BMC Public Health

Background: Lung cancer screening can reduce lung cancer mortality through early detection, but uptake of the NHS Targeted Lung Health Check (TLHC) programme remains low. Behaviourally informed invitation messages have been proposed as a low-cost approach to increase attendance, but evidence of their effectiveness in lung cancer screening is mixed. Few intervention studies used evidence-based behaviour change frameworks, and rarely tailored invitation strategies to empirically identified barriers and enablers. Methods: In an online experiment, 3,274 adults aged 55-74 years and with a history of smoking were randomised to see one of four behaviourally informed invitation messages or a control message. Participants then rated their intention to attend a TLHC appointment, and selected barriers and enablers to attending from a pre-defined list, which were classified according to the Theoretical Domains Framework. Invitation messages were mapped to Behaviour Change Techniques using the Theory and Techniques Tool. Message conditions were compared on intention to attend TLHC using bootstrapped ANOVA followed by pairwise comparisons. Exploratory counterfactual mediation analyses examined the role of fear in intention to attend. Results: Behaviourally informed invitation messages did not meaningfully increase intention to attend TLHC compared with the control message. While a GP-endorsed message showed a small potential benefit relative to the other conditions, this finding was not robust after adjustment for multiple comparisons. Participants most frequently reported barriers related to Emotion (particularly fear), Social Influence, and Knowledge, while Beliefs about Consequences emerged as the primary enabler of attendance. Only around half of reported barriers and enablers were addressed by the invitation messages. Exploratory analyses found that fear was associated with lower intention to attend a TLHC appointment, yet none of the behaviourally informed messages appeared to reduce fear compared to the control message. Conclusions: Improving lung cancer screening uptake will likely require invitation messages that directly address emotional concerns, particularly fear, alongside credible recommendations. These findings highlight the importance of systematically aligning invitation message content with empirically identified behavioural influences when designing scalable interventions to improve lung cancer screening uptake.

IntroductionIncreasing global prevalence of overweight and obesity underscores the need for context-specific evidence to guide preventive policy implementation. Previous modelling showed that promoting healthy indigenous foods, implementing a 20% tax on sugar-sweetened beverages (SSBs), and introducing mandatory kilojoule menu labelling in formal-sector restaurants in Kenya were health-promoting, cost-saving, and cost-effective. Cost-effectiveness evidence is strengthened when considered alongside broader policy implementation considerations. We engaged stakeholders to assess additional implementation considerations relevant to decision-makers and to evaluate the stakeholder engagement process used in the modelling study. MethodsUsing the Assessing Cost-Effectiveness approach, we conducted a stakeholder-engaged study with national-level Kenya stakeholders recruited through purposive and snowball sampling. Through deliberative dialogue at a hybrid workshop, stakeholders assessed implementation considerations such as equity, feasibility and sustainability using a colour-coded scoring tool. We evaluated the engagement process using an anonymous survey covering seven stakeholder-engaged research domains. We analysed responses thematically. ResultsAcross the three interventions, most implementation considerations for feasibility, reach and impact, affordability, acceptability, and sustainability were assessed as medium or high. Industry acceptability of kilojoule labelling and SSB tax and affordability of kilojoule labelling to industry were rated low. Equity scores varied. Stakeholders proposed complementary measures that could raise low ratings to favorable scores. Clarity on stakeholder roles was identified as a key strength of the engagement process, while competing time commitments limited participation. ConclusionStakeholder insights contextualise prior cost-effectiveness evidence within policy-relevant implementation considerations and inform current fiscal and regulatory debates. Evaluation of the stakeholder engagement process underscores its contribution to strengthening public health research.

