Public Health in Practice

BackgroundDengue outbreaks have become a severe threat to Bangladesh as the infections and mortality numbers are skyrocketing in recent years. Favorable environmental and anthropogenic conditions have established the capital of Bangladesh, Dhaka city as the epicenter of dengue outbreak. Studies have showed that climate change induced extreme weather events are exacerbating Aedes mosquito breeding and dengue virus transmission conditions. Methodology/Principal FindingsIn this study, short-term (0-6 weeks) associations of maximum temperature and heatwave days on dengue cases in Dhaka city were examined through Distributed Lag Non-linear Model (DLNM) methodology for weekly measurement of 2016-2024, taking into account relative humidity, cumulative rainfall, seasonality and hospital closure effect. Two separate negative binomial models were constructed. The maximum temperature model rendered an overall inverted U-shaped association, where the maximum temperature range of 31.5-33.2{degrees}C showed a sustained elevated dengue risk, with highest risk estimate at 33.2{degrees}C [relative risk (RR): 1.186, 95% CI: 1.002, 1.403]. Whereas, results of weekly heatwave days showed an overall protective effect (RR<1) for dengue cases. The lowest risk of infection was found at 3 heatwave days per week, with RR 0.275 (95% CI: 0.178, 0.423). Multiple sensitivity analyses were conducted for both models to evaluate their robustness. Lastly, the optimized models were analyzed under three distinct sub-periods, to capture the association of exposure variables with predominant circulating serotypes. Conclusions/SignificanceThe findings of the study aim to support public health policymakers and healthcare authorities in designing and implementing effective vector control interventions under emerging climatic emergencies. Author SummaryDengue disease is one of the most buringing issue in Bangladesh in recent years. This vector-borne disease is inherently influenced by climatic variables, i.e., temperature, rainfall, humidity, etc. Moreover, these relations are complex and non-linearly associated. Due to shift in climatic conditions, the occurance of extreme weather events are becoming frequent, with increased magnitude and longer duration. In this study, the nonlinear and delayed association of dengue infections due to the exposure of extreme temperature events were assessed in climate-change vulnerable Dhaka city. To do this, a statistical method was used, called distributed lag nonlinear methodology (DLNM). The results showed that dengue infections had an inverted U-shaped (parabolic) relationship with maximum temperature, while compared to mean maximum temperature, and a suppressive association with heatwaves relative to days without heatwaves. The findings aim to work as an early warning system, and support to policymakes and healthcare authorities to tackle the dengue surge in the changing climate.

Childhood malnutrition remains a major public health challenge in Ethiopia, where stunting and wasting co-exist but may arise from distinct spatial and etiological processes. Analyses focusing on a single outcome may overlook the interdependence of these conditions and their geographic heterogeneity. This study aimed to disentangle the determinants of stunting and wasting among children under five years of age using a Bayesian bivariate spatial modelling framework. Data from 5,405 children included in the 2019 Ethiopia Mini Demographic and Health Survey were analyzed. Stunting and wasting were modelled as correlated binary outcomes using Bayesian bivariate hierarchical geostatistical models implemented through SPDE-INLA, accounting for child, maternal, household, and environmental covariates, non-linear age effects, and spatial dependence. Model performance was assessed using the deviance information criterion, Watanabe-Akaike information criterion, and marginal log-likelihood. The bivariate model identified shared socio-economic and biological determinants. Multiple births, male sex, low maternal education, a higher number of under-five children, and household poverty were associated with increased risks of both outcomes. Female-headed households were associated with lower odds of stunting but higher odds of wasting. Spatial analysis revealed elevated residual stunting risk in the northern and central highlands, whereas wasting hotspots were concentrated in northeastern pastoralist regions. Residual spatial correlation was weak ({rho} = -0.12), indicating largely independent geographic patterns. These findings suggest that effective child nutrition policies in Ethiopia require outcome-specific and regionally tailored interventions addressing both chronic and acute forms of malnutrition.

