Global Health Action

Introduction: Low and middle-income countries suffer from a high burden of undernutrition. Fetal malnutrition negatively impacts a newborn's body composition, metabolism, and enzymatic processes, predisposing the newborn to malnutrition during childhood period. This study aims to assess the magnitude of fetal malnutrition and its predictors in southern Ethiopia. Methods: A facility-based cross-sectional study was conducted among 423 pairs of mother and term newborn delivered from February 1- 28, 2025, at five randomly selected public hospitals in southern Ethiopia. The Clinical Assessment of Nutrition (CAN) Score is used to assess fetal malnutrition. Logistic regression was employed to identify predictors of fetal malnutrition. Statistical significance of the association was declared at p < 0.05. Results: Among 423 newborns included in the study, 60 (14.1%) had fetal malnutrition. Newborns born to women with a placental weight of 519 grams or less had ten times higher odds of fetal malnutrition compared to their counterparts (AOR=9.795, 95% CI: 4.881-19.657). Dietary counselling during pregnancy reduced odds of fetal malnutrition by 62.3% (AOR=0.377, 95% CI: 0.162-0.877); similarly, an extra meal during pregnancy was associated with reduced odds of fetal malnutrition by 71.6% (AOR=0.284, 95% CI: 0.131-0.616). Newborns delivered from women who had a MUAC (Mid Upper Arm Circumference) >22 cm had 75.7% lower odds of fetal malnutrition (AOR=0.243, 95% CI 0.074 -0.797), whereas maternal chronic medical illness increased the odds by threefold (AOR=3.419, 95% CI: 1.269-9.153). Conclusion: There is a high magnitude of fetal malnutrition in the study area. Placental weight, dietary counselling, extra meals during pregnancy, MUAC and chronic medical illness were predictors of fetal malnutrition, signifying the need for a comprehensive approach targeting maternal nutrition during pregnancy

Background: Indonesia, as an upper-middle-income country, is undergoing a nutrition transition. The persistent problem of undernutrition is now accompanied by rising overnutrition, creating a double burden of malnutrition. The Human Development Index (HDI) that measures socio-economic development, has shown steady improvements in Indonesia, yet nutritional disparities remain across provinces with varying HDI levels. Objective: This study aims to map the relationship between HDI and nutritional status by analyzing the prevalence of stunting, wasting, underweight, and overweight across different HDI categories and provinces in Indonesia. Additionally, this study explores the determinants of malnutrition to provide a deeper understanding of the factors influencing child nutrition status. Methods: This ecological study utilizes data from 2023 Indonesian Nutrition Status Study, Central Bureau of Statistics and Indonesian Demographic and Health Survey and creates provincial level dataset with malnutrition prevalence, HDI, and other health indicators. The analysis employs spatial relationship, descriptive statistics, and correlation analysis to assess the determinants of malnutrition. This ecological study used 2023 provincial-level data from the Indonesian Health Survey (SKI) and the Human Development Index (HDI) published by the Central Bureau of Statistics. Nutritional indicators (stunting, underweight, wasting, and overweight) were analyzed in relation to HDI and other determinants. Spearmans correlation and Mann-Whitney U tests were used for statistical analysis. Spatial patterns were visualized through GIS mapping to explore geographic relationships between HDI levels and nutritional status. Results: Provinces with high to very high HDI had significantly lower prevalence of stunting (21.36% vs. 31.80%), underweight (16.60% vs. 21.89%), and wasting (9.49% vs. 13.00%) compared to those with low to medium HDI (p < 0.05). No significant difference was found for overweight. Significant negative correlations were observed between stunting, underweight, and wasting with several key determinants, including exclusive breastfeeding, proper infant and young child feeding practices, adequate vitamin A intake, proper handwashing and sanitation practices, parental education, immunization coverage, and HDI. However, no significant correlations were found between these determinants and overweight. Conclusion: This study highlights the complex relationship between HDI and nutritional status, emphasizing the need for region-specific interventions. While improving HDI can help to reduce undernutrition, rising overweight prevalence requires targeted public health strategies. These findings offer valuable insights for policymakers to design holistic, multi-dimensional approaches to combat malnutrition in Indonesia. Keywords: Human Development Index, Nutritional Status, Spatial Analysis, Malnutrition, Indonesia

