��app opinion

Why isn't the UK's paternity leave policy helping more parents?

lshpw5 — Tue, 27 May 2025 11:42:25 +0000

Why isn't the UK's paternity leave policy helping more parents? by lshpw5 Tue, 05/27/2025 - 12:42

Becoming a parent is a major life event. It brings new responsibilities, demanding time, money and emotional resources, all coinciding with loss of sleep and with biological changes. Depression is common in new parents, affecting around a sixth of mothers and a tenth of fathers – and this matters for both of them and their babies.

Paternity leave might help. It gives fathers or partners a chance to spend some time with their families shortly after a birth without needing to leave their job. It could allow them to better support a partner recovering from childbirth; to establish new routines; and to care for their child.

But our new research has found that for many fathers taking paternity leave in the UK between 2009 and 2019, there was no link to better mental health or mental wellbeing. In our sample only higher-income fathers seemed to have better mental wellbeing if they’d taken paternity leave. We also found that take-up of paternity leave was unequal. Even after adjusting for other factors, fathers who were less educated and fathers who were born outside the UK were less likely to use it. A partner’s paternity leave wasn’t associated with either mental health or wellbeing for mothers.

Our study was not designed to find out why many people didn’t have better mental health and wellbeing after paternity leave, but one possibility is that paternity leave is not generous enough. We know that mothers need paid maternity or parental leave of at least two to three months for mental health benefits to be really clear. If the same is true for paternity leave, this could help explain our findings.

What we do already know is that paternity leave rights in the UK are very limited compared to other parts of Europe and many OECD countries. Most UK fathers or partners are entitled to two weeks of paternity leave paid at a maximum of around £187 per week. Unless their employer offers more generous terms, the rules mean that families using paternity leave will see a reduction in their income at a time when they have a lot of costs to meet – and we know from other research that reductions in income can affect mental health. Mothers can transfer some maternity leave to fathers, but few do.

Other countries have very different arrangements. Almost all of those included in a recent international review offered a better pay rate for paternity leave than the UK. In Belgium, Bulgaria, Estonia, France, Greece, Japan, Lithuania, the Netherlands, Portugal, Slovenia and Spain, paternity leave is longer as well as better paid. Beyond paternity leave, EU countries also offer at least four months of parental leave to each parent, with two months being non-transferable. Some are even more generous. For example, in Sweden, each parent is individually entitled to up to 90 days of non-transferable leave, and parents share a total of 480 days of paid parental leave paid at up to 80% of their salary.

National policies for paternity leave are important. They set entitlements that go to everyone, not just those who are lucky enough to work for a more generous employer. They might also help to change social norms, making it easier for more fathers to take leave and to play a greater role in childcare.

Our study only looked at mental health and wellbeing. But others have suggested that paternity leave could have a much wider range of benefits by increasing gender equality at home and work; supporting child development; and improving family health.

Legislation is already making its way through Westminster which gives basic entitlements to paternity leave to all employed fathers. This will give new rights to tens of thousands of people per year. But it won’t increase statutory paternity pay, and it won’t do much to incentivise dads to take longer leave.

The government has said that it will soon carry out a wider review of the parental leave system. When it does, our findings suggest that it should try to narrow inequalities in both uptake and outcomes.

Emily Humphreys, a research student at the ��app of Hygiene & Tropical Medicine

Introduction

New parents in the UK have limited rights to paid paternity leave compared to some other countries. Emily Humphreys discusses new research on its relationship to mental wellbeing for parents.

Why the world needs a vision for public health now more than ever

lshpw5 — Tue, 11 Mar 2025 11:16:21 +0000

Why the world needs a vision for public health now more than ever by lshpw5 Tue, 03/11/2025 - 11:16

Recent political changes have shifted the priorities of wealthier countries away from health, equity, and sustainable development, creating huge challenges for health and science communities worldwide. Science itself is being attacked, and scientists are afraid to speak out. In addition, unprecedented cuts have been made to international development, science and health budgets, with devastating results for health programmes across the globe.

At the same time, the world is facing a perfect storm of challenges. Conflict, misinformation, rising costs and growing poverty risk making populations more vulnerable to outbreaks and emerging disease threats. Discrimination and inequities remain widespread and in some areas are even getting worse. Climate change threatens our entire planet and all of us on it, with the greatest impact being seen on those with the least resources and resilience.

Human health is at the heart of all these challenges. Firstly, health is fundamental to human resilience – our ability to deal with what the world throws at us. And secondly, health is central to human happiness and fulfilment. And it is not just health, but health equity that should concern us: meaning everyone has a fair opportunity to attain their full potential for a healthy and fulfilled life.

LSHTM’s mission is to improve health and health equity both in the UK and worldwide through two interwoven activities: research and education. In such a challenging landscape, it is tempting to give up on both of these. But I would argue that this is exactly the time when we need to recommit to our mission.

When resources are in short supply, better understanding the fundamental drivers of health and what the most cost-effective interventions are to improve it becomes more important - not less. Research provides the evidence needed to underpin our united efforts to improve health and health equity in the belief that the future of public and global health is an ongoing commitment to improving the lives of everyone in society

In a time of accelerating change and uncertainty, in which so many of our communities face ever more complex challenges to human health, the expertise and knowledge that come from education are needed more than ever. Strengthening human capacity, training the next generation of health scientists and leaders, becomes ever more vital. As in the past, if we’re going to continue to survive and thrive, we’ll need the insights and disciplines of public health to play their part.

This means stepping up to face new threats, such as the health misinformation that, if left unchecked, threatens to drown out life-saving public health advice. But at the same time always engaging with empathy, recognising people’s hopes and fears and communicating what a brighter future for our shared health looks like.

