Public Health in Practice

Background: Anaemia in women of reproductive age is a persistent contributor to maternal morbidity and adverse birth outcomes in sub-Saharan Africa. Ghanaian surveys have repeatedly placed national anaemia prevalence in the World Health Organization's severe public health problem range, yet the geographical distribution of this burden, and the socioeconomic factors that may account for it after geographical adjustment, remain insufficiently elucidated. Methods: This cross-sectional study analysed the women's and geospatial files of the 2022 Ghana Demographic and Health Survey. Anaemia was defined as altitude- and smoking-adjusted haemoglobin below World Health Organization thresholds among 7,557 women aged 15-49 years with a valid measurement. Survey-weighted multivariable logistic regression, accounting for clustering, stratification, and sampling weights, was used to elucidate socioeconomic and demographic correlates. Cluster-level prevalence was tested for spatial clustering with global Moran's I and local Getis-Ord Gi* statistics (k-nearest neighbour weights, k = 8). Results: Weighted anaemia prevalence was estimated at 41.1% (mild: 22.6%, moderate: 17.3%, and severe: 1.1%). Pregnant women appeared to have higher adjusted odds of anaemia than non-pregnant women (adjusted odds ratio [AOR] 1.71, 95% CI 1.38-2.12), as did women in the Northern (AOR 1.54, 95% CI 1.16-2.06) and Savannah (AOR 1.35, 95% CI 1.04-1.76) regions relative to Greater Accra, while the Ahafo region showed lower odds (AOR 0.64, 95% CI 0.43-0.94). Associations with rural residence, education, and wealth that were significant in crude analysis appeared substantially attenuated after adjustment. Moran's I suggested significant positive spatial autocorrelation (I = 0.156, p = 0.001); Getis-Ord Gi* identified 109 hotspot and 117 cold spot clusters among 618 clusters, with hotspots concentrated in the north and cold spots in the mid-southern forest belt. Conclusion: Two in five women of reproductive age in Ghana were estimated to have been anaemic in 2022. Risk appeared to be shaped more by region and pregnancy status than by household wealth or education once geography was accounted for. Anaemia-control programming may benefit from prioritising the identified northern hotspot areas alongside routine antenatal supplementation.

Background: Workplace discrimination and violence against health workers including sexual harassment is a societal problem worldwide. We aimed to assess the frequency, predictive factors, and effects of sexual harassment using a nationwide survey of physicians working in Switzerland. Materials and Methods: We conducted a self-administered questionnaire survey of physicians working in Swiss healthcare institutions. The questionnaire assessed experiences of sexual harassment at work, including frequency, types, and sources of harassment. It also asked about the impact of sexual harassment, whether incidents were reported, and what actions were taken following a report. Results: Among the 1837 physicians that participated in the survey, 575 (31.3%) had experienced sexual harassment at least once during their career. Among those reporting sexual harassment, 39.1% of women and 13.2% of men had experienced harassment at least once in their job. Women reported more verbal harassment, while men reported more physical harassment. Women were also more likely to face both forms combined. The main sources of harassment were colleagues of the same profession (46.7%), patients (42.3%), and superiors (41.0%). The most frequently reported impacts included stress (60.1%), emotional exhaustion (34.7%), reduced motivation at work (30%), and considering leaving the job (7.5%). Gender-men was associated with a lower likelihood of experiencing harassment 0.24 (0.18 to 0.31), whereas working in the German-speaking region was associated with a slightly higher likelihood of having experienced sexual harassment at least once (OR 1.35, 95% CI:1.02-1.81). Conclusions: Sexual harassment is common among physicians in Swiss healthcare institutions. It adversely affects the mental health and career trajectories of both men and women yet remains widely underreported due to fears of reprisals and inaction. Institutions should effectively intervene to ensure that reported incidents result in appropriate actions, and that those who report them receive adequate protection from reprisals.

