Lassila + Covvey Epi Final

Core functions of Public Health

• Assessment

  • Constitutes the diagnostic function, in which a public health agency collects, assembles, analyzes and makes available information on the health of the population

• Policy development

  • Like a doctors development of a treatment plan for a sick patient, involves the use of scientific knowledge to develop a strategic approach to improving the communities health

• Assurance

  • Is the equivalent to the doctor’s actual treatment of the patient. Public health has the responsibility of assuring that the services needed for the protection of public health in the community are available and accessible to everyone

Purpose of Public Health

• Prevent epidemics and spread of disease

• Protect against environmental hazards

• Prevent injuries

• Promote and encourage healthy behaviors

• Respond to disasters and assist communities in recovery

• Assure the quality and accessibility of services

The Disciplines of Public Health- be familiar with all of them

• Epidemiology

• Statistics

• Biomedical Sciences

• Environmental Health Science

• Social and Behavioral Sciences

• Health Policy and Management

Discipline - Epidemiology

• Epidemiology is the basic science of public health.

• The study of epidemics

  • Focuses on human populations, usually starting with an outbreak of disease in a community.

  • Aims to control the spread of infectious diseases.

  • Seeks causes of chronic disease and ways to limit harmful exposures.

• Epidemiologists are mainstays of local public health departments.

  • “Shoe-leather epidemiology”

Discipline - Statistics

• Government collects health data on the population.

• These numbers are diagnostic tools for the health of the community.

• The science of statistics is used to calculate risks and benefits.

• Statistical analysis is an integral part of any epidemiological study seeking the cause of a disease.

• Statistical analysis is an integral part of any clinical study testing the effectiveness of a new drug.

Discipline - Biomedical Sciences

• Infectious diseases are pathogens.

• Control of infectious diseases was a major public health focus in the 19th and early 20th centuries.

• Biomedical research is important to understanding control of new diseases and noninfectious diseases.

  • Chronic diseases

  • Genetics

Discipline - Environmental Health Science

• A classic component of public health

  • Much of the public health improvement in the U.S. in the 20th century was due to improved environmental health.

• Health is affected by exposure to environmental factors:

  • Air quality

  • Water quality

  • Solid and hazardous wastes

  • Safe food and drugs

  • Global environmental change

• Thousands of new chemicals enter the environment every year. (e-cigs)

Discipline - Social and Behavioral Sciences

• Behavior is now the leading concern of factors that affect people’s health.

• A theory of health behavior is that social environment affects people’s behavior.

  • Major health threats are tobacco, poor diet, and physical inactivity and injuries.

  • Ethnic minority groups are also at increased risk for a variety of health problems.

Discipline - Health Policy and Managment

• This area of study examines the role of medical care in public health.

• Cost of medical care in the U.S. is out of control.

• U.S. has a high percentage of population without health insurance.

  • These people often lack access to medical care.

• Quality of medical care can be measured and is often questionable.

• Medical care has eaten up profits that could be used more beneficially for education, housing, and the environment.

What is the definition of chronic disease

Conditions that last 1 year or more AND require ongoing medical attention or limit activities of daily living or both

Health Promotion

Occurs while individuals are healthy to improve overall health, reduce risks, and increase resistance if exposed. These activities often target entire populations (e.g., non-smoking campaigns).

Exposure/Risk factors

Factors that increase the risk of a disease developing in a person

or population (smoking)

Disease Prevention

Related to exposure and risk factors; Activities focus on

prevention of a specific disease and target populations will

consist of at-risk individuals. (smoking cessation)

What are the steps to the Public Health approach

• Define the health problem.

• Identify risk factors associated with the problem.

• Develop and test community-level interventions to control or prevent the cause of the problem.

• Implement interventions to improve the health of the population.

• Monitor interventions to assess their effectiveness.

Understand the difference between prevention vs intervention

• Main task of prevention is to develop interventions designed to prevent specific problems that have been identified

  • Public health recognizes four levels of prevention: primordial, primary, secondary and tertiary.

• Interventions are designed to prevent undesirable health outcomes

Primordial Prevention

• Interventions are designed for risk factor reduction targeted towards an entire population through a focus on social and environmental conditions. Such measures typically get promoted through laws and national policy

• Examples include improving access to an urban neighborhood to safe sidewalks to promote physical activity; this, in turn, decreases risk factors for obesity, cardiovascular disease, type 2 diabetes. Decreasing the advertisement of tobacco (vaping), access to stores with healthy food options.

