London School of Hygiene and Tropical Medicine

Drylands, encompassing 41% of global land and supporting over 2 billion people, face significant challenges, including water scarcity, extreme temperatures, and soil degradation. Dryland spans vast areas of Middle East and North Africa (MENA) and Sub‐Sahara Africa (SSA) regions and poses a threat to food security and resilience. This study examines the potential of neglected and underutilized species (NUS) to improve dryland food and nutrition security, focusing on their agronomic performance, water productivity, economic viability, and nutritional benefits. Using long‐term data from FAOSTAT, USDA Food Data Central, and peer‐reviewed literature, we analyzed trends in the cultivation, yield, and nutritional contributions of 26 NUS across 22 countries in the MENA region comparing them with major staples—rice, wheat, and maize. Between 1961 and 2022, NUS crop areas in MENA fluctuated, decreasing by 7.0% since 2018 to 21.17 Mha. Despite this, NUS demonstrated superior water productivity—up to 30% higher than major cereals. For instance, sorghum and cowpea achieved 2.5 kg/m³ compared to maize (0.83 kg/m³) and wheat (0.91 kg/m³) and exhibited strong heat tolerance, withstanding temperatures of up to 42°C and 38°C, respectively. Despite a negative trade balance, NUS significantly contributed to dietary calories, surpassing wheat. A field experiment in Merchouch, Morocco, confirmed that NUS offered a higher economic value per unit than wheat, and outperformed conventional crops across key indicators. Integrating NUS into dryland farming systems can enhance food security, sustainability, and resilience to climate change. Advancing NUS requires breeding programs, tailored good agricultural practices, value addition and market linkage, supportive policies, and farmer education. Collaborative efforts among international organizations, governments, and civil society are crucial to mainstreaming NUS in agrifood systems and contributing to the diversity, sustainability, and resilience of dryland farming systems in MENA and SSA regions.

Introduction Obtaining informed consent for research includes the use of information sheets, which are often long and may be difficult for participants to understand. We conducted a trial to investigate whether consent procedures using a study information video coupled with electronic consent were non-inferior to standard consent procedures using participant information sheets (PIS) among youth aged 18–24 years in Zimbabwe. Methods The trial was nested within an endline population-based survey for a cluster-randomised trial from October 2021 to June 2022. Randomisation of participants to video or paper-based consent was at household level. We assessed non-inferiority in comprehension of the study using a questionnaire. The video method was accepted as non-inferior to standard consent procedures if the 95% CIs of the mean difference did not fall below the prespecified margin of 1.98. Thematic analysis was conducted on brief qualitative discussions with randomly selected youth to explore the acceptability of video and PIS within consent methods. Results Overall, 921 participants were enrolled (54% female). The median age was 20 (IQR 18–24) years. The mean comprehension score was 25.4/30 in both arms. The mean difference in comprehension between arms was −0.02 (95% CI −0.51 to 0.47) showing non-inferiority of the intervention in comprehension of study information. Youth (N=90) described both consent methods as interactive and inclusive. Those in the video consent arm felt it was exciting and youth focused. The use of imagery to explain procedures strengthened the perceived trustworthiness of the research. However, the high volume of information in both arms reduced acceptability. Conclusion Comprehension of study information using an information video is non-inferior to a paper-based consent method. Using information videos for consent processes shows promise as a person-centred and context-sensitive approach to enhance the informed consent process and should be encouraged by ethics committees.

Background We conducted three serial cross-sectional representative surveys after a mass cholera vaccination campaign in Uvira, Democratic Republic of the Congo to (1) estimate the vaccination coverage and explore heterogeneity by geographic and demographic factors; (2) examine barriers and facilitators of vaccine uptake and (3) describe the changes in coverage over time and predict future coverage. Methods We collected data on sociodemographics, self-reported vaccination status, population movement and knowledge, attitudes and behaviours related to killed oral cholera vaccines (kOCVs) in August 2021, April 2022 and April 2023, approximately 11, 19 and 30 months postvaccination. We compared the characteristics of participants by vaccination status and explored the potential role of population movement as a cause for low coverage. We used an exponential decay model to predict the proportion of the population vaccinated with ≥1 dose of kOCV over time based on age-specific coverage. Results We enrolled 8735 participants from 1433 households across all surveys. Coverage in survey 1 (August 2021) was 55% for ≥1 dose of kOCV (95% CI 51 to 60) and 23% for ≥2 doses (95% CI 20 to 27). Vaccine refusal was associated with a lack of confidence in the vaccine’s safety, and 29% of unvaccinated adults reported it was unlikely they would accept kOCVs if an additional mass vaccination campaign was conducted in their area. Coverage of ≥1 one dose of kOCV declined on average by 18% per year (95% credible interval 14 to 23) and was 39% (95% CI 36 to 43) by survey 3 (approx. 30 months after second dose campaign). Conclusions Our findings suggest that in settings like Uvira, efforts to strengthen vaccine confidence are needed to achieve higher campaign coverage, and vaccine coverage dilution may be reduced by more frequent and coordinated geographic vaccination efforts.

