• Chapter 6: Noncommunicable Diseases, Mental Health, and Injuries

    • Chapter 6: Noncommunicable Diseases, Mental Health, and Injuries

    General Overview Intro

    As infectious/communicable diseases have declined in recent years, chronic non-communicable diseases (NCDs) have become the leading cause of death globally. NCDs are not passed from person-to-person, but develop slowly and last for years. Deaths from NCDs are likely to continue increasing, and by 2030 will exceed deaths from communicable, maternal, perinatal, and nutritional diseases combined.

    The four main types of NCDs are:

    The four main risk factors are similar for all of the main NCDs

    The risk factors are in turn influenced by social and economic conditions including poverty, globalization, trade, education, urbanization, climate change, employment conditions, and gender disparities (World Health Organization, n.d.).

    Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. Social, genetic and environmental factors, such as poverty and violence, interact to influence mental health. Influences during childhood such as harsh parenting or bullying can be especially harmful to mental health (World Health Organization, 2022e).

    Additional leading causes of death and suffering worldwide include violence and injuries. Traffic injuries, homicide, and suicide are three of the leading five causes of death for individuals between the ages of 5 and 29. Other leading injury-related causes of death and disability are drowning in childhood and falls in older adults. Violence and injuries cause death and suffering in all countries, but the risks and associated consequences for violence and injury are not evenly distributed across populations. Risks for most injuries and violence are much higher among youth, males, and individuals living in poverty (World Health Organization, 2021a).

    The following pages will provide you with an overview of some of the leading NCDs, mental health concerns, and contributors to injury-related death and disability globally.

    Noncommunicable diseases

    (World Health Organization, 2022h)

    Key facts

    Overview

    Noncommunicable diseases (NCDs), also known as chronic diseases, tend to be of long duration and are the result of a combination of genetic, physiological, environmental, and behavioral factors.

    The main types of NCD are cardiovascular diseases (such as heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructive pulmonary disease and asthma) and diabetes.

    NCDs disproportionately affect people in low- and middle-income countries, where more than three quarters of global NCD deaths (31.4 million) occur.

    People at risk

    People of all age groups, regions and countries are affected by NCDs. These conditions are often associated with older age groups, but evidence shows that 17 million NCD deaths occur before the age of 70 years. Of these premature deaths, 86% are estimated to occur in low- and middle-income countries. Children, adults and the elderly are all vulnerable to the risk factors contributing to NCDs, whether from unhealthy diets, physical inactivity, exposure to tobacco smoke or the harmful use of alcohol.

    These diseases are driven by forces that include rapid unplanned urbanization, globalization of unhealthy lifestyles and population aging. Unhealthy diets and a lack of physical activity may show up in people as raised blood pressure, increased blood glucose, elevated blood lipids and obesity. These are called metabolic risk factors and can lead to cardiovascular disease, the leading NCD in terms of premature deaths.

    Risk factors

    Modifiable behaviors, such as tobacco use, physical inactivity, unhealthy diet, and the harmful use of alcohol, all increase the risk of NCDs.

    Tobacco accounts for over 8 million deaths every year (including from the effects of exposure to second-hand smoke). 1.8 million annual deaths have been attributed to excess salt/sodium intake. More than half of the 3 million annual deaths attributable to alcohol use are from NCDs, including cancer. 830,000 deaths annually can be attributed to insufficient physical activity.

    Metabolic risk factors contribute to four key metabolic changes that increase the risk of NCDs:

    In terms of attributable deaths, the leading metabolic risk factor globally is elevated blood pressure (to which 19% of global deaths are attributed), followed by raised blood glucose, and overweight and obesity.

    Socioeconomic impact

    NCDs threaten progress towards the 2030 Agenda for Sustainable Development, which includes a target of reducing the probability of death from any of the four main NCDs between ages 30 and 70 years by one third by 2030.

    Poverty is closely linked with NCDs. The rapid rise in NCDs is predicted to impede poverty reduction initiatives in low-income countries, particularly by increasing household costs associated with health care. Vulnerable and socially disadvantaged people get sicker and die sooner than people of higher social positions, especially because they are at greater risk of being exposed to harmful products, such as tobacco, or unhealthy dietary practices, and have limited access to health services.

    In low-resource settings, health-care costs for NCDs quickly drain household resources. The exorbitant costs of NCDs, including treatment, which is often lengthy and expensive, combined with loss of income, force millions of people into poverty annually and stifle development.

    Prevention and control

    An important way to control NCDs is to focus on reducing the risk factors associated with these diseases. Low-cost solutions exist for governments and other stakeholders to reduce the common modifiable risk factors. Monitoring progress and trends of NCDs and their risk is important for guiding policy and priorities.

    To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed requiring all sectors, including health, finance, transport, education, agriculture, planning and others, to collaborate to reduce the risks associated with NCDs, and to promote interventions to prevent and control them.

    Investing in better management of NCDs is critical. Management of NCDs includes detecting, screening and treating these diseases, and providing access to palliative care for people in need. High impact essential NCD interventions can be delivered through a primary health care approach to strengthen early detection and timely treatment. Evidence shows such interventions are excellent economic investments because, if provided early to patients, they can reduce the need for more expensive treatment. Countries with inadequate health care coverage are unlikely to provide universal access to essential NCD interventions. NCD management interventions are essential for achieving the SDG target on NCDs.

    Cardiovascular diseases (CVDs)

    (World Health Organization, 2021b)

    Key facts

    What are cardiovascular diseases?

    Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels. They include:

    Heart attacks and strokes are usually acute events and are mainly caused by a blockage that prevents blood from flowing to the heart or brain. The most common reason for this is a build-up of fatty deposits on the inner walls of the blood vessels that supply the heart or brain. Strokes can be caused by bleeding from a blood vessel in the brain or from blood clots.

    What are the risk factors for cardiovascular disease?

    The most important behavioral risk factors of heart disease and stroke are unhealthy diet, physical inactivity, tobacco use, and harmful use of alcohol. The effects of behavioral risk factors may show up in individuals as raised blood pressure, raised blood glucose, raised blood lipids, and overweight and obesity. These “intermediate risk factors” can be measured in primary care facilities and indicate an increased risk of heart attack, stroke, heart failure and other complications.

    Cessation of tobacco use, reduction of salt in the diet, eating more fruit and vegetables, regular physical activity and avoiding harmful use of alcohol have been shown to reduce the risk of cardiovascular disease. Health policies that create conducive environments for making healthy choices affordable and available are essential for motivating people to adopt and sustain healthy behaviors.

    CVDs may also be caused by other underlying determinants. These are a reflection of the major forces driving social, economic and cultural change – globalization, urbanization and population aging. Other determinants of CVDs include poverty, stress, and hereditary factors.

    In addition, drug treatment of hypertension, diabetes, and high blood lipids are necessary to reduce cardiovascular risk and prevent heart attacks and strokes among people with these conditions.

    What are common symptoms of cardiovascular diseases?

    Often, no symptoms of the underlying disease of the blood vessels are seen. A heart attack or stroke may be the first sign of underlying disease. Symptoms of a heart attack include:

    The most common symptom of a stroke is sudden weakness of the face, arm, or leg, most often on one side of the body. Other symptoms include sudden onset of:


    People experiencing these symptoms should seek medical care immediately.

    What is rheumatic heart disease?

    Rheumatic heart disease is caused by damage to the heart valves and heart muscle from the inflammation and scarring caused by rheumatic fever. Rheumatic fever is caused by an abnormal response of the body to infection with streptococcal bacteria, which usually begins as a sore throat or tonsillitis in children.

    Rheumatic fever mostly affects children in developing countries, especially where poverty is widespread. Globally, about 2% of deaths from cardiovascular diseases are related to rheumatic heart disease.

    Symptoms of rheumatic heart disease

    Symptoms of rheumatic heart disease include: shortness of breath, fatigue, irregular heartbeats, chest pain, and fainting.

    Symptoms of rheumatic fever include: fever, pain and swelling of the joints, nausea, stomach cramps, and vomiting.

    Why are cardiovascular diseases a development issue in low- and middle-income countries?

    At least three-quarters of the world's deaths from CVDs occur in low- and middle-income countries. People living in low- and middle-income countries often do not have the benefit of primary health care programmes for early detection and treatment of people with risk factors for CVDs. People in low- and middle-income countries who suffer from CVDs and other noncommunicable diseases have less access to effective and equitable health care services which respond to their needs. As a result, for many people in these countries detection is often late in the course of the disease and people die at a younger age from CVDs and other noncommunicable diseases, often in their most productive years.

    The poorest people in low- and middle-income countries are most affected. At the household level, evidence is emerging that CVDs and other noncommunicable diseases contribute to poverty due to catastrophic health spending and high out-of-pocket expenditure. At the macro-economic level, CVDs place a heavy burden on the economies of low- and middle-income countries.

    How can the burden of cardiovascular diseases be reduced?

    The key to cardiovascular disease reduction lies in the inclusion of cardiovascular disease management interventions in universal health coverage packages, although in a high number of countries health systems require significant investment and reorientation to effectively manage CVDs.

