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Firearm Injuries and Public Health  

Linda Dahlberg, Alexander Butchart, James Mercy, and Thomas Simon

An important function of public health is to prevent injuries or to lessen their impact when they occur. An estimated 251,000 people worldwide die each year from a firearm-related death and many more suffer nonfatal injuries with consequences that can last a lifetime. Firearm injuries, which include those that are intentionally self-inflicted, unintentional, or from an act of interpersonal violence, are heavily concentrated in the Americas, driven largely by firearm homicides. Firearm-related deaths and injuries disproportionately impact males and younger populations and are associated with factors such as access, substance use, adverse childhood experiences, involvement in high-risk social networks, drug trafficking, density of alcohol outlets, and neighborhood and social disadvantage. While progress is being made to understand firearm injuries and how to effectively prevent them, much more needs to be done to improve the availability and timeliness of data; apply the knowledge that is generated to effectively reduce firearm-related injuries, deaths, and costs; strengthen the scientific infrastructure; and move countries closer to achieving the violence-related targets in the 2030 Sustainable Development Goals.


Preterm Birth: Epidemiology, Risk Factors, Pathogenesis, and Prevention  

Xiaojing Zeng, Wen Jiang, Xiaoqing He, and Jun Zhang

Preterm birth is a significant global public health issue. It is defined by the World Health Organization as infants born alive before 37 completed weeks of gestation. The preterm birth rate varies significantly across countries and regions. Globally, an estimated 13.4 million babies were born preterm in 2020 (i.e., 1 in 10 babies worldwide was preterm birth). It is the leading cause of under-5 child mortality worldwide, and preterm infants are particularly vulnerable to respiratory complications, feeding difficulty, poor body temperature regulation, and high risk of infection. Both genetic and nongenetic factors (exposome factors) contribute to the risk of preterm birth. Social and behavioral factors, medical and pregnancy conditions, and environmental exposures are common nongenetic risk factors for preterm birth. Individuals from certain ethnic and racial groups, in low- and middle-income countries, or with a low socioeconomic status are at an increased risk of having preterm birth, and social determinants of health are the root causes of these factors. Existing pregnancy complications, history of preterm birth, and other medical conditions are also common risk factors. Environmental exposures such as air pollution, climate change, and endocrine-disrupting chemicals have been increasingly realized as potential risk factors for preterm birth. Various pathological events in different feto-maternal systems have been reported to be involved in the development of preterm birth. Immunopathogenesis plays a pivotal role, and both pathogenic and nonpathogenic inflammation can induce preterm birth. Oxidative stress, decidual hemorrhage and vascular lesions, uterine overdistension, and cervical insufficiency have all been proposed to contribute to the pathophysiology of preterm birth. Prevention strategies for preterm birth include primary prevention aimed at the modifiable risk factors at the individual and societal levels and therapeutic approaches using pharmaceuticals and mechanical interventions, such as progesterone and cervical cerclage. A comprehensive approach is still needed to reduce the global disease burden of preterm birth.


