Medicine and Health Sciences Commons^™

The Effect Of Ex-Ante Government Responsibility For Health On Public Health Financing In Post Pandemic Budgets, Denis Granados, Rylee Roman, Hallie Sidman

Working Papers Series

This paper investigates how pre-pandemic levels of government responsibility for public health financing influenced post-pandemic health spending across selected OECD countries. Using a combination of descriptive analysis and regression modeling, the study examines changes in public health expenditure per capita between 2019 and 2022, focusing on key variables such as the government’s share of health financing, the Total Pandemic Policy Intensity (PPI) index, and GDP per capita. Findings suggest that while all countries increased health spending post-COVID-19, the scale of change varied significantly based on economic capacity, institutional readiness, and political will. Notably, countries with higher pre-pandemic public health investment …

Functional Resilience Of Healthcare In The Critical Juncture Of The Covid-19 Pandemic, Avner Kronisch, Christian Bongiorno, Kerane Smith, John Baker

Working Papers Series

This paper offers a comparative analysis of eight national healthcare systems—spanning democracies, autocracies, and various institutional models—to evaluate resilience during the COVID-19 pandemic. Drawing on Shvetsova et al.’s framework of informational and authority redundancies, and Parker & Klein’s “choke point” theory of healthcare rationing, we examine how institutional structure shaped pandemic response, system adaptability, and continuity of non-COVID services. Using indicators like life expectancy, under-five mortality, hospital capacity, cancer survival, and excess mortality, we explore how systems absorbed shock and maintained essential care. We find that decentralized and polycentric governance structures, when paired with coordination and resource adequacy, enhanced resilience—exemplified …

Covid-19 & Healthcare (Re)Privatization? A Comparative Analysis Of High And Medium Per Capita Gdp Countries, Kristina Donders, Kaitlyn Matthews, Brittany Reyes, Frank. H. Rizzo

Working Papers Series

This paper examines whether the COVID-19 pandemic accelerated healthcare privatization in high- and medium-GDP countries. Drawing on political economy theories of path dependence and privatization, we analyze changes in public and private healthcare expenditures in eight countries: Canada, Chile, Denmark, Georgia, Luxembourg, Norway, the Philippines, and South Korea—comparing data from 2019 and 2022. Using World Bank indicators on healthcare financing, GDP, aging populations, and food insecurity, we find that although healthcare expenditures generally increased during the pandemic, this increase was primarily in public, not private, spending. Case studies of Georgia and South Korea reveal that local economic and demographic pressures, …

Institutional Change In Healthcare As Brought About By The Critical Juncture Of The Covid-19 Pandemic, Olga Shvetsova

Working Papers Series

This introduction to the 2025 capstone symposium lays the conceptual groundwork for a new approach to analyzing institutional change in healthcare systems triggered by the COVID-19 pandemic. Departing from conventional legal-institutional perspectives, it extends the decision space framework developed by Bossert (1998) to capture both formal authority and the de-facto responsibilities exercised by public and non-public actors. By disaggregating health responsibilities across levels of government and sectors—public, private, and hybrid—and operationalizing these as quantifiable indicators over time, the framework allows for real-time and comparative assessment of institutional transformation. The pandemic is treated as a critical juncture that exposed and reconfigured …

Public Health Simulation Infused Program (Pship) Toolkit, Desiree A. Díaz, Mindi Anderson, Francisco Guido-Sanz, Peggy Hill, Samantha Stephenson, Heather Peralta, Syretta Spears, Geraldine Luzincourt

Faculty Scholarship and Creative Works

Project Narrative

PURPOSE AND NEED

Purpose: Priorities set forth by the Health Resources & Services Administration (HRSA) are addressed in the proposed simulation program in an effort to meet curricular needs and foster care to the medically underserved in Florida, further exposing students to public healthcare needs. Interprofessional (nursing and social work) and intraprofessional (undergraduate nurse and Nurse Practitioner [NP]) instruction is essential in the simulation-based education (SBE) program, promoting important content on identifying risk factors and health assessment of the medically underserved community (MUC) (Education Priority 2, §831). Coordination of medical care is a vicarious learning opportunity for all …

Comparison Between Pipeline Embolization Device (Ped) Versus Flow Redirection Endoluminal Device (Fred) For Intracranial Aneurysms: A Comprehensive Systematic Review And Meta-Analysis, Seyed Maroufi, Mohammad Fallahi, Muhammad Waqas, Othman Bin-Alamer, Manisha Koneru, Joanna Roy, Jane Khalife, Hamza Shaikh, Daniel Tonetti

Department of Neurosurgery Faculty Papers

OBJECTIVES: The performance of the Pipeline Embolization Device (PED) and relatively newer double-layered Flow Re-Direction Endoluminal Device (FRED) have been studied for the treatment of intracranial aneurysms, but direct comparisons between PED and FRED are limited. The current systematic review aims at comparing the efficacy and safety of PED and FRED.

