The burden of neurological conditions in north Africa and the Middle East, 1990-2019: a systematic analysis of the Global Burden of Disease Study 2019

BACKGROUND

The burden of neurological conditions in north Africa and the Middle East is increasing. We aimed to assess the changes in the burden of neurological conditions in this super-region to aid with future decision making.

METHODS

In this analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 data, we examined temporal trends of disability-adjusted life-years (DALYs; deaths and disabilities combined), deaths, incident cases, and prevalent cases of 14 major neurological conditions and eight subtypes in 21 countries in the north Africa and the Middle East super-region. Additionally, we assessed neurological DALYs due to 22 potentially modifiable risk factors, within four levels of classification, during the period 1990-2019. We used a Bayesian modelling estimation approach, and generated 95% uncertainty intervals (UIs) for final estimates on the basis of the 2·5th and 97·5th percentiles of 1000 draws from the posterior distribution.

FINDINGS

In 2019, there were 441·1 thousand (95% UI 347·2-598·4) deaths and 17·6 million (12·5-24·7) neurological DALYs in north Africa and the Middle East. The leading causes of neurological DALYs were stroke, migraine, and Alzheimer's disease and other dementias (hereafter dementias). In north Africa and the Middle East in 2019, 85·8% (82·6-89·1) of stroke and 39·9% (26·4-54·7) of dementia age-standardised DALYs were attributable to modifiable risk factors. North Africa and the Middle East had the highest age-standardised DALY rates per 100 000 population due to dementia (387·0 [172·0-848·5]), Parkinson's disease (84·4 [74·7-103·2]), and migraine (601·4 [107·0-1371·8]) among the global super-regions. Between 1990 and 2019, there was a decrease in the age-standardised DALY rates related to meningitis (-75·8% [-81·1 to -69·5]), tetanus (-88·2% [-93·9 to -76·1]), stroke (-32·0% [-39·1 to -23·3]), intracerebral haemorrhage (-51·7% [-58·2 to -43·8]), idiopathic epilepsy (-26·2% [-43·6 to -1·1]), and subarachnoid haemorrhage (-62·8% [-71·6 to -41·0]), but for all other neurological conditions there was no change. During 1990-2019, the number of DALYs due to dementias, Parkinson's disease, multiple sclerosis, ischaemic stroke, and headache disorder (ie, migraine and tension-type headache) more than doubled in the super-region, and the burden of years lived with disability (YLDs), incidence, and prevalence of multiple sclerosis, motor neuron disease, Parkinson's disease, and ischaemic stroke increased both in age-standardised rate and count. During this period, the absolute burden of YLDs due to head and spinal injuries almost doubled.

INTERPRETATION

The increasing burden of neurological conditions in north Africa and the Middle East accompanies the increasing ageing population. Stroke and dementia are the primary causes of neurological disability and death, primarily attributable to common modifiable risk factors. Synergistic, systematic, lifetime, and multi-sectoral interventions aimed at preventing or mitigating the burden are needed.

FUNDING

Bill & Melinda Gates Foundation.

TRANSLATIONS

For the Persian, Arabic and Turkish translations of the abstract see Supplementary Materials section.

Temporal patterns of cancer burden in Asia, 1990-2019: a systematic examination for the Global Burden of Disease 2019 study

Background

Cancers represent a challenging public health threat in Asia. This study examines the temporal patterns of incidence, mortality, disability and risk factors of 29 cancers in Asia in the last three decades.

Methods

The age, sex and year-wise estimates of incidence, mortality, and disability-adjusted life years (DALYs) of 29 cancers for 49 Asian countries from 1990 through 2019 were generated as a part of the Global Burden of Disease, Injuries and Risk Factors 2019 study. Besides incidence, mortality and DALYs, we also examined the cancer burden measured in terms of DALYs and deaths attributable to risk factors, which had evidence of causation with different cancers. The development status of countries was measured using the socio-demographic index. Decomposition analysis was performed to gauge the change in cancer incidence between 1990 and 2019 due to population growth, aging and age-specific incidence rates.

Findings

All cancers combined claimed an estimated 5.6 million [95% uncertainty interval, 5.1-6.0 million] lives in Asia with 9.4 million [8.6-10.2 million] incident cases and 144.7 million [132.7-156.5 million] DALYs in 2019. The age-standardized incidence rate (ASIR) of all cancers combined in Asia was 197.6/100,000 [181.0-214.4] in 2019, varying from 99.2/100,000 [76.1-126.0] in Bangladesh to 330.5/100,000 [298.5-365.8] in Cyprus. The age-standardized mortality rate (ASMR) was 120.6/100,000 [110.1-130.7] in 2019, varying 4-folds across countries from 71.0/100,000 [59.9-83.5] in Kuwait to 284.2/100,000 [229.2-352.3] in Mongolia. The age-standardized DALYs rate was 2970.5/100,000 [2722.6-3206.5] in 2019, varying from 1578.0/100,000 [1341.2-1847.0] in Kuwait to 6574.4/100,000 [5141.7-8333.0] in Mongolia. Between 1990 and 2019, deaths due to 17 of the 29 cancers either doubled or more, and 20 of the 29 cancers underwent an increase of 150% or more in terms of new cases. Tracheal, bronchus, and lung cancer (both sexes), breast cancer (among females), colon and rectum cancer (both sexes), stomach cancer (both sexes) and prostate cancer (among males) were among top-5 cancers in most Asian countries in terms of ASIR and ASMR in 2019 and cancers of liver, stomach, hodgkin lymphoma and esophageal cancer posted the most significant decreases in age-standardized rates between 1990 and 2019. Among the modifiable risk factors, smoking, alcohol use, ambient particulate matter (PM) pollution and unsafe sex remained the dominant risk factors between 1990 and 2019. Cancer DALYs due to ambient PM pollution, high body mass index and fasting plasma glucose has increased most notably between 1990 and 2019.

