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Lebanon is in the midst of a rapidly escalating, unprecedented humanitarian crisis that is plunging the country deep into poverty and threatens population well-being, economic development, social welfare and national and regional stability. The dire situation is due to the compounding effects of the August 2020 Beirut blast, massive economic collapse and the COVID-19 pandemic, in a setting of longstanding entrenched political corruption and a dysfunctional, mismanaged crisis response by the state. This current emergency occurs on the background of a turbulent history and complex regional geopolitical context – including the Syrian refugee crisis, the ongoing influence of foreign actors and their local proxies, the United-States-imposed sanctions, endemic corruption, a culture of nepotism and entitlement among the political dynasties, dysfunctional power-sharing and deep-seated sectarian divides. With over half the population now living in poverty, a generation of children are among those at risk. This Perspective provides a brief overview of Lebanon's current complex humanitarian crisis, discusses the impacts of the evolving situation on youth and proposes a suite of recommendations to mitigate the effects.

Backgorund. While there has been a growth of research on health and the Syrian conflict, most such research covers Syrian refugees. There is limited information about the scope and focus of research on health and population inside Syria. While there are several systemtic and scoping literarure reviews of health of Syrian refugees, there has not been a sccoping review of research literature on health issues inside Syria. Methods. As part of a broader scoping review covering January 2011 to December 2019, we examined English-language conflict-related research papers that studied health issues inside Syria and focused on Syrians or those permanently resident in Syria. We classified research articles based on the major thematic areas studied. We abstracted bibliometric information, study characteristics, funding statements and reported key limitations and challenges of conducting research. To gain additional insights or data, we examined separately publications reporting field and operational activities as well as personal reflections and narrative accounts of first-hand experiences inside Syria. Results. Of 2,088 papers identified in the scoping review, 708 (34%) exclusively focus on health issues of Syrians inside Syria, of which 350 (49%) are conflict-related with. Of conflict-related publications, 89 (25%) are research papers. Annual volume of research increased over time, from one publication in 2013 to 27 publications in each of 2018 and 2019. Damascus is the most frequently studied governorate (n=33), followed by Aleppo (n=25). Papers used a wide range of research methodologies, primarily quantitative (n=68). The country of institutional affiliation(s) of first and last authors are Syria (n=30, 20 respectively), the United States (n=25, 19 respectively) or the United Kingdom (n=12, 10 respectively). Themes most covered were health status, health system and humanitarian assistance, response or needs (n=38, 32, 26 respectively). Thirty one publications presented field and operational activities and eight publications were reflections or first-hand personal accounts of experiences inside Syria. Authors encountered contextual, methodological and administrative challenges in doing research on health inside Syria. Conclusions. Although it is commonly stated that Syria is among the most documented of recent wars, our analysis shows that a relatively limited number of research studies focused on health or populations inside Syria have been published over the nine years of the conflict. Beyond the need to increase the volume of research, it is important to address the knowledge gaps identified in this review.

Rheumatic heart disease (RHD) is an avoidable disease of poverty that persists predominantly in low resource settings and among Indigenous and other high-risk populations in some high-income nations. Following a period of relative global policy inertia on RHD, recent years have seen a resurgence of research, policy and civil society activity to tackle RHD; this has culminated in growing momentum at the highest levels of global health diplomacy to definitively address this disease of disadvantage. RHD is inextricably entangled with the global development agenda, and effective RHD action requires concerted efforts both within and beyond the health policy sphere. This report provides an update on the contemporary global and regional policy landscapes relevant to RHD, and highlights the fundamental importance of good data to inform these policy dialogues, monitor systems responses and ensure that no one is left behind.

Background To assess the proportion of Australian Indigenous adults who require eye care services (separately among those with and without diabetes) and determine implications for eye care service planning. Design The National Indigenous Eye Health Survey (NIEHS) was a population-based study of 30 randomly selected geographical areas. Participants The NIEHS included 1189 Indigenous adults aged 40–80 years. Methods A standardized eye examination was performed. Main Outcome Measure The number requiring eye care services by diabetes status. Results Those with diabetes were older (median 53 years) than those without diabetes (median age 50 years), P

