Economic instability, income, and unemployment effects on mortality: using SUR panel data in Iran.

This study aims to investigate the effects of socioeconomic factors on mortality in Iran. To this end, this research examines how economic instability, income, and unemployment affect mortality using a seemingly unrelated regression (SUR) with panel data for 30 provinces in Iran from 2004 to 2019. The results indicate that unemployment and mortality have a countercyclical relationship among the working age-groups 20-59 but a procyclical pattern among old-age (60+), except for rural mortality. This result is harmonious between employment and age-group mortality. This finding implies that unemployment increases mortality in working age-groups due to psychological stress and poverty risk. In addition, the income level decreases mortality in all ages over 40 years due to the provision of higher access to health and medical services and social welfare. However, it increases mortality in rural areas and age-group 20-39 because of their hazardous, unsafe, and stressful work conditions. Therefore, policymakers should plan for an inclusive economic growth to reduce poverty and out-of-pocket payments and increase the quality and accessibility of public health services, especially for beneficiaries of lower social groups. Moreover, they should adopt strategies to alleviate the burden of premature, preventable, and treatable deaths.

Now Is the Time to Strengthen Government-Academic Data Infrastructures to Jump-Start Future Public Health Crisis Response.

During public health crises, the significance of rapid data sharing cannot be overstated. In attempts to accelerate COVID-19 pandemic responses, discussions within society and scholarly research have focused on data sharing among health care providers, across government departments at different levels, and on an international scale. A lesser-addressed yet equally important approach to sharing data during the COVID-19 pandemic and other crises involves cross-sector collaboration between government entities and academic researchers. Specifically, this refers to dedicated projects in which a government entity shares public health data with an academic research team for data analysis to receive data insights to inform policy. In this viewpoint, we identify and outline documented data sharing challenges in the context of COVID-19 and other public health crises, as well as broader crisis scenarios encompassing natural disasters and humanitarian emergencies. We then argue that government-academic data collaborations have the potential to alleviate these challenges, which should place them at the forefront of future research attention. In particular, for researchers, data collaborations with government entities should be considered part of the social infrastructure that bolsters their research efforts toward public health crisis response. Looking ahead, we propose a shift from ad hoc, intermittent collaborations to cultivating robust and enduring partnerships. Thus, we need to move beyond viewing government-academic data interactions as 1-time sharing events. Additionally, given the scarcity of scholarly exploration in this domain, we advocate for further investigation into the real-world practices and experiences related to sharing data from government sources with researchers during public health crises.

Momentary Factors and Study Characteristics Associated With Participant Burden and Protocol Adherence: Ecological Momentary Assessment.

BACKGROUND: Ecological momentary assessment (EMA) has become a popular mobile health study design to understand the lived experiences of dynamic environments. The numerous study design choices available to EMA researchers, however, may quickly increase participant burden and could affect overall adherence, which could limit the usability of the collected data. OBJECTIVE: This study quantifies what study design, participant attributes, and momentary factors may affect self-reported burden and adherence. METHODS: The EMA from the Phase 1 Family Matters Study (n=150 adult Black, Hmong, Latino or Latina, Native American, Somali, and White caregivers; n=1392 observation days) was examined to understand how participant self-reported survey burden was related to both design and momentary antecedents of adherence. The daily burden was measured by the question "Overall, how difficult was it for you to fill out the surveys today?" on a 5-item Likert scale (0=not at all and 4=extremely). Daily protocol adherence was defined as completing at least 2 signal-contingent surveys, 1 event-contingent survey, and 1 end-of-day survey each. Stress and mood were measured earlier in the day, sociodemographic and psychosocial characteristics were reported using a comprehensive cross-sectional survey, and EMA timestamps for weekends and weekdays were used to parameterize time-series models to evaluate prospective correlates of end-of-day study burden. RESULTS: The burden was low at 1.2 (SD 1.14) indicating "a little" burden on average. Participants with elevated previous 30-day chronic stress levels (mean burden difference: 0.8; P=.04), 1 in 5 more immigrant households (P=.02), and the language primarily spoken in the home (P=.04; 3 in 20 more non-English-speaking households) were found to be population attributes of elevated moderate-high burden. Current and 1-day lagged nonadherence were correlated with elevated 0.39 and 0.36 burdens, respectively (P=.001), and the association decayed by the second day (ß=0.08; P=.47). Unit increases in momentary antecedents, including daily depressed mood (P=.002) and across-day change in stress (P=.008), were positively associated with 0.15 and 0.07 higher end-of-day burdens after controlling for current-day adherence. CONCLUSIONS: The 8-day EMA implementation appeared to capture momentary sources of stress and depressed mood without substantial burden to a racially or ethnically diverse and immigrant or refugee sample of parents. Attention to sociodemographic attributes (eg, EMA in the primary language of the caregiver) was important for minimizing participant burden and improving data quality. Momentary stress and depressed mood were strong determinants of participant-experienced EMA burden and may affect adherence to mobile health study protocols. There were no strong indicators of EMA design attributes that created a persistent burden for caregivers. EMA stands to be an important observational design to address dynamic public health challenges related to human-environment interactions when the design is carefully tailored to the study population and to study research objectives.

