Background : Globally, one in five infants under 6 months is at risk of death, illness and poor development. They may be identified as being malnourished, growing poorly, or underweight and may have been born too early or too small. The MAMI Care Pathway Package is an integrated care pathway approach, with a package of adaptable resources to guide inter-disciplinary continuity of care for these at-risk infants under 6 months and their mothers within health systems. This approach supports implementation of WHO health and nutrition guidelines that recommend outpatient care. However, the MAMI Care Pathway approach has not been robustly tested within national health systems that has impeded national policy transtion from inpatient-only care for this age-group. To address this evidence gap, the MAMI RISE (Research, Innovate, Scale, Establish) Research Project was developed to test the MAMI Care Pathway in a randomised controlled trial (RCT) in outpatient clinics in Ethiopia. This five-year project (2019-2025) was delivered in a co-creative partnership between LSHTM, Emergency Nutrition Network, Jimma University and GOAL Ethiopia funded by the Eleanor Crook Foundation. Within this research project, I investigated what factors influence implementation of an integrated care pathway in outpatient clinics in Ethiopia through three studies. Methods: I undertook a scoping review of global policies to appraise global policy guidance relevant to the care of at-risk infants under 6 months and their mothers in Ethiopia (Study 1); a pre-trial feasibility study to identify factors that may influence implementation of the MAMI Care Pathway in outpatient health facilities (Study 2); and a realist-informed process evaluation to evaluate how the MAMI Care Pathway worked, for whom and under what circumstances during the RCT (Study 3). The scoping review of global policies involved a literature search of publicly available data according to PRISMA-ScR guidance. The feasibility study involved interviews with health workers and senior policymakers in Ethiopia to explore both health service and policy fit. The process evaluation involved interviews with mothers, fathers, health and research staff in intervention and control sites, and secondary RCT data from research team meetings and incident logs. Results: The scoping review of global policies found rich but fragmented policy guidance that mask interdiscipline policy synergies and important guidance gaps. Evidenced growth markers of infant mortality risk are largely absent from WHO health-oriented guidance. Continuity of care for mothers and infants lacked depth and detail. Using the MAMI Care Pathway to support WHO recommendation uptake is constrained by institutional procedures that limit consideration of nonUN guidance. Transitioning to a living guideline system is necessary and urgent. Applying the WHOINTEGRATE framework to handle complexity within guidance could improve policy fit for implementation of integrated care. The feasibility study found the intervention was perceived by staff as feasible to implement in outpatient services with additional structural support and likely acceptable to mothers. High staff acceptability was influenced by perceived demand, need, implementation realities and integration potential with Integrated Management of Childhood Illness (IMCI) protocols. Identified service constraints included low availability of maternal nutrition and health services and limited breastfeeding and mental health counselling competencies. Policymakers identified good coherence of the MAMI Care Pathway with national policy provisions and intent but emphasised their need for implementation evidence to appraise policy implications of RCT findings. Overall, the process evaluation found the MAMI Care Pathway approach was acceptable, feasible, valued and impactful during a pragmatic, responsive RCT in outpatient services. Positive and varied RCT outcomes were explainable, given case complexities, setting differences, and implementation conditions. Synergism between intervention components, people and health-research systems maximised what was possible. Shared vision gave purpose and drove impact. Adaptive changes meant implementation varied between clinics, settings and over time. Both mothers and health workers had improved access to resources and experienced motivational outcomes that empowered them to cooperatively act. The study also identified that routine service gaps have negative consequences for infants, mothers and families. It is likely that greater scope and intensity of intervention is needed for some cases. Embedded staff generated rich transferable knowledge that strengthens integration potential. Evidencing approaches should transition to locally led implementation research embedded in health services. In summary, the scoping review of global policies identified strong potential but important limitations with global policy content and processes that risk limiting implementation of integrated care. The feasibility study confirmed consistency of the MAMI Care Pathway approach with national policy guidance and IMCI based outpatient protocols. The process evaluation confirmed intervention fit with outpatient services in Ethiopia and strong integration potential. Implications: This body of research provides contextualised evidence for the interpretation of an RCT of the MAMI Care Pathway approach in Ethiopia. Findings have informed national policy development on malnutrition management in Ethiopia. This research provides transferable learning on evidencing and implementing integrated, equitable and just systems of health for localised, scalable, and sustainable care. Co-creative research partnerships that plan for scale maximise national policy fit and system readiness. Implementation research should accompany trials of complex health interventions. The generative knowledge of local stakeholders is essential to evidencing how to deliver effective sustainable care. Programming approaches for at risk infants and mothers must extend beyond nutrition interventions, health interventions must embed action on infant growth and maternal wellbeing. Integrated care is feasible with structural and professional support for staff. Multi-level research, programming and policy action and interaction is necessary for synergistic effects. Inter-disciplinary and inter-system brokerage and stronger global accountability mechanisms to secure better international policy order are needed to achieve this. My findings demonstrate how implementation of integrated care requires policies and programmes that empower local stakeholders to develop, adapt and deliver interventions for at risk infants under 6 months and their mothers. This approach will require a re-focus of international support on catalytic long-term investments in systems of person-centred care, and the pursuit of sustainable scale through contextually grounded, locally led implementation research and learning exchange.
