Cardiovascular and metabolic diseases account for an increasing share of morbidity and mortality globally. Folic acid supplementation has been linked to a lowered risk of stroke and some metabolic indicators due to its involvement in homocysteine and one-carbon metabolism and its role in the production of nitric oxide; however, the evidence on these associations is inconclusive. We searched MEDLINE, Embase, CINAHL, the Cochrane Library, and the Database of Abstracts of Reviews of Effects from inception to February 2024 for systematic reviews and meta-analyses investigating the associations of folate (dietary intake, supplementation, or blood concentrations) with any cardiometabolic outcome. We performed screening, data abstraction, and risk of bias assessment in duplicate, and assessed the credibility of the evidence using predefined criteria. We identified 113 unique associations from 49 reviews. The included syntheses mostly had low risk of bias of and provided pooled risk estimates from intervention trials or prospective cohorts. A larger volume of evidence was available for composite cardiovascular outcomes, coronary heart disease, and stroke compared to other outcomes. No association reached a convincing or highly suggestive level of credibility. Six directional associations and five null associations met the criteria for a suggestive level of credibility. Three dose-response relationships, all at suggestive levels of credibility, supported an association between higher dietary folate intake and a reduced risk of coronary heart disease and stroke. The available evidence on the association between folate status and cardiometabolic outcomes primarily focuses on secondary prevention of cardiometabolic diseases and substantially underrepresents low- and middle-income countries. More large-scale studies are warranted to validate a relationship between folate status and cardiometabolic events or indicators. Overall, the evidence landscape around folate and cardiometabolic diseases appears to be limited both in volume and scope. PROSPERO: CRD42021265041.

The shift from home to facility births has not translated into substantial mortality reduction in Pakistan. Therefore, we assessed whether health care facilities (HCFs) offer or have the capacity to offer critical maternal and newborn interventions. We aimed to propose tailored facility-based maternal and newborn care strategies, especially for the perinatal period. We conducted an HCF assessment in 275 public and private HCFs across 141 districts of Pakistan. We employed a comprehensive, quantitative tool to assess the availability and readiness of resources needed for critical maternal and newborn interventions, including Basic Emergency Obstetric and Newborn Care, Comprehensive Emergency Obstetric and Newborn Care signal functions, and Every Newborn Action Plan interventions. We analysed the data using Stata, version 13.0. A high proportion of facilities offered delivery services (93%), yet lacked specialised staff, especially paediatric surgeons (18%) and neonatologists (18.5%). Availability of neonatal nurses was also critically low, especially in Balochistan (19.4%) and Gilgit-Baltistan (22.2%). Clinical guidelines, especially for newborn resuscitation (8.8%), kangaroo mother care (KMC) (8.4%), and use of injectable antibiotics (10.9%), were largely unavailable. Notable regional disparities were observed, with Balochistan displaying the poorest service availability and readiness. Only 8.3% of facilities in Balochistan had newborn resuscitation equipment, and none had guidelines. To make a substantial impact on reducing maternal and newborn mortality, data-driven, equitable allocation of funds and resources to HCFs is crucial. The availability of skilled health care providers, basic newborn care, and low-cost, high-impact interventions, such as the optimal use of antenatal corticosteroids, KMC, newborn resuscitation, and injectable antibiotics, should be prioritised and scaled up.

Static body mass index (BMI) measurements overlook longitudinal weight dynamics. We examined the association between time in target range for BMI (TTR-BMI), which integrates stability and target attainment, and incident multimorbidity. We performed a landmark analysis using the English Longitudinal Study of Ageing and China Health and Retirement Longitudinal Study. We included participants aged ≥45 years free of multimorbidity. We calculated TTR-BMI via linear interpolation based on the trapezoidal rule to quantify continuous exposure to a target weight range. We used stratified Cox proportional hazards models to estimate hazard ratios (HRs) for incident multimorbidity. To address proportional hazards violations, we employed time-dependent coefficient analysis to examine temporal heterogeneity (≤3 years vs. >3 years). Lastly, we used negative binomial regression to assess secondary outcomes (disease accumulation). Among 6935 participants, there were 2483 incident cases. Higher TTR-BMI was inversely associated with multimorbidity risk in a dose-response manner. In fully adjusted models, each one standard deviation increase in TTR-BMI reduced risk by 6% (HR = 0.94; 95% confidence interval (CI) = 0.90-0.99). Time-dependent analysis revealed this protection was specific to the late (>3 years) follow-up phase (HR = 0.91; P = 0.003), with no significant effect in the early phase. Furthermore, higher TTR-BMI was associated with a lower rate of disease accumulation (incidence rate ratio = 0.97; 95% CI = 0.95-1.00, P = 0.046). We found that TTR-BMI is an independent predictor of incident multimorbidity. Maintaining a higher TTR-BMI serves as a protective factor against disease onset. Maximising time spent in a healthy weight range offers a precise, longitudinal target for primary prevention in older adults.

