Cognitive performance during senescence in untreated congenital isolated GH deficiency

Individuals with untreated isolated GH deficiency (IGHD) due to a mutation in the GHRH receptor gene from Itabaianinha Brazil have increased insulin sensitivity, normal life expectancy, and an extended health span, i.e. the period of life free from disabilities. We hypothesize that their prolonged health span is accompanied by a delayed cognitive decline in senescence. To test this hypothesis, we have administered the Literacy-Independent Cognitive Assessment (LICA) to 15 IGHD individuals aged over 50 years and 15 controls matched by age, sex, years of education, and percentage of illiteracy. All individuals were negative for HIV and syphilis serology, and there were no differences in serum levels of folate, vitamin B12 and TSH between the two groups, while free T4 was higher in the IGHD group. IGHD subjects had a higher total LICA score than controls, 215 (22.7) vs 204.2 (18.1), without reaching statistical significance. Scores of memory, visuoconstruction, language and calculation were similar between the two groups, with better attention (9.5 (1.4) vs 8.3 (1.1), P = 0.01) and executive function (38.3 (4.8) vs 35.1 (2.5), P = 0.03) scores in IGHD. MANCOVA revealed that group (but no age) had a significant effect on the LICA variables (partial eta squared of 0.455, power of 0.812, P = 0.02). This effect is verified on attention (partial eta squared 0.216, power of 0.749, P = 0.01) and executive function (partial eta squared 0.154, power of 0.570, P = 0.03. In conclusion, IGHD in senescence is associated with similar total cognitive performance but better attention and executive function than controls.

Influência de Fatores Psicológicos e Sociais nos Comportamentos Preventivos de Saúde dos Homens

Introdução: Homens tendem a retardar a procura por serviços de saúde e têm baixa adesão a tratamentos, causando piores indicadores de saúde. Objetivou-se analisar a influência de fatores psicológicos e sociais nos comportamentos preventivos de saúde adotados por homens. Métodos: Utilizaram-se um questionário sociodemográfico, o Inventário de Conformidade com Normas Masculinas (CMNI), o Self-Reporting Questionnaire (SRQ) e o Questionário de Atitudes e Comportamentos de Saúde (QACS). Participaram da análise 315 homens adultos de todo o Brasil. Resultados: Uma regressão linear revelou que eram preditores de menor prevenção: pontuar alto em traços que indicavam desejo por admiração e respeito e comportamentos sexuais arriscados, bem como a maior probabilidade de presença de transtorno mental, ter cor de pele preta e menor nível educacional. Discussão: Foram mapeados fatores de risco para a menor conduta preventiva em homens. Conclusão: Conclui-se que variáveis psicológicas e sociais exercem forte influência sobre os comportamentos de saúde dos homens, sendo necessárias ações de promoção da saúde masculina para além das políticas públicas existentes, na busca pela elaboração de novas ações focadas neste grupo e temática específicos.

Avaliação da Relação entre Eventos Traumáticos Infantis e Comportamentos Autolesivos em Adolescentes

Resumo Esta pesquisa teve como objetivo verificar a relação entre eventos traumáticos (ET) na infância e a ocorrência de comportamentos autolesivos em adolescentes. Os instrumentos utilizados foram o Questionário sobre Traumas na Infância (QUESI) e o Inventário de Autolesão Deliberada - reduzido (IAD-r). Participaram 494 estudantes do ensino médio de ambos os sexos e idade entre 15 e 18 anos (M = 16,4). Destes, 58,5% afirmaram ter sofrido abuso emocional de forma recorrente e 19,0% e 59,5% assumiram já ter sofrido abuso sexual e físico, respectivamente. Quanto à prática de autolesão, 65,0% revelaram já ter se engajado em comportamentos autolesivos. De acordo com a análise de Regressão Logística Binomial, todos os tipos de ET exibiram associação significativa com a prática de comportamentos autolesivos. A análise de moderação a respeito da interação entre a ocorrência de ET infantis e a prática de autolesão revelou ausência de moderação pelo sexo e pela idade. Porém, quanto ao abuso físico, o efeito de moderação da idade apresentou significância estatística limítrofe e indicou que os adolescentes mais novos, de 15 e 16 anos, que sofreram este tipo de abuso na infância, foram mais susceptíveis à prática autolesiva. Portanto, as altas taxas de ET e de autolesão encontradas nesta pesquisa revelam a gravidade do problema. Espera-se que esta investigação possa contribuir para a elaboração de intervenções para prevenção e controle dos fatores de risco que acometem a população infanto-juvenil.

