public health 101 exam 1

How is public health different?

• Focuses more on access to care and looks beyond the doctor’s office 

  • keeping people healthy before they even need clinical care

• preventing the disease in the first place

• promoting the conditions that would prevent the disease 

• protecting existing health so that it doesn’t become ill health 

three p’s of public health and ex of each

• prevention: vaccination programs, clean water systems

• promotion: anti smoking campaigns, nutrition education

• protection: pollution control, safety laws

what does access to health care mean

• physical access: availability of clinics, hospitals, transportation

  • geographic barriers : rural areas might have fewer providers

• economic access

  • affordability of care and insurance

  • programs like medicaid and aca (affordable care act) expand coverage

• health literacy: can people understand and use health info (like translators at hospitals)

what are the different determinants of health?

environmental

• both natural and build env, the conditions in which we live,

• ex. housing conditions

social environment

• broader society (nation,state, laws and policies)

• social networks

• occupation (jobs)

genetic inheritance

• genetic factors that combine with social factors to influence health

what’s the difference between scale and sector in public health?

• scale: where the action happens (local, state, national, global) so usually think like place is associated with sector 

  • think where public health work is happening 

• sector: who is involved (departments of health, education)

  • so think the type of organization or actor involved 

what does the federal gov do?

• enacts influence rather than authority 

• sets priorities 

  • enacts emergency declarations which increases influence and offers more funding

    • trump enacted a public health emergency for drug overdose in 2017

• this system is called federalism 

what is public health infrastructure

the system that delivers and supports public health services

• it connects public sector, private sector, and civil society 

• the government is the backbone of this infrastructure

• also rely on contracts and connections with for profit and nonprofit entities

• in the US, public health is very decentralized 

What are three key federal public health agencies and how do they relate?

for public health infrastructure 

• CDC: prevention: finds new treatments

• FDA (federal drug) → approves and monitors safety

• NIH : research → finds new treatments

NIH discovers, FDA approves (tests), CDC protects and distributes and tracks its effetiveness nationwide

what is the main reason for the federal gov regarding taxing

tax citizens and interstate commerce to generate funds

• can always tax citizens

what are the four key activties of federal gov in public health

1. allocation and distribution of resources 

• Collects taxes and funds national agencies (like CDC, NIH, FDA).

• 2. Information generation and distribution → produces and shares health data from studies and health surveillance systems

3. Health care access assurasnce

   1. Provides and expands coverage through Medicaid, Medicare, and the Affordable Care Act (ACA).

4. regulation and enforcement:

   1. Uses laws and incentives to guide behavior; enforces safety in food, drugs, and workplaces.

federal gov agencies (5 of them)

• CDC

• FDA

• NIH

• USDA (agriculture)

• EPA (environmental protection)

State Level

• Varies state  by state 

• Usually states have a department of health and human services 

• In PA, there was a department for drug and acl programs and there are other agencies for mental health 

• Other sector’s have state agencies that impact public health – PA department of crime and delinquency for example

County/City Level 

• There are city and county departments of public health 

• These  vary from jurisdiction to jurisdiction 

• Often they contract or rely upon the services of nonprofits and other kinds of philanthropic organizations to deliver their services

What’s an example of scale and sector in
public health infrastructure?

a) Climate change and flooding in Houston

b) New York Department of Education and Department of
Health and Human Services collaborating on vaccine
distribution for students in Rochester

c) New York City applies for a federal grant to fund clean
energy construction

d) The Police Department and the Department of Drug and
Alcohol Services collaborate in Monroe County
What’s an example of scale and sector in
public health infrastructure?

b) New York Department of Education and Department of
Health and Human Services is collaborating on vaccine
distribution for students in Rochester

• sector: department of education and health 

• scale: collaborating with rochester 

What are the three main types of public health interventions

1. Environmental Interventions

   • Acting on water, food, or other things in the environment that we take in as a population

   • ex. treating water, inspecting food before consumption 

2. Community/group interventions

   • target specific populations at risk, acting on a community of group of people through the distribution of drugs, medication, tools, or specific treatment protocol 

   • ex.PrEP to prevent HIV, Narcan distribution for opioid overdoses

3. Global Interventions: partners in health accompaniment model → trained helpers patients with chronic diseases like HIV, TB take meds and reach clinics 

📊 What does the CDC do with Evidence-Based Interventions (DEBIs)?

