scenarios; this finding does not establish equivalence. The item-level results generate a hypothesis that staff-supported PHC delivery may be useful for some older adults, but actual uptake, effectiveness, accessibility, and equity require evaluation in real-world studies that include less digitally capable and more vulnerable populations. Full article

(This article belongs to the Topic Digital Patient Care: Bridging Technology and Clinical Practice)

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11 pages, 423 KB

Open AccessArticle

Risk of Obstructive Sleep Apnea in Patients with Emphysema Versus Bronchiectasis: A Propensity Score-Matched Cohort Study

by Ling-Hui Chang, Wen-Che Hsieh, Hui-Cheng Lin and Chao-Yu Hsu

Healthcare 2026, 14(16), 2659; https://doi.org/10.3390/healthcare14162659 - 21 Aug 2026

Abstract

Background: Obstructive sleep apnea (OSA) is common in patients with chronic respiratory disease, but whether its risk differs between emphysema and bronchiectasis remains unclear. We compared the subsequent risk of OSA between these two structural lung diseases using a large real-world database. Methods: [...] Read more.

Background: Obstructive sleep apnea (OSA) is common in patients with chronic respiratory disease, but whether its risk differs between emphysema and bronchiectasis remains unclear. We compared the subsequent risk of OSA between these two structural lung diseases using a large real-world database. Methods: This retrospective cohort study used data from the TriNetX research network. Adults with emphysema or bronchiectasis were identified and followed for incident OSA. Baseline demographic characteristics, comorbidities, and medication use were balanced using 1:1 propensity score matching. OSA risk was evaluated at 1-, 2-, 3-, 4-, and 5-year intervals and cumulatively through 29 July 2026, using risk ratios, odds ratios, and hazard ratios (HRs). Results: Before matching, 526,877 patients with emphysema and 147,700 with bronchiectasis were included. After propensity score matching, 129,761 patients remained in each cohort, with all standardized differences below 0.10. In the matched analysis, OSA risk was modestly lower in the emphysema group at 1 year (HR = 0.829, 95% CI = 0.778–0.883), 2 years (0.885, 0.843–0.931), 3 years (0.923, 0.884–0.964), 4 years (0.946, 0.910–0.984), and 5 years (0.960, 0.925–0.995). However, the cumulative hazard did not differ significantly between groups (HR = 1.006, 95% CI = 0.976–1.038). Conclusion: After propensity score matching, bronchiectasis was associated with a modestly higher early risk of OSA, but this difference diminished over time and was absent over long-term follow-up. These findings should be considered hypothesis-generating and warrant prospective confirmation. Full article

(This article belongs to the Section Clinical Care)

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21 pages, 1289 KB

Open AccessArticle

Social Determinants of Healthcare Access: Horizontal Inequity in Rehabilitation Utilization and the Limits of Care in Mediating the Income–Depression Gradient in Türkiye

by Derya Azim, Muhammed Emre Güvey, Sevde Betül Kara, Sümeyra Gündem, Ecenur Aydemir and Salim Yılmaz

Healthcare 2026, 14(16), 2658; https://doi.org/10.3390/healthcare14162658 - 21 Aug 2026

Abstract

Background/Objectives: Structural inequalities in access to healthcare persist even within systems that have achieved near-universal coverage, reflecting the enduring influence of social determinants of health on service utilization. This study examines horizontal inequity in rehabilitation and specialist care in Türkiye and investigates whether [...] Read more.