BackgroundZero-dose children, defined as those who have not received the first dose of a diphtheria-tetanus-pertussis-containing vaccine (DPT1), are a key indicator of inequitable access to immunization services. Nigeria remains one of the largest contributors to the global burden of zero-dose children. This study estimated the prevalence of zero-dose children aged 12-23 months and identified individual-and community-level determinants using the 2024 Nigeria Demographic Health Survey (NDHS). MethodsA secondary analysis of cross-sectional analysis was conducted using data from 4,711 children aged 12-23 months in the 2024 NDHS kids recode dataset. A multilevel mixed-effects logistic regression model was fitted to account for the hierarchical structure of the data. Four models were compared: null, individual-level, community-level, and combined models. Adjusted odds ratios (AORs) with 95% confidence interval (CI) were used to identify significant determinants at p<0.05. ResultsThe weighted prevalence of zero-dose children was 37.3% (95% CI: 35.1-39.6%). Significant factors included birth order, maternal age, maternal occupation, parental education, household wealth, antenatal attendance, postnatal care utilization, place of delivery, religion, distance to health facilities, and geographical region. Children whose mothers had higher educational attainment, attending antenatal care, deliver in the health facilities, and received postnatal care were significantly less likely to be zero-dose status. Conversely, children from poorer households, those facing distance barriers to health facilities, those belongings to Muslim and traditional religion group and those residing in certain geographical regions had higher odds of zero-dose children, with significant regional variations observed. Conclusionzero-dose vaccination remains highly prevalent in Nigeria and is strongly influenced by socioeconomic disadvantage, maternal healthcare utilization, religion, and regional inequities. Strengthening integrated maternal and child health services and improving access in underserved regions are essential to achieving equitable vaccination coverage.

Objective: To investigate in the National School Feeding Program (PNAE) the local level drivers and barriers to the implementation of four guidelines: the banning of sugary drinks; restrictions on the procurement of processed and ultra-processed foods; the mandatory increase in weekly servings of fruits and vegetables offered to students; and mandatory direct procurement from family farmers. Design: Qualitative study that used semi-structured interviews. Street level bureaucracy theory informed the theoretical framework and thematic analysis. Setting: Brazilian municipalities, across the country five geographic regions (North, Northeast, Southeast, South, and Midwest). Participants: Stakeholders (e.g. nutritionists, school cooks, and food procurement managers) involved in the local implementation of the PNAE program across the country. Results: Ninety stakeholders were interviewed. Stakeholders reported having autonomy to perform their activities, collaboration and support from other members within the local government and food providers, adequate infrastructure such as a well-equipped kitchens, the availability of trained personnel, and political commitment as drivers for optimum program implementation. Reported barriers included lack of support and resistance to change among cooks, teachers and parents; insufficient physical and human resources; and limited political commitment. When barriers outweighed drivers, interviewees reported adapting their practices, often in restrictive ways that could compromise the implementation of the program. Conclusions: Drivers and barriers to local PNAE implementation were generally similar across studied municipalities, although their magnitude varied. In contexts of greater economic vulnerability and fiscal constraint, additional support and targeted actions from the federal government may be required to strengthen local implementation

BackgroundDrowning remains a major global public health challenge. This study examined whether the timing and trajectories of urbanisation--beyond the current built environment--are associated with subnational drowning mortality. MethodsWe linked satellite-derived measures of built-environment change (GHSL), population crowding (WorldPop), surface water exposure (JRC Global Surface Water), and infrastructure proxies (VIIRS/DMSP nighttime lights) to GBD 2021 drowning mortality estimates across 203 ADM1 regions in 12 countries (2006-2021; 3,248 region-year observations). Temporal predictors captured recent expansion, development "newness" ([&le;]10-year built share), acceleration/volatility, and a crowdingxgrowth interaction. We screened predictors using LASSO (10-fold cross-validation) and fitted mixed-effects models with region random intercepts. Distributed-lag models tested temporal precedence and development age, and income-stratified models assessed heterogeneity. ResultsAdding temporal predictors improved fit beyond contemporaneous built-environment measures ({Delta}AIC=177; {Delta}BIC=147). In adjusted models, crowdingxgrowth was strongly positively associated with drowning mortality, and a higher share of recent development was associated with higher mortality. Lag models showed a development age gradient: older built environment was most protective. Associations differed by income group, with several key coefficients reversing sign across strata. DiscussionDrowning mortality appears shaped by development histories as well as present-day conditions, with risk concentrated in rapidly changing, dense settings and the newest built environments. Cross-context heterogeneity suggests mechanisms and prevention priorities are unlikely to be uniform. ConclusionsDevelopment timing and trajectories help explain subnational drowning mortality beyond current built form alone. Prevention and planning should prioritise transition-period safety strategies in newly developing and rapidly densifying areas.

