PLOS Global Public Health

Globally, the risk of acquiring Tuberculosis (TB) among Diabetes mellitus (DM) patients is three (3) times higher than in the general population. Patients with DM not only have a high risk of getting TB disease but also have poor treatment outcomes Despite the National TB guideline recommending TB screening among DM patients, adherence remains low. This study aims to assess the implementation fidelity (IF) and factors affecting TB screening for DM patients among providers offering DM services in public health facilities in Ubungo district. We conducted a descriptive cross-sectional study from April 4th to May 25th, 2025, in 20 public facilities (3 hospitals, 5 health centers, 12 dispensaries) in Ubungo district using quantitative methods among 94 health providers offering DM services. Data were collected through a questionnaire and analyzed for fidelity levels (low or high) using descriptive statistics. Then, regression models using STATA version 16 identified factors affecting the fidelity of TB screening for DM patients among the healthcare providers offering DM services. The overall fidelity score was 83.0% with (n=78) out of 94 providers achieving high fidelity, with only 17.0 % (n=16) of the total providers having lower fidelity levels. Teamwork (aPR 2.28, 95% CI 1.11-7.12; p-value =0.031), self-efficacy (aPR 2.29, 95% CI 1.04-5.02; p-value =0.024), and facility-level the provider was working, especially hospital level (aPR 3.60, 95% CI 1.52-8.50; p-value =0.004) were significantly associated with IF of TB screening for DM patients among healthcare providers. Key factors influencing TB screening for DM patients among healthcare providers were effective teamwork, self-efficacy, and the level of the facility where the healthcare was working, such as hospitals. Therefore, strengthening teamwork and provider self-efficacy through training, is critical in universalizing high-fidelity practice and accelerating TB screening for DM patients among healthcare providers offering DM services in Ubungo district.

Background: Tanzania introduced the human papillomavirus (HPV) vaccine in 2018 for girls aged 9-14 years; however, coverage remains suboptimal. Missed opportunities (MOs) for vaccination are an important but understudied barrier, particularly in urban settings. This study assessed factors associated with MOs and explored healthcare providers perspectives on barriers and potential solutions in Dar es Salaam. Methods: An embedded mixed-methods study was conducted in public health facilities in Temeke Municipal Council from June - July 2025. The quantitative component involved a cross-sectional survey of 252 parents or caregivers of eligible adolescent girls using structured exit interviews. The qualitative component included in-depth interviews with 20 healthcare providers using a phenomenological approach. Multivariable logistic regression identified factors associated with MOs. Qualitative data were analyzed thematically using Braun and Clarkes framework. Results: The prevalence of MOs for HPV vaccination was 71.4%. Factors independently associated with MOs included caregiver age [≥]40 years (aOR 1.87, 95% CI: 1.02-3.42), female caregiver gender (aOR 1.61, 95% CI: 1.00-2.59), primary education (aOR 2.14, 95% CI: 1.03-4.45), married status (aOR 1.72, 95% CI: 1.01-2.94), and receiving care at health centers or dispensaries versus hospitals (aOR 1.83, 95% CI: 1.05-3.19). Qualitative findings identified key drivers of MOs, including limited caregiver knowledge, vaccine hesitancy, time constraints, failure to routinely offer vaccination, stock-outs, poor documentation, high workload, and limited outreach. Proposed strategies included routine eligibility screening, reminder systems, community engagement, and supportive supervision. Conclusion: MOs for HPV vaccination are highly prevalent and driven by both caregiver and health system factors. Strengthening routine screening, reminder systems, community engagement, and supervision may improve vaccine uptake.

