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.
Child growth failure (CGF), which includes underweight, wasting, and stunting, is among the factors most strongly associated with mortality and morbidity in children younger than 5 years worldwide. Poor height and bodyweight gain arise from a variety of biological and sociodemographic factors and are associated with increased vulnerability to infectious diseases. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 to estimate CGF prevalence, the risk of infectious diseases associated with CGF, and the disease mortality, morbidity, and overall burden associated with CGF. In this analysis we estimated the all-cause and cause-specific (diarrhoea, lower respiratory tract infections, malaria, and measles) disability-adjusted life-years (DALYs) lost and mortality associated with stunting, wasting, underweight, and CGF in aggregate. We combined the burden associated with mild, moderate, and severe forms of CGF: stunting was defined as height-for-age Z scores (HAZ) less than -1, underweight was defined as weight-for-age Z scores (WAZ) less than -1, and wasting was defined as weight-for-height Z scores (WHZ) less than -1, according to WHO Child Growth Standards. Population-level continuous distributions of HAZ, WAZ, and WHZ were estimated for 2000 to 2023 using data from surveys, literature, and individual-level study data. The risk of incidence of, and mortality due to, diarrhoea, lower respiratory infections, malaria, and measles was separately estimated in a meta-regression framework from longitudinal cohort data for Z scores less than -1. Finally, fatal outcomes associated with these diseases were estimated with vital registration, verbal autopsy, and case-fatality data, while non-fatal outcomes were estimated with surveys as well as health-care utilisation and case reporting data. The exposure prevalence and relative risk estimates were from continuous distributions, allowing for direct assessment of the attributable fractions for mild, moderate, and severe stunting, underweight, wasting, and the combined impact of child growth failure within populations. All estimates were age-specific, sex-specific, geography-specific, and year-specific. We estimated that, in children younger than 5 years in 2023, CGF was associated with 79·4 million (95% uncertainty interval [UI] 47·0-106) DALYs lost and 880 000 (517 000-1 170 000) deaths. This represented 17·9% (10·6-23·8) of 444 million (434-457) total under-5 DALYs and 18·8% (11·1-25·0) of all 4·67 million (4·59-4·75) under-5 deaths. Compared to stunting (33·0 million [24·1-42·2] DALYs, 373 000 [272 000-477 000] deaths) and wasting (39·2 million [23·8-53·0] DALYs, 428 000 [256 000-583 000] deaths), childhood underweight was associated with the largest share of CGF-related disease burden: 52·2 million (21·9-75·1) DALYs and 573 000 (236 000-824 000) deaths in children younger than 5 years in 2023. CGF remains a leading factor associated with death and disability in children younger than 5 years, despite global attention and focused interventions to reduce the prevalence of associated CGF indicators. Our findings underscore the need for policies, strategies, and interventions that focus on all indicators of CGF to reduce its associated health burden. Gates Foundation.
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.
BACKGROUND: Offspring of parents with alcohol use disorder (AUD) have elevated risk of substance use. However, few studies have comprehensively assessed risks associated with different substances. This study investigated the risk of substance use disorders (SUDs) in adult children with severe parental AUD over four decades, contributing information on the risk of each disorder, the roles of important risk factors, and the general versus substance-specific nature of SUD risk. METHODS: Swedish national register data were used to follow children with and without ≥ 1 parent with an inpatient diagnosis of AUD from 1973 to 2018 to investigate risk of alcohol, opioid, cannabinoid, sedative/hypnotic, cocaine, other stimulant, hallucinogen, volatile solvent, and multiple drug use disorder. The composite outcomes any SUD, 1 SUD, and ≥ 2 SUDs including and excluding AUD were also investigated. Severe parental AUD and outcomes were defined with hospital inpatient diagnoses (ICD codes). Hazard ratios (HRs) were calculated with Cox regression. Model 1: unadjusted. Model 2: adjusted for child’s sex, parental education, and parental mortality. Model 3: Model 2 plus parental SUD. Model 4: Model 3 plus parental psychiatric disorder. RESULTS: Risks of all outcomes were higher in those with (n = 99,723) than without (n = 2,321,756) severe parental AUD. For SUD diagnoses, the highest unadjusted risks were for other stimulant (HR 5.33, 95% CI 5.03–5.64), volatile solvent (HR 4.95, 95% CI 3.98–6.15), and opioid (HR 4.62, 95% CI 4.37–4.87) use disorders. After full adjustment, risks declined, and HRs of the different diagnoses converged to approximately twice as high in the adult children of parents with AUD. Risks of any SUD and of ≥ 2 SUDs were more elevated (95% CIs did not overlap) when AUD was included than when AUD was excluded. Risk of ≥ 2 SUDs was higher than risk of 1 SUD, but only when AUD was included. CONCLUSIONS: Severe parental AUD was associated with elevated risk for all SUDs. After full adjustment, SUD risks declined and converged but remained doubled. Sociodemographic factors, parental SUD, and parental psychiatric disorder explained much of the excess risk. Drug combinations that included alcohol elevated the risk of ≥ 2 SUDs and any SUD.
