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전체arXiv Math12,367arXiv CS.AI8,535arXiv Physics4,150arXiv Stat1,858PLOS ONE871arXiv Econ593arXiv Q-Bio496eLife165PLOS Global Public Health131PLOS Biology67PLOS Medicine46
PLOS Global Public Health

“At the end of the day I’d still have to use a condom!”: A qualitative investigation of use of HIV pre-exposure prophylaxis among young gay and bisexual men in Nairobi, Kenya

by Carlos Cheruiyot, Peter Kaberia, Walter Nyagah, James Kang’ethe, Adrian D. Smith, Thesla Palanee-Phillips, Samuel Mwaniki Despite availability of highly effective oral HIV pre-exposure prophylaxis (PrEP) for close to a decade, uptake and adherence among at-risk young men who have sex with men (YMSM) in Kenya, remain significantly low. This study investigated levels of PrEP knowledge, motivations, facilitators and barriers influencing PrEP initiation, persistence and adherence among YMSM, in efforts to optimise use and reduce risk of new HIV infections. In September 2021, 22 YMSM selected from 248 YMSM who had previously participated in an integrated bio-behavioural sexual health survey, took part in semi-structured in-depth interviews. Data analysis generated three key categories informed by the Information-Motivation-Behavioural skills (IMB) model: knowledge, motivation, and barriers influencing the use of oral and on-demand PrEP. Participants expressed PrEP awareness and effectiveness in HIV prevention, but were concerned about PrEP- and HIV-related stigma, with the fear that family, friends, and potential romantic partners might perceive them as being promiscuous, or as living with HIV. Participants reported being capable of seeking PrEP services provided in MSM-friendly facilities, with public health facilities perceived as hostile considering the criminalisation of, and societal stigma toward same-sex practices. These findings highlight the crucial need to re-strategise PrEP promotion not only as an effective but also a safe HIV-prevention option for at-risk populations. This study recommends expediting the integration of long acting lenacapavir and cabotegravir in the Kenyan health system as a means to diversify PrEP modalities and potentially reduce the stigma experienced in oral PrEP use.

PLOS Global Public Health

Optimal pooling strategies for respiratory virus testing: A comparative cost-effectiveness analysis

by Fan Zhong, Changyu Ni, Bingshun Wang Pooled testing represents a cost-efficient strategy for large-scale respiratory virus screening. However, determining the optimal pool size (OPS) across varying prevalence rates and diagnostic performance metrics remains a critical challenge in respiratory virus surveillance. We evaluated four hierarchical OPS algorithms, all employing the original solution method (OSM), and proposed a modified solution method (MSM) based on objective function optimization. Through Monte Carlo simulations and logit modeling, we generated COVID-19 infection data representative of community transmission patterns. These data were analyzed using a comparative cost-effectiveness framework to assess OSM and MSM approaches. Our analysis across various prevalence rates (0.1-30.0%), sensitivities (0.8-1.0), and specificities (0.97-1.00) revealed Hanel et al.‘s algorithm consistently yielded the largest OPS values under OSM. MSM revealed minimal deviations from OSM in most scenarios, though it effectively corrected Kim et al.’s inflated OPS values at high prevalence (~30%) with low sensitivity/specificity. Three algorithms produced comparable OPS configurations, outperforming OSM. Hanel’s and Regen’s algorithms emerged as the most cost-effective options, with Hanel’s method being optimal for low additional costs in second-stage testing and Regen’s for high additional costs. MSM significantly reduced inter-algorithm cost differences compared to OSM. This study provides a comprehensive evaluation of OPS determination algorithms in pooled PCR testing for respiratory viruses, demonstrating robust OPS configurations and enhanced cost-effectiveness through MSM implementation. The proposed MSM addresses existing limitations in pooled testing strategies, facilitates efficient resource allocation, and contributes to improved respiratory virus surveillance and pandemic response.

PLOS Global Public Health

Community-based, peer-led psychosocial support to address stigma and reduce depression among adults with tuberculosis in Indonesia: A prospective interventional cohort study

