Abebaw Fekadu

Science stands at a critical crossroads. Rapid technological advances, global partnerships, science diplomacy, and demographic trends in some parts of the world have positioned science for unprecedented societal impact. On the other hand, severe funding cuts, political disharmony, national and regional fragility and weaponisation of misinformation are eroding the institutional and epistemic foundations of science. In this paper, we call for a renewed commitment to science as a global public good. We argue that safeguarding science requires collective action through responsive national and global governance, sustained investment, moral clarity, public legitimacy, and the meaningful inclusion of indigenous knowledge systems. We place particular emphasis on Africa as a vital driver of scientific progress. Its large-scale unmet needs, expanding research capacity, demographic dividend and intellectual potential position Africa as an important partner in shaping the future of global science. We appeal for global action (with strategic recommendations) to reaffirm science as a mission-driven public good for sustainable development and a fairer future.

Introduction: In many Low- and Middle-Income countries (LMIC), access to psychological therapies for psychosis remains extremely limited, contributing to significant treatment gaps and persistent inequalities in care. Novel interventions that are effective, scalable, and culturally acceptable across diverse settings are urgently needed. AVATAR therapy is an innovative digital intervention for distressing voices in psychosis, developed in the UK. The therapy enables voice-hearers to engage in a series of facilitated dialogues with a customized computer-based representation of their main distressing voice. AVATAR3 represents the first initiative to contextually adapt AVATAR therapy and evaluate its acceptability in two LMIC settings (Ethiopia and India). Methods and analysis: We will establish Innovation and Implementation Hubs in Addis Ababa, Ethiopia (Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa) at Addis Ababa University (AAU) and Mental Health Service Users Association (MHSUA), Ethiopia) and New Delhi, India (All India Institute of Medical Sciences). Phase 1 employs formative work and diverse stakeholder engagement to inform context-specific adaptations. Reflexive thematic analysis will be used, with data synthesis informed by the Cultural Adaptation of Scalable Psychological Interventions (CASPI) framework and Ecological Validity Model (EVM). Phase 2 tests adapted AVATAR therapy through a parallel case series (n=15 per site, targeting 70% completion rate) measuring feasibility, acceptability, and safety indicators at baseline, 12-weeks, and 24-weeks. Qualitative research will explore the experiences of participants (n=10) and therapists (n=8) at each site. Ethics and dissemination: Ethical approval has been obtained from Addis Ababa University College of Health Science Institutional Review Board, All India Institute of Medical Sciences (AIIMS) Institutional Review Board and the King’s College London (study sponsor) Research Ethics Committee. Findings will be disseminated to inform the implementation of AVATAR therapy across diverse international settings. Strengths and limitations of this study: Interdisciplinary and participatory approach Contextual adaptation of a digital innovation Expert by experience leadership and involvement from the conception of the study The study will develop tools and share learning to support future digital mental health innovation across diverse international settings The case-series at each site will not have a control group

Background: Clinical research coordinators play a crucial role in ensuring the scientific rigor, regulatory compliance, and operational integrity of clinical trials. However, in Africa, they often lack access to structured, competency-based training, especially in operational, regulatory, and trial management domains. This study evaluated the effectiveness of a comprehensive training intervention designed to standardize and enhance core competencies of clinical trial coordinators. Methods: We conducted a prospective pre-post interventional study among cohorts of clinical research professionals completing a 10-week, internationally-accredited, Moodle-based clinical trial operations training program aligned with the Joint Task Force Core Competency Framework, covering 10 lessons and 25 domains. Self-reported competence was evaluated at baseline and post-training. Data analyses included paired t-tests for aggregate scores, McNemar’s exact test for domain-level proportions, multivariable logistic regression for predictors of improvement, and Cohen’s d for effect size. Results: Among the 166 participants enrolled from 19 African countries and completed the pre-training survey, 152 who completed the program and post-training survey were included. The training significantly increased the mean aggregate competence from 12.24±7.85 (out of a maximum of 25) to 23.35±2.73 (mean difference: 11.11; 95% CI 9.86-12.36; p . 001 ; Cohen’s d =1.41). Score variance decreased, with the median score increasing from 12.0 (IQR: 6.0-19.0) to 24.5 (IQR: 23.0-25.0). All 25 domains improved (pp>0 . 05 ). Conclusion: Structured, competency-based training strengthens clinical trial coordinators’ capabilities, particularly in technical and administrative domains that are often overlooked. Accredited, framework-aligned clinical trial training programs promote consistent trial quality, strengthen research capacity, and sustain excellence in clinical trial delivery. WHAT IS ALREADY KNOWN ON THIS TOPIC: - Clinical research coordinators play a crucial role in ensuring the scientific rigor, regulatory compliance, and operational integrity of clinical trials WHAT THIS STUDY ADDS: - The study evaluated the effectiveness of a comprehensive training intervention designed to standardize and enhance core competencies of clinical trial coordinators in Africa, where they often lack access to structured, competency-based training HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY: - This study should encourage the design and delivery of internationally-accredited, Moodle-based clinical trial operations training programs in Africa that enhance clinical trial competency.

