Background: Effective triage in the emergency department (ED) is crucial for ensuring timely and appropriate care. The Emergency Severity Index (ESI) is a widely used triage system with strong predictive value for clinical outcomes. However, its performance in middle-income countries remains understudied, particularly in settings with variable resource availability, diverse patient populations, and inconsistent triage practices. This study aimed to assess in-hospital mortality across ESI levels and evaluate the ESI's diagnostic performance in predicting mortality among ED patients in Thailand.
Methods: We conducted a retrospective cohort study at a tertiary care hospital in Thailand, including 331,182 ED patients from January 2016 to December 2021. Data on demographics, ESI level, comorbidities, and outcomes (mortality, ICU admission, and length of stay) were analyzed. The primary outcome was in-hospital mortality across ESI levels 1–5, while secondary outcomes included ICU admission, hospital length of stay, and ED resource utilization.
Results: The overall in-hospital mortality rate was 0.6%. However, mortality was significantly higher among patients triaged as ESI level 1 (17%), compared with those at levels 2 (1.7%), 3 (0.3%), 4 (< 0.1%), and 5 (0%). ICU admission rates were highest among ESI level 1 patients (35%), followed by those at level 2 (9.8%), with rates declining as triage acuity decreased. ESI levels 1 and 2 demonstrated strong predictive performance for mortality, with a sensitivity of 82.1% and a negative predictive value of 99.9%. Patients classified as ESI level 1 had the highest utilization of diagnostic and therapeutic interventions, including blood tests (93%), supplemental low-flow oxygen (36%), and mechanical ventilation (30%).
Conclusions: ESI level 1 was associated with significantly higher in-hospital mortality, ICU admissions, and resource utilization compared with other levels. These findings support the continued use of the ESI for ED triage, especially in middle-income setting hospitals.

Background: Community-based health insurance (CBHI) has emerged as a promising option to enhance the attainment of Universal Health Coverage in Low- and middle-income countries and Sub-Saharan Africa. However, CBHI schemes in Africa particularly in the eastern regions, grapple with chronic low enrolment, jeopardizing their sustainability and intended impact. Understanding the determinants of enrolment in these schemes is critical for designing effective strategies to boost participation. In this scoping review, we categorized and discussed these determinants across socio-ecological levels.
Methods: We conducted a scoping review of literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extended for Scoping Review checklist. Literature searches were conducted across academic databases to identify studies on determinants of enrolment to CBHI schemes in East Africa in June 2023 and updated in June 2025. Peer-reviewed, English-language studies using cross-sectional, case-control, qualitative, case studies, or mixed-methods designs were included which were conducted in East Africa and reported primary outcomes on determinants of CBHI enrolment (2000–2025). Excluded studies were reviews, non-peer reviewed articles, willingness to pay/willingness to enrol studies, and those on satisfaction, dropouts, or compulsory schemes (e.g., Rwanda post-2007, Seychelles as a high-income country). Data extraction and thematic analysis guided by a socio-ecological model framework were performed on the data.
Results: A total of thirty articles met the inclusion criteria. The findings unveiled a broad spectrum of determinants influencing CBHI enrolment. At the individual level, key factors included awareness, socio-demographics, and personal predisposition. At the household level, household characteristics, social capital, and cohesion played significant roles. Community-level determinants included cultural beliefs, religion, and geographical location, while system-level factors were stakeholder influence, governance, benefit package design, premium structure, human resource management, supply chain, access to care, and referral systems.
Conclusions: The findings emphasize the need for a holistic and multi-level approach to enhancing enrolment. Policymakers and stakeholders should integrate these determinants into interventions to strengthen CBHI schemes, expand healthcare access, and reinforce financial protection. Further studies are needed to explore the interplay between these factors.

