Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Impact Of Hospitals Accreditation On Service Delivery From The Perspective Views Of Experts: A Qualitative Study

Background and Aim: Accreditation is one of the evaluating health care organization tools especially in hospitals and is also one of the priorities of Ministry of Health in Iran. The aim of this study was to examine the impact of accreditation on health service delivery in hospitals from perspective views of experts. Materials and Methods: This qualitative study was conducted by semi-structured interviews and opinions of 12 experts at Isfahan University of Medical Science in the field of hospital accreditation in 2012. After transcription of each interview, content analyses was used to minimize and structuring qualitative data. Results: According to this study, 10 main theme and 72 sub- themes were identified. Main themes included: Necessity, implementations priorities and mechanisms of Accreditation effect, accreditation impact on service quality and organizational performance, patient satisfaction, commitment and job satisfaction of staff, reducing factors the impact of accreditation, confounder factors the effect of accreditation and the executive proposals in order to implement accreditation program in Iran. Conclusion : Accreditation could be properly implemented through setting Conditions, selecting the appropriate accreditation model, justify stakeholders about the necessity of accreditation, monitoring, establishment of appropriate information systems, information transparency and changing the general attitude of the organization. It would take positive effects to achieve hospital goals and improve the quality of services

Satisfaction of nurses from health system evolution’s implementation in teaching hospitals of Shiraz: 2015

Background and Objectives: Nurses&rsquo; satisfaction plays an important role in advancing the objectives of Health System Evolution Plam and more importantly in patients&rsquo; satisfaction of treatment. The present study was conducted with the aim of determining nurses&rsquo; satisfaction level of implementation of Health System Evolution Plan in teaching hospitals of Shiraz City. &nbsp; Methods: This descriptive cross-sectional study was conducted on nurses of 13 teaching hospitals in Shiraz city (March 2015). Out of 3100 nurses, 342 were selected by Cochran formula and stratified sampling method proportionate to the size. The research tool was a questionnaire retrieved from Nurses Survey Questionnaire of National Institutes of Health Research, including 2 parts of demographic information and satisfaction questions. Data were analyzed using Pearson correlation coefficient, independent t-, and one-way ANOVA tests. &nbsp; Results: Overall, 68.9% of the nurses were dissatisfied and 29.2% were satisfied of the plan&rsquo;s implementation. The highest satisfaction was from details&rsquo; training (43.3%) and the highest dissatisfaction was from number of patients (71.2%). 68.5% of nurses were dissatisfied from accommodation facilities of workplace after the plan&rsquo;s implementation, and there was an significant inverse correlation between age and satisfaction (r= -0.71, p<0.001). &nbsp; Conclusion: According to the results of this study and to decrease nurses&rsquo; dissatisfaction in cases, such as increased number of patients, number of night shifts, and inappropriate accommodation facilities, it is suggested to take strategies, such as establishment of an integrated patient distribution system, employment, maintenance and return of experts, and allocating an appropriate place as nurses&rsquo; pavilion. &nbsp; &nbsp

Management of cosmetic surgery in iran: challenges and solutions

Background: Nowadays, beauty practices have attracted the attention of people following the change in lifestyle and social values. Therefore, the present study was conducted with the aim of examining the opinion of experts regarding the challenges and management solutions of the aforementioned practices in Iran. Methods: This qualitative study was conducted through interviews with 26 policymakers and cosmetic surgery service providers in Tehran from April to September 2022. Sampling was purposeful and snowball. The interviews were semi-structured and thematic analysis was used to analyze the data obtained from the interviews. The inclusion criteria for the interviewees' entry were knowledge and experience in the subject and willingness to participate. Results: Challenges under the four categories of service providers (improper education, non-specialist providers, moral hazards, deficiencies in the way laws are written, and the ineffectiveness of the complaint handling process), service receivers (being influenced by deceptive advertisements, low level of public health literacy and lack of mental health), the place of providing services (performing surgeries in non-standard places and non-integrated information system) and medicines, products and medical equipment (insufficient control over supply, distribution and use and price fluctuations) were categorized. Experts considered the major part of the challenges to be related to the service providers. In the category of service recipients, "being influenced by deceptive advertisements" was the main problem mentioned by the experts. Performing surgeries in non-standard places, including limited surgery centers, non-sterile places, and unauthorized places, is among the unsolved problems regarding the place of providing services. In relation to medicines, products, and medical equipment, the main problem was insufficient supply, distribution, and use supervision. Conclusion: The main effective measure to solve the challenges is to strengthen the supervision of the health system administrator with internal and external coordination and cooperation. In this regard, it is recommended to develop educational, ethical, and legal frameworks, regulate regulatory laws, public awareness, clinical interviews and psychological counseling, especially before cosmetic surgery, and the establishment of an integrated electronic health record system

Priority strategic directions in adolescent health in Iran based on the WHO's Global Accelerated Action for the Health of Adolescents

OBJECTIVES: In line with the World Health Organization's Global Accelerated Action for the Health of Adolescents (AA-HA!) guidance, the goal of the current research was to identify critical strategies for adolescents' health and to determine the role and distribution of responsibilities among the leading players in the field of adolescent health in Iran. METHODS: The current qualitative and applied study is part of the Ministry of Health and Medical Education's "Adolescent, Youth and School Health" plan to develop the "National Adolescent Health Plan Document" in 2020. First, stakeholder analysis was done, then a pool of nationally appropriate strategies was selected from the list of priority strategies recommended by the WHO in the AA-HA! through several group sessions. After that, the experts selected priority strategies based on the criteria of feasibility, acceptability, effectiveness, guaranteed resources, coordination with other plans and temporal priority, scoring, and executive priorities. Eventually, the priority strategies were assigned to different players/stakeholders in the field over several sessions bearing in mind the methods of implementation and the target groups. RESULTS: The experts identified 58 priority strategies/actions for adolescent health under the seven priority areas of positive development, sexual protection, reproductive health, mental health, substance abuse, self-harm, violence, unintentional injury, communicable and non-communicable diseases, nutrition, and physical activity. CONCLUSIONS: The highest identified priority areas were in the areas of vaccination; special health care package for service providers; training and education to promote health literacy and self-care, life skills, sexual awareness, and prevention/protection against violence; community-based mental health services, planning for adolescents' spare time, substance use prevention

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BackgroundRegular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.MethodsThe Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model—a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates—with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality—which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.FindingsThe leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2–100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1–290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1–211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4–48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3–37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7–9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.InterpretationLong-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere