PLOS Global Public Health

Family planning (FP) self-care is a strategic pillar for advancing Universal Health Coverage (UHC) and mitigating health workforce shortages. However, a significant disconnect persists between global normative frameworks and local implementation realities. This study examines the local meanings, perceptions, and experiences of FP self-care in Niger to inform contextualized scale-up of self-care interventions. We employed a sequential mixed-methods design in the Niamey (urban) and Zinder (rural) regions of Niger. A quantitative household survey was conducted with 510 women and 357 men to assess fertility awareness, method preferences, and information-seeking behaviors. This was complemented by qualitative in-depth interviews with 36 women, 18 men, 12 healthcare providers, and 15 community leaders. Quantitative data were analyzed using descriptive statistics, while qualitative transcripts underwent iterative thematic analysis mapped to global self-care frameworks. "Self-care" was locally reconstructed not as autonomy. While defined by all participants as hygiene, it was uniquely reconstructed by men and community leaders as economic provision. A distinct "medicalization paradox" emerged: women defined self-care as the agency to seek clinical dependence, prioritizing facility-based providers over community sources (e.g., 58.1% vs. 12.1% for oral contraceptives) to mitigate fears regarding product quality and side effects. Conversely, men favored Community Health Workers (34.3%) driven by logistical efficiency and economic motivations. Physiological knowledge was low; only 11.8% of women correctly identified the fertile window, with misconceptions reinforced by fatalistic narratives propagated by community gatekeepers. Furthermore, providers expressed strong skepticism regarding user competence, fearing "chaos" without medical supervision. Implementing FP self-care in Niger requires shifting from a "product-first" to a "values-first" approach. Strategies must be gender-stratified: leveraging "medicalized validation" to address womens safety concerns while utilizing community-based channels to meet mens efficiency needs. Ultimately, self-care should be framed not as independence from the health system, but as an empowered partnership with it.

Background Kenya's facility autonomy reforms are intended to improve health system equity, efficiency, and responsiveness to community needs by shifting decision-making to the frontline. This study evaluates the implementation process and experience of facility autonomy reforms in Kenya post devolution of health services. Methods We conducted a concurrent mixed methods study of counties (n=6) in Kenya, selected based on their implementation of facility financial autonomy reforms as of June 2023. For the quantitative aspect, we assessed 141 randomly selected public health facilities across all levels of service provision. We then did a descriptive analysis to measure the level and perceptions of autonomy. For the qualitative aspect, we reviewed documents and interviewed purposively selected stakeholders (n=71) involved with autonomy reforms at national, county, and facility levels, cutting across health, finance, legal, political and community actors. We analyzed the transcripts thematically using NVivo 12. Results The emergence of the FIF reforms in Kenya was driven by the convergence of political, technical, and public needs. While counties have developed their own facility autonomy laws to fit local contexts, some provisions are not fully aligned with the national legislation. Some aspects of both the county specific and national laws are not implemented. These include allocation of matching funds from the exchequer and reimbursing facilities for expenses incurred from providing care to indigents and for unpaid bills. The implementation of autonomy also varies, with some aspects partially or not implemented. Autonomy reforms have contributed to improved decision-making, staff satisfaction, availability of essential medicines, and facility maintenance. However, challenges have emerged, including the failure of counties to provide matching funds, which disproportionately affects lower-level facilities that do not generate revenue. Additionally, the absence of waiver repayment mechanisms has led to inequities, and the risk of increased service costs threatens financial accessibility for marginalized populations. Conclusion Facility autonomy reforms support people-centered decision-making and aligns with PHC principles. While these reforms hold promise for improving service delivery and access, their success depends on complementary measures such as sustainable funding mechanisms and stronger protections for vulnerable populations.

Background: Primary health centres in tribal areas of India collect large volumes of maternal and child health (MCH) data through routine health information systems, yet this data rarely informs local clinical or programmatic decision-making. The gap between data collection and data use in tribal settings, where health disparities are most acute, remains poorly documented from the perspective of frontline decision-makers. Methods: We conducted a qualitative study embedded in the diagnostic phase of an Action Research project in three tribal primary health centres under the Integrated Tribal Development Agency (ITDA), Rampachodavaram, Alluri Sitharama Raju District, Andhra Pradesh. Eight key informant interviews were conducted with medical officers (n=5), a district programme officer (n=1), and data entry operators (n=2). Participant observation at weekly convergence meetings and document review of registers and reports supplemented interview data. Transcripts were independently coded by two analysts using Braun and Clarke's reflexive thematic analysis. Findings: Three interconnected domains emerged. First, local MCH decision-makers needed individual-level, geographically disaggregated, prospective information to plan outreach and follow-up, but formal systems provided only retrospective aggregate statistics. Second, three structural constraints prevented formal systems from meeting these needs: digital infrastructure designed for connected settings, upward data flows with no local feedback, and a single-point- of-access governance vulnerability where one data entry operator's mobile phone controlled portal authentication for all facilities in the jurisdiction. Third, decision-makers constructed four complementary information practices (WhatsApp networks, self-built tracking tools, cross-sectoral convergence meetings, and reliance on intermediary-consolidated reports) to bridge the gap. Interpretation: Complementary information practices are expressions of local ingenuity under structural constraint, not system failures. MCH digital health reform should map and strengthen these practices rather than bypass them. Authentication governance in low- connectivity tribal settings requires urgent policy attention