Background: Disaster medicine has been a formal curricular recommendation in German health professions education since 2006, and comparable recommendations exist internationally. Evidence on implementation is confined almost entirely to human medicine, rests on faculty self-reports or small student samples, and measures delivery rather than retention. Whether curricular exposure is associated with willingness to serve has not been adequately examined in interprofessional samples. Objective: We aimed to characterize disaster medicine education across 7 health professions in Germany, distinguishing delivery from retention, to identify profession-specific gaps and training priorities, and to examine how educational and experiential factors relate to willingness to serve. Methods: We conducted an anonymous nationwide online cross-sectional survey of students and trainees across 7 health professions in Germany between July 9 and August 25, 2026, recruited through institutional distribution lists. The interprofessionally developed instrument comprised 48 items. We assessed delivery and retention of 12 disaster medicine topics (4-point scale), self-rated confidence in 22 clinical and nursing skills (6-point scale), desired content, formats, motivators and barriers, and formal and spontaneous willingness. For all rating scales, higher values denote the more favorable level. We derived a delivery-retention gap and a want-deficit index, examined the dimensional structure of the competence battery, tested for differential item functioning by prior civil protection engagement, and modeled willingness with a cumulative link model. Results: Of 8133 respondents (completion rate 87.5%), 33.1% had never been taught disaster medicine and 25.0% only in passing; 22.1% had comprehensive teaching including practical exercises. Across the 12 topics, the proportion able to retrieve content confidently never exceeded 23.9%; the delivery-retention gap reached 47.3 percentage points. More than half (54.6%) had never taken part in a practical exercise. Competence formed more than 1 dimension: 18 acute-technical items loaded 0.54-0.86 on the first factor, 4 relational and nursing items 0.14-0.28. Prior civil protection engagement was associated with higher confidence on every acute-technical item (Cliff delta 0.26-0.55) and lower confidence on all 4 relational items (-0.22 to -0.09). Willingness was high and homogeneous across groups (78.7% formal, 84.1% spontaneous), whereas competence varied by about 2 scale points. Adjusted, active civil protection engagement (odds ratio 2.49, 95% CI 2.12-2.94) and practical exercise experience (odds ratio 1.78, 95% CI 1.54-2.05) were the strongest predictors; curricular exposure contributed weakly (odds ratio 1.06 per SD, 95% CI 0.99-1.14). Conclusions: Two decades after the curricular recommendation, disaster medicine is largely absent from health professions education in Germany, and what is delivered is not retained. Willingness is nevertheless high and largely decoupled from competence, so qualification and recruitment require separate instruments. Curricula should be prioritized by the coincidence of demand and deficit rather than by coverage, built for retention, and should treat relational and nursing competence as a distinct learning objective.

Sex workers remain disproportionately affected by HIV and mental health distress because their access to prevention and support services is shaped by stigma, criminalisation, violence, poverty, unequal client power, fear of disclosure and negative healthcare encounters. These pressures are particularly visible in district-level settings where sex workers must balance unstable income, personal safety and healthcare needs. A qualitative research design was used. Participants were recruited through purposive and snowball sampling. Twenty unique participants took part in the study: five participated in individual semi-structured interviews and 15 different participants attended two focus group discussions comprising seven and eight participants, respectively. No individual interview participant attended a focus group discussion. Participants were aged 18 years or older and lived or worked in the West Rand District. The interviews and focus group discussions were audio-recorded, transcribed verbatim and analysed through reflexive thematic analysis informed by Braun and Clarkes six-phase process, with data organisation supported by NVivo. Six themes were developed: sex work as economic survival rather than simple choice; HIV prevention under conditions of unequal client power; healthcare access shaped by stigma, fear and lack of confidentiality; mental health distress as part of everyday sex work; peer educators as trusted bridges to care; and the need for inclusive and differentiated support. HIV prevention and mental health support were interconnected through poverty, client negotiation, clinic mistrust, emotional distress and reliance on peer-led services. Economic insecurity, client power, stigma, weak confidentiality and psychological distress constrained access to HIV prevention and mental health support services. Peer educators facilitated access through information, referrals, emotional support and clinic navigation. Services should therefore be integrated, confidential, stigma-free and responsive to diverse gender identities, sexual orientations and sex-work settings.

Abstract Background: The risk of developmental delays among infants in the refugee camps is high due to prolonged exposure to adverse situations such as poverty, violence, lack of access to basic necessities, safety, poor maternal mental health and inadequate access to healthcare. To reduce the risk of developmental delays, a contextualized early child development and maternal mental health care package, was implemented through enabling and engaging the refugee women as community-based care providers. Methods: The process evaluation study was conducted using a mix-method design to explore the acceptability, feasibility, appropriateness, adoption, and cost of the Early Child Development (ECD) and maternal mental health care package in refugee camps, by applying Proctor et al framework. Data on quantitative indicators was reviewed for 348 mother-child dyads in the intervention arm. Qualitative interviews were conducted with 12 mothers, 5 community health workers, and 2 members of the implementing research team. Incremental Cost-Effectiveness Ratio (ICER) was calculated using the healthcare provider perspective to estimate the incremental cost-effectiveness of the ECD care package in reducing proportion of children with two or more developmental delays. Results: Home-based delivery of counselling sessions was a key facilitator in ensuring the successful implementation of intervention. The delivery of intervention by modestly educated refugee women reduced cultural and language barriers and facilitated the home-based delivery of sessions. Mothers found the recommended activities feasible to do in routine as they were culturally appropriate, and did not require maternal literacy or additional resources. The intervention was cost-effective with an ICER of 63 USD in reducing the proportion of children with two or more developmental delays by one percentage point. Conclusion: Contextualized ECD and maternal health care package is a potentially replicable and scalable intervention for refugee healthcare systems.

