One of my favorite courses during my Master's of Health Informatics has been Information Design and Visual Analytics. We learned basic principles of visual design, how to use Tableau for health data, and the importance of storytelling in communicating data. For my final project, I incorporated my work with World Spine Care while trying to make the massage accessible for a broader audience, not just healthcare workers.

Project Focus

Not enough attention is given to the burden of disability from low back and neck pain and the lack of public health funding to address these problems. Low back and neck pain are the leading cause of disability worldwide.¹ Yet, musculoskeletal pain, in general, is an overlooked cause of disability and does not receive funding commensurate with its impact on population health. I’ve highlighted the importance of these conditions and demonstrated the economic incongruity of the development assistance for health (DAH) funding.

Background

What comes to mind when you think of global health? For most people, it is the number of people dying from infectious diseases, such as malaria or HIV. They may also think of deaths from cancer or heart disease, especially if they have lost loved ones to these non-communicable diseases.

The tragedy is compounded when people die well before their life expectancy. Global health experts don’t just measure deaths but the years of life lost (YLLs) due to these conditions.

The suffering and disability patients experience before death can be overlooked. For days, weeks, months, and even years before succumbing to their illness, patients experience a significant decrease in their quality of life. This is measured as Years Lived with Disability (YLDs). Perhaps surprisingly, most disability does not arise from communicable diseases or chronic illness.

It can be challenging to compare conditions that cause both disability and death with conditions that are not deadly but have high levels of disability. To adjust for these differences, global health experts combined Years Lived with Disability with Years of Life Lost into a new metric called Disability-Adjusted Life Years (DALYs).² When we look at the top 10 causes of DALYs, we see the conditions we would expect – child illness, heart disease, stroke – but a few surprising causes begin to emerge. Traffic accidents, for instance, cause significant death and disability. Even more surprising, low back pain is the 9th leading cause of DALYs.

If we remove death as an outcome and look more closely at YLDs, we see that the leading cause of disability worldwide is low back pain. The number of people experiencing low back pain has steadily increased over the past 30 years, as has the associated disability.

An estimated 577 million people suffer from low back pain.³ Nearly 1 in 10 people worldwide suffer from low back pain at any given moment. Every year spinal conditions and back pain result in the loss of billions of dollars worldwide through health care costs, diminished individual income, and loss of productivity. The resulting pandemic of chronic spinal conditions compromises the quality of our lives and the vitality of our communities.

The Global Burden of Disease Study evaluates the impact of over 369 health conditions. In this report, the following information regarding spinal conditions was reported:⁴

Low back pain is the leading cause of disability.
Neck pain is the fourth leading cause of disability.
Low back pain and neck pain affect 1 billion people worldwide.
Spinal pain contributes more to the global disease burden (including death and disability) than HIV, diabetes, malaria, stroke, Alzheimer’s disease, breast and lung cancer combined, traffic injuries, and lower respiratory infections.

In 2017, the World Health Organization launched the Rehabilitation 2030 initiative, which calls for policymakers to address the causes of disability, including low back pain.⁵ The next year, a special series in The Lancet called low back pain “an urgent global public health concern.”⁶

Despite this, international funding for public health initiatives focuses heavily on communicable diseases. As of 2015, the most common communicable diseases (tuberculosis, malaria, HIV/AIDS, etc.) accounted for 868,024 Daily Adjusted Life Years (DALYs), while non-communicable diseases (NCDs), including back and neck pain, accounted for 1,343,396 DALYs. And yet, DAH funding for communicable diseases reached $36 billion, while total DAH funding for NCDs was only $475 million. There was no recorded DAH funding for back and neck pain.⁷

Comparing the amount of funding spent on each category of disease, dollar for DALY, communicable diseases are receiving over 100x the spending as non-communicable diseases. If we focus on disability as a metric of importance, low back pain is being neglected in global health funding.

Design Methods

I have focused on raising awareness in the persona of a general healthcare provider and layperson. To do this, I framed the problem using mental models they are familiar with (diseases causing death) while relating those to mental models used by public health officials (burden of disease).

Questions

Some questions have answered include:

What are the leading causes of death & disability worldwide?
How does the burden of disease from communicable diseases compare with non-communicable diseases, particularly low back pain?
What is the disease burden from low back pain, measured as Years Lived with Disability?
How much money is spent on communicable diseases vs. non-communicable diseases?
How much money is proportionally spent on each condition ($/DALYs)?

Value

These data visualizations are intended to raise awareness of the significant disease burden from low back pain and call people to action. By highlighting the need to address the prevention, treatment, and management of spine pain, I encourage providers to contribute to organizations and institutions focused on these conditions.

Data Collection

I downloaded datasets from the Global Health Data Exchange created by the Institute for Health Metrics and Evaluation.⁸ Datasets were imported into Tableau and filtered by the top ten leading causes of disability as measured by DALYs and YLDs. I chose to focus on the global numbers rather than comparing regions and countries.

I also extracted IHME data provided in the Financing Global Health reports to illustrate the amount of funding directed towards the larger categories of conditions.

Visualization

I used bar graphs for most of the visualizations because I was comparing similar categories. I also created line charts to show the change in data over time. I experimented with several ways to compare the large discrepancy in funding between categories, but the difference is so drastic it was very difficult to illustrate on one chart. The best option I found was a split bar chart.

An assignment earlier in the semester was creating an infographic to illustrate the highlights of the selected topic. I was introduced to the importance of selecting colors that accommodate vision impairments such as color blindness. There are a number of apps that will show what a given design will look like to people with various forms of color blindness. I used the open-source Sim Daltonism.
Reviewing this infographic now, there is already a lot that I would change. I had to make some concessions based on the assignment requirements which resulted in fonts that are too small. There are also some alignment issues, but generally I’m quite pleased. The technique I think provides the most value is reducing the need for chart legends by matching the **color of the variable** in the caption (e.g. prevalence of low back pain) with the **color of the line** on the chart.
Click to download the full infographic as a PDF. **CC BY-NC 4.0 DEED**

References

Hurwitz, E. L., Randhawa, K., Yu, H., Côté, P., & Haldeman, S. (2018). The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies. European Spine Journal, 66(S6), 75–801. ↩︎
World Bank. (1993). World Development Report 1993: Investing in Health. World Bank. ↩︎
Wu, A., March, L., Zheng, X., Huang, J., Wang, X., Zhao, J., et al. (2020). Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Annals of Translational Medicine, 8(6), 299–299. ↩︎
Vos, T., Lim, S. S., Abbafati, C., Abbas, K. M., Abbasi, M., Abbasifard, M., Abbasi-Kangevari, M., Abbastabar, H., Abd-Allah, F., Abdelalim, A., Abdollahi, M., Abdollahpour, I., Abolhassani, H., Aboyans, V., Abrams, E. M., Abreu, L. G., Abrigo, M. R. M., Abu-Raddad, L. J., Abushouk, A. I., … Murray, C. J. L. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: A systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396(10258), 1204–1222. ↩︎
World Health Organization. (2020). Rehabilitation 2030: A call for action: 6–7 February 2017, Executive Boardroom, WHO Headquarters, meeting report. World Health Organization. ↩︎
Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q. A., Ferreira, M. L., Genevay, S., Hoy, D., Karppinen, J., Pransky, G., Sieper, J., Smeets, R. J., & Underwood, M. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 1–12. ↩︎
Financing global health 2015. (2016). Institute of Health Metrics and Evaluation / University of Washington. ↩︎
Global health data exchange | ghdx. (n.d.). Retrieved January 29, 2023, from https://ghdx.healthdata.org/ ↩︎