Browsing by Person "Bou-Orm, Ibrahim"

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Addressing Non-Communicable Diseases in Fragile Lebanon: A Mixed-Methods Research Study
(Queen Margaret University, Edinburgh, 2023-06-28) Bou-Orm, Ibrahim
Introduction: Lebanon has faced a substantial increase in the burden of NonCommunicable Diseases (NCD) over the last decade. There is a dearth of research focusing on health systems and policy responses to NCD. This PhD thesis analyses how the NCD burden is addressed in the context of fragile Lebanon and identifies policy-, health system- and community-related factors affecting NCD prevention and control. Methodology: This thesis adopts a pragmatic paradigm and incorporates: 1. a political economy analysis of NCD, based on a literature review; 2. a system analysis of NCD prevention and control, based on semi-structured interviews and group-model building workshops with 79 health providers and community members in urban Greater Beirut; 3. a survey with 941 persons living with NCDs to identify the magnitude of key factors affecting NCD control in Greater Beirut. Findings: The political economy analysis revealed an unbalanced power relationship between NCD policy promoters (e.g. civil society) and blockers(e.g. private entities). This has led to a gap in the prevention policy landscape. Care is provided under the auspices of a highly privatized hospital-centric model where services are offered for commercial gain rather than public good. The systems analysis validated these insights, with health provider and community participants linking the challenging socio-political environment to lacking prevention policy/action. This increases NCD incidence and creates barriers in accessing care. Experiences with NCD care were noted to be varied and influenced by perceptions of service quality and trust in providers. The survey confirmed that inequities in access to care exist in Greater Beirut and highlighted that service delivery patterns differ by provider. Communities evaluated different dimensions of trust in healthcare and identified gaps in the reliability, fairness and fidelity of the current system. Conclusions: The thesis concludes with an overview of how to strengthen Lebanon’s response to NCDs.
Addressing the COVID-19 emergency during the ongoing political and economic crisis in Fragile Lebanon: A call to action (Letter to the editor]
(BMC, 2021-09-03) Lobkowicz, Ludmila; Lahoud, Julien; Bou-Orm, Ibrahim
This Letter to the Editor aims to reflect on the current challenges to increase the coverage of COVID-19 vaccination in the fragile and conflict-affected setting of Lebanon, which is currently experiencing one of the biggest economic crises globally as well as a recent surge in COVID-19 cases. Addressing the supply- and demand-related factors affecting vaccination would increase COVID-19 vaccine coverage and prevent the complete collapse of an already overwhelmed Lebanese health care system.
Barriers and Opportunities for WHO ‘Best Buys’ Non-Communicable Disease Policy Adoption and Implementation From a Political Economy Perspective: A Complexity Systematic Review
(Maad Rayan Publishing Company, 2023-12-31) Loffreda, Giulia; Arakelyan, Stella; Bou-Orm, Ibrahim; Holmer, Hampus; Allen, Luke N.; Witter, Sophie; Ager, Alastair; Diaconu, Karin
Background: Improving the adoption and implementation of policies to curb noncommunicable diseases (NCDs) is a major challenge for better global health. The adoption and implementation of such policies remain deficient in various contexts, with limited insights into the facilitating and inhibiting factors. These policies have traditionally been treated as technical solutions, neglecting the critical influence of political economy dynamics. Moreover, the complex nature of these interventions is often not adequately incorporated into evidence for policymakers. This study aims to systematically review and evaluate the factors affecting NCD policy adoption and implementation. Methods: We conducted a complex systematic review of articles discussing the adoption and implementation of WHO's ‘best buys' NCD policies. We identified political economy factors and constructed a causal loop diagram (CLD) program theory to elucidate the interplay between factors influencing NCD policy adoption and implementation. A total of 157 papers met the inclusion criteria. Results: Our CLD highlights a central feedback loop encompassing three vital variables: 1) the ability to define, (re)shape and pass appropriate policy into law; 2) the ability to implement the policy (linked to the enforceability of the policy and to addressing NCD local burden); 3) ability to monitor progress, evaluate and correct the course. Insufficient context-specific data impedes the formulation and enactment of suitable policies, particularly in areas facing multiple disease burdens. Multisectoral collaboration plays a pivotal role in both policy adoption and implementation. Effective monitoring and accountability systems significantly impact policy implementation. The commercial determinants of health (CDoH) serve as a major barrier to defining, adopting, and implementing tobacco, alcohol, and diet-related policies. Conclusion: To advance global efforts, we recommend focusing on the development of robust accountability, monitoring, and evaluation systems, ensuring transparency in private sector engagement, supporting context-specific data collection, and effectively managing the CDoH. A system thinking approach can enhance the implementation of complex public health interventions.
Cervical cancer screening among Lebanese women
(Elsevier Masson, 2017-12-14) Bou-Orm, Ibrahim; Sakr, R E; Adib, S M
Background Cervical cancer is a very common malignancy amongst women worldwide. Pap smear is an effective and inexpensive screening test in asymptomatic women. The aim of this paper was to assess the prevalence of Pap smear screening for cervical cancer among Lebanese women and to determine associated sociodemographic and psychosocial characteristics. Methods This national survey included 2255 women, selected by multi-stage random cluster sampling across Lebanon. A questionnaire about practices and perceptions related to cervical cancer screening was developed based on the “Health Belief Model”. Results The weighted national prevalence of “ever-use” of the Pap smear for screening purposes was 35%. Most important determinants of screening behavior were: residence within Greater Beirut, higher socio-economic status and educational attainment, marriage status, presence of a health coverage, awareness of Pap smear usefulness, knowing someone who had already done it, and a balance between perceived benefits and perceived barriers to Pap smear screening. Conclusion Regular information campaigns regarding the availability and effectiveness of the test should be devised, targeting in priority the sexually vulnerable women in Lebanon. Moreover, healthcare providers should be encouraged to discuss with their patients the opportunity of obtaining a Pap smear.
Colorectal cancer screening knowledge and uptake in Lebanon: a national survey
(Elsevier Masson, 2022-03-24) Moussallem, Marianne; Jreij, Marc; Yeretzian, Joumana Stephan; Asmar, Michèle Kosremelli; Bou-Orm, Ibrahim
Objective The main aim of this national survey was to identify the levels of colorectal cancer screening knowledge and uptake in Lebanon. Methods A total of 1200 participants were enrolled in this cross-sectional household survey targeting the Lebanese population aged 50 years and above. The sample was recruited using a two-stage stratified cluster sampling approach. Results Of the total sample, 38.3% knew about any screening test for colorectal cancer but only 7.5% had ever used any. Thirty-nine percent of the participants rated their risk of getting colorectal cancer as very low or low, and only 53.5% were confident in their ability to undertake a screening test. Almost all participants agreed that medical advice and test reimbursement would encourage them to do a screening test. At the multivariate analysis level, hearing of an awareness campaign in the last two years showed the strongest association with the knowledge of a colorectal cancer screening test with an estimated ORadj = 5.12 (95%CI: 3.67 – 7.15). Other factors that were significantly associated with this knowledge variable included: a family history of colorectal cancer, a personal history of colorectal illness, having a health coverage, and knowledge of colorectal cancer signs and symptoms. Discussion This national study highlights an alarming lack of uptake and low levels of knowledge of colorectal cancer screening tests even though it is among the most prevalent cancers in Lebanon and its prevalence has been continuously increasing in the past years. The evidence suggests that people who had an experience with colorectal cancer diagnostic tests, either personally or through a family member, and those who have heard of an awareness campaign about colorectal cancer in the last two years are more likely to know its screening tests. Conclusion Colorectal cancer screening knowledge and uptake in Lebanon are limited and justify the need for public health interventions. This study gives evidence that awareness campaigns, coupled with the involvement of medical providers and the reimbursement of screening test fees, would alleviate the burden of colorectal cancer in Lebanon.
