Background Disproportionate uptake of and access to maternal and child health services remain significant challenges across and within countries. Differing geographic, economic, environmental, and social factors contribute to varying degrees of vulnerabilities among individuals, which manifest as disparities in maternal and newborn health outcomes. Designing solutions according to need is vital to improve maternal and child health outcomes. In this paper, we describe our study protocol on developing and evaluating the effectiveness of human-centered design (HCD) solutions to improve maternal health service uptake among vulnerable pregnant women in rural areas of Ethiopia. Methods Disproportionate uptake of and access to maternal and child health services remain significant challenges across and within countries. Differing geographic, economic, environmental, and social factors contribute to varying degrees of vulnerabilities among individuals, which manifest as disparities in maternal and newborn health outcomes. Designing solutions according to need is vital to improve maternal and child health outcomes. In this paper, we describe our study protocol on developing and evaluating the effectiveness of human-centered design (HCD) solutions to improve maternal health service uptake among vulnerable pregnant women in rural areas of Ethiopia. Conclusions and Implications Our sequential approach to evaluating initial solutions, which in turn will inform the enhancement of solutions, will provide practical insights into how solutions are accepted among vulnerable women and how they can be better integrated into women’s lives and health systems. This will inform equity-focused practice and policies targeting populations experiencing greater barriers to accessing care and provide insights into system strengthening in rural areas. Our findings will be disseminated to the Ethiopian Ministry of Health and its partners to inform large-scale implementation at the national level.

Background Resistance monitoring is a key element in controlling vector-borne diseases. The World Health Organization (WHO) and Centres for Disease Control and Prevention (CDC) have each developed bottle bioassay methods for determining insecticide susceptibility in mosquito vectors which are used globally. Methods This study aimed to identify variations in bottle bioassay methodologies and assess the potential impact on the data that is generated. Our approach involved a systematic examination of existing literature and protocols from WHO and CDC, with a focus on the specifics of reported methodologies, variation between versions, and reported outcomes. Building on this, we experimentally evaluated the impact of several variables on bioassay results. Results Our literature review exposed a significant inconsistency in the how bioassay methods are reported, hindering reliable interpretation of data and the ability to compare results between studies. The experimental research provided further insight by specifically identifying two key factors that influence the outcomes of bioassays: mosquito dry weight and relative humidity (RH). This finding not only advances our comprehension of these assays but also underscores the importance of establishing precisely defined methodologies for resistance monitoring. The study also demonstrates the importance of controlling bioassay variables, noting the significant influence of wing length, as an indicator of mosquito size, on mortality rates in standardized bioassays. Conclusions Generating data with improved protocol consistency and precision will not only deepen our understanding of resistance patterns but also better inform vector control measures. We call for continued research and collaboration to refine and build consensus on bioassay techniques, to help bolster the global effort against vector-borne diseases like malaria.

Effective contraceptive education is essential to reducing unwanted pregnancy, increasing uptake of modern contraceptive methods, and thoughtfully planning desired births. New World Health Organization (WHO) and family planning organization guidelines recommend situating contraceptive education and counseling within a broader context of self-care that emphasizes individual agency and reproductive empowerment. Digital health interventions, and games for health specifically, have been validated as effective and scalable tools for self-guided and interactive health education, especially among younger tech-savvy individuals. Barbados currently supplements provider-based contraceptive counseling with analog materials (pamphlets and posters) and informational videos that play on a screen in the waiting room. As part of an implementation framework, this study seeks to conduct a formative evaluation of the What’s My Method? (WMM) game intervention as a tool to support contraceptive counseling and increase reproductive empowerment among childbearing persons in Barbados. We test-deployed the WMM game in Bridgetown, Barbados, conducting playtests and unstructured discussions with prototypes of the WMM game among three groups of stakeholders (youth contraception ambassadors: n=8; healthcare providers: n=7; and nursing students: n=27) to determine acceptability of the intervention, efficacy of the game as a learning tool, and willingness to adopt the tool in their healthcare context. Feedback on acceptability of the game was largely positive. Detailed constructive comments informed modifications and improvements to the game. The questionnaire used to assess contraceptive knowledge gain did not prove effective. Results indicate that the WMM game is well-received and accepted by the healthcare professionals who would be deploying it. This pilot testing has informed the design of the modified WMM for a randomized controlled trial (RCT) to test the deployment of the game in a healthcare setting.

