Multilevel analysis of dropout from maternal continuum of care and its associated factors: Evidence from 2022 Tanzania Demographic and Health Survey

BACKGROUND

The maternal continuum of care (CoC) is a cost-effective approach to mitigate preventable maternal and neonatal deaths. Women in developing countries, including Tanzania, face an increased vulnerability to significant dropout rates from maternal CoC, and addressing dropout from the continuum remains a persistent public health challenge.

METHOD

This study used the 2022 Tanzania Demographic and Health Survey (TDHS). A total weighted sample of 5,172 women who gave birth in the past 5 years and had first antenatal care (ANC) were included in this study. Multilevel binary logistic regression analyses were used to examine factors associated with dropout from the 3 components of maternal CoC (i.e., ANC, institutional delivery, and postnatal care (PNC)).

RESULTS

The vast majority, 83.86% (95% confidence interval (CI): 82.83%, 84.83%), of women reported dropout from the maternal CoC. The odds of dropout from the CoC was 36% (AOR = 0.64, (95% CI: 0.41, 0.98)) lower among married women compared to their divorced counterparts. Women who belonged to the richer wealth index reported a 39% (AOR = 0.61, (95% CI: 0.39, 0.95)) reduction in the odds of dropout, while those belonged to the richest wealth index demonstrated a 49% (AOR = 0.51, (95% CI: 0.31, 0.82)) reduction. The odds of dropout from CoC was 37% (AOR = 0.63, (95% CI: 0.45,0.87)) lower among women who reported the use of internet in the past 12 months compared to those who had no prior exposure to the internet. Geographical location emerged as a significant factor, with women residing in the Northern region and Southern Highland Zone, respectively, experiencing a 44% (AOR = 0.56, 95% CI: 0.35-0.89) and 58% (AOR = 0.42, 95% CI: 0.26-0.68) lower odds of dropout compared to their counterparts in the central zone.

CONCLUSION

The dropout rate from the maternity CoC in Tanzania was high. The findings contribute to our understanding of the complex dynamics surrounding maternity care continuity and underscore the need for targeted interventions, considering factors such as marital status, socioeconomic status, internet usage, and geographical location.

Prevalence of Violence Against Women in Ethiopia: A Meta-Analysis

Violence against women (VAW) is a major public health problem globally, particularly in developing countries including Ethiopia. Accordingly, sustainable development goal (SDG) 5 (by United Nation) prioritizes VAW and calls for the design and implementation of programs relevant to its elimination by 2030. However, little is known about the epidemiology of VAW as all estimates from few, cross-sectional studies so far are inconsistent and inconclusive. This study, therefore, was conducted to determine the pooled national prevalence of VAW in Ethiopia. Databases including PUBMED, MEDLINE, Cochrane review, CINAHL, African Journals Online, and Google Scholar were reviewed, using relevant search engines. The meta-analysis was conducted using STATA 14 software, and forest plots were used to present the pooled estimates of VAW. The Cochran Q, I² statistics, and Egger's test were used to test heterogeneity and publication bias of the included studies. A total of 36 published articles, 23,782 participants, were included in the meta-analysis. The overall pooled lifetime and the past 12 months VAW prevalence was 46.93% (95% confidence interval [CI] = [39.96, 54.00]) and 37.02% (95% CI [26.47, 47.56]), respectively. The pooled lifetime physical, sexual, and psychological violence were 38.15%, 39.33%, and 39.51%, respectively. Pooled lifetime prevalence of rape was 13.02%. Overall, nearly half of Ethiopian women experience lifetime VAW, with substantial levels of physical, sexual, or psychological violence. The country should work toward enhancing gender equality, coupled with addressing risk factors at multiple levels, using community- and institution-based approaches to prevent VAW and to specifically achieve SDG₅ of eliminating VAW by 2030.

Child Maltreatment and Persistent Smoking From Adolescence Into Adulthood: A Birth Cohort Study

OBJECTIVE

A prospective record-linkage analysis to examine whether notified and/or substantiated child maltreatment is associated with the prevalence and persistence of smoking in early adulthood.

METHODS

The sample consisted of 3758 participants enrolled in a population-based birth cohort study in Brisbane, Australia, who were followed up at both 14 and 21 years of age. Suspected experience of child maltreatment was measured by linkage with state child protection agency data. The two main outcomes were the prevalence and persistence of smoking at 21-year follow-up, as well as the 12-month prevalence of nicotine use disorder for participants who completed the Composite International Diagnostic Interview-Auto version.

RESULTS

Of the 3758 young people at the 21-year follow-up, 7.5% (n = 282) had a history of notified maltreatment by the age of 16 years. Of these, 167 cases were substantiated. There were 1362 (35.3%) smokers at 21-year follow-up, although only 220 (5.9%) smoked more than 20 cigarettes daily. Of the 602 participants who smoked at 14 years, 289 were still smoking 7 years later. On adjusted analyses, participants who had experienced any form of notified and/or substantiated maltreatment were approximately twice as likely to be smokers at 21 years old and persistent smokers from 14 years of age. Any form of maltreatment, except sexual abuse, was also associated with an increase in the 12-month prevalence of nicotine use disorders.

CONCLUSIONS

Child maltreatment is associated with both an increased onset and persistence of smoking from adolescence into young adulthood. This may have implications for smoking cessation programs and early interventions for individuals who have experienced maltreatment.

Married Women's Decision-Making Power in Family Planning Use and its Determinants in Basoliben, Northwest Ethiopia

Background

Women’s decision-making power influences the use of family planning. It is one of the denied fundamental rights of women, particularly in developing countries.

Objective

This study was aimed to assess married women’s decision-making power in the use of family planning and its associated factors among married reproductive age women in Basoliben, Amhara, Ethiopia, 2018.

Methods

A community-based cross-sectional study was conducted among married reproductive age women from March 1 to 30, 2018. A multistage simple random sampling technique was employed in selecting study participants. Data were collected using structured questionnaires and analyzed through SPSS 20 software. The binary and multiple variable logistic regression models were fitted to identify factors associated with women’s decision-making power on family planning use. Statistical significance was declared at p-value less than 0.05.

Results

A total of 734 married women aged 18–49 years are making a 98% response rate included in this study. The level of married women's decision-making power in family planning among married women was 80%; 95% CI (76.9, 82.8). Monthly income (AOR=2.2; 95% CI: 1.1, 4.2), husband’s desired number of children of <3 (AOR=9.9; 95% CI: 3.6), husband’s desired time for additional child after 3 years postbirth (AOR=4.0; 95% CI: 1.9, 8.5) and women's information on any contraceptive (AOR=9.6; 95% CI: 2.4, 39.0) were factors significantly associated with married women’s decision-making power in family planning.

Conclusion

Married women’s decision-making power in family planning use was optimal. Household monthly income, husband’s desired ideal number of children, husband’s desired time when to have another child and information about any contraceptive methods were predictors of their decision-making power on family planning use. There should be awareness creation of family planning methods to increase its utilization.

Adverse obstetric outcomes in public hospitals of southern Ethiopia: the role of parity

Purpose: Direct obstetric causes have a significant contribution for severe maternal morbidities and mortalities, although the effect of grand multiparity on adverse obstetric outcomes remains controversial across studies. This study aimed to compare obstetric outcomes in grand multiparous and low multiparous women in two hospitals of southern Ethiopia.Materials and methods: A comparative cross-sectional study was conducted in one general and one comprehensive specialized hospitals in 2018. Four hundred and sixty-one mothers were included in the study. Data were collected by structured questionnaire and extraction sheets from clinical documents, and were analyzed using STATA version 14 (StataCorp, College Station, TX, USA).Results: About 39% of the included mothers had at least one adverse obstetric outcome. Hypertensive disorders of pregnancy, antepartum hemorrhage, and premature rupture of membrane and were higher in the grand multiparous mothers. However, obstructed labor and risk of cesarean delivery were higher in low multiparous women. History of medical illnesses, previous cesarean delivery, and high birth weight were independent predictors of adverse maternal outcomes regardless of parity. However, parity did not show statistically significant difference in obstetric outcomes.Conclusion: Parity did not show statistically significant difference in experiencing adverse obstetric outcomes in women. Early identification and treatment of high-risk mothers is recommended regardless of parity.

Early Resumption of Sexual Intercourse and Its Associated Factors Among Postpartum Women in Western Ethiopia: A Cross-Sectional Study

Background

Women are often forced to recommence sexual intercourse after childbirth to maintain intimacy and fulfill their partners’ desires. Early resumption of postpartum sexual intercourse leads to sexual health problems and unwanted pregnancy if not complemented with appropriate contraceptive use. However, sexual practice during the early postpartum period has received little attention in clinical and research settings. The aim of this study was therefore to assess the early resumption of sexual intercourse and its associated factors among postpartum women attending public health institutions in Nekemte town, Western Ethiopia.

Methods

An institution-based cross-sectional study was carried out from March to April 2019. A systematic random sampling technique was used to select 528 postpartum women. An interviewer-administered, pretested, and structured questionnaire was used to collect data. Data were coded and entered into Epi Info 7.2.1, and exported to SPSS version 20.0 to run bivariable and multivariable logistic regressions.

Results

One in five postpartum women (20.2%, 95% CI: 17.1–23.6) practiced an early resumption of sexual intercourse, of whom three-fifths (58%) did not use any contraceptives. Women’s secondary education (AOR=0.22, 95% CI: 0.07–0.71), husband’s elementary (AOR=0.23, 95% CI: 0.06–0.87) and secondary education (AOR=0.25, 95% CI: 0.07–0.88), as well as women’s fertility status (parity of one) (AOR=3.52, 95% CI: 1.24–10.01), normal vaginal delivery (AOR=5.44, 95% CI: 1.84–16.12), giving birth to a male child (AOR=1.94, 95% CI: 1.05–3.60), desire for another child (AOR=5.71, 95% CI: 1.89–17.25), and pressure from the husband to initiate intercourse (AOR=9.89, 95% CI: 4.99–19.58) were significantly associated with early resumption of sexual intercourse.

Conclusion

A significant proportion of postpartum women who resume early sexual intercourse do not use any contraceptives. Interventions that focus on strengthening the integration of postpartum sexual health education and service use are warranted.

Why Too Soon? Early Initiation of Sexual Intercourse Among Adolescent Females in Ethiopia: Evidence from 2016 Ethiopian Demographic and Health Survey

Background

Early sexual initiation - sexual activity that begun earlier than 18 years of age - is among risky sexual behaviors which may be associated with increased risks of adverse outcomes such as sexually transmitted infections (STIs), unwanted pregnancy and unsafe abortions. However, there is no nationally representative evidence on early initiation of sexual intercourse and its determinant factors among adolescent females in Ethiopia.

Methods

Data were extracted from the 2016 Ethiopian Demographic and Health Survey (EDHS) to assess early initiation of sexual intercourse and factors contributing to it in adolescent females. The analysis included a weighted sample of 3881 adolescent females aged 15-19 years. A multivariable logistic regression analysis was conducted and the results were presented as adjusted odds ratio (AOR) at 95% confidence interval (CI), declaring statistical significance at a p-value <0.05 in all analyses.