Somalia's escalating humanitarian financing crisis is exposing a neglected dimension of health-system vulnerability: aid volatility can itself become a determinant of primary health-care (PHC) failure. Recent funding contractions have disrupted hospitals, primary facilities, mobile teams, and nutrition services while drought, displacement, infectious-disease outbreaks, and undernutrition continue to intensify health needs. In a system heavily reliant on external financing, abrupt donor withdrawal can destabilise frontline staffing, essential medicines, referral pathways, surveillance, and continuity of care. These disruptions disproportionately threaten populations already experiencing structural disadvantage, particularly children, displaced communities, and households exposed to recurrent climate shocks. We argue that humanitarian financing should, therefore, be understood not only as emergency assistance but also as a critical determinant of health-system resilience and equity. Protecting essential PHC functions, strengthening government stewardship, establishing predictable transition financing, and investing in climate-resilient community health systems are essential to prevent financing shocks from becoming enduring public-health crises.
Fardowso Mohamed Harbi, Ilyas Abdullahi Khalif, Samar Yusuf Omar et al.
Somalia's National Transformation Plan (NTP) 2025–2029 presents an ambitious health-reform agenda centred on maternal and child health, workforce development, health-system strengthening, regulation, financing, digitalisation, and emergency preparedness. The policy challenge is whether the institutional conditions required for implementation can be assembled in a fragile, federal, highly aid-dependent and predominantly mixed-provider health system. This Policy and Practice Review critically examines the implementation readiness of the NTP health chapter and proposes a sequenced framework for converting national commitments into measurable results. A structured narrative review was undertaken from June to July 2026 using peer-reviewed literature, national policy documents, and reports from governmental and international institutions. Evidence was interpreted through the health-policy triangle, the updated Consolidated Framework for Implementation Research (CFIR), applied prospectively to anticipated determinants, and a health-system resilience lens. The synthesis generated six interdependent proposed readiness foundations: a negotiated federal-state governance compact; a technically validated, costed and sequenced operational plan; sustainable financing and strategic purchasing; workforce and regulatory capacity; integrated information, monitoring and public accountability systems; and shock-responsive adaptive management. Important policy strengths include explicit targets for service coverage, workforce expansion, hospital rehabilitation, regulation and digital health. Key risks include inconsistent or under-specified targets and baselines, uncertain fiscal pathways, weak federal-state role specification, and dependence on external resources and non-state providers. Comparative evidence suggests that contracting and pooled financing can expand services when stewardship, fiduciary safeguards, workforce integration, community accountability and learning systems develop concurrently. We propose a phased 2026–2029 pathway prioritising technical validation, essential-service continuity, subnational compacts, workforce payroll transition, interoperable data systems and annual public performance reviews. The proposed framework is prospective and has not yet been empirically validated; consultation with federal and subnational authorities, providers, partners, civil society and communities is required before formal adoption.
Nor Haji Osman, Dahir Osman Mohamed, Hamdi Mohamud Osman et al.
