Avoidable Mortality in Paradise – a Benchmarking Descriptive Analysis of the UK Overseas Territory, Anguilla

Avoidable Mortality in Paradise – a Benchmarking Descriptive Analysis of the UK Overseas Territory, Anguilla | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Avoidable Mortality in Paradise – a Benchmarking Descriptive Analysis of the UK Overseas Territory, Anguilla Aisha Andrewin, Ward Schrooten This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7502165/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background: Avoidable mortality is widely recognized as an indicator of health systems performance, yet evidence from small island settings remains limited. This study was conducted to establish benchmarks in avoidable mortality and to elucidate areas for further investigation towards the improvement of health care services in Anguilla, a UK overseas territory (UKOT). Methods: The authors conducted a descriptive analysis of deaths in Anguilla, between 2010 and 2019. Using 2018 OECD/Eurostat definitions, deaths were considered avoidable if the underlying cause was preventable through public health intervention or amenable to optimal health care. Counts, proportions, and age-adjusted mortality rates were determined for avoidable, preventable and amenable deaths, disaggregated by age-group, gender and broad causal groups. Simple linear regression was conducted with year as the independent variable (x) and the raw (annual) counts as the dependent variable (y). Results: Almost 40% of deaths in Anguilla between 2010 and 2019 were avoidable. Cardiovascular diseases, external causes, cancers, diabetes, alcohol-related diseases collectively accounted for almost 80%. Seventy (70%) of avoidable deaths were males , mainly due to external causes, while neoplasms predominated among women. Avoidable deaths in children, mainly perinatal, averaged one per year and accounted for 7% of avoidable deaths. Age-standardized avoidable mortality was 310.5 per 100,000, exceeding UK (232.0) and OECD (255.0) rates. A significant increasing trend over time was observed (p=0.0005), with the sharpest rise following Hurricane Irma in 2017. The top five broad causal groups found in this study were the same as those of the Pan American Health Organization’s (PAHO) 2024 report on data from 2000 to 2019 for the Region of the Americas. The predominance of males in the avoidable mortality burden notably from preventable causes was also a similar finding. Conclusions: Avoidable deaths are high in Anguilla and males are more adversely affected. Gender disparities, gaps in the health system, and the other contributing factors need further study. Since data from this benchmarking analysis precedes the COVID-19 pandemic, it would be interesting to see the impact on avoidable deaths in future analyses and possible implications for investment in primary health care. Avoidable mortality Health system performance Small island states Anguilla Men’s health Figures Figure 1 Figure 2 Figure 3 Background Generating evidence to guide health priorities and action is often challenging for small island territories. First, small population numerators and denominators lead to inherently unstable rates and imprecise estimates which can fluctuate greatly from year to year. Additionally, these settings are often very limited in the resources required to manage data to an acceptable standard. This includes limited availability of data and the human resources required to devise and implement data management protocols and subsequently to collect, collate and perform the required analyses in a timely manner. On the other hand, mortality data tends to be available across contexts. Therefore, concepts involving the analysis of mortality data are not only feasible but can add to the body of evidence. Avoidable mortality refers to the combination of deaths that can be avoided through public health intervention (preventable) and deaths that can be avoided through optimal health care (amenable) ( 1 ). Additionally, some deaths are considered both preventable through public health interventions and amenable through effective and timely health care when they occur. e.g. ischemic heart diseases, colorectal cancer and breast cancer( 2 ). These concepts have been used by several high-income countries as measures of health system performance( 3 )( 4 )( 5 )( 6 ).. Indicators of avoidable mortality can also be used to herald health conditions that may warrant further investigation and address( 1 ). The objective of this research was to establish benchmarks in avoidable mortality for Anguilla as well as to elucidate areas for further investigation for potential improvement as relates to serving the health needs of the population. Anguilla is a democratic internally self-governing UK Overseas Territory (UKOT). The most northerly of the Leeward Islands, it is 35 square miles in area with a population of 13,572 according to the 2011 census( 7 ) and an estimated 2019 mid-year population of 18,000 ( 8 ). Anguilla is a popular tourism destination best known for its magnificent beaches and waters( 9 ). With regards to the underlying health determinants, the context is that of a high income, politically and socially stable country with favourable indicators in key areas such for literacy, education, water and sanitation( 10 ). Health care services are delivered mainly through the public sector and a small private sector. Between 2004 and 2024, the government purchased primary and limited secondary health care services for the public sector from a semiautonomous health authority while maintaining governance, policy and regulatory roles. Tertiary level services are sought overseas ( 11 ). Prior to 2017 when catastrophic Hurricane Irma impacted the island, health care infrastructure (public sector) consisted of one polyclinic, four health centres and a thirty-two bed hospital( 10 ). The hospital is the only institution on the island for emergencies, inpatient care and deliveries (births) ( 12 ). Health care infrastructure sustained major damage due to Hurricane Irma, the Category Five hurricane which hit the island in September of 2017( 13 ). However, through the support of the UK government, health infrastructure was not only restored by 2021, but underwent significant improvements including major infrastructural improvements to the hospital through which the number of hospital beds were increased to 48, an oxygen generating plant was installed and the establishment of molecular laboratory testing inclusive of COVID-19 and the construction of two modern, fit-for-purpose and disaster resilient polyclinics for the Central and Western district. Methods Descriptive analysis of avoidable deaths in Anguilla was conducted adopting the standard methodology used by the UK( 8 ) and OECD( 9 ) countries. The international avoidable mortality definition as developed in 2018 by the Organization for Economic Co-operation and Development (OECD) and Eurostat was used to determine avoidable mortality ( 14 ). This method, which has also been adopted by the Office for National Statistics, United Kingdom, uses the cutoff age of 75 years below which deaths are assessed as being preventable, amenable or both. The total avoidable deaths were the sum of preventable and amenable deaths. For deaths that were considered both preventable and amenable, a count of 0.5 was allocated to the respective counts. For example, a death from ischaemic heart disease would contribute 0.5 to the sum of amenable deaths and 0.5 the sum of preventable deaths. This approach also prevented