Results

About 1 in 5 (21.9%, 95% CI: 20.5%, 23.33%) adolescent females experienced early sexual debut. Administrative regions (Amhara, AOR = 2.3, 95% CI: 1.30, 4.09 and Gambella, AOR = 4.89, CI 95%: 1.08, 22.07), religion (Muslim, AOR = 1.76, 95% CI: 1.24, 2.49), substance use (e.g., ever chewed khat, AOR = 2.02, 95% CI: 1.47, 2.77, ever drunk alcohol, AOR = 1.83, 95% CI: 1.35, 2.48) and having no knowledge on family planning (AOR = 4.47, 95% CI: 2.22, 8.99) were found to have statistically significant association with early sexual debut in adolescent females. Whereas any levels of formal education decreased the odds of early sexual debut (primary, AOR = 0.44, 95% CI: 0.35, 0.56; secondary, AOR = 0.19, 95% CI: 0.13, 0.28, and higher, AOR= 0.31, 95% CI: 0.15, 0.63). Similarly, all categories of wealth indices as compared to the poorest were protective of early sexual initiation in adolescent females (AOR = 0.40-0.57) as was for education as compared to no education (AOR = 0.19-0.44).

Conclusion

A significant proportion of adolescent females initiate early sexual intercourse in Ethiopia and multifaceted factors appear to determine their early sexual experiences. Contextualized interventions including strengthening information, education and communication on adverse consequences of early sexual initiation in regions and improving contraceptive knowledge of teenagers will play a paramount role.

Burden of anemia and its association with HAART in HIV infected children in Ethiopia: a systematic review and meta-analysis

Background

Anemia is a common problem in HIV (human immunodeficiency virus) infected patients, and is associated with decreased functional capacity and quality of life. Ethiopia is one of the countries which has expanded highly active antiretroviral treatment (HAART) over the past years. The effect of HAART on anemia among HIV remains inconsistent and inconclusive, particularly in children. This study thus aimed to synthesize the prevalence of anemia among HIV infected Ethiopian children and its association with HAART initiation.

Methods

MEDLINE/PubMed, EMBASE, PsycINFO, Web of Science and Google scholar were used to identify 12 eligible studies reporting an association between anemia and HIV using a priori set criteria. PRISMA guideline was used to systematically review and meta-analysis these studies. Details of sample size, magnitude of effect sizes, including odds ratio (OR) and standard errors were extracted. Random-effects model was used to calculate the pooled estimates using STATA/SE version-14. I² and meta-bias statistics assessed heterogeneity and publication bias of the included studies. Sub-group analyses, based on study designs, were also carried out.

Results

In Ethiopia, the overall prevalence of anemia in HIV infected children was 22.3% (95% CI: 18.5–26.0%). The OR of anemia-HIV/AIDS comorbidity was 0.4 (95% CI, 0.2–0.5) in HAART initiated children as compared to non-initiated counterparts. Meta-bias and funnel plot detected no publication bias.

Conclusion

On aggregate, anemia is a common comorbidity in pediatric HIV patients. HAART was significantly associated with a reduced anemia-HIV/AIDS comorbidity. Prompt start of HAART might help decreasing the prevalence of anemia and its subsequent complications.

Prevalence of antenatal depression and associated factors among pregnant women in Aneded woreda, North West Ethiopia: a community based cross-sectional study

OBJECTIVES

To assess the prevalence of antenatal depression and factors associated with antenatal depression among pregnant women in Aneded woreda, Northwest Ethiopia, 2019. A community based- cross sectional study was conducted in Aneded woreda among 7 kebles' of North-West, Ethiopia from March 16 to April 23, 2019. A total of 342 pregnant women were recruited using simple random sampling.

RESULT

The prevalence of antenatal depression was 15.20%. Urban residence [AOR = 6.8; 95% CI (1.97, 23.32)], marital status of being unmarried [AOR = 5.1; 95% CI (1.79, 14.63)], occupation of being government employee [AOR = 8.8; 95% CI (2.06, 37.12)] and merchant [AOR = 3.7; 95% CI (1.27, 10.91)], prim gravid [AOR = 5.3; 95% CI (2.03, 13.82)], not attend ANC follow up [AOR = 8.7; 95% CI (3.46, 21.79)], intimate partner violence [AOR = 4.5; 95% CI (1.28, 15.52)], unplanned pregnancy [AOR = 6.2; 95% CI (2.37, 16.06)], and substance use [AOR = 5.6; 95% CI (2.12, 14.92)] were significantly factors. Strengthen the risk prevention activities so important to tackle the problem of antenatal depression.

A meta-analysis of inpatient treatment outcomes of severe acute malnutrition and predictors of mortality among under-five children in Ethiopia

BACKGROUND

Severe forms of malnutrition have drastic effects on childhood morbidity and mortality in sub-Saharan countries, including Ethiopia. Although few studies have previously estimated treatment outcomes of severe acute malnutrition (SAM) in Ethiopia, the findings were widely varied and inconsistent. This study thus aimed to pool estimates of treatment outcomes and identify predictors of mortality among children with SAM in Ethiopia.

METHODS

A systematic review was carried out to select 21 eligible articles from identified 1013 studies (dating from 2000 to 2018) that estimated treatment outcomes and predictors of mortality among SAM children. Databases including PubMed, CINHAL, Web of Sciences; Cochrane, Psych INFO and Google Scholar were comprehensively reviewed using medical subject headings (MESH) and a priori set criteria PRISMA guideline was used to systematically review and meta-analyze eligible studies. Details of sample size, magnitude of effect sizes, including Hazard Ratio (HRs) and standard errors were extracted. Random-effects model was used to calculate pooled estimates in Stata/se version-14. Cochran's Q, I2, and meta-bias statistics were assessed for heterogeneity and Egger's test for publication bias.

RESULT

Twenty-one studies were included in the final analysis, which comprised 8057 under-five children with SAM in Ethiopia. The pooled estimates of treatment outcomes, in terms of death, recovery, defaulter and transfer out and non-response rates were 10.3% (95% CI: 8.3, 12.3), 70.5% (95% CI: 65.7, 72.2), 13.8% (95% CI: 10.8, 16.9) and 5.1% (95% CI: 3.3, 6.9), respectively. Diarrhea (HR: 1.5, 95% CI: 1.1, 2.2), dehydration (HR: 3.1, 95% CI: 2.3, 4.2) and anemia (HR: 2.2, 95% CI: 1.5, 3.3) were statistically significant predictors of mortality among these children. No publication bias was detected.

CONCLUSION

Treatment outcomes in under-five children with SAM are lower than the World Health Organization (WHO) standard, where mortality is being predicted by comorbidities at admission. Children with SAM need to be treated for diarrhea, dehydration and anemia at the primary point of care to reduce mortality.

Skilled Delivery Service Utilization and Associated Factors among Mothers Who Gave Birth in the Last Two Years in Northwest Ethiopia

Background

Giving birth in a medical institution, under the care and supervision of trained health-care providers, reduces the risk of maternal mortality and promotes child survival. Despite this, most mothers in Ethiopia are giving birth at home. Thus, this study was conducted to assess the level of skilled delivery service use and associated factors among mothers in Enarje Enawga District, Northwest Ethiopia.

Materials and Methods

A community-based cross-sectional study design was employed to recruit a total of 777 mothers who gave birth in the last two years. Data were collected using structured questionnaire. Bi-variable and multivariable logistic regression analyses were employed to assess factors associated with skilled delivery service use. Odds ratios with 95% confidence intervals were computed.

Results

Only 156 (20.1%) of the mothers had utilized skilled delivery service in the last two years. Mothers aged 15–24 years (AOR = 5.57), residing in urban areas (AOR = 1.80), and residing within a walking time of 16–30 minutes from health facility (AOR = 3.52) were more likely to use skilled delivery practice. Additionaly, mothers who had four and more antenatal care (ANC) visits (AOR = 4.94) and mothers who received health education (AOR = 5.04) were more likely to use skilled delivery service.

Conclusion

The level of skilled delivery service use among mothers was low. Age, residence, distance from health facility, number of ANC visits and health education were found to be associated with skilled delivery service use. Community-based health education programs regarding the risks of home delivery is necessary with a special focus on younger mothers residing in rural area.

Treatment cure rate and its predictors among children with severe acute malnutrition in northwest Ethiopia: A retrospective record review

BACKGROUND

More than 29 million that is an estimated 5%, under-five children suffer from severe acute malnutrition (SAM) globally, with a nine times higher risk of mortality than that of well-nourished children. However, little is known regarding outcomes and predictors of SAM in Ethiopia. Therefore, this study aims to determine treatment cure rate and its predictors among children aged 6-59 months with SAM admitted to a stabilization center.

METHODOLOGY

A retrospective record review was employed in SAM children at the University of Gondar Comprehensive Specialized Hospital (UOGCSH) from 2014 to 2016. SAM defined as weight for height below -3 z scores of the median World Health Organization (WHO) growth standards or presence of bilateral edema or mid upper arm circumference < 115mm for a child ≥6months age. All SAM patients with medical complication(s) or failure to pass appetite test are admitted to the malnutrition treatment center for inpatient follow-up. Data were extracted from a randomly selected records after getting ethical clearance. Data were cleaned, coded and entered to Epi-info version-7, and analyzed using STATA/se version-14. Descriptive statistics and analytic analyses schemes including bivariable and multivariable Cox proportional hazards model were conducted.

RESULT

Among a total of 416 records recruited for this study, 288 (69.2%) SAM children were cured at the end of the follow up, with a median cure time of 11 days. Kwash-dermatosis (AHR (Adjusted Hazard Ratio): 1.48(95% CI: 1.01, 2.16)), anemia (AHR: 1.36(95% CI: 1.07, 1.74)), tuberculosis (AHR: 1.6(95% CI: 1.04, 2.43)) and altered body temperature at admission (AHR: 1.58(95% CI: 1.04, 2.4) were independent predictors of time to cure.

CONCLUSION

The cure rate in SAM children was low relative to sphere standard guideline. Prognosis of SAM largely depends on the presence of other comorbidities at admission. Available intervention modalities need to address coexisting morbidities to achieve better outcomes in SAM children.

Child maltreatment and mental health problems in adulthood: birth cohort study

BACKGROUND

Retrospective studies have shown a high association between child abuse and subsequent psychiatric morbidity. Prospective studies are rarer.AimsTo examine, using a prospective record-linkage analysis, whether substantiated child maltreatment is associated with adverse psychological outcomes in early adulthood.

METHOD

The participants were 3778 mother and child pairs enrolled in a population-based birth cohort study in Brisbane, Australia. Exposure to suspected child maltreatment was measured by linkage with state child protection agency data. The primary outcomes were the internalising and externalising scales of the Youth Self-Report and the Centre for Epidemiological Studies-Depression scales (CES-D) at approximately 21 years of age. A subset completed the Composite International Diagnostic Interview-Auto version (CIDI-Auto).

