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01.
arXiv (CS.AI) 2026-06-16

Explainable deep learning improves human mental models of self-driving cars

arXiv:2411.18714v3 Announce Type: replace-cross Abstract: Self-driving cars increasingly rely on deep neural networks to achieve human-like driving. The opacity of such black-box planners makes it challenging to accurately anticipate when they will fail, with potentially catastrophic consequences. While research into interpreting these systems has surged, most of it is confined to simulations or toy setups due to the difficulty of real-world deployment, leaving the practical utility of such techniques unknown. Here, we introduce the Concept-Wrapper Network (CW-Net), a method for faithfully explaining the behavior of machine-learning-based planners that causally grounds their reasoning in human-interpretable concepts without sacrificing performance. We deploy CW-Net on a real self-driving car and show that the resulting explanations improve the human driver's mental model of the vehicle, allowing them to better predict its behavior, particularly in surprising situations. This demonstrates that explainable deep learning integrated into self-driving cars can be both understandable and useful in a realistic deployment setting. We anticipate our method could be applied to other safety-critical systems, such as autonomous drones and robotic surgeons, as well as to other architectures, such as end-to-end learning systems and vision-language-action models. Overall, our study establishes a deployment-validated pathway to interpretability for autonomous agents, which could help make them more transparent and safe.

02.
arXiv (CS.LG) 2026-06-11

Density estimation for Hellinger via minimum-distance estimators: mixtures of Gaussians, log-concave, and more

arXiv:2606.11469v1 Announce Type: cross Abstract: We study the task of density estimation, where we hope to accurately estimate a probability density from $n$ samples. A textbook method for density estimation in total variation distance is the minimum-distance estimator approach, where we conclude both the algorithm and the analysis merely from bounding the VC dimension of a particular concept class (the so-called Yatracos class). While this technique has originally yielded sharp guarantees primarily for total variation distance, in this work we extend the minimum-distance estimator approach for learning within Hellinger distance. Our main observation is that we may produce an analogous recipe for Hellinger (where we only require bounding the VC dimension of a related concept class) by drawing connections to recent results yielding reverse data processing inequalities. This recipe is flexible enough to accommodate fast algorithms originally designed for total variation distance; by modifying the approach of Acharya et al. (2017) we conclude the first near-linear time algorithm for learning classes including univariate mixtures of log-concave densities and mixtures of Gaussians (with arbitrary variances), with near-optimal sample complexity.

03.
medRxiv (Medicine) 2026-06-12

Does the method matter? Evaluating the effectiveness, efficiency and ease of hearing-aid gain self-adjustment

In conventional hearing-aid personalisation, clinicians cannot hear what their patients hear, and patients cannot often reliably detect or describe what they hear. Self-adjustment avoids this issue but requires user controls that adjust hearing-aid signal processing parameters to be effective, efficient and easy. In this study, we explored (a) the roles of interface complexity and stimulus type in the self-adjustment of hearing-aid gain, and (b) how well individuals can adjust one sound to match another to assess the same interfaces and stimuli. Adult hearing-aid users with mild to moderate symmetrical sensorineural hearing loss repeatedly adjusted the gain (a) to their preference from individual prescription (n = 41) and (b) to match their previous preferences from a random starting point (n = 32) using three interfaces representing different bass/mid/treble configurations and three stimuli (music, speech and speech-in-noise). The large interindividual variability in self-adjusted gains clustered into three patterns of deviation from initial prescription: increased relative bass, overall gain reduction, and close to initial prescription. There were no substantial effects of interface nor stimulus on self-adjustment reliability (median {sigma} = 2.8 dB), whereas absolute sound-matching error increased with increasing interface complexity and centre frequency. Neither individual matching accuracy nor questionnaire responses predicted either self-adjusted gains or reliability. Overall, these results show that many - but not all - hearing-aid users can adjust gains with reasonable reliability, and while it can be difficult to predict the behaviour from the individual, the individual applies a similar self-adjustment behaviour across different interfaces and stimuli.

04.
arXiv (CS.LG) 2026-06-18

Quantifying and Auditing LLM Evaluation via Positive–Unlabeled Learning

arXiv:2606.19057v1 Announce Type: cross Abstract: Large Language Models (LLMs) are increasingly used as judges for scalable evaluation, yet such LLM–as–a–Judge systems exhibit systematic biases that are decoupled from semantic quality, most notably verbosity bias. Meanwhile, human supervision is costly and typically selective, yielding reliable positive judgments but leaving most outputs unlabelled and potentially mixed in quality. We formulate LLM evaluation under selective human supervision as a positive–unlabelled learning problem and propose a geometric auditing framework based on Partial Optimal Transport. By aligning a small set of human–verified positives with a reliable subset of unlabelled outputs in a fixed embedding space, our method identifies human–consistent preferences and corrects biased judges without retraining. Experiments demonstrate improved alignment with human preferences, increased robustness to presentation biases, and interpretable confidence estimates, offering a scalable and statistically grounded alternative to existing LLM–as–a–judge pipelines.

05.
arXiv (math.PR) 2026-06-19

Finite-Sample Bounds for Expected Signature Estimation under Weak Dependence

arXiv:2605.20541v2 Announce Type: replace-cross Abstract: The expected signature uniquely determines the law of a random rough path under a moment-growth condition, yet finite-sample bounds for estimating its truncations from a single long dependent trajectory remain unavailable. We study a strictly stationary stochastic process equipped with a geometric rough-path lift, observed in non-overlapping blocks of equally-spaced samples, and prove a non-asymptotic mean-squared error (MSE) bound for the block-averaging estimator of its truncated expected signature. Under moment and stationarity assumptions together with a direct covariance-decay condition on block signatures – strictly weaker than $\alpha$-mixing and applicable to long-range-dependent processes – the error separates into a discretization term and a fluctuation term, with rates determined respectively by path regularity and dependence strength. A levelwise rough-factorial variance analysis keeps finite-truncation constants explicit and yields an optimal allocation rule under a fixed observation budget. We verify the assumptions for independent-coordinate fractional Ornstein–Uhlenbeck processes in three regimes: short-range (Hurst $1/41/2$. Monte Carlo experiments show empirical slopes steeper than the guaranteed upper-bound rates.

06.
arXiv (CS.CV) 2026-06-15

Visual Quality Score Assessment of Large White Goods in Remanufacture with Multi-View Deformable-DETR

Remanufacturing large white goods is essential for a circular economy, yet visual quality assessment remains a manual bottleneck for training and pricing. Conventional detection methods require extensive annotation and struggle with small defects in high-resolution multi-view data. We present a multi-view framework based on Deformable-DETR for automated quality scoring that aggregates information across redundant views to extract fine-grained features. To enhance robustness with limited labels, we employ self-supervised pretraining followed by supervised fine-tuning on expert-annotated scores. Additionally, a linear projection over frozen feature maps identifies regions of interest to explain model decisions. Evaluated on an industrial multi-view dataset, our approach delivers precise quality assessments while reducing reliance on manual annotation and per-part customization, enabling scalable and transparent inspection for remanufacturing lines.

07.
arXiv (CS.AI) 2026-06-18

Efficient Zeroth-Order Federated Finetuning of Language Models on Resource-Constrained Devices

arXiv:2502.10239v3 Announce Type: replace-cross Abstract: Federated Learning (FL) is a promising paradigm for finetuning Large Language Models (LLMs) across distributed data sources while preserving data privacy. However, finetuning such large models is challenging on edge devices due to its high resource demand. Zeroth-order Optimization (ZO) estimates gradients through finite-difference approximations, which rely on function evaluations under random perturbations of the model parameters. Consequently, ZO with task alignment provides a potential solution, allowing finetuning using only forward passes with inference-level memory requirements and low communication overhead, but it suffers from slow convergence and higher computational demand. In this paper, we propose a new ZO-based method that applies a more efficient technique to reduce the computational demand associated with using a large number of perturbations while preserving their convergence benefits. This is achieved by splitting the model into consecutive blocks and allocating a higher number of perturbations to the second block, enabling efficient reuse of intermediate activations to update the full network with fewer forward evaluations. Our evaluation on RoBERTa-large, OPT1.3B, LLaMa-3-3.2B models shows up to $3\times$ reduction in computation compared to the other ZO-based techniques, while retaining the memory and communication benefits over first-order federated learning techniques.