Background Acute malnutrition remains a major public health challenge among children under five in Malawi due to undetected and untreated cases. While several policies and programmes are in place, they face significant resource input and implementation constraints. In this study, we evaluate the potential health impact and cost-effectiveness of three interventions designed to address constraints along the care pathway in childhood acute malnutrition management. These include improving early recognition of symptoms by caregivers, increasing attendance at routine growth monitoring visits through community outreach, and scaling up the availability of therapeutic food supplements. Methods and Findings We use a newly developed model representing the natural history and management of acute malnutrition, implemented within the Thanzi La Onse (TLO) dynamic individual-based simulation framework, which captures the public health system in Malawi. Each of the three interventions is assessed both individually and in combination, translated into seven scenarios which we evaluate in comparison to the status quo. The optimal strategy combines two interventions, improved caregiver awareness of early symptoms with increased availability of therapeutic food supplements. Over five years, this strategy is predicted to avert 840,470 (95% CI: 682,057-998,883) DALYs with total incremental costs of $34 million. This corresponds to an annual health expenditure increase of $0.32 per capita. At a cost-effectiveness threshold of $76 per DALY averted, the strategy results in an incremental net health benefit of 394,252 (95% CI: 235,839-552,665) DALYs averted. Conclusions The cost-effective strategy for addressing constraints in childhood acute malnutrition management is simultaneously improving caregiver recognition of early symptoms and expanding therapeutic food supplement availability. Out of the seven scenarios evaluated, this integrated approach was found to be the optimal strategy within the Malawian public health system, yielding substantial health at modest costs. These findings provide critical evidence to inform national policy and guide investment prioritisation for the management of childhood acute malnutrition.

BackgroundThe COVID-19 pandemic required South African public sector HIV viral load (VL) laboratories to scale up Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) testing while maintaining essential HIV services. This placed additional pressure on diagnostic services. This dual mandate introduced significant occupational and environmental challenges (OEC) for staff that remain underexplored. ObjectiveThis study aimed to investigate the OEC and effects that staff experienced during the implementation of COVID-19 testing at public sector VL laboratories in South Africa. MethodsA quantitative, cross-sectional study utilised a census approach among technical and support staff. Data were collected via a structured REDCap questionnaire using 5-point Likert scales. Pre- and post-implementation challenges were assessed across four domains: workload, environmental conditions (space, ventilation, waste), communication, and PPE availability. Statistical analyses included the Wilcoxon Signed-Rank and Spearmans correlation tests. ResultsPerceived occupational challenges increased significantly across all domains post-implementation. Staff workload saw the highest rise (mean score 3.02 to 3.53). Adverse health effects were pervasive; 80.2% of staff reported burnout/fatigue, and 76.5% reported increased anxiety/stress. A strong positive correlation was observed between post-COVID-19 challenges and adverse mental and physical health outcomes (rho = 0.449, p < 0.001). Furthermore, 35.8% of staff considered resigning due to increased job demands. ConclusionIntegrating COVID-19 testing exacerbated systemic weaknesses, causing measurable psychological injury and threatening workforce retention. Findings suggest that the diagnostic workforce requires formal crisis surge staffing models and institutionalised mental health support to safeguard personnel and maintain essential services during future health emergencies.

BackgroundAcute respiratory infection (ARI) remains a leading cause of morbidity and mortality among children under five in Nigeria. Although polluting cooking fuels are widely considered a key risk factor, their effects may be shaped by broader socioeconomic and geographic conditions. This study examined both individual and structural determinants of ARI and assessed how these factors intersect to pattern risk. MethodsWe analysed data from 28,728 children under five in the 2024 Nigeria Demographic and Health Survey. Three ARI definitions were applied. Survey-weighted quasibinomial logistic regression estimated associations between ARI and cooking fuel type, child age and sex, household wealth quintile, residence type, geopolitical zone, and parental education. To examine intersectional patterning, we conducted a Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA), constructing strata defined by combinations of cooking fuel, wealth, residence, and geopolitical zone. The intraclass correlation coefficient (ICC) quantified between-strata variance. ResultsStrict ARI prevalence was 1.9%, and 8.3% of children had broader respiratory symptoms. In unadjusted analyses, polluting fuel use was associated with higher odds of respiratory symptoms (OR 1.85, 95% CI 1.43-2.39). After adjustment, this association was substantially attenuated, indicating confounding by structural factors. Child age was the most consistent predictor: children aged 24-59 months had about half the odds of strict ARI compared with infants (aOR 0.53, 95% CI 0.41-0.68). Geopolitical zone showed the strongest overall association. MAIHDA revealed that 9% of total ARI variance lay between intersectional strata (ICC = 0.09), and this variance was not explained by child age or sex. The population-attributable fraction for polluting fuel declined from 41.4% to 12.4% after adjustment. ConclusionsARI risk among Nigerian children is shaped more by structural and geographic inequalities than by household fuel use alone. Equity-focused, subnational policies addressing intersecting socioeconomic and regional disadvantage are needed to reduce the ARI burden.

