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.

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.

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: 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.

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. 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

Background: In Tanzania, over 10,000 women aged 15-44 are diagnosed with cervical cancer annually, and more than 6525 die. The majority are diagnosed at an advanced stage, which contributes to delays in treatment enrollment and illness complications. Multiple factors can affect womens willingness and ability to access cervical pre-cancer screening. Purpose: To explore the barriers and facilitators to attending cervical pre-cancer screening among women living in a resource-constrained area of Southern Tanzania Methods: A qualitative study of 17 focus group discussions and 12 in-depth interviews was conducted from December 2023 to July 2024. Data collection took place in the community and health centers of a town and the surrounding rural areas in Kilombero district. The study used purposive sampling to recruit 112 women and 23 men aged 18- 50+ years. Results: Fear of death emerged as a central theme in the data, acting as both a barrier to and a facilitator of womens screening behavior. Women linked death with the screening procedure, receiving results and undergoing treatment. Participants mistrusted the speculum itself and linked it to pain, vaginal infection, and infertility. Conversely, fear of physical and social death motivated other women to attend the screening to learn about their health and prevent the consequences of a positive diagnosis. Public trust in the healthcare system and the role of health information sources were also identified as influencing women's decisions to undergo or not undergo screening. Conclusion: Our findings showed that cervical cancer screening uptake is influenced by fear of death and other co-factors. To improve early cervical cancer screening, programs and policy interventions are needed to raise awareness of the disease while also addressing womens specific concerns. Also, strengthening structural dimensions such as the availability of the healthcare workforce, healthcare facilities, and ensuring equitable service availability are essential to reducing cervical cancer complications and avoidable mortality.

Background: Tuberculosis (TB) remains a major public health challenge globally, with Pakistan ranking among the highest TB burden countries worldwide. Although several novel TB vaccine candidates for adolescents and adults are advancing through late-stage clinical trials, little is known about how these vaccines may be introduced in high-burden settings such as Pakistan. Understanding stakeholder perspectives is crucial for informing early implementation planning and policy development. Methods: We conducted an exploratory qualitative study using semi-structured in-depth interviews with key stakeholders involved in TB control, immunization, clinical care, and health policy in Pakistan. Participants were purposively selected from national and provincial TB programs, Expanded Programme on Immunization (EPI), clinical settings, and academia. Interviews were conducted in English or Urdu, audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis following the Braun and Clarke framework. A hybrid deductive-inductive coding approach was used. Results: Ten stakeholders participated including one whose interview also served as a pilot test of the interview guide. Participants expressed strong support for the introduction of a new TB vaccine, driven largely by Pakistan's high TB burden and the limitations of current prevention strategies. However, support was based on the availability of strong evidence regarding vaccine safety, effectiveness, and feasibility. Key barriers to vaccine acceptability included low perceived risk of TB, misinformation, stigma, sociocultural influences, and limited public awareness. Stakeholders emphasized community engagement, trusted healthcare providers, and effective communication as critical enablers. Health system challenges included workforce shortages, cold chain limitations, and financing constraints. Household contacts of TB patients were consistently identified as the priority group followed by adolescents and people living with HIV. A phased implementation strategy was broadly preferred followed by gradual integration into existing health services. Conclusion: Stakeholders in Pakistan broadly support new TB vaccines for adolescents and adults. Successful implementation will require addressing sociocultural barriers, strengthening health system capacity, and developing context-specific delivery and prioritization strategies. Early stakeholder engagement and implementation planning are essential for meaningful public health impact in Pakistan.

