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.
In vitro fertilisation is a widely used reproductive technique that can be undertaken with or without intracytoplasmic sperm injection. The endometrial scratch procedure is an in vitro fertilisation 'add-on' that is sometimes provided prior to the first in vitro fertilisation cycle, but there is a lack of evidence to support its use. (1) To assess the clinical effectiveness, safety and cost-effectiveness of endometrial scratch compared with treatment as usual in women undergoing their first in vitro fertilisation cycle (the 'Endometrial Scratch Trial') and (2) to undertake a systematic review to combine the results of the Endometrial Scratch Trial with those of previous trials in which endometrial scratch was provided prior to the first in vitro fertilisation cycle. A pragmatic, multicentre, superiority, open-label, parallel-group, individually randomised controlled trial. Participants were randomised (1 : 1) via a web-based system to receive endometrial scratch or treatment as usual using stratified block randomisation. The systematic review involved searching electronic databases (undertaken in January 2020) and clinicaltrials.gov (undertaken in September 2020) for relevant trials. Sixteen UK fertility units. Women aged 18-37 years, inclusive, undergoing their first in vitro fertilisation cycle. The exclusion criteria included severe endometriosis, body mass index ≥ 35 kg/m2 and previous trauma to the endometrium. Endometrial scratch was undertaken in the mid-luteal phase of the menstrual cycle prior to in vitro fertilisation, and involved inserting a pipelle into the cavity of the uterus and rotating and withdrawing it three or four times. The endometrial scratch group then received usual in vitro fertilisation treatment. The treatment-as-usual group received usual in vitro fertilisation only. The primary outcome was live birth after completion of 24 weeks' gestation within 10.5 months of egg collection. Secondary outcomes included implantation, pregnancy, ectopic pregnancy, miscarriage, pain and tolerability of the procedure, adverse events and treatment costs. One thousand and forty-eight (30.3%) women were randomised to treatment as usual (n = 525) or endometrial scratch (n = 523) and were followed up between July 2016 and October 2019 and included in the intention-to-treat analysis. In the endometrial scratch group, 453 (86.6%) women received the endometrial scratch procedure. A total of 494 (94.1%) women in the treatment-as-usual group and 497 (95.0%) women in the endometrial scratch group underwent in vitro fertilisation. The live birth rate was 37.1% (195/525) in the treatment-as-usual group and 38.6% (202/523) in the endometrial scratch group: an unadjusted absolute difference of 1.5% (95% confidence interval -4.4% to 7.4%; p = 0.621). There were no statistically significant differences in secondary outcomes. Safety events were comparable across groups. No neonatal deaths were recorded. The cost per successful live birth was £11.90 per woman (95% confidence interval -£134 to £127). The pooled results of this trial and of eight similar trials found no evidence of a significant effect of endometrial scratch in increasing live birth rate (odds ratio 1.03, 95% confidence interval 0.87 to 1.22). A sham endometrial scratch procedure was not undertaken, but it is unlikely that doing so would have influenced the results, as objective fertility outcomes were used. A total of 9.2% of women randomised to receive endometrial scratch did not undergo the procedure, which may have slightly diluted the treatment effect. We found no evidence to support the theory that performing endometrial scratch in the mid-luteal phase in women undergoing their first in vitro fertilisation cycle significantly improves live birth rate, although the procedure was well tolerated and safe. We recommend that endometrial scratch is not undertaken in this population. This trial is registered as ISRCTN23800982. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 10. See the NIHR Journals Library website for further project information. The endometrial scratch is a simple procedure that involves ‘scratching’ the lining of the womb (the endometrium). Several small studies have shown that undertaking this before the first in vitro fertilisation cycle may improve live birth rates; however, other studies have contradicted this. This large study was carried out to confirm whether or not having an endometrial scratch before the first in vitro fertilisation cycle would increase the number of women having a live birth compared with those having ‘usual’ in vitro fertilisation treatment (known as the ‘control’ group). We collected information about pregnancy, miscarriage, stillbirth, pain during the procedure and costs of treatment to find out if there were any meaningful differences. A total of 1048 women aged between 18 and 37 years were randomly allocated to the two groups, so participants had a 50% chance of having the endometrial scratch. Women were followed up throughout their pregnancy to ascertain the outcome of their in vitro fertilisation cycle. Although the live birth rate was 1.5% higher in the endometrial scratch group (38.6%) than in the control group (37.1%), the difference was not large enough to show any benefit of having the procedure. Other outcomes did not differ significantly between the two groups. However, the procedure was safe and tolerable. We found that the cost of treatment was, on average, £316 per participant higher in the group that received endometrial scratch than in the control group; the difference was not large enough to show that receiving endometrial scratch was more cost-effective. We combined the results of this trial with those of previous trials that looked to answer a similar question, and found that, overall, the endometrial scratch procedure does not enhance the chances of achieving a live birth. We conclude that endometrial scratch before first-time in vitro fertilisation does not improve the outcome of treatment, and we recommend that this procedure is not undertaken prior to a first cycle of in vitro fertilisation.