METHODS: A systematic review of the literature was conducted according to the PRISMA guideline. PubMed, Embase, Scopus, Web of Science, and Cochrane Library were searched, and related records were identified. A meta-analysis of double-arm studies comparing PED and FRED was conducted on angiographic and clinical outcomes, retreatment rates, and …

Adipocyte/Tumor Cell Crosstalk Via Igf-1/Txnip Axis Promotes Malignancy And Endocrine Resistance In Breast Cancer, Amanda Caruso, Felice Maria Accattatis, Cinzia Giordano, Luca Gelsomino, Piercarlo Del Console, Maria Francesca Fiorita, Balazs Gyorffy, Laura Bianchi, Alfonso Carleo, Rossana De Salvo, Bruno M Simões, Robert B Clarke, Lorenzo Memeo, Cristina Colarossi, Eleonora Aiello, Francesco Conforti, Suzanne A W Fuqua, Matilde Todaro, Giorgio Stassi, Catia Morelli, Diego Sisci, Daniela Bonofiglio, Stefania Catalano, Sebastiano Andò, Ines Barone

Faculty, Staff and Students Publications

Background: Despite significant improvements in the outcome of Estrogen Receptor (ER) α-positive breast cancer (BC) following the use of endocrine therapies, resistance remains a major challenge. Clinical studies proved that obesity, in addition to promote BC progression, is associated with a reduced efficacy to these treatments, but mechanisms remain unclear.

Methods: We used co-culture systems followed by validation through an ‘ex vivo’ model of human mammary obese (Ob) adipocytes and obese endocrine-resistant metastatic Patient-Derived Organoids (PDOs). Transcriptomics with MixOmics-MINT and MetaCore Functional Tools along with lentiviral and pharmacological approaches provide insights into mechanisms. Clinical relevance was investigated using public datasets, …

Phage-Induced Protection Against Lethal Bacterial Reinfection, Yikun Xing, Haroldo J Hernandez Santos, Ling Qiu, Samantha R Ritter, Jacob J Zulk, Rachel Lahowetz, Kathryn A Patras, Austen L Terwilliger, Anthony W Maresso

Faculty, Staff and Students Publications

Bacteriophages, or phages, are viruses that target and infect bacteria. Due to a worldwide rise in antimicrobial resistance (AMR), phages have been proposed as a promising alternative to antibiotics for the treatment of resistant bacterial infections. Up to this point in history, phage use in preclinical animal studies, clinical trials, and emergency-use compassionate care cases has centered around the original observation from 1915 showing phage as lytic agent, and thus a treatment that kills bacteria. Here, we describe an activity associated with phage therapy that extends beyond lytic activity that results in long-term protection against reinfection. This activity is potent, …

How Far-Right Populism Harms Ethnic Minorities’ Health: The Case Of The United States, Dina Rosenberg

Working Papers Series

Public health is a political issue, and the health of ethnic minorities is a key component of it. We argue that far-right populism, whether grassroots or elitist, harms the health of immigrants and minorities. Anti-minority attitudes and policies—such as health chauvinism promoted by far-right populists—along with hate rhetoric and ensuing personal and institutional discrimination create a climate of hostility that negatively affects health outcomes in underprivileged communities. We hypothesize that immigrants and ethnic minorities living in such a climate are more likely to experience health problems and underutilize healthcare. To test this, we leverage the significant variation between U.S. states …

Arts-Based Sustainability: From New York To Malawi, Martha B. Lerski

Publications and Research

Recognizing that libraries serve multiple constituencies and subject areas, this chapter documents and advocates for development of transdisciplinary arts-based research (ABR) and culture-related projects linked to environmental challenges. Libraries contribute collections and spaces, as well as the research of library and information scientists. Libraries are currently among invisible contributors to sustainability planning and services. The chapter will link this invisibility to the value of what visual arts refer to as negative space elements in subjects ranging from traditional ecological knowledge to environmental science. Library collections, projects, and research contribute to education for sustainable development (ESD) as required to achieve the …