Introduction Access to safe water, sanitation, and hygiene (WASH) in schools is critical for child health, learning, and gender equity. In Kenya, the Kenya School Health Policy and the Basic Education Act outline standards for school WASH; however, implementation remains uneven due to inadequate infrastructure, weak inter-sectoral coordination, and limited financing. This study aimed to identify priority components for strengthening school WASH implementation and generate policy-relevant recommendations based on expert consensus in Uasin Gishu County, Kenya. Methods and Results A Delphi technique consisting of two iterative rounds was used to reach expert consensus. In Round 1, 20 purposively selected experts including head teachers, county education officials, public health officers, water and public works officers, and NGO representatives participated in key informant interviews. Emergent themes informed development of a structured Round 2 questionnaire administered through CommCare online app. Quantitative data were analyzed using descriptive statistics (means, standard deviations, percentage agreement), while qualitative responses underwent thematic coding using NVivo 12. Experts reached strong consensus on essential components required for strengthening school WASH implementation. Key priorities included clear governance structures, designated budget lines, inclusive infrastructure, menstrual hygiene management (MHM), curriculum integration, sustained capacity building, and systematic monitoring. Multi-sectoral collaboration and recognition of best-performing schools were also emphasized as important motivators for compliance and sustainability. Equity considerations particularly the need for disability-friendly facilities and school-community outreach were highlighted as critical. Agreement levels ranged from 74% to 100%, with most items scoring mean values between 4.5 and 4.8 on a 5-point Likert scale, indicating strong consensus among experts. Conclusion strengthening implementation of school WASH in Kenya requires coordinated governance, predictable funding, reliable water systems, inclusive sanitation, strengthened MHM, and consistent monitoring beyond infrastructure investment alone. Integrating these expert-validated priorities within existing national policies offers a practical pathway to improving learner health, reducing absenteeism especially among girls and promoting equitable educational outcomes.

Objective To analyse sociodemographic determinants of maternal health indicators in Kenyas conflict-affected regions. Methods A cross-sectional secondary analysis of the 2022 Kenya Demographic and Health Survey (KDHS) was conducted. Conflict-affected counties were identified using ACLED (>25 fatalities). The sample included 1,060 women aged 15-49 years. Outcomes were adequate antenatal care (ANC 4+), facility delivery, and skilled birth attendance (SBA). Predictors included age, education, wealth, employment, residence, and county; intimate partner violence was adjusted for. Weighted descriptive statistics, chi-square tests, and multivariable logistic regression were applied (p<0.05). Results Six counties met conflict criteria. While 90.2% of women attended at least one ANC visit, only 53.5% achieved ANC 4+. Facility delivery and SBA were 68.2% and 72.2%, respectively. Adolescents (15-19) were least likely to attain adequate ANC; women aged 20-24 had higher odds (aOR=1.83; 95% CI: 1.01-3.34). Education strongly predicted outcomes: higher education increased ANC 4+ (aOR=2.74; 95% CI: 1.19-6.34) and facility delivery (aOR=2.72; 95% CI: 1.15-6.47). Wealth showed strong gradients: middle quintile increased facility delivery (aOR=5.50; 95% CI: 2.14-14.14), while richer quintile increased SBA (aOR=11.04; 95% CI: 2.06-59.25). Rural residence reduced facility delivery (aOR=0.32) and SBA (aOR=0.22). County disparities persisted. IPV was not independently associated. Conclusion Maternal health indicators in conflict-affected Kenya follow a marked inequity gradient. Adolescents, rural residents, and socioeconomically disadvantaged women are most excluded. Strengthening adolescent ANC continuity, reducing rural access barriers, and investing in education and economic empowerment are critical for improving outcomes.