Armed conflict in Sub-Saharan Africa has exposed millions of civilians to repeated and severe traumatic events, yet the prevalence of posttraumatic stress disorder (PTSD) and its associated determinants across the region have not been comprehensively synthesised. This study aimed to estimate the prevalence of PTSD and examine its associated factors among conflict-affected adult populations in Sub-Saharan Africa. Methodological quality was assessed using the Joanna Briggs Institute (JBI) criteria for cross-sectional and epidemiological studies A systematic search of PubMed, MEDLINE, Embase, Scopus, CINAHL, APA PsycINFO, the Cochrane Library, and the WHO Global Index Medicus (including African Index Medicus) was conducted for studies published between January 1, 2000, and May 31, 2025. Observational studies reporting PTSD prevalence among adults aged 18 years or older exposed to armed conflict were included. Study selection followed PRISMA 2020 guidelines, with independent screening by two reviewers. Random-effects meta-analyses with logit transformation were used to pool prevalence estimates, and determinants were synthesised narratively with emphasis on adjusted effect estimates. Heterogeneity was assessed using the I{superscript 2} statistic. Sixty-eight studies comprising 82,021 participants from 13 countries met inclusion criteria. The pooled prevalence of PTSD was 43% (95% CI, 35.9%-50.0%), with substantial heterogeneity (I{superscript 2} = 99.9%). Prevalence was highest among refugees (79%), followed by internally displaced persons (48%) and residents of conflict-affected communities (34%). Female sex was consistently associated with increased odds of PTSD (pooled adjusted odds ratio approximately 2.0), as were comorbid depression or depressive symptoms (AOR range 4.2-9.5). Additional correlates included cumulative trauma exposure, displacement, poor social support, and substance use. Overall, PTSD is highly prevalent among conflict-affected adults in Sub-Saharan Africa, underscoring the need for integrated, context-sensitive mental health strategies to address the enduring psychological consequences of armed conflict in the region.

Iron deficiency (ID) is the most common nutritional deficiency worldwide, often caused by insufficient dietary intakes. Oral supplementation is one of the means to improve iron status. This study evaluated the efficacy and safety of two low-dose iron supplements - >Your< Iron Forte Capsules (YIFC) and Ferrous Sulfate Capsules (FSC) - in individuals with dietary ID. One hundred and one participants (mean age 30.6 years; 98% women) with low iron stores (mean serum ferritin 16.1 {micro}g/L) were randomized to receive either YIFC or FSC once daily for 12 weeks. Changes in blood indices and iron-related parameters were assessed at four and 12 weeks of intervention relative to baseline. The primary outcome was the change in hemoglobin (Hb) after 12 weeks. Eighty-seven participants completed the study. Both supplements significantly increased Hb at 12 weeks (YIFC: mean 6.52 g/L, p<0.001; FSC: mean 5.71 g/L, p<0.001). Product-related adverse events (AEs) were few (17% of all AEs) and of mild to moderate intensity only. One participant receiving FSC withdrew due to a probable product-related AE. The frequencies of product-related AEs were similar between study arms, however, statistically significantly more AEs judged to be definitely related to the product occurred in in the FSC arm. While product-related AEs were confined to the gastrointestinal tract in the YIFC arm, they affected multiple organ systems in the FSC arm. Supplementation with either YIFC or FSC proved as an effective, well-tolerated, and safe strategy for improving iron status in non-anemic dietary iron deficiency. In terms of the AE profile, supplementation with YIFC may offer advantages over supplementation with FSC.

IntroductionFlooding events, which are strongly linked to climate change and variability, have the potential to disrupt communities and health systems. Vaccination, a highly effective public health intervention, plays a pivotal role in preventing numerous deaths annually, particularly among children. However, the relationship between exposure to flood events and early childhood vaccination remains unexplored. MethodsThis study utilizes validated flood exposure data from the Global Flood Database (GFD) and five waves of nationally representative survey data regarding the vaccination history of children under 3 years from the Bangladesh Demographic and Health Surveys (DHS) collected between 2004 and 2018. Using the geographical coordinates of each surveyed household grouping and matching it with the spatially resolved GFD data, we determined whether children reside in a flood-prone area. We then used Generalized Estimating Equations, accounting for geographical clustering and including an inverse probability of treatment weighting (IPTW) for covariate balance, to assess the relationship between living in a flood-prone area and incomplete vaccination. Incomplete vaccination was defined as having missed at least one does of the four World Health Organization-recommended childhood vaccines: Tuberculosis (BCG), Diphtheria-Tetanus-Pertussis (DTP), Polio (OPV), and Measles (MCV). The sensitivity of the association measure to various definitions of exposure was explored. ResultsOur sample included 13,649 children, of which 16% resided in flood-prone areas and 84% were fully vaccinated. Our findings indicate that children living in a flood-prone area have a higher risk of not receiving the DTP vaccine (PR = 1.24, CI: 1.05-1.46), the BCG vaccine (PR = 1.27, 1.08-1.50), and the OPV vaccine (PR = 1.24, CI: 1.06-1.46). The direction of the relationship remained but the effect became non-significant when looking at the MCV vaccine alone (PR = 1.06, CI: 0.90-1.25), as well as the four vaccines together (PR = 1.05, CI: 0.90, 1.22). InterpretationThese findings hold critical implications for disaster management protocols, emphasizing the need to ensure uninterrupted access to routine healthcare services during floods, which are becoming increasingly more common due to climate change. Considering that populations in low- and middle-income countries are disproportionately impacted by extreme climate events such as floods and that preventable infectious diseases remain among the leading causes of child death in these regions, ensuring access to essential vaccines is critical for safeguarding public health.

