Violence in migrants and refugees in Europe: determinants and preventable measures

Introdução A violência sexual e de género (VSG) é um problema global de saúde pública, ao qual refugiados, requerentes de asilo e imigrantes não documentados, estão particularmente vulneráveis. Nos centros de acolhimento Europeus, residentes e profissionais estão predispostos à vitimização e perpetuação de VSG. Objetivos Esta tese tem como objetivo contribuir para melhorar o conhecimento do conceito de VSG, casos reportados, causas, medidas preventivas, e fatores preditivos de vitimização em residentes (refugiados, requerentes de asilo e imigrantes não documentados) e profissionais (prestadores de serviços, e serviços de saúde), em centros de acolhimento Europeus. Métodos Foram utilizados dados recolhidos no âmbito do projeto Europeu "Senperforto", com o objetivo de contribuir para a proteção e promoção da saúde de refugiados, requerentes de asilo e imigrantes não documentados, de forma a prevenir a VSG nos centros de acolhimento. Senperforto incluiu um estudo sobre conhecimentos, atitudes e práticas relativo à VSG, de residentes e profissionais, que vivem e trabalham em centros de acolhimento, em oito países (Bélgica, Grécia, Hungria, Irlanda, Malta, Holanda, Portugal, Espanha). No total foram realizadas 600 entrevistas: 398 a residentes e 202 a profissionais. A análise de dados incluiu uma análise por componentes principais (ACP), testes de associação como o Qui-quadrado ou teste exato de Fisher, e técnicas de machine learning. Resultados O resultado da ACP relativo ao conceito de VSG para o grupo de residentes incluiu 14 dimensões de VSG que representam 83,56% da variância total de dados. No grupo de profissionais resultou em 17 dimensões de VSG correspondendo a 86,92% da variância total de dados. Para ambos, o conceito de VSG diferiu de acordo com o país de acolhimento, sexo, idade e estado civil. Nos residentes, foram encontradas diferenças relacionadas com a duração de residência no país de acolhimento/Europa, e com os tipos de alojamento. Para os profissionais, as diferenças estavam ligadas ao estatuto legal e competências educacionais. Os participantes reportaram 698 casos de VSG (residentes 328, profissionais 370), correspondendo a 1110 atos de vários tipos de violência. As principais causas presumidas foram: frustração e stress (residentes 23,6%, profissionais 37,6%, p0,008) e diferenças relacionadas com aspectos culturais (residentes 19,3%, profissionais 20,3%, p0,884). Os participantes relataram que estes atos de violência poderiam ser evitados melhorando: intervenções preventivas de VSG (residentes 31,5%, profissionais 24,7%, p0,293); condições habitacionais (residentes 21,7%, profissionais 15,3%, p0,232); e comunicação (residentes 16,1%, profissionais 28,2%, p0,042). A maioria dos residentes não tinha conhecimento da existência de medidas preventivas nos centros de acolhimento (58,3%) ou no país deacolhimento (72,4%). As medidas preventivas de VSG propostas pelos participantes incluíram: sensibilização sobre a VSG, melhoria das condições habitacionais e melhoria da comunicação entre residentes e profissionais. Os modelos preditivos de VSG destacaram as condições habitacionais como uma característica importante para prever a vitimização. Assim, instalações sanitárias apropriadas, o tipo de alojamento, o estatuto legal, a idade, o tipo de ocupação e a idade das pessoas com quem as instalações sanitárias são partilhadas, foram variáveis essenciais para prever a vitimização. Ser residente ou profissional provou ter baixa característica preditiva. Conclusão Nos centros de acolhimento Europeus, as estratégias de prevenção primária deverão focalizar-se na harmonização do conceito de VSG, abordando possíveis diferenças relacionadas com características sociodemográficas. Os resultados sugerem que nos centros de acolhimento, tanto os residentes como os profissionais, os homens e as mulheres estão em risco de VSG, reduzindo os estereótipos: masculinos/profissionais - agressores e mulheres/residentes - vítimas. A elevada incidência de VSG apresentada nos nossos resultados sugere que a prevenção secundária deverá incidir numa maior sensibilização para o problema, melhorar as condições habitacionais e de trabalho, melhorar a comunicação, assegurar um procedimento de asilo equitativo e justo, e incluir os residentes e profissionais como participantes ativos no processo de desenvolvimento e implementação destas medidas. Enfatiza-se ainda, a necessidade emergente da criação e implementação de