The COVID-19 pandemic interrupted and, in some cases, transformed the way health visiting teams work, the way they interact with families and children and with the wider community and other service providers. Health visiting services are organised, delivered and experienced differently in different places, with little evidence to suggest what works best, for whom and in what contexts. To synthesise the evidence on changes during the pandemic to identify the potential for improving health visiting services and their delivery in the United Kingdom. This realist review engaged professional stakeholders (N = 28) and those caring for babies during the pandemic (N = 6) throughout the process. We searched five electronic databases for publications on health visiting during the COVID-19 pandemic from October 2022 to April 2023. This was followed by citation searching and review of organisational websites. Programme theory was iteratively refined through discussions with the team, professional stakeholders and people with lived experience and was translated into key findings and recommendations. One hundred and eighteen documents informed this review; most focused on health visiting in England (56%) or the United Kingdom (34%), with relatively few from Wales (6%), Scotland (3%) and Northern Ireland (1%). Documents highlighted the widespread, uneven and lasting impact of the COVID-19 pandemic on babies and families. Findings revealed significant concerns expressed by both families and practitioners and corresponding actions taken by health visiting services. These concerns and responses emphasised the flexibility and resourcefulness of health visitors, the vital role of trusting relationships between health visitors and families and the importance of holistic assessments for early intervention. Changes in service delivery were varied and were not always evaluated or sustainable. While the data illuminated some of the hidden complexities of health visiting practice, limited evidence was found on decision-making at organisational and managerial levels during the pandemic response. Included papers were predominantly from an advocacy or practitioner perspective, and few focused on health visiting in Scotland, Wales and Northern Ireland. Our focus on the universal health visiting pathways meant that documents pertaining to additional support received by the most vulnerable families might have been excluded. Experiences of Black, Asian and minority ethnic families and staff were illustrated in several papers. The COVID-19 pandemic highlighted the essential role of health visitors in safeguarding child and family well-being in the United Kingdom. While digital adaptations provide necessary continuity, face-to-face interactions remain essential for effective health visiting. The crisis exposed pre-existing workforce pressures and inconsistencies in service provision, emphasising the need for adequate support and funding. Policy-makers must recognise the complexity of health visiting and ensure sustained investment in universal home visiting services. Future resilience requires a realistic understanding of health visitors' work, integration into broader child health policies and enhanced interagency collaboration to address inequalities and improve long-term public health outcomes. Our implications for policy-makers will be translated into reflexive questions to prompt critical thinking about health visiting services in local areas. The small number of documents from countries outside England highlights this as a key area for future research. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR134986. Health visiting services provide checks and support for every child in the United Kingdom up to 5-year-olds. These services are organised and delivered differently across the United Kingdom, and there were further changes during the COVID-19 pandemic. We wanted to learn what happened and how health visiting services might be improved in the future. We carried out a review of published research and information from organisations about what has happened in health visiting services since March 2020. We also involved 28 professional stakeholders in our study, and 6 people with lived experience of caring for babies during the pandemic. They helped us make sense of the findings. Of the 118 documents in our review, most came from charities, professional organisations or health visitors. Most documents focused on England rather than other parts of the United Kingdom. Findings showed concerns from parents and health visitors about how the pandemic affected children’s health and development. Health visitors worked hard to adapt with new ways to support families. But, not all these changes were evaluated or were sustainable in the long run. Trusting relationships between families and health visitors were key, and early checks on a child’s well-being remained essential. However, there was little information on how big decisions were made at a management or policy level during the pandemic. The pandemic underlined the vital role of health visitors in protecting young children and their families. While video calls and online services helped maintain some level of support, they could not replace face-to-face visits, which are crucial for identifying concerns early. The pandemic also revealed existing problems, such as staff shortages and uneven service delivery across the United Kingdom. To ensure families get the support they need, health visiting services need adequate funding, integration into broader child health policies and strengthened collaboration between different services.
African American and rural-dwelling family caregivers of persons with newly diagnosed advanced cancer perform critical, time-intensive tasks and historically have had limited resources to support their role. To determine the effect of a lay coach-led, early palliative care telehealth intervention (Educate, Nurture, Advise, Before Life Ends [ENABLE] Cornerstone) for African American and rural-dwelling family caregivers of patients with advanced cancer on caregiver and patient outcomes at 24 weeks. This single-blind randomized clinical trial was conducted from January 2020 to May 2025 at outpatient oncology clinics at 2 large cancer centers in the Southeastern US. Participants were African American and rural-dwelling family caregivers aged 21 years or older self-identifying as an unpaid close friend or family member who is involved with the day-to-day medical care of a patient with advanced cancer. The intervention included 6 weekly, 20- to 60-minute psychosocial telephonic sessions facilitated by a trained lay coach plus monthly follow-up. Usual care consisted of mailed pamphlets outlining resources for families at each of the cancer centers. The primary outcome was caregiver distress (anxiety and depressive symptoms as measured by the Hospital Anxiety and Depression Scale [HADS]) at 24 weeks. Secondary outcomes were caregiver and patient quality of life (QOL; measured with the Patient-Reported Outcomes Measurement Information System Global Health Short Form), caregiver burden (Montgomery-Borgatta Caregiver Burden Scale), and patient distress (HADS). Outcomes were assessed using baseline-constrained linear mixed-effects models. A total of 222 family caregivers (mean [SD] age, 55.5 [14.7] years; 169 [76.1%] female; 114 [51.4%] African American; 101 White [45.5%]; 7 other race [3.2%]) and 165 patients (mean [SD] age, 60.7 [12.2] years; 98 [59.4%] female; 79 African American [47.9%]; 84 White [50.9%]; 2 other race [1.2%]) were randomized. At week 24, no relevant between-group differences were observed in caregiver HADS anxiety (mean [SE] baseline-adjusted difference, 0.23 [0.44]; Cohen d = 0.05; 95% CI, -0.14 to 0.24; P = .60) or HADS depressive symptom scores (mean [SE] baseline-adjusted difference, 0.04 [0.41]; Cohen d = 0.01; 95% CI, -0.19 to 0.21; P = .91). For all other outcomes, 24-week differences were of small magnitude and not statistically significant. Exploratory sensitivity analyses of caregivers distressed at baseline indicated improvements in caregiver anxiety (mean [SE] baseline-adjusted difference, -1.21 [0.53]; Cohen d = -0.38; 95% CI, -0.70 to -0.05) and patient mental health QOL (mean [SE] baseline-adjusted difference, 3.00 [1.37]; Cohen d = 0.45; 95% CI, 0.04 to 0.86), but no statistically significant differences in caregiver burden (mean [SE] baseline-adjusted difference, -1.15 [0.69]; Cohen d = -0.32; 95% CI, -0.71 to 0.06) and patient depression (mean [SE] baseline-adjusted difference, -1.30 [0.71]; Cohen d = -0.37; 95% CI, -0.77 to 0.03). This randomized clinical trial of a telehealth intervention for African American and rural-dwelling caregivers of patients with advanced cancer found no differences in caregiver and patient outcomes at 24 weeks. However, an exploratory sensitivity analysis indicated potential improvements in caregiver anxiety and patient mental health QOL. ClinicalTrials.gov Identifier: NCT04318886.
