The European Journal of Public Health Advance Access originally published online on June 3, 2006
The European Journal of Public Health 2007 17(1):80-85; doi:10.1093/eurpub/ckl072
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International perspectives |
The burden of disease and injury in Serbia
Slavenka Jankovi
1,
Hristina Vlajinac1,
Vesna Bjegovi2,
Jelena Marinkovi3,
Sandra 
ipeti-Gruji
i1,
Ljiljana Markovi-Deni1,
Nikola Kocev3,
Milena antri-Milievi2,
Zorica Terzi-upi2,
Nata
a Maksimovi1 and
Ulrich Laaser4
1 Institute of Epidemiology, School of Medicine, University of Belgrade Serbia and Montenegro
2 Institute of Social Medicine, School of Medicine, University of Belgrade Serbia and Montenegro
3 Institute of Medical Statistics and Informatics, School of Medicine, University of Belgrade Serbia and Montenegro
4 Section for International Public Health, Faculty of Health Sciences University of Bielefeld, Germany
Correspondence: Prof Slavenka Jankovi, MD, MSc, PhD, Institute of Epidemiology, School of Medicine, Viegradska 26, 11000 Belgrade, Serbia and Montenegro, e-mail: slavenka{at}eunet.yu
Received August 22, 2005, accepted May 4, 2006
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Abstract |
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Background: In the last decade of the 20th century, a considerable effort has been put into the development of summary measures of population health that combine information on mortality and non-fatal health outcomes. We used the DALYs (Disability adjusted life years) method to assess the burden of disease and injury in the population of Serbia. Methods: Our study, largely based on the methods developed for the Global burden of disease study, was conducted between October 2002 and September 2003. DALYs, stratified by gender and age, were calculated for 18 selected health conditions for the population of Serbia, Serbia and Montenegro for 2000. Years of life lost (YLL) were calculated using country mortality statistics, while years lived with disability (YLD) were calculated using different sources of information. Also, the YLD/YYL ratio and age-adjusted rates of DALYs were calculated. Results: Ischaemic heart disease, cerebrovascular diseases, lung cancer, unipolar depressive disorders, and diabetes mellitus were responsible for almost two-thirds (70%) of the total burden of 18 selected disorders in Serbia 2000. The leading five causes for males were ischaemic heart disease (26.1 DALY per 1000), stroke (17.9), lung cancer (12.7), road traffic accidents (6.5), and self-inflicted injuries (5.5). For females, the leading five causes were stroke (18.1 DALY per 1000), ischaemic heart disease (14.1), depression (8.7), breast cancer (6.1), and diabetes mellitus (5.2). Conclusions: The final results of the study have shown that the national health priority areas should cover cardiovascular diseases, cancers, and mental health.
Keywords: burden of disease study, DALY, YLD, YLL, Serbia
Traditionally, mortality-based indicators such as life expectancy and infant mortality have been used to measure changes in the health status of a population. In a ‘mild low mortality society’ [measured by child mortality under 5 years of age and adult 15–59 years mortality, for World Health Organization's (WHO's) member states], such as Serbia, deaths have become increasingly concentrated into old age. This made mortality data less informative about health at earlier stages of the life cycle. Also, with the majority of the population living into old age and so increasingly at risk of chronic disease and disability, the need for information on quality as well as quantity of life has become more pressing.1 In addition, given the obvious incongruence between available resources and technological as well as human potential in health care, the setting of priorities for investment in health is mandatory in all societies. This is likely to lead to demands for more reliable and useful evidence about population health problems, and for affordable and effective measures to address them.2
In the last decade of the 20th century, a considerable effort has been put into the development of summary measures of population health that combine information on mortality and non-fatal health outcomes. In 1993, the Harvard School of Public Health in collaboration with The World Bank and WHO assessed the global burden of disease (GBD).3 Aside from generating the most comprehensive and consistent set of estimates of mortality and morbidity by age, sex, and region ever produced, GBD study also introduced a new metric—disability adjusted life year (DALY)—to quantify the burden of disease and to compare disease burden across a range of diseases, injuries, and risk factors.4 The use of DALY allows researchers to combine in a single indicator years of life lost (YLL) from premature death and years of ‘healthy’ life lost because of illness and disabilities [years lived with disability (YLD)].4,5
With the publication of the original GBD study (1993–1996), there was immediate interest in applying the methods in countries. Since 1993, when the study in Andhra Pradesh in India started,6 a number of national burden of disease studies (NBS) have been undertaken.7,8
Population of Serbia experienced many social and economic threats during 1990s. Years of life under severe stress and trauma-ridden environment have brought depression and hopelessness, followed by general negligence towards health and increased risk behaviour. During the last decade of the 20th century, the health status of the population of Serbia was harmfully influenced by numerous factors, but especially by the general situation in the country (the long-lasting economic crisis, the consequences of war in the surrounding countries and in Serbia as well, wide range of economic and diplomatic sanctions).9–11
We used the DALY method to assess the burden of disease and injury in the population of Serbia, Serbia and Montenegro, for 2000 year. As well we discuss the relative importance of specific health problems and the relevance of these findings for the future health strategy in Serbia.