Background Individuals experiencing or at risk of homelessness face substantial barriers to preventive eye care that are poorly addressed by standard service models. Interdisciplinary optometry-social work collaboration offers a rights-based approach to improving engagement and continuity of care. Methods A convergent mixed-methods study was conducted between February and August 2024 at a multidisciplinary community centre. Clients experiencing or at risk of homelessness received integrated optometry and social work assessment and were prioritised as high, medium, or low based on combined clinical and social risk. Social work follow-up was guided by the Triple Mandate and W-Questions framework. Quantitative data were summarised using mean (SD), median [IQR], or n (%). Qualitative case notes were analysed using content analysis with inductive coding and secondary review for consistency. Results A total of 165 clients had priority categories coded (high: 68; medium: 47; low: 154). Demographic data were available for 132 clients (60% male; mean age 49.5 years [SD 16]); 27% had not completed high school, 89% reported weekly income below AUD 1000, and 28% had vision impairment. Two hundred forty-five case-note entries were consolidated into 146 unique records. SMS (46%) and phone calls (38%) were the most documented contact methods, although only 21% of calls were answered; missed calls (13%) and disconnected numbers (7%) were common. Multi-modal contact was more frequently documented for higher-priority clients. Appointment assistance was the most recorded facilitator (71%), while rights-based supports, including interpreter and transport assistance, were infrequently documented (<=5%). Qualitative analysis identified unstable communication, reliance on informal supports, and service fragmentation as key influences on recall outcomes. Conclusion This study supports an interdisciplinary, rights-based optometry-social work model to address barriers to preventive eye care among people experiencing or at risk of homelessness. Embedding structured handovers and tiered recall processes within community-based services may strengthen continuity and accountability for high-priority clients. Future implementation should evaluate outcomes related to equity of reach, service integration, and sustained engagement in care.

Women living with HIV face about a six-fold higher risk of cervical cancer, yet screening uptake remains low in many sub-Saharan African settings. We explored factors influencing repeated decisions to decline cervical cancer screening during routine HIV care among women living with HIV at a large HIV clinic in Jos, Nigeria. Between September and December 2024, we conducted an exploratory qualitative study at the AIDS Prevention Initiative in Nigeria Clinic in Jos, Nigeria. We purposively recruited 27 women living with HIV aged 21 to 65 years who had never undergone cervical cancer screening and had repeatedly declined screening offers during routine HIV care, including at the current clinic visit. Semi-structured in-depth interviews were conducted in English or Hausa, audio-recorded, transcribed verbatim, and translated into English where needed. Data were analyzed thematically using theory-informed coding based on the Health Belief Model and Social Ecological Model. Among 27 women living with HIV who had repeatedly declined screening, perceived susceptibility was often low or uncertain despite recognition of cervical cancer severity. Perceived benefits were acknowledged but were frequently outweighed by overlapping barriers, including knowledge gaps and misinformation, indirect and downstream costs, emotional barriers, logistical constraints, clinic-flow and service-delivery barriers, and anticipated stigma. Education, reminders, and supportive clinic processes acted as cues to action, and most participants expressed willingness to screen in future. Among women living with HIV at this clinic who repeatedly declined screening when it was offered, perceived benefits were often outweighed by multilevel barriers. Screening programs may integrate fear-reduction and stigma-sensitive counseling with practical service delivery improvements, including shorter waiting times, reduced indirect costs, predictable and streamlined clinic flow, and consistent provider invitations and reminders, while addressing misinformation through community-embedded, culturally tailored messaging. These strategies may improve screening uptake and support more equitable cervical cancer prevention for women living with HIV in similar HIV-care settings.

ObjectiveThis study aimed to assess the effectiveness of SMS and voice message reminders in reducing the dropout rate in Lome-Togo, in 2026. MethodsWe conducted a cross-sectional study between October 2025 and March 2026 in the Grand Lome region. The intervention consisted of an integrated digital system used by health facilities to send automated SMS. Categorical variables were described in terms of frequency and proportion; Fishers exact test was used to compare proportions. Quantitative variables were described by their means accompanied by their standard deviation; the Wilcoxon rank-sum test was used to compare means. The significance level for statistical tests was set at 5%. ResultsA total of 30 health facilities were included. Seventy percent (70.0%) of the health facilities used messages associated with calls. Ninety percent (90.0%) of participants found the reminders useful, and 60.0% reported an improvement in Expanded Program on Immunization services related to their use. Among participants who received a reminder, 51.0% kept their vaccination appointments. The Penta 1/3 dropout rate decreased from 3.2% before the intervention to 1.3% (p < 0.001). Among the 323 parents of children included, only 20.74% reported receiving a reminder by phone. Sixty-point-five percent (60.5%) preferred to receive both text messages and voice calls. ConclusionThis study demonstrates the operational feasibility of an SMS/call-based reminder system in reducing dropout rate for childhood vaccination in Togo.