08.
bioRxiv (Bioinfo) 2026-06-11

Revealing trajectories of multi-modal voxel-level changes in neurodegenerative diseases using latent event mapping

Neurodegenerative diseases are driven by pathological mechanisms that can be indirectly measured in vivo using multi-modal neuroimaging. However, current computational methods that aim to reconstruct trajectories of voxel-level changes in the brain are either not computationally scalable or fully interpretable, limiting their ability to reveal associations between disease progression and underlying mechanisms. Here we introduce Latent Event Mapping (LEMING), a generative unsupervised modelling technique that learns a latent map of disease events along a common pseudo-timeline of events. We apply LEMING to amyloid PET and structural MRI data from the Alzheimer's Disease Neuroimaging Initiative to reveal the first voxel-level trajectories of events in Alzheimer's disease. Notably, we show how LEMING can provide new insights into progression-dependent disease mechanisms. We find that acetylcholine receptor density is significantly positively associated with both late-stage amyloid and atrophy events, suggesting that either these receptors are targeted later in disease progression, or that amyloid does not play an active role. This has strong implications for therapeutics that target acetylcholine receptors, particularly for early-stage intervention strategies.

09.
arXiv (CS.CV) 2026-06-12

Diffusion Transformer World-Action Model for AV Scene Prediction

Action-conditioned world models let an autonomous vehicle predict future camera scenes from its own planned controls, enabling planning and simulation without real-world rollouts, but at compact, trainable scale the futures are ambiguous and the field's standard distortion metrics actively mislead: they reward a blurry regression mean over a realistic prediction. We confront this with a compact latent world model that, given the present front-camera latent and a sequence of ego-actions, predicts future scene latents a frozen decoder renders to $256 \times 256$ frames up to 8 seconds ahead, evaluated on 150 held-out nuScenes scenes. We first benchmark where to predict: across six frozen encoders spanning four representation families, V-JEPA2 with temporal context reduces steering RMSE by 40% over the best single-frame encoder. We then train a latent Diffusion Transformer (DiT) and, through a controlled diagnosis, identify the four ingredients it needs: spatial tokens, the $x_0$ objective, residual anchoring, and sampling matched to target uncertainty. In a Stable-Diffusion-VAE encode-predict-decode pipeline we expose the central tension: distortion metrics (cosine similarity, SSIM) favor the blurry mean, masking that the diffusion model is far closer to the real frame distribution. Inception-based FID and KID reveal a clean perception-distortion frontier: diffusion attains KID 0.078 versus 0.375 for regression ($4.8\times$ better), and a deployable train-derived calibration makes this practical without test-time ground truth. The model is genuinely action-controllable (steering drives scene displacement, Spearman $\rho = 0.81$, vs $-0.18$ for regression). We trace limited single-pass motion to a shared-present anchor and engineer a compact 1.7M-parameter "jump" model that recovers full ground-truth motion magnitude ($1.02\times$ GT), where single-pass models capture less than half.