Background/Objectives: Structural inequalities in access to healthcare persist even within systems that have achieved near-universal coverage, reflecting the enduring influence of social determinants of health on service utilization. This study examines horizontal inequity in rehabilitation and specialist care in Türkiye and investigates whether access inequality mediates the well-documented income–depression gradient. Methods: Analyzing the nationally representative 2022 Türkiye Health Survey (adults aged ≥15; N = 22,742), we employed Latent Profile Analysis (LPA) to construct people-centered, multidimensional bodily burden profiles, and assessed need-adjusted access using survey-weighted logistic regression, Erreygers-corrected concentration-index decomposition, Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA), and restricted cubic splines, with measurement-invariance and classification-uncertainty sensitivity analyses. Statistical mediation was examined with natural-effect models and E-value sensitivity analysis. Results: Although the system demonstrated responsiveness to need—78.8% of the highest-burden profile accessed specialist services—only 13.7% of this same group reached dedicated physiotherapy or rehabilitation, revealing a profound structural bottleneck in care coordination for marginalized populations with the greatest functional impairment. A persistent pro-rich gradient was confirmed by an Erreygers-corrected concentration index of 0.058 (95% CI 0.043–0.072), driven additively by income and education. Access did not mediate the income–depression pathway (natural indirect effect OR 1.001, 95% CI 1.0003–1.002). Conclusions: The mental health burden of low income operates through pathways that equitable healthcare access alone cannot address. These findings call for macroeconomic and people-centered health system reforms—including direct physiotherapy access, transportation subsidies, and social protection interventions—to advance health equity in rehabilitation utilization. Full article

(This article belongs to the Special Issue Health Equity and People-Centered Systems: Meeting Needs and Creating Opportunities for Diverse Communities)

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16 pages, 1870 KB

Open AccessArticle

Smartphone Screen Time, Sleep Quality, and Headache in Young Adults Presenting to the Emergency Department: A Case–Control Study

by Yusuf Kantar, Yusuf Ertuğrul Aslan, Arif Onur Eden, Yasin Bilgin, Orhan Tanrıverdi, Abdullah Emre Yurttutan, Erdem Yakup Çimen and Fatih Mehmet Sarı

Healthcare 2026, 14(16), 2657; https://doi.org/10.3390/healthcare14162657 - 21 Aug 2026

Abstract

Background: Smartphone screen exposure has increased substantially among young adults and has been associated with headache and sleep disturbances. This study aimed to investigate the associations between smartphone screen time, headache severity, sleep duration, and sleep quality in young adults presenting to [...] Read more.

Background: Smartphone screen exposure has increased substantially among young adults and has been associated with headache and sleep disturbances. This study aimed to investigate the associations between smartphone screen time, headache severity, sleep duration, and sleep quality in young adults presenting to the emergency department with headache. Methods: This single-center case–control study was conducted in the emergency department of a tertiary university hospital between November 2025 and April 2026. A total of 300 participants aged 18–40 years were enrolled, including 150 patients with headache and 150 controls without headache. Daily smartphone screen time was obtained from the built-in smartphone records for the preceding completed seven-day period, headache severity was assessed using the 11-point Numeric Rating Scale, and sleep quality was evaluated using the validated Turkish version of the Single-Item Sleep Quality Scale. Results: Participants with headache had longer smartphone screen time (7.0 vs. 5.0 h/day; p < 0.001), shorter sleep duration (7.0 vs. 8.0 h/day; p = 0.005), and poorer sleep quality (5.0 vs. 7.0; p < 0.001) than controls. Screen time correlated with headache severity (ρ = 0.430, p < 0.001) and inversely with sleep quality after adjustment for study group (partial ρ = −0.185, p = 0.001). Nonlinear multivariable modeling showed an association with headache presentation (p < 0.001); relative to 6 h/day, the aOR at 7 h/day was 8.83 (95% CI: 5.00–15.60), with a plateau at higher exposures. Conclusions: Longer device-recorded smartphone screen time was associated with headache presentation and severity in young adults. Participants with headache also reported poorer sleep quality and shorter sleep duration. These findings suggest relevant associations between smartphone exposure, sleep, and headache but do not establish causality or a clinical screen-time threshold. Prospective studies are warranted. Full article

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21 pages, 1344 KB

Open AccessArticle

Cost-Minimization and Procedural Outcomes of Cold Snare Versus Cold Forceps Polypectomy for Small Colorectal Polyps: A Prospective Cohort Study Using Real Institutional Pricing

by Güney Özkaya, İsmail Ege Subaşı, Sangar Abdullah, Sertaç Doğan and Şiva Nafez

Healthcare 2026, 14(16), 2656; https://doi.org/10.3390/healthcare14162656 - 21 Aug 2026

Abstract

Background/Objectives: Although current guidelines (European Society of Gastrointestinal Endoscopy [ESGE] 2024, U.S. Multi-Society Task Force [USMSTF] 2020) recommend cold snare polypectomy (CSP) over cold forceps polypectomy (CFP) for small colorectal polyps, CFP remains widely used. Comparative economic data using real institutional pricing are [...] Read more.

