Public Health in Practice

Hemoglobinopathies are inherited disorders of hemoglobin, most notably sickle cell anemia and thalassemia. These conditions result from mutations in the globin genes, leading either to structural abnormalities in the globin chains or to reduced synthesis of normal globin chains. Hemoglobinopathies is a worldwide health problem according to the World Health Organization; it affects mostly the indigenous Tharu groups in Nepal. Both the global and local rates of illness and death associated with these diseases are on the rise. The objective of this study was to assess the presence of hemoglobinopathies and common mutations of the beta-globin gene within the Tharu population in western Nepal. A cross-sectional study of 1,400 Tharu individuals was conducted among individuals obtained through hospitals within the Banke district, Bardiya district, and Kailali district in western Nepal. A thorough hematological analysis was done with the use of a Sysmex XN-350 analyzer. Hemoglobin variants were detected via high-performance liquid chromatography (HPLC). The molecular characterization of the seven most common mutations of {beta}-thalassemia was performed on a subset of 20 confirmed cases by using a real-time PCR kit.The total number of cases diagnosed with hemoglobinopathies was 14.43% (n=202 out of 1,400). Sickle cell trait (HbAS) was reported as the most prevalent type of Hemoglobinopathies (8.50% of population), followed by {beta}-thalassemia trait (4.00%). In addition to these disorders were sickle cell disease (HbSS), HbE trait, and compound heterozygous states. Hematological parameters differed significantly across types of hemoglobinopathies, and the patterns of microcytic, hypochromic, and hemolytic anemia were also distinct. Commonly documented symptoms included fatigue and joint pain (42.5% and 23.1%, respectively). Molecular characterization of {beta}-thalassemia cases demonstrated that most individuals were compound heterozygotes with IVS1-6 (T>C) as the most prevalent variant. The research identified that the Tharu population in western Nepal has a significant burden of hemoglobinopathies (especially sickle cell trait and {beta}-thalassemia), highlighting the requirement for appropriate screening programs, genetic counseling and public health strategies to help manage and prevent these conditions within this particular region.

Background Individuals experiencing or at risk of homelessness face substantial barriers to preventive eye care that are poorly addressed by standard service models. Interdisciplinary optometry-social work collaboration offers a rights-based approach to improving engagement and continuity of care. Methods A convergent mixed-methods study was conducted between February and August 2024 at a multidisciplinary community centre. Clients experiencing or at risk of homelessness received integrated optometry and social work assessment and were prioritised as high, medium, or low based on combined clinical and social risk. Social work follow-up was guided by the Triple Mandate and W-Questions framework. Quantitative data were summarised using mean (SD), median [IQR], or n (%). Qualitative case notes were analysed using content analysis with inductive coding and secondary review for consistency. Results A total of 165 clients had priority categories coded (high: 68; medium: 47; low: 154). Demographic data were available for 132 clients (60% male; mean age 49.5 years [SD 16]); 27% had not completed high school, 89% reported weekly income below AUD 1000, and 28% had vision impairment. Two hundred forty-five case-note entries were consolidated into 146 unique records. SMS (46%) and phone calls (38%) were the most documented contact methods, although only 21% of calls were answered; missed calls (13%) and disconnected numbers (7%) were common. Multi-modal contact was more frequently documented for higher-priority clients. Appointment assistance was the most recorded facilitator (71%), while rights-based supports, including interpreter and transport assistance, were infrequently documented (<=5%). Qualitative analysis identified unstable communication, reliance on informal supports, and service fragmentation as key influences on recall outcomes. Conclusion This study supports an interdisciplinary, rights-based optometry-social work model to address barriers to preventive eye care among people experiencing or at risk of homelessness. Embedding structured handovers and tiered recall processes within community-based services may strengthen continuity and accountability for high-priority clients. Future implementation should evaluate outcomes related to equity of reach, service integration, and sustained engagement in care.