Type 2 diabetes prevalence is rising globally, and varies by socio-economic position. Amongst other factors, rising prevalence may reflect increasing incidence. Worldwide, few studies have examined population-level longitudinal trends in incident type 2 diabetes, and reports on secular trends in diabetes incidence by socio-economic measures such as educational attainment are lacking. Finland has a long-standing, comprehensive disease surveillance infrastructure. Using data collected over four decades from serial FINRISK surveys, the National Drug Reimbursement Register and the National Causes of Death Register, we examined secular trends in type 2 diabetes incidence in Finland from the 1970s to 2007. The diabetes status of 38,689 FINRISK participants aged 30–59 years at baseline assessment and without diagnosed diabetes at the time was followed for 10 years. Among men, incidence of diagnosed, pharmacologically managed type 2 diabetes increased over time. Compared with men surveyed in the 1970s, diabetes incidence was higher among men in the 1980s (adjusted HR 1.44, 95 % CI 1.13–1.84) and 1990s (adjusted HR 1.72, 1.32–2.24). Body mass index explained some, but not all of this variation. Increases occurred predominantly among men with low (adjusted HR 1980s: 2.07, 95 % CI 1.28–3.35; adjusted HR 1990s: 2.12, 95 % CI 1.28–3.53) and middle (adjusted HR 1980s: 1.30, 95 % CI 0.85–1.99; adjusted HR 1990s: 1.65, 95 % CI 1.05–2.60) educational attainment. No secular changes were apparent among women. This rising diabetes incidence among men over recent decades has occurred despite Finland’s sustained health promotion efforts. Renewed public health campaigns are urgently required. In addition to population-level initiatives, lower educational strata should be specifically targeted.

Some of the highest recorded rheumatic heart disease (RHD) prevalence and mortality rates are from the World Health Organization's Western Pacific Region (WPR). RHD burden has been well documented in much of the WPR subregion of Oceania, but less is known about RHD outside the Pacific Islands and Australasia. We aimed to review RHD burden in WPR outside Oceania to identify countries with high RHD burden and those with contemporary data gaps. We searched the peer-reviewed literature for English-language primary studies published between 1980 and April 2017 that reported RHD prevalence or mortality in the 13 WPR countries/areas outside Oceania, and Taiwan. We also searched for official government reports and health indicator documents. Results were synthesised narratively and reported stratified by 2015 Human Development Index (HDI) level. 30 peer-reviewed publications fulfilling inclusion criteria were identified, representing nine countries/areas. RHD prevalence and mortality have fallen in association with economic development, particularly in very high HDI countries. In several countries that have undergone recent economic development, RHD persists particularly among older populations. In poorer WPR countries there is a persistent RHD burden, including in young populations. Some countries had no available data. Although RHD burden has declined in many high-resource settings across the WPR, in several poorer countries, the impact of RHD appears to continue. Elsewhere, insufficient contemporary data make it difficult to gauge the current status of RHD burden and control. Concerted efforts are needed to fill information gaps and implement action to address this avoidable disease.

Aims Several socio-cultural and biomedical risk factors for gestational diabetes mellitus (GDM) are modifiable. However, few studies globally have examined socio-cultural associations. To eliminate confounding of increased risk of diabetes in subsequent pregnancies, elucidating socio-cultural associations requires examination only of first pregnancies. Methods Data for all women who delivered their first child in Victoria, Australia between 1999 and 2008 were extracted from the Victorian Perinatal Data Collection. Crude and adjusted GDM rates were calculated. Multivariate logistic regression was used to examine odds of GDM within and between socio-cultural groups. Results From 1999 to 2008, 269,682 women delivered their first child in Victoria. GDM complicated 11,763 (4.4%) pregnancies and burden increased with maternal age, from 2.1% among women aged below 25 years at delivery to 7.0% among those aged 35 years or more. Among younger women, GDM rates were relatively stable across socioeconomic levels. Amongst older women GDM rates were highest in those living in most deprived areas, with a strong social gradient. Asian-born mothers had highest GDM rates. All migrant groups except women born in North-West Europe had higher odds of GDM than Australian-born non-Indigenous women. In all ethnic groups, these differences were not pronounced among younger mothers, but became increasingly apparent amongst older women. Conclusions Socio-cultural disparities in GDM burden differ by maternal age at first delivery. Socio-cultural gradients were not evident among younger women. Health and social programs should seek to reduce the risk amongst all older women to that of the least deprived older mothers.