double counting of the same death under each category. Registration of deaths and mortality coding and reporting is completely centralized and is managed by the Health Information Unit (HIU) of the Health Authority of Anguilla (HAA). This is the national mortality database. The International Classification of Diseases Version 10 (ICD-10), the coding system used, is also the coding system utilized by the Caribbean Public Health Agency (CARPHA). CARPHA is the regional public health institution that coordinates public health surveillance, including mortality surveillance, within the region. The HIU sends mortality data annually for validation by CARPHA. Mortality data from the entire island for the years 2010 to 2019 were included in this study. The descriptors used of avoidable, preventable and amenable deaths were counts, proportions and (indirect) age-adjusted mortality disaggregated by gender, five-year age groups and broad causal groups. The European 2013 standard( 15 ) population was utilized as the reference population for the age adjustment. The population structure for Anguilla was based on the 2011 housing and population census, the most recent population census. The ten-year averages for the population strata were provided to mitigate the inherent instability of statistical calculations involving small populations. Results Avoidable deaths account for almost 40% of deaths in Anguilla between 2010 and 2019, most of which are preventable A total of 776 deaths were recorded from 2010 to 2019. The underlying cause of death was missing for 17 deaths; 14 of these were in persons less than 75 years of age - and all were from the 2010–2014 interval. Applying a conservative approach, those deaths could not be assessed to determine if they were avoidable deaths; were treated as deaths that were not avoidable. This missing data represented 2.1% of deaths overall. In total 285 deaths, 36.7% of all deaths from 2010 to 2019, were identified as avoidable. Of these, 117 (41.1%) were preventable, 63 deaths (22.1%) were amenable and 105 (36.8%) were both amenable and preventable. Five broad causes account for almost 90% of avoidable deaths in Anguilla Five broad causes accounted for 245 of 285 avoidable deaths (86.0%) as follows: diseases of the circulatory system (N = 82; 28.9%), external causes (N = 75; 26.3%), neoplasms (N = 44, 15.4%), endocrine diseases (N = 32, 11.2%) and diseases of the digestive system (N = 12, 4.2%), which were mainly alcoholic liver disease (Table 1 ). Table 1 Avoidable Death Causes in Anguilla from 2010 to 2019 Disease group Condition N %Total Circulatory System Diseases 82 28.8 Cerebrovascular diseases 24 8.4 Hypertensive diseases 24 8.4 Ischaemic heart disease 14 4.9 Aortic aneuryms 7 2.5 Alcoholic cardiomyopathy 5 1.8 Venous thromboembolism 5 1.8 Other 3 1.1 External causes 75 26.3 Accidental injuries 37 13.0 Assault 15 5.3 Transport accidents 15 5.3 Undetermined intent 6 2.1 Patient care misadventures 2 0.7 Neoplasms 44 15.4 Colorectal cancer 9 3.2 Breast cancer 6 2.1 Cervical cancer 4 1.4 Lung cancer 4 1.4 Lip, oral cavity and pharynx cancer 4 1.4 Stomach cancer 4 1.4 Other cancers 13 4.6 Endocrine disorders 32 11.2 Diabetes 30 10.5 Thyroid disease 2 0.7 Diseases of the digestive system 12 4.2 Alcoholic liver diseases (including cirrhosis, hepatitis, hepatic failure…) 8 2.8 Ulcer/hernia 4 1.4 Perinatal conditions 10 3.5 Certain infectious and parasitic diseases 6 2.1 Mental and behavioural disorders 6 2.1 Alcohol-specific disorders and poisonings 6 2.1 Diseases of the nervous system 5 1.8 Diseases of the respiratory system 5 1.8 Congenital malformations, deformations and chromosomal abnormalities 4 1.4 Diseases of the genitourinary system 2 0.7 Pregnancy, childbirth and the puerperium 2 0.7 Total 285 100.0 Children and young people account for less than 10% of avoidable deaths and the leading cause is amenable Twenty-two (22) avoidable deaths were in children (persons less than nineteen years of age). This represented 7.7% of total avoidable deaths. Furthermore, 17 (77.2%) of avoidable deaths in children occurred in persons one year old or younger and the leading cause was perinatal conditions with 10 deaths (58.8% of avoidable deaths amongst children one year or younger). More than 70% of avoidable deaths were males and more than 40% of deaths among males were avoidable. In total, 208 avoidable deaths were males, representing 73% of total avoidable deaths and 44.2% of the total 471 male deaths for the period. Furthermore, 106 avoidable deaths among males were preventable (51.0%); 33 (were amenable 15.9%) and 69 were both preventable and amenable (33.2%). In comparison, 77 of avoidable deaths were females, representing 27% of avoidable deaths and 25.2% of the total 305 female deaths for the period. Moreover, among females 11 avoidable deaths (14.3%) were preventable; 30 were amenable (39.0%) and 36 (46.8%) were both preventable and amenable. External causes had the highest proportion of avoidable deaths for males, 68 (32.7%). In comparison, 7 (9.1%) avoidable deaths because of external causes were found among women (Fig. 1 ). For females, neoplasms with 22 (28.6%) avoidable deaths were the most frequent cause. Diseases of the circulatory system were the second leading cause for both sexes with 62 (29.8%) deaths for males and 20 (26.0%) for females. On most other categories, males tended to have a higher absolute number of avoidable deaths compared to females. There is an increasing trend in age-standardized mortality and a significant positive correlation between deaths and time as the years increase. Utilizing the 2013 European standard population as a reference, the age-standardized mortality rates for avoidable, amenable and preventable deaths respectively between 2010 to 2019 were 310.5, 132.5, 178.0, and per 100,000 inhabitants. The age-standardized mortality rates for the five leading causes (per hundred thousand population) were as follows: 207.5 for diseases of the circulatory system; 120.8 for external causes; 108.4 for neoplasms; 87.3 for endocrine diseases (mainly diabetes) and 27.0 for diseases of the digestive system (which were mainly alcohol-related liver disease). Additionally, the age-standardized avoidable mortality exhibited an increasing trend over the period (Fig. 2 ), with the greatest increase occurring between 2017 and 2018 Linear regression conducted on the raw counts (y variable) also exhibited a strong positive linear correlation between the raw death counts and time as the years increase (x variable) (p = 0.000533)(Fig. 3 ). Discussion Avoidable deaths accounted for almost 40% of mortality in Anguilla for the period between 2010 and 2019. Moreover, almost three quarters of avoidable deaths were males and male deaths were predominantly due to preventable causes- transport accidents, accidental injuries and assault. Additionally, the share of male deaths due to alcohol-related liver diseases in Anguilla, another preventable condition, was roughly eight times that as for females. On the other hand, women were predominantly affected by the non-communicable diseases (NCDs) including cardiovascular conditions, cancers and diabetes, which are considered both preventable and amenable. The same NCDs were also a leading cause for males and the proportion of deaths was similar for both genders. The avoidable disease burden for children was predominantly perinatal conditions which are considered amenable. The relatively large increase in avoidable mortality between 2017 and 2018 is hypothesized to be the result of the massive damage