Journal of Global Health

Background Concurrent wasting and stunting (WaSt) is a severe form of child undernutrition, linked to higher mortality and long-term negative health outcomes. Malnutrition is a significant challenge in Yemen, where the country is experiencing a long-standing conflict, food insecurity, and socioeconomic deprivation. But there is still limited evidence on the burden and determinants of WaSt in Yemen on a national level. This study aimed to estimate the prevalence and identify factors associated with WaSt among children under 5 years in Yemen. Methods We conducted a cross-sectional analysis using nationally representative data from the 2022-2023 Yemen Multiple Indicator Cluster Survey (MICS). A significantly large dataset of 17,734 children aged 0-59 months from all the 22 governorates of Yemen was analyzed. Concurrent wasting and stunting (WaSt) was defined as the coexistence of a weight-for-height z-score (WHZ) below -2 standard deviations and a height-for-age z-score (HAZ) below -2 standard deviations from the WHO Child Growth Standards in the same child. Survey-weighted logistic regression was performed to analyze the factors associated with WaSt among the under 5 children in Yemen. Results The national prevalence of WaSt was 8.4% (95% CI: 7.6-9.2). The highest prevalence of WaSt was found in children aged 12-23 months (12.0%) and in the Western Coastal region (11.6%). After adjustment, male sex (AOR 1.52, 95% CI: 1.30-1.80), residence in the Western Coastal (AOR 2.00, 95% CI: 1.60-2.40), Eastern (AOR 2.00, 95% CI: 1.50-2.70), and Southern regions (AOR 1.60, 95% CI: 1.20-2.10), poorest household wealth (AOR 1.96, 95% CI: 1.30-2.90), moderate (AOR 1.51, 95% CI: 1.13-1.94) and severe food insecurity (AOR 1.94, 95% CI: 1.40-2.60), and recent diarrhoea (AOR 1.22, 95% CI: 1.02-1.44) were associated with higher odds of WaSt. Having a handwashing facility and improved sanitation were protective. Conclusion At least 1 in every 12 under-five children in Yemen was affected by WaSt, and there were significant socioeconomic, geographic, food-security and WASH-related factors influencing this devastating outcome. Instead of simple, one-dimensional approaches, multi-sectoral interventions are needed to address this adversity. And those efforts must be integrated into the system, interconnected with each other and specifically targeted to vulnerable children and households.

Background. Skilled healthcare workers are essential for neonatal survival; however, the Kenyan public health system has historically faced strikes compounded by a human resource crisis. Evidence on how strikes affect neonatal care and mortality remains limited. This study evaluated changes in neonatal admissions, clinical care processes, and inpatient mortality associated with 56 days of disruption during the 2024 Kenyan physicians' strike. Methods. We conducted a retrospective interrupted time-series analysis of 12,184 admissions to 11 Kenyan neonatal units implementing with the NEST360 Alliance, recorded in the Neonatal Inpatient Dataset from December 2023 to August 2024. Weekly admissions and inpatient mortality were modeled over a 72-week window (27,638 admissions) using hospital-clustered generalized estimating equations with seasonal terms. Care processes, case fatality, and birthweight-specific mortality were compared across study periods. Results. Weekly admissions fell from 413 to 189 during the strike (incidence rate ratio (IRR) 0.49, 95% confidence interval (CI) 0.31-0.75), approximately 1,700 fewer admissions than expected, and returned to baseline afterward (IRR 1.00, CI 0.81-1.23). Newborns admitted during the strike were of lower birthweight, more often premature, and more often outborn. Admissions fell across all birth-location categories, most steeply among inborn neonates. No measurable change was detected in documented inpatient coverage of care measures, in crude mortality (12.5% to 14.9%; risk ratio (RR) 1.07, CI 0.85-1.33), or in trend-adjusted mortality (IRR 0.88, CI 0.53-1.45). Case fatality among neonates with recorded infection doubled, from 4.7% to 9.6% (RR 2.06, CI 1.18-3.58; adjusted p = 0.047). Conclusions. The 2024 physicians' strike was associated with severe disruption to neonatal service utilization, with admissions returning to baseline when the strike ended. Among newborns who continued to reach care, inpatient mortality did not change measurably, but case fatality among those with recorded infection doubled. This analysis was confined to inpatient data; hence, the outcomes of newborns who did not reach the hospitals were not captured. Both inpatient and population-level data are needed to assess the full impact of the strike. Mitigating harm during future labor disruptions requires interventions such as resilient care models, formalized task-shifting protocols, and minimum service coverage agreements.

