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 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.

Subnational inequalities in years of life lost and associations with socioeconomic factors in pre-pandemic Europe, 2009-19: an ecological study

BACKGROUND

Health inequalities have been associated with shorter lifespans. We aimed to investigate subnational geographical inequalities in all-cause years of life lost (YLLs) and the association between YLLs and socioeconomic factors, such as household income, risk of poverty, and educational attainment, in countries within the European Economic Area (EEA) before the COVID-19 pandemic.

METHODS

In this ecological study, we extracted demographic and socioeconomic data from Eurostat for 1390 small regions and 285 basic regions for 32 countries in the EEA, which was complemented by a time-trend analysis of subnational regions within the EEA. Age-standardised YLL rates per 100 000 population were estimated from 2009 to 2019 based on methods from the Global Burden of Disease study. Geographical inequalities were assessed using the Gini coefficient and slope index of inequality. Socioeconomic inequalities were assessed by investigating the association between socioeconomic factors (educational attainment, household income, and risk of poverty) and YLLs in 2019 using negative binomial mixed models.

FINDINGS

Between Jan 1, 2009, and Dec 31, 2019, YLLs lowered in almost all subnational regions. The Gini coefficient of YLLs across all EEA regions was 14·2% (95% CI 13·6-14·8) for females and 17·0% (16·3 to 17·7) for males. Relative geographical inequalities in YLLs among women were highest in the UK (Gini coefficient 11·2% [95% CI 10·1-12·3]) and among men were highest in Belgium (10·8% [9·3-12·2]). The highest YLLs were observed in subnational regions with the lowest levels of educational attainment (incident rate ratio [IRR] 1·19 [1·13-1·26] for females; 1·22 [1·16-1·28] for males), household income (1·35 [95% CI 1·19-1·53]), and the highest poverty risk (1·25 [1·18-1·34]).

INTERPRETATION

Differences in YLLs remain within, and between, EEA countries and are associated with socioeconomic factors. This evidence can assist stakeholders in addressing health inequities to improve overall disease burden within the EEA.

FUNDING

Research Council of Norway; Development, and Innovation Fund of Hungary; Norwegian Institute of Public Medicine; and COST Action 18218 European Burden of Disease Network.

The Coronavirus Anxiety Scale: Cross-national measurement invariance and convergent validity evidence

Coronavirus Anxiety Scale (CAS) is a widely used measure that captures somatic symptoms of coronavirus-related anxiety. In a large-scale collaboration spanning 60 countries (Ntotal = 21,513), we examined the CAS's measurement invariance and assessed the convergent validity of CAS scores in relation to the fear of COVID-19 (FCV-19S) and the satisfaction with life (SWLS-3) scales. We utilized both conventional exact invariance tests and alignment procedures, with results revealing that the single-factor model fit the data well in almost all countries. Partial scalar invariance was supported in a subset of 56 countries. To ensure the robustness of results, given the unbalanced samples, we employed resampling techniques both with and without replacement and found the results were more stable in larger samples. The alignment procedure demonstrated a high degree of measurement invariance with 9% of the parameters exhibiting noninvariance. We also conducted simulations of alignment using the parameters estimated in the current model. Findings demonstrated reliability of the means but indicated challenges in estimating the latent variances. Strong positive correlations between CAS and FCV-19S estimated with all three different approaches were found in most countries. Correlations of CAS and SWLS-3 were weak and negative but significantly differed from zero in several countries. Overall, the study provided support for the measurement invariance of the CAS and offered evidence of its convergent validity while also highlighting issues with variance estimation. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The burden of breast, cervical, and colon and rectum cancer in the Balkan countries, 1990-2019 and forecast to 2030

BACKGROUND

Despite effective prevention and control strategies, in countries of the Balkan region, cancers are the second leading cause of mortality, closely following circulatory system diseases.

OBJECTIVE

To describe trends in the burden of breast, cervical, and colon and rectum cancer in the Balkan region and per country between 1990 and 2019, including a forecast to 2030.

METHODS

We described the 2019 Global Burden of Disease (GBD) estimates for breast, cervical, and colon and rectum cancers in eleven Balkan countries over the period 1990-2019, including incidence, years lived with disability (YLD), years of life lost (YLL), and disability-adjusted life years (DALYs) rates per 100,000 population and accompanied 95% uncertainty interval. With the Autoregressive Integrated Moving Average, we forecasted these rates per country up to 2030.

RESULTS

In the Balkan region, the highest incidence and DALYs rates in the study period were for colon and rectum, and breast cancers. Over the study period, the DALYs rates for breast cancer per 100,000 population were the highest in Serbia (reaching 670.84 in 2019) but the lowest in Albania (reaching 271.24 in 2019). In 2019, the highest incidence of breast cancer (85 /100,000) and highest YLD rate (64 /100,000) were observed in Greece. Romania had the highest incidence rates, YLD rates, DALY rates, and YLL rates of cervical cancer, with respective 20.59%, 23.39% 4.00%, and 3.47% increases for the 1990/2019 period, and the highest forecasted burden for cervical cancer in 2030. The highest incidence rates, YLD rates and DALY rates of colon and rectum cancers were continuously recorded in Croatia (an increase of 130.75%, 48.23%, and 63.28%, respectively), while the highest YLL rates were in Bulgaria (an increase of 63.85%). The YLL rates due to colon and rectum cancers are forecasted to progress by 2030 in all Balkan countries.

