To examine whether the association between child marriage and maternal healthcare utilization differs between conflict and non-conflict settings, and whether armed conflict amplifies the negative effects of child marriage on maternal healthcare utilization.

Armed conflicts hinder progress in reproductive and maternal health, particularly in low- and lower-middle-income countries, by weakening health systems, disrupting access to care, and increasing gender-based vulnerabilities. Child marriage, which is common in such contexts, may further limit women’s ability to seek adequate maternal healthcare. While both conflict exposure and child marriage are known to adversely affect maternal health outcomes, evidence on their intersection remains limited. Understanding their combined influence is essential for designing effective primary healthcare and humanitarian interventions.

We used data from 82 Demographic and Health Surveys (1994–2020) across 49 countries, linked spatially and temporally with armed conflict information from the Uppsala Conflict Data Program. The sample included 452,192 women aged 15–49. Maternal healthcare utilization was measured using continuum-of-care indicators: at least one antenatal care (ANC) visit, four or more ANC visits, four or more ANC visits with institutional delivery, and four or more ANC visits with institutional delivery and postnatal care (PNC). Associations were estimated using binomial logistic regression models, with robustness checks including interaction effects, macro-level analyses, and mediation analyses.

Women married before age 18 had significantly lower odds of utilizing maternal healthcare compared to those married at 18 or older. These disparities were strongest in conflict-affected areas, where child brides consistently showed the lowest utilization of ANC, institutional delivery, and PNC. Maternal education, household wealth, urban residence, and media exposure partially mitigated these associations. Additional analyses confirmed the robustness of findings across alternative model specifications, conflict measures, and subgroups.

Ethiopia has been working to achieve universal health coverage through optimizing the Health Extension Programme (HEP). The HEP optimization aspires to increase health service access, quality, and equity through different strategies, including establishing HEP units in health centres and primary hospitals. Therefore, understanding the processes of the HEP unit and its implementation experience is crucial for scale-up and sustainability.

This paper aims to document and share the lessons learned from implementing the HEP unit.

This research collected qualitative data from 14 districts/woredas in 2023. Forty-three in-depth interviews (IDIs) and four focus group discussions (FGDs) were conducted. Audio-recorded data were transcribed verbatim and translated. A thematic analysis approach was used to analyze the data, and direct quotations were used to present the findings.

In the Improve Primary Health Care Service Delivery (IPHCSD) project implementation sites, all 64 health centres, and primary hospitals established HEP units. Setting up the unit improved healthcare provision by promoting collaboration and teamwork, enhancing their skills, coordination, technical support to the catchment health post and increased access to healthcare services through outreach delivery. However, challenges such as a shortage of human resources, dedicated offices for the unit coordinators and team members, inadequate stakeholders’ engagement in the establishment processes, and insufficient tools and supplies were identified.

The HEP unit has improved community-level health services, enhanced health professionals’ skills and teamwork, and technical support to catchment health posts. Strengthening community engagement, advocacy, mentorship, training, and ensuring sufficient staffing, infrastructure, and supplies are essential for the programme’s scale-up and sustainability.

To develop strategies to lower barriers to sexual and reproductive health (SRH) care for migrant women (MW) in Milan, Lombardy, Italy.

SRH is a fundamental human right, yet MW experience poorer SRH outcomes than non-MW due to cultural, linguistic, legal, and financial barriers. Despite Italy’s universal healthcare system (Servizio Sanitario Nazionale, SSN), disparities persist.

Quantitative SRH data from the health information system of a non-governmental organization (NGO) clinic in Milan was used to describe the demographic, socioeconomic, and administrative profile of MW with SRH needs, and to examine factors associated with SRH-related consultations. Qualitative data were collected through semi-structured interviews with 29 stakeholders, including MW, healthcare workers, NGO representatives, and policymakers. Thematic analysis was guided by a socio-ecological framework across individual, organizational, societal, and policy levels.

