Public Health 370 Midterm

1988 Institute of Medicine’s definition of Public Health

“What we as a society do collectively to assure the conditions in which people can be healthy.”

Health

A dynamic state of complete physical, mental, spiritual, and social well-being; not merely the absence of disease or infirmity

Political nature

Population-based approaches often involve policy and law; Balance health protection with individual rights (paternalism); Governmental public health officials are often working for people elected to office (and therefore need to be “political”)

Social justice view

individual health is largely determined by their social and environmental conditions

Social justice principles

Shared responsibility and concern for the community well-being; Societal support for those with limited opportunities or resources is encouraged; Maintains that all persons are entitled equally to basic services (e.g., health care, minimum stds of income, housing, environmental quality, education and personal safety and security)

Market justice view

individuals health results from free choice in an unregulated capitalist society

Market justice principles

Individualism and personal responsibility; Self-determination; You “get what you work for”; You “get what you deserve”; With hard work anyone can achieve what they wish “Winners & Losers”; Minimal collective action

Public Health vs Medicine

Public health is population-level, medicine is individual-level

River metaphor

Public health is about working “upstream” to investigate and solve problems

Approaches to Protect and Promote Health

Healthcare (Systems for delivering one-on-one individual health services); Traditional Public Health (Group and community-based interventions directed at health promotion and disease prevention); Social Interventions (Interventions with another non-health-related purpose, which have secondary impacts on health)

Multiple determinants of health

Genetics, behavior, environmental and physical influences, medical care, and social factors

Steps of the PERIE model

Problem, Etiology, Recommendations, Implementation, and Evaluation

Problem

What is the burden of disease? How serious is the problem? Are there disparities in the population? Surveillance, monitoring morbidity, morality, and trends

Disease

The study of health and diseases, morbidity, injuries, disability, and mortality in populations

Incidence

(# new cases / population) x 1000

Attack rate

Incidence in an outbreak

Mortality

Incidence of death

Morbidity

\# people/incidence/prevalence

Prevalence

(# existing cases / population) x 1000

Epidemiology

The study of health and disease in populations

Measuring health outcomes

Mortality and morbidity, length of life, premature deaths, quality of life

Etiology

Find the determinants (causes, risk factors, prognostic factors)

Triad of epidemiology

Calculate rates by time, person, and place (when, who, where)

Disease occurrence

Not random, but can vary depending on a variety of characteristics and predisposing factors

Cross sectional studies

Subjects are studied at a single point in time

Cohort studies

Subjects are surveyed and then followed over time

Case-control studies

Subjects (with disease and without) are surveyed and asked about past experiences

Recommendations

Finding programs that work; Experiments (trials) and observations (quasi experiments)

Experimental studies

Subjects in a defined population are allocated to groups; One group is given a “treatment” and a control group is simply observed; The assignment to groups can be “random,” “blinded,” and/or placebo controlled; Sometimes assignment is not random (we call that a “quasi-experiment).

Clinical vs public health interventions

Randomized experiences are better for clinical interventions, but it’s hard to “experiment” in public health

Primary Implementation

Prior to disease or conditions; individual; information/education

Secondary Implementation

Prior to symptoms; At-risk group; motivation/incentives

Tertiary Implementation

Prior to irreversible complications; general population/community'; obligation/requirement

Evaluation

Critical to measure how much of the problem has been eliminated by the intervention(s) and what is the nature of the problem that remains; RE-AIM

RE-AIM

Reach, Effectiveness, Adoption, Implementation, Maintenance

Public Health Surveillance

Provides *ongoing* information that can be used to improve public health; Monitoring for changes in public health (new problems, returning outbreaks, worsening problems, improvements, issues)

Surveillance provides health related data that is…

Systematic; Ongoing; Timely; Often collected, analyzed, and interpreted continuously; Disseminated to practitioners; Intended to guide action to improve public health

Sources of public health and population data

Collected by local, state, federal, and global agencies

Quantitative sources table

Single case or small series; Statistics and reportable diseases; Surveys and sampling; Self-reporting; Sentinel monitoring; Syndromic surveillance

Single case or small series

e.g.case reports of one or a small number of cases; Alert to new disease or resistant disease or to potential spread beyond initial area; Useful for dramatic conditions but requires alertness and rapid info dissemination