    Evidence from 18 countries has shown that hypertension programmes can be implemented efficiently and cost-effectively at the primary care level which will ultimately result in reduced coronary heart disease and stroke. Patients with cardiovascular disease should have access to appropriate technology and medication. Basic medicines that should be available include:

    An acute event such as a heart attack or stroke should be promptly managed.

    Sometimes, surgical operations are required to treat CVDs. They include:

    Medical devices are required to treat some CVDs. Such devices include pacemakers, prosthetic valves, and patches for closing holes in the heart.

    Diabetes

    (World Health Organization, 2022g)

    Key facts

    Overview

    Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood glucose. Hyperglycemia, also called raised blood glucose or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body's systems, especially the nerves and blood vessels.

    In 2014, 8.5% of adults aged 18 years and older had diabetes. In 2019, diabetes was the direct cause of 1.5 million deaths and 48% of all deaths due to diabetes occurred before the age of 70 years. Another 460,000 kidney disease deaths were caused by diabetes, and raised blood glucose causes around 20% of cardiovascular deaths (Institute for Health Metrics and Evaluation, 2020).

    Between 2000 and 2019, there was a 3% increase in age-standardized mortality rates from diabetes. In lower-middle-income countries, the mortality rate due to diabetes increased 13%.

    By contrast, the probability of dying from any one of the four main noncommunicable diseases (cardiovascular diseases, cancer, chronic respiratory diseases or diabetes) between the ages of 30 and 70 decreased by 22% globally between 2000 and 2019.

    Type 2 diabetes

    Type 2 diabetes (formerly called non-insulin-dependent, or adult-onset diabetes) results from the body’s ineffective use of insulin. More than 95% of people with diabetes have type 2 diabetes. This type of diabetes is largely the result of excess body weight and physical inactivity.

    Symptoms may be similar to those of type 1 diabetes, but are often less marked. As a result, the disease may be diagnosed several years after onset, after complications have already arisen.

    Until recently, this type of diabetes was seen only in adults but it is now also occurring increasingly frequently in children.

    Type 1 diabetes

    Type 1 diabetes (previously known as insulin-dependent, juvenile or childhood-onset) is characterized by deficient insulin production and requires daily administration of insulin. In 2017 there were 9 million people with type 1 diabetes; the majority of them live in high-income countries. Neither its cause nor the means to prevent it are known.

    Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight loss, vision changes, and fatigue. These symptoms may occur suddenly.

    Gestational diabetes

    Gestational diabetes is hyperglycemia with blood glucose values above normal but below those diagnostic of diabetes. Gestational diabetes occurs during pregnancy

    Women with gestational diabetes are at an increased risk of complications during pregnancy and at delivery. These women and possibly their children are also at increased risk of type 2 diabetes in the future.

    Gestational diabetes is diagnosed through prenatal screening, rather than through reported symptoms.

    Impaired glucose tolerance and impaired fasting glycemia

    Impaired glucose tolerance (IGT) and impaired fasting glycemia (IFG) are intermediate conditions in the transition between normality and diabetes. People with IGT or IFG are at high risk of progressing to type 2 diabetes, although this is not inevitable.

    Health impact

    Over time, diabetes can damage the heart, blood vessels, eyes, kidneys, and nerves.

    Adults with diabetes have a two- to three-fold increased risk of heart attacks and strokes (The Emerging Risk Factors Collaboration, 2010). Combined with reduced blood flow, neuropathy (nerve damage) in the feet increases the chance of foot ulcers, infection and eventual need for limb amputation. Diabetic retinopathy is an important cause of blindness and occurs as a result of long-term accumulated damage to the small blood vessels in the retina. Close to 1 million people are blind due to diabetes (Steinmetz et al., 2021). Diabetes is among the leading causes of kidney failure.

    People with diabetes are more likely to have poor outcomes for several infectious diseases, including COVID-19.

    Prevention

    Lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes. To help prevent type 2 diabetes and its complications, people should:

    Diagnosis and treatment

    Early diagnosis can be accomplished through relatively inexpensive testing of blood glucose.

    Treatment of diabetes involves diet and physical activity along with lowering of blood glucose and the levels of other known risk factors that damage blood vessels. Tobacco use cessation is also important to avoid complications.

    Interventions that are both cost-saving and feasible in low- and middle-income countries include:


    Other cost saving interventions include:

    Chronic obstructive pulmonary disease (COPD)

    (World Health Organization, 2022b)

    Key facts

    Overview

    Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable chronic lung disease which affects men and women worldwide.

    Abnormalities in the small airways of the lungs lead to limitation of airflow in and out of the lungs. Several processes cause the airways to become narrow. There may be destruction of parts of the lung, mucus blocking the airways, and inflammation and swelling of the airway lining.

    COPD is sometimes called emphysema or chronic bronchitis. Emphysema usually refers to destruction of the tiny air sacs at the end of the airways in the lungs. Chronic bronchitis refers to a chronic cough with the production of phlegm resulting from inflammation in the airways.

    COPD and asthma share common symptoms (cough, wheeze and difficulty breathing) and people may have both conditions.

    Impact

    Common symptoms of COPD develop from mid-life onwards, including:

    As COPD progresses, people find it more difficult to carry out their normal daily activities, often due to breathlessness. There may be a considerable financial burden due to limitation of workplace and home productivity, and costs of medical treatment.

    During flare-ups, people with COPD find their symptoms become much worse and they may need to receive extra treatment at home or be admitted to hospital for emergency care. Severe flare-ups can be life threatening.

    People with COPD often have other medical conditions such as heart disease, osteoporosis, musculoskeletal disorders, lung cancer, depression, and anxiety.

    Causes

    COPD develops gradually over time, often resulting from a combination of risk factors:

    Reducing the burden of COPD

    No cure exists for COPD, but early diagnosis and treatment are important to slow the progression of symptoms and reduce the risk of flare-ups.

    COPD should be suspected if a person has typical symptoms, and the diagnosis confirmed by a breathing test called spirometry, which measures how the lungs are working. In low- and middle-income countries, spirometry is often not available and so the diagnosis may be missed.

    People with COPD can take action to improve their overall health and help control their COPD:


    Inhaled medication can be used to improve symptoms and reduce flare-ups. Different types of inhaled medication work in different ways and can be given in combination inhalers, if available.

    Some inhalers open the airways and may be given regularly to prevent or reduce symptoms, and to relieve symptoms during acute flare-ups. Inhaled corticosteroids are sometimes given in combination with these to reduce inflammation in the lungs.

    Inhalers must be taken using the correct technique, and in some cases with a spacer device to help deliver the medication into the airways more effectively. Access to inhalers is limited in many low- and middle-income countries; in 2021 salbutamol inhalers were generally available in public primary health care facilities in half of low- and low-middle income countries.

    Flare-ups are often caused by a respiratory infection, and people may be given an antibiotic or steroid tablets in addition to inhaled or nebulised treatment as needed.

    People living with COPD must be given information about their condition, treatment, and self-care to help them to stay as active and healthy as possible.

    Cancer

    (World Health Organization, 2022a)

    Key facts

    Overview

    Cancer is a generic term for a large group of diseases that can affect any part of the body. Other terms used are malignant tumors and neoplasms. One defining feature of cancer is the rapid creation of abnormal cells that grow beyond their usual boundaries, and which can then invade adjoining parts of the body and spread to other organs; the latter process is referred to as metastasis. Widespread metastases are the primary cause of death from cancer.

    The problem

    Cancer is a leading cause of death worldwide, accounting for nearly 10 million deaths in 2020 (Ferlay et al., 2020). The most common in 2020 (in terms of new cases of cancer) were:

    The most common causes of cancer death in 2020 were:

    Each year, approximately 400,000 children develop cancer. The most common cancers vary between countries. Cervical cancer is the most common in 23 countries.

    Causes

    Cancer arises from the transformation of normal cells into tumor cells in a multi-stage process that generally progresses from a precancerous lesion to a malignant tumor. These changes are the result of the interaction between a person's genetic factors and three categories of external agents, including:

    WHO, through its cancer research agency, the International Agency for Research on Cancer (IARC), maintains a classification of cancer-causing agents.

    The incidence of cancer rises dramatically with age, most likely due to a build-up of risks for specific cancers that increase with age. The overall risk accumulation is combined with the tendency for cellular repair mechanisms to be less effective as a person grows older.

    Risk factors

    Tobacco use, alcohol consumption, unhealthy diet, physical inactivity, and air pollution are risk factors for cancer and other noncommunicable diseases.

    Some chronic infections are risk factors for cancer; this is a particular issue in low- and middle-income countries. Approximately 13% of cancers diagnosed in 2018 globally were attributed to carcinogenic infections, including Helicobacter pylori, human papillomavirus (HPV), hepatitis B virus, hepatitis C virus, and Epstein-Barr virus (de Martel et al., 2020).

    Hepatitis B and C viruses and some types of HPV increase the risk for liver and cervical cancer, respectively. Infection with HIV increases the risk of developing cervical cancer six-fold and substantially increases the risk of developing select other cancers such as Kaposi sarcoma.