Background: Pregnancy within a year of childbirth has negative impacts on women and their children’s health. We developed a digital health intervention (DHI) to empower women in contraceptive choices postpartum. Our pilot randomised controlled trial (RCT) aimed to establish the feasibility of a main RCT of the effects of the DHI compared with standard care on long-acting contraception use. Methods: Our pilot RCT recruited 52, 20–24 weeks pregnant women in NHS Lothian, UK between October 2022 and April 2023. Participants were randomised 7:3 to receive either the DHI (n=37) in addition to standard care, or standard care alone (n=15). Telephone survey follow-up was at 24 weeks’ gestation and 6 weeks postpartum. Semi-structured qualitative interviews (n=10) were conducted with participants receiving the DHI. Results: All eligible women joined the study and completed follow-up. All intervention participants found the animation highly acceptable; one participant requested text message discontinuation. We completed followed up on 37/37 (100%) of participants. DHI participants reported they valued access to credible contraceptive information that supported decision making in a non-pressurised way. Conclusions: Our DHI is highly acceptable and a trial is feasible. A larger trial is needed to establish if the DHI increases uptake of long-acting reversible contraception postpartum and reduces unintended pregnancies within 12 months of childbirth. Trial registration number (Trial registration ISRCTN48521918).

Background Health systems across Europe are facing a workforce crisis, with some experiencing severe shortages of doctors. In response, many are exploring greater task-sharing, across established professions, such as doctors, nurses, and pharmacists, with patients and carers, and with new occupational groups, in particular ones that can assist doctors and relieve their workload. Case presentation In the early 2000s the United Kingdom created a new occupational role, that of physician assistant. They had a science degree and then underwent a 2-year postgraduate training course. The name soon changed, to physician associate, and the range of roles and responsibilities expanded greatly, although in a largely unregulated manner; by 2024, some were undertaking complex procedures or managing undifferentiated patients in primary care. Catalysed by some high-profile failings, this expansion has generated major concerns, over patient safety and consent, the scope of practice and preferential employment conditions of this group, the adverse consequences for medical training, and the additional medical workload involved in supervision. This has led to a widespread grassroots backlash by the medical profession, often challenging their leaders who had supported this idea. As a consequence, professional bodies that were initially in favour are now expressing serious concerns and it seems likely that the roles and responsibilities of physician associates (and related occupations) will be curtailed. We review published literature and official documentation about this policy to understand the drivers of its development, its benefits, and risks. Conclusions The experience in the UK offers cautionary lessons for other European countries contemplating similar ideas. It underscores the importance of maintaining trust with those affected by change, undertaking a detailed systems analysis with attention to risks of unintended consequences, agreeing clear role definitions, providing adequate regulatory oversight, and the need to avoid damaging training of future doctors. This case study highlights the need for a carefully thought-out approach that considers both the potential benefits and pitfalls of integrating new roles like physician associates into a healthcare system. The failure to do so has created a new occupational group with unrealistic expectations and has further demoralised an already unhappy medical profession.

Urethritis is a common condition predominantly caused by sexually transmitted pathogens such as Chlamydia trachomatis , Neisseria gonorrhoeae , and Mycoplasma genitalium . It is not possible to differentiate with certainty between pathogens on the basis of clinical characteristics alone. However, empirical antibiotic therapy is often initiated in clinical practice. The aim of this clinical practice guideline is to promote an evidence‐based syndrome‐orientated approach to the management of male adolescents and adults with symptoms of urethritis. Besides recommendations for the diagnosis, classification and choice of treatment, this guideline provides recommendations for the indication to empirically treat patients with penile urethritis. A novel feature compared to existing, pathogen‐specific guidelines is the inclusion of a flowchart for the syndrome‐orientated practical management. For suspected gonococcal urethritis requiring empirical treatment, ceftriaxone is recommended. Due to the risk of Chlamydia trachomatis co‐infection, doxycycline should also be prescribed, unless follow‐up for the treatment of possible co‐infections is assured. For suspected non‐gonococcal urethritis, doxycycline is the recommended empirical treatment. In the empiric treatment of both gonococcal and non‐gonococcal penile urethritis, azithromycin is reserved for cases where doxycycline is contraindicated. This guideline also includes detailed recommendations on differential diagnosis, pathogen‐specific treatments and specific situations, as well as patient counselling and follow‐up.

