Burden of disease scenarios for 204 countries and territories, 2022-2050: a forecasting analysis for the Global Burden of Disease Study 2021

BACKGROUND

Future trends in disease burden and drivers of health are of great interest to policy makers and the public at large. This information can be used for policy and long-term health investment, planning, and prioritisation. We have expanded and improved upon previous forecasts produced as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) and provide a reference forecast (the most likely future), and alternative scenarios assessing disease burden trajectories if selected sets of risk factors were eliminated from current levels by 2050.

METHODS

Using forecasts of major drivers of health such as the Socio-demographic Index (SDI; a composite measure of lag-distributed income per capita, mean years of education, and total fertility under 25 years of age) and the full set of risk factor exposures captured by GBD, we provide cause-specific forecasts of mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) by age and sex from 2022 to 2050 for 204 countries and territories, 21 GBD regions, seven super-regions, and the world. All analyses were done at the cause-specific level so that only risk factors deemed causal by the GBD comparative risk assessment influenced future trajectories of mortality for each disease. Cause-specific mortality was modelled using mixed-effects models with SDI and time as the main covariates, and the combined impact of causal risk factors as an offset in the model. At the all-cause mortality level, we captured unexplained variation by modelling residuals with an autoregressive integrated moving average model with drift attenuation. These all-cause forecasts constrained the cause-specific forecasts at successively deeper levels of the GBD cause hierarchy using cascading mortality models, thus ensuring a robust estimate of cause-specific mortality. For non-fatal measures (eg, low back pain), incidence and prevalence were forecasted from mixed-effects models with SDI as the main covariate, and YLDs were computed from the resulting prevalence forecasts and average disability weights from GBD. Alternative future scenarios were constructed by replacing appropriate reference trajectories for risk factors with hypothetical trajectories of gradual elimination of risk factor exposure from current levels to 2050. The scenarios were constructed from various sets of risk factors: environmental risks (Safer Environment scenario), risks associated with communicable, maternal, neonatal, and nutritional diseases (CMNNs; Improved Childhood Nutrition and Vaccination scenario), risks associated with major non-communicable diseases (NCDs; Improved Behavioural and Metabolic Risks scenario), and the combined effects of these three scenarios. Using the Shared Socioeconomic Pathways climate scenarios SSP2-4.5 as reference and SSP1-1.9 as an optimistic alternative in the Safer Environment scenario, we accounted for climate change impact on health by using the most recent Intergovernmental Panel on Climate Change temperature forecasts and published trajectories of ambient air pollution for the same two scenarios. Life expectancy and healthy life expectancy were computed using standard methods. The forecasting framework includes computing the age-sex-specific future population for each location and separately for each scenario. 95% uncertainty intervals (UIs) for each individual future estimate were derived from the 2·5th and 97·5th percentiles of distributions generated from propagating 500 draws through the multistage computational pipeline.

FINDINGS

In the reference scenario forecast, global and super-regional life expectancy increased from 2022 to 2050, but improvement was at a slower pace than in the three decades preceding the COVID-19 pandemic (beginning in 2020). Gains in future life expectancy were forecasted to be greatest in super-regions with comparatively low life expectancies (such as sub-Saharan Africa) compared with super-regions with higher life expectancies (such as the high-income super-region), leading to a trend towards convergence in life expectancy across locations between now and 2050. At the super-region level, forecasted healthy life expectancy patterns were similar to those of life expectancies. Forecasts for the reference scenario found that health will improve in the coming decades, with all-cause age-standardised DALY rates decreasing in every GBD super-region. The total DALY burden measured in counts, however, will increase in every super-region, largely a function of population ageing and growth. We also forecasted that both DALY counts and age-standardised DALY rates will continue to shift from CMNNs to NCDs, with the most pronounced shifts occurring in sub-Saharan Africa (60·1% [95% UI 56·8-63·1] of DALYs were from CMNNs in 2022 compared with 35·8% [31·0-45·0] in 2050) and south Asia (31·7% [29·2-34·1] to 15·5% [13·7-17·5]). This shift is reflected in the leading global causes of DALYs, with the top four causes in 2050 being ischaemic heart disease, stroke, diabetes, and chronic obstructive pulmonary disease, compared with 2022, with ischaemic heart disease, neonatal disorders, stroke, and lower respiratory infections at the top. The global proportion of DALYs due to YLDs likewise increased from 33·8% (27·4-40·3) to 41·1% (33·9-48·1) from 2022 to 2050, demonstrating an important shift in overall disease burden towards morbidity and away from premature death. The largest shift of this kind was forecasted for sub-Saharan Africa, from 20·1% (15·6-25·3) of DALYs due to YLDs in 2022 to 35·6% (26·5-43·0) in 2050. In the assessment of alternative future scenarios, the combined effects of the scenarios (Safer Environment, Improved Childhood Nutrition and Vaccination, and Improved Behavioural and Metabolic Risks scenarios) demonstrated an important decrease in the global burden of DALYs in 2050 of 15·4% (13·5-17·5) compared with the reference scenario, with decreases across super-regions ranging from 10·4% (9·7-11·3) in the high-income super-region to 23·9% (20·7-27·3) in north Africa and the Middle East. The Safer Environment scenario had its largest decrease in sub-Saharan Africa (5·2% [3·5-6·8]), the Improved Behavioural and Metabolic Risks scenario in north Africa and the Middle East (23·2% [20·2-26·5]), and the Improved Nutrition and Vaccination scenario in sub-Saharan Africa (2·0% [-0·6 to 3·6]).

INTERPRETATION

Globally, life expectancy and age-standardised disease burden were forecasted to improve between 2022 and 2050, with the majority of the burden continuing to shift from CMNNs to NCDs. That said, continued progress on reducing the CMNN disease burden will be dependent on maintaining investment in and policy emphasis on CMNN disease prevention and treatment. Mostly due to growth and ageing of populations, the number of deaths and DALYs due to all causes combined will generally increase. By constructing alternative future scenarios wherein certain risk exposures are eliminated by 2050, we have shown that opportunities exist to substantially improve health outcomes in the future through concerted efforts to prevent exposure to well established risk factors and to expand access to key health interventions.

FUNDING

Bill & Melinda Gates Foundation.

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Global fertility in 204 countries and territories, 1950-2021, with forecasts to 2100: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Accurate assessments of current and future fertility-including overall trends and changing population age structures across countries and regions-are essential to help plan for the profound social, economic, environmental, and geopolitical challenges that these changes will bring. Estimates and projections of fertility are necessary to inform policies involving resource and health-care needs, labour supply, education, gender equality, and family planning and support. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 produced up-to-date and comprehensive demographic assessments of key fertility indicators at global, regional, and national levels from 1950 to 2021 and forecast fertility metrics to 2100 based on a reference scenario and key policy-dependent alternative scenarios.

