Rural Research Articles

Factors associated with type 2 diabetes control in hard-to-reach communities in Esmeraldas, Ecuador

Abstract Background The rising prevalence of type 2 diabetes mellitus (T2DM) and its detrimental effects on population health make it an urgent public health concern. Maintaining blood glucose control is crucial for avoiding complications; however, there are notable socioeconomic disparities in disease management, especially in low- and middle-income settings. We aimed to examine the factors associated with controlled fasting capillary glucose in a difficult-to-access rural setting of Esmeraldas, Ecuador, and to examine the role of social support in this context. Methods Between October 2020 and May 2022, we conducted a cross-sectional study of T2DM adult patients in Esmeraldas’ Eloy Alfaro health district. We collected data on socio-demographic and clinical patient characteristics using a questionnaire and measured Fasting Capillary Blood Glucose levels. We estimated the prevalence of controlled glycaemia and used logistic regression to calculate odds ratios (OR) with 95% confidence intervals. Results Only 18.1% (95%CI: 14.9-21.8) of the 476 study participants had controlled glucose levels, with a significantly higher percentage in men (28.2%) compared to women (13.8%). Participants reported moderate perceived social support (median=2.33, on a scale of 1 to 4), without significant impact on glycaemic control. Women in urbanised areas were more likely to have controlled glucose levels compared to those in rural areas (aOR=2.34, 95%CI: 1.23-4.44) after adjusting for family support. In contrast, unemployed and older men had non-significant trends towards better odds of achieving controlled fasting glycaemia. Conclusions The complex interplay of factors affecting diabetes management and glycaemic control highlights the need for targeted, context and gender-specific public health strategies to address diabetes disparities in vulnerable populations. Key messages • The majority of individuals with T2DM residing in the remote communities of Eloy Alfaro district in Esmeraldas (Ecuador) have uncontrolled glycaemia, showing notable gender-specific disparities. • Participants reported a moderate level of social support, with family as the most important source. Yet, this perceived support may not effectively overcome contextual barriers in T2DM management.

Inequalities in education in the COVID-19 pandemic: health and education professionals’ perspectives

Abstract Background Cycles of school closure and reopening during the COVID-19 pandemic, coupled with remote learning, led to concerns about increasing inequality in education that persist in 2024. The aim of this abstract, within a wider study of safe school reopening, is to explore health and education professionals’ perceptions of inequalities among students during the pandemic. Methods In 2021, online semi-structured interviews were conducted in 6 languages with education and health professionals. They explored the: 1-effect of the pandemic on schools/pupils/teachers; 2-reorganisation of schools; 3-experience of implementing infection control measures in schools; 4-intersectoral working; 5-important resources for keeping schools open. Interviews were transcribed verbatim and translated into English where needed. A deductive qualitative analysis was undertaken using the conceptual framework developed by the United Nations H6+ Technical Working Group on Adolescent Health and Well-Being. Domain 3 (safety and supportive environment) includes consideration of equality. Results 62 interviews were included in the analysis (22 health and 40 education professionals from 28 countries). Professionals perceived greater negative impact on education for specific groups of students. Those with chronic illness stayed out of school for longer than others. Good access to distance learning was difficult for students from rural areas (lack of internet/electricity), disadvantaged families (lack of electronic equipment) or larger families (less learning space at home). Conclusions Professionals perceived that school closures intensified the disadvantage experienced by certain groups of students, exacerbating inequalities in education. Targeted catch-up strategies are still needed. Key messages • School closure during the COVID-19 pandemic have exacerbated inequalities in education. • In future health crisis impacting schooling, targeted catch-up strategies would be needed for certain groups of students.

Determinants of the consumption of ultra-processed foods in the Brazilian population.

This article aims to evaluate the sociodemographic determinants of ultra-processed foods (UPF) consumption in the Brazilian population ≥ 10 years of age. The study used data from the personal and resident food consumption module of the Family Budget Surveys, grouping foods according to the NOVA classification of food processing. The classification and regression tree (CART) was used to identify the factors determining the lowest to highest percentage participation of UPF in the Brazilian population. UPF accounted for 37·0 % of energy content in 2017-2018. In the end, eight nodes of UPF consumption were identified, with household situation, education in years, age in years and per capita family income being the determining factors identified in the CART. The lowest consumption of UPF occurred among individuals living in rural areas with less than 4 years of education (23·78 %), while the highest consumption occurred among individuals living in urban areas, < 30 years of age and with per capita income ≥ US$257 (46·27 %). The determining factors identified in CART expose the diverse pattern of UPF consumption in the Brazilian population, especially conditions directly associated with access to these products, such as penetration in urban/rural regions. Through the results of this study, it may be possible to identify focal points for action in policies and actions to mitigate UPF consumption.