Background Childhood sensory and intellectual disabilities represent significant yet under-recognized barriers to learning and human capital development. This study analyzes prevalence and severity of these conditions among 149.3 million children aged 5-19 years across 25 countries in Latin America and the Caribbean (LAC) using Global Burden of Disease 2023 data. Methods We extracted GBD 2023 estimates for vision loss, hearing loss, and intellectual disability across 25 LAC countries, stratified by age, sex, and severity. Regional estimates were calculated using population-weighted averages. Severity distributions were compared with OECD countries to contextualize regional patterns. Results: These conditions are estimated to affected 9,282,921 children (6.22%; 95% UI: 5.89-6.54%). Hearing loss was predominant, affecting an estimated 5.42 million (3.63%, 3.41-3.86), with 87.6% mild-to-moderate. Intellectual disability estimated to affected 2.56 million (1.71%, 1.58-1.85), with 61.7% borderline-to-mild. Vision loss estimated to affected 1.30 million (0.87%, 0.79-0.96), with 89% that can be effectively addressed with spectacles. Prevalence increased with age across all conditions. Male predominance was consistent for intellectual disability (2.00% vs 1.42%). Annual economic cost totaled US$19.3-29.0 billion, while comprehensive interventions would require US$9.45-14.23 billion with benefit-cost ratios of 2:1 to 15:1. Conclusions The distribution of children across milder levels of difficulty underscores the opportunity for education and public health systems to provide timely and accessible support. With approximately 88% of sensory impairments addressable through established technologies, investments in inclusive services can yield strong social and economic returns.

IntroductionOver one billion people worldwide have hypertension. In Zimbabwe, prevalence is an estimated 38%, surpassing the global average of 34%, and >50% of hypertensives are undiagnosed. The Community BP groups (Com-BP) study examined whether community groups of people living with hypertension, provided with BP machines and led by trained Facilitators could improve awareness, screening and support for those diagnosed with hypertension, to help blood pressure (BP) control. We present findings from the quantitative evaluation of the Com-BP pilot intervention. MethodsThe acceptability of the Com-BP intervention, its potential effectiveness in improving knowledge, attitudes and practices (KAP) and in reducing BP among hypertensive adults in Zimbabwe, was evaluated. Cross-sectional surveys using standardised questionnaires, and BP and Body Mass Index (BMI) assessments, were done at the start and end of the pilot intervention. Statistical evidence of difference between baseline and follow-up was examined using Wilcoxon signed-rank test for continuous data and McNemars test for categorical data. ResultsFourteen groups (seven urban and seven rural) were formed and 151 participants joined over a median of 5months. Retention in the groups was 97.9% (137/140 recruited at baseline), with approximately equal numbers from the urban and rural sites. Median age at baseline was 54 years (IQR 45-66y; min-max 30-92y) and the majority (79%, n=108) were female. Most participants (82.5%, n=113) rated their experience of the group sessions as excellent. The proportions of participants with changes in KAP from baseline to endline were as follows: 45.3% (n=62) to 81.0% (n=111) (p=0.004) able to identify at least two pre-disposing factors for hypertension; 65.0% (n=89) to 77.4% (n=106) (p=0.02) reporting [&ge;]1day of vigorous physical activity/week; 28.5% (n=39) to 13.9% (n=19) (p=0.001) reporting salt added to meals at the table. There was no statistical evidence of any difference in medication adherence, p=0.06. The proportion of participants with uncontrolled hypertension was 58.1% (n=79) at baseline and reduced to 31.8% (n=43) at follow-up (p<0.001). DiscussionCommunity groups for improving awareness, detection and support are acceptable and led to improvements in self-reported KAP and prevalence of uncontrolled BP. Further research on the sustainability and impact of the intervention is required.