We conducted a cross-sectional cohort study to assess how continuity of primary care within community-based health centers (CHCs) might have changed during the years surrounding the COVID-19 pandemic and how continuity varied by patient and visit characteristics. In a national sample of CHCs providing primary care, we assessed the usual provider of care (UPC) index-the fraction of patient visits to the patient's most frequently seen clinician within the CHC-for patients with at least 2 primary care encounters within a calendar year during 2019-2023. We used age-stratified multilevel logit analyses to assess patient, clinic, and visit characteristics associated with the perfect UPC index of 1 in 2023. Among an annual average of 353,608 patients seen in an average of 186 CHCs, the median UPC index was 1 in each year, with the mean index varying from a low of 0.822 in 2020 to a high of 0.831 in 2021. In the 2023 sample, logit analyses adjusted for clustering of patients within clinics found that among adults, the likelihood of achieving a UPC index of 1 was higher for patients who were middle-aged or older and had an income greater than 138% of the federal poverty level or an unknown income, whereas it was lower for patients who were of Hispanic ethnicity, were of Black/African American race, had multimorbidity, had a telehealth visit, and received care at large clinics. Among children, the likelihood of achieving a UPC of 1 was lower for those who were of Hispanic ethnicity, had a telehealth visit, and received care at large clinics. In a large national sample of patients seen at CHCs, continuity of primary care within CHCs remained high before, during, and after the COVID-19 pandemic, and was associated with practice and patient characteristics that provide targets for systemic intervention. Although health care systems explore different approaches to balance continuity with easy access, CHCs continue to value and deliver high-continuity care.
Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. Gates Foundation.
For more than three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has provided a framework to quantify health loss due to diseases, injuries, and associated risk factors. This paper presents GBD 2023 findings on disease and injury burden and risk-attributable health loss, offering a global audit of the state of world health to inform public health priorities. This work captures the evolving landscape of health metrics across age groups, sexes, and locations, while reflecting on the remaining post-COVID-19 challenges to achieving our collective global health ambitions. The GBD 2023 combined analysis estimated years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 375 diseases and injuries, and risk-attributable burden associated with 88 modifiable risk factors. Of the more than 310 000 total data sources used for all GBD 2023 (about 30% of which were new to this estimation round), more than 120 000 sources were used for estimation of disease and injury burden and 59 000 for risk factor estimation, and included vital registration systems, surveys, disease registries, and published scientific literature. Data were analysed using previously established modelling approaches, such as disease modelling meta-regression version 2.1 (DisMod-MR 2.1) and comparative risk assessment methods. Diseases and injuries were categorised into four levels on the basis of the established GBD cause hierarchy, as were risk factors using the GBD risk hierarchy. Estimates stratified by age, sex, location, and year from 1990 to 2023 were focused on disease-specific time trends over the 2010-23 period and presented as counts (to three significant figures) and age-standardised rates per 100 000 person-years (to one decimal place). For each measure, 95% uncertainty intervals [UIs] were calculated with the 2·5th and 97·5th percentile ordered values from a 250-draw distribution. Total numbers of global DALYs grew 6·1% (95% UI 4·0-8·1), from 2·64 billion (2·46-2·86) in 2010 to 2·80 billion (2·57-3·08) in 2023, but age-standardised DALY rates, which account for population growth and ageing, decreased by 12·6% (11·0-14·1), revealing large long-term health improvements. Non-communicable diseases (NCDs) contributed 1·45 billion (1·31-1·61) global DALYs in 2010, increasing to 1·80 billion (1·63-2·03) in 2023, alongside a concurrent 4·1% (1·9-6·3) reduction in age-standardised rates. Based on DALY counts, the leading level 3 NCDs in 2023 were ischaemic heart disease (193 million [176-209] DALYs), stroke (157 million [141-172]), and diabetes (90·2 million [75·2-107]), with the largest increases in age-standardised rates since 2010 occurring for anxiety disorders (62·8% [34·0-107·5]), depressive disorders (26·3% [11·6-42·9]), and diabetes (14·9% [7·5-25·6]). Remarkable health gains were made for communicable, maternal, neonatal, and nutritional (CMNN) diseases, with DALYs falling from 874 million (837-917) in 2010 to 681 million (642-736) in 2023, and a 25·8% (22·6-28·7) reduction in age-standardised DALY rates. During the COVID-19 pandemic, DALYs due to CMNN diseases rose but returned to pre-pandemic levels by 2023. From 2010 to 2023, decreases in age-standardised rates for CMNN diseases were led by rate decreases of 49·1% (32·7-61·0) for diarrhoeal diseases, 42·9% (38·0-48·0) for HIV/AIDS, and 42·2% (23·6-56·6) for tuberculosis. Neonatal disorders and lower respiratory infections remained the leading level 3 CMNN causes globally in 2023, although both showed notable rate decreases from 2010, declining by 16·5% (10·6-22·0) and 24·8% (7·4-36·7), respectively. Injury-related age-standardised DALY rates decreased by 15·6% (10·7-19·8) over the same period. Differences in burden due to NCDs, CMNN diseases, and injuries persisted across age, sex, time, and location. Based on our risk analysis, nearly 50% (1·27 billion [1·18-1·38]) of the roughly 2·80 billion total global DALYs in 2023 were attributable to the 88 risk factors analysed in GBD. Globally, the five level 3 risk factors contributing the highest proportion of risk-attributable DALYs were high systolic blood pressure (SBP), particulate matter pollution, high fasting plasma glucose (FPG), smoking, and low birthweight and short gestation-with high SBP accounting for 8·4% (6·9-10·0) of total DALYs. Of the three overarching level 1 GBD risk factor categories-behavioural, metabolic, and environmental and occupational-risk-attributable DALYs rose between 2010 and 2023 only for metabolic risks, increasing by 30·7% (24·8-37·3); however, age-standardised DALY rates attributable to metabolic risks decreased by 6·7% (2·0-11·0) over the same period. For all but three of the 25 leading level 3 risk factors, age-standardised rates dropped between 2010 and 2023-eg, declining by 54·4% (38·7-65·3) for unsafe sanitation, 50·5% (33·3-63·1) for unsafe water source, and 45·2% (25·6-72·0) for no access to handwashing facility, and by 44·9% (37·3-53·5) for child growth failure. The three leading level 3 risk factors for which age-standardised attributable DALY rates rose were high BMI (10·5% [0·1 to 20·9]), drug use (8·4% [2·6 to 15·3]), and high FPG (6·2% [-2·7 to 15·6]; non-significant). Our findings underscore the complex and dynamic nature of global health challenges. Since 2010, there have been large decreases in burden due to CMNN diseases and many environmental and behavioural risk factors, juxtaposed with sizeable increases in DALYs attributable to metabolic risk factors and NCDs in growing and ageing populations. This long-observed consequence of the global epidemiological transition was only temporarily interrupted by the COVID-19 pandemic. The substantially decreasing CMNN disease burden, despite the 2008 global financial crisis and pandemic-related disruptions, is one of the greatest collective public health successes known. However, these achievements are at risk of being reversed due to major cuts to development assistance for health globally, the effects of which will hit low-income countries with high burden the hardest. Without sustained investment in evidence-based interventions and policies, progress could stall or reverse, leading to widespread human costs and geopolitical instability. Moreover, the rising NCD burden necessitates intensified efforts to mitigate exposure to leading risk factors-eg, air pollution, smoking, and metabolic risks, such as high SBP, BMI, and FPG-including policies that promote food security, healthier diets, physical activity, and equitable and expanded access to potential treatments, such as GLP-1 receptor agonists. Decisive, coordinated action is needed to address long-standing yet growing health challenges, including depressive and anxiety disorders. Yet this can be only part of the solution. Our response to the NCD syndemic-the complex interaction of multiple health risks, social determinants, and systemic challenges-will define the future landscape of global health. To ensure human wellbeing, economic stability, and social equity, global action to sustain and advance health gains must prioritise reducing disparities by addressing socioeconomic and demographic determinants, ensuring equitable health-care access, tackling malnutrition, strengthening health systems, and improving vaccination coverage. We live in times of great opportunity. Gates Foundation and Bloomberg Philanthropies.
BACKGROUND: Despite the growing recognition of oral health as a vital component of overall well-being, utilization of dental services in many low- and middle-income countries remains low. In Nigeria, oral health-seeking behavior is often delayed, reactive, and shaped by complex socio-cultural and economic factors. Understanding these influences is essential to developing responsive oral health policies and interventions. OBJECTIVE: This study explored the perceptions of Nigerian adults regarding the factors influencing their choice of oral health care and how these choices impact their oral health-related quality of life (OHRQoL). METHODS: A qualitative study using a thematic approach was conducted at the Dental Centre of the University College Hospital, Ibadan. Twenty-five purposively selected adult patients attending the clinic for the first time participated in in-depth, semi-structured interviews. Interviews were conducted in English or Yoruba, transcribed, and thematically analyzed using ATLAS.ti 8. Data saturation, the point at which no new themes or concepts were emerging from subsequent interviews, was reached and reflexivity was maintained throughout the study to reduce bias. RESULTS: Three overarching themes emerged: (1) Factors driving care-seeking behavior, (2) Influencers of oral healthcare choices, and (3) The perceived impact of these choices on oral health-related quality of life. Most participants sought care only in response to pain, highlighting a predominantly symptom-driven pattern of behavior. Key barriers included financial constraints, fear of dental procedures, limited accessibility to services, and misinformation, often passed through family or community networks. Influences such as spousal encouragement, social media exposure, and self-motivation also shaped healthcare decisions. Participants reported that delayed care adversely affected their quality of life, contributing to physical discomfort, psychological distress, and reduced self-esteem. CONCLUSION: Oral health-seeking behavior among Nigerian adults is influenced by a complex interplay of economic, cultural, psychological, and systemic factors. Addressing these barriers requires multi-level interventions, including community-based oral health education, integration of dental services into primary healthcare, expansion of insurance coverage, and patient-centered clinical care. Leveraging social media for accurate health communication and fostering early health education through schools and family-centered programs are also recommended. These findings provide critical insights for policymakers, healthcare providers, and researchers aiming to improve oral health outcomes in Nigeria.
Women in many developing nations lack information about family spacing and contraceptives. Thus, nations worldwide frequently employ mass media to promote family planning and raise public awareness. Therefore, this study aims to ascertain the prevalence and factors associated with exposure messages on family planning among reproductive-age women in five sub-Saharan African countries. Demographic and Health Survey data (2021-2023) from five sub-Saharan African countries (n = 48,133 women of reproductive age) were analyzed using STATA 17. Multilevel mixed-effects logistic regression identified significant factors (p < 0.05) associated with family planning message exposure, interpreted via adjusted odds. The prevalence of exposure to family planning messages was 56.29%. Maternal age groups 25-34 and 35-49 had adjusted odds ratios (AOR) of 1.49 and 1.59, one by one (95% CI: 1.36-1.64, 1.44-1.76). Maternal education levels primary, secondary, and higher had AORs of 1.52, 2.08, and 3.17, accordingly with (95% CI: 1.43-1.61, 1.95-2.23, 2.75-3.66) sequentially. Employed women had an AOR of 1.61 (95% CI: 1.54-1.69). Middle and rich socioeconomic statuses had AORs of 1.49 and 2.16, respectively with (95% CI: 1.41-1.58, 2.03-2.30). Distance to a health facility being a significant problem had an AOR of 1.09 with (95% CI: 1.04-1.14). Antenatal care (ANC) visits of 1-3 and ≥ 4 had AORs of 1.43 and 1.58, in turn with (95% CI: 1.25-1.46, 1.39-1.78). Community variables included urban residence (AOR: 1.16, 95% CI: 1.09-1.23), low illiteracy (AOR: 0.70, with 95% CI: 0.64-0.77), and low poverty (AOR: 1.19, 95% CI: 1.09-1.23). Country categories Burkina Faso, Ghana, Mozambique, and Tanzania had AORs of 1.00, 1.62, 0.55, and 0.73, respectively. These factors were significantly associated with exposure to family planning messages. This study concluded that exposure message on family planning among reproductive-age women in five sub-Saharan African countries were high. Both individual and community-level variables as determinants of exposure message on family planning.
