Global Health Action

Introduction: Nutritional challenges are a global public health concern, especially among children under five in sub-Saharan African countries. The coexistence of an overweight/obese mother and an underweight child in the same household is recognized as a dual burden of malnutrition (DBM). Our study aimed to examine the prevalence and associated factors of DBM among mother-child dyads in Mozambique. Methods: We used nationally representative, cross-sectional data from the Mozambique Demographic and Health Survey 2022-2023 (n=3,605 mother-child dyads). The children's undernutrition condition and maternal BMI status were calculated using the WHO standard reference guidelines. The outcome variable, dual burden of malnutrition, was then created if the children had any undernutrition condition (stunting, wasting, or undernutrition) and the corresponding mother was overweight/obese. Multivariable binary logistic regression, Erreygers's concentration index, and concentration curve were analyzed to determine associated factors and social inequalities. Results: The prevalence of the dual burden of malnutrition was about 5.51%. Mothers aged [&ge;]34 years [aOR (95% CI): 4.01(1.44, 11.14); p<0.05] and mothers with four or more children [aOR (95% CI): 2.68(1.29, 5.57); p<0.05] had higher odds of DBM. Rural residence and using unimproved toilet facilities (latter an indicator) were also significantly associated with experiencing DBM. Additionally, maternal age modified the association between women's empowerment and mother-child DBM. Women aged 15-19 years at the lowest and highest empowerment levels were more likely to experience DBM compared to women 20 years or older. A positive and statistically significant concentration index indicates that wealth-related inequalities exist, with DBM more concentrated among wealthier mother-child dyads. Conclusion: Our study highlights the persistence of household-level DBM in Mozambique. These findings emphasize the need for targeted interventions addressing social and economic inequalities, including poor sanitation marker of broader household deprivation. Prioritizing integrated maternal-child nutrition interventions within national strategies is essential to improving equity in nutrition and health outcomes.

Objective: Malnutrition and micronutrient deficiency are significant public health problems affecting the well-being of both the mother and her offspring. It is important to first quantify their burden in underserved communities and then to tackle this problem. The objective of this study was to assess the nutritional status, micronutrient deficiency profile, and associated determinants among pregnant women attending antenatal care clinics under PMSMA in selected government health facilities across three districts of Jharkhand, India. Design: The study employed a cross-sectional study design to assess the burden of malnutrition and micronutrient deficiency among pregnant women. Setting: The study was conducted in 4 health facilities in 3 districts of Jharkhand. The selected facilities were Rajendra Institute of Medical Sciences (RIMS), Ranchi; District Hospital (Sadar), Ranchi; District Hospital (Sadar), Godda; and Community Health Centre (Gamharia, Saraikela) under RHTC, Department of Community Medicine, Manipal Tata Medical College, Jamshedpur. The study was conducted during the period of September to December, 2022. Participant: Eligible pregnant women attending ANC clinics under PMSMA in the selected health facilities were enrolled until the required sample size of 977 was achieved. Pregnant women who were critically ill or those who presented with some emergency conditions were excluded from the study. Result: Based on BMI assessment, 38.6% of participants were malnourished, with 17.7% being underweight and 20.9% overweight or obese. Anaemia affected 69.3% of women, while clinical features suggestive of iron deficiency were observed among 21.1% of the participants. Vitamin A deficiency, iodine deficiency, and fluoride excess were also identified among a smaller proportion of women. Conclusion: The present study highlights a substantial burden of both malnutrition and micronutrient deficiency among pregnant women in Jharkhand and justifies the need for integrated maternal nutrition strategies during antenatal care.

