PLOS Global Public Health

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.

Community Health Promoters (CHPs) connect households with formal health services. In maternal nutrition, they provide counselling, follow-up and referrals. However, pregnant women experiencing poverty, food insecurity, and socio-cultural issues in resource-constrained settings may be unable to act on nutritional advice. While social protection could alleviate such socioeconomic issues, maternal nutrition and social safety nets operate in institutional silos, creating gaps that systematically exclude vulnerable mothers from essential relief. This qualitative study examines how CHPs navigate these gaps across three underserved Kenyan settings. We analysed semi-structured interviews of 12 purposively selected CHPs from a broader study of 75 stakeholders, using the Braun and Clarke thematic analysis framework. CHPs described recurrent gaps between household needs and resources available through formal maternal health, nutrition, and social protection systems. CHPs stepped in; extending follow-up care, brokering information, negotiating access, and spending personal resources with inadequate formal mechanisms. They experienced emotional and relational pressure from community mistrust, cultural limitations, administrative gatekeeping, digital-system failures, heavy workloads, and performance targets tied to unreliable pay. These insights reveal that CHPs act as invisible safety nets for fragmented services, taking on burdens that official programs overlook. We describe this as workforce cost absorption. Recognising this hidden contribution is important for workforce planning and for designing integrated maternal nutrition and social protection programs.

Children with developmental disabilities remain among the most underserved globally, with significant delays in early identification and access to care. In Kenya, limited capacity in the frontline workforce further disrupts the timely recognition and management of DDs. This study evaluated the impact of a multi-cadre capacity-strengthening training intervention on the knowledge and practice of healthcare workers (HCWs) and community support workers (CSWs) (including community health promoters, teachers, and caregivers of children with disabilities) to improve early identification, assessment, care, and referral of children with DDs in Kenya. We conducted a sequential mixed-methods study and collected data between 2023 and 2025. Quantitative measures included sociodemographic surveys for all participants (CSWs and HCWs) and pre- and post-knowledge assessments using a 15-item Mental Health Gap Action Programme Intervention Guide (mhGAP-IG)- based questionnaire administered only to HCWs participating in the training. Qualitative data were obtained through focus group discussions with CSWs (n=5, 58 participants) and HCWs (n=5, 48 participants) to explore training experiences, perceived skill gains, and implementation experiences. Quantitative analysis used descriptive statistics and Wilcoxon signed-rank tests, while qualitative data were analysed thematically. A total of 321 frontline providers were trained. Ninety-seven HCWs from 25 public health facilities received DDs training based on the WHO mhGAP-IG module, while 224 CSWs received a DD-focused co-designed training on community-based early identification and referral. Among HCWs with pre-post assessments (n=70), knowledge scores improved significantly (mean change: +0.86, p < 0.001), and the proportion scoring [&ge;]12 increased from 51% to 75%. Qualitative findings post-implementation indicated strengthened capacity in developmental milestone assessment, identification of DDs, and improved referral across the community, facility and other related sectors. Both cadres reported improved confidence in addressing myths and misconceptions related to DDs, coordinated teamwork, and improved caregiver engagement during assessment, and referrals driven by improved provider confidence and more supportive communication following the training. Increased workload, limited time for assessments, and limited resources were reported as challenges. This evaluation of a multi-cadre training model demonstrated improved knowledge, skills, and confidence among CSWs and HCWs, improving early identification, care, and referral practices for children with DDs. Sustaining these gains will require ongoing supervision, integration into routine workflows, strengthened referral systems, and continued investment in frontline workforce development within primary care settings.