SRH needs were the most frequent presentations among MW accessing the clinic. Most MWs came from Romania, Morocco, and Peru. Nearly half of those eligible for SSN registration were not enrolled, primarily due to lack of awareness. Economic vulnerability was strongly linked to SRH needs, while language proficiency alone showed no significant effect. Interviews underscored the importance of culturally sensitive care and mental health support. They also emphasized the inconsistent enforcement of regulations across government facilities and legislative gaps that leave certain groups, particularly undocumented EU nationals, without essential services. Community networks and stronger coordination across providers - including formal collaboration between NGOs and the SSN - were identified as promising levers to improve SRH access and equity in Milan and similar settings.

The rapidly growing burden of non-communicable diseases (NCDs) in sub-Saharan Africa necessitates a better understanding of access gaps along the care continuum. This study assessed the prevalence and inequality in unmet need for hypertension and diabetes care in Tanzania, South Africa, and Lesotho using a care cascade framework.

We conducted a cross-sectional analysis of nationally representative Demographic Health Survey (DHS) datasets from Tanzania (2022), South Africa (2016), and Lesotho (2023/24), focusing on adults aged 15 years and older. The study estimated the proportion of adults with hypertension or diabetes who had not been screened, diagnosed, treated, or achieved disease control. Inequality was assessed using Erreygers Normalized Concentration Indices (ENCI), stratified by sex and residence.

Hypertension prevalence was 12.6% (95% CI: 11.7–13.4) in Tanzania, 46.7% (95% CI: 45.0–48.4) in South Africa, and 15.4% (95% CI: 13.8–17.2) in Lesotho. In Lesotho, 9.1% (95% CI: 7.8–10.6) of adults had diabetes. Unmet need was substantial across all countries: 96.5% for hypertension in Tanzania, 84.2% in South Africa, 65.8% in Lesotho, and 84.2% for diabetes in Lesotho. The care cascade framework revealed critical bottle-necks at screening and treatment stages. Inequality analyses revealed strong pro-poor gradients, particularly in screening (ENCIs: Tanzania −0.19, South Africa −0.17, Lesotho hypertension −0.15, Lesotho diabetes −0.24; all p < 0.01), with poor men experiencing the most disparities.

Substantial and inequitable gaps exist in hypertension and diabetes care. Policy strategies should prioritize community-based screening, primary care integration, and equity-focused interventions targeting poor men to improve NCD outcomes in the region.

To explore facilitators and barriers to smoking cessation among smokers experiencing socioeconomic disadvantage, from the perspectives of patients and healthcare providers (HP) participating in the STOP randomized controlled trial (STOP-RCT).

Smoking remains disproportionately prevalent among socioeconomically disadvantaged individuals, contributing to significant health disparities. The STOP-RCT evaluates a preference-based smoking cessation intervention offering free nicotine replacement therapy (NRT) and e-cigarettes to disadvantaged smokers.

A qualitative study was conducted involving semi-structured interviews with 14 participants and 5 HP from the STOP-RCT. Data collection explored participants’ smoking cessation experiences, perceptions of the intervention, the quitting process, and the factors that influence cessation. Thematic analysis was used to analyse the transcribed data. Themes were categorized into structural and individual factors, refined iteratively, and supported by illustrative quotes.

Four key facilitators were identified: (1) longer consultations enabling tailored support; (2) regular follow-up promoting patient engagement; (3) immediate and free access to NRT and carbon monoxide (CO) monitoring, reducing financial and practical barriers while providing feedback; and (4) shared decision-making, strengthening trust and improving the fit of support. These findings highlight the importance of addressing both treatment approach (contextual) and interpersonal factors for this population. Considering these elements may help adapt cessation programmes to the specific difficulties and needs of patients with low socioeconomic position, thereby reinforcing treatment adherence and improving effectiveness.

‘It was aimed to establish the validity and reliability of the “Mothers’ Breastfeeding Empowerment Scale”’.

