PLOS Global Public Health

Introduction: Adolescents in low- and middle-income countries continue to face barriers to family planning (FP) and post-abortion care (PAC), including stigma, limited confidentiality, inadequate information, and health-system constraints. This study explored adolescents and key stakeholders perspectives on strategies to improve uptake of adolescent FP and PAC services in Lira District, Northern Uganda. Methods and Materials: An exploratory qualitative descriptive study was conducted using 13 focus group discussions (FGDs) with 65 adolescent citizen scientists aged 10-19 years and 13 key informant interviews (KIIs) with stakeholders involved in adolescent sexual and reproductive health and PAC. Data were collected using semi-structured guides, audio-recorded with consent, and supplemented by field notes, then analyzed thematically using Braun and Clarkes six-phase framework. Results: Five interconnected themes emerged, including strengthening school, community, and faith-based SRH education; strengthening the health system and service delivery; policy, legal, and institutional clarity; community engagement and trust building; and integration of FP and PAC. Participants prioritized accessible and accurate SRH education, supportive community engagement, confidential and respectful care, and reliable commodities, clear operational guidance, coordinated referrals, and integrated services. The findings indicate that uptake is shaped by interacting with individual, social, health-system, and policy conditions rather than knowledge alone. A participatory, multilevel approach that connects community-generated knowledge with adolescent-responsive health-system strengthening may offer a feasible pathway for improving FP and PAC uptake in Northern Uganda. Conclusion: Adolescents and key stakeholders identified interconnected community, health-system, policy, and service-delivery strategies for improving uptake of FP and PAC services. Priority actions included accessible SRH education, supportive community engagement, confidential and respectful care, reliable commodities, clear operational and legal guidance, and integrated FP and PAC delivery.

Multimorbidity exposes tensions between complex health needs and health systems historically organized vertically around single diseases. While integrated chronic care has become a policy priority for many low- and middle-income countries, responses remain constrained by disease-specific configurations of knowledge, policy and practice. The USAID cuts represent a critical rupture in these arrangements, exposing dependencies while creating opportunities for integration, institutionalisation and local ownership. We examined challenges and opportunities for multimorbidity-responsive primary healthcare through a Learning Health System (LHS) lens, focusing on how information, deliberation, and action shape learning and adaptation processes in Zimbabwe during this period of transition. We conducted an ethnographic study in two urban metropolitan centers in Zimbabwe between October 2025 and February 2026, using patient journey mapping (n=23), participant observation, and in-depth interviews with healthcare workers, patients, decision-makers, health information specialists, and technical partners (n=19). We analyzed data thematically using an iterative framework informed by LHS concepts. Participants widely recognized multimorbidity as an increasingly common feature of primary care, yet care remained constrained by systems organized around individual diseases. Fragmentation was evident not only in clinical pathways but also in the information, accountability, and decision-making architectures through which health priorities were recognized and acted upon. At the same time, frontline providers routinely adapted care around patients' multiple conditions, revealing capacity for more integrated and person-centered approaches. Existing HIV platforms, including differentiated service delivery models and regional learning networks, were frequently identified as foundations for broader chronic care integration. These findings suggest that advancing multimorbidity-responsive care requires more than service integration; it requires strengthening the learning architectures through which health priorities are defined, knowledge is generated, and action is coordinated.

Seasonal flooding in Adamawa State, Nigeria damages health facilities, breaks supply chains, and displaces health workers and communities, while increasing health needs. Sexual and reproductive health (SRH) services are often deprioritized, yet evidence on how they are sustained remains limited. We examined how SRH services were sustained during recurrent flooding. We conducted a qualitative descriptive study in the flood-prone Local Government Areas of Numan and Fufore. We held eight focus group discussions with women and girls and 20 key informant interviews with health providers, supply chain actors, and program implementers. Flooding closed or damaged health facilities, broke supply and cold chains, and displaced health workers. Participants linked these disruptions to unattended births and to rising hemorrhage, stillbirth, miscarriage, and genital infections. Service continuity depended less on the formal health system than on anticipatory, community-led adaptation across three phases. Before floods, stakeholders mapped risk, pre-positioned commodities, trained women in contraceptive self-injection, and dispensed medicines in advance. During floods, care shifted to mobile outreach, task-sharing, transport by canoe and boat, and community-led referral. Community health workers, traditional birth attendants, Ward Development Committees, and women's groups reached cut-off communities. Across seasons, adaptations evolved toward cash transfers, savings groups, local reusable-pad production, and decentralized commodity hubs. Continuity relied heavily on unpaid community labor and women's own resources. Sustaining SRH services in flood-prone settings requires institutionalized preparedness, decentralized supply, empowered communities, and protected health financing. Community-led models offer a transferable approach to health security in a changing climate.

