The research team, led by Mamo Feyissa Senbeta of Addis Ababa University together with colleagues Teferi Gedif Fenta, Kaleab Asres, and Tsige Gebre-Mariam, employed a qualitative descriptive design built around key informant interviews. Twenty-five healthcare professionals who provide direct care to HIV/AIDS and TB patients in selected facilities across Metekel Zone were interviewed, with conversations audio recorded, transcribed verbatim, and then systematically coded and thematically analyzed using the qualitative analysis software MAXQDA 2020. The choice of a qualitative approach is significant: rather than counting how many patients use herbal remedies, the study sought to understand the texture of professional experience, the reasoning behind counseling decisions, and the structural conditions that make herb-drug interactions so difficult to detect in practice.

Thematic analysis of the interviews surfaced six major themes capturing the range of professional encounters with herbal medicine use. Perhaps the most striking finding was the deep divide in what clinicians actually observed. Some healthcare professionals reported having no direct encounters with herbal medicine users at all, a gap the researchers attribute to patient non-disclosure or to the failure of routine clinical assessment to probe for concurrent traditional remedy use. Others, working in the same zone and caring for similar patient populations, described encounters spanning the full clinical spectrum: patients presenting with relief of symptoms after taking plant-based preparations, but also cases of severe toxicity, advanced AIDS, and even fatalities that clinicians linked to herbal medicine use alongside or instead of prescribed therapy.

This inconsistency in reported encounters is not merely a curiosity of qualitative research; it points to a structural blind spot in clinical practice. When patients conceal their herbal medicine use, whether out of fear of judgment, anticipation of disapproval, or simple belief that traditional remedies are not relevant to biomedical care, the pharmacological dialogue between clinician and patient breaks down. Antiretroviral therapy and anti-tuberculosis drugs are among the most interaction-prone medications in clinical use, with narrow therapeutic windows and dependence on metabolic enzymes such as those of the cytochrome P450 family. Plant constituents can induce or inhibit these pathways, alter drug absorption, or add hepatotoxic and nephrotoxic burdens, meaning that undisclosed co-use can silently undermine treatment efficacy or precipitate harm that is misattributed to disease progression.

The counseling behaviors reported by the healthcare professionals were equally varied, and this variability emerged as a central theme. Some clinicians advised patients against using herbal medicines entirely, taking a prohibitive stance grounded in the unknown composition and unquantified risk of most local preparations. Others adopted harm-reduction strategies, recommending that patients separate the timing of herbal medicine use from their antiretroviral therapy or anti-TB medications, a pragmatic attempt to reduce the chance of direct pharmacokinetic interaction. Still others suggested limiting herbal remedies to topical use only, confining application to the skin where systemic absorption and interaction potential are lower. The absence of a standardized counseling protocol means that a patient’s guidance may depend less on evidence than on which professional happens to be on duty.

Underlying all of these counseling positions was a consistent current of safety concern. The interviewed professionals expressed considerable worry about toxicity, herb-drug interactions, and the potential for herbal medicine use to drive disease progression, particularly when remedies substituted for or delayed effective biomedical treatment. These concerns are grounded in well-documented pharmacological realities. Herbal preparations are chemically complex mixtures whose active constituents, concentrations, and contaminants vary with plant species, harvest conditions, preparation method, and storage. Without quality control, dose standardization, or interaction studies, neither clinician nor patient can know what a given decoction contains or how it will behave in a body already metabolizing combination antiretroviral therapy and months of anti-TB chemotherapy.

Yet the study’s authors are careful to note that the healthcare professionals did not dismiss herbal medicine out of hand. The same clinicians who voiced safety concerns also acknowledged the powerful cultural, economic, and accessibility factors that drive patients toward plant-based remedies. In rural Ethiopia, traditional medical practitioners are embedded in community life, trusted across generations, and often geographically and financially more accessible than formal health services. Anecdotal claims of efficacy circulate through social networks and reinforce use. For patients managing the stigma, cost, and lifelong demands of HIV care, or the exhausting six-month regimen of TB treatment, herbal medicine can represent continuity with cultural identity, a perceived supplement to incomplete relief, or simply the most reachable option when clinics are distant and drug supplies uncertain.

The consequence of this collision between biomedical and traditional systems, the study concludes, is compromised integrated care. Inadequate assessment means clinicians rarely ask about herbal use; limited counseling means patients receive inconsistent or no guidance; and patient non-disclosure means that even motivated clinicians are working without essential information. The researchers recommend a multi-pronged response: improved communication between patients and providers, formal training of healthcare professionals on herbal medicine and its interaction potential, dedicated research into the safety and efficacy of commonly used Ethiopian remedies, and collaboration between the formal health system and traditional practitioners rather than mutual exclusion. Such collaboration, the findings suggest, could convert a hidden risk into a managed, monitored component of patient care.

The significance of the work extends well beyond Metekel Zone. The World Health Organization has long recognized that traditional and complementary medicine use is widespread across sub-Saharan Africa, particularly among people living with HIV/AIDS, and that the evidence base for safety in combination with antiretroviral therapy remains thin. Studies of this kind, which capture the lived experience of providers rather than simply surveying prevalence, are essential for designing interventions that clinicians will actually adopt. The Ethiopian context adds urgency: with one of the largest HIV-positive populations in the region and an expanding rural health infrastructure, the country is well positioned to pioneer models of integrated care that formally acknowledge, assess, and counsel on herbal medicine use rather than pretending it does not exist.

Funded in part by the German Academic Exchange Service and Germany’s Federal Ministry of Education and Research through the Tri-Sustain Project, and conducted under the ethical approval of Addis Ababa University’s School of Pharmacy, the study offers a candid portrait of a health system negotiating between two medical worlds. Its message to the global health community is direct: wherever antiretroviral therapy and tuberculosis treatment meet deep traditions of plant-based healing, patient safety depends on asking the right questions, training providers to answer them, and building bridges to the traditional practitioners that patients already trust. Until then, the most dangerous ingredient in a rural Ethiopian patient’s treatment regimen may be silence.

Subject of Research: Healthcare professionals' experiences with herbal medicine use among HIV/AIDS and tuberculosis patients in rural Ethiopia

Article Title: Experiences and perspectives of healthcare professionals on herbal medicine use among HIV/AIDS and tuberculosis patients in Metekel Zone, northwest Ethiopia: a qualitative descriptive study

Article References: Senbeta, M. F., Fenta, T. G., Asres, K., & Gebre-Mariam, T. (2026). Experiences and perspectives of healthcare professionals on herbal medicine use among HIV/AIDS and tuberculosis patients in Metekel Zone, northwest Ethiopia: a qualitative descriptive study. BMC Complementary Medicine and Therapies. https://doi.org/10.1186/s12906-026-05624-8

Image Credits: AI Generated

DOI: 10.1186/s12906-026-05624-8

Keywords: herbal medicine, HIV/AIDS, tuberculosis, Ethiopia, healthcare professionals, herb-drug interactions, antiretroviral therapy, qualitative research, traditional medicine, patient safety, Metekel Zone, integrated care

The research team, led by Johanna Johansson together with Caroline Fischl and Susanne Gustafsson at Jönköping University, conducted semi-structured interviews with fourteen occupational therapists recruited through purposive and network sampling designed to capture geographic variation across the country. Each interview lasted between 24 and 55 minutes, averaging 46 minutes, and followed an interview guide built around the Occupational Therapy Intervention Process Model, a framework that structures the therapist’s work into phases emphasizing the therapeutic relationship and collaboration with the patient. The transcribed material ran to 117 A4 pages and was analyzed using systematic text condensation, a qualitative strategy in which meaning units are identified, coded, grouped, condensed into artificial quotations, and then recontextualized against the original transcripts to ensure the participants’ voices remain intact.

The analysis converged on three overlapping domains through which the therapists organized their thinking: telehealth considered through the lens of the patient, through the lens of their own profession, and in relation to the surrounding context. Within the patient-centered domain, a striking ambivalence emerged around energy. For patients with stress-related illness or fatigue, telehealth conserves resources by eliminating travel and preparatory effort, allowing rehabilitation to begin earlier than an in-person visit would allow. Yet the therapists also described video meetings as potentially draining in their own right, noting that the blue light of screens, the association of computers with workplace performance pressure, and the sheer cognitive load of mediated communication can tax patients in ways a quiet clinic room does not.