Content validity was evaluated with the content validity index (CVI) agreed upon by experts. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used for construct validity. Before factor analysis, the sample size was decided using KMO and Bartlett’s Sphericity test. For the reliability study of the scale, Cronbach’s Alpha coefficient and total score correlation coefficients of parallel forms were examined.

While 49.9% of the infants were between 4–6 months old, the average age of the infants was determined as 3.64 ± 1.77. 70.6% of the mothers were between the ages of 26–43 and the average age of the mothers was 28.83 ± 5.38. In the factor analysis it was found that item loadings of the scale was between 0.57 and 0.95. Also, the fit values of the scale were within acceptable limits. Additionally, it was determined that there was a high-level positive relationship between the scale used for the parallel form and our scale.

The use of the scale in Turkish society is valid and reliable. Validity and reliability analyses support this.

This study evaluated the impact of a novel social prescribing service designed specifically for the Armed Forces Community (AFC) and its influence on service users’ wellbeing.

Social prescribing connects individuals with non-clinical, community-based support to address loneliness, long-term conditions, and mental health. Despite advances in social prescriber training, a gap remains in resources for working with the AFC, who present distinct wellbeing needs. A two-year project, funded by the NHS Armed Forces Health and the Armed Forces Covenant Fund Trust, sought to enhance provision by equipping Social Prescriber Link Workers with specialist skills.

A sequential mixed-method design was adopted. Quantitatively, changes in wellbeing for 259 AFC service users were measured using the Short Warwick and Edinburgh Wellbeing Scale before and after consultations with Armed Forces Social Prescriber Link Workers (AFCSPLWs). Qualitatively, semi-structured interviews were undertaken with AFCSPLWs, general social prescribers, General Practitioners, and AFCSPLW line managers to explore experiences of service delivery.

Wellbeing scores significantly increased from initial (mean = 15.3) to final consultations (mean = 18.79), indicating positive effects; however, scores remained lower than national averages, reflecting the complex needs within the AFC population. Thematic analysis identified four themes: Armed Forces Experience and Perspective, Challenges and Barriers, Service Delivery and Effectiveness, and Skill Development and Attributes. Subthemes highlighted AFC-specific challenges, the practical complexity of the AFCSPLW role, and the importance of cultural competence. Advocacy, navigation, and relationship-building emerged as central mechanisms, with AFCSPLWs acting as vital connectors across primary care, third-sector services, and professional networks.

Women’s sexual and reproductive rights are crucial for achieving gender equality and promoting women’s rights. Across East Africa, there are limited studies about husbands’ knowledge of their partner’s reproductive rights and their associated factors. Hence, this study aimed to assess husbands’ knowledge of partners’ reproductive health rights and associated factors in Central Ethiopia.

A community-based cross-sectional study was conducted from March 15 to April 30, 2023, using multi-stage stratified sampling. A structured, interviewer-administered questionnaire was utilized to gather the data, and then SPSS version 26 was employed for analysis. Statistical significance was declared at a p-value < 0.05.

The overall good knowledge of partners’ reproductive health rights was found to be 47.8% (95% CI: 43.8, 51.8). Age of the husbands 25–35 years (AOR: 2.7; 95% CI: 1.10, 6.6), below primary educational status (AOR: 2.4; 95% CI: 1.3,4.3), primary educational status (AOR: 5.98; 95% CI: 3.10, 11.4), secondary educational status (AOR: 2.1; 95% CI: 1.01, 4.3), above secondary education status (AOR: 8.0; 95% CI: 4.3, 15.2), discussion with a partner (AOR: 3.2; 95% CI: 2.0, 5.2), and vehicle as a means of transport (AOR: 3.3; 95% CI: 2.2, 4.9) were statistically significant for good husbands’ knowledge of partners reproductive health rights.

These findings indicate that more than half (52.2%) of the study participants had a poor understanding of their partners’ reproductive rights. Therefore, counselling and education should be offered to husbands to ensure equitable access to health services and to disseminate information on reproductive rights, particularly targeting young men.

