Trends in young adult mortality in three European cities: Barcelona, Bologna and Munich, 1986-1995

Agents of change among people living with HIV and their social networks: stepped-wedge randomised controlled trial of the NAMWEZA intervention in Dar es Salaam, Tanzania

INTRODUCTION

NAMWEZA is a novel intervention that focuses on preventing HIV and promoting sexual and reproductive health and rights by addressing underlying factors related to vulnerability of acquiring HIV, such as depression, intimate partner violence (IPV) and stigma. The goal of the study was to evaluate the effect of the NAMWEZA intervention on risk behaviour as well as factors potentially contributing to this vulnerability for people living with HIV and their network members.

METHODS

A stepped-wedge randomised controlled trial was conducted from November 2010 to January 2014 among people living with HIV and their network members in Dar es Salaam, Tanzania. 458 people living with HIV were randomised within age/sex-specific strata to participate in the NAMWEZA intervention at three points in time. In addition, 602 members of their social networks completed the baseline interview. Intention-to-treat analysis was performed, including primary outcomes of uptake of HIV services, self-efficacy, self-esteem, HIV risk behaviour and IPV.

RESULTS

For people living with HIV, a number of outcomes improved with the NAMWEZA intervention, including higher self-efficacy and related factors, as well as lower levels of depression and stigma. IPV reduced by 40% among women. Although reductions in HIV risk behaviour were not observed, an increase in access to HIV treatment was reported for network members (72% vs 94%, p=0.002).

CONCLUSION

These results demonstrate the complexity of behavioural interventions in reducing the vulnerability of acquiring HIV, since it is possible to observe a broad range of different outcomes. This study indicates the importance of formally evaluating interventions so that policymakers can build on evidence-based approaches to advance the effectiveness of HIV prevention interventions.

TRIAL REGISTRATION NUMBER

NCT01693458.

Educational inequalities in young-adult mortality between the 1990s and the 2000s: regional differences in Belgium

Background

This study addresses educational inequalities in young-adult mortality between the 1990s and the 2000s by comparing trends in the three different regions in Belgium stratified by sex. Social inequalities in mortality are of major concern to public health but are rarely studied at young ages. Substantial health differences have been found between the Flemish (FR) and Walloon region (WR) concerning (healthy) life expectancy and avoidable mortality, but little is known about regional differentials in young-adult mortality, and comparisons with the Brussels-Capital Region (BCR) have thus far never been made.

Methods

Data are derived from record linkage between the Belgian censuses of 1991 and 2001 and register data on death and emigration for the periods 01/03/1991-01/03/1999 and 01/10/2001-01/10/2009. Analyses are restricted to young adults aged 25 to 34 years at the moment of each of the censuses. Absolute (directly standardized mortality rates (ASMRs)) and relative (mortality rate ratio using Poisson regression) measures were calculated.

Results

There is a significant drop in young-adult mortality between the 1990s and the 2000s in all regions and both sexes, with the strongest decline in the BCR (e.g. ASMR of men declined from 165.6 [151.1-180.1] per 100,000 person years to 73.8 [88.3-98.3]). The mortality rates remain highest in the WR in the 2000s Between the 1990s and the 2000s, a remarkable change in the educational distribution occurred as well, with much lower proportions of primary educated in all regions in the 2000s in favour of higher proportions in all other educational levels, especially in higher education. All educational groups show lower mortality over time, except for lower educated men in the FR.

Conclusions

There is a positive evolution towards lower mortality among the young-adult Belgian population. The WR trails behind in this evolution, which calls for tailored preventive actions. Educational inequalities are marked in all regions and time periods. A more general discussion is needed on the responsibility of society in rendering support and capability to enhance the state of well-being of those not able to achieve a high social position.

Electronic supplementary material

The online version of this article (doi:10.1186/s13690-014-0059-3) contains supplementary material, which is available to authorized users.

Health status and mortality rates of adolescents and young adults in the Brussels-Capital Region: differences according to region of origin and migration history

OBJECTIVE

To examine and quantify differences in both self-rated health (SRH) and mortality according to region of origin, migration history and educational level among adolescents and young adults living in the Brussels-Capital Region (BCR).