BackgroundAccess to safe, equitable, and affordable surgical and anesthesia care is critical to reducing the burden of surgical diseases in Africa. To understand the state of access in South Sudan, we conducted a baseline assessment of surgical services in Central Equatoria State (CES) in May 2024. ObjectivesThis study aimed to survey public healthcare facilities in CES capable of providing essential surgical services. We used the capacity to perform cesarean section, laparotomy, and open fracture management--Bellwether procedures--as a proxy for assessing workforce, infrastructure, financing, information management, and service delivery. MethodsWe used a validated and contextualized Surgical Assessment Tool developed by the Harvard Program on Global Surgery and Social Change and the World Health Organization. Data were collected at the facility level and summarized descriptively using percentages, means (standard deviations), medians (minimum, maximum), and visualized in graphs, charts, and tables. ResultsAll three public health facilities assessed could perform Bellwether procedures for their catchment populations. However, workforce availability, financing, and surgical infrastructure were major constraints. The surgical workforce density was 2.27 surgical, anesthesia, and obstetric specialists per 100,000 population. Specialized procedures--such as repair of cleft lip and palate, clubfoot, and hydrocephalus shunt--were unavailable at all sites. None had magnetic resonance imaging (MRI) machines. The total average annual facility budget was $918,850, ranging from $3,960 to $800,000 at the teaching hospital--insufficient for proper operations. ConclusionWhile Bellwether procedures are routinely performed, access to quality and affordable care is compromised by deficits in workforce, financing, and infrastructure. We recommend that the Ministry of Health scale this survey nationally and develop a surgical policy and strategic plan focused on improving infrastructure, workforce, and financing for surgical and anesthesia care in South Sudan.

Abstract Importance Stigma and discrimination against transgender and gender-diverse people are prevalent across many settings and may contribute to substantial health disparities. Objective To synthesize global evidence on the prevalence of stigma, discrimination, and resilience among transgender (trans) and gender-diverse adults. Data Sources A systematic search was conducted in PubMed, Embase, CINAHL, Cochrane Central, LILACS, and PsycInfo for articles published between January 1, 2010 and January 2, 2023. This database search was supplemented by grey literature and secondary reference searches. Article Selection Studies were eligible if they presented primary quantitative data on prevalence of stigma, discrimination, and/or resilience among trans and gender-diverse adults (aged 18 and over), with no restrictions on study design, language, or geographic region. Data Extraction and Synthesis Two independent reviewers extracted data using standardized forms, with discrepancies resolved by consensus. The JBI Critical Appraisal Checklist for Prevalence Articles was used to assess risk of bias. Random effects meta-analysis was conducted for dichotomous prevalence measures using inverse variance weighting and logit transformation; non-dichotomous prevalence data were summarized descriptively. Main Outcomes and Measures Outcomes included prevalence estimates for various forms of stigma (anticipated, perceived, internalized, and experienced), discrimination in legal/institutional settings (housing, healthcare, employment, police/prison), and resilience. Results A total of 97 articles, with data from 72,158 unique trans and gender-diverse participants across 26 countries, met inclusion criteria. Studies showed moderate levels of anticipated stigma, perceived stigma, and internalized stigma. Meta-analyses of 36 studies provided pooled estimates of discrimination prevalence across multiple domains: 21.4% in housing (e.g., eviction, rental denial), 24.6% in healthcare (e.g., denial of care, mistreatment), 32.8% in employment (e.g., hiring bias, workplace harassment), and 39.1% in police/prison settings (e.g., profiling, mistreatment). High heterogeneity was observed across studies, reflecting regional and methodological differences. Resilience scores ranged from moderate to high, indicating variation within trans and gender-diverse communities. Conclusions and Relevance This systematic review and meta-analysis found that stigma and discrimination against trans and gender-diverse adults are pervasive globally. Variation in stigma and discrimination across settings and regions underscores the need for targeted interventions and policy reforms. Funding World Health Organization through a grant from the Elton John AIDS Foundation and the Bill and Melinda Gates Foundation.

