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Akseer N, Phillips DE. Drivers of success in global health outcomes: A content analysis of Exemplar studies. PLOS Glob Public Health 2024; 4:e0003000. [PMID: 38722816 PMCID: PMC11081220 DOI: 10.1371/journal.pgph.0003000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 03/04/2024] [Indexed: 05/12/2024]
Abstract
Applying a positive outlier lens is one effective approach for generating evidence to inform global health policy, program, and funding decisions. Exemplars in Global Health (EGH) is a program that studies positive outlier countries that have made extraordinary progress in health outcomes (despite limited resources) and disseminates their successes through multiple types of outputs. To date, EGH has studied, or is studying, 14 global health topics in 28 countries. This paper aims to identify findings, summarized as themes and sub-themes, that appear among all completed EGH studies. We developed a conceptual framework and used a content analysis approach to identify the top thematic areas that appear as drivers for programmatic success across EGH studies that were completed between June 2020-May 2023. The EGH studies (N = 31) spanned six topics including under-five child mortality (n = 6), childhood stunting (n = 5), community health workers (CHW) (n = 4), vaccine delivery (n = 3), COVID-19 response (n = 6), and newborn and maternal mortality reduction (n = 7) across 19 countries in sub-Saharan Africa, Latin America, South and Central Asia, and the Caribbean regions. Top drivers of success were defined as those critical or catalytic in achieving the intended outcome. Eight key drivers were identified: (1) efficient data collection and use for decision-making, (2) strong political commitment and health leadership, (3) effective stakeholder coordination, (4) a local, connected, and capacitated workforce, (5) intentional women's empowerment and engagement, (6) effective adoption and implementation of national policies, (7) effective and sustainable financing, and (8) equitable, efficient outreach and targeting. These cross-cutting drivers span a broad range of development outcomes, sectors, and populations, and indicate a need to effectively integrate people, systems, and sectors to improve global health outcomes. Findings from this study aim to support peer learning among countries and support evidence-based decision-making for funders, policymakers, and other key stakeholders.
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Affiliation(s)
- Nadia Akseer
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, United States of America
- Exemplars in Global Health, Gates Ventures, Seattle, Washington, United States of America
| | - David E. Phillips
- Exemplars in Global Health, Gates Ventures, Seattle, Washington, United States of America
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Kante AM, Youssoufa LO, Mounkaila A, Mahamadou Y, Bamogo A, Jiwani SS, Hazel E, Maïga A, Munos MK, Walton S, Tam Y, Walker N, Akseer N, Jue Wong H, Moussa M, Dagobi AE, Jessani NS, Amouzou A. Challenges in reducing maternal and neonatal mortality in Niger: an in-depth case study. BMJ Glob Health 2024; 9:e011732. [PMID: 38770808 DOI: 10.1136/bmjgh-2023-011732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/22/2024] [Indexed: 05/22/2024] Open
Abstract
INTRODUCTION Recent modelled estimates suggest that Niger made progress in maternal mortality since 2000. However, neonatal mortality has not declined since 2012 and maternal mortality estimates were based on limited data. We researched the drivers of progress and challenges. METHODS We reviewed two decades of health policies, analysed mortality trends from United Nations data and six national household surveys between 1998 and 2021 and assessed coverage and inequalities of maternal and newborn health indicators. Quality of care was evaluated from health facility surveys in 2015 and 2019 and emergency obstetric assessments in 2011 and 2017. We determined the impact of intervention coverage on maternal and neonatal lives saved between 2000 and 2020. We interviewed 31 key informants to understand the factors underpinning policy implementation. RESULTS Empirical maternal mortality ratio declined from 709 to 520 per 100 000 live births during 2000-2011, while neonatal mortality rate declined from 46 to 23 per 1000 live births during 2000-2012 then increased to 43 in 2018. Inequalities in neonatal mortality were reduced across socioeconomic and demographic strata. Key maternal and newborn health indicators improved over 2000-2012, except for caesarean sections, although the overall levels were low. Interventions delivered during childbirth saved most maternal and newborn lives. Progress came from health centre expansion, emergency care and the 2006 fee exemptions policy. During the past decade, challenges included expansion of emergency care, continued high fertility, security issues, financing and health workforce. Social determinants saw minimal change. CONCLUSIONS Niger reduced maternal and neonatal mortality during 2000-2012, but progress has stalled. Further reductions require strategies targeting comprehensive care, referrals, quality of care, fertility reduction, social determinants and improved security nationwide.
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Affiliation(s)
- Almamy Malick Kante
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Aida Mounkaila
- Direction des Statistiques Sanitaires, Ministère de la Santé Publique, Niamey, Niger
| | - Yahaha Mahamadou
- Direction des Statistiques Sanitaires, Ministère de la Santé Publique, Niamey, Niger
| | - Assanatou Bamogo
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Safia S Jiwani
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Hazel
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abdoulaye Maïga
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda Kay Munos
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shelley Walton
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yvonne Tam
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neff Walker
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nadia Akseer
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Heather Jue Wong
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Nasreen S Jessani
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Knowledge, Impact and Policy Unit, Institute of Development Studies, Brighton, UK
| | - Agbessi Amouzou
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Tasnim Hossain A, Hazel EA, Rahman AE, Koon AD, Jue Wong H, Maïga A, Akseer N, Tam Y, Walker N, Jiwani SS, Munos MK, El Arifeen S, Black R, Amouzou A. Effective multi-sectoral approach for rapid reduction in maternal and neonatal mortality: the exceptional case of Bangladesh. BMJ Glob Health 2024; 9:e011407. [PMID: 38770805 DOI: 10.1136/bmjgh-2022-011407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/20/2023] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Bangladesh experienced impressive reductions in maternal and neonatal mortality over the past several decades with annual rates of decline surpassing 4% since 2000. We comprehensively assessed health system and non-health factors that drove Bangladesh's success in mortality reduction. METHODS We operationalised a comprehensive conceptual framework and analysed available household surveys for trends and inequalities in mortality, intervention coverage and quality of care. These include 12 household surveys totalling over 1.3 million births in the 15 years preceding the surveys. Literature and desk reviews permitted a reconstruction of policy and programme development and financing since 1990. These were supplemented with key informant interviews to understand implementation decisions and strategies. RESULTS Bangladesh prioritised early population policies to manage its rapidly growing population through community-based family planning programmes initiated in mid-1970s. These were followed in the 1990s and 2000s by priority to increase access to health facilities leading to rapid increases in facility delivery, intervention coverage and access to emergency obstetric care, with large contribution from private facilities. A decentralised health system organisation, from communities to the central level, openness to private for-profit sector growth, and efficient financing allocation to maternal and newborn health enabled rapid progress. Other critical levers included poverty reduction, women empowerment, rural development, and culture of data generation and use. However, recent empirical data suggest a slowing down of mortality reductions. CONCLUSION Bangladesh demonstrated effective multi-sectoral approach and persistent programming, testing and implementation to achieve rapid gains in maternal and neonatal mortality reduction. The slowing down of recent mortality trends suggests that the country will need to revise its strategies to achieve the Sustainable Development Goals. As fertility reached replacement level, further gains in maternal and neonatal mortality will require prioritising universal access to quality facility delivery, and addressing inequalities, including reaching the rural poor.
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Affiliation(s)
- Aniqa Tasnim Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Elizabeth A Hazel
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ahmed Ehsanur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Adam D Koon
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Heather Jue Wong
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abdoulaye Maïga
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nadia Akseer
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yvonne Tam
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neff Walker
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Safia S Jiwani
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda Kay Munos
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Robert Black
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Agbessi Amouzou
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Walton S, Jessani NS, Jue‐Wong H, Hazel EA, Akseer N, Kante AM, Youssoufa O, Heidkamp R, Bamogo A, Amouzou A. Climate shocks and nutrition: The role of food security policies and programs in enhancing maternal and neonatal survival in Niger. Matern Child Nutr 2024; 20:e13566. [PMID: 37794716 PMCID: PMC10750024 DOI: 10.1111/mcn.13566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 10/06/2023]
Abstract
Niger is afflicted with high rates of poverty, high fertility rates, frequent environmental crises, and climate change. Recurrent droughts and floods have led to chronic food insecurity linked to poor maternal and neonatal nutrition outcomes in vulnerable regions. We analyzed maternal and neonatal nutrition trends and subnational variability between 2000 and 2021 with a focus on the implementation of policies and programs surrounding two acute climate shocks in 2005 and 2010. We used four sources of data: (a) national household surveys for maternal and newborn nutritional indicators allowing computation of trends and differences at national and regional levels; (b) document review of food security reports; (c) 30 key informant interviews and; (d) one focus group discussion. Many food security policies and nutrition programs were enacted from 2000 to 2020. Gains in maternal and neonatal nutrition indicators were more significant in targeted vulnerable regions of Maradi, Zinder, Tahoua and Tillabéri, from 2006 to 2021. However, poor access to financial resources for policy execution and suboptimal implementation of plans have hindered progress. In response to the chronic climate crisis over the last 20 years, the Nigerien government and program implementers have demonstrated their commitment to reducing food insecurity and enhancing resilience to climate shocks by adopting a deliberate multisectoral effort. However, there is more that can be achieved with a continued focus on vulnerable regions to build resilience, targeting high risk populations, and investing in infrastructure to improve health systems, food systems, agriculture systems, education systems, and social protection.
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Affiliation(s)
- Shelley Walton
- Johns Hopkins Bloomberg School of Public Health, International Health DepartmentJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Nasreen S. Jessani
- Johns Hopkins Bloomberg School of Public Health, International Health DepartmentJohns Hopkins UniversityBaltimoreMarylandUSA
- Centre for Evidence Based Health CareStellenbosch UniversityCape TownSouth Africa
| | - Heather Jue‐Wong
- Johns Hopkins Bloomberg School of Public Health, International Health DepartmentJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Elizabeth A. Hazel
- Johns Hopkins Bloomberg School of Public Health, International Health DepartmentJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Nadia Akseer
- Johns Hopkins Bloomberg School of Public Health, International Health DepartmentJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Almamy Malick Kante
- Johns Hopkins Bloomberg School of Public Health, International Health DepartmentJohns Hopkins UniversityBaltimoreMarylandUSA
| | | | - Rebecca Heidkamp
- Johns Hopkins Bloomberg School of Public Health, International Health DepartmentJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Assanatou Bamogo
- Johns Hopkins Bloomberg School of Public Health, International Health DepartmentJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Agbessi Amouzou
- Johns Hopkins Bloomberg School of Public Health, International Health DepartmentJohns Hopkins UniversityBaltimoreMarylandUSA
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Xavier MO, Amouzou A, Maïga A, Akseer N, Huicho L, Matijasevich A. The impact of the COVID-19 pandemic on trends in stillbirths, under-5 and maternal mortality in Brazil: Excess deaths and regional inequalities. J Glob Health 2023; 13:06040. [PMID: 37772786 PMCID: PMC10540663 DOI: 10.7189/jogh.13.06040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
Background Despite the proliferation of studies on the impact of the coronavirus disease 2019 (COVID-19) pandemic, there is less evidence on the indirect death toll compared to the health system and service provision disruptions. We assessed the impact of the COVID-19 pandemic on national and regional trends and differences in stillbirths, under-5 and maternal deaths in Brazil. Methods We used the nationwide routine health information system data from January 2017 to December 2021, to which we applied descriptive and advanced mixed effects ordinary least squared regression models to measure the percent change in mortality levels during the COVID-19 pandemic (March 2020 to December 2021). We carried out counterfactual analyses comparing the observed and expected mortality levels for each type of mortality at national and regional levels. Results Stillbirths increased 4.8% (3.1% in 2020 and 6.2% in 2021) and most noticeably maternal deaths increased 71.6% (35.3% in 2020 and 103.3% in 2021) over the COVID-19 period. An opposite pattern was observed in under-5 mortality, which dropped -10.2% (-12.5% in 2020 and -8.1% in 2021). We identified regional disparities, with a higher percent increase in stillbirths observed in the Central-West region and in maternal deaths in the South region. Discussion Based on pre-pandemic trends and expected number of deaths in the absence of the COVID-19, we observed increases in stillbirths and maternal deaths and reductions in under-5 deaths during the pandemic. The months with the highest number of deaths (stillbirths and maternal deaths) coincided with the months with the highest mortality from COVID-19. The increase in deaths may also have resulted from indirect effects of the pandemic, such as unavailability of health services or even reluctance to go to the hospital when necessary due to fear of contagion. Conclusions In Brazil, the COVID-19 outbreak and subsequent restrictions had a detrimental impact on stillbirths and maternal deaths. Even before the pandemic, mortality trends highlighted pre-existing regional inequalities in the country's health care system. Although there were some variations, increases were observed in all regions, indicating potential weaknesses in the health system and inadequate management during the pandemic, particularly concerning pregnant and postpartum women.
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Affiliation(s)
- Mariana Otero Xavier
- Departamento de Medicina Preventiva, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brasil
| | - Agbessi Amouzou
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abdoulaye Maïga
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nadia Akseer
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Luis Huicho
- Centro de Investigación en Salud Materna e Infantil, Centro de Investigación para el Desarrollo Integral y Sostenible and Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Alicia Matijasevich
- Departamento de Medicina Preventiva, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, Brasil
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Akseer N, Tasic H, Adeyemi O, Heidkamp R. Concordance and determinants of mothers' and children's diets in Nigeria: an in-depth study of the 2018 Demographic and Health Survey. BMJ Open 2023; 13:e070876. [PMID: 37433728 DOI: 10.1136/bmjopen-2022-070876] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
OBJECTIVES Improving the diversity of the diets in young children 6-23 months is a policy priority in Nigeria and globally. Studying the relationship between maternal and child food group intake can provide valuable insights for stakeholders designing nutrition programmes in low-income and middle-income countries. DESIGN We examined the relationship between maternal and child dietary diversity among 8975 mother-child pairs using the Nigeria 2018 Demographic and Health Survey (DHS). We assessed concordance and discordance between maternal and child food group intake using the McNemar's χ2 test, and the determinants of child minimum dietary diversity (MDD-C) including women MDD (MDD-W) using hierarchical multivariable probit regression modelling. SETTING Nigeria. PARTICIPANTS 8975 mother-child pairs from the Nigeria DHS. PRIMARY AND SECONDARY OUTCOME MEASURES MDD-C, MDD-W, concordance and discordance in the food groups consumed by mothers and their children. RESULTS MDD increased with age for both children and mothers. Grains, roots and tubers had high concordance in mother-child dyads (90%); discordance was highest for legumes and nuts (36%), flesh foods (26%), and fruits and vegetables (39% for vitamin-A rich and 57% for other). Consumption of animal source food (dairy, flesh foods, eggs) was higher for dyads with older mothers, educated mothers and more wealthy mothers. Maternal MDD-W was the strongest predictor of MDD-C in multivariable analyses (coef 0.27; 95% CI 0.25 to 0.29, p<0.000); socioeconomic indicators including wealth (p<0.000), mother's education (p<0.000) were also statistically significant in multivariable analyses and rural residence (p<0.000) was statistically significant in bivariate analysis. CONCLUSION Programming to address child nutrition should be aimed at the mother-child dyad as their food consumption patterns are related and some food groups appear to be withheld from children. Stakeholders including governments, development partners, non-governmental organizations, donors and civil society can act on these findings in their efforts to address undernutrition in the global child population.
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Affiliation(s)
- Nadia Akseer
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hana Tasic
- Modern Scientist Global, St Catharines, Ontario, Canada
| | - Olutayo Adeyemi
- Department of Human Nutrition and Dietetics, University of Ibadan, Ibadan, Nigeria
| | - Rebecca Heidkamp
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Nasiri K, Akseer N, Tasic H, Rafiqzad H, Akseer T. Disability types, determinants and healthcare utilisation amongst Afghan adults: a secondary analysis of the Model Disability Survey of Afghanistan. BMJ Open 2023; 13:e062362. [PMID: 36717138 PMCID: PMC9887472 DOI: 10.1136/bmjopen-2022-062362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES The needs of people with disability in Afghanistan are not well understood. We describe the characteristics, healthcare utilisation patterns, and experience of care among Afghan adults with moderate or severe disability (MSD) by disability type. DESIGN We mapped 47 questions related to functional disability in the cross-sectional Model Disability Survey of Afghanistan (MDSA) 2019 into 7 disability domains based on the WHO Disability Assessment Schedule 2.0. We conducted multivariable hierarchical logistic regression to identify drivers of high disability burden. SETTING The MDSA primary sampling unit were villages in rural areas and neighbourhoods in urban areas, and the secondary sample units were the settlements within districts. PARTICIPANTS The MDSA collected data for 14 520 households across all 34 provinces. The adult tool of the survey was administered to a randomly selected household member aged 18 years or older. MAIN OUTCOME MEASURES The main outcome measured was moderate or severe disability (MSD), which was estimated using a Rasch composite score. RESULTS MSD prevalence was upwards of 35% in 6/7 domains. Across most disability types, being a woman, older age, residing in rural areas, being uneducated, non-Pashtun ethnicity, being unmarried, living in a household in the low-income tertiles and a non-working household had the highest levels of MSD (p<0.05). Determinants of MSD varied by domain; however, variables including better access to health facilities and better experience of care (higher satisfaction with time spent and respect during visits) were generally protective. People with MSD in the self-care and life activities domains had the highest and lowest healthcare utilisation, respectively. CONCLUSIONS Disability in Afghanistan is at public health crisis levels, with vulnerable populations being impacted most severely. To ensure progress towards Afghanistan's 2030 Sustainable Development Goals, targeted interventions for disability types based on population risk factors should be implemented.
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Affiliation(s)
- Khalidha Nasiri
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Modern Scientist Global, St. Catharines, Ontario, Canada
| | - Nadia Akseer
- Modern Scientist Global, St. Catharines, Ontario, Canada
- School of Public Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hana Tasic
- Modern Scientist Global, St. Catharines, Ontario, Canada
| | - Hadia Rafiqzad
- Department of Psychology, University of Toronto Scarborough, Toronto, Ontario, Canada
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Varyvoda Y, Akseer N, Sadkoviy V, Carmona R, Muramoto M, Wazny K, San Martin T, Taren D. Ukraine's most vulnerable need healthcare: Priorities during the armed conflict. Public Health Pract (Oxf) 2022; 4:100296. [PMID: 36570404 PMCID: PMC9773054 DOI: 10.1016/j.puhip.2022.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 06/29/2022] [Indexed: 12/27/2022] Open
Affiliation(s)
- Yevheniia Varyvoda
- Department of Community, Environment and Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, USA
| | - Nadia Akseer
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, USA,Corresponding author.
| | - Volodymyr Sadkoviy
- National University of Civil Protection of Ukraine of the State Emergency Service, Ukraine
| | - Richard Carmona
- 17th Surgeon General of the United States, Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, USA
| | - Myra Muramoto
- Department of Family Medicine, School of Medicine, University of Colorado, USA
| | - Kerri Wazny
- Children's Investment Fund Foundation, United Kingdom
| | | | - Douglas Taren
- Department of Pediatrics, School of Medicine, University of Colorado, USA
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Akseer N, Keats EC, Thurairajah P, Cousens S, Bétran AP, Oaks BM, Osrin D, Piwoz E, Gomo E, Ahmed F, Friis H, Belizán J, Dewey K, West K, Huybregts L, Zeng L, Dibley MJ, Zagre N, Christian P, Kolsteren PW, Kaestel P, Black RE, El Arifeen S, Ashorn U, Fawzi W, Bhutta ZA. Characteristics and birth outcomes of pregnant adolescents compared to older women: An analysis of individual level data from 140,000 mothers from 20 RCTs. EClinicalMedicine 2022; 45:101309. [PMID: 35243274 PMCID: PMC8885463 DOI: 10.1016/j.eclinm.2022.101309] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/20/2022] [Accepted: 02/01/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Adolescence is a critical period of maturation when nutrient needs are high, especially among adolescents entering pregnancy. Using individual-level data from 140,000 participants, we examined socioeconomic, nutrition, and pregnancy and birth outcomes for adolescent mothers (10-19 years) compared to older mothers in low and middle-income countries. METHODS This study was conducted between March 16, 2018 and May 25, 2021. Data were obtained from 20 randomised controlled trials of micronutrient supplementation in pregnancy. Stratified analyses were conducted by age (10-14 years, 15-17 years, 18-19 years, 20-29 years, 30-39 years, 40+ years) and geographical region (Africa, Asia). Crude and confounder-adjusted means, prevalence and relative risks of pregnancy, nutrition and birth outcomes were estimated using multivariable linear and log-binomial regression models with 95% confidence intervals. FINDINGS Adolescent mothers comprised 31.6% of our data. Preterm birth, small-for-gestational age (SGA), low birthweight (LBW) and newborn mortality followed a U-shaped trend in which prevalence was highest among the youngest mothers (10-14 years) and then reduced gradually, but increased again for older mothers (40+ years). When compared to mothers aged 20-29 years, there was a 23% increased risk of preterm birth, a 60% increased risk of perinatal mortality, a 63% increased risk of neonatal mortality, a 28% increased risk of LBW, and a 22% increased risk of SGA among mothers 10-14 years. Mothers 40+ years experienced a 22% increased risk of preterm birth and a 103% increased risk of stillbirth when compared to the 20-29 year group. INTERPRETATION The youngest and oldest mothers suffer most from adverse pregnancy and birth outcomes. Policy and programming agendas should consider both biological and socioeconomic/environmental factors when targeting these populations. FUNDING Bill and Melinda Gates Foundation (Grant No: OP1137750).
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Affiliation(s)
- Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Emily Catherine Keats
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Pravheen Thurairajah
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
| | - Simon Cousens
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - David Osrin
- Institute for Global Health, University College London, United Kingdom
| | - Ellen Piwoz
- The Bill and Melinda Gates Foundation, United States
| | | | | | | | | | | | - Keith West
- Johns Hopkins Bloomberg School of Public Health, United States
| | | | - Lingxia Zeng
- School of Public Health, Xi'an Jiaotong University Health Science Centre, China
| | | | - Noel Zagre
- UNICEF Regional Office for West and Central Africa, Senegal
| | - Parul Christian
- Johns Hopkins Bloomberg School of Public Health, United States
| | | | | | - Robert E. Black
- Johns Hopkins Bloomberg School of Public Health, United States
| | | | - Ulla Ashorn
- Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Wafaie Fawzi
- Harvard T.H. Chan School of Public Health, United States
| | - Zulfiqar Ahmed Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute for Global Health and Development, The Aga Khan University, Karachi, Pakistan
- Corresponding author at: Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada.
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Akseer N, Tasic H, Nnachebe Onah M, Wigle J, Rajakumar R, Sanchez-Hernandez D, Akuoku J, Black RE, Horta BL, Nwuneli N, Shine R, Wazny K, Japra N, Shekar M, Hoddinott J. Economic costs of childhood stunting to the private sector in low- and middle-income countries. EClinicalMedicine 2022; 45:101320. [PMID: 35308896 PMCID: PMC8927824 DOI: 10.1016/j.eclinm.2022.101320] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 02/01/2022] [Accepted: 02/09/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Stunting during childhood has long-term consequences on human capital, including decreased physical growth, and lower educational attainment, cognition, workforce productivity and wages. Previous research has quantified the costs of stunting to national economies however beyond a few single-country datasets there has been a limited number of which have used diverse datasets and have had a dedicated focus on the private sector, which employs nearly 90% of the workforce in many low- and middle-income countries (LMICs). We aimed to examine (i) the impact of childhood stunting on income loss of private sector workforce in LMICs; (ii) to quantify losses in sales to private firms in LMICs due to childhood stunting; and (iii) to estimate potential gains (benefit-cost ratios) if stunting levels are reduced in select high prevalence countries. METHODS This multiple-methods study engaged multi-disciplinary technical advisers, executed several literature reviews, used innovative statistical methods, and implemented health and labor economic models. We analyzed data from seven longitudinal datasets (up to 30+ years of follow-up; 1982-2016; Peru, Ethiopia, India, Vietnam, Philippines, Tanzania, Brazil), 108 private firm datasets (spanning 2008-2020), and many global datasets including Joint Malnutrition Estimates, and World Development Indicators to produce estimates for 120+ LMICs (with estimates up to 2021). We studied the impact of childhood stunting on adult cognition, education, and height as pathways to wages/productivity in adulthood. We employed cloud-based artificial intelligence (AI) platforms, and conducted comparative analyses using three analytic approaches: traditional frequentist statistics, Bayesian inferential statistics and machine learning. We employed labour and health economic models to estimate wage losses to the private sector worker and firm revenue losses due to stunting. We also estimated benefit-cost ratios for countries investing in nutrition-specific interventions to prevent stunting. FINDINGS Across 95 LMICs, childhood stunting costs the private sector at least US$135.4 billion in sales annually. Firms from countries in Latin America and the Caribbean and East Asia and Pacific regions had the greatest losses. Totals sales losses to the private sector accumulated to 0.01% to 1.2% of national GDP across countries. Sectors most affected by childhood stunting were manufacturing (non-metallic mineral, fabricated metal, other), garments and food sectors. Sale losses were highest for larger sized private firms. Across regions (representing 123 LMICs), US$700 million (Middle East and North Africa) to US$16.5 billion (East Asia and Pacific) monthly income was lost among private sector workers. Investing in stunting reduction interventions yields gains from US$2 to US$81 per $1 invested annually (or 100% to 8000% across countries). Across sectors, the highest returns were in elementary occupations (US$46) and the lowest were among agricultural workers (US$8). By gender, women incurred a higher income penalty from childhood stunting and earned less than men; due to their relatively higher earnings, the returns for investing in stunting reduction were consistently higher for men across most countries studied. INTERPRETATION Childhood stunting costs the private sector in LMICs billions of dollars in sales and earnings for the workforce annually. Returns to nutrition interventions show that there is an economic case to be made for investing in childhood nutrition, alongside a moral one for both the public and private sector. This research could be used to motivate strong public-private sector partnerships to invest in childhood undernutrition for benefits in the short and long-term.
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Affiliation(s)
- Nadia Akseer
- Johns Hopkins Bloomberg School of Public Health, USA
- Modern Scientist Global, Canada
- Corresponding author at: Johns Hopkins Bloomberg School of Public Health, USA.
| | | | | | | | | | | | | | | | | | - Ndidi Nwuneli
- Sahel Consulting Agriculture and Nutrition Ltd., Nigeria
| | - Ritta Shine
- Global Alliance for Improved Nutrition, Switzerland
| | - Kerri Wazny
- Johns Hopkins Bloomberg School of Public Health, USA
- The Power of Nutrition, UK
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Taren D, Akseer N, Davis CD, Miller JW, Moustaid-Moussa N, Novotny R, Slupsky CM, Saroja Voruganti V, Cameron JM. Eighty years of nutritional sciences, and counting. Nutr Rev 2021; 80:1-5. [PMID: 34891168 DOI: 10.1093/nutrit/nuab112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Douglas Taren
- Department of Pediatrics Nutrition Section, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nadia Akseer
- Modern Scientist Global and the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Cindy D Davis
- Agricultural Research Service, U.S. Department of Agriculture, Beltsville, Maryland, USA
| | - Joshua W Miller
- Department of Nutritional Sciences, School of Environmental and Biological Sciences, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Naima Moustaid-Moussa
- Department of Nutritional Sciences, College of Human Services and the Obesity Research Institute, Texas Tech University, Lubbock, Texas, USA
| | - Rachel Novotny
- Human Nutrition, Food and Animal Sciences Department, College of Tropical Agriculture and Human Resources, and the Children's Healthy Living Center of Excellence, University of Hawaii at Mānoa, Honolulu, Hawaii, USA
| | - Carolyn M Slupsky
- Department of Nutrition, University of California, Davis, California, USA
| | - V Saroja Voruganti
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Kannapolis, North Carolina, USA
| | - James M Cameron
- International Life Sciences Institute, Washington, District of Columbia, USA
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12
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Akseer N, Heidkamp RA, Thorne-Lyman A. Using National Survey Data From Nigeria to Assess Maternal-Child Dietary Concordance and Inform Nutrition Program Strategy. Curr Dev Nutr 2021. [DOI: 10.1093/cdn/nzab038_001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Improving child diet diversity is a policy priority in many settings. Multiple factors influence complementary feeding practices in low-income countries including household food access, caregiver-level factors and cultural practices. Child's dietary data is often available in national surveys (i.e., Demographic and Health Surveys, DHS), but they typically lack diet data from adults. The 2018 Nigeria DHS was among the first to measure food group intake in both young children and women. We describe the relationship between child and maternal diet diversity in Nigeria and highlight implications for design of infant and young child feeding (IYCF) programs.