Accessibility was the strongest argument in favor of the technology. Therapists reported that telehealth allowed patients to connect from home or even their workplace, saved time for relatives, reduced cancellations, and made group interventions feasible for so-called highly sensitive patients who otherwise spend energy reading the moods of others in a shared room. But preferences told a more complicated story. Most patients, the therapists observed, still prefer to meet in person, and few ever ask for a digital appointment, a pattern one participant called quite odd given the assumed demand for remote services. The therapists admitted their own preconceptions had been overturned: older patients, whom they expected to resist technology, often accepted telehealth willingly, while some patients in their thirties insisted on physical meetings, and patients with neuropsychiatric problems generally did not choose the digital route despite expectations to the contrary.

The professional lens exposed the deepest tensions. Occupational therapy rests on two pillars that telehealth strains: the therapeutic relationship and the performance analysis, the structured observation of a patient doing real activities in a real environment. Building trust through a screen proved slower, and for some therapists impossible, because body language is harder to read, eye contact is compromised, the reassuring gesture of a hand on a shoulder vanishes, and the small talk that lubricates human connection simply disappears in sessions that feel permanently on and off. Observation fared somewhat better. The therapists saw genuine opportunity in virtual home visits, which let them glimpse the patient’s actual living environment, something organizational structures had long prevented. Still, they worried that patients control what the camera shows, act less naturally when they know they are being watched, and that the crucial interplay between person, environment, and activity can be invisible in a framed video feed.

Hands-on elements of the profession proved the hardest to translate. Cognitive assessments, joint walks, ergonomic demonstrations, and hand evaluations that require the therapist to feel and grasp the patient’s hand resist digitization entirely. Some therapists managed to mail assistive devices such as orthoses to patients’ homes, but they described the risk of rehabilitation delays and the difficulty of teaching device use remotely, and others judged remote prescription impossible without direct demonstration. Even the creative scaffolding of therapy, writing with pen and paper, drawing schedules, sorting needs on a whiteboard, loses something on screen; as one therapist explained, writing by hand forces both patient and therapist to slow down in ways that benefit the work. The therapists also recognized that their own attitudes, from self-described pioneers to self-described reactionaries, shaped whether they experienced telehealth as liberation or loss.

The contextual domain revealed that the barriers are not merely technical but structural and political. All participants reported good access to equipment on their side, yet patients often had to use smartphones with small screens, lacked the electronic identification some platforms demand, or suffered unstable internet connections. Platforms showed inconsistent screen displays, made document sharing insecure or impossible for paper-based self-assessments, and forced therapists to guard against other patients’ data appearing on screen. Regionally, management actively promoted telehealth, and some therapists felt real pressure to match private digital providers, even as their immediate supervisors insisted that patient needs must guide practice. This dissonance matters because person-centred care, by definition, requires adapting services to individual needs, preferences, and resources, and a top-down push toward digital delivery risks overlooking exactly those individual differences.

The workload question cut against the efficiency narrative that often justifies digitalization. Therapists described double booking systems, more administration, fewer pauses, and heavier concentration demands during screen-based sessions, with one noting bluntly that although she could save time, she did not take on two patients instead of one. Those who used telehealth heavily found themselves teaching colleagues, adding further burden, while others lacked adequate training altogether. The study’s authors are careful to note that they did not set out to measure whether performance analysis through telehealth is clinically inferior; rather, they mapped how therapists justify their choices. Even so, the findings expose a clear knowledge gap about how the quality of observation-based assessment can be maintained across different modes of service delivery, a question the authors flag as a priority for future research.

The significance of the study extends well beyond Sweden. Most prior telehealth research in occupational therapy has been conducted outside Europe, much of it spurred by the pandemic-era scramble to keep services running, and this investigation is the first to document therapists’ reasoning within Swedish primary care specifically. Its central conclusion is measured rather than polemical: conventional occupational therapy is not always feasible through telehealth, so realizing its full potential will require genuinely new ways of working, not merely transplanting old routines onto new platforms. The therapists uniformly insisted on retaining in-person meetings while embracing further developed telehealth as a valuable complement, one that can extend access, enable environmental observation, and support continuity for patients who cannot travel. For policymakers racing toward integrated, person-centred care, the message is that the digital transition will succeed only if it bends to the grain of the profession’s craft, and to the very human preferences of the patients it serves.

Subject of Research: Occupational therapists' reasoning about telehealth use in Swedish primary care

Article Title: Telehealth within occupational therapy in primary care settings – an interview study

Article References: Johansson, J., Fischl, C., & Gustafsson, S. (2025). Telehealth within occupational therapy in primary care settings – an interview study. Scandinavian Journal of Occupational Therapy, 32(1), Article 2611542. https://doi.org/10.1080/11038128.2025.2611542

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2611542

Keywords: telehealth, occupational therapy, primary care, digitalization, person-centred care, telerehabilitation, integrated care, Sweden, qualitative interviews, therapeutic relationship, remote OT, within

The review, registered prospectively on PROSPERO and updated through repeated searches in June 2024, April 2025 and May 2026, cast a deliberately wide net. The researchers included quantitative intervention studies involving adults with longstanding and severe eating disorders, with no restrictions on diagnosis, type of intervention or treatment setting. After screening, they identified seventeen main empirical studies, reported across twenty publications, together with eight additional case reports or case studies. The dominant participant profile was female, and the dominant diagnosis was anorexia nervosa, reflecting the composition of the severe and enduring eating disorder population as it presents in specialist services. Crucially, most of the included studies reported real-world clinical data drawn from actual treatment services rather than from tightly controlled trial environments, which gives the synthesis an unusually strong ecological validity even as it exposes the fragility of the underlying evidence base.

The interventions examined spanned the full breadth of modern practice. Specialist inpatient treatment programs, high-calorie re-alimentation protocols, integrated pathways built around enhanced cognitive behavioral therapy, standalone outpatient care, digital and virtual transition support, pharmacological treatments, neuromodulation and even neurosurgery all came under scrutiny. Yet despite this breadth of therapeutic activity, the review found only two level II randomized controlled trials in the entire literature. One of those trials tested whether adding a low-intensity digital self-management program after intensive treatment could sustain recovery, and found no added benefit. The other, conducted in a small inpatient sample of patients with eating disorders and comorbid post-traumatic stress disorder, reported preliminary benefits from adjunctive infra-low frequency neurofeedback. The scarcity of randomized evidence for one of psychiatry’s highest-morbidity populations is itself one of the most striking findings of the review.

Against that limited trial evidence, the level III cohort studies told a more coherent story. Specialist inpatient treatment and intensive integrated care pathways were consistently associated with improvements in body mass index, eating disorder psychopathology, broader psychological symptoms, day-to-day functioning and, where it was assessed, quality of life. The clearest signal of benefit, the authors report, emerged from integrated pathways that combined collaborative psychological treatment, weight restoration into the normal range, and continuity of care across different levels of the health system, from inpatient admission through to supported outpatient follow-up. In other words, it was not any single therapeutic ingredient but the combination and the continuity that appeared to drive recovery in this hardest-to-treat group.

Perhaps the most consequential clinical insight from the synthesis concerns what does and does not predict outcome. Duration of illness, long treated as a proxy for hopelessness, was not a consistent predictor of how patients fared. What mattered far more was discharge body mass index within the healthy range, which was associated with good outcomes at follow-up. That single observation carries an enormous practical weight: it reframes the therapeutic goal from simply managing an incurable condition toward actively achieving and maintaining physiological restoration as the foundation for psychological recovery. Standalone outpatient treatment and low-intensity digital transition support, by contrast, showed only limited benefits in this population, suggesting that severely unwell adults may require more intensive, structured and supervised care than routine community services typically provide.

The less conventional arms of the evidence base were far less encouraging. Studies of pharmacological interventions, neuromodulation techniques and neurosurgical procedures were small, largely uncontrolled, and produced inconsistent effects on the core outcomes that matter in eating disorders, such as weight restoration, reduced food-related anxiety and normalized eating behavior. For a field in which deep brain stimulation and experimental pharmacotherapy occasionally generate dramatic headlines, the review’s sober verdict functions as an important corrective: the most reliable gains currently come from well-organized, multidisciplinary clinical care, not from technological interventions that remain at an experimental stage.