Uganda ranks third with the highest malaria cases globally, highlighting limitations in existing prevention efforts. Malaria vaccination is a key promising strategy to reduce both morbidity and severity among children under 5 (U5) years. In April 2025, Uganda introduced a four-dose R21 malaria vaccine for U5s. We assessed willingness to vaccinate with the malaria vaccine and associated factors among caregivers of U5s to support vaccine rollout in the targeted population. In March 2025, we conducted a cross-sectional study at the Maternal and Child Health unit of Masaka Regional Referral Hospital among 292 caretakers. We generated caretaker attendance lists daily to serve as sampling frames and developed a sampling interval. We used systematic sampling to obtain the total sample size. We administered a questionnaire assessing caregivers’ willingness to vaccinate, and identified associated factors using modified Poisson regression. We interviewed 292 caretakers, 250(86%) were female and 249(85%) indicated willingness to vaccinate their children. Prior experience with adverse events following immunization (AEFIs) (adjusted prevalence ratio [aPR]=0.2,95%Confidence Interval [CI]0.05-0.5), having other relatives than biological parents as main decision makers (aPR 0.2, 95%CI0.04-0.9) and having tertiary education (aPR 0.14, 95%CI0.04-0.6) were associated with reduced willingness to vaccinate, while receipt of malaria Intermittent Preventive Treatment in pregnancy (IPTp) (aPR 6.2, 95%CI1.6-23) and trust in vaccine safety (aPR 13, 95%CI4.0-43) were associated with increased willingness to vaccinate. Majority of the caretakers were not aware of the malaria vaccine butwere willing to vaccinate their children when oriented. AEFI history, household decision-making roles, and education level were associated with reduced willingness, while having received malaria IPTp and trust in vaccine safety were associated with increased willingness to vaccinate. We recommended providing malaria vaccine information through antenatal care, preparing health workers to address the AEFI history and vaccine-safety concerns and prioritizing safety-focused messaging over general awareness messaging.
Annet Mary Namusisi, Richard Migisha, Dominic Kizza et al.
ABSTRACT Protein-Energy Malnutrition among young children under five years old remains a critical public health concern in many developing countries, particularly in Burundi partly due to the overreliance of high energy but deficient in vitamin A, and essential amino acids such as lysine and tryptophan. Food fortification using animal protein is a potentially sustainable approach to increasing protein quality in young children’s diets. This study aimed to develop and evaluate the nutritional, functional, sensory properties, and stability of the ready-to-use porridge flours formulated using maize-orange-fleshed sweet potato (OFSP) blends fortified with silver cyprinid powder. Six formulations were prepared by the extrusion technique by substituting the blends of maize and OFSP with 5, 10, 15, 20 and 25% of silver cyprinid powder. Proximate, mineral, and beta-carotene compositions, invitro protein digestibility, reactive lysine, water absorption capacity, oil absorption capacity, bulk density, swelling index and consumer acceptability were determined. Additionally, storage stability of the flours was assessed over a period of 12 weeks. Substituting maize-OFSP blends with silver cyprinid powder significantly increased the protein, ash, fat, and mineral contents, the protein digestibility and reactive lysine. Water absorption capacity, bulk density and swelling index significantly decreased while oil absorption capacity increased. The formulated ready-to-use porridge was acceptable and the formulated flours were stable throughout the storage period. The formulated ready-to-use porridge flours fortified with silver cyprinid powder have the potential to serve as complementary foods for alleviating Protein-Energy Malnutrition in infants and young children under 5 years old.
