Search Results (2,734)

Accurate and scalable driver performance assessment is critical for improving road safety and reducing traffic-related injuries and fatalities, particularly in low- and middle-income countries where the majority of global road deaths occur. This paper presents an exploratory proof-of-concept framework for automated driver evaluation that combines real-world dashcam footage, YOLOv8-based object detection, and multimodal large language models (MLLMs), specifically Gemini 1.5 Flash. Two prompting strategies, narrative and rule-based, were designed to assess driver behavior against standardized licensing criteria derived from the California Department of Motor Vehicles (DMV) driving performance evaluation score sheet. The framework was evaluated across 11 manually curated driving scenarios covering intersections, pedestrian crossings, stop signs, cyclists, and emergency vehicles. Ground-truth labels were established through consensus between two traffic engineering experts cross-referencing official California DMV evaluation criteria. In this preliminary evaluation, the rule-based prompt achieved higher agreement with ground-truth assessments (10/11 scenarios, 90.9%) compared to the narrative prompt (7/11 scenarios, 63.6%), particularly in detecting clear rule violations. The narrative approach demonstrated greater contextual flexibility in ambiguous situations. These results should be interpreted as preliminary, given the small sample size, manually curated dataset, and absence of large-scale statistical validation. Nonetheless, the findings illustrate how combining visual detection with structured language-model prompting may support interpretable, policy-aligned driver evaluation. Key limitations include dependence on video quality, limited scenario diversity, absence of temporal behavioral modeling, and reproducibility constraints tied to proprietary API behavior. Future work should expand validation to larger annotated datasets, incorporate temporal sequence modeling, and explore region-specific regulatory adaptation. Full article

Background: The Mediterranean diet (MD) has well-established health benefits, yet modern food systems are driving a nutrition transition. Quantifying how Mediterranean countries have shifted relative to global trends is essential for evidence-based public health. Aim: Dietary changes between 1990 and 2018 were examined in Mediterranean coastline countries (MED) in comparison with high-income non-Mediterranean countries (HIC non-MED) and middle-/low-income non-Mediterranean countries (MLIC non-MED). Methods: Using the Global Dietary Database, within-country changes (1990 vs. 2018) for 13 food categories were analysed across 185 nations in three groups: MED countries (n = 21), HIC non-MED (n = 18), and MLIC non-MED (n = 146). MED countries were further grouped into Southern Europe (SE), Western Asia (WA), and North Africa (NA). Paired unweighted country-level analyses were the primary analyses; population-weighted analyses were sensitivity checks. Benjamini–Hochberg’s false-discovery-rate correction and centred log-ratio compositional analysis were applied. Results: MED seafood intake rose from 20.5 to 33.8 g/day (Δ = +13.3 g/day; 95% CI: +6.2 to +18.4; q = 0.003), and non-starchy vegetables increased from 135.5 to 173.6 g/day (Δ = +38.0 g/day; q = 0.626). Refined/starchy carbohydrate intake rose by 63.3 g/day in MED countries while declining by 33.6 g/day in HIC non-MED countries (between-group divergence +96.9 g/day; q = 0.006). Nuts and seeds rose across all groups; legumes declined modestly in MED countries. Saturated fatty acids + omega-6 polyunsaturated fatty acids (% kcal) rose by +0.6 percentage points in MED countries but fell in HIC non-MED countries. Monounsaturated fatty acids were stable. MED-WA showed the greatest overall divergence from the SE 1990 pattern. Conclusions: These findings highlight a public health paradox: the MD is globally promoted as a model of healthy eating, yet adherence within its region of origin is declining. Targeted, region-specific strategies are urgently needed to preserve beneficial MD elements while addressing emerging diet-related risks. Full article

Objective: To investigate the burden of environmental enteric dysfunction (EED) and its association with water, sanitation, and hygiene (WASH) and linear growth amongst infants in rural Central Java, Indonesia. Study design: A longitudinal study of 119 infants aged from 5–19 months was conducted in five villages of Wonosobo District, Central Java, Indonesia. Infant length and weight were measured at baseline and 5-month follow-up and stool samples were collected for the investigation of alpha-1-antitrypsin (AAT), neopterin (NEO), and myeloperoxidase (MPO) levels. Linear mixed-effects regression (LMER) models estimated the associations between WASH and height-for-age z-score (HAZ) on biomarker concentrations. Results: Biomarkers increased from baseline to follow-up where AAT, NEO, and MPO were elevated in 68.7%, 79.0%, and 71.4% of infants. Breastfed infants and infants with recent diarrhoea had higher biomarker levels than non-breastfed infants. After correction for multiple testing, few significant associations between EED biomarkers and WASH variables or HAZ were detected. EED biomarkers measured at baseline or follow-up were not significantly associated with growth faltering over the follow-up period. In cross-sectional analysis, compared to infants at risk of stunting (−2 < HAZ ≤ −1), infants with HAZ > −1 had lower AAT at baseline (β = −0.43, 95% CI = −0.82 to −0.05, p_adj < 0.05). Conclusions: Elevated EED biomarker levels were frequently observed and had mixed associations with WASH and HAZ, highlighting the complexity of EED and need to understand EED etiology through intervention studies. Full article

