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.

Associations of self-forgiveness processes with distress and well-being outcomes: Evidence from a longitudinal study of Indonesian adults

To date, few empirical studies have examined the benefits of the processes involved in self-forgiveness-value reorientation and esteem restoration-for individual well-being using longitudinal data from non-Western samples. In this study, we take a step toward addressing this gap by analysing three waves of data collected among 595 Indonesians (Mage  = 21.95, SD = 4.39). Applying the analytic templates for lagged exposure-wide and outcome-wide longitudinal designs, we performed a series of linear regressions to estimate associations of value reorientation and esteem restoration in Wave 2 with three indicators of distress and 10 indicators of well-being in Wave 3, adjusting for Wave 1 covariates. Value reorientation and esteem restoration were each associated with improvements in several well-being outcomes (six for value reorientation and three for esteem restoration), but both showed little evidence of associations with the distress outcomes. In a secondary analysis, those who scored higher on both value reorientation and esteem restoration (i.e., self-forgiveness group) in Wave 2 reported higher well-being on five outcomes in Wave 3 compared to those who scored lower on value reorientation, esteem restoration, or both (i.e., no or partial self-forgiveness group). We discuss some implications of the findings for conceptualising self-forgiveness and promoting well-being.

Positive affect during adolescence and health and well-being in adulthood: An outcome-wide longitudinal approach

BACKGROUND

Several intergovernmental organizations, including the World Health Organization and United Nations, are urging countries to use well-being indicators for policymaking. This trend, coupled with increasing recognition that positive affect is beneficial for health/well-being, opens new avenues for intervening on positive affect to improve outcomes. However, it remains unclear if positive affect in adolescence shapes health/well-being in adulthood. We examined if increases in positive affect during adolescence were associated with better health/well-being in adulthood across 41 outcomes.

METHODS AND FINDINGS

We conducted a longitudinal cohort study using data from Add Health-a prospective and nationally representative cohort of community-dwelling U.S. adolescents. Using regression models, we evaluated if increases in positive affect over 1 year (between Wave I; 1994 to 1995 and Wave II; 1995 to 1996) were associated with better health/well-being 11.37 years later (in Wave IV; 2008; N = 11,040) or 20.64 years later (in Wave V; 2016 to 2018; N = 9,003). Participants were aged 15.28 years at study onset, and aged 28.17 or 37.20 years-during the final assessment. Participants with the highest (versus lowest) positive affect had better outcomes on 3 (of 13) physical health outcomes (e.g., higher cognition (β = 0·12, 95% CI = 0·05, 0·19, p = 0.002)), 3 (of 9) health behavior outcomes (e.g., lower physical inactivity (RR = 0·80, CI = 0·66, 0·98, p = 0.029)), 6 (of 7) mental health outcomes (e.g., lower anxiety (RR = 0·81, CI = 0·71, 0·93, p = 0.003)), 2 (of 3) psychological well-being (e.g., higher optimism (β = 0·20, 95% CI = 0·12, 0·28, p < 0.001)), 4 (of 7) social outcomes (e.g., lower loneliness (β = -0·09, 95% CI = -0·16, -0·02, p = 0.015)), and 1 (of 2) civic/prosocial outcomes (e.g., more voting (RR = 1·25, 95% CI = 1·16, 1·36, p < 0.001)). Study limitations include potential unmeasured confounding and reverse causality.

CONCLUSIONS

Enhanced positive affect during adolescence is linked with a range of improved health/well-being outcomes in adulthood. These findings suggest the promise of testing scalable positive affect interventions and policies to more definitively assess their impact on outcomes.

Hope in adolescence and subsequent health and well-being in adulthood: An outcome-wide longitudinal study

BACKGROUND

A sense of hopelessness is rising at alarming levels among adolescents in the United States. There is urgent need to understand the potential implications of being hopeful on adolescents' future health and wellbeing.

METHODS

This study utilized data from the National Longitudinal Study of Adolescent to Adult Health (N = 11,038, mean age at baseline = 15 years) to prospectively examine the relationship between baseline hope and a wide range of outcomes 12 years later. Thirty-eight outcomes were examined in the domains of physical health, health behavior, mental health, psychological well-being, social factors, and civic and prosocial behavior. Regression models were used to regress each outcome on baseline hope separately. Models controlled for a wide range of factors as well as prior values of the exposure (hope) and outcomes.

RESULTS

Having hope for the future in adolescence was associated with improvements in 11 subsequent outcomes after Bonferonni correction, including higher cognition and self-rated health, less physical inactivity, fewer depressive symptoms, lower perceived stress, and improvement on a number of psychological and social factors including greater happiness, more satisfaction with parenting, and increased voting and volunteering in adulthood. There were also a number of associations that were close to the null, which are equally important to explore and understand.

IMPLICATIONS

The results of the study may have important implications for hope-based efforts and programs aimed at improving the lives of young people and promoting their current and future well-being.

Do Forgiveness Campaign Activities Improve Forgiveness, Mental Health, and Flourishing?

Objectives: To evaluate the effectiveness of a forgiveness public health intervention at promoting forgiveness, mental health, and flourishing. Methods: Colombian students (N = 2,878) at a private, nonreligious university were exposed to a 4-week forgiveness community campaign and were assessed pre- and post-campaign. Results: Forgiveness, mental health, and flourishing outcomes showed improvements after the campaign. On average, participants reported engaging in 7.18 (SD = 3.99) of the 16 types of campaign activities. The number of types of campaign activities that participants engaged in evidenced a positive linear association with forgiveness, although some activities were more popular than others and some activities were more strongly associated with increased forgiveness. For depression, anxiety, and flourishing, engaging in more activities was generally associated with greater improvements, but the patterns were less consistent relative to forgiveness. Conclusion: This forgiveness public health intervention effectively promoted forgiveness, mental health, and flourishing. Effective campaigns in diverse communities involve promoting mental and physical health through forgiveness. However, recent conflict may hinder acceptance, necessitating political capital for leadership advocating forgiveness initiatives.

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.

Salutogenic health measures: Psychometric properties of the Danish versions of the Flourish Index and the Secure Flourish Index

Measurement of human flourishing represents a salutogenic approach to epidemiological and behavioral research emphasizing factors contributing to "good lives" rather than pathology. The objective of this study was to translate and psychometrically test the 10-item Flourish Index (FI) and 12-item Secure Flourish Index (SFI) in a convenience sample of Danish adults. A total of 325 participants completed a cross-sectional survey, with 148 of those participants completing the survey a second time (retest). Confirmatory factor analysis in a structural equation modelling framework was used to establish structural validity by comparing four different pre-specified models of the indexes. Additionally, internal consistency, convergent and incremental validity, and retest reliability were examined. The FI models exhibited superior structural validity compared with similar models of the SFI, although all models had good fits. Internal consistencies with McDonald's omega were 0.89 and 0.87 for the FI and SFI, respectively. The five (FI) or six (SFI) domains were happiness & life satisfaction, mental & physical health, meaning & purpose, character & virtue, close social relationships, and financial & material stability (λ4  = 0.51-0.91). Convergent and incremental validity tests supported predefined hypotheses. Retest analyses with the FI and SFI showed a high degree of retest reliability. Based on the psychometric evidence reported in this study, the Danish Flourish Index and Secure Flourish Index seem suitable for use with healthy adult Danes. The authors hope that this psychometric evaluation of the FI and SFI will stimulate research on patterns, health and economic outcomes, and predictors of human flourishing in Denmark.

Divine struggles and whole person functioning: a 9-year longitudinal study of middle-aged U.S. adults

OBJECTIVE

This longitudinal study examined the associations of divine struggles with 25 psychological distress, psychological well-being, social well-being, prosociality, physical health, and health behavior outcomes assessed approximately nine years later.