    Reducing the burden

    Between 30 and 50% of cancers can currently be prevented by avoiding risk factors and implementing existing evidence-based prevention strategies. The cancer burden can also be reduced through early detection of cancer and appropriate treatment and care of patients who develop cancer. Many cancers have a high chance of cure if diagnosed early and treated appropriately.

    Prevention

    Cancer risk can be reduced by:

    Early detection

    Cancer mortality is reduced when cases are detected and treated early. Two components of early detection are: early diagnosis and screening.

    Early diagnosis

    When identified early, cancer is more likely to respond to treatment and can result in a greater probability of survival with less morbidity, as well as less expensive treatment. Significant improvements can be made in the lives of cancer patients by detecting cancer early and avoiding delays in care.

    Early diagnosis consists of three components:

    Screening

    Screening aims to identify individuals with findings suggestive of a specific cancer or pre-cancer before they have developed symptoms. When abnormalities are identified during screening, further tests to establish a definitive diagnosis should follow, as should referral for treatment if cancer is proven to be present.

    Screening programmes are effective for some but not all cancer types and in general are far more complex and resource-intensive than early diagnosis as they require special equipment and dedicated personnel. Even when screening programmes are established, early diagnosis programmes are still necessary to identify those cancer cases occurring in people who do not meet the age or risk factor criteria for screening.

    Patient selection for screening programmes is based on age and risk factors to avoid excessive false positive studies. Examples of screening methods are:

    HPV test (including HPV DNA and mRNA test), as preferred modality for cervical cancer screening; and mammography screening for breast cancer for women aged 50–69 residing in settings with strong or relatively strong health systems. Quality assurance is required for both screening and early diagnosis programmes.

    Treatment

    A correct cancer diagnosis is essential for appropriate and effective treatment because every cancer type requires a specific treatment regimen. Treatment usually includes surgery, radiotherapy, and/or systemic therapy (chemotherapy, hormonal treatments, targeted biological therapies). Proper selection of a treatment regimen takes into consideration both the cancer and the individual being treated. Completion of the treatment protocol in a defined period of time is important to achieve the predicted therapeutic result.

    Determining the goals of treatment is an important first step. The primary goal is generally to cure cancer or to considerably prolong life. Improving the patient's quality of life is also an important goal. This can be achieved by support for the patient’s physical, psychosocial, and spiritual well-being and palliative care in terminal stages of cancer.

    Some of the most common cancer types, such as breast cancer, cervical cancer, oral cancer, and colorectal cancer, have high cure probabilities when detected early and treated according to best practices.

    Some cancer types, such as testicular seminoma and different types of leukemia and lymphoma in children, also have high cure rates if appropriate treatment is provided, even when cancerous cells are present in other areas of the body.

    Treatment availability varies between countries of different income levels; comprehensive treatment is reportedly available in more than 90% of high-income countries but less than 15% of low-income countries (World Health Organization, 2020).

    Palliative care

    Palliative care is treatment to relieve, rather than cure, symptoms and suffering caused by cancer and to improve the quality of life of patients and their families. Palliative care can help people live more comfortably. It is particularly needed in places with a high proportion of patients in advanced stages of cancer where chance of cure is small.

    Relief from physical, psychosocial, and spiritual problems through palliative care is possible for more than 90% of patients with advanced stages of cancer.

    Effective public health strategies, comprising community- and home-based care, are essential to provide pain relief and palliative care for patients and their families.

    Improved access to oral morphine is strongly recommended for the treatment of moderate to severe cancer pain, suffered by over 80% of people with cancer in the terminal phase.

    Tobacco

    (World Health Organization, 2022c)

    Key facts

    Overview

    The tobacco epidemic is one of the biggest public health threats the world has ever faced, killing more than 8 million people a year, including around 1.2 million deaths from exposure to second-hand smoke.

    All forms of tobacco are harmful, and no level of exposure to tobacco is safe. Cigarette smoking is the most common form of tobacco use worldwide. Other tobacco products include waterpipe tobacco, various smokeless tobacco products, cigars, cigarillos, roll-your-own tobacco, pipe tobacco, bidis, and kreteks.

    Over 80% of the 1.3 billion tobacco users worldwide live in low- and middle-income countries, where the burden of tobacco-related illness and death is heaviest. Tobacco use contributes to poverty by diverting household spending from basic needs such as food and shelter to tobacco.

    The economic costs of tobacco use are substantial and include significant health care costs for treating the diseases caused by tobacco use as well as the lost human capital that results from tobacco-attributable morbidity and mortality.

    Key measures to reduce the demand for tobacco

    Second-hand smoke

    Second-hand tobacco smoke is the smoke emitted from the burning end of a cigarette or from other smoked tobacco products (such as bidis and water-pipes) and the smoke exhaled by the smoker. More than 4000 chemicals have been identified in tobacco smoke and no level of exposure to second-hand tobacco smoke is safe.

    Based on the scientific evidence, the Conference of the Parties to the WHO Framework Convention of Tobacco Control (WHO FCTC) has concluded that 100% smoke-free environments are the only proven way to adequately protect the health of people from the harmful effects of second-hand tobacco smoke. Smoke-free laws protect the health of non-smokers and are popular, as they do not harm business and they encourage smokers to quit.

    Pictorial health warnings

    Large pictorial or graphic health warnings, including plain packaging, with hard hitting messages can persuade smokers to protect the health of non-smokers by not smoking inside the home, increase compliance with smoke-free laws and encourage more people to quit tobacco use. Studies show that pictorial warnings significantly increase people's awareness of the harms from tobacco use. Mass media campaigns can also reduce demand for tobacco by promoting the protection of non-smokers and by convincing people to stop using tobacco.

    Tobacco advertising

    Comprehensive bans on tobacco advertising, promotion, and sponsorship can reduce tobacco consumption. A comprehensive ban covers both direct and indirect varieties of promotion:

    Taxes

    Tobacco taxes are the most cost-effective way to reduce tobacco use and health care costs, especially among youth and low-income people, while increasing revenue in many countries. The tax increases need to be high enough to push prices up above income growth. An increase of tobacco prices by 10% decreases tobacco consumption by about 4% in high-income countries and about 5% in low- and middle-income countries.

    Tax avoidance (licit) and tax evasion (illicit) undermine the effectiveness of tobacco control policies, particularly higher tobacco taxes. The tobacco industry and others often argue that high tobacco product taxes lead to tax evasion. However, experience from many countries demonstrate that illicit trade can be successfully addressed even when tobacco taxes and prices are raised.

    Quitting tobacco

    When tobacco users become aware of the dangers of tobacco, most want to quit. However, nicotine contained on tobacco products is highly addictive and without cessation support only 4% of users who attempt to quit tobacco use will succeed. Professional support and proven cessation medications can more than double a tobacco user's chance of successful quitting.

    Novel and emerging nicotine and tobacco products

    Heated tobacco products (HTPs)

    HTPs are, like all other tobacco products, inherently toxic and contain carcinogens. They should be treated like any other tobacco product when it comes to setting policies. HTPs produce aerosols containing nicotine and toxic chemicals upon heating of the tobacco, or activation of a device containing the tobacco. The aerosols are inhaled by users during a process of sucking or smoking involving a device. They contain the highly addictive substance nicotine, non-tobacco additives and are often flavored.

    In recent years, HTPs have been promoted as reduced harm products or products that can help people quit conventional tobacco smoking. HTPs expose users to toxic emissions, many of which cause cancer and currently not enough evidence suggests that they are less harmful than conventional cigarettes. Little is known at present on the effects of second-hand emissions produced by HTPs, though the emissions from these products contain harmful and potentially harmful chemicals.

    E-cigarettes

    Electronic nicotine delivery systems (ENDS) and electronic non-nicotine delivery systems (ENNDS), commonly referred to as e-cigarettes, are devices which heat a liquid to create an aerosol which is then inhaled by the user. These may or may not contain nicotine. The main constituents of the solution by volume are propylene glycol, with or without glycerol, and flavoring agents. E-cigarettes do not contain tobacco but are harmful to health and are not safe. However, it is too early to provide a clear answer on the long-term impacts of using them or being exposed to them.

    E-cigarettes are particularly risky when used by children and adolescents. Nicotine is highly addictive and young people’s brains develop up to their mid-twenties.

    ENDS use increases the risk of heart disease and lung disorders. They also pose significant risks to pregnant women who use them, as they can damage the growing fetus.

    Advertising, marketing, and promotion of ENDS has grown rapidly, through channels which rely heavily on internet and social media (Huang et al., 2014). Much of the marketing around these products gives rise to concern about deceptive health claims, deceptive claims on cessation efficacy, and targeting of youth (especially with the use of flavors).

    ENDS/ENNDS should not be promoted as a cessation aid until adequate evidence is available and the public health community can agree upon the effectiveness of those specific products. Where ENDS and ENNDS are not banned, WHO recommends that the products be regulated in accordance with 4 key objectives:

    WHO response

    The scale of the human and economic tragedy that tobacco imposes is shocking, but it’s also preventable. The tobacco industry is fighting to ensure the dangers of their products are concealed, but the WHO is fighting back. In 2003, WHO Member States unanimously adopted the WHO Framework Convention on Tobacco Control (WHO FCTC). In force since 2005, the FCTC currently has 182 Parties covering more than 90% of the world’s population.