Background: Access to maternal healthcare services is essential for improving maternal and neonatal health outcomes. Health insurance can reduce financial barriers to healthcare access and may facilitate utilisation of maternal health services, and contextualized evidence can further support policy development and implementation. This study assessed the association between health insurance coverage and utilisation of antenatal care (ANC), institutional delivery, skilled birth attendance and postnatal care (PNC) services among women in Nepal. Methods: This study used data from the 2022 Nepal Demographic and Health Survey (NDHS), a nationally representative cross-sectional survey. The analysis included women aged 15-49 years who had a live birth within the 24 months preceding the survey. Inverse probability of treatment weighting (IPTW) based on propensity scores was applied to balance measured socioeconomic and demographic characteristics between insured and uninsured women. Weighted marginal structural models were used to estimate the association between health insurance coverage and maternal healthcare utilisation outcomes. Robustness was assessed using alternative propensity score specifications and E-values for unmeasured confounding. Results: Among 14,845 women interviewed, 2,078 reported a recent live birth and were included in the analysis (unweighted; 1,998 when survey-weighted). Of these, 201 (9.7%) had health insurance coverage and 1,877 (90.3%) were uninsured. After adjustment using IPTW, health insurance coverage was associated with significantly higher utilisation of maternal healthcare services. Insured women had more than twice the odds of attending at least four ANC visits compared with uninsured women (AOR 2.14; 95% CI 1.15-3.98). Similarly, insured women had higher odds of receiving a PNC check-up within two days of delivery (AOR 2.05; 95% CI 1.28-3.27) and receiving PNC from a skilled provider (AOR 1.94; 95% CI 1.23-3.06). Although insurance coverage was positively associated with institutional delivery (AOR 1.55; 95% CI 0.91-2.62) and skilled birth attendance (AOR 1.57; 95% CI 0.90-2.72), these associations did not reach statistical significance. Conclusion: Health insurance coverage was associated with greater utilisation of antenatal and postnatal healthcare services among women in Nepal. However, no significant association was observed for institutional delivery or skilled birth attendance. Expanding health insurance coverage, particularly among underserved populations, may help improve maternal healthcare utilisation and support progress towards universal health coverage and maternal health-related Sustainable Development Goals.

Disability is an important population-health concern, but adult-specific evidence on its distribution and socioeconomic patterning remains limited in Somaliland. This study estimated the prevalence and distribution of reported disability among adults in Somaliland and examined socioeconomic inequality, reported mental/psychological illness, and their co-occurrence. We conducted a cross-sectional secondary analysis of the 2020 Somaliland Health and Demographic Survey. The analysis included 14,579 adults aged [≥]18 years who were usual residents, had the disability module administered, and had a defined reported mental/psychological illness measure. Reported disability was defined as at least one positive response across seven disability domains: sight, hearing, speech, learning, mobility, self-care, and mental. Survey-weighted prevalence estimates and design-based comparisons were calculated. Survey-weighted logistic regression assessed associations with household wealth and other covariates. Socioeconomic inequality was assessed using a concentration index and the normalized Erreygers concentration index. Co-occurrence was evaluated by comparing observed joint prevalence with that expected under statistical independence and by survey-weighted logistic regression. The survey-weighted prevalence of any reported disability was 7.30% (95% CI 6.65-8.02). Sight was the most frequently reported domain (3.83%, 95% CI 3.19-4.59), followed by hearing (1.54%, 95% CI 1.20-1.97) and mobility (1.39%, 95% CI 1.14-1.70). Disability prevalence increased markedly with age, from 4.15% among adults aged 18-29 years to 23.96% among those aged [≥]60 years. The crude wealth pattern was non-monotonic and was not statistically detectable after adjustment for residence and region. The concentration index for reported disability was 0.0584 (SE 0.0284, p=0.0415). Reported mental/psychological illness had a weighted prevalence of 0.71% (95% CI 0.50-1.00). Both reported disability and reported mental/psychological illness occurred in 0.5032% of adults, compared with 0.05185% expected under statistical independence; the observed-to-expected ratio was 9.70 (95% CI 7.60-11.81). After adjustment for age group and sex, reported disability was strongly associated with reported mental/psychological illness (OR 42.99, 95% CI 18.45-100.18). Reported disability affected approximately one in fourteen adults in Somaliland and showed a marked age gradient and substantial geographic variation. The crude socioeconomic pattern was attenuated after adjustment for geographic context, while concentration analysis indicated modest marginal concentration toward higher wealth ranks. Reported mental/psychological illness was uncommon but co-occurred with reported disability more often than expected under independence. These findings provide an adult population baseline for Somaliland while highlighting the need to distinguish survey-reported disability from the separate mental/psychological illness construct and to interpret the findings within the limitations of cross-sectional, survey-reported measures.