by Ahmad Fuady, Marinda Asiah Nuril Haya, Mariska Anindhita, Matsna Haniifah, Fathinah Ranggauni Hardy, Dzul Faridah Arinal Haq, Imelda Aliska, Elvira Radhiatul Febriani, Adji Fauzan Rifky, Artasya Karnasih, Feranindhya Agiananda, Finny Fitry Yani, Trevino Aristarkus Pakasi, Adhityawarman Menaldi, Budi Hermawan, Tom Wingfield We co-developed and evaluated a community-based, peer-led psychosocial support intervention consisting of individual and peer-led group counselling, online group messaging, and community-based “TB-Talks” to address tuberculosis (TB)-Stigma and reduce depression among adults with TB in Indonesia. A non-randomized, single-arm prospective interventional cohort study was conducted in five primary healthcare centres and two public hospitals in Depok and Padang cities from June 2024 to January 2025. All newly-diagnosed individuals with either drug-sensitive (DS-) or drug-resistant (DR-) TB, aged 15 years and above, were consecutively recruited and offered individual counselling at baseline, then monthly peer-led group counselling and online group messaging and TB Talks during six months of treatment. Participants were assessed at baseline, end of intensive phase (Month-2), and continuation phase (Month-6) for TB-stigma, depression, and quality of life (QoL), using locally-adapted and validated tools including the Van Rie TB-Stigma scale, PHQ-9, and EQ5D5L, respectively. In addition, we collated quantitative acceptability, appropriateness and feasibility feedback from participants and stakeholders. A total of 129 people with TB (Depok = 85, Padang = 44) participated, including 55 (43%) women. Most participants had new DS-TB (62%), 19 (15%) recurrent DS-TB, and 30 (23%) DR-TB. At baseline, most participants had moderate-to-severe TB-Stigma (74%; 95%CI = 65–82%) and depression symptoms (57%; 35–72%). Among 112 participants who completed all assessments, moderate-to-severe TB-Stigma decreased to 43% (34–53%) and 21% (13–28%) and depression symptom prevalence decreased to 32% (20–47%) and 15% (6–23%) at Month-2 and Month-6, respectively. Participants’ QoL increased from median 0.84 (0.63-1.00, at baseline) to 0.92 (0.83-1.00, Month-2) and 1.00 (0.91-1.00, Month-6). Both study participants and stakeholders perceived that activities in this study were feasible, acceptable, and locally-appropriate. Community-based, peer-led psychosocial support, combining individual and monthly group counselling, has potential to mitigate TB-Stigma and depression while improving QoL among adults with TB in Indonesia.

PLOS Global Public Health

Advancing gender equity in primary health care: Lessons from integrating gender-responsive strategies into service delivery in Ethiopia

by Gizachew Tadele Tiruneh, Agumasie Semahegn, Biruhtesfa Bekele Shiferaw, Mesele Damte Argaw, Nebreed Fesseha, Chala Tesfaye, Temesgen Ayehu, Biruk Bogale, Metadel Tesfaye, Addis Girma, Wuleta Betemariam, Alex Munive, Frank DelPizzo, Lidiya Tefera, Helina Worku, Misrak Makonnen, Addis Tamire, Dessalew Emaway Gender inequities remain a major barrier to women’s access to reproductive, maternal, newborn, and child health (RMNCH) services. To address this gap, the Improve Primary Health Care Service Delivery (IPHCSD) project integrated a set of gender-responsive strategies into primary health care (PHC) systems. This paper presents lessons from implementing gender-responsive strategies that empowered women and communities while enhancing access to essential health services. A quasi-experimental embedded implementation research with a participatory mixed-methods approach was employed. The study combined controlled before-and-after household studies, phenomenological research, gender analysis, and stakeholder engagement to identify gender-related barriers and co-design contextually appropriate interventions. A mixed-effect logistic regression model was fitted to estimate the net effect using a difference-in-difference (DiD) approach. The study identified substantial gender-related barriers to RMNCH service utilization, including restrictive social norms, high workloads for women, limited decision-making power and control over resources, and inadequate male involvement. In response, the project implemented a comprehensive gender integration strategy. This included strengthening women’s participation through learning and action groups, establishing gender-sensitive service standards, and expanded home visits and targeted outreach and promoting male engagement. These strategies demonstrated strong transformative potential of enhancing women’s agency and improving RMNCH service delivery and utilization. Quantitatively, the intervention significantly improved women’s agency in agrarian settings (DiD: + 13.6 percentage points; p < 0.001). Uptake of maternal and newborn health services also increased significantly: DiD of +15.8 percentage points (p < 0.001) and +12.3 percentage points (p = 0.031) under the community-based MNH delivery strategy, and +29.0 (agrarian) and +15.9 (pastoral) under the PLA strategy. Gender-integrated approaches strengthened women’s agency, improved access to and use of RMNCH services, and contributed to universal health coverage. Integrating gender considerations and enhancing men and youth involvement into PHC is essential for reducing disparities and building more inclusive health systems in vulnerable communities.