Fall Prevention and Interventions for Older People  

Claudia Meyer and Lindy Clemson

Across the globe, falls among older people can have grave consequences for individuals and for the healthcare and aged-care systems more broadly. The synergy between intrinsic and situational risk factors adds complexity to the identification and management of falls, as does the public health response at primary, secondary, and tertiary levels of prevention. Falls among people age 65 years and over are recognized as a geriatric syndrome and as a marker of frailty, with increasing rates among those experiencing other chronic conditions, such as Parkinson’s disease, stroke, and dementia. Prevention or management of falls requires a combination of strategies as single or multicomponent interventions. Multimodal exercise, combining balance and functional exercise, environmental adaptation, medication reduction and withdrawal, cataract surgery, single-lens glasses, vitamin D supplementation, management of foot problems and footwear, and cardiac pacing have a degree of evidence to support their implementation. Multicomponent programs, such as i-FOCIS and PDSAFE, have important benefits for specific population groups. Importantly, over the past few decades, falls prevention has shifted from a biomedical approach to a holistic biopsychosocial model. This model aids promotion of a whole-of-community approach through building healthy public policy, creating supportive environments, and strengthening personal skills and community action. The biopsychosocial approach also focuses attention on understanding local contexts, ensuring that falls prevention interventional research can be adapted and fit-for-purpose for low-, middle- and high-income countries. The uptake of falls prevention evidence into practice and policy still faces challenges and new frontiers. Supporting the adoption, implementation, and sustainability of interventions is complex at the individual level, the service provider level, and the healthcare system level. Practice-change frameworks and models are useful, such as those utilized in the Stopping Elderly Accidents, Deaths and Injuries (USA), iSOLVE (Australia), and STRIDE (USA) trials. Falls prevention is complex, yet solutions can be relatively simple. Working together with older people, health professionals and community health leaders can champion ways of bringing falls prevention activities to scale. Research collaboration between stakeholders is a crucial mechanism for drawing together unique perspectives to address ongoing gaps and concerns.


Injury Prevention Methods  

Samuel Forjuoh and Guohua Li

Injury prevention encompasses all the processes, strategies, and approaches designed to mitigate any unintentional or intentional bodily damage from external causes, such as motor vehicle crashes, falls from height, or incidents resulting in deprivation of the two essential elements needed for the proper functioning of the body, oxygen and heat. The methods for developing injury prevention strategies have undergone a steady upward developmental trajectory since Hippocratic times. In particular, the past few decades have witnessed transformative innovations from a myriad of studies that focused on the best strategies to prevent injury from occurring and/or to mitigate the severity of injury when primary prevention fails. These methods, techniques, and processes for developing injury prevention strategies and interventions are generally classified as falling under the “6 Es” of injury prevention: education, engineering modifications, enforcement/enactment, economic incentive (equity), empowerment, and evaluation. The Haddon matrix is the primary conceptual framework for developing injury prevention strategies. Other issues that are germane to effective injury prevention include synergism of interventions and appropriate transfer of interventions across settings.


Behavioral Interventions to Reduce and Prevent Racial Bias  

Nicole Farmer, Alyssa Baginski, and Talya Gordon

Unlike other public health crises, attention to the role of prevention in racial bias has not predominated. Most human actions, including racism, are informed by unconscious thoughts. Behavior-change interventions seek to understand facilitators and barriers to human action and antecedent unconscious thoughts, which are guided not only within an individual but also in interpersonal and societal environments. Current behavioral interventions on implicit and explicit racial bias can identify gaps and opportunities in the literature to evaluate operational definitions of behavior and bias, discuss psychological and neurobiological processes involved in racial bias, that may provide insight into prevention. Furthermore, a focus on public health–based interventions which integrate behavioral science foundations may assist to develop adaptable, accurate, and effective interventions across global communities. Based on the literature results discussed, the benefit for the field of public health may be to inform future studies and create a multilevel, behavioral-based framework to prevent or mitigate racial bias behaviors..


