Research Articles (School of Public Health)

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Strengthening teamwork and respect (STAR): nurses’ perspectives and experiences of disrespectful maternity care in rural district hospitals in KwaZulu-Natal, South Africa
(Taylor and Francis Ltd., 2026) Horwood, Christiane; Haskins, Lyn; Luthuli, Silondile; Mapumulo, Sphindile; Filippi, Veronique; Penn-Kekana, Loveday; Doherty, Tanya
Background: Disrespectful maternal care has been reported from women’s perspectives, but less is known about how health workers understand these behaviours. To develop interventions, it is important to explore the drivers of disrespectful care from providers’ perspectives. Objective: To explore nurses’ perspectives on disrespectful maternal care. Methods: Semi-structured interviews were conducted with 18 nurses in maternity units in nine rural district hospitals in KwaZulu-Natal, South Africa, between April and August 2024. This was part of a continuous process evaluation for a participatory learning and action intervention called Strengthening Teamwork and Respect (STAR). One STAR champion and one team member were selected from each hospital. Interviews were recorded, transcribed, and thematically analysed using a reflexive thematic approach. Results: Participants reflected on how STAR changed their perceptions and understanding of respectful care. Five themes were identified: limited understanding of disrespectful care; normalisation of disrespectful behaviours; justification of disrespectful care; blaming women for disrespectful care; and perceptions of disrespect in the community. Overt incidents of disrespectful care were reported to be commonplace, including rudeness, shouting and slapping women. Lack of dignity and privacy was also common. Nurses recognised these behaviours as unacceptable and unprofessional and offered several explanations, including peer pressure, stress, burnout, and a poor work environment. Some believed that harsh behaviour was sometimes necessary to ensure safe delivery, particularly when women were perceived as uncooperative. Conclusions: Normalisation of disrespectful care highlights the need for interventions that address the underlying culture and the organisational and contextual factors that support and sustain these behaviours.
USAID withdrawal and the erosion of development assistance for health: Considerations for health system leadership in LMICs
(Elsevier B.V., 2025) Schneider, Helen; Sheikh, Kabir
Development assistance for health (DAH) is entering a period of retrenchment, exemplified by the withdrawal of USAID from global health. This commentary examines, the implications of a declining DAH landscape for health systems in low- and middleincome, countries (LMICs). The loss of donor support not only creates significant funding gaps but also removes certain benefits that donors have provided - such as sustained financing for high-impact vertical programs (e.g. immunization and disease control) and coordination functions. At the same time, the reduction in DAH may alleviate some longstanding distortions, including the fragmentation caused by vertical initiatives and the internal “brain drain” of talent into donor-funded projects, opening opportunities for countries to reclaim leadership. The immediate challenge for health system leaders is to mitigate service disruptions through short-term measures, while pursuing long-term strategies to increase domestic health investment and strengthen system-wide capacities. We emphasize the need for renewed commitment to the principles of country ownership and alignment - now driven by domestic stewardship rather than donor conditionality. In a changing global context, new arrangements that complement national efforts are needed to ensure that global solidarity and support for shared health goals persist despite a reduced role for traditional aid
Advancing regional and international cooperation in public health diplomacy: summary of the methods and outcomes of the 2nd University of Memphis school of public health diplomacy summit (2026)
(Frontiers Media SA, 2026) Amde, Woldekidan; Joshi, Ashish; El-Metwally, Ashraf
Public health diplomacy has emerged as a critical mechanism for addressing complex global health challenges. This paper summarizes the key discussions, lessons learned, and recommendations from the Public Health Diplomacy 2nd Summit, organized by University of Memphis. In the summit, participants explored the role of public health diplomacy in strengthening health systems and building resilient partnerships. This paper employed a qualitative descriptive approach for the data analysis. Participants emphasized the need to integrate diplomacy competencies into public health education and professional training while fostering stronger connections between evidence generation and policy action. The findings suggest that public health diplomacy should be recognized as both a strategic and operational tool for strengthening global health governance, promoting international cooperation, and preparing future public health leaders.