Background/Objectives: Although current guidelines (European Society of Gastrointestinal Endoscopy [ESGE] 2024, U.S. Multi-Society Task Force [USMSTF] 2020) recommend cold snare polypectomy (CSP) over cold forceps polypectomy (CFP) for small colorectal polyps, CFP remains widely used. Comparative economic data using real institutional pricing are scarce, limiting evidence for guideline-concordant resource allocation. We evaluated the healthcare economics and procedural outcomes of CSP versus CFP to assess their institutional resource implications. Methods: This prospective cohort study analyzed 153 consecutive patients (181 polyps ≤ 9 mm) at a single tertiary care center (June–October 2025). Technique allocation was based on endoscopist preference. The primary outcome was histopathologically confirmed complete resection; secondary outcomes were one-piece resection rate, procedure time, and cost outcomes based on institutional pricing. Firth penalized logistic regression, propensity score matching, and a neoplastic-restricted sensitivity analysis were performed. Results: Complete resection rates did not differ significantly (CSP 97.4% vs. CFP 94.2%, p = 0.29). CSP achieved higher one-piece resection rates (96.2% vs. 84.5%, p = 0.011) and shorter procedure time (median 3.2 vs. 5.1 min, p < 0.001). For 6–9 mm polyps, piecemeal resection was reduced with CSP (6.8% vs. 28.6%, p = 0.010). Despite higher device costs ($6 vs. $3), direct device-plus-labor cost was lower for CSP ($18.06 vs. $22.24, p < 0.001), with no statistically significant difference in complete resection. High-grade dysplasia was the only variable independently associated with incomplete resection. Findings were consistent in propensity score-matched (n = 61 pairs) and neoplastic-restricted (n = 134) analyses. Conclusions: By reducing direct device-plus-labor costs by 19% while improving one-piece resection, and remaining consistent across multivariable, propensity score-matched, and sensitivity analyses, these findings indicate that, within a cost-minimization framework, CSP is a cost-saving, guideline-concordant technique with no statistically significant difference in complete resection or observed adverse events. Full article

(This article belongs to the Section Healthcare and Sustainability)

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19 pages, 701 KB

Open AccessReview

Skin Assessment Strategies for Identification of Pressure Injuries in Dark-Skin-Tone Patients: A Scoping Review

by Vainess Banda Mbuzi, Susan Morgan, Dianne Stratton-Maher, Tracey Tulleners and Leah East

Healthcare 2026, 14(16), 2655; https://doi.org/10.3390/healthcare14162655 - 21 Aug 2026

Abstract

Background: Early pressure injury detection is essential in acute care, yet diagnostic inequities persist for individuals with dark skin tones. Traditional visual assessment relies on colour changes that may not be visible in richly pigmented skin, contributing to delayed diagnosis and poorer outcomes. [...] Read more.

Background: Early pressure injury detection is essential in acute care, yet diagnostic inequities persist for individuals with dark skin tones. Traditional visual assessment relies on colour changes that may not be visible in richly pigmented skin, contributing to delayed diagnosis and poorer outcomes. Objective: Our aim was to identify and map strategies reported in the literature for assessing skin and underlying tissue to support early pressure injury detection in adults with dark skin tones in acute care settings. Methods: A scoping review was conducted following Joanna Briggs Institute methodology and reported according to PRISMA-ScR. Searches were performed in CINAHL, PubMed, Scopus, Web of Science, and Google Scholar (April 2025; updated February 2026). Primary research published in English since 2017 was eligible. After screening and data extraction, descriptive thematic analysis was applied to identify recurrent strategies reported in the literature for assessment of skin and underlying tissues for detection of pressure injury. No appraisal of the included sources was conducted. Results: Ten studies met the inclusion criteria. Strategies identified for detecting pressure injuries were mainly for implementation across diverse skin tones, but all included aspects of dark-skin-tone participants. These approaches are clustered into four categories: thermographic imaging, subepidermal moisture sensors, image processing and colorimetry, and enhanced assessment and lighting techniques. The evidence highlights the growing value of objective, technology-supported methods for improving detection in people with dark skin tones. Routine bedside visual and tactile assessment was notably underrepresented, indicating a clear evidence gap. Overall, the review emphasises the need to integrate objective technologies into everyday practice to support more equitable pressure injury detection. Conclusions: This scoping review highlighted that evidence for routine visual and tactile assessment in dark skin tones remains limited. Technology-supported assessment approaches show promise for improving diagnostic equity in pressure injury detection. Identification of strategies used to perform skin assessment for pressure injury identification is critical to the wellbeing of persons with dark skin tones. This review demonstrates that while emerging technologies offer promising ways to improve pressure injury detection across diverse skin tones, evidence supporting everyday bedside visual and tactile assessment for individuals with dark skin tones remains notably limited. Strengthening this evidence base and integrating objective technologies into routine care are essential steps toward more accurate and equitable pressure injury detection. Full article