Postpartum haemorrhage (PPH) remains the leading direct cause of maternal mortality globally, with a disproportionate burden in low- and middle-income countries. Although prophylactic uterotonics are effective, their impact is often constrained by health system limitations, including unreliable cold-chain storage affecting oxytocin quality. Heat-stable carbetocin (HSC) offers a thermally stable alternative; however, evidence on its large-scale integration into routine public health systems remains limited. We conducted a district-wide implementation evaluation of an HSC-based Active Management of the Third Stage of Labour (AMTSL) strengthening model across 32 public-sector delivery facilities in Dewas district, Madhya Pradesh, India. Implemented through a phased public-private partnership, the model integrated HSC into routine labour room practice alongside provider capacity building, strengthened documentation, and supportive supervision. A retrospective observational design was used to analyse routinely collected facility-level data from August 2022 to December 2024. Key outcomes included prophylactic uterotonic coverage, timeliness of administration, PPH incidence, and management practices. A total of 48,487 institutional deliveries were recorded during the study period. Documented prophylactic uterotonic coverage was nearly universal (99.9%), with administration within one minute of birth achieved in 99.4% of deliveries. Among deliveries with documented prophylactic uterotonic use, 41,658 (85.9%) received HSC and 6,812 (14.1%) received oxytocin. Overall, 275 PPH cases (0.57%) were documented. Among women receiving HSC prophylaxis, 200 (0.48%) developed PPH, compared with 75 (1.10%) among those receiving oxytocin. These findings are descriptive because prophylactic uterotonic allocation reflected routine programme implementation rather than random assignment. Uterine atony was the leading documented cause of PPH (176/275; 64.0%). Management included tranexamic acid in 239 (86.9%) cases, intravenous fluids in 273 (99.3%), blood transfusion in 36 (13.1%), and referral to a higher-level facility in 84 (30.5%) cases. HSC uptake was significantly higher in First Referral Units than non-FRU facilities (89.3% vs. 81.4%; p<0.001), as was administration within one minute among HSC recipients (100% vs. 98.7%; p<0.001). District-wide implementation of an HSC-based AMTSL strengthening model achieved high coverage and timely administration of prophylactic uterotonics across public-sector facilities operating at different levels of obstetric capacity. The findings provide real-world implementation evidence supporting the feasibility of integrating HSC into routine government maternity services using existing health-system infrastructure, supervision, and reporting mechanisms. Such embedded implementation approaches may offer a pragmatic pathway for strengthening PPH prevention in settings where reliable maintenance of the oxytocin cold chain remains challenging.

Background Patient-reported satisfaction is a core tracer of health-system responsiveness in Universal Health Coverage (UHC) monitoring, yet its determinants in rural Sierra Leone are poorly characterised. We quantified overall and domain-specific satisfaction and identified modifiable predictors across three rural border districts. Methods We conducted a cross-sectional, population-based household survey in October 2024 in Kailahun, Kambia and Pujehun districts, using a two-stage cluster design (chiefdoms sampled with probability proportional to size; households sampled at random). A validated 29-item instrument measured overall satisfaction and eight patient-experience domains on five-point Likert scales. The primary outcome was the five-level single-item overall satisfaction rating. We fitted a multivariable proportional-odds ordinal logistic regression, with 95% confidence intervals (CIs) obtained by a cluster bootstrap resampling the 20 chiefdom clusters. Robustness was assessed with binary and composite-outcome sensitivity models. Results Of 750 respondents, 679 (90.5%) had used a formal health facility in the previous 12 months and formed the analytic sample (510 [75.1%] female; mean age 28.2 years [SD 13.8]). The instrument showed high internal consistency (Cronbach = 0.87 for the five core domains). Overall, 375/679 (55.2%) were satisfied or very satisfied, ranging from 185/244 (75.8%) in Kambia to 110/224 (49.1%) in Kailahun and 80/211 (37.9%) in Pujehun ({chi}{superscript 2} = 70.8; p<0.001). In the adjusted model, staff attitude was the strongest predictor of higher satisfaction (adjusted odds ratio [AOR] 2.74, 95% CI 2.03-3.70; p<0.001 per one-point increase), followed by waiting-time satisfaction (AOR 1.89, 1.39-2.46) and medicine availability (AOR 1.43, 1.16-2.10). Travel-time category, facility type and sex were not independently associated. Large district disparities persisted after adjustment: relative to Kambia, the AOR for higher satisfaction was 0.27 (0.15-0.50) in Kailahun and 0.33 (0.20-0.66) in Pujehun. Adjusted probabilities of high satisfaction were 0.72, 0.48 and 0.43, respectively. Conclusions Respectful provider behaviour, shorter waits and reliable medicine supply, all amenable to district-level management, were the dominant and actionable drivers of patient satisfaction, whereas geographic distance was not. Persistent between-district gaps call for tailored quality-improvement in Kailahun and Pujehun. Institutionalising routine patient-experience measurement would strengthen accountability for people-centred care and support equitable progress towards UHC.