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Methods |
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The Serbian burden of disease study (SBDS) was conducted between October 2002 and September 2003. It is largely based on the methods developed for the GBD study.12 The method allows the quantification of all states of ill health into a universal indicator, DALY. The reference year for the analysis was 2000. Kosovo and Metohia were not included in the study because relevant data for this part of Serbia were not available for the period observed.
Disease selecton and staging
Eighteen diseases were selected which covered a range of severity and different dimensions of disability and were relevant for the Serbian situation. Factors influencing restriction of total burden estimates in SBDS on 18 diseases and injuries were relatively short study period, results of other NBS, share of selected disorders in total mortality in Serbia, and availability and reliability of data. Each condition was subdivided into stages with respect to functional health status, treatment, and prognosis, validated by clinical experts. Over 100 stages or sequelae were included.
Social value choices
Disability weights. In the absence of Serbia specific values (social preferences for health states), SBDS 2000 project adopted GBD 1990/2000 health state valuation results expressed in the form of disability weights.12,13 Only for some conditions we used Duch weights (e.g. for HIV/AIDS and sense organ disorders).14
Discounting. As in the GBD study and other national studies, both undiscounted and discounted (3% per year) DALYs were calculated. Only discounted data are presented in this article to allow international comparisons.
Age weighting. A GBD study weighted a year of healthy life lived at young ages lower than for others ages. This choice was based on a number of studies that have indicated there is a broad social preference to value a year lived by a young adult more highly than a year lived by young child or at older ages.12 Because the influence of age weighting on the ranking of conditions is not very great and the latter are controversial in literature, we have decided to use it for comparison with other studies. Recommended values of C = 0.1658 and ß = 0.04 were applied.
Mortality data
We collected mortality data for selected conditions for 2000, from the Serbian Office of Statistics mortality database.
Disability data
For the majority of conditions, the numbers of incidence cases were available directly from disease registers, routine databases, or epidemiological studies,15–21 but for some conditions only prevalence data were available (e.g. for diabetes mellitus and sense organ disorders). Where sufficient Serbian data were not available to run the model, the incidence estimates developed in other studies were used, like for asthma, unipolar depression, and injuries.22
DALY estimation
DALYs were obtained from the addition of two components: YLL and YLD at the population level and thus reflect the burden of disease in population (DALY = YLL + YLD).
YLL were calculated by multiplying age-specific mortality rates by age-specific standard expected YLL and population numbers. Standard expected YLL were derived from the standard life table West 2623 with a life expectancy at birth of 82.5 years for women. Life table West 2524 for females was used for men with life expectancy at birth of 80 years.
For most conditions YLD were estimated by multiplying age-specific incidence rates by average duration of each incident case (or, more precisely, of the associated disability until death or recovery) and average disability weight. Only for diabetes mellitus and sense organ disorders YLD were calculated on the basis of prevalence. In some cases, a software program, DISMOD,25 was used to model disease incidence and duration from estimates of prevalence, remission, case fatality, and background mortality (e.g. for nephritis and nephrosis). To estimate YLD for each disease, the SBDS estimated the amount of time lived in each of the disease stages, severity levels, and with various sequelae. For most disease and injury groups experts were consulted during the development and revision of YLD estimates.
