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.

Background: Indoor Residual Spraying (IRS) is a proven vector control intervention for malaria prevention, yet community acceptance remains suboptimal in many settings. This study assessed the knowledge, attitudes, and perceptions towards IRS among residents of Masala Township in Ndola, Copperbelt Province, Zambia. Methods: A community-based cross-sectional study was conducted among 282 systematically selected adult residents of Masala Township using a structured questionnaire administered through face-to-face interviews (response rate: 89.5%). Knowledge scores (range 0-6) were categorized as poor, moderate, or good. Attitudes were measured using Likert scale items (range 1-5) and categorized as positive, neutral, or negative. Data were analysed using descriptive statistics, chi-square tests, and binary logistic regression (p<0.05). Results: IRS coverage in the last 12 months was low at 24.8% (70/282). Knowledge levels were moderate in 43.6%, with only 24.8% demonstrating good knowledge. Attitudes were neutral overall (mean score 3.2), with 29.8% positive, 43.6% neutral, and 26.6% negative. Perceptions of chemical safety were poor, with only 39.7% believing IRS chemicals are safe. Fear of side effects (46.2%) and limited of trust in the spraying process (31.6%) were the most commonly reported barriers to acceptance. Associated factors with positive attitudes included: past spraying experience (AOR=4.56, p<0.001), tertiary education (AOR=3.45, p=0.002), higher income (AOR=2.89, p=0.007), plastered walls (AOR=2.12, p=0.029), and better knowledge (AOR=1.42, p=0.003). Conclusion: IRS coverage in Masala (24.8%) is substantially below the WHO-recommended 80% threshold. Fear of side effects and lack of trust were the main barriers to acceptance. Factors associated with positive attitudes included education, income, knowledge, wall type, past spraying experience, and trust in health workers. Given the cross-sectional design, these findings represent associations, not causal relationships. Urgent interventions addressing safety concerns through enhanced community sensitization and trust-building are needed to improve IRS uptake and progress towards Zambia's malaria elimination goals.

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.

Abstract Background The COVID-19 pandemic disrupted Ghanas health, economic, and social systems, prompting the government to launch a mass vaccination programme in March 2021, targeting 20 million people by the end of 2022, to reduce transmission and mitigate socio-economic strain. This study explored stakeholders perspectives on the politics of the COVID-19 vaccination programme, highlighting implementation challenges, political dynamics, and lessons for future pandemics. Methods A qualitative, exploratory, descriptive study was conducted between June and September 2021. Fourteen stakeholders from the Ministry of Health, the Ghana Health Service, academia, political leaders, and professional associations were purposively selected and engaged in key informant interviews. Data were analysed using Braun and Clarke's thematic analysis approach, guided by the Health Policy Triangle and Campos and Reichs policy implementation framework. Results Three main themes were generated. First, governance and institutional capacity shaped implementation through issues of procurement transparency, communication gaps, donor dependence, and operational constraints in data systems and logistics. Second, the political economy of vaccine procurement and distribution was influenced by leadership politics, bureaucratic dynamics, fiscal constraints, donor priorities, and interest-group influence. Third, stakeholders highlighted lessons for future pandemic preparedness, including strengthening transparent governance, improving public communication, building local vaccine research and manufacturing capacity, enhancing intersectoral coordination, and establishing robust monitoring and evaluation systems. Conclusion The rollout of COVID-19 vaccines in Ghana was shaped not only by technical and logistical considerations but also by complex political and governance dynamics. The study highlights how governance structures, political incentives, and interactions among key stakeholders influence policy implementation in resource-constrained settings. Ghanas experience underscores the importance of transparent governance, effective multistakeholder coordination, sustainable financing mechanisms, and strategic investment in regional vaccine research and manufacturing as critical pillars of pandemic preparedness. Strengthening these institutional and governance dimensions is essential not only for sustaining immunisation programmes but also for building resilient health systems capable of responding effectively to future global health emergencies.