The gap between what primary healthcare (PHC) could achieve and what it currently delivers remains wide. Preventable child deaths remain a reality, particularly in underserved communities, and hard-won gains risk being reversed by diminishing attention. Making PHC work for children and adolescents requires clear, evidence-based standards, supportive health systems, and community-driven engagement. The WHO Pocket Book of Primary Health Care for Children and Adolescents and its mobile application bridge these pillars into one actionable strategy. Over the past decades, global child mortality has fallen by nearly 60%, largely due to services delivered through PHC. Yet millions of preventable deaths persist, reflecting weaknesses in governance, financing, workforce, and quality of care. Selective interventions contributed to earlier progress but narrowed the Alma Ata vision, limiting PHC to a small set of conditions. The Pocket Book and its app provide an integrated, evidence-based framework spanning birth to 18 years that operationalises comprehensive PHC. Country adaptation processes act as catalysts for systems change by identifying and correcting health systems' dysfunctions and engaging parents and caregivers as partners in care. This approach offers a practical pathway to halving child mortality again.

We address the growing concern of requests for post-submission and post-acceptance changes in authorship which our editorial team has observed in recent years. We emphasise that authorship order should be agreed upon by all contributors before submission, as all authors are expected to approve the final version of their manuscript and agree on their respective authorship positions. This editorial identifies seven categories of authorship change requests, ranging from adding or removing ordinary authors to modifying first or last authorship positions, or introducing group authorship. We consider some of these requests legitimate, such as adding author(s) who performed additional analyses based on reviewers' feedback or removing author(s) disagreeing with such revisions. We consider some others indicative of potentially concerning practices, particularly those involving changes to first or last authorship positions. We place this trend within a broader context of questionable research practices, including 'honorary' or 'gift' authorships driven by institutional power dynamics and the more recent emergence of 'paper mills'. These practices seem to be increasing in frequency with the rise of artificial intelligence (AI) and large publicly available data sets, which have lowered the barriers to producing large volumes of research of questionable value. Existing safeguards developed by organisations such as the International Committee of Medical Journal Editors (ICMJE) and the Committee on Publication Ethics (COPE) are helpful, but limited in their ability to prevent such practices. To address these challenges, the Journal of Global Health introduces the GUidelines for Authors on Requesting and DIsclosing changes in Authorship Nominations (GUARDIAN), which mandate full transparency whenever authorship changes occur after submission. Specifically, in the part of the standard 'acknowledgements' section at the end of each paper, where the mandatory 'authorship contributions' statement is typically detailed, the authors will be required to: (i) declare that the authorship byline has been changed since submission; (ii) disclose precisely what changes to the byline occurred between these two versions; (iii) provide an explanation for this change; and (iv) provide the final authorship contributions accordingly. Supporting documentation will also be archived by our editors and may be shared upon legitimate requests. The GUARDIAN aim to deter misconduct through transparency, protect early-career researchers from authorship pressure, and improve accountability in academic publishing. Together with our previously introduced Guidelines for Reporting Analyses of Big Data Repositories Open to the Public (GRABDROP) and other integrity initiatives, the GUARDIAN represent a proactive effort to safeguard credibility of authorships, while allowing legitimate adjustments whenever they are properly justified.