We need to continue our long and strong track record of being responsive and of innovating. Responding to the emerging health threats, and embracing new opportunities as they arise, such as those provided by advances in artificial intelligence.

We need to continue to build partnerships based on equity and mutual respect. Modern complex health challenges demand we work together across disciplines and across international boundaries. The world needs supportive networks and collaborative approaches now more than ever.

Today, we must continue to face forward together, with a vision to help create a more healthy, sustainable and equitable world. We promise to bring our scientific rigour, our determination, our hope and compassion to bear, to make that happen.

Liam Smeeth, Professor of Clinical Epidemiology and Director of the ��app of Hygiene & Tropical Medicine

Introduction

With health and science under attack globally LSHTM’s Director Liam Smeeth argues public health research and education can help us fight back.

How affordable reading glasses could save the global economy billions

lshpf1 — Mon, 17 Feb 2025 08:00:08 +0000

How affordable reading glasses could save the global economy billions by lshpf1 Mon, 02/17/2025 - 08:00

Reading glasses are an essential and normal part of life for many adults. Yet globally it is estimated that up to 800 million people need spectacles for close work, but do not have them.

Typically beginning around age 35, near vision impairment, or presbyopia, results from the eye’s lens losing flexibility, which makes it more difficult to focus on objects close up. Left uncorrected, presbyopia can hinder daily tasks such as reading, using digital devices, and performing work that requires precision.

The impact is substantial, affecting a person’s ability to function and their quality of life. The overall economic productivity losses due to unaddressed vision impairment are around $411bn each year worldwide, of which presbyopia is a major component. Ensuring that people who need them can get reading glasses, or ‘readers’, could bring huge potential gains to society, economies and lives.

Presbyopia has a very simple and highly effective solution that has existed for over 700 years: glasses. But it only works if people can access them. Currently far too many people are less able to work, study, take care of their family or enjoy life to the full because of unaddressed presbyopia. Many cannot afford spectacles or are not aware they have a problem due to a lack of screening.

Gathering robust evidence on this issue is crucial to ensure that countries worldwide are able to effectively identify and provide people with good quality and affordable glasses. There is currently limited evidence demonstrating the economic benefit of readers for policymakers when considering whether to prioritise addressing this condition.

That’s why two new studies, which will investigate to what extent providing reading glasses can lead to improvements in economic wellbeing and quality of life, are so important. The five-year programme will involve two randomised controlled trials – one in India and one in Kenya – to measure the impact in adults 35-65, after being provided with glasses. A total of 20,000 people across the two countries will either be given glasses at the start of the study, or be in a control arm where they don’t have them. Those in the control group will receive glasses at the end if they need them.

We’ll collect data at baseline, one and two years to assess the impact of the glasses on those who were and were not given them, through household consumption (how much people have spent on goods like food), quality of life, and other factors like employment, productivity and income.

This research is being coordinated by the team at the International Centre for Eye Health at the ��app of Hygiene & Tropical Medicine (LSHTM), in partnership with colleagues in India – Dr Shroff’s Charity Eye Hospital, Operation Eyesight Universal and Peek Vision – and Kenya – KEMRI, Kisii Eye Hospital, and Peek. This work is being supported by a $4.8m (£3.9m) grant from GiveWell, Founders Pledge and the Livelihood Impact Fund.

Through this work we aim to give governments and major donors a mandate to improve lives and livelihoods, at scale, through a simple and cost-effective solution, giving millions the opportunity to see, work and thrive.

Matthew Burton, Professor of Global Eye Health and Director of the International Centre for Eye Health at LSHTM, and Andrew Bastawrous, Professor of Global Eye Health at LSHTM and Co-Founder and CEO of Peek Vision Ltd.

Introduction

Hundreds of millions of people are currently living without reading glasses. LSHTM’s Matthew Burton and Andrew Bastawrous explain why two new trials, involving 20,000 people in India and Kenya, are needed to measure the impact of providing near vision glasses.

England’s organ donation law: Why the ‘soft’ opt-out system has fallen short and what can be done to improve it

lshpf1 — Fri, 15 Nov 2024 11:56:10 +0000

England’s organ donation law: Why the ‘soft’ opt-out system has fallen short and what can be done to improve it by lshpf1 Fri, 11/15/2024 - 11:56

In May 2020, England introduced a "soft" opt-out system for organ donation, following the earlier adoption of similar legislation in Wales (2015) and later Scotland (2021). The goal was to increase organ availability by presuming most adults to be willing donors unless they explicitly opted out. However, several years on, the anticipated improvements in organ donation rates have not materialised, and the implementation of the law has been shown to be more complicated than proponents had expected.

What we did

The Policy Innovation and Evaluation Research Unit (PIRU) at the ��app of Hygiene & Tropical Medicine (LSHTM), in collaboration with Bangor University, conducted a comprehensive evaluation between 2020 and 2023. This included an analysis of public opinion, healthcare practices, and the experiences of families and healthcare professionals involved in organ donation.

Why reality fell short

We identified several areas where there were significant problems with the current opt-out approach.

Before the law was changed in 2019 people had to opt-in, by providing explicit consent for their organs to be donated. The new opt-out approach presumed everyone to consent to donation, but was implemented within the existing framework, leading to a hybrid, and often poorly understood “soft” opt-out system.

Our research found that families continued to be central to the decision-making process, often overriding the presumed consent, and thereby undermining the law’s intent. This “soft” opt-out approach was chosen to avoid concerns of state overreach. In practice, it resulted in families overruling both presumed consent and explicit consent.

