High-income Asia Research Articles

Examining sociopolitical elements of health system reform: The experience of Singapore and Taiwan.

This essay suggests five sociopolitical dimensions that influence the success of health system reforms. It examines the experience of two high-income Asian countries, Singapore and Taiwan, and illustrates how these five dimensions matter. These five sociopolitical dimensions are public trust, perceived government performance, political legitimacy, equity/solidarity, and demand for choice. Public trust in government, perceived government performance, and the legitimacy of political authorities were necessary for governments in both countries to enact key reforms. Public perceptions of government capacity combined with public conceptions of equity were deliberated and clarified as stakeholders sought to reach consensus based on values upheld by segments of each society. Nevertheless, these elements alone are not enough to sustain major institutional reforms in light of ongoing social, political, and demographic changes. This essay provides a different approach to traditional policy cycle models and seeks to emphasize stewardship and governance in health systems.

Efficacy of pre-participation cardiac evaluation recommendations among athletes participating in World Athletics Championships.

Athletes competing in athletics (track and field) at international level may be participating with underlying undiagnosed life-threatening cardiovascular conditions. Our objective was to analyse variations in pre-participation cardiac evaluation prevalence among athletes participating in two International Association of Athletics Federations (IAAF) World Athletics Championships, with regard to the human developmental level and global region of their home countries, as well as athletes' age category, gender, event group and medical insurance type. Cross-sectional web-based survey. A total of 1785 athletes competing in the IAAF World Under 18 Championships Nairobi 2017 and World Championships London 2017 were invited to complete a pre-participation health questionnaire investigating the experience of a pre-participation cardiac examination. A total of 704 (39%) of the athletes participated. Among these, 59% (60% of women; 58% of men) reported that they had been provided at least one type of pre-participation cardiac evaluation. Athletes from very high income countries, Europe and Asia, showed a higher prevalence of at least one pre-participation cardiac evaluation. The prevalence of pre-participation cardiac evaluation in low to middle income countries, and the African continent in particular, needs urgent attention. Furthermore, increases in evaluation prevalence should be accompanied by the development of cost-effective methods that can be adopted in all global regions.

The global, regional, and national burden of stomach cancer in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease study 2017

SummaryBackgroundStomach cancer is a major health problem in many countries. Understanding the current burden of stomach cancer and the differential trends across various locations is essential for formulating effective preventive strategies. We report on the incidence, mortality, and disability-adjusted life-years (DALYs) due to stomach cancer in 195 countries and territories from 21 regions between 1990 and 2017.MethodsEstimates from GBD 2017 were used to analyse the incidence, mortality, and DALYs due to stomach cancer at the global, regional, and national levels. The rates were standardised to the GBD world population and reported per 100 000 population as age-standardised incidence rates, age-standardised death rates, and age-standardised DALY rates. All estimates were generated with 95% uncertainty intervals (UIs).FindingsIn 2017, more than 1·22 million (95% UI 1·19–1·25) incident cases of stomach cancer occurred worldwide, and nearly 865 000 people (848 000–885 000) died of stomach cancer, contributing to 19·1 million (18·7–19·6) DALYs. The highest age-standardised incidence rates in 2017 were seen in the high-income Asia Pacific (29·5, 28·2–31·0 per 100 000 population) and east Asia (28·6, 27·3–30·0 per 100 000 population) regions, with nearly half of the global incident cases occurring in China. Compared with 1990, in 2017 more than 356 000 more incident cases of stomach cancer were estimated, leading to nearly 96 000 more deaths. Despite the increase in absolute numbers, the worldwide age-standardised rates of stomach cancer (incidence, deaths, and DALYs) have declined since 1990. The drop in the disease burden was associated with improved Socio-demographic Index. Globally, 38·2% (21·1–57·8) of the age-standardised DALYs were attributable to high-sodium diet in both sexes combined, and 24·5% (20·0–28·9) of the age-standardised DALYs were attributable to smoking in males.InterpretationOur findings provide insight into the changing burden of stomach cancer, which is useful in planning local strategies and monitoring their progress. To this end, specific local strategies should be tailored to each country's risk factor profile. Beyond the current decline in age-standardised incidence and death rates, a decrease in the absolute number of cases and deaths will be possible if the burden in east Asia, where currently almost half of the incident cases and deaths occur, is further reduced.FundingBill & Melinda Gates Foundation.