Walk A Mile: Exploring Cause-Based Charity Event Participation As A Catalyst For Increasing Physical Activity Behavior, Kimberly S. Fasczewski, Andrey A. Sanko Posada, Meg Hopkins

Journal of Social, Behavioral, and Health Sciences

Despite the known benefits of physical activity (PA), more than half of U.S. adults do not meet the American College of Sports Medicine’s PA recommendations for health, often resulting in negative health outcomes. Developing programming that increases motivation for PA participation is critical for healthcare professionals to combat physical inactivity. Previous research has demonstrated that framing disease-based PA charity fundraising events as “helping a cause” improved motivation for PA due to the individual’s emotional connection to the cause. There is currently no congruent research on motivation for participation in cause-based charity events. Behavioral economics theory posits that cognitive, emotional, and …

Association Between Health Insurance, Antiretroviral Treatment, And Hiv Preexposure Prophylaxis In Men Aged 20–85 In Virginia, Lauren Elizabeth Maxwell

Walden Dissertations and Doctoral Studies

HIV prevention and treatment disparities persist among men in Virginia, particularly in racial and ethnic minority groups. This study examined how insurance type and demographic factors influence prescriptions for antiretroviral treatment (ART) and preexposure prophylaxis (PrEP). Addressing these disparities is critical to advancing public health equity and reducing HIV rates. The purpose was to assess whether age, race, ethnicity, region, and insurance type are associated with the type of oral HIV medication prescribed. Guided by the HIV prevention and care cascade frameworks, the study focused on access and adherence. Using a cross-sectional quantitative design, the study analyzed secondary data from …

Social Exclusion And Mental Health Of Youths Affected By Parental Hiv/Aids In China: Based On A Serial Mediating Model, Jiaojiao Wan, Lili Ji, Zheqian Wang, Junfeng Zhao, Xiaoming Li

Faculty Publications

The mental health of youth living with patients with HIV needs focused attention. The primary source of psychological distress they experience may stem from social exclusion. Therefore, the current study was designed to explore the relationship between social exclusion and mental health among youths affected by parental HIV/AIDS in rural China.

Methods

297 youths affected by parental HIV/AIDS were recruited to completed questionnaires of social exclusion, perceived stress, future orientation and mental health. The bootstrap method was used to examine the mediation effects.

Results

It showed that: (1) the social exclusion (M = 32.48, SD = 15.25) significantly and …

Impact Of An Adapted Diabetes Prevention Program In A Spanish Primary Care Setting: Protocol For A Type Ii Hybrid Effectiveness-Implementation Cluster-Randomized Trial (Aladim), Miquel Bennasar-Veny, Manuela Abbate, Miquel Colom-Rosselló, Laura Capitán-Moyano, Ivonne C Hernández-Bermúdez, Ignacio Ricci-Cabello, Aina M Yañez, Maria E Fernandez

Faculty, Staff and Student Publications

Background: Type 2 diabetes (T2D) is a global health concern affecting 10.5% of the adult population and is projected to rise significantly in the coming decades. Lifestyle modification programs, such as the Diabetes Prevention Program (DPP), can effectively reduce T2D risk among individuals with prediabetes. However, their implementation in real-world healthcare settings remains poor, particularly in Spain, where T2D prevalence is the highest in Europe. The ALADIM study aims to evaluate the effectiveness and implementation of an adapted DPP in Spanish Primary Care Centers (PCCs). The primary effectiveness outcome is weight, the co-primary implementation outcome is implementation fidelity. We will …

Longitudinal Outcomes Of The Covid-19 Pandemic On Youth Physical Fitness, Andjelka Pavlovic, David Leonard, Timothy J Walker, Derek W Craig, Jizyah Injil, Laura F Defina

Faculty, Staff and Student Publications

Importance: The COVID-19 pandemic led to a decline in physical activity levels among youths, which could have a negative impact on their fitness.

Objective: To examine longitudinal changes in cardiorespiratory fitness (CRF) and musculoskeletal fitness (MSF) among students at schools participating in a school-based physical activity program during fall 2019 through spring 2023.

Design, setting, and participants: This longitudinal cohort study included US schools reporting CRF and MSF data at least once during the pandemic (fall 2020 to fall 2021) and at least 1 additional time before or after. In a subset of schools for which learning modality data was …

The Evolvement Of The 100 Most Cited Articles In Spine Surgery In The Last Decade Compared To All-Time, Mark Miller, Matthew Meade, Ruchir Nanavati, William T Diciurcio, Maneesha Palakurthi, Adam Kohring, Justin Le, Christopher Giuditta, Christopher Kepler, Barrett Woods

Rowan-Virtua School of Osteopathic Medicine Departmental Research

BACKGROUND: Decision-making in spine surgery is continuously shaped by advancements in the field through evidence-based medicine. This is demonstrated through the evolution of the quality and impact of scientific research within the field of spine surgery. To date, there is limited literature investigating interval changes in methodological rigor of scientific investigation within the field of spine surgery.

METHODS: The top 100 cited articles were recorded for manuscripts from January 1, 2013, to December 31, 2023, and the top 100 most cited manuscripts of all time for spine surgery, via the Scopus abstract and citation database. Data collected included year of …

Improving Health Information Systems For Universal Health Coverage In The Philippines, Catherine Agas Chung, Jenilyn Ann Vergara Dabu, Fiona Rose Andres Norada, Arianna Maever Loreche, Veincent Christian Pepito, Manuel M. Dayrit

Ateneo School of Medicine and Public Health Publications

Health information systems are a key building block of a well-functioning health system and are a vital component in the implementation of universal health coverage. The Philippines's current transition toward universal health coverage had attendant health information system reforms, such as the establishment of the country's National Health Data Repository and the Health Sector Enterprise Architecture. However, many issues remain in this transition, such as insufficient investments in health information systems, poor reliability of health information systems, technical support delays, data quality issues, and cybersecurity issues. We recommend making health data portable throughout the health system while adhering to data …

Prevalence And Associated Factors Of Mental And Substance Use Problems Among Adults In Kenya: A Community-Based Cross-Sectional Study, Patrick Nzivo Mwangala, Anita Kerubo, Millicent Makandi, Rachel Odhiambo, Amina Abubakar

Institute for Human Development, East Africa

Data on the burden and determinants of mental and substance use problems among women in urban and rural informal settlements in Kenya is sparse, thus limiting preventive and treatment efforts in these areas. To bridge the gap, we (a) determined the prevalence of depressive, anxiety and post-traumatic stress disorder (PTSD) symptoms and alcohol and drug use problems among women compared to their spouses and (b) examined the correlates of these outcomes. Data collection for this cross-sectional survey was conducted in 2022 in Mombasa, Kwale and Nairobi counties in Kenya. A total of 1528 adults (1048 women) took part. The 9-Item …

Insights On Human Papillomavirus Among Medical Students And Professionals, Fathima Thansiha, Amogha Shree, Rashmi S

Digital Journal of Clinical Medicine

Background: As per World Health Organization, in 2022, 660000 women were diagnosed with cervical cancer worldwide and 350000 women died from the disease. Sexual behaviour is the major risk factor and exposure to Human Papillomavirus has been established as a causative agent in 70-80% of the cases for development of cervical cancer. Most infections with HPV resolve spontaneously and cause no symptoms, persistent infection can cause cervical cancer in women. Effective primary (HPV vaccination) and secondary prevention approaches (screening and treating precancerous lesions) will prevent most cervical cancer cases. Thus, study was conducted with the objective of assessing the knowledge …

Mechanisms Of Interventions Targeting Modifiable Factors For Dementia Risk Reduction, Anna Matton, Ruth Stephen, Makrina Daniilidou, Mariagnese Barbera, Vilma Alanko, Marcel Ballin, Jamie Ford, Katri Hemiö, Jenni Lehtisalo, Chinedu Momoh

Brain and Mind Institute

The global prevalence of dementia is increasing. With no widely available and accessible treatments to halt or reverse the progression of dementia, exploring preventative strategies is critical. Lifestyle-based interventions show promise in preventing or delaying dementia onset. However, understanding the complex and multifactorial mechanisms underlying dementia, and how interventions target these pathways, is essential for developing personalized and effective strategies. In this review, we examined the current evidence of the mediating pathways in dementia risk reduction. We focused on mechanisms investigated in single-domain interventions on physical exercise, cognitive training, diet, metabolic/cardiovascular or psycho-social risk factors in line with those combined …