CONTRASTING HEALTH POLICY AND SYSTEMS RESEARCH (HPSR) IN DIFFERENT LOW AND MIDDLE INCOME COUNTRY CONTEXTS AND DISCUSSION ON PRIORITIES FOR FUTURE GLOBAL HPSR
(Oxford University Press, 2019) Bou-Orm, Ibrahim; Yang, J; Merritt, R K; Omigbodun, A; Whitty, C
Cost of oncology drugs in the Middle-Eastern country of Lebanon: An update (2014-2016)
(American Society of Clinical Oncology (ASCO), 2018-12) Elias, Fadia; Bou-Orm, Ibrahim; Adib, Salim M.; Gebran, Selim; Gebran, Anthony; Ammar, Walid
Purpose This study aims to evaluate trends in the increasing costs of oncology drugs procured by the Lebanese Ministry of Public Health (MOPH) between 2014 and 2016 and to assess the impact of the introduction in mid-2015 of new immunotherapy drugs for the treatment of lung cancer on the overall and specific costs of that treatment. Methods A secondary analysis of data from the MOPH Cancer Drug Scientific Committee data base was conducted using a total of 18,133 cancer files between 2014 and 2016. Results Over the 3-year period, about $140 million (USD) was spent on cancer drugs by the MOPH free cancer drug dispensing program. The expenditures increased by 27% after immunotherapy was phased in. The average cost of drugs per patient per year measured across all cancer types increased from $7,000 in 2014 to $8,400 in 2016. Trastuzumab, approved for treating human epidermal growth factor receptor 2–positive breast cancer ranked first in total expenditures for 2014-2015. By 2016, two new immunotherapy drugs had topped the list: pembrolizumab ranked first and nivolumab ranked third, representing 64% of the total cost of lung cancer treatment and approximately 19% of the total yearly budget; beneficiaries represented only 3% of all patients. Conclusion This update documents the increasing financial impact of newer cancer drugs on the procurement process in the middle-income country of Lebanon. The trend is aligned with the financial burden of cancer drugs worldwide, which calls for a collaborative global response to this crisis.
Determinants of poor cognitive function using A-IQCODE among Lebanese older adults: a cross-sectional study
(Taylor and Francis Group, 2017-03-22) Bou-Orm, Ibrahim; Khamis, Assem M.; Chaaya, Monique
Introduction: Dementia characterized by gradual cognitive decline is an increasing public health problem due to population ageing. This study aims at assessing the prevalence and determinants of cognitive decline among Lebanese older adults. Methods: Secondary analysis of data from a cross-sectional sample of 502 elders from two Lebanese governorates was conducted. Cognitive decline was assessed using the Arabic Version of 16-item Informant Questionnaire on Cognitive Decline for the older adults (A-IQCODE 16). A multivariable logistic regression model assessed the associations of socio-demographic, clinical and behavioral factors with the presence of cognitive decline. Results: Almost one of six Lebanese older adults (14.8%) scored below 3.34. Higher odds of cognitive decline were associated with higher age, being female, having heart disease and suffering from depression. Pack-years of cigarette smoking showed a protective effect and this relationship seems to be only statistically significant among older adults aged more than 75 years. Conclusions: Screening programs of cardiovascular risk factors and early detection of depression are ‘best buy’ public health interventions that could prevent cognitive decline among Lebanese older adults. Differential survival bias seems the reasonable explanation for the protective effect of smoking that is not the common finding from the literature.
Disgust and fear: common emotions between eating and phobic disorders.
(Springer, 2018-05-15) Bou Khalil, Rami; Bou-Orm, Ibrahim; Tabet, Yara; Souaiby, Lama; Azouri, Hayat
Eating disorders (ED) are prevalent mental illnesses composed mainly of anorexia nervosa, bulimia nervosa and binge eating disorders. Anxiety disorders are another set of mental illnesses, with phobic disorder (PD) being the most prevalent disorder. ED and PD are highly comorbid. The aim of this study is to assess, in 131 individuals attending an outpatient clinic for different health issues, the level of fear related to situations generating avoidance such as in social anxiety and specific phobias according to the fear questionnaire (FQ), the level of disgust according to the disgust scale (DS-R) and the vulnerability towards ED according to the SCOFF scale to demonstrate that high levels of both fear and disgust increase the vulnerability towards ED. The study demonstrated that the level of disgust increased when fear increases (r = 0.377, p < 0.001 for the first part of the FQ; r = 0.225, p = 0.01 for the second part of the FQ). Moreover, individuals with vulnerability towards having an ED presented a higher level of disgust than individuals without this vulnerability (p = 0.009). Furthermore, individuals with vulnerability towards ED have a higher level of anxiety related to PD subtypes (p = 0.008 for agoraphobia; p = 0.001 for injection/blood phobia) as well as to social anxiety (p = 0.01), independently from having a depressive or another anxiety disorder. In the multivariate analysis, a history of psychiatric consultation has been the only significantly different parameter between individuals with or without vulnerability towards ED (p = 0.0439). Accordingly, fear and disgust are negative emotions that seem to be clinically associated which better explains the comorbidity of ED with PD. Level III. Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
Dynamics of non-communicable disease prevention, diagnosis and control in Lebanon, a fragile setting
(BMC, 2021-01-11) Zablith, Nadine; Diaconu, Karin; Naja, Farah; El Koussa, Maria; Loffreda, Giulia; Bou-Orm, Ibrahim; Saleh, Shadi; National Institute for Health Research (NIHR)
Abstract: Background: Non-communicable diseases (NCD) present an increasing global health challenge, particularly for settings affected by fragility where access to care may be disrupted, and where high-quality continuous care delivery is difficult to achieve. This study documents the complex dynamics of NCD prevention and management in the fragile setting of rural Beqaa, Lebanon. Methods: Participatory system dynamics methods were used, including 30 semi-structured interviews and three Group Model Building (GMB) workshops. Participants included health care providers offering NCD care, and Lebanese host- and Syrian refugees community members affected by NCDs. Results: Participants across all groups articulated a shared complex understanding of both the structural and direct determinants behind NCD onset. Lebanese and Syrian community members further identified several barriers to health seeking, including restrictions in health coverage, limited availability of services in the Beqaa and perceptions of poor-quality care. Health providers and community members described a health system overtly focused on disease control and overwhelmed by delivery of care to people living with NCD across both communities. Conclusion: Participants across all groups agreed on the need for health promotion and primary prevention activities and identified priority interventions in these areas.