Background This study aims to explore the initiation and implementation of Jamkesus Disabilitas, a health financing scheme for people with disabilities in Yogyakarta Province, using the UK Medical Research Council (MRC) Process Evaluation for Complex Intervention. Methods We interviewed 19 people with disabilities with different types of impairment as beneficiaries, 3 people from Organisations for People with Disabilities (OPDs), 4 government officials, and 4 health providers, either in person, online, or by phone. Interviews were conducted by LA, and took place in Yogyakarta Province in July-September 2024. Data were analysed using a thematic analysis approach using NVivo 15 software. Findings Jamkesus Disabilitas has improved access to assistive technology (AT) and demonstrated inclusive care through its one-stop service. It also highlights the importance of consistent leadership in disability-inclusive health systems. However, challenges persist, including uneven AT quality, low coverage, limited availability, and inadequate data for evaluation and planning persisted. Moreover, the absence of inclusive features in the regular service means the scheme has not fully closed the equity gap in healthcare access for people with disabilities. Conclusion Jamkesus Disabilitas has expanded access to AT overlooked by the national health insurance (JKN). However, implementation should prioritise AT quality standards, financial and operational sustainability, and stronger data systems. Broader systemic reforms are also needed to embed disability inclusive practices in regular healthcare service delivery. Keywords Health equity, inclusive health system, social protection, health insurance, health financing

Introduction: School feeding programs (SFPs) can contribute to address undernutrition in low- and middle-income country settings while can simultaneously improve education outcomes and deliver social and economic benefits. However, evidence on their comprehensive value for money (VfM) remains limited. This study models the multi-sectoral impacts of SFPs across education, health, social protection, and the local agricultural economy in five sub-Saharan African countries, providing benefit-cost ratio (BCR) and VfM estimates to inform policy decisions. Methods: The analysis used secondary data from national reports, program budgets, and national household surveys. SFP impacts on education were assessed through changes in years of schooling and linked to lifetime income gains. Health impacts were quantified as averted anemia cases, converted into disability-adjusted life years (DALYs) and monetized using gross domestic product (GDP) per capita. Social protection benefits were measured as the in-kind value of school meals relative to household food expenditures, while local economic impacts were assessed through monetary transfers to smallholder farmers (SHFs) from local food procurement. BCRs were calculated considering education and health impacts, with additional VfM and expanded BCR estimates considering broader benefits and transfers. Results: Across countries, SFPs were associated with a cumulative gain of 0.6 to 2.3 years of schooling per beneficiary. Moreover, reductions in anemia cases are expected to avert between 4 to 51 DALYs per 1,000 beneficiaries. The BCR for education and health ranged between 3 and 31. Meals provided covered up to 28% of annual household food expenditures for low-income families. Local food procurement generated economic transfers between USD 7 and USD 15 per beneficiary per year to SHFs. Conclusion: SFPs demonstrate high VfM, offering significant educational, health, and economic benefits. Policymakers in sub-Saharan Africa should prioritize the expansion and scaling of SFPs to enhance educational attainment, improve health, and foster economic resilience, contributing to sustainable development.

Background: Climate change is an escalating global health threat, with sub-Saharan Africa disproportionately affected due to entrenched spatial inequalities, high exposure to environmental hazards, and limited adaptive capacity. Increasingly frequent extreme weather events (EWEs), including floods and cyclones, are reshaping the material and social conditions of place, with implications for mental health and wellbeing. However, evidence remains limited, particularly multi-country qualitative research that examines how mental health impacts are produced through lived experiences of place in contexts of recurring environmental disruption and structural vulnerability. This study explored the mental health and wellbeing impacts of EWEs among individuals with lived experience of such events in Mozambique, Burkina Faso, South Africa, and Kenya, using participatory methods that centred community narratives and place-based accounts of everyday life. Methods: This qualitative study employed digital storytelling as a participatory visual method to examine how EWEs are experienced and narrated across diverse socio-spatial contexts. A total of 37 participants (8 to 10 per country) were recruited from rural, peri-urban, and informal urban settlements with recent exposure to flooding or cyclone events. Participants produced digital stories during facilitated five-day workshops. These narratives were analysed using inductive and deductive thematic analysis informed by Braun and Clarke's framework, with attention to the spatial and relational production of distress and coping. Results: Across Mozambique, Burkina Faso, South Africa, and Kenya, findings show that the mental health impacts of EWEs are deeply embedded in place-based conditions and are cyclical, cumulative, and relational rather than confined to discrete disaster events. Participants described how repeated environmental disruptions reconfigured everyday life in place, generating ongoing uncertainty, anticipatory anxiety during rainfall periods, and acute fear during floods and cyclones. Loss of housing, livelihoods, infrastructure, and social anchors of place contributed to enduring psychological distress, which was frequently reactivated by subsequent environmental cues such as heavy rain, wind, and deteriorating physical environments. Persistent anxiety, hypervigilance, sleep disturbance, and emotional distress were reported across all sites. While social and community networks constituted critical infrastructures of care within place, these were often simultaneously overwhelmed as entire communities experienced shared disruption. Limited and delayed institutional responses further compounded spatial and social precarity. Conclusions: This study provides a comparative participatory account of how EWEs shape mental health through their embeddedness in place across diverse sub-Saharan African contexts. The findings demonstrate that psychological distress is produced through the interaction of repeated environmental exposure, structural inequality, and disrupted place-based infrastructures of daily life, rather than emerging solely as a post-disaster outcome. These results underscore the need for climate-responsive mental health and psychosocial support that is integrated into place-based disaster risk governance, alongside strengthened social protection and community infrastructure that can sustain wellbeing in contexts of recurring environmental instability.