Despite Malawi's progress toward the UNAIDS 95-95-95 targets, facility-level rights-based challenges in HIV services persist, including stigma, discrimination and limited community participation. Community-led monitoring (CLM) has been promoted as an accountability mechanism, yet independent, facility-level evidence from urban settings remains scarce. This convergent parallel mixed-methods study assessed CLM at Ndirande and Limbe health facilities in Blantyre using a client survey (n=250), key informant interviews (n=12), and focus group discussions (three groups, 15 participants), totalling 277 participants. Chi-square tests (with Cramer's V) and binary logistic regression were used for the quantitative data; qualitative data were thematically analysed and triangulated. Analysis was guided by the rights-based approach to health and Arnstein's ladder of citizen participation. Awareness of CLM was moderate (56.0%) but participation was lower (40.2%), with involvement rated 2.78 out of 5, indicating consultative engagement. Awareness of CLM was the strongest and only robust predictor of participation (adjusted odds ratio {approx} 5.0, 95% confidence interval 2.4-10.6, p<0.001); a bivariate gender association did not survive adjustment. Notably, 41% of participants engaged in monitoring without recognising the term "CLM." CLM strengthened community-provider communication (68.5%) more than responsiveness (36.2%). Accountability mechanisms existed but functioned informally and were inconsistently documented. The two facilities did not differ significantly on any of nine indicators (all p>0.12). Barriers were structural: funding, transport, staff attitudes, fear of reprisal, and cultural norms. Urban CLM is a real but under-institutionalised accountability practice. The decisive lever is closing the awareness-action gap and formalising existing, unrecognised community monitoring through low-cost documentation, scheduled feedback, and independent, confidential complaint mechanisms. Findings are analytically transferable and offered as hypotheses for national piloting rather than as statistically generalisable conclusions.

Background: Sexual and reproductive health (SRH) is essential for youth development, particularly in Sub-Saharan Africa where youth represent a significant proportion of the population. Despite global efforts to promote Sexual and Reproductive Health rights, many disadvantaged youths face barriers to accessing comprehensive information and services. Youth-friendly sexual and reproductive health (YFSRH) services are central to improving youth health outcomes. Despite national standards in Ethiopia, implementation challenges persist. Healthcare workers (HCWs) are key actors in promoting and delivering YFSRH services Method: A concurrent mixed-methods design was employed among youth (18-24 years) and health care workers in Guraghe Zone, Southern Ethiopia. Quantitative data were collected using self-administered questionnaires, while qualitative data were gathered through key informant interviews. Quantitative data were analyzed using SPSS version 29, and qualitative data were analyzed thematically. Result: Although youths showed strong interest in Sexual and Reproductive Health information, help-seeking was often delayed due to discomfort, secrecy, social pressure, and limited foresight. Utilization of youth-friendly Sexual and Reproductive Health services was constrained by distance, inconvenient service hours, limited privacy and confidentiality, perceived judgmental provider attitudes, and financial barriers, reducing trust and repeat use. Conclusion: Improving youth Sexual and Reproductive Health requires integrated actions across education, families, and health services. Strengthening multi-channel Sexual and Reproductive Health education with life skills and psychosocial support, alongside decentralized, affordable, confidential, and non-judgmental youth-friendly services, is essential.

Background: Measles outbreaks in Uganda persist despite the availability of an effective vaccine, suggesting persistent immunity gaps and health system weaknesses. We conducted a multi-district outbreak causality analysis (OCA) to identify programmatic and health-system contributors to measles outbreaks and inform measles elimination programming. Methods: We conducted a cross-sectional mixed-methods OCA across 12 affected districts in Uganda (2025-2026), guided by the World Health Organization framework. We reviewed measles case investigation reports and triangulated findings with qualitative interviews with district health teams, health workers, surveillance and immunisation staff, community leaders, Village Health Teams, and caregivers. We deductively analysed data to identify causal pathways and contributing factors. Findings were organized into four prespecified analytical themes: immunization service delivery, caregiver access and demand, surveillance and case detection, and outbreak preparedness and response. Results: The 12 districts reported 1,302 cases, including 80 laboratory-confirmed cases and 10 suspected deaths (case-fatality rate: 0.77%); 46.5% (n=606) occurred among children aged 18-59 months. Most cases (65.3%) occurred in unvaccinated children, versus 1.0% in children with both measles-rubella (MR) doses. Across districts, incomplete MR2 implementation, irregular outreach, inconsistent fixed-site vaccination, weak follow-up of children who missed vaccination, and transport and distance barriers contributed to persistent immunity gaps. Low clinical suspicion, limited engagement of Village Health Teams, laboratory and surveillance-information bottlenecks, absence of pre-positioned response plans, delayed response activation, and inadequate isolation capacity further limited early detection and control. Conclusion: Measles outbreaks were driven primarily by missed vaccination, especially incomplete delivery of the two-dose MR schedule, compounded by access barriers, delayed case detection, and limited outbreak preparedness. Strengthening routine MR1 and MR2 delivery, targeted catch-up vaccination, community-linked surveillance, and pre-positioned district response plans with clear activation triggers will be critical to closing immunity gaps and accelerating measles elimination in Uganda.

