Conducting national burden of disease studies in small countries in Europe–a feasible challenge?

Sarah Cuschieri, Elena Pallari, Natasa Terzic, Ala’a Alkerwi, Rannveig Sigurvinsdottir, Inga Dora Sigfusdottir & Brecht Devleesschauwer

Archives of Public Health , Volume 79, Article number: 73 (2021) 



Burden of Disease (BoD) studies use disability-adjusted life years (DALYs) as a population health metric to quantify the years of life lost due to morbidity and premature mortality for diseases, injuries and risk factors occurring in a region or a country. Small countries usually face a number of challenges to conduct epidemiological studies, such as national BoD studies, due to the lack of specific expertise and resources or absence of adequate data. Considering Europe’s small countries of Cyprus, Iceland, Luxembourg, Malta and Montenegro, the aim was to assess whether the various national data sources identified are appropriate to perform national BoD studies.

Main body

The five small countries have a well-established mortality registers following the ICD10 classification, which makes calculation of years of life lost (YLL) feasible. A number of health information data sources were identified in each country, which can provide prevalence data for the calculation of years lived with disability (YLD) for various conditions. These sources include disease-specific registers, hospital discharge data, primary health care data and epidemiological studies, provided by different organisations such as health directorates, institutes of public health, statistical offices and other bodies. Hence, DALYs can be estimated at a national level through the combination of the YLL and YLD information.

On the other hand, small countries face unique challenges such as difficulty to ensure sample representativeness, variations in prevalence estimates especially for rarer diseases, existence of a substantial proportion of non-residents affiliated to healthcare systems and potential exclusion from some European or international initiatives.

Recently established BoD networks may provide a platform for small countries to share experiences, expertise, and engage with countries and institutions that have long-standing experience with BoD assessment.


Apart from mortality registries, adequate health data sources, notably for cancer, are potentially available at the small states to perform national BoD studies. Investing in sharing expert knowledge through engagement of researchers in BoD networks can enable the conduct of country specific BoD studies and the establishment of more accurate DALYs estimates. Such estimates can enable local policymakers to reflect on the relative burden of the different conditions that are contributing to morbidity and mortality at a country level.

Read the full article in Archives of Public Health.

Conducting national burden of disease studies in small countries in Europe–a feasible challenge?