Background Rural-urban disparities in SARS-CoV-2 infection epidemiology remain poorly quantified and understood in Zambia despite differences in healthcare access, services and preventive interventions. This study examined the geographical distribution and associated factors of SARS-CoV-2 cases across selected rural and urban districts of Zambia. Methods A convergent mixed-methods study comprised of quantitative survey and qualitative interviews was conducted in; Ndola (Urban), Kafue (Peri-urban) and Lufwanyama (Rural). The proximate determinant framework guided variable selection and interpretation. Quantitative combined (Hospital-surveillance data with community survey), while qualitative included In-depth interviews. Participants were sampled using multistage sampling technique. Quantitative data were analysed using STATA version 17, while qualitative data were analysed thematically. Findings were integrated through triangulation. Results A total of 528 participants were included, with a median age 31 years (15-71). Overall SARS-CoV-2 positivity was 12.6%, varying across rural (16.5%), peri-urban (14.9%), and urban (9.9%) settings, though residence was not associated with infection (P<0.132). Participants aged [&ge;]49 years had significantly higher odds of infection (aOR=8.78; 95% CI:1.15-66.99), whereas secondary education (aOR=0.37; 95% CI:0.16-0.86) and hospital-based testing (aOR=0.37; 95% CI:0.15-0.92) were associated with lower odds of infection. Vaccine uptake was highest in urban areas but was not independently associated with infection. Qualitative findings revealed marked rural-urban differences in perceived susceptibility, testing access, vaccine decision-making, and adherence to preventive measures, explaining several quantitative observations. Conclusion SARS-CoV-2 infection across rural and urban settings in Zambia was influenced by demographic, behavioral, and health-system factors rather than geographic residence alone. These findings highlight the need for context-specific prevention strategies, equitable access to testing, strengthened community surveillance, and targeted risk communication to improve preparedness and response for future respiratory disease outbreaks.

Background Global labor migration from LMIC to higher-income destinations has expanded rapidly, placing increasing pressure on destination-country health. Existing research on cross-border migrant workers has focused largely on occupational health, general healthcare utilization, and disease-specific risks, while there is considerably less evidence on their sexual and reproductive health. This study contributes to this understudied field by examining the policy and health-system factors that shape the sexual and reproductive health services for migrant workers in Taiwan. Methods A qualitative study was conducted in Taiwan between November 2025 and August 2026. 22 stakeholders were purposively recruited from academia, healthcare, nongovernmental organizations, government, labor brokerage, and employers. Data were collected through semi-structured interviews and small focus groups. Interviews were conducted in Mandarin Chinese, transcribed verbatim, and translated into English. Data were analyzed using framework analysis combining deductive coding based on the AAAQ framework with inductive coding of implementation and contextual themes. Results Gaps were identified across all four AAAQ dimensions. Participants described limited migrant-responsive SRH programming; physical, financial, administrative, social, and information barriers; shortcomings in linguistic and cultural responsiveness; and weaknesses in interpretation, coordination, and continuity of care, despite generally favorable views of Taiwan's clinical quality. Conclusions Our findings show that broad insurance coverage and strong clinical capacity do not by themselves ensure the realization of migrant workers' SRHR. In Taiwan, rights were mediated through labor brokerage, gendered live-in work arrangements, and fragmented governance across health, labor, immigration, and social-welfare systems. Improving migrant SRHR therefore requires stronger implementation of existing protections, reduced dependence on informal intermediaries, and more integrated institutional responsibility for cross-sector migrant health needs.

Introduction Continuous Glucose Monitoring (CGM) is considered standard care in high-income countries. There is, however, limited published evidence on CGM use in low- and middle-income countries. The purpose of this study was to assess the usability, acceptability, and feasibility of CGM use among people living with type 1 diabetes (T1D) and caregivers in a low-resource setting. Research Design and Methods This prospective study conducted at the Kenyatta National Hospital purposively enrolled persons aged 4-25 years who had been on management for T1D for at least six months, and caregivers of those under 18 years. Fourty youth living with T1D used CGM for three months in place of self monitoring of blood glucose (SMBG). The System Usability Scale (SUS), a Theoretical Framework of Acceptability-based questionnaire, the Diabetes Distress Scale (DDS), the Glucose Monitoring Satisfaction Survey (GMSS), and a feasibility survey were administered. Outcomes were summarized descriptively, including means, medians, and frequencies using R statistical software. Results The median SUS score was 98.8 (IQR 92.5-100.0). Acceptability was high, and the median total GMSS score improved from 3.73 to 4.73. Among adolescents and adults, the median overall DDS score reduced from 1.54 to 1.36, with reductions in scores in all domains, except for hypoglycemia distress which increased, and physician distress which remained low. Among caregivers, the median overall DDS score declined from 2.05 (moderate distress) to 1.90 (low distress), with modest reductions in teen management and parent-teen relationship distress and a slight increase in personal distress. Median CGM active wear time was 89%. Conclusion This study comprehensively evaluated CGM across usability, acceptability, and feasibility outcomes, with the findings supporting the integration of CGM into routine diabetes management in low-resource settings. The short follow-up period, however, may not capture changing perceptions or long-term adherence.

