PLOS Global Public Health

Sexually transmitted infections (STIs) remain a major global public health concern, with a disproportionate burden in low- and middle-income countries affected by conflict and displacement. In Nigeria, STI prevention and treatment sit within a crowded sexual and reproductive health (SRH) policy landscape shaped by vertically financed HIV programmes, expanding self-care agendas and one of the largest internally displaced populations in Africa. This qualitative study examines how structural, institutional and sociocultural forces shape STI service delivery for IDPs and how they reproduce or challenge sexual and reproductive health and rights. We conducted in-depth interviews with federal and state policymakers, United Nations representatives and national and international non-governmental actors involved in SRH and humanitarian programming in Nigeria. Using an interpretive, structurally informed approach, we explored participants accounts of funding architectures, governance priorities, humanitarian protocols, provider practices and gendered norms. Nigeria was considered "policy-rich but implementation-poor", with HIV-centred vertical financing creating a hierarchy of infections that renders non-HIV STIs comparatively invisible, unsubsidised and often effectively privatised in displacement settings. Chronic commodity shortages, workforce depletion in conflict-affected areas, weak surveillance systems and reliance on informal providers were seen as routine features of STI care in IDP camps. Sociocultural dynamics, including toilet infection narratives, gendered gatekeeping of womens healthcare and STI-related stigma, shaped how IDPs interpreted symptoms, when they sought care and which providers they used. At programme and government levels, self-care and task-shifting policies, although framed as expanding choice and autonomy, were implemented through fragile supply chains, limited regulation of informal providers and uneven access to digital platforms. The findings indicate that improving STI care for IDPs in Nigeria will require rebalancing HIV-dominated financing, securing affordable STI commodities, strengthening supervision and data systems and referral pathways so that self-care and humanitarian responses translate into accessible, reliable services.

Poor menstrual health (MH) has been associated with reduced participation in school activities and diminished psychosocial wellbeing among adolescent girls. Despite increasing recognition of the importance of MH interventions, there is limited economic evidence to inform large-scale adoption and financial planning. We conducted an incremental costing analysis of an MH intervention (MENISCUS) alongside a cluster-randomized trial in 60 secondary schools in Uganda. MENISCUS delivered puberty education, a drama skit, an MH kit, pain management strategies and improvements to water, sanitation and hygiene (WASH) facilities. We categorized the provider costs into start-up and implementation, and calculated unit costs per school, per student (male and female) and per female student respectively. We modelled two potential national scale-up scenarios (basic and enhanced) to 2,995 secondary schools using government delivery structures. The total cost of the basic scenario is US$10,224,685 and the enhanced scenario is US$16,549,123. The unit cost of scaling the intervention nationwide was estimated at US$28 per student and US$58 per female student (basic scenario) and US$46 per student and US$95 per female student (enhanced scenario). The primary cost drivers were the MH kit and associated training, followed by pain management activities and improvements to WASH facilities. The enhanced scenario generated a higher unit cost per student and unit cost per female student due to additional components. Compared with trial costs, unit costs were lower in national scale-up, demonstrating economies of scale. This study provides the first economic analysis of a potential national implementation of a school-based MH intervention in a low-resource setting. The findings provide critical benchmarks for governments seeking to integrate MH into national education curriculum and inform future investment decisions in adolescent health.

