BMC Public Health

Background Type 2 diabetes (T2D) disproportionately affects socioeconomically disadvantaged communities. Evidence on the feasibility and effectiveness of prevention and self-management strategies in complex contexts remains limited. Objective To report effectiveness outcomes from a feasibility trial comparing the SMART2D intervention with routine primary care for T2D prevention and control in two neighbourhoods in Stockholm. Methods A cluster-randomized feasibility trial with hybrid type 1 design was conducted in two neighbourhoods among individuals at high risk of T2D (n=84) or with diagnosed T2D (n=58), allocated to an integrated care arm (n=70; personal coaching and community outreach) or facility-only arm (n=72; routine care). Primary outcomes were glycaemic control (participants with T2D) and HbA1c reduction (participants at high risk of T2D); secondary outcomes were retention to care and diabetes incidence (participants at high risk of T2D). Analysis used intention-to-treat principles: difference-in-differences with mixed-effects models for HbA1c reduction, and modified Poisson regression (IRR, 95% CI) for other outcomes. Results Among participants with T2D, glycaemic control (adjusted IRR=0.92, 95% CI=0.89-0.95) and retention to care (adjusted IRR=0.91, 95% CI=0.91-0.92) were significantly lower in the integrated care arm. Among participants at high risk of T2D, integrated care showed a marginally significant, greater HbA1c reduction (adjusted 2.02, 0.20-3.84) and significantly higher retention to care (adjusted IRR=1.22, 1.15-1.29), plus fewer incident diabetes cases (0 vs. 2 in facility-only). Conclusions Integrated care (personal coaching, community outreach) benefited HbA1c reduction and retention among participants at high risk of T2D, whereas facility-only care improved glycaemic control and retention among participants with T2D.

Background. Metabolic syndrome is a cluster of cardiometabolic risk factors that may increase the risk of cardiovascular disease and type 2 diabetes, and African studies report a higher prevalence in women than in men. Prevention may depend, in part, on whether women recognise the condition and its modifiable risk factors. Relatively little appears to be known about this among women using primary-level health facilities in fast-growing peri-urban areas of Ghana. Objective. To assess knowledge of metabolic syndrome, describe lifestyle risk behaviours, self-reported cardiometabolic conditions and preventive practices, and examine selected lifestyle correlates of self-reported diabetes and hypertension among women attending Kasoa Polyclinic, Ghana. Methods. A descriptive cross-sectional survey was conducted in June and July 2024 among 174 women aged 18-45 years recruited by convenience sampling. A structured, interviewer-assisted questionnaire covered knowledge, lifestyle behaviours, self-reported diagnoses and preventive practices. Data were summarised as frequencies and percentages, and associations were examined with Pearson's chi-square test. Results. Only 37 women (21.3%) described metabolic syndrome as a condition that raises the risk of heart disease and type 2 diabetes, 40 (23.0%) identified central (apple-shaped) fat as the high-risk pattern and 31 (17.8%) knew that dietary recommendations exist. Most reported no weekly physical activity (116; 66.7%), daily sugary drinks (109; 62.6%), daily processed or fast food (100; 57.5%), high stress (103; 59.2%), and less than six hours' sleep (94; 54.0%). Self-reported diagnoses were hypertension in 60 (34.5%) and type 2 diabetes in 49 (28.2%). Fifty-nine (33.9%) had never received advice on prevention and 105 (60.3%) did not monitor their weight or waist. Self-reported diabetes was associated with short sleep (36.2% among those sleeping under six hours; p = 0.035) and with stress level (p = 0.028), being most frequent among women reporting low stress. Self-reported hypertension was more common with high stress (42.7%; p = 0.022) and with some physical activity (p = 0.005). Conclusion. Women attending this polyclinic appeared to have limited understanding of metabolic syndrome and a high burden of modifiable risk behaviours. Routine counselling on diet, activity, sleep, and weight monitoring at the polyclinic may be warranted. The bivariate, self-reported associations should be interpreted cautiously.