Background Birth Preparedness and Complication Readiness (BPCR) education is an important component of antenatal care. However, health education materials translated from one language into another may lose their intended meaning if linguistic, cultural, experiential, and sociolinguistic differences are not considered. In Tanzania, maternal health education is commonly delivered in Swahili, while many source materials are developed in English. This study explored the cultural and linguistic equivalence of BPCR terminology and concepts in a translated Swahili BPCR education manual among Hehe pregnant women in the rural Iringa Region, Tanzania. Methods A descriptive qualitative study was conducted in seven villages across Kilolo and Mufindi districts of Iringa Region. Seven focus group discussions (FGDs) involving 56 pregnant women were conducted. Participants were purposively selected from the Hehe community and were asked to interpret terminology and concepts contained in a harmonized Swahili BPCR education manual. The translation and adaptation process comprised six sequential steps: forward translation, synthesis, back translation, expert review, community exploration, and finalization. FGDs were conducted in Swahili by trained facilitators fluent in both Swahili and Hehe, audio-recorded with consent, transcribed, and thematically analyzed using Braun and Clarkes six-phase approach. Analysis focused on semantic, conceptual, experiential, and sociolinguistic equivalence. Reporting was informed by the Consolidated Criteria for Reporting Qualitative Research (COREQ). Results Five themes were developed: (1) culturally and linguistically familiar expressions conveyed BPCR concepts; (2) experiential and contextual language shaped descriptions of danger signs; (3) sociolinguistic norms and modesty influenced communication about sensitive health topics; (4) some clinically important concepts had partial or limited conceptual equivalence; and (5) unfamiliar concepts required supplementary explanation. Participants identified culturally familiar expressions including "matazamio ya kujifungua" ("anticipated date of delivery"), "fedha ndiyo usafiri" ("money itself is transport"), "chupa imepasuka" ("the water bag has burst"), "mtoto kutokucheza tumboni" ("the baby is not moving in the womb"), and "sehemu za siri" ("private parts"). Some expressions were familiar but broader than their biomedical equivalents, while cord prolapse and neonatal cyanosis had no readily recognized community equivalents. Conclusion The findings indicate that cultural and linguistic equivalence cannot be achieved through literal translation alone. Community exploration identified expressions that were familiar and socially acceptable while also revealing clinical concepts requiring additional explanation. The findings informed refinement of the Swahili BPCR education manual while preserving the intended clinical meaning. The adapted terminology should subsequently be evaluated separately for its effects on knowledge, attitudes, practices, and other health outcomes.

Abstract Background: Vaginal steaming has gained popularity among women for reasons known best to them. However, the effects of vaginal steaming on vaginal lactobacilli levels remain poorly understood and understudied. This study investigated the prevalence, assessed differences in the presence of bacterial vaginosis (BV) among women who practiced vaginal steaming and those who do not and determined the factors associated with vaginal steaming among women attending Mulago Sexually Transmitted Infections (STI) clinic in Uganda. Methods: This study utilized a cross-sectional design to enroll 181 women aged 18 to 49 years who were systematically sampled at Mulago STI clinic. Interviews were conducted to obtain the demographic characteristics of the participants. Vaginal swabbing and Gram staining were done to attain lactobacilli counts by microscopy which were categorized using the Nugent score. Data were analyzed using Stata. The potential confounding effects of other variables on the relation between vaginal steaming and the presence of bacterial vaginosis as well as factors associated with vaginal steaming were assessed using modified Poisson regression. Results: Prevalence of vaginal steaming was 40.3%, (95% confidence interval (CI) 33.0% - 48.0%). There were 41.1% women who practiced vaginal steaming occasionally, 53.4% who used hot water having herbs and 78.1% who practiced vaginal steaming for medical reasons. There was no difference in the presence of bacterial vaginosis when women who practiced vaginal steaming were compared to those who did not (p-value = 0.286). Factors that were significantly associated with vaginal steaming included having experienced vaginal issues (aPR = 0.07, 95% CI 0.01 - 0.12, p value = < 0.001) and contraceptive use (aPR= 0.52, 95% CI 0.37 - 0.72, p value = 0.001). Conclusions: About 2 in every 5 women at Mulago STI clinic reported to have indulged in vaginal steaming. There was no difference in the presence of bacterial vaginosis when women who practiced vaginal steaming were compared to those who did not. Having experienced vaginal issues and contraceptive use were significantly associated with vaginal steaming among women at Mulago STI clinic, Uganda. The Ministry of Health of Uganda should establish targeted screening and treatment for bacterial vaginosis alongside other sexually transmitted infections.

