Population Health Research Articles

A personalized clinical assessment: multi-sensor approach for understanding musculoskeletal health in the frail population

BackgroundSarcopenia is a muscle disorder causing a progressive reduction of muscle mass and strength, but the mechanism of its manifestation is still partially unknown. The three main parameters to assess are: muscle strength, muscle volume or quality and low physical performance. There is not a definitive approach to assess the musculoskeletal condition of frail population and often the available tests to be performed in those clinical bedridden patients is reduced because of physical impairments. In this paper, we propose a novel instrumental multi-domain and non-invasive approach during a well-defined protocol of measurements for overcoming these limitations. A group of 28 bedridden elder people, subjected to surgery after hip fracture, was asked to perform voluntary isometric contractions at the 80% of their maximum voluntary contraction with the non-injured leg. The sensor employed before and/or during the exercise were: ultrasound to determine the muscle architecture (vastus lateralis); force acquisition with a load cell placed on the chair, giving an indication of the muscle strength; surface electromyography (EMG) for monitoring muscular electrical activity; time-domain (TD) near-infrared spectroscopy (NIRS) for evaluating muscle oxidative metabolism.ResultsA personalized “report card” for each subject was created. It includes: the force diagram (both instantaneous and cumulative, expected and measured); the EMG–force diagram for a comparison between EMG derived median frequency and measured force; two graphs related to the hemodynamic parameters for muscle oxidative metabolism evaluation, i.e., oxy-, deoxy-, total-hemoglobin and tissue oxygen saturation for the whole exercise period. A table with the absolute values of the previous hemodynamic parameters during the rest and the ultrasound related parameters are also included.ConclusionsIn this work, we present the union of protocols, multi-domain sensors and parameters for the evaluation of the musculoskeletal condition. The novelties are the use of sensors of different nature, i.e., force, electrical and optical, together with a new way to visualize and combine the results, by means of a concise, exhaustive and personalized medical report card for each patient. This assessment, totally non-invasive, is focused on a bedridden population, but can be extended to the monitoring of rehabilitation progresses or of the training of athletes.

Effects of a self-guided digital mental health self-help intervention for Syrian refugees in Egypt: A pragmatic randomized controlled trial

Background Digital mental health interventions for smartphones, such as the World Health Organization (WHO) Step-by-Step (SbS) program, are potentially scalable solutions to improve access to mental health and psychosocial support in refugee populations. Our study objective was to evaluate the effectiveness of SbS as self-guided intervention with optional message-based contact-on-demand (COD) support on reducing psychological distress, functional impairment, symptoms of posttraumatic stress disorder (PTSD), and self-identified problems in a sample of Syrian refugees residing in Egypt. Methods and findings We conducted a 2-arm pragmatic randomized controlled trial. A total of 538 Syrians residing in Egypt with elevated levels of psychological distress (Kessler Psychological Distress Scale; K10 > 15) and reduced psychosocial functioning (WHODAS 2.0 > 16) were randomized into SbS + CAU (N = 266) or CAU only (N = 272). Primary outcomes were psychological distress (Hopkins Symptom Checklist 25) and impaired functioning (WHO Disability Assessment Schedule 2.0) at 3-month follow-up. Secondary outcomes were symptoms of PTSD (PTSD Checklist for DSM-5 short form, PCL-5 short) and self-identified problems (Psychological Outcomes Profiles Scale, PSYCHLOPS). Intention-to-treat (ITT) analyses showed significant but small effects of condition on psychological distress (mean difference: −0.15; 95% CI: −0.28, −0.02; p = .02) and functioning (mean difference: −2.04; 95% CI: −3.87, −0.22; p = .02) at 3-month follow-up. There were no significant differences between groups on symptoms of PTSD and self-identified problems. Remission rates did not differ between conditions on any of the outcomes. COD was used by 9.4% of participants for a median of 1 contact per person. The main limitations are high intervention dropout and low utilization of COD support. Conclusions The trial provides a real-world implementation case, showing small positive effects of a digital, potentially scalable and self-guided mental health intervention for Syrian refugees in Egypt in reducing psychological distress and improving overall functioning. Further user-centered adaptations are required to improve adherence and effectiveness while maintaining scalability. Trial registration German Register for Clinical Studies DRKS00023505.