Background: Quantifying behavioral drivers of protective action during infectious disease outbreaks remains challenging. App-based experimental epidemic games (epigames) provide a framework for studying these decisions in naturalistic settings, but correspondence between in-game measures and real-life beliefs or behaviors requires evaluation. We examined whether an activity-based opportunity cost influenced voluntary quarantine decisions within an epigame and whether real-life health beliefs transferred into the game and predicted observed choices. Methods: We conducted a two-week randomized controlled trial from May 4 to May 17, 2026, at VinUniversity (VinUni) in Hanoi, Vietnam. Participants using the Epigames app installed in their smartphone were randomized to a low-barrier group, earning 1 point per qualifying contact with other participant when remaining active, or a high-barrier group, earning 2 points per contact. Of 439 enrolled participants, 283 were successfully randomized to one of the two groups, made at least one valid daily quarantine decision, and their data was used in the analysis. Real-life (S1) and in-game (S2) beliefs measured susceptibility, severity, quarantine self-efficacy, and perceived benefits. Belief correspondence was assessed using Holm-adjusted Spearman correlations and prospective cumulative-logit models. Quarantine choices were analyzed using participant-day binomial generalized estimating equations (GEE) and participant-level quasi-binomial models. Results: Participants made 1,823 valid daily decisions and chose quarantine on 458 participant-days (25.1%). Quarantine rates were 30.1% in the low-barrier group and 20.2% in the high-barrier group. The high barrier was associated with 41% lower population-averaged odds of quarantine (GEE odds ratio [OR] 0.59, 95% confidence interval [CI] 0.40-0.86, = 0.0059); the quasibinomial estimate was identical (OR 0.59, 95% CI 0.40-0.86, = 0.0055). Among 251 participants with matched S1-S2 data, all four corresponding beliefs were positively associated (Spearman's = 0.259-0.418; all Holm-adjusted < 0.001). Prospective ordinal models confirmed positive matched-domain associations (ORs 1.39-2.18 per one-point S1 increase). Beliefs showed little robust association with quarantine behavior, and neither S1 nor S2 beliefs jointly modified the randomized effect. Self-efficacy, network degree, and the preregistered gender main effect were also unsupported. Conclusion: A higher activity-based opportunity cost reduced voluntary quarantine within the VinUni epigame, while participants carried relative differences in stated health beliefs from real-life to in-game framing. These beliefs did not reliably predict observed quarantine choices within the game framing. Epigames can support controlled study of incentives and belief correspondence in naturalistic settings such as college campuses, but behavioral validity or real-world generalizability requires further work.

Introduction Vaccination against human papillomavirus (HPV) is the most effective strategy for preventing cervical cancer. We evaluated HPV Vaccine Integrated Service Implementation (HPV-VISION), a program aimed at integrating HPV vaccination with adolescent health (AH) services and the Expanded Program on Immunization (EPI) to improve vaccine uptake among girls aged 9 to 14 years in rural Ethiopia. Methods This mixed-methods implementation study was implemented in four woredas testing two models of integrating HPV vaccination into routine health services: integration with EPI and with an AH service package. We used program monitoring data; exit interviews, in-depth interviews, and focus group discussions with adolescent girls and caregivers; key informant interviews; and costing data. We analyzed effectiveness using negative binomial generalized estimating equation models with facility-level monthly HPV vaccinations as the primary outcome. We analyzed exit interview data descriptively across models. We analyzed qualitative data thematically and conducted a costing analysis. Results The HPV-VISION program delivered 25,821 HPV vaccinations from March to August 2025. Adjusting for baseline differences, facilities in the AH model delivered, on average, 34% fewer HPV vaccinations per month compared to those in the EPI model (adjusted IRR: 0.66; 95% CI: 0.51-0.87). Nearly all girls said they would be happy to receive services again at the place they were interviewed (EPI: 94%, AH: 98%). Experience of care was positive overall with individual measures varying across models. The incremental delivery cost (excluding vaccine cost) per vaccinated girl was USD $7.54 in the EPI model and USD $14.28 in the AH model. Conclusion We recommend that HPV vaccine delivery incorporates integration with AH services and routine vaccination to most efficiently reach underserved girls. An optimal mix of integration with the EPI program and AH services should be based on regional HPV vaccination indicators, other AH needs, population demographics, and costs of the models.

