Tropical Medicine & International Health

Reproductive tract infections (RTI) are associated with adverse outcomes in pregnant African women. However, many diagnostic strategies are unaffordable or perform poorly. Here, we assess RTI prevalence and predictors of chlamydia/gonorrhea (CT/NG) in pregnant women reporting vaginal discharge and the performance of our previously published CT/NG risk algorithm in this population versus Rwandan National Guidelines (RNG). From 2017-2020, free sexually transmitted infections (STI) services were provided to residents in Kigali, Rwanda. Medical history and gynecologic examination were done. Laboratory assessments included HIV; syphilis; microscopy for trichomoniasis, bacterial vaginosis (BV), and candida; and PCR for CT/NG. Eighty-seven pregnant women received STI services. Prevalence was 28% for CT/NG, 15% for trichomoniasis, 24% for BV, 39% for candida, and 79% for any RTI. Predictors of CT/NG were age <=25 (adjusted prevalence odds ratio [aPOR]=4.92; 95% confidence interval [CI]: 1.52-15.90; p=0.008), inconsistent condom use (aPOR=4.86; 95%CI: 0.98-24.10; p=0.053), absence of candida (aPOR=4.23; 95%CI: 1.13-15.82; p=0.032), and endocervical inflammation/discharge (aPOR=4.91; 95%CI: 1.40-17.20; p=0.013). Our algorithm outperformed the 2019 and 2024 RNG (sensitivity: 92% versus 46% and 35% respectively). Pregnant women seeking STI services had high RTI prevalence. Our algorithm performed well. Algorithms tailored for pregnant women and including male partner risk factors should be explored.

Indigenous and nomadic communities worldwide face disproportionate and persistent barriers to reproductive health services, including family planning and safe abortion. The Raute of Nepal -- one of the country's last nomadic hunter-gatherer groups represent a uniquely marginalized population for whom no prior population-level quantitative reproductive health data exist. This gap prevents health authorities and program implementers from designing evidence-based, culturally appropriate interventions for this community. This census-based cross-sectional study enrolled all 192 eligible married women of reproductive age in the Raute community of Parshuram Municipality, Dadeldhura district, Sudurpaschim Province, Nepal. Data were collected through structured, pre-tested, face-to-face interviews, and analyzed using descriptive statistics, chi-square tests, and binary logistic regression in IBM SPSS version 16. More than half of participants (53.6%) currently used family planning, with injectable contraceptives being the most common method (42.7%), followed by female sterilization (33.0%) and implants (24.3%). Condom use was negligible at 1.0%. Among non-users (46.4%), 97.7% cited lack of interest as the primary reason for non-use. Knowledge of safe abortion services was reported by 61.5% of women, yet only 8.3% had ever accessed such services, and awareness of Nepal's national safe abortion policy, which has been in effect since 2002 was critically low at 10.4%. In bivariate analysis, no socio-demographic or socioeconomic variable was significantly associated with family planning use. The sole significant independent predictor of current family planning utilization in the adjusted logistic regression model was non-utilization of safe abortion services (adjusted odds ratio = 4.275; 95% confidence interval: 1.145-15.954; p = 0.030), suggesting that contraceptive use and abortion service use represent alternative reproductive management strategies in this community. Younger age ([&le;]30 years) and urban residence were significantly associated with safe abortion use in bivariate analysis but were attenuated after adjustment, reflecting limited statistical power arising from the small number of outcome events (n = 16). These findings reveal critical gaps in reproductive method diversity, safe abortion policy literacy, and male partner engagement. Community-based mobile outreach tailored to nomadic movement patterns, targeted legal literacy programs in the local language, and structured male involvement strategies are urgently required to improve reproductive health equity in this vulnerable indigenous population.