Are patients willing to discuss the possibility of treatment being unsuccessful as part of routine care offered at clinics, and what are the factors associated with this willingness? Nine in every 10 patients are willing to discuss this possibility as part of routine care, with willingness being associated with higher perceived benefits, lower barriers, and stronger positive attitudes towards it. Fifty-eight percent of patients who complete up to three cycles of IVF/ICSI in the UK do not achieve a live birth. Offering psychosocial care for unsuccessful fertility treatment (PCUFT), defined as assistance and guidance on the implications of treatment being unsuccessful, could reduce the psychosocial distress patients experience when it happens, and promote positive adjustment to this loss. Research shows 56% of patients are willing to plan for an unsuccessful cycle, but little is known about their willingness and preferences towards discussing the possibility of definitive unsuccessful treatment. The study was of cross-sectional design, comprising a theoretically driven and patient-centred bilingual (English, Portuguese) mixed-methods online survey. The survey was disseminated via social media (April 2021-January 2022). Eligibility criteria included being aged 18 or older, waiting to or undergoing an IVF/ICSI cycle, or having completed a cycle within the previous 6 months without achieving a pregnancy. Out of 651 people accessing the survey, 451 (69.3%) consented to participate. From these, 100 did not complete 50% of the survey questions, nine did not report on the primary outcome variable (willingness), and 342 completed the survey (completion rate 75.8%, 338 women). The survey was informed by the Health Belief Model (HBM) and Theory of Planned Behaviour (TPB). Quantitative questions covered sociodemographic characteristics and treatment history. Quantitative and qualitative questions gathered data on past experiences, willingness, and preferences (with whom, what, how and when) to receive PCUFT, as well as theory-informed factors hypothesized to be associated with patients' willingness to receive it. Descriptive and inferential statistics were used on quantitative data about PCUFT experiences, willingness, and preferences, and thematic analysis was applied to textual data. Two logistic regressions were used to investigate the factors associated with patients' willingness. Participants were, on average, 36 years old and most resided in Portugal (59.9%) and the UK (38.0%). The majority (97.1%) were in a relationship for around 10 years, and 86.3% were childless. Participants were undergoing treatment for, on average, 2 years [SD = 2.11, range: 0-12 years], with most (71.8%) having completed at least one IVF/ICSI cycle in the past, almost all (93.5%) without success. Around one-third (34.9%) reported having received PCUFT. Thematic analysis showed participants received it mainly from their consultant. The main topic discussed was patients' low prognosis, with the emphasis being put on achieving a positive outcome. Almost all participants (93.3%) would like to receive PCUFT. Reported preferences indicated that 78.6% wanted to receive it from a psychologist/psychiatrist/counsellor, mostly in case of a bad prognosis (79.4%), emotional distress (73.5%), or difficulties in accepting the possibility of treatment being unsuccessful (71.2%). The preferred time to receive PCUFT was before initiating the first cycle (73.3%), while the preferred format was in an individual (mean = 6.37, SD = 1.17; in 1-7 scale) or couple (mean = 6.34, SD = 1.24; in 1-7 scale) session. Thematic analysis showed participants would like PCUFT to provide an overview of treatment and all possible outcomes tailored to each patient's circumstances and to encompass psychosocial support, mainly focused on coping strategies to process loss and sustain hope towards the future. Willingness to receive PCUFT was associated with higher perceived benefit of building psychosocial resources and coping strategies (odds ratios (ORs) 3.40, 95% CI 1.23-9.38), lower perceived barrier of triggering negative emotions (OR 0.49, 95% CI 0.24-0.98), and stronger positive attitudes about PCUFT being beneficial and useful (OR 3.32, 95% CI 2.12-5.20). Self-selected sample, mainly composed of female patients who had not yet achieved their parenthood goals. The small number of participants unwilling to receive PCUFT reduced statistical power. The primary outcome variable was intentions, and research shows a moderate association between intentions and actual behaviour. Fertility clinics should provide patients with early opportunities to discuss the possibility of their treatment being unsuccessful as part of routine care. PCUFT should focus on minimizing suffering associated with grief and loss by reassuring patients they can cope with any treatment outcome, promoting coping resources, and signposting to additional support. M.S.-L. holds a doctoral fellowship from the Portuguese Foundation for Science and Technology, I.P. [Fundação para a Ciência e a Tecnologia] (FCT; SFRH/BD/144429/2019). R.C. holds a post-doctoral fellowship supported by the European Social Fund (ESF) and FCT (SFRH/BPD/117597/2016). The EPIUnit, ITR and CIPsi (PSI/01662) are also financed by FCT through the Portuguese State Budget, in the scope of the projects UIDB/04750/2020, LA/P/0064/2020 and UIDB/PSI/01662/2020, respectively. Dr Gameiro reports consultancy fees from TMRW Life Sciences and Ferring Pharmaceuticals A/S, speaker fees from Access Fertility, SONA-Pharm LLC, Meridiano Congress International and Gedeon Richter, grants from Merck Serono Ltd, an affiliate of Merck KgaA, Darmstadt, Germany. N/A.
