PLOS Global Public Health

Background: Antenatal care (ANC) utilization is critical for improving maternal and neonatal health outcomes. Despite the World Health Organization recommendation of at least eight ANC contacts during pregnancy and the implementation of free maternal healthcare policies in Ghana, significant geographic and socioeconomic disparities in ANC utilization persist. This study therefore assessed the spatial distribution and geographically varying determinants of ANC utilization among women in Ghana. Methods: A cross sectional analytical study was conducted using women data from the 2022 Ghana Demographic and Health Survey. The analysis included women aged 15 to 49 years with an index child younger than five years preceding the survey. Descriptive statistics were computed using Stata version 18, while spatial analyses were conducted in QGIS version 3.44. Global Morans I was used to assess spatial autocorrelation, whereas Local Morans I and Getis Ord Gi analyses identified spatial clusters, hotspots, and coldspots of ANC utilization. Ordinary Least Squares (OLS) regression and Geographically Weighted Regression (GWR) models were fitted to assess global and local determinants of ANC utilization. Results: Overall, only 26.0% of women achieved adequate ANC utilization, while 74.0% reported inadequate ANC attendance. Adequate ANC utilization was higher among women with higher education (42.0%) and those from the richest households (41.3%) compared with women without formal education (19.1%) and those from the poorest households (17.6%). Regional disparities were observed, with Western (48.8%), Eastern (48.0%), and Greater Accra (47.3%) regions recording the highest ANC utilization, whereas Savannah (24.7%), Northern (25.8%), and North East (26.8%) regions recorded the lowest utilization levels. Global Morans I demonstrated significant positive spatial autocorrelation (Morans I = 0.457, p = 0.044), indicating geographic clustering of ANC utilization across Ghana. Getis Ord Gi analysis identified significant coldspots within Northern, Savannah, and North East regions, while Central Region demonstrated significant hotspot clustering. OLS regression showed that maternal education (B = 0.284, p = 0.003) and household wealth (B = 0.191, p = 0.011) positively influenced ANC utilization, whereas distance to health facility negatively influenced utilization (B = -0.156, p = 0.019). The GWR model demonstrated improved explanatory performance (Adjusted R-squared = 0.71), confirming substantial spatial heterogeneity in ANC determinants across Ghana. Conclusion: Adequate ANC utilization in Ghana remains low and geographically unequal. Maternal education, household wealth, and geographic accessibility significantly influence ANC utilization, with pronounced disparities concentrated within Northern Ghana. Spatially targeted maternal health interventions aimed at improving education, reducing socioeconomic inequalities, and enhancing healthcare accessibility are required to improve equitable ANC utilization across Ghana.

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.

Background Tanzanias Direct Health Facility Financing (DHFF) reform was introduced to strengthen primary health care through decentralized financing, autonomy, and accountability, but persistent weaknesses in monitoring and evaluation (M&E) data management and use continue to constrain implementation effectiveness, particularly in rural settings. Methods A convergent mixed-methods design was used to examine how M&E data management and use influence DHFF implementation effectiveness in an urban council (Kinondoni Municipal Council, KMC) and a rural council (Morogoro District Council, MDC), while also assessing the role of stakeholder perceptions of the DHFF M&E framework and contextual variation. Quantitative data were analyzed using descriptive statistics, relative importance indices, regression and ANOVA, while qualitative data from key informant interviews and focus group discussions were thematically analyzed and triangulated with quantitative results. Results Of 233 respondents analysed, 51.1% were from Morogoro District Council, 48.9% from Kinondoni Municipal Council, 51.2% worked in rural settings, 42.9% were from health centres, and 38.2% from dispensaries, providing an analytically useful spread across managerial and frontline contexts relevant to DHFF implementation. Descriptive statistics showed generally favourable perceptions across the five major constructs, with mean scores ranging from 3.09 for M&E capacity to 3.73 for urban-rural M&E practice context, while DHFF implementation effectiveness scored 3.71 overall. Data quality checks showed acceptable factor loadings above 0.4, reliability coefficients above 0.7, bivariate correlations of 0.34-0.76, and VIF values of 1.31-2.95, indicating that the dataset was screened, cleaned and analytically fit for regression and ANOVA modelling. In the aggregated model, the explanatory variables jointly accounted for about 52% of the variation in DHFF implementation effectiveness, with M&E data management and use, stakeholder perceptions of the DHFF M&E framework, and urban-rural context emerging as the most influential predictors. Qualitative testimonies clarified these patterns: one council respondent explained, "We have DHIS2... GoTHOMIS... FFARS... also PlanRep," while another facility respondent observed, "We only add up numbers for the monthly report--we dont really analyze what they mean," illustrating the contrast between data availability and meaningful local use. Conclusions DHFF implementation effectiveness in Tanzania depends substantially on robust M&E data management and use, supportive stakeholder perceptions of the M&E framework, and context-sensitive strategies that address persistent urban-rural inequities. Strengthening technical capacity, digital infrastructure, participatory governance and feedback systems is essential for sustaining DHFF gains and improving equitable service delivery.