To conduct a systematic review of the literature on the impact of team-based primary care on downstream health care utilization (all-cause or mental health-specific emergency department (ED) visits and hospitalizations) among people with mental or substance use disorders. A literature search was conducted using the Scopus, MEDLINE, and Web of Science databases. Gray literature and forward and backward citation searches yielded additional results. Two independent reviewers screened the abstracts and full texts. Both reviewers performed a critical appraisal of the methodological quality using a modified Downs and Black checklist. The data were extracted using a standardized data extraction spreadsheet, and the effect sizes of studies were synthesized. A total of 18 studies were included (16 in the USA and 2 in Canada). Seven of the 15 studies that assessed the effect of team-based care on all-cause ED visits found they were associated with a lower number or odds of visits. Of the 15 studies that assessed the effect of team-based approaches on all-cause hospitalizations, 8 found that they were associated with an overall decrease. Very few studies assessed mental health-related ED visits (n = 2) or hospitalizations (n = 4), and the findings varied. All included studies were of fair quality (mean score ± standard deviation: 17.4 ± 1.3). Team-based care is likely associated with a decrease in all-cause ED visits and hospitalizations. A team-based primary care approach has the potential to reduce downstream healthcare utilization for patients with mental or substance use disorders and improve health outcomes.
 Climate change is impacting health and healthcare in Africa. Primary health care can improve community resilience, but only if the workforce is prepared. Pre-service training does not yet address climate change, so continuing professional development (CPD) is needed.  This study aimed to evaluate what primary care providers in sub-Saharan Africa need to know about building climate-resilient facilities and services, and how their learning needs should be addressed.  The Primary Care and Family Medicine (PRIMAFAMED) network in sub-Saharan Africa.  A descriptive exploratory qualitative study purposefully selected members of the network who had published on their experience of climate change. Snowball sampling was used to identify additional informants. Data were analysed with ATLAS.ti and the framework method.  Nine respondents from eight countries across Africa identified six major learning needs: (1) awareness of the pathways that link climate change to health and social effects and changes in the management of diseases, (2) management of diseases linked to exposure to extreme heat, (3) development of a community-orientated primary care approach that includes attention to environmental determinants of health, (4) disaster preparedness and management, (5) how to make your facility and services more climate resilient and (6) how to educate patients and communities on climate related health issues. Most respondents supported web-based approaches to CPD in their contexts.  Key learning needs were identified and will be further quantified and validated in a cross-sectional survey.Contribution: The findings will inform the development of CPD on planetary health for primary care providers in sub-Saharan Africa.
Chronic pain is a major global health challenge that impairs quality of life through physical disability, psychological distress, and socioeconomic burden. Despite its prevalence, limited research examines its multidimensional impact in South African primary healthcare. This study evaluated the quality of life and factors influencing chronic pain in patients attending a primary healthcare clinic in Gqeberha, South Africa. A cross-sectional study was conducted among 208 adults with chronic pain attending Walmer 14th Avenue Clinic. Data were collected using the Brief Pain Inventory, capturing demographics, pain severity, interference, relief, and management. Descriptive statistics, bivariate analysis, and multivariable logistic regression were performed using SPSS v29. Participants had a mean age of 50.2 years; most were female (71.6%). Back pain was most common (43.8%), while pelvic/groin pain was most severe. Pain relief was inadequate in 74% of participants, with 15.9% reporting none. Sleep was the most affected quality-of-life domain (72% interference). Predictors of higher pain interference included pain severity (p  0.001), pain relief (p = 0.003), marital status (p = 0.004), and employment status (p = 0.005). Disease-specific treatments and adjuvant therapies provided better relief than paracetamol, nonsteroidal anti-inflammatory drugs, or opioids. Severe pain and inadequate relief are prevalent in primary healthcare. Improving access to adjuvant and disease-specific therapies, as well as addressing socioeconomic factors, is thus essential for enhanced patient outcomes.Contribution: This study highlights the interplay between chronic pain, sociodemographic factors, and quality of life in South African primary care and underscores the need for tailored, multimodal, resource-sensitive pain management strategies to inform policy.
Hypertension is a leading comorbidity among people with HIV in South Africa, yet integration of hypertension screening and treatment into HIV care remains limited. To address persistent gaps in implementation, context-specific strategies grounded in implementation science frameworks are needed. This formative study aimed to develop locally relevant implementation strategies for integrating hypertension and HIV care in South African primary care clinics using the Behavior Change Wheel (BCW). Barriers to hypertension care were identified through patient interviews (n = 46), manager interviews (n = 7), and clinical staff focus group discussions (nine groups; n = 44 total participants) and were ranked by a Community Advisory Board (CAB) to inform implementation strategy development. Using the BCW, we mapped intervention functions and behavior change techniques based on prioritized barriers, then identified and specified strategies through community engagement. This process consisted of virtual meetings and workshops with CAB members, surveys, and qualitative feedback from clinic managers. Priority barriers identified included long clinic wait times, limited clinician training, poor patient understanding of hypertension, and weak information management systems. To address these barriers, the CAB identified feasible, high-priority strategies, including structured patient education, clinician training, use of care champions, providing audit and feedback, revising clinic workflows and record systems, and adding resources to support routine blood pressure checks. This study demonstrates the utility of the BCW to guide community-informed implementation strategy design. The resulting implementation strategies will be tested in a type 2 hybrid effectiveness-implementation trial to determine their impact on clinical and implementation outcomes. High blood pressure (hypertension) is common among people living with HIV in South Africa, but health clinics often do not provide treatment for high blood pressure as part of HIV care. To help close this gap, our team worked with patients, clinic staff, and community members to design practical ways to improve care for patients with HIV. We interviewed 46 patients, seven clinic managers, and held group discussions with nine groups of staff at urban clinics in Johannesburg. They described what helps or gets in the way of patients receiving good blood pressure care. Common challenges included long clinic wait times, limited training for health workers, poor patient understanding of hypertension, and weak systems for keeping records. Together with a Community Advisory Board, we reviewed these findings to identify practical ways to address barriers faced by clinics and patients. The solutions focused on gaps in patient education, limited training and support for clinic staff, inconsistent blood pressure screening, and weaknesses in clinic workflows and record keeping. Proposed approaches included patient education activities, additional staff training, use of care champions to support routine blood pressure checks, and changes to clinic processes to improve documentation and follow up. The strategies identified will be tested in future research to determine whether they improve hypertension and HIV care.
