Background: Oral health significantly influences overall well-being, health care costs, and quality of life. In Saudi Arabia, the burden of oral diseases, such as dental caries and periodontal disease, has increased over recent decades, driven by various lifestyle changes. Objective: To explore the associations between proximal (direct) and distal (indirect) influences that affect oral pain (OP) and self-rated oral health (SROH) status in the Kingdom of Saudi Arabia (KSA) using an adapted conceptual framework. Methods: This retrospective cross-sectional study used data from a national health survey conducted in KSA in 2017. The sample included adults (N=29,274), adolescents (N=9910), and children (N=11,653). Sociodemographic data, health characteristics, and access to oral health services were considered distal influences, while frequency and type of dental visits, tooth brushing frequency, smoking, and consumption of sweets and soft drinks were considered proximal influences. Path analysis modeling was used to estimate the direct, indirect, and total effects of proximal and distal influences on OP and SROH status. Results: The mean age of adult respondents was 42.2 years; adolescents, 20.4 years; and children, 10.58 years. Despite OP reports from 39% of children, 48.5% of adolescents, and 47.1% of adults, over 87% across all groups rated their oral health as good, very good, or excellent. A higher frequency of tooth brushing showed a strong inverse relationship with OP and a positive correlation with SROH (P<.001). Frequent dental visits were positively associated with OP and negatively with SROH (P<.001). Sweet consumption increased OP in adolescents (β=0.033, P=.007) and negatively affected SROH in children (β=–0.086, P<.001), adolescents (β=–0.079, P<.001), and adults (β=–0.068, P<.001). Soft drink consumption, however, was associated with lower OP in adolescents (β=–0.034, P=.005) and improved SROH in adolescents (β=0.063, P<.001) and adults (β=0.068, P<.001). Smoking increased OP in adults (β=0.030, P<.001). Distal influences like higher education were directly linked to better SROH (β=0.046, P=.003) and less OP (indirectly through tooth brushing, β=–0.004, P<.001). For children, high household income correlated with less OP (β=–0.030, P=.02), but indirectly increased OP through other pathways (β=0.024, P=.003). Lack of access was associated with negative oral health measures (P<.001). Conclusions: Among the KSA population, OP and SROH were directly influenced by many proximal and distal influences that had direct, indirect, or combined influences on OP and SROH status.

Background: In-flight medical emergencies (IMEs) might cause severe outcomes, including the deaths of passengers or aircraft diversion. Information is lacking regarding the incidence and characteristics of IMEs for most countries, especially in mainland China. Objective: To investigate the frequency, pattern, and risk factors of IME occurrence in mainland China. Methods: This population-based retrospective study examined electronic records for all IME reports from a top-three major airline company between January 1, 2018 and December 31, 2022, on the mainland of China. Outcome variables included the medical category of the IMEs, the outcomes of first aid, and whether the IMEs led aircraft to an unscheduled landing (flight diversion) or not. Results: A total of 299 IMEs and 28 deaths occurred among 447.2 million passengers, yielding an incidence and all-cause mortality rate of 0.67 (95% confidence interval [CI]: 0.60-0.75) and 0.06 (95% CI: 0.04-0.09) per million passengers, respectively. The incidence of aircraft diversion was 42.50 (95% CI: 37.02-48.12) per million flights. Cardiac symptoms (15.7%), seizures (11.7%), and syncope or presyncope (8.0%) were the most common medical problems and main reasons for aircraft diversion. The leading cause of deaths was cardiopulmonary arrest (64.3%), which significantly increased the risk of death (adjusted odds ratio [aOR]: 55.66, 95% CI: 5.79–554.21). The age of 50–64 years (aOR: 3.98, 95% CI: 1.56–10.18) and the long flight ≥ 4000 km (aOR: 16.40, 95% CI: 1.78–151.29) were significantly associated with a higher risk of diversion. Conclusions: The occurrence and deaths of IMEs are rare in mainland China. The establishment of a unified reporting and registration system for IMEs is of great value to reduce IMEs and deaths in the global community.