Background: Childhood experiences contribute to health and wellbeing across the life course, yet research from low- and middle-income countries has largely focused on a few outcomes rather than broader patterns of adult wellbeing, behaviors, and social and financial circumstances. Methods: In this cross-sectional analysis, we used a nationally representative sample of adults in India (N = 12,765; aged [&ge;] 18 years) from the Global Flourishing Study (GFS) Wave 1 (2023) to examine associations between eight retrospectively reported childhood experience items, 45 adult outcomes, and two composite flourishing indices. Survey-weighted linear, logistic, and proportional-odds models adjusted for age, gender, education, and residential setting, with Bonferroni correction were used to assess associations and effect modification by gender. Findings: Although the breadth and strength of associations differed across childhood experiences, less favorable childhood experiences were generally associated with poorer wellbeing and flourishing, greater odds of adverse health outcomes, and reduced access to resources and safety in adult life. However, outcomes related to prosocial behaviors showed a different pattern: childhood abuse (physical or sexual) was associated with greater odds of volunteering (OR 1.31, 95% confidence interval or CI [1.13,1.51]), feeling like an outsider in one's family with greater odds of donating (OR 1.80, 95% CI [1.52,2.13]), volunteering (OR 1.53, 95% CI [1.28,1.82]), and helping a stranger (OR 1.49, 95% CI [1.27,1.74]). Associations were broadly similar between females and males, with little evidence of gender differences. Interpretation: Associations of childhood adversity with poorer health and increased prosocial behavior in adult life may reflect unmeasured social, cultural, or dispositional factors and heterogeneous life-course responses. Nevertheless, these findings support strengthening child-protection, financial assistance programs, and mental health services in India.

BackgroundSocial isolation (SI) is an established risk factor for chronic disease and mortality. How people travel, including the modes of transportation they use, may shape opportunities for social interaction and influence the impacts of SI. This study assessed heterogeneity of the association between SI and mortality across primary modes of non-commute transportation. MethodsWe analyzed cohort data from the UK Biobank, following participants aged 40-69 years from 2006 to 2022. SI at baseline was derived from three items and dichotomized. Cox models were used to estimate the association between SI and mortality, adjusting for socioeconomic factors, health behaviours, and comorbidities. Effect modification by participants primary mode of non-commute transportation was assessed using interaction terms with SI. ResultsThere were 490,114 participants with complete baseline exposure data. SI was associated with increased hazard of all-cause (Hazard Ratio [HR] = 1.34, 95% Confidence Interval [CI]: 1.31-1.38) and cardiovascular mortality (HR = 1.49, CI: 1.41-1.57). The association with cardiovascular mortality was stronger among participants who only used public transport compared with those who only used a car (interaction HR = 1.17, CI: 1.00-1.37). In contrast, using a car alongside active or public transport, compared to using a car alone, attenuated the association between SI and all-cause mortality (interaction HR = 0.93, CI: 0.87-0.99). ConclusionMixed transport, including a car, showed the greatest reduction in the association between SI and all-cause mortality. Our findings motivate further exploration of the role of transportation modes in enhancing social connection, mobility, and health.

Background: Short birth intervals are a well-documented, modifiable risk factor for child death in low- and middle-income countries, yet nationally representative evidence from Ghana's most recent Demographic and Health Survey has not been fully examined. This study assessed the association between the preceding birth interval and under-five mortality using the 2022 Ghana Demographic and Health Survey. Methods: The analysis used the complete birth history reported by women aged 15-49 years. The cohort comprised births occurring 60-119 completed months (5-10 years) before the survey, which allowed a complete five-year observation window for under-five survival (n = 8,418; 397 deaths). Spacing models were restricted to second-or-higher-order births with a defined preceding interval (n = 6,340; 282 deaths), categorised as under 18, 18-23, 24-35 (reference), 36-47, and 48 or more months. Crude and adjusted odds ratios were estimated using survey-weighted, Taylor-linearised logistic regression, adjusting for birth order, child sex, plurality, maternal age, residence, region, maternal education, wealth quintile, and marital status. Results: Weighted under-five mortality in the cohort was 45.4 per 1,000 live births (4.54%). Among second-or-higher-order births, weighted mortality fell from 9.3% after intervals of under 18 months and 8.0% after 18-23 months to 4.2%, 3.2%, and 3.5% after 24-35, 36-47, and 48 or more months, respectively. Relative to 24-35 months, the adjusted odds of death were higher after intervals of under 18 months (adjusted odds ratio [AOR] 2.58, 95% confidence interval [CI] 1.48-4.49, p < 0.001) and 18-23 months (AOR 2.09, 95% CI 1.33-3.29, p = 0.001); longer intervals did not differ from the reference. Multiple birth (AOR 2.48, 95% CI 1.33-4.63) and having a mother who was never in union (AOR 3.25, 95% CI 1.29-8.17) were also associated with higher odds of death, and marked regional variation persisted after adjustment. Conclusion: A short preceding birth interval, particularly one of under 18 months, was independently associated with an approximately two- to two-and-a-half-fold increase in the odds of under-five death in this nationally representative sample. The findings support continued investment in postpartum family planning to help women space births at least 24 months apart, alongside closer attention to multiple births, unmarried mothers, and the regions carrying the greatest burden.