Abstract Importance Stigma and discrimination against transgender and gender-diverse people are prevalent across many settings and may contribute to substantial health disparities. Objective To synthesize global evidence on the prevalence of stigma, discrimination, and resilience among transgender (trans) and gender-diverse adults. Data Sources A systematic search was conducted in PubMed, Embase, CINAHL, Cochrane Central, LILACS, and PsycInfo for articles published between January 1, 2010 and January 2, 2023. This database search was supplemented by grey literature and secondary reference searches. Article Selection Studies were eligible if they presented primary quantitative data on prevalence of stigma, discrimination, and/or resilience among trans and gender-diverse adults (aged 18 and over), with no restrictions on study design, language, or geographic region. Data Extraction and Synthesis Two independent reviewers extracted data using standardized forms, with discrepancies resolved by consensus. The JBI Critical Appraisal Checklist for Prevalence Articles was used to assess risk of bias. Random effects meta-analysis was conducted for dichotomous prevalence measures using inverse variance weighting and logit transformation; non-dichotomous prevalence data were summarized descriptively. Main Outcomes and Measures Outcomes included prevalence estimates for various forms of stigma (anticipated, perceived, internalized, and experienced), discrimination in legal/institutional settings (housing, healthcare, employment, police/prison), and resilience. Results A total of 97 articles, with data from 72,158 unique trans and gender-diverse participants across 26 countries, met inclusion criteria. Studies showed moderate levels of anticipated stigma, perceived stigma, and internalized stigma. Meta-analyses of 36 studies provided pooled estimates of discrimination prevalence across multiple domains: 21.4% in housing (e.g., eviction, rental denial), 24.6% in healthcare (e.g., denial of care, mistreatment), 32.8% in employment (e.g., hiring bias, workplace harassment), and 39.1% in police/prison settings (e.g., profiling, mistreatment). High heterogeneity was observed across studies, reflecting regional and methodological differences. Resilience scores ranged from moderate to high, indicating variation within trans and gender-diverse communities. Conclusions and Relevance This systematic review and meta-analysis found that stigma and discrimination against trans and gender-diverse adults are pervasive globally. Variation in stigma and discrimination across settings and regions underscores the need for targeted interventions and policy reforms. Funding World Health Organization through a grant from the Elton John AIDS Foundation and the Bill and Melinda Gates Foundation.

Background: Since September 2024, France has implemented a national reform allowing prescription-free access (PFA) to sexually transmitted infection (STI) screening in medical biological laboratories (MBLs). This study aims to characterize the populations undergoing STI testing according to their access modality and evaluate the probability of test positivity in relation to testing pathway, sex, and age groups. Methods: We conducted a cross-sectional analysis of all individuals screened for Chlamydia trachomatis, Gonorrhoea, human immunodeficiency virus (HIV), hepatitis B virus (HBV), and syphilis by treponemal-specific immunoassay (TSI) in Cerballiance MBLs between Mars 2025 and February 2026. Multivariable logistic regression models stratified by sex and adjusted for age and region assessed associations between screening modality and STI positivity. Results: Among 1,008,737 individuals included, 27.8% were under PFA and 72.2 under prescription-based access (PBA). PFA users were more frequently male (47.4% vs. 36.3%, p<0.001) and aged 20-39 years (34.0%, p<0.001). Overall positivity rates differed by modality: PFA was associated with higher detection of Chlamydia (4.6% vs. 3.6%). PBA group showed more positive cases of syphilis (3.4% vs. 1.2%), HBV (1.3% vs. 0.4%), and HIV infections (0.3% vs. 0.2%, all p<0.001). Co-infection and gonorrhoea proportions did not significantly differ between modalities. Conclusions: PFA substantially increased STI screening uptake, particularly among young adults and men, and enhanced detection of bacterial STIs. PBA remains essential for diagnosing viral and chronic infections. These findings highlight the complementary roles of both access strategies and support PFA screening as an effective public health intervention to broaden STI detection and reduce transmission.