The authors are candid about the limitations of the literature they synthesized. This is a heterogeneous patient group with high rates of psychiatric and medical comorbidity, yet many studies provided little information on ethnicity, socioeconomic background, comorbid conditions or the legal treatment status of participants. Definitions of what constitutes longstanding or severe eating disorder varied across studies, making direct comparison difficult. Observational designs dominated, follow-up periods were generally short, and reporting of outcomes that patients and families prioritize, including quality of life, relapse, readmission and treatment acceptability, was inconsistent. These weaknesses do not undermine the central conclusion that improvement is possible, but they do mean clinicians and policymakers must interpret the magnitude and durability of those improvements with appropriate caution.

The implications reach well beyond academic debate. In several countries, including the United Kingdom, insurers and health systems have at times restricted access to intensive eating disorder treatment for patients judged to have chronic, unremitting illness, on the reasoning that prolonged disease duration predicts poor response. By showing that illness duration alone does not forecast outcome, while achieving a healthy weight and sustained psychological support does, the review provides an evidence-based argument for expanding rather than rationing access to integrated care. It also aligns with the growing involvement of people with lived experience in eating disorder research; the author team itself includes a peer researcher with lived experience, and the authors call for future studies to prioritize lived-experience perspectives alongside comorbidity, legal status and continuity of care.

The review’s agenda for future research is explicit. The authors call for standardized definitions and outcome reporting so that studies can be compared and pooled, for implementation research that examines how integrated pathways can be scaled in real health systems, for longer follow-up periods that capture relapse and sustained recovery, and for trials that deliberately include the comorbidities and legal complexities that characterize real clinical populations. Until that evidence arrives, the message for patients, families and clinicians is one of qualified hope. Adults whose eating disorders have endured for years are not beyond help. The treatment that works best is demanding, multidisciplinary and continuous, combining nutritional rehabilitation to a healthy weight with evidence-based psychotherapy and seamless support after discharge, and the review makes clear that the real barrier to recovery for many patients may not be their diagnosis or its duration, but the assumption that treatment is futile.

Subject of Research: Treatment interventions for adults with longstanding and severe eating disorders

Article Title: Treatment interventions for longstanding and severe eating disorders: an updated systematic review and narrative synthesis

Article References: Ayton, A., Kumar, A., Downs, J., Boniface, S., & Treasure, J. (2026). Treatment interventions for longstanding and severe eating disorders: an updated systematic review and narrative synthesis. Journal of Eating Disorders. https://doi.org/10.1186/s40337-026-01722-7

Image Credits: AI Generated

DOI: 10.1186/s40337-026-01722-7

Keywords: eating disorders, anorexia nervosa, systematic review, CBT-E, nutritional rehabilitation, weight restoration, inpatient treatment, treatment outcomes, integrated care, digital interventions, continuity of care, Journal of Eating Disorders

The stakes of this gap are considerable. Serious emotional disturbance, defined as a mental, behavioral, or emotional disorder diagnosed before age 18 that causes significant functional impairment in family, school, and community life, affects an estimated 7 to 12 percent of the total U.S. youth population. Left untreated, these conditions carry a cascade of risks: school dropout, involvement with the juvenile justice system, repeated hospitalizations, and long-term residential placement. Roughly one-third of children with serious emotional disturbance also live with a chronic physical illness, with asthma the most common comorbidity. For families, the toll extends to relationships, employment, income, and physical health, and children with mental health disorders account for a remarkable 55 percent of Medicaid spending among 3-to-17-year-olds.

The Behavioral Health Home model was created under Section 2703 of the Affordable Care Act in 2010 as a way to knit together fragmented care. Its intellectual roots reach back to the Patient Centered Medical Home, a concept the American Academy of Pediatrics developed in the 1960s, but the Medicaid version targets high-need, high-cost populations and focuses on integrating mental, physical, and social care. The model pursues the so-called triple aim—better population health, better care quality, and lower costs—by embedding primary care services into community behavioral health settings, where many people with mental illness receive most of their care. Core components include preventive services, care coordination, population health management, transitional care, patient and family support, and referrals to community and social supports.

Typically nurse-led and team-based, though not standardized, the model gives states wide flexibility in design. Caseworkers, mental health counselors, psychiatrists, and peer support providers often play central roles, physician consultation is required, and expanded hours and service locations aim to improve access. Because federal rules require states offering health homes for serious mental health conditions to serve both adults and children, youth are enrolled in substantial numbers: roughly 20 percent of enrollment in Missouri, 13 percent in Maryland, and, under a dedicated State Plan Amendment, 100 percent of a Rhode Island program for children and youth with special healthcare needs.

Yet the evidence base underpinning the model was built almost entirely on adults with serious mental illness. Randomized trials and evaluations in adult populations have linked behavioral health home participation to improved primary care access, better screening and monitoring of cardiometabolic conditions, healthcare savings, reduced inpatient utilization, and higher patient satisfaction. But other comprehensive reviews found no significant effects on diabetes control, weight management, or smoking cessation, and only modest reductions in cardiometabolic risk with wide variability across studies. Researchers attribute these mixed real-world results to variations in implementation and the highly context-specific nature of a multilevel, multisystem intervention. Documented barriers in adult implementations include increased administrative load, financial constraints, difficulties with patient recruitment and retention, staffing problems, health information technology challenges, and misalignment between the model’s values and those of the host community mental health center.

Crucially, the review’s authors argue that children are not simply small adults in this context. Children with serious emotional disturbance typically have shorter enrollment periods, since their conditions often resolve with proper care, whereas adult behavioral health homes are designed as lifetime homes. Prevention carries greater weight in pediatric care, and children generally have fewer comorbid conditions. Most importantly, care coordination differs fundamentally: adult coordinators work mainly with primary and specialty medical providers, while children require coordination across child welfare, juvenile justice, and special education systems, each governed by legal mandates such as expedited health evaluations for children entering foster care. And where adult care is person-centered, pediatric care must be patient and family centered, incorporating the social and economic needs of the whole household.

The review itself followed rigorous PRISMA guidelines, with a protocol registered in PROSPERO. The team searched PubMed, CINAHL, and PsycINFO for studies published from 2010 through mid-2026, supplemented by a targeted gray literature search of state Medicaid agency websites and reports from policy research organizations. After removing 1,529 duplicates, reviewers screened 3,171 titles and abstracts, excluding 3,144 as unrelated to the intervention, focused on adults, or non-empirical. Twenty-seven full-text articles underwent independent dual review, and all 27 were excluded—most because they studied related integrated care models rather than the Medicaid Behavioral Health Home itself. Fifteen gray literature documents, including state program reports and evaluations from organizations such as the Urban Institute, were also assessed and all excluded for reasons ranging from unrelated outcomes to insufficient methodological rigor. Data extraction and coding using the Consolidated Framework for Implementation Research, the planned analytical lens, proved impossible because there was nothing to extract.

A null result of this kind is not a dead end but a redirection. Drawing on adjacent literatures—adult behavioral health homes, pediatric integrated care, and evidence-based parenting programs—the authors identify three likely battlegrounds for youth implementation. The first is family engagement. Unlike adult models, pediatric care depends on caregivers as the prime movers of treatment: they set routines around diet, sleep, and activity, model healthy behavior, and maintain continuity of care. Unmet caregiver psychosocial needs, stigma, distrust of health systems, fear of child welfare involvement, chaotic routines, and frequent residential moves all demonstrably reduce engagement in related programs. The authors suggest embedding family support providers with lived experience into care teams, giving program managers flexible assistance funds for urgent needs like transportation or utility bills, and pursuing broader policies on caregiver Medicaid coverage, housing, and childcare.