Use of veterinary medicinal products in the Philippines: regulations, impact, challenges, and recommendations.

Agricultural production is a major driver of the Philippine economy. Mass production of animal products, such as livestock and poultry farming, is one of the most prominent players in the field. Filipino farmers use veterinary medicinal products (VMPs) when raising agricultural animals to improve animal growth and prevent diseases. Unfortunately, the extensive use of VMPs, particularly antibiotics, has been linked to drug resistance in animals, particularly antibiotics. Antimicrobial gene products produced in animals due to the prolonged use of VMPs can passed on to humans when they consume animal products. This paper reviews information on the use of VMPs in the Philippines, including the regulations, their impact, challenges, and potential recommendations. The Philippines has existing legislation regulating VMP use. Several agencies were tasked to regulate the use of VMPs, such as the Department of Agriculture, the Department of Health, and the Philippine National Action Plan. Unfortunately, there is a challenge to implementing these regulations, which affects consumers. The unregulated use of VMPs influences the transmission of antibiotic residues from animals to crops to humans. This challenge should be addressed, with more focus on stricter regulation.

Health risk assessment and prevalence of work-related musculoskeletal disorders among the aged brick molders, in India.

The Brickfield Industry is the major and oldest informal industry in India, where millions of brickfield workers make their livelihood. Aged brickfield workers are also involved in different activities in the brickfield, especially in brick mold activities owing to poor socioeconomic conditions. A cross-sectional study was designed to determine the prevalence of work-related musculoskeletal disorders among the aged brick molders and compare them with aged control subjects. A Nordic Questionnaire was applied to assess the discomfort felt among both groups of workers and the Rapid Upper Limb Assessment (RULA) method was used to evaluate posture during their job. The RULA posture analysis showed that the posture adopted by aged brick molders required changes immediately. The result of the ART tool also stated that the brick molding activities' exposure level was high and required further investigation urgently. The study concluded that due to working in a forward bending posture for a prolonged period, aged brickmolders suffered from severe low back and knee pain along with upper-limb disorders due to repetitive activities.

Practices and outcomes of responsive caregiving on child neurodevelopment and mental health across diverse global populations: a scoping review protocol.

INTRODUCTION: Responsive caregiving (RC) leads to positive outcomes in children, including secure attachment with caregivers, emotional regulation, positive social interactions and cognitive development. Through our scoping review, we aim to summarise the practices and outcomes of RC in diverse caregiver and child populations from 0 to 8 years. METHODS AND ANALYSIS: We will use the Arksey and O'Malley framework and the Joanna Briggs Institute methodology for scoping reviews. We shall present our findings as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping review. Only peer-reviewed, English-language articles from 1982 to 2022 will be included from PubMed, Web of Science, APA PsychInfo, APA PsycArticles, SocINDEX and Google Scholar databases. Reference lists of included articles will also be screened. The search strategy will be developed for each database, and search results will be imported into Rayyan. Screening will be done in two phases: (1) titles and abstracts will be screened by two authors and conflicts will be resolved by mutual discussion between both or by consulting with a senior author; and (2) full-texts of shortlisted studies from the first phase will then be screened using the same inclusion/exclusion criteria. A data extraction form will be developed to collate relevant information from the final list of included articles. This form will be pilot tested on the first 10 papers and iteratively refined prior to data extraction from the remaining articles. Results will be presented in figures, tables and a narrative summary. ETHICS AND DISSEMINATION: No ethics approval needed as the review shall only use already published data. We shall publish the review in an open-access, peer-reviewed journal and disseminate through newsletters, social media pages, and presentations to relevant audiences.

Incorporating art into a biology course: a student-curated art exhibition about COVID-19.

