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.

Abstract Background: Maternal disability can reduce the ability to provide adequate care and increase the likelihood of undernutrition among children. In Malawi, over one third of under-five children are affected by stunting. There has been no study that assessed the association between maternal functional difficulty and undernutrition among children in Malawi. The objective was to assess if maternal functional difficulty is associated with stunting, underweight, and wasting in children in Malawi. Methods: Data were extracted from the nationally representative cross-sectional Malawi 2024 Demographic and Health Survey (MDHS). Mother-child dyads were included for mothers aged 15-49 years and children aged [&le;] 59 months, with valid anthropometric z-scores. Maternal functional difficulty was assessed using the Washington Group Short Set on six domains (seeing, hearing, walking, cognition, self-care, communication) and classified as severe vs. no difficulty. Child undernutrition was defined as height-for-age z-score (HAZ) < -2 (stunting), weight-for-age z-score (WAZ) < -2 (underweight), and weight-for-height z-score (WHZ) < -2 (wasting). Survey-adjusted multivariable logistic regression models were fitted, accounting for complex sampling design whilst population attributable fraction was calculated. Results: A total of 4,361 mother-child dyads were analyzed for this study. The overall weighted prevalence of maternal functional difficulty was 3.74% (SE 0.35). There was a reported 36.4% prevalence for child stunting, 8.7% for underweight and 1.7% for wasting. Maternal functional difficulty was not associated with child stunting (AOR 0.85, 95% CI: 0.55-1.33), underweight (AOR 1.06, 95% CI: 0.55-2.02) and wasting (AOR 0.96, 95% CI: 0.26-3.53) after adjustments for confounders. The population-attributable fractions were also found to be negligible for all three nutrition outcomes. Maternal height [&ge;] 150 cm showed strong protective effect against child stunting (AOR 0.29, 95% CI: 0.16-0.54) as well as belonging to the richest wealth quintile (AOR 0.61, 95% CI: 0.42-0.89). In conclusion, there was no statistically significant association between maternal functional difficulty and child undernutrition in Malawi. The family and community support networks in Malawi may be buffering the nutritional effects of maternal disability on children. To reduce child undernutrition in Malawi, efforts should focus on maternal height, household wealth and the first 1,000 days interventions.

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.

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: 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.

ABSTRACT Background: Vaccination coverage in Brazil declined between 2015 and 2022, followed by a recovery in 2023 and 2024. Given this instability, driven by multiple determinants, we sought to identify factors associated with childhood vaccination and group Brazilian municipalities into scenarios that could guide interventions to improve coverage. Methods: In this ecological study of 5,274 Brazilian municipalities, we assessed the rate of children under 1 year unvaccinated with the third dose of the Inactivated Poliovirus Vaccine (IPV) in 2024, chosen for its high correlation with other tracer vaccines such as Diphtheria, Tetanus and Pertussis (DTP) and Measles, Mumps and Rubella (MMR). We applied a hierarchical model with three levels of determinants (socioeconomic, health service structure, and operational), using Poisson regression to estimate standardized Rate Ratios (RR), followed by a K-means cluster analysis to identify municipal profiles. Results: Several determinants were associated with higher rates of unvaccinated children, most notably the proportion of the population not covered by Community Health Workers (CHW) (RR = 1.15; 95% CI 1.14-1.15) and inequality measured by the Gini Index (RR = 1.33; 95% CI 1.32-1.34). We identified six municipal profiles that differed in tracer-vaccine coverage up to four years of age and in the composite Vaccination Needs Index (VNI). Conclusion: Multiple socioeconomic, structural and operational factors were associated with unvaccinated rates, highlighting the relevance of healthcare service organization even in favorable social contexts. Classifying municipalities into risk profiles may support more targeted interventions aligned with local needs. Keywords: Vaccination coverage, Childhood vaccination, Primary Health Care, Determinants, Scenarios, Profiles.