Predictive value of metabolic syndrome for prostate cancer risk is not clear. We aimed to assess the association between metabolic syndrome and its components with prostate cancer incidence. The primary outcome was prostate cancer incidence, i.e., incidence rate ratios and adjusted cumulative incidence curves derived from flexible parametric survival models. Adjusted cumulative incidence curves were derived using a flexible survival parametrical modeling framework. We analysed UK Biobank data including 242,349 adult males, recruited during 2006–2010 and followed up until 2021, during which 6,467 (2.7%) participants were diagnosed with prostate cancer. Our findings indicate that metabolic syndrome, as a whole, was not associated with prostate cancer risk (incidence rate ratios, 1.07; 95% confidence interval, 0.94–1.22). However, specific components such as hypertension and obesity increased the risk (incidence rate ratios, 1.22; 95% confidence interval, 1.03–1.44 and incidence rate ratios, 1.24; 95% confidence interval, 1.05–1.46, respectively). Other components, such as prediabetes/diabetes and low cholesterol, were associated with a reduced risk (incidence rate ratios, 0.80; 95% confidence interval, 0.67–0.94 and incidence rate ratios, 0.82; 95% confidence interval, 0.69–0.97, respectively), while hyperlipidaemia showed no significant effect (incidence rate ratios, 1.07; 95% confidence interval, 0.93–1.24). Further research is needed to understand the underlying mechanisms behind these relationships. Prostate cancer prevention strategies might benefit from targeting modifiable risk factors, particularly hypertension and obesity.

Background Takayasu arteritis (TAK) and giant cell arteritis (GCA), the most common forms of large‐vessel vasculitis (LVV), can result in serious morbidity. Understanding the molecular basis of LVV should aid in developing better biomarkers and treatments. Methods Plasma proteomic profiling of 184 proteins was performed in two cohorts. Cohort 1 included patients with established TAK (n=96) and large‐vessel GCA (LV‐GCA, n=35) in addition to healthy control participants (HCs, n=35). Cohort 2 comprised patients presenting acutely with possible cranial‐GCA in whom the diagnosis was subsequently confirmed (C‐GCA, n=150) or excluded (Not C‐GCA, n=89). Proteomic findings were compared to published transcriptomic data from LVV‐affected arteries. Results In Cohort 1, comparison to HCs revealed 52 differentially abundant proteins (DAPs) in TAK and 72 in LV‐GCA. Within‐case analyses identified 16 and 18 disease activity‐associated proteins in TAK and LV‐GCA, respectively. In Cohort 2, comparing C‐GCA versus Not C‐GCA revealed 31 DAPs. Analysis within C‐GCA cases suggested the presence of distinct endotypes, with more pronounced proteomic changes in the biopsy‐proven subgroup. Cross‐comparison of TAK, LV‐GCA and biopsy‐proven C‐GCA revealed highly similar plasma proteomic profiles, with 26 shared DAPs including IL6, monocyte/macrophage related proteins (CCL7, CSF1), tissue remodelling proteins (TIMP1, TNC) and novel associations (TNFSF14, IL7R). Plasma proteomic findings reflected LVV arterial phenotype; for 42% of DAPs, the corresponding gene was differentially expressed in tissue. Conclusions These findings suggest shared pathobiology across the LVV spectrum involving innate immunity, lymphocyte homeostasis and tissue remodelling. Network‐based analyses highlighted immune‐stromal crosstalk and identified novel therapeutic targets (e.g. TNFSF14).