Introduction Reducing delays in leprosy case detection is essential for achieving global leprosy targets. Accurate measurement of these delays and their determinants relies largely on patient-reported data, as routine health records are often inadequate. The leprosy case detection delay (CDD) questionnaire, developed under the Post Exposure Prophylaxis for Leprosy (PEP4LEP) project, has been validated in Ethiopia, Mozambique, Tanzania, and Indonesia. However, it has not been adapted or validated for Nigeria or any major Nigerian indigenous language. This study aimed to culturally adapt and validate the CDD questionnaire for Igbo-speaking populations in Nigeria. Methodology/Principal Findings The CDD questionnaire underwent a standardized cross-cultural adaptation process. Content validity was assessed using item- and scale-level content validity indices, while construct validity was evaluated through hypothesis testing. Reproducibility was assessed using test-retest and inter-rater reliability; agreement using the Bland-Altman method and the Wilcoxon Signed-Rank test; reliability using Spearmans rank correlation coefficient and the Intraclass Correlation Coefficient (ICC); and internal consistency using Cronbachs alpha. Data were collected through face-to-face interviews with persons affected by leprosy at two time points separated by at least two weeks. Participants (n=100) had a mean age of 45.1 years (SD=18.7). Mean CDD was 77.2 months at baseline and 77.9 months at retest. The instrument demonstrated excellent content validity (I-CVI/S-CVI: 0.90-1.00), good internal consistency (Cronbachs =0.77), and excellent test-retest reliability (ICC=0.996, 95% CI: 0.994-0.997). Test and retest measurements were highly correlated ({rho}=0.985, p<0.001), with no evidence of systematic change over time (p=0.864). Seventy-two percent of participants reported identical CDD values across assessments. All items from the original English version were retained without modification. Conclusion/Significance The Igbo version of the CDD questionnaire demonstrated good validity and reliability and is suitable for assessing leprosy case detection delay among Igbo-speaking populations in Nigeria

Introduction: Viral load (VL) monitoring is the gold standard for antiretroviral therapy (ART) monitoring. Still, due to limited funds and infrastructure, many people living with HIV (PLHIV) in low- and middle-income countries do not receive timely VL testing. We evaluated the clinical performance and end-user acceptability of a prototype interferon gamma-induced protein 10 (IP-10) point-of-care (POC) test as a rule-out triage tool to identify individuals unlikely to have unsuppressed VL in PLHIV in Mozambique. Methods: A mixed-methods study was conducted between November 2023 and November 2024 at two primary healthcare facilities in Maputo Province. We enrolled 1,057 PLHIV on ART from stable and specialized risk clinics. Clinical performance of the IP-10 POC test (index test) was compared against plasma HIV VL (reference test; unsuppressed defined as >1000 copies/mL). Socio-demographic and clinical predictors of false-positive results were identified using multivariable logistic regression. Immediate acceptability was assessed through exit interviews on a subset of 43 PLHIV. Results: Among participants (71.7% female; median age 41.4 years), 12.0% had unsuppressed VL. The IP-10 POC test demonstrated high sensitivity (90.6%) and moderate specificity (35.6%). Specificity was higher in clinics treating stable patients (44.5% 95%CI: 39.7-49.3) compared to specialized risk clinics (26.5% 95%CI: 21.1-28.9). The proportion of false-positive results was also higher in patients attending specialized risk clinics. Independent predictors of false positivity included enrolment in a one-stop TB/HIV clinic (aOR=2.99 95%CI: 1.09-8.15), cotrimoxazole use (aOR=2.16, 95% CI: 1.13-4.13), and obesity (aOR=3.47 95%CI: 1.74-6.93). Acceptability was high: 70% of participants appreciated the test simplicity and rapid results, and 95.3% expressed interest in future testing. Most patients preferred finger-prick collection over venous draws. Conclusions: The IP-10 POC test is a highly sensitive triage tool, demonstrating superior performance among stable PLHIV enrolled in differentiated service delivery models like six-month multi-month dispensing. While factors associated with co-infections can reduce specificity, the test's high acceptability and potential to reduce confirmatory VL test demand suggests it could serve as a viable triage strategy for optimizing resources particularly in stable care pathways with a lower prevalence of inflammatory comorbidities. This could enable health systems to reallocate intensive monitoring toward higher-risk populations.

There are several barriers to uptake of intrauterine devices (IUDs), with the fear of pain during insertion an emerging concern. Using data from an online survey, we sought to understand the experience of women who had undergone IUD insertion, with a particular focus on their expectation compared with their reported experience of pain. We found that, while most participants expected a moderate level of pain at insertion, many reported a high level of pain. Pain relief offered was variable, and, aside from that administered by an anaesthetist, no single method appeared to significantly reduce reported pain.

