Population Attributable Risk Fraction Research Articles

Trends and inequalities in adequate antenatal care coverage among women in Sierra Leone, 2008-2019.

Prenatal care is a critical component of maternal and child health, providing essential preventive, diagnostic, and therapeutic services to pregnant women. Adequate antenatal care has been linked to reduced maternal and infant mortality and improved birth outcomes. Despite its importance, disparities in antenatal care coverage persist globally, including Sierra Leone,with significant implications for maternal and child health. This study examined the trends and inequalities in antenatal care utilisation in Sierra Leone. We used data from the 2008, 2013, and 2019 Sierra Leone Demographic and Health Surveys. Simple inequality measures (Difference and Ratio) and complex measures (Population Attributable Risk and Population Attributable Fraction) were computed using the World Health Organization's Health Equity Assessment Toolkit software. Inequality in antenatal care was calculated on six stratefiers:age groups for women, birth order, educational levels, economic status, residential areas, and sub-national province. There was a significant increase in adequate antenatal care coverage from 2008 (15.2%) to 2013 (36.5%) but a decrease in 2019 (22.1%). The inequality in age increased over time from a Difference of2.7 percentage points in 2008 to a Difference of 5.3 percentage points in 2019, indicating age-related inequalities. The Population Attributable Fraction decreased from 2.7% in 2008 to zero in 2013, indicating no further improvement in the national average of adequate antenatal care coverage can be achieved in the absence of age-related inequalities. However, it increased to 7.7% in 2019, indicating that the national average of adequate antenatal care coverage would have increased by 7.7% in the absence of age-related inequalities. The birth order inequality increased from a Difference of - 5.2 percentage points in 2008 to 2.6 percentage points in 2019. The Population Attributable Fraction was zero in 2008 and3.4% in 2019, showing that the national average of adequate antenatal care coverage would have increased by 3.4% if there was no parity-based inequality. Inequality in economic status decreased from 32.1 percentage points in 2008(Difference = 32.1) to 2.8 percentage points in 2019(Difference = 2.8). The Population Attributable Fraction revealed that the national average could have been 164.4% higher in 2008 and 20.8% higher in 2013; however, it was zero in 2019, indicating that no further improvement can be achieved in the national average if there was no inequality related to economic status. Inequality for education decreased from 49.9 percentage points in 2008(Difference = 49.9) to 11.0 percentage points in 2019(Difference = 11.0). Inequality decreased from a Difference of20.8 percentage points in 2008 to a Difference of1.7 percentage points in 2019 for place of residence inequality, showing a reduction in inequality. Provincial inequality decreased from a Difference of 33.9 percentage points in 2008 to 8.5 percentage points in 2019. While there have been notable improvements in antenatal care coverage in Sierra Leone, adequate antenatal care coverage is still below the WHO target of 78% in 2016, and significant inequalities persist. Addressing these inequalities requires a multifaceted approach considering demographic, economic, educational, and geographic indicators considered in this study. Sustained efforts and targeted interventions are critical by the Sierra Leone government to ensure that all women, regardless of their background, have access to essential antenatal care services up to at least eight visits.

Trends and inequalities in oral rehydration therapy and continued feeding for children under five with diarrhoea in Sierra Leone

BackgroundSierra Leone has improved child health outcomes in recent decades. However, diarrhoeal diseases remain a public health concern, particularly among children under five. This study investigates the trends and inequalities in oral rehydration therapy and continued feeding for children under five with diarrhoea in Sierra Leone in 2008, 2013 and 2019.MethodsThe analysis utilised data from the Sierra Leone Demographic Health Survey rounds conducted in 2008, 2013, and 2019. The software utilised for the calculation of various measures of inequality, including simple difference, ratio, population-attributable risk, and population-attributable fraction, was the World Health Organization Health Equity Assessment Toolkit. An inequality assessment was conducted for six stratifiers: maternal age, maternal economic status, maternal level of education, place of residence, sex of the child, and sub-national region.ResultsOur findings reveal that children under five with diarrhoea receiving oral rehydration therapy and continued feeding increased from 56.5% in 2008 to 59.7% in 2019 in Sierra Leone. Children of mothers aged 20–49 had more coverage over time than those with mothers aged 15–19. Children of mothers who are wealthy, more educated, and living in urban areas show a decrease in coverage with time compared to the poor, the lowly educated, and those residing in rural areas. Male children had higher coverage than female children. Regional inequality decreased slightly from 21.5 percentage points in 2008 to 21.2 percentage points in 2019.ConclusionThe findings revealed a mixed picture of progress in oral rehydration therapy and continued feeding for children under five in Sierra Leone. While national coverage has increased, inequalities persist. Children of older mothers and those from disadvantaged backgrounds have experienced improvements, while children of younger, wealthier, and more educated mothers in urban areas have seen a decline in coverage. The gender and regional inequalities remain. Expanding community-based health programs, providing subsidised or free supplies, and strengthening health systems in underserved areas are key strategies to ensure equitable and effective healthcare for all children in Sierra Leone.

