Journal of applied clinical medical physicsJoseph R Steiner, Shengwen Deng, Ching-Mei Feng, Joshua M Wilson, Mary Ellen Jafari, Megan E Lipford, Lei Qin, Dustin Gress, David Jordan
INTRODUCTION: In 2020, the American Association of Physicists in Medicine (AAPM) conducted a comprehensive imaging physics workforce survey (2020 Survey) to evaluate staffing needs, validate prior time and effort estimates, and explore workforce satisfaction. This report summarizes key findings, highlighting gaps between training and professional demands, challenges in recruitment, and shifts in workforce demographics and employment patterns. METHODS: The 2020 Survey, administered by the American Institute of Physics (AIP) Statistical Research Center (SRC) to AAPM and Health Physics Society members, had 953 responses from participants who were primarily diagnostic and nuclear medical physicists. The data were analyzed across four key areas: professional task workloads, workforce demographics and retirement outlook, lifestyle factors, and skill gaps. RESULTS AND DISCUSSION: The AIP SRC analyzed the results of the 2020 Survey (results archived on the AAPM members-only website). The 2020 Survey validated the relative time required for equipment performance evaluations and the wide range of Level 2 services performed by the imaging physics workforce relative to AAPM Report 301. The 2020 Survey showed that the imaging physics workforce is aging (30% of respondents providing their age stated they were 66 years or older) and that many of these individuals could retire within 5 years of completing the survey. Finally, the 2020 Survey demonstrated that there were gaps between the skills and knowledge employers look for when hiring compared to the same self-identified qualities of the imaging physics workforce. CONCLUSIONS: The 2020 Survey provided insights into the imaging physics workforce that validated prior publications estimating imaging physics workforce activities. The 2020 Survey indicates the imaging physics workforce is aging, with a wave of retirements on the horizon, and that individuals entering the workforce may not possess the skills and knowledge desired by employers. The data from this survey can be used to guide analyses and address future trends of the imaging physics field and workforce.
Journal of applied clinical medical physicsKenneth Lewis, John Metyko, Jessica Clements, Marc Felice, Mary Ellen Jafari, Melissa Martin, Thomas Morgan, Glenn Sturchio, Chu Wang, Neil Whiteside
The field of Medical Health Physics (MHP) lies at the intersection of Health Physics (HP) and Medical Physics (MP). The MHP is one of the five subfields identified by the AAPM that in which a Qualified Medical Physicist (QMP) may operate independently to provide clinical professional services. The pathway to become a QMP employed in the field of MHP varies depending on which community an individual originates from (HP or MP). This document aims to identify the minimum educational requirement, appropriate professional certification(s), work experience, and the minimum areas of responsibility (scope of practice) for a QMP working the MHP subfield.
Journal of applied clinical medical physicsSundari Mehta, J John Lucido, Douglas Moseley, Catherine Holly Frank, Christopher L Deufel
PURPOSE: Bibliometric indicators are widely used to evaluate faculty productivity, yet these metrics change with career stage, evolving authorship practices, and technological shifts in how science is produced. This study examines patterns of scholarly output among radiation therapy medical physics faculty at leading cancer centers and provides a framework and quantitative metrics for managing career age- and era-based effects. METHODS: Peer-reviewed articles (1969-2025) were collected from Scopus for 397 Ph.D. medical physics faculty at the 20 U.S. cancer centers most highly ranked by US News and World Report in 2025. The bibliometric measures included annual rates of authorships ( A ̇ ), first/last authorships ( F L ̇ ), monograph-equivalents ( M E ̇ ), as well as the cumulative h-index and contribution-normalized ha-index. Career age was defined by year of first publication. Productivity distributions were evaluated by career age using empirical cumulative distribution functions derived from 2016-2025 data. Era-dependent fluctuations (1990-2025) were examined using age-normalized metrics and trends in authorship team size. Tabulated bibliometrics as a function of career age are provided for evaluation of individual performance. RESULTS: Productivity increased substantially with career age, peaking in late career. Senior faculty produced approximately two-fold higher annual output than early-career peers. At career ages of 1, 10, 20, 30, and 40 years, the median bibliometric rates were A ̇ = (1.2, 1.6, 2.5, 2.5,1.8) year-1, F L ̇ = (0.4, 0.4, 0.5, 0.5,0.2) year-1, M E ̇ = (0.2, 0.2, 0.3, 0.3,0.3) year-1, h-index = (0, 7, 15, 23,43), and ha-index = (0, 3.3, 6.0, 9.4,15.0). Era-based effects were substantial. Between 1990 and 2025, median authors per paper increased from 4 to 10, inflating authorship-based metrics. In contrast, contribution-weighted measures (FL, ME, ha-index) demonstrated greater temporal stability. CONCLUSIONS: Scholarly productivity in radiation therapy medical physics is strongly dependent on career age, with peak output occurring near the end of a typical career before declining modestly near retirement. Career-age-based percentile benchmarks provide a more balanced framework for evaluating academic performance than unadjusted bibliometric comparisons, especially for early-career investigators. Due to changes in authorship norms over time, first/last authorships, monograph equivalents, and ha-index may provide more accurate and equitable assessments of research performance than authorships or h-index.
Journal of applied clinical medical physicsJoel St-Aubin, Alonso Gutierrez, Erica Kinsey, Cassandra Stambaugh, Dongxu Wang
This work of fiction is part of a case study series developed by the medical physics leadership academy (MPLA). It is designed to generate discussion of the managerial and leadership challenges medical physicists can face. Through discussion and quantitative analysis, the case aims to teach learners basic finance concepts and build their ability to gather and analyze financial information for capital budgeting decisions. In this case, medical physicist Dr. Angel Allende is a junior physicist who started a new position at a cancer center with two linear accelerators. A recent upgrade outfitted one linear accelerator with state-of-the-art capabilities for image-guided stereotactic radiation therapy. Dr. Allende is tasked by the chief medical physicist to establish a new stereotactic quality assurance (QA) program at the cancer center. The physics team needs to prepare a business case for obtaining the necessary QA software and equipment. Unfortunately, Dr. Allende anticipates complications due to the existing budget appearing too low. Despite having never done capital budgeting before, Dr. Allende doesn't want to turn down this unique opportunity. This case study falls under the scope of and is supported by the MPLA, a committee in the American Association of Physicists in Medicine (AAPM).
Disaster medicine and public health preparednessAbdullah Yaseen Shihab, Chiara Cadeddu, Hiba Mohammad, Jamla Rizek, Houssem Eddine Ben-Ahmed, Mohanad Ghaleb, Sadeq Al-Fayyadh
Conflicts in the Middle East have intensified public health emergencies through progressive failure of water, sanitation, and hygiene (WASH) systems. This policy-oriented narrative review synthesizes peer-reviewed and humanitarian evidence published between January 2020 and March 2026 on WASH system failure and related public health consequences in Gaza and the occupied Palestinian territory, Yemen, Syria, Lebanon, and Iraq. Across these settings, four recurring mechanisms emerged: physical damage; loss of electricity, fuel, chemicals, and spare parts; restrictions on access and workforce safety; and governance, financing, and coordination failures. These mechanisms impaired water treatment and distribution, wastewater and waste management, and hygiene in health care facilities. The evidence documented plausible pathways connecting these failures to diarrheal illness, cholera, hepatitis A, environmental exposure, and weakened infection prevention and control, although disrupted surveillance limited causal attribution. The settings also showed distinct patterns, ranging from acute infrastructure damage in Gaza to protracted institutional attrition in Yemen and Syria, conflict spillover and economic stress in Lebanon, and episodic vulnerability in Iraq. The review advances a cross-setting failure-to-harm pathway and a phased preparedness framework. Immediate priorities are protecting WASH workers and assets, sustaining energy and critical inputs, and linking WASH indicators with health surveillance; medium-term recovery requires service restoration, workforce capacity, and coordinated financing; and long-term resilience requires decentralized, redundant, conflict-resilient systems.
PloS oneSilvia Landa, Fahrunnisa, Sarah Lebu, Novika Noerdiyanti, Musa Manga
Climate change increasingly disrupts water, sanitation, and hygiene (WASH) services, disproportionately affecting women, children, people with disabilities, and groups with limited adaptive resources. Evidence remains limited on how WASH programs integrate climate resilience, equity, and social inclusion and on the conditions that enable benefits to reach households. Researchers examined how Climate Change Response for Inclusive WASH (CCRIW) guidance was implemented and adapted within routine programming in Indonesia, how implementation outcomes related to post-implementation household access, and which contextual factors enabled or constrained such access. Researchers conducted a mixed-methods study using program data collected between August 2023 and October 2024. Data included key informant interviews (n = 29) and a group discussion (n = 10). Quantitative data included village workshop records (n = 91) and household surveys and observations (n = 1,243) from 12 villages affected by floods, landslides, and drought. Researchers used descriptive statistics and logistic regression and triangulated the findings with deductive qualitative analysis informed by an implementation science framework. Results indicated that CCRIW guidance was perceived as relevant but was adapted during implementation rather than adopted as a complete stand-alone protocol. These adaptations appeared to improve short-term practicality while reducing consistent application, depth of learning, and recall of CCRIW as a distinct approach. Communities primarily adopted lower-cost actions aligned with immediate needs, available resources, and perceived feasibility. Household modifications supported more resilient and inclusive access but could not replace system-level investments under severe hazards. Regression models showed district-level associations for several facility-specific outcomes, limited associations with multiple-hazard exposure, and no consistent associations with reported household characteristics. The findings suggest that CCRIW could connect lived hazard experience with inclusive WASH assessment and local planning but should be embedded within sequenced programming that provides a WASH inclusion foundation and coordinated institutional support to address risks beyond household and village capacity.