Moreover, it has become clear, that many people do not fully understand what presumed consent means, often equating it with less commitment to donating than an explicit opt-in decision. Misinformation campaigns, particularly targeting ethnic minorities, have created further confusion, and led to higher opt-out rates within these communities.

Lastly, the new law was introduced at the peak of the COVID-19 pandemic, when healthcare resources were already stretched and unable to prioritise organ donation.

What needs to change?

The presumed consent system for organ donation in England has been limited by existing laws, especially the Human Tissue Act (HTA). This law requires specific consent for each type of organ, tissue and use not covered under the presumed consent rules. This adds complexity to the work of specialist staff in organ donation who have to work with two forms of consent pulling in different directions. This lengthens discussions with bereaved families and heightens the risk of error.

Building and sustaining public trust is essential. The public must understand that organ donation does not compromise end-of-life care. Organ donation remains low-profile within the NHS, largely disconnected from broader end-of-life care conversations. A cultural shift is necessary — one that incorporates organ donation as a routine and expected consideration within end-of-life care. This would help to reduce the emotional shock families experience when confronted with organ donation during acute grief.

Simplifying the consent process and making organ donation a seamless part of end-of-life care is critical. This requires avoiding further reactive legislation. The current HTA Act was created in the wake of a scandal widely regarded to have harmed trust in the NHS. Instead, healthcare professionals should be empowered to implement meaningful changes. Ensuring that all relevant staff, not just specialists in organ donation, are adequately prepared and equipped to facilitate organ donation when the opportunity arises will enhance both the system's efficiency and effectiveness, benefiting donors and recipients alike.

Ultimately, the success of England’s opt-out system will depend on more than legal reforms. Increasing organ donation rates will require a comprehensive effort to enhance public understanding, for example through new media campaigns to help explain the changed role of the family, and demystify the processes involved in organ donation. It will also need a strengthening of healthcare infrastructure by ensuring that organ donation is suitably resourced and providing clearer guidance for families and professionals navigating what remains a highly sensitive and challenging process, by making it a priority for everyone.

This study was funded by the NIHR Policy Research Programme through its core support to the Policy Innovation and Evaluation Research Unit (Project No: PR-PRU-1217-20602). The views expressed are those of the author(s) and are not necessarily those of the NIHR or the Department of Health and Social Care

Nicholas Mays, Professor of Health Policy at the ��app of Hygiene & Tropical Medicine, and Leah McLaughlin, Research Officer in School of Health Sciences, Bangor University

Introduction

Several years after a change of the organ donation law with the aim of increasing organ availability, LSHTM experts explain why expectations were not met.

Septins give insights into inflammation

lshpw5 — Tue, 06 Aug 2024 07:53:16 +0000

Septins give insights into inflammation by lshpw5 Tue, 08/06/2024 - 08:53

Look deep into the structure of any cell or organism with a defined nucleus (eukaryote), and you are likely to find septins.

Septins have been identified in nearly all eukaryotes, including humans. They are components of the cytoskeleton, a network of protein filaments that helps eukaryotic cells hold their shape and carry out essential functions.

Septins were originally discovered by Nobel Laureate Leland Hartwell in 1971 as being essential for cell division in budding yeast.

Over the last 50 years they have been shown to play key roles in a wide variety of cellular processes including cell division, sprouting cilia and flagella, and forming neurons. It is known that different septins can assemble to form structures including filaments, rings and cages that interact with cellular membranes.

But despite all this research the mechanisms underlying septin assembly and function are nothing like as well understood as those of other cytoskeleton components actin and microtubules.

Previous LSHTM research has found an association between septin dysfunction and cancer, neuropathies and a range of other conditions.

Now new LSHTM research using zebrafish, published in Cell Chemical Biology, is uncovering the role septins play in regulating the inflammatory response. We asked study authors Dominik and Serge about their work and what it could reveal about inflammatory conditions.

How can zebrafish help us understand the human immune system?

Zebrafish are an important animal model for biomedical research, in part because they share 80% of the genes that control their immune system with humans.

Zebrafish develop rapidly, are transparent (allowing for live cell and high-resolution fluorescent microscopy imaging) and are highly amenable to genetic manipulation via CRISPR technology. In our lab, we can exploit these properties to investigate the complex interactions between bacterial pathogens and the host innate immune response.

We are best known for using the zebrafish infection model to study Shigella infection. Shigella causes shigellosis, a bacterial infection characterised by diarrhoea, fever, and abdominal pain that leads to approximately 200,000 deaths each year.

There is no natural mouse model of shigellosis (mice are naturally resistant to Shigella infections), so our lab pioneered the zebrafish model to study Shigella infection in vivo.

The zebrafish infection model recreates the major hallmarks of human disease, including cell death caused by macrophages (a type of white blood cell that act as a first line of host defence against pathogens).

As a result, our work at LSHTM using the zebrafish infection model has significantly contributed to understanding Shigella interactions with innate immunity, as highlighted by recent studies of temperature-dependent virulence, bacterial persistence, innate immune training, and bacterial cell-cell interactions.

What different roles do septins play within cells?

The vast majority of research labs studying septins are focused on their role in cell division. But in our lab we have been studying the role of septins in host defence against Shigella infection, to better understand the role of septins in non-dividing cells..

We discovered that septins can entrap Shigella in cage-like structures to restrict their replication and dissemination. Despite extensive research on Shigella-septin cage entrapment, we still don’t know that much about the breadth of roles septins play in host defence.

At LSHTM we have a Schedule 5 lab and zebrafish infection facility to study Shigella. Together this research environment uniquely enables us to exploit our zebrafish infection models to discover previously unknown role for septins in the regulation of inflammatory responses during Shigella infection.

What is the role of septins in immune cells?