METHODS

We used three waves of data from the National Survey of Midlife Development in the United States (N = 4041): M1 (1995-1996), M2 (2004-2006), and M3 (2013-2014). Following the analytic template for outcome-wide longitudinal designs, our primary analysis employed a series of regression models to estimate the associations between a continuous measure of divine struggles assessed at M2 with each outcome assessed at M3. All models adjusted for a rich set of covariates, including prior values of all outcomes.

RESULTS

There was modest evidence suggesting that divine struggles were associated with worse subsequent functioning on one or more outcomes for each domain except health behaviors (effect sizes were generally very small).

CONCLUSIONS

Divine struggles have the potential to degrade long-term functioning across multiple domains of life. Practitioners should attend to and address divine struggles in their clinical work.

Coping Resources among Forced Migrants in South Africa: Exploring the Role of Character Strengths in Coping, Adjustment, and Flourishing

This phenomenological qualitative study explored how forced migrants in South Africa cope with violent, traumatic experiences and precarious resettlement conditions. Data came from a larger empirical project examining migration, psychological distress, and coping. In-depth interviews were conducted with 14 refugees and asylum seekers (Mage = 30.27, SDage = 9.27; male = 71.43%) who migrated from five African countries to Durban, South Africa. Despite overwhelming stressors, participants described pathways to transcend victimhood and hardship through engaging character strengths in ways that promote post-traumatic growth. Qualitative analysis revealed five overarching domains: spirituality and religiousness, love and kindness, hope and optimism, persistence and fortitude, and gratitude and thankfulness. Findings are framed within positive existential psychology and dual-factor understandings of mental health, which attend to both human suffering and flourishing. Limitations, future research directions, and clinical and community implications are discussed, with attention to the role of character strengths in adaptive coping and psychological well-being. The intergenerational transmission of strengths is explored as one potential means of buffering intergenerational trauma impacts and promoting family post-traumatic growth.

Bereavement, Memorial Attendance, and Mental Health During the COVID-19 Pandemic: Longitudinal Results from the Nurses' Health Study

BACKGROUND

Mortality increased during the COVID-19 pandemic. Many bereaved individuals were not able to gather to memorialize their loved ones, yet it is unknown if this contributed to worsening mental health.

OBJECTIVE

Examine the association of bereavement in the early part of the COVID-19 pandemic with subsequent psychological distress and the role of memorial attendance in reducing psychological distress among the bereaved.

DESIGN, SETTINGS, SUBJECTS

In May 2020, 39,564 older females from the Nurses' Health Study II enrolled in a longitudinal COVID-19 substudy (meanage = 65.2 years, SD = 4.5).

METHODS

Linear regression analyses estimated associations of bereavement reported between March and October, 2020 with subsequent psychological distress between January and October 2021, adjusting for sociodemographic and prepandemic depression symptoms. Secondary models examined associations between memorial attendance and psychological distress.

RESULTS

Bereavement during the early part of the COVID-19 pandemic was associated with higher psychological distress (adjusted β = 0.21, 95% CI: 0.15, 0.26) assessed over the next year. Among the bereaved, memorial attendance was associated with lower psychological distress (in-person: adjusted β = -0.41, 95% CI: -0.53, -0.29; online: adjusted β = -0.24, 95% CI: -0.46, --0.02).

CONCLUSION

Attending memorials was associated with lower subsequent psychological distress among bereaved older females.

Body appreciation around the world: Measurement invariance of the Body Appreciation Scale-2 (BAS-2) across 65 nations, 40 languages, gender identities, and age

The Body Appreciation Scale-2 (BAS-2) is a widely used measure of a core facet of the positive body image construct. However, extant research concerning measurement invariance of the BAS-2 across a large number of nations remains limited. Here, we utilised the Body Image in Nature (BINS) dataset - with data collected between 2020 and 2022 - to assess measurement invariance of the BAS-2 across 65 nations, 40 languages, gender identities, and age groups. Multi-group confirmatory factor analysis indicated that full scalar invariance was upheld across all nations, languages, gender identities, and age groups, suggesting that the unidimensional BAS-2 model has widespread applicability. There were large differences across nations and languages in latent body appreciation, while differences across gender identities and age groups were negligible-to-small. Additionally, greater body appreciation was significantly associated with higher life satisfaction, being single (versus being married or in a committed relationship), and greater rurality (versus urbanicity). Across a subset of nations where nation-level data were available, greater body appreciation was also significantly associated with greater cultural distance from the United States and greater relative income inequality. These findings suggest that the BAS-2 likely captures a near-universal conceptualisation of the body appreciation construct, which should facilitate further cross-cultural research.

Associations of Social Support with Sexual Practices, Health Behaviours, and Health Outcomes Among Adolescent Girls and Young Women: Evidence From a Longitudinal Study in KwaZulu-Natal, South Africa

BACKGROUND

Several studies have reported on the benefits of social support for health behaviour, including risky sex. Social support may thus be an important resource for promoting individual health and well-being, particularly in regions where HIV rates are high and healthcare resources are scarce. However, prior research on the implications of social support for the health behaviour of young women has yielded mixed and inconclusive findings. Using prospective data from young women in South Africa, this study examines the associations of social support with subsequent sexual practices, health behaviour, and health outcomes.

METHOD

We used two rounds of longitudinal data from a sample of n = 1446 HIV-negative emerging adult women, aged 18 to 29 years, who participated in a population-based HIV study in KwaZulu-Natal, South Africa. Applying the analytic template for outcome-wide longitudinal designs, we estimated the associations between combinations of social support (i.e. tangible, educational, emotional) and ten HIV risk-related outcomes.

RESULTS

Combinations of tangible, educational, and emotional support, as well as tangible support by itself, were associated with lower risk for several outcomes, whereas educational and emotional support, by themselves or together, showed little evidence of association with the outcomes.

CONCLUSION

This study highlights the protective role of tangible support in an environment of widespread poverty, and the additional effect of combining tangible support with non-tangible support. The findings strengthen recent evidence on the benefits of combining support in the form of cash and food with psychosocial care in mitigating risk behaviours associated with HIV and negative health outcomes among young women.

Associations of online religious participation during COVID-19 lockdown with subsequent health and well-being among UK adults

BACKGROUND

In-person religious service attendance has been linked to favorable health and well-being outcomes. However, little research has examined whether online religious participation improves these outcomes, especially when in-person attendance is suspended.

METHODS

Using longitudinal data of 8951 UK adults, this study prospectively examined the association between frequency of online religious participation during the stringent lockdown in the UK (23 March -13 May 2020) and 21 indicators of psychological well-being, social well-being, pro-social/altruistic behaviors, psychological distress, and health behaviors. All analyses adjusted for baseline socio-demographic characteristics, pre-pandemic in-person religious service attendance, and prior values of the outcome variables whenever data were available. Bonferroni correction was used to correct for multiple testing.

RESULTS

Individuals with online religious participation of ≥1/week (v. those with no participation at all) during the lockdown had a lower prevalence of thoughts of self-harm in week 20 (odds ratio 0.24; 95% CI 0.09-0.62). Online religious participation of <1/week (v. no participation) was associated with higher life satisfaction (standardized β = 0.25; 0.11-0.39) and happiness (standardized β = 0.25; 0.08-0.42). However, there was little evidence for the associations between online religious participation and all other outcomes (e.g. depressive symptoms and anxiety).

CONCLUSIONS

There was evidence that online religious participation during the lockdown was associated with some subsequent health and well-being outcomes. Future studies should examine mechanisms underlying the inconsistent results for online v. in-person religious service attendance and also use data from non-pandemic situations.

