In rural sub-Saharan Africa (sSA), the burden of antimicrobial resistance (AMR) remains high. As AMR continues to rise, there is a strong need for practical, implementable surveillance to monitor and mitigate risks, as well as inform timely, evidence-based clinical decision-making. Emerging evidence points to possible community-level drivers, such as transmission between human, animal and environmental reservoirs as contributing factors, yet microbiological surveillance or opportunities for wastewater-based surveillance are often limited and insufficient in these settings. Therefore, alternative sustainable and affordable approaches are needed. We intend to build on the demonstrated potential of metagenomic profiling of pooled faecal material, which accurately predicted population-level AMR prevalence in invasive Enterobacterales infections.

We aim to validate this metagenomic pooled approach on additional populations, and to evaluate whether AMR patterns could be similarly predicted from surveillance of community One Health reservoirs. We will assemble existing data from hospital-based microbiology diagnostic laboratories in rural Burkina Faso and Kenya, and determine to what extent community-level metagenomic data, and/or faecal material of patients on hospital admission, can predict AMR in clinical isolates. We will perform community-level surveys in eight clusters per country, randomly selecting 15 households per cluster. We will systematically sample suspected environmental AMR exposure sites in and around households (soil, drinking water, latrines, chicken faeces) and collect data on community-level antibiotic use, hygiene practices, contact with domestic animals and sanitary facilities. Samples and data will be collected twice: during the dry and during the rainy season.

In addition to evaluating the accuracy of predicting resistance in clinical isolates, we will quantify community-level exposure risks. We will conduct metagenomic profiling on pooled DNA extracts from human stool samples (hospital and community-level) and from household environments. Bayesian statistical models will quantify relationships between AMR gene abundance in the environment and in human stool, and invasive bacteria identified among clinical patients, accounting for geography and seasonality. A cost-utility analysis will determine under what circumstances the use of pooled metagenomic data to inform empirical antibiotic policies would represent an efficient use of resources.

The proposed surveillance protocol is developed in partnership with local communities and local and international researchers and has received ethical approval in Kenya and Burkina Faso. It will assess whether intermittent, pooled-sample metagenomics provides a viable, low-cost and practical approach for population-level AMR surveillance in settings that—like many in rural sSA—lack systematic microbiological diagnostics and where sewage systems for wastewater-based surveillance are absent. By providing an alternative to routine microbiological-based surveillance where this proves challenging to implement, this approach may help improve treatment outcomes, contribute to equity and public health. Findings will be disseminated through peer-reviewed publications and academic conferences and will contribute to the recently proposed WHO AMR surveillance strategy, which combines survey-based approaches with routine AMR surveillance.

Young children and children living with HIV are at high risk of progressing to tuberculosis (TB) disease following Mycobacterium tuberculosis (Mtb) exposure and infection, and also of developing severe forms of disease and TB-related mortality. Identifying children who have very early (sub-clinical) TB disease, prior to progression to clinically apparent TB, would mean that TB preventive treatment (TPT) could be more efficiently targeted to this group. Identifying biomarker changes on drug therapy in children with Mtb infection or very early disease could pave the way for the development of tests that can identify which children have viable bacilli and are therefore at increased risk of disease progression.

The INTREPID study will use already collected samples taken from well-phenotyped paediatric cohorts in three clinical studies conducted in South Africa in children Mtb exposure to disease and from children treated for Mtb infection and early TB disease, as well as targeted Mtb antibody analysis. Data on viral co-infections and relevant clinical and epidemiological parameters will be integrated and evaluated to identify the optimal biosignatures that can predict future progression to clinically overt disease in children below 5 years of age, including those living with HIV.

The study protocol received ethical approval from the Stellenbosch University Health Research Ethics Committee (N23/03/025). The study findings will be disseminated through peer-reviewed publications, scientific conferences and formal presentations to healthcare professionals and to local communities, in collaboration with the Desmond Tutu TB Centre Community Advisory Board.

More than 300 million major surgical procedures are carried out under general anaesthesia each year worldwide, and advanced airway management remains one of the leading daily challenges for clinicians. Data from large international prospective cohort studies on adverse events such as cardiovascular collapse, cardiac arrest and severe hypoxaemia during advanced airway management to facilitate anaesthesia are lacking.