The obesity transition: stages of the global epidemic

Summary The global prevalence of obesity has increased substantially over the past 40 years, from less than 1% in 1975, to 6–8% in 2016, among girls and boys, and from 3% to 11% among men and from 6% to 15% among women over the same time period. Our aim was to consolidate the evidence on the epidemiology of obesity into a conceptual model of the so-called obesity transition. We used illustrative examples from the 30 most populous countries, representing 77·5% of the world's population to propose a four stage model. Stage 1 of the obesity transition is characterised by a higher prevalence of obesity in women than in men, in those with higher socioeconomic status than in those with lower socioeconomic status, and in adults than in children. Many countries in south Asia and sub-Saharan Africa are presently in this stage. In countries in stage 2 of the transition, there has been a large increase in the prevalence among adults, a smaller increase among children, and a narrowing of the gap between sexes and in socioeconomic differences among women. Many Latin American and Middle Eastern countries are presently at this stage. High-income east Asian countries are also at this stage, albeit with a much lower prevalence of obesity. In stage 3 of the transition, the prevalence of obesity among those with lower socioeconomic status surpasses that of those with higher socioeconomic status, and plateaus in prevalence can be observed in women with high socioeconomic status and in children. Most European countries are presently at this stage. There are too few signs of countries entering into the proposed fourth stage of the transition, during which obesity prevalence declines, to establish demographic patterns. This conceptual model is intended to provide guidance to researchers and policy makers in identifying the current stage of the obesity transition in a population, anticipating subpopulations that will develop obesity in the future, and enacting proactive measures to attenuate the transition, taking into consideration local contextual factors.

Targeting and Mistargeting of Family Policies in High-Income Pacific Asian Societies: A Review of Financial Incentives

Very low fertility rates can be found in many high-income Pacific Asian societies, such as Hong Kong, South Korea, Japan, Singapore, and Taiwan. Governments in these territories have already taken pronatalist policies but with only modest effects, especially when measured by overall total fertility rate. Mistargeting has been cited as a potential explanation for this impact. To explore this notion in greater depth, we first identify the potential target groups that are most influential in changing the TFR for the five societies, based on a stochastic model and fertility elasticity analyses. Then we examine the targeting of current pronatalist policies, especially financial incentives and marriage policies. The analyses show that marriage rates, especially among women aged 25–29 are the most influential factor in shaping contemporary TFRs. Third and higher order births are insignificant in changing the fertility trajectories for all the five places. Besides, there are also territory-specific patterns. For Hong Kong, Taiwan and Singapore, first births (especially among women aged 30–34) are the second most influential factor; for South Korea, second births (especially among women aged 30–34) actually play a very important role, next only to marriage; for Japan, first- and second births are much less influential while marriage is an overwhelmingly essential factor of fertility. Furthermore, the review of financial incentives in these places reveals the mismatch between the targeting suggested by our analysis and the targeting implied by current policy measures. The mistargeting, piecemeal measures and the low level of financial support may be partly responsible for the ineffectiveness of the governmental action.

Geographical and Temporal Variation in the Incidence and Mortality of Hepato–Pancreato–Biliary Primary Malignancies:1990-2017

