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Where are the world’s disease patterns heading?: The challenges of epidemiological transition
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

INTRODUCTION: Epidemiological transition theory, first postulated by Omran in 1971, provides a useful framework for understanding cause-specific mortality changes and may contribute usefully to predictions about cause-specific mortality. However, understandings of mortality transitions and associated epidemiological changes remain poorly defined for public health practitioners due to lack of evidence from low- and middle-income countries. Therefore, understanding of the concept and development of epidemiological transition theory as well as population burden of premature mortality attributable to risk factors is needed.

OBJECTIVES: This thesis aims to understand how epidemiological transition theory has been applied in different contexts, using available evidence on mortality transitions from high, middle- and low- income countries, as well as the contribution of risk factors to mortality transitions, particularly for premature mortality.

METHODS: A Medline literature search from 1971 to 2013 was conducted to synthesise published evidence on mortality transition (paper I). A descriptive analysis of trends in cause of death using INDEPTH data was conducted, focusing on specific causes of death in 12 INDEPTH sites in Africa and Asia, using the INDEPTH 2013 standard population structure for appropriate comparisons across sites (paper II). A retrospective dynamic cohort database was constructed from Swedish population registers for the age range 30-69 years during 1991-2006, to measure reductions in premature non-communicable disease mortality using a life table method (paper III). Prospective cohort data from Västerbotten Intervention Programme from 1990 to 2006 were used to measure the magnitude of premature non-communicable disease mortality reductions associated with risk factor changes for each period of time (paper IV).

FINDINGS: There were changes in emphasis in research on epidemiological transition over the four decades from 1971 to 2013, from cause of death to wide-ranging aspects of the determinants of mortality with increasing research interests in low-and middle-income countries, with some unconsidered aspects of social determinants contributing to deviations from classic theoretical pathways. Mortality rates declined in most sites, with the annual reductions in premature adult mortality varied across INDEPTH sites, Sweden, which now is at late stage of epidemiological transition stage, achieved a 25% reduction in premature mortality during 1991-2006. Overall downward trends in risk factors have helped to reduce premature mortality in the population of Västerbotten County, but some benefits were offset by other increasing risks. The largest mortality changes accrued from reductions in smoking, hypertension and hypercholesterolaemia.

CONCLUSIONS: This thesis established patterns of current epidemiological transition in high, middle-and low-income countries (Asia and Africa), where the theory fits the transition patterns in some countries, but with some needs for further adjustments in other settings, as well as deviations from the classical ET theory in the last four decades. It highlights the need to identify the burden of mortality and morbidity, particularly for reducing mortality occurring before the age of 70 years and its attribution to risk factors, which are a major public health challenge. This informs shifting of public health priorities and resources towards prevention and control of chronic non-communicable disease risk factors.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2015. , 66 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1728
Keyword [en]
epidemiological transition, premature mortality, non-communicable disease, risk factors, Sweden, low-and middle-income countries, INDEPTH Network, Västerbotten Intervention Programme
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-103281ISBN: 978-91-7601-289-5 (print)OAI: oai:DiVA.org:umu-103281DiVA: diva2:812623
Public defence
2015-06-12, Room 135, Family Medicine, Umeå University Hospital, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2015-05-22 Created: 2015-05-19 Last updated: 2015-05-22Bibliographically approved
List of papers
1. The development and experience of epidemiological transition theory over four decades: a systematic review
Open this publication in new window or tab >>The development and experience of epidemiological transition theory over four decades: a systematic review
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2014 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, 23574Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Epidemiological transition (ET) theory, first postulated in 1971, has developed alongside changes in population structures over time. However, understandings of mortality transitions and associated epidemiological changes remain poorly defined for public health practitioners. Here, we review the concept and development of ET theory, contextualising this in empirical evidence, which variously supports and contradicts the original theoretical propositions.

DESIGN: A Medline literature search covering publications over four decades, from 1971 to 2013, was conducted. Studies were included if they assessed human populations, were original articles, focused on mortality and health or demographic or ET and were in English. The reference lists of the selected articles were checked for additional sources.

RESULTS: We found that there were changes in emphasis in the research field over the four decades. There was an increasing tendency to study wide-ranging aspects of the determinants of mortality, including risk factors, lifestyle changes, socio-economics, and macro factors such as climate change. Research on ET has focused increasingly on low- and middle-income countries rather than industrialised countries, despite its origins in industrialised countries. Countries have experienced different levels of progress in ET in terms of time, pace, and underlying mechanisms. Elements of ET are described for many countries, but observed transitions have not always followed pathways described in the original theory.

CONCLUSIONS: The classic ET theory largely neglected the critical role of social determinants, being largely a theoretical generalisation of mortality experience in some countries. This review shows increasing interest in ET all over the world but only partial concordance between established theory and empirical evidence. Empirical evidence suggests that some unconsidered aspects of social determinants contributed to deviations from classic theoretical pathways. A better-constructed, revised ET theory, with a stronger basis in evidence, is needed.