Rational use of medicines (RUM) is a global health priority, yet significant challenges persist in low- and middle-income countries (LMICs), particularly around medicine access, affordability, and quality. While RUM studies often focus on prescribing practices, systemic barriers such as supply chain inefficiencies and pricing receive less attention. This study assessed three key health system components of RUM (availability, affordability, and quality of essential medicines) at two public primary health facilities in Ghana and examined patient care practices against WHO RUM standards. A quantitative, cross-sectional study was conducted at Kekele Polyclinic and Rawlings Circle Polyclinic in Accra. Retrospective data were extracted from prescription sheets, medicine tally cards, and ledgers to evaluate WHO Level II core drug use indicators. Fifteen essential medicines were selected based on the Ghana Essential Medicines List, Standard Treatment Guidelines, and municipal disease burden data. Exit interviews with 107 patients assessed dispensing and counselling practices, and structured observation covered storage conditions and pharmaceutical handling. Availability of key medicines fell significantly short of WHO targets, with Rawlings Circle meeting only 40% and Kekele 73.3% of the 100% benchmark. Treatment of malaria and pneumonia cost patients up to three times the national daily minimum wage, indicating poor affordability. The average number of medicines prescribed per encounter (3.2) exceeded the WHO recommended standard ([≤]2). Storage and handling infrastructure was inadequate, with both facilities falling short of recommended conservation standards. Gaps in medicine availability, affordability, and infrastructure undermine rational medicine use in primary healthcare. Strengthening procurement systems, enforcing storage protocols, and implementing financial protection mechanisms are essential for equitable and safe medicine use within Ghanas health system.

Indigenous and nomadic communities worldwide face disproportionate and persistent barriers to reproductive health services, including family planning and safe abortion. The Raute of Nepal -- one of the country's last nomadic hunter-gatherer groups represent a uniquely marginalized population for whom no prior population-level quantitative reproductive health data exist. This gap prevents health authorities and program implementers from designing evidence-based, culturally appropriate interventions for this community. This census-based cross-sectional study enrolled all 192 eligible married women of reproductive age in the Raute community of Parshuram Municipality, Dadeldhura district, Sudurpaschim Province, Nepal. Data were collected through structured, pre-tested, face-to-face interviews, and analyzed using descriptive statistics, chi-square tests, and binary logistic regression in IBM SPSS version 16. More than half of participants (53.6%) currently used family planning, with injectable contraceptives being the most common method (42.7%), followed by female sterilization (33.0%) and implants (24.3%). Condom use was negligible at 1.0%. Among non-users (46.4%), 97.7% cited lack of interest as the primary reason for non-use. Knowledge of safe abortion services was reported by 61.5% of women, yet only 8.3% had ever accessed such services, and awareness of Nepal's national safe abortion policy, which has been in effect since 2002 was critically low at 10.4%. In bivariate analysis, no socio-demographic or socioeconomic variable was significantly associated with family planning use. The sole significant independent predictor of current family planning utilization in the adjusted logistic regression model was non-utilization of safe abortion services (adjusted odds ratio = 4.275; 95% confidence interval: 1.145-15.954; p = 0.030), suggesting that contraceptive use and abortion service use represent alternative reproductive management strategies in this community. Younger age ([≤]30 years) and urban residence were significantly associated with safe abortion use in bivariate analysis but were attenuated after adjustment, reflecting limited statistical power arising from the small number of outcome events (n = 16). These findings reveal critical gaps in reproductive method diversity, safe abortion policy literacy, and male partner engagement. Community-based mobile outreach tailored to nomadic movement patterns, targeted legal literacy programs in the local language, and structured male involvement strategies are urgently required to improve reproductive health equity in this vulnerable indigenous population.