The International obServational sTudy on AiRway manaGement in operAting room and non-operaTing room anaEsthesia (STARGATE) study will be an international prospective observational cohort study describing the incidence of major adverse events associated with advanced airway management (tracheal intubation or supraglottic airway device placement) for general anaesthesia in the operating and non-operating room for surgery and medical procedures. The secondary aim will be to describe the practice of airway management in a large international cohort. Critically ill patients will be excluded from this study. Data on patients’ characteristics, type of procedure and the adopted airway management strategy, post-procedure adverse events, operator characteristics and in-hospital mortality will be prospectively collected. The study aims to enrol 10 500 patients.

The study has been approved by the Ethics Committee of the coordinating centre (Comitato Etico Interaziendale AOU San Luigi Gonzaga, N° 25/2023). Each of the participating centres will then seek approval of their local Ethics Committee before enrolment. Data will be disseminated to the scientific community by original articles submitted to international peer-reviewed journals.

NCT05759299.

The aim of this study was to assess the prevalence of poor sleep quality and its determinants in people with schizophrenia in Northwest Ethiopia.

Institutional-based cross-sectional study design.

University of Gondar, Comprehensive and Specialized Hospital, Gondar, Ethiopia.

A total of 405 people with schizophrenia attending outpatient treatment at University of Gondar, Comprehensive and Specialized Hospital were recruited in this study employing systematic random sampling technique from 1 April to 30 May 2024.

An interviewer-administered questionnaire and chart review were used to collect the data. Pittsburgh Sleep Quality Index, Clinical Global Impression-Schizophrenia Scale, Glasgow Antipsychotic Side-Effects Scale, Medication Adherence Report Scale and Oslo Social Support Scale were used. A binary logistic regression was employed to measure the association of poor sleep quality and its determinants and variables with a p value of

The overall prevalence of poor sleep quality in people with schizophrenia was found to be 58.3% with a 95% CI 53.38 to 63. Age less than 45 years (adjusted OR (AOR)=2.1, 95% CI 1.2 to 3.7), poor and moderate social support (AOR=10, 95% CI 5.7 to 17.8 and AOR=4.7, 95% CI 2.5 to 8.8), poor medication adherence (AOR=1.9, 95% CI 1.8 to 3.1) and a family history of mental illness (AOR=1.9, 95% CI 1.2 to 3.3) were significantly associated with poor sleep quality in this study.

This study revealed that around six in 10 people with schizophrenia experience poor sleep quality. Therefore, healthcare providers should routinely screen people with schizophrenia for sleep and consider targeted interventions to achieve the ultimate goal of treatment process.

Due to the multisystemic nature of sickle cell disease (SCD), complications can occur together and thus discerning costs associated with individual complications requires a methodology that can estimate the costs of a given complication while accounting for the presence of other complications. In this study, we aimed to estimate period-based incremental costs associated with specific chronic complications in patients with SCD in England while accounting for multimorbidity.

All-cause primary and secondary care healthcare resource utilisation (HCRU) was obtained for a retrospective cohort of patients with SCD using Clinical Practice Research Datalink (CPRD) Aurum linked to Hospital Episode Statistics (HES) datasets. Annualised HCRU and costs were calculated, dividing patient-level events by patient-level time (in years) to obtain per person per year estimates. A series of generalised linear models were used with adjustment for demographic factors and proportion of follow-up time with each complication to estimate the costs associated with 10 chronic SCD-related complications of interest. For these costs, annual equivalent costs can be obtained by dividing by the median follow-up time of 4.74 years.

Patients with a diagnosis of SCD, with or without complications, in CPRD or HES with at least 12 months follow-up.

Period-based all-cause direct healthcare costs.

Of the 1271 patients with SCD included in the study, 49.9% (n=634) had at least one complication and of these 41.3% (n=262) had two or more complications either at baseline or during follow-up. Patients with complications had higher all-cause healthcare costs compared with patients without complications (mean (SD) annualised cost £16 058 (£21 488) vs £4399 (£6635)). Patients with complications had four times the number of annualised inpatient admissions (6.1 vs 1.5 admissions) and more than double the number of annualised bed days in hospital (8.3 vs 3.8 days) over a median 4.74 years of follow-up. Of the complications evaluated, end-stage renal disease had the highest estimated incremental cost of £252 083 (95% CI £214 478 to £283 745) over 4.74 years; this is in addition to the £18 547 period-based cost among patients with SCD without complications. Osteonecrosis was the most common complication with an estimated incremental cost of £27 399 (95% CI £6417 to £43 319) over the same period.