Background: Returnee migrants in Nigeria often face significant psychosocial and economic challenges during reintegration, necessitating resilience to adapt and recover. This study examined factors influencing resilience among returnee migrants in Nigeria. Methodology: A mixed methods design was employed, involving 1316 returnees selected through multistage sampling across Nigeria six geopolitical zones. Quantitative data were collected using the Connor Davidson Resilience Scale and analyzed using SPSS version 28. Qualitative data was obtained through eight focus group discussions and analyzed thematically. Result: Social support from family and friends was inconsistent (70.8% reported occasional support), while community support was largely absent (85.9%). Financial insecurity was widespread (gt 90%). Male gender (AOR = 6.092, plt 0.001), ethnicity, and higher education were significant predictors of resilience. Qualitative findings highlighted the role of family support, faith, adaptive coping, and skill acquisition in strengthening resilience. Conclusion: Resilience among returnee migrants in Nigeria is limited by weak structural and economic support, despite moderate personal coping capacity. Strengthening economic opportunities, community integration, and access to mental health services is essential for sustainable reintegration. Keywords: Returnee migrants, resilience, Reintegration, and psychosocial factors.

Background Indias maternal nutrition profile is undergoing a dual-direction shift, with persistent undernutrition coexisting alongside rising overweight and micronutrient deficiencies. Despite national efforts through Integrated Child Development Services (ICDS) and the National Health Mission (NHM), maternal dietary diversity remains suboptimal in India. Frontline health workers (FLWs) play a central role in delivering nutrition counselling; however, gaps remain between knowledge and its translation into practice, highlighting the need to strengthen training, applied competencies, and health system support within primary care settings. Objective To assess knowledge, attitudes, and practices (KAP) regarding maternal nutrition counselling among FLWs and to explore contextual factors influencing counselling delivery. Methods A sequential explanatory mixed-methods study was conducted in Udupi, Karnataka, India. In phase one, 46 FLWs- Accredited Social Health Activists (ASHA), Community Health Officers (CHO), and Primary Health Care Officers (PHCO) completed a validated Knowledge, Attitudes, and Practices (KAP) questionnaire. Data were analysed using descriptive statistics, Kruskal-Wallis test, Spearman correlation, and exploratory multiple linear regression. In phase two, one focus group discussion with 21 participants was conducted and analysed using reflexive thematic analysis. Results FLWs demonstrated moderate KAP scores (37.50 {+/-} 5.09), with lower scores observed in dietary diversity knowledge and counselling practices. CHOs and PHCOs had significantly higher knowledge (p < 0.001) and practice scores (p = 0.002) compared to ASHAs, while attitudes were similar across cadres. Knowledge was positively associated with practice ({rho} = 0.389, p = 0.008). Exploratory regression indicated that cadre and knowledge were associated with practice, while attitude was not statistically significant. Qualitative findings suggested that counselling was largely protocol-based and constrained by workload, limited counselling tools, economic barriers, and cultural food practices. Conclusion Despite positive attitudes towards maternal nutrition counselling, frontline health workers demonstrated gaps in knowledge and counselling practices. Mixed-methods findings suggest that counselling delivery is shaped by both provider competencies and health-system constraints, highlighting the need for implementation-focused strategies to strengthen maternal nutrition counselling in routine antenatal care.