Methods
Using the Nigeria DHS 2018 dataset, we estimated consumption of individual food groups in the previous 24 hours as well as minimum dietary diversity for children 6–23 months (MDD-C) and their mothers, women 15–49 years (MDD-W) using WHO-UNICEF definitions. We compare rates of concordance and discordance between n = 8975 mother-child pairs for individual food groups and MDD using McNemar's tests. Probit regression was used to identify drivers of MDD-C.
Results
Nationally, 22% of children achieve MDD-C; 51% of mothers achieve MDD-W. For both populations, the most commonly consumed group is grains, roots and tubers (>80%) Dairy and eggs are the least consumed. Maternal-child (age 12–23 months) discordance is highest for consumption of legumes and nuts (36%), vitamin A rich fruits and vegetables (39%) and other fruits and vegetables (57%); mothers consume these more frequently. Children are more likely than mothers to consume dairy (19% vs 8%) and eggs (8% vs 4%). Maternal-child food group discordance is consistently higher for children 6–11months than children 12–23 months. Results vary at state level and by maternal age group. Children's MDD probability is increased by MDD-W (27%, P < 0.001), higher maternal education (8%, P < 0.01) and household wealth (7%, P < 0.01).
Conclusions
Maternal and child diet diversity is suboptimal in Nigeria. Maternal diet is a primary driver of child diet in Nigeria. Legumes and nuts and fruits and vegetables are available but not consistently fed to children; an important finding for IYCF program design. The forthcoming DHS-8 core questionnaire will provide child and maternal diet data for more than 90 countries.
Funding Sources
Bill & Melinda Gates Foundation.
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Carter A, Akseer N, Ho K, Rothschild O, Bose N, Binagwaho A, Hirschhorn LR, Price M, Muther K, Panjabi R, Freeman MC, Bednarczyk RA, Bhutta ZA. A framework for identifying and learning from countries that demonstrated exemplary performance in improving health outcomes and systems. BMJ Glob Health 2021; 5:bmjgh-2020-002938. [PMID: 33272938 PMCID: PMC7716663 DOI: 10.1136/bmjgh-2020-002938] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 10/02/2020] [Accepted: 10/04/2020] [Indexed: 12/14/2022] Open
Abstract
This paper introduces a framework for conducting and disseminating mixed methods research on positive outlier countries that successfully improved their health outcomes and systems. We provide guidance on identifying exemplar countries, assembling multidisciplinary teams, collecting and synthesising pre-existing evidence, undertaking qualitative and quantitative analyses, and preparing dissemination products for various target audiences. Through a range of ongoing research studies, we illustrate application of each step of the framework while highlighting key considerations and lessons learnt. We hope uptake of this comprehensive framework by diverse stakeholders will increase the availability and utilisation of rigorous and comparable insights from global health success stories.
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Affiliation(s)
- Austin Carter
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kevin Ho
- Gates Ventures, Kirkland, Washington, USA
| | | | | | | | - Lisa R Hirschhorn
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Kyle Muther
- Last Mile Health, Boston, Massachusetts, USA
| | - Raj Panjabi
- Last Mile Health, Boston, Massachusetts, USA
| | - Matthew C Freeman
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | | | - Zulfiqar Ahmed Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
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Keats EC, Akseer N, Thurairajah P, Cousens S, Bhutta ZA. Multiple-micronutrient supplementation in pregnant adolescents in low- and middle-income countries: a systematic review and a meta-analysis of individual participant data. Nutr Rev 2021; 80:141-156. [PMID: 33846729 PMCID: PMC8754251 DOI: 10.1093/nutrit/nuab004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
CONTEXT Approximately 7.3 million births occur annually among adolescents in low- and middle-income countries. Pregnant adolescents constitute a nutritionally vulnerable group that could benefit from intervention to mitigate the mortality and adverse birth outcomes associated with adolescent pregnancy. OBJECTIVE The aim of this systematic review and meta-analysis was to assess the following: (1) the effect of multiple-micronutrient (MMN) supplementation vs iron and folic acid (IFA) supplementation among adolescents on maternal morbidity, birth outcomes, and mortality outcomes, (2) the effects of MMN supplementation in adolescents compared with the effects in adult women, and (3) the effect modification, if any, of MMN supplementation by baseline and geographic characteristics of adolescents. DATA SOURCES MEDLINE and Cochrane databases were searched, along with the reference lists of relevant reviews. STUDY SELECTION Multiple-micronutrient supplementation trials in pregnancy that were conducted in a low- or middle-income country and had included at least 100 adolescents (10-19 years of age) were eligible for inclusion. Two independent reviewers assessed study eligibility. DATA EXTRACTION Thirteen randomized controlled trials conducted in Africa and Asia were identified from 1792 reviews and 1578 original trials. Individual-level data was shared by study collaborators and was checked for completeness and extreme values. One- and two-stage individual participant data meta-analyses were conducted using data from randomized controlled trials of MMN supplementation. RESULTS A total of 15 283 adolescents and 44 499 adult women with singleton births were included in the individual participant data meta-analyses of MMN supplementation vs IFA supplementation. In adolescents, MMN supplementation reduced low birth weight (1-stage OR = 0.87, 95%CI 0.77-0.97; 2-stage OR = 0.81; 95%CI 0.74-0.88), preterm birth (1-stage OR = 0.88, 95%CI 0.80-0.98; 2-stage OR = 0.86, 95%CI 0.79-0.95), and small-for-gestational-age births (1-stage OR = 0.90, 95%CI 0.81-1.00; 2-stage OR = 0.86, 95%CI 0.79-0.95) when compared with IFA supplementation. The effects of MMN supplementation did not differ between adolescents and older women, although a potentially greater reduction in small-for-gestational-age births was observed among adolescents. Effect modification by baseline characteristics and geographic region was inconclusive. CONCLUSIONS Multiple-micronutrient supplementation can improve birth outcomes among pregnant adolescents in low- and middle-income countries. Policy related to antenatal care in these settings should prioritize MMN supplementation over the currently recommended IFA supplementation for all pregnant women, especially adolescents.
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Affiliation(s)
- Emily C Keats
- E.C. Keats, N. Akseer, P. Thurairajah, and Z.A. Bhutta are with the Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. S. Cousens is with the London School of Hygiene & Tropical Medicine, London, United Kingdom. Z.A. Bhutta is with the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Z.A. Bhutta is with the Aga Khan University, Karachi, Pakistan. H. Ali is with the JiVitA Maternal and Child Nutrition and Health Research Project, Gaibandha, Bangladesh. S. El Arifeen is with the International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. U. Ashorn is with the Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. J. Belizan is with the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. R.E. Black, P. Christian, A.B. Labrique, K. West, and L.S-F. Wu are with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. L.M. De-Regil is with Nutrition International, Ottawa, Ontario, Canada. K. Dewey is with the University of California, Davis, Davis, California, USA. M.J. Dibley is with The University of Sydney, Sydney, New South Wales, Australia. W. Fawzi and C.R. Sudfeld are with the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA. H. Friis and P. Kaestel are with the University of Copenhagen, Copenhagen, Denmark. E. Gomo is with the University of Zimbabwe, Harare, Zimbabwe. L. Huybregts is with the International Food Policy Research Institute, Washington, DC, USA. R. Jayatissa is with the Medical Research Institute, Colombo, Sri Lanka. S.K. Khatry is with the Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal. P.W. Kolsteren is with Ghent University, Ghent, Belgium. M. McCauley is with the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom. B.M. Oaks is with the University of Rhode Island, Kingston, Rhode Island, USA. E. Piwoz is with the Bill & Melinda Gates Foundation, Seattle, Washington, USA. S. Shaikh is with the Society for Applied Studies, New Delhi, India. D.D. Soekarjo is with the Savica Consultancy, Jakarta, Indonesia. W. Urassa is with the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. N. Zagre is with the UNICEF Regional Office for West and Central Africa, Dakar, Senegal. L. Zeng and Z. Zhu are with the School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
| | - Nadia Akseer
- E.C. Keats, N. Akseer, P. Thurairajah, and Z.A. Bhutta are with the Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. S. Cousens is with the London School of Hygiene & Tropical Medicine, London, United Kingdom. Z.A. Bhutta is with the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Z.A. Bhutta is with the Aga Khan University, Karachi, Pakistan. H. Ali is with the JiVitA Maternal and Child Nutrition and Health Research Project, Gaibandha, Bangladesh. S. El Arifeen is with the International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. U. Ashorn is with the Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. J. Belizan is with the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. R.E. Black, P. Christian, A.B. Labrique, K. West, and L.S-F. Wu are with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. L.M. De-Regil is with Nutrition International, Ottawa, Ontario, Canada. K. Dewey is with the University of California, Davis, Davis, California, USA. M.J. Dibley is with The University of Sydney, Sydney, New South Wales, Australia. W. Fawzi and C.R. Sudfeld are with the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA. H. Friis and P. Kaestel are with the University of Copenhagen, Copenhagen, Denmark. E. Gomo is with the University of Zimbabwe, Harare, Zimbabwe. L. Huybregts is with the International Food Policy Research Institute, Washington, DC, USA. R. Jayatissa is with the Medical Research Institute, Colombo, Sri Lanka. S.K. Khatry is with the Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal. P.W. Kolsteren is with Ghent University, Ghent, Belgium. M. McCauley is with the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom. B.M. Oaks is with the University of Rhode Island, Kingston, Rhode Island, USA. E. Piwoz is with the Bill & Melinda Gates Foundation, Seattle, Washington, USA. S. Shaikh is with the Society for Applied Studies, New Delhi, India. D.D. Soekarjo is with the Savica Consultancy, Jakarta, Indonesia. W. Urassa is with the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. N. Zagre is with the UNICEF Regional Office for West and Central Africa, Dakar, Senegal. L. Zeng and Z. Zhu are with the School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
| | - Pravheen Thurairajah
- E.C. Keats, N. Akseer, P. Thurairajah, and Z.A. Bhutta are with the Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. S. Cousens is with the London School of Hygiene & Tropical Medicine, London, United Kingdom. Z.A. Bhutta is with the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Z.A. Bhutta is with the Aga Khan University, Karachi, Pakistan. H. Ali is with the JiVitA Maternal and Child Nutrition and Health Research Project, Gaibandha, Bangladesh. S. El Arifeen is with the International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. U. Ashorn is with the Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. J. Belizan is with the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. R.E. Black, P. Christian, A.B. Labrique, K. West, and L.S-F. Wu are with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. L.M. De-Regil is with Nutrition International, Ottawa, Ontario, Canada. K. Dewey is with the University of California, Davis, Davis, California, USA. M.J. Dibley is with The University of Sydney, Sydney, New South Wales, Australia. W. Fawzi and C.R. Sudfeld are with the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA. H. Friis and P. Kaestel are with the University of Copenhagen, Copenhagen, Denmark. E. Gomo is with the University of Zimbabwe, Harare, Zimbabwe. L. Huybregts is with the International Food Policy Research Institute, Washington, DC, USA. R. Jayatissa is with the Medical Research Institute, Colombo, Sri Lanka. S.K. Khatry is with the Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal. P.W. Kolsteren is with Ghent University, Ghent, Belgium. M. McCauley is with the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom. B.M. Oaks is with the University of Rhode Island, Kingston, Rhode Island, USA. E. Piwoz is with the Bill & Melinda Gates Foundation, Seattle, Washington, USA. S. Shaikh is with the Society for Applied Studies, New Delhi, India. D.D. Soekarjo is with the Savica Consultancy, Jakarta, Indonesia. W. Urassa is with the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. N. Zagre is with the UNICEF Regional Office for West and Central Africa, Dakar, Senegal. L. Zeng and Z. Zhu are with the School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
| | - Simon Cousens
- E.C. Keats, N. Akseer, P. Thurairajah, and Z.A. Bhutta are with the Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. S. Cousens is with the London School of Hygiene & Tropical Medicine, London, United Kingdom. Z.A. Bhutta is with the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Z.A. Bhutta is with the Aga Khan University, Karachi, Pakistan. H. Ali is with the JiVitA Maternal and Child Nutrition and Health Research Project, Gaibandha, Bangladesh. S. El Arifeen is with the International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. U. Ashorn is with the Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. J. Belizan is with the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. R.E. Black, P. Christian, A.B. Labrique, K. West, and L.S-F. Wu are with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. L.M. De-Regil is with Nutrition International, Ottawa, Ontario, Canada. K. Dewey is with the University of California, Davis, Davis, California, USA. M.J. Dibley is with The University of Sydney, Sydney, New South Wales, Australia. W. Fawzi and C.R. Sudfeld are with the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA. H. Friis and P. Kaestel are with the University of Copenhagen, Copenhagen, Denmark. E. Gomo is with the University of Zimbabwe, Harare, Zimbabwe. L. Huybregts is with the International Food Policy Research Institute, Washington, DC, USA. R. Jayatissa is with the Medical Research Institute, Colombo, Sri Lanka. S.K. Khatry is with the Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal. P.W. Kolsteren is with Ghent University, Ghent, Belgium. M. McCauley is with the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom. B.M. Oaks is with the University of Rhode Island, Kingston, Rhode Island, USA. E. Piwoz is with the Bill & Melinda Gates Foundation, Seattle, Washington, USA. S. Shaikh is with the Society for Applied Studies, New Delhi, India. D.D. Soekarjo is with the Savica Consultancy, Jakarta, Indonesia. W. Urassa is with the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. N. Zagre is with the UNICEF Regional Office for West and Central Africa, Dakar, Senegal. L. Zeng and Z. Zhu are with the School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
| | - Zulfiqar A Bhutta
- E.C. Keats, N. Akseer, P. Thurairajah, and Z.A. Bhutta are with the Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. S. Cousens is with the London School of Hygiene & Tropical Medicine, London, United Kingdom. Z.A. Bhutta is with the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. Z.A. Bhutta is with the Aga Khan University, Karachi, Pakistan. H. Ali is with the JiVitA Maternal and Child Nutrition and Health Research Project, Gaibandha, Bangladesh. S. El Arifeen is with the International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. U. Ashorn is with the Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. J. Belizan is with the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. R.E. Black, P. Christian, A.B. Labrique, K. West, and L.S-F. Wu are with the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA. L.M. De-Regil is with Nutrition International, Ottawa, Ontario, Canada. K. Dewey is with the University of California, Davis, Davis, California, USA. M.J. Dibley is with The University of Sydney, Sydney, New South Wales, Australia. W. Fawzi and C.R. Sudfeld are with the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA. H. Friis and P. Kaestel are with the University of Copenhagen, Copenhagen, Denmark. E. Gomo is with the University of Zimbabwe, Harare, Zimbabwe. L. Huybregts is with the International Food Policy Research Institute, Washington, DC, USA. R. Jayatissa is with the Medical Research Institute, Colombo, Sri Lanka. S.K. Khatry is with the Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal. P.W. Kolsteren is with Ghent University, Ghent, Belgium. M. McCauley is with the Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom. B.M. Oaks is with the University of Rhode Island, Kingston, Rhode Island, USA. E. Piwoz is with the Bill & Melinda Gates Foundation, Seattle, Washington, USA. S. Shaikh is with the Society for Applied Studies, New Delhi, India. D.D. Soekarjo is with the Savica Consultancy, Jakarta, Indonesia. W. Urassa is with the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. N. Zagre is with the UNICEF Regional Office for West and Central Africa, Dakar, Senegal. L. Zeng and Z. Zhu are with the School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, Shaanxi, China
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Kamali M, Wright JE, Akseer N, Tasic H, Conway K, Brar S, Imanalieva C, Maritz G, Rizvi A, Stanbekov B, Abduvalieva S, Toialieva E, Bhutta ZA. Trends and determinants of newborn mortality in Kyrgyzstan: a Countdown country case study. Lancet Glob Health 2021; 9:e352-e360. [PMID: 33308422 PMCID: PMC7886658 DOI: 10.1016/s2214-109x(20)30460-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Kyrgyzstan has made considerable progress in reducing child mortality compared with other countries in the region, despite a comparatively low economic standing. However, maternal mortality is still high. Given the availability of an established birth registration system, we aimed to comprehensively assess the trends and determinants of reproductive, maternal, newborn, and child health in Kyrgyzstan. METHODS For this Countdown to 2030 country case study, we used publicly available data repositories and the national birth registry of Kyrgyzstan to examine trends and inequalities of reproductive, maternal, and newborn health and mortality between 1990 and 2018, at a national and subnational level. Coverage of newborn and maternal health interventions was assessed and disaggregated by equity dimensions. We did Oaxaca-Blinder decomposition to determine the contextual factors associated with the observed decline in newborn mortality rates. We also undertook a comprehensive review of national policies and programmes, as well as a prospective Lives Saved Tool analysis, to highlight interventions that have the potential to avert the most maternal, neonatal, and child deaths. FINDINGS Over the past two decades, Kyrgyzstan reduced newborn mortality rates by 46% and mortality rates of children younger than 5 years by 69%, whereas maternal mortality rates were reduced by 7% and stillbirth rates by 29%. The leading causes of neonatal deaths were prematurity and asphyxia or hypoxia, and preterm small-for-gestational-age infants were more than 80 times more likely to die in their first month of life compared with those born appropriate-for-gestational age at term. Except for contraceptive use, coverage of essential interventions has increased and is generally high, with limited sociodemographic inequities. With scale-up of a few essential neonatal and maternal interventions, 39% of neonatal deaths, 11% of stillbirths, and 19% of maternal deaths could be prevented by 2030. INTERPRETATION Kyrgyzstan has reduced newborn mortality rates considerably, with the potential for further reduction. To achieve and exceed the Sustainable Development Goal 3 targets for newborn survival and reducing stillbirths, Kyrgyzstan needs to scale up packages of interventions for the care of small and sick babies, assure quality of care in all health-care facilities with regionalised perinatal care, and create a linked national registry for mothers and neonates with rapid feedback and accountability. FUNDING US Fund for UNICEF under the Countdown to 2015, UNICEF Kyrgyzstan Office.
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Affiliation(s)
- Mahdis Kamali
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - James E Wright
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Hana Tasic
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Kaitlin Conway
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Saman Brar
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | | | | | - Arjumand Rizvi
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Sagynbu Abduvalieva
- National Center of Mother and Child Health, Ministry of Health, Bishkek, Kyrgyzstan
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
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Bendavid E, Boerma T, Akseer N, Langer A, Malembaka EB, Okiro EA, Wise PH, Heft-Neal S, Black RE, Bhutta ZA. The effects of armed conflict on the health of women and children. Lancet 2021; 397:522-532. [PMID: 33503456 PMCID: PMC7612212 DOI: 10.1016/s0140-6736(21)00131-8] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 10/03/2020] [Accepted: 10/05/2020] [Indexed: 01/16/2023]
Abstract
Women and children bear substantial morbidity and mortality as a result of armed conflicts. This Series paper focuses on the direct (due to violence) and indirect health effects of armed conflict on women and children (including adolescents) worldwide. We estimate that nearly 36 million children and 16 million women were displaced in 2017, on the basis of international databases of refugees and internally displaced populations. From geospatial analyses we estimate that the number of non-displaced women and children living dangerously close to armed conflict (within 50 km) increased from 185 million women and 250 million children in 2000, to 265 million women and 368 million children in 2017. Women's and children's mortality risk from non-violent causes increases substantially in response to nearby conflict, with more intense and more chronic conflicts leading to greater mortality increases. More than 10 million deaths in children younger than 5 years can be attributed to conflict between 1995 and 2015 globally. Women of reproductive ages living near high intensity conflicts have three times higher mortality than do women in peaceful settings. Current research provides fragmentary evidence about how armed conflict indirectly affects the survival chances of women and children through malnutrition, physical injuries, infectious diseases, poor mental health, and poor sexual and reproductive health, but major systematic evidence is sparse, hampering the design and implementation of essential interventions for mitigating the harms of armed conflicts.
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Affiliation(s)
- Eran Bendavid
- Center for Population Health Sciences, Division of Primary Care and Population Health, Department of Medicine, Stanford University, CA, USA.
| | - Ties Boerma
- Center for Global Public Health, University of Manitoba, Winnipeg, MB, Canada
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children (SickKids), Toronto, ON, Canada; The Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Ana Langer
- Women and Health Initiative, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Espoir Bwenge Malembaka
- Ecole Régionale de Santé Publique, Faculté de Médecine, Université Catholique de Bukavu, Bukavu, DR Congo
| | - Emelda A Okiro
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Paul H Wise
- Department of Pediatrics, Stanford University, CA, USA
| | - Sam Heft-Neal
- Center on Food Security and the Environment, Stanford University, CA, USA
| | - Robert E Black
- The Institute for International Programs, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children (SickKids), Toronto, ON, Canada; Centre of Excellence in Women and Child Health and Institute for Global Health and Development, The Aga Khan University, Karachi, Pakistan
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Akseer N, Mehta S, Wigle J, Chera R, Brickman ZJ, Al-Gashm S, Sorichetti B, Vandermorris A, Hipgrave DB, Schwalbe N, Bhutta ZA. Non-communicable diseases among adolescents: current status, determinants, interventions and policies. BMC Public Health 2020; 20:1908. [PMID: 33317507 PMCID: PMC7734741 DOI: 10.1186/s12889-020-09988-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 11/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Addressing non-communicable disease (NCDs) is a global priority in the Sustainable Development Goals, especially for adolescents. However, existing literature on NCD burden, risk factors and determinants, and effective interventions and policies for targeting these diseases in adolescents, is limited. This study develops an evidence-based conceptual framework, and highlights pathways between risk factors and interventions to NCD development during adolescence (ages 10-19 years) and continuing into adulthood. Additionally, the epidemiologic profile of key NCD risk factors and outcomes among adolescents and preventative NCD policies/laws/legislations are examined, and a multivariable analysis is conducted to explore the determinants of NCDs among adolescents and adults. METHODS We reviewed literature to develop an adolescent-specific conceptual framework for NCDs. Global data repositories were searched from Jan-July 2018 for data on NCD-related risk factors, outcomes, and policy data for 194 countries from 1990 to 2016. Disability-Adjusted Life Years were used to assess disease burden. A hierarchical modeling approach and ordinary least squares regression was used to explore the basic and underlying causes of NCD burden. RESULTS Mental health disorders are the most common NCDs found in adolescents. Adverse behaviours and lifestyle factors, specifically smoking, alcohol and drug use, poor diet and metabolic syndrome, are key risk factors for NCD development in adolescence. Across countries, laws and policies for preventing NCD-related risk factors exist, however those targeting contraceptive use, drug harm reduction, mental health and nutrition are generally limited. Many effective interventions for NCD prevention exist but must be implemented at scale through multisectoral action utilizing diverse delivery mechanisms. Multivariable analyses showed that structural/macro, community and household factors have significant associations with NCD burden among adolescents and adults. CONCLUSIONS Multi-sectoral efforts are needed to target NCD risk factors among adolescents to mitigate disease burden and adverse outcomes in adulthood. Findings could guide policy and programming to reduce NCD burden in the sustainable development era.
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Affiliation(s)
- N. Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4 Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - S. Mehta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4 Canada
| | - J. Wigle
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4 Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - R. Chera
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4 Canada
| | - Z. J. Brickman
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4 Canada
| | - S. Al-Gashm
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4 Canada
| | - B. Sorichetti
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4 Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - A. Vandermorris
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4 Canada
- Division of Adolescent Medicine, Hospital for Sick Children, Toronto, Canada
| | | | | | - Z. A. Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4 Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
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Amsalu R, Schulte-Hillen C, Garcia DM, Lafferty N, Morris CN, Gee S, Akseer N, Scudder E, Sami S, Barasa SO, Had H, Maalim MF, Moluh S, Berkelhamer S. Lessons Learned From Helping Babies Survive in Humanitarian Settings. Pediatrics 2020; 146:S208-S217. [PMID: 33004642 DOI: 10.1542/peds.2020-016915l] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 11/24/2022] Open
Abstract
Humanitarian crises, driven by disasters, conflict, and disease epidemics, have profound effects on society, including on people's health and well-being. Occurrences of conflict by state and nonstate actors have increased in the last 2 decades: by the end of 2018, an estimated 41.3 million internally displaced persons and 20.4 million refugees were reported worldwide, representing a 70% increase from 2010. Although public health response for people affected by humanitarian crisis has improved in the last 2 decades, health actors have made insufficient progress in the use of evidence-based interventions to reduce neonatal mortality. Indeed, on average, conflict-affected countries report higher neonatal mortality rates and lower coverage of key maternal and newborn health interventions compared with non-conflict-affected countries. As of 2018, 55.6% of countries with the highest neonatal mortality rate (≥30 per 1000 live births) were affected by conflict and displacement. Systematic use of new evidence-based interventions requires the availability of a skilled health workforce and resources as well as commitment of health actors to implement interventions at scale. A review of the implementation of the Helping Babies Survive training program in 3 refugee responses and protracted conflict settings identify that this training is feasible, acceptable, and effective in improving health worker knowledge and competency and in changing newborn care practices at the primary care and hospital level. Ultimately, to improve neonatal survival, in addition to a trained health workforce, reliable supply and health information system, community engagement, financial support, and leadership with effective coordination, policy, and guidance are required.
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Affiliation(s)
- Ribka Amsalu
- Department of Global Health, Save the Children, Washington, District of Columbia; .,University of California San Francisco, San Francisco, California
| | - Catrin Schulte-Hillen
- Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | | | - Nadia Lafferty
- Medical Department, Médecins Sans Frontières, Barcelona, Spain
| | - Catherine N Morris
- Department of Global Health, Save the Children, Washington, District of Columbia
| | - Stephanie Gee
- Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Elaine Scudder
- Department of Global Health, Save the Children, Washington, District of Columbia
| | - Samira Sami
- Department of International Health and Center for Humanitarian Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Sammy O Barasa
- Department of Nursing, Kenya Medical Training College, Machakos, Kenya
| | - Hussein Had
- Save the Children, Garowe, Puntland, Somalia
| | | | - Seidou Moluh
- Public Health Section, United Nations High Commissioner for Refugees, Geneva, Switzerland
| | - Sara Berkelhamer
- Department of Pediatrics, University of Washington, Seattle, Washington
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Vaivada T, Akseer N, Akseer S, Somaskandan A, Stefopulos M, Bhutta ZA. Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline. Am J Clin Nutr 2020; 112:777S-791S. [PMID: 32860401 PMCID: PMC7487433 DOI: 10.1093/ajcn/nqaa159] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 05/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Progress has been made worldwide in reducing chronic undernutrition and rates of linear growth stunting in children under 5 y of age, although rates still remain high in many regions. Policies, programs, and interventions supporting maternal and child health and nutrition have the potential to improve child growth and development. OBJECTIVE This article synthesizes the available global evidence on the drivers of national declines in stunting prevalence and compares the relative effect of major drivers of stunting decline between countries. METHODS We conducted a systematic review of published peer-reviewed and gray literature analyzing the relation between changes in key determinants of child linear growth and contemporaneous changes in linear growth outcomes over time. RESULTS Among the basic determinants of stunting assessed within regression-decomposition analyses, improvement in asset index score was a consistent and strong driver of improved linear growth outcomes. Increased parental education was also a strong predictor of improved child growth. Of the underlying determinants of stunting, reduced rates of open defecation, improved sanitation infrastructure, and improved access to key maternal health services, including optimal antenatal care and delivery in a health facility or with a skilled birth attendant, all accounted for substantially improved child growth, although the magnitude of variation explained by each differed substantially between countries. At the immediate level, changes in several maternal characteristics predicted modest stunting reductions, including parity, interpregnancy interval, and maternal height. CONCLUSIONS Unique sets of stunting determinants predicted stunting reduction within countries that have reduced stunting. Several common drivers emerge at the basic, underlying, and immediate levels, including improvements in maternal and paternal education, household socioeconomic status, sanitation conditions, maternal health services access, and family planning. Further data collection and in-depth mixed-methods research are required to strengthen recommendations for those countries where the stunting burden remains unacceptably high.