This study aimed to examine the experiences of self-identification, diagnosis, and support for adults with tic disorders (including Tourette Syndrome) in the United Kingdom (UK).

Traditionally viewed as a neurological disorder of childhood-onset, tic disorders have been observed to remit or persist, often in a milder form, into adulthood. However, the reappearance of problematic symptoms after periods of asymptomatic latency might be more common than previously recognized. The medical exposure and standardization of clinical practice for primary adult-onset or non-typical adult-presenting cases of tic disorders is currently limited and poses barriers to diagnosis.

An online survey of 42 adults with self-identified tic symptomology explored their tic recognition and journey of attaining a confirmed diagnosis and/or self-identifying after the age of 18 in the UK.

No significant differences were found between adult and childhood-onset cases. Elevated scores on the Acceptance and Action Tic Specific Questionnaire (AAQ-T) correlated with higher overall frequency, intensity, and severity of motor tics from the Adult Tic Questionnaire (ATQ). The AAQ-T was also shown to negatively correlate with increasing age. Nearly all adults expressed dissatisfaction with the diagnostic process, especially regarding information provided and lack of post-diagnostic support. Those who self-identified quoted fear of dismissal, long waiting lists and lack of understanding from clinicians as reasons for not seeking a formal diagnosis. Overall, the results emphasize the importance for a standardized improved comprehension of tic conditions in healthcare including how to best support adults seeking recognition later in life.

This study evaluates the psychological factors influencing vaccination attitudes and behaviors among individuals visiting family health centers. Using the 5C model, the study identifies key determinants affecting vaccination intention and hesitancy, providing insights into strategies to enhance vaccine acceptance.

A cross-sectional study was conducted among 1712 adults aged 18 and over in Ankara, Turkey. Data were collected through face-to-face interviews, covering socio-demographic characteristics, vaccination attitudes, and internet usage. The Turkish version of the ‘Psychological Antecedents of Vaccination (5C) Scale’ was used to assess participants’ responses. Multivariate logistic regression analysis was performed to determine factors influencing vaccination intention.

Individuals whose income exceeds their expenses (OR: 1.532, 95% CI: 1.107–2.119), those who received the COVID-19 vaccine (OR: 2.362, 95% CI: 1.429–3.906), and those who are not active social media users (OR: 1.417, 95% CI: 1.096–1.833) were more likely to get vaccinated without hesitation. Higher confidence (OR: 1.268, 95% CI: 1.231–1.306) and collective responsibility (OR: 1.083, 95% CI: 1.046–1.122) scores were associated with increased willingness to vaccinate, while higher calculation scores (OR: 0.932, 95% CI: 0.899–0.965) were linked to hesitancy.

The findings suggest that fostering confidence and collective responsibility is crucial for improving vaccine acceptance. Communication strategies should be tailored to reduce hesitancy among active social media users. Future research should explore the underlying risk factors contributing to vaccine hesitancy in different populations.

Ischaemic heart disease (IHD) is a global health issue, with people of Indian origin facing earlier onset and more severe cases, leading to higher mortality at younger ages compared to Western countries. Indian migrants maintain similar risks post-migration. Managing modifiable risk factors and improving risk knowledge and health-seeking behaviours are essential, but research on IHD risk perceptions among Indian migrants is limited.

This study explores how first-generation Indian migrants perceive their IHD risk and the factors influencing these perceptions.

As a component of a mixed- method study, a qualitative descriptive study design was employed to examine study participants perception of their IHD risk and the influencing factors. Semi-structured interviews were conducted with Indian migrants residing in metropolitan Melbourne, Victoria using multiple Indian languages and English. Data were analysed in the original language, with findings reported in English. NVivo software was used for data management and analysis. A qualitative content analysis was conducted using a hybrid coding approach where the main categories were developed deductively and subcategories were developed inductively from the data.

Twenty interviews were conducted with participants aged 32 to 70, 55% of whom were female, with an average stay in Australia of 11.2 years. The main themes included: perceptions shaped by personal experiences, especially family history, with most underestimating their risk; migration, cultural norms, and time constraints hindering behaviour change; family support, religious beliefs, and longevity aspirations motivating healthier behaviours; and limited primary healthcare engagement and culturally appropriate health resources. These results are discussed within the context of Capability, Opportunity and Motivation model of behaviour change (COM-B).

The study highlights key factors influencing IHD risk perceptions among Indian migrants. By understanding these specific risk perceptions and cultural nuances, healthcare professionals can develop and implement more effective, culturally sensitive health promotion and disease prevention strategies. This tailored approach can lead to better patient outcomes and a more equitable healthcare system.

We aimed to examine the association between team functioning in primary care and patients’ self-efficacy and quality of life. We also examined the moderation effect of multimorbidity and social vulnerability on this association.

Team-based care has been adopted as an appropriate model to deliver comprehensive primary care services to meet the complex needs of patients. Little is known about the association between team functioning and patients’ self-efficacy for managing chronic conditions (SEMCD) and quality of life.

We used mixed-random effect modelling to analyse secondary cross-sectional data. Data were collected in primary care practices in three Canadian regions. Dependent variables included patients’ SEMCD and quality of life. The independent variable was team functioning measured using the Team Climate Inventory scale (TCI). We also included two interaction terms: social vulnerability and TCI, and multimorbidity and TCI. Control variables included patient characteristics, patients’ experience with care and practice characteristics.

Eighty-seven practices and 1,929 patients participated in the study. Of these, 67% were female, 5% had two or more social vulnerabilities and 65% had multimorbidity. Regression analyses failed to find an association between team functioning and patients’ self-efficacy or quality of life. There was a strong positive association between team functioning and self-efficacy for people with multimorbidity (p = .005) compared to those without multimorbidity. There was also a strong positive association between team functioning and quality of life for those with two or more vulnerabilities (p < .001) but not for those with fewer vulnerabilities. The findings showed people with multimorbidity and increased vulnerabilities could benefit from well-functioning teams. Supporting better team functioning through effective communication (e.g., team meetings) and care coordination; encouraging full participation of all team members in service delivery; and establishing clear team objectives, roles and responsibilities can better meet the needs of complex patients.

To identify key factors associated with varying levels of Medicare’s Chronic Care Management (CCM) programme implementation in rural primary care practices in the United States.

Despite demonstrated benefits for both patients and providers, CCM implementation remains low nationwide. While previous studies have examined payment-related challenges, limited research exists on other implementation factors such as leadership engagement, organizational culture, and provider training, particularly in rural settings.

This mixed-methods study examined CCM implementation across six rural primary care practices in Wyoming. Thirteen healthcare professionals participated in semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR). Practice performance data collected over three consecutive months were used to categorize sites as high or low implementers based on care coordinator productivity, percentage of care coordinated, and programme sustainability. Interview transcripts were analysed using CFIR constructs to identify factors that distinguished high from low-implementing sites, with each factor rated based on its impact (positive, negative, or neutral) and strength of influence.

Three CFIR constructs strongly distinguished between high and low implementation sites: networks and communication, leadership engagement, and reflecting and evaluating. High-implementing sites demonstrated effective team communication, supportive leadership, and regular programme evaluation practices. In contrast, low-performing sites faced poor communication, minimal leadership support, and weak feedback mechanisms. Further research is needed to examine the effectiveness of targeted interventions designed to strengthen these organizational factors in rural primary care settings, particularly focusing on developing scalable strategies that account for resource limitations and geographic isolation.

The urban First Nations population in Australia is rapidly increasing. The health policy and research focus on urban First Nations Australians, however, is limited. To contribute to addressing this situation, The University of Queensland Poche Centre for Indigenous Health (UQ Poche Centre), a First Nations-led health research centre, is working closely with urban Aboriginal Community-Controlled Health Services (ACCHS) across Australia.