The second battleground is cross-system coordination. Adult implementation studies document fragmented organizational relationships, difficulty engaging primary care providers, inconsistent communication, and weak external partnerships—and colocation of services or data exchange alone proved insufficient to ensure coordination. For children, where coordination must extend into schools and courts, these challenges are likely amplified. Emerging evidence points to facilitators such as alternative payment models like Vermont’s hub-and-spoke structure and collaborative agreements emphasizing shared purpose, as seen in Ohio. The third battleground is measurement. The mandatory Health Home Core Set of quality measures skews toward adult-relevant indicators: Missouri’s 2024 pediatric measures included asthma medication adherence, diabetes control, and tobacco use, which capture only a sliver of enrolled youth. The authors point to promising alternatives, including North Carolina’s Integrated Care for Kids program, school attendance data sharing led by Children’s National Hospital, and cross-sector outcomes such as recidivism used by Multisystemic Therapy. Looking forward, they call for research grounded in implementation frameworks like the CFIR, hybrid effectiveness-implementation designs, and multi-axis conceptions of integration spanning vertical, horizontal, and longitudinal dimensions. Until such studies exist, the fate of a model serving some of the nation’s most vulnerable children rests on evidence borrowed from adults.

Subject of Research: Implementation barriers and facilitators of the Medicaid Behavioral Health Home model for children with serious emotional disturbance

Article Title: Opportunities to Strengthen Implementation of the Medicaid Behavioral Health Home Model for Children with Serious Emotional Disturbance: A Systematic Review

Article References: Winning Verry, T., Eisen, S., Farabi, S., Lengnick-Hall, R., & Dell, N. A. (2026). Opportunities to Strengthen Implementation of the Medicaid Behavioral Health Home Model for Children with Serious Emotional Disturbance: A Systematic Review. Community Mental Health Journal. https://doi.org/10.1007/s10597-026-01709-3

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01709-3

Keywords: Medicaid, Behavioral Health Home, serious emotional disturbance, children's mental health, integrated care, care coordination, implementation science, Affordable Care Act, family engagement, health services research, systematic review, population health

Atrial fibrillation, the most common sustained cardiac arrhythmia, becomes increasingly prevalent with age, and contemporary patients are typically older, frailer and burdened by multiple chronic conditions. This complexity raises the risk not only of stroke and bleeding but also of non-cardiovascular events and hospital admissions, driving substantial healthcare costs. The ABC pathway was proposed as a structured framework to streamline integrated management: ‘A’ for anticoagulation and stroke risk avoidance, ‘B’ for better symptom control, and ‘C’ for cardiovascular and comorbidity optimisation. Observational studies repeatedly linked adherence to the pathway with lower mortality, stroke and bleeding, and two cluster-randomised trials in Asia—one app-based in largely urban China and one delivered by village doctors with telehealth support in rural settings—had shown that ABC implementation improved guideline adherence and reduced adverse outcomes, including hospitalisations.

What remained unknown was whether the same approach would work in European healthcare systems, specifically among patients aged 65 or older with atrial fibrillation and at least one additional chronic condition. The AFFIRMO investigators, led by Gregory Y.H. Lip and Marco Proietti, designed a multicentre, open-label cluster-randomised trial across Bulgaria, Denmark, Italy, Romania, Serbia and Spain. Clinical centres, not individual patients, were randomised to deliver either the integrated mHealth intervention—dubbed the iABC system—or routine guideline-based care. The intervention combined a patient-facing mobile application with a clinician dashboard, and every intervention patient underwent a comprehensive geriatric assessment at baseline to identify functional domains requiring management.

The AFFIRMO Mobile App collected daily data on vital signs, oral anticoagulant adherence, arrhythmia symptoms and chronic conditions, while dispensing tailored health tips for lifestyle and comorbidity management. Each patient also completed the Patient Health Engagement scale at activation, which determined the level of personalised educational material they received about atrial fibrillation. On the clinical side, the AFFIRMO Clinician Dashboard summarised app usage and patient-entered data, organised by the three ABC pillars, to inform follow-up consultations. Between April 2024 and January 2025, the trial enrolled 1,260 patients, with 634 assigned to the iABC system and 626 to usual care. Follow-up visits occurred at 3, 6 and 12 months, and the primary endpoint was unplanned all-cause hospitalisation during one year of follow-up, adjudicated by a blinded event validation committee.

The enrolled population reflected the modern reality of atrial fibrillation care: a mean age of 73 to 74 years, a median CHA2DS2-VASc stroke risk score of 4, and a heavy burden of comorbidity. Roughly 40 percent had more than two chronic conditions, hypertension treated with multiple drugs was nearly universal, and polypharmacy affected 72 percent of participants. Yet the trial’s most consequential baseline finding was how well these patients were already being treated: 97.3 percent were on oral anticoagulation, overwhelmingly direct oral anticoagulants, and use of beta-blockers, anti-arrhythmic drugs and other guideline-directed therapies was uniformly high. Comprehensive geriatric assessment in the intervention arm revealed a largely functionally preserved cohort, with 95.7 percent showing normal cognition, 83.9 percent normal nutritional status, and only about 20 percent reporting meaningful mobility impairment.

After a mean follow-up of 367 days, unplanned all-cause hospitalisation occurred in 17.1 percent of the iABC group versus 18.2 percent of the usual care group—an adjusted odds ratio of 0.95 with a 95 percent confidence interval of 0.61 to 1.49 and a p-value of 0.84. Sensitivity analyses, including a Cox proportional hazards model and a composite endpoint of hospitalisation or death, told the same neutral story. No secondary endpoint differed between groups: all-cause death, any hospitalisation, stroke or cardiovascular death, heart failure events, renal worsening, and major bleeding, which occurred in only 0.7 percent of all participants, were statistically indistinguishable across arms. Subgroup analyses by age, sex, comorbidity count, medication number and country revealed no hidden pockets of benefit.

The investigators attribute the null result to a convergence of factors, each instructive in its own right. First, the trial’s power calculation assumed a 30 percent event rate in usual care and a 25 percent relative reduction with the intervention; instead, usual care produced only an 18.2 percent hospitalisation rate. With such low residual risk, several thousand patients would have been required to detect a statistically significant difference. Second, the baseline quality of care starkly contrasts with the prior Asian trials: in the mAFA trial, oral anticoagulant use at baseline was just 48.4 percent in usual care, and in the MIRACLE-AF rural trial it was around 11 percent. In those settings, the ABC intervention raised anticoagulation dramatically and reduced hospitalisations. In AFFIRMO, with anticoagulation already at 97 percent, there was simply little therapeutic ground left for a digital nudge to reclaim.

Third, and perhaps most telling, patients barely used the app. The median percentage of days on which patients accessed the AFFIRMO Mobile App was 15.1 percent, and 68.5 percent of patients fell into the lowest tertile of use, opening the app on only about one-third or fewer of their study days. The authors point to well-documented implementation barriers—digital literacy in an older population, workflow incompatibility, and difficulty integrating digital tools into complex health systems. Clinical decision support, they note, only works when it is actually used; in the O’CAFÉ trial, modest overall effects sharpened into significant anticoagulation improvements only among clinicians who actively engaged with the tool. Because the mobile app is half of the iABC system, its companion physician dashboard inheriting the consequences of underuse, suboptimal engagement directly undermined the intervention’s theoretical effectiveness.

Fourth, comprehensive geriatric assessment itself ran into a ceiling effect. Although more than half of the intervention patients showed some degree of frailty on the FRAIL scale, most were robust on objective measures of daily functioning, cognition, nutrition and mood. In such high-functioning individuals, geriatric assessment may serve a descriptive rather than an interventional role, and prior evidence suggests little clinical benefit from CGA in robust patients. The trial’s design assumed more functional impairment than it found, constraining the scope for assessment-driven management changes. Not all signals were negative, however: patients in the intervention arm showed numerically higher uptake of several guideline-directed treatments at the final visit, including mineralocorticoid receptor antagonists, SGLT2 inhibitors and anti-arrhythmic drugs, and a significantly lower rate of uncontrolled systolic blood pressure at 12 months (1.5 versus 4.0 percent), hinting at secondary improvements in care quality even without hard outcome benefits.