ABSTRACT Prevalence and sociodemographic factors associated with unwanted pregnancy among adolescent girls in Kakuma Refugee Camp, Kenya: a cross-sectional mixed-methods study Authors : Benson Simba*1, Louisa Ndunyu1 and Lilian Ogonda2 Globally, an estimated 21 million adolescent girls aged 15-19 years become pregnant annually, with the burden often higher in refugee contexts. Adolescent pregnancy remains an important public health concern, particularly in humanitarian settings. Despite the availability of sexual and reproductive health services in Kakuma Refugee Camp, unwanted pregnancy among adolescent girls persists. According to routine health data from the United Nations High Commissioner for Refugees (UNHCR), 1,079 adolescent pregnancy cases were reported between January 2024 and July 2025 in Kakuma Refugee Camp. However, evidence on the factors associated with unwanted pregnancy among adolescent girls in this multinational refugee setting remains limited. This study estimated the prevalence of unwanted pregnancy and examined socio-demographic factors associated with unwanted pregnancy among adolescent girls in Kakuma Refugee Camp. We conducted a community-based analytical cross-sectional mixed-methods study among 431 adolescent girls aged 12-18 years recruited through multistage cluster sampling. Quantitative data were collected using a pretested structured questionnaire. For the qualitative data, audio-recorded interviews were conducted with four purposively selected health workers as key informants, together with a focus group discussion involving adolescent girls. Quantitative data were analysed using descriptive statistics, chi-square tests, bivariable logistic regression to estimate crude odds ratios (CORs), and multivariable logistic regression to estimate adjusted odds ratios (AORs), with statistical significance set at p [&le;] 0.05. Qualitative data were analysed thematically. The prevalence of unwanted pregnancy was 28.7%. The proportion varied considerably across camp sections, with the highest prevalence observed in Kakuma 2 (56.7%) and Kakuma 4 (54.1%). In adjusted analysis, adolescents aged 12-14 years had lower odds of unwanted pregnancy than those aged 15-18 years, although the association was borderline statistically significant (AOR = 0.348; 95% CI: 0.121-1.000; p = 0.050). Married adolescents had substantially higher adjusted odds of unwanted pregnancy than single/divorced/separated adolescents (AOR = 5.108; 95% CI: 3.065-8.512; p = 0.001), and Christian adolescents had higher adjusted odds than adolescents of other religions (AOR = 3.010; 95% CI: 1.087-8.337; p = 0.034). Compared with Kakuma 4, lower adjusted odds were observed in Kakuma 1 (AOR = 0.168; 95% CI: 0.059-0.483; p < 0.001) and Kakuma 3 (AOR = 0.073; 95% CI: 0.021-0.248; p < 0.001), while Kakuma 2 did not differ significantly. Qualitative findings highlighted older age, being out of school, lower educational attainment, and socioeconomic vulnerability as factors perceived to increase vulnerability to unwanted pregnancy. Unwanted pregnancy remains an important public health concern among adolescent girls in Kakuma Camp. The findings identify marital status, religion, and camp location as important independent correlates, with age showing borderline evidence of an adjusted association. School attendance and education level were associated with unwanted pregnancy in unadjusted analyses but were not independently significant in the adjusted results presented. These findings support context-specific interventions that improve contraceptive access, support school retention, engage married adolescents, and address social and structural vulnerabilities across Kakuma.

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.

Introduction Despite efforts to eliminate tuberculosis (TB) in the United States (U.S.), many individuals diagnosed with latent TB infection (LTBI) who are at increased risk of progressing to TB disease do not initiate TB preventive treatment. Methods Among adults receiving primary care in a federally qualified community health center in the San Francisco Bay Area, California, we conducted a cross-sectional online survey using a situational choice experiment to assess the circumstances in which individuals at risk for TB based on nativity would accept LTBI treatment. In 10 randomized choice tasks, participants answered whether or not they would accept LTBI treatment. In situations where LTBI treatment was accepted, participants were asked a follow-up question about whether they would change their response knowing that reinfection is still possible with LTBI treatment. Attributes assessed included risk level of progression to TB, side effects, changes to co-medication, cost, number of clinic visits, blood draws, and reinfection risk. We conducted a mixed-effects logistic regression to estimate factors associated with treatment acceptance and predicted acceptance across scenarios. Results Of 852 individuals who consented, 458 (53.8%) had complete responses and were included in the analysis. LTBI treatment was accepted in 69.4% of choice scenarios (3180/4580); among scenarios where treatment was initially accepted, 91.5% of scenarios (2911/3180) remained accepted when reinfection possibility was introduced. Compared to situations with low risk of TB progression, high TB progression risk increased the acceptance of LTBI treatment (adjusted odds ratio aOR 2.55, 95% Confidence Interval (CI) = 2.03-3.19). Compared with fatigue as a referent, risk of any liver injury/inflammation (aOR 0.29, 95% CI = 0.22-0.38), gastrointestinal side effects (aOR 0.53, 95% CI 0.41-0.69), rash (aOR 0.62, 95% CI 0.48-0.80) and out-of-pocket cost of $100 (aOR 0.32, 95% CI = 0.26-0.41 compared to $0) were associated with lower acceptance of LTBI treatment. Conclusions The decision to accept LTBI treatment was sensitive to treatment characteristics, suggesting that shared decision-making should be broadly promoted among individuals diagnosed with or at risk of LTBI, particularly in diverse primary care settings serving individuals born in high TB burden countries, with attention to individual concerns such as cost and side effects to improve LTBI treatment uptake.