Rastreamento domiciliar da sintomatologia depressiva em Aracaju (Sergipe, Brasil)

Esta pesquisa objetivou realizar o rastreamento de sintomatologia depressiva em Aracaju (Sergipe, Brasil) e estimar as chances para depressão a partir e características do perfil amostral. Os instrumentos utilizados foram um questionário sociodemográfico e clínico, além do Inventário de Depressão de Beck, segunda edição (BDI-II). A amostra foi composta por 693 indivíduos, por meio de coleta domiciliar. Além das análises descritivas, conduziram-se análises de regressão logística binomial e multinomial, tendo como variáveis dependentes a presença de sintomatologia depressiva e os respectivos níveis de severidade. As variáveis explicativas foram aquelas relativas ao perfil sociodemográfico e clínico. Constatou-se que mais de um terço dos participantes revelaram presença significativa de sintomatologia depressiva. Região geográfica, sexo, doença crônica, grupo etário e IMC afetaram a chance de pertencer ao grupo com diagnóstico de rastreamento positivo. Já as variáveis escolaridade, ocupação laboral, doença crônica e IMC impactaram de modo diferenciado na severidade dos sintomas. Conclui-se que o rastreamento de depressão é fundamental no atendimento preventivo em saúde mental, especialmente para a minimização do subdiagnóstico e demora no início do tratamento psicológico e psiquiátrico apropriados.

Suicídio em Estudantes Universitários: Ocorrência e Fatores Psicológicos e Sociais Associados

O presente estudo objetivou investigar a ocorrência de ideação suicida em universitários, bem como sua relação com a presença de sofrimento mental significativo e características sociodemográficas. Em fevereiro de 2020, 223 estudantes da Universidade Federal de Sergipe responderam a um questionário presencialmente, em uma proporção de aproximadamente metade entre os gêneros. Participaram estudantes de todas as áreas do conhecimento, nos turnos da manhã, tarde e noite. Além do questionário sociodemográfico, foram aplicados o Questionário de Impulso, Autodano e Ideação Suicida (QIAIS-A) e o Self-Reporting Questionnaire (SRQ-20). Foi encontrado que 52,9% dos participantes relataram sofrimento mental significativo e 32,3% possuíam ideação suicida. Por meio de regressão logística, constatou-se que apenas a variável sofrimento mental significativo permaneceu no modelo final. Com isso, viu-se que aqueles que relataram sofrimento mental possuiam quase nove vezes mais chances de apresentar ideação suicida. Frente aos achados desta pesquisa, concluiu-se que o cuidado com a saúde mental dos estudantes é urgente e medidas de intervenção precisam ser adotadas pelas instituições o quanto antes.

Evidências de Validade da GAD-7 em Adolescentes Brasileiros

Resumo O objetivo deste estudo foi investigar evidências validade para a escala Generalized Anxiety Disorder (GAD-7) em adolescentes brasileiros, bem como validade concorrente para esta escala e apresentar a distribuição social do Transtorno de Ansiedade Generalizada (TAG). Participaram 302 adolescentes, com idades entre 15 e 19 anos, de ambos os sexos. Aplicou-se o questionário sociodemográfico, a GAD-7, a Hospital Anxiety and Depression Scale (HADS) e o Patient Health Questionnaire (PHQ-9). Os resultados da Análise Fatorial Exploratória (AFE) atestaram a unidimensionalidade da GAD-7 e indicaram consistência interna satisfatória. As evidências de validade concorrente apresentaram associações estatisticamente significativas e positivas entre a GAD-7 e as escalas PHQ-9 e HADS-A. Quanto à distribuição social, aproximadamente metade da amostra apresentou a ocorrência de sintomatologia positiva para TAG, sendo mais comum para o sexo feminino e em adolescentes mais jovens. Esses dados sugerem que a GAD-7 apresenta adequadas propriedades psicométricas para rastreamento de ansiedade em adolescentes.

Communication Apprehension Among Health Professions Students in Brazil

Objective. To determine the levels of communication apprehension experienced by health professions students in Brazil.Method. A cross-sectional study of dentistry, pharmacy, medicine, and nursing students at a Brazilian university was conducted from December 2019 to May 2020. The students were invited to complete the Personal Report of Communication Apprehension (PRCA-24) and provide demographic data. Univariate and bivariate analyses were conducted.Results. A total of 644 health students answered the survey, and 25.5% were classified as having high communication apprehension. Male participants had significantly lower PRCA-24 scores than female participants. No significant differences were found between PRCA-24 scores by age category or academic year. Medical students had significantly lower mean PRCA-24 scores than pharmacy students.Conclusion. The prevalence of communication apprehension was high among health professions students. Women and pharmacy students had the highest communication apprehension scores. Health educators should consider the effects of communication apprehension on students and use adequate interventions during communication skills training to alleviate this apprehension.