The role of septins in immune cells is relatively understudied. Much of our current understanding of septin biology stems from research in yeast and epithelial cell lines.

Initially, our work using macrophages was consistent with our work using HeLa epithelial cells, showing that septins play key roles in mitochondrial dynamics and septin caging during Shigella infection.

We hoped that by investigating the role of septins in macrophages we could gain fresh insights into septin-mediated immunity and identify new ways to control infection and inflammation.

Out of the different mechanisms of cell death, why were you interested in pyroptosis?

Pyroptosis is a process of regulated cell death associated with inflammation. The name ‘comes from the Greek words ‘pyro’ meaning ‘fire’ or ‘fever’ and ‘ptosis’ meaning ‘to fall’.

Pyroptosis is of great interest because of its pro-inflammatory potential and its association with various human pathological conditions, including neurodegenerative diseases, autoimmune disorders and infectious disease.

This new research published in Cell Chemical Biology, investigating septins in pyroptosis, has been very challenging. This is partly because of the diverse roles of septins in cellular processes and the complexity of the pyroptotic pathway.

Two proteins, gasdermin D and ninjurin-1, became important for our study because of their recently discovered ability to form pores at the plasma membrane (facilitating the release of pro-inflammatory cytokines) and to promote cell-membrane rupture, respectively.

These new data offered clues into how septins could be involved in the regulation of the pyroptotic pathway, as both gasdermin D and ninjurin-1 are located at the plasma membrane (where we found that septins in macrophages are also located).

What link did you find between septins and how macrophages die upon Shigella infection?

Our main findings showed that macrophage pyroptosis triggered by septins is a critical mechanism for infection control because of how it manages inflammation.

Septins enhance macrophage pyroptosis during Shigella infection, by regulating gasdermin D pore formation and ninjurin-1 membrane rupture. Based on our results, we hypothesise that septins organise plasma membrane composition and create a favourable platform for gasdermin D pore formation and its coordination with ninjurin-1 mediated membrane rupture. Taken together, we conclude that septins are gatekeepers of membrane disintegration during pyroptosis. Our future research will look to identify more precisely how septins interact and regulate the pyroptotic apparatus.

Over the past 4 years working as a postdoc at LSHTM, Dominik has combined his research on septin biology with the Mostowy lab’s renowned zebrafish infection models. This means we are now able to use CRISPR genome editing to manipulate septins in zebrafish, enabling us to explore the role of septins during Shigella infection in vivo.

These results show that septins play a central role in host defence and future work using complementary models (in vitro using cell-free systems, in cellulo using tissue culture cells, in vivo using zebrafish) will be important to promote discovery of anti-bacterial and anti-inflammatory treatments.

How might this ultimately lead to new ways of managing human inflammatory disease?

For the first time, our work has directly linked septins to pyroptosis. In addition to our study, a companion study has shown that a septin-modifying compound, forchlorfenuron, can activate the inflammasome and induce pyroptosis. Taken together, these two studies highlight the potential for using septin-targeting drugs to effectively manage inflammation.

This approach may be useful as a therapy aiming to support the body’s natural defence mechanisms against bacterial pathogens which depend on inflammation for their life cycle, including Shigella.

By manipulating septins to manage inflammation, such therapies could offer significant benefits for patients suffering from a wide range of conditions in which septins have been implicated.

Dr Dominik Brokatzky, Research Fellow, and Serge Mostowy, Professor of Cellular Microbiology, both at the ��app of Hygiene & Tropical Medicine

Introduction

Dominik Brokatzky and Serge Mostowy discuss their new research in Cell Chemical Biology investigating the role of septins in immune cells.

Antibiotic resistance – what you need to know

lshkb29 — Tue, 28 May 2024 08:30:23 +0000

Antibiotic resistance – what you need to know by lshkb29 Tue, 05/28/2024 - 09:30

Each year, an estimated 7.7 million deaths are caused by bacterial infections, globally. Out of these deaths, about 1.27 million are attributable to bacteria which have developed resistance to antibiotics.

What is antibiotic resistance and what does it mean for us?

Bacteria are an important part of our lives and bodies but sometimes, we can be infected by bacteria that go on to cause adverse effects. When the body is unable to fight an infection, which can be seen in cases of pneumonia, sepsis or peritonitis, bacteria can also directly lead to death. These serious infections disproportionately affect those who are most vulnerable, such as those who may be undergoing treatment for cancer but with antibiotics, often these deaths are avertable.

Antibiotics started to be mass-produced from the 1950s and due to their success at both fighting and preventing serious infections, they are now widely used. Unfortunately, bacteria are continually evolving to resist these medicines, meaning that infections people might previously have overcome with the use of antibiotics can now be untreatable. As this happens, and as our global demographics change, we will need to keep-up with a changing profile of drug resistance. This means we will need effective antibiotics, improved infection prevention measures and to be better able to manage infections. This applies both to humans and to animals, who also suffer from drug-resistant infections.

Why is this happening and what could be influencing the rise in the burden of resistance?

Bacteria have always evolved to survive better in the presence of substances that may be harmful to them, including antibiotic medicines. However, there are several factors which may be contributing to a rise in the burden of drug resistance.

Although many prescriptions of antibiotics can be vital, they can also be used unnecessarily, for example, for a cold that is likely to be caused by a virus. The antibiotic will not have an effect on the cold and the patient will continue to feel unwell, but it will affect their own community of microbes and those in the wider environment once passed through the body. This creates an opportunity for the bacteria to evolve, without benefit to the person taking the medicine.

We also use these substances to treat infections in our domestic animals like cats and dogs, as well as in livestock and fish farming, which can further add to the pressure on microbial communities to evolve.

How impactful could the misuse of antibiotics be for health systems across the world?