Background. Vietnam's disease burden has shifted from communicable, maternal, neonatal, and nutritional (CMNN) causes to non-communicable diseases (NCDs), but the tempo, drivers, and regional positioning of this transition have not been jointly quantified. We characterised Vietnam's epidemiological transition 1990-2023 against ten Southeast-Asian (SEA) peers. Methods. Using Global Burden of Disease 2023 data, we computed joinpoint-regression AAPC with 95% CI (BIC-penalised, up to three break-points) for age-standardised DALY rates and cause-composition shares. We applied Das Gupta three-factor decomposition to 1990-2023 absolute DALY change (population-size, age-structure, age-specific-rate effects) and benchmarked Vietnam's NCD share against an SDI-conditional peer trajectory via leave-one-out quadratic regression. Premature mortality was quantified as WHO 30q70 under both broad NCD and strict SDG 3.4.1 definitions, using Chiang II life-table adjustment identically across all eleven countries. Findings. The CMNN age-standardised DALY rate fell from 13,295.9 to 4,022.1 per 100,000 (AAPC -4.63%/year; 95% CI -4.80 to -4.46); the NCD rate fell only from 21,688.2 to 19,282.8 (AAPC -0.37; -0.45 to -0.30). NCD share of total DALYs rose from 52.99% to 70.67% (+17.67 pp; AAPC +1.09). Vietnam ranked fourth of eleven SEA countries in 2023 (up from sixth in 1990) and sat 5.3% above the SDI-expected trajectory. Das Gupta decomposition attributed the +10.63 million NCD DALY increase to population growth (+6.26 M) and ageing (+6.08 M); rate change removed only 1.71 M. Premature NCD mortality fell from 25.02% to 21.80% (broad, 12.9% reduction) and from 22.17% to 19.50% (SDG 3.4.1, 12.0%; Vietnam sixth of eleven) - far short of the SDG 3.4 one-third-reduction target. Interpretation. Vietnam has entered a disability- and ageing-dominated NCD phase. Meeting SDG 3.4 by 2030 requires population-scale primary prevention sized to demographic momentum.

Background: Since September 2024, France has implemented a national reform allowing prescription-free access (PFA) to sexually transmitted infection (STI) screening in medical biological laboratories (MBLs). This study aims to characterize the populations undergoing STI testing according to their access modality and evaluate the probability of test positivity in relation to testing pathway, sex, and age groups. Methods: We conducted a cross-sectional analysis of all individuals screened for Chlamydia trachomatis, Gonorrhoea, human immunodeficiency virus (HIV), hepatitis B virus (HBV), and syphilis by treponemal-specific immunoassay (TSI) in Cerballiance MBLs between Mars 2025 and February 2026. Multivariable logistic regression models stratified by sex and adjusted for age and region assessed associations between screening modality and STI positivity. Results: Among 1,008,737 individuals included, 27.8% were under PFA and 72.2 under prescription-based access (PBA). PFA users were more frequently male (47.4% vs. 36.3%, p<0.001) and aged 20-39 years (34.0%, p<0.001). Overall positivity rates differed by modality: PFA was associated with higher detection of Chlamydia (4.6% vs. 3.6%). PBA group showed more positive cases of syphilis (3.4% vs. 1.2%), HBV (1.3% vs. 0.4%), and HIV infections (0.3% vs. 0.2%, all p<0.001). Co-infection and gonorrhoea proportions did not significantly differ between modalities. Conclusions: PFA substantially increased STI screening uptake, particularly among young adults and men, and enhanced detection of bacterial STIs. PBA remains essential for diagnosing viral and chronic infections. These findings highlight the complementary roles of both access strategies and support PFA screening as an effective public health intervention to broaden STI detection and reduce transmission.

Women living with HIV face about a six-fold higher risk of cervical cancer, yet screening uptake remains low in many sub-Saharan African settings. We explored factors influencing repeated decisions to decline cervical cancer screening during routine HIV care among women living with HIV at a large HIV clinic in Jos, Nigeria. Between September and December 2024, we conducted an exploratory qualitative study at the AIDS Prevention Initiative in Nigeria Clinic in Jos, Nigeria. We purposively recruited 27 women living with HIV aged 21 to 65 years who had never undergone cervical cancer screening and had repeatedly declined screening offers during routine HIV care, including at the current clinic visit. Semi-structured in-depth interviews were conducted in English or Hausa, audio-recorded, transcribed verbatim, and translated into English where needed. Data were analyzed thematically using theory-informed coding based on the Health Belief Model and Social Ecological Model. Among 27 women living with HIV who had repeatedly declined screening, perceived susceptibility was often low or uncertain despite recognition of cervical cancer severity. Perceived benefits were acknowledged but were frequently outweighed by overlapping barriers, including knowledge gaps and misinformation, indirect and downstream costs, emotional barriers, logistical constraints, clinic-flow and service-delivery barriers, and anticipated stigma. Education, reminders, and supportive clinic processes acted as cues to action, and most participants expressed willingness to screen in future. Among women living with HIV at this clinic who repeatedly declined screening when it was offered, perceived benefits were often outweighed by multilevel barriers. Screening programs may integrate fear-reduction and stigma-sensitive counseling with practical service delivery improvements, including shorter waiting times, reduced indirect costs, predictable and streamlined clinic flow, and consistent provider invitations and reminders, while addressing misinformation through community-embedded, culturally tailored messaging. These strategies may improve screening uptake and support more equitable cervical cancer prevention for women living with HIV in similar HIV-care settings.