Healthcare workers’ knowledge and acceptance of the malaria vaccine in the Nanoro health district of Burkina Faso: a cross-sectional study
(BioMed Central Ltd, 2026) Lamien, Jean-Vincent; Kaboré, Bérenger; Derra, Karim; Compaoré, Zanma Michaël John; Nassa, Guétawendé Job Wilfried; Yaro, Aimé Parfait Korou; Gbangou, Bapouguini Raymond; Ravinetto, Raffaella; Tinto, Halidou; Dochez, Carine
Background: In February 2024, Burkina Faso introduced the malaria vaccine RTS,S/AS01 into its Expanded Programme on Immunisation (EPI). For vaccination to be successful, an important criterion is its acceptance by the population. Healthcare workers (HCWs) are among the primary sources of information for caregivers when deciding whether to vaccinate their children or not. This study aimed to assess HCWs’ knowledge and acceptance of the new malaria vaccine (MV) in the Nanoro Health District and to identify factors associated with MV acceptance within this group. Methods: We conducted a cross-sectional study among HCWs from April to May 2025 in Nanoro (Burkina Faso), using an online questionnaire. All HCWs employed in the public or private health sectors of the Nanoro Health District at the time of data collection were eligible to participate, upon voluntary informed consent. The vaccine acceptance rate was expressed as the proportion of HCWs willing to vaccinate their children out of the total number of participants. Logistic regression was employed for both bivariate and multivariate analyses to test associations. Results: Two hundred fifty-seven (257) HCWs out of 340 eligible HCWs participated in the survey. The vaccine acceptance rate was 98.8%. Insufficient information about the vaccine was the primary reason for hesitancy. Twenty-two percent (22.6%) of the HCWs were unaware of the type of vaccine used in the district and had no knowledge of the vaccination schedule. More than half (58.0%) stated that they did not receive any training before the vaccine rollout. Willingness to recommend the vaccine and positive attitudes were associated with HCWs’ willingness to vaccinate their children, although independent effects could not be confirmed. No links were found between vaccine acceptance and sociodemographic characteristics. Conclusions: Most HCWs were willing to vaccinate their children against malaria. However, few were hesitant due to insufficient information about the vaccine and more than one-fifth had limited knowledge about this specific vaccine. Training all HCWs on the MV (whether involved in EPI or not) and strengthening communication about it are essential to address concerns around the vaccine, and ensure sustained uptake in the community, thereby improving national vaccination coverage.
Health and the city: why urban health systems need greater authority
(BMJ, 2026) Schneider, Helen; Sheikh, Kabir; Nundy, Madhurima
Around four billion people, just over half the global population, live in urban areas. This proportion is projected to rise to two thirds by 2050, with most growth occurring in low and middle income countries (LMICs).1 Urbanisation affects health by changing the conditions in which people live, work, travel, and obtain care. Dense urban settings can improve access to services and economic opportunity, but rapid growth can also out pace housing, water, sanitation, transport, environmental regulation, and health service capacity increasing exposure to air pollution, heat, injury, infectious disease, and conditions associated with non-communicable disease.2 These risks fall disproportionately on people living in informal settlements or facing insecure housing and employment, who may also have poorer access to care.
Organisational learning culture in maternity units: a mixed-method study in rural district hospitals in KwaZulu-Natal, South Africa
(Elsevier B.V, 2025) Horwood, Christiane; Doherty, Tanya; Haskins, Lyn
Background Building organisational learning in health facilities is a health system strengthening strategy that has particular relevance for rural health workers (HWs) who may be geographically isolated without access to learning opportunities or specialist support. We present the findings of a mixed methods study exploring organisational learning in rural hospital maternity units. Methods Data were collected from all cadres of HWs working in maternity units in 11 health facilities in two districts, including doctors, nurse managers, midwives and nursing assistants. A quantitative survey was conducted with all HWs using the validated Dimensions of Learning Organisation Questionnaire (DLOQ). We then conducted individual in-depth interviews with purposively selected HWs in each facility to explore their perceptions and experiences of learning, teamwork and leadership. Findings We completed 116 DLOQ self-administered questionnaires and conducted 35 in-depth interviews. Strategic leadership scored highest on the DLOQ, with HWs reporting that managers provided opportunities for mentoring and learning. Doctors and nurse managers experienced team learning, leadership and communication more positively than midwives and nursing assistants. Learning was driven by senior doctors and managers, frequently taking a top-down didactic approach rather than employing reflection and dialogue. This is supported by low DLOQ scores for inquiry and dialogue and empowerment among nurses compared to doctors and managers. Conclusions There is a need for shifts in learning approaches in maternity units from a didactic clinical focus to participatory dialogue and reflection, including interpersonal issues like respect and communication, and to ensure that all team members have access to learning opportunities.