RESULTS

In total, 171 (4.5%) participants had a history of substantiated child maltreatment, most commonly emotional abuse (n = 91), followed by physical abuse (n = 78), neglect (n = 73) and sexual abuse (n = 54). After adjustment for potential confounders, depressive symptoms on the CES-D, as well as internalising and externalising behaviours were strongly associated with substantiated abuse in all forms, except sexual abuse. The results for the subset of the sample who completed the CIDI-Auto were less clear. Anxiety, especially post-traumatic stress disorder, showed the strongest association whereas the findings for depressive disorder were equivocal. However, across all diagnostic categories, emotional abuse and neglect, as well as multiple forms of abuse, showed a consistent association.

CONCLUSIONS

Child maltreatment, particularly neglect and emotional abuse, has serious adverse effects on early adult mental health. These two warrant the attention given to other forms of child maltreatment. Children experiencing more than one type of maltreatment are at particular risk.Declaration of interestNone.

Does short message service improve focused antenatal care visit and skilled birth attendance? A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

In low resource circumstances, non-adherence for available health services is a major cause of inefficiency in health care delivery. MHealth has been projected as a possible solution to support women during pregnancy, birth and puerperium period, to increase the uptake of essential maternal services.

OBJECTIVES

This systematic review and meta-analysis study was aimed to determine the effectiveness of short message services (SMS)on Focused Antenatal Care (FANC) visits and the attendance of skilled birth professionals in Low and Middle Income Countries (LMICs).

METHODS

We searched a broad body of literature from electronic databases-Cochrane review, CINAHL, PsycINFO, PubMed and Google Scholar to collect comprehensive evidence on the role of SMS on FANC visits and skilled birth attendance. We extracted data from randomized clinical trials (RCTs) only. Meta-analyses were conducted using random-effects models with inverse variance method in Review Manager (RevMan) computer software. Qualities of the included studies were determined by GRADEpro, and risk of bias was assessed using Cochrane Collaboration risk of bias tool.

RESULTS

Of the 1224 non-duplicated articles screened, only 7 RCT studies representing 8324 participants met eligibility criteria and included in this synthesis. On aggregate, there were statistically significant associations in experimental group in that pregnant mothers who received text messaging had a 174% increase in FANC visits (OR = 2.74 (95% CI: 1.41, 5.32) and 82% in skilled birth attendance (OR = 1.82 (95% CI; 1.33, 2.49). The I2 test result indicated high heterogeneity I2 = 78% (P < .001). The overall qualities of included studies were moderate, and had low risk of bias.

CONCLUSIONS

SMS has positive effects for the uptake of FANC visits and skilled birth attendance in LMICs. A short messaging service targeting pregnant woman is an invaluable, affordable intervention to improve maternal healthcare seeking behaviors.

Predictors of mortality among under-five children with severe acute malnutrition, Northwest Ethiopia: an institution based retrospective cohort study

BACKGROUND

Globally, approximately 19 million children under 5 years are suffering from Severe Acute Malnutrition (SAM). It is a major cause of morbidity and mortality in low-income countries including Ethiopia. However, little is known regarding predictors of mortality among these children in Ethiopia. The current study aimed to assess the potential predictors of mortality among under-five children with SAM admitted to a stabilization center.

METHOD

A retrospective cohort study was conducted in 527 under-five children who were admitted for SAM at the University of Gondar comprehensive specialized hospital from 2014 to 2016. Data were collected from a randomly selected chart after getting ethical clearance. Data were cleaned, coded and entered to Epi-info (version 7) and analyzed using STATA (version14). The outcome was computed by using tables and graphs. A multivariable cox proportional hazards model was fitted to identify predictors of mortality.

RESULT

Overall, the median follow-up period was 10 days with interquartile range (Q1, Q3: 8, 17). At the end of the follow-up, the mortality rate was 66(12.52%). Anemia (AHR(Adjusted Hazard Ratio): 2.3, 95% CI: 1.2, 4.5), Shock (AHR: 7.9, 95% CI: 3.7, 16.7), no intake of antibiotics (AHR: 2.3 95% CI: 1.2, 4.4), IV-Fluid (AHR: 3.2, 95% CI: 1.7, 5.8), no intake of F75 (AHR: 6.6,95% CI: 2.9, 14.7) and no intake of F100 (AHR: 3, 95% CI: 1.6, 5.4) were independent predictors of mortality.

CONCLUSION

The survival status of under-five children with SAM was lower than the national standard protocol. Altered general conditions such as shock, anemia, not adhering to medical and nutritional therapies were identified as predictors of mortality among SAM children. Health education on early medical seeking behavior and adherence on the routine regimens may improve this gap in child survival.

Maternal intimate partner violence victimization and child maltreatment

There is some limited evidence of an association between maternal intimate partner victimization (IPV) and children's experience of maltreatment. Using data from a longitudinal study, we examine whether this relationship is independent of range of potential confounders including socio-economic, familial and psychological factors. Data were taken from the 14 and 30-year follow-ups of the Mater-University of Queensland Study of Pregnancy (MUSP) in Australia. A subsample of 2064 mothers and children (59.0% female) whose data on maternal IPV and child maltreatment was available, were analysed. In families with maternal IPV, two in five children reported being maltreated, compared to one in five children maltreated in families without maternal IPV. Except for sexual maltreatment which was consistently higher in female offspring, there was no gender differences in experiencing different types of maltreatment in families manifesting maternal IPV. Although both males and females were at increased risk of child maltreatment in families where mothers were victimized by their male partners, male children were more likely to be emotionally maltreated. The main associations were substantially independent of measured confounders, except for father's history of mental health problems which attenuated the association of maternal IPV victimization and male offspring's physical abuse. Our findings confirm that there is a robust association between maternal IPV and child maltreatment. Both maternal IPV victimization and child maltreatment co-occur in a household characterized by conflict and violence. Consequences of IPV go beyond the incident and influence all family members. Efforts to reduce child maltreatment may need to address the greater level of IPV associated with the cycle of family violence.

Are Past Adverse Pregnancy Outcomes Associated with Maternal Anxiety and Depressive Symptoms in a Sample of Currently Pregnant Women?

Background

There has been a great deal of concern about the mental health of women whose pregnancies involve miscarriage, termination of a pregnancy (ToP), child death or where a child has been given up for adoption. Despite this concern there has been remarkably little population-based research which has addressed the long-term consequences of pregnancy loss and child death. This study investigated the maternal mental health consequences of women whose pregnancies involve miscarriage, ToP, child death or where a child has been given up for adoption at two different time points, adjusting for socio-demographic characteristics and baseline mental health.

Methods

The Mater-University of Queensland Study of Pregnancy is a prospective pre-birth cohort study. Women were recruited early in pregnancy over the period 1981 to 1983 at their first antenatal clinic visit (FCV). Women were interviewed again at the 14-year follow-up. Data from 4403 mothers were analysed using maternal reports of a prior history of giving a child up for adoption, miscarriage, ToP, and neonatal, infant and/or child deaths. Symptoms of maternal anxiety and depression were measured at FCV and the 14-year follow-up using the Delusions-Symptoms-States Inventory. We carried out logistic regression analysis using Stata 13. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to display the findings.

Results

A prior miscarriage was associated with anxiety (adjusted OR (AOR) = 1.30; 95% CI: 1.10-1.66) and depressive (AOR = 1.70; 95% CI: 1.21-2.39) symptoms at the 14-year follow-up. Having had a neonatal, infant and/or child deaths was associated with symptoms of depression at 14-year follow-up (AOR = 2.12; 95% CI: 1.06-4.25).

Conclusion

The period after a child loss which involves a new pregnancy may be associated with relatively good mental health despite the fact that some mothers have experienced previous adverse pregnancy outcomes.

Meta-analysis of the prevalence of tuberculosis in diabetic patients and its association with cigarette smoking in African and Asian countries

Objective

This systematic review and meta-analysis was undertaken to estimate the prevalence of tuberculosis in diabetic patients and to determine the effect of cigarette smoking.

Results

A total of 15 studies was included in the meta-analysis. The pooled overall prevalence of tuberculosis in diabetes was 4.72% (95% CI 3.62–5.83%). In sub-group analyses, the prevalence was 5.13% (95% CI 4.34–5.92%) in Africa, followed by 4.16% (95% CI 2.9–5.4%) in Asia. The odd ratio of tuberculosis among diabetes patients was 7.6 (95% CI 1.46–39) in cigarette smokers as compared to nonsmokers. Publication bias was detected based on graphic asymmetry of fun-nel plots, Begg’s and Egger’s tests (p < 0.05). Tuberculosis is a common co-morbidity in diabetic patients. Tuberculosis-diabetes co-morbidity is significantly higher in cigarette smokers.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3390-x) contains supplementary material, which is available to authorized users.

The global burden of tuberculosis: results from the Global Burden of Disease Study 2015

BACKGROUND

An understanding of the trends in tuberculosis incidence, prevalence, and mortality is crucial to tracking of the success of tuberculosis control programmes and identification of remaining challenges. We assessed trends in the fatal and non-fatal burden of tuberculosis over the past 25 years for 195 countries and territories.

METHODS

We analysed 10 691 site-years of vital registration data, 768 site-years of verbal autopsy data, and 361 site-years of mortality surveillance data using the Cause of Death Ensemble model to estimate tuberculosis mortality rates. We analysed all available age-specific and sex-specific data sources, including annual case notifications, prevalence surveys, and estimated cause-specific mortality, to generate internally consistent estimates of incidence, prevalence, and mortality using DisMod-MR 2.1, a Bayesian meta-regression tool. We assessed how observed tuberculosis incidence, prevalence, and mortality differed from expected trends as predicted by the Socio-demographic Index (SDI), a composite indicator based on income per capita, average years of schooling, and total fertility rate. We also estimated tuberculosis mortality and disability-adjusted life-years attributable to the independent effects of risk factors including smoking, alcohol use, and diabetes.

FINDINGS

Globally, in 2015, the number of tuberculosis incident cases (including new and relapse cases) was 10·2 million (95% uncertainty interval 9·2 million to 11·5 million), the number of prevalent cases was 10·1 million (9·2 million to 11·1 million), and the number of deaths was 1·3 million (1·1 million to 1·6 million). Among individuals who were HIV negative, the number of incident cases was 8·8 million (8·0 million to 9·9 million), the number of prevalent cases was 8·9 million (8·1 million to 9·7 million), and the number of deaths was 1·1 million (0·9 million to 1·4 million). Annualised rates of change from 2005 to 2015 showed a faster decline in mortality (-4·1% [-5·0 to -3·4]) than in incidence (-1·6% [-1·9 to -1·2]) and prevalence (-0·7% [-1·0 to -0·5]) among HIV-negative individuals. The SDI was inversely associated with HIV-negative mortality rates but did not show a clear gradient for incidence and prevalence. Most of Asia, eastern Europe, and sub-Saharan Africa had higher rates of HIV-negative tuberculosis burden than expected given their SDI. Alcohol use accounted for 11·4% (9·3-13·0) of global tuberculosis deaths among HIV-negative individuals in 2015, diabetes accounted for 10·6% (6·8-14·8), and smoking accounted for 7·8% (3·8-12·0).