Background: Given the lack of legal status, stateless persons often live in precarious situations that put them at risk of mental health problems, especially in urban settings. Moreover, pathways to citizenship may involve navigating different legal statuses over a lifetime, posing additional challenges. Yet, research on the nexus between legal status and mental health remains scant. This study examines the factors that influence the mental health of persons with different legal statuses in a Thai urban context.
Methods: This study employed a qualitative design. Data were collected through 47 in-depth interviews in Northern Thailand’s largest city in July 2023 using purposive and snowball sampling strategies. The interviews were recorded and transcribed verbatim. Thematic analysis, based on a social determinants of mental health framework, was used to analyse the data.
Results: Legal status was related to multiple and interdependent conditions of precarity in the city. Together they created a compounding effect that threatened mental health. The more restricted the rights attached to a legal status, the greater the effect. Past negative life events, adversed employment conditions, and discrimination were key factors that led to mental health challenges. Obtaining permanent legal status, on the other hand, alleviated legal uncertainty and provided immediate benefits by enhancing access to fundamental rights, with positive effects on mental health. Yet, it cannot reverse pernicious long-term effects of past deprivations, such as foregone opportunities for education and employment, as well as past traumatic events on mental health.
Conclusions: The 2024 landmark move of Thailand’s Cabinet to accelerate progress in resolving citizenship problems for almost 500,000 persons should be accompanied by multi-pronged interventions aimed at improving the social determinants of mental health. In addition, access to mental healthcare should be facilitated.

Background: Road traffic injury is a significant global health challenge, and timely available data are significant to monitor this trend. We aimed to develop a cost-effective approach in resource-limited settings to estimate the number of road traffic crashes at the national level by utilizing media-reported data.
Methods: Media-reported data about road traffic crashes were extracted from the Automated Road Traffic Crash Data Platform (ARTCDP) and augmented based on the available police reports with limited free-access. Besides, crash data were approximated according to the national disease surveillance point (DSP). We then fitted four common machine learning models (linear regression, artificial neural network, support vector machine, classification and regression tree) with six predictors to determine the best predictive model for road traffic crashes in China and correct underestimation of police-reported data.
Results: Of the 50,850 media outlets indexed by the ARTCDP, 379 media outlets reporting road traffic crash news quarterly were determined as the most reliable media-reported data sources. Of the four machine learning methods, artificial neural network performed best, yielding an R ² of 0.93 for training data, 0.92 for validation data, and 0.88 for testing. The number of road traffic crashes estimated by the approach closely matched actual trends in national number of crashes from official statistics.
Conclusions: Our approach based on ARTCDP-collected media outlets demonstrated excellent predictive performance and has potential to be used for estimating national road traffic crash statistics in resource-limited locations where official statistics are absent, not freely accessible, not reliable, or not yet released.

Background: Coronary artery disease (CAD) remains a leading cause of global mortality and disability. CAD patients face tradeoffs between antithrombotic therapy benefits and bleeding risks, underscoring the need to incorporate patient values and preferences into clinical guidelines. Establishing minimal important differences (MIDs) for patient-important outcomes supports clinical guideline development by determining the smallest change in outcomes that patients consider important. However, directly conducting patient surveys to establish MIDs presents several methodological challenges.
Methods: We established a multidisciplinary working group to guide the MID investigation. Using a three-phase process, we identified key outcomes through literature review and discussion. We will develop draft health outcome descriptions by synthesizing evidence from clinical guidelines and qualitative studies, supplemented with patient interviews, and refine the drafts through iterative cognitive interviews. We then designed outcome-specific draft MID questionnaires and will employ cognitive interviews to assess clarity and comprehensibility.
Discussion: This study will develop standard materials for surveying patient values and determining MIDs in Chinese CAD patients. The resulting methodology will support future investigations into patient-important outcomes and provide critical evidence for clinical guideline development.

Background: Respiratory infections pose a major global health burden. While green spaces are generally thought to benefit respiratory health, research often overlooks the roles of private gardens and the interaction between environmental exposures and lifestyle behaviors. This study uses UK Biobank data to examine the integrated associations of environmental exposures, lifestyle habits, and respiratory infections.
Methods: We conducted a large-scale cohort analysis based on UK Biobank data. Environmental exposures were assessed using geospatial data linked to residential addresses, including green space and domestic garden percentage (within 300 m and 1000 m buffers), natural environment accessibility, and coastal proximity. Cox proportional hazards regression models were used to estimate hazard ratios (HRs), adjusting for demographic characteristics (sex, age, BMI), socioeconomic status, and lifestyle behaviors (insomnia, smoking status, alcohol consumption, and physical activity).
Results: A total of 46,288 healthy individuals and 21,602 patients with respiratory infection were included. Results revealed a scale-dependent “dual effect” of green space: higher greenspace percentage within a 300 m buffer was protective (HR=0.93, 95% CI: 0.88–0.99), whereas within a 1000 m buffer, it was associated with an increased risk (HR=1.10, 95% CI: 1.02–1.19). Domestic gardens and natural environments at 1000 m were generally protective. Greater distance to the coast was associated with a lower risk of most respiratory infections but a potentially higher risk of tuberculosis. Male gender, older age, higher BMI, smoking, and insomnia were risk factors, while physical activity and alcohol consumption were associated with lower risks.
Conclusions: This study provides novel insights into the complex interplay between environmental exposures and lifestyle factors. The divergence between the protective effects of immediate greenness (300 m) and the risks associated with broader vegetation coverage (1000 m) suggests a trade-off between accessibility benefits and potential exposure to aeroallergens. Public health strategies should prioritize “low-allergen” urban planning and promote healthy lifestyles-particularly physical activity and smoking cessation-to mitigate respiratory infection risks.