BackgroundMental well-being encompasses positive psychological functioning, life satisfaction, and engagement with daily activities. It is influenced by multiple interrelated factors, including symptoms of stress, anxiety, depression, and psychological inflexibility. Network analysis provides a data-driven framework for examining the complex interconnections between these components and for identifying elements that may play a central role in the mental well-being system. The present study aimed to identify key elements related to stress, anxiety, depression, and psychological inflexibility associated with mental well-being in individuals seeking online psychological support. MethodsThis cross-sectional study analyzed data drawn from the Online Well-being intervention. A total of 967 Mexican participants were included. A psychological network comprising seventy-four items was estimated, and centrality indices (strength, closeness, and betweenness) were computed to determine the relative importance of individual elements within the network. Network comparisons by gender were conducted to evaluate global and local differences. ResultsThe network revealed multiple inter-domain associations, particularly negative relationships between mental well-being and symptoms of depression, anxiety, negative stress, and psychological inflexibility. Items reflecting self-evaluation and emotional well-being consistently emerged as the most central elements in the network across centrality metrics. Gender-based comparisons indicated overall structural similarity between networks, although differences were observed in the strength of specific connections. ConclusionsNetwork analysis identified central elements linking mental well-being with psychological distress and inflexibility in a population seeking online psychological support. These findings contribute to a systems-level understanding of mental well-being and highlight potential targets for psychological interventions to enhance well-being and reduce distress.

BackgroundThe accelerating pace of urbanization worldwide has highlighted the improvement of disaster response in cities as a global priority. Yet, there remains a poor understanding of the emergency response to mass casualty incidents (MCI) in these environments. This study aimed to develop a conceptual framework for cities responses and potential policy levers. MethodsWe conducted a scoping review followed by in-depth interviews (IDIs), focus group discussions (FGDs), and a modified Delphi process to develop the framework for Cities Assessment of Mass Casualty Emergency Response and Action (CAMERA). ResultsCAMERA framework consists of six essential components of urban emergency response systems: 1) communication, 2) safety and security, 3) human resources, 4) policy and plans, 5) command control and coordination, and 6) care delivery. IDIs and FGDs also provided insight on assessment methodologies for evaluating response capacity. Using these components, we then developed a framework consisting of a diagnostic and management approach that city leadership can undertake in MCI management to ensure effective functioning at various levels of incident response. ConclusionThe CAMERA framework offers novel and simplified guidance to policymakers and other stakeholders in their attempt to improve MCI response systems across cities globally.

Food costs are more significantly impacted by climate change as countries grow. It is well known that climate change has an impact on the productivity of most agricultural goods, but it is unclear how specifically it will affect food costs. The present research explores how the North Atlantic Oscillation (NAO) index, a widely used climate indicator, affects food prices around the world. This is achieved by applying a robust bivariate Hurst exponent (robust bHe). The research creates a color map of this coefficient using a window-sliding technique over various intervals of time, displaying an illustration that changes overtime. Additionally, the NAO index and global food prices are examined for causal connections using variable-lag transfer entropy using a window-sliding technique. The results show that notable rises in a number of international food prices for long as well as short periods are associated with significant increases in the NAO index. Furthermore, the causative function of the NAO index in influencing global food costs is confirmed by variable-lag transfer entropy. Is highly recommended as it directly connects the research to actionable outcomes for policymakers and the overarching goal of sustainability and food security. This study provides the first direct evidence of a robust, long-range cross-correlation and causal link between the North Atlantic Oscillation (NAO) index and key global food prices. It introduces a novel, robust methodological framework to visualize this time-varying relationship, offering a critical tool for policymakers and forecasting models.