Background: Despite high prevalence of chronic hepatitis B virus (HBV) infection in adults in Lao People’s Democratic Republic (PDR), Lao healthcare workers (HCWs) were previously been shown to have low levels of protection against infection. Furthermore, the prevalence of hepatitis D virus (HDV; which increases disease severity in HBV infected individuals) is not known in Lao PDR. Objective: To estimate the exposure, and seroprotection against HBV as well as exposure to HDV in Lao healthcare workers from five provinces. Methods: In 2020, 666 HCWs aged 20-65 years from five provinces of the Lao PDR were recruited and sera were tested by Enzyme-linked immunosorbent assay (ELISA) to determine their HBV and HDV co-infection status. Results: HBV exposure, as indicated by the presence of anti-HB core (anti-HBc) antibodies, was 267/666 (40%) overall and significantly higher for HCWs from Oudomxay province (67.7%, aOR 3.69 [1.68-8.12] P=.001). The prevalence of hepatitis B surface antigen (HBsAg) was 36/666 (5.4%) overall and increased with age from 3.6% in those aged ≤ 30 years to 6.8% in those aged ≥ 50 years. Only 191/666 (28.7%) of participants had serological indication of immunization. We could find no evidence for HDV exposure in the current study. Conclusions: The study finds intermediate HBsAg prevalence among HCWs in Lao PDR, with no evidence of HDV coinfection. Notably, a significant proportion of HCWs remains susceptible to HBV, indicating a substantial gap in seroprotection against the disease.

Background: Hand, foot, and mouth disease (HFMD) is a highly contagious viral illness. Understanding the long-term trends of HFMD incidence and the epidemic characteristics under the circumstances of the vaccination program and the outbreak of the novel coronavirus disease is crucial for effective disease surveillance and control. Objective: To give an overview of the trends of HFMD during the past decades and evaluate the impact of the vaccination program and the COVID-19 pandemic on the epidemic trends of HFMD. Methods: Using official surveillance data from Yunnan Province, China, we described long-term incidence trends, severity rates of HFMD, and the variation of enterovirus proportion among cases. We conducted the Autoregressive Integrated Moving Average (ARIMA) of time series analysis to predict monthly incidences based on given subsets. The difference between the actual incidences and their counterfactual predictions was compared using absolute percentage errors (APEs) for periods after the vaccination program and the COVID-19 pandemic, respectively. Results: The annual incidence of HFMD fluctuated between 25.62 cases per 100,000 population in 2008 and 221.52 cases per 100,000 population in 2018 overtime. The incidence for males ranged from 30 to 250 cases per 100,000 population from 2008 to 2021, which was constantly higher than that of females. The annual incidence for children aged 1 to 2 years old ranging from 54.54 to 630.06 cases per 100,000 population was persistently higher than for other age groups. For monthly incidence, semiannual peaks were observed for each year. All actual monthly incidences of 2014-2015 fell within the predicted 95% Confidence Interval (CI) by the ARIMA(1,0,1)(1,1,0)[12] model. The average APE was 19% for a two-year prediction. After the vaccination program, the actual monthly incidence of HFMD was constantly lower than the counterfactual predictions (ARIMA(1,0,1)(1,1,0)[12]) with negative APEs ranging from -11% to -229% from January 2017 to April 2018. In the meantime, the proportion of EV71 among the enteroviruses causing HFMD decreased significantly, and the proportion was highly correlated (r=0.73, P=.004) with the severity rate. After the onset of the COVID-19 outbreak in 2020, the actual monthly incidence of HFMD consistently maintained a lower magnitude compared to the counterfactual predictions (ARIMA(1,0,1)(0,1,0)[12]) from February to September, with considerable negative APEs (ranging from -31% to -2248%). Conclusions: Vaccination alleviated severe HFMD cases and altered epidemiological trends. The HFMD may also benefit from non-pharmaceutical interventions (NPIs) during the COVID-19 epidemic. Further development of a multivalent virus vaccine is crucial for effectively controlling HFMD outbreaks. Policymakers should implement NPIs and emphasize personal hygiene for routine prevention when appropriate.

