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Article

Measuring the impact of a public health crisis in terms of mortality might seem a straightforward method to quantify its effect on the population because deaths are much more easily registered compared to other health outcomes. However, despite the intuitive appeal of this path, it is far from obvious how to best operationalize it, and all the most used methods have drawbacks that should be kept in mind. Especially during the COVID-19 pandemic, the major routes that have been considered are cause-specific death counts (and related measures such as case fatality rates), excess deaths estimates, and life expectancy decline. All the considered approaches have limitations: Cause-specific deaths are often subject to undercount or overcount issues with significant differences both between and within countries, excess deaths estimates may strongly depend on the baseline (there are several methods to estimate it), and life expectancy drop estimates (or estimates of years of life lost) also depend on the reference level used, which can vary substantially across countries. More generally, the issues of available data quality and standardization of age structure should be taken into proper account. Thus, the choice of which approach is worth using depends on the characteristics of the crisis that need to be evaluated and the type and quality of data available. Interestingly, the three approaches can also be combined so that some of their limitations can be mitigated.

Article

Danuta Wasserman

Around 700,000 people take their lives each year worldwide. Suicide accounts for approximately 1.3% of all deaths and therefore represents a major public health problem. The global age-standardized suicide rate is 9 per 100,000 population, yet there are large variations among genders, ages, countries, and world regions. The stress–vulnerability model of suicidal behaviors has been proposed to explain how a diathesis, developed through the influence of genetic and neurodevelopmental factors in relation to perinatal, postnatal, and life experiences, interacts with different risk and protective factors that either decrease or enhance the individual’s level of resilience to stress and suicidal risk. Public health suicide prevention strategies include suicide means restriction, reducing harmful substance use, promoting responsible media reporting, public-awareness campaigns, gatekeeper trainings, school-based interventions, crisis helplines, and postvention. Mental health strategies comprise identification, treatment, and rehabilitation of persons in distress and at risk for suicide. Multicomponent strategies that use a combination of evidence-based methods from public and mental health sectors are recommended. Future work should aim at enhancing the quality of epidemiological data, improving the research on protective and ideation-to-action factors, expanding the quantity and quality of data coming from low- and middle-income countries, and evaluating the cost-effectiveness of different suicide prevention strategies.

Article

Ashley van Niekerk

A burn occurs when cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns), or flames (flame burns). Injuries to the skin or other organic tissue due to radiation, radioactivity, electricity, friction or contact with chemicals are also identified as burns. Globally, burns have been in decline, but are still a major cause of injury, disability, death and disruption in some regions, with about 120,000 deaths and 9 million injuries estimated in 2017. Low-to-middle-income countries carry the bulk of this burden with the majority of all burn injuries occurring in the African and Southeast Asia regions. Thermal injuries are physically painful and may leave disabling scars not only to the skin or the body, but also impair psychological wellbeing. Severe injuries often impose significant psychological, but also educational consequences and social stigmatization, with the consequent adjustments exacerbated by a range of factors, including the circumstances of the burn incident, the severity and site of the injury, the qualities of the affected individual’s personality, and the access to supportive interpersonal and social relationships. The contributions of: economic progress, enhanced environmental and home structures, energy technology, and safety education interventions have been reported as significant for burn prevention. Similarly, legislative and policy frameworks that support access to modern energies such as electricity, govern domestic appliances and heating technology, and control storage and decanting of fossil fuels are important in energy impoverished settings. The recovery of burn survivors is affected by the availability of specialized treatment, physical rehabilitation and psychosocial support to burn victims and families, but which is still limited especially in resource constrained settings.

Article

Linda Dahlberg, Alexander Butchart, James Mercy, and Thomas Simon

An important function of public health is to prevent injuries or to lessen their impact when they occur. An estimated 251,000 people worldwide die each year from a firearm-related death and many more suffer nonfatal injuries with consequences that can last a lifetime. Firearm injuries, which include those that are intentionally self-inflicted, unintentional, or from an act of interpersonal violence, are heavily concentrated in the Americas, driven largely by firearm homicides. Firearm-related deaths and injuries disproportionately impact males and younger populations and are associated with factors such as access, substance use, adverse childhood experiences, involvement in high-risk social networks, drug trafficking, density of alcohol outlets, and neighborhood and social disadvantage. While progress is being made to understand firearm injuries and how to effectively prevent them, much more needs to be done to improve the availability and timeliness of data; apply the knowledge that is generated to effectively reduce firearm-related injuries, deaths, and costs; strengthen the scientific infrastructure; and move countries closer to achieving the violence-related targets in the 2030 Sustainable Development Goals.

