SWEDISH RESEARCH COUNCIL
Committe for Development Research
2014-09-08
Non-communicable diseases, mental health and substance
abuse
The following questions are designed based on Swedish Research Council's mission and refer in this
case only the research areas of chronic diseases (limited to CVD and diabetes), mental health and substance
abuse (including alcohol, tobacco, illicit drugs and betel nuts).
Keywords
Social determinants, intervention, implementation research, capacity building, interdependent
partnerships
Description of the research
This inventory is based on both scientific publications and on assessments and suggestions from
responses from national and international experts and includes the research areas of non-communicable
diseases (limited to CVD and diabetes), mental health and substance abuse (including alcohol, tobacco,
illicit drugs and betel nuts).
Non-Communicable Diseases (NCD), including cardiovascular disease (largely heart disease and
stroke), cancer, chronic respiratory diseases, and diabetes, cause two of every three deaths each year. The
massive global toll of NCD deepens poverty, impedes development, threatens health systems, and is a
major cause of disability and health inequality. The last two decades have shown a rapid increase in NCD
mortality primarily in middle-income countries. It is more difficult to assess if development in low-income
countries is showing a corresponding pattern, due to insufficient mortality data. Based on WHO data, it is
evident that nearly 80 % of all NCD deaths occur in low-and middle-income countries (LMICs). NCDs
affect middle age to a large extent as one third are people younger than 60 years. It is essential to better
ascertain the social and individual causes of the drastic increase in CVD, especially among younger
individuals (< 60 years) in LMICs where the vast majority of all deaths from stroke and heart attack take
place.
Mental, neurological and substance abuse disorders constitute an unmatched burden of disease
globally and are the cause of a huge amount of disability and disease throughout the world. To date, these
conditions have not been given sufficient attention in development research. In Africa, where mental
disorders account for a substantial proportion of the burden of disease, less than 1% of national health
budgets are spent on these disorders. In communities in which they live, and even in the health care system,
patients, their families and caregivers are frequently stigmatized and discriminated against, and it is often
assumed that little can be done to address their conditions. A growing body of scientific evidence shows
that much can be done, at moderate cost, and with significant economic benefits to countries, while
reducing suffering, and improving or even saving the lives of those who are affected.
There are major Swedish research collaborations with universities in LMIC within the NCD area. Some
Swedish research groups have focused their research collaborations on more general NCD primary
prevention interventions (mainly focused on lifestyle interventions), while others have collaborated in
disease specific programs (secondary prevention) addressing, for example, new approaches for diabetes
prevention. Other projects have focused on improving mental health (combating structured violence,
suicide prevention among adolescents, or reduced alcohol consumption) or on research collaborations
where Swedish universities are partners in multi-center studies in which, inter alia, societal and individual
factors behind NCD are identified and compared.
However, this research is not reflected in project applications till SIDA/ SAREC and VR. A review of
project applications over the past decade submitted to these councils shows that only a few have addressed
development research on NCDs, mental health and substance abuse. One possible explanation could be that
the researchers have interpreted the announcements not to be focused NCDs, mental health and drug abuse.
Given this, it is less meaningful to separately assess the Swedish development research in the areas of
THEME DESCRIPTION NON-COMMUNICABLE DISEASES, MENTAL HEALTH AND SUBSTANCE ABUSE 2014
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SWEDISH RESEARCH COUNCIL
Committe for Development Research
2014-09-08
NCD, mental health and substance abuse, as long as research project on mental health and substance abuse
has been so rare.
Development research has in many respects a broad perspective of great importance to academic
environments. The different issues it covers enrich our thinking, create opportunities for comparisons
between different settings, and can thus help to better understand the significance of cultural and socioeconomic conditions for the origin, development and treatment of various disease conditions. Creative and
stimulating research collaboration requires a common understanding of problem areas, research questions,
methods, etc., which in turn both require time, venues and financial resources.
Sweden and other Western countries have long experience in the prevention and treatment of NCD.
These experiences are available for exploitation in the form of research collaborations around the
methodological and analytical models for context relevant action. Overall, it is of extreme importance for
Swedish universities to build up leading international positions in global health research. The health
transition in LMICs is occurring surprisingly fast and Sweden has every reason to pay attention to the
strategic importance not to be left behind in this growing and critically important area of research.
The experts consulted for this report warn that development research is linked too strongly to
development aid policy, and this could result in a significant limitation on opportunities for research
collaborations around both NCD, mental health and substance abuse. If calls for research are formulated