Sepsis caused by drug-resistant pathogens remains a major contributor to under-five mortality in low- and middle-income countries, threatening progress toward Sustainable Development Goal (SDG) 3.2. Blood culture, the gold standard for sepsis diagnosis and antimicrobial stewardship, remains underutilised in routine pediatric care. This study assessed the extent and determinants of blood culture utilisation among hospitalised children under five years with suspected sepsis at four antimicrobial resistance (AMR) surveillance sites in Uganda. We conducted a cross-sectional mixed-methods study involving retrospective review of 384 pediatric patient records and in-depth interviews with 20 clinicians. Modified Poisson regression was used to identify factors associated with blood culture requests, while thematic analysis explored behavioral and contextual influences on diagnostic practices. Blood cultures were requested in 28.1% of suspected sepsis cases. Higher utilisation was independently associated with markers of clinical severity, including severe acute malnutrition (adjusted prevalence ratio [aPR] 1.3, 95% CI: 1.14-1.34), sickle cell disease (aPR 1.3, 95% CI: 1.19-1.40), and presence of WHO danger signs (aPR 1.1, 95% CI: 1.00-1.14). Senior clinician involvement (aPR 1.2, 95% CI: 1.08-1.32) and consultant review (aPR 1.4, 95% CI: 1.21-1.48) were also associated with higher use, while prior antibiotic exposure reduced the likelihood of blood culture request (aPR 0.9, 95% CI: 0.84-0.96). Qualitative findings identified four overarching themes influencing diagnostic behavior: motivation amid systemic constraints, institutional and environmental barriers, mentorship and teamwork, and emotional fatigue in the context of adaptive practices. Despite high clinician awareness, blood culture utilisation remains low, driven primarily by health system fragility, inefficient workflows, and emotional exhaustion rather than knowledge gaps. Improving utilisation will require integrated behavioral, workflow, and structural interventions, including clinical decision support and strengthened microbiology laboratory capacity, to enhance pediatric sepsis care, antimicrobial stewardship, and progress toward SDG 3.2.

IntroductionThe long-standing disconnection of abortion legislation in Nigeria with the estimated incidence of 1.8 million terminations a year has contributed to systematic gaps in reliable abortion data for health policy. Any subnational monitoring under conditions of legal restraint tends to remain hidden beneath under-reporting and spatial instability such that policy makers are not left with a clear picture of where and why these decisions are being made. Methods and AnalysisTo address this ambiguity, this paper traces the path of state-level evolution of reproductive choices within the 2013, 2018 and 2024 NDHS. We detected the latent socio-demographic causes of terminated pregnancy using a Bayesian spatio-temporal framework, such as wealth, education, literacy, and contraceptive prevalence. ResultsThe rates were highly spatio-temporally intense and polarized in the region, with probabilistic evidence to justify state-specific reproductive health interventions between 2013 and 2024. Southern and coastal states (e.g., Lagos, Bayelsa) demonstrated sustained increases in prevalence in line with a high fertility transition, termination is more reproductive agency, access to services and reporting. Conversely, the unmet contraceptive need and structural vulnerability were the major causes of increased rates in the northern states (e.g., Yobe, Kano). Patterns of determinants also changed with time: in previous surveys, household wealth turned out to be a protective factor, as of 2024, education and literacy had become the strongest predictors. ConclusionsSuch findings affirm a dual reproductive regime in Nigeria--choice based in the South and vulnerability based in the North necessitating a shift from homogenous national approaches to state-specific reproductive health policies. What is already known on this topicStudies have noted the continuous disparities in the maternal and reproductive health indicators between northern and southern Nigerian states. Nevertheless, most of the studies done before were based on cross-sectional analysis and national-level summaries. Not many considered spatial dependence among states or studied how decisions on termination vary over time. What this study addsThrough shared modelling of spatial effects, temporal trends and space-time interactions, it establishes consistent high-risk conditions, arising hotspots and areas with decoding risk. The Bayesian model enhances the accuracy of the estimation since it takes into consideration the spatial correlation and the strength of borrowing on neighboring states. How this study might affect research, practice or policyIn the case of research, the study offers a methodological approach to the analysis of other maternal and public healthcare indicators by small-area estimation methods. Practically, with high-risk and emerging hotspots states identified, reproductive health more focused interventions can be implemented and limited resources can be efficiently allocated. To the policy, the study provides state-specifics evidence to inform subnational reproductive health planning and monitoring.