Summary Of: Lessons Learned: Enhancing Rural Risk Communication For Future Health Crises Through The Phercc Framework, Abimbola Leslie, Elizabeth K. Woods, Eline M. Van Den Broek-Altenburg, Jan K. Carney

Northern New England Clinical & Translational Research

This study shows the importance of evidence-based, adaptive, and population subgroup sensitive communication during public health emergencies. The PHERCC framework provided a useful structure for identifying barriers, building trust, and guiding responsive strategies. Investing in inclusive communication systems and leveraging community partnerships are important for effective responses to future health crises.

Study found @ Lessons learned: enhancing rural risk communication for future health crises through the PHERCC framework

Intersectoral Interventions: Integration For Impact On Preterm Birth, Etienne V. Langlois, Maria El Bizri, Kelly Thompson, Amy Reid, Merette Khalil, Giulia Gasparri, Joy E. Lawn, Teesta Dey, Judith Robb-Mccord, Marleen Temmerman

Centre of Excellence in Women and Child Health

Progress: The last two decades have seen a growing focus on intersectoral interventions to improve maternal and newborn health and well-being outcomes, as refected in eforts to achieve the Millennium Development Goals (MDGs) and advance the Sustainable Development Goals (SDGs). Preterm births are linked to cross-sectoral determi‑ nants that afect health outcomes and human capital across the life-course, necessitating an intersectoral approach that addresses these multifaceted challenges.

Programmatic priorities: Recognizing that social, biological and economic determinants signifcantly infuence health outcomes, it is critical that robust health systems are reinforced by a comprehensive intersectoral approach. Evidence suggests that the factors infuencing …

Occupational Stress: Lifestyle And Health In Blue- And White-Collar Workers In The United States, Carice T. Craffey

Dissertations and Theses

ABSTRACT

Occupational Stress: Lifestyle and Health in Blue- and White-Collar Workers in the United States

by

Carice Craffey

Advisor: Catherine M. Schooling, Ph.D.

Background: Heart disease and diabetes are leading causes of death in the United States and globally, particularly heart disease in men. Employment conditions can contribute to illness and death. Occupational or job stress (OS) is a potential contributor to heart disease and diabetes, but its conceptualization and role for men and women remain unclear. To address this gap, I conceptualized OS, then examined the role of OS in heart disease and diabetes.

Methods: I used a literature …

Blueprint For A Youth Violence Intervention Program In East Baton Rouge Parish: Adapting Hospital-Based Strategies, Kristina G. Little, Elizabeth Winchester, Judith L F Rhodes

Reports

Youth violence in East Baton Rouge Parish remains a persistent public safety and public health challenge. This report proposes an adapted, evidence-informed model for East Baton Rouge Parish that retains the core components of traditional HVIPs while leveraging existing legal, hospital, and social service resources. The model is grounded in a public health framework and emphasizes trauma-informed, bedside intervention at the “teachable moment” when youth are most receptive to change, and long-term wraparound case management. The report concludes with recommendations for implementing this adapted approach, including identifying a health system champion, building referral protocols, embedding training, and developing a long-term …

Understanding Garden Resource Use By Low-Income Families With Children, Mai Thao, Rita S. Stephenson, Katherine R. Arlinghaus, Abby L. Gold

Journal of Human Sciences and Extension

Home gardens are an important supplemental source of food for many families and provide multiple health benefits. However, the practice of gardening may be more challenging for low-income families with limited access to gardening resources. The University of Minnesota Extension offers gardening resources, but it is unclear how these resources are used by low-income families with children. Aim 1 of the project was to understand access to and use of Extension and other vegetable gardening resources by low-income families with children. Aim 2 of the project was to develop a set of recommendations for improving access to existing resources and …

Small And Sick Newborn Care: Changes In Service Readiness Scoring Between Baseline And 2023 For 65 Neonatal Units Implementing With Nest360 In Kenya, Malawi, Nigeria, And Tanzania, Rebecca E. Penzias, Morris Ondieki Ogero, Robert Tillya, Irabi Kassim, Olabisi Dosunmu, Opeyemi Odedere, Hannah Mwaniki, Vincent Ochieng, Dolphine Mochache, William Macharia

