Epilepsy surgery beyond seizure control: implications for reproductive health in women.

Smoking remains a leading cause of preventable morbidity and mortality globally, with significant public health and economic implications. In Jordan, smoking prevalence among men is alarmingly high, necessitating a deeper understanding of its determinants. This study aims to identify sociodemographic factors influencing smoking behavior among Jordanian men aged 15-59 years using nationally representative data. The study utilized data from the 2023 Jordan Population and Family Health Survey (JPFHS) to analyze sociodemographic factors influencing smoking behavior. Descriptive statistics and binary logistic regression analyses were performed. Associations were assessed using adjusted odds ratios (AORs) and 95% confidence intervals (CIs), with statistical significance set at p < 0.05. Our study included 5,873 Jordanian men, with 3,072 (52.30%) classified as non-smokers, 2,615 (44.52%) as everyday smokers, and 186 (3.17%) as someday smokers. Multivariable analysis revealed several factors significantly associated with higher odds of smoking, including increasing age, working in agriculture, services, and skilled manual occupations, being widowed, residing in Zarqa, being in the poorest or richest wealth categories, and using the internet at least once a week or almost every day (p < 0.05). On the other hand, living in Tafiela and reading newspapers or magazines at least once a week were significantly associated with lower odds of smoking (p < 0.05). Our study identified several sociodemographic factors significantly associated with smoking among Jordanian men, including older age, working in agriculture or skilled manual labor, widowhood, residence in Zarqa, extreme wealth levels, and frequent internet use. In contrast, newspaper readership and residence in Tafiela were protective. These findings highlight the importance of targeted public health interventions aimed at high-risk groups and strengthening tobacco control efforts across the country.

Introduction This study aimed to characterize the viral diversity in the blood of marmots in the Qinghai-Tibet Plateau region, to assess their role as potential viral reservoirs and evaluate the potential implications for wildlife and human health. Methodology Seventy marmot blood samples were collected from Yushu and Guoluo Prefectures in Qinghai Province. Viral communities were comprehensively analyzed using high-throughput sequencing and bioinformatics techniques. Results Analysis identified a wide range of viral families, including Anelloviridae , Flaviviridae , Parvoviridae , and Polyomaviridae , and revealed multiple novel viral sequences. Notably, we documented the first evidence of Anelloviridae in marmot serum; phylogenetic analysis indicated these sequences cluster with those from marmot feces and tissues, suggesting a natural host relationship. A critical finding was the detection of Tick-borne encephalitis virus, with a sequence highly similar to human-derived strains, implying potential involvement of marmots in the transmission cycle. Furthermore, identification of a novel polyomavirus was supported by prediction of all main large tumor antigen functional domains and motifs, including a putative nuclear localization signal between its LXCXE motif and origin-binding domain, typical of mammalian-infecting polyomaviruses. Comparative analysis revealed significant regional differences in viral diversity between sampling areas, potentially linked to local ecological factors. Discussion This study significantly expands the known viral diversity in marmots and underscores their role as potential zoonotic reservoirs. However, the functional and pathogenic implications of these viruses require further experimental validation. These findings highlight the importance of ongoing wildlife surveillance for understanding viral ecology and mitigating emerging public health risks.

This work investigated the physicochemical characteristics, heavy metal concentrations, and depth-release properties of soils impacted by the deposition of automechanic (A), paint-processing (P), and abattoir (AB) waste in a coastal milieu in Southern Nigeria. Composite soil samples were collected directly beneath the waste piles at various subsurface depths to assess the vertical distribution and mobility of heavy metals within the waste-impacted soils. The samples were analyzed for their pH, electrical conductivity, organic carbon, organic matter, total nitrogen, available phosphorus, exchangeable calcium, exchangeable magnesium, exchangeable acidity, effective cation exchange capacity, and base saturation. The samples were also analyzed for their aqua regia-extractable concentrations of Lead (Pb), Cadmium (Cd), Chromium (Cr), Nickel (Ni), and Vanadium (V). The results indicated that waste inputs significantly altered the chemical characteristics of the soil, producing significant shifts in soil physicochemical properties. Maximum concentrations of Pb (3918 mg/kg), Cd (116.5 mg/kg), and Ni (226.1mg/kg) were recorded in soils impacted by automechanic wastes, while maximum concentrations of Cr (511.0 mg/kg) and V (179.3mg/kg) were recorded in soils impacted by paint wastes. These concentrations exceeded international guideline limits for residential soils and indicated severe anthropogenic contamination. Measures of contamination factor (CF) indicated severe and widespread heavy-metal contamination across all sites. Heavy Metal Release Percentage (HMR) indicated a vertical gradient in metal release, with the highest percentages of metals released within the topsoil (0-20cm), with attenuation occurring with depth. Overall, these results indicate that indiscriminate disposal of activity-specific wastes has degraded soil quality at the study sites and poses a threat to underlying groundwater resources. Enforcement of stringent waste management regulations, recycling at source, and phytoremediation of contaminated soils are recommended to mitigate further contamination.