Estimating the cost of complications, while accounting for multimorbidity, is essential to determine the true direct cost of SCD. The modelling method presented in our study provides period-based estimates of cost and hospital admissions for individual complications in patients with SCD, accounting for multimorbidity. This approach can be used and extended to other diseases with multisystemic complications to estimate the direct HCRU and costs of individual complications.

The timing of a woman’s first birth is significantly associated with maternal and child health outcomes and socioeconomic opportunities. Delaying the first birth is associated with reduced risks of adolescent pregnancy complications, improved birth outcomes and enhanced interpregnancy intervals, all of which contribute to better maternal and child health. In Somaliland, early childbearing is prevalent, necessitating an understanding of its associated factors. Early childbearing, defined as a first birth before age 20, is prevalent in Somaliland, with 47.02% of women having their first birth by this age, significantly higher than the average for sub-Saharan Africa (approximately 30%) and global figures.

This study aimed to identify the sociodemographic factors associated with age at first birth among married women in Somaliland.

The median duration from marriage to first birth was 3 years, with a median age at first birth of 21 years. Women residing in the Sool (adjusted HR: 1.318, 95% CI 1.138 to 1.527) and Sanaag (adjusted HR: 1.265, 95% CI 1.095 to 1.462) regions had a significantly higher hazard of first birth compared with those in Awdal (reference). Conversely, women in the middle (adjusted HR: 0.821, 95% CI 0.685 to 0.985) and highest (Adjusted HR: 0.799, 95% CI 0.663 to 0.964) wealth quintiles had a significantly lower hazard of first birth compared with the lowest wealth quintile. Age at first marriage was a strong factor associated with the outcome; marrying at age 20 or older (adjusted HR: 0.699, 95% CI 0.644 to 0.759) was associated with a significantly lower hazard of first birth compared with those who married before age 20. After adjustment, other factors including residence, media exposure and husband’s employment status were not significantly associated with the timing of first birth.

Region, wealth quintile and age at first marriage are critical factors associated with first birth timing in Somaliland. Interventions should focus on addressing regional disparities and promoting delayed marriage to improve maternal and child health outcomes. Further research is needed to explore the complex social and cultural drivers of these findings.

Mothers’ mental health and life satisfaction may have been negatively affected due to challenges during the COVID-19 pandemic. Given the risk of future crises, knowledge of possible mitigating factors in this population is essential. This study aims to examine whether the pandemic affected the level of protective factors such as social support, physical activity and employment situation, and how these factors are associated with mental distress and life satisfaction.

Longitudinal cohort study.

Primary outcomes were mental distress (measured by the eight-item version of the Hopkins Symptom Checklist) and life satisfaction (measured by the Satisfaction With Life Scale). As the first step, we investigated changes in the levels of social support (defined by the number and frequency of social contact), physical activity (average hours of physical activity during a week), employment situation (actively working vs sick leave or unemployed), alcohol consumption (measured by the Alcohol Use Disorders Identification Test-Consumption) and relationship satisfaction (measured by the five-item version of the Relationship Satisfaction Scale).

We analysed data from two waves of the Norwegian Mother, Father and Child Cohort Study (n=~18 000 mothers); one pre-pandemic wave and one wave where half of the sample responded after the onset of the pandemic, with pandemic exposure being defined by questionnaire response timing rather than cohort recruitment. To assess changes in protective factors over time and pandemic exposure, we used difference-in-differences analyses and regression discontinuity design. Associations between protective factors with mental distress and life satisfaction, and possible moderation by pandemic exposure, were investigated using multiple regression models with interaction terms adjusted for potential confounders.

Apart from physical activity, which declined less across time in the pandemic group (B=0.09, 99% CI 0.05 to 0.12), protective factors did not change during the pandemic. Social support, employment situation and relationship satisfaction were associated with mental distress and life satisfaction, whereas physical activity showed a unique relationship with mental distress. Most associations were similar across pandemic exposure groups, except employment situation which appeared to have a stronger protective effect in the pandemic group (β=–0.12, 99% CI –0.24 to –0.00).