    In 2007, WHO introduced a practical, cost-effective way to scale up implementation of the main demand reduction provisions of the WHO FCTC on the ground: MPOWER.

    The 6 MPOWER measures are:

    Mental disorders

    (World Health Organization, 2022d)

    Key facts


    A mental disorder is characterized by a clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior. It is usually associated with distress or impairment in important areas of functioning. Mental disorders are of many different types. Mental disorders may also be referred to as mental health conditions. The latter is a broader term covering mental disorders, psychosocial disabilities and other mental states associated with significant distress, impairment in functioning, or risk of self-harm. This fact sheet focuses on mental disorders as described by the International Classification of Diseases 11th Revision (ICD-11).

    In 2019, 1 in every 8 people, or 970 million people around the world were living with a mental disorder, with anxiety and depressive disorders the most common (Institute of Health Metrics and Evaluation, n.d.). In 2020, the number of people living with anxiety and depressive disorders rose significantly because of the COVID-19 pandemic. Initial estimates show a 26% and 28% increase respectively for anxiety and major depressive disorders in just one year. While effective prevention and treatment options exist, most people with mental disorders do not have access to effective care. Many people also experience stigma, discrimination, and violations of human rights.

    Anxiety Disorders

    In 2019, 301 million people were living with an anxiety disorder including 58 million children and adolescents (Institute of Health Metrics and Evaluation, n.d.). Anxiety disorders are characterized by excessive fear and worry and related behavioral disturbances. Symptoms are severe enough to result in significant distress or significant impairment in functioning. Anxiety disorders are of several different kinds, including: generalized anxiety disorder (characterized by excessive worry), panic disorder (characterized by panic attacks), social anxiety disorder (characterized by excessive fear and worry in social situations), separation anxiety disorder (characterized by excessive fear or anxiety about separation from those individuals to whom the person has a deep emotional bond), and others. Effective psychological treatment exists, and depending on the age and severity, medication may also be considered.

    Depression

    In 2019, 280 million people were living with depression, including 23 million children and adolescents (Institute of Health Metrics and Evaluation, n.d.). Depression is different from usual mood fluctuations and short-lived emotional responses to challenges in everyday life. During a depressive episode, the person experiences a depressed mood (feeling sad, irritable, empty) or a loss of pleasure or interest in activities, for most of the day, nearly every day, for at least two weeks. Several other symptoms are also present, which may include poor concentration, feelings of excessive guilt or low self-worth, hopelessness about the future, thoughts about dying or suicide, disrupted sleep, changes in appetite or weight, and feeling especially tired or low in energy. People with depression are at an increased risk of suicide. Yet, effective psychological treatment exists, and depending on the age and severity, medication may also be considered.

    Bipolar Disorder

    In 2019, 40 million people experienced bipolar disorder (Institute of Health Metrics and Evaluation, n.d.). People with bipolar disorder experience alternating depressive episodes with periods of manic symptoms. During a depressive episode, the person experiences a depressed mood (feeling sad, irritable, empty) or a loss of pleasure or interest in activities, for most of the day, nearly every day. Manic symptoms may include euphoria or irritability, increased activity or energy, and other symptoms such as increased talkativeness, racing thoughts, increased self-esteem, decreased need for sleep, distractibility, and impulsive reckless behavior. People with bipolar disorder are at an increased risk of suicide. Effective treatment options exist including psychoeducation, reduction of stress and strengthening of social functioning, and medication.

    Post-Traumatic Stress Disorder (PTSD)

    The prevalence of PTSD and other mental disorders is high in conflict-affected settings (Charlson et al., 2019). PTSD may develop following exposure to an extremely threatening or horrific event or series of events. It is characterized by all of the following: 1) re-experiencing the traumatic event or events in the present (intrusive memories, flashbacks, or nightmares); 2) avoidance of thoughts and memories of the event(s), or avoidance of activities, situations, or people reminiscent of the event(s); and 3) persistent perceptions of heightened current threat. These symptoms persist for at least several weeks and cause significant impairment in functioning. Effective psychological treatment exists.

    Schizophrenia

    Schizophrenia affects approximately 24 million people, or 1 in 300 people worldwide (Institute of Health Metrics and Evaluation, n.d.). People with schizophrenia have a life expectancy 10-20 years below that of the general population (Laursen et al., 2014). Schizophrenia is characterized by significant impairments in perception and changes in behavior. Symptoms may include persistent delusions, hallucinations, disorganized thinking, highly disorganized behavior, or extreme agitation. People with schizophrenia may experience persistent difficulties with their cognitive functioning. A range of effective treatment options exist, including medication, psychoeducation, family interventions, and psychosocial rehabilitation.

    Eating Disorders

    In 2019, 14 million people experienced eating disorders, including almost 3 million children and adolescents (Institute of Health Metrics and Evaluation, n.d.). Eating disorders, such as anorexia nervosa and bulimia nervosa, involve abnormal eating and preoccupation with food as well as prominent body weight and shape concerns. The symptoms or behaviors result in significant risk or damage to health, significant distress, or significant impairment of functioning. Anorexia nervosa often has its onset during adolescence or early adulthood and is associated with premature death due to medical complications or suicide. Individuals with bulimia nervosa are at a significantly increased risk for substance use, suicidality, and health complications. Effective treatment options exist, including family-based treatment and cognitive-based therapy.

    Disruptive behavior and dissocial disorders

    40 million people, including children and adolescents, were living with conduct-dissocial disorder in 2019 (Institute of Health Metrics and Evaluation, n.d.). This disorder, also known as conduct disorder, is one of two disruptive behavior and dissocial disorders, the other is oppositional defiant disorder. Disruptive behavior and dissocial disorders are characterized by persistent behavior problems such as persistently defiant or disobedient behaviors that persistently violate the basic rights of others or major age-appropriate societal norms, rules, or laws. Onset of disruptive and dissocial disorders is commonly, though not always, during childhood. Effective psychological treatments exist, often involving parents, caregivers, and teachers, cognitive problem-solving or social skills training.

    Neurodevelopmental disorders

    Neurodevelopmental disorders are behavioral and cognitive disorders that arise during the developmental period, and involve significant difficulties in the acquisition and execution of specific intellectual, motor, language, or social functions.

    Neurodevelopmental disorders include disorders of intellectual development, autism spectrum disorder, and attention deficit hyperactivity disorder (ADHD) amongst others. ADHD is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that has a direct negative impact on academic, occupational, or social functioning. Disorders of intellectual development are characterized by significant limitations in intellectual functioning and adaptive behavior, which refers to difficulties with everyday conceptual, social, and practical skills that are performed in daily life. Autism spectrum disorder (ASD) constitutes a diverse group of conditions characterized by some degree of difficulty with social communication and reciprocal social interaction, as well as persistent restricted, repetitive, and inflexible patterns of behavior, interests, or activities.

    Effective treatment options exist including psychosocial interventions, behavioral interventions, occupational and speech therapy. For certain diagnoses and age groups, medication may also be considered.

    Who is at risk from developing a mental disorder?

    At any one time, a diverse set of individual, family, community, and structural factors may combine to protect or undermine mental health. Although most people are resilient, people who are exposed to adverse circumstances – including poverty, violence, disability, and inequality – are at higher risk.

    Protective and risk factors include individual psychological and biological factors, such as emotional skills as well as genetics. Many of the risk and protective factors are influenced through changes in brain structure and/or function.

    Health systems and social support

    Health systems have not yet adequately responded to the needs of people with mental disorders and are significantly under-resourced. The gap between the need for treatment and its provision is wide all over the world; and is often poor in quality when delivered. For example, only 29% of people with psychosis and only one third of people with depression receive formal mental health care (Moitra et al., 2022).

    People with mental disorders also require social support, including support in developing and maintaining personal, family, and social relationships. People with mental disorders may also need support for educational programmes, employment, housing, and participation in other meaningful activities.

    WHO response

    WHO’s Comprehensive Mental Health Action Plan 2013-2030 recognizes the essential role of mental health in achieving health for all people. The plan includes 4 major objectives:

    WHO's Mental Health Gap Action Programme (mhGAP) uses evidence-based technical guidance, tools and training packages to expand services in countries, especially in resource-poor settings. It focuses on a prioritized set of conditions, directing capacity building towards non-specialized health-care providers in an integrated approach that promotes mental health at all levels of care. The WHO mhGAP Intervention Guide 2.0 is part of this Programme, and provides guidance for doctors, nurses, and other health workers in non-specialist health settings on assessment and management of mental disorders.

    Mental health

    (World Health Organization, 2022e)

    Key facts

    Concepts in mental health

    Mental health is a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community. It is an integral component of health and well-being that underpins our individual and collective abilities to make decisions, build relationships and shape the world we live in. Mental health is a basic human right. And it is crucial to personal, community, and socio-economic development.