10.
arXiv (CS.AI) 2026-06-11

Bimanual Robot Manipulation via Multi-Agent In-Context Learning

arXiv:2604.20348v2 Announce Type: replace-cross Abstract: Language Models (LLMs) have emerged as powerful reasoning engines for embodied control. In particular, In-Context Learning (ICL) enables off-the-shelf, text-only LLMs to predict robot actions without any task-specific training while preserving their generalization capabilities. Applying ICL to bimanual manipulation remains challenging as the high-dimensional joint action space and tight inter-arm coordination constraints rapidly overwhelm standard context windows. To address this, we introduce BiCICLe (Bimanual Coordinated In-Context Learning), the first framework that enables standard LLMs to perform few-shot bimanual manipulation without fine-tuning. BiCICLe frames bimanual control as a multi-agent leader-follower problem, decoupling the action space into sequential, conditioned single-arm predictions. Evaluated on 13 tasks from the TWIN benchmark, BiCICLe achieves 70.5% average success rate, outperforming the best training-free baseline by 6.1 percentage points and surpassing most supervised methods. We also demonstrate superior real-world performance on 3 tasks without hardware-specific retraining.

12.
arXiv (CS.AI) 2026-06-16

Topological Flow Matching

arXiv:2606.15897v1 Announce Type: cross Abstract: Flow matching is a powerful generative modeling framework, valued for its simplicity and strong empirical performance. However, its standard formulation treats signals on structured spaces, such as fMRI data on brain graphs, as points in Euclidean space, overlooking the rich topological features of their domains. To address this, we introduce topological flow matching, a topology-aware generalization of flow matching. We interpret flow matching as a framework for solving a degenerate Schrödinger bridge problem and inject topological information by augmenting the reference process with a Laplacian-derived drift. This principled modification captures the structure of the underlying domain while preserving the desirable properties of flow matching: a stable, simulation-free objective and deterministic sample paths. As a result, our framework serves as a drop-in replacement for standard flow matching. We demonstrate its effectiveness on diverse structured datasets, including brain fMRIs, ocean currents, seismic events, and traffic flows.

13.
arXiv (CS.CV) 2026-06-12

On Pitfalls of $RemOve-And-Retrain$: Data Processing Inequality Perspective

The RemOve-And-Retrain (ROAR) benchmark is widely used to evaluate feature attribution methods, yet its validity remains underexplored from an information-theoretic perspective. We show that model- and data-agnostic post-processing of attribution maps (transformations that, by the data processing inequality, cannot add information about the decision function) can often improve ROAR scores. This means that an improved ROAR ranking is not, by itself, evidence that an attribution map carries more information about the model. We trace this failure mode to a bias toward spatially blurry masks. Experiments on CIFAR-10, SVHN, and CUB-200 show a consistent association between blurriness and ROAR performance, a pattern that also appears in the ROAD variant. We provide guidelines for more cautious removal-based benchmarking, with implications for validating mechanistic understanding of neural network internals.

14.
arXiv (CS.AI) 2026-06-16

AP-GRPO: Anchor-Gated Phonetic Alignment with Policy Optimization for Pathological Speech Reconstruction

arXiv:2606.15540v1 Announce Type: cross Abstract: Pathological speech from patients with neurodegenerative and neuromotor disorders is often acoustically distorted and linguistically fragmented, making pathological speech reconstruction necessary to recover intended textual content from distorted and incomplete speech recordings. Crucially, such recordings are rarely uniformly degraded: some words or short phrases remain reliable and can serve as audible anchors for reconstructing the corrupted surrounding content. We introduce Anchor-gated Phonetic Group Relative Policy Optimization (AP-GRPO), a GRPO framework with phonetic reward that aligns speech language models (SLMs) through audible-anchor preservation and inter-anchor phonetic compatibility to the original speech signal. AP-GRPO consists of: (i) an anchor-gated reward that matches reliable audible anchors in clear regions; and (ii) an inter-anchor phonetic alignment reward that evaluates whether recovered contents are phonetically supported by the corresponding corrupted inter-anchor speech span. Across four disease conditions, AP-GRPO improves faithful speech reconstruction, and the learned anchor constraint automatically adapts to each condition and thus reveals interpretable disease-specific profiles: conditions with severe articulatory degradation require stronger anchor enforcement, whereas milder impairment or linguistically impaired conditions rely more on phonetic alignment for inter-anchor recovery.