to health infrastructure caused by the passing of Hurricane Irma in late 2017. While there was one fatality in the direct aftermath of the storm, the impact on health care services and seeking behavior in the ensuing months has not been formally studied. This notwithstanding, however, the increasing trend in avoidable mortality over the entire period as corroborated by both the rates and the linear regression is concerning. The methodology adopted for this first-time analysis allows for interesting comparisons of Anguilla’s results as an overseas UK territory with those of the UK (as well was the OECD countries). The proportion of deaths that are avoidable in Anguilla is almost 1.8 times greater than “mainland” UK’s in 2019 of 22.5% of deaths and 1.6 times greater than that of the OECD countries in 2017 of 25%( 16 ). Similarly, Anguilla’s age standardized avoidable mortality rate of 310.5 per 100,000 was 1.3 times larger than UK’s rate of 232.0 and 1.2 times higher than the rate of the OECD countries of 255.0 deaths per 100,000 people for those reference years. One study comparing the Kingdom of the Netherlands to the Dutch Caribbean Islands of Aruba and Curacao also found gaps in amenable mortality compared with the Kingdom( 17 ). Alcohol-related deaths was a leading cause in Anguilla, the UK and the OECD countries. The predominance of males among avoidable deaths was a finding of the OECD report which indicated that preventable mortality rates were almost three times higher among men than among women (235 per 100 000 population for men, compared with 89 for women) while mortality rates from treatable causes were also nearly 40% higher among men than women. On the other hand, neoplasms had greater share of the avoidable disease burden in the UK and the OECD countries than for Anguilla. That finding may be, in part, a reflection of differences in risk factors such as tobacco smoking. For example, lung cancer is the leading cause of cancer deaths in the UK. On the other hand, lung cancer is not a leading cause of cancer deaths in Anguilla. Furthermore, the estimated prevalence of smoking in adults in Anguilla is less than 6% ( 20 ), compared to 13.5% and 18.2% for the UK and OECD countries respectively( 21 )(22). For children in Anguilla, the leading cause of deaths, which were perinatal conditions, amounted to 10 deaths within the 10-year period, averaging one death per year. Conversely, in the UK, most deaths in children and young people were due to injuries, with perinatal conditions being the second leading cause. An analysis conducted by the Pan American Health Organization (PAHO ) for the Region of the Americas, using the same age cutoff of 75 years, pointed out that the lists of causes for potentially avoidable premature deaths have varied over time and have been modified according to the context of the countries, their available medical technological advances, and the circumstances at the time of consolidating a list of causes( 18 ). The PAHO report does not include data from Anguilla and the other overseas territories. Furthermore, methodological differences (including a different reference population for the calculation of age-adjusted rates) preclude more direct and precise comparisons with the findings of this study. However, interesting observations can be made on the broad trends between that study and our findings. The PAHO study noted a general decreasing trend over time in avoidable mortality where this study found an increasing trend for Anguilla. However, in the PAHO study, the decrease included in communicable disease and child and maternal mortality which are not major contributors to avoidable death in Anguilla. Furthermore, the overall decline in avoidable mortality in the PAHO study was more evident for the Latin than for the non-Latin Caribbean countries like Anguilla. On the other hand, the top five broad causal groups were the same for both the PAHO study and this study with the Diseases of the Circulatory System and External Causes being the top two. The predominance of males in the avoidable mortality burden with preventable causes being the higher proportion was also a similar finding. The findings for the males are consistent with the increasing recognition of men’s health issues, particularly men’s premature mortality from violence, including homicides and injuries( 19 ). Similarly, data emerging from the Dutch and English-speaking Caribbean also corroborate the higher proportion of deaths for men compared to women due to injuries with as many as four times the number deaths. ( 20 ) The calculation of ten-year averages for mortality rates was employed to overcome a major challenge of dealing with data from small populations - potentially unstable rates and spurious findings. A major strength of the study is that mortality data in Anguilla gives complete population coverage and ensures the estimates are of high precision and representative of the underlying population at risk. Furthermore, the methodological approach is quite feasible, sustainable and is apt for settings where the resources for analysis are limited. Conclusions Avoidable deaths in Anguilla are high especially among men. The implications for men’s health in Anguilla are stark and point to an urgent need for further investigation into the risk factors as well as a myriad of services that will likely be needed to address complex issues that will likely be rooted in complex social factors. Notwithstanding the limited levels of health care services on the island, the findings also point of a need to elucidate the gaps in health care services that may be contributing to the deaths that are amenable to timely and adequate health care interventions. This study also adds to the insight of mortality of overseas territories as previous studies have been done both in Europe and the Americas, both with exclusion of overseas territories. The Organisation for Economic Co-operation and Development (OECD) created a new category in the definition of avoidable mortality in 2020 to include COVID-19 as a preventable cause of death( 14 ). This was done because COVID-19 can be avoided through effective public health and primary prevention interventions before its onset. Although data from this benchmarking analysis precede the COVID-19 pandemic, it would be interesting to see the impact on avoidable deaths and possible implications for investment in primary health care. Abbreviations CARPHA Caribbean Public Health Agency PAHO Pan American Health Organization NCD Non-communicable disease OECD Organisation for Economic Co-operation and Development UKOT United Kingdom Overseas Territory Declarations Acknowledgements We would like to thank the Health Information Unit of Department of Health Services (formerly the Health Authority of Anguilla) for providing the national mortality data for analysis. Authors’ Contributions AA and WS both conceptualized the study and jointly drafted the manuscript. WS took the lead on the data analysis while AA lead on manuscript revisions. Both authors approved the final version. Funding This study received no external funding. Availability of data and materials De-identified mortality data were available upon request to the Health Information Unit Ethics approval and consent to participate This study is a retrospective analysis of anonymized mortality data where no interventions on human subjects were performed. This article was written as part of a PhD project of AA who is affiliated with both Hasselt University and the Ministry of Health, Anguilla. Approval was obtained from the Committee for Medical Ethics, Faculty of Medicine and Life Sciences, Hasselt University – Reference No.CME2025/070 which also waived the need for consent to participate. This study complies with the ethical principles of the Declaration of Helsinki. Informed consent Consent for publication Not applicable. Competing interests The authors declare that there are no competing interests. References World Health Organization. WHO methods and data sources for global burden of disease estimates 2000–2016 [Internet]. 