Background: Antenatal care (ANC) utilization is critical for improving maternal and neonatal health outcomes. Despite the World Health Organization recommendation of at least eight ANC contacts during pregnancy and the implementation of free maternal healthcare policies in Ghana, significant geographic and socioeconomic disparities in ANC utilization persist. This study therefore assessed the spatial distribution and geographically varying determinants of ANC utilization among women in Ghana. Methods: A cross sectional analytical study was conducted using women data from the 2022 Ghana Demographic and Health Survey. The analysis included women aged 15 to 49 years with an index child younger than five years preceding the survey. Descriptive statistics were computed using Stata version 18, while spatial analyses were conducted in QGIS version 3.44. Global Morans I was used to assess spatial autocorrelation, whereas Local Morans I and Getis Ord Gi analyses identified spatial clusters, hotspots, and coldspots of ANC utilization. Ordinary Least Squares (OLS) regression and Geographically Weighted Regression (GWR) models were fitted to assess global and local determinants of ANC utilization. Results: Overall, only 26.0% of women achieved adequate ANC utilization, while 74.0% reported inadequate ANC attendance. Adequate ANC utilization was higher among women with higher education (42.0%) and those from the richest households (41.3%) compared with women without formal education (19.1%) and those from the poorest households (17.6%). Regional disparities were observed, with Western (48.8%), Eastern (48.0%), and Greater Accra (47.3%) regions recording the highest ANC utilization, whereas Savannah (24.7%), Northern (25.8%), and North East (26.8%) regions recorded the lowest utilization levels. Global Morans I demonstrated significant positive spatial autocorrelation (Morans I = 0.457, p = 0.044), indicating geographic clustering of ANC utilization across Ghana. Getis Ord Gi analysis identified significant coldspots within Northern, Savannah, and North East regions, while Central Region demonstrated significant hotspot clustering. OLS regression showed that maternal education (B = 0.284, p = 0.003) and household wealth (B = 0.191, p = 0.011) positively influenced ANC utilization, whereas distance to health facility negatively influenced utilization (B = -0.156, p = 0.019). The GWR model demonstrated improved explanatory performance (Adjusted R-squared = 0.71), confirming substantial spatial heterogeneity in ANC determinants across Ghana. Conclusion: Adequate ANC utilization in Ghana remains low and geographically unequal. Maternal education, household wealth, and geographic accessibility significantly influence ANC utilization, with pronounced disparities concentrated within Northern Ghana. Spatially targeted maternal health interventions aimed at improving education, reducing socioeconomic inequalities, and enhancing healthcare accessibility are required to improve equitable ANC utilization across Ghana.

Background Microbiological confirmation of paediatric pulmonary tuberculosis is frequently unattainable, rendering chest radiography a critical yet underutilised diagnostic tool. Methods We conducted a retrospective diagnostic accuracy study of the qXR version 4.2.1 (Qure.ai), a paediatric optimized computer-aided detection (CAD) algorithm, for pulmonary tuberculosis. Diagnostic performance was assessed against microbiological (MRS) and clinical reference standards (ClRS). Bayesian latent class analysis (LCA) was applied to address the imperfection of both reference standards in children. Performance was quantified using area under the receiver operating characteristic curve (AUROC) and estimates of sensitivity and specificity. Results We included digital chest radiographs of 932 Gambian children (< 15 years) comprising 80 (9%) children with confirmed tuberculosis, 163 (17%) with unconfirmed tuberculosis, and 689 (74%) classified as unlikely tuberculosis. Against MRS, qXR demonstrated AUROC, sensitivity and specificity of 0.68 (95% CI, 0.61 to 0.75), 54% (95% CI, 43 to 64%), and 82% (95% CI, 79 to 84%), respectively. Against ClRS, the AUROC, sensitivity and specificity were 0.73 (95% CI, 0.69 to 0.77), 41% (95% CI, 34 to 49%), and 87% (95% CI, 84 to 89%), respectively. Bayesian LCA, assuming conditional independence, estimated sensitivity of 79% (95% CrI, 65 to 89%) and specificity of 82% (95% CrI, 79 to 84%). Assuming conditional dependence between qXR and expert radiologist, and between culture and Xpert, estimated sensitivity increased to 89% (95% CrI, 71 to 98%), with specificity remaining at 82% (95% CrI, 79 to 84%). Conclusions Paediatric optimized qXR algorithm provides a valuable complementary tool for diagnosis of paediatric pulmonary tuberculosis. Conventional reference standards likely underestimate the true diagnostic performance of CAD systems in children.