Childhood illnesses such as anaemia and malaria continue to pose significant health risks for children under five in sub-Saharan Africa. These conditions often co-occur, reflecting complex interdependencies driven by shared biological and environmental factors. Traditional analytical approaches typically assume independence between health outcomes, potentially overlooking meaningful associations. This study aims to identify the dependence structure among anaemia and malaria in children under five using a joint modeling approach. Data were drawn from the most recent Malaria Indicator Survey (MIS), comprising 5,755 children. A bivariate probit model was estimated using a Gaussian copula framework with probit margins for each outcome. This approach allowed for the simultaneous modeling of the marginal probability of each illness and the latent correlations among them. The model incorporated a range of child-, household-, and maternal-level covariates. Average Marginal Effects (AMEs) were calculated to facilitate interpretation. The copula correlation (ρ) between anaemia and malaria from the copula structure was estimated to quantify the dependence between the two illnesses. Descriptive analyses revealed substantial co-occurrence: 13.8% of children experienced both illnesses simultaneously. The joint copula model detected significant positive copula correlations (ρ ≈ 0.19) between anaemia and malaria. Several covariates displayed differential effects in the joint versus separate models. For instance, the association between maternal anaemia and child malaria risk reversed direction once interdependence was accounted for. Joint modeling yielded more stable and plausible estimates across outcomes. This study highlights the critical importance of accounting for outcome dependence in the analysis of child morbidity. The significant correlations among malaria and anaemia suggest that these illnesses are influenced by common or interacting risk factors. Joint modeling using a Gaussian copula framework enhances both the precision of marginal effect estimates and the understanding of comorbidity patterns. These findings support the design of integrated health interventions that address the interconnected nature of childhood illnesses in high-burden settings.
Grace Kakaire, Robert Too, Gregory Kibet Kerich et al.
Chronic aflatoxins exposure may impair immune function, but evidence in African children is limited. We assessed their association with hepatitis B surface antibody (Anti-HBs) levels in Rwandan children receiving nutritional support for malnutrition recovery or prevention. A total of 216 children aged 7–59 months were enrolled, including 70 malnutrition cases and 146 controls. Anti-HBs concentrations were measured using the ARCHITECT System (Abbott Diagnostics), and aflatoxins (AFB1, AFB2, AFG1, AFG2 and AFB1-lysine) were quantified by liquid chromatography-tandem mass spectrometry (LC–MS/MS). Anti-HBs levels were highly variable (median = 84.8 IU/ml, IQR 14.0–283.4). Serum analysis for AFB1-lysine revealed a mean concentration of 23.43 ± 5.76 pg/mg albumin, while none of the samples showed detectable levels of AFB1, AFB2, AFG1, or AFG2 above the limit of detection. In unadjusted analyses, no significant differences in Anti-HBs or aflatoxin levels were observed between cases and controls (Mann–Whitney U, p = 0.452 and p = 0.119, respectively) or between sexs (t-test, p = 0.642 and p = 0.352). Age was not correlated with aflatoxin levels (r = 0.06, p = 0.556). In multivariable linear regression analyses adjusting for age, place of residence, socioeconomic status, and sex, nutritional status emerged as a significant determinant of Anti-HBs levels. Specifically, the control group had higher Anti-HBs levels than the case group (β = 0.573, 95% CI 0.076–1.070, p = 0.024), while aflatoxin exposure showed no independent association with Anti-HBs levels (β = − 0.003, 95% CI − 0.031–0.025, p = 0.832). These findings suggest that, in this population, nutritional status rather than chronic aflatoxins burden, is the primary determinant of Anti-HBs response, highlighting the importance of targeted nutritional interventions to support immune protection in children.
Somalia records one of the highest global burdens of child wasting and stunting, with approximately 1.7–1.85 million children under five estimated to be affected by acute malnutrition annually during 2022–2025, including approximately 421,000–513,550 children with severe acute malnutrition. For over two decades, the dominant policy response has been community-based management of acute malnutrition (CMAM), a curative intervention that treats clinical endpoints rather than underlying drivers. Despite meeting international cure-rate standards, CMAM alone cannot address the food insecurity, water, sanitation and hygiene (WASH), microbial and parasitic infectious diseases, health-system, and climatic drivers that perpetuate malnutrition. This paper integrates recent Somali survey, programme-evaluation, and administrative data to show that the national burden of acute malnutrition has remained high despite continued treatment scale-up, with stunting falling only 9.7 percentage points over 24 years, relapse after discharge remaining a documented challenge, and nationally representative Somalia-specific estimates of CMAM treatment coverage remaining unavailable. Diagnostic discordance between screening tools leaves an unknown share of wasted children undetected, and persistent sex- and region-based disparities highlight structural gaps. Ending child malnutrition in Somalia requires rebalancing investment from an emergency, treatment-centred paradigm toward integrated, multisectoral strategies combining therapeutic feeding with WASH investment, maternal and infant feeding support, primary health-care strengthening, climate-resilient livelihoods, and shock-responsive social protection. We propose four policy shifts: sustaining CMAM while addressing diagnostic gaps, mandating nutrition-sensitive financing, institutionalizing relapse prevention, and expanding anticipatory financing. These shifts require governance reforms and multi-year donor commitment to address the determinants of child nutrition in Somalia comprehensively.