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Affiliation(s)
- Tyler Vaivada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Selai Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Ahalya Somaskandan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
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Bhutta ZA, Akseer N, Keats EC, Vaivada T, Baker S, Horton SE, Katz J, Menon P, Piwoz E, Shekar M, Victora C, Black R. How countries can reduce child stunting at scale: lessons from exemplar countries. Am J Clin Nutr 2020; 112:894S-904S. [PMID: 32692800 PMCID: PMC7487427 DOI: 10.1093/ajcn/nqaa153] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Child stunting and linear growth faltering have declined over the past few decades and several countries have made exemplary progress. OBJECTIVES To synthesize findings from mixed methods studies of exemplar countries to provide guidance on how to accelerate reduction in child stunting. METHODS We did a qualitative and quantitative synthesis of findings from existing literature and 5 exemplar country studies (Nepal, Ethiopia, Peru, Kyrgyz Republic, Senegal). Methodology included 4 broad research activities: 1) a series of descriptive analyses of cross-sectional data from demographic and health surveys and multiple indicator cluster surveys; 2) multivariable analysis of quantitative drivers of change in linear growth; 3) interviews and focus groups with national experts and community stakeholders and mothers; and 4) a review of policy and program evolution related to nutrition. RESULTS Several countries have dramatically reduced child stunting prevalence, with or without closing geographical, economic, and other population inequalities. Countries made progress through interventions from within and outside the health sector, and despite significant heterogeneity and differences in context, contributions were comparable from health and nutrition sectors (40% of change) and other sectors (50%), previously called nutrition-specific and -sensitive strategies. Improvements in maternal education, maternal nutrition, maternal and newborn care, and reductions in fertility/reduced interpregnancy intervals were strong contributors to change. A roadmap to reducing child stunting at scale includes several steps related to diagnostics, stakeholder consultations, and implementing direct and indirect nutrition interventions related to the health sector and nonhealth sector . CONCLUSIONS Our results show that child stunting reduction is possible even in diverse and challenging contexts. We propose that our framework of organizing nutrition interventions as direct/indirect and inside/outside the health sector should be considered when mapping causal pathways of child stunting and planning interventions and strategies to accelerate stunting reduction to achieve the 2030 Sustainable Development Goals.
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Affiliation(s)
- Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Emily C Keats
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tyler Vaivada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shawn Baker
- United States Agency for International Development, Washington, DC, USA
| | - Susan E Horton
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Joanne Katz
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, South Asia Office, New Delhi, India
| | - Ellen Piwoz
- Global Development Division, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Meera Shekar
- Health, Nutrition & Population, World Bank, Washington, DC, USA
| | - Cesar Victora
- Federal University of Pelotas, Pelotas, Rio Grande do Sul, Brazil
| | - Robert Black
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Huicho L, Vidal-Cárdenas E, Akseer N, Brar S, Conway K, Islam M, Juarez E, Rappaport AI, Tasic H, Vaivada T, Wigle J, Bhutta ZA. Drivers of stunting reduction in Peru: a country case study. Am J Clin Nutr 2020; 112:816S-829S. [PMID: 32860403 PMCID: PMC7487430 DOI: 10.1093/ajcn/nqaa164] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 06/01/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Peru reduced its under-5 child stunting prevalence notably from 31.3% in 2000 to 13.1% in 2016. OBJECTIVES We aimed to study factors and key enablers of child stunting reduction in Peru from 2000-2016. METHODS Demographic and Health Surveys were used to conduct descriptive analyses [height-for-age z scores (HAZ) means and distributions, equity analysis, predicted child growth curves through polynomial regressions] and advanced regression analyses. An ecological (at department level) multilevel regression analysis was conducted to identify the major predictors of stunting decline from 2000 to 2016, and Oaxaca-Blinder decomposition was conducted to identify the relative contribution of each factor to child HAZ change. A systematic literature review, policy and program analysis, and interviews with relevant stakeholders were conducted to understand key drivers of stunting decline in Peru. RESULTS The distribution of HAZ scores showed a slight rightward shift from 2000 to 2007/2008, and a greater shift from 2007/2008 to 2016. Stunting reduction was higher in the lowest wealth quintile, in rural areas, and among children with the least educated mothers. Decomposing predicted changes showed that the most important factors were increased maternal BMI and maternal height, improved maternal and newborn health care, increased parental education, migration to urban areas, and reduced fertility. Key drivers included the advocacy role of civil society and political leadership around poverty and stunting reduction since the early 2000s. Key enablers included the economic growth and the consolidation of democracy since the early 2000s, and the acknowledgement that stunting reduction needs much more than food supplementation. CONCLUSIONS Peru reduced child stunting owing to improved socioeconomic determinants, sustained implementation of out-of-health-sector and within-health-sector changes, and implementation of health interventions. These efforts were driven through a multisectoral approach, strong civil society advocacy, and keen political leadership. Peru's experience offers useful lessons on how to tackle the problem of stunting under differing scenarios, with the participation of multiple sectors.
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Affiliation(s)
- Luis Huicho
- Research Center for Integral and Sustainable Development, Cayetano Heredia University, Lima, Peru
- Maternal and Child Health Research Center, Cayetano Heredia University, Lima, Peru
- School of Medicine, Cayetano Heredia University, Lima, Peru
| | - Elisa Vidal-Cárdenas
- Research Center for Integral and Sustainable Development, Cayetano Heredia University, Lima, Peru
- Maternal and Child Health Research Center, Cayetano Heredia University, Lima, Peru
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Samanpreet Brar
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kaitlin Conway
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Muhammad Islam
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elisa Juarez
- Center for the Promotion and Defense of Sexual and Reproductive Rights (PROMSEX), Lima, Peru
| | - Aviva I Rappaport
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hana Tasic
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tyler Vaivada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jannah Wigle
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
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Akseer N, Vaivada T, Rothschild O, Ho K, Bhutta ZA. Understanding multifactorial drivers of child stunting reduction in Exemplar countries: a mixed-methods approach. Am J Clin Nutr 2020; 112:792S-805S. [PMID: 32649742 PMCID: PMC7487431 DOI: 10.1093/ajcn/nqaa152] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 05/22/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Several countries have notably reduced childhood stunting relative to economic growth over the past 15-20 y. The Exemplars in Stunting Reduction project, or "Exemplars," studies success factors among these countries with a lens toward replicability. OBJECTIVES This paper details the standardized mixed-methods framework for studying determinants of childhood stunting reduction applied in Exemplars studies. METHODS An expert technical advisory group (TAG), criteria for identifying Exemplar countries, evidence-based frameworks, mixed methodologies (quantitative, qualitative, policy, literature review), effective research partnerships, case study process and timeline, and data triangulation and corroboration are presented. RESULTS Experts in health, nutrition, and evaluation methods were selected at the study outset to provide technical support to all phases of research (TAG). Exemplar countries were selected by the TAG, who considered quantitative data (e.g., annual rates of stunting change compared with economic growth, country population size) and qualitative insights (e.g., logistics of country work, political stability). Experienced country research partners were selected and an inception meeting with stakeholder consultations was held to launch research and garner support. Evidence-based conceptual frameworks underpinned all Exemplars research activities. A systematic review of published peer-reviewed and grey literature was undertaken, along with in-depth policy and program analysis of nutrition-specific and -sensitive investments. Both descriptive and advanced quantitative analysis was undertaken (e.g., equity analyses, difference-in-difference regression, Oaxaca-Blinder decomposition). Qualitative data collection using in-depth interviews and focus groups was conducted with national and community stakeholders (i.e., child care workers and mothers) to understand country experiences. The case study process was iterative, and all research outputs were triangulated to develop the stunting reduction narrative for each country. Findings were shared with country experts for weigh-in and corroboration through dissemination events. CONCLUSIONS Exemplars research uses a mixed-methods framework for studying positive outliers that can be applied across diverse health and development outcomes.
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Affiliation(s)
- Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Tyler Vaivada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | | | - Kevin Ho
- Gates Ventures, Kirkland, Washington, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
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23
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Wigle JM, Akseer N, Mogilevskii R, Brar S, Conway K, Enikeeva Z, Iamshchikova M, Islam M, Kirbasheva D, Rappaport AI, Tasic H, Vaivada T, Bhutta ZA. Drivers of stunting reduction in the Kyrgyz Republic: A country case study. Am J Clin Nutr 2020; 112:830S-843S. [PMID: 32672334 PMCID: PMC7487426 DOI: 10.1093/ajcn/nqaa120] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 04/30/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic malnutrition among infants and children continues to represent a global public health concern. The Kyrgyz Republic has achieved rapid declines in stunting over the last 20 y, despite modest increases in gross domestic product per capita. OBJECTIVE This study aimed to conduct a systematic, in-depth assessment of national, community, household, and individual drivers of nutrition change and stunting reduction, as well as nutrition-specific and -sensitive policies and programs, in the Kyrgyz Republic. METHODS This mixed methods study employed 4 inquiry methods, including: 1) a systematic scoping literature review; 2) retrospective quantitative data analyses, including linear regression multivariable hierarchical modeling, difference-in-difference analysis, and Oaxaca-Blinder decomposition; 3) qualitative data collection and analysis; and 4) analysis of key nutrition-specific and -sensitive policies and programs. RESULTS Stunting prevalence has decreased in the Kyrgyz Republic, however, subnational variations and inequities persist. Child growth Victora curves show improvements in height-for-age z-scores (HAZ) for children in the Kyrgyz Republic between 1997 and 2014, indicating increased intrauterine growth and population health improvements. The decomposition analysis explained 88.9% (0.637 SD increase) of the predicted change in HAZ for children under 3 y (1997-2012). Key factors included poverty (61%), maternal nutrition (14%), paternal education (6%), fertility (6%), maternal age (3%), and wealth accumulation (2%). Qualitative analysis revealed poverty reduction, increased migration and remittances, food security, and maternal nutrition as key drivers of stunting decline. Systematic scoping literature review findings supported quantitative and qualitative results, and indicated that land reforms and improved food security represented important factors. Key nutrition-specific and -sensitive policies and programs implemented involved breastfeeding promotion, social protection schemes, and land and health sector reforms. CONCLUSIONS Improvements in stunting were achieved amidst political and economic changes. Multilevel enablers, including poverty reduction, improved food security, and introduction of land and health reforms have contributed to improvements in health, nutrition, and stunting among children in the Kyrgyz Republic.
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Affiliation(s)
- Jannah M Wigle
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Roman Mogilevskii
- Institute of Public Policy and Administration, University of Central Asia, Bishkek, Kyrgyz Republic
| | - Samanpreet Brar
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Kaitlin Conway
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Zalina Enikeeva
- Institute of Public Policy and Administration, University of Central Asia, Bishkek, Kyrgyz Republic
| | - Mariia Iamshchikova
- Institute of Public Policy and Administration, University of Central Asia, Bishkek, Kyrgyz Republic
| | - Muhammad Islam
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Dilbara Kirbasheva
- Institute of Public Policy and Administration, University of Central Asia, Bishkek, Kyrgyz Republic
| | - Aviva I Rappaport
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Hana Tasic
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Tyler Vaivada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
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Conway K, Akseer N, Subedi RK, Brar S, Bhattarai B, Dhungana RR, Islam M, Mainali A, Pradhan N, Tasic H, Thakur DN, Wigle J, Maskey M, Bhutta ZA. Drivers of stunting reduction in Nepal: a country case study. Am J Clin Nutr 2020; 112:844S-859S. [PMID: 32889522 PMCID: PMC7487432 DOI: 10.1093/ajcn/nqaa218] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 07/09/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Chronic child malnutrition represents a serious global health concern. Over the last several decades, Nepal has seen a significant decline in linear growth stunting - a physical manifestation of chronic malnutrition - despite only modest economic growth and significant political instability. OBJECTIVE This study aimed to conduct an in-depth assessment of the determinants of stunting reduction in Nepal from 1996 to 2016, with specific attention paid to national-, community-, household-, and individual-level factors, as well as relevant nutrition-specific and -sensitive initiatives rolled out within the country. METHODS Using a mixed-methods approach, 4 types of inquiry were employed: 1) a systematic review of published peer-reviewed and gray literature; 2) retrospective quantitative data analyses using Demographic and Health Surveys from 1996 to 2016; 3) a review of key nutrition-specific and -sensitive policies and programs; and 4) retrospective qualitative data collection and analyses. RESULTS Mean height-for-age z-scores (HAZ) improved by 0.94 SDs from 1996 to 2016. Subnational variation and socioeconomic inequalities in stunting outcomes persisted, with the latter widening over time. Decomposition analysis for children aged under 5 y explained 90.9% of the predicted change in HAZ, with key factors including parental education (24.7%), maternal nutrition (19.3%), reduced open defecation (12.3%), maternal and newborn health care (11.5%), and economic improvement (9.0%). Key initiatives focused on decentralizing the health system and mobilizing community health workers to increase accessibility; long-standing nationwide provision of basic health interventions; targeted efforts to improve maternal and child health; and the prioritization of nutrition-sensitive initiatives by both government and donors. National and community stakeholders and mothers at village level highlighted a mixture of poverty reduction, access to health services, improved education, and increased access to water, sanitation, and hygiene as drivers of stunting reduction. CONCLUSIONS Improvements in both nutrition-specific and nutrition-sensitive sectors have been critical to Nepal's stunting decline, particularly in the areas of poverty reduction, health, education, and sanitation.
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Affiliation(s)
- Kaitlin Conway
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Samanpreet Brar
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | | | | | - Muhammad Islam
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | | | | | - Hana Tasic
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | | | - Jannah Wigle
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Tasic H, Akseer N, Gebreyesus SH, Ataullahjan A, Brar S, Confreda E, Conway K, Endris BS, Islam M, Keats E, Mohammedsanni A, Wigle J, Bhutta ZA. Drivers of stunting reduction in Ethiopia: a country case study. Am J Clin Nutr 2020; 112:875S-893S. [PMID: 32844167 PMCID: PMC7487434 DOI: 10.1093/ajcn/nqaa163] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 06/01/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Chronic undernutrition in children continues to be a global public health concern. Ethiopia has documented a significant decline in the prevalence of childhood stunting, a measure of chronic undernutrition, over the last 20 y. OBJECTIVES The aim of this research was to conduct a systematic assessment of the determinants that have driven child stunting reduction in Ethiopia from 2000 to 2016, focused on the national, community, household, and individual level. METHODS This study employed both quantitative and qualitative methods. Specifically, a systematic literature review, retrospective quantitative data analysis using Demographic and Health Surveys from 2000-2016, qualitative data collection and analysis, and analyses of key nutrition-specific and -sensitive policies and programs were undertaken. RESULTS National stunting prevalence improved from 51% in 2000 to 32% in 2016. Regional variations exist, as do pro-rich, pro-urban, and pro-educated inequalities. Child height-for-age z score (HAZ) decomposition explained >100% of predicted change in mean HAZ between 2000 and 2016, with key factors including increases in total consumable crop yield (32% of change), increased number of health workers (28%), reduction in open defecation (13%), parental education (10%), maternal nutrition (5%), economic improvement (4%), and reduced diarrhea incidence (4%). Policies and programs that were key to stunting decline focused on promoting rural agriculture to improve food security; decentralization of the health system, incorporating health extension workers to improve rural access to health services and reduce open defecation; multisectoral poverty reduction strategies; and a commitment to improving girls' education. Interviews with national and regional stakeholders and mothers in communities presented improvements in health service access, women and girls' education, improved agricultural production, and improved sanitation and child care practices as drivers of stunting reduction. CONCLUSIONS Ethiopia's stunting decline was driven by both nutrition-specific and -sensitive sectors, with particular focus on the agriculture sector, health care access, sanitation, and education.
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Affiliation(s)
- Hana Tasic
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Seifu H Gebreyesus
- Department of Nutrition and Dietetics, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Anushka Ataullahjan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Samanpreet Brar
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Erica Confreda
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kaitlin Conway
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bilal S Endris
- Department of Nutrition and Dietetics, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Muhammad Islam
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Emily Keats
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Afrah Mohammedsanni
- Department of Nutrition and Dietetics, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Jannah Wigle
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
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Brar S, Akseer N, Sall M, Conway K, Diouf I, Everett K, Islam M, Sène PIS, Tasic H, Wigle J, Bhutta Z. Drivers of stunting reduction in Senegal: a country case study. Am J Clin Nutr 2020; 112:860S-874S. [PMID: 32778881 PMCID: PMC7487429 DOI: 10.1093/ajcn/nqaa151] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/20/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Senegal has been an exemplar country in the West African region, reducing child stunting prevalence by 17.9% from 1992 to 2017. OBJECTIVES In this study, we aimed to conduct a systematic in-depth assessment of factors at the national, community, household, and individual levels to determine the key enablers of Senegal's success in reducing stunting in children <5 y old between 1992/93 and 2017. METHODS A mixed methods approach was implemented, comprising quantitative data analysis, a systematic literature review, creation of a timeline of nutrition-related programs, and qualitative interviews with national and regional stakeholders and mothers in communities. Demographic and Health Surveys and Multiple Indicator Cluster Surveys were used to explore stunting inequalities and factors related to the change in height-for-age z-score (HAZ) using difference-in-difference linear regression and the Oaxaca-Blinder decomposition method. RESULTS Population-wide gains in average child HAZ and stunting prevalence have occurred from 1992/93 to 2017. Stunting prevalence reduction varied by geographical region and prevalence gaps were reduced slightly between wealth quintiles, maternal education groups, and urban compared with rural residence. Statistical determinants of change included improvements in maternal and newborn health (27.8%), economic improvement (19.5%), increases in parental education (14.9%), and better piped water access (8.1%). Key effective nutrition programs used a community-based approach, including the Community Nutrition Program and the Nutrition Enhancement Program. Stakeholders felt sustained political will and multisectoral collaboration along with improvements in poverty, women's education, hygiene practices, and accessibility to health services at the community level reduced the burden of stunting. CONCLUSIONS Senegal's success in the stunting decline is largely attributed to the country's political stability, the government's prioritization of nutrition and execution of nutrition efforts using a multisectoral approach, improvements in the availability of health services and maternal education, access to piped water and sanitation facilities, and poverty reduction. Further efforts in the health, water and sanitation, and agriculture sectors will support continued success.
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Affiliation(s)
- Samanpreet Brar
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Kaitlin Conway
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Ibrahima Diouf
- Agence Nationale de la Statistique et de la Démographie, Dakar, Senegal
| | - Karl Everett
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Muhammad Islam
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | | | - Hana Tasic
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Jannah Wigle
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Campisi SC, Carducci B, Akseer N, Zasowski C, Szatmari P, Bhutta ZA. Suicidal behaviours among adolescents from 90 countries: a pooled analysis of the global school-based student health survey. BMC Public Health 2020; 20:1102. [PMID: 32772922 PMCID: PMC7416394 DOI: 10.1186/s12889-020-09209-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 07/05/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Understanding the burden and determinants of suicide during adolescence is key to achieving global health goals. We examined the prevalence and determinants of self-reported suicidal ideation and attempts among younger (13-15 years) and older adolescents (16-17 years). METHODS Pooled prevalence estimates with 95% confidence interval, were calculated for suicide ideation and attempts for 118 surveys from 90 countries that administered the Global School-based Student Health Survey (GSHS) to adolescents (13-17 years of age) from 2003 to 2017. Indicators (including individual and social factors) associated with suicidal ideation and attempts were determined from multivariable linear regressions on key outcomes. RESULTS The prevalence of suicidal ideation representing 397,299 adolescents (51.3% female) was significantly higher among girls than boys whereas attempts did not differ by age or sex. Being bullied, or having no close friends was associated with suicidal ideation among girls 13-15 years and 16-17 years, respectively. Among all boys, being in a fight and having no close friends was associated with suicidal ideation with the addition of serious injury for boys 13-15 years. Common to all younger adolescents was an association of suicide attempt with being bullied and having had a serious injury. Among young boys, having no close friends was an additional indicator for suicide attempt. Having no close friends was associated with suicide attempt in older adolescents with the addition to being bullied in older girls and serious injury in older boys. CONCLUSIONS Building positive social relationships with peers and avoiding serious injury appear key to suicide prevention strategies for vulnerable adolescents. Targeted programs by age group and sex for such indicators could improve mental health during adolescence in low and middle-income countries, given the diverse risk profiles for suicidal ideation and attempts.
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Affiliation(s)
- Susan C. Campisi
- Centre for Global Child Health, Hospital for Sick Children, 686 Bay Street, 11th Floor, Suite 11.9805, Toronto, ON M5G 0A4 Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King’s Circle College, Toronto, Ontario M5S 1A8 Canada
| | - Bianca Carducci
- Centre for Global Child Health, Hospital for Sick Children, 686 Bay Street, 11th Floor, Suite 11.9805, Toronto, ON M5G 0A4 Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King’s Circle College, Toronto, Ontario M5S 1A8 Canada
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, 686 Bay Street, 11th Floor, Suite 11.9805, Toronto, ON M5G 0A4 Canada
| | - Clare Zasowski
- School of Nutrition, Faculty of Community Service, Ryerson University, Kerr Hall South, Room KHS-349; 50 Gould Street, Toronto, Ontario M5B 1X8 Canada
| | - Peter Szatmari
- Department of Psychiatry, Hospital for Sick Children, 555 University Avenue, Burton Wing, Toronto, Ontario M5G 1X8 Canada
- Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario M5T 1R8 Canada
- Centre for Addiction, and Mental Health, Cundill Centre for Child and Youth Depression, 80 Workman Way, Toronto, Ontario M6J 1H4 Canada
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, Hospital for Sick Children, 686 Bay Street, 11th Floor, Suite 11.9805, Toronto, ON M5G 0A4 Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King’s Circle College, Toronto, Ontario M5S 1A8 Canada
- Centre of Excellence in Women, and Child Health, Aga Khan University, Stadium Road, PO Box 3500, Karachi, 74800 Pakistan
- Dalla Lana School of Public Health University of Toronto, Health Sciences Building, 155 College Street, 6th floor, Toronto, Ontario M5T 3M7 Canada
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Akseer N, Kandru G, Keats EC, Bhutta ZA. COVID-19 pandemic and mitigation strategies: implications for maternal and child health and nutrition. Am J Clin Nutr 2020; 112:251-256. [PMID: 32559276 PMCID: PMC7337702 DOI: 10.1093/ajcn/nqaa171] [Citation(s) in RCA: 150] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/08/2020] [Indexed: 02/01/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) continues to ravage health and economic metrics globally, including progress in maternal and child nutrition. Although there has been focus on rising rates of childhood wasting in the short term, maternal and child undernutrition rates are also likely to increase as a consequence of COVID-19 and its impacts on poverty, coverage of essential interventions, and access to appropriate nutritious foods. Key sectors at particular risk of collapse or reduced efficiency in the wake of COVID-19 include food systems, incomes, and social protection, health care services for women and children, and services and access to clean water and sanitation. This review highlights key areas of concern for maternal and child nutrition during and in the aftermath of COVID-19 while providing strategic guidance for countries in their efforts to reduce maternal and child undernutrition. Rooted in learnings from the exemplars in Global Health's Stunting Reduction Exemplars project, we provide a set of recommendations that span investments in sectors that have sustained direct and indirect impact on nutrition. These include interventions to strengthen the food-supply chain and reducing food insecurity to assist those at immediate risk of food shortages. Other strategies could include targeted social safety net programs, payment deferrals, or tax breaks as well as suitable cash-support programs for the most vulnerable. Targeting the most marginalized households in rural populations and urban slums could be achieved through deploying community health workers and supporting women and community members. Community-led sanitation programs could be key to ensuring healthy household environments and reducing undernutrition. Additionally, several COVID-19 response measures such as contact tracing and self-isolation could also be exploited for nutrition protection. Global health and improvements in undernutrition will require governments, donors, and development partners to restrategize and reprioritize investments for the COVID-19 era, and will necessitate data-driven decision making, political will and commitment, and international unity.
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Affiliation(s)
- Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | | | - Emily C Keats
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada,Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan,Address correspondence to ZAB (e-mail: )
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Memon ZA, Muhammad S, Soofi S, Khan N, Akseer N, Habib A, Bhutta Z. Effect and feasibility of district level scale up of maternal, newborn and child health interventions in Pakistan: a quasi-experimental study. BMJ Open 2020; 10:e036293. [PMID: 32665387 PMCID: PMC7365487 DOI: 10.1136/bmjopen-2019-036293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Pakistan has a high burden of maternal, newborn and child morbidity and mortality. Several factors including weak scale-up of evidence-based interventions within the existing health system; lack of community awareness regarding health conditions; and poverty contribute to poor outcomes. Deaths and morbidity are largely preventable if a combination of community and facility-based interventions are rolled out at scale. METHODS AND ANALYSIS Umeed-e-Nau (UeN) (New Hope) project aims is to improve maternal, newborn and child health (MNCH) in eight high-burden districts of Pakistan by scaling up of evidence-based interventions. The project will assess interventions focused on, first, improving the quality of MNCH care at primary level and secondary level. Second, interventions targeting demand generation such as community mobilisation, creating awareness of healthy practices and expanding coverage of outreach services will be evaluated. Third, we will also evaluate interventions targeting the improvement in quality of routine health information and promotion of use of the data for decision-making. Hypothesis of the project is that roll out of evidence-based interventions at scale will lead to at least 20% reduction in perinatal mortality and 30% decrease in diarrhoea and pneumonia case fatality in the target districts whereas two intervention groups will serve as internal controls. Monitoring and evaluation of the programme will be undertaken through conducting periodical population level surveys and quality of care assessments. Descriptive and multivariate analytical methods will be used for assessing the association between different factors, and difference in difference estimates will be used to assess the impact of the intervention on outcomes. ETHICS AND DISSEMINATION The ethics approval was obtained from the Aga Khan University Ethics Review Committee. The findings of the project will be shared with relevant stakeholders and disseminated through open access peer-reviewed journal articles. TRIAL REGISTRATION NUMBER NCT04184544; Pre-results.
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Affiliation(s)
- Zahid Ali Memon
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Shah Muhammad
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid Soofi
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Nimra Khan
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Atif Habib
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
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Carducci B, Das J, Akseer N, Zareen S, Bhutta Z. Protocol: Dietary Intake and Nutritional Status of School-Aged Children in Sindh and Punjab, Pakistan. Curr Dev Nutr 2020. [DOI: 10.1093/cdn/nzaa061_012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
Healthy eating habits in childhood promote optimal growth and development. With rapid globalization and urbanization, dietary patterns have been negatively impacted in many countries. For households and ultimately children, there is increased access to unhealthy, nutrient-poor, ultra-processed foods. In Pakistan, there is a persistent high burden of undernutrition and micronutrient deficiencies coupled with rising overweight and obesity. The recent Pakistan Demographic and Health Survey 2017–18 and National Nutrition Survey 2018 has offered insights into the nutritional status of children under-5 years, adolescents and women of reproductive age. However, there is a marked absence of school-aged children (5–9.9 years) within these surveys, and other school-based surveys miss children out-of-school. As such, the objectives of this research are to determine dietary intake, investigate the household and retail food environments and its association with nutritional status.
Methods
A multi-stage complex household survey was developed for the provinces of Sindh and Punjab, Pakistan. Both in-school and out-of-school-aged children are eligible to participate. Three core modules will be administered to the total sample of children (n = 3832) (and their caregivers): Module 1: Household, Module 2: Child and Module 3: Child Anthropometric Assessment. Three expanded modules will be administered to a subsample of children (n = 1691): Module 4: 24-hour Dietary Recall, Module 5: Child Biochemical Collection and Module 6: Food Environment.
Results
Preliminary results will be available in May 2020.
Conclusions
Given our limited knowledge of dietary intake and food environments of school-aged children in Pakistan, this research aims to provide an understanding of both upstream predictors and downstream health outcomes in order to inform policy and develop an evidence-based school health and nutrition intervention planned for 2021.
Funding Sources
The survey was undertaken under the auspices of the Ministries of Health, Punjab and Sindh, Pakistan with technical support from the Mother & Child Care & Research Inc. and Aga Khan University, Pakistan. Financial support was provided by the Trust for Vaccines & Immunizations Pakistan, MCCR, Governments, with additional unrestricted funding from the Societe des Produits Nestle Ltd, Switzerland.
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Akseer N, Wright J, Tasic H, Everett K, Scudder E, Amsalu R, Boerma T, Bendavid E, Kamali M, Barros AJD, da Silva ICM, Bhutta ZA. Women, children and adolescents in conflict countries: an assessment of inequalities in intervention coverage and survival. BMJ Glob Health 2020; 5:e002214. [PMID: 32133179 PMCID: PMC7042600 DOI: 10.1136/bmjgh-2019-002214] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 12/18/2019] [Indexed: 01/22/2023] Open
Abstract
Introduction Conflict adversely impacts health and health systems, yet its effect on health inequalities, particularly for women and children, has not been systematically studied. We examined wealth, education and urban/rural residence inequalities for child mortality and essential reproductive, maternal, newborn and child health interventions between conflict and non-conflict low-income and middle-income countries (LMICs). Methods We carried out a time-series multicountry ecological study using data for 137 LMICs between 1990 and 2017, as defined by the 2019 World Bank classification. The data set covers approximately 3.8 million surveyed mothers (15-49 years) and 1.1 million children under 5 years including newborns (<1 month), young children (1-59 months) and school-aged children and adolescents (5-14 years). Outcomes include annual maternal and child mortality rates and coverage (%) of family planning services, 1+antenatal care visit, skilled attendant at birth (SBA), exclusive breast feeding (0-5 months), early initiation of breast feeding (within 1 hour), neonatal protection against tetanus, newborn postnatal care within 2 days, 3 doses of diphtheria, pertussis and tetanus vaccine, measles vaccination, and careseeking for pneumonia and diarrhoea. Results Conflict countries had consistently higher maternal and child mortality rates than non-conflict countries since 1990 and these gaps persist despite rates continually declining for both groups. Access to essential reproductive and maternal health services for poorer, less educated and rural-based families was several folds worse in conflict versus non-conflict countries. Conclusions Inequalities in coverage of reproductive/maternal health and child vaccine interventions are significantly worse in conflict-affected countries. Efforts to protect maternal and child health interventions in conflict settings should target the most disadvantaged families including the poorest, least educated and those living in rural areas.