• CDC collects and shares national evidence-based behavioral interventions (DEBIs).

• Provides technical assistance so states can implement them locally.

• Focuses on HIV prevention and other behavior-related public health issues (like substance use or sexual health).
  💡 Think: CDC finds what works → trains states to use it effectively.

🌷 core differences between pre-modern and modern public health 🌟

• pre-modern public health

  • focused on disease outbreaks and environmental control (especially like water)

  • response to poor industrial/factory conditions, malnutrition, overcrowding 

  • goal: contain illness once it appeared 

• modern public health

  • focused on prevention and promotion: improving health before disease occurs

  • promotes health equity: everyone deserves health regardless of race or socioeconomic status (medicaid, translators etc) 

  • emphasis also on health promotion and behavioral interventions 

💡 Shifted from reacting to disease → creating healthy living conditions and equal access for all.

What characterized early (pre-modern) public health conditions?

• early death from disease, overwork, and malnutrition 

• abuse of laborers → long hours, beatings to force productivity 

• mill ever: from inhaling factory dust; freq work injuries like lacerations, broken bones, crushed limbs 

• bad living conditions: no sewage systems, cramped housing 

These bad conditions caused for pre-modern public health to treat these factors 

*industrial revolution era

⚖ What was the social outcry and political response during early public health reform?

• gov set oversaw social and work conditions

• set age limits and workday restrictions for children

• parliament investigated factories → passed laws for safer labor conditions

• realized free markets couldn’t protect health — only gov regulation could ensure safety

💡 Marked the shift from private responsibility → public responsibility for population health.

Why is data and surveillance important in public health?

• Shows the magnitude of health problems

  • answers how many people are sick and who is at risk 

• reveals connections between people and things

  • when, where, and how did people act before getting sick 

  • what actions created more risk

• tracks how risks and patterns change over time (life course + population trends)

ex. John Snow’s water pump study

What does John Snow’s water pump study have to do with data and surveillance in regards to public health?

• John Snow mapped cholera deaths in London and traced them to a contaminated water pump.

• Removing the pump handle stopped the outbreak.

• First use of data mapping to find a disease source — foundation of modern epidemiology and surveillance systems.
  💡 Proved disease spread through contaminated water, not bad air.

What is John Snow’s water pump study an
example of?

a) A population level epidemiological study that helped
reveal the lack of clean water access in London in the
pre-modern to modern public health transition

b) A scientific leader who paved the way for modern
medicine through his water-based scientific studies

c) A germ theory analysis that led to the rise of modern
public health in the 19th century

d) A modern public health calamity that left thousands of
people dead in the 20th century

a) A population level epidemiological study that helped
reveal the lack of clean water access in London in the
pre-modern to modern public health transition

What are the 4 main different types of public health problems?

• infectious (communicable)

  • sprad person to person 

  • ex. HIV, covid, flu 

• non-infectious (non-communicable) 

  • chronic or lifestyle related

  • heart disease

Modern public health expanded focus beyond infections to include

• mental health: addition, depression, schizophrenia

• chronic diseases (diabetes)

• injuries 

  • intentional: drug overdose, suicide \

  • unintentional: car accident, workplace 

What are the early public health achievements 19th and 20th century (know the era)

• sewage systems: removed waste safely, prevented waterborne disease (1800s)

• clean waterways and water distribution systems → treated and recycled water to protect natural supplies

• housing zoning and regulations: reduced overcrowding and improved sanitation (late 19th-early 20th)

• early vaccine development and distrbution: smallpox and rabies introduced (late 19th-early 20)

• access to safe, nutrious food: food inspections and food safety laws (early 20th)

20th century achievements in public health: vaccine development and global distribution

• reduction in infectious disease and prevantable deaths 

• post WW2 global organizations like UNICEF launched mass vaccination campaigns in developing countries