Navigating context, power and politics: a qualitative case study of co-designing gender integration in South Africa
(Taylor and Francis Ltd, 2026) Walmisley, Ulla; Akintola, Olagoke; Nyembezi, Anam; Schaay, Nichola; Jacobs, Tanya; George, Asha
Gender is an intersectional determinant of health that remains insufficiently integrated in programmes and policies. Sustained processes of dialogue and collaboration, including participatory approaches such as co-design, are needed to effect gender integration. However, the contexts and power dynamics through which co-design may support gender integration are not well understood. This qualitative case study examined a co-design partnership that undertook gender integration within an established adolescent sexual and reproductive health programme in South Africa from 2022-2025, drawing on (n = 37) project documents, (n = 36) post-meeting reflections, (n = 2) annual project group reflections, and (n = 12) key informant interviews. Analysis was deductive–inductive and informed by theories of context, organisational logics, gender, and power. Three interlinked contextual levels influenced the partnership. Macro-level funding arrangements and accountability structures created hierarchical pressures that constrained participatory and gender-responsive work. Meso-level organisational logics differed across partners, creating misalignment with the reflective co-design approach and between partner organisations. At the micro-level, boundary-spanning individuals enabled trust-building and adaptation. Interactions across levels revealed how institutionalised power shaped feasible forms of participation and gender integration. Co-design partnerships can strengthen gender integration in programmes but require macro-level enabling systems, institutional support, and navigation of meso-level organisational logics alongside sustained micro-level action.
The ocean view community care centre (ccc): lessons for everyday health systems resilience from a community-led response to the covid-19 pandemic in South Africa
(Elsevier B.V., 2026) Brady, Leanne; George, Asha; De Vries, Shaheem
Community engagement is widely acknowledged as critical to Everyday Health Systems Resilience (EHSR), but there are few empirical case studies that examine ‘how’ and ‘why’ initiatives at the community-health system interface unfold over time. In this paper, we present the experience of the Ocean View Community Care Centre (CCC), a community-led response to the Covid-19 pandemic in the Western Cape, South Africa. Using a five-year long embedded research approach, we drew on traditions of participatory action research and organisational ethnography. Data collection included documenting observations and reflections in a research diary during implementation, in-depth interviews, focus group discussions (using photo-elucidation methods) and a WhatsApp archive. In addition, a series of sensemaking discussions with academic research team members were done. Our analysis draws on and extends the EHSR framework which characterises resilience as an emergent phenomena of health systems. We consider the CCC as a potentially transformative resilience strategy as it nurtured system capacities (networks and relationships) that could support future responses to shocks. Our findings demonstrate how relationships and networks can generate resources (hardware and software) and nurture system capacities for EHSR, but also highlights that relationships and networks on their own are not enough. The CCC experience offers the notion of boundary spanning (not yet explored in the EHSR literature) to shed light on how the energy of these networks needs to be harnessed by individuals who have a ‘passport of legitimacy’ to work across networks, suggesting that boundary spanners are themselves important in nurturing system capacities for resilience.
Global burden of enteric infectious diseases, diarrhoeal diseases, and corresponding aetiologies, 1990–2023: a systematic analysis for the global burden of disease study 2023
(Elsevier, 2026) Vongpradith, Avina; Adebiyi, Babatope. Oluwadamitare; Dominguez, Regina-Mae Villanueva
Background Enteric infectious diseases claim more than 1 million lives annually and are among the top ten causes of death in children younger than 5 years. Remarkable global investment has been dedicated to enteric infectious disease prevention and control; however, the shifting global health landscape is testing the continuance of progress. To evaluate the current status and guide future interventions, we present the latest epidemiological estimates of enteric infectious diseases from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 and assess progress towards the Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) mortality target of fewer than 20 deaths per 100 000 children younger than 5 years by 2025. Methods We quantified the incidence, mortality, and disability-adjusted life-years (DALYs) of enteric infectious diseases by age, sex, and year across 204 countries and territories from 1990 to 2023. In GBD 2023, the following were considered under the category of enteric infectious diseases: diarrhoeal diseases, enteric fever (typhoid and paratyphoid), invasive non-typhoidal Salmonella spp (iNTS) infections, and other intestinal infectious diseases. We also examined 15 aetiologies contributing to diarrhoeal diseases. Incidence and prevalence were estimated with DisMod-MR (version 2.1), a Bayesian meta-regression tool, drawing on data from systematic reviews, population-based surveys, claims data, and hospital sources. Cause-specific mortality was modelled with Cause of Death Ensemble Modelling based on data from sources including vital registration, mortality surveillance, verbal autopsy, and minimally invasive tissue sampling. Years of life lost and years lived with disability were computed and combined to derive DALYs. For aetiology-specific estimation, population-attributable fractions (PAFs) for 15 pathogens were derived with a counterfactual framework. Point estimates and 95% uncertainty intervals (UIs) were generated from 250 draws from the posterior distribution.
“It’s not easy, but we need to support them so they don’t get tired on the way”: provider perspectives on delivering HIV services for people returning to HIV care in Cape Town, South Africa
(BioMed Central Ltd, 2026) Phillips, Tamsin Kate; Wolpe, Hannah; Gwiji, Nasiphi; Clouse, Kate; Chi, Benjamin H; Maman, Suzanne; Myer, Landon; Knight, Lucia
Background: People living with HIV who interrupt treatment often face challenges when re-engaging in care and remain at risk for future interruptions. Understanding the provider perspective on the healthcare context in which re-engagement occurs is essential for designing effective and scalable support interventions. We aimed to characterize the implementation context for re-engaging in HIV care in Cape Town, South Africa, with a view to inform the design of future interventions in this setting. Methods: We conducted semi-structured in-depth interviews with nurses (n = 5), counsellors (n = 3) and administrative clerks (n = 3) at two public-sector health facilities. Data collection and thematic analysis were guided by the inner setting of the Consolidated Framework for Implementation Research (CFIR), including structural characteristics, organizational culture, relational dynamics, and communication. Results: We identified compounding and interconnected challenges within the CFIR inner setting. Limited staffing and fragmented clinic organization contributed to delays and frustration for both clients of HIV services and providers, reinforcing negative client-provider interactions. Despite valuing person-centred care, providers struggled to uphold these principles amid high workloads and systemic pressures relating to physical, information system, and human resource infrastructure limitations. Additionally, a cross-cutting theme was the challenge of inter-facility transfers, driven by geographic mobility and stigmatizing clinic interactions. Difficulties in linking client information across clinics intersected with the structural and relational barriers, adding another layer of complexity to providing supportive care for people returning to HIV services. Conclusions: Providers in this context were empathetic but layered inner setting barriers made it challenging to provide person-centred care. Addressing these challenges requires interventions that not only accommodate the changing life circumstances of people living with HIV but crucially facility- and system-level changes to support the providers and their working environments, which together will foster strong reciprocal client-provider relationships.
Global and regional progress towards reduced burden of oral conditions between 2019 and 2023: a systematic analysis for the global burden of disease study 2023
(Elsevier Ltd, 2026) Adebiyi, Babatope Oluwadamilare; Adedokun, Kamoru Ademola; Bernabe, Eduardo
Background WHO's Global Oral Health Action Plan (GOHAP) targets include a 10% relative reduction in the combined prevalence of main oral conditions by 2030. The first GOHAP evaluation was planned for 2023, with subsequent evaluations scheduled for 2026 and 2030. The aim of this systematic analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 was to evaluate global and regional progress (2019–23) towards this target and related complementary indicators. Methods Using modelled estimates from epidemiological surveys and registries in 204 countries and territories, we estimated the age-standardised prevalence of untreated caries in deciduous and permanent teeth, severe periodontitis, edentulism, other oral disorders and orofacial clefts, and the age-standardised incidence of lip and oral cavity cancer. Progress towards GOHAP targets was measured by comparing the percentage change from 2019 to 2023 in the above indicators against the stated GOHAP target of a 10% relative reduction. Findings Globally, the age-standardised prevalence of main oral conditions declined (−1·55% [95% uncertainty interval −2·32 to −0·82]) between 2019 and 2023, but global cases increased by 3·07% (2·32 to 3·75), from 3·62 billion (3·35 to 3·95) to 3·73 billion (3·45 to 4·06). Among complementary indicators, reductions in age-standardised prevalence were observed for untreated caries in permanent teeth (−1·99% [−2·49 to −1·40]) whereas the age-standardised incidence of lip and oral cavity cancer increased (8·35% [0·13 to 16·32]), as did the age-standardised prevalence of orofacial clefts (2·25% [0·77 to 3·83]). Progress was heterogeneous across GBD super-regions, with south Asia having the largest reductions in the age-standardised prevalence of main oral conditions (−3·34% [−4·95 to −1·80]) and untreated caries in deciduous teeth (−9·09% [−17·62 to −0·08]). Sub-Saharan Africa showed the largest increase in prevalent cases of main oral conditions (9·51% [8·09–10·94]) and age-standardised incidence of lip and oral cavity cancer (14·86% [1·19–32·45]). The high-income super-region had an increase in the age-standardised prevalence of main oral conditions (1·24% [0·56–1·96]) and untreated caries in deciduous teeth (9·21% [6·60–11·89]).
