Subnational mapping of HIV incidence and mortality among individuals aged 15–49 years in sub-Saharan Africa, 2000–18 : a modelling study

Background: High-resolution estimates of HIV burden across space and time provide an important tool for tracking and monitoring the progress of prevention and control efforts and assist with improving the precision and efficiency of targeting efforts. We aimed to assess HIV incidence and HIV mortality for all second-level administrative units across sub-Saharan Africa. Methods: In this modelling study, we developed a framework that used the geographically specific HIV prevalence data collected in seroprevalence surveys and antenatal care clinics to train a model that estimates HIV incidence and mortality among individuals aged 15–49 years. We used a model-based geostatistical framework to estimate HIV prevalence at the second administrative level in 44 countries in sub-Saharan Africa for 2000–18 and sought data on the number of individuals on antiretroviral therapy (ART) by second-level administrative unit. We then modified the Estimation and Projection Package (EPP) to use these HIV prevalence and treatment estimates to estimate HIV incidence and mortality by second-level administrative unit. Findings: The estimates suggest substantial variation in HIV incidence and mortality rates both between and within countries in sub-Saharan Africa, with 15 countries having a ten-times or greater difference in estimated HIV incidence between the second-level administrative units with the lowest and highest estimated incidence levels. Across all 44 countries in 2018, HIV incidence ranged from 2 ·8 (95% uncertainty interval 2·1–3·8) in Mauritania to 1585·9 (1369·4–1824·8) cases per 100 000 people in Lesotho and HIV mortality ranged from 0·8 (0·7–0·9) in Mauritania to 676· 5 (513· 6–888·0) deaths per 100 000 people in Lesotho. Variation in both incidence and mortality was substantially greater at the subnational level than at the national level and the highest estimated rates were accordingly higher. Among second-level administrative units, Guijá District, Gaza Province, Mozambique, had the highest estimated HIV incidence (4661·7 [2544·8–8120·3]) cases per 100000 people in 2018 and Inhassunge District, Zambezia Province, Mozambique, had the highest estimated HIV mortality rate (1163·0 [679·0–1866·8]) deaths per 100 000 people. Further, the rate of reduction in HIV incidence and mortality from 2000 to 2018, as well as the ratio of new infections to the number of people living with HIV was highly variable. Although most second-level administrative units had declines in the number of new cases (3316 [81· 1%] of 4087 units) and number of deaths (3325 [81·4%]), nearly all appeared well short of the targeted 75% reduction in new cases and deaths between 2010 and 2020. Interpretation: Our estimates suggest that most second-level administrative units in sub-Saharan Africa are falling short of the targeted 75% reduction in new cases and deaths by 2020, which is further compounded by substantial within-country variability. These estimates will help decision makers and programme implementers expand access to ART and better target health resources to higher burden subnational areas

Mapping local patterns of childhood overweight and wasting in low- and middle-income countries between 2000 and 2017

A double burden of malnutrition occurs when individuals, household members or communities experience both undernutrition and overweight. Here, we show geospatial estimates of overweight and wasting prevalence among children under 5 years of age in 105 low- and middle-income countries (LMICs) from 2000 to 2017 and aggregate these to policy-relevant administrative units. Wasting decreased overall across LMICs between 2000 and 2017, from 8.4% (62.3 (55.1–70.8) million) to 6.4% (58.3 (47.6–70.7) million), but is predicted to remain above the World Health Organization’s Global Nutrition Target of <5% in over half of LMICs by 2025. Prevalence of overweight increased from 5.2% (30 (22.8–38.5) million) in 2000 to 6.0% (55.5 (44.8–67.9) million) children aged under 5 years in 2017. Areas most affected by double burden of malnutrition were located in Indonesia, Thailand, southeastern China, Botswana, Cameroon and central Nigeria. Our estimates provide a new perspective to researchers, policy makers and public health agencies in their efforts to address this global childhood syndemic

Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods: GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings: Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation: As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and developm nt investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Global, regional, and national mortality among young people aged 10-24 years, 1950-2019: a systematic analysis for the Global Burden of Disease Study 2019

Background Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10-24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Methods We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10-24 years by age group (10-14 years, 15-19 years, and 20-24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10-24 years with that in children aged 0-9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10-24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017). Findings In 2019 there were 1.49 million deaths (95% uncertainty interval 1.39-1.59) worldwide in people aged 10-24 years, of which 61% occurred in males. 32.7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32.1% were due to communicable, nutritional, or maternal causes; 27.0% were due to non-communicable diseases; and 8.2% were due to self-harm. Since 1950, deaths in this age group decreased by 30.0% in females and 15.3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10-14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15-19 years was 1.3% in males and 1.6% in females, almost half that of males aged 1-4 years (2.4%), and around a third less than in females aged 1-4 years (2.5%). The proportion of global deaths in people aged 0-24 years that occurred in people aged 10-24 years more than doubled between 1950 and 2019, from 9.5% to 21.6%. Interpretation Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10-24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group. Copyright (C) 2021 The Author(s). Published by Elsevier Ltd

Determinants of skilled attendance for delivery in Northwest Ethiopia: a community based nested case control study

