BackgroundPromoting handwashing with soap reduces risk of diarrhoea by 30% and respiratory infections by 17%. Handwashing promotion in nonhealthcare settings is widely considered cost-effective, but there is no systematic review on this topic. To inform resource allocation decisions, we reviewed the state and quality of evidence regarding cost-effectiveness and benefit-cost of interventions promoting handwashing with soap in domestic, educational, and childcare settings globally.Methods and findingsWe searched Medline, Embase, Global Health, EconLit, and Web of Science for studies published from January 1, 1980 to September 3, 2025, as well as grey literature (PROSPERO CRD42021288727). We included full economic evaluations comparing the cost of two or more interventions with their outcomes. We included interventions promoting the practice of handwashing with soap, including those providing information, motivational campaigns, and/or handwashing facilities. We scored quality of reporting using the Consolidated Health Economic Evaluation Reporting Standards. We identified 15 studies of which 3 were in high-income countries. Five used empirical data collection to evaluate interventions actually implemented and 10 modelled from secondary data only. Amongst the 3 medium- or high-quality studies reporting cost per disability-adjusted life-year averted, estimates ranged from US$ 37 to 937 (2024 prices). Of these 3 estimates, 2 were cost-effective compared to plausible thresholds for the respective country. In the only medium- or high-quality benefit-cost study, the mean benefit-cost ratio was 2.1 with "medium" levels of handwashing adoption (40% of population) and adherence (50% of those adopting). Few studies measured or modelled adoption of handwashing over time, and none which focussed on diarrhoea also valued respiratory infections. Limitations of our review include that we excluded alcohol-based handrub interventions, and that there is high uncertainty about cost-effectiveness thresholds.ConclusionsPromoting handwashing with soap is very likely to be cost-effective for interventions that successfully increase and sustain adoption of handwashing behaviours. More empirical studies are needed, especially those comparing multiple promotion options and valuing reductions in respiratory infections as well as diarrhoea.

IntroductionBetween 8–39 % of people living with HIV (PLWH) in sub-Saharan Africa have depressive disorders (DD). Despite considerable gains in the treatment of PLWH, DD is increasingly recognised as a threat to successful treatment and prevention. PLWH are generally known to suffer from stress and incur higher health-related costs compared to the general population due to care management demand throughout their lifespan. There have been limited studies examining healthcare costs borne by PLWH with DD specifically.ObjectiveWe aimed to estimate the economic burden of DD and HIV amongst PLWH and explore their mechanisms of coping with high out of pocket (OOP) health expenditure.MethodologyThis is a cost of illness study nested in an ongoing cluster-randomised trial assessing the effectiveness of integrating treatment of DD into routine HIV care in Uganda (HIV+D trial). The study is using cross-sectional data collected from 1,115 PLWH at trial baseline, using the Patient Health Questionnaire (PHQ-9) to measure DD and a structured cost questionnaire was administered. Forty public health care facilities that provide HIV care in Kalungu, Masaka and Wakiso Districts were randomly selected, and study participants were recruited amongst their patients. Eligibility criteria were patients attending the HIV clinic, aged ≥ 18 years who screen positive for DD (PHQ-9 ≥ 10). Economic costs (OOP expenditure and opportunity costs) were estimated from the household perspective.ResultsMean monthly economic costs amongst those incurring any costs (n=1,115) were UGX 255,910 (US$ 68.64). Mean monthly OOP expenditures were UGX 94,500 (US$ 25.60). On average, respondents missed 6 days of work per month due to healthcare seeking or ill-health for any condition. Key cost drivers were facility bed charges and medication. The majority of respondents (73%) borrowed money from families and friends to cope with the economic burden. About 29.7% reported moderate (PHQ-9 15-19) and 5.12% severe (PHQ-9 ≥ 20) DD symptoms. Respondents with moderate or severe DD had slightly higher average monthly costs than those with mild DD (PHQ-10-14), but the difference was not statistically significant.ConclusionPeople living with HIV who experience DD incur in high OOP expenditure and productivity losses. The monthly OOP health expenditure is in the range of 23% of their monthly household income. Social protection mechanisms combined with the integration of the management of DD into routine HIV care could alleviate this burden.

BACKGROUND:In sub-Saharan Africa, young women face disproportionate challenges transitioning from school to employment, with high rates of those not in education, employment or training (NEET). Structural barriers-including unequal gender norms, early marriage and unpaid labour-limit their economic participation. The Campaign for Female Education (CAMFED) Livelihoods programme supports young women's transition from school to independent adulthood through mentoring, life skills, business and agricultural training and access to financial resources. AIM:This study will evaluate the impact, process and mechanisms of change, and cost-benefit of CAMFED Livelihoods programme in Tanzania and Zimbabwe (2024-2027), focusing on outcomes related to economic activity, empowerment, leadership, mental health, subjective well-being and sexual and reproductive health among adolescent and young women (aged 15-24 years). METHODS AND ANALYSIS:We will conduct a mixed-method, longitudinal evaluation across five districts in Tanzania and three districts in Zimbabwe. The quantitative component includes a pre-post cohort with a comparison group in Tanzania (n=1520) and a single-cohort design in Zimbabwe (n=500), with data collected at baseline, midline and endline. Primary outcomes are NEET status and leadership, complemented by measures of well-being, empowerment and health. The qualitative component will explore mechanisms of change and programme delivery. A cost-benefit analysis will estimate social and economic returns using a provider perspective. Youth researchers will be engaged to enhance participatory learning. ETHICS AND DISSEMINATION:We have received ethics approvals from the London School of Hygiene and Tropical Medicine (31266), the National Health Research Ethics Committee (6732) in Tanzania and the Medical Research Council of Zimbabwe (MRCZ/A/3239) in Zimbabwe. Results of this study will be published in peer-reviewed academic journals and shared with policymakers, study participants and the other stakeholders in Tanzania and Zimbabwe.

Negative menstruation experiences adversely affect schoolgirls' social participation, education, and overall health, yet comprehensive menstrual health interventions are limited in Tanzanian schools. This study evaluated the feasibility, acceptability, cost, and potential impact mechanisms of a comprehensive school-based menstrual, sexual, and reproductive health (MSRH) intervention. The intervention, piloted in four secondary schools, included education sessions for girls and boys, pain management, distribution of menstrual kits (reusable pads and menstrual cups), WASH improvements, and stakeholder engagement. A mixed-methods process evaluation assessed acceptability, fidelity, cost, context, and potential impact mechanisms using qualitative methods (in-depth interviews, focus group discussions, and WASH observations) and quantitative methods (survey questionnaires, structured observation of education sessions, costing, and monitoring data). The intervention was well received by students, teachers, and local government authorities; MSRH education reached 86% of schoolgirls and 72% of schoolboys, while over 93% of girls received menstrual kits. Total implementation cost across the four schools was 111,347,467 TZS (38,003 GBP), approximately 39.05 GBP per student, lower than comparable initiatives in East Africa. Findings indicate the intervention is feasible and acceptable in school settings and can inform future menstrual health and hygiene programs, though further research is needed to assess broader effectiveness and sustainability.

Poor menstrual health (MH) has been associated with reduced participation in school activities and diminished psychosocial wellbeing among adolescent girls. Despite increasing recognition of the importance of MH interventions, there is limited economic evidence to inform large-scale adoption and financial planning. We conducted an incremental costing analysis of an MH intervention (MENISCUS) alongside a cluster-randomized trial in 60 secondary schools in Uganda. MENISCUS delivered puberty education, a drama skit, an MH kit, pain management strategies and improvements to water, sanitation and hygiene (WASH) facilities. We categorized the provider costs into start-up and implementation, and calculated unit costs per school, per student (male and female) and per female student respectively. We modelled two potential national scale-up scenarios (basic and enhanced) to 2,995 secondary schools using government delivery structures. The total cost of the basic scenario is US$10,224,685 and the enhanced scenario is US$16,549,123. The unit cost of scaling the intervention nationwide was estimated at US$28 per student and US$58 per female student (basic scenario) and US$46 per student and US$95 per female student (enhanced scenario). The primary cost drivers were the MH kit and associated training, followed by pain management activities and improvements to WASH facilities. The enhanced scenario generated a higher unit cost per student and unit cost per female student due to additional components. Compared with trial costs, unit costs were lower in national scale-up, demonstrating economies of scale. This study provides the first economic analysis of a potential national implementation of a school-based MH intervention in a low-resource setting. The findings provide critical benchmarks for governments seeking to integrate MH into national education curriculum and inform future investment decisions in adolescent health. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial ISRCTN45461276 ### Clinical Protocols ### Funding Statement This study was supported by the Joint Global Health Scheme with funding from the UK Foreign, Commonwealth and Development Office (FCDO), the UK Medical Research Council (MRC), the UK Department of Health and Social Care (DHSC) through the National Institute for Health Research (NIHR) and Wellcome (grant ref MR/V005634/1). The funders had no role in the identification, design, conduct, reporting of the analysis and in the writing of the article. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: We obtained ethics approval from the Uganda Virus Research Institute (UVRI) & Ethics Committee (reference GC/127/819), the Uganda National Council of Science and Technology (reference HS1525ES), and the London School of Hygiene & Tropical Medicine (reference 22952). An independent Trial Steering Committee provided scientific guidance and monitored the progress of the trial. The Independent Data Monitoring and Ethics Committee (IDMEC) reviewed the trial recruitment and safety data and provided scientific guidance. The trial was prospectively registered ([ISRCTN45461276][1]). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes the data will be available on the LSHTM repositary [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN45461276