Does 8 weeks of daily low-dose hCG administration affect androgen or inhibin B levels in serum and/or follicular fluid (FF) during the subsequent IVF/ICSI cycle in women with low ovarian reserve? Androgen levels in serum and FF, and inhibin B levels in serum, decreased following 8 weeks of hCG administration. Recently, we showed that 8 weeks of low-dose hCG priming, in between two IVF/ICSI treatments in women with poor ovarian responder (anti-Müllerian hormone (AMH) <6.29 pmol/l), resulted in more follicles of 2-5 mm and less of 6-10-mm diameter at the start of stimulation and more retrieved oocytes at oocyte retrieval. The duration of stimulation and total FSH consumption was increased in the IVF/ICSI cycle after priming. Hypothetically, hCG priming stimulates intraovarian androgen synthesis causing upregulation of FSH receptors (FSHR) on granulosa cells. It was therefore unexpected that antral follicles were smaller and the stimulation time longer after hCG priming. This might indicate a different mechanism of action than previously suggested. Blood samples were drawn on stimulation day 1, stimulation days 5-6, trigger day, day of oocyte retrieval, and oocyte retrieval + 5 days in the IVF/ICSI cycles before and after hCG priming (the control and study cycles, respectively). FF was collected from the first aspirated follicle on both sides during oocyte retrieval in both cycles. The study was conducted as a prospective, paired, non-blinded, single-center study conducted between January 2021 and July 2021 at a tertiary care center. The 20 participants underwent two identical IVF/ICSI treatments: a control cycle including elective freezing of all blastocysts and a study cycle with fresh blastocyst transfer. The control and study cycles were separated by 8 weeks (two menstrual cycles) of hCG priming by daily injections of 260 IU recombinant hCG. Women aged 18-40 years with cycle lengths of 23-35 days and AMH <6.29 pmol/l were included. Control and study IVF/ICSI cycles were performed in a fixed GnRH-antagonist protocol. Inhibin B was lower on stimulation day 1 after hCG priming (P = 0.05). Dehydroepiandrosterone sulfate (DHEAS) was significantly lower on stimulation day 1 (P = 0.03), and DHEAS and androstenedione were significantly lower on stimulation days 5-6 after priming (P = 0.02 and P = 0.02) The testosterone level in FF was significantly lower in the study cycle (P = 0.008), while the concentrations of inhibin B and androstenedione in the FF did not differ between the study and control cycles. A lower serum inhibin B in the study cycle corresponds with the antral follicles being significantly smaller after priming, and this probably led to a longer stimulation time in the study cycle. This contradicts the theory that hCG priming increases the intraovarian androgen level, which in turn causes more FSHR on developing (antral up to preovulatory) follicles. However, based on this study, we cannot rule out that an increased intra-follicular androgen level was present at initiation of the ovarian stimulation, without elevating the androgen level in serum and that an increased androgen level may have rescued some small antral follicles that would have otherwise undergone atresia by the end of the previous menstrual cycle. We retrieved significantly more oocytes in the Study cycle, and the production of estradiol per follicle ≥10-mm diameter on trigger day was comparable in the study and control cycles, suggesting that the rescued follicles were competent in terms of producing oocytes and steroid hormones. The sample size was small, and the study was not randomized. Our study design did not allow for the measurement and comparison of androgen levels or FSHR expression in small antral follicles before and immediately after the hCG-priming period. The results make us question the mechanism of action behind hCG priming prior to IVF. It is important to design a study with the puncture of small antral follicles before and immediately after priming to investigate the proposed hypothesis. Improved cycle outcomes, i.e. more retrieved oocytes, must be confirmed in a larger, preferably randomized study. This study was funded by an unrestricted grant from Gedeon Richter awarded to the institution. A.P. reports personal consulting fees from PregLem SA, Novo Nordisk A/S, Ferring Pharmaceuticals A/S, Gedeon Richter Nordics AB, Cryos International, and Merck A/S outside the submitted work and payment or honoraria for lectures from Gedeon Richter Nordics AB, Ferring Pharmaceuticals A/S, Merck A/S, and Theramex and Organon & Co and payment for participation in an advisory board for Preglem. Grants to the institution have been provided by Gedeon Richter Nordics AB, Ferring Pharmaceuticals A/S, and Merck A/S, and equipment and travel support has been given to the institution by Gedeon Richter Nordics AB. The remaining authors have no conflicts of interest to declare. ClinicalTrials.gov Identifier: NCT04643925.
Teenage pregnancies remain a pressing issue in Sub-Saharan Africa, including Rwanda. Adolescent girls and young women (AGYW) continue to face a myriad of challenges in accessing sexual reproductive health (SRH) services. This study examines the accessibility and utilization of SRH services provided to AGYW in youth corners in Rwamagana district, Rwanda. It seeks to explore challenges and opportunities for accessing SRH services in youth corners. Utilising a descriptive qualitative research design, the study included 8 in-depth focus group discussions and 4 key informant interviews. Stratified sampling methodology was utilised to increase the representativeness of the AGYW and 71 AGYW participated in the study. The feminist standpoint theory aided in focusing on marginalised voices, analysing power structures and contextualising experiences of AGYW in Rwamagana. The socio-ecological model was used to analyse data using thematic analysis. The findings reveal various SRH services accessed by AGYW in youth corners, including family planning, services regarding sexually transmitted infections (STIs) and menstrual hygiene management. Barriers to service utilisation included limited knowledge about the available services, distance to health facility, unavailability of some services, AGYW being viewed as a prostitute when one is seen with condoms, norms that discourage open discussions about sexual health, and stigma surrounding the use of contraceptives. This was further worsened by the gender norms which create additional hurdles for AGYW, as they navigate societal expectations and restrictions that are not equally imposed on their male counterparts. The inconsistent availability of services coupled with diverse operating schedules also posed a challenge to accessing services. Most AGYW expressed trust in the healthcare providers' ability to maintain confidentiality, given their training and professional obligations. This sense of trust acted as a motivating factor for AGYW to be more open and forthcoming in utilising the available SRH services. Addressing the identified challenges faced by AGYW in accessing SRH services in youth corners will help to promote their well-being and bodily autonomy. Adolescent girls and young women (AGYW) in many communities face challenges in accessing sexual and reproductive health (SRH) services, which are critical for their well-being and rights. This study examines the availability, accessibility, and acceptability of SRH services offered to AGYW in youth corners within the Rwamagana district, while identifying barriers and opportunities for improvement.The research revealed that a variety of SRH services are available at youth corners, including family planning, menstrual hygiene management, and services regarding sexually transmitted infections (STIs). However, despite the availability of these services, many young women face barriers to accessing them. These barriers include a lack of knowledge about the available services, cultural norms that discourage open discussions about sexual health, and stigma surrounding the use of contraceptives.The study highlights the need for greater awareness and education to encourage AGYW to seek sexual reproductive health services. It also calls for community involvement to reduce the cultural stigma and misconceptions surrounding SRH. By addressing these challenges, the accessibility and utilisation for young women can be improved, which in turn will promote their well-being and protect their reproductive rights. This will contribute to reducing teenage pregnancies and empowering AGYW to make informed decisions and choices about their sexual health.