Reliability and validity of early adolescent mental health scale: an analysis of cross-sectional and longitudinal data of the global early adolescent study
(Elsevier B.V., 2026) Kinoshita, Rinko; Yu, Chunyan; Ahmed, Saifuddin
Objective: Assessment of mental health problems among young adolescents remains challenging because of a scarcity of suitable measurement tools. A 6-item questionnaire, the Early Adolescent Mental Health Scale (EAMHS), was designed to measure the mental health of young adolescents in urban, low-resource settings and was used in the Global Early Adolescent Study (GEAS). This study aims to assess the reliability and validity of the EAMHS. Method: Through a secondary data analysis of cross-sectional and longitudinal datasets from the GEAS, we first refined the underlying constructs of the EAMHS using exploratory factor analysis and assessed its internal reliability. We then took a set of measurement invariance tests to verify the cross-group, cross-cultural, and cross–time-point validity of the refined scale. Subsequently, we conducted a hypothesis test of construct validity and responsiveness using linear regression, incorporating adjustments for the complex sampling design. We carried out calibration between the EAMHS and the Patient Health Questionnaire—4 (PHQ-4) through a single-group design kernel equipercentile equating method, and obtained suggested cut-off scores at each site based on the first follow-up (T2) data. The discriminative ability of the scale with suggested cut-offs was assessed against the adolescents’ PHQ-4 scores of 6 or higher at the second follow-up (T3) using receiver operating characteristic (ROC) curve analyses. Results: The initial 6-item EAMHS was reduced to a 4-item version of a unidimensional structure. Scalar invariance was achieved across genders, age groups, and cultures in longitudinal datasets of 5 study sites. The 4-item EAMHS demonstrated acceptable internal reliability and structural validity, as well as excellent construct validity relative to that of the PHQ-4. Suggested EAMHS cut-off scores showed fair to good discriminative ability in the subsequent follow-up round, with area under the curve (AUC) values ranging from 0.71 (95% CI = 0.64-0.74) in Kinshasa to 0.82 (95% CI = 0.77-0.87) in Shanghai. Conclusion: The findings verified the EAMHS as a consistent and accurate measure, supporting its use for monitoring and evaluating general emotional disturbance within the study context. Diversity & Inclusion Statement: We worked to ensure sex and gender balance in the recruitment of human participants. We worked to ensure that the study questionnaires were prepared in an inclusive way.
Strengthening pediatric oncology pharmacy in Africa: a continental assessment of workforce capacity, training gaps, and network development
(SAGE Publications Ltd, 2026) Wiafe, Ebenezer; Arao, Shauna; Kikonyogo, Steven
Introduction: In Africa, where pediatric cancer survival rates remain low due to interrelated health system challenges, continent-wide data on the availability, training pathways, and distribution of pediatric oncology pharmacists (POPs) are poorly characterized. This study aimed to assess the presence of pharmacists, the availability of formal POP training across pediatric oncology units (POUs) in Africa, and to map existing continent-based training initiatives. Methods: This study profiled POP workforce capacity and training across Africa using data from 109 POUs in 41 countries listed in the SIOP Global Mapping Programme (GMP). POP training programmes were identified through online searches, professional networks, and direct outreach, with data collected on duration, content, accreditation, and trainee capacity. Data collection occurred from February to March 2025, supported by the formation of the African Pediatric Oncology Pharmacy Group (APOP). Results: APOP was established in January 2025, enrolling 97 pharmacists from 28 countries to strengthen networking, mentorship, research collaboration, and standardized training. Among 109 POUs, 83.5% reported a dedicated pharmacist, though coverage varied regionally: Northern Africa (95%), Southern Africa (88%), West Africa (78%), and East/Central Africa (62%). Only three formal POP training programmes were identified, in Egypt, Morocco, and Ghana, varying in duration, certification status, and annual trainee capacity. Collectively, these programmes train approximately 32 pharmacists per year against a backdrop of growing continental need. Conclusion: Although the majority of POUs have a dedicated pharmacist, formal POP training remains scarce. The substantial gap between the availability of training-qualified personnel and access to structured, accredited programmes underscores the need for investment in POP training infrastructure. Enhancing pharmacy training and fostering professional networks are critical to strengthening paediatric oncology care across Africa.