Faced with declining donor funding for HIV, low- and middle-income countries must identify efficient and cost-effective ways to integrate HIV prevention programs into public health systems for long-term sustainability. In Zambia, donor support to the voluntary medical male circumcision (VMMC) program, which previously funded non-governmental organizations as implementing partners, is increasingly being directed through government structures instead. We developed a framework to understand how the behaviors of individual decision-makers within the government could be barriers to this transition. We interviewed key stakeholders from the national, provincial, and district levels of the Ministry of Health, and from donors and partners funding and implementing Zambia’s VMMC program, exploring the decisions required to attain a sustainable VMMC program and the behavioral dynamics involved at personal and institutional levels. Using pattern identification and theme matching to analyze the content of the responses, we derived three core decision-making phases in the transition to a sustainable VMMC program: 1) developing an alternative funding strategy, 2) developing a policy for early-infant (0–2 months) and early-adolescent (15–17 years) male circumcision, which is crucial to sustainable HIV prevention; and 3) identifying integrated and efficient implementation models. We formulated a framework showing how, in each phase, a range of behavioral dynamics can form barriers that hinder effective decision-making among stakeholders at the same level (e.g., national ministries and donors) or across levels (e.g., national, provincial and district). Our research methodology and the resulting framework offer a systematic approach for in-depth investigations into organizational decision-making in public health programs, as well as development programs beyond VMMC and HIV prevention. It provides the insights necessary to map organizational development and policy-making transition plans to sustainability, by explaining tangible factors such as organizational processes and systems, as well as intangibles such as the behaviors of policymakers and institutional actors.

Background Tobacco use trends among adolescents in low- and middle-income countries, and in particular narrowing gender gaps, highlight the need for interventions to prevent and/or reduce tobacco use among adolescent girls. We evaluated a social marketing program in Ghana discouraging tobacco use among adolescent girls and additionally investigated the pathways influencing smoking behaviors to identify programmatic opportunities for impact. Leveraging the data collected through the stepped wedge cluster randomized trial and panel survey of 9000 girls aged 13–19 , we sought to apply machine learning (ML) techniques to identify the most important variables for predicting initiation of smoking. Methods To identify predictors of smoking initiation we sought to develop a model which could accurately differentiate smokers from non-smokers and evaluated various ML approaches for training classifier algorithms to achieve this. We selected a Synthetic Minority Over-sampling Technique (SMOTE) because it optimized the recall and precision of the model. We then utilized the technique of feature importance for greater insight into how the model arrived at its decisions and to rank the most important variables for predicting smokers. To explore different dimensions of smoking behavior, including initiation and continuation, we trained our model by using several combinations of target outcomes and input variables from the panel survey. Results The resulting features of smokers highlight the importance of girls’ independence and connectivity, social environment, and peer influence on likelihood of smoking, and in particular subsequent initiation. These results were largely consistent with our formative research findings based on qualitative interviews informed by behavioral science. Conclusions This novel application of ML techniques demonstrates how data science approaches can generate new programmatic insights from rigorous evaluation data, especially when data collection is informed by behavioral theory. Such insights about the relative importance of different features can be valuable input for program planning and outreach.

Background South African adolescents experience barriers to sexual and reproductive health (SRH) knowledge and uptake. This study provides insight into contraceptive and other SRH service knowledge, perceptions, and uptake among adolescents in high HIV prevalence settings. Methods A baseline cross sectional survey was conducted among 3432 grade 8s enrolled into the Girls Achieve Power (GAP Year) trial from 26 public high schools across three South African townships (Soweto, Thembisa and Khayelitsha) (2017 - 2018). An interviewer-led survey collected information on SRH knowledge and perceptions; an audio computer-assisted self-interviewing technique gathered SRH service uptake. Descriptive analysis indicates frequency distribution of socio-demographics and knowledge, uptake and perceptions of SRH services. Chi-square test tested for associations between age and sex and selected variables that measure SRH knowledge and uptake. Results In total, 2383 participants completed both survey components. Of these, 63.1% (n=1504) were female and 81.4% (n=1938) aged 12-14. Almost a fifth (18.3%, n=436) had ever had sex and less than 1% had accessed SRH services in the last year. Of the 157 females who had ever had sex, 50.9% had ever used contraception. Of those who had sex in the last three months, 59.0% reported using a contraceptive method. Condom use was inconsistent: almost all females said they had not used or could not remember if a condom was used at last sex. Conclusion This paper contributes to the evidence strengthening learner SRH education, including the national Integrated School Health Programme. Key themes include the need for age-appropriate, differentiated comprehensive sexuality education (CSE) for the range of ages found in the same grade in South African schools. Education on different contraceptive methods, informed decision-making, and emergency contraception is key. School-based interventions should embrace integrated HIV, STI, and pregnancy prevention messages. Closer links with health services need to be constantly fostered and reinforced.

The global prevalence of diseases transmitted by Aedes aegypti mosquitoes, such as dengue, Zika and Yellow Fever, is increasing, but development of promising new mosquito control technologies could reverse this trend. Target Product Profiles (TPPs) and Preferred Product Characteristics (PPCs) documents issued by the World Health Organization can guide the research and development pathways of new products and product combinations transitioning from proof of concept to operational use. We used high resolution global maps of the case and economic burden of dengue to derive programmatic cost targets to support a TPP for Wolbachia replacement. A compartmental entomological model was used to explore how release size, spacing and timing affect replacement speed and acceptability. To support a PPC for a hybrid suppress-then-replace approach we tested whether Wolbachia replacement could be achieved faster, more acceptably or at a lower cost if preceded by a mosquito suppression programme. We show how models can reveal trade-offs, identify quantitative thresholds and prioritise areas and intervention strategies for further development. We estimate that for Wolbachia replacement to be deployable in enough areas to make major contributions to reducing global dengue burden by 25% (in line with 2030 WHO targets), it must have the potential for cost to be reduced to between $7.63 and $0.24 (USD) per person protected or less. Suppression can reduce the number of Wolbachia mosquitoes necessary to achieve replacement fixation by up to 80%. A hybrid approach can also achieve fixation faster and potentially improve acceptability, but may not justify their cost if they require major new investments in suppression technologies. Here we demonstrate the value dedicated modelling can provide for interdisciplinary groups of experts when developing TPPs and PPCs. These models could be used by product developers to prioritise and shape development decisions for new Wolbachia replacement products.