Xenomas are distinctive hypertrophic host–cell lesions caused by intracellular parasites and represent a recurrent pathological finding in wild and farmed fish. Their presence has implications for fish health, diagnostic workflows, aquaculture productivity, and in some cases product quality and consumer acceptability. Despite this relevance, information on xenoma diversity, associated pathogens, and diagnostic practices remains fragmented across decades of literature. This scoping review synthesised available evidence on naturally occurring xenomas in fish, following PRISMA-ScR guidelines. Eligible sources included studies reporting clinical, pathological, or diagnostic information on xenomas in fish. Data were charted on host species and families, taxonomic identification of the aetiological agents, xenoma morphology, and diagnostic approaches. Across 114 publications published between 1968 and 2024, xenomas were reported in a wide range of teleost families and were attributed mostly to microsporidian infections, particularly species of Glugea, Loma, Spraguea, Pleistophora, and Microgemma, although myxosporean-associated cases (Kudoa, Myxidium, Nephrocystidium) were also documented. Light and electron microscopy were the most frequently applied diagnostic methods, whereas molecular techniques were used less consistently, with increasing use in the most recent decade. Macroscopic xenomas were typically described as whitish, rounded to oval, and well delimited, yet substantial morphological variation occurred across hosts and tissues. Overall, the review highlights major heterogeneity in pathogen identification and diagnostic pathways, underscoring the need for more standardised and integrative approaches.

Introduction Beverage intake is an important yet understudied contributor to blood pressure (BP) and proteinuria. This is particularly relevant in sub-Saharan Africa, where rapid shifts toward sugar-sweetened beverages (SSBs) and ultra-processed beverages, driven by affordability and aggressive marketing, are occurring alongside a high burden of Chronic Kidney Disease (CKD) within resource-limited health systems. Additionally, there are cultural differences within African populations that make beverage patterns in sub-Saharan Africa differ across populations and from Western cultures. Methods We conducted a cross-sectional analysis of 494 participants in the Diet, CKD, and APOL1 (DCA) Study cohort in West Africa. We assessed beverage consumption from 24-h dietary recalls and patterns using principal component analysis. We analyzed associations of beverage patterns with systolic BP (SBP), diastolic BP (DBP), and proteinuria using univariate and multivariable linear mixed-effects regression models. We adjusted for covariates, such as clinical site (random effect), socio-demographic factors, and lifestyle factors. Results We identified 4 unique beverage patterns: (i) SSB and Alcohol, (ii) Milk and Alcohol, (iii) SSB and Water without Alcohol, and (iv) Milk and Milk Products. No beverage patterns showed consistent association with SBP or DBP, and sensitivity analyses of individual beverages yielded null findings. In adjusted analyses, the Milk and Milk Products beverage pattern showed a positive association with SBP (Tertile 2 vs. 1: β = 5.61 mm Hg; 95% CI: 1.54–9.57) and a directionally consistent but not significant association in tertile 3 vs. tertile 1. An exploratory interaction suggested a stronger positive association of this pattern with SBP among individuals with diabetes. Conclusion The Milk and Milk Products beverage pattern may be associated with higher SBP in adults with CKD in West Africa, with a potentially stronger association among those with diabetes. Given that no associations remained significant after false discovery rate correction, these findings should be interpreted cautiously. Future studies are needed to confirm these findings and clarify their long-term implications for kidney and cardiovascular health.