International journal of hygiene and environmental healthLauren Sprouse, Sarah Lebu, Huijoo Shon, Chimdi Muoghalu, Herbert Kaboggoza, Yaoska Reyes, Richard K Mugambe, Najib Lukooya Batenganya, Barbra Mary Aine, Glori…
Shared sanitation is widely used in rapidly growing informal settlements globally, but is classified as "limited" by current global monitoring standards due to concerns over hygiene, safety, and health risks. While previous studies have identified key features of high-quality shared sanitation, it remains unclear which aspects most strongly influence health outcomes. This study aimed to: (1) identify shared sanitation quality factors associated with diarrhea, stomach pain, and urinary tract infection (UTI); (2) construct a composite indicator of high-quality shared sanitation; and (3) assess whether associations vary across countries. We conducted a cross-sectional study of 5700 households using shared sanitation in informal settlements in Delhi (India), Nairobi (Kenya), and Kampala (Uganda) between June 2025 and January 2026. We assessed five sanitation quality domains - sharing intensity, cleanliness, hygiene, privacy/safety, and accessibility - and examined associations with health outcomes using multilevel logistic regression models. Overall, 14.5% of households reported diarrhea, 13.0% stomach pain, and 10.3% UTI. Sharing intensity was modestly associated with diarrhea (aOR: 1.04 per additional household [95% CI: 1.02-1.07]), while visible fecal contamination in the facility was strongly associated with all outcomes. In composite analyses, facilities meeting ≥4 quality criteria among 6 primary indicators (no visible feces/urine; water available for flushing/cleaning; functional handwashing station; lighting availability; lockable from inside; 24-h access) were consistently protective against diarrhea (aOR: 0.50 [0.41-0.62]), stomach pain (aOR: 0.45 [0.35-0.58]), and UTI (aOR: 0.36 [0.29-0.46]). These findings suggest that incremental improvements in shared sanitation quality may reduce health risks, and moving toward quality-based metrics may better inform investment priorities.
International journal of hygiene and environmental healthArgaw Ambelu, Seblework Mekonen, Taffere Addis, Abayneh Melaku, Alemu Kejela, Ziyad Ahmed Abdo, Ashrafedin Youya, Claudio Valsangiacomo
Access to basic sanitation remains a major public health challenge in rural sub-Saharan Africa, where open defecation and unimproved facilities sustain preventable morbidity and mortality. Despite government-led initiatives, rural sanitation coverage in Ethiopia remains critically below the Sustainable Development Goal 6 target. This community-based cross-sectional study among 842 rural households across seven Ethiopian regions aimed to identify determinants of basic sanitation service achievement and to develop predictive models using multivariable logistic regression and explainable machine learning algorithms. Only 20.9% of households achieved at least basic sanitation service, while 55.8% used unimproved facilities and 17.1% practiced open defecation. Logistic regression identified privacy motivation (AOR = 1.59, 95% CI: 1.10-2.33, p = 0.015), perception of sanitation as a constitutional right (AOR = 1.51, 95% CI: 1.03-2.20, p = 0.034), and access to professional guidance (AOR = 1.49, 95% CI: 1.02-2.19, p = 0.039) as the strongest positive predictors, while households motivated primarily by peer observation had significantly lower odds of service achievement (AOR = 0.48, 95% CI: 0.28-0.81, p = 0.007). Among machine learning models, Categorical Boosting outperformed Extreme Gradient Boosting in accuracy (72.6% versus 60.1%) and balanced accuracy (74.7% versus 68.8%). Shapley Additive Explanations analysis confirmed that rights-based perception and professional consultation were the leading protective factors, while peer-driven motivation and absence of household toilet prioritization were the most influential predictors of non-achievement. Non-achievement of basic sanitation in rural Ethiopia reflects perceptual and behavioral barriers beyond infrastructure gaps. Sanitation programs should strengthen rights awareness, extension-worker engagement, and household prioritization alongside infrastructure investment.
Bundesgesundheitsblatt, Gesundheitsforschung, GesundheitsschutzAnnette Peters, Hajo Zeeb, Caroline Herr, Wolfgang Straff, Claudia Traidl-Hoffmann, Tobia Lakes, Claudia Hornberg, Geschäftsstelle der Kommission Environmental…
Negative environmental impacts on human health-which are a central focus of the health sciences-are primarily the result of human interference with ecosystems. This is evident in global and local issues such as climate change, environmental pollution, biodiversity loss, emerging pandemics, and the numerous health consequences of war. In times of multiple crises, the interplay between the environment and health should be a priority, as it forms the foundation for a resilient society.In a globalized world marked by political and ecological tensions, it is clear that environmental, health, and security issues are closely intertwined. An intact environment is not only an ecological and ethical goal but also serves as a central health resource that contributes significantly to the stability and security of modern societies.Using three illustrative areas-climate change and health, air pollutants and health, and biodiversity and health-conclusions regarding environmental and health-related security issues are presented. Based on these findings, the Environmental Public Health Commission summarizes specific recommendations for ensuring and continuing cross-sectoral cooperation on environment and health.
Population health metricsTessa M I Haverkate, Brecht Devleesschauwer, Gunn Marit Aasvang, Ricardo Assunção, Anette K Bølling, Susanne Breitner-Busch, Jurgen Buekers, Alberto Castro, Va…
BACKGROUND: Environmental Burden of Disease (EBoD) quantifies health impacts attributable to environmental risk factors. The methodological choice on which risk-outcome pairs to include in EBoD studies is technically and conceptually demanding, with diffuse exposures and complex causal chains. This makes transparent criteria for inclusion of risk-outcome pairs essential. In response, we developed a standardised approach for systematically and transparently selecting risk-outcome pairs within environmental burden of disease research. METHODS AND RESULTS: The standardised approach was developed through expert elicitation and iterative discussions, ultimately resulting in five sequential steps designed to strengthen consistency and transparency: (1) define and characterise the exposure to the environmental risk factor; (2) identify potential health outcomes from the literature; (3) evaluate the strength of evidence criteria according to set criteria; (4) select risk-outcome pairs based on strength of evidence; and (5) select exposure-response functions. CONCLUSIONS: By making underlying assumptions explicit, the proposed approach to the selection of risk-outcome pairs can reduce subjectivity in the selection process and support more consistent, evidence-based decisions.
International journal of public healthWei Li, Zhengyan Ge, Hui Wang, Mingzi Yuan, Zhican Yin
OBJECTIVES: This systematic review examines how artificial intelligence (AI) mitigates occupational and environmental health risks in waste management, a sector where workers and communities face infectious, toxic, and physical hazards. METHODS: Following PRISMA guidelines, we systematically searched the SCOPUS database and reviewed 81 peer-reviewed articles. The analysis focused on the types of AI technologies applied, their deployment across waste management stages, and the specific health risks they address. RESULTS: The analysis identifies five types of health risks targeted by AI applications. AI is deployed across five waste management stages and four technical paradigms (supervised, unsupervised, reinforcement, and deep learning). AI alleviates hazards via three primary pathways: automated risk-source isolation, robotic substitution for high-risk tasks, and macro-level exposure monitoring. CONCLUSION: Current public health research has largely neglected health risk reduction gains from waste management technological innovation. Institutional innovations that can facilitate responsible AI deployment are discussed. This interdisciplinary perspective underscores the necessity of cross-sector collaboration to tackle public health issues.
Frontiers in public healthAya Abu Aqab, Thikrayat Majdi Yahya, Mahmoud Al-Hussami, Abeer Ismail
BACKGROUND: Maintaining good hygiene, which is easily applied with access to safe and adequate water, is an important preventive step against various infectious disease transmissions that might spread as a result of unclean water and inadequate sanitation. Jordan is one of the world's most water-stressed countries, and only one in three schools has basic sanitary facilities, which poses severe health risks to students. Assessing WASH-related knowledge, attitudes, and practices provides valuable evidence to guide interventions that promote healthy behaviors and reduce these risks. PURPOSE: This study aimed to assess the level of WASH knowledge, attitudes, and practices among preadolescent schoolchildren and to examine the relationship between student knowledge, attitudes, and practices with selected socio-demographics, as well as to investigate differences between public and private schools' students in Jordan. Furthermore, identifying predictors of schools' pre-adolescent practices. PARTICIPANTS AND METHODS: A cross-sectional School-Based Study design was employed among a sample of School students from Amman city (n = 600). Data collection included a Self-administered questionnaire and a list of school characteristics that were observed and recorded. The statistical analysis included descriptives, Pearson r correlation, independent t-test, and hierarchical linear regression. RESULTS: Statistics revealed a significant positive relationship (p < 0.001) between knowledge and attitude, and between (p < 0.001) knowledge, attitudes, and practices with grades and age. A t-test revealed a statistically significant difference between public and private schools in scoring attitudes and practices of water, sanitation, and hygiene (P ≤ 0.001, P ≤ 0.000, respectively). Despite the absence of significant differences in knowledge between public and private schools, six items had the highest agreement rate. Furthermore, a multiple hierarchical linear regression analysis showed that sex, school type, age, knowledge, and attitudes were significant predictors of practices (p < 0.001). CONCLUSION: The results of our study showed the need for interventions to address gaps and challenges in health education and to develop policies to ensure adequate, hygienic WASH facilities, particularly in public schools, to reduce health risks, especially among pre-adolescent age groups.