Differences in Multi-Dimensional Well-Being Among Factory Workers: Evidence from Six Countries

This paper presents cross-cultural comparisons of well-being among factory workers, as measured by the six well-being domains of happiness and life satisfaction, physical and mental health, meaning and purpose, character and virtue, close social relationships, and financial and material stability. Relative ranks of well-being domains across examined groups of workers are also compared. Results are based on survey data from factory workers in Cambodia, China, Mexico, Poland, Sri Lanka, and the United States. Average well-being scores are higher among factory workers in Mexico, China, and Cambodia than in the U.S., Poland, and Sri Lanka across all domains except financial and material stability. Close social relationships were the highest ranked domain in Cambodia and China but ranked much lower (5th) in the U.S. Meaning and purpose, as well as character and virtue were highly ranked across the board. Strong social relationships seem to thrive in contexts where financial insecurity is high.

Exposure to negative life events, change in their perceived impact, and subsequent well-being among U.S. adults: A longitudinal outcome-wide analysis

OBJECTIVE

Negative life events have the potential to undermine an individual's ability to function and thrive, but less is known about the implications of changes in subjective appraisals of those events for long-term well-being. This research examines how exposure to negative life events and subsequent changes in the perceived impact of those events are related to longer-term well-being in adulthood.

METHOD

Drawing on three waves of data from the Midlife in the United States study (M1: 1995-1996, M2: 2004-2006, M3: 2013-2014), we applied the analytic template for outcome-wide longitudinal designs to investigate associations of (a) negative life event exposure between M1 and M2 and (b) change in the perceived impact of negative life event exposure assessed at M2 with 25 outcomes across several domains of well-being assessed approximately 9 years later at M3: psychological distress, psychological well-being, social well-being, prosociality, physical health, and health behavior.

RESULTS

Whereas negative life event exposure was associated with worse subsequent well-being on selected outcomes (5/25 in total) in some domains, positive change in the perceived impact of negative life event exposure was associated with better well-being on one or more outcomes in most domains (11/25 in total). Effect sizes in both sets of analyses were generally small, with more consistent associations found for psychological and social outcomes.

CONCLUSION

Subjective appraisals of negative life events (particularly positive changes in those appraisals over time) may be more closely related to individual well-being in the long run than mere exposure to negative life events themselves. The findings bring attention to the possibility that positive changes in a person's subjective appraisal of negative life events could have beneficial consequences for long-term well-being.

Children and young women in eastern and southern Africa are key to meeting 2030 HIV targets: time to accelerate action

New HIV infections and AIDS-related deaths among children and adolescent girls and young women (aged 15-24 years) in eastern and southern Africa continue to occur at unacceptably high rates. The COVID-19 pandemic has also severely undermined ongoing initiatives for HIV prevention and treatment, threatening to set the region back further in its efforts to end AIDS by 2030. Major impediments exist to attaining the UNAIDS 2025 targets among children, adolescent girls, young women, young mothers living with HIV, and young female sex workers residing in eastern and southern Africa. Each population has specific but overlapping needs with regard to diagnosis and linkage to and retention in care. Urgent action is needed to intensify and improve programmes for HIV prevention and treatment, including sexual and reproductive health services for adolescent girls and young women, HIV-positive young mothers, and young female sex workers.

Associations of dispositional forgivingness with facets of well-being among Colombian adults: A longitudinal outcome-wide analysis

Many studies have reported evidence suggesting that dispositional forgivingness has positive implications for different domains of well-being. However, relatively few methodologically rigorous studies have been conducted in the Global South, particularly in post-conflict settings where forgiveness could play an important role in supporting individual well-being. In this three-wave cohort study of predominantly young adult Colombians (n = 1575), we examined the associations of dispositional forgivingness with 20 well-being outcomes across several domains of well-being: psychological distress, psychological well-being, physical health, social well-being, and character strengths/virtues. Using an outcome-wide analytic design that included extensive control for potential confounding and reverse causation by adjusting for a range of covariates assessed in Wave 1 (2017), we found that dispositional forgivingness assessed in Wave 2 (2018) was at least modestly associated with improvements in one or more facet of each well-being domain assessed approximately 1 year later in Wave 3 (2019). Associations tended to be stronger for outcomes in the domains of psychological distress, psychological well-being, social well-being, and character strengths/virtues compared to the physical health domain. These longitudinal findings suggest that dispositional forgivingness might promote individual well-being in societies with a long history of ongoing civil unrest, conflict, and war.

Flourishing During the COVID-19 Pandemic: A Longitudinal Study in South Africa

In this longitudinal study, we examine changes in psychological distress and multidimensional well-being from before to during the COVID-19 pandemic among South African adults. As a secondary purpose, we explore whether pre-pandemic flourishing is protective against subsequent psychological distress during the public health crisis. The analytic sample (n = 293; M_age = 44.27, SD = 14.28; female = 65.19%) completed measures of anxiety symptoms, depression symptoms, and well-being shortly before the stringent nationwide lockdown started in South Africa (T₁). A follow-up assessment was completed approximately 6 months later (T₂). Paired samples t-tests supported very small improvements in anxiety (d = -0.09) and depression symptoms (d = -0.13). For domains of well-being, small increases were found in close social relationships (d = 0.25) and financial and material stability (d = 0.19). Positive changes in the domains of character and virtue (d = 0.10) and meaning and purpose (d = 0.07) were very small. Changes in physical and mental health (d = -0.03) and life satisfaction and happiness (d = 0.02) were more negligible. Results from the generalized linear models indicated that continuous scores of secure flourishing assessed before the COVID-19 pandemic were associated with lower subsequent psychological distress (particularly depression symptoms) during the public health crisis. We discuss the implications of the findings for the development and delivery of interventions to promote and sustain human flourishing during public health crises, especially in contexts of social-structural vulnerability.

Psychological caring climate at work, mental health, well-being, and work-related outcomes: Evidence from a longitudinal study and health insurance data

Psychological climate for caring (PCC) is a psychosocial factor associated with individual work outcomes and employee well-being. Evidence on the impacts of various psychological climates at work is based mostly on self-reported health measures and cross-sectional data. We provide longitudinal evidence on the associations of PCC with subsequent diagnosed depression and anxiety, subjective well-being, and self-reported work outcomes. Employees of a US organization with a worker well-being program provided data for the analysis. Longitudinal survey data merged with data from personnel files and health insurance claims records comprising medical information on diagnosis of depression and anxiety were used to regress each outcome on PCC at baseline, adjusting for prior values of all outcomes and other covariates. PCC was found to be associated with lower odds of subsequent diagnosed depression, an increase in overall well-being, mental health, physical health, social connectedness, and financial security, as well as a decrease in distraction at work, an increase in productivity/engagement and possibly in job satisfaction. There was little evidence of associations between PCC and subsequent diagnosed anxiety, character strengths, and work-family conflict. Work policies focused on improving PCC may create a promising pathway to promoting employee health and well-being as well as improving work-related outcomes.

The road to postpandemic recovery in the USA: a repeated cross-sectional survey of multidimensional well-being over two years

OBJECTIVES

Examine differences in multidimensional well-being from before (January 2020) to three timepoints during the COVID-19 pandemic (June 2020, January 2021, January 2022).

STUDY DESIGN

Repeated cross-sectional design.

METHODS

Nationally representative cross-sectional cohorts of US adults completed the Secure Flourish Index before (January 2020 cohort: N = 1010) and during the COVID-19 pandemic (June 2020 cohort: N = 3020; January 2021 cohort: N = 3366; January 2022 cohort: N = 2598). We estimated differences in indicators, domains, and composite well-being between the January 2020 cohort and each of the subsequent cohorts. We also explored whether changes in well-being between January 2020 and January 2022 varied based on age, gender, and race/ethnicity.