Background: A responsive and resilient health system that is informed by community needs and guided by evidence-based interventions is fundamental to delivering quality essential health services and achieving Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs). Ethiopia committed to improve access to and quality of essential health services through the Health Extension Program Optimization (HEPO) roadmap, which restructured primary healthcare facilities into three categories i.e., Basic Health Posts (BHPs), Comprehensive Health Posts (CHPs), and Health Extension Program units imbedded within Health Centers (HCs). However, evidence on the reproductive, maternal, newborn, and child health (RMNCH) service availability and readiness of these restructured primary health-care facilities remains limited. Methods: This multi-region cross-sectional facility based study was conducted between December 2024 and February 2025. A structured questionnaire adapted from the World Health Organization Service Availability and Readiness Assessment (SARA) was used to measure service availability, general facility readiness, and RMNCH service-specific readiness using predefined domains and tracer items. Differences across facility types were assessed using Kruskal-Wallis or categorical association tests, with Benjamini-Hochberg adjustment for multiple comparisons. Multivariable linear regression estimated the adjusted differences in overall RMNCH readiness, controlling for region, urban-rural residence, and log-transformed catchment population, with robust standard errors clustered at woreda level. Results: A total of 305 primary health care facilities were assessed, including 107 BHPs (35.1%), 142 CHPs (46.6%), and 56 HCs (18.4%). Nearly all BHPs were located in rural settings (99.1%), compared with 86.6% of CHPs and 71.4% of HCs. The median general health facility readiness were increased significantly across facility levels, from 33.1% (IQR: 24.4-40.7) in BHPs to 62.9% (IQR: 54.1-71.4) in CHPs and 89.6% (IQR: 81.3-93.6) in HCs (p<0.001). And the median overall RMNCH service readiness was 67.9%, 77.8%, and 91.1% for BHPs, CHPs, and HCs, respectively (p<0.001). skilled Birth Attendance readiness was demonstrated the largest gap between facility types. Compared with CHPs, BHPs scored 9.9 percentage points lower in adjusted RMNCH service readiness (95% CI: -14.7 to -5.1; p<0.001), while HCs scored 8.7 points higher (95% CI: 1.7-15.8; p=0.015). Conclusions: The restructured primary healthcare facilities expanded access to essential services, particularly through CHPs, which occupy an intermediate position between BHPs and HCs through substantial expansion of RMNCH service packages for underserved communities. Nevertheless, significant gaps remain in staffing, infrastructure, commodities, diagnostics, and childbirth readiness. Future HEPO scale-up should prioritize strengthening childbirth-readiness packages and ensuring reliable supply chains for essential medicines and diagnostics.