políticas e diretrizes europeias personalizadas que melhorem as condições habitacionais e de trabalho nos centros de acolhimento. Por último, estamos convencidos de que os Estados-Membros poderão beneficiar do desenvolvimento de capacidades e ferramentas para a implementação destas políticas e diretivas.Background Worldwide sexual and gender-based violence (SGBV) is a major public health problem. Refugees, asylum-seekers and undocumented migrants (RAUM) are vulnerable to SGBV. In the context of European asylum reception facilities, residents and professionals are exposed to both SGBV victimisation and perpetration. Objectives This thesis aims to contribute to expand the knowledge on SGBV conceptualisation, reported cases and causes of SGBV, preventive measures and predictive factors of SGBV in residents (refugees, AS and undocumented migrants) and professionals (services and health care providers), living and working in EARF. Methods We used data collected in the scope of the European Project “Senperforto”, aiming to contribute to health protection and promotion of young refugees, asylum seekers and undocumented migrants by preventing SGBV in asylum reception facilities. Senperforto included a knowledge, attitudes and practices study, of residents and professionals, living and working in asylum reception facilities, in eight countries (Belgium, Greece, Hungary, Ireland, Malta, the Netherlands, Portugal, Spain). In total 600 interviews were conducted: 398 residents and 202 professionals. Data analysis included a principal component analysis (PCA), Chi-square or Fisher’s exact test, and machine learning techniques. Results PCA results regarding SGBV knowledge for residents included 14 SGBV dimensions representing 83.56% of the total data variance, while for professionals it resulted in 17 SGBV dimensions representing 86.92% of the total data variance. For both groups, SGBV conceptualisation differed according to the host country, sex, age and marital status. For residents, specific differences related to the time of arrival to host country/Europe, and type of accommodation were found, while for professionals, differences were linked to legal status and education skills. Participants reported 698 cases of SGBV (residents 328, professionals 370), comprising 1110 acts of multiple types of violence. The main assumed causes were frustration and stress (residents 23.6%, professionals 37.6%, p 0.008), and differences related to cultural background (residents 19.3%, professionals 20.3%, p 0.884). Respondents assumed these acts could be prevented by improving: SGBV prevention interventions (residents 31.5%, professionals 24.7%, p 0.293); living conditions (residents 21.7%, professionals 15.3%, p 0.232); and communication (residents 16.1%, professionals 28.2%, p 0.042). The majority of residents were not aware of existent preventable measures in the asylum facility (58.3%) or host country (72.4%). Proposed SGBV preventive measures included: SGBV sensitisation and awareness, improving living conditions and improving communication between residents and professionals.Predictive models highlighted living conditions as an important feature to predict SGBV victimisation. Accordingly, the appropriated sanitary facilities, accommodation types, age of people with whom sanitary facilities are shared, type of occupation, immigration status and age were key variables to predict victimisation. Being a resident or a professional proved to have low predictive characteristic. Conclusion In European asylum reception facilities, primary prevention strategies should focus on harmonising SGBV conceptualisation addressing potential differences linked to sociodemographic characteristics. SGBV seems to be more gender-balanced than what is stereotyped, contributing to demonstrate that both residents and professionals, male and female are at risk of SGBV, reducing the stereotypes male/professionals – perpetrators, and female/residents – victims. As SGBV was highly reported, secondary prevention should focus on sensitisation, enhance living and working conditions, improve communication, gender-balanced and fair asylum procedure, and include residents and professionals as active voices in its’ development process. Furthermore, we stress the urgency of tailored European policies and directives improving living and working conditions in reception facilities. Finally, we are convinced that Member States should benefit from capacity building and facilitating tools in order to implement those policies and directives