ObjectiveTo 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 designA longitudinal study of 119 infants aged between 5-19 months was conducted in five villages of Wonosobo District, Central Java, Indonesia. Anthropometric measurements of infants and their mothers were performed at baseline and 5-month follow-up alongside a quantitative questionnaire on household, socio-economic, WASH and caregiving variables and stool sample collection for the investigation of alpha-1-antitrypsin (AAT), neopterin (NEO), and myeloperoxidase (MPO) levels. Linear mixed-effects regression models estimated the associations between WASH and height-for-age z-score (HAZ) on log-transformed EED biomarkers. ResultsBiomarkers increased from baseline to follow-up despite a declining trend with age and 68.7%, 79.0%, and 71.4% of infants experienced elevated AAT, NEO, and MPO respectively follow-up. Infants had higher AAT if they averaged > 30 minutes playing on soiled surfaces per day ({beta} = 0.11, p<0.05). NEO was elevated in infants with diarrhoea ({beta} = 1.04, p<0.05), municipal water source ( = {beta} 0.71, p<0.05), and in infants who mouthed soiled fomites weekly ({beta} = 0.55, p<0.05). Infants in houses with municipal water source had higher MPO ({beta} = 0.56, p<0.05) and higher MPO if mouthing soil weekly ({beta} = 0.41, p<0.05). Compared to infants at risk of stunting, stunted infants at baseline had lower AAT at follow-up ({beta} = -0.39, p<0.05) while infants with HAZ > -1 had lower AAT at baseline ( = -0.43, p<0.05). HAZ at baseline was positively associated with NEO at follow-up ({beta} = 0.36, p<0.05). MPO was higher in infants with HAZ > -1 at follow-up ({beta} = 0.59, p<0.05) and stunted infants ({beta} = -0.54, p<0.05) compared to infants at risk of stunting. ConclusionElevated EED biomarker levels were frequent and associated weakly with WASH and HAZ with bi-directionality, highlighting the need for quality birth cohort studies to improve understanding of EED and develop interventions.

Compassion fatigue is a well-documented hazard among healthcare and veterinary professionals, yet the psychological toll on informal caregivers of feral cat colonies, likely numbering several tens of thousands in Portugal, remains largely unexplored. This cross-sectional study examines internal and external factors associated with the secondary traumatic stress component of compassion fatigue among 172 informal caregivers in Portugal. Secondary traumatic stress refers to work-related secondary exposure to individuals who have experienced extremely stressful or traumatic events. Structured telephone interviews assessed sociodemographics, colony management, compassion satisfaction, resilience, spiritual well-being, and perceived social support. Univariate and multivariable linear regression identified predictors of compassion fatigue. Results indicate that 47% of participants experienced moderate compassion fatigue, and 10% reported high levels. Multivariable analysis revealed that caring for large colonies (more than 25 cats) and being unemployed were significantly associated with higher fatigue. Conversely, older age, higher perceived family support, and the resilience dimension of serenity served as protective factors. Interestingly, finding meaning in life was positively correlated with fatigue, suggesting that caregivers who perceive their role as central to their life purpose may become more emotionally invested, increasing vulnerability to distress when unable to help animals. Official colony registration and formal institutional support did not significantly alleviate fatigue. These findings highlight that institutional support alone is insufficient to mitigate fatigue among informal caregivers, who experience significant distress driven by both practical burdens and profound emotional involvement. The most frequently reported concern among caregivers was the inability to cover the costs of feeding and veterinary care for the cats. Interventions must address both external needs (e.g., support to cover veterinary and feeding expenses for the cats) and internal coping mechanisms. Implementing psychosocial support alongside trap-neuter-return programs may also improve caregiver well-being and foster sustainable urban feral cat management. This underscores a One Health perspective, demonstrating that animal health is closely interconnected with human well-being and environmental health.

ObjectivesTo quantify patterns of preventable death in Australian coronial findings, measure government compliance with coroner recommendations across jurisdictions, and identify case characteristics associated with recommendation issuance and acceptance. DesignCross-sectional computational text analysis of publicly available coronial findings using unsupervised topic modelling and rule-based classification. SettingAustralian coronial system, all eight state and territory jurisdictions, findings published on the Australasian Legal Information Institute (AustLII) database, 2000-2024. Participants9833 coronial findings and 2040 linked government responses. Main outcome measuresDeath-type topic prevalence, recommendation rate by jurisdiction, government response acceptance rate. ResultsTwenty-six death-type topics were identified, with medical/surgical deaths (12.5%), men-tal health (10.4%), and deaths in custody (8.6%) most prevalent. Overall, 45.6% of published find-ings contained formal recommendations (95% CI, 44.6-46.5%). Of 2040 government responses, 43.0% were unclassifiable (predominantly Victorian administrative cover letters). Among classifi-able responses, 53.2% were accepted (implemented, already implemented, or partially accepted), ranging from 26.0% (Western Australia) to 88.0% (Queensland). Multivariable logistic regression showed that jurisdiction was the strongest measured predictor of acceptance (pseudo R2 0.13 vs 0.14 with all covariates), though most variance remained unexplained. Among published findings, In-digenous Australians were represented in 10.1% (2.7 times the 3.8% population share).12 Findings involving medication errors had the highest recommendation rate (55.1%) but among the lowest acceptance rates (26.4%). ConclusionsAmong publicly available coronial findings, fewer than half contain formal recom-mendations. Government acceptance is low and structurally determined by jurisdiction rather than case characteristics, suggesting that legislative reform is needed to improve the systems preventive effectiveness.