Interpretation

With growing incidence, cancer has become more significant public health threat in Asia, demanding urgent policy attention and guidance. Its heightened risk calls for increased cancer awareness, preventive measures, affordable early-stage detection, and cost-effective therapeutics in Asia. The current study can serve as a useful resource for policymakers and researchers in Asia for devising interventions for cancer management and control.

Funding

The GBD study is funded by the Bill and Melinda Gates Foundation.

Global, regional, and national mortality due to unintentional carbon monoxide poisoning, 2000-2021: results from the Global Burden of Disease Study 2021

BACKGROUND

Unintentional carbon monoxide poisoning is a largely preventable cause of death that has received insufficient attention. We aimed to conduct a comprehensive global analysis of the demographic, temporal, and geographical patterns of fatal unintentional carbon monoxide poisoning from 2000 to 2021.

METHODS

As part of the latest Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), unintentional carbon monoxide poisoning mortality was quantified using the GBD cause of death ensemble modelling strategy. Vital registration data and covariates with an epidemiological link to unintentional carbon monoxide poisoning informed the estimates of death counts and mortality rates for all locations, sexes, ages, and years included in the GBD. Years of life lost (YLLs) were estimated by multiplying deaths by remaining standard life expectancy at age of death. Population attributable fractions (PAFs) for unintentional carbon monoxide poisoning deaths due to occupational injuries and high alcohol use were estimated.

FINDINGS

In 2021, the global mortality rate due to unintentional carbon monoxide poisoning was 0·366 per 100 000 (95% uncertainty interval 0·276-0·415), with 28 900 deaths (21 700-32 800) and 1·18 million YLLs (0·886-1·35) across all ages. Nearly 70% of deaths occurred in males (20 100 [15 800-24 000]), and the 50-54-year age group had the largest number of deaths (2210 [1660-2590]). The highest mortality rate was in those aged 85 years or older with 1·96 deaths (1·38-2·32) per 100 000. Eastern Europe had the highest age-standardised mortality rate at 2·12 deaths (1·98-2·30) per 100 000. Globally, there was a 53·5% (46·2-63·7) decrease in the age-standardised mortality rate from 2000 to 2021, although this decline was not uniform across regions. The overall PAFs for occupational injuries and high alcohol use were 13·6% (11·9-16·0) and 3·5% (1·4-6·2), respectively.

INTERPRETATION

Improvements in unintentional carbon monoxide poisoning mortality rates have been inconsistent across regions and over time since 2000. Given that unintentional carbon monoxide poisoning is almost entirely preventable, policy-level interventions that lower the risk of carbon monoxide poisoning events should be prioritised, such as those that increase access to improved heating and cooking devices, reduce carbon monoxide emissions from generators, and mandate use of carbon monoxide alarms.

FUNDING

Bill & Melinda Gates Foundation.

The Global, Regional, and National Burden of Adult Lip, Oral, and Pharyngeal Cancer in 204 Countries and Territories: A Systematic Analysis for the Global Burden of Disease Study 2019

Importance

Lip, oral, and pharyngeal cancers are important contributors to cancer burden worldwide, and a comprehensive evaluation of their burden globally, regionally, and nationally is crucial for effective policy planning.

Objective

To analyze the total and risk-attributable burden of lip and oral cavity cancer (LOC) and other pharyngeal cancer (OPC) for 204 countries and territories and by Socio-demographic Index (SDI) using 2019 Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study estimates.

Evidence Review

The incidence, mortality, and disability-adjusted life years (DALYs) due to LOC and OPC from 1990 to 2019 were estimated using GBD 2019 methods. The GBD 2019 comparative risk assessment framework was used to estimate the proportion of deaths and DALYs for LOC and OPC attributable to smoking, tobacco, and alcohol consumption in 2019.

Findings

In 2019, 370 000 (95% uncertainty interval [UI], 338 000-401 000) cases and 199 000 (95% UI, 181 000-217 000) deaths for LOC and 167 000 (95% UI, 153 000-180 000) cases and 114 000 (95% UI, 103 000-126 000) deaths for OPC were estimated to occur globally, contributing 5.5 million (95% UI, 5.0-6.0 million) and 3.2 million (95% UI, 2.9-3.6 million) DALYs, respectively. From 1990 to 2019, low-middle and low SDI regions consistently showed the highest age-standardized mortality rates due to LOC and OPC, while the high SDI strata exhibited age-standardized incidence rates decreasing for LOC and increasing for OPC. Globally in 2019, smoking had the greatest contribution to risk-attributable OPC deaths for both sexes (55.8% [95% UI, 49.2%-62.0%] of all OPC deaths in male individuals and 17.4% [95% UI, 13.8%-21.2%] of all OPC deaths in female individuals). Smoking and alcohol both contributed to substantial LOC deaths globally among male individuals (42.3% [95% UI, 35.2%-48.6%] and 40.2% [95% UI, 33.3%-46.8%] of all risk-attributable cancer deaths, respectively), while chewing tobacco contributed to the greatest attributable LOC deaths among female individuals (27.6% [95% UI, 21.5%-33.8%]), driven by high risk-attributable burden in South and Southeast Asia.

Conclusions and Relevance

In this systematic analysis, disparities in LOC and OPC burden existed across the SDI spectrum, and a considerable percentage of burden was attributable to tobacco and alcohol use. These estimates can contribute to an understanding of the distribution and disparities in LOC and OPC burden globally and support cancer control planning efforts.

