PH Exam 2

Doneisha Bohannon MPH

Director of community health initiatives at BJC healthcare

STL city infant death rate

9.4 deaths per 1000 live births

higher than national and state average

Maternal mortality racial difference

Black women die at 2.5x the rate of white women, it peaked during the pandemic

Social determinants of health 

education access and quality

economic stability

social and community context

neighborhood and built envio

healthcare access and quality

Drivers of health percentages

40% socioeconomic

10% physical envio

30% health behaviors

20% healthcare

Socioecological model for health

policy

community

institutional

interpersonal

individual

Why doulas

higher satisfaction with birth

less c-sections

higher rates of breastfeeding

less pre-term babies

less post-partum depression

What is maternal mortality

death associated with pregnancy, childbirth (and up to 30 days later), miscarriage, or abortion 

what is Infant mortality

death during first year of life

what is neonatal mortality

stillbirths, deaths to 30 days

Is infant mortality going down from 1965-2005

yes

Infant mortality and education and race

it goes down with more education, blacks always the most though and at first hispanic is the least but then with college+ asian is the least

Causes for infant mortality

congenital

LBW and premature

SIDS

Old standard to judge infant mortality

NCHS - 1978, US

new standard to judge infant mortality

WHO - 2008, US, NHANES, plus data from brazil, ghana, india, oman, norway

What is looked at when looking at infant mortality

weight for age z score (WFA or WAZ)

height for age z score (HFA or HAZ)

weight for heigh z score (WFH or WHZ)

mid-upper arm circumferemce in cm.

Why do you use a z score when looking at kids health

age and sex lead to differences in expectation so the z-score and percentiles make it easier to compare

Wasting

low weight for age or weight for height

what does wasting mean

measure of acute malnutrtion

occur at any age

recovery is possible

how is wasting classified

moderate acute malnutrition: WHZ < -2 and >-3

severe acute malnutrition: WHZ < -3 with additional symptoms 

Stunting

low height for age

what does stunting show

usually measure of chronic malnutrition

often occurs by age 2

catch-up growth is possible but often height deficits persist

Kwashiorkor

protein-energy malnutrition

accumulation of fluid (edema) in tissues

dermatitis, hair color change

Marasmus

energy malnutrition

loss of weight, fat, muscle

low body temp

low blood sugar

infection

severe malnutrition by prevalence ranges

How many children have SAM

20 million kids

How many children have MAM

41 million kids

Where does most SAM and MAM occur

southern asia, subsaharan africa

How many ppl have expereince(d) stunting

195 million children, 800 million including adults

In 20 countries what percent of kids experience SAM, MAM, stunting, etc.

85%

Micronutrients

micronutrients are nutrients needed in very small amounts compared to macronutrients (fat, carbs, protein)

Why are micronutrients important

balance is associated with dietary diversity

six common micronutrients

iodine

vitamin a

iron 

vitamin c

thiamine

niacin

iodine purpose

produce specific thyroid hormones

source of iodine

marine foods

iodine deficiency can lead to

goiter which is the expansion of the thyroid can cause cretinism in pregnancy (serious growth and mental problems)

vitamin a

fat soluble vitamin needed for retinal function

vitamin a deficiecny can lead to

night blindness and retinal defects (congenital)

sources of vitamin a

meat and vegetables

iron deficiency anemia prevelance

one of the most common forms

1.62 billion ppl have it 

symptoms of iron deficiency

fatigue, muscle weakness, cold hands, cold feet, change to heart rate, change to nails, change to skin, irritability

what is anemia associated with

infection, poor dietary intakes

what does anemia have impact on

growth and cognitive function

vitamin c deficiency where is it found

emergency situations or displaced ppl

what can a lack of vitamin c lead to 

increased bruising, bleeding, loss of teeth, fatigue

what provides a lack of vitamin c

lack of fresh fruits and veggies

thiamine deficiency (beriberi) leads to

loss of motor control, difficulty walking, overall muscle weakness, GI and cardiovascular issues

thiamine purpose

breakdown of glucose, neurons

what is thiamine associated with in terms of diet

rice based diet, modern commercial rice commonly fortified

niacain deficiency (pellagra) common in

corn, maize consuming population

symptoms of pellagra

diarrhea, dermatitis, dementia, death

how pellagra is treated

treatment of corn with lime and consumption of beans

contributors to malnutrition

infection

marginal nutrition

complimentary foods/inappropriate

improperly prepared foods

infection types as a contributor to malnutrition

fever

viral/bacterial

helminthic

marginal nutrition as a contributor to malnutrition

seasonality in food supply

difficulties accessing food

sex based priorities in feeding 

complimentary foods/inappropriate or improperly prepared foods in malnutrition

contaminated foods

early introduction

suboptimal breastfeeding

non-fortified foods (low iron, other vitamins)

infection

vector borne (dengue, malaria)

communicable (pneumonia, measles)

helminths (worms)

associated with increase in metabolic needs, wasting, stunting

contributes to morbidity and mortality 

malnutrition infection synergy

inadequate diet —> infection —> weight loss, decreased immunity, growth faltering —> more disease, increased severity —> increased nutritional needs, loss of appetite

helminths

intestinal parasites (worms)

extremely common in children

infection start at 6 months

weight loss, growth stunting (even if they have enough calories)

malaria

common in many parts of the world

mosquito borne illness

once infected can have later cycles of malaria without reinfection

associated with significant <5 year old mortality 

marginal nutrition

acute or chronic

seasonality of food intake

inappropriate weaning practices

acute marginal nutrition

disruption due to natural disaster, conflict, displacement, etc.