Leveraging publicly available data to evaluate health reform: establishing a methodology to assess the future impact of over-the-counter hearing aids

Health systems are complex and health reform is uncertain. With an aging global population, chronic health conditions are increasing and have become a priority for policymakers. Hearing loss is the third most common chronic condition among older adults and if left untreated, is associated with poor health and social outcomes. In the US, accessibility and affordability have been significant barriers to hearing aid utilization. Through new reform, over-the-counter (OTC) hearing aids are now available. This study demonstrates how publicly available health data was used to establish a methodology to define, characterize, and analyze the target population of this reform. In this retrospective cross-sectional cohort analysis, data from the National Health Interview Survey (NHIS) was utilized, with a sample that included respondents from the 2021 NHIS Sample Adult Interview. Three hearing aid groups (Active, Potential, General) were defined using questions from the NHIS annual core questionnaire and a baseline population health framework was developed. Binary logistic regression confirmed that the framework sufficiently described two group comparisons (Active-Potential, Active General) and also identified the key determinants of hearing aid utilization. Classification and regression tree (CART) classification amply predicted active hearing aid users and verified the key determinants as important predictors. These findings aligned nicely with literature published before OTC hearing aids were made available, confirming the NHIS to be consistent and representative. Our methodology can be repeated to examine the impact of OTC hearing aids in the post-implementation period and similar approaches should be taken to examine other emerging health reforms.

Uptake of Cancer Genetic Services for Chatbot vs Standard-of-Care Delivery Models: The BRIDGE Randomized Clinical Trial.

Increasing numbers of unaffected individuals could benefit from genetic evaluation for inherited cancer susceptibility. Automated conversational agents (ie, chatbots) are being developed for cancer genetics contexts; however, randomized comparisons with standard of care (SOC) are needed. To examine whether chatbot and SOC approaches are equivalent in completion of pretest cancer genetic services and genetic testing. This equivalence trial (Broadening the Reach, Impact, and Delivery of Genetic Services [BRIDGE] randomized clinical trial) was conducted between August 15, 2020, and August 31, 2023, at 2 US health care systems (University of Utah Health and NYU Langone Health). Participants were aged 25 to 60 years, had had a primary care visit in the previous 3 years, were eligible for cancer genetic evaluation, were English or Spanish speaking, had no prior cancer diagnosis other than nonmelanoma skin cancer, had no prior cancer genetic counseling or testing, and had an electronic patient portal account. Participants were randomized 1:1 at the patient level to the study groups at each site. In the chatbot intervention group, patients were invited in a patient portal outreach message to complete a pretest genetics education chat. In the enhanced SOC control group, patients were invited to complete an SOC pretest appointment with a certified genetic counselor. Primary outcomes were completion of pretest cancer genetic services (ie, pretest genetics education chat or pretest genetic counseling appointment) and completion of genetic testing. Equivalence hypothesis testing was used to compare the study groups. This study included 3073 patients (1554 in the chatbot group and 1519 in the enhanced SOC control group). Their mean (SD) age at outreach was 43.8 (9.9) years, and most (2233 of 3063 [72.9%]) were women. A total of 204 patients (7.3%) were Black, 317 (11.4%) were Latinx, and 2094 (75.0%) were White. The estimated percentage point difference for completion of pretest cancer genetic services between groups was 2.0 (95% CI, -1.1 to 5.0). The estimated percentage point difference for completion of genetic testing was -1.3 (95% CI, -3.7 to 1.1). Analyses suggested equivalence in the primary outcomes. The findings of the BRIDGE equivalence trial support the use of chatbot approaches to offer cancer genetic services. Chatbot tools can be a key component of sustainable and scalable population health management strategies to enhance access to cancer genetic services. ClinicalTrials.gov Identifier: NCT03985852.

Physical Exercise Prevents the Cognitive Decline among Older Adults in Romania.

