Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time. We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden. In 2010, the three leading risk factors for global disease burden were high blood pressure (7·0% [95% uncertainty interval 6·2-7·7] of global DALYs), tobacco smoking including second-hand smoke (6·3% [5·5-7·0]), and alcohol use (5·5% [5·0-5·9]). In 1990, the leading risks were childhood underweight (7·9% [6·8-9·4]), household air pollution from solid fuels (HAP; 7·0% [5·6-8·3]), and tobacco smoking including second-hand smoke (6·1% [5·4-6·8]). Dietary risk factors and physical inactivity collectively accounted for 10·0% (95% UI 9·2-10·8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0·9% (0·4-1·6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania. Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children. Bill & Melinda Gates Foundation.

Jansen and colleagues explore the role of shared decision making in tackling inappropriate polypharmacy in older adults

Background: In response to the COVID-19 pandemic, telehealth has rapidly been adopted to deliver health care services around the world. To date, studies have not compared people’s experiences with telehealth services during the pandemic in Australia to their experiences with traditional in-person visits. Objective: This study aimed to compare participants’ perceptions of telehealth consults to their perceptions of traditional in-person visits and investigate whether people believe that telehealth services would be useful after the pandemic. Methods: A national, cross-sectional, community survey was conducted between June 5 and June 12, 2020 in Australia. In total, 1369 participants who were aged ≥18 years and lived in Australia were recruited via targeted advertisements on social media (ie, Facebook and Instagram). Participants responded to survey questions about their telehealth experience, which included a free-text response option. A generalized linear model was used to estimate the adjusted relative risks of having a poorer telehealth experience than a traditional in-person visit experience. Content analysis was performed to determine the reasons why telehealth experiences were worse than traditional in-person visit experiences. Results: Of the 596 telehealth users, the majority of respondents (n=369, 61.9%) stated that their telehealth experience was “just as good as” or “better than” their traditional in-person medical appointment experience. On average, respondents perceived that telehealth would be moderately useful to very useful for medical appointments after the COVID-19 pandemic ends (mean 3.67, SD 1.1). Being male (P=.007), having a history of both depression and anxiety (P=.016), and lower patient activation scores (ie, individuals’ willingness to take on the role of managing their health/health care) (P=.036) were significantly associated with a poor telehealth experience. In total, 6 overarching themes were identified from free-text responses for why participants’ telehealth experiences were poorer than their traditional in-person medical appointment experiences, as follows: communication is not as effective, limitations with technology, issues with obtaining prescriptions and pathology results, reduced confidence in their doctor, additional burden for complex care, and inability to be physically examined. Conclusions: Based on our sample’s responses, telehealth appointment experiences were comparable to traditional in-person medical appointment experiences. Telehealth may be worthwhile as a mode of health care delivery while the pandemic continues, and it may continue to be worthwhile after the pandemic.

Background: Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids. Methods: Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team. Results: Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy. Discussion: Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental “nudging” toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.

Background: Misinformation about COVID-19 is common and has been spreading rapidly across the globe through social media platforms and other information systems. Understanding what the public knows about COVID-19 and identifying beliefs based on misinformation can help shape effective public health communications to ensure efforts to reduce viral transmission are not undermined. Objective: This study aimed to investigate the prevalence and factors associated with COVID-19 misinformation in Australia and their changes over time. Methods: This prospective, longitudinal national survey was completed by adults (18 years and above) across April (n=4362), May (n=1882), and June (n=1369) 2020. Results: Stronger agreement with misinformation was associated with younger age, male gender, lower education level, and language other than English spoken at home (P<.01 for all). After controlling for these variables, misinformation beliefs were significantly associated (P<.001) with lower levels of digital health literacy, perceived threat of COVID-19, confidence in government, and trust in scientific institutions. Analyses of specific government-identified misinformation revealed 3 clusters: prevention (associated with male gender and younger age), causation (associated with lower education level and greater social disadvantage), and cure (associated with younger age). Lower institutional trust and greater rejection of official government accounts were associated with stronger agreement with COVID-19 misinformation. Conclusions: The findings of this study highlight important gaps in communication effectiveness, which must be addressed to ensure effective COVID-19 prevention.

Background: Decision aid developers have to convey complex task-specific numeric information in a way that minimizes bias and promotes understanding of the options available within a particular decision. Whereas our companion paper summarizes fundamental issues, this article focuses on more complex, task-specific aspects of presenting numeric information in patient decision aids. Methods: As part of the International Patient Decision Aids Standards third evidence update, we gathered an expert panel of 9 international experts who revised and expanded the topics covered in the 2013 review working in groups of 2 to 3 to update the evidence, based on their expertise and targeted searches of the literature. The full panel then reviewed and provided additional revisions, reaching consensus on the final version. Results: Five of the 10 topics addressed more complex task-specific issues. We found strong evidence for using independent event rates and/or incremental absolute risk differences for the effect size of test and screening outcomes. Simple visual formats can help to reduce common judgment biases and enhance comprehension but can be misleading if not well designed. Graph literacy can moderate the effectiveness of visual formats and hence should be considered in tool design. There is less evidence supporting the inclusion of personalized and interactive risk estimates. Discussion: More complex numeric information. such as the size of the benefits and harms for decision options, can be better understood by using incremental absolute risk differences alongside well-designed visual formats that consider the graph literacy of the intended audience. More research is needed into when and how to use personalized and/or interactive risk estimates because their complexity and accessibility may affect their feasibility in clinical practice.