BackgroundHigh-risk fertility behaviors (HRFB) remain a public health concern in Zambia due to their association with maternal and newborn complications. Despite improvements in reproductive health services, updated national evidence on the magnitude and determinants of HRFB is limited. This study used data from the 2024 Zambia Demographic and Health Survey (ZDHS) to estimate the prevalence of HRFB and identify associated factors among women of reproductive age. MethodsA cross-sectional analysis was conducted using weighted data from 13,951 women aged 15-49 years. HRFB was defined as experiencing at least one of the following: first birth before 18 years, last birth after 34 years, short birth interval (<24 months), or high parity ([&ge;]4 births). Explanatory variables included socio-demographic, economic, and reproductive health factors. Multilevel mixed-effects Poisson regression with robust standard errors was used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI), accounting for clustering at the community level. Four models were fitted, and model fit was assessed using deviance, AIC, BIC, intra-class correlation (ICC), and median odds ratio (MOR). ResultsThe prevalence of HRFB was 48.4%. Older maternal age increased risk (25-34 years: aPR 1.28; 95% CI 1.20-1.37; 35-49 years: aPR 1.89; 95% CI 1.78-1.99), while higher maternal and partner education were protective (secondary: aPR 0.78; tertiary: aPR 0.53). Employment and contraceptive use were associated with higher HRFB, whereas prior pregnancy termination and lower household wealth were protective. Rural residence was not significant. Minimal community-level variation was observed (ICC {approx} 0, MOR = 1), indicating that most variation occurred at the individual level. ConclusionHRFB remain highly prevalent in Zambia, with older maternal age, lower education, employment, and contraceptive use after risk onset as key risk factors. Interventions should prioritize improving education, promoting early family planning uptake, and supporting older women continuing childbearing to reduce HRFB and improve maternal and newborn outcomes.

IntroductionWith one of the highest rates of maternal mortality in the world, improving antenatal care for the poorest communities is a high priority in Nigeria. In 2022, Project HOPE partnered with the Nigerian Ministry of Health to implement a group antenatal care project in Niger State. Government managers and Project HOPE aligned policy documents and budgets, and conducted a baseline assessment. Project staff then trained health care workers on group antenatal care. The project also connected women with a national health insurance scheme and strengthened monitoring and supervision systems. MethodsUsing quantitative implementation research, an instrumental case study was developed describing the design and implementation of the project. A final evaluation used both program and national health information system data to examine service utilization and health outcomes. Two tools were created for this purpose--a patient register and a monthly summary derived from that register. ResultsThe project trained 300 health workers and established group antenatal care in 150 health facilities. Over 17,000 women participated in 1,054 antenatal care groups. Multivariate analysis found statistically significant increases in first and fourth antenatal visits and facility births following the intervention. ConclusionDespite challenges, this project demonstrated success in increasing service use. Influencing factors were the use of indigenous master trainers, engaging stakeholders, revitalizing facility monitoring and evaluation, and the inclusion of the group antenatal care model in national antenatal care guidelines. Noted challenges included inadequate skilled birth attendants and lack of antenatal care commodities. O_LIWhat is already known on this topic - Maternal mortality is high in Nigeria. Antenatal care and facility birth are evidence-based practices for reducing maternal mortality. A large-scale group antenatal care project was implemented in 150 primary health centers in Niger State. C_LIO_LIWhat this study adds - We documented project implementation and analyzed changes in service use and health outcomes to share program challenges and impact. Despite funding limitations and a short implementation period, the project increased antenatal care attendance and facility births. C_LIO_LIHow this study might affect research, practice or policy - The results show that group antenatal care implemented using a midwifery care model, and connected to state health insurance schemes and facility mentorship, can increase evidence-based practices that lower maternal mortality. C_LI