Routine adolescent health check-ups can support healthy development and well-being, but evidence on the feasibility, acceptability and effectiveness of contextually relevant comprehensive check-ups in low- and middle-income settings is limited. We conducted a hybrid implementation-effectiveness study incorporating a mixed-methods pre-post design of Y-Check, a comprehensive health check-up intervention in Zimbabwe, as part of a multicountry study developed and coordinated by the World Health Organization. Eligible participants were 10-19-year-old adolescents attending school or community venues. We used self-administered digital questionnaires, provider-led clinical tests and nurse reviews to screen for 25 conditions/behaviors. We provided health promotion, on-site care and referral to relevant providers. From October 2022 to September 2023, 2,097 adolescents were enrolled, of whom 1,843 (87.9%) were seen at 6 months. The primary outcome of appropriate care and/or referral(s) for all identified issues was achieved for 70.8% (95% confidence interval: 68.7-72.9%) of 1,865 participants with at least one issue. At follow-up, there were improvements in nutrition, health-related quality of life, self-esteem, behaviors and educational outcomes. The intervention was feasible and largely acceptable. Uptake of referral services varied by issue. Y-Check cost US$47 per participant. Through Y-Check, we identified untreated conditions and risk behaviors and successfully treated and linked adolescents to services. Here we provide evidence on the potential of the intervention to positively impact health and well-being.

Abstract Background Early childhood intervention strategies have the potential to promote health, participation and quality of life for young children at risk of developmental disabilities and their caregivers, however evidence on the impact of integrated care strategies in sub-Saharan Africa is lacking. Access to early intervention is crucial for affected children and families, particularly in resource-constrained settings with limited access to specialised services. This trial aims to evaluate the effectiveness and implementation of a bundle of early identification, care and support, integrated into government health systems in Rwanda: the Pediatric Development Clinic (PDC)/Baby Ubuntu programme. Methods The study is a single-blind, effectiveness implementation-hybrid (type II) cluster randomised controlled trial with two arms (1:1 ratio). At cluster level, all community health centres in the three trial districts will be eligible for inclusion. At the participant level, at risk children aged ≤ 59 months will be eligible where ‘at risk’ is defined as being a survivor of a newborn condition that is a recognised risk factor for developmental disability (neonatal encephalopathy, prematurity, meningitis, severe jaundice, cerebral malaria, suspected genetic and chromosomal conditions and seizures), and/or not meeting age-specific developmental milestones. Those receiving inpatient hospital treatment or in institutional care will not be eligible. Primary outcomes will be family health-related quality of life (PedsQL) and child participation (Young Child Participation & Environment Measure) assessed 12 months after enrolment and randomisation. Secondary outcomes include caregiver knowledge and confidence (scored structured assessments), psychological distress (Self-Report Questionnaire), experience of disability-affiliated stigma (Affiliate Stigma Scale), and economic activity (time-use survey), in addition to child mortality, illness and hospitalisation, child development/function (Global Scales of Early Development, Malawi Developmental Assessment Tool, PEDI-CAT), and nutritional status (weight-for-age, height-for-age). Analysis will be by intention-to-treat, consisting of all randomised subjects analysed according to assigned study arm. Cluster-level analyses will assess intervention effect. Discussion The trial utilises best practice methodology and frameworks to conduct rigorous and comprehensive impact, process and economic evaluation of the intervention implemented and is guided by a multi-disciplinary team and steering committee. Trial registration ISRCTN, ISRCTN17523514. Retrospectively registered 24 July 2024, https://doi.org/10.1186/ISRCTN17523514

BACKGROUND:Although depression is common in people with HIV, mental health interventions are not available to the vast majority of people with HIV in Africa. We aimed to test the effectiveness of the HIV+D collaborative stepped care depression intervention in adult HIV care in Uganda. METHODS:A cluster-randomised controlled trial was done at 40 randomly selected primary HIV care centres (clusters) at public health-care facilities in three districts in Uganda. The 40 clusters were randomly allocated (1:1) to enhanced usual care only (EUC arm) or to HIV+D intervention plus EUC, with the randomisation stratified by level of health facility. We recruited adults (aged 18 years or older) with HIV with depression, defined by the locally validated version of the Patient Health Questionnaire 9 (PHQ-9). Participants were consecutively recruited into the study clinics until there was a maximum of 30 participants per cluster. HIV+D was coordinated by a lay counsellor and involved four sequential steps of psychoeducation, behavioural activation, antidepressant medication, and referral. EUC comprised sharing screening results with the HIV clinic physician and training on the WHO guidelines for depression management in routine care. The primary outcome was PHQ-9 scores at 3 months. The trial is registered with the ISRCTN registry (ISRCTN86760765) and is completed. FINDINGS:8441 people with HIV were referred to the trial, and 1115 (13%) were enrolled between May 3 and Dec 31, 2021. The mean age was 38 years, 859 (77%) were female, 535 were enrolled in the EUC group, and 580 were enrolled in the HIV+D plus EUC group. Primary outcome data were available for 1097 (98%) participants. We observed high levels of fidelity, with 290 (92%) of 316 participants in the HIV+D plus EUC intervention group receiving the recommended 4-10 sessions of behavioural activation. At 3 months, the mean PHQ-9 scores were lower in the HIV+D plus EUC group, at 3·0 (SD 3·2) compared with the EUC group, at 7·6 (SD 4·2; adjusted mean difference 4·4; 95% CI 3·4-5·5; p<0·0001; effect size [d]=1·34). This effect was sustained, although attenuated, at 12 months (adjusted mean difference 1·9; 95% CI 1·0-2·8; p<0·0001; d=0·81). Baseline depression severity scores moderated the HIV+D plus EUC intervention effect, with the intervention having stronger effects for those with baseline scores in the severe range (≥20) than for those whose scores were in the moderate range (10-19) both at 3 and 12 months (p values for effect modification were <0·001 and 0·005, respectively). There was no evidence of effect modification by sex nor baseline HIV viral load. One participant in the HIV+D plus EUC group was hospitalised because of severe depression. INTERPRETATION:The HIV+D plus EUC intervention had a significant and sustained effect on depression compared with EUC. This intervention offers a scalable approach to integrate mental health care for adult HIV care settings. FUNDING:Wellcome Trust Senior Research Fellowship in Public Health and Tropical Medicine.

BACKGROUND:School attendance and completion among girls protect them from multiple sexual and reproductive health problems. However, inadequate resources for managing menstruation remains a barrier to school participation and learning in low- and middle-income countries. With the increased global focus on closing the gender gap in education, schoolgirls' voices are important in understanding drivers of suboptimal social and school participation during menstruation. This paper explores how menstruation influences social and school participation from the perspectives of schoolgirls. METHODS:We conducted 40 in-depth interviews with purposively-selected secondary schoolgirls aged 13-20 years in two rural and two urban schools in Northern Tanzania from 2021 to 2022. To be eligible for participation, the schoolgirls must have reported missing school during their last menstruation. We used an in-depth interview guide to elicit girls' menstrual experiences and how such experience influenced their school and social participation. We used NVivo 12 software to code data and employed thematic analysis using the social-ecological model. RESULTS:The respondents described the drivers of suboptimal social and school participation at the individual level (negative menstrual experience, i.e. menstrual pain and constant worries of menstrual blood leaking, and individual economic constraints); interpersonal level (the fear of menstrual status disclosure, and peer's attitude); school level (inadequate emergency pad at school, lack of private place to change, and unhygienic school WASH); and societal level socio-cultural restrictions (girls are prohibited from touching plants/vegetables, engaging in household chores/religious worship, or physical contact with men during menstruation, and refusal to use conventional painkillers to relief menstrual pain). CONCLUSIONS:The findings suggest that drivers of suboptimal social and school participation among secondary schoolgirls exist at the individual, interpersonal relationship, school, and societal levels. Multi-level evidence-based multicomponent interventions to improve menstrual health at all socio-ecological levels are warranted for optimal social and school participation among schoolgirls.

INTRODUCTION:Schools provide an important opportunity to sustainably reach and improve menstrual experiences and outcomes among adolescent girls. This study examined changes in psychosocial outcomes and menstrual practices after a pilot menstrual health intervention in schools in Northwest Tanzania. METHODS:We conducted a pre/post evaluation of a pilot menstrual health intervention in four schools in Mwanza region. The intervention included: (i) 10-hours comprehensive menstrual sexual and reproductive health (MSRH) education curriculum delivered over 5 days, (ii) distribution of menstrual management kits, (iii) improvement of school WASH facility guided by needs, and (iv) training on menstrual pain management strategies, supply of pain killers and training a specific teacher on dispensing. The primary outcome was measured using the Menstrual Practices Need Scale (MPNS). We assessed seven secondary outcomes: menstrual pain management practice; self-efficacy in managing menstruation; menstrual-related anxiety; self-reported urogenital infection symptoms; MSRH knowledge; participation in school during menstruation; and school climate score. We used linear (for MPNS, and school climate score), and logistic (for remaining secondary outcomes) random-effect regression models to examine changes in outcomes between baseline and endline. RESULTS:A total of 486 schoolgirls (mean age 15.6 years [SD 1.3]) were recruited for the baseline survey; of these 396 participated in the endline survey. At 12-months follow up, menstrual experience improved for MPNS-36 subscales of transport and menstrual material needs, (mean difference (MD), 0.52; 95% CI 0.38-0.66), and menstrual material reuse needs, (MD 0.32; 0.14-0.50), while menstrual materials reuse insecurity did not change, (MD -0.08; -0.27-0.11). For the secondary outcomes, there was an increased use of analgesics for menstrual pain management, (OR 2.21; 95% CI 1.33-3.67); improved self-efficacy for managing menstruation, (OR 2.02; 1.35-3.04); MSRH knowledge, (OR 5.23; 3.25-8.39), participation in school (OR 2.80; 1.89-4.16) and reduced menstrual-related anxiety, (OR 0.38; 0.25-0.59). There was no evidence of change in self-reported urogenital symptoms, (OR 0.71; 0.49-1.01) or school climate, (MD 0.05; -0.19-0.28). CONCLUSION:The pilot intervention showed improvements in menstrual practices, psychosocial outcomes and school participation among schoolgirls but had no effect on school climate or self-reported urogenital symptoms. Stronger evidence from rigorously designed trials is needed to confirm the effectiveness of the intervention and scalability of these findings.

Since the 2021 coup in Myanmar, the country has been driven into further social, political and economic turmoil. The United Nations estimates that 18.6 million people need humanitarian support. Among those most affected are adolescent girls aged 10-19 years who, as adolescents and young women, face unique risks to their health and wellbeing and require tailored interventions to promote their health and wellbeing both now and in the future. Supporting adolescent girls and young women during conflict means addressing their increased risk of gender-based violence, forced marriage, disrupted education, and access to health services. There is limited evidence on the effects of Myanmar's current political situation on adolescent girls and young women, and even less on what can be done to support their health and wellbeing during this period of protracted instability. In this qualitative study, we used the capabilities approach to conceptualise wellbeing from the perspectives of adolescent girls and young women in Myanmar. Collaborating with four young female peer-researchers, we conducted 12 participatory focus group discussions with 73 girls from Yangon, Sagaing and Mandalay. Our findings identified key themes of wellbeing that were prioritised by our study population: education, agency, hope and happiness, which were being undermined by gender inequality and the ongoing conflict. This study highlights the benefits of the capabilities approach in identifying the complex wellbeing needs of adolescent girls and young women in crisis settings as a basis for programme design and implementation.