PLOS Global Public Health

Nutritional intake, biochemical profiles, and functional outcomes in elderly inpatients: A hospital-based cross-sectional study in Vietnam

by Tran Thi Phuong Lan, Pham Van Phu, Le Thi Huong, Le Xuan Hung, Nguyen Quang Dung Malnutrition poses a significant challenge for elderly inpatients, particularly in developing countries, contributing to adverse clinical outcomes. This cross-sectional study examined associations between nutritional intake, biochemical profiles, and functional outcomes in 264 elderly inpatients (mean age 73.39 ± 4.12 years, 50.4% male) at Military Hospital 354, Hanoi, Vietnam, from January to June 2025. Nutritional status was assessed using the Mini Nutritional Assessment Short Form (MNA-SF), in conjunction with energy intake (24-hour dietary recall), body mass index (BMI), serum albumin levels, Activities of Daily Living (ADL) scores, and EuroQol-5 Dimensions (EQ-5D) dimension scores (range: 5–15; summative approach used for simplicity in resource-constrained settings, though it may limit utility comparisons). Higher EQ-5D scores indicate worse health status. Results revealed 34.8% of participants were malnourished (MNA-SF < 8), 37.9% at risk (8–11), and 33.0% had hypoalbuminemia (<35 g/dL). Functional impairment (ADL < 6) affected 33.3%. Significant correlations were observed between MNA-SF and albumin (r = 0.44, p < 0.01) and ADL (r = 0.63, p < 0.01). Multiple linear regression, adjusted for age, sex, and comorbidities, revealed that MNA-SF and albumin were significantly associated with ADL (β = 0.43, p < 0.01; β = 0.13, p < 0.01) and EQ-5D (β = -0.46, p < 0.01; β = -0.12, p < 0.01). These findings underscore the urgent need for routine nutritional screening and interventions in Vietnamese hospitals to mitigate the impact of malnutrition on functional outcomes and quality of life. This study provides additional limited empirical evidence from Vietnam on the association between nutritional and functional measures among elderly inpatients, contributing to the geriatric nutrition literature in developing countries.

PLOS Global Public Health

Progress towards measles and rubella elimination in Eswatini by 2024

by Xolisile Dlamini, Tholokwakhe Simelane, Susan Kamalizeni, Lonkululeko Khumalo, Angel Dlamini, Kassahun Mitiku, Balcha Masresha Eswatini has been implementing measles and rubella elimination strategies, aligning with the WHO African Regional goal. This report reviews the immunization coverage and surveillance data to evaluate the country’s progress towards the elimination goals. We reviewed routine immunisation coverage data, supplemental immunisation activity coverage data, and case based and laboratory surveillance data for measles and rubella. Routine immunization coverage for the first and second dose was 85% and 82% respectively in 2023 according to the WHO UNICEF coverage estimates. Eswatini implemented regular nationwide preventive supplemental immunisation activities, with the most recent one in 2021 attaining 97% administrative coverage. Eswatini has consistently met the performance targets for the principal indicators since 2008. The incidence of both measles and rubella have been maintained at less than 5 cases per million for more than 10 years, with zero incidence of measles documented over multiple years. Eswatini has made immense progress towards measles and rubella elimination. The country will need to address programmatic gaps that may negatively impact population immunity and will need to maintain high quality measles and rubella surveillance, including molecular surveillance in order to attain and maintain the verification of measles and rubella elimination.

PLOS Global Public Health

Non-communicable disease care in peri-urban Nepal: Potential for community-based interventions

by Maryam Hameed Khan, Yoko Inagaki, Sonam Magar, Sweta Koirala, Nisha Rana, Pabitra Babu Soti, Gabriella Rose Chalker, Kamal Ghimire, Svea Closser, Dinesh Neupane Non-communicable diseases (NCDs) are a growing public health challenge in Nepal, driven by hypertension, diabetes, and smoking, and contributing substantially to morbidity and mortality. Access to equitable and affordable care remains limited, particularly in community settings. Task-sharing with Female Community Health Volunteers (FCHVs), a national cadre of volunteer community health workers primarily engaged in maternal and child health, offers a potential strategy to improve community-based NCD management, but its feasibility requires careful assessment. During the formative phase of the SCALE-NCD project, this qualitative study explored community and health system perspectives on NCD care and community-based delivery models in Pokhara, Nepal. Data were collected through 17 in-depth interviews and six focus group discussions with community members, FCHVs, facility-based community health workers (FB-CHWs), and representatives from government, public health, academia, and telecommunications. Thematic analysis revealed five core findings. Community members recognized NCD risk factors but reported deep mistrust in government health services driven by negative care experiences, financial, and structural barriers. Perceptions of FCHVs were shaped by limited community exposure to their roles beyond maternal and child health. While some participants questioned FCHVs’ capacity to manage NCDs, others valued their familiarity and accessibility when services were reliably supported. FCHVs and FB-CHWs emphasized that infrequent training, limited supervision, chronic stockouts, financial strain, and inconsistent incentives undermined service delivery and FCHV motivation. Stakeholders stressed that sustainable integration of community-based NCD care would require government resourcing, local ownership, and alignment with existing systems. Participants expressed cautious interest in mHealth strategies, including SMS and audio messages, to support awareness and follow-up. These findings informed the final design of SCALE-NCD, a multi-component task-sharing intervention, and underscore the importance of strengthening FCHV training and supervision, ensuring supplies and incentives, and building community trust through consistent, locally supported service delivery when scaling community-based NCD programs in similar resource-limited settings.