BackgroundEarly initiation of antenatal care (ANC) is a cornerstone of maternal and child health, enabling timely detection of complications and delivery of preventive interventions, including education about cervical cancer. However, coverage of early ANC remains uneven across low-resource settings. This study assessed patterns and predictors of early antenatal care initiation in Zambia by analysing data from the 2007, 2013/14, and 2018 Demographic and Health Surveys, with an emphasis on equity-related disparities. MethodsWe analyzed pooled cross-sectional DHS data from 20,548 women aged 15-49 who had a recent live birth and received at least one ANC visit. Early ANC was defined as the first visit occurring during the first trimester. We generated weighted descriptive statistics, plotted trends over time, and used multivariable logistic regression to identify factors associated with early ANC initiation. Analyses accounted for complex survey design. ResultsEarly ANC coverage rose from 19.7% in 2007 to 37.2% in 2018. Adolescents (15-19 years) made up 9.2% of the sample and had lower early ANC rates (26.3%) compared to older women (28.4%). Multivariable models revealed a consistent rise in early ANC over time, with each subsequent survey year associated with increased odds (AOR: 1.09; 95% CI: 1.08- 1.11; p < 0.001). Older maternal age (AOR: 1.16; 95% CI: 1.01-1.32; p = 0.039), higher educational attainment (AOR: 1.06; 95% CI: 1.00-1.13; p = 0.049), and greater household wealth (AOR: 1.05; 95% CI: 1.01-1.09; p = 0.039) were all associated with significantly greater odds of initiating ANC early. Urban residence was linked to decreased odds (AOR: 0.71; 95% CI: 0.63-0.80; p < 0.001). ConclusionWhile early ANC coverage has improved in Zambia, gaps persist across age, education, wealth, and residence. Targeted interventions addressing adolescent needs and integrating cervical cancer prevention into ANC services may enhance timely care and promote health equity.

This observational cohort study explores the association between maternal, newborn and child health care implementation strength and child survival in rural Tanzania from 2011-2015. We used data from a 2011 service availability and readiness assessment that quantified primary health care facilities ability to implement maternal, newborn and child health services and a population-level household survey that measured the utilization of such services to develop domain-specific summary measures of the effective coverage of facility-based maternal, newborn and child health care. We reduced domain specific effective coverage scores into fewer, independent scales of implementation strength using principal components analysis, and integrated them into gradients of the collective implementation strength exerted by groups of facilities on villages they served using Bayesian mixed effects models. We linked these scales to longitudinal data on the survival of children that were born in the catchment areas of the surveyed health facilities during the assessment period and followed up until December 31, 2015. We fit survival time models to estimate the relationship between implementation strength and child mortality. Increases in the implementation strength gauged by our first scale, which represented general facility readiness and the provision of antenatal, postnatal, and early childhood preventive services, were associated with child mortality risks that were, on average, 0.62 times lower. Increases in implementation strength gauged by our second scale, which represented sick childcare service provision, were associated with child mortality risks that were, on average, 0.56 times lower. We detected no significant child mortality response to our third scale, which represented intrapartum care provision. The findings suggest that strong implementation of antenatal, postnatal, early childhood preventive services and sick child care can accelerate child mortality reduction and that routine data on service availability and readiness can be used to measure health systems strengthening and its impacts.

BackgroundMaternal and newborn studies in Uganda have primarily focused on measuring coverage of facility-based birth. However, this is inadequate and tends to overestimate the benefits of services provided to women and newborns if the quality of care in the facilities is not considered. Effective coverage of care addresses this limitation and adjusts for the quality of services. This study aimed to assess the effective coverage of maternal and newborn care in Uganda. MethodsWe analyzed the 2022 Uganda Demographic and Health Survey (DHS) and the 2023 Harmonized Health Facility Assessment (HHFA). We included 5,618 women who had a live birth in the two years preceding the DHS, and we estimated the HHFA readiness indicators for 636 facilities providing childbirth care. Facility readiness was assessed using human resources, equipment, amenities, and drugs and supplies as indicators. We calculated crude coverage as the percentage of facility births. Two effective coverage measures were used: intervention coverage as a percentage of women who received all ten recommended interventions for the most recent birth, and readiness-adjusted coverage as a product of crude coverage and facility readiness using an ecological linking method by region. ResultsAmong the 5,618 women included from the DHS, 85.9% gave birth in a facility; however, only 14.0% reported receiving all ten recommended interventions. Readiness was highest in government hospitals (81.9%), followed by private facilities (58.7%), and lowest in lower government health centers (46.4%). Only 47.8% of women gave birth in a ready health facility. The readiness-adjusted coverage varied across regions, with the lowest readiness in Kampala (40.9%) and the highest in the North-Eastern (61.4%). ConclusionsSignificant gaps exist between crude coverage and effective coverage. The largest gap was in intervention coverage, disproportionately affecting regions and lower-level health centers. There is a need to enhance the capacity of lower-level health centers to deliver quality maternal and newborn care.