2018 [cited 2022 Nov 21]. Available from: https://www.who.int/publications-detail/gbd-methods-2000-2016 Olatunde O, Windsor-Shellard B. Revised definition of avoidable mortality. London: Office for National Statistics (UK); 2016. Andreev EM, Nolte E, Shkolnikov VM, Varavikova E, McKee M. The evolving pattern of avoidable mortality in Russia. Int J Epidemiol [Internet]. 2003 [cited 2019 May 13]; 32(3):437–46. Available from: https://academic.oup.com/ije/article-abstract/32/3/437/637110 Wheller L, Baker A, Griffiths C, Rooney C. Trends in avoidable mortality in England and Wales, 1993–2005 [Internet]. 2007 [cited 2019 May 12]. Available from: https://pdfs.semanticscholar.org/3790/eda37eca2c55ad1e35b061187a131cfc5425.pdf London NH. Avoidable deaths: falling in England; stalled in Scotland and Wales; rising in Northern Ireland [Internet]. 2019 [cited 2019 May 13]. Available from: http://group.bmj.com/group/rights-licensing/ Katikireddi SV, Cezard G, Bhopal RS, Williams L, Douglas A, Millard A, et al. Assessment of health care, hospital admissions, and mortality by ethnicity: population-based cohort study of health-system performance in Scotland. Lancet Public Health. 2018;3(5):e226–36. Eurostat. Amenable and preventable deaths statistics [Internet]. 2019 [cited 2019 May 8]. Available from: https://ec.europa.eu/eurostat/statistics-explained/index.php/Amenable_and_preventable_deaths_statistics Anguilla Statistics Department. Census 2011 – Vision statement press release: Preliminary census findings #6D How young are we? – Age structure and characteristics. 2011. Pan American Health Organization, World Health Organization. Health situation in the Americas: Core indicators 2018. Washington, D.C.: PAHO; 2018. Anguilla - Cultural life | Britannica [Internet]. 2022 [cited 2022 Nov 27]. Available from: https://www.britannica.com/place/Anguilla-island-West-Indies/Cultural-life Pan American Health Organization. Health in the Americas. 2017 Edition [Internet]. 2017 [cited 2022 Nov 27]. Available from: https://iris.paho.org/handle/10665.2/34321 Pan American Health Organization. Health in the Americas+, 2017 Edition: Summary: Regional outlook and country profiles. Washington, D.C.: PAHO; 2017. Andrewin A. Anguilla Health Profile 2018 - Report of the Chief Medical Officer. 2019. Government of Anguilla. Anguilla health recovery: Post-IRMA APM Award 2022 – Social Project of the Year. 2017. OECD E. Avoidable mortality: OECD/Eurostat lists of preventable and treatable causes of death (January 2022 version) [Internet]. 2022 [cited 2022 Feb 6]. Available from: https://www.oecd.org/health/health-systems/Avoidable-mortality-2019-Joint-OECD-Eurostat-List-preventable-treatable-causes-of-death.pdf Eurostat. 2013 edition revision of the European standard population: Report of Eurostat’s task force [Internet]. 2013 [cited 2022 Apr 13]. Available from: http://europa.eu Etienne CF. Addressing masculinity and men’s health to advance universal health and gender equality. Rev Panam Salud Publica [Internet]. 2018 [cited 2022 Nov 28];42. Available from: http://www.who.int/bulletin/ Caribbean Public Health Agency. Injuries and violence in the Caribbean: How big is the problem? In: Caribbean Public Health Agency: 60th Annual Scientific Meeting. Kingston: The University of the West Indies, Faculty of Medical Sciences. 2015. pp. 1–75. [Internet]. [cited 2022 Nov 28]. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/med-17912 OECD. Health at a Glance 2019 [Internet]. Paris: OECD. 2019 [cited 2022 Dec 1]. Available from: https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en Verstraeten SPA, van Oers HAM, Mackenbach JP. Contribution of amenable mortality to life expectancy differences between the Dutch Caribbean islands of Aruba and Curaçao and the Netherlands. Rev Panam Salud Publica. 2020;44:1–10. Pan American Health Organization. Health in the Americas: Potentially avoidable premature mortality. Washington, D.C.: PAHO. 2024. Available from: https://doi.org/10.37774/9789275127933 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 28 Oct, 2025 Reviewers invited by journal 28 Oct, 2025 Editor assigned by journal 23 Oct, 2025 Editor invited by journal 30 Sep, 2025 Submission checks completed at journal 29 Sep, 2025 First submitted to journal 29 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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10:17:20","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":61591,"visible":true,"origin":"","legend":"","description":"","filename":"b1724bca1dc946929ce3a7a54dc5efb91structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7502165/v1/e8cde984a94fed0000c27bcf.xml"},{"id":95528269,"identity":"78984208-7d87-4093-b52b-2088cde23128","added_by":"auto","created_at":"2025-11-10 10:15:48","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":67966,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7502165/v1/e4eda21eb3a5e82c31fd361c.html"},{"id":95501098,"identity":"a639b694-2bf4-4a4b-a0e4-53137175cd70","added_by":"auto","created_at":"2025-11-10 05:24:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":100580,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eProportionate mortality of leading causes of avoidable deaths 2010-2019, by sex\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7502165/v1/8ac8692be89f4c88d3279ee2.jpg"},{"id":95527929,"identity":"d9c760d2-d860-4089-8335-c8078f735b17","added_by":"auto","created_at":"2025-11-10 10:15:12","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":63835,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eAge-standardized Avoidable Mortality by Year and % of Total Avoidable Mortality for the Period 2010-2019\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7502165/v1/6e4df2e3d43b658bb53c9fc0.jpg"},{"id":95529078,"identity":"db3e625f-ea3d-4024-b5ce-79468c871541","added_by":"auto","created_at":"2025-11-10 10:16:46","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":41473,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eLinear regression on raw counts of avoidable deaths between 2010 and 2019\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7502165/v1/ad52359b531b2377a1e0ee58.jpg"},{"id":95531692,"identity":"c3137a55-5827-4972-8d04-fa63ab704ce2","added_by":"auto","created_at":"2025-11-10 10:23:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":843309,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7502165/v1/ba48c999-6574-4b31-9d37-c0b53be5a263.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Avoidable Mortality in Paradise – a Benchmarking Descriptive Analysis of the UK Overseas Territory, Anguilla","fulltext":[{"header":"Background","content":"\u003cp\u003eGenerating evidence to guide health priorities and action is often challenging for small island territories. First, small population numerators and denominators lead to inherently unstable rates and imprecise estimates which can fluctuate greatly from year to year. Additionally, these settings are often very limited in the resources required to manage data to an acceptable standard. This includes limited availability of data and the human resources required to devise and implement data management protocols and subsequently to collect, collate and perform the required analyses in a timely manner.