Introduction: Vaping public education campaigns are a central prevention strategy for young adults (YAs), but message effectiveness varies widely and formative testing typically evaluates one message attribute at a time. This study examined how four perceptual dimensions, including cognitive engagement, social relevance, emotional arousal, and emotional valence, relate to perceived message effectiveness (PME), and whether multiple combinations of these dimensions correspond to similarly high PME. Methods: In a cross-sectional online message-testing study conducted from March to April 2025, 540 U.S. YAs who vape each evaluated 15 messages randomly sampled from a corpus of 229 text-image vaping public education messages, yielding 8,100 message evaluations. Cross-classified multilevel models estimated associations between each perceptual dimension and PME. An Explainable Boosting Machine probed nonlinear associations, and k-means clustering of high-predicted-PME perceptual configurations identified distinct profiles. Analyses were conducted in 2026. Results: Cognitive engagement (b = 0.20, 95% CI [0.18, 0.22]) and social relevance (b = 0.15, 95% CI [0.13, 0.17]) showed the strongest associations with PME, followed by emotional arousal (b = 0.06, 95% CI [0.04, 0.08]); emotional valence showed no linear association (b = 0.00, 95% CI [-0.02, 0.02]). The Explainable Boosting Machine revealed a U-shaped valence pattern, with higher predicted PME at both the negative and positive ends of the scale. Clustering yielded five distinct perceptual profiles with similarly high predicted PME (4.10-4.25). Conclusions: Multiple perceptual configurations correspond to similarly high PME, supporting a configurational approach to formative message testing rather than a single optimal message formula.

Background: Anaemia in women of reproductive age is a persistent contributor to maternal morbidity and adverse birth outcomes in sub-Saharan Africa. Ghanaian surveys have repeatedly placed national anaemia prevalence in the World Health Organization's severe public health problem range, yet the geographical distribution of this burden, and the socioeconomic factors that may account for it after geographical adjustment, remain insufficiently elucidated. Methods: This cross-sectional study analysed the women's and geospatial files of the 2022 Ghana Demographic and Health Survey. Anaemia was defined as altitude- and smoking-adjusted haemoglobin below World Health Organization thresholds among 7,557 women aged 15-49 years with a valid measurement. Survey-weighted multivariable logistic regression, accounting for clustering, stratification, and sampling weights, was used to elucidate socioeconomic and demographic correlates. Cluster-level prevalence was tested for spatial clustering with global Moran's I and local Getis-Ord Gi* statistics (k-nearest neighbour weights, k = 8). Results: Weighted anaemia prevalence was estimated at 41.1% (mild: 22.6%, moderate: 17.3%, and severe: 1.1%). Pregnant women appeared to have higher adjusted odds of anaemia than non-pregnant women (adjusted odds ratio [AOR] 1.71, 95% CI 1.38-2.12), as did women in the Northern (AOR 1.54, 95% CI 1.16-2.06) and Savannah (AOR 1.35, 95% CI 1.04-1.76) regions relative to Greater Accra, while the Ahafo region showed lower odds (AOR 0.64, 95% CI 0.43-0.94). Associations with rural residence, education, and wealth that were significant in crude analysis appeared substantially attenuated after adjustment. Moran's I suggested significant positive spatial autocorrelation (I = 0.156, p = 0.001); Getis-Ord Gi* identified 109 hotspot and 117 cold spot clusters among 618 clusters, with hotspots concentrated in the north and cold spots in the mid-southern forest belt. Conclusion: Two in five women of reproductive age in Ghana were estimated to have been anaemic in 2022. Risk appeared to be shaped more by region and pregnancy status than by household wealth or education once geography was accounted for. Anaemia-control programming may benefit from prioritising the identified northern hotspot areas alongside routine antenatal supplementation.

