ABSTRACT Social vulnerability has been shown to be a strong predictor of disparities in health outcomes. A common approach to estimating social vulnerability is using a composite index, such as the social vulnerability index (SVI), which combines multiple factors corresponding to key social determinants of health. Lawal and Osayomi created an SVI to explore key social determinants of health-related COVID-19 infection among the Nigerian population. This study explored the association of COVID-19 SVI with COVID-19 seroprevalence using a large household survey in Nigeria. Weighted COVID-19 seroprevalence estimates at the Local Government Areas (LGA) were estimated and merged with the Lawal and Osayomi SVI, also at the LGA-level. Linear regression models were constructed to evaluate the relationship between the SVI and COVID-19 seroprevalence. The effect of SVI was evaluated both as a continuous variable and categorized into quintiles to evaluate dose–response effects. Our results confirmed a positive relationship between social vulnerability and COVID-19 infection in four states and the Federal Capital Territory in Nigeria. Compared to class 1 (the least vulnerable group), COVID-19 seroprevalence was, on average, 9.21% and 6.42% higher in classes 4 and 5 LGAs, respectively, after adjustment by phase of the survey. The effect was particularly strong farther into the pandemic (June 2021), when COVID-19 mitigation measures were relaxed. In conclusion, SVI can potentially be a useful tool to effectively prioritize communities for resource allocation as part of emergency response and preparedness in Africa.

ABSTRACT Fuzzy cognitive mapping (FCM) is a practical tool in participatory research. Its main use is clarifying causal understandings from several knowledge sources. It provides a shared substrate or language for sharing views of causality. This makes it easier for different interest groups to agree what to do next. Each map is a collection of causal relationships with three elements: factors (cause and outcome), arrows linking factors, and weights indicating the perceived influence of each cause on its outcome. Stakeholder maps are soft models of how they see causes of an outcome, such as access to services or systemic racism. Based on a standardized FCM protocol, we present four moments in FCM analysis. (1) Agree shared meaning across maps. (2) Calculate the maximum influence of perceived causes. (3) Simplify the maps for communication. (4) Identify priorities for action. We provide explanations of the four moments in FCM analysis, with examples from five countries. FCM offers a practical means to guide health action. It incorporates local perspectives with transparent and traceable procedures.

ABSTRACT Background Since the 1990s, Tanzania has actively encouraged stakeholder participation in health services through Health Facility Governing Committees (HFGCs) to promote social accountability within its broader health system reforms. While previous studies have explored the functionality of the HFGCs, this study aimed to understand whether stakeholder participation in the HFGCs contributes to promoting social accountability in the health system. Methods Between July and October 2022, a qualitative study in two districts of Tanzania was carried out. Selected participants, knowledgeable about HFGCs, included facility managers, HFGC members representing diverse stakeholders in the committees, local government leaders, district health secretaries, and religious leaders. Twenty in-depth interviews were conducted and analysed thematically. Results Findings revealed low stakeholder participation in the committees´ activities, partly due to the committees´ inability to effectively sensitize and mobilize them. Inadequate support from local government leaders and the dominance of the facility managers in the committees´ activities, also affected the committees´ role as promoters of social accountability. Conclusion The HFGCs in Tanzania have faced challenges in promoting social accountability due to weak stakeholder participation. Key issues include limited awareness of HFGCs, inadequate mobilization, and insufficient training, supervision, and guidelines from district councils. Additionally, flawed election processes, leadership interference, lack of political support, and limited financial resources undermined the committees’ effectiveness. To improve engagement, district councils should enhance stakeholder sensitization, build HFGC capacity, ensure that facilities allocate 5% of their budgets for committee activities, monitor performance, and encourage local government support for HFGCs.

ABSTRACT Background Postpartum depression is associated with low socioeconomic status, adverse birthing processes, and life stress. Increasing evidence of mistreatment during childbirth, negative birth experiences, and poor quality of maternal care is of global concern. Objective To assess the risk of experiencing depressive symptoms among postpartum women exposed to mistreatment during institutional birthing in Nepal. Method We conducted a prospective cohort study from 29 March to 19 August 2022. Of 1629 women who gave birth in a hospital in Nepal, 1222 were assessed for mistreatment during childbirth and depressive symptoms using the Edinburgh Postnatal Depression Scale. We used binomial generalized linear mixed model to examine the risk ratio of postpartum depressive symptoms in women exposed to mistreatment during childbirth. Results The prevalence of postpartum depressive symptoms was 4.4%. Women exposed to mistreatment during childbirth were almost fifty percent more likely to have postpartum depressive symptoms (cRR 1.47; 95% CI 1.14, 1.89; p = 0.003) compared with the unexposed group. Furthermore, adolescent mothers exposed to mistreatment during childbirth had a seventy percent increased risk of depressive symptoms (aRR 1.72; 95% CI 1.23, 2.41; p = 0.002). Similarly, women who gave birth to female infants were thirty percent more likely to experience postpartum depressive symptoms (aRR 1.32; 95% CI 1.01–1.74; p = 0.039). Conclusion We observed an association between postpartum depressive symptoms and mistreatment during institutional births in Nepal. The implementation of appropriate respectful maternity care during childbirth and also routine screening for depressive symptoms is critical to improving perinatal mental health and well-being.