Primary Prevention

• Consists of interventions aimed at a susceptible population or individual. The purpose of primary prevention is to prevent a disease or injury from ever occurring. Thus, its target population is healthy individuals. Interventions that limit risk exposure or increase the immunity of individuals at risk to prevent a disease from progressing in a susceptible individual to subclinical disease.

• Examples- immunizations, tobacco cessation programs, needle exchange programs

Secondary Prevention

• Interventions emphasize early disease detection, and its target is healthy-appearing individuals with subclinical forms of the disease. Secondary prevention often occurs in the form of screenings.

• Examples-For example, a Papanicolaou (Pap) smear is a form of secondary prevention aimed to diagnose cervical cancer in its subclinical state before progression, mammogram, colonoscopy, blood pressure screening

Tertiary Prevention

• Tertiary interventions target both the clinical and outcome stages of a disease. It is implemented in symptomatic patients and aims to reduce the severity of the disease as well as of any associated sequelae (outcomes). Tertiary prevention aims to reduce the effects of the disease once established in an individual.

• Tertiary interventions are commonly rehabilitation efforts, medication therapy management, disease management activities. (diabetic foot care)

Epidemiologic Triangle/Chain of Causation

• Agent

• Host

• Environment

Agent

• A factor—such as a microorganism or chemical substance, —whose presence or excessive presence, is essential for the occurrence of a disease

• Examples

  • Bacteria

  • Rickettsia

    • small bacteria frequently transmitted by mites, ticks, and lice

  • Virus

  • Fungal infection

  • Parasites

  • Prions

    • misfolded proteins of the brain that have the ability to transmit and involve normal proteins

Host

“A person or other living animal, including birds and arthropods, that affords lodgment to an infectious agent under natural conditions.”

Environment

The domain in which disease-causing agents may exist, survive, or originate

Examples of Pharmacists and Public Health activities

• Immunizations

• Health promotion and disease prevention

  • Screenings

• Disease state management

  • Diabetes Education

• Medication Therapy management

• COVID-19 testing

• HIV Prevention: PrEP (pre-exposure prophylaxis) and PEP (post- exposure prophylaxis)

• Harm reduction strategies (needle exchange)

• Medication safety

• Naloxone (education and dispensing)

• Intimate Partner Violence

• Mandated reporting

Who is the Father of Epidemiology?

John Snow

Who was the first epidemiologist?

Hippocrates

What was the Framingham study and what 3 risk factors were identified early on in this study

• First major epidemiologic study of chronic disease

• Main risk factors for cardiovascular disease:

  • High Blood Pressure

  • High Cholesterol

  • Smoking

Tuskegee: what was this, what important?

• US Public Health Service Syphilis Study

• Total of 600 African American men participated

  • Never gave informed consent

  • Despite discovery of penicillin, men were never offered treatment.

Disease Surveillance

A process of monitoring and reporting levels of disease activity in a community or county or at the sate or national level. Information is used to identify outbreaks earlier with the intention of containing and controlling the spread of disease more effectively

Incidence Rates

The number of new cases of a disease in a population within a specified time period

Prevalence Rates

The number of existing cases of a disease in a population regardless of how long individuals have been ill

Reportable diseases/Notifiable diseases

Diseases usually infectious, are monitored in a population. Laboratories and health care workers who identify potential cases of reportable diseases are expected to notify the local health department.

Sentinel case

The first case of a disease in an outbreak. It usually refers to infectious disease. Epidemiological field methods can be used to determine the sentinel case in a large outbreak.

Endemic

A disease that occurs in a population at a low but consistent and persistent levels so that a limited number of cases occur each year

Epidemic

When a disease outbreak spreads to many individuals in one or more populations across two or more geographic areas

Pandemic

A disease outbreak that involves many people and many countries around the globe.