Multimorbidity - the co-existence of two or more long-term health conditions (LTCs) - is increasingly common in low- and middle-income countries. Yet, in the African region, its prevalence in people with tuberculosis (TB) and its impact on treatment outcomes remain poorly characterised. We sought to determine the prevalence and patterns of multimorbidity and its impact on health and treatment outcomes in people with TB in Kampala, Uganda, and to evaluate cascades of care for hypertension, diabetes mellitus, HIV and mental health conditions. This was a prospective cohort study of adults ([&ge;]18 years) commencing anti-TB treatment at four clinics in Kampala between June 2024-June 2025. LTCs were identified through self-report, validated screening tools, clinical examination and blood analysis, using definitions informed by the Ho et al. Delphi consensus. Multimorbidity was defined as TB plus two or more LTCs. Participants were followed to month six to assess health-related quality of life (HRQoL), physiological status (National Early Warning Score (NEWS)), sputum bacillary clearance (TB-Molecular Bacterial Load Assay (TB-MBLA)) and WHO-defined treatment outcomes. Descriptive statistics were used to examine the prevalence and patterns of multimorbidity and evaluate cascades of care. The effect of multimorbidity on health and treatment outcomes was assessed using regression models. Among 254 adults with TB, the prevalence of multimorbidity was 39.4% (95% CI 33.3-45.7%); only 22.4% had TB with no co-existing condition. The most prevalent LTCs were HIV (44.1%), undernutrition (39.8%) and depression (16.1%). Care cascades revealed substantial gaps in screening and diagnosis (HIV, diabetes mellitus and mental health conditions) and treatment (hypertension). At enrolment, multimorbidity was associated with worse NEWS (adjusted mean difference 0.88, 95% CI 0.36 to 1.42) and HRQoL (adjusted mean difference in HRQoL score -10.75, 95% CI -16.77 to -4.73). Multimorbidity was associated with a higher risk of a positive sputum TB-MBLA at month 2 and a higher risk of an unsuccessful TB treatment outcome (adjusted risk difference 9.88%, 95% CI 2.59 to 17.17). All deaths occurred among participants with multimorbidity. Multimorbidity affected two in five adults with TB in this cohort and was associated with worse health at diagnosis and poorer treatment outcomes. National TB programmes are well placed to identify and manage co-existing LTCs, but care cascades show gaps at different stages for different conditions, underscoring the need for tailored, integrated approaches.

Adolescent girls living in internally displaced persons (IDP) camps manage menstruation amid food insecurity, inadequate water, sanitation and hygiene (WASH), disrupted education, gendered social norms and protection systems. These challenges are often addressed through separate humanitarian programmes, obscuring how they interact in girls everyday lives. This study explored menstrual-health experiences and perceived nutritional deprivation among adolescent girls in five IDP camps in Benue State, Nigeria. We conducted a focused ethnographic qualitative study in the International Market, Mega, Ortese, Uikpam, and Abagana camps. Twenty-five in-depth interviews with menstruating adolescent girls aged 13-19 years were complemented by focus group discussions with adolescent girls, adult women, adult men, and camp leaders, and structured WASH and food observations. Interviews and discussions were conducted in English, Tiv or both, transcribed verbatim and translated where necessary. Data were managed in MAXQDA and analysed using reflexive thematic analysis. Frequencies describe the distribution of 435 coded excerpts and are not participant prevalence estimates. Six themes and 20 subthemes were generated. Menstrual-health management and material constraints accounted for 95 coded excerpts (21.8%), followed by knowledge and lived experience (80; 18.4%), food insecurity and perceived nutritional deprivation (70; 16.1%), coping and adaptive agency (70; 16.1%), sociocultural beliefs and taboos (65; 14.9%), and self-reported symptoms and participation restrictions (55; 12.6%). Girls described irregular access to commercial pads, reliance on improvised materials, limited water and soap, and toilets that were unsafe or inaccessible at night. Dietary monotony, meal skipping, and hunger were perceived to intensify pain, weakness, and fatigue. Fear of staining, menstrual silence, and household restrictions contributed to withdrawal from school, livelihood, and domestic activities. Peer support was protective, but some girls undertook informal work to obtain menstrual materials, raising safeguarding concerns. Menstrual health in prolonged displacement is not an isolated hygiene issue but an outcome of interacting material, nutritional, sociocultural, educational, and protection constraints. Humanitarian responses should combine predictable access to acceptable menstrual materials with safe WASH facilities, adolescent-responsive food and nutrition support, confidential health services, community education and safeguarding mechanisms. Reported symptoms and nutritional experiences were not clinically measured.

Background Drug-resistant tuberculosis (DR-TB) remains a major problem in Indonesia, with a significant low treatment initiation rate. This study identifies factors influencing treatment initiation and assess the impact of delay on patient outcomes. Methods We conducted a mixed-methods study using a parallel convergent design. The quantitative component analyzed the Tuberculosis Information System (TBIS) data from three hospitals in Jakarta and Bogor from January 2022 to December 2023. The qualitative component involved in-depth interviews and Focus Group Discussions (FGD) with DR-TB patients, healthcare workers, patient supporters, and program managers. Results Among 1,665 people with DR-TB included in this study, we found a pre-treatment attrition rate of 6.4%. We identified two factors of pre-treatment attrition: prior TB treatment (aOR=1.7, 95%CI 1.082-2.671) and distance to hospital (aOR=1.9, 95%CI: 1.136-3.180). Conversely, referred patients, treatment in suburban areas, and people with rifampicin-resistant (RR)-TB were 85%, 82%, and 63% less likely to experience attrition, respectively. Qualitative findings identify patient, social, and health system barriers to the treatment initiation, and alternative remedies emerged as a coping mechanism. Conclusion Strengthening referral systems, decentralizing care, and addressing socio-economic barriers are critical for ensuring timely DR-TB treatment initiation.