Despite the existence of strong global and national human rights frameworks that support disability inclusion, women with disabilities in Kenya are still heavily discriminated against and stigmatised due to the negative perceptions of the community. This study examined community attitudes toward the sexuality of women with disabilities in Kibra Sub-County, Nairobi, and investigated demographic factors influencing these views. Using a quantitative cross-sectional design, a stratified multistage random sample of 420 adult residents was surveyed using a perception questionnaire and the Attitudes Toward Disabled Person (ATDP) tool. The findings show that a large number of respondents recognize that women with disabilities have sexual feelings, have normal sexual organs, and are sexually active. Even though most demographic variables did not have a significant association with perceptions of sexual activity, religion was one variable that had a significant association with perceptions of sexual anatomy. Overall attitudes towards women and men based on the ATDP test were positive as evidenced by mean ATDP scores for women (118. 76) and men (116. 36) which were above the respective standard thresholds (110 and 113). Multiple linear regression identified religion and education as significant negative predictors of positive attitudes, whereas close contact with persons with disabilities predicted more positive views. Their results indicated that the Kibra community, to some extent, recognizes the sexual agency of women with disabilities, nevertheless, this recognition is largely symbolic. In order to protect the sexual and reproductive rights of these women, the focus of the intervention should be shifted from the mere symbolic acceptance to the implementation of rights, based policies and culturally responsive strategies for inclusion in informal settlements.

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

Healthcare inequality remains a major challenge for health systems globally. While previous studies have examined inequalities in specific healthcare services or sub-domains of care, evidence on disparities in access across formal inpatient healthcare settings in Nigeria remains limited. This study examines income-related inequalities and inequities in access to inpatient healthcare among rural households in Nigeria. The study used cross-sectional data from 624 rural households collected in 2022 as part of a human capital research project commissioned by the African Economic Research Consortium (AERC). Information on demographic characteristics, household income, consumption expenditure, health conditions, region of residence, and access to inpatient care was analyzed. Income-related inequalities and need-adjusted inequities were assessed using the Concentration Index (CI) and the Horizontal Inequity (HI) index. Overall, 81.4%, 49.9%, and 18.4% of respondents reported access to inpatient care at public primary, secondary, and tertiary health facilities, respectively, while 32.7% accessed inpatient care at private facilities. Access to public primary and secondary inpatient care decreased with household wealth, whereas access to public tertiary and private inpatient care increased with wealth. Significant pro-poor inequalities and inequities were observed in access to public primary (CI = -0.1054; HI = -0.0374) and secondary (CI = -0.1063; HI = -0.0377) inpatient care. In contrast, access to tertiary (CI = 0.2382; HI = 0.3660) and private (CI = 0.1502; HI = 0.2180) inpatient care exhibited significant pro-rich inequalities and inequities. Decomposition analysis indicated that non-need factors--particularly household economic status and region of residence--were the largest contributors to inequalities in access across all inpatient care types. ConclusionInequalities in access to inpatient healthcare were driven mainly by economic status and region of residence.

This study examines the impact of the Drugs for Neglected Diseases initiative (DNDi) on health research capacity and health system strengthening in the Democratic Republic of Congo (DRC) from 2005 to 2023. Using a qualitative approach with semi-structured interviews, stakeholders and beneficiaries shared their perceptions of DNDis interventions. The analysis, grounded in an integrative model of organizational performance, found that DNDis efforts significantly enhanced clinical and operational research capacity, improved healthcare infrastructure, and fostered knowledge exchange among health practitioners. Notably, the partnership contributed to reduced morbidity and mortality from sleeping sickness through the development of safer, more effective treatments such as nifurtimox-eflornithine combination therapy (NECT), fexinidazole, and acoziborole. DNDis support also enabled healthcare providers to expand research capacity beyond sleeping sickness, promoting collaboration and knowledge transfer between institutions. Overall, stakeholders reported positive outcomes for patients, communities, and practitioners, highlighting DNDis role in building sustainable research networks and enabling environments for innovation in resource-limited settings. The study underscores the importance of continued investment in research capacity and collaborative partnerships to address neglected diseases and strengthen health systems in low-resource contexts.