Intimate Partner Violence (IPV) has been shown to affect womens access to sexual and reproductive health services, including modern contraceptives. However, there is conflicting data in the literature on how the experience of IPV among women affects modern contraceptive use, with some studies showing decreased rates of modern contraceptive use, while others have shown increased rates of modern contraceptive use among these women. This study therefore, aimed at studying the association between the experience of IPV and modern contraceptive use among women presenting for abortion care in Lusaka District, Zambia. A cross-sectional study was conducted from 1 November to 31 December 2024 at four hospitals in Lusaka District. Women seeking abortion care were enrolled via convenience sampling, and data were obtained using a pre-tested interviewer-administered questionnaire. The outcome variable was modern contraceptive use in the preceding six months; exposures included IPV within the prior six months, as well as socio-demographic and reproductive characteristics. Analyses comprised descriptive statistics, chi-square test and multiple logistic regression. A total of 372 women participated in the study and data was analysed for 367 women, with a median age of 25 years (IQR 22-30). IPV was reported by 231 participants (62.9%), most commonly emotional violence (44.7%). Modern contraceptive use within the preceding six months was reported by 150 women (40.9%). The odds of modern contraceptive use was lower amon women with IPV exposure compared with those who were not exposed (aOR 0.3; 95% CI 0.17-0.52), but higher among women seeking abortion care services from Chawama First Level Hospital compared to those seeking services from the Women and Newborn University Teaching Hospital ((aOR 4.4; 95% CI 1.68 - 11.65) and among women aged above 24 years compared to adolescent girls and young women (AGYW) aged 14-24 years (aOR 14; 95% CI, 6.40 - 30.60). More than half of the women accessing abortion care services in Lusaka district experienced intimate partner violence, and less than half had used modern contraceptives within six months before they participated in the study. Thus, policies and programmes aimed at increasing modern contraceptive use among women should pay particular attention at addressing IPV and the reproductive health needs of AGYW and women residing in peri-urban areas.

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

Background Despite decades of investment in immunization, an estimated 14.3 million children worldwide remain zero-dose (ZD). Kenya's national coverage of approximately 72% masks significant subnational disparities, with existing methods failing to capture the context-specific drivers of zero-dose status. Objective: To apply human centered design (HCD) and continuous learning to understand Who are ZD children, Why they are ZD and to co-design and pilot tailored interventions in two high-burden Kenyan sub-counties. Methods We implemented the Zero Dose Learning Agenda in Turkana Central (rural, nomadic) and Rachuonyo North (semi urban) between November 2023 and December 2025. We applied PATHs Living Labs 4D HCD methodology (Discover, Define, Dream, Design) to guide the data collection process (interviews, observations, focus group discussions [FGDs], facilitated discussions), analysis (quantitative surveys, qualitative and data triangulation), co-creation/ideation (ideation, concept validation), prototyping (detailed concept sheet development, measurement and implementation plans) and iterative testing of three ZD interventions in select facilities and communities. Results We engaged 798 participants and identified six distinct caregiver archetypes per site. Gender norms dominated drivers in Rachuonyo North; geographic access and marginalization dominated in Turkana Central. Chanjo Talks Kazini (n=188) achieved 60.1% completion and 92.5% satisfaction; perceived spousal support increased from 37.1% to 74.4%. Quality Household Assessment and Sensitization trained 68 community health promoters, reached 874 households, and identified 15 zero dose and 39 under-immunized children, all subsequently vaccinated. Chanjo Mashinani conducted 30 low cost outreach events, reached 266 zero dose children, and reduced costs by over 70% versus conventional outreach. Iterative adaptation uncovered barriers including male caregivers' fear of HIV testing, invisible to baseline instruments. Conclusion Combining human-centered design with continuous learning enables immunization programs to diagnose context-specific barriers and correct course in real time. Zero-dose children share a label but not pathways to exclusion; effective reach requires tailored strategies that account for local gender dynamics, health system trust, and access constraints. Teaser key message ZD and UI children require tailored approaches and interventions to be identified, understood and reached, all while ensuring local voices engagement are not left at problem identification, and resources are availed to support weaker health systems.

