Tropical Medicine & International Health

Backgroundanaemia remains a major comorbidity among children living with HIV (CLHIV) in sub-Saharan Africa, yet sex-specific risk factors are poorly characterized. This study investigated the prevalence and sex-based determinants of anaemia among CLHIV in the Southern Province, Zambia. MethodsA retrospective cohort study was conducted using medical records from 321 CLHIV aged 0-14 years. Data on demographic, clinical, and anthropometric variables were analysed. Sex-stratified multivariable logistic regression identified factors associated with anaemia. ResultsOverall anaemia prevalence was 47.0% (151/321), with a higher, though not statistically significant, burden in males (52.6%) than females (41.9%). Younger age was a strong, independent risk factor across both sexes. Distinct sex-specific determinants were identified. In males, cotrimoxazole (CTX) use during treatment was associated with increased odds of anaemia (Adjusted Odds Ratio, AOR=3.04; 95% CI: 0.95-9.74). Conversely, among females, the type of caregiver was a significant factor; care provided by an aunt was associated with 90% lower odds of anaemia compared to other arrangements (AOR=0.10; 95% CI: 0.01-0.90). Poor anthropometric indices (height and weight) were significantly associated with anaemia in both sexes. ConclusionsThe study findings reveal a high prevalence of anaemia among CLHIV in Zambia, with nuanced sex-based differences in its determinants. The findings advocate for differentiated, gender-sensitive intervention strategies. For boys, careful review of CTX prophylaxis is warranted, while for girls, enhancing supportive caregiving environments may be protective. Integrating these sex-specific approaches into paediatric HIV programs is crucial for reducing the anaemia burden and improving clinical outcomes.

IntroductionAnaemia is one of the most prevalent global public health challenges, particularly among women of reproductive age and children. According to the World Health Organization, anaemia is defined as a hemoglobin concentration below 13.0 g/dL in adult men, 12.0 g/dL in non-pregnant women, and 11.0 g/dL in pregnant women. Hemoglobin measurement therefore plays a critical role in diagnosis, classification, and monitoring of anaemia at both clinical and public health levels. Hemoglobin estimation allows early identification and intervention in at-risk populations. MethodologyA cross-sectional study was conducted at Aniniwaa Medical Centre, Kumasi, involving 100 participants who visited the laboratory for a complete blood count. Venous blood samples were collected aseptically into EDTA tubes and analysed first with the fully automated analyser, followed by the two Hb meters. Data were analysed using Chi-square tests, Bland-Altman plots, and descriptive statistics. ResultsResults showed that the prevalence of anaemia varied across methods: 28% by the analyser, 60% by Urit, and 64% by Mission. Both meters demonstrated 100% sensitivity but lower specificities (55.6% for Urit and 50.0% for Mission). Bland-Altman analysis indicated negative biases (Urit = -1.665 g/dL; Mission = -1.55 g/dL), suggesting both underestimated hemoglobin values compared to the reference. ConclusionThe study revealed that while Hb meters offer convenience and portability for field screening, the fully automated analyser remains more accurate and reliable for diagnosing anaemia in clinical settings.

INTRODUCTIONThe timing of antenatal care (ANC) attendance may affect outcomes for mother and child health. Using the Zambia Demographic and Health Survey (ZDHS), we describe the adoption of at least four early ANC (ANC4+) visits and early uptake of ANC among women of reproductive age in Zambia between 2007 and 2019. METHODSWe made use of ZDHS data gathered between 2007 and 2019. In this investigation, all women between the ages of 15 and 49 were taken into account. Early ANC4+ was the desired result, which was defined as having at least four ANC visits with the first ANC visit occurring during the first four months of pregnancy. In Stata v17, weighted univariate, bivariate, and multivariate logistic regression analyses were performed. RESULTSA total of 11633 (56%) of the 20661 women enrolled in our study had received early initiation of ANC4+. We saw an increase in the proportion of women who started ANC4+ early, from 55% in 2007 to 63% in 2018/19. There was a decreasing trend in the odds of early ANC4+ initiation with parity, but an increasing trend in the odds of early ANC4+ initiation with a higher level of education. Being a member of a wealthier household was associated with a lower risk of ANC4+ (OR= 0.81, 95%CI: 0.66-0.99, P=0.03). Twenty-seven percent of the 12,333 women who had at least four ANC visits, regardless of the timing of their first visit, reported being late for ANC. CONCLUSIONEarly ANC4+ uptake increased in Zambia between 2007 and 2019. There were, however, disparities due to wealth, education, and parity. We found that 27% of women who were misclassified as having at least ANC4+ using conventional analysis were actually late for ANC. We provide some key considerations for ensuring that Zambia and other similar settings achieve universal antenatal care coverage by 2030.