BackgroundHepatic, pancreas, and biliary (HPB) cancers pose serious challenges to global health care systems. These malignancies demonstrate great geographical variations with shifting trends over time. The aim of the present study was to determine the recent trends in incidence, prevalence, and mortality of primary HPB malignancies to guide the further development of effective strategies for prevention, screening, and treatment. MethodsThe Global Burden of Disease (GBD) dataset 1990-2017 was interrogated for end point variables by age, sex, year, and geography. Epidemiologic data were modeled in DisMod-MR 2.1, a Bayesian meta-regression tool that pools data points from different sources and adjusts for known sources of variability. Global Burden of Disease data were extracted from 284 country-year, and 976 subnational-year combinations from 27 countries in North America, Latin America, Europe, India, and New Zealand. ResultsAlthough the global incidence of primary HPB malignancies increased by 1.43% from 1990 to 2017 (1,400,739 cases), the incidence of extrahepatic biliary and gallbladder malignancies decreased by −0.32% (210,878 cases) over the same period. There was significant variability in the incidence, prevalence, and mortality of HPB cancers by the sociodemographic index (SDI), as well as by geography. The largest incidence increase of primary liver and pancreas cancers was seen in the high-income Asia–Pacific group, followed by the high-income North America and Western Europe groups. The highest incidences and prevalence of extrahepatic biliary and gallbladder malignancies were observed in Asia–Pacific, Southern Latin American, and Andean Latin American regions. In general, mortality rates of HPB malignancies were larger in the low SDI when compared with the high SDI group in all geographical regions. ConclusionsThe global incidence and prevalence of primary liver and pancreatic malignancies continue to increase with great geographical variation. The mortality trends mirror those of the incidence. Although the global incidence and prevalence of extrahepatic biliary and gallbladder malignancies has decreased, the mortality rate has not significantly changed. The results of this article can assist local and regional authorities in policy development to improve health care access for screening, early detection, and treatment of HPB malignancies.

Considerable international variation exists in blood pressure control and antihypertensive prescription patterns in chronic kidney disease

Although blood pressure control is a major goal in chronic kidney disease, no worldwide overview of either its achievement or antihypertensive prescriptions is currently available. To evaluate this we compared crude prevalence of uncontrolled blood pressure among 17 cohort studies, including 34 602 individuals with estimated glomerular filtration rate under 60 ml/min/1.73 m2 and treated hypertension across four continents, and estimated observed to expected prevalence ratios, adjusted for potential confounders. Crude prevalence of blood pressure of 140/90 mmHg or more varied from 28% to 61% and of blood pressure of 130/80 or more from 54% to 84%. Adjusted prevalence ratios indicated poorer hypertension control than expected in cohorts from European countries, India, and Uruguay, and better control in patients from North American and high-income Asian countries. Four antihypertensive drug classes or more were prescribed to more than 30% of participants in North American and some European cohorts, but this practice was less common elsewhere. Renin angiotensin-aldosterone system inhibitors were the most common antihypertensive drugs, prescribed for 54% to 91% of cohort participants. Differences for other drug classes were much stronger, ranging from 11% to 79% for diuretics, 22% to 70% for beta-blockers, and 27% to 75% for calcium-channel blockers. The confounders studied explain only a part of the international variation in blood pressure control among individuals with chronic kidney disease. Thus, considerable heterogeneity in prescription patterns worldwide calls for further investigation into the impact of different approaches on patient outcomes.

Global, national, and urban burdens of paediatric asthma incidence attributable to ambient NO2 pollution: estimates from global datasets

Paediatric asthma incidence is associated with exposure to traffic-related air pollution (TRAP), but the TRAP-attributable burden remains poorly quantified. Nitrogen dioxide (NO2) is a major component and common proxy of TRAP. In this study, we estimated the annual global number of new paediatric asthma cases attributable to NO2 exposure at a resolution sufficient to resolve intra-urban exposure gradients. We obtained 2015 country-specific and age-group-specific asthma incidence rates from the Institute for Health Metrics and Evaluation for 194 countries and 2015 population counts at a spatial resolution of 250 × 250 m from the Global Human Settlement population grid. We used 2010-12 annual average surface NO2 concentrations derived from land-use regression at a resolution of 100 × 100 m, and we derived concentration-response functions from relative risk estimates reported in a multinational meta-analysis. We then estimated the NO2-attributable burden of asthma incidence in children aged 1-18 years in 194 countries and 125 major cities at a resolution of 250 × 250 m. Globally, we estimated that 4·0 million (95% uncertainty interval [UI] 1·8-5·2) new paediatric asthma cases could be attributable to NO2 pollution annually; 64% of these occur in urban centres. This burden accounts for 13% (6-16) of global incidence. Regionally, the greatest burdens of new asthma cases associated with NO2 exposure per 100 000 children were estimated for Andean Latin America (340 cases per year, 95% UI 150-440), high-income North America (310, 140-400), and high-income Asia Pacific (300, 140-370). Within cities, the greatest burdens of new asthma cases associated with NO2 exposure per 100 000 children were estimated for Lima, Peru (690 cases per year, 95% UI 330-870); Shanghai, China (650, 340-770); and Bogota, Colombia (580, 270-730). Among 125 major cities, the percentage of new asthma cases attributable to NO2 pollution ranged from 5·6% (95% UI 2·4-7·4) in Orlu, Nigeria, to 48% (25-57) in Shanghai, China. This contribution exceeded 20% of new asthma cases in 92 cities. We estimated that about 92% of paediatric asthma incidence attributable to NO2 exposure occurred in areas with annual average NO2 concentrations lower than the WHO guideline of 21 parts per billion. Efforts to reduce NO2 exposure could help prevent a substantial portion of new paediatric asthma cases in both developed and developing countries, and especially in urban areas. Traffic emissions should be a target for exposure-mitigation strategies. The adequacy of the WHO guideline for ambient NO2 concentrations might need to be revisited. George Washington University.

Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016

ObjectivesTo use the estimates from the Global Burden of Disease Study 2016 to describe patterns of suicide mortality globally, regionally, and for 195 countries and territories by age, sex, and...

Global, regional, and national burden of motor neuron diseases 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

SummaryBackgroundUnderstanding how prevalence, incidence, and mortality of motor neuron diseases change over time and by location is crucial for understanding the causes of these disorders and for health-care planning. Our aim was to produce estimates of incidence, prevalence, and disability-adjusted life-years (DALYs) for motor neuron diseases for 195 countries and territories from 1990 to 2016 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016.MethodsThe motor neuron diseases included in this study were amyotrophic lateral sclerosis, spinal muscular atrophy, hereditary spastic paraplegia, primary lateral sclerosis, progressive muscular atrophy, and pseudobulbar palsy. Incidence, prevalence, and DALYs were estimated using a Bayesian meta-regression model. We analysed 14 165 site-years of vital registration cause of death data using the GBD 2016 cause of death ensemble model. The 84 risk factors quantified in GBD 2016 were tested for an association with incidence or death from motor neuron diseases. We also explored the relationship between Socio-demographic Index (SDI; a compound measure of income per capita, education, and fertility) and age-standardised DALYs of motor neuron diseases.FindingsIn 2016, globally, 330 918 (95% uncertainty interval [UI] 299 522–367 254) individuals had a motor neuron disease. Motor neuron diseases have caused 926 090 (881 566–961 758) DALYs and 34 325 (33 051–35 364) deaths in 2016. The worldwide all-age prevalence was 4·5 (4·1–5·0) per 100 000 people, with an increase in age-standardised prevalence of 4·5% (3·4–5·7) over the study period. The all-age incidence was 0·78 (95% UI 0·71–0·86) per 100 000 person-years. No risk factor analysed in GBD showed an association with motor neuron disease incidence. The largest age-standardised prevalence was in high SDI regions: high-income North America (16·8, 95% UI 15·8–16·9), Australasia (14·7, 13·5–16·1), and western Europe (12·9, 11·7–14·1). However, the prevalence and incidence were lower than expected based on SDI in high-income Asia Pacific.InterpretationMotor neuron diseases have low prevalence and incidence, but cause severe disability with a high fatality rate. Incidence of motor neuron diseases has geographical heterogeneity, which is not explained by any risk factors quantified in GBD, suggesting other unmeasured risk factors might have a role. Between 1990 and 2016, the burden of motor neuron diseases has increased substantially. The estimates presented here, as well as future estimates based on data from a greater number of countries, will be important in the planning of services for people with motor neuron diseases worldwide.FundingBill & Melinda Gates Foundation.