Trends and inequalities in antenatal care coverage in Benin (2006–2017): an application of World Health Organization’s Health Equity Assessment Toolkit

IntroductionBetween 2006 and 2017, antenatal care (ANC) coverage in Benin declined, potentially exacerbating inequalities and substantiating the need for health inequality monitoring. This study examines inequalities in ANC attendance in Benin, disaggregated by women’s age, educational level, economic status, place of residence, region of residence, and the extent to which they have changed over time.MethodsThree rounds of the Benin Demographic and Health Surveys (2006, 2011–12, and 2017–18) were analyzed to examine inequalities in ANC coverage. An exploratory descriptive approach was adopted for the analysis. Simple [difference (D) and ratio (R)] and complex [population attributable risk (PAR) and population attributable fraction (PAF)] measures of inequalities were computed using the World Health Organization’s Health Equity Assessment Toolkit (WHO’s HEAT) online platform. The measures were computed separately for each of the three surveys, and their estimates were compared.ResultsThe findings revealed an 8.4% decline in at least four ANC visits between 2006 and 2017–18. The decline occurred irrespective of age, educational status, economic status, place of residence, and region. Region-related inequalities were the largest and increased slightly between 2006 (D = 54.6; R = 2.6; PAF = 47.8, PAR = 29.0) and 2017–18 (D = 55.8; R = 3.1; PAF = 57.2, PAR = 29.8). Education (2006: D = 31.3, R = 1.6, PAF = 40.5, PAR = 24.5; 2017–18: D = 25.2, R = 1.6, PAF = 34.9, PAR = 18.1) and rural-urban (2006: D = 16.8, R = 1.3, PAF = 17.8, PAR = 10.8; 2017–18: D = 11.2, R = 1.2, PAF = 13.1, PAR = 6.8) inequalities reduced while economic status inequalities did not improve (2006: D = 48, R = 2.2, PAF = 44.5, PAR = 26.9; 2017–18: D = 43.9, R = 2.4, PAF = 45.0, PAR = 23.4). Age inequalities were very minimal.ConclusionANC inequalities remain deeply ingrained in Benin. Addressing their varying levels requires comprehensive strategies that encompass both supply—and demand-side interventions, focusing on reaching uneducated women in the poorest households and those residing in rural areas and Atacora.

Determinants of mortality status and population attributable risk fractions of the North West Province, South African site of the international PURE study

BackgroundMortality data and comparative risk assessments from sub-Saharan Africa are limited. There is an urgent need for high quality population health surveys to be conducted, to improve the national health surveillance system. Our aim was to perform a comparative risk assesment and report on the mortality status and cause of death data of participants from a South African site of the international Prospective Urban Rural Epidemiology study.Methods1 921 Black participants were included, with a median observational time of 13 years resulting in 21 525 person-years. We performed a comparative risk assessment considering four health status domains: locality (rural vs. urban), socio-economic status (SES) (education and employment), lifestyle factors (physical activity, smoking and alcohol consumption) and prevalent diseases (human immunodeficiency virus (HIV), type 2 diabetes mellitus and hypertension). Next, population-attributable fractions (PAFs) were calculated to determine the mortality risk attributable to modifiable determinants.Results577 all-cause deaths occurred. Infectious diseases (28.1% of all deaths) were the most frequent cause of death, followed by cardiovascular disease (CVD) (22.4%), respiratory diseases (11.6%) and cancer (11.1%). The three main contributors to all-cause mortality were HIV infection, high SES and being underweight. HIV infection and underweight were the main contributors to infectious disease mortality and hypertension, the urban environment, and physical inactivity to CVD mortality. HIV had the highest PAF, followed by physical inactivity, alcohol and tobacco use and hypertension (for CVD mortality).ConclusionThis African population suffers from a quadruple burden of disease. Urban locality, high SES, prevalent disease (HIV and hypertension) and lifestyle factors (physical inactivity, tobacco and alcohol use) all contributed in varying degrees to all-cause and cause-specific mortalities. Our data confirm the public health importance of addressing HIV and hypertension, but also highlights the importance of physical inactivity, tobacco use and alcohol consumption as focal points for public health strategies to produce the most efficient mortality reduction outcomes.