Objective: Drinking motives predict drinking behaviors and outcomes among adults. Drinking motives are rarely studied using self-determination theory (SDT), which aligns with harm-reduction approaches to alcohol use, but SDT can offer a complementary theoretical framework to existing drinking motives frameworks that may help explain the observed heterogeneity in drinking motives and account for more variance in drinking outcomes. This study examined the associations between five SDT-based drinking motives with drinking frequency, intensity, and consequences. Method: A total number of 630 adults (Mage = 21.5, 55% female, 88% undergraduates) rated drinking motives using the Comprehensive Relative Autonomy Index for Drinking (CRAI-Drinking) and the Drinking Motives Questionnaire (DMQ), typical alcohol consumption, and negative and positive drinking consequences. Results: Poisson regressions indicated that intrinsic (IRR = 1.13) and identified (IRR = 1.11) regulations were significantly associated with drinking frequency, identified (IRR = 0.94) and positive introjected (IRR = 1.07) regulations were significantly associated with drinking intensity, and amotivation (IRR = 1.16) and intrinsic regulation (IRR = 1.09) were associated with negative and positive consequences, respectively, after controlling for other CRAI-Drinking and DMQ scores, sex, and drinking intensity. After accounting for DMQ scores and sex, CRAI-Drinking scores accounted for 1.7%-9.9% additional deviance in drinking behaviors and consequences. Conclusions: Adults high in autonomous reasons for drinking reported low-risk, high-enjoyment drinking experiences. In contrast, adults with higher scores for amotivation for drinking reported more negative consequences, even after accounting for drinking intensity, suggesting that high amotivation for drinking may be a novel signal for future alcohol-related risks. These findings support the idea that SDT provides a useful framework for understanding drinking motives, behaviors, and consequences.
Against the backdrop of accelerating climate change and more frequent extreme weather events, typhoon disasters have become a major challenge to mental health. Based on the Social Determinants of Health theory and integrating the Cumulative Disadvantage Model with Structural Causal Influence analysis, this study evaluates how typhoon exposure affects the burden of mental health disorders and how these effects vary with social structural differences. To investigate the mechanisms linking typhoon exposure to the burden of mental health disorders, and to quantify the moderating roles of macro-level social structural variables. By constructing both main effect and year-on-year difference models, combined with structural equation modelling and multinational panel data, this research quantifies the moderating roles of macro-level social variables, including gross national income, Human Development Index, Gini coefficient, government health expenditure, out-of-pocket health spending, educational attainment, and life expectancy. Typhoons were found to increase prevalence, incidence, and disability-adjusted life years (DALYs) related to mental disorders, with the strongest impact in the 25-34 age group. High income, education, HDI, and public health investment were linked to greater resilience, while low income, high OOP, and high inequality indicated vulnerability. Secondary disaster frequency and the number of people affected acted as mediators, forming a pathway from 'typhoon' to 'social stress' to 'mental disorders.' Typhoon impacts on mental health are shaped by both direct exposure and structural inequalities. Improving socioeconomic conditions, lowering OOP costs, reducing inequality, and increasing public health investment can strengthen psychological resilience and disaster response capacity. Main findings: This study reveals that typhoon disasters significantly exacerbate the mental health burden across multiple countries, with pronounced heterogeneity by age and socioeconomic status, and that their impacts are strongly moderated by social structure and institutional resources – addressing a key gap in quantifying structural inequality mechanisms in disaster mental epidemiology.Added knowledge: For the first time, this research integrates multinational panel data with multidimensional subgroup heterogeneity models and structural equation modelling (SEM) to quantify the moderating and mediating roles of social determinants of health in the typhoon – mental health relationship.Global health impact for policy and action: The findings provide empirical evidence for global disaster response policy, underscoring the importance of advancing universal health coverage, optimizing resource allocation, and delivering targeted mental health interventions for vulnerable populations in the context of climate change.