Stakeholders’ Perspectives on Rehabilitation Services in KwaZulu-Natal Province, South Africa: A Mixed-method Study

Background and Objectives: South Africa is committed to enhancing rehabilitation services by 2030 through the National Rehabilitation Policy and the United Nations Convention on the rights of persons with disabilities. However, limited research focuses on rehabilitation services in KwaZulu-Natal (KZN) Province, South Africa. This study aims to provide insights from stakeholders on rehabilitation services in KZN Province focused on infrastructure, referrals, human resources, and multidisciplinary practices. Methods: Using mixed methods, we conducted focus group discussions, interviews, and surveys involving 99 stakeholders, including rehabilitation practitioners, district and provincial managers, and social development representatives from eThekwini, AmaJuba, and King Cetshwayo in South Africa. Descriptive statistics and thematic analysis were used for quantitative and qualitative data. Results: Public institutions reported inadequate referral pathways (2.9 out of 5) compared to private institutions (3.4 out of 5). Acute rehabilitation referrals primarily targeted secondary or tertiary facilities. Disjointed pathways, a lack of protocols, delayed referrals due to various factors and insufficient staff were identified. Physiotherapists were disproportionally more prominent, while social workers, psychologists and bio-kineticists were scarce. Both public (93%) and private (73%) care exhibited high doctor-to-patient ratios. Rehabilitation service disciplines were limited and fragmented, especially in rural areas. Thirty-four respondents (81%) stated no designated rehabilitation services units in their respective institutions. Conclusion: Rehabilitation services, though present at all care levels in KZN, mostly begin at tertiary levels. Local-level rehabilitation is non-existent, with the public healthcare system relying on community rehabilitation workers. Referral pathways require standardization, especially at the local level. Enhancing primary healthcare’s rehabilitation focus by bolstering workforce recruitment can significantly improve multidisciplinary practices. Expanding intermediate care facility licenses can alleviate system strain on KZN’s public health sector.

Assessing cyberchondria and eHealth literacy differences in urban and rural China

Abstract Background and Objectives This study aimed to explore the association between cyberchondria and eHealth literacy in the general Chinese population, and to assess how this relationship changes between urban and rural residents. Methods Data obtained from a web-based, cross-sectional survey that evaluate cyberchondria and its impact on health in February 2024. The Cyberchondria Severity Scale - 12 item was used to measure the cyberchondria, while the eHealth Literacy Scale was used to evaluate eHealth literacy. Descriptive analysis was used to describe the background characteristics of the participants. Then, a multivariable linear regression model was then performed for urban and rural subsample to examine the relationship between cyberchondria and eHealth literacy, respectively, providing a comparative analysis between the urban and rural populations. Results A total of 634 individuals completed the questionnaire. The average age was 33.2 years (SD = 7.4), with approximately 50.3% (n = 319) being female. Urban residents made up 71.4% (n = 451) of the participants. The mean eHEALS scores for urban and rural residents were 31.9 (SD = 4.3) and 30.4 (SD = 4.2), respectively. The CSS-12 scores for urban residents were 40.3 (SD = 7.58) and for rural residents were 39.1 (SD = 7.2). Linear regression analyses showed a significant association between eHealth literacy and cyberchondria for urban residents (Beta = 0.30, p &amp;lt; 0.001), but age and education level had no significant impact. For rural residents, a statistically significant association between eHealth literacy and cyberchondria was also observed (Beta = 0.40, p = 0.002). Conclusions Overall, eHealth literacy consistently predicts cyberchondria severity in both urban and rural samples. Higher eHealth literacy is linked to greater cyberchondria, especially in rural areas. Future research should explore other potential mediators, including psychological factors, internet usage patterns, and access to healthcare services. Key messages • eHealth literacy strongly predicts cyberchondria severity in both urban and rural populations, with a notably stronger impact observed in rural settings. • Urban and rural differences highlight the need for customized digital health literacy programs to effectively address region-specific challenges and behaviors.