Infectious Diseases Among Migrant Populations  

Silvia Declich, Maria Grazia Dente, Christina Greenaway, and Francesco Castelli

Increasing human mobility, of which migration is a component, is a key driver of microorganism circulation. Migration is a minor component of all human mobility, with most movement due to international tourism, travel for work, business, or study, and military operations abroad. Migration flows from southern low-income countries to the industrialized north have steadily increased as a consequences of a complex array of distal and proximal factors such as economic inequality, climate change, political turbulence, war and persecution, and family reunification. This has raised concerns about the potential transmission and reintroduction of microorganisms and infectious diseases into high-income host countries from migrants with asymptomatic infections such as tuberculosis, HIV, viral hepatitis, malaria, Chagas disease, and arboviral infections. These factors contribute to the mounting hostile attitude sometimes observed in receiving countries and deserve careful scientific assessment to inform policies and interventions. The available evidence does not support the hypothesis that migrants constitute a relevant infectious public health risk for the local population, although careful epidemiological surveillance is mandatory, especially where competent vectors for specific infection are present in the destination area, where certain diseases may potentially be introduced or reintroduced. The greatest risk of infectious diseases is to the migrants themselves due to increased risk of exposure within their own communities and from the burden of undetected and untreated infections caused by marginalization and poor living conditions. The health conditions vary at the different stages of settlement and interventions need to be tailored accordingly. In the early arrival phase the main health concerns are psychological, traumatic, and chronic conditions. Crowded unhygienic living conditions often experienced by migrants in reception camps coupled with low vaccination rate may facilitate the transmission of respiratory or gastrointestinal infections or vaccine-preventable diseases. After resettlement, undetected infections and the lack of access to health care due to social marginalization may lead to the reactivation or progression of infections such as tuberculosis, viral hepatitis, HIV, and chronic helminthiasis. These outcomes could be prevented through screening and treatment and would benefit both migrants and the host populations. Pretravel interventions that increase the awareness of the possible infectious risks in their countries of origin are critical to decrease travel-related infection among visiting friends and relatives, especially those traveling with children. Migrant-friendly health systems that ensure prompt access to diagnosis and treatment, regardless of legal status, are the best interventions to limit the burden and transmission of infections in this population.


Fetal Deaths in High-Income Countries  

Sarka Lisonkova and K. S. Joseph

Fetal death refers to the death of a post-embryonic product of conception while in utero or during childbirth, and it is one of the most distressing events faced by women and families. Birth following spontaneous fetal death is termed “miscarriage” if it occurs early in gestation, and “stillbirth,” if it occurs beyond the point of viability. There are substantial between-country differences in the criteria used for reporting stillbirths and these differences compromise international comparisons of stillbirth rates. In high-income countries, a majority of fetal deaths occur due to genetic causes, fetal infection, or other pregnancy complications. Congenital anomalies, placental insufficiency, and/or intrauterine growth restriction are frequent antecedents of fetal death. Maternal risk factors include advanced maternal age, high body mass index, smoking and substance use during pregnancy, prior stillbirth, chronic morbidity, and multifetal pregnancy. Disparities in education and socioeconomic status and other factors influencing maternal health also contribute to elevated rates of stillbirth among vulnerable women.


Burn-Related Injuries  

Ashley van Niekerk

A burn occurs when cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns), or flames (flame burns). Injuries to the skin or other organic tissue due to radiation, radioactivity, electricity, friction or contact with chemicals are also identified as burns. Globally, burns have been in decline, but are still a major cause of injury, disability, death and disruption in some regions, with about 120,000 deaths and 9 million injuries estimated in 2017. Low-to-middle-income countries carry the bulk of this burden with the majority of all burn injuries occurring in the African and Southeast Asia regions. Thermal injuries are physically painful and may leave disabling scars not only to the skin or the body, but also impair psychological wellbeing. Severe injuries often impose significant psychological, but also educational consequences and social stigmatization, with the consequent adjustments exacerbated by a range of factors, including the circumstances of the burn incident, the severity and site of the injury, the qualities of the affected individual’s personality, and the access to supportive interpersonal and social relationships. The contributions of: economic progress, enhanced environmental and home structures, energy technology, and safety education interventions have been reported as significant for burn prevention. Similarly, legislative and policy frameworks that support access to modern energies such as electricity, govern domestic appliances and heating technology, and control storage and decanting of fossil fuels are important in energy impoverished settings. The recovery of burn survivors is affected by the availability of specialized treatment, physical rehabilitation and psychosocial support to burn victims and families, but which is still limited especially in resource constrained settings.