METHODS

To estimate fertility indicators from 1950 to 2021, mixed-effects regression models and spatiotemporal Gaussian process regression were used to synthesise data from 8709 country-years of vital and sample registrations, 1455 surveys and censuses, and 150 other sources, and to generate age-specific fertility rates (ASFRs) for 5-year age groups from age 10 years to 54 years. ASFRs were summed across age groups to produce estimates of total fertility rate (TFR). Livebirths were calculated by multiplying ASFR and age-specific female population, then summing across ages 10-54 years. To forecast future fertility up to 2100, our Institute for Health Metrics and Evaluation (IHME) forecasting model was based on projections of completed cohort fertility at age 50 years (CCF50; the average number of children born over time to females from a specified birth cohort), which yields more stable and accurate measures of fertility than directly modelling TFR. CCF50 was modelled using an ensemble approach in which three sub-models (with two, three, and four covariates variously consisting of female educational attainment, contraceptive met need, population density in habitable areas, and under-5 mortality) were given equal weights, and analyses were conducted utilising the MR-BRT (meta-regression-Bayesian, regularised, trimmed) tool. To capture time-series trends in CCF50 not explained by these covariates, we used a first-order autoregressive model on the residual term. CCF50 as a proportion of each 5-year ASFR was predicted using a linear mixed-effects model with fixed-effects covariates (female educational attainment and contraceptive met need) and random intercepts for geographical regions. Projected TFRs were then computed for each calendar year as the sum of single-year ASFRs across age groups. The reference forecast is our estimate of the most likely fertility future given the model, past fertility, forecasts of covariates, and historical relationships between covariates and fertility. We additionally produced forecasts for multiple alternative scenarios in each location: the UN Sustainable Development Goal (SDG) for education is achieved by 2030; the contraceptive met need SDG is achieved by 2030; pro-natal policies are enacted to create supportive environments for those who give birth; and the previous three scenarios combined. Uncertainty from past data inputs and model estimation was propagated throughout analyses by taking 1000 draws for past and present fertility estimates and 500 draws for future forecasts from the estimated distribution for each metric, with 95% uncertainty intervals (UIs) given as the 2·5 and 97·5 percentiles of the draws. To evaluate the forecasting performance of our model and others, we computed skill values-a metric assessing gain in forecasting accuracy-by comparing predicted versus observed ASFRs from the past 15 years (2007-21). A positive skill metric indicates that the model being evaluated performs better than the baseline model (here, a simplified model holding 2007 values constant in the future), and a negative metric indicates that the evaluated model performs worse than baseline.

FINDINGS

During the period from 1950 to 2021, global TFR more than halved, from 4·84 (95% UI 4·63-5·06) to 2·23 (2·09-2·38). Global annual livebirths peaked in 2016 at 142 million (95% UI 137-147), declining to 129 million (121-138) in 2021. Fertility rates declined in all countries and territories since 1950, with TFR remaining above 2·1-canonically considered replacement-level fertility-in 94 (46·1%) countries and territories in 2021. This included 44 of 46 countries in sub-Saharan Africa, which was the super-region with the largest share of livebirths in 2021 (29·2% [28·7-29·6]). 47 countries and territories in which lowest estimated fertility between 1950 and 2021 was below replacement experienced one or more subsequent years with higher fertility; only three of these locations rebounded above replacement levels. Future fertility rates were projected to continue to decline worldwide, reaching a global TFR of 1·83 (1·59-2·08) in 2050 and 1·59 (1·25-1·96) in 2100 under the reference scenario. The number of countries and territories with fertility rates remaining above replacement was forecast to be 49 (24·0%) in 2050 and only six (2·9%) in 2100, with three of these six countries included in the 2021 World Bank-defined low-income group, all located in the GBD super-region of sub-Saharan Africa. The proportion of livebirths occurring in sub-Saharan Africa was forecast to increase to more than half of the world's livebirths in 2100, to 41·3% (39·6-43·1) in 2050 and 54·3% (47·1-59·5) in 2100. The share of livebirths was projected to decline between 2021 and 2100 in most of the six other super-regions-decreasing, for example, in south Asia from 24·8% (23·7-25·8) in 2021 to 16·7% (14·3-19·1) in 2050 and 7·1% (4·4-10·1) in 2100-but was forecast to increase modestly in the north Africa and Middle East and high-income super-regions. Forecast estimates for the alternative combined scenario suggest that meeting SDG targets for education and contraceptive met need, as well as implementing pro-natal policies, would result in global TFRs of 1·65 (1·40-1·92) in 2050 and 1·62 (1·35-1·95) in 2100. The forecasting skill metric values for the IHME model were positive across all age groups, indicating that the model is better than the constant prediction.

INTERPRETATION

Fertility is declining globally, with rates in more than half of all countries and territories in 2021 below replacement level. Trends since 2000 show considerable heterogeneity in the steepness of declines, and only a small number of countries experienced even a slight fertility rebound after their lowest observed rate, with none reaching replacement level. Additionally, the distribution of livebirths across the globe is shifting, with a greater proportion occurring in the lowest-income countries. Future fertility rates will continue to decline worldwide and will remain low even under successful implementation of pro-natal policies. These changes will have far-reaching economic and societal consequences due to ageing populations and declining workforces in higher-income countries, combined with an increasing share of livebirths among the already poorest regions of the world.

FUNDING

Bill & Melinda Gates Foundation.

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

METHODS

The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

FINDINGS

Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

INTERPRETATION

Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

FUNDING

Bill & Melinda Gates Foundation.

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.

METHODS

22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.

FINDINGS

Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.

INTERPRETATION

Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national burden of disorders affecting the nervous system, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Disorders affecting the nervous system are diverse and include neurodevelopmental disorders, late-life neurodegeneration, and newly emergent conditions, such as cognitive impairment following COVID-19. Previous publications from the Global Burden of Disease, Injuries, and Risk Factor Study estimated the burden of 15 neurological conditions in 2015 and 2016, but these analyses did not include neurodevelopmental disorders, as defined by the International Classification of Diseases (ICD)-11, or a subset of cases of congenital, neonatal, and infectious conditions that cause neurological damage. Here, we estimate nervous system health loss caused by 37 unique conditions and their associated risk factors globally, regionally, and nationally from 1990 to 2021.

METHODS

We estimated mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs), with corresponding 95% uncertainty intervals (UIs), by age and sex in 204 countries and territories, from 1990 to 2021. We included morbidity and deaths due to neurological conditions, for which health loss is directly due to damage to the CNS or peripheral nervous system. We also isolated neurological health loss from conditions for which nervous system morbidity is a consequence, but not the primary feature, including a subset of congenital conditions (ie, chromosomal anomalies and congenital birth defects), neonatal conditions (ie, jaundice, preterm birth, and sepsis), infectious diseases (ie, COVID-19, cystic echinococcosis, malaria, syphilis, and Zika virus disease), and diabetic neuropathy. By conducting a sequela-level analysis of the health outcomes for these conditions, only cases where nervous system damage occurred were included, and YLDs were recalculated to isolate the non-fatal burden directly attributable to nervous system health loss. A comorbidity correction was used to calculate total prevalence of all conditions that affect the nervous system combined.

FINDINGS

Globally, the 37 conditions affecting the nervous system were collectively ranked as the leading group cause of DALYs in 2021 (443 million, 95% UI 378-521), affecting 3·40 billion (3·20-3·62) individuals (43·1%, 40·5-45·9 of the global population); global DALY counts attributed to these conditions increased by 18·2% (8·7-26·7) between 1990 and 2021. Age-standardised rates of deaths per 100 000 people attributed to these conditions decreased from 1990 to 2021 by 33·6% (27·6-38·8), and age-standardised rates of DALYs attributed to these conditions decreased by 27·0% (21·5-32·4). Age-standardised prevalence was almost stable, with a change of 1·5% (0·7-2·4). The ten conditions with the highest age-standardised DALYs in 2021 were stroke, neonatal encephalopathy, migraine, Alzheimer's disease and other dementias, diabetic neuropathy, meningitis, epilepsy, neurological complications due to preterm birth, autism spectrum disorder, and nervous system cancer.

INTERPRETATION

As the leading cause of overall disease burden in the world, with increasing global DALY counts, effective prevention, treatment, and rehabilitation strategies for disorders affecting the nervous system are needed.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national age-specific progress towards the 2020 milestones of the WHO End TB Strategy: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Global evaluations of the progress towards the WHO End TB Strategy 2020 interim milestones on mortality (35% reduction) and incidence (20% reduction) have not been age specific. We aimed to assess global, regional, and national-level burdens of and trends in tuberculosis and its risk factors across five separate age groups, from 1990 to 2021, and to report on age-specific progress between 2015 and 2020.