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20 pages, 1157 KB

Open AccessArticle

Digital Health Adoption Among Patients with Diabetes inQassim Unaizah, Saudi Arabia: A Cross-Sectional Study

by Nada Abdelrahman M. Ibrahim, Mohammed Saif Anaam, Talal Sami Alkeraidees, Bader Ayman Alsaegh, Mabrouk AL-Rasheedi, Majd Abdullah Alharbi, Ghaidaa Hamad Almotairi, Rama Mohammed Aldubaikhy and Waleed M. Altowayan

Healthcare 2026, 14(16), 2654; https://doi.org/10.3390/healthcare14162654 - 21 Aug 2026

Abstract

Background: Diabetes mellitus is a major public health concern in Saudi Arabia, affecting approximately 18.3% of adults. Although over 95% of people in the Qassim region own smartphones, limited information exists regarding how and why patients with diabetes utilize digital health technologies. Objective: [...] Read more.

Background: Diabetes mellitus is a major public health concern in Saudi Arabia, affecting approximately 18.3% of adults. Although over 95% of people in the Qassim region own smartphones, limited information exists regarding how and why patients with diabetes utilize digital health technologies. Objective: This study employed an extended Technology Acceptance Model (TAM) incorporating trust, privacy concerns, and self-efficacy to investigate the factors influencing digital health technology adoption among patients with diabetes in Qassim Unaizah, Saudi Arabia. Methods: A cross-sectional study was conducted from November 2025 to January 2026 following institutional review board approval. The quantitative phase utilized a structured survey (n = 203) measuring TAM constructs via validated 5-point Likert scales. Descriptive statistics, Pearson correlations, and one-way ANOVA were performed. Qualitative themes were derived from open ended responses to contextualize quantitative findings. Results: Most participants were male (62.6%), with a mean age of 47.2 years (SD ± 13.1). Smartphone ownership was nearly universal (99.5%), and 82.8% used blood glucose tracking applications. All TAM constructs exhibited significant positive correlations with behavioural intention (p < 0.001): attitude (r = 0.450), perceived usefulness (r = 0.438), self-efficacy (r = 0.394), trust (r = 0.379), ease of use (r = 0.340), and privacy concern (r = 0.309). Mean scores indicated strong acceptance: perceived usefulness (4.31, SD ± 0.39), behavioural intention (4.21, SD ± 0.44), and attitude (4.17, SD ± 0.42). Daily usage was reported by 63.1% of participants, 81.8% expressed satisfaction, and 63.1% reported that digital tools greatly improved their diabetes management. Privacy concerns were notably low (mean 1.70, SD ± 0.89, reverse-coded; Cronbach’s α = 0.921). Supplementary qualitative content analysis of optional open-ended comments (n = 40 respondents) identified six recurring topics: clinical utility, digital literacy, trust, data security awareness, patient empowerment, and social support. Conclusions: Patients with diabetes in Qassim Unaizah demonstrate substantial digital health adoption, predominantly driven by perceived usefulness, positive attitudes, and self-efficacy. The extended TAM effectively explains adoption within this Saudi Arabian context. Findings support interventions emphasizing clinical benefits, user friendly design, and trust building to optimize digital health utilization in diabetes care. Full article

(This article belongs to the Section Digital Health Technologies)

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