quite generically, and are not specifically linked with topical policy formulations, its relevance becomes far
greater. The ultimate goal should be to widen VR's responsibility in terms of development research, to
apply knowledge building that is generally useful for LMIC needs, and not solely guided by Swedish
development aid policy goals.
Capacity building is a key issue for the future. Capacity must be developed in close collaboration with
universities in LMIC. The aim should be to develop research infrastructures in LMIC that provide capacity
to customize methods that can feasibly be applied in the local context, and to provide guidance on the
implementation of relevant methods. This in turn highlights the importance of development research policy
also allowing for a matching capacity building within Swedish universities.
Recently, a U.S. analysis concluded that there remains a huge deficit in education and training in chronic
diseases in LMICs, especially in the public health sciences such as epidemiology and community health.
Contributing to this is the "brain drain" of people who acquire skills only to move to higher income
countries. Research in epidemiology/surveillance at the country level constitutes another shortage area, as
is the science of the implementation of programs in the local context. The role of individual countries’
culture, economy, climate, etc., on chronic disease policy implementation is poorly understood. Capacity
building requires partnering for the long term, which in turn entails the development of inter-institutional
programs rather than single disease-centered projects.
The needs of new knowledge both regarding NCD, mental health and substance abuse is similar
everywhere in the world. Countries have much to learn from each other. Although there are large variations
in culture and tradition, a number of countries are committed to finding improved methods and policies, for
example, to counteract obesity, to stop the smoking epidemic, and to combat drug abuse. Rather than
identifying the specific development aid policy relevance in these issues, national Swedish research policy
should highlight the global nature of these issues. All VR calls ought to be opened to applications to meet
these challenges, regardless of whether the application is addressing projects in LMIC or Sweden.
Strengths and weaknesses
Both national and international experts prioritize intervention research aiming to implement practices
with lasting impact, as a core task, in terms of NCD, mental health and substance abuse. There is a big
knowledge gap on which interventions work best and in which contexts. Understanding of local contexts
that might influence the effectiveness of an intervention is critical, as it generally not is feasible to import
an intervention that was successful in one place into another setting or context, without first adapting it to
local wisdom and needs. Formative research in the development of interventions is a fundamental
requirement.
A particular challenge is to transfer research results into policy. Health policy research goes beyond
medically-oriented epidemiological analyses and studies of social determinants of health, as it also must be
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SWEDISH RESEARCH COUNCIL
Committe for Development Research
2014-09-08
extended via, for example, legislation and social science. Thus is should include cooperation with political
science, law, communication research, anthropology, cognitive science and IT.
Swedish universities have extensive research collaborations in NCD research with universities and
Ministries of Health in LMIC via the INDEPTH Network, a unique, global association of 49 field sites in
20 countries. Through these systematically developed health and demographic surveillance sites, health
data with similar content are collected to illustrate health conditions and development trends in each site,
thus providing the basis for comparisons between regions and over time. A relatively large proportion of
doctoral dissertations in Swedish universities use NCD-oriented, empirical data from these collaborations.
A number of examples illustrate how Swedish universities over the years, through support from SIDA,
have been engaged in efforts to build research capacity in LMICs. These collaborations have resulted in
significant added value for the collaborating Swedish researchers. Unlike many other universities in the
western world, Swedish universities strive to prevent "brain drain", notably by designing doctoral training
that enables the PhD-students to spend most of their time in their home environment for data collection,
and after the defense return to the home university and to a more advanced position in teaching, research or
other official missions. Thus, graduate education constitutes an important asset in the development
cooperation between Sweden and LMIC.
Within a 5-10 year perspective, research into NCD, mental health and substance abuse in LMICs will
increase significantly in pace, with a commensurate need to translate research into action. Decisions on
actions at all levels of the community must be grounded in evidence from research, and this knowledge has
to be translated into action through innovative approaches in the context of low and middle income
countries. Swedish universities can support LMICs in building capacity for epidemiological and health
system research, including the analytical and operational research required for program implementation and
evaluation in the area of NCD.
Trends, tendencies and prognosis for the future
In recent years, SIDA has supported several Partner Driven Cooperation projects in order to utilize
research findings to move from words to action. In several LMICs this has supported the development of
multi-sectorial collaboration on the prevention and control of NCDs. Through workshops with multisectorial actors from governmental institutions, academics, industries, NGOs, and lawyers, this processes