    Mental health is more than the absence of mental disorders. It exists on a complex continuum, which is experienced differently from one person to the next, with varying degrees of difficulty and distress, and potentially very different social and clinical outcomes.

    “Mental health should be seen as a valued source of human capital or well-being in society. It contributes to individual and population health, happiness and welfare, enables social interaction, cohesion and security, and feeds national output and labor force productivity. We need good mental health to succeed in all areas of life.

    Yet, individuals with mental ill-health are often shunned and denied access to care, with services for promoting and protecting mental health and preventing ill-health often starved of resources. It is vital to not only address the needs of people with defined mental disorders but also to protect and promote the mental health of all people, and recognize the intrinsic value of positive mental health” (World Health Organization, 2019).

    Mental health conditions include mental disorders and psychosocial disabilities as well as other mental states associated with significant distress, impairment in functioning, or risk of self-harm. People with mental health conditions are more likely to experience lower levels of mental well-being, but this is not always or necessarily the case.

    Determinants of mental health

    Throughout our lives, multiple individual, social and structural determinants may combine to protect or undermine our mental health and shift our position on the mental health continuum.

    Individual psychological and biological factors such as emotional skills, substance use and genetics can make people more vulnerable to mental health problems.

    Exposure to unfavorable social, economic, geopolitical and environmental circumstances – including poverty, violence, inequality and environmental deprivation – also increases people’s risk of experiencing mental health conditions.

    Risks can manifest themselves at all stages of life, but those that occur during developmentally sensitive periods, especially early childhood, are particularly detrimental. For example, harsh parenting and physical punishment is known to undermine child health, and bullying is a leading risk factor for mental health conditions.

    Protective factors similarly occur throughout our lives and serve to strengthen resilience. They include our individual social and emotional skills and attributes as well as positive social interactions, quality education, decent work, safe neighborhoods and community cohesion, among others.

    Mental health risks and protective factors can be found in society at different scales. Local threats heighten risk for individuals, families, and communities. Global threats heighten risk for whole populations and include economic downturns, disease outbreaks, humanitarian emergencies and forced displacement and the growing climate crisis.

    Each single risk and protective factor has only limited predictive strength. Most people do not develop a mental health condition despite exposure to a risk factor and many people with no known risk factor still develop a mental health condition. Nonetheless, the interacting determinants of mental health serve to enhance or undermine mental health.

    Mental health promotion and prevention

    Promotion and prevention interventions work by identifying the individual, social, and structural determinants of mental health, and then intervening to reduce risks, build resilience and establish supportive environments for mental health. Interventions can be designed for individuals, specific groups, or whole populations.

    Reshaping the determinants of mental health often requires action beyond the health sector and so promotion and prevention programmes should involve the education, labor, justice, transport, environment, housing, and welfare sectors. The health sector can contribute significantly by embedding promotion and prevention efforts within health services; and by advocating, initiating and, where appropriate, facilitating multisectoral collaboration and coordination.

    Suicide prevention is a global priority and is included in the Sustainable Development Goals. Much progress can be achieved by limiting access to means, responsible media reporting, social and emotional learning for adolescents and early intervention. Banning highly hazardous pesticides is a particularly inexpensive and cost–effective intervention for reducing suicide rates.

    Promoting child and adolescent mental health is another priority and can be achieved by policies and laws that promote and protect mental health, supporting caregivers to provide nurturing care, implementing school-based programmes and improving the quality of community and online environments. School-based social and emotional learning programmes are among the most effective promotion strategies for countries at all income levels.

    Promoting and protecting mental health at work is a growing area of interest and can be supported through legislation and regulation, organizational strategies, manager training and interventions for workers.

    Mental health care and treatment

    In the context of national efforts to strengthen mental health, it is vital to not only protect and promote the mental well-being of all, but also to address the needs of people with mental health conditions.

    This should be done through community-based mental health care, which is more accessible and acceptable than institutional care, helps prevent human rights violations and delivers better recovery outcomes for people with mental health conditions. Community-based mental health care should be provided through a network of interrelated services that comprise:

    The vast care gap for common mental health conditions such as depression and anxiety means countries must also find innovative ways to diversify and scale up care for these conditions, for example, through non-specialist psychological counseling or digital self-help.

    Comorbidities and mental health

    In many Western countries, mental disorders are the leading cause of disability, responsible for 30-40% of chronic sick leave and costing some 3% of GDP. The links between mental disorders and major noncommunicable disease (NCDs) are well established. Mental disorders affect, and are in turn affected by, major NCDs: they can be a precursor or a consequence of chronic conditions such as cardiovascular disease, diabetes or cancer. Risk factors for these diseases, such as sedentary behavior and harmful use of alcohol, are also risk factors for mental disorders and strongly link the two. In clinical practice, however, such interactions and co-morbidities are routinely overlooked. Premature mortality and disability could be reduced if there were a greater focus on addressing comorbidity. People with mental disorders die 20 years younger than the general population. The great majority of these deaths are not due to a specific cause (such as suicide) but rather to other causes, notably NCDs that have not been appropriately identified and managed (World Health Organization, 2019).

    Injuries and violence

    (World Health Organization, 2021a)

    Key facts

    Preventing injuries and violence will facilitate achievement of several Sustainable Development Goal (SDG) targets.

    Overview:

    Injuries result from road traffic crashes, falls, drowning, burns, poisoning, and acts of violence against oneself or others, among other causes.

    Of the 4.4 million injury-related deaths, unintentional injuries take the lives of 3.16 million people every year and violence-related injuries kill 1.25 million people every year. Roughly 1 in 3 of these deaths result from road traffic crashes, 1 in 6 from suicide, 1 in 10 from homicide and 1 in 61 from war and conflict.

    For people age 5-29 years, 3 of the top 5 causes of death are injury-related, namely road traffic injuries, homicide, and suicide. Drowning is the sixth leading cause of death for children aged 5-14 years. Falls account for over 684,000 deaths each year and are a growing and under-recognized public health issue.

    Tens of millions more people suffer non-fatal injuries each year, which lead to emergency department and acute care visits, hospitalizations or treatment by general practitioners and often result in temporary or permanent disability and the need for long-term physical and mental health care and rehabilitation. For example, there has been a significant rise in road traffic injuries in the African region since 2000, with an almost 50% increase in healthy life-years lost.

    Impact

    Beyond death and injury, exposure to any form of trauma, particularly in childhood, can increase the risk of mental illness and suicide; smoking, alcohol and substance abuse; chronic diseases like heart disease, diabetes and cancer; and social problems such as poverty, crime and violence. For these reasons, preventing injuries and violence, including by breaking intergenerational cycles of violence, goes beyond avoiding the physical injury to contributing to substantial health, social and economic gains.

    Injuries and violence are a significant cause of death and burden of disease in all countries; however, they are not evenly distributed across or within countries – some people are more vulnerable than others depending on the conditions in which they are born, grow, work, live and age. For instance, in general, being young, male and of low socioeconomic status all increase the risk of injury and of being a victim or perpetrator of serious physical violence. The risk of fall-related injuries increases with age.

    Twice as many males than females are killed each year as a result of injuries and violence. Worldwide, about three quarters of deaths from road traffic injuries, four fifths of deaths from homicide, and two thirds of deaths from war are among men. In many low- and middle-income countries, however, women and girls are more likely to be burned than men and boys, in large part due to exposure to unsafe cooking arrangements and energy poverty. Across all ages, the three leading causes of death from injuries for males are road traffic injuries, homicide and suicide, while for females they are road traffic injuries, falls and suicide.

    Poverty also increases the risk of injury and violence. About 90% of injury-related deaths occur in low- and middle-income countries. Across the world, injury death rates are higher in low-income countries than in high-income countries. Even within countries, people from poorer economic backgrounds have higher rates of fatal and non-fatal injuries than people from wealthier economic backgrounds. This holds true even in high-income countries.

    The uneven distribution of injuries that makes them more prevalent among the less advantaged is related to several risk factors. These include living, working, traveling and going to school in more precarious conditions, less focus on prevention efforts in underprivileged communities, and poorer access to quality emergency trauma care and rehabilitation services. These issues are explained in more detail below.

    Risk factors and determinants:

    Risk factors and determinants common to all types of injuries include alcohol or substance use; inadequate adult supervision of children; and broad societal determinants of health such as poverty; economic and gender inequality; unemployment; a lack of safety in the built environment, including unsafe housing, schools, roads and workplaces; inadequate product safety standards and regulations; easy access to alcohol, drugs, firearms, knives and pesticides; weak social safety nets; frail criminal justice systems; and inadequate institutional policies to address injuries in a consistent and effective manner, in part due to the availability of sufficient resources. In settings where emergency trauma care services are weak or access to services is inequitable, the consequences of injuries and violence can be exacerbated.

    Prevention

    Injuries and violence are predictable, and compelling scientific evidence exists for successfully preventing injuries and violence and for treating their consequences in various settings.

