Association between gender social norms and cardiovascular disease mortality and life expectancy: an ecological study.

OBJECTIVE: Examine the association between country-level gender social norms and (1) cardiovascular disease mortality rates; (2) female to male cardiovascular disease mortality ratios; and (3) life expectancy. DESIGN: Ecological study with the country as the unit of analysis. SETTING: Global, country-level data. PARTICIPANTS: Global population of countries with data available on gender social norms as measured by the Gender Social Norms Index (developed by the United Nations Development Programme). MAIN OUTCOME MEASURES: Country-level female and male age-standardised cardiovascular disease mortality rates, population age-standardised cardiovascular disease mortality rates, female to male cardiovascular disease mortality ratios, female and male life expectancy at birth. Outcome measure data were retrieved from the WHO and the Institute for Health Metrics and Evaluation. Multivariable linear regression models were fitted to explore the relationship between gender social norms and the outcome variables. RESULTS: Higher levels of biased gender social norms, as measured by the Gender Social Norms Index, were associated with higher female, male and population cardiovascular disease mortality rates in the multivariable models (ß 4.86, 95% CIs 3.18 to 6.54; ß 5.28, 95% CIs 3.42 to 7.15; ß 4.89, 95% CIs 3.18 to 6.60), and lower female and male life expectancy (ß -0.07, 95% CIs -0.11 to -0.03; ß -0.05, 95% CIs -0.10 to -0.01). These results included adjustment within the models for potentially confounding country-level factors including gross domestic product per capita, population mean years of schooling, physicians per 1000 population, year of Gender Social Norms Index data collection and maternal mortality ratio. CONCLUSIONS: Our analysis suggests that higher levels of biased gender social norms are associated with higher rates of population cardiovascular disease mortality and lower life expectancy for both sexes. Future research should explore this relationship further, to define its causal role and promote public health action.

Global burden of Clostridium difficile infections: a systematic review and meta-analysis.

BACKGROUND: Clostridium difficile is a leading cause of morbidity and mortality in several countries. However, there are limited evidence characterizing its role as a global public health problem. We conducted a systematic review to provide a comprehensive overview of C. difficile infections (CDI) rates. METHODS: Seven databases were searched (January 2016) to identify studies and surveillance reports published between 2005 and 2015 reporting CDI incidence rates. CDI incidence rates for health care facility-associated (HCF), hospital onset-health care facility-associated, medical or general intensive care unit (ICU), internal medicine (IM), long-term care facility (LTCF), and community-associated (CA) were extracted and standardized. Meta-analysis was conducted using a random effects model. RESULTS: 229 publications, with data from 41 countries, were included. The overall rate of HCF-CDI was 2.24 (95% confidence interval CI = 1.66-3.03) per 1000 admissions/y and 3.54 (95%CI = 3.19-3.92) per 10 000 patient-days/y. Estimated rates for CDI with onset in ICU or IM wards were 11.08 (95%CI = 7.19-17.08) and 10.80 (95%CI = 3.15-37.06) per 1000 admission/y, respectively. Rates for CA-CDI were lower: 0.55 (95%CI = 0.13-2.37) per 1000 admissions/y. CDI rates were generally higher in North America and among the elderly but similar rates were identified in other regions and age groups. CONCLUSIONS: Our review highlights the widespread burden of disease of C. difficile, evidence gaps, and the need for sustainable surveillance of CDI in the health care setting and the community.