PLOS Global Public Health

Prevalence and factors associated with adolescent pregnancy in Hoima district, Uganda: A community-based cross-sectional study

by Joyce Wamakote Wandeka, Ronald Kooko, Justine Bukenya, Rogers Kisame Adolescent pregnancy is a global public health problem with serious social and medical implications relating to maternal and child health. In Uganda, particularly Hoima district, limited information about the factors influencing adolescent pregnancy is available. The study estimated the prevalence of adolescent pregnancy and identified factors independently associated with adolescent pregnancy among girls aged 13–19 years in Hoima district. We conducted a community-based cross-sectional study among 543 adolescent girls randomly selected using multistage sampling. Data were collected using a structured, interviewer-administered questionnaire. Bivariate logistic regression was used to assess associations between independent variables and adolescent pregnancy. Variables with p < 0.20 at bivariate analysis were included in a multivariable logistic regression model to identify factors independently associated with adolescent pregnancy. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported, and statistical significance was set at p < 0.05. Findings revealed 29.1% prevalence of adolescent pregnancy. Age (18–19 years) AOR 4.4 (95%CI 1.5–12.8), low parents’ economic status AOR 5.4 (95%CI 2.5–11.8), multiple sexual partners AOR 8.0 (95%CI 4.5–14.2), being out of school AOR 12.0 (95%CI 5.0–29.1), early marriage AOR 37.0 (95%CI 13.4–107.5), having no control over sex AOR 7.4 (95%CI 3.7-16.4), not discussing SRH with parents AOR 8.4 (95%CI 3.3–21.5), witnessed domestic violence AOR 30.0 (95%CI 12.0–77.5), never received counselling AOR 5.7 (95%CI 3.6–9.0), and, rural residence AOR 1.8 (95%CI 1.2–2.9) were significant predictors of adolescent pregnancy. These findings suggest that adolescent pregnancy in Hoima district remains high and is associated with interconnected individual, family, health system, and community-level factors. Interventions should prioritize keeping girls in school, strengthening adolescent-friendly and non-judgmental health services, addressing household poverty, preventing early marriage, and promoting supportive family and community environments to reduce adolescent pregnancy in rural Ugandan settings.

PLOS Global Public Health

Exploring risk factors associated with catastrophic health expenditure on diarrhea management in Karachi, Pakistan, 2022-2024

by Naveed Ahmed, Mohammad Tahir Yousafzai, Sonia I. Rao, Arianna Rubin Means, Patricia B. Pavlinac, Chloe Morozoff, Farah Naz Qamar Catastrophic health expenditure (CHE) is a situation where a household’s out-of-pocket medical payments are excessively high relative to its income, potentially leading to impoverishment. This study explores the risk factors associated with CHE in the management of diarrhea among children enrolled in Enterics for Global Health (EFGH) facilities in Karachi, Pakistan. We conducted a secondary analysis of data from 1,400 children presenting with diarrhea at Pakistan EFGH facilities. We estimated households’ direct medical and non-medical costs per diarrheal episode. CHE was defined as healthcare expenditures exceeding 10% of total monthly household expenditure. Risk factors for CHE were assessed using univariate and multivariate regression models. CHE was observed in 9 (0.6%) households. Children experiencing severe diarrhea were 9.53 times (95%CI:1.93-46.91, p = 0.006) more likely to incur CHE compared to those with mild cases. Children with Cryptosporidium had a 7.08 times higher risk (95%CI:1.46-34.38, p = 0.015) compared to non- cryptosporidium. Children with moderate or severe wasting were 5.47 and 9.71 times more likely to experience CHE compared to those without wasting (95%CI:1.01-29.69, p = 0.011 and 1.64-57.6, p = 0.012, respectively). Similarly, moderately underweight children were 5.4 times more likely to experience CHE compared to their non-underweight counterparts (95%CI:1.01-29.69, p = 0.043). After adjusting for diarrhea severity, the risk of CHE among households where the father’s education was limited to Quranic schooling was 8.4 times higher compared to no formal education (95%CI:1.13-62.49, p = 0.038). Estimates were based on a small number of CHE events and had wide confidence intervals. Although rare, CHE remains a potential risk for the vulnerable population. While limited statistical power due to small sample sizes warrants cautious interpretation of our risk ratios, our analyses suggest that severe diarrhea, malnutrition, and Cryptosporidium infection are associated with increased risk of CHE. Improving access to affordable healthcare, vaccination and nutritional programs, water, sanitation, and hygiene (WASH) practices, and financial support could reduce the impact of CHE.