Incorporating art into science, technology, engineering, and mathematics (STEM) courses can be an effective way to help students understand scientific concepts and think about those concepts more holistically. Additionally, art can be used to inform the public about scientific issues. To explore this topic more fully, we developed an assignment for an upper-level biology course in which students curated an art exhibition focused on the 2019 coronavirus disease, COVID-19. Working in pairs, students identified pieces of art in the College's permanent collection that they felt related to some aspect of the pandemic. Each pair wrote a short curator's statement and a more traditional academic essay. The works of art and the curator's statements were displayed on campus. Visitors to the exhibition were invited to complete a short survey about the exhibition and its relevance to COVID-19. Anecdotal evidence suggests that the students enjoyed and valued the assignment. Limited data from visitors to the exhibition show that they thought the art helped them think more deeply about the pandemic. Based on these results, we conclude that the development of art exhibitions in STEM courses can benefit the students and the public.

A country's efforts toward creating an advanced practice nurse in public health.

AIM: The study goal was to inform the creation of a blueprint for an advanced practice nurse (APN) in public health. BACKGROUND: No internationally accepted standard for an APN in public health exists. Activities of public health nurses (PHN) traditionally have centered on health promotion and disease prevention, but many have added other population-based activities such as chronic and acute disease treatment. INTRODUCTION: An APN in public health is needed to address the global challenges threatening the physical, social, and mental health of populations worldwide. METHODS: This qualitative study was comprised of six focus groups, each containing a different group of stakeholders (n = 40). Study results followed the requirements of the consolidated criteria for reporting qualitative research (COREQ). FINDINGS: Two major themes emerged: the APN role in public health and core expectations. From the APN role theme, four subthemes emerged on APN domains of public health practice and functions. From the core expectations theme, nine subthemes emerged on the APN's qualifications and behaviors. DISCUSSION: Agreement among stakeholders was found in the nine core expectations; however, among the four different visions of an APN in public health, two fit a population-based model rather than the traditional PHN model. CONCLUSIONS: A single APN role in public health is insufficient to address the breadth and complexity of today's global challenges as detailed by the sustainable development goals. Due to the interaction between health and the biopsychosocial environments, we need APNs with different areas of expertise. IMPLICATION FOR NURSING POLICY: Nurses working at universities, in public health services, and as healthcare policymakers are needed to create a multistage strategy that gradually introduces several different types of APNs in public health.

Sunlight: Time for a Rethink?

UVR is a skin carcinogen, yet no studies link sun exposure to increased all-cause mortality. Epidemiological studies from the United Kingdom and Sweden link sun exposure with reduced all-cause, cardiovascular, and cancer mortality. Vitamin D synthesis is dependent on UVB exposure. Individuals with higher serum levels of vitamin D are healthier in many ways, yet multiple trials of oral vitamin D supplementation show little benefit. Growing evidence shows that sunlight has health benefits through vitamin D-independent pathways, such as photomobilization of nitric oxide from cutaneous stores with reduction in cardiovascular morbidity. Sunlight has important systemic health benefit as well as risks.

Glossary of healthcare pathways: a methodological approach involving a transdisciplinary team in public health.

Introduction: The healthcare pathway is at the heart of public health organization concerns, but communication between the various players can be an obstacle. This work, produced by a French transdisciplinary team, offers a methodological approach based on formalized consensus to elaborate a glossary of healthcare pathways. A two-steps procedure was elaborated, including a double rounded Delphi method to formalize expert consensus, and two groups of experts: a workgroup and a review group. Methods: The workgroup provided a list of words or expressions that, in their opinion, described, evaluated or compared the healthcare pathways for patients, caregivers or regulators. The review group checked this list and added or deleted words or expressions. Then, definitions were added by the workgroup based into account three dimensions: official, academic and from the field. The review group validated the definitions and provided complementary proposals if needed. Results: After pooling the list of words proposed by each of the six members of the working group, 417 words/expressions were ranked. After the two rounds of evaluation, 294 words/expressions were rated "appropriate" and were analyzed by the review group. This group, after two rounds of evaluation, agreed on 263 words/expressions that were transmitted to the working group who defined them. These definitions were rated by the review group. The first round of evaluation established 195 definitions as being appropriated whereas 68 definitions were amended by the review group. Conclusion: This glossary supports transdisciplinary communication, reduces the extent of variations in practice and optimizes decision-making. International debate on all aspects might be strengthened by an improved understanding of the concept of health pathway.

The information, control, and value models of mobile health-driven empowerment.