INTERPRETATION

Despite a concerted global effort to reduce the burden of tuberculosis, it still causes a large disease burden globally. Strengthening of health systems for early detection of tuberculosis and improvement of the quality of tuberculosis care, including prompt and accurate diagnosis, early initiation of treatment, and regular follow-up, are priorities. Countries with higher than expected tuberculosis rates for their level of sociodemographic development should investigate the reasons for lagging behind and take remedial action. Efforts to prevent smoking, alcohol use, and diabetes could also substantially reduce the burden of tuberculosis.

FUNDING

Bill & Melinda Gates Foundation.

Substantiated childhood maltreatment and young adulthood cannabis use disorders: A pre-birth cohort study

This study investigates the association between exposure to prospectively-substantiated childhood maltreatment between 0 and 14 years of age and lifetime cannabis use, abuse and dependence reported at 21 years. Data were taken from 2526 (51.6% female) participants in the Mater Hospital-University of Queensland Study of Pregnancy, a pre-birth, prospective, cohort study. Prospectively-substantiated cases of childhood maltreatment, reported to the government child protection agencies between 0 and 14 years of age, were linked to CIDI DSM-IV self-report data from the 21-year follow-up. Exposure to any childhood maltreatment, and childhood neglect in particular, predicted subsequent cannabis abuse with adjusted odds ratios (AORs) of 1.79 and 2.62, respectively. Any childhood maltreatment, physical abuse, emotional abuse and neglect predicted cannabis dependence with AORs of 2.47, 2.81, 2.44 and 2.68, respectively. The associations for an early age of onset of cannabis abuse and dependence were significant and consistent for maltreated children. In addition, frequency of maltreatment substantiations predicted cannabis abuse, dependence and an early age of onset of these disorders. The AORs for cannabis ever use without any DSM-IV cannabis disorder were 1.78 for any maltreatment and 2.15 for emotional abuse. Any childhood maltreatment and neglect predicted lifetime ever cannabis use, as well as cannabis use disorder. There was little evidence for any interaction between gender and different forms of childhood maltreatment and its association with cannabis use disorders. Physical abuse, emotional abuse and neglect, as well as multiple episodes of maltreatment independently predicted cannabis use disorders.

The association between substantiated childhood maltreatment, asthma and lung function: A prospective investigation

BACKGROUND

Asthma reflects multiple and likely complex causal pathways. We investigate the possibility that childhood maltreatment is one such causal pathway. Childhood maltreatment can be interpreted as a form of early life adversity and like other life adversities may predict a range of negative health outcomes, including asthma.

METHODS

A total of 3762 young adults (52.63% female) from the Mater Hospital-University of Queensland Study of Pregnancy (MUSP) participated in this study. MUSP is a prospective Australian birth cohort study of mothers consecutively recruited during their first antenatal clinic visit at Brisbane's Mater Hospital from 1981 to 1983. The study followed both mother-child dyads to the age of 21years after birth. Participants reported whether they had been diagnosed by a physician with asthma by the 21-year follow-up. Trained research assistants also performed gender- and height-standardized lung function tests using a Spirobank G spirometer system attached to a laptop computer. We linked this dataset with data obtained from the child protection services and which comprised all substantiated cases of childhood maltreatment in the MUSP cohort. Substantiations of childhood maltreatment included children in an age range of 0-14years.

RESULTS

The experience of any childhood maltreatment, particularly emotional abuse, was independently associated with self-reported physician-diagnosed asthma by the 21-year follow-up. The association was no longer significant after adjustment for a range of confounders and covariates in neglected children. Childhood maltreatment, including multiple events, was not associated with lung function in adjusted models.

CONCLUSIONS

Childhood maltreatment, including emotional abuse, was associated with lifetime ever asthma. This was in contrast to the absence of an association with objective measures of lung function. More research is indicated on the effect of childhood maltreatment on lung function using objective measures. In the meantime, there should be a greater awareness of the potential impact of childhood maltreatment on the potential to develop asthma, as well as of the possibility that asthma in adulthood may precede childhood maltreatment.

Childhood maltreatment and high dietary fat intake behaviors in adulthood: A birth cohort study

Childhood maltreatment has been associated with a wide range of chronic medical conditions including obesity, other metabolic events and eating disorders. However, little is known about the association between childhood maltreatment and high dietary fat intake. This study addresses the extent to which co-occurring and specific forms of substantiated childhood maltreatment are associated with self-reported high dietary fat intake in adulthood and whether there is a gender-childhood maltreatment interaction in predicting this association. The study also examines the association between age at substantiation of maltreatment, number of childhood maltreatment substantiations and high dietary fat intake-related behaviors. The data were from a prospective Australian pre-birth mother-child dyads study, the Mater-University of Queensland Study of Pregnancy. The study followed 7223 mother-child dyads following the birth of a live, singleton baby at the Mater hospital. Recruitment was early in pregnancy, and then follow-ups at 3-5days postpartum and again when the child was 6 months, 5, 14 and 21 years of age. The data were linked to agency-substantiated cases of childhood maltreatment 0-14 years. This study extended the data linkage to 3766 (47.4% female) participants who had complete data on dietary fat intake behaviors at the 21-year follow-up. Consecutive logistic regressions were used to estimate odds ratios with respective 95% confidence intervals for high dietary fat intake for multiple and specific forms of childhood maltreatment, as well as age at and number of childhood maltreatment substantiations. Finally, a gender-childhood maltreatment interaction term was used to predict the outcome. In both unadjusted and adjusted analyses, substantiated childhood maltreatment including physical abuse were associated with high dietary fat intake-related behaviors. Similarly, substantiation of childhood maltreatment between the ages of 5 and 14 years was significantly associated with high dietary fat intake-related behaviors as were two or more substantiations of maltreatment. Inclusion of gender-childhood maltreatment interaction only had a minor impact on the size and direction of the association. Chronic and severe forms of childhood maltreatment including physical abuse are associated with a higher rate of dietary fat intake in young adulthood. Further research to replicate this association might focus on possible neuro-hormonal mechanisms that might explain this behavior.

Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016.

METHODS

We estimated prevalence and incidence for 328 diseases and injuries and 2982 sequelae, their non-fatal consequences. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between incidence, prevalence, remission, and cause of death rates for each condition. For some causes, we used alternative modelling strategies if incidence or prevalence needed to be derived from other data. YLDs were estimated as the product of prevalence and a disability weight for all mutually exclusive sequelae, corrected for comorbidity and aggregated to cause level. We updated the Socio-demographic Index (SDI), a summary indicator of income per capita, years of schooling, and total fertility rate. GBD 2016 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

FINDINGS

Globally, low back pain, migraine, age-related and other hearing loss, iron-deficiency anaemia, and major depressive disorder were the five leading causes of YLDs in 2016, contributing 57·6 million (95% uncertainty interval [UI] 40·8-75·9 million [7·2%, 6·0-8·3]), 45·1 million (29·0-62·8 million [5·6%, 4·0-7·2]), 36·3 million (25·3-50·9 million [4·5%, 3·8-5·3]), 34·7 million (23·0-49·6 million [4·3%, 3·5-5·2]), and 34·1 million (23·5-46·0 million [4·2%, 3·2-5·3]) of total YLDs, respectively. Age-standardised rates of YLDs for all causes combined decreased between 1990 and 2016 by 2·7% (95% UI 2·3-3·1). Despite mostly stagnant age-standardised rates, the absolute number of YLDs from non-communicable diseases has been growing rapidly across all SDI quintiles, partly because of population growth, but also the ageing of populations. The largest absolute increases in total numbers of YLDs globally were between the ages of 40 and 69 years. Age-standardised YLD rates for all conditions combined were 10·4% (95% UI 9·0-11·8) higher in women than in men. Iron-deficiency anaemia, migraine, Alzheimer's disease and other dementias, major depressive disorder, anxiety, and all musculoskeletal disorders apart from gout were the main conditions contributing to higher YLD rates in women. Men had higher age-standardised rates of substance use disorders, diabetes, cardiovascular diseases, cancers, and all injuries apart from sexual violence. Globally, we noted much less geographical variation in disability than has been documented for premature mortality. In 2016, there was a less than two times difference in age-standardised YLD rates for all causes between the location with the lowest rate (China, 9201 YLDs per 100 000, 95% UI 6862-11943) and highest rate (Yemen, 14 774 YLDs per 100 000, 11 018-19 228).

INTERPRETATION

The decrease in death rates since 1990 for most causes has not been matched by a similar decline in age-standardised YLD rates. For many large causes, YLD rates have either been stagnant or have increased for some causes, such as diabetes. As populations are ageing, and the prevalence of disabling disease generally increases steeply with age, health systems will face increasing demand for services that are generally costlier than the interventions that have led to declines in mortality in childhood or for the major causes of mortality in adults. Up-to-date information about the trends of disease and how this varies between countries is essential to plan for an adequate health-system response.

FUNDING

Bill & Melinda Gates Foundation, and the National Institute on Aging and the National Institute of Mental Health of the National Institutes of Health.

Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Detailed assessments of mortality patterns, particularly age-specific mortality, represent a crucial input that enables health systems to target interventions to specific populations. Understanding how all-cause mortality has changed with respect to development status can identify exemplars for best practice. To accomplish this, the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) estimated age-specific and sex-specific all-cause mortality between 1970 and 2016 for 195 countries and territories and at the subnational level for the five countries with a population greater than 200 million in 2016.

METHODS

We have evaluated how well civil registration systems captured deaths using a set of demographic methods called death distribution methods for adults and from consideration of survey and census data for children younger than 5 years. We generated an overall assessment of completeness of registration of deaths by dividing registered deaths in each location-year by our estimate of all-age deaths generated from our overall estimation process. For 163 locations, including subnational units in countries with a population greater than 200 million with complete vital registration (VR) systems, our estimates were largely driven by the observed data, with corrections for small fluctuations in numbers and estimation for recent years where there were lags in data reporting (lags were variable by location, generally between 1 year and 6 years). For other locations, we took advantage of different data sources available to measure under-5 mortality rates (U5MR) using complete birth histories, summary birth histories, and incomplete VR with adjustments; we measured adult mortality rate (the probability of death in individuals aged 15-60 years) using adjusted incomplete VR, sibling histories, and household death recall. We used the U5MR and adult mortality rate, together with crude death rate due to HIV in the GBD model life table system, to estimate age-specific and sex-specific death rates for each location-year. Using various international databases, we identified fatal discontinuities, which we defined as increases in the death rate of more than one death per million, resulting from conflict and terrorism, natural disasters, major transport or technological accidents, and a subset of epidemic infectious diseases; these were added to estimates in the relevant years. In 47 countries with an identified peak adult prevalence for HIV/AIDS of more than 0·5% and where VR systems were less than 65% complete, we informed our estimates of age-sex-specific mortality using the Estimation and Projection Package (EPP)-Spectrum model fitted to national HIV/AIDS prevalence surveys and antenatal clinic serosurveillance systems. We estimated stillbirths, early neonatal, late neonatal, and childhood mortality using both survey and VR data in spatiotemporal Gaussian process regression models. We estimated abridged life tables for all location-years using age-specific death rates. We grouped locations into development quintiles based on the Socio-demographic Index (SDI) and analysed mortality trends by quintile. Using spline regression, we estimated the expected mortality rate for each age-sex group as a function of SDI. We identified countries with higher life expectancy than expected by comparing observed life expectancy to anticipated life expectancy on the basis of development status alone.