Exclusive breastfeeding (EBF) for the first six months is a critical protective practice, yet determinants beyond knowledge among young mothers in peri-urban sub-Saharan Africa remain insufficiently understood. This facility-based cross-sectional study assessed factors associated with EBF among 413 mothers aged 15-29 attending postnatal services at two public facilities in Lusaka, Zambia (Aug-Oct, 2025). Data from structured interviewer-administered questionnaires covered demographic, socioeconomic, cultural, mental health, peer support, and neonatal care knowledge factors. Logistic regression produced adjusted odds ratios (AOR) with 95% confidence intervals (CI). Although 99.5% reported receiving neonatal care education, 71.6% practiced EBF. Mothers aged 25-29 had lower odds of EBF than those aged 15-19 (AOR = 0.17, 95% CI: 0.03-0.99). Married mothers were more likely to exclusively breastfeed (AOR = 4.83, 95% CI: 1.59-14.65). Separated mothers also showed higher odds (AOR = 13.66, 95% CI: 1.89-98.71), although the wide confidence interval indicates substantial uncertainty and its based on a small subgroup (n=13). Formal employment was positively associated with EBF (AOR = 3.94, 95% CI: 1.12-13.85). Avoidance of specific traditional neonatal practices (AOR = 0.14, 95% CI: 0.04-0.53) and not consulting traditional healers (AOR = 0.06, 95% CI: 0.02-0.18) were also independently associated with EBF. Postnatal anxiety showed a strong inverse association (AOR = 0.14, 95% CI: 0.03-0.76). Parity, income, education, neonatal care awareness, and receipt of health education were not independently associated. These findings suggest that EBF in peri-urban Lusaka is shaped more by social, cultural, and psychological influences than knowledge alone, underscoring the need to integrate mental health screening, culturally sensitive counselling, and family-centred support within postnatal services to improve EBF uptake among young mothers in similar settings.

Background: Vasectomy remains one of the most underutilized contraceptive methods in Uganda, with a prevalence of only 0.2% despite its safety, effectiveness, and potential contribution to fertility reduction. Understanding the factors influencing awareness, knowledge, and attitudes toward vasectomy acceptance is crucial for developing effective promotion strategies in the Ugandan context. Methods: A cross-sectional study was conducted among 617 men aged 20-60 years, selected through simple random sampling of participants attending Kapchorwa General Hospital. Data were collected using a structured questionnaire. Results: Knowledge scores showed a negative association with age ({beta} = -0.044, p < 0.001) and varied significantly by marital status, with married participants demonstrating higher knowledge than single ({beta} = -0.624, p < 0.001) and widowed ({beta} = -0.950, p < 0.001) individuals. Counterintuitively, higher knowledge was associated with more negative attitudes ({beta} = -1.729, p < 0.001). Age demonstrated the strongest negative effect on attitudes ({beta} = -0.249, p < 0.001), and 99.9% of participants believed contraception is primarily women's responsibility. Behavioral data revealed that 75.0% desired more children, with 51.2% preferring a family size of 3-4 as the ideal. Conclusion: The study shows a disconnect between knowledge, attitudes, and behaviors regarding vasectomy. While general awareness is high, deep-seated misconceptions, cultural norms around masculinity and contraceptive responsibility, and fertility preferences present significant barriers to acceptance.

Rectal artesunate (RAS) is a pre-referral intervention recommended for children with suspected severe malaria in remote settings where injectable treatment is not readily available. Although clinical trials have demonstrated efficacy, less is known about the behavioural and health system factors influencing effectiveness under routine conditions. A convergent parallel mixed-methods design was used to assess implementation of Zambia's RAS intervention package across three districts: Serenje, Chama, and Mwinilunga. A retrospective case-tracking investigation of all 300 children with suspected severe malaria recorded by community health workers (CHWs) assigned to study facilities examined progression and attrition across the severe malaria care cascade. In-depth interviews and focus group discussions with caregivers, CHWs, and other stakeholders explored barriers and facilitators influencing progression. Among 300 enrolled children, early attrition occurred due to negative rapid diagnostic test results. Of 239 RDT-positive children, 218 (91.2%) received RAS. Referral completion was lower; among 261 children referred and followed up at health facilities, 209 (80.1%) were confirmed to have completed referral. Of 186 children diagnosed with severe malaria at the facility, 167 (89.8%) received both injectable artesunate and follow-on artemether-lumefantrine. Patterns of disengagement varied by district, with Serenje demonstrating the most consistent progression, Chama experiencing the largest drop-off at RAS administration, and Mwinilunga showing the lowest completion of follow-on treatment. Qualitative findings revealed strong community appreciation for RAS despite stockouts, alongside social and behavioural barriers, including gendered responsibilities, transport challenges, and confusion following symptom improvement, that discouraged referral completion. RAS can be a life-saving intervention when embedded within strong health systems and community structures. Zambia's experience underscores the need for comprehensive implementation strategies that extend beyond drug distribution to include sustained CHW training, reliable commodity supply, functional referral systems, and meaningful caregiver engagement.