Subjective wellbeing measures arepopular tools for assessing quality of life and progress in societies. There are concerns aboutthe validity of answers to questions about happiness and life satisfaction because thesemeasures might suffer from biases during survey administration. This study used a surveyexperiment to understand if measures of life satisfaction and happiness suffered from contexteffects during the administration of a survey in Uttar Pradesh, India, and test the use of a bufferquestion to mitigate any bias. In addition, we examined the association of life satisfaction andhappiness with key socio-economic variables as a further means of validation. While happinessappears to be robust enough to not be influenced by the context, the question on life satisfactionsuffered from mild context effects. The buffer question proved to be able to mitigate this bias.Mental and physical health are significantly correlated with both happiness and life satisfaction.Education is strongly correlated with life satisfaction. Major negative life shocks are stronglyassociated with happiness but not with life satisfaction. This study makes a significantcontribution to the evolving scholarship on subjective wellbeing measurement in a non-WEIRDsetting, by clarifying two critical issues: the conceptual distinction between different subjectivewellbeing measures (happiness and life satisfaction), and their contextual sensitivity. The resultslead to two recommendations that should be considered when measuring subjective wellbeing:happiness and life satisfaction are different concepts, and should not be used interchangeably.Evaluative measures of subjective wellbeing can be context-sensitive. To avoid context effects, it is critical to put the context-sensitive question early in the questionnaire, or to add a buffer/transition question preceding the context-sensitive one.

TRIAL REGISTRATION:ClinicalTrials.gov NCT06093646.

BACKGROUND:Menstrual health is a human rights issue, affecting many aspects of life including mental health, wellbeing, and education. We assessed the effectiveness and costs of a school-based, multi-component menstrual health intervention (MENISCUS) to improve mental health problems and educational performance among in-school adolescents. METHODS:We conducted a parallel-arm, cluster-randomised trial in secondary schools in Wakiso and Kalungu districts in Uganda. Schools were eligible for inclusion if they had both male and female students; senior 1-4 classes; day or mixed day and boarding students; at least minimal water, sanitation, and hygiene (WASH) facilities; and enrolments of 50-125 female Senior 1 students in Wakiso district and 40-125 female Senior 1 students in Kalungu district. Schools were randomised (1:1) to the intervention or control condition, stratified by district and baseline mean school examination score. The intervention included creating action groups, strengthening teacher-delivered puberty education, distributing menstrual kits, supporting student-led drama skits, providing pain-management strategies, and improving school water and sanitation facilities. The control condition was provision of printed government menstrual health materials. Schools, participants, and implementors, including the study clinician who monitored adverse events, could not be masked to allocation status. Primary outcomes were mental health problems using the Strength and Difficulties Questionnaire (SDQ) Total Difficulties Score and independently assessed educational performance at individual level, assessed in all female participants at endline. We estimated cluster-intention-to-treat intervention effects using mixed-effects models accounting for school clustering and adjusted for randomisation strata and baseline school-level means of outcomes. The study was registered at the ISRCTN registry, ISRCTN45461276 and is completed. FINDINGS:60 randomly selected schools (44 from Wakiso and 16 from Kalungu) were randomly assigned (30 per group) to the intervention or the control group, and none withdrew. Between March 21 and July 5, 2022, 3841 female students participated in baseline assessments (89·7% of those eligible) and between June 5 and Aug 22, 2023, 3356 participated in endline assessments (1666 in the control group and 1690 in the intervention group). Female participants had a median age of 16 years (IQR 15-16). At endline, there was no evidence of a difference in mental health problems (mean SDQ score, 10·8 in the intervention group vs 10·7 in the control group; adjusted mean difference [aMD] 0·05 [95% CI -0·40 to 0·50]) nor educational performance (mean z score, 0·20 in the intervention group vs 0·12 in the control group; aMD 0·05 [95% CI -0·10 to 0·19]), despite improvements to menstrual health. The annual implementation cost was US$85 per Senior 2 female student. One participant had a serious adverse event (severe anaemia secondary to excess vaginal bleeding), which was deemed to be possibly related to the intervention. INTERPRETATION:Improving multiple dimensions of menstrual health in secondary schools in Uganda is important for health and human rights but is not sufficient to improve mental health or educational performance over 1 year. FUNDING:UK Foreign, Commonwealth and Development Office; Medical Research Council; Department of Health and Social Care; and Wellcome.