METHODS

We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 (GBD 2021) analytical framework to compute age-specific tuberculosis mortality and incidence estimates for 204 countries and territories (1990-2021 inclusive). We quantified tuberculosis mortality among individuals without HIV co-infection using 22 603 site-years of vital registration data, 1718 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, 680 site-years of mortality surveillance data, and 9 site-years of minimally invasive tissue sample (MITS) diagnoses data as inputs into the Cause of Death Ensemble modelling platform. Age-specific HIV and tuberculosis deaths were established with a population attributable fraction approach. We analysed all available population-based data sources, including prevalence surveys, annual case notifications, tuberculin surveys, and tuberculosis mortality, in DisMod-MR 2.1 to produce internally consistent age-specific estimates of tuberculosis incidence, prevalence, and mortality. We also estimated age-specific tuberculosis mortality without HIV co-infection that is attributable to the independent and combined effects of three risk factors (smoking, alcohol use, and diabetes). As a secondary analysis, we examined the potential impact of the COVID-19 pandemic on tuberculosis mortality without HIV co-infection by comparing expected tuberculosis deaths, modelled with trends in tuberculosis deaths from 2015 to 2019 in vital registration data, with observed tuberculosis deaths in 2020 and 2021 for countries with available cause-specific mortality data.

FINDINGS

We estimated 9·40 million (95% uncertainty interval [UI] 8·36 to 10·5) tuberculosis incident cases and 1·35 million (1·23 to 1·52) deaths due to tuberculosis in 2021. At the global level, the all-age tuberculosis incidence rate declined by 6·26% (5·27 to 7·25) between 2015 and 2020 (the WHO End TB strategy evaluation period). 15 of 204 countries achieved a 20% decrease in all-age tuberculosis incidence between 2015 and 2020, eight of which were in western sub-Saharan Africa. When stratified by age, global tuberculosis incidence rates decreased by 16·5% (14·8 to 18·4) in children younger than 5 years, 16·2% (14·2 to 17·9) in those aged 5-14 years, 6·29% (5·05 to 7·70) in those aged 15-49 years, 5·72% (4·02 to 7·39) in those aged 50-69 years, and 8·48% (6·74 to 10·4) in those aged 70 years and older, from 2015 to 2020. Global tuberculosis deaths decreased by 11·9% (5·77 to 17·0) from 2015 to 2020. 17 countries attained a 35% reduction in deaths due to tuberculosis between 2015 and 2020, most of which were in eastern Europe (six countries) and central Europe (four countries). There was variable progress by age: a 35·3% (26·7 to 41·7) decrease in tuberculosis deaths in children younger than 5 years, a 29·5% (25·5 to 34·1) decrease in those aged 5-14 years, a 15·2% (10·0 to 20·2) decrease in those aged 15-49 years, a 7·97% (0·472 to 14·1) decrease in those aged 50-69 years, and a 3·29% (-5·56 to 9·07) decrease in those aged 70 years and older. Removing the combined effects of the three attributable risk factors would have reduced the number of all-age tuberculosis deaths from 1·39 million (1·28 to 1·54) to 1·00 million (0·703 to 1·23) in 2020, representing a 36·5% (21·5 to 54·8) reduction in tuberculosis deaths compared to those observed in 2015. 41 countries were included in our analysis of the impact of the COVID-19 pandemic on tuberculosis deaths without HIV co-infection in 2020, and 20 countries were included in the analysis for 2021. In 2020, 50 900 (95% CI 49 700 to 52 400) deaths were expected across all ages, compared to an observed 45 500 deaths, corresponding to 5340 (4070 to 6920) fewer deaths; in 2021, 39 600 (38 300 to 41 100) deaths were expected across all ages compared to an observed 39 000 deaths, corresponding to 657 (-713 to 2180) fewer deaths.

INTERPRETATION

Despite accelerated progress in reducing the global burden of tuberculosis in the past decade, the world did not attain the first interim milestones of the WHO End TB Strategy in 2020. The pace of decline has been unequal with respect to age, with older adults (ie, those aged >50 years) having the slowest progress. As countries refine their national tuberculosis programmes and recalibrate for achieving the 2035 targets, they could consider learning from the strategies of countries that achieved the 2020 milestones, as well as consider targeted interventions to improve outcomes in older age groups.

FUNDING

Bill & Melinda Gates Foundation.

Differences in physical and mental health symptoms among residents living near municipal solid waste sites: a cross sectional study in the Ashanti Region, Ghana

OBJECTIVE

Physical and mental health concerns and symptoms, including sleep problems, low mood, extreme tiredness, and appetite loss are prevalent among people living near waste sites. This research examines differences in health symptoms among residents living near municipal solid waste sites in the Ashanti Region, Ghana.

METHODS

The study used cross-sectional data from 827 residents living near three municipal waste sites, including Besease, Asokore, and Dompoase sites in the Ashanti Region, Ghana. Descriptive statistics, Pearson's chi-square, and binary logistic regressions were performed to examine the differences and associations between the variables.

RESULTS

Health symptoms, including sleep problems/insomnia, frequent extreme tiredness, low mood, loss of appetite, stress, anxiety, and depression, were reported by the majority of the participants. Residents near open dumpsites (Besease and Asokore) exhibit significantly higher likelihoods of experiencing various health symptoms such as extreme fatigue, depression, psychological disorders, thinking and concentration problems, low mood, loss of appetite, and anxiety compared to those near the engineered Oti landfill in Dompoase.

CONCLUSION

While emphasizing the importance of proper landfill design and management in Ghana, this study underscores the need for further longitudinal and clinical investigations. Clinically establishing the link between dumpsites and health symptoms is imperative for informed public health interventions and policy decisions aimed at mitigating the potential adverse health effects of landfills on residents' well-being.

Caregiver burden and health-related quality of life: A study of informal caregivers of older adults in Ghana

BACKGROUND

Similar to many developing countries, caregiver burden remains high in Ghana which may affect informal caregivers of older adults' health-related quality of life (HRQoL). However, no study has examined the association between caregiver burden and HRQoL among informal caregivers of older adults in Ghana to date. Understanding this association may well help to inform health and social policy measures to improve HRQoL among  informal caregivers of older adults in Ghana. Situated within a conceptual model of HRQoL, the purpose of this study was to examine the relationship  between caregiver burden and HRQoL among informal caregivers of older adults in Ghana.

METHODS

We obtained cross-sectional data from informal caregiving, health, and healthcare (N = 1853) survey conducted between July and September 2022 among caregivers (≥ 18 years) of older adults (≥ 50 years) in the Ashanti Region of Ghana. The World Health Organization Impact of Caregiving Scale was used to measure caregiver burden. An 8-item short form Health Survey scale developed by the RAND Corporation and the Medical Outcomes Study was used to measure HRQoL. Generalized Linear Models were employed to estimate the association between caregiver burden and HRQoL. Beta values and standard errors were reported with a significance level of  0.05 or less.

RESULTS

The mean age of the informal caregivers was 39.15 years and that of the care recipients was 75.08 years. In our final model, the results showed that caregiver burden was negatively associated with HRQoL (β = - .286, SE = .0123, p value = 0.001). In line with the conceptual model of HRQoL, we also found that socio-economic, cultural, demographic and healthcare factors were significantly associated with HRQoL. For instance, participants with no formal education (β = -1.204, SE= .4085, p value = 0.01), those with primary level of education (β = -2.390, SE= .5099, p value = 0.001) or junior high school education (β = -1.113, SE= .3903, p value= 0.01) had a significantly decreased HRQoL compared to those with tertiary level of education. Participants who were between the ages of 18-24 (β = 2.960, SE= .6306, p value=0.001), 25-34 (β = 1.728, SE= .5794, p value = 0.01) or 35-44 (β = 1.604, SE= .5764, p value= 0.01) years significantly had increased HRQoL compared to those who were 65 years or above. Also, participants who did not utilize healthcare services in the past year before the survey significantly had increased HRQoL compared to those who utilized healthcare services five or more times in the past year (β = 4.786, SE=. 4610, p value= 0.001).