This study evaluated the occurrence of ochratoxin A (OTA) in Turkish coffee and its potential health implications under current consumption patterns by analyzing 65 ground and roasted Turkish coffee samples collected across Türkiye. OTA contamination was detected in 53 samples (82%). Based on the mean OTA concentration, the Estimated Daily Intake (EDI) was calculated as 0.1403 ng/kg body weight/day, and health risk characterization was performed using the Margin of Exposure (MOE) approach in accordance with the European Food Safety Authority (EFSA) recommendations for chronic exposure assessment. MOE calculations enabled a refined characterization of health risks under realistic (0.5 cup/day), average (1 cup/day), and high (3 cups/day) consumption scenarios. The MOE values for carcinogenic (neoplastic) effects ranged from 34,450 to 206,847, all exceeding the EFSA reference threshold of 10,000 and indicating a low level of concern for carcinogenic risk associated with Turkish coffee consumption. For non-carcinogenic (non-neoplastic) kidney effects, MOE values ranged from 11,238 to 67,475 across the different consumption scenarios, all exceeding the EFSA reference threshold of 200, indicating a low level of concern for the general population. In conclusion, the findings demonstrate that Turkish coffee consumption does not pose an OTA-related carcinogenic or non-neoplastic health risk for the general population under current consumption patterns. Nevertheless, considering the widespread consumption of Turkish coffee, continued monitoring and strict implementation of control measures throughout the production chain remain advisable to ensure long-term consumer safety.

The ongoing care of individuals with Autism Spectrum Disorder (ASD) involves persistent physical demands that expose caregivers to significant risks of muscle and musculoskeletal disorders. However, how these risks are perceived directly influences pain recognition, attention to one's own physical limitations, and self-care practices. In this sense, this study aimed to analyze the perception of the risk of muscle disorders in the context of caring for individuals with ASD and its implications for caregiver health. This is a narrative literature review, qualitative in nature and descriptive-analytical in approach, based on studies published between 2010 and 2025, identified in the SciELO and Google Scholar databases, using descriptors related to caregiving, ASD, musculoskeletal disorders, and risk perception. The results indicate that the perception of the risk of muscle disorders among caregivers is generally fragile and constructed late, since pain and physical discomfort tend to be naturalized as an inherent part of the act of caregiving. It was observed that repetitive physical efforts, lack of technical guidance, and sociocultural factors contribute to the neglect of initial signs of bodily overload. In the care of people with ASD, the unpredictability of demands and the need for constant vigilance direct the caregiver's attention primarily to the person being cared for, reducing the perception of their own physical limitations. It is concluded that limited or delayed risk perception acts as a central element in the maintenance and chronicity of preventable musculoskeletal conditions among caregivers.

Highly sensitive and selective sensing of lead (II) ions in Paris polyphylla using fluorescence-enhanced sulfur quantum dots in deep eutectic solvent micelles.

Hypertensive urgencies (HU) and hypertensive emergencies (HE) have significant clinical and public health implications, yet standardized management strategies are lacking. To address this gap, the European Society of Hypertension (ESH) initiated the ESH-URGEM registry to assess the epidemiology, clinical characteristics, and management of HU and HE across Europe over 12 months. ESH conducted a prospective, observational study in emergency departments (EDs) of ESH-affiliated hospitals (ESH Excellence Centers). Adult patients (≥18 years) presenting with HU or HE were enrolled during ≥12-h shifts, once weekly, over 1 year. Among 115 169 ED visits, 998 cases (0.87%) were identified as hypertensive crises (HC): 77.3% HU and 22.7% HE. HE patients were older (mean age 70 vs. 66 years; P = 0.004) and had more comorbidities, including coronary artery disease, heart failure, and chronic kidney disease. The most frequent triggers were emotional stress (44.8%), acute pain (33.7%), and medication nonadherence (15.5%). HE commonly manifested as acute coronary syndromes (39.6%), pulmonary edema (33.8%), or neurological complications (14.1%). HE treatment most often included intravenous nitrates (60.5%) and diuretics (45.8%). Also, 35.1% of HU cases also received intravenous therapy. Only 18.9% of HE patients were admitted to coronary or intensive care units, while 16.1% of HU patients were hospitalized, frequently for nonhypertension-related conditions. Guideline-recommended assessments for target organ damage and cardiovascular risk estimation such as fundoscopy and albuminuria testing were rarely performed. This registry highlights critical issues in the ED management of HC and hypertension, including: underdiagnosis of chronic hypertension, insufficient admission of HE patients to intensive or coronary care units, overly aggressive treatment of HU, and underuse of fundoscopy and albuminuria screening. Addressing these deficiencies through guideline implementation, structured care pathways, and improved follow-up could enhance outcomes for this high-risk population.