Adolescents living with HIV (ALHIV) in Eastern and Southern Africa experience substantial challenges around medication adherence, treatment, care, mental health and wellbeing. Although interventions such as Zvandiri aim to strengthen mental health and wellbeing to impact HIV treatment outcomes, available measures often focus on negative outcomes or rely on positive psychology instruments developed in high-income settings. These tools may not adequately capture culturally embedded, relational and fluctuating dimensions of wellbeing among ALHIV. We describe the development of the Zvandiri Character Strength (ZCS) scale and draw methodological lessons for culturally grounded wellbeing measurement. The multi-stage scale-development process (2023-2025) comprised a scoping and systematic review, qualitative interviews and focus group discussions, expert panel input, construct and item prioritisation with ALHIV, cognitive interviews, iterative item reduction, and exploratory factor and Rasch analyses. An initial item bank was reduced to a 53-item candidate scale, then to the ZCS 38 and finally ZCS 25, based on quantitative analyses and participant feedback. The ZCS 25 was subsequently assessed using retrospective pretest, post-test and follow-up administration. The review identified conceptually overlapping positive psychological constructs, many of which are measured using instruments developed in high-income settings and not adequately validated for ALHIV in sub-Saharan Africa. Qualitative work highlighted connectedness, happiness, hope, motivation, optimism, and perseverance as key. In addition, discussions highlighted how wellbeing was relational, contextually situated, and often co-occurring with distress. Quantitative testing showed highly positive responses, disordered thresholds, ceiling effects, weak internal structure and fluctuating retrospective ratings. Participant feedback suggested that positive responses were likely due to affirmations and partly linked to social desirability. In conclusion, the ZCS scale did not support a single interpretable total score, but the process of its development offers important methodological lessons. Future measurement should begin with clearer construct definition, response-process validation, domain-level testing, and explicit decisions about whether the measure aims to capture lived wellbeing, domain-specific positive outcomes or intervention-relevant change.

Abstract Background The continuum of maternal healthcare utilization is crucial for enhancing maternal and child health outcomes. Despite high individual service utilization, completion of the continuum of care among many women in Kenya remains suboptimal, with significant attrition across the stages of care. This study examined socioeconomic and sociodemographic inequalities in the continuum of maternal healthcare utilization in Kenya. Methods This study used the 2022 Kenya Demographic and Health Survey, specifically the womens file. A total of 13,612 women aged 15-49 years who had a live birth within 5 years before the survey were included in the analysis. Continuum of care was categorized as no, partial, or complete. A multivariable multinomial logistic regression model was used to estimate inequalities across the continuum of care, with no continuum as the reference category. Results were expressed as adjusted Relative Risk Ratios (aRRR) with 95% confidence intervals. Results Overall, approximately 36.6% (95% CI: 35.1-38.0) achieved a complete continuum, while a majority, 60.8% (95% CI: 59.3 - 62.2), achieved a partial continuum. In terms of individual service utilization, 67% of women had 4 or more antenatal care contacts, 62% had a skilled delivery, and 54% had a postnatal visit within 48 hours of delivery. We observed inequalities across parity, age, wealth quintiles, education, pregnancy intention, place of residence, and media exposure that influenced both the partial and complete continuum of maternal healthcare utilization. Conclusion Approximately one-third of women in Kenya received a complete continuum of care during the prenatal and postnatal periods. The government and stakeholders should prioritize targeted, equity-focused interventions for women with no education and those from low-income households to increase service utilization. Non-governmental organizations and the Ministry of Health should also intensify media sensitization and expand access to family planning services.

Abstract Background: Human papillomavirus (HPV) infection is a leading cause of cervical cancer globally, disproportionately affecting women in developing countries like Ghana. Despite the recent introduction of national HPV vaccination programs, vaccine uptake among young adults remains suboptimal. This study aimed to assess the levels of knowledge, attitudes, and perceived barriers toward HPV, cervical cancer, and vaccination among undergraduate students in Ghana to inform future public health interventions. Methods: A cross-sectional study was conducted among 699 undergraduate students at the University of Cape Coast, Ghana. A multistage stratified random sampling technique was employed to ensure disciplinary representation. Data were collected using a validated, semi-structured digital questionnaire covering socio-demographics, knowledge of HPV, attitudes toward vaccination, and perceived barriers. Descriptive statistics were utilized to summarize findings. Chi-square tests were performed to assess bivariate associations, and binary logistic regression analysis was conducted to identify predictors of good knowledge and positive attitudes toward vaccination, with statistical significance set at p < 0.05. Results: 51.9% of students demonstrated good knowledge of HPV and vaccination. A significant gender disparity was observed: while male students displayed higher levels of clinical knowledge, female students held significantly more positive attitudes toward vaccination (p < 0.05). Major barriers included profound social stigma, with 77.9% of students expressing concern over partner perception and 65.6% reporting embarrassment regarding the association between the vaccine and sexually transmitted infections. Misconceptions were prevalent, with 46.6% of participants incorrectly believing the vaccine could cure existing infections. Conclusion: A clear knowledge-attitude gap exists among Ghanaian undergraduates, complicated by pervasive psychosocial barriers. Current vaccine delivery models, which often center on reproductive health or STI clinics, inadvertently reinforce stigma. To improve vaccination coverage, public health initiatives must transition toward a stigma-neutral model of care that integrates HPV immunization into routine primary health services, framing it as a preventive cancer-fighting strategy rather than a sexual health intervention.