Background In 2017, Zambia adopted surveillance as a core intervention towards achieving malaria elimination. Among the surveillance strategies is the malaria case investigation and response 1-3-7 (MCIR 1-3-7), which has been piloted in two low-incidence districts in the Southern Province since 2021. The study aimed to assess the implementation of MCIR 1-3-7 under programmatic conditions. It examined the timeliness, and completeness of the MCIR 1-3-7 activities, including the completeness of data entry in surveillance forms, and explored the experiences and perspectives of healthcare workers involved in the pilot. Methods A mixed-methods design was employed to assess the MCIR 1-3-7. Using a descriptive cross-sectional design, quantitative data were collected from 19 healthcare facilities in the two districts to assess the timeliness and completeness of MCIR 1-3-7. Additionally, 12 qualitative interviews were conducted with 29 healthcare workers from 11 of the 19 healthcare facilities. The interviews were voice-recorded and then transcribed manually. A codebook was developed using an iterative process to explore the facilitators and barriers encountered by healthcare workers in implementing the MCIR 1-3-7 intervention. All the visited facilities were purposively selected based on logistical convenience. Results This study retrospectively assessed 510 malaria cases that were diagnosed between January 2022 and June 2023, presenting at 19 health facilities: 283 cases in Chikankata and 227 in Mazabuka districts. A total of 278 cases (54.5%) were deemed to have been imported from outside the district, province, or country, while 45.5% (232/510) of the cases were classified as transmitted locally. Overall, 29.6% of case notification forms were found to be complete. Twelve interviews with 29 healthcare workers revealed a lack of transportation modalities as the main obstacle in executing the MCIR 1-3-7 intervention. The healthcare workers also indicated that monetary incentives, and supportive supervision would help them succeed in implementing this intervention. Conclusions The MCIR 1-3-7 has the potential to accelerate elimination in areas with low-transmission of malaria in Zambia. This study highlights opportunities to improve future implementation of the MCIR 1-3-7 intervention via strengthening supportive supervision, availing job aids, and ensuring access to malaria commodities as the intervention expands.

South Sudan faces among the highest maternal and newborn mortality rates globally, with approximately 87% of deliveries occurring at home without skilled birth attendance. In 2024, the International Rescue Committee launched a Community-Based Maternal and Newborn Care (CBMNC) program in Aweil East County, Northern Bahr El Ghazal, deploying trained Boma Health Workers (BHWs) to deliver essential maternal and newborn health services at the household level. This study explored the acceptability of the CBMNC model among diverse stakeholders. This qualitative descriptive study was grounded in the Theoretical Framework of Acceptability (TFA). Data were collected between May and July 2025 through 17 focus group discussions (FGDs), 14 in-depth interviews (IDIs), and 10 key informant interviews (KIIs) with 185 participants, including program recipients, male partners, mothers and mothers-in-law, Boma and Hospital Health Committee (BHC/HHC) members, BHWs, supervisors, and health system stakeholders at state and national levels. Framework analysis, combining deductive coding based on the seven TFA constructs with inductive thematic analysis, was used. CBMNC was well accepted by recipients and their families, despite provider and health system concerns about sustainability. Trust in community-selected BHWs made home-based care valuable, especially given limited facility access. Intervention coherence relied on pictorial aids, repeated visits, and peer learning to address low literacy. Participants perceived commodity interventions like misoprostol and chlorhexidine as impactful, while behavioral counseling was less recognized. Clients faced minimal burden, but providers experienced significant challenges and inadequate compensation. Health stakeholders were cautiously optimistic but questioned lay provider capacity and long-term viability in a fragile environment. CBMNC can achieve high community acceptability when delivered through trusted, community-selected health workers using contextually appropriate strategies. However, community acceptability alone is insufficient for sustainable scale-up. Addressing provider compensation, workload, and structural integration into national health systems is essential to ensure that gains in acceptability translate into sustained service delivery.

Background: Vasectomy remains one of the most underutilized contraceptive methods in Uganda, with a prevalence of only 0.2% despite its safety, effectiveness, and potential contribution to fertility reduction. Understanding the factors influencing awareness, knowledge, and attitudes toward vasectomy acceptance is crucial for developing effective promotion strategies in the Ugandan context. Methods: A cross-sectional study was conducted among 617 men aged 20-60 years, selected through simple random sampling of participants attending Kapchorwa General Hospital. Data were collected using a structured questionnaire. Results: Knowledge scores showed a negative association with age ({beta} = -0.044, p < 0.001) and varied significantly by marital status, with married participants demonstrating higher knowledge than single ({beta} = -0.624, p < 0.001) and widowed ({beta} = -0.950, p < 0.001) individuals. Counterintuitively, higher knowledge was associated with more negative attitudes ({beta} = -1.729, p < 0.001). Age demonstrated the strongest negative effect on attitudes ({beta} = -0.249, p < 0.001), and 99.9% of participants believed contraception is primarily women's responsibility. Behavioral data revealed that 75.0% desired more children, with 51.2% preferring a family size of 3-4 as the ideal. Conclusion: The study shows a disconnect between knowledge, attitudes, and behaviors regarding vasectomy. While general awareness is high, deep-seated misconceptions, cultural norms around masculinity and contraceptive responsibility, and fertility preferences present significant barriers to acceptance.