Postnatal care (PNC) is essential for reducing preventable maternal and neonatal deaths, but its utilization remain low across sub-Saharan Africa. Intimate Partner Violence (IPV) may be an under-recognized barrier to PNC utilization, particularly in Tanzania, where direct evidence shows that IPV is linked to limited utilization of PNC. Therefore, this study assessed the association between IPV and PNC utilization within 42 days postpartum among women in Tanzania. This study conducted a secondary analysis of the 2022 Tanzania Demographic and Health Survey (TDHS), a nationally representative cross-sectional survey. The analysis included 2,674 women aged 15-49 years who had a live birth in the five years preceding the survey and were selected for the domestic violence module. IPV (any, physical, sexual, and emotional) was the primary exposure, and PNC utilization within 42 days postpartum was the outcome. Modified Poisson regression was used to estimate crude and adjusted prevalence ratios (cPR/aPR) with 95% confidence intervals (CI) because the prevalence of the outcome was common. The prevalence of PNC utilization within 42 days postpartum was 42.0%, and the overall prevalence of IPV was 33.6% (physical 26.1%, emotional 21.8% and sexual 7.3%). Women who experienced any IPV had 16% lower PNC utilization than those who did not (aPR=0.84; 95% CI: 0.74-0.96). Physical IPV (16%, aPR=0.84; 95% CI: 0.73-0.96) and sexual IPV (25%, aPR=0.75; 95% CI: 0.57-0.98) were significantly associated with lower PNC utilization, while emotional IPV was not. Maternal education, partners age, travel time to the nearest health facility, and media exposure were also other covariates associated with PNC utilization. Intimate partner violence is associated with low utilization of PNC within 42 days postpartum in Tanzania. Integrating IPV screening and survivor support into postnatal care services, alongside addressing structural barriers to access, may improve postpartum care coverage and maternal-neonatal outcomes.

Background: South Africa adopted evidence-based antenatal care (ANC) frameworks to improve maternal health outcomes. However, the maternal mortality ratio remains above Sustainable Development Goal target 3.1 and routine data indicate declining ANC first-visit coverage. Aim: This study sought to explore implementation gaps, barriers and facilitators in the delivery and uptake of ANC. Setting: Ugu and uMzinyathi districts in KwaZulu-Natal, and Capricorn and Waterberg districts in Limpopo, South Africa. Methods: A qualitative descriptive design was utilised. Semi-structured interviews were conducted with 70 purposively sampled participants, comprising 30 health system providers and 40 service users. Data were analysed thematically using NVivo. Results: Health system providers attributed declining ANC coverage to fertility decline rather than reduced access alone. Providers identified mentorship, community outreach and enhanced screening as key strengths. Implementation was constrained by staffing and equipment shortages. While service users recognised the benefits of ANC, they reported that long waiting times, negative provider attitudes and limited privacy during consultations undermined the quality of service delivery. Providers and service users linked delayed ANC initiation to financial constraints, stigma and pregnancy concealment. Conclusion: Improving early ANC initiation requires an approach that addresses health system, socioeconomic and cultural barriers. Concerns about declining fertility as a driver of declining coverage warrant further investigation into coverage calculation methodologies. Contribution: The study provides insights into the interconnected factors influencing ANC delivery and uptake in primary healthcare settings. It further highlights the need to consider changing fertility patterns when interpreting ANC coverage. The findings can inform targeted interventions and strengthen maternal health planning, monitoring, and service delivery.

Background: Early childhood caries remains one of the most prevalent and among the most neglected chronic diseases of childhood in low- and middle-income countries, and cariogenic feeding practices introduced in infancy are a principal, modifiable driver. National, spatially explicit estimates of such practices are lacking for Ghana, constraining geographically targeted interventions. Methods: We analyzed 3,007 children aged 6-23 months from the 2022 Ghana Demographic and Health Survey, linked to 600 georeferenced clusters. A composite cariogenic feeding index was built from bottle feeding, sugar-sweetened beverage consumption, and other cariogenic foods; a child was classified as exposed if any one component was present. Complex survey design was handled by Taylor series linearization. Determinants were examined using survey-weighted and two-level random-intercept logistic regression, and spatial clustering was assessed using global and local Morans I and Getis-Ord Gi* from a five-nearest-neighbour weights matrix. Results: Weighted national prevalence was 52.97% (95% confidence interval 50.19-55.75), ranging from 27.95% in the Savannah Region to 73.55% in the Western Region and patterned by residence (63.07% urban versus 43.90% rural) and wealth (32.87% in the poorest versus 74.45% in the richest quintile). Wealth and maternal education were the strongest multilevel correlates: the richest households showed roughly four times the odds of exposure relative to the poorest (adjusted odds ratio 4.00), and higher maternal education showed roughly two and a half times the odds relative to no education (adjusted odds ratio 2.51). The intraclass correlation coefficient was 0.219. Global Morans I was 0.231 (z = 9.73, p < 0.001), confirming significant positive spatial autocorrelation, with high-high clusters along the southern coastal belt (Western, Central, Greater Accra, Volta) and low-low clusters in the middle and northern belts (Bono, Ahafo, Upper West, Northern, North East). Conclusions: Cariogenic feeding among Ghanaian infants is common, socioeconomically patterned, and spatially clustered rather than random. Oral health promotion through routine growth monitoring and immunization platforms should be prioritized in the high-high clusters, while closing socioeconomic gradients would yield collateral benefit nationally. Trial registration: Not applicable. Keywords: cariogenic feeding, early childhood caries, infant and young child feeding, spatial analysis, Morans I, Getis-Ord Gi*, multilevel modeling, Ghana. Demographic and Health Survey; oral health epidemiology