Male involvement in family planning remains a critical yet underexplored factor influencing contraceptive uptake and decision-making support for long-acting reversible contraceptives (LARCs) in Kampala, Uganda. This mixed-methods study assessed male participation in decision-making and support for long-acting reversible contraceptives among couples in Kampala. The study involved 362 male participants who completed structured questionnaires, six focus group discussions (FGDs) conducted with both men and women, and five key informant interviews (KIIs) with healthcare providers. Ethical approval was obtained from the Kampala International University Research Ethics Committee and the Uganda National Council for Science and Technology. Quantitative findings revealed that 96.4% of men reported that their partners discussed contraception with healthcare providers ({chi}{superscript 2} = 31.366, p < 0.001), yet only 9.7% of men accompanied their partners to clinics. Male support for family planning was primarily financial (60.2%), while joint decision-making on LARCs was reported by only 38.7% ({chi}{superscript 2} = 2.776, p = 0.596). Key determinants of male involvement included marital status, education level, and number of children. However, cultural norms ({chi}{superscript 2} = 42.813, p < 0.000) and religious beliefs ({chi}{superscript 2} = 29.402, p < 0.021) were identified as significant barriers to male participation. Qualitative findings from FGDs and KIIs echoed the limited involvement of men in family planning services, attributing this to entrenched gender norms, misconceptions about contraceptives, and the perception that reproductive health services are primarily for women. Although 44.2% of participants indicated that mens concerns were addressed during consultations, 77.3% reported limited availability of couple-focused counseling ({chi}{superscript 2} = 6.294, p = 0.178). The study concludes that male involvement in family planning decision-making and support for LARCs remains low, largely due to socio-cultural barriers and limited male-friendly services. The study recommends strengthening male engagement strategies by training health workers on inclusive counseling, involving community and religious leaders in awareness campaigns, and promoting male-friendly and couple-centered reproductive health services through community-based platforms.

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

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

BackgroundIntimate partner violence (IPV) during pregnancy is a critical public health and human rights issue that affect almost 30% of women and threatens maternal and fetal health among pregnant women. Despite the recognized burden of IPV in Tanzania, the prevalence and determinants among pregnant women need to be well identified using the national representative data. ObjectiveThis study aimed to determine the forms, prevalence, and factors associated with intimate partner violence among pregnant women in Tanzania using the 2022 Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) data. MethodsA cross-sectional study analyzed secondary data from the 2022 Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) on intimate partner violence (IPV) among pregnant women aged 15 - 49 years. A total of 435 pregnant women who responded to the IPV module were included. Weighted descriptive statistics estimated prevalence and forms of IPV, while modified Poisson regression determined factors associated with IPV. Adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) were reported. ResultsThe overall prevalence of IPV among pregnant women was 27.46% (95% CI: 22.94-32.50). Emotional violence was most common (25.26%), followed by sexual (11.04%) and physical (11.01%) violence. IPV prevalence was highest in Mara (60.3%), Songwe (50.1%), and Singida (39.0%) regions. Factors independently associated with IPV included partner alcohol use (APR = 2.55; 95% CI: 1.50-4.31), partner having other wives (APR = 1.75; 95% CI: 1.11-2.87), and union duration of 5-9 years (APR = 2.65; 95% CI: 1.14-6.18). Having a marriage certificate (APR = 0.51; 95% CI: 0.28-0.92) and one child (APR = 0.40; 95% CI: 0.17-0.95) were protective. ConclusionsIPV affects more than one in four pregnant women in Tanzania, with emotional abuse being predominant. Partner alcohol use, polygamy, and longer union duration heighten IPV risk. Integrating IPV screening and counseling into antenatal care and implementing behavior change interventions for partners could reduce the burden of violence during pregnancy.