In the context of growing international recognition of geospatial information as a strategic driver of evidence-based decision-making, digital transformation, and sustainable development, robust assessment frameworks are essential for guiding the development of National Spatial Data Infrastructures (NSDIs). This paper presents the first baseline assessment of Senegal’s NSDI using the United Nations Integrated Geospatial Information Framework (UN-IGIF). Drawing on the UN-IGIF Diagnostic Tool, supplemented by surveys, semi-structured interviews, and multi-stakeholder consultations, the analysis reveals a low overall maturity level (33/100), despite relatively better performance in institutional governance and geospatial data availability. Significant weaknesses persist in the areas of legislation, funding, standards implementation, innovation, partnerships, communication, and capacity building. The findings confirm the relevance of the UN-IGIF for assessing challenges related to geospatial governance in Francophone African countries and identify priority areas for reform, including strengthening coordination mechanisms, legal and regulatory modernization, sustainable financing, and strategic planning. By providing empirical evidence on both the NSDI maturity level and the operational applicability of the UN-IGIF, this study contributes to the international literature on geospatial governance and offers a solid foundation for future reforms in Senegal and other low- and middle-income countries. Full article

Enterotoxigenic Escherichia coli (ETEC) is a leading cause of bacterial diarrheal illness in low- and middle-income countries and among travelers to endemic regions, impacting morbidity and mortality and impairing childhood development. Despite its significant importance in public health, the propensity of ETEC diarrhea in endemic settings is influenced by complex interactions among epidemiological, immunological, environmental, and pathogen-related factors. This review aims to provide a comprehensive understanding of ETEC diarrhea in endemic regions by examining epidemiological trends, host immune responses, environmental determinants, and progress in current ETEC vaccine development. We discuss disease burden, seasonality, age-specific susceptibility, toxin and colonization factor diversity, and their relation to diarrheal disease severity at the community level and in hospitalized patients. In addition, we summarize current knowledge on natural immunity, including mucosal and systemic immune responses induced in ETEC-infected diarrheal patients. The review further highlights advances in ETEC vaccine development, focusing on candidate vaccines, safety, immunogenicity, protective efficacy, and challenges associated with implementation in resource-limited settings. By integrating clinical, microbiological, immunological, environmental, and public health perspectives, this review provides a multisectoral framework to better understand ETEC pathogenesis and prevention. It also highlights future research priorities, vaccine strategies, and policy interventions to reduce the burden of ETEC-associated diarrhea in endemic settings. Full article

Globally, invasive fungal diseases are increasing in incidence and are associated with high rates of mortality. A lack of effective diagnostic protocols, antifungal resistance and poor antifungal stewardship contribute to negative outcomes. Aspergillus, Candida, Cryptococcus, and Pneumocystis are the most common pathogens associated with fatal fungal diseases. These species are responsible for 90% of reported invasive fungal deaths globally. Fungal species employ a diverse and effective array of virulence factors to sabotage, evade, and manipulate host immune systems, allowing for colonisation and dissemination in vivo. Invasive fungal infections are clinically challenging, as they penetrate organs and deep tissues, contributing to the aetiology of respiratory tract, endocarditis, meningitis, and medical device infections and resulting in false negative diagnostic attempts. The 2025 WHO report outlines a lack of diagnostic and therapeutic options available, especially in low-to-middle-income countries. Geographical and economic factors impact fungal disease and mortality rates. There is an urgent need for new approaches to combat fungal diseases clinically with improved biocompatibility profiles. This timely review discusses the prevalent invasive fungal species, namely, Candida, Aspergillus, Cryptococcus, and Pneumocystis, which have high mortality rates, as identified by the WHO priority pathogen list, and discusses recent advances in the treatment of fungal diseases. This dissemination of information is an important aspect of the United Nations Sustainable Development Goals (SDGs) and One Health. Full article