Drowning: Global Burden, Risk Factors, and Prevention Strategies  

Aminur Rahman, Amy E. Peden, Lamisa Ashraf, Daniel Ryan, Al-Amin Bhuiyan, and Stephen Beerman

Drowning has been described as a major global public health problem and has recently been acknowledged by a United Nations Declaration on Global Drowning Prevention. While drowning impacts countries of all income levels, the burden is overwhelmingly borne by low- and middle-income countries (LMICs) who account for 90% of the global death toll. In addition, there is scarce data collection on drowning in LMICs, so the magnitude of drowning may be far greater than is represented. A range of factors including sex, age, education, income, access to water, a lack of swimming skills, certain occupations like commercial fishing, geographically isolated and flood-prone locations, preexisting medical conditions, and unsafe water transport systems, influence the risk of drowning. Some behavioral factors, such as alcohol or drug consumption, not wearing life jackets, and engaging in risky behaviors such as swimming or boating alone, increase drowning risk. Geopolitical factors such as migration and armed conflict can also impact drowning risk. There is a growing body of evidence on drowning prevention strategies. These include pre-event interventions such as pool fencing, enhancing community education and awareness, providing swimming lessons, use of lifejackets, close supervision of children by adults, and boating regulations. Interventions to reduce harm from drowning include appropriate training for recognition of a drowning event, rescue, and resuscitation. An active and/or passive surveillance system for drowning, focusing on individual settings and targeting populations at risk, is required. Drowning requires coordinated multisectoral action to provide effective prevention, rescue, and treatment. Therefore, all countries should aim to develop a national water safety plan, as recommended in the WHO Global Report on Drowning. Further research is required on the epidemiology and treatment of drowning in LMICs as well as non-fatal and intentional drowning in both high-income countries (HICs) and LMICs. Effective and context-specific implementation of drowning prevention strategies, including pilot testing, scale up and evaluation, are likely to help reduce the burden of both fatal and non-fatal drowning in all countries.


Violence and Health  

Maria Cecília de Souza Minayo and Saul Franco

Violence is a problem that accompanies the trajectory of humanity, but it presents itself in different ways in each society and throughout its historical development. Despite having different meanings according to the field of knowledge from which it is addressed and the institutions that tackle it, there are some common elements in the definition of this phenomenon. It is acknowledged as the intentional use of force and power by individuals, groups, classes, or countries to impose themselves on others, causing harm and limiting or denying rights. Its most frequent and visible forms include homicides, suicides, war, and terrorism, but violence is also articulated and manifested in less visible forms, such as gender violence, domestic violence, and enforced disappearances. Although attention to the consequences of different forms of violence has always been part of health services, its formal and global inclusion in health sector policies and guidelines is very recent. It was only in 1996 that the World Health Organization acknowledged it as a priority in the health programs of all countries. Violence affects individual and collective health; causes deaths, injuries, and physical and mental trauma; decreases the quality of life; and impairs the well-being of people, communities, and nations. At the same time, violence poses problems for health researchers trying to understand the complexity of its causes, its dynamics, and the different ways of dealing with it. It also poses serious challenges to health systems and services for the care of victims and perpetrators and the formulation of interdisciplinary, multi-professional, inter-sectoral, and socially articulated confrontation and prevention policies and programs.


Disability and Rural Health  

Rayna Sage, Genna Mashinchi, and Craig Ravesloot

The ways in which disability impacts people and their health in rural places are a result of the interaction between the person and the rural environment in which they live. Disability is defined as ongoing difficulties engaging in daily activities and social roles due to physical or mental conditions. The United Nations Convention on the Rights of People with Disabilities (UN-CRPD) implemented policy in 2008 that recognized that disabled people are worthy of autonomy and dignity. The social and physical environment are constructed in ableist ways that make it difficult for people with disabilities to realize their independence and this is particularly true in many rural places. Person–environment fit and urbanormativity (the favoring of urban spaces at the expense of rural ones) are important concepts in understanding the experiences of rural disabled people. There is little existing research regarding the epidemiology of disability and rural health, but rural people report higher and earlier rates of disability than urban people and rural places have higher rates of older adults with higher rates of disability. Furthermore, rural people with disabilities experience various secondary health conditions and higher rates of mortality compared to urban people with disabilties. The lack of access to health care and advocacy help explain some of the differences in health outcomes when comparing rural and urban people. The disability rights movement led to the creation of different types of advocacy and service organizations across the globe to address these disparities. An important way to improve the experiences and health of rural people with disabilities is to ensure they have access to quality and dependable in-home services and community-based rehabilitation, which currently tend to be under-funded with dramatic worker shortages in many rural places. A final promising approach to improving the health of rural disabled people is through evidence-based health promotion programming that targets early indicators of health problemsand recovery and health-sustaining efforts following a health problem.