IntroductionAnaemia is a major cause of morbidity and mortality among children in sub-Saharan Africa. Anaemia has many aetiologies best addressed by different treatments, so regional studies of the aetiology of anaemia may be required. MethodsWe analysed data from Nigerias 2018 Demographic and Health Survey (DHS) to study predictors of anaemia among children ages 6-59m. We computed the fraction of anaemia at different degrees of severity attributable to malaria and sickle cell disease (SCD) using a regression model adjusting for demographic and socioeconomic risk factors. We also estimated the contribution of the risk factors to haemoglobin concentration. ResultsWe found that 63.7% (95% CI: 58.3-69.4) of semi-severe anaemia (<80 g/L) was attributable to malaria compared to 12.4% (95% CI: 11.1-13.7) of mild-to-severe (adjusted haemoglobin concentration <110 g/L) and 29.6% (95% CI: 29.6-31.8) of moderate-to-severe (<100 g/L) anaemia and that SCD contributed 0.6% (95%CI: 0.4-0.9), 1.3% (95% CI: 1.0-1.7), and 7.3% (95%CI: 5.3-9.4) mild-to-severe, moderate-to-severe, and semi-severe anaemia, respectively. Sickle trait was protective against anaemia and was associated with higher haemoglobin concentration compared to children with normal haemoglobin (HbAA) among malaria-positive but not malaria-negative children. ConclusionThis approach used offers a new tool to estimate the contribution of malaria to anaemia in many settings using widely available DHS data. The fraction of anaemia among young children in Nigeria attributable to malaria and SCD is higher at more severe levels of anaemia. Prevention of malaria and SCD and timely treatment of affected individuals would reduce cases of severe anaemia.

IntroductionRadical cure of Plasmodium vivax malaria remains a major challenge in endemic countries. New treatment options add opportunities but also increase complexity of policy decisions. Malaria treatment policies are often shaped by World Health Organisation (WHO) guidance, limiting scope for local adaptation. The Options Assessment Toolkit (OAT) was developed to support national policy making for the radical cure of vivax malaria. This study evaluates its co-development, uptake and practical influence. MethodsWe conducted a qualitative study with stakeholders in Afghanistan, the Solomon Islands, and Vietnam (co-developers) and Nepal (new user context). In-depth interviews were conducted with representatives from the National Malaria Programs between January and March 2025. Thematic analysis was conducted using NVivo 12, guided by pre-defined research questions, and reported according to COREQ criteria. ResultsParticipants described a strong ownership resulting from the inclusive co-development process. However, none of the co-developing countries used the OAT for formal policy decision-making. Instead, it primarily supported structured deliberation, planning, and contextual appraisal of emerging treatment options. A key finding was the conflation between decision-support and implementation feasibility: the toolkits perceived value was often judged according to whether recommended strategies could be operationalised within existing system constraints. Instrumental uptake was shaped by institutional structures, system readiness, variation in national analytic capacity, and reliance on WHO endorsement. ConclusionsThe findings suggest that ownership alone is insufficient for institutional uptake. Decision-support tools exert influence primarily by reshaping deliberation, but require embedding within formal policy, regulatory, and financing processes for sustained impact.

Sickle cell disease (SCD) is associated with chronic systemic morbidity that extends beyond acute crises. However, data describing the clinical and laboratory adolescents and young adults with SCD at steady state in sub-Saharan Africa are limited. We described clinical and laboratory characteristics of adolescents and young adults with SCD at steady state in Uganda. We conducted a hospital-based cross-sectional study of 60 adolescents and young adults with SCD in steady state at Mulago National Referral Hospital. Descriptive statistics were used to summarize participant characteristics and medication use. The mean age was 16.5 {+/-} 3.3 years, and 34 (56.7%) participants were female. Mean hemoglobin was 9.1 {+/-} 2.2 g/dl. Mean systolic and diastolic blood pressures were 107.9 {+/-} 15.5 mmHg and 60.3 {+/-} 12.6 mmHg, respectively; mean heart rate was 89.5 {+/-} 15.5 beats/min. Fifty-two (86.7%) participants reported using hydroxyurea. These observations show that adolescents and young adults with SCD at steady state exhibit hematologic abnormalities and distinctive hemodynamic profiles that underscore substantial chronic subclinical abnormalities that extend beyond acute complications.