Objective: To address the need for improved measurement of the ways contraception impacts the baseline menstrual cycle (i.e., contraceptive-induced menstrual changes; CIMCs) by assembling an interdisciplinary, global research collective to rigorously develop a person-centered measure for CIMCs in multiple languages. As the first step, this paper reports on our conceptual model development, which is the foundation for ongoing measure development. Study design: We conducted 18 focus groups with 106 people experiencing CIMCs while using hormonal or intrauterine contraception in Durban, South Africa, Santo Domingo, Dominican Republic, and Portland Oregon, United States. We used a virtual affinity mapping approach to analyze qualitative data, which was the basis of our conceptual model along with relevant theory and related models in the literature. Results: The conceptual model of experiences with CIMCs depicts the baseline menstrual cycle, including CIMCs and conceptually-linked effects and the impacts and perceptions of those CIMCs. We found key domains of changes in pain, bleeding volume, bleeding patterns, and characteristics of blood. Conclusion: Our CIMC conceptual model will inform development of a measure with evidence of validation across three language and global contexts. Adoption of a person-centered, standardized CIMC measurement across trials will improve knowledge and decision-making between methods.

Background Vector control is essential to malaria control and elimination. National Malaria Programmes (NMPs) must make complicated decisions about vector control in the face of evolving epidemiology, biological threats like insecticide resistance, a growing vector control toolbox, and an increasingly constrained funding landscape. The WHO recently published a manual on subnational tailoring of malaria strategies, but limited efforts have been made to understand how NMPs prioritize data and factors that impact decision-making in practice. This study explores vector control decision-making processes, enablers, and barriers across 12 African malaria programmes. Methods We conducted semi-structured interviews with 13 NMP managers or designated representatives from 12 African countries. Interviews were conducted virtually via Zoom or in-person, audio-recorded, transcribed, and thematically analyzed using content analysis. Participants described the interventions in use, decision-making factors, stratification approaches, perspectives on new tools, and operational challenges. Results Insecticide-treated bed nets (ITNs) and indoor residual spraying (IRS) are the core interventions in all countries, with limited but growing use of larval source management, mainly larviciding. Vector control tool selection is driven by WHO guidance, resistance profiles and patterns, epidemiological trends, operational feasibility, and donor funding priorities. Sub-national stratification is widely applied; however, limited analytic and modeling capacity hinder consistent application. Gaps in entomological data result in incomplete data availability to guide stratification. New vector control tools were perceived as promising options, albeit constrained by cost, limited evidence, regulatory delays, and community acceptability. Funding emerged as the dominant driver of decisions, shaping intervention choices regardless of country preference. Participants emphasized substantial gaps in vector control protection related to residual transmission, outdoor biting, insecticide resistance, and unprotected populations living in temporary structures or associated with high-risk occupations. Conclusions Vector control decision-making among NMPs is shaped by an interplay of scientific evidence, operational realities, and external funding dynamics. Strengthening entomological surveillance, enhancing SNT analytic and model output interpretation capacity, securing sustainable financing, and improving community engagement are critical to advancing tailored deployment of tools. Decision-support frameworks that reflect the complexities facing NMPs may further enhance evidence-based, context-specific vector control planning.