PLOS Global Public Health

Spatial inequalities in breastfeeding initiation in the United States: A multiscale analysis of county-level determinants

by Tony H. Grubesic, Wei Kang, Kelly M. Durbin, Edward Helderop Deepening our understanding of geographic variations in breastfeeding initiation (BFI) remains an important element in developing a comprehensive snapshot of maternal and infant health. Identifying spatial variations in socioeconomic, demographic, cultural, and environmental barriers to breastfeeding can advance intervention efforts to educate and encourage breastfeeding within a community. The purpose of this paper is to provide a comprehensive snapshot of county-level trends in BFI in the United States. Using a suite of exploratory spatial data analysis (ESDA) techniques and multiscale geographically weighted regression (MGWR), we highlight several important regional determinants of BFI and improve model performance, increasing the adjusted R2 from 0.641 in a traditional OLS model, to 0.852 in the MGWR model. We concluded the paper by identifying potential locations for public health interventions, especially in Appalachia and the Gulf Coast regions of the United States, and provide three relatively cost-effective strategies to improve BFI that focus on community support, healthcare infrastructure, and education.

PLOS Global Public Health

Costs and cost-effectiveness of an infection prevention bundle to reduce neonatal sepsis and mortality in Zambia: The Sepsis Prevention in Neonates in Zambia (SPINZ) trial

by Lora L. Sabin, Rebecca L. West, Susan E. Coffin, Sylvia Machona, Carter Cowden, Lawrence Mwananyanda, Chileshe Lukwesa-Musyani, John Tembo, Matthew Bates, Davidson H. Hamer The Sepsis Prevention in Neonates in Zambia (SPINZ) trial was a prospective observational cohort study conducted in the neonatal intensive care unit of the University Teaching Hospital in Lusaka, Zambia. Introduction of an infection prevention and control (IPC) bundle reduced hospital-associated mortality, total mortality, suspected sepsis, and confirmed bloodstream infections. This companion analysis was undertaken to analyze intervention costs and cost-effectiveness in this low-resource setting. We conducted a retrospective cost analysis, using SPINZ study-related records, and expressed costs in real 2016 US dollars. We also estimated intervention cost-effectiveness using both outcomes from SPINZ (avoided deaths, confirmed bloodstream infections, and suspected episodes of infection) and estimated disability-adjusted life years (DALYs) averted by the intervention. To provide data for policymakers, a future cost projection was undertaken to estimate costs of the program implemented nationally over a 10-year period in real 2025 US dollars. A total of 2,035 neonates were enrolled from September 2015 to March 2017. Total costs during implementation (introduction of the IPC bundle) (April-May 2016) and the subsequent intervention period were $17,641 and $5,265, respectively, of which most expenses were incurred during the preparation period due to travel and training. During the intervention period, the program’s running cost was approximately $478 per month. The estimated cost per death, confirmed infection, and suspected episode averted was $208, $204, and $32, respectively; the estimated cost per DALY averted was $7. The future model was estimated to cost an average of $107,561 annually to implement nationally. The analysis indicated that the IPC bundle to prevent sepsis-related neonatal mortality was highly cost-effective. Cost reductions from task-shifting, reduced preparation (start-up) costs, and longer intervention periods would further decrease cost per death averted. IPC bundle implementation can thus be recommended for resource-constrained settings where sepsis and other nosocomial infections are associated with high neonatal mortality.

PLOS Global Public Health

Shifts in seasonal timing of respiratory diseases and causes of death following a natural pandemic event

by Michael Sieber, Arne Traulsen Seasonal respiratory infections typically surge within a limited time window, but what determines the exact timing within a given year is not well understood. Major causes of death show a similar seasonal pattern, but whether this pattern is linked to respiratory infections is unclear. The disruptions caused by the COVID-19 pandemic led to dramatic changes in the transmission dynamics of many respiratory pathogens, providing a unique opportunity to study the determinants of seasonal epidemics and the role of infectious diseases in driving seemingly unrelated causes of mortality. We analyzed publicly available data on weekly incidences of respiratory infections and all-cause mortality in Germany for the last 14 years. The analysis was complemented with results from an epidemiological model to determine the main drivers of seasonal timing. The timing of the seasonal epidemic of respiratory infections in Germany has been remarkably consistent for years, peaking during just few weeks in late winter. During the COVID-19 pandemic the seasonal surge in respiratory infections occurred substantially earlier, initially driven by the emerging COVID-19 and during later seasons by the resurgence of influenza and RSV. Remarkably, this shift was accompanied by a similar shift in the seasonality of all-cause mortality, and in particular mortality due to cardiovascular disease. The observed shift in epidemic timing is a consistent, but transient, outcome of disrupted epidemic seasonality, predictable from basic epidemiological principles. Our study reinforces that the buildup of susceptibles after the pandemic disruption was responsible for the shift in timing of the seasonal epidemic of respiratory infections. We show that more generally the rate of immune waning is the main determinant of the exact timing of seasonal epidemics of infectious diseases. The corresponding shift in seasonality of cardiovascular mortality suggests a connection between recent respiratory infections and severe cardiovascular events. This highlights the importance of monitoring individual infection history and improving vaccination coverage, in particular against influenza.