Background The World Health Organization (WHO) actively promotes breastfeeding as the optimal source of nourishment for infants and young children. However, not all newborns have access to breast milk, leading to deprivation of its nutritional benefits or incurring financial burdens from alternative feeding options. Establishing Human Milk Banks (HMBs) can help ensure equitable access to donated human milk. However, several factors may hinder breast milk donation. This study aims to identify the factors influencing milk donation to HMBs in Iran. Methods We conducted a case-control study involving mothers who had given birth at least one year prior to the study. The study included 51 cases (mothers who donated their milk to HMBs) and 153 controls. Data were collected using a questionnaire designed to gather retrospective information on individual health, social networks, and other relevant factors. Logistic regression analysis was performed to examine the relationships between breast milk donation and these factors. Additionally, qualitative data were collected through face-to-face interviews with HMB senior staff and mothers. Thematic analysis was employed to identify perspectives on factors influencing milk donation. Results Family factors, social influences, individual social welfare scores, and breast milk adequacy were significantly associated with increased milk donation. Among these, family support emerged as one of the strongest predictors of milk donation. Conclusion To establish HMBs and promote human milk donation, health policymakers and planners should implement strategies that motivate mothers to donate. Evidence-based training and motivational programs for mothers and their families, which address barriers to milk donation, are essential to achieving this goal.

This opinion piece emerged from a collaboration of mental health researchers working on the National Institute of Health Research 3-schools mental health programme in underserved communities. The aim is to encourage debate and reflection on the challenges encountered with university research ethics committees when undertaking qualitative research with vulnerable young people. We explore the tension between principles of safeguarding and protection of research participants, on the one hand, and the potential for this oversight to become obstructive and thus to effectively stifle the voices and experiences of an already marginalised population, on the other hand.

Background The WHO recommends taxes on sugar sweetened beverages (SSBs) to improve population health. We examined changes in volume of and amount of sugar in purchases of soft drinks according to household income and composition, 19 months following the implementation of the UK soft drinks industry levy. Methods Data were from the Kantar Fast Moving Consumer Goods panel, a market research panel which collects data on weekly household purchases (mean weekly number of households=21 908), March 2014–November 2019. Interrupted time series analysis of volume and sugar purchases was used to estimate absolute and relative differences in the volume and amount of sugar in soft drinks, confectionery and alcohol purchased weekly by household income (<£20 000, £20–50 000 or >£50 000) and composition (presence of children (<16 years) in the household (yes or no)), 19 months after soft drinks industry levy (SDIL) implementation, compared with the counterfactual scenario based on pre-announcement trends and using a control group (toiletries). Results By November 2019, purchased weekly sugar in soft drinks fell by 7.46 g (95% CI: 12.05, 2.87) per household but volumes of drinks purchased remained unchanged, compared with the counterfactual. In low-income households, weekly sugar purchased in soft drinks decreased by 14.0% (95% CI: 12.1, 15.9) compared with the counterfactual but in high-income households increased by 3.4% (1.07, 5.75). Among households with children, sugar purchased decreased by 13.7% (12.1, 15.3) but increased in households without children by 5.0% (3.0, 7.0). Low-income households and those with children also reduced their weekly volume of soft drinks purchased by 5.7% (3.7, 7.7) and 8.5% (6.8, 10.2) respectively. There was no evidence of substitution to confectionary or alcohol. Conclusion In the second year following implementation of the SDIL, effects on sugar purchased were greatest in those with the highest pre-SDIL purchasing levels (low-income households and those with children). The SDIL may contribute to reducing dietary inequalities. Trial registration number ISRCTN18042742. Registered: August 2017.

Background Despite being an underserved ethnic minority group, characteristics which have been associated with low vaccine uptake, the Bangladeshi community in the UK exhibits high childhood vaccination uptake for several vaccines, including measles, mumps and rubella compared with several ethnic groups. This study explored key enablers for early childhood vaccination uptake among the Bangladeshi community in East London, UK. Methods A qualitative study using semi-structured interviews was conducted with 23 Bangladeshi parents 11 primary healthcare professionals (HCPs) and 5 community service providers (CSPs) involved in delivering childhood vaccination services, predominantly in the East London borough of Tower Hamlets. Parents were recruited purposively from the community while HCPs and CSPs were recruited from relevant organisations. The Social Ecological Model (SEM) was used as a theoretical framework for data collection and analysis. Data were analysed thematically. Results Multilevel vaccination enablers identified by parents, HCPs and CSPs across the different levels of the SEM included: parental trust in the immunisation programme and HCPs; a rigorous call and recall service; the normalisation of receiving childhood vaccinations within the Bangladeshi community and the availability of culturally tailored and accessible vaccination services. Conclusions This study highlights how multi-level trust in a vaccination programme can propel positive vaccine uptake in an underserved, ethnic minority population. Our findings suggest culturally sensitive, person-centred delivery of vaccination services, alongside leveraging community dynamics and trusted social networks, are imperative to meeting the informational, linguistic and cultural needs that facilitate vaccine uptake within the Bangaldeshi community. We recommend using existing trusted community networks to disseminate tailored vaccine information and actively reminding parents about due vaccinations to promote uptake amongst other underserved, ethnic minority communities with low uptake in high-income settings. Further research involving non-immunising parents is recommended to gain more comprehensive insight into vaccine decision-making within this community.