Background: Snakebite envenoming is a major cause of preventable death and disability in the Brazilian Amazon, where long distances, sparse roads, and dependence on river transport delay access to antivenom. We developed location-allocation models to identify community health centers that could strategically expand access to antivenom in Amazonas State, Brazil. Methodology/Principal Findings: We conducted an ecological geospatial study using a 2025 WorldPop population surface, locations of existing and candidate health facilities, and a multimodal road-and-river transportation network derived from OpenStreetMap and HydroSHEDS. Population demand was represented by 7,065 populated centroids, including 1,586 within Indigenous territories. We applied a maximize-coverage algorithm with a six-hour travel-time threshold. Two models were developed: one for Amazonas excluding Manaus and one for populations living in Indigenous territories. Both models began with 77 facilities already providing antivenom and progressively added candidate community health centers until coverage gains plateaued. The plateau occurred at 110 facilities, corresponding to 33 additional centers. In the model excluding Manaus, this configuration covered 1,118,831 people, or 75.11% of the target population; 87.61% of those covered could reach care within three hours. In Indigenous territories, coverage increased from 50.55% to 69.50%, reaching 50,434 people, of whom 81.39% were within three hours of care. Validation used 3,595 snakebite notifications from the 30 highest-burden municipalities in the Brazilian Notifiable Diseases Information System during 2023-2025. The median proportion reaching care within six hours was 40.81% in observed data and 72.17% in model estimates. Conclusions/Significance: Strategically equipping 33 additional existing community health centers could substantially expand timely access to antivenom, particularly in rural and Indigenous areas. Location-allocation modeling that incorporates river transportation can support evidence-based decentralization of time-sensitive health services in geographically complex settings.

All primary healthcare centers owned by the Ugandan government in the Western Region of Uganda were submitted to a questionnaire concerning current availability of POCT from the Essential diagnostic List 2 part 1a and 1b, and the African laboratory inventory done by African Society of Laboratory Medicine and AfricaCDC. The data from the questionnaire was then linked to open source geodata provided by TomTom, and population data to calculate and visualize the accessibility of captured POCT. Findings: Availability of POCT Malaria is almost 100%, HIV 68-90%, and >30% for a majority of the POCT in the EDL-2 panel. 90% of the population in Western Region live within 1 hour by car from most of the essential POCT. Figures in the complementary web-based application visualize the accessibility of POCT for Western Uganda. Diagnostic deserts are visualized. Interpretation: Access to POCT at primary health care facilities in western Uganda has expanded substantially over the past decades. The geo-mapping tool presented here could inform policy decisions on strengthening diagnostic capacity at the national, regional, and provincial level. Funding: Swedish Research Council and Infravis All supplementary materials and a preprint of this submission are available on our OSF repository https://osf.io/j7puk/.

Background: Cancer is a growing public health challenge in Ghana, with 27,385 new cases and 17,944 deaths recorded in 2022. Ghana developed a National Cancer Control Strategy (NCCS) in 2011 to guide prevention, early detection, treatment, and palliative care. The strategy expired in 2016 and has not been formally evaluated or renewed, leaving cancer control efforts without a guiding policy framework for nearly a decade. This study examined how the strategy was implemented, what barriers were encountered and what stakeholders recommend for a strengthened national cancer response. Methods: We conducted a qualitative descriptive study using semi-structured key informant interviews. Fifteen participants were recruited through purposive sampling, supplemented by snowball referrals, representing three groups: Ministry of Health policymakers, frontline healthcare providers and representatives of cancer-focused non-governmental organisations. Data were collected between June and September 2025 and analysed using Braun and Clarke's six-phase thematic analysis framework, guided deductively by the WHO Health Systems Building Blocks framework Results: Three themes emerged: NCCS interventions and systems implemented, capturing progress in cancer awareness, HPV vaccination and pilot screening programmes alongside persistent geographic and financial inequities in access; barriers to implementation, including inadequate financing, infrastructure and workforce shortages, the absence of a national cancer registry and governance failures, among them the finding that no frontline healthcare provider interviewed had any awareness of the NCCS; and recommended implementation strategies, including co-production of a renewed strategy, establishment of a dedicated National Cancer Control Programme, expanded health insurance coverage and decentralisation of oncology services. Conclusion: The NCCS was not operationally embedded in the health system. The evidence points to failures in policy dissemination as a constraint that precedes resource constraints. Addressing Ghana's rising cancer burden requires renewed political commitment, co-produced governance structures and accountability mechanisms. These findings have relevance for other low- and middle-income country settings facing similar challenges.