PLOS Global Public Health

Traditional bone setter practices and the interaction with biomedical care in the treatment of hip fractures in The Gambia: A qualitative study

by Awa Touray, Kimberly Lakin, Rachael Gooberman-Hill, Omar Cessay, Lucy Gates, Jainaba Badjie, Tida Saidy, Kaddy Darboe, Matthew L. Costa, Celia L. Gregson, Kate A. Ward, Kebba Marenah, Sarah Drew A growing ageing population in Africa underscores the need to reorient health systems to provide care for non-communicable conditions impacting older populations such as hip fractures. In The Gambia, the number of hip fractures are expected to quadruple for both men and women in the next 30 years. This is comparable to hip fracture incidence rates in other South and West African countries. Moreover, mortality rates post-hip fracture are 2–3 fold higher in populations from the African Region than for those in other high-income countries. Globally, in many countries including in The Gambia, musculoskeletal conditions are treated in a pluralistic medical system by both biomedical healthcare professionals and traditional bone setters (TBS). Further research is required to understand the interactions between these different therapeutic modalities in the treatment of fractures, including hip fractures – a life changing injury. Such evidence is important for developing collaborative initiatives between traditional and biomedical practitioners. This study sought to describe the practices and procedures used by TBS to treat hip fractures and their interactions between with biomedical care in The Gambia. In-depth interviews were conducted with 16 TBS and 38 healthcare professionals involved in hip fracture care provision in both rural and urban regions of the country. Data were analysed using an inductive thematic analysis. TBS used different modalities to identify a hip fracture. Most TBS misidentified and treated hip fractures as dislocations. On account of this, treatment consisted of pulling, massaging, and kneading the limb back into the hip socket. During this process, TBS applied concoctions of herbs and butters followed by splinting and tying the limb. Few TBS provided pain relief medication during treatment and most advised an extensive period of immobilisation of the limb. Follow up visits reviewed recovery. The narratives of both TBS and healthcare professionals further highlighted the informal referral of hip fracture patients from TBS to biomedical care to receive radiographs, analgesia, and for other ailments. While some biomedical healthcare professionals maintained that TBS should have no role in hip fracture care, others noted the importance of regulation of TBS practices and training initiatives. Considering these findings, we propose short-, medium- and long-term recommendations for the integration of traditional and biomedical sectors in the treatment of hip fractures in The Gambia. This includes the need to establish regulatory mechanisms for TBS practices and patient referral pathways between biomedical and TBS care.

PLOS Global Public Health

Identifying age-common and age-specific factors of <i>Plasmodium</i> infection in Nigerian children under five: Application of a cluster-aware multistage selection framework to the 2018 Nigeria Demographic and Health Survey

by Woojae Choi, Yunhee Kang, Joonsup Yeom Despite developmental heterogeneity, children under five are often analyzed as a single group, obscuring age-related differences in Plasmodium infection. Using the 2018 Nigeria Demographic and Health Survey data, we analyzed 2,914 younger children (6–23.9 months) and 5,553 older children (24–59 months) to identify age-common and age-specific factors. We applied a Cluster-aware Multistage Selection (CMS) framework integrating penalized regression, interaction testing, and bidirectional selection while accounting for sampling weights, clustering, and stratification. Plasmodium prevalence was 37.3% in younger children and 49.4% in older children. Each 10-percentage-point increase in community-level livestock and agricultural land ownership was associated with 2.5% (PR = 1.025; 95% CI: 1.011–1.039) and 4.6% (PR = 1.046; 95% CI: 1.029–1.062) higher prevalence, respectively. Socioeconomic disadvantage was associated with higher prevalence. Children in the lowest wealth quintile had 80.7% higher prevalence than those in the richest quintile (PR = 1.807; 95% CI: 1.467–2.224), and children whose mothers had no formal education had 55.8% higher prevalence than those with higher education (PR = 1.558; 95% CI: 1.225–1.980). Severe maternal anemia was associated with 22.5% higher prevalence (PR = 1.225; 95% CI: 1.012–1.483). Stunting and household insecticide-treated net (ITN) ownership were associated with 8.0% (PR = 1.080; 95% CI: 1.024–1.139) and 10.4% (PR = 1.104; 95% CI: 1.017–1.198) higher prevalence, respectively. Conversely, sleeping under an ITN (PR = 0.916; 95% CI: 0.858–0.977), breastfeeding (PR = 0.845; 95% CI: 0.764–0.934), maternal internet use (PR = 0.638; 95% CI: 0.475–0.857), and overweight-for-height (PR = 0.761; 95% CI: 0.631–0.917) were associated with lower prevalence. Age-specific associations were observed only in younger children, including paternal lack of education (PR = 1.301; 95% CI: 1.025–1.652) and rural residence (PR = 1.462; 95% CI: 1.266–1.688). These findings support age-tailored Plasmodium prevention and highlight the utility of CMS for complex population data.