Adolescent girls living in low-income urban informal settlements face unique challenges that elevate their susceptibility to early childbearing. However, there has been limited research attention, especially qualitative studies, on their use or non-use of antenatal care (ANC) services. Informed by the socioecological theory, we examined the obstacles to and facilitators of ANC services use among pregnant adolescent girls in a low-income urban informal settlement in Kenya. The study adopted a qualitative explanatory design. We purposively selected 22 adolescent girls aged 13-19 who were either pregnant or had given birth, 10 parents and three health providers to participate in individual interviews. We employed inductive and deductive thematic analyses informed by socioecological theory to explain the barriers to enablers of antenatal services use among pregnant adolescent girls in low-income informal settlements. Most adolescent girls interviewed faced barriers at multiple socioecological levels, resulting in delayed ANC initiation and fragmented engagement with services. At the intrapersonal level, girls grappled with internalised stigma and late pregnancy recognition and acceptance, often dismissing early signs due to fear or denial. Their young age and limited knowledge of maternal health left them terrified in fear, caught between societal judgement and the daunting prospect of confronting their condition. At the interpersonal level, societal stigma and discrimination pushed many into secrecy, hindering their access to antenatal services. However, parents, other family members, and health providers played a key role in enabling access to care by offering various forms of support to pregnant girls, including offering counselling and accompanying girls to clinics. At the organisational level, user fees and condescending health providers' attitudes hindered ANC use. Yet, good patient-provider communication, privacy and confidentiality played a key role in enabling ANC attendance. Pregnant adolescent girls face unique challenges that prevent them from accessing ANC early and completing the recommended number of visits. These challenges range from intrapersonal factors to interpersonal and organisational factors. Programmes to improve early initiation of ANC for pregnant adolescents should include interventions that address the social stigma associated with early and unintended pregnancy, promote family support and make health facilities responsive to the needs of pregnant girls.
A growing number of couples worldwide are seeking in vitro fertilization-embryo transfer (IVF-ET) to achieve pregnancy. However, failed IVF-ET treatment inflicts multidimensional stress on patients, involving individual, familial, and social levels, yet existing research has largely focused on single-dimensional analyses. Therefore, this study aims to systematically explore the treatment experiences of patients with failed IVF-ET using the Social-Ecological Systems Theory (SEST) as a guiding framework, in order to comprehensively understand the interplay of factors across individual, familial, and social levels. Based on the social-ecological systems theory, this study adopted a phenomenological qualitative research approach. From November 2024 to January 2025, patients who experienced failed in vitro fertilization-embryo transfer (IVF-ET) were recruited using purposive sampling for face-to-face, semi-structured interviews at a tertiary hospital in Kunming, Yunnan Province. Colaizzi's seven-step analysis method was applied to analyze the interview data. A total of 15 patients with failed IVF-ET participated in this study, and three themes and eight sub-themes were derived from the interview data: (1) Microsystem: Experiencing physical and psychological distress (dynamic changes in complex emotional experiences; experiences of somatic discomfort); (2) Mesosystem: Confronting challenges of imbalance in economic status, family relationships and life patterns (excessive economic burden; barriers to maintaining family relationships; imbalance in life and work patterns); (3) Macrosystem: Weakness of the diversified external support system (insufficient informational support; need for improvement in medical service experience; inadequate policy support). Patients who experience failed IVF-ET-assisted pregnancy exhibit compromised social-ecological system status, accompanied by severe psychological distress and substantial economic burden, along with multiple adaptive challenges. These findings highlight the urgent clinical need to implement targeted psychological interventions, optimize medical support strategies, and mobilize multidisciplinary resources including medical staff, family, and social institutions, thereby improving the coping ability and long-term mental health outcomes of this population.
The global population of older adults is rapidly increasing, while the number of relative caregivers is declining. This creates a critical need for solutions that support caregiving and enable older adults to age in place while maintaining their independence. Many existing caregiving technologies focus on easing caregivers' burdens through surveillance-based systems, which often prioritize caregivers' needs over those of older adults. Such designs can unintentionally disempower older adults by devaluing their autonomy and decision-making capabilities. This study explored older adults' and designers' reactions to a technology-enabled system called LifeTomorrow that was built by centering older adults as the primary users. The system aims to support their autonomy to make informed choices and their desire for independent living, while balancing their social and functional needs with those of informal caregivers. A total of 37 participants, including older adults, caregivers, and designers, engaged in 2 iterative rounds of user studies to explore daily caregiving needs and technology usage. The system's design and features were refined based on these insights. A qualitative thematic analysis was conducted using the framework of the self-determination theory to evaluate how the system fulfills the basic psychological needs of competence, autonomy, and relatedness. The analysis underscored the system's value to older adults and their caregivers, and its fulfillment of basic human psychological needs (competence, autonomy, and relatedness), consistent with the goals of supporting a high quality of life for older users and caregivers. We found that relatedness is fostered through features enabling remote connection and communication, such as chat functions and shared health data. Autonomy is supported by empowering older adults to manage their health information, make informed choices about data sharing, and benefit from safety features like fall detection and emergency calls. Competence is enhanced through accessible design elements, including intuitive navigation, high-contrast visuals, and multigenerational usability. These features allow older adults and caregivers to confidently engage with the system and are targeted at improving their overall quality of life. Through evaluation of the LifeTomorrow system, this study suggests possibilities for using a holistic, inclusive solution to support safe and independent aging in place and prioritizing the autonomy and empowerment of older adults while addressing caregivers' needs for support and connection. By centering older adults as active participants rather than passive recipients of care, the system exemplifies a shift toward equitable, user-centered technology in caregiving. Future research should investigate the long-term impacts of such systems on aging-in-place outcomes.