15.
arXiv (CS.AI) 2026-06-17

SkillJect: Effectively Automating Skill-Based Prompt Injection for Skill-Enabled Agents

arXiv:2602.14211v3 Announce Type: replace-cross Abstract: Agent skills extend LLM agents with task-specific instructions, executable scripts, and auxiliary resources, improving reusability but creating a new supply-chain attack surface. A malicious or compromised skill can be repeatedly loaded as trusted guidance and steer downstream tool use. Existing skill-based prompt-injection attacks are often manual and brittle, because explicit malicious instructions are rejected or ignored when they are not aligned with the original workflow. We propose SkillJect, the first automated framework for generating poisoned skills against skill-enabled agent systems. SkillJect uses two coordinated channels. In the artifact channel, it hides the payload inside an auxiliary helper script. In the instruction channel, it rewrites SKILL.md with a front-loaded inducement strategy, placing injected content at the beginning and framing the helper script as a mandatory prerequisite or initialization step. The rewritten instruction explicitly references the helper-script path and provides an executable example command, making the helper appear to be a legitimate setup step before normal skill operations. SkillJect further adopts a closed-loop multi-agent process to improve attack effectiveness. An Attack Agent generates poisoned skills, a Victim Agent executes downstream tasks with the poisoned skill, and an Evaluate Agent inspects execution traces to determine whether the hidden payload was executed. The Attack Agent then uses this feedback to diagnose failure causes and rewrite SKILL.md, while keeping the payload fixed. Experiments across skill-enabled platforms, backend LLMs, and attack categories show that SkillJect substantially outperforms naive direct injection and prior manual skill-injection attacks, highlighting poisoned skills as a persistent threat in reusable skill ecosystems.

16.
arXiv (math.PR) 2026-06-18

Random Schrödinger operators on manifolds and abstract bounds for multiplier-type operators

arXiv:2606.19075v1 Announce Type: cross Abstract: We study random Schrödinger operators on closed Riemannian manifolds with Anderson-type potentials. We prove high-probability spectral inclusion bounds showing that eigenvalues remain close to those of the Laplacian, with deviations controlled by a norm of the potential coefficients. Compared with deterministic bounds, this yields a square-root cancellation gain. The proof is based on a general principle showing that randomisation improves operator norm bounds for multiplier-type operators, which we formulate in both discrete and continuous settings.

17.
medRxiv (Medicine) 2026-06-15

Routine use of oral iron for people with heart failure and iron deficiency in primary care; retrospective cohort study

Aims: Iron deficiency is common among people with heart failure and associated with morbidity and mortality. While intravenous iron improves clinical outcomes, oral iron continues to be prescribed in routine practice despite limited evidence of benefit. Methods: We completed a retrospective primary care cohort study (2016 to 2021) to investigate the proportion of people with an incident diagnosis of heart failure who had iron deficiency identified (defined as ferritin

18.
arXiv (CS.AI) 2026-06-16

From Agent Traces to Trust: A Survey of Evidence Tracing and Execution Provenance in LLM Agents

arXiv:2606.04990v2 Announce Type: replace-cross Abstract: Large language model (LLM)-based agents are evolving from passive text generators into autonomous systems capable of planning, tool use, retrieval, memory access, environmental interaction, and multi-agent collaboration. These capabilities expand agent autonomy, but also make agent behavior harder to verify, debug, and audit. Final-answer accuracy alone cannot explain how an output was produced, which evidence supported each claim, whether tool calls were justified, how memory influenced later decisions, or where failures originated. This survey examines evidence tracing and execution provenance as foundations for process-level accountability in trustworthy LLM agents. We define execution provenance as the typed graph of an agent execution and evidence tracing as its projection onto evidence-support relations. This perspective connects retrieval grounding, claim support, tool-use safety, memory lineage, observability, debugging, audit, and recovery within a unified framework. We introduce a taxonomy covering trace sources, evidence and execution units, provenance relations, tracing granularity and timing, representation forms, and trust functions. We then review key methodological directions, including provenance representation, evidence attribution, tool-use provenance, runtime guardrails, provenance-bearing memory, observability, and failure diagnosis. Finally, we discuss benchmarks, datasets, metrics, and open challenges for building provenance-aware, auditable, and recoverable agent systems.