The broader lesson echoes the recent STEEER-AF trial, in which an electronic education programme for clinicians also yielded only marginal improvements because guideline adherence was already high in both arms. The authors emphasise that the results do not disqualify integrated care or the ABC pathway, which remains embedded in European Society of Cardiology guidance through the 2020 ABC framework and the 2024 AF-CARE scheme. Rather, they argue, integrated care interventions and digital health tools must be targeted at settings with genuine unmet clinical need—populations with low baseline guideline adherence, higher residual risk, or greater functional impairment. Future studies may also need easier-to-use apps, co-designed with older patients, and more selected populations in which the theoretical benefit of holistic optimisation has room to translate into fewer hospitalisations. For now, AFFIRMO stands as a rigorous, well-conducted demonstration that in medicine, as in engineering, the marginal return on optimisation shrinks as the system approaches its ceiling—and that digital tools, however elegantly engineered, cannot multiply benefit that better baseline care has already claimed.

Subject of Research: A cluster-randomised trial of mHealth-based integrated care and comprehensive geriatric assessment in older multimorbid patients with atrial fibrillation.

Article Title: Integrated care management and comprehensive geriatric assessment using a mHealth-based approach in older multimorbid patients with atrial fibrillation: the AFFIRMO cluster-randomised trial

Article References: Lip, G. Y., Proietti, M., Ainsworth, J., Dan, G.-A., Frost, L., Graffigna, G., Lane, D. A., Lucci, D., Fabbri, G., Marin, F., O'Flaherty, M., Petrovic, M., Potpara, T. S., Proietti, R., Sanaullah, A., Tokmakova, M., Vetrano, D. L., Johnsen, S. P., Maggioni, A. P., … Tokmakova, M. (2026). Integrated care management and comprehensive geriatric assessment using a mHealth-based approach in older multimorbid patients with atrial fibrillation: the AFFIRMO cluster-randomised trial. The Lancet Regional Health – Europe, 70, Article 101832. https://doi.org/10.1016/j.lanepe.2026.101832

Image Credits: AI Generated

DOI: 10.1016/j.lanepe.2026.101832

Keywords: atrial fibrillation, AFFIRMO trial, mHealth, integrated care, ABC pathway, comprehensive geriatric assessment, multimorbidity, cluster-randomised trial, unplanned hospitalisation, digital health, older adults, guideline adherence

The context for the study is a demographic and policy pressure cooker. Societies and healthcare systems worldwide are confronting the demands of an aging population, and the European Commission has emphasized cross-sector collaboration to build sustainable, health-promoting solutions that support active and healthy ageing. In Sweden, healthcare is undergoing a deliberate transition toward person-centered and integrated care, with proactive, health-promoting approaches and digital solutions intended to deliver more equal, efficient, and accessible services. Municipal healthcare, provided in people’s homes or in specialized housing, serves a population in which up to 83 percent of recipients in 2023 were aged 65 or older, and many of these individuals also receive municipal social services such as home care. Staff in these services frequently perform delegated healthcare tasks, blurring the boundaries between sectors and making shared, collaborative perspectives essential to any preventive shift.

The scientific rationale is compelling. Cohort studies suggest that today’s older adults generally show higher levels of physical and mental functioning than previous generations, and Swedish data report improvements in health, longevity, and activity performance among people up to 80 years of age. Health promotion, defined as the process of enabling people to increase control over the determinants of their health, offers a way to consolidate those gains. Interventions that target key health determinants among community-dwelling older adults before they enter municipal care could help maintain health, delay the onset of care needs, and reduce future demand on strained health and social care systems. Within occupational therapy, engagement in meaningful everyday activities is considered a key determinant of health, and prior evidence supports both group-based formats and digital delivery, suggesting that combining the two could offer promising, resource-efficient routes to supporting healthy ageing.

To understand the organizational ground truth before any large-scale implementation, the researchers turned to the people who run and staff municipal services. Using a qualitative focus group design, they recruited 22 participants from seven municipalities in northern Sweden, including occupational therapists, development managers, area managers, operations managers, and case managers. The participants were purposively sampled across professional roles and organizational levels, and grouped with others in similar positions to reduce the distorting effects of hierarchy on candid discussion. Five focus groups were held over five months, three digitally because of the long distances between workplaces and two in person. To anchor the conversation, the researchers presented a shared case: a web-based, group-delivered occupational therapy intervention called Health Web, which their team had previously developed and piloted. The case was not being evaluated; it served as a concrete stimulus for broader reflection on what health-promoting work would demand of the organization. Discussions, lasting between 56 minutes and one hour and 50 minutes, were audio recorded, verbatim transcribed, and analyzed inductively using a structured focus group analysis approach.

The analysis converged on a single overarching theme: creating organizational readiness for health-promoting interventions. This theme was supported by three interrelated subthemes: supportive structures for health-promoting work are needed within the organization; a shared health-promoting focus and new collaborations are required; and new working methods are necessary to facilitate health promotion. The researchers found that these subthemes do not operate as isolated barriers or facilitators but interact dynamically in everyday practice, collectively shaping whether preventive ambitions can actually be realized. Every focus group judged current readiness to be insufficient, yet participants also expressed a clear sense that health-promoting interventions are essential as the organization aligns with person-centered and integrated care.

The first subtheme exposed a structural paradox. Participants described legal agreements, frameworks, and priority orders that govern municipal work as failing to stipulate health-promoting activity. Development managers explained that the home care agreement, for example, directs effort almost entirely toward technical aids and reactive, treatment-focused care, leaving professionals who are trained to work preventively feeling actively hindered. In their words, staff are left to put out fires without ever being able to prevent the fires from starting. The absence of supportive structures led to a shared perception of health promotion as optional work, something to be attempted only when time and resources allowed. Participants called for revised agreements, clearer interpretation of the new social services act, explicit direction on resource allocation and competence use, and political and managerial leadership to initiate the change, emphasizing that long-term sustainability requires extra resources during a transition period rather than short-term projects vulnerable to annual budget cuts.

The second subtheme revealed a cultural trap: daily practice is dominated by reactive, compensatory interventions. Occupational therapists are mainly contacted for acute needs following hospital discharge and are often perceived as an overburdened group with few staff, so managers hesitate to add anything beyond ordinary tasks. Interventions in older adults’ daily activities are frequently delegated to home care staff who lack formal competence and face language barriers, leading to deprioritization in favor of basic care. Collaboration between health and social care typically emerges only late, when complex needs have already arisen, and is further restricted by secrecy regulations. Participants proposed earlier, closer collaboration, tools such as life story forms used proactively to map health determinants, and outreach into society, including associations, libraries, and digital platforms, to reach resourceful older adults whose changing life circumstances make them ideal candidates for preventive intervention before poor health takes hold.

The third subtheme highlighted new working methods, particularly digital and group-based formats. Participants viewed digital solutions as a way to reach older adults who have difficulty leaving home, including informal caregivers and those with limited energy or mobility, and to build digital competence, itself a health-promoting skill in modern society. Yet current municipal digital use is largely one-way, covering security alarms and camera surveillance rather than mutual communication. Group formats were judged inherently health-promoting: shared activities foster mutual encouragement, social learning, empowerment, cognitive and physical stimulation, and a sense of purpose, right down to the motivation to look presentable for a meeting. Flexible design was seen as important, since combining an initial physical meeting with later digital sessions could lower the threshold for isolated older adults, while for others a screen feels safer as a first step out of isolation.

Interpreted through Weiner’s theory of organizational readiness for change and the Consolidated Framework for Implementation Research, the findings suggest low change efficacy and fragmented change commitment among staff, but also extend those frameworks by showing that readiness is continuously negotiated through structural conditions, shared views, and everyday collaborative practices rather than being a static psychological state. The authors argue that the study provides a foundation for structured dialogue between policymakers, managers, and professionals, ideally within collaborative co-creation processes, and call on the occupational therapy profession to engage across organizational levels in deciding how its competencies can shift from reactive, compensatory roles toward proactive, health-promoting practice. For a system facing an ever-growing older population, the message is stark but constructive: the potential for prevention already exists within municipal organizations, but it must be deliberately built, resourced, and led from the top if health promotion is ever to move from aspiration to everyday routine.

Subject of Research: A qualitative focus group study exploring organizational opportunities and challenges for delivering health-promoting interventions to older adults within municipal health and social care in Sweden.