Community-led urban greening may contribute to neighborhood safety, but its relationship with crime remains uncertain. We examined whether Keep Indianapolis Beautiful Project GreenSpaces in Indianapolis were associated with changes in violence and total crime. We used a matched-pair difference-in-differences design comparing funded sites with matched unfunded applicant sites. The primary analysis included 29 matched pairs with two years of pre- and post-grant follow-up. Monthly Part I violent offenses and total crime within 600-m buffers were modeled using Poisson pseudo-maximum likelihood. In the first post-grant year, the violent-crime estimate was lower but imprecise (IRR, 0.903; 95% CI, 0.805-1.014). In the second post-grant year, the relative rate was lower (IRR, 0.830; 95% CI, 0.718-0.961). Total crime estimates showed no clear post-grant change. Additional analyses indicated some sensitivity to spatial scale, but no sustained divergence in pre-grant crime patterns. Analyses of short-term crime dependence showed clear month-to-month persistence in violent crime within sites but limited evidence of stable spatial dependence across nearby sites. Therefore, within the two-year post-grant period examined, Project GreenSpaces was associated most consistently with lower relative violent-crime rates in the second year, while no corresponding decrease was observed for total recorded crime. Longer follow-up is needed to determine whether these patterns persist or change as projects mature.

Background Chemsex, drug use before/during sex to facilitate and enhance the experience, is undertaken by a minority of gay, bisexual and other men who have sex with men (GBMSM), but evidence of chemsex prevalence in England is limited. This study describes trends in chemsex prevalence between 2022-2025 and identifies factors associated with chemsex amongst GBMSM in England. Methods Data from the RiiSH study (2022-2025), an annual online cross-sectional survey of GBMSM recruited through social networking/dating apps and community partners, were analysed. Trends in chemsex prevalence and adjusted prevalence were estimated using log-binomial regression models. The following seven variables were candidate factors associated with chemsex and were assessed through logistic regression: age, sexual orientation, education, employment, HIV status, HIV PrEP use, and sexual health service (SHS) use. Results 5728 GBMSM were included in this study. Adjusted chemsex prevalence varied from 6.1% in 2022 to 4.2% in 2023, 5.1% in 2024 and 6.8% in 2025. Chemsex was more likely in GBMSM who were: gay (aOR=1.57 versus other sexual orientations; 95%CI 1.11-2.29, p=0.01), unemployed (aOR=3.08 versus employed full-time; 95%CI 2.19-4.26, p<0.001); aged 35-59 versus 16-34 years (p<0.001), with recent HIV PrEP use (aOR=3.79 versus no recent use; 95%CI 2.63-5.56, p<0.001), SHS use (aOR=2.23 versus no recent use; 95%CI 1.76-2.83, p<0.001), and living with HIV (aOR=3.16 versus negative/unknown HIV status; 95%CI 2.43-4.09, p<0.001). Conclusions Chemsex prevalence was low and stable between 2022-2025. PrEP and SHS use were associated with chemsex, supporting integration of specialist support services within SHS.

Introduction: Adolescents in low- and middle-income countries continue to face barriers to family planning (FP) and post-abortion care (PAC), including stigma, limited confidentiality, inadequate information, and health-system constraints. This study explored adolescents and key stakeholders perspectives on strategies to improve uptake of adolescent FP and PAC services in Lira District, Northern Uganda. Methods and Materials: An exploratory qualitative descriptive study was conducted using 13 focus group discussions (FGDs) with 65 adolescent citizen scientists aged 10-19 years and 13 key informant interviews (KIIs) with stakeholders involved in adolescent sexual and reproductive health and PAC. Data were collected using semi-structured guides, audio-recorded with consent, and supplemented by field notes, then analyzed thematically using Braun and Clarkes six-phase framework. Results: Five interconnected themes emerged, including strengthening school, community, and faith-based SRH education; strengthening the health system and service delivery; policy, legal, and institutional clarity; community engagement and trust building; and integration of FP and PAC. Participants prioritized accessible and accurate SRH education, supportive community engagement, confidential and respectful care, and reliable commodities, clear operational guidance, coordinated referrals, and integrated services. The findings indicate that uptake is shaped by interacting with individual, social, health-system, and policy conditions rather than knowledge alone. A participatory, multilevel approach that connects community-generated knowledge with adolescent-responsive health-system strengthening may offer a feasible pathway for improving FP and PAC uptake in Northern Uganda. Conclusion: Adolescents and key stakeholders identified interconnected community, health-system, policy, and service-delivery strategies for improving uptake of FP and PAC services. Priority actions included accessible SRH education, supportive community engagement, confidential and respectful care, reliable commodities, clear operational and legal guidance, and integrated FP and PAC delivery.