Intestinal parasitic infections, particularly soil-transmitted helminths (STHs), remain a major public health concern in low- and middle-income countries. As control programs reduce infection intensity, accurate diagnosis becomes increasingly challenging. The McMaster technique has been proposed as an alternative diagnostic method for detecting human intestinal parasites; however, its diagnostic performance in human populations remains unclear. This study aimed to evaluate the diagnostic sensitivity of the McMaster technique for detecting intestinal parasites, particularly STHs. A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines and registered in PROSPERO (CRD420261298952). Electronic databases (PubMed, Scopus, Web of Science, Ovid, Nursing & Allied Health Premium, and Google Scholar) were searched up to January 2026. Studies assessing the McMaster technique in human populations and reporting sufficient data to calculate sensitivity were included. A random-effects model was used to estimate pooled sensitivity, with subgroup analyses by parasite species, geographic region, and population characteristics. Risk of bias was assessed using the the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Among the 1514 records identified through database searching, 10 studies were included in the final analysis. The pooled sensitivity of the McMaster technique was 73% (95% confidence interval [CI]: 67–78%; I² = 91.0%) for detecting any intestinal parasites and 72% (95% CI: 65–78%; I² = 93.5%) for STHs. Species-specific sensitivities were 67% (95% CI: 61–72%; I² = 80.7%) for Ascaris lumbricoides, 79% (95% CI: 57–91%; I² = 96.9%) for Trichuris trichiura, and 71% (95% CI: 61–80%; I² = 89.9%) for hookworms. The McMaster technique demonstrates moderate sensitivity for detecting intestinal parasites in humans. While it offers practical advantages for field applications, its reduced sensitivity in low-intensity infections limits its utility as a standalone diagnostic tool in control and elimination settings. Further research should focus on methodological standardization and integration with more sensitive diagnostic approaches. Full article

Universal Design for Learning (UDL) is increasingly recognised as an evidence-based framework for promoting inclusive education through flexible curriculum design. In 2015, Ghana adopted UDL in its inclusive education policy to address the diverse educational needs of all children. However, existing research has not developed instruments to assess teacher educators’ incorporation of UDL-aligned practices in preservice teacher preparation, particularly true in low- and middle-income countries. In this study, we developed and explored the factor structure of the UDL Incorporation Scale (UDL-IS) and examined teacher educators’ self-reported incorporation of UDL-aligned practices in their preparation of preservice teachers in Ghanaian colleges of education for future teaching. A cross-sectional survey was conducted among 156 teacher educators from three public colleges of education in Ghana. The 36-item UDL-IS, which was developed using the Centre for Applied Special Technology (CAST) UDL Guidelines, was derived from considerations/checkpoints across the three core UDL principles of representation, engagement, and action and expression. We used descriptive statistics to summarise the data, reliability analysis to assess internal consistency, and exploratory factor analysis to examine the scale’s factor structure. The exploratory factor analysis provided preliminary evidence of a multidimensional structure comprising three empirically derived and conceptually interconnected dimensions: Engagement, Relevance and Meaningful Learning; Action, Expression and Strategic Learner Support; and Reflective and Socially Responsive Learning. These dimensions drew on practices across the original CAST principles rather than reproducing the theoretical three-domain structure. The three empirical dimensions demonstrated acceptable to excellent internal consistency. Among the 132 participants with complete data across the 35 retained items, teacher educators generally reported high incorporation of UDL-aligned practices. Reflective and Socially Responsive Learning recorded the highest mean, followed by Action, Expression, and Strategic Learner Support, while Engagement, Relevance, and Meaningful Learning recorded the lowest mean. Regression analyses showed distinct associations between selected demographic and professional characteristics and reported UDL incorporation across the empirical dimensions; however, most models were not statistically significant, and individual coefficients were therefore interpreted with caution. This study provides preliminary psychometric evidence for the UDL-IS as a measure of teacher educators’ reported incorporation of UDL-aligned practices in preservice teacher preparation and suggests that these practices may be organised around interconnected pedagogical dimensions within the Ghanaian teacher education context. Further research using larger, independent samples is needed to examine the factor structure through confirmatory factor analysis and provide additional evidence of the scale’s psychometric properties. Full article