Introduction Universal health coverage (UHC) for women of reproductive ages is a critical component of country and global health strategies but most evidence in high-fertility settings is limited to maternity care. Our study aimed to comprehensively assess women’s health service utilisation and expenditure, including an equity dimension. Methods We conducted a household survey among 15–49 years as a nested study within the Magu health and demographic surveillance study, northwest Tanzania, during 2020–2021. Data were collected on self-reported health, fertility, utilisation of health services, health expenditure and health insurance. We analysed key indicators by household wealth quintiles, place of residence and health insurance, using logistic regression models controlling for age and other confounders. Results Among 8665 women aged 15–49 years (response rate 81%), 3.0% reported poor or very poor health, 13% gave birth in the preceding year, and health insurance coverage was 5.1%. Coverage of antenatal (99.5%) and institutional delivery care (88%) were high; 7.3% of women reported at least one outpatient visit in the last 4 weeks, of which 81% were for their own non-maternal healthcare; 9.3% had been admitted to a hospital during the last year, and 74% of these admissions were for deliveries. The total average annual health expenditure per woman was about TZS 16 860 (US$7.50), of which 82$10.00) per year on self-treatment. The poorest women had poorer self-reported health, lower coverage of maternity care, lower utilisation of services for their own healthcare and lower health insurance coverage, and limited their expenditure by making greater use of nearby public services than richer women. Conclusion Women spent more financial resources on their own non-maternal healthcare than maternity care with poorer women still facing disadvantages for their own healthcare. Health insurance programmes were hardly but were associated with an increase in service use. Comprehensive assessments of women’s health needs, service use and expenditures with an equity focus are crucial for shaping UHC strategies tailored to women of reproductive ages.

Introduction Childhood illness and hospitalisation result in both direct and indirect costs to families before, during and after admission. We aimed to estimate the catastrophic expenditure during hospitalisation for children with acute illness. Methods This was a prespecified cross-sectional substudy nested within two prospective studies. Participants were recruited and interviewed from three rural and three urban hospitals in Kenya and Uganda. A costing questionnaire was administered to the caregivers of 731 children hospitalised for acute illness to evaluate direct and indirect costs incurred by caregivers and families. Costs incurred were compared for families with children both with and without complicated severe malnutrition (CSM). Catastrophic out-of-pocket expenditure exceeding 10% and 25% of monthly income was assessed. Results The median (IQR) total cost during hospitalisation per child was US$47 (US$24–US$84), with higher costs for children with CSM, especially during hospitalisation (US$56 (US26–US99) vs US$36 (US$20–US$65); p<0.001). During hospitalisation, bed charges followed by food were the main cost drivers. Caregivers reported losing a median of 7 (4–11) days of productive time during a child’s hospitalisation with a mean loss of income of US$10 (SD US$25.6, median US$0 (US0–US10)). 92% and 74% of households experienced catastrophic expenditure at thresholds of 10% and 25% of monthly income, respectively. Caregivers reported borrowing, selling property and withdrawing other children from school to cope with costs. Conclusions Despite intentions of free healthcare services for under 5, families of acutely ill children very commonly faced catastrophic expenditure, especially for children with CSM. Interventions aimed at supporting financial protection, reducing additional healthcare costs, and lowering health service charges may help prevent catastrophic expenditures.

Mycoplasma pneumoniae causes atypical pneumonia in children and young adults. Its lack of a cell wall makes it resistant to beta-lactams, which are the first-line treatment for typical pneumonia. Current diagnostic tests are time-consuming and have low specificity, leading clinicians to administer empirical antibiotics. Using a LASSO regression simulation approach and blood microarray data from 107 children with pneumonia (including 30 M. pneumoniae) we identify eight different transcriptomic signatures, ranging from 3-10 transcripts, that differentiate mycoplasma pneumonia from other bacterial/viral pneumonias with high accuracy (AUC: 0.84–0.95). Additionally, we demonstrate that existing signatures for broadly distinguishing viral/bacterial infections and viral/bacterial pneumonias are ineffective in distinguishing M. pneumoniae from viral pneumonia. The new signatures are successfully validated in an independent RNAseq cohort of children with pneumonia, demonstrating their robustness. The high sensibility of these signatures presents a valuable opportunity to guide the treatment and management of M. pneumoniae pneumonia patients.