Global, regional, and national burden of rheumatoid arthritis, 1990-2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021

Background

Rheumatoid arthritis is a chronic autoimmune inflammatory disease associated with disability and premature death. Up-to-date estimates of the burden of rheumatoid arthritis are required for health-care planning, resource allocation, and prevention. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, we provide updated estimates of the prevalence of rheumatoid arthritis and its associated deaths and disability-adjusted life-years (DALYs) by age, sex, year, and location, with forecasted prevalence to 2050.

Methods

Rheumatoid arthritis prevalence was estimated in 204 countries and territories from 1990 to 2020 using Bayesian meta-regression models and data from population-based studies and medical claims data (98 prevalence and 25 incidence studies). Mortality was estimated from vital registration data with the Cause of Death Ensemble model (CODEm). Years of life lost (YLL) were calculated with use of standard GBD lifetables, and years lived with disability (YLDs) were estimated from prevalence, a meta-analysed distribution of rheumatoid arthritis severity, and disability weights. DALYs were calculated by summing YLLs and YLDs. Smoking was the only risk factor analysed. Rheumatoid arthritis prevalence was forecast to 2050 by logistic regression with Socio-Demographic Index as a predictor, then multiplying by projected population estimates.

Findings

In 2020, an estimated 17·6 million (95% uncertainty interval 15·8-20·3) people had rheumatoid arthritis worldwide. The age-standardised global prevalence rate was 208·8 cases (186·8-241·1) per 100 000 population, representing a 14·1% (12·7-15·4) increase since 1990. Prevalence was higher in females (age-standardised female-to-male prevalence ratio 2·45 [2·40-2·47]). The age-standardised death rate was 0·47 (0·41-0·54) per 100 000 population (38 300 global deaths [33 500-44 000]), a 23·8% (17·5-29·3) decrease from 1990 to 2020. The 2020 DALY count was 3 060 000 (2 320 000-3 860 000), with an age-standardised DALY rate of 36·4 (27·6-45·9) per 100 000 population. YLDs accounted for 76·4% (68·3-81·0) of DALYs. Smoking risk attribution for rheumatoid arthritis DALYs was 7·1% (3·6-10·3). We forecast that 31·7 million (25·8-39·0) individuals will be living with rheumatoid arthritis worldwide by 2050.

Interpretation

Rheumatoid arthritis mortality has decreased globally over the past three decades. Global age-standardised prevalence rate and YLDs have increased over the same period, and the number of cases is projected to continue to increase to the year 2050. Improved access to early diagnosis and treatment of rheumatoid arthritis globally is required to reduce the future burden of the disease.

Funding

Bill & Melinda Gates Foundation, Institute of Bone and Joint Research, and Global Alliance for Musculoskeletal Health.

Global, regional, and national burden of meningitis and its aetiologies, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Although meningitis is largely preventable, it still causes hundreds of thousands of deaths globally each year. WHO set ambitious goals to reduce meningitis cases by 2030, and assessing trends in the global meningitis burden can help track progress and identify gaps in achieving these goals. Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we aimed to assess incident cases and deaths due to acute infectious meningitis by aetiology and age from 1990 to 2019, for 204 countries and territories.

METHODS

We modelled meningitis mortality using vital registration, verbal autopsy, sample-based vital registration, and mortality surveillance data. Meningitis morbidity was modelled with a Bayesian compartmental model, using data from the published literature identified by a systematic review, as well as surveillance data, inpatient hospital admissions, health insurance claims, and cause-specific meningitis mortality estimates. For aetiology estimation, data from multiple causes of death, vital registration, hospital discharge, microbial laboratory, and literature studies were analysed by use of a network analysis model to estimate the proportion of meningitis deaths and cases attributable to the following aetiologies: Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, group B Streptococcus, Escherichia coli, Klebsiella pneumoniae, Listeria monocytogenes, Staphylococcus aureus, viruses, and a residual other pathogen category.

FINDINGS

In 2019, there were an estimated 236 000 deaths (95% uncertainty interval [UI] 204 000-277 000) and 2·51 million (2·11-2·99) incident cases due to meningitis globally. The burden was greatest in children younger than 5 years, with 112 000 deaths (87 400-145 000) and 1·28 million incident cases (0·947-1·71) in 2019. Age-standardised mortality rates decreased from 7·5 (6·6-8·4) per 100 000 population in 1990 to 3·3 (2·8-3·9) per 100 000 population in 2019. The highest proportion of total all-age meningitis deaths in 2019 was attributable to S pneumoniae (18·1% [17·1-19·2]), followed by N meningitidis (13·6% [12·7-14·4]) and K pneumoniae (12·2% [10·2-14·3]). Between 1990 and 2019, H influenzae showed the largest reduction in the number of deaths among children younger than 5 years (76·5% [69·5-81·8]), followed by N meningitidis (72·3% [64·4-78·5]) and viruses (58·2% [47·1-67·3]).

INTERPRETATION

Substantial progress has been made in reducing meningitis mortality over the past three decades. However, more meningitis-related deaths might be prevented by quickly scaling up immunisation and expanding access to health services. Further reduction in the global meningitis burden should be possible through low-cost multivalent vaccines, increased access to accurate and rapid diagnostic assays, enhanced surveillance, and early treatment.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Diabetes is one of the leading causes of death and disability worldwide, and affects people regardless of country, age group, or sex. Using the most recent evidentiary and analytical framework from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), we produced location-specific, age-specific, and sex-specific estimates of diabetes prevalence and burden from 1990 to 2021, the proportion of type 1 and type 2 diabetes in 2021, the proportion of the type 2 diabetes burden attributable to selected risk factors, and projections of diabetes prevalence through 2050.