PHP92 - The Growth of Cost-Effectiveness Analyses in Asia

This study describes the cost-effectiveness analyses (CEA) literature for health interventions in Asian countries and identifies disease areas for which the number of CEA studies either exceeds or is less than the number expected given the disease’s population burden. We analyzed Tufts Medical Center’s CEA Registry, containing English-language cost-per-quality-adjusted life year (QALY) studies, and the Global Health CEA Registry, containing cost-per-disability-adjusted life year (DALY) averted studies, across four regions in Asia (defined by the World Health Organization’s Global Burden of Disease study): (1) South Asia; (2) Southeast Asia; (3) East Asia; and (4) High-Income Asia Pacific. For each region and disease area, we determined the number of published CEAs and the corresponding disease burden. Using ordinary least squares regression of publication count against disease burden in each region, we identified disease areas that are relatively “over”- or “under”-studied within that region compared to other conditions. We identified 613 CEAs in the four regions, including 243 for East Asia, 180 for Southeast Asia, 130 for South Asia, and 200 for High-Income Asia Pacific (not mutually exclusive). Publication grew rapidly, from one study in 1996 to 114 studies in 2016. Neoplasms were the most studied disease category in East Asia (n=60) and High-Income Asia Pacific (n=44), while diarrheal diseases were the most studied disease category in South Asia (n=25) and Southeast Asia (n=30). Non-communicable diseases in East Asia, and cardiovascular disease in Southeast Asia and High-Income Asia Pacific were under-studied relative to their disease burden. Neoplasms in East Asia were relatively over-studied, as were HIV and tuberculosis in South Asia. Publication of CEAs for Asian countries is growing rapidly. There are opportunities to focus future research on disease areas that have received less attention than apparently warranted by their population burden.

Incidence, prevalence and mortality of hepatobiliary & pancreatic malignancies at the global and regional level: 1990 to 2016. GBD 2016 study

Background: Cancer is the second most common cause of death. We aim to determine the incidence, prevalence, and mortality trends for HPB malignancy at a Global/Regional levels. We report on disability-adjusted life years (DALYs), and years lost to disability (YLD). Methods: The Global Burden of Disease (GBD) 2016 dataset was interrogated for end point variables by age, sex, year, and geography from 1990 to 2016. Data was modeled in DisMod-MR 2.1. Results are expressed as age-standardized rates (ASR). Results: The global ASIR for primary liver and pancreatic neoplasm rose from 12.49 to 14.55 and 6.11 to 6.37 (1990 to 2016); an increase of 17.87% and 6.25%, respectively. In contrast, the ASIR for biliary cancer decreased from 3.71 to 2.8, a decrease of 24.5%. In addition, the global ASPR for primary liver, pancreatic, and biliary cancers all increased 75.27%, 13.44%, and 31.15%, respectively. Global ASMR stayed constant for primary liver and pancreatic cancer. Interestingly, biliary cancer saw a global decrease in ASMR of 23.77%. The global DALY's decreased for primary liver, pancreatic, and biliary cancers. In contrast, the YLD rose for primary liver cancers 22.3%, stayed relatively constant for pancreatic cancer, yet fell slightly for biliary cancer. High-Income Asia Pacific had the highest ASR of incidence for pancreatic and biliary cancers, yet was the second highest incidence of primary liver cancers. Conclusions: The incidence/prevalence of HPB malignancies has seen an overall increased with no change in mortality rates, albeit a significant geographical variation. DALY's have decreased for HPB neoplasms.

The relationship between per capita GDP and road accidents in Sri Lanka: an ARDL bound test approach

The objective of this study is to examine the relationship between road accidents and per capita GDP in Sri Lanka during the period of 1977 to 2016. The study examines the existence of Kuznets curve relationship between number of road accidents and per capita GDP in Sri Lanka, and the relationship of some other variables such as merchandise imports from various regions and different age group of population as well. The Auto Regressive Distributed Lags (ARDL) bound test approach is employed to analyse the time series data. The findings of this study confirm the existence of the Kuznets curve relationship between road accidents and per capita GDP. The results further reveal that there is a long-run relationship between road accidents and merchandise imports from high income and East Asian countries, urban population and age group of population 30-34 and 35-39. Coefficients of these variables are statistically significant at 1% level and positively associated with number of accidents in Sri Lanka.