Evaluating the governance and preparedness of the Lebanese health system for the COVID-19 pandemic: a qualitative study
(BMJ Publishing Group, 2022-06-01) Moussallem, Marianne; Zein-El-Din, Anna; Hamra, Rasha; Rady, Alissar; Kosremelli Asmar, Michèle; Bou-Orm, Ibrahim
Objectives: This study aimed to assess the capacities and governance of Lebanon’s health system throughout the response to the COVID-19 pandemic until August 2020. Design: A qualitative study based on semi-structured interviews. Setting: Lebanon, February–August 2020. Participants: Selected participants were directly or indirectly involved in the national or organisational response to the COVID-19 pandemic in Lebanon. Results: A total of 41 participants were included in the study. ‘Hardware’ capacities of the system were found to be responsive yet deeply influenced by the challenging national context. The health workforce showed high levels of resilience, despite the shortage of medical staff and gaps in training at the early stages of the pandemic. The system infrastructure, medical supplies and testing capacities were sufficient, but the reluctance of the private sector in care provision and gaps in reimbursement of COVID-19 care by many health funding schemes were the main concerns. Moreover, the public health surveillance system was overwhelmed a few months after the start of the pandemic. As for the system ‘software’, there were attempts for a participatory governance mechanism, but the actual decision-making process was challenging with limited cooperation and strategic vision, resulting in decreased trust and increased confusion among communities. Moreover, the power imbalance between health actors and other stakeholders affected decision-making dynamics and the uptake of scientific evidence in policy-making. Conclusions: Interventions adopting a centralised and reactive approach were prominent in Lebanon’s response to the COVID-19 pandemic. Better public governance and different reforms are needed to strengthen the health system preparedness and capacities to face future health security threats.
Evolution and lessons from an integrated service delivery network in North West Syria
(BioMed Central, 2023-03-24) Witter, Sophie; Diaconu, Karin; Bou-Orm, Ibrahim; Jamal, Zeina; Shroff, Zubin Cyrus; Mahmoud, Abdulbaki; Daher, Mahmoud; Varma, Vinod
Background: Northwest Syria (NWS) is a complex and extremely fragile operating environment, with more than 2.8 million people needing humanitarian assistance. To support a common standard of care delivery and enable coordination among the multiple providers in NWS, WHO developed an Essential Health Services package (EHSP) in 2016-17 and subsequently supported a facility network model to deliver the EHSP. This article provides an evaluation of the network to date, aiming to inform further development of the network and draw wider lessons for application of similar approaches in complex emergency settings. Methods: This mixed method study included document review, participatory, qualitative and quantitative data, gathered in the first half of 2021. Participatory data came from two group model building workshops with 21 funders and implementers. Semi-structured interviews with 81 funders, health professionals and community members were also conducted. Analyses of the workshops and interviews was inductive, however a deductive approach was used for synthesising insights across this and the document review. The final component was a survey of health providers (59 health care professionals) and service users (233 pregnant women and 214 persons living with NCDs) across network and other comparable facilities, analysed using routine descriptive and inferential statistics. Findings across all methods were triangulated. Results: The study finds that the network and its accompanying essential service package were relevant to the dynamic and challenging context, with high but shifting population needs and multiple uncoordinated providers. Judged in relation to its original goals of comprehensive, coordinated services, equitable access and efficient service delivery, the data indicate that gains have been made in all three areas through the network, although attribution is challenging, given the complex environment. The context remains challenging, with shifting boundaries and populations displaced by conflict, difficulties in retaining staff, the need to import medicines and supplies across borders, and governance gaps. Conclusion: This study adds to a very limited literature on coordinated network approaches used to raise care quality and improve referrals and efficiency in a complex emergency setting. Although areas of ongoing challenge, including for sustainability, are noted, the network demonstrated some resilience strategies and can provide lessons for other similar contexts.