CONCLUSION

As most of the DALYs burden for breast, cervical, and colon and rectum cancer is due to premature mortality, the numerous country-specific barriers to cancer early detection and quality and care continuum should be a public priority of multi-stakeholder collaboration in the Balkan region.

Inequalities in the burden of non-communicable diseases across European countries: a systematic analysis of the Global Burden of Disease 2019 study

BACKGROUND

Although overall health status in the last decades improved, health inequalities due to non-communicable diseases (NCDs) persist between and within European countries. There is a lack of studies giving insights into health inequalities related to NCDs in the European Economic Area (EEA) countries. Therefore, the aim of the present study was to quantify health inequalities in age-standardized disability adjusted life years (DALY) rates for NCDs overall and 12 specific NCDs across 30 EEA countries between 1990 and 2019. Also, this study aimed to determine trends in health inequalities and to identify those NCDs where the inequalities were the highest.

METHODS

DALY rate ratios were calculated to determine and compare inequalities between the 30 EEA countries, by sex, and across time. Annual rate of change was used to determine the differences in DALY rate between 1990 and 2019 for males and females. The Gini Coefficient (GC) was used to measure the DALY rate inequalities across countries, and the Slope Index of Inequality (SII) to estimate the average absolute difference in DALY rate across countries.

RESULTS

Between 1990 and 2019, there was an overall declining trend in DALY rate, with larger declines among females compared to males. Among EEA countries, in 2019 the highest NCD DALY rate for both sexes were observed for Bulgaria. For the whole period, the highest DALY rate ratios were identified for digestive diseases, diabetes and kidney diseases, substance use disorders, cardiovascular diseases (CVD), and chronic respiratory diseases - representing the highest inequality between countries. In 2019, the highest DALY rate ratio was found between Bulgaria and Iceland for males. GC and SII indicated that the highest inequalities were due to CVD for most of the study period - however, overall levels of inequality were low.

CONCLUSIONS

The inequality in level 1 NCDs DALYs rate is relatively low among all the countries. CVDs, digestive diseases, diabetes and kidney diseases, substance use disorders, and chronic respiratory diseases are the NCDs that exhibit higher levels of inequality across countries in the EEA. This might be mitigated by applying tailored preventive measures and enabling healthcare access.

Smokers' support for the ban on sale of slim cigarettes in six European countries: findings from the EUREST-PLUS ITC Europe Surveys

Background: Efforts to regulate tobacco products and reduce consumption in the European Union (EU) include the European Tobacco Products Directive (TPD), which went into force in May 2016. Despite the initial discussion to include a ban on sale of slim cigarettes, it was excluded in the final TPD. The main goal of this study was to examine support for a ban on slim cigarettes among smokers in six European Countries. Methods: Data from the 2018 (Wave 2) International Tobacco Control Policy Evaluation Project 6 European Country (ITC 6E) EUREST-PLUS project survey, a cross sectional study of adult smokers (n=5592) from Germany, Greece, Hungary, Poland, Romania, and Spain, was analysed. Descriptive statistics were used to estimate support for a ban on slim cigarettes by sociodemographic characteristics and smoking behaviors. Logistic regression analysis was used to examine factors associated with support for a ban on slim cigarettes and perceptions of harm. Results: Support for a ban on slims varied across countries, with highest support in Romania (33.8%), and lowest in Greece (18.0%). Female smokers (OR=0.78; 95%CI=0.67-0.91, daily smokers (OR=0.68; 95%CI=0.47-0.97), menthol smokers (OR=0.55; 95%CI=0.36-0.86), and smokers who did not have plans to quit within next six months (OR=0.45; 95%CI=0.36-0.56) had significantly lower odds of supporting a ban on slim cigarettes. Overall, 21% of smokers perceived slim cigarettes as less harmful than regular cigarettes. Conclusions: Support for a ban of slim cigarettes was relatively low among smokers, while misperceptions that slim cigarettes are less harmful is high, particularly among countries where slim cigarette use is more prevalent. Findings support a ban on slim cigarettes to reduce misperceptions around slim cigarettes being less harmful.

Evidence-Based Conceptual Collection of Methods for Spatial Epidemiology and Analysis to Enhance Cancer Surveillance and Public Health

(1) Background: Although spatial statistics are often used by cancer epidemiologists, there is not yet an established collection of methods to serve their needs. We aimed to develop an evidence-based cancer-oriented conceptual collection of methods for spatial analysis; (2) Methods: A triangulation of approaches was used; literature review, consensus meetings (expert panel), and testing the selected methods on "training" databases. The literature review was conducted in three databases. This approach guided the development of a collection of methods that was subsequently commented on by the expert panel and tested on "training data" of cancer cases obtained from the Cancer Registry of Crete based on three epidemiological scenarios: (a) low prevalence cancers, (b) high prevalence cancers, (c) cancer and risk factors; (3) Results: The final spatial epidemiology conceptual collection of methods covered: data preparation/testing randomness, data protection, mapping/visualizing, geographic correlation studies, clustering/surveillance, integration of cancer data with socio-economic, clinical and environmental factors. Some of the tests/techniques included in the conceptual collection of methods were: buffer and proximity analysis, exploratory spatial analysis and others. All suggested that statistical models were found to fit well (R2 = 0.72-0.96) in "training data"; Conclusions: The proposed conceptual collection of methods provides public health professionals with a useful methodological framework along with recommendations for assessing diverse research questions of global health.

Spatio-Temporal Variation of Lung Cancer in Crete, 1992-2013. Economic or Health Crisis?