Lower respiratory infections (LRIs) remain the world's leading infectious cause of death. This analysis from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides global, regional, and national estimates of LRI incidence, mortality, and disability-adjusted life-years (DALYs), with attribution to 26 pathogens, including 11 newly modelled pathogens, across 204 countries and territories from 1990 to 2023. With new data and revised modelling techniques, these estimates serve as an update and expansion to GBD 2021. Through these estimates, we also aimed to assess progress towards the 2025 Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea (GAPPD) target for pneumonia mortality in children younger than 5 years. Mortality from LRIs, defined as physician-diagnosed pneumonia or bronchiolitis, was estimated using the Cause of Death Ensemble model with data from vital registration, verbal autopsy, surveillance, and minimally invasive tissue sampling. The Bayesian meta-regression tool DisMod-MR 2.1 was used to model overall morbidity due to LRIs. DALYs were calculated as the sum of years of life lost (YLLs) and years lived with disability (YLDs) for all locations, years, age groups, and sexes. We modelled pathogen-specific case-fatality ratios (CFRs) for each age group and location using splined binomial regression to create internally consistent estimates of incidence and mortality proportions attributable to viral, fungal, parasitic, and bacterial pathogens. Progress was assessed towards the GAPPD target of less than three deaths from pneumonia per 1000 livebirths, which is roughly equivalent to a mortality rate of less than 60 deaths per 100 000 children younger than 5 years. In 2023, LRIs were responsible for 2·50 million (95% uncertainty interval [UI] 2·24-2·81) deaths and 98·7 million (87·7-112) DALYs, with children younger than 5 years and adults aged 70 years and older carrying the highest burden. LRI mortality in children younger than 5 years fell by 33·4% (10·4-47·4) since 2010, with a global mortality rate of 94·8 (75·6-116·4) per 100 000 person-years in 2023. Among adults aged 70 years and older, the burden remained substantial with only marginal declines since 2010. A mortality rate of less than 60 deaths per 100 000 for children younger than 5 years was met by 129 of the 204 modelled countries in 2023. At a super-regional level, sub-Saharan Africa had an aggregate mortality rate in children younger than 5 years (hereafter referred to as under-5 mortality rate) furthest from the GAPPD target. Streptococcus pneumoniae continued to account for the largest number of LRI deaths globally (634 000 [95% UI 565 000-721 000] deaths or 25·3% [24·5-26·1] of all LRI deaths), followed by Staphylococcus aureus (271 000 [243 000-298 000] deaths or 10·9% [10·3-11·3]), and Klebsiella pneumoniae (228 000 [204 000-261 000] deaths or 9·1% [8·8-9·5]). Among pathogens newly modelled in this study, non-tuberculous mycobacteria (responsible for 177 000 [95% UI 155 000-201 000] deaths) and Aspergillus spp (responsible for 67 800 [59 900-75 900] deaths) emerged as important contributors. Altogether, the 11 newly modelled pathogens accounted for approximately 22% of LRI deaths. This comprehensive analysis underscores both the gains achieved through vaccination and the challenges that remain in controlling the LRI burden globally. Furthermore, it demonstrates persistent disparities in disease burden, with the highest mortality rates concentrated in countries in sub-Saharan Africa. Globally, as well as in these high-burden locations, the under-5 LRI mortality rate remains well above the GAPPD target. Progress towards this target requires equitable access to vaccines and preventive therapies-including newer interventions such as respiratory syncytial virus monoclonal antibodies-and health systems capable of early diagnosis and treatment. Expanding surveillance of emerging pathogens, strengthening adult immunisation programmes, and combating vaccine hesitancy are also crucial. As the global population ages, the dual challenge of sustaining gains in child survival while addressing the rising vulnerability in older adults will shape future pneumonia control strategies. Gates Foundation.