Influences of Governance and Economic Development Level on Happiness in High Income Asian and European Countries

This study explores the relationship between governance and human development indicators with happiness using the panel data fixed effect and random effect estimation approach. Findings from the study stress on the importance of good governance in influencing life satisfaction. In a way, good governance stimulates happiness in a positive manner. Governments in developed countries in Asia and Europe may increase happiness and promote equality through enhancements in the quality of governance. This can be done by ensuring good practices in managing the economy and resources of the country. However, the relationship between the economic development level and happiness is inconclusive and insignificant

Contributions of mean and shape of blood pressure distribution to worldwide trends and variations in raised blood pressure: a pooled analysis of 1018 population-based measurement studies with 88.6 million participants.

BackgroundChange in the prevalence of raised blood pressure could be due to both shifts in the entire distribution of blood pressure (representing the combined effects of public health interventions and secular trends) and changes in its high-blood-pressure tail (representing successful clinical interventions to control blood pressure in the hypertensive population). Our aim was to quantify the contributions of these two phenomena to the worldwide trends in the prevalence of raised blood pressure.MethodsWe pooled 1018 population-based studies with blood pressure measurements on 88.6 million participants from 1985 to 2016. We first calculated mean systolic blood pressure (SBP), mean diastolic blood pressure (DBP) and prevalence of raised blood pressure by sex and 10-year age group from 20–29 years to 70–79 years in each study, taking into account complex survey design and survey sample weights, where relevant. We used a linear mixed effect model to quantify the association between (probit-transformed) prevalence of raised blood pressure and age-group- and sex-specific mean blood pressure. We calculated the contributions of change in mean SBP and DBP, and of change in the prevalence-mean association, to the change in prevalence of raised blood pressure.ResultsIn 2005–16, at the same level of population mean SBP and DBP, men and women in South Asia and in Central Asia, the Middle East and North Africa would have the highest prevalence of raised blood pressure, and men and women in the high-income Asia Pacific and high-income Western regions would have the lowest. In most region-sex-age groups where the prevalence of raised blood pressure declined, one half or more of the decline was due to the decline in mean blood pressure. Where prevalence of raised blood pressure has increased, the change was entirely driven by increasing mean blood pressure, offset partly by the change in the prevalence-mean association.ConclusionsChange in mean blood pressure is the main driver of the worldwide change in the prevalence of raised blood pressure, but change in the high-blood-pressure tail of the distribution has also contributed to the change in prevalence, especially in older age groups.

Road Safety Risk Assessment: An Analysis of Transport Policy and Management for Low-, Middle-, and High-Income Asian Countries

Road safety assessment has played a crucial role in the theory and practice of transport management systems. This paper focuses on risk evaluation in the Asian region by exploring the interaction between road safety risk and influencing factors. In the first stage, a data envelopment analysis (DEA) method is applied to calculate and rank the road safety risk levels of Asian countries. In the second stage, a structural equation model (SEM) with latent variables is applied to analyze the interaction between the road safety risk level and the latent variables, measured by six observed performance indicators, i.e., financial impact, institutional framework, infrastructure and mobility, legislation and policy, vehicular road users, and trauma management. Finally, this paper illustrates the applicability of this DEA-SEM approach for road safety performance analysis.

Global-, Regional-, and Country-Level Economic Impacts of Dental Diseases in 2015

Up-to-date information about the economic impact of dental diseases is essential for health care decision makers when seeking to make rational use of available resources. The purpose of this study was to provide up-to-date estimates for dental expenditures (direct costs) and productivity losses (indirect costs) due to dental diseases on the global, regional, and country level. Direct costs of dental diseases were estimated using a previously established systematic approach; indirect costs were estimated using an approach developed by the World Health Organization Commission on Macroeconomics and Health and factoring in 2015 values for gross domestic product and disability-adjusted life years from the Global Burden of Disease Study. The estimated direct costs of dental diseases amounted to $356.80 billion and indirect costs were estimated at $187.61 billion, totaling worldwide costs due to dental diseases of $544.41 billion in 2015. After adjustment for purchasing power parity, the highest levels of per capita dental expenditures were found for High-Income North America, Australasia, Western Europe, High-Income Asia Pacific, and East Asia; the highest levels of per capita productivity losses were found for Western Europe, Australasia, High-Income North America, High-Income Asia Pacific, and Central Europe. Severe tooth loss was found to imply 67% of global productivity losses due to dental diseases, followed by severe periodontitis (21%) and untreated caries (12%). From an economic perspective, improvements in population oral health may be highly beneficial and could contribute to further increases in people’s well-being given available resources.