BackgroundFebrile neutropenia requires rapid empirical antibiotic therapy, with regimen selection shaped by local prescribing practice and pathogen patterns. We described starting treatment, later drug changes, microbiological findings, and inpatient outcomes. MethodsThis ambispective cohort comprised 96 episodes from 90 patients admitted to a tertiary-level teaching hospital. Treatment and outcome analyses used each episode as the unit of observation. Recorded variables included the starting antibiotics, later regimen modification, microbiology, hospitalization length, invasive fungal infection (IFI) as captured in study records, and disposition. Comparisons based on escalation status were exploratory. ResultCefoperazone-sulbactam appeared in 62/96 initial regimens (64.6%), amikacin in 42 (43.8%), teicoplanin in 28 (29.2%), and meropenem in 14 (14.6%). Eighteen episodes (18.8%) required a change that broadened or substituted antibacterial therapy. Among 31 microbiologically documented infections, 22 (71.0%) yielded Gram-negative organisms and 9 (29.0%) were polymicrobial. Median length of admission was 18.5 days in the escalation group and 9 days in the remainder (p<0.001). Mortality was 27.8% (5/18) with escalation and 5.1% (4/78) without it (p=0.011), with nine inhospital deaths overall (9.4%). ConclusionAntibacterial management differed within this cohort, with treatment escalation required in 18 of 96 episodes. Gram-negative organisms comprised most microbiologically confirmed infections. Escalation marked a clinically complex course with prolonged hospitalization and greater observed mortality; the observational design does not establish comparative efficacy or causation.

Adolescent suicidal ideation is a critical public health issue, yet empirical evidence on its prevalence and associated factors among adolescents in northern Bangladesh remains limited. This study estimated the 12-month prevalence of suicidal ideation and examined its associated factors among school-going adolescents in Nilphamari District, Bangladesh. A cross-sectional survey was conducted between May and June 2026 among 365 adolescents aged 13-19 years across eight secondary schools and colleges. Self-administered questionnaires assessed suicidal ideation alongside validated tools for depression (PHQ-9), anxiety (GAD-7), and perceived social support (MSPSS). Factors associated with suicidal ideation were examined using multivariable logistic regression. The 12-month prevalence of suicidal ideation was 30.7% (112/365; 95% CI 26.0%-35.7%). In the primary multivariable model, moderate depression (AOR = 6.05, 95% CI 1.03-35.38; p = 0.046) and moderately severe depression (AOR = 6.86, 95% CI 1.05-44.62; p = 0.044) were associated with higher odds of suicidal ideation compared to minimal depression. However, this association was not statistically significant in a sensitivity analysis using the PHQ-8 score after excluding Item 9 (AOR = 1.06, 95% CI: 0.96-1.17; p = 0.228). Loneliness "often" showed the strongest association with suicidal ideation (AOR = 10.59, 95% CI: 2.53-44.35; p = 0.001). Suicidal ideation was also associated with truancy of 6-9 days (AOR 4.44, 95% CI 1.24-15.90; p = 0.022), truancy of [&ge;]10 days (AOR 3.77, 95% CI 1.34-10.59; p = 0.012), intentional self-harm (AOR = 2.51, 95% CI: 1.17-5.41; p = 0.018), and physical harm exposure (AOR = 2.63, 95% CI: 1.24-5.57; p = 0.012). Maternal secondary education was associated with lower odds of suicidal ideation (AOR = 0.34, 95% CI: 0.12-0.99; p = 0.048). Suicidal ideation was common among school-going adolescents in northern Bangladesh, affecting nearly one in three participants. Early school-based identification and support for adolescents experiencing mental-health and psychosocial difficulties, together with family engagement and strengthened suicide-prevention services, are warranted.

Violence against women is a key contributor to mental health gender disparities, with greater gender gaps observed in low-and middle-income countries. This study examines state-level associations between gender-based violence against women and mental health burden in India over time. We linked 1) annual state-level age-standardised disability-adjusted life year rates (ASDR) from the Global Burden of Disease study for overall mental health disorders, depressive disorders, anxiety disorders, bipolar disorder, schizophrenia and self-harm, with 2) annual state-level gender-based violence rates from the Open Government Data Platform, India. We used descriptive ecological analyses and multilevel modelling to estimate the state-level association between gender-based violence and sex-stratified mental health outcomes over time (2001 - 2021). Results showed higher state-level gender-based violence (GBV) rates were associated with higher state-level ASDR of schizophrenia ({beta}women = 0.39 [95%CI 0.25 - 0.52]; {beta}men = 0.42 [0.29 - 0.55]) and bipolar disorder ({beta}women = 0.02 [0.01- 0.03]; {beta}men = 0.04 [0.03 - 0.05]), after adjustment for state-level social development, but not with other outcomes. Higher GBV rates were associated with a lower gender disparity in depressive disorders. Longitudinal findings revealed that the state-level association between GBV rates and ASDR of overall mental health disorders strengthened over time ({beta}women = 5.08 [3.96 - 6.20]; {beta}men = 3.38 [2.60 - 4.15]), whereas the association weakened for self-harm and schizophrenia. Lagged findings suggested that with an increase in GBV rate, ASDR of overall mental health disorders increased for men over two years and for both sexes over five years. Our findings highlight the importance of considering state-level trends in GBV and related policies, and considering impacts of GBV on both men and women's mental health.