ABSTRACT Background In 2015, Uganda joined the Global Financing Facility (GFF), a Global Health Initiative for Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH). Similar initiatives have been found to be powerful entities influencing national policy and priorities in Uganda, but few independent studies have assessed the GFF. Objective To understand the policy process and contextual factors in Uganda that influenced the content of the GFF policy documents (Investment Case and Project Appraisal). Methods We conducted a qualitative policy analysis. The data collection included a document review of national RMNCAH policy documents and key informant interviews with national stakeholders involved in the development process of GFF policy documents (N = 16). Data were analyzed thematically using the health policy triangle. Results The process of developing the GFF documents unfolded rapidly with a strong country-led approach by the government. Work commenced in late 2015; the Investment Case was published in April 2016 and the Project Appraisal Document was completed and presented two months later. The process was steered by technocrats from government agencies, donor agencies, academics and selected civil society organisations, along with the involvement of political figures. The Ministry of Health was at the center of coordinating the process and navigating the contestations between technical priorities and political motivations. Although civil society organisations took part in the process, there were concerns that some were excluded. Conclusion The learnings from this study provide insights into the translation of globally conceived health initiatives at country level, highlighting enablers and challenges. The study shows the challenges of trying to have a ‘country-led’ initiative, as such initiatives can still be heavily influenced by ‘elites’. Given the diversity of actors with varying interests, achieving representation of key actors, particularly those from underserved groups, can be difficult and may necessitate investing further time and resources in their engagement.

ABSTRACT Background Postpartum depression (PPD) affects approximately 17% of the women worldwide with nearly half of all cases going undetected. More research on maternal mental health, particularly among healthcare professionals and pregnant mothers, could help identify PPD risks and reduce its prevalence. Objective Given that awareness of PPD is a crucial preventive factor, we studied PPD awareness among midwives and pregnant women in Arkhangelsk, Arctic Russia. Methods A qualitative study was conducted using in-depth semi-structured interviews. Midwives and pregnant women were recruited from the women’s clinic of the Arkhangelsk municipal polyclinic. Seven midwives and 12 pregnant mothers were interviewed. Results Midwives described limited time for psychological counselling of pregnant women; they reported that their primary focus was on the physiological well-being of women. Pregnant women have expressed a desire for their families to share responsibilities. The participants considered PPD as a mix of psychological and physiological symptoms, and they also highlighted a discrepancy between the expectations of pregnant women and the reality of motherhood. The present study underscored the limited understanding of PPD identification. Conclusions The findings suggest that there is a need for increased awareness among midwives and pregnant women regarding PPD. Prevention programs targeting PPD with a specific emphasis on enhancing maternal mental health knowledge are warranted.

ABSTRACT Background Local and global surveillance of antibiotic resistance (ABR) has proven a challenge to implement effectively in low- and middleincome (LMI) settings. Environmental surveillance solutions are increasingly highlighted as a strategy to help overcome such problems, and thus to promote global health as well as the local management of ABR in LMI countries. While technical and scientific aspects of such solutions are being probed continuously, no study has investigated their practical feasibility. Objective Explore practical barriers for environmental surveillance of ABR in LMI countries, and pathways for surveillance experts to manage these. Methods To start charting this unknown territory, we conducted an explorative, qualitative interview study with key informants, applying a constructivist grounded theory approach to analyze the results. Results Barriers were identified across infrastructural, institutional and social dimensions, and pathways to manage them were mostly counterproductive from an ABR management perspective, including avoiding entire regions, applying substandard methods and failing to include local collaborators. Conclusion The research community as well as international agencies, organizations and states have key roles and responsibilities for improving the prospects of feasible environmental ABR surveillance in LMI-settings.

