Public Health 101 - Exam 1

Public Health

What we do as a society to collectively assure the conditions in which people can be healthy.
(Essentially the same as population health)

Population Health

All the ways that society & communities are affected by health issues and how they address these issues. Uses evidence-based approach to analyze determinants & interventions.

Name the three main public health functions.

1. Assessment (monitoring of health of communities to identify issues)
2. Policy Development (formulation of public policies to solve issues)
3. Assurance (assure that all populations have access to health care & disease prevention services)

Describe the health-care approach to population health.

One-on-one individual health services.

Examples: preventative medications, vaccines, and screening.

Describe the traditional public health approach to population health.

Group/community based interventions aimed at health promotion/disease prevention.

Examples: communicable disease control, food & drug safety, reduction in risk factors for disease.

Describe the social intervention approach to population health.

Interventions with another non-health-related purpose, which have secondary impacts on health.

Examples: improving built environment, alter nutrition, improve education, address disparities through tax laws etc.

Demographic Transition

The impact of falling childhood death rates and extended life spans on size and age distribution of populations.

Epidemiological/Public Health Transition

The idea that with more development, different types of diseases become more prominent.

Upstream vs. Downstream Intervention

Downstream is merely treating cases (individual intervention) while upstream is treating the root cause to prevent future cases. Upstream intervention (usually involves government or local policies) is more difficult but much more effective.

Name the vision and mission of Healthy People 2020

Vision: A society in which all people live long, healthy lives.

Mission: Identify priorities, increase public awareness, provides measurable objectives & goals, engage multiple sectors, and identify data needs.

Describe P.E.R.I.E.

Evidence-based public health approach to address a problem:

> Problem (what is it?)
> Etiology (what is the contributory cause?)
> Recommendations (what reduces the health impacts?)
> Implementation (how can we get the job done?)
> Evaluation (how well does the intervention work?)

Refer to cigarettes and lung cancer

What is "etiology"?

Establishing a contributory cause.

Burden of disease

This is the occurrence of morbidity (disability) and mortality (death) due to a disease

Course of disease

This is how often a disease occurs, how likely it is to be present currently, and what happens once it occurs.

Use incidence and prevalence rates to describe course of disease

Distribution of disease

the Who? When? Where?

Incidence rate

Measure the chance of developing a disease over a period of time.

= # of NEW cases during set time period / # of people in at-risk population

Does NOT include people who aren't at risk or already have the disease

Prevalence rate

Tells us the proportion of individuals who have the disease at a point in time.

= TOTAL # of cases / # of people in at-risk population

How do you establish a causal relationship?

Determine the strength of relationship between cause & effect, dose response (if cause increases, does effect increase), consistency in findings, biological plausibility (does the cause make sense for the effect)

What are the three definitive requirements to establish a contributory cause?

1. Cause is associated with the effect.
2. Cause precedes the effect in time.
3. Altering the cause alters the effect.

Primary type of prevention

Prevention phase. This is intervention before onset of the disease. "Upstream" intervention.

Secondary type of prevention

After the development of disease but before symptoms.

Tertiary type of prevention

Symptoms have appeared. Diagnose and treat diseases. Goal is to prevent the irreversible consequences of disease. "Downstream" intervention.

Where most interventions reside

What is "RE-AIM" ?

Reach
Effectiveness
Adoption
Implementation
Maintenance

Used to see how much of problem has been eliminated and what remains.

Name the 6 methods of collecting public health data.

1. Single case/small series
2. Statistics
3. Surveys/sampling
4. Self-reporting
5. Sentinel monitoring
6. Syndromic surveillance

Single case/small series (data source)

Uses: alert to a new disease/potential spread beyond known initial area

Examples: case reports of SARS, mad cow, etc., first report of AIDS

Pros/cons: useful for new conditions; clinicians need to be alert/able to determine the condition

Statistics (data source)

Uses: it is required by law, use birth/death rates to decipher diseases/causes

Examples: vital statistics (birth/death rates, key communicable & non-communicable diseases (elevated lead levels, child abuse)

Pros/cons: required by law so statistics are complete; delays in reporting data, relies on institutional reporting rather than the individual clinician

Surveys (data source)

Uses: drawing conclusions about population from samples

Examples: WHO surveys door-to-door for rate of child vaccinations in third world countries

Pros/cons: well-conducted surveys give good info about larger populations; delays in reporting data (it's a lot of data)

Self-reporting (data source)

Uses: helps identify unrecognized/unusual events

Examples: reporting side-effects from drug or vaccine

Pros/cons: useful when unusual events follow drug or vaccine; tends to be incomplete, difficult to evaluate because not everyone reports

Sentinel monitoring (data source)

Uses: early warnings or warnings of previously unrecognized events
Examples: monitoring flu to identify start of outbreak or change in virus type
Pros/cons: real-time monitoring; requires knowledge of patterns of disease

Syndromic surveillance (data source)

Uses: could detect unexpected and subtle changes like bio-terrorism or new epidemic that produces commonly occurring symptoms

Examples: Use of symptom patterns (headaches, cough, etc) to raise alert of possible new or increased disease

Pros/cons: can be used for early warning; doesn't provide diagnosis and could have false positives, data is incomplete

What are social determinants?

