School policies, built environment and practices for non-communicable disease (NCD) prevention and control in schools of Delhi, India.

OBJECTIVE: To assess school policies, built environment and practices for prevention and control of non-communicable diseases in schools of Delhi, India. METHODS: School built environments and policies were assessed using a structured observation checklist in 10 private and 9 government schools which were randomly selected from all 184 co-educational schools with primary to senior secondary level education in Delhi, India. A self-administered questionnaire was also completed by teachers from each school (n = 19) to capture information specific to school policies. Surveys were also conducted with parent of students in class II (aged 6-7 years; n = 574) and student in class XI (aged 15-16 years, n = 755) to understand school practices. RESULTS: The majority of government (88.9%; n = 8) and private (80%; n = 8) schools reported having comprehensive school health policy. In terms of specific health behaviours, policies related to diet and nutrition in government schools were mostly restricted to primary levels with provision of the mid-day meal programme. All schools had two physical education periods per week of about 45-50 minutes. Most schools were compliant with tobacco-free school guidelines (n = 15 out of 19) and had alcohol control policies (n = 13 out of 19). Parent and student reports of practices indicated that school policies were not consistently implemented. CONCLUSION: Most schools in Delhi have policies that address health behaviours in students, but there was considerable variation in the types and number of policies and school environments. Government schools are more likely to have policies in place than private schools. Further work is needed to evaluate how these policies are implemented and to assess their impact on health outcomes

Behavioural activation therapy for anxiety disorders in adults

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: 1. To study the effects of BA in comparison with other psychological therapies (e.g. mindfulness therapy, CBT, dialectical behavioural therapy) for anxiety disorders in adults. 2. To study the effects of BA compared with pharmacotherapy for anxiety disorders in adults. 3. To study the effects of BA compared with treatment as usual, waiting list, placebo, and no treatment for anxiety disorders in adults

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

Prevalence of Excessive Weight and Underweight and Its Associated Knowledge and Lifestyle Behaviors among Urban Private School-Going Adolescents in New Delhi

With rapid urbanization and the Indian nutrition transition, Indian adolescents face a high risk of developing an energy imbalance. This study aims to assess the prevalence of excessive weight, underweight, and associated knowledge and lifestyle behaviors among private school-going adolescents in Delhi. A cross-sectional study was conducted in students (6th–7th grades) of eight randomly selected private schools in Delhi, India in 2019. A self-administered survey was used to assess students’ dietary-and-physical-activity-related knowledge and behavior. Anthropometric measurements (height, weight, and waist circumference) were also conducted. Out of 1567 participants, 7.2% were underweight, 61.3% normal, and 31.5% excess in weight. Underweight was associated with significantly more eating whilst studying for exams (relative risk ratio (RRR) 1.7 (1.0–2.9)). Excessive weight was associated with less incorrect knowledge on behaviors causing overweight (RRR 0.7 (0.5–0.9)), more often reading nutritional labels of packed food items (RRR 0.6 (0.4–0.9)), and less frequent vegetable-intake (RRR 0.7 (0.4–0.9)). Underweight students showed more suboptimal knowledge and unhealthy behaviors, whilst students with excessive weight showed more correct knowledge and healthy behaviors. This study highlights the immediate need for effective health-promoting interventions focused on the importance of healthy lifestyle at least in underweight adolescents

An evaluation of outdoor school environments to promote physical activity in Delhi, India