Background Persistent gaps in Neglected Tropical Diseases (NTDs) knowledge and skills among frontline health workers in endemic countries remain an important factor limiting progress toward elimination targets. Blended learning approaches offer a potentially scalable solution, but robust evidence from low- and middle-income countries (LMICs) remains scarce. This study evaluated the effectiveness, acceptability, behavioral effects, and cost of a blended learning program for NTD capacity building in India and Nigeria. Methods A mixed-methods intervention study was conducted in India and Nigeria. A total of 177 purposively selected health workers across three levels (frontline/community workers [Level 1], clinicians and primary care providers [Level 2], and district supervisors/program managers [Level 3]) participated in a blended training program combining interactive online modules with practical onsite skill sessions. Guided by the integrated frameworks of Implementation Science and Kirkpatrick, outcomes were assessed using pre/post knowledge tests, 3-6 month follow-up observations and interviews, focus group discussions, and comprehensive costing. Quantitative data were analyzed using Stata, and qualitative data underwent thematic analysis. Results The program achieved high acceptability across all cadres and settings. Knowledge scores improved significantly after training (average gains 5-42.5%, p<0.001, Cohens d 1.1-1.8) across the 3 training courses. At 3-6 months, workplace observations and supervisor feedback observed improved service delivery. Challenges included internet connectivity, language barriers, and lower online completion rates among Level 1 workers. Conclusions A contextually adapted blended learning approach is feasible, acceptable, effective, and cost-efficient for strengthening NTD workforce capacity in resource-limited settings. With targeted adaptations (local languages, offline access, and cadre-specific tailoring), this model offers a promising strategy to support the WHO NTD Roadmap 2021-2030 and Zero Leprosy goals.

Diabetes mellitus is an increasing public health challenge in Uganda and other low- and middle-income countries, where health systems face growing demands for chronic disease care. Although quantitative studies have documented poor glycemic control and health system constraints, less is known about how patients and healthcare providers experience diabetes management in peri-urban public health settings. This study explored barriers and facilitators to diabetes management among adults with diabetes mellitus and healthcare providers at a peri-urban health facility in Uganda. We conducted a qualitative descriptive study at Kasangati Health Centre IV, Wakiso District, Uganda, between February and March 2025. Data were collected through 15 in-depth interviews with adults living with diabetes mellitus and 8 key informant interviews with healthcare providers involved in diabetes care. Participants were purposively selected based on their experience with diabetes management and service delivery. Interviews were audio-recorded, transcribed verbatim, translated where necessary, and analyzed using a hybrid inductive-deductive thematic approach informed by the Theoretical Domains Framework. Five interrelated themes were identified: (1) institutional and environmental factors influencing access to diabetes care; (2) cognitive and informational factors influencing medication adherence; (3) social influences on diabetes management; (4) emotional experiences of patients and healthcare providers; and (5) self-management strategies and continuity of care. Across these themes, participants identified barriers including resource limitations, communication challenges, medication management difficulties, stigma, emotional distress, and weak follow-up systems. Facilitators included peer support, religious and community networks, health education, provider flexibility, and patient-developed adherence strategies. Diabetes management was influenced by interacting health-system, social, informational, and behavioural factors. Resource constraints, limited health literacy, stigma, and weak follow-up systems hindered effective management, while social support, health education, and patient self-management strategies facilitated continued engagement in care. Interventions that strengthen chronic care services, patient education, and community support may improve diabetes outcomes in similar resource-constrained settings.