Background: Lung cancer screening can reduce lung cancer mortality through early detection, but uptake of the NHS Targeted Lung Health Check (TLHC) programme remains low. Behaviourally informed invitation messages have been proposed as a low-cost approach to increase attendance, but evidence of their effectiveness in lung cancer screening is mixed. Few intervention studies used evidence-based behaviour change frameworks, and rarely tailored invitation strategies to empirically identified barriers and enablers. Methods: In an online experiment, 3,274 adults aged 55-74 years and with a history of smoking were randomised to see one of four behaviourally informed invitation messages or a control message. Participants then rated their intention to attend a TLHC appointment, and selected barriers and enablers to attending from a pre-defined list, which were classified according to the Theoretical Domains Framework. Invitation messages were mapped to Behaviour Change Techniques using the Theory and Techniques Tool. Message conditions were compared on intention to attend TLHC using bootstrapped ANOVA followed by pairwise comparisons. Exploratory counterfactual mediation analyses examined the role of fear in intention to attend. Results: Behaviourally informed invitation messages did not meaningfully increase intention to attend TLHC compared with the control message. While a GP-endorsed message showed a small potential benefit relative to the other conditions, this finding was not robust after adjustment for multiple comparisons. Participants most frequently reported barriers related to Emotion (particularly fear), Social Influence, and Knowledge, while Beliefs about Consequences emerged as the primary enabler of attendance. Only around half of reported barriers and enablers were addressed by the invitation messages. Exploratory analyses found that fear was associated with lower intention to attend a TLHC appointment, yet none of the behaviourally informed messages appeared to reduce fear compared to the control message. Conclusions: Improving lung cancer screening uptake will likely require invitation messages that directly address emotional concerns, particularly fear, alongside credible recommendations. These findings highlight the importance of systematically aligning invitation message content with empirically identified behavioural influences when designing scalable interventions to improve lung cancer screening uptake.

BackgroundAnimal bites represent a significant public health concern due to the risk of injuries and transmission of zoonotic diseases such as Rabies, particularly in low and lower- middle-income countries (LMICs). Understanding the epidemiological characteristics of animal bite incidents is essential for improving the prevention and control strategies. This study aimed to characterize the epidemiological patterns and characteristics of animal bite cases in Sylhet, Bangladesh. Methodology/Principal findingsWe conducted a retrospective analysis of 6,565 animal bite cases reported between January 1 and December 31, 2024, in Sylhet, Bangladesh. Data on demographic characteristics, type of biting animal, site of bite, and exposure category were collected and analyzed to determine associations using correlation analyses and chi-square tests. Among the victims, 3,917 (60%) were male and 2,648 (40%) were female and young adults aged 20-39 years comprised the largest group (39% of cases). The majority of cases (88.1%) originated from urban areas within Sylhet City Corporation. Cats were the leading cause of bites (56.6%), followed by dogs (35.0%) and monkeys (7.5%), suggesting a shift from the traditional dog-dominated pattern. The most frequently affected anatomical sites were the legs (50.3%) and hands (40.9%). Most exposures were classified as World Health Organization (WHO) Category II (98.2%). Bite incidents showed moderate seasonal variation, with peaks in spring and early autumn. A significant declining temporal trend was observed for monkey bites (R = -0.59, p = 0.044), whereas cat and dog bite patterns remained relatively stable throughout the year. Significant associations were identified between bite site and age group, as well as between biting animal and demographic characteristics (p < 0.05). Conclusion/SignificanceThese findings highlight the epidemiological patterns of animal bites in Sylhet and emphasize the need for strengthened public awareness, surveillance, and preventive strategies to reduce animal bite incidents and associated zoonotic disease risks. SynnopsisO_LIA large-scale retrospective analysis of 6,565 animal bite cases revealed a cat-dominant bite pattern (56.6%), contrasting with the traditional dog-dominant paradigm in South Asia. C_LIO_LIYoung adults (20-39 years) and males (60%) were disproportionately affected, reflecting occupational and behavioral exposure risks. C_LIO_LIUrban residents (88.1%) accounted for the majority of cases, highlighting the growing public health burden of animal bites in rapidly urbanizing settings. C_LIO_LIThe most frequently affected anatomical sites were the legs (50.3%) and hands (40.9%). Bite incidents showed moderate seasonal variation, with peaks in spring and early autumn. C_LIO_LICategory II exposures (98.2%) predominated, indicating a high burden of seemingly minor injuries that may be underestimated in rabies prevention strategies. C_LI