Global, regional, and national burden of road injuries 1990–2023: a systematic analysis for the global burden of disease study 2023
(Elsevier Ltd, 2026) Adebiyi, Babatope Oluwadamilare; van der Lubbe, Stephanie C.C.; Moberg, Madeline E.
Background Road injuries are a leading cause of mortality and morbidity worldwide. Years of international efforts have aimed to strengthen policy engagement, including the 2020 UN General Assembly's proclamation of the Second Decade of Action for Road Safety (2021–30), targeting a 50% reduction in road traffic deaths and serious injuries by 2030. The aim of this study is to provide estimates to monitor progress and identify intervention gaps. Methods As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2023, we estimated incidence, mortality, and morbidity of road injuries for 204 countries and territories from 1990 to 2023. Four road injury types and 47 nature-of-injury categories were examined. Morbidity and mortality data from clinical records, vital registration, and police reports were harmonised using meta-analytic techniques to ensure consistency and correct for systematic bias. Incidence was modelled with the meta-regression tool Disease Modelling-Meta-Regression version 2.1 and cause-specific mortality with the Cause of Death Ensemble model, both incorporating location-specific covariates to support interpolation. Years of life lived with disability (YLDs) were estimated from the prevalence and severity of the nature of road injury, and years of life lost (YLLs) from the number of cause-specific deaths multiplied by the standard life expectancy at the age of death. Disability-adjusted life-years (DALYs) were the sum of YLLs and YLDs. All metrics were calculated with 95% uncertainty intervals (UIs). Findings In 2023, there were 50·9 million (95% UI 46·1–56·1) road injury incident cases, 1·34 million (1·04–1·58) deaths, and 75·3 million (59·8–89·2) DALYs globally. Road injuries were the leading global cause of death among males aged 10–39 years. Between 1990 and 2023, age-standardised incidence decreased by 38·3% (95% UI 36·9–39·7) and mortality decreased by 32·3% (6·1–49·0), but progress varied widely by World Bank income group. Mortality in low-income countries (43·8 [95% UI 31·7–56·0] deaths per 100 000 population) was approximately six times higher than in high-income countries (7·5 [7·1–7·9] deaths per 100 000), despite the high-income countries showing the highest age-standardised incidence rates (858·1 [95% UI 781·9–947·1] cases per 100 000).
Determinants and strategies for implementation of an adapted data to care vertical HIV prevention intervention in a South African context
(Springer, 2026) Knight, Lucia; Gomba, Yolanda; Myer, Landon
Despite progress in preventing new HIV infections in children, retention in vertical transmission prevention (VTP) remains a challenge in low-resource settings. The REMInD intervention used an adapted Data to Care (D2C) approach with tracing to support mother-infant pairs in completing VTP care. This qualitative study aimed to explore the potential implementation determinants and strategies to enhance the successful implementation of the REMInD intervention in Gugulethu, South Africa. Interviews were conducted with nurses, policy implementers, and mothers who had participated in the REMInD proof-of-concept study. We applied the Consolidated Framework for Implementation Research (CFIR) to identify determinants that could influence future implementation. Data were analysed using inductive thematic analysis. Key potential implementation determinants were identified across multiple CFIR domains. Within the Inner setting domain, limited availability of human resources and infrastructure posed key barriers. Under the Individual domain, the capability to retrieve and use data reports was a central concern. The Innovation domain was reflected in the perceived complexity of data retrieval and tracing procedures, particularly in informal settlements with poor infrastructure. Finally, in the Outer setting domain, HIV-related stigma emerged as a potential barrier. To address these challenges, several strategies were proposed by participants: (i) train and give access to the intervention for all nurses to mitigate staffing shortages, (ii) partnerships with NGOs to enhance patient tracing and support service delivery, (iii) collaboration within the health system to sustain support and resource availability, and (iv) dedicated champions to drive implementation. These findings highlight intersecting systemic, contextual, and individual factors influencing REMInD and similar D2C implementation. Strategies addressing staffing, infrastructure, and tracing gaps could enhance implementation success and HIV retention in low-resource settings.