Background Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 and the Free Maternal Healthcare Policy (FMHCP) in 2008 to remove financial barriers and promote universal health coverage. Despite these landmark policies, socioeconomic inequalities in maternal healthcare utilisation may persist. This study quantifies socioeconomic inequalities in antenatal care (ANC) receipt and place of delivery and decomposes the key drivers of inequality using the most recent nationally representative survey data. Methods We analysed the 2022 Ghana Demographic and Health Survey women's file, restricting to women who reported a live birth in the five years preceding the survey (n = 5,134; weighted population {approx} 4.66 million). Outcome variables were adequate ANC ([&ge;]4 visits, and [&ge;]8 visits in sensitivity analysis) and place of delivery (home, public facility, private facility). The concentration index (CI) was computed for adequate ANC, and the Wagstaff decomposition method was applied to quantify the contribution of wealth, education, residence, NHIS membership, and access barriers. Multinomial logistic regression examined factors associated with place of delivery. Missing data were handled using multiple imputation by chained equations (20 datasets). All analyses accounted for the complex survey design. Results Overall, 88.6% (95% CI: 87.0-90.2%) of women achieved [&ge;]4 ANC visits. The concentration index for adequate ANC was 0.0391 (95% CI: 0.0291-0.0491; p < 0.001), indicating statistically significant pro-rich inequality. Using the WHO threshold of [&ge;]8 visits, the CI increased more than fourfold to 0.1728 (95% CI: 0.1428-0.2028). Home delivery was most prevalent among the poorest women (46.7%), while private facility delivery dominated among the richest (46.1%). Decomposition showed that rural residence (16.4%), NHIS membership (16.4%), and geographical region (15.6%) were the largest positive contributors to pro-rich inequality, whereas secondary education exerted the strongest equalising effect (-22.5%). NHIS membership was associated with lower odds of home delivery (RRR = 0.24, 95% CI: 0.18-0.32) but did not eliminate the wealth gradient. Together, included determinants explained 71.3% of total inequality. Conclusions Despite high coverage of basic ANC, substantial and policy-relevant socioeconomic inequalities persist in maternal healthcare utilisation in Ghana. Inequalities widen markedly when the stricter WHO standard is applied. Educational attainment and rural residence are primary drivers; NHIS alone is insufficient to achieve equity. Policies should address non-financial barriers, strengthen rural health infrastructure, invest in public facility quality, and promote girls' secondary education to reduce persistent maternal health disparities.

Despite robust policy frameworks, Ugandas digital health landscape is characterised by fragmentation--often termed "Pilotitis"--where stand-alone applications impede the integrated delivery of health, nutrition, and food security services. As part of the IGNITE project, this study mapped existing digital health systems (DHSs), identified systemic gaps, and explored opportunities and resource requirements for sustainable integration of existing Health, Nutrition and Food security data systems. The IGNITE project adopted a mixed-methods design; however, this paper reports findings from the first phase--a national cross-sectional survey conducted in Uganda. The survey mapped digital health, nutrition, and food security systems, identifying gaps, resource needs, and potential actions. Stakeholders from government, NGOs, academia, UN agencies, and frontline health workers were included using purposive and snowball sampling. Data were collected online and through field support. Of 134 respondents, 110 with [&ge;]70% survey completion was included in the analysis. While 93% of respondents utilise digital tools (predominantly DHIS2 and mobile apps), only 20% reported full automated integration with national platforms. Critical barriers to interoperability included a lack of technical expertise (90%), insufficient DHIS2 training (82%), different data formats (77%), and infrastructure constraints (75%). Respondents identified workforce development (56%) and DHIS2 use and adoption (29%) as primary opportunities. Immediate priorities include staff training and provision of mobile hardware, while long-term strategies focus on standardised data formats (78%) and formalised governance frameworks for Integrated platforms (64%) and automated data exchange (56%). Uganda possesses a vibrant but disconnected digital ecosystem. Transitioning from isolated "data islands" to a cohesive system requires addressing the massive technical capacity gap and establishing mandated interoperability guidelines. The findings provide a data-driven roadmap for the Ministry of Health and partners to optimise digital health adoption, ensuring that nutrition and food security interventions are supported by a unified, evidence-informed digital architecture

Protracted conflict in Sudan since April 2023 has severely disrupted routine immunization services, particularly in the Darfur region, resulting in widespread vaccine stockouts, declining coverage, and increased risk of vaccine-preventable disease outbreaks. Traditional national supply routes became largely inaccessible, exacerbating inequities in immunization access for conflict-affected and displaced populations. This paper examines the design, implementation, and outcomes of a cross-border vaccine deployment strategy implemented in 2025 through Chad to restore vaccine availability in Darfur. Using programmatic data, shipment records, coverage reports, and partner monitoring outputs, the study assessed the operational feasibility, partnership arrangements, and public health impact of the intervention on routine immunization and outbreak response. In 2025, nearly 20 million doses of vaccines were successfully delivered to the five Darfur states through cross-border operations, supporting routine immunization services and outbreak response campaigns. Average coverage for the first dose of a DPT-containing vaccine (DPT1) increased from 22.6% in 2024 to 83.2% in 2025, while DPT3 and MCV1 coverage rose to 55.4% and 50.4%, respectively. Oral cholera vaccine campaigns achieved 90.4% coverage among targeted populations, and polio outbreak response campaigns exceeded 100% administrative coverage, reflecting both successful reach and uncertainties in target population estimates due to population displacement. Investments in cold chain infrastructure and strengthened coordination among government, UNICEF, Gavi, and implementing partners were critical to these outcomes. The findings demonstrate that cross-border vaccine deployment can serve as a viable and effective mechanism for restoring immunization availability and support recovery of immunization service delivery in a highly constrained conflict setting. While not a substitute for functional national systems, such approaches are essential life-saving interventions during acute crises and should be integrated into preparedness planning for fragile and conflict-affected contexts.