Despite significant progress in reducing vaccine-preventable diseases, Cameroons Expanded Programme on Immunisation operates within structures shaped by colonial history. Overreliance on external donor funding, centralised governance, and limited recognition of local knowledge raise concerns about equity, local ownership, and programme sustainability, particularly as the country plans for donor transition and self-financing. This study, aligned with the decolonising global health movement, examines how colonial legacies shape stakeholders experiences within the EPI and proposes practical steps towards a more locally owned immunisation programme. A qualitative case study was conducted in the Southwest Region of Cameroon from June to July 2025, comprising fifteen online semi-structured interviews in English with selected stakeholders (regional and district EPI managers, civil society members, and community leaders). Interviews were audio-recorded, transcribed verbatim, and analysed thematically using Clarke and Brauns six-step framework in NVivo version 11. Participants identified subtle colonial influences, including centralised decision-making, donor-driven priorities, pay disparities favouring international actors over local staff, and the marginalisation of local and traditional knowledge. The COVID-19 response was frequently cited as an example of inequity, with Western biomedical approaches prioritised over locally led solutions. Major structural issues included heavy reliance on external funding, outdated colonial-era training curricula, centralised governance, and a lack of local vaccine manufacturing capacity. Despite these issues, participants recognised the significant technical and financial support from international organisations. They proposed concrete pathways for decolonisation, including decentralised governance, participatory programme design, regulation and integration of traditional medicine, community engagement, domestic resource mobilisation, leveraging Cameroons emerging universal health coverage to reduce donor dependence, and investing in local vaccine production. Conclusion: Colonial legacies continue to influence Cameroons EPI, undermining local ownership and self-determination, even when external support is effective. Achieving decolonisation requires multifaceted efforts to strengthen domestic financing and governance, empower local stakeholders, and legitimise local knowledge alongside biomedical approaches. Policymakers should embed local ownership, governance reforms, and local capacity building in transition strategies while donor funding persists, ensuring immunisation gains are sustained beyond external support. These insights provide a context-specific roadmap for developing a sustainable, equitable, and locally driven immunisation programme in Cameroon and other countries facing similar donor transitions.

Background: Ebola virus disease is a life-threatening illness caused by the Ebolavirus, with symptoms manifesting two to twenty-one days after infection. Although Uganda has faced multiple Ebola outbreaks, many patients survive only to encounter persistent challenges. Therefore, this study explored the post-discharge experiences of survivors following the 2022 Ebola Virus Disease outbreak in Uganda. Methods: An exploratory qualitative study comprising of in-depth participant interviews was conducted at Mubende Regional Referral Hospital in central Uganda. Interviews were face-to-face and data were analyzed manually by inductive content analysis. Ten male and female participants were Ebola Virus Disease survivors in Mubende district who had lived in the community for at least six months post-discharge from the Ebola Treatment Unit. Results: Four themes emerged: (i) Psychosocial Burdens and Social Exclusion, (ii) Economic Hardship and Loss of Financial Stability, (iii) Chronic Physical and Health Burdens Post-Recovery and (iv) Rebuilding Lives: Psychological, Social, and Medical Pathways to Recovery. Survivors faced significant emotional burdens such as survivor guilt, grief, trauma from loss, and anxiety about transmission risks. They experienced social isolation, stigma, and discrimination, which often led to their exclusion from community activities. Financially, they struggled with debt and the loss of livelihoods, compounded by ongoing health issues. Additionally, survivors endured chronic physical complications, including pain and fatigue, which hindered their recovery. Despite these challenges, survivors sought psychological, social, and medical pathways to recovery, including confirmation of their recovery, support from family and organizations, and health maintenance practices. Supportive medical care and community assistance were crucial in their physical and emotional rehabilitation. Conclusion: Ebola Virus Disease survivors in Uganda face significant psychosocial, health, social, and economic challenges post-discharge. The findings highlight the critical need for comprehensive medical and community-based support systems to aid survivors' recovery and well-being. Further research on long-term neurological effects and community reintegration programmes is needed to inform targeted interventions that support Ebola survivors and reduce stigma and discrimination.

Background: Neonatal mortality remains a significant public health challenge in Sub Saharan Africa (SSA). The continuum of maternal care (COC), spanning antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) represents an integrated pathway to improving neonatal survival. Multi-country evidence on how adherence to this full continuum affects neonatal outcomes across SSA is limited. Objectives: This study aimed to: (1) construct a composite COC indicator and describe its sociodemographic distribution; (2) estimate its association with neonatal mortality; (3) conduct a counterfactual analysis; and (4) examine cross country heterogeneity in the COC effect on neonatal mortality. Methods: Pooled Demographic and Health Survey (DHS) data from 35 SSA countries (2010 to 2026) were analyzed (N = 867,984 live births). A binary CoC indicator (coc1 = 1 if mother received [&ge;]4 ANC visits, skilled birth attendance, and PNC within 48 hours) was constructed. Survey-weighted logistic regression adjusted for wealth, education, residence, parity, maternal age, child sex, child age, and country. Counterfactual predictive margins and a COC and country interaction model were estimated in Stata 18. Results: Only 13.47% of mothers met the full COC threshold. COC completion was higher among wealthier, urban, more educated, and lower-parity women. After adjustment, CoC receipt was associated with significantly lower odds of neonatal death (aOR = 0.638, 95% CI: 0.577 - 0.706, p < 0.001). Counterfactual analysis showed the predicted neonatal mortality probability would fall from 3.15% (no CoC) to 2.04% (full CoC), an absolute risk reduction of 1.11 percentage points. Cross-country interaction terms were largely non-significant; only Namibia reached significance (p = 0.036). Conclusion: Completion of the full continuum of maternal care is independently associated with reduced neonatal mortality across SSA. Equity focused policies should prioritize integrated service delivery for rural, poor, and less educated women.