Background: The rapid rise of myopia worldwide, particularly in East and Southeast Asia, has implied environmental influences beyond genetics. To address this growing public health concern, the World Health Organization and International Telecommunication Union launched the MyopiaEd program. South Korea, with its high rates of myopia and smartphone use, presented a suitable context for implementing and evaluating the MyopiaEd program. Objective: This is the first study to date to evaluate the effectiveness and scalability of the MyopiaEd program in promoting eye health behavior change among parents of children in South Korea. Methods: Parents of children aged 7 and 8 years were recruited through an open-access website with a recruitment notice distributed to public elementary schools in Gwangju Metropolitan City. Beginning in September 2022, parents received 42 SMS text messages from the MyopiaEd program over 6 months. This digital trial used a mixed methods approach combining both quantitative and qualitative data collection. Pre- and postintervention surveys were used to assess changes in parental knowledge and behavior regarding myopia prevention. Additionally, semistructured interviews were conducted to explore participants’ experiences in depth and receive feedback on program design. Prior to the intervention, the MyopiaEd program design and message libraries were adapted for the Korean context following World Health Organization and International Telecommunication Union guidelines. Results: A total of 133 parents participated in this study, including 60 parents whose children had myopia and 73 parents whose children did not. Both groups reported high engagement and satisfaction with the program. Significant increases in knowledge about myopia were observed in both groups (P<.001). While time spent on near-work activities did not change significantly, parents of children with myopia reported increased outdoor time for their children (P=.048). A substantial increase in eye checkups was observed, with 52 (86.7%) out of 60 children with myopia and 50 (68.5%) out of 73 children without myopia receiving eye examinations following the intervention. Qualitative analysis indicated a shift in parents’ attitudes toward outdoor activities, as increased recognition of their benefits prompted positive changes in behavior. However, reducing near-work activities posed challenges due to children’s preference for smartphone use during leisure periods and the demands of after-school academies. The credibility of the institution delivering the program enhanced parental engagement and children’s adoption of healthy behaviors. Messages that corrected common misconceptions about eye health and provided specific behavioral guidance were regarded as impactful elements of the program. Conclusions: This study demonstrates the MyopiaEd program’s potential as a scalable and innovative digital intervention to reduce myopia risk in children. The program’s effectiveness provides support for broader adoption and offers valuable insights to inform future myopia prevention policies.

Background: China is a country with a high burden of hepatitis B (Hep B) but a low treatment rate. One of the key reasons for the low treatment rate is inadequate health literacy (HL) of the people, which may affect the awareness and knowledge of Hep B and the treatment, as well as the ability to actively and correctly seek medical resources. Objective: This study analyzed how HL contributed to scale-up of antiviral treatment of Hep B in China. We expect that the findings of this study could be used to inform resource allocation for health education and other approaches intending to improve the HL of the Chinese population, thus facilitating the nationwide scale-up of Hep B treatment, and contributing to the achievement of the 2030 goal in China. Methods: We used the two-stage least squares (2SLS) regression and took the mobile phone penetration as the instrumental variable (IV) to estimate the effect of improved HL on the number of 12-month standard Hep B antiviral treatment in China based on the panel data of 31 provinces from 2013 to 2020. Results: In the cross-sectional dimension, the higher the HL, the higher the number of treatment in the provinces in a specific year. In the time-series dimension, the number of treatment of a specific province increased with the improvement of HL over time. After controlling the time-invariant inherent attributes of provinces, the IV estimation with 2SLS regression based on the province fixed-effect model found that for every 1% increase of HL in each province, the number of treatment increased by 7.15% (0.0715= e0.0691-1, P< 0.001). Such an increase turned to 5.19% (0.0519 = e0.0506-1, P<0.001) for the subgroup analysis targeting the observation time from 2013 to 2019, by removing the data of 2020, when the COVID pandemic emerged. The study found no statistically significant effect of HL on Hep B treatment in the provinces with higher newly reported Hep B incidence, and lower GDP per capita. Conclusions: Our findings suggest that improved HL of the population is an important favourable facilitator for the scale-up of Hep B treatment in China. Building awareness and knowledge of Hep B and treatment can help understanding individual health status, forming a healthier lifestyle and appropriate healthcare seeking behaviours and healthcare service utilization, so that to be diagnosed and treated timely and appropriately. Enhancing resource allocation to improve overall HL of the population and Hep B specific messages to infected people would be a feasible and effective approach to scale up the treatment of Hep B in the developing settings with high Hep B disease burden but limited resources, and contribute to achieving the 2030 global goal for elimination of the public health threat of Hep B.