Objectives: The primary aim of this study was to assess the feasibility of delivering an adapted problem-solving skills (PSS) intervention by quantifying the recruitment, follow-up and completion rates using a brief problem-solving intervention for people with a mental health diagnosis in two Polish prisons. Design: IAPPS is an open, multi-centred, parallel group feasibility randomised controlled trial (RCT). Setting: Two prisons in Poland. Participants: Men in custody aged 18 years and older, having a mental illness and living within the prison therapeutic unit. Interventions: The intervention consisted of an adapted PSS skills intervention plus care as usual (CAU) or care as usual only. Delivered in groups of up to five people in 1.5-hour sessions over the course of two weeks. Main outcome measures: Primary outcomes - rate of recruitment, follow-up, and feasibility to deliver the intervention. Secondary outcomes included measures of depression, general mental health, and coping strategies. Results: 129 male prisoners were screened, 64 were randomly allocated, with a mean age of 53.5 years (SD 14, range 23-84). 59 (95%) prisoners were of Polish origin. Our recruitment rate was 48%. There was differential follow up with those in the intervention group less likely to complete the post-test battery versus those who received care as usual. Outcome measures were successfully collected at both time points. Conclusions We were able to recruit, retain and deliver the intervention within the prison setting; some logistical challenges limited our assessment of intervention engagement. Our data helps to demonstrate how use of the RCT study design can be implemented and delivered within the complex prison environment. Trial registration number ISRCTN 70138247, protocol registration date May 2021

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

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.

Objectives: In Latin America, up-to-date information to monitor UNAIDS 95-95-95 HIV targets in key populations, such as men who have sex with men, is limited. Elsewhere, structural homophobia restricts access to ART. Conceptual frameworks suggest that intersecting forms of violence and discrimination may negatively influence HIV care outcomes through psychosocial and structural pathways, although empirical evidence remains limited. The study aimed to assess whether sexual orientation outness and recent homophobic violence are associated with not being on ART among Latin American MSM living with HIV. Methods: This cross-sectional study is a secondary analysis of data from LAMIS-2018, including 7,609 MSM aged 18+ with an HIV diagnosis [&ge;]1 year prior from 18 Latin American countries. Participants self-reported ART status, sociodemographic characteristics, homophobic violence, and sexual orientation outness. Bivariate and multivariate logistic regressions identified those factors associated with not being on ART. Results: Nine percent of MSM with HIV were not on ART, 18% reported low sexual orientation outness, and 27% experienced homophobic violence, especially in Andean and Central American countries. Not being on ART was associated with recent homophobic violence (aPR=1.25), low outness (aPR=1.22), unemployment (aPR=1.27), and residence in the Andean subregion (aPR=1.87), Mexico (aPR=1.28), or the Southern Cone (aPR=1.45) versus Brazil. Protective factors included being older (25-39: aPR=0.72; >39: aPR=0.49), living in large cities (aPR=0.72), having a stable partner (aPR=0.78), and university education (aPR=0.74). Conclusions: Recent homophobic violence and low sexual orientation outness were associated with not being on ART among MSM in Latin America. While access varies across countries, structural factors such as stigma and violence may limit engagement in care. Addressing these barriers alongside strengthening health systems may be key to improving ART uptake and advancing progress toward the 95-95-95 targets.