Childhood experiences are important antecedents of adult flourishing, yet gender patterns in these experiences are under-studied in large global samples using a common survey instrument and population-based study design. From the Global Flourishing Study Wave 1 data (2022-2024), we analyzed responses from 203,430 adults (51% female, 49% male) in nationally representative samples from 21 nations on eight childhood-related items: experiencing physical or sexual abuse, feeling like an outsider in the family, feeling loved by one's mother or father, quality of relationship with one's mother or father, health growing up, and perceived family financial situation. Greater negative experiences were noted in more affluent nations (as measured by gross domestic product (GDP) per capita), with negative experiences generally reported more often among females than males, again especially in more affluent nations. Gender differences were more pronounced when it came to relationships with mothers compared to fathers. Perceptions regarding health and family finance while growing up did not show appreciable gender differences and had weaker correlations with other items.

Background: Unpaid caregiving is a recognised social determinant of health, yet most research treats it as a fixed exposure measured at a single time point, and little is known about how patterns of caregiving transitions relate to health behaviours. Methods: Secondary analysis of the UK Household Longitudinal Study (waves 2 to 13, approximately 2010 to 2023; n=25,049). Latent class analysis was applied to binary caregiving status across 12 waves to identify caregiving trajectories. Associations between trajectories and four health behaviours (physical inactivity, fruit and vegetable consumption, problematic drinking, current smoking) at waves 7 to 13 were estimated using logistic and linear regression, adjusting for sociodemographic, health and baseline behavioural confounders. Results: An eight-class solution identified a non-caregiving class comprising 62.9% (n=15,760) of the sample. Among caregivers (n=9,289), trajectories were Temporary (20.0%), Former-short (20.2%), Former-long (10.9%), Emerging-short (15.4%), Emerging-long (11.6%), Long-term (15.7%) and Recurrent (6.3%). In fully adjusted models, Recurrent caregivers had higher odds of smoking (OR=1.67, 95%CI: 1.17 to 2.40) compared with non-caregivers but lower odds of physical inactivity (OR=0.65, 95%CI: 0.53 to 0.81) and problematic drinking (OR=0.75, 95%CI: 0.59 to 0.94). Associations for other trajectory classes were largely attenuated after adjustment. Conclusion: The pattern and timing of caregiving transitions are an under-explored dimension of the caregiving experience. Recurrent caregivers had a distinctive profile, with elevated smoking but lower physical inactivity and problematic drinking. Recurrent caregiving should be recognised alongside intensity and duration, and support systems better equipped for people who move into and out of care repeatedly.

Background: Early pandemic responses must balance transmission control against socioeconomic costs but the strategy that minimises total costs and whether it varies by country remain unknown. We analysed country-specific cost-optimal intervention strategies and examined whether national indices could inform response targets. Methods: We fitted mechanistic models to the first year of reported COVID-19 cases in 110 countries and assessed structural identifiability and parameter uncertainty. Multi-objective optimisation identified efficient trade-offs between transmission reduction and infections across 26-, 40-, and 52-week horizons without vaccination. We selected cost-minimising strategies using GDP-scaled intervention costs and infection costs incorporating quarantine and mortality. Excess-cost ratios, defined as the relative cost increase over the optimum, quantified deviations from the cost-minimising strategy. We also examined associations with national socioeconomic and health-system indices. Results: Cost-optimal average transmission reduction ranged from 31.2% to 57.3% across countries. Across the time horizons, the mean excess-cost ratio for 110 countries was 55.2% (median 30.8%). Excess costs increased asymmetrically around the country-specific optimal transmission reduction: a five-percentage-point transmission reduction below the optimum was associated with excess-cost ratios exceeding 400%, compared with 10-80% for an equivalent increase above the optimum. The range of transmission reduction associated with excess-cost ratios below 40% widened 1.47-fold as the horizon increased from 26 to 52 weeks. Among national indices, the Socio-Demographic Index (SDI) and GDP per capita had the largest redundancy indices (0.40 and 0.37, respectively). Conclusions: Under the modelled assumptions, transmission reduction below the country-specific optimum resulted in greater excess costs than reduction above the optimum, highlighting the potential value of precautionary early-response strategies when intervention effectiveness is uncertain. National socioeconomic and health-system indices may provide a broad indication of cost-optimal intervention intensity, although country-specific conditions remain important. These findings provide a quantitative framework for balancing intervention intensity, infection burden, and economic costs across diverse national settings.