The global occurrence of sexually transmitted infections (STIs) continues to rise, necessitating accurate diagnosis and treatment to curb their spread and associated complications. With the alarming increase in antimicrobial resistance (AMR) in Neisseria gonorrhoeae, effective STI management relies heavily on etiological diagnosis. The Tanzania National Standard for Medical Laboratories 2017 outlines recommended STI testing protocols based on facility levels, yet adherence to these guidelines and associated challenges remain poorly documented. This study describes the diagnostic capacity for different STIs in northern Tanzania. A cross-sectional study was conducted between May and July 2023, encompassing 14 laboratories across Moshi Municipal Council, Kilimanjaro region. The laboratories assessed were in five hospitals and nine health centres (HCs). Data regarding facility type and STI diagnostic capabilities were gathered through questionnaires administered during site visits and supplemented by observations. All five hospitals were equipped to conduct rapid diagnostic tests for HIV, syphilis, and wet preparation microscopy for Trichomonas vaginalis (TV). Only three hospitals had the capacity to perform culture and sensitivity testing using chocolate and blood agar medium, however none reported isolating Neisseria gonorrhoeae in the past year. Critical STI diagnostic tests including the Treponema pallidum particle agglutination assay (TPPA) and Treponema pallidum hemagglutination assay (TPHA) for the laboratory confirmation of syphilis, assays for Chlamydia trachomatis, Herpes Simplex virus -2, and Human papillomavirus (HPV) were absent across all five hospitals. Conversely, all health centers demonstrated proficiency in rapid treponemal tests for syphilis, together with rapid HIV test and TV testing, although one health center lacked the capacity for wet laboratory preparation for TV detection. Findings underscore a concerning lack of STI testing capacity within surveyed healthcare facilities, posing significant barriers to effective STI management and exacerbating the threat of AMR in Tanzania. In particular, the capacity for conventional microbiology culture was limited in most settings, severely compromising the ability to track and monitor AMR. Urgent investment in laboratory infrastructure and training is imperative to enhance STI diagnosis and treatment, ultimately curtailing transmission and mitigating the impact of AMR.

While significant progress has been made in perinatal outcomes over recent decades in low- and middle-income countries (LMICs), maternal and newborn quality improvement initiatives often fail to account for the spatial conditions in which they are implemented. Health systems are increasingly deploying evidence-based care models into built environments that are not optimally structured to meet the needs of its patient population. As the principal users, patients and health care workers can offer pragmatic insights about improving these structural designs. Our objective was to gather insights from patients, providers, and companions about how the physical design of their health facilities influenced their experience receiving or delivering perinatal care. We conducted a prospective observational study using a human-centred design (HCD) approach to analyse perceptions of the quality of perinatal care across two low resource settings: Ethiopia and Bangladesh. Using engagement and assessment tools, we conducted interviews, focus groups, facility walk-throughs, co-design workshops, and infrastructural assessments with patients, companions, providers, and Ministry of Health representatives. Descriptive statistics and thematic analysis were used to identify key learnings and develop recommendations. Across both countries, participants identified the need for facility layouts that better support privacy, mobility during labour, alternative birth positions, companion involvement, cultural and religious practices, sanitation, and provider visibility. Based on these insights, we developed six recommendations to better align health facility infrastructure with maternal and newborn care delivery needs. Our findings suggest that investments in health facility infrastructure may improve care experiences and help enable respectful, safe, and evidence-based maternal and newborn care. Alongside targeted spatial improvements, government authorities responsible for health facility planning should incorporate participatory design processes to ensure infrastructure reflects the needs of patients, companions, and providers and supports high-quality care delivery.