BACKGROUND: Indigenous tribes face a disproportionately high tuberculosis (TB) burden due to deep-rooted socioeconomic disadvantage, highlighting the need for strengthened, culturally sensitive control strategies. METHODS: We conducted a 21-year retrospective study (2005-2025) among tribal and neighboring non-tribal populations attending a tribal-serving hospital in Karnataka. Pre-Nikshay data were transcribed from paper registers, and post-Nikshay data were obtained from the digital system. We assessed negative binomial interrupted time-series regression model, data completeness, TB risk factors, and used multivariable logistic regression to identify determinants of poor treatment outcomes and household contact screening yield. RESULTS: We analyzed 1,512 TB cases (tribal = 1,021; non-tribal = 491). TB detection increased significantly over time, with a steeper rise among tribal populations (p<0.001). Nikshay implementation significantly improved data completeness (Wilcoxon W = 9900, p<0.001). Among tribal patients, males had higher odds of poor treatment outcome (aOR 2.81, 95% CI 1.70- 4.85; p<0.001). Diabetes (aOR 2.10, 95% CI 1.05- 4.03; p=0.029) was independently associated with poor treatment outcome. Among 503 index cases, 1,535 household contacts were identified and 1,161 (75.6%) screened; coverage was lower among tribal contacts (69.8% vs 87.2%; p<0.001). CONCLUSIONS: Nikshay strengthened TB surveillance and improved assessment of TB burden and risk factors in tribal communities.

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 Preventing tuberculosis (TB) through TB Preventive Treatment (TPT) is an essential component of TB control and elimination. In recent years, many countries including Bangladesh, have revised their national programs to extend TPT to household contacts of TB patients. However, coverage remains well below the target, and evidence remains limited on context-specific barriers and facilitators. This study aimed to explore the barriers and facilitators to TPT uptake among household contacts in Bangladesh. Methods This study followed an exploratory qualitative approach. The setting was Moulvibazar district, Bangladesh. Qualitative data were collected through key-informant interviews with health providers and in-depth interviews with household contacts, and participants were selected through purposive sampling. Thematic analysis was used to explore the factors influencing TPT uptake. Results Perceived lack of need for treatment among household contacts and side effects of TPT medicines emerged as major barriers. Stigma associated with TB and resource shortage at the health facility level further hampered uptake. Counseling on the importance of TPT and its possible side effects, along with public awareness campaigns, facilitated TPT uptake by addressing household contacts concerns. Perceived risk of TB, free TPT services, support from family members, and health providers positive attitudes also supported uptake. Conclusion Addressing household contacts concerns about the need for treatment and potential side effects, along with strengthening health facility capacity, is required for improving TPT uptake. Both individual counseling and mass awareness campaigns can help address these concerns and facilitate uptake. These strategies may help increase TPT coverage in Bangladesh and beyond, contributing to global TB elimination efforts.

Geocoded health facility data are essential for spatial analyses, yet routine health information systems in many low- and middle-income countries often contain inaccurate, incomplete, inconsistent, or outdated facility coordinates. For Greater Accra, Ghana, we created a geocoded health facility dataset aligned with routine maternal health service data from the District Health Information Management System (DHIMS2). We undertook a desk-based, multi-source geocoding and verification workflow of 602 facilities reporting maternal health services between 2020 and 2024. Candidate coordinates were triangulated using national facility records, online mapping platforms, facility websites and social media, directories, photographs, satellite imagery, and local expert knowledge. Coordinates were classified according to the strength and concordance of supporting evidence, with uncertain cases undergoing secondary review. Coordinates were identified for 96.4% of 602 health facilities (n = 580), with 59.3% assigned a high confidence classification (n = 357). Only 22 facilities (3.7%) could not be located with sufficient supporting evidence. Our resulting dataset is made available in a version-controlled openly-modifiable repository for long-term use, permitting routine service utilisation data to be linked with facility locations; thereby facilitating spatial analysis important for equitable health service planning. By documenting our process, this study makes a typically hidden stage of spatial health research transparent and reproducible. Our findings also highlight the need to treat geocoded facility datasets as living, maintainable geospatial health data infrastructure rather than as static research outputs.