• polio, measles, rubella, influenza, hep. B, rubella 

• cluster the vaccines together so it allowed fewer shots

  • 2010: HBV vaccines showed to decrease the rate of cervical cancer 

🚰 20th Century achievement— Water Fluoridation

• goal: reduce dental cavities and improve dental health 

• this was due to research discovering excess fluoride leads to fluorosis 

  • grand rapids, michigan became the first city to fluoridate public water (1945)

🌾 20th Century achievements — Enriched Flour

• guarantees B-vitamins and later, folate for pregnant women 

• change in flour production due to industrialization which caused a lot of diseases associated with B-vitamin (deficiencies)

• 1938-1942: governments began fortifying flour with B-vitamins

“Naturalgenic” — human-made nutritional problems solved by policy.

🚭 20th Century achievements — Tobacco Control

• research and health promotion around smoking risks 

• changes to smoke free public spaces to reduce second hand smoking risk 

• 1964: a massive change in tobacco control was the publishing of the health risks of smoking on every packet of cigs

• 1965: federal cig labeling and advertising act required labels on all packs talking about the risks of smoking

  • late 20th: banned cigs in public spaces (colleges, restaurants), anti-tobacco campaigns and taxation to reduce use and second hand exposure

Mid late 20th century achievements 1950s and beyond: motor vehicle safety 

• invention of seatbelts and car seats 

• 1966: seatbelts req in all US cars

• 1966: national traffic and motor vehicle safety act→ national safety standards 

• car seats mandated state by state 

• rest areas ones without food and gas were renamed as text safe areas

Mid late 20th century achievements: occupational safety

• particularly developments for hospital and farm workers

  • 1970: creation of OSHA (occupational safety and health administration)

maternal and infant health

• screening for fetuses, prenatal care for mothers 

• rights to abortion (roe v wade 1973), reduced maternal mortality 

overall effect of mid late 20th century achievements

• modern, comprehensive sense of government responsibility for social and economic life 

Open-ended Short Answer:
Focus on one of the major 20th century achievements of public
health and utilize TWO of the following four concept pairs to
construct an imaginary implementation plan in a particular
location:
1) Federal influence vs authority
2) Scale and sector
3) Data and surveillance
4) Public and private government

short answer

behaviorism and motivation

• theoretical specializations in psych

• behaviorism: behavior is learned through conditioning —responses to environmental stimuli

• motivation: internal drive that compels action and acts as the driving factor to engage in specific behavior 

what is the health belief model

• developed in 1950s by social psychologists

• explains why people engage (or don’t) in health behaviors/ health seeking

• people act when they believe the benefits outweigh the risks or barrier

what makes health belief model unique from other models

• focuses on individual perception and motivation, it’s about what people believe about their risks, benefits, and ability to act

the four perceived… health belief model

1. perceived susceptibility: am I at risk for being susceptible to the health issue (I could get lung cancer if I smoke)

2. perceived severity: how serious is it (lung cancer is deadly)

3. perceived benefits: will doing this behavior offer benefits (quitting smoking improves my health)

4. perceived barriers to taking this action: what’s in my way (cravings, stress, social pressure)

cues to action health belief model

• final push that some needs 

  • ex. seeing a terrible image of disease lungs and if people see this pic they won’t buy cigs 

self-efficacy health belief model

• belief in one’s capability to take action (confidence in quitting successfully) 

theory planned behavior

• developed from the Theory of Reasoned Action (TRA) in the 1960s

• Explains how attitudes and social factors shape behavioral intention 

• created the concept of behavioral intention

  • combination of an attitude about a behavior AND perceptions of subjective norms (how it is perceived by others) 

• This model is more social (ppl around us are inherent to the model) yet in a very limited way

theory of planned behavior: behavioral intention

• behavioral intention: the motivation or plan to perform a behavior

• based on two components 

  • attitude toward a behavior

  • assessment of subjective norm  

TPB – Attitude Toward the Behavior

• a person’s beliefs about outcomes of doing something and whether they’re good or bad 

• ex. exercising will make me feel better — that’s good

TPB – assessment of Subjective Norms

• what a person believes others in their social group think about the behavior

• includes social pressure or motivation to conform

• ex. my friends think i should quit smoking so i will 

💪 TPB – Perceived Behavioral Control

(ACTION)

• control beliefs: factors that help or hinder the behavior (making it easy or hard like time, money, skill) 

• perceived power: how strong those factors are 

• ex. i can go to the gym even if I’m tired after work

  • belief in how much control one has over doing the behavior

What is Social Cognitive Theory (SCT)?