For comparisons between populations and over time, DALY rates per 1000 population were calculated and age-standardized by direct method, using WHO world population as standard.26,27As well we calculated YLD/YLL ratios.
Calculations were realized using STATISTICA, MORTPAK-LITE version 3.0/CP, NCSS, DISMOD II, Microsoft Excel, and @Risk.28
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Results |
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Figure 1 shows the YLL and YLD contributions to total DALYs for 18 selected conditions in Serbia. There were more relevant YLL for observed disorders than YLD (78% : 22%) with the exception of non-fatal health outcomes (unipolar major depression, vision and hearing loss), and low birth weight and asthma, the burden of which was mainly caused by lengthy period of disability. For HIV/AIDS contribution of YLL and YLD in DALYs was almost the same. These 18 selected conditions caused 484 995 YLLs or nearly 60% of the total mortality burden in Serbia.
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In 2000, there were 58 492 deaths from selected diseases and injuries in Serbia that contributed to 621 993 DALYs or 82 DALYs lost per 1000 population. Ischaemic heart disease, cerebrovascular diseases, lung cancer, unipolar major depression, and diabetes mellitus were responsible for almost two-thirds (70%) of the total burden of selected disorders (table 1).
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The DALY rates (crude and age-standardized) for men and women are shown in tables 2 and 3. Comparing health problems by gender, it appears that the burden of the majority of selected conditions was higher for males. The burden of breast cancer, depressive disorders, diabetes mellitus, and cerebrovascular diseases was higher for females, and the burden of vision and hearing loss was almost the same for both sexes. The leading five causes of DALYs for males in the Serbia were ischaemic heart disease (26.1 DALY per 1000), stroke (17.9 per 1000), lung cancer (12.7 per 1000), road traffic injuries (6.5 per 1000), and self-inflicted injuries (5.5 per 1000). For females, the leading five causes were stroke (18.1 per 1000), ischaemic heart disease (14.1 per 1000), depression (8.7 per 1000), breast cancer (6.1 per 1000), and diabetes mellitus (5.2 per 1000).
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The total male burden of selected health problems was 32% higher than the total female burden (94 per 1000 males and 71.4 per 1000 females). Non-fatal outcomes (YLD) were responsible for 20% of the male burden and for 25% of the female burden.
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Discussion |
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SBDS has been the first attempt to identify the most important health problems in the Republic of Serbia using DALY as a common metric, which combines information on both the impact of premature death and the impact of disability. The burden of non-fatal or low-fatality conditions such as depression, asthma, and vision and hearing loss, has been overlooked in an analysis based solely on mortality data.
Ranking of total burden in Serbia based on DALYs differ substantially from ranking based on the number of deaths only.28 In particular, it was found that unipolar major depression accounted for a substantial health burden that was not captured by mortality data alone. The DALYs rank order of road traffic accidents, and of all observed cancers, except the lung cancer, differed from the rank order of their contribution to deaths (see table 1). The greatest number of deaths and DALYs were attributed to chronic disease conditions that occur in adulthood. In terms of specific conditions, according to DALYs, the total burden in Serbia was highest for ischaemic heart disease, followed by cerebrovascular diseases, like in many other developed and developing countries.29–33 The biggest improvement in life expectancy at birth in 2000 in Serbia would occur with the elimination of ischaemic heart disease mortality in males (2.40 years) and elimination of cerebrovascular diseases in females (2.10 years).28 The DALY rate for ischaemic heart disease in Serbia was higher in comparison with the DALY rates in EURO regions (A, B, and C). The proportion of YLD in DALY for stroke in Serbia was half of that in EURO B. It was lower even when compared with EURO C.12 In addition to the obvious need for improvement of cerebrovascular disease primary prevention, such result calls for efforts to improve stroke therapy.