Background: The decline of mental health among adolescents in the UK over the past two decades has occurred amidst many societal and technological changes making it difficult to identify drivers of these trends. We aimed to identify which aspect of life showed the most rapid deterioration in satisfaction in the UK since 2009 and which aspects have become increasingly correlated with mental health. Methods: Between 2009 and 2024, 15,829 adolescents aged 10-15 rated their satisfaction with life as well as five aspects of life (family, friends, school, schoolwork, appearance), via the UK Household Longitudinal Study. Population-weighted regressions were used to estimate annual summary statistics on these items (means, proportions) and the relative associations between satisfaction items and socioemotional difficulties, as measured by the Strengths and Difficulties Questionnaire (SDQ). Meta-regressions estimated linear changes over time, with interactions testing for heterogeneity across sexes, age-groups, and household income. Results: Mean satisfaction with life dropped over the 16 years of study (B=-0.028, 95% CI=-0.034, -0.022), as did satisfaction with all five aspects of life. Satisfaction with school declined most rapidly (B=-0.027, 95% CI=-0.034,-0.020), becoming accelerated in the most recent 5-year window (2020-24; B=-0.139, 95% CI=-0.178,-0.099). The proportion of dissatisfied individuals rose most rapidly for schoolwork, particularly for females. Satisfaction with appearance became increasingly associated with general life satisfaction (B=0.009, 95% CI=0.005, 0.013, p<.001) and socioemotional difficulties (B=-0.051, 95% CI=-0.073,-0.029, p<.001) over time. Conclusions: Our findings add to international evidence for academic pressure and school environments as plausible drivers of recent declines in life satisfaction, particularly among female adolescents. Future studies should aim to identify the specific aspects of school life that are influencing adolescent mental health and the impact of existing educational policies on student wellbeing should be evaluated.

Since its inception in 2003, the United States President's Emergency Plan for AIDS Relief (PEPFAR) has played a central role in HIV/AIDS prevention and treatment across Sub-Saharan Africa. Following the January 2025 suspension of United States foreign aid, which includes PEPFAR funding, countries across Sub-Saharan Africa demonstrated varying governmental responses to the resulting HIV funding disruptions. This study evaluates whether national characteristics were associated with a country's ability to respond to this funding crisis. Countries in Sub-Saharan Africa receiving PEPFAR funding were classified into one of three response categories: Level 1 (minimal or no governmental response), Level 2 (government response without sufficient plans or resources to fully offset funding losses), or Level 3 (high governmental response with strategies to maintain HIV/AIDS prevention and treatment services). Response categories were compared with national Human Development Index (HDI), GDP per capita, HIV prevalence, total population living with HIV, annual HIV mortality, and historical PEPFAR funding. Univariable proportional-odds ordinal logistic regression was used to identify factors associated with response level. Five countries (17.2%) were classified as Level 1, 10 (34.5%) as Level 2, and 14 (48.3%) as Level 3. Higher HDI was significantly associated with stronger governmental response (OR = 4.05; 95% CI, 1.49-11.04; Holm-adjusted p = 0.0376). GDP per capita (OR = 2.35; 95% CI, 1.00-5.51; unadjusted p = 0.0489) and HIV prevalence (OR = 3.53; 95% CI, 1.03-12.11; unadjusted p = 0.0452) demonstrated positive associations before adjustment for multiple comparisons, but neither remained significant after Holm correction (adjusted p = 0.2261 for both). Historical PEPFAR funding, total population living with HIV, and annual HIV mortality were not significantly associated with response level after adjustment. Countries with higher levels of human development demonstrated stronger governmental responses to the 2025 PEPFAR funding disruptions. Several countries with minimal documented responses were also affected by active conflict or political instability, potentially compounding their vulnerability to treatment interruptions. These findings suggest that broader national development may play an important role in governmental responses to funding disruptions and highlight the need to strengthen resilient health systems, diversify HIV financing, and prioritize support for countries at greatest risk of future funding shocks.