Abstract Background Anemia is a condition characterized by nutritional deficiencies and blood disorders, predominantly affecting children aged 6 to 59 months and women of reproductive age, especially in low and middle-income countries. In Zambia, anemia is a public health problem. This study aims to assess the spatial patterns and determine factors associated with anemia severity in Zambia over six years (2018 to 2024). Method The study included a total of 19,362 WRA from the two waves of the ZDHS, 2018 and 2024. The ZDHS is a periodic national survey that uses multistage sampling. We adopted an analytical cross-sectional design, and the three-level multivariable ordinal logistic regression model was used to identify variables (individual, household, and community level) associated with anemia severity. Global Morans I, Local Morans I, and Getis-Ord Gi* statistics were used to determine the hotspots and spatial patterns, while spatial scan statistics were used to detect primary and secondary clusters and their distribution over the two cycles. Results The prevalence of anemia among women of reproductive age in Zambia was 31.0% (n=3,946) and 30.4% (n=2,015) in 2018 and 2024, respectively. The factors associated with higher odds of anemia severity were HIV status (HIV-positive: AOR=2.63, 95% CI:2.25,3.09), pregnancy (AOR=1.96, 95% CI:1.67,2.31), and rural residency (AOR=1.21, 95% CI:1.08,1.35). While being in a union was protective compared to never being in a union (AOR=0.66, 95% CI:0.57,0.77), not having financial barriers for medical assistance was equally protective. Spatial analysis showed geographic disparities and a non-random distribution of anemia (Global Morans I, 2018: I=0.147, p<0.001; 2024: I=0.130, p<0.001). the Hotspot analysis depicted an expansion of high-risk areas Western in 2018 to the North-Western and Luapula in 2024. Spatial scan analysis identified the south-west region (Western, Southern and North-Western) as the significant primary cluster of anemia consistently for both waves.

Abstract Background: To influence malaria-related behaviours, it is important to understand key behavioural drivers, encourage enablers and address barriers to individuals and communities adoption of interventions to prevent malaria. The capability(C), opportunity(O), and motivation(M) Behaviour(B) model (COM-B model) was used to inform development of perennial malaria chemoprevention (PMC) social, and behaviour change (SBC) message delivered through routine immunization (RI) platform. This paper presents how the COM-B model was used for designing the SBC messages for PMC using the findings from a qualitative study. Methodology The COM-B model provided the theoretical framework for designing the PMC SBC intervention by identifying, capability, opportunity motivation for PMC as well as the barriers, and possible enablers for PMC uptake. A qualitative study was conducted as key source of information. Twelve focus group discussions (FGDs) were conducted with the target audience comprising of mothers of children under two years, pregnant women, men, ward development committee members, community mobilizers and health workers. A total of 120 people participated in the study. An SBC workshop was conducted to develop key messages and content for a community dialogue flipbook and facilitators' guide. Results Knowledge of malaria signs that prompt mothers to seek health care for their children as well as awareness about malaria prevalence and severity, were identified as capabilities that could drive behaviour change, while forgetting the time to visit the health facility was noted as a hindrance. Opportunities and social influencers included spousal support, the positive influence of health workers, accessibility and affordability of the intervention, and the availability of transportation. Motivation was shaped by the perceived seriousness of malaria as a health problem that could lead to the death of children. Fathers were motivated when they observed reduced malaria burden and improved child health, although a lack of perceived urgency remained a demotivating factor for seeking care. Mothers' motivation was strengthened by encouragement from husbands, community mobilisers and health workers. Conclusion The COM-B model provided an effective framework for identifying and developing key messages that informed changes needed to improve capability, opportunities, motivation of individuals and communities towards increased uptake of PMC during PMC pilot study in Osun state Nigeria.