METHODS

Estimates of diabetes prevalence and burden were computed in 204 countries and territories, across 25 age groups, for males and females separately and combined; these estimates comprised lost years of healthy life, measured in disability-adjusted life-years (DALYs; defined as the sum of years of life lost [YLLs] and years lived with disability [YLDs]). We used the Cause of Death Ensemble model (CODEm) approach to estimate deaths due to diabetes, incorporating 25 666 location-years of data from vital registration and verbal autopsy reports in separate total (including both type 1 and type 2 diabetes) and type-specific models. Other forms of diabetes, including gestational and monogenic diabetes, were not explicitly modelled. Total and type 1 diabetes prevalence was estimated by use of a Bayesian meta-regression modelling tool, DisMod-MR 2.1, to analyse 1527 location-years of data from the scientific literature, survey microdata, and insurance claims; type 2 diabetes estimates were computed by subtracting type 1 diabetes from total estimates. Mortality and prevalence estimates, along with standard life expectancy and disability weights, were used to calculate YLLs, YLDs, and DALYs. When appropriate, we extrapolated estimates to a hypothetical population with a standardised age structure to allow comparison in populations with different age structures. We used the comparative risk assessment framework to estimate the risk-attributable type 2 diabetes burden for 16 risk factors falling under risk categories including environmental and occupational factors, tobacco use, high alcohol use, high body-mass index (BMI), dietary factors, and low physical activity. Using a regression framework, we forecast type 1 and type 2 diabetes prevalence through 2050 with Socio-demographic Index (SDI) and high BMI as predictors, respectively.

FINDINGS

In 2021, there were 529 million (95% uncertainty interval [UI] 500-564) people living with diabetes worldwide, and the global age-standardised total diabetes prevalence was 6·1% (5·8-6·5). At the super-region level, the highest age-standardised rates were observed in north Africa and the Middle East (9·3% [8·7-9·9]) and, at the regional level, in Oceania (12·3% [11·5-13·0]). Nationally, Qatar had the world's highest age-specific prevalence of diabetes, at 76·1% (73·1-79·5) in individuals aged 75-79 years. Total diabetes prevalence-especially among older adults-primarily reflects type 2 diabetes, which in 2021 accounted for 96·0% (95·1-96·8) of diabetes cases and 95·4% (94·9-95·9) of diabetes DALYs worldwide. In 2021, 52·2% (25·5-71·8) of global type 2 diabetes DALYs were attributable to high BMI. The contribution of high BMI to type 2 diabetes DALYs rose by 24·3% (18·5-30·4) worldwide between 1990 and 2021. By 2050, more than 1·31 billion (1·22-1·39) people are projected to have diabetes, with expected age-standardised total diabetes prevalence rates greater than 10% in two super-regions: 16·8% (16·1-17·6) in north Africa and the Middle East and 11·3% (10·8-11·9) in Latin America and Caribbean. By 2050, 89 (43·6%) of 204 countries and territories will have an age-standardised rate greater than 10%.

INTERPRETATION

Diabetes remains a substantial public health issue. Type 2 diabetes, which makes up the bulk of diabetes cases, is largely preventable and, in some cases, potentially reversible if identified and managed early in the disease course. However, all evidence indicates that diabetes prevalence is increasing worldwide, primarily due to a rise in obesity caused by multiple factors. Preventing and controlling type 2 diabetes remains an ongoing challenge. It is essential to better understand disparities in risk factor profiles and diabetes burden across populations, to inform strategies to successfully control diabetes risk factors within the context of multiple and complex drivers.

FUNDING

Bill & Melinda Gates Foundation.

Elucidating experiences of faculty members in applying effective teaching strategies in the online class during the COVID-19: A qualitative study

BACKGROUND

Despite the restrictions on providing medical courses online in medical universities, all instructors were required to provide training on virtual platforms. This study aimed to explain faculty members' experiences applying effective strategies in online class teaching.

MATERIALS AND METHODS

This study has been done with a qualitative approach and using the method of conventional content analysis. Participants included 14 faculty members working at the Shiraz University of Medical Sciences. Semistructured interviews were used to collect data. Faculty members who had experience in conducting online classes were purposefully selected. Graneheim and Lundman's (2004) approach was used to analyze interview data.

RESULTS

Two main categories were obtained from the data analysis: interpersonal communication and supportive behavior. The category of interpersonal communications comprises the subcategories of emotional expression and flexibility. The category of supportive behavior includes the subcategories of educational design, learner encouragement, diversity in evaluation, collaborative learning, and prompt feedback.

CONCLUSION

Our findings confirmed that an appropriate teaching strategy leads to better attention to class and deep learning in learners. The cause is that in online classes, the student's attention is more minor than in daily classes due to its virtual nature. Appropriate educational strategies will motivate learners, interest them, and improve teacher interaction. These strategies increase students' participation in educational activities.

Age-sex differences in the global burden of lower respiratory infections and risk factors, 1990-2019: results from the Global Burden of Disease Study 2019

BACKGROUND

The global burden of lower respiratory infections (LRIs) and corresponding risk factors in children older than 5 years and adults has not been studied as comprehensively as it has been in children younger than 5 years. We assessed the burden and trends of LRIs and risk factors across all age groups by sex, for 204 countries and territories.

METHODS

In this analysis of data for the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we used clinician-diagnosed pneumonia or bronchiolitis as our case definition for LRIs. We included International Classification of Diseases 9th edition codes 079.6, 466-469, 470.0, 480-482.8, 483.0-483.9, 484.1-484.2, 484.6-484.7, and 487-489 and International Classification of Diseases 10th edition codes A48.1, A70, B97.4-B97.6, J09-J15.8, J16-J16.9, J20-J21.9, J91.0, P23.0-P23.4, and U04-U04.9. We used the Cause of Death Ensemble modelling strategy to analyse 23 109 site-years of vital registration data, 825 site-years of sample vital registration data, 1766 site-years of verbal autopsy data, and 681 site-years of mortality surveillance data. We used DisMod-MR 2.1, a Bayesian meta-regression tool, to analyse age-sex-specific incidence and prevalence data identified via systematic reviews of the literature, population-based survey data, and claims and inpatient data. Additionally, we estimated age-sex-specific LRI mortality that is attributable to the independent effects of 14 risk factors.

