Digital health interventions for all? Examining inclusivity across all stages of the digital health intervention research process

Digital interventions offer many possibilities for improving health, as remote interventions can enhance reach and access to underserved groups of society. However, research evaluating digital health interventions demonstrates that such technologies do not equally benefit all and that some in fact seem to reinforce a "digital health divide." By better understanding these potential pitfalls, we may contribute to narrowing the digital divide in health promotion. The aim of this article is to highlight and reflect upon study design decisions that might unintentionally enhance inequities across key research stages-recruitment, enrollment, engagement, efficacy/effectiveness, and retention. To address the concerns highlighted, we propose strategies including (1) the standard definition of "effectiveness" should be revised to include a measure of inclusivity; (2) studies should report a broad range of potential inequity indicators of participants recruited, randomized, and retained and should conduct sensitivity analyses examining potential sociodemographic differences for both the effect and engagement of the digital interventions; (3) participants from historically marginalized groups should be involved in the design of study procedures, including those related to recruitment, consent, intervention implementation and engagement, assessment, and retention; (4) eligibility criteria should be minimized and carefully selected and the screening process should be streamlined; (5) preregistration of trials should include recruitment benchmarks for sample diversity and comprehensive lists of sociodemographic characteristics assessed; and (6) studies within trials should be embedded to systematically test recruitment and retention strategies to improve inclusivity. The implementation of these strategies would enhance the ability of digital health trials to recruit, randomize, engage, and retain a broader and more representative population in trials, ultimately minimizing the digital divide and broadly improving population health.

Reducing intervention- and research-induced inequalities to tackle the digital divide in health promotion

Social inequalities are an important contributor to the global burden of disease within and between countries. Using digital technology in health promotion and healthcare is seen by some as a potential lever to reduce these inequalities; however, research suggests that digital technology risks re-enacting or evening widening disparities. Most research on this digital health divide focuses on a small number of social inequality indicators and stems from Western, educated, industrialized, rich, and democratic (WEIRD) countries. There is a need for systematic, international, and interdisciplinary contextualized research on the impact of social inequality indicators in digital health as well as the underlying mechanisms of this digital divide across the globe to reduce health disparities. In June 2023, eighteen multi-disciplinary researchers representing thirteen countries from six continents came together to discuss current issues in the field of digital health promotion and healthcare contributing to the digital divide. Ways that current practices in research contribute to the digital health divide were explored, including intervention development, testing, and implementation. Based on the dialogue, we provide suggestions for overcoming barriers and improving practices across disciplines, countries, and sectors. The research community must actively advocate for system-level changes regarding policy and research to reduce the digital divide and so improve digital health for all.

Psychiatric morbidity among pregnant and non pregnant women in Ibadan, Nigeria

A comparative cross-sectional study was conducted among 991 pregnant and 674 non-pregnant women of reproductive age attending healthcare facilities in Ibadan, Nigeria using the General Health Questionnaire-12 (GHQ), and WHO self-reporting questionnaire (SRQ). Logistic regression analysis was conducted to identify predictors of psychiatric morbidity at p < 0.05. A significantly higher proportion of pregnant women experienced psychological distress on the GHQ (51.8%) and psychiatric morbidity on SRQ (33.3%) compared with 28.6% and 18.2% of non-pregnant women, respectively. Predictors of psychiatric morbidity among pregnant women were the type of facility, poor satisfaction and communication with partners, the experience of violence in the home, previous abortions, and previous history of depression. Psychiatric morbidity among non-pregnant women was predicted by younger age, previous history of depression, poor satisfaction and communication with partners. There is a need for early identification of psychiatric morbidity among women of reproductive age, to ensure early interventions and prevent long-term disability.Impact statementWhat is already known on this subject? Psychiatric morbidity has immense effects on a woman's quality of life, social functioning, obstetric outcome, and economic productivity.What do the results of this study add? Psychiatric morbidity among women of reproductive age is high. Pregnant women when compared to non-pregnant women had significantly higher rates of psychiatric morbidity. This high prevalence of psychiatric morbidity in both groups was predicted by poor satisfaction and communication with partners, and a previous history of depression.What are the implications of these findings for clinical practice and/or further research? Simple screening for women of reproductive age attending healthcare facilities may help with the early identification of psychiatric morbidity leading to prompt interventions, and preventing long-term disability.