Background: Rising antibiotic resistance challenges empirical therapies for urinary tract infections (UTIs). This study evaluated the microbial etiology, susceptibility profiles, and multidrug resistance (MDR) patterns of uropathogens among outpatients at the Berekum Holy Family Hospital, Ghana. Methods: This cross-sectional study (February to August 2021) screened 263 symptomatic outpatients. Mid-stream urine samples underwent quantitative culture, biochemical identification, and antimicrobial susceptibility testing via the Kirby-Bauer disc diffusion method following the 2021 CLSI guidelines. Results: Significant bacteriuria prevalence was 22.8% (60/263). UTIs predominated in females (78.3%, 47/60; p = 0.1501) and individuals [&ge;]45 years (33.3%, 20/60). Gram-negative rods accounted for 90.0% of isolates, primarily Escherichia coli (26.7%), Citrobacter spp. (25.0%), and Enterobacter spp. (21.7%); Staphylococcus aureus (10.0%) was the only Gram-positive pathogen. Extreme phenotypic resistance was observed against piperacillin/tazobactam (98.3%), cefotaxime (93.3%), tetracycline (88.3%), and cefoperazone (85.0%). Conversely, highest therapeutic susceptibilities were retained by amikacin (78.3%), levofloxacin (61.7%), and gentamicin (58.3%). Conclusion: The high prevalence of MDR uropathogens against advanced beta-lactamase inhibitor combinations and cephalosporins necessitates an immediate re-evaluation of regional empirical protocols. Amikacin, levofloxacin, and gentamicin remain viable options prior to culture confirmation. These findings establish a crucial phenotypic baseline to guide localized prescribing policies and regional antimicrobial resistance tracking strategies.

Background: The traditional wealth index, based on principal component analysis (PCA), used in the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), suffers from urban bias, distorting estimates of health inequality. We compared the traditional index (PEAR1) with an alternative two-component polychoric PCA index (POLY2) using annual expenditure from 12 LSMS surveys as the gold standard to determine which provides more accurate SEP measures for equitable policy targeting. Methods: We compared the traditional wealth index (PEAR1) with a two-component polychoric PCA approach (POLY2) using 12 LSMS (Living Standards Measurement Study) surveys (2015-2022) from 12 African countries. Annual household consumption expenditure was the gold standard. We assessed agreement using weighted Cohen's kappa and validated against education (proportion of households with secondary or higher education) using the concentration index (CIX) and slope index of inequality (SII). Results: The POLY2 index showed higher agreement with expenditure quintiles (average national weighted kappa = 43.3%) than the PEAR1 index (35.1%), with notable improvements in urban (43.5% vs. 27.5%) and rural (35.3% vs. 22.4%) areas. POLY2 also attenuated extreme household distributions observed in PEAR1. Education validation showed that POLY2 produced intermediate inequality gradients between the flatter expenditure-based gradient and the steeper PEAR1-based gradient. Conclusion: The POLY2 wealth index is superior to the traditional index, reducing urban-rural bias and providing more accurate socioeconomic classifications. Its adoption in large-scale surveys such as DHS and MICS is recommended to improve equitable monitoring of health inequalities in low- and middle-income countries.

Background Malawis healthcare system faces strain due to an insufficient number of healthcare workers (HCWs). The number of HCWs currently employed falls below the Malawian governments own facility-based staffing standards, which are known as the establishment target. While vacancy rates from this target have been estimated, the health consequences of this workforce gap on the population have not. Methods This study quantifies the health-cost of unfilled establishment HCW positions using the Thanzi La Onse (TLO) model, an "all diseases - whole healthcare system" individual-based model, which self-consistently accounts for the dynamics between health system constraints and population health. We constructed two staffing scenarios: one (Current) in which the currently employed staff are represented, and another (Target) where all positions planned under the establishment target are filled. Using the TLO model, we then estimate the health impact of filling all establishment positions as the difference in the Disability-Adjusted Life Years (DALYs) incurred between the two scenarios. Results Our results indicate that fulfilling Target positions could reduce the health losses by 13.6% (43.1 million DALYs averted, 95% CI: 40.8-48.6) over the projection period. The largest proportional reductions are for DALYs caused by HIV/AIDS (41%), tuberculosis (26%), and malaria (24%) compared to the Current provision. Conclusions The analysis shows the potential health benefits associated with increasing the fulfilment of establishment positions in Malawi and offers key quantifications for policymakers as they strive to achieve Universal Health Coverage.