To evaluate the impact of digital supportive supervision (DiSS) for maternal and child healthcare on utilisation of services in Rajasthan state of India, as well as exploring the perceived enablers and barriers to the implementation of DiSS. We employed a sequential mixed-method study design. Routine monthly service data from April 2016 to March 2023 were analysed using an interrupted time-series (ITS) analysis with a control group, followed by qualitative in-depth key-informant interviews. The study is set at the primary healthcare level in Rajasthan state in India, where maternal health, child health and nutrition (MCHN) sessions are conducted at village level to deliver essential maternal and child health services. Based on the proportion of MCHN sessions supervised digitally, two districts demonstrating high DiSS uptake were selected as intervention districts, and two matched districts were identified as comparator districts, creating a quasi-experimental design. Using routine data extracted from the pregnancy, child tracking and health services database, a segmented regression analysis using ITS was undertaken to assess temporal changes in service utilisation. For the qualitative component, we purposively sampled supervisors in intervention districts (ranked by DiSS supervisory volume) and conducted interviews until thematic saturation (n=18). The intervention involved digitising the traditional paper-based supportive supervision of MCHN sessions in Rajasthan through a DiSS tool. Supervisors across state, district, block and sector levels used smartphones or tablets to record MCHN session data offline, which was automatically analysed and reported on dashboards on submission. The study aims to measure the change in the monthly rate of MCHN service uptake following the rollout of DiSS in Rajasthan state. Pentavalent and inactivated-polio vaccine uptake significantly improved in the intervention group, while no change was observed in the comparator group. Both groups showed significant improvement in the iron and folic acid supplementation among pregnant women and uptake of BCG, Hepatitis B birth dose and Measles vaccines among children, with greater increase in the intervention group. Notably, pneumococcal-conjugate-vaccine uptake declined significantly in the comparator group, whereas no significant change occurred in the intervention group. Limited digital literacy during the initial rollout and compatibility restriction of the digital application to Android devices were chief barriers. Among the enablers, its user-friendly interface, offline functionality, GIS-based monitoring and automated report generation were reported to enhance the timeliness, accountability and efficiency of supportive supervision. This, in turn, strengthened the feedback loop, empowering programme managers to promptly identify and address any shortcomings. DiSS has the potential to strengthen the healthcare system and significantly improve the utilisation of MCHN services.
Like many other countries, Denmark has recently seen a sharp increase in outsourced social service provision for children and adults. While quasi-market theory suggests that complex social services could be ill-suited to market provision, there has been little assessment of how ownership relates to service quality for welfare services due to fragmented data. This paper presents findings from a population-wide analysis of quality and inspection outcomes across public, non-profit, and for-profit providers in Denmark's social services for children and working-age adults with support needs, including children's homes and adult residential facilities (N = 2375, 2020-2024). First, we document a 44.1 % increase in for-profit providers over five years (2020-2024), while public and non-profit provision remained stable or declined. Second, for-profit providers were significantly more likely to receive regulatory sanctions, including intensified monitoring and forced closure compared to other ownership types. Third, non-profit providers received higher quality ratings, while newer for-profit entrants underperformed relative to both public and older for-profit providers. Fourth, quality and regulatory differences were most pronounced between for-profit and not-for-profit providers rather than between public and private providers, indicating that ownership form and the profit-motive within the private sector matters more than the public-private distinction. These findings support theoretical claims that welfare markets for complex social services are prone to market failure due to information asymmetries, user complexity, and incomplete contracts. Finally, the findings have policy implications for market regulation, procurement and pricing strategies in terms of how to sustain high-performing providers in an increasingly marketised social service landscape.