Malaria imposes societal costs beyond health, including substantial effects on education, yet economic evaluations often overlook these broader impacts. We conducted a cross-sectoral benefit-cost analysis of malaria chemoprevention in school-aged children (SAC) across ten high-burden sub-Saharan African countries. Using recent trial data, we estimated impacts on malaria morbidity, mortality, school absenteeism, and literacy. The intervention was projected to cost $422 million and generate $5.7 billion in societal net benefits, yielding a benefit-cost ratio (BCR) of 14.3. Country-level BCRs ranged from 3.71 to 39.5, with the highest returns in Nigeria. Results were sensitive to drug choice, discount rate, and valuation of education benefits. When using school quality metrics (estimated via Learning-Adjusted Years of Schooling (LAYS)), BCRs increased up to 100-fold compared to estimates based on school quantity alone. Probabilistic sensitivity analysis yielded a mean simulated BCR of 11.00 (95% CI: 10.89-11.11), with a >95% probability of being cost-beneficial at a BCR threshold of 3. This study advances the evidence base for malaria chemoprevention in SAC, highlighting its dual health and educational benefits. These findings offer policymakers and funders strong evidence to prioritize malaria chemoprevention in SAC as a high-value investment in both health and human capital in malaria-endemic regions.

Adolescent girls and young women face significant sexual and reproductive health (SRH) challenges. We assessed the preliminary effectiveness of a community-based, peer-led SRH education intervention on risky sexual behaviors and comprehensive SRH knowledge among adolescent girls and young women aged 15-24 years in Moroto District, northeastern Uganda. From October 2024 to January 2025, we conducted a pre-post quasi-experiment study without a comparison group across six villages. Participants were selected through multi-stage sampling and assessed at baseline. They subsequently received the community-based peer-led SRH education intervention; each participant served as her own control in the absence of a comparison group. Risky sexual behavior was the primary outcome, and comprehensive SRH knowledge was the secondary outcome. The intervention effect was assessed using a generalized estimating equation with a Poisson distribution, log link function, and exchangeable correlation structure. We reported adjusted risk ratios (aRR) with 95% confidence intervals (CI). Of 389 participants who completed both the pre- and post-intervention evaluation, the mean ages were comparable (19.29 {+/-} 2.94 years vs. 19.31 {+/-} 2.91 years; p = 0.922, respectively). After the intervention, there was a significant decline in the proportion of participants who engaged in risky sexual behavior (57.1% before vs. 37.8% after, p<0.001) and a significant improvement in comprehensive SRH knowledge (85.6% before vs. 99.5% after, p<0.001). In cause-effect analysis, there was a 33% reduction in risky sexual behavior (aRR 0.67, 95% CI: 0.57-0.75), and a 16% improvement in comprehensive SRH knowledge (aRR 1.16, 95% CI: 1.12-1.20). A community-based, peer-led SRH education intervention reduces risky sexual behavior and improves comprehensive SRH knowledge. These findings should be considered preliminary, as robust studies are needed, including a need for nuanced strategies to address contextual factors that contribute to risky behavior despite improved comprehensive SRH knowledge.