The aim of this study was to develop a theory based on the understanding of collective alcohol use as a cultural phenomenon by exploring the perceptions and meanings attributed to this behaviour by health science university students. This research is a grounded theory study. This study was conducted between 2021 and 2022. Data were collected through 10 focus groups, 15 in-depth interviews, and 44 field journals documenting observations in alcohol consumption settings. A total of 72 health science students participated, including 51 nuring students, 14 medical students, and 7 psychology students from two cities. The data were analysed using Charmaz's constructivist grounded theory approach and coded through constant comparative analysis with Atlas.ti software. The analysis revealed five categories that support the development of the theory: (1) 'Understanding the Practice of Drinking,' (2) 'Replicating Learned Patterns: Cultural Influence,' (3) 'Adopting and Taking Risks,' (4) 'Confronting Prefabricated Imaginaries with Reality,' and (5) 'Reflecting on Mitigating Actions and Alternatives to Problematic Consumption.' The findings demonstrate that culture significantly influences young adults' behaviours related to alcohol consumption, with a tendency to follow established patterns while accepting the risks involved. Studying health sciences, encourages deeper reflection on these behaviours, potentially guiding moderation in alcohol use. These insights contribute to multicultural nursing practice by examining the dynamics surrounding alcohol consumption and the factors that motivate moderation. Understanding alcohol use among young university students enrolled in healthcare courses as a cultural phenomenon helps identify underlying factors and attitudes that shape these behaviours. This model was used as the foundation for developing a preventive care strategy, with young people and their experiences serving as key elements in its design and implementation. No patient or public contribution.
BACKGROUND: Insufficient multicomponent physical activity is prevalent in older adults. In China, a series of supportive policies to promote physical activity (PA) has been implemented. However, feasible PA interventions to promote multicomponent PA among community-dwelling older adults are limited. OBJECTIVE: We aimed to develop a multicomponent PA intervention program for community-dwelling older adults and assess the feasibility. METHODS: The multicomponent PA intervention was developed by a multidisciplinary working group based on Social Cognitive Theory, the Transtheoretical Model, and behavior change techniques. A three-month feasibility study was conducted in a community in Hangzhou, China. Feasibility was tested by Bowen’s framework for assessing the acceptability, demand, implementation, practicality, adaptation, integration, expansion, and limited efficacy of the PA intervention program. Demographic and clinical information, group exercise attendance, experience questionnaires, physical measurements, and self-reported exercise records were collected. RESULTS: The developed PA intervention combined face-to-face group exercise in a community center and home-based exercise assisted by a WeChat applet or exercise manuals, with a weekly goal of engaging in multicomponent exercise at least three days per week recommended by PA guidelines for older adults. A total of 20 participants were recruited for the feasibility study. Overall, 19 participants (95%) completed the intervention in the feasibility study (average age 77 (SD 9) years), with 12 participants using the WeChat applet and 7 using the exercise manuals for home-based exercises. The intervention satisfied all of Bowen’s feasibility criteria. In the third month, 93% of the WeChat applet group and 79% of the non-WeChat applet group adhered to weekly exercise goals. After three months of intervention, statistically significant improvements were observed in physical activity level (Physical Activity Scale for the Elderly score + 33.6, 95% CI 23.5to 43.6), grip strength (mean difference + 1.4 kg, 95% CI 0.1 to 2.7) and chair stand test (mean difference − 3.5 s, 95% CI -4.9 to -2.2). CONCLUSION: High exercise adherence was observed throughout the three-month intervention. The theory-based blended PA intervention program was quite feasible in real-world settings, serving as a novel model for promoting multicomponent PA engagement among community-dwelling older adults in China. A future large-scale randomized controlled trial is needed to test the long-term effectiveness and scalability of the PA intervention program. CLINICAL TRIAL NUMBER: Not applicable.
A drinking game (DG) is a widely practiced social activity that tends to encourage rapid alcohol consumption. While social restrictions during the pandemic (COVID-19) academic year were implemented as a health measure across many colleges/universities, the extent to which college student drinkers continued to play DGs in-person is not well understood. Because theory and research suggest that drinking motives are proximal correlates of drinking behaviors, we examined which drinking motives increased the likelihood of playing DGs in-person, and playing DGs in-person in a group of 10 + people during the 2020-21 pandemic academic year. College students (past-year drinkers) from 12 universities completed an online survey (N = 900; Mage = 19.42, Range = 18-25; SDage = 1.45, White = 73.1%, 69.2% female). Of the students surveyed, 590 students played DGs, with 460 students only playing DGs in-person. Of the students who played DGs in-person, 274 students reported that the maximum number of people they played DGs with in-person exceeded the CDC's recommended guidelines (10 + people). Accounting for demographics, general alcohol use, and perceived COVID-19 threat, social drinking motives were positively associated with an increased likelihood of playing DGs in-person; the inverse was found for coping motives. Drinking motives were not associated with the likelihood of playing DGs with 10 + people but greater alcohol use and lower perceived threat of COVID-19 were. Given that the pandemic did not deter many student drinkers from playing DGs in-person, further investment in targeted intervention and public health initiatives aimed at substance-free alternatives promoting engagement and enhancement of social activities may be needed.