HIV Ed: A Global Perspective  

Ralph J. DiClemente and Nihari Patel

At the end of 2016, there were approximately 36.7 million people living with HIV worldwide with 1.6 million people being newly infected. In the same year, 1 million people died from HIV-related causes globally. The vast prevalence of HIV calls for an urgent need to develop and implement prevention programs aimed at reducing risk behaviors. Bronfenbrenner’s socio-ecological model provides an organizing framework to discuss HIV prevention interventions implemented at the individual, relational, community, and societal level. Historically, many interventions in the field of public health have targeted the individual level. Individual-level interventions promote behavior change by enhancing HIV knowledge, attitudes, and beliefs and by motivating the adoption of preventative behaviors. Relational-level interventions focus on behavior change by using peers, partners, or family members to encourage HIV-preventative practices. At the community-level, prevention interventions aim to reduce HIV vulnerability by changing HIV-risk behaviors within schools, workplaces, or neighborhoods. Lastly, societal interventions attempt to change policies and laws to enable HIV-preventative practices. While previous interventions implemented in each of these domains have proven to be effective, a multipronged approach to HIV prevention is needed such that it tackles the complex interplay between the individual and their social and physical environment. Ideally, a multipronged intervention strategy would consist of interventions at different levels that complement each other to synergistically reinforce risk reduction while simultaneously creating an environment that promotes behavior change. Multilevel interventions provide a promising avenue for researchers and program developers to consider all levels of influences on an individual’s behavior and design a comprehensive HIV risk-reduction program.


Mass Shootings as a Global Phenomenon  

Jason R. Silva

There has been extensive media coverage, public concern, and calls for action surrounding mass shootings in the United States at the turn of the 21st century. To address this concern, there is a growing body of research aimed at understanding and remedying this problem in America. However, recent attacks around the world—like the Kerch Polytechnic College shooting in Ukraine, the Christchurch Mosque shooting in New Zealand, and the Suzano School shooting in Brazil—illustrate that mass shootings are a global phenomenon. To this end, it is critical for research to shed light on this troubling and complex issue and contribute to a more informed public and scholarly discourse on mass shootings and their impact around the world. To understand the global problem, it is necessary to evaluate the prevalence of incidents across countries, mass shooter backgrounds and profiles, and common locations targeted during these attacks. To address this phenomenon, it is important to consider strategies for prevention and harm mitigation, including instituting responsible gun legislation, addressing warning signs and leakage, implementing situational crime prevention measures, and advancing law enforcement responses.


Prevention of Suicide  

Danuta Wasserman

Around 700,000 people take their lives each year worldwide. Suicide accounts for approximately 1.3% of all deaths and therefore represents a major public health problem. The global age-standardized suicide rate is 9 per 100,000 population, yet there are large variations among genders, ages, countries, and world regions. The stress–vulnerability model of suicidal behaviors has been proposed to explain how a diathesis, developed through the influence of genetic and neurodevelopmental factors in relation to perinatal, postnatal, and life experiences, interacts with different risk and protective factors that either decrease or enhance the individual’s level of resilience to stress and suicidal risk. Public health suicide prevention strategies include suicide means restriction, reducing harmful substance use, promoting responsible media reporting, public-awareness campaigns, gatekeeper trainings, school-based interventions, crisis helplines, and postvention. Mental health strategies comprise identification, treatment, and rehabilitation of persons in distress and at risk for suicide. Multicomponent strategies that use a combination of evidence-based methods from public and mental health sectors are recommended. Future work should aim at enhancing the quality of epidemiological data, improving the research on protective and ideation-to-action factors, expanding the quantity and quality of data coming from low- and middle-income countries, and evaluating the cost-effectiveness of different suicide prevention strategies.