In this prospective birth cohort study, we examined whether the dietary intake of A, B, C, D and E vitamins is associated with the risk of islet autoimmunity or type 1 diabetes in children who are genetically at risk for type 1 diabetes. Data on vitamin intakes in the Finnish Type 1 Diabetes Prediction and Prevention (DIPP) cohort study were available for 5674 children born between September 1996 and September 2004 in Oulu University Hospital or Tampere University Hospital. Diet was assessed using 3-day food records at the age of 3 and 6 months, and annually from 1 to 6 years. The primary outcomes were: (1) islet autoimmunity defined as repeated positivity for islet cell autoantibodies and at least one out of three type 1 diabetes-related biochemical autoantibodies or a diagnosis of type 1 diabetes; and (2) a diagnosis of type 1 diabetes. During the 6-year follow-up, 247 children (4.4%) developed islet autoimmunity and 94 (1.7%) developed type 1 diabetes. When adjusted for total energy intake, sex, HLA genotype and family history of diabetes, the intakes of retinol (HR 0.91; 95% credible interval [CrI] 0.86, 0.97 per 10 µg/MJ increase in intake), vitamin C (HR 0.70; 95% CrI 0.54, 0.90 per 10 µg/MJ) and vitamin E (HR 0.93; 95% CrI 0.89, 0.97 per 0.1 mg/MJ) were associated with decreased risk of islet autoimmunity and also with the risk of type 1 diabetes (retinol: HR 0.83; 95% CrI 0.74, 0.96 per 10 µg/MJ; vitamin C: HR 0.45; 95% CrI 0.23, 0.84 per 10 µg/MJ; vitamin E: HR 0.89; 95% CrI 0.80, 0.99 per 0.1 mg/MJ). The associations remained statistically significant after multiple testing correction for the risk of islet autoimmunity but not for type 1 diabetes. The association between retinol intake and islet autoimmunity risk was not significant when the 3-month age point, during which the child is primarily breastfed, was excluded. We observed a weak inverse association for vitamin D and islet autoimmunity, and no associations for B vitamins. High intake of vitamin C and vitamin E was associated with a decreased risk of islet autoimmunity.
Health-related quality of life (HRQoL) is a multidimensional construct encompassing physical, psychological, and social functioning. It is increasingly used as a universal outcome in evaluating interventions for children with psychiatric disorders. This study examined the effects of group cognitive behavioral therapy (GCBT) on child HRQoL in naturalistic clinical settings and explored associations between child HRQoL and parental well-being dimensions using network analysis. The sample included 109 children with mixed psychiatric disorders. Of these, 56 were initially assigned to a waitlist condition receiving treatment as usual (TAU) before participating in GCBT. The final GCBT group comprised 99 children: 53 referred directly to GCBT and 46 who received it following TAU. Child HRQoL was assessed using child- and parent-rated KINDL-R, and parental well-being via the General Health Questionnaire and Jenkins Sleep Questionnaire. Assessments were conducted pre- and post-treatment, and at a 7-month follow-up. The parent-rated child HRQoL dimension Self-esteem showed significant improvement following GCBT, with gains maintained at follow-up. Although associations between child HRQoL and parental well-being dimensions were generally weak, both self- and parent-rated child HRQoL dimensions were interconnected. Notably, the parent-rated child HRQoL dimension Friends emerged as a central node in the network. GCBT may enhance self-esteem in children with mixed psychiatric disorders. The findings also highlight the potential value of targeting peer relationships in interventions in this population, given their central role in child HRQoL and parental well-being.
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.
Caregivers of children in child welfare encounter many unique challenges, increasing their potential risk for caregiver stress. To support children and their caregivers, providers must accurately assess caregiver stress before they can deliver a brief intervention or make an appropriate referral. The current study utilized the PedsQL Family Impact Module to assess foster and kinship caregiver's well-being. Method: This study assessed the construct validity of PedsQL FIM through confirmatory factor analysis, mean differences between medically complex and noncomplex children, and its correlation with child behavior problems in caregivers of children in child welfare. Caregivers reported above-average well-being. The factor structure of PedsQL FIM did not fit the data well, and no differences in well-being were found between caregivers of medically complex and noncomplex children. Small correlations (r = 0.14-0.26) were found between caregiver well-being and child externalizing problems. Although the PedsQL FIM has demonstrated reliability and validity within other special populations, the use of the PedsQL FIM to assess well-being of caregivers of children in child welfare needs further exploration to ensure its validity with these caregivers.