Subject-method barriers and cognitive load (CL) of students have a particular importance in the complex learning process of scientific inquiry. In this work, we investigate the valid measurement of CL as well as different scaffolds to reduce it during experimentation. Specifically, we examine the validity of a subjective measurement instrument to assess CL [in extraneous cognitive load (ECL), intrinsic cognitive load, and germane cognitive load (GCL)] during the use of multimedia scaffolds in the planning phase of the scientific inquiry process based on a theoretical framework of the CL theory. The validity is analyzed by investigating possible relationships between causal (e.g., cognitive abilities) and assessment (e.g., eye-tracking metrics) factors in relation to the obtained test scores of the adapted subjective measurement instrument. The study aims to elucidate possible relationships of causal factors that have not yet been adequately investigated in relation to CL. Furthermore, a possible, still inconclusive convergence between subjective test scores on CL and objectively measured indicators will be tested using different eye-tracking metrics. In two studies (n=250), 9th and 11th grade students experimentally investigated a biological phenomenon. At the beginning of the planning phase, students selected one of four multimedia scaffolds using a tablet (Study I: n=181) or a computer with a stationary eye-tracking device (Study II: n=69). The subjective cognitive load was measured via self-reports using a standardized questionnaire. Additionally, we recorded students' gaze data during learning with the scaffolds as objective measurements. Besides the causal factors of cognitive-visual and verbal abilities, reading skills and spatial abilities were quantified using established test instruments and the learners indicated their representation preference by selecting the scaffolds. The results show that CL decreases substantially with higher grade level. Regarding the causal factors, we observed that cognitive-visual and verbal abilities have a significant influence on the ECL and GCL in contrast to reading skills. Additionally, there is a correlation between the representation preference and different types of CL. Concerning the objective measurement data, we found that the absolute fixation number is predictive for the ECL. The results are discussed in the context of the overall methodological research goal and the theoretical framework of CL.
BACKGROUND: The Mahama camp was established in 2015 to accommodate displaced populations from different countries, including Burundi, the Democratic Republic of Congo, and Rwanda. The camp, located in Rwanda's Eastern Province, Kirehe District, spans 50 hectares and encompasses 18,360 households across 15 villages. The prevalence of adolescent pregnancy in the Mahama camp was alarming at the time of the study, despite multiple campaigns by the government and international partners, underscoring the complexity of the problem and the need for further research. This study identified factors influencing the accessibility of contraceptives for adolescent refugee girls in Mahama camp in 2022, from the perspective of girls aged 10–19, to inform the design of interventions based on insights gained from the social cognitive theory. METHODS: We undertook in-depth interviews using a semi-structured guide with 19 adolescent girls aged 10–19 years. Participants were selected to represent diverse socio-demographic characteristics, including in-school and out-of-school girls, married and unmarried girls, and those who have or have not ever been pregnant. Data were analysed thematically using the Social Cognitive Theory to identify barriers and facilitators to accessing contraceptive services in the Mahama refugee camp. RESULTS: Enablers of access to contraceptive services included free service provision and support from healthcare providers. Furthermore, community awareness campaigns, convenient service locations, and knowledge about contraception also played an important role. Barriers to access included cultural and religious norms, fear, and misconceptions, as well as camp-specific challenges such as limited funding, shortages of contraceptives, and too few service providers. CONCLUSION: Improving adolescents’ access to contraceptive services in the Mahama Refugee Camp requires coordinated action among key stakeholders, including the government, international partners, and the Mahama camp community. All these stakeholders require a joint effort to ensure consistent availability of contraceptives at youth-friendly and safe service points, alongside expanded and amplified community awareness programs. Furthermore, it is essential to improve efforts to address the shortage of supplies and human resources. The shortage of healthcare workers and revising age-based legal restrictions would further improve adolescents’ access to contraceptive services, which also need to be addressed.
Nitroimidazole-based derivatives serve as fundamental components in the treatment of microbial infections. Metronidazole (MNZ), a synthetic nitroimidazole compound, is widely used as an important antimicrobial agent (AMA). Since the 1950s, MNZ has been a key drug in clinical medicine for treating a number of bacterial and protozoal diseases. It is commonly prescribed for bacterial vaginosis, amoebiasis, trichomoniasis, giardiasis, Clostridioides difficile-related diarrhoea, and anaerobic intra-abdominal infections. However, the use of MNZ as a therapeutic agent is often limited by unfavourable pharmacokinetics and side effects, including nausea, metallic taste, headache, and neurotoxicity (with long-term use). Therefore, our research explored various modified derivatives of MNZ to enhance its pharmacological activity and toxicity profiles. The geometrical characteristics of the analogues were further optimized via density functional theory (DFT) calculations via the B3LYP/6-31G+ (d, p) basis set. Molecular docking studies were conducted against bacterial thymidylate kinase and protozoal DNA, which revealed that most of the derivatives enhanced the ligand-protein binding affinities and favourable interactions at the protein active sites of both targets. Furthermore, a 100 ns molecular dynamics (MD) simulation was performed to evaluate the mode of interaction and stability of the ligand-protein complex under biological conditions. This result indicated that BNZ, SRZ, and EF5 improved the binding stability and dynamic flexibility patterns of these compounds. The pharmacological activity and safety parameters of the analogues were evaluated through ADMET and PASS analyses. Overall, the results revealed that most of the analogues possess favourable physicochemical and pharmacokinetic properties with few side effects. This research could facilitate the further development of BNZ, SRZ, and EF5 as promising candidates for next-generation AMAs, necessitating advanced preclinical evaluations. The online version contains supplementary material available at 10.1007/s40203-025-00538-8.