Journal of applied clinical medical physicsHiroyuki Okamoto, Shie Nishioka, Takeshi Kamomae, Kohei Okawa, Souichi Kikuchi, Junji Suzuki
BACKGROUND: Risk analysis is becoming increasingly important in advanced radiotherapy, as treatment workflows grow more complex and require multidisciplinary expertise. Although failure mode and effects analysis (FMEA) has been recommended for risk-based quality management, opportunities for users to practically learn and apply FMEA within CyberKnife® workflows remain limited. PURPOSE: To evaluate the feasibility and educational value of a group-based, hands-on seminar for teaching FMEA methodology in CyberKnife® stereotactic radiotherapy, using four representative treatment sites as practical examples. METHODS: A half-day seminar was conducted for eight radiation technologists and six medical physicists from CyberKnife® institutions, supported by four facilitators. Following a didactic lecture on risk analysis, participants were divided into four site-specific groups (intracranial, lung, spine, and prostate). Each group utilized institution-prepared process maps and a shared Excel-based worksheet to identify potential failure modes, score them using a five-point FMEA scale for occurrence, severity, and detectability, and discuss possible countermeasures. Risk priority numbers (RPNs) were calculated to rank the identified failure modes. A postseminar questionnaire was administered to assess participants' prior experience, level of understanding of risk analysis, and willingness to implement it in clinical practice. RESULTS: The seminar generated site-specific failure mode lists as educational outputs. The highest-ranked risks were contouring errors for intracranial lesions (RPN 48), irregular respiration for lung lesions (RPN 64), pain-induced patient motion for spinal lesions (RPN 36), and target delineation errors for prostate lesions (RPN 80). Other major risks included inappropriate selection of immobilization devices, prescription and fractionation errors, tracking-related issues, image registration inaccuracies, and incorrect patient-specific QA evaluation criteria. Thirteen participants completed the questionnaire. Most participants had limited prior experience with risk analysis; however, 85% reported a good level of understanding after the seminar, and 92% expressed willingness to implement risk analysis at their institutions. CONCLUSIONS: This group-based seminar provided participants with practical experience in applying FMEA to CyberKnife treatment workflows. The questionnaire responses suggested that most participants gained a better understanding of risk analysis and were interested in applying it at their own institutions. The failure mode lists generated during the seminar were not intended to represent a complete FMEA for any participating institution but may provide practical examples for initiating multidisciplinary risk analysis based on local workflows and clinical practices.
Frontiers in public healthM Khalid Ijaz, Raymond W Nims, Joseph R Rubino, Bushra S F Hasan, Maryum K Ijaz, Frank Y Xu, Charles P Gerba
BACKGROUND: Recognition of the synergistic cycle of malnutrition, immune dysfunction, and recurrent enteric infection in children and its role in linear growth stunting and impaired cognitive development (the "stunting syndrome"), dates back to the 1960s. Early hypotheses emphasized reduced intestinal absorption associated with diarrhea as the primary enteropathy driving malnutrition and developmental deficits. However, recent evidence indicates that a subclinical condition termed environmental enteropathy (EE), or environmental enteric dysfunction (EED), may be a more critical contributor. Mitigating the adverse impacts of EE/EED requires a holistic, integrated approach that combines improved nutrition, water, sanitation, and hygiene (WASH), appropriate vaccination, and targeted non-pharmaceutical hygiene interventions designed to prevent recurrent enteric infections. These interventions aim to reduce pathogen exposure in infants' immediate environments, a prerequisite for achieving sustained physical and neurocognitive development and, ultimately, economic progress in low- and middle-income countries (LMICs). OBJECTIVE: This Hypothesis and Theory article synthesizes current understanding of EE/EED as a proximate driver of chronic childhood malnutrition and its major sequelae: stunting, impaired neurocognitive development, immune dysfunction (including poor pediatric vaccine response), and nutrient malabsorption. We hypothesize the necessity of reducing enteric infection occurrence as a cornerstone for breaking the malnutrition-infection cycle and propose that non-pharmaceutical interventions targeting pathogen exposure in household and infant play environments are essential. In addition to pathogen exposure, we examine other determinants of malnutrition, including microbiome dysbiosis and epigenetic alterations as possible targets for therapeutic interventions intended to mitigate negative outcomes on health and nutrition. METHODS: We reviewed literature addressing malnutrition, immune impacts, enteric infections, EE, growth stunting, cognitive impairment, epigenetic alterations, and mitigation strategies including WASH, baby WASH, hand and surface hygiene, and vaccination, using databases such as PubMed, Embase, and Google Scholar. RESULTS: The synergistic malnutrition and infection cycle underlying the stunting syndrome comprises multiple interdependent components: chronic malnutrition, immune dysfunction, recurrent pathogen assault, microbiome dysbiosis, and EE/EED. Previous interventions have largely failed, likely because they targeted isolated components rather than the entire cycle. Here, we describe this cycle, its interactions, and prior attempts at disruption. We advocate for a novel, integrated approach, termed baby WASH or environmental hygiene, focused on creating hygienically clean environments where infants live and play, thereby reducing exposure to enteric pathogens. We also explore the link between malnutrition, EE/EED, and epigenetic reprogramming, as a contributor to health risks. Importantly, malnutrition is linked to epigenetic reprogramming, which contributes to neurocognitive impairment. We hypothesize that by combining baby WASH strategies with emerging pharmaceutical interventions addressing epigenetic and nutritional deficits, and associated socioeconomic and political factors, a comprehensive maternal-child health framework may be established to interrupt this vicious cycle. CONCLUSION: Preventing recurrent pathogen exposure during both prenatal and postnatal periods is hypothesized to be essential to interrupting the malnutrition and infection cycle and reducing stunting. Interventions must address infants' immediate living, feeding, and educational environments, as well as maternal environments during gestation. Early-life nutritional deficiencies may influence epigenetic programming, with developmental consequences. Breaking this cycle remains an unmet global health priority, warranting urgent international attention due to the human and economic tolls in resource-limited settings LMICs.
Infectious diseases of povertyCallum Lowe, Matthew Kelly, Salvador Amaral, Novia Handayani, Bagoes Widjanarko, Budiyono Budiyono, Nissa Kusariana, Budi Laksono, Juniawati Juniawati, Muharso…
BACKGROUND: Much work remains to achieve the sustainable development goals for improved sanitation access for all. Subsidised sanitation interventions are often criticised due to the possibility of the infrastructure being neglected or culturally inappropriate for target communities. The BALatrine intervention is a novel approach consisting of a community-wide subsidised recipient-aided installation of an improved latrine with septic tank ('BALatrine') and education package. This study aimed to investigate the long-term usage and cultural acceptability of the BALatrine project four to six years following its implementation in a main trial. METHODS: We conducted a cross-sectional follow-up study in September 2022 of 88 households who received BALatrines in two villages between 2016 and 2017. Quantitative and qualitative interviews with the household head and members were conducted to understand BALatrine usage and perceptions. Descriptive statistics were used to tabulate interview responses. RESULTS: The BALatrines were still in excellent condition with 89% still functional as initially intended corresponding to 95% of participants regularly passing a bowel motion in the BALatrine. A 77% reduction in self-reported open defecation was achieved. Participants expressed concerns towards the prospect of having to empty the septic tanks. Interviews with key village stakeholders demonstrated participants desire for aid and financial difficulties in obtaining and maintaining such improved sanitation. CONCLUSIONS: Follow-up results of the BALatrine intervention demonstrate that the BALatrine's in the two surveyed villages are overall culturally acceptable and well-maintained. The BALatrine intervention may be suitable for use in other rural areas of Indonesia and the region for improving sanitation coverage.
