Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: Quantifying the epidemiological transition

Background The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age–sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. Methods We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. Findings Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6–6·6), from 65·3 years (65·0–65·6) in 1990 to 71·5 years (71·0–71·9) in 2013, HALE at birth rose by 5·4 years (4·9–5·8), from 56·9 years (54·5–59·1) to 62·3 years (59·7–64·8), total DALYs fell by 3·6% (0·3–7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6–29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non–communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. Interpretation Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition—in which increasing sociodemographic status brings structured change in disease burden—is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5–89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

Transition of self: Repositioning the celebrity brand through social media—The case of Elizabeth Gilbert

Transitioning the personal brand from one representation to another is sometimes necessary, particularly within the public eye. Marketing literature regarding celebrities focuses on brand endorsement (see for example Till, 1998 or Erdogan, 1999), rather than the positioning of a celebrity brand. Furthermore, the role of social media in strengthening the celebrity brand has received limited attention in the literature outside of political marketing (see for example Crawford, 2009 and Grant, Moon and Grant, 2010). This study focuses on the brand of “Elizabeth Gilbert,” author of the bestseller memoir, Eat, Pray, Love (2006). Through critical discourse analysis, the way the author has used social media to reposition her celebrity brand at the time of the launch of her new novel, ‘The Signature of All Things’ (2013) is examined. This study focuses on the use of social media by celebrities to strengthen the celebrity brand.

Lumometsän syli : Anni Swanin satusymbolismi 1896-1923

Lumometsän syli, Anni Swanin satusymbolismi 1896-1923 on suomenkielisen satukirjallisuuden poetiikkaa ja 1900-luvun alun modernia naiseutta selvittävä feministiseen tutkimustraditioon liittyvä tutkimus. Sen kohteena ovat lasten- ja nuortenkirjailija Anni Swanin (1875-1958) satukokoelmat vuosilta 1901-1923 ja Uusi Suometar -lehden sadunomaiset novellit vuosilta 1896-1904. Tutkimus tuo uutta tietoa lastenkirjallisuuden osalta 1900-luvun alun modernin ihmisen problematiikasta. Se sisältää naissubjektin kehityskaaren ja sisäisen kasvun kohti naistaiteilijuutta. Yksityiskohtaisen tarkastelun kohteina ovat sadut Veli ja sisar (1917), Ihmekukka (1905), Marjaanan helmikruunu (1912), Aaltojen salaisuus (1901), Jääkukka (1905), Tyttö ja kuolema (1917), Merenkuningatar ja hänen poikansa (1905), Lumolinna (1905) ja Tarina Kultasirkasta (1901). Tutkimuksessa tarkastellaan Swanin satujen poeettista kieltä ja naiseuden tematiikkaa ranskalaisen postmodernin ajan feministisen viitekehyksen valossa. Siinä keskeisiä ovat Julia Kristevan psykoanalyyttispohjaiset näkemykset ja Hélène Cixous´n sekä Luce Irigarayn ajatukset feminiinisestä kirjoituksesta. Sadut kontekstualisoidaan ajankohdan symbolistiseen taidevirtaukseen ja Suomen taiteen kultakauteen. Satuja tulkitaan naiskirjailijan lajina ja erityisenä naisen metaforisen ilmaisun muotona. Satujen feministinen lukutapa purkaa perinteisiä lukemiskonventioita ja merkitsee satutekstin lukemista "toisin". Se avaa varhaista modernia naiseutta ja sille ominaista naisen ilmaisukielen erityisyyttä sekä mykkää ei-kielellistä, melankolian ilmaisua. Tutkimus tuo esiin uudenlaisen naiskirjailijan aistimusvoimaisen kielen. Swanin satusymbolismi on luonnon kauneuden synesteettista ja aistimusvoimaista kerrontaa, jolle on luonteenomaista aistiestetiikka, metaforisuus, metonymisyys ja metamorfoosit. Swan vahvistaa osaltaan naisen sankaruutta, omaa ilmaisukieltä ja ääntä. Tuloksena paljastuu satuperinteeseen verrattuna uudenlaisia tyttöyden, äitiyden, naistaiteilijuuden ja perheen malleja ja niiden representaatioita. Satumallit osoittautuvat aikanaan moderneiksi tyttösankareiksi, osin ambivalenteiksi uudenlaista naiseutta ja suhteessa oloa heijastaviksi ja ovat siten varhaisia feministisen sadun tunnusmerkkejä. Tutkimus selvittää, miten Swan rakentaa omaperäisen satusymboliikan. Satumetsä on luonnonkauniin suomalaismetsän symbolinen mielenmaisema ja samanaikaisesti sadun myyttis-symbolinen topos. Swanin luontokäsitys sisältää luonnonsuojelun ja varhaisen ekokriittisen näkemyksen. Tutkimus osoittaa Swanin satujen kytkeytyvän 1900-luvun alun modernismiin ja Suomen taiteen kultakauteen. Swan on suomenkielisen symbolistisen taidesadun kehittäjä ja feministisen sadun aloittaja.