\u003c/p\u003e\u003cp\u003eOn the other hand, mortality data tends to be available across contexts. Therefore, concepts involving the analysis of mortality data are not only feasible but can add to the body of evidence.\u003c/p\u003e\u003cp\u003eAvoidable mortality refers to the combination of deaths that can be avoided through public health intervention (preventable) and deaths that can be avoided through optimal health care (amenable) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Additionally, some deaths are considered both preventable through public health interventions and amenable through effective and timely health care when they occur. e.g. ischemic heart diseases, colorectal cancer and breast cancer(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These concepts have been used by several high-income countries as measures of health system performance(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).. Indicators of avoidable mortality can also be used to herald health conditions that may warrant further investigation and address(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe objective of this research was to establish benchmarks in avoidable mortality for Anguilla as well as to elucidate areas for further investigation for potential improvement as relates to serving the health needs of the population.\u003c/p\u003e\u003cp\u003eAnguilla is a democratic internally self-governing UK Overseas Territory (UKOT). The most northerly of the Leeward Islands, it is 35 square miles in area with a population of 13,572 according to the 2011 census(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) and an estimated 2019 mid-year population of 18,000 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Anguilla is a popular tourism destination best known for its magnificent beaches and waters(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). With regards to the underlying health determinants, the context is that of a high income, politically and socially stable country with favourable indicators in key areas such for literacy, education, water and sanitation(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Health care services are delivered mainly through the public sector and a small private sector. Between 2004 and 2024, the government purchased primary and limited secondary health care services for the public sector from a semiautonomous health authority while maintaining governance, policy and regulatory roles. Tertiary level services are sought overseas (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Prior to 2017 when catastrophic Hurricane Irma impacted the island, health care infrastructure (public sector) consisted of one polyclinic, four health centres and a thirty-two bed hospital(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The hospital is the only institution on the island for emergencies, inpatient care and deliveries (births) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Health care infrastructure sustained major damage due to Hurricane Irma, the Category Five hurricane which hit the island in September of 2017(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, through the support of the UK government, health infrastructure was not only restored by 2021, but underwent significant improvements including major infrastructural improvements to the hospital through which the number of hospital beds were increased to 48, an oxygen generating plant was installed and the establishment of molecular laboratory testing inclusive of COVID-19 and the construction of two modern, fit-for-purpose and disaster resilient polyclinics for the Central and Western district.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eDescriptive analysis of avoidable deaths in Anguilla was conducted adopting the standard methodology used by the UK(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and OECD(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) countries.\u003c/p\u003e\u003cp\u003eThe international avoidable mortality definition as developed in 2018 by the Organization for Economic Co-operation and Development (OECD) and Eurostat was used to determine avoidable mortality (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This method, which has also been adopted by the Office for National Statistics, United Kingdom, uses the cutoff age of 75 years below which deaths are assessed as being preventable, amenable or both. The total avoidable deaths were the sum of preventable and amenable deaths. For deaths that were considered both preventable and amenable, a count of 0.5 was allocated to the respective counts. For example, a death from ischaemic heart disease would contribute 0.5 to the sum of amenable deaths and 0.5 the sum of preventable deaths. This approach also prevented double counting of the same death under each category.\u003c/p\u003e\u003cp\u003eRegistration of deaths and mortality coding and reporting is completely centralized and is managed by the Health Information Unit (HIU) of the Health Authority of Anguilla (HAA). This is the national mortality database. The International Classification of Diseases Version 10 (ICD-10), the coding system used, is also the coding system utilized by the Caribbean Public Health Agency (CARPHA). CARPHA is the regional public health institution that coordinates public health surveillance, including mortality surveillance, within the region. The HIU sends mortality data annually for validation by CARPHA.\u003c/p\u003e\u003cp\u003eMortality data from the entire island for the years 2010 to 2019 were included in this study. The descriptors used of avoidable, preventable and amenable deaths were counts, proportions and (indirect) age-adjusted mortality disaggregated by gender, five-year age groups and broad causal groups. The European 2013 standard(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) population was utilized as the reference population for the age adjustment. The population structure for Anguilla was based on the 2011 housing and population census, the most recent population census. The ten-year averages for the population strata were provided to mitigate the inherent instability of statistical calculations involving small populations.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAvoidable deaths account for almost 40% of deaths in Anguilla between 2010 and 2019, most of which are preventable\u003c/p\u003e\u003cp\u003eA total of 776 deaths were recorded from 2010 to 2019. The underlying cause of death was missing for 17 deaths; 14 of these were in persons less than 75 years of age - and all were from the 2010\u0026ndash;2014 interval. Applying a conservative approach, those deaths could not be assessed to determine if they were avoidable deaths; were treated as deaths that were not avoidable. This missing data represented 2.1% of deaths overall.\u003c/p\u003e\u003cp\u003eIn total 285 deaths, 36.7% of all deaths from 2010 to 2019, were identified as avoidable. Of these, 117 (41.1%) were preventable, 63 deaths (22.1%) were amenable and 105 (36.8%) were both amenable and preventable.