Female Genital Schistosomiasis (FGS) is a gynaecological condition, arising from complication from schistosomiasis - a neglected tropical disease (NTD). FGS shares overlapping symptoms with several sexually transmitted infections, making it challenging to diagnose and manage especially in primary health care settings where diagnostic tools are often unavailable. In response to this challenge, an FGS screening tool (COUNTDOWN screening tool) was developed to support primary health care workers in identifying persons at risk of FGS. We investigated the sensitivity and specificity of adapted versions of the COUNTDOWN screening tool and evaluated the costs associated with providing these services in two Nigerian schistosomiasis endemic states (Ondo and Kebbi). Using three adapted versions of the screening tool against colposcopy and unit costs of activities, performance of the tool and cost-effectiveness analysis were evaluated. Compared to the colposcopy, the performance of the FGS screening tool varied using different screening definitions. When only direct and indirect contact with surface water was considered it demonstrated a sensitivity of 66.7% (95%CI: 60.1-72.8) and specificity of 35.4% (30.2-40.9); and when water contact together with any self-reported urogenital symptom was considered, the sensitivity and specificity were 50.2% (95%CI: 43.5 - 56.9) and 48.0% (95%CI: 42.5 - 53.6) respectively. Activity based micro-costing, showed that the FGS screening tool could screen individuals for approximately US$11 per woman, compared with US$20 per woman when using colposcopy. The screening tool detected far fewer true positive cases than the reference standard, assuming colposcopy did not miss true positives. The sub-optimal performance of the screening tool indicates the need for further refinement, to balance cost and effectiveness.

Background: In malaria-endemic tropical regions, the overlapping coagulopathy in COVID-19 and malaria poses diagnostic and prognostic challenges, particularly with potential sex differences. This study evaluated sex-specific variations in platelet indices and fibrinolytic markers and assessed the utility of Platelet Distribution Width (PDW) and D-dimer in mild/asymptomatic cases. Methods: A case-control study was conducted with 220 participants (55 each in healthy controls, malaria-positive, COVID-19-positive, and COVID-19+malaria co-infected groups), aged 20-65 years, in Port Harcourt, Nigeria. Platelet indices were analysed using Sysmex XP-300 haematology analyser, while D-dimer and fibrinogen were measured by ELISA. Data were analysed using SAS 9.4 with ANOVA, Tukey's HSD, Pearson correlation, and sex-stratified comparisons. Results: PDW was significantly elevated in all infected groups compared to controls (malaria: 15.21 +/- 0.22 fL; COVID-19: 15.21 +/- 0.22 fL; co-infection: 15.61 +/- 0.21 fL vs. control: 13.26 +/- 0.17 fL; F=25.850, p < 0.001). D-dimer levels were highest in the co-infected group (553.42 +/- 59.74 ng/ml, F=2.816, p = 0.040). No significant changes were observed in other platelet indices or fibrinogen across groups. No significant correlation existed between platelet indices and the fibrinolytic markers. Males exhibited significantly higher D-dimer levels across all infected groups (p < 0.05) and higher fibrinogen in COVID-19 subjects (p = 0.036). Sex exerted a stronger influence on parameters than age. Conclusion: Males show heightened fibrinolytic activation in COVID-19 and malaria co-infection. PDW and D-dimer are promising, cost-effective biomarkers for screening mild infections in resource-limited tropical settings.

BackgroundFemale Genital Schistosomiasis (FGS) is an critical complication of schistosome infection, especially in schistosomiasis-endemic areas. It is a neglected disease and remains under-recognized in many areas. The prevalence of visual FGS in the endemic areas of Southern Malawi is 26.9%. This is higher in other African countries including Zambia and Tanzania and nosuch studies have been conducted in endemic areas in the Central Region of Malawi. The study aimed to determine the prevalence and risk factors for FGS in Nkhotakota district, Central Malawi. MethodsThe cross-sectional study was conducted from November 2024 to March 2025. Two hundred and sixty women (N=260) of childbearing age accessing healthcare services were consecutively sampled from the selected healthcare facilities. An interviewer-guided questionnaire was used to collect data regarding the demographics and FGS symptoms of the participants. Colposcopy was conducted by an experienced gynecological clinical officer to identify FGS lesions and was supervised by a specialist gynecologist. Data were coded, cleaned, and analyzed using the R software (version 4.3.1). ResultsThe prevalence of FGS using colposcope as a diagnostic tool in women of childbearing age was 32.6%(84/258). Age and a history of cervical cancer screening were associated with increased odds of FGS. The odds of FGS increased by 5% for each additional year (OR, 1.05; 95% CI: 1.02-1.09; p = 0.003). Women with a history of cervical cancer screening were twice as likely to have FGS than those without a history of cervical cancer screening (OR, 1.91; 95% CI: 1.01-3.70; p = 0.05). ConclusionWe found a huge burden of undetected FGS in Nkhotakota district, Central Malawi. Integrated interventions are needed to reduce the burden of FGS and improve its early detection, particularly in schistomiasis-endemic areas.

BackgroundAnaemia during childhood adversely affects mental, physical and social development of the children, therefore morphological patterns of anaemia in under-five children are considered essential for classification, diagnosis and management. AimThis study aimed at assessing morphological patterns, the prevalence and associated factors of anaemia among under-five children on Prevention of Mother-To-Child Transmission (PMTCT) programmes in Masogo sub-county hospital, Kisumu County, Kenya. MethodA cross-sectional health facility-based study was conducted among 175 children aged 6 to 59 months who attended clinic for the PMTCT programme for the period of January 2020 to December 2020. Pretested and structured questionnaires were used to collect socioeconomic and demographic characteristics of the family and child. Capillary blood sample was collected from each child for malaria parasite and Peripheral Blood Film (PBF) examination. ResultComplete blood counts indicate that microcytic pattern was the most common, representing 30 (42.3%) followed by microcytic hypochromic pattern 20 (28.2%), normocytic normochromic pattern with 11 (15.5%) and lastly dimorphic pattern with 10 (14.0%). High prevalence of anaemia was observed in children who were urban dwellers (50.0%), in children whose mothers aged 18-27 years (44.0%) and had no formal education (48.1%). Besides, the high prevalence rate of anaemia was found among children with a family monthly income of less than 500 Ksh. (46.9%), early (<6 months) introduction of complementary foods (71.4%) ConclusionThis study has revealed that the prevalence of anaemia in children less than five years is high and is a severe public health problem in the study area. Therefore, the policymakers should make a strategy that can reduce poverty and increase the awareness to women on breastfeeding, nutrition, and other associated factors to reduce anaemia.

BackgroundThe WHO recommends at least eight antenatal care (ANC) contacts per pregnancy to improve maternal and child health. However, ANC coverage remains low in many settings in sub-Saharan Africa. Preventive measures, including intermittent preventive treatment of malaria with sulfadoxine-pyrimethamine during pregnancy (IPTp-SP), are crucial for reducing adverse pregnancy outcomes. This study assessed the effect of a community-based intervention on maternal and child health outcomes and malaria incidence in pregnancy in rural Mali and Burkina Faso. MethodsThis is a secondary analysis based on data from the INTEGRATION randomized cluster trial, encompassing 40 trial clusters (20 in Mali and 20 in Burkina Faso). The INTEGRATION intervention consisted of delivering IPTp-SP to pregnant women during seasonal malaria chemoprevention home visits from July to October over two consecutive years (2022 and 2023). Outside this four-month period, as in the control arm, IPTp-SP was given at the maternity clinic. Data were collected from the 40 study health facilities between January 2020 and June 2022 (pre-intervention period) and July 2022 and April 2024 (post-intervention period). The primary outcomes were ANC4+ coverage, cumulative incidence of malaria in pregnancy, and adverse pregnancy and birth outcomes, defined as any of the following: prematurity, low birth weight, stillbirth, or maternal death. A difference-in-differences model assessed the interventions effect on outcomes at the cluster level. Statistical significance was set at a 0.05 level. ResultsA total of 11,199 women in Burkina Faso and 35,351 women in Mali delivered during the study period. After adjusting for age and parity, the intervention did not show any statistically significant effect on ANC4+ coverage (Burkina Faso: -2.598; 95% CI [-13.400 - 8.202], Mali: -2.72; 95% CI [-14.35 - 8.91]), adverse pregnancy and birth outcomes (Burkina Faso: -0.194; 95% CI [-4.375 - 6.593], Mali: -0.36; 95% CI [-8.61 - 7.89]), or cumulative incidence of malaria in pregnancy (Burkina Faso: 125.56; 95% CI [-389 - 640], Mali: -12.68; 95% CI [-221 - 196]). ConclusionIn both Burkina Faso and Mali, the four-month community-based intervention did not yield any statistically significant effect on maternal or pregnancy outcomes. Extending the duration of such interventions may be necessary to achieve meaningful reductions in the targeted outcomes. Trial registrationRetrospectively registered on August 11th, 2022; registration # PACTR202208844472053 (Pan African Clinical Trials Registry: https://pactr.samrc.ac.za/Search.aspx). Protocol v4.0 dated September 04, 2023. Trail sponsor: University of Sciences Techniques and Technologies of Bamako (USTTB), Mali.