DESIGN

The data consist of the census of 2001 for the BCR linked to death and emigration records for the period of 01/10/2001-01/01/2006. Belgian, Maghreb, Turkish and sub-Saharan African 15-34 year olds are included in the analyses. Odds ratios are calculated for SRH (0 = poor health, 1 = good health) using logistic regression. Age-standardised mortality rates are computed and mortality rate ratios are shown using Poisson regression.

RESULTS

There are marked health differences according to region of origin. While Maghrebins and Turks (M/T) feel less healthy, sub-Saharan Africans (SSA) feel healthier than Belgians. Furthermore, there are important differences within nationality groups, with second-generation M/T having a worse health status than the first generation. While first-generation SSA feel a lot healthier than Belgians, there is no difference between second-generation SSA and Belgians. Education plays a marked role in health and mortality differences, especially in young adulthood (25-34 years). Migration history is even more important than region of origin concerning mortality differences. First-generation M/T show lower mortality risks compared to Belgians and second-generation M/T, while the latter show comparable mortality risks as Belgians after controlling for education.

CONCLUSION

Important differences are observed according to both region of origin and migration history among adolescents and young adults in the BCR. These differences significantly reduce when accounting for education, suggesting that investing in education is a public-health strategy worth considering. Further research in this area may benefit from taking migration history into account.

Influence of war on quantitative and qualitative changes in drug-induced mortality in Split-Dalmatia County, Croatia

Aim

To study drug-induced mortality and characteristics of overdose deaths in the war (1991-1995), pre-war (1986-1990), and post-war period (1996-2000) in Split-Dalmatia County.

Methods

We retrospectively searched through Databases of the Department of Forensic Medicine, University Hospital Split, the national register of death records, the archives of the Split-Dalmatia County Police, and the Register of Treated Drug Addicts of the Croatian National Institute of Public Health, covering the period from 1986 to 2000, according to drug poisoning codes IX and X of the International Classification of Diseases. The indicators were statistically analyzed.

Results

There were 146 registered drug-induced deaths, with 136 (93%) deceased being men. The median age of all cases was 27 years (interquartile range 8). Most of them were single (70.6%), unemployed (44.6%), and secondary school graduates (69.2%). In the war period, there were 4.8 times more deaths than in the pre-war period (P = 0.014), and in the post-war period there were 5.2 times more deaths than in the pre-war period (P = 0.008). The most common site of death was the deceased person’s home. The toxicological analyses showed that 59 (61%) deaths were heroin related, alcohol use was found in 62 cases (42.5%), and multi-substance use was found in more than a half of the cases. In 133 (91.1%) cases, deaths were classified as unintentional, whereas 13 (8.9%) were classified as suicides.

Conclusion

The war, along with other risk factors, contributed to unfavorable developments related to drug abuse in Split-Dalmatia County, including the increase in the drug-induced mortality rate.

Mortality of HIV-infected patients starting potent antiretroviral therapy: comparison with the general population in nine industrialized countries

BACKGROUND

Mortality in HIV-infected patients has declined substantially with combination antiretroviral therapy (ART), but it is unclear whether it has reached that of the general population. We compared mortality in patients starting ART in nine countries of Europe and North America with the corresponding general population, taking into account their response to ART.

METHODS

Eligible patients were enrolled in prospective cohort studies participating in the ART Cohort Collaboration. We calculated the ratio of observed to expected deaths from all causes [standardized mortality ratio (SMR)], measuring time from 6 months after starting ART, according to risk group, clinical stage at the start of ART and CD4 cell count and viral load at 6 months. Expected numbers of deaths were obtained from age-, sex- and country-specific mortality rates.

RESULTS

Among 29 935 eligible patients, 1134 deaths were recorded in 131 510 person-years of follow-up. The median age was 37 years, 8162 (27%) patients were females, 4400 (15%) were injecting drug users (IDUs) and 6738 (23%) had AIDS when starting ART. At 6 months, 23 539 patients (79%) had viral load measurements <or=500 copies/ml. The lowest SMR, 1.05 [95% confidence interval (CI) 0.82-1.35] was found for men who have sex with men (MSM) who started ART free of AIDS, reached a CD4 cell count of >or=350 cells/microL and suppressed viral replication to <or=500 copies/ml by the sixth month. In contrast, the SMR was 73.7 (95% CI 46.4-116.9) in IDUs who failed to suppress viral replication and had CD4 cell counts <50 cells/microL at 6 months. The percentage of patients with SMRs <2 was 46% for MSM, 42% for heterosexually infected patients and 0% for patients with a history of injection drug use. Corresponding percentages for SMRs >10 were 4, 14 and 47%.

