Global burden of 292 causes of death in 204 countries and territories and 660 subnational locations, 1990–2023:a systematic analysis for the Global Burden of Disease Study 2023

BackgroundTimely 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.MethodsGBD 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.FindingsThe 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.InterpretationWe 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.<br/

Investigating Person-Centred Care Planning in Care Homes Across England:An Exploratory Study of Practices and Contextual Factors

AimsTo report how person-centred care principles are applied to care planning and to explore the contextual factors affecting their implementation in older adult care homes in England. DesignA combined framework analysis and quantitative content analysis study. MethodsUsing a semi-structured questionnaire, we interviewed 22 care home managers in England, exploring topics around care planning processes. Audio recordings were transcribed verbatim. Transcripts were analysed through a combined framework approach and content analysis. ResultsMost care home managers discussed person-centred care planning in terms of understanding residents' values and preferences and their engagement in decision-making. Factors facilitating person-centred planning implementation included accessible planning tools, supportive care home leadership, effective communication and collaborative partnerships. Inhibiting factors included regulatory and care practice misalignment, time constraints and adverse staffing conditions. ConclusionDifferences between care home practitioners' understanding and practice of person-centred care planning require further examination to improve understanding of the sector's complexity and to develop suitable care planning instruments. Implications for the Profession Findings demonstrate a need for improved staff access to specialised person-centred care training and an opportunity for care home nursing practitioners to lead the co-development of digital person-centred care planning tools that reflect the reality of long-term care settings. ImpactIdentifying factors influencing the implementation of holistic approaches to care planning makes clear the need for modernising long-term care policy and practice to adapt to the contemporary challenges of the care home sector. Reporting MethodStudy reporting was guided by the Standards for Reporting Qualitative Research. Patient or Public ContributionTwo public involvement advisors with lived experience of caring for a relative living in a care home contributed to the development of the interview guide, advised on care home engagement, guided the interpretation of the findings and commented on the drafted manuscript.<p/

Maximizing the Quality and Reporting Standards of Autism Intervention Science

Although there are clear international standards for intervention science and reporting in healthcare, implementation and uptake have been limited within autism intervention research. To address this concern, a Special Interest Group (SIG) was convened at the International Society for Autism Research (INSAR) Annual Meetings in May 2023 and May 2024. This SIG comprised members of the autistic community, senior clinical scientists, clinicians, advanced researchers, and early career researchers, who discussed and debated quality standards for autism intervention trials. This commentary summarizes relevant literature highlighted by SIG panelists and recommendations generated from small breakout groups and larger group discussions with SIG attendees. We recommend that all journals publishing autism intervention findings, especially autism-focused journals, institute mandatory reporting practices (e.g., trial registration, protocol, analysis plan) to facilitate transparency and rigorous autism intervention science, as well as related education initiatives in support of this goal. Findings from the SIG offer practical, actionable recommendations that we advocate be systematically adopted across autism-focused journals.</p

Ten Common Messes in Researching Religion

Learning from other researchers about what to expect and how to navigate challenges and mistakes has many benefits. Drawing on the authors’ experiences, those of their students, and the contributors in this collection, this introduction explores ten of the most common messes that occur in researching religion. A ‘mess’ may refer to what is ‘out there’ being complex, heterogeneous, and unpredictable, but it also has to do with our (in)comprehension. A mess may confuse, annoy, disappoint, or shame. It can also challenge, stimulate, and provoke. Exposing common messes equips researchers to tell the difference between error and complexity, to be better prepared, and more honest. That things go wrong need not be a problem when it is part of a process of self- critical learning and correction. This introduction suggests that research is an art as well as a science, and a matter of temperament as well as technique.</p

The pacification model in Port-au-Prince and Rio de Janeiro as a prefiguration of Bolsonarismo? Reflections on the far-right turn and the role of military-religious actors in security governance in Brazil

While much critical scholarship has pointed out that liberal peacebuilding can contribute to consolidating authoritarianism in host countries, little is known about the political effects in the deployer country. This article analyses the relationship between foreign and domestic peace processes and far-right forces in Brazil. We ask if Brazil's leadership role in the United Nations' Stabilisation Mission in Haiti (2004-17) and its own domestic pacification efforts in Rio de Janeiro with the Pacifying Police Units (2008-14) contributed to the strengthening of the far right in Brazil. Relying on a combination of literature review, document analysis, and fieldwork interviews, we argue that Brazil's engagement in liberal peacebuilding processes strengthened the far right in Brazil in two important ways. The first was through a military capture of politics, as a large portion of the military elite that participated in both interventions enabled the military to take a more prominent role in Brazil's domestic politics. Second, Port-au-Prince and Rio de Janeiro became crucial sites for experimentation with a range of policy ideas that Bolsonaro later capitalised on, namely, a punitive turn in security policies and the mobilisation of conservative Evangelical actors and morals to support and justify the military occupation.</p