Objectives This paper reports secular trends in diabetes in pregnancy in Victoria, Australia and examines the effect of including or excluding women with pre-existing diabetes on gestational diabetes (GDM) prevalence estimates. Design Population-based observational study. Setting All births in Victoria, Australia between 1999 and 2008 Participants 634 932 pregnancies resulting in a birth registered with the Victorian Perinatal Data Collection Outcome measures Crude and age-standardised secular trends in pre-existing diabetes and GDM prevalence; secular GDM trends by maternal birthplace; effects on GDM prevalence of including and excluding pre-existing diabetes from the denominator. Results Of the 634 932 pregnancies, 2954 (0.5%) occurred in women with pre-existing diabetes and 29 147 (4.6%) were complicated by GDM. Mean maternal age increased from 29.7 years in 1999 to 30.8 years in 2008. GDM prevalence increased in most maternal age groups. In 2008, age-standardised GDM prevalence was 31% higher than in 1999; secular increases were greater for Australian-born non-Indigenous (29% increase) than immigrant women (12.3% increase). The annual number of pregnancies in women with pre-existing diabetes almost doubled from 1999 to 2008 and prevalence increased from 0.4% to 0.6%. However, including or excluding pre-existing diabetes had little effect on GDM prevalence estimates. Conclusions Pre-existing diabetes and GDM prevalence increased in Victoria between 1999 and 2008 and rising maternal age does not fully explain these trends. These findings have important implications for preventive initiatives. Including or excluding small numbers of women with pre-existing diabetes resulted in minimal changes in GDM estimates. As pre-existing diabetes in young women increases, this methodological issue will likely become important.

To assess the proportion of Australian Indigenous adults who require eye care services (separately among those with and without diabetes) and determine implications for eye care service planning.The National Indigenous Eye Health Survey (NIEHS) was a population-based study of 30 randomly selected geographical areas.The NIEHS included 1189 Indigenous adults aged 40-80 years.A standardized eye examination was performed.The number requiring eye care services by diabetes status.Those with diabetes were older (median 53 years) than those without diabetes (median age 50 years), P 0.001. The total estimated population-based need for annual eye care in the NIEHS population was 52% (n = 615), and of those 72% were people with diabetes. Among those with diabetes, 29% required further primary referral for diabetic retinopathy, 12% for cataract, 1% for trachomatous trichiasis and 5% for uncorrected distance refractive error. Among those without diabetes 13% required further primary referral for cataract, 0% for trachomatous trichiasis and 5% for uncorrected distance refractive error.This study has shown that among Indigenous adults, those with diabetes form 72% of those requiring an eye examination in any year. A key strategy to close the gap for vision for Australia's Indigenous population is to ensure those with diabetes undergo annual eye screening, have clearly defined care pathways and receive timely treatment. Establishing care pathways for those who have diabetes would also improve access to eye care services for others in the community.

Ethnicity influences health in many ways. For example, type 2 diabetes (T2DM) is disproportionately prevalent among certain ethnic groups. Assessing ethnicity is difficult, and numerous proxy measures are used to capture its various components. Australian guidelines specify a set of variables for measuring ethnicity, and how such parameters should be categorised. Using T2DM data collections as an illustrative example, this study sought to examine how ethnicity is measured in Australian health databases and, by comparing current practice with Australia's existing benchmark recommendations, to identify potential areas for improvement of the health data landscape.We identified databases containing information from which ethnic group-specific estimates of T2DM burden may be gleaned. For each database, details regarding ethnicity variables were extracted, and compared with the Australian guidelines.Data collection instruments for 32 relevant databases were reviewed. Birthplace was recorded in 27 databases (84%), but mode of birthplace assessment varied. Indigenous status was commonly recorded (78%, n=25), but only nine databases recorded other aspects of self-perceived race/ethnicity. Of 28 survey/audit databases, 14 accommodated linguistic preferences other than English, and 11 either excluded non-English speakers or those for whom a translator was not available, or only offered questionnaires in English.Considerable variation exists in the measurement of ethnicity in Australian health data-sets. While various markers of ethnicity provide complementary information about the ethnic profile within a data-set, non-uniform measurement renders comparison between data-sets difficult. A standardised approach is necessary, and identifying the ethnicity variables that are particularly relevant to the health sector is warranted. Including self-identified ethnicity in Australia's set of recommended indicators and as a core component of the national census should be considered. Globalisation and increasing migration mean that these findings have implications internationally, including for multi-ethnic countries throughout North America and Europe.