Initial experience with a 5G cellular network and robotic arm-based remote echocardiographic system in an all-comers setting

Abstract Background Echocardiography is the test-of-choice for the initial evaluation of many cardiac diseases and requires expertise that is often limited in rural area. Robotic arm-assisted remote echocardigram has been attampted for teleconsultation but was limited to heart failure patients(ref), primarily due to the network delay in telecommunication and the subsequent incoordination in robotic arm control. Purpose We aim to assess the feasibility and diagnostic accuracy of a 5G cellular network and robotic arm-based remote echocardiographic system in an all-comers setting. Methods 51 pts were enrolled from the outpatient cardiology clinic of our institute. All pts underwent standard comprehensive echocardiography on a 5G cellular network and robotic arm-based remote echocardiographic system (the robotic part was deployed at our hospital and the control part was located at another campus 20 kilometers away) (Figure 1)and a conventional echocardiographic platform (at our hospital) successively. The order in which patients were examined on the remote and conventional instruments was randomly determined. There was no interval between the two examinations, and examinations of the same patient were performed by experienced but different cardiologists, who were blinded to each other’s diagnosis. The doctor who used the remote system was also randomly allocated and had not been previously specifically trained. The exams were real-time and diagnoses were made right after the exams. Results Of the 51 pts, the image quality was sufficient for diagnosis in 50 patients (48% female, 40±18 years). 1 pt was excluded because some key views could not be obtained using the remote system (98% of exams successful). 17 pts had positive findings, including 10 with a primary diagnosis of valvulopathy (1 Barlow's syndrome, 1 bicuspid aortic valve and 8 less-than-moderate regurgitation), 2 cardiac surgery follow-ups (1 case of aortic valve replacement and septal myectomy, and 1 case of mitral valve replacement and tricuspid annuloplasty), and 2 hypertrophic cardiomyopathy (including 1 case of obstruction at papillary muscle level), 2 with abnormal left ventricular wall motion(including 1 case of apical mural thrombus) (Figure 2), and 1 with congenital heart disease (secumdum atrial septal defect). The main diagnosis was consistent in 98% of cases (papillary muscle level obstruction was missed in one case), using conventional echocardiographic findings as the standard. Time for image acquision using remote echocardiography was significantly longer than conventional one (24 minutes 36 seconds ± 4 minutes 52 seconds vs. 16 minutes 15 seconds ± 1 minute 54 seconds, p&amp;lt;0.0001, paired t-test). Conclusions Comprehensive echocardiographic exam with a 5G cellular network and robotic arm-based remote system is feasible with relatively good diagnostic accuracy.Figure 1Figure 2

A new digital model for Italian Integrated Home Care: strengths, barriers, and future implications

Abstract Issue/Problem After the COVID-19 pandemic, Italy’s National Health Service (NHS) is transforming by adopting telemedicine through its National Recovery and Resilience Plan, aiming to modernize healthcare delivery and ensure equity. In this plan Territorial Coordination Centers (COT) were designed to improve patient access and continuity of care. However, regulatory challenges hinder the widespread adoption of telemedicine. Our work describes the technical, structural, and operational aspects of the new Italian Integrated Home Care (IHC) digital model, addressing strengths, barriers, and future implications. Description of the problem The implementation of the IHC digital model faces multiple challenges. Italy’s poor technical infrastructure, especially in rural areas, hampers access to critical services. Resistance to change among rural systems and the elderly, coupled with low digital literacy, inhibits telemedicine adoption. Fragmentation in the NHS leads to resource disparities, particularly disadvantaging southern regions. Italy also grapples with a severe shortage of healthcare professionals, posing a threat to the model’s sustainability. Results The National Digital Health Agency enacts the IHC model by overseeing telemedicine services through a cloud-based protocol. Each Region provides “Basic Telemedicine Services”: healthcare professionals’ and patient teleconsultation, telemonitoring, teleassistance. Communication between services, infrastructures, and local health authorities is facilitated by a modular interoperability layer, ensuring data standards and quality. A national telemedicine dissemination portal will contain data on all telemedicine solutions provided. Lessons Clear communication is essential for telemedicine acceptance. COTs enhance coordination and management. Bridging the technology gap for disadvantaged groups, supporting frontline employees and addressing adoption factors is vital to overcome the challenges faced. Key messages • The National Digital Health Agency drives telemedicine services under the IHC model. Each region offers Basic Telemedicine Services, ensuring data standards, quality and interoperability of data. • Italy’s telemedicine adoption faces poor infrastructure, resistance and workforce shortages. Focusing on equity, healthcare workers support and bridging the technology gap will be key.