Statistics and reportable diseases

e.g. birth, death, marriage, and reporting of diseases; Required by law with some penalties for noncompliance; Very complete and may be helpful for changes over time but often relies on institutional reporting and has frequent delays

Surveys and sampling

e.g. NHANES and BRFSS; Drawing conclusions about overall population and subgroups from representative samples; Allow inferences to be drawn about larger populations but have frequent delays in reporting data

Self-reporting

e.g. adverse effect monitoring of drugs and vaccines; May help identify unrecognized or unusual events; Useful when dramatic unusual events closely follow initial use of drug or vaccine, but tends to be incomplete and is difficult to evaluate due to selective reporting process

Sentinel monitoring

e.g. influenza monitoring to identify start of outbreak and virus changes; Early warnings or warning of previously unrecognized events; can be used for real-time monitoring but requires knowledge of disease patterns and use of services

Syndromic surveillance

e.g. use of symptom patterns to raise alert of possible new or increased disease; May be able to detect unexpected & subtle changes, such as bio-terrorism producing common symptoms; May be used for early warning pre-diagnosis, but does not provide a diagnosis and may have false positives

Rates

People affected / People at risk

Infant mortality rate (IMR)

1000(# deaths

Life expectancy (LE)

Life expectancy at birth is defined as how long, on average, a newborn can expect to live, if current death rates do not change; Aggregates morality rates for all ages, shifts can be used to describe long-term or high-impact trends, sensitive to morality at younger ages, often used for high-level planning

Under-5 mortality

1000(# deaths

Health-adjusted life expectancy (HALE)

The average number of years that a person is expected to live in good health by taking into account years lived in less than full health due to disease and/or injury; Allow morality and morbidity to be considered simultaneously, useful for comparisons across a range of populations and situations

Years of potential life lost (YPLLs)

A summary measure of premature mortality, add up years for everyone who dies under 75, x100000; Useful for directing resources, can identify theoretically preventable deaths, “counts” death at younger ages more than older

Health communications

The goal of surveillance findings is to disseminate them; This allows targeted action for disease prevention and health promotion

Relationship between health and social sciences

These subject areas share a fundamental belief that understanding the organization behind social forces can be used to improve the lives of individuals, as well as society as a whole.

Social determinants of health

Conditions in which people live and systems that affect health and quality of life; Shaped by wider set of forces (economics, policies, history, societal norms, and policies

How are social systems related to health?

Influencing behavior (norms, opportunities), producing stress, complex interactions

Key categories of social determinants of health

Social status, Social support or alienation, Food, Housing, Education, Work, Stress, Transportation, Place, Access to health services

Socio-ecological model of health

This model considers the complex interplay between individual, relationship, community, and societal factors.

Health disparity

Preventable differences in health that are experienced by socially disadvantaged populations.

Racial disparities in US

Heart disease and stroke, motor vehicle crashes, HIV, STIs

Global health disparity

DALY rates worse in central/south Africa and south Asia

Why is SES a fundamental cause of health?

May affect health directly or indirectly; contribute to wide variety of diseases rooted in lifestyle, environmental, and social factors; affects both physical and mental health

Categories of social determinants of health

Economic Stability; Education Access and Quality; Health Care Access and Quality; Neighborhood and Built Environment; Social and Community Context.

Health behavior theory

The science of why we do things that affect our health

Theory

A set of interrelated concepts that presents a systematic view of relationships among variables in order to explain and predict events and situations

Model

Combination of ideas and concepts taken from multiple theories and applied to specific problems in particular settings

Theory of change levels of influence

Intrapersonal, Interpersonal, Community

Intrapersonal

Focusing on individual characteristics; Knowledge, attitudes, beliefs, motivations, self-concept, past experiences, skills

Interpersonal

Focusing on relationships between people; Other people influence behavior by sharing their thoughts, advice, feelings, and emotional support

Community

Focusing on factors within social structures; Norms, rules, regulations, policies, laws

Key theories/models used to address health behavior

Stages of Change Model; Diffusion of Innovation Theory; Health Belief Model

Stages of Change Model

Intra-personal model; People go through a set of incremental stages when changing behavior rather than making significant change all at once

Stages of Change Model stages

Precontemplation, contemplation, preparation, action, maintenance, relapse

Diffusion of Innovation Theory

Population level model; How a new idea, product, or social practice is disseminated and adopted in a population

Levels of diffusion of innovation adopters

Innovators, early adopters, early majority, late majority, laggards

COM-B

Capability (can this behavior be accomplished?) + Opportunity (Is there sufficient opportunity for the behavior?) + Motivation (Is there sufficient motivation for the behavior?) = Target behavior

Theory-driven practice

Education (skills and abilities; intrapersonal), Communications (motivation; interpersonal), Environmental interventions, laws, and policies (opportunity; community)

Global health

An area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues determinants and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and a synthesis of population-based prevention and individual-level clinical care.