(1) Background: This is the first population-based study in Greece, with the aim to measure the changing trends of lung cancer (LC) and the associated risk factors before and after the economic crisis. Among the main objectives were the identification of LC hot spots and high-risk areas; (2) Methods: The study was conducted in Crete, the biggest island in Greece. Data (5057 LC cases) were collected from the Cancer Registry of Crete (CRC). The age-standardized incidence and mortality rates (ASIR, ASMR/100,000/year) were estimated, while additional indexes were used, including the adjusted Charlson's comorbidity index (CCI%), the deprivation index (HPI-2), and the exposure to outdoor air pollution (OAP). The analysis was performed for two time periods (Period A: 1992-2008; Period B: 2009-2013); (3) Results: ASIR presented a significant increase during the economic crisis, while an even higher increase was observed in ASMR (Period A: ASMR = 30.5/100,000/year; Period B: ASMR = 43.8/100,000/year; p < 0.001). After 2009, a significant increase in the observed LC hot spots was identified in several sub-regions in Crete (p = 0.04). The risk of LC mortality increased even more for smokers (RR = 5.7; 95%CI = 5.2-6.3) and those living in highly deprived geographical regions (RR = 5.4; 95%CI = 5.1-5.8) during the austerity period. The multiple effect of LC predictors resulted in adjusted RRs ranging from 0.7 to 5.7 within the island (p < 0.05); (4) Conclusions: The increased LC burden after the onset of the economic crisis, along with a changing pattern of LC predictors stressed the urgent need of geographically oriented interventions and cancer control programs focusing on the most deprived or vulnerable population groups.

Screening for Depression in Cardiovascular Patients in Albania: Findings from the Country Check-Up Program

This is a retrospective study conducted in Vlora from January 2016 to April 2017 and the aim was to report the prevalence of depression in cardiovascular (CVD) patients. Depression assessment was done using the Patient Health Questionnaire (PHQ)-9 (PHQ-9). Data were derived from the patient records and the standard recommended cut-off point of PHQ-9 ≥ 10 was used. In total, data of 300 patients were analyzed. Depressive symptoms (PHQ-9 ≥ 10) were observed at 6% of the participants. Trouble falling asleep or staying asleep or sleeping too much, feeling tired or having little energy and having little interest or pleasure in doing things were the most common symptoms reported. In multivariate analysis, only family status showed statistical significance. Unmarried (mean rank = 207.22) are more likely to have moderate or severe depression level (OR 3.529; C.I. 95% 1.017-12.238). Future research should focus on the needed actions after depression screening (i.e. referral, treatment etc.).

Participatory Action Research for Tackling Distress and Burnout in Young Medical Researchers: Normative Beliefs before and during the Greek Financial Crisis

(1) Background: We aimed to explore Young medical researchers (YMR) normative beliefs and perceived causes of distress and burnout, prior and during the financial crisis in Greece, and to assess their views on Participatory Action Research (PAR) interventions towards tackling these disorders. (2) Methods: A Participatory Learning and Action (PLA) methodology was performed in two time periods (prior crisis: December 2008; during crisis: February-March 2017). In both time periods, three different groups (Group 1: females, Group 2: males, Group 3: mixed) of 5-7 participants and two sessions (≈1 h/session) per group took place in each site. Overall, 204 sessions with 1036 YMR were include in the study. (3) Results: Several socio-demographic characteristics of YMR altered during the crisis (lower income, higher smoking/alcohol consumption, etc.). The majority of YMR conceived distress and burnout as serious syndromes requiring professional support. Feeling very susceptible and the necessity for establishing PAR interventions were frequently reported during the crisis. Numerous (a) barriers and (b) cues to action were mentioned: (a) lack of time, money and support from friends/family/colleagues (b) being extensively informed about the intervention, participation of their collaborators, and raising awareness events. (4) Conclusions: The changing pattern of Greek YMR's beliefs and needs during the crisis stresses the necessity of interventions to tackle distress and burnout. Effectiveness of these interventions could be enhanced by the suggested cues to action that emerged from this study.

Methodological considerations in injury burden of disease studies across Europe: a systematic literature review

Background

Calculating the disease burden due to injury is complex, as it requires many methodological choices. Until now, an overview of the methodological design choices that have been made in burden of disease (BoD) studies in injury populations is not available. The aim of this systematic literature review was to identify existing injury BoD studies undertaken across Europe and to comprehensively review the methodological design choices and assumption parameters that have been made to calculate years of life lost (YLL) and years lived with disability (YLD) in these studies.

Methods

We searched EMBASE, MEDLINE, Cochrane Central, Google Scholar, and Web of Science, and the grey literature supplemented by handsearching, for BoD studies. We included injury BoD studies that quantified the BoD expressed in YLL, YLD, and disability-adjusted life years (DALY) in countries within the European Region between early-1990 and mid-2021.

Results

We retrieved 2,914 results of which 48 performed an injury-specific BoD assessment. Single-country independent and Global Burden of Disease (GBD)-linked injury BoD studies were performed in 11 European countries. Approximately 79% of injury BoD studies reported the BoD by external cause-of-injury. Most independent studies used the incidence-based approach to calculate YLDs. About half of the injury disease burden studies applied disability weights (DWs) developed by the GBD study. Almost all independent injury studies have determined YLL using national life tables.

Conclusions

Considerable methodological variation across independent injury BoD assessments was observed; differences were mainly apparent in the design choices and assumption parameters towards injury YLD calculations, implementation of DWs, and the choice of life table for YLL calculations. Development and use of guidelines for performing and reporting of injury BoD studies is crucial to enhance transparency and comparability of injury BoD estimates across Europe and beyond.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13925-z.