Cognitive decline is one of the most important challenges related to the aging process, due to its important impact on individuals. Several studies have reported that physical exercise with a specific intensity and frequency is beneficial for maintaining cognitive health in the ageing population. The present study investigated the impact of general physical exercise on cognitive health in the older population in Romania. The study involved 60 individuals (60% male, 40% female), with a mean age of 60.78 years (SD = 2.97). The Health Interview Survey and The Minnesota Heart Survey assessed exercise frequency and intensity, while the Montreal Cognitive Assessment (MoCA) determined mild cognitive impairment (MCI) levels. The results of the statistical analysis showed that high-intensity physical exercise at a frequency of three to four times a week at the age of 40-50 years is recommended in order to significantly reduce cognitive decline. In addition, for the age of 60 years old, the results established that engaging in physical activities of a moderate intensity with a frequency of 2-3 times per month is sufficient to maintain healthy cognition. The findings suggest that exercise can serve as a behavioral intervention to mitigate cognitive dysfunction and complement past research on its cognitive health advantages.

A systems approach to improving health consideration in UK urban development: a real estate perspective

ABSTRACT This research investigates how population health is considered in urban development decision-making by developing a causal loop diagram from 21 interviews with senior real estate actors. It classifies variables in the model in structural, attitudinal, and transactional dimensions, links them to relevant decision-making actors, and identifies key feedback loops. This enhances understanding of the system and informs intervention strategies for improving the consideration of health. Structural and attitudinal variables are powerful leverage points but are more challenging to influence directly and slower to change. Yet, when activated through a transactional variable, such as enhancing a data-led health metric to increase the ability of stakeholders to include health in planning, investment and development decisions, they generate virtuous feedback loops. These drive and sustain decision-making that shapes a healthier built environment.

The impact of urbanization on growth patterns of non‐adults in medieval England

AbstractIncreasing urbanization seen during the medieval period (7th to 16th centuries) is associated with adverse living conditions that may have negatively impacted childhood growth via the influence of infectious diseases and nutritional deficiencies due to increasing population density and periodic food shortages. This study aims to compare the growth of non‐adults (less than 12 years of age) from urban, proto‐urban, and rural environments from medieval England to determine whether settlement type influenced child health, and by proxy overall population health, during this period. Tibial and femoral maximum diaphyseal lengths and dental age of non‐adults (0–12 years) from urban St. Gregory's Priory (n = 60), urban York Barbican (n = 16), proto‐urban Black Gate (n = 38), and rural Raunds (n = 30) were examined using z‐scores. The results reveal that non‐adults < 2 years from St. Gregory's Priory had the lowest growth values followed by Raunds, Black Gate, and York Barbican with the highest growth values. Further, non‐adults 2–12 years from York Barbican had the lowest growth values followed by Raunds, Black Gate, and St. Gregory's Priory with the higher growth values. The femoral and tibial diaphyseal growth values are explored within the context of breastfeeding and weaning practices, stability of economies, and environmental conditions.

Assessing the effect of high-dose rosuvastatin in elderly patients over 75 with acute coronary syndrome

Backgrounds and objectiveStatins, inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A reductase, are pivotal in managing hypercholesterolemia and reducing cardiovascular risk. While rosuvastatin demonstrates superior efficacy and tolerability compared to other statins, its safety profile in elderly patients older than 75 years old with acute coronary syndrome (ACS) remains underexplored. So, the objective of this study is to evaluate the frequency of adverse reactions and investigate the efficacy of high-dose rosuvastatin on lipid profiles in elderly patients aged over 75 with ACS.MethodsIn this observational study, 110 consecutive elderly ACS patients attending Modarres Hospital in Tehran, Iran, in 2019 were enrolled. The effects of high-dose rosuvastatin were assessed in elderly patients older than 75 years old by comparison of the adverse effects, lipid profile, cardiac function, and other biomarkers at the baseline and after 6 weeks of rosuvastatin therapy with a dose of 40 mg.ResultsFollowing 6 weeks of treatment, there was a significant reduction in total cholesterol (136.2 ± 24.3 to 115.5 ± 24.0, p = 0.001) and LDL levels (72.6 ± 17.5 to 50.9 ± 18.9, p = 0.001), accompanied by a notable increase in HDL levels (38.3 ± 7.1 to 47.2 ± 7.4, p = 0.001). Cardiac function, as measured by ejection fraction (EF), significantly improved from 43.4 ± 8.8 to 48.5 ± 8.5 (p = 0.001). Adverse effects such as cramps (N = 12, p = 0.001), weakness (N = 28, p = 0.001), and anorexia (N = 12, p = 0.001) were reported but did not warrant discontinuation of therapy. Notably, no cases of jaundice were observed. Two deaths occurred due to major adverse cardiac events (MACE) during the study period, unrelated to stroke or recurrent myocardial infarction.ConclusionTotally, high-dose rosuvastatin therapy effectively improved lipid profiles, cardiac function, and liver enzyme levels in elderly ACS patients, with manageable adverse effects. These findings underscore the importance of rosuvastatin in optimizing cardiovascular health in this vulnerable population.