• people learn from their immediate social and cultural environments

• emphasizes that individuals are active agents — they can influence and change their environment 

• reciprocal determinism: behavior, personal factorsm and enviironment all influence each other 

  • ex. a person’s exercise habits affect their friends (social) which then reinforces their own motivation

social cognitive theory: vicarious learning

• considered a social and environmental characteristic

• learning by observing others (social modeling)

• ex. seeing a friend quit smoking successfully makes you believe you can too 

🌎 How does SCT view the environment?

• This model already accounts for social, cultural, and structural factors as they shape the immediate environment 

• But as a result, they dont’t create as clear of a target for programs/interventions

• You have to change individual psychology and aspects of the immediate environment

🎯 What makes SCT different from other models?

• Already accounts for social and cultural context — broader than HBM or TPB.

• But it’s less specific for designing interventions since both individual psychology and environmental change must be addressed.
  💡 Change happens through personal effort + supportive environment.

social ecological model

• 1980s

• shows that health is shaped by multiple levels— individual, social, community, institutional, and policy

• factors have bi-directional and mutually reinforcing effects

• expands on reciprocal determinism (SCT)

  • behvaior and env continiously affect one another

what makes SEM unique 

• Views the individual as political — health is affected by social determinants like housing, income, and policy.

• To improve health, people must address both personal behavior and structural conditions.
  💡 Self-efficacy alone isn’t enough; change must occur across all levels.

risk factor

an action of condition that enhances risk for a disease

determinant

• An exposure, behavior, phenomenon, or system that impacts health positively or negatively 

exposure 

Contact of body/brain to a particular substance and or phenomenon at one point in time or cumulatively over time

co-morbidity

• An additional disease or condition that is experienced in tandem with a primary condition

• two or more health conditions at the same time

• Life-course

• The entirety of someone’s life that refer specifically to different stages of physiological and psychological change— childhood, adolescence, young adulthood, adulthood, middle age, and elderly life

Ecological Study

• Focuses on populations, not individuals.

• Compares disease rates or exposures between groups or regions.
  💡 Great for population-level comparisons (e.g., pollution & asthma rates).

case series

• Follows a group with the same disease or exposure to capture data about clinical symptoms …

• Describes symptoms, exposure history, prognosis, or unusual patterns.
  💡 Useful for identifying emerging health issues (e.g., early HIV cases).

📸 Cross-Sectional / Prevalence Study

representative population “snapshot” study to offer a broader overview of the health of a particular group

Case-Control Study

• Compares similar groups of cases, those with disease and those without to identify differences in risk factors and produces an odd ratio 

⏳ Cohort Study

• Prospective: follows a group over time to see who develops disease.

• Tracks exposure → outcome.
  💡 Good for identifying causes and risk progression.

Framingham Heart Study

• Sought to identify common risk factors and characteristics that contributed to cardiovascular disease in an otherwise heart-healthy population of men and women 30-62. The first cohort was recruited in 1948, and a second generation was recruited in 1971. 

• British doctor study 

• A study in the late 1940s sought to understand the impact of smoking on health. The study group was composed of men and women with different smoking patterns – some non-smokers, some ex-smokers, and some regular smokers. The study evolved to only focus on men. 

nurse’s health study 

• A study among married nurses between 30-55 years old to examine risk factors for major chronic diseases: cancer and cardiovascular disease in particular 

🌸 Whitehall studies

• One of the few comprehensive studies on socio economic status and health. Studied a group of lower status british civil servants and discovered stress, acess to health care, work-life balance, early life experiences, and social support all had major effects on health outcomes 

• cohort study for the impcat of social and economic determinants 

• longest study 

basic components of healthcare models?

