Measuring Total Health Inequality: Adding Individual Variation to Group-Level Differences

Background: Studies have revealed large variations in average health status across social, economic, and other groups. No study exists on the distribution of the risk of ill-health across individuals, either within groups or across all people in a society, and as such a crucial piece of total health inequality has been overlooked. Some of the reason for this neglect has been that the risk of death, which forms the basis for most measures, is impossible to observe directly and difficult to estimate. Methods: We develop a measure of total health inequality – encompassing all inequalities among people in a society, including variation between and within groups – by adapting a beta-binomial regression model. We apply it to children under age two in 50 low- and middle-income countries. Our method has been adopted by the World Health Organization and is being implemented in surveys around the world; preliminary estimates have appeared in the World Health Report (2000).Results Countries with similar average child mortality differ considerably in total health inequality. Liberia and Mozambique have the largest inequalities in child survival, while Colombia, the Philippines and Kazakhstan have the lowest levels among the countries measured. Conclusions: Total health inequality estimates should be routinely reported alongside average levels of health in populations and groups, as they reveal important policy-related information not otherwise knowable. This approach enables meaningful comparisons of inequality across countries and future analyses of the determinants of inequality.Governmen

Death by Survey: Estimating Adult Mortality without Selection Bias from Sibling Survival Data

The widely used methods for estimating adult mortality rates from sample survey responses aboutthe survival of siblings, parents, spouses, and others depend crucially on an assumption that, as we demonstrate, does not hold in real data. We show that when this assumption is violated so that the mortality rate varies with sibship size, mortality estimates can be massively biased. By using insights from work on the statistical analysis of selection bias, survey weighting, and extrapolation problems, we propose a new and relatively simple method of recovering the mortality rate with both greatly reduced potential for bias and increased clarity about the source of necessary assumptions.Governmen

Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000–2013

Results for key maternal and child health indicators from 2000 to 2013, state and national. (XLSX 383 kb

Contraceptive Use and the Poor: A Matter of Choice?

Gillespie discusses a new study showing that, despite the overall increase in the use of modern contraceptives, use among the poor remains quite low compared with wealthier segments of society

Mortality Measurement Matters: Improving Data Collection and Estimation Methods for Child and Adult Mortality

Colin Mathers and Ties Boerma discuss three research articles in PLoS Medicine that address the measurement and analysis of child and adult mortality data collected through death registration, censuses, and household surveys

Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990–2019 : a systematic analysis from the Global Burden of Disease Study 2019

Background Ending the global tobacco epidemic is a defining challenge in global health. Timely and comprehensive estimates of the prevalence of smoking tobacco use and attributable disease burden are needed to guide tobacco control efforts nationally and globally. Methods We estimated the prevalence of smoking tobacco use and attributable disease burden for 204 countries and territories, by age and sex, from 1990 to 2019 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. We modelled multiple smoking-related indicators from 3625 nationally representative surveys. We completed systematic reviews and did Bayesian meta-regressions for 36 causally linked health outcomes to estimate non-linear dose-response risk curves for current and former smokers. We used a direct estimation approach to estimate attributable burden, providing more comprehensive estimates of the health effects of smoking than previously available. Findings Globally in 2019, 1·14 billion (95% uncertainty interval 1·13–1·16) individuals were current smokers, who consumed 7·41 trillion (7·11–7·74) cigarette-equivalents of tobacco in 2019. Although prevalence of smoking had decreased significantly since 1990 among both males (27·5% [26·5–28·5] reduction) and females (37·7% [35·4–39·9] reduction) aged 15 years and older, population growth has led to a significant increase in the total number of smokers from 0·99 billion (0·98–1·00) in 1990. Globally in 2019, smoking tobacco use accounted for 7·69 million (7·16–8·20) deaths and 200 million (185–214) disability-adjusted life-years, and was the leading risk factor for death among males (20·2% [19·3–21·1] of male deaths). 6·68 million [86·9%] of 7·69 million deaths attributable to smoking tobacco use were among current smokers. Interpretation In the absence of intervention, the annual toll of 7·69 million deaths and 200 million disability-adjusted life-years attributable to smoking will increase over the coming decades. Substantial progress in reducing the prevalence of smoking tobacco use has been observed in countries from all regions and at all stages of development, but a large implementation gap remains for tobacco control. Countries have a clear and urgent opportunity to pass strong, evidencebased policies to accelerate reductions in the prevalence of smoking and reap massive health benefits for their citizens

Diarrhoea, acute respiratory infection, and fever among children in the Democratic Republic of Congo