IntroductionKenya adopted a decentralized health system as part of the efforts to improve access, eliminate inequalities and make progress towards universal health coverage (UHC). With significant investments, county governments are charged with the responsibility of delivering healthcare to their population. However, questions remain about the efficiency of resource utilization to meet the health goals. MethodsWe assembled a dataset comprising health sector inputs, outputs, and contextual factors to measure the efficiency of Kenyas health system across 47 counties in 2022. We estimated overall technical efficiency (OTE), pure technical efficiency (PTE) and scale efficiency (SE) employing Simar and Wilsons single-step data envelopment analysis (DEA) approach. We assessed the impact of contextual factors on efficiency levels using a truncated regression model. ResultsConsidering child survival as a health system output, the national average for OTE was 0.74 (95% CI:0.70-0.78), while PTE was 0.85 (95%CI:0.82-0.88) and SE was 0.87 (95%CI:0.85-0.89). Meanwhile, for childhood immunization coverage, average OTE was 0.83 (95%CI:0.81-0.87), while PTE was consistently high across the counties. For maternal survival, OTE was low at 0.51 (95%CI:0.48-0.55), and PTE was 0.61 (95%CI:0.57-0.69), with SE averaging 0.82 (95%CI:0.79-0.84). Taking healthy adjusted life expectancy (HALE) as the health system output, average OTE was 0.83 (95%CI:0.81-0.85). There was a high correlation between OTE scores that considered child survival, childhood immunization coverage and HALE as health system outputs. Efficiency scores showed a heterogenous picture across the country both at the provincial and county levels. ConclusionIn 2022 the Kenyan health system was inefficient. Decision makers in Kenya have an opportunity to improve health outcomes without the injection of additional resources particularly through better managerial practices as pointed by low attainment in PTE. Additionally, reorganizing the scale of health programs to operate at the optimal level would yield improved efficiency.

BackgroundDespite population mobility being on the rise globally, it remains neglected in the development of national health policies. This study sought to examine how population mobility is problematized in National Neglected Tropical Disease Masterplans and how these representations shape policy implementation within 4 NTD endemic districts in Zambia. MethodsWe used Policy as discourse analysis by guided by Bacchis "Whats the Problem Represented to be?" (WPR) approach. We reviewed all four NTD Masterplans that have been developed in Zambia between 2011 and 2022. Interviews on everyday implementation experiences were conducted with key policy actors (n=20), community health workers (n-34) and community members (n=35) guided by the Consolidated Framework for Implementation Research. Data was analysed using critical discourse analysis informed by the WPR approach. ResultsAcross all four Masterplans, the construction of migration and its role in NTD prevention, control and treatment was scant indicating limited recognition of the role that migration plays on health. Migrant groups recognized were forced migrant (refugees) or voluntary migrants (foreign tourists), labour migrants (fishing or farming) or environmental migrants. Assumptions underlying these constructions of migration include territoriality and associated internalization practices, medical nativism, migrant deservingness and universalization. Silences in the Masterplans included failure to account for local migration patterns, lack of migrant sensitive services and lack of clarity on entitlement of health services. ConclusionsThough the mobility is poorly problematized in the Masterplans, through policy design and implementation can strengthened such as using more comprehensive and standardized definitions of migration and migrant groups in public policies, capturing migration data and using it to inform decision making as well as establishing accountability mechanisms for policy actions, training of frontline workers using standards and engagement of migrant and mobile populations in migration governance. AUTHOR SUMMARYZambia has a robust migration governance framework aimed at enhancing population mobility. In order to identify if the policy intent of these governance frameworks in bringing about orderly, safe regular and responsible migration and mobility of people was being translated into health, we examined the problem representations of population mobility in National NTD Masterplans. We found that across all four Masterplans, the construction of migration and its role in NTD prevention, control and treatment was scant indicating limited recognition of the role that migration plays on health. There was an absence of data on the magnitude of migration related inequalities and how migration interacts with other dimensions of social identity. Key assumptions underlying these representations of mobility include territoriality where the Masterplans view borders as fixed orderings of space with cross border migration being seen as responsible for new diseases that are non-endemic in Zambia (onchocerciasis) or reintroduction of NTDs which have been eliminated (leprosy). The failure of the Masterplans to establish strong links between migration and NTD prevention, control, and treatment could be linked to a broader policy agenda surrounding migration nationally, regionally and internationally.