Gut dysbiosis is increasingly recognized as a factor in asthma pathogenesis, yet its relationship with disease severity and specific clinical phenotypes remains unclear. This longitudinal study investigated the dynamic changes in gut microbiota composition associated with asthma control and severity in children. We identified asthmatic children and matched them with healthy controls within the prospective Taiwan Childhood Environment and Allergic Diseases Cohort Study. Phenotypic data, including childhood asthma control test (C-ACT) scores, clinical severity, serum immunoglobulin E (IgE) levels, and peak expiratory flow (PEF) rates, were collected at the time of fecal sample collection. Gut microbiota composition was assessed using 16S rRNA sequencing and compared between groups. Subgroup analyses and longitudinal paired case comparisons were conducted to track microbial shifts between exacerbation and remission phases. A total of 173 children, including 82 children with asthma (mean age: 6.9 ± 4.1 years) and 91 age- and gender-matched healthy controls (mean age: 7.5 ± 2.6 years), were recruited. Generally, children with asthma exhibited a lower relative abundance of Akkermansia, Anaerostipes, and Escherichia compared to controls. The relative abundance of Escherichia showed a significant negative correlation with C-ACT scores (β = -0.337, p = 0.016), whereas Akkermansia exhibited a significant negative correlation with PEF (β = -0.325, p = 0.032). Notably, longitudinal paired case comparisons distinguished asthma attack from remission phases, demonstrating a paradoxical enrichment of Akkermansia during exacerbations (LDA = 3.66, p = 0.023). In contrast to the prevailing view of Akkermansia solely as a beneficial microbe, our study identifies a specific severe asthma-associated gut profile characterized by an unexpected enrichment of Akkermansia in children with poor control. This finding suggests a complex interaction between the gut microbiome and asthma severity, potentially influenced by high-intensity corticosteroid therapy. These results challenge the one-size-fits-all probiotic approach and highlight the need for precision microbiome-based interventions considering asthma phenotypes and medication history.
Childhood sexual abuse (CSA) is associated with significant psychiatric morbidity and has been reported at notable rates among Jewish Israeli women. Yet data regarding abuse characteristics, psychiatric history and longitudinal treatment outcomes in this population are lacking. We assessed abuse experiences, clinical profiles and psychiatric histories of adult Jewish women CSA survivors and evaluated the effectiveness of designated psychotherapy over one year. A clinical sample of women CSA survivors (N = 122) were treated in weekly psychotherapy in public specialized outpatient centers in Israel. Patients self-reported on Childhood Maltreatment (CM), posttraumatic stress disorder (PTSD) symptoms, dissociation, borderline personality (BPD) traits, and psychological well-being at treatment onset (T1), after six months (T2), and after one year of therapy (T3). CSA characteristics and psychiatric history were assessed by a semi-structured clinical interview at T1. Most (85.3%) patients reported prolonged CSA histories, with 71.3% reporting intrafamilial abuse. At T1, 7.5% reported currently being abused and 8.3% were currently living with the abuser. Higher levels of CM were significantly associated with higher PTSD, dissociative and BPD symptoms and lower psychological well-being at T1. CM was significantly associated with suicide attempts, psychiatric hospitalizations and psychiatric medication use at T1. Specifically, nearly all individuals with these clinical histories reported moderate to extreme CM. Over the course of treatment (T1 to T3), PTSD symptoms significantly decreased and dissociative symptoms showed reductions from baseline to the one-year assessment, although the overall time effect approached statistical significance. Psychological well-being demonstrated a positive trend throughout the treatment year, with significant improvements observed between baseline and the one-year follow-up, while BPD traits did not change. These findings underscore the complex clinical needs of CSA survivors and demonstrate that specialized, long-term psychotherapy effectively reduces core trauma symptoms while fostering significant gains in psychological well-being.