RESULTS

Initial declines in well-being observed by June 2020 were largely followed by a return to prepandemic levels in January 2022, with some exceptions. Notably, general declines in mental health have persisted through to January 2022. On the other hand, there was evidence of general improvements in character & virtue that exceeded prepandemic levels in January 2022. Young adults and racial/ethnic minorities reported lower financial & material stability in January 2022 compared to before the COVID-19 pandemic.

CONCLUSIONS

Although there are promising signs that the well-being of US adults has mostly recovered to prepandemic levels, a coordinated response is urgently needed to support population mental health and the financial security of vulnerable groups. As society continues the journey toward postpandemic recovery, continued tracking of multidimensional well-being will be important for making informed decisions about public health priorities.

More spiritual than religious: Concurrent and longitudinal relations with personality traits, mystical experiences, and other individual characteristics

People who self-identify as predominantly spiritual constitute a considerable and well-established part of the religious landscape in North America and Europe. Thus, further research is needed to document predictors, correlates, and outcomes associated with self-identifying primarily as a spiritual person. In the following set of studies, we contribute to some of these areas using data from German and United States adults. Study 1 (n = 3,491) used cross-sectional data to compare four religious/spiritual (R/S) self-identity groups-more religious than spiritual (MRTS), more spiritual than religious (MSTR), equally religious and spiritual (ERAS), and neither religious nor spiritual (NRNS)-on sociodemographic characteristics and a range of criterion variables (i.e., Big Five personality traits, psychological well-being, generativity, mystical experiences, religious schemata). In Study 2 (n = 751), we applied the analytic template for outcome-wide longitudinal designs to examine associations of the four R/S self-identifications with a range of subsequent outcomes (assessed approximately 3 years later) that were largely comparable to the criterion variables assessed in Study 1. The cross-sectional and longitudinal findings from these complementary studies provide further evidence of differences between these four categories of R/S self-identification, including strong evidence in both studies of an association between the MSTR self-identity and mysticism.

Working from home and subsequent work outcomes: Pre-pandemic evidence

Frequent working from home (WFH) may stay as a new work norm after the COVID-19 pandemic. Prior observational studies on WFH and work outcomes under non-pandemic circumstances are mostly cross-sectional and often studied employees who worked from home in limited capacity. To provide additional insights that might inform post-pandemic work policies, using longitudinal data collected before the COVID-19 pandemic (June 2018 to July 2019), this study aims to examine the associations between WFH and multiple subsequent work-related outcomes, as well as potential modifiers of these associations, in a sample of employees among whom frequent or even full-time WFH was common (N = 1,123, Meanage = 43.37 years). In linear regression models, each subsequent work outcome (standardized score was used) was regressed on frequencies of WFH, adjusting for baseline values of the outcome variables and other covariates. The results suggested that WFH for 5 days/week versus never WFH was associated with subsequently less work distraction (ß = -0.24, 95% CI = -0.38, -0.11), greater perceived productivity/engagement (ß = 0.23, 95% CI = 0.11, 0.36), and greater job satisfaction (ß = 0.15, 95% CI = 0.02, 0.27), and was associated with subsequent work-family conflicts to a lesser extent (ß = -0.13, 95% CI = -0.26, 0.004). There was also evidence suggesting that long work hours, caregiving responsibilities, and a greater sense of meaningful work can all potentially attenuate the benefits of WFH. As we move towards the post-pandemic era, further research will be needed to understand the impacts of WFH and resources for supporting employees who work from home.

Development and Initial Validation of the Persevering Hope Scale: Measuring Wait-Power in Four Independent Samples

Hope has been conceptualized as agency and pathways to achieve goals. However, this goal-directed conceptualization does not encapsulate all situations in which hope may be beneficial. To address the dispositional motivation to endure when a desired goal seems unattainable, unlikely, or even impossible (i.e., goal-transcendent hope), we provide initial psychometric evidence for the new Persevering Hope Scale (PHS). We developed and refined the PHS with undergraduates at a public college (Study 1) and replicated our findings in a community adult sample (Study 2). We replicated and extended these findings using longitudinal data with undergraduates at a faith-based college (Study 3) and a community sample of chronically ill adults (Study 4), and examined measurement invariance (Study 5). Scores on the PHS demonstrated robust evidence of estimated internal consistency and of criterion-related, convergent/discriminant, and incremental validity. Estimated temporal stability was modest. Partial scalar invariance was evidenced across samples, and full scalar invariance was evidenced across gender, race/ethnicity, and time. These preliminary findings suggest that the PHS is a psychometrically sound measure of persevering hope. Its use can broaden the current body of literature on trait hope to include goal-transcendent hope and advance research on the nature and benefits of this important construct.

Accelerating the science and practice of psychology beyond WEIRD biases: Enriching the landscape through Asian psychology

More than a decade has passed since major concerns emerged about the WEIRD-centric focus of mainstream psychological science. Since then, many calls have been made for the discipline of psychology (and other disciplines within the social sciences) to become more broadly representative of the human species. However, recent evidence suggests that progress toward improving the inclusivity and generalizability of psychological science has been slow, and that the dominance of WEIRD psychology has persisted. To build a more comprehensive psychological science that truly represents the global population, we need strategies that can facilitate more rapid expansion of empirical evidence in psychology beyond WEIRD biases. In this paper, we draw on several examples (i.e., non-duality and dialectical interaction, Wu-Wei, Zhong Yong) to illustrate how principles of Asian psychology could contribute to reshaping mainstream psychology. We discuss some strategies for advancing a global psychological science, along with some complementary practical suggestions that could enrich the WEIRD-centric landscape of current psychological science.

Mapping age- and sex-specific HIV prevalence in adults in sub-Saharan Africa, 2000-2018

BACKGROUND

Human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) is still among the leading causes of disease burden and mortality in sub-Saharan Africa (SSA), and the world is not on track to meet targets set for ending the epidemic by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations Sustainable Development Goals (SDGs). Precise HIV burden information is critical for effective geographic and epidemiological targeting of prevention and treatment interventions. Age- and sex-specific HIV prevalence estimates are widely available at the national level, and region-wide local estimates were recently published for adults overall. We add further dimensionality to previous analyses by estimating HIV prevalence at local scales, stratified into sex-specific 5-year age groups for adults ages 15-59 years across SSA.

METHODS

We analyzed data from 91 seroprevalence surveys and sentinel surveillance among antenatal care clinic (ANC) attendees using model-based geostatistical methods to produce estimates of HIV prevalence across 43 countries in SSA, from years 2000 to 2018, at a 5 × 5-km resolution and presented among second administrative level (typically districts or counties) units.

RESULTS

We found substantial variation in HIV prevalence across localities, ages, and sexes that have been masked in earlier analyses. Within-country variation in prevalence in 2018 was a median 3.5 times greater across ages and sexes, compared to for all adults combined. We note large within-district prevalence differences between age groups: for men, 50% of districts displayed at least a 14-fold difference between age groups with the highest and lowest prevalence, and at least a 9-fold difference for women. Prevalence trends also varied over time; between 2000 and 2018, 70% of all districts saw a reduction in prevalence greater than five percentage points in at least one sex and age group. Meanwhile, over 30% of all districts saw at least a five percentage point prevalence increase in one or more sex and age group.

CONCLUSIONS

As the HIV epidemic persists and evolves in SSA, geographic and demographic shifts in prevention and treatment efforts are necessary. These estimates offer epidemiologically informative detail to better guide more targeted interventions, vital for combating HIV in SSA.