CONCLUSION

Consistent with our hypothesis, this study reported a significant negative association between caregiver burden and HRQoL. Our findings partially  support the conceptual model of HRQoL used in this study. We recommend that health and social policy measures to improve HRQoL among  informal caregivers of older adults should consider caregiver burden as well as other significant socio-economic, cultural, demographic, and healthcare factors.

Perceived neighborhood social cohesion and functional disability among older adults: The moderating roles of sex, physical activity, and multi-morbidity

Though the Ghanaian social structure is largely communal in several of its social life and social spaces, the extent to which cohesive neighbourhood affects functional ability of older persons and the moderating factors of the relationship, are unknown in Ghana. This study examines the moderating roles of sex, multimorbidity, and physical activity on the association between neighbourhood social cohesion and functional disability among older people in Ghana. A cross-sectional study of 4,446 people-50 years and older-from WHO's Study on global AGEing and adult health Ghana Wave 2 was employed. Functional disability-WHO Disability Assessment Schedule 2.0-and neighbourhood social cohesion measured with community-level participation, perceived trust and safety were studied. Generalised Logistic regressions with interactional tests were used to examine the associations. A more socially cohesive neighbourhood was significantly associated with a lower functional disability among older people (OR = 0.94, 95%CI: 0.93, 0.94; P<0.001). A similar relationship was found for community-level participation (aOR = 0.94, 95%CI: 0.94, 0.95; P<0.001) and perceived trust (aOR = 1.00, 95%CI: 0.99, 1.00; P<0.001). Community-level participation is associated with a lower functional disability among older people who were physically active (aOR = 0.98, 95%CI: 0.96, 0.99; P<0.001). Among the three individual-level measures of neighbourhood social cohesion, only physical activity (OR = 0.98, 95%CI: 0.98, 0.99; P<0.01) moderated the association between community-level participation and functional disability. Community-level participation, along with physical activity, may be relevant in improving functional ability among older people. The results highlight the usefulness of policy to ensure a more socially cohesive neighbourhood for older people in Ghana to improve their quality of life.

Intimate partner violence as a determinant of pregnancy termination among women in unions: evidence from the 2016-2018 Papua New Guinea Demographic and Health Survey

There is a demonstrated link between intimate partner violence (IPV) and pregnancy termination, and this association has received much attention in developed settings. Despite the high prevalence of IPV in Papua New Guinea (PNG), little is known about the association between these experiences and pregnancy termination. This study examined the association between IPV and pregnancy termination in PNG. The present study used population-based data from the PNG's first Demographic and Health Survey (DHS) conducted in 2016-2018. The analysis involved women aged 15-49 years who were in intimate unions (married or co-habiting). We used binary logistic regression modelling to analyse the association between IPV and pregnancy termination. Results were reported as crude odds ratios (cOR) and adjusted odds ratios (aOR) with 95% confidence intervals (CIs). Overall, 6.3% of women involved in this study had ever terminated a pregnancy, and 6 in 10 women (61.5%) reported having experienced IPV in the last 12 months preceding the survey. Of those women who experienced IPV, 7.4% had ever terminated a pregnancy. Women who had experienced IPV had a 1.75 higher odds of reporting pregnancy termination (cOR: 1.75; 95% CI: 1.29-2.37) than women who did not experience IPV. After controlling for theoretically and empirically relevant socio-demographic and economic factors, IPV remained a strong and significant determinant of pregnancy termination (aOR: 1.67, 95% CI: 1.22-2.30). The strong association between IPV and pregnancy termination among women in intimate unions in PNG calls for targeted policies and interventions that address the high prevalence of IPV. The provision of comprehensive sexual reproductive health, public education, and awareness creation on the consequences of IPV, regular assessment, and referral to appropriate services for IPV may reduce the incidence of pregnancy termination in PNG.

Cyberbullying victimization and suicidal ideation among in-school adolescents in three countries: implications for prevention and intervention

BACKGROUND

Countries in South and Central America and the Caribbean are among the countries with the highest adolescent cyberbullying crimes. However, empirical evidence about the effect of cyberbullying victimization on suicidal ideation among in-school adolescents in these countries remains limited. The present study examined the association between cyberbullying victimization and suicidal ideation among in-school adolescents in Argentina, Panama, St Vincent, and the Grenadines.

METHODS

A representative cross-sectional data from 51,405 in-school adolescents was used. Hierarchical logistic regression analysis was used to estimate the association between cyberbulling victimization and suicidal ideation.

RESULTS

Overall, 20% and 21.1% of the adolescents reported cyberbullying victimization and suicidal ideation, respectively in the past year before the survey. Suicidal ideation was higher among adolescents who experienced cyberbullying victimization (38.4%) than those who did not experience cyberbullying victimization (16.6%). Significantly higher odds of suicidal ideation were found among adolescents who had experienced cyberbullying victimization than those who had not experienced cyberbullying victimization [aOR = 1.88, 95% CI: 1.77-1.98].

CONCLUSION

This finding calls for developing and implementing evidence-based programs and practices by school authorities and other relevant stakeholders to reduce cyberbullying victimization among adolescents in this digital age. Protective factors such as parental support and peer support should be encouraged.

Healthcare utilization among informal caregivers of older adults in the Ashanti region of Ghana: a study based on the health belief model

BACKGROUND

Existing global evidence suggests that informal caregivers prioritize the health (care) of their care recipients (older adults) over their own health (care) resulting in sub-optimal health outcomes among this population group. However, data on what factors are associated with healthcare utilization among informal caregivers of older adults are not known in a sub-Saharan African context. Guided by the Health Belief Model (HBM), the principal objective of this study was to examine the association between the dimensions of the HBM and healthcare utilization among informal caregivers of older adults in the Ashanti Region of Ghana.

METHODS

Data were extracted from a large cross-sectional study of informal caregiving, health, and healthcare survey among caregivers of older adults aged 50 years or above (N = 1,853; mean age of caregivers = 39.15 years; and mean age of care recipients = 75.08 years) in the Ashanti Region of Ghana. Poisson regression models were used to estimate the association between the dimensions of the HBM and healthcare utilization among informal caregivers of older adults. Statistical significance of the test was set at a probability level of 0.05 or less.

RESULTS

The results showed that 72.9% (n = 1351) of the participants were females, 56.7% (n = 1051) were urban informal caregivers and 28.6% (n = 530)  had no formal education. The results further showed that 49.4% (n = 916) of the participants utilized healthcare for their health problems at least once in the past year before the survey. The final analysis showed a positive and statistically significant association between perceived susceptibility to a health problem (β = 0.054, IRR = 1.056, 95% CI = [1.041-1.071]), cues to action (β = 0.076, IRR = 1.079, 95% CI = [1.044-1.114]), self-efficacy (β = 0.042, IRR = 1.043, 95% CI = [1.013-1.074]) and healthcare utilization among informal caregivers of older adults. The study further revealed a negative and statistically significant association between perceived severity of a health problem and healthcare utilization (β= - 0.040, IRR = 0.961, 95% CI= [0.947-0.975]) among informal caregivers of older adults. The results again showed that non-enrollment in a health insurance scheme (β= - 0.174, IRR = 0.841, 95% CI= [0.774-0.913]) and being unemployed (β= - 0.088, IRR = 0.916, 95% CI= [0.850-0.986]) were statistically significantly associated with a lower log count of healthcare utilization among informal caregivers of older adults.