CONCLUSIONS

In industrialized countries, the mortality experience of HIV-infected patients who start ART and survive the first 6 months continues to be higher than in the general population, but for many patients excess mortality is moderate and comparable with patients having other chronic conditions. Much of the excess mortality might be prevented by earlier diagnosis of HIV followed by timely initiation of ART.

Global patterns of mortality in young people: a systematic analysis of population health data

BACKGROUND

Pronounced changes in patterns of health take place in adolescence and young adulthood, but the effects on mortality patterns worldwide have not been reported. We analysed worldwide rates and patterns of mortality between early adolescence and young adulthood.

METHODS

We obtained data from the 2004 Global Burden of Disease Study, and used all-cause mortality estimates developed for the 2006 World Health Report, with adjustments for revisions in death from HIV/AIDS and from war and natural disasters. Data for cause of death were derived from national vital registration when available; for other countries we used sample registration data, verbal autopsy, and disease surveillance data to model causes of death. Worldwide rates and patterns of mortality were investigated by WHO region, income status, and cause in age-groups of 10-14 years, 15-19 years, and 20-24 years.

FINDINGS

2.6 million deaths occurred in people aged 10-24 years in 2004. 2.56 million (97%) of these deaths were in low-income and middle-income countries, and almost two thirds (1.67 million) were in sub-Saharan Africa and southeast Asia. Pronounced rises in mortality rates were recorded from early adolescence (10-14 years) to young adulthood (20-24 years), but reasons varied by region and sex. Maternal conditions were a leading cause of female deaths at 15%. HIV/AIDS and tuberculosis contributed to 11% of deaths. Traffic accidents were the largest cause and accounted for 14% of male and 5% of female deaths. Other prominent causes included violence (12% of male deaths) and suicide (6% of all deaths).

INTERPRETATION

Present global priorities for adolescent health policy, which focus on HIV/AIDS and maternal mortality, are an important but insufficient response to prevent mortality in an age-group in which more than two in five deaths are due to intentional and unintentional injuries.

FUNDING

WHO and National Health and Medical Research Council.

Socioeconomic differentials in premature mortality in Rome: changes from 1990 to 2001

Background

While socioeconomic inequalities in mortality have widened in many countries, evidence of social differentials is scarce in Southern Europe. We studied temporal changes in premature mortality across socioeconomic groups in Rome between 1990 and 2001.

Methods

We analysed all 126,511 death certificates of residents of Rome aged 0–74 years registered between 1990–2001. A 4-level census block index based on the 1991 census was used as an indicator of socioeconomic position (SEP). Using routine mortality data, standardised mortality rates (per 100,000 inhabitants) were calculated by SEP and gender for four time periods. Rate ratios were used to compare mortality by gender and age.

Results

Overall premature mortality decreased in both genders and in all socioeconomic groups; the change was greater in the highest socio-economic group. In both men and women, inequalities in mortality strengthened during the 1990s and appeared to stabilise at the end of the 20th century. However, for 60–74 year old women the gap continued to widen.

Conclusion

Socioeconomic inequalities in health in Rome are still present at the beginning of the 21^st century. Strategies to monitor the impact of SEP on mortality over time in different populations should be implemented to direct health policies.

AIDS mortality before and after the introduction of highly active antiretroviral therapy: does it vary with socioeconomic group in a country with a National Health System?

BACKGROUND

The aim of this study is to determine whether socioeconomic AIDS mortality inequalities before and after the introduction of highly active antiretroviral therapy (HAART) have increased or decreased in a Spanish city where HAART is free.

METHODS

The study used a trend design, including all Barcelona residents older than 19 years of age. All AIDS deaths, which occurred among these residents between 1991 and 2001 were included. The variables studied were age, sex, socioeconomic (SES) group and HIV transmission group. AIDS age-standardized mortality rates for each year were estimated. Poisson regression models were fitted to obtain the relative risk (RR) of AIDS death for each socioeconomic group with respect to the reference group.