In Sri Lanka, as non-communicable diseases rise, the significance of physical activity is increasingly recognised, particularly in children. The Physical Activity Questionnaire for Older Children (PAQ-C) is widely used and can be considered as one of the best available tools for assessing physical activity in children. However, a validated tool for Sinhala-speaking children in Sri Lanka has been lacking. This study aims to culturally adapt and validate the PAQ-C for Sinhala-speaking children and evaluate its psychometric properties. This cross-sectional study involved 301 schoolchildren (197 males and 104 females) aged 8-11 years, during which the PAQ-C was translated into Sinhala, and a pre-final version was developed. In terms of validity, content validity, that is, the degree to which the content of an instrument is an adequate reflection of the construct to be measured, was assessed using the content validity index. In terms of reliability, test-retest reliability was measured with the intraclass correlation coefficient (ICC). The Sinhala version of the PAQ-C demonstrated CVI at both item and scale levels is as one. The ICC was acceptable at 0.83. The Sinhala version of the PAQ-C demonstrates good content validity and acceptable test-retest reliability, affirming its suitability as a cost-effective tool for assessing physical activity levels among Sinhala-speaking children in Sri Lanka and supporting informed interventions and public health strategies in the country.
Especially, the coxsackievirus B group of enteroviruses has been linked to the development of islet autoimmunity and type 1 diabetes in genetically susceptible individuals. Our aim was to study the possible associations of 10 different microbial infections with islet autoimmunity in a large international prospective study. In a nested case-control study within the TRIGR study, follow-up serum samples from 240 islet autoantibody-positive case children and 436 age- and country-matched control children were analysed for IgG class antibodies against 10 different respiratory and gastrointestinal microbes using an enzyme immunoassay, and for neutralising antibodies against all six coxsackievirus B types. The samples were obtained at several time points prior to and at the time of seroconversion for multiple islet autoantibodies. All children had a first-degree relative with type 1 diabetes, and they carried risk-associated HLA-DQ alleles. Coxsackievirus B5 was associated with an increased risk of islet autoimmunity (OR 2.22, 95% CI 1.29-3.80, p = 0.004, corrected p = 0.024), which remained after adjustment for HLA, sex, and maternal type 1 diabetes. This association was particularly seen for infections occurring more than 12 months (OR 2.02, 95% CI 1.06-3.84, p = 0.032) and 0-6 months (OR 2.66, 95% CI 1.11-6.35, p = 0.028) before the first detection of multiple islet autoantibodies. After correction for multiple comparisons, none of the other viruses showed an association with islet autoimmunity. This study supports previous evidence of the risk association of coxsackievirus B infections. These results support the role of certain virus infections as possible modulating factors in the pathogenesis of type 1 diabetes.
BACKGROUND: The foundation of preventive healthcare is immunization, which is also one of the most cost-effective public health interventions. Immunization reduces the prevalence of infectious diseases like measles, polio, and pertussis, which has resulted in significant decreases in childhood morbidity and mortality globally. Despite the significant strides made in global immunization efforts, there remains a crucial gap in understanding the experiences of community health nurses providing immunization services at Child Welfare Clinics (CWCs). OBJECTIVE: The study explored the experiences of community health nurses providing immunization services at the child welfare clinics in Fanteakwa North District. METHODOLOGY: A descriptive design was employed for the qualitative study at the Fanteakwa North District. Purposive sampling was used to select participants for this study. 15 participants partook in the study based on saturation during data collection. The interviews were audio-recorded, transcribed, and examined using thematic analysis. RESULTS: Four main themes with eleven subthemes emerged, providing insight into the daily experiences of Community Health Nurses (CHNs). These included: the core roles and responsibilities of CHNs in delivering immunization services; strategies they use to support vaccination, such as door-to-door campaigns, mobile clinics, and collaboration with community leaders; challenges affecting service delivery, including vaccine shortages and language or cultural barriers; and adaptive measures CHNs employ to manage these challenges, such as maintaining a positive attitude, practicing self-care, and seeking support from colleagues and supervisors. CONCLUSION: The findings highlight the challenges CHNs face and the strategies they adopt to manage them. They suggest that supportive work environments, access to resources, effective communication, and opportunities for peer and supervisory support may help enhance CHNs’ capacity to deliver immunization services. Similarly, self-care and stress-management practices reported by CHNs indicate areas where workforce well-being could be supported. Further research is needed to explore which interventions are most effective in addressing these challenges.