Despite established national immunization programmes for children and livestock, pastoral communities in Kenya remain chronically underserved, with low vaccination coverage attributed mainly due to seasonal mobility, vast terrain, and limited health infrastructure. Even less understood is whether these assumptions hold across all pastoral contexts, and how livelihood practices such as hiring herders during drought seasons may intersect with vaccine access. This study examined factors associated with child and livestock vaccination among Maasai communities in Kajiado Central Subcounty, Kenya, using a One Health lens. We employed a mixed-methods design across three wards (Dalalekutuk, Ildamat, and Purko). Quantitative data were collected through semi-structured household surveys (n=180), with bivariate analysis examining the associations between the vaccine hesitant group and the vaccine accepting group in children and livestock. Qualitative data were gathered through two gendered focus group discussions (FGDs, n=31) and seven key informant interviews (KIIs). Inductive thematic analysis was interpreted through the COM-B framework, and findings were integrated using convergent triangulation. Child immunization coverage averaged 90% (range 87-98%), which is higher than typically reported for pastoral populations. In contrast, livestock vaccination coverage averaged 53% (range 5-87%) despite comparable willingness to vaccinate in both children (97%) and livestock (93%). Vaccine hesitancy co-occurred across children and livestock within the same households (OR 36.7, 95% CI 5.9 - 227.5). Eighty-eight percent of households hired herders to migrate with livestock during the cool-dry season (June-September), suggesting a shift toward sedentarization. Qualitatively, supply chain failures including vaccine production monopoly, counterfeit vaccines, stockouts, and understaffing were identified as key contributors to low livestock vaccination coverage. Closing the livestock vaccination gap requires supply-chain reforms such as breaking the KEVEVAPI monopoly, strengthening the VMD regulatory framework, and securing transport budgets to avoid stockouts. The relationship between hiring herders and vaccine access warrants further investigation as a potential structural enabler towards strengthening pastoral health programming.

Background Infection with human papillomavirus (HPV), the primary cause of cervical cancer, disproportionately affects women in low- and middle-income countries (LMICs). While school-based vaccination of adolescent girls against HPV is highly effective, this strategy systematically excludes out-of-school (OOS) girls. Using the RE-AIM framework, we explored strategies to reach OOS girls with HPV vaccination across six African and Asian LMICs. Methods We conducted semi-structured key informant interviews with 32 vaccination program stakeholders from Cambodia, Cameroon, Kenya, Malawi, Mozambique, and Uganda between May and September 2024. Interviews explored countries implementation successes, challenges, and strategies to reach OOS girls with HPV vaccination and sustainability considerations. Data were analyzed using a hybrid team-based thematic analysis approach guided by the RE-AIM framework. Results Community outreach-based strategies, typically integrated into routine immunization outreach, were identified as the most effective approach to reach OOS girls with HPV vaccination. Targeted strategies, such as locating outreach clinics in community venues frequented by OOS girls (e.g., churches, markets) enhanced implementation. Perceived effectiveness of these strategies varied across participants, and formal assessment of effectiveness was constrained by the absence of disaggregated vaccination coverage data by school enrollment status. Some subpopulations of OOS girls (i.e., girls in nomadic or migrant communities, urban OOS girls) were not readily reached through standard outreach approaches, prompting implementation of adapted and tailored strategies for these subpopulations. Costs associated with conducting outreach in harder-to-reach areas were major barriers to reaching OOS girls, presenting challenges to the sustainability and cost-effectiveness of these approaches. Conclusions Routine community outreach platforms were widely perceived as most effective for reaching OOS girls. Strengthening disaggregated monitoring systems, adapting outreach for harder-to-reach subpopulations of OOS girls, and financing delivery models for tailored outreach strategies will be critical to improving equitable HPV vaccine coverage among OOS girls.

Background: Evidence regarding the double burden of malnutrition (DBM) among hospitalized patients in Vietnam remains limited. This study examined nutritional status at admission and its association with length of hospital stay among adults in Hanoi. Methods: This prospective observational cohort study was conducted in eight public hospitals in Hanoi between September 2018 and November 2019. Adults aged 18-60 years were assessed within 48 hours of admission using interviews, physical examination, anthropometric measurements, and medical records. Nutritional status was classified using the Subjective Global Assessment (SGA) and body mass index (BMI): undernourished (SGA-B or SGA-C or BMI <18.5 kg/m2) and overnourished (SGA-A and BMI [&ge;]25.0 kg/m2). Length of stay was compared across nutritional-status groups using the Kruskal-Wallis test. Results: Among 1,183 registered patients, 1,115 had sufficient data for analysis. Overall, 24% were undernourished and 16% overnourished. Weight loss during the preceding six months was reported by 54%, although most losses were <5%. SGA-B or SGA-C was identified in 20%, whereas 11% had BMI <18.5 kg/m2. The median hospital stay was 8 days, with no significant difference across nutritional status groups. Conclusions DBM was prevalent among hospitalized adults in Hanoi. Indicators of recent nutritional deterioration were more common than low BMI, suggesting that BMI alone may overlook early disease-related nutritional decline. Nutritional status was not associated with length of stay in this relatively young, predominantly mild-to-moderate patient population. Hospital nutritional screening should therefore assess recent nutritional changes across the full BMI spectrum.