Background: Community case management has been scaled up nationally in Zambia over the last decade. However, there is limited evidence on how this nationwide implementation has affected febrile patients' access to malaria diagnosis and treatment in Zambia. Methodology: This study analyzed four rounds of Malaria Indicator Survey (MIS) data (2012-2021) to evaluate: 1) proportion of all-ages individuals with fever who sought treatment from a formal provider, 2) proportion of individuals going to CHWs over time, among those who sought treatment at a formal provider, 3) time duration between fever onset and treatment seeking at a formal provider, and 4) proportion of children <5 with malaria that received Artemether-Lumefantrine (AL) treatment. Mixed-effect logit models were employed to examine determinants of treatment-seeking behavior and factors affecting AL receipt among children <5 with malaria cases. Results: The proportion of febrile patients seeking treatment remained below 60% throughout 2012-2021, and AL receipt among children with malaria cases consistently stayed below 50%. The mean interval between fever onset and initial treatment-seeking encounter decreased from 2.42 days in 2012 to 1.71 days in 2021. Among formal care seekers, CHW utilization increased from 1.5% in 2012 to 10.0% in 2018 before declining to 3.2% in 2021. Longer walking time to the nearest health facility was associated with lower odds of treatment seeking, whereas CHW density was not associated with treatment seeking or AL receipt. Children who did not went to formal providers had lower odds of AL receipt than those who sought treatment from CHWs. Conclusion: Despite nationwide CCM scale-up over the last decade, significant barriers persist in malaria patients' access to diagnosis and treatment in Zambia. Our results indicate that while CCM coverage should be maintained and further expanded, additional complementary interventions are also needed to overcome remaining access barriers.

ABSTRACT Background: Rapidly urbanising complex ecosystems present several challenges to the organisation, availability, and accessibility of healthcare services. This study describes the availability and distribution of health facilities offering services, with a focus on maternal and newborn health services in the seven health districts of Grand Conakry, Methods: This study using primary data from a census of health facilities (June 2025). Finally, healthcare landscape was drawn up using the GPS coordinates collected, based on the boundaries of the seven including health districts. The census started with an existing list of 459 facilities and snowball sampling was used to identify facilities that were not initially on the list. We collected information on basic facility characteristics and GPS coordinates. Results: A total of 795 health facilities exist in Grand Conakry, with 564 facilities which were not on the initial lists, 104 were either closed, out of service, or refused to participate. The questionnaire was completed by 691 health facilities. The private sector dominated the landscape and was mainly concentrated in the Ratoma and Matoto health districts; with most facilities (63%) not reporting to the national health information system, in contrast to those in public sector (85.7%). 332/691 facilities reported providing childbirth care, and 132 of them (40%) offered caesarean section, while 87 (26%) offered blood transfusions. Conclusion: Despite the high number of facilities, geographic imbalances in distribution exist. Equitable access to healthcare in rapidly urbanising Grand Conakry requires strengthening urban health planning and public-private collaboration regarding ongoing rapid urbanisation in Grand Conakry.