Development of a Nutrient Profile Model for Dishes in Japan Version 1.0: A New Step towards Addressing Public Health Nutrition Challenges.

To address the rising incidence of non-communicable diseases (NCDs) and promote healthier eating habits, Japan requires a culturally tailored Nutrient Profile Model. This study aimed to develop a Nutrient Profile Model for Dishes in Japan version 1.0 (NPM-DJ (1.0)) that corresponds to the nutritional issues and food culture in Japan. The aim of the NPM-DJ (1.0) was to promote the health of the general population, and to prevent the increase in NCDs in Japan. The NPM-DJ (1.0) categorizes dishes into staples, sides, mains, mixed dishes, and mixed dishes with staples. The model evaluates dishes based on energy, saturated fats, sugars, and sodium as restricted nutrients, while considering protein, dietary fiber, and the weight of certain food groups as recommended nutrients. The distribution of the overall score for each dish category was analyzed and a rating algorithm was created. The baseline, modification points, and final scores were significantly lower for side dishes than for staple dishes. In contrast, the baseline points and final scores were significantly higher for mixed dishes with staple. The model effectively differentiated nutritional profiles across five dishes categories, which may promote healthier dish reformulation by food businesses operators and encourage consumers to select healthier dishes.

ANÁLISE COMPARATIVA ENTRE O SISTEMA DE SAÚDE DOS EUA E O SISTEMA ÚNICO DE SAÚDE BRASILEIRO: UMA REVISÃO DE LITERATURA

This article conducts a comparative analysis of the healthcare systems in the United States and Brazil’s Unified Health System (SUS), examining structural and funding differences and their impact on healthcare access and quality. In the U.S., a predominantly private insurance based system supplemented by federal programs like Medicare and Medicaid grapples with challenges in achieving universal coverage and managing high healthcare costs despite the Affordable Care Act reforms. Conversely, Brazil’s SUS, founded on principles of universality and comprehensiveness, faces funding and operational efficiency issues despite significant health indicator improvements. The COVID-19 pandemic has tested the resilience of both systems, underscoring the need for robust and adaptable healthcare frameworks. The study concludes that ongoing dialogue and mutual learning between the systems can inform reforms aimed at enhancing population health and effectively managing health crises.

Developing a systems-focused tool for modeling lung cancer screening resource needs

BackgroundEarly detection through screening dramatically improves lung cancer survival rates, including among war Veterans, who are at heightened risk. The effectiveness of low dose computed tomography scans in lung cancer screening (LCS) prompted the Veteran’s Affairs Lung Precision Oncology Program (VA LPOP) to increase screening rates. We aimed to develop an adaptive population health tool to determine adequate resource allocation for the program, with a specific focus on primary care providers, nurse navigators, and radiologists.MethodsWe developed a tool using C + + that uses inputs that represents the process of the VA LCS program in Ann Arbor, Michigan to calculate FTEs of human resource needs to screen a given population. Further, we performed a sensitivity analysis to understand how resource needs are impacted by changes in population, screening eligibility, and time allocated for the nurse navigators’ tasks.ResultsUsing estimates from the VA LCS Program as demonstrative inputs, we determined that the greatest number of full-time equivalents required were for radiologists, followed by nurse navigators and then primary care providers, for a target population of 75,000. An increase in the population resulted in a linear increase of resource needs, with radiologists experiencing the greatest rate of increase, followed by nurse navigators and primary care providers. These resource requirements changed with primary care providers, nurse navigators and radiologists demonstrating the greatest increase when 1–20, 20–40 and > 40% of Veterans accepted to be screened respectively. Finally, when increasing the time allocated to check eligibility by the nurse navigator from zero to three minutes, there was a linear increase in the full-time equivalents required for the nurse navigator.ConclusionVariation of resource utilization demonstrated by our user facing tool emphasizes the importance of tailored strategies to accommodate specific population demographics and downstream work. We will continue to refine this tool by incorporating additional variability in system parameters, resource requirements following an abnormal test result, and resource distribution over time to reach steady state. While our tool is designed for a specific program in one center, it has wider applicability to other cancer screening programs.