The indigenous knowledge of bonesetters and the practice of bone setting has contributed a lot to the modern medicine, and yet serving as primary source of care in low- and middle-income countries but got little attention. This study explored the indigenous knowledge of traditional bonesetters and bone-setting practice in Southwest Ethiopia. A mixed study design approach was done in southwest of Ethiopia, from August 15 to December 15, 2022. A total of 80 traditional bonesetter who predominantly manage injury and disorder to the bone and the musculoskeletal, and also health professionals were interviewed regarding their traditional knowledge and range of practice. The mean age of the study participant was 69 ± 6 and majority (99%) of them were male. Traditional bonesetters participated in this study primarily acquired their knowledge through family transmission (45%), spiritual belief or divine gift (30%), and observation or experience (25%). Qualitative interviews revealed three themes: transgenerational learning, spiritual grant often linked to twin births, and experiential practice. Most TBSs had over 20 years of experience treating fractures, dislocations, and sprains, mainly at home or via mobile visits. Diagnostic methods included history-taking, palpation, and inspection. Treatment relied on massage, splinting, and natural materials like leaves, butter, and animal skin. All TBSs emphasized that healing power resides in their hands, often viewed as a divine gift. Traditional bonesetters in Southwest Ethiopia possess rich indigenous knowledge rooted in family heritage, spiritual beliefs, and experiential learning. Their practices reflect deep cultural traditions and community trust, often passed down through generations or revealed through personal experience. Despite limited formal training, they demonstrate diagnostic skill and therapeutic effectiveness using locally available materials. Massage and splinting remain central to their treatment approach. Recognition and documentation of these practices are essential to preserve Ethiopia's healing heritage. Future collaboration with formal healthcare could enhance integration and mutual learning.
The burden of malnutrition among children under-5 in Sub-Saharan Africa (SSA) remains a significant public health concern. Traditional indices such as stunting, wasting, and underweight often failing to capture the overlapping and multifaceted nature of malnutrition. The Extended Composite Index of Anthropometric Failure (ECIAF) offers a comprehensive measure by integrating stunting, wasting, underweight and obese/overweight addressing the overlap and co-occurrence of different forms of malnutrition conditions, thus providing a more accurate depiction of nutritional deficiencies. Aligning with the Sustainable Development Goals, the ECIAF serves as a robust tool for health policymakers and public health practitioners to identify high-risk populations, allocate resources effectively, and improve health outcomes for young children in this region. This study aimed to determine the pooled prevalence of the Extended Composite Index of Anthropometric Failure and to identify its associated factors among children under-5 in SSA countries. This study is a secondary data analysis of nationally representative community-based cross-sectional Demographic and Health Surveys (DHS) conducted in Sub-Saharan African countries, including a weighted sample of 176,141 children under-5 years. The recent demographic and health survey of 26 Sub-Saharan African countries were involved in this analysis. A multilevel binary logistic regression model was fitted to identify factors associated with ECIAF in children under-5 years old. The AOR with its 95% CI was estimated, and a level of significance of 0.05 was used to determine the significant factors of ECIAF. The pooled prevalence of ECIAF among children under-5 was 36% (95% CI: 33%, 40%) in Sub-Saharan Africa. Key factors associated with increased odds of ECIAF included: increasing child age (6-23 months [AOR = 1.56; 95% CI: 1.46, 1.66] & 24-59 months [AOR = 2.03; 95% CI: 1.88-2.19]), multiple births [AOR = 2.38; 95% CI: 2.05-2.76], reducing birth size (average [AOR = 1.20; 95% CI: 1.14, 1.26] & small [AOR = 1.80; 95% CI: 1.68-1.93]), having comorbidity [AOR = 1.12; 95% CI: 1.07, 1.16], reducing level of mother's educational status (primary [AOR = 1.20; 95% CI: 1.12, 1.28] & no formal education [AOR = 1.36; 95% CI: 1.27, 1.45]), increasing number of children under-5 in the household (2 children [AOR = 1.17; 95% CI: 1.10, 1.23] & 3-5 children [AOR = 1.14; 95% CI: 1.06, 1.22]), reducing household wealth status (rich [AOR = 1.28; 95% CI: 1.17, 1.41], middle [AOR = 1.31; 95% CI: 1.19, 1.44], poor [AOR = 1.42; 95% CI: 1.28, 1.56] & poorest [AOR = 1.45; 95% CI: 1.31, 1.61]), living in rural area [AOR = 1.15; 95% CI: 1.09, 1.22]. Protective factors included female sex [AOR = 0.69; 95% CI: 0.66-0.72], birth interval >24 months [AOR = 0.86; 95% CI: 0.81, 0.91] health facility delivery [AOR = 0.79; 95% CI: 0.74-0.83], and antenatal care attendance [AOR = 0.83; 95% CI: 0.77-0.90]. The pooled prevalence of ECIAF in children under-5 was high in Sub-Saharan Africa. Addressing this burden requires scaling up nutrition-sensitive interventions that tackle underlying determinants of child malnutrition, including poverty reduction, women's education and empowerment, improved access to quality health services, safe water, sanitation, and hygiene programs. Such multisectoral strategies, alongside maternal and child health interventions, are essential to mitigate the identified risk factors and sustainably reduce ECIAF in the region.