BackgroundRespondent-driven sampling (RDS) is a widely used peer-recruitment strategy to study hard-to-reach populations including people who use drugs. South Africa continues to experience increasing illicit substance use alongside high burdens of tuberculosis (TB) and HIV. Little is known about the factors that influence RDS recruitment success in these settings, especially in rural areas. MethodsA total of 750 people who smoke drugs (PWSD) were recruited through RDS in a rural town in the Western Cape, South Africa to estimate TB and HIV prevalence. Participant characteristics were compared by recruitment success, defined as distributing at least one study coupon that resulted in peer enrollment, to identify factors associated with successful recruitment. Recruitment homophily was assessed to quantify within-group recruitment, and the stabilization of selected participant characteristics across recruitment waves were visualized to assess sample diversity over time. ResultsRecruitment success was more common among unemployed participants (p=0.032), those without an incarceration history (p=0.053), current cannabis users (p=0.086), and participants with moderate-to-severe methamphetamine (p=0.019) or methaqualone (p=0.014) use. High within-group recruitment was observed by neighborhood of residence and racial population group. The proportion of males, individuals with incarceration history, and participants with TB or HIV stabilized across recruitment waves, regardless of seed characteristics. ConclusionsRecruitment dynamics in this setting were strongly influenced by social and geographic factors, including neighborhood, population group, incarceration history, and substance use type and severity. Identifying characteristics associated with recruitment success may inform more efficient peer-recruitment strategies, such as targeted coupon distribution. These findings support the use of RDS as an effective approach for engaging PWSD in research.

Background: Diabetes is a growing public health challenge globally, with a disproportionate burden occurring in low- and middle-income countries (LMICs). In Kenya, limited evidence exists on type 2 diabetes mellitus (T2DM) screening coverage, undiagnosed diabetes, and progression through the diabetes care cascade. This study assessed the prevalence and determinants of T2DM testing, quantified undiagnosed T2DM, and examined the T2DM care cascade in Kenya. Methods: We analysed data from the 2015 Kenya WHO STEPwise survey, a nationally representative cross-sectional survey of adults aged 18-69 years. The analysis included 4,167 participants after excluding individuals with missing fasting plasma glucose (FPG) measurements and those below the age of 18 and above 69 years. Diabetes testing was defined as self-reported prior blood glucose measurement by a health worker among individuals without known diabetes. Diabetes was defined as FPG [&ge;]7 mmol/L, previous diagnosis, or current diabetes treatment. Weighted prevalence estimates with 95% confidence intervals (CI) were calculated. Univariable and multivariable logistic regression analyses were conducted to identify factors associated with diabetes screening while accounting for the complex survey design. Results: Overall, 11.9% (95% CI: 9.7-14.5) of participants reported ever being tested for diabetes. The weighted prevalence of diabetes was 2.66% (95% CI: 2.06-3.42), while 53.4% (95% CI: 39.0-67.4) of diabetes cases were previously undiagnosed. Testing prevalence was highest among older adults, individuals with tertiary education, obese participants, and those with hypertension, but lowest among younger adults, individuals with no formal education, and residents of the North Eastern region. Among individuals with diabetes, 46.9% were aware of their diagnosis, 40.8% of those aware were on treatment, and only 26.4% of those on treatment had achieved glycaemic control. In multivariable analysis, older age (60-69 years: aOR=6.29, 95% CI: 3.66-10.79), tertiary education (aOR=2.65, 95% CI: 1.33-5.27), poorest wealth quintile (aOR=8.42, 95% CI: 4.11-17.24), obesity (aOR=2.13, 95% CI: 1.41-3.21), and hypertension (aOR=1.64, 95% CI: 1.21-2.23) were significantly associated with increased odds of diabetes testing. Conclusion: Diabetes testing coverage in Kenya remains low, with more than half of diabetes cases remaining undiagnosed and substantial losses occurring across the diabetes care cascade. These findings highlight critical gaps in early diagnosis, linkage to care, treatment uptake, and glycaemic control. Strengthening integrated diabetes screening and care services, particularly for underserved and high-risk populations, is essential to improve early detection and continuity of care in Kenya.