Background There has been a proliferation of new person-centered and human rights-based contraception measures in recent years, though their application in research remains limited. Improved measures offer an opportunity to examine how contraceptive decision-making agency relates to individuals ability to act in line with their contraceptive preferences. We sought to assess the association between contraceptive agency and subsequent Preference-aligned Fertility Management (PFM) over 12 months in a cohort of women in rural Uganda. Methods We analyzed data from a prospective cohort study conducted in five largely rural Ugandan districts from 2022 to 2024. Data were collected at baseline, 6 and 12 months from a convenience sample of women who were new users of contraception or not using contraception. We used mixed-effects logistic regression models to examine the association between baseline Agency in Contraceptive Decisions Scale overall and subscale scores and future PFM Index scores at 6 and 12 months, assessing whether associations varied over time using interaction terms for follow-up time point. We used interactions between agency scores and follow-up visit to assess whether associations differed between the 6- and 12-month visits. We assessed effect modification by age group and baseline contraceptive method category using three-way interaction terms and predicted probabilities. Results The analytic sample comprised 2,227 women. The percentage of women practicing PFM increased from 85.7% at baseline to 93.3% at 12 months. A one-unit increase in Agency in Contraceptive Decisions Scale score was associated with higher odds of subsequent PFM (aOR: 1.68, 95% CI: 1.10-2.54). Subscales 3 (knowledge aligned with preferences) and 4 (control over use or non-use) of the Agency in Contraceptive Decisions Scale were significantly associated with future PFM (aOR: 1.31, 95% CI: 1.04-1.66 and aOR: 1.27, 95% CI: 1.06-1.51, respectively). The association between overall contraceptive agency and PFM did not differ between the 6- and 12-month visits. Three-way interaction tests suggested that the associations between the overall Agency in Contraceptive Decisions Scale score and the PFM outcomes varied jointly by age group and baseline contraceptive method category: overall PFM Index (p<0.001), PFM1 (p=0.011), and PFM2 (p<0.001). Conclusion Our findings suggest that higher levels of contraceptive agency may help women act in line with their contraceptive preferences. Increasing womens knowledge and control over contraceptive use may be particularly essential for preferred contraceptive use. The findings also suggest that the association between contraceptive agency and PFM may vary by womens age group and the method of choice, though further exploration is necessary to examine this influence.

Background: Adolescent and youth substance use is an important public health concern in rapidly urbanizing low- and middle-income countries; however, evidence on how social networks and community substance-use environments jointly shape recent use remains limited, particularly in African megacities. Methods: We conducted a cross-sectional, community-based, convergent mixed-methods study of adolescents and young adults aged 12-24 years in the Yaba Local Council Development Area, Lagos, Nigeria. Quantitative data were collected using a structured questionnaire adapted from established, international survey instruments. The primary outcome was self-reported substance use within the past 30 days. Key exposures included a Social Exposure Score incorporating substance use among friends and family members, membership in a substance-using peer group, and perceived easy community availability of substances. Multivariable logistic regression was used to examine factors associated with past-30-day substance use, followed by an interaction model to assess whether perceived availability modified the association between social exposure and recent use. Open-ended responses on community approaches to reducing substance use were thematically analyzed and integrated with quantitative findings through a joint display. Results: Among 285 participants (mean age 18.9 years; 52.6% male), 66 (23.2%) reported past-30-day substance use and 84 (29.5%) reported lifetime polysubstance use. A Higher Social Exposure Score was associated with increased odds of past-30-day substance use (adjusted odds ratio [aOR]=2.18; 95% CI: 1.59-2.99; p<0.001), while perceived easy community availability was independently associated with recent use (aOR=3.22; 95% CI: 1.42-7.30; p=0.005). The interaction between social exposure and perceived availability was statistically significant (aOR=1.51; 95% CI: 1.01-2.27; p=0.047), indicating that the association between social exposure and recent use varied according to perceived availability. The marginal effect of a one-unit increase in the Social Exposure Score on the predicted probability of past-30-day use was +0.08 when easy availability was not reported and +0.18 when it was reported. Among lifetime substance users, past-30-day use was more common among polysubstance users than single substance users (50.0% vs. 22.0%; chi-square[1]=16.51; p<0.001). Qualitative findings identified supply side law enforcement (43.5%), population awareness campaigns (24.6%), regulatory and legislative control (16.1%), enhanced parental supervision (14.7%), and economic and youth empowerment (13.3%) as prominent community-proposed solutions. Integrated analysis demonstrated complementarity between the quantitatively identified social and environmental correlates and community-proposed intervention priorities. Conclusions: In this urban Nigerian setting, past-30-day substance use was independently associated with social exposure and perceived community availability, with evidence that the association between social exposure and recent use varied according to perceived availability. The findings support multilevel prevention approaches that address environmental access alongside peer, family, community, and broader socioeconomic influences.