BACKGROUND: The fifth Millennium Development Goal calls for a reduction of maternal mortality ratio by 75% between 1990 and 2015. A key indicator to measure this goal is the proportion of births attended by skilled health personnel. The maternal mortality ratio of Ethiopia is 676 deaths per 100,000 live births. Skilled birth attendance is correlated with lower maternal mortality rates globally and in Sub-Saharan Africa. However, the proportion of births with a skilled attendant is only 10% in Ethiopia. Therefore identifying the determinants of skilled attendance for delivery is a priority area to give policy recommendations. METHODS: A community based nested case control study was conducted from October 2009 – August 2011 at the University of Gondar health and demographic surveillance systems site located at Dabat district, Northwest Ethiopia. Data were obtained from the infant mortality prospective follow up study conducted to identify the determinants of infant survival. A pretested and structured questionnaire via interview was used to collect data on the different variables. Logistic regression analysis was used to identify the determinants of skilled birth attendance. Strength of the association was assessed using odds ratio with 95% CI. RESULTS: A total of 1065 mothers (213 cases and 852 controls) were included in the analysis. Among the cases, 166 (77.9%) were from urban areas. More than half (54%) of the cases have secondary and above level of education. Secondary and above level of education [AOR (95%CI) = 2.8 (1.29, 3.68)] and urban residence [AOR (95%CI) = 8.8 (5.32, 14.46)] were associated with skilled attendance for delivery. Similarly, women who had ANC during their pregnancy four or more times [AOR (95%CI) = 2.8 (1.56, 4.98)] and who own TV [AOR (95%CI) = 2.5 (1.32, 4.76)] were more likely to deliver with the assistance of a skilled attendant. CONCLUSIONS: Women’s education, place of residence, frequency of antenatal care visit and ever use of family planning were found to be determinants of skilled birth attendance. Encouraging women to complete at least secondary education and to have antenatal care frequently are important to increase skilled attendance during delivery

Contraceptive adoption in the extended postpartum period is low in Northwest Ethiopia

BACKGROUND: The extended postpartum period is a one year period after delivery which is critical for women to prevent unintended pregnancy and to reduce the risk of maternal and child mortality by ensuring safe birth intervals. Studies indicate that birth intervals of three to five years reduce maternal mortality and provide health benefits to newborn babies, infants, and children. As a result, assessing postpartum contraceptive use and its determinants are an increasingly important component of global health. The objectives of the study were to determine postpartum contraceptive use and identify the variables which affect postpartum contraceptive use among women of Dabat district. METHODS: All women aged 15 to 49 years who delivered a child between January 1, 2012 and December 31, 2012 in the Debat district were interviewed by house-to- house survey. RESULTS: A total of 10.3 % of the mothers reported adopting contraception in the extended postpartum period. Women who delivered with the assistance of a skilled attendant [AOR = 1.88, 95 % CI (1.01-3.51)] and attended postnatal care services [AOR = 2.19, 95 % CI (1.06-4.52)] were more likely to use contraceptives. Secondary and above level of the husband’s education was also a variable that significantly affected postpartum contraceptive use [AOR = 2.98, 95 % CI (1.49-5.97)]. CONCLUSIONS: Contraceptive use in the extended postpartum period was found to be low placing women at risk for a pregnancy in the extended postpartum period. Advice about contraceptives during postnatal clinic visits was limited. Improving utilization of institutional delivery by a skilled attendant and enhancing postnatal care services are important to increase contraceptive use in the extended postpartum period

High prevalence of workplace violence among nurses working at public health facilities in Southern Ethiopia

BACKGROUND: The rising rate of workplace violence in health care facilities has become a major problem for health care providers including nurses. However, evidences are lacking in Ethiopia particularly in the study area. The aim of this study is to assess the prevalence and associated factors of workplace violence among nurses working at health care facilities in Hawassa City Administration, Southern Ethiopia. METHODS: An institution-based cross-sectional study was conducted on 660 randomly selected nurses working at public health facilities in Hawassa City Administration in April 2014. A pre-tested and structured questionnaire was used to collect the data. Data were entered using EPI-Info and exported to SPSS for further analysis. Descriptive statistics were done. Logistic regression analyses were used to see the association between different variables and the outcome variable. Odds ratios with 95% Confidence Interval (CI) were computed to determine the presence and strength of the association. RESULTS: In this study, the prevalence of workplace violence was 29.9% [95% CI: 26.5, 33.5)] of which physical violence accounted for 36 (18.22%), verbal abuse for 172 (89.58%) and sexual harassment for 25 (13.02%). Female sex [AOR=2.00, 95% CI: (1.28, 2.39)], short work experience [AOR=8.86, 95% CI: (3.47, 22.64)], age group of 22–25 [AOR=4.17, 95% CI: (2.46, 7.08)], age group of (26–35) [AOR=1.9, 95% CI (1.16, 3.1)], work in emergency [(AOR=4.28, 95% CI: (1.39, 4.34)] and work in the Inpatient Department [(AOR=2.11, 95% CI: (1.98, 2.64)] were the factors positively associated with workplace violence. CONCLUSIONS: A significant proportion of nurses faced violence while providing care at in public health facilities. Being female, younger age, short work experience, and assignment in emergency and inpatient departments were positively associated with workplace violence. Policy makers and stakeholders should focus on workplace violence prevention strategies