Experiences of communities with Lebanon’s model of care for non-communicable diseases: a cross-sectional household survey from Greater Beirut
(BMJ Publishing Group, 2023-09-04) Bou-Orm, Ibrahim; deVos, Pol; Diaconu, Karin
Objectives Assess community perceptions of the Lebanese care model for non-communicable diseases (NCDs) and trust in the health system among others, and test association between them. Design Cross-sectional study using multistage random sampling and targeting adult community members living with NCDs. Setting Households in Greater Beirut—Lebanon. Participants 941 respondents including 574 Lebanese community members and 367 Syrian refugees. Primary and secondary outcomes Three main outcomes (barriers to care seeking, perceptions of the care model and trust in healthcare) were assessed including by multiple linear regressions. Results Reported NCDs were hypertension (51.3%) and diabetes (34.5%), followed by chronic respiratory conditions (21.9%) and other cardiovascular diseases (20.0%). Communities reported seeking care from different sources. While 78% of Lebanese participants had visited private clinics at least once within the 6 months preceding the survey, 56% of Syrian refugees had done so. Determinants of access to care were health coverage, gender, and employment among Lebanese, and socioeconomic status among Syrian refugees. Lebanese community members had more positive perceptions of the care model compared with Syrian refugees and determinants included sociodemographic characteristics and the type of providers. Trust in the health system was higher among Syrian compared with Lebanese participants and was significantly influenced by the care model score and barriers to care seeking. Conclusion Our study generated evidence about the experience of people living with NCDs with Lebanon’s care model and can inform service delivery interventions towards a more inclusive person-centred approach.
Factors associated with waterpipe tobacco smoking among Lebanese women
(Taylor and Francis Group, 2018-01-19) Daou, Karim N.; Bou-Orm, Ibrahim; Adib, Salim M.
Waterpipe tobacco smoking (WTS) has become a serious public health threat in the Middle East and beyond. To estimate the prevalence rates of cigarette and WTS among Lebanese women and describe characteristics associated with each behavior. Secondary analysis of women’s health data obtained in a national survey in 2010. Of 2,255 selected women, 78 percent reported no or past long-term WTS. Among the 12 percent of regular waterpipe smokers, 40 percent were light users (mean three waterpipe heads weekly), while 60 percent were heavy users (mean of 11 heads per week). About 70 percent were never or past long-term cigarette smokers. Younger age, location within Greater Beirut (GB) and having professional employment were significantly associated with use of WTS. Older age, GB location, lower education, and ever-married were significantly associated with cigarette smoking. WTS is becoming a socially normative behavior among empowered professional women, who can spare the time and expense to engage in this behavior in easily accessible cafés, which prohibit cigarette smoking. Government, media, and NGO campaigns against smoking should target waterpipe use, not only in Lebanon but also across the Arab world and among Arab communities in the Diaspora with messages different from anti-cigarette campaigns.
Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017
(Elsevier, 2018-11-10) GBD 2017 Risk Factor Collaborators; Bou-Orm, Ibrahim
Background The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 comparative risk assessment (CRA) is a comprehensive approach to risk factor quantification that offers a useful tool for synthesising evidence on risks and risk–outcome associations. With each annual GBD study, we update the GBD CRA to incorporate improved methods, new risks and risk–outcome pairs, and new data on risk exposure levels and risk–outcome associations. Methods We used the CRA framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or groups of risks from 1990 to 2017. This study included 476 risk–outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk and exposure estimates from 46 749 randomised controlled trials, cohort studies, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. We explored the relationship between development and risk exposure by modelling the relationship between the Socio-demographic Index (SDI) and risk-weighted exposure prevalence and estimated expected levels of exposure and risk-attributable burden by SDI. Finally, we explored temporal changes in risk-attributable DALYs by decomposing those changes into six main component drivers of change as follows: (1) population growth; (2) changes in population age structures; (3) changes in exposure to environmental and occupational risks; (4) changes in exposure to behavioural risks; (5) changes in exposure to metabolic risks; and (6) changes due to all other factors, approximated as the risk-deleted death and DALY rates, where the risk-deleted rate is the rate that would be observed had we reduced the exposure levels to the TMREL for all risk factors included in GBD 2017. Findings In 2017, 34·1 million (95% uncertainty interval [UI] 33·3–35·0) deaths and 1·21 billion (1·14–1·28) DALYs were attributable to GBD risk factors. Globally, 61·0% (59·6–62·4) of deaths and 48·3% (46·3–50·2) of DALYs were attributed to the GBD 2017 risk factors. When ranked by risk-attributable DALYs, high systolic blood pressure (SBP) was the leading risk factor, accounting for 10·4 million (9·39–11·5) deaths and 218 million (198–237) DALYs, followed by smoking (7·10 million [6·83–7·37] deaths and 182 million [173–193] DALYs), high fasting plasma glucose (6·53 million [5·23–8·23] deaths and 171 million [144–201] DALYs), high body-mass index (BMI; 4·72 million [2·99–6·70] deaths and 148 million [98·6–202] DALYs), and short gestation for birthweight (1·43 million [1·36–1·51] deaths and 139 million [131–147] DALYs). In total, risk-attributable DALYs declined by 4·9% (3·3–6·5) between 2007 and 2017. In the absence of demographic changes (ie, population growth and ageing), changes in risk exposure and risk-deleted DALYs would have led to a 23·5% decline in DALYs during that period. Conversely, in the absence of changes in risk exposure and risk-deleted DALYs, demographic changes would have led to an 18·6% increase in DALYs during that period. The ratios of observed risk exposure levels to exposure levels expected based on SDI (O/E ratios) increased globally for unsafe drinking water and household air pollution between 1990 and 2017. This result suggests that development is occurring more rapidly than are changes in the underlying risk structure in a population. Conversely, nearly universal declines in O/E ratios for smoking and alcohol use indicate that, for a given SDI, exposure to these risks is declining. In 2017, the leading Level 4 risk factor for age-standardised DALY rates was high SBP in four super-regions: central Europe, eastern Europe, and central Asia; north Africa and Middle East; south Asia; and southeast Asia, east Asia, and Oceania. The leading risk factor in the high-income super-region was smoking, in Latin America and Caribbean was high BMI, and in sub-Saharan Africa was unsafe sex. O/E ratios for unsafe sex in sub-Saharan Africa were notably high, and those for alcohol use in north Africa and the Middle East were notably low. Interpretation By quantifying levels and trends in exposures to risk factors and the resulting disease burden, this assessment offers insight into where past policy and programme efforts might have been successful and highlights current priorities for public health action. Decreases in behavioural, environmental, and occupational risks have largely offset the effects of population growth and ageing, in relation to trends in absolute burden. Conversely, the combination of increasing metabolic risks and population ageing will probably continue to drive the increasing trends in non-communicable diseases at the global level, which presents both a public health challenge and opportunity. We see considerable spatiotemporal heterogeneity in levels of risk exposure and risk-attributable burden. Although levels of development underlie some of this heterogeneity, O/E ratios show risks for which countries are overperforming or underperforming relative to their level of development. As such, these ratios provide a benchmarking tool to help to focus local decision making. Our findings reinforce the importance of both risk exposure monitoring and epidemiological research to assess causal connections between risks and health outcomes, and they highlight the usefulness of the GBD study in synthesising data to draw comprehensive and robust conclusions that help to inform good policy and strategic health planning.