Article Title: Opportunities and Challenges for Health-Promoting Interventions for Older Adults: A Focus Group Study with Professionals in Municipal Health and Social Care

Article References: Körlof, L., Nyman, A., Larsson, E., & Isaksson, G. (2026). Opportunities and Challenges for Health-Promoting Interventions for Older Adults: A Focus Group Study with Professionals in Municipal Health and Social Care. Scandinavian Journal of Occupational Therapy, 33(1), Article 6. https://doi.org/10.1007/s44474-026-00008-0

Image Credits: AI Generated

DOI: 10.1007/s44474-026-00008-0

Keywords: health promotion, older adults, occupational therapy, organizational readiness, municipal health care, social care, person-centered care, integrated care, digital interventions, group-based interventions, healthy ageing, qualitative research

The research, led by Jamie L. Humphrey of RTI International together with Jason Williams, Sofia A. Oviedo, Bradley R. Ray, and Jessica D. Cance, addresses a question that has lingered as the synthetic opioid crisis deepened. Fentanyl and its analogs have driven unprecedented overdose mortality in the United States, but their effects extend beyond fatal poisoning. The drug’s extreme potency and rapid onset have altered injection frequency and syringe-sharing behavior in ways that heighten the risk of HIV transmission, and clusters of new infections in several states have underscored the urgency of embedding HIV testing, prevention, and treatment within settings where people who use drugs already seek care.

Integrated HIV services within substance use disorder treatment facilities have long been viewed as a critical intervention point for this syndemic of addiction, overdose, and infectious disease. Whether such services actually proliferated as fentanyl spread geographically, however, remained unknown. To find out, the research team assembled a longitudinal dataset of United States counties from 2015 through 2023, relying on geocoded facility listings from the National Survey of Substance Abuse Treatment Services and its successor, the National Substance Use and Mental Health Services Survey. The outcome of interest was the annual county-level proportion of substance use disorder treatment facilities reporting that they provided HIV services.

A central methodological challenge was defining when the fentanyl era began for any given county. Rather than relying on a single national date, the investigators derived state-specific onset points for rapid illicit fentanyl market penetration using data from the National Forensic Laboratory Information System, which tracks drug submissions to forensic laboratories across the country. This allowed the team to model each county’s trajectory of HIV service availability before and after the moment fentanyl effectively took over the local illicit drug supply, capturing the staggered diffusion of the synthetic opioid wave as it moved across the country.

The statistical approach was equally refined. The researchers employed longitudinal growth models with a beta distribution, a technique suited to modeling proportions bounded between zero and one, to estimate rates of change in HIV service availability across the study period. The models incorporated a set of time-varying covariates designed to isolate the effect of fentanyl’s arrival from other concurrent forces: county-level drug overdose mortality and HIV incidence rates, each lagged by two years to reflect plausible causal timing, as well as state-level policy factors including Medicaid expansion and prohibitions on prior authorization requirements for medications for opioid use disorder.

The headline result is striking in its simplicity. Between 2015 and 2023, the average proportion of substance use disorder treatment facilities providing HIV services doubled among counties that had treatment infrastructure in place. This was not a uniform trend, however. The geographic heterogeneity was considerable: following the introduction of fentanyl, HIV service availability increased in 38.8 percent of counties, remained stable in 14.0 percent, and decreased in 24.5 percent. Perhaps most sobering, 22.7 percent of counties had no measurable HIV service availability at all during the period because they lacked substance use disorder treatment facilities entirely, leaving residents of those areas without any local point of access to integrated care.

The adjusted models sharpened the temporal story. Before fentanyl’s arrival, the increase in HIV service provision within counties was modest and not statistically significant, with an estimated slope of 0.021 and a standard error of 0.013. After fentanyl was detected in a state’s drug market, integration accelerated markedly, with a post-fentanyl slope of 0.072 and a standard error of 0.009, a difference that was highly significant at P less than .001. A formal test of the interaction between the slope and fentanyl’s introduction confirmed that the acceleration was genuinely tied to the synthetic opioid’s arrival, with an interaction coefficient of 0.051 and a standard error of 0.014, also significant at P less than .001.

What these coefficients imply, in practical terms, is that the arrival of fentanyl appears to have functioned as a shock to the addiction treatment system, prompting facilities to adapt their service portfolios in response to a visibly escalating threat. The authors interpret this pattern as evidence of adaptive integration of HIV prevention and care within addiction treatment systems during the fentanyl era. Treatment organizations, confronting a drug supply that dramatically raised both overdose risk and injection-related HIV vulnerability, appear to have recognized that testing for HIV, linking patients to antiretroviral care, and offering preventive services were no longer optional adjuncts but core components of responsible care for a population facing compounded dangers.

Yet the study’s darker findings demand equal attention. Nearly one-quarter of United States counties had no in-person substance use disorder treatment infrastructure at all during the study window, a persistent service desert that no amount of integration within existing facilities can remedy. Moreover, even among counties with treatment capacity, the post-fentanyl period saw service availability decline in roughly one in four, indicating that the adaptive response was far from universal. Geographic disparities in access to integrated HIV and addiction services remain substantial, and the counties most vulnerable to overlapping overdose and HIV epidemics are often precisely those least equipped to respond.

The authors conclude that these patterns underscore the need for policies that expand substance use disorder treatment capacity and actively incentivize HIV service integration in underserved communities. As fentanyl, and increasingly its more potent analogs, continues to dominate the illicit drug supply, the window for preventive action narrows in the places least served. The research, which was supported by the National Institute on Drug Abuse under Award Number U24DA057611 and reviewed by the RTI International Institutional Review Board under protocol STUDY00022322, provides both a benchmark and a warning: the treatment system can respond to crisis, but only where treatment exists, and only when policy deliberately directs resources toward the communities where the syndemic burns hottest.

Subject of Research: Longitudinal county-level analysis of HIV service availability in US substance use disorder treatment facilities before and after the state-specific arrival of illicit fentanyl, 2015 to 2023.

Article Title: HIV service integration in substance use treatment facilities in the fentanyl era, 2015–2023

Article References: HIV service integration in substance use treatment facilities in the fentanyl era, 2015–2023. (n.d.). https://doi.org/10.1186/s12889-026-29460-0

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29460-0

Keywords: HIV services, fentanyl, substance use disorder treatment, integrated care, overdose crisis, health services accessibility, geospatial analysis, HIV prevention, Medicaid expansion, opioid epidemic, public health, service integration

The authors draw on a targeted, non-systematic review of the literature to document what clinicians and researchers have long observed: mental health difficulties can drive young people toward substance use, and substance use can, in turn, precipitate or worsen mental health disorders. Yet the commentary notes that this bidirectional relationship is frequently recognized only in hindsight, after a young person is already in treatment for one condition or the other. By the time the interplay becomes visible, opportunities for earlier, more effective intervention may have been lost, and the course toward a full co-occurring disorder may already be set.

Central to the authors’ argument is the developmental vulnerability of the adolescent brain. Neuroimaging and longitudinal studies cited in the commentary show that the prefrontal cortex, which governs impulse control, decision-making, and emotional regulation, continues to mature well into the mid-twenties. The limbic circuits that mediate reward and emotional reactivity, however, develop earlier, creating a period in which emotional distress is intense while regulatory capacity is still under construction. This mismatch helps explain why anxiety, depression, trauma, and attention-deficit/hyperactivity disorder frequently precede or coincide with the initiation of alcohol, cannabis, nicotine, and other substance use during the teenage years.

The self-medication hypothesis features prominently in the evidence the authors synthesize. Studies of posttraumatic stress disorder and problematic alcohol use, along with epidemiological reviews of mood and anxiety disorders, indicate that many young people begin using substances not primarily for pleasure but to manage unbearable internal states. Research on reasons for first cannabis use, for example, links coping-motivated initiation to heavier subsequent consumption and elevated risk of first-episode psychosis. High-potency delta-9-tetrahydrocannabinol products have been associated in systematic reviews with adverse mental health outcomes, and large cohort studies have documented increased risks of depression, bipolar disorder, and psychosis following cannabis use disorder in youth and young adults.