Changes over time in self-reported levels of protective factors were generally consistent among mothers independent of the pandemic. These factors appear to play an equally important role for mental distress and life satisfaction both under ordinary circumstances and during public health crises. Our findings enhance the understanding of how potential protective factors among mothers are associated with mental distress and life satisfaction in the context of a global stressor. Future studies should investigate additional mitigating factors that may be particularly relevant during global crises and explore the causal relationship between protective factors, mental health and life satisfaction.

To assess patient satisfaction and identify associated factors in plastic and hand reconstructive surgery at ALERT Comprehensive Specialised Hospital in Addis Ababa, Ethiopia.

A hospital-based cross-sectional study was conducted from February to March 2023 using a structured questionnaire that incorporated the Patient Satisfaction Questionnaire Short Form and the Outpatient Assessment of healthcare scales. Patient satisfaction was measured using a five-point Likert scale. Descriptive statistics and multivariable logistic regression were employed using Stata V.17.

ALERT Comprehensive Specialised Hospital, Addis Ababa, Ethiopia.

A total of 391 systematically selected adult patients attended the plastic and hand reconstructive surgery outpatient departments.

Overall patient satisfaction and factors influencing satisfaction with surgical services.

Of the 379 respondents (response rate 96.9%), 51.2% were male. The overall patient satisfaction rate was 75.7%. However, 78.6% experienced long waiting times (mean: 2 hours 15 min), 84.4% reported inadequate information provision, and 90.3% indicated that medical care was unaffordable. Significant factors associated with higher satisfaction included age 30–39 years (AOR=2.7; 95% CI 1.09 to 6.83), having laboratory tests ordered (AOR=2.03; 95% CI 1.03 to 4.03) and X-ray/ultrasound imaging (AOR=2.20; 95% CI 1.19 to 4.06). Patients who received care free of charge were less likely to be satisfied compared with those paying out of pocket (AOR=0.23; 95% CI 0.07 to 0.82).

Although overall satisfaction was moderately high, significant dissatisfaction was reported regarding service accessibility, waiting times, communication and affordability. Targeted interventions in these areas are recommended to improve patient-centred care.

The COmmunity HEalth System InnovatiON (COHESION) project (2016–2019) was a 4-year collaboration between research teams from Mozambique, Nepal, Peru and Switzerland. It conducted formative health system research using tracer chronic conditions, non-communicable diseases (diabetes and hypertension) and one neglected tropical disease per country (schistosomiasis in Mozambique, leprosy in Nepal and neurocysticercosis in Peru).

Findings guided the co-creation of interventions to improve diagnosis and management through a participatory approach with communities, primary healthcare workers and regional health authorities.

As a continuation of this effort, the research team initiated the COHESION Implementation project (COHESION-I) with two objectives: (1) implement and evaluate the context-specific co-created interventions in Mozambique, Nepal and Peru (Component 1) and (2) adapt the COHESION approach to India, a country that did not benefit from a formative phase previously (Component 2). This protocol manuscript focuses on Component 1.

A mixed-methods, pre–post quasi-experimental design will be used, including quantitative, qualitative, economic and process evaluations. Each country will have three arms: (1) co-created and co-designed interventions; (2) only co-designed intervention and (3) the usual care arm. Data will be collected longitudinally over 18 months to assess the effect of the interventions. The main outcomes include patient satisfaction (Patient Satisfaction Questionnaire Short Form), health system responsiveness (WHO responsiveness domains) and quality of life (EuroQol 5 dimensions 5 levels). The qualitative evaluation will explore how satisfaction is perceived among service users with chronic conditions and healthcare workers. Other outcomes per type of evaluation will be considered such as perceived value of health services, cost estimation and acceptability of the intervention components, among others.

Approvals were obtained from Ethics Committees of Universidad Peruana Cayetano Heredia (Peru), Universidade Eduardo Mondale (Mozambique) and Nepal Health Research Council (Nepal). Results will be disseminated through peer-reviewed publications and scientific conferences.

NCT06989502.

The roles and functions of traditional birth attendants in the community and in relation to the formal healthcare system have to the best of our knowledge, not previously been explored in Somaliland. This study aimed to explore the past and current roles and practices of traditional birth attendants from the traditional birth attendants’ perspective.