BackgroundEvidence from high-income countries suggests that COVID-19 may adversely affect cognitive functioning, yet population-based data from African countries remain scarce. Understanding how COVID-19 symptom burden, chronic disease, and mental health intersect to shape cognitive outcomes is critical in low-resource settings disproportionately affected by structural and health system constraints. MethodsCross-sectional data were collected from 3,058 adults (M_age = 27.2 years) in Botswana, Ghana, Nigeria, and Tanzania between April 2020 and November 2022 using the Sonde Health platform. Participants self-reported sociodemographic characteristics, COVID-19 symptoms, chronic disease diagnoses, mental health symptoms, physical activity, and sedentary behavior. Executive function was assessed using the Stroop Color-Word interference score. Multivariable linear regression models estimated adjusted mean differences in executive function associated with COVID-19 symptom burden and chronic disease, controlling for sociodemographic, health, mental health, and behavioral factors. Effect modification by country was evaluated using interaction terms (p < 0.10). ResultsExecutive function declined with increasing COVID-19 symptom burden, with Stroop scores decreasing from 0.14 among participants reporting no symptoms to 0.07 among those reporting three or more symptoms (p < 0.001). Being symptom-free was associated with better executive function in Ghana (adjusted mean difference = 0.06; 95% CI: 0.00, 0.11) and Nigeria (adjusted mean difference = 0.07; 95% CI: 0.02, 0.12), but not in Botswana or Tanzania. Lower chronic disease burden was associated with better executive function in Nigeria (adjusted mean difference = 0.16; 95% CI: 0.06, 0.26). Higher educational attainment was consistently associated with better executive function across countries. ConclusionsCOVID-19 symptom burden and chronic disease were associated with poorer executive function across the four African countries studied, with substantial cross-country variation. Education emerged as a consistent protective factor. These findings highlight the importance of integrated, context-sensitive approaches that address both physical and mental health to support cognitive well-being during and beyond public health crises.

Structured AbstractO_ST_ABSObjectiveC_ST_ABSThis mixed-methods study investigated the lived-experience perspectives of receiving a novel, brief digital mental health intervention after psychological trauma. The online gamified imagery-competing task intervention (ICTI) involves one researcher-guided session followed by self-use. Tested in two randomised controlled trials (GAINS-01; GAINS-02), ICTI led to fewer intrusive memories at week-4, with the reduction sustained over 24 weeks, alongside reductions in post-traumatic stress. Here, we contrasted user experiences of ICTI with an Active Control (AC; music-listening task), and explored longer-term impact in qualitative interviews to contextualise GAINS-02 findings. Methods and AnalysisThe GAINS-02 trial randomised healthcare staff experiencing intrusive memories after work-related trauma to ICTI (N=40), AC (N=39), or treatment-as-usual (TAU; N=20). Expectancy was assessed before the researcher-guided session (Day 0), acceptability at week-4, and usage tracked for 24-weeks. Semi-structured interviews (N=27) were conducted in ICTI and AC arms only (15 at week-4; 12 during 12-24-weeks). Interviews were analysed using reflexive thematic analysis. ResultsPrior to use, many trial participants did not think the intervention would work, favouring AC over ICTI. However, after completing the tasks, participants found ICTI more acceptable and relevant to intrusive memories than AC. After the one guided session, median ICTI usage the next four weeks was 4.00 times with little additional use (once more) over the next 20 weeks because of lack of need. Potential implementation facilitators included ease of use, and advantages over existing interventions due to not needing to talk about the trauma, brevity, and lesser resource commitment. Perceived barriers included a lack of staff and manager education about the nature and consequences of intrusive memories, with a need for workplace buy-in and demonstration of organisational benefits. ConclusionHealthcare staff experiencing workplace-related trauma found ICTI to be acceptable and effective for reducing intrusive memories with low effort and emotional burden, even among participants who initially expressed scepticism. Participants highlighted implementation considerations including offering ICTI both within and outside the workplace, and providing a self-guided version of ICTI with optional support. Future work should assess cost-effectiveness, impacts on presenteeism and retention, and real-world implementation including the feasibility and effectiveness of a self-guided ICTI. Summary BoxO_ST_ABSWhat is already known on this topicC_ST_ABSIn a previous randomised controlled trial (GAINS-01) with Intensive Care Unit (ICU) staff exposed to work-related trauma, a brief online gamified imagery-competing task intervention (ICTI) reduced intrusive memories compared to usual care at four-weeks. What this study addsThe GAINS-02 randomised controlled trial replicated GAINS-01 and extended results by comparing ICTI to an active control (AC; music listening) task, enrolling hospital staff from outside ICU, and a follow-up period of 24-weeks. Qualitative interviews found that, despite initial scepticism from healthcare staff prior to using the intervention, ICTI was more acceptable than an AC due to specific effects on swiftly reducing intrusive memories and requiring minimal support or usage after an initial researcher-guided session. After one guided session, ICTI was used 4 more times in the first four weeks, with little additional usage (once) thereafter because of lack of need (i.e., no longer experiencing intrusive memories). How this study might affect research, practice or policyICTI is an efficacious scalable intervention to relieve staff of intrusive memories with effects sustained for at least 6-months. It was found to be more acceptable to participants than alternatives, requiring less time commitment than standard psychological treatments.