\u003c/p\u003e\u003cp\u003eFive broad causes account for almost 90% of avoidable deaths in Anguilla\u003c/p\u003e\u003cp\u003eFive broad causes accounted for 245 of 285 avoidable deaths (86.0%) as follows: diseases of the circulatory system (N\u0026thinsp;=\u0026thinsp;82; 28.9%), external causes (N\u0026thinsp;=\u0026thinsp;75; 26.3%), neoplasms (N\u0026thinsp;=\u0026thinsp;44, 15.4%), endocrine diseases (N\u0026thinsp;=\u0026thinsp;32, 11.2%) and diseases of the digestive system (N\u0026thinsp;=\u0026thinsp;12, 4.2%), which were mainly alcoholic liver disease (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAvoidable Death Causes in Anguilla from 2010 to 2019\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisease group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCondition\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%Total\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCirculatory System Diseases\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.8\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCerebrovascular diseases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHypertensive diseases\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIschaemic heart disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAortic aneuryms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAlcoholic cardiomyopathy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVenous thromboembolism\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExternal causes\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e75\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e26.3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAccidental injuries\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssault\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTransport accidents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUndetermined intent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatient care misadventures\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNeoplasms\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e44\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e15.4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eColorectal cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBreast cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCervical cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLung cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLip, oral cavity and pharynx cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStomach cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOther cancers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEndocrine disorders\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e32\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e11.2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThyroid disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiseases of the digestive system\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e12\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e4.2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAlcoholic liver diseases (including cirrhosis, hepatitis, hepatic failure\u0026hellip;)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUlcer/hernia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerinatal conditions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCertain infectious and parasitic diseases\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMental and behavioural disorders\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAlcohol-specific disorders and poisonings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiseases of the nervous system\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiseases of the respiratory system\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCongenital malformations, deformations and chromosomal abnormalities\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiseases of the genitourinary system\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePregnancy, childbirth and the puerperium\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e285\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eChildren and young people account for less than 10% of avoidable deaths and the leading cause is amenable\u003c/p\u003e\u003cp\u003eTwenty-two (22) avoidable deaths were in children (persons less than nineteen years of age). This represented 7.7% of total avoidable deaths. Furthermore, 17 (77.2%) of avoidable deaths in children occurred in persons one year old or younger and the leading cause was perinatal conditions with 10 deaths (58.8% of avoidable deaths amongst children one year or younger).\u003c/p\u003e\u003cp\u003eMore than 70% of avoidable deaths were males and more than 40% of deaths among males were avoidable.\u003c/p\u003e\u003cp\u003eIn total, 208 avoidable deaths were males, representing 73% of total avoidable deaths and 44.2% of the total 471 male deaths for the period. Furthermore, 106 avoidable deaths among males were preventable (51.0%); 33 (were amenable 15.9%) and 69 were both preventable and amenable (33.2%). In comparison, 77 of avoidable deaths were females, representing 27% of avoidable deaths and 25.2% of the total 305 female deaths for the period. Moreover, among females 11 avoidable deaths (14.3%) were preventable; 30 were amenable (39.0%) and 36 (46.8%) were both preventable and amenable.\u003c/p\u003e\u003cp\u003eExternal causes had the highest proportion of avoidable deaths for males, 68 (32.7%). In comparison, 7 (9.1%) avoidable deaths because of external causes were found among women (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). For females, neoplasms with 22 (28.6%) avoidable deaths were the most frequent cause. Diseases of the circulatory system were the second leading cause for both sexes with 62 (29.8%) deaths for males and 20 (26.0%) for females. On most other categories, males tended to have a higher absolute number of avoidable deaths compared to females.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThere is an increasing trend in age-standardized mortality and a significant positive correlation between deaths and time as the years increase.\u003c/p\u003e\u003cp\u003eUtilizing the 2013 European standard population as a reference, the age-standardized mortality rates for avoidable, amenable and preventable deaths respectively between 2010 to 2019 were 310.5, 132.5, 178.0, and per 100,000 inhabitants.\u003c/p\u003e\u003cp\u003eThe age-standardized mortality rates for the five leading causes (per hundred thousand population) were as follows: 207.5 for diseases of the circulatory system; 120.8 for external causes; 108.4 for neoplasms; 87.3 for endocrine diseases (mainly diabetes) and 27.0 for diseases of the digestive system (which were mainly alcohol-related liver disease).\u003c/p\u003e\u003cp\u003eAdditionally, the age-standardized avoidable mortality exhibited an increasing trend over the period (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), with the greatest increase occurring between 2017 and 2018\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eLinear regression conducted on the raw counts (y variable) also exhibited a strong positive linear correlation between the raw death counts and time as the years increase (x variable) (p\u0026thinsp;=\u0026thinsp;0.000533)(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAvoidable deaths accounted for almost 40% of mortality in Anguilla for the period between 2010 and 2019.