Depressão em pessoas sob aprisionamento no sistema carcerário: revisão integrativa

Resumo Esta revisão integrativa objetivou reunir estudos sobre a depressão em pessoas sob aprisionamento no sistema carcerário. As bases de dados pesquisadas foram PePSIC, PsycINFO, SciELO e Web of Science. As ferramentas de suporte para a extração dos artigos selecionados foram o programa computacional StArt e as recomendações Prisma. Os termos usados na busca eletrônica foram “inmate”, “prison”, “prisoner”, “penitentiary” e “depression”. A amostra final foi composta por 10 estudos primários, os quais atenderam aos critérios de inclusão e à questão norteadora da revisão. Dentre os achados, a ocorrência de depressão foi evidente em todos os artigos selecionados, e o Inventário de Depressão de Beck foi o instrumento mais utilizado. Por fim, percebeu-se que a identificação precoce de sintomatologia depressiva pode minimizar prejuízos físicos e mentais na população em encarceramento.

O papel da autoeficácia, da autoestima e do autoconceito na depressão em adolescentes

Este estudo buscou avaliar a relação entre autoeficácia, autoestima, autoconceito e depressão em adolescentes. Para tanto, realizou-se o rastreamento de sintomas depressivos e dos níveis de autoeficácia, autoestima e autoconceito, bem como se analisou a capacidade de predição desses construtos sobre a sintomatologia. Verificou-se, ainda, se a relação entre preditor(es) e sintomas foi moderada pelo gênero e idade. A amostra foi constituída por 501 adolescentes, com média de idade de 16,4 anos. Quase metade dos adolescentes apresentou diagnóstico positivo de rastreamento para depressão e níveis moderados nos três construtos avaliados. Apenas a autoeficácia foi preditora negativa da sintomatologia e essa relação não sofreu efeito de interação do gênero ou idade do adolescente. Os resultados denotam a relevância da autoeficácia no entendimento da ocorrência de depressão nesse grupo, fornecendo subsídios para sua utilização como suporte ao diagnóstico, ações preventivas e tratamento.

Brazilian version of the Personal Report of Communication Apprehension: Cross-cultural adaptation and psychometric evaluation among healthcare students

INTRODUCTION

Communication apprehension (CA) refers to an individual's level of fear or anxiety toward either real or anticipated communication with another person or persons. The Personal Report of Communication Apprehension (PRCA-24) is the most widely used measure of CA, even among healthcare students.

OBJECTIVE

This study aimed to undertake a cross-cultural adaptation of this scale, translate it into Brazilian Portuguese, and examine its psychometric properties among healthcare students.

METHODS

The translation and cross-cultural adaptation procedures were undertaken with the objective of establishing compatibility between the original and translated scales. The content validity of the scale was established based on the feedback of a multidisciplinary expert committee. Its psychometric properties were evaluated using a convenience sample of 616 healthcare students. Its construct validity was examined using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Its internal consistency was examined by computing Cronbach's alpha and McDonald's omega coefficients. Its criterion validity was examined against the Interpersonal Communication Competence Scale (ICCS).

RESULTS

The adapted scale demonstrated acceptable content validity. EFA showed that it was undergirded by one dimension, and this observation was confirmed by the results of CFA. The scale demonstrated excellent internal consistency. Its convergent validity was examined by conducting correlation analysis, and scores on the adapted PRCA-24 were negatively correlated with scores on the ICCS.

CONCLUSION

The Brazilian version of the PRCA-24 has satisfactory psychometric properties and is, therefore, suitable for use with Brazilian healthcare students. It can be used to assess their communication needs for the purpose of designing tailored training programs.