Divisions within the Department of Health and Human Services

• AHRQ - Agency for Healthcare Research and Quality

• ATSDR - Agency for Toxic Substances and Disease Registry

• CDC - Centers for Disease Control and Prevention

• FDA - Food and Drug Administration

• HRSA - Health Resources and Services Administration

• IHS - Indian Health Service

• NIH - National Institutes of Health

• SAMHSA - Substance Abuse and Mental Health Services Administration

• CMS - Centers for Medicare & Medicaid Services

• ACF - Administration for Children and Families

• AoA - Administration on Aging

CDC

• CDC is the main epidemiologic and assessment agency for the nation.

• CDC publishes Morbidity and Mortality Weekly Report (MMWR).

• CDC’s National Center for Health Statistics collects data on the U.S. population concerning all aspects of health.

NIH

• NIH is the greatest biomedical research complex in the world.

• National Library of Medicine is an NIH institute

• NIH has laboratories in Bethesda, MD and provides grant funding to researchers at universities and research centers

• NIH has a clinical center where medical researchers test experimental therapies.

Federal Government Health Structure

• Department of Health and Human Services (HHS) is the primary federal public health agency.

• Sets national priorities for health and public health.

• Supports and funds public health programs and research.

• Monitors the health of the nation.

• Interacts with international partners to promote health.

State Government Health Structure

• State health departments coordinate activities of local health agencies and serve as a link to federal agencies.

• Have police power to enforce public health laws (e.g., vaccination mandates, quarantine).

• Collect and analyze data from local agencies.

• License and certify medical personnel, facilities, and services.

• Administer Medicaid and manage services like mental health, social services, and aging.

Local Government Health Structure

• Local health departments handle day-to-day public health tasks and direct community-level services.

• Provide core public health functions and medical care to underserved populations.

• Derive police power from the state via local government delegation.

• Hire and advise department directors through local boards.

• May receive funding from city, county, state, or federal sources.

Social Justice

The approach views the equitable distribution of health as a social responsibility

• Collective responsibility for health

• Everyone is entitled to a basic package of services

• Strong obligation to the collective good

• Community well-being supersedes that of the individual

• Public solutions to social problems

• Planned rationing of health care

Market Justice

This approach emphasizes individual rather than collective responsibility for health.

• Individual responsibility for health

• Benefits based on individual purchasing power

• Limited obligation to the collective good

• Emphasis on individual well-being

• Private solutions to social problems

• Rationing based on ability to pay

Review the ethical issues which lead to the Belmont Report

Tuskegee and WWII studies done on humans

What was the Belmont report and the three principles relevant to the ethics of research (know the differences between them and what they are)

• “Ethical Principles and Guidelines for the Protection of Human Subjects of Research“

• Three principles relevant to the ethics of research involving human subjects.

  • Respect

  • Beneficence

  • Justice

Belmont Principle - Respect

• Informed consent

• Protect those that can not make decisions (e.g. children, pregnancy, critically ill, elderly)

• Free choice to participate (e.g. prisoners, students,unemployed)

Belmont Principle - Beneficence

• Assessment of benefits and risks

• Do best to ensure no harm

• Minimize risk and maximize potential benefit

Belmont Principle - Justice

• Equitable distribution of burdens and benefits

• Study includes all groups that may benefit

• Equitable selection of subjects so that the risks and benefits or research are fairly distributed in the population

• Not just one socioeconomic class

What is the IRB?

• A committee charged with the review of human participants research to assure that the rights and welfare of human participants are adequately protected

• Created to ensure ethical conduct of research

• Uses the framework set forth by the Belmont Report to review research proposals

What are the responsibilities of the IRB?

• Protect human subjects

• Minimize risks and maximize benefits

• Interim analysis

• Procedures for obtaining informed consent are adequate

• Subject selection is equitable

• Safeguards for vulnerable subjects

What is informed consent and what reading level should it be written

8th grade level

Review NHANES (why important)

• Designed to assess the health and nutritional status of adults and children in the United States

• Combines interviews and physical exams

• Findings will be used to determine the prevalence of major diseases and risk factors for diseases.

• Used to access nutritional status and its association with health promotion and disease prevention.

• Use data to develop public health policy,direct and design health programs and services, and expand the health knowledge of the nation.