Background: Measles remains a major cause of morbidity and mortality among children in low- and middle-income countries (LMICs), despite widespread implementation of routine two-dose measles-containing vaccine (MCV) schedules. Serological assessment provides an objective measure of vaccine-induced immunity; however, evidence describing post-vaccination serological protection among children in LMICs remains fragmented and methodologically heterogeneous. Objective: To synthesize evidence on serological protection following routine two-dose MCV among children aged 1–5 years in LMICs and to identify determinants of immunity, methodological limitations, and evidence gaps relevant to immunization programmes. Methods: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines and prospectively registered in PROSPERO (CRD420261300545). Literature searches were conducted in PubMed, MEDLINE, Scopus, Cochrane Library, CINAHL (EBSCO), and SciSpace on 21 January 2026. Two reviewers independently screened studies, extracted data, and assessed quality of evidence using Joanna Briggs Institute critical appraisal tools. Substantial clinical and methodological heterogeneity precluded meta-analysis; therefore, findings were synthesized narratively. Results: Eighteen studies met the eligibility. These studies were from 14 LMICs across four WHO regions (61.1% African Region, 27.8% Eastern Mediterranean Region, 5.6% each South-East Asia and the region of the Americas). Reported MCV seroprotection following completion of the two-dose schedule generally ranged from 30.6% to 100%, with the highest levels (87–100%), but with evident lower protection in specific settings, such as rural Pakistan (30.6%) and Ethiopia (40–54%) despite having documented vaccination records. Lower protection was consistently associated with undernutrition, human immunodeficiency virus (HIV) infection, incomplete or delayed vaccination, younger age at first dose, and weak programme performance. Considerable variability was observed in study design, vaccination schedules, laboratory assays (ELISA, PRNT, haemagglutination inhibition, and others), seroprotective thresholds, timing of antibody assessment, and participant characteristics. Risk of bias was largely moderate-to-high, and certainty of evidence ranged from low to very low. Conclusions: Routine two-dose measles vaccination generally provides substantial serological protection among children aged 1–5 years in LMICs. Nevertheless, methodological heterogeneity and geographical evidence gaps limit direct comparisons and reduce confidence in cross-study interpretation. Greater standardization of serological assessment and thresholds, harmonized reporting methods, and well-designed longitudinal studies are needed to strengthen the evidence base and support immunization policies aimed at achieving and sustaining measles elimination. Full article

Background: Wastewater and Environmental Surveillance (WES) has become a useful public health tool as an early-warning system revealing emergence/re-emergence of pathogenic diseases and spread of antimicrobial resistance (AMR). We characterized the taxonomic composition, relative abundance, and antibiotic resistance genes (ARGs) of wastewater-identified bacterial pathogens across socioeconomically and epidemiologically diverse sewerage catchments in Nairobi, Kenya—a key East African urban city representing a low- and middle-income country (LMIC). Results: Metagenomic analysis of Nairobi’s wastewater revealed distinct bacterial and antimicrobial resistance (AMR) profiles. Campylobacteraceae (52.5% ± 17.9%) and Bacteroidaceae (19.8% ± 9.9%) dominated the communities. While Arcobacter cryaerophilus was ubiquitous, Bacteroides fragilis and A. suis abundances varied by neighborhood socioeconomic status. We detected critical clinical pathogens—including Escherichia coli, Vibrio cholerae, Mycobacterium tuberculosis, and the ESKAPE species—alongside 207 distinct ARGs conferring resistance to 11 antibiotic classes. Both taxonomic and ARG compositions showed high spatial heterogeneity, with maximum variation in low-income areas. Temporal analysis captured shifting pathogen dynamics, and metagenomic abundances for Vibrio cholerae and Klebsiella pneumoniae were validated via qPCR. Conclusions: Our findings underscore the utility of WES as a scalable, non-invasive public health tool. By capturing community-level pathogen composition and AMR dynamics, WES bypasses the limitations of clinical diagnostic access, providing a vital early-warning system for underserved urban populations. To maximize its public health utility, environmental genomic signals must serve as actionable triggers for coordinated One Health responses, including targeted clinical diagnostics, localized antimicrobial stewardship reviews, proactive risk communication, and prioritized sanitation infrastructure upgrades. Full article