Abstract 4826: Cancer mortality attributable to area-level socioeconomic inequalities in Japan from 2015 to 2020

Abstract Background: In the 3rd Healthy Japan 21 and the 4th National Cancer Plan, the government focused on reducing health inequalities. However, current monitoring of socioeconomic inequalities in cancer is still insufficient to set the targets for the plan. To prioritize strategy aimed at reducing socioeconomic inequalities in cancer mortality, we estimated the population attributable risk fraction (PAF) and excess death due to socioeconomic inequalities, by sex, age group and cancer site. Method: We used the areal deprivation index (ADI) to establish area-based socioeconomic status. We categorized municipalities to ADI quintile weighted by the size of population, Q1 is the least deprived and Q5 the most deprived group. Excess death due to socioeconomic inequalities was calculated by the difference between observed number of deaths and expected death of Q2 to Q5 group with Q1 as standard population. We used cancer mortality data obtained from vital statistics in 2015-2020. Results: In total, about 12000 male and 2800 female excess deaths per year due to socioeconomic inequalities were estimated; that is 5.5% and 1.8% as PAF. PAF due to socioeconomic inequalities limited to premature death, less than 75 years old, was estimated as 7.6% in men and 3.3% in women. By age group, the 0-39 years group showed the largest PAF at 15.7% in men and 16.6% in women. In men of all age groups, except 0-39 years, lung cancer was the highest excess death due to socioeconomic inequalities. For women, some cancer sites (breast, ovary, esophagus) showed an opposite association, Q1 was the highest mortality group. Therefore, total excess death was lower than in men. In women of all ages, the highest rate of excess death due to socioeconomic inequalities was gallbladder cancer. For the 0-39 years group, a high rate of excess death in stomach, leukemia, and cervical cancer was observed. Discussion: Excess death and PAF due to socioeconomic inequalities differed by sex and age group. A greater impact of socioeconomic inequality on cancer mortality was observed in men than in women. Among women, further attention should be paid to areal variation of cancer death related to socioeconomic inequalities, based on the different area-based indices. Citation Format: Yuri Ito, Tomoki Nakaya, Manami Inoue, Tomotaka Sobue, Hitoshi Nakagama. Cancer mortality attributable to area-level socioeconomic inequalities in Japan from 2015 to 2020 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4826.

Inequities and trends of polio immunisation among children aged 12–23 months in Ethiopia: a multilevel analysis of Ethiopian demographic and health survey

IntroductionDespite Ethiopia’s policy intention to provide recommended vaccination services to underprivileged populations, inequity in polio immunisation persists.ObjectiveThis study examined inequity and trends in polio immunisation and determinant factors among children...

Prevention of cardiovascular disease, a major non-communicable disease, in a super-aging society: Health success and unsolved issues in Japan.

As far as non-communicable disease is concerned, Japan is unique in showing a substantial decline in stroke mortality and the lowest and declining mortality from ischemic heart disease during the past half century, which contributed to the elongation of a 4-year average life expectancy, leading to top longevity in the world. However, several issues have remained in the prevention of cardiovascular disease with super-aging: i) how to manage the screening and lifestyle modification for both individuals with metabolic syndrome and those with non-overweight/ obesity plus metabolic risk factors, and ii) how to enhance the referral of very high-risk individuals screened at health checks to physicians for seeking treatment and examine whether an early clinical visit was associated with a lower risk of cardiovascular disease and total mortality. Health counseling is needed for both persons with metabolic syndrome and high-risk individuals with non-obese/overweight because the population attributable risk fraction of ischemic cardiovascular disease was similar for both high-risk individuals. Standardized counseling for very high-risk individuals accelerated clinical visits and reduced levels of risk factors. In health counseling, public health nurses were more effective in increasing clinic visits. Furthermore, the earlier clinic visit after the counseling suggested a lower risk of hospitalization for stroke, coronary heart disease, heart failure, and all-cause mortality. This article reviews these epidemiological findings for health practitioners and policymakers to perform further prevention and control for cardiovascular disease in Japan and other Asian and African countries with emerging cardiovascular burden and aging.