Energy efficiency retrofits are central to climate policy, yet their implications for indoor environmental quality (IEQ) and occupant health remain underexplored. This study investigates IEQ outcomes following staged retrofits in Irish social housing, where achieving Building Energy Rating (BER) targets is the primary performance metric. Four dwellings, three retrofitted and one control, were monitored over six weeks during the heating season. Built in the 1980s, these homes represent the typical social and private housing stock of that era. Continuous measurements of carbon dioxide, temperature, relative humidity, and thermal performance were complemented by analyses of vapour pressure excess and ventilation rates. While all retrofitted homes achieved BER improvement targets, persistent IEQ challenges were identified. Elevated pollutant concentrations and increased condensation/mould risk occurred in the presence of inadequate ventilation. Thermal anomalies and cold bridging were associated with cavity wall insulation, whereas external wall insulation provided more stable surface temperatures and reduced moisture-related risks. These results underscore the complex interplay between retrofit measures, occupancy patterns, and ventilation performance. The study highlights the need for retrofit strategies that integrate energy efficiency with occupant health objectives. At scale, retrofit programmes risk embedding systemic vulnerabilities unless ventilation and moisture control are prioritised, with implications that extend to health, wellbeing, and long-term building resilience.

Prenatal depression is a prevalent mental health disorder that adversely affects maternal well-being and offspring health. Emerging evidence suggests that vitamin C (L-ascorbic acid), a key antioxidant, may influence this process through the regulation of DNA methylation (DNAm)-a critical epigenetic mechanism governing gene expression. This review summarizes current research on the role of vitamin C in modulating DNAm and explores its potential to mitigate the intergenerational impacts of prenatal depression. We analyze findings indicating that vitamin C may alleviate depressive symptoms and improve offspring health outcomes via epigenetic pathways. Furthermore, we highlight existing research gaps and propose future directions for investigation. By elucidating the interplay between vitamin C, epigenetic regulation, and prenatal depression, this article aims to provide novel insights for developing nutritional strategies to enhance maternal mental health and promote offspring well-being.

Rabies, a fatal zoonotic encephalitis, is rarely reported in elephants. To present the first confirmed case of rabies in a captive Asian elephant in Bihar, India, using both ante-mortem and post-mortem diagnostics and discuss its implications for wildlife conservation and public health. An 8-year-old female elephant exhibited acute neurologic signs including aggression, muscle spasms, anorexia and recumbency. Corneal smears and saliva samples were tested ante-mortem using the fluorescent antibody test (FAT) and a rapid diagnostic kit. Following the animal's death on Day 6, a post-mortem necropsy was performed, and direct fluorescent antibody (DFA) testing on brain tissues confirmed the diagnosis. Rabies antigen was detected in corneal smears (FAT) and confirmed in cerebellum and brainstem tissues (DFA). No bite history was evident. The elephant died on Day 6 post-onset. All personnel classified as exposed under WHO criteria through contact with infectious secretions or involvement in high-risk clinical or necropsy procedures received immediate post-exposure prophylaxis.

Municipal Urban Cleaners (MUCs) perform an essential yet hazardous work, but evidence on how to design Occupational Health and Safety (OHS) training that truly reflects their real-world barriers, risks, and learning needs remains limited. This qualitative study, conducted as part of the MUC-Training for Health initiative, explored barriers, occupation-attributed health implications, perceptions, and attitudes toward OHS, and training needs. Ten focus groups were held with 74 MUCs and their supervisors/managers across 5 European countries, and the data were analyzed using thematic analysis. Participants identified substandard working facilities, insufficient or unsuitable equipment, understaffing, inconsistent safety practices, limited knowledge of protective measures, and inaccurate information as major barriers. Both psychosocial and physical risks were frequently emphasized. Across all settings, tailored, practical, and motivating face-to-face training was viewed as essential. Designing effective OHS training requires a nuanced understanding of MUCs' daily realities, occupational risks, and preferences to ensure engagement, accessibility, and relevance.