Antibiotics are hugely important medicines that have the power to enable people to survive serious infections. If they are no longer working, much of the modern healthcare system is at stake, as well as wider aspects of our modern lives.

Reducing the overuse of antibiotics should buy us time but resistance to antibiotics does raise a spectre over different components of health systems that rely on these medicines being effective. Examples include neonatal and maternal health, in cancer care and in surgery. Without effective antibiotics, the mortality rates for each of these areas are at risk of escalating.

What changes can we make to reduce the impact of antibiotic resistance?

To reduce the volume of antibiotics interacting with microbial communities, we need to decrease the overall amount of antibiotics we use. We can do this by reducing unnecessary prescribing in humans and animals, and avoiding the use of antibiotics as animal growth promoters.

Bacteria can be transmitted by numerous routes, so it’s important that we take the most appropriate steps to slow down transmission of antibiotic-resistant infections. For example, gonorrhoea bacteria have become resistant to a lot of available antibiotics. We should therefore continue to encourage preventative measures, such as condom use, to prevent catching this sexually-transmitted infection.

Basic hygiene measures such as hand washing, careful food preparation, and the availability of clean drinking water and good sanitation systems, are also vital in preventing the spread of these infections.

Is this one of the greatest concerns for health in modern times?

Drug resistant infections are a great concern. As well as needing to ensure the pipeline of new antibiotics is effective – which is a major challenge – we also need to work on building resilient health systems, robust to the prospect of operating without reliably effective antibiotics.

The burden of drug resistance is also unevenly shouldered, as some communities do not have access to the treatments they need including next-line antibiotics. We must strive towards equal access to medication, high vaccine coverage and improved infrastructure that helps to prevent disease.

Drug resistance is often called a ‘One Health Problem’ because of the way that the journeys of bugs and drugs moves between animals, people and the environment. There are no easy or simple solutions, and scientists are working hard to evaluate different options to avoid the negative trajectory that has been projected in the coming decades. This problem requires serious political attention and commitment to act now, as it’s clear that significant changes are needed to slow the tide of drug resistance and manage it into the future.

Clare Chandler, Professor of Medical Anthropology at the ��app of Hygiene & Tropical Medicine (LSHTM)

Introduction

As leading scientists call for urgent action to address antimicrobial resistance, LSHTM’s Clare Chandler explains why our overuse of antibiotics is a growing risk to public health

Women need to be at the heart of clinical trials

lshpf1 — Thu, 16 May 2024 11:01:19 +0000

Women need to be at the heart of clinical trials by lshpf1 Thu, 05/16/2024 - 12:01

What’s the issue?

Across many types of trials, the recruitment and retention of women is a challenge. In cardiovascular trials, approximately a third of participants are women.

Why is there gender inequity in clinical trials?

It’s often extremely challenging to recruit people to take part in clinical trials under any circumstances, so the focus has been on recruiting sufficient numbers rather than the ratio of men and women.

Research has shown that women are often excluded from trials due to their age and health status. Follow-up visits can also be a barrier for women with children or caring responsibilities. In some cultures partners and family members expect to be involved in decision making, which is not usually addressed well in trials.

There is also a perception that women are more difficult to enrol into trials than men. In a resource-strapped system, research nurses may understandably feel forced to choose the option that takes less resource. True or not, this could also be because trials have been designed without women’s needs in mind.

What are the challenges for cardiovascular trials in particular?

Heart disease is largely considered a male issue, despite cardiovascular disease being the number one cause of death for women globally.

Cardiovascular trials are a male-dominated field at all levels – funders, researchers, consultants and patients.

The biggest challenge is underdiagnosis of heart problems in women. Women may describe their symptoms differently; they are more likely than men to have a heart attack with no severe blockage in an artery; medical professionals may prioritise other aspects of their symptoms; and it often takes longer for women to be diagnosed.

When it comes to treatment, fewer women receive interventions such as heart bypass surgery or non-surgical procedures, which trials are often designed around. Because there is an idea that it’s challenging to recruit women to cardiovascular trials, there is sometimes a reluctance to fund research in women. This clearly needs to change in order to address this issue.

Why does it matter if not many women take part in trials?

If the evidence is based predominantly on male participants, the results may not be applicable to women. This inequity means there is limited evidence for the best way to treat women, which could potentially lead to a lower quality of life, higher mortality, more hospitalisations and co-morbidities.

Women have additional cardiovascular risks, including menopause, pregnancy related conditions and gynaecological conditions. However, these risks are still not well understood. Inclusion in trials where these risk factors are collected and analysed will improve our understanding.

What are the potential benefits for public health if more women are involved in trials?

We should ultimately be aiming for involvement in trials to better reflect our society. Women are still underrepresented - and women from ethnic minority and low socioeconomic backgrounds even more so - at all levels from funders to researchers, to clinicians to patients. Addressing this will improve the health of all.

More women participating in trials will improve understanding of cardiovascular risk, potentially helping to address the under-diagnosis of cardiovascular disease in women.

What’s been tried before to improve gender equity in clinical trials?

There has been increased focus on gender equity in the management of clinical trials in recent years. This has included increasing diversity among funder panels, trial committees and researchers, and so some progress has been made.

Publishers are also requesting information on equity, diversity and inclusion which has helped to highlight work that really needs to be done at the beginning of trials – not just the end.

Researchers involve patients, carers and the public in designing and running trials – known as patient and public involvement (PPI). As this improves in terms of gender and ethnic diversity, so do the numbers of women speaking about their experiences which gives us valuable insights we can learn from. We have successfully embedded PPI in our trial management groups and trial steering committees, and have developed a Research Advisory Group which is a diverse PPI group that advised on our cardiovascular trials.