Our study examined urban ACCHSs stakeholders’ perspectives of the health and wellbeing of urban First Nations Australians and identified their priorities for a national Indigenous urban health research agenda.

Ten stakeholders were recruited for in-depth interviews from ACCHS that were members of the Research Alliance for Urban Community-Controlled Health Services (RAUCCHS), a partnership between the UQ Poche Centre and urban ACCHS focused on achieving equitable health outcomes for urban First Nations Australians. Six stakeholders identified as First Nations Australians. Interviews were audio-recorded and transcribed verbatim. Interview data were analysed using inductive thematic analysis.

Stakeholders highlighted a lack of research focused on the health of urban First Nations Australians. Specific priority areas they identified for an urban First Nations health research agenda were: evaluating the effectiveness and adaptability of Indigenous models of care, strengthening care pathways between ACCHS and specialist services, examining the intersection of cultural identity, racism and determinants of health, and greater investment in Indigenous research governance structures and processes.

There is a clear opportunity for researchers to engage with RAUCCHS members to establish a body of urban First Nations health research in Australia that responds to their research priorities.

To investigate the decision-making processes of nurse prescribers in general practice when managing acute episodes of illness in patients with multimorbidity.

Nurse independent prescribers in UK general practice are facing increasing complex clinical decision-making when assessing patients presenting acutely with undifferentiated and undiagnosed conditions as multimorbidity and polypharmacy becomes increasingly common. This qualitative study investigated the decision-making processes of nurse prescribers in general practice when managing acute episodes of illness in patients with multimorbidity.

Fourteen general practice nurse prescribers were recruited through purposive sampling. Think aloud in response to staged vignettes was used followed by semi-structured interviews. Thematic analysis was used to analyse think aloud and interview data.

Participants were experienced nurses with a range of clinical exposure and training who mostly made appropriate diagnostic and prescribing decisions. Pockets of expertise were revealed which reflected participants’ clinical experience, but there was a high rate of referral to the GP for some vignettes. Participants’ decision-making was underpinned by both analytical and intuitive processes, the quality of which was dependent on their individual knowledge and experience. A reliance on pattern recognition, aligned to intuitive decision-making, to determine the content of the consultations was identified as an area of risk and showed all participants to be inconsistent in their identification of complex factors. Omission of these factors could have important implications for prescribing decision-making. Organizational issues such as time-limited clinics also shaped the content of participants’ consultations, encouraged a limited, problem-focused approach, and reduced the opportunity for mentorship. Comprehensive knowledge, clinical experience, and mentorship are critical to ensure nurse prescribers make optimal decisions in the context of patients with multimorbidity. A team approach to the management of acute presentations in these patients is recommended to improve patient experience and maximize nurse prescribers’ contribution to the general practice workforce.

Smartphones have become essential, making our daily lives more manageable; however, excessive use may cause problems. University students are particularly vulnerable to smartphone addiction. This study examines the relationship between smartphone addiction and health-promoting lifestyles among university students.

A cross-sectional study was conducted with 911 students at Dokuz Eylul University, Izmir, Turkey. Data were collected via Smartphone Addiction Scale-Short Version (SAS-SV) and Health Promotion Lifestyle Profile II (HPLP II). The printed forms were used, and the researcher administered the survey in person and recorded the responses.

Prevalence of smartphone addiction was 34.1%. Several factors were significantly associated, including female gender (p = 0.049), being single (p = 0.042), self-perceived smartphone addiction (p < 0.001), daytime sleepiness (p < 0.001), and poor sleep quality (p < 0.001). Students with smartphone addiction had significantly lower HPLP II scores (p = 0.001).

Logistic regression analysis showed that gender was no longer a significant factor. Those without a partner (OR: 1.47, 95% CI: 1.07–2.03), those who considered themselves smartphone addicts (OR: 6.86, 95% CI: 4.99–9.42), and those with daytime sleepiness (OR: 1.52, 95% CI: 1.08–2.14) had higher odds of smartphone addiction. Higher HPLP II scores were protective against smartphone addiction (OR: 0.99, 95% CI: 0.98–0.99).