\u003c/p\u003e\u003cp\u003eMoreover, almost three quarters of avoidable deaths were males and male deaths were predominantly due to preventable causes- transport accidents, accidental injuries and assault. Additionally, the share of male deaths due to alcohol-related liver diseases in Anguilla, another preventable condition, was roughly eight times that as for females. On the other hand, women were predominantly affected by the non-communicable diseases (NCDs) including cardiovascular conditions, cancers and diabetes, which are considered both preventable and amenable. The same NCDs were also a leading cause for males and the proportion of deaths was similar for both genders. The avoidable disease burden for children was predominantly perinatal conditions which are considered amenable.\u003c/p\u003e\u003cp\u003eThe relatively large increase in avoidable mortality between 2017 and 2018 is hypothesized to be the result of the massive damage to health infrastructure caused by the passing of Hurricane Irma in late 2017. While there was one fatality in the direct aftermath of the storm, the impact on health care services and seeking behavior in the ensuing months has not been formally studied. This notwithstanding, however, the increasing trend in avoidable mortality over the entire period as corroborated by both the rates and the linear regression is concerning.\u003c/p\u003e\u003cp\u003eThe methodology adopted for this first-time analysis allows for interesting comparisons of Anguilla\u0026rsquo;s results as an overseas UK territory with those of the UK (as well was the OECD countries). The proportion of deaths that are avoidable in Anguilla is almost 1.8 times greater than \u0026ldquo;mainland\u0026rdquo; UK\u0026rsquo;s in 2019 of 22.5% of deaths and 1.6 times greater than that of the OECD countries in 2017 of 25%(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Similarly, Anguilla\u0026rsquo;s age standardized avoidable mortality rate of 310.5 per 100,000 was 1.3 times larger than UK\u0026rsquo;s rate of 232.0 and 1.2 times higher than the rate of the OECD countries of 255.0 deaths per 100,000 people for those reference years. One study comparing the Kingdom of the Netherlands to the Dutch Caribbean Islands of Aruba and Curacao also found gaps in amenable mortality compared with the Kingdom(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlcohol-related deaths was a leading cause in Anguilla, the UK and the OECD countries. The predominance of males among avoidable deaths was a finding of the OECD report which indicated that preventable mortality rates were almost three times higher among men than among women (235 per 100 000 population for men, compared with 89 for women) while mortality rates from treatable causes were also nearly 40% higher among men than women.\u003c/p\u003e\u003cp\u003eOn the other hand, neoplasms had greater share of the avoidable disease burden in the UK and the OECD countries than for Anguilla. That finding may be, in part, a reflection of differences in risk factors such as tobacco smoking. For example, lung cancer is the leading cause of cancer deaths in the UK. On the other hand, lung cancer is not a leading cause of cancer deaths in Anguilla. Furthermore, the estimated prevalence of smoking in adults in Anguilla is less than 6% (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), compared to 13.5% and 18.2% for the UK and OECD countries respectively(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)(22).\u003c/p\u003e\u003cp\u003eFor children in Anguilla, the leading cause of deaths, which were perinatal conditions, amounted to 10 deaths within the 10-year period, averaging one death per year. Conversely, in the UK, most deaths in children and young people were due to injuries, with perinatal conditions being the second leading cause.\u003c/p\u003e\u003cp\u003eAn analysis conducted by the Pan American Health Organization (PAHO ) for the Region of the Americas, using the same age cutoff of 75 years, pointed out that the lists of causes for potentially avoidable premature deaths have varied over time and have been modified according to the context of the countries, their available medical technological advances, and the circumstances at the time of consolidating a list of causes(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The PAHO report does not include data from Anguilla and the other overseas territories. Furthermore, methodological differences (including a different reference population for the calculation of age-adjusted rates) preclude more direct and precise comparisons with the findings of this study. However, interesting observations can be made on the broad trends between that study and our findings. The PAHO study noted a general decreasing trend over time in avoidable mortality where this study found an increasing trend for Anguilla. However, in the PAHO study, the decrease included in communicable disease and child and maternal mortality which are not major contributors to avoidable death in Anguilla. Furthermore, the overall decline in avoidable mortality in the PAHO study was more evident for the Latin than for the non-Latin Caribbean countries like Anguilla.\u003c/p\u003e\u003cp\u003eOn the other hand, the top five broad causal groups were the same for both the PAHO study and this study with the Diseases of the Circulatory System and External Causes being the top two.\u003c/p\u003e\u003cp\u003eThe predominance of males in the avoidable mortality burden with preventable causes being the higher proportion was also a similar finding. The findings for the males are consistent with the increasing recognition of men\u0026rsquo;s health issues, particularly men\u0026rsquo;s premature mortality from violence, including homicides and injuries(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Similarly, data emerging from the Dutch and English-speaking Caribbean also corroborate the higher proportion of deaths for men compared to women due to injuries with as many as four times the number deaths. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe calculation of ten-year averages for mortality rates was employed to overcome a major challenge of dealing with data from small populations - potentially unstable rates and spurious findings.\u003c/p\u003e\u003cp\u003eA major strength of the study is that mortality data in Anguilla gives complete population coverage and ensures the estimates are of high precision and representative of the underlying population at risk. Furthermore, the methodological approach is quite feasible, sustainable and is apt for settings where the resources for analysis are limited.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAvoidable deaths in Anguilla are high especially among men. The implications for men\u0026rsquo;s health in Anguilla are stark and point to an urgent need for further investigation into the risk factors as well as a myriad of services that will likely be needed to address complex issues that will likely be rooted in complex social factors.\u003c/p\u003e\u003cp\u003eNotwithstanding the limited levels of health care services on the island, the findings also point of a need to elucidate the gaps in health care services that may be contributing to the deaths that are amenable to timely and adequate health care interventions.\u003c/p\u003e\u003cp\u003eThis study also adds to the insight of mortality of overseas territories as previous studies have been done both in Europe and the Americas, both with exclusion of overseas territories.