BackgroundWomens autonomy in healthcare decision-making has become one of the most critical yet inequitably distributed determinants of health outcomes, gender equity, and sustainable development worldwide. In Northern Nigeria, the presence of ethnic and socio-cultural inequality is frequently concealed by the aggregated statistics of a region. MethodsThis cross-sectional secondary analysis utilized the 2024 Nigeria Demographic and Health Survey. The sample included 9,998 married women (15-49 years) identifying as Hausa, Fulani, or Kanuri in Northern Nigeria. Healthcare autonomy was categorized as husband/partner alone, respondent alone, or joint decision-making. Analysis included weighted descriptive statistics, Rao-Scott adjusted chi-square tests for residential associations, and complex sample multinomial logistic regression to identify multivariable correlates while adjusting for sampling weights, strata, and clusters. ResultsMean age was 30.38 years. Most participants lacked formal education (69.6%) and resided in rural areas (72.0%). Husband-only decision-making predominated (72.6%), while 22.5% reported joint and 4.9% independent autonomy. Joint decision-making was significantly higher in urban (33.3%) than rural areas (18.3%; Adjusted F=50.892, p<0.001). In adjusted models (Reference: Kanuri), Hausa and Fulani women had substantially lower odds of joint decision-making relative to husband-only outcomes. Rural residence correlated with lower odds of both independent and joint agency. Notably, wealth status was not a significant predictor after adjustment (p > 0.05). ConclusionsEthnicity and residence are robust determinants of healthcare autonomy among women in Northern Nigeria, persisting regardless of education or wealth. This "socio-cultural paradox" suggests that economic interventions alone are insufficient. Policies must complement socioeconomic approaches with culturally responsive strategies addressing household power dynamics and entrenched social norms.

Background: Health systems in low- and middle-income countries are frequently described as "data rich, information poor", collecting substantial amounts of data that rarely inform local decision-making. In tribal settings, this challenge is compounded by geographic isolation, fragmented governance, sectoral silos, and the absence of disaggregated tribal health data within routine health information systems. We conducted a systematic mapping of data sources available for maternal and child health (MCH) decision-making at tribal Primary Health Centres (PHCs) in Andhra Pradesh, India. Methods: Using a participatory data discovery approach embedded within an action research project, we mapped data sources across three PHCs under the Integrated Tribal Development Agency (ITDA) - Rampachodavaram, Alluri Sitarama Raju District of Andhra Pradesh, India. Data discovery proceeded through three phases: document review, key informant interviews with Medical Officers and frontline health workers, and stakeholder validation. Sources were classified using the HEALTHY framework (Healthcare, Education, Access, Labour, Transportation, Housing, Income) and the Keller's data discovery typology (Designed, Administrative, Opportunity, Procedural). Accessibility was assessed based on whether Medical Officers could retrieve data for local planning and decision-making. Results: We identified 28 distinct data sources relevant to MCH decision-making. Healthcare dominated (57.1%), while determinant domains remained underrepresented: Housing (10.7%), Income (10.7%), Education (7.1%), Labour (7.1%), Transportation (3.6%), and Access to healthy choices (3.6%). By data origin, Administrative sources predominated (46.4%), followed by Opportunity (21.4%), Procedural (17.9%), and Designed (14.3%). Despite 67.9% of sources having digital components, only 32.1% were fully accessible to Medical Officers, with 10.7% partially accessible and 57.1% inaccessible at the PHC level. Accessibility barriers were consistent across data categories, ranging from 50.0% to 66.7% inaccessibility. Conclusions: The tribal PHC data ecosystem exhibits a fundamental mismatch between data generation and local utility. Data is predominantly collected for administrative reporting rather than local decision-making. Addressing MCH outcomes in tribal populations requires reorienting health information systems toward local needs.

Dropout from essential maternal health services across pregnancy, childbirth, and the postnatal period remains a major barrier to improving maternal and neonatal outcomes in Bangladesh. This study examined stage-specific dropout patterns along the maternal continuum of care and identified factors associated with discontinuation. We analysed nationally representative data from the Bangladesh Demographic and Health Survey 2022 for 5,162 women with a recent live birth. Dropout from antenatal care, skilled birth attendance, and postnatal care was examined using multivariable logistic regression to estimate adjusted odds ratios and 95% confidence intervals, with comparisons to BDHS 2017-18 and assessment of regional variation. Only 44% of women received four or more antenatal care visits. Of these, 33% delivered with a skilled birth attendant, and among those receiving both antenatal care and skilled delivery, only 15% received postnatal care within 48 hours. Overall, 57% dropped out before completing adequate antenatal care, with additional dropouts between antenatal care and delivery (10%) and between delivery and postnatal care (18%). Compared with 2017-18, overall dropout from the maternal continuum of care more than doubled in 2022 (5.0% to 11.7%), driven by increased antenatal care dropout, while skilled birth attendance dropout declined and postnatal care dropout increased slightly. Higher maternal education, household wealth, media exposure, and womens decision-making power were consistently associated with lower odds of dropout, whereas higher birth order increased dropout risk. Substantial regional variation was observed, with the highest overall dropout in Sylhet and the lowest in Khulna. High dropout from the maternal continuum of care in Bangladesh occurs predominantly at the antenatal care stage and is shaped by socioeconomic status, birth order, womens access to information, and regional disparities. Strengthening early antenatal engagement and womens decision-making autonomy is critical to improving continuity of maternal care and reducing preventable maternal and neonatal risks.