Water environment research : a research publication of the Water Environment FederationClélio Rodrigo Paiva Rafael, Joan Garcia, Eduardo Lucas Subtil
Constructed wetlands (CWs) are low-cost, low-energy nature-based solutions for wastewater treatment and are commonly regarded as robust; however, this perception is often based on removal efficiencies or mean effluent concentrations, without accounting for effluent variability or the probability of maintaining concentrations below regulatory limits. This study applied the reliability coefficient (RC) to 34 vertical-flow constructed wetland (VFCW), horizontal-flow constructed wetland (HFCW), and hybrid constructed wetland (HCW) systems treating domestic wastewater identified through a systematic literature review. Removal efficiencies and final effluent concentrations were evaluated against Brazilian discharge and non-potable reuse benchmarks. Reliability was calculated separately for each system-parameter combination at a 95% target non-exceedance probability. Grouped comparisons examined only descriptive patterns, dispersion, and overlap among configurations. Sensitivity to alternative target probabilities and analytical applications to design and monitoring were also examined. Mean removal efficiencies ranged from 79.8%-94.5% for biochemical oxygen demand (BOD), 76.9%-87.8% for chemical oxygen demand (COD), 73.6%-90.8% for total suspended solids (TSS), 59.6%-65.9% for total nitrogen (TN), and 68.0%-75.4% for total phosphorus (TP). Under the stringent scenario, mean effluent concentrations were below the selected limits in 21/22 systems for BOD, 33/34 for COD, 22/22 for TSS, 4/25 for TN, and 6/18 for TP. Under the assumed log-normal model, incorporating effluent variability at 95% reduced probabilistic compatibility to 20/22, 27/34, 21/22, 2/25, and 4/18 systems, respectively. Grouped mean RC values ranged from 0.38 to 0.69, but substantial within-configuration dispersion and overlap showed that no single RC can represent a flow configuration or treatment train. At target probabilities of 95% or higher, increasing variability consistently reduced the RC; at lower probabilities, the non-monotonic response of the equation altered system rankings. Incorporating the RC into first-order HFCW and VFCW models converted regulatory limits into system- and parameter-specific allowable mean effluent concentrations, providing an analytical basis for reliability-informed design and monitoring, although the framework was not experimentally validated as an independent sizing method. The results support comparatively wide operating margins for organic matter and suspended solids, whereas sustained nutrient compatibility remained less frequent. Removal efficiency, residual concentration, and reliability should therefore be interpreted jointly using RC values specific to each system and parameter.
Journal of applied clinical medical physicsGuang-Pei Chen, Douglas E Prah, Eric S Paulson
BACKGROUND: Large multi-hospital radiation oncology networks often rely on site-exclusive physicist coverage models that can lead to imbalanced workload distribution, inconsistent task execution, communication fragmentation, and vulnerability to delayed or missed quality checks. Increasing clinical complexity and distributed staffing models necessitate operational strategies that improve efficiency, standardization, and safety across geographically separated sites. PURPOSE: To describe the implementation of a shared-duty physicist-of-the-day (POD) model supported by a real-time operational dashboard and to evaluate its impact on workload distribution, task efficiency, and safety metrics across a multi-hospital radiation oncology network. METHODS: A structural transition from a site-exclusive to a shared-duty POD model was implemented in our institution-a four-site academic radiation oncology system. A custom application, RadOncStatusBoard, was developed using structured query language (SQL)-based integration with the Mosaiq Record & Verify system to aggregate real-time patient appointments, treatment progress, quality checklist (QCL) items, and weekly chart check (WCC) eligibility. Microsoft Teams channels were used for daily communication and task coordination. Operational data from two matched 21-month intervals-before and after POD restructuring-were extracted using SQL. Evaluated metrics included task volumes, claim times, completion times, WCC performance, billing accuracy, and dosimetry-related Radiation Oncology Incident Learning System (RO-ILS) event reporting. Right-skewed distributions were summarized using medians and interquartile ranges (IQR). Surveys of physicists and dosimetrists were performed to assess end-user perceptions of workflow and safety. RESULTS: Workload balance improved across all task categories, with substantial decreases in main-to-satellite task ratios (e.g., the ratio for chart close decreased from 1.91 to 1.27). Task claim and completion times decreased markedly at both main and satellite locations (e.g., chart-close claim time decreased from 36.8 to 6.2 min at the main campus). WCC completion improved from 97.7% to 99.9%, and WCC charge capture increased from 96.1% to 99.4%. The proportion of dosimetry-related RO-ILS events decreased numerically from 31.0% to 26.7% (p = 0.339). Survey responses from physicists and dosimetrists indicated improved workflow clarity, communication, workload balance, and perceived patient safety. CONCLUSIONS: Implementation of a shared-duty POD model improved workload balance, enhanced operational efficiency, and strengthened routine safety processes across a multi-site radiation oncology program. Integration of a real-time operational dashboard, standardized communication pathways, and structured task-claiming workflows enabled measurable gains in responsiveness, compliance, and perceived safety culture.
Philosophy, ethics, and humanities in medicine : PEHMCihat Tanış
This study examines the multidimensional impact of infectious diseases on societies through the case of malaria, with particular emphasis on the anti-malaria campaigns implemented in Türkiye during the early Republican period within the framework of the studies titled The Sanitary and Social Geography of Turkey. These works constitute primary-source materials that systematically document the country's health conditions, social structure, and geographical characteristics during the early years of the Republic. In this study, data on swamps and malaria contained in these publications were analysed through a systematic document analysis and regional comparative approach. The findings demonstrate that the relationship between swamps and malaria varied considerably across provinces. While a strong positive association was identified along the Mediterranean and Aegean coasts and in the major river deltas, this relationship was substantially weaker in the high-altitude regions of Eastern Anatolia. Furthermore, the effectiveness of swamp-drainage programmes in controlling malaria remained limited due to factors such as fragmented implementation, recurrent flooding, and irrigation projects. The analysis also indicates that agricultural activities, particularly rice cultivation, contributed to the spread of malaria by creating artificial swamp environments. Consequently, malaria control emerged as a central policy domain during the early Republican period, becoming closely integrated with the state's broader strategies of nation-building and socio-economic development.
Frontiers in public healthYue Gong, Shan Man, Wei Liu
Border counties often face challenges in transforming tourism resources into sustainable development advantages due to constraints in economic conditions, accessibility, public services, and environmental quality. However, existing tourism competitiveness studies have mainly focused on resource endowment and economic performance, with limited attention to environmental health and public service support as foundations for sustainable tourism development. This study develops a multidimensional framework incorporating Tourism Economic Development, Tourism Resource Attractiveness, Environmental Health, Accessibility and Supporting Infrastructure, and Tourism Service and Public Service Support to evaluate tourism competitiveness in 33 border counties of Northeast China from 2014 to 2023. The Criteria Importance Through Intercriteria Correlation (CRITIC) weighting method and the VIKOR evaluation model were used to measure tourism competitiveness, and an obstacle degree model was applied to identify key constraints and their evolution. The results show that tourism competitiveness in Northeast China's border counties generally improved, although disparities among counties remained pronounced. Competitiveness levels shifted upward overall, with a gradual increase in high-competitiveness counties distributed across multiple locations in all three provinces. The dominant constraints also shifted from inadequate Tourism Service and Public Service Support toward limitations in Tourism Economic Development, resource transformation, and accessibility. Environmental Health was less frequently identified as a dominant obstacle but remained an important foundation for sustainable tourism development by supporting destination quality and resilience. This study provides insights into sustainable border tourism development by integrating Environmental Health and public service dimensions into tourism competitiveness assessment.
Global public healthTeresita Rocha-Jiménez, Báltica Cabieses, Loreto Watkins, Estela Blanco, Miguel Pérez, Javiera Barraza
Migrants living in informal settlements face overlapping health and environmental vulnerabilities shaped by exclusion from formal housing and essential services. Un Nuevo Amanecer, an informal settlement located on a former landfill on the outskirts of Santiago, Chile, illustrates these dynamics. Rising housing costs and precarious labour conditions have pushed migrants to self-construct housing on land with limited state oversight. This qualitative study examines how residents experience and respond to health and infrastructure challenges through community-based strategies. Drawing on long-term, community-engaged research, data were collected through in-depth interviews and a focus group with a total of 19 participants recruited via snowball sampling. Interviews explored settlement trajectories, access to services, waste exposure, food insecurity and coping strategies. Findings reveal persistent challenges, including irregular water access, inadequate sanitation, waste accumulation and power outages, that compromise hygiene and food safety. Despite these constraints, residents developed grassroots responses, including informal water systems and collective waste management. The study highlights migrant communities as active agents whose practices should inform inclusive urban health policies.
Frontiers in public healthGracie Hornsby, Canon Pham, Jennifer Davis, Gary L Darmstadt
INTRODUCTION: Investments in the provision of water, sanitation, and hygiene (WASH) services in schools (WinS) can only generate health benefits if students use WASH facilities correctly and consistently. Valid and reliable measurement of student WASH behavior is thus critical for evaluating WinS interventions. METHODS: This study examines the relative validity of direct observation versus reported (survey-based) measures of WASH behaviors in schools, using both primary data and a review of literature. We conducted a sub-analysis of a four-arm, cluster-randomized controlled trial among 200 primary schools in Uttar Pradesh, India, that tested the effect of WASH education and infrastructure operation and maintenance (O&M) on student handwashing and toilet use. We compared unannounced observations of student behavior against self-, peer-, and teacher-reports. We also stress-tested reported data against direct observation of WASH infrastructure and consumables availability. Finally, we conducted a comparative analysis of 42 published WinS studies to contextualize our primary findings. RESULTS: Reported data indicated significant behavioral change and suggested that combining education with O&M created a synergistic effect. In contrast, direct observation revealed no significant changes in behavior under any treatment. Stress-testing showed that students frequently reported toilet use when toilets were observed to be locked, and soap use when soap was not observed to be present. Findings from our comparative analysis of WinS literature mirrors the findings of our primary data, revealing that 83% of intervention effects measured with reported data yielded positive results, compared to 58% when measured through observation. DISCUSSION: We find that reported behavioral data systematically overstate the effectiveness of WinS interventions. Current WinS policy and practice is thus grounded in an evidence base that varies significantly depending on the measurement tools employed. Direct observation is less prone to reporting bias but is resource-intensive. Future research should prioritize objective measures of behavior, such as sensors or unannounced checks, to build more robust evidence for WinS policy and practice.