PLOS Global Public Health

Addressing historical biases and the limits of biomedical commodities in vector-borne disease control in Africa

by Jennifer S. Lord, Ellie Sherrard-Smith, Antoine Sanou, Fredros Okumu In this essay, we describe efforts to curtail the spread of vector-borne infections and how these efforts are entangled in the causes and consequences of the destruction of life, and the ecosystems which support life, on our planet. Using examples from malaria and sleeping sickness, we show how current efforts to control vector-borne diseases reflect the Western logic of a highly compartmentalized, hierarchical approach, dominated by biomedicine and commoditized interventions. These have dramatically reduced morbidity and mortality yet perpetuate colonial legacies, global inequities, and environmental harm. For instance, billions of insecticide-treated nets, rapid diagnostic tests, and other single-use plastics used in health products generate waste and emissions, while reinforcing fossil-fuel dependence and Global North dominance. These approaches treat diseases as isolated problems detached from the broader socio-ecological system. They excel at suppressing symptoms but leave untouched the root causes such as poverty, ecosystem destruction, and entrenched power imbalances. Current disease research and control strategies are situated within a wider dominant culture that has led to multiple undesirable effects on our planet (including climate, ecological functions, and biosphere integrity) driven largely by wealthy minorities and a global extractive economic system. Our intention is not to promote the idea that communities should be denied commodities that protect against vector-borne disease, but to identify that a shift is urgently required to make space for alternatives. A change involving transdisciplinary, socially-just strategies, that center local leadership, and enforce full life-cycle responsibility for health commodities; all of which are essential to safeguard both human and planetary health.

PLOS Global Public Health

Animal husbandry and environmental conditions are associated with cefotaxime-resistant <i>Escherichia coli</i> in yard soil in peri-urban Malawi

by Emma Budden, Caitlin G. Niven, Benjamin Clark, Emily Floess, Blessings Chirwa, Monica Matekenya, Stella Cadono, John Chavula, Victor Chisamanga, Aubrey Dzinkambani, Chisomo Kaponda, Neema Ngondo, Norah Patterson, Sheena Symon, Brighton Austin Chunga, Rochelle H. Holm, Petros Chigwechokha, Francis L. de los Reyes III, Cassandra L. Workman, Angela Rose Harris, Ayse Ercumen Soil is an important reservoir for antimicrobial resistance (AMR) and increasingly recognized as a pathogen transmission pathway, especially for young children. However, drivers of domestic AMR soil contamination in low-income countries remain unidentified. We conducted a cross-sectional study with 237 peri-urban households in southern Malawi to identify household and environmental factors associated with cefotaxime-resistant E. coli in yard soil. Enumerators employed structured surveys and sampled 900 cm2 of yard soil per household. We enumerated cefotaxime-resistant E. coli in soil using IDEXX Quanti-Tray/2000 with Colilert-18 and cefotaxime supplement, and assessed associations with household sanitation, animal ownership and management, child health and antibiotic use, and weather. Among children E. coli at a mean of 0.90 log10 most probable number (MPN) per dry gram. Compared to households without animals, household soil had approximately 0.50-log lower mean cefotaxime-resistant E. coli concentration if animals were enclosed at night and 0.40-log higher concentration if they were not (p-valuesE. coli concentrations were approximately 0.90-log lower if soil was dry at the time of collection, 0.70-log lower if the household was in the top wealth quintile (p-valuesE. coli in soil compared to sanitation or antibiotic use, underscoring the importance of a One Health approach to AMR that incorporates domestic animals and environmental factors. Given children’s frequent soil contact, our findings also highlight potential AMR acquisition from soilborne pathways. Studies should quantify soilborne AMR exposure and evaluate associations with animal management/enclosure practices.

PLOS Global Public Health

Modelling climatic and temporal dynamics of dengue transmission in Bangladesh using deep learning models

by Mahadee Al Mobin, Arju Manara Begum Dengue fever is a significant public health issue in tropical and subtropical areas, and predicting its spread is challenging due to the complex interactions between climate factors, mosquito behavior, and case reporting. This study develops a high-resolution forecasting framework that integrates daily dengue case data with meteorological drivers (including mean, maximum, and minimum temperature; precipitation; specific and relative humidity; surface pressure; mean, minimum, and maximum wind speed; wind speed range; wind direction; and sunshine duration) to improve predictions in Bangladesh. Aggregated case counts were disaggregated using a Stochastic Bayesian Downscaling (SBD) algorithm, followed by systematic feature engineering. A wide range of deep learning models, including Artificial Neural Networks (ANN), recurrent networks (LSTM, GRU, BiLSTM, BiGRU), attention-based models, and hybrid convolution neural network (CNN) based ensembles, were optimized through Bayesian hyperparameter tuning and evaluated under a unified process. Results demonstrated that a simple ANN achieved the highest performance, with an accuracy of 97.05%, RMSE of 145.02, and MAPE of 0.51%, surpassing more complex recurrent and attention-based models. Feature importance analysis revealed that weather variables accounted for 76.2% of predictive accuracy, with lagged climate features contributing 59.4%. Short-term lags of three to seven days proved especially influential, underscoring the importance of near-real-time weather monitoring. The strongest predictors included surface pressure with a 3-day lag, precipitation, and maximum wind speed with 7-day lags, while measures of variability such as rolling standard deviations also contributed. The study highlights three key contributions: the benefit of combining downscaling, lagged climate features, and systematic feature selection; evidence that ANN models can outperform more complex architectures in dengue forecasting; and the identification of short-lag weather factors that can support early warning systems. The framework provides an efficient, reproducible, and scalable approach that can strengthen dengue preparedness in public health systems with limited resources.