Adolescent girls and young women (AGYW) in Ethiopia face persistent barriers to accessing quality sexual and reproductive health (SRH) services, including limited information, stigma, and lack of youth-responsive care. This study aimed to compare the efficacy of digitized versus paper-based counselling tools within an intervention designed to address behavioral and structural barriers contributing to low contraceptive use among AGYW, by reframing contraception as a tool to achieve their life goals. The study employed a cross-sectional mixed-methods design, including client exit interviews with 302 AGYW, key informant interviews with 18 Health Extension Workers (HEWs), secondary analysis of service delivery data from DHIS2, and costing data from program records. Quantitative data were analyzed using descriptive statistics and chi-square tests. Qualitative data were thematically analyzed. Digital counselling was significantly associated with higher MII Plus scores (93% vs. 73.8%, p=0.001), client knowledge of side effects, and confidence in discussing and managing contraception. Clients rated paper-based tools as easier to understand, but digital tools enhanced comprehension, goal-setting, and integration of financial planning and reproductive health concepts. HEWs reported improved consistency in counselling, better referrals, and operational efficiencies with digital tools. Challenges included device glitches, limited connectivity, and variable digital literacy, often requiring concurrent use of paper and digital tools. This study shows that transitioning from paper-based to digital counselling tools improved service quality, client engagement, and informed contraceptive decision-making. Higher MII Plus scores and positive client experiences indicate more standardized, participatory, and respectful counselling. Providers reported operational benefits, including easier counselling and improved data management, though productivity gains were limited. Implementation challenges highlight the need for context-sensitive strategies, ongoing training, and supportive supervision during digital integration. Importantly, the findings suggest that digital tools can improve how services are delivered (quality and consistency), even when service volume remains stable.

Between 2015 and 2025, Cambodia reported a 99.9% decline in the number of cases of malaria. To aid acceleration of elimination, the National Center for Parasitology, Entomology and Malaria Control (CNM) implemented a package of interventions known as the Last Mile (LM) elimination program. The aim of this study was to determine the impact of the LM program on case numbers and evaluate the coverage of interventions. LM was rolled out between November 2020 and December 2023 in villages reporting a locally acquired case of Plasmodium falciparum or mixed infection with P. falciparum and P. vivax and included combinations of targeted drug administration (TDA), intermittent preventative treatment for forest goers (IPTf), active fever screening (AFS), the recruitment of a village or mobile malaria worker (VMW/MMW) and the top-up of insecticide-treated bed nets (ITN) depending on the vulnerability and receptivity of the village. A total of 103 full and 82 partial villages in seven provinces were included. Two rounds of TDA were administered, with a total of 10,678 individuals (67.6%) given during the first round and 9,678 (62.3%) during the second round. Coverage varied by province with none meeting the recommended threshold of 80%. IPTf was implemented each month among 35% (n=35) of full LM villages and 56% (n=42) of partial LM villages. A total of 11.7% (n=12) of full LM villages implemented AFS consistently on a weekly basis. Controlled interrupted time series showed no statistically significant difference in the number of malaria cases before and after the implementation of LM. Although we were unable to prove a statistically significant impact of LM, likely due to the small number of cases prior to LM, it is important to add to the limited evidence-based for Accelerator Strategies in countries approaching the elimination of malaria. Furthermore, findings from the feasibility and impact of individual interventions were used to change policy at the national level.

Maternal health during pregnancy is critical for favorable birth outcomes and long-term wellbeing of both mothers and infants. Women in rural, malaria-endemic regions face unique biological and socioeconomic challenges that may increase the risk of adverse pregnancy outcomes (APOs). This study investigated the incidence and determinants of APOs among pregnant women attending antenatal care at Webuye sub-County Hospital in Western Kenya, a rural malaria-endemic setting. We conducted a retrospective cohort analysis utilizing previously collected data of 300 women enrolled during early pregnancy and followed through delivery. Maternal demographic, clinical, and infection-related factors were assessed, and associations with APOs were evaluated using chi-square tests and multivariable logistic regression. Maternal age and gestational age at enrollment were significantly associated with malaria history (P<0.001). Maternal BMI abnormality (124.5/1000 pregnancies), anemia (99.3/1000), fetal or neonatal death (81.3/1000), and preterm birth (43.8/1000) were observed (all P<0.001), suggesting a substantial burden. Younger mothers (<20 years) and older mothers (>35 years) were significantly more likely to develop anemia (P =0.026), and prior malaria infection further increased anemia risk (P =0.02). Abnormal urinalysis findings indicative of urinary tract infection were significantly associated with low birthweight (P =0.031). No significant associations were found between APOs and infant sex, parity, gravidity, or maternal ABO blood type. These findings highlight a substantial burden of APOs in this rural population, exceeding national and global estimates. Strengthening malaria prevention, nutritional support, urinary infection screening, and encouraging early antenatal care attendance are critical to improving maternal and neonatal outcomes. Targeted interventions for adolescent and older mothers, along with enhanced point-of-care diagnostics, may reduce preventable complications in similar resource-limited, malaria-endemic settings.