CONCLUSION

The findings of this study to a large extent support the dimensions of the HBM in explaining healthcare utilization among informal caregivers of older adults in the Ashanti Region of Ghana. Although all the dimensions of the HBM were significantly associated with healthcare utilization in Model 1, perceived barriers to care-seeking and perceived benefits of care-seeking were no longer statistically significant after controlling for demographic, socio-economic and health-related variables in the final model. The findings further suggest that the dimensions of the HBM as well as demographic, socio-economic and health-related factors contribute to unequal healthcare utilization among informal caregivers of older adults in the Ashanti Region of Ghana.

Family Support, Perceived Physical Activeness and Chronic Non-Communicable Diseases as Determinants of Formal Healthcare Utilization Among Older Adults with Low Income and Health Insurance Subscription in Ghana

Evidence suggests that enrollment in a health insurance scheme is associated with higher levels of formal healthcare utilization among older adults, especially those with low income in sub-Saharan Africa (SSA), including Ghana. This study examines the prevalence of formal healthcare utilization and associated factors among older adults with low income and health insurance subscription enrolled in a social intervention program (known as the Livelihood Empowerment Against Poverty [LEAP] program) in Ghana. Cross-sectional data were obtained from an Aging, Health, Lifestyle and Health Services Survey conducted in 2018 among 200 older adults aged 65 years and above enrolled in the LEAP program. The results showed that almost 9 in 10 (87%) older adults utilized formal healthcare services for their health problems. Older adults who received family support, rated themselves to be physically active and had non-communicable diseases (NCDs) were more significantly likely to utilise formal health care services than their counter parts. We recommend that health policies and programs for older adults with low income and health insurance subscription under the LEAP program should consider the roles of family support, physical activeness and NCDs in influencing their use of formal healthcare services.

Health needs of migrant female head porters in Ghana: evidence from the Greater Accra and Greater Kumasi Metropolitan areas

BACKGROUND

In low-and middle-income countries, migrants are confronted with health needs which affect the promotion of their well-being and healthy lives. However, not much is known about the health needs of migrant female head porters (Kayayei) in Ghana. This study assesses the health needs of migrant female head porters in the Greater Kumasi Metropolitan Area (GKMA) and Greater Accra Metropolitan Area (GAMA).

METHODS

The study adopted a convergent mixed methods design where both qualitative and quantitative data were used. A representative sample size of 470 migrant female head porters was used for the study.

RESULTS

The study revealed that ante-natal care, post-natal care, treatment of malaria, treatment of diarrhoea diseases, mental health, sexual health, and cervical cancer were health needs of migrant female head porters. The findings showed that participants from the GAMA significantly have greater cervical cancer needs (71.6% vrs 67.1%, p = 0.001) compared to those from the GKMA. Kayeyei from the GKMA significantly have greater mental health needs than those from the GAMA (84.6% vrs 79.2%, p = 0.031). Also, Kayeyei from the GKMA significantly have higher attendance of post-natal care compared to those from the GAMA (99.4% vrs 96.2%, p = 0.013).

CONCLUSION

The findings underscore differential health needs across geographical localities. Based on the findings of the study, specific health needs such as ante-natal care and post-natal care should be included in any health programmes and policies that aim at addressing health needs of migrant female head porters in the two metropolitan areas of Ghana.

Staying in or out? COVID-19-induced healthcare utilization avoidance and associated socio-demographic factors in rural India

BACKGROUND

Although evidence on healthcare utilization avoidance during COVID-19 pandemic is emerging, such knowledge is limited in rural settings. An effective policy to the COVID-19 shocks and stresses in rural settings require empirical evidence to inform the design of health policies and programmes. To help overcome this evidence gap and also contribute to policy decisions, this study aimed at examining COVID-19-induced healthcare utilization avoidance and associated factors in rural India.

METHODS

This study used the third-round data from the COVID-19-Related Shocks in Rural India survey conducted between 20-24 September, 2020 across six states. The outcome variable considered in this study was COVID-19-induced healthcare utilization avoidance. Multivariable Binary Logistic Regression Model via Multiple Imputation was used to assess the factors influencing COVID-19-induced healthcare utilization avoidance.

RESULTS

Data on 4,682 respondents were used in the study. Of this, the prevalence of COVID-19-induced healthcare utilization avoidance was 15.5% in rural India across the six states. After adjusting for relevant covariates, participants from the Bihar State have significantly higher likelihood of COVID-19-induced healthcare utilization avoidance compared to those from the Andhra Pradesh. Also, participants whose educational level exceeds high school, those who use government hospital/clinic, engage in daily wage labour in agriculture have significantly higher odds of COVID-19-induced healthcare utilization avoidance compared to their counterparts.

CONCLUSION

Our study revealed that state of residence, type of health facility used, primary work activity and educational level were associated with COVID-19-induced healthcare utilization avoidance in rural India. The findings suggest that policy makers and public health authorities need to formulate policies and design interventions that acknowledge socioeconomic and demographic factors that influence healthcare use avoidance.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Bill & Melinda Gates Foundation.

Mobility limitations and emotional dysfunction in old age: The moderating effects of physical activity and social ties

BACKGROUND

This study aims to examine the association between mobility limitations and emotional dysfunction among older Ghanaians and evaluate the buffering effect of physical activity (PA) and social ties in this association.

METHODS

The analysis included 1201 adults aged ≥50 from the 2016-17 Aging, Health, Psychological Well-being, and Health-seeking Behavior study. The Medical Outcomes Study Short Form-36 (MOS SF-36) assessed mobility limitations and emotional dysfunction. We measured PA using the International Physical Activity Questionnaire Short Form (IPAQ-SF). Hierarchical OLS regressions were performed to evaluate the hypothesized direct and interactive relationships.

RESULTS

The mean age of the sample was 66.2 (SD = 11.9), and 63.3% were women. After full adjustment for potential confounders, OLS regressions found that mobility limitations increased the risk of emotional dysfunction (β = 0.113, p = 0.004). Moreover, social ties (β = -0.157, p < 0.001) and PA (β = -0.096, p < 0.001) were independently and negatively associated with emotional dysfunction. We finally found a significant effect modification of the association of mobility limitations with emotional dysfunction by PA (β = -0.040, p < 0.002) and social ties (β = -0.013, p = 0.013).

CONCLUSIONS

Mobility-enhancing strategies such as engagement in positive behavioral choices, focusing on regular PA, and maintaining resourceful interpersonal social networks can mitigate the impact of mobility limitations on emotional dysfunction in later life.

Healthcare seeking behaviour during illness among older adults in Ghana: does food security status matter?

BACKGROUND

Ghana's growing older adult population raises critical questions regarding healthcare for these older adults. At the same time, food insecurity is high among older adults in Ghana. This underscores the need to investigate the issues of food security and healthcare seeking behaviour among older adults. However, research on the association between food security status and healthcare seeking behaviour among older adults is scant in the Ghanaian context. In this study, we advance the social gerontology literature by examining the association between food security status and healthcare seeking behaviors among older adults.

METHODS

Using a multi-stage sampling framework, we collected data from a representative sample of older adults across three regions in Ghana. Data were analyzed using logistic regression technique. We determined the significance of the test at a probability value of 0.05 or less.

RESULTS

Over two-thirds (69%) of respondents did not seek care during their last illness. Additionally, 36% of respondents were severely food insecure, 21% were moderately food insecure, 7% were mildly food insecure, and 36% were food secure. After controlling for theoretically relevant variables, our multivariable analysis revealed a statistically significant association between food security status and healthcare seeking behaviors with older people who are food secure (OR = 1.80, p < 0.01) and mildly food insecure (OR = 1.89, p < 0.05) being more likely to seek healthcare compared with their counterparts who are food insecure.