Review Healthy People 2030- Includes high priority areas called Leading Health Indicators (why important)

• Set of national public health objectives produced by the Office of Disease Prevention and Health Promotion of the U.S. Department of Health & Human Services

• Goals

  • Achieve high quality, longer lives free of preventable disease

  • Achieve health equity, eliminate disparities

  • Create social and physical environments that promote good health

  • Promote quality of life, healthy development, healthy behaviors across life stages

• Healthy People prioritizes the issues that affect the health of the U.S. population

  • Leading Health Indicators—high-priority health issues and actions throughout the decade

What are risk factors? (Identify examples: smoking, hypertension, etc.)

• Modifiable

  • Smoking, obesity, diet, substance use, cholesterol levels

• Non-modifiable

  • Genetics, Family History

What is the USPSTF and why is it so important?

• The U.S. Preventive Services Task Force (USPSTF or Task Force) is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications.

Health Literacy: review the lecture and focus on risk factors, red flags, ways to work with individuals with low health literacy (ask me 3 - know the ask me 3)

• What Is My Main Problem?

• What Do I Need to Do?

• Why Is It Important for Me to Do This?

Prose Literacy

The patient has scheduled some blood tests and is instructed in writing to fast the night before the tests. The skill needed to follow this instruction is Prose Literacy.

Numeracy

A patient is given a prescription for a new medication that needs to be taken at a certain dosage twice a day. The skill needed to take the medication properly is Numeracy.

Document Literacy

The patient is told to buy a glucose meter and use it 30 minutes before each meal and before going to bed. If the number is higher than 200, he should call the office. The skill needed to follow this instruction is Document Literacy.

Three Formal Assessments of Health Literacy

• The Rapid Estimate of Adult Literacy in Medicine (REALM)

  • First health literacy assessment to be developed and remains the most commonly used test of health literacy in medical settings.

  • The evaluation asks the patient to pronounce 66 medical terms that are ordered in increasing difficulty and number of syllables

• The Test of Functional Health Literacy in Adults (TOFHLA)

  • Test of health literacy used mostly commonly in health care research.

  • The evaluation consists of two parts, testing both reading comprehension and numeracy.

• The Newest Vital Sign (NVS)

  • This evaluation requires the patient to look at an ice cream nutrition label and answer six questions by referring to the label

Three Indicators of Readability

• The Flesch-Kincaid Readability Test (FK)

• The Fry Readability Formula (Fry)

• The Simplified Measure of Gobbledygook (SMOG)

Reading level for consumer information/patient medication information

5th grade

Populations at risk for limited health literacy

• Elderly

• Ethnic and racial minorities

• Limited education

• Low socioeconomic status

• People with chronic disease

Strategies for improving health literacy among patients

• Recognize red flags

• Create a shame-free experience

• Improve interpersonal communication

• Empower patients

• Use teach-back method

• Use patient-friendly materials and forms

Health literacy impacts?

• Access

• Safety

• Quality

• Outcomes

The TOFHLA is the test of health literacy used mostly commonly in health care research and measures both reading and numeracy

True

What is the first step in achieving cultural competence?

Being self-aware

LEARN Model

• Listen to and understand the patient’s perception of the problem

• Explain your perceptions of the problem and your strategy of treatment

• Acknowledge and discuss the differences and similarities between these perceptions

• Recommend treatment while considering the patient’s cultural parameters

• Negotiate agreement to align medical treatment with the patient’s cultural framework

What it takes to be a culturally competent clinician

• Be aware and accepting of cultural differences; value diversity

• Understand the dynamics of difference

• Assess cultural knowledge

• Be able to adapt to diversity

Ethnocentrism

How a person interprets other cultures or co-cultures ethnocentrism - the view that ones own group or the groups way is superior to others.

Attitudes

Represent our preferences- simply our likes and dislikes

Beliefs

Represent what we hold to be true or false

Values

Express judgments between what is desirable or undesirable, right or wrong, and good or evil.

Bias

Unjustified negative attitude

Stereotyping

• The process by which people use social categories (race, gender) in acquiring, processing and recalling information about others.

• Assumes all members of a particular group share the same characteristics

• No allowances for individual differences

• Cognitive shortcuts

Pharmacogenetics

Study of the relationship between variations in a single gene and variability in drug disposition, response, and toxicity

Pharmacogenomics

Study of the relationship between variations in a large collection of genes (up to the whole genome) and variability in drug disposition, response, and toxicity

Pharmacokinetics

• The study of the relationship between the dose administered of a drug and the serum or blood level achieved

• Concerned with the body's actions on the drug

Pharmacodynamics

• The study of the relationship between drug level and drug effect.