Background: Unintended adolescent pregnancies remain a public health challenge in Zambia, where LARC use is low despite their effectiveness. Barriers such as stigma, misconceptions, and limited access persist. Previous studies conducted in Lusaka district did not explore the challenges faced by adolescents in trying to access and use LARCs. Understanding these challenges is crucial for developing targeted interventions to promote safe and effective contraception practices. This study examined factors influencing adolescent knowledge, willingness, and uptake of LARCs in public health facilities in Lusaka. Methods: A cross-sectional study was conducted between November 2024 and March 2025 among adolescent girls aged 15-19 years in five first-level hospitals in Lusaka, Zambia, using structured questionnaires to obtain quantitative data1. LARC use was measured as a binary outcome, with multiple regression identifying associated factors. Results: There were 400 participants in total, of whom 48% (181/376) had ever used a LARC. In the adjusted model, age was significantly associated with LARC use (AOR = 1.27, 95% CI: 1.11-1.77; p < 0.001). Adolescents who were willing to delay pregnancy had markedly higher odds of using LARCs (AOR = 7.46, 95% CI: 1.42-39.06; p = 0.017). Knowledge of LARCs remained a strong independent predictor, more than doubling the likelihood of uptake (AOR = 2.69, 95% CI: 1.12-6.46; p = 0.027). Having children was also significantly associated with higher LARC use (AOR = 2.62, 95% CI: 1.11-6.23; p = 0.029), while participants with unknown HIV status had lower odds of LARC use (AOR = 0.31, 95% CI: 0.10-0.97; p = 0.044). In addition, adolescents residing in Chipata had substantially higher odds of LARC uptake compared to those in Kanyama (AOR = 317.93, 95% CI: 35.01-2887.2; p < 0.001). Conclusions: The findings indicate that age, knowledge of LARCs, reproductive experience (having children), and willingness to delay pregnancy were significantly associated with higher odds of LARC uptake, and almost half of the participants had already used a LARC method. Although higher education showed an upward trend, it was not statistically significant in the adjusted model. Limited awareness and variability in service delivery across clinics highlight the need for strengthened counseling and reliable access to LARCs. As this study focused only on adolescents already attending Family Planning Clinics, further research is needed to assess LARC availability, accessibility, and quality of counseling across different settings in Zambia.

The rapid reduction in foreign development assistance from the United States and other countries has led to disruptions in essential global health programming. Countries that previously received development assistance, such as Zambia, may experience weakening of health system capacity due to program cancellations. This study aimed to describe the impacts of USAID program defunding on healthcare delivery in Zambia. We conducted a cross-sectional survey at 34 healthcare facilities in three districts of Zambia in April and May 2025. Through facility-level assessments and individual surveys with 330 healthcare workers, we identified changes in health system building blocks that may have arisen from program defunding. The facility-level assessment found that 71% of healthcare facilities (n=24) experienced changes related to funding cuts within the previous three to four months. In open-ended surveys, healthcare workers reported impacts on the health system, including stock-outs of essential medicines, diagnostic tests, and infection control supplies; layoffs of US-supported healthcare workers; and reduced ability to work with electronic medical records. Workers described how these changes impacted workplace morale, patient satisfaction, and their ability to deliver essential services. This study reveals the immediate consequences of defunding foreign assistance, which, if left unaddressed, may weaken health systems and worsen health outcomes. To mitigate these impacts, country governments and partner organizations should prioritize interventions and investments that strengthen health systems, such as expanding healthcare revenue streams and building workforce capacity. In the wake of funding cuts, health system strengthening can reduce countries reliance on foreign assistance and improve population health.