Breast cancer is a leading cause of mortality and morbidity among females worldwide. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, we provided an updated comprehensive assessment of the epidemiological trends, disease burden, and risk factors associated with breast cancer globally, regionally, and nationally from 1990 to 2023. Breast cancer incidence, mortality, prevalence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) were estimated by age and sex for 204 countries and territories from 1990 to 2023. Mortality estimates were generated using GBD Cause of Death Ensemble models, leveraging data from population-based cancer registration systems, vital registration systems, and verbal autopsies. Mortality-to-incidence ratios were calculated to derive both mortality and incidence estimates. Prevalence was calculated by combining incidence and modelled survival estimates. YLLs were established by multiplying age-specific deaths with the GBD standard life expectancy at the age of death. YLDs were estimated by applying disability weights to prevalence estimates. The sum of YLLs and YLDs equalled the number of DALYs. Breast cancer burden attributable to seven risk factors was examined through the comparative risk assessment framework. The GBD forecasting framework was used to forecast breast cancer incidence and mortality from 2024 to 2050. Age-standardised rates were calculated for each metric using the GBD 2023 world standard population. In 2023, there were an estimated 2·30 million (95% uncertainty interval [UI] 2·01 to 2·61) breast cancer incident cases, 764 000 deaths (672 000 to 854 000), and 24·1 million (21·3 to 27·5) DALYs among females globally. In the World Bank low-income group, where a low age-standardised incidence rate (ASIR) was estimated (44·2 per 100 000 person-years [31·2 to 58·4]), the age-standardised mortality rate (ASMR) was the highest (24·1 per 100 000 [16·8 to 31·9]). The highest ASIR was in the high-income group (75·7 per 100 000 [67·1 to 84·0]), and the lowest ASMR was in the upper-middle-income group (11·2 per 100 000 [10·2 to 12·3]). Between 1990 and 2023, the ASIR in the low-income group increased by 147·2% (38·1 to 271·7), compared with a 1·2% (-11·5 to 17·2) change in the high-income group. The ASMR decreased in the high-income group, changing by -29·9% (-33·6 to -25·9), but increased by 99·3% (12·5 to 202·9) in the low-income group. The increase in age-standardised DALY rates followed that of ASMRs. Risk factors such as dietary risks, tobacco use, and high fasting plasma glucose contributed to 28·3% (16·6 to 38·9) of breast cancer DALYs in 2023. The risk factors with a decrease in attributable DALYs between 1990 and 2023 were high alcohol use and tobacco. By 2050, the global incident cases of breast cancer among females were forecast to reach 3·56 million (2·29 to 4·83), with 1·37 million (0·841 to 2·02) deaths. The stable incidence and declining mortality rates of female breast cancer in high-income nations reflect success in screening, diagnosis, and treatment. In contrast, the concurrent rise in incidence and mortality in other regions signals health system deficits. Without effective interventions, many countries will fall short of the WHO Global Breast Cancer Initiative's ambitious target of achieving an annual reduction of 2·5% in age-standardised mortality rates by 2040. The mounting breast cancer burden, disproportionately affecting some of the world's most vulnerable populations, will further exacerbate health inequalities across the globe without decisive immediate action. Gates Foundation, St Jude Children's Research Hospital.