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

Adolescents and young people living with HIV (AYPLHIV) face persistent challenges related to stigma, autonomy, and sustained engagement in care. Self-care services including tools and practices that enable individuals to manage their health play a critical role in HIV prevention and treatment by promoting adherence, empowerment, quality of life, and improved health outcomes. Despite their importance, evidence on the uptake and determinants of self-care services among AYPLHIV in Zambia remains limited. This study assessed the level of self-care service utilization and associated factors among adolescents and young people receiving HIV care in selected health facilities in Kitwe District. A facility-based cross-sectional study was conducted between September 2024 and April 2025 among 485 adolescents and young people aged 15-24 years attending four health facilities in Kitwe. Data were collected using structured, pre-tested questionnaires administered by trained research assistants. Data were analysed using Stata version 17. Overall, uptake of self-care services was suboptimal. Slightly more than half of participants (58%) reported ever using self-care services, while a substantial proportion (42%) had never utilized them. Awareness was generally low, with over half (56%) reporting no knowledge of available self-care interventions. Multivariable analysis showed that adolescents with secondary education had significantly lower odds of utilizing self-care services compared to those with no formal education (AOR = 0.54, p = 0.048). Accessibility was positively associated with utilization (AOR = 1.67, p = 0.031), whereas moderate and high levels of stigmatization were strongly associated with reduced uptake (AOR = 0.53, p = 0.022; AOR = 0.63, p = 0.029). Age, gender, peer influence, and provider support were not significantly associated with self-care service utilization. In conclusion, self-care service uptake among AYPLHIV in Kitwe District remains low, largely driven by limited awareness, accessibility barriers, and persistent stigma. Strengthening awareness campaigns, improving service availability, and implementing stigma-reduction strategies are essential to enhance self-care engagement and optimize HIV outcomes among adolescents and young people in Zambia.

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

As programs for azithromycin mass drug administration to reduce child mortality have begun in some parts of West Africa, it is imperative to understand their financial costs. We combined a micro-costing framework and observations from an implementation-focused sub-study within the AVENIR trials in 80 communities in the Dosso region of Niger to estimate the national health sector costs of a scaled-up programmatic approach for azithromycin biannual distribution to children aged 1-59 months of age living in nonurban areas, using the door-to-door modality. Our outcomes of interest were the annual budget at the regional and national levels for Niger and the cost per dose delivered. We found that the annual national budget required for azithromycin mass drug administration (MDA) achieving 90% average coverage would be $12.5M (95% Uncertainty Interval (UI) $12.2M, $13.0M) translating to $1.59 (95% UI $1.40, $2.30) per dose delivered. Across regions, cost per dose would vary from $1.17 (95% UI $1.03, $1.69) to $3.61 (95% UI $3.20, $5.16), with higher cost per dose expected for more sparsely populated regions. Training costs represented a large fraction (16.4%) of total costs, and integration of training with that for existing health interventions may provide opportunities for efficiency.

Seasonal Malaria Chemoprevention (SMC) is a promising intervention for Turkana, Northern Kenya, where malaria transmission is highly seasonal. Traditional malaria control methods, such as indoor residual spraying (IRS) and insecticide-treated nets (ITNs), are impractical due to the populations semi-nomadic lifestyle, temporary dwellings, sparse settlements, and limited access to health facilities. In 2024, following the WHOs updated guidance on SMC use, this intervention was implemented in Turkana Central for the first time, involving five monthly cycles of sulphadoxine-pyrimethamine with amodiaquine (SPAQ). To assess the programs feasibility, a mixed-methods study was conducted at the end of the campaign. Survey data from a randomly selected, representative sample of 449 households with 680 eligible children were analyzed using multi-level logistic regression to compare partial versus complete SMC adopters, accounting for clustering. It was supplemented by qualitative interviews involving 45 caregivers to explore barriers and facilitators to SMC adoption. The campaign achieved notable success, with 97% of children receiving at least one SMC cycle (95% CI: 94-99%), and 71% receiving all 5 cycles (95% CI: 66-75%), primarily through door-to-door delivery. The quality of delivery was evident, as 99% of caregivers reported direct observation of the first dose and proper instructions for subsequent days. Adherence to day 2 and 3 medication remained high at 95% (95% CI: 93.5-98.1). Regression analysis suggested that households familiar with their Community Health Promoter (CHP) and who communicated SMC information had lower odds of missing cycles. In contrast, children from wealthier families showed a 93% higher odds of missing cycles. Qualitative findings revealed that positive caregiver experiences with SMC effectiveness drove continuation, while late adoption was linked to illness/ineligibility, uncertainty, and rumors. Overall, these findings indicate that high and sustained SMC coverage is feasible in marginalized settings through adaptive delivery strategies and leveraging of trusted CHP networks, establishing a scalable model for similar mobile populations.

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