Ethnic minority and migrant populations experienced disproportionately severe COVID-19 outcomes across Europe, yet the mechanisms underlying these disparities, particularly inequities in healthcare access, remain insufficiently understood at the patient level. This qualitative study examines healthcare-seeking behaviours and access to care among ethnically diverse patients hospitalised with COVID-19 in Amsterdam between 2020 and 2022, and the contextual factors shaping their pathways to care. Twenty adults of Turkish, Moroccan, Surinamese, Ghanaian, and Dutch ethnic backgrounds, all hospitalised with COVID-19, were interviewed using a semi-structured retrospective approach to reconstruct individual care pathways from symptom onset to hospitalisation. Data were analysed thematically, guided by the Candidacy Framework and the Health Belief Model. Pandemic-induced structural disruptions, including healthcare system strain, capacity shortages, absent care protocols, and fragmented referral pathways, constituted the primary barriers to care across all ethnic groups. Participants with longer hospital stays tended to be older, less educated, and with more comorbidities, yet reported fewer barriers once hospitalised, as disease severity triggered prioritisation. Those with shorter stays or emergency department visits without admission encountered greater difficulties, including repeated discharge despite worsening symptoms. Language barriers and prior negative experiences with healthcare services compounded access challenges for some participants with migrant backgrounds, though pandemic phase and disease severity were the dominant determinants across the sample. Inequities in access to care were driven primarily by pandemic-induced structural factors rather than ethnic background. Pre-existing vulnerabilities among migrant groups, including reduced institutional trust and language barriers, intensified these structural barriers for some. These findings are directly relevant for equity-sensitive pandemic preparedness: crisis response frameworks must explicitly address structural accessibility alongside targeted support for groups facing compounding disadvantage.

Abstract Effective health communication is central to patient-centred care and improved health outcomes, particularly in culturally diverse healthcare settings. In clinical and assistive practice, communication breakdowns may negatively affect diagnosis, treatment adherence, and preventive care. A qualitative phenomenological design was employed, utilizing Semi-Structured interviews with purposively sampled twenty patients and healthcare professionals from Tamale Teaching Hospital, Yendi Hospital, and Bimbilla Hospital. The researchers adopted Content Analysis as the tool of analysis for the data. The findings of this study revealed that language discrepancies Poor attitudes of healthcare providers hinderer patient openness and the quality treatment. Logistical issues, such as inadequate medicines and medical supplies, resulted in delayed treatment and additional financial burden on patients and their relatives. Cultural and social factors discourage patients from discussing certain health conditions with healthcare providers, leading to delayed treatment. These hurdles adversely impact on treatment and assistive practice, specifically in culturally diverse environment and preventive care. The study recommends training and capacity-building programs for healthcare providers in cultural competence, fostering effective and ethical health communication between patients and healthcare providers, and recruiting professional interpreters to bridge the linguistics gap between patients and providers. Abstract Effective health communication is central to patient-centered care and improved health outcomes, particularly in culturally diverse healthcare settings. In clinical and assistive practice, communication breakdowns may negatively affect diagnosis, treatment adherence, and preventive care. A qualitative phenomenological design was employed, utilizing semi-structured interviews with twenty purposively sampled patients and healthcare professionals from Tamale Teaching Hospital, Yendi Hospital, and Bimbilla Hospital. The researchers adopted content analysis as the tool of analysis for the data. The findings of this study revealed that language discrepancies Poor attitudes of healthcare providers hinder patient openness and quality treatment. Logistical issues, such as inadequate medicines and medical supplies, resulted in delayed treatment and additional financial burden on patients and their relatives. Cultural and social factors discourage patients from discussing certain health conditions with healthcare providers, leading to delayed treatment. These hurdles adversely impact treatment and assistive practice, specifically in culturally diverse environments and preventive care. The study recommends training and capacity-building programs for healthcare providers in cultural competence, fostering effective and ethical health communication between patients and healthcare providers, and recruiting professional interpreters to bridge the linguistics gap between patients and providers.