This study aimed to explore the experiences of people diagnosed with opioid use disorder (OUD) and recently involved with the criminal-legal system (CLS) as they received addiction treatment services from a Mobile Medications for Opioid Use Disorder (MOUD) programme in Chicago. By assessing perceptions and satisfaction with receiving addiction treatment and additional wraparound services, including factors influencing care-seeking decisions, this research provides insight to tailor care and services to this population of people who have involvement with the CLS. Insights from this population are critical to increasing their access to MOUD and other services, given that people with CLS involvement are at disproportionately higher risk of overdose than people without such involvement. Semi-structured interviews were conducted with people with OUD engaged in mobile MOUD services who had CLS involvement in the past 90 days (arrested, booked, or charged; released from prison, jail, or electronic monitoring; or currently on probation, parole, or supervised release). Eligibility for participation was determined by an outreach specialist with knowledge of past service utilisation and access to the medical record. Questions were based on Consolidated Framework for Implementation Research (CFIR) domains. Interviews were recorded, transcribed, deidentified, and inductively analyzed using Dedoose qualitative analysis software. The primary phenomenon of interest was a description of perceived benefits, barriers, and facilitators to accessing mobile MOUD services by CLS-involved individuals. A total of 13 interviews were conducted. The mean age of the participants was 48.5 years (SD 11.4). Over half of participants identified as Black or African American (61.5%) and male (61.5%). In the 30 days prior to interview, seven (53.8%) participants reported stable housing, five (38.5%) were living outdoors, and one (7.7%) had been incarcerated. Five themes and eight sub-themes were identified. Participants viewed the mobile unit services as essential to their communities, citing proximity to an open-air drug market and limited services in the area. Participants overwhelmingly praised the non-judgmental, approachable, and trustworthy environment compared to other healthcare settings. Law enforcement interactions ranged from positive to neutral, with some noting CLS referrals to mobile medical unit care. Key facilitators included onsite MOUD dispensing, walk-in appointments, and comprehensive medical services. Word-of-mouth, co-utilisation of mobile services with partners, friends, and/or family, and intrinsic self-motivation were identified as facilitators to mobile unit access. Barriers to accessing care included incarceration, transportation, and schedule/service awareness. By exploring the perspectives of people with opioid use disorder and involvement with the CLS, the study contributes to the design and tailoring of an established mobile MOUD programme to meet their collective needs, including broader implementation of services that support re-entry to the community, like peer recovery and recovery-oriented support groups. This study directly involved people with opioid use disorder who were recently involved in the criminal-legal system, a population historically marginalised in healthcare settings, enabling a client-informed approach to service improvement. By centreing their voices through qualitative interviews, the research provides insight into how structural barriers such as incarceration, housing instability, stigma, and limited service availability affect their ability to access treatment. Results from this qualitative study will be discussed with members of the Community Outreach Intervention Projects (COIP) organisation who have lived experience with substance use disorders and living experience with the neighbourhoods these services are offered in. The findings inform actionable strategies to adapt mobile healthcare services to better meet the unique needs of this population, including facilitating access immediately post-release.
Violence against women and against children are human rights violations with lasting harms to survivors and societies at large. Intimate partner violence (IPV) and sexual violence against children (SVAC) are two major forms of such abuse. Despite their wide-reaching effects on individual and community health, these risk factors have not been adequately prioritised as key drivers of global health burden. Comprehensive x§and reliable estimates of the comparative health burden of IPV and SVAC are urgently needed to inform investments in prevention and support for survivors at both national and global levels. We estimated the prevalence and attributable burden of IPV among females and SVAC among males and females for 204 countries and territories, by age and sex, from 1990 to 2023, as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2023. We searched several global databases for data on self-reported exposure to IPV and SVAC and undertook a systematic review to identify the health outcomes associated with each of these risk factors. We modelled IPV and SVAC prevalence using spatiotemporal Gaussian process regression, applying data adjustments to account for measurement heterogeneity. We employed burden-of-proof methodology to estimate relative risks for outcomes associated with IPV and SVAC. These estimates informed the calculation of population attributable fractions, which were then used to quantify disability-adjusted life-years (DALYs) attributable to each risk factor. Globally, in 2023, we estimated that 608 million (95% uncertainty interval 518-724) females aged 15 years and older had ever been exposed to IPV, and 1·01 billion (0·764-1·48) individuals aged 15 years and older had experienced sexual violence during childhood. 18·5 million (8·74-30·0) DALYs were attributed to IPV among females and 32·2 million (16·4-52·5) DALYs were attributed to SVAC among males and females in 2023. IPV and SVAC were among the top contributors to the global disease burden in 2023, particularly among females aged 15-49 years, ranking as the fourth and fifth leading risk factors, respectively, for DALYs in this group. Among the eight health outcomes found to be associated with IPV, anxiety disorders and major depressive disorder were the leading causes of IPV-attributed DALYs, accounting for 5·43 million (-1·25 to 14·6) and 3·96 million (1·71 to 6·92) DALYs in 2023, respectively. SVAC was associated with 14 health outcomes, including mental health disorder, substance use disorder, and chronic and infectious disease outcomes. Self-harm and schizophrenia were the leading causes of SVAC-attributed burden, with SVAC accounting for 6·71 million (2·00 to 12·7) DALYs due to self-harm and 4·15 million (-1·92 to 13·1) DALYs due to schizophrenia in 2023. IPV and SVAC are substantial contributors to global health burden, and their health consequences span a variety of individual health outcomes. Importantly, mental health disorders account for the greatest share of disease burden among survivors. Investing in prevention of these avoidable risk factors has the potential to avert millions of DALYs and considerable premature mortality each year. Our findings represent strong evidence for global and national leaders to elevate IPV and SVAC among public health priorities. Sustained investments are needed to prevent IPV and SVAC and to implement interventions focused on supporting the complex social and health needs of survivors. Gates Foundation.
The COVID-19 pandemic affected healthcare utilization, particularly for populations with chronic disease. This study examined impact of the COVID-19 pandemic on Emergency Department (ED) visits among adults with diabetes in the U.S. We conducted a cross-sectional analysis of adults with diabetes using deidentified, publicly available data from the 2019-2021 National Health Interview Survey (NHIS). The primary independent variable was survey year: 2019 (pre-COVID-19 era) and 2020-2021 (COVID era). The outcome variable was any ED visit in the last 12 months. We conducted multivariable logistic regression to estimate the difference in ED visits before and during the COVID-19 pandemic among adults with diabetes. We estimated adjusted odds ratios and 95% confidence intervals adjusting for healthcare access, self-reported health status, demographic, and socioeconomic characteristics. The sample consisted of 9,845 adults with diabetes (3,066 in 2019, 3,086 in 2020, and 2,899 in 2021). Of these, 19.5% were immigrants, 15.6% Non-Hispanic Black, 17.2% Hispanic, and 58.5% Non-Hispanic White. People with diabetes were 15% in 2020 [AOR 0.85 (95% CI 0.73-0.98)] and 24% in 2021 [AOR 0.76 (95% CI 0.65-0.88)] less likely to visit ED compared to 2019. Delayed care due to cost was significantly associated with increased odds (AOR 1.65; 95% CI 1.32, 2.06) of ED visits compared to those who did not delay their care due to cost. Having fair or poor health status was associated with higher odds of ED visits (AOR 2.01; 95% CI 1.68, 2.41) compared to those reporting excellent health status. Limited access to routine care during the COVID-19 pandemic for diabetes should have led to increased ED visits but the study found significant reduction in ED visits compared to pre-pandemic in people living with diabetes. Future studies are needed to examine whether the reductions in ER were derived from better telemedicine use or avoidance of using necessary care. Also, studies are needed for developing solutions that preserves healthcare delivery in public health care crisis.