ObjectivesTo estimate age trajectories of infant mortality among Palestinian refugees using electronic health records, addressing the scarcity of reliable mortality data in forced displacement settings. SettingPalestinian refugees living in Gaza, West Bank, Jordan, Syria and Lebanon. DesignWe fitted a Bayesian Negative Binomial model to observed death counts, using a flexible parametric function (a shifting power function) to capture the shape of the infant mortality curve, across strata to infer age trajectories of infant mortality. ParticipantsPalestinian refugees born in 2010-2020 and registered with UNRWA health services in Gaza, West Bank, Jordan, Syria and Lebanon. The sample was stratified by sex, field, gestational age and birth cohort. Main outcome measuresSurvival rate to age 1. ResultsOverall, the survival rate to age 1 was 98.64%, with slightly lower rates for males (98.57%) than females (98.68%). Across settings, West Bank refugees had the lowest infant mortality (99.08% survival rate), and Jordan refugees had the highest (98.22% survival rate). Results by gestational age showed a 98.85% survival rate at age 1 among term births compared to a 73.32% survival rate among very preterm births. Survival rates by cohort (births up to 2015 or after) were 98.78% and 98.42%, respectively. ConclusionOur findings highlight the potential of electronic health records for mortality monitoring in forced displacement settings as they reveal consistent mortality trajectories by sex and gestational age, while identifying meaningful variation across refugee settings and subgroups. Summary boxesO_ST_ABSWhat is already known in this topicC_ST_ABSWe searched PubMed and Google Scholar for articles published between Jan 1, 2000, and Feb 20, 2026, in English, using the terms "Palestinian refugees," "infant mortality," "neonatal mortality," and "UNRWA." We found a handful of studies estimating infant mortality among Palestinian refugees, mostly based on household surveys (eg, MICS, national statistical office surveys) or UNRWA surveys using preceding birth techniques. The preceding birth technique has notable limitations, including recall bias, small sample sizes, and selection bias. The majority of these studies focus exclusively on Palestinian refugees residing in Gaza. Estimates for Gaza suggest a sustained decline, from around 127 deaths per 1,000 births in 1960 to 20.2 per 1,000 births in 2006, with a slowdown thereafter and an increase in more recent years. A combined estimate (excluding Syria) across four settings where Palestinian refugees reside measures infant mortality at 18 per 1,000 births in 2011. What this study addsThis study uses a unique data linkage bringing together UNRWAs obstetric and child health records, providing more extensive information and a larger sample size than previous studies. This is also the first study to assess the data quality of these electronic records and to estimate age trajectories of infant mortality among Palestinian refugees. We developed a statistical strategy that estimated infant mortality trajectories covering all five UNRWA fields (Gaza, Jordan, Lebanon, Syria, and the West Bank) for children born in 2010-2020, and examined differences across subpopulations by sex, field, gestational age and cohort.

Background Concurrent wasting and stunting (WaSt) is a severe form of child undernutrition, linked to higher mortality and long-term negative health outcomes. Malnutrition is a significant challenge in Yemen, where the country is experiencing a long-standing conflict, food insecurity, and socioeconomic deprivation. But there is still limited evidence on the burden and determinants of WaSt in Yemen on a national level. This study aimed to estimate the prevalence and identify factors associated with WaSt among children under 5 years in Yemen. Methods We conducted a cross-sectional analysis using nationally representative data from the 2022-2023 Yemen Multiple Indicator Cluster Survey (MICS). A significantly large dataset of 17,734 children aged 0-59 months from all the 22 governorates of Yemen was analyzed. Concurrent wasting and stunting (WaSt) was defined as the coexistence of a weight-for-height z-score (WHZ) below -2 standard deviations and a height-for-age z-score (HAZ) below -2 standard deviations from the WHO Child Growth Standards in the same child. Survey-weighted logistic regression was performed to analyze the factors associated with WaSt among the under 5 children in Yemen. Results The national prevalence of WaSt was 8.4% (95% CI: 7.6-9.2). The highest prevalence of WaSt was found in children aged 12-23 months (12.0%) and in the Western Coastal region (11.6%). After adjustment, male sex (AOR 1.52, 95% CI: 1.30-1.80), residence in the Western Coastal (AOR 2.00, 95% CI: 1.60-2.40), Eastern (AOR 2.00, 95% CI: 1.50-2.70), and Southern regions (AOR 1.60, 95% CI: 1.20-2.10), poorest household wealth (AOR 1.96, 95% CI: 1.30-2.90), moderate (AOR 1.51, 95% CI: 1.13-1.94) and severe food insecurity (AOR 1.94, 95% CI: 1.40-2.60), and recent diarrhoea (AOR 1.22, 95% CI: 1.02-1.44) were associated with higher odds of WaSt. Having a handwashing facility and improved sanitation were protective. Conclusion At least 1 in every 12 under-five children in Yemen was affected by WaSt, and there were significant socioeconomic, geographic, food-security and WASH-related factors influencing this devastating outcome. Instead of simple, one-dimensional approaches, multi-sectoral interventions are needed to address this adversity. And those efforts must be integrated into the system, interconnected with each other and specifically targeted to vulnerable children and households.