Substantial evidence demonstrates that men have a higher prevalence of tuberculosis (TB) and decreased use of TB services compared to women. Gender roles and norms contribute to these disparities by influencing social and structural determinants, as well as individual behaviours. In this analysis, we investigated attitudes towards gender equitable norms and TB testing behaviours amongst Malawian men and women participating in a prevalence survey conducted before a community-based TB active case finding trial in Blantyre. Perceptions of gender norms were captured through a modified version of the Gender Equitable Men Scale (GEMS). Gender inequitable views were prevalent among both men (56.1%) and women (55.8%). The association between a composite GEMS score and TB testing history was modelled using logistic regression, accounting for various sociodemographic covariates (age, sex, wealth quantile, education, and HIV status) (OR = 1.12, 95% CI: 0.88-1.42, p=0.373). Bivariate analysis demonstrated no notable confounding by any covariates and no strong effect modification. While GEMS score had no association with TB testing history among women, men with higher GEMS scores (less gender-equitable views) were more likely to have been tested for TB across age groups. These findings provide a basis for future investigation into the patterns and motives TB behaviours, particularly in older men. Tailored public health strategies may then be implemented to address this important population.

Healthcare workers (HCWs) face a high risk of infection during pandemics or public health emergencies as demonstrated in the ongoing COVID-19 pandemic. Understanding how governments respond can inform public health control measures and support health system functioning. An economic impact analysis examining HCW COVID-19 infections in Kenya and three other countries estimated that the total economic costs related to HCW COVID-19 infections costs and deaths in Kenya were US$113.2 million (range US$35.8-US$246.1). We examined the governance arrangements for HCW protection during the COVID-19 pandemic in Kenya between March 2020 and March 2021. Governance arrangements were examined following a scoping review of 44 policy and legislative documents and reports of HCW protection and 22 media articles. We adopted the transparency, accountability, participation, integrity and capacity (TAPIC) governance framework to analyse and summarize our findings into policy gaps and implementation challenges. Policy design gaps included inadequate provisions for emerging threats, inconsistencies with the devolved context and inadequate structures to monitor, inform and respond to HCW COVID-19 infections. Implementation challenges were attributed to inadequate quantity and quality of PPE, difficulty in accessing medical care for HCWs, delays in HCW remuneration, insufficient infection prevention and control measures, the top-down application of plans, difficulties in working in a decentralized context, and pre-existing public finance management (PFM) bottlenecks. Implementation of HCW protection during the COVID-19 pandemic and beyond could leverage the revamping of current legislation on labour relations to reflect devolved governance and develop a broader and long-term approach to occupational health and safety implementation that considers all HCWs. Improvements in PFM arrangements coupled with increased investment in the health sector and attention to efficient use of resources will also impact positively on HCW protection.

Leadership and governance are key components of health systems, nevertheless research into leadership and governance of mental healthcare at the community level is probably the least well researched and understood part of these systems. As part of assessing the integration of mental health in Primary Health Care in Ghana, the leadership and governance organisation and structures to ensure oversight and coordination were examined. A concurrent mixed-methods design involving both quantitative and qualitative research methods approach was adopted. The quantitative data were collected through a questionnaire, which was either self-administered or interviewer administered, on 1010 respondents with 830 completed (response rate 82%). Key informant interviews and focus group discussions were used to collect the qualitative data. Thematic content analysis with the use of NVivo 12 was applied for the qualitative field data and Stata SE16 was used for quantitative data. Data triangulation strategy was used to report the qualitative and quantitative results. The study showed that leadership and governance of mental health at the PHC level were lowly developed due to the modest level of awareness of the Mental Health Law, inadequate functioning of mental health units and coordination, low level of private sector participation in mental health care services, and low levels of provision of monitoring, supervision, and evaluation. This affected the integration of mental health at the PHC level, which was also gauged as low. The study concludes that despite the presence of legislation and policy aiming to achieve decentralised and integrated mental health services at the PHC level, mental health care is still a low-level priority within the health care system in Ghana and tends to operate within a silo. The study recommends that more practical and concerted leadership of mental health at the regional and district levels is required to drive decentralisation and integration at these levels.

