The goal of this study was to identify strategies and assess priorities to increase human papillomavirus (HPV) vaccination among unvaccinated young adults using a concept mapping approach.

The concept mapping process was conducted in two phases. In phase 1, eligible participants generated qualitative statements in response to a topic prompt. In phase 2, participants organised and grouped the statements by perceived similarity, and then rated each statement on a scale of perceived effectiveness. Multidimensional scaling and hierarchical cluster analysis were conducted to develop a conceptual map of the data.

This study was conducted at a university in the southwestern USA.

Eligibility criteria for participation included individuals (1) aged 18–26, (2) who had not received any dose of the HPV vaccine or were unsure if they had received the vaccine and (3) who were enrolled students at the study site institution. 24 participants engaged in the concept mapping process; five participated in phase 1 only, five participated in phase 2 only and 14 participated in both phases.

The 41 statements generated were organised into five cluster concepts: media and messaging, information and education, promotion, legal and accessibility. Accessibility was the highest-rated cluster for effectiveness followed by information and education. Exploratory trends across participant demographics were also identified. Differences in perceived effectiveness of the cluster concepts were observed by gender, race, political affiliation and vaccination status.

This study provides valuable preliminary insights into strategies and factors perceived influential in enhancing HPV vaccination from the perspective of unvaccinated young adults. Using concept mapping, multiple factors were identified that varied in their degree of perceived effectiveness across different groups. Future HPV vaccination interventions should consider multi-component elements to ensure their success and reduce the burden of HPV-related disease.

The literature examining direct-to-consumer (DTC) commercial virtual care has expanded rapidly over the past decade. Our objective was to synthesise the nature and range of evidence on DTC commercial virtual care.

Scoping review.

MEDLINE ALL, EMBASE Classic+Embase, CINAHL, HealthSTAR, PsycINFO, CENTRAL and grey literature sources.

We included original research studies published in English or French between 1 January 2016 and 30 April 2025 that assessed DTC commercial virtual care in all contexts and in all populations.

Screening titles and abstracts, and full-text manuscripts, and extracting data was done in duplicate. We analysed quantitative data using descriptive statistics and reported findings in tables. We provided a narrative summary of textual data.

After excluding duplicates, we identified 8055 studies for title and abstract screening; 691 articles for full-text screening; and 103 studies meeting our inclusion criteria. 32 studies (31.1%) reported financial ties to the virtual care industry. 67 (65.0%) studies were conducted in the USA. Studies were largely quantitative (87/103 (84.5%)) or mixed methods (8/103 (7.8%)) studies and used cross-sectional (85/95 (89.5%)) designs. Most quantitative studies were descriptive, reporting on quality of care, health outcomes, platform characteristics and patient views, with only 24 of the 95 quantitative studies (25.3%) including a control or comparison group. 18 of these 24 studies (75.0%) compared the quality of care, costs and/or utilisation to other models of care and reported variable findings. The rest compared patient characteristics. Few studies assessed clinician perspectives or addressed privacy-related ethical concerns.

Despite a large number of studies assessing DTC commercial virtual care, we have little insight into impacts on quality of care, health outcomes, health system utilisation and privacy-related ethical concerns. The financial ties with industry suggest that there may be bias in the body of research literature.

Genitourinary syndrome of menopause (GSM) is a prevalent condition among breast cancer survivors, often exacerbated by oncological treatments. Hormonal therapies are typically contraindicated in this population, necessitating effective non-hormonal interventions.

This randomised controlled trial aims to compare the effectiveness and cost-effectiveness of multimodal pelvic floor physiotherapy—comprising pelvic floor muscle training, non-ablative radiofrequency, therapeutic pelvic health education and the use of vaginal moisturisers—versus fractional CO₂ laser therapy combined with vaginal moisturisers in alleviating GSM symptoms in breast cancer survivors. Participants will be randomly assigned to one of the two intervention groups. Primary outcomes include measures of sexual function (assessed by the Female Sexual Function Index), subjective pelvic perineal pain intensity (measured with a 100 mm Visual Analogue Scale) and health-related quality of life (assessed by the Functional Assessment of Cancer Therapy-Breast), assessed at baseline, post-intervention and at 3, 6 and 12 months of follow-up. Statistical analyses will be conducted to evaluate the clinical efficacy and cost-effectiveness of the interventions.

The study protocol has been approved by the Ethics and Health Research Committee of the University of Alcalá (Reference: CEIP/2024/1/012). All participants will provide informed consent prior to inclusion in the study. Findings will be disseminated through peer-reviewed journals and conference presentations, and by engaging with patient associations and survivor groups through tailored materials.

NCT06721936.