Conceptualizing sexual and gender-based violence in European asylum reception centers

Background: Sexual and gender based violence (SGBV) is a major public health problem and a violation of human rights. Refugees, asylum seekers and migrants are exposed to a constant risk for both victimization and perpetration. Yet, in the context of European asylum reception centers (EARF) professionals are also considered to be at risk. Our study explores the conceptualization of SGBV that residents and professionals have in this specific context. Further, we intent to identify key socio-demographic characteristics that are associated with SGBV conceptualization for both groups. Methods: We developed a cross-sectional study using the Senperforto project database. Semi-structured interviews were conducted with residents (n=398) and professionals (n=202) at EARF. A principal component analysis (PCA) was conducted to variables related with knowledge on SGBV. Chi-square test and Fisher's exact test were applied to understand if significant statistical association exists with socio-demographic characteristics (significant level 0.5%). Results: The majority of residents were male (64.6%), aged from 19 to 29years (41.4%) and single (66.8%); for professionals the majority were women (56.2%), aged from 30 to 39years (42.3%) and married (56.8%). PCA for residents resulted in 14 dimensions of SGBV representing 83.56% of the total variance of the data, while for professionals it resulted in 17 dimensions that represent 86.92% of the total variance of the data. For both groups differences in SGBV conceptualization were found according to host country, sex, age and marital status. Specific for residents we found differences according to the time of arrival to Europe/host country and type of accommodation, while for professionals differences were found according to legal status and education skills. Conclusion: Residents and professionals described different conceptualization of SGBV, with specific types of SGBV not being recognized as a violent act. Primary preventive strategies in EARF should focus on reducing SGBV conceptualization discrepancies, taking into account socio-demographic characteristics

How much leaf area do insects eat? A data set of insect herbivory sampled globally with a standardized protocol

Herbivory is ubiquitous. Despite being a potential driver of plant distribution and performance, herbivory remains largely undocumented. Some early attempts have been made to review, globally, how much leaf area is removed through insect feeding. Kozlov et al., in one of the most comprehensive reviews regarding global patterns of herbivory, have compiled published studies regarding foliar removal and sampled data on global herbivory levels using a standardized protocol. However, in the review by Kozlov et al., only 15 sampling sites, comprising 33 plant species, were evaluated in tropical areas around the globe. In Brazil, which ranks first in terms of plant biodiversity, with a total of 46,097 species, almost half (43%) being endemic, a single data point was sampled, covering only two plant species. In an attempt to increase knowledge regarding herbivory in tropical plant species and to provide the raw data needed to test general hypotheses related to plant–herbivore interactions across large spatial scales, we proposed a joint, collaborative network to evaluate tropical herbivory. This network allowed us to update and expand the data on insect herbivory in tropical and temperate plant species. Our data set, collected with a standardized protocol, covers 45 sampling sites from nine countries and includes leaf herbivory measurements of 57,239 leaves from 209 species of vascular plants belonging to 65 families from tropical and temperate regions. They expand previous data sets by including a total of 32 sampling sites from tropical areas around the globe, comprising 152 species, 146 of them being sampled in Brazil. For temperate areas, it includes 13 sampling sites, comprising 59 species

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: A systematic analysis from the Global Burden of Disease Study 2016

Background: A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings In 2016, HAQ Index performance spanned from a high of 97\ub71 (95% UI 95\ub78-98\ub71) in Iceland, followed by 96\ub76 (94\ub79-97\ub79) in Norway and 96\ub71 (94\ub75-97\ub73) in the Netherlands, to values as low as 18\ub76 (13\ub71-24\ub74) in the Central African Republic, 19\ub70 (14\ub73-23\ub77) in Somalia, and 23\ub74 (20\ub72-26\ub78) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91\ub75 (89\ub71-93\ub76) in Beijing to 48\ub70 (43\ub74-53\ub72) in Tibet (a 43\ub75-point difference), while India saw a 30\ub78-point disparity, from 64\ub78 (59\ub76-68\ub78) in Goa to 34\ub70 (30\ub73-38\ub71) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4\ub78-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20\ub79-point to 17\ub70-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17\ub72-point to 20\ub74-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle- SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations

Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: A systematic analysis from the Global Burden of Disease Study 2016

Copyright © 2018 The Author(s). Published by Elsevier Ltd. Background A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle- SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view - and subsequent provision - of quality health care for all populations

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P < 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men

Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016.

BACKGROUND: A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. METHODS: Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita