Barriers and facilitators to mental health service accessibility among youth in Zambia

Background. Mental health challenges among Zambian youths are an increasing public health concern. Recent studies estimate that ~20% of the Zambian population is affected by mental health disorders, with adolescents showing a sharp rise in reported cases, from 0.7% in 2021 to 1.54% in 2023 (2 914 to 6 825 cases). Despite this growing burden, only 0.1% of government health expenditure is allocated to mental health services, and there is currently no youth-specific policy framework in place. With young people aged 15 - 35 years comprising 36.7% of Zambia’s total population, the lack of investment and targeted interventions underscores the urgency of addressing barriers and strengthening facilitators to improve youth access to mental healthcare. Objectives. To explore the barriers and facilitators that influence youths’ access to mental health services in Zambia, with a focus on understanding the underlying factors that impact service utilisation. Methods. A systematic literature review was conducted, drawing on studies published between 2005 and 2025 from databases including Google Scholar, PubMed and ResearchGate. A total of 20 articles were identified and reviewed, with inclusion based on relevance to youth mental health service accessibility in Zambia. The review did not involve any primary participants; instead, the sample consisted of peer- reviewed studies, national reports and institutional documents. Data were analysed manually using a qualitative thematic approach, where key patterns, recurring themes and emerging categories of barriers and facilitators were identified and synthesised. This approach allowed for an in-depth understanding of the cultural, social and systemic factors that influence youths’ access to mental health services. Results. The findings highlight several barriers to accessing mental health services, including stigma, cultural beliefs, inadequate infrastructure and resources, low mental health awareness and gendered norms. The majority of the reviewed literature focused on urban and peri-urban settings, with fewer studies addressing rural contexts. In urban and peri-urban settings, common themes included stigma, limited infrastructure concentrated in tertiary hospitals and gendered expectations that discouraged male youths from seeking care. In rural contexts, the analysis revealed geographical inaccessibility, severe shortages of trained personnel and reliance on traditional or informal sources of support. Across both settings, low awareness of mental health conditions consistently emerged as a barrier. Conversely, facilitators such as school-based mental health programmes, community outreach initiatives, peer support groups and mobile-based interventions were identified as effective strategies to enhance accessibility for youths. Conclusion. Access to mental health services for Zambian youths is a multifaceted web of social, cultural and systemic factors. Addressing these challenges requires a comprehensive approach. The article concludes with recommendations aimed at improving youth-friendly mental health service delivery and access

Gender-affirming care in South Africa: A cross-sectional survey of transgender and gender-diverse people in the Eastern and Western Cape provinces, South Africa

Background. Transgender and gender-diverse (TGD) people face significant discrimination in the South African (SA) health system, limiting their access to HIV services and gender-affirming care, which supports an individual’s gender identity when it does not align with their sex assigned at birth. Despite the critical role of these services for TGD people, access to care remains understudied in SA. Objectives. To describe TGD people and their access to and need for social, legal and medical transition, including psychosocial care, hormone therapy and surgery, as well as HIV services, in the Eastern Cape and Western Cape provinces, South Africa. Methods. A cross-sectional quantitative survey design was utilised, with 150 TGD individuals recruited via convenience sampling in the Western and Eastern Cape provinces. Interviews were conducted using structured questionnaires, with data captured on REDCap. Descriptive analysis was conducted using Stata 18. Results. Of the 150 respondents, 74.0% were people assigned male at birth (AMAB) and 26.0% were people assigned female at birth (AFAB). Reported gender identities showed that 68.5% of AMAB respondents identified as transgender women/female, 56.4% of AFAB respondents identified as transgender men/male and 34.0% of all respondents identified as gender diverse or non-binary. Demographics showed a vulnerable population, with 18.7% with housing insecurity and 66.0% unemployed. While social transition was common (98.7%), access to legal transition (4.0%) was very low, as was access to all forms of medical gender-affirming care, with 44.7% of TGD people accessing psychosocial care, 32.0% accessing hormone therapy and 2.7% surgery. Of the respondents who had not legally transitioned, 71.4% wanted to. Most respondents who had not accessed medical gender-affirming care services expressed a need for psychosocial care (77.1%) and hormone therapy (68.6%). Gender-affirming surgery was more variable, with 33.3% of AFAB respondents wanting bottom surgery compared with top surgery (63.9%), and 49.5% of AMAB respondents wanting bottom surgery compared with top surgery (55.9%). Almost all (99.3%) respondents had had an HIV test in their lifetime, with reported HIV prevalence differing between AMAB (34.2%) and AFAB (7.9%) respondents. PrEP uptake among HIV-negative AMAB respondents was 30.4%, and 5.7% among AFAB respondents, while 78.0% of TGD people living with HIV were on antiretroviral treatment. Conclusion. Findings demonstrate a critical gap between needed and actual access to legal and medical gender-affirming care services. There is an urgent need for the provision of integrated and accessible gender-affirming care and HIV services as part of comprehensive care for TGD populations within inclusive health systems nationally