The reverse pathway is equally well documented. Prospective research shows that adolescent substance use can alter neurodevelopmental trajectories and increase vulnerability to internalizing symptoms, suicidality, and psychiatric comorbidity. Data from national surveys, including the Youth Risk Behavior Survey and the National Survey on Drug Use and Health, reveal that high school students who use substances report substantially higher rates of suicidal thoughts and co-occurring psychiatric conditions. In other words, the arrow of causation runs in both directions, and the commentary stresses that prevention and treatment systems must be designed with that bidirectionality in mind rather than addressing one condition at a time.

Despite this robust evidence base, services for young people remain fragmented. Mental health providers often lack training and confidence in addressing substance use, while addiction treatment programs frequently are not equipped to manage depression, trauma, or anxiety. Screening practices reflect the same divide: many pediatric, school-based, and primary care settings screen for one domain but not the other, or refer young people to separate agencies whose records and treatment plans never converge. The commentary argues that this separation creates missed opportunities at every stage, from prevention education that ignores emotional drivers of use to treatment planning that fails to account for the psychiatric function a substance may be serving.

The authors point to models demonstrating that integration is practical and cost-effective. Evidence-based outpatient behavioral treatments for adolescent substance use updated through 2023, along with integrated treatment frameworks for co-occurring depression and substance use disorder, show that combined interventions improve engagement and outcomes. The American Society of Addiction Medicine’s criteria for adolescents and guidance from the Substance Abuse and Mental Health Services Administration already call for co-occurring competent care, yet implementation continues to lag behind the evidence. School connectedness interventions, trauma-informed prevention models, and alternatives to punitive school responses for substance-related infractions, such as curriculum-based approaches tested in pragmatic clinical trials, illustrate concrete entry points for earlier identification.

The commentary also highlights the importance of listening to young people themselves. Studies of adolescents’ reasons for substance use show that these motivations are not trivial; they are clinically meaningful predictors of treatment response and outcome. A young person who uses cannabis to quiet intrusive trauma memories needs a different intervention than one who drinks socially at parties. Qualitative research with adults and adolescents in substance misuse treatment confirms that many recognized only later how strongly their addiction and mental health difficulties reinforced each other, underscoring the cost of systems that fail to ask about both domains from the outset.

For policymakers, the authors frame integrated, co-occurring competent care as a matter of both scientific fidelity and fiscal prudence. Preventing the escalation from experimentation to disorder, and from a single condition to a co-occurring one, reduces downstream demand on emergency departments, criminal justice systems, and long-term treatment services. The commentary calls on prevention professionals, educators, clinicians, and policymakers to embed dual-domain screening in schools, primary care, and behavioral health settings, to train the workforce in the interplay between mental health and substance use, and to fund service models in which the same team addresses both conditions simultaneously.

Ultimately, the message of the commentary is one of urgency tempered by optimism. The science of adolescent brain development, the epidemiology of co-occurring conditions, and the clinical evidence on integrated treatment all converge on the same conclusion: mental health and substance use are two faces of the same set of vulnerabilities during youth, and systems that treat them separately will continue to miss the young people who need help most. What remains is the institutional will to translate an evidence base that has been accumulating for decades into everyday practice across the settings where young people live, learn, and seek care.

Subject of Research: Integrated prevention and treatment of co-occurring substance use and mental health disorders in adolescents

Article Title: Advancing an Integrated Approach to Prevention, Early Identification, and Intervention for Youth with Co-Occurring Substance Use and Mental Health Challenges

Article References: Advancing an Integrated Approach to Prevention, Early Identification, and Intervention for Youth with Co-Occurring Substance Use and Mental Health Challenges. (n.d.). https://doi.org/10.1007/s10597-026-01717-3

Image Credits: AI Generated

DOI: 10.1007/s10597-026-01717-3

Keywords: adolescent mental health, substance use disorder, co-occurring disorders, integrated care, prevention, early identification, self-medication, cannabis, screening, school-based intervention, addiction treatment, public health policy

The study focused on occupational therapists, physiotherapists, and registered nurses working in a large Swedish municipality of roughly 150,000 inhabitants. These professionals deliver the bulk of municipal primary healthcare, including home healthcare, residential care facilities, and services for adults needing special support. Under Swedish law and their professional codes of ethics, all three groups are obliged to use science and proven experience in their daily work. Yet the researchers found that few had completed advanced-level education, the uptake of new knowledge was low, and care was more often grounded in personal experience than in research-based knowledge, leaving patients potentially exposed to out-of-date assessments and treatments.

Methodologically, the study combined five audio-recorded dialogue meetings with a web-based survey sent to all 290 employed registered healthcare professionals in the municipality. The survey drew 102 valid responses, a response rate of 35 percent overall, with notably higher participation among occupational therapists at 54 percent and physiotherapists at 50 percent compared with 27 percent among nurses. The qualitative strand used inductive, latent thematic analysis following Braun and Clarke’s six-step procedure, while the quantitative strand applied single-item logistic regression analyses to identify which attitudes and conditions were statistically associated with basing work on research. Convergent design principles guided the integration of the two data streams in joint display tables.

The qualitative analysis yielded one overarching theme: a struggle between personal and organizational conditions to use research and work according to evidence-based practice. This struggle unfolded along two dimensions. The first captured clinicians being torn between personal ambitions and a lack of skills to use research. The second described how organizational conditions and limited access to support challenged any attempt to translate evidence into practice. Participants were acutely aware of their professional obligations to use science and proven experience, but when they could not fulfil those obligations because of missing resources, structures, and support, many resigned themselves to relying on experience-based knowledge.

The skills gap emerged as a strikingly consistent finding. Slightly more than half of survey respondents said they did not feel confident searching for and interpreting research results. Advanced-level education made a measurable difference: 63 percent of those with education beyond the bachelor’s level felt confident interpreting research findings, compared with only 37 percent of those with a bachelor’s degree or less. Clinicians described research as hard to understand and generalize, noting that studies are typically conducted at the group level while their patients present complex, individualized problems. One physiotherapist wrote that it can be difficult to judge how reliable a result is and how to apply group-level findings to a single patient.

Despite these struggles, the regression analyses revealed that several individual attitudes and conditions were significantly associated with actually basing work on research. Clinicians who believed that evidence-based work saves time were more than three and a half times as likely to base their work on research. Finding research interesting nearly quintupled the odds, active searching for work-relevant research increased them eightfold, and feeling confident in searching for, reviewing, and interpreting studies each roughly tripled the likelihood. Critically, holding an advanced-level education was itself significantly associated with evidence-based working, with an odds ratio of 3.7, echoing earlier findings among physiotherapists and occupational therapists in Sweden and internationally.

The organizational picture was bleaker. Only a minority of participants said evidence-based practice was highly valued in their workplace, with the smallest proportion among occupational therapists, at just 24 percent, compared with 53 percent of nurses and 41 percent of physiotherapists. Fewer than 15 percent experienced that their manager encouraged the use of research results, and a similarly small share reported any ongoing systematic implementation of evidence-based methods. A lack of allocated time emerged as the single most-cited barrier: 91 percent said they had no time to read research during working hours, and 88 percent lacked access to research at work. When clinicians did carve out time, they described it as coming directly at the expense of hands-on patient care, creating a culture of busyness in which reading research could induce guilt.

Organizational conditions that did support evidence-based working were statistically meaningful. Having access to research results at work increased the odds of basing work on research more than fourfold, having support to try new methods nearly tripled them, and perceiving that evidence-based work was valued at work nearly tripled them. Participants also pointed to structural confusion: unclear boundaries between municipal primary healthcare and county council-run health centres, underutilized professional competencies, and missing structures for multi-professional teamwork. Occupational therapists and physiotherapists described being unable to initiate health-promoting or preventive interventions they had identified, because responsibility fell to another provider under Sweden’s so-called threshold principle, which directs patients who can travel to local health centres instead.

The researchers situate these findings within the knowledge-to-action gap, the well-documented chasm between what research produces and what clinical practice adopts. They draw on prior scholarship describing organizational cultures oriented toward doing, focused on tasks and outcomes, rather than being, which allows reflective time for assessing, reading, and critiquing research. In such cultures, direct patient care is valorized and evidence work is sidelined. The study also notes a troubling ethical dimension: although clinicians were aware they were falling short, there was a consistent absence of reflection on their individual responsibility to fulfil professional codes of ethics, and on the potential consequences for patients of receiving care not grounded in current evidence.