Background: Unobtrusive observation is a promising method for assessing physical activity and other well-being behaviors (eg, social interactions) in urban environments, without participant burden and biases associated with self-report. However, current methods require multiple in-person observers. Using video cameras instead could allow for more accurate observations at lower cost and with greater flexibility in scheduling. Objective: This research aimed to test the feasibility of using stationary wireless video cameras to observe physical activity and other well-being behaviors, and to assess its reliability and potential participant reactivity. Methods: Across 3 cross-sectional studies, 148 hours of video recordings were collected from 6 outdoor public spaces in Manchester, United Kingdom. The videos were coded by 3 researchers using MOHAWk (Method for Observing Physical Activity and Wellbeing)—a validated in-person observation tool for assessing physical activity, social interactions, and people taking notice of the environment. Inter- and intrarater reliabilities were assessed using intraclass correlation coefficients (ICCs). Intercept surveys were conducted to assess public awareness of the cameras and whether they altered their behavior due to the presence of cameras. Results: The 148 hours of video recordings were coded in 85 hours. Interrater reliability between independent coders was mostly “excellent” (ICCs>0.90; n=36), with a small number of “good” (ICCs>0.75; n=2), “moderate” (ICCs=0.5-0.75; n=3), or “poor” (ICCs<0.5; n=1) ICC values. Reliability decreased at night, particularly for coding ethnic group and social interactions, but remained mostly “excellent” or “good.” Intrarater reliability within a single coder after a 2-week interval was “excellent” for all but 1 code, with 1 “good” ICC value for assessing vigorous physical activity, indicating that the coder could reproduce similar results over time. Intrarater reliability was generally similar during the day and night, apart from ICC values for coding ethnic group, which reduced from “excellent” to “good” at night. Intercept surveys with 86 public space users found that only 5 (5.8%) participants noticed the cameras used for this study. Importantly, all 5 said that they did not alter their behavior as a result of noticing these cameras, therefore, indicating no evidence of reactivity. Conclusions: Camera-based observation methods are more reliable than in-person observations and do not produce participant reactivity often associated with self-report methods. This method requires less time for data collection and coding, while allowing for safe nighttime observation without the risk to research staff. This research is a significant first step in demonstrating the potential for camera-based methods to improve natural experimental studies of real-world environmental interventions. It also provides a rigorous foundation for developing more scalable automated computer vision algorithms for assessing human behaviors.

Background: Recently, the phase angle (PhA) emerged as an essential indicator of cellular health. Most studies examined its association with physiological conditions, such as sarcopenia, frailty, and physical function in older populations. Simultaneously, growing attention is being paid to the clinical relevance of segmental PhA for future applications. However, few studies explored the relationship between PhA, especially segmental PhA, and the psychological aspects of health, particularly cognitive function. Objective: We thus investigated the association between whole-body and segmental PhA and cognitive function in older adults. Methods: Individuals aged 65+ years were recruited from adult community groups residing in Busan, South Korea, through the 2022 BUs-based Screening and Assessment Network study (BUSAN study) of Pusan National University Hospital. Participants’ whole-body and segmental PhAs were measured using a bioelectrical impedance analyzer (BWA 2.0 Body Water Analyzer, InBody, California, USA), and cognitive functions (overall and subdomains, including memory, orientation, attention, calculation, and language) were self-reported using the Korean version of the Mini-Mental State Examination (K-MMSE). Multiple linear regression analyses were performed to examine these associations. Results: This study included 625 older adults aged 65–96 years (444 women, 71.0%). A positive association was observed between whole-body PhA and cognitive function (B=0.62, 95% CI: 0.16-1.08, p < .01). We observed significant positive associations between the PhA of the lower limbs (B=0.72, 95% CI: 0.38-1.06, p < .001) and cognitive function. Analysis of MMSE subdomains revealed that whole-body PhA was significantly related to memory (B=0.11, 95% CI: 0.00-0.22, p = .04), PhA of the upper limbs to orientation (B=0.29, 95% CI: 0.09-0.49, p = .01), and PhA of the lower limbs to orientation (B=0.24, 95% CI: 0.10-0.38, p < .001), attention and calculation (B=0.21, 95% CI: 0.06-0.37, p = .01), memory (B=0.14, 95% CI: 0.05-0.22, p = .001), and language functions (B=0.07, 95% CI: 0.01-0.12, p = .01). However, trunk PhA showed no significant association. Conclusions: Our findings bolster the emerging evidence of a significant positive correlation between whole-body PhA and cognitive function in our sample, with nuanced relationships observed across different segmental PhA and cognitive subdomains. Therefore, this study revealed that PhA could be a useful tool for screening or preventing cognitive decline in the general older population, offering substantial evidence for future interventional studies. Further research should delve into the mechanisms and assess targeted interventions that enhance regional physical function to support cognitive health in older adults. Further long-term investigation on these associations is warranted.