RESULTS

AIDS mortality increased up until 1995 and subsequently decreased due to the introduction of HAART. The increase in AIDS mortality was greater in the lowest SES group, which had higher rates and a RR of dying larger than that of the highest SES group, fact that remained fairly stable over the whole period. A similar pattern was observed in intravenous drug users. In the homosexual transmission group, rates for the lowest SES group were higher for the whole period and increased until 1996, while rates for the other SES groups were lower and decreased over the entire period.

CONCLUSIONS

The fact that inequalities in AIDS mortality by SES group remained fairly stable for the whole period suggests that perhaps access to HAART, or adherence, is lower than desirable, in people of lower SES groups. These results ought to be taken into account when implementing treatment and prevention strategies.

Evaluating the impact of methadone maintenance programmes on mortality due to overdose and aids in a cohort of heroin users in Spain

AIMS

To assess the relationship between methadone treatment (MT) and overdose and HIV/AIDS mortality among heroin users resident in Barcelona city.

DESIGN

All patients who started treatment in any treatment centre between 1992 and 1997 were included in a cohort the first time they were admitted for heroin addiction treatment. Follow-up controls were carried out every 9 months, on average, until 31 December 1999. Variables, both constant and varying over time, were fitted into Cox regression models.

FINDINGS

The study recruited 5049 patients, which provided 23,048.2 person-years. Fifty per cent were in MT during the study period; of the total cohort 1005 patients died: 38.4% due to AIDS, 34.7% to overdose and 27% to other causes. Overall mortality decreased from 5.9 deaths per 100 person-years in 1992 to 1.6 in 1999. Globally, life expectancy at birth was 39 years, 38 years lower than that of the general population. The main factor for overdose mortality was not being in MT at the time of death [relative ratio (RR) = 7.1]; other factors were being a current injector at baseline and being HIV positive. For AIDS mortality, the main factor was the calendar year (RR for 1996 versus 1999 = 4.6), the next major factor was more than 10 years of heroin consumption, followed by not being in MT, being unemployed, then having a prison record.

CONCLUSIONS

The observed mortality decline could be linked to the effectiveness of low-threshold MT. The life expectancy of heroin users increased by 21 years during the study period.

The effect of HIV infection on overdose mortality

OBJECTIVES

To quantify the association of HIV infection with overdose mortality and explore the potential mechanisms.

DESIGN

A prospective cohort study.

METHODS

A total of 1927 actively injecting drug users who were HIV seronegative at baseline, of whom 308 later HIV seroconverted, were followed semi-annually for death from 1988 to 2001. Survival analyses using marginal structural and standard Cox models were used to evaluate the effect of HIV infection on the risk of overdose mortality.

RESULTS

Overdose death rates were higher in HIV-seropositive than HIV-seronegative drug users: 13.9 and 5.6 per 1000 person-years, respectively (P < 0.01). The hazard ratio (HR) was 2.54 [95% confidence interval (CI) 1.47, 4.38] for the marginal structural model and 2.06 (95% CI 1.25, 3.38) for the standard Cox model, both adjusted for demographics, drug injection characteristics, alcohol abuse, substance abuse treatment, and sexual orientation. Adjusting for possible time-varying mediators (i.e. drug use, medical conditions and healthcare access) in extended marginal structural models reduced the effect of HIV on overdose mortality by 30% (HR 1.82, 95% CI 1.01, 3.30). Abnormal liver function was associated with a higher risk of overdose mortality (HR 2.00, 95% CI 1.05, 3.84); adjustment for this further reduced the effect of HIV on overdose mortality.

CONCLUSION

HIV infection was associated with a higher risk of overdose mortality. Drug use behavior, systematic disease and liver damage associated with HIV infection appeared to account for a substantial portion of this association. The data suggest a group to target with interventions to reduce overdose mortality rates.

[Impact of smoking and alcohol consumption on mortality in the population of Barcelona [Spain]: 1983-1998]

OBJECTIVES

To analyze the mortality attributable to smoking and alcohol consumption in the city of Barcelona from 1983 to 1998.

METHODS

All deaths among residents of the city of Barcelona from 1983 to 1998 were included. Population data were obtained from the city inhabitants register. The mortality attributable to smoking and alcohol consumption was calculated by population attributable fractions using relative risks from previous studies in the US population.