Background. Stunting and wasting drive child mortality and are central to Sustainable Development Goal target 2.2. In 2025, 24.0% of Bangladeshi children under five were stunted and 12.9% wasted, meeting the national stunting target but missing the 8% wasting target. We compared where the two occur and tested whether environmental factors explain the patterns. Methods. We linked the 2025 Bangladesh Multiple Indicator Cluster Survey to cluster GPS locations and environmental data. Moran's I tested clustering and Getis-Ord Gi* found hotspots across 64 districts and 3,144 clusters. We tested whether six environmental and access factors explained the hotspots, estimated what share of affected children each hotspot list reached, and used a joint model to compare factor associations between outcomes. Results. Stunting clustered by region (district Moran's I 0.21, P=0.002), with a north-eastern hotspot centred on Sylhet and Sunamganj. Six environmental factors together removed this clustering (I -0.01, P=0.45) and about 60% of between-district variation (95% CI 28 to 84), more than rainfall alone, with the gain over generic regional terms uncertain. Wasting showed no clear regional clustering (I 0.05, P=0.17), and district stunting and wasting rates were unrelated (r -0.01). Stunting hotspot districts held 5.9% of wasted children, the same as their 5.9% population share. Children with both conditions (902 cases) did not cluster. Altitude and rainfall related differently to stunting than to wasting (all P<0.004), but altitude associations were sensitive to how altitude was modelled. Conclusion. Stunting in Bangladesh is concentrated in the north-east, and six environmental and access factors together account for much of this, though no single factor, including rainfall, does. Wasting shows no clear regional pattern. A stunting hotspot list reached no more wasted children than population share, so surveillance may need both measures, with finer-scale data for wasting.

ObjectivesTo estimate age trajectories of infant mortality among Palestinian refugees using electronic health records, addressing the scarcity of reliable mortality data in forced displacement settings. SettingPalestinian refugees living in Gaza, West Bank, Jordan, Syria and Lebanon. DesignWe fitted a Bayesian Negative Binomial model to observed death counts, using a flexible parametric function (a shifting power function) to capture the shape of the infant mortality curve, across strata to infer age trajectories of infant mortality. ParticipantsPalestinian refugees born in 2010-2020 and registered with UNRWA health services in Gaza, West Bank, Jordan, Syria and Lebanon. The sample was stratified by sex, field, gestational age and birth cohort. Main outcome measuresSurvival rate to age 1. ResultsOverall, the survival rate to age 1 was 98.64%, with slightly lower rates for males (98.57%) than females (98.68%). Across settings, West Bank refugees had the lowest infant mortality (99.08% survival rate), and Jordan refugees had the highest (98.22% survival rate). Results by gestational age showed a 98.85% survival rate at age 1 among term births compared to a 73.32% survival rate among very preterm births. Survival rates by cohort (births up to 2015 or after) were 98.78% and 98.42%, respectively. ConclusionOur findings highlight the potential of electronic health records for mortality monitoring in forced displacement settings as they reveal consistent mortality trajectories by sex and gestational age, while identifying meaningful variation across refugee settings and subgroups. Summary boxesO_ST_ABSWhat is already known in this topicC_ST_ABSWe searched PubMed and Google Scholar for articles published between Jan 1, 2000, and Feb 20, 2026, in English, using the terms "Palestinian refugees," "infant mortality," "neonatal mortality," and "UNRWA." We found a handful of studies estimating infant mortality among Palestinian refugees, mostly based on household surveys (eg, MICS, national statistical office surveys) or UNRWA surveys using preceding birth techniques. The preceding birth technique has notable limitations, including recall bias, small sample sizes, and selection bias. The majority of these studies focus exclusively on Palestinian refugees residing in Gaza. Estimates for Gaza suggest a sustained decline, from around 127 deaths per 1,000 births in 1960 to 20.2 per 1,000 births in 2006, with a slowdown thereafter and an increase in more recent years. A combined estimate (excluding Syria) across four settings where Palestinian refugees reside measures infant mortality at 18 per 1,000 births in 2011. What this study addsThis study uses a unique data linkage bringing together UNRWAs obstetric and child health records, providing more extensive information and a larger sample size than previous studies. This is also the first study to assess the data quality of these electronic records and to estimate age trajectories of infant mortality among Palestinian refugees. We developed a statistical strategy that estimated infant mortality trajectories covering all five UNRWA fields (Gaza, Jordan, Lebanon, Syria, and the West Bank) for children born in 2010-2020, and examined differences across subpopulations by sex, field, gestational age and cohort.