Enhancing cervical cancer screening coverage in selected primary healthcare sites using Lean thinking: The CerviScreen programme

Background. Cervical cancer is the most common malignancy among South African (SA) women of reproductive age, with women living with HIV (WLWH) facing a six-fold higher susceptibility. The National Department of Health recommends baseline cervical cancer screening (CCS) for WLWH upon HIV diagnosis. SA’s reported CCS rate is 19.3%, despite the World Health Organization (WHO)’s recommended 2030 target of 70%. AIDS Healthcare Foundation initiated the CerviScreen programme to improve CCS rates using Lean thinking. Objectives. To evaluate the effect of the programme on CCS coverage over a 7-month period at selected sites in the Eastern Cape and KwaZulu-Natal provinces of SA. Methods. This quantitative, controlled before-and-after study retrospectively evaluated changes in CCS coverage at purposively selected quality improvement programme (QIP) sites, compared with matched control sites. Key CCS indicator data from Lean A3 tools were analysed. Repeated analysis of variance measures tested changes in CCS proportions over time, at a p<0.05 significance level. Results. Nine CerviScreen and nine control sites per province were assessed. Significant increases in CCS mean proportions were observed at QIP sites in KwaZulu-Natal (5% - 62.9%; F=8.336, p<0.001) and Eastern Cape (21.2% - 82.4%; F=15.525, p<0.001) provinces. Differences in the change of mean proportions between CerviScreen and control sites were not statistically significant in KwaZulu-Natal (F=0.022, p=0.884) and Eastern Cape (F=0.882, p=0.362). Clinically significant improvements were observed, with the estimated marginal mean at KwaZulu-Natal QIP sites consistently surpassing control sites from month 3 onwards. Eastern Cape sites maintained over 80% coverage from month 4. Screening coverage trends differed significantly between provinces (F=11.12, p=0.004). Conclusion. Lean thinking, through the CerviScreen programme, has potential to enhance and accelerate CCS among SA WLWH toward attaining the WHO target. The findings underscore the importance of adopting systematic quality improvement approaches, highlighting the need for scale-up of Lean thinking in primary healthcare settings to address underperforming indicators

Pregnancy-related pulmonary embolism: Clinical characteristics, management and outcomes in a South African academic hospital

Background. Pulmonary embolism (PE) is a leading cause of death in pregnant and postpartum women. Objective. To evaluate the clinical presentation, management and outcomes of pregnancy-related PE managed by a multidisciplinary team. Methods. A retrospective review was conducted of pregnant and postpartum women diagnosed with PE between 2018 and 2024 at a tertiary hospital in Johannesburg, South Africa. Pretest probability scores (pregnancy-adapted YEARS and Geneva) were applied in a subgroup with D-dimers available. Results. Seventy-seven women were included: 33 with antepartum and 44 with postpartum PE. The median (interquartile range) age was 29 (9) years, and most were of black African ethnicity. PE risk factors were present in 85% of antepartum and 96% of postpartum cases. Women with antepartum PE more frequently presented with chest pain, shortness of breath and palpitations (p<0.05). Pretest probability scores were assessed in a subgroup with D-dimers available. Based on the pregnancy-adapted YEARS and Geneva scores, imaging would have been required to rule out PE in 87.8% and 73.5% of cases, respectively. Computed tomography pulmonary angiography was the preferred diagnostic modality in 74.0%. Most women (97.4%) were treated as inpatients, and 57% required management in the intensive care and/or high care units. The median length of hospital stay was 14 (8) days. Low-molecular-weight heparin was the most frequently prescribed anticoagulant, with a median treatment duration of 3 (1) months. The live birth rate was 84.4%. One maternal death occurred due to sepsis, unrelated to venous thromboembolism. Antepartum/secondary postpartum major bleeding and primary postpartum major bleeding occurred in 6.5% and 3.9%, respectively. Conclusion. Pregnancy-associated PE managed by a multidisciplinary team was associated with favourable maternal and fetal outcomes

Obituary of Dr Norman M. Mabasa

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Prevalence and socioeconomic determinants of post-acute sequelae of SARS-CoV-2 among individuals from a peri-urban township and an informal settlement in Johannesburg, South Africa