Globally, 75% of adolescents do not meet recommendations for fruits and vegetables (F&V) consumption. This study investigated drivers of F&V choices among adolescents in Benin and identified barriers and facilitators to modifying F&V consumption. We conducted 16 focus group discussions (FGDs) with 126 adolescents and 5 semi-structured school observations in December 2024. FGDs were purposively chosen to explore variation by region (north/south), school location (urban/rural), adolescent age (12 to 15 years/16-18 years) and gender (boys/girls). Inductive and deductive thematic content analysis was performed using Atlas.ti. Findings showed that adolescents perceived a healthy diet as one composed of meals providing nutrients and strength, and including F&V. At home, adolescents mentioned eating staples and other vegetables more than other food groups. The foods adolescents reported typically eating at school varied by age, gender, and location. The primary categories of factors that influenced adolescent F&V choices were: intrapersonal (knowledge related to healthy eating and the nutrition and health benefits of F&V, taste preferences, and health prioritisation), socio-cultural (family and peer influences), and food environment (low availability, low affordability, convenience, and desirability). DFC factors were consistent across adolescent age, gender, and location. Multiple, dynamic, and multilevel factors influence adolescent F&V choices. Interventions that simultaneously address multiple barriers and involve family and peers are likely to be more successful in promoting F&V consumption and healthy diets than interventions only addressing individual barriers.

Background Personal choice, the opportunity to select an action from available options, free from external constraint, significantly affects health, risks, and treatment needs. Unhealthy lifestyles contribute substantially to global disease burden, pressuring health systems and reigniting debate about individual responsibility for health. The COVID-19 pandemic brought these debates into sharp focus. In South Africa's private health sector, vaccine hesitancy persisted where vaccines were freely available, raising questions about fairness when avoidable costs are imposed on others within pooled insurance. This paper develops and applies a structured framework to assess the case for applying personal responsibility(policies linking contributions, coverage, or costs to factors under individual control) using COVID-19 vaccination in a South African insured population. Methods We employed a multi-part approach drawing on administrative claims and vaccination data from approximately 550,000 insured members (March 2020 to December 2022). We examined vaccination on hospitalisation, utilisation, and expenditure; evaluated fairness from utilitarian (cost-effectiveness and cost-utility) and luck egalitarian (choice vs cost distribution) perspectives; assessed the practical feasibility of responsibility-based mechanisms; and integrated findings through a decision framework. Results Vaccination was associated with >90% lower hospitalisation risk, shorter stays, and 35 to 55% lower costs. Cost-utility analysis showed vaccination dominated non-vaccination (more QALYs at lower cost). Predictive modelling indicated non-vaccination in higher-risk groups reflected personal choice rather than constrained circumstance. Observed costs exceeded modelled costs (if all vaccinated) by 22%, concentrated among older adults and those with comorbidities. Practical assessment identified a hierarchy from low-risk vaccination rewards to higher-risk surcharges and benefit restrictions. Conclusion Vaccination was impactful and cost-effective; non-vaccination in higher-risk groups reflected personal choice. Responsibility-sensitive approaches may be justified where choice is demonstrable, impacts clear, and mechanisms proportionate, fair, and feasible. Incentive-based mechanisms offer lower-risk starting points than punitive designs. The framework offers policymakers a tool to weigh accountability, fairness, and solidarity in health-financing policy. Key Words COVID-19 vaccination; personal responsibility; luck egalitarianism; health insurance; South Africa; priority-setting

Background and aims: Maternal overweight and obesity are increasing worldwide, including Nepal. This study assessed BMI trajectories from early pregnancy to one year postpartum and trends in overweight and obesity over the past two decades in Bhaktapur, Nepal. Methods: In the most recent study, BMI was measured in 800 Nepalese women at three time points: at early pregnancy, 6 and 12 months postpartum (2017-2021). The prevalence of undernutrition, overweight, and obesity was estimated using the World Health Organization and the Asian specific cut-offs. Long-term trends were assessed by comparing these findings with three population-based studies conducted in Bhaktapur between 2001 and 2021 among 2400 women at similar life stages. Results: Mean (SD) BMI increased from 23.7 (3.0) kg/m^2 in early pregnancy to 26.1 (3.3) kg/meter squre at 6 and 25.2 (3.3) kg/m^2 and 12 months. The prevalence of overweight increased from 32.9% in early pregnancy to 48% at 6 months. Using the Asia-specific cut-offs, the prevalences were higher. Results from the three previous population-based studies demonstrated an upward trend where postpartum overweight increased from 11.4% in 2001- 2002 to 44.6% in 2017- 2021. The obesity prevalence rose from 1.8% to 10.9% during this period. Conclusion: Overweight and obesity among Nepalese women have risen dramatically over the past two decades, with postpartum overweight increasing nearly fourfold and obesity more than sixfold. These findings highlight the need for interventions to prevent excessive weight retention and reduce adverse health outcomes.