Kessler Psychological Distress Scale: Internal Structure and Relation to Other Variables

Abstract This study aimed to present validity evidence based on internal structure of the Kessler Scale of Psychological Distress (K10), to show its relations with the Perceived Stress Scale (PSS-10), and to present a social distribution of distress in the present sample. Participated in the study 717 residents of Aracaju, State of Sergipe, by means of household data collection. A sociodemographic questionnaire, K10, and PSS-10 were used as instruments. Exploratory Factor Analysis was performed using the Factor software, which indicated the scale unidimensionality, explaining 69.9% of the variance. Cronbach’s alpha was 0.93, and the model adjustment indices were satisfactory. A positive and statistically significant association between K10 and PSS-10 was observed. Regarding the social distribution, the levels of distress were higher in women, patients with chronic diseases, users of controlled drugs, and unemployed participants. It was concluded that K10 presented robust psychometric properties for the detection of distress in general population.

A Percepção da Experiência de Primeiro Aprisionamento em uma Unidade Prisional

Resumo Este estudo buscou compreender a experiência do primeiro aprisionamento no sistema penitenciário e identificar os comportamentos adaptativos desencadeados a partir desse contexto estressor. A amostra foi composta por 61 detentos, divididos em dois grupos: G1 (internos provisórios, n = 42) e G2 (internos sentenciados, n = 19). Utilizou-se um questionário sociodemográfico e criminal, além da técnica de evocação livre de palavras com os termos indutores “prisão” e “futuro”. As evocações foram analisadas com o auxílio do software OpenEvoc e os demais dados com o SPSS. Os resultados mostraram que, a partir do termo indutor “prisão”, o conteúdo evocado pelos dois grupos revelou a instituição como um lugar difícil de se viver, de adoecimento e de sofrimento físico e psicológico. Já a partir do termo “futuro”, observou-se que ambos apresentaram expectativas positivas para o recomeço de suas vidas em liberdade, tais como ter responsabilidade, fé, estar próximo da família e sentir-se reinserido socialmente por meio do trabalho e dos estudos. Em resumo, mesmo diante do impacto do aprisionamento, foi perceptível no conteúdo evocado a existência de fatores considerados protetivos na adaptação do indivíduo à vida na prisão. Finalmente, acredita-se que, a partir do discurso evocado, profissionais da saúde e de áreas afins possam identificar fatores de risco e de proteção que deem suporte à atenção e aos cuidados prestados à saúde física e mental dos detentos ou em condição de primeiro encarceramento.

Evidências de Validade da Escala de Autoeficácia da Bateria de Avaliação de Indicadores da Depressão Infantojuvenil

Este estudo analisou evidências de validade da Escala de Autoeficácia da Bateria de Avaliação de Indicadores da Depressão Infatojuvenil, avaliou a validade divergente da escala em relação à depressão e examinou a distribuição social da autoeficácia segundo as variáveis sexo, idade e ano escolar. A amostra consistiu de 388 adolescentes, com idades entre 14 e 19 anos que responderam a um questionário sociodemográfico e à Escala de Autoeficácia. A Análise Fatorial Exploratória foi conduzida por meio do software Factor. Os resultados indicaram a unidimensionalidade da medida, explicando 56,3% de variância. Os índices de ajuste do modelo e o índice de confiabilidade foram satisfatórios. A avaliação da distribuição social mostrou que houve relações estatisticamente significativas quanto ao sexo e a idade. Constatou-se que a Escala de Autoeficácia apresentou boas propriedades psicométricas, o que recomenda seu uso por parte da comunidade científica e profissional para futuras pesquisas, intervenções e avaliações da autoeficácia em adolescentes.

A Diagnostic-Oriented Screening Scale for Anxiety Disorders: The Center for Epidemiologic Studies Anxiety Scale (CESA)

Objectives

This paper introduces a new diagnostically oriented screening scale for anxiety disorders, the Center for Epidemiologic Studies Anxiety scale (CESA), designed in parallel to the revised Center for Epidemiologic Studies Depression scale (CESD-R). In this study, the CESA was used as a diagnostic screening tool for detecting the presence of anxiety disorder symptomatology ascertained by a clinical psychiatric evaluation based on the DSM-5 criteria. The CESA is designed to provide an overall evaluation of anxiety as well as to screen for four important anxiety disorders (agoraphobia, social phobia, blood-illness phobia, and panic disorder).

Methods

The test sample was composed of 80 adults seeking treatment for mental problems in a general psychiatric clinic. We assessed the receiver operating characteristic (ROC) curve of the CESA in comparison to the psychiatric interview.

Results

The main findings suggest that the CESA is useful for screening for anxiety in general (alpha coefficient of 0.83), as well as for the four common anxiety disorders. The criterion validation confirmed a high level of compatibility between the CESA and the psychiatric evaluation.

Conclusion

This is the initial report regarding the CESA and future research will focus on specific aspects of criterion validity for each disorder.