Background: Global mpox outbreaks have exposed healthcare inequities in testing accessibility. Socioeconomic disparities and medical discrimination and distrust influence testing service utilization among vulnerable populations. We examined how medical discrimination and distrust affect testing intention across socioeconomic strata among men who have sex with men (MSM) in China.
Methods: We conducted a nationwide cross-sectional study across six regions of China (November 2023 to March 2024). MSM aged ≥ 18 years who reported male sexual partners within previous six months were recruited through local Centers for Disease Control and Prevention and community-based organizations. Participants completed anonymous questionnaires measuring medical discrimination and distrust (DS), structural determinants, behavioral factors, psychosocial factors, and mpox testing intention. Path analysis was used to examine the effects of medical discrimination and distrust on testing intention, stratified by socioeconomic status (SES).
Results: 50.7% of 2403 participants reported high testing intention. Path analysis revealed that medical discrimination and distrust were associated with testing intention through distinct mechanisms across SES groups. For high-SES participants, positive indirect associations were found between medical discrimination and distrust and testing intention ( β = 0.061, P < 0.001) mediated by voluntary HIV counseling and testing services, social support and depression. For low-SES participants, medical discrimination and distrust demonstrated a negative direct effect ( β = −0.218, P < 0.001) and indirect effects through social support, depression, and mpox prevention-related self-efficacy ( β = −0.028, P < 0.001). Social support emerged as a crucial mediator among low-SES groups, while depression served as the crucial mediator among high-SES groups.
Conclusions: Healthcare inequities manifest through socioeconomically patterned pathways affecting mpox testing intention. Our findings suggest differentiated intervention strategies: integrating services with existing healthcare infrastructure for high-SES populations while strengthening community-based support for low-SES groups. These insights inform efforts to address healthcare disparities in infectious disease responses, particularly in resource-limited settings.

Background: As global health challenges become increasingly complex, understanding the dynamic evolution of teaching models in higher education is critical. This study aims to employ bibliometric methods to map the status, identify hotpots, and capture key trends in global health curriculum design over the past decade.
Methods: Utilizing CiteSpace 6.4.R1, a comprehensive bibliometric analysis was conducted on 209 studies focusing on global health curriculum teaching models, indexed in the Web of Science Core Collection between 2014 and 2024. Articles and reviews published in English were retrieved using a structured search strategy combining four keyword domains: “Global Health”, “Curriculum”, “Teaching Model”, and “Higher Education”. The analysis comprised performance analysis and science mapping techniques, including co-authorship analysis, Global North-South collaboration assessment, co-citation analysis, keyword co-occurrence and clustering, and burst detection to identify emerging research fronts.
Results: Global health education has experienced rapid development over the past decade, with the number of publications increasing from 9 in 2014 to 38 in 2020, and maintaining a relatively high level since then. Developed countries, particularly the United States, are leading the field in terms of publication volume (n = 121, 57.9%), while Global South institution’s participation remained limited (28.9%). North-South collaborations were uneven, with 77.6% of curricula incorporating collaborative development elements but only 57.9% reflecting co-authorship partnerships in transnational studies. According to the co-occurrence analyses of keywords, the most frequently occurring teaching models are “Interprofessional learning” (n = 9), “Competency-based education” (n = 8), “Online learning” (n = 7), “Experiential learning” (n = 4) and “Community-engaged learning” (n = 4).
Conclusion: This study provides a comprehensive evaluation of global health curriculum teaching models, highlighting key developments and trends. The field has advanced markedly but reflects persistent inequities in knowledge production and resource allocation. Future efforts must prioritize equitable North-South collaboration, culturally adapted competency frameworks, and inclusive technological integration to foster a globally representative workforce capable of addressing interconnected health challenges. Moving forward, global health education should embrace dynamic, forward-thinking approaches to prepare a versatile workforce capable of tackling both current and future global health challenges.