Background/Objectives: Tanzania is a low-to-middle-income-country (LMIC) which endures significant adverse impact from HIV-1- and HPV-associated malignancies. We investigated the performance of visual inspection with acetic acid (VIA) compared to the Pap smear. Methods: Screening performance was assessed in a cross-sectional study design across rural catchment clinics in Bagamoyo and Chalinze, and an urban site, Ocean Road Cancer Institute (ORCI), in Dar es Salaam. Pap smears were performed and were read in triplicate by readers blinded to HIV status and patient demographic data. Blood samples were collected for HIV status confirmation. All cytopathology, VIA, and HIV status data were compared with patient demographic factors. Results: Here we present results from 672 patients. Analysis of participants across the cohort revealed a high rate of HIV (25%) and exchange of “sex for money” in the rural site of Chalinze. Bagamoyo and ORCI had slightly lower HIV rates of about 16% and 12%, respectively. Despite the high HIV rates in Chalinze (25%), there was a contrastingly low-level of detectable lesions by VIA (9%) in this region. Conclusions: Overall, VIA-positive cases were 26% HSIL-positive, whereas VIA-negative cases were 14% HSIL-positive, suggesting that performance of VIA is limited. Full article

Background/Objectives: Trauma remains a leading global cause of mortality and morbidity, particularly in low- and middle-income countries. Multitrauma patients often require intensive care and exhibit high mortality rates. Prognostic scoring systems such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) and Revised Trauma Score (RTS) are widely used to predict outcomes; however, their performance in middle-income settings like Turkey has not been well established. This study aimed to evaluate the prognostic accuracy of APACHE II and RTS in predicting intensive care unit (ICU) mortality among multitrauma patients. Methods: This retrospective observational study was conducted in the General ICU of Diyarbakır Gazi Yaşargil Training and Research Hospital between January 2022 and December 2024. Adult patients (≥18 years) with multitrauma involving at least two anatomical regions were included. Demographic data, clinical scores (APACHE II, RTS, Sequential Organ Failure Assessment [SOFA], Injury Severity Score [ISS], Trauma and Injury Severity Score [TRISS]), laboratory parameters, complications, and outcomes were recorded. Univariate and multivariate logistic regression analyses identified independent predictors of ICU mortality. Receiver operating characteristic (ROC) analysis assessed the discriminatory ability of prognostic scores. Results: A total of 145 patients were analyzed, with an ICU mortality rate of 13.1%. Non-survivors had significantly higher APACHE II (27 ± 4 vs. 13 ± 6, p < 0.001) and SOFA scores (7 [4–13] vs. 2 [1–6], p < 0.001) and lower RTS (4.2 ± 1.7 vs. 7.2 ± 1.1, p < 0.001). Acute kidney injury, sepsis, septic shock, and mechanical ventilation were more frequent among non-survivors (p < 0.01 for all). In multivariate analysis, APACHE II (odds ratio [OR]= 1.54, 95% confidence interval [CI] 1.16–2.04, p = 0.003) and RTS (OR = 0.36, 95% CI 0.16–0.81, p = 0.013) were independent predictors of ICU mortality. ROC analysis showed excellent prognostic performance for APACHE II (area under the curve [AUC] = 0.959) and RTS (AUC = 0.888). Conclusions: In this retrospective single-center cohort, APACHE II and RTS were independently associated with ICU mortality and demonstrated good discriminatory performance for early risk stratification in critically ill multitrauma patients. The lower mortality observed in our cohort should be interpreted cautiously, as it may also reflect differences in case-mix, injury severity, ICU admission practices, and referral patterns. These findings require external validation in larger multicenter cohorts before broader generalization. Future studies should also validate the identified cut-off values and further investigate the prognostic role of biomarkers such as procalcitonin. Full article

Background: Maternal anemia remains a major public health concern in low- and middle-income countries, including Indonesia, where access to hemoglobin and iron-status measurements remains uneven. Although non-laboratory screening cannot confirm anemia or iron deficiency, digital collection of anemia-related symptoms, clinical signs, nutritional indicators, and reproductive risk factors may support preliminary risk identification in settings with limited diagnostic capacity. This study aimed to describe the nationwide implementation of a digital composite anemia-risk checklist and to examine maternal, reproductive, and regional factors associated with screening-positive status among pregnant women in Indonesia. Methods: A retrospective cross-sectional study was conducted using secondary data recorded through the e-Nutri mobile application during routine antenatal care from February to April 2025. The analysis included 205,822 pregnant women recorded across all 34 Indonesian provinces. Screening-positive anemia-related risk was defined operationally as at least one positive response among ten checklist indicators. Associations between maternal age, gestational age, parity, birth spacing, geographic region, and screening-positive status were examined using Poisson regression with robust variance estimation to obtain adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). Results: Overall, 65.3% of participants met the operational criterion for screening-positive anemia-related risk. Multiparity was associated with a higher prevalence of screening-positive status (aPR 1.20; 95% CI 1.19–1.21), as was a birth interval of less than two years (aPR 1.10; 95% CI 1.09–1.11). Screening-positive status was slightly less prevalent during the second and third trimesters than during the first trimester. Compared with Sulawesi, the adjusted prevalence was higher in Kalimantan and lower in Sumatra and Maluku–Papua. Although 91.6% of participants reported iron supplementation use, the available data did not measure dosage, duration, adherence, or biochemical response. Conclusions: Nearly 7 of 10 pregnant women are at risk of anemia. Digital symptom-based screening conducted at a national scale identified widespread maternal anemia risk and consistent associations with cumulative reproductive burden and regional context. This approach potentially offers an alternative complement to laboratory-based surveillance in resource-limited settings. Full article