PURPOSE OF REVIEW: This review critically examines the role of citizen science in air-pollution monitoring and its integration into environmental health research. It explores how participatory approaches, including low-cost sensors and community co-creation, can enhance spatial resolution, public engagement, and environmental justice, while assessing data quality, health relevance, and scalability. RECENT FINDINGS: Recent studies document the expanding global deployment of citizen science air quality monitoring networks. Advances in calibration algorithms, wearable technologies, and participatory data-collection methods have strengthened capacity to assess real-time exposure. Several projects demonstrate the increasing technical sophistication and policy relevance of citizen-generated air quality data. Citizen science provides hyperlocal insights into air quality and exposure, strengthens risk communication, and contributes to health-impact assessment. Although challenges remain regarding data reliability, representativeness, and policy uptake, emerging approaches, including AI-assisted calibration and distributed sensor networks, offer promising pathways forward. An integrative framework can support sustained community engagement and evidence-informed action to improve air quality.
Physica medica : PM : an international journal devoted to the applications of physics to medicine and biology : official journal of the Italian Association of Biomedical Physics (AIFB)Mark Pokoo-Aikins, Francis Hasford, Theresa Bebaaku Dery, Edem Kwabla Sosu, Theophilus Akumea Sackey, Linda Osei Poku, Shiraz Issahaku, Mary Boadu, Annette Agy…
BACKGROUND: Ghana's imaging services face rising demand, uneven digital infrastructure, and limited access to advanced modalities. Artificial intelligence (AI) could improve diagnostic accuracy, workflow efficiency, and access, but real-world adoption is early. OBJECTIVE: Assess Ghana's readiness to adopt AI in medical imaging, identify pathways and barriers, and propose a phased, context-specific roadmap. METHODS: A review of peer-reviewed and grey literature (2012-March 2025) using PubMed, IEEE Xplore, Scopus, Google Scholar, and Ghanaian institutional documents. The review emphasizes imaging AI, LMIC experiences, and Ghana-specific evidence on infrastructure, policy, and pilots, distinguishing Ghana-based findings from international evidence extrapolated to Ghana. RESULTS: Major gaps include digital infrastructure (limited PACS, variable DR/CR adoption, uneven connectivity), financing (license and maintenance costs), governance (SaMD pathways exist but AI-specific provisions are evolving; operational data protection needs strengthening), and workforce (limited AI literacy; urban - rural disparities). Ghana-relevant touchpoints include MinoHealth.AI chest radiography evaluations, the national imaging equipment inventory, Ghana Health Service digital health strategy (2023-2027), and FDA SaMD guidance. A phased roadmap is proposed: establish PACS and connectivity; implement AI governance and data stewardship; run targeted pilots in CXR triage, low-dose CT, and MRI acceleration; scale via public-private partnerships and pooled procurement; and sustain workforce development with human-in-the-loop oversight. CONCLUSIONS: AI can improve equity and efficiency in imaging in Ghana if adoption builds on strong digital foundations, robust governance, local validation, and clinician-led implementation. Priorities include PACS deployment, AI-specific regulatory strengthening, ethical data governance, and capacity building to support safe, equitable, and sustainable use.
Anais da Academia Brasileira de CienciasDaniela P Vaiss, Livia S Freitas, Fernanda B DE Miranda, Denise S Brião, Stálin S Damasceno, Gabriella M G V DE Azevedo, Fabiana Finger-Jardim, Flavio Manoel R…
Regional inequalities in basic sanitation remain a major public health challenge in Brazil. This study assessed the relationship between sanitation indicators and health outcomes related to Diseases Related to Inadequate Environmental Sanitation (DRSAI) in Brazilian capitals from 2010 to 2019. Mortality and hospitalization data were obtained from DATASUS, and water and sewerage coverage indicators from the National Sanitation Information System (SNIS). Pearson correlations and hierarchical cluster analyses were used to explore spatial patterns and associations. Pronounced regional disparities were observed. Northern and Northeastern capitals, including Macapá, Recife, and Salvador, had the highest DRSAI mortality and hospitalization rates, coinciding with the lowest sewerage coverage (<30%) and limited potable water access (<60%). In contrast, Southern and Southeastern capitals, including Curitiba, Porto Alegre, and São Paulo, showed better sanitation and health indicators. Sewage coverage was significantly and negatively correlated with hospitalization and mortality rates (p<0.05), indicating an inverse association between sanitation coverage and DRSAI outcomes. The findings highlight the central role of sanitation in reducing inequalities in DRSAI-related hospitalizations and mortality. Despite progress, universal access remains distant and requires targeted investments and integrated public policies to improve sanitation and public health outcomes in Brazil, particularly in the country's most socially vulnerable urban areas.
International journal for equity in healthK Vigneshwaran, C Krishnendhu, Rakhal Gaitonde
BACKGROUND: Sanitation work in India remains concentrated among the Scheduled Castes despite constitutional protections and modernisation. Although this concentration is widely recognised, it has not been systematically incorporated into empirical analyses examining the mechanisms through which caste operates. This paper also describes the development of variables that aim to go beyond mainstream descriptive variables. It specifically examines the association between intergenerational occupational continuity and mental health outcomes (depression, anxiety, and stress) among sanitation workers. METHODS: A cross-sectional survey of 243 sanitation workers was conducted in Dindigul Municipal Corporation, Tamil Nadu, January-February 2025. Based on initial meetings and discussions with sanitation workers, as well as a review of the literature, measures were developed to capture the experiences of intergenerational sanitation work and of continuing in sanitation. Structured interviews collected data on parental and grandparental occupations, desire to leave sanitation work, and mental health outcomes assessed using the Depression, Anxiety, and Stress Scale (DASS-21). Bivariate analysis was used to screen covariates; multivariable binary logistic regression was then fitted for each outcome. Full bivariate tables are provided as Supplementary Material. RESULTS: Nearly half (49.8%) reported both parents and grandparents in sanitation work; 64.2% had at least one parent in sanitation. Among those with parents in "other" occupations, employment remained confined to precarious manual labour - wage labour (44.8%), agriculture (21.8%), and casual loading (14.9%) - with no formal employment across generations. While 74.5% cited family tradition as the reason for entering sanitation work, 66.7% expressed a desire to leave if given alternative opportunities, and 69.5% explicitly attributed their entry into the job to their caste "background." Workers from multi-generational sanitation families were significantly more likely to have severe or extremely severe depression (adjusted OR [AOR] = 3.59, 95% CI: 1.95-6.80, p < 0.001, adjusted for tobacco use) and severe or extremely severe anxiety (AOR = 10.8, 95% CI: 3.65-46.4, p < 0.001). For stress, intergenerational occupational status was not an independent predictor in multivariable analysis; stress was significantly and independently predicted by alcohol use (AOR = 20.5, 95% CI: 8.18-58.3) and tobacco use (AOR = 24.5, 95% CI: 10.1-67.9), suggesting its burden is channelled through substance use patterns rather than occupational inheritance directly. CONCLUSIONS: Sanitation work functions as a caste-bound occupation marked by intergenerational continuity and severely constrained intergenerational mobility. Intergenerational occupational status, as measured by a variable developed through a bottom-up process, independently predicts depression and anxiety among sanitation workers. Stress, while prevalent, is driven primarily by substance use rather than occupational inheritance directly. These findings are consistent with anti-caste and structural-violence accounts of occupational segregation and underscore the psychosocial costs of caste-bound intergenerational entrapment, though the cross-sectional design means they should be read as evidence of association rather than causal mechanism.
Frontiers in public healthHai Liu, Yubing Wang, Tiancheng Wang, Si Chen, Yuhui Bao, Liang Zheng, Min Wang
INTRODUCTION: Gross primary productivity (GPP) is a key component of the global carbon cycle, and its dynamics are influenced by climate conditions and human activities. However, the nonlinear response of GPP to climate change and human activities remains unclear. The Hanjiang River Basin (HJRB), a crucial water-source region of the South-to-North Water Diversion Project in China, is vital to China's ecological security. Changes in vegetation productivity in this water-source basin may affect water conservation, soil erosion control, drought and flood regulation, and the environmental conditions to which downstream populations are exposed. In recent decades, the region has experienced significant climate change, intensified human activities, and notable increases in vegetation greenness. However, previous literature relying on the assumption of stationarity and traditional linear methods has limited capability in detecting nonlinear and gradual vegetation changes. METHODS: The long-term nonlinear trend in GPP in the HJRB was analyzed using ensemble empirical mode decomposition (EEMD), and the nonlinear response relationships among climatic factors, human activities, and GPP were further quantified using the LightGBM machine-learning method. RESULTS: From 2000 to 2020, the annual growth rate of vegetation productivity in the HJRB was 12.27 g C m-2 yr-1 (P < 0.01). Most vegetated areas exhibited an upward trend in GPP. However, 28.25% and 4.41% of the region experienced transitions from growth to decline and from decline to growth, respectively, primarily in the southern upstream and eastern downstream areas. Drought (25.28%), precipitation (10.75%), and relative humidity (10.69%) were identified as significant factors influencing vegetation productivity trends. Annual precipitation above approximately 1,000 mm was associated with lower SHAP values for the continuous-increase trend, which may reflect combined hydrothermal, radiation, and topographic constraints rather than a direct inhibitory effect of precipitation. Additionally, an increase in SPEI12 was associated with higher SHAP values for the continuous-increase trend. DISCUSSION: This study elucidates trends and underlying response patterns in vegetation productivity in the HJRB, reveals the driving factors behind regional vegetation productivity changes, and provides environmental evidence for vegetation monitoring, water-source ecosystem management, and climate-related health-risk prevention in the HJRB and similar water-source regions.