Gentrification has traditionally been understood as a phenomenon associated with Anglo-American cities, where speculative real estate markets and visible displacement reshape urban neighbourhoods. By contrast, Sweden, long recognized for its welfare state, universal housing policies and social equity commitments, has often been assumed to be insulated from such disruptive urban transformations. This viewpoint challenges this assumption, describing the emergence of a “quiet gentrification” in Swedish cities such as Stockholm, Gothenburg and Malmö. Unlike overt market-driven processes, the shift unfolds through state-led redevelopment, housing privatization, and renovation-induced rent increases, disproportionately affecting low-income and disadvantaged communities. This viewpoint argues that these subtle, yet profound changes have important implications for public and population health, given the established links between neighbourhood deprivation, housing insecurity, and adverse health outcomes. Moreover, the viewpoint contends that Sweden is facing a critical paradox: that institutions designed to promote equity are to some extent contributing to socio-spatial inequalities. At the same time, the transformation presents opportunities to reframe urban governance through equity-oriented planning, housing justice, and interdisciplinary collaboration between urban planners and public health researchers. By recognizing and addressing the health dimensions of gentrification, policy makers can safeguard social sustainability and ensure that urban renewal enhances, rather than undermining, population health and equity.

Due to successful maternal antiretroviral therapy (ART), pediatric HIV infections have declined, leading to a growing population of children HIV-exposed uninfected (CHEU) in Sub-Saharan Africa. However, studies report poorer growth and development in CHEU versus children HIV-unexposed uninfected (CHUU), raising concerns about maternal HIV and ART exposure, particularly Tenofovir Disoproxil Fumarate (TDF). This analysis of data from the Gumba study compares growth trajectories, bone mineral accretion, and biochemical markers of growth and bone metabolism to age 18 months in Ugandan CHEU, exposed to maternal HIV and TDF-containing ART in utero and via breastmilk (n=85), and CHUU peers (n=80). The groups had similar weight and length 2 weeks after birth (WK2), but, despite higher exclusive breastfeeding rates, CHEU had slower growth by WK14 and ~0.5 kg lower body weight and fat mass by WK26. Growth faltering occurred in both groups from WK26, with widening differences: by WK78, 59% of CHEU were stunted compared to 33% of CHUU. CHEU had lower whole-body bone mineral content and bone area at WK14 and WK26 (Pinteraction: 0.03 and 0.0003 respectively), but similar whole-body areal bone mineral density before and after size adjustment, indicating accrued bone mineral was appropriate for their slower growth. There were no group differences in biochemical markers of growth or bone formation. However, CHEU had higher C-terminal telopeptide (CTX), a marker of bone resorption, at WK14 (group difference (95% confidence interval): +50.9 (24.1)%, P <0.001) coinciding with higher maternal CTX concentrations, and at WK78 (+45.6 (28.9)%, P <0.05). These findings suggest early onset growth deficits and altered bone metabolism in CHEU by 3 months of age, possibly linked to the TDF-containing ART initiated during pregnancy and/or disruptions in bone metabolism observed in their mothers. Further studies are needed to investigate the mechanisms and long-term implications for growth and bone health in CHEU.

Widespread vaccination for human papillomavirus (HPV) alters the landscape of cervical cancer (CC) risk, requiring adaptations to the CC screening program. To assess the cost-effectiveness and harm-benefit tradeoffs of adapting CC screening strategies on the basis of age at HPV vaccination. Individual-based mathematical modeling study. Published data. Hypothetical cohorts of women vaccinated in 7 different age groups (12, 13 to 15, 16 to 18, 19 to 21, 22 to 24, 25 to 27, and 28 to 30 years) with either bivalent or nonavalent vaccines in Norway. Lifetime. Extended health care sector (that is, including patient time and travel costs). HPV-based screening strategies that varied screening start age, interval, and number of lifetime screening tests. Incremental cost-effectiveness ratios, defined as the additional cost per quality-adjusted life-year (QALY) gained. "Preferred" (that is, cost-effective) screening for each age group was identified using a cost-effectiveness threshold of $55 000 per QALY. Harm-benefit tradeoffs were quantified as the ratio of colposcopy referrals to CC cases averted. For all vaccination age groups and both vaccines, less frequent screening with longer intervals between screening than the 5-year interval currently recommended was consistently preferred at the threshold of $55 000 per QALY, but the preferred strategy varied by age at vaccination. For women vaccinated between ages 12 and 24 years, preferred strategies involved screening every 15 to 25 years, resulting in screening 2 to 3 times per lifetime. Less frequent screening remained a preferred strategy under imperfect screening adherence and in scenarios that excluded bivalent vaccine cross-protection. The analysis did not address screening for unvaccinated women, who may benefit from herd immunity. A high-value screening program likely involves less frequent screening for women who were vaccinated against HPV by age 30 years. Strategies could be tailored on the basis of age at vaccination and type of HPV vaccine. Norwegian Cancer Society and National Cancer Institute.