1. number of sources of insurance coverage

   1. single payer model or multi payer model

2. source of funding 

   1. government— single payer

   2. private OR joint public/private — multi-payer models

3. sector responsible for care

   1. private or public

   2. privately employed healthcare workforce or privately employed healthcare workforce?

multipayer model (US healthcare system)

• The U.S. uses a multipayer system — health care is funded by multiple sources depending on the population:

  • Veterans → VA system

  • Seniors (65+) → Medicare

  • Disabled / low-income → Medicaid

  • Employed → Employer-based insurance

  • Uninsured / indigent → Safety-net or charity care
    💡 Different groups = different “payers” (government, employer, or individual).

• risk and accountability: Who covers the cost if you get sick?

  • In a multipayer system, risk and accountability vary by payer:

    • Government (Medicare/Medicaid) → shares financial and policy risk.

    • Employers/Insurers → manage cost and coverage risk.

    • Individuals → responsible for personal behavior and care decisions.

employer insurance (US healthcare system)

• Working population 

  • Employer provide insurance, partners with private insurance company, private insurance companies, employers, and patients pay

  • For-profit insurance companies insure 

  • Private sector delivers

  • Government is only in a regulatory role

insurance: premium

monthly payment to insurer

deductible

how much the insured person pays BEFORE insurance begins to cover

claim

a claim for insurance submitted by a provider

co-payment

• the portion of healthcare delivered that the insured person is responsible for 

How does Medicaid financing work in regards to the match and waiver program?

• Funded through a federal–state partnership.

• Federal government matches at least 50% of each state’s Medicaid spending.

• Each state has its own Medicaid agency, overseen by CMS (Centers for Medicare & Medicaid Services).

• states have a large amount of flexability in saying 

  • who is eligible for medicare

  • scope of benefits provided

  • payment structures

  • delivery systems

Why is Medicaid so important in the U.S. health system?

• largest source of federal spending

  • engine of state healthcare sector growth 

  • founder of social safety net for states

• fills gaps in our health insurance system 

  • People who have lost employer based insurance or who don’t receive employer-based insurance

• Funds much of long-term support services

  • People with chronic disabilities, nursing facilities, at home care

medicaid waiver program

• Allows states to apply for federal waivers to:
  1⃣ Expand coverage to groups not eligible under federal law.
  2⃣ Change how care is delivered or paid for.
  3⃣ Target specific populations’ health needs (esp. people with disabilities).

• Enables innovation and flexibility so Medicaid can adapt to state and population health needs.

Who are the insurers, payers, and providers for medicaid?

• Federal gov → gives match money to state agencies.

• State agencies → add their own funds and contract with Medicaid Managed Care Organizations (MCOs) — usually for-profit insurers that manage Medicaid dollars.

• MCOs → pay hospitals (public & private) and community-based providers for services.
  💡 MCOs are the direct payers, but the federal and state governments are the original funders.

• Healthcare is somewhat regulated by Medicaid but Drs and care providers are under private authority not under the government’s 

Medicare Structure — Parts A & B

• Federal government = primary insurer and payer.

• Funds go directly from the federal gov to private or public providers.

• No managed care organizations — except under Medicare Advantage (Part C) or Part D (prescription drug plans).
  💡 Traditional Medicare = direct federal payment to providers.

Medicare Part D (and Medicare Advantage)

• Part D: covers prescription drugs.

• Medicare Advantage (Part C) and Part D plans are run by private insurers, but highly regulated and overseen by the federal government.

• private management under strict fedreal rules

Why is the law important for public health?

• Guarantees rights to care

  • Estelle v Gamble (1976) prisoners have a right to medical care

  • Roe v Wade (1973): established reproductive rights 

• defines government power → can limit or expand executive authority 

• Limiting or expanding private authority (businesses)

• Protecting public exposure 

  • environment hazards,

  • communicable diseases (ex if you’re HIV positive you have to disclose that to your partner before having sex in some states)

Law as a determinant of health?