Did the COVID-19 Pandemic Affect Suicide Rates Differently in Urban and Rural South Korea?

Abstract Background The influence of the COVID-19 pandemic on suicide rates remains a subject of debate. Despite increases in suicidal ideation and attempts reported during the pandemic, several recent meta-analyses have not demonstrated corresponding rises in suicide rates. Given the potential for substantial regional and demographic variability in the psychological consequences of COVID-19-related restrictions, this study explores differential suicide rates in urban versus rural contexts within South Korea subsequent to the pandemic outbreak. Methods This investigation employed age-standardized suicide rates from two periods, 2015-2019 and 2020-2022, across 234 administrative divisions (152 urban, 82 rural). A difference-in-differences approach was utilized to evaluate the pandemic’s impact on suicide rates, segmented by urban and rural classifications. A linear regression model was developed to examine the interaction between location (urban/rural) and time period, controlled for annual variations, perceived stress, and health status within each locale. Results Analysis revealed higher suicide rates in rural areas compared to urban counterparts (β = 1.247, p = 0.003), although no significant changes were observed during the pandemic period itself (β=-0.425, p = 0.682). Furthermore, the interaction between urban/rural status and the pandemic period did not reach statistical significance (p = 0.367). Conclusions The findings indicate no significant contribution of the COVID-19 pandemic to increased suicide rates, irrespective of the urban or rural setting. Further research is warranted to dissect the impact of more direct socioeconomic factors on this dynamic. Key messages • There in no evidence of increased suicide rates during the COVID-19 pandemic in South Korea. • The impact of the COVID-19 pandemic on suicide rates did not significantly different between urban and rural areas.

The impact of healthcare worker migration in source countries: Colombia, Indonesia, and Jordan

Abstract Background To address domestic shortages, high-income countries are increasingly recruiting healthcare workers from low- and middle-income countries. This practice is much debated, yet empirical evidence is rare. This study fills this knowledge gap by reporting high-level stakeholders’ perspectives on health system impacts of international migration and active recruitment of HCWs in Colombia, Indonesia, and Jordan. Methods We used a multiple case study methodology, based on qualitative methods integrated with information available in the published literature. Results All respondents decried a lack of robust and detailed data as a serious challenge in ascertaining their perspectives on impacts of healthcare workersmigration. Stakeholders described current emigration levels as not substantially aggravating existing healthcare workforce availability challenges. This is due to the fact that all three countries are faced with healthcare worker unemployment grounded in unwillingness to work in rural areas and/or overproduction of certain cadres. Respondents, however, pleaded against targeting very experienced and specialised individuals. While observing little harm of healthcare worker migration at present, stakeholders also noted few benefits such as brain gain, describing how various barriers to skill enhancement, return, and reintegration into the health system hamper in practice what may be possible in theory. Conclusions Improved availability of data on healthcare workers migration, including their potential return and reintegration into their country of origin’s health system, is urgently necessary to understand and monitor costs and benefits in dynamic national and international health labour markets. Our results imply that potential benefits of migration do not come into being automatically, but need in-country supportive policy, such as favourable reintegration policies or programs targeting engagement of the diaspora.

Introduction to the digital health divide

Abstract This presentation will introduce the concept of digital health divide. It refers to inequalities in accessing and using digital technologies, leading to digital exclusion. Digital inclusion is defined by the United Nations as “equitable, meaningful, and safe access to use, lead, and design of digital technologies, services, and associated opportunities for everyone, everywhere”. Indeed, digitalisation is a worldwide phenomenon that permeates all levels of determinants of health inequities, leading to several populations being more adversely affected. Age, gender, education, and economic status are significant determinants amplifying the digital divide’s impact, with older individuals, women, less educated individuals, and economically disadvantaged populations bearing disproportionate effects. The relationship between the digital divide and health leading to the digital health divide can be direct and indirect. Here, access to the latest advancements in health technologies used along the health span (eHealth, mHealth) - from health prevention to patient care - can directly influence the user’s health. However, the lack of access to or use of existing technologies can also indirectly affect their well-being. A globally informative example of this indirect association is the lack of internet access in rural areas during the hard COVID-19 lockdowns, leading to the loss of a school year for many pupils. Indeed, school attendance and attainment are associated with better physical and mental health. Currently, there is a lack of operationalisation of the digital health divide, making it difficult to measure it accurately. The absence of a standardised evaluation and therefore evidence-based information hinders governments and organizations’ efforts to effectively address digital health divide.