Suffering, psychological distress, and well-being in Indonesia: A prospective cohort study

Research on the subjective experience of suffering has typically focussed on older clinical samples living in Western, educated, industrialised, rich, and democratic (WEIRD) countries. To further extend the existing body of empirical research on suffering to less WEIRD contexts, we use three waves of data (Wave 1: December 2020; Wave 2: January 2021; Wave 3: February 2021) from a sample of nonclinical Indonesian adults (n = 594) to examine associations between suffering, two indices of psychological distress, and 10 facets of well-being. In our primary analysis, we estimated a series of multiple regression models that adjusted for a range of sociodemographic characteristics, financial and material stability, religious/spiritual factors, prior values of overall suffering, and prior values of each outcome assessed in Wave 1. Results indicated that overall suffering assessed in Wave 2 was associated with an increase in both indices of psychological distress and a decrease in eight facets of well-being assessed in Wave 3. Using a similar analytic approach, results from a secondary analysis indicated that higher scores on both indices of psychological distress and lower scores on seven of the well-being facets assessed in Wave 2 were associated with worse subsequent overall suffering assessed in Wave 3. These findings contribute to empirical literature on the implications of suffering for well-being.

Identifying pathways to religious service attendance among older adults: A lagged exposure-wide analysis

We used prospective data (spanning 8 years) from a national sample of older U.S. adults aged > 50 years (the Health and Retirement Study, N = 13,771) to evaluate potential factors that lead to subsequent religious service attendance. We applied a lagged exposure-wide epidemiologic design and evaluated 60 candidate predictors of regular subsequent religious service attendance. Candidate predictors were drawn from the following domains: health behaviors, physical health, psychological well-being, psychological distress, social factors, and work. After rigorous adjustment for a rich set of potential confounders, we observed modest evidence that changes in some indices of physical health, psychological well-being, psychological distress, and social functioning predicted regular religious service attendance four years later. Our findings suggest that there may be opportunities to support more regular religious service attendance among older adults who positively self-identify with a religious/spiritual tradition (e.g., aid services for those with functional limitations, psychological interventions to increase hope), which could have downstream benefits for various dimensions of well-being in the later years of life.

Associations of suffering with facets of health and well-being among working adults: longitudinal evidence from two samples

Suffering is an experiential state that every person encounters at one time or another, yet little is known about suffering and its consequences for the health and well-being of nonclinical adult populations. In a pair of longitudinal studies, we used two waves of data from garment factory workers (Study 1 [T1: 2017, T2: 2019]: n = 344) and flight attendants (Study 2 [T1: 2017/2018, T2: 2020]: n = 1402) to examine the prospective associations of suffering with 16 outcomes across different domains of health and well-being: physical health, health behavior, mental health, psychological well-being, character strengths, and social well-being. The primary analysis involved a series of regression analyses in which each T2 outcome was regressed on overall suffering assessed at T1, adjusting for relevant sociodemographic characteristics and the baseline value (or close proxy) of the outcome assessed at T1. In Study 1, associations of overall suffering with worse subsequent health and well-being were limited to a single outcome on each of the domains of physical health and mental health. Overall suffering was more consistently related to worse subsequent health and well-being in Study 2, with associations emerging for all but two outcomes. The pattern of findings for each study was largely similar when aspects of suffering were modeled individually, although associations for some aspects of suffering differed from those that emerged for overall suffering. Our findings suggest that suffering may have important implications for the health and well-being of worker populations.

Perceived posttraumatic growth after interpersonal trauma and subsequent well-being among young Colombian adults: A longitudinal analysis

Research has shown that people sometimes report self-perceived growth as a result of dealing with a potentially traumatic event, but relatively few methodologically rigorous studies have examined whether perceived posttraumatic growth is associated with improved subsequent well-being across a wide range of outcomes. In this three-wave longitudinal study of Colombian emerging adults (n = 636), we examined the associations of perceived posttraumatic growth with 17 well-being outcomes across domains of psychological well-being (i.e., self-rated mental health, meaning in life, sense of purpose, happiness, life satisfaction), psychological distress (i.e., anxiety symptoms, depression symptoms, subjective suffering), social well-being (i.e., content with relationships, satisfying relationships, loneliness), physical well-being (i.e., self-rated physical health, sleep quality), and character strengths (i.e., state hope, trait forgivingness, orientation to promote good, delayed gratification). Using an outcome-wide analytic design that adjusted for a range of covariates assessed in Wave 1, we found that overall perceived posttraumatic growth assessed in Wave 2 was robustly associated with improvements in one or more facet of each well-being domain (15/17 outcomes in total) assessed approximately six months later in Wave 3. Our findings suggest that perceived posttraumatic growth may contribute to individual well-being over the longer-term.

Differential effects of decisional and emotional forgiveness on distress and well-being: A three-wave study of Indonesian adults

Research suggests that interpersonal forgiveness is beneficial to individual functioning, but few longitudinal studies have explored the independent contributions of decisional and emotional forgiveness to reducing different forms of distress and improving multidimensional well-being. In this three-wave (T1: December 2020; T2: January 2021; T3: February 2021) prospective study of predominantly young Indonesian adults (n = 595), we examined the associations of decisional and emotional forgiveness with three indicators of distress and 10 components of well-being. Applying the outcome-wide analytic template for longitudinal designs, our primary analysis involved estimating two sets of linear regression models (one set for decisional forgiveness and one set for emotional forgiveness) in which the outcomes were regressed on each interpersonal forgiveness process (one outcome at a time). Adjusting for a range of covariates (including prior values of decisional forgiveness, emotional forgiveness, and all 13 outcomes) assessed at T1, decisional forgiveness assessed at T2 was associated with an increase in seven components of well-being (i.e., life satisfaction, physical health, sense of purpose, promote good, delayed gratification, content with relationships, satisfying relationships) approximately 1 month later at T3. In contrast, emotional forgiveness assessed at T2 was associated with an increase in a single component of well-being (i.e., satisfying relationships) assessed at T3. Neither decisional nor emotional forgiveness assessed at T2 showed evidence of associations with any of the subsequent indicators of distress assessed at T3. Our findings suggest that, at least within a principally collectivistic cultural context such as Indonesia, decisional forgiveness in the aftermath of a transgression may have greater short-term benefits for well-being compared to emotional forgiveness. Implications of the findings for research and interventions are discussed.

National Data on Age Gradients in Well-being Among US Adults

This survey study assesses well-being among US adults by age group.

Demographic Predictors of Complete Well-Being

This paper examines demographic differences in flourishing, defined as "complete well-being" and consisting of six domains: emotional health, physical health, purpose, character strengths, social connectedness, and financial security. Results are based on a random, cross-sectional sample of 2363 survey respondents drawn from employees of a large, national, self-insured employer based in the United States. We found that well-being across domains tends to increase with age, although there are some variations. Results are similar across most domains for men and women, although women score higher on character strengths, while men had higher scores on financial security. Racial and ethnic differences were striking. Black employees score higher than the reference group (White employees) on the emotional, purpose, and character strengths domains, but considerably lower on financial security. Hispanics also score lower on financial security (though not as low as Blacks), but higher than Whites on purpose, character strengths, and social connectedness. Asians reported higher well-being than Whites across all domains except purpose.

Are depression and suffering distinct? An empirical analysis

Depression and the subjective experience of suffering are distinct forms of distress, but they are sometimes commingled with one another. Using a cross-sectional sample of flight attendants (n = 4,652), we tested for further empirical evidence distinguishing depression and suffering. Correlations with 15 indices covering several dimensions of well-being (i.e., physical health, emotional well-being, psychological well-being, character strengths, social well-being, financial/material well-being) indicated that associations with worse well-being were mostly stronger for depression than suffering. There was a large positive correlation between depression and suffering, but we also found evidence of notable non-concurrent depression and suffering in the sample. After dividing participants into four groups that varied based on severity of depression and suffering, regression analyses showed higher levels of well-being among those with both none-mild depression and none-mild suffering compared to those with moderate-severe depression, moderate-severe suffering, or both. All indices of well-being were lowest among the group of participants with moderate-severe depression and moderate-severe suffering. In addition to providing further evidence supporting a distinction between depression and suffering, our findings suggest that concurrent depression and suffering may be more disruptive to well-being than when either is present alone.

The mental health of healthcare workers during the COVID-19 pandemic: a narrative review

PURPOSE OF REVIEW

Mental health (MH) problems among healthcare workers (HCWs) have the potential to impact negatively on the capacity of health systems to respond effectively to COVID-19. A thorough understanding of the factors that degrade or promote the MH of HCWs is needed to design and implement suitable intervention strategies to support the wellbeing of this population.

RECENT FINDINGS

MH problems among HCWs were elevated prior to the COVID-19 pandemic. Accumulating evidence indicates that this public health crisis has had a disproportionately negative impact on the MH of specialised populations, including HCWs. Literature from prior health pandemics suggests that the adverse effects of the COVID-19 pandemic on the MH of HCWs are likely to persist in the aftermath of the public health crisis. Primary and secondary risk factors for adverse MH outcomes have been identified and should be considered when implementing interventions to protect the MH of HCWs.

SUMMARY

The MH of HCWs has been negatively impacted by the COVID-19 pandemic, which is having a detrimental influence on the public health response to COVID-19. Protecting the MH of HCWs both during and beyond this public health crisis should remain a top priority, with particular emphasis on multifaceted interventions that aim to balance the psychological needs of individual HCWs with organisational-level strategies that could be targeted to promote their wellbeing.

Population-level risks of alcohol consumption by amount, geography, age, sex, and year: a systematic analysis for the Global Burden of Disease Study 2020

BACKGROUND

The health risks associated with moderate alcohol consumption continue to be debated. Small amounts of alcohol might lower the risk of some health outcomes but increase the risk of others, suggesting that the overall risk depends, in part, on background disease rates, which vary by region, age, sex, and year.

METHODS

For this analysis, we constructed burden-weighted dose-response relative risk curves across 22 health outcomes to estimate the theoretical minimum risk exposure level (TMREL) and non-drinker equivalence (NDE), the consumption level at which the health risk is equivalent to that of a non-drinker, using disease rates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020 for 21 regions, including 204 countries and territories, by 5-year age group, sex, and year for individuals aged 15-95 years and older from 1990 to 2020. Based on the NDE, we quantified the population consuming harmful amounts of alcohol.

FINDINGS

The burden-weighted relative risk curves for alcohol use varied by region and age. Among individuals aged 15-39 years in 2020, the TMREL varied between 0 (95% uncertainty interval 0-0) and 0·603 (0·400-1·00) standard drinks per day, and the NDE varied between 0·002 (0-0) and 1·75 (0·698-4·30) standard drinks per day. Among individuals aged 40 years and older, the burden-weighted relative risk curve was J-shaped for all regions, with a 2020 TMREL that ranged from 0·114 (0-0·403) to 1·87 (0·500-3·30) standard drinks per day and an NDE that ranged between 0·193 (0-0·900) and 6·94 (3·40-8·30) standard drinks per day. Among individuals consuming harmful amounts of alcohol in 2020, 59·1% (54·3-65·4) were aged 15-39 years and 76·9% (73·0-81·3) were male.

INTERPRETATION

There is strong evidence to support recommendations on alcohol consumption varying by age and location. Stronger interventions, particularly those tailored towards younger individuals, are needed to reduce the substantial global health loss attributable to alcohol.

FUNDING

Bill & Melinda Gates Foundation.

Long-Term Associations between Disaster-Related Home Loss and Health and Well-Being of Older Survivors: Nine Years after the 2011 Great East Japan Earthquake and Tsunami

BACKGROUND

Little research has examined associations between disaster-related home loss and multiple domains of health and well-being, with extended long-term follow-up and comprehensive adjustment for pre-disaster characteristics of survivors.

OBJECTIVES

We examined the longitudinal associations between disaster-induced home loss and 34 indicators of health and well-being, assessed ∼9y post-disaster.

METHODS

We used data from a preexisting cohort study of Japanese older adults in an area directly impacted by the 2011 Japan Earthquake (n=3,350 and n=2,028, depending on the outcomes). The study was initiated in 2010, and disaster-related home loss status was measured in 2013 retrospectively. The 34 outcomes were assessed in 2020 and covered dimensions of physical health, mental health, health behaviors/sleep, social well-being, cognitive social capital, subjective well-being, and prosocial/altruistic behaviors. We estimated the associations between disaster-related home loss and the outcomes, using targeted maximum likelihood estimation and SuperLearner. We adjusted for pre-disaster characteristics from the wave conducted 7 months before the disaster (i.e., 2010), including prior outcome values that were available.

RESULTS

After Bonferroni correction for multiple testing, we found that home loss (vs. no home loss) was associated with increased posttraumatic stress symptoms (standardized difference=0.50; 95% CI: 0.35, 0.65), increased daily sleepiness (0.38; 95% CI: 0.21, 0.54), lower trust in the community (-0.36; 95% CI: -0.53, -0.18), lower community attachment (-0.60; 95% CI: -0.75, -0.45), and lower prosociality (-0.39; 95% CI: -0.55, -0.24). We found modest evidence for the associations with increased depressive symptoms, increased hopelessness, more chronic conditions, higher body mass index, lower perceived mutual help in the community, and decreased happiness. There was little evidence for associations with the remaining 23 outcomes.

DISCUSSION

Home loss due to a disaster may have long-lasting adverse impacts on the cognitive social capital, mental health, and prosociality of older adult survivors. https://doi.org/10.1289/EHP10903.

Associations of lockdown stringency and duration with Google searches for mental health terms during the COVID-19 pandemic: A nine-country study

OBJECTIVES

We examined the associations of lockdown stringency and duration with Google searches for four mental health concepts (i.e., "Anxiety," "Depression," "Suicide," "Mental Health") in nine countries (i.e., Hungary, India, Iran, Italy, Paraguay, Serbia, South Africa, Spain, Turkey) during the COVID-19 pandemic.

METHODS

We retrieved national-level data for each country from Google Trends and the Global Panel Database of Pandemic Policies. In our primary analysis, we used data from all countries to estimate a set of multilevel regression models examining associations of overall lockdown stringency and lockdown duration with relative search volumes for each mental health term. We repeated the models after replacing overall lockdown stringency with each of the lockdown stringency components.

RESULTS

A negative association was found between overall lockdown stringency and "Depression." Lockdown duration and the most stringent stay-at-home requirements were negatively associated with "Anxiety." Policies that recommended or required the cancelation of public events evidenced negative associations with "Depression," whereas associations between policies that required some or all levels of schooling to close and "Depression" were positive. Policies that recommended or required workplaces to close and those that enforced quarantines on non-citizens arriving from high-risk regions or closed borders entirely were negatively associated with "Suicide."

CONCLUSIONS

Lockdown duration and some lockdown policies during the COVID-19 pandemic were generally associated with significantly lower, rather than higher, Google searches for selected mental health terms. These findings could be used alongside other evidence to develop future lockdown strategies that are sensitive to mental health issues during public health crises.

Associations of Changes in Religiosity With Flourishing During the COVID-19 Pandemic: A Study of Faith Communities in the United States

This study explored the extent to which perceived changes in religiosity from before to during the COVID-19 pandemic are associated with flourishing. Participants from a diverse set of faith communities in two United States metropolitan regions (N = 1,480) completed an online survey between October and December 2020. The survey included items capturing perceived changes in four dimensions of religiosity (i.e., importance of religion, frequency of prayer, frequency of religious service attendance, and sense of connectedness to one's faith community) and a multidimensional measure of flourishing. Based on multilevel regressions, results indicated that self-reported decreases in each dimension of religiosity were associated with lower overall flourishing. This pattern of findings was largely similar for the domains of flourishing, with some variation in the strength of associations that emerged. An increase in frequency of religious service attendance was associated with lower overall flourishing and lower scores on selected domains of flourishing (e.g., mental and physical health), indicating possible evidence of religious coping. Faith communities might have to find ways of supporting members during the challenging COVID-19 period to prevent long-term declines in flourishing.