19.
arXiv (CS.AI) 2026-06-16

The Quality-Utility Paradox: Why High-Reward Data Impairs Small Model Mathematical Reasoning

arXiv:2606.16152v1 Announce Type: new Abstract: Knowledge distillation from powerful reasoning models is widely used to improve Small Language Models (SLMs) on mathematical reasoning, often assuming that traces with higher reward model scores provide more useful supervision. We identify a counterintuitive Quality-Utility Paradox in mathematical reasoning distillation. Data refined or synthesized by a stronger Oracle obtains higher perceived quality according to reward models, yet consistently underperforms traces generated by the SLM itself and selected through rejection sampling across Qwen2.5, LLaMA-3, and DeepSeek families. Our analysis shows that Oracle refinement couples logical repair with distributional drift away from the SLM's native reasoning distribution. This drift increases the learner's adaptation cost and can outweigh the benefit of improved reasoning logic. To test this mechanism, we introduce Style-Aligned Refinement, which preserves the native trajectory of the SLM while retaining logical repair from the Oracle. This intervention lowers adaptation cost and restores downstream utility. These findings suggest that effective mathematical reasoning distillation should jointly optimize perceived solution quality and learner-data compatibility, rather than relying solely on reward-model scores. The datasets and code are available at https://github.com/Dracoqhl/Quality-Utility-Paradox.

20.
medRxiv (Medicine) 2026-06-16

Daily Healthy Eating Index (HEI-2020) scoring reveals diet quality patterns masked by aggregation

The Healthy Eating Index (HEI-2020) is conventionally computed by aggregating intake across days before scoring. Digital food logging enables an alternative: scoring each day and averaging daily scores. These methods are not equivalent. The HEI's density-based structure and component caps cause aggregation to inflate adequacy scores when intake is irregular. Using Food & You data, we show daily HEI correlates more strongly with microbiome diversity, and recommend co-reporting both metrics.

21.
arXiv (math.PR) 2026-06-18

The FBSDE approach to sine-Gordon up to $6\pi$

arXiv:2401.13648v3 Announce Type: replace-cross Abstract: We develop a stochastic analysis of the sine-Gordon Euclidean quantum field $(\cos (\beta \varphi))_2$ on the full space up to the second threshold, i.e. for $\beta^2 < 6 \pi$. The basis of our method is a forward-backward stochastic differential equation (FBSDE) for a decomposition $(X_t)_{t \geqslant 0}$ of the interacting Euclidean field $X_{\infty}$ along a scale parameter $t \geqslant 0$. This FBSDE describes the optimiser of the stochastic control representation of the Euclidean QFT introduced by Barashkov and one of the authors. We show that the FBSDE provides a description of the interacting field without cut-offs and that it can be used effectively to study the sine-Gordon measure to obtain results about large deviations, integrability, decay of correlations for local observables, singularity with respect to the free field, Osterwalder-Schrader axioms and other properties.

22.
PLOS Medicine 2026-05-21

Novel symptoms associated with eclampsia could improve detection and save lives

by Alice Beardmore-Gray, Andrew Shennan Eclampsia is a life-threatening complication of pre-eclampsia, yet remains difficult to predict. In this Perspective, Alice Beardmore-Gray and Andrew Shennan highlight a recent study that identifies 10 novel prodromal symptoms of eclampsia, with potential to better predict which women are at risk and therefore reduce delays in intervention.