The Case for the Role of Primary Care in Patient Blood Management.

Patient blood management (PBM) is a patient-centered evidence-based strategy designed to preserve a patient's own blood and improve health outcomes. The effectiveness of PBM programs is now well-established globally within tertiary and secondary sectors, with demonstrable outcome benefits and cost savings. However, the role of primary care and the general practitioner in PBM is poorly understood. Yet the essential attributes of primary care, including access, continuity, coordination, and comprehensiveness, align well with PBM principles, enabling general practitioners to provide personalized holistic management of anemia for the community. The skill set of general practitioners in integrating and continuing care through the transition period after hospitalization is especially important. General practitioners are well-suited to the roles of health promotion and prevention, and have the potential to deliver substantial population health benefits. Given the public health imperative of this condition, it is vital that policy-makers appropriately support the role of general practitioners with financing, education, and resources for PBM in primary care.

К вопросу об общественном и популяционном здоровье.

In modern domestic scientific literature, various terms are used to define population health, often used as synonyms: “public health”, “population health”, “society health”, “social health” and others. Domestic sources note that public health reflects the qualitative property of society or the state of people, emphasizing the aspect of public health as an indicator of the viability of the country. Public health, considered as the medical, social and economic development potential of the country and society, is influenced by environmental factors and lifestyle of the population, and ensures an optimal level of quality and safety of life for the population. Foreign researchers are looking at population health from a variety of perspectives, including analysis of income inequality, social capital, macroeconomic determinants, information systems, health promotion, global burden of disease, physical activity, structural racism, etc. Since 2019. Population health issues are currently receiving unprecedented attention in many countries, with a sharp increase in research in this area during the COVID‑19 pandemic. Currently, the global health system is developing approaches that combine population and public health issues into a single discipline. With the emergence of a new generation of scientists, proposals are being made to focus efforts on coherence of ideas, values and priorities of a single discipline, identifying problems and opportunities for the development of a more unified field of health care.

Cardiometabolic multimorbidity in Mexican adults: a cross-sectional analysis of a national survey.

Cardiometabolic multimorbidity is a rising phenomenon that has been barely explored in middle-income countries such as Mexico. This study aimed to estimate the prevalence, associated factors, and patterns of cardiometabolic multimorbidity (2 and 3+ diseases) in Mexican adults (≥20 years old) by age group. A cross-sectional and secondary analysis of Mexico's National Health and Nutrition Survey 2018-2019 was conducted. Information on eight diseases and other sociodemographic and health/lifestyle characteristics was obtained through self-reporting. Descriptive analyses were performed, and multinomial logistic regression models were calculated to identify the variables associated with cardiometabolic multimorbidity. Factor analysis and latent classes were estimated to determine disease patterns. The prevalence of cardiometabolic multimorbidity for the total population study was 27.6% (13.7% for people with 2 diseases and 13.9% for people with 3+ diseases). By age group, the prevalence of 2+ diseases was 12.5% in the age group of 20-39 years, 35.2% in the age group of 40-59 years, and 44.5% in the age group of 60 years and older. The variables of depressive symptomatology and having functional limitations (1+) were statistically associated with cardiometabolic multimorbidity in almost all age groups. Patterns of cardiometabolic multimorbidity varied among adults in different age groups. Understanding the behavior of cardiometabolic multimorbidity at various stages of adulthood is a resource that could be used to design and implement intervention strategies. Such strategies should correspond to the population's sociodemographic, health, and lifestyle characteristics and the specific disease patterns of each age group.

Syndromic Surveillance in Public Health Emergencies: A Systematic Analysis of Cases Related to Exposure to 2023 Floodwaters in Romagna, Italy.