FINDINGS

Completeness in the registration of deaths increased from 28% in 1970 to a peak of 45% in 2013; completeness was lower after 2013 because of lags in reporting. Total deaths in children younger than 5 years decreased from 1970 to 2016, and slower decreases occurred at ages 5-24 years. By contrast, numbers of adult deaths increased in each 5-year age bracket above the age of 25 years. The distribution of annualised rates of change in age-specific mortality rate differed over the period 2000 to 2016 compared with earlier decades: increasing annualised rates of change were less frequent, although rising annualised rates of change still occurred in some locations, particularly for adolescent and younger adult age groups. Rates of stillbirths and under-5 mortality both decreased globally from 1970. Evidence for global convergence of death rates was mixed; although the absolute difference between age-standardised death rates narrowed between countries at the lowest and highest levels of SDI, the ratio of these death rates-a measure of relative inequality-increased slightly. There was a strong shift between 1970 and 2016 toward higher life expectancy, most noticeably at higher levels of SDI. Among countries with populations greater than 1 million in 2016, life expectancy at birth was highest for women in Japan, at 86·9 years (95% UI 86·7-87·2), and for men in Singapore, at 81·3 years (78·8-83·7) in 2016. Male life expectancy was generally lower than female life expectancy between 1970 and 2016, and the gap between male and female life expectancy increased with progression to higher levels of SDI. Some countries with exceptional health performance in 1990 in terms of the difference in observed to expected life expectancy at birth had slower progress on the same measure in 2016.

INTERPRETATION

Globally, mortality rates have decreased across all age groups over the past five decades, with the largest improvements occurring among children younger than 5 years. However, at the national level, considerable heterogeneity remains in terms of both level and rate of changes in age-specific mortality; increases in mortality for certain age groups occurred in some locations. We found evidence that the absolute gap between countries in age-specific death rates has declined, although the relative gap for some age-sex groups increased. Countries that now lead in terms of having higher observed life expectancy than that expected on the basis of development alone, or locations that have either increased this advantage or rapidly decreased the deficit from expected levels, could provide insight into the means to accelerate progress in nations where progress has stalled.

FUNDING

Bill & Melinda Gates Foundation, and the National Institute on Aging and the National Institute of Mental Health of the National Institutes of Health.

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of risk factor exposure and attributable burden of disease. By providing estimates over a long time series, this study can monitor risk exposure trends critical to health surveillance and inform policy debates on the importance of addressing risks in context.

METHODS

We used the comparative risk assessment framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2016. This study included 481 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk (RR) and exposure estimates from 22 717 randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources, according to the GBD 2016 source counting methods. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. Finally, we explored four drivers of trends in attributable burden: population growth, population ageing, trends in risk exposure, and all other factors combined.

FINDINGS

Since 1990, exposure increased significantly for 30 risks, did not change significantly for four risks, and decreased significantly for 31 risks. Among risks that are leading causes of burden of disease, child growth failure and household air pollution showed the most significant declines, while metabolic risks, such as body-mass index and high fasting plasma glucose, showed significant increases. In 2016, at Level 3 of the hierarchy, the three leading risk factors in terms of attributable DALYs at the global level for men were smoking (124·1 million DALYs [95% UI 111·2 million to 137·0 million]), high systolic blood pressure (122·2 million DALYs [110·3 million to 133·3 million], and low birthweight and short gestation (83·0 million DALYs [78·3 million to 87·7 million]), and for women, were high systolic blood pressure (89·9 million DALYs [80·9 million to 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million to 87·6 million]), and high fasting plasma glucose (63·8 million DALYs [53·2 million to 76·3 million]). In 2016 in 113 countries, the leading risk factor in terms of attributable DALYs was a metabolic risk factor. Smoking remained among the leading five risk factors for DALYs for 109 countries, while low birthweight and short gestation was the leading risk factor for DALYs in 38 countries, particularly in sub-Saharan Africa and South Asia. In terms of important drivers of change in trends of burden attributable to risk factors, between 2006 and 2016 exposure to risks explains an 9·3% (6·9-11·6) decline in deaths and a 10·8% (8·3-13·1) decrease in DALYs at the global level, while population ageing accounts for 14·9% (12·7-17·5) of deaths and 6·2% (3·9-8·7) of DALYs, and population growth for 12·4% (10·1-14·9) of deaths and 12·4% (10·1-14·9) of DALYs. The largest contribution of trends in risk exposure to disease burden is seen between ages 1 year and 4 years, where a decline of 27·3% (24·9-29·7) of the change in DALYs between 2006 and 2016 can be attributed to declines in exposure to risks.

INTERPRETATION

Increasingly detailed understanding of the trends in risk exposure and the RRs for each risk-outcome pair provide insights into both the magnitude of health loss attributable to risks and how modification of risk exposure has contributed to health trends. Metabolic risks warrant particular policy attention, due to their large contribution to global disease burden, increasing trends, and variable patterns across countries at the same level of development. GBD 2016 findings show that, while it has huge potential to improve health, risk modification has played a relatively small part in the past decade.

FUNDING

The Bill & Melinda Gates Foundation, Bloomberg Philanthropies.

Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND

Monitoring levels and trends in premature mortality is crucial to understanding how societies can address prominent sources of early death. The Global Burden of Disease 2016 Study (GBD 2016) provides a comprehensive assessment of cause-specific mortality for 264 causes in 195 locations from 1980 to 2016. This assessment includes evaluation of the expected epidemiological transition with changes in development and where local patterns deviate from these trends.

METHODS

We estimated cause-specific deaths and years of life lost (YLLs) by age, sex, geography, and year. YLLs were calculated from the sum of each death multiplied by the standard life expectancy at each age. We used the GBD cause of death database composed of: vital registration (VR) data corrected for under-registration and garbage coding; national and subnational verbal autopsy (VA) studies corrected for garbage coding; and other sources including surveys and surveillance systems for specific causes such as maternal mortality. To facilitate assessment of quality, we reported on the fraction of deaths assigned to GBD Level 1 or Level 2 causes that cannot be underlying causes of death (major garbage codes) by location and year. Based on completeness, garbage coding, cause list detail, and time periods covered, we provided an overall data quality rating for each location with scores ranging from 0 stars (worst) to 5 stars (best). We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to generate estimates for each location, year, age, and sex. We assessed observed and expected levels and trends of cause-specific deaths in relation to the Socio-demographic Index (SDI), a summary indicator derived from measures of average income per capita, educational attainment, and total fertility, with locations grouped into quintiles by SDI. Relative to GBD 2015, we expanded the GBD cause hierarchy by 18 causes of death for GBD 2016.

FINDINGS

The quality of available data varied by location. Data quality in 25 countries rated in the highest category (5 stars), while 48, 30, 21, and 44 countries were rated at each of the succeeding data quality levels. Vital registration or verbal autopsy data were not available in 27 countries, resulting in the assignment of a zero value for data quality. Deaths from non-communicable diseases (NCDs) represented 72·3% (95% uncertainty interval [UI] 71·2-73·2) of deaths in 2016 with 19·3% (18·5-20·4) of deaths in that year occurring from communicable, maternal, neonatal, and nutritional (CMNN) diseases and a further 8·43% (8·00-8·67) from injuries. Although age-standardised rates of death from NCDs decreased globally between 2006 and 2016, total numbers of these deaths increased; both numbers and age-standardised rates of death from CMNN causes decreased in the decade 2006-16-age-standardised rates of deaths from injuries decreased but total numbers varied little. In 2016, the three leading global causes of death in children under-5 were lower respiratory infections, neonatal preterm birth complications, and neonatal encephalopathy due to birth asphyxia and trauma, combined resulting in 1·80 million deaths (95% UI 1·59 million to 1·89 million). Between 1990 and 2016, a profound shift toward deaths at older ages occurred with a 178% (95% UI 176-181) increase in deaths in ages 90-94 years and a 210% (208-212) increase in deaths older than age 95 years. The ten leading causes by rates of age-standardised YLL significantly decreased from 2006 to 2016 (median annualised rate of change was a decrease of 2·89%); the median annualised rate of change for all other causes was lower (a decrease of 1·59%) during the same interval. Globally, the five leading causes of total YLLs in 2016 were cardiovascular diseases; diarrhoea, lower respiratory infections, and other common infectious diseases; neoplasms; neonatal disorders; and HIV/AIDS and tuberculosis. At a finer level of disaggregation within cause groupings, the ten leading causes of total YLLs in 2016 were ischaemic heart disease, cerebrovascular disease, lower respiratory infections, diarrhoeal diseases, road injuries, malaria, neonatal preterm birth complications, HIV/AIDS, chronic obstructive pulmonary disease, and neonatal encephalopathy due to birth asphyxia and trauma. Ischaemic heart disease was the leading cause of total YLLs in 113 countries for men and 97 countries for women. Comparisons of observed levels of YLLs by countries, relative to the level of YLLs expected on the basis of SDI alone, highlighted distinct regional patterns including the greater than expected level of YLLs from malaria and from HIV/AIDS across sub-Saharan Africa; diabetes mellitus, especially in Oceania; interpersonal violence, notably within Latin America and the Caribbean; and cardiomyopathy and myocarditis, particularly in eastern and central Europe. The level of YLLs from ischaemic heart disease was less than expected in 117 of 195 locations. Other leading causes of YLLs for which YLLs were notably lower than expected included neonatal preterm birth complications in many locations in both south Asia and southeast Asia, and cerebrovascular disease in western Europe.

INTERPRETATION

The past 37 years have featured declining rates of communicable, maternal, neonatal, and nutritional diseases across all quintiles of SDI, with faster than expected gains for many locations relative to their SDI. A global shift towards deaths at older ages suggests success in reducing many causes of early death. YLLs have increased globally for causes such as diabetes mellitus or some neoplasms, and in some locations for causes such as drug use disorders, and conflict and terrorism. Increasing levels of YLLs might reflect outcomes from conditions that required high levels of care but for which effective treatments remain elusive, potentially increasing costs to health systems.

FUNDING

Bill & Melinda Gates Foundation.

Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016

BACKGROUND

The UN's Sustainable Development Goals (SDGs) are grounded in the global ambition of "leaving no one behind". Understanding today's gains and gaps for the health-related SDGs is essential for decision makers as they aim to improve the health of populations. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016), we measured 37 of the 50 health-related SDG indicators over the period 1990-2016 for 188 countries, and then on the basis of these past trends, we projected indicators to 2030.

