Health risk factor No. 4: Low fruit and vegetable intake. Worldwide, 19% of gastrointestinal cancer, 31% of ischemic heart disease and 11% of strokes are attributed to low intake of fruits and vegetables. In developed countries, this amounts to 3.9% of DALYs. Health risk factor No. 5: Physical activity. Exercise protects against the risk of cardiovascular disease, cancers and diabetes. Inactivity is related to 10-16% of cases of breast cancer, colon and rectal cancers, and diabetes mellitus. It is responsible for 1.9 million deaths and 19 million DALYs globally, and 3.3% of DALYs in developed countries. Health risk factor No. 6: Illicit drugs. The non-medical use of drugs is related to increased overall mortality though HIV/AIDS, overdose, suicide and trauma. Overall illicit drug use is implicated in 0.4% of all deaths worldwide and is most common in the industrialised countries of the Americas, Eastern Mediterranean and Europe. In developed countries, illicit drug use is responsible for 1.8% of DALYs. Health risk factor No. 7: Unsafe sex. The overwhelming majority of DALYs attributable to unsafe sex result from the global HIV/AIDS epidemic. Although much of this occurs in countries outside of the OECD, of the HIV/AIDS related deaths that occurred outside of Africa in 2001, 25-90% were caused by unsafe sex. In developed countries, 0.8% of DALYs is attributable to unsafe sex. Service use Another important health behaviour is health service utilisation. We define service use in a general sense to include not just the uptake of services per se in terms of quantity of resources used but also in terms of the efficiency of service use and more generally in terms of the communication with health professionals, use of preventative treatments, compliance with advice, expert patients and community level access to health provision. Because of the importance for health of appropriate and effective use of services we add this to the list of health behaviours considered as markers of health. There are three main elements to service use relevant here: • A preventative element which is manifested through the use of health services for preventative reasons (e.g. regular checkups) or to monitor health conditions. • A responsive element, characterised by individuals' use of health facilities in response to diseases, pains, accidents, or in general poor health conditions which usually limit daily activities. • The management of chronic and/or disabling conditions. The role of education We introduce education into the model in Figure 4.2.4. At the centre of the framework is the self in context. Education matters to health firstly through direct effects on the people that engage in it and secondly because it impacts on the choices of contexts that people come to inhabit or on their opportunities to choose such contexts. Also, through effects on multiple individuals and on social relations and wider socialisation and civic processes, education has the potential to impact on the nature of the contexts themselves, changing workplaces, ho...