Evolution of health policy and systems research (HPSR) capacity in West Africa and authorship pattern: a bibliometric analysis from 2015 to 2024
(Elsevier B.V., 2026) Defor, Selina; Gnamon Abe, Juliana F.; Agyepong, Irene A.; Lehmann, Uta
Background The generation of HPSR evidence in West Africa has historically been driven by external institutions, with limited leadership from local researchers. Recent investments, including the establishment of the West African Network of Emerging Leaders in Health Policy and Systems Research (WANEL), aimed to strengthen local research capacity. The objective of this study was to assess how authorship patterns and publication outputs have evolved over the past decade. Methods We conducted a bibliometric analysis using PubMed to identify peer-reviewed publications authored by 103 WANEL members between 2015 and 2024. We analysed the frequency of publication overtime by study type, research domain, authorship order, institutional affiliation, and collaboration patterns. Results Overall, WANEL members produced 1027 publications during the study period, of which 617 (60.1%) were HPSR-related. Of these, 62.9% (388) had West African first authors, mostly from Nigeria (47.0%) and Ghana (17.5%), while contributions from Francophone countries remained limited (6%). First-author institutions were predominantly in West Africa (62.9%), indicating a remarkable shift toward southern-led research. However, intra-network collaboration appeared quite low: only 62 (10%) of HPSR publications were co-authored by multiple WANEL members. Thematic analysis showed service delivery (49.1%) dominated research focus, followed by financing (12.6%) and information systems (11.2%). Conclusion A growing regional research capacity and ownership is observed; this is depicted by the increased West African leadership in HPSR publication. Persistent disparities call for more persistence, increasing targeted investments in underrepresented contexts and stronger cross-country partnerships, for a more equitable and sustainable HPSR ecosystem in West Africa.
Awareness of abortion legality and safe abortion uptake in Ghana: assessing the moderating role of education in a cross‐sectional study
(John Wiley and Sons Inc, 2026) Somefun, Oluwaseyi Dolapo; Banchani, Emmanuel; Gwebu, Hengliwe
Background and Aims: Although awareness of abortion legality has been associated with reproductive health service utilization, little is known about whether legal awareness influences safe abortion uptake in Ghana or whether educational attainment modifies this relationship. This study examined the association between awareness of abortion legality and safe abortion uptake and assessed the moderating role of education among women in Ghana. Methods: Data were drawn from 1282 women aged 15–49 years who reported an induced abortion in the 5 years preceding the 2017 Ghana Maternal Health Survey. Abortions were classified as safe if they involved a recommended abortion method, were performed by a trained provider, and occurred in a recognized health facility. Awareness of abortion legality was assessed by asking respondents whether they knew abortion was legally permitted in Ghana under specific circumstances. Responses were categorized as aware or unaware. Covariates were selected based on existing literature relevant to abortion care-seeking behavior. Multivariable logistic regression models were used to estimate adjusted associations between legal awareness, education, and safe abortion uptake. Results: Overall, 39.39% of abortions were classified as safe, while only 12.09% of women were aware of Ghana's abortion law. Legal awareness was strongly associated with safe abortion uptake (aOR = 2.09; 95% CI: 1.42–3.08; p < 0.001). Educational attainment was also positively associated with safety, with women with secondary (aOR = 1.98; 95% CI: 1.22–3.22; p = 0.006) and higher education (aOR = 3.06; 95% CI: 1.57–5.96; p = 0.001) more likely to obtain safe abortions compared with those with no education. However, education did not significantly moderate the association between legal awareness and abortion safety. Predicted probabilities indicated the highest likelihood of safe abortion among legally aware women with higher education (69%). Conclusion: These findings highlight the importance of improving women's awareness of abortion legality and strengthening women's educational attainment to enhance reproductive health autonomy and reduce unsafe abortion in Ghana.