Factor structure and gender invariance of the Beck Depression Inventory - second edition (BDI-II) in a community-dwelling sample of adults

Objective: The main purpose of this study was to investigate the factor structure of the Beck Depression Inventory – Second Edition (BDI-II) in a sample of adults. Specifically, we evaluated the BDI-II based on confirmatory factor analysis of different measurement models, and compared the optimal factor structure of the BDI-II by gender using measurement invariance analysis.

Method: A cross-sectional survey with 717 community-dwelling adults was conducted. The Brazilian Portuguese version of the BDI-II was administered. Seven different models (one-, two-, three-factor models and their bifactor structures) were tested through CFA. CFA and multigroup analysis were executed with the software MPLUS (Weighted Least Squares Estimator – WLSMV).

Results: Four bifactor models reached acceptable fit indices. A bifactor model with two specific factors (Cognitive–Affective, and Somatic-Affective) provided the best fit to the data. The multigroup analysis of this model demonstrated invariance by gender.

Conclusions: Our findings support the use of the total BDI-II score to identify depressive symptoms, including gender comparisons. Since a bifactor structure fit the data better, the scores of the specific factors should not be used as the first choice, or at least should be used with caution. The analysis of the severity of depression, based on a total score, seems to be the most appropriate option.

COVID-19 e saúde mental: a emergência do cuidado

Resumo Considerando-se a situação atual mundial, marcada por importantes crises na saúde pública e, mais recentemente, a pandemia causada pela COVID-19, o presente artigo buscou reunir informações e achados de pesquisa a respeito do impacto de tais crises na saúde mental. O texto traz conceitos relacionados à problemática do novo coronavírus e analisa consequências de medidas adotadas para lidar com situações desse tipo, tais como distanciamento social, quarentena e isolamento, ao longo de três períodos distintos: pré-crise, intracrise e pós-crise. O artigo enfoca as repercussões observadas na saúde mental da população, refletindo acerca dos desfechos favoráveis e desfavoráveis dentro do processo de crise. Por fim, são apresentadas questões relacionadas à emergência do cuidado em saúde mental, tanto aquele prestado pela Psicologia, como aquele que pode ser desenvolvido pelos demais profissionais de saúde, de modo a minimizar os impactos negativos da crise e atuar de modo preventivo.

Estratégias de Enfrentamento de Adultos Vítimas de Acidente Vascular Cerebral e sua Relação com o Ajustamento Psicológico

Objetivo: Identificar as estratégias de enfrentamento utilizadas por pessoas com AVC e analisar como elas atuam no processo de ajustamento após o Acidente vascular Cerebral. Método: Participaram deste estudo 23 pessoas que sofreram AVC há pelo menos seis meses. Como instru- mento utilizou-se uma entrevista semiestruturada e um questionário sociodemográfico que foram anali- sados com o auxílio do Software IRAMUTEQ, através da Classificação Hierárquica Descendente (CHD) e a análise de contrastes. Resultados: Os resultados geraram um dendrograma com três categorias que representaram o foco da estratégias de enfrentamento (Foco no problema, na emoção e Suporte Social) e oito Classes que mostrou as principais estratégias de enfrentamento utilizadas pelas vítimas de AVC, a saber: classe 1 – Busca pela reabilitação (40 % dos segmentos de palavras); classe 2 – Superação das sequelas (29,7 %); classe 3 - Reorganização financeira (31,3 %); Classe 4 – Fé para enfrentar a culpa (37,0 % dos segmentos da classe); Classe 5 – Regulação emocional (63,0 %); Classe 6 – Reconhecimento da importância do apoio comunitário (47,4 % dos segmentos); Classe 7 – Ressignificação da vida laboral (27,0 %) e Classe 8 – Busca pelo suporte familiar (24,7%) . A análise de contrastes mostrou que pessoas com menos limitação tendem a buscar mais estratégias voltadas pra o problema do que para emoção. Conclusiones: Não houve um tipo de estratégia que se sobressaísse das demais e que todas elas possuíam uma denotação positiva no ajustamento após AVC inclusive a longo prazo. Sugere-se que hajam mais estudos sobre enfrentamento possam ser realizados, principalmente aqueles com uma metodologia longi- tudinal, para suprir as limitações deste estudo.