Background Intimate partner controlling behavior (IPCB) is a key manifestation of coercive control and an important precursor to other forms of intimate partner violence. Despite its adverse consequences for women’s autonomy, mental health, and well-being, evidence on the prevalence and factors associated with IPCB in Somaliland remains limited. This study aimed to estimate the prevalence and identify the individual- and community-level factors associated with IPCB among ever-married women in Somaliland. Methods A secondary analysis of the 2020 Somaliland Demographic and Health Survey (SLDHS) was conducted using a weighted sample of 9,428.14 (unweighted n = 9,593) ever-married women aged 15–49 years. IPCB was defined as experiencing at least one of five partner controlling behaviors reported for the respondent’s current husband/partner. Multilevel logistic regression models, incorporating the DHS sample weight (V005) and clustering by primary sampling unit (135 clusters), were fitted to account for the hierarchical structure of the survey data and to identify factors associated with IPCB. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported, and statistical significance was declared at p < 0.05. Results The prevalence of IPCB was 26.7% (95% CI: 25.8–27.6%; unweighted prevalence 25.1%). Women aged 25–29 years (AOR = 1.60, 95% CI: 1.01–2.53), those with primary education (AOR = 1.70, 95% CI: 1.44–2.00), and women from middle- (AOR = 1.46, 95% CI: 1.20–1.77) and rich-wealth households (AOR = 1.56, 95% CI: 1.30–1.88) had higher odds of experiencing IPCB. Conversely, joint healthcare decision-making (AOR = 0.69, 95% CI: 0.60–0.79), current pregnancy (AOR = 0.73, 95% CI: 0.63–0.85), marriage at ages 19–26 years (AOR = 0.71, 95% CI: 0.63–0.80) or >26 years (AOR = 0.63, 95% CI: 0.49–0.81), household size of 4–7 members (AOR = 0.81, 95% CI: 0.71–0.92), partner employment (AOR = 0.77, 95% CI: 0.68–0.87), and residence in Marodijeh, Togdheer, Sool, and Sanaag regions were associated with lower odds of IPCB. Conclusion Approximately one in four ever-married women in Somaliland experienced intimate partner controlling behavior, underscoring IPCB as an important public health and gender equality concern. Both individual- and community-level factors were significantly associated with women’s odds of experiencing IPCB, highlighting the need for multilevel interventions that strengthen women’s decision-making autonomy, delay early marriage, promote girls’ education, and implement context-specific strategies to prevent coercive control and advance gender equality.
<p>This paper explores how to employ effective, community-engaged strategies to understand and address the underlying power asymmetries that fuel violence against women and children. Utilising Participatory Action Research and underpinned by Integral Activist Epistemology, the action research adopts a novel approach combining Theory U and Powercube frameworks to facilitate a comprehensive understanding and transformation of these power relations in Shinyanga district, Tanzania.</p> <p>The paper describes the journey of engaging the community in identifying and challenging the unwritten rules that perpetuate violence. Key to this process is the recognition of violence as a manifestation of deeply ingrained patriarchal power structures, which are sustained through coercion and social exclusion, yet paradoxically fragile due to the pain these norms inflict on the whole community, including men. This understanding leads to the development of practical, community-led interventions, or 'prototypes', aimed at reshaping these dynamics.</p> <p>Key messages from the action research highlight the critical role of local context in shaping interventions, the importance of reframing existing cultural practices so that they are more inclusive, and the necessity for long-term commitment from development actors for sustainable change. The implications extend beyond Shinyanga, offering insights for practitioners globally. This paper contributes to the academic discourse on violence prevention but also serves as a practical guide, providing tools and strategies for practitioners working towards creating safer, more inclusive communities.</p>
