Reliable, comparable information about the main causes of disease and injury in populations, and how these are changing, is a critical input for debates about priorities in the health sector. Traditional sources of information about the descriptive epidemiology of diseases, injuries, and risk factors are generally incomplete, fragmented, and of uncertain reliability and comparability. The Global Burden of Disease (GBD) Study has provided a conceptual and methodological framework to quantify and compare the health of populations using a summary measure of both mortality and disability, the disability-adjusted life year (DALY). This article describes key features of the Global Burden of Disease analytic approach, the evolution of the GBD starting from the first study for the year 1990, and summarizes the methodological improvements incorporated into GBD revisions carried out by the World Health Organization. It also reviews controversies and criticisms, and examines priorities and issues for future GBD updates.

Global Burden of Disease

The dimensions of women’s autonomy and their relationship to maternal health care utilization were investigated in a probability sample of 300 women in Varanasi, India. We examined the determinants of women’s autonomy in three areas: control over finances, decision-making power, and freedom of movement. After we control for age, education, household structure, and other factors, women with closer ties to natal kin were more likely to have greater autonomy in each of these three areas. Further analyses demonstrated that women with greater freedom of movement obtained higher levels of antenatal care and were more likely to use safe delivery care. The influence of women’s autonomy on the use of health care appears to be as important as other known determinants such as education.

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Dimensions of women's autonomy and the influence on maternal health care utilization in a north Indian city.

Background: Whereas organized trauma care systems have decreased trauma mortality in the United States, trauma system design has not been well addressed in developing nations. We sought to determine areas in greatest need of improvement in the trauma systems of developing nations. Methods: We compared outcome of all seriously injured (Injury Severity Score ≥ 9 or dead), nontransferred, adults managed over I year in three cities in nations at different economic levels: (1) Kumasi, Ghana: low income, gross national product (GNP) per capita of $310, no emergency medical service (EMS); (2) Monterrey, Mexico: middle income, GNP $3,900, basic EMS; and (3) Seattle, Washington: high income, GNP $25,000, advanced EMS. Each city had one main trauma hospital, from which hospital data were obtained. Annual budgets (in US$) per bed for these hospitals were as follows: Kumasi, $4,100; Monterrey, $68,000; and Seattle, $606,000. Data on prehospital deaths were obtained from vital statistics registries in Monterrey and Seattle, and by an epidemiologic survey in Kumasi. Results: Mean age (34 years) and injury mechanisms (79% blunt) were similar in all locations. Mortality declined with increased economic level: Kumasi (63% of all seriously injured persons died), Monterrey (55%), and Seattle (35%). This decline was primarily due to decreases in prehospital deaths. In Ku-masi, 51% of all seriously injured persons died in the field; in Monterrey, 40%; and in Seattle, 21%. Mean prehospital time declined progressively: Kumasi (102 ± 126 minutes) > Monterrey (73 ± 38 minutes) > Seattle (31 ± 10 minutes). Percent of trauma patients dying in the emergency room was higher for Monterrey (11%) than for either Kumasi (3%) or Seattle (6%). Conclusions: The majority of deaths occur in the prehospital setting, indicating the importance of injury prevention in nations at all economic levels. Additional efforts for trauma care improvement in both low-income and middle-income developing nations should focus on prehospital and emergency room care. Improved emergency room care is especially important in middle-income nations which have already established a basic EMS.

Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development

ContextThe 1998-1999 war in Kosovo had a direct impact on large numbers of
civilians. The mental health consequences of the conflict are not known.ObjectivesTo establish the prevalence of psychiatric morbidity associated with
the war in Kosovo, to assess social functioning, and to identify vulnerable
populations among ethnic Albanians in Kosovo.Design, Setting, and ParticipantsCross-sectional cluster sample survey conducted from August to October
1999 among 1358 Kosovar Albanians aged 15 years or older in 558 randomly selected
households across Kosovo.Main Outcome MeasuresNonspecific psychiatric morbidity, posttraumatic stress disorder (PTSD)
symptoms, and social functioning using the General Health Questionnaire 28
(GHQ-28), Harvard Trauma Questionnaire, and the Medical Outcomes Study Short-Form
20 (MOS-20), respectively; feelings of hatred and a desire for revenge among
persons surveyed as addressed by additional questions.ResultsOf the respondents, 17.1% (95% confidence interval [CI], 13.2%-21.0%)
reported symptoms that met Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition criteria for PTSD; total mean score
on the GHQ-28 was 11.1 (95% CI, 9.9-12.4). Respondents reported a high prevalence
of traumatic events. There was a significant linear decrease in mental health
status and social functioning with increasing amount of traumatic events (P≤.02 for all 3 survey tools). Populations at increased
risk for psychiatric morbidity as measured by GHQ-28 scores were those aged
65 years or older (P = .006), those with previous
psychiatric illnesses or chronic health conditions (P<.001
for both), and those who had been internally displaced (P = .009). Populations at risk for poorer social functioning were living
in rural areas (P = .001), were unemployed (P = .046) or had a chronic illness (P = .01). Respondents scored highest on the physical functioning and
role functioning subscales of the MOS-20 and lowest on the mental health and
social functioning subscales. Eighty-nine percent of men and 90% of women
reported having strong feelings of hatred toward Serbs. Fifty-one percent
of men and 43% of women reported strong feelings of revenge; 44% of men and
33% of women stated that they would act on these feelings.ConclusionsMental health problems and impaired social functioning related to the
recent war are important issues that need to be addressed to return the Kosovo
region to a stable and productive environment.

https://jamanetwork.com/journals/jama/articlepdf/192943/JOC00483.pdf

Mental Health, Social Functioning, and Attitudes of Kosovar Albanians Following the War in Kosovo

Evidence to support that antenatal screenings and interventions are effective in reducing maternal mortality has been scanty and studies have presented contradictory findings. In addition, antenatal care utilization is poorly characterized in studies. As an exposure under investigation, antenatal care should be well defined. However, measures typically only account for the frequency and timing of visits and not for care content. We introduce a new measure for antenatal care utilization, comprised of 20 input components covering care content and visit frequency. Weights for each component reflect its relative importance to better maternal and child health, and were derived from a survey of international researchers. This composite measure for antenatal care utilization was studied in a probability sample of 300 low to middle income women who had given birth within the last three years in Varanasi, Uttar Pradesh, India. Results showed that demarcating women's antenatal care status based on a simple indicator--two or more visits versus less--masked a large amount of variation in care received. Logistic regression analyses were conducted to examine the effect of antenatal care utilization on the likelihood of using safe delivery care, a factor known to decrease maternal mortality. After controlling for relevant socio-demographic and maternity history factors, women with a relatively high level of care (at the 75th percentile of the score) had an estimated odds of using trained assistance at delivery that was almost four times higher than women with a low level of care (at the 25th percentile of the score) (OR = 3.97, 95% CI = 1.96, 8.10). Similar results were obtained for women delivering in a health facility versus at home. This strong positive association between level of care obtained during pregnancy and the use of safe delivery care may help explain why antenatal care could also be associated with reduced maternal mortality.

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Does Antenatal Care Make a Difference to Safe Delivery? A Study in Urban Uttar Pradesh, India

The Expanded Program on Immunization (EPI) is using a simplified cluster sampling method based on the random selection of 210 children in 30 clusters of 7 children each to estimate immunization coverage levels. This article analyzes the results of this method in actual and computer simulated surveys. Results from 60 actual surveys conducted in 25 countries were available for analysis for a total of 446 sample estimations of immunization coverage. 83% of the sample results had 95% confidence limits within + or - 10% and none of the surveys had 95% confidence limits exceeding + or - 13%. In addition 12 hypothetical population strata with immunization coverage rates ranging from 10%-99% were established for the purposes of computer simulation and 10 hypothetical communities were established by allocating to them various proportions of each of the strata. These simulated surveys also supported the validity of the EPI method: over 95% of the results were less than + or - 10% from the actual population mean. The precision of this method as estimated from the results of both actual and simulated surveys is considered satisfactory for the requirements of the EPI. Among the actual surveys the proportion of results whose confidence limits exceeded + or - 10% was greatest (50%) when immunization coverage in the sample was 45%-54%.

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Sundaresan T

Papers

Cluster sampling to assess immunization coverage: a review of experience with a simplified sampling method.