Background: Tuberculosis (TB) remains the leading infectious cause of death worldwide, with India accounting for nearly one-fourth of global TB cases. Ni-kshay, the countrys digital case-based TB notification platform is rich in data pertaining to the continuum of care of TB patients. This study aims to develop a standardized analytical approach to programmatic data to identify predictors of unfavourable treatment outcomes and mortality among adult drug-sensitive TB patients at the state level for Maharashtra during 2021 and 2022. Methods: Two separate analyses were undertaken comparing treatment success with: (1) unfavourable outcomes (death, treatment failure, loss to follow-up, regimen change, or not evaluated); and (2) mortality. Multivariate logistic regression was used to compute adjusted odds ratios (aOR) for key risk factors, adjusting for age, gender, and weight. Results: The final cohort included 323,124 cases for unfavourable outcome analysis and 315,579 cases for mortality analysis. Increasing age, male gender, lower body weight, known HIV and diabetes comorbidities, tobacco and alcohol consumption, and "unknown" status for behavioural risks and comorbidity status were significantly associated with increased odds of both unfavourable outcomes and mortality. Conclusions: This study highlights the utility of programmatic data in identifying high-risk TB patients and offers a reproducible analytic framework.

Background: Persons with disabilities, particularly deaf individuals, remain a largely overlooked population in sexual and reproductive health (SRH) programming globally, with this gap especially pronounced in low- and middle-income countries. Deafness imposes substantial barriers to accessing information and services that are routinely available to hearing peers, further exacerbated in the post-COVID-19 era. This study assessed deaf adolescents' knowledge of and access to SRH education and services in Wakiso District, Uganda, and explored systemic, institutional, community, and adolescent-level factors shaping access. Methods: A mixed-methods cross-sectional study was conducted at Wakiso Secondary School for the Deaf from July 2022 to January 2023. Quantitative data were collected from 70 consecutively sampled deaf adolescents aged 13-19 years using a structured questionnaire. Qualitative data were gathered through key informant interviews (KIIs) with four purposively selected stakeholders and a focus group discussion (FGD) with deaf adolescent students. Qualitative data were analysed thematically. Results: The mean participant age was 17 years (SD {+/-}1.8); 65.7% were female. A large majority (88.6%) had heard of SRH components, and 98.6% perceived a need for SRH education or services. However, 84.3% reported challenges accessing these services at least 85% of the time. No participant had ever received SRH education or services through a formal health facility. The FGD revealed that adolescents' conceptualisation of SRH was narrow, centred on body hygiene and HIV prevention, while service-seeking was reactive and symptom-driven. Five cross-cutting themes emerged from the KIIs and were reinforced by FGD findings: communication barriers; inadequate and inaccessible services; family and community isolation; existing platforms and positive practices; and negative provider attitudes and limited capacity. The school nurse emerged as the sole functional SRH access point for most participants. Conclusion: Despite high awareness and near-universal perceived need, deaf adolescents in Uganda face profound multilevel barriers to SRH access. Structural, psychosocial, and knowledge-related barriers interact to exclude this population from formal health services. Findings call for disability-responsive SRH integration into health systems, training of health workers in accessible communication, community capacity building, and co-design of SRH programmes with deaf adolescents.

Background In 2017, Zambia adopted surveillance as a core intervention towards achieving malaria elimination. Among the surveillance strategies is the malaria case investigation and response 1-3-7 (MCIR 1-3-7), which has been piloted in two low-incidence districts in the Southern Province since 2021. The study aimed to assess the implementation of MCIR 1-3-7 under programmatic conditions. It examined the timeliness, and completeness of the MCIR 1-3-7 activities, including the completeness of data entry in surveillance forms, and explored the experiences and perspectives of healthcare workers involved in the pilot. Methods A mixed-methods design was employed to assess the MCIR 1-3-7. Using a descriptive cross-sectional design, quantitative data were collected from 19 healthcare facilities in the two districts to assess the timeliness and completeness of MCIR 1-3-7. Additionally, 12 qualitative interviews were conducted with 29 healthcare workers from 11 of the 19 healthcare facilities. The interviews were voice-recorded and then transcribed manually. A codebook was developed using an iterative process to explore the facilitators and barriers encountered by healthcare workers in implementing the MCIR 1-3-7 intervention. All the visited facilities were purposively selected based on logistical convenience. Results This study retrospectively assessed 510 malaria cases that were diagnosed between January 2022 and June 2023, presenting at 19 health facilities: 283 cases in Chikankata and 227 in Mazabuka districts. A total of 278 cases (54.5%) were deemed to have been imported from outside the district, province, or country, while 45.5% (232/510) of the cases were classified as transmitted locally. Overall, 29.6% of case notification forms were found to be complete. Twelve interviews with 29 healthcare workers revealed a lack of transportation modalities as the main obstacle in executing the MCIR 1-3-7 intervention. The healthcare workers also indicated that monetary incentives, and supportive supervision would help them succeed in implementing this intervention. Conclusions The MCIR 1-3-7 has the potential to accelerate elimination in areas with low-transmission of malaria in Zambia. This study highlights opportunities to improve future implementation of the MCIR 1-3-7 intervention via strengthening supportive supervision, availing job aids, and ensuring access to malaria commodities as the intervention expands.