Background: Nigeria bears one of the highest maternal mortality burdens globally, with skilled birth attendance (SBA) remaining critically low in many regions. Understanding the independent determinants of SBA is essential for designing targeted interventions. Methods: This cross sectional study analyzed 21,465 births from the 2018 Nigeria Demographic and Health Survey (NDHS), a nationally representative household survey using stratified two stage cluster sampling. SBA was defined as delivery attended by a doctor, nurse, midwife, or auxiliary midwife. Multivariable logistic regression was used to estimate adjusted odds ratios (aOR) with 95% confidence intervals for the associations between SBA and maternal education, household wealth, place of residence, geopolitical region, maternal age, parity, and antenatal care (ANC) utilization, after accounting for confounding. Results: The overall prevalence of SBA was 44.9%. In the fully adjusted model, higher education (aOR = 7.01, 95% CI: 5.68-8.67), richest wealth quintile (aOR = 6.27, 95% CI: 5.27-7.46), and attending [&ge;]4 ANC visits (aOR = 3.80, 95% CI: 3.51-4.11) were the strongest independent predictors of SBA. Regional inequalities were pronounced, with SBA prevalence ranging from 17.7% in the North West to 85.6% in the South West. Crude effect estimates for education and wealth were substantially attenuated after adjustment, indicating large confounding by correlated socioeconomic factors. Conclusions: Maternal education, household wealth, ANC utilization, and geopolitical region are independent determinants of SBA in Nigeria. Scaling up ANC programs represents the most immediately actionable intervention, while long term gains require investment in girls' education and wealth equity. Targeted strategies for the northern regions are urgently needed. Keywords: skilled birth attendance, maternal mortality, Nigeria, DHS, antenatal care, logistic regression, health equity

Background: HIV/AIDS remains a major public health challenge in Tanzania, where viral load suppression among adults on ART stands at 78% and HVL testing uptake among eligible patients is approximately 22%. Since the introduction of the National HVL Testing Guideline in 2015, little has been done to systematically evaluate its implementation. Objective: To evaluate adherence to the National HVL Testing Guideline across CTC clinics in Dar es Salaam Region, covering ART monitoring, documentation, turnaround time, and factors affecting implementation. Methods: A cross-sectional study was conducted in 2021 across 15 public health facilities with CTC clinics in all five Dar es Salaam districts. A total of 330 PLHIV on ART for more than six months were selected through systematic random sampling with proportional to size allocation, and 45 healthcare providers through convenient sampling. Data were collected via abstraction forms and self-administered questionnaires, and analysed using SPSS Version 23 with descriptive statistics, bivariate analysis, and binary logistic regression. Results: Only 25.1% of patients had their first HVL sample taken at six months as per guideline, with 68.8% delayed beyond six months. Second and third samples were similarly delayed. MoHCDGEC sample tracking forms were absent in 96.7% of facilities and incomplete in 99.1%, and no facility captured specimen acceptance or rejection as site feedback. Turnaround time exceeded the 14-day guideline threshold in 64.5%, 66.7%, and 69.4% of first, second, and third results respectively. Patient negligence (AOR=9.84; 95% CI: 1.83-52.77) and storage (AOR=5.72; 95% CI: 0.94-35.0) were independently associated with guideline adherence. Conclusion: Adherence to the National HVL Testing Guideline in Dar es Salaam is suboptimal across testing timelines, documentation, and turnaround time, with patient negligence and storage capacity as significant determinants. Targeted interventions are needed to strengthen patient education, improve storage infrastructure, enhance documentation systems, and support providers in adhering to guideline-specified timelines.