Mobile health tools are often said to empower users by providing them with the information they need to exercise control over their health. We aim to bring clarity to this claim, and in doing so explore the relationship between empowerment and autonomy. We have identified three distinct models embedded in the empowerment rhetoric: empowerment as information, empowerment as control, and empowerment as values. Each distinct model of empowerment gives rise to an associated problem. These problems, the Problem of Interpretation, the Value Alignment Problem, and the Priority Problem, show that mobile health tools in their current form are either insufficient for empowerment or are self-defeating. These digital health technologies encourage users to adopt an individualized conception of autonomy, one that may weaken the doctor-patient relationship and undermine practices in shared decision making, and ultimately may not deliver on improving the health outcomes for those that need it the most.

Defining a public health approach to substance use: Perspectives from professionals and practitioners across Canada.

BACKGROUND: While increasingly referenced in the literature and policy discussions, a "public health approach" (PHA) to substance use has been inconsistently defined or remained undefined. As part of a larger project on building the capacity to implement a PHA to substance use, we aimed to understand how professionals and practitioners across Canada who work with or whose work directly impacts the lives of people who use substances conceptualize a PHA. METHODS: We conducted a cross-sectional national online survey of public health professionals, public safety professionals, health and social service providers, and other relevant professionals and practitioners. The survey contained closed- and open-ended questions designed to gauge familiarity and comfort with application of a PHA to substance use, and perspectives on an organizational definition of such an approach. Survey recruitment was active between May and July 2021. Data analysis included descriptive statistics and thematic analysis. RESULTS: A total of 1041 surveys were completed. Most respondents (76 %) reported having heard of a PHA to substance use, as it was defined. Over half (54 %) indicated a high level of comfort with applying such an approach within their work. In relation to defining a PHA to substance use, the following thematic suggestions emerged from respondent's open-ended answers: explicitly recognize people with lived/living experience of substance use; incorporate trauma-informed understanding and acknowledge the varied underlying reasons for substance use; decolonize approaches to substance use and empower communities; and consider a more critical appraisal of a PHA and the terminology in its definition. CONCLUSION: Empirically unpacking multi-stakeholder understandings of a PHA to substance use can help to inform a more cohesive definition and build the consensus needed for more effective, coordinated, and community-led responses to substance use. Future work, especially qualitative research, will provide richer and more practical understandings of a PHA to substance use.

Evidence and antibiotic resistance profiles of clinical Acinetobacter calcoaceticus-Acinetobacter baumannii (ACB) and non-ACB complex members in companion animals: A 2020-2022 retrospective study.

To evaluate the frequency of Acinetobacter spp., belonging to both Acinetobacter calcoaceticus-baumannii (ACB) and non-ACB complex, and their antibiotic resistance profiles in veterinary medicine, a three-year (2020-2022) retrospective study was carried out on sick companion animals. Epidemiological data from different clinical canine, feline, and equine samples, were acquired. For each strain, MALDI-TOF MS identification and susceptibility to a panel of 11 antibiotics, by Kirby-Bauer and E-test methods, were performed. Out of 628 bacteriological examinations, 2.5% resulted positive for strains belonging to Acinetobacter genus. Frequencies of 2.3%, 1.9%, and 3% were obtained from both in-visiting and hospitalized dogs, cats, and horses, respectively. Members of ACB-complex accounted for 50% of isolates. Since all strains resulted susceptible to aminoglycosides and polymyxins, no pandrug-resistant (PDR) species were recorded. While 12.5% A. baumannii resulted extensively-drug resistant (XDR), a higher percentage of multidrug-resistant strains was recorded among non-ACB strains (35.5%) than ACB strains (25%). Susceptibility was observed in the same percentage in both groups (62.5%). All ACB strains confirmed their intrinsic resistances. Non-ACB species showed lower resistances against antipseudomonal penicillins plus beta-lactamase inhibitors (P=0.1306), III generation cephalosporins (P=0.0547), and tetracyclines (P=0.0209) than ACB species. Carbapenem-resistance was observed for XDR A. baumannii (12.5%) and, in particular for MDR non-ACB complex members (25%). To our knowledge, A. lactucae represents the first description in two sick dogs in Italy. Furthermore, our results emphasize the role of non-ACB-complex species as important zoonotic pathogens, which could be reservoirs of clinically relevant resistance profiles.

Determinants of normal haemoglobin concentration among under-five children in Sub-Saharan Africa: a Positive deviance inquiry using cross-sectional study design.