Wars have multiple complex effects on population health. Countries suffer extensively from disruptions to their societies, economies, and environment. Understanding the pathways of disruption helps to adapt and mitigate the catastrophic effects of war. We used a previously published 12-dimensional framework on the health impacts of war to derive pathways of influence under three phases. The first phase, before overt aggression, includes economic sanctions, trade wars, and embargoes, often combined with covert military action and disrupted supply chains, infrastructure, and health services. The second phase of overt aggression has multiple direct and indirect effects on health: (a) morbidity and mortality; (b) population displacements with psychosocial implications; (c) opportunity costs from military expenditures often reversing economic growth and widening inequalities; (d) environmental degradation; (e) air and soil pollution from explosives; (f) destroyed infrastructure include housing, basic amenities, and health infrastructure; (g) destroyed arable land, deforestation, and loss of biodiversity; (h) and contamination of water sources. The third phase occurs during peace negotiations and when peace appears and consists of long-term effects. The latter includes transgenerational impacts on human well-being. Considering the wide health, social, and environmental implications of wars lasting for generations, we reiterate the call for an "end to all wars."

Microplastics (MPs) are pervasive environmental contaminants with significant bioaccumulation potential, posing a growing threat to global health through multi-organ toxicity. This review systematically synthesizes current knowledge on MPs-induced organ-specific damage and its systemic health implications. We detail the accumulation of MPs in major organ systems, including the liver, brain, lungs, kidneys, intestines, heart, and reproductive organs. Furthermore, we emphasize the critical role of inter-organ communication in amplifying toxicity, such as gut-liver axis-mediated hepatotoxicity and gut-brain axis-driven neurotoxicity. Emerging evidence on the transgenerational adverse effects of parental MPs exposure is also discussed. The core cellular and molecular mechanisms across these organs are examined, with a particular focus on oxidative stress, inflammatory activation, mitochondrial dysfunction, and programmed cell death. This review is distinct in its integrative approach, offering a novel perspective by synthesizing organ-specific pathologies with cross-organ communication networks and transgenerational effects, thereby providing a more holistic understanding of MPs’ systemic toxicity. Collectively, this review elucidates the exposure-organ damage correlation, analyzes the underlying pathogenic mechanisms, and aims to provide a scientific foundation for public health risk assessment and informed environmental policy formulation.

Air pollution is a growing threat to environmental and human health, particularly in densely populated and industrial regions such as Baja California (Mexico) and California (USA). This narrative review, informed by a structured literature search, explores the use of honey bees (Apis mellifera) as bioindicators of air quality and their relevance for environmental and public health surveillance within a One Health framework. A systematic literature search was conducted in PubMed/PubMed Central in May 2025, with no restrictions on language or study type, using MeSH terms and relevant keywords combined with Boolean operators. A manual search of key references was also performed. The selection process included duplicate removal, title and abstract screening, and full-text review using predefined inclusion criteria. Evidence indicates that bees accumulate atmospheric contaminants, including heavy metals, pesticides, particulate matter, and microplastics, across various matrices such as wings, pollen, and honey. These exposures trigger sublethal physiological responses, including oxidative stress and enzymatic alterations, paralleling early pathophysiological mechanisms in humans (e.g., IL-6 and TNF-α–mediated inflammation). Bee-based biomonitoring represents a cost-effective, sensitive, and scalable approach for identifying pollution hotspots and potential human exposure zones. The use of honey bees as environmental bioindicators can enhance early detection of pollution-related health risks, especially in regions with limited air quality infrastructure. Implementing standardized analytical protocols and fostering binational cooperation between Mexico and the United States could strengthen One Health surveillance networks. This integrative approach provides a practical model for linking environmental monitoring with preventive public health strategies.