    Analysis of the costs and benefits for several selected injury and violence prevention measures shows that they offer significant value for money, making investment in such measures of great societal benefit. For example, with regard to child injury prevention, a study found that every US$ 1 invested in smoke detectors saves US$ 65, in child restraints and bicycle helmets saves US$ 29, and in-home visitation saves US$ 6 in medical costs, loss productivity and property loss. In Bangladesh, teaching school-age children swimming and rescue skills returned US$ 3000 per death averted. The social benefits of injuries prevented through home modification to prevent falls have been estimated to be at least six times the cost of intervention. It is estimated that in Europe and North America, a 10% reduction in adverse childhood experiences could equate to annual savings of 3 million Disability Adjusted Life Years or US$ 105 billion.

    Post-injury care

    For all injuries and violence, providing quality emergency care for victims can prevent fatalities, reduce the amount of short-term and long-term disability, and help those affected to cope physically, emotionally, financially and legally with the impact of the injury or violence on their lives. As such, improving the organization, planning and access to trauma care systems, including telecommunications, transport to hospital, prehospital and hospital-based care, are important strategies to minimize fatalities and disabilities from injury and violence. Providing rehabilitation for people with disabilities, ensuring they have access to assistive products such as wheelchairs, and removing barriers to social and economic participation are key strategies to ensure that people who experience disability as the result of an injury or violence may continue a full and enjoyable life.

    Road traffic injuries

    (World Health Organization, 2022f)

    Key facts

    Road traffic injuries cause considerable economic losses to individuals, their families, and to nations as a whole. These losses arise from the cost of treatment as well as lost productivity for those killed or disabled by their injuries, and for family members who need to take time off work or school to care for the injured. Road traffic crashes cost most countries 3% of their gross domestic product.

    Who is at risk?

    Socioeconomic status

    More than 90% of road traffic deaths occur in low- and middle-income countries. Road traffic injury death rates are highest in the African region and lowest in the European region. Even within high-income countries, people from lower socioeconomic backgrounds are more likely to be involved in road traffic crashes.

    Age

    Road traffic injuries are the leading cause of death for children and young adults aged 5-29 years.

    Sex

    From a young age, males are more likely to be involved in road traffic crashes than females. About three quarters (73%) of all road traffic deaths occur among young males under the age of 25 years who are almost 3 times as likely to be killed in a road traffic crash as young females.

    Risk factors

    The safe system approach: accommodating human error

    The safe system approach to road safety aims to ensure a safe transport system for all road users. Such an approach takes into account people’s vulnerability to serious injuries in road traffic crashes and recognizes that the system should be designed to be forgiving of human error. The cornerstones of this approach are safe roads and roadsides, safe speeds, safe vehicles, and safe road users, all of which must be addressed in order to eliminate fatal crashes and reduce serious injuries.

    Speeding

    An increase in average speed is directly related both to the likelihood of a crash occurring and to the severity of the consequences of the crash. For example, every 1% increase in mean speed produces a 4% increase in the fatal crash risk and a 3% increase in the serious crash risk; the death risk for pedestrians hit by car fronts rises rapidly (4.5 times from 50 km/h to 65 km/h); and in car-to-car side impacts the fatality risk for car occupants is 85% at 65 km/h.

    Driving under the influence of alcohol and other psychoactive substances

    Driving under the influence of alcohol and any psychoactive substance or drug increases the risk of a crash that results in death or serious injuries. In the case of drinking and driving, the risk of a road traffic crash starts at low levels of blood alcohol concentration (BAC) and increases significantly when the driver's BAC is ≥ 0.04 g/dl. In the case of driving under the influence of drugs, the risk of incurring a road traffic crash is increased to differing degrees depending on the psychoactive drug used. For example, the risk of a fatal crash occurring among those who have used amphetamines is about five times the risk of someone who hasn't.

    Nonuse of motorcycle helmets, seat-belts, and child restraints

    Correct helmet use can lead to a 42% reduction in the risk of fatal injuries and a 69% reduction in the risk of head injuries. Wearing a seat-belt reduces the risk of death among drivers and front seat occupants by 45 - 50%, and the risk of death and serious injuries among rear seat occupants by 25%. The use of child restraints can lead to a 60% reduction in deaths.

    Distracted driving

    Many types of distractions can lead to impaired driving. The distraction caused by mobile phones is a growing concern for road safety.

    Drivers using mobile phones are approximately four times more likely to be involved in a crash than drivers not using a mobile phone. Using a phone while driving slows reaction times (notably braking reaction time, but also reaction to traffic signals), and makes it difficult to keep in the correct lane, and to keep the correct following distances. Hands-free phones are not much safer than hand-held phone sets, and texting while driving considerably increases the risk of a crash.

    Unsafe road infrastructure

    The design of roads can have a considerable impact on their safety. Ideally, roads should be designed keeping in mind the safety of all road users. This would mean providing adequate facilities for pedestrians, cyclists, and motorcyclists. Measures such as footpaths, cycling lanes, safe crossing points, and other traffic calming measures can be critical to reducing the risk of injury among these road users.

    Unsafe vehicles

    Safe vehicles play a critical role in averting crashes and reducing the likelihood of serious injury. If UN regulations on vehicle safety were applied to countries’ manufacturing and production standards, they would potentially save many lives. These include requiring vehicle manufacturers to meet front and side impact regulations, to include electronic stability control (to prevent over-steering) and to ensure airbags and seat-belts are fitted in all vehicles. Without these basic standards the risk of traffic injuries – both to those in the vehicle and those out of it – is considerably increased.

    Inadequate post-crash care

    Delays in detecting and providing care for those involved in a road traffic crash increase the severity of injuries. Care of injuries after a crash has occurred is extremely time-sensitive: delays of minutes can make the difference between life and death. Improving post-crash care requires ensuring access to timely prehospital care, and improving the quality of both prehospital and hospital care, such as through specialist training programmes.

    Inadequate law enforcement of traffic laws

    If traffic laws on drinking and driving, seat-belt wearing, speed limits, helmets, and child restraints are not enforced, they cannot bring about the expected reduction in road traffic fatalities and injuries related to specific behaviors. Thus, if traffic laws are not enforced or are perceived as not being enforced, it is likely they will not be complied with and therefore will have very little chance of influencing behavior.

    Effective enforcement includes establishing, regularly updating, and enforcing laws at the national, municipal, and local levels that address the above mentioned risk factors. It also includes the definition of appropriate penalties.

    What can be done to address road traffic injuries

    Road traffic injuries can be prevented. Governments need to take action to address road safety in a holistic manner. This requires involvement from multiple sectors such as transport, police, health, education, and actions that address the safety of roads, vehicles, and road users.

    Effective interventions include designing safer infrastructure and incorporating road safety features into land-use and transport planning, improving the safety features of vehicles; enhancing post-crash care for victims of road traffic crashes; setting and enforcing laws relating to key risks, and raising public awareness.

    Falls

    (World Health Organization, 2021b)

    Key facts

    A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. Fall-related injuries may be fatal or non-fatal though most are non-fatal. For example, of children in the People's Republic of China, for every death due to a fall, there are four cases of permanent disability, 13 cases requiring hospitalization for more than ten days, 24 cases requiring hospitalization for 1–9 days and 690 cases seeking medical care or missing work/school.

    The problem

    Globally, falls are a major public health problem. An estimated 684,000 fatal falls occur each year, making it the second leading cause of unintentional injury death, after road traffic injuries. Over 80% of fall-related fatalities occur in low- and middle-income countries, with regions of the Western Pacific and SouthEast Asia accounting for 60% of these deaths. In all regions of the world, death rates are highest among adults over the age of 60 years.

    Though not fatal, approximately 37.3 million falls severe enough to require medical attention occur each year. Globally, falls are responsible for over 38 million DALYs (disability-adjusted life years) lost each year, and result in more years lived with disability than transport injury, drowning, burns and poisoning combined.

    While nearly 40% of the total DALYs lost due to falls worldwide occurs in children, this measurement may not accurately reflect the impact of fall-related disabilities for older individuals who have fewer life years to lose. In addition, those individuals who fall and suffer a disability, particularly older people, are at a major risk for subsequent long-term care and institutionalization.

    The financial costs from fall-related injuries are substantial. For people aged 65 years or older, the average health system cost per fall injury in the Republic of Finland and Australia are US$3,611 and US$1,049 respectively. Evidence from Canada suggests the implementation of effective prevention strategies with a subsequent 20% reduction in the incidence of falls among children under ten years of age could create a net savings of over US$120 million each year.

    Who is at risk?

    While all people who fall are at risk of injury, the age, gender, and health of the individual can affect the type and severity of injury.

    Age

    Age is one of the key risk factors for falls. Older people have the highest risk of death or serious injury arising from a fall and the risk increases with age. For example, in the United States of America, 20–30% of older people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head trauma. This risk level may be in part due to physical, sensory, and cognitive changes associated with aging, in combination with environments that are not adapted for an aging population.

    Another high risk group is children. Childhood falls occur largely as a result of their evolving developmental stages, innate curiosity in their surroundings, and increasing levels of independence that coincide with more challenging behaviors commonly referred to as ‘risk taking’. While inadequate adult supervision is a commonly cited risk factor, the circumstances are often complex, interacting with poverty, sole parenthood, and particularly hazardous environments.