Background: Seasonal influenza, commonly known as flu, is an acute respiratory, highly contagious illness caused by influenza viruses. A clear understanding of influenza seasonality is crucial for guiding prevention and treatment strategies, including decisions on vaccination timing to prevent outbreaks. While well documented in temperate regions, data on influenza epidemiology in tropical areas, particularly sub-Saharan Africa, remain limited. We described the types, subtypes and positivity rate of seasonal influenza in Uganda during 2019-2023. Methods: We abstracted data from the National Influenza database on positive seasonal influenza cases confirmed by Polymerase Chain Reaction. The cases were disaggregated by age group, sex, region, month and year of reporting. Using Microsoft excel, we calculated the influenza positivity rate and disaggregated it by strain, sex, age, region and time. Test positivity rate was computed as the number of positive cases as a percentage of the total samples tested. Results: Among 17,957 individuals tested, the overall positivity rate for seasonal influenza was 5% (936 cases). Positivity was higher among males compared to females (7% vs. 4%), with children aged 5-9 years having the highest positivity rate (16%), while individuals aged 50-54 years had the lowest (1%). The median positivity rate was 4%, with a range of 1-16%. Regionally, the central region reported a positivity rate of 5%, with rates across all regions ranging from 5% to 8%. Over time, there was a gradual decline in positivity rates, decreasing from 16.5% in 2019 to 5.3% in 2023. Seasonal influenza exhibited bimodal peaks, with the primary peak occurring between March and May and a secondary peak from October to December. Influenza A was the predominant strain, accounting for 70% of seasonal influenza cases (669/936). Among the Influenza A subtypes, H3N2 was most common, representing 63% of cases (425/669). Conclusions: The declining seasonal influenza positivity rates from 2019 to 2023 and the predominance of Influenza A and H3N2 highlight the need for sustained surveillance in Uganda. Given Influenza A's high genetic variability and potential for novel strain emergence, monitoring circulating strains, informing vaccine development, and implementing targeted interventions for high-risk groups and regions are critical to controlling and preventing outbreaks.

In primary healthcare centers lacking advanced imaging, community-based active tuberculosis (TB) case finding often relies on basic symptom screening. This approach often misses cases and leads to the inefficient allocation of rapid molecular testing (RMT). We aimed to develop and internally validate a simple clinical triage scorecard to improve TB detection and guide RMT use in resource-constrained settings. We conducted a retrospective cross-sectional study of 15,137 adults ([&ge;]18 years) evaluated within the Zero TB Yogyakarta program (2020-2025). Participants with complete clinical assessments and confirmatory GeneXpert results were included. Using multivariable logistic regression, we identified independent clinical predictors, which were subsequently transformed into an integer-based point scorecard. Model performance was evaluated via discrimination and calibration, utilizing bootstrap resampling (1,000 iterations) for internal validation. Among the 15,137 participants, 251 (1.7%) were GeneXpert-positive. The final multivariable model identified eight independent predictors: age, male sex, body mass index, prolonged cough, hemoptysis, unexplained weight loss, TB contact history, and diabetes mellitus. The model demonstrated strong predictive accuracy, with an optimism-adjusted AUROC of 0.836 and good calibration. When translated to the integer scorecard and compared directly to standard national symptom screening, the scorecard performed (AUROC 0.81 vs. 0.73; p<0.001). At a high sensitivity cut off score of [&ge;] 0, the tool achieved 93.63% sensitivity and 41.33% specificity. This point-of-care clinical scorecard provides higher diagnostic accuracy than standard symptom screening algorithms. By offering flexible operational thresholds, it empowers local health programs to dynamically balance the urgency of case detection with available diagnostic capacity, optimizing GeneXpert allocation where advanced radiological imaging is unavailable.