Background. Nigeria carries one of the world's largest burdens of neonatal death and remains far from the Sustainable Development Goal target. Whether health financing and macroeconomic instability are associated with newborn survival has rarely been examined for neonatal mortality specifically. Methods. We conducted an ecological time-series analysis of national annual data, covering 1990-2024 for macroeconomic models (n = 35) and 2000-2023 for health-financing models (n = 24), the periods for which published data exist; no values were imputed. Neonatal mortality came from the UN Inter-agency Group for Child Mortality Estimation 2025 round with 90% uncertainty intervals, and other series from the World Development Indicators. The primary model regressed log neonatal mortality on government health expenditure per capita (purchasing power parity), out-of-pocket share and currency instability, with a linear trend, a post-break trend spline and Newey-West standard errors; first differences without trend terms were the main sensitivity analysis. The break was located by segmented regression; currency instability was tested under four constructions. Results. The decline broke around 2010, the trend moving from -0.74 to +0.14 deaths per 1,000 annually (F = 145.4, p < 0.001). The subsequent rise fell within estimation uncertainty (2012: 37.6, 90% interval 33.9-41.5; 2022: 39.3, 33.4-46.4), supporting stagnation rather than reversal; Demographic and Health Surveys concur, reporting 42 per 1,000 for the five years preceding the 1990 survey and 41 preceding the 2024 survey. Government health expenditure per capita was inversely associated with neonatal mortality (-0.040, 95% CI -0.051 to -0.029, p < 0.001; first differences -0.016, p = 0.033) and was the only expenditure measure surviving both specifications; share-of-GDP measures did not (p = 0.196 and 0.889) and correlated positively in raw terms. Currency instability showed no association under any construction (p = 0.65-0.83). Public expenditure per capita moved non-monotonically, peaking in 2005, falling by 2010 and recovering by 2023 to a level still below the 2005 peak. Conclusions. Neonatal mortality in Nigeria is ecologically associated with public health expenditure per capita, but not with commonly used share-based measures, nor with currency instability. Rising public spending accompanied stalled progress, directing attention toward how health resources are converted into services. Annual modelled mortality estimates could not support year-to-year inference, a limitation relevant to comparable studies

This study investigated the prevalence of physical and non-physical disciplining methods used by mothers of young children in Rwanda and examined their association with child stunting. The role of disciplining practices in child linear growth remains largely overlooked in interventions across low- and middle-income countries, including Rwanda, despite growing attention to psychosocial factors. This cross-sectional study, conducted between November 15 and December 31, 2021, included 601 mother-child pairs selected through systematic random sampling. Child disciplining practices were assessed using the UNICEF Multiple Indicator Cluster Surveys questionnaire. Stunting, defined as chronic undernutrition during critical growth periods that leads to impaired growth and development, was measured using WHO standards (height-for-age Z score <-2 SD). Child disciplining methods were categorized into two types: physical (e.g., hitting or spanking) and non-physical (e.g., shouting or yelling). Multivariable logistic regression assessed the association between disciplining methods and stunting, adjusting for socioeconomic factors, IPV, and social support. The study included predominantly low-income, married mothers, >30 years old, with low educational attainment, and working in unskilled jobs as defined by the national occupational classification. Physical disciplining methods were used by 76.5% (n=449) of mothers, while 38.3% (n=225) used non-physical methods. Younger mothers used physical methods more than older ones (p=0.002). Mothers exposed to physical and sexual intimate partner violence (IPV) had a higher likelihood of using physical methods (p<0.001 and p=0.036, respectively). Exposure to psychological IPV was significantly associated with both non-physical (p=0.025) and physical methods (p=0.004). Of the 601 children, 27.1% (n=163) were stunted; 88.3% (n=144) were >1 year old. The odds of stunting were higher in older children subjected to both physical and non-physical methods (odds ratio [OR], 1.92; 95% confidence interval, 1.08-3.41). Using both disciplining methods was most strongly associated with stunting, with adjusted ORs ranging from 1.96 to 2.04.Findings suggest disciplining methods may contribute to the risk of stunting, especially in older children in Rwanda. These findings highlight the urgent need for positive parenting education, child abuse prevention, and the integration of child protection screening into routine healthcare services in Rwanda.