Introduction Within the Tobacco and Vapes Act 2026, the UK Government is considering restricting retail displays of vaping and other nicotine products to discourage youth uptake. We explored how adult nicotine users and adolescents responded to conventional and restricted displays. Methods Two UK-wide cross-sectional online surveys were conducted April-June 2026, with current and former adult nicotine users (n=2,851), and adolescents (11-17 years; n=2,123). Participants rated images of vape and nicotine pouch point-of-sale (POS) displays (two conventional, two restricted) across 10 items. Other measures included demographics, smoking/vaping/nicotine pouch use, vaping susceptibility, and product choice. Results Ratings of two conventional POS images were consistently favourable. Two restricted POS images were almost exclusively rated unfavourably. GEE analyses, controlling for demographics and behaviour, indicated that a display with standardised white packs (versus a conventional display) consistently had lower odds of favourable ratings (adults range:0.13-0.31; adolescents range:0.11-0.32). A fully covered display had even lower odds of favourable ratings on all items (adults range:0.06-0.19; adolescents range:0.05-0.10). Presented with hypothetical restricted displays, most adults using nicotine remained consistent with their product choice. Favourable ratings of conventional displays were positively associated with adolescents' vaping susceptibility. Those favourably rating a large, branded display were more likely to be susceptible than those giving unfavourable/neutral ratings (AOR=2.73, 95%CI [2.16-3.45] p<0.001). No association was found between favourable ratings of restricted displays and susceptibility. Conclusion Restricting POS displays could reduce positive messaging around vaping and adolescent susceptibility. The potential impact of restrictions on adult users' perceptions of harm and accessibility should be considered.

ObjectiveTo assess the knowledge, willingness and barriers to human papillomavirus (HPV) vaccination among caregivers of adolescent girls living with HIV in Sierra Leone. MethodsThis cross-sectional study examined HPV vaccine knowledge, willingness, and barriers among 249 caregivers of adolescent girls living with HIV in Sierra Leone. Data were collected through structured questionnaires at public tertiary hospitals and high-volume HIV clinics, and associations were assessed using chi-square tests, logistic regression, and Kruskal-Wallis analyses. ResultsOnly 32.1% (80/249) of caregivers had heard of HPV, with even fewer aware of its link to cervical cancer (24.4%, 60/246) or prevention methods of cervical cancer (31.9%, 79/248). Misconceptions were prevalent; 16.3% (36/221) erroneously linked oral contraceptives to cervical cancer, and 61.1% (44/72) of caregivers unwilling to vaccinate cited distrust in vaccine efficacy. While tertiary-educated caregivers exhibited the highest level of knowledge (45.5%, p < 0.001), their willingness to vaccinate (50%, 33/66) was comparable to that of less-educated groups, highlighting a knowledge-action gap. Structural barriers dominated, with 66.1% (154/233) citing unawareness of the vaccine and 10.3% (24/233) missing school-based vaccination days. Relationship dynamics significantly influenced willingness: extended family members showed the highest willingness (69.4%, p = 0.029), whereas grandparents were least willing (31%, 9/29). Although systemic gaps such as disrupted vaccination services, vaccine supplies and cold chain limited uptake, healthcare workers emerged as the most effective information source (rank sum = 889.5, p = 0.039). ConclusionThe study highlights the need for culturally tailored education to dispel myths and community-driven strategies engaging trusted actors like healthcare workers and extended families. This study justifies the need for integration of HPV vaccination and cervical cancer screening into HIV care services.

Objective: Overweight and obesity in childhood and adolescence are major risk factors for health problems across the lifespan. This manuscript reports the current prevalence of overweight and obesity among children and adolescents aged 4-17years living in Germany and compares them with previous population-based results. Methods: A representative, cross-sectional sample of 4-17-year-olds was drawn following a multistage sampling process. Analyses are based on weight and height of 3,978 individuals measured in the field by trained test instructors between 2023-2025. Overweight and obesity classification was defined using age- and sex-specific body-mass-index percentiles. To allow for comparability of prevalence estimates derived from previous assessment waves and other panel studies dating back to 2005, an alignment factor was derived using an inverse probability of participation weighting approach. Together with sampling weights, the alignment factor was applied to obtain current, representative prevalence estimates of overweight and obesity. Results: The aligned, weighted prevalence of overweight and obesity was 16.1% (95%CI[14.5-17.9%]), whereas prevalence of obesity was 6.7% (95%CI [5.5-8.1%]). Age- and sex-specific prevalence rates are reported and compared to previous waves. Conclusions: The current prevalence of overweight and obesity in children and adolescents aged 4-17 years living in Germany remains stable over the past two decades.