Background Physical activity (PA) surveillance is an important component of non-communicable disease risk factor monitoring, and occurs through national and international surveillance systems. This review identifies population PA estimates for adults in the Asia-Pacific region, and examines variation in trends and prevalence rates obtained using different PA measures. Methods Data were obtained from a MEDLINE search; World Health Organization's Global Health Infobase; Government websites and reference lists of relevant papers. Inclusion criteria included: national studies or those reporting large scale population-level data; data published from 2000 to 2010 and trend data prior; sample sizes over n = 1000, or fewer subjects in small nations. Results In total, 56 population surveys from 29 Asia-Pacific countries were identified. Data on 'sufficient physical activity' amongst adults were available from 45 studies (80%), with estimates ranging from 7% to 93% (median 62%, inter-quartile range 40%-85%). For 14 countries, estimates of 'sufficient activity' were documented in multiple surveys using different methods, with the largest variation from 18% to 92% in Nepal. Median or mean MET-minutes/day, reported in 20 studies, ranged from 6 to 1356. Serial trend data were available for 11 countries (22%), for periods spanning 2-10 years. Of these, five countries demonstrated increases in physical activity over time, four demonstrated decreases and three showed no changes. Conclusions Many countries in the Asia-Pacific region collect population-level PA data. This review highlights differences in estimates within and between countries. Some differences may be real, others due to variation in the PA questions asked and survey methods used. Use of standardized protocols and measures, and combined reporting of data are essential goals of improved international PA surveillance.

Objective Military veterans experience a high prevalence of psychopathologies such as posttraumatic stress disorder (PTSD). Relationships between physical and psychological health are increasingly recognised. This study investigated associations between PTSD and hypertension in male Australian Gulf War veterans. Methods In 2000–02, 1456 veterans underwent medical and psychological assessments. Medical practitioners rated self-reported medical conditions as probable diagnoses, possible, unlikely or non-medical. The Composite International Diagnostic Interview (CIDI) assessed psychological symptomatology present in the 12 months preceding evaluation, and lifetime prevalence. Odds of hypertension among those with and without PTSD were calculated for each timeframe using logistic regression. Results Analysis was restricted to the 1381 veterans for whom CIDI and medical data were available. Hypertension was considered probable in 100 subjects (7.2%). Adjusted odds ratios of hypertension were 2.90 (95% CI 1.19–7.09) amongst veterans with PTSD in the past 12 months and 2.27 (95% CI 1.01–5.10) for lifetime prevalence, compared with those without PTSD. Hypertension was over seven times more likely amongst veterans with PTSD alone than those with no mental illness in the past 12 months. Conclusions Veterans with a history of PTSD had increased odds of having hypertension. Given the array of disabling psychosocial associations of PTSD, and the numerous potential clinical sequelae of hypertension, co-existence of these conditions may have implications for prevention and management at the individual, clinical, and public health policy and practice level. Early identification of PTSD in military samples may help to ameliorate longer-term adverse physical health outcomes.

Background Ethnic diversity is increasing through migration in many developed countries. Evidence indicates that type 2 diabetes mellitus (T2DM) prevalence varies by ethnicity and socio-economic status (SES), and that in many settings, migrants experience a disproportionate burden of disease compared with locally-born groups. Given Australia’s multicultural demography, we sought to identify groups at high risk of T2DM in Victoria, Australia. Methods Using population data from the Australian National Census and diabetes data from the National Diabetes Services Scheme, prevalence of T2DM among immigrant groups in Victoria in January 2010 was investigated, and prevalence odds versus Australian-born residents estimated. Distribution of T2DM by SES was also examined. Results Prevalence of diagnosed T2DM in Victoria was 4.1% (n = 98671) in men and 3.5% (n = 87608) in women. Of those with T2DM, over 1 in 5 born in Oceania and in Southern and Central Asia were aged under 50 years. For both men and women, odds of T2DM were higher for all migrant groups than the Australian-born reference population, including, after adjusting for age and SES, 6.3 and 7.2 times higher for men and women born in the Pacific Islands, respectively, and 5.2 and 5.0 times higher for men and women born in Southern and Central Asia, respectively. Effects of SES varied by region of birth. Conclusions Large socio-cultural differences exist in the distribution of T2DM. Across all socio-economic strata, all migrant groups have higher prevalence of T2DM than the Australian-born population. With increasing migration, this health gap potentially has implications for health service planning and delivery, policy and preventive efforts in Australia.