Background: COVID-19 movement restrictions reduced social contact worldwide, curbing viral spread but with unequal economic consequences where social safety nets are limited. Little evidence exists on how these impacts varied by occupation, wealth and age in resource-constrained settings. This paper examined pre-pandemic contact and lockdown-related change. Methods: The paper documents analysis of a population-representative survey (N=8,499) in Manicaland, Zimbabwe, during April-May 2021, capturing typical weekday contacts before and during the first COVID-19 lockdown. Negative binomial regression models assessed pre-lockdown contact counts by socio-economic characteristics, overall and by place (home, school, work, transport, entertainment); linear regression assessed predictors of lockdown declines. Results: Pre-COVID-19, respondents reported a median of 12 daily contacts (interquartile range [IQR] 4-47), with higher counts among manual labourers (incidence rate ratio [IRR] 2.21, 95% confidence interval [CI] 2.00, 2.44), retail and public sector workers (IRR 2.33, 95%CI 2.09, 2.60) and students (IRR 2.59, 95%CI 2.38, 2.82), males, wealthier respondents, under-30s, and urban and agricultural estate residents. Counts were highest in schools. During lockdown, contacts fell across all subgroups to a median of 8 (IQR 4-28). Declines were greatest among those with most pre-COVID-19 contacts: urban (mean -17.5, 95%CI -19.53, -15.37) and agricultural estate residents (-18.1, 95%CI -19.99, -16.13), students and teachers (-17.7, 95%CI -19.82, -15.59), males and 30-44 year olds. Drops were greatest in schools and on transport. Conclusion: Reductions in contact under blanket lockdown varied markedly between subgroups and places in Manicaland, Zimbabwe. Selectively targeting high-contact groups might have achieved similar transmission reductions while limiting economic damage, holding lessons for similar settings.

Background: Childhood experiences contribute to health and wellbeing across the life course, yet research from low- and middle-income countries has largely focused on a few outcomes rather than broader patterns of adult wellbeing, behaviors, and social and financial circumstances. Methods: In this cross-sectional analysis, we used a nationally representative sample of adults in India (N = 12,765; aged [&ge;] 18 years) from the Global Flourishing Study (GFS) Wave 1 (2023) to examine associations between eight retrospectively reported childhood experience items, 45 adult outcomes, and two composite flourishing indices. Survey-weighted linear, logistic, and proportional-odds models adjusted for age, gender, education, and residential setting, with Bonferroni correction were used to assess associations and effect modification by gender. Findings: Although the breadth and strength of associations differed across childhood experiences, less favorable childhood experiences were generally associated with poorer wellbeing and flourishing, greater odds of adverse health outcomes, and reduced access to resources and safety in adult life. However, outcomes related to prosocial behaviors showed a different pattern: childhood abuse (physical or sexual) was associated with greater odds of volunteering (OR 1.31, 95% confidence interval or CI [1.13,1.51]), feeling like an outsider in one's family with greater odds of donating (OR 1.80, 95% CI [1.52,2.13]), volunteering (OR 1.53, 95% CI [1.28,1.82]), and helping a stranger (OR 1.49, 95% CI [1.27,1.74]). Associations were broadly similar between females and males, with little evidence of gender differences. Interpretation: Associations of childhood adversity with poorer health and increased prosocial behavior in adult life may reflect unmeasured social, cultural, or dispositional factors and heterogeneous life-course responses. Nevertheless, these findings support strengthening child-protection, financial assistance programs, and mental health services in India.