Prevalence and sociodemographic correlates of COVID-19 vaccine acceptance in 20 European countries

Abstract Our study aimed to analyze the prevalence and socio-economic factors associated with COVID-19 vaccine hesitancy using individual data from representative national samples of 20 European countries. Data from round 10 of the European Social Survey, collected from May 2021 to September 2022, were analyzed. Prevalence (with a 95% confidence interval (CI 95%)) of participants’ intention to get vaccinated against COVID-19 was calculated. Crude differences in vaccine hesitancy proportions across sociodemographic strata were assessed using the Chi-square test. There were 31,771 adult participants (46.0 % men). The percentage of those hesitant (i.e. those who were not already vaccinated and intended not to be) toward the COVID-19 vaccine was 18.0% (CI 95% 17.6 - 18.4). Men and women were equally hesitant (18.0% vs. 18.0%, p = 0.93). There were differences between those under 40 (22.9%), adults between 40 and 59 (18.1%), and those over 60 (14.3%, p &amp;lt; 0.001). The unemployed had a higher proportion of hesitancy (32.9%) compared to the employed (17.4%), retirees (14.8%), and students (21.1%, p &amp;lt; 0.001). People living in rural areas have higher levels of hesitancy compared to those in urban areas (19.3% vs. 17.3%, p &amp;lt; 0.001). The estimates indicate that the highest prevalence of vaccine hesitancy was in Bulgaria (61.6%), Slovenia (40.4%) and Slovakia (30.7%), while Iceland (2.3%), Portugal (3.6%) and Italy (4.0%) had the lowest. Our study confirms high prevalence and high variability of hesitancy towards COVID-19 vaccines in Europe and identify groups for potential targeted interventions.

Configurational Design of a Hybrid System Based on an Air–Water Heat Pump and Biomass Boiler for a Rural Dwelling

Hybrid energy systems combine multiple energy sources and storage technologies to enhance performance and meet diverse energy needs. Hybrid heat pump systems are particularly suitable for heating and cooling buildings in rural areas. Air-source heat pumps have two well-known disadvantages during the coldest period of the year, when the building’s heating load is at its peak: the heat pump’s capacity is reduced and it needs to perform defrost cycles. A potential solution is to size the heat pump to cover only a portion of the peak load and to use a second heat generator in a hybrid heat pump system. There is a gap in the literature regarding the configurational analysis of hybrid heat pump (HHP) systems, particularly in terms of combining heat pumps and biomass boilers, and evaluating their efficiency, economic aspects, and environmental impact. Thus, in this research, a dynamic model of a HHP system, consisting of an air-to-water heat pump paired with a biomass boiler as a backup, is presented. Various configurations of the HHP system have been developed to evaluate key performance indicators, such as efficiency, emissions, operational costs, and other relevant factors. The findings of this paper indicate that the energy performance of HHP systems is significantly affected by the system layout, heat pump size, cut-off temperature, and the control algorithm used to activate the heat generators. Moreover, series operation of HHP systems is not only more efficient than parallel operation but also results in lower emissions and reduced operation costs. As expected, the energy loss associated with defrost cycles significantly impacts the overall performance of a hybrid system based on an air-source heat pump. Finally, the impact of the cut-off temperature on the key parameters in the configuration analysis was examined, and the optimal performance of the HHP system, in terms of minimizing operational costs and emissions, was depicted using a heat map diagram.