Ambulatory Care Sensitive Conditions (ACSCs) are conditions for which effective and timely primary health care (PHC) can prevent hospitalizations. They are widely used as a proxy indicator of access to and quality of PHC. Despite their relevance, evidence from Central America remains scarce. This study aimed to quantify the burden, describe the epidemiological profile, and assess temporal trends of ACSCs hospitalizations in Honduras from 2014 to 2024. We conducted a retrospective observational study using national administrative hospital discharge data from all Ministry of Health hospitals. ACSCs were defined using a standardized list of 20 diagnostic groups based on ICD-10 codes. We estimated percentages and sex-age-standardized hospitalization rates per 10,000 inhabitants. Clinical indicators included length of stay (LOS) and in-hospital fatality rates. Temporal trends were evaluated using joinpoint regression models to estimate annual percent changes (APC). Analyses included stratification by age, sex, and disease category. A total of 4,023,944 hospitalizations were analyzed, of which 547,486 (13.6%) were classified as ACSCs. The overall sex-age-standardized rate was 54.1 per 10,000 inhabitants. ACSCs' standardized rates increased between 2014 and 2018 (APC: 2.7%; 95% CI: -2.4; 15.2), declined sharply between 2018 and 2021 (APC: -17.8%; 95% CI: -30.6; -10.3), and increased again between 2021 and 2024 (APC: 15.9%; 95% CI: 4.6; 37.6). Despite this rebound, rates remained below pre-pandemic levels. ACSCs were concentrated among children under 5 years (27.7%) and adults aged 60 years and older (29.9%). Noncommunicable diseases accounted for 56.8% of cases, with diabetes mellitus as the leading cause. Compared with non-ACSCs hospitalizations, ACSCs were associated with longer LOS (4.9 vs. 3.9 days; p <0.001) and higher in-hospital fatality rates (2.4% vs. 1.7%; p <0.001). ACSCs hospitalizations constitute a substantial burden in Honduras and reflect persistent gaps in PHC performance. Strengthening PHC resilience and capacity, particularly for chronic disease management and vulnerable populations, is essential to reduce avoidable hospitalizations and improve health system efficiency and equity.

Objective To analyse sociodemographic determinants of maternal health indicators in Kenyas conflict-affected regions. Methods A cross-sectional secondary analysis of the 2022 Kenya Demographic and Health Survey (KDHS) was conducted. Conflict-affected counties were identified using ACLED (>25 fatalities). The sample included 1,060 women aged 15-49 years. Outcomes were adequate antenatal care (ANC 4+), facility delivery, and skilled birth attendance (SBA). Predictors included age, education, wealth, employment, residence, and county; intimate partner violence was adjusted for. Weighted descriptive statistics, chi-square tests, and multivariable logistic regression were applied (p<0.05). Results Six counties met conflict criteria. While 90.2% of women attended at least one ANC visit, only 53.5% achieved ANC 4+. Facility delivery and SBA were 68.2% and 72.2%, respectively. Adolescents (15-19) were least likely to attain adequate ANC; women aged 20-24 had higher odds (aOR=1.83; 95% CI: 1.01-3.34). Education strongly predicted outcomes: higher education increased ANC 4+ (aOR=2.74; 95% CI: 1.19-6.34) and facility delivery (aOR=2.72; 95% CI: 1.15-6.47). Wealth showed strong gradients: middle quintile increased facility delivery (aOR=5.50; 95% CI: 2.14-14.14), while richer quintile increased SBA (aOR=11.04; 95% CI: 2.06-59.25). Rural residence reduced facility delivery (aOR=0.32) and SBA (aOR=0.22). County disparities persisted. IPV was not independently associated. Conclusion Maternal health indicators in conflict-affected Kenya follow a marked inequity gradient. Adolescents, rural residents, and socioeconomically disadvantaged women are most excluded. Strengthening adolescent ANC continuity, reducing rural access barriers, and investing in education and economic empowerment are critical for improving outcomes.

Background Depressive symptoms among reproductive-aged women represent a major public health concern in low- and middle-income countries, yet systematic screening remains limited. In most population survey datasets, the low prevalence of depression results in severe class imbalance, which challenges conventional machine learning models. Therefore, we develop and evaluate a bagging-based ensemble machine learning framework to predict depressive symptoms among reproductive-aged women using highly imbalanced Bangladesh demographic and health survey (BDHS) 2022 data. Methods The sample comprised women aged 15-49 years drawn from BDHS 2022 data. Depressive symptoms were defined using the Patient Health Questionnaire (PHQ-9 [&ge;]10). Candidate predictors were drawn from sociodemographic, reproductive, nutritional, psychosocial, healthcare access, and environmental domains. Feature selection was performed using Elastic Net (EN), Random Forest (RF), and XGBoost model. Five classifiers (EN, RF, Support Vector Machine (SVM), K-nearest neighbors (KNN), and Gradient Boosting Machine (GBM)) were trained using both oversampling-based approaches and the proposed ensemble framework. Model performance was evaluated on an independent test set using accuracy, sensitivity, specificity, F1-score, and the normalized Matthews correlation coefficient (normMCC). Results Approximately 4.8% of women were identified with depressive symptoms. The proposed bagging ensemble framework consistently achieved more balanced predictive performance than oversampling-based models. Average normMCC improved from 0.540 (oversampling) to 0.557 (ensemble). RF and GBM ensembles demonstrated notable improvements in identifying depressive cases, while the EN ensemble achieved the highest overall performance and sensitivity. Threshold optimization yielded stable normMCC across models, indicating robust trade-offs between sensitivity and specificity. Conclusions Bagging-based ensemble learning provides a more robust and balanced approach than synthetic oversampling for predicting depressive symptoms in highly imbalanced population survey data. This approach has important implications for improving early identification and population-level mental health surveillance in resource-constrained settings.