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Affiliation(s)
- Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Wright
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hana Tasic
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karl Everett
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elaine Scudder
- Save the Children USA, Washington, District of Columbia, USA
| | - Ribka Amsalu
- Save the Children USA, Washington, District of Columbia, USA
| | - Ties Boerma
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Eran Bendavid
- Centers for Health Policy, Primary Care and Outcomes Research, Stanford University, Stanford, California, USA
| | - Mahdis Kamali
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aluisio J D Barros
- International Centre for Equity in Health, Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | | | - Zulfiqar Ahmed Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
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Akseer N, Rizvi A, Bhatti Z, Das JK, Everett K, Arur A, Chopra M, Bhutta ZA. Association of Exposure to Civil Conflict With Maternal Resilience and Maternal and Child Health and Health System Performance in Afghanistan. JAMA Netw Open 2019; 2:e1914819. [PMID: 31702799 PMCID: PMC6902774 DOI: 10.1001/jamanetworkopen.2019.14819] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Current studies examining the effects of Afghanistan's conflict transition on the performance of health systems, health service delivery, and health outcomes are outdated and small in scale and do not span all essential reproductive, maternal, newborn, and child health interventions. OBJECTIVE To evaluate associations of conflict severity with improvement of health system performance, use of health services, and child nutrition outcomes in Afghanistan during the 2003 to 2018 reconstruction period. DESIGN, SETTING, AND PARTICIPANTS This population-based survey study included a sequential cross-sectional analysis of individual-level panel data across 2 periods (2003-2010 and 2010-2018) and a difference-in-differences design. Surveys included the 2003 to 2004 and 2010 to 2011 Multiple Indicator Cluster Surveys and the 2018 Afghanistan Health Survey. Afghanistan's 2013 National Nutrition Survey was used to assess nutritional outcomes, and the annual Balanced Scorecard data sets were used to evaluate health system performance. Participants included girls and women aged 12 to 49 years and children younger than 5 years who completed nationally representative household surveys. All analyses were conducted from January 1 through April 30, 2019. EXPOSURES Provinces were categorized as experiencing minimal-, moderate-, and severe-intensity conflict using battle-related death data from the Uppsala Conflict Data Program. MAIN OUTCOMES AND MEASURES Health intervention coverage was examined using 10 standard indicators: contraceptive method (any or modern); antenatal care by a skilled health care professional; facility delivery; skilled birth attendance (SBA); bacille Calmette-Guérin vaccination (BCG); diphtheria, pertussis, and tetanus vaccination (DPT3) or DPT3 plus hepatitis B and poliomyelitis (penta); measles vaccination; care-seeking for acute respiratory infection; oral rehydration therapy for diarrhea; and the Composite Coverage Index. The health system performance was analyzed using the following standard Balanced Scorecard composite domains: client and community, human resources, physical capacity, quality of service provision, management systems, and overall mission. Child stunting, wasting, underweight, and co-occurrence of stunting and wasting were estimated using World Health Organization growth reference cutoffs. RESULTS Responses from 64 815 women (mean [SD] age, 31.0 [8.5] years) were analyzed. Provinces with minimal-intensity conflict had greater gains in contraceptive use (mean annual percentage point change [MAPC], 1.3% vs 0.5%; P < .001), SBA (MAPC, 2.7% vs 1.5%; P = .005), BCG vaccination (MAPC, 3.3% vs -0.5%; P = .002), measles vaccination (MAPC, 1.9% vs -1.0%; P = .01), and DPT3/penta vaccination (MAPC, 1.0% vs -2.0%; P < .001) compared with provinces with moderate- to severe-intensity conflict after controlling for confounders. Provinces with severe-intensity conflict fared significantly worse than those with minimal-intensity conflict in functioning infrastructure (MAPC, -1.6% [95% CI, -2.4% to -0.8%]) and the client background and physical assessment index (MAPC, -1.0% [95% CI, -0.8% to 2.7%]) after adjusting for confounders. Child wasting was significantly worse in districts with greater conflict severity (full adjusted β for association between logarithm of battle-related deaths and wasting, 0.33 [95% CI, 0.01-0.66]; P = .04). CONCLUSIONS AND RELEVANCE Associations between conflict and maternal and child health in Afghanistan differed by health care intervention and delivery domain, with several key indicators lagging behind in areas with higher-intensity conflict. These findings may be helpful for planning and prioritizing efforts to reach the United Nations' Sustainable Development Goals in Afghanistan.
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Affiliation(s)
- Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Arjumand Rizvi
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zaid Bhatti
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jai K. Das
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Karl Everett
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Zulfiqar A. Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
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Science M, Akseer N, Asner S, Allen U. Risk stratification of immunocompromised children, including pediatric transplant recipients at risk of severe respiratory syncytial virus disease. Pediatr Transplant 2019; 23:e13336. [PMID: 30604582 DOI: 10.1111/petr.13336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/18/2018] [Accepted: 11/02/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) infection is associated with increased morbidity and mortality in immunocompromised patients. Our goal was to develop a framework for risk stratifying immunocompromised patients, including transplant patients, for RSV prophylaxis. METHODS Risk factors for severe RSV disease in immunocompromised patients were identified in the literature and by an expert panel via survey. Experts assigned a probability of developing severe disease (0 to 100 scale) to the risk factors for each immunocompromised population. The results were validated using a clinical dataset. Linear mixed models adjusted for within-expert clustering of ranks were used to estimate average scores, and differences were tested using paired t tests. Logistic regression was utilized to identify important determinants of severe RSV disease. RESULTS The survey was emailed to twenty-seven experts and thirteen responded (48%). Across all transplant groups, age <2 years (mean 77.1, 95% CI 71.7, 82.5) and day care attendance (mean 72.8, 95% CI 67.3, 78.3) were assigned the highest risk of severe disease. The highest risk groups were lung transplant recipients (mean 73.2, 95% CI 67.6, 78.8), combined lung and heart transplant recipients (mean 75.2, 95% CI 69.6, 80.7), allogeneic stem cell transplant (mean 76.0, 95% CI 70.4, 81.6), and severe combined immunodeficiency (mean 74.7, 95% CI 69.1, 80.3). CONCLUSION The results provide a logical validity to current practice and provide guidance for prioritizing patients to receive prophylactic agents to prevent severe RSV disease. The results will facilitate the development of a risk stratification tool for RSV prophylaxis for immunocompromised patients.
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Affiliation(s)
- Michelle Science
- Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Sandra Asner
- Pediatric Infectious Diseases Unit, Department of Pediatrics, University Hospital Lausanne, Lausanne, Switzerland
| | - Upton Allen
- Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
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James SL, Theadom A, Ellenbogen RG, Bannick MS, Montjoy-Venning W, Lucchesi LR, Abbasi N, Abdulkader R, Abraha HN, Adsuar JC, Afarideh M, Agrawal S, Ahmadi A, Ahmed MB, Aichour AN, Aichour I, Aichour MTE, Akinyemi RO, Akseer N, Alahdab F, Alebel A, Alghnam SA, Ali BA, Alsharif U, Altirkawi K, Andrei CL, Anjomshoa M, Ansari H, Ansha MG, Antonio CAT, Appiah SCY, Ariani F, Asefa NG, Asgedom SW, Atique S, Awasthi A, Ayala Quintanilla BP, Ayuk TB, Azzopardi PS, Badali H, Badawi A, Balalla S, Banstola A, Barker-Collo SL, Bärnighausen TW, Bedi N, Behzadifar M, Behzadifar M, Bekele BB, Belachew AB, Belay YA, Bennett DA, Bensenor IM, Berhane A, Beuran M, Bhalla A, Bhaumik S, Bhutta ZA, Biadgo B, Biffino M, Bijani A, Bililign N, Birungi C, Boufous S, Brazinova A, Brown AW, Car M, Cárdenas R, Carrero JJ, Carvalho F, Castañeda-Orjuela CA, Catalá-López F, Chaiah Y, Champs AP, Chang JC, Choi JYJ, Christopher DJ, Cooper C, Crowe CS, Dandona L, Dandona R, Daryani A, Davitoiu DV, Degefa MG, Demoz GT, Deribe K, Djalalinia S, Do HP, Doku DT, Drake TM, Dubey M, Dubljanin E, El-Khatib Z, Ofori-Asenso R, Eskandarieh S, Esteghamati A, Esteghamati S, Faro A, Farzadfar F, Farzaei MH, Fereshtehnejad SM, Fernandes E, Feyissa GT, Filip I, Fischer F, Fukumoto T, Ganji M, Gankpe FG, Gebre AK, Gebrehiwot TT, Gezae KE, Gopalkrishna G, Goulart AC, Haagsma JA, Haj-Mirzaian A, Haj-Mirzaian A, Hamadeh RR, Hamidi S, Haro JM, Hassankhani H, Hassen HY, Havmoeller R, Hawley C, Hay SI, Hegazy MI, Hendrie D, Henok A, Hibstu DT, Hoffman HJ, Hole MK, Homaie Rad E, Hosseini SM, Hostiuc S, Hu G, Hussen MA, Ilesanmi OS, Irvani SSN, Jakovljevic M, Jayaraman S, Jha RP, Jonas JB, Jones KM, Jorjoran Shushtari Z, Jozwiak JJ, Jürisson M, Kabir A, Kahsay A, Kahssay M, Kalani R, Karch A, Kasaeian A, Kassa GM, Kassa TD, Kassa ZY, Kengne AP, Khader YS, Khafaie MA, Khalid N, Khalil I, Khan EA, Khan MS, Khang YH, Khazaie H, Khoja AT, Khubchandani J, Kiadaliri AA, Kim D, Kim YE, Kisa A, Koyanagi A, Krohn KJ, Kuate Defo B, Kucuk Bicer B, Kumar GA, Kumar M, Lalloo R, Lami FH, Lansingh VC, Laryea DO, Latifi A, Leshargie CT, Levi M, Li S, Liben ML, Lotufo PA, Lunevicius R, Mahotra NB, Majdan M, Majeed A, Malekzadeh R, Manda AL, Mansournia MA, Massenburg BB, Mate KKV, Mehndiratta MM, Mehta V, Meles H, Melese A, Memiah PTN, Mendoza W, Mengistu G, Meretoja A, Meretoja TJ, Mestrovic T, Miazgowski T, Miller TR, Mini GK, Mirica A, Mirrakhimov EM, Moazen B, Mohammadi M, Mohammed S, Mokdad AH, Molokhia M, Monasta L, Mondello S, Moosazadeh M, Moradi G, Moradi M, Moradi-Lakeh M, Moradinazar M, Morrison SD, Moschos MM, Mousavi SM, Murthy S, Musa KI, Mustafa G, Naghavi M, Naik G, Najafi F, Nangia V, Nascimento BR, Negoi I, Nguyen TH, Nichols E, Ningrum DNA, Nirayo YL, Nyasulu PS, Ogbo FA, Oh IH, Okoro A, Olagunju AT, Olagunju TO, Olivares PR, Otstavnov SS, Owolabi MO, P A M, Pakhale S, Pandey AR, Pesudovs K, Pinilla-Monsalve GD, Polinder S, Poustchi H, Prakash S, Qorbani M, Radfar A, Rafay A, Rafiei A, Rahimi-Movaghar A, Rahimi-Movaghar V, Rahman M, Rahman MA, Rai RK, Rajati F, Ram U, Rawaf DL, Rawaf S, Reiner RC, Reis C, Renzaho AMN, Resnikoff S, Rezaei S, Rezaeian S, Roever L, Ronfani L, Roshandel G, Roy N, Ruhago GM, Saddik B, Safari H, Safiri S, Sahraian MA, Salamati P, Saldanha RDF, Samy AM, Sanabria J, Santos JV, Santric Milicevic MMM, Sartorius B, Satpathy M, Savuon K, Schneider IJC, Schwebel DC, Sepanlou SG, Shabaninejad H, Shaikh MAA, Shams-Beyranvand M, Sharif M, Sharif-Alhoseini M, Shariful Islam SM, She J, Sheikh A, Shen J, Sheth KN, Shibuya K, Shiferaw MS, Shigematsu M, Shiri R, Shiue I, Shoman H, Siabani S, Siddiqi TJ, Silva JP, Silveira DGA, Sinha DN, Smith M, Soares Filho AM, Sobhani S, Soofi M, Soriano JB, Soyiri IN, Stein DJ, Stokes MA, Sufiyan MB, Sunguya BF, Sunshine JE, Sykes BL, Szoeke CEI, Tabarés-Seisdedos R, Te Ao BJ, Tehrani-Banihashemi A, Tekle MG, Temsah MH, Temsah O, Topor-Madry R, Tortajada-Girbés M, Tran BX, Tran KB, Tudor Car L, Ukwaja KN, Ullah I, Usman MS, Uthman OA, Valdez PR, Vasankari TJ, Venketasubramanian N, Violante FS, Wagnew FWS, Waheed Y, Wang YP, Weldegwergs KG, Werdecker A, Wijeratne T, Winkler AS, Wyper GMA, Yano Y, Yaseri M, Yasin YJ, Ye P, Yimer EM, Yip P, Yisma E, Yonemoto N, Yoon SJ, Yost MG, Younis MZ, Yousefifard M, Yu C, Zaidi Z, Zaman SB, Zamani M, Zenebe ZM, Zodpey S, Feigin VL, Vos T, Murray CJL. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2019; 18:56-87. [PMID: 30497965 PMCID: PMC6291456 DOI: 10.1016/s1474-4422(18)30415-0] [Citation(s) in RCA: 917] [Impact Index Per Article: 183.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/02/2018] [Accepted: 10/30/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) and spinal cord injury (SCI) are increasingly recognised as global health priorities in view of the preventability of most injuries and the complex and expensive medical care they necessitate. We aimed to measure the incidence, prevalence, and years of life lived with disability (YLDs) for TBI and SCI from all causes of injury in every country, to describe how these measures have changed between 1990 and 2016, and to estimate the proportion of TBI and SCI cases caused by different types of injury. METHODS We used results from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2016 to measure the global, regional, and national burden of TBI and SCI by age and sex. We measured the incidence and prevalence of all causes of injury requiring medical care in inpatient and outpatient records, literature studies, and survey data. By use of clinical record data, we estimated the proportion of each cause of injury that required medical care that would result in TBI or SCI being considered as the nature of injury. We used literature studies to establish standardised mortality ratios and applied differential equations to convert incidence to prevalence of long-term disability. Finally, we applied GBD disability weights to calculate YLDs. We used a Bayesian meta-regression tool for epidemiological modelling, used cause-specific mortality rates for non-fatal estimation, and adjusted our results for disability experienced with comorbid conditions. We also analysed results on the basis of the Socio-demographic Index, a compound measure of income per capita, education, and fertility. FINDINGS In 2016, there were 27·08 million (95% uncertainty interval [UI] 24·30-30·30 million) new cases of TBI and 0·93 million (0·78-1·16 million) new cases of SCI, with age-standardised incidence rates of 369 (331-412) per 100 000 population for TBI and 13 (11-16) per 100 000 for SCI. In 2016, the number of prevalent cases of TBI was 55·50 million (53·40-57·62 million) and of SCI was 27·04 million (24·98-30·15 million). From 1990 to 2016, the age-standardised prevalence of TBI increased by 8·4% (95% UI 7·7 to 9·2), whereas that of SCI did not change significantly (-0·2% [-2·1 to 2·7]). Age-standardised incidence rates increased by 3·6% (1·8 to 5·5) for TBI, but did not change significantly for SCI (-3·6% [-7·4 to 4·0]). TBI caused 8·1 million (95% UI 6·0-10·4 million) YLDs and SCI caused 9·5 million (6·7-12·4 million) YLDs in 2016, corresponding to age-standardised rates of 111 (82-141) per 100 000 for TBI and 130 (90-170) per 100 000 for SCI. Falls and road injuries were the leading causes of new cases of TBI and SCI in most regions. INTERPRETATION TBI and SCI constitute a considerable portion of the global injury burden and are caused primarily by falls and road injuries. The increase in incidence of TBI over time might continue in view of increases in population density, population ageing, and increasing use of motor vehicles, motorcycles, and bicycles. The number of individuals living with SCI is expected to increase in view of population growth, which is concerning because of the specialised care that people with SCI can require. Our study was limited by data sparsity in some regions, and it will be important to invest greater resources in collection of data for TBI and SCI to improve the accuracy of future assessments. FUNDING Bill & Melinda Gates Foundation.
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Das JK, Akseer N, Mirzazada S, Peera Z, Noorzada O, Armstrong CE, Mukhtar K, Naeem AJ, Bhutta ZA. Scaling up primary health services for improving reproductive, maternal, and child health: a multisectoral collaboration in the conflict setting of Afghanistan. BMJ 2018; 363:k4986. [PMID: 30530529 PMCID: PMC6282736 DOI: 10.1136/bmj.k4986] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Jai Das and colleagues present an innovative and evolutionary model of multistakeholder and multisectoral collaboration in scaling up coverage of health services in Afghanistan
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Affiliation(s)
- Jai K Das
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Canada
| | | | - Zahra Peera
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Omarwalid Noorzada
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | | | - Kashif Mukhtar
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Zulfiqar A Bhutta
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Canada
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Keats EC, Akseer N, Bhatti Z, Macharia W, Ngugi A, Rizvi A, Bhutta ZA. Assessment of Inequalities in Coverage of Essential Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions in Kenya. JAMA Netw Open 2018; 1:e185152. [PMID: 30646326 PMCID: PMC6324360 DOI: 10.1001/jamanetworkopen.2018.5152] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Previous work has underscored subnational inequalities that could impede additional health gains in Kenya. OBJECTIVE To provide a comprehensive assessment of the burden, distribution, and change in inequalities in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) interventions in Kenya from 2003 to 2014. DESIGN, SETTING, AND PARTICIPANTS This population-based cross-sectional study used data from the 2003, 2008, and 2014 Kenya Demographic and Health Surveys. The study included women of reproductive age (ages 15-49 years) and children younger than years, with national, regional, county, and subcounty level representation. Data analysis was conducted from April 2018 to November 2018. EXPOSURES Socioeconomic position that was derived from asset indices and presented as wealth quintiles. Urban and rural residence and regions of Kenya were also considered. MAIN OUTCOMES AND MEASURES Absolute and relative measures of inequality in coverage of RMNCAH interventions. RESULTS For this analysis, representative samples of 31 380 women of reproductive age and 29 743 children younger than 5 years from across Kenya were included. The RMNCAH interventions examined demonstrated pro-rich and bottom inequality patterns. The most inequitable interventions were skilled birth attendance, family planning needs satisfied, and 4 or more antenatal care visits, whereby the absolute difference in coverage between the wealthiest (quintile 5) and poorest quintiles (quintile 1) was 61.6% (95% CI, 60.1%-63.1%), 33.4% (95% CI, 31.9%-34.9%), and 31.0% (95% CI, 30.5%-31.6%), respectively. The most equitable intervention was early initiation of breastfeeding, with an absolute difference (quintile 5 minus quintile 1) of -7.9% (95% CI, -11.1% to -4.8%), although antenatal care (1 visit) and diphtheria-tetanus-pertussis immunization (3 doses) demonstrated the best combination of high coverage and low inequalities. Our geospatial analysis revealed significant socioeconomic disparities in the northern and eastern regions of Kenya that have translated to suboptimal intervention coverage. A significant gap remains for rural, disadvantaged populations. CONCLUSIONS AND RELEVANCE Coverage of RMNCAH interventions has improved over time, but wealth and geospatial inequalities in Kenya are persistent. Policy and programming efforts should place more emphasis on improving the accessibility of health facility-based interventions, which generally demonstrate poor coverage and high inequalities, and focus on integrated approaches to maternal health service delivery at the community level when access is poor. Scaling up of health services for the urban and, in particular, rural poor areas and those residing in Kenya's former north eastern province will contribute toward achievement of universal health coverage.
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Affiliation(s)
- Emily Catherine Keats
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | - Zulfiqar Ahmed Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Aga Khan University, Karachi, Pakistan
- Aga Khan University, Nairobi, Kenya
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Zunt JR, Kassebaum NJ, Blake N, Glennie L, Wright C, Nichols E, Abd-Allah F, Abdela J, Abdelalim A, Adamu AA, Adib MG, Ahmadi A, Ahmed MB, Aichour AN, Aichour I, Aichour MTE, Akseer N, Al-Raddadi RM, Alahdab F, Alene KA, Aljunid SM, AlMazroa MA, Altirkawi K, Alvis-Guzman N, Animut MD, Anjomshoa M, Ansha MG, Asghar RJ, Avokpaho EFGA, Awasthi A, Badali H, Barac A, Bärnighausen TW, Bassat Q, Bedi N, Belachew AB, Bhattacharyya K, Bhutta ZA, Bijani A, Butt ZA, Carvalho F, Castañeda-Orjuela CA, Chitheer A, Choi JYJ, Christopher DJ, Dang AK, Daryani A, Demoz GT, Djalalinia S, Do HP, Dubey M, Dubljanin E, Duken EE, El Sayed Zaki M, Elyazar IRF, Fakhim H, Fernandes E, Fischer F, Fukumoto T, Ganji M, Gebre AK, Gebremeskel A, Gessner BD, Gopalani SV, Guo Y, Gupta R, Hailu GB, Haj-Mirzaian A, Hamidi S, Hay SI, Henok A, Irvani SSN, Jha RP, JÜRISSON M, Kahsay A, Karami M, Karch A, Kasaeian A, Kassa GM, Kassa TDD, Kefale AT, Khader YS, Khalil IA, Khan EA, Khang YH, Khubchandani J, Kimokoti RW, Kisa A, Lami FH, Levi M, Li S, Loy CT, Majdan M, Majeed A, Mantovani LG, Martins-Melo FR, Mcalinden C, Mehta V, Melese A, Memish ZA, Mengistu DT, Mengistu G, Mestrovic T, Mezgebe HB, Miazgowski B, Milosevic B, Mokdad AH, Monasta L, Moradi G, Moraga P, Mousavi SM, Mueller UO, Murthy S, Mustafa G, Naghavi M, Naheed A, Naik G, Newton CRJ, Nirayo YL, Nixon MR, Ofori-Asenso R, Ogbo FA, Olagunju AT, Olagunju TO, Olusanya BO, Ortiz JR, Owolabi MO, Patel S, Pinilla-Monsalve GD, Postma MJ, Qorbani M, Rafiei A, Rahimi-Movaghar V, Reiner RC, Renzaho AM, Rezai MS, Roba KT, Ronfani L, Roshandel G, Rostami A, Safari H, Safari S, Safiri S, Sagar R, Samy AM, Santric Milicevic MM, Sartorius B, Sarvi S, Sawhney M, Saxena S, Shafieesabet A, Shaikh MA, Sharif M, Shigematsu M, Si S, Skiadaresi E, Smith M, Somayaji R, Sufiyan MB, Tawye NY, Temsah MH, Tortajada-Girbés M, Tran BX, Tran KB, Ukwaja KN, Ullah I, Vujcic IS, Wagnew FS, Waheed Y, Weldegwergs KG, Winkler AS, Wiysonge CS, Wiyeh AB, Wyper GM, Yimer EM, Yonemoto N, Zaidi Z, Zenebe ZM, Feigin VL, Vos T, Murray CJL. Global, regional, and national burden of meningitis, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2018; 17:1061-1082. [PMID: 30507391 PMCID: PMC6234314 DOI: 10.1016/s1474-4422(18)30387-9] [Citation(s) in RCA: 190] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/24/2018] [Accepted: 10/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute meningitis has a high case-fatality rate and survivors can have severe lifelong disability. We aimed to provide a comprehensive assessment of the levels and trends of global meningitis burden that could help to guide introduction, continuation, and ongoing development of vaccines and treatment programmes. METHODS The Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2016 study estimated meningitis burden due to one of four types of cause: pneumococcal, meningococcal, Haemophilus influenzae type b, and a residual category of other causes. Cause-specific mortality estimates were generated via cause of death ensemble modelling of vital registration and verbal autopsy data that were subject to standardised data processing algorithms. Deaths were multiplied by the GBD standard life expectancy at age of death to estimate years of life lost, the mortality component of disability-adjusted life-years (DALYs). A systematic analysis of relevant publications and hospital and claims data was used to estimate meningitis incidence via a Bayesian meta-regression tool. Meningitis deaths and cases were split between causes with meta-regressions of aetiological proportions of mortality and incidence, respectively. Probabilities of long-term impairment by cause of meningitis were applied to survivors and used to estimate years of life lived with disability (YLDs). We assessed the relationship between burden metrics and Socio-demographic Index (SDI), a composite measure of development based on fertility, income, and education. FINDINGS Global meningitis deaths decreased by 21·0% from 1990 to 2016, from 403 012 (95% uncertainty interval [UI] 319 426-458 514) to 318 400 (265 218-408 705). Incident cases globally increased from 2·50 million (95% UI 2·19-2·91) in 1990 to 2·82 million (2·46-3·31) in 2016. Meningitis mortality and incidence were closely related to SDI. The highest mortality rates and incidence rates were found in the peri-Sahelian countries that comprise the African meningitis belt, with six of the ten countries with the largest number of cases and deaths being located within this region. Haemophilus influenzae type b was the most common cause of incident meningitis in 1990, at 780 070 cases (95% UI 613 585-978 219) globally, but decreased the most (-49·1%) to become the least common cause in 2016, with 397 297 cases (291 076-533 662). Meningococcus was the leading cause of meningitis mortality in 1990 (192 833 deaths [95% UI 153 358-221 503] globally), whereas other meningitis was the leading cause for both deaths (136 423 [112 682-178 022]) and incident cases (1·25 million [1·06-1·49]) in 2016. Pneumococcus caused the largest number of YLDs (634 458 [444 787-839 749]) in 2016, owing to its more severe long-term effects on survivors. Globally in 2016, 1·48 million (1·04-1·96) YLDs were due to meningitis compared with 21·87 million (18·20-28·28) DALYs, indicating that the contribution of mortality to meningitis burden is far greater than the contribution of disabling outcomes. INTERPRETATION Meningitis burden remains high and progress lags substantially behind that of other vaccine-preventable diseases. Particular attention should be given to developing vaccines with broader coverage against the causes of meningitis, making these vaccines affordable in the most affected countries, improving vaccine uptake, improving access to low-cost diagnostics and therapeutics, and improving support for disabled survivors. Substantial uncertainty remains around pathogenic causes and risk factors for meningitis. Ongoing, active cause-specific surveillance of meningitis is crucial to continue and to improve monitoring of meningitis burdens and trends throughout the world. FUNDING Bill & Melinda Gates Foundation.