What have you done to address the issue so far?

Within the Clinical Trials Unit at LSHTM, we have focused on making trials more accessible to all in recent years, collaborating with PPI groups to improve the patient experience.

We have improved communication with patients and diversified methods of communication; improved patient information, providing it in diverse ways such as videos and animations. In addition, we have simplified patient visits and follow-up.

We are also members of the Women in Cardiovascular Trials (WiCVT) group, which has been set up to investigate the barriers and facilitators to women’s participation in trials. The group is an international collaboration of patients, researchers, nurses and clinicians dedicated to improving representation of women in cardiovascular research.

What are you going to be investigating in your upcoming new trials?

Our next generation of trials due to start this summer are designed to be accessible to all. We have planned them with PPI input from the beginning to minimise barriers to women, people from ethnic minorities and low socioeconomic areas.

We are launching new trials that deal with issues more commonly seen in women, including female patients admitted with heart attacks and angina to investigate the best way to treat women in an acute setting. We will also be looking at other forms of heart disease that are more common in women than in men – heart failure with preserved ejection fraction (HFpEF) and Spontaneous coronary artery dissection (SCAD).

What actions are you taking to increase participation among women?

Women with lived experience have been involved with research design to ensure that the needs and priorities of women have been considered at every stage.

We plan to create patient information that is tailored specifically to women and properly takes into account the way in which women process the risks and potential benefits of taking part in the trial. We will discuss these with PPI groups before the trial starts.

We will use audio, video and written formats and allow participants sufficient time to make a fully informed decision. We will also provide information tailored to a patient’s partner and family, as in many cultures this forms a large part of the decision making process.

Practical steps include reimbursing for travel where needed and covering the cost of childcare or caring commitments for trial-specific visits, as this prevents many women from enrolling in trials. We will ensure that communication is flexible and there are different options for collecting information from patients that can fit better around their lives.

How will you measure the effects of new strategies and trial design?

We plan to start monitoring representativeness in real time. We are already doing that to some extent but we will now monitor sex, ethnicity and socioeconomic status in regular reports so that we can take action quickly and test the effectiveness of new approaches.

PPI members will sit on the Trial Management Groups, advising in real time on any issues affecting recruitment and help provide solutions to any new barriers we identify.

We plan to enhance monitoring of the enrolment process at participating hospitals, recording reasons for non-enrolment, along with sex (and potentially also ethnicity). We will also monitor usage of online resources to see which ones reach the most patients.

We will include small studies (SWATs) within the trial to evaluate how well some of the proposed solutions work at improving enrolment, presenting and publishing the results. That way we hope to contribute to improving recruitment of women across trials in future.

If successful, what kind of impact could this have in the future and what needs to happen next?

Funders need to accept that underrepresentation of women is unacceptable and consider it as a call to action. We need funding in order to test these strategies in a clinical trial setting.

Ultimately our job is to impact positively on public health. We do this in the CTU by answering clinical questions through trials. However, there are unanswered questions on women’s cardiovascular health that aren’t being considered as subjects for clinical trials because of a lack of confidence that these trials can be delivered.

If we can prove that recruiting women into clinical trials is feasible and achievable, it will provide a case for many more of these issues to be investigated in future.

The overall aim is to find new strategies and treatments that improve health and quality of life for all women.

Publication: Julie Sanders, Tim Clayton, Stacey Matthews, Sarah Murray, Lynn Laidlaw, Richard Evans & Rochelle Wynne, Strategies for the delivery of sex-based equity in cardiovascular clinical trials. Nature Reviews Cardiology. https://www.nature.com/articles/s41569-024-01025-x

Richard Evans, Senior Manager of the Clinical Trials Unit at the ��app of Hygiene & Tropical Medicine (LSHTM)

Introduction

As the LSHTM Clinical Trials Unit prepares to launch new trials to test treatments for heart disease, Richard Evans explains what they are doing to increase the number of women taking part, and why this matters

UK abortion law – what you need to know

lshkb29 — Tue, 16 Apr 2024 12:01:52 +0000

UK abortion law – what you need to know by lshkb29 Tue, 04/16/2024 - 13:01

Proposals to modernise UK abortion law are expected to be discussed in parliament soon and our extensive research says this would improve the lives of both women and healthcare professionals.

What is the current law on abortion for the UK?

Differences in abortion law across the UK are still not widely understood, even by healthcare professionals, as revealed in our extensive research through the SACHA (Shaping Abortion for CHAnge) study, the largest research project on abortion to be carried out in Britain.

Abortions across England, Wales and Scotland continue to be regulated by the 1967 Abortion Act. This means that, currently, abortions can only be carried out legally up to 24 weeks, must be approved by two independent doctors and performed only in an NHS hospital or a place approved by the Secretary of State. Abortions not meeting these strict conditions may be treated as a criminal offence.

What about other countries?

England, Scotland and Wales are falling behind a range of countries that have modernised their abortion laws. In 2019, Northern Ireland and the Isle of Man removed abortion offences from criminal law, a process known as decriminalisation. This led to speculation that other parts of the UK may follow. The Republic of Ireland, New Zealand, Australia, Canada and Sweden are all examples of countries which have already removed abortion offences from their criminal law.

How do current abortion laws affect patients and healthcare professionals?

All the evidence we've collected in the SACHA study points in the same direction. The current law on abortion in Britain is outdated and no longer serves any useful purpose. It increases the stress of an unintended pregnancy and sets up hurdles along the abortion pathway causing delay. The earlier in pregnancy abortion takes place, the safer it is.

Healthcare professionals, who are already stretched to capacity, are also being prevented from providing best practice and compassionate care to the women who urgently need it, through fear and risk of prosecution.