Measuring health literacy is important in addressing health inequity. However, current measures are developed from the individualistic perspective that values personal autonomy and choice. Applying such measures to people from a communal culture that values collective actions may lead to biased responses. To address this gap, a health literacy measure drawing on the communal perspective was developed in Thailand. With the aim to also develop an equitable measure, a grounded approach including strategies to include people with special needs such as people with chronic illness or physical disabilities, blind people and deaf people, was used. Concept mapping workshops were conducted, involving 254 participants including general community members, people with special needs, health professionals and policymakers. The result was a draft questionnaire of 17 hypothesized scales. Psychometric testing involving a survey of 2,228 participants resulted in a 14-scale questionnaire, the Information and Support for Health Actions Questionnaire (ISHAQ). This paper reports on the psychometric testing of the 14-scale ISHAQ and its supplementary scales for people with special needs. Item difficulty, scale reliability, one-factor confirmatory factor analysis using robust maximum likelihood estimator, and measurement invariance across groups with special needs using the alignment method with Bayesian estimation, were evaluated. A total of 2,262 respondents participated in the survey. Six scales achieved excellent model fit while one with reasonable fit and seven scales achieved reasonable to excellent fit following modifications. Supplementary scales also achieved reasonable to excellent model fit. Reliability for all scales were acceptable to good. Measurement invariance was confirmed for eight scales. With strong validity evidence, the ISHAQ is translated into English and ready for implementation. With the potential to be applied in different settings given cultures exist in a continuum, the ISHAQ can be used for health literacy needs assessment to support intervention development to improve health outcomes and equity.

ABSTRACT Background: Rapidly urbanising complex ecosystems present several challenges to the organisation, availability, and accessibility of healthcare services. This study describes the availability and distribution of health facilities offering services, with a focus on maternal and newborn health services in the seven health districts of Grand Conakry, Methods: This study using primary data from a census of health facilities (June 2025). Finally, healthcare landscape was drawn up using the GPS coordinates collected, based on the boundaries of the seven including health districts. The census started with an existing list of 459 facilities and snowball sampling was used to identify facilities that were not initially on the list. We collected information on basic facility characteristics and GPS coordinates. Results: A total of 795 health facilities exist in Grand Conakry, with 564 facilities which were not on the initial lists, 104 were either closed, out of service, or refused to participate. The questionnaire was completed by 691 health facilities. The private sector dominated the landscape and was mainly concentrated in the Ratoma and Matoto health districts; with most facilities (63%) not reporting to the national health information system, in contrast to those in public sector (85.7%). 332/691 facilities reported providing childbirth care, and 132 of them (40%) offered caesarean section, while 87 (26%) offered blood transfusions. Conclusion: Despite the high number of facilities, geographic imbalances in distribution exist. Equitable access to healthcare in rapidly urbanising Grand Conakry requires strengthening urban health planning and public-private collaboration regarding ongoing rapid urbanisation in Grand Conakry.

Background Community health workers (CHWs) are central to universal health coverage strategies across sub-Saharan Africa. Yet whether CHW programs equitably reach women across socioeconomic and demographic groups remains poorly characterized at the multi-country level. Methods A cross-sectional secondary analysis of Standard DHS-8 data from Ghana (2022), Kenya (2022), Tanzania (2022), and Malawi (2024) was conducted (N = 68,019 women aged 15-49). The primary outcome was self-reported contact with a CHW or fieldworker in the prior 12 months. Survey-weighted logistic regression was performed using Taylor series linearization to account for complex survey design, both individually per country and pooled. The RE-AIM framework guided the evaluation of program reach. Results National CHW coverage varied 7-fold, from 3.1% in Tanzania to 22.8% in Malawi. The most consistent cross-country equity finding was by age: women aged 15-19 had approximately half the adjusted odds of CHW contact compared to women aged 25-29 in every country (pooled aOR = 0.47, 95% CI [0.42, 0.52], p < .001). Pro-poor wealth gradients were significant in Kenya and Malawi, whereas Ghana achieved equitable reach across all wealth quintiles (p = .685). Rural residence was independently associated with higher CHW contact in Kenya (aOR = 1.48) and Malawi (aOR = 1.91). Conclusions Adolescent women aged 15-19 are systematically underserved by CHW programs across sub-Saharan Africa, a finding consistent across four countries with widely different program scales. This adolescent gap is the most consistent equity finding across the dataset, persisting across all four countries regardless of program scale, wealth distribution, or governance structure. Ghana's Community-based Health Planning and Services (CHPS) program demonstrates that equitable CHW reach across wealth quintiles is achievable at scale. Kenya's extreme within-county variation indicates that sub-national governance quality is a dominant driver of equity. Targeted strategies, including CHW protocol redesign and school-based outreach, are urgently needed to close the adolescent reach gap.