Decreased Hospital Visits and Increased Mortality Rate in Emergency Department during the COVID-19 Pandemic: Evidence from Albania

Objective:

To investigate the hospital visits and mortality rate during the COVID-19 in emergency department of Vlora regional hospital in Albania and to compare with the three previous years (2017–2019).

Methods:

Secondary data of patients that visited emergency department of Vlora Regional hospital Albania (largest hospital in the south of the country), since January 1, 2017 till December 31, 2020. This is a retrospective study. We used the hard copy of the patients’ health register records. The data extraction was conducted during March 2021 till June 2021. Eligible were all patients admitted and recorded in the registry of the emergency department. The causes of admission were categorized in 14 different disease categories. All registered patients admitted to the Vlora regional hospital were included in the study.

Results:

Study population included 44,917 patients during 2017–2020. Mean age of patients was 51.5 years, while 53.6% were females. The highest number of patients was in 2017 (n=12,407) and the lowest in 2020 (n=9,266). Increase of patients presented with cardiovascular, psychiatric and renal/urinary tract was observed in 2020 in comparison to 2019. Patients decreased over time with an average annual percent decrease of 7% (p-value=0.22). Joinpoint analysis revealed that mortality rate increased over time with an average annual percent increase of 34.3% (95% confidence interval=42.7% to 214.8%, p-value=0.27).

Conclusions:

The number of patients visiting emergency department decreased while mortality rate increased. Educating and raising awareness of patient to seek medical assistance should be a key objective of health policy makers and health personnel.

The burden of injury in Central, Eastern, and Western European sub-region: a systematic analysis from the Global Burden of Disease 2019 Study

BACKGROUND

Injury remains a major concern to public health in the European region. Previous iterations of the Global Burden of Disease (GBD) study showed wide variation in injury death and disability adjusted life year (DALY) rates across Europe, indicating injury inequality gaps between sub-regions and countries. The objectives of this study were to: 1) compare GBD 2019 estimates on injury mortality and DALYs across European sub-regions and countries by cause-of-injury category and sex; 2) examine changes in injury DALY rates over a 20 year-period by cause-of-injury category, sub-region and country; and 3) assess inequalities in injury mortality and DALY rates across the countries.

METHODS

We performed a secondary database descriptive study using the GBD 2019 results on injuries in 44 European countries from 2000 to 2019. Inequality in DALY rates between these countries was assessed by calculating the DALY rate ratio between the highest-ranking country and lowest-ranking country in each year.

RESULTS

In 2019, in Eastern Europe 80 [95% uncertainty interval (UI): 71 to 89] people per 100,000 died from injuries; twice as high compared to Central Europe (38 injury deaths per 100,000; 95% UI 34 to 42) and three times as high compared to Western Europe (27 injury deaths per 100,000; 95%UI 25 to 28). The injury DALY rates showed less pronounced differences between Eastern (5129 DALYs per 100,000; 95% UI: 4547 to 5864), Central (2940 DALYs per 100,000; 95% UI: 2452 to 3546) and Western Europe (1782 DALYs per 100,000; 95% UI: 1523 to 2115). Injury DALY rate was lowest in Italy (1489 DALYs per 100,000) and highest in Ukraine (5553 DALYs per 100,000). The difference in injury DALY rates by country was larger for males compared to females. The DALY rate ratio was highest in 2005, with DALY rate in the lowest-ranking country (Russian Federation) 6.0 times higher compared to the highest-ranking country (Malta). After 2005, the DALY rate ratio between the lowest- and the highest-ranking country gradually decreased to 3.7 in 2019.

CONCLUSIONS

Injury mortality and DALY rates were highest in Eastern Europe and lowest in Western Europe, although differences in injury DALY rates declined rapidly, particularly in the past decade. The injury DALY rate ratio of highest- and lowest-ranking country declined from 2005 onwards, indicating declining inequalities in injuries between European countries.

The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990-2019: Findings from the Global Burden of Disease Study 2019

Background

Mental health is a public health issue for European young people, with great heterogeneity in resource allocation. Representative population-based studies are needed. The Global Burden of Disease (GBD) Study 2019 provides internationally comparable information on trends in the health status of populations and changes in the leading causes of disease burden over time.

Methods

Prevalence, incidence, Years Lived with Disability (YLDs) and Years of Life Lost (YLLs) from mental disorders (MDs), substance use disorders (SUDs) and self-harm were estimated for young people aged 10-24 years in 31 European countries. Rates per 100,000 population, percentage changes in 1990-2019, 95% Uncertainty Intervals (UIs), and correlations with Sociodemographic Index (SDI), were estimated.

Findings

In 2019, rates per 100,000 population were 16,983 (95% UI 12,823 - 21,630) for MDs, 3,891 (3,020 - 4,905) for SUDs, and 89·1 (63·8 - 123·1) for self-harm. In terms of disability, anxiety contributed to 647·3 (432-912·3) YLDs, while in terms of premature death, self-harm contributed to 319·6 (248·9-412·8) YLLs, per 100,000 population. Over the 30 years studied, YLDs increased in eating disorders (14·9%;9·4-20·1) and drug use disorders (16·9%;8·9-26·3), and decreased in idiopathic developmental intellectual disability (-29·1%;23·8-38·5). YLLs decreased in self-harm (-27·9%;38·3-18·7). Variations were found by sex, age-group and country. The burden of SUDs and self-harm was higher in countries with lower SDI, MDs were associated with SUDs.