Maternal and newborn mortality in The Gambia remains high despite expanded coverage of essential interventions, and progress towards SDG targets 3.1 and 3.2 has stalled. The National Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Policy (2017 to 2026) ends in 2026, and a successor plan is in development. We aimed to identify and rank nationally defined maternal and newborn health (MNH) research priorities in The Gambia to inform the successor RMNCAH plan and align research investment with national health system needs. We conducted a national, stakeholder-led MNH research prioritisation exercise in October 2023 using an adapted Child Health and Nutrition Research Initiative (CHNRI) method. Forty-six participants, including Ministry of Health policymakers and programme managers, clinicians, midwives, researchers, and development partners, took part in a two-day workshop. A starting set of 46 questions from the 2019 African Academy of Sciences (AAS) continental MNH prioritisation exercise and four questions from The Gambia's National Health Research Agenda was expanded through facilitated discussion to a final list of 61 questions, organised by MNH grand challenge area and CHNRI research domain. Participants independently scored each question against four weighted criteria, and national rankings were compared descriptively with AAS continental and West African subregional rankings. The priority list was dominated by delivery-focused research (49 of 61 questions, 80 percent), concentrated in better care during pregnancy and better postnatal care. The five highest-ranked priorities addressed management of obstetric emergencies before referral, retention and equitable distribution of the MNH workforce, neonatal resuscitation at peripheral facilities, maternal recognition of danger signs, and kangaroo mother care. Pre-transfer emergency obstetric management was the top national priority but was not prominent in AAS continental or West African subregional rankings. This first national MNH research priority-setting exercise in The Gambia identifies a coherent set of implementation and health systems research priorities and surfaces context-specific questions, particularly pre-transfer emergency management, that were under-emphasised in continental rankings. The agenda provides an evidence base for the successor RMNCAH plan and for partner alignment in The Gambia and comparable high-burden settings.

Of the 500 000 children born with sickle cell disease annually, most cases occur in Africa, contributing to significant morbidity and mortality associated with limited sickle cell disease (SCD) health outcomes data and reduced access to therapeutic plus preventive care. We aim to develop and manage a standardized electronic SCD registry, establish consistent standards of care (SoC) for patients, improve the SCD research and biobanking capacity in Zimbabwe and Zambia. This five-year program employs mixed methods that include infrastructure and skilled manpower capacity building of SCD clinics, registry, biobanking, cohort and implementation science research studies to improve SCD treatment outcomes. We are collaborating with the SickleInAfrica consortium (Ghana, Mali, Nigeria, Tanzania, Uganda, and South Africa), the African Institute of Biomedical Sciences and Technology (AiBST) and St Judes Children Research Hospital. We established the SCD registry in Zimbabwe and Zambia for children and adult patients enrolling 1796/4000 (45%) participants to date. We are participating in SickleInAfrica consortium research activities, training health workers and educating SCD patient communities on SoC. This collaboration with African researchers, policymakers, health workers, and SCD patient communities will improve uptake of SCD SoC and increase our research capacity.