Race and Ethnicity, Deprivation, and Infant Mortality in England, 2019-2022

England has one of the highest infant mortality rates in Europe. Much of the variation in infant mortality rates between races and ethnicities may be due to socioeconomic factors, but how deprivation and race and ethnicity are associated with infant mortality is unclear. To investigate the association of infant race and ethnicity with the infant mortality rate in England, adjusted for preterm birth and level of deprivation. This cohort study included children who died younger than 1 year of age, born at or after 22 weeks' gestation, occurring from April 1, 2019, to March 31, 2022, in England. Characteristics of the infant were derived from death notifications. The racial and ethnic groups were derived from National Health Service data and were reported by the parents and characterized using the Office of National Statistics classification: Asian or Asian British (Bangladeshi, Chinese, Indian, Pakistani, or any other Asian background), Black or Black British (African, Caribbean, or any other Black background), multiracial (White and Asian, White and Black African, White and Black Caribbean, or any other multiracial background), White or White British (British, Irish, any other White background, or Gypsy or Irish Traveler), and other (Arab or any other racial or ethnic group). Risk of death for all racial and ethnic groups and relative risk of death compared with the reference group (White) were calcuated. Analyses were repeated, adjusting for deprivation, gestational age of infants, and region of England. A total of 5621 infants who died younger than 1 year of age were reported to the National Child Mortality Database. A total of 2842 of 5130 infants (55.4%) were male; the median gestational age was 33 weeks (IQR, 25-38 weeks); of 5149 infants, 927 (18.0%) were Asian, 448 (8.7%) were Black, 3318 (64.4%) were White, 343 (6.7%) were multiracial, and 113 (2.2%) were from other racial and ethnic groups; and the median deprivation score was 4 (IQR, 3-5). In the unadjusted analysis, the relative risk of death compared with White infants was higher for Black (1.93 [95% CI, 1.75-2.13]) and Asian (1.67 [95% CI, 1.55-1.80]) infants. The population attributable risk fraction for all mortality rates among infants who were not White was 12.0% (95% CI, 10.3%-13.8%) (unadjusted), 9.8% (95% CI, 8.0%-11.7%) (adjusted for deprivation), 7.7% (95% CI, 5.9%-9.5%) (adjusted for gestational age at birth), and 12.8% (95% CI, 11.0%-14.5%) (adjusted for region of England). This cohort study suggests that the proportion of infants who died before 1 year of age is associated with race and ethnicity, with a population attributable risk fraction of 12.0%. An overconservative adjustment for deprivation did not explain the overall patterns seen. Approximately half the population attributable risk fraction may be due to increased risk of preterm birth in Asian and Black communities. Work is needed to identify what can be done to reduce this incidence of infant mortality.

Magnitude and trends in inequalities in healthcare-seeking behavior for pneumonia and mortality rate among under-five children in Bangladesh: Evidence from nationwide cross-sectional survey 2007 to 2017.

