sphg 351 exam 1

does this scenario describe an inequity? “Black women have higher breast cancer rates than White women, despite lower diagnosis rates”

yes, because Black women can be diagnosed more. that is a reasonable and practical solution.

does this scenario describe an inequity? “Less than 1% of breast cancer diagnoses occur in men. In 2022, about 2700 men and 287000 women were projected to be diagnosed with breast cancer”

this is not an inequity because of unavoidable biological differences between men and women.

WHO definition of health

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

challenges with WHO definition of health

• difficult to operationalize because “complete” is impossible to measure

Canguilhem definition of health

• rejects the idea of “normal” and “abnormal” states of health

• health can’t be defined statistically or mechanistically

• not a fixed entity and varies for every individual

• health should be defined by the individual

• risk of reactive instead of proactive actions

challenges with Canguilhem’s definition of health

• difficult to measure

• may only be applicable to circumstances within one’s control

human rights

universal rights of all human beings, regardless of race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status

core components of the right to health

• availability

• accessibility

• acceptability

• quality

availability as a core component of the right to health

the need for sufficient quantity of functioning health facilities, goods, and services for all

accessibility as a core component of the right to health

health facilities, goods, and services must be accessible to everyone

acceptability as a core component of the right to health

health facilities, goods, services, and programs are people-centered and cater to the specific needs of diverse population groups

quality as a core component of the right to health

the underlying determinants of health as well as requiring that health facilities, goods, and services are scientifically and medically approved

public health

the science and art of prevention of disease, prolonging life and promoting health through organized community effort

mission of public health

the fulfillment of society’s interest in assuring the conditions in which people can be healthy

substance of public health

organized community efforts aimed at the prevention of disease and the promotion of health

organizational framework of public health

both activities undertaken within the formal structure of government and the associated efforts of private and voluntary organizations and individuals

population health science

• studies conditions that shape the distributions of health and the factors that influence the health of populations

• uses qualitative and quantitative science to understand the causes of health for populations

bell-curve shift in populations

shifting the whole population into a lower risk category benefits more individuals than shifting high risk individuals into a lower risk category

public health approach

• define and monitor the problem

• identify risk and protective factors

• develop and test prevention strategies

• assure widespread adoption

activities associated with “defining the problem”

• case definitions

• notifiable disease reporting

• surveillance systems

• epidemic curves

activities associated with “identifying risk and protective factors”

• case-control and cohort studies

• network analysis

activities associated with “developing and testing prevention strategies”

• randomized trials

• pilot programs

• natural experiments created by policy differences

activities associated with “assuring widespread adoption and evaluating”

• implementation and funding

• policy

• monitoring

• equity-stratified outcome measures

HIV case study

• in early 1980s a new disease outbreak occurs

• became known that it can be transmitted through contaminated blood

• defining the problem

  • speculated that it was a white gay male disease that attacks the immune system

  • officially named AIDS and then specified HIV

• identify risk and protective factors

  • 4H disease: homosexuals, hemophiliacs, Haitians, heroin users

  • risk groups → risk behaviors → risk conditions and networks

  • cohort studies quantified transmission routes

• develop and test prevention strategies

  • AZT given to pregnant women to lower mother-to-baby transmission

  • circumcision

  • PrEP and partner treating

• assure widespread adoption and evaluate

  • PEPFAR funds HIV treatment abroad

  • finding where people drop out of the care continuum

• global occurrence

  • more prevalent in nonwhites

  • primary mode of transmission is heterosexual contact

  • slightly more females than males are living with HIV/AIDS

health inequality

unequal access to healthcare and opportunities to achieve optimal health

health equity

• absence of unfair, avoidable, or remediable differences among groups of people

• custom tools that identify and address inequality so that everyone can attain their full potential for health and well-being

equality

evenly distributed tools and assistance

justice

fixing the system to offer equal access to both tools and opportunities

health inequity

unfair, avoidable, or remediable differences among groups of people

Sankofa

• “to go back and get it”

• we should retrieve things of value from our knowledge of the past

public health in the Middle Ages

• Europe experiencing a series of plague epidemics

• quarantine and isolation used during plagues to protect the population

public health history in mid-1800s London

• Edwin Chadwick advocated for improving living conditions in order to improve health

• argued that improved health would improve productive output and reduce social costs

• proposed providing clean water, removing wastes, and having access to a physician

• aligned emerging field of public health with the economic priorities of the government

John Snow

• Broad Street pump outbreak during the 1854 cholera epidemic in London

• population-level data

• father of epidemiology

key historical lessons from public health history

• public health looks at whole populations rather than individual

• prevention focused

• relies on evidence + political will to act on that evidence

public health in Ancient Egypt

• state funded health care

  • doctors available

  • housing provided

  • designed to ensure workers were able to stay healthy and be productive

• paid sick days

• social safety nets

smallpox and the Song Dynasty

variolation (inhaling smallpox scabs to introduce disease to body in a less intense form) used to immunize against smallpox

core functions of public health

assessment, policy development, assurance

assessment

• assess and monitor population health

• investigate, diagnose, and address health hazards and root causes

policy development

• communicate effectively to inform and educate

• strengthen, support, and mobilize communities and partnerships

• create, champion, and implement policies, plans, and laws

• utilize legal and regulatory actions

assurance

• enable equitable access

• build a diverse and skilled workforce

• improve and innovate through evaluation, research, and quality improvement

• build and maintain a strong organizational infrastructure

major public health achievements over the 20th century?