Methods INCA is a prospective, single-center cohort study with nationwide recruitment. Participation is open to adult patients and informal caregivers who provide paid informal care through home care agencies (Spitex organizations) in Switzerland. Eligible participants are enrolled consecutively. The cohorts primary outcome is health-related quality of life of patients, assessed monthly through patient-reported outcome measures. Secondary outcomes include home care needs, including the overall health and well-being of patients (measured semi-annually), the type, amount, and quality of care (recorded daily), and caregiver burden and resilience (measured quarterly). Additional analysis will include structured medical data, extracted from patient-provided documents using Optical Character Recognition (OCR) technology and analysed using Large Language Models (LLM). Results Since recruiting started in July 2025, the cohort has enrolled 855 patients and 851 caregivers. Among patients, 53% are female, with a median age of 73 years. Caregivers are predominantly female (72%) with a median age of 56 years. Most patients experience impairments in physical functioning and participation in social roles. Among them, 85% require less than two hours of care per day, though care needs vary considerably. This is further reflected in the multi-attribute utility, where the overall PROMIS-Preference (PROPr) score is very low for most patients, with a median of 0.102, indicating a substantial need for medical assistance and care. With a median of 9 comorbidities, health-related quality of life is overall low for most patients. Cardiovascular and endocrine & metabolic diseases are amongst the most prevalent, affecting 69% and 65% of patients with available diagnoses (n=771). Certain diagnostic pairs occur more frequently than expected by chance, suggesting underlying links between disease categories. Conclusions INCA responds to a growing policy need for robust evidence on how new models of informal care are associated with the health and well-being of patients and their caregivers. Its longitudinal design, combining patient- and caregiver-reported data with medical records and innovative data extraction methods, will lay the groundwork for a better understanding of new informal care models in real-world settings. INCAs findings are expected to have significant policy relevance and contribute to evidence-based policies on long-term care at home in Switzerland.

The present study aimed to assess 8 key Maternal and Child Health (MCH) indicators and their socio-demographic determinants in Afghanistan using the 2015 Demographic and Health Survey. It was quantitative analysis on cross-sectional data of ever-married women aged 15-49. The MCH indicators included possession of a health card, birth weight of the child, postnatal check-up, full immunization, exclusive breastfeeding, tetanus toxoid, place of delivery, and antenatal check-up (ANC). We employed multiple correspondence analysis (MCA) and a general linear model to identify associations of MCH indicators with their determinants. The analysis was conducted among 30,000 women. MCA yielded one strong latent construct that accounted for 76.7% of the total variation. The ANC visits, place of delivery, possession of health cards, postnatal visits, and tetanus toxoid vaccination were strongly discriminating items for this dimension. Women who were younger, had a girl child, belonged to the lower wealth quintile, were illiterate, and did not have access to improved drinking water had a higher probability of poor maternal and child health indicators (p<0.05). The MCH situation and their socio-demographic determinants need to be addressed as a priority with concurrent investment in health infrastructure, womens education, and health literacy of populations.

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.

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

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.

Introduction: Engaging Community Influencers (CIs) was a key strategy for polio eradication in India, also contributing to routine vaccination and COVID-19 vaccination. CIs were high status individuals selected for their pre-existing reach into vaccine-hesitant communities. This paper describes the factors that kept the CIs engaged over time. The findings add to our understanding of what drives CHW motivation. Methods: We performed a thematic analysis of 65 in-depth interviews conducted across six study districts of Uttar Pradesh, involving 36 CIs, 18 CGPP field staff, nine project managers and two representatives from other stakeholders. Findings: The most important motivational factors that emerged from the research were improved social status, altruism, and effective working relationships. The inputs required to foster these were information support; providing respect and visibility; and fostering robust working relationships between program staff, CIs, CHWs, and government functionaries. Conclusions: CIs' engagement in the program maintained and bolstered their pre-existing status. Deploying and sustaining this cadre requires a strategic approach to maintaining motivation over time. Providing respect and visibility and maintaining effective working relationships is key to sustaining the CIs' motivation.

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.

Abstract Objective: This study aimed to assess the magnitude of undernutrition and associated factors among pregnant women attending public health facilities in the Goba district, Bale zone, Oromia Region, Ethiopia, 2022. Design: Institution-based, cross-sectional study design was used. Setting: The study was conducted in selected public health facilities from May to June 2022. Participants: The study population consisted of pregnant women who lived for at least 6 months in the study area and who attended antenatal care follow-up at selected public health facilities during the study period. Pregnant women who lived for less than six months in the study area and those who were critically ill were excluded from the study. Results: 487 respondents participated in this study with a 100% response rate. More than half (50.7%) of pregnant mothers were undernourished. The significant factors associated with maternal undernutrition during pregnancy in this study were mothers with no formal education (AOR = 5.050; 95% CI: 1.470- 17.346), a history of illness during pregnancy (AOR = 2.089; 95% CI: 1.246-3.504), and eating frequency of meals less than or equal to three times per day (AOR = 3.292; 95% CI: 1.040- 10.42). Poor nutritional knowledge (AOR = 5.588; 95% CI: 2.921-10.689), poor household (HH) wealth status (AOR = 4.774; 95% CI: 2.216- 10.285), and mothers who had >= 4 pregnancies were included (AOR = 0.852; 95% CI: 342-0.989). Conclusion: The magnitude of Undernutrition among pregnant women was 50.7%. Significant associations with Undernutrition were found in mothers with no formal education, poor dietary knowledge, a meal frequency of three or fewer times per day, a history of illness during pregnancy, lower and medium household wealth status, and those who had experienced four or more pregnancies while attending antenatal care (ANC) services at public health facilities.