Article

Aminur Rahman, Amy E. Peden, Lamisa Ashraf, Daniel Ryan, Al-Amin Bhuiyan, and Stephen Beerman

Drowning has been described as a major global public health problem and has recently been acknowledged by a United Nations Declaration on Global Drowning Prevention. While drowning impacts countries of all income levels, the burden is overwhelmingly borne by low- and middle-income countries (LMICs) who account for 90% of the global death toll. In addition, there is scarce data collection on drowning in LMICs, so the magnitude of drowning may be far greater than is represented. A range of factors including sex, age, education, income, access to water, a lack of swimming skills, certain occupations like commercial fishing, geographically isolated and flood-prone locations, preexisting medical conditions, and unsafe water transport systems, influence the risk of drowning. Some behavioral factors, such as alcohol or drug consumption, not wearing life jackets, and engaging in risky behaviors such as swimming or boating alone, increase drowning risk. Geopolitical factors such as migration and armed conflict can also impact drowning risk. There is a growing body of evidence on drowning prevention strategies. These include pre-event interventions such as pool fencing, enhancing community education and awareness, providing swimming lessons, use of lifejackets, close supervision of children by adults, and boating regulations. Interventions to reduce harm from drowning include appropriate training for recognition of a drowning event, rescue, and resuscitation. An active and/or passive surveillance system for drowning, focusing on individual settings and targeting populations at risk, is required. Drowning requires coordinated multisectoral action to provide effective prevention, rescue, and treatment. Therefore, all countries should aim to develop a national water safety plan, as recommended in the WHO Global Report on Drowning. Further research is required on the epidemiology and treatment of drowning in LMICs as well as non-fatal and intentional drowning in both high-income countries (HICs) and LMICs. Effective and context-specific implementation of drowning prevention strategies, including pilot testing, scale up and evaluation, are likely to help reduce the burden of both fatal and non-fatal drowning in all countries.

Article

Suzanne O. Bell, Mridula Shankar, and Caroline Moreau

Induced abortion is a common reproductive experience, with more than 73 million abortions occurring each year globally. Worldwide, the annual abortion incidence decreased in the 1990s and the early decades of the 21st century, but this decline has been driven by high-resource settings, whereas abortion rates in low- and middle-resource countries have remained stable. Induced abortion is a very safe procedure when performed according to World Health Organization guidelines; however, legal restrictions, stigma, cost, lack of resources, and poor health system accountability limit the availability, accessibility, and use of quality abortion care services. Even as women’s use of safer self-managed medication abortion options becomes more common in some parts of the world, 45% of all abortions annually are unsafe, nearly all of which occur in low- and middle-resource settings, where unsafe abortion remains a primary cause of maternal death. Beyond country-level legal and health care system factors, significant disparities exist in women’s reliance on unsafe abortion. Even among women who receive a safe abortion, quality of care is often poor. Yet abortion’s precarious status as a health care service and its clandestine practice have precluded a systematic focus on quality monitoring and evaluation of service inputs. Improving abortion and postabortion care quality is essential to meeting this reproductive health need, as are efforts to prevent abortion-related mortality and morbidity more broadly. This requires a three-tier approach: primary prevention to reduce unintended pregnancy, secondary prevention to make abortion procedures safer, and tertiary prevention to reduce the negative sequelae of unsafe abortion procedures. Strategies include two complementary approaches: vulnerability reduction and harm reduction, the first focusing on the root causes of unsafe abortion by addressing the determinants of unwanted pregnancy and clandestine abortion, while the latter addresses the harmful consequences of clandestine abortion. Political commitments to extend service coverage of abortion and postabortion care need to be implemented through actions that build the public health system’s capacity. Beyond the model of receiving care exclusively in clinical settings, models of guided self-managed abortion are expanding the capacity of individuals to take evidence-based actions to terminate their pregnancies safely and without the threat of judgment. Research has strived to keep up with the changes in the abortion care landscape, but there remains a continuing need to improve methodologies to generate robust evidence to identify and address inequities in abortion care and its health consequences in a diversified landscape. Doing so will provide information for stakeholders to take actions toward a new era of health care reforms that repositions abortion as an integral component of sexual and reproductive health care.

Article

Sarka Lisonkova and K. S. Joseph

Fetal death refers to the death of a post-embryonic product of conception while in utero or during childbirth, and it is one of the most distressing events faced by women and families. Birth following spontaneous fetal death is termed “miscarriage” if it occurs early in gestation, and “stillbirth,” if it occurs beyond the point of viability. There are substantial between-country differences in the criteria used for reporting stillbirths and these differences compromise international comparisons of stillbirth rates. In high-income countries, a majority of fetal deaths occur due to genetic causes, fetal infection, or other pregnancy complications. Congenital anomalies, placental insufficiency, and/or intrauterine growth restriction are frequent antecedents of fetal death. Maternal risk factors include advanced maternal age, high body mass index, smoking and substance use during pregnancy, prior stillbirth, chronic morbidity, and multifetal pregnancy. Disparities in education and socioeconomic status and other factors influencing maternal health also contribute to elevated rates of stillbirth among vulnerable women.