• Concerned with the drug’s actions on the body

What is the difference between a genotype and a phenotype?

(Genotype is the set of unique genes that determines a specific trait in an individual and phenotype is an observable trait such as hair color)

Genotype

The set of unique genes that determines a specific trait in an individual

Phenotype

An observable trait such as hair color

Recognize the 4 types of metabolizers for codeine and what happens when codeine is given to the different metabolizers

• Ultrarapid Metabolizer (~1–2% of patients)

  • Increased formation of morphine following codeine administration

  • Higher risk of toxicity

  • Avoid codeine use due to potential for toxicity

• Extensive Metabolizer (~77–92% of patients)

  • Normal morphine formation

  • Use label-recommended age or weight-specific dosing

• Intermediate Metabolizer (~2–11% of patients)

  • Reduced morphine formation

  • Use label-recommended age or weight-specific dosing

• Poor Metabolizer (~5–10% of patients)

  • Greatly reduced morphine formation following codeine administration

  • Insufficient pain relief

  • Avoid codeine use due to lack of efficacy

What is CLAS?

• Culturally and Linguistically Appropriate Services

• U.S. Department of Health and Human Services identifies guidelines to health care systems and practitioners on providing CLAS

• 3 areas

  • Culturally competent care

  • Language access services

  • Organizational supports for cultural competence

Assessing Cancer Stage and Screening Disparities among Native American Patients

• Native American patients with cancer presented with:

  • Higher rates of advanced-stage disease for screening detectable cancers

  • Lower levels of basic cancer screening knowledge

  • More negative attitudes about cancer treatment than white patients.

• Public health interventions regarding screening and cancer education are needed.

Be able to recognize Cross- Cultural Communication Barriers

• Lack of knowledge

• Fear and distrust

• Stereotyping

• Assumed similarity

• Nonverbal communication

• Authority

• Physical contact/touch

• Verbal languages and styles

What is the Scientific Method?

• The scientific method involves using appropriate study designs and statistical techniques for investigating an observable occurrence and acquiring new knowledge.

  • The health problem

  • Hypotheses

  • Statistical testing

  • Interpretation

  • Dissemination

What is epidemiology?

Epidemiology is the study of the distribution and determinants of health-related states or events in human populations, and the application of this study to prevent and control health problems.

Epidemiology Key Term - Study

• Epidemiology involves sound methods of scientific investigation

• Relies on careful observation and valid comparison groups

• Determines whether observed health events differ from what is expected

Epidemiology Key Term - Distribution

Study of frequency and pattern of health events in the population

• Frequency: Number and proportion in relation to the population

• Pattern: Characteristics of health events by person, place, and time

Epidemiology Key Term - Determinants

Search for causes and contributing factors of health-related states or events

Epidemiology Key Term - Health-Related States or Events

• Disease states

  • Cholera, influenza, pneumonia, mental illness

• Conditions associated with health

  • Physical activity, nutrition, environmental poisoning, seat belt use, provision and use of health services

• Events

  • Injury, drug abuse, suicide

Epidemiology Key Term - Application

Applying the study of epidemiology to prevent and control health problems

Epidemiologic measures provide what types of information

• Frequency

• Associations/Relationship

• Strength

Natural disease timeline - where do the 3 types of prevention fall on this timeline

• Susceptability

  • Primary Prevention

• Subclinical

  • Secondary Prevention

• Clinical

• Recovery, Disability, or Death

  • Tertiary Prevention

Descriptive epidemiology vs analytic epidemiology

Descriptive Epidemiology

• Involves study designs used to answer: Who? What? When? Where?

• Takes place first, then analytic

Analytic Epidemiology

• Involves study designs used to answer: Why? How?

• Takes place after descriptive

Selected activities performed in epidemiology

• Identifying risk factors for disease, injury, and death

• Describing the natural history of disease

• Identifying individuals and populations at greatest risk for disease

• Identifying where the public health problem is greatest

• Monitoring diseases and other health-related events over time

• Evaluating the efficacy and effectiveness of prevention and treatment programs

• Providing information useful in health planning and decision making for establishing health programs with appropriate priorities

• Assisting in carrying out public health programs

• Being a resource person

• Communicating public health information