Abstract Background Evaluating antenatal care (ANC) quality is critical to reducing maternal and neonatal mortality. In Zambia, despite high basic ANC attendance, comprehensive national evidence on the clinical content and quality of services remains limited. This study assessed the coverage of WHO-recommended ANC interventions and identified factors associated with care quality using the latest national data. Methods A cross-sectional analysis was conducted using data from the 2024 Zambia Demographic and Health Survey. The final analytic sample comprised 4,829 women aged 15-49 with a live birth in the preceding 5 years. A composite index of 15 selected, equally weighted WHO-recommended components evaluated clinical assessment, counseling/screening, preventive interventions, and utilization. Survey-weighted Poisson regression estimated adjusted incidence rate ratios (aIRRs) for the count of ANC components received. Results The mean ANC quality score was 12.5 out of 15 (95% CI: 12.4-12.6), and 78.5% (95% CI: 77.0-80.0) of women achieved adequate ANC ([&ge;] 12/15 components). While individual clinical and counseling coverage generally exceeded 90%, only 47.2% (95% CI: 45.3-49.0) of women initiated care during the first trimester, and just 4.8% (95% CI: 4.1-5.6) achieved [&ge;] 8 ANC contacts. Maternal education was the strongest and most stable predictor of quality across all models. Compared to no education, higher education was associated with an 8.0% higher expected quality score (aIRR = 1.080, 95% CI: 1.051-1.110). Lower ANC quality was significantly associated with unwanted pregnancies (aIRR = 0.970, 95% CI: 0.956-0.993) and with residence in Western (aIRR = 0.923, 95% CI: 0.897-0.951) and North Western (aIRR = 0.966, 95% CI: 0.937-0.996) provinces. Absence of distance barriers and residence in Eastern, Luapula, and Copperbelt provinces were associated with higher quality scores. Conclusion While average ANC component coverage in Zambia is high, critical gaps persist in early initiation and total contact frequency. Care adequacy is strongly influenced by maternal education, relationship status, pregnancy intention, and regional inequities. These findings underscore the need for interventions targeted at uneducated women, preventing unintended pregnancies, and underserved regions such as Western and North Western Provinces. Keywords: Antenatal care quality, ANC content, Zambia, maternal education.

Background: Persons with disabilities, particularly deaf individuals, remain a largely overlooked population in sexual and reproductive health (SRH) programming globally, with this gap especially pronounced in low- and middle-income countries. Deafness imposes substantial barriers to accessing information and services that are routinely available to hearing peers, further exacerbated in the post-COVID-19 era. This study assessed deaf adolescents' knowledge of and access to SRH education and services in Wakiso District, Uganda, and explored systemic, institutional, community, and adolescent-level factors shaping access. Methods: A mixed-methods cross-sectional study was conducted at Wakiso Secondary School for the Deaf from July 2022 to January 2023. Quantitative data were collected from 70 consecutively sampled deaf adolescents aged 13-19 years using a structured questionnaire. Qualitative data were gathered through key informant interviews (KIIs) with four purposively selected stakeholders and a focus group discussion (FGD) with deaf adolescent students. Qualitative data were analysed thematically. Results: The mean participant age was 17 years (SD {+/-}1.8); 65.7% were female. A large majority (88.6%) had heard of SRH components, and 98.6% perceived a need for SRH education or services. However, 84.3% reported challenges accessing these services at least 85% of the time. No participant had ever received SRH education or services through a formal health facility. The FGD revealed that adolescents' conceptualisation of SRH was narrow, centred on body hygiene and HIV prevention, while service-seeking was reactive and symptom-driven. Five cross-cutting themes emerged from the KIIs and were reinforced by FGD findings: communication barriers; inadequate and inaccessible services; family and community isolation; existing platforms and positive practices; and negative provider attitudes and limited capacity. The school nurse emerged as the sole functional SRH access point for most participants. Conclusion: Despite high awareness and near-universal perceived need, deaf adolescents in Uganda face profound multilevel barriers to SRH access. Structural, psychosocial, and knowledge-related barriers interact to exclude this population from formal health services. Findings call for disability-responsive SRH integration into health systems, training of health workers in accessible communication, community capacity building, and co-design of SRH programmes with deaf adolescents.