Background/Objectives: Maternal anemia remains a critical public health issue in Ethiopia, with iron deficiency anemia (IDA) being the most prevalent form, primarily due to low dietary iron intake and poor bioavailability from cereal-based diets. Despite the widespread cultivation of nutrient-rich amaranth in Ethiopia, its role in improving maternal iron status remains understudied. To address this gap, we conducted a cluster-randomized controlled trial to evaluate the effectiveness of amaranth grain flatbread consumption, compared to maize bread consumption, on hemoglobin concentration and IDA among pregnant women in southern Ethiopia. Methods: We conducted a six-month, community-based, parallel-group, cluster-randomized controlled trial involving 306 pregnant women with anemia (mild or moderate) to evaluate the effectiveness of locally prepared amaranth grain flatbread in enhancing hemoglobin concentration and reducing IDA, compared to the standard maize bread. At the end of the intervention, hemoglobin levels were measured, and IDA was assessed using World Health Organization (WHO) defined cutoffs of serum ferritin levels. Multilevel linear and modified Poisson regression models were used to estimate adjusted effects, accounting for confounders and community-level clustering. All analyses were conducted following the intention-to-treat principle. Results: The loss to follow-up rate was similar between the amaranth and maize groups (4.6% vs. 3.9%). In the unadjusted analysis, the mean hemoglobin concentration was higher in the amaranth group (12.39 g/dL, 95% CI: 12.17–12.61) compared to the maize group (10.17 g/dL, 95% CI: 9.95–10.39). The proportion of IDA was also lower in the amaranth group (26.71% [95% CI: 20.14–34.49] vs. 65.98% [95% CI: 57.93–73.21]). After adjusting for potential confounders (due to baseline differences after randomization) and clustering, pregnant women who received amaranth grain flatbread had higher hemoglobin levels (adjusted β = 2.67 g/dL; 95% CI: 2.41–2.90) and a 53% lower risk of IDA compared to those in the maize group (adjusted risk ratio = 0.47; 95% CI: 0.26–0.84). No serious adverse events were reported in either group. Conclusion: Consumption of amaranth grain flatbread during pregnancy improved hemoglobin levels and reduced IDA compared to maize-based diets. These findings highlight the potential of locally available, nutrient-dense foods, such as amaranth, to address maternal iron deficiency among pregnant women with mild or moderate anemia in resource-limited settings. Trial registration number: NCT06536153

Older adults with low back pain (LBP) experience challenges when seeking rehabilitation; a comprehensive view of structural factors to access is needed to inform rehabilitation delivery. We aimed to systematically map the experiences regarding structural barriers and facilitators to accessing rehabilitation among adults aged 50 years and older with LBP; and explore whether experiences vary by social factors. We conducted a scoping review based on Joanna Briggs Institute methodology. Eligible studies were qualitative and mixed-method studies (qualitative component) on structural barriers or facilitators to rehabilitation access among adults ≥ 50 years with LBP. Structural factors included socioeconomic and political contexts, governance, policies, and cultural/societal values. We searched databases from inception to February 2025. Paired reviewers independently screened citations and extracted data. We conducted a descriptive synthesis to map the structural barriers/facilitators and identify knowledge gaps. An Advisory Committee including people with lived experience, family members, and healthcare practitioners provided critical input across stages. Of the 8550 citations screened, 16 studies were relevant (3 from middle-income countries, 12 from high-income countries, 1 covering both; 12 studies on LBP, 4 studies on lumbar spinal stenosis). Common domains of structural barriers/facilitators to access were mapped for LBP and lumbar spinal stenosis in middle- or high-income countries: (1) finances (e.g., costs, insurance coverage, financial support from family); (2) location, transportation, inaccessibility or service unavailability (e.g., inadequate public transportation, wait-times, close proximity to services and resources); (3) lack of knowledge, perceptions, or stigma with certain rehabilitation approaches (e.g., limited education of treatment options provided to patients). Some older adults described ageism from providers (e.g., advised to accept back pain as part of aging) or stigma with certain rehabilitation approaches (e.g., mobility aids) as barriers. Studies in high-income countries also explored healthcare-related factors (e.g., referrals, collaboration across providers) as structural barriers/facilitators to access. Findings varied by rurality, socioeconomic strata, and disabilities. In middle- and high-income countries, older adults with LBP or lumbar spinal stenosis experience many structural barriers to rehabilitation access that vary across social factors. Structural factors relate to finances, location/transportation, availability of services, healthcare provider-related factors, ageism, and stigma. Findings inform future work towards strategies for equitable rehabilitation delivery in middle- and high-income countries. Research is needed in low-income countries.

Background: Low back pain (LBP) is a major contributor to disability and rehabilitation needs globally. A proportion of patients with LBP undergo surgery and require postsurgical rehabilitation to optimize functioning. However, many encounter barriers to accessing rehabilitation due to structurally generated inequities linked to socioeconomic position. Structural barriers to accessing rehabilitation intersect with diversity-related factors (e.g., gender, ethnicity) to perpetuate stigma and marginalization, leading to tremendous consequences. This literature needs to be reviewed to identify key themes and knowledge gaps focused on structural factors to accessing post-surgical rehabilitation. Our objectives are to conduct a scoping review of the literature to (1) systematically map the literature on the experiences with structural barriers and facilitators to accessing post-surgical rehabilitation of adults who were treated with surgery for LBP (including with or without radiculopathy, symptomatic spinal stenosis); (2) investigate whether these experiences differ when grouped by diversity-related factors (e.g., gender, ethnicity, geographic region). Methods: We will conduct a scoping review of the literature based on Joanna Briggs Institute (JBI) scoping review guidance and report it according to PRISMA-Scoping Reviews. We will search multiple databases from inception to 2025 for qualitative research exploring experiences with structural barriers or facilitators to rehabilitation access after surgery among adults with LBP. Drawing upon the World Health Organization (WHO) Action on Social Determinants of Health framework, structural factors to accessing rehabilitation will include socioeconomic and political contexts; governance; macroeconomic, social and public policies; and cultural and societal values/norms. Paired reviewers will independently screen articles and extract data. Results will be summarized and grouped by type of LBP and rehabilitation, and by intersections with diversity-related factors (e.g., gender, age, ethnicity, disabilities, geographic region). Our interdisciplinary team will engage with an Advisory Committee of knowledge users with lived experience throughout. Discussion: Aligned with WHO and EUROSPINE priorities, our scoping review will elucidate the structural barriers and facilitators influencing access to post-surgical rehabilitation for LBP more inclusively. Findings will advance knowledge of structural challenges experienced by adults needing post-surgical rehabilitation, informing rehabilitation and other healthcare strategies to remove barriers and improve functioning globally. Systematic review registration: Open Science Framework (OSF) https://osf.io/26h9w