Regulação emocional e sintomas depressivos em pacientes portadores de psoríase

O presente estudo objetivou avaliar a influência de estratégias de regulação emocional, características sociodemográficas e clínicas na sintomatologia depressiva em pacientes psoriáticos. Participaram do estudo 72 pacientes adultos de ambos os sexos, com idades entre 18 e 78 anos, por meio dos critérios de amostragem acidental e por conveniência. Os instrumentos utilizados foram um questionário sociodemográfico e clínico: o Questionário de Regulação Emocional (QRE) e a Hospital Anxiety and Depression Scale (HADS). A regressão logística indicou características clínicas (autorrelato de grau da doença), bem como a estratégia supressão emocional, como covariáveis com significativa relação com a presença de sintomas depressivos em pacientes psoriáticos. Concluiu-se sobre a influência da supressão emocional e percepção de gravidade da própria doença como principais correlatos para a depressão. Por fim, acredita-se na importância de destacar a necessidade de se desenvolverem intervenções psicológicas com tais pacientes. Ademais, é relevante focar no desenvolvimento de estratégias de enfrentamento da doença, para favorecer maior qualidade de vida a esses pacientes.

Otimismo, Autoeficácia e Lócus de Controle na Adesão ao Tratamento de Pessoas Hipertensas

Este estudo analisou a relação do otimismo, da autoeficácia e do lócus de controle na adesão ao tratamento de pessoas hipertensas, bem como os principais preditores da adesão na amostra selecionada, considerando-se as variáveis sociodemográficas e os construtos psicológicos avaliados. A amostra foi composta de 100 hipertensos, e foram utilizados cinco instrumentos: questionário sociodemográfico e clínico, a Escala de Adesão Terapêutica de Morisky, o Teste de Orientação na Vida, a Escala de Autoeficácia Geral Percebida e a Escala de Lócus de Controle da Saúde. Por meio da técnica de regressão logística, verificou-se que praticar atividade física, não consumir álcool, ter maiores pontuação no lócus de controle acaso e na autoeficácia foram preditores de média e alta adesão ao tratamento. Finalmente, os resultados demonstraram a necessidade de mais investigações acerca da relação entre variáveis psicológicas e aderência ao tratamento hipertensivo, especialmente no que se refere ao lócus de controle acaso e sua influência sobre os comportamentos de saúde.

Otimismo: Teoria e Aplicabilidade para a Psicologia

Estudos revelam que otimistas apresentam mais comportamentos de promoção de saúde, maior qualidade de vida e melhores índices de saúde física e mental. Diante disso, este trabalho objetivou apresentar aspectos conceituais, principais medidas usadas para aferir o otimismo e evidências de pesquisa em relação ao otimismo, por meio de um estudo teórico. Inicialmente, delimitou-se o conceito de otimismo, teoria e seus principais tipos. Em seguida, abarcaram-se evidências da relação do otimismo com saúde, coping e bem-estar, caracterizando o seu impacto na saúde das pessoas. Elencaram-se, por fim, intervenções relacionadas à manutenção ou ao aumento dos níveis de otimismo e seus resultados. Em geral, viu-se que o otimismo influencia positivamente o ajustamento psicológico em diferentes contextos. Ao final, foram feitas recomendações de novos estudos, com base nas lacunas detectadas na produção nacional a respeito da temática.

Crenças de adolescentes frente a diferentes contextos de tentativa de suicídio

Esta pesquisa avaliou as crenças de adolescentes frente à tentativa de suicídio em cinco contextos de explicação do ato. Para tanto, analisou-se a importância atribuída aos fatores considerados suicidógenos, investigando-se se um recebe maior destaque que o outro e se os mesmos variam a depender da situação evocadora. Participaram 478 estudantes, entre 15 e 18 anos. Coletaram-se dados sociodemográficos e aplicou-se um conjunto de perguntas relativas à influência dos fatores suicidógenos perante uma tentativa fictícia de suicídio. Executaram-se testes de comparação de médias entre contextos, os fatores suicidógenos e o perfil sociodemográfico. Ao final, viu-se que o Desespero, a Separação dos Pais e o Sentimento de Inadequação foram importantes contextos para uma suposta explicação da tentativa de suicídio. 

Análise prototípicea das representações sociais sobre as infecções sexualmente transmissíveis entre adolescentes

Objetivo: Este estudo teve como objetivo apreender e analisar as representações sociais de adolescentes acerca das doenças sexualmente transmissíveis. Método: Participaram 576 adolescentes, com idade média de 15,67 anos (DP= 1,66). Utilizou-se a técnica de associação livre de palavras, com o estímulo indutor “infecções sexualmente transmissíveis”, que foi utilizada a técnica da análise prototípica, através do programa IRAMUTEQ. Resultados: As representações sociais dos participantes enfatizam os riscos e as formas de prevenção, os conhecimentos básicos sobre as infecções sexualmente transmissíveis, a irresponsabilidade de fazerem sexo desprotegido mesmo sabendo das consequências. Conclusão: Identifica-se a necessidade de implantação de programas de educação em saúde dentro das escolas, utilizando métodos didáticos e reflexivos com profissionais da saúde, que permitam a mudança de atitudes diante da exposição as infecções sexualmente transmissíveis.