Global displacement has increased reliance on private and homestay hosting as community-based responses to humanitarian crises. While these arrangements provide immediate shelter and opportunities for social integration, they also create complex and often unequal dynamics, particularly for displaced women. This policy brief draws on emerging evidence and lived experiences from displaced Ukrainian women in Canada to highlight how homestay hosting operates at the intersection of housing, health, and social care systems. Hosting functions as both refuge and risk: it can foster safety, connection, and temporary stability, while also creating challenges related to limited privacy, unclear expectations, dependency, and unequal power relations. Gendered caregiving roles and emotional labor further shape women’s well-being, access to healthcare, and integration trajectories. Structural gaps, including fragmented policy frameworks and limited coordination with health and social services, contribute to ongoing vulnerabilities. Homestay hosting is therefore positioned as a critical yet under-recognized social determinant of health. To address these challenges, this policy brief calls for the development of a coordinated national framework that integrates hosting within health and social care systems, ensures access to trauma-informed and culturally responsive supports, and strengthens guidance for both hosts and guests. Establishing monitoring mechanisms and linking hosting to long-term housing and integration pathways are essential to promote equity, safety, and sustainable outcomes for displaced women.

Background: Previous studies have extensively investigated the association between leisure-time physical activity (LTPA) and chronic musculoskeletal pain (CMSP). However, the results have been inconsistent. It is not known whether the differences in the association between LTPA and CMSP are due to underlying factors such as demographic patterns, geographical characteristics, and location(s) of pain.
Methods: The systematic review and meta-analysis was conducted to assess global disparities in association between LTPA and CMSP .PubMed, EMBASE, MEDLINE, and Web of Science were searched for observational studies examining LTPA and the prevalence or incidence of CMSP in the general population. The systematic review with quality assessment using the JBI checklist and the Newcastle-Ottawa Scale was followed by a random-effects meta-analysis, including subgroup analysis using the following variables: sex, age group, geographical regions and location(s) of pain. Clinical significance of the pooled odds ratio (OR) was assessed using Cohen’s d and risk of publication bias was assessed using Egger’s test, funnel plot and trim-and-fill analysis.
Results: Across 119 studies, the overall OR for the association between LTPA and CMSP averaged 0.78 (95% CI: 0.70–0.87, I² = 99.5%) with no clinical significance (d = −0.137). Differences between genders were insignificant. Among age subgroups, adults and middle-aged/older adults showed a negative association between LTPA and CMSP (OR = 0.62, 95% CI: 0.47–0.82). Pain locations with reduced odds included unspecified pain locations (OR = 0.73, 95% CI: 0.62–0.86) and lower back (OR = 0.82, 95% CI: 0.69–0.98). Geographic subgroups with negative LTPA-CMSP associations included high-income countries (OR = 0.78, 95% CI: 0.70–0.88), the continents of North and South America and Europe, and the regions of Northern and Western Europe. The differences between continents and between subcontinental regions were both significant ( p = 0.0211 and p = 0.0260, respectively), suggesting an influence of sociocultural factors in addition to income level.
Conclusions: LTPA was inversely associated with CMSP, especially in selected populations and pain locations. This association could be due to underlying factors, such as local factors that characterize LTPA in different countries. These findings suggest that the benefits of LTPA cannot be considered universally applicable. Locally and regionally tailored interventions should be developed, taking into account place-specific structural, economic and social characteristics.

This commentary examines the ongoing shift from multilateral to bilateral health development aid in Africa and its implications for regional public health governance. Multilateral institutions, such as the World Health Organization (WHO) and the Africa Centre for Disease Control and Prevention (AfCDC), have fostered coordination and regional integration in Africa. However, recent geopolitical fragmentation, donor realignment, and pandemic-era disruptions, including vaccine nationalism and bilateral vaccine diplomacy, have shifted coordination structures, weakened harmonization, and increased political conditionalities, thereby challenging Africa's public health resilience. We explore the key drivers and consequences of this transition and propose seven policy recommendations, including revisiting regional coordination models, strengthening global health diplomacy, enhancing sustainable domestic financing, investing in local production, and fostering an enabling environment for regional knowledge generation. The implementation of these measures has grown particularly urgent, considering the recent shifts in development assistance priorities and the restructuring of major donor agencies and other multilateral and international non-governmental organizations that previously supported African governments with technical assistance, thereby increasing vulnerabilities. These findings suggest the importance of facilitating the adoption of a recalibrated, context-specific governance model to build resilient national health systems and safeguard continental health security amid current changes in development aid.

Background: Undernutrition is a major driver of common infectious morbidity among children under five; however, the relationship between different forms of undernutrition and childhood infectious morbidity remains poorly understood. This study examined variations in the association between different forms of undernutrition measured according to the Composite Index of Anthropometric Failure (CIAF) and common infectious morbidity among children under the age of five in sub-Saharan Africa (SSA).
Methods: We performed a multilevel binary logistic regression analysis using country and community clusters as random effects. Our study utilised demographic and health survey (DHS) data collected between 2016 and 2024 in 27 SSA countries. A total weighted sample of 157,800 under-five children whose nutritional status was assessed based on the World Health Organization (WHO) anthropometric techniques and data on Acute Respiratory tract Infection (ARI) and diarrhea recorded were included. An adjusted odds ratio (AOR) with a 95% Confidence Interval (CI) was reported, and variables’ effects with a p -value less than 0.05 were declared significant determinants of common infectious morbidity.
Results: The prevalence of common infectious morbidity among children under five in SSA was 30.20% (95% CI: 27.34, 33.06). The lowest and highest prevalences were reported in Mozambique (16.96%; 95% CI: 16.94, 16.98) and Uganda (53.26%; 95% CI: 53.24, 53.28), respectively. The odds of infectious morbidity significantly differs between children with standalone, double and triple forms of undernutrition. Children with double (AOR: 1.25; 95% CI: 1.16, 1.34 for stunting-underweight; AOR: 1.36; 95% CI: 1.22, 1.51 for wasting-underweight) and triple undernutrition (AOR: 1.51; 95% CI: 1.36, 1.68) were more susceptible to common infectious morbidity.
Conclusions: Children with coexisting undernutrition were more likely to experience common infectious morbidity, and those affected by the coexistence of stunting-wasting-underweight experienced the highest odds of infectious morbidity. Among the standalone forms, only underweight children were more likely to experience common infectious morbidity. Therefore, to mitigate the burden of childhood infectious morbidity, it is crucial for policymakers to implement targeted nutritional interventions for children experiencing coexisting undernutrition.

Background: Surgical site infections (SSIs) are significant complications following cesarean delivery, and preoperative antibiotic prophylaxis (PAP) is crucial for prevention. Limited data exist on PAP compliance in low- to middle-income countries such as Jordan. This study aimed to assess the compliance with PAP guidelines in women undergoing cesarean delivery in Jordan and evaluate its impact on the incidence of SSIs.
Methods: A retrospective cross-sectional study was conducted using electronic health records from 60,212 women who underwent cesarean delivery between 2015 and 2022 in 20 Ministry of Health hospitals in Jordan. PAP compliance was defined as the administration of cefazolin (1–2 g) within one hour before surgery for patients without penicillin allergy, or appropriate alternatives for those with an allergy, following USAID and MOH protocols. Multilevel logistic regression models with hospital code as a random effect were used to identify factors associated with PAP compliance and SSIs.
Results: Only 19.4% of patients received PAP as recommended. The monthly rate of women who received antibiotics increased slightly over time by an average of almost 1.0% per month (95% CI: 0.07–0.09; p < 0.001). Factors positively associated with receiving PAP included age, undergoing elective cesarean delivery (adjusted odds ratio [aOR]: 2.60; 95% CI: 2.43–2.79; p < 0.001), and longer time between admission and surgery (aOR per hour: 1.02; 95% CI: 1.02–1.02; p < 0.001). Patients who received PAP had 41% lower odds of readmission due to SSIs (aOR: 0.59; 95% CI: 0.39–0.89; p = 0.012). The monthly rate of SSIs decreased by approximately 1.6% over the study period (incidence rate ratio: 0.984; 95% CI: 0.979–0.989; p < 0.001).
Conclusion: PAP compliance in women undergoing cesarean delivery in Jordan is suboptimal, with less than one-fifth receiving prophylaxis per guidelines. Compliance with PAP is significantly associated with reduced SSIs. Interventions to improve PAP compliance, such as enhancing guideline awareness, implementing antibiotic stewardship programs, and improving preoperative planning, are urgently needed to enhance patient outcomes and reduce postoperative complications.