Food insecurity (also called, simply, FI) levels in sub-Saharan Africa are rising among its growing adolescent population, the world's fastest-growing teenage population. This study examines food insecurity and its role as a social determinant of poor mental health among African adolescents. The study utilised the Gallup World Poll data between 2014 and 2019, including adolescents aged 15 -19 (n=25,368). Poor mental health was measured using five validated responses about negative experiences. We employed a two-level binary logistic regression model to determine the associations between food insecurity and poor mental health. At the individual level, the primary explanatory variable, food insecurity, was measured using the FAO (2015) Food Insecurity Experience Scale (FIES). The odds of poor mental health exhibited a dose-response relationship with food insecurity severity, with mild (OR=1.70; 95% CI (1.57-1.84), moderate (OR=2.35; 95% CI (2.17-2.54) and severe food insecurity (OR=3.19; 95% CI (2.96-3.54) being associated with poorer mental health. Other assessed covariates showed that residing in a Francophone state increased the odds of poor mental health experiences, whereas positive experiences reduced the chances of poor mental health, as did residing in rural areas. There was no difference in the relationship between mental health and food insecurity across the two colonial origins. Food insecurity remains an important determinant of adolescent mental health in Francophone and Anglophone Africa. Investing in cost-effective agricultural and nutrition-sensitive interventions that boost food production could improve adolescent mental well-being while reducing long-term social and economic burdens on families and health systems in sub-Saharan Africa.

Adolescent girls and young women (AGYW) in Ethiopia face persistent barriers to accessing quality sexual and reproductive health (SRH) services, including limited information, stigma, and lack of youth-responsive care. This study aimed to compare the efficacy of digitized versus paper-based counselling tools within an intervention designed to address behavioral and structural barriers contributing to low contraceptive use among AGYW, by reframing contraception as a tool to achieve their life goals. The study employed a cross-sectional mixed-methods design, including client exit interviews with 302 AGYW, key informant interviews with 18 Health Extension Workers (HEWs), secondary analysis of service delivery data from DHIS2, and costing data from program records. Quantitative data were analyzed using descriptive statistics and chi-square tests. Qualitative data were thematically analyzed. Digital counselling was significantly associated with higher MII Plus scores (93% vs. 73.8%, p=0.001), client knowledge of side effects, and confidence in discussing and managing contraception. Clients rated paper-based tools as easier to understand, but digital tools enhanced comprehension, goal-setting, and integration of financial planning and reproductive health concepts. HEWs reported improved consistency in counselling, better referrals, and operational efficiencies with digital tools. Challenges included device glitches, limited connectivity, and variable digital literacy, often requiring concurrent use of paper and digital tools. This study shows that transitioning from paper-based to digital counselling tools improved service quality, client engagement, and informed contraceptive decision-making. Higher MII Plus scores and positive client experiences indicate more standardized, participatory, and respectful counselling. Providers reported operational benefits, including easier counselling and improved data management, though productivity gains were limited. Implementation challenges highlight the need for context-sensitive strategies, ongoing training, and supportive supervision during digital integration. Importantly, the findings suggest that digital tools can improve how services are delivered (quality and consistency), even when service volume remains stable.