    Gender

    Across all age groups and regions, both genders are at risk of falls. In some countries, it has been noted that males are more likely to die from a fall, while females suffer more non-fatal falls. Older women and younger children are especially prone to falls and increased injury severity. Worldwide, males consistently sustain higher death rates and DALYs lost. Possible explanations of the greater burden seen among males may include higher levels of risk-taking behaviors and hazards within occupations.

    Other risk factors include:

    Prevention

    A range of interventions exist to prevent falls across the life-course. These include, but are not limited to, the following:

    For children and adolescents
    For workers
    For older people

    In addition to the interventions mentioned above, others are considered prudent to implement despite the fact that they may never have a body of research to support them. This is because the nature of the intervention is such that they are unlikely to be the subject of high-quality research studies either due to difficulties in performing the required research, or because the interventions seem so basic or fundamental that research is not deemed necessary. Examples of such interventions include:

    Drowning

    (World Health Organization, 2021c)

    Key facts

    Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid; outcomes are classified as death, morbidity, and no morbidity.

    Scope of the problem

    In 2019, an estimated 236,000 people died from drowning, making drowning a major public health problem worldwide. In 2019, injuries accounted for almost 8% of total global mortality. Drowning is the 3rd leading cause of unintentional injury death, accounting for 7% of all injury-related deaths.

    The global burden and death from drowning is found in all economies and regions, however:

    Despite limited data, several studies reveal information on the cost impact of drowning. In the United States of America, 45% of drowning deaths are among the most economically active segment of the population. Coastal drowning in the United States alone accounts for US$ 273 million each year in direct and indirect costs. In Australia and Canada, the total annual cost of drowning injury is US$ 85.5 million and US$ 173 million respectively.

    The estimate of global drowning deaths is uncertain. Official data categorization methods for drowning exclude intentional drowning deaths (suicide or homicide) and drowning deaths caused by flood disasters and water transport incidents.

    Data from high-income countries suggest these categorization methods result in significant underrepresentation of the full drowning toll by up to 50% in some high-income countries. Non-fatal drowning statistics in many countries are not readily available or are unreliable.

    Risk factors

    Age

    The Global report on drowning (2014) shows that age is one of the major risk factors for drowning. This relationship is often associated with a lapse in supervision. Globally, the highest drowning rates are among children 1–4 years, followed by children 5–9 years. In the WHO Western Pacific Region children aged 5–14 years die more frequently from drowning than any other cause.

    Child drowning statistics from a number of countries presented in the Global Report on Drowning (2014) are particularly revealing:

    Gender

    Males are especially at risk of drowning, with twice the overall mortality rate of females. They are more likely to be hospitalized than females for non-fatal drowning. Studies suggest that the higher drowning rates among males are due to increased exposure to water and riskier behavior such as swimming alone, drinking alcohol before swimming alone and boating.

    Access to water

    Increased access to water is another risk factor for drowning. Individuals with occupations such as commercial fishing or fishing for subsistence, using small boats in low-income countries are more prone to drowning. Children who live near open water sources, such as ditches, ponds, irrigation channels, or pools are especially at risk.

    Flood disasters

    Drowning accounts for 75% of deaths in flood disasters. Flood disasters are becoming both more frequent as well as more severe and this trend is expected to continue as part of climate change. Drowning risks increase with floods particularly in low- and middle-income countries where people live in flood prone areas and the ability to warn, evacuate, or protect communities from floods is weak or only just developing.

    Traveling on water

    Daily commuting and journeys made by migrants or asylum seekers often take place on overcrowded, unsafe vessels lacking safety equipment or are operated by personnel untrained in dealing with transport incidents or navigation. Personnel under the influence of alcohol or drugs are also at risk.

    Other risk factors

    Other factors that are associated with an increased risk of drowning include:

    Prevention

    Many precautions may prevent drowning. Installing barriers (e.g. covering wells, using doorway barriers and playpens, fencing swimming pools etc.) to control access to water hazards, or removing water hazards entirely greatly reduces water hazard exposure and risk.

    Community-based, supervised child care for pre-school children can reduce drowning risk and has other proven health benefits. Teaching school-age children basic swimming, water safety and safe rescue skills is another approach. But these efforts must be undertaken with an emphasis on safety, and an overall risk management that includes a safety-tested curriculum, a safe training area, screening and student selection, and student-instructor ratios established for safety.

    Effective policies and legislation are also important for drowning prevention. Setting and enforcing safe boating, shipping and ferry regulations is an important part of improving safety on the water and preventing drowning. Building resilience to flooding and managing flood risks through better disaster preparedness planning, land use planning, and early warning systems can prevent drowning during flood disasters.

    Developing a national water safety strategy can raise awareness of safety around water, build consensus around solutions, provide strategic direction and a framework to guide multisectoral action and allow for monitoring and evaluation of efforts.

    Burns

    (World Health Organization, 2018)

    Key facts

    A burn is an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals.

    Thermal (heat) burns occur when some or all of the cells in the skin or other tissues are destroyed by:

    The problem

    Burns are a global public health problem, accounting for an estimated 180,000 deaths annually. The majority of these occur in low- and middle-income countries and almost two thirds occur in the WHO African and South-East Asia regions.

    In many high-income countries, burn death rates have been decreasing, and the rate of child deaths from burns is currently over seven times higher in low- and middle-income countries than in high-income countries.

    Non-fatal burns are a leading cause of morbidity, including prolonged hospitalization, disfigurement and disability, often with resulting stigma and rejection.

    Some country data

    Economic impact

    For 2000, direct costs for care of children with burns in the United States of America exceeded US$211 million. In Norway, costs for hospital burn management in 2007 exceeded €10.5 million.

    In South Africa an estimated US$26 million is spent annually for care of burns from kerosene (paraffin) cookstove incidents. Indirect costs such as lost wages, prolonged care for deformities and emotional trauma, and commitment of family resources, also contribute to the socioeconomic impact.

    Who is at risk?

    Gender

    Females have slightly higher rates of death from burns compared to males according to the most recent data. This is in contrast to the usual injury pattern, where rates of injury for the various injury mechanisms tend to be higher in males than females.

    The higher risk for females is associated with open fire cooking, or inherently unsafe cookstoves, which can ignite loose clothing. Open flames used for heating and lighting also pose risks, and self-directed or interpersonal violence are also factors (although understudied).

    Age

    Along with adult women, children are particularly vulnerable to burns. Burns are the fifth most common cause of non-fatal childhood injuries. While a major risk is improper adult supervision, a considerable number of burn injuries in children result from child maltreatment.

    Regional factors

    Burn rates vary significantly by region.

    Socioeconomic factors

    People living in low- and middle-income countries are at higher risk for burns than people living in high-income countries. Within all countries however, burn risk correlates with socioeconomic status.

    Other risk factors

    Other risk factors for burns include:

    In which settings do burns occur?

    Burns occur mainly in the home and workplace. Community surveys in Bangladesh and Ethiopia show that 80–90% of burns occur at home. Children and women are usually burned in domestic kitchens, from upset receptacles containing hot liquids or flames, or from cookstove explosions. Men are most likely to be burned in the workplace due to fire, scalds, chemical, and electrical burns.

    Prevention

    Burns are preventable. High-income countries have made considerable progress in lowering rates of burn deaths, through a combination of prevention strategies and improvements in the care of people affected by burns. Most of these advances in prevention and care have been incompletely applied in low- and middle-income countries. Increased efforts to do so would likely lead to significant reductions in rates of burn-related death and disability.

    Prevention strategies should address the hazards for specific burn injuries, education for vulnerable populations and training of communities in first aid. An effective burn prevention plan should be multisectoral and include broad efforts to:

    In addition, specific recommendations for individuals, communities and public health officials to reduce burn risk include:

    First aid

    Basic guidance on first aid for burns is provided below.

    What to do
    What not to do

    Disability

    (World Health Organization, 2023)

    Key facts

    Overview

    Disability is part of being human and is integral to the human experience. It results from the interaction between health conditions such as dementia, blindness or spinal cord injury, and a range of environmental and personal factors. An estimated 1.3 billion people – or 16% of the global population – experience a significant disability today. This number is growing because of an increase in noncommunicable diseases and people living longer. Persons with disabilities are a diverse group, and factors such as sex, age, gender identity, sexual orientation, religion, race, ethnicity, and their economic situation affect their experiences in life and their health needs. Persons with disabilities die earlier, have poorer health, and experience more limitations in everyday functioning than others.

    Factors contributing to health inequities

    Health inequities arise from unfair conditions faced by persons with disabilities.

    Structural factors

    Persons with disabilities experience ableism, stigma, and discrimination in all facets of life, which affects their physical and mental health. Laws and policies may deny them the right to make their own decisions and allow a range of harmful practices in the health sector, such as forced sterilization, involuntary admission and treatment, and even institutionalization.

    Social determinants of health

    Poverty, exclusion from education and employment, and poor living conditions all add to the risk of poor health and unmet health care needs among persons with disabilities. Gaps in formal social support mechanisms mean that persons with disabilities are reliant on support from family members to engage in health and community activities, which not only disadvantages them but also their caregivers (who are mostly women and girls).