Interpretation

Mental health conditions represent an important burden among young people living in Europe. National policies should strengthen mental health, with a specific focus on young people.

Funding

The Bill and Melinda Gates Foundation.

Predictors of nurses' intention to accept COVID-19 vaccination: A cross-sectional study in five European countries

AIMS AND OBJECTIVES

To investigate nurses' intention in accepting COVID-19 vaccination and the factors affecting their decision.

BACKGROUND

COVID-19 vaccination has started in most European countries with healthcare personnel being the first group receiving the vaccine shots. Their attitude towards vaccination is of paramount significant as their role in the frontline could help in the awareness of general population.

METHODS

A study was conducted in Albania, Cyprus, Greece, Spain and Kosovo with the use of an online questionnaire. The Fear of COVID-19 Scale was used. The STROBE checklist was followed for this cross-sectional study.

RESULTS

Study population consisted of 1135 nurses. Mean age of the participants was 38.3 years, while most of them were female gender (84.7%) and married (53.1%). Acceptance of a safe and effective COVID-19 vaccine was higher among Greek (79.2%) and Spanish (71.6%) nurses, followed by Cypriot (54%), Albanian (46.3%) and Kosovo (46.2%) nurses. Key factors for willingness to get vaccinated were male gender, living in a country with a high mortality rate in comparison with low mortality, being not infected with COVID-19, having high level of knowledge about COVID-19 vaccines and having been vaccinated for influenza in the last 2 years. Moreover, trusting the government and doctors regarding the information about the COVID-19 and having high level of fear about this virus were key factors for willingness to get vaccinated.

CONCLUSION

Vaccination of healthcare personnel is a crucial issue not only for their own safety but also for their patients'. Healthcare acceptance to get vaccinated can work as a role model for general population.

RELEVANCE TO CLINICAL PRACTICE

Gender, country, mortality rate, trust in government and health professionals and the level of fear were key factors that should be managed in clinical practice.

Assessment of COVID-19 Fear in Five European Countries before Mass Vaccination and Key Predictors among Nurses and Nursing Students

Background: Levels of fear have increased since the COVID-19 pandemic outbreak. The absence of a safe and effective vaccine for mass-vaccination deteriorates this situation, which has a significant impact on mental health. This study aimed to assess the feelings of fear among nurses and nursing students in five European countries. Methods: A multicenter cross-sectional study was conducted in five European countries (Greece, Albania, Cyprus, Spain, and Kosovo) before the start of mass vaccination in Europe. Data collection was conducted in December 2020–January 2021 using an online questionnaire for nursing students and professional nurses. Fear of COVID-19 Scale (FCV-19S) was used for measuring levels of fear. IBM SPSS version 21.0 was used for statistical analysis. Results: The study population included 1135 nurses and 1920 nursing students from Kosovo (n = 1085), Spain (n = 663), Greece (n = 534), Albania (n = 529), and Cyprus (n = 244). According to multivariable analysis, females (OR = 2.53, 95% CI = 1.89–3.15), married (OR = 0.86, 95% CI = 0.24–1.48), nurses (OR = 0.87, 95% CI = 0.28–1.45) and those with a chronic disease (OR = 0.86, 95% CI = 0.11–1.62) were more fearful of COVID-19. Conclusions: It is important to decrease fear in the population of nurses who are at the frontlines of the pandemic. The provision of appropriate education and training activities for nurses and students to manage their stress levels is of high importance. Future studies should focus on levels of fear after the administration of several safe and effective vaccines worldwide.

Primary healthcare personnel challenges and barriers on the management of patients with multimorbidity in Albania

The number of people living with chronic conditions is increasing worldwide with most of these people receiving the needed healthcare services in primary healthcare (PHC) settings. The objective of this study was to explore the main challenges and barriers that PHC providers confront while treating multimorbid patients. This is a qualitative study utilising semi-structured individual in-depth interviews. The study took place in Vlora City, which is the biggest city located in south Albania. Τhe two biggest PHC centres of the city were enrolled. Purposive sampling method was used to recruit PHC practitioners. Main criteria of participation in the study were being fully employed at the enrolled primary care centres, having worked for at least 1 year and to deal with multimorbid patients in daily practice. Data collection took place from September 2019 to January 2020. In total, 36 semi-structured interviews took place with 23 (63.9%) nurses and 12 (33.3%) physicians (general practitioners/family doctors). Communication problems and disputes, lack of materials/equipment and the inappropriate infrastructure, miscommunication and problems in doctor-nurse relationships, coordination problems, lack of protocols and problems in the referral system were reported as the main challenges and barriers that the PHC personnel confront. The findings of this study are critical in understanding challenges that PHC personnel face when dealing with multimorbid patients in PHC settings. The emerged knowledge contributes significantly in a better understanding of the actual situation and to inform health policy makers on how to deal with the existing problems.

The Association between GDP and non-communicable disease mortality in the WHO European Region

Background

The WHO Europe Region consists of 53 countries, each of which has differences in mortality from cardiovascular (CVD), neurological, and chronic respiratory diseases. Such diverse metrics result from political, social, and economic events that have influenced the health performance of each European sub-region. From a public health perspective, an updated analysis of such metrics is required for policymakers and health system organisations to improve the overall population health outcomes.