Background: Opioid-related mortality in Texas has escalated dramatically, increasingly driven by illicitly manufactured fentanyl. To address local surges in mortality, the Galveston County Health District deployed the Galveston County Opioid Defense Effort (GCODE) in July 2023, leveraging digitally integrated surveillance data from emergency medical services (EMS) and the Medical Examiner to provide targeted naloxone distribution in identified overdose hot spots. Methods: Using a segmented interrupted time series (ITS) design and Poisson regression with robust standard errors, we evaluated the population-level impact of GCODE on opioid-involved mortality through the end of 2025. Data were sourced from the Galveston Area Ambulance Authority (GAAA) and vital statistics (ICD-10 codes). We assessed mortality trajectory changes, the observed fatality ratio among EMS-detected opioid events (the Survival Gap), and demographic and geographic covariates. Results: The Poisson ITS model included 519 weekly observations (N = 14,827 tract-weeks across 101 census tracts). Pre-intervention, opioid mortality increased by 0.16% weekly (IRR = 1.0016; 95% CI: 1.000-1.003; p = 0.011). Following GCODE deployment, the mortality trajectory reversed to a sustained 0.55% weekly decrease (IRR = 0.9945; 95% CI: 0.990-0.999; p = 0.021). The observed fatality ratio among EMS-detected events declined from 7.59% (preintervention mean; SD = 0.111) to 1.71% (post-intervention; SD = 0.042; Chi^2 = 19.824; p = 0.0001). Opioid decedents were significantly younger than the general mortality population (OR = 0.945 per year of age; p < 0.001), and were descriptively more likely to lack documented race/ethnicity data (41.23% vs. 8.27% Unknown; p < 0.001), limiting equity analysis. Conclusions: The findings are consistent with GCODE having meaningfully reduced opioid mortality by substantially lowering event-level lethality. These results suggest that targeted, digitally coordinated harm reduction can decouple overdose incidence from fatal outcomes, with implications for harm reduction program design in structurally constrained environments.

ABSTRACT Background Medical students face demanding academic schedules and elevated stress levels, predisposing them to poor sleep quality. Sleep hygiene, a set of behavioural and environmental practices aimed at optimising sleep, has been identified as a modifiable determinant of sleep quality, yet its role among medical students in Sudan remains unstudied. Objectives To assess current sleep hygiene practices among medical students at UMST and determine their association with sleep quality outcomes. Methods A facility based cross-sectional study was conducted at UMST among 240 medical students from three academic batches (3rd, 4th, and 5th year), selected via stratified random sampling. Data were collected using two validated self administered instruments: the Pittsburgh Sleep Quality Index (PSQI) and the Sleep Hygiene Index (SHI). Descriptive statistics, independent sample t tests, one way ANOVA, chi-square tests, Pearson correlation, and binary logistic regression were performed using SPSS version 23. Results Poor sleep quality (PSQI >5) was prevalent in 72.1% of participants (mean PSQI 7.25 +/- 2.66), and poor sleep hygiene (SHI >16) in 92.5% (mean SHI 27.1 +/- 7.9). SHI score (continuous) was the only significant independent predictor of sleep quality on logistic regression (OR = 1.13 per unit increase; 95% CI: 1.08-1.19; p < 0.001), equivalent to a 3.4-fold increase in odds per 10-unit rise in SHI score. Female sex was additionally identified as a significant predictor (OR = 1.88; 95% CI: 1.00-3.53; p = 0.049). A significant positive correlation was observed between PSQI and SHI scores (r = 0.359, p < 0.001). Conclusion Poor sleep hygiene is highly prevalent among UMST medical students and is the most significant modifiable predictor of poor sleep quality, with each unit increase in SHI score increasing the odds of poor sleep quality by 13%. These findings highlight a gap in sleep health education within Sudanese medical institutions and support the integration of targeted sleep hygiene interventions into the medical curriculum. Keywords: sleep hygiene; sleep quality; medical students; Sudan; PSQI; SHI; cross-sectional study