RESULTS

In 1998, 2,205 deaths were attributable to smoking, representing 13.8% of all deaths among the population aged 35 years or older and a decrease of 9.6% compared with deaths in 1983. From 1983 to 1998 there was an increase in smoking-attributable adjusted mortality rates for lung cancer (155.84/100,000 inhabitants in men and 9.39/100,000 in women in 1998) and chronic obstructive pulmonary disease (COPD) (95.89/100,000 in men and 11.29/ 100,000 in women in 1998). In 1998, deaths attributed to alcohol consumption accounted for 4.3% of total mortality, representing a reduction of 26% since 1983. Among men, the primary cause of alcohol-attributable mortality was liver cirrhosis (17.1%), although its relative importance decreased (accounting for 17.1% of alcohol-attributable mortality in 1998 compared with 24.3% in 1983).

CONCLUSIONS

The mortality attributable to smoking and alcohol consumption decreased in the city of Barcelona during the study period. Smoking-attributable mortality from lung cancer and COPD increased in both sexes. Alcohol consumption-attributable mortality from liver cirrhosis decreased in men.

Role of individual and contextual effects in injury mortality: new evidence from small area analysis

OBJECTIVE

To analyse the role of individual and contextual variables in injury mortality inequalities from a small area analysis perspective, looking at the data for the city of Barcelona (Spain) for 1992-98.

SETTING

Barcelona (Spain).

METHODS

All injury deaths in residents older than 19, which occurred in the period 1992-98 were included (n=4393). Age and sex specific mortality rates were calculated for each educational level and each cause of death (traffic injuries, falls, drug overdose, suicide, other injuries). The contextual variables included were the proportion of men unemployed, and the proportion of men in jail, in each neighbourhood. Multilevel Poisson regression models were fitted using data grouped by age, educational level, and neighbourhood for each sex.

RESULTS

Death rates were higher in males, at the extremes of the age distribution (under 44 and over 74 years), and for lower educational levels. The results of the Poisson multilevel models indicate that inequalities by educational level follow a gradient, with higher risks for the population with no schooling, after having adjusted for the contextual variables of the neighbourhood. Such inequalities were more important in the youngest age group (20-34 years), as relative risk of 5.41 (95% confidence interval (CI) 3.9 to 7.4) for all injury causes in males and 4.38 (95% CI 2.3 to 8.4) in females. The highest relative risks were found for drug overdose. There was a contextual neighbourhood effect (the higher the deprivation, the higher the mortality) after having taken into account individual variables.

CONCLUSION

The findings underscore the need to implement injury prevention strategies not only at the individual level taking into account socioeconomic position, but also at the neighbourhood level.

Factors associated with severity and hospital admission of motor-vehicle injury cases in a southern European urban area

OBJECTIVES

To describe the characteristics of motor-vehicle (MV) injury cases admitted to Emergency departments (ED), and to assess factors related to injury severity and hospital admission.

SETTING

Subjects were MV injury patients, aged 16 or more, admitted to four EDs in the city of Barcelona (Spain), from July 1995 to June 1996.

METHODS

Cross-sectional design. The data analyzed were obtained from the information routinely transmitted from the EDs to the Municipal Institute of Health, based on the processing of ED logs. Severity was assessed with the Abbreviated Injury Scale and the Injury Severity Score. Univariate and bivariate descriptive statistical analyses were performed, as well as multiple logistic regressions.

RESULTS

For the 3791 MV-injury cases included in the study period, a larger contribution of cases was noted for males (63.1%), for cases younger than 30 years (55.3%) and for motorcycle or moped occupants (47.1%). After adjusting for age, sex and the presence of multiple injuries, pedestrians, followed by moped and motorcycle occupants were at a higher risk of a more severe injury (OR: 1.77, 1.61 and 1.50 respectively). Correspondingly, these user groups also showed a higher likelihood of a hospital admission (OR: 2.03, 1.92 and 2.00 respectively), when attended to in an ED. Injury cases attended to in the ED during night hours (OR: 2.06) were also at a higher risk of a hospital admission.

CONCLUSIONS

In Barcelona, pedestrians and two-wheel MV occupants, besides accounting for two-thirds of MV injury cases, are the user groups with a greater risk of a more severe injury. as well as a higher chance of a hospital admission, independently of demographic and health care factors.