Abstract Objective To Estimate cost of integrating HBV, HCV, and HIV screening at Antenatal using Time-Driven Activity Based Costing (TDACB) Approach; A providers perspective comparing Intervention and standard of care at lower health facilities in West Nile sub region, Uganda Methods Design The Time Driven Activity-Based Costing (TDABC) approach was used to capture resource use and costs associated with delivering integrated HBV, HCV, and HIV screening among pregnant women. This study compared screening uptake among study participants in the intervention, and control group respectively. Five lower health facilities in Koboko and Maracha districts respectively in West Nile region of Uganda. A total of 1,338 study participants wo were pregnant mothers in first ANC, first trimester at the selected 10 facilities were enrolled in this study. Data were abstracted, and also collected on; Personnel/staff time; facility space utilisation; and Medical and non-medical equipment. Total cost per patient visit=Staff time costs+Space cost Equipment cost. Outcome Measure was the estimated provider-perspective costs of delivering integrated screening for HBV, HCV and HIV, using Integrated Care Model by comparing intervention and control groups. Results Staff CCRs demonstrated considerable variability across cadres and facilities, with an overall mean of USD 0.492 per minute (Range: USD 0.167 - 1.318). Laboratory technicians exhibited the highest mean CCR at USD 0.767 per minute for personnel CCRs per patient visit. the mean lowest CPP visit was noted for HBV in the intervention arm (USD 11.43) while HIV test was the lowest in the control arm (USD 0.43). HCV test had the highest cost in the control arm (USD 0.52). The CPP visit for positive clients were generally higher than those that were negative. Equipment CCRs were minimal and highly consistent across facilities, with a mean of USD 0.00069 per minute ({+/-}0.0002). HIV/Syphilis combo was the costliest test kits at USD 3.14 per test kit followed by viral hepatitis C test kit and Hep B at USD 2.47 and USD 0.28 respectively. Facility space CCRs exhibited moderate variation across facilities, ranging from USD 0.01593 to USD 0.03474 per minute. Overall mean CCR for the space for delivering HBV, HCV or HIV testing was USD 0.0256 (0.0066). Conclusion; Overall, the integration of screening resulted in: Cost efficiencies where the same staff and space were used for multiple simultaneous tests, reduced marginal costs for HIV tests due to larger procurement volumes, and higher marginal cost additions for HBV and HCV due to pricier reagents.

Women shoulder the majority of water collection labor globally, yet how their water collection and water-related work experiences may change over time or by water source type remains insufficiently understood. We conducted a longitudinal, mixed-methods study in rural Kenya and Honduras to understand how women's experiences collecting water and performing water-related work varied between (a) two time points, (b) improved and unimproved water source types, and (c) water source location. Data were collected in 2023 and 2024 using interviews, observation, GPS-enabled watches, and scales to measure time and distance traveled, water weight and volume carried, and calories expended. 133 women participated in data collection (66 Kenya, 67 Honduras). We compared women's experience data by time point (2023 vs. 2024), source type (improved vs. unimproved), and source location (off-premises vs. on-premises) (t-test, Mann-Whitney U test). We also mapped participants' routes and activities to show which sources were visited, when, and for what activities. In Kenya, mean water collection time, distance, and caloric expenditure were significantly lower and water volume was significantly higher in 2024 when there were unexpected rains compared to 2023 when there was a persistent drought. When comparing source types during the 2023 drought, journeys to improved sources took significantly less time and energy and covered less distance than journeys to unimproved sources. These differences were not observed during the rainy conditions of 2024 when unimproved sources were closer and more accessible. In Honduras, water collection and water work burdens did not differ significantly by time point or source type. We found women with on-premises water access to still expend considerable time and caloric expenditure engaging in water work within their household compounds. Findings from Kenya suggest that water infrastructure improvements can reduce women's water collection burdens, though benefits may depend on and vary by season and source location. Findings from Honduras show that water labor does not end once water is in the household. Rather, substantial time and energy are expended carrying out water-related work even when sources are on premises, suggesting that efforts to assess water labor need to extend beyond collection alone. To meaningfully reduce burdens and ensure improved water sources are utilized during all seasons, initiatives need to consider source location, seasonal variability, and work beyond collection. Evaluations to assess infrastructure impacts on women's labor and well-being are needed and long overdue.