BackgroundAnxiety disorders impose a substantial burden on individuals and society, affecting mental health, quality of life, and health care systems. Virtual reality exposure therapy (VRET) has emerged as a promising treatment. However, existing meta-analyses often included participants without clinically diagnosed anxiety or related disorders. This study aimed to evaluate the efficacy of VRET in reducing anxiety, phobia, behavioural symptoms, and posttraumatic stress disorder (PTSD) among patients with anxiety-related disorders and PTSD.MethodsA systematic search was conducted across seven databases – CINAHL, Embase, PubMed, PsycINFO, Web of Science, Cochrane Library, and Medline-OVID. Eligible studies included randomised controlled trials (RCTs) examining the effects of VRET on anxiety-related outcomes. Data were pooled using a random-effects model with Comprehensive Meta-Analysis (version 3.0; Biostat, Englewood, NJ, USA). Effect size were calculated using Hedges’ g, and moderator analyses explored potential factors influencing the effect sizes.ResultsTwenty-six RCTs involving 1649 participants met the inclusion criteria. Overall, VRET demonstrated significant and clinically meaningful effects across multiple domains. It reduced phobia symptoms (Hedges’ g = −0.98; 95% confidence interval (CI) = −1.37, −0.60, P < 0.001), increased approach behaviour (Hedges’ g = 0.62; 95% CI = 0.11, 1.12, P = 0.02), alleviated anxiety symptoms (Hedges’ g = −0.61; 95% CI = −0.90, −0.33, P < 0.001), and mitigated PTSD symptoms (Hedges’ g = −0.51; 95% CI = −0.72, −0.30, P < 0.001). Moderator analyses indicated that shorter intervention durations (<60 minutes) were associated with larger treatment effects on anxiety and phobia. VR-based Cognitive Behavioral Therapy (VR-CBT) and VRET demonstrated large and significant effects for phobia.ConclusionsVRET effectively reduces anxiety, phobia, and PTSD symptoms while enhancing approach behaviour in clinically diagnosed patients. Its immersive and adaptable features make it a valuable exposure-based treatment tool. Further RCTs using advanced VR technologies and standardised protocols are needed to strengthen the evidence and optimise clinical application.RegistrationOpen Science Framework (https://doi.org/10.17605/OSF.IO/AD4M2).

Although obesity is a well-established risk factor for metabolic dysfunction-associated steatotic liver disease (MASLD), the impact of long-term weight trajectories on MASLD risk remains unclear. We aimed to examine the association between weight change trajectories across adulthood and the risk of ultrasound-defined MASLD. We analysed data from 4999 participants from the Healthy Happy Aging Community Cohort. Weight trajectories were assessed using body mass index (BMI) at age 25 years, ten years before baseline, one year before baseline, and at baseline. MASLD was defined as a median (MD) controlled attenuation parameter (CAP) of ≥274 dB/m and severe steatosis as a MD CAP of ≥302 dB/m via vibration-controlled transient elastography. There were 2247 (44.9%) patients with MASLD, of whom 1468 (29.4%) had severe steatosis. Compared with stable normal weight, sustained obesity (BMI ≥ 30 kg/m2 at all time points) demonstrated a strong association with MASLD risk (adjusted odds ratio (aOR) = 2.17; 95% confidence interval (CI) = 1.64-2.86), particularly for severe steatosis (aOR = 2.52; 95% CI = 1.74-3.66). The transition from non-obese to obese status was associated with a 2.5-fold increase in risk (aOR = 2.51; 95% CI = 1.81-3.48), with a more pronounced effect observed in men (P-interaction <0.05). Weight gain of ≥5 kg between ages 25-40 years showed particularly strong associations (aOR = 2.20; 95% CI = 1.70-2.86), while baseline severe obesity (BMI ≥ 35 kg/m2) remained the strongest independent predictor (aOR = 4.12; 95% CI = 2.70-6.29). Long-term obesity and weight gain, especially in early adulthood, significantly increase MASLD risk. Sustained obesity and progression to obesity were key risk factors, with severe obesity showing the strongest association. Early weight management is crucial for MASLD prevention.