Brief Digital Interventions to Support the Psychological Well-being of NHS Staff During the COVID-19 Pandemic: 3-Arm Pilot Randomized Controlled Trial

BACKGROUND

Health and social care staff are at high risk of experiencing adverse mental health (MH) outcomes during the COVID-19 pandemic. Hence, there is a need to prioritize and identify ways to effectively support their psychological well-being (PWB). Compared to traditional psychological interventions, digital psychological interventions are cost-effective treatment options that allow for large-scale dissemination and transcend social distancing, overcome rurality, and minimize clinician time.

OBJECTIVE

This study reports MH outcomes of a Consolidated Standards of Reporting Trials (CONSORT)-compliant parallel-arm pilot randomized controlled trial (RCT) examining the potential usefulness of an existing and a novel digital psychological intervention aimed at supporting psychological health among National Health Service (NHS) staff working through the COVID-19 pandemic.

METHODS

NHS Highland (NHSH) frontline staff volunteers (N=169) were randomly assigned to the newly developed NHSH Staff Wellbeing Project (NHSWBP), an established digital intervention (My Possible Self [MPS]), or a waitlist (WL) group for 4 weeks. Attempts were made to blind participants to which digital intervention they were allocated. The interventions were fully automated, without any human input or guidance. We measured 5 self-reported psychological outcomes over 3 time points: before (baseline), in the middle of (after 2 weeks), and after treatment (4 weeks). The primary outcomes were anxiety (7-item General Anxiety Disorder), depression (Patient Health Questionnaire), and mental well-being (Warwick-Edinburgh Mental Well-being Scale). The secondary outcomes included mental toughness (Mental Toughness Index) and gratitude (Gratitude Questionnaire-6).

RESULTS

Retention rates mid- and postintervention were 77% (n=130) and 63.3% (n=107), respectively. Postintervention, small differences were noted between the WL and the 2 treatment groups on anxiety (vs MPS: Cohen d=0.07, 95% CI -0.20 to 0.33; vs NHSWBP: Cohen d=0.06, 95% CI -0.19 to 0.31), depression (vs MPS: Cohen d=0.37, 95% CI 0.07-0.66; vs NHSWBP: Cohen d=0.18, 95% CI -0.11 to 0.46), and mental well-being (vs MPS: Cohen d=-0.04, 95% CI -0.62 to -0.08; vs NHSWBP: Cohen d=-0.15, 95% CI -0.41 to 0.10). A similar pattern of between-group differences was found for the secondary outcomes. The NHSWBP group generally had larger within-group effects than the other groups and displayed a greater rate of change compared to the other groups on all outcomes, except for gratitude, where the rate of change was greatest for the MPS group.

CONCLUSIONS

Our analyses provided encouraging results for the use of brief digital psychological interventions in improving PWB among health and social care workers. Future multisite RCTs, with power to reliably detect differences, are needed to determine the efficacy of contextualized interventions relative to existing digital treatments.

TRIAL REGISTRATION

ISRCTN Registry (ISRCTN) ISRCTN18107122; https://www.isrctn.com/ISRCTN18107122.

Association of HIV Intervention Uptake With HIV Prevalence in Adolescent Girls and Young Women in South Africa

IMPORTANCE

In South Africa, adolescent girls and young women aged 15 to 24 years are among the most high-risk groups for acquiring HIV. Progress in reducing HIV incidence in this population has been slow.

OBJECTIVE

To describe HIV prevalence and HIV risk behaviors among a sample of adolescent girls and young women and to model the association between exposure to multiple or layered interventions and key HIV biological and behavioral outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey was conducted between March 13, 2017, and June 22, 2018, in 2 districts in Gauteng province and in 2 districts in KwaZulu-Natal province in South Africa. A stratified cluster random sampling method was used. Participants included adolescent girls and young women aged 12 to 24 years who lived in each sampled household. Overall, 10 384 participants were enrolled in Gauteng province and 7912 in KwaZulu-Natal province. One parent or caregiver was interviewed in each household. Data analysis was performed from March 12, 2021, to March 1, 2022.

EXPOSURES

DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe)-like interventions.

MAIN OUTCOMES AND MEASURES

The primary outcome was HIV prevalence. HIV status was obtained from laboratory-based testing of peripheral blood samples. Secondary outcomes included HIV testing and antiretroviral therapy uptake as well as numerous HIV risk variables that the DREAMS program sought to improve, such as pregnancy, sexually transmitted infection, intimate partner violence, and age-disparate sex.

RESULTS

The final sample included 18 296 adolescent girls and young women (median [IQR] age, 19 [15-21] years) in 10 642 households. Approximately half of participants (49.9%; n = 8414) reported engaging in sexual activity, and 48.1% (n = 3946) reported condom use at the most recent sexual encounter. KwaZulu-Natal province had a higher HIV prevalence than Gauteng province (15.1% vs 7.8%; P < .001). Approximately one-fifth of participants (17.6%; n = 3291) were not exposed to any interventions, whereas 43.7% (n = 8144) were exposed to 3 or more interventions. There was no association between exposure to DREAMS-like interventions and HIV status. Adolescent girls and young women who accessed 3 or more interventions were more likely to have undergone HIV testing (adjusted odds ratio, 2.39; 95% CI, 2.11-2.71; P < .001) and to have used condoms consistently in the previous 12 months (adjusted odds ratio, 1.68; 95% CI, 1.33-2.12; P < .001) than those who were not exposed to any interventions.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that self-reported exposures to multiple or layered DREAMS-like interventions were associated with favorable behavioral outcomes. The beneficial aspects of layering HIV interventions warrant further research to support the sexual and reproductive health of adolescent girls and young women.

Associations of home confinement during COVID-19 lockdown with subsequent health and well-being among UK adults

During the COVID-19 pandemic, the United Kingdom (UK) government introduced public health safety measures to mitigate the spikes in infection rates. This included stay-at-home orders that prevented people from leaving their homes for work or study, except for urgent medical care or buying essential items. This practice could have both short and long-term implications for health and wellbeing of people in the UK. Using longitudinal data of 10,630 UK adults, this study prospectively examined the association between home confinement status during the stringent lockdown in the UK (March 23-May 13, 2020) and 20 indicators of subjective well-being, social well-being, pro-social/altruistic behaviors, psychological distress, and health behaviors assessed approximately one month after the stringent lockdown ended. All analyses adjusted for socio-demographic characteristics and social isolation status in the beginning of the pandemic. Home confinement during the lockdown was associated with greater subsequent compliance with COVID-19 rules, more perceived major stressors, and a lower prevalence of physical activity. There was modest evidence of associations with lower life satisfaction, greater loneliness, greater depressive symptoms, greater anxiety symptoms, and more perceived minor stressors post-lockdown. However, there was little evidence that home confinement was associated with other indices of subsequent health and well-being. While our study shows that home confinement impacts some indices of subsequent health and wellbeing outcomes even after lockdown, the degree of the psychological adaptation to the difficult confinement behavior remains unclear and should be further studied.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-022-03001-5.