ObjectivesNon-communicable diseases (NCDs) account for almost 90% of deaths in Europe, yet comparative estimates of the productivity costs associated with premature NCD mortality across diseases and countries remain limited. This study estimates and compares productivity losses attributable to cardiovascular disease (CVD) and cancer mortality among working-age populations across Europe. Population-based data were used to estimate productivity costs for CVD and cancer deaths across 30 European countries. Sex- and age-specific mortality data for 2021 were obtained from the World Health Organization Mortality Database. Economic data, including wages, unemployment rates, and labour force participation rates, were sourced from Eurostat. Productivity losses were valued using a human capital approach incorporating an age-transition lifecycle simulation model that adjusts for lifetime wage trajectories and labour market dynamics. Costs were discounted at 3.5%. Total productivity losses from cancer and CVD mortality in working-age populations were estimated at {euro}195.7 billion, equivalent to 1.24% of European GDP. Cancer accounted for 62.5% ({euro}122.2 billion) of total productivity losses, while CVD accounted for 37.5% ({euro}73.5 billion). Total CVD-related productivity costs exceeded cancer-related costs in Central and Eastern Europe, whereas cancer productivity costs were higher in Western, Northern, and Southern Europe. Mean productivity costs per death were higher for CVD ({euro}219,848; 95% CI 165,241-270,247) than for cancer ({euro}217,744; 95% CI 166,554-273,144). A larger gender gap was observed for CVD mortality, with a male-to-female cost ratio of 2.5 compared with 1.6 for cancer. Productivity losses associated with premature cancer and CVD mortality represent a substantial economic burden across Europe, with pronounced variation by disease, region, and sex. These findings provide comparative, cross-country estimates of the human capital costs associated with major NCD causes of death.

Malnutrition among infants aged under six months (u6m) is a global public health problem. As countries begin implementing 2023 WHO malnutrition guidelines, local prevalence and epidemiology must be well understood. We analysed Bangladesh Demographic Health Survey data (2004 - 2022), describing the prevalence and time trends of infant u6m wasting (weight-for-length z-score [WLZ] <-2), stunting (length-for-age z-score [LAZ] <-2), and underweight (weight-for-age z-score [WAZ] <-2). In bivariate and multivariate analyses, we tested the association between wasting and underweight and established risk factors for malnutrition. Over the last 20 years, Bangladesh has seen a substantial reduction in stunting and underweight while wasting has remained relatively stable. In 2022, out of 476 infants u6m, 10.6% were wasted, 12.8% stunted, 13.7% underweight, 0.5% concurrently wasted/stunted, and 14.8% were reported small at birth. This translates to 185,390 infants u6m being wasted, 223,867 stunted, and 239,608 underweight, in 2022. WAZ had the lowest percentage of flagged data (0.8%) compared to WLZ (6.0%) and LAZ (6.4%). Underweight was associated with delivery place, small birth size, infant sex, post-natal check-ups, fever in the past 2 weeks, drinking water source, maternal BMI, and maternal height. Fewer factors were associated with being wasted, including the sex of the household head. Our findings support the urgent need to roll out 2023 WHO Guidelines in Bangladesh. They also support the superiority of underweight as a measure of undernutrition. Packages of care tackling a wide range of potential underlying causes are important for effective local interventions tailored to this age group.