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
(Elsevier, 2017-09-16) GBD 2016 Risk Factors Collaborators; Bou-Orm, Ibrahim
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. Methods We used the comparative risk assessment framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2016. This study included 481 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk (RR) and exposure estimates from 22 717 randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources, according to the GBD 2016 source counting methods. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. Finally, we explored four drivers of trends in attributable burden: population growth, population ageing, trends in risk exposure, and all other factors combined. Findings Since 1990, exposure increased significantly for 30 risks, did not change significantly for four risks, and decreased significantly for 31 risks. Among risks that are leading causes of burden of disease, child growth failure and household air pollution showed the most significant declines, while metabolic risks, such as body-mass index and high fasting plasma glucose, showed significant increases. In 2016, at Level 3 of the hierarchy, the three leading risk factors in terms of attributable DALYs at the global level for men were smoking (124·1 million DALYs [95% UI 111·2 million to 137·0 million]), high systolic blood pressure (122·2 million DALYs [110·3 million to 133·3 million], and low birthweight and short gestation (83·0 million DALYs [78·3 million to 87·7 million]), and for women, were high systolic blood pressure (89·9 million DALYs [80·9 million to 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million to 87·6 million]), and high fasting plasma glucose (63·8 million DALYs [53·2 million to 76·3 million]). In 2016 in 113 countries, the leading risk factor in terms of attributable DALYs was a metabolic risk factor. Smoking remained among the leading five risk factors for DALYs for 109 countries, while low birthweight and short gestation was the leading risk factor for DALYs in 38 countries, particularly in sub-Saharan Africa and South Asia. In terms of important drivers of change in trends of burden attributable to risk factors, between 2006 and 2016 exposure to risks explains an 9·3% (6·9–11·6) decline in deaths and a 10·8% (8·3–13·1) decrease in DALYs at the global level, while population ageing accounts for 14·9% (12·7–17·5) of deaths and 6·2% (3·9–8·7) of DALYs, and population growth for 12·4% (10·1–14·9) of deaths and 12·4% (10·1–14·9) of DALYs. The largest contribution of trends in risk exposure to disease burden is seen between ages 1 year and 4 years, where a decline of 27·3% (24·9–29·7) of the change in DALYs between 2006 and 2016 can be attributed to declines in exposure to risks. 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.
Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016
(Elsevier, 2017-09-16) GBD 2016 DALYs and HALE Collaborators; Bou-Orm, Ibrahim
Background Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI). Methods We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate. Findings The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9–78·6) for females and 72·0 years (68·8–75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0–49·5]) and for males was in Lesotho (41·5 years [39·0–44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97–6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74–6·27) for males and 6·49 years (6·08–6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61–1·93) for males and 1·96 years (1·69–2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (–2·3% [–5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally. Interpretation At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support.
Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017
(Elsevier, 2018-11-10) GBD 2017 DALYs and HALE Collaborators; Bou-Orm, Ibrahim
Background How long one lives, how many years of life are spent in good and poor health, and how the population's state of health and leading causes of disability change over time all have implications for policy, planning, and provision of services. We comparatively assessed the patterns and trends of healthy life expectancy (HALE), which quantifies the number of years of life expected to be lived in good health, and the complementary measure of disability-adjusted life-years (DALYs), a composite measure of disease burden capturing both premature mortality and prevalence and severity of ill health, for 359 diseases and injuries for 195 countries and territories over the past 28 years. Methods We used data for age-specific mortality rates, years of life lost (YLLs) due to premature mortality, and years lived with disability (YLDs) from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to calculate HALE and DALYs from 1990 to 2017. We calculated HALE using age-specific mortality rates and YLDs per capita for each location, age, sex, and year. We calculated DALYs for 359 causes as the sum of YLLs and YLDs. We assessed how observed HALE and DALYs differed by country and sex from expected trends based on Socio-demographic Index (SDI). We also analysed HALE by decomposing years of life gained into years spent in good health and in poor health, between 1990 and 2017, and extra years lived by females compared with males. Findings Globally, from 1990 to 2017, life expectancy at birth increased by 7·4 years (95% uncertainty interval 7·1–7·8), from 65·6 years (65·3–65·8) in 1990 to 73·0 years (72·7–73·3) in 2017. The increase in years of life varied from 5·1 years (5·0–5·3) in high SDI countries to 12·0 years (11·3–12·8) in low SDI countries. Of the additional years of life expected at birth, 26·3% (20·1–33·1) were expected to be spent in poor health in high SDI countries compared with 11·7% (8·8–15·1) in low-middle SDI countries. HALE at birth increased by 6·3 years (5·9–6·7), from 57·0 years (54·6–59·1) in 1990 to 63·3 years (60·5–65·7) in 2017. The increase varied from 3·8 years (3·4–4·1) in high SDI countries to 10·5 years (9·8–11·2) in low SDI countries. Even larger variations in HALE than these were observed between countries, ranging from 1·0 