Bangladesh did not have enough evidence on the current estimates and trend in inequities in the under-five mortality rate (U5MR). There is also a shortage of evidence on trends and inequalities in healthcare-seeking for pneumonia among under-five children (U5C) in Bangladesh. Hence, this study investigated the inequalities in U5MR and health care seeking for pneumonia in U5C through socioeconomic and geographic disparities in Bangladesh between 2007 and 2017. Data from 2007, 2011, 2014, and 2017 Bangladesh Demographic and Health surveys were analyzed using the Health Equity Assessment Toolkit (HEAT) software by World Health Organization (WHO). The data on U5MR and healthcare-seeking for pneumonia were first disaggregated into five equity dimensions: wealth status, education, child sex, place of residence, and administrative divisions. Second, using summary metrics such as difference (D), population attributable risk (PAR), ratio (R), and population attributable fraction (PAF), inequalities were assessed. The U5MR declined from 73.9 deaths per 1000 live births in 2007 to 48.6 deaths in 2017, while the prevalence of healthcare-seeking for pneumonia in U5C fluctuated over time (34.6% in 2007, 35.4% in 2011, 42.0% in 2014, and 39.8% in 2017). Profound socioeconomic and geographic disparities in U5MR and the prevalence of healthcare-seeking for pneumonia in U5C favored the wealthy, educated, and urban residents. At the same time, the Sylhet division showed the worst situation for U5MR. There were also sex-related disparities in U5MR (PAR = -4.5, 95% confidence interval: -5.3 to -3.7) with higher risk among male children than females. These results indicate that improving disadvantaged women, such as the poor, uneducated, and rural inhabitants, who exhibit disproportionate disparities in U5MR and healthcare-seeking behavior is important. To reduce childhood mortality, it is essential to improve healthcare-seeking for pneumonia among U5C. Facilitating women for better education and economic encompasses would help reducing disparity.

Population-based birth cohort study on diabetes in pregnancy and infant hospitalisations in Cree, other First Nations and non-Indigenous communities in Quebec

ObjectivesDiabetes in pregnancy, whether pre-gestational (chronic) or gestational (de novo hyperglycaemia), increases the risk of adverse birth outcomes. It is unclear whether gestational diabetes increases the risk of postnatal morbidity...

Newborn Health and Child Mortality Across England

Although the immediate impact of neonatal illness is well recognized, its wider and longer term outcomes on childhood mortality and the role of specific illnesses across childhood are unclear. To investigate how many deaths in childhood are associated with neonatal illness and the underlying conditions of the children who died. This population-based cohort study of children who died before age 10 years in England between April 1, 2019, and March 31, 2021, used data from the National Child Mortality Database. Data analysis was performed from September 2022 to May 2023. Children who received care in a neonatal unit after birth plus those who died in the first day of life, before admission to a neonatal unit, were considered to have likely neonatal illness. The primary outcome was the relative risk (RR) of dying, stratified by likely neonatal illness and specific neonatal conditions. Comparisons were made using the χ2 or likelihood ratio test, as appropriate. A total of 4829 children were included (median [IQR] age at death, 28 [2-274] days; 2606 boys [54.8%]; 2690 White children [64.0%]). Overall, 3456 children who died (71.6%) had evidence of likely neonatal illness. Children with neonatal illness were more likely to die before their tenth birthday than those without evidence of neonatal illness (RR, 13.82; 95% CI, 13.00-14.71). The estimated population-attributable risk fraction for neonatal illness among all deaths before age 10 years was 66.4% (95% CI, 64.9%-67.9%). Children with preceding neonatal illness who died were more likely to have underlying behavioral or developmental disorders (odds ratio [OR], 3.31; 95% CI, 2.47-4.42), chronic neurological disease (OR, 3.00; 95% CI, 2.51-3.58), and chronic respiratory disease (OR, 3.01; 95% CI, 2.43-3.73) than children without neonatal illness. In this cohort study, most children who died before age 10 years had some evidence of neonatal illness, and they died of a range of causes, including infections and sudden, unexpected, unexplained death. These findings suggest that improvements to perinatal morbidity, an area with an existing evidence base for improvement, may have important impacts on child health across the next decade.

Trends in Radiation Dose to the Contralateral Breast During Breast Cancer Radiation Therapy.