Background: Digital health tools are increasingly promoted for strengthening health information systems in low- and middle-income countries, yet routine maternal and child health (MCH) data in tribal primary health centres (PHCs) in India remains underutilised for local decision-making. Top-down digital tools often fail in low-resource settings because they are designed without meaningful input from end-users. Co-creation approaches for digital health in tribal and indigenous settings are largely unexplored. Methods: We conducted an action research study in three tribal PHCs under the Integrated Tribal Development Agency (ITDA), Rampachodavaram, Andhra Pradesh, India. We applied the Three Co's Framework (Co-Define, Co-Design, Co-Refine) to co-create data science solutions for MCH decision-making with five medical officers, 24 auxiliary nurse midwives, and 36 accredited social health activists across two action research cycles (August 2023 to August 2024). Co-creation involved collaborative indicator definition, data modelling, data quality validation, health facility catchment area construction, spatial analysis, and interactive dashboard development. Keller's Data Science Framework was employed using R to structure the analytical pipeline, and Data.org's Data Maturity Assessment (DMA) was used to assess organisational data maturity pre- and post-intervention. Findings: During Co-Define, co-creators identified a fundamental mismatch between system outputs (aggregate statistics for upward reporting) and their operational need for individual-level, geographically disaggregated, prospective information. Co-Design produced five interconnected data science solutions: (1) 42 co-defined MCH indicators grounded in clinical workflows; (2) a data model linking individuals, health services, providers, and facilities; (3) a data quality framework using the pointblank R package; (4) health facility catchment area boundaries constructed from scratch using medical officers' local knowledge, enabling spatial analysis that revealed significant clustering of ANC coverage and anaemia prevalence; and (5) an R Shiny dashboard integrating these solutions into an offline-capable interface with lifecycle-organised views and village-level navigation. The DMA showed moderate improvement in organisational data maturity from 5.04 to 5.75 out of 10, with the largest gain in Analysis (+1.90). Co-Refine continued beyond the formal study period, with two transferred medical officers maintaining analytical engagement from new postings. Interpretation: The Three Co's Framework, combined with a data science approach, provided a structured yet flexible method for co-creating locally relevant data science solutions in a tribal setting. The framework's explicit separation of problem definition from solution design was particularly valuable in a context where "the problem" is typically defined externally. Co-creation in tribal digital health settings is feasible and produces solutions that address locally articulated needs.

BackgroundCurable sexually transmitted infections (STIs), including Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis, remain highly prevalent among pregnant women in South Africa. Despite poor diagnostic performance in pregnancy, syndromic management remains standard care. Point-of-care (POC) screening enables aetiological diagnosis and same-visit treatment but is not yet included in national guidelines. We conducted a mixed-methods process evaluation to examine determinants of antenatal POC STI screening implementation in public facilities. MethodsThis evaluation was embedded within the three-arm Philani Ndiphile randomized trial (March 2021-February 2025) across four public clinics in the Eastern Cape. Screening used a near-POC, electricity-dependent nucleic acid amplification test with a 90-minute turnaround time. Reach, Adoption, Implementation, and Maintenance were assessed using the RE-AIM framework. Quantitative indicators included uptake of screening, treatment, and follow-up attendance. Qualitative data included in-depth interviews with 20 pregnant women and five focus group discussions with 21 research staff and government healthcare workers. The Consolidated Framework for Implementation Research guided qualitative analysis. Findings were integrated using narrative weaving. ResultsScreening uptake was high (99.0%), with treatment coverage of 95.2% at baseline and 93.5% at repeat screening. Same-day treatment was lower (50.7% and 69.8%) and varied substantially by facility, reflecting operational constraints including turnaround time, patient volume, infrastructure, and electricity. Attendance was higher when screening was integrated into routine ANC. Women valued screening for infant health, while providers recognised advantages over syndromic management but highlighted workforce, resource, and maintenance constraints. Socioeconomic factors, including transport costs, hunger, and work commitments, influenced retention and waiting. ConclusionsAntenatal POC STI screening was acceptable and achieved high treatment coverage in a research setting. However, same-day treatment was constrained by operational requirements of the testing platform. Scale-up will require workflow integration, strengthened health system capacity, and faster diagnostics suited to routine antenatal care. Key MessagesO_ST_ABSWhat is already known on this topicC_ST_ABSSyndromic management remains standard antenatal care in many low-resource settings despite failing to capture up to 89% of infections that remain asymptomatic. Point-of-care aetiological screening has demonstrated feasibility, acceptability, and potential clinical benefit in research settings, yet has not been widely adopted into national policy. Limited evidence exists on the health system requirements and contextual determinants influencing scale-up within routine public facilities. What this study addsThis mixed-methods process evaluation demonstrates high uptake and treatment coverage of antenatal POC STI screening in a trial setting, while identifying facility-level, structural, and socioeconomic factors shaping same-day treatment and retention. We show that implementation success varies substantially across clinics and depends on assay characteristics, workflow integration, human resources, infrastructure reliability, and follow-up capacity. How this study might affect research, practice or policyThese findings provide implementation-relevant evidence to inform national policy deliberations on integrating POC STI screening into antenatal care. Sustainable scale-up will require context-adapted delivery models, strengthened workforce and supply systems, faster diagnostics, and alignment with existing ANC workflows to ensure equitable and durable impact.