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

Background: Nigeria's malaria burden is the highest in the world, both in terms of incidence and fatalities. Case management uses the WHO's Test, Treat, Track (T3) approach, where failures can occur at three stages (care-seeking, diagnostic testing, and treatment appropriateness), which are often combined into a single coverage measure. In this study, we split the cascade into two outcomes and compared four predictive modeling approaches to identify determinants. Methods: From the Children's Recode file of the 2023-24 Nigeria DHS, we identified 3,962 children under 5 years of age who reported having a fever in the two weeks before the survey. Gap A (access) was defined as: seeking care from any source and receiving a diagnostic blood test. Gap B (quality) was limited to the 1,776 children who had received any antimalarial, and specifically defined as receipt of an artemisinin-based combination therapy (ACT) only. To predict both outcomes, we tested and compared survey-weighted logistic regression, elastic-net regression, random forest, and gradient boosting (XGBoost) using a single held-out test partition and the area under the receiver operating characteristic curve (AUC) for all four models across both outcomes. Results: The proportion of febrile children with combined access threshold was 16.0%, and 60.2% of children treated with antimalarials received an ACT. The Gap A logistic model did not reach overall statistical significance (p = 0.189); the Gap B model did (p = 0.003), with caregiver-reported financial barriers to care significantly associated with lower odds of ACT receipt ({beta} = -0.97, p = 0.013), a finding that replicated across three of the four modeling approaches. AUCs were between 0.48 and 0.62 for the eight models, and all 95% CIs contained 0.50, meaning that none of the models could be confidently ruled out as being no better at discrimination than chance. For both outcomes, gradient boosting had the lowest AUC of the four methods, similar to what has been previously reported for a comparable treatment-cascade outcome in Mexico's ENSANUT survey. Conclusion: Limited variation in Nigeria's malaria care-seeking, testing, and treatment cascade can be explained by household and maternal characteristics captured in standard survey data. The consistent association between financial access barriers and reduced likelihood of ACT-specific treatment suggests point-of-sale cost, rather than caregiver knowledge alone, as a target for intervention within Nigeria's pharmacy and patent/proprietary medicine vendor distribution channels.

Cervical cancer is a leading cause of cancer death among women in Zambia, and vaccination of girls aged 9-14 years against human papillomavirus (HPV) is the principal primary prevention strategy. Because the vaccine is given to minors, uptake depends on parental consent, which is shaped by how parents perceive the vaccine. In Kabompo, a rural, ethnically diverse district of North-Western Province, only 59% of eligible girls had been vaccinated by 2024, well below the global target, yet no qualitative evidence existed on how parents in such settings understand and decide about the vaccine. We conducted a descriptive phenomenological study at Kabompo Hospital Affiliated Health Centre between June and August 2025. Twenty parents and legal guardians of girls aged 9-14 years were purposively selected using maximum variation sampling and interviewed in depth in English or Luvale. Interviews were audio-recorded, transcribed verbatim and analysed using Colaizzi's seven-step method with QDA Miner Lite. Five themes were generated: knowledge and awareness of HPV and its vaccine; perceptions of safety and efficacy; sociocultural and religious influences; the role of health workers; and barriers to access. Most parents knew the vaccine prevents cervical cancer, but few could explain how HPV causes cancer or state the schedule, and several first learned about the vaccine at the point of service. Fear of infertility was the most prominent concern, alongside unease that the vaccine was too new. Religious framings of divine protection, preference for herbal remedies, and concern that vaccination condones early sexual activity shaped decisions. Health workers were the most trusted source of information and were often decisive. Distance, transport costs, fear of injections and incomplete dosing limited uptake. Stated acceptability was high but did not consistently translate into vaccination, indicating an intention-behaviour gap that information campaigns alone are unlikely to close.

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

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: Death is a social and cultural phenomenon whose meaning shapes how and whether losses are mourned, disclosed, and reported. These dynamics have direct implications for maternal and perinatal death surveillance and response (MPDSR), yet remain understudied, particularly in humanitarian contexts. Methods: This phenomenological qualitative study was conducted in two conflict-affected health zones in Eastern Democratic Republic of Congo. In-depth interviews (n=50) were conducted with bereaved family members of maternal or perinatal deaths, community leaders, and health providers to understand the socio-cultural practices surrounding death and the factors influencing MPDSR. Interviews were transcribed in French and analyzed using inductive thematic content analysis. Results: Four themes characterized the socio-cultural practices surrounding maternal and perinatal deaths: burial practices, mourning and bereavement traditions, rationale for these practices, and the impact of insecurity on customs. Burial and mourning practices differed markedly by type of death, with stillbirths and neonatal deaths accorded significantly less social recognition than maternal deaths. Deaths were commonly attributed to witchcraft or spiritual causality, or blame directed at mothers, husbands, and health providers. Active conflict further disrupted customary practices and eroded community trust. Collectively, these dynamics inhibit disclosure and reporting of deaths, undermining MPDSR case identification. Conclusion: Effective MPDSR in conflict-affected settings requires culturally responsive adaptation, community involvement in case identification, and trust in health sector actors. By documenting specific actors involved in burials, variations in burial and mourning practices, and how conflict changes socio-cultural practices, findings offer actionable entry points for strengthening MPDSR in conflict-affect health zones in Eastern DRC.

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