IntroductionFamily Constellation Therapy (FCT) has been widely disseminated in clinical, public health, and judicial settings despite persistent concerns regarding its theoretical basis, safety, and the limited availability of rigorous randomised evidence supporting its clinical use. ObjectiveThe aim of this systematic review is to assess the effects of FCT across all clinical conditions, explicitly considering both benefits and harms; and summarise the characteristics of studies and intervention settings used in randomised controlled trials of FCT. MethodsFollowing a prospectively registered protocol (CRD420251136190), we conducted a systematic search of seven databases (PubMed, EMBASE, APA PsycInfo, CENTRAL, BVS, Web of Science, and CINAHL) and grey literature (ICTRP and ProQuest database) without language or date restrictions to identify published and unpublished randomised controlled trials of FCT. Study selection, data extraction, risk of bias (RoB 2), and certainty of evidence (GRADE) were performed in duplicate. Statistical analyses followed a prospectively registered analysis plan with prespecified criteria for data pooling and for handling analytical limitations. ResultsNo reliable evidence was found to support the use of FCT for any condition across both clinical and non-clinical samples. All trials included were judged to be at high risk of bias and all comparisons were rated as very low-certainty evidence. Concerns regarding potential adverse effects were identified, and the available data was insufficient to establish the effectiveness of the intervention, precluding any clinical recommendation. ConclusionClinicians, policymakers, and consumers should reconsider adopting FCT while reliable evidence is not available.

BackgroundAn upsurge in Streptococcus pyogenes infections 2022-2023 highlighted potential benefits of point-of-care tests (POCT) to support clinical pathways, prevent outbreaks, and optimise antibiotic use. ObjectivesWe conducted a pilot research study in a west London paediatric emergency department (ED) to determine whether a molecular POCT had potential to alter management in children who were also having a conventional throat swab taken for culture. MethodsChildren <16 years presenting to ED who had a throat swab requested by a clinician were invited to have a second swab taken for research purposes only. Clinical management was unaffected by the research swab result, which was processed using a molecular POCT that was not approved for use in the host NHS Trust. ResultsPrevalence of streptococcal infection was low during the study (May 2023-June 2025); swab positivity in symptomatic children was 12.8% (6/47). Overall, 38/49 (77.6%) participants who had throat swabs received antibiotics. Of those children recommended to receive antibiotics, 29/38 (76.3%) had a negative POCT. Mean time to reporting of positive throat swab culture results was 3.67 days (range 3-5 days) leading to occasional delay in treatment, although POCT identified positive results within minutes. ConclusionAntibiotic use was frequent and could be avoided or stopped by use of a rule out POCT in over three-quarters of children in the ED, if suspicion of S. pyogenes is the main driver for prescribing. POCT were easy to process and produced immediate results compared with culture, in theory enabling timely decision-making and avoiding treatment delay.

ABSTRACT Background: Malaria remains a leading public health burden in sub-Saharan Africa, disproportionately affecting children under five years. In response, Kenya introduced the RTS,S/AS01 malaria vaccine in selected regions, including Siaya County where malaria transmission is endemic. Despite this milestone, uptake has been inconsistent, with hesitancy emerging as a significant barrier. Objective: This study aimed to determine factors associated with malaria vaccine hesitancy among caregivers of children 6-59 months in Ugenya Subcounty, Siaya County. Methodology: A cross-sectional mixed methods design was employed involving 425 caregivers and 15 healthcare workers and County health officials between January to February 2025. Quantitative data were collected using structured questionnaires and analyzed in Stata version 17 through descriptive statistics, bivariate analysis at 20% significance threshold, and multivariable logistic regression at 5% level to determine key factors associated with malaria vaccine hesitancy. Qualitative data from 15 key informant interviews were transcribed verbatim and thematically analyzed using NVivo. Thematic analysis, guided by a predefined codebook, was used to identify recurring patterns and extract key themes, which were illustrated with direct quotations from participants Results: Overall, 42.9% of caregivers (n=181; 95% CI: 38.9%-47.3%) reported hesitancy. Significant predictors included caregiver age, marital status, family size, access to health facilities, and vaccine availability. Single caregivers, those from smaller households, and those facing health facility access challenges were more likely to be hesitant to malaria vaccine. Despite high levels of knowledge, misconceptions and misinformation about vaccine safety, often spread via social media persisted. Conversely, caregivers relying on healthcare workers and mainstream media showed greater acceptance of malaria vaccine. Conclusion and Recommendations: Malaria vaccine hesitancy remains significant at 42.9%, driven by demographic factors such as younger age, single status, and smaller household size. Structural barriers including limited vaccine availability and poor access to health facilities further contribute to reluctance. Although knowledge and awareness were high, misinformation, particularly from social media, persisted, while information from healthcare workers improved acceptance. Addressing these gaps through targeted community engagement, improved access, and trusted communication channels is essential to increase uptake of malaria vaccine.