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Global, regional, and national age-sex-specific mortality and life expectancy, 1950-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392:1684-1735. [PMID: 30496102 PMCID: PMC6227504 DOI: 10.1016/s0140-6736(18)31891-9] [Citation(s) in RCA: 575] [Impact Index Per Article: 95.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/14/2018] [Accepted: 08/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Assessments of age-specific mortality and life expectancy have been done by the UN Population Division, Department of Economics and Social Affairs (UNPOP), the United States Census Bureau, WHO, and as part of previous iterations of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD). Previous iterations of the GBD used population estimates from UNPOP, which were not derived in a way that was internally consistent with the estimates of the numbers of deaths in the GBD. The present iteration of the GBD, GBD 2017, improves on previous assessments and provides timely estimates of the mortality experience of populations globally. METHODS The GBD uses all available data to produce estimates of mortality rates between 1950 and 2017 for 23 age groups, both sexes, and 918 locations, including 195 countries and territories and subnational locations for 16 countries. Data used include vital registration systems, sample registration systems, household surveys (complete birth histories, summary birth histories, sibling histories), censuses (summary birth histories, household deaths), and Demographic Surveillance Sites. In total, this analysis used 8259 data sources. Estimates of the probability of death between birth and the age of 5 years and between ages 15 and 60 years are generated and then input into a model life table system to produce complete life tables for all locations and years. Fatal discontinuities and mortality due to HIV/AIDS are analysed separately and then incorporated into the estimation. We analyse the relationship between age-specific mortality and development status using the Socio-demographic Index, a composite measure based on fertility under the age of 25 years, education, and income. There are four main methodological improvements in GBD 2017 compared with GBD 2016: 622 additional data sources have been incorporated; new estimates of population, generated by the GBD study, are used; statistical methods used in different components of the analysis have been further standardised and improved; and the analysis has been extended backwards in time by two decades to start in 1950. FINDINGS Globally, 18·7% (95% uncertainty interval 18·4-19·0) of deaths were registered in 1950 and that proportion has been steadily increasing since, with 58·8% (58·2-59·3) of all deaths being registered in 2015. At the global level, between 1950 and 2017, life expectancy increased from 48·1 years (46·5-49·6) to 70·5 years (70·1-70·8) for men and from 52·9 years (51·7-54·0) to 75·6 years (75·3-75·9) for women. Despite this overall progress, there remains substantial variation in life expectancy at birth in 2017, which ranges from 49·1 years (46·5-51·7) for men in the Central African Republic to 87·6 years (86·9-88·1) among women in Singapore. The greatest progress across age groups was for children younger than 5 years; under-5 mortality dropped from 216·0 deaths (196·3-238·1) per 1000 livebirths in 1950 to 38·9 deaths (35·6-42·83) per 1000 livebirths in 2017, with huge reductions across countries. Nevertheless, there were still 5·4 million (5·2-5·6) deaths among children younger than 5 years in the world in 2017. Progress has been less pronounced and more variable for adults, especially for adult males, who had stagnant or increasing mortality rates in several countries. The gap between male and female life expectancy between 1950 and 2017, while relatively stable at the global level, shows distinctive patterns across super-regions and has consistently been the largest in central Europe, eastern Europe, and central Asia, and smallest in south Asia. Performance was also variable across countries and time in observed mortality rates compared with those expected on the basis of development. INTERPRETATION This analysis of age-sex-specific mortality shows that there are remarkably complex patterns in population mortality across countries. The findings of this study highlight global successes, such as the large decline in under-5 mortality, which reflects significant local, national, and global commitment and investment over several decades. However, they also bring attention to mortality patterns that are a cause for concern, particularly among adult men and, to a lesser extent, women, whose mortality rates have stagnated in many countries over the time period of this study, and in some cases are increasing. FUNDING Bill & Melinda Gates Foundation.
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Roth GA, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, Abbastabar H, Abd-Allah F, Abdela J, Abdelalim A, Abdollahpour I, Abdulkader RS, Abebe HT, Abebe M, Abebe Z, Abejie AN, Abera SF, Abil OZ, Abraha HN, Abrham AR, Abu-Raddad LJ, Accrombessi MMK, Acharya D, Adamu AA, Adebayo OM, Adedoyin RA, Adekanmbi V, Adetokunboh OO, Adhena BM, Adib MG, Admasie A, Afshin A, Agarwal G, Agesa KM, Agrawal A, Agrawal S, Ahmadi A, Ahmadi M, Ahmed MB, Ahmed S, Aichour AN, Aichour I, Aichour MTE, Akbari ME, Akinyemi RO, Akseer N, Al-Aly Z, Al-Eyadhy A, Al-Raddadi RM, Alahdab F, Alam K, Alam T, Alebel A, Alene KA, Alijanzadeh M, Alizadeh-Navaei R, Aljunid SM, Alkerwi A, Alla F, Allebeck P, Alonso J, Altirkawi K, Alvis-Guzman N, Amare AT, Aminde LN, Amini E, Ammar W, Amoako YA, Anber NH, Andrei CL, Androudi S, Animut MD, Anjomshoa M, Ansari H, Ansha MG, Antonio CAT, Anwari P, Aremu O, Ärnlöv J, Arora A, Arora M, Artaman A, Aryal KK, Asayesh H, Asfaw ET, Ataro Z, Atique S, Atre SR, Ausloos M, Avokpaho EFGA, Awasthi A, Quintanilla BPA, Ayele Y, Ayer R, Azzopardi PS, Babazadeh A, Bacha U, Badali H, Badawi A, Bali AG, Ballesteros KE, Banach M, Banerjee K, Bannick MS, Banoub JAM, Barboza MA, Barker-Collo SL, Bärnighausen TW, Barquera S, Barrero LH, Bassat Q, Basu S, Baune BT, Baynes HW, Bazargan-Hejazi S, Bedi N, Beghi E, Behzadifar M, Behzadifar M, Béjot Y, Bekele BB, Belachew AB, Belay E, Belay YA, Bell ML, Bello AK, Bennett DA, Bensenor IM, Berman AE, Bernabe E, Bernstein RS, Bertolacci GJ, Beuran M, Beyranvand T, Bhalla A, Bhattarai S, Bhaumik S, Bhutta ZA, Biadgo B, Biehl MH, Bijani A, Bikbov B, Bilano V, Bililign N, Bin Sayeed MS, Bisanzio D, Biswas T, Blacker BF, Basara BB, Borschmann R, Bosetti C, Bozorgmehr K, Brady OJ, Brant LC, Brayne C, Brazinova A, Breitborde NJK, Brenner H, Briant PS, Britton G, Brugha T, Busse R, Butt ZA, Callender CSKH, Campos-Nonato IR, Campuzano Rincon JC, Cano J, Car M, Cárdenas R, Carreras G, Carrero JJ, Carter A, Carvalho F, Castañeda-Orjuela CA, Castillo Rivas J, Castle CD, Castro C, Castro F, Catalá-López F, Cerin E, Chaiah Y, Chang JC, Charlson FJ, Chaturvedi P, Chiang PPC, Chimed-Ochir O, Chisumpa VH, Chitheer A, Chowdhury R, Christensen H, Christopher DJ, Chung SC, Cicuttini FM, Ciobanu LG, Cirillo M, Cohen AJ, Cooper LT, Cortesi PA, Cortinovis M, Cousin E, Cowie BC, Criqui MH, Cromwell EA, Crowe CS, Crump JA, Cunningham M, Daba AK, Dadi AF, Dandona L, Dandona R, Dang AK, Dargan PI, Daryani A, Das SK, Gupta RD, Neves JD, Dasa TT, Dash AP, Davis AC, Davis Weaver N, Davitoiu DV, Davletov K, De La Hoz FP, De Neve JW, Degefa MG, Degenhardt L, Degfie TT, Deiparine S, Demoz GT, Demtsu BB, Denova-Gutiérrez E, Deribe K, Dervenis N, Des Jarlais DC, Dessie GA, Dey S, Dharmaratne SD, Dicker D, Dinberu MT, Ding EL, Dirac MA, Djalalinia S, Dokova K, Doku DT, Donnelly CA, Dorsey ER, Doshi PP, Douwes-Schultz D, Doyle KE, Driscoll TR, Dubey M, Dubljanin E, Duken EE, Duncan BB, Duraes AR, Ebrahimi H, Ebrahimpour S, Edessa D, Edvardsson D, Eggen AE, El Bcheraoui C, El Sayed Zaki M, El-Khatib Z, Elkout H, Ellingsen CL, Endres M, Endries AY, Er B, Erskine HE, Eshrati B, Eskandarieh S, Esmaeili R, Esteghamati A, Fakhar M, Fakhim H, Faramarzi M, Fareed M, Farhadi F, Farinha CSES, Faro A, Farvid MS, Farzadfar F, Farzaei MH, Feigin VL, Feigl AB, Fentahun N, Fereshtehnejad SM, Fernandes E, Fernandes JC, Ferrari AJ, Feyissa GT, Filip I, Finegold S, Fischer F, Fitzmaurice C, Foigt NA, Foreman KJ, Fornari C, Frank TD, Fukumoto T, Fuller JE, Fullman N, Fürst T, Furtado JM, Futran ND, Gallus S, Garcia-Basteiro AL, Garcia-Gordillo MA, Gardner WM, Gebre AK, Gebrehiwot TT, Gebremedhin AT, Gebremichael B, Gebremichael TG, Gelano TF, Geleijnse JM, Genova-Maleras R, Geramo YCD, Gething PW, Gezae KE, Ghadami MR, Ghadimi R, Ghasemi Falavarjani K, Ghasemi-Kasman M, Ghimire M, Gibney KB, Gill PS, Gill TK, Gillum RF, Ginawi IA, Giroud M, Giussani G, Goenka S, Goldberg EM, Goli S, Gómez-Dantés H, Gona PN, Gopalani SV, Gorman TM, Goto A, Goulart AC, Gnedovskaya EV, Grada A, Grosso G, Gugnani HC, Guimaraes ALS, Guo Y, Gupta PC, Gupta R, Gupta R, Gupta T, Gutiérrez RA, Gyawali B, Haagsma JA, Hafezi-Nejad N, Hagos TB, Hailegiyorgis TT, Hailu GB, Haj-Mirzaian A, Haj-Mirzaian A, Hamadeh RR, Hamidi S, Handal AJ, Hankey GJ, Harb HL, Harikrishnan S, Haro JM, Hasan M, Hassankhani H, Hassen HY, Havmoeller R, Hay RJ, Hay SI, He Y, Hedayatizadeh-Omran A, Hegazy MI, Heibati B, Heidari M, Hendrie D, Henok A, Henry NJ, Herteliu C, Heydarpour F, Heydarpour P, Heydarpour S, Hibstu DT, Hoek HW, Hole MK, Homaie Rad E, Hoogar P, Hosgood HD, Hosseini SM, Hosseinzadeh M, Hostiuc M, Hostiuc S, Hotez PJ, Hoy DG, Hsiao T, Hu G, Huang JJ, Husseini A, Hussen MM, Hutfless S, Idrisov B, Ilesanmi OS, Iqbal U, Irvani SSN, Irvine CMS, Islam N, Islam SMS, Islami F, Jacobsen KH, Jahangiry L, Jahanmehr N, Jain SK, Jakovljevic M, Jalu MT, James SL, Javanbakht M, Jayatilleke AU, Jeemon P, Jenkins KJ, Jha RP, Jha V, Johnson CO, Johnson SC, Jonas JB, Joshi A, Jozwiak JJ, Jungari SB, Jürisson M, Kabir Z, Kadel R, Kahsay A, Kalani R, Karami M, Karami Matin B, Karch A, Karema C, Karimi-Sari H, Kasaeian A, Kassa DH, Kassa GM, Kassa TD, Kassebaum NJ, Katikireddi SV, Kaul A, Kazemi Z, Karyani AK, Kazi DS, Kefale AT, Keiyoro PN, Kemp GR, Kengne AP, Keren A, Kesavachandran CN, Khader YS, Khafaei B, Khafaie MA, Khajavi A, Khalid N, Khalil IA, Khan EA, Khan MS, Khan MA, Khang YH, Khater MM, Khoja AT, Khosravi A, Khosravi MH, Khubchandani J, Kiadaliri AA, Kibret GD, Kidanemariam ZT, Kiirithio DN, Kim D, Kim YE, Kim YJ, Kimokoti RW, Kinfu Y, Kisa A, Kissimova-Skarbek K, Kivimäki M, Knudsen AKS, Kocarnik JM, Kochhar S, Kokubo Y, Kolola T, Kopec JA, Koul PA, Koyanagi A, Kravchenko MA, Krishan K, Kuate Defo B, Kucuk Bicer B, Kumar GA, Kumar M, Kumar P, Kutz MJ, Kuzin I, Kyu HH, Lad DP, Lad SD, Lafranconi A, Lal DK, Lalloo R, Lallukka T, Lam JO, Lami FH, Lansingh VC, Lansky S, Larson HJ, Latifi A, Lau KMM, Lazarus JV, Lebedev G, Lee PH, Leigh J, Leili M, Leshargie CT, Li S, Li Y, Liang J, Lim LL, Lim SS, Limenih MA, Linn S, Liu S, Liu Y, Lodha R, Lonsdale C, Lopez AD, Lorkowski S, Lotufo PA, Lozano R, Lunevicius R, Ma S, Macarayan ERK, Mackay MT, MacLachlan JH, Maddison ER, Madotto F, Magdy Abd El Razek H, Magdy Abd El Razek M, Maghavani DP, Majdan M, Majdzadeh R, Majeed A, Malekzadeh R, Malta DC, Manda AL, Mandarano-Filho LG, Manguerra H, Mansournia MA, Mapoma CC, Marami D, Maravilla JC, Marcenes W, Marczak L, Marks A, Marks GB, Martinez G, Martins-Melo FR, Martopullo I, März W, Marzan MB, Masci JR, Massenburg BB, Mathur MR, Mathur P, Matzopoulos R, Maulik PK, Mazidi M, McAlinden C, McGrath JJ, McKee M, McMahon BJ, Mehata S, Mehndiratta MM, Mehrotra R, Mehta KM, Mehta V, Mekonnen TC, Melese A, Melku M, Memiah PTN, Memish ZA, Mendoza W, Mengistu DT, Mengistu G, Mensah GA, Mereta ST, Meretoja A, Meretoja TJ, Mestrovic T, Mezgebe HB, Miazgowski B, Miazgowski T, Millear AI, Miller TR, Miller-Petrie MK, Mini GK, Mirabi P, Mirarefin M, Mirica A, Mirrakhimov EM, Misganaw AT, Mitiku H, Moazen B, Mohammad KA, Mohammadi M, Mohammadifard N, Mohammed MA, Mohammed S, Mohan V, Mokdad AH, Molokhia M, Monasta L, Moradi G, Moradi-Lakeh M, Moradinazar M, Moraga P, Morawska L, Moreno Velásquez I, Morgado-Da-Costa J, Morrison SD, Moschos MM, Mouodi S, Mousavi SM, Muchie KF, Mueller UO, Mukhopadhyay S, Muller K, Mumford JE, Musa J, Musa KI, Mustafa G, Muthupandian S, Nachega JB, Nagel G, Naheed A, Nahvijou A, Naik G, Nair S, Najafi F, Naldi L, Nam HS, Nangia V, Nansseu JR, Nascimento BR, Natarajan G, Neamati N, Negoi I, Negoi RI, Neupane S, Newton CRJ, Ngalesoni FN, Ngunjiri JW, Nguyen AQ, Nguyen G, Nguyen HT, Nguyen HT, Nguyen LH, Nguyen M, Nguyen TH, Nichols E, Ningrum DNA, Nirayo YL, Nixon MR, Nolutshungu N, Nomura S, Norheim OF, Noroozi M, Norrving B, Noubiap JJ, Nouri HR, Nourollahpour Shiadeh M, Nowroozi MR, Nyasulu PS, Odell CM, Ofori-Asenso R, Ogbo FA, Oh IH, Oladimeji O, Olagunju AT, Olivares PR, Olsen HE, Olusanya BO, Olusanya JO, Ong KL, Ong SKS, Oren E, Orpana HM, Ortiz A, Ortiz JR, Otstavnov SS, Øverland S, Owolabi MO, Özdemir R, P A M, Pacella R, Pakhale S, Pakhare AP, Pakpour AH, Pana A, Panda-Jonas S, Pandian JD, Parisi A, Park EK, Parry CDH, Parsian H, Patel S, Pati S, Patton GC, Paturi VR, Paulson KR, Pereira A, Pereira DM, Perico N, Pesudovs K, Petzold M, Phillips MR, Piel FB, Pigott DM, Pillay JD, Pirsaheb M, Pishgar F, Polinder S, Postma MJ, Pourshams A, Poustchi H, Pujar A, Prakash S, Prasad N, Purcell CA, Qorbani M, Quintana H, Quistberg DA, Rade KW, Radfar A, Rafay A, Rafiei A, Rahim F, Rahimi K, Rahimi-Movaghar A, Rahman M, Rahman MHU, Rahman MA, Rai RK, Rajsic S, Ram U, Ranabhat CL, Ranjan P, Rao PC, Rawaf DL, Rawaf S, Razo-García C, Reddy KS, Reiner RC, Reitsma MB, Remuzzi G, Renzaho AMN, Resnikoff S, Rezaei S, Rezaeian S, Rezai MS, Riahi SM, Ribeiro ALP, Rios-Blancas MJ, Roba KT, Roberts NLS, Robinson SR, Roever L, Ronfani L, Roshandel G, Rostami A, Rothenbacher D, Roy A, Rubagotti E, Sachdev PS, Saddik B, Sadeghi E, Safari H, Safdarian M, Safi S, Safiri S, Sagar R, Sahebkar A, Sahraian MA, Salam N, Salama JS, Salamati P, Saldanha RDF, Saleem Z, Salimi Y, Salvi SS, Salz I, Sambala EZ, Samy AM, Sanabria J, Sanchez-Niño MD, Santomauro DF, Santos IS, Santos JV, Milicevic MMS, Sao Jose BP, Sarker AR, Sarmiento-Suárez R, Sarrafzadegan N, Sartorius B, Sarvi S, Sathian B, Satpathy M, Sawant AR, Sawhney M, Saxena S, Sayyah M, Schaeffner E, Schmidt MI, Schneider IJC, Schöttker B, Schutte AE, Schwebel DC, Schwendicke F, Scott JG, Sekerija M, Sepanlou SG, Serván-Mori E, Seyedmousavi S, Shabaninejad H, Shackelford KA, Shafieesabet A, Shahbazi M, Shaheen AA, Shaikh MA, Shams-Beyranvand M, Shamsi M, Shamsizadeh M, Sharafi K, Sharif M, Sharif-Alhoseini M, Sharma R, She J, Sheikh A, Shi P, Shiferaw MS, Shigematsu M, Shiri R, Shirkoohi R, Shiue I, Shokraneh F, Shrime MG, Si S, Siabani S, Siddiqi TJ, Sigfusdottir ID, Sigurvinsdottir R, Silberberg DH, Silva DAS, Silva JP, Silva NTD, Silveira DGA, Singh JA, Singh NP, Singh PK, Singh V, Sinha DN, Sliwa K, Smith M, Sobaih BH, Sobhani S, Sobngwi E, Soneji SS, Soofi M, Sorensen RJD, Soriano JB, Soyiri IN, Sposato LA, Sreeramareddy CT, Srinivasan V, Stanaway JD, Starodubov VI, Stathopoulou V, Stein DJ, Steiner C, Stewart LG, Stokes MA, Subart ML, Sudaryanto A, Sufiyan MB, Sur PJ, Sutradhar I, Sykes BL, Sylaja PN, Sylte DO, Szoeke CEI, Tabarés-Seisdedos R, Tabuchi T, Tadakamadla SK, Takahashi K, Tandon N, Tassew SG, Taveira N, Tehrani-Banihashemi A, Tekalign TG, Tekle MG, Temsah MH, Temsah O, Terkawi AS, Teshale MY, Tessema B, Tessema GA, Thankappan KR, Thirunavukkarasu S, Thomas N, Thrift AG, Thurston GD, Tilahun B, To QG, Tobe-Gai R, Tonelli M, Topor-Madry R, Torre AE, Tortajada-Girbés M, Touvier M, Tovani-Palone MR, Tran BX, Tran KB, Tripathi S, Troeger CE, Truelsen TC, Truong NT, Tsadik AG, Tsoi D, Tudor Car L, Tuzcu EM, Tyrovolas S, Ukwaja KN, Ullah I, Undurraga EA, Updike RL, Usman MS, Uthman OA, Uzun SB, Vaduganathan M, Vaezi A, Vaidya G, Valdez PR, Varavikova E, Vasankari TJ, Venketasubramanian N, Villafaina S, Violante FS, Vladimirov SK, Vlassov V, Vollset SE, Vos T, Wagner GR, Wagnew FS, Waheed Y, Wallin MT, Walson JL, Wang Y, Wang YP, Wassie MM, Weiderpass E, Weintraub RG, Weldegebreal F, Weldegwergs KG, Werdecker A, Werkneh AA, West TE, Westerman R, Whiteford HA, Widecka J, Wilner LB, Wilson S, Winkler AS, Wiysonge CS, Wolfe CDA, Wu S, Wu YC, Wyper GMA, Xavier D, Xu G, Yadgir S, Yadollahpour A, Yahyazadeh Jabbari SH, Yakob B, Yan LL, Yano Y, Yaseri M, Yasin YJ, Yentür GK, Yeshaneh A, Yimer EM, Yip P, Yirsaw BD, Yisma E, Yonemoto N, Yonga G, Yoon SJ, Yotebieng M, Younis MZ, Yousefifard M, Yu C, Zadnik V, Zaidi Z, Zaman SB, Zamani M, Zare Z, Zeleke AJ, Zenebe ZM, Zhang AL, Zhang K, Zhou M, Zodpey S, Zuhlke LJ, Naghavi M, Murray CJL. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392:1736-1788. [PMID: 30496103 PMCID: PMC6227606 DOI: 10.1016/s0140-6736%2818%2932203-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 08/29/2018] [Accepted: 08/30/2018] [Indexed: 01/19/2024]
Abstract
BACKGROUND Global development goals increasingly rely on country-specific estimates for benchmarking a nation's progress. To meet this need, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016 estimated global, regional, national, and, for selected locations, subnational cause-specific mortality beginning in the year 1980. Here we report an update to that study, making use of newly available data and improved methods. GBD 2017 provides a comprehensive assessment of cause-specific mortality for 282 causes in 195 countries and territories from 1980 to 2017. METHODS The causes of death database is composed of vital registration (VR), verbal autopsy (VA), registry, survey, police, and surveillance data. GBD 2017 added ten VA studies, 127 country-years of VR data, 502 cancer-registry country-years, and an additional surveillance country-year. Expansions of the GBD cause of death hierarchy resulted in 18 additional causes estimated for GBD 2017. Newly available data led to subnational estimates for five additional countries-Ethiopia, Iran, New Zealand, Norway, and Russia. Deaths assigned International Classification of Diseases (ICD) codes for non-specific, implausible, or intermediate causes of death were reassigned to underlying causes by redistribution algorithms that were incorporated into uncertainty estimation. We used statistical modelling tools developed for GBD, including the Cause of Death Ensemble model (CODEm), to generate cause fractions and cause-specific death rates for each location, year, age, and sex. Instead of using UN estimates as in previous versions, GBD 2017 independently estimated population size and fertility rate for all locations. Years of life lost (YLLs) were then calculated as the sum of each death multiplied by the standard life expectancy at each age. All rates reported here are age-standardised. FINDINGS At the broadest grouping of causes of death (Level 1), non-communicable diseases (NCDs) comprised the greatest fraction of deaths, contributing to 73·4% (95% uncertainty interval [UI] 72·5-74·1) of total deaths in 2017, while communicable, maternal, neonatal, and nutritional (CMNN) causes accounted for 18·6% (17·9-19·6), and injuries 8·0% (7·7-8·2). Total numbers of deaths from NCD causes increased from 2007 to 2017 by 22·7% (21·5-23·9), representing an additional 7·61 million (7·20-8·01) deaths estimated in 2017 versus 2007. The death rate from NCDs decreased globally by 7·9% (7·0-8·8). The number of deaths for CMNN causes decreased by 22·2% (20·0-24·0) and the death rate by 31·8% (30·1-33·3). Total deaths from injuries increased by 2·3% (0·5-4·0) between 2007 and 2017, and the death rate from injuries decreased by 13·7% (12·2-15·1) to 57·9 deaths (55·9-59·2) per 100 000 in 2017. Deaths from substance use disorders also increased, rising from 284 000 deaths (268 000-289 000) globally in 2007 to 352 000 (334 000-363 000) in 2017. Between 2007 and 2017, total deaths from conflict and terrorism increased by 118·0% (88·8-148·6). A greater reduction in total deaths and death rates was observed for some CMNN causes among children younger than 5 years than for older adults, such as a 36·4% (32·2-40·6) reduction in deaths from lower respiratory infections for children younger than 5 years compared with a 33·6% (31·2-36·1) increase in adults older than 70 years. Globally, the number of deaths was greater for men than for women at most ages in 2017, except at ages older than 85 years. Trends in global YLLs reflect an epidemiological transition, with decreases in total YLLs from enteric infections, respiratory infections and tuberculosis, and maternal and neonatal disorders between 1990 and 2017; these were generally greater in magnitude at the lowest levels of the Socio-demographic Index (SDI). At the same time, there were large increases in YLLs from neoplasms and cardiovascular diseases. YLL rates decreased across the five leading Level 2 causes in all SDI quintiles. The leading causes of YLLs in 1990-neonatal disorders, lower respiratory infections, and diarrhoeal diseases-were ranked second, fourth, and fifth, in 2017. Meanwhile, estimated YLLs increased for ischaemic heart disease (ranked first in 2017) and stroke (ranked third), even though YLL rates decreased. Population growth contributed to increased total deaths across the 20 leading Level 2 causes of mortality between 2007 and 2017. Decreases in the cause-specific mortality rate reduced the effect of population growth for all but three causes: substance use disorders, neurological disorders, and skin and subcutaneous diseases. INTERPRETATION Improvements in global health have been unevenly distributed among populations. Deaths due to injuries, substance use disorders, armed conflict and terrorism, neoplasms, and cardiovascular disease are expanding threats to global health. For causes of death such as lower respiratory and enteric infections, more rapid progress occurred for children than for the oldest adults, and there is continuing disparity in mortality rates by sex across age groups. Reductions in the death rate of some common diseases are themselves slowing or have ceased, primarily for NCDs, and the death rate for selected causes has increased in the past decade. FUNDING Bill & Melinda Gates Foundation.