Over 4 million survivors of breast cancer live in the United States, 35% of whom were treated before 2009. Approximately half of patients with breast cancer receive radiation therapy, which exposes the untreated contralateral breast to radiation and increases the risk of a subsequent contralateral breast cancer (CBC). Radiation oncology has strived to reduce unwanted radiation dose, but it is unknown whether a corresponding decline in actual dose received to the untreated contralateral breast has occurred. The purpose of this study was to evaluate trends in unwanted contralateral breast radiation dose to inform risk assessment of second primary cancer in the contralateral breast for long-term survivors of breast cancer. Individually estimated radiation absorbed doses to the four quadrants and areola central area of the contralateral breast were estimated for 2,132 women treated with radiation therapy for local/regional breast cancers at age <55 years diagnosed between 1985 and 2008. The two inner quadrant doses and two outer quadrant doses were averaged. Trends in dose to each of the three areas of the contralateral breast were evaluated in multivariable models. The population impact of reducing contralateral breast dose on the incidence of radiation-associated CBC was assessed by estimating population attributable risk fraction (PAR) in a multivariable model. The median dose to the inner quadrants of the contralateral breast was 1.70 Gy; to the areola, 1.20 Gy; and to the outer quadrants, 0.72 Gy. Ninety-two percent of patients received ≥1 Gy to the inner quadrants. For each calendar year of diagnosis, dose declined significantly for each location, most rapidly for the inner quadrants (0.04 Gy/year). Declines in dose were similar across subgroups defined by age at diagnosis and body mass index. The PAR for CBC due to radiation exposure >1 Gy for women <40 years of age was 17%. Radiation dose-reduction measures have reduced dose to the contralateral breast during breast radiation therapy. Reducing the dose to the contralateral breast to <1 Gy could prevent an estimated 17% of subsequent radiation-associated CBCs for women treated under 40 years of age. These dose estimates inform CBC surveillance for the growing number of breast cancer survivors who received radiation therapy as young women in recent decades. Continued reductions in dose to the contralateral breast could further reduce the incidence of radiation-associated CBC.

Population attributable risk fraction of modifiable risk factors associated with poor self-rated health among children and adolescent; the CASPIAN-V study

BackgroundWe aimed to determine the population attributable risk fraction (PARF) of the risk factors for poor SRH in Iranian children and adolescents. MethodThis was a nationwide cross-sectional study conducted in 2015 among 14,400 students aged 6–18 years, living in 30 provinces of Iran. Data were collected using global school health survey questionnaire. Logistic regression was employed to determine the adjusted association of modifiable risk factors with SRH. We used average PARF to determine the preventable proportion of poor reported SRH. ResultsOf 14,400 recruited students, data on 13,983 subjects were analyzed in current study. The mean (SD) age of participants (n = 13,983) was 12.3 (3.16) years, and 49.3% were female. Poor SRH was reported in 19% of subjects. In total, 77% of poor reported SRH in Iranian children and adolescents could be attributed to insufficient daily sleep duration, physical injury, lack of close friend, dissatisfaction with family relationship, and the lack of a companion to share personal problems. We also found that physical pain had the largest PARF (32.4%) followed by anxiety (26.1%) and un-satisfaction with family relationship (5.2%). ConclusionThe established physical and social support factors of poor SRH were associated with a remarkable proportion of poor SRH in the Iranian pediatric population. Changing the children's risk factor profile to the lowest physical risk factor as well as reducing the anxiety level and preventing from physical painsmay significantly improve the SRH of children and adolescents.

Association between cannabis use disorder and schizophrenia stronger in young males than in females.

Previous research suggests an increase in schizophrenia population attributable risk fraction (PARF) for cannabis use disorder (CUD). However, sex and age variations in CUD and schizophrenia suggest the importance of examining differences in PARFs in sex and age subgroups. We conducted a nationwide Danish register-based cohort study including all individuals aged 16-49 at some point during 1972-2021. CUD and schizophrenia status was obtained from the registers. Hazard ratios (HR), incidence risk ratios (IRR), and PARFs were estimated. Joinpoint analyses were applied to sex-specific PARFs. We examined 6 907 859 individuals with 45 327 cases of incident schizophrenia during follow-up across 129 521 260 person-years. The overall adjusted HR (aHR) for CUD on schizophrenia was slightly higher among males (aHR = 2.42, 95% CI 2.33-2.52) than females (aHR = 2.02, 95% CI 1.89-2.17); however, among 16-20-year-olds, the adjusted IRR (aIRR) for males was more than twice that for females (males: aIRR = 3.84, 95% CI 3.43-4.29; females: aIRR = 1.81, 95% CI 1.53-2.15). During 1972-2021, the annual average percentage change in PARFs for CUD in schizophrenia incidence was 4.8 among males (95% CI 4.3-5.3; p < 0.0001) and 3.2 among females (95% CI 2.5-3.8; p < 0.0001). In 2021, among males, PARF was 15%; among females, it was around 4%. Young males might be particularly susceptible to the effects of cannabis on schizophrenia. At a population level, assuming causality, one-fifth of cases of schizophrenia among young males might be prevented by averting CUD. Results highlight the importance of early detection and treatment of CUD and policy decisions regarding cannabis use and access, particularly for 16-25-year-olds.