23.
arXiv (CS.CV) 2026-06-16

S23DR 2026: End-to-End 3D Wireframe Prediction via DETR-Style Set Prediction with Contrastive Denoising

作者:

We present WireframeDETR, our submission to the Structured Semantic 3D Reconstruction (S23DR) 2026 Challenge, which requires predicting a 3D building wireframe from multi-view COLMAP point clouds. Our method applies DETR-style set prediction directly to 3D point clouds, producing wireframes as sets of edge coordinate pairs without any intermediate vertex detection stage. We introduce three technical contributions: (1) contrastive denoising training that stabilises noisy Hungarian matching in early epochs; (2) a multi-scale encoder that aggregates the last encoder layer outputs via learned scalar weights; and (3) progressive auxiliary loss weighting that concentrates gradient signal on the decoder layers that most benefit from it. Our model achieves a public test HSS of 0.575 (F1~=~0.664, IoU~=~0.516) and a best validation HSS of 0.534 on the cleaned val split.

24.
medRxiv (Medicine) 2026-06-11

Decoding the Genetic Architecture of Autistic Traits in the Aging Population

Autism research has mostly focused on diagnostic frameworks in childhood. However, autistic traits including social skills, communication, attention switching, attention to detail, and imagination may also vary in many undiagnosed individuals beyond childhood, and the genetic architecture of autistic traits in undiagnosed aging adults remains poorly understood. Here, we performed an exome-wide association study of autistic traits in adults aged >=40 from the UK Biobank (n = 161,269) and independently validated key findings in the SPARK cohort (n = 142,357). We identified exome-wide significance at 17q21.31, represented by a lead variant associated with social skills (rs199533, beta = 0.081, P = 2.04e-11). In addition, we identified an independent signal for communication (rs12632110, beta = 0.042, P = 3.07e-12) and two independent signals for attention switching (rs690733, beta = 0.046, P = 4.26e-12; rs2164272, beta = -0.047, P = 1.73e-12). Gene-based analyses further implicated loss-of-function variation in ZSCAN2 (beta = 1.00, P = 2.44e-6), which was associated with communication differences. Enrichment analyses revealed preferential expression of implicated genes in the cerebral cortex, while phenotypic and neuroimaging analyses linked those variants to cortical brain structure and regional volume. Taken together, these findings delineate the genetic architecture of autistic traits in the aging population and link genetic variation to downstream molecular and neuroanatomical mechanisms.

25.
medRxiv (Medicine) 2026-06-15

Reaching out-of-school girls with HPV vaccination: A qualitative evaluation in six low- and middle-income countries using the RE-AIM framework

Background Infection with human papillomavirus (HPV), the primary cause of cervical cancer, disproportionately affects women in low- and middle-income countries (LMICs). While school-based vaccination of adolescent girls against HPV is highly effective, this strategy systematically excludes out-of-school (OOS) girls. Using the RE-AIM framework, we explored strategies to reach OOS girls with HPV vaccination across six African and Asian LMICs. Methods We conducted semi-structured key informant interviews with 32 vaccination program stakeholders from Cambodia, Cameroon, Kenya, Malawi, Mozambique, and Uganda between May and September 2024. Interviews explored countries implementation successes, challenges, and strategies to reach OOS girls with HPV vaccination and sustainability considerations. Data were analyzed using a hybrid team-based thematic analysis approach guided by the RE-AIM framework. Results Community outreach-based strategies, typically integrated into routine immunization outreach, were identified as the most effective approach to reach OOS girls with HPV vaccination. Targeted strategies, such as locating outreach clinics in community venues frequented by OOS girls (e.g., churches, markets) enhanced implementation. Perceived effectiveness of these strategies varied across participants, and formal assessment of effectiveness was constrained by the absence of disaggregated vaccination coverage data by school enrollment status. Some subpopulations of OOS girls (i.e., girls in nomadic or migrant communities, urban OOS girls) were not readily reached through standard outreach approaches, prompting implementation of adapted and tailored strategies for these subpopulations. Costs associated with conducting outreach in harder-to-reach areas were major barriers to reaching OOS girls, presenting challenges to the sustainability and cost-effectiveness of these approaches. Conclusions Routine community outreach platforms were widely perceived as most effective for reaching OOS girls. Strengthening disaggregated monitoring systems, adapting outreach for harder-to-reach subpopulations of OOS girls, and financing delivery models for tailored outreach strategies will be critical to improving equitable HPV vaccine coverage among OOS girls.