Objectives Concerns about COVID-19 were a key driver of infection-prevention behaviour during the pandemic. The aim of this study was to gain an in-depth longitudinal understanding of the type and frequency of concerns experienced throughout the first two years of the COVID-19 pandemic. Design Content analysis of qualitative descriptions provided in a prospective longitudinal online survey as part of the COVID-19 UK Public Experiences (COPE) Study. Method At baseline (March/April 2020), when the UK entered its first national lockdown, 11,113 adults completed the COPE survey. Follow-up surveys were conducted at 3, 12, 18 and 24 months. Participants were recruited via the HealthWise Wales research registry and social media. Baseline surveys collected demographic and health data, and all waves included an open-ended question about COVID-19 concerns. Content analysis was used to identify the type and frequency of concerns at each time point. Results A total of 41,564 open-text responses were coded into six categories: personal harm (n=16,353), harm to others (n=11,464), social/economic impact (n=6,433), preventing transmission (n=4,843), government/media (n=1,048), and general concerns (n=1,423). The proportion of respondents reporting any concern declined from 75.3% at baseline to 65.8% at 24 months. Over time, concerns about personal harm increased (baseline 41.8% vs. 24-months 52.7%) whereas concerns about harm to others decreased (baseline 48.5% vs. 24-months 28.6%). Concerns about harm were also expressed in relation to clinical vulnerability, lack of trust in government/media, and perceived lack of adherence by others. These were balanced against concerns about wider social and economic impacts of restrictions. Conclusions Public concerns about COVID-19 evolved substantially over the first two years of the pandemic, reflecting changing perceptions of risk and responsibility. Monitoring concerns longitudinally is vital to help guide effective communication and behavioural interventions during future pandemics.

BackgroundWomens autonomy in healthcare decision-making has become one of the most critical yet inequitably distributed determinants of health outcomes, gender equity, and sustainable development worldwide. In Northern Nigeria, the presence of ethnic and socio-cultural inequality is frequently concealed by the aggregated statistics of a region. MethodsThis cross-sectional secondary analysis utilized the 2024 Nigeria Demographic and Health Survey. The sample included 9,998 married women (15-49 years) identifying as Hausa, Fulani, or Kanuri in Northern Nigeria. Healthcare autonomy was categorized as husband/partner alone, respondent alone, or joint decision-making. Analysis included weighted descriptive statistics, Rao-Scott adjusted chi-square tests for residential associations, and complex sample multinomial logistic regression to identify multivariable correlates while adjusting for sampling weights, strata, and clusters. ResultsMean age was 30.38 years. Most participants lacked formal education (69.6%) and resided in rural areas (72.0%). Husband-only decision-making predominated (72.6%), while 22.5% reported joint and 4.9% independent autonomy. Joint decision-making was significantly higher in urban (33.3%) than rural areas (18.3%; Adjusted F=50.892, p<0.001). In adjusted models (Reference: Kanuri), Hausa and Fulani women had substantially lower odds of joint decision-making relative to husband-only outcomes. Rural residence correlated with lower odds of both independent and joint agency. Notably, wealth status was not a significant predictor after adjustment (p > 0.05). ConclusionsEthnicity and residence are robust determinants of healthcare autonomy among women in Northern Nigeria, persisting regardless of education or wealth. This "socio-cultural paradox" suggests that economic interventions alone are insufficient. Policies must complement socioeconomic approaches with culturally responsive strategies addressing household power dynamics and entrenched social norms.