Background: The use of amphetamine-type stimulants such as khat has been spreading quickly in eastern parts of Africa, the Arabian region and Asia. However, screening for the provision of early intervention has been inadequate, primarily because of the lack of culturally acceptable and valid screening tools. Aims: To evaluate the the accuracy of the Problematic Khat Use Screening Tool (PKUST-17) in screening for khat use disorder against the DSM-5 criteria for substance use disorder. Method: A cross-sectional validation study was conducted in Ethiopia from February to December 2018, among a randomly selected sample of 506 individuals. The study subsample comprised 236 participants. We used the DSM-5 criteria for stimulant use disorders as the standard for determining the criterion validity and optimal cut-off score for the PKUST-17, using the receiver operating characteristic (ROC) curve. The DSM-5 criteria for substance use disorders were examined by researchers in a subsample of 232 participants. The PKUST-17 uses a five-point Likert scale (0–4), with total scores ranging from 0 to 68. At the optimal cut-off scores, sensitivity and specificity were determined. In addition, we conducted multivariate logistic regression analysis to evaluate potential convergent validity of the tool. Results: The area under the ROC curve showed good performance of the PKUST-17 (0.78, 95% CI 0.70–0.85, P < 0.001). A cut-off score above 17 demonstrated a sensitivity of 72% and specificity of 73%. The positive predictive value was 77.6% and the negative predictive value was 65.8% in identifying stimulant use disorder, as per the DSM-5 criteria. Among others, problematic khat use was significantly associated with higher World Health Organization Disability Assessment Schedule 2.0 scores (adjusted odds ratio 1.78, 95% CI 1.04–3.03, P < 0.01) and more depressive symptoms (adjusted odds ratio 4.10, 95% CI 2.36–7.12, P < 0.05). Conclusions: We found that the PKUST-17 is a valid tool for screening for khat use disorder against the DSM-5 criteria for substance use disorder, and identifying high-risk problematic khat users.

Background: The high comorbidity of substance use disorders (SUDs) among people with severe mental health conditions (MHCs) poses major challenges to providing effective care, particularly in low- and middle-income countries (LMICs), where treatment options are limited. Aims: The aim of this scoping review was to produce an overview of the current evidence on psychosocial interventions for people with comorbid MHCs and SUDs in LMICs. Method: The following databases were searched from their inception to 23 July 2024: PubMed/Medline, Global Health, Embase, PsycINFO and Global Index Medicus. We also searched for grey literature, using Google Scholar, ProQuest and Clinicaltrials.gov. Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. Studies were eligible if they focused on any psychosocial intervention targeting substance use in people with severe MHCs from LMICs. Of the 6304 records screened by titles and abstracts, 138 full-text articles were assessed and included for data extraction. Results: Of the 6304 records screened by titles and abstracts, 138 full-text articles were assessed and 13 articles were included for data extraction. Many of the studies (n = 9) had a quasi-experimental design, and were from Latin America and South Asia. Four studies were randomised controlled trials. The primary outcomes examined were substance use abstinence, treatment engagement and retention, reduction in psychiatric symptoms, functioning and suicidal behaviours. Despite some heterogeneity in study designs, target populations and evaluated outcomes, interventions including various tobacco cessation programmes, screening and brief intervention with family support, and community-based programmes, have demonstrated positive outcomes in reducing tobacco, alcohol and khat use, respectively. Conclusions: The review shows that there have been few initiatives to design and test psychosocial interventions for individuals with comorbid severe MHCs and SUDs in LMICs. There is a clear need to design and test feasible, acceptable, and effective interventions to address both severe MHCs and substance use when they co-occur.

Aim: HOPE (National Institute for Health and Care Research Global Health Research Group on Homelessness and Mental Health in Africa) aims to develop and evaluate interventions that address the unmet needs of people who are homeless and have severe mental illness (SMI) living in three African countries in ways that are rights-based, contextually grounded, scalable and sustainable. Methods: We will work in the capital city (Addis Ababa) in Ethiopia, a regional city (Tamale) in Ghana, and the capital city (Nairobi) and a rural county (Makueni) in Kenya to understand different approaches to intervention needed across varied settings. We will be guided by the MRC/NIHR framework on complex interventions and implementation frameworks and emphasise co-production. Formative work will include synthesis of global evidence (systematic review, including grey literature, and a Delphi consensus exercise) on interventions and approaches to homelessness and SMI. We will map contexts; conduct focused ethnography to understand lived experiences of homelessness and SMI; carry out a cross-sectional survey of people who are homeless (n = 750 Ghana/Ethiopia; n = 350 Kenya) to estimate prevalence of SMI and identify prioritised needs; and conduct in-depth interviews and focus group discussions with key stakeholders to understand experiences, challenges and opportunities for intervention. This global and local evidence will feed into Theory of Change (ToC) workshops with stakeholders to establish agreement about valued primary outcomes, map pathways to impact and inform selection and implementation of interventions. Intervention packages to address prioritised needs will be co-produced, piloted and optimised for feasibility and acceptability using participatory action research. We will use rights-based approaches and focus on community-based care to ensure sustainability. Realist approaches will be employed to analyse how contextual variation affects mechanisms and outcomes to inform methods for a subsequent evaluation of larger scale implementation. Extensive capacity-strengthening activities will focus on equipping early career researchers and peer researchers. People with lived experience of SMI and policymakers are an integral part of the research team. Community engagement is supported by working closely with multisectoral Community Advisory Groups. Conclusions: HOPE will develop evidence to support action to respond to the needs and preferences of people experiencing homelessness and SMI in diverse settings in Africa. We are creating a new partnership of researchers, policymakers, community members and people with lived experience of SMI and homelessness to enable African-led solutions. Key outputs will include contextually relevant practice and policy guidance that supports achievement of inclusive development.