Assessing the inequalities in demand for family planning satisfied in Ghana: evidence from the 1993-2014 Demographic and Health Surveys.

Family planning is essential in promoting the well-being of women and their families and communities and ensuring quality of care in contraceptive use. This study sought to assess the trend and inequalities in the demand for family planning satisfied (DFPS) in Ghana from 1993 to 2014. The World Health Organization's Health Equity Assessment Toolkit was employed to analyse the data. We disaggregated DFPS by five equity stratifiers: age, economic status, education, residence and region. Inequality was measured using difference (D), population attributable risk (PAR), ratio (R) and population attributable fraction (PAF). The study showed an increment in DFPS from 17.8% to 38.7% between 1993 and 2014. With respect to age, we noted substantial inequality in 2003 (D=21.9 [95% confidence interval {CI} 15.2 to 28.7]), 1993 (D=4.8 [95% CI -1.8 to 11.4]) and 2014 (D=15 [95% CI 3 to 26.9]). The greatest economic inequality occurred in 1993 (PAF=69.7 [95% CI 50.8 to 88.6]; D=20.1 [95% CI 14.8 to 25.4]). Regarding education, significant inequality existed in 1993 (PAF=112 [95% CI 100.8 to 123.2]; D=29.7 [95% CI 21.9 to 37.4]). Ashanti and the Upper West regions reported significant inequalities (PAF=55.6 [95% CI 33.1 to 78.2]; D=16.1 [95% CI 8.9 to 23.3]). There are age-, education-, wealth-, residence- and region-related inequalities with respect to DFPS. Policymakers will have to prioritize the needs of women with no formal or low educational attainment in order to improve DFPS coverage. Special attention needs to be given to adolescent girls since they suffer greater inequalities than adult women.

Population-Attributable Risk Fractions for Antiplatelets and Anticoagulants in Spontaneous Intracranial Hemorrhages

Introduction: Concerns about spontaneous intracranial hemorrhages (sICHs) have increased over time with the increasing use of antithrombotic agents. Hence, we aimed to analyze the risk and risk fractions for antithrombotics in sICHs in South Korea. Methods: From the National Health Insurance Service-National Sample Cohort including 1,108,369 citizens, 4,385 cases, aged 20 years or more and newly diagnosed as sICHs between 2003 and 2015, were included in this study. A total of 65,775 sICH-free controls were randomly selected at a ratio of 1:15 from individuals with the same birth year and sex according to a nested case-control study design. Results: Although the incidence rate of sICHs started to decrease from 2007 onward, the use of antiplatelets, anticoagulants, and statins continued to increase. Antiplatelets (adjusted odds ratio [OR] 3.59, 95% confidence interval [CI] 3.18–4.05), anticoagulants (adjusted OR 7.46, 95% CI 4.92–11.32), and statins (adjusted OR 1.98, 95% CI 1.79–2.18) were significant risk factors for sICHs even after adjusting for hypertension, alcohol intake, and cigarette smoking. From 2003–2008 to 2009–2015, the population-attributable fractions changed from 28.0% to 31.3% for hypertension, from 2.0% to 3.2% for antiplatelets, and from 0.5% to 0.9% for anticoagulants. Conclusion: Antithrombotic agents are significant risk factors for sICHs, and their contribution is increasing over time in Korea. These findings are expected to draw the attention of clinicians to precautions to be taken when prescribing antithrombotic agents.

Metabolic Risk Factors for Hepatocellular Carcinoma in Patients with Nonalcoholic Fatty Liver Disease: A Prospective Study.