Air pollution is an environmental stimulus that may predispose pregnant women to postpartum depression (PPD). However, the relationship between maternal exposure to air pollutants and PPD is still unclear. Understanding the magnitude of this effect is critical to developing public health policies that protect women's reproductive health. We searched all studies published in PubMed, Embase, Scopus, and Web of Science up to December 2024. The research protocol has been registered in PROSPERO. Test for homogeneity based on Cochran's Q and I2 statistics was calculated, and the restricted maximum likelihood random effect model was applied. We assessed the overall quality of pooled estimates, the influence of single studies on the meta-analytic estimates, sources of between-study heterogeneity, and publication bias. Of the 7881 unique publications identified, nine studies met the inclusion criteria for final review, involving 405 635 pregnant women. We comprehensively assessed the available data on air pollutants and PPD risk. Maternal exposure to particulate matter diameter ≤10 μm (PM10) increases the risk of PPD (pooled odds ratio (OR) = 1.08; 95% CI = 1.02-1.14, the whole pregnancy; pooled OR = 1.09; 95% CI = 1.03-1.15, the second trimester). Additionally, PPD was significantly associated with an increase of carbon monoxide (CO), nitrate ion (NO3-), and ammonium ion (NH4+). Maternal exposure to PM10, CO, NO3-, and NH4+ during pregnancy is associated with PPD occurrence, especially in the second trimester. Interventions to improve air pollutants may mitigate the maternal risks of developing PPD. Our findings support public health interventions and environmental policy reforms to protect maternal mental health. PROSPERO CRD42024626359.

The Government of Bangladesh's routine data capturing system of health care facilities doesn't adequately capture Robson ten group classification system (TGCS)-related variables required to monitor caesarean section rates. To address this gap, we developed an integrated intervention and assessed its impact on the Robson TGCS-related variables availability and completeness. We conducted implementation research in eight district hospitals in Bangladesh from January 2021 to June 2023, where the primary population was mothers who gave birth within the implementing health care facilities. Our integrated intervention included the introduction of Robson TGCS; development and implementation of 'Robson TGCS Report Form'; capacity development training; a multi-level monitoring and supportive supervision system; and collaborative stakeholders' advisory workshops and review meetings. The primary outcome was the percentage of availability and completeness of TGCS-related data across study phases. The study was divided into five phases. Phase one focused on developing the data-capturing system, while data collection began in Phase two. The average availability of six variables improved significantly (P < 0.001) from 76% (95% confidence interval (CI) = 75.7-76.8%) in phase two to 99% (95% CI = 98.8-99.1%) in Phase five. Similarly, data completeness for these variables increased significantly (P < 0.001) from 53% (95% CI = 52.2-54.2%) to 97% (95% CI = 96.2-97%). Consequently, the percentage of classified groups improved significantly (P < 0.001) from 55% (95% CI = 54.1-56.1%) to 97% (95% CI = 96.8-97.5%). The integrated intervention significantly improved data availability and completeness. Active engagement of stakeholders, including governmental bodies and technical experts from local and central levels, is crucial to ensure data quality for identifying, planning and implementing targeted interventions.

BackgroundChild anaemia remains a major public health concern in low- and middle-income countries, particularly among children aged <2 years. Given Tanzania’s slow progress towards addressing this challenge, despite the implementation of targeted national strategies, we aimed to examine the prevalence and associated factors of anaemia in children aged <2 years.MethodsThis cross-sectional study was based on secondary data from the Tanzania Demographic and Health Surveys (2004–2005, 2010, 2015–2016, and 2022). We applied individual sampling weights to ensure national representativeness and used descriptive analyses to estimate the prevalence of child anaemia, both overall and in specific age group distributions (6–23 and 24–59 months), by severity. Then, employed geographic information system mapping to visualise the regional anaemia prevalence among children aged <2 years. Finally, we conducted a multivariable logistic regression analysis to identify risk factors related to child anaemia and sensitivity analyses to check the robustness of our findings.ResultsWe included 25 590 children aged <5 years with available haemoglobin data, of whom 10 166 were aged 6–23 months. In 2022, 59.9% of children aged <5 years and 73.1% of those aged 6–23 months were anaemic. Using spatial analysis, we found that 16 of 31 regions experienced increased prevalence of anaemia, while the remaining 15 saw slight to moderate declines since 2015. In the multivariable analysis, being male (adjusted odds ratio (aOR) = 1.380; 95% confidence interval (CI) = 1.133–1.681), having low birth weight (aOR = 1.713; 95% CI = 1.076–2.727), being underweight (aOR = 1.438; 95% CI = 1.032–2.005), and not having health insurance (aOR = 1.768; 95% CI = 1.247–2.508) were factors significantly associated with increased risk of anaemia.Conclusions Child anaemia in Tanzania has stagnated between 2015–2022, failing to meet national targets. The burden has remained disproportionately high among low birth weight children and those aged <2 years, with those residing in coastal regions and high food production areas being especially vulnerable. Targeted interventions during the first 1000 days of life should be prioritised to break the intergenerational cycle of anaemia.