has been focused on (i) the review of existing evidence on the burden, the risk factors, the management,
and the intervention/prevention strategies for NCDs; and (ii) to build networks to increase the policy
capacity for evidence-based decision making among policy makers and other stakeholder on NCDs.
The general area of global health, and the role of universities in it, continues to evolve from one of
development aid to international cooperation and global solidarity. Swedish Universities can be at the
forefront on this new thinking of global health – beyond that of single disease programs to that of
interdependence with low and middle income countries. NCDs, mental health, and substance abuse
highlight the need for an interdependence model, as chronic disease risk factors are increasingly affected by
economics, politics, trade, and media exposure. Therefore, the non-communicable disease agenda for
Swedish universities cannot add much using uni-dimensional programs, as compared to the potential that
could be attained through interdependent partnerships across sectors of health, economics, etc.
The challenge is to identify what really works, mainly in terms of prevention (in relation to the many
strong social determinants of ill-health in LMICs that are the result of powerful globalization forces), but
also, within the health system, in terms of ensuring that people have access to proper diagnosis facilities,
follow-up and treatment. It is important that the research into these topics is not ' siloed', or diseasespecific, but rather that it represents real efforts by VR to facilitate broader, cross-cutting research on
identifying and addressing the social determinants that cause them (as well as causing wider social
problems). Thus efforts should be made to support operational research with innovative community-based
organization that are addressing the conditions that lead to NCDs, mental health and substance abuse.
Research collaborations widen the perspective and understanding of both research and social conditions,
as well as of the cultural contexts in the partner countries. Thereby they create the conditions for allowing
applicable knowledge in return for Sweden, or so-called "mirror research". They build networks of research
departments that would otherwise have been beyond the reach of most academics, and they increase the
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SWEDISH RESEARCH COUNCIL
Committe for Development Research
2014-09-08
capacity of academic scientists to be exposed to and to communicate with policymakers, a skill which is
not nurtured sufficiently in many academic settings.
The evolution away from developmental aid toward international cooperation and/or global solidarity
requires closer partnerships between high-income countries’ universities and their counterpart
organizations in low and middle income countries. This includes more integrated research, education,
policy, and healthcare services programs. In such a model, there may be umbrella relationships with
selected organizations with whom a working relationship has succeeded, rather than a large number of
“one-off”, transient projects with no follow-up. This would also provide a better long term infrastructure
for allowing for student exchanges, clinical services expansion, clinical trial development, etc.
For the future, an obvious need is for surveillance of non-communicable diseases, mental illness and
substance abuse. A particular need is to identify geographic, gender, ethnic, age, religion, or other
subgroups at especially high risk, and for research into the causes of any disparities identified. Media and
health education is usually culturally linked, and much research is needed to evaluate specific interventions
to change behaviors in various cultural settings. The provision of essential health services represents a
huge area with which implementation science should engage.
Many countries have professional societies, but these mostly fall far short in terms of implementing
evidence-based guidelines. Various methods of bringing about evidence-based guidelines have
demonstrated good success in high income countries, but rarely in the context of low or middle income
countries, or in different healthcare systems. Finally, advocacy and policy change would provide numerous
research questions as to model policies which might be exported from one country to the next.
The more basic science research opportunities frequently involve molecular epidemiology studies to
understand why a low or middle income population has an exceptionally high or low risk. The basic
science infrastructures for the study of molecular mechanisms of disease already present in wealthy
countries would be hard to justify in low-income countries in the face of other opportunities for these
countries to develop more context-specific knowledge on tackling chronic diseases.
Recommendations

Concentrate resources on a limited number or research partnering universities in low or middle
income countries for long-term development of research, education, and clinical programs.

Support education and training programs which would discourage the “brain drain”.

Identify unique opportunities for research on the basis of high/low risk populations, unique
healthcare or education systems, unusual environmental factors impacting chronic diseases, and
policy infrastructure’s gaps and opportunities for change.

Provide incentive to form inter-university teams with funds for pilot studies, graduate student
training, core facilities, etc.

Make core facilities in Swedish Universities available to low and middle income universities as
a means to further collaborations.
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Committe for Development Research
2014-09-08
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Committe for Development Research
2014-09-08
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