An exploratory study was conducted using purposive sampling technique first followed by snowballing technique from January to December 2023.

Somaliland rural communities in the six regions of the country.

Traditional birth attendants from all six regions of Somaliland were interviewed. Thematic analysis inspired by Braun and Clarke was used to analyse the data.

Traditional birth attendants were historically involved in pregnancy care, childbirth and the practice of female genital mutilation/cutting. Their role has undergone a significant shift in recent years. Traditional birth attendants are increasingly acting as vital links between the community and the formal healthcare system. They report that they have maintained strong trust within their communities, which positions them as effective mediators in promoting access to professional maternal and reproductive health services.

Traditional birth attendants are becoming trusted intermediaries between the community and the formal healthcare system. In the pursuit of universal health coverage and the goal of delivering high-quality, equitable care for all, leveraging traditional birth attendants as part of a broader midwifery-led care model offers a cost-effective strategy in the Somaliland context.

To describe the point prevalence of major ECG abnormalities, their coexistence with screen-detected cardiovascular disease (CVD) and the proportion requiring referral for cardiac work-up and interventions.

A population-based cohort study.

Primary and secondary care settings in Denmark.

Since 2014, all 67-year-old Danish men and women from Viborg municipality were invited to the ‘Viborg Screening Programme’ (VISP).

VISP includes screening for lower extremity artery disease (LEAD), carotid plaque (CP), abdominal aortic aneurysm (AAA), hypertension, diabetes mellitus and cardiac conditions.

A single resting 12-lead ECG was recorded and coded using the Minnesota criteria. Major ECG abnormalities were divided into rhythm and rate disorders, signs of myocardial damage and conduction disorders.

Over the first 5 years, 4612 (83.8% of those invited) were screened, with 4437 (96.4%) undergoing an ECG. We found major ECG abnormalities in 152 (3.4%), including 92 (2.1%) rhythm and rate disorders, 28 (0.6%) with signs of myocardial damage and 32 (0.7%) with conduction disorders. Fifty-nine (1.3%) had newly screen-detected ECG abnormalities, and 34 (0.8%) required intervention after cardiac consultation (32 medication adjustments and/or 11 advanced treatments). Participants with major ECG abnormalities had a higher frequency of coexisting CVD, including CP (46.4% vs 38.1%; p=0.040), LEAD (9.5% vs 5.3%; p=0.026) and AAA (2.7% vs 0.9%; p=0.032) and were also more common in men than in women (4.7% vs 2.2%; p

This study provides a detailed overview of major ECG abnormalities in a population-based cardiovascular screening context. Although the yield of ECG screening was low, ECG may still add value as a simple and low-cost tool within multimodal programmes, enabling timely detection and treatment.

NCT03395509.

Although the WHO and the Centers for Disease Control and Prevention (CDC) classify preconception health risks (PCHRs) into biomedical, behavioural and social categories, this classification remains theoretical, mainly inconsistent and lacks a scientifically robust framework. Data-driven clustering techniques may help clarify this complexity for policymakers and healthcare providers. This study aimed to assess the status of PCHRs and identify latent classes of these risks among women preparing for pregnancy.

This community-based cross-sectional study was conducted from 31 July to 16 August 2024 in Tigray, Ethiopia, among 865 married women planning to conceive within the next 6 months. Data were gathered through face-to-face interviews using a structured questionnaire. Risk factor indicators covering lifestyle behaviours, substance use, nutritional risks and related factors were developed based on guidelines from the WHO, the CDC and national recommendations. Latent class analysis (LCA) was employed to identify distinct classes of PCHRs, with the optimal number of classes determined using statistical fit indices, adequacy criteria and interpretability. The study also evaluated the overall distribution of PCHRs among participants.

The study took place in Tigray, Ethiopia, among married women intending to become pregnant within 6 months.

Burden of PCHRs and identified distinct latent classes of these risks within the participants.

All participants were exposed to at least four PCHRs, with 84.2% experiencing between 6 and 12 risk factors. The optimal LCA model identified four distinct classes of PCHRs: lifestyle behavioural risks (n=458, 52.9%), reproductive health risks and chronic medical conditions (n=106, 12.25%), nutritional risks and environmental exposure (n=149, 17.23%) and social determinants of health (n=152, 17.57%).