Background. Targeted Universal Tuberculosis Testing (TUTT) may increase tuberculosis (TB) case detection by including people who are not actively seeking TB care but are at high risk of the disease. Non-invasive tongue swab (TS) testing may facilitate TUTT. We evaluated two TS testing protocols in people with HIV (PWH) tested irrespective of TB symptoms. Methods. Study staff collected Copan FLOQSwab and Medline foam swab specimens, alongside urine and sputa, from PWH, most of whom were presenting for antiretroviral therapy initiation at primary healthcare clinics in KwaZulu-Natal, South Africa. FLOQSwabs were tested by sequence-specific magnetic capture (SSMaC) with qPCR (FLOQSwab-SSMaC). Foam swabs were tested by centrifuge-sedimentation and high-volume qPCR (foam-sedimentation). Urine lipoarabinomannan was detected using LF-LAM. The extended microbiological reference standard (eMRS) comprised any positive result on Xpert Ultra and/or liquid culture of sputum. Results. We enrolled 251 participants (median age 34 years, 56% female, 67% with self-reported TB symptoms). Participants had a median CD4 count of 347 cells/ul, and 16% (40/251) had prior TB. FLOQSwab-SSMaC was 43% sensitive (13/30) and 100% specific (131/131) relative to eMRS. Foam-sedimentation was 47% (9/29) sensitive and 100% (176/176) specific. Sensitivity increased to 52% (FLOQSwab-SSMaC) and 50% (foam-sedimentation) when sputum Xpert Ultra Trace positive results were excluded from eMRS. TS was more sensitive than urine LAM, and both sample types were more sensitive when CD4 counts were below 200. Discussion. TS testing detected about half of PWH with TB and outperformed urine LAM within this population, including among PWH with low CD4 counts.

BackgroundLymphatic filariasis remains a public health concern in many endemic regions, where chronic disease persists despite substantial reductions in transmission. In Ghana, more than two decades of mass drug administration have significantly reduced disease prevalence and transmission; however, chronic manifestations and gaps in community understanding continue to be reported in parts of the north. This study assessed infection status, chronic morbidity burden, and community knowledge in a rural setting in northern Ghana approaching elimination. Methodology/Principal FindingsA community-based cross-sectional study was conducted in Birifor, northern Ghana, from October 2024 to January 2025. A total of 261 residents aged ten years and above were selected using random sampling. Data collection included structured questionnaires, clinical examination for chronic disease, and night blood microscopy for the detection of infection. No microfilariae were detected (0/261; 0%). However, chronic lymphoedema was identified in five individuals (1.9%), all aged over 40 years. Awareness of the disease was high (95.8%), yet only 39.5% of participants demonstrated good community knowledge and perceptions and self-reported preventive practices. Misconceptions regarding transmission, particularly beliefs that the disease is hereditary or caused by spiritual factors, were common. Participation in mass drug administration was high (93.1%). Despite this, chronic disease imposed a notable socioeconomic burden: all affected individuals reported loss of income, and 60% reported additional household income loss due to caregiving. Conclusions/SignificanceThese findings suggest that transmission in the study area is likely very low, although residual infection cannot be excluded; however, chronic disease and gaps in community knowledge persist. Strengthening morbidity management, improving community education, and providing support for affected households are essential. Sustained surveillance and integrated approaches will be critical to prevent resurgence and support long-term elimination efforts. Author SummaryLymphatic filariasis, also known as elephantiasis, is a mosquito-borne disease that can cause long-term swelling of the legs, arms, or genitals. Global efforts have greatly reduced its occurrence, especially through repeated mass drug administration to afflicted communities. However, many people continue to live with chronic swelling caused by past infections, which can affect their ability to work and participate fully in daily life. In this study, we examined the current situation of lymphatic filariasis in a rural community in northern Ghana that has received many years of treatment. We tested people for active infection, assessed signs of chronic disease, and explored what community members know and believe about the disease. We found no evidence of active infection, suggesting that transmission is now very low. However, some individuals were still living with chronic swelling and reported loss of income, while households also experienced financial strain due to caregiving. Although most people had heard of the disease, many did not fully understand how it is transmitted. Our findings show that reducing transmission alone is not enough. Continued education, community support, and access to care are needed to address the long-term impact of the disease and support ongoing elimination efforts.