Place, publisher, year, edition, pages
CoAction Publishing, 2014
Keyword
epidemiological transition, demographic transition, mortality, social determinants
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-90531 (URN)10.3402/gha.v7.23574 (DOI)000336456100003 ()24848657 (PubMedID)
Note

Special Issue: Epidemiological Transitions – Beyond Omran’s Theory

Available from: 2014-06-24 Created: 2014-06-24 Last updated: 2017-12-05Bibliographically approved
2. Diverse empirical evidence on epidemiological transition in low- and middle-income countries: population-based findings from INDEPTH Network data
Open this publication in new window or tab >>Diverse empirical evidence on epidemiological transition in low- and middle-income countries: population-based findings from INDEPTH Network data
2016 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 5, e0155753Article in journal (Refereed) Published
Abstract [en]

Background Low-and middle-income countries are often described as being at intermediate stages of epidemiological transition, but there is little population-based data with reliable cause of death assignment to examine the situation in more detail. Non-communicable diseases are widely seen as a coming threat to population health, alongside receding burdens of infection. The INDEPTH Network has collected empirical population data in a number of health and demographic surveillance sites in low-and middle-income countries which permit more detailed examination of mortality trends over time.

Objective To examine cause-specific mortality trends across all ages at INDEPTH Network sites in Africa and Asia during the period 1992-2012. Emphasis is given to the 15-64 year age group, which is the main focus of concern around the impact of the HIV pandemic and emerging non-communicable disease threats.

Methods INDEPTH Network public domain data from 12 sites that each reported at least five years of cause-specific mortality data were used. Causes of death were attributed using standardised WHO verbal autopsy methods, and mortality rates were standardised for comparison using the INDEPTH standard population. Annual changes in mortality rates were calculated for each site.

Results A total of 96,255 deaths were observed during 9,487,418 person years at the 12 sites. Verbal autopsies were completed for 86,039 deaths (89.4%). There were substantial variations in mortality rates between sites and over time. HIV-related mortality played a major part at sites in eastern and southern Africa. Deaths in the age group 15-64 years accounted for 43% of overall mortality. Trends in mortality were generally downwards, in some cases quite rapidly so. The Bangladeshi sites reflected populations at later stages of transition than in Africa, and were largely free of the effects of HIV/AIDS.

Conclusions To some extent the patterns of epidemiological transition observed followed theoretical expectations, despite the impact of the HIV pandemic having a major effect in some locations. Trends towards lower overall mortality, driven by decreasing infections, were the general pattern. Low-and middle-income country populations appear to be in an era of rapid transition.

Keyword
mortality transition, premature mortality, non-communicable disease, low- and middle incom countries, INDEPTH Network
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-103276 (URN)10.1371/journal.pone.0155753 (DOI)000376282300065 ()
Available from: 2015-05-19 Created: 2015-05-19 Last updated: 2017-12-04Bibliographically approved
3. Achieving a 25% reduction in premature non-communicable disease mortality: the Swedish population as a cohort study
Open this publication in new window or tab >>Achieving a 25% reduction in premature non-communicable disease mortality: the Swedish population as a cohort study
2015 (English)In: BMC Medicine, ISSN 1741-7015, E-ISSN 1741-7015, Vol. 13, no 65Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The 2012 World Health Assembly set a target for Member States to reduce premature non-communicable disease (NCD) mortality by 25% over the period 2010 to 2025. This reflected concerns about increasing NCD mortality burdens among productive adults globally.

OBJECTIVES: We firstly considered whether the WHO target of a 25% reduction in the unconditional probability of dying between ages of 30 and 70 from NCDs (cardiovascular diseases, cancer, diabetes or chronic respiratory diseases) had already taken place in Sweden during an equivalent 15-year period. Secondly, we assessed which population sub-groups had been more or less successful in contributing to overall changes in premature NCD mortality in Sweden.

METHODS: A retrospective dynamic cohort database was constructed from Swedish population registers in the Linnaeus database, covering the entire population in the age range 30-69 years for the period 1991 to 2006, which was used directly to measure reductions in premature NCD mortality. Multivariate Poisson regression models were used to assess the contributions of individual background factors to decreases in premature NCD mortality.

RESULTS: A total of 292,320 deaths occurred in the 30-69 year age group during the period 1991 to 2006, against 70,768,848 person-years registered. The crude all-cause mortality rate declined from 5.03 to 3.72 per 1,000 person-years, a 26% reduction. Within this, the unconditional probability of dying between the ages of 30 and 70 from NCD causes as defined by WHO fell by 30.0%. Age was consistently the strongest determinant of NCD mortality. Background determinants of NCD mortality changed significantly over the four time periods 1991-1994, 1995-1998, 1999-2002 and 2003-2006.

CONCLUSIONS: Sweden, now at a late stage of epidemiological transition, has already exceeded the 25% premature NCD mortality reduction target during an earlier 15-year period. This should be encouraging news for countries currently implementing premature NCD mortality reduction programmes. Our findings suggest, however, that it may be difficult for Sweden and other late-transition countries to reach the current 25x25 target, particularly where substantial premature mortality reductions have already been achieved.

Keyword
non-communicable disease, mortality, Sweden, World Health Organization, 25x25 target
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-103028 (URN)10.1186/s12916-015-0313-8 (DOI)000352599700001 ()25889300 (PubMedID)
Available from: 2015-05-15 Created: 2015-05-15 Last updated: 2017-12-04Bibliographically approved
4. What kills middle-aged Swedes? Non-communicable disease risk factors and mortality in a prospective population cohort study
Open this publication in new window or tab >>What kills middle-aged Swedes? Non-communicable disease risk factors and mortality in a prospective population cohort study
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(English)Manuscript (preprint) (Other academic)
Keyword
non-communicable diseases, premature deaths, risk factors, population attributable risk, Västerbotten Intervention Program
National Category
Medical and Health Sciences
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-103272 (URN)
Available from: 2015-05-19 Created: 2015-05-19 Last updated: 2015-10-08Bibliographically approved

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