CONCLUSION

Our findings highlight the need for sustainable intervention programs to improve food access and health service use among older adults in Ghana and similar contexts.

Understanding the association between unmet dental care needs and household food security status among older people in Ghana

The literature recognizes food insecurity as a barrier to access to health care services. However, we know very little about the association between food insecurity and unmet dental care needs among older people in Ghana. To address this void in the literature, this study uses a representative survey of adults aged 60 or older from three regions in Ghana to examine whether older people who experienced household food insecurity differently report unmet dental care needs in comparison to their counterparts without any food insecurity. We find that 40% of older adults reported unmet dental care needs. Results from logistic regression analysis show that older people who experienced severe household food insecurity were more likely to report unmet dental care needs, compared to those who did not experience any type of food insecurity, even after accounting for theoretically relevant variables (OR = 1.94, p < 0.05). Based on these findings, we discuss several implications for policymakers and directions for future research.

System, institutional, and client-level factors associated with formal healthcare utilisation among older adults with low income under a social protection scheme in Ghana

BACKGROUND

In sub-Saharan African context, effect of system, institutional and client-level factors on formal healthcare utilisation among older adults with low income, especially those under a social protection scheme (called Livelihood Empowerment against Poverty [LEAP] programme) is least explored in the literature. However, an adequate understanding of how these factors contribute to formal healthcare utilisation among older adults who are classified as poor (in terms of low income) is important to inform health policy decisions. The aim of this study, therefore, was to examine the contributions of system, institutional and client-level factors in formal healthcare utilisation among older adults with low income under the LEAP programme in Ghana.

METHODS

Data associated with this study were obtained from an Ageing, Health, Lifestyle and Health Services survey conducted between 1 and 20 June 2018 (N = 200) in the Atwima Nwabiagya Municipal and Atwima Nwabiagya North District of Ghana. Multivariable logistic regressions were used to determine system, institutional and client-level factors associated with formal healthcare utilisation among older adults with low income under the LEAP programme in Ghana. The significance of the test was set at a probability value of 0.05 or below.

RESULTS

The study revealed that participants who relied on the LEAP programme and/or health insurance subscription to cater for their healthcare expenses (AOR: 11.934, CI: 1.151-123.777), those whose family/caregivers decided on when and where to use formal healthcare (AOR:12.409; CI: 2.198-70.076) and those who did not encounter communication problem with healthcare providers (AOR: 1.358; CI: 1.074-3.737) were significantly more likely to utilise formal healthcare services compared with their counterparts. The study further found that participants who perceived the attitude of healthcare providers as poor (AOR: 0.889; CI: 0.24-0.931) and those who spent 20-40 minutes at the healthcare facility were significantly less likely to utilise formal healthcare services compared with their counterparts (AOR: 0.070; CI: 0.006-0.195).

CONCLUSION

Our findings suggest that reducing waiting time at healthcare facilities, improving social protection and/or health insurance schemes, improving patient-doctor communication and promoting attitudinal change programmes (such as orientations and supportive supervision) for healthcare providers may help to facilitate the use of needed formal healthcare services by older adults with low income in Ghana.

A moderated mediation analysis of the association between smoking and suicide attempts among adolescents in 28 countries

Globally, evidence has shown that many adolescents are victims of substance use, mainly cigarette smoking, and it has been associated with suicidal ideation. However, the mechanisms underlying this association are poorly understood. This study examines whether truancy mediates and gender moderates the association of cigarette smoking with suicide attempts among adolescents in 28 countries. Data from the Global School-Based Student Health Survey were used. Hierarchical multiple logistic regression analyses were used to estimate the effect-modification of gender on cigarette smoking and suicide attempt. The mediating effect of truancy on the association between cigarette smoking and suicidal attempt was assessed using the generalized decomposition method. Cigarette smoking was associated with suicide attempts after adjusting for several confounding variables (aOR = 1.21; 95% CI = 1.09-1.33). The bootstrap results from the generalized decomposition analysis indicated that truancy partially mediated the association of cigarette smoking with a suicide attempt, contributing 21% of the total effect among in-school adolescents. Hierarchical regression analyses suggested that gender moderated the effect of cigarette smoking on suicidal attempts: female adolescents who smoked had 36% higher odds of suicidal attempts compared to male adolescents. The findings suggest possible pathways for designing and implementing interventions to address adolescents' cigarette smoking and truancy to prevent suicidal attempts.

Self-reported symptoms of ocular allergy and its comorbid factors among residents living near a landfill site in Ghana

Residents close to landfill sites may be exposed to long-term emitted toxic compounds that may have effects on their eyes. The aim of this study was to determine the prevalence of symptomatic ocular allergy and its comorbid factors among residents living near a landfill site in Ghana. An exploratory cross-sectional design involving 400 inhabitants living around a landfill site was employed. The prevalence of symptomatic ocular allergy was 59.3%. In a bivariate analysis, comorbid conditions including respiratory disease, coughing, flu, cholera, skin disease, diarrhoea, and hypertension predicted symptomatic ocular allergy. However, only cholera remained a significant predictor of symptomatic ocular allergy in the multivariate analysis. Symptomatic ocular allergy was high among inhabitants around the landfill site in Ghana. While proper design and management of landfills in Ghana is crucial, further longitudinal and clinical studies are required to clinically establish the link between landfill and ocular allergy.

University Students' Reasons and Attitudes Towards Online Gambling and its Implication on Their Lives

Despite the fact that online gambling is increasing among students in low- and middle-income countries, studies on the reasons and attitudes of university students toward gambling and its associated social, economic, and academic implications on their lives have not been adequately explored in the Ghanaian setting. This study employed an exploratory research design to investigate the reasons and attitudes of students toward online gambling and how online gambling has affected their social, economic, and academic lives on campus. An interview guide was used in soliciting data from fifteen participants. The thematic analytical framework was used to analyze the data. The analysis of the empirical data revealed that the ease of making quick money, the anonymous nature of online gambling and a source of entertainment were the main reasons why participants engaged in online gambling. Again, concerning participants' attitudes towards gambling, most of them were frequent gamblers and gambled four to seven times a week while a few were occasional gamblers who gambled one to three times a month. The study also found that participants who gambled online ended up becoming depressed, had difficulties with sleeping, and barely concentrated in class because of their addictive attitudes towards online gambling. The study further revealed that the academic lives of participants were negatively affected as a result of excessive gambling. The study recommends that the university management should introduce university gambling policies and programmes to regulate gambling among university students and its associated socio-economic and academic implications.

Understanding the Link between Household Food Insecurity and Self-Rated Oral Health in Ghana

There is increasing scholarly attention on the role of food insecurity on the health of older adults in sub-Saharan Africa, including Ghana. Yet, we know very little about the association between food insecurity and self-rated oral health. To address this void in the literature, this study uses a representative survey of adults aged 60 or older from three regions in Ghana to examine whether respondents who experienced household food insecurity rated their oral health as poor compared to their counterparts who did not. We found that 34% of respondents rated their oral health as poor, while 7%, 21%, and 36% experienced mild, moderate, and severe food insecurity, respectively. Moreover, the results from the logistic regression analysis showed that older adults who experienced mild (OR = 1.66, p < 0.05), moderate (OR = 2.06, p < 0.01), and severe (OR = 2.71, p < 0.01) food insecurity were more likely to self-rate their oral health as poor, compared to those who did not experience any type of food insecurity. Based on these findings, we discuss several implications for policymakers and directions for future research.