Conditions in which people are born, grow up, live, learn, work, etc. as well as the systems put in place to deal with illnesses that affect health & quality of life.

Connected with health disparities, impact a wide variety of diseases, and affect physical/mental health.

BIG GEMS

A device for remembering the determinants of disease:

Behavior
Infection
Genetics

Geography
Environment
Medical Care
Socioeconomic-cultural

Examples of social determinants.

BIG GEMS.

Gender, age, race, geography, health-care, education, genetics, social-economic status.

Trans-theoretical Stages of Change Model

Assesses an individual's readiness to act on a new (healthier) behavior:
Pre-contemplation
Contemplation
Preparation
Action
Maintenance

Expectancy-value theory

Theory that behavior is the function of expectancies one has and the value of the goal toward they're working. Among several behaviors, they will choose the one that is most beneficial/valuable.

Health Belief Model

Intra-personal (individual) level. Expectancy-value theory:

Perceived susceptibility.
Perceived severity.
Perceived benefits.
Perceived barriers.
Cues to action.
Self-efficacy.

Perceived susceptibility (HBM)

Beliefs about the chances one will get a condition.

To change: define who exactly is at risk, tailor to individual's behaviors, help individual develop an accurate perception of their risk.

Perceived severity (HBM)

Beliefs about the seriousness of a condition and its consequences.

To change: specify the consequences of a condition and recommend action.

Perceived benefits (HBM)

Beliefs about the effectiveness of taking action to reduce the risk.

To change: explain how, where, & when to take action and what the potential positive results will be.

Perceived barriers (HBM)

Beliefs about the material and psychological costs of taking action.

To change: offer reassurance, incentives, assistance; correct misinformation.

Cues to action (HBM)

Factors (strategies or events) that activate "readiness to change"

To change: provide "how to" information, promote awareness, and employ reminder systems.

Self-efficacy (HBM)

Confidence in one's ability to take action.

To change: provide training, verbal reinforcement

Social Ecological Model

Developed to further understand the dynamic relationships between levels of society:

Individual > Interpersonal > Organizational > Community > Public Policy

Diffusion of Innovation

Group-based model. How a new idea, product, social practice is adopted into population:

Innovators (2.5%)
Early Adopters (13.5%)
Early Majority (34%)
Late Majority (34%)
Laggards (16%)

**Think of apple products

Seven questions to answer in health campaign.

1. What is the problem?
2. What do we want to accomplish?
3. Who do we want to reach?
4. What do we want to say?
5. How do we want to say it?
6. Where do we want to say it?
7. Did it work?

Four P's of social marketing.

Product- desired change
Price- cost to implement
Place- audience
Promotion- message to encourage change

Primary stakeholders

Directly affected.

Secondary stakeholders

Indirectly affected.

Key stakeholders

Can have positive or negative effect or are critical to success of project.

Stakeholders

Those who may be affected by, or have an effect on, an effort

Definition of Epidemiology

Study of the distribution and determinants of disease in specified populations, and the application of this study to the control of health problems.

Communicable disease vs. non-communicable disease

Communicable: contagious (smallpox, mumps)

Non-communicable: not contagious (heart disease, violence, lung disease, diabetes)

Difference between risk factors and causes of disease

Risk factor: a variable associated with an increased risk of disease/infection (like being a woman and breast cancer)

Cause of disease:

Endemic disease pattern

Disease occurs at expected frequency in a given population/present at all times

Example: malaria

Epidemic disease pattern

Disease occurs at greater than expected frequency in a given population/excess of normal
Example: ebola, SARS

Pandemic disease pattern

Epidemic of world-wide proportions

Example:

Sporadic disease pattern

Single case or cluster of cases

Horizontal transmission

Direct contact (physical, sexual) and indirect contact (vectors, vehicular like food)

Vertical transmission

Mother to child (during delivery, breastfeeding, etc.)

Natural history of disease

Refers to progress of a disease process in an individual over time (in the absence of intervention)

Natural history of infectious diseases

Exposure to susceptible host -> Infection/no infection -> Disease -> Death or recovery or disability

Natural immunity

Infection has already occurred so immune system will create memory B- & T-cells that will recognize and react to any new exposure to the organism.

Acquired immunity

Immunity has been established without infection:

Active- vaccination (creates memory cells to react if an exposure occurs)

Passive- antibodies for transient/short-term protection

How does herd immunity work?

When a substantial proportion of the population (70-90%) are vaccinated against an infection so that those who are susceptible will rarely encounter an individual with the disease.

Natural history of non-communicable diseases

Gaps that make it hard to determine natural history:

1. Long latent period (lung cancer from smoking)
2. Indefinite onset (usually slow to occur)
3. Multifactorial causation (different risk factors for heart disease like blood pressure, smoking, cholesterol)

How is healthcare considered a right in the US?