Black men experience disproportionate prostate cancer mortality compared with men of other races. As of 2018, major guidelines concur that all men make informed decisions about whether to be screened for prostate cancer after a discussion with their clinician. The objectives of this study were to determine the frequency at which clinicians document prostate cancer screening shared decision-making (SDM) conversations, to examine whether SDM documentation rates differ by race and other sociodemographic factors, and to evaluate whether SDM affects rates of prostate cancer screening. We conducted retrospective chart reviews of a random sample of men (N=600) aged 45 to 69 years seen within an academic family medicine practice in South Carolina in 2019-2020. We used χ2 analyses to compare documentation of a prostate cancer SDM conversation and prostate-specific antigen (PSA) testing by race, age, family history of cancer, family history of prostate cancer, colon cancer screening adherence, and insurance. Logistic regressions assessed the effect of SDM, race, age, and insurance status on the completion of screening PSAs. SDM conversations were documented for 7.3% of Black men and 5.3% of non-Black men (P=0.37). Screening PSAs were ordered in 39.7% of Black men and 36.0% of non-Black men (P=0.41). SDM conversations were positively associated with prostate cancer screening in all men (71.8% vs 35.6%, P<0.01) and Black men specifically (85.0% vs 35.7%, P<0.01). Our results indicate very low rates of prostate cancer SDM in Black and non-Black men. Men with documented SDM conversations were significantly more likely to receive prostate cancer screening. Study results suggest the need for increased SDM in all patients and the need for improved clinician documentation of SDM conversations to evaluate whether men receive the standard of care regarding prostate cancer screening.
Newborn survival requires high-quality small and sick newborn care (SSNC). Domestic and donor financing for SSNC is low, yet real-world cost data to inform investment are scarce. We analysed primary financial data for SSNC health system improvements nationally in Malawi and subnationally in Kenya, Nigeria, and Tanzania. We analysed incremental health system perspective costs using hospital-specific assessments, inpatient data (n=93 942 admissions per year), and government and NEST360 costs. We compared annual hospital-specific costs post-implementation (June, 2022, to June, 2023) and pre-implementation (September, 2019, to March, 2021). We calculated per-hospital and per-baby costs disaggregating by health system building blocks and payers. We benchmarked per-hospital costs for Tanzania against national SSNC investment modelled costs for high-quality care. Mean costs per referral hospital ranged from US$125 286 in Nigeria to $296 706 in Tanzania; higher costs were associated with hospitals receiving substantial health system inputs. Per-hospital costs were lower in Malawian district hospitals ($67 874) than in referral hospitals ($178 724). Mean per-baby cost ranged from $69 in Kenya to $265 in Nigeria; lower admissions were associated with higher per-baby costs in Nigeria. Mean per-baby cost in Malawian district hospitals was $132. The most substantial cost driver for governments was human resources, exceeding half of total cost in all countries except Kenya, where nurse numbers declined. Top cost drivers for NEST360 were data systems and devices. Benchmarking measured costs ($251 046 per Tanzanian hospital) with Tanzania's investment case ($669 447 per hospital) suggested that investments need to triple to reach government high-quality norms. Governments and partners are investing in human resources, data systems, and medical devices and supplies. More investments are required to achieve high-quality care and accelerate progress towards newborn survival targets. Gates Foundation, ELMA Philanthropies, the Mohamed bin Zayed Foundation for Humanity, the Beginnings Fund, Sall Family Foundation, private donors, and previously John D and Catherine T MacArthur Foundation.
The 2023 iteration of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) estimated prevalence, incidence, and health burden for 375 diseases and injuries, including 12 mental disorders. We assess past, current, and emerging trends in the prevalence and burden of mental disorders across sexes and age groups, for 21 regions, 204 countries and territories, and by Socio-demographic Index (SDI) quintile, from 1990 to 2023. Mental disorders included in GBD 2023 were anxiety disorders, major depressive disorder, dysthymia, bipolar disorder, schizophrenia, autism spectrum disorders, conduct disorder, attention-deficit hyperactivity disorder, anorexia nervosa, bulimia nervosa, idiopathic developmental intellectual disability, and a residual category of other mental disorders. A literature review identified epidemiological data for each disorder. These were analysed via a Bayesian meta-regression to estimate prevalence by disorder, sex, age, location, and year. Disorder-specific prevalence was multiplied by disability weights representing the severity of health loss associated with each disorder to estimate years lived with disability (YLDs). Deaths due to anorexia nervosa were assessed with a Cause of Death Ensemble modelling strategy to estimate deaths by sex, age, location, and year, and then multiplied by the standard life expectancy at age of death to estimate years of life lost (YLLs). YLDs equalled disability-adjusted life-years (DALYs) for all mental disorders except anorexia nervosa (the only mental disorder considered as an underlying cause of death in GBD), for which DALYs represented the sum of YLDs and YLLs. We presented prevalence, deaths, YLDs, YLLs, and DALYs as counts, age-specific rates per 100 000 population, and age-standardised rates per 100 000 population. We estimated 1·17 billion (95% uncertainty interval 1·06-1·31) prevalent cases of mental disorders globally in 2023, equivalent to an age-standardised prevalence rate of 14 210·7 cases (12 849·5-15 940·1) per 100 000 population. These estimates represented a 95·5% (75·0-121·2) increase in prevalent cases and 24·2% (11·4-41·4) increase in age-standardised prevalence rate between 1990 and 2023. All mental disorders showed increases in prevalent cases between 1990 and 2023, while notable increases were seen in age-standardised prevalence rates for anxiety disorders, major depressive disorder, dysthymia, anorexia nervosa, bulimia nervosa, schizophrenia, and conduct disorder. There were an estimated 171 million (127-228) DALYs due to mental disorders globally across sex and age in 2023, equivalent to an age-standardised DALY rate of 2070·5 DALYs (1519·1-2750·5) per 100 000 population. Mental disorders contributed to 6·1% (4·8-7·6) of all-cause DALYs in 2023, making them the fifth leading cause of global DALYs (up from 12th in 1990). DALYs were almost entirely composed of YLDs. Mental disorders were the leading cause of YLDs in 2023 (up from second in 1990), explaining 17·3% (14·8-20·6) of all-cause global YLDs. Leading causes of mental disorder DALYs were anxiety disorders (ranked 11th among the 304 diseases and injuries at Level 4 of the GBD cause hierarchy), major depressive disorder (15th), and schizophrenia (41st). Globally in 2023, mental disorder age-standardised DALY rates were higher among females (2239·6 [1643·7-3014·1] per 100 000) than among males (1900·2 [1399·8-2510·8] per 100 000), and peaked in the 15-19 years age group (2617·3 [1850·6-3696·8] per 100 000). All locations showed increased mental disorder DALY rates in 2023 compared with 1990, ranging across countries and territories from 1302·4 (952·7-1683·7) per 100 000 in Viet Nam to 3555·8 (2661·9-4715·0) per 100 000 in the Netherlands. Across SDI quintiles, DALY rates ranged from 1853·0 (1352·1-2469·3) per 100 000 for middle SDI to 2184·1 (1606·1-2890·3) per 100 000 for high SDI. A significant health burden was imposed by mental disorders in all countries and territories in 2023, irrespective of the health resources available. In some instances, this burden has increased over time and is unevenly distributed across populations. Stronger surveillance systems, particularly in low-income and middle-income countries, are required. Additionally, we need more coordinated and inclusive policies to reduce the burden through early treatment and prevention, tailored to sex and age differences across locations. Responding to the mental health needs of our global population, especially those most vulnerable, is an obligation, not a choice. Gates Foundation, Queensland Health, and University of Queensland.