The global burden of cancer attributable to risk factors, 2010-19: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally.

METHODS

The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk-outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented.

FINDINGS

Globally, in 2019, the risk factors included in this analysis accounted for 4·45 million (95% uncertainty interval 4·01-4·94) deaths and 105 million (95·0-116) DALYs for both sexes combined, representing 44·4% (41·3-48·4) of all cancer deaths and 42·0% (39·1-45·6) of all DALYs. There were 2·88 million (2·60-3·18) risk-attributable cancer deaths in males (50·6% [47·8-54·1] of all male cancer deaths) and 1·58 million (1·36-1·84) risk-attributable cancer deaths in females (36·3% [32·5-41·3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20·4% (12·6-28·4) and DALYs by 16·8% (8·8-25·0), with the greatest percentage increase in metabolic risks (34·7% [27·9-42·8] and 33·3% [25·8-42·0]).

INTERPRETATION

The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden.

FUNDING

Bill & Melinda Gates Foundation.

Indepth Interviews' on Acceptability and Concerns for Human Papilloma Virus Vaccine Uptake among Mothers of Adolescent Girls in Community Settings in Ibadan, Nigeria

Human papillomavirus (HPV) vaccine offers protection of between 80 and 100% for anogenital warts and 60-80% in reducing the incidence of pre-malignant lesions from cervical cancer. However, uptake remains low in Nigeria among adolescent girls. This study was a qualitative study that assessed mothers' acceptability and concerns regarding uptake of HPV vaccine by their adolescent daughters. In-depth interviews were conducted with 20 mothers of adolescents girls aged 9-15 years. A snowballing sampling technique was adopted to select the mothers within the community. Consent was obtained for the use of audiotapes, which were transcribed verbatim with thematic analysis of data. Mothers were between the ages of 30-49 years and most of them were traders. Almost all of the women have heard about cervical cancer, but their knowledge about cervical cancer and HPV vaccine was low. Despite their low knowledge, most of the mothers accepted that the vaccine is good and was willing for their adolescent daughters to take the HPV vaccine for the prevention of HPV. However, cost of the vaccine, side effects, and potential exposure of their daughters to promiscuity after taking the vaccine for protection were the major concerns expressed by the mothers as regards to HPV vaccine uptake by their daughters. Findings highlight the need for health promotion and education programs about cervical cancer, HPV, and HPV vaccine to increase awareness and knowledge among mothers of adolescent girls. Also, HPV vaccination should be included as part of routine immunization for female adolescents.

The global burden of adolescent and young adult cancer in 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

In estimating the global burden of cancer, adolescents and young adults with cancer are often overlooked, despite being a distinct subgroup with unique epidemiology, clinical care needs, and societal impact. Comprehensive estimates of the global cancer burden in adolescents and young adults (aged 15-39 years) are lacking. To address this gap, we analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, with a focus on the outcome of disability-adjusted life-years (DALYs), to inform global cancer control measures in adolescents and young adults.

METHODS

Using the GBD 2019 methodology, international mortality data were collected from vital registration systems, verbal autopsies, and population-based cancer registry inputs modelled with mortality-to-incidence ratios (MIRs). Incidence was computed with mortality estimates and corresponding MIRs. Prevalence estimates were calculated using modelled survival and multiplied by disability weights to obtain years lived with disability (YLDs). Years of life lost (YLLs) were calculated as age-specific cancer deaths multiplied by the standard life expectancy at the age of death. The main outcome was DALYs (the sum of YLLs and YLDs). Estimates were presented globally and by Socio-demographic Index (SDI) quintiles (countries ranked and divided into five equal SDI groups), and all estimates were presented with corresponding 95% uncertainty intervals (UIs). For this analysis, we used the age range of 15-39 years to define adolescents and young adults.