Bullying entre adolescentes em Sergipe: Estudo na Capital e Interior do Estado

Resumo Esta pesquisa objetivou conhecer a distribuição social do bullying em uma amostra de adolescentes no Estado de Sergipe. Participaram 555 sujeitos entre 14 e 18 anos. Utilizou-se a Escala Califórnia de Vitimização ao Bullying (ECVB) e um questionário sociodemográfico. Realizou-se regressão logística (método Forward Wald), tendo como variável dependente o bullying e variáveis independentes as relativas ao perfil sociodemográfico. Dentre os participantes, 19,1% (n = 106) foram classificados como vítimas de bullies. O modelo de regressão classificou como preditores do bullying o tipo de escola [OddsRatio (O.R.) = 2,8 para escolas privadas], município (O.R. = 1,8 para a capital) e idade (O.R. = 1,9, para 16 anos; 2,0 para até 17 anos; 1,3 para mais de 17 anos). Ao final foram recomendados novos estudos a respeito da predição de variáveis, visto que tipo de escola e município, por exemplo, ampliaram as chances de vitimização ao bullying.

Burden of disease in Brazil, 1990-2016: a systematic subnational analysis for the Global Burden of Disease Study 2016

BACKGROUND

Political, economic, and epidemiological changes in Brazil have affected health and the health system. We used the Global Burden of Disease Study 2016 (GBD 2016) results to understand changing health patterns and inform policy responses.

METHODS

We analysed GBD 2016 estimates for life expectancy at birth (LE), healthy life expectancy (HALE), all-cause and cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and risk factors for Brazil, its 26 states, and the Federal District from 1990 to 2016, and compared these with national estimates for ten comparator countries.

FINDINGS

Nationally, LE increased from 68·4 years (95% uncertainty interval [UI] 68·0-68·9) in 1990 to 75·2 years (74·7-75·7) in 2016, and HALE increased from 59·8 years (57·1-62·1) to 65·5 years (62·5-68·0). All-cause age-standardised mortality rates decreased by 34·0% (33·4-34·5), while all-cause age-standardised DALY rates decreased by 30·2% (27·7-32·8); the magnitude of declines varied among states. In 2016, ischaemic heart disease was the leading cause of age-standardised YLLs, followed by interpersonal violence. Low back and neck pain, sense organ diseases, and skin diseases were the main causes of YLDs in 1990 and 2016. Leading risk factors contributing to DALYs in 2016 were alcohol and drug use, high blood pressure, and high body-mass index.

INTERPRETATION

Health improved from 1990 to 2016, but improvements and disease burden varied between states. An epidemiological transition towards non-communicable diseases and related risks occurred nationally, but later in some states, while interpersonal violence grew as a health concern. Policy makers can use these results to address health disparities.

FUNDING

Bill & Melinda Gates Foundation and the Brazilian Ministry of Health.

Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016

BACKGROUND

A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016.

METHODS

Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita.

FINDINGS

In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries.

INTERPRETATION

GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations.

FUNDING

Bill & Melinda Gates Foundation.

Trends in future health financing and coverage: future health spending and universal health coverage in 188 countries, 2016-40

BACKGROUND

Achieving universal health coverage (UHC) requires health financing systems that provide prepaid pooled resources for key health services without placing undue financial stress on households. Understanding current and future trajectories of health financing is vital for progress towards UHC. We used historical health financing data for 188 countries from 1995 to 2015 to estimate future scenarios of health spending and pooled health spending through to 2040.

METHODS

We extracted historical data on gross domestic product (GDP) and health spending for 188 countries from 1995 to 2015, and projected annual GDP, development assistance for health, and government, out-of-pocket, and prepaid private health spending from 2015 through to 2040 as a reference scenario. These estimates were generated using an ensemble of models that varied key demographic and socioeconomic determinants. We generated better and worse alternative future scenarios based on the global distribution of historic health spending growth rates. Last, we used stochastic frontier analysis to investigate the association between pooled health resources and UHC index, a measure of a country's UHC service coverage. Finally, we estimated future UHC performance and the number of people covered under the three future scenarios.