FINDINGS

Globally, in 2019, we estimated that there were 257 million (95% uncertainty interval [UI] 240-275) LRI incident episodes in males and 232 million (217-248) in females. In the same year, LRIs accounted for 1·30 million (95% UI 1·18-1·42) male deaths and 1·20 million (1·07-1·33) female deaths. Age-standardised incidence and mortality rates were 1·17 times (95% UI 1·16-1·18) and 1·31 times (95% UI 1·23-1·41) greater in males than in females in 2019. Between 1990 and 2019, LRI incidence and mortality rates declined at different rates across age groups and an increase in LRI episodes and deaths was estimated among all adult age groups, with males aged 70 years and older having the highest increase in LRI episodes (126·0% [95% UI 121·4-131·1]) and deaths (100·0% [83·4-115·9]). During the same period, LRI episodes and deaths in children younger than 15 years were estimated to have decreased, and the greatest decline was observed for LRI deaths in males younger than 5 years (-70·7% [-77·2 to -61·8]). The leading risk factors for LRI mortality varied across age groups and sex. More than half of global LRI deaths in children younger than 5 years were attributable to child wasting (population attributable fraction [PAF] 53·0% [95% UI 37·7-61·8] in males and 56·4% [40·7-65·1] in females), and more than a quarter of LRI deaths among those aged 5-14 years were attributable to household air pollution (PAF 26·0% [95% UI 16·6-35·5] for males and PAF 25·8% [16·3-35·4] for females). PAFs of male LRI deaths attributed to smoking were 20·4% (95% UI 15·4-25·2) in those aged 15-49 years, 30·5% (24·1-36·9) in those aged 50-69 years, and 21·9% (16·8-27·3) in those aged 70 years and older. PAFs of female LRI deaths attributed to household air pollution were 21·1% (95% UI 14·5-27·9) in those aged 15-49 years and 18·2% (12·5-24·5) in those aged 50-69 years. For females aged 70 years and older, the leading risk factor, ambient particulate matter, was responsible for 11·7% (95% UI 8·2-15·8) of LRI deaths.

INTERPRETATION

The patterns and progress in reducing the burden of LRIs and key risk factors for mortality varied across age groups and sexes. The progress seen in children younger than 5 years was clearly a result of targeted interventions, such as vaccination and reduction of exposure to risk factors. Similar interventions for other age groups could contribute to the achievement of multiple Sustainable Development Goals targets, including promoting wellbeing at all ages and reducing health inequalities. Interventions, including addressing risk factors such as child wasting, smoking, ambient particulate matter pollution, and household air pollution, would prevent deaths and reduce health disparities.

FUNDING

Bill & Melinda Gates Foundation.

Perceived Challenges Caused by Covid-19 Outbreak in Students of Medical Sciences

BACKGROUND

Students of medical sciences are a highly vulnerable group during COVID-19 pandemic who may experience a wide range of challenges and stresses. The aim of this study was to investigate the perceived challenges caused by COVID-19 outbreak in students of medical sciences.

MATERIALS AND METHODS

A qualitative study was carried out based on conventional qualitative content analysis following Graneheim and Lundman from December 2020 to February 2021. The participants were 17 students of medical sciences and data gathering was done through semistructured interviews.

RESULTS

Data analyses revealed 5 categories and 12 subcategories. The extracted categories were perceived fear of contracting coronavirus, social limitation, changes in education, neglecting health protocols, and worrying news and information overload.

CONCLUSIONS

The findings indicated that students of medical sciences had been facing challenges and the COVID-19 had affected the psychological, social, and academic functioning of the health-care students. It is important to take measures to improve their mental health. These measures can prevent medical complications in these students, especially during clinical internship.

The global burden of cancer attributable to risk factors, 2010-19: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally.

METHODS

The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented.

FINDINGS

Globally, in 2019, the risk factors included in this analysis accounted for 4·45 million (95% uncertainty interval 4·01-4·94) deaths and 105 million (95·0-116) DALYs for both sexes combined, representing 44·4% (41·3-48·4) of all cancer deaths and 42·0% (39·1-45·6) of all DALYs. There were 2·88 million (2·60-3·18) risk-attributable cancer deaths in males (50·6% [47·8-54·1] of all male cancer deaths) and 1·58 million (1·36-1·84) risk-attributable cancer deaths in females (36·3% [32·5-41·3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20·4% (12·6-28·4) and DALYs by 16·8% (8·8-25·0), with the greatest percentage increase in metabolic risks (34·7% [27·9-42·8] and 33·3% [25·8-42·0]).

INTERPRETATION

The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden.

FUNDING

Bill & Melinda Gates Foundation.

The Relationship Between the Use of Medicinal Plants and Medication Adherence in the Elderly with Chronic Diseases

Objectives Many older patients use medicinal plants, assuming that they are safe and without side effects. The present study aims to investigate the relationship between the use of medicinal plants and medication adherence in the elderly patients with chronic diseases. Methods & Materials In this descriptive cross-sectional study, 358 patients aged ≥60 years with chronic diseases were selected by a convenience sampling method. Data collection instrument was a three-part questionnaire assessing demographic information, history of using medicinal plants, and medication adherence using the Morisky medication adherence scale (MMAS). The data were entered into SPSS v.21 and analyzed using one-way analysis of variance, Chi-square test, independent t-test and logistic regression. Results The mean age of participants was 69.44±8.13 years and 52.23% were female. The majority of them were married (87.68%) with a junior high school education (71.64%).The overall mean score of MMAS was 5.48 (poor adherence). The percentage of patients with a history of taking medicinal plants in the last year with the prescription of physician was 41.34% (n=148) while the percentage of those used medicinal plants without the physician’ prescription was 27.3% (n=98). The mean of MMAS score in the groups who used medicinal plants was lower than in the group with no history of using medicinal plants (P=0.001). The number of used medicinal plants, the frequency of using medicinal plants, and the duration of chronic disease had a statistically significant relationship with the medication adherence (P <0.05). Conclusion Due to the high consumption of medicinal plants in the elderly with chronic diseases and its relationship with poor medication adherence, it is necessary to educate them about the correct use of medicinal plants, their side effects, herb-drug interactions, the need to inform the doctor about use of medicinal plants, and adherence to medication.