Tuberculosis (TB) is prevalent in Uganda and overlaps with a high rate of HIV/TB coinfection. While nearly all hospital-based TB cases in Kampala, the capital of Uganda, show clear TB symptoms, 30% or more of undiagnosed TB cases found through active screening are asymptomatic. Additionally, the host risk factors for TB in Kampala cannot be distinguished from environmental risk factors. These TB-specific challenges are just part of the complexity, especially in areas with high HIV/AIDS burden. Data science techniques, especially Artificial Intelligence (AI) and Machine Learning (ML) algorithms, could help untangle this complexity by identifying factors related to the host, pathogen, and environment, which are difficult to explain or predict with traditional/conventional methods. In this project, we will use health data science approaches (AI/ML) to identify factors driving TB transmission within households and reasons for anti-TB treatment failure. We will utilize the computational resources at Makerere University and available demographic, clinical, and laboratory data from TB patients and their contacts to develop AI and ML algorithms. These will aim to: (1) identify patients at baseline (month 0) unlikely to convert their sputum or culture results by months 2 and 5, thus at risk of failing TB treatment; (2) identify household contacts of TB cases who are at risk of developing TB disease, as well as contacts who may resist TB infection despite repeated exposure to M. tuberculosis. Achieving these objectives will provide evidence that data science methods are effective for early detection of potential TB cases and high-risk patients, thereby helping to reduce TB transmission in the community. The study protocol received approval from the School of Biomedical Sciences IRB, protocol number SBS-2023-495.

Culture plays a crucial role in health; family, community, culture, and social conventions all have a significant impact on how an infant with jaundice is treated. Written or unwritten rules govern what parents and the community are allowed to do, which may have a detrimental effect on the neonates care. ObjectivesThe study explored how social expectations affect midwives management of neonatal jaundice at the St Patricks hospital in Maase-Offinso, in the Ashanti region of Ghana. MethodA total of seventeen midwives were sampled purposively using an exploratory descriptive design. Participants were engaged in interviews and focus group discussion after ethical approval was obtained. A semi-structured focus group discussion guide and interview guide was used to collect data. ResultsThe study discovered that the treatment of neonatal jaundice was adversely affected by social pressures, misconceptions, maternal choices, and spiritual views. Mothers and midwives socially approved sunbathing, and there were indications that grandmothers disapproved hospital care for their grandchildren. ConclusionCulture, family and social norms cannot be separated from health especially for the neonate whose means of identification is to belong to a family. Consequently, it is essential to respond to social influences, cultural conventions, and the various cultures of families with a culturally sensitive approach.

Background: Malaria remains a major global health threat, with 249 million cases and 609,000 deaths reported in 2022. The Ashanti Region of Ghana bears a disproportionate burden, with severe malaria accounting for 24% of hospital admissions in 2021, above the national average of 19%. Despite intensified control efforts, inpatient mortality patterns remain poorly understood. This study identifies key determinants of severe malaria mortality among hospitalized patients in the Ashanti Region. Methods: We analyzed inpatient surveillance data from the District Health Information Management System 2 (DHIMS2) for severe malaria admissions from 2018 to 2022. Descriptive statistics, bivariate analyses with robust survey estimation (accounting for design effects), and multivariable Firth penalized logistic regression were used to identify mortality predictors. Survey-adjusted logistic regression served as a sensitivity analysis to validate findings. Results: Among 54,544 severe malaria admissions, females comprised 51.1% and children under five 39.4%. The case fatality rate was 0.4% (200 deaths). Mortality was significantly associated with age, occupation, insurance status, facility ownership, admitting department, length of stay, and comorbidities. Males had 1.4 times higher mortality odds than females. Compared to children under five, patients aged 5 to 17 years had 44% lower odds of mortality (aOR = 0.56, 95% CI: 0.33, 0.94). Active NHIS membership had lower mortality odds by 67% (aOR=0.33, 95% CI: 0.25, 0.45) compared to inactive membership. Admissions to faith-based facilities showed lower mortality odds (aOR=0.38, 95% CI: 0.23, 0.65) than government facilities, while medical wards had higher odds (aOR=2.38, 95% CI: 1.48, 3.84) than paediatric wards. Stays of 3 to 5 days were associated with lower mortality odds (aOR=0.67, 95% CI: 0.47, 0.97) compared to stays <3 days. Those with comorbidities had twice the mortality odds versus those without. Sensitivity analysis confirmed consistent direction and significance. Conclusion: Age, comorbidities, insurance coverage, facility type, and admission practices strongly influence severe malaria mortality in Ashanti. Strengthening NHIS enrollment, extending inpatient monitoring beyond three days, and adopting best practices from paediatric and faith based facilities could improve survival. Integrating comorbidity screening and management into malaria protocols is essential to reducing preventable deaths.