Introduction: Thyroid cancer is the most common and rapidly increasing malignancy among adolescents and young adults (AYAs, aged 15–39 years). While this trend is well-documented, a critical gap exists in understanding how the disease burden varies with socioeconomic development. This study analyzes global disparities in the AYAs thyroid cancer burden across Socio-demographic Index (SDI) levels, identifying ecological patterns that suggest the dual challenges of overdiagnosis and inadequate care.
Methods: We explored the global disparity in disease burden of thyroid cancer among AYAs utilizing the Global Burden of Disease Study 2021. Age standardized incidence rate (ASIR), age standardized prevalence rate (ASPR), age standardized mortality rate (ASMR), and age standardized disability-adjusted life years (DALYs) rate (ASDR) were extracted for analysis. Temporal trends were assessed using Average Annual Percentage Change (AAPC), estimated through joinpoint regression analysis. To further explore the relationship between development level and disease burden, restricted cubic splines were employed to model the non-linear relationship between SDI and AAPC.
Results: From 1990–2021, the global ASIR and ASPR for thyroid cancer in AYAs increased significantly ( P < 0.001), with ASIR rising from 0.93 (95% UI: 0.83–1.06) to 1.59 (95% UI: 1.34–1.92) per 100,000 population. In contrast, the ASMR and ASDR remained consistently low and stable. In 2021, high SDI regions recorded the highest ASIR and ASPR, whereas low SDI regions showed the highest ASMR and ASDR. Notably, an inverse U-shaped curve was observed when exploring the correlation between SDI and the AAPC, with AAPC peaking at an SDI of approximately 0.55.
Conclusions: Socioeconomic development acts as a double-edged sword in the AYA thyroid cancer epidemic. High-SDI regions exhibit a burden pattern indicative of potential overdiagnosis, while low-SDI regions experiencing higher mortality likely reflect gaps in timely diagnosis and care capacity. The peak burden increase at a low-middle SDI of 0.55 signals a critical transition point. These findings support differentiated strategies that emphasize diagnostic appropriateness, risk stratification, and avoidance of unnecessary detection in high-SDI regions while strengthening essential treatment capacities in resource-limited settings.

Primary health care (PHC) is fundamental to achieving universal health coverage and health equity, yet building sustainable PHC systems remains a global challenge. This commentary compares the contrasting yet complementary experiences of Brazil and China along four analytical dimensions: community embeddedness, financial protection and sustainability, continuity of care and coordination across levels, digital support and its dual equity effect. Brazil’s Family Health Strategy (FHS), rooted in community-based multidisciplinary teams and a rights-based framework, has significantly reduced mortality from preventable conditions and expanded access for marginalized populations, but faces sustainability threats from underfunding and political instability. China, by contrast, has adopted a state-driven, technologically enabled approach, leveraging telemedicine, electronic records, and AI-enabled tools to scale up PHC. Despite impressive coverage and financial protection, China struggles with limited public trust in frontline providers, fragmented care continuity, and a notable dual pattern in digital health: telemedicine has helped narrow the rural-urban gap, while the gap between younger and older users has widened. Drawing on recent policy documents and empirical studies, we distinguish broadly transferable principles from resource-intensive pathways, offering low- and middle-income country (LMIC) policymakers an integrative framework that prioritizes human-centered relational care reinforced by context-appropriate digital tools, predictable financing, and strong referral linkages within an equity-focused PHC foundation.