Background Malaria and HIV remain major causes of illness in sub-Saharan Africa, accounting for 94% of the global malaria burden and over two-thirds of the global HIV burden. HIV-related immunosuppression increases susceptibility to malaria, with a higher malaria burden of up to 47% and severe malaria complications compared to HIV-negative individuals. Socio-demographic factors, individual knowledge, attitude, and perception are recognized determinants of malaria prevention behaviours, but no study has modelled their combined contribution, and there is scant research on these factors among people living with HIV. We assessed the level of knowledge, attitudes, and perceptions towards malaria, and identified the predictors of malaria prevention practice among HIV-positive individuals in Kampala, Uganda. Methods This cross-sectional study enrolled 620 HIV-positive patients attending the ART clinic of China-Uganda Friendship Hospital, Naguru, selected by systematic random sampling. Data collection was conducted from 21st July 2025 to 18th August 2025 using a structured, interviewer-administered questionnaire that measured socio-demographic characteristics, knowledge, attitude, perception, and the practice of malaria prevention. Associations were assessed using Mann-Whitney U, Kruskal-Wallis H, and Spearman correlation. The independent predictors of good malaria prevention practice were identified using binary logistic regression. Results Participants had a mean age of 34.8 years, were predominantly female (68.9%), Baganda (38.1%) by tribe, and the majority had a secondary level of education(46.0%). Most had good knowledge of malaria (97.3%) and a positive attitude (90.5%), while 57.3% held a positive perception of malaria risk and prevention; only 62.6% reported good malaria prevention practice, and most prevention methods used were sleeping under a mosquito net (71.1 3%) and closing windows early in the evening (70.3%). In regression analysis, knowledge (adjusted odds ratio [AOR] 1.198, 95% CI 1.03-1.40, p = 0.023) and attitude (AOR 1.101, 95% CI 1.04-1.17, p = 0.001) independently predicted good practice, while perception did not (AOR 1.00, 95% CI 0.96-1.04, p = 0.994). Scores of Attitude, perception, and malaria prevention practices varied significantly, though non-linearly, by education level, and were highest among non-educated participants. Conclusions Despite near-universal knowledge and predominantly positive attitudes in this study, more than a third of HIV-positive participants did not practice adequate malaria prevention, and perception did not independently predict malaria prevention practice once knowledge and attitude were accounted for. Programmes seeking to close this know-do gap should pair health education with structural support for prevention tools rather than education alone.

Background: Girls are more likely than boys to experience psychological distress during adolescence. Drivers of this gender gap remain under-studied, despite its large impact on later life and outcomes, especially for women. Explanatory factors can be gendered in their prevalence (differential exposure) and/or in their impact (differential susceptibility). We developed a multi-domain framework of explanatory factors for distress and applied it in four low- and middle-income countries. Methods: We first proposed a framework of explanatory factors for psychological distress grouped into seven domains (biological, cognitive, psychological, behavioural, social, environmental and broader societal). We applied this framework to identify explanatory variables assessed in childhood and adolescence in the Young Lives longitudinal cohort studies in Ethiopia (N=908), India (N=952), Peru (N=634) and Vietnam (N=887). Distress symptoms at 18-19 years were measured with the Strengths and Difficulties Questionnaire Emotional Symptoms scale. Gendered prevalence of each explanatory factor was tested with Mann-Whitney tests, and gendered impact with country-specific linear regressions including a gender-by-factor interaction term. Exploratory boosted-tree machine-learning models, interpreted with SHAP values and permutation feature importance, examined the contribution of these factors to the gender gap in each country. Results: Distress was higher in girls than boys in every country, the gap ranging from 0.62 points in Ethiopia and Vietnam to 1.76 in India and 2.45 in Peru. Some explanatory factors were consistently gendered in prevalence (e.g. girls experienced greater role overload in each country), while others were gendered only in some countries (e.g. study amount was higher for girls in Peru and Vietnam, but not Ethiopia or India). Gendered impacts on distress displayed more variability across countries. For example, higher self-esteem was more protective for boys than girls in India, Peru and Vietnam, but more protective for girls in Ethiopia. The machine-learning models identified important predictors across all framework domains, though their salience varied by country. Conclusions: Our findings underscore the importance of considering multi-domain explanations for mental-health outcomes and observed inequalities in mental health. Large cross-country differences in the gender gap and in the prevalence and influence of explanatory factors caution against generalising drivers of mental-health outcomes and inequalities across contexts.

Background Circadian eating patterns, referring to the timing and regularity of meal intake relative to the body's internal clock, are increasingly recognized as important determinants of metabolic health among university students. However, empirical evidence on how the university food environment influences circadian eating patterns remains scarce, particularly within Nigerian tertiary institutions. This study assessed the influence of the university food environment on the circadian eating patterns of undergraduate students at the University of Medical Sciences, Ondo (UNIMED). Methods A descriptive cross-sectional study was conducted among 302 undergraduate students selected through a multistage sampling technique. Data were collected using a structured, facilitator-administered questionnaire assessing socio-demographic characteristics, the university food environment (UNI-FOOD, across six domains), circadian eating patterns, influencing factors, and anthropometric measurements. Data were analysed using SPSS version 27, employing descriptive statistics, chi-square tests, and univariable and multivariable binary logistic regression, with significance set at p < 0.05. Results The mean age of respondents was 20.03 {+/-} 2.58 years, and the majority were female (68.9%). Students generally perceived the university food environment as moderate, with affordability rated the weakest domain (mean 2.65 {+/-} 0.51) and food promotion/visibility the strongest (3.27 {+/-} 0.52). Most respondents (71.9%) exhibited moderate circadian eating patterns, while 21.2% had poor patterns. A significant association was found between the overall food environment and circadian eating patterns ({chi}2 = 44.369, p < 0.001). After adjustment, poor physical food accessibility (AOR = 6.44, 95% CI: 2.00-20.72, p = 0.002) and a poor food policy environment (AOR = 9.53, 95% CI: 3.51-25.87, p < 0.001) were independent predictors of poor circadian eating patterns. Circadian eating pattern was also significantly associated with BMI category ({chi}2 = 7.346, p = 0.025). Conclusion The university food environment, particularly physical accessibility and food policy, significantly influences circadian eating patterns among undergraduate students. Improving campus food accessibility and implementing supportive food policies may promote healthier meal timing and nutritional outcomes.