Comprehensive, comparable, and timely estimates of demographic metrics-including life expectancy and age-specific mortality-are essential for evaluating, understanding, and addressing trends in population health. The COVID-19 pandemic highlighted the importance of timely and all-cause mortality estimates for being able to respond to changing trends in health outcomes, showing a strong need for demographic analysis tools that can produce all-cause mortality estimates more rapidly with more readily available all-age vital registration (VR) data. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is an ongoing research effort that quantifies human health by estimating a range of epidemiological quantities of interest across time, age, sex, location, cause, and risk. This study-part of the latest GBD release, GBD 2023-aims to provide new and updated estimates of all-cause mortality and life expectancy for 1950 to 2023 using a novel statistical model that accounts for complex correlation structures in demographic data across age and time. We used 24 025 data sources from VR, sample registration, surveys, censuses, and other sources to estimate all-cause mortality for males, females, and all sexes combined across 25 age groups in 204 countries and territories as well as 660 subnational units in 20 countries and territories, for the years 1950-2023. For the first time, we used complete birth history data for ages 5-14 years, age-specific sibling history data for ages 15-49 years, and age-specific mortality data from Health and Demographic Surveillance Systems. We developed a single statistical model that incorporates both parametric and non-parametric methods, referred to as OneMod, to produce estimates of all-cause mortality for each age-sex-location group. OneMod includes two main steps: a detailed regression analysis with a generalised linear modelling tool that accounts for age-specific covariate effects such as the Socio-demographic Index (SDI) and a population attributable fraction (PAF) for all risk factors combined; and a non-parametric analysis of residuals using a multivariate kernel regression model that smooths across age and time to adaptably follow trends in the data without overfitting. We calibrated asymptotic uncertainty estimates using Pearson residuals to produce 95% uncertainty intervals (UIs) and corresponding 1000 draws. Life expectancy was calculated from age-specific mortality rates with standard demographic methods. For each measure, 95% UIs were calculated with the 25th and 975th ordered values from a 1000-draw posterior distribution. In 2023, 60·1 million (95% UI 59·0-61·1) deaths occurred globally, of which 4·67 million (4·59-4·75) were in children younger than 5 years. Due to considerable population growth and ageing since 1950, the number of annual deaths globally increased by 35·2% (32·2-38·4) over the 1950-2023 study period, during which the global age-standardised all-cause mortality rate declined by 66·6% (65·8-67·3). Trends in age-specific mortality rates between 2011 and 2023 varied by age group and location, with the largest decline in under-5 mortality occurring in east Asia (67·7% decrease); the largest increases in mortality for those aged 5-14 years, 25-29 years, and 30-39 years occurring in high-income North America (11·5%, 31·7%, and 49·9%, respectively); and the largest increases in mortality for those aged 15-19 years and 20-24 years occurring in Eastern Europe (53·9% and 40·1%, respectively). We also identified higher than previously estimated mortality rates in sub-Saharan Africa for all sexes combined aged 5-14 years (87·3% higher in GBD 2023 than GBD 2021 on average across countries and territories over the 1950-2021 period) and for females aged 15-29 years (61·2% higher), as well as lower than previously estimated mortality rates in sub-Saharan Africa for all sexes combined aged 50 years and older (13·2% lower), reflecting advances in our modelling approach. Global life expectancy followed three distinct trends over the study period. First, between 1950 and 2019, there were considerable improvements, from 51·2 (50·6-51·7) years for females and 47·9 (47·4-48·4) years for males in 1950 to 76·3 (76·2-76·4) years for females and 71·4 (71·3-71·5) years for males in 2019. Second, this period was followed by a decrease in life expectancy during the COVID-19 pandemic, to 74·7 (74·6-74·8) years for females and 69·3 (69·2-69·4) years for males in 2021. Finally, the world experienced a period of post-pandemic recovery in 2022 and 2023, wherein life expectancy generally returned to pre-pandemic (2019) levels in 2023 (76·3 [76·0-76·6] years for females and 71·5 [71·2-71·8] years for males). 194 (95·1%) of 204 countries and territories experienced at least partial post-pandemic recovery in age-standardised mortality rates by 2023, with 61·8% (126 of 204) recovering to or falling below pre-pandemic levels. There were several mortality trajectories during and following the pandemic across countries and territories. Long-term mortality trends also varied considerably between age groups and locations, demonstrating the diverse landscape of health outcomes globally. This analysis identified several key differences in mortality trends from previous estimates, including higher rates of adolescent mortality, higher rates of young adult mortality in females, and lower rates of mortality in older age groups in much of sub-Saharan Africa. The findings also highlight stark differences across countries and territories in the timing and scale of changes in all-cause mortality trends during and following the COVID-19 pandemic (2020-23). Our estimates of evolving trends in mortality and life expectancy across locations, ages, sexes, and SDI levels in recent years as well as over the entire 1950-2023 study period provide crucial information for governments, policy makers, and the public to ensure that health-care systems, economies, and societies are prepared to address the world's health needs, particularly in populations with higher rates of mortality than previously known. The estimates from this study provide a robust framework for GBD and a valuable foundation for policy development, implementation, and evaluation around the world. Gates Foundation.