The applicability of AWaRe-based antibiotic quality indicators to assess the appropriateness of antibiotic prescribing in primary healthcare in South Africa: A multicentre point prevalence study and implications for the future
(Multidisciplinary Digital Publishing Institute (MDPI), 2026) Johnson, Yasmina; Chigome, Audrey; Cook, Aislinn
Background/Objectives: Inappropriate antibiotic prescribing in primary healthcare (PHC) contributes to bacterial antimicrobial resistance (AMR). Antibiotic stewardship, including measuring the appropriateness of antibiotic prescribing using quality indicators, is a priority in PHC where most antibiotics are used. Using previously developed WHO AWaRe classification-based quality indicators, we aim to test the clinimetric properties of 13 acute respiratory tract infection (RTI) quality indicators and qualitatively explore factors influencing PHC antibiotic prescribing in South Africa. Methods: We conducted a mixed-methods exploratory feasibility study using point prevalence surveys (PPSs) with clinimetric assessment and prescriber interviews. PPSs were conducted at four PHC facilities in Gauteng province that had taken part in previous PPS studies, alongside face-to-face interviews with PHC personnel. Results: In total, 52/52 (100%) RTI patients received antibiotics. Four (30.8%) indicators achieved scores above 85%, while six (46.2%) scored below 50%. All indicators had applicability scores ≥10%. Twelve (92.3%) indicators had a measurability score of 100%, while one (7.7%) had a measurability score <75%. Twelve (92.3%) indicators met all predefined acceptable scores for applicability and measurability. No participant knew of the WHO’s AWaRe classification and none had specific training on antibiotic prescribing and AMR. They also had no antibiotic stewardship programmes (ASPs) or specific antibiotic-prescribing guidelines at their facilities.
Strengthening pharmacovigilance and regulatory capacity in Southern Africa (SPaRCS): achievements, experiences and lessons learned from a participatory action learning project
(Frontiers Media SA, 2026) Bradley, Hazel; Viljoen, Michelle; Khoza, Star
Effective regulatory systems play a critical role in improving access to safe, efficacious and quality medicines and vaccines. However, most regulatory and pharmacovigilance (PV) systems in sub-Saharan Africa (SSA) are still underresourced and lack recognition of their public health service role, despite encouraging developments in several countries, and positive experiences of harmonization across the continent. The aim of Strengthening pharmacovigilance and regulatory capacities in four Southern African countries (SPaRCS), was to improve pharmacovigilance and clinical trials oversight in Namibia, Eswatini, Zimbabwe and South Africa. The project used a participatory action learning and co-creation approach and built on existing relationships with national regulatory authorities and PV centres in the four countries. Key activities included a mapping of PV and clinical trials oversight in the four partner countries; participatory workshops and learning exchanges in two thematic areas; Strengthening PV systems and Clinical trials oversight, and collaborative development of a training package for community health workers on adverse drug reaction reporting. Intentionally SPaRCS provided opportunities for partners in the four countries to develop relationships amongst those involved in PV and clinical trials oversight in the region. This included sharing of challenges, field experiences and best practices in a sub-national, national and regional setting. Strong commitment of country partners and the flexible learning and co-creation approach facilitated positive achievements. Strengthening PV and clinical trial oversight requires a multi-faceted approach involving the establishment of robust systems, addressing infrastructure and training gaps, integrating PV into public health programs and building formal collaborative platforms at regional level. The regional platform created by SPaRCS provided a starting point, for the establishment of the Centre of Excellence for Pharmacovigilance in Southern Africa (CEPSA) launched at the end of 2024.
Barriers and determinants of low lifestyle and dietary adherence among adults with hypertension in resource-limited settings: A cross-sectional survey from Mokhotlong and Butha-Buthe districts, Lesotho
(SAGE Publications Ltd, 2026) Sello, Mamakase G.; Hlephole, Lieketseng V.; Monyane, Boitumelo
Background: Adherence to lifestyle and dietary modifications is crucial for effective hypertension management, yet non-adherence remains a significant challenge. Aim: This study aimed to identify determinants and perceived barriers of low lifestyle and dietary adherence among adults with hypertension attending chronic care units in Butha-Buthe and Mokhotlong districts, Lesotho. Methods: A quantitative cross-sectional survey of 200 adults with hypertension attending chronic care units in the Butha-Buthe and Mokhotlong districts of Lesotho was conducted. Logistic and linear regression were used to identify determinants of dietary and lifestyle adherence, respectively, with statistical significance set at p < 0.05. Summary: The mean age of participants was (48 ± 11.87 years). Only 8.0% of participants adhered to WHO dietary recommendations, while 36.5% adhered to lifestyle recommendations. Patients with low education were substantially less likely to adhere to dietary guidelines (OR = 0.18, 95% CI: 0.03–0.82, p < 0.05), and those reporting specific food preferences were likewise less likely to adhere (OR = 0.18, 95% CI: 0.03–0.88, p < 0.05). Low educational level was also a significant predictor of lifestyle adherence (β = −0.275, p < 0.05), as were food preferences (β = −0.205, p < 0.05). These findings highlight the need for patient education, nutritionist support, and context-appropriate dietary counseling to improve hypertension management in resource-limited settings.

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