Background: In Burkina Faso, typhoid fever remains a major public health concern, with a high incidence among children younger than 15 years of age. To address this burden, the country introduced typhoid conjugate vaccine in January 2025 through a national vaccination campaign reaching children aged 9 months to 14 years. This study aimed to estimate the cost of typhoid conjugate vaccine delivery during the national campaign and to identify the main cost drivers across different administrative levels. Methods: We conducted a cross-sectional, retrospective costing study using a microcosting approach from the government perspective. We collected data from fifty health facilities, eight health districts, five health regions, and the national level. Financial and economic costs were estimated for each level, excluding vaccine and syringe costs. All costs were converted to 2024 USD using the official exchange rate. Findings: Vaccinators administered a total of 10.5 million typhoid conjugate vaccine doses. The average financial cost per dose was $0.47 (95% CI: $0.39-$0.51), and the economic cost was $2.16 (95% CI: $1.71-$2.56). Human resources and per diem payments were the main contributors to costs. Costs varied by geography, delivery strategy, and security context, with higher costs observed in rural and conflict-affected areas. The mobile-temporary posts strategy had the highest economic cost per dose ($2.02; 95% CI: $1.64-$2.40), while the fixed strategy had the highest financial cost per dose ($0.41; 95% CI: ($0.32-$0.49). Conclusion: The financial cost per dose remained within Gavi, the Vaccine Alliance's operational support range. The observed cost variations highlight the need for targeted funding and enhanced logistical support to ensure equitable access, particularly in rural and insecure areas. This study provides evidence to inform future vaccination campaigns and supports decision-making for typhoid conjugate vaccine introduction in other countries in the region.

Drowning remains a major global public health challenge, yet how built environment characteristics shape population-level drowning risk remains poorly understood. This study linked satellite-derived built environment data to subnational drowning mortality estimates across 203 regions in 12 countries from 2006-2021. It found that built environment associations with drowning mortality are complex, non-linear, and shaped by development context. Urban extent was strongly protective, while built area near water showed protection overall but increased risk when combined with high population crowding. Almost all drowning mortality variance occurred between regions rather than within regions over time, indicating risk is predominantly determined by place-based characteristics. Income-stratified analyses revealed profound heterogeneity: crowding was protective in low-to middle-income settings but near-null in high-income regions, while waterfront development captured very different realities across contexts. These findings highlight the importance of tailoring drowning prevention strategies to local built environment configurations and development contexts.

Background. Vietnam's disease burden has shifted from communicable, maternal, neonatal, and nutritional (CMNN) causes to non-communicable diseases (NCDs), but the tempo, drivers, and regional positioning of this transition have not been jointly quantified. We characterised Vietnam's epidemiological transition 1990-2023 against ten Southeast-Asian (SEA) peers. Methods. Using Global Burden of Disease 2023 data, we computed joinpoint-regression AAPC with 95% CI (BIC-penalised, up to three break-points) for age-standardised DALY rates and cause-composition shares. We applied Das Gupta three-factor decomposition to 1990-2023 absolute DALY change (population-size, age-structure, age-specific-rate effects) and benchmarked Vietnam's NCD share against an SDI-conditional peer trajectory via leave-one-out quadratic regression. Premature mortality was quantified as WHO 30q70 under both broad NCD and strict SDG 3.4.1 definitions, using Chiang II life-table adjustment identically across all eleven countries. Findings. The CMNN age-standardised DALY rate fell from 13,295.9 to 4,022.1 per 100,000 (AAPC -4.63%/year; 95% CI -4.80 to -4.46); the NCD rate fell only from 21,688.2 to 19,282.8 (AAPC -0.37; -0.45 to -0.30). NCD share of total DALYs rose from 52.99% to 70.67% (+17.67 pp; AAPC +1.09). Vietnam ranked fourth of eleven SEA countries in 2023 (up from sixth in 1990) and sat 5.3% above the SDI-expected trajectory. Das Gupta decomposition attributed the +10.63 million NCD DALY increase to population growth (+6.26 M) and ageing (+6.08 M); rate change removed only 1.71 M. Premature NCD mortality fell from 25.02% to 21.80% (broad, 12.9% reduction) and from 22.17% to 19.50% (SDG 3.4.1, 12.0%; Vietnam sixth of eleven) - far short of the SDG 3.4 one-third-reduction target. Interpretation. Vietnam has entered a disability- and ageing-dominated NCD phase. Meeting SDG 3.4 by 2030 requires population-scale primary prevention sized to demographic momentum.