Global Health vs Public Health

Public health professionals may work in communities or organizations, or for government agencies helping an entire country (such as the United States). Global health professionals, however, work internationally to develop health programs for all populations in need.

Sustainable Development Goals history

Alma Ata, Millennium Development Goals, then the SDG

One Health

The collaborative effort of multiple disciplines working locally and nationally and globally –to obtain optimal health for people, animals and our environment

Planetary Health

the achievement of the highest attainable standard of health, wellbeing, and equity worldwide though judicious attention to the human systems--political, economic and social, that shape the future of humanity and the earth’s natural systems that define the safe environmental limits within which humanity can flourish

Major global health successes

Smallpox eradication, guinea worm eradication efforts, reduction of death and child mortality, life expectancy increases

Major global health challenges

Medicalized Approaches; Leadership is not Inclusive; Global North Dominates; Pervasive Coloniality; One Size Fits All Mindset; Persistent Inequity; Failure to Address Root Causes in relation to Population, Consumption, Technology, Equity and more…..

Characteristics that make a disease eradicable

It’s an infectious disease; Humans are the major host of for the disease; Effective vaccines or treatments are available for the disease; There is political and financial support for eradication efforts

Herd immunity

>90% coverage = high potential for elimination

Current challenges to achieving better global vaccination rates in children

Limited resources; Competing health priorities; Poor management of health systems; Inadequate monitoring and supervision; Political instability; Vaccine Hesitancy

How to overcome challenges to children’s’ vaccination rates

**Routine vaccination**; Obtain basic financial resources; Achieve sustained political commitment; Pursue collective action: local to international; Mobilize child health advocates; Improve disease surveillance; Closely monitor for vaccine safety concerns

How are vaccine coverage, adverse events, and disease related?

Vaccine coverage goes up, then dips briefly down. Disease goes down, then jumps briefly up. Adverse effects increase gradually, but dip a little during outbreak.

Beverage

Healthcare is __provided__ and __financed__ by the **government**, through tax payments; There are no medical bills; Medical treatment is a public service; Providers can be government employees; Lows costs b/c the government controls costs as the __**sole payer**__

Bismarck

Providers and payers are private; Private insurance plans financed jointly by employers and employees through payroll deduction; The plans cover everyone and __do not__ make a profit; Tight regulation of medical services and fees (cost control)

National Health Insurance Model

Providers are private; Payer is a government-run insurance program that every citizen pays into; has considerable market power to negotiate lower prices; National insurance collects monthly premiums and pays medical bills; Plans tend to be cheaper and much simpler administratively than American-style insurance; Can control costs by: (1) limiting the medical services they will pay for or (2) making patients wait to be treated

Out of Pocket

Only the rich get medical care; the poor do not have resources of access; Most medical care is paid for by the patient, out-of-pocket; No insurance or government plan; Some public health services are provided; Positive change is occurring in this area –especially in middle income countries

Key drivers of cost

Multiple Systems Create Waste; Drug Costs Are Rising; Doctors (and Nurses) Are Paid More; Hospitals Are Profit Centers; U.S. Healthcare Practices Defensive Medicine; U.S. Prices Vary Wildly

Underperforming metrics compared to OECD countries

Ranked last (11th) except for care processes (2nd)

Strengths of the system

Care processes, research and innovation, patient choice

Access to Care

Affordability and timeliness

Care Process

Preventive care, safe care, coordinated care, engagement and patient preferences

Administrative Efficiency

Insurance, timeliness, efficiency

Equity

Disparities, including cost-related access, healthy lives, effective care

Health Care Outcomes

Infant/maternal mortality, obesity, chronic conditions, life expectancy, avoidable death