Among all cancers, which are selected for analysis, lung cancer was at the first place, followed by colorectal cancer. In overall rankings of selected diseases and injuries, lung cancer had third rank. The greatest proportion of lung cancer burden in Serbia was associated with use of tobacco: more than 80% of total DALYs attributable to lung cancer for males, and 90% for females.28 A comprehensive public health approach to tobacco control (prevention of the beginning of tobacco use and promotion of its cessation) as WHO proposed34 is an urgent need in Serbia. It must include young people and women and reach the entire population. The proportion of YLD in DALY for lung and stomach cancers in Serbia was similar to that estimated for the EURO region.13,35 For colorectal, breast, and cervical cancer, the proportion of YLD in DALY was lower even in comparison to EURO B and EURO C regions.13,35 This can be explained by the fact that possibility of early detection of mostly cervical and breast cancers has not been used sufficiently yet.
As one could expect, on the basis of the previous studies12,31,36 the SBDS found depression as the leading cause of non-fatal disease burden in Serbia 2000, and put it into priority area for policymakers and health care providers. Depressive disorders were the fourth leading cause of GBD in the year 2000, and they caused the large amount of non-fatal burden, accounting for almost 12% of total YLD worldwide.37,33 Depression, once considered to be of little importance to policymakers has now become an area of national concern.
SBDS showed that diabetes mellitus was in the fifth place in Serbia in 2000, although it was 20th leading cause of DALYs at the global level in the same year.38 The proportion of YLD in DALY is lower than in EURO region.38 The results obtained suggest that only an early diagnosis of the disease, adequate treatment, and continuous follow-up of diabetic patients may reduce early death from this condition and undesired complications contributing to burden of disease.
During the time available for SBDS no new data were collected, but rather use of existing resources was made. Although substantial efforts have been made to identify and use the best available information relating to each disease and injury category, and although wide consultations in the relevant fields have been undertaken, the estimates made in this study should be regarded as a subject of further refinement. In the course of undertaking this study, like in the other studies12,34 a number of methodological issues have emerged, which require further development and refinement in order to improve the validity and applicability of the DALY metric. One of the major areas where methods need to be improved is numerical valuation of health states. Although, for reasons of comparability between countries, it would be preferable to use internationally standardized disability weights, development of our own Serbian-specific disability weights, that reflect the preferences of Serbian population, will be desirable.
The analyses presented in this article provide a framework for completion of DALY estimates for all conditions that are not covered in SBDS; for more detailed analysis of particular conditions; for burden of disease estimates for subpopulations; and for analysis of the impact of risk factors and health determinants to inform health policymaking and priority setting. These first results can serve as baseline against which the future evolution of the health status of population in Serbia can be compared in a more complete way than using only mortality data.
The main limitation of this study is the lack of morbidity data for some diseases, which forced us to use estimates. The study points to the need for consistent long-term data collection, particularly for those conditions where mortality plays a minor part in the attributable disease burden. Agenda setting for the collection of epidemiological data is perhaps the most important issue to emerge from burden of disease estimation.39 In the absence of information from disease registers or notification systems, population health surveys should provide useful self-reported information on disabilities, impairments, and diseases, and they are urgently needed. The mental health of communities should be monitored by including mental health indicators in health information and reporting system. For a number of diseases a population-based epidemiological studies, particularly longitudinal ones, which can provide a wealth of information on the incidence, average duration, levels of severity, remission, and case fatality, should be very useful.
The SBDS is a first step towards exploring the usefulness of burden of disease methods for Serbia in providing information to assist in health planning and priority setting in the health sector. The results coming from the SBDS analysis are not only of relevance for the decision-makers in the government but also in all key institutions related to health. The DALYs measure is a promising tool to improve the capacity of public health professionals to assess population health and establish evidence-based decision-making in public health.
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Acknowledgments |
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This work was carried out as an European Union project funded by European Agency for Reconstruction (EAR), 2002–2003, and by the Ministry of Science and Ecology of Serbia, contract no. 101460, 2002–2005.
Conflict of interest: None declared.
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