BackgroundIntimate partner violence (IPV) is a pervasive public health and human rights issue, yet survivors' agency is often framed narrowly within linear victim-survivor narratives that overlook how intersecting identities and structural constraints shape their options and responses. Objectives: To explore how women who have experienced IPV negotiate agency and reclaim voice within intersecting social, cultural, and personal borderlands of experience.DesignQualitative narrative inquiry informed by intersectionality and borderlands theory.MethodsTwo women living in a Canadian city, who self -identified as having experienced IPV and had been out of violent relationships for at least three years, participated in biweekly narrative conversations from August to December 2023. Analysis attended to intersecting social locations (including Indigeneity, sexuality, socioeconomic position, and professional roles) and to liminal in-between moments of safety and danger, love and abuse, dependence and resistance, silence and voice.ResultsAnalysis identified three interrelated movements in women's agency over time, regressive transformation, hibernation, and progressive transformation, operating simultaneously rather than sequentially. For example, Aila's parenting decisions revealed agency constrained by child welfare surveillance yet oriented toward intergenerational change, while Artemisia rediscovered her pre-abuse self through old journals and art, illustrating hibernated agency gradually re-emerging.ConclusionThis study challenges linear victim-survivor models of recovery by conceptualizing agency as a dynamic, relational process shaped by intersectional locations and borderland spaces. Intimate partner violence (IPV) is abuse by a current or former partner. It affects millions of people worldwide and causes serious, lasting harm to physical and mental health. Much of what has been written about this issue focuses on the moment a survivor leaves an abusive relationship, as if that single decision defines their experience. But surviving abuse is far more complicated than that. This study shares the stories of two women in Canada, called Aila and Artemisia, who experienced IPV. Over five months, each woman had in-depth conversations with the researcher about their relationships, how they coped, and how they rebuilt their lives. Their stories were analyzed paying close attention to how factors like race, sexuality, economic situation, and personal history shaped their experiences in unique ways. Three patterns emerged from both women’s stories. First, over time, abuse gradually wore down their confidence, independence, and sense of self. Second, both women went through periods of going quiet and suppressing their feelings and opinions. This was not out of weakness, but as a way to stay safe. Third, both women slowly began to rediscover themselves, often through small acts like setting a boundary, speaking up, or imagining a different future. Importantly, these were not neat, one-after-another stages. The women moved back and forth between all three at different times and in different parts of their lives. This research challenges the idea that recovery is a straight line from victim to survivor. It shows that strength looks different for every person. Support services need to respect that complexity rather than expecting women to follow a single path to healing.
Institutional child sexual abuse has come to public attention in recent decades due to persistent advocacy by victim/survivors and their supporters. Disclosure is often a critical step, and victim/survivors' lived experience is central to informing policy and practice. We studied the narratives of male victim/survivors who spoke with the Australian Royal Commission into Institutional Responses to Child Sexual Abuse (Royal Commission) to understand the experience of their abuse over their life course. De-identified narratives of 412 male victim/survivors from four institutional types - armed forces, religious, sport and recreation, and youth detention - where abuse occurred in the 1970s and 1980s - were reviewed, coded and analysed. A qualitative content analysis approach allowed for an examination of the data. Inductive coding was the method used to develop categories from the data - survivor narratives - emerging from the Royal Commission. Survivor narrative comments were grouped into three categories: (1) the abuse; (2) reporting/not reporting the abuse; and (3) the institutions. This article focuses on the analysis of the second category, finding several reasons for victim/survivors not talking about their abuse at the time, primarily that they would not be believed, concerns about their parents' possible responses, and threats from perpetrators. Frequently, victim/survivors adopted a strategy of shut it down/shut it out. Victim/survivors who spoke about their abuse following the event commonly reported negative responses. Implications particularly with respect to understanding and responding to disclosure are discussed, as are strengths and limitations of this research.
Various interventions have been developed with the intention to increase the amount of physical activity among children, including those promoting active school travel (AST). However, no gold standard currently exists for measuring different travel modes in AST. This study evaluates the criterion validity of a web-based data collection tool designed for children to self-report their school travel. To assess the criterion validity of a web-based data collection tool for daily self-registration of commuting mode, time, and distance among middle school children in Sweden. Thirty children (10-12 years old) from six schools in Falun, Sweden, were recruited using snowball sampling. The children self-reported their school travel data for one day, including travel mode, commuting time, and distance. Their reports were compared to a criterion standard based on direct observations. Spearman correlation and the Wilcoxon signed-rank test were used to analyze the accuracy of the self-reported data. The web-based data collection tool demonstrated 100% agreement between self-reported and observed travel modes, with high correlations for commuting time and distance (rs=0.953-0.989, p < 0.001). The Wilcoxon signed rank test showed no significant differences between self-reported data and criterion standard (p = 0.243-0.903). The strong agreement between self-reported and observed travel data indicates high criterion validity, suggesting that the web-based data collection tool is a reliable method for middle school children to self-report their daily school travel.