The predictive role of tendency toward mobile learning and emotional intelligence in Internet addiction in healthcare professional students

INTRODUCTION

Internet addiction is a psychological disorder that can lead to serious damages to university students as a group at risk. This study aimed to determine the predictive role of tendency toward mobile learning (purposeful use of mobile technologies for educational purposes) and emotional intelligence in Internet addiction in healthcare professional students.

METHODS

A cross-sectional descriptive study was carried out on 403 healthcare professional students at Saveh University of Medical Sciences-Iran in 2021 using convenience sampling method. For data gathering, three questionnaires were used: willingness to use mobile learning, Young's Internet Addiction Test, and the Emotional Intelligence Appraisal. Data analyses were done using Pearson Correlation Coefficient and Hierarchical Regression in SPSS 16 (Inc SPSS USA, IL, Chicago).

RESULTS

The mean age of the participants was 21.09±1.47 years; 125 subjects (31.01%) were boys and 278 (68.99%) girls. As the findings showed, 16.87% of the students had Internet addiction and 33% were on the edge of developing Internet addiction. Internet addiction was significantly negatively correlated with willingness to m-learning (r=-0.45, P=0.001) and emotional intelligence (r=-0.32, P=0.01). In addition, regression analysis results showed that the variables willingness to use learning and emotional intelligence explained 23% of the Internet addiction variance (P<0.001).

CONCLUSION

In the present study, a considerable number of the healthcare professional students had excessive and unnecessary use of the Internet. Emotional intelligence and willingness to use mobile learning had an inverse relationship with Internet addiction. There is a need to screen Internet-addicted students using proper screening tools and take primary preventive measures in this regard. In addition, proper measures are needed to be taken to improve emotional intelligence and mobile learning skills and control Internet addiction to some extent.

Development and psychometric properties of COVID-19 related Healthcare Student stress scale (CHSSS)

Background

There is no valid and reliable tool to measure COVID-19 healthcare stress felt by healthcare students. A scale was developed to assess COVID-19 stress in healthcare students and its psychometrics was examined.

Methods

This is a two phases mixed-method study including a qualitative stage consisting of student interview and literature review to develop content of the tool. In the quantitative stage, the psychometrics of the scale was examined in 2020–2021.

Results

The COVID-19 related healthcare student stress scale (CHSSS) featured five factors including fear of catching coronavirus, social constraints, changes in education, non-compliance of health protocols and worrying news and overload information, which totally explained 51.75% of the total variance.

Conclusion

Validity and reliability of CHSSS with 17 items were supported to measure COVID-19 stress in healthcare students as a self-assessment tool. Researchers can utilize this tool to assess COVID-19 stress in healthcare students and introduce policies and intervention especially designed for healthcare students.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00778-9.

The relationship between mental distress and perception of COVID-19 stress in healthcare students

Introduction/Aim: Healthcare students are among the groups affected by the COVID-19 pandemic in various ways. This study aimed to investigate the relationship between mental distress and perceptions of COVID-19 stress in healthcare students. Methods: The present analytical cross-sectional study included all students of Saveh University of Medical Sciences in 2021 as the statistical population. Through convenience sampling, 419 students were included in the study. A 12-item general health questionnaire (GHQ-12) and a 19-item the COVID-19 related healthcare students stress scale were used to collect data. Data analysis was performed using SPSS and descriptive and analytical statistical methods methods (Pearson correlation coefficient, paired t-test and analysis of variance). Results: The mean score of students' mental health status was 12.91, and 41.05% (N = 172) of them had some degree of mental distress. There was a significant relationship between mental distress score with the perception of COVID-19 stress, gender and field of study (P < 0.05). Conclusion: A significant number of students had some degree of mental distress, which had a direct and significant correlation with the perception of COVID-19 stress. Therefore, planning to identify and reduce the stressors associated with COVID-19 is one of the most beneficial actions for the students in restoring their mental health.

The effects of combination of Zingiber officinale and Echinacea on alleviation of clinical symptoms and hospitalization rate of suspected COVID-19 outpatients: a randomized controlled trial

OBJECTIVES

Herbal medicines, as a treatment method, have received a great deal of attention. The effects of two herbal medicines namely Zingiber officinale and Echinacea on alleviation of clinical symptoms and hospitalization rate of suspected COVID-19 outpatients were examined.

METHODS

A clinical trial with 100 suspected COVID-19 outpatients as participants was conducted. The participants were allocated randomly to two groups of 50 members. The intervention group received concurrent Zingiber officinale (Tablet Vomigone 500 mg II tds) and Echinacea (Tablet Rucoldup I tds) for seven days in addition to the standard treatment. The control group only received the standard treatment (Hydroxychloroquine). After seven days, alleviation of clinical symptoms and hospitalization rate were examined. In addition, 14 days after treatment, the hospitalization was assessed again by telephone follow up.

RESULTS

The two groups were identical in terms of basic characteristics. Improvement level as to coughing, dyspnea, and muscle pain was higher in the intervention group (p value <0.05). There was no significant difference between the two groups in terms of the other symptoms. In addition, the hospitalization rate in the intervention and control groups were 2 and 6% respectively, which are not significantly different (p value >0.05).