Paediatrics and Child Health, East Africa

Health Facility Assessments (HFAs) are important for measuring and tracking service readiness for small and sick newborn care (SSNC). NEST360 Alliance aims to reduce neonatal mortality in four countries (Kenya, Malawi, Nigeria, Tanzania). NEST360 and UNICEF facilitated HFA tool design with ministries of health in four African countries and developed two complimentary approaches to summarize readiness. Using the NEST360/UNICEF HFA tool, we collected data, developed two service readiness scoring approaches for SSNC (standards-based scoring by adapted World Health Organization (WHO) health system building blocks (HSBBs) and assessing service readiness across the health system, and level-2+ scoring by WHO clinical interventions), …

What, When, And How Food And Beverage Are Advertised On Ghanian Television, Morgan Boncyk, Krystal K. Rampalli, Marian N. Winters, Muskaan K. Makkar, Silver Nanema, Gideon S. Amevinya, Amos Laar, Edward A. Frongillo Ph.D., Christine E. Blake

Faculty Publications

Food marketing has increased volume, precision, and reach to influence viewers’ food attitudes, beliefs, and eating behaviors. What and how much people eat has implications for health. While many countries regulate food advertising to protect consumers and encourage healthy eating, Ghana has none. Understanding the content and framing of food and beverage advertisements can inform the development of effective policies and practices that encourage healthier diets. This content analysis examines the foods and beverages advertised, their timing, and marketing techniques on Ghanaian television. From February to May 2020, 486 hours of advertisements were recorded. Advertisements with ≥1 actors were coded …

Using Industry-Level Characteristics To Assess The Degree To Which Interventions Engage An Employee Population, Haley C. Trust, Brett Amazon, Anthony Puline, Evan Sassenberger, Kristin Horan

The Kennesaw Journal of Undergraduate Research

Participation is an essential component in workplace health and safety programs or interventions. While those who conduct interventions often report participation rates among the overall organization, it could be useful to compare participants to industry statistics, given that health and safety risks can diverge widely among industries. Research students from Kennesaw State University analyzed a sample of published papers that focus on occupational health psychology interventions. This narrative review analyzed existing studies to look for similarities or dissimilarities between a sample of intervention participants and employees of their industry as a whole. The students considered demographic, socioeconomic, job-related, and health-related …

Epidemiology Of Shigella Species And Serotypes In Children: A Retrospective Substudy Of The Mal-Ed Observational Birth Cohort Study, Elizabeth T. Rogawski Mcquade, Jie Liu, Mustafa Mahfuz, Alexandre Havt, Furqan Kabir, Adil Kalam, Fatima Aziz, Sahrish Muneer, Najeeha Talat Iqbal, Zulfiqar Ahmed Bhutta

Department of Paediatrics and Child Health

Background: Shigellosis is a leading cause of diarrhoea in children globally. We aimed to assess the burden of specific Shigella species and Shigella flexneri serotypes, characterise their clinical syndromes and natural immunity, and evaluate their relevance as causes of diarrhoea and linear growth faltering.
Methods: In the MAL-ED birth cohort study, children younger than 17 days were enrolled from Nov 3, 2009, to Feb 29, 2012, in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, Tanzania, and South Africa and were followed up for 2 years. In this retrospective substudy, we retested Shigella quantitative PCR-positive diarrhoeal and non-diarrhoeal stool samples with molecular …

Exploring Early Childhood Development Programming In Kenya’S Arid And Semi-Arid Lands, Phyllis Magoma, Amina Abubakar, Martha Kaniala, Barack Aoko, Moses Wesala, Joyce Marangu, Susan Nyamanya, Margaret Kabue, Anil Khamis, Esther Chongwo

Institute for Human Development, East Africa

Background: Promoting high-quality early childhood development (ECD) is vital for individuals’ physical and social well-being and yields significant societal returns. However, children in marginalised regions like Kenya’s arid and semi-arid lands (ASALs) face significant barriers to accessing quality ECD services.

Aim: This study aimed to document existing ECD services in Kenya’s ASAL areas, including their availability, types and key characteristics; identify gaps in their provision and propose solutions to enhance access and quality. Setting: This qualitative study was conducted in 10 ASAL counties in Kenya.

Methods: Using purposive and snowball sampling techniques, 103 key informants, including pre-primary …