FINDINGS

There were 1·19 million (95% UI 1·11-1·28) incident cancer cases and 396 000 (370 000-425 000) deaths due to cancer among people aged 15-39 years worldwide in 2019. The highest age-standardised incidence rates occurred in high SDI (59·6 [54·5-65·7] per 100 000 person-years) and high-middle SDI countries (53·2 [48·8-57·9] per 100 000 person-years), while the highest age-standardised mortality rates were in low-middle SDI (14·2 [12·9-15·6] per 100 000 person-years) and middle SDI (13·6 [12·6-14·8] per 100 000 person-years) countries. In 2019, adolescent and young adult cancers contributed 23·5 million (21·9-25·2) DALYs to the global burden of disease, of which 2·7% (1·9-3·6) came from YLDs and 97·3% (96·4-98·1) from YLLs. Cancer was the fourth leading cause of death and tenth leading cause of DALYs in adolescents and young adults globally.

INTERPRETATION

Adolescent and young adult cancers contributed substantially to the overall adolescent and young adult disease burden globally in 2019. These results provide new insights into the distribution and magnitude of the adolescent and young adult cancer burden around the world. With notable differences observed across SDI settings, these estimates can inform global and country-level cancer control efforts.

FUNDING

Bill & Melinda Gates Foundation, American Lebanese Syrian Associated Charities, St Baldrick's Foundation, and the National Cancer Institute.

Cervical Cancer and Human Papillomavirus Vaccine Knowledge, Utilisation, Prevention Educational Interventions and Policy Response in Nigeria: A Scoping Review

PURPOSE

This review evaluated the knowledge, utilisation, prevention education, and policy response across the six geopolitical regions of Nigeria to inform national efforts for the prevention and control of cervical cancer.

METHODS

A keyword-based systematic search was conducted in PubMed/MEDLINE (NCBI), Google Scholar, and AJOL electronic databases, including a manual scan of papers, journals and websites to identify relevant peer-reviewed studies. Articles were screened and assessed for eligibility.

RESULTS

Many (158) articles were downloaded and after duplicates were removed, 110 articles were included in the final analysis. These were made up of qualitative, quantitative (cross-sectional), intervention and policy studies. Studies have generally reported poor knowledge and awareness of cervical cancer screening but those carried out in urban areas demonstrated a slightly higher level of awareness of Human Papilloma Virus (HPV) vaccine, HPV vaccination uptake and utilization of cervical cancer preventive services than the rural studies. The studies did not show strong government support or policies in relation to cervical cancer control.

CONCLUSION

Knowledge and uptake of cervical cancer preventive services across diverse groups in Nigeria remain poor. These could be linked to socio-cultural factors, the lack of an organised cervical cancer screening programme and low financial resource pool for cervical cancer prevention. Therefore, it is necessary to increase government, donor prioritisation and political support in order to ensure increased investment and commitment to cervical cancer elimination in Nigeria.

Perceptions of participation in school and association with health and wellbeing: comparison among Nigerian and Irish pupils

School participation among pupils is considered a key value of the health promoting school approach. However, few studies have documented the relationship between the school participation of pupils and health and wellbeing outcomes in different geographical contexts, especially looking at developing and developed country contexts. This study investigated the perceptions of Nigerian and Irish pupils on participation in school and reported health and wellbeing. Data was collected using self-completed questionnaires among 333 and 231 primary school pupils in 4th, 5th and 6th classes across 17 schools in Nigeria and Ireland. Logistic regression analysis was used to analyse the data from both countries. There was no statistically significant difference in the mean scores for participation in school activities (NIG mean = 22.8, SD 3.5; IRE mean = 22.3, SD 3.4) and school events (NIG mean = 18.8, SD 3.7; IRE mean = 17.1, SD 3.6). However, participation in school decisions and rules (NIG mean = 17.3, SD 4.7; IRE mean = 15.8, SD 3.6) and health and wellbeing (NIG mean = 16.9, SD 1.7; IRE mean = 15.3, SD 2.4) scores were significantly higher among Nigerian pupils, while positive perception of school participation (NIG mean = 24.2, SD 4.1; IRE mean = 26.2, SD 3.4) was significantly higher among Irish pupils. The findings suggest that Irish and Nigerian pupils have positive perceptions of their schools irrespective of their location and levels of development. However, further research using qualitative approaches might be needed to better clarify dimensions of pupils' perceptions of school life and school participation among Nigerian pupils in order to substantiate these claims.

Urban Poor Community Settings' Knowledge and Screening Practices for Cervical Cancer in Ibadan, Nigeria

PURPOSE

This study investigated knowledge and screening practices for cervical cancer among two urban poor community settings in Ibadan, Nigeria.