When we asked 771 health professionals across England, Scotland and Wales, one in five were not aware that the legal requirement still requires two doctors to sign off every abortion.

How would a change to law improve women’s health and support healthcare professionals?

Decriminalisation would mean that those who undergo or perform abortions, either where a pregnancy is intentionally ended by the woman herself or by a qualified health professional acting with her consent, would no longer be at risk of legal repercussions.

This would allow women to rightly put their health and wellbeing at the forefront of decision-making around when and where to seek professional help, without the added fear of prosecution.

The COVID-19 pandemic was a clear example of how impactful a legal change would be, where governments in England, Wales and Scotland approved home administration of early abortion through medication, with remote consultations and telemedical support. Patients told us that they valued the comfort, privacy and confidentiality of abortion at home while still also wanting a choice of options, including surgical abortion.

When we spoke to healthcare professionals, we found a consensus with more than nine out of 10 supporting abortion being a woman’s choice and a clear majority favouring abortion being treated as a health rather than as a legal issue.

They also said that nurses and midwives should be able to authorise an abortion, rather than doctors, as they are already trained in relevant procedures and care-giving for women who experience miscarriage, and are the ones in most frequent contact with the patient.

Would a change to law affect abortions and patient safety?

Decriminalisation does not mean deregulation. The safety of abortion services would continue to be ensured through the same regulations that govern other medical procedures. Non-consensual abortions and abortions offered by unqualified providers would remain punishable through other existing laws such as malpractice.

There is also no evidence to show that decriminalisation of abortion increases the number of abortions requested or performed. Rather, data show that abortion rates are lowest in countries with available and effective information, education and services.

There is also no evidence to show that the rate of abortions performed after 20 weeks increases when the procedure is decriminalised. In countries with lawful abortion and reliable data, 90% or more of abortions are performed at less than 13 weeks and two-thirds at less than nine weeks of gestation. For the small number of women who need abortions further into a pregnancy, the priority must be support, not prosecution.

Can abortions put women’s lives or health at risk?

Abortion is one of the most common health procedures and is likely to be experienced by one in three women in their lifetime. Globally, virtually all legal abortions are safe and research shows that a legal abortion is considerably safer than carrying a pregnancy to term.

Abortion does not cause infertility, ectopic pregnancy, placental abruption or breast cancer, as is sometimes claimed.

While we all hold personal views regarding the morality of abortion, what our research shows is the clear benefits to women’s rights, health and the livelihoods of healthcare professionals of removing abortion offences from criminal law.

Like other medical procedures, abortions should be a decision made between patients and trained healthcare professionals, not a legal issue.

Further reading

Sally Sheldon and Kaye Wellings (eds), Decriminalising Abortion in the UK: What Would It Mean?, Policy Press, 2020, 176 pp., Open Access, ISBN 9781447354024.

Kaye Wellings, Professor of Sexual & Reproductive Health and SACHA co-lead at the ��app of Hygiene & Tropical Medicine (LSHTM)

Introduction

LSHTM sexual and reproductive health expert Kaye Wellings explains why a change to Britain’s current legal restrictions on abortion would improve the lives of both women and healthcare professionals

Why is healthcare leaving people with disabilities behind?

lshkb29 — Fri, 12 Apr 2024 08:40:23 +0000

Why is healthcare leaving people with disabilities behind? by lshkb29 Fri, 04/12/2024 - 09:40

The 1.3 billion people with disabilities around the world face increased risk factors associated with poorer overall health, such as poverty, issues in older age, malnutrition and exposure to violence. While disability is diverse, people with disabilities often report experiencing similar barriers when seeking healthcare support.

Reports continue to highlight that health services are failing to accommodate people with disabilities. Barriers include: inadequate knowledge from the healthcare provider about the patient’s disability, limited physical accessibility (such as a lack of ramps for wheelchair users) and limited accessible communication (such as easy read formats for patients with cognitive impairment). Barriers like stigma, negative attitudes and misconceptions about disability can also lead to exclusion from some general health services, for example sexual and reproductive care.

These barriers compound marginalisation of people with disabilities and amplify the impact of underlying health conditions and impairments on mortality rates. In our recent article published in The Lancet Global Health, we found that in low- and middle-income countries (LMICs), people with disabilities had a mortality rate twice that of people without disabilities.

This issue also extends beyond LMICs. In the UK, the Confidential Inquiry into premature deaths of people with intellectual disabilities found that 37% of the deaths reported were "avoidable deaths" due to factors relating to the quality of healthcare received. This is in contrast to 13% in the general population. In the USA, studies have shown that adults with any disability face a higher likelihood of mortality and in Scotland, research has shown that children with intellectual disabilities exhibit elevated all-cause mortality rates compared to their peers.

The COVID-19 pandemic also underscored this health inequity and our research estimated a 2.7-times higher COVID-19-related mortality rate for people with disabilities compared to those without. We found that the rate for those with intellectual impairments was even higher.

While our recent findings show higher mortality rates for people with disabilities in LMIC remain regardless of impairment types or age, this was particularly stark for people living with neurological conditions and children with disabilities. Neurological conditions, for example dementia, can affect critical processes such as respiratory and cardiovascular functions that may worsen with time. Children with cerebral palsy, for instance, are at extremely high risk of early death due to respiratory infections, malnutrition, and comorbid brain disorders such as epilepsy. Nevertheless, these patients, who need and should be receiving a high level of support, still face general health system barriers.

Our evidence points to a systemic failure to accommodate people with disabilities within existing health systems. To achieve comprehensive health for all, we must actively challenge stereotypes and create health systems to include people with disabilities.