South Sudan faces among the highest maternal and newborn mortality rates globally, with approximately 87% of deliveries occurring at home without skilled birth attendance. In 2024, the International Rescue Committee launched a Community-Based Maternal and Newborn Care (CBMNC) program in Aweil East County, Northern Bahr El Ghazal, deploying trained Boma Health Workers (BHWs) to deliver essential maternal and newborn health services at the household level. This study explored the acceptability of the CBMNC model among diverse stakeholders. This qualitative descriptive study was grounded in the Theoretical Framework of Acceptability (TFA). Data were collected between May and July 2025 through 17 focus group discussions (FGDs), 14 in-depth interviews (IDIs), and 10 key informant interviews (KIIs) with 185 participants, including program recipients, male partners, mothers and mothers-in-law, Boma and Hospital Health Committee (BHC/HHC) members, BHWs, supervisors, and health system stakeholders at state and national levels. Framework analysis, combining deductive coding based on the seven TFA constructs with inductive thematic analysis, was used. CBMNC was well accepted by recipients and their families, despite provider and health system concerns about sustainability. Trust in community-selected BHWs made home-based care valuable, especially given limited facility access. Intervention coherence relied on pictorial aids, repeated visits, and peer learning to address low literacy. Participants perceived commodity interventions like misoprostol and chlorhexidine as impactful, while behavioral counseling was less recognized. Clients faced minimal burden, but providers experienced significant challenges and inadequate compensation. Health stakeholders were cautiously optimistic but questioned lay provider capacity and long-term viability in a fragile environment. CBMNC can achieve high community acceptability when delivered through trusted, community-selected health workers using contextually appropriate strategies. However, community acceptability alone is insufficient for sustainable scale-up. Addressing provider compensation, workload, and structural integration into national health systems is essential to ensure that gains in acceptability translate into sustained service delivery.

IntroductionMaternal Waiting Homes (MWHs) are lodgings located near health facilities where women await their delivery date and be transferred to a health facility shortly before delivery or earlier should complications arise. They are a critical strategy to improve maternal health outcomes, as they been identified as a tool for reducing maternal and perinatal mortality, especially in low-resourced countries. However, they are limited countries with deliberate policies to promote their implementation. This study aimed to review the policy and strategic framework of modern maternal waiting homes in Africa and Zambia. MethodsWe searched published, unpublished, and grey literature from the following sources: Google Scholar, CINAHL, PubMed, Scopus, Medline, and ResearchGate. Initial search between the 25th and 27th March 2024 and the final search was re-run on December 18, 2024. We used relevant synonyms and keywords (such as policy on MWHs, strategies on MWHs, National Development Plans, strategic plans, Health policies, and initiatives on MWHs in developing countries or middle- and low-income countries in the English language. The study further reviewed policies, strategies, development plans, and health strategic plans that facilitated the promotion of maternal health in Zambia. ResultsDatabase search yielded a total of ninety-four (94) items. Eighteen (18) additional items were located through hand-searching reference at the Zambia National Archives Centre. Ten (10) articles described MWH policies, strategies, and implementation guidelines from the seven (7) countries. From the Zambia National Archives Centre, nine (9) documents comprised policies, national development plans and strategic plans obtained through the national archives centre. Only one country (Timor-Leste) had a deliberate policy on maternal waiting homes. Zambia does not have a policy or strategy in place that promotes maternal waiting homes. ConclusionLike in many other African countries, In Zambia, no strategic policy has been implemented to promote maternal waiting homes. While MWHs are acknowledged in various strategic health plans and some policies, they are not consistently prioritised or adequately funded. countries, including Zambia must have MWHs policy that should employ deliberate strategies to reduce maternal and newborn morbidities and mortalities.

The concurrent need for both humanitarian and development assistance in fragile settings and protracted emergencies has been termed the humanitarian-development nexus (HDN) or the humanitarian-development-peace nexus (HDpN). We undertook a scoping review on the operationalization of the HDpN for sexual, reproductive, maternal, newborn, child, and adolescent health interventions in fragile settings. We screened 2,183 publications, of which 29 peer-reviewed and 16 grey literature publications met inclusion criteria. No included studies focused on peace aspects within the HDpN and very few focused on child and adolescent health. Publications by humanitarian authors often classified maternal and newborn health as a component of sexual and reproductive health (SRH). Data extraction and analysis focused on three overarching themes: SRH prioritization across the HDN, the transition between minimum and comprehensive services, and health systems strengthening. This review provides concrete guidance on how to operationalize the HDN for SRH interventions in fragile settings. Expansion of SRH preparedness measures is necessary given the current trajectory of the climate emergency and other destabilizing events. The ability to flexibly transition between minimum and comprehensive services is important for maintaining service continuity in crisis-affected settings. COVID-19 proved to be a significant disruptor of SRH services, and a key inflection point in the collaboration between humanitarian and development practitioners. The use of task-shifting, decentralization, and telemedicine were approaches that may be adopted to maintain service delivery according to different contexts. Lastly, strengthening health systems was identified as essential across the HDN. With more crises extending for years, the wider literature has emphasized the necessity of health systems strengthening for reaching the Sustainable Development Goals, including in fragile settings.