year (0·4–1·7) in Saint Vincent and the Grenadines (62·4 years [59·9–64·7] in 1990 to 63·5 years [60·9–65·8] in 2017) to 23·7 years (21·9–25·6) in Eritrea (30·7 years [28·9–32·2] in 1990 to 54·4 years [51·5–57·1] in 2017). In most countries, the increase in HALE was smaller than the increase in overall life expectancy, indicating more years lived in poor health. In 180 of 195 countries and territories, females were expected to live longer than males in 2017, with extra years lived varying from 1·4 years (0·6–2·3) in Algeria to 11·9 years (10·9–12·9) in Ukraine. Of the extra years gained, the proportion spent in poor health varied largely across countries, with less than 20% of additional years spent in poor health in Bosnia and Herzegovina, Burundi, and Slovakia, whereas in Bahrain all the extra years were spent in poor health. In 2017, the highest estimate of HALE at birth was in Singapore for both females (75·8 years [72·4–78·7]) and males (72·6 years [69·8–75·0]) and the lowest estimates were in Central African Republic (47·0 years [43·7–50·2] for females and 42·8 years [40·1–45·6] for males). Globally, in 2017, the five leading causes of DALYs were neonatal disorders, ischaemic heart disease, stroke, lower respiratory infections, and chronic obstructive pulmonary disease. Between 1990 and 2017, age-standardised DALY rates decreased by 41·3% (38·8–43·5) for communicable diseases and by 49·8% (47·9–51·6) for neonatal disorders. For non-communicable diseases, global DALYs increased by 40·1% (36·8–43·0), although age-standardised DALY rates decreased by 18·1% (16·0–20·2). Interpretation With increasing life expectancy in most countries, the question of whether the additional years of life gained are spent in good health or poor health has been increasingly relevant because of the potential policy implications, such as health-care provisions and extending retirement ages. In some locations, a large proportion of those additional years are spent in poor health. Large inequalities in HALE and disease burden exist across countries in different SDI quintiles and between sexes. The burden of disabling conditions has serious implications for health system planning and health-related expenditures. Despite the progress made in reducing the burden of communicable diseases and neonatal disorders in low SDI countries, the speed of this progress could be increased by scaling up proven interventions. The global trends among non-communicable diseases indicate that more effort is needed to maximise HALE, such as risk prevention and attention to upstream determinants of health.
Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017
(Elsevier, 2018-11-10) GBD 2017 Disease and Injury Incidence and Prevalence Collaborators; Bou-Orm, Ibrahim
Background The Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data. Methods We estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting. Findings Globally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1–4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0–8·4) while the total sum of global YLDs increased from 562 million (421–723) to 853 million (642–1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6–9·2) for males and 6·5% (5·4–7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782–3252] per 100 000 in males vs s1400 [1279–1524] per 100 000 in females), transport injuries (3322 [3082–3583] vs 2336 [2154–2535]), and self-harm and interpersonal violence (3265 [2943–3630] vs 5643 [5057–6302]). Interpretation Global all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury.
Health system governance in settings with conflict-affected populations: a systematic review
(Oxford University Press, 2022-03-22) Lokot, Michelle; Bou-Orm, Ibrahim; Zreik, Thurayya; Kik, Nour; Fuhr, Daniela C; El Masri, Rozane; Meagher, Kristen; Smith, James; Asmar, Michele Kosremelli; McKee, Martin; Roberts, Bayard
Health system governance has been recognized as critical to strengthening healthcare responses in settings with conflict-affected populations. The aim of this review was to examine existing evidence on health system governance in settings with conflict-affected populations globally. The specific objectives were (1) to describe the characteristics of the eligible studies; (2) to describe the principles of health system governance; (3) to examine evidence on barriers and facilitators for stronger health system governance; and (4) to analyse the quality of available evidence. A systematic review methodology was used following Preferred Reporting Items for Systematic Review and Meta-Analysis criteria. We searched six academic databases and used grey literature sources. We included papers reporting empirical findings on health system governance among populations affected by armed conflict, including refugees, asylum seekers, internally displaced populations, conflict-affected non-displaced populations and post-conflict populations. Data were analysed according to the study objectives and informed primarily by a governance framework from the literature. Quality appraisal was conducted using an adapted version of the Mixed Methods Appraisal Tool. Of the 6511 papers identified through database searches, 34 studies met eligibility criteria. Few studies provided a theoretical framework or definition for governance. The most frequently identifiable governance principles related to participation and coordination, followed by equity and inclusiveness and intelligence and information. The least frequently identifiable governance principles related to rule of law, ethics and responsiveness. Across studies, the most common facilitators of governance were collaboration between stakeholders, bottom-up and community-based governance structures, inclusive policies and longer-term vision. The most common barriers related to poor coordination, mistrust, lack of a harmonized health response, lack of clarity on stakeholder responsibilities, financial support and donor influence. This review highlights the need for more theoretically informed empirical research on health system governance in settings with conflict-affected populations that draws on existing frameworks for governance.