BACKGROUND: Undernutrition is the leading risk factor for tuberculosis (TB), yet evidence on programmatic nutritional support during treatment is limited. Benin and Togo are neighboring West African counties. Benin provides in-kind food support to all people with drug-susceptible TB; neighbouring Togo does not. This created the opportunity for a natural experiment. METHODS: We conducted a prospective cohort study at 13 sites in Benin and Togo (September 2023-June 2024). We compared recipients of nutritional support with non-recipients, using Beninese non-recipients as an internal comparison. Primary outcomes were [&ge;]5% weight gain at month 2, change in 6-minute walk test (6MWT) distance, and pill-count adherence. We used multivariable regression adjusted for pre-specified covariates. RESULTS: Of 769 participants, 450 received nutritional support and 319 did not. Recipients had higher odds of [&ge;]5% weight gain at month 2 (adjusted odds ratio [aOR] 1.57, 95% CI 1.13-2.19) and [&ge;]10% at month 6 (aOR 1.92, 1.35-2.74), greater 6MWT improvement (adjusted {beta} 40.6 m, 26.5-54.6), and higher adherence (aOR 3.43, 1.81-6.51). Mortality was lower among recipients (aOR 0.32, 0.11-0.93). Sputum conversion and treatment success did not differ. Beninese non-recipients resembled Togolese participants across outcomes. CONCLUSION: Programmatic nutritional support was associated with improved weight gain, functional recovery, adherence, and lower mortality during TB treatment, supporting its integration into national TB programmes.

Purpose Despite the high documented prevalence of hunger and poor mental health in adolescent girls and young women (AGYW) in South Africa, this relationship remains understudied, with existing studies limited by their cross-sectional designs. This longitudinal study aimed to identify the association of hunger trajectories with anxiety and depressive symptoms, and hope in AGYW. Methods We used secondary data from the HIV Prevention Trials Network (HPTN) -068 conducted in rural Agincourt, South Africa. Complete data from 1779 AGYW collected at baseline (2011/12) and three annual follow-up visits were used. Hunger trajectories, measured using the Household Hunger Scale, were estimated via Group-Based Trajectory Modelling. Self-reported incident anxiety and depressive symptoms and hope were assessed based on AGYWs last two follow-up visits. Covariate adjusted modified Poisson regression models estimated the association between hunger trajectories and incident anxiety symptoms, incident depressive symptoms, and hope. Results Moderate-severe hunger was prevalent in 11.0%, 10.8%, and 6.0% of the households at baseline, follow-up 1, and 2, respectively. Incident anxiety symptoms were reported by 4.5%, incident depressive symptoms by 20.0% and hopelessness by 52.8% of the AGYW. Two hunger trajectories were identified- no hunger (82%) and marginal hunger (18%). Hunger trajectories were not associated with incident anxiety symptoms [RR:1.09, 95% CI: 0.55, 2.18], incident depressive symptoms [RR: 0.97; 95% CI: 0.72, 1.33] nor hope [RR: 1.00; 95% CI: 0.81, 1.23] in AGYW. Conclusion Better understanding of the factors that promote resiliency and mental health of AGYW in this setting is warranted to inform the design of interventions.

Background Floods are among the most devastating natural disasters worldwide and are increasingly associated with adverse mental health outcomes, particularly Post-Traumatic Stress Disorder (PTSD). In December 2023, Hanang District in northern Tanzania experienced catastrophic mud floods that resulted in extensive loss of life, destruction of property, displacement of households, and disruption of livelihoods. While emergency humanitarian responses focused primarily on physical needs, limited evidence exists regarding the long-term psychological consequences among survivors. Therefore, this study aimed to determine the patterns of PTSD manifestations and assess cognitive factors associated with PTSD symptoms among flood victims in Hanang District, Tanzania. Methods A community-based cross-sectional study was conducted among 360 flood victims one year after the disaster. PTSD symptoms were assessed using the PTSD Checklist for DSM-5 (PCL-5). Descriptive statistics summarized PTSD severity, while chi-square tests and regression analyses examined associations between socio-demographic characteristics and PTSD manifestations. Cognitive factors were assessed based on participants' exposure to traumatic experiences and perceptions of traumatic events. Results The mean PCL-5 score was 39.2 (SD = 20.6), indicating a high burden of psychological distress. Approximately 45% of respondents had severe PTSD symptoms (PCL-5 [&ge;]45), while another substantial proportion demonstrated moderate symptom severity. PTSD manifestations varied significantly by geographical location (p < 0.001), household income (p = 0.011), and marital status (p = 0.002). Age positively predicted PTSD severity ({beta} = 0.019, p = 0.001), whereas household income negatively predicted symptom severity ({beta} = -0.297, p = 0.001). Exposure to natural disasters constituted the predominant cognitive factor, with 45% directly experiencing the flood and 38.3% witnessing the event. Exposure to secondary traumatic experiences through witnessing or learning about violent events was also common. Cognitive trauma exposure demonstrated a significant association with PTSD symptoms ({chi}2, p < 0.001). Conclusion PTSD remains highly prevalent among flood survivors in Hanang district. Both direct and indirect trauma exposure significantly contributed to PTSD manifestations. Comprehensive disaster recovery programmes should integrate trauma-focused psychological services, cognitive behavioural interventions, routine PTSD screening, and community-based psychosocial support alongside socioeconomic recovery initiatives.

Background: In Tanzania, over 10,000 women aged 15-44 are diagnosed with cervical cancer annually, and more than 6525 die. The majority are diagnosed at an advanced stage, which contributes to delays in treatment enrollment and illness complications. Multiple factors can affect womens willingness and ability to access cervical pre-cancer screening. Purpose: To explore the barriers and facilitators to attending cervical pre-cancer screening among women living in a resource-constrained area of Southern Tanzania Methods: A qualitative study of 17 focus group discussions and 12 in-depth interviews was conducted from December 2023 to July 2024. Data collection took place in the community and health centers of a town and the surrounding rural areas in Kilombero district. The study used purposive sampling to recruit 112 women and 23 men aged 18- 50+ years. Results: Fear of death emerged as a central theme in the data, acting as both a barrier to and a facilitator of womens screening behavior. Women linked death with the screening procedure, receiving results and undergoing treatment. Participants mistrusted the speculum itself and linked it to pain, vaginal infection, and infertility. Conversely, fear of physical and social death motivated other women to attend the screening to learn about their health and prevent the consequences of a positive diagnosis. Public trust in the healthcare system and the role of health information sources were also identified as influencing women's decisions to undergo or not undergo screening. Conclusion: Our findings showed that cervical cancer screening uptake is influenced by fear of death and other co-factors. To improve early cervical cancer screening, programs and policy interventions are needed to raise awareness of the disease while also addressing womens specific concerns. Also, strengthening structural dimensions such as the availability of the healthcare workforce, healthcare facilities, and ensuring equitable service availability are essential to reducing cervical cancer complications and avoidable mortality.

Introduction: Cash transfer programs could reduce diabetes risk by decreasing chronic stress and increasing food security, physical activity, and preventive care, but there is an evidence gap on the relationship between cash transfer access and diabetes and prediabetes incidence. Methods: We used data from the Health and Ageing in Africa: Longitudinal Studies in South Africa (HAALSA) Indepth cohort of Black South Africans ages 40+ (N=5059). We fit log binomial models to estimate the relationship between household cash transfer eligibility (HCT) and cumulative incidence of diabetes and prediabetes between 2014/15 and 2021/22. We performed quantile regression to estimate change in continuous glucose values across the glucose distribution with additional HCT. Results: No association was observed between HCT and diabetes risk. Each additional unit of HCT was associated with reduced prediabetes risk [aCIR (95% CI): 0.94 (0.90, 0.98); p=0.007]. The largest reduction in glucose values associated with additional HCT was at the highest end of the glucose distribution. Discussion: Our observations suggest household cash transfer access reduces risk of prediabetes but not diabetes. However, household cash transfer access was associated with the largest decrease in glucose for the most severely glucose-impaired, implying the potential for HCT to reduce risk of hyperglycemic complications.

Background Obstetric ultrasound is an essential tool for assessing fetal growth and wellbeing. While evidence-based recommendations advise one routine scan before 24-weeks of gestation, research suggests its use in low- and middle-income countries often extends beyond medical necessity. This study examined how ultrasound technology has become integrated into antenatal practices in rural Pakistan and how cultural, economic, and institutional factors shape its use. Methods Drawing on data from two qualitative and one mixed-method studies conducted across six rural districts of Punjab, we used a pragmatic mixed-methods approach integrating latent content analysis of interviews, focus group discussions and observations with quantitative survey data. Results Ultrasound use is common, with nearly 80-percent of women reported having at least one ultrasound and many undergoing three to six scans. For some participants, ultrasound had become synonymous with antenatal care, overtaking basic tests such as blood and urine analysis. The technology was widely perceived as both diagnostic and therapeutic, with some women believing it could cure health problems. Providers, particularly in the private sector, promoted frequent scans to meet patient expectations and financial targets, while womens demand was driven by reassurance, perceived modernity, and son preference. This dynamic created a self-reinforcing supply-demand cycle in which clinical need played a secondary role. Conclusions In rural Pakistan, obstetric ultrasound has evolved into a central socio-technical feature of pregnancy care that extends far beyond its clinical purpose. These findings highlight the interplay of technology, culture, and market forces in shaping maternal health behaviors and underscore the need for context-sensitive policy responses that align ultrasound use with evidence-based care while engaging with the social realities that sustain its widespread adoption.

Background: South Africa adopted evidence-based antenatal care (ANC) frameworks to improve maternal health outcomes. However, the maternal mortality ratio remains above Sustainable Development Goal target 3.1 and routine data indicate declining ANC first-visit coverage. Aim: This study sought to explore implementation gaps, barriers and facilitators in the delivery and uptake of ANC. Setting: Ugu and uMzinyathi districts in KwaZulu-Natal, and Capricorn and Waterberg districts in Limpopo, South Africa. Methods: A qualitative descriptive design was utilised. Semi-structured interviews were conducted with 70 purposively sampled participants, comprising 30 health system providers and 40 service users. Data were analysed thematically using NVivo. Results: Health system providers attributed declining ANC coverage to fertility decline rather than reduced access alone. Providers identified mentorship, community outreach and enhanced screening as key strengths. Implementation was constrained by staffing and equipment shortages. While service users recognised the benefits of ANC, they reported that long waiting times, negative provider attitudes and limited privacy during consultations undermined the quality of service delivery. Providers and service users linked delayed ANC initiation to financial constraints, stigma and pregnancy concealment. Conclusion: Improving early ANC initiation requires an approach that addresses health system, socioeconomic and cultural barriers. Concerns about declining fertility as a driver of declining coverage warrant further investigation into coverage calculation methodologies. Contribution: The study provides insights into the interconnected factors influencing ANC delivery and uptake in primary healthcare settings. It further highlights the need to consider changing fertility patterns when interpreting ANC coverage. The findings can inform targeted interventions and strengthen maternal health planning, monitoring, and service delivery.

Background and Aims: Anxiety remains prevalent among adolescents while tobacco and nicotine product use, especially the recent increases of novel product use such as e-cigarettes and nicotine pouches, raises further public health concerns. The associations between novel tobacco and nicotine product use and anxiety remains understudied. This study aims to determine whether tobacco and nicotine product use is associated with generalised anxiety and whether this association differs by used product. Design: Cross-sectional survey, School Health Promotion study in 2025. Setting: A school-based nationwide survey conducted in all Finnish lower and upper secondary schools. Participants: Students aged 13-20 years in three school levels: 8.-9. grade students in lower secondary schools (N= 94 743, 73% of the students), 1st and 2nd-year students in general upper secondary schools (n=47 248, 70% of the students) and of vocational institutions (n=24 998, 38% of the students). Measurements: Exclusive (single product) and non-exclusive ([&ge;]1 products) daily or weekly use of tobacco and nicotine products, including nicotine pouches, e-cigarettes, cigarettes, and smokeless tobacco (snus). Generalised anxiety was measured using the Generalised Anxiety Disorder Scale (GAD-7). The cut-off of >10 points indicated participants with moderate to severe self-reported generalised anxiety symptoms. Background variables included sociodemographic variables and heavy drinking. Results: Of the 166,989 participants 51.4% were females, mean age was 15.7 (SD 1.27), 21.2% reported generalised anxiety. Prevalence of generalised anxiety increased gradient-wise in accordance with both non-exclusive and exclusive use frequency of different tobacco and nicotine products, as well as with number of products used. Daily use of nicotine pouches was associated with higher odds of anxiety compared with never use (boys: adjusted odds ratios (aOR) 1.19, 95% CI, 1.05 to 1.34; girls: aOR 1.74, 95% CI, 1.58 to 1.91), yet the association between daily e-cigarette use seemed to be stronger (boys aOR 1.96, 95% CI, 1.54 to 2.49; girls: aOR 2.29, 95% CI, 2.09 to 2.51). Summary: Any use of tobacco and nicotine products, including new products, is associated with generalised anxiety among adolescents, with some differences between products. Measures to prevent the initiation of tobacco and nicotine product use and to promote mental health among adolescents should be enacted.

Introduction People with severe mental illness (SMI) and learning disabilities (LD) experience significant health inequalities, with diet-related conditions contributing substantially to early and preventable death. Despite high levels of nutritional risk, the presence and effectiveness of nutritional screening in mental health (MH) and LD settings remains under-researched. This study aimed to investigate nutritional screening practices in UK inpatient MH and LD services from the perspectives of dietitians. Methods A cross-sectional mixed-methods study was conducted using a novel 22-question online survey. Data was collected via the British Dietetic Association Mental Health Specialist Group (April-June 2025). Quantitative data was analysed descriptively and qualitative data by reflexive thematic analysis. Findings were integrated and presented thematically. Ethical approval was granted by Teesside University (2025Mar26544). Results Forty-seven dietitians participated, most with substantial dietetic experience, from a range of MH settings. Screening practices were widely established and supported by policy and audit. However, participants reported low confidence in screening translating into meaningful patient care. Barriers to screening included appropriateness of available tools, time constraints, difficulty engaging distressed patients and poor prioritisation of physical health. Digital integration and wider infrastructure were also important. Dietitians rarely undertook screening directly, instead holding secondary or leadership roles, while screening was most often completed by nursing staff who were often perceived to place limited importance on the process. Existing tools, particularly the Malnutrition Universal Screening Tool (MUST), were viewed as insufficiently capturing the broader nutritional risks relevant to MH/LD populations, leading some services to adopt bespoke, unvalidated tools. Conclusion Concerns regarding the suitability of existing nutritional screening tools in MH/LD settings are consistent with previous literature. However, we suggest cautious use of unvalidated bespoke tools. Whilst there was no clear front runner, MH specific tools such as the St Andrews Nutrition Screening Instrument (SANSI) and the NutriMental Screener warrant further evaluation. Importantly, findings indicate that optimising tool choice alone is unlikely to improve screening effectiveness. Nutritional screening must be embedded within clear care pathways, supported by organisational leadership, digital infrastructure, and multiprofessional engagement to move beyond procedural completion and support meaningful clinical action to improve patient care.

Background Birth Preparedness and Complication Readiness (BPCR) education is an important component of antenatal care. However, health education materials translated from one language into another may lose their intended meaning if linguistic, cultural, experiential, and sociolinguistic differences are not considered. In Tanzania, maternal health education is commonly delivered in Swahili, while many source materials are developed in English. This study explored the cultural and linguistic equivalence of BPCR terminology and concepts in a translated Swahili BPCR education manual among Hehe pregnant women in the rural Iringa Region, Tanzania. Methods A descriptive qualitative study was conducted in seven villages across Kilolo and Mufindi districts of Iringa Region. Seven focus group discussions (FGDs) involving 56 pregnant women were conducted. Participants were purposively selected from the Hehe community and were asked to interpret terminology and concepts contained in a harmonized Swahili BPCR education manual. The translation and adaptation process comprised six sequential steps: forward translation, synthesis, back translation, expert review, community exploration, and finalization. FGDs were conducted in Swahili by trained facilitators fluent in both Swahili and Hehe, audio-recorded with consent, transcribed, and thematically analyzed using Braun and Clarkes six-phase approach. Analysis focused on semantic, conceptual, experiential, and sociolinguistic equivalence. Reporting was informed by the Consolidated Criteria for Reporting Qualitative Research (COREQ). Results Five themes were developed: (1) culturally and linguistically familiar expressions conveyed BPCR concepts; (2) experiential and contextual language shaped descriptions of danger signs; (3) sociolinguistic norms and modesty influenced communication about sensitive health topics; (4) some clinically important concepts had partial or limited conceptual equivalence; and (5) unfamiliar concepts required supplementary explanation. Participants identified culturally familiar expressions including "matazamio ya kujifungua" ("anticipated date of delivery"), "fedha ndiyo usafiri" ("money itself is transport"), "chupa imepasuka" ("the water bag has burst"), "mtoto kutokucheza tumboni" ("the baby is not moving in the womb"), and "sehemu za siri" ("private parts"). Some expressions were familiar but broader than their biomedical equivalents, while cord prolapse and neonatal cyanosis had no readily recognized community equivalents. Conclusion The findings indicate that cultural and linguistic equivalence cannot be achieved through literal translation alone. Community exploration identified expressions that were familiar and socially acceptable while also revealing clinical concepts requiring additional explanation. The findings informed refinement of the Swahili BPCR education manual while preserving the intended clinical meaning. The adapted terminology should subsequently be evaluated separately for its effects on knowledge, attitudes, practices, and other health outcomes.