Bias in Evaluating Trends of Thyroid Cancer Incidence between Rural and Urban Populations

Abstract Background Diagnosis of thyroid cancer is based on fine needle aspiration cytology of thyroid nodules, based on nodules’ sonographic appearance and size. The American Thyroid Association published new guidelines for management of thyroid nodules in 2009 and 2015, where in some cases, only follow-up of thyroid nodules without any other procedure is recommended. This may lead to a decrease in diagnosed thyroid cancer cases. We studied thyroid cancer trends in Israel between the Arab population who are more likely to be living in rural areas, and the Jewish population who predominantly living in urban areas, and assesses whether these guidelines were reflected in the trends. Methods Data on new thyroid cancer cases were retrieved for Jews and Arabs separately from the Israel National Cancer Registry. Trends in age standardized incidence rates between 1996-2019 were evaluated for the two population groups using joinpoint regression model. Population group was included in the regression models to compare the trends between the two groups. We also studied trends in treatment of thyroid cancer at Rambam Health Care Campus. Results In both populations, age standardized thyroid cancer incidence rate increased between 1996 and 2013. However, between 2013-2019, Annual Percentage Change continuously increased in Arabs, but decreased in Jews. In the hospital study, we found that the Arab patients were 30% more likely to have surgery for small tumors. Conclusions The decrease in thyroid cancer incidence in the Jewish population compared with the Arab population may be related to differences in implementing the 2009 guidelines, which do not recommend fine needle aspiration cytology for very small tumors. We have found evidence that these guidelines were not followed to the same extent among Arab community clinics. This may explain the persisting increasing trend among Arabs, and could be one of the possible explanations for the differences in trends between the two groups. Key messages • Updated Guidelines regarding thyroid cancer diagnosis may be differently implemented by rural and urban populations. • Trends assessment may be biased due to differences in guidelines implementation.

Risk perceptions and risk behavior among children attending a road safety education program in Greece

Abstract Background Road Traffic Injuries (RTI’s) are a significant public health concern for children, placing a considerable burden on their well-being. Greece has consistently recorded high numbers of RTI’s among adolescents. Methods A university lab (LaHeRS, HMU) offers a road safety education program for primary and secondary students in Heraklion, Greece. The program consists of two parallel sessions (practical training using a driving simulator and activity-based risk-perception training) aimed at enhancing competencies in resilience to peer influence, empowering children to engage in informed decision-making and fostering hazard perceptions skills. The current presentation reports on 800 students who attended the program between October 2023 and April 2024. A structured questionnaire was used to collect data on student’s beliefs, attitudes and practices on road safety. Results A total of 800 students attended the program from the broader Crete Region. 50.5% were girls with a mean age of 12.6 (SD = 2.3) years, 60.9% secondary education students, 58% resided in rural areas. 33.9% reported using a motorcycle and 33.8% a car without a driving license. 23.3% reported experiencing a road traffic incident while commuting. 57.1% identified road safety as a problem in their place of residence, only 26.5% felt safe on local streets and only 9.1% considered other road users as watchful. Additionally, 66.8% highly valued helmet use as a precaution in short distances. 71.6% reported always wearing seatbelt in front seats and 68.9% thought seatbelts are important at back seats. 52.1% did not identify themselves as risk takers on the street, and only 22.5% felt competent in avoiding road risks. 32.9% admitted experiencing peer pressure while commuting. Conclusions Risk taking behaviors and low use of protective measures are prevalent among school aged children and need to be addressed through targeted road safety education programs and interventions. Key messages • Promoting safe behaviors and enhancing risk perception is critical among children and young adolescents. • Road safety education should be integrated into school curricula, starting from pre-school education.

The profile and aberrant driving behavior of juvenile traffic law violators in Greece

Abstract The majority of juvenile offenses in Greece are related to road traffic violations. Juveniles in Crete region are required to attend an educational program offered by LaHeRS lab (HMU), in collaboration with the Prosecutor’s Office as part of reformative measures. The current presentation reports on the profile and aberrant driving behavior of juvenile offenders who attended the program between 2023-2024. The Driver Behavior Questionnaire (DBQ) was administered to 181 juvenile offenders. Participants were males (97.8), with a mean age 18.6 (SD = 1.2), resided in rural settings (51.8%) and secondary students 60.7%. The mean age of the first offence was 15.8 (SD = 1.1, min 13 - max 18). Participants scored low in all DBQ scales (covered violations mean=6.1, sd = 7.5; unintentional violations mean=0.9, sd = 1.6; lapses mean=8.9, sd = 10.5). No statistically significant difference was found in DBQ scores between those who had and did not have a driver’s license, as well as between those from urban or rural areas. The three DBQ subscales significant correlated (p &amp;lt; .001). Among other risky behaviors, 54.9% reported exceeding the legal speed limit, 66.3% reported aggression feelings when driving behind a slow vehicle, 34.5% used mobile phones while driving, 17.7% reported alcohol use while driving. Surprisingly, 85.5% stated high confidence addressing risks on the roads. Key messages • Early interventions on aberrant driving behavior among adolescents is crucial. • Educational programs should be tailored to address the unique needs of juvenile traffic law violators.

Digital development and rural financial inclusion: Evidence from China

Digital technology has profoundly influenced the development of the financial sector and is of great importance to financial inclusion. This paper employs sub-provincial panel data from 2005 to 2019 to analyse the impact mechanisms of digital economy development on rural finance, exploring the impact of digitalization and overall digital literacy on rural finance. Our findings verify that digitalization has a positive contribution to rural finance, while digital literacy has a significant inhibitory effect on rural finance. This still holds after a series of robustness tests. Subsequent mechanism analysis reveals that digital technology benefits rural finance by optimizing industrial structure and promoting technological progress, while digital literacy accelerates urbanization, leading to the loss of rural labor and thus inhibiting rural finance. Heterogeneity analysis shows that the role of the digital economy in rural inclusive finance is more pronounced in the eastern and central regions. Additionally, higher levels of human capital, economic development, entrepreneurship, and digitalization will further enhance the impact of the digital economy on rural inclusive finance. This study offers a new pathway for the realization of financial inclusion and a theoretical reference for financial development in rural areas. Our empirical analysis also provides new perspectives and insights for the formulation of policies and measures to coordinate the development of various elements of digital finance and cope with the impact of the digital economy on rural finance.

Burden and sociodemographic disparities in cardiovascular mortality rates associated with hypercholesterolemia in united states: a nationwide county-level analysis from 2010 to 2019

Abstract Background Hypercholesterolemia (HC), a major public health concern, has seen a rising prevalence in US adults and globally, leading to increased morbidity and mortality. Despite well-established links between HC and cardiovascular mortality (CVM), the specific impacts and disparities at the population level remain poorly understood. Purpose This study aims to assess the independent effects of HC on VM across the overall US population, examining variations across sociodemographic groups and geographic locations. Methods Age-adjusted county-level CV rates (ACVM per 100,000 individuals) between 2010 to 2019 were obtained using the Center for Disease Control and Prevention (CDC) database. Using the CDC surveillance system, HC rates per county were assessed as the proportion of adults (+18) with high total blood cholesterol. County health ranking project databases were utilized to acquire county characteristics and demographics. Poison generalized estimating equation models were employed to assess incidence rate ratios (IRR). Results Of 307,045,656 residents who lived in 3142 US counties in 2010, a total of 8,157,580 (2.7%) CV deaths occurred between 2010-2019. In a fully adjusted model*, high HC rates associated with high ACVM (Standardized IRR: 1.049; Figure 1). In subgroup analyses, HC rates associated with a greater ACVM among counties with high minority (IRR: 1.070) versus low (IRR: 1.043), and in rural areas (IRR: 1.052) versus urban (IRR: 1.041). Notably, this association was prominent in areas with high poverty (Q4 vs. Q1) (IRR: 1.062 vs. 1.035; p interaction &amp;lt;0.001; Figure 1). Further, higher ACVM rates related to HC were observed in the South and Northeast U.S. regions. Conclusions HC rates are independently associated with high ACVM across most sociodemographic groups and locations, with the most pronounced effect in areas with high poverty levels and minority populations. These findings call on targeted interventions and policymaking aimed at mitigating the prevalence of HC and cardiovascular burden, particularly in vulnerable populations.

Regional variations in breast cancer screening uptake and its associated factors in Ghana