METHODS

We used standardised GBD 2016 methods to measure 37 health-related indicators from 1990 to 2016, an increase of four indicators since GBD 2015. We substantially revised the universal health coverage (UHC) measure, which focuses on coverage of essential health services, to also represent personal health-care access and quality for several non-communicable diseases. We transformed each indicator on a scale of 0-100, with 0 as the 2·5th percentile estimated between 1990 and 2030, and 100 as the 97·5th percentile during that time. An index representing all 37 health-related SDG indicators was constructed by taking the geometric mean of scaled indicators by target. On the basis of past trends, we produced projections of indicator values, using a weighted average of the indicator and country-specific annualised rates of change from 1990 to 2016 with weights for each annual rate of change based on out-of-sample validity. 24 of the currently measured health-related SDG indicators have defined SDG targets, against which we assessed attainment.

FINDINGS

Globally, the median health-related SDG index was 56·7 (IQR 31·9-66·8) in 2016 and country-level performance markedly varied, with Singapore (86·8, 95% uncertainty interval 84·6-88·9), Iceland (86·0, 84·1-87·6), and Sweden (85·6, 81·8-87·8) having the highest levels in 2016 and Afghanistan (10·9, 9·6-11·9), the Central African Republic (11·0, 8·8-13·8), and Somalia (11·3, 9·5-13·1) recording the lowest. Between 2000 and 2016, notable improvements in the UHC index were achieved by several countries, including Cambodia, Rwanda, Equatorial Guinea, Laos, Turkey, and China; however, a number of countries, such as Lesotho and the Central African Republic, but also high-income countries, such as the USA, showed minimal gains. Based on projections of past trends, the median number of SDG targets attained in 2030 was five (IQR 2-8) of the 24 defined targets currently measured. Globally, projected target attainment considerably varied by SDG indicator, ranging from more than 60% of countries projected to reach targets for under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria, to less than 5% of countries projected to achieve targets linked to 11 indicator targets, including those for childhood overweight, tuberculosis, and road injury mortality. For several of the health-related SDGs, meeting defined targets hinges upon substantially faster progress than what most countries have achieved in the past.

INTERPRETATION

GBD 2016 provides an updated and expanded evidence base on where the world currently stands in terms of the health-related SDGs. Our improved measure of UHC offers a basis to monitor the expansion of health services necessary to meet the SDGs. Based on past rates of progress, many places are facing challenges in meeting defined health-related SDG targets, particularly among countries that are the worst off. In view of the early stages of SDG implementation, however, opportunity remains to take actions to accelerate progress, as shown by the catalytic effects of adopting the Millennium Development Goals after 2000. With the SDGs' broader, bolder development agenda, multisectoral commitments and investments are vital to make the health-related SDGs within reach of all populations.

FUNDING

Bill & Melinda Gates Foundation.

Childhood Maltreatment and Young Adulthood Hallucinations, Delusional Experiences, and Psychosis: A Longitudinal Study

Child maltreatment is a widespread public health problem associated with a range of mental health disorders later in life. In order to effectively address these disorders, there is a need to understand more about the mental health consequences of different types of child maltreatment. This study examines the associations between prospectively substantiated child maltreatment (ages 0-14 y) and reports of hallucinations and delusional experiences at 21 years after birth. As well, we examined 12-month and lifetime psychotic disorders using data from a longitudinal birth cohort. The study comprised 3752 participants from the Mater-University of Queensland Study of Pregnancy, a prospective Australian prebirth cohort study. Psychotic experiences and 12-month and lifetime psychosis were measured using the Achenbach Young Adults Self-Report, the Peter's Delusions Inventory, and Composite International Diagnostic Interview at the 21-year follow-up. In adjusted analyses, those children who had experienced any maltreatment and who were emotionally abused and neglected were more likely to report (1) hallucinations and lifetime delusional experiences and (2) more likely to experience lifetime psychosis than their nonabused counterparts. In expanded models, those exposed to multiple forms of maltreatment, in particular with emotional abuse and neglect, had an increased likelihood of hallucinations and delusional experiences. There is an association between child maltreatment, especially emotional abuse and neglect, and later hallucinations, delusional experiences, and psychosis. It is, however, relevant to note that the vast majority of children experiencing childhood maltreatment do not appear to develop psychotic experiences or psychotic disorder. Further research to determine the reasons for highly variable outcomes of child maltreatment is warranted.

Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015: a novel analysis from the Global Burden of Disease Study 2015

BACKGROUND

National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015.

METHODS

We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure-the Healthcare Quality and Access (HAQ) Index-on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time.

FINDINGS

Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0-42·8) in 1990 to 53·7 (52·2-55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015.

INTERPRETATION

This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world.

FUNDING

Bill & Melinda Gates Foundation.

Incidence, prevalence and mortality rates of malaria in Ethiopia from 1990 to 2015: analysis of the global burden of diseases 2015

Background

In Ethiopia there is no complete registration system to measure disease burden and risk factors accurately. In this study, the 2015 global burden of diseases, injuries and risk factors (GBD) data were used to analyse the incidence, prevalence and mortality rates of malaria in Ethiopia over the last 25 years.

Methods

GBD 2015 used verbal autopsy surveys, reports, and published scientific articles to estimate the burden of malaria in Ethiopia. Age and gender-specific causes of death for malaria were estimated using cause of death ensemble modelling.

Results

The number of new cases of malaria declined from 2.8 million [95% uncertainty interval (UI) 1.4–4.5 million] in 1990 to 621,345 (95% UI 462,230–797,442) in 2015. Malaria caused an estimated 30,323 deaths (95% UI 11,533.3–61,215.3) in 1990 and 1561 deaths (95% UI 752.8–2660.5) in 2015, a 94.8% reduction over the 25 years. Age-standardized mortality rate of malaria has declined by 96.5% between 1990 and 2015 with an annual rate of change of 13.4%. Age-standardized malaria incidence rate among all ages and gender declined by 88.7% between 1990 and 2015. The number of disability-adjusted life years lost (DALY) due to malaria decreased from 2.2 million (95% UI 0.76–4.7 million) in 1990 to 0.18 million (95% UI 0.12–0.26 million) in 2015, with a total reduction 91.7%. Similarly, age-standardized DALY rate declined by 94.8% during the same period.

Conclusions

Ethiopia has achieved a 50% reduction target of malaria of the millennium development goals. The country should strengthen its malaria control and treatment strategies to achieve the sustainable development goals.

Child and Adolescent Health From 1990 to 2015: Findings From the Global Burden of Diseases, Injuries, and Risk Factors 2015 Study

Importance

Comprehensive and timely monitoring of disease burden in all age groups, including children and adolescents, is essential for improving population health.

Objective

To quantify and describe levels and trends of mortality and nonfatal health outcomes among children and adolescents from 1990 to 2015 to provide a framework for policy discussion.

Evidence Review

Cause-specific mortality and nonfatal health outcomes were analyzed for 195 countries and territories by age group, sex, and year from 1990 to 2015 using standardized approaches for data processing and statistical modeling, with subsequent analysis of the findings to describe levels and trends across geography and time among children and adolescents 19 years or younger. A composite indicator of income, education, and fertility was developed (Socio-demographic Index [SDI]) for each geographic unit and year, which evaluates the historical association between SDI and health loss.

Findings

Global child and adolescent mortality decreased from 14.18 million (95% uncertainty interval [UI], 14.09 million to 14.28 million) deaths in 1990 to 7.26 million (95% UI, 7.14 million to 7.39 million) deaths in 2015, but progress has been unevenly distributed. Countries with a lower SDI had a larger proportion of mortality burden (75%) in 2015 than was the case in 1990 (61%). Most deaths in 2015 occurred in South Asia and sub-Saharan Africa. Global trends were driven by reductions in mortality owing to infectious, nutritional, and neonatal disorders, which in the aggregate led to a relative increase in the importance of noncommunicable diseases and injuries in explaining global disease burden. The absolute burden of disability in children and adolescents increased 4.3% (95% UI, 3.1%-5.6%) from 1990 to 2015, with much of the increase owing to population growth and improved survival for children and adolescents to older ages. Other than infectious conditions, many top causes of disability are associated with long-term sequelae of conditions present at birth (eg, neonatal disorders, congenital birth defects, and hemoglobinopathies) and complications of a variety of infections and nutritional deficiencies. Anemia, developmental intellectual disability, hearing loss, epilepsy, and vision loss are important contributors to childhood disability that can arise from multiple causes. Maternal and reproductive health remains a key cause of disease burden in adolescent females, especially in lower-SDI countries. In low-SDI countries, mortality is the primary driver of health loss for children and adolescents, whereas disability predominates in higher-SDI locations; the specific pattern of epidemiological transition varies across diseases and injuries.

Conclusions and Relevance

Consistent international attention and investment have led to sustained improvements in causes of health loss among children and adolescents in many countries, although progress has been uneven. The persistence of infectious diseases in some countries, coupled with ongoing epidemiologic transition to injuries and noncommunicable diseases, require all countries to carefully evaluate and implement appropriate strategies to maximize the health of their children and adolescents and for the international community to carefully consider which elements of child and adolescent health should be monitored.

Gender-based differences in injecting drug use by young adults who experienced maltreatment in childhood: Findings from an Australian birth cohort study

BACKGROUND

Childhood maltreatment has been associated with a range of adverse mental and psychosocial outcomes, but its association with subsequent injecting drug use (IDU) is less clear. This study investigates the associations between specific and multiple forms of substantiated childhood maltreatment and IDU reported at 21 years.

METHOD

The Mater-University of Queensland Study of Pregnancy is a prospective birth cohort study. It recruited pregnant women at their first antenatal clinic visit and collected data on their children at 21 years. Data from 3750 participants (1769 males and 1981 females) were analysed using agency substantiated childhood maltreatment from birth to 14 years of age and self-reports of ever IDU at 21 years. We used multivariable logistic regression analyses to control for possible confounders.

RESULTS

The sample's mean age was 20.6 years. Some 4.1% (n=72) of males and 4.6% (n=91) of females had experienced substantiated childhood maltreatment. The prevalence of IDU was 6.6% (n=118) and 4.6% (n=91) for males and females, respectively. In adjusted models, all forms of substantiated childhood maltreatment, with the exception of sexual abuse, were associated with IDU in females (adjusted odds ratios (AORs)=2.69-3.02) but only emotional abuse (AOR=2.51) was associated with IDU in males. Multiply occurring forms of childhood maltreatment were also associated with IDU in females (AORs=2.36-3.41) but not in males.

CONCLUSIONS

Injecting drug use appears to be an adverse outcome of childhood maltreatment particularly in females. Additional research is needed to better understand why females appear to be more affected than males.