IntroductionDespite being curable, leprosy-related stigma in Pakistan persists, undermining dignity, delaying care, and hindering progress toward zero-leprosy targets. Empowerment is critical in counteracting stigma and restoring agency among affected persons. Participatory, contact-based storytelling has potential to reduce stigma and strengthen empowerment, but evidence remains limited. This study evaluates a participatory storytelling intervention involving persons affected by leprosy in Karachi.Objectives This study investigates how a participatory storytelling intervention influences stigma and empowerment among persons affected by leprosy in Pakistan. It explores changes in participants experiences, examines the mechanisms through which storytelling engages with stigma and identifies practical insights to strengthen future intervention design. MethodsWe conducted a qualitative study following the 2024-25 participatory storytelling pilot at MALC, Karachi. Persons affected by leprosy who participated in the intervention were purposively sampled (age 30-65 years); sixteen participated in photovoice and fourteen completed in-depth interviews (IDIs) (thirteen of which had also participated in photovoice) (total n= 17). Data were analysed thematically using the Social Ecological Model (SEM). ResultsThe programme supported a shift from shame and concealment to greater self-acceptance, confidence and openness. Peer groups and creative storytelling built solidarity, a sense of belonging and transferable skills, while organisational endorsement enhanced participants visibility and roles. However, stigma remained reinforced by community misconceptions, gender norms and practical barriers. Overall, the interventions greatest effect was at the individual level, reducing self and anticipated stigma, with intrapersonal empowerment emerging as the primary gain. ConclusionParticipatory storytelling enhanced identity and empowerment, but broader social change remained constrained by gender norms, visible disability, and structural barriers. Strengthening impact requires sustained community contact, supported peer educators, inclusive outreach to women and persons with visible impairments, and links to socioeconomic opportunities. Embedding peer-led storytelling within skin NTD services and national and WHO strategies can support community ownership and sustainability. Author summaryLeprosy is a curable disease, yet many people affected by it continue to experience stigma that affects their mental health, confidence, relationships and health seeking behaviour. In Pakistan, stigma remains a major barrier to achieving zero-leprosy goals and improving quality of life. Our study explored the degree to which a participatory storytelling intervention, where persons affected by leprosy share their experiences through creative methods, supported empowerment and reduced stigma. We conducted a qualitative study with participants involved in a storytelling pilot intervention in Karachi, using interviews and photovoice to explore their experiences. Participants described the transition from shame and secrecy toward openness, greater self-confidence and self-acceptance. The storytelling process encouraged peer support, strengthened social connections and helped participants develop new skills and a stronger sense of identity. However, persistent community misconceptions, gender norms, visible disability and economic constraints limited broader social change. Our findings suggest that participatory storytelling interventions present a promising approach for reducing internalised stigma and strengthening individual empowerment among persons affected by leprosy. To achieve wider impact, storytelling initiatives should be combined with sustained community engagement, inclusive outreach and integration into skin neglected tropical disease (NTD) services and broader social support programmes.

Depression is a common and clinically significant mental health condition among university students, particularly those experiencing academic failure and course repetition, and is associated with adverse effects on cognitive functioning, emotional regulation, and academic performance. This study evaluated the efficacy of an internet-based cognitive behavioural therapy (iCBT) intervention, MoodGYM, in reducing depressive symptoms among repeating undergraduate students at the University of Zambia Ridgeway Campus. A quasi-experimental quantitative study design was employed. Seventy-five repeating undergraduate students with depressive symptoms were enrolled, with 33 assigned to the MoodGYM intervention group and 42 to a control group. Depressive symptom severity was assessed using the Beck Depression Inventory (BDI) at baseline and after an eight-week intervention period. Statistical analyses included within-group and between-group comparisons, difference-in-differences estimation, and fixed-effects regression modelling. At baseline, participants exhibited predominantly moderate to severe depressive symptoms, with no statistically significant differences between the intervention and control groups. Following the eight-week intervention, the MoodGYM group demonstrated a statistically and clinically significant reduction in depressive symptoms, with median BDI scores decreasing from 22 to 16 (p < 0.001), representing a large effect size (Cohens d = 1.02). In contrast, the control group showed persistence or worsening of depressive symptoms over the same period. Difference-in-differences analysis confirmed a robust intervention effect, with an approximately 10-point greater reduction in depression scores among MoodGYM participants compared with controls (p < 0.001). These findings indicate that MoodGYM is an effective internet-based intervention for reducing depressive symptoms among repeating undergraduate students and offers a feasible and scalable approach to addressing student mental health needs in low-resource university settings.