Background Despite substantial improvements in maternal and child health over the past two decades, preventable maternal and neonatal morbidity and mortality remain major public health concerns in rural Bangladesh. Community-based interventions involving Community Volunteers (CVs), Community Groups (CGs), and Community Support Groups (CSGs) have been introduced to strengthen maternal and child health (MCH) services through health promotion, community engagement, and improved linkage with primary healthcare facilities. This study explored the roles, challenges, and opportunities of these community-based platforms in improving maternal and child health services. Methods A qualitative study was conducted in Kalaroa Upazila of Satkhira District, Bangladesh, between July and October 2020. Data were collected through focus group discussions and in-depth interviews with mothers, Community Volunteers, Community Group members, and Community Support Group members. Participants were purposively selected to capture diverse experiences from intervention and comparison areas. Interviews were conducted using semi-structured guides, audio-recorded with informed consent, transcribed verbatim, translated into English, and analyzed thematically using an inductive approach. Results Participants from intervention areas demonstrated greater knowledge of birth preparedness, antenatal care, pregnancy danger signs, institutional delivery, postnatal care, and newborn care than those from comparison areas. Community Volunteers, CGs, and CSGs played important roles in identifying pregnant women, conducting household counselling, promoting skilled maternal healthcare, facilitating referrals, and strengthening community participation. Participants perceived that these activities increased maternal awareness, improved health-seeking behaviour, and enhanced utilization of maternal and newborn health services. However, persistent barriers, including socio-cultural beliefs, financial constraints, transportation difficulties, shortages of skilled healthcare providers, and inadequate logistical support for community volunteers, continued to limit equitable access to quality services. Participants recommended strengthening community awareness programmes, improving community clinic readiness, enhancing referral systems, and providing regular training and supportive supervision for community-based health workers. Conclusions Community-based maternal health interventions involving Community Volunteers, Community Groups, and Community Support Groups contribute to improved maternal knowledge, health-seeking behaviour, and utilization of essential maternal and newborn health services in rural Bangladesh. Sustaining these gains will require stronger primary healthcare services, continued community engagement, and targeted strategies to address persistent health system and socio-cultural barriers. These findings provide important evidence for strengthening community-based maternal and child health programmes in Bangladesh and similar resource-constrained settings.

ABSTRACT Background: The double burden of malnutrition, combining overweight or obesity with anemia is vital in nutritional transitions. Evidence regarding its national distribution and prediction using routine survey data in Ethiopia remains limited. Objective: To estimate the national prevalence of individual-level double burden of malnutrition among non-pregnant Ethiopian women aged 15-49 years and evaluate machine-learning models using data from the 2024/25 Ethiopian Demographic and Health Survey. Methods: we analyzed 14250 non-pregnant women. Double burden of malnutrition was defined as a body mass index equal to or greater than 25.0 kilograms per square meter with an altitude- and smoking-adjusted hemoglobin concentration below 12.0 grams per deciliter. Data were split into an 80% training set and a 20% holdout test set. Six algorithms were evaluated using cross-validation, while SHapley Additive exPlanations described feature contributions. Results: the weighted national double burden of malnutrition prevalence was 8.4% (95% confidence interval 7.9%-8.9%), higher in urban residents (20.0% versus 4.0%) and the richest wealth quintile (26.7% versus 2.7%). Extreme Gradient Boosting achieved an area under the receiver operating characteristic curve of 0.892 (95% confidence interval 0.875-0.909) and an area under the precision-recall curve of 0.764 outperforming logistic regression (area under the receiver operating characteristic curve of 0.781). Extreme Gradient Boosting sensitivity was 82.1%, specificity was 81.4% and the Brier score was 0.068. Household wealth, residence and respondent age were top predictors. Conclusions; the double burden of malnutrition affected one in twelve non-pregnant Ethiopian women unevenly across groups. Routine characteristics effectively discriminated double burden of malnutrition cases though external validation is needed prior to clinical use.

Abstract Background: The risk of developmental delays among infants in the refugee camps is high due to prolonged exposure to adverse situations such as poverty, violence, lack of access to basic necessities, safety, poor maternal mental health and inadequate access to healthcare. To reduce the risk of developmental delays, a contextualized early child development and maternal mental health care package, was implemented through enabling and engaging the refugee women as community-based care providers. Methods: The process evaluation study was conducted using a mix-method design to explore the acceptability, feasibility, appropriateness, adoption, and cost of the Early Child Development (ECD) and maternal mental health care package in refugee camps, by applying Proctor et al framework. Data on quantitative indicators was reviewed for 348 mother-child dyads in the intervention arm. Qualitative interviews were conducted with 12 mothers, 5 community health workers, and 2 members of the implementing research team. Incremental Cost-Effectiveness Ratio (ICER) was calculated using the healthcare provider perspective to estimate the incremental cost-effectiveness of the ECD care package in reducing proportion of children with two or more developmental delays. Results: Home-based delivery of counselling sessions was a key facilitator in ensuring the successful implementation of intervention. The delivery of intervention by modestly educated refugee women reduced cultural and language barriers and facilitated the home-based delivery of sessions. Mothers found the recommended activities feasible to do in routine as they were culturally appropriate, and did not require maternal literacy or additional resources. The intervention was cost-effective with an ICER of 63 USD in reducing the proportion of children with two or more developmental delays by one percentage point. Conclusion: Contextualized ECD and maternal health care package is a potentially replicable and scalable intervention for refugee healthcare systems.

Background Micronutrient deficiencies are a major public health problem for women of reproductive age (WRA), especially in conflict settings, such as Yemen. However, there is little information on knowledge, attitudes and practices (KAP) toward micronutrient-rich foods among WRA in Aden Governorate. This study aimed to assess knowledge, attitude and practices of WRA toward micronutrient rich foods attending health facilities in Aden Governorate, Yemen. Methods A facility based descriptive cross-sectional study was conducted among 348 WRA aged 15-49 years who visited selected primary health care and maternal and child health facilities in the eight districts of Aden governorate, Yemen. Data were collected using structured interviewer administered questionnaire which was adapted from guidelines of Food and Agriculture Organization and World Health Organization. Chi-square test and Pearson correlation were used to assess the association between the KAP indicators and sociodemographic characteristics. Results The mean age of the participants was 26.3 {+/-} 8.8 years and 73.9% had high-grade education. In general, 77.9% identified micronutrients as essential for health and 92.8% correctly identified liver/red meat as micronutrient-rich food. However, only 29.6% identified iodized salt as a source of iodine. Although 95.7% perceived supplementation as important, only 9.8% reported regular supplement use. The most commonly reported barrier to access to nutritious food was high food cost (43.4%) and 70.6% perceived healthy foods as too expensive. Restriction in daily consumption was observed for eggs (36.2%), meat/poultry/fish (32.2%) and fruits (13.2%). Education was moderately positively correlated with micronutrient knowledge (r = 0.514, p < 0.001) and age was weakly positively correlated (r = 0.162, p = 0.002). Conclusion WRA in Aden had good knowledge and positive perceptions about micronutrients and supplementation but major gaps in dietary practices and access to affordable nutritious foods. Integrated, culturally appropriate interventions that include nutrition education and improved access to affordable micronutrient-rich foods and appropriate supplementation are needed.

Aim: This study aimed to estimate the prevalence and distribution of minimum dietary diversity for women (MDD-W) and underweight/thinness and examine sociodemographic and dietary factors associated with underweight/thinness among Cambodian women aged 15-49 years. Methods: We conducted a cross-sectional analysis of 9,181 women aged 15-49 years (9,262.5 weighted) from the 2021-22 Cambodia Demographic and Health Survey. Survey-weighted descriptive statistics and provincial mapping were used to describe MDD-W, food-group consumption and underweight/thinness. Rao-Scott chi-square tests assessed group differences, and survey-weighted logistic regression estimated factors associated with underweight/thinness. MDD-W and household wealth were retained a priori in the adjusted model, while other covariates with an overall crude Wald P value <0.20 were included. Results: The analysis included 9,181 women (9,262.5 weighted). Overall, 57.2% achieved MDD-W, and 6.7% had underweight/thinness; 22.8% were overweight, and 5.7% had obesity. Underweight/thinness was highest among women aged 20-24 years (17.7%). Achieving MDD-W was not associated with underweight/thinness in crude analysis (OR 0.93, 95% CI 0.74 to 1.17; P=0.545). In the adjusted analysis, the association remained imprecise (aOR 0.86, 95% CI 0.67 to 1.09; P=0.219). Provincial estimates showed geographic variation in both MDD-W and underweight/thinness. Conclusion: More than half of Cambodian women achieved MDD-W, while underweight/thinness coexisted with overweight and obesity. MDD-W was not clearly associated with underweight/thinness. These findings support monitoring dietary diversity, anthropometric status, and socioeconomic inequalities together in women's nutrition.

Objectives: Women's empowerment is a key determinant of health and well-being and may shape how women access and benefit from publicly-funded health insurance (PFHI). We aimed to examine whether different levels of women's empowerment were associated with 1) verification in India's PFHI Pradhan Mantri Jan Arogya Yojana (PM-JAY), 2) outpatient care utilization, and 3) resultant out-of-pocket expenditure. Design: We conducted a cross-sectional observational study. We analyzed data from a household survey, created a composite empowerment index using structural equation models, and used multivariate regression models to test associations between women's empowerment and the outcome variables. Setting: The study was conducted between December 2019 and February 2020 among PM-JAY eligible households in six Indian states (Bihar, Chhattisgarh, Gujarat, Meghalaya, Tamil Nadu, and Uttar Pradesh). Participants: 14,378 women across the six states. Results: Three main findings emerged: First, high levels of women's empowerment were associated with higher odds of completing PM-JAY verification (AOR: 1.22, 95% CI: 1.09-1.36). Second, women's empowerment was not associated with outpatient service utilization. And third, either medium levels of empowerment (coef = -0.49, p = 0.020) or PM-JAY verification (coef = -0.37, p = 0.034) was associated with lower OOPE for outpatient services. Women who had both, PM-JAY verification and medium levels of empowerment, experienced higher OOPE (coef = 0.45, p = 0.058). Conclusions: Women's empowerment is an important factor related with PM-JAY verification, but not with outpatient service use. OOPE varied depending on whether women were both empowered and PM-JAY verified or not. Our results suggest that institutional and structural barriers may play a greater role in healthcare access than individual factors pertaining to empowerment alone. Achieving equitable access therefore requires gender-responsive systems that reduce administrative barriers and support women in navigating the healthcare pathway. Our findings highlight the importance of integrating outpatient care into PM-JAY to increase financial protection, streamlining verification processes to improve women's engagement with PM-JAY and the broader health system, and advancing health financing reforms that better support women.

Every day, 1990 children die from an injury, with the majority in low- and middle-income countries. In Tanzania, reaching definitive care, or the appropriate level of care for a child's injury, often requires referral to a higher level facility. This hierarchical system introduces challenges that may lead to delayed care and, for severely injured children, cause mortality. The aim was to identify patient, healthcare provider, and health system-level barriers to timely referral for pediatric injury patients at the first site of care in order to identify targets for an intervention to reduce time to definitive care. In this mixed-methods study, a pediatric injury registry was established at three health facilities spanning three health system levels in Northern Tanzania. Thirty family caregivers of pediatric injury patients participated in interviews, while healthcare providers participated in four focus group discussions. The Consolidated Framework for Implementation Research framed interview guides and thematic analysis of the qualitative data. Of 782 patients enrolled in the pediatric injury registry from Aug 2024-Aug 2025, 269 were referred. Most visited 1-4 facilities before reaching definitive care (range 1-6). The median time from injury to definitive care was 15.1 hours (IQR 1.8-33). Qualitative data collection with family caregivers and healthcare providers revealed barriers to explain the delays to care in the outer setting (such as non-standardized referral pathways), the inner setting (such as delays in the decision to refer), and individual characteristics (such as inadequate training in pediatric injury care). According to the World Health Organization standards, every child who needs referral should be sent within 2 hours of arrival. To improve the referral delays found in this study, a locally co-designed, multicomponent health systems intervention for healthcare providers at the first site of care must be developed that includes pediatric injury care training and standardized referral decision support.

This study examines the impact of various maternal factors and continuous labor support on birth outcomes among 124 birthing people in the Baltimore region of Maryland who sought and/or received doula care. The cohort primarily consists of Black birthing people and includes detailed data on maternal age, race, education level, employment status, health insurance status, income level, preexisting health challenges, and pregnancy or delivery-related health challenges. The study also explores whether the pregnancy was the birthing person's first, as well as neonatal outcomes such as NICU admission, low birth weight, and other newborn health concerns. Due dates and delivery dates were compared and analyzed, where available, to provide a comprehensive understanding of the timing of births among the cohort. The findings highlight known correlations between maternal socioeconomic factors, health factors, and adverse birth outcomes, emphasizing the critical role of doula support during the prenatal period and labor and delivery in improving maternal and neonatal health, as well as in providing culturally competent care and positive birth experiences. This research contributes to the growing body of evidence on the benefits of doula care, particularly for marginalized communities, and underscores the need for targeted interventions to address health disparities among Black Birthing persons.

Abstract Background: Cervical cancer is a leading malignancy and mortality cause among Ethiopian women. Despite screening expansions coverage remains low. Traditional models miss complex determinants. This study aimed to develop machine learning models to predict cervical cancer screening utilization and identify drivers using the 2024 to 2025 Ethiopian Demographic and Health Survey. Methods: A secondary analysis of the 2024 to 2025 Ethiopian Demographic and Health Survey was conducted among women aged 15 to 49. Six algorithms Logistic Regression, Decision Tree, Support Vector Machine, Random Forest, Gradient Boosting Machine and Extreme Gradient Boosting were trained. Synthetic Minority Over-sampling Technique handled class imbalance with a 4.2 percent screening prevalence. Models were evaluated on a holdout set using Area Under the Receiver Operating Characteristic curve, Area Under the Precision-Recall Curve, Brier score and Decision Curve Analysis. SHapley Additive exPlanations explained model predictions. Results: Extreme Gradient Boosting achieved superior discrimination with an Area Under the Receiver Operating Characteristic curve of 0.896 and Area Under the Precision-Recall Curve of 0.781 outperforming baseline Logistic Regression at 0.772. Isotonic calibration optimized prediction loss with a Brier score of 0.038. Decision Curve Analysis confirmed clinical net benefit across thresholds from 5 percent to 55 percent. Explanatory analysis identified cancer awareness, education, autonomy, wealth quintile, recent health visits and urban residence as primary screening drivers. Conclusions: Probability-calibrated Extreme Gradient Boosting with explainability provides an accurate tool for identifying un-screened women in Ethiopia. Public health programs can deploy these tools in primary care applications to target outreach, optimize community engagement and accelerate World Health Organization elimination targets.

Background Urban inequities are often masked by the misleading notion of an urban advantage, despite persistent unequal access to quality healthcare services. Moreover, negative perceptions about the urban poor and slum-dwellers persist, despite their substantial role in driving and holding up the urban economy. It is thus essential to work with the media to bring visibility to these realities, raise public awareness, and inform more equitable health policies. In low- and middle-income countries (LMICs), evidence remains scarce on how health-related information from media outlets influences policy decisions. This study aimed to understand how journalists get information, engage with stakeholders in the health systems, and contribute to influencing urban health discourse in Bangladesh and Nepal. Methods We conducted a cross-country exploratory qualitative study comprising 30 key informant interviews from Bangladesh and Nepal, including 17 journalists, 10 health policymakers, and 3 public health advocates. Participants were purposively selected to ensure diversity across media types, gender, and professional roles. Interviews were conducted between September 2024 and March 2025. Data were transcribed, translated, and analyzed thematically using NVivo software. Cross-country comparative analysis was carried out to identify common themes and contextual differences. Findings Across both countries, participants relied on multiple and diverse information sources. Government data were often prioritized as a primary source of information, although they were shaped by political influences and accessibility constraints. Research evidence was valued but underutilized due to difficulties in interpreting scientific articles. Urban health issues received limited priority in health news reporting due to journalists constraints in covering multiple issues and financial constraints for in-depth coverage. Additional challenges included inadequate health and urban health-related training, limited fellowship opportunities for investigative reporting, and restricted access to data, while health policymakers and public health advocates frequently questioned the credibility and use of media-reported information. Media engagement in policymaking largely remained indirect and issue-focused or event-driven. However, consistent media coverage raised public awareness and generated public pressure and, at times, indirectly influenced health policy decisions such as immediate inspection after reporting on pesticides, installation of oxygen plants during the pandemic, dengue surveillance, and tobacco control measures and actions. Conclusion In Bangladesh and Nepal, news media play a significant but indirect role in shaping urban health policy decisions. Enhancing journalists capacity, improving access to credible information and data, and continuous engagement of stakeholders could strengthen evidence-informed urban health policymaking. Furthermore, establishing greater independence of journalists and government and community recognition of their responsible health reporting could help and motivate the media to contribute more meaningfully to public debate and policy reform processes.

BackgroundModern contraceptive use remains low in many sub-Saharan African countries, including Mozambique, limiting progress towards sexual and reproductive health and Sustainable Development Goals (SDGs). Understanding the prevalence, determinants, and inequalities in modern contraceptive use based on Mozambique-wide national survey is critical to informing effective family planning interventions. MethodWe analyzed the most recent data from the Mozambique Demographic and Health Survey (DHS), 2022-2023, focusing on a total of 11,783 reproductive-aged women (15-49 years). The outcome variable was current use of modern contraceptives. Several individual, household-related and community determinants of modern contraceptives were examined employing multivariable logistic regression. Adjusted odds ratio with corresponding confidence intervals and p-values were reported. Erreygers Concentration Index (ECI) and concentration curves were used to assess wealth-and empowerment-related inequalities. All analyses were conducted on weighted data. ResultOverall, 27.6% of women reported current use of modern contraceptive methods. Younger age, higher education, being employed, higher parity, greater wealth, and a partner with higher education were positively associated with modern contraceptive use. Significant wealth-related (ECI = 0.32, p < 0.001) and womens empowerment-related (ECI = 0.26, p < 0.001) inequalities were observed, indicating that wealthier and more empowered women had higher use of modern contraceptive methods. ConclusionModern contraceptive use in Mozambique is suboptimal and influenced by a combination of individual, household, and contextual factors, with marked socioeconomic and empowerment-related disparities. Policy interventions should focus on improving access to and encouraging use of contraceptives for economically disadvantaged and women with low-empowerment, promoting womens autonomy, enhancing male involvement, and leveraging media and community-based programs to increase awareness and uptake. Equity-focused strategies are essential to achieving national and global family planning targets.