Global smoking‐attributable burden of periodontal disease in 186 countries in the year 2015

We aimed to quantify the smoking-attributable burden of periodontal disease (PD). The association between smoking and PD was evaluated. Population, smoking and PD data from the Global Burden of Disease Study were used, and the burden in different sex and age groups in 186 countries in 2015 calculated, adjusted for PD prevalence and numbers of cigarettes smoked. No adjustment was performed in a sensitivity analysis. The global smoking-attributable burden was 251,160 disability-adjusted life years (DALYs; 95% uncertainty interval: 190,721-324,241; sensitivity analysis: 344,041 DALYs) or 38.5million cases. The burden was lower in females than males, and highest in the age group of the 50- to 69-year-olds. On super-regional level, the burden was highest in South-East Asia, East Asia and Oceania (83,052 DALYs), and high-income North America and Asia Pacific (55,362 DALYs). On regional level, it was highest in East Asia (70,845 DALYs), South Asia (30,808 DALYs) and North Africa and the Middle East (24,095 DALYs). On national level, it was highest in China (69,148 DALYs), India (29,362 DALYs) and the United States (12,714 DALYs). The relative smoking-attributable burden ranged between >25% in Suriname and <1% in Chad. There is great need to monitor and tackle the smoking-attributable burden of PD.

Identifying the most Influential Groups in Determining Singapore's Fertility

AbstractIn recent years, various pro-natalist policies have been adopted in Singapore and other high-income Asian countries with low fertility, aiming at raising fertility rates. Previous studies were mainly focused on the impact or outcome of the policies. This paper, however, aims to identify the most influential groups in determining Singapore's total fertility rate (TFR) and evaluate the targeting of pro-natalist measures adopted by the government. We first reveal the changing age-parity-and-marital-status composition of women at childbearing age, and further conduct an elasticity analysis to assess the roles of different subgroups of women in changing the TFR. Our results show that compared to other groups, the 20–29-year-old single women and the married childless women aged 30–34 (‘married’ throughout this paper includes women who are or have been married) are more influential in determining the TFR and should be the potential pro-natalist target groups. However, Singapore's pro-natalist policies are more in favour of third and higher-order births. Such mismatch indicates that, if more efforts are devoted to facilitating marriage and first births in these potential groups, the TFR may be increased effectively. In order to achieve a long-term and significant fertility reversal, it calls for a long-term and integrated policy package.

The Discrepancy Between Ideal and Actual Parity in Hong Kong: Fertility Desire, Intention, and Behavior

The total fertility rate of Hong Kong has remained below 1.3 children per woman for about three decades, but it is still unknown whether this ultra-low fertility is driven by a downward shift in people’s fertility desires, or by low fertility intention. This study investigates the fertility desires and fertility intentions of married women via a parity-specific approach, using data from the knowledge, attitude, and practice survey conducted in 2012. The results show that the average ideal parity has shifted to sub-replacement level, indicating that the “two-child family” ideal is waning. The logistic regressions show that the determinants of low fertility intentions vary across parities: marital life satisfaction, household income, and good communication with husbands regarding childbearing are positively associated with first-birth intentions; wives’ part-time work depresses second-birth intentions; wives’ full-time work and gender inequality in the division of housework are negatively associated with third-birth intentions. It is noteworthy that fertility desire has become a strong predictor of fertility intention—especially related to first and second births, independent of other socioeconomic factors. Motivations for childbearing and difficulties in childrearing also differ across actual parities. These results should be applicable to women in other high-income Asian countries. The formulation of any pronatalist policy in Hong Kong should consider these parity-specific differences to enhance its effectiveness.