Methods

This study utilised data between 1990-2017 from the Global Burden of Disease study 2017 to explore the association between GDP and NCD mortality in Western, Central, and Eastern Europe and Central Asia. The mortality data was already stratified by age and sex, and a fixed effected regression analysis was run to observe associations between both variables using STATA. Data completeness was 80-100% for GDP and 100% for mortality across the European region. The final results were reported as a rate per 100,000, with confidence intervals. The rate changes were calculated using an equation from the GBD.

Results

The most significant decrease per 100,000 of the population across all three NCDs as GDP increased was in Central Asia and Eastern Europe among both sexes. For every 1000 unit increase in GDP, we expect -12.13 [-13.60, -10.66] and -14.49 [-16.89, -12.29] less deaths in CVD in females and males per 100,000 of population, respectively. Western Europe had the lowest decrease per 100,000 of the population, as with every 1000 unit increase in GDP, we expect -2.42 [-2.59, -2.25] and -4.09 [-4.33, -3.84] fewer deaths in CVD in females and males, respectively.

Conclusions

The overall differential rate of mortality from the three NCDs is decreasing across all regions. However, there is a large disparity between the sexes. Males have a higher mortality rate across CVD and chronic respiratory diseases, whilst neurological disorders were highest among females.

Key messages

This study’s analysis has added to existing knowledge on chronic health patterns in the WHO European region. Governments in Eastern Europe and Central Asia should introduce health policies targeting unhealthy consumption of alcohol, smoking and diets, as seen in Western Europe.

Global Patterns and Prevalence of Dual and Poly-Tobacco Use: A Systematic Review

INTRODUCTION

Improving understanding of the epidemiology of dual and poly-tobacco product use is essential for tobacco control policy and practice. The present study aimed to systematically review existing epidemiologic evidence on current dual and poly-tobacco use among adults globally.

METHODS

We systematically searched online databases for studies published up to June 30, 2020. We included quantitative studies with measures of nationally representative prevalence of current dual or poly-tobacco use among adults. Prevalence estimates for each country were extracted manually and stratified by WHO regions and World Bank income classifications.

RESULTS

Twenty studies with nationally representative prevalence data on current dual or poly-tobacco use in the adult population across 48 countries were included. Definitions of dual and poly-tobacco use varied widely. Prevalence of dual and poly-tobacco use was higher in low- and lower-middle-income countries compared to other higher-income countries. Current dual use of smoked and smokeless tobacco products among males ranged from 0.2% in Ukraine (2010) and Mexico (2009) to 17.9% in Nepal (2011). Poly-tobacco use among males ranged from 0.8% in Mexico (2009) and 0.9% in Argentina (2010) to 11.4% in the United Kingdom and 11.9% in Denmark in 2012. Dual tobacco use was generally higher in South-East Asia; poly-tobacco use was prevalent in Europe as well as in South-East Asia.

CONCLUSIONS

This is the first systematic review of the prevalence estimates of dual and poly-tobacco use among adults globally. The results of the current study could significantly help health policy makers to implement effective tobacco control policies.

IMPLICATIONS

This study demonstrates that dual/poly-tobacco use is common in many countries of the world, and highlights the need for in-depth exploration of this field in future studies, especially in high prevalence regions such as South-East Asian and European countries. In light of this, the global tobacco control community and health authorities should also agree upon a consistent operational definition of dual and poly-tobacco use to propel research and improve surveillance of dual/poly-use in health surveys for better communication and understanding of these phenomena.

Factors influencing nursing students' intention to accept COVID-19 vaccination: A pooled analysis of seven European countries

BACKGROUND

Experiencing the third wave of COVID-19 pandemic, high vaccination coverage by a safe and effective vaccine globally would be a great achievement. Acceptance of vaccination by nursing students is an important issue as they play a decisive role as future professionals in educating patients, counselling, and guiding them to the right clinical decision.

OBJECTIVES

To explore the intention of nursing students to get vaccinated for SARS-CoV-2 infection and the factors acting either as motivators or as barriers towards vaccination.

DESIGN

A multicenter cross-sectional design.

PARTICIPANTS

In total 2249 undergraduate nursing students participated.

METHODS

The study was conducted in 7 universities in participating countries (Greece, Albania, Cyprus, Spain, Italy, Czech Republic, and Kosovo) through a web survey. Data was collected during December 2020-January 2021 in all countries.

RESULTS

Forty three point 8% of students agreed to accept a safe and effective COVID-19 vaccine, while the acceptance was higher among Italian students. The factors for intention to get vaccinated were male gender (p = 0.008), no working experience in healthcare facilities during the pandemic (p = 0.001), vaccination for influenza in 2019 and 2020 (p < 0.001), trust in doctors (p < 0.001), governments and experts (p = 0.012), high level of knowledge (p < 0.001) and fear of COVID-19 (p < 0.001).

CONCLUSIONS

Understanding of factors that influence students' decision to accept COVID-19 vaccination could increase the acceptance rate contributing to a management of the pandemic.