ABSTRACT Background Globally, every year, approximately 1 million foetal deaths take place during the intrapartum period, fetal heart monitoring (FHRM) and timely intervention can reduce these deaths. Objective This study evaluates the implementation barriers and facilitators of a device, Moyo for FHRM. Methods The study adopted a qualitative study design in four hospitals in Nepal where Moyo was implemented for HRM. The study participants were labour room nurses and convenience sampling was used to select them. A total of 20 interviews were done to reach the data saturation. The interview transcripts were translated to English, and qualitative content analysis using deductive approach was applied. Results Using the deductive approach, the data were organised into three categories i) changes in practice of FHRM, ii) barriers to implementing Moyo and iii) facilitators of implementing Moyo. Moyo improved adherence to intermittent FHRM as the device could handle higher caseloads compared to the previous devices. The implementation of Moyo was hindered by difficulty to organise training ondevice during non-working hours, technical issue of the device, nurse mistrust towards the device and previous experience of poor implementation to similar innovations. Facilitators for implementation included effective training on how to use Moyo, improvement in intrapartum foetal monitoring and improvement in staff morale, ease of using the device, Plan Do Study Act (PDSA) meetings to improve use of Moyo and supportive leadership. Conclusion The change in FHRM practice suggests that the implementation of innovative solution such as Moyo was successful with adequate facilitation, supportive staff attitude and leadership.

ABSTRACT Background Wider healthcare-strengthening interventions are recommended in cholera hotspots and could benefit other types of diarrhoeal diseases which contribute to greater mortality than cholera. Objective Describe facility capacity and provider knowledge for case management of diarrhoea and cholera surveillance in cholera hotspots in the Democratic Republic of Congo (DRC) among health facilities, drug shops, and traditional health practitioners. Methods We conducted a sequential exploratory mixed-method study, using focus group discussions, facility audits, and provider knowledge questionnaires during September and October 2022 in North Kivu and Tanganyika provinces, Eastern DRC. Content analysis was used for qualitative data. Quantitative data were summarised by facility level and healthcare provider type. Audit and knowledge scores (range 0–100) were generated. Multivariable linear regression estimated association between scores and explanatory factors. Qualitative and quantitative data were triangulated during interpretation. Results Overall, 244 facilities and 308 providers were included. The mean audit score for health facilities was 51/100 (SD: 17). Private facilities had an −11.6 (95% CI, −16.7 to −6.6) lower adjusted mean score compared to public. Mean knowledge score was 59/100 (95% CI, 57 to 60) for health facility personnel, 46/100 (95% CI, 43 to 48) for drug shop vendors and 37/100 (95% CI, 34 to 39) for traditional health practitioners. Providers had particularly low knowledge concerning when to check for low blood sugar, use of nasogastric tubes, and dosing schedules. Knowledge about case definitions for cholera was similar between groups (range 41–58%) except for traditional health practitioners for the definition during an outbreak 15/73 (21%). Conclusions Increasing awareness of cholera case definitions in this context could help improve cholera surveillance and control. Increased support and supervision, especially for private providers, could help ensure facilities are equipped to provide safe care. More nuanced aspects of case management should be emphasised in provider training.

ABSTRACT Background The impact of heat waves and atmospheric oxidising pollutants on residential mortality within the framework of global climate change has become increasingly important. Objective In this research, the interactive effects of heat waves and oxidising pollutants on the risk of residential mortality in Fuzhou were examined. Methods We collected environmental, meteorological, and residential mortality data in Fuzhou from 1 January 2016, to 31 December 2021. We then applied a generalised additive model, distributed lagged nonlinear model, and bivariate three-dimensional model to investigate the effects and interactions of various atmospheric oxidising pollutants and heat waves on the risk of residential mortality. Results Atmospheric oxidising pollutants increased the risk of residential mortality at lower concentrations, and O3 and Ox were positively associated with a maximum risk of 2.19% (95% CI: 0.74–3.66) and 1.29% (95% CI: 0.51–2.08). The risk of residential mortality increased with increasing temperature, with a strong and long-lasting effect and a maximum cumulative lagged effect of 1.11% (95% CI: 1.01, 1.23). Furthermore, an interaction between atmospheric oxidising pollutants and heat waves may have occurred: the larger effects in the longest cumulative lag time on residential mortality per 10 µg/m3 increase in O3, NO2 and Ox during heat waves compared to non-heat waves were [−3.81% (95% CI: −14.82, 8.63)]; [−0.45% (95% CI: −2.67, 1.81)]; [67.90% (95% CI: 11.55, 152.71)]; 16.37% (95% CI: 2.43, 32.20)]; [−3.00% (95% CI: −20.80, 18.79)]; [−0.30% (95% CI: −3.53, 3.04)]. The risk on heat wave days was significantly higher than that on non-heat wave days and higher than the separate effects of oxidising pollutants and heat waves. Conclusions Overall, we found some evidence suggesting that heat waves increase the impact of oxidising atmospheric pollutants on residential mortality to some extent.