The low recognition of depression in primary healthcare (PHC) remains a major obstacle to rendering adequate care for people with depression globally. This study aimed to evaluate the feasibility and potential benefit of a contextually developed multicomponent and multilevel intervention to improve the identification of depression in PHC. A pilot, four-arm, parallel-group, cluster, non-randomised controlled trial was conducted in a predominantly rural district in Ethiopia. The active interventions were allocated to three PHC facilities: (1) a core multicomponent intervention focusing on providers—a manualised training package along with system intervention (mobile application, posters, quality improvement and supervision) (Level-I/Arm I), (2) Level-I intervention plus a 4-item screening questionnaire administered by triage nurses (Level-II/Arm II), (3) Level-II intervention plus service user awareness raising (Level-III/Arm III). In the control facility, standard integrated mental healthcare (care by providers trained in the standard WHO mhGAP intervention guide) was available. The outcomes were the identification of depression and the feasibility and acceptability of implementation by PHC clinicians. Quantitative and qualitative data were collected post-intervention. Descriptive analysis and thematic analysis were used to analyse the data. A total of 21 providers (14 clinicians and 7 triage nurses) and 1659 adult outpatients participated in the study. Overall, 116 outpatients (7.0%) received a diagnosis of depression by PHC clinicians. Detection of depression was significantly better in the active intervention arms combined: 8.3% (n = 115/1380) vs. 0.4% (n = 1/279) in the control arm. Level-II and Level-III intervention arms had significantly higher rates of detection (10.1% Level II, 9.2% Level III) compared with Level I (5.2%); however, there was no significant difference between Level-II and Level-III. The interventions demonstrated very good acceptability, feasibility and appropriateness although screening, which was included in the Level II and Level III intervention arms, had relatively lower acceptability and an overall low positive predictive value. The tested interventions hold good promise of enhancing the identification of depression in PHC, with excellent feasibility and acceptability parameters. Although screening has good potential, implementation in routine care requires further optimisation and evaluation. Trial ID: PACTR202206723109626. Registration date: 21 June 2022. Retrospectively registered.

Aim: HOPE (National Institute for Health and Care Research Global Health Research Group on Homelessness and Mental Health in Africa) aims to develop and evaluate interventions that address the unmet needs of people who are homeless and have severe mental illness (SMI) living in three African countries in ways that are rights-based, contextually grounded, scalable and sustainable. Methods: We will work in the capital city (Addis Ababa) in Ethiopia, a regional city (Tamale) in Ghana, and the capital city (Nairobi) and a rural county (Makueni) in Kenya to understand different approaches to intervention needed across varied settings. Formative work will include synthesis of global evidence (systematic review, including grey literature, and a Delphi consensus exercise) on interventions and approaches to improving outcomes for people who are homeless and have SMI. We will map contexts; conduct a focused ethnographic study to understand lived experiences of homelessness and SMI; carry out a cross-sectional survey of people who are homeless (n=750 in Ghana and Ethiopia; n=350 in Kenya) to estimate prevalence of SMI and identify prioritised needs; and conduct in-depth interviews and focus group discussions with key stakeholders to understand experiences, challenges and opportunities for intervention. This global and local evidence will feed into Theory of Change workshops with stakeholders to establish agreement about valued primary outcomes, map pathways to impact and inform selection and implementation of interventions. Intervention packages to address prioritised needs will be co-produced, piloted in each country with people who are homeless and have SMI, and will be optimised for feasibility and acceptability using participatory action research. We will use rights-based approaches and focus on community-based care to ensure sustainability. Realist approaches will be employed to analyse how contextual variation affects mechanisms and outcomes to inform methods for a subsequent evaluation of larger scale implementation. Extensive capacity strengthening activities will focus on equipping early career researchers and peer researchers. People with lived experience of SMI and policymakers are an integral part of the research team. Community engagement is supported by working closely with multi-sectoral Community Advisory Groups. Conclusions: HOPE will develop evidence to support action to respond to the needs and preferences of people who are homeless and have SMI in diverse settings in Africa. We are creating a new partnership of researchers, policy makers, community members and people with lived experience of SMI and homelessness to lead this work in and for the Global South.