Article

Jeff Levin and Ellen Idler

Religion, in both its personal and institutional forms, is a significant force influencing the health of populations across the life course. Decades of research have documented that expressions of faith and the practice of spiritual pursuits exhibit significantly protective effects for physical and mental health, psychological well-being, and population rates of morbidity, mortality, and disability. This finding has been observed across sociodemographic categories, across nations and cultures, across specific disease outcomes, and regardless of one’s religious affiliation. A salutary religious effect on health and well-being is especially apparent among older adults, but is also observed across generations and age cohorts. Moreover, this association has been persistently found for various religious indicators, including attendance at worship services, prayer and other private practices, subjective feelings of religiosity, and numerous measures of religious behaviors, attitudes, beliefs, and experiences. Finally, a protective or primary preventive effect of religion has been observed in clinical, epidemiologic, social, and behavioral studies, regardless of research design or methodology. Faith-based organizations also have contributed to the health of populations, in partnerships or alliances with medical institutions and public health agencies, many of these dating back many decades. Examples include congregational health promotion and disease prevention programs and community-wide interventions, especially targeting the health and well-being of older congregants and those in less well-resourced communities, as well as faith–health partnerships in healthcare delivery, public health policymaking, and legislative advocacy for healthcare reform. Religious denominations and institutions also play a substantial role in global health development throughout the world, individually and in partnership with national health ministries, transnational medical mission organizations, and established nongovernmental agencies. These efforts focus on a wide range of goals and objectives, including building public health infrastructure, addressing ongoing environmental health needs, and responding to acute public health challenges and crises, such as infectious disease outbreaks. Constituencies include at-risk populations and cohorts throughout the life course, and programming ranges from perinatal care to maternal and child healthcare to geriatric medicine.

Article

Karen Setty and Giuliana Ferrero

Water safety plans (WSPs) represent a holistic risk assessment and management approach covering all steps in the water supply process from the catchment to the consumer. Since 2004, the World Health Organization (WHO) has formally recommended WSPs as a public health intervention to consistently ensure the safety of drinking water. These risk management programs apply to all water supplies in all countries, including small community supplies and large urban systems in both developed and developing settings. As of 2017, more than 90 countries had adopted various permutations of WSPs at different scales, ranging from limited-scale voluntary pilot programs to nationwide implementation mandated by legislative requirements. Tools to support WSP implementation include primary and supplemental manuals in multiple languages, training resources, assessment tools, and some country-specific guidelines and case studies. Systems employing the WSP approach seek to incrementally improve water quality and security by reducing risks and increasing resilience over time. To maintain WSP effectiveness, water supply managers periodically update WSPs to integrate knowledge about prior, existing, and potential future risks. Effectively implemented WSPs may translate to positive health and other impacts. Impact evaluation has centered on a logic model developed by the Centers for Disease Control and Prevention (CDC) as well as WHO-refined indicators that compare water system performance to pre-WSP baseline conditions. Potential benefits of WSPs include improved cost efficiency, water quality, water conservation, regulatory compliance, operational performance, and disease reduction. Available research shows outcomes vary depending on site-specific context, and challenges remain in using WSPs to achieve lasting improvements in water safety. Future directions for WSP development include strengthening and sustaining capacity-building to achieve consistent application and quality, refining evaluation indicators to better reveal linked outcomes (including economic impacts), and incorporating social equity and climate change readiness.

Article

Louise Biddle, Kayvan Bozorgmehr, and Rosa Jahn

Ensuring the health of migrants and access to appropriate health services presents a challenge to health systems in the age of global migration. Reliable and timely information is key to decision-making in all sectors of the health system to ensure that health system goals are met. Such information is even more important among a mobile, sometimes rapidly changing, dynamic and heterogeneous migrant population. While health information systems (HIS) are crucial for effective functioning of other health system blocks as well as for evidence-informed decision-making, they are often sidelined in health system policy and development. Looking across the World Health Organization (WHO) European Region, HIS for migrants are deficient both in their overall availability and their integration into regular monitoring structures. Less than half of the 53 member states routinely report health data for refugees and migrants. Most of the routinely collected data on migrant and refugee health can be identified in countries with strong population-based records, with some good practice examples of well-integrated and high-quality health monitoring surveys, disease-specific registries, and “parallel” HIS in migrant-specific settings. Overall, however, HIS in the WHO European Region are not able to provide data of sufficient quality and comparability to be well integrated into regular health monitoring structures. The reasons for this can be highlighted by five key barriers to improved information systems for migrant health: barriers in recording data, standardizing data collection, harmonizing migrant indicators, producing high-quality data, and sharing information. Better integration can be achieved through increased multilateral collaboration for the harmonization of indicators, strengthening of governance frameworks for data-sharing and protection measures, and the increased use of currently underutilized data collection mechanisms, including health monitoring surveys and medical records from refugee reception facilities. These steps will remain essential for the adequate planning and provision of needs-based care for refugees and migrants.