Over 777 million COVID-19 infections have occurred globally, with data suggesting that 10%–20% of those infected develop Long COVID. Fatigue is one of the most common and disabling symptoms of Long COVID. We aim to assess the feasibility and safety of a new, remotely delivered, multimodal rehabilitation intervention, paced to prevent post-exertional malaise (PEM), to support the conduct of a future, definitive randomised trial.

We will conduct a randomised, two-arm feasibility trial (COVIDEx intervention vs usual care). Sixty participants with Long COVID will be recruited and randomised prior to giving informed consent under a modified Zelen design using 1:1 allocation with random permuted blocks via central randomisation to receive either the COVIDEx intervention or usual care. The 50-minute, remotely delivered, COVIDEx intervention will occur twice weekly for 8 weeks. All participants will wear a non-invasive device throughout their entire study participation, to track heart rate, blood oxygen saturation, steps, sleep and monitor PEM. The primary feasibility objectives will be recruitment rates, intervention fidelity, adherence, acceptability (intervention and design), retention, blinding success and outcome completeness. Secondary objectives will include refined estimates for the standard deviation and correlation between baseline and follow-up measurements of fatigue. Feasibility and clinical outcomes will be collected at baseline, 4, 8, 12 and 24 weeks. Qualitative interviews with participants and physiotherapists will explore intervention acceptability and barriers/facilitators.

Ethical approval for this study was obtained by the Western University Health Sciences Research Ethics Board (REB# 123902). Dissemination plans include sharing of trial findings at conferences and through open access publications and patient/community channels.

NCT06156176

This study sought to explore decision making among caregivers of children with cancer in Pakistan, one of the largest lower middle-income countries in the world.

Cross-sectional survey study

This study was conducted in Pakistan at Indus Hospital and Health Network in Karachi and Children’s Hospital of Lahore. Children’s Hospital of Lahore is a public sector hospital, and Indus Hospital has a foundation-based funding structure. Both are larger tertiary care centers. Over 2,500 new patients are seen at these centers annually, this accounts for almost 50% of all children with cancer in Pakistan

Eligible participants included bedside caregivers, defined as a parent or family member involved in communication with the medical team, of children with cancer (

Primary outcome measures included caregiver priorities and experiences related to communication including decision-making role, involvement of the paediatric patient and decisional regret.

Participants included 200 caregivers of children

Findings from this study highlight the importance of exploring preferences for decision making and empowering bedside caregivers while respecting cultural norms. In the Pakistani context, it may be specifically important to consider gender roles and the inclusion of extended family members. Future work should investigate paediatric patient involvement in diverse settings.

Forcibly displaced children and adolescents in the WHO European Region have high mental health needs, yet few manage to access mental health services and even fewer receive high-quality care. Addressing this gap is crucial, as inadequate mental health support has profound and lasting negative effects on individuals, families and communities. This scoping review aims to identify and synthesise the available evidence on the barriers and facilitators to quality mental healthcare for forcibly displaced children and adolescents in the WHO European Region.

Quantitative, qualitative and mixed-method studies that examine barriers and facilitators of quality mental healthcare for forcibly displaced children and adolescents in the WHO European Region will be included. Eligible participants include forcibly displaced children and adolescents, mental healthcare providers, policymakers and humanitarian actors in the mental health and psychosocial support field. We will adhere to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews) guidelines. A comprehensive search of databases, including Embase, Medline, PsycINFO, Scopus and Web of Science, will be conducted. We will systematically search for relevant studies published between January 2004 and December 2024. At least two reviewers will independently screen titles, abstracts and full texts. Data extraction will involve systematically charting relevant information from included studies. We will use the WHO Quality Standards for Child and Adolescent Mental Health Services as an analytical lens to map the evidence. Our study will provide a comprehensive overview of the barriers and facilitators to quality mental healthcare for forcibly displaced children and adolescents, and identify knowledge gaps and areas for potential quality improvement.

Ethical approval will not be required since this study will retrieve data from already published research and no new data will be collected. The results of this study will be published in a peer-reviewed journal and presented at international conferences in order to disseminate to academic and non-academic stakeholders such as non-governmental organisations, government bodies and community organisations involved in mental healthcare for forcibly displaced persons.

https://doi.org/10.17605/OSF.IO/AK74F.

Maternal respiratory syncytial virus (RSV) vaccination has been introduced to protect infants from severe respiratory infections. However, its uptake and impact on perinatal outcomes are unknown in the UK.

To evaluate uptake of RSV vaccine during pregnancy in a UK population.

This cross-sectional study was conducted at a tertiary maternity hospital in London. The participants included pregnant women who delivered between 1 September and 17 December 2024 (n=1157). For the analysis of vaccine uptake, the cohort included women eligible for vaccination who delivered beyond 28 weeks’ gestation and were at 36 weeks or less on 1 September 2024 (n=911). The main outcome measures were RSV vaccine uptake and its association with sociodemographic factors, perinatal outcomes including preterm birth (PTB), hypertensive disorders of pregnancy and stillbirth.

Of 911 eligible women, 19% (n=173) received the RSV vaccine during pregnancy. Uptake increased significantly from 4% in September to 32% in December (p

RSV vaccine uptake shows significant increases over time, with disparities in uptake by ethnicity and socioeconomic status. Further research is needed to increase vaccination rates, particularly in disadvantaged groups, and evaluate perinatal outcomes.

Although low-density lipoprotein cholesterol (LDL-C) is established as the primary cardiovascular disease (CVD) risk factor, some individuals with LDL-C within desirable limits still develop coronary artery disease (CAD). Lipoprotein(a) (Lp(a)) has emerged as a genetically determined independent risk factor for CVD. This study aims to investigate Lp(a) by determining its association with coronary artery stenosis severity, identifying its ethnic-specific genetic determinants and assessing its relationship with an energy-dense dietary pattern.

The PUTRA-CV study is a 3-year, multicentre, case-control observational study involving adult patients who have undergone coronary angiography. The primary outcome is the association between Lp(a) levels and the severity of angiographic CAD (assessed by Gensini or Syntax score). Secondary outcomes include the frequencies of Lp(a)-associated single nucleotide polymorphisms (SNPs) (rs10455872 and rs3798220) and the association between dietary patterns and Lp(a) levels. Lp(a) will be measured using a particle-enhanced immunoturbidimetric method, and SNPs will be genotyped using high-resolution melting. Dietary intake will be assessed using a validated semiquantitative food frequency questionnaire. Data will be analysed using SPSS. Descriptive statistics will be used to summarise population characteristics. Bivariate analyses will use chi-square (2), independent t-tests or Mann-Whitney U tests as appropriate. The independent association between Lp(a) and coronary artery stenosis severity will be determined using multivariable logistic regression, adjusting for confounders. Empirically driven dietary patterns will be derived using reduced rank regression, and their association with Lp(a) will be assessed. For genetic analysis, allele frequencies of the LPA SNPs rs10455872 and rs3798220 will be calculated and compared between cases and controls.

Ethical approval has been obtained from the ethics committees of the Ministry of Health Malaysia (NMRR ID-24-00877-2ID-IIR), Universiti Putra Malaysia (JKEUPM-2024–246), Universiti Teknologi MARA (REC/07/2024-OT/FB/2) and Universiti Malaya Medical Centre (MREC ID NO: 2 02 453–13692). The findings will be disseminated via peer-reviewed journals and conferences.

The ageing population in Europe is experiencing a significant rise in urinary incontinence (UI), which affects millions and incurs substantial healthcare costs. While conservative treatment (eg, behavioural strategies, pelvic floor exercises) can help manage UI, there is a need for evidence-based eHealth solutions to improve adherence and treatment outcomes. The KOKU Bladder project aims to co-create, develop and test an eHealth intervention to improve bladder health (BH) and UI in adults aged 50 and over.

Phase 1 will consist of the co-creation and technological development of the eHealth solution. First, a rapid review will be undertaken to identify eHealth solutions (ie, technologies and websites), including behaviour change techniques (BCTs) and elements of gamification for self-management of BH and UI in adults aged 50 and over. Also, a consultation with eight experts on BH/UI and/or BCTs will be conducted to explore recommendations for the new eHealth solution. The PROSECO framework will facilitate an assessment of the co-creation process. Phase 1 will additionally include the conduction of at least six focus groups, to be held in Kaunas (Lithuania), Catalonia (Spain) and Manchester (UK) to co-create the contents of the digital solution. Each focus group will include 10–12 community-dwelling adults aged 50+, with different physical conditions and continence status, as well as health professionals and other stakeholders. The information collected will be analysed thematically. First, we will hold three focus groups, one in each country, to find out the opinion of the participants. Once the focus groups are finished and the first version of the technological solution is created, participants will test it and provide feedback in three additional focus groups. Participants’ opinions will be taken into account to make modifications to the solution and co-create the final version. Gamification methods and the Honeycomb model for user experience will be followed in order to achieve a technological solution that is adequate for its target population.

Phase 2 will consist of a multicentre pilot study with a mixed method (quantitative and qualitative) approach to assess the feasibility and acceptability of the newly developed technological solution. At least 120 participants (40 per country) will be recruited and randomised into two groups: intervention (KOKU Bladder) and control (indirect health education). The primary outcome will be the severity of UI, according to the International Consultation on Incontinence Questionnaire-UI short form. Secondary outcomes will include quality of life (EuroQol 5-Dimension, 5-Level), life-impact related to UI (Incontinence Impact Questionnaire-7), lower urinary tract symptoms (Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index-10 (LURN SI-10)), International Consultation Questionnaire on Incontinence Bowel Score, Patient Global Impression of Improvement; levels of physical activity and sedentary behaviour (accelerometer), as well as satisfaction with treatment (Client Satisfaction Questionnaire (CSQ-8)). The latter, together with recruitment, adherence, retention, attrition and data loss, will be used for measuring intervention feasibility and acceptability. Statistical and clinical significance, as well as effect size, will be calculated.