Background: Tuberculosis (TB) remains a major public health challenge globally, with Pakistan ranking among the highest TB burden countries worldwide. Although several novel TB vaccine candidates for adolescents and adults are advancing through late-stage clinical trials, little is known about how these vaccines may be introduced in high-burden settings such as Pakistan. Understanding stakeholder perspectives is crucial for informing early implementation planning and policy development. Methods: We conducted an exploratory qualitative study using semi-structured in-depth interviews with key stakeholders involved in TB control, immunization, clinical care, and health policy in Pakistan. Participants were purposively selected from national and provincial TB programs, Expanded Programme on Immunization (EPI), clinical settings, and academia. Interviews were conducted in English or Urdu, audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis following the Braun and Clarke framework. A hybrid deductive-inductive coding approach was used. Results: Ten stakeholders participated including one whose interview also served as a pilot test of the interview guide. Participants expressed strong support for the introduction of a new TB vaccine, driven largely by Pakistan's high TB burden and the limitations of current prevention strategies. However, support was based on the availability of strong evidence regarding vaccine safety, effectiveness, and feasibility. Key barriers to vaccine acceptability included low perceived risk of TB, misinformation, stigma, sociocultural influences, and limited public awareness. Stakeholders emphasized community engagement, trusted healthcare providers, and effective communication as critical enablers. Health system challenges included workforce shortages, cold chain limitations, and financing constraints. Household contacts of TB patients were consistently identified as the priority group followed by adolescents and people living with HIV. A phased implementation strategy was broadly preferred followed by gradual integration into existing health services. Conclusion: Stakeholders in Pakistan broadly support new TB vaccines for adolescents and adults. Successful implementation will require addressing sociocultural barriers, strengthening health system capacity, and developing context-specific delivery and prioritization strategies. Early stakeholder engagement and implementation planning are essential for meaningful public health impact in Pakistan.

Introduction: Clinical students are a future health workforce, yet their roles during outbreaks of highly infectious diseases remain uncertain because of safety, training, supervision and welfare concerns. Ugandas 2022 outbreak of Ebola disease caused by Sudan ebolavirus highlighted the need to understand how clinical students perceive outbreak-related care. Aim: This study explored willingness to care for patients with Ebola virus disease among clinical students at a Ugandan medical school and examined how perceived risks, perceived benefits and support needs shaped that willingness. Methods: An exploratory descriptive qualitative study was conducted among clinical students of Makerere University in Kampala, Uganda. Fifteen undergraduate medical and nursing students in the later years of training were purposively selected. Data were collected through in-depth interviews, audio-recorded with consent, transcribed verbatim, de-identified and analysed using latent content analysis. The Health Belief Model sensitised interpretation, and reporting was strengthened using the COREQ guidance. Results: Five interrelated themes emerged, showing that willingness to care was conditional rather than simply present or absent. Students described an initial willingness grounded in professional duty, devotion to patients and the desire to save life. This willingness was restrained by perceived risks of contracting Ebola virus disease, dying, transmitting infection to family members or colleagues, emotional distress, lack of epidemic-readiness in the curriculum, inadequate preparedness and weak welfare support. Perceived benefits, including patient survival, professional learning, outbreak experience and personal fulfilment, strengthened willingness but did not override safety concerns. Students identified reliable personal protective equipment, epidemic-ready curricula, practical infection-prevention and control training, simulation, clear protocols, close supervision, psychosocial support, insurance and fair compensation as cues to action that could convert willingness into safe participation. Conclusions: Clinical students in this Ugandan teaching hospital expressed a strong sense of professional responsibility, but their willingness to participate in Ebola care was conditional upon preparedness, protection, epidemic-ready education and institutional trust. Professional duty and learning opportunities promoted participation, whereas perceived risks and inadequate support limited it. Medical education programmes and outbreak-response systems should develop ethical, supervised, competency-based student roles supported by practical curricula, reliable protective equipment and psychosocial and welfare safeguards.