The development and experience of epidemiological transition theory over four decades: a systematic review.
BACKGROUND
Epidemiological transition (ET) theory, first postulated in 1971, has developed alongside changes in population structures over time. However, understandings of mortality transitions and associated epidemiological changes remain poorly defined for public health practitioners. Here, we review the concept and development of ET theory, contextualising this in empirical evidence, which variously supports and contradicts the original theoretical propositions.


METHODS
A Medline literature search covering publications over four decades, from 1971 to 2013, was conducted. Studies were included if they assessed human populations, were original articles, focused on mortality and health or demographic or ET and were in English. The reference lists of the selected articles were checked for additional sources.


RESULTS
We found that there were changes in emphasis in the research field over the four decades. There was an increasing tendency to study wide-ranging aspects of the determinants of mortality, including risk factors, lifestyle changes, socio-economics, and macro factors such as climate change. Research on ET has focused increasingly on low- and middle-income countries rather than industrialised countries, despite its origins in industrialised countries. Countries have experienced different levels of progress in ET in terms of time, pace, and underlying mechanisms. Elements of ET are described for many countries, but observed transitions have not always followed pathways described in the original theory.


CONCLUSIONS
The classic ET theory largely neglected the critical role of social determinants, being largely a theoretical generalisation of mortality experience in some countries. This review shows increasing interest in ET all over the world but only partial concordance between established theory and empirical evidence. Empirical evidence suggests that some unconsidered aspects of social determinants contributed to deviations from classic theoretical pathways. A better-constructed, revised ET theory, with a stronger basis in evidence, is needed.
Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden; ailiana.santosa@epiph.umu.se.
Ailiana
A
Santosa
Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden.
Stig
S
Wall
Institute for Global Health, University College London, London, UK.
Edward
E
Fottrell
Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
Ulf
U
Högberg
Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden; MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Peter
P
Byass
D002423:Cause of Death; D004813:Epidemiology; D014943:Global Health; D019456:Health Transition; D049673:History, 20th Century; D049674:History, 21st Century; D006801:Humans; D008954:Models, Biological; D009026:Mortality
demographic transition; epidemiological transition; mortality; social determinants