This study highlights that students with smartphone addiction engage in less health-promoting behaviours and experience poor sleep quality and daytime sleepiness. Self-perceived smartphone addiction was strongly associated with actual addiction, while a healthier lifestyle appeared to have a protective effect. There is a need for strategies to promote healthy habits and reduce smartphone addiction among university students.

Palliative care development in primary care is crucial worldwide. This study reports on the secondary outcomes of a study that evaluated whether a complex intervention in primary care for patients with palliative care needs impacted their healthcare utilization.

A before-after study was conducted with family physicians and patients with palliative care needs. Physicians received palliative care training and implemented a new primary palliative care consultation model. Healthcare utilization in the 12 weeks before, during, and after the intervention was compared.

We analysed healthcare utilization for 33 patients with advanced disease. Pre-intervention, there were high rates of no medical consultations, emergency visits, hospital admissions, and outpatient referrals (84.8%, 75.8%, 81.8%, and 84.8%, respectively). Despite slight reductions during and after the intervention, the differences were not statistically significant.

The reduction in healthcare utilization was not statistically significant, but the data inform sample size calculations for future economic analyses.

ClinicalTrials.gov ID – NCT05244590. Registration: 14th February 2022.

The increasing diversity of the UK’s population, along with significant inequalities in health outcomes among diverse cultural and ethnic groups, highlights the critical need for healthcare providers, including physiotherapists, to deliver culturally competent care. Research demonstrates that cultural competency (CC) in healthcare can enhance patient outcomes, improve treatment adherence, and address health inequalities. This quality improvement project aimed to evaluate the impact of a brief training intervention on perceived CC among physiotherapists engaging in cross-cultural, clinical encounters.

The design of this project was informed by principles of the Plan-Do-Study-Act (PDSA) cycle. Musculoskeletal physiotherapists voluntarily participated in this educational intervention by completing a CC e-learning course developed by Health Education England. A retrospective evaluation method was used, where participants rated their awareness, knowledge, and skills in providing care to diverse patient groups after completing the training as compared to before.

The pre-and post-training responses assessed three constructs of CC: awareness, knowledge, and skills. Significant increases were observed in the mean scores for each construct, as well as in the overall aggregate CC score, indicating measurable improvements following the training.

Improvement in CC is viable and achievable through targeted training. CC is a lifelong, dynamic process that requires ongoing education. Therefore, further PDSA cycles are recommended with more advanced educational sessions. Additionally, future projects should assess the impact of enhanced CC on patient outcomes and experiences. Cultural competency must encompass cultural issues beyond racial and ethnic differences.

This study analyses the relationship between fear of stigma and bypassing primary ART facilities by ART clients in the Upper East Region of Ghana.

Methodology: The study employed an exploratory case study design, involving 52 participants of: ART clients (n = 37), nurses (n = 7), a counsellor (n = 1), cadres (n = 2), pharmacists (n = 2) and data managers (n = 3) through convenient and purposive sampling techniques. Data was collected using semi-structured interview guides and analysed using a thematic framework.

The study provides ample evidence of the occurrence of stigma-driven bypassing of primary ART facilities by clients. The analysis shows entrenched cultural norms and values and the population’s low awareness of the efficacy of ART fuel the processes of stigma and discrimination towards ART clients.

We acknowledge the following limitations and strengths: convenient and purposive sampling procedures may not represent the views of all ART clients on bypassing primary facilities. Sensitive nature of HIV and the location of ART centres, coupled with time constraints in probing into all ART bypassing issues. Yet, given the depth of the issues presented and the scope of participants and ART facilities, we believe relevant data was generated to address the research question.

An integrated approach could be used to address the drivers of stigma and discrimination focusing on awareness creation to undo the entrenched negative cultural beliefs around HIV transmission, and implement anti-HIV stigma legislation to eliminate prejudice towards PLHIV.