Cigarette smoking during breastfeeding in Papua New Guinea: Prevalence and demographic and socio-economic predictors

BACKGROUND

Cigarette smoking during breastfeeding is reported to contribute to significant changes in the composition of breast milk not only by reducing its protective features but also affecting infants' response to breastfeeding and breast milk. However, studies on the prevalence of cigarette smoking and associated factors during breastfeeding are limited in Papua New Guinea (PNG). This study estimates the prevalence of cigarette smoking and its association with demographic and economic factors among breastfeeding women in PNG.

METHODS

We used weighted survey data from the 2016-2018 PNG Demographic and Health Survey (PNGDHS). A weighted sample of 3,822 women who were breastfeeding during the survey were included in the study. The outcome variable in the present study is current cigarette smoking. A multiple logistic regression analysis was used to estimate the association between current cigarette smoking status and socio-demographic and economic variables of breastfeeding women. The regression analysis results were reported using adjusted odds ratios (aOR) with their respective 95% confidence intervals (CIs).

RESULTS

From the weighted sample, the prevalence of cigarette smoking among breastfeeding women was 21.9%; of which 60.8% smoked daily. The mean number of cigarettes smoked in the last 24 hours preceding the survey was 6.05(SD = 5.99). Multiple logistic regression analysis revealed that breastfeeding women who were from the Momase (aOR: 2.337, CI: 1.786-3.058, p<0.001) and Highlands (AOR: 1.589, CI: 1.213-2.082, p = 0.001), had no religious affiliation (aOR: 3.665, CI: 1.235-10.877, p = 0.019), and households with daughters as household heads (aOR: 1.901, CI: 1.231-2.935, p = 0.004) and being in more than one union (aOR: 2.374, CI: 1.805-3.123, p<0.001) were significantly more likely to smoke cigarette compared to women from southern region, those affiliated to Anglican church, those with husband as household heads, and being in one union respectively.

CONCLUSION

Cigarette smoking among breastfeeding women in PNG is relatively high, and region of residence, religion, relationship to household head, and the number of unions remain independent predictors. Interventions should target the individual socio-economic and cultural contexts within which breastfeeding occurs.

An integrative review on individual determinants of enrolment in National Health Insurance Scheme among older adults in Ghana

BACKGROUND

We conducted an integrative review in an attempt to methodically and systematically understand the individual (personal factors) that influence National Health Insurance Scheme [NHIS] enrolment among older adults aged 50 years and above. The study was premised on evidence pointing to a state of little or no change in the enrolment rates [especially among older adults], which contrasts with the initial euphoria that greeted the launch of the scheme - which culminated in high enrolment rates.

METHODS

The integrative literature review was conducted to synthesise the available evidence on individual determinants of NHIS among older adults. The methodological approach of the integrative literature review follows a five-stage interdependent and interconnected procedure of problem identification, literature search, data evaluation, data analysis and results presentation. Studies that met the inclusion criteria were peer-reviewed articles published in the English Language, from January 2010 to July 2020 and have Ghana as its setting or study area. The Andersen's Behavioural Model was used to categorize the predictor variables.

RESULTS

Predisposing factors [gender, age, level of education and marital status], enabling factors [income] and need factors [health conditions or health attributes of older adults] were identified as individual predictors of NHIS enrolment among older adults. The findings support argument of Andersen's Behavioural Model [where predisposing, enabling and need factors are considered as individual determinants of health behaviour].

CONCLUSIONS

The findings call for policy reforms that take into account the aforementioned individual predictors of NHIS enrolment, especially among the aged.

Impact of socio-demographic and economic factors on intimate partner violence justification among women in union in Papua New Guinea

BACKGROUND

Justification of intimate partner violence (IPV) has several implications, including reduced likelihood of help-seeking, increased experiences episodes of partner abuses, and poor health status and outcomes. However, in Papua New Guinea (PNG), where IPV is among the highest globally, little is known about factors influencing IPV justification among women in union. This study aimed at examining the prevalence of IPV justification and associated factors among women in union in PNG.

METHODS

Data from the nationally representative cross-sectional demographic and health survey conducted among women aged 15-49 years during 2016-2018 in PNG were used. In all 9,943 women aged 15-49 years who were married or cohabiting during the survey were included. Bivariate and multivariate logistic regressions were performed and the results reported as crude odds ratios (cOR) and adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

Overall, almost 7 in 10 women (68.9%, 95%CI:68.0-69.9) justified IPV. Multiple regression analysis revealed that co-habitation (aOR: 1.33, 95%CI: 1.17-1.50, p < 0.001), polygyny (aOR: 1.36, 95%CI: 1.20-1.53, p < 0.001), exposure to television (aOR: 1.24, 95%CI: 1.08-1.42, p = 0.002) and richer wealth status (aOR: 1.19, 95%CI: 1.01-1.40, p = 0.035), significantly increased the odds of justifying IPV. We found significantly lower odds of IPV justification among women aged 45-49 years (aOR: 0.53, 95%CI: 0.37-0.77, p = 0.001) and those with higher level of education (aOR: 0.56, 95%CI: 0.42-0.74, p < 0.001).

CONCLUSION

The prevalence of IPV justification was high among women in union in PNG. Women's justification of IPV was associated with socio-demographic and economic factors. Our findings call for appropriate strategies including public education and empowerment programmes that target IPV in PNG. Moreover, strategies and interventions to address IPV justification should target the women's socio-economic and demographic contexts that influence IPV justification.

Association between experiences of intimate partner sexual violence and cigarette smoking among women in union in Papua New Guinea: evidence from a nationally representative survey

Background

Intimate partner sexual violence (IPSV) is a prevalent public health problem affecting millions of people each year globally, particularly in developing countries like Papua New Guinea (PNG). Although over two-thirds of women in PNG are estimated to experience some form of sexual violence in their lifetime, empirical evidence is limited on the association between IPSV and cigarette smoking. Thus, the present study aims to examine the prevalence of IPSV and its association with cigarette smoking among women in union  in PNG.

Methods

This cross-sectional study used data from the first demographic and health survey of PNG conducted between 2016 and 2018. A total of 9,943 women aged 15–49 years in intimate unions were included in this study. We estimated the relative risk of smoking cigarette using modified Poisson regression models with a robust variance and 95% confidence intervals.

Results

The rates of IPSV and current cigarette smoking were 25.9% and 26.8%, respectively. The modified Poisson regression results showed that IPSV was significantly associated with an elevated risk for cigarette smoking. Women with IPSV history were more likely to smoke cigarette relative to their counterparts with no IPSV history (RR: 1.33, 95% CI: 1.18–1.50) in the absence of covariates. After controlling for demographic, social and economic factors, the association between IPSV and cigarette smoking remained statistically significant (RR: 1.24, 95% CI: 1.08–1.42).

Conclusions

The rates of IPSV and cigarette smoking among women in union in PNG in the current study were relatively high. Irrespective of diverse demographic, social and economic factors, IPSV was still significantly associated with cigarette smoking among women in union in PNG. The findings presented call the attention of policy-makers and relevant authorities in PNG to an important association that needs to be addressed. Counseling, awareness creation, service provision and program design on IPSV are urgently required to minimize cigarette smoking and IPSV among women in union in PNG.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13003-4.