Understanding the determinants of Australian hospital nurses' hand hygiene decisions following the implementation of a national hand hygiene initiative

Hand hygiene is the primary measure in hospitals to reduce the spread of infections, with nurses experiencing the greatest frequency of patient contact. The ‘5 critical moments’ of hand hygiene initiative has been implemented in hospitals across Australia, accompanied by awareness-raising, staff training and auditing. The aim of this study was to understand the determinants of nurses’ hand hygiene decisions, using an extension of a common health decision-making model, the theory of planned behaviour (TPB), to inform future health education strategies to increase compliance. Nurses from 50 Australian hospitals (n = 2378) completed standard TPB measures (attitude, subjective norm, perceived behavioural control [PBC], intention) and the extended variables of group norm, risk perceptions (susceptibility, severity) and knowledge (subjective, objective) at Time 1, while a sub-sample (n = 797) reported their hand hygiene behaviour 2 weeks later. Regression analyses identified subjective norm, PBC, group norm, subjective knowledge and risk susceptibility as the significant predictors of nurses’ hand hygiene intentions, with intention and PBC predicting their compliance behaviour. Rather than targeting attitudes which are already very favourable among nurses, health education strategies should focus on normative influences and perceptions of control and risk in efforts to encourage hand hygiene adherence.

Autographed portrait of Martin Buber Portraits; Men

Handwritten dedication: Robert Weltsch in herzlicher Gesinnung MB

Studio Portrait of Elizabeth, Kurt and Hal Godshaw (Gottschalk).

From left to right: Elizabeth, Kurt, Hal Godshaw

Elizabeth Engel nee Benjamin-Rasmussen in her home; Silver Springs, Maryland Portraits Women

Digital Image

Elizabeth Engel nee Benjamin-Rasmussen with her daughter Dorel Hall nee Engel in Elizabeth's home; Silver Springs, Maryland Portraits Family

Digital Image

Hans Krakauer and Elizabeth Krakauer nee Gottschalk; Boston, New York. Portraits Couples

Photograph taken in front of the house in Boston, in upstate New York outside of Buffalo, where in 1939 they set up their private medical practice. After WWII, they built a new house next door.

Wedding portrait of Hans Krakauer and Elizabeth Godshaw (Gottschalk); Hannover, Germany. Portraits Couples

In the apartment on Ruemkorffstrasse that the Gottschalks occupied after being forced to sell their house.

Elizabeth Krakauer nee Gottschalk seated in a Oberprima (high school) chemistry laboratory; Sophienschule; Hannover, Germany.

This picture was taken during her last year of high school. The chemistry teacher, Professor Schmigielski was one of Elizabeth's favorite teachers.

Portrait of Elizabeth Krakauer nee Gottschalk with pigtails; Hannover, Germany.

This portrait shows Elizabeth with pig tails. In a defiant mood, she cut them off.

Freddy, Ursula, Elizabeth, Hal, Walter, and Kurt Gottschalk sharing a bed with their parents.

From left to right: Fred Gottschalk, grandma, Ursula Gottschalk, Elizabeth Gottschalk, grandpa, Hal Gottschalk, Walter Gottschalk, and Kurt Gottschalk