    Risk factors

    Persons with disabilities are more likely to have risk factors for non-communicable diseases, such as smoking, poor diet, alcohol consumption and a lack of physical activity. A key reason for this is that they are often left out of public health interventions.

    Health system

    Persons with disabilities face barriers in all aspects of the health system. For example, a lack of knowledge, negative attitudes, and discriminatory practices among healthcare workers; inaccessible health facilities and information; and lack of information or data collection and analysis on disability, all contribute to health inequities faced by this group.

    International frameworks

    Countries have an obligation under international human rights law, and in some cases domestic laws, to address the health inequities faced by persons with disabilities. Two important international frameworks relate to health equity for persons with disabilities.

    The Convention on the Rights of Persons with Disabilities requires States Parties to ensure that persons with disabilities have access to the same range, quality and standard of free or affordable health care as other people.

    The World Health Assembly Resolution WHA74.8 on the highest attainable standard of health for persons with disabilities calls for Member States to ensure that persons with disabilities receive effective health services as part of universal health coverage; equal protection during emergencies; and equal access to cross-sectoral public health interventions.

    Achieving health for all

    Disability inclusion is critical to achieving the Sustainable Development Goals and global health priorities to achieve health for all.

    Universal health coverage will not be achieved if persons with disabilities do not receive quality health services on an equal basis with others. Investing in universal health coverage for persons with disabilities will benefit not only individuals but also communities.

    There could be almost a US$10 return for every US$1 spent on implementing disability inclusive prevention and care for noncommunicable diseases.

    Persons with disabilities must be considered when preventing and responding to health emergencies because they are more likely to be affected, both directly and indirectly. For example, during the COVID-19 pandemic, persons with disabilities living in institutions have been “cut off from the rest of society” with reports of residents being overmedicated, sedated, or locked up, and examples of self-harm also occurring (Brennan, 2020).

    In the COVID-19 pandemic, persons with intellectual disabilities had higher mortality rates (Williamson et al., 2021), and were also less likely to receive intensive care services (Baksh et al., 2021).

    Promoting healthier populations through clean air and water, road safety, child nutrition and addressing violence against women will only be achieved if public health interventions for the wider population consider the needs, skills and capacities of persons with disabilities.

    Women with disabilities being 2–4 times more likely to experience intimate partner violence than those without disabilities (Dunkle et al., 2018).

    The WHO Global report on health equity for persons with disabilities outlines 40 key actions for countries to take to strengthen their health systems and reduce health inequities for persons with disabilities. All governments and health sector partners can do three things. First, they must consider health equity for persons with disabilities in all health sector actions. Second, they can include persons with disabilities in decision-making processes. Third, they can monitor how persons with disabilities are being reached and benefiting from health sector actions.


    References


    Baksh, R. A., Pape, S. E., Smith, J., & Strydom, A. (2021). Understanding inequalities in COVID-19 outcomes following hospital admission for people with intellectual disability compared to the general population: A matched cohort study in the UK. BMJ Open, 11(10), e052482. https://doi.org/10.1136/bmjopen-2021-052482

    Brennan, C. S. (2020, October 22). Disability Rights During the Pandemic: A Global Report on Findings of the COVID-19 Disability Rights Monitor. Africaportal. https://www.africaportal.org/publications/disability-rights-during-pandemic-global-report-findings-covid-19-disability-rights-monitor/

    Charlson, F., van Ommeren, M., Flaxman, A., Cornett, J., Whiteford, H., & Saxena, S. (2019). New WHO prevalence estimates of mental disorders in conflict settings: A systematic review and meta-analysis. The Lancet, 394(10194), 240–248. https://doi.org/10.1016/S0140-6736(19)30934-1

    de Martel, C., Georges, D., Bray, F., Ferlay, J., & Clifford, G. M. (2020). Global burden of cancer attributable to infections in 2018: A worldwide incidence analysis. The Lancet Global Health, 8(2), e180–e190. https://doi.org/10.1016/S2214-109X(19)30488-7

    Dunkle, K., van der Heijden, I., Stern, E., & Chirwa, E. (2018). Disability and Violence against Women and Girls. UKaid. https://ww2preventvawg.org/sites/default/files/2022-03/6.pdf

    Ferlay, J., Ervik, M., Lam, F., Colombet, M., Mery, L., Piñeros, M., & International Agency for Research on Cancer. (2020). Global Cancer Observatory: Cancer Today. https://gco.iarc.fr/today

    Huang, J., Kornfield, R., Szczypka, G., & Emery, S. L. (2014). A cross-sectional examination of marketing of electronic cigarettes on Twitter. Tobacco Control, 23(suppl 3), iii26–iii30. https://doi.org/10.1136/tobaccocontrol-2014-051551

    Institute for Health Metrics and Evaluation. (2020). Global Burden of Disease Study 2019. VizHub. https://vizhub.healthdata.org/gbd-results/

    Institute of Health Metrics and Evaluation. (n.d.). Global Health Data Exchange (GHDx). VizHub. Retrieved May 14, 2022, from https://vizhub.healthdata.org/gbd-results/

    Laursen, T. M., Nordentoft, M., & Mortensen, P. B. (2014). Excess Early Mortality in Schizophrenia. Annual Review of Clinical Psychology, 10(1), 425–448. https://doi.org/10.1146/annurev-clinpsy-032813-153657

    Moitra, M., Santomauro, D., Collins, P. Y., Vos, T., Whiteford, H., Saxena, S., & Ferrari, A. J. (2022). The global gap in treatment coverage for major depressive disorder in 84 countries from 2000–2019: A systematic review and Bayesian meta-regression analysis. PLOS Medicine, 19(2), e1003901. https://doi.org/10.1371/journal.pmed.1003901

    Steinmetz, J. D., Bourne, R. R. A., Briant, P. S., Flaxman, S. R., Taylor, H. R. B., Jonas, J. B., Abdoli, A. A., Abrha, W. A., Abualhasan, A., Abu-Gharbieh, E. G., Adal, T. G., Afshin, A., Ahmadieh, H., Alemayehu, W., Alemzadeh, S. A. S., Alfaar, A. S., Alipour, V., Androudi, S., Arabloo, J., … Vos, T. (2021). Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: The Right to Sight: an analysis for the Global Burden of Disease Study. The Lancet Global Health, 9(2), e144–e160. https://doi.org/10.1016/S2214-109X(20)30489-7

    The Emerging Risk Factors Collaboration. (2010). Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: A collaborative meta-analysis of 102 prospective studies. The Lancet, 375(9733), 2215–2222. https://doi.org/10.1016/S0140-6736(10)60484-9

    Williamson, E. J., McDonald, H. I., Bhaskaran, K., Walker, A. J., Bacon, S., Davy, S., Schultze, A., Tomlinson, L., Bates, C., Ramsay, M., Curtis, H. J., Forbes, H., Wing, K., Minassian, C., Tazare, J., Morton, C. E., Nightingale, E., Mehrkar, A., Evans, D., … Kuper, H. (2021). Risks of covid-19 hospital admission and death for people with learning disability: Population based cohort study using the OpenSAFELY platform. BMJ, n1592. https://doi.org/10.1136/bmj.n1592

    World Health Organization. (n.d.). Noncommunicable Diseases. World Health Organization, African Region. https://www.afro.who.int/health-topics/noncommunicable-diseases

    World Health Organization. (2018, March 6). Burns. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/burns

    World Health Organization. (2019). Mental health: Fact sheet. World Health Organization. https://www.euro.who.int/__data/assets/pdf_file/0004/404851/MNH_FactSheet_ENG.pdf

    World Health Organization. (2020). Assessing national capacity for the prevention and control of noncommunicable diseases: Report of the 2019 global survey. World Health Organization. https://apps.who.int/iris/handle/10665/331452

    World Health Organization. (2021a, March 19). Injuries and violence. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/injuries-and-violence

    World Health Organization. (2021b, April 26). Falls. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/falls

    World Health Organization. (2021c, April 27). Drowning. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/drowning

    World Health Organization. (2021d, June 11). Cardiovascular diseases (CVDs). World Health Organization. https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)

    World Health Organization. (2022a, February 3). Cancer. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/cancer

    World Health Organization. (2022b, May 20). Chronic obstructive pulmonary disease (COPD). World Health Organization. https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd)

    World Health Organization. (2022c, May 24). Tobacco. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/tobacco#:~:text=Key%20facts,exposed%20to%20second%2Dhand%20smoke

    World Health Organization. (2022d, June 8). Mental disorders. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/mental-disorders

    World Health Organization. (2022e, June 17). Mental health. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response

    World Health Organization. (2022f, June 20). Road traffic injuries. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries

    World Health Organization. (2022g, September 16). Diabetes. World Health Organization, African Region. https://www.who.int/news-room/fact-sheets/detail/diabetes

    World Health Organization. (2022h, September 16). Noncommunicable diseases. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases

    World Health Organization. (2023, March 7). Disability. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/disability-and-health

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