Several years of war have created a humanitarian crisis in the Democratic Republic of Congo (DRC) with extensive disruption of civil society, the economy and provision of basic services including health care. Health policy and planning in the DRC are constrained by a lack of reliable and accessible population data. Thus there is currently a need for primary research to guide programme and policy development for reconstruction and to measure attainment of the Millennium Development Goals (MDGs). This study uses the 2001 Multiple Indicators Cluster Survey to disentangle children's health inequalities by mapping the impact of geographical distribution of childhood morbidity stemming from diarrhoea, acute respiratory infection, and fever. We observe a low prevalence of childhood diarrhoea, acute respiratory infection and fever in the western provinces (Kinshasa, Bas-Congo and Bandundu), and a relatively higher prevalence in the south-eastern provinces (Sud-Kivu and Katanga). However, each disease has a distinct geographical pattern of variation. Among covariate factors, child age had a significant association with disease prevalence. The risk of the three ailments increased in the first 8–10 months after birth, with a gradual improvement thereafter. The effects of socioeconomic factors vary according to the disease. Accounting for the effects of the geographical location, our analysis was able to explain a significant share of the pronounced residual geographical effects. Using large scale household survey data, we have produced for the first time spatial residual maps in the DRC and in so doing we have undertaken a comprehensive analysis of geographical variation at province level of childhood diarrhoea, acute respiratory infection, and fever prevalence. Understanding these complex relationships through disease prevalence maps can facilitate design of targeted intervention programs for reconstruction and achievement of the MDGs

Use of Modern Contraception by the Poor Is Falling Behind

BACKGROUND: The widespread increase in the use of contraception, due to multiple factors including improved access to modern contraception, is one of the most dramatic social transformations of the past fifty years. This study explores whether the global progress in the use of modern contraceptives has also benefited the poorest. METHODS AND FINDINGS: Demographic and Health Surveys from 55 developing countries were analyzed using wealth indices that allow the identification of the absolute poor within each country. This article explores the macro level determinants of the differences in the use of modern contraceptives between the poor and the national averages of several countries. Despite increases in national averages, use of modern contraception by the absolute poor remains low. South and Southeast Asia have relatively high rates of modern contraception in the absolute poor, on average 17% higher than in Latin America. Over time the gaps in use persist and are increasing. Latin America exhibits significantly larger gaps in use between the poor and the averages, while gaps in sub-Saharan Africa are on average smaller by 15.8% and in Southeast Asia by 11.6%. CONCLUSIONS: The secular trend of increasing rates of modern contraceptive use has not resulted in a decrease of the gap in use for those living in absolute poverty. Countries with large economic inequalities also exhibit large inequalities in modern contraceptive use. In addition to macro level factors that influence contraceptive use, such as economic development and provision of reproductive health services, there are strong regional variations, with sub-Saharan Africa exhibiting the lowest national rates of use, South and Southeast Asia the highest use among the poor, and Latin America the largest inequalities in use

Population health metrics: crucial inputs to the development of evidence for health policy

Valid, reliable and comparable measures of the health states of individuals and of the health status of populations are critical components of the evidence base for health policy. We need to develop population health measurement strategies that coherently address the relationships between epidemiological measures (such as risk exposures, incidence, and mortality rates) and multi-domain measures of population health status, while ensuring validity and cross-population comparability. Studies reporting on descriptive epidemiology of major diseases, injuries and risk factors, and on the measurement of health at the population level – either for monitoring trends in health levels or inequalities or for measuring broad outcomes of health systems and social interventions – are not well-represented in traditional epidemiology journals, which tend to concentrate on causal studies and on quasi-experimental design. In particular, key methodological issues relating to the clear conceptualisation of, and the validity and comparability of measures of population health are currently not addressed coherently by any discipline, and cross-disciplinary debate is fragmented and often conducted in mutually incomprehensible language or paradigms. Population health measurement potentially bridges a range of currently disjoint fields of inquiry relating to health: biology, demography, epidemiology, health economics, and broader social science disciplines relevant to assessment of health determinants, health state valuations and health inequalities. This new journal will focus on the importance of a population based approach to measurement as a way to characterize the complexity of people's health, the diseases and risks that affect it, its distribution, and its valuation, and will attempt to provide a forum for innovative work and debate that bridge the many fields of inquiry relevant to population health in order to contribute to the development of valid and comparable methods for the measurement of population health and its determinants

Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016 : a systematic analysis for the Global Burden of Disease Study 2016

Background The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of risk factor exposure and attributable burden of disease. By providing estimates over a long time series, this study can monitor risk exposure trends critical to health surveillance and inform policy debates on the importance of addressing risks in context. Interpretation Increasingly detailed understanding of the trends in risk exposure and the RRs for each risk-outcome pair provide insights into both the magnitude of health loss attributable to risks and how modification of risk exposure has contributed to health trends. Metabolic risks warrant particular policy attention, due to their large contribution to global disease burden, increasing trends, and variable patterns across countries at the same level of development. GBD 2016 findings show that, while it has huge potential to improve health, risk modification has played a relatively small part in the past decade