The fear of COVID-19 scale: Its structure and measurement invariance across 48 countries

Coronavirus disease (COVID-19) has been a source of fear around the world. We asked whether the measurement of this fear is trustworthy and comparable across countries. In particular, we explored the measurement invariance and cross-cultural replicability of the widely used Fear of COVID-19 scale (FCV-19S), testing community samples from 48 countries (N = 14,558). The findings indicate that the FCV-19S has a somewhat problematic structure, yet the one-factor solution is replicable across cultural contexts and could be used in studies that compare people who vary on gender and educational level. The validity of the scale is supported by a consistent pattern of positive correlations with perceived stress and general anxiety. However, given the unclear structure of the FCV-19S, we recommend using latent factor scores, instead of raw scores, especially in cross-cultural comparisons. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Global Trends of Mean and Inequality in Multidimensional Wellbeing: Analysis of 1.2 Million Individuals From 162 Countries, 2009–2019

Introduction

Human flourishing is a multidimensional concept characterized by a state of complete wellbeing. However, much of the prior research on wellbeing has principally focused on population averages assessed using a single item of wellbeing. This study examined trends in population averages and inequalities for a multidimensional index of wellbeing and compared emergent patterns with those found for Cantril's ladder, a measure of life satisfaction commonly used as a unidimensional index of wellbeing.

Methods

Data were from the Gallup World Poll from the years 2009 to 2019, a repeated cross-sectional survey of nationally representative samples comprising ~1.2 million individuals from 162 countries. We assessed five domains of flourishing: (1) happiness, (2) health, (3) purpose, (4) character, and (5) social relationships. We used the Gini Index to estimate inequalities in wellbeing within populations. We examined and compared country ranking, global and region-specific trajectories of mean and inequality, and relationships with age for flourishing and Cantril's ladder.

Results

Although all trends were highly correlated across the two metrics of wellbeing, we identified distinct patterns in flourishing concerning geography, time, and age relationships that were not observed for Cantril's ladder. Temporal trends and age relationships were different across domains of flourishing. Evidence of changing inequalities in wellbeing was also found, even when population averages were high or stable over time.

Conclusion

Comprehensive measures of wellbeing are needed to capture the complex and changing patterns of wellbeing both within and across populations.

COVID-19 vaccines for children and adolescents in Africa: aligning our priorities to situational realities

The evolving COVID-19 pandemic is an unprecedented global public health crisis that continues to have a major impact on the African continent. Most countries within Africa are facing significant challenges vaccinating their populations for COVID-19. Inadequate COVID-19 vaccine supply, weaknesses in health system infrastructure, COVID-19 misinformation and disinformation, and ineffective health risk communication are contributing to low adult vaccination rates on the continent. Without sufficient COVID-19 vaccine coverage on the African continent, the prolonged social, economic and health impacts of this public health crisis are likely to exacerbate pre-existing social-structural issues in this part of the world. In this paper, we highlight trends in SARS-CoV-2 infections among children and adolescents (CA), compare COVID-19 vaccination patterns in Africa to those in high-income countries, and discuss some of the benefits, challenges and unknowns associated with vaccinating CA for COVID-19. In light of ongoing COVID-19 vaccine supply challenges and the slow progress that the African continent is making towards vaccinating the adult population, we suggest that the immediate priority for Africa is to accelerate COVID-19 vaccinations among adults (particularly high-risk populations) and vulnerable CA (ie, those who are immunocompromised and/or living with certain medical conditions). Accelerating the roll-out of COVID-19 vaccines and rapidly achieving high levels of vaccination coverage in the adult population will free up capacity to vaccinate CA sooner rather than later. While we hope that COVID-19 vaccines will soon become available to CA throughout Africa, countries must continue to prioritise non-pharmaceutical interventions.

Health trends, inequalities and opportunities in South Africa's provinces, 1990-2019: findings from the Global Burden of Disease 2019 Study

BACKGROUND

Over the last 30 years, South Africa has experienced four 'colliding epidemics' of HIV and tuberculosis, chronic illness and mental health, injury and violence, and maternal, neonatal, and child mortality, which have had substantial effects on health and well-being. Using data from the 2019 Global Burden of Diseases, Injuries and Risk Factors Study (GBD 2019), we evaluated national and provincial health trends and progress towards important Sustainable Development Goal targets from 1990 to 2019.

METHODS

We analysed GBD 2019 estimates of mortality, non-fatal health loss, summary health measures and risk factor burden, comparing trends over 1990-2007 and 2007-2019. Additionally, we decomposed changes in life expectancy by cause of death and assessed healthcare system performance.

RESULTS

Across the nine provinces, inequalities in mortality and life expectancy increased over 1990-2007, largely due to differences in HIV/AIDS, then decreased over 2007-2019. Demographic change and increases in non-communicable diseases nearly doubled the number of years lived with disability between 1990 and 2019. From 1990 to 2019, risk factor burdens generally shifted from communicable and nutritional disease risks to non-communicable disease and injury risks; unsafe sex remained the top risk factor. Despite widespread improvements in healthcare system performance, the greatest gains were generally in economically advantaged provinces.

CONCLUSIONS

Reductions in HIV/AIDS and related conditions have led to improved health since 2007, though most provinces still lag in key areas. To achieve health targets, provincial governments should enhance health investments and exchange of knowledge, resources and best practices alongside populations that have been left behind, especially following the COVID-19 pandemic.

The mental health of NHS staff during the COVID-19 pandemic: two-wave Scottish cohort study

BACKGROUND

Health and social care workers (HSCWs) are at risk of experiencing adverse mental health outcomes (e.g. higher levels of anxiety and depression) because of the COVID-19 pandemic. This can have a detrimental effect on quality of care, the national response to the pandemic and its aftermath.

AIMS

A longitudinal design provided follow-up evidence on the mental health (changes in prevalence of disease over time) of NHS staff working at a remote health board in Scotland during the COVID-19 pandemic, and investigated the determinants of mental health outcomes over time.

METHOD

A two-wave longitudinal study was conducted from July to September 2020. Participants self-reported levels of depression (Patient Health Questionnaire-9), anxiety (Generalised Anxiety Disorder-7) and mental well-being (Warwick-Edinburgh Mental Well-being Scale) at baseline and 1.5 months later.

RESULTS

The analytic sample of 169 participants, working in community (43%) and hospital (44%) settings, reported substantial levels of depression and anxiety, and low mental well-being at baseline (depression, 30.8%; anxiety, 20.1%; well-being, 31.9%). Although mental health remained mostly constant over time, the proportion of participants meeting the threshold for anxiety increased to 27.2% at follow-up. Multivariable modelling indicated that working with, and disruption because of, COVID-19 were associated with adverse mental health changes over time.

CONCLUSIONS

HSCWs working in a remote area with low COVID-19 prevalence reported substantial levels of anxiety and depression, similar to those working in areas with high COVID-19 prevalence. Efforts to support HSCW mental health must remain a priority, and should minimise the adverse effects of working with, and disruption caused by, the COVID-19 pandemic.

Self-esteem and antiretroviral therapy adherence among young people living with HIV: An exploratory serial mediation analysis

Capitalising further on the benefits of antiretroviral therapy (ART) for individual treatment requires an improved understanding of the psychological processes that may affect optimal ART adherence among people living with HIV. We examined internalised HIV/AIDS-related stigma and body appreciation as mediators of the association between self-esteem and ART adherence among young people living with HIV (YPLHIV). A sample of 76 YPLHIV (Mage = 19.36, s.d.age = 2.56; male 56.58%) residing in an HIV hyperendemic region of South Africa completed self-report measures of self-esteem, internalised HIV/AIDS-related stigma, body appreciation, and ART adherence. Path-analytic mediation modelling was performed to test for direct and indirect effects linking self-esteem with ART adherence. Results of serial mediation analyses indicated that self-esteem and ART adherence were indirectly associated through a two-step path of internalised HIV/AIDS-related stigma and then body appreciation, as well as a one-step path through internalised HIV/AIDS-related stigma. The results provide preliminary support for internalised HIV/AIDS-related stigma and body appreciation as mechanisms underlying the association between self-esteem and ART adherence. Implications of the findings for promoting ART adherence among YPLHIV are discussed.