Background: COVID-19 has not only resulted in acute health issues but also led to persistent symptoms known as long COVID, which have been linked to disruptions in sleep quality. Objective: This study aims to investigate the associations between COVID-19, long COVID, and sleep disturbances, focusing on demographic, socioeconomic, and psychological factors among a Chinese population. Methods: This cross-sectional study included 1,062 participants from China. Demographic, socioeconomic, and clinical data were collected through online questionnaires. Participants were divided into two groups based on COVID-19 infection status: infected and non-infected. Within the infected group, participants were further categorized into those with long COVID and those without long COVID. Non-infected participants were included in the non-long COVID group for comparison. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), while depression and anxiety were evaluated using the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) scales, respectively.Multivariable linear regression was conducted to examine the associations between COVID-19, long COVID, and sleep quality, adjusting for demographic and psychosocial factors. Results: COVID-19 infection was confirmed in 857 participants, with 273 of them developing long COVID. No significant sex disparities were observed in infection rates (p=0.633). However, a marginal statistical difference was noted in the prevalence of long COVID among females (p=0.051). Age was significantly associated with both infection rates (p<0.001) and long COVID (p=0.001). Participants aged 60-70 were particularly vulnerable to both outcomes. Sleep latency was significantly longer in the infected group compared to the non-infected group (p<0.05), and total PSQI scores were significantly higher in the infected group (p<0.05). Those with long COVID exhibited significantly worse outcomes across all sleep metrics, including disturbances in subjective sleep quality, sleep duration, and daytime dysfunction (p<0.01 or p<0.001). Multivariable linear regression analysis showed no significant relationship between COVID-19 infection and overall PSQI scores (B=0.104, p=0.686). However, higher education levels were associated with better sleep quality (B=1.828, p<0.001), while lower income and work-related stress were associated with poorer sleep quality (p<0.001). Conclusions: Our findings indicate that long COVID is strongly associated with significant sleep disturbances, while initial COVID-19 infection shows a more moderate association with sleep issues. Long COVID-related sleep disturbances were exacerbated by factors such as age, income, and chronic health conditions. The study highlights the need for targeted interventions that address the multifaceted impacts of long COVID on sleep, especially among vulnerable groups such as older adults and those with lower socioeconomic status. Future research should utilize longitudinal designs to better establish the temporal relationships and causal pathways between COVID-19 and sleep disturbances.

Background: From medication usage to the time-of-day, a number of external factors are known to alter human body temperature (BT), even in the absence of underlying pathology. In select cases, clinical guidance already suggests the consideration of clinical and demographic factors when interpreting BT, for example decreased threshold for fever as age increases. Recent work has indicated factors impacting BT extend to environmental conditions including ambient temperature. However, the effect sizes of these relationships are often small, and it remains unclear if such relationships result in a meaningful impact to real-world healthcare practices. Objective: Temperature remains a common element underlying public health screening efforts. Leveraging the unique testing and reporting infrastructure developed around the COVID-19 pandemic, this manuscript utilizes a unique resource of daily-level statewide testing data to assess the relationship of ambient temperatures and positivity rates. As fever was a primary symptom that triggered diagnostic testing for COVID-19, this work hypothesizes that environmentally-mediated BT increases would not reflect pathology, leading to decreased COVID-19 test positivity rates as temperature rises. Methods: Statewide COVID-19 PCR testing data curated by the California Department of Public Health was used to obtain the daily number of total tests and positivity rates for all counties across the state. These data were combined with ambient temperature data provided by National Centers for Environmental Information for a period of 133 days between widespread testing availability and vaccine approval. A mixed-effects Beta-regression model was used to estimate daily COVID-19 test positivity rate as a function of ambient temperature, population, and estimates of COVID prevalence, with nested random effects for day of the week within unique counties across the state. Results: Considering over 19-millions tests performed over 4-months and across 45 distinct counties, adjusted model results highlighted a significant negative association between daily ambient temperature and testing positivity rate (P<.001). Results of the model are strengthened as, utilizing the same testing data, this relationship was not present in a sensitivity analysis using random daily temperatures drawn from the range of observed values (P=.52). Conclusions: These results support the underlying hypothesis and demonstrate the relationship between environmental factors and BT can impact an essential public health activity. As healthcare continues to operate using thresholds of BT as anchor points (i.e., ≥100.4 as fever) it is increasingly important to develop approaches to integrate the array of factors known to influence BT measurement. Moreover, as weather data are not often readily available in the same systems as patient data, these findings present a compelling case for future research into when and how environmental context can best be used to improve interpretation of patient data.