To report four cases of in vitro fertilization-embryo transfer (IVF-ET) with discordance between chorionicity and embryo transfer number. A case series. Four cases underwent ART treatment in Kaohsiung Chang Gung Memorial Hospital between 2018 and 2020: a 34-year-old woman who underwent an IVF-frozen cycle with embryo transfer of one blastocyst and one morula, resulting in a quintuplet pregnancy. The ultrasound of the quintuplets showed four gestational sacs, one of which was a blighted ovum (one empty gestational sac), and one of the remaining three was a monochorionic-monoamniotic twin (MCMA); a 39-year-old woman who underwent an IVF-frozen cycle with the transfer of two blastocysts, resulting in a quintuplet pregnancy. The ultrasound of the quintuplets showed four completely separate chorionic sacs, one of which was a blighted ovum, and one of the remaining three was a monochorionic-diamniotic (MCDA) twin; a 33-year-old woman who underwent an IVF-frozen cycle and a 36-year-old woman who underwent an IVF fresh cycle, both with single blastocyst transfer, resulting in twin pregnancies with two completely separate chorionic sacs with one blighted ovum. Excluding the possibility of spontaneous ovulation and conception and laboratory procedure errors, these four cases demonstrate monozygotic splitting after the blastocyst stage, challenging the existing dogma that only monochorionic can develop after day three post-fertilization. The accepted theory of monozygotic twinning resulting from the splitting of an embryo per a strict postfertilization timing protocol must be re-examined with the advent of discordance between chorionicity and embryo transfer number. Reducing the number of embryo transfers in IVF treatment is important.
Assistive technologies may play a crucial role in addressing needs of people with dementia. While technical feasibility often drives development, the decision-making process that might lead to their adoption (or rejection) is not fully understood. We aim to explore contextual factors influencing this process and "necessities" technology should fulfil from the user-perspective, so that the use of assistive technologies can be better targeted- potentially fostering a more supportive home environment. In this qualitative study, interviews (8 people with dementia and 7 partners) and focus groups (7 focus groups included a total of 29 participants) with individuals with milder stages of dementia living at home and their support/care-network were carried out. Grounded Theory and Structuring Content Analysis were used to analyse the data. Six main thematic categories outline the decision-making process. The "assessment of (one's own) resources", while evaluating the "(potential) benefits of assistive technologies" contrasts with "(potential) adverse effects" of their use (or their non-use respectively), shaping the context of the decision-making process. There is an appraisal of necessary "(pre-existing) trust" in technology. An a priori "openness towards assistive technologies" intersects latter aspects. A very substantial "need for information" is noted. While technical feasibility and tailored solutions are important, they are not the sole determinants of assistive technology adoption in this group. The desire to preserve self-determination and independence emerges as a key motive for choosing assistive technologies; technology can also be seen to invoke stress and negative emotions, and will consequently be rejected. Technology should, moreover, be perceived to be "meaningful" on different levels. Considering these points when developing technologies and addressing them when counselling those affected by dementia and their networks may "tip the scale" towards acceptance.
In 2019, Native youth had the highest rate of teen pregnancy of all racial/ethnic groups. "Respecting the Circle of Life" (RCL) is one of the first evidence-based teen pregnancy prevention programs for Native teens and there is interest in replicating the program across tribal communities. To inform replication, it is important to consider process data including quality, fidelity, and dosage as these may all moderate impact of the program. Participants were Native youth aged 11-19 and a trusted adult. This study includes participants randomized to the RCL program only (N = 266). Data sources include independent observations, facilitator self-assessments, attendance logs, and self-report assessments completed by enrolled youth at baseline and 3 months post assessment. Data was compiled and summed by cohort. Dosage was number of minutes participating in activities separated by theoretical constructs. Linear regression models were utilized to assess moderation of the effects of the intervention dosage on outcomes of interest. Eighteen facilitators delivered RCL. One hundred eighteen independent observations and 320 facilitator self-assessments were collected and entered. Findings indicate RCL was implemented with high fidelity and quality (4.40 to 4.82 out of a 5-point Likert scale; 96.6% of planned activities completed). Dosage was high with an average completion of 7 out of 9 lessons. There was no association between theoretical construct dosage and outcomes of interest. Overall, this study indicates RCL was delivered with high fidelity, quality, and dosage in this trial. This paper informs future replication of RCL and provides support for hiring paraprofessionals from the local community as facilitators, delivering the RCL to peer groups of the same age and sex, delivering the RCL with short duration and high frequency, and encouraging youth to attend all RCL lessons, but continue to serve youth who have missed one or more lessons.
Perspectives of IVF users on their spare embryos is a less explored subject in the Indian context despite the country's population and abundance of IVF clinics. We conducted a qualitative study using in-depth interviews in a selected district of the Indian state of Karnataka. Seven individuals were recruited independently of any assistance from an IVF clinic. The interviews explored participants' knowledge and perception of the spare embryos using a set of guiding questions exploring the theme of the informed consent process, views on research, preferences for embryo donation, the role of family and the dynamics of decision-making, amongst other things. The interviews were qualitatively analysed using Corbin and Strauss's grounded theory approach. Our findings reveal that the participants do not learn about the prospects of spare embryos from the very start of their IVF journeys, and they may not be informed about the various options available to decide the fate of the spare embryos. Irrespective of their views on research and moral perceptions of embryos, participants expressed a sense of responsibility and ownership towards their embryos and a general reluctance to donate them. Our findings have implications for guiding future inquiries on this subject, which can better the informed consent process and unravel the role of ownership in the ethics of spare embryos in the Indian context.