METHODS

A cross-sectional design was used. ODK tool was used to collect quantitative data among a sample size of 500 respondents. Data were analyzed using IBM SPSS version 21 for descriptive and inferential statistics. Scores for knowledge were on a scale of 0-39 points (0-18 low, 19-23 fair, and 24-39 high knowledge).

RESULTS

A majority of respondents (77.2%) had low knowledge of cervical cancer and were not aware (93.6%) of the Papanicolaou test (Pap smear test) or cervical cancer screening (91.2%). Very few women (10%) were aware of the human papillomavirus vaccine for the prevention of cervical cancer, 4% had been screened with the Papanicolaou test, and one woman (0.3%) with visual inspection with acetic acid. Four (1.1%) women had taken human papillomavirus vaccine before.

CONCLUSION

The findings of this study have underscored a necessity for increased awareness creation through health promotion interventions and strategies to alleviate low knowledge, prevention, and screening practices for cervical cancer in poor community settings in Nigeria.

Prevalence and Factors Associated With Alcohol Use in Selected Urban Communities in Ibadan, Nigeria

Nigeria is ranked high among African countries in the consumption of alcohol and the national adult per capita consumption was estimated at 12.3litres. Harmful alcohol use is the sixth leading cause of disability and deaths in Nigeria. This study assessed the prevalence and factors associated with alcohol use in selected urban communities in Ibadan, Nigeria. This community-based cross sectional study was conducted among 500 respondents in two selected urban communities in Ibadan, Nigeria. The World Health Organization STEPS tool was used to collect data on socio-demographic characteristics of respondents and the history of alcohol use. Alcohol users were categorized into ever consumed, current consumers, consumers within last 12 months, and frequent consumers within 30 days (low, medium, and high consumers).Chi-square analysis was used to identify factors associated with the different categories of alcohol consumption. The mean age of the respondents was 35.36 ± 12.24 years. Almost one third of the participants (29.0%) reported they had ever consumed alcohol and (13.6%) had consumed alcohol within 30 days prior to the study. Factors significantly associated with the ever-use of alcohol were gender (p = 0.000), and income (p = 0.000). Current use of alcohol had a statistically significant relationship with male gender (p = 0.000). The prevalence of high alcohol use is low in the sample of urban communities studied, and factors influencing include sex, marital status, level of education, income. These results should inform policy decisions to address the alcohol use in urban communities in Southwest Nigeria.

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages.

METHODS

Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0-100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target-1 billion more people benefiting from UHC by 2023-we estimated additional population equivalents with UHC effective coverage from 2018 to 2023.

FINDINGS

Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2-47·5) in 1990 to 60·3 (58·7-61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9-3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010-2019 relative to 1990-2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6-421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0-3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5-1040·3]) residing in south Asia.

INTERPRETATION

The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people-the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close-or how far-all populations are in benefiting from UHC.

FUNDING

Bill & Melinda Gates Foundation.

Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries.

METHODS

GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution.

FINDINGS

Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990-2010 time period, with the greatest annualised rate of decline occurring in the 0-9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10-24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10-24 years were also in the top ten in the 25-49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50-74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI.

INTERPRETATION

As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and development investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve.

FUNDING

Bill & Melinda Gates Foundation.

Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease.

METHODS

GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk-outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk-outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk-outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden.

FINDINGS

The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10·8 million (95% uncertainty interval [UI] 9·51-12·1) deaths (19·2% [16·9-21·3] of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8·71 million (8·12-9·31) deaths (15·4% [14·6-16·2] of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253-350) DALYs (11·6% [10·3-13·1] of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0-9 years, the three leading detailed risk factors for attributable DALYs were all related to malnutrition. Iron deficiency was the leading risk factor for those aged 10-24 years, alcohol use for those aged 25-49 years, and high systolic blood pressure for those aged 50-74 years and 75 years and older.

INTERPRETATION

Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public.

FUNDING

Bill & Melinda Gates Foundation.

Estimating global injuries morbidity and mortality: methods and data used in the Global Burden of Disease 2017 study

BACKGROUND

While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria.

METHODS

In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced.

RESULTS

GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes.