Introduction: India’s immunization initiatives are among the largest globally, characterized by a substantial birth cohort of 27 million children annually, and have achieved significant progress in increasing coverage through the UIP. However, there are still challenges that persist, and multiple determinants contribute to the existing challenges; migration is one of them. Migration has always been a key driver of socio-economic and demographic changes, particularly in low and middle-income countries (LMICs). Specifically, there is a need to better understand the vulnerabilities of immunization among recent migrants. To examine this, the study explores the association between a mother’s recent migration and the full immunization coverage of children aged 12–23 months in India. Data & Methods: Our study utilized data from the National Family Health Survey-5 (2019–21). The outcome variable of interest in this study is the full immunization among children aged 12–23 months (receipt of all basic vaccinations). The primary predictor variable in this study was recent maternal migration, defined as the mother’s duration of residence at the current place of residence. We used a series of multivariate logistic regression models to examine the relationship between full Immunization among children and maternal migration status, with some data restrictions in the models. Results: The results show a 17 percentage-point difference in full immunization between children of migrant and non-migrant mothers. The adjusted odds ratios of children of mothers who had recently migrated had significantly lower odds of full immunization (aOR: 0.39, 95% CI: 0.35–0.43) compared to children whose mothers had not recently migrated. Even across the household wealth quintile and social groups, the recent migration of the mother was associated with being less likely to be fully immunized among children 12–23 months. Conclusions: The findings of this study provide significant quantitative evidence that recent migration (less than 3 years) of mother is a key factor influencing Immunization coverage and is a predictor of full immunization among children aged 12–23 months in India. The recent migration was consistently linked with lower odds of full immunization coverage across different household wealth levels and social groups. This study suggests that children of recently migrated mother are a vulnerable subgroup of the population at risk of not receiving full immunization among children aged 12–23 months. Full article

Background: Antimicrobial resistance is a growing global health challenge, particularly in low- and middle-income countries where antimicrobial stewardship (AMS) implementation and leadership capacity remain limited. Pharmacists play a central role in AMS but often lack access to structured leadership development. To address this gap, the Commonwealth Pharmacists Association developed the UK–Africa Leadership Fellowship in Antimicrobial Stewardship (UK-ALF-A), a 12-month bidirectional leadership development programme combining online learning modules, live webinars, peer-learning sessions, dual mentorship from UK- and Africa-based mentors, and workplace-based AMS continuous quality improvement projects. UK-ALF-A was designed to strengthen leadership capability among pharmacists in the United Kingdom and sub-Saharan Africa. Methods: This study evaluated changes in leadership capability among pharmacists participating in the programme and explored how fellows applied these capabilities within AMS-related practice. A mixed-methods evaluation was conducted with 40 fellows (20 UK, 20 Africa), using pre- and post-programme self-assessments and 360-degree colleague feedback based on the International Pharmaceutical Federation Global Advanced Development Framework (FIP GADF), alongside post-fellowship surveys and semi-structured interviews. Results: The proportion of fellows self-assessing at the highest competency level increased from 10% pre-programme to 39% post-programme, with corresponding increases in colleague feedback ratings from 17% to 49%. Qualitative data from open-ended survey responses and semi-structured interviews suggested improvements in leadership confidence, communication, and ability to influence AMS practice. Fellows reported leading prescribing improvements and multidisciplinary engagement, often without formal authority, with greater relative gains observed among Africa-based participants. Conclusions: UK-ALF-A was associated with enhanced leadership capability and contributions to AMS practice, alongside reported changes in individual and organisational practices that support broader health system strengthening, highlighting its value as a workforce development model. Full article