Non-alcoholic fatty liver disease (NAFLD) is a fast-growing public health problem and predisposes to hepatocellular carcinoma (HCC) in a significant proportion of patients. Metabolic alterations might underlie the progression of NAFLD to HCC, but the magnitudes of risk and population-attributable risk fractions (PAFs) for various metabolic conditions that are associated with HCC risk in patients with NAFLD are unknown. We investigated the associations between metabolic conditions and HCC development in individuals with a prior history of NAFLD. The study included 11,245 participants in the SEER-Medicare database, comprising 1310 NAFLD-related HCC cases and 9835 NAFLD controls. We excluded individuals with competing liver diseases (e.g., alcoholic liver disease and chronic viral hepatitis). Baseline pre-existing diabetes mellitus, dyslipidemia, obesity, hypertension, hypothyroidism, and metabolic syndrome were assessed. Multivariable-adjusted logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). PAFs were also calculated for each metabolic condition. The results show that diabetes (OR = 2.39, 95% CI: 2.04-2.79), metabolic syndrome (OR = 1.73, 95% CI: 1.49-2.01), and obesity (OR = 1.62, 95% CI: 1.43-1.85) were associated with a higher HCC risk in individuals with NAFLD. The highest PAF for HCC was observed for pre-existing diabetes (42.1%, 95% CI: 35.7-48.5), followed by metabolic syndrome (28.8%, 95% CI: 21.7-35.9) and obesity (13.2%, 95% CI: 9.6-16.8). The major predisposing factors for HCC in individuals with NAFLD are diabetes mellitus, metabolic syndrome, and obesity, and their control would be critically important in mitigating the rising incidence of NAFLD-related HCC.

Inequalities in the prevalence of skilled birth attendance in Ghana between 1993 and 2014.

Globally, maternal and neonatal health remains a public health priority, particularly for resource-constrained regions like sub-Saharan Africa (SSA). Skilled birth attendance (SBA) is essential in promoting maternal and neonatal health. This study investigated the inequalities in the prevalence of SBA in Ghana using data from the Ghana Demographic and Health Survey (GDHS) between 1993 and 2014. Data were analysed using the World Health Organization's Health Equity Assessment Toolkit software. In analysing the data, we first disaggregated SBA by four inequality stratifiers: wealth index, education, residence, and region. Second, we measured the inequality through summary measures, namely difference, population attributable risk, ratio, and population attributable fraction. A 95% confidence interval was constructed for point estimates to measure statistical significance. Throughout the period, SBA was highest among women in the highest wealth quintile and those with a secondary or higher level of education. The analysis also indicated that SBA was highly concentrated among urban residents in 1993 (80.78 [95% uncertainty interval {UI} 76.20-84.66]) and persisted to 2014 (91.55 [95% UI 88.80-93.68]). In 1993, Northern region recorded the lowest prevalence of SBA in Ghana (15.69 [95% UI 11.20-21.54]) and the region consistently recorded the lowest SBA prevalence even into 2014 (38.21 [95% UI 27.44-50.27]). There are significant inequalities in SBA across education, wealth, residence, and region in Ghana. To enhance SBA, there is the need for policymakers and interventionists to design and develop targeted policies and programs that are tailored to the needs of the subpopulations at risk of low SBA: women with no formal education, those within the poorest wealth quintile, rural-dwelling women and women in the Northern region. This will facilitate the uptake of SBA and ultimately translate into the realization of Sustainable Development Goals 3.1 and 3.2.

Development over time of the population-attributable risk fraction for cannabis use disorder in schizophrenia in Denmark

Development over time of the population-attributable risk fraction for cannabis use disorder in schizophrenia in Denmark

Childhood individual and family modifiable risk factors for criminal conviction: a 7-year cohort study from Brazil

Crime is a major public problem in low- and middle-income countries (LMICs) and its preventive measures could have great social impact. The extent to which multiple modifiable risk factors among children and families influence juvenile criminal conviction in an LMIC remains unexplored; however, it is necessary to identify prevention targets. This study examined the association between 22 modifiable individual and family exposures assessed in childhood (5–14 years, n = 2511) and criminal conviction at a 7-year follow-up (13–21 years, n = 1905, 76% retention rate) in a cohort of young people in Brazil. Population attributable risk fraction (PARF) was computed for significant risk factors. Criminal convictions were reported for 81 (4.3%) youths. Although most children living in poverty did not present criminal conviction (89%), poverty at baseline was the only modifiable risk factor significantly associated with crime (OR 4.14, 99.8% CI 1.38–12.46) with a PARF of 22.5% (95% CI 5.9–36.1%). It suggests that preventing children’s exposure to poverty would reduce nearly a quarter of subsequent criminal convictions. These findings highlight the importance of poverty in criminal conviction, as it includes several deprivations and suggest that poverty eradication interventions during childhood may be crucial for reducing crime among Brazilian youth.