PLoS neglected tropical diseasesCollins Okoyo, Michael Odhiambo, Geofrey Chepchieng, John Kioko, Britney Nyanchama, Michelle Anjela, Charles Mwandawiro, Mark Minnery
BACKGROUND: Soil-transmitted helminthiasis (STH) remains a major public health problem in many low- and middle-income countries (LMICs) despite widespread implementation of mass drug administration (MDA). Rapid reinfection after treatment highlights the limitations of MDA approaches and underscores the need for complementary interventions. Water, sanitation, hygiene, and health education (WASH) interventions are widely promoted as essential components of integrated STH control strategies. However, evidence on WASH impact and cost-effectiveness remains fragmented and is poorly synthesized. This scoping review aimed to systematically map and summarize the evidence on the impact and cost-effectiveness of WASH interventions for STH control and elimination. METHODS: Following Arksey and O'Malley's framework and the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) guidelines, we conducted a scoping review of peer-reviewed and grey literature with no date restrictions. We searched PubMed and Google Scholar for papers that met our inclusion criteria. Studies assessing the impact and/or cost-effectiveness of WASH interventions, alone or integrated with MDA, on STH outcomes were included. PRINCIPAL FINDINGS: Sixteen studies, predominantly from LMICs, met the inclusion criteria, with Kenya contributing the largest number. Findings showed that combining WASH interventions with MDA led to greater reductions in reinfection with Ascaris lumbricoides than MDA alone, particularly in school- and community-based programs. However, behavioural improvements alone were insufficient without supporting infrastructure, and their effects on other helminths were inconsistent. Notably, only one study conducted a formal cost-effectiveness analysis of WASH interventions, revealing a critical gap in economic evidence. CONCLUSION: Integrating WASH interventions with MDA can enhance STH control outcomes, particularly for A. lumbricoides, but the lack of robust economic evaluations limits informed policy and investment decisions. Future research should prioritize cost-effectiveness analyses and long-term assessments of integrated WASH strategies to support sustainable STH elimination efforts.
Anais da Academia Brasileira de CienciasMarília Cerciná, Nelson Luiz S Gruber, Darci B Campani, Juan Adolfo Chica-Ruiz
Inadequate infrastructure for the final disposal of solid waste increases the vulnerability of coastal areas to environmental impacts. Poor waste management in these regions leads to severe marine contamination, as land-based waste reaches the oceans through rivers, storm water, and improper land disposal, threatening marine life. This study analyzes the integration between the National Sanitation Information System and the National Solid Waste Policy in regulating the Municipal Integrated Solid Waste Management Plans, focusing on coastal municipalities. A descriptive documentary approach was adopted, involving an analytical review of urban sanitation indicators. The results reveal significant governance gaps and the need for improved coordination in coastal management. In municipalities along the Northern Coast of Rio Grande do Sul, weak integration was found between data repositories and legislation, with extensive and redundant reporting forms. Strengthening Sanitation Information System through alignment with international standards, regulatory mechanisms, social participation, and circular economy principles - especially through the inclusion of low-income waste pickers - can enhance transparency and accountability. Integration with reports from the United Nations Environment Programme would enable the system to become a global reference, contributing to sustainable coastal management and climate change mitigation.
Frontiers in public healthSoumyaranjan Sahu, Manisha Jnyanajyoti, Jaya Singh Kshatri, Subrata Kumar Palo, Sanghamitra Pati
BACKGROUND: Adults with musculoskeletal disabilities (MSDs) including arthritis, spinal cord injuries, amputations, and congenital deformities face significant barriers in accessing water, sanitation, and hygiene (WASH) services. These barriers compromise health, dignity, and independence, particularly in low- and middle-income countries. This systematic review aimed to identify WASH-related barriers and facilitators for adults with MSDs and synthesize existing interventions to promote inclusive WASH access. METHODS: This systematic review was conducted following PRISMA 2020 guidelines. We searched MEDLINE, Embase, and CENTRAL databases up to March 1, 2025, using MeSH and free-text terms. Inclusion criteria were primary research studies involving adults (≥18 years) with MSDs, reporting on WASH barriers, facilitators, or interventions. Only qualitative or mixed-methods studies published in English were included. Studies involving children, lacking primary data, or behind paywalls were excluded. Two independent reviewers conducted screening and full-text appraisal using Covidence. Data were extracted using a standardized template, and findings were thematically synthesized. Study quality was assessed using the NIH Quality Assessment Tool. RESULTS: From 5,301 initial records, 19 studies met the inclusion criteria, representing diverse geographical settings. Key barriers included inaccessible infrastructure (e.g., lack of ramps or handrails), stigma, poverty, exclusion from planning, and inadequate menstrual hygiene management. Facilitators included home modifications, affordable technology (e.g., biosand filters), caregiver and community support, gender-sensitive WASH education, and inclusive policies. Interventions ranged from inclusive Community-Led Total Sanitation (CLTS) programs to disability-aware infrastructure designs. Despite progress, participation of adults with MSDs in WASH planning and services remained limited. CONCLUSION: This review highlights persistent exclusion of adults with MSDs from WASH access. Inclusive design, community engagement, and policy-level integration are essential for achieving equitable WASH services. Future research should evaluate the scalability and effectiveness of low-cost interventions, particularly in resource-constrained settings. However, the findings should be interpreted considering the absence of meta-analysis and formal risk-of-bias assessment.
Western Pacific surveillance and response journal : WPSARJulius R Migriño, Edroico Mari B Brillante, Maria Cecil Elisa G Esguerra, Orlie John Y Lavilla, Juan Miguel Lorenzo C Milla, Jennifer G Coritico
PROBLEM: Open defecation is practised in several communities in the Philippines. Achieving zero open defecation (ZOD) certification in the Philippines has been shown to reduce disease burden and improve overall community health and well-being. CONTEXT: Philippine communities are guided by the Department of Health to achieve ZOD status through verified municipal inspections. The Barangay Anahaw II administrative unit was selected as a site for implementing sustainable, community-based health programmes aimed at achieving ZOD. ACTION: In 2013, a community diagnosis was conducted in the barangay to assess sanitation and health needs. In 2016, a multisectoral water, sanitation and hygiene committee, guided by a Community-Led Total Sanitation campaign, focused on improving the barangay's sanitation status and promoting behavioural change. By 2017, the campaign's activities had been implemented to prepare for and support ZOD verification and certification. OUTCOME: The community diagnosis in the barangay identified improper waste management, including limited access to toilets, as one of its top health concerns. The community-led campaign included strategies such as household inspections, assessments of the knowledge of heads of households, clean-up drives and incentives to encourage toilet construction. While an initial attempt at certification in May 2017 was unsuccessful, the barangay achieved provincial ZOD certification in July 2019. DISCUSSION: A coordinated approach involving an initial community diagnosis, a multisectoral sanitation programme supported by local officials and the community, and continuing household engagement through activities and incentives enabled the achievement of ZOD certification.
Frontiers in public healthEsther Adekunle, Ferdinand Ottoh, Goddy Osimen, Adedotun Akinola
Drivers and barriers influencing the impact of Water, Sanitation and Hygiene (WASH) on attendance and retention of pupils in schools in developing countries were examined in this study. A Narrative review was adopted for this study which involved a Literature search of literature published between 2015 and 2025. The study identified Water Availability, Sanitation access, Hygiene Practices, Health improvements, Community involvement, Menstrual Hygiene Management (MHM) Support, Policy and funding support, Behavior change and Socio-economic context as the drivers of the impact of WASH on attendance and retention of pupils in primary schools in developing countries. Also, Inadequate Infrastructure, Poor design of infrastructure, Poor Maintenance of facilities, Overcrowding, Lack of Menstrual Hygiene Management (MHM) Facilities, Cultural and Social Norms, Low awareness and Poor Hygiene Behavior, Financial Constraints, Weak Institutional and Policy Support, Environmental Challenges, Household Responsibilities and socio-economic factors and Poor monitoring and evaluation were identified as barriers of the impact of WASH on attendance and retention of pupils in primary schools in developing countries. The study recommends that the collaboration of governments, civil societies, private sectors, and research institutions is crucial as far as dealing with political, economic, and other underlying factors of WASH policies in primary schools in developing countries. This study will provide empirical data for researchers and policy makers towards achieving Sustainable Development Goals 4.
OBJECTIVE: Sanitation workers experience elevated occupational health risks due to hazardous exposures and social marginalisation. This study assessed access to safe sanitation services and examined Health Belief Model-based factors associated with personal protective equipment (PPE) use among sanitation workers in Ethiopia. DESIGN: A concurrent mixed-methods cross-sectional study was conducted from November 2021 to June 2022. Quantitative data were collected through face-to-face interviews using a structured interviewer-administered questionnaire via multistage simple random sampling. Concurrently, qualitative data were collected through key informant interviews and focus group discussions guided by semistructured interview guides. The quantitative data were analysed using Stata V.14, and associations between variables were examined using multivariable logistic regression. The results were presented as adjusted ORs with 95% CIs, and statistical significance was set at p<0.05. Qualitative data were analysed thematically using OpenCode V.4.03. SETTING: The study was conducted in Addis Ababa, Ethiopia. PARTICIPANTS: The quantitative survey included 821 sanitation workers, while the qualitative component comprised 12 key informants and 65 focus group participants. OUTCOME MEASURES: The primary outcomes were access to safe sanitation services and PPE use. RESULTS: Overall, 38.2% (95% CI 34.9% to 41.6%) of sanitation workers had adequate access to safe sanitation services and 54.3% (95% CI 50.8% to 57.8%) reported PPE use. PPE use was positively associated with larger household size, workplace PPE availability, supervision, higher cues to action and greater self-efficacy, whereas perceived barriers were associated with lower odds of PPE use. Qualitative findings complemented these results by showing that inconsistent PPE provision, inadequate occupational health training, weak enforcement of safety regulations, precarious employment conditions and persistent social stigma contributed to poor occupational safety practices. CONCLUSION: Sanitation workers in Addis Ababa have limited access to safe sanitation services and suboptimal PPE use. Improving organisational support, consistent PPE provision, effective supervision and occupational health training may enhance PPE use and strengthen the health, safety and resilience of this essential workforce.
Frontiers in public healthJiansheng Cai, Liang Cao, Huixia Zhang, Weiyi Pang, Yan Sun, Chengqiang Wang, Xi Zeng, You Li
INTRODUCTION: In the post-pandemic era, online teaching has been widely adopted. Although traditional offline instruction remains essential for mastering medical knowledge, the integration of online and offline modalities under an outcome-based education (OBE) framework has gained an inevitable trend. However, the effectiveness of this hybrid model in environmental health education has not been fully evaluated. This study aims to evaluate the effectiveness of a hybrid teaching model grounded in OBE for the environmental health course. METHODS: This study comprised the preventive medicine undergraduates from Guilin Medical University (the Classes of 2017-2020). A quasi-experimental design was employed, with the Class of 2017 serving as the control group (traditional face-to-face instruction) and the Classes of 2018-2020 as the experimental groups (OBE-based hybrid online-offline teaching). Educational efficacy was evaluated by comparing overall final exam scores, specifically analyzing written scores, objective item scores, and subjective item scores across groups. Surveys regarding hybrid teaching satisfaction and related indicators were conducted among the Class of 2018 majoring in preventive medicine. RESULTS: The experimental group achieved markedly higher total scores relative to the control group (Z = -6.869, p < 0.001). The Classes of 2018-2020 outperformed the Class of 2017 in total scores (all p < 0.001); within the experimental group, the Class of 2020 scored significantly better than the Classes of 2018 and 2019 (both p < 0.001). The experimental group attained superior written examination scores (78.89 ± 8.15 vs. 68.61 ± 8.27, t = -11.140, p < 0.001) and median objective test scores (p < 0.01), with the Class of 2019 presenting the highest median objective score. Subjective scores also improved significantly in the experimental group and across successive classes (p < 0.001). The Cronbach's alpha coefficient of the total scale was 0.911, with a coefficient of 0.961 for the satisfaction subscale. Students in the Class of 2018 reported high satisfaction (94.51%) with the OBE-based hybrid teaching model, and 40.66% of students preferred application-focused curriculum reform over theory-centered teaching. CONCLUSION: Integrating the OBE philosophy into hybrid online-offline teaching may potentially enhance teaching performance in environmental health course. Future studies could further optimize the design of online resources and the structure of offline interactions within hybrid learning.
Frontiers in public healthYousef Khader, Muhammad Sartaj, Mohannad Al Nsour, Ruba Kamal Alsouri, Mirza Zeeshan Iqbal Baig, Ariana Zeka, Muhammad Asif Khan, Rebecca Mary Close
BACKGROUND: Climate change, environmental degradation, and chemical hazards increasingly shape population health risks, particularly in the Eastern Mediterranean Region (EMR), where water scarcity, rapid urbanization, conflict, and fragile health systems amplify vulnerability. Despite these growing threats, Field Epidemiology Training Programs (FETPs) lack systematically defined competencies in climate change and environmental epidemiology. This study aimed to identify, prioritize, and validate a core set of practice-oriented competencies for integrating climate change and environmental epidemiology into FETPs, with particular relevance to the EMR. METHODS: We conducted a three-round modified Delphi study. Round 1 used a qualitative online survey to elicit expert input on essential competencies, priority areas, and implementation considerations. In Round 2, experts rated synthesized competencies using a 5-point Likert scale to assess importance and curricular inclusion. Round 3 consisted of a multidisciplinary expert workshop to validate and refine the competencies, clarify their applicability across FETP levels (Basic, Intermediate, Advanced), and translate them into applied learning modalities, including teaching case studies and structured fieldwork activities. RESULTS: Consensus was achieved on a comprehensive set of competencies spanning foundational knowledge; environmental exposures and risk assessment; epidemiological and analytical skills; climate-informed environmental public health surveillance; environmental incident and event response; vulnerability, adaptation, and preparedness; policy and governance; risk communication and community engagement; and One Health and multisectoral collaboration. The highest-rated competencies extended core field epidemiology functions-particularly surveillance, outbreak and environmental event investigation, and data analysis-into climate and environmental contexts. Workshop validation confirmed the relevance, clarity, and feasibility of all competency domains and emphasized tiered implementation and integration within existing FETP curricula. CONCLUSION: This study presents a consensus-based, practice-oriented competency framework for integrating climate change and environmental epidemiology into FETPs. By combining Delphi consensus with expert validation and operationalization, the framework offers a feasible and scalable approach to strengthening climate-resilient field epidemiology capacity, particularly in vulnerable regions such as the EMR.
Environmental monitoring and assessmentYue Wang, Ciyun Lin, Ganghao Sun, Bowen Gong, Hongchao Liu
Driving behaviors at urban intersections are frequently associated with increased traffic emissions, noise, and ground vibrations due to stop-and-go dynamics and complex vehicular interactions. These factors pose risks to public health and nearby buildings under heavy traffic conditions. Therefore, active environmental monitoring and evaluation at intersections are essential for sustainable urban planning. To assess traffic-related environmental impacts at an area-wide scale, a multi-dimensional evaluation framework was proposed for intersection environmental health using a roadside light detection and ranging (LiDAR) sensor. First, high-resolution vehicle trajectories were extracted to estimate traffic emissions, noise, and traffic-induced ground vibrations. Key indicators were derived from the pollutant evaluation results. Then, a combined weighting strategy was developed by integrating quadratic programming under ranking constraints for health-effect weight, variable-weight grey entropy under threshold constraints for data-driven weight, and game theory to balance the two perspectives. Finally, an improved fuzzy comprehensive assessment (FCA) method was proposed by incorporating an improved Jenks Natural Breaks method and standard threshold values to construct a triangular membership function for environmental health classification. Results reveal significant spatiotemporal heterogeneity in traffic-induced environmental health at intersections. At the urban intersection, the comprehensive score decreased from 69.45 during daytime to 57.12 at night, representing an approximately 18% reduction. In contrast, conditions at the suburban intersection remained stable, with scores of 72.80 in daytime and 74.54 at night. Population-dimension scores were consistently lower than environmental-dimension scores, indicating higher human sensitivity to traffic-related pollution. The proposed framework effectively captures dynamic pollution characteristics and supports intersection-level environmental health assessment.
JMIR medical educationJulia Nitsche, Theresa Sophie Busse, Sonja Schmalen, Ina Otte, Jan Peter Ehlers
BACKGROUND: The focus on sustainability in university teaching and education about the climate catastrophe is constantly increasing and is essential for creating change. The chances offered by digital technological innovations are decisive in spotlighting planetary health education. Alongside welfare economies and social movements, they are among the areas with great potential to drive sustainable development. OBJECTIVE: This study aimed to evaluate attitudes toward digital planetary health before and after a fully digital planetary health lecture series. This included assessing environmental health awareness, climate-related health risks, and perceptions of the need to integrate digital and planetary health education into university curricula. METHODS: A repeated, pseudonymous, nonexperimental, cross-sectional online survey was conducted before (T1) and after (T2) a fully digital lecture series on digital planetary health during the 2022-2023 winter term. Because participant matching across time points was unsuccessful, descriptive analyses were conducted at the group level. RESULTS: A total of 180 participants completed the T1 survey, and 79 participants completed the T2 survey. The mean age in the T1 survey was 27.92 (SD 10.95) years, with a minimum age of 18 years and a maximum age of 77 years. The mean age in T2 was 29.22 (SD 12.78) years, with a minimum age of 18 years and a maximum age of 78 years. In the T2 survey, 70.9% (56/79) of the participants rated it as "(very) important" (mean 5.38, SD 1.15) to incorporate climate-related health impacts and digital health issues into their studies. In the T2 survey, 51.9% (41/79) of the participants stated that the range of educational events on digital health at universities was inadequate. Qualitative responses highlighted perceived benefits of digitalization for collaboration, knowledge dissemination, and health care access, while concerns regarding resource consumption and ethical challenges were also described. CONCLUSIONS: Participants who attended the lecture series perceived digital planetary health as highly relevant to university education. The findings provide exploratory insights into attitudes toward the integration of planetary health and digital health topics into higher education curricula.
Cholera remains a public health concern in Rumonge Health District. The area is regularly affected by the disease outbreaks despite control measures that are periodically taken after the outbreaks occur. The last outbreak started in late 2018 and ended in February 2019, with a cumulative of 234 cases, and one death. This study aimed to identify the risk factors associated with the 2019 cholera outbreak in Rumonge Health District. We conducted a retrospective unmatched (1:2) case-control study to investigate risk factors associated with the 2019 cholera outbreak. This was carried out from 5 March 2021-30 April 2021 in 150 households, comprising 50 cases and 100 controls. Cholera cases were drawn from the admission register of cholera patients at Rumonge referral hospital. Stratified proportional allocation sampling followed by simple random selection were used to select the cases. Afterwards, we visited the households of the selected cases and controls that were chosen among the neighborhood of the cases. An interviewer-administered questionnaire was administered to the head of each household to collect sociodemographic, water, sanitation, and hygiene practice data. Multivariate analysis with logistic regression model was used to analyze the data. A multivariate analysis revealed that drinking lake/river water (OR=3.6 [1.46-8.87]), utilizing untreated water for domestic purposes (OR=5.2 [1.31-20.59]), consuming unwashed raw fruit (OR=2.9 [1.08-7.97]), eating without washing hands with soap (OR=3.2 [1.30-8.29]) and improper washing of hands after defecation (OR=2.7 [1.10-6.84]) were predictors of cholera outbreaks in Rumonge Health District. The study revealed that drinking lake or river water, using untreated water for domestic purposes, consuming unwashed raw fruits, eating without washing hands with soap, and improper handwashing after defecation were all strongly associated with increased risk of cholera. We recommend a community-based approach through the provision of safe water, strengthened hygiene education, and integrated WASH interventions in Rumonge Health District.
Journal of applied clinical medical physicsBenjamin S Rosen, Zheng Zhang, Karolyn M Hopfensperger, Kelly C Paradis, Choonik Lee, Lana Critchfield, Ikechi Ozoemelam, Charles K Matrosic, Christopher Kehay…
BACKGROUND: Clinical shift scheduling for medical physicists is challenging given multidisciplinary roles and competing clinical, research, and service demands. Manual workflows often lack the flexibility and transparency needed for this complex field. PURPOSE: To develop, deploy, and evaluate a preference-driven, optimization-based scheduling platform for an academic radiation oncology medical physics division. METHODS: Using a graphical user interface, each physicist encoded half-day shift slots as unavailable (0), available but not preferred (0.5), available (1), or preferred (2) for each two-month scheduling block over two years of clinical use. Shift requirements were defined across ten service categories with weighted effort units, and individual targets were adjusted for non-clinical effort (e.g., research, teaching, administrative service) and planned time off. Scheduling was formulated as a constrained binary integer optimization problem, with coverage, sequencing, and availability constraints, solved using a genetic algorithm to minimize a preference-based fitness function. Final schedules were exported to clinical calendars. Retrospective evaluation computed descriptive statistics per scheduling period and overall, including the distribution of assigned shifts by preference category and concordance between assignments and stated availability/preferences. Qualitative feedback from users and scheduling leads was collected to further assess operational impact. RESULTS: From January 2024 through February 2026, 4980 shifts were assigned across fifteen scheduling blocks for 23 physicists. Across 25,796 preference entries, 95% of assignments matched stated preference and availability, with non-preferred assignments accounting for only 5% of total assignments. All clinical coverage requirements were met, and no staff were scheduled for shifts marked as unavailable. Manual interventions were rare, and user feedback indicated improved transparency, satisfaction, and reduced administrative burden. CONCLUSIONS: Preference-integrated optimization reliably produced feasible, clinically robust schedules for medical physics shift scheduling. This approach is readily implementable and supports efficient, equitable scheduling in multidisciplinary settings.
Journal of applied clinical medical physicsDarren Zuro, Michael Reilly, Jessica Salas, Jiayi Liu, Maryam Shirmohammad, Xinyi Li, Theodore Geoghegan, Peter Maxim, Mengying Shi
BACKGROUND: Medical physics residency programs require reliable systems for organizing rotation files, documenting educational activities, recording competency sign-offs, and monitoring resident progression. Current residency standards from the Commission on Accreditation of Medical Physics Educational Programs (CAMPEP) require clearly defined training schedules, rotation objectives, resident progress evaluation, and regular documentation of trainee development. Many programs continue to rely on static documents, spreadsheets, or multiple disconnected platforms, which may create version-control problems, increase administrative burden, and reduce transparency. Prior reports have described dedicated educational-management software (Typhon Group and MedHub) for this purpose, but these require separate licensing and onboarding. RadMachine (Radformation, Inc., New York, NY) is widely used in radiation oncology departments for machine quality assurance (QA) management; repurposing such an existing QA platform for residency management has not been previously described. PURPOSE: To describe the repurposing of RadMachine as a platform for medical physics residency rotation organization, activity tracking, competency sign-offs, and compliance with residency documentation needs. METHODS: A residency management framework was developed within the RadMachine platform. Each resident was configured as a virtual device. Test lists were created and assigned to each resident to represent clinical rotations, an operation sign-off list, a proficiency checklist, and a comprehensive examination. Individual tests represented, but were not limited to, learning objectives, practical tasks, reading topics, or sign-off requirements. Completion status was recorded in various ways, including binary completion states, supervisor sign-offs, detailed comments, or report upload. The prior Microsoft Word-based workflows were qualitatively compared with the proposed RadMachine-based framework. RESULTS: The RadMachine-based framework transformed static training documents into dynamic, trackable test lists. Compared with the prior workflow, the new framework improved version control, reduced administrative effort, simplified updates, allowed transparency, and ensured access to the most current curriculum. Residents could view completed and pending requirements in real time, while faculty could rapidly review trainee progress and outstanding competencies. CONCLUSIONS: Implementing the machine QA software RadMachine for residency education provides a practical, scalable, and low-overhead solution for rotation management and competency tracking. Because it reuses cloud-based QA software already licensed and deployed in the department for routine clinical QA-that is, existing departmental infrastructure-the approach requires no additional procurement, licensing, or information-technology onboarding. This approach is particularly useful for residency programs seeking efficient alternatives to document-based systems and offers strong potential for future expansion.
Journal of applied clinical medical physicsTiziana Malatesta, Agnese Barbareschi, Rita Alaimo, Emilio Mezzenga, Maria Grazia Brambilla, Anna Delana, Stefano Andreoli, Rita Consorti, Stefano Ren Kaiser, …
AIM: Current radiotherapy (RT) guidelines for Cardiac Implantable Electronic Devices (CIEDs) are largely based on clinical management strategies and retrospective reports. This systematic review adopts a medical physics perspective to provide a critical, quantitative analysis of the technical evidence required for developing robust safety action plans. MATERIALS AND METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted (January 2014-December 2024) across five major databases. Sixteen physicists from the Associazione Italiana di Fisica Medica e Sanitaria (AIFM) Working Group (WG) performed a double-review and standardized data extraction, focusing on physics-specific variables for the irradiation of Left Ventricular Assist Devices (LVADs), Pacemakers (PMs), and Implantable Cardioverter-Defibrillator (ICD) devices. Data were grouped into five topics: photon/electron RT, hadron therapy, modeling RT effects (Treatment Planning System [TPS]/Monte Carlo [MC]), imaging, and specific considerations regarding Magnetic Resonance Imaging Linac (MRI-Linac) systems. The Malfunction Rate (MR)-the percentage of devices with a clinically relevant malfunction-was calculated, and a Z-test was carried out to highlight safer irradiation conditions. Additionally, a narrative synthesis was performed. RESULTS: Of the 60 selected articles, 47 were co-authored by physicists. The studies considered a total of 1769 real devices, while 13 studies reported on virtual devices (i.e., simulations, electronics, or measurements only). Reported irradiation beams included photons (encompassing Intra-Operative RadioTherapy [IORT], Total Body Irradiation [TBI], and Flattening Filter Free [FFF] beams), electrons, protons, and carbon ions. Thirty-seven manuscripts investigated CIED malfunctions, yielding an overall MR of 12.6%. The MR was significantly lower for devices irradiated under scatter conditions and when non-neutron-producing beams were used. Information on the entire RT process (imaging, dose calculation, planning, and irradiation) was analyzed, and a flowchart was developed to guide medical physicists in their daily clinical practice. CONCLUSION: The review concludes that the medical physicist's role is non-negotiable in developing and implementing advanced planning and dosimetry strategies to prevent CIED malfunction and ensure patient safety.