chronic marginal nutrition

chronic low nutrient intake reflection larger social, political, economic forces (structural violence)

seasonality and malnutrition

seasonal changes can impact food availability and infection risk

access to food often decreases before a harvest, when workload increases

rainfall (rainy vs. dry) also alter pathogen risk by limiting clean water (dry) or flooding (rainy)

london 1854 two competing disease theories

miasma theory (the establishment)

germ theory (john snow)

Miasma theory (the establishment)

disease is spread by “bad air”

supported by leading physicians

made intuitive sense (bad smells = disease)

treatment: perfumes, flowers, flee to countryside

germ theory (john snow)

disease spread by contaminated water

based on mapped evidence

contradicted common sense

treatment: remove pump handle

When has “common sense” killed

thalidomide for morning sickness —> 10,000+ birth defects

bed rest for back pain —> prolonged disability

SIDS and stomach sleeping —> thousands of preventable deaths 

evidence based medicine

individual patients

RCTs common

clear outcomes

direct physician-patient relationship

evidence based public health

entire populations

RCTs often impossible

complex long-term outcomes

multiple stakeholders, politics

bradford hill criteria

strength of association

consistency across studies

specificity of effect

temporality (exposure before outcome)

biological gradient (dose response)

plausibility (makes biological sense)

coherence with existing knowledge

experimental evidence

analogy to similar exposures  

research to reality

research

evidence synthesis

guidelines

implementation

evaluation

tradeoffs in PH decisions: type 1 error (false positive)

implementing ineffective intervention

wasted resources

potential harm

example: vitamin e

tradeoffs in PH decisions: type 2 error (false negative)

missing effective intervention

continued suffering

example: delayed seat belt laws

when evidence is incomplete when should we do smth before cause and effect is fully established

precautionary measures should be taken if not raises threats to harm health 

when evidence is incomplete when should we do smth before cause and effect is fully established examples 

banning CFCs before ozone mechanism

COVID masks before aerosol transmission proven

climate action despite uncertainty

where to look for findings (databases)

pubmed/medline

cochrane library

campbell collab

guide to preventative services

where to look for findings (key resources)

CDC’s community gudelines

WHO guidelines

NICE (UK)
USPSTF recommendations

where to look for findings (grey literature)

gov reports, NGO evaluations, unpublished data

Forumulating answerable questions using PICO

population (who)

intervention (what)

comparison (compared to what)

outcome (what are we measuring)

gold standard of evidence

systematic review

meta-analysis

systemic review

comprehensive search

explicit inclusion criteria

quality assessment

narrative synthesis

meta-analysis

stat pooling of results

forest plots

heterogenity assessment

When science decisions cant wait

during emergencies when there are rapid reviews, living systematic reviews, real-time surveillance, adaptive trial designs, precautionary actions

Skills for EBPH practice

ask answerable questions (PICO)

acquire evidence efficiently

appraise evidence critically

apply evidence appropriately

assess impact and adjust

other types of knowledge

qualitative research (understanding why)

community knowledge (local context)

indigenous knowledge (traditional practices)

practice based evidence (what works in real world)

emerging trends in research

big data and predictive analytics

machine learning for evidence syntheis

real world evidence from EHRs 

citizen science

implementation science focus

equity centered evidence

when evidence conflicts with values (scenarios)

evidence supports needle exchange, community opposes

RCT would be ideal but unethical

evidence is weak but need is urgent

when evidence conflicts with values (framework)

transparency about evidence quality

community engagement

clear value trade-offs

monitoring and adjustment

important notes about evidence

evidence based does not equal evidence paralyzed

best available evidence is not perfect evidence

context always matters

absence of evidence is not the evidence of absence

evidence is necessary but not sufficient

community values and feasibility matter

17 points of public health

surveillance

disease and health event investigation

outreach

screening

referral and followup

care mgmt

delegated functions

health teaching

counseling

consultation

collaboration

coalition building

community organizing

advocacy

social marketing

policy development and enforcement

Population health

involves choices and value judgements in both construction and application

opportunity for healthcare systems, agencies, orgs to work together to improve healt outcome

population health vs. public health

Public health focuses on the health of entire communities through policies, education, and disease prevention, while population health uses data analysis to improve the health outcomes of specific subgroups within a larger population. Population also can be more focused on a particular group

Populations

often geogrpahic

groups like employees, ethnic groups, disabled ppl, prisoners

determinants of health like med care systems, social envio, physical envio have biologcial impact on individuals at pop level

population health research concerned about

interactions between them, prefer to refer to them as patterns

methods used by population health researchers have what characteristics

examin systematic differences in outcomes across pops

complex interactions among determinants

biological pathways linking determinants to population health outcomes

influence of different determinants over time and throughout the life cycle 

population health considers

multiple levels of factors that drive health and how these levels intersect

Sweet and Kuzawa use two different explanatory models for population health

social

genetic 

Population health: social

social forces like economics, psychosocial stress, institutional, interpersonal, discrimination account for health disparities 

Population health: genetic

genetic variation in conventional racial clusters accounts for higher rates of health disparities