The project is approved by the Research Ethics Committee of IRIS-CC approved the project on 9 January 2025 (code 24/095), the Research Ethics Committee of Hospital Universitari Arnau de Vilanova of Lleida on 27 January 2025 (CEIC-3201), the Commission on Research Ethics of Lithuania on 3 March 2025 (SMTEK-31) and the Research Ethics Committee 3 of the University of Manchester on 13 August 2025 (2025-23619-43258). Participation and withdrawal will be voluntary. Informed consent will be obtained from candidates willing to join the project. Study results will be disseminated via publication of scientific articles, presentations at professional workshops, webinars and congresses, as well as through social media and lay summaries for participants and the general public.

NCT06583733.

CRD42024597624.

To determine the prevalence and its associated factors of dual tobacco use among Malaysian adolescents in developing effective public health strategies.

Cross-sectional study.

This study analysed data from the National Health and Morbidity Survey (NHMS) 2022: Adolescent Health Survey (AHS), a nationwide cross-sectional survey conducted among secondary school students across Malaysia.

This cross-sectional study used data from the NHMS 2022: AHS, which included a representative national sample of Malaysian adolescents between the ages of 13 and 17. Using a two-stage stratified sampling approach, this study included participation from 33 523 adolescents from 240 schools nationwide.

The primary outcome was the prevalence of dual tobacco use among Malaysian school-going adolescents aged 13–17, defined as self-reported concurrent use of conventional cigarettes and e-cigarettes in the past 30 days. Secondary outcomes included the factors associated with dual tobacco use, such as sociodemographic characteristics, dual tobacco use behaviour, marital status of parents, tobacco use of parent or guardian, supervision, connectedness, bonding and respect for privacy of parent or guardian, along with peer support and truancy. A complex sample analysis was performed using SPSS V.27.0, maintaining a 95% CI and multiple logistic regression was applied.

Out of 33 380 Malaysian adolescents surveyed, 1728 (5.5%; 95% CI: 4.88% to 6.28%) reported dual tobacco use. The prevalence was significantly higher among males (9.7%; 95% CI: 8.54% to 10.98%) compared with females (1.4%; 95% CI: 1.15% to 1.70%) and highest among 17 years (8.6%; 95% CI: 7.05% to 10.41%), with a decreasing trend in younger age groups. Predominant vapers constituted the largest proportion (9.9%, 95% CI: 8.66% to 10.13%) among adolescents who reported dual tobacco use, followed by predominant smokers (6.2%, 95% CI: 5.53% to 7.06%), dual daily users (4.5%, 95% CI: 3.18% to 5.64%) and non-daily dual users (3.9%, 95% CI: 2.79% to 4.39%). Dual tobacco use was more prevalent among adolescents whose parents or guardians used tobacco (8.1%; 95% CI: 7.10% to 9.20%). Multiple logistic regression analysis suggested that significant predictors of dual tobacco use included older age (adjusted OR (AOR) for 17 years: 2.92; 95% CI: 2.19 to 3.89), male sex (AOR: 8.53; 95% CI: 6.78 to 10.74), ‘others’ ethnicity (AOR: 1.82; 95% CI: 1.40 to 2.35), predominant vapers (AOR 2.65, 95% CI: 1.96 to 2.72), separated or widowed parental status (AOR: 1.69; 95% CI: 1.42 to 2.02), parental or guardian tobacco use (AOR: 2.47; 95% CI: 2.08 to 2.94), lack of bonding (AOR: 1.79; 95% CI: 1.49 to 2.14), lack of privacy respect (AOR: 1.53; 95% CI: 1.29 to 1.81), lack of peer support (AOR: 1.65; 95% CI: 1.39 to 1.96) and truancy (AOR: 1.81; 95% CI: 1.55 to 2.10).

This study highlights a concerning prevalence of dual tobacco use (5.5%) among Malaysian adolescents, which is notably higher than the current prevalence of exclusive cigarette smoking (6.2%) and closely approaches that of e-cigarette use (14.9%). Compared with previous national surveys and international benchmarks, the prevalence of dual use among Malaysian youth appears to be rising and represents a significant public health concern. These findings underscore the urgent need for targeted prevention and control strategies addressing both conventional and emerging tobacco products in this population.