CONCLUSIONS

GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future.

Global injury morbidity and mortality from 1990 to 2017: results from the Global Burden of Disease Study 2017

BACKGROUND

Past research in population health trends has shown that injuries form a substantial burden of population health loss. Regular updates to injury burden assessments are critical. We report Global Burden of Disease (GBD) 2017 Study estimates on morbidity and mortality for all injuries.

METHODS

We reviewed results for injuries from the GBD 2017 study. GBD 2017 measured injury-specific mortality and years of life lost (YLLs) using the Cause of Death Ensemble model. To measure non-fatal injuries, GBD 2017 modelled injury-specific incidence and converted this to prevalence and years lived with disability (YLDs). YLLs and YLDs were summed to calculate disability-adjusted life years (DALYs).

FINDINGS

In 1990, there were 4 260 493 (4 085 700 to 4 396 138) injury deaths, which increased to 4 484 722 (4 332 010 to 4 585 554) deaths in 2017, while age-standardised mortality decreased from 1079 (1073 to 1086) to 738 (730 to 745) per 100 000. In 1990, there were 354 064 302 (95% uncertainty interval: 338 174 876 to 371 610 802) new cases of injury globally, which increased to 520 710 288 (493 430 247 to 547 988 635) new cases in 2017. During this time, age-standardised incidence decreased non-significantly from 6824 (6534 to 7147) to 6763 (6412 to 7118) per 100 000. Between 1990 and 2017, age-standardised DALYs decreased from 4947 (4655 to 5233) per 100 000 to 3267 (3058 to 3505).

INTERPRETATION

Injuries are an important cause of health loss globally, though mortality has declined between 1990 and 2017. Future research in injury burden should focus on prevention in high-burden populations, improving data collection and ensuring access to medical care.

Experience of Stress and Coping Mechanism Among Police Officers in South Western Nigeria

Prior research on stress among police officers in Nigeria is limited. Most researchers have focused on the predictors of workplace stress among the police officer, and fewer still have examined their coping mechanisms. This study assessed the stress experienced and coping mechanism among police officers in Ibadan Metropolis, Oyo State, Nigeria. The study was a descriptive cross-sectional study, which utilized a pretested self-administered questionnaire. The study population included 342 selected respondents using a multistage sampling technique from police stations in Ibadan North Local Government, Oyo State, Nigeria. The data were analyzed using descriptive statistics, χ² test, and Fisher's exact test at p = .05. Results revealed that majority (92.5%) of the respondents had poor knowledge of stress with a mean knowledge of 5.4 ± 1.7. Majority (80.1%) of the respondents reported experience of stress such as feeling depressed sometimes at work, while 60.5% said that they usually have headache and body ache. In addition, 36.9% had good coping mechanism and more than half (58.8%) had a fair coping mechanism with a mean coping score of 5.0 ± 3.0. This study showed that knowledge of stressors was poor and respondents perceived that they experienced stress and its symptoms. Strategies such as training using teaching, discussion, and explanation to educate the police officers about stress and its coping mechanism and policy interventions to facilitate the construction of standard stress management centers would be appropriate strategies to reduce stress, increase the knowledge of police officers on stressors, and enhance their coping mechanism.

Knowledge and Screening Practices for Cervical Cancer Among Urban Poor Communities in Ibadan, Nigeria

PURPOSE

Prevalence of cervical cancer remains high in sub-Saharan Africa, including Nigeria. Literature has documented knowledge of cervical cancer as important in promoting the adoption of preventive strategies, including screening, but most research has focused on women and health organization settings. This study assessed knowledge and screening practices of cervical cancer among male and female adults in urban poor communities in Ibadan, Oyo State, Nigeria.

METHODS

A cross-sectional study was carried out in two urban poor community settings in Ibadan. Data were collected from 250 randomly selected consenting respondents in each of the two communities (N = 500). Data were collected with an electronic device using the electronic data capture tool (Open Data Kit) database. Descriptive statistics were summarized using frequencies and percentages for categorical variables, and mean and standard deviation were used for continuous variables. Knowledge was scored on a scale of 0 to 39 points (0 to 18, low knowledge; 19 to 23, fair knowledge; 24 to 39, high knowledge). Associations between variables were tested using χ2.