Child maltreatment (CM) is a global phenomenon, yet its prevalence, acceptability, and psychosocial consequences vary across cultures. This study examined self-reported CM, its perceived acceptability, and associations with psychosocial outcomes among 1,617 adults (Mage = 25.21, SD = 6.74) across 13 countries and regions. Participants completed an online survey assessing physical neglect, physical abuse, emotional maltreatment, sexual abuse, and witnessing domestic violence, alongside perceived acceptability, post-traumatic growth, resilience, perceived social support, post-traumatic symptoms, and psychological distress. Country/region differences were tested via mixed-effects; whether CM-outcome associations varied by country/region was tested via fixed-effects interaction models. Significant cross-country/region variability emerged for most CM subtypes, especially for emotional maltreatment. Witnessing domestic violence rates did not differ significantly, though its acceptability still varied significantly, as did all other types. Greater CM exposure was linked to poorer mental health for several subtypes and to greater acceptability of maltreatment, raising concerns about intergenerational normalisation. CM-outcome associations were largely consistent across countries/regions, with only isolated, exploratory exceptions. Findings show that while CM's adverse psychosocial impact shows little cross-national variation, its prevalence and normative framing are culturally shaped, underscoring the need for culturally sensitive assessment and intervention.

Background Street food vending is a major source of food supply in Nepal. Poor food hygiene practices among street food vendors pose a health risk by increasing the risk of foodborne diseases. Studies regarding food hygiene knowledge and practices are needed to improve public awareness. Therefore, this study aimed to assess food hygiene knowledge and practice among street food vendors and their associated factors in selected districts of Bagamati Province. Methods A community-based cross-sectional analytical study was carried out among 186 street food vendors of Districts located in central Nepal. Face-to-face interviews were conducted using a semi-structured questionnaire and an observation checklist. Knowledge and practice levels were categorized as good and poor. Chi-square test, Fisher's exact test, odds ratio, and Mann-Whitney U test were applied for data analysis. Results Less than half (39.8%) of the vendors had good food hygiene knowledge, while 91.4% of the respondents reported good food safety and hygiene practices. The education level of street food vendors was significantly associated with food hygiene knowledge (p = 0.001) and food safety and hygiene practices (p = 0.042). Significant association was not seen between overall food hygiene knowledge and overall food safety and hygiene practices levels. Conclusion The study identified a gap between food hygiene knowledge and self-reported food hygiene practices among street food vendors. Education, infrastructure, and regulations among street food vendors play a key role in good food hygiene practices more than knowledge alone. Policymakers should focus on training of food vendors, regular supervision, and monitoring of vending sites to enhance food safety.

Every day, 1990 children die from an injury, with the majority in low- and middle-income countries. In Tanzania, reaching definitive care, or the appropriate level of care for a child's injury, often requires referral to a higher level facility. This hierarchical system introduces challenges that may lead to delayed care and, for severely injured children, cause mortality. The aim was to identify patient, healthcare provider, and health system-level barriers to timely referral for pediatric injury patients at the first site of care in order to identify targets for an intervention to reduce time to definitive care. In this mixed-methods study, a pediatric injury registry was established at three health facilities spanning three health system levels in Northern Tanzania. Thirty family caregivers of pediatric injury patients participated in interviews, while healthcare providers participated in four focus group discussions. The Consolidated Framework for Implementation Research framed interview guides and thematic analysis of the qualitative data. Of 782 patients enrolled in the pediatric injury registry from Aug 2024-Aug 2025, 269 were referred. Most visited 1-4 facilities before reaching definitive care (range 1-6). The median time from injury to definitive care was 15.1 hours (IQR 1.8-33). Qualitative data collection with family caregivers and healthcare providers revealed barriers to explain the delays to care in the outer setting (such as non-standardized referral pathways), the inner setting (such as delays in the decision to refer), and individual characteristics (such as inadequate training in pediatric injury care). According to the World Health Organization standards, every child who needs referral should be sent within 2 hours of arrival. To improve the referral delays found in this study, a locally co-designed, multicomponent health systems intervention for healthcare providers at the first site of care must be developed that includes pediatric injury care training and standardized referral decision support.