Abstract Background: We developed and evaluated a behaviour change intervention to improve health outcomes for pregnant women and neonates in rural Pakistan. Methods: We used a parallel, three-arm, unblinded, cluster randomised controlled trial design. Eligible clusters were upgraded health facilities plus all associated community health workers (CHWs) and catchment populations. Randomisation was by computer program (1:1:1 ratio). All pregnant women were eligible. Control CHWs provided usual care to pregnant women. Arm 1 CHWs provided structured birth planning, including birth preparedness and complication readiness planning, and a voucher allowing free travel to access emergency obstetric/neonatal care. Arm 2 CHWs provided structured planning alone. Co-primary outcomes were skilled (doctors and midwifery-trained cadres) birth attendance and neonatal mortality (NNM) at 28 days. Findings: Between November 2011 to May 2012, respectively in arms 1, 2 and the control 21,317, 19,267 and 18,867 women were recruited, and 21,214, 19,125 and 18,812 were followed-up and analysed. Vouchers were almost never used to reclaim travel costs. Skilled attendance was 64% (12,045/18,812) in the control arm, 72.3% (15,335/21,214) (adjusted odds ratio [aOR] 1.56 [95% CI: 0.93, 2.62; p = 0.21]) in arm 1 and 78.1% (14,944/19,125) (aOR 2.16 [95% CI: 1.29, 3.62; p = 0.007]) in arm 2. NNM was 13.4 (per 1,000 live births) in the control arm, 45 (aOR 2.32 [95% CI: 1.48, 3.63; p < 0.001]) in arm 1 and 16.2 (aOR 1.36 [95% CI: 0.84, 2.21; p = 0.21]) in arm 2. Conclusions: Birth planning had inconsistent effects on skilled attendance and NNM, including apparently negative effects on NNM, with concerns about the quality of midwifery care. However, the control arm and arm 2 NNM was improbably low for this setting, and bias in the outcome may explain the observed differences. The travel voucher was little used.

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.

Background. Despite relatively high coverage of interventions to prevent vertical transmission, HIV incidence among children born to women living with HIV (WLH) remains above elimination targets, partly because of substantial disengagement from antiretroviral therapy (ART) during the postpartum period. We evaluated the effectiveness of a data-driven continuous quality improvement (CQI) intervention in improving retention in care, virological suppression, and prevention of vertical transmission among pregnant and breastfeeding WLH receiving ART in maternal and child health (MCH) clinics. Methods and findings. This pragmatic cluster-randomized trial was conducted in 105 MCH clinics--three high-volume clinics in each of the 35 health zones (HZs) of Kinshasa Province, Democratic Republic of the Congo. During the pre-randomization phase (November 2016-December 2017), routine data collection using prevention of mother-to-child transmission registers was strengthened in all participating clinics. In January 2018, HZs were randomized 1:1 to implement CQI or continue the standard of care. In intervention HZs, quality improvement (QI) teams were established at the HZ and clinic levels. Indicators selected collaboratively with QI teams were calculated from routine program data and shared quarterly. Through July 2019, QI teams met quarterly to identify service-delivery challenges and develop strategies to improve outcomes, with an emphasis on retention. Thereafter, responsibility for producing indicators was transferred to QI teams, and meetings continued virtually through WhatsApp. Pregnant and breastfeeding WLH and their infants receiving care at participating clinics between November 2016 and July 2019 were enrolled and followed for at least 24 months. Primary outcomes were loss to follow-up (LTFU), viral suppression (<1,000 copies/mL), and a positive HIV test among live-born infants. Overall, 2,376 women were enrolled, including 1,217 (51.2%) before randomization. The analysis of CQI effectiveness included 1,900 participants who remained in care at randomization or enrolled thereafter: 1,103 (58.1%) in control HZs and 797 (41.9%) in intervention HZs. At 6, 12, and 24 months, LTFU was lower in the intervention group than in the control group: 18.6% versus 21.6% (adjusted risk difference [aRD], -5.2 percentage points; 95% CI, -9.6 to -0.8), 29.2% versus 31.0% (aRD, -3.9; 95% CI, -10.2 to 2.4), and 50.1% versus 55.5% (aRD, -7.1; 95% CI, -15.2 to 1.0), respectively. Estimated effects were larger in PEPFAR-supported and urban clinics, although interaction tests were not statistically significant. Viral-load results were available for 38.2%, 50.4%, and 73.5% of eligible participants at 6, 12, and 24 months, respectively. Neither viral-load-result availability nor viral suppression differed between groups. Infant HIV-test results were available for 8.1%, 32.7%, 34.2%, and 28.5% of eligible infants at 6 weeks and 6, 12, and 24 months, respectively. Conclusions. CQI implementation produced a modest improvement in retention, with the clearest evidence at 6 months and favorable but imprecise estimates through 24 months. Limited availability of maternal viral-load and infant HIV-test results precluded definitive conclusions about virological suppression and vertical transmission. Local quality-improvement interventions may strengthen processes within frontline teams control but cannot alone overcome failures across an interconnected care system. Future studies should align interventions operational reach with all health-system levels responsible for the intended outcomes.