The COVID-19 pandemic exposed vulnerabilities in health systems abilities to detect, report, and respond to threats. Inadequate preparedness led to healthcare worker infections (HCW), essential service disruptions, and impacts on communities. Primary health care (PHC) is often overlooked in health security initiatives. Epidemic Ready Primary Health Care (ERPHC) is an initiative that strengthens PHC facilities to prevent, detect and respond to outbreaks, while maintaining essential services. ICAP at Columbia University, the Ministry of Health of Sierra Leone, and Resolve to Save Lives is implementing a multi-year ERPHC project in Sierra Leone. A retrospective data review of 52 confirmed measles cases across four PHC facilities from January - March 2024 was conducted. Data is presented using an adapted 7-1-7 quality improvement approach for detection and notification to evaluate the key tenants of ERPHC: speed, safety, surge. Out of 52 confirmed cases, 98% and 100% met the first "7" and "1" for detection and notification. Immediate case management and safety actions were completed for all 52 cases (100%). Zero facilities were able to implement two readiness parameters for surge: sufficient supplies and referral pathways. Key bottlenecks included late presentation to health facilities, delayed notification via the electronic case-based surveillance system, inadequate PPE, and no updated referral pathways. These results underscore the need to scale and implement ERPHC, using adapted 7-1-7 metrics, in PHC facilities. HCW safety, increased community engagement, national supply chain mechanism strengthening, and established patient referral pathways need to be the foci of further health security investment in Sierra Leone.

BackgroundCommunity health workers (CHWs) are central to primary health care delivery in Madagascar, yet their perspectives on what enables effective work are rarely centered in programme design and implementation. Evidence is needed on the support CHWs receive in practice and the priorities they identify to strengthen effectiveness and equity. MethodsWe conducted a qualitative study nested within the formative phase of a participatory action research initiative aimed at strengthening Madagascars community health workforce. Tuberculosis (TB) programme support was used as a tracer condition for universal health coverage-relevant service delivery. Five focus group discussions were held with 26 CHWs in August-September 2024 in two contrasting regions (Analamanga and Atsimo-Andrefana). Discussions were conducted in Malagasy and its dialects, audio-recorded, transcribed, translated into French, and analyzed using inductive reflexive thematic analysis. ResultsCHWs articulated five interlinked priorities for effectiveness in the TB response: (1) stable and equitable socio-economic protection; (2) standardized, continuous, and practical training; (3) formative and collaborative supervision; (4) reliable provision of tools, equipment, transport, and personal protective equipment; and (5) recognition and integration within communities and the health system. CHWs emphasised reliability and fulfilment of promised entitlements and described fragmentation across implementing partners as a key source of inequity, uncertainty, and demotivation. ConclusionsCHWs accounts point to a persistent implementation gap between policy commitments and day-to-day support. Strengthening CHW effectiveness in Madagascar will require coordinated national stewardship and partner accountability to deliver a predictable minimum support package and to include CHWs meaningfully in programme design and evaluation.