• right and access to healthcare

• gun laws 

• criminal laws: drugs, sex offense law, jail and prison conditions

• limiting or expanding executive authority 

• limiting or expanding private industry authority/rights

legislative branch of gov

writes/makes the law

executive

carries out laws

• modify or alter laws in small ways 

  • all wereintended to guarantee

judicial law

• interprets laws

Who wrote and implemented the affordable care act (ACA)?

• Senate and House of Reps (congress): wrote and passed the ACA into law

• Department of Health and Human Services: enacted regulations associated with ACA and enforced it too

• Supreme Court and Federal Courts: Ruled that mandatory medicaid expansion was unconstitutionally coercive (states could choose whether to expand)

what is considered a federal issue?

• federal cases

  • violations of federal law and treaties

  • constitutionally of state laws (these become US Supreme Court Cases)

  • disputes between states

  • bankruptcy cases

what is a state case?

• violations of state law and treaties

• criminal cases

• civil cases (dispute between private parties)

• contract cases (marriage, divorce, adoption 

what are the key tensions in pubic health?

• individual autonomy vs public protection/health

  • personal freedom vs collective safety

• 1st amendment vs public health

  • when religious or political beliefs conflict with health mandates (eg vaccines)

• healthcare privacy vs population health

  • protecting individual data vs enabling surveillance and disease tracking

• research vs ethics and population safety

  • research goals (scientific knowledge) vs participant health and safety

⚖ Jacobson v. Massachusetts (1904)

• questioned the constitutionality of compulsory vaccination

• everyone in the city of cambridge was charge $5 dollars if they did not follow the law

• jacobson refused vaccination and argued it violated his 14th amendment right to personal liberty

• the supreme court that it wasn’t a violation of the 14th amendment

  • the state could use it’s “police power” to enforce “reasonable regulations” required to protect “public safety”

⚖ Prince v. Massachusetts (1944)

• Sarah prince let her 9 yr old niece distribute religious pamphlets, violating child labor laws

• argued it violated the child’s 1st (free speech) and 14 (due process) rights

• Supreme court rules against Prince, saying the state’s interest in protecting child welfare outweighed religious freedom

  • child safety can override parental or religious rigths

⚖ What was the Chevron Case (Chevron v. NRDC, 1984)?

• Chevron vs Natural Resources Defense Counsel

• Req a two step analysis

  • First, was the statue under consideration ambiguous?

  • if not, the corporation was to follow the intent of the statue written by Congress, and enforced by the Executive Branch

  • if it was ambigiuous, the court would determine whether the agency’s FDA, EPA’s interpreation of the statue was reasonable

⚖ What was the Fall of Chevron (Loper Bright v. Raimondo, 2024)?

• Supreme Court ruled that courts must use their own judgment rather than deferring to agency interpretations.

• Ended 40 years of Chevron deference.
  💡 Now, judges—not experts—decide how laws are interpreted, reducing federal agency authority.

affordable care act

• children must stay on parents’ insurance until they are 26

• free preventative services/standardized components of plan

• medcaid expansion

• employer mandate

  • no discrimination for underlying conditions

risk pooling

healthier people subsidize less healthy people

Key Cases from Guest Lecture Dr. Dorfmann

• Sebelius: upheld most of the ACA but made medcaid expansion optional for states

• Bradwood v Becerra (2023): challenged the ACA’s preventive care mandate (like PrEP coverage) on religious grounds 

• Bostock v Clayton County (2020): Supreme Court ruled that discrimination based on sexual orientation or gender idneitity is illegal under the civil rights act

comparative effectiveness research (dr. dorfmann)

evaluates different treatments for the same condition to find best outcomes and lower costs

current changes in staffing

-poltically appointed staff based on affliation rather than expertise (nepo)

current changes in funding cuts

significant cuts in federal support

mistrust of science 

political appointees sowing mistrust in scientific experts rather than encouraging the public to follow their guidance

current changes in deregulation

loosening the already thin regulatory power of the federal governemnt

current changes in NIH

• radical funding cuts

  • banning research that uses particular words associated with the themes of justice, racial inequality, or gender and reproduction