Height deficit in early adulthood following substantiated childhood maltreatment: A birth cohort study

Early life stress including childhood maltreatment has been associated with reduced head circumference and/or brain size, cognitive, and academic deficits in children and adolescents. However, little is known about the effect of childhood maltreatment on height, especially in early adulthood. This study was designed to examine the association between confirmed cases of multiple or subtypes of childhood maltreatment and stunted growth in young adulthood controlling for perinatal and familial confounding factors. A total of 2661 (48.4% female) young adults from the Mater Hospital-University Study of Pregnancy (MUSP) had data on standardised height-for-age score measurement as part of physical assessment at the 21-year follow-up. Prospectively substantiated cases of childhood maltreatment, 0-14 years of age, were linked to the MUSP dataset. Ethical approval was obtained from the Human Ethics Review Committee of The University of Queensland and the Mater Hospital. Multiple regression analyses were performed to determine the effects of childhood maltreatment on height in young adults. Childhood physical or emotional abuse and neglect were significantly associated with a deficit in height in young adulthood after controlling for perinatal and familial confounders. Multiple incidents of childhood maltreatment also were associated with a deficit in height.

Gender differences in the association between childhood sexual abuse and risky sexual behaviours: A systematic review and meta-analysis

This meta-analytic review examines the association between childhood sexual abuse and risky sexual behaviours with sub-group analyses by gender. Systematic searches of electronic databases including MEDLINE, PubMed, EMBASE, and PsycINFO were performed using key terms. We used a priori criteria to include high quality studies and control for heterogeneities across eligible studies. The review was registered with PROSPERO and used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The final meta-analysis applied fixed-effects model to generate pooled odds ratio (OR). Subgroup analyses were conducted to identify potential methodological moderators. The meta-analysis included 8 eligible studies (N=38,989, females=53.1%). The overall syndemic of risky sexual behaviors at adulthood was 1.59 times more common in childhood sexual abuse victims. There was a similar association between childhood sexual abuse in general and subsequent risky sexual behaviors in both females and males. However, in cases of substantiated childhood sexual abuse, there was a greater odds of risky sexual behaviors in females (OR=2.72) than males (OR=1.69). The magnitude of association of childhood sexual abuse and risky sexual behaviors was similar for males and females regardless of study time, study quality score and method of childhood sexual abuse measurement. There were nonsignificant overall and subgroup differences between males and females. Childhood sexual abuse is a significant risk factor for a syndemic of risky sexual behaviors and the magnitude is similar both in females and males. More research is needed to explore possible mechanisms of association.

Mortality and Disability-Adjusted Life-Years (Dalys) for Common Neglected Tropical Diseases in Ethiopia, 1990-2015: Evidence from the Global Burden of Disease Study 2015

INTRODUCTION

Neglected tropical diseases (NTDs) are important public health problems in Ethiopia. In 2013, the Federal Ministry of Health (FMOH) has launched a national NTD master plan to eliminate major NTDs of public health importance by 2020. Benchmarking the current status of NTDs in the country is important to monitor and evaluate the progress in the implementation of interventions and their impacts. Therefore, this study aims to assess the trends of mortality and Disability-adjusted Life-Years (DALY) for the priority NTDs over the last 25 years.

METHODS

We used the Global Burden of Disease (GBD) 2015 estimates for this study. The GBD 2015 data source for cause of death and DALY estimation included verbal autopsy (VA), Demographic and Health Surveys (DHS), and other disease specific surveys, Ministry of Health reports submitted to United Nations (UN) agencies and published scientific articles. Cause of Death Ensemble modeling (CODEm) and/or natural history models were used to estimate NTDs mortality rates. DALY were estimated as the sum of Years of Life Lost (YLL) due to premature mortality and Years Lived with Disability (YLD).

RESULTS

All NTDs caused an estimated of 6,293 deaths (95% uncertainty interval (UI): 3699-10,080) in 1990 and 3,593 deaths (95% UI: 2051 - 6178) in 2015, a 43% reduction over the 25 years. Age-standardized mortality rates due to schistosomiasis, STH and leshmaniasis have declined by 91.3%, 73.5% and 21.6% respectively between 1990 to 2015. The number of DALYs due to all NTDs has declined from 814.4 thousand (95% UI: 548 thousand-1.2million) in 1990 to 579.5 thousand (95%UI: 309.4 thousand-1.3 million) in 2015. Age-standardized DALY rates due to all NTDs declined by 30.7%, from 17.6 per 1000(95%UI: 12.5-26.5) in 1990 to 12.2 per 1000(95%UI: 6.5 - 27.4) in 2015. Age-standardized DALY rate for trachoma declined from 92.7 per 100,000(95% UI: 63.2 - 128.4) in 1990 to 41.2 per 100,000(95%UI: 27.4-59.2) in 2015, a 55.6% reduction between 1990 and 2015. Age-standardized DALY rates for onchocerciasis, schistosomiasis and lymphiaticfilariasis decreased by 66.2%, 29.4% and 12.5% respectively between 1990 and 2015. DALY rate for ascariasis fell by 56.8% over the past 25 years.

CONCLUSIONS

Ethiopia has made a remarkable progress in reducing the DALY rates for most of the NTDs over the last 25 years. The rapid scale of interventions and broader system strengthening may have a lasting impact on achieving the 2020 goal of elimination of most of NTDs. Ethiopia should strengthen the coverage of integrated interventions of NTD through proper coordination with other health programs and sectors and community participation to eliminate NTDs by 2020.

Measuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015

BACKGROUND

In September, 2015, the UN General Assembly established the Sustainable Development Goals (SDGs). The SDGs specify 17 universal goals, 169 targets, and 230 indicators leading up to 2030. We provide an analysis of 33 health-related SDG indicators based on the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015).

METHODS

We applied statistical methods to systematically compiled data to estimate the performance of 33 health-related SDG indicators for 188 countries from 1990 to 2015. We rescaled each indicator on a scale from 0 (worst observed value between 1990 and 2015) to 100 (best observed). Indices representing all 33 health-related SDG indicators (health-related SDG index), health-related SDG indicators included in the Millennium Development Goals (MDG index), and health-related indicators not included in the MDGs (non-MDG index) were computed as the geometric mean of the rescaled indicators by SDG target. We used spline regressions to examine the relations between the Socio-demographic Index (SDI, a summary measure based on average income per person, educational attainment, and total fertility rate) and each of the health-related SDG indicators and indices.

FINDINGS

In 2015, the median health-related SDG index was 59·3 (95% uncertainty interval 56·8-61·8) and varied widely by country, ranging from 85·5 (84·2-86·5) in Iceland to 20·4 (15·4-24·9) in Central African Republic. SDI was a good predictor of the health-related SDG index (r2=0·88) and the MDG index (r2=0·92), whereas the non-MDG index had a weaker relation with SDI (r2=0·79). Between 2000 and 2015, the health-related SDG index improved by a median of 7·9 (IQR 5·0-10·4), and gains on the MDG index (a median change of 10·0 [6·7-13·1]) exceeded that of the non-MDG index (a median change of 5·5 [2·1-8·9]). Since 2000, pronounced progress occurred for indicators such as met need with modern contraception, under-5 mortality, and neonatal mortality, as well as the indicator for universal health coverage tracer interventions. Moderate improvements were found for indicators such as HIV and tuberculosis incidence, minimal changes for hepatitis B incidence took place, and childhood overweight considerably worsened.

INTERPRETATION

GBD provides an independent, comparable avenue for monitoring progress towards the health-related SDGs. Our analysis not only highlights the importance of income, education, and fertility as drivers of health improvement but also emphasises that investments in these areas alone will not be sufficient. Although considerable progress on the health-related MDG indicators has been made, these gains will need to be sustained and, in many cases, accelerated to achieve the ambitious SDG targets. The minimal improvement in or worsening of health-related indicators beyond the MDGs highlight the need for additional resources to effectively address the expanded scope of the health-related SDGs.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015

BACKGROUND

The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context.

METHODS

We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors-the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI).

FINDINGS

Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6-58·8) of global deaths and 41·2% (39·8-42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa.

INTERPRETATION

Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015

BACKGROUND

Healthy life expectancy (HALE) and disability-adjusted life-years (DALYs) provide summary measures of health across geographies and time that can inform assessments of epidemiological patterns and health system performance, help to prioritise investments in research and development, and monitor progress toward the Sustainable Development Goals (SDGs). We aimed to provide updated HALE and DALYs for geographies worldwide and evaluate how disease burden changes with development.

METHODS

We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2015. We calculated DALYs by summing years of life lost (YLLs) and years of life lived with disability (YLDs) for each geography, age group, sex, and year. We estimated HALE using the Sullivan method, which draws from age-specific death rates and YLDs per capita. We then assessed how observed levels of DALYs and HALE differed from expected trends calculated with the Socio-demographic Index (SDI), a composite indicator constructed from measures of income per capita, average years of schooling, and total fertility rate.

FINDINGS

Total global DALYs remained largely unchanged from 1990 to 2015, with decreases in communicable, neonatal, maternal, and nutritional (Group 1) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). Much of this epidemiological transition was caused by changes in population growth and ageing, but it was accelerated by widespread improvements in SDI that also correlated strongly with the increasing importance of NCDs. Both total DALYs and age-standardised DALY rates due to most Group 1 causes significantly decreased by 2015, and although total burden climbed for the majority of NCDs, age-standardised DALY rates due to NCDs declined. Nonetheless, age-standardised DALY rates due to several high-burden NCDs (including osteoarthritis, drug use disorders, depression, diabetes, congenital birth defects, and skin, oral, and sense organ diseases) either increased or remained unchanged, leading to increases in their relative ranking in many geographies. From 2005 to 2015, HALE at birth increased by an average of 2·9 years (95% uncertainty interval 2·9-3·0) for men and 3·5 years (3·4-3·7) for women, while HALE at age 65 years improved by 0·85 years (0·78-0·92) and 1·2 years (1·1-1·3), respectively. Rising SDI was associated with consistently higher HALE and a somewhat smaller proportion of life spent with functional health loss; however, rising SDI was related to increases in total disability. Many countries and territories in central America and eastern sub-Saharan Africa had increasingly lower rates of disease burden than expected given their SDI. At the same time, a subset of geographies recorded a growing gap between observed and expected levels of DALYs, a trend driven mainly by rising burden due to war, interpersonal violence, and various NCDs.

INTERPRETATION

Health is improving globally, but this means more populations are spending more time with functional health loss, an absolute expansion of morbidity. The proportion of life spent in ill health decreases somewhat with increasing SDI, a relative compression of morbidity, which supports continued efforts to elevate personal income, improve education, and limit fertility. Our analysis of DALYs and HALE and their relationship to SDI represents a robust framework on which to benchmark geography-specific health performance and SDG progress. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform financial and research investments, prevention efforts, health policies, and health system improvement initiatives for all countries along the development continuum.

FUNDING

Bill & Melinda Gates Foundation.

The Role of Community Health Workers in Preventing Adolescent Repeat Pregnancies and Births

Intervention by community health workers (CHWs) is believed to prevent repeated childbearing among teenagers. This review investigated the effectiveness of CHWs in reducing repeated pregnancies and births among adolescents aged <20 years, 2 years after the delivery of their first child. Through electronic database and hand searching, experimental and/or observational studies were screened with their results undergoing systematic review and meta-analyses. Subgroup analyses were performed to further assess how study characteristics affected the pooled estimates and heterogeneity. A total of 11 eligible articles, from January 1980 to May 2015, were included. Seven studies evaluated repeated births and eight measured repeated pregnancies. Studies showed relevant disparities in terms of selected methodological aspects and program characteristics. Although most studies (n = 9) were either of "strong" or of "moderate" quality, only two of five finding a significant reduction exhibited a high level of quality as the other three failed to adjust results for confounders. Random effects modeling revealed an overall 30% decrease in repeated adolescent births (odds ratio = .70, confidence interval = .49-.99) among CHW-visited areas relative to nonvisited sites. On the other hand, no significant association was detected in terms of repeated pregnancies (odds ratio = .96, confidence interval = .70-1.28).