Objective. To identify antimicrobial stewardship targets by triangulating provider knowledge and practice, government-facility prescribing indicators and patient-reported treatment experience in three districts of Chhattisgarh, India. Methods. We analysed three independently sampled cross-sectional components: a provider survey (171 providers), a World Health Organization and International Network for Rational Use of Drugs assessment (600 encounters at 20 government facilities) and patient exit interviews (371 consultations). We used descriptive indicators and multivariable ordinal or binary logistic regression. Findings. Among providers, 149 of 163 (91.4%) recognized antimicrobial resistance, but 131 of 163 (80.4%) reported providing antibiotics for colds or sore throats to at least some patients. Guideline familiarity was not associated with less frequent provision (adjusted common odds ratio [aOR], 1.13; 95% confidence interval [CI], 0.57-2.24; P=0.725). Government facilities prescribed antibiotics in 329 of 600 encounters (54.8%), with a facility range of 16.7-80.0%. In exit interviews, 131 of 142 informal-provider consultations (92.3%) involved a reported injection; informal providers accounted for 131 of 181 reported injections (72.4%). Clear or very clear instructions were associated with satisfaction (aOR: 13.66; 95% CI: 6.37-29.28; P<0.001). Conclusion. High awareness coexisted with frequent self-reported antibiotic provision, wide facility variation and sector-specific injection exposure. Stewardship programmes should diagnose local drivers before selecting interventions and prospectively evaluate adapted decision support, audit and feedback, independent drug information, informal-provider engagement and communication training.

BackgroundMalaria in pregnancy (MiP) imposes a substantial economic burden on households in sub-Saharan Africa. We estimated household costs of MiP and their distribution across wealth quintiles among HIV-uninfected pregnant women in western Kenya receiving intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP), dihydroartemisinin-piperaquine (DP), or dihydroartemisinin-piperaquine plus provider education. MethodsThis study was nested within a three-armed, pragmatic, open-label, cluster-randomised trial across 15 health facilities over 10 months. Exit interviews were conducted during the second and third trimesters, approximately 5-6 months after the start of the intervention period. Direct and indirect household costs from the most recent malaria episode were compared with income to estimate catastrophic health expenditure (CHE). Costs were analysed using mixed-effects generalised linear model and their distribution across wealth quintiles using the concentration index. Cost data collected in 2020 (Kenyan shillings) were inflated and converted to 2024 US dollars. FindingsAmong 1,189 participants, 247 (21%) self-reported having sought care for MiP (212 outpatients, 24 inpatients, 11 unspecified). Mean costs were USD 24.9 for outpatient and USD 57.1 for inpatient care per episode. Indirect costs accounted for 87% and 70% of outpatient and inpatient costs, respectively. The mean outpatient malaria costs were equivalent to six or more days while inpatient costs were half a month or more of the minimum wages in the study area. The incidence of CHE for outpatient care was 8%, and neither outpatient costs nor CHE varied between wealth quintiles (concentration index =0.02, p=0.571 and 0.01, p=0.304, respectively). ConclusionsMiP imposes a substantial economic burden on households in western Kenya, despite a national policy of free maternal health services. Most costs arose from productivity losses rather than payments for care; financial protection therefore depends on the prevention of malaria episodes.