Background: Tuberculosis (TB) remains a critical public health challenge in Pakistan. The SPOT-TB trial evaluated MATCH-AI; an AI tool designed to geographically target active case finding (ACF) by identifying sites for screening TB. Qualitative study was conducted to examine field team and stakeholder experiences to understand the human, organizational, and contextual factors effecting implementation. Methods: Five sub-recipients (SRs) were randomly selected; two districts per SR based on certain selection criteria. Thematic analysis was conducted on thirty In-Depth Interviews (IDIs) and two Focus Group Discussions (FGDs), guided by the Socio-Technical Systems (STS) framework. Findings: Themes included (1) MATCH-AI as a useful tool, (2) operational and contextual challenges, (3) challenges of the staff, (4) organizational readiness, and (5) stakeholder engagement across hierarchy. The staff valued MATCH-AI for reducing bias and external pressure, and it identified TB cases in previously overlooked areas. Local knowledge of staff was crucial as the AI didnot account for operational barriers and contextual issues in certain areas. Weak infrastructure, and inconsistent stakeholder engagement, the system lacked the readiness needed for a new technology to make optimal impact. Understanding of how MATCH-AI functioned varied across hierarchical levels diminishing the sense of ownership among field staff. Interpretation: MATCH-AI holds genuine potential to systematize TB screening and reduce selection bias. Yet it cannot replace the contextual intelligence of field staff like knowledge of community trust, gender norms, and security realities. Effective implementation demands reliable infrastructure, meaningful stakeholder engagement, and field staff orientation. AI integration succeeds only when technical solutions align with human and organizational readiness.

Given high mortality rates and low access to health facilities, the International Rescue Committee introduced Community-based Maternal and Newborn Care (CBMNC) Programs in rural areas of Somalia and South Sudan. The programs included distribution of evidence-based commodities for maternal or newborn health as well as health counseling during home visits, delivered by low-literate community health workers. The pre-post study used population-representative cross-sectional surveys among women who delivered in the twelve months preceding the program, conducted before and 18-24 months after the CBMNC program introduction (n=338 baseline, n=340 endline in South Sudan, n=351 baseline, n=302 endline in Somalia). The study employed rigorous statistical methods to adjust for potential confounding factors and strengthen inference regarding changes associated with the program despite the non-experimental study design. Program enrollment was high (79.1% in South Sudan, 87.7% in Somalia). In South Sudan, Skin-to-skin care, clean cord care, early initiation of breastfeeding, and use of Fansidar were statistically significantly higher among those who received four or more visits, but marginally significantly lower uptake of institutional delivery and SBA. For Somalia, skin-to-skin care showed statistically significant positive change among those who received four or more visits, with early initiation of breastfeeding, no prelacteal feeding, and making four or more facility-based ANC visits demonstrated marginally significant higher uptake. The positive change in uptake of evidence-based community-based MNH services showed promise in Somalia, but mixed results in South Sudan. This shows promise for change in service uptake even in a relatively short duration of program implementation, but also underscores that community health interventions do not operate in isolation and that parallel investment in facility strengthening and consistent messaging on the complementary roles of community and facility-based care remains essential.

Background Alcohol is a leading modifiable risk factor for non-communicable disease. Zambia's National Alcohol Policy and the World Health Organization's target of a 10% relative reduction in the harmful use of alcohol both require that the trend be monitored. Alcohol items appear in four rounds of the Zambia Demographic and Health Survey (ZDHS), and those rounds are widely treated as a trend series, although whether they are one has never been tested. Methods Secondary analysis of ZDHS 2007, 2013-14, 2018 and 2024 (women aged 15-49, men aged 15-59). A direct current-use item is available in three rounds, with three different instruments for men and two for women. Four identification strategies were applied in ascending order of assumption: nesting bounds, which exploit the fact that a seven-day window falls within a thirty-day window and that within undated current status; restriction to the fieldwork months common to both rounds; a lifetime-use analogue available in 2024; and an instrument-constant partner-report series available in all four rounds, validated by linking each woman to her co-resident husband. Estimation throughout was design-based. Results The conventional series suggests a fall in current drinking among men from 42.0% (95% CI 39.9-44.1) in 2007 to 28.2% (95% CI 27.0-29.3) in 2024, and among women from 11.1% (95% CI 9.9-12.4) to 8.8% (95% CI 8.0-9.6). Neither change is sign-identified. Placed on a common thirty-day basis with matched fieldwork months, the 2013-14 to 2024 change lies between -7.6 and +1.2 percentage points for men and between -0.2 and +3.7 for women. The instrument-constant proxy fell from 53.7% in 2007 to 37.7% in 2018, then plateaued at 37.0% in 2024; a constant-decline model is rejected (Q = 15.9, 2 df, p = 0.0003). Sensitivity of the proxy against husbands' own reports fell from 86.0% to 66.8%. The 2024 cross-section is unaffected and is reported in full. Conclusions These data do not establish the apparent national decline in alcohol use. Differences in reported prevalence across ZDHS rounds substantially reflect instrument change, reference-period shift, fieldwork seasonality and decay in proxy reporting. On present evidence Zambia cannot monitor its alcohol commitments from national survey data. Trend monitoring would require a consistent alcohol module restored to the questionnaire, an occasion-based heavy-drinking item, and the reporting of fieldwork month.