In May 2023, Romagna, Italy, faced a devastating flood resulting in 16 fatalities, forced displacement of 26,000 citizens, and significant economic losses. Due to potential water contamination, implementing public health strategies became imperative for the Local Health Authority to mitigate the health consequences, analyze the flood's impact on the local population's health, and detect early anomalies requiring timely public health interventions. Between June and July 2023, general practitioners who were part of the RespiVirNet surveillance network completed weekly structured forms. These forms collected data on individuals exposed or not to floodwaters and clinical syndromes. Rates per 1000 resident population aged > 14 were stratified by district, week of observation, and symptomatology. Missing data were addressed by imputation using second-order autoregressive modeling. An incidence of 3.52 syndromes potentially related to flood water exposure per 1000 individuals (95% CI 2.82-4.35) was estimated. Ravenna, the city most affected by the flood, recorded the highest rate (6.05 per 1000, 95% CI 4.59-7.82). Incidence decreased in the weeks post-event. Anxiety, or trauma and stress symptoms, exhibited higher rates among the exposed, diminishing over weeks. The incidence for the non-exposed (12.76 per 1000, 95% CI 10.55-15.29) showed no significant territorial differences compared to the exposed ones. Syndromic surveillance provided timely information on the flood's health impact, revealing a higher incidence of individual syndromes among the non-exposed. This study contributes to guiding the implementation of future public health preparedness and response strategies for populations facing similar natural disasters.

Trends in Distress‐Free Life Expectancy in Japan, 2010–2022

ABSTRACTExtensive literature exists on the physical health of the Japanese population whereas relatively little is known about their mental health. Moreover, most studies have assessed physical and mental health separately, and this further confounds the relationship between the two. Using the concept of health expectancy, this study investigated the trends in the relationship between physical and mental health among Japanese men and women aged 20 years or more between 2010 and 2022. Psychological distress, based on the Comprehensive Survey of Living Conditions, was used as an indicator of mental health. We employed Sullivan's method to estimate the length of life with or without distress of varying degrees. Our results showed substantial improvements in distress‐free life expectancy for both genders during the study period. Younger people have gained more distress‐free years than their older counterparts, placing older individuals, especially men, at an increased risk of psychological distress. These findings contribute to the literature on longevity in Japan by quantifying the role of mental health in the population's overall health. Given the recent increase in mental health problems, greater policy emphasis on the relationship between physical and mental health status is required.

Implementation of the Expert Nursing Standard: Caregivers' Oral Health Knowledge.

The promotion of oral health in nursing care is essential for preventing oral diseases and maintaining health in elderly vulnerable populations. There is a need for standardized guidelines and education. The aim of this study was to collect data on the attitudes and hopes of caregivers regarding the implementation of the German Expert Nursing Standard "Promotion of Oral Health in Nursing" (GENS-POHN) and to evaluate their oral healthcare knowledge before implementation. A cross-sectional study was conducted in five different care settings in Germany. A self-administered questionnaire was used to collect data on the attitudes and hopes of nursing assistants regarding the GENS-POHN. Oral healthcare knowledge was evaluated before implementation. Most participants had a positive attitude towards the GENS-POHN and hoped that its implementation would lead to greater safety and competence in daily oral healthcare tasks. Few participants currently use screening or assessment instruments for oral care. There is a need for further education and training, as well as the development and implementation of standardized guidelines and tools for screening and assessment, in oral care. The GENS-POHN as an expert standard could be made accessible to an international audience by translating it into other respective national languages, thereby enhancing its usability for a wider range of users.

Identify Affecting Factors on Total Fertility Rate: A Systematic Review

Background: The total fertility rate (TFR) is a key indicator of population dynamics and health. It shows the average number of children a woman would have in her lifetime, based on the current fertility rates for different age groups. Various factors affect the TFR, such as social, economic, political, technological, environmental, and health factors. By analyzing these factors and how they influence the TFR, policymakers and planners can design and implement interventions to achieve optimal population and health outcomes. Methods: We searched PubMed, Scopus, ISI Web of Science, and ProQuest databases, as well as the Google Scholar search engine systematically. We searched for studies from 13 December 2021 - 20 May 2022, without time limits. We included studies that described at least one driver of TFR. We applied the STEEPH framework (social, technology, environmental, economic, political, and health) method to analyze the qualitative data. Results: We included 64 studies from 26 countries. We identified 410 drivers of TFR, and classified 181 drivers into six main categories: Social, technological, environmental, economic, political, and health. The main factors that lower the fertility rate are education, aging, poverty, postponing marriage (social), exposure of women to mass media (technology), type of residence and living in urban areas, road accidents (environmental), income and economic situation (recession and inflation), unemployment, debt, women’s employment (economic), government policies (political), use of anti-fertility drugs (health). The main drivers that raise the fertility rate are having first child girls, women’s proximity to their workplace (social), use of assisted reproductive technology (technology), living in rural areas and natural and unnatural disasters (environmental), improvement in men’s labor market conditions, employment opportunities (economic), increased parental leave (political), high infant mortality (health). Conclusions: We identified a comprehensive list of effective drivers that have increased or decreased TFR in different parts of the world. It is necessary to review these drivers considering the specific conditions and social, cultural, economic, and political coordinates of each country. This review should inform policymakers' actions in this area.