RESULTS

Mean age of respondents was 35.36 years (± 12.24). The majority of respondents were female (70.6%), and more than half (52.6%) had completed secondary school education. The majority had never heard of the Papanicolaou test (93.6%) or cervical cancer screening (91.2%), and only 10% had ever heard of the human papillomavirus vaccine for the prevention of cervical cancer. The majority had low knowledge of cervical cancer (77.2%); knowledge included detection, symptoms, and risk factors for cervical cancer. Only 7.4% of females had ever heard of the Papanicolaou test, and few women (4%) had ever been screened for cervical cancer using the Papanicolaou test. Only one woman (0.2%) had been screened for cervical cancer using visual inspection with acetic acid, and four (0.8%) had ever taken human papillomavirus vaccine for protection against cervical cancer. There was a significant association between knowledge of cervical cancer and employment status of respondents (χ2 = 11.19; P < .05).

CONCLUSION

Health promotion interventions and strategies for awareness creation about cervical cancer and screening practices should be used in alleviating low knowledge and screening practices in urban poor communities.

Access to Information on Family Planning and Use of Modern Contraceptives Among Married Igbo Women in Southeast, Nigeria

This study was conducted among married Igbo women in Nigeria who have the lowest median birth interval coupled with a culture of sex preference and low use of modern contraceptives. We examined the relationship between access to information on family planning and sex preference on the use of modern contraceptive (MC). The 2013 Nigeria Demographic and Health Survey data were used. The data of 1,661 women of reproductive age were analyzed in this study. Access to information on family planning was low, and almost half (48.6%) of the women had a score of zero. Controlling for possible confounding variables, the data show that women who have good (odds ratio [ OR]= 3.92; CI [2.28, 6.75], p < .001) and poor ( OR = 2.56; CI [1.85, 3.56], p < .001) access to information on family planning were more likely to use MC than those with no access to information on family planning. Sex preference showed no relationship with the use of MC. Families where husbands want more children than their wives inhibit ( OR = 0.62, CI [0.42, 0.90], p < .05) the use of MC compared with those families where husbands and wives fertility desire is the same. Public health programs by government and donors should intensify interventions to increase access to family planning information to promote the use of MC among married Igbo women.

Relationship Between Parenting Styles and Adolescents’ Self-Esteem

Poor self-esteem among adolescents poses a great challenge, which parenting styles can influence. This study examined gender differences in perceived parenting styles and self-esteem of adolescents and examined the relationship between perceived parenting styles and adolescents’ self-esteem among in-school adolescents in Ibadan, Oyo State, Nigeria. This study utilized a multistage sampling technique. Responses were elicited from 504 consenting pupils using the parental authority questionnaire and a self-esteem questionnaire adjusted to the Rosenberg scale. Self-esteem was scored on a (12–30) scale; scores ≥ 26 indicate high self-esteem, and scores ≤ 25 indicate low self-esteem. The mean age and self-esteem score were 14.9±1.5 years and 24.0±3.3. About one third of respondents reported parenting styles as authoritative or flexible (fathers: 36.3%, mothers: 38.9%). Pearson correlation coefficient test showed a positive significant relationship between flexible parenting style and adolescent self-esteem for fathers ( r = 0.141, p = .001) and mothers ( r = 0.137, p = .001). Research findings reveal significant association between perceived parenting styles and adolescents’ self-esteem.

A Qualitative Study of Intimate Partner Violence Among Women in Nigeria

Negative health outcomes caused by intimate partner violence (IPV) have been recognized as a public health problem with extensive effects on the society. Cultural and traditional beliefs that reinforce IPV in Nigeria need to be understood to guide public health approaches aimed at preventing IPV. The purpose of this study was to determine women's attitudes and societal norms that support IPV, causes and consequences of IPV, and coping strategies, and to document suggested measures to prevent it. Six focus group discussions (FGDs) were conducted among 56 women aged 15 to 49 years purposively selected from rural and urban communities in Akinyele Local Government Area (LGA) of Oyo State, Nigeria. The FGDs were conducted in Yoruba language, translated to English, and analyzed using thematic approach. Findings were grouped into six major themes: triggers, societal norms, attitude, consequences, coping strategies, and preventive measures. Women reported experience of physical, psychological, and sexual violence and controlling behavior. Major causes of IPV reported by the women were having more money than partner, and building a house or having a business without partner's knowledge. Most participants reported that social norms dictate that a woman should have full regard for in-laws, and submit to and agree with all that the partner says and does. Most of the discussants in both the urban and rural areas reported that violence in any form is not justifiable or acceptable. Participants mentioned various ways through which IPV negatively impacted on women's health such as depression, hypertension, and damage to the reproductive system. They were however willing to endure suffering because of their children. Women who experienced IPV reported to close relatives but did not seek legal redress because these were unavailable. Ending IPV requires long-term commitment and strategies involving contributions from the government, community, and the family.