BACKGROUND: Low haemoglobin level in children is linked with short-term and long-term consequences including developmental delay. Globally, over half of the children under the age of five years had low haemoglobin concentration. However, there is limited research on the prevalence and determinants of normal haemoglobin concentration among under-five children in sub-Saharan Africa. OBJECTIVE: To assess determinants of normal haemoglobin concentration among under-five children in SSA. DESIGN: Cross-sectional study design using a positive deviance approach SETTING: 33 SSA countries. PARTICIPANTS: 129 408 children aged 6-59 months PRIMARY AND SECONDARY OUTCOME MEASURES: A multilevel Poisson regression model with robust variance was fitted to identify determinants of normal haemoglobin concentration. An adjusted prevalence ratio with a 95% CI was reported to declare the statistical significance. RESULT: The pooled prevalence of normal haemoglobin concentration among under-five children in SSA was 34.9% (95% CI: 34.6% to 35.1%). High maternal education, middle and rich household wealth, female child, frequent antenatal care visits, non-anaemic mothers, taking anthelmintic drugs and normal nutritional status were associated with increased odds of normal haemoglobin concentration. On the other hand, higher birth order, having fever and diarrhoea, rural residence were associated with lower odds of normal haemoglobin levels. CONCLUSION: According to our finding, only four out of 10 under-five children in SSA had a normal haemoglobin level. This finding proved that anaemia among children in SSA remains a serious public health concern. Therefore, improving maternal education, provision of drugs for an intestinal parasite and early detection and treatment of maternal anaemia, febrile illness and diarrhoeal disease is important.

Age-period-cohort analysis of the global burden of visual impairment according to major causes: an analysis of the Global Burden of Disease Study 2019.

BACKGROUND: Cataract, glaucoma and age-related macular degeneration (AMD) are major causes of visual impairment. As these are age-related conditions, the prevalence of associated visual impairment is anticipated to increase as the population ages. However, age-period-cohort effects on the disease burden have not been investigated. METHODS: This was a population-based study using aggregated data from the Global Burden of Disease Study 2019. Age-period-cohort analysis was conducted using age-standardised prevalence rates (ASPRs) of visual impairment caused by cataract, glaucoma and AMD as disease burden indicator. RESULTS: In 2019, the estimated global ASPRs of visual impairment due to cataract, glaucoma and AMD were 1207.9, 94.7 and 96.8 per 100 000 people, respectively. Between 1990 and 2019, the global visual impairment ASPRs for glaucoma and AMD declined by 15.4% and 2.0%, respectively, whereas that for cataract increased by 5.0%. Wide heterogeneity was observed in age-period-cohort effects on ASPRs across different Sociodemographic Index (SDI) regions. Low-middle SDI regions had the largest ASPR reductions for all three eye diseases and showed improvement in both period and cohort effects. In contrast, in high-middle SDI regions, visual impairment ASPRs significantly increased during the study period with unfavourable patterns. CONCLUSIONS: The wide heterogeneity in age-period-cohort effects reflects different stages of societal transition and vision health. The unfavourable trends in age-period-cohort effects on disease prevalence identified in specific groups provide key information that may be used to identify priority groups in need of treatment and prevention.

Determining the prevalence of Escherichia coli, Salmonella, and shiga toxin-producing Escherichia coli in manure of dairy lagoons.

AIM: The aim of this study was to determine the prevalence of microbial pathogens in manure of dairy lagoons in California. METHODS AND RESULTS: To determine pathogens in dairy manure stored in anaerobic lagoons of dairy farm, an extensive field study was conducted across California to sample manure from 20 dairy farms. Samples were analyzed to determine the prevalence of indicator E. coli, Shiga toxin producing E. coli (STEC), Salmonella, and E. coli O157:H7. To test the E. coli, STEC, and Salmonella, we used agar culture-based method followed by polymerase chain reaction (PCR) method. In addition, a real- time PCR based method was used to determine the presence of E coli O157:H7. Study demonstrated that the prevalence of Salmonella in manure sample is lower than E. coli. The presence of Salmonella was found in 2.26% of the samples, and both the culture-based and PCR methods yielded comparable outcomes in detecting Salmonella. Moreover, approximately 11.30% of the total samples out of the 177 were identified as positive for STEC by qPCR. CONCLUSION: These findings demonstrate that indicator E. coli are abundantly present in anaerobic lagoons. However, the presence of STEC, and Salmonella is substantially low.

Implementing good life with osteoArthritis from Denmark (GLA:D®) in Australian public hospitals. Part 2: Service providers' perceptions.