\u003c/p\u003e\u003cp\u003eThe Organisation for Economic Co-operation and Development (OECD) created a new category in the definition of avoidable mortality in 2020 to include COVID-19 as a preventable cause of death(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This was done because COVID-19 can be avoided through effective public health and primary prevention interventions before its onset. Although data from this benchmarking analysis precede the COVID-19 pandemic, it would be interesting to see the impact on avoidable deaths and possible implications for investment in primary health care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCARPHA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCaribbean Public Health Agency\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePAHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePan American Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNCD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNon-communicable disease\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOECD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOrganisation for Economic Co-operation and Development\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUKOT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Kingdom Overseas Territory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe would like to thank the Health Information Unit of Department of Health Services (formerly the Health Authority of Anguilla) for providing the national mortality data for analysis.\u003c/p\u003e\n\u003cp\u003eAuthors’ Contributions\u003c/p\u003e\n\u003cp\u003eAA and WS both conceptualized the study and jointly drafted the manuscript. WS took the lead on the data analysis while AA lead on manuscript revisions. \u0026nbsp; Both authors approved the final version.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study received no external funding.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eDe-identified mortality data were available upon request to the Health Information Unit\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study is a retrospective analysis of anonymized mortality data where no interventions on human subjects were performed. This article was written as part of a PhD project of AA who is affiliated with both Hasselt University and the Ministry of Health, Anguilla. \u0026nbsp;Approval was obtained from the Committee for Medical Ethics, Faculty of Medicine and Life Sciences, Hasselt University – Reference No.CME2025/070 which also waived the need for consent to participate.\u003c/p\u003e\n\u003cp\u003eThis study complies with the ethical principles of the Declaration of Helsinki. Informed consent\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO methods and data sources for global burden of disease estimates 2000\u0026ndash;2016 [Internet]. 2018 [cited 2022 Nov 21]. 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Kingston: The University of the West Indies, Faculty of Medical Sciences. 2015. pp. 1\u0026ndash;75. [Internet]. [cited 2022 Nov 28]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pesquisa.bvsalud.org/portal/resource/pt/med-17912\u003c/span\u003e\u003cspan address=\"https://pesquisa.bvsalud.org/portal/resource/pt/med-17912\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOECD. Health at a Glance 2019 [Internet]. Paris: OECD. 2019 [cited 2022 Dec 1]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en\u003c/span\u003e\u003cspan address=\"https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2019_4dd50c09-en\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVerstraeten SPA, van Oers HAM, Mackenbach JP. Contribution of amenable mortality to life expectancy differences between the Dutch Caribbean islands of Aruba and Cura\u0026ccedil;ao and the Netherlands. Rev Panam Salud Publica. 2020;44:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePan American Health Organization. Health in the Americas: Potentially avoidable premature mortality. Washington, D.C.: PAHO. 2024. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.37774/9789275127933\u003c/span\u003e\u003cspan address=\"10.37774/9789275127933\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Avoidable mortality, Health system performance, Small island states, Anguilla, Men’s health","lastPublishedDoi":"10.21203/rs.3.rs-7502165/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7502165/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Avoidable mortality is widely recognized as an indicator of health systems performance, yet evidence from small island settings remains limited. This study was conducted to establish benchmarks in avoidable mortality and to elucidate areas for further investigation towards the improvement of health care services in Anguilla, a UK overseas territory (UKOT).\u003c/p\u003e\n\u003cp\u003eMethods: The authors conducted a descriptive analysis of deaths in Anguilla, between 2010 and 2019. Using 2018 OECD/Eurostat definitions, deaths were considered avoidable if the underlying cause was preventable through public health intervention or amenable to optimal health care. Counts, proportions, and age-adjusted mortality rates were determined for avoidable, preventable and amenable deaths, disaggregated by age-group, gender and broad causal groups. Simple linear regression was conducted with year as the independent variable (x) and the raw (annual) counts as the dependent variable (y).\u003c/p\u003e\n\u003cp\u003eResults: Almost 40% of deaths in Anguilla between 2010 and 2019 were avoidable. Cardiovascular diseases, external causes, cancers, diabetes, alcohol-related diseases collectively accounted for almost 80%. Seventy (70%) of avoidable deaths were males , mainly due to external causes, while neoplasms predominated among women. Avoidable deaths in children, mainly perinatal, averaged one per year and accounted for 7% of avoidable deaths. Age-standardized avoidable mortality was 310.5 per 100,000, exceeding UK (232.0) and OECD (255.0) rates. A significant increasing trend over time was observed (p=0.0005), with the sharpest rise following Hurricane Irma in 2017. The top five broad causal groups found in this study were the same as those of the Pan American Health Organization’s (PAHO) 2024 report on data from 2000 to 2019 for the Region of the Americas. The predominance of males in the avoidable mortality burden notably from preventable causes was also a similar finding. Conclusions: Avoidable deaths are high in Anguilla and males are more adversely affected. Gender disparities, gaps in the health system, and the other contributing factors need further study. Since data from this benchmarking analysis precedes the COVID-19 pandemic, it would be interesting to see the impact on avoidable deaths in future analyses and possible implications for investment in primary health care.\u003c/p\u003e","manuscriptTitle":"Avoidable Mortality in Paradise – a Benchmarking Descriptive Analysis of the UK Overseas Territory, Anguilla","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 05:24:26","doi":"10.21203/rs.3.rs-7502165/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"272580598898199567963487554700096796829","date":"2025-10-28T18:21:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-28T10:00:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-23T09:04:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-30T12:23:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-29T19:06:36+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-09-29T19:04:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"21f8e588-aa05-40fb-90ab-c06a8d4631b0","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T05:24:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 05:24:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7502165","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7502165","identity":"rs-7502165","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}