Objectives: Antimicrobial resistance (AMR) is no longer a future health problem but rather a present public health crisis. For over a decade, national AMR awareness initiatives have been undertaken in Tanzania to implement National Action Plans (NAPs). However, the assessment of whether these initiatives have reached the target population is still limited. This study evaluated physical reach, public perception and community participation in national AMR awareness campaigns in two regions in Tanzania. Methodology: This is a quantitative, community based, cross sectional study in Dar es Salaam and Mwanza regions, Tanzania. The multistage technique was used to sample 2,672 questionnaire respondents. Participant characteristics and perceptions of the campaign were summarised using descriptive statistics. Multivariable logistic and Firth regression were used to establish predictors of high AMR campaign perception and physical campaign reach. Results: Only 81 (3.03%) respondents reported being reached by AMR awareness physical campaigns. Physical reach was strongly linked with high education and skilled occupation. Respondents in Mwanza were less likely to be reached by campaigns compared to Dar es Salaam. Despite limited physical reach, the overall perception of the campaigns was positive. The majority of the respondents agreed on the importance of community involvement (91.6%), AMR education should be brought into schools (98.9%), believed the campaign messages were accurate (79.6%) and would like to get involved with future campaigns (91.4%). Higher odds for favourable perception were found to be independently associated with physical campaign reach (AOR=2.77, 95% CI: 1.40 to 5.49). Conclusions: The Promotion of AMR awareness campaigns in Tanzania seems to be well accepted by the public despite limited reach. Future campaigns need to shift away from one off activities and towards ongoing and inclusive community engagement, leveraging schools, community leaders, community based structures, and systematically tracking reach and behaviours.

Background: Hand hygiene (HH) is one of the most effective measures to prevent healthcare-associated infections (HAIs) and limit the transmission of antimicrobial-resistant pathogens in healthcare facilities (HCFs). Effective HH programs depend not only on the availability of essential resources but also on healthcare workers' (HCWs) knowledge, attitudes, and adherence to recommended HH practices. Despite the critical role of these factors in improving infection prevention and control (IPC), evidence on HH knowledge and practices among HCWs remains limited. In Uganda, such evidence from lower-level district health facilities is particularly scarce. This study assessed HH knowledge and practices, along with associated factors, among HCWs at selected health facilities in the Mukono and Kagadi districts of Uganda. Methods: A cross-sectional study was conducted among 586 HCWs at selected health facilities in the Mukono and Kagadi districts from May to June 2025. Data were collected using a structured questionnaire administered via KoboCollect, covering participants' socio-demographic and professional characteristics, HH knowledge, self-reported HH practices, and facility-related factors. Descriptive statistics summarized the data, and modified Poisson regression with generalized estimating equations (GEE), accounting for clustering of HCWs within facilities, was used to estimate prevalence ratios for factors associated with HH knowledge and practices. Results: Overall, 82.1% of HCWs had adequate HH knowledge, and 43.0% had good HH practice. Nearly all respondents correctly identified the recommended handwashing duration (98.8%), the minimum effective alcohol concentration for alcohol-based hand rub (ABHR) (98.8%), proper HH as the most effective method for preventing HAIs (97.6%), and 89.9% correctly listed all five WHO Moments for HH. HCWs in Mukono were more likely to have adequate HH knowledge than those in Kagadi (aPR = 1.36; 95% CI: 1.15-1.60). HCWs with 6-10 years of experience had higher knowledge of HH than those with less than two years of experience (aPR=1.16, 95% CI: 1.02-1.33). Good HH practice was significantly more common among clinical officers (aPR=1.36, 95% CI: 1.06-1.75) and other cadres (aPR=1.65, 95% CI: 1.14-2.39) than nurses and nursing assistants. Conclusion: HCWs demonstrated high HH knowledge but suboptimal HH practice, suggesting a gap between knowledge and self-reported practice. Interventions should move beyond knowledge dissemination to strengthen compliance through multimodal, cadre-specific strategies, particularly for nurses and nursing assistants.