Purpose: The purpose of this study was to examine the barriers and facilitators experienced by non-U.S. born persons during the diagnosis and treatment of latent tuberculosis infection (LTBI) in primary care settings, including the impact of culturally and linguistically congruent care navigation. Design: 25 interviews with non-U.S. born patients, along with focus groups and surveys with 31 primary care team members and leadership, were conducted. Setting: The study was conducted within a network of Federally Qualified Health Center (FQHC) clinics. Participants: Participants were adult non-U.S. born patients with LTBI and FQHC care team members. A purposefully selected subsample of randomized participants was interviewed. Intervention: Care navigators followed participants randomized to receive care navigation after a positive test for tuberculosis (TB) infection and offered health navigation and education about the importance of TB screening and treatment. Method: Data collection was followed by thematic analysis guided by a critical ideological paradigm. Results: Culturally and linguistically congruent navigation emerged as central to potentially reducing barriers, fostering trust, and improving treatment continuity. Participants without navigation support reported confusion and disengagement from care, while those with culturally aligned navigators described clarity and comfort, with influence overall by intrinsic motivation, relational support, and culturally shaped beliefs about care. Conclusion: Care navigation that includes culturally and linguistically congruent navigators whenever possible may help increase LTBI treatment completion among non-U.S. born populations. Limitations of the study include the potential influence of cultural norms, power dynamics, and selection bias.

Between 2015 and 2025, Cambodia reported a 99.9% decline in the number of cases of malaria. To aid acceleration of elimination, the National Center for Parasitology, Entomology and Malaria Control (CNM) implemented a package of interventions known as the Last Mile (LM) elimination program. The aim of this study was to determine the impact of the LM program on case numbers and evaluate the coverage of interventions. LM was rolled out between November 2020 and December 2023 in villages reporting a locally acquired case of Plasmodium falciparum or mixed infection with P. falciparum and P. vivax and included combinations of targeted drug administration (TDA), intermittent preventative treatment for forest goers (IPTf), active fever screening (AFS), the recruitment of a village or mobile malaria worker (VMW/MMW) and the top-up of insecticide-treated bed nets (ITN) depending on the vulnerability and receptivity of the village. A total of 103 full and 82 partial villages in seven provinces were included. Two rounds of TDA were administered, with a total of 10,678 individuals (67.6%) given during the first round and 9,678 (62.3%) during the second round. Coverage varied by province with none meeting the recommended threshold of 80%. IPTf was implemented each month among 35% (n=35) of full LM villages and 56% (n=42) of partial LM villages. A total of 11.7% (n=12) of full LM villages implemented AFS consistently on a weekly basis. Controlled interrupted time series showed no statistically significant difference in the number of malaria cases before and after the implementation of LM. Although we were unable to prove a statistically significant impact of LM, likely due to the small number of cases prior to LM, it is important to add to the limited evidence-based for Accelerator Strategies in countries approaching the elimination of malaria. Furthermore, findings from the feasibility and impact of individual interventions were used to change policy at the national level.

Maternal health during pregnancy is critical for favorable birth outcomes and long-term wellbeing of both mothers and infants. Women in rural, malaria-endemic regions face unique biological and socioeconomic challenges that may increase the risk of adverse pregnancy outcomes (APOs). This study investigated the incidence and determinants of APOs among pregnant women attending antenatal care at Webuye sub-County Hospital in Western Kenya, a rural malaria-endemic setting. We conducted a retrospective cohort analysis utilizing previously collected data of 300 women enrolled during early pregnancy and followed through delivery. Maternal demographic, clinical, and infection-related factors were assessed, and associations with APOs were evaluated using chi-square tests and multivariable logistic regression. Maternal age and gestational age at enrollment were significantly associated with malaria history (P<0.001). Maternal BMI abnormality (124.5/1000 pregnancies), anemia (99.3/1000), fetal or neonatal death (81.3/1000), and preterm birth (43.8/1000) were observed (all P<0.001), suggesting a substantial burden. Younger mothers (<20 years) and older mothers (>35 years) were significantly more likely to develop anemia (P =0.026), and prior malaria infection further increased anemia risk (P =0.02). Abnormal urinalysis findings indicative of urinary tract infection were significantly associated with low birthweight (P =0.031). No significant associations were found between APOs and infant sex, parity, gravidity, or maternal ABO blood type. These findings highlight a substantial burden of APOs in this rural population, exceeding national and global estimates. Strengthening malaria prevention, nutritional support, urinary infection screening, and encouraging early antenatal care attendance are critical to improving maternal and neonatal outcomes. Targeted interventions for adolescent and older mothers, along with enhanced point-of-care diagnostics, may reduce preventable complications in similar resource-limited, malaria-endemic settings.