Our study reveals a high baseline level of PCHRs, with all participants exhibiting multiple risk factors for adverse pregnancy outcomes. The identification of four distinct risk profiles underscores the need for tailored risk-specific interventions, particularly in conflict-affected settings. Our findings point out the need for targeted preconception care and risk stratification in national health strategies to improve maternal and child health outcomes.

Immunisation is one of the most valuable, impactful and cost-effective public health interventions which delivers positive health, social and economic benefits. Globally, 4 million deaths worldwide are prevented by childhood vaccination every year. In Ethiopia, despite huge progress being made, the routine immunisation coverage has never reached the targeted figures and planned goals. Pastoralist communities are often disproportionately under-vaccinated, and there is often a confluence of interrelated factors that drive this outcome. This study enables us to identify factors affecting immunisation service utilisation in the pastoralist communities of Ethiopia, which helps to design effective and context-specific interventions.

This study aims to explore the behavioural and social drivers (BeSDs) of routine immunisation among the communities with high numbers of zero-dose and under-immunised children in Afar, Somali and Gambella regions of Ethiopia.

A qualitative exploratory study was conducted in three selected regions of Ethiopia (Gambella, Somali and Afar) from 9 November 2023 to 30 December 2023. Purposive sampling was used. A total of 33 interviews were conducted in the three regions. Sample size was determined based on idea saturation. Data was collected using interview guides. The interview guide was developed after reviewing relevant literature, desk review and using the journey to health and immunisation framework. A separate interview guide was developed for the journey mapping exercise, in-depth interview, healthcare workers discussion guide, focus group discussion and observation. Data was analysed thematically.

Behavioural (lack of awareness, lack of reminder/forgetting, misperception about vaccines, negative previous experience, lost card and fear of post-vaccination adverse events).

Structural (language barrier, long distance from home to facility, high cost of transportation, long waiting time, limited training of healthcare professionals and incentives, inconvenient service hours, shortage of health professionals, disrespect by the healthcare provider), Socio-cultural (competing priorities, low community engagement, lack of decision-making autonomy, limited husband involvement, workload, rural residence and larger family size were the commonly mentioned barriers to routine immunisation uptake. On the other hand, structural (house to house visit by health extension workers, counselling about adverse events, presence of outreach service, affordability (free of charge)), behavioural and socio-cultural (knowledge of adverse event management, and respect from community) were enablers to routine immunisation service uptake in pastoralist communities.

The study found several individual and contextual factors affecting routine immunisation uptake in pastoralist communities. Context-specific and tailored interventions which address zero dose drivers should be designed so as to enhance vaccine uptake. The findings suggested the need to design context-specific interventions to address the aforementioned barriers to immunisation.

Acute coronary syndrome (ACS) is the leading cause of morbidity and mortality among individuals with cardiovascular disease, accounting for half of all global cardiovascular-related deaths. No prior research has examined ACS treatment outcomes and associated factors in the study area. This study aimed to evaluate the risk factors and treatment outcome of ACS patients admitted to public hospitals in Harari Regional State, Eastern Ethiopia.

A retrospective hospital-based cross-sectional study was conducted among 308 ACS patients. Patient records from admissions between 1 November 2018 and 31 October 2023 were reviewed, with data collected between 10 January and 10 February 2024 using a structured checklist adapted from previous research. Statistical analysis was performed using SPSS V.25.0, with bivariable and multivariable logistic regression identifying significant associations at a p value

The mean patient age was 56.4±16 years, with males comprising 77.3% of participants. Half (51.6%) resided in rural areas, and only 16.2% presented within 12 hours of symptom onset. Overall, 81 patients (26.3%) experienced a poor treatment outcome for ACS, including 39 (12.7%) in-hospital deaths, 24 (7.8%) referrals to higher-level facilities and 18 (5.8%) who left against medical advice. Factors significantly associated with poor outcome included hospital presentation more than 72 hours after symptom onset (AOR 2.734 (95% CI 1.006 to 7.435)), left ventricular ejection fraction (LVEF)

Poor treatment outcome was independently predicted by the presence of ischaemia features on the echocardiography, LVEF (