Ukraine has experienced armed conflict since 2014, with significant escalation in 2022. Since then, an estimated 3.7 million people have been internally displaced. Alcohol misuse remains a substantial public health challenge in Ukraine, with high levels of psychological distress among the displaced population. The current study aims to evaluate the effectiveness and cost-effectiveness of a transdiagnostic intervention (CHANGE) to address alcohol misuse and psychological distress through problem-solving therapy and selected behavioural strategies for managing alcohol misuse. We hypothesize that CHANGE, together with enhanced usual care (EUC), will be more effective in increasing the percentage of days abstinent (PDA) than EUC alone. This study is a parallel-arm, single-blind, individually randomised controlled trial across Ukraine government-controlled territories. Following informed consent, we will recruit 500 adult war-affected men, randomised 1:1 to EUC and CHANGE, or EUC alone. Inclusion criteria include elevated levels of alcohol use (between 8 and 19, inclusive, on the Alcohol Use Disorder Identification Test); psychological distress (≥ 16 on the Kessler Psychological Distress Scale) and ability to speak Ukrainian or Russian. CHANGE will be delivered over 6 weeks by 14 community-based facilitators, with outcomes assessed at 3 months post-randomisation. The primary outcome for CHANGE is the PDA from alcohol at 3 months, measured using the Timeline Follow Back. Secondary outcomes include percentage days of heavy drinking, alcohol misuse, psychological distress (depression, anxiety, and posttraumatic stress disorder), functional disability, intimate partner violence perpetration and health economics indicators at 3 months. The primary analysis will follow an intention-to-treat approach. A mixed-methods process evaluation will examine facilitator competency, recruitment, retention/completion, appropriateness, dose received, fidelity and feasibility of delivery and acceptability. CHANGE is the first intervention aiming to address alcohol misuse and psychological distress in an active conflict setting. ISRCTN14881856. Registered on 5th of July 2024.

Experiences of violence have been reported to be associated with lower levels of subjective wellbeing (SWB). However, little is known about this association in conflict settings and among forcibly displaced populations. In this study we exploit data from a representative sample of refugee teachers from Nyarugusu Refugee Camp collected as part of a larger study, to examine the association between demographic characteristics and SWB, and between experiences of violence and SWB. Three cross-sectional surveys of primary and secondary school teachers were conducted, collecting data on lifetime experience of violence (physical and sexual) and SWB (measured by life satisfaction and current happiness, on 1-5 Likert scales). Linear mixed models were used to estimate the associations between violence and SWB accounting for teacher and school clustering, unadjusted and adjusted for main factors associated with SWB. The 3 surveys included 1,666 responses completed by 885 teachers. Country of origin and number of meals consumed per day were strongly associated with SWB. Individuals who experienced physical violence reported on average, 0.13 lower life satisfaction scores (95% CI [-0.23, -0.02], p = .016) compared to those who did not experience physical violence, while survivors of sexual violence reported on average, 0.24 lower happiness scores ([-0.43, -0.05], p = .014) compared to those who did not experience sexual violence, after adjusting for confounders and clustering. We found an important negative association between past experience of violence and SWB in a refugee camp setting. These findings contribute to the evidence that violent experiences are likely to have a long-lasting impact on people's wellbeing. There is a need for improved mental health and psychosocial support in humanitarian settings.

Background During adolescence, behaviours are initiated that will have substantial impacts on the individual’s short-term and long-term health and well-being. However, adolescents rarely have regular contact with health services, and available services are not always appropriate for their needs. We co-developed with adolescents a health and well-being check-up programme (Y-Check). This paper describes the methods to evaluate the feasibility, acceptability, short-term effects and cost-effectiveness of Y-Check in three African cities.Method This is a multi-country prospective intervention study, with a mixed-method process evaluation. The intervention involves screening, on-the-spot care and referral of adolescents through health and well-being check-up visits. In each city, 2000 adolescents will be recruited in schools or community venues. Adolescents will be followed-up at 4 months. The study will assess the effects of Y-Check on knowledge and behaviours, as well as clinical outcomes and costs. Process and economic evaluations will investigate acceptability, feasibility, uptake, fidelity and cost effectiveness.Ethics and dissemination Approval has been received from the WHO (WHO/ERC Protocol ID Number ERC.0003778); Ghana Health Service (Protocol ID Number GHS-ERC: 027/07/22), the United Republic of Tanzania National Institute for Medical Research (Clearance No. NIMR/HQ/R.8a/Vol.IX/4199), the Medical Research Council of Zimbabwe (Approval Number MRCZ/A/2766) and the LSHTM (Approval Numbers 26 395 and 28312). Consent and disclosure are addressed in the paper. Results will be published in three country-specific peer-reviewed journal publications, and one multicountry publication; and disseminated through videos, briefs and webinars. Data will be placed into an open access repository. Data will be deidentified and anonymised.Trial registration number NCT06090006.