Abstract Background Increasing physical activity in children is an important public health goal in India. Schools may be a target for physical activity promotion, but little is known about outdoor school environments. The purpose of this study was to describe characteristics of the surrounding outdoor school environments that may promote children’s physical activity in Delhi, India. Methods For this cross-sectional study, we conducted a structured observation of outdoor school environments in a random sample of 16 private schools in Delhi, India using the Sport, Physical activity and Eating behavior: Environmental Determinants in Young people (SPEEDY) audit tool. The SPEEDY school audit measured six categories, including (1) access to the school; (2) surrounding area; (3) school grounds; (4) aesthetics; (5) usage; and (6) overall environment. Six trained data collectors conducted the audit independently in the summer of 2012 while schools were in session. Results Of the 16 schools, one had cycle lanes separated from the road while two schools had cycle lanes on the road. Two schools had pavement on both sides of the road for pedestrians. One school had marked pedestrian crossings. No schools had school warning signs, road safety signs, or route signs for cyclists that would help calm vehicular traffic. Fifteen schools had playground equipment and nine had courts, an assault course (a sequence of equipment designed to be used together), and a quadrangle (an enclosed or semi-enclosed courtyard) for outdoor physical activity. The majority of schools were shielded from the surrounding area by hedges, trees, or fences (n = 13) and were well maintained (n = 10). One school had evidence of vandalism. Two schools had graffiti, seven had litter, and 15 had murals or art. Conclusions The majority of schools did not have infrastructure to support physical activity, such as cycle lanes, marked pedestrian crossings, or traffic calming mechanisms such as school warning signs. However, most had playground equipment, courts, and outdoor play areas. Nearly all were free from vandalism and many had murals or art. These results provide preliminary data for future work examining outdoor school environments, active transport to school, and children’s physical activity in India

Perceived effectiveness of larger graphic health warnings and plain packaging among urban and rural adolescents and adults of Delhi and Telangana, India

Background Plain packaging has been demonstrated to be effective in Australia, where it led to increased quit attempts among adult smokers. Graphic Health Warnings (GHWs) on tobacco packs in India have increased from 40% to 85%. This qualitative study assesses perceptions of Indian adults and children about impact of larger GHWs and plain packaging of tobacco products. Methods Focus Group Discussions (FGDs), conducted with children aged 13-17 years and adults aged 17+ years in the community settings. Separate FGDs were conducted with adults (male and female) and children (boys and girls) in selected urban and rural communities in Delhi and Telangana in 2016. Four dummy tobacco packs categories [A-40% old GHWs, B-40% new GHWs, C-85% new GHWs; D-85% new GHWs with plain pack] were shown. Data was coded and thematic analysis undertaken with using Atlas.ti 6.2. Results In total, fourteen (six in Delhi and eight in Telangana) FGDs were conducted. Participants highlighted the importance of larger GHWs on tobacco products in demonstrating the consequences of tobacco use and limit the pack's appeal. Participants opined, category C and D warnings were most effective to curb tobacco use. Category D was considered the most unattractive pack due to larger GHW, dull color and brand name not being prominent. Conclusions Larger GHWs and PP were perceived to be effective in reducing tobacco use. Plain packaging was further perceived to reduce the attractiveness of pack, enhance noticeability of the GHW, deter new users, and improve quitting among users

Impact of the COVID-19 Pandemic Measures on the Number of Meals and the Types of Physical Activity of Adolescents: Cross-Sectional Study in Delhi, India

COVID-19 greatly affected the lives of adolescents through restrictions such as less playtime, more screen time, and limited interaction with peers. In this study, we assessed the impact of the COVID-19 pandemic on the dietary and physical activity-related behavior of school students aged 10–16 years. This cross-sectional study was conducted with adolescents recruited from seven randomly selected private schools in Delhi, India, during 2021. A self-administered web-based survey was conducted to evaluate the behavior of the participants before and during the pandemic. Of the 512 students (53% males) who participated in the survey, 39% gained weight during the COVID-19 pandemic. There was a significant increase in the number of meals per day (p = 0.005) and a reduction in physical activity (p = 0.00) compared to the situation before the pandemic. The percentage of students who played indoor board and computer games increased from 13% to 46%. Students’s gender (p = 0.007) and parents’ education (mother: p = 0.003; father: p = 0.025) were significantly associated with physical activity during the pandemic. Higher socioeconomic status was significantly associated with consumption of more than two meals per day. The students who had working fathers with advanced/professional degrees were three times more likely [AOR 3.24, 95% CI (0.91–11.53)] to be physically active and eat a minimum of three major meals per day [AOR 3.21, 95% CI (1.77–5.81)] during the pandemic compared to those whose fathers were unemployed. This study highlighted the need for innovative strategies for adolescents and parents to adopt and practice a healthy lifestyle, especially during public health crises, such as the COVID-19 pandemic