BackgroundGlobal studies indicate that sexual gender based violence (SGBV) may increase during pandemics including the COVID-19. The Mid-Eastern region in Uganda was of a concern due to high prevalence of intimate partner sexual violence among adolescent girls and young women (AGYW) (13% in 2016). Due to limited data, we investigated factors associated with SGBV among AGYW during the COVID-19 pandemic in Eastern Uganda, April 2022. MethodsWe line listed all AGYW 10-24 years who obtained SGBV services at ten high-volume health facilities from March 2020 to December 2021, the main COVID-19 period in Uganda. We conducted a case-control study among these AGYW. A case was [&ge;]1 SGBV episode experienced by an AGYW aged 10-24 years residing in Tororo and Busia Districts. For every randomly-selected case from the health facility line list, we identified two neighbourhood-matched AGYW controls who reported no SGBV. We interviewed 108 and 216 controls on socio-demographics, socio-economics, and SGBV experiences during COVID-19. We conducted logistic regression to obtain adjusted odds ratios and confidence intervals. ResultsAmong 389 SGBV cases, the mean age was 16.4 (SD{+/-} 1.6: range 10-24) years, and 350 (90%) were 15-19 years. Among 108 cases interviewed, 79 (73%) reported forced sex. Most (73; 68%) knew the perpetrator. In multivariate analysis, self-reported SGBV before the COVID-19 period [aOR=5.8, 95%CI: 2.8-12] and having older siblings [aOR=1.9, 95%:CI 1.1-3.4] were associated with SGBV during the period. Living with a family that provided all the basic needs was protective [aOR=0.42, 95%: CI 0.23-0.78]. ConclusionPrevious SGBV experiences and family dynamics, such as having older siblings, increased the odds of SGBV during the COVID-19 pandemic in Uganda. Conversely, a supportive family environment was protective. Identifying, supporting, and enacting protective interventions for existing SGBV victims and socioeconomically vulnerable AGYW could reduce the burden of SGBV during similar events.

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.

BackgroundClimate change is increasingly recognised as a significant barrier to malaria elimination, especially in low-and middle-income countries (LMICs), where vulnerability to vector-and waterborne diseases is heightened. Climate variability increasingly influences malaria transmission dynamics, yet its impact on malaria control efforts remains underexplored. This study explored healthcare workers and community-based volunteers (CBVs) perspectives on climate change and the perceived contribution of climate variability to malaria transmission in Zambia. MethodsA cross-sectional qualitative study was conducted between August and October 2023 across twenty purposefully selected districts representing high-and low-burden malaria settings. Nine key informant interviews and fourteen focus group discussions were conducted with malaria program officers, clinicians, environmental health officers and CBVs. Data were transcribed verbatim, imported into ATLAS.ti version 23, and analysed thematically. ResultsParticipants consistently reported that flooding, drought, deforestation, and shifting rainfall patterns were increasing mosquito breeding sites and altering malaria transmission seasons. Climate-related disruptions, poor road access during floods and competing health priorities, including cholera outbreaks and COVID-19, were perceived to hinder effective malaria prevention and case management. While participants acknowledged the need for a more integrated response, they largely emphasised reinforcing existing malaria control strategies, such as indoor residual spraying (IRS) and insecticide-treated nets (ITNs), with limited reference to broader climate adaptation measures or national climate policies, highlighting gaps in policy dissemination and implementation. Participants also noted contextual barriers, including vector resistance and diagnostic inaccuracies. Notably, the emerging role of malaria vaccination was not mentioned, indicating a potential knowledge gap in climate-adaptive malaria strategies. ConclusionsFrontline perspectives highlight substantial climate-related challenges to sustaining malaria control in Zambia and gaps in climate-health knowledge among HCWs and CBVs. Strengthening climate-resilient systems, improving policy dissemination and integrating climate adaptation into malaria programming and training are critical to sustaining progress towards elimination. Author SummaryDespite clear evidence that climate change is reshaping malaria transmission in sub-Saharan Africa, little is known about how frontline health workers perceive and respond to these shifts. This study provides the first multi-district qualitative examination of healthcare worker and community volunteer perspectives on climate-malaria interactions in Zambia. Our findings reveal critical knowledge gaps, limited awareness of existing climate-health policies, and an over-reliance on traditional malaria interventions that fail to integrate climate-resilient strategies. These insights underscore a pressing need for targeted training, strengthened policy dissemination, and multisectoral collaboration to build climate-ready malaria programmes. By illuminating the disconnect between climate science and frontline practice, this study highlights a fundamental barrier to sustaining malaria elimination in a rapidly changing climate.