CONCLUSIONS

Taking into account the efficiency and trivial side-effects of Zingiber officinale and Echinacea, using them for alleviation and control of the clinical symptoms in COVID-19 outpatients is recommended.

Designing and psychometric properties of coping strategies scale for family caregivers of hemodialysis patients

The present study tries to design and evaluate the psychometric properties of coping strategies scale for family caregivers of hemodialysis patients. This study consisted of two phases: phase one was a qualitative study to analyze the experiences of coping strategies of hemodialysis patients' family caregivers' (N = 14). Then, the items were extracted from the interviews and the literature. Phase two was a psychometric assessment including face validity, content validity, construct validity (N = 245) and reliability. In phase one, 89 items were extracted and after face and content validity, 56 items remained. Construct validity of the scale, based on exploratory factor analysis, removed another 22 items. The remaining 34 items contained nine subscales (active coping, positive thinking, appeal to spirituality, help-seeking, altruism, acting out, self-blaming, seeking isolation, and intentional forgetting). The reliability of the scale with Cronbach's Alpha was 0.91 and its stability was obtained through test-retest (ICC = 0.9). Coping strategies scale for family caregivers of hemodialysis patients has an acceptable validity and reliability. The tool can be used to assess effective and ineffective coping strategies in family caregivers of hemodialysis patients that may be useful for facilitating management and education of efficient coping strategies to family caregivers of hemodialysis patients.

The relationship between the willingness to mobile learning and educational achievements in health-care professional students

BACKGROUND

The relationship between willingness to mobile learning (m-learning) and educational achievement was examined in health-care professional students.

MATERIALS AND METHODS

This is a descriptive correlative study that was conducted from January 2020 to February 2020. A total of 295 students in Saveh University of Medical Sciences in Iran were selected through census method. The data were collected using the standard willingness to m-learning questionnaire. The data collected were analyzed statistically using Pearson's correlation coefficient and concurrent regression analysis.

RESULTS

The mean score of willingness to m-learning was 165.55 ± 13.4, which is an indicative of a higher willingness level in the health-care professional students for m-learning. There was a positive and significant relationship between willingness for m-learning and educational achievement (r = 0.77, P < 0.01). The predictive variable, i.e., willingness to m-learning, predicted 53.8% of the variance of educational achievement (F = 58.801, P = 0.00). Among the variables of willingness to m-learning, the regression coefficients of perceived ease, attitude, self-management in learning, educational use, and efficiency of m-learning were significant (P < 0.05). This means that these variables are direct predictors of educational achievement.

CONCLUSIONS

Willingness to m-learning had a positive and significant relationship with educational achievement. Although this study was performed just before the corona outbreak, paying attention to the results of this study can be helpful for students, faculty members, and policymakers in filling the educational gap during the coronavirus disease 2019 outbreak.

A comparison of learning styles of undergraduate health-care professional students at the beginning, middle, and end of the educational course over a 4-year study period (2015-2018)

BACKGROUND AND AIM

There is a growing interest in learning styles of undergraduate health-care professional students; however, the evidences about learning styles over time during undergraduate programs are rare. In this study, the learning styles of undergraduate health-care professional students from the beginning to the completion of the program were examined to determine changes in learning style over time.

METHODOLOGY

This is a longitudinal descriptive study from 2015 to 2018. A total of 101 health-care professional students were selected by census method. Learning styles were evaluated using the Perceptual Learning-Style Preference Questionnaire three times in the study at the beginning (T1), the middle (T2), and the end of the educational course (T3). The data were analyzed using repeated measures ANOVA.

RESULTS

In T1, auditory (mean = 13.99) and visual (mean = 13.54) styles were preferred as major learning styles, whereas at T2, visual style (mean = 13.6) was the only preferred major learning style. At T3, the major learning styles were kinesthetic (mean = 14.32), tactile (mean = 13.98), and visual (mean = 13.58). There were statistically significant differences in auditory, kinesthetic, tactile and group scale scores between the three time points (P < 0.05). Group learning style was in the negative type at all three time points.

CONCLUSIONS

Learning styles can change depending on the context, environment, teaching method, and the subject of learning material and are probably a flexible changing feature rather than a fixed inherent feature a student possesses.

Design and psychometric properties of willingness to mobile learning scale for medical sciences students: A mixed-methods study

BACKGROUND AND AIM

Given the absence of a scale specially designed to measure willingness to mobile learning (m-learning) in medical sciences students, the present study was conducted to design and evaluate the psychometric properties of "willingness to m-learning" scale for medical sciences students.

METHODOLOGY

The study was carried out as a mixed-method study in two phases at Saveh University of Medical Sciences in 2019. Phase one was a qualitative study to elaborate on the students' perception of m-learning. Then, the statements were extracted, and statement pool was completed through reviewing the text. In the second phase, the psychometric properties including face, content, and construct validities (using explorative factor analysis), internal consistency (Cronbach's alpha), and test-retest reliability (intercluster correlation test) were measured. A total of 482 students who were selected randomly participated in the second phase. Data analysis was done with MAXQDA software (VERBI Software 2019, Berlin, Germany) for qualitative data and SPSS 19 software (SPSS Inc., Chicago, IL, USA) for quantitative data.

RESULTS

Based on qualitative content analysis and literature review, 92 statements were extracted. After checking face and content validity, 55 statements remained in the study. Construct validity of the questionnaire based on explorative factor analysis removed 10 more statements and the remaining 45 statements were categorized into nine factors, namely technophilia, perceived attraction, perceived ease, perceived conflict, self-management, attitude, behavioral intention to use, educational use, and efficacy of m-learning. Reliability of the scale was obtained as 0.95 based on Cronbach's alpha and stability was checked using test-retest method (intercluster correlation coefficient; r = 0.92).