Vaccination is a cornerstone of public health and a critical enabler of universal health coverage, yet Ethiopia’s immunization system remains largely oriented toward early childhood. Although childhood coverage for key antigens has improved substantially, recent evidence shows persistent zero-dose and under-immunization among children, uneven uptake of vaccines for adolescents, pregnant women, adults, and older adults, and missed opportunities even among populations living near health facilities. Life course immunization (LCI), defined by Immunization Agenda 2030 as vaccination across all ages and life stages through integrated health systems, offers a policy pathway to close these gaps. This policy brief argues that Ethiopia should institutionalize LCI as a routine primary health care function rather than relying on fragmented campaigns or childhood-focused platforms alone. The evidence points to interacting demand-side, supply-side, and health-system barriers, including limited awareness of vaccines beyond childhood, low perceived risk, concerns about side effects, gender-related decision-making constraints, weak adolescent and adult service platforms, and insufficient age-disaggregated monitoring. By embedding LCI into national immunization policy, Ethiopia can create repeated vaccination contact points, strengthen risk communication, improve accountability across age and risk groups, and reposition vaccination as a lifelong public good for equity and universal health coverage.

Background: As population aging accelerates, the escalating prevalence of comorbidity of chronic diseases (CCD) necessitates evidence-based preventive strategies. This study aims to examine associations between continuous participation in health examinations and the long-term CCD trajectories among Chinese adults aged 45 and older, providing evidence to optimize targeted prevention.
Methods: This study used data from four waves of China Health and Retirement Longitudinal Study (CHARLS), specifically 2013, 2015, 2018, and 2020. Latent class growth analysis was used to classify trajectories of CCD. Chi-square tests and multivariate logistic regression were conducted to examine the relationship between CCD and health examination behaviors. A regression discontinuity design was also implemented to assess the impact of China’s free health examination policy.
Results: A total of 12,510 participants data were categorized into six latent classes. In the unadjusted model, continuous health examination participants were significantly more likely to be classified into the Health Risk (Relative risk ratio (RRR) = 2.249; 95% CI: 1.780–2.842) and Multiple Chronic Diseases Worsening groups (RRR = 7.124; 95% CI: 5.454–9.305) compared to non-participants. After adjusting for baseline burden, individuals with a low baseline burden who participated in health examination had a lower likelihood of unfavorable CCD trajectories (RRR = 0.456; 95% CI: 0.278–0.748; P < 0.01) than non-participants. Older adults were more likely to participate in continuous examinations (OR = 21.571; 95% CI: 11.732–39.662). After controlling for sociodemographic factors, the association between continuous health examinations and CCD trajectories varied by baseline burden, showing stronger effects in individuals with lower baseline burden and weaker effects in those with higher burden ( P < 0.01).
Conclusions: Continuous health examinations are significantly associated with CCD trajectories. However, their effectiveness remains moderated by baseline disease burden. The current free health examination policy effectively fosters CCD management, yet this association is contingent upon age and socioeconomic determinants. The extension of eligibility to individuals below 65 could maximize the potential for early chronic disease control. This may also serve as a valuable blueprint for other low- and middle-income countries for optimizing cost-effectiveness of their preventive healthcare systems before populations age into high-burden morbidity.

The persistent "know-do gap"-the lag between the development of evidence-based practices (EBPs) and their routine use in health systems-remains a barrier to achieving global health equity. Implementation science offers a pathway to bridge this gap, but without an explicit equity focus, it risks reinforcing existing disparities. In this perspective, we propose an equity-centered adaptation of the PEDALs model (Problem, Evidence-based practice, Determinants, Action, Long-term use, and scale) to guide more just and context-sensitive implementation efforts in global health. We describe how each stage of PEDALs can be used to embed equity considerations in implementation research and practice. These include identifying root causes of inequity-linked health problems (P), using both scientific and practice-based evidence while adapting or de-implementing interventions (E), engaging marginalized voices when analyzing barriers and facilitators (D), co-designing contextually grounded implementation strategies (A), and measuring long-term implementation outcomes through an equity lens (L), including attention to scalability, iterative learning, and proper design and methods (s). We highlight methodological considerations-such as hybrid designs, embedded and workflow-based research, and rapid and participatory methods-that support timely, relevant, and equitable implementation. Our model builds on the concept of “radical incrementalism” to emphasize steady, equity-driven change that is responsive to diverse settings, especially in low- and middle-income countries. This modified PEDALs-based approach offers a practical structure for design and methodological considerations in advancing equity-centered implementation science.