Introduction Literacy is a determinant of mental health, wellbeing, and social participation. Although literacy interventions improve educational and socioeconomic outcomes, their effects on mental health and social participation are poorly evidenced. We aimed to assess the feasibility and acceptability of a group-based literacy and numeracy intervention and explore its effects on literacy, mental health, numeracy, wellbeing, and social participation. We also estimated implementation costs. Methods We conducted a mixed-methods study using an uncontrolled pre-post design among women in low-income urban communities in Lucknow, India. A total of 115 women were recruited to a 17-week group literacy intervention using the Accelerating Learning for All literacy intervention. Outcomes measured at baseline, midline, and endline used literacy and numeracy assessments and validated scales of mental distress, wellbeing, and social participation. Quantitative data were analysed using multilevel mixed-effects models. Qualitative interviews and focus groups were analysed thematically. Costs were calculated per participant. Results The intervention was feasible and acceptable with functional recruitment of 71% (82/115), 74/82 participants (90%) completed it (retention), and mean attendance of 69% of scheduled sessions. In multilevel mixed-effects models, mean literacy scores increased by 29.5 (95% CI: 23.6, 35.3) between baseline and endline, while mean mental distress (SRQ20) decreased by 3.4 (95% CI: 2.2, 4.6), mean mental wellbeing (WEMWBS) improved by 2.6 (95% CI: 0.1, 5.1), while social exclusion (P scale) declined by 4.1 (95% CI: 1.6, 6.5). Qualitatively, participants described greater confidence, autonomy, financial literacy, and social support. Implementation enablers included local facilitators. Implementation cost was US$25 per participant. Conclusion This low-cost literacy intervention was feasible and acceptable for women in low-income urban communities in India. Findings provide preliminary evidence of improvements in literacy, mental health, and social participation. Controlled studies are needed to establish causal effects, long-term outcomes, and scalability.

Background: Long-term mortality data among Brazilian police officers and firefighters are scarce. This study investigated the leading causes of death in Brazilian male military police officers and firefighters over three decades, comparing their mortality and mean age at death with those of the male population. Methods: We retrospectively analyzed death records of male military police officers and firefighters from Espirito Santo (ES), Brazil, from 1988 to 2019. Mortality was analyzed across three decades and the standardized mortality ratios (SMRs) for the three leading causes were calculated using the male populations of ES and Brazil as references. Results: Overall, 2,198 deaths were identified, with a mean age at death of 59 {+/-} 18.5 years, compared with 60.5 {+/-} 23.9 years among men in ES and 63.4 {+/-} 23.7 years among Brazilian men. Mean age at death was 36 {+/-} 9 years among active-duty and 68 {+/-} 13 years among inactive personnel. Across the study population, the leading causes of death were circulatory system diseases (32%), external causes (26%) and neoplasms (15%). Circulatory disease mortality was higher in the second and third decades compared with both reference populations, whereas external-cause mortality shifted from higher, in the first two decades, to lower than expected in the last decade. Neoplasm mortality was higher relative to Brazil only in the last decade. Conclusion: Mortality patterns differed by cause and over time. The younger mean age at death among active-duty personnel, together with cause-specific excess mortality, highlights the importance of long-term occupational health surveillance and preventive strategies.

Background: Cardiovascular-Kidney-Metabolic Syndrome (CKMS) is defined as a cluster of disease conditions that are highly prevalent in the U.S. population. This study aims to assess psychosocial adversities at different CKMS stages in a large survey of U.S. adults, measured by lack of emotional support, low life satisfaction, and loneliness. Methods: This cross-sectional study used data on 159,511 adults from the 2023 Behavioral Risk Factor Surveillance System (BRFSS) survey. Proxy CKMS stages (0, 1, 2/3, and 4) were determined using self-reported health conditions. Separate multivariable logistic regression models were estimated to obtain the predictive margins of respective psychosocial attributes across proxy CKMS stages. Results: Compared to adults at lower CKMS stages (Stages 0 and 1), adults at advanced CKMS stages (Stages 2/3 and 4) generally reported having higher psychosocial toll. At CKMS stage 4, the predicted probabilities of lack of emotional support, low life satisfaction, and loneliness were 6.96, 3.24, and 10.10 percentage points (pp) higher, respectively, than at stage 0. Compared to stage 1, the corresponding differences were 5.92, 2.89, and 9.65 pp. At CKMS stage 2/3, the corresponding differences were 4.36, 1.66, and 5.69 pp compared to stage 0 and 3.33, 1.32, and 5.25 pp compared to stage 1. The high burden at advanced CKMS stages was generally evident across sex, and different socioeconomic status conditions manifested by income and education. Conclusions: Findings of this study suggest that adults with advanced CKMS stages were more likely to experience a psychosocial toll. Further research is warranted to facilitate strategies for improving psychosocial wellbeing of CKMS patients.