CONCLUSION

Willingness to m-learning scale had an acceptable reliability and validity in medical sciences students. Therefore, it can be used for medical sciences students for improve learning and education.

Immersing in problems: Challenges of women living with the husband on hemodialysis

Background & Aim: The caregivers of hemodialysis patients experience a heavy caregiving burden. More caregiving pressure and burden have been reported of the women than men insofar as they are encountered with more physical and psychological problems. This paper explores the challenges faced by women living with husband on hemodialysis. Methods & Materials: The study followed a conventional content analysis method. The participants were selected through a purposive sampling method in hospitals of Shahid Beheshti University of Medical Sciences, Tehran, Iran, in 2017-2018. The first author performed semi-structured, individualized interviews with 14 participants. Results: By analyzing the data, the main category "Immersing in problems" was extracted with two following categories: 1- Inadequate support network (subcategories: inadequate informational support, inadequate instrumental support, inadequate emotional support) and 2- Difficult coexistence with problems (subcategories: role overload, worry and anxiety, fear and hope for the future, suffering of frequent dialyses). Conclusion: The findings of the study showed that women living with the husband on hemodialysis have been encountered with challenges and numerous stressing factors in the course of caregiving. Given the challenges experienced by participants, telenursing, and community health nurses can play an essential role in eliminating the many problems of hemodialysis patients and their caregivers.

Lived experiences of nursing students about ethical concerns regarding mobile learning in educational and clinical contexts

The field of education has experienced a profound change following the introduction of mobile technology over the last decades, and nursing education is not an exception. This study explored the experiences of nursing students about the ethical concerns regarding the use of mobile devices for learning purposes, that is, mobile learning, in educational and clinical contexts. A qualitative phenomenological study was carried out on nursing students (n = 19) in Saveh University of Medical Sciences of Iran between December 2017 and April 2018. Data were collected through semi-structured interviews with open-ended questions. Data analysis was done using Colaizzi's 7-step method, revealing four themes and nine sub-themes including: 1) preserving professional dignity (in front of the patient, and the teacher, and preserving academic virtual identity); 2) securing informed consent and respecting personal (the patient's and teachers) autonomy; 3) proper and efficient use (observing the regulations and codes, and making educational use); and 4) avoiding harm (responsible use of class and patient data). It was revealed that using mobile technology in education could raise ethical concerns for nursing students, and this should be emphasized in nursing educational programs.

Psychometric parameters of the Persian version of the BriefCOPE among wives of patients under hemodialysis

Background: The Brief COPE is widely validated and popularly used in assessing coping strategies in major life stressors on various populations. This study carried out to determine the validity and reliability of the Persian version of the Brief COPE among wives of patients under hemodialysis. Methods: The Brief COPE was translated into Persian language according to the standard method and the psychometric properties of the instrument were assessed among 212 wives of patients under hemodialysis in Tehran, Iran, in 2016. Content validity was established, by 15 expert opinions. Face validity was determined by respondents and expert opinion. Construct validity was analyzed through confirmatory factor analysis. The Cronbach's alpha coefficient and intraclass correlation coefficient were used to determine the internal consistency and test-retest reliability, respectively. Results: All 28 Items of Brief COPE scale had content validity index greater than 0.7, suggesting a good validity value of the items in terms of relevancy (range 0.8 - 0.94). The wording of some items was modified to make them more readily understood by the participants, although the core meaning of each item was kept intact and to observe Iranian cultural adaptation; two items were adjusted. Result of confirmatory factor support 14 factor structure of the scale has good fit. Cronbach's alpha coefficient was acceptable for the total scale (α= 0.77) and for subscales (range 0.7 - 0.91). The intraclass correlation coefficient was acceptable for scale (r=0.76, P value= 0.001). Conclusion: The Persian translation of the Brief COPE is a valid and reliable instrument to determine coping strategies in women living with the husband on hemodialysis.

A comparison of the cooperative learning and traditional learning methods in theory classes on nursing students' communication skill with patients at clinical settings

The purpose of this study was to compare the effect of traditional learning and cooperative learning methods on nursing students' communication skill with patients. This was an experimental study in which 34 nursing students in their 2nd semester of program participated. They were divided randomly into two groups, a control group who were taught their medical/surgical nursing course by traditional learning method and an experimental group, who were taught the same material using cooperative learning method. Before and after the teaching intervention, the students' communication skills with patients at clinical settings were examined. The results showed that no significant difference between the two groups in students' communication skills scores before the teaching intervention, but did show a significant difference between the two groups in the interaction skills and problem follow up sub-scales scores after the teaching intervention. This study provides evidence that cooperative learning is an effective method for improving and increasing communication skills of nursing students especially in interactive skills and follow up the problems sub-scale, thereby it is recommended to increase nursing students' participation in arguments by applying active teaching methods which can provide the opportunity for increased communication skills.

Placebo use in clinical practice by nurses in an Iranian teaching hospital

The present study was carried out to explore Iranian nurses' use of placebos in clinical practice and their knowledge and attitude towards its use. A cross-sectional, descriptive study was conducted using self-report questionnaires. All nurses working in a university hospital in Arak (n=342) were invited to participate in the study. Among 295 respondents, 221 (75%) reported that they had used at least one placebo within the past year and 179 (81%) told patients they were receiving actual medication. The most common reason and symptom for placebo use were after unjustified demand for medication and pain, respectively. Only 60 (20.33%) of the nurses believed that placebos should never be used. Results showed that most nurses in our study had used placebos and probably will continue to use them. Placebo use is viewed as ethically permissible among nurses. Some patients benefit from the placebos, but their use raises ethical questions. The role of placebo treatment, its mechanisms, and its ethics issues should be taught to nurses.