Abstract Introduction Timely identification of breast cancer is critical for successful treatment and prevention, reducing its burden. Despite its significance, breast cancer screening services in Ghana are underutilized, with considerable regional variations in uptake rates. We examined the regional differences in breast cancer screening uptake and its associated factors in Ghana. Methods We analyzed data from 15,014 women of reproductive age from the 2022 Ghana Demographic and Health Survey. Spatial mapping illustrated regional variations in screening uptake. Multilevel logistic regression was employed to examine the factors associated with breast cancer screening uptake. Results National breast cancer screening prevalence was 18.4%, with regional variations observed across the 16 regions. Eastern, Western, Brong Ahafo, and Greater Accra had the highest screening uptake. The likelihood of breast cancer screening was higher among women aged 45-49 (aOR = 3.59; 95% CI = 12.52, 5.12), Married women (aOR = 1.44; 95% CI = 1.17-1.77), Higher education, employment, health insurance, recent health facility visits, media access, and wealth index (middle: aOR = 1.45, 95% CI = 1.08, 1.94; richest: aOR = 1.91, 95% CI = 1.36, 2.70). Islamic and African Traditional affiliations decrease screening likelihood (aOR = 0.77; 95% CI = 0.63, 0.95; aOR = 0.46; 95% CI = 0.22, 0.97). Rural residence and specific regions (Ashanti, Oti, Savannah, Upper West) reduce odds, while living in North East increases odds (aOR: 1.86; 95% CI = 1.14-3.03). Conclusions Cost-effective breast cancer screening services are crucial, particularly in rural areas with geographical disparities. Culturally and religiously sensitive protocols are needed to address regional and religious differences. Expanding Ghana’s national health insurance to cover preventive measures like breast cancer screening is essential. Promoting awareness through conventional and digital platforms is crucial for advocating screening. Key messages • Addressing geographical and cultural differences crucial for equitable breast cancer screening in Ghana. • Expanding health insurance and raising awareness vital to promote screening access and reduce disparities.

Impact of public health expenditure on malnutrition among Peruvians during the period 2010-2020: A panel data analysis

Background The study analyzes the impact of public health spending on malnutrition among Peruvians, using data from the National Household Survey, the Central Reserve Bank of Peru, the National Institute of Statistics and Informatics and the Ministry of Economy and Finance from 2010. -2020. Previous studies have revealed the existing relationship of health spending with the reduction of malnutrition. Methods A quantitative approach is considered, with an explanatory type of research using panel data methodology considering the bidimensionality of the data, which allows quantifying this effect for the Peruvian case using the National Household Survey, data from the Central Reserve Bank of Peru, as well as information from the National Institute of Statistics and Informatics and the Transparency Portal of the Ministry of Economy and Finance in the period 2010-2020. Results The results show that public expenditure on health has a negative relationship with malnutrition; the rural sector has a positive relationship with malnutrition given the limitations present for access to adequate food. Similarly, the unemployment rate shows a positive relationship with malnutrition, given that being unemployed leads to a higher cause of malnutrition in the population, and the gross domestic product has a negative relationship with malnutrition, given that greater economic growth produces an impact on reducing malnutrition, with the greatest impact being on the rural population and the gross domestic product. Conclusions In the analysis period 2010-2020 in Peru, based on the panel data analysis, the impact of public health expenditure on reducing malnutrition is observed in 10 departments, achieving a reduction in malnutrition; while in 14 departments, this indicator has not been reduced.

Land covers associated with forest expansion hot spots in the Nepal Himalaya

Abstract Many regions of the Himalaya are experiencing forest expansion, signifying a widespread forest transition across this fragile mountain system. In the Nepal Himalaya, forest expansion is increasingly attributed to the narrative of cropland abandonment driven by rural outmigration. Understanding forest change dynamics as consequences of land use changes is critical in the context of rural mountain societies such as Nepal, which exhibit complex interactions between forest, agriculture, and livelihoods. We analysed forest gain in Nepal from 2000–2019 to inquire where and when forests have expanded and what land covers transitioned into forests. We integrated spatiotemporal analysis of national land cover maps and photointerpretation of very high resolution (VHR) imagery to improve analytical estimates. The Middle Mountain physiographic region experienced the strongest hot spots of forest gains relative to the high mountains or lowlands. Visual interpretation of VHR showed that 68.8% of forest gains since 2000 occurred on shrubland, and 26.5% on cropland. The dominance of shrubland-forest transitions implied that shrubland is an intermediate stage in a multi-decadal succession process, or a semi-permanent state such as arrested succession. Notably however, we also detected cropland-forest transitions occurring as fast as 6–10 years, indicating the potential for rapid forest succession if biophysical conditions permit. Thus, variations in land cover transitions to forests in the hills implicated multiple pathways of forest regeneration, reflecting a variety of spatiotemporally explicit drivers. Our results differ from previous studies because VHR image analysis accounted for land cover classification errors and improved land cover quantification. Further research on spatially explicit mechanisms and drivers of forest gain are needed to understand the synergies of forest, agriculture, and livelihoods to inform land use land cover policies that could be leveraged to enhance rural mountain livelihoods.