Background Cancer stigma contributes to low cervical cancer screening rates among Nepali women. However, no stigma reduction interventions have been implemented thus far in Nepal. This study assessed the effectiveness of a muticomponent cervical cancer stigma reduction intervention on cancer stigma scores and cervical cancer screening uptake rates among urban Nepali women. Methods A two-arm, parallel cluster-randomized trial was conducted in Budhanilkantha Municipality, Kathmandu District, Nepal. Twelve administrative wards were randomized in a 1:1 ratio to the intervention or control group, with wards serving as the unit of randomization and individual women as the unit of analysis. A total of 310 women aged 30-60 years who had not undergone cervical cancer screening during the previous five years were enrolled. The three-hour intervention included cervical cancer education, a video featuring cervical cancer survivors, participatory group discussions, and myth-versus-fact activities addressing cancer stigma. Cancer stigma was assessed two months after the intervention using the Nepali version of the Cancer Stigma Scale. Cervical cancer screening uptake was assessed six months after the intervention. Data were analyzed using intent-to-treat and as treated approaches with a generalized estimation equation with logistic regression. Results From June 2022 to February 2023, 310 women were enrolled. At 2 months, stigma data were available for 248 participants (120 intervention, 128 control). In the intention-to-treat analysis, the odds of cancer stigma were lower in the intervention group than in the control group (OR 0.25, 95% CI 0.08 to 0.8; p=0.022). Odds were also lower for the severity domain (OR 0.31, 95% CI 0.10 to 0.90; p=0.048) and awkwardness domain (OR 0.21, 95% CI 0.08 to 0.56; p=0.001) with no differences in other subdomains. At 6 months, the odds of cervical cancer screening was 3.9 times greater in the intervention group than in the control group (95% CI: 1.1-13.20, p=0.028). As treated analysis reinforced these findings, with lower odds of stigma (AOR:0.09, 95% CI: 0.01-0.53, p=0.007), severity (AOR:0.16, 95% CI: 0.06-0.42, p<0.001), and awkwardness (AOR:0.1, 95% CI: 0.02-0.44, p=0.02). Cervical cancer screening odds was 4.02 times higher in the intervention group (95% CI:1.1-13.7, p=0.026). Conclusions Compared with the control condition, participants allocated to a community-based multicomponent intervention designed to reduce cancer stigma had lower odds of elevated cancer stigma two months after the intervention and higher odds of cervical cancer screening by six months. Larger cluster-randomized trials with more clusters and longer follow-up are needed to assess the reproducibility, durability, and generalizability of these findings.

As internet and mobile phone access increases, digital health interventions are increasingly used to support remote and low-resource populations. In many settings, the health impact of digital interventions is constrained by limited or short-lived engagement. We tested if conditional mobile data credit incentives increase digital intervention engagement within a digital intervention trial. This nested cluster randomized controlled trial was conducted with caregivers of children 3-9 months at baseline. Of 72 neighborhood clusters from the treatment arm of the parent trial (evaluating a digital early childhood development intervention), 20 were randomly assigned to treatment and 52 as controls. Eligible participants had a phone provider through which mobile data credits could be most affordably administered. Treated participants received around 250 MB mobile data credits every two weeks, conditional upon using the digital intervention at least once in the same period. Credits were digitally administered via a third-party service. Digital intervention engagement (primary outcome) was monitored continuously until endline data collection approximately 2 years after assignment. Secondary outcomes included caregivers views, behaviors, and early childhood development. We used intent-to-treat analyses to assess all outcomes. This trial was registered as NCT05202106 at clinicaltrials.gov and was completed in 2025. Participants were recruited between September 2021 and March 2023 (N Treatment = 147; N Control = 333). Conditional mobile data credits extended engagement with the digital early childhood development intervention by 6.50 weeks on average (treatment mean = 26.19 weeks, control mean = 19.69; p=0.011). No significant impacts were identified on secondary outcomes. As such, mobile data credits may be a cost-effective way for increasing caregiver engagement with digital health intervention in low resource settings.