Burden of disease attributable to risk factors in European countries: a scoping literature review
Authors: Gorasso Vanessa , Morgado Joana Nazaré , Charalampous Periklis , Pires Sara M. , Haagsma Juanita A. , Santos João Vasco , Idavain Jane , Ngwa Che Henry , Noguer Isabel , Padron-Monedero Alicia , Sarmiento Rodrigo , Pinheiro Vera , Von der Lippe Elena , Jakobsen Lea Sletting , Devleesschauwer Brecht , Plass Dietrich ,   The COST Action CA18218 participants, Aasvang Gunn Marit , Ádám Balázs , Alkerwi Ala’a , Arabloo Jalal , Baltazar Ana Lúcia , Uysal Hilal Bektas , Bikbov Boris , Bolling Anette Kocbach , Borrell-Pages Maria , Carreras Giulia , Castelpietra Giulio , Chen-Xu José , Lagarija Šeila Cilović , Corso Barbara , Cuschieri Sarah , De Pauw Robby , Dhaouadi Sonia , Dokova Klara , Dopelt Keren , Economou Mary , Emeto Theophilus I. , Fantke Peter , Fischer Florian , Freitas Alberto , Galluzzo Lucia , García-González Juan Manuel , Gazzelloni Federica , Gissler Mika , Gkitakou Artemis , Gubes Sezgin , Canu Irina Guseva , Hincapié Cesar A. , Hynds Paul , Ilic Irena , Ilic Milena , Isola Gaetano , Kabir Zubair , Kolkhir Pavel , Konar Naime Meriç , Kretzschmar Mirjam , Kulimbet Mukhtar , La Vecchia Carlo , Ladeira Carina , Lassen Brian , Lauriola Paolo , Lehtomäki Heli , Levi Miriam , Majer Marjeta , McDonald Scott A. , Mechili Enkeleint A. , Misins Janis , Monasta Lorenzo , Laguna Javier Muñoz , Namorado Sónia , Nena Evangelia , Ng Edmond S. W. , Nguewa Paul , Niranjan Vikram , Nola Iskra Alexandra , Obradović Marija , O’Caoimh Rónán , Öztürk Nazife , Pastorinho M. Ramiro , Petrou Panagiotis , Peyroteo Mariana , Ortiz Miguel Reina , Riva Silvia , Rocha-Gomes João , Santoso Cornelia Melinda Adi , Schmitt Tugce , Shigdel Rajesh , Sigurvinsdottir Rannveig , Soriano Joan B. , Sousa Ana Catarina , Sprügel Maximilian , Steiropoulos Paschalis , Tozija Fimka , Unim Brigid , Vandeninden Bram , Varga Orsolya , Vasic Milena , Viegas Susana , Vieira Rafael , Violante Francesco S. , Wyper Grant M. A. , Yigit Vahit , Zaletel Jelka 
Published: June 2023

Abstract
Objectives
Within the framework of the burden of disease (BoD) approach, disease and injury burden estimates attributable to risk factors are a useful guide for policy formulation and priority setting in disease prevention. Considering the important differences in methods, and their impact on burden estimates, we conducted a scoping literature review to: (1) map the BoD assessments including risk factors performed across Europe; and (2) identify the methodological choices in comparative risk assessment (CRA) and risk assessment methods.

Methods
We searched multiple literature databases, including grey literature websites and targeted public health agencies websites.

Results
A total of 113 studies were included in the synthesis and further divided into independent BoD assessments (54 studies) and studies linked to the Global Burden of Disease (59 papers). Our results showed that the methods used to perform CRA varied substantially across independent European BoD studies. While there were some methodological choices that were more common than others, we did not observe patterns in terms of country, year or risk factor. Each methodological choice can affect the comparability of estimates between and within countries and/or risk factors, since they might significantly influence the quantification of the attributable burden. From our analysis we observed that the use of CRA was less common for some types of risk factors and outcomes. These included environmental and occupational risk factors, which are more likely to use bottom-up approaches for health outcomes where disease envelopes may not be available.

Conclusions
Our review also highlighted misreporting, the lack of uncertainty analysis and the under-investigation of causal relationships in BoD studies. Development and use of guidelines for performing and reporting BoD studies will help understand differences, avoid misinterpretations thus improving comparability among estimates.

Registration
The study protocol has been registered on PROSPERO, CRD42020177477 (available at: https://www.crd.york.ac.uk/PROSPERO/).