One example of the many projects working to enact positive change in this area is the Missing Billion Initiative (MBI). The initiative aims to improve health access and outcomes for people with disabilities worldwide through developing tools, solutions and collecting data. MBI’s reports highlight that people with disabilities are being excluded in health, present a clear pathway for action towards defined disability-inclusive health systems, and emphasise that addressing the lack of disability data is the crucial first step for health systems and policy makers to reduce care inequities for people with disabilities.

In confronting the stark reality of higher mortality rates among people with disabilities, it’s evident that inclusive actions are not just an option but a necessity. We need to work together to dismantle barriers and foster a health system that truly accommodates everyone.

Dr Tracey Smythe, Associate Professor with the International Centre for Evidence in Disability at the ��app of Hygiene & Tropical Medicine (LSHTM)

Introduction

LSHTM’s Tracey Smythe discusses why embracing inclusivity isn't just a call for change; it's a collective responsibility to ensure comprehensive health for all, leaving no one behind

Ebola 10 years on: why trust remains key

lshpf1 — Fri, 22 Mar 2024 16:30:45 +0000

Ebola 10 years on: why trust remains key by lshpf1 Fri, 03/22/2024 - 16:30

23 March 2024 marks 10 years since the World Health Organization reported an outbreak of Ebola Virus Disease in Guinea. This was the beginning of what remains the largest Ebola epidemic to date, as in the following months the disease spread rapidly across West Africa.

Sierra Leone, Liberia, and Guinea were worst affected, registering a cumulative 28,616 cases and 11,310 deaths. The declaration of a public health emergency of international concern, coupled with national state of emergency legislation in these countries, also had long-lasting social and economic repercussions.

The experience of Ebola has had a profound impact on vaccine development, as well as global and national public health systems, particularly in response to new epidemics. This includes new global mechanisms for assessing epidemic preparedness, funding response, and supporting knowledge sharing and research. In affected countries like Sierra Leone, a newly established National Public Health Agency builds on the significant expertise that now exists in the country for infectious disease surveillance, laboratory testing, infection prevention and control, clinical research, and risk communication.

LSHTM academics played a key role in the 2014 Ebola outbreak response, from infectious disease modelling to establishing the Ebola Anthropology Platform to provide rapid social science expertise to support outbreak response. LSHTM also led clinical trials of the Jansen Ebola vaccine (EBOVAC) in Kambia District, Northern Sierra Leone, with the College of Medicine and Allied Health Sciences of the University of Sierra Leone. While a vaccine had been in development since soon after the discovery of Ebola in the Democratic Republic of Congo (DRC) in 1976, none had been licensed by the time of the West African outbreak.

The EBOVAC trial opened its doors in October 2015. We worked as anthropologists on the trial, and, with a team of local social scientists, we conducted research on local experiences and perspectives of the vaccines. We established a system for feeding social science data into community engagement to address anxieties and mistrust of the vaccine in real time. Our work highlighted the understandable reasons why people were suspicious of the arrival of a large international clinical research project in the middle of a health crisis. We showed, for example, how fears that the trial staff might have come to steal blood from the population revealed broader mistrust in international actors that had deep historical roots in colonial and post-colonial violence. At the same time, we also chronicled people’s narratives of sacrifice and altruism when deciding to join the trial and take the vaccine.

The two-dose vaccine candidate tested in the EBOVAC trial was found to be well tolerated and immunogenic, leading to approval by the European Commission. During the West African Ebola outbreak, the ERVEBO vaccine produced by Merck was also trialled and found to be protective, achieving European and FDA approval. The arrival of vaccines was a game changer, and it meant that during subsequent epidemics, such as those between 2018-2020 in DRC and 2021 in Guinea, responders had better tools to contain the epidemic. The Janssen Ebola vaccine is now used to protect health workers in potentially epidemic areas and the ERVEBO vaccine has been used in ring vaccinations – a method co-developed by LSHTM which involves vaccinating people in rings of contacts and contacts of contacts of confirmed cases - to stop active transmission. 

Nonetheless, as the protracted Ebola epidemic in DRC and epidemics of a different Ebola strain in Uganda in 2022-2023 have shown, having effective vaccines is not enough. In the immediate aftermath of the West African epidemic, expert panels reflected on lessons to prevent future outbreaks. A key insight that shapes future response is recognising the need to build the trust of communities affected by health emergencies. The work done by social scientists and community activists during the Ebola outbreak highlighted the importance of two-way dialogue and the development of response measures that take into account people’s experiences and perspectives. For example, such dialogue led to the integration of local funerary practices in the ways safe and dignified burials were conducted. Community engagement is now an established component of any international response. Recent efforts to develop “integrated outbreak analytics” similarly reflect a recognised need for multidisciplinary approaches to outbreak response, including social science data and local perspectives in how we understand and respond to health emergencies.

Despite the reforms and scientific advancements achieved after Ebola, the world faced significant challenges when confronted with the COVID-19 pandemic. This included difficulties in securing citizens’ trust and building confidence in novel vaccines. We did however observe that communities that had been affected by Ebola were able to build on their experience and react more effectively to the pandemic. Whatever the disease or exact nature of the next epidemic or pandemic, trust and engagement with communities must be part of the solution at every stage.

Dr Luisa Enria, Associate Professor of Anthropology, and Shelley Lees, Professor of Anthropology of Public Health, from the Vaccine Centre at the ��app of Hygiene & Tropical Medicine (LSHTM)

Introduction

A decade on from the devastating Ebola outbreak in West Africa, Luisa Enria and Shelley Lees reflect on the importance of building trust in communities to sustain progress in epidemic response

������app opinion

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Ebola 10 years on: why trust remains key

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