From mourning to memorialising – A lasting connection through remembrance:The role of memory making in preserving the identity of parenthood amongst women who have suffered a perinatal bereavement

Problem: Perinatal bereavement can severely disrupt women's anticipated role as mothers, affecting their psychological wellbeing and identity as parents. Background: Existing research highlights many women report persistent and enduring grief for months or even years post-loss, highlighting the urgent need for interventions to help maintain a healthy parental identity and mitigate long-term mental health impacts. Aim: To explore how memory-making practices, supported by compassionate care, serve to preserve the parental identity of bereaved mothers after perinatal loss. Methods: Semi-structured qualitative interviews were conducted with 54 UK-based women who had experienced a perinatal bereavement. Grounded Theory Analysis guided the inductive coding and thematic development. Findings: Five themes emerged: (1) Compassion to Care; (2) Finding Comfort in Guidance; (3) Deriving Hope from Parental Identity; (4) Altruism as Catharsis; and (5) Comforted and Consoled. Together, these themes gave rise to the final theory, ‘From Mourning to Memorialising – A Lasting Connection through Remembrance,’ demonstrating how memory-making enables bereaved mothers to preserve their sense of parenthood after loss. Discussion: Memory-making activities allow bereaved mothers to acknowledge their baby's existence and uphold their parental identity. When supported by compassionate care and support, these activities help to integrate the baby's memory into daily life, gradually easing acute grief. Over time, they become lasting markers which validate motherhood, foster continuity, and provide solace, ensuring that parenthood endures despite the absence of a living child. Conclusions: Structured memory-making and compassionate care strategies can enhance parental identity retention, fostering emotional resilience and guiding more effective bereavement care provision.</p

The epidemiology and burden of ten mental disorders in countries of the Association of Southeast Asian Nations (ASEAN), 1990–2021:findings from the Global Burden of Disease Study 2021

Background: The Association of Southeast Asian Nations (ASEAN), a geopolitical and economic network of ten member states, recognises mental disorders as a health priority; however, sparse epidemiological data hinder the development of effective strategies to reduce their prevalence and burden. We aimed to examine the prevalence, morbidity, and disease burden associated with ten mental disorders from 1990 to 2021 in the ASEAN. Methods: As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD 2021), we analysed estimates for depressive disorders, anxiety disorders, bipolar disorders, schizophrenia, autism spectrum disorders, conduct disorder, attention-deficit hyperactivity disorder (ADHD), eating disorders, idiopathic developmental intellectual disability, and other mental disorders in ten ASEAN member states (Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, and Viet Nam). Case definitions were based on Diagnostic and Statistical Manual of Mental Disorders or ICD criteria. Prevalence estimates by age, sex, year, and location were derived using DisMod-MR 2.1, a Bayesian meta-regression modelling tool. Disease burden was quantified by estimating years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs). Estimates are presented with 95% uncertainty intervals (UIs). Findings: In 2021, 80·4 million (95% UI 73·8–87·2) cases of mental disorders were reported across ASEAN countries, representing a 70·0% (63·5–77·2) increase since 1990. The age-standardised prevalence of mental disorders was 11·9% (10·9–12·9) in 2021, ranging from 10·1% (9·1–11·3) in Viet Nam to 13·2% (11·6–15·3) in Malaysia, with anxiety and depressive disorders being the most common. The age-standardised prevalence of mental disorders increased by 6·5% (3·7–9·8) between 1990 and 2021. Mental disorders accounted for 11·2 million (8·5–14·3) DALYs in 2021, representing an 87·4% (81·1–94·0) increase since 1990. The 10–14 years age group had the highest disease burden attributable to mental disorders, which accounted for 16·3% (12·7–20·5) of total DALYs in this age group. The largest relative increases in the number of cases of mental disorders between 1990 and 2021 were seen in older adults (182·8% [174·9–192·1] among those aged ≥70 years), despite small relative changes in prevalence in these age groups. Interpretation: The increase in mental disorder prevalence and burden found in this study might partly reflect recent improvements in detection. However, mental disorders now rank among the top ten causes of disease burden in all ASEAN countries except Myanmar, underscoring the urgent need for a comprehensive intersectoral approach to address prevention and treatment gaps across entire populations. Funding: Gates Foundation.</p