Socio-ecological school environments and children’s health and wellbeing outcomes

Purpose

– Attention to improving the school environment is a common activity in school health promotion. The role of the school environment in supporting improved health and wellbeing has a theoretical base, but has rarely been directly investigated empirically. The purpose of this paper is to investigate the associations between school socio-ecological environment and health and wellbeing outcomes.

Design/methodology/approach

– Questionnaire data were collected from 231 pupils in nine primary schools: urban and rural; single and mixed gender; disadvantaged and non-disadvantaged; and health promoting schools (HPS) and non-HPS. Questionnaire items included perceptions of the school socio- ecological environment (school perception, class relationships, teacher relationships, school policy and parental participation) and health and wellbeing outcomes.

Findings

– Reported school perception (OR 1.21, 95 per cent CI 1.12-1.30), class relationships (OR 1.13, 95 per cent CI 1.06-1.21), relationship with teacher (OR 1.20, 95 per cent CI 1.11-1.29), perception of school policy (OR 1.25, 95 per cent CI 1.13-1.37) and parents’ participation in school life (OR 1.32, 95 per cent CI 1.15-1.51) were all significantly associated with health and wellbeing outcomes for all groups of pupils. Very few differences emerged between different school types on the measures of either school socio-ecological environment or measures of health and wellbeing.

Originality/value

– The socio-ecological environment is clearly related to general health and wellbeing outcomes, which underlines its relevance to school health promotion. The lack of discernable differences between HPS and non-HPS demonstrate the lack of clarity in definitions of the health promoting status of schools.

Children's participation in school: a cross-sectional study of the relationship between school environments, participation and health and well-being outcomes

Background

Schools are a key setting for health promotion and improvement activities and the psycho-social environment of the school is an important dimension for promoting the health and well-being of children. The development of Health Promoting Schools (HPS) draws on the settings-based approach to health promotion and includes child participation as one of its basic values. This paper investigates the relationships between child participation, the school environment and child outcomes.

Methods

Study participants were recruited from nine primary schools, three of which were designated as Health Promoting Schools (HPS). Each HPS was matched with two non-HPS (NHPS) with similar characteristics. Two hundred and thirty-one pupils in the 4th-6th class groups completed self-report questionnaires to document their perspectives on the school socio-ecological environment, how they take part in school life, school processes and their health and well-being.

Results

School participation was measured with four scales: participation in school decisions and rules, school activities, school events and positive perception of school participation. The differences in the reported mean score for three of the four scales were marginal and not statistically significant. However, the mean score for reported positive perception of school participation was significantly lower (χ² = 5.13, df =1, p < 0.05) among pupils in HPS (mean = 26.03; SD 3.37) compared to NHPS (mean = 26.30; SD 3.36). Participation in school decisions and rules (OR 1.22, 95% CI 1.12-1.33), participating in school activities (OR 1.20, 95% CI 1.10-1.31), participating in school events (OR 1.19, 95% CI 1.10-1.29) and reported positive perception of school participation (OR 1.26, 95% CI 1.15-1.39) were all positively associated with health and well-being outcomes for all pupils. Logistic regression analyses indicated positive associations between school participation and school socio-ecological environment.

Conclusions

These findings suggest that school participation is important for children in schools and is relevant for improved school environment, relationships and positive health and well-being outcomes. The positive associations between school participation and school socio-ecological environment and health and well-being outcomes suggests that pupil health and well-being and school relationships could be improved or sustained by providing or supporting an environment that encourages pupil participation in school life.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-964) contains supplementary material, which is available to authorized users.