Is the mental health of young students and their family members affected during the quarantine period? Evidence from the COVID-19 pandemic in Albania

WHAT IS KNOWN ON THE SUBJECT?: Mental health is deteriorated during the quarantine period. Mental health status is affected by the quarantine even after the end of it and for an extended period. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Depression levels among nursing/midwifery students during the quarantine period are high. Depression levels among students' family members during the quarantine period are high. Those who are not satisfied with COVID-19 prevention measures and those who believe that COVID-19 and quarantine can cause problems on health, have elevated levels of depression. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Provision of mental health services during the quarantine period should be a priority for the healthcare system. Offering mental health first aid training and support can improve the mental health status of students and their family members. ABSTRACT: Introduction The use of quarantine method has a significant impact on mental health status. Aim This study aimed to assess the levels of depression among bachelor and master university students (nurses/midwives) and their family members' during the quarantine period of COVID-19 pandemic. Method A cross-sectional study was conducted in Vlora University, Albania. Patient Health Questionnaire (PHQ-9) was used. Institutional e-mails of all active students were used for their recruitment. Results In total, 863 students and 249 family members participated in the study. The mean PHQ-9 score was 6.220 (SD = 5.803) and 6.280 (SD = 5.857) for students and family members, respectively. Being unsatisfied with COVID-19 prevention measures, beliefs that COVID-19 infection and quarantine process can cause problems on their health status were the key factors for students to be screened positive for mental problems in multiple regression analysis. For parents, the last two factors were found to contribute significantly. Discussion Our findings indicate that quarantine measures have a significant impact on the levels of depression among both university students and their family members. Broader population studies are necessary to safeguard these results. Implications for Practice Provision of mental health services during the quarantine period is of paramount significance. Mental health first aid training and support could benefit both students and their parents significantly. Additionally, follow-up services after the end of quarantine are recommended.

Nursing students, mental health status during COVID-19 quarantine: evidence from three European countries

BACKGROUND

The SARS-CoV2 pandemic obligated most of the European countries to implement strict measures and lockdowns to minimize the spread of the virus. Universities closed and on-line classes started. However, COVID-19 epidemic has significant impact on mental health of population.

AIM

To assess depression level of nursing students (undergraduate and master) in Greece, Spain and Albania during COVID-19 pandemic as well as to identify possible determinants of depression level.

METHODS

A multicenter cross-sectional study was conducted between April and May 2020. An on-line questionnaire was used to collect the data. The Patient Health Questionnaire-9 was used to evaluate the depression levels of nursing students.

RESULTS

Seven hundred and eighty-seven nursing students participated in the study out of which 83.9% were of female gender, 92.9% single and 94.7% lived with others. One third of the nursing student population experienced mild depression, with higher depression levels noted for Spanish students (59.1%) followed by Albanian (34.5%) and Greek (21.8%) students. Multivariate linear regression analysis identified that Spanish students experienced more depression than Greek and Albanian (p < 0.001). Also, decreased age was associated with increased depression.

CONCLUSION

The impact of lockdown and quarantine on nursing students mental health is clear. Provision of university based mental health interventions should be a priority.

Educational Interventions for Teaching Evidence-Based Practice to Undergraduate Nursing Students: A Scoping Review

Background: Evidence-based practice (EBP) is the appropriate approach to guide healthcare personnel in their clinical practice. Despite the importance of EBP, undergraduate nursing students are not very much engaged and have a lack of knowledge and skills. Aim: The aim of this study was to gather, assess and synthesize evidence on educational interventions promoting evidence-based practice competencies in traditional undergraduate nursing students. Methods: This is a scoping review on sixteen English and non-English databases. A data extraction form was established including authors, year of publication, country, types of participant, specific objectives, study design, educational intervention, comparison if existed, and outcomes of significance. Results: The search strategy retrieved 8901 records in total. After screening for duplicates and eligibility, 20 articles were included in the qualitative synthesis. Improvement in EBP domains such as knowledge, skills, attitudes/behaviours, EBP beliefs, use, practice, level of evidence, critical thinking and future use of EBP were mentioned and assessed in different studies. Conclusions: EBP training can improve nursing students’ capacity in healthcare provision. Teaching EBP competencies along undergraduate nursing curricula should be a high priority at nursing programmes. The use of innovative approaches seems to be more effective than traditional ways. Education of EBP increases its future use and critical thinking and EBP programs improve self-efficacy and the level of evidence utilization.

Perceptions, Predictors of and Motivation for Quitting among Smokers from Six European Countries from 2016 to 2018: Findings from EUREST-PLUS ITC Europe Surveys

The European Tobacco Products Directive (TPD) was introduced in 2016 in an effort to decrease prevalence of smoking and increase cessation in the European Union (EU). This study aimed to explore quitting behaviours, motivation, reasons and perceptions about quitting, as well as predictors (reported before the TPD implementation) associated with post-TPD quit status. A cohort study was conducted involving adult smokers from six EU countries (n = 3195). Data collection occurred pre-(Wave 1; 2016) and post-(Wave 2; 2018) TPD implementation. Bivariate and logistic regression analyses of weighted data were conducted. Within this cohort sample, 415 (13.0%) respondents reported quitting at Wave 2. Predictors of quitting were moderate or high education, fewer cigarettes smoked per day at baseline, a past quit attempt, lower level of perceived addiction, plans for quitting and the presence of a smoking-related comorbidity. Health concerns, price of cigarettes and being a good example for children were among the most important reasons that predicted being a quitter at Wave 2. Our findings show that the factors influencing decisions about quitting may be shared among European countries. European policy and the revised version of TPD could emphasise these factors through health warnings and/or campaigns and other policies.

Current practices and perceived barriers to tobacco-treatment delivery among healthcare professionals from 15 European countries. The EPACTT Plus project

INTRODUCTION

The latest evidence-based Guidelines for Treating Tobacco Dependence highlight the significant role of healthcare professionals in supporting smokers interested to quit. This study aimed to identify the current practices of healthcare professionals in Europe and perceived barriers in delivering tobacco treatment to their patients who smoke.

METHODS

In the context of EPACTT-Plus, collaborating institutions from 15 countries (Albania, Armenia, Belgium, Italy, France, Georgia, Greece, Kosovo, Romania, North Macedonia, Russia, Serbia, Slovenia, Spain, Ukraine) worked for the development of an accredited eLearning course on Tobacco Treatment Delivery available at http://elearning-ensp.eu/. In total, 444 healthcare professionals from the wider European region successfully completed the course from December 2018 to July 2019. Cross-sectional data were collected online on healthcare professionals’ current practices and perceived barriers in introducing tobacco-dependence treatment into their daily clinical life.

RESULTS

At registration, 41.2% of the participants reported having asked their patients if they smoked. Advise to quit smoking was offered by 47.1% of the participants, while 29.5% reported offering assistance to their patients who smoked in order to quit. From the total number of participants, 39.9% regarded the lack of patient compliance as a significant barrier. Other key barriers were lack of: interest from the patients (37.4%), healthcare professionals training (33.1%), community resources to refer patients (31.5%), and adequate time during their everyday clinical life (29.7%).

CONCLUSIONS

The identification of current practices and significant barriers is important to build evidence-based guidelines and training programs (online and/or live) that will improve the performance of healthcare professionals in offering tobacco-dependence treatment for their patients who smoke.

Impact of the ENSP eLearning platform on improving knowledge, attitudes and self-efficacy for treating tobacco dependence: An assessment across 15 European countries

INTRODUCTION

In 2018, the European Network for Smoking Cessation and Prevention (ENSP) released an update to its Tobacco Treatment Guidelines for healthcare professionals, which was the scientific base for the development of an accredited eLearning curriculum to train healthcare professionals, available in 14 languages. The aim of this study was to evaluate the effectiveness of ENSP eLearning curriculum in increasing healthcare professionals' knowledge, attitudes, self-efficacy (perceived behavioral control) and intentions in delivering tobacco treatment interventions in their daily clinical routines.

METHODS

We conducted a quasi-experimental pre-post design study with 444 healthcare professionals, invited by 20 collaborating institutions from 15 countries (Albania, Armenia, Belgium, Italy, France, Georgia, Greece, Kosovo, Romania, North Macedonia, Russia, Serbia, Slovenia, Spain, Ukraine), which completed the eLearning course between December 2018 and July 2019.

RESULTS

Healthcare professionals' self-reported knowledge improved after the completion of each module of the eLearning program. Increases in healthcare professionals' self-efficacy in delivering tobacco treatment interventions (p<0.001) were also documented. Significant improvements were documented in intentions to address tobacco use as a priority, document tobacco use, offer support, provide brief counselling, give written material, discuss available medication, prescribe medication, schedule dedicated appointment to develop a quit plan, and be persistent in addressing tobacco use with the patients (all p<0.001).

CONCLUSIONS

An evidence-based digital intervention can be effective in improving knowledge, attitudes, self-efficacy and intentions on future delivery of tobacco-treatment interventions.

Cost, prevalence and correlates of cigarillo use in 28 European countries in 2017

OBJECTIVES

Although manufactured cigarettes remain the most popular tobacco product worldwide, the use of other products, including little cigar and cigarillo, has been rising in recent years; however, there is a paucity of data on the correlates of current and ever use of cigarillos in Europe. The aim of this study was to explore the extent and determinants of cigarillo use, as well as to describe the cost and affordability of cigarillos across the EU, in light of the current regulatory framework at a European level.

METHODS

We performed a secondary analysis of data collected across 28 European Union (EU) Member States through wave 87.1 of the Eurobarometer survey, conducted in March 2017 (N = 27,901). A multilevel logistic regression model was fitted to assess the association of current and ever cigarillo use with the above socio-demographic factors. We also analysed Euromonitor International data on cigarillo prices in 2017 from 24 EU Member States.

RESULTS

Across the EU, 0.46% (95% CI: 0.33-0.63) of those aged ≥ 15 years reported at least weekly current use of cigarillos in 2017, which corresponds to 1,966,516 (95% CI: 1,426,554-2,709,563) people. Finland recorded the highest prevalence (20.51%) of ever cigarillo use in Europe while Ireland had the lowest (1.15%). Male sex, living in urban area and being over 55 years old compared to 15-24 year olds were associated with greater odds of ever cigarillo use. Median cigarillo prices varied widely, ranging from 3.60 Euros in Portugal to 20.40 Euros in Bulgaria per 20 sticks.

CONCLUSIONS

The use of cigarillos in Europe is associated with several socio-demographic factors such as gender, age and living area. Policy makers of EU countries, especially now under the regulatory framework of the EU Tobacco Products Directive, should work together to enforce more restrictive rules for cigarillos.

WHO FCTC Article 14 enforcement in Albania: An urgent issue to tackle

Tobacco use is a major preventable risk factor for non-communicable diseases such as cardiovascular disease, cancer etc. Smoking prevalence in Albania is high. The country ratified the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) in 2006 and has passed different bills and adopted strict tobacco control laws during the years. Despite this, there is a huge gap in primary healthcare (PHC) personnel education in this field. Additionally, tobacco treatment support facilities, such as free of charge telephone quit lines, tobacco treatment clinics in hospitals or in the community, are lacking or not well established. Training of healthcare professionals in evidence-based practices as well as the development of national guidelines on tobacco treatment, capacity building for tobacco treatment delivery, pharmacotherapy availability, public opinion awareness and promotion of smoking cessation practices are some of the measures Albanian policy makers should undertake.