Housing conditions and long-term care needs of older adults in Ghana: Evidence from the WHO SAGE Ghana Wave 1

The present study examined the association between housing conditions and long-term care needs of older adults in Ghana. We used data from 4,920 adults aged ≥50 years that participated in the World Health Organisation's (WHO) Study on adult health and AGEing Ghana Wave 1. Housing conditions were assessed with drinking water, sanitation, cooking conditions and building materials, and long-term care needs were based on WHO Disability Assessment Schedule 2.0. Multivariable logistic regressions modelled the effect of housing conditions on long-term care needs. After full adjustment for all available potential confounders, older adults living in households with unimproved cooking conditions had higher odds of reporting long-term care needs (OR = 6.87, 95%CI: 5.04-9.37) compared to those in improved cooking condition households. Moreover, those in households with unimproved housing materials (OR = 1.27, 95%CI: 1.01-1.72) and those in unimproved sanitation households (OR = 1.26, 95%CI: 1.05-1.54) were more likely to experience long-term care needs after respectively controlling for demographic and health-related covariates. Poor housing conditions are risk factors of long-term care needs in Ghana. Efforts to improve housing conditions may benefit older age functional abilities and unmet long-term care needs.

Protecting the patches from the footprints: examining the land use factors associated with forest patches in Atewa range forest reserve

BACKGROUND

Land use practices are noted to contribute to changes in forest landscape composition. However, whereas studies have reported the intermix of land uses and forest patches and measured the direct impacts of land uses on forest patches, little is known regarding the spatially-explicit association between the most recent forest patches and land use footprints in protected areas. In this study, we use methods from GIS, remote sensing, and statistics to model the spatial relationship between footprints of land uses and patches of forest cover by drawing on geospatial data from the Atewa range forest reserve (ARFR).

RESULTS

The study finds that forest patches that are within 1 km from agricultural land use footprints (AOR = 86.625, C.I. 18.057-415.563, P = 0.000), logging sites (AOR = 55.909, C.I. 12.032-259.804, P = 0.000), mine sites (53.571, C.I. 11.287-254.255, P = 0.000), access roads (AOR = 24.169, C.I. 5.544-105.357, P = 0.000), and human settlement footprints (AOR = 7.172, C.I. 1.969-26.128, P = 0.003) are significantly more likely to be less than the mean patch area (375,431.87 m² = 37.54 ha) of forest cover. A ROC statistic of 0.995 achieved in this study suggests a high predictive power of the proposed model.

CONCLUSION

The study findings suggest that to ensure sustainable land uses and ecological integrity, there is a need for land use policies and land management strategies that ensure responsible livelihood activities as well as further restrictions on logging and mining in the globally significant biodiversity area.

Removing barriers to healthcare through an intercultural healthcare system: Focus group evidence

OBJECTIVE

Barriers to healthcare in Ghana are multifaceted. Many people, including patients and providers, face them at different levels. To address these barriers, there is a need to explore the role of an intercultural healthcare system. This paper explores and provides the first evidence on ways through which an intercultural healthcare system can reduce the sociocultural and economic barriers to healthcare in Ghana.

METHODS

Focus group discussions with 35 participants comprising 17 healthcare users, 11 formal healthcare providers and 7 alternative healthcare providers were conducted to gather data. Thematic analyses were performed on the transcribed data and presented based on a posteriori inductive reduction approach.

RESULTS

Findings reveal that an intercultural healthcare system in Ghana can help reduce barriers to healthcare, especially cultural, social and economic barriers, by fostering an enhanced relationship between culture and healthcare, promoting affordable healthcare and promoting effective communication between healthcare providers and users. Weak institutional support, lack of strong political will and commitment, lack of training to meet standards of practice, poor registration and regulatory measures, and lack of universal acceptance inhibit implementation of an intercultural healthcare system in Ghana.

CONCLUSION

The support for intercultural healthcare system and the agreement on its perceived ability to reduce social, cultural and economic healthcare barriers for service users offer an opportunity for policymakers to demonstrate a stronger political will and improved commitment for effective education and training, enforcement of regulatory measures, inclusion of intercultural healthcare in medical school curricula across the country, and community engagement.

Healthcare Concerns of Older Adults during the COVID-19 Outbreak in Low- and Middle-Income Countries: Lessons for Health Policy and Social Work

Older people have been identified to be one of the most vulnerable population groups to the 2019 novel coronavirus (COVID-19). At the same time, more health workers in low-and middle-income countries (LMICs) including Ghana are contracting COVID-19. This poses healthcare utilization concerns for older adults. As a result, many older adults are changing their health-seeking behavior by staying at home and resorting to informal healthcare such as the use of traditional therapies and over-the-counter medicines for self-treatment or to boost their immune system. This commentary calls for social workers to collaborate with health authorities and community pharmacists to develop social and health programs to increase older adults' access to healthcare during the COVID-19 crisis. Policies are also required to deal with the pandemic and its impact on health systems in LMICs for both short and long term. We have suggested in this commentary how governments, health institutions, and local authorities in LMICs can address the healthcare concerns of older adults during this and any future pandemic.

"With tramadol, I ride like a Jaguar": a qualitative study of motivations for non-medical purpose tramadol use among commercial vehicle operators in Kumasi, Ghana

BACKGROUND

The misuse of tramadol has become a major aspect of the wider substance use challenge in recent years and is evolving into a health crisis at an alarming rate. However, literature on motivations for non-medical purpose tramadol use among commercial vehicle operators remains inadequate. The aim of this study was to document the motivations for non-medical purposes tramadol use in Kumasi. Such an understanding could inform policy direction to regulate non-medical purposes tramadol use in Ghana.

METHODS

We conducted this exploratory qualitative study with 23 purposively selected commercial vehicle drivers (15) and assistants (8) in Kumasi, Ghana. Data for the study were collected through in-depth face-to-face interviews between June 2018 and March 2019. Using a thematic analytical approach, the interviews were coded and analysed.

RESULTS

Multiple motivations for non-medical purposes tramadol use were found including those related to: (1) sexual; (2) psychological; (3) physical; and (4) economic factors. Participants also reported three main inter-linking categories of perceived tramadol adverse effects: (1) physical; (2) psychological; and (3) social effects. Although participants indicated no plans for stopping their non-medical use of tramadol any time soon, strong willingness was voiced for supporting officials in finding and dealing with non-medical purpose tramadol sellers.

CONCLUSION

Non-medical purposes tramadol use was associated with a confluence of factors, ranging from enhanced sexual performance to economic reasons. Based on the findings of the study and the dependence and addictive potentials of tramadol, there is the need for psychoeducational programmes for persons who misuse tramadol and enhancement of operational capacities of regulatory agencies.

Dynamics of health information-seeking behaviour among older adults with very low incomes in Ghana: a qualitative study

Background

Exploration of health information-seeking behaviour among older adults with very low incomes is critical in shaping our understanding of how health information is sought in later life. Although studies have focused on health information-seeking behaviour among older people worldwide, subjective views of older adults, especially those with very low incomes in Ghana remain scant. Thus, this study aimed to fill this significant knowledge gap by exploring health information-seeking behaviour among older adults with very low incomes in Ghana.

Methods

In-depth interviews and focus group discussions were conducted with 30 older adults with very low incomes, 15 caregivers and 15 formal healthcare providers in the Atwima Nwabiagya District of Ghana. A thematic analytical framework was used to analyse the data.

Results

The study revealed multiple sources of health information to include healthcare providers, family members, media and friends. The kind of health information sought by older adults with very low incomes consisted of information on diets, causes of chronic non-communicable diseases and medication dosage. The study also identified inadequate knowledge about the benefits of seeking health information, perceived poor attitude of healthcare providers and communication problems as the factors that limit older adults with very low incomes from acquiring health information.

Conclusion

An adequate and reliable source of information is essential to promoting the health of older people. Their inability to secure the right health information could further worsen their health status. Thus, the study provides the need for appropriate health policy interventions on the sources and types of health information sought by older adults with very low incomes in Ghana. Healthcare providers are recommended to remain open, friendly and receptive to older people to allow them to seek and obtain health information as they [healthcare providers] constitute the most reliable health information source.