Like many others, Malawis health care system faces significant health workforce shortages largely due to budget constraints that limit training, recruitment and retention of staff. A crucial question is how to best allocate a limited budget to expand different health care workers (HCW) cadres so that the potential health gains are maximised, which is more important now than ever considering recent withdraw and reduction in donor funding. This research aims to provide a practical answer to this question. We designed a range of budget allocation scenarios for HCW expansion across different cadres, and used the "all diseases - whole healthcare system" Thanzi La Onse (TLO) model to estimate the resulting population health outcomes. We find that, indeed, how to allocate additional resources for HRH across different cadres is an important determinant of potential health impact. Putting all resources into increasing staffing in a single cadre is not the most effective use of the resources, even if that cadre has the most limited availability currently. Similarly, allocating new resources in a manner that mirrors the current distribution of spending does not generate the greatest possible gains. Instead, an allocation that uplifts staffing for all cadres, according to extra time and cost required to meet the arising healthcare needs, gives the greatest benefits. We conclude that in the context of complex interplay between demography, epidemiology, treatment scope and effectiveness, and health resource constraints in the health care system, human resources for health (HRH) bottlenecks in achieving health gains are multifactorial and a balanced mix of cadres and skills is required for future HRH expansion. As such, health system models such as the TLO that capture this interplay can make potential contributions to strengthening HRH planning. What is already known on this topicTo date, very few studies have quantitatively analysed the potential future health impact of HRH expansion in the context of evolving healthcare needs for a whole population. One existing study shows that investing in HRH expansion has the potential to achieve better health outcomes for Malawians, assuming a uniform expansion of multiple cadres (1). What this study addsUnder a detailed individual-based simulation model capturing the wide range of healthcare needs and the interdependency between cadres for delivering care, we have shown that there is not a simple HRH bottleneck driving future health outcomes and health gains could be achieved by allocating additional resources to expand cadres in a carefully balanced way. How this study might affect research, practice or policyThis study answers the hard question of how to use the limited funding for HRH expansion to achieve greatest health gains in Malawi; and demonstrates the essential use of system-wide modelling to support decision-making in complex health systems.

BackgroundDespite decades of intervention, Nigeria continues to face critical challenges in maternal and child health, ranking among the highest globally for maternal mortality and under-five deaths. Sustainable Development Goals (SDGs) 3.1 and 3.2 call for substantial reductions in these outcomes by 2030. Assessing national progress requires not only measuring quantitative indicators but also understanding contextual and systemic barriers that shape health access and equity. MethodsThis study adopted a mixed-methods design combining descriptive quantitative analysis of the NDHS 2018 and 2023-24 datasets with a thematic qualitative analysis using NVivo software. Five focus areas were assessed: maternal and under-five mortality, immunization coverage, exclusive breastfeeding and malnutrition, antenatal care and skilled birth attendance, and treatment-seeking behavior for childhood illnesses. Quantitative results were complemented with thematic insights drawn from NDHS narrative and policy sections to capture structural and community-level determinants. ResultsThe under-five mortality rate declined from 132 to 102 deaths per 1,000 live births. Improvements were also observed in immunization coverage, exclusive breastfeeding (from 29% to 34%), and antenatal care attendance (from 57% to 68%). Skilled birth attendance rose to 52%, and treatment-seeking for childhood illnesses increased. However, maternal mortality data for 2023 were unavailable, and persistent disparities, particularly in rural and northern regions, remain evident. Qualitative analysis revealed themes of access barriers, mistrust in services, inconsistent program implementation, and gaps in data systems. ConclusionNigeria has made measurable but uneven progress in maternal and child health. Structural challenges, regional inequities, and weak data governance continue to hinder national gains. A combination of integrated service delivery, targeted social protection, and equitable policy implementation is needed to accelerate progress toward SDG 3 targets.

Background: Sickle cell anaemia (SCA) is characterised by chronic haemolysis, inflammation, platelet activation, and recurrent vaso-occlusive complications. Mean platelet volume (MPV) is a readily available platelet index, but evidence regarding its relationship with disease severity in paediatric SCA remains limited and inconsistent, particularly in African populations. Objective: To evaluate the relationship between MPV and disease severity among children with SCA in Kwara State, North-Central Nigeria. Methods: This hospital-based cross-sectional study included 51 clinically stable children with confirmed SCA consecutively recruited from the paediatric haematology clinic of Children Emergency Specialist Hospital, Ilorin. Complete blood count, including MPV, was performed using a Rayto RT-7600 automated haematology analyser. Disease severity was assessed using a composite clinical and laboratory scoring system based on a previously described method. Pearson's correlation, Spearman's rank correlation, simple linear regression, and the Kruskal-Wallis test were used as appropriate. Statistical significance was set at p < 0.05. Results: Of 51 participants, 14 (27.5%) had mild, 33 (64.7%) moderate, and 4 (7.8%) severe disease. Mean MPV was 9.34 +/- 0.76 fL (range, 8.0-11.2). Pearson's correlation showed a weak positive, non-significant linear relationship with severity score (r = 0.231, p = 0.103), whereas Spearman's analysis showed a weak positive monotonic association (rho = 0.286, p = 0.042). Regression explained 5.3% of severity-score variation (R2 = 0.053, p = 0.103). MPV did not differ significantly across severity categories (H = 2.163, p = 0.339). MPV correlated inversely with haemoglobin (r = -0.556, p < 0.001) and positively with platelet count (r = 0.307, p = 0.029). Conclusion: MPV showed a weak relationship with disease severity but inconsistent statistical evidence across analyses. The limited explained variance and absence of significant differences between severity categories do not support MPV as a standalone severity marker. Larger longitudinal studies are warranted. Keywords: Sickle cell anaemia; Mean platelet volume; Disease severity; Platelet indices; Paediatric haematology; Cross-sectional study; Nigeria.