BACKGROUND: Previous literature has reported the successful implementation of the Good Life with osteoArthritis in Denmark (GLA:D®) program into predominantly private practice settings. There may be unique challenges present within the public hospital setting that influence GLA:D® implementation in public health. OBJECTIVE: Explore the attitudes and experiences of service providers directly involved in implementing GLA:D® in Australian public tertiary hospitals. DESIGN: Qualitative descriptive study design. METHOD: Service providers (n = 14) from three participating hospitals took part in semi-structured focus groups at the completion of the 6-month implementation period. Inductive thematic analysis was employed to identify primary domains across all facilities. RESULTS: Four broad domains were identified. Factors that influenced uptake included GLA:D® being a recognisable, evidence-based product requiring minimal development or adaptation. The fidelity of the GLA:D® Australia program was challenged by referral of patients with multiple/complex medical comorbidities, and patient preference to complete registry data via paper rather than online. Several operational considerations are required when delivering GLA:D® in a public hospital setting, including adequate numbers of GLA:D®-trained staff, additional screening requirements, obtaining appropriate clinical space, and persisting patient barriers to attending the service. GLA:D® provided benefits beyond improvement in pain and function, including social interactivity, high attendance and promotion of long-term self-management, while also maximising service efficiencies. CONCLUSIONS: Implementing GLA:D® in Australian public hospitals was supported by service providers. Specific operational and administrative factors, including staff training, patient complexity, and registry requirements should be considered when attempting to embed and sustain GLA:D® in large Australian public tertiary hospitals.

Evaluating Night-Eating Syndrome in bariatric surgery patients: A cross-sectional study.

BACKGROUND: Night-Eating Syndrome (NES) is a complex eating disorder that has gained recognition in the context of bariatric surgery. However, its prevalence and associated factors in this specific patient population remain understudied, particularly in the Saudi Arabian context. METHODS: This cross-sectional study was conducted at King Abdulaziz University Hospital in Jeddah, Saudi Arabia, from June to November 2022. Adult patients who had undergone bariatric surgery with a postoperative follow-up of 6 months were included. NES was assessed using the Night Eating Questionnaire (NEQ). RESULTS: A total of 154 patients were enrolled in the study, with a mean age of 38.8 ± 11.4 years. The mean BMI before surgery was 44.8 ± 8.2 kg/m2, which reduced to 28.9 ± 5.8 kg/m2 post-surgery. Of these, 52 patients (33.8%) met the criteria for NES based on NEQ scores. The prevalence of NES was significantly higher among female patients, with 35 out of 83 females (42.2%) compared to 17 out of 71 males (23.9%) experiencing NES. While NES was not significantly associated with age, nationality, diet adherence, BMI, or surgery type, chronic diseases-particularly diabetes-emerged as significant risk factors for NES in post-bariatric surgery patients. CONCLUSION: NES is a prevalent concern among post-bariatric surgery patients, with distinct associations with gender and chronic diseases, particularly diabetes. This study provides valuable insights into NES prevalence and its risk factors in the Saudi Arabian context, highlighting the importance of addressing eating disorders within the framework of bariatric surgery care.

'Insulin is super dangerous if you don't know what you're doing': Situating the risks of insulin within the image and performance enhancing drug community.

INTRODUCTION: Insulin is an essential treatment within diabetes management; however, it takes on a role of enhancement within image and performance enhancing drug (IPED) communities due to its anabolic effects. This study sought to provide insight into how IPED users perceive and manage the risks linked to insulin. METHODS: We conducted semi-structured interviews with 10 individuals from Australia and United Kingdom who used insulin as part of their IPED protocols. The analysis followed an iterative categorisation approach and applied the lens of situated rationality theory. RESULTS: The decision to incorporate insulin was influenced by peers' experiences and preferences. Participants highlighted the risks and responsibilities associated with insulin use, emphasising the need for precise lifestyle habits. They recognised the potential dangers and called for comprehensive harm reduction strategies within IPED communities to respond to such concerns. Some participants expressed reluctance to discuss insulin openly, underlining the importance of education and awareness to mitigate health risks associated with underground and uninformed use. DISCUSSION AND CONCLUSIONS: While people who use IPEDs demonstrate awareness of the risks associated with insulin, their practices of routinisation moderate these risks within the context of IPED use. Silence as a risk-reduction strategy highlights vulnerabilities among certain prospective users, while the hierarchical structure of IPED use establishes expertise and status within the community. Reconsidering insulin risks entails reframing harm reduction messages to better match the social dynamics of IPED communities. Closer ties between IPED communities can enhance support accessibility, particularly through peers, who, with their firsthand knowledge, can offer tailored guidance.