PLOS Global Public Health

Perceived stigma among hospitalized pulmonary tuberculosis patients in Hue Central Hospital: A 2024 mixed method study in Vietnam

by Thao Thi Van Luong, Huong Thi Thanh Le, Anh Quynh Nguyen, Bao Quy Quoc Truong, Thuy Thi Thu Tran Perceived tuberculosis related stigma remains a critical structural barrier to timely healthcare-seeking and a major driver of the global tuberculosis burden. This study aimed to estimate the prevalence of perceived stigma and identify its associated factors among hospitalized pulmonary tuberculosis inpatients in Hue Central Hospital - a national tertiary hospital in Vietnam - in 2024. A mixed-methods design was employed, incorporating both quantitative and qualitative components. The quantitative component utilized the validated Van Rie Tuberculosis Stigma Scale (VTSS) with 200 pulmonary tuberculosis inpatients from May to July 2024 to measure multiple dimensions of perceived stigma. Additionally, 13 in-depth interviews were conducted with inpatients and healthcare workers following the quantitative phase. Quantitative data were analyzed using multivariable regression while qualitative data were audio-recorded, transcribed, thematically coded, and used to enrich interpretation of quantitative findings. Overall, 43.5% of inpatients experienced perceived stigma, 90.5% intentionally kept physical distance from others, and 87.0% disclosed their disease status selectively to close family members. Perceived stigma was more prevalent among patients with higher socioeconomic status (aOR = 2.01; 95%CI: 1.01-3.99), and those who were unmarried or widowed (aOR = 2.93; 95%CI: 1.01-8.47). Qualitative results further highlighted how social isolation, fear of contagion, and persistent cultural misconceptions about tuberculosis - compounded by the visibility of a tertiary hospital - significantly shaped these perceived stigmatizing experiences. Perceived pulmonary tuberculosis related stigma among pulmonary tuberculosis inpatients remains high. These findings underscore the urgent need for integrating stigma-reduction strategies into routine tuberculosis programs, including community education, patient-centered counselling, and strengthened social support mechanisms to mitigate the psychological burden of the disease.

PLOS Global Public Health

Parents’ and guardians’ perceptions of sexual and reproductive health communication with youth: A qualitative study in Gurage Zone, Southern Ethiopia

by Getachew Gebreselassie Nida, Sisinyana H. Khunou, David Mphuthi Youth sexual and reproductive health (YSRH) remains a significant global public health concern. Effective communication between parents and youth plays an important role in shaping young people’s knowledge, attitudes, and behaviors related to sexual and reproductive health (SRH). However, sociocultural norms and limited parental knowledge often hinder open discussions about SRH within families in many low- and middle-income countries, including Ethiopia. This study explored parents’ and guardians’ perceptions of SRH communication with youth in Gurage Zone, Southern Ethiopia. A qualitative study design was employed using focus group discussions (FGDs) with parents and guardians. Twelve participants aged 40–68 years participated in the discussions. Data were collected using a semi-structured interview guide exploring parental perceptions, attitudes, barriers and strategies related to SRH communication with youth. Audio recordings were transcribed, translated into English and analyzed using thematic analysis. The reporting of this qualitative study was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) to enhance transparency, completeness and methodological rigor. Four major themes emerged: parental perceptions of SRH communication with youth; parental attitudes and beliefs regarding SRH communication; barriers to effective communication; and strategies to strengthen communication. Parents emphasized the importance of open dialogue, emotional safety and early discussions with youth. However, communication was often hindered by sociocultural taboos, generational gaps, limited parental knowledge and competing socioeconomic responsibilities. Parent–youth communication regarding SRH remains constrained by cultural norms and structural barriers. Strengthening parental knowledge and communication skills, alongside community-based interventions and multisectoral collaboration, may enhance youth access to accurate SRH information and promote healthier behaviors.

PLOS Global Public Health

Correction: Keeping the “R” in LARC (long-acting reversible contraception): Measuring client-centered implant removal services in sub-Saharan Africa

by Celia Karp, Katherine Tumlinson, Brooke W. Bullington, Linnea A. Zimmerman, Leigh Senderowicz

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