FINDINGS

In the reference scenario, global health spending was projected to increase from US$10 trillion (95% uncertainty interval 10 trillion to 10 trillion) in 2015 to $20 trillion (18 trillion to 22 trillion) in 2040. Per capita health spending was projected to increase fastest in upper-middle-income countries, at 4·2% (3·4-5·1) per year, followed by lower-middle-income countries (4·0%, 3·6-4·5) and low-income countries (2·2%, 1·7-2·8). Despite global growth, per capita health spending was projected to range from only $40 (24-65) to $413 (263-668) in 2040 in low-income countries, and from $140 (90-200) to $1699 (711-3423) in lower-middle-income countries. Globally, the share of health spending covered by pooled resources would range widely, from 19·8% (10·3-38·6) in Nigeria to 97·9% (96·4-98·5) in Seychelles. Historical performance on the UHC index was significantly associated with pooled resources per capita. Across the alternative scenarios, we estimate UHC reaching between 5·1 billion (4·9 billion to 5·3 billion) and 5·6 billion (5·3 billion to 5·8 billion) lives in 2030.

INTERPRETATION

We chart future scenarios for health spending and its relationship with UHC. Ensuring that all countries have sustainable pooled health resources is crucial to the achievement of UHC.

FUNDING

The Bill & Melinda Gates Foundation.

Aspectos conceituais da autoinjúria: Uma revisão teórica

A conduta autolesiva se refere ao comportamento direto e deliberado de autolesão que resulta em prejuízo físico e psicológico para o indivíduo. Dealta prevalência e considerado problema de saúde pública, esse comportamento tem sido associado a vários fatores biopsicossociais, principalmentena adolescência, fase em qual tende a emergir e é mais prevalente. A conduta autolesiva é geralmente associada a comportamentos e pensamentossuicidas e, de modo geral, a literatura ainda é heterogênea sobre o fenômeno, assim como formas de mensurá-lo. O presente artigo objetivou reunir osprincipais conceitos e achados teóricos sobre a conduta autolesiva, classificando e descrevendo o comportamento autolesivo em relação aos períodosdesenvolvimentais, principais fatores associados, formas de avaliação, tratamento/intervenção e prevenção.

Motivações, dificuldades e expectativas acerca da adoção: Perspectivas de futuros pais adotivos

O presente estudo objetivou delinear motivos, dificuldades e expectativas em torno do futuro filho na perspectiva de pais candidatos ao processo de adoção, como também, caracterizar o perfil da criança pretendida em uma Vara da Infância e Juventude de Aracaju (SE). Entrevistaram-se 13 candidatos a pais adotivos (monoparentais e casais), a partir dos seguintes eixos temáticos: motivações para a adoção; preferências quanto à criança; expectativas concernentes à adoção; e medos e receios em torno da adoção. As falas foram analisadas com o software IRAMUTEQ. Os resultados reiteraram a complexidade subjetiva do processo de adoção, em especial pelo embate entre fantasia e realidade no que toca à futura adaptação à nova família. Ademais, houve preferência por meninas, brancas ou pardas e menores que cinco anos. Conclui-se que compreender a forma pela qual os adotantes significam a adoção pode auxiliar no delineamento de ações mais apropriadas de orientação e aconselhamento na temática.

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.

Associações entre estresse parental e práticas socioeducativas parentais em pais/mães de filhos com e sem diabetes mellitus tipo 1

Nesta pesquisa de delineamento correlacional e comparativo, examinaram-se os níveis de estresse parental e as práticas socioeducativas parentais em 135 pais/mães de filhos sem doença crônica (grupo controle) e com diabetes mellitus tipo 1 (DM1; grupo clínico). Para tanto, os grupos foram estratificados quanto ao nível de estresse parental relatado (baixo ou alto estresse) e foram constatadas diferenças significativas entre eles, exceto entre os grupos controle e clínico com baixo estresse. A regressão logística multinomial também revelou diferenças significativas entre os grupos quanto ao uso de práticas socioeducativas de afeto, educação e disciplina, onde os pais/mães do grupo controle baixo estresse parental apresentaram maiores chances de uso de tais práticas. Ao final, acredita-se que os resultados encontrados podem auxiliar intervenções com pais/mães que busquem minimizar o estresse parental e potencializar o uso de práticas parentais positivas, e promover um melhor controle glicêmico do(a) filho(a) portador(a) de DM1.