Kajiado County ranks eighth in the country for adolescent pregnancy, with one in five teenagers between the ages of 15 and 19 (21.8%) likely to be pregnant or have begun having children. The objectives of the study were to establish the dietary practices and nutrition status of pregnant adolescents in Kajiado County. The study employed a cross-sectional analytical design in a target population of 196 pregnant adolescents living in Kajiado West, Ewauso and Keekonyoike wards which were randomly selected. Qualitative data was gathered through key informant interview guides with facility nurse in charge and head teacher/principal. Dietary data was collected using a 24-hour dietary recall questionnaire.Dietary diversity was established using the minimal dietary diversity questionnaire for women of reproductive age (MDD-W). Nutrisurvey software was to analyze dietary data. Married respondent was at 41.8% (40.8 users and 44.1% non-users) of ANC with a p-value of 0.212. Dietary energy intake was 1086.82 {+/-} 90.57kcals having RDA of 29.0% (users at 1105.72 {+/-}95.43 and RDA 29.6%, non-users 1070.12{+/-}8.36 with RDA of 28.4%). The Minimum Dietary Diversity (MDD-W) for Women of Reproductive Age 98.4% users was 68.3% of women who utilized antenatal care (ANC) services consumed foods and beverages from 5 or more food groups on the previous day, compared to only 31.7% non-users having a p-value 0.24. Respondent having (MUAC < 22 cm) indicates potential malnutrition or nutritional risk at 31.2% (users at 30.8% and non-users 32.2%) with a p-value 0.534.Overall mean hemoglobin level is 12.35g/dl with a standard deviation of 0.93g/dl having low ranges of < 11.5g/dl (users at 30 and non-users at 12) total of 42 adolescent. These findings underscore the urgent need for targeted interventions at increasing nutrient intake and dietary diversity among pregnant adolescents towards improved nutrition status.

This study examines the effects of rural out-migration and remittance inflows on food consumption outcomes among rural households in the Tigray region of Ethiopia. Utilizing household survey data collected from 521 rural households across three distinct Weredas (districts) (Tahtay Maichew, Kola Tembien, and Kilte-awlaelo). A Binary Probit model was employed to identify factors influencing migration decisions, while an Endogenous Switching Regression (ESR) model was used to estimate the impact of migration on food consumption outcomes while controlling for selection bias and unobserved heterogeneity. Food security was measured using the Food Consumption Score (FCS) and dietary diversity indicators. The empirical results reveal that severe food insecurity is widespread, with over 60% of all surveyed households falling into the "Poor" food consumption category. Descriptive baseline comparisons show that migration and remittance transfers marginally shift the raw average FCS upward from 23.86 to 25.48. However, this impact is profoundly nuanced: remittances serve as an immediate consumption-smoothing safety net but run parallel to a "labor-lost" constraint that reduces own-production capacities, forcing households to rely increasingly on market purchases for staple foods. The findings reveal that migration creates short-term labor shortages in agricultural production; however, remittance inflows substantially improve household food consumption frequencies, particularly for pulses, vegetables, and other nutrient-rich foods. After accounting for self-selection bias and unobserved traits, the rigorous ESR estimates indicate that migration increases the Food Consumption Score of participating households by an average Treatment Effect on the Treated (ATT) of 10.75 points, shifting them into more secure dietary tiers. Moreover, remittances help households mitigate the adverse effects of drought and other shocks by relaxing liquidity constraints and supporting both food purchases and agricultural investments. The study recommends establishing target food security safety nets for non-remittance households, promoting scale-appropriate labor-saving agricultural technologies, expanding traditional communal labor-sharing innovations, and boosting irrigation and agricultural input support programs to enhance rural food security and livelihood resilience.

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