Background The WHO’s recommendations on antenatal care underscore the need for ultrasound assessment during pregnancy. Given that maternal and perinatal mortality remains unacceptably high in underserved regions, these guidelines are imperative for achieving better outcomes. In recent years, portable ultrasound devices have become increasingly popular in resource-constrained environments due to their cost-effectiveness, useability, and adoptability in resource-constrained settings. This desk review presents the capabilities and costs of currently available portable ultrasound devices, and is meant to serve as a resource for clinicians and researchers in the imaging community. Methods A list of ideal technical features for portable ultrasound devices was developed in consultation with subject matter experts (SMEs). Features included image acquisition modes, cost, portability, compatibility, connectivity, data storage and security, and regulatory certification status. Information on each of the devices was collected from publicly available information, input from SMEs and/or discussions with company representatives. Results 14 devices were identified and included in this review. The output is meant to provide objective information on ideal technical features for available ultrasound systems to researchers and clinicians working in obstetric ultrasound in low-resource settings. No product endorsements are provided. Conclusions This desk review provides an overview of the landscape of low-cost portable ultrasound probes for use in obstetrics in resource-constrained environments, and provides a description of key capabilities and costs for each. Methods could be applied to mapping the landscape of portable ultrasound devices for other clinical applications, or may be extended to reviewing other types of healthcare technologies. Further studies are recommended to evaluate portable ultrasound devices for usability and durability in global field settings.

Background This study sought to document and understand facilitators and barriers to producing, translating, and using modeled evidence in decision-making in Burkina Faso, Nigeria, India, and Kenya. We explored researcher-decision-maker engagement mechanisms as key facilitators of evidence use, with a focus on knowledge brokers and boundary organizations. Methods The study used sequential mixed methods drawing on data collected from surveys and key informant interviews, complemented by a rapid desk review to map modeling activities and actors. The survey was conducted online while the qualitative research entailed in-depth interviews with modelers, knowledge brokers, and decision-makers working in a representative variety of health fields, organizations, and levels of government. This study was approved by Health Media Lab IRB (Institutional Review Board) in the United States and a local IRB in each study country and conducted between September 2021 and June 2022. Results Informants interviewed for this study described a range of factors that facilitate and inhibit the use of modeled evidence in public health decision-making at the individual, organizational, and environmental levels. Key themes included the capacity to produce, translate, and use modeled evidence; the timing and relevance of modeling outputs; the existence of communications channels between modelers and decision-makers; the strength of underlying data systems; the role of sustained funding; and the impact of global crises. Conclusion This study highlights the importance of taking an ecosystem approach to supporting modeling activities, considering individual, organizational, and environmental factors and how different actors and interact to inform the production, translation, and use of modeled evidence. Structured interaction that promotes dialogue, debate, and joint sense making between the producers and users of evidence is critical to informing and influencing the use of evidence in decision-making.

Maternal immunization is a critical strategy to prevent both maternal and infant morbidity and mortality from several infectious diseases. When the first COVID-19 vaccines became available during the pandemic, there was mixed messaging and confusion amongst the broader public and among those associated with health care systems about the recommendations for COVID-19 vaccinations in pregnancy in many countries. A multi-country, mixed-methods study is being undertaken to describe how vaccine decision-making occurs amongst pregnant and postpartum women, with a focus on COVID-19 vaccines. The study is being conducted in Brazil, Ghana, Kenya, and Pakistan. In each country, participants are being recruited from either 2 or 3 maternity hospitals and/or clinics that represent a diverse population in terms of socio-economic and urban/rural status. Data collection includes cross-sectional surveys in pregnant women and semi-structured in-depth interviews with both pregnant and postpartum women. The instruments were designed to identify attitudinal, behavioral, and social correlates of vaccine uptake during and after pregnancy, including the decision-making process related to COVID-19 vaccines, and constructs such as risk perception, self-efficacy, vaccine intentions, and social norms. The aim is to recruit 400 participants for the survey and 50 for the interviews in each country. Qualitative data will be analyzed using a grounded theory approach. Quantitative data will be analyzed using descriptive statistics, latent variable analysis, and prediction modelling. Both the quantitative and qualitative data will be used to explore differences in attitudes and behaviors around maternal immunization across pregnancy trimesters and the postpartum period among and within countries. Each country has planned dissemination activities to share the study findings with relevant stakeholders in the communities from which the data is collected and to conduct country-specific secondary analyses.