BackgroundGlobally, thrombocytopenia is one of the most common hematologic conditions seen in ill neonates. In countries with limited resources, like Ethiopia, it is a serious concern. Because the burden of thrombocytopenia is so great, generating updates evidence on predictors of mortality and survival status is vital to fight it. However, the problem is not well investigated in Addis Ababa. Therefore, this study aimed to assess survival and predictor of thrombocytopenic neonatal death in Public Hospitals, Addis Ababa, Ethiopia, 2024/2025. Methods and MaterialsA prospective follow-up study was done among a total of 350 neonates from March 20, 2025, to April 30, 2025, in Addis Ababa public hospitals. All thrombocytopenic neonates that meet the inclusion criteria were chosen as study participants. Data were collected using the Kobo Tool through direct observation and review of maternal and neonatal charts. After export to an Excel spreadsheet, data cleaning and recoding were performed using SPSS version 26, followed by statistical analysis using STATA version 17. The Kaplan-Meier failure curve was used to demonstrate the pattern of death, estimate the chance of death, and compare failure curves. Collinearity, Schoenfeld residual, and log-rank tests were performed. The Cox proportional hazards model was fitted with global test result of 0.7882. Finally, the findings were presented both descriptively and analytically. ResultsIn this study, the overall magnitude of thrombocytopenic neonatal death was 14.1% (95% CI: 10.4-18.1), with an incidence rate of 13.04/1000 (95% CI: 0.009-0.017) neonate-days. The restricted mean time to death in this study was 23.36 days (95% CI: 22.23-24.50). Being born to a mother with severe preeclampsia (AHR = 3.84; 95% CI: 1.78-8.26), very low birth weight (<1499g) (AHR = 3.67; 95% CI: 1.14-11.80), perinatal asphyxia (AHR = 2.76; 95% CI: 1.32-5.79), necrotizing enterocolitis (AHR = 2.45; 95% CI: 1.14-5.31), and delayed initiation of feeding (AHR = 3.37; 95% CI: 1.10-10.29) were the identified predictors of mortality. Conclusion and recommendationIn this study, a high burden of thrombocytopenic neonatal death. Early detection and treatment of high-risk conditions like severe preeclampsia, very low birth weight, perinatal asphyxia, and necrotizing enterocolitis should be the main goal of efforts to lower thrombocytopenic neonatal mortality. Furthermore, prompt neonatal feeding initiation ought to be given top priority.

1.Mathematical models hold the potential to generate valuable evidence for shaping vaccination policies. However, maximizing their impact requires a deeper understanding of how modelling efforts can be aligned with the real-world priorities of policymakers and health officials. This study explores how structured engagement with stakeholders can help co-identify decision-relevant questions that are amenable to quantitative modelling. The focus is the human papillomavirus (HPV) vaccination programme in Mozambique. We conducted semi-structured interviews with stakeholders involved in the HPV vaccine programme to identify key knowledge gaps in their decision-making context, i.e., practice. These were translated into research questions that informed the application of a mathematical model. An evidence brief was developed to synthesize and contextualize findings, and follow-up interviews were conducted to reflect on the utility of the evidence. Qualitative data were analysed inductively to identify emergent themes. Stakeholders identified four priority questions: optimal vaccine delivery strategy, distributional impact, vaccine economics, and comparison with other prevention methods. They emphasized the value of tailored evidence--particularly at the provincial level--for informing financial planning, resource allocation, and advocacy. The approach facilitated collaboration between researchers and stakeholders, helped uncover previously untapped data sources, and improved the policy relevance of the modelling outputs. This study demonstrates how co-identifying modelling questions with decision-makers can help ensure that evidence generated through mathematical models is context-specific, and policy-relevant. This type of engagement enabled clearer alignment between model development and decision-making needs--offering lessons for future applications of modelling in public health policy.