Background. Individuals infected with SARS-CoV-2 who develop COVID-19 are susceptible to persistent symptoms and sequelae, referred to as post-acute sequelae of SARS-CoV-2 (PASC). The prevalence of PASC is estimated to range between 10% and 30%. However, there is a paucity of data from African countries. Objectives. To investigate the prevalence and sociodemographic determinants of PASC in a peri-urban township and an informal settlement in South Africa (SA) during the COVID-19 pandemic. Methods. A prospective cohort study was conducted among individuals residing in sampled households within the Soweto and Thembelihle Health and Demographic Surveillance System in Gauteng Province, SA. Between August 2021 and January 2022, all individuals from 214 sampled households were tested for SARS-CoV-2 and followed up for 6 months for symptoms. The prevalence of PASC, defined as persistence of symptoms through to at least 30 (PASC-30) and 90 (PASC-90) days, was evaluated, and determinants of PASC were identified using logistic regression models. Results. There were 268 individuals with documented COVID-19 illness identified, of whom 65.3% (n=175) were female. The median age was 24 years. The overall prevalence of PASC-30 was 23.9% (95% confidence interval (CI) 19.2 - 29.3), including 24.6% (95% CI 19.7 - 30.3) and 12.5% (95% CI 3.5 - 36.0) in individuals who were unvaccinated or had received a COVID-19 vaccine, respectively (p=0.283). The overall prevalence of PASC-90 was 2.2% (95% CI 1.0 - 4.8). Factors associated with PASC-30 included living in an informal (39.2%, 105/268) v. formal settlement (60.6%, 163/268) (adjusted odds ratio (aOR) 4.1, 95% CI 2.1 - 8.3), although participants living in larger households (aOR 0.8, 95% CI 0.7 - 0.9, p=0.011) were less likely to report PASC-30 than those from smaller households. Age, gender, marital status, level of education, employment status, vaccination status and the presence of comorbidities were not significantly associated with PASC. Conclusion. PASC-30 (23.9%) was prevalent at the population level in individuals with documented COVID-19, particularly among residents of informal settlements, while PASC-90 (2.2%) was low. Further exploration into PASC within informal settlements is imperative to comprehensively understand these findings

Case fatality in severe acute malnutrition: Determinants and modifiable factors in hospitalised children in Vhembe district, South Africa

Background. In 2019, one-quarter of child deaths in South African (SA) hospitals were attributed to severe acute malnutrition (SAM). Objectives. To identify demographic, clinical, case management and health system factors contributing to mortality in children aged <5 years with SAM admitted to three hospitals in Vhembe district, Limpopo, SA. Methods. A retrospective record review was conducted for children aged 6 - 59 months admitted with SAM over a 30-month period. Bivariable and multivariable regression analyses were used to determine mortality factors. Results. A total of 245 children with SAM were identified, with a median (interquartile range) age of 14 (10 - 18) months. The overall SAM case-fatality rate was 26.9% (66/245), significantly higher than routine data estimates. Key clinical factors associated with mortality included diarrhoea at presentation (odds ratio (OR) 3.34, 95% confidence interval (CI) 1.38 - 8.10), anaemia (OR 3.30, 95% CI 1.28 - 8.50), raised C-reactive protein (OR 9.29, 95% CI 2.81 - 30.76) and hyponatraemia (OR 6.64, 95% CI 2.70 - 16.31). Additional contributors included late presentation, self-referral, limited triage, poor recognition and management of comorbidities and inadequate compliance with SAM guidelines. HIV status and shock were not significant determinants of mortality. Conclusion. SAM mortality was alarmingly high, particularly in the context of a high middle-income country setting with established treatment protocols. The striking discrepancy between the observed case fatality rate and routine district health information system data highlights the need for review of data quality and reporting systems. Targeted interventions addressing both clinical risk factors and systemic gaps are essential to reduce mortality and improve outcomes for children with SAM

Persistent hypertension, albuminuria and low glomerular filtration rate in schoolchildren in Kano metropolis, Nigeria

Background. Screening for persistent hypertension, albuminuria and low estimated glomerular filtration rate (eGFR) in children may allow for early detection of kidney disease, paving the way for early intervention to slow disease progression. Objective. To determine the prevalence of persistent hypertension, albuminuria and low eGFR and their associated factors in schoolchildren. Method. The study screened 228 schoolchildren (aged 5 - 15 years) from February 2020 to February 2021. Information about participants’ sociodemographic profile and medical history was obtained through questioning. Participants’ height, weight and blood pressure (BP) were measured. Their spot urine was assessed for albumin creatinine ratio (ACR), and blood for serum creatinine and eGFR. Participants with abnormal findings had a repeat assessment after a minimum of 3 months for BP, ACR and eGFR. Results. The median (range) age was 13.0 (11.1 - 14.0) years, with 117 males and 111 females. Seventy-eight of the children (34%) had at least one abnormality (hypertension 1.8%, albuminuria 28% and low eGFR 9%) at recruitment. At follow-up, 33 (42%) of the 78 children had persistent abnormal findings (hypertension 1.3%, albuminuria 10.1%, low eGFR 6%). Persistent albuminuria was seen more commonly in girls and in children with low eGFR. Older children (>10 years) were more likely to have low eGFR. Conclusion. A two-point, multiparameter screening of children may reveal high-risk groups for kidney disease that would require further evaluation and long-term follow-up. Such screenings can be integrated into school entry health assessment programmes to allow for early detection of kidney disease