The authors conclude that strengthening clinicians’ competence, particularly through advanced-level education, is essential, but insufficient on its own. Managerial support, education, clinical goals, allocated time, access to research, and clear strategies for implementing evidence-based practice are all needed to shift the organizational culture. Participants themselves called for planning and management that clarifies professional roles and responsibilities, and for structures that make teamwork and evidence-based development possible. As Sweden’s national reform toward local, integrated care moves advanced care out of hospitals and into municipalities, the stakes of closing this gap rise. Without deliberate action, the study warns, the very professionals expected to anchor the new model of care will continue to run, in one participant’s words, like hamsters in a wheel, well-intentioned but unable to move the system forward.

Subject of Research: Evidence-based practice and research usage among registered healthcare professionals in Swedish municipal primary healthcare

Article Title: Ambitions and obstacles for evidence-based municipal primary healthcare – a mixed- methods study

Article References: Gustafsson, M., Zingmark, M., Iwarsson, S., & Ekstam, L. (2025). Ambitions and obstacles for evidence-based municipal primary healthcare – a mixed- methods study. Scandinavian Journal of Occupational Therapy, 32(1), Article 2451265. https://doi.org/10.1080/11038128.2025.2451265

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2451265

Keywords: evidence-based practice, municipal primary healthcare, research usage, occupational therapy, physiotherapy, nursing, knowledge translation, organizational culture, integrated care, mixed methods, health promotion, advanced-level education

The scale of the problem is staggering. In 2019 alone, an estimated 4.3 million new fragility fractures occurred across the EU27, Switzerland, and the United Kingdom, including approximately 827,000 hip fractures. The direct cost of these new fractures reached 36.3 billion euros, with an additional 19.0 billion euros attributable to long-term disability from fractures sustained in previous years. When pharmacological assessment and treatment costs of 1.6 billion euros are added, the total direct cost climbed to 56.9 billion euros in a single year. Healthcare costs remain elevated above pre-fracture levels for five full years after the injury, placing an unsustainable strain on health systems already stretched by aging populations.

What makes these figures particularly troubling is how preventable many of these fractures are. More than 95 percent of hip fractures are caused by falling, yet the clinical systems designed to prevent falls and those designed to prevent fractures operate almost entirely in isolation from one another. Hip fracture outcomes are grim: one-year mortality reaches 20 to 24 percent, and among survivors, 40 percent are unable to walk independently while 60 percent still require assistance a full year after injury. Approximately one-third of patients become fully dependent or require residential care within twelve months of sustaining a hip fracture.

The biological logic for integration is compelling. The paper presents a conceptual framework showing how bone fragility and fall risk jointly determine fracture probability, with their relative contributions shifting over time. A common geriatric syndrome called osteosarcopenia—the combination of sarcopenia and osteopenia or osteoporosis—illustrates this overlap, affecting an estimated 5 to 37 percent of community-dwelling older adults and elevating the risk of both falls and fractures simultaneously. Crucially, researchers have documented an imminent subsequent fracture risk after both an incident fracture and an incident fall, and conversely, an increased risk of falling soon after a fracture. This bidirectional cascade means that missing one risk dimension inevitably undermines the other.

Despite this, clinical practice lags badly. In a recent survey among European healthcare professionals, fewer than 60 percent of respondents reported including fracture risk assessment often or always within the multifactorial fall risk assessment. On the fracture side, fall risk assessment is not routinely performed in many Fracture Liaison Services, the specialized secondary prevention programs established after a first fracture. In a 2025 national UK evaluation, only about 65 percent of FLS patients received or were referred for a fall risk assessment, with substantial variation between services, and the picture is likely worse or entirely absent in many other countries. The authors contend that FLS programs are uniquely positioned to operationalize integrated care but frequently remain predominantly bone-focused rather than comprehensively risk-focused.

The paper lays out a detailed technical roadmap for how fracture risk assessment can be embedded within fall prevention services, drawing on the 2022 World Guidelines for Fall Prevention and Management. These guidelines introduce a fall risk stratification algorithm for community-dwelling older adults and recommend that those at moderate to high risk of falls undergo bone health assessment using validated tools. Fracture risk calculators such as FRAX, Garvan, and QFracture can identify older adults at high fracture risk, with Garvan and QFracture already incorporating falls as a predictor. FRAXplus further refines conventional FRAX estimates by accounting for the number of falls in the previous year, allowing clinicians to treat fall history as a modifiable fracture risk amplifier that directly informs both risk stratification and therapeutic choice.

Conversely, established osteoporosis management pathways should embed fall prevention. An internationally applicable algorithm for postmenopausal women categorizes fracture risk into low, intermediate, and very high zones using FRAX, with bone densitometry and recalculation refining intermediate cases. Women with a prior fragility fracture are automatically considered at least high risk. The authors emphasize that fall prevention strategies must be embedded within treatment pathways for patients at high and very high fracture risk, and that cognitively impaired and dementia patients should never be denied fracture prevention measures, including pharmacological osteoporosis treatments. This population deserves particular attention: 60 to 80 percent of people with dementia fall annually, and cognitive impairment is present in approximately 40 percent of all older adults with hip fractures.

Education represents another critical pillar. Among nearly 4,000 European healthcare professionals surveyed, approximately 12 percent reported low or very low knowledge of both falls and bone health, and 35.9 percent reported low knowledge of orthogeriatric care. Only about a quarter of surveyed professionals agreed that their undergraduate education adequately prepared them for fall prevention in clinical practice. The authors call for interprofessional training that bridges medicine, physiotherapy, nursing, pharmacy, and dietetics, alongside a core set of competencies for integrated fall and fracture assessment that local teams can adapt to their resources while remaining evidence-based.

On the policy front, the paper argues that integrated fall and fracture prevention must be recognized as a public health priority and incorporated into national healthy aging strategies aligned with the WHO’s Decade of Healthy Ageing. Promising national initiatives already exist: France launched a 2022 plan targeting a 20 percent reduction in fall-related fractures and deaths; the Netherlands has introduced an Integrated Approach to Fall Prevention strategy; and Belgium operates a dedicated Center of Expertise for Falls and Fracture Prevention in Flanders. Hip fracture registries, another policy instrument, should include fall prevention quality markers, as the Danish National Hip Fracture Database has done since 2010.

Emerging technologies offer powerful new tools. Wearable sensors capturing real-world balance and mobility data, combined with AI-driven predictive models, demonstrate superior fall prediction performance compared with traditional approaches, while in silico clinical trials enable simulation of virtual populations to optimize preventive interventions before deployment. Emerging pharmacological findings add intrigue: pooled analyses suggest that romosozumab and denosumab may each reduce fall risk in postmenopausal women with osteoporosis, hinting at mechanisms that might involve muscle mass, though the authors caution that studies with falls as the primary outcome are still needed. The WHO and ESCEO have signed a five-year collaboration agreement to develop a strategic global roadmap on bone health and aging, signaling that momentum toward truly integrated prevention may finally be building. The authors’ message is unambiguous: unify the science, unify the services, and millions of preventable fractures and falls could be avoided.

Subject of Research: Integrated fall and fragility fracture prevention in older adults through coordinated international clinical, educational, policy, and research strategies

Article Title: Position paper: a coordinated approach to fracture and fall prevention from seven international organizations

Article References: van der Velde, N., Seppala, L. J., Bahat, G., Blain, H., Casas Herrero, A., Harvey, N. C., Masud, T., Rizzoli, R., Reginster, J.-Y., Ruggiero, C., Barbagallo, M., de Lima, A. B., Bonnici, M., Bousquet, J., Cortet, B., Chiari, L., Dionyssiotis, Y., Dreinhöfer, K., Duque, G., … Öztürk, Y. (2026). Position paper: a coordinated approach to fracture and fall prevention from seven international organizations. European Geriatric Medicine. https://doi.org/10.1007/s41999-026-01596-7

Image Credits: AI Generated

DOI: 10.1007/s41999-026-01596-7

Keywords: fall prevention, fragility fractures, osteoporosis, geriatric medicine, Fracture Liaison Services, hip fracture, osteosarcopenia, integrated care, healthy aging, bone health, wearable sensors, public health policy