A right to healthcare was incorporated in 1948 but until it is recognized by the US constitution, we won't have universal healthcare like other developed countries.

Powers of Federal government when making health policy

-taxing (individual mandate)
-spending (medicaid $$ and grants to health departments)
-regulating interstate commerce (regulate FDA)

Powers of State Government when making health policy

10th amendment in the Bill of Rights

Police power: allows states to pass legislation to protect common good (limited by rights of individuals)

Powers of Local Government when making health policy

Granted by state.

Parks 'n' rec services, police/fire departments, housing services, medical services, municipal courts, transportation, public works (streets, snow removal, etc.)

How can public health policy be made in legislative branch?

Congress writes a bill that can become law (like affordable care act)

An act of congress can then create an agency (FDA, CDC, EPA)

These agencies create regulations (safe levels of toxins in water, safe clinical practices)

How can health policy be made in the executive branch?

Executive departments created by acts of congress, secretaries for the cabinet, 15 executive cabinets (specifically labor, health & human services, housing & urban development, education)

Can also create regulations and executive orders.

How can health policy be made in the judicial branch?

Supreme court rulings based on civil/criminal charges according to constitution.

NFIB v Sebelius - ruled that requiring Medicaid expansion in all states was coercive

Jacobson v Mass. - upheld authority of states to enforce vacc laws

Ethical ramifications of public health policy (individual vs. greater good)

(soda tax)

What is the US's standing in terms of healthcare spending/quality compared to other OECD countries?

The US spends significantly more on healthcare but the quality is worse.

Life expectancy: 27 out of 34
Obesity rates: 1 out of 16
Health expenditure: 1 out of 34
Public health expenditure: 34 out of 34

Medicare

Government, entitlement program that guarantees benefits to:

-65 and older
-Eligible for SS disability benefits
-End-stage renal disease

Medicaid

Means-tested program, funded by state and federal government.

Covers medically needy people based on income and poverty level

CHIP

Means-tested program, funded by state and federal government.

States can use to make separate child health programs, expand medicaid program, or combine these approaches.

Cost-sharing/out-of-pocket expenses

Cost of healthcare that is not covered by insurance and must be paid by the insured

Cap

A limit on the total amount that the insurance will pay for a service per period

Deductible

The amount that an individual or family must pay before their insurance will kick in

Copayment

A fixed amount that the insured is responsible for paying even when service is covered by insurance.

Coinsurance

The percentage of charges that the insured is responsible for paying (instead of having copayment/set amount)

Balance billing

Practice of a healthcare provider billing a patient for the difference between what the patient's health insurance choose to reimburse and what the provider chooses to charge

Premium

The price paid by the purchaser for the insurance policy, on monthly or yearly basis

Fee-for-service

Employment-based insurance.

Insurance companies pay fees to providers based on the services provided to the insured.

*Less incentive for providers to give low-cost solutions.

HMO

Prepaid health plans, clinicians paid based on capitation (fixed amount per month to provide services to individuals--based on # individuals enrolled)

POS

Similar to HMO.

Can pay a lot more to see out-of-network provider.

PPO

Fee-for-service system with limited network of clinicians.

Patients can pay a lot more to see out-of-network provider.

High deductible health plan

High deductibles, low premiums. Can link to health savings accounts.

Affordable Care Act

Costs- ACOs, medical loss ratio, IPAB, CER; Consumer protections- no limits, out of pocket spending limits, no rescission, guaranteed issue; Quality- EHBs, free preventing services, close donut hole; Access- individual mandate, employer mandate, small business tax incentives, marketplace subsidies, expanding Medicare

Environmental and Occupational Health

The prevention of adverse health effects related to environmental and occupational exposures through research, education and service.

Ex: air- & water-borne contaminants, housing, workplace safety

Risk assessments

Process used to formally assess the potential for harm due to a hazard.

Includes: likelihood, timing, and duration of exposure.

1. Hazard identification
2. Dose-response relationship
3. Exposure assessment
4. Risk characterization

Public Health assessments

Incorporates risk assessment but also includes data on the actual exposure of a hazard to a population.

Controversial, take a long time to complete, addresses risks to large numbers of individuals.

Unaltered environment

"Natural" environment and exposures (like sunlight)

Altered environment

Impacts of chemicals, radiation, and biological products that humans have introduced into the environment.

Built environment

Physical environment constructed by humans.

Impact health through hazardous exposure, transportation system, where we work/play/live.

Affects social interactions, activity levels, and are geographic/economically dependent

Interaction analysis approach

Looks at consequences of two or more exposures and how they add up to worsen the hazard.

System analysis approach

Multiplicative interaction. Means that the consequences of two or more exposures can multiply the hazard

Environmental policies that impact health

Clean Air Act, Clean Water Act, National Environmental Policy Act

Health Impact Assessment

Goal: identify areas that will maximize potential health benefits and minimize harm.

Outcome: to provide decision makers with tangible recommendations for how decisions can affect health.