The burden of liver cancer in Mongolia from 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.

Liver cancer remains the leading cause of death and public health threat among the Mongolian population. So far, there has been no in-depth analysis to describe the burden of common attributable factors to liver cancer in Mongolia. Therefore, we aimed to explore the most prevalent causes of liver cancer and its trends from 1990 to 2019. We extracted the primary liver cancer data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to examine the mortality and morbidity of liver cancer by its etiological types, which included alcohol, viral hepatitis B and C, and non-alcoholic steatohepatitis (NASH). The data was extracted by sex and 5-year age intervals from 1990 to 2019. Data included mortality, incidence, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) of liver cancer among the Mongolian population. Mongolia had the world's highest age-standardized DALYs for liver cancer (2558.1) in 2019. Alcohol-attributable DALYs (786.6) were 29 times higher than the global average (26.1), and liver cancer due to hepatitis C (752.6) and B (763.2) were 21.5 (35.0) and 10.9 (69.1) times higher, respectively. Over the past 30 years, there has been a steady increase in the incidence and number of deaths caused by liver cancer in Mongolia. In 2019, liver cancer incidence due to alcohol consumption was 3.1 times higher for males than females, and hepatitis B was 2.7 times higher for males than females. However, the incidence of hepatitis C and NASH were slightly higher for females. Deaths from liver cancer accounted for 9.51% (2365) of total deaths in Mongolia in 2019, with a continuously increasing trend in the fraction of death compared to 1990, which was 11 times higher than the global average (0.86%), particularly in females with a 319.6% (95% UI 234.9-435.7) increase observed during the study period. Liver cancer due to hepatitis B, C, and alcohol each shared about one-third of liver cancer deaths. A comprehensive analysis of the burden of liver cancer in Mongolia reveals alcohol use as a primary cause of liver cancer mortality, particularly affecting men and significantly impacting the disease burden. Viral hepatitis continues to pose a major public health concern in the country. Although significant milestones have progressed, addressing the unique demographic and geographical challenges requires tailored approaches for specific target populations. The evidence generated from this analysis is crucial to support policy guidance, contribute to evidence-based decisions, guide public health prevention measures, and amplify population health promotion and disease prevention throughout Mongolia.

On the edge: Conservation genomics of the critically endangered dwarf mountain pine Pherosphaera fitzgeraldii

Pherosphaera fitzgeraldii, the Dwarf Mountain Pine, is a critically endangered conifer restricted to cliff ledges within waterfall spray zones in the Greater Blue Mountains Area of New South Wales, Australia. This species is under threat from pollution, invasive weeds, and limited recruitment, which are contributing to its declining population. Using a comprehensive conservation genomic approach, we assessed the population health of P. fitzgeraldii and developed strategic recommendations for its management.Genomic analysis of P. fitzgeraldii revealed the presence of two distinct genetic groups despite the limited distribution of the species. This genetic structure aligns with prevailing wind currents, indicating potential restrictions to pollen or seed exchange between subpopulations. Furthermore, limited gene flow was observed even among nearby subpopulations, emphasizing the risk of increased genetic differentiation due to ongoing isolation. Clonality is widespread in some subpopulations, and all subpopulations displayed signs of inbreeding and genetic depletion despite subdioecy, indicative of historical constraints on gene flow and small population sizes.We offer genomic-based recommendations for prioritizing conservation sites, enhancing genetic diversity in ex situ collections, and guiding future management. Further studies to uncover the sex determination mechanism of P. fitzgeraldii could help maintain balanced sex ratios in ex situ collections and support future genetic rescue efforts. This study underscores the value of genomics in informing protection and recovery of unique threatened species.