Substantiated Childhood Maltreatment and Intimate Partner Violence Victimization in Young Adulthood: A Birth Cohort Study

Little is known about the associations between various types of childhood maltreatment and multiple forms of intimate partner violence victimization in early adulthood. This study examines the extent to which childhood experiences of maltreatment increase the risk for intimate partner violence victimization in early adulthood. Data for the present study are from 3322 young adults (55 % female) of the Mater Hospital-University of Queensland Study of Pregnancy with the mean age of 20.6 years. The Mater Hospital-University of Queensland Study of Pregnancy is a prospective Australian pre-birth cohort study of mothers consecutively recruited during their first antenatal clinic visit at Brisbane's Mater Hospital from 1981 through to 1983. Participants completed the Composite Abuse Scale at 21-year follow-up and linked this dataset to agency recorded substantiated cases of childhood maltreatment. In adjusted models, the odds of reporting emotional intimate partner violence victimization were 1.84, 2.64 and 3.19 times higher in physically abused, neglected and emotionally abused children, respectively. Similarly, the odds of physical intimate partner violence victimization were 1.76, 2.31, 2.74 and 2.76 times higher in those children who had experienced physical abuse, sexual abuse, neglect and emotional abuse, respectively. Harassment was 1.63 times higher in emotionally abused children. The odds of severe combined abuse were 3.97 and 4.62 times greater for emotionally abused and neglected children, respectively. The strongest associations involved reports of child emotional abuse and neglect and multiple forms of intimate partner violence victimization in young adulthood. Childhood maltreatment is a chronic adversity that is associated with specific and multiple forms of intimate partner violence victimization in adulthood.

Estimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2015: the Global Burden of Disease Study 2015

BACKGROUND

Timely assessment of the burden of HIV/AIDS is essential for policy setting and programme evaluation. In this report from the Global Burden of Disease Study 2015 (GBD 2015), we provide national estimates of levels and trends of HIV/AIDS incidence, prevalence, coverage of antiretroviral therapy (ART), and mortality for 195 countries and territories from 1980 to 2015.

METHODS

For countries without high-quality vital registration data, we estimated prevalence and incidence with data from antenatal care clinics and population-based seroprevalence surveys, and with assumptions by age and sex on initial CD4 distribution at infection, CD4 progression rates (probability of progression from higher to lower CD4 cell-count category), on and off antiretroviral therapy (ART) mortality, and mortality from all other causes. Our estimation strategy links the GBD 2015 assessment of all-cause mortality and estimation of incidence and prevalence so that for each draw from the uncertainty distribution all assumptions used in each step are internally consistent. We estimated incidence, prevalence, and death with GBD versions of the Estimation and Projection Package (EPP) and Spectrum software originally developed by the Joint United Nations Programme on HIV/AIDS (UNAIDS). We used an open-source version of EPP and recoded Spectrum for speed, and used updated assumptions from systematic reviews of the literature and GBD demographic data. For countries with high-quality vital registration data, we developed the cohort incidence bias adjustment model to estimate HIV incidence and prevalence largely from the number of deaths caused by HIV recorded in cause-of-death statistics. We corrected these statistics for garbage coding and HIV misclassification.

FINDINGS

Global HIV incidence reached its peak in 1997, at 3·3 million new infections (95% uncertainty interval [UI] 3·1-3·4 million). Annual incidence has stayed relatively constant at about 2·6 million per year (range 2·5-2·8 million) since 2005, after a period of fast decline between 1997 and 2005. The number of people living with HIV/AIDS has been steadily increasing and reached 38·8 million (95% UI 37·6-40·4 million) in 2015. At the same time, HIV/AIDS mortality has been declining at a steady pace, from a peak of 1·8 million deaths (95% UI 1·7-1·9 million) in 2005, to 1·2 million deaths (1·1-1·3 million) in 2015. We recorded substantial heterogeneity in the levels and trends of HIV/AIDS across countries. Although many countries have experienced decreases in HIV/AIDS mortality and in annual new infections, other countries have had slowdowns or increases in rates of change in annual new infections.

INTERPRETATION

Scale-up of ART and prevention of mother-to-child transmission has been one of the great successes of global health in the past two decades. However, in the past decade, progress in reducing new infections has been slow, development assistance for health devoted to HIV has stagnated, and resources for health in low-income countries have grown slowly. Achievement of the new ambitious goals for HIV enshrined in Sustainable Development Goal 3 and the 90-90-90 UNAIDS targets will be challenging, and will need continued efforts from governments and international agencies in the next 15 years to end AIDS by 2030.

FUNDING

Bill & Melinda Gates Foundation, and National Institute of Mental Health and National Institute on Aging, National Institutes of Health.

A systematic review and meta-analysis of the association between unintended pregnancy and perinatal depression

BACKGROUND

There is a growing interest in exploring maternal mental health effects of unintended pregnancies carried to term. However, the evidence base from a small number of available studies is characterised by considerable variability, inconsistency and inconclusive findings. We present a systematic review and meta-analysis of all available studies on unintended pregnancy as these are related to maternal depression.

METHODS

Using PRISMA guideline, we systematically reviewed and meta-analysed studies reporting an association between unintended pregnancy and maternal depression from PubMed, EMBASE, PsychINFO and Google Scholar. We used a priori set criteria and included details of quality and magnitude of effect sizes. Sample sizes, adjusted odds ratios and standard errors were extracted. Random effects were used to calculate pooled estimates in Stata 13. Cochran's Q, I(2) and meta-bias statistics assessed heterogeneity and publication bias of included studies.

RESULTS

Meta-bias and funnel plot of inverse variance detected no publication bias. Overall prevalence of maternal depression in unintended pregnancy was 21%. Unintended pregnancy was significantly associated with maternal depression. Despite statistically significant heterogeneities of included studies, sub-group analyses revealed positive and significant associations by types of unintended pregnancies, timing of measurements with respect to pregnancy and childbirth, study designs and settings.

CONCLUSIONS

The prevalence of perinatal depression is two-fold in women with unintended pregnancy. Perinatal care settings may screen pregnancy intention and depression of women backed by integrating family planning and mental health services.

Level of male involvement and associated factors in family planning services utilization among married men in Debremarkos town, Northwest Ethiopia

Background

Men’s participation is crucial to the success of family planning programs and women’s empowerment and associated with better outcomes in reproductive health such as contraceptive acceptance and continuation, and safer sexual behaviors. Limited choice and access to methods, attitudes of men towards family planning, perceived fear of side-effects, poor quality of available services, cultural or religious oppositions and gender-based barriers are some of the reasons for low utilization of family planning. Hence, this study assessed the level of male involvement in family planning services utilization and its associated factors in Debremarkos town, Northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted from October to November, 2013. Multi-stage sampling technique was used to select 524 eligible samples. Data were collected by using semi-structured questionnaires. Epi Info and SPSS were used to enter and analyze the data; univariate, bivariate and logistic regression analyses were performed to display the outputs.

Results

Only 44 (8.4%) respondents were using or directly participating in the use of family planning services mainly male condoms. The reasons mentioned for the low participation were the desire to have more children, wife or partner refusal, fear of side effects, religious prohibition, lack of awareness about contraceptives and the thinking that it is the only issue for women. Opinion about family planning services, men approval and current use of family planning methods were associated with male involvement in the services utilization.

Conclusions

In this study, the level of male involvement was low. Lack of information, inaccessibility to the services and the desire to have more children were found to be the reasons for low male involvement in family planning services utilization. Governmental and nongovernmental organizations, donors and relevant stakeholders should ensure availability, accessibility and sustained advocacy for use of family planning services. The family planning programs should incorporate the responsibility and role of males in the uptake of family planning services.

Work-related stress and associated factors among nurses working in public hospitals of Addis Ababa, Ethiopia: a cross-sectional study

Work-related stress is a pattern of reactions to work demands unmatched to nurses' knowledge, skills, or abilities; these challenges exceed their ability to cope, resulting in burnout, turnover, and low quality patient care. An institution-based cross-sectional study of 343 nurses was conducted in public hospitals of Addis Ababa in 2012. Data were collected by pretested and self-administered questionnaires using a nursing stress scale. One hundred twenty-one (37.8%) (95% confidence interval: 34.3 to 39.1) nurses reported experiencing occupational stress. Significant associations were found between nurses' stress and gender, work shift, illness, marital status, and worksite or unit. Prevalence of work-related stress was higher than expected and opportunities exist for stake holders to design stress reduction and management programs for nurses.

Reproductive health knowledge and services utilization among rural adolescents in east Gojjam zone, Ethiopia: a community-based cross-sectional study

BACKGROUND

According to World Health Organization, adolescents are people between 10 and 19 years of age; one-fifth of Ethiopian population constitutes adolescents and four-fifth live in rural areas. Local evidence about adolescents' reproductive health knowledge, services utilization and associated factors are relevant to design age-appropriate program interventions and strategies. Hence, this study assessed the level of reproductive health knowledge and services utilization among rural adolescents in Machakel district, Northwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted to assess the level of reproductive health knowledge and services utilization of rural adolescents in Machakel district. The study employed both quantitative and qualitative methods. A systematic random sampling technique was used to select 415 adolescents from eligible households. Data were collected using pre-tested structured questionnaires and in-depth interview guides. The data were entered into Epi Info and analyzed by SPSS software for windows. Univariate, bivariate and multivariate analyses were done.

RESULT

More than two-third (67%) of the adolescents had knowledge about reproductive health. Age (AOR = 3.77, 95% CI: 3.1-8.98), living arrangement (AOR = 2.21, 95% CI: 1.81-6.04) and economic status (AOR = 3.37, 95% CI: 1.65-6.87) were associated with reproductive health knowledge. However, only one-fifth (21.5%) of the adolescents had ever used reproductive health services including family planning, sexually transmitted infections treatment and information, education and communication. Reproductive health services utilization was significantly associated with age (AOR = 2.18, 95% CI: 1.13-8.03) and knowledge for reproductive health (AOR = 1.23, 95% CI: 1.23-4.21). Parent disapproval, lack of basic information and pressure from partners were found to deter adolescents from accessing and using reproductive health services.

CONCLUSION

Reproductive health knowledge and services utilization amongst rural adolescents remained low. Age and economic status were significantly associated with reproductive health knowledge; moreover, reproductive health services utilization was associated with age and respective knowledge for reproductive health. Community-conversation in line with adolescent-to-adolescent-counseling, peer education and parent-adolescent communication should address sensitive topics such as sex education and life skill development.