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Lozano R, Fullman N, Abate D, Abay SM, Abbafati C, Abbasi N, Abbastabar H, Abd-Allah F, Abdela J, Abdelalim A, Abdel-Rahman O, Abdi A, Abdollahpour I, Abdulkader RS, Abebe ND, Abebe Z, Abejie AN, Abera SF, Abil OZ, Aboyans V, Abraha HN, Abrham AR, Abu-Raddad LJ, Abu-Rmeileh NM, Abyu GY, Accrombessi MMK, Acharya D, Acharya P, Adamu AA, Adebayo OM, Adedeji IA, Adedoyin RA, Adekanmbi V, Adetokunboh OO, Adhena BM, Adhikari TB, Adib MG, Adou AK, Adsuar JC, Afarideh M, Afshari M, Afshin A, Agarwal G, Aghayan SA, Agius D, Agrawal A, Agrawal S, Ahmadi A, Ahmadi M, Ahmadieh H, Ahmed MB, Ahmed S, Akalu TY, Akanda AS, Akbari ME, Akibu M, Akinyemi RO, Akinyemiju T, Akseer N, Alahdab F, Al-Aly Z, Alam K, Alam T, Albujeer A, Alebel A, Alene KA, Al-Eyadhy A, Alhabib S, Ali R, Alijanzadeh M, Alizadeh-Navaei R, Aljunid SM, Alkerwi A, Alla F, Allebeck P, Allen CA, Almasi A, Al-Maskari F, Al-Mekhlafi HM, Alonso J, Al-Raddadi RM, Alsharif U, Altirkawi K, Alvis-Guzman N, Amare AT, Amenu K, Amini E, Ammar 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Laryea DO, Lassi ZS, Latifi A, Lau KMM, Laxmaiah A, Lazarus JV, Leasher JL, Lebedev G, Ledesma JR, Lee JB, Lee PH, Leever AT, Leigh J, Leinsalu M, Leshargie CT, Leung J, Lewycka S, Li S, Li X, Li Y, Liang J, Liang X, Liben ML, Lim LL, Limenih MA, Linn S, Liu S, Liu Y, Lodha R, Logroscino G, Lopez AD, Lorkowski S, Lotufo PA, Lucchesi LR, Lyons RA, Macarayan ERK, Mackay MT, Maddison ER, Madotto F, Maghavani DP, Magis-Rodriguez C, Mahotra NB, Majdan M, Majdzadeh R, Majeed A, Malekzadeh R, Malta DC, Mamun AA, Manda AL, Mandarano-Filho LG, Mangalam S, Manguerra H, Mansournia MA, Mapoma CC, Maravilla JC, Marcenes W, Marks A, Martin RV, Martins SCO, Martins-Melo FR, Martopullo I, Mashamba-Thompson TP, Massenburg BB, Mathur MR, Maulik PK, Mazidi M, McAlinden C, McGrath JJ, McKee M, McMahon BJ, Mehata S, Mehndiratta MM, Mehrotra R, Mehta KM, Mehta V, Mejia-Rodriguez F, Mekonen T, Mekonnen TCC, Meles HG, Melese A, Melku M, Memiah PTN, Memish ZA, Mendoza W, Mengistu DT, Mengistu G, Mensah GA, 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Zucker I, Zuhlke LJJ, Lim SS, Murray CJL. Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392:2091-2138. [PMID: 30496107 PMCID: PMC6227911 DOI: 10.1016/s0140-6736(18)32281-5] [Citation(s) in RCA: 264] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/06/2018] [Accepted: 09/12/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Efforts to establish the 2015 baseline and monitor early implementation of the UN Sustainable Development Goals (SDGs) highlight both great potential for and threats to improving health by 2030. To fully deliver on the SDG aim of "leaving no one behind", it is increasingly important to examine the health-related SDGs beyond national-level estimates. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), we measured progress on 41 of 52 health-related SDG indicators and estimated the health-related SDG index for 195 countries and territories for the period 1990-2017, projected indicators to 2030, and analysed global attainment. METHODS We measured progress on 41 health-related SDG indicators from 1990 to 2017, an increase of four indicators since GBD 2016 (new indicators were health worker density, sexual violence by non-intimate partners, population census status, and prevalence of physical and sexual violence [reported separately]). We also improved the measurement of several previously reported indicators. We constructed national-level estimates and, for a subset of health-related SDGs, examined indicator-level differences by sex and Socio-demographic Index (SDI) quintile. We also did subnational assessments of performance for selected countries. To construct the health-related SDG index, we transformed the value for each indicator on a scale of 0-100, with 0 as the 2·5th percentile and 100 as the 97·5th percentile of 1000 draws calculated from 1990 to 2030, and took the geometric mean of the scaled indicators by target. To generate projections through 2030, we used a forecasting framework that drew estimates from the broader GBD study and used weighted averages of indicator-specific and country-specific annualised rates of change from 1990 to 2017 to inform future estimates. We assessed attainment of indicators with defined targets in two ways: first, using mean values projected for 2030, and then using the probability of attainment in 2030 calculated from 1000 draws. We also did a global attainment analysis of the feasibility of attaining SDG targets on the basis of past trends. Using 2015 global averages of indicators with defined SDG targets, we calculated the global annualised rates of change required from 2015 to 2030 to meet these targets, and then identified in what percentiles the required global annualised rates of change fell in the distribution of country-level rates of change from 1990 to 2015. We took the mean of these global percentile values across indicators and applied the past rate of change at this mean global percentile to all health-related SDG indicators, irrespective of target definition, to estimate the equivalent 2030 global average value and percentage change from 2015 to 2030 for each indicator. FINDINGS The global median health-related SDG index in 2017 was 59·4 (IQR 35·4-67·3), ranging from a low of 11·6 (95% uncertainty interval 9·6-14·0) to a high of 84·9 (83·1-86·7). SDG index values in countries assessed at the subnational level varied substantially, particularly in China and India, although scores in Japan and the UK were more homogeneous. Indicators also varied by SDI quintile and sex, with males having worse outcomes than females for non-communicable disease (NCD) mortality, alcohol use, and smoking, among others. Most countries were projected to have a higher health-related SDG index in 2030 than in 2017, while country-level probabilities of attainment by 2030 varied widely by indicator. Under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria indicators had the most countries with at least 95% probability of target attainment. Other indicators, including NCD mortality and suicide mortality, had no countries projected to meet corresponding SDG targets on the basis of projected mean values for 2030 but showed some probability of attainment by 2030. For some indicators, including child malnutrition, several infectious diseases, and most violence measures, the annualised rates of change required to meet SDG targets far exceeded the pace of progress achieved by any country in the recent past. We found that applying the mean global annualised rate of change to indicators without defined targets would equate to about 19% and 22% reductions in global smoking and alcohol consumption, respectively; a 47% decline in adolescent birth rates; and a more than 85% increase in health worker density per 1000 population by 2030. INTERPRETATION The GBD study offers a unique, robust platform for monitoring the health-related SDGs across demographic and geographic dimensions. Our findings underscore the importance of increased collection and analysis of disaggregated data and highlight where more deliberate design or targeting of interventions could accelerate progress in attaining the SDGs. Current projections show that many health-related SDG indicators, NCDs, NCD-related risks, and violence-related indicators will require a concerted shift away from what might have driven past gains-curative interventions in the case of NCDs-towards multisectoral, prevention-oriented policy action and investments to achieve SDG aims. Notably, several targets, if they are to be met by 2030, demand a pace of progress that no country has achieved in the recent past. The future is fundamentally uncertain, and no model can fully predict what breakthroughs or events might alter the course of the SDGs. What is clear is that our actions-or inaction-today will ultimately dictate how close the world, collectively, can get to leaving no one behind by 2030. FUNDING Bill & Melinda Gates Foundation.
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Stanaway JD, Afshin A, Gakidou E, Lim SS, Abate D, Abate KH, Abbafati C, Abbasi N, Abbastabar H, Abd-Allah F, Abdela J, Abdelalim A, Abdollahpour I, Abdulkader RS, Abebe M, Abebe Z, Abera SF, Abil OZ, Abraha HN, Abrham AR, Abu-Raddad LJ, Abu-Rmeileh NME, Accrombessi MMK, Acharya D, Acharya P, Adamu AA, Adane AA, Adebayo OM, Adedoyin RA, Adekanmbi V, Ademi Z, Adetokunboh OO, Adib MG, Admasie A, Adsuar JC, Afanvi KA, Afarideh M, Agarwal G, Aggarwal A, Aghayan SA, Agrawal A, Agrawal S, Ahmadi A, Ahmadi M, Ahmadieh H, Ahmed MB, Aichour AN, Aichour I, Aichour MTE, Akbari ME, Akinyemiju T, Akseer N, Al-Aly Z, Al-Eyadhy A, Al-Mekhlafi HM, Alahdab F, Alam K, Alam S, Alam T, Alashi A, Alavian SM, Alene KA, Ali K, Ali SM, Alijanzadeh M, Alizadeh-Navaei R, Aljunid SM, Alkerwi A, Alla F, Alsharif U, Altirkawi K, Alvis-Guzman N, Amare AT, Ammar W, Anber NH, Anderson JA, Andrei CL, Androudi S, Animut MD, Anjomshoa M, Ansha MG, Antó JM, Antonio CAT, Anwari P, Appiah LT, Appiah SCY, Arabloo J, Aremu O, Ärnlöv J, Artaman A, Aryal KK, Asayesh H, Ataro Z, Ausloos M, Avokpaho EFGA, Awasthi A, Ayala Quintanilla BP, Ayer R, Ayuk TB, Azzopardi PS, Babazadeh A, Badali H, Badawi A, Balakrishnan K, Bali AG, Ball K, Ballew SH, Banach M, Banoub JAM, Barac A, Barker-Collo SL, Bärnighausen TW, Barrero LH, Basu S, Baune BT, Bazargan-Hejazi S, Bedi N, Beghi E, Behzadifar M, Behzadifar M, Béjot Y, Bekele BB, Bekru ET, Belay E, Belay YA, Bell ML, Bello AK, Bennett DA, Bensenor IM, Bergeron G, Berhane A, Bernabe E, Bernstein RS, Beuran M, Beyranvand T, Bhala N, Bhalla A, Bhattarai S, Bhutta ZA, Biadgo B, Bijani A, Bikbov B, Bilano V, Bililign N, Bin Sayeed MS, Bisanzio D, Biswas T, Bjørge T, Blacker BF, Bleyer A, Borschmann R, Bou-Orm IR, Boufous S, Bourne R, Brady OJ, Brauer M, Brazinova A, Breitborde NJK, Brenner H, Briko AN, Britton G, Brugha T, Buchbinder R, Burnett RT, Busse R, Butt ZA, Cahill LE, Cahuana-Hurtado L, Campos-Nonato IR, Cárdenas R, Carreras G, Carrero JJ, Carvalho F, Castañeda-Orjuela CA, Castillo Rivas J, Castro F, Catalá-López F, Causey K, Cercy KM, Cerin E, Chaiah Y, Chang HY, Chang JC, Chang KL, Charlson FJ, Chattopadhyay A, Chattu VK, Chee ML, Cheng CY, Chew A, Chiang PPC, Chimed-Ochir O, Chin KL, Chitheer A, Choi JYJ, Chowdhury R, Christensen H, Christopher DJ, Chung SC, Cicuttini FM, Cirillo M, Cohen AJ, Collado-Mateo D, Cooper C, Cooper OR, Coresh J, Cornaby L, Cortesi PA, Cortinovis M, Costa M, Cousin E, Criqui MH, Cromwell EA, Cundiff DK, Daba AK, Dachew BA, Dadi AF, Damasceno AAM, Dandona L, Dandona R, Darby SC, Dargan PI, Daryani A, Das Gupta R, Das Neves J, Dasa TT, Dash AP, Davitoiu DV, Davletov K, De la Cruz-Góngora V, De La Hoz FP, De Leo D, De Neve JW, Degenhardt L, Deiparine S, Dellavalle RP, Demoz GT, Denova-Gutiérrez E, Deribe K, Dervenis N, Deshpande A, Des Jarlais DC, Dessie GA, Deveber GA, Dey S, Dharmaratne SD, Dhimal M, Dinberu MT, Ding EL, Diro HD, Djalalinia S, Do HP, Dokova K, Doku DT, Doyle KE, Driscoll TR, Dubey M, Dubljanin E, Duken EE, Duncan BB, Duraes AR, Ebert N, Ebrahimi H, Ebrahimpour S, Edvardsson D, Effiong A, Eggen AE, El Bcheraoui C, El-Khatib Z, Elyazar IR, Enayati A, Endries AY, Er B, Erskine HE, Eskandarieh S, Esteghamati A, Estep K, Fakhim H, Faramarzi M, Fareed M, Farid TA, Farinha CSES, Farioli A, Faro A, Farvid MS, Farzaei MH, Fatima B, Fay KA, Fazaeli AA, Feigin VL, Feigl AB, Fereshtehnejad SM, Fernandes E, Fernandes JC, Ferrara G, Ferrari AJ, Ferreira ML, Filip I, Finger JD, Fischer F, Foigt NA, Foreman KJ, Fukumoto T, Fullman N, Fürst T, Furtado JM, Futran ND, Gall S, Gallus S, Gamkrelidze A, Ganji M, Garcia-Basteiro AL, Gardner WM, Gebre AK, Gebremedhin AT, Gebremichael TG, Gelano TF, Geleijnse JM, Geramo YCD, Gething PW, Gezae KE, Ghadimi R, Ghadiri K, Ghasemi Falavarjani K, Ghasemi-Kasman M, Ghimire M, Ghosh R, Ghoshal AG, Giampaoli S, Gill PS, Gill TK, Gillum RF, Ginawi IA, Giussani G, Gnedovskaya EV, Godwin WW, Goli S, Gómez-Dantés H, Gona PN, Gopalani SV, Goulart AC, Grada A, Grams ME, Grosso G, Gugnani HC, Guo Y, Gupta R, Gupta R, Gupta T, Gutiérrez RA, Gutiérrez-Torres DS, Haagsma JA, Habtewold TD, Hachinski V, Hafezi-Nejad N, Hagos TB, Hailegiyorgis TT, Hailu GB, Haj-Mirzaian A, Haj-Mirzaian A, Hamadeh RR, Hamidi S, Handal AJ, Hankey GJ, Hao Y, Harb HL, Harikrishnan S, Haro JM, Hassankhani H, Hassen HY, Havmoeller R, Hawley CN, Hay SI, Hedayatizadeh-Omran A, Heibati B, Heidari B, Heidari M, Hendrie D, Henok A, Heredia-Pi I, Herteliu C, Heydarpour F, Heydarpour S, Hibstu DT, Higazi TB, Hilawe EH, Hoek HW, Hoffman HJ, Hole MK, Homaie Rad E, Hoogar P, Hosgood HD, Hosseini SM, Hosseinzadeh M, Hostiuc M, Hostiuc S, Hoy DG, Hsairi M, Hsiao T, Hu G, Hu H, Huang JJ, Hussen MA, Huynh CK, Iburg KM, Ikeda N, Ilesanmi OS, Iqbal U, Irvani SSN, Irvine CMS, Islam SMS, Islami F, Jackson MD, Jacobsen KH, Jahangiry L, Jahanmehr N, Jain SK, Jakovljevic M, James SL, Jassal SK, Jayatilleke AU, Jeemon P, Jha RP, Jha V, Ji JS, Jonas JB, Jonnagaddala J, Jorjoran Shushtari Z, Joshi A, Jozwiak JJ, Jürisson M, Kabir Z, Kahsay A, Kalani R, Kanchan T, Kant S, Kar C, Karami M, Karami Matin B, Karch A, Karema C, Karimi N, Karimi SM, Kasaeian A, Kassa DH, Kassa GM, Kassa TD, Kassebaum NJ, Katikireddi SV, Kaul A, Kawakami N, Kazemi Z, Karyani AK, Kefale AT, Keiyoro PN, Kemp GR, Kengne AP, Keren A, Kesavachandran CN, Khader YS, Khafaei B, Khafaie MA, Khajavi A, Khalid N, Khalil IA, Khan G, Khan MS, Khan MA, Khang YH, Khater MM, Khazaei M, Khazaie H, Khoja AT, Khosravi A, Khosravi MH, Kiadaliri AA, Kiirithio DN, Kim CI, Kim D, Kim YE, Kim YJ, Kimokoti RW, Kinfu Y, Kisa A, Kissimova-Skarbek K, Kivimäki M, Knibbs LD, Knudsen AKS, Kochhar S, Kokubo Y, Kolola T, Kopec JA, Kosen S, Koul PA, Koyanagi A, Kravchenko MA, Krishan K, Krohn KJ, Kromhout H, Kuate Defo B, Kucuk Bicer B, Kumar GA, Kumar M, Kuzin I, Kyu HH, Lachat C, Lad DP, Lad SD, Lafranconi A, Lalloo R, Lallukka T, Lami FH, Lang JJ, Lansingh VC, Larson SL, Latifi A, Lazarus JV, Lee PH, Leigh J, Leili M, Leshargie CT, Leung J, Levi M, Lewycka S, Li S, Li Y, Liang J, Liang X, Liao Y, Liben ML, Lim LL, Linn S, Liu S, Lodha R, Logroscino G, Lopez AD, Lorkowski S, Lotufo PA, Lozano R, Lucas TCD, Lunevicius R, Ma S, Macarayan ERK, Machado ÍE, Madotto F, Mai HT, Majdan M, Majdzadeh R, Majeed A, Malekzadeh R, Malta DC, Mamun AA, Manda AL, Manguerra H, Mansournia MA, Mantovani LG, Maravilla JC, Marcenes W, Marks A, Martin RV, Martins SCO, Martins-Melo FR, März W, Marzan MB, Massenburg BB, Mathur MR, Mathur P, Matsushita K, Maulik PK, Mazidi M, McAlinden C, McGrath JJ, McKee M, Mehrotra R, Mehta KM, Mehta V, Meier T, Mekonnen FA, Melaku YA, Melese A, Melku M, Memiah PTN, Memish ZA, Mendoza W, Mengistu DT, Mensah GA, Mensink GBM, Mereta ST, Meretoja A, Meretoja TJ, Mestrovic T, Mezgebe HB, Miazgowski B, Miazgowski T, Millear AI, Miller TR, Miller-Petrie MK, Mini GK, Mirarefin M, Mirica A, Mirrakhimov EM, Misganaw AT, Mitiku H, Moazen B, Mohajer B, Mohammad KA, Mohammadi M, Mohammadifard N, Mohammadnia-Afrouzi M, Mohammed S, Mohebi F, Mokdad AH, Molokhia M, Momeniha F, Monasta L, Moodley Y, Moradi G, Moradi-Lakeh M, Moradinazar M, Moraga P, Morawska L, Morgado-Da-Costa J, Morrison SD, Moschos MM, Mouodi S, Mousavi SM, Mozaffarian D, Mruts KB, Muche AA, Muchie KF, Mueller UO, Muhammed OS, Mukhopadhyay S, Muller K, Musa KI, Mustafa G, Nabhan AF, Naghavi M, Naheed A, Nahvijou A, Naik G, Naik N, Najafi F, Nangia V, Nansseu JR, Nascimento BR, Neal B, Neamati N, Negoi I, Negoi RI, Neupane S, Newton CRJ, Ngunjiri JW, Nguyen AQ, Nguyen G, Nguyen HT, Nguyen HLT, Nguyen HT, Nguyen M, Nguyen NB, Nichols E, Nie J, Ningrum DNA, Nirayo YL, Nishi N, Nixon MR, Nojomi M, Nomura S, Norheim OF, Noroozi M, Norrving B, Noubiap JJ, Nouri HR, Nourollahpour Shiadeh M, Nowroozi MR, Nsoesie EO, Nyasulu PS, Obermeyer CM, Odell CM, Ofori-Asenso R, Ogbo FA, Oh IH, Oladimeji O, Olagunju AT, Olagunju TO, Olivares PR, Olsen HE, Olusanya BO, Olusanya JO, Ong KL, Ong SK, Oren E, Orpana HM, Ortiz A, Ota E, Otstavnov SS, Øverland S, Owolabi MO, P A M, Pacella R, Pakhare AP, Pakpour AH, Pana A, Panda-Jonas S, Park EK, Parry CDH, Parsian H, Patel S, Pati S, Patil ST, Patle A, Patton GC, Paudel D, Paulson KR, Paz Ballesteros WC, Pearce N, Pereira A, Pereira DM, Perico N, Pesudovs K, Petzold M, Pham HQ, Phillips MR, Pillay JD, Piradov MA, Pirsaheb M, Pischon T, Pishgar F, Plana-Ripoll O, Plass D, Polinder S, Polkinghorne KR, Postma MJ, Poulton R, Pourshams A, Poustchi H, Prabhakaran D, Prakash S, Prasad N, Purcell CA, Purwar MB, Qorbani M, Radfar A, Rafay A, Rafiei A, Rahim F, Rahimi Z, Rahimi-Movaghar A, Rahimi-Movaghar V, Rahman M, Rahman MHU, Rahman MA, Rai RK, Rajati F, Rajsic S, Raju SB, Ram U, Ranabhat CL, Ranjan P, Rath GK, Rawaf DL, Rawaf S, Reddy KS, Rehm CD, Rehm J, Reiner RC, Reitsma MB, Remuzzi G, Renzaho AMN, Resnikoff S, Reynales-Shigematsu LM, Rezaei S, Ribeiro ALP, Rivera JA, Roba KT, Rodríguez-Ramírez S, Roever L, Román Y, Ronfani L, Roshandel G, Rostami A, Roth GA, Rothenbacher D, Roy A, Rubagotti E, Rushton L, Sabanayagam C, Sachdev PS, Saddik B, Sadeghi E, Saeedi Moghaddam S, Safari H, Safari Y, Safari-Faramani R, Safdarian M, Safi S, Safiri S, Sagar R, Sahebkar A, Sahraian MA, Sajadi HS, Salam N, Salamati P, Saleem Z, Salimi Y, Salimzadeh H, Salomon JA, Salvi DD, Salz I, Samy AM, Sanabria J, Sanchez-Niño MD, Sánchez-Pimienta TG, Sanders T, Sang Y, Santomauro DF, Santos IS, Santos JV, Santric Milicevic MM, Sao Jose BP, Sardana M, Sarker AR, Sarmiento-Suárez R, Sarrafzadegan N, Sartorius B, Sarvi S, Sathian B, Satpathy M, Sawant AR, Sawhney M, Saylan M, Sayyah M, Schaeffner E, Schmidt MI, Schneider IJC, Schöttker B, Schutte AE, Schwebel DC, Schwendicke F, Scott JG, Seedat S, Sekerija M, Sepanlou SG, Serre ML, Serván-Mori E, Seyedmousavi S, Shabaninejad H, Shaddick G, Shafieesabet A, Shahbazi M, Shaheen AA, Shaikh MA, Shamah Levy T, Shams-Beyranvand M, Shamsi M, Sharafi H, Sharafi K, Sharif M, Sharif-Alhoseini M, Sharifi H, Sharma J, Sharma M, Sharma R, She J, Sheikh A, Shi P, Shibuya K, Shiferaw MS, Shigematsu M, Shin MJ, Shiri R, Shirkoohi R, Shiue I, Shokraneh F, Shoman H, Shrime MG, Shupler MS, Si S, Siabani S, Sibai AM, Siddiqi TJ, Sigfusdottir ID, Sigurvinsdottir R, Silva DAS, Silva JP, Silveira DGA, Singh JA, Singh NP, Singh V, Sinha DN, Skiadaresi E, Skirbekk V, Smith DL, Smith M, Sobaih BH, Sobhani S, Somayaji R, Soofi M, Sorensen RJD, Soriano JB, Soyiri IN, Spinelli A, Sposato LA, Sreeramareddy CT, Srinivasan V, Starodubov VI, Steckling N, Stein DJ, Stein MB, Stevanovic G, Stockfelt L, Stokes MA, Sturua L, Subart ML, Sudaryanto A, Sufiyan MB, Sulo G, Sunguya BF, Sur PJ, Sykes BL, Szoeke CEI, Tabarés-Seisdedos R, Tabuchi T, Tadakamadla SK, Takahashi K, Tandon N, Tassew SG, Tavakkoli M, Taveira N, Tehrani-Banihashemi A, Tekalign TG, Tekelemedhin SW, Tekle MG, Temesgen H, Temsah MH, Temsah O, Terkawi AS, Tessema B, Teweldemedhin M, Thankappan KR, Theis A, Thirunavukkarasu S, Thomas HJ, Thomas ML, Thomas N, Thurston GD, Tilahun B, Tillmann T, To QG, Tobollik M, Tonelli M, Topor-Madry R, Torre AE, Tortajada-Girbés M, Touvier M, Tovani-Palone MR, Towbin JA, Tran BX, Tran KB, Truelsen TC, Truong NT, Tsadik AG, Tudor Car L, Tuzcu EM, Tymeson HD, Tyrovolas S, Ukwaja KN, Ullah I, Updike RL, Usman MS, Uthman OA, Vaduganathan M, Vaezi A, Valdez PR, Van Donkelaar A, Varavikova E, Varughese S, Vasankari TJ, Venkateswaran V, Venketasubramanian N, Villafaina S, Violante FS, Vladimirov SK, Vlassov V, Vollset SE, Vos T, Vosoughi K, Vu GT, Vujcic IS, Wagnew FS, Waheed Y, Waller SG, Walson JL, Wang Y, Wang Y, Wang YP, Weiderpass E, Weintraub RG, Weldegebreal F, Werdecker A, Werkneh AA, West JJ, Westerman R, Whiteford HA, Widecka J, Wijeratne T, Winkler AS, Wiyeh AB, Wiysonge CS, Wolfe CDA, Wong TY, Wu S, Xavier D, Xu G, Yadgir S, Yadollahpour A, Yahyazadeh Jabbari SH, Yamada T, Yan LL, Yano Y, Yaseri M, Yasin YJ, Yeshaneh A, Yimer EM, Yip P, Yisma E, Yonemoto N, Yoon SJ, Yotebieng M, Younis MZ, Yousefifard M, Yu C, Zaidi Z, Zaman SB, Zamani M, Zavala-Arciniega L, Zhang AL, Zhang H, Zhang K, Zhou M, Zimsen SRM, Zodpey S, Murray CJL. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392:1923-1994. [PMID: 30496105 PMCID: PMC6227755 DOI: 10.1016/s0140-6736(18)32225-6] [Citation(s) in RCA: 2618] [Impact Index Per Article: 436.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/31/2018] [Accepted: 09/05/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk-outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk-outcome pairs, and new data on risk exposure levels and risk-outcome associations. METHODS We used the CRA 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 groups of risks from 1990 to 2017. This study included 476 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. 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. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017. FINDINGS In 2017, 34·1 million (95% uncertainty interval [UI] 33·3-35·0) deaths and 1·21 billion (1·14-1·28) DALYs were attributable to GBD risk factors. Globally, 61·0% (59·6-62·4) of deaths and 48·3% (46·3-50·2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10·4 million (9·39-11·5) deaths and 218 million (198-237) DALYs, followed by smoking (7·10 million [6·83-7·37] deaths and 182 million [173-193] DALYs), high fasting plasma glucose (6·53 million [5·23-8·23] deaths and 171 million [144-201] DALYs), high body-mass index (BMI; 4·72 million [2·99-6·70] deaths and 148 million [98·6-202] DALYs), and short gestation for birthweight (1·43 million [1·36-1·51] deaths and 139 million [131-147] DALYs). In total, risk-attributable DALYs declined by 4·9% (3·3-6·5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23·5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18·6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low. INTERPRETATION By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning. FUNDING Bill & Melinda Gates Foundation.
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James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, Abbastabar H, Abd-Allah F, Abdela J, Abdelalim A, Abdollahpour I, Abdulkader RS, Abebe Z, Abera SF, Abil OZ, Abraha HN, Abu-Raddad LJ, Abu-Rmeileh NME, Accrombessi MMK, Acharya D, Acharya P, Ackerman IN, Adamu AA, Adebayo OM, Adekanmbi V, Adetokunboh OO, Adib MG, Adsuar JC, Afanvi KA, Afarideh M, Afshin A, Agarwal G, Agesa KM, Aggarwal R, Aghayan SA, Agrawal S, Ahmadi A, Ahmadi M, Ahmadieh H, Ahmed MB, Aichour AN, Aichour I, Aichour MTE, Akinyemiju T, Akseer N, Al-Aly Z, Al-Eyadhy A, Al-Mekhlafi HM, Al-Raddadi RM, Alahdab F, Alam K, Alam T, Alashi A, Alavian SM, Alene KA, Alijanzadeh M, Alizadeh-Navaei R, Aljunid SM, Alkerwi A, Alla F, Allebeck P, Alouani MML, Altirkawi K, Alvis-Guzman N, Amare AT, Aminde LN, Ammar W, Amoako YA, Anber NH, Andrei CL, Androudi S, Animut MD, Anjomshoa M, Ansha MG, Antonio CAT, Anwari P, Arabloo J, Arauz A, Aremu O, Ariani F, Armoon B, Ärnlöv J, Arora A, Artaman A, Aryal KK, Asayesh H, Asghar RJ, Ataro Z, Atre SR, Ausloos M, Avila-Burgos L, Avokpaho EFGA, Awasthi A, Ayala Quintanilla BP, Ayer R, Azzopardi PS, Babazadeh A, Badali H, Badawi A, Bali AG, Ballesteros KE, Ballew SH, Banach M, Banoub JAM, Banstola A, Barac A, Barboza MA, Barker-Collo SL, Bärnighausen TW, Barrero LH, Baune BT, Bazargan-Hejazi S, Bedi N, Beghi E, Behzadifar M, Behzadifar M, Béjot Y, Belachew AB, Belay YA, Bell ML, Bello AK, Bensenor IM, Bernabe E, Bernstein RS, Beuran M, Beyranvand T, Bhala N, Bhattarai S, Bhaumik S, Bhutta ZA, Biadgo B, Bijani A, Bikbov B, Bilano V, Bililign N, Bin Sayeed MS, Bisanzio D, Blacker BF, Blyth FM, Bou-Orm IR, Boufous S, Bourne R, Brady OJ, Brainin M, Brant LC, Brazinova A, Breitborde NJK, Brenner H, Briant PS, Briggs AM, Briko AN, Britton G, Brugha T, Buchbinder R, Busse R, Butt ZA, Cahuana-Hurtado L, Cano J, Cárdenas R, Carrero JJ, Carter A, Carvalho F, Castañeda-Orjuela CA, Castillo Rivas J, Castro F, Catalá-López F, Cercy KM, Cerin E, Chaiah Y, Chang AR, Chang HY, Chang JC, Charlson FJ, Chattopadhyay A, Chattu VK, Chaturvedi P, Chiang PPC, Chin KL, Chitheer A, Choi JYJ, Chowdhury R, Christensen H, Christopher DJ, Cicuttini FM, Ciobanu LG, Cirillo M, Claro RM, Collado-Mateo D, Cooper C, Coresh J, Cortesi PA, Cortinovis M, Costa M, Cousin E, Criqui MH, Cromwell EA, Cross M, Crump JA, Dadi AF, Dandona L, Dandona R, Dargan PI, Daryani A, Das Gupta R, Das Neves J, Dasa TT, Davey G, Davis AC, Davitoiu DV, De Courten B, De La Hoz FP, De Leo D, De Neve JW, Degefa MG, Degenhardt L, Deiparine S, Dellavalle RP, Demoz GT, Deribe K, Dervenis N, Des Jarlais DC, Dessie GA, Dey S, Dharmaratne SD, Dinberu MT, Dirac MA, Djalalinia S, Doan L, Dokova K, Doku DT, Dorsey ER, Doyle KE, Driscoll TR, Dubey M, Dubljanin E, Duken EE, Duncan BB, Duraes AR, Ebrahimi H, Ebrahimpour S, Echko MM, Edvardsson D, Effiong A, Ehrlich JR, El Bcheraoui C, El Sayed Zaki M, El-Khatib Z, Elkout H, Elyazar IRF, Enayati A, Endries AY, Er B, Erskine HE, Eshrati B, Eskandarieh S, Esteghamati A, 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Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392:1789-1858. [PMID: 30496104 PMCID: PMC6227754 DOI: 10.1016/s0140-6736(18)32279-7#] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/30/2018] [Accepted: 09/12/2018] [Indexed: 08/12/2023]
Abstract
BACKGROUND The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data. METHODS We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting. FINDINGS Globally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1-4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0-8·4) while the total sum of global YLDs increased from 562 million (421-723) to 853 million (642-1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6-9·2) for males and 6·5% (5·4-7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782-3252] per 100 000 in males vs s1400 [1279-1524] per 100 000 in females), transport injuries (3322 [3082-3583] vs 2336 [2154-2535]), and self-harm and interpersonal violence (3265 [2943-3630] vs 5643 [5057-6302]). INTERPRETATION Global all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury. FUNDING Bill & Melinda Gates Foundation.
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Murray CJL, Callender CSKH, Kulikoff XR, Srinivasan V, Abate D, Abate KH, Abay SM, Abbasi N, Abbastabar H, Abdela J, Abdelalim A, Abdel-Rahman O, Abdi A, Abdoli N, Abdollahpour I, Abdulkader RS, Abebe HT, Abebe M, Abebe Z, Abebo TA, Abejie AN, Aboyans V, Abraha HN, Abreu DMX, Abrham AR, Abu-Raddad LJ, Abu-Rmeileh NME, Accrombessi MMK, Acharya P, Adamu AA, Adebayo OM, Adedeji IA, Adekanmbi V, Adetokunboh OO, Adhena BM, Adhikari TB, Adib MG, Adou AK, Adsuar JC, Afarideh M, Afshin A, Agarwal G, Agesa KM, Aghayan SA, Agrawal S, Ahmadi A, Ahmadi M, Ahmed MB, Ahmed S, Aichour AN, Aichour I, Aichour MTE, Akanda AS, Akbari ME, Akibu M, Akinyemi RO, Akinyemiju T, Akseer N, Alahdab F, Al-Aly Z, Alam K, Alebel A, Aleman AV, Alene KA, Al-Eyadhy A, Ali R, Alijanzadeh M, Alizadeh-Navaei R, Aljunid SM, Alkerwi A, Alla F, Allebeck P, Almasi A, Alonso J, Al-Raddadi RM, Alsharif U, Altirkawi K, Alvis-Guzman N, Amare AT, Ammar W, Anber NH, Andrei CL, Androudi S, Animut MD, Ansari H, Ansha MG, Antonio 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Campuzano Rincon JC, Cano J, Car M, Cárdenas R, Carrero JJ, Carvalho F, Castañeda-Orjuela CA, Castillo Rivas J, Castro F, Catalá-López F, Çavlin A, Cerin E, Chalek J, Chang HY, Chang JC, Chattopadhyay A, Chaturvedi P, Chiang PPC, Chin KL, Chisumpa VH, Chitheer A, Choi JYJ, Chowdhury R, Christopher DJ, Cicuttini FM, Ciobanu LG, Cirillo M, Claro RM, Collado-Mateo D, Comfort H, Constantin MM, Conti S, Cooper C, Cooper LT, Cornaby L, Cortesi PA, Cortinovis M, Costa M, Cromwell E, Crowe CS, Cukelj P, Cunningham M, Daba AK, Dachew BA, Dandona L, Dandona R, Dargan PI, Daryani A, Das Gupta R, Das Neves J, Dasa TT, Dash AP, Weaver ND, Davitoiu DV, Davletov K, De Leo D, De Neve JW, Degefa MG, Degenhardt L, Degfie TT, Deiparine S, Demoz GT, Demtsu B, Denova-Gutiérrez E, Deribe K, Dervenis N, Des Jarlais DC, Dessie GA, Dharmaratne SD, Dhimal M, Dicker D, Ding EL, Dinsa GD, Djalalinia S, Do HP, Dokova K, Doku DT, Dolan KA, Doyle KE, Driscoll TR, Dubey M, Dubljanin E, Duken EE, Duraes AR, Ebrahimpour S, Edvardsson D, El Bcheraoui C, El-Khatib Z, Elyazar IR, Enayati A, Endries AY, Ermakov SP, Eshrati B, Eskandarieh S, Esmaeili R, Esteghamati A, Esteghamati S, Estep K, Fakhim H, Farag T, Faramarzi M, Fareed M, Farinha CSES, Faro A, Farvid MS, Farzadfar F, Farzaei MH, Fay KA, Fazeli MS, Feigin VL, Feigl AB, Feizy F, Fenny AP, Fentahun N, Fereshtehnejad SM, Fernandes E, Feyissa GT, Filip I, Finegold S, Fischer F, Flor LS, Foigt NA, Foreman KJ, Fornari C, Fürst T, Fukumoto T, Fuller JE, Fullman N, Gakidou E, Gallus S, Gamkrelidze A, Ganji M, Gankpe FG, Garcia GM, Garcia-Gordillo MÁ, Gebre AK, Gebre T, Gebregergs GB, Gebrehiwot TT, Gebremedhin AT, Gelano TF, Gelaw YA, Geleijnse JM, Genova-Maleras R, Gething P, Gezae KE, Ghadami MR, Ghadimi R, Ghadiri K, Ghasemi Falavarjani K, Ghasemi-Kasman M, Ghiasvand H, Ghimire M, Ghoshal AG, Gill PS, Gill TK, Giussani G, Gnedovskaya EV, Goli S, Gomez RS, Gómez-Dantés H, Gona PN, Goodridge A, Gopalani SV, Goulart AC, Goulart BNG, Grada A, Grosso G, Gugnani HCC, Guo J, Guo Y, Gupta PC, Gupta R, Gupta R, Gupta T, Haagsma JA, Hachinski V, Hafezi-Nejad N, Hagos TB, Hailegiyorgis TT, Hailu GB, Haj-Mirzaian A, Haj-Mirzaian A, Hamadeh RR, Hamidi S, Handal AJ, Hankey GJ, Hao Y, Harb HL, Haririan H, Haro JM, Hasan M, Hassankhani H, Hassen HY, Havmoeller R, Hay SI, He Y, Hedayatizadeh-Omran A, Hegazy MI, Heibati B, Heidari B, Hendrie D, Henok A, Henry NJ, Herteliu C, Heydarpour F, Hibstu DT, Hole MK, Homaie Rad E, Hoogar P, Hosgood HD, Hosseini SM, Hosseini Chavoshi MM, Hosseinzadeh M, Hostiuc M, Hostiuc S, Hsairi M, Hsiao T, Hu G, Huang JJ, Iburg KM, Igumbor EU, Ikeda CT, Ilesanmi OS, Iqbal U, Irenso AA, Irvani SSN, Isehunwa OO, Islam SMS, Jahangiry L, Jahanmehr N, Jain SK, Jakovljevic M, Jalu MT, James SL, Jassal SK, Javanbakht M, Jayatilleke AU, Jeemon P, Jha RP, Jha V, Ji JS, Jonas JB, Jozwiak JJ, Jungari SB, Jürisson M, Kabir Z, Kadel R, Kahsay A, Kalani R, Kapil U, Karami M, Matin BK, Karch A, Karema C, Karimi SM, Kasaeian A, Kassa DH, Kassa GM, Kassa TD, Kassa ZY, Kassebaum NJ, Kastor A, Katikireddi SV, Kaul A, Kawakami N, Karyani AK, Kebede S, Keiyoro PN, Kemp GR, Kengne AP, Keren A, Kereselidze M, Khader YS, Khafaie MA, Khajavi A, Khalid N, Khalil IA, Khan EA, Khan MS, Khang YH, Khanna T, Khater MM, Khatony A, Khazaeipour Z, Khazaie H, Khoja AT, Khosravi A, Khosravi MH, Kibret GD, Kidanemariam ZT, Kiirithio DN, Kilgore PE, Kim D, Kim JY, Kim YE, Kim YJ, Kimokoti RW, Kinfu Y, Kinra S, Kisa A, Kivimäki M, Kochhar S, Kokubo Y, Kolola T, Kopec JA, Kosek MN, Kosen S, Koul PA, Koyanagi A, Krishan K, Krishnaswami S, Krohn KJ, Defo BK, Bicer BK, Kumar GA, Kumar M, Kumar P, Kumsa FA, Kutz MJ, Lad SD, Lafranconi A, Lal DK, Lalloo R, Lam H, Lami FH, Lang JJ, Lanksy S, Lansingh VC, Laryea DO, Lassi ZS, Latifi A, Laxmaiah A, Lazarus JV, Lee JB, Lee PH, Leigh J, Leshargie CT, Leta S, Levi M, Li S, Li X, Li Y, Liang J, Liang X, Liben ML, Lim LL, Limenih MA, Linn S, Liu S, Lorkowski S, Lotufo PA, Lozano R, Lunevicius R, Mabika CM, Macarayan ERK, Mackay MT, Madotto F, Mahmood TAE, Mahotra NB, Majdan M, Majdzadeh R, Majeed A, Malekzadeh R, Malik MA, Mamun AA, Manamo WA, Manda AL, Mangalam S, Mansournia MA, Mantovani LG, Mapoma CC, Marami D, Maravilla JC, Marcenes W, Marina S, Martins-Melo FR, März W, Marzan MB, Mashamba-Thompson TP, Masiye F, Mason-Jones AJ, Massenburg BB, Mathur MR, Maulik PK, Mazidi M, McGrath JJ, Mehata S, Mehendale SM, Mehndiratta MM, Mehrotra R, Mehrzadi S, Mehta KM, Mehta V, Mekonnen TC, Meles HG, Meles KG, Melese A, Melku M, Memiah PTN, Memish ZA, Mendoza W, Mengesha MM, Mengistu DT, Mengistu G, Mensah GA, Mereta ST, Meretoja A, Meretoja TJ, Mestrovic T, Mezgebe HB, Miangotar Y, Miazgowski B, Miazgowski T, Miller TR, Miller-Petrie MK, Mini GK, Mirabi P, Mirica A, Mirrakhimov EM, Misganaw AT, Moazen B, Mohammad KA, Mohammadi M, Mohammadifard N, Mohammadi-Khanaposhtani M, Mohammed MA, Mohammed S, Mokdad AH, Mola GD, Molokhia M, Monasta L, Montañez JC, Moradi G, Moradi M, Moradi-Lakeh M, Moradinazar M, Moraga P, Morgado-Da-Costa J, Mori R, Morrison SD, Mosapour A, Moschos MM, Mousavi SM, Muche AA, Muchie KF, Mueller UO, Mukhopadhyay S, Muller K, Murphy TB, Murthy GVS, Musa J, Musa KI, Mustafa G, Muthupandian S, Nachega JB, Nagel G, Naghavi M, Naheed A, Nahvijou A, Naik G, Naik P, Najafi F, Naldi L, Nangia V, Nansseu JR, Nascimento BR, Nawaz H, Ncama BP, Neamati N, Negoi I, Negoi RI, Neupane S, Newton CRJ, Ngalesoni FN, Ngunjiri JW, Nguyen G, Nguyen LH, Nguyen TH, Ningrum DNA, Nirayo YL, Nisar MI, Nixon MR, Nomura S, Noroozi M, Noubiap JJ, Nouri HR, Shiadeh MN, Nowroozi MR, Nyandwi A, Nyasulu PS, Odell CM, Ofori-Asenso R, Ogah OS, Ogbo FA, Oh IH, Okoro A, Oladimeji O, Olagunju AT, Olagunju TO, Olivares PR, Olusanya BO, Olusanya JO, Ong SK, Ortiz A, Osgood-Zimmerman A, Ota E, Otieno BA, Otstavnov SS, Owolabi MO, Oyekale AS, P A M, Pakhale S, Pakhare AP, Pana A, Panda BK, Panda-Jonas S, Pandey AR, Park EK, Parsian H, Patel S, Patil ST, Patle A, Patton GC, Paturi VR, Paudel D, Pedroso MM, Peprah EK, Pereira DM, Perico N, Pesudovs K, Petri WA, Petzold M, Pierce M, Pigott DM, Pillay JD, Pirsaheb M, Polanczyk GV, Postma MJ, Pourmalek F, Pourshams A, Poustchi H, Prakash S, Prasad N, Purcell CA, Purwar MB, Qorbani M, Quansah R, Radfar A, Rafay A, Rafiei A, Rahim F, Rahimi-Movaghar A, Rahimi-Movaghar V, Rahman M, Rahman MS, Rahman MHU, Rahman MA, Rahman SU, Rai RK, Rajati F, Rajsic S, Ram U, Ranabhat CL, Ranjan P, Rawaf DL, Rawaf S, Ray SE, Razo-García C, Reiner RC, Reis C, Remuzzi G, Renzaho AMN, Resnikoff S, Rezaei S, Rezaeian S, Rezai MS, Riahi SM, Rios-Blancas MJ, Roba KT, Roberts NLS, Roever L, Ronfani L, Roshandel G, Rostami A, Rubagotti E, Ruhago GM, Sabde YD, Sachdev PS, Saddik B, Saeedi Moghaddam S, Safari H, Safari Y, Safari-Faramani R, Safdarian M, Safi S, Safiri S, Sagar R, Sahebkar A, Sahraian MA, Sajadi HS, Salahshoor MR, Salam N, Salama JS, Salamati P, Saldanha RDF, Saleem Z, Salimi Y, Salimzadeh H, Salomon JA, Salvi SS, Salz I, Sambala EZ, Samy AM, Sanabria J, Sanchez-Niño MD, Santos IS, Santric Milicevic MM, Sao Jose BP, Sardana M, Sarker AR, Sarmiento-Suárez R, Saroshe S, Sarrafzadegan N, Sartorius B, Sarvi S, Sathian B, Satpathy M, Sawant AR, Sawhney M, Saxena S, Schaeffner E, Schelonka K, Schneider IJC, Schwebel DC, Schwendicke F, Seedat S, Sekerija M, Sepanlou SG, Serván-Mori E, Shabaninejad H, Shackelford KA, Shafieesabet A, Shaheen AA, Shaikh MA, Shakir RA, Shams-Beyranvand M, Shamsi M, Shamsizadeh M, Sharafi H, Sharafi K, Sharif M, Sharif-Alhoseini M, Sharma J, Sharma R, She J, Sheikh A, Shi P, Shibuya K, Shigematsu M, Shiri R, Shirkoohi R, Shiue I, Shokraneh F, Shukla SR, Si S, Siabani S, Sibai AM, Siddiqi TJ, Sigfusdottir ID, Sigurvinsdottir R, Silpakit N, Silva DAS, Silva JP, Silveira DGA, Singam NSV, Singh JA, Singh NP, Singh V, Sinha DN, Sliwa K, Soares Filho AM, Sobaih BH, Sobhani S, Soofi M, Soriano JB, Soyiri IN, Sreeramareddy CT, Starodubov VI, Steiner C, Stewart LG, Stokes MA, Strong M, Subart ML, Sufiyan MB, Sulo G, Sunguya BF, Sur PJ, Sutradhar I, Sykes BL, Sylaja PN, Sylte DO, Szoeke CEI, Tabarés-Seisdedos R, Tabb KM, Tadakamadla SK, Tandon N, Tassew AA, Tassew SG, Taveira N, Tawye NY, Tehrani-Banihashemi A, Tekalign TG, Tekle MG, Temsah MH, Terkawi AS, Teshale MY, Tessema B, Teweldemedhin M, Thakur JS, Thankappan KR, Thirunavukkarasu S, Thomas N, Thomson AJ, Tilahun B, To QG, Tonelli M, Topor-Madry R, Torre AE, Tortajada-Girbés M, Tovani-Palone MR, Toyoshima H, Tran BX, Tran KB, Tripathy SP, Truelsen TC, Truong NT, Tsadik AG, Tsegay A, Tsilimparis N, Tudor Car L, Ukwaja KN, Ullah I, Usman MS, Uthman OA, Uzun SB, Vaduganathan M, Vaezi A, Vaidya G, Valdez PR, Varavikova E, Varughese S, Vasankari TJ, Vasconcelos AMN, Venketasubramanian N, Villafaina S, Violante FS, Vladimirov SK, Vlassov V, Vollset SE, Vos T, Vosoughi K, Vujcic IS, Wagnew FS, Waheed Y, Walson JL, Wang Y, Wang YP, Weiderpass E, Weintraub RG, Weldegwergs KG, Werdecker A, Westerman R, Whiteford H, Widecka J, Widecka K, Wijeratne T, Winkler AS, Wiysonge CS, Wolfe CDA, Wu S, Wyper GMA, Xu G, Yamada T, Yano Y, Yaseri M, Yasin YJ, Ye P, Yentür GK, Yeshaneh A, Yimer EM, Yip P, Yisma E, Yonemoto N, Yoon SJ, Yotebieng M, Younis MZ, Yousefifard M, Yu C, Zadnik V, Zaidi Z, Zaman SB, Zamani M, Zare Z, Zeleke MM, Zenebe ZM, Zerfu TA, Zhang X, Zhao XJ, Zhou M, Zhu J, Zimsen SRM, Zodpey S, Zoeckler L, Lopez AD, Lim SS. Population and fertility by age and sex for 195 countries and territories, 1950-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392:1995-2051. [PMID: 30496106 PMCID: PMC6227915 DOI: 10.1016/s0140-6736(18)32278-5] [Citation(s) in RCA: 243] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 09/07/2018] [Accepted: 09/12/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Population estimates underpin demographic and epidemiological research and are used to track progress on numerous international indicators of health and development. To date, internationally available estimates of population and fertility, although useful, have not been produced with transparent and replicable methods and do not use standardised estimates of mortality. We present single-calendar year and single-year of age estimates of fertility and population by sex with standardised and replicable methods. METHODS We estimated population in 195 locations by single year of age and single calendar year from 1950 to 2017 with standardised and replicable methods. We based the estimates on the demographic balancing equation, with inputs of fertility, mortality, population, and migration data. Fertility data came from 7817 location-years of vital registration data, 429 surveys reporting complete birth histories, and 977 surveys and censuses reporting summary birth histories. We estimated age-specific fertility rates (ASFRs; the annual number of livebirths to women of a specified age group per 1000 women in that age group) by use of spatiotemporal Gaussian process regression and used the ASFRs to estimate total fertility rates (TFRs; the average number of children a woman would bear if she survived through the end of the reproductive age span [age 10-54 years] and experienced at each age a particular set of ASFRs observed in the year of interest). Because of sparse data, fertility at ages 10-14 years and 50-54 years was estimated from data on fertility in women aged 15-19 years and 45-49 years, through use of linear regression. Age-specific mortality data came from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 estimates. Data on population came from 1257 censuses and 761 population registry location-years and were adjusted for underenumeration and age misreporting with standard demographic methods. Migration was estimated with the GBD Bayesian demographic balancing model, after incorporating information about refugee migration into the model prior. Final population estimates used the cohort-component method of population projection, with inputs of fertility, mortality, and migration data. Population uncertainty was estimated by use of out-of-sample predictive validity testing. With these data, we estimated the trends in population by age and sex and in fertility by age between 1950 and 2017 in 195 countries and territories. FINDINGS From 1950 to 2017, TFRs decreased by 49·4% (95% uncertainty interval [UI] 46·4-52·0). The TFR decreased from 4·7 livebirths (4·5-4·9) to 2·4 livebirths (2·2-2·5), and the ASFR of mothers aged 10-19 years decreased from 37 livebirths (34-40) to 22 livebirths (19-24) per 1000 women. Despite reductions in the TFR, the global population has been increasing by an average of 83·8 million people per year since 1985. The global population increased by 197·2% (193·3-200·8) since 1950, from 2·6 billion (2·5-2·6) to 7·6 billion (7·4-7·9) people in 2017; much of this increase was in the proportion of the global population in south Asia and sub-Saharan Africa. The global annual rate of population growth increased between 1950 and 1964, when it peaked at 2·0%; this rate then remained nearly constant until 1970 and then decreased to 1·1% in 2017. Population growth rates in the southeast Asia, east Asia, and Oceania GBD super-region decreased from 2·5% in 1963 to 0·7% in 2017, whereas in sub-Saharan Africa, population growth rates were almost at the highest reported levels ever in 2017, when they were at 2·7%. The global average age increased from 26·6 years in 1950 to 32·1 years in 2017, and the proportion of the population that is of working age (age 15-64 years) increased from 59·9% to 65·3%. At the national level, the TFR decreased in all countries and territories between 1950 and 2017; in 2017, TFRs ranged from a low of 1·0 livebirths (95% UI 0·9-1·2) in Cyprus to a high of 7·1 livebirths (6·8-7·4) in Niger. The TFR under age 25 years (TFU25; number of livebirths expected by age 25 years for a hypothetical woman who survived the age group and was exposed to current ASFRs) in 2017 ranged from 0·08 livebirths (0·07-0·09) in South Korea to 2·4 livebirths (2·2-2·6) in Niger, and the TFR over age 30 years (TFO30; number of livebirths expected for a hypothetical woman ageing from 30 to 54 years who survived the age group and was exposed to current ASFRs) ranged from a low of 0·3 livebirths (0·3-0·4) in Puerto Rico to a high of 3·1 livebirths (3·0-3·2) in Niger. TFO30 was higher than TFU25 in 145 countries and territories in 2017. 33 countries had a negative population growth rate from 2010 to 2017, most of which were located in central, eastern, and western Europe, whereas population growth rates of more than 2·0% were seen in 33 of 46 countries in sub-Saharan Africa. In 2017, less than 65% of the national population was of working age in 12 of 34 high-income countries, and less than 50% of the national population was of working age in Mali, Chad, and Niger. INTERPRETATION Population trends create demographic dividends and headwinds (ie, economic benefits and detriments) that affect national economies and determine national planning needs. Although TFRs are decreasing, the global population continues to grow as mortality declines, with diverse patterns at the national level and across age groups. To our knowledge, this is the first study to provide transparent and replicable estimates of population and fertility, which can be used to inform decision making and to monitor progress. FUNDING Bill & Melinda Gates Foundation.
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Salehi AS, Saljuqi ATK, Akseer N, Rao K, Coe K. Factors influencing performance by contracted non-state providers implementing a basic package of health services in Afghanistan. Int J Equity Health 2018; 17:128. [PMID: 30286770 PMCID: PMC6172740 DOI: 10.1186/s12939-018-0847-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 08/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2002 Afghanistan's Ministry of Public Health (MoPH) and its development partners initiated a new paradigm for the health sector by electing to Contract-Out (CO) the Basic Package of Health Services (BPHS) to non-state providers (NSPs). This model is generally regarded as successful, but literature is scarce that examines the motivations underlying implementation and factors influencing program success. This paper uses relevant theories and qualitative data to describe how and why contracting out delivery of primary health care services to NSPs has been effective. The main aim of this study was to assess the contextual, institutional, and contractual factors that influenced the performance of NSPs delivering the BPHS in Afghanistan. METHODS The qualitative study design involved individual in-depth interviews and focus group discussions conducted in six provinces of Afghanistan, as well as a desk review. The framework for assessing key factors of the contracting mechanism proposed by Liu et al. was utilized in the design, data collection and data analysis. RESULTS While some contextual factors facilitated the CO (e.g. MoPH leadership, NSP innovation and community participation), harsh geography, political interference and insecurity in some provinces had negative effects. Contractual factors, such as effective input and output management, guided health service delivery. Institutional factors were important; management capacity of contracted NSPs affects their ability to deliver outcomes. Effective human resources and pharmaceutical management were notable elements that contributed to the successful delivery of the BPHS. The contextual, contractual and institutional factors interacted with each other. CONCLUSION Three sets of factors influenced the implementation of the BPHS: contextual, contractual and institutional. The MoPH should consider all of these factors when contracting out the BPHS and other functions to NSPs. Other fragile states and countries emerging from a period of conflict could learn from Afghanistan's example in contracting out primary health care services, keeping in mind that generic or universal contracting policies might not work in all geographical areas within a country or between countries.
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Affiliation(s)
| | | | - Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children Toronto and the University of Toronto, Ontario, ON, Canada
| | - Krishna Rao
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kathryn Coe
- Fairbanks School of Public Health, Indiana University- Purdue University Indianapolis, Indianapolis, USA
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Wigle JM, Akseer N, Carbone S, Barac R, Barwick M, Zlotkin S. Developing a tool to measure the reciprocal benefits that accrue to health professionals involved in global health. BMJ Glob Health 2018; 3:e000792. [PMID: 30167333 PMCID: PMC6112395 DOI: 10.1136/bmjgh-2018-000792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 06/15/2018] [Accepted: 07/20/2018] [Indexed: 11/05/2022] Open
Abstract
Research to date on global health collaborations has typically focused on documenting improvements in the health outcomes of low/middle-income countries. Recent discourse has characterised these collaborations with the notion of ‘reciprocal value’, namely, that the benefits go beyond strengthening local health systems and that both partners have something to learn and gain from the relationship. We explored a method for assessing this reciprocal value by developing a robust framework for measuring changes in individual competencies resulting from participation in global health work. The validated survey and evidence-based framework were developed from a comprehensive review of the literature on global health competencies and reciprocal value. Statistical analysis including factor analysis, evaluation of internal consistency of domains and measurement of floor and ceiling effects were conducted to explore global health competencies among diverse health professionals at a tertiary paediatric health facility in Toronto, Canada. Factor analysis identified eight unique domains of competencies for health professionals and their institutions resulting from participation in global health work. Seven domains related to individual-level competencies and one emphasised institutional capacity strengthening. The resulting Global Health Competency Model and validated survey represent useful approaches to measuring the reciprocal value of global health work among diverse health professionals and settings. Insights gained through application of the model and survey may challenge the dominant belief that capacity strengthening for this work primarily benefits the recipient individuals and institutions in low/middle-income settings.
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Affiliation(s)
- Jannah Margaret Wigle
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sarah Carbone
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Raluca Barac
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Melanie Barwick
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Stanley Zlotkin
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Naghavi M, Marczak LB, Kutz M, Shackelford KA, Arora M, Miller-Petrie M, Aichour MTE, Akseer N, Al-Raddadi RM, Alam K, Alghnam SA, Antonio CAT, Aremu O, Arora A, Asadi-Lari M, Assadi R, Atey TM, Avila-Burgos L, Awasthi A, Ayala Quintanilla BP, Barker-Collo SL, Bärnighausen TW, Bazargan-Hejazi S, Behzadifar M, Behzadifar M, Bennett JR, Bhalla A, Bhutta ZA, Bilal AI, Borges G, Borschmann R, Brazinova A, Campuzano Rincon JC, Carvalho F, Castañeda-Orjuela CA, Dandona L, Dandona R, Dargan PI, De Leo D, Dharmaratne SD, Ding EL, Phuc Do H, Doku DT, Doyle KE, Driscoll TR, Edessa D, El-Khatib Z, Endries AY, Esteghamati A, Faro A, Farzadfar F, Feigin VL, Fischer F, Foreman KJ, Franklin RC, Fullman N, Futran ND, Gebrehiwot TT, Gutiérrez RA, Hafezi-Nejad N, Haghparast Bidgoli H, Hailu GB, Haro JM, Hassen HY, Hawley C, Hendrie D, Híjar M, Hu G, Ilesanmi OS, Jakovljevic M, James SL, Jayaraman S, Jonas JB, Kahsay A, Kasaeian A, Keiyoro PN, Khader Y, Khalil IA, Khang YH, Khubchandani J, Ahmad Kiadaliri A, Kieling C, Kim YJ, Kosen S, Krohn KJ, Kumar GA, Lami FH, Lansingh VC, Larson HJ, Linn S, Lunevicius R, Magdy Abd El Razek H, Magdy Abd El Razek M, Malekzadeh R, Carvalho Malta D, Mason-Jones AJ, Matzopoulos R, Memiah PTN, Mendoza W, Meretoja TJ, Mezgebe HB, Miller TR, Mohammed S, Moradi-Lakeh M, Mori R, Nand D, Tat Nguyen C, Le Nguyen Q, Ningrum DNA, Akpojene Ogbo F, Olagunju AT, Patton GC, Phillips MR, Polinder S, Pourmalek F, Qorbani M, Rahimi-Movaghar A, Rahimi-Movaghar V, Rahman M, Rai RK, Ranabhat CL, Rawaf DL, Rawaf S, Rowhani-Rahbar A, Safdarian M, Safiri S, Sagar R, Salama JS, Sanabria J, Santric Milicevic MM, Sarmiento-Suárez R, Sartorius B, Satpathy M, Schwebel DC, Seedat S, Sepanlou SG, Shaikh MA, Sharew NT, Shiue I, Singh JA, Sisay M, Skirbekk V, Soares Filho AM, Stein DJ, Stokes MA, Sufiyan MB, Swaroop M, Sykes BL, Tabarés-Seisdedos R, Tadese F, Tran BX, Thanh Tran T, Ukwaja KN, Vasankari TJ, Vlassov V, Werdecker A, Ye P, Yip P, Yonemoto N, Younis MZ, Zaidi Z, El Sayed Zaki M, Hay SI, Lim SS, Lopez AD, Mokdad AH, Vos T, Murray CJL. Global Mortality From Firearms, 1990-2016. JAMA 2018; 320:792-814. [PMID: 30167700 PMCID: PMC6143020 DOI: 10.1001/jama.2018.10060] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/23/2018] [Indexed: 12/21/2022]
Abstract
Importance Understanding global variation in firearm mortality rates could guide prevention policies and interventions. Objective To estimate mortality due to firearm injury deaths from 1990 to 2016 in 195 countries and territories. Design, Setting, and Participants This study used deidentified aggregated data including 13 812 location-years of vital registration data to generate estimates of levels and rates of death by age-sex-year-location. The proportion of suicides in which a firearm was the lethal means was combined with an estimate of per capita gun ownership in a revised proxy measure used to evaluate the relationship between availability or access to firearms and firearm injury deaths. Exposures Firearm ownership and access. Main Outcomes and Measures Cause-specific deaths by age, sex, location, and year. Results Worldwide, it was estimated that 251 000 (95% uncertainty interval [UI], 195 000-276 000) people died from firearm injuries in 2016, with 6 countries (Brazil, United States, Mexico, Colombia, Venezuela, and Guatemala) accounting for 50.5% (95% UI, 42.2%-54.8%) of those deaths. In 1990, there were an estimated 209 000 (95% UI, 172 000 to 235 000) deaths from firearm injuries. Globally, the majority of firearm injury deaths in 2016 were homicides (64.0% [95% UI, 54.2%-68.0%]; absolute value, 161 000 deaths [95% UI, 107 000-182 000]); additionally, 27% were firearm suicide deaths (67 500 [95% UI, 55 400-84 100]) and 9% were unintentional firearm deaths (23 000 [95% UI, 18 200-24 800]). From 1990 to 2016, there was no significant decrease in the estimated global age-standardized firearm homicide rate (-0.2% [95% UI, -0.8% to 0.2%]). Firearm suicide rates decreased globally at an annualized rate of 1.6% (95% UI, 1.1-2.0), but in 124 of 195 countries and territories included in this study, these levels were either constant or significant increases were estimated. There was an annualized decrease of 0.9% (95% UI, 0.5%-1.3%) in the global rate of age-standardized firearm deaths from 1990 to 2016. Aggregate firearm injury deaths in 2016 were highest among persons aged 20 to 24 years (for men, an estimated 34 700 deaths [95% UI, 24 900-39 700] and for women, an estimated 3580 deaths [95% UI, 2810-4210]). Estimates of the number of firearms by country were associated with higher rates of firearm suicide (P < .001; R2 = 0.21) and homicide (P < .001; R2 = 0.35). Conclusions and Relevance This study estimated between 195 000 and 276 000 firearm injury deaths globally in 2016, the majority of which were firearm homicides. Despite an overall decrease in rates of firearm injury death since 1990, there was variation among countries and across demographic subgroups.
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Affiliation(s)
- Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Laurie B Marczak
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Michael Kutz
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | | | - Megha Arora
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Molly Miller-Petrie
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | | | - Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Rajaa M Al-Raddadi
- Department of Family and Community Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khurshid Alam
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Suliman A Alghnam
- Department of Population Health, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Carl Abelardo T Antonio
- Department of Health Policy and Administration, University of the Philippines Manila, Manila, Philippines
| | - Olatunde Aremu
- Department of Public and Community Health, Birmingham City University, Birmingham, England
| | - Amit Arora
- School of Science and Health, Western Sydney University, Penrith, NSW, Australia
- Oral Health Services, Sydney Local Health District, Sydney, Australia
| | - Mohsen Asadi-Lari
- Department of Epidemiology and Biostatistics, Iran University of Medical Sciences, Tehran, Iran
- International Relations Department, Iranian Ministry of Health and Medical Education, Tehran, Iran
| | - Reza Assadi
- Education Development Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Leticia Avila-Burgos
- Center of Health System Research, The National Institute of Public Health, Cuernavaca, Mexico
| | - Ashish Awasthi
- Indian Institute of Public Health, Gandhinagar, India
- Public Health Foundation of India, Gurugram, India
| | - Beatriz Paulina Ayala Quintanilla
- The Judith Lumley Centre, La Trobe University, Melbourne, VIC, Australia
- General Office for Research and Technological Transfer, Peruvian National Institute of Health, Lima, Peru
| | | | - Till Winfried Bärnighausen
- Institute of Public Health, Heidelberg University, Heidelberg, Germany
- Department of Global Health and Population, Harvard University, Boston, Massachusetts
| | - Shahrzad Bazargan-Hejazi
- Department of Psychiatry, Charles R. Drew University of Medicine and Science, Los Angeles, California
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles
| | - Masoud Behzadifar
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorranmabad, Iran
| | - Meysam Behzadifar
- Faculty of Health and Nutrition, Lorestan University of Medical Sciences, Khorranmabad, Iran
| | - James R Bennett
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Ashish Bhalla
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Arebu Issa Bilal
- School of Pharmacy, Addis Ababa University, Addis Ababa, Ethiopia
| | - Guilherme Borges
- Department of Epidemiology, National Institute of Psychiatry Ramón de la Fuente, Mexico City, Mexico
| | - Rohan Borschmann
- Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | | | - Julio Cesar Campuzano Rincon
- National Institute of Health, Cuernavaca, Mexico
- Escuela de Medicina, Universidad Valle de Cuernavaca, Cuernavaca, Mexico
| | - Félix Carvalho
- Ucibio, Requimte, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Carlos A Castañeda-Orjuela
- Colombian National Health Observatory, Instituto Nacional de Salud, Bogota, Colombia
- Epidemiology and Public Health Evaluation Group, Universidad Nacional de Colombia, Bogota, Colombia
| | - Lalit Dandona
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
- Public Health Foundation of India, Gurugram, India
| | - Rakhi Dandona
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
- Public Health Foundation of India, Gurugram, India
| | - Paul I Dargan
- Department of Clinical Toxicology, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
- Department of Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Diego De Leo
- Australian Institute for Suicide Research and Prevention, Griffith University, Mt Gravatt, QLD, Australia
| | - Samath Dhamminda Dharmaratne
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
- Department of Community Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Eric L Ding
- Harvard School of Public Health, Department of Nutrition, Harvard University, Boston, Massachusetts
| | - Huyen Phuc Do
- Institute for Global Health Innovations, Duy Tan University, Hanoi, Vietnam
| | - David Teye Doku
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Kerrie E Doyle
- School of Health and Biomedical Sciences, Royal Melbourne Institute of Technology University (RMIT), Bundoora, VIC, Australia
| | - Tim Robert Driscoll
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Dumessa Edessa
- School of Pharmacy, Haramaya University, Harar, Ethiopia
| | - Ziad El-Khatib
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Aman Yesuf Endries
- Department of Public Health, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Alireza Esteghamati
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Andre Faro
- Department of Psychology, Federal University of Sergipe, Sao Cristovao, Brazil
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Valery L Feigin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | - Florian Fischer
- Department of Public Health Medicine, Bielefeld University, Bielefeld, Germany
| | - Kyle J Foreman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Richard Charles Franklin
- College of Public Health Medical and Veterinary Science, James Cook University, Douglas, QLD, Australia
| | - Nancy Fullman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Neal D Futran
- School of Medicine Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle
| | | | - Reyna Alma Gutiérrez
- Epidemiological and Psychosocial Investigations, National Institute of Psychiatry Ramon de la Fuente, Mexico City, Mexico
| | - Nima Hafezi-Nejad
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Department of Radiology, Johns Hopkins University, Baltimore, Maryland
| | | | | | - Josep Maria Haro
- Research Unit, Parc Sanitari Sant Joan de Déu (CIBERSAM), Sant Boi de Llobregat, Spain
- Department of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Hamid Yimam Hassen
- Department of Public Health, Mizan-Tepi University, Mizan Teferi, Ethiopia
- Unit of Epidemiology and Social Medicine, University Hospital Antwerp, Wilrijk, Belgium
| | - Caitlin Hawley
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Delia Hendrie
- School of Public Health, Curtin University, Bentley, Perth, WA, Australia
| | - Martha Híjar
- Research Coordination, Fundación Entornos AC, Cuernavaca, Mexico
- CISS, National Institute of Public Health, Cuernavaca, Mexico
| | - Guoqing Hu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | | | | | - Spencer L James
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Sudha Jayaraman
- Department of Surgery, Virginia Commonwealth University, Richmond
| | - Jost B Jonas
- Department of Ophthalmology, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- Capital Medical University, Beijing Institute of Ophthalmology, Beijing Tongren Hospital, Beijing Ophthalmology & Visual Science Key Laboratory, Beijing, China
| | - Amaha Kahsay
- Department of Nutrition and Dietetics, Mekelle University, Mekelle, Ethiopia
| | - Amir Kasaeian
- Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Hematologic Malignancies Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Peter Njenga Keiyoro
- School of Continuing and Distance Education, University of Nairobi, Nairobi, Kenya
| | - Yousef Khader
- Public Health and Community Medicine, Jordan University of Science and Technology, Alramtha, Jordan
| | - Ibrahim A Khalil
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Young-Ho Khang
- Department of Health Policy and Management, College of Medicine, Seoul National University, Seoul, South Korea
- Institute of Health Policy and Management, SNU Medical Research Center, Seoul National University, Seoul, South Korea
| | - Jagdish Khubchandani
- Department of Nutrition and Health Science, Ball State University, Muncie, Indiana
| | | | - Christian Kieling
- Department of Psychiatry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
- Child & Adolescent Psychiatry Division, Hospital of Clinics of Porto Alegre, Porto Alegre, Brazil
| | - Yun Jin Kim
- School of Medicine, Xiamen University Malaysia, Sepang, Malaysia
| | | | - Kristopher J Krohn
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - G Anil Kumar
- Public Health Foundation of India, Gurugram, India
| | - Faris Hasan Lami
- Department of Community and Family Medicine, Academy of Medical Science, Baghdad, Iraq
| | - Van C Lansingh
- Helpmesee, New York, New York
- Department of International Relations, Mexican Institute of Ophthalmology, Queretaro, Mexico
| | - Heidi Jane Larson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Shai Linn
- School of Public Health, University of Haifa, Haifa, Israel
| | - Raimundas Lunevicius
- General Surgery Department, Aintree University Hospital National Health Service Foundation Trust (NHS), Liverpool, United Kingdom
- School of Medicine, University of Liverpool, Liverpool, United Kingdom
| | | | | | - Reza Malekzadeh
- Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Non-Communicable Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Deborah Carvalho Malta
- Departamento Materno Infantil e Saúde Publica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Richard Matzopoulos
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Peter T N Memiah
- Department of Public Health, University of West Florida, Pensacola
| | - Walter Mendoza
- Peru Country Office, United Nations Population Fund (UNFPA), Lima, Peru
| | - Tuomo J Meretoja
- Comprehensive Cancer Center, Breast Surgery Unit, Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, University of Helsinki, Helsinki, Finland
| | | | - Ted R Miller
- School of Public Health, Curtin University, Bentley, Perth, WA, Australia
- Pacific Institute for Research & Evaluation, Calverton, Maryland
| | - Shafiu Mohammed
- Institute of Public Health, Heidelberg University, Heidelberg, Germany
- Health Systems and Policy Research Unit, Ahmadu Bello University, Zaria, Nigeria
| | - Maziar Moradi-Lakeh
- Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Rintaro Mori
- Department of Health Policy, National Center for Child Health and Development, Setagaya, Japan
| | - Devina Nand
- Health Information Unit, Ministry of Health, Suva, Fiji
- Accamargo Cancer Center, São Paulo, Brazil
| | - Cuong Tat Nguyen
- Institute for Global Health Innovations, Duy Tan University, Hanoi, Vietnam
| | - Quyen Le Nguyen
- Institute for Global Health Innovations, Duy Tan University, Hanoi, Vietnam
| | - Dina Nur Anggraini Ningrum
- Public Health Department, Semarang State University, Kota Semarang, Indonesia
- Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei City, Taiwan
| | | | - Andrew T Olagunju
- School of Medicine, University of Adelaide, Adelaide, SA, Australia
- Department of Psychiatry, University of Lagos, Lagos, Nigeria
| | - George C Patton
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Department of Paediatrics, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Michael R Phillips
- Shanghai Mental Health Center, Shanghai Jiao Tong University, Shanghai, China
| | - Suzanne Polinder
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Farshad Pourmalek
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mostafa Qorbani
- Non-Communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahfuzar Rahman
- Research and Evaluation Division, BRAC (Bangladesh Rehabilitation Assistance Committee), Dhaka, Bangladesh
| | - Rajesh Kumar Rai
- Society for Health and Demographic Surveillance, Suri, India
- Department of Economics, University of Göttingen, Göttingen, Germany
| | - Chhabi Lal Ranabhat
- Institute for Poverty Alleviation and International Development, Yonsei University, South Korea
| | - David Laith Rawaf
- WHO Collaborating Centre for Public Health Education & Training, Imperial College London, London, United Kingdom
- University College London Hospitals, London, United Kingdom
| | - Salman Rawaf
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
- Public Health England, London, United Kingdom
| | | | - Mahdi Safdarian
- Sina Trauma and Surgery Center, Iran University of Medical Sciences, Tehran, Iran
| | - Saeid Safiri
- Managerial Epidemiology Research Center, Department of Public Health, School of Nursing and Midwifery, Maragheh University of Medical Sciences, Maragheh, Iran
| | - Rajesh Sagar
- Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Joseph S Salama
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Juan Sanabria
- Department of Surgery, Marshall University, Huntington, West Virginia
- Department of Nutrition and Preventive Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Milena M Santric Milicevic
- Faculty of Medicine, Institute of Social Medicine, Centre School of Public Health and Health Management, University of Belgrade, Belgrade, Serbia
| | - Rodrigo Sarmiento-Suárez
- Department of Health and Society, Faculty of Medicine, Universidad Ciencias Aplicadas y Ambientales, Bogotá, Colombia
| | - Benn Sartorius
- Department of Public Health Medicine, University of Kwazulu-Natal, Durban, South Africa
| | - Maheswar Satpathy
- UGC Centre of Advanced Study in Psychology, Utkal University, Bhubaneswar, India
| | - David C Schwebel
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Soraya Seedat
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | - Sadaf G Sepanlou
- Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Non-Communicable Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | - Ivy Shiue
- Instituts Für Medizinische Epidemiologie, Biometrie Und Informatik, Martin Luther University Halle-Wittenberg, Haale, Germany
| | - Jasvinder A Singh
- School of Medicine, University of Alabama at Birmingham
- Department of Epidemiology, University of Alabama at Birmingham
| | - Mekonnen Sisay
- School of Pharmacy, Haramaya University, Harar, Ethiopia
| | | | - Adauto Martins Soares Filho
- Department of Diseases and Noncommunicable Diseases and Health Promotion, Federal Ministry of Health, Brasilia, Brazil
| | - Dan J Stein
- South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | | | | | - Mamta Swaroop
- Department of Surgery, Northwestern University, Chicago, Illinois
| | - Bryan L Sykes
- Department of Criminology, Law, & Society, University of California Irvine
| | | | - Fentaw Tadese
- Department of Public Health, Wollo University, Dessie, Ethiopia
| | - Bach Xuan Tran
- Department of Health Economics, Hanoi Medical University, Hanoi, Vietnam
| | - Tung Thanh Tran
- Institute for Global Health Innovations, Duy Tan University, Hanoi, Vietnam
| | | | | | - Vasily Vlassov
- Department of Health Care Management and Economics, National Research University Higher School of Economics, Moscow, Russia
| | - Andrea Werdecker
- Demographic Change and Ageing, Federal Institute for Population Research, Wiesbaden, Germany
| | - Pengpeng Ye
- Division of Injury Prevention and Mental Health Improvement, National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Xicheng District, China
| | - Paul Yip
- Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong SAR, China
| | - Naohiro Yonemoto
- Department of Biostatistics, School of Public Health, Kyoto University, Kyoto, Japan
| | - Mustafa Z Younis
- Healthcare Management-Health Economics & Finance/Global Health, Jackson State University, Jackson, Missouri
- Research Center for Public Health, Tsinghua University, Beijing, China
| | - Zoubida Zaidi
- Department of Epidemiology, University Hospital of Setif, Setif, Algeria
- Faculty of Medical Sciences, A.C.S. Medical College and Hospital, Algiers, Algeria
| | | | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Stephen S Lim
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Alan D Lopez
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
- School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Ali H Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | - Theo Vos
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
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Keats EC, Macharia W, Singh NS, Akseer N, Ravishankar N, Ngugi AK, Rizvi A, Khaemba EN, Tole J, Bhutta ZA. Accelerating Kenya's progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015. BMJ Glob Health 2018; 3:e000655. [PMID: 29862055 PMCID: PMC5969726 DOI: 10.1136/bmjgh-2017-000655] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 04/14/2018] [Accepted: 04/16/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Despite recent gains, Kenya did not achieve its Millennium Development Goal (MDG) target for reducing under-five mortality. To accelerate progress to 2030, we must understand what impacted mortality throughout the MDG period. METHODS Trends in the under-five mortality rate (U5MR) were analysed using data from nationally representative Demographic and Health Surveys (1989-2014). Comprehensive, mixed-methods analyses of health policies and systems, workforce and health financing were conducted using relevant surveys, government documents and key informant interviews with country experts. A hierarchical multivariable linear regression analysis was undertaken to better understand the proximal determinants of change in U5MR over the MDG period. RESULTS U5MR declined by 50% from 1993 to 2014. However, mortality increased between 1990 and 2000, following the introduction of facility user fees and declining coverage of essential interventions. The MDGs, together with Kenya's political changes in 2003, ushered in a new era of policymaking with a strong focus on children under 5 years of age. External aid for child health quadrupled from 40 million in 2002 to 180 million in 2012, contributing to the dramatic improvement in U5MR throughout the latter half of the MDG period. Our multivariable analysis explained 44% of the decline in U5MR from 2003 to 2014, highlighting maternal literacy, household wealth, sexual and reproductive health and maternal and infant nutrition as important contributing factors. Children living in Nairobi had higher odds of child mortality relative to children living in other regions of Kenya. CONCLUSIONS To attain the Sustainable Development Goal targets for child health, Kenya must uphold its current momentum. For equitable access to health services, user fees must not be reintroduced in public facilities. Support for maternal nutrition and reproductive health should be prioritised, and Kenya should acknowledge its changing demographics in order to effectively manage the escalating burden of poor health among the urban poor.
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Affiliation(s)
- Emily C Keats
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Neha S Singh
- Centre for Maternal, Adolescent, Reproductive, and Child Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Nadia Akseer
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Anthony K Ngugi
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - Arjumand Rizvi
- Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - John Tole
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Akseer N, Kamali M, Bakhache N, Mirza M, Mehta S, Al-Gashm S, Bhutta ZA. Status and drivers of maternal, newborn, child and adolescent health in the Islamic world: a comparative analysis. Lancet 2018; 391:1493-1512. [PMID: 29395272 DOI: 10.1016/s0140-6736(18)30183-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 11/23/2017] [Accepted: 11/28/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The Millennium Development Goal (MDG) period saw dramatic gains in health goals MDG 4 and MDG 5 for improving child and maternal health. However, many Muslim countries in the south Asian, Middle Eastern, and African regions lagged behind. In this study, we aimed to evaluate the status of, progress in, and key determinants of reproductive, maternal, newborn, child, and adolescent health in Muslim majority countries (MMCs). The specific objectives were to understand the current status and progress in reproductive, maternal, newborn, child, and adolescent health in MMCs, and the determinants of child survival among the least developed countries among the MMCs; to explore differences in outcomes and the key contextual determinants of health between MMCs and non-MMCs; and to understand the health service coverage and contextual determinants that differ between best and poor or moderate performing MMCs. METHODS In this country-level ecological study, we examined data from between 1990 and 2015 from multiple publicly available data repositories. We examined 47 MMCs, of which 26 were among the 75 high-burden Countdown to 2015 countries. These 26 MMCs were compared with 48 non-Muslim Countdown countries. We also examined characteristics of the eight best performing MMCs that had accelerated improvement in child survival (ie, that reached their MDG 4 targets). We estimated adolescent, maternal, under-5, and newborn mortality, and stillbirths, and the causes of death, essential interventions coverage, and contextual determinants for all MMCs and comparative groups using standardised methods. We also did a hierarchical multivariable analysis of determinants of under-5 mortality and newborn mortality in low-income and middle-income MMCs. FINDINGS Despite notable reductions between 1990 and 2015, MMCs compared with a global esimate of all countries including MMCs had higher mortality rates, and MMCs relative to non-MMCs within Countdown countries also performed worse. Coverage of essential interventions across the continuum of care was on average lower among MMCs, especially for indicators of reproductive health, prenatal care, delivery, and labour, and childhood vaccines. Outcomes within MMCs for mortality and many reproductive, maternal, newborn, child, and adolescent health indicators varied considerably. Structural and contextual factors, especially state governance, conflict, and women and girl's empowerment indicators, were significantly worse in MMCs compared with non-MMCs within the high-burden Countdown countries, and were shown to be strongly associated with child and newborn mortality within low-income and middle-income MMCs. In adjusted hierarchical models, among other factors, under-5 mortality in MMCs increased with more refugees originating from a country (β=23·67, p=0·0116), and decreased with better political stability or absence of terrorism (β=-0·99, p=0·0285), greater political rights or government effectiveness (β=-1·17, p<0·0001), improvements in log gross national income per capita (β=-4·44, p<0·0001), higher total adult literacy (β=-1·69, p<0·0001), higher female adult literacy (β=-0·97, p<0·0001), and greater female to male enrolment in secondary school (β=-16·1, p<0·0001). The best performing MMCs were Azerbaijan, Bangladesh, Egypt, Indonesia, Kyrgyzstan, Morocco, Niger, and Senegal, which had higher coverage of family planning interventions and newborn or child vaccinations, and excelled in many of the above contextual determinants when compared with moderate or poorly performing MMCs. INTERPRETATION The status and progress in reproductive, maternal, newborn, child, and adolescent health is heterogeneous among MMCs, with little indication that religion and its practice affects outcomes systemically. Some Islamic countries such as Niger and Bangladesh have made great progress, despite poverty. Key findings from this study have policy and programmatic implications that could be prioritised by national heads of state and policy makers, development partners, funders, and the Organization of the Islamic Cooperation to scale up and improve these health outcomes in Muslim countries in the post-2015 era. FUNDING US Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn, and Child Survival, the Centre for Global Child Health, Hospital for Sick Children, and the Aga Khan University.
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Affiliation(s)
- Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Mahdis Kamali
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Nour Bakhache
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Maaz Mirza
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Seema Mehta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Sara Al-Gashm
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan.
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Yan LD, Mwale J, Straitz S, Biemba G, Bhutta Z, Ross JF, Mwananyanda L, Nambao M, Ngwakum P, Genovese E, Banda B, Akseer N, Yeboah-Antwi K, Rockers PC, Hamer DH. Equity dimensions of the availability and quality of reproductive, maternal and neonatal health services in Zambia. Trop Med Int Health 2018; 23:433-445. [PMID: 29457318 DOI: 10.1111/tmi.13043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess how quality and availability of reproductive, maternal, neonatal (RMNH) services vary by district wealth and urban/rural status in Zambia. METHODS We conducted a retrospective analysis of data from the Millennium Development Goal Acceleration Initiative baseline assessment of 117 health facilities in 9 districts. Quality was assessed through a composite score of 23 individual RMNH indicators, ranging from 0 to 1. Availability was evaluated by density of providers and facilities. Districts were divided into wealth groups based on the multidimensional poverty index (MPI). Relative inequity was calculated using the concentration index for quality indicators (positive favours rich, negative favours poor). Multivariable linear regression was performed for the dependent variable composite quality indicator using MPI, urban/rural, and facility level of care as independent variables. RESULTS 13 hospitals, 85 health centres and 19 health posts were included. The RMNH composite quality indicator was 0.64. Availability of facilities and providers was universally low. The concentration index for the composite quality indicator was -0.015 [-0.043, 0.013], suggesting no clustering to favour either rich or poor districts. Rich districts had the highest absolute numbers of health facilities and providers, but lowest numbers per facility per 1 000 000 population. Urban districts had slightly better service quality, but not availability. Using regression analysis, only facility level of care was significantly associated with quality outcome. CONCLUSIONS Composite quality of RMNH services did not vary by district wealth, but was slightly higher in urban districts. The availability data suggest that the higher population in richer districts outpaces health infrastructure.
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Affiliation(s)
- Lily D Yan
- Department of Medicine, Boston Medical Center, Boston, MA, USA.,Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | | | - Samantha Straitz
- Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | - Godfrey Biemba
- National Health Research Authority, Ministry of Health, Lusaka, Zambia
| | - Zulfiqar Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.,Centre for Global Child Health, SickKids Hospital, Toronto, ON, Canada
| | - Julia F Ross
- Delegation of the European Union in Zambia, Lusaka, Zambia
| | | | - Mary Nambao
- Maternal and Child Health, Ministry of Health, Lusaka, Zambia
| | | | | | - Bowen Banda
- Zambian Centre for Applied Health Research and Development, Lusaka, Zambia
| | - Nadia Akseer
- Centre for Global Child Health, SickKids Hospital, Toronto, ON, Canada
| | - Kojo Yeboah-Antwi
- Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | - Peter C Rockers
- Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA
| | - Davidson H Hamer
- Department of Medicine, Boston Medical Center, Boston, MA, USA.,Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA.,Zambian Centre for Applied Health Research and Development, Lusaka, Zambia
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50
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Akseer N, Bhatti Z, Mashal T, Soofi S, Moineddin R, Black RE, Bhutta ZA. Geospatial inequalities and determinants of nutritional status among women and children in Afghanistan: an observational study. Lancet Glob Health 2018; 6:e447-e459. [PMID: 29454554 DOI: 10.1016/s2214-109x(18)30025-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 12/12/2017] [Accepted: 12/21/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND Undernutrition is a pervasive condition in Afghanistan, and prevalence is among the highest in the world. We aimed to comprehensively assess district-level geographical disparities and determinants of nutritional status (stunting, wasting, or underweight) among women and children in Afghanistan. METHODS The study used individualised data from the recent Afghanistan National Nutrition Survey 2013. Outcome variables were based on growth and weight anthropometry data, which we analysed linearly as Z scores and as dichotomous categories. We analysed data from a total of almost 14 000 index mother-child pairs using Bayesian spatial and generalised least squares regression models accounting for the complex survey design. FINDINGS We noted that childhood stunting, underweight, and combined stunting and wasting were consistently highest in districts in Farah, Nangarhar, Nuristan, Kunar, Paktia, and Badakhshan provinces. District prevalence ranged from 4% to 84% for childhood stunting and 5% to 66% for underweight. Child wasting exceeded 20% in central and high-conflict regions that bordered Pakistan including east, southeast, and south. Among mothers, dual burden of underweight and overweight or obesity existed in districts of north, northeast, central, and central highlands (prevalence of 15-20%). Linear growth and weight of children were independently associated with household wealth, maternal literacy, maternal anthropometry, child age, food security, geography, and improved hygiene and sanitation conditions. The mother's body-mass index was determined by many of the same factors, in addition to ethnolinguistic status and parity. Younger mothers (<20 years old) were more underweight and shorter than older mothers (aged 20-49 years). INTERPRETATION Afghanistan's rapidly changing political, socioeconomic, and insecurity landscape has both direct and indirect implications on population nutrition. Novel evidence from our study can be used to understand these multifactorial determinants and to identify granular disparities for local level tracking, planning, and implementation of nutritional interventions. FUNDING None.
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Affiliation(s)
- Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Zaid Bhatti
- Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
| | - Taufiq Mashal
- Former Afghanistan Ministry of Public Health, Kabul, Afghanistan
| | - Sajid Soofi
- Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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