• vaccination

  • smallpox eradicated

  • polio banished from Western Hemisphere

  • spread of measles, diphtheria, rubella, and tetanus well controlled through childhood vaccination

• control measures for infectious diseases

  • water purification

  • sanitation

  • vaccination

two-prompt source evaluation

• credibility challenge

  • could this source be reasonably questioned? consider current data, author expertise, funding source, etc

• limitation

  • one genuine weakness for a particular source

scientific evidence

• peer reviewed research

• clinical and epidemiological studies

• systematic reviews and meta-analyses

surveillance and population data

• CDC surveillance systems

• vital statistics

• census data

• state and local health dept data

• GBD

community knowledge

• lived experiences

• community priorities

• cultural context

• community-based participatory research findings

professional and practice-based evidence/knowledge

• reputable public health organizations (ex: WHO)

• public health practitioner expertise

• clinical observation

policy and regulatory evidence

• laws and regulations

• government reports

• national guidelines and recommendations

primary source

• has a methods section

• results are new

• cohort and case-control studies, trials, surveys, surveillance reports

secondary source

• no new data collection

• often organized by topic rather than by a single research question

• reviews and meta-analyses, textbooks, CDC/WHO topic pages, news coverages

• gray literature (literature that hasn’t been peer reviewed)

critical appraisal

process of carefully and systematically examining research to judge its trustworthiness, and its relevance and value in a particular context

AACDOS

• authority: who is responsible for content and what makes them credible

• accuracy: does it state an aim and a method and does it follow them? are the claims supported by documented sources?

• coverage: what are the limits of the report?

• objectivity: is the author’s standpoint clear and is the presentation balanced?

• date: is there a clear date tied to the content?

• significance: does this add context, a unique finding, or a counterweight?

emergence of the racial disparity in US breast-cancer mortality

• age adjusted breast cancer mortality is 40% higher among Black women despite lower incidence among Black women

• age-period cohort models: distinguish among changes in mortality based on age at death, year of death, or year of birth

• important to ensure access to high-quality medical care

disease

• abnormal processes or functions with specific signs and symptoms that can be observed or measured

• signals something is amiss and not fully healthy

occurrence

amount of disease or injury present within a population at or over a specific period

prevalence

• total number of cases of disease/injury over specific period of time

• commonly used for chronic diseases

incidence

• total number of new cases of disease/injury over a specific period of time

• commonly used for infectious diseases and injuries

incidence or prevalence: in 2024, 8900 women in NC received a breast cancer diagnosis

incidence

incidence or prevalence: as of January 1, an estimated 4 million women in the US were living with a history of breast cancer

prevalence

incidence or prevalence: among women screened at clinic, those with dense breast tissue were 2 times as likely to be diagnosed over the next 5 years

incidence

incidence or prevalence: breast cancer death rates fell about 1% over the past decade

incidence

rate

proportion of population

counts

absolute number of cases

primary sources of occurrence health data

• CDC

• WHO

• state department of Health and Human Services

• GBD study

• county health departments

• peer reviewed research studies

biomedical burden

• impact of disease and disability on bodies, from the onset of illness or injury to the outcome that includes sickness or disability, recovery, or death

• ex: morbidity & mortality

economic burden

• financial costs of an illness or injury for individuals, households, healthcare systems, and societies

• direct medical costs → productivity losses

• caregiver costs

• public health response

quality of life burden

• the impact on a person’s subjective wellbeing, daily functioning, and social participation

• physical functioning

• caregiver burden

YLL

years of life lost

YLD

years lived with disability

DALY

• disability adjusted life years

• overall measure of biomedical disease burden

• one DALY represents the loss of the equivalent of one year of full health

• amount of life lost in a population as a result of premature death or disability

DALY =

YLD + YLL

WHO quality of life (WHOQOL)

• assesses individuals’ perceptions of position in life in relation to goals, expectations, standards and concerns in the context of their culture and value systems

• 29 language versions

• adaptations for people with HIV and spiritual individuals

breast cancer

• female breast cancer fairly common compared to other cancers

• most frequently diagnosed among women aged 65-74

  • median age at diagnosis is 64

• mortality

  • 42000 women and 530 men die in the US annually

• morbidity

  • surgical effects

  • lymphedema

  • chemo-induced neuropathy

  • premature menopause and infertility

  • bone density loss

  • second cancers from radiation

• less diagnosed in Black women than White women, but Black women are about 40% more likely to die of it

• qol burden

  • depression and anxiety

  • mastectomy, hair loss, scarring

  • sexual health and intimacy

  • fatigue

  • employment and identity

• economic burden

  • medical costs for US

  • costs borne by patients directly

  • productivity loss

  • caregiver costs

global burden of disease

• systematic, scientific effort to quantify the comparative magnitude of health loss due to injuries, and risk factors by age, sex, and geographies for specific points in time

• goals:

  • what are world’s leading health problems?

  • how well is society addressing those problems?

  • how do we allocate resources to maximize health improvements?

leading causes of early death and poor health globally, 2023

1. ischemic heart disease

2. neonatal disorders

3. stroke

health effects associated with household air pollution

• increased risk of ischemic heart disease

• lung cancer

• COPD

• lower-respiratory infections

• stroke

• type 2 diabetes

• adverse birth outcomes

• development of cataracts

GBD cause list

• 3 categories

  • communicable, maternal, neonatal, and nutritional causes

  • non-communicable disease causes

  • injuries

• increasing specificity at each level within each category

which of the following is a cause of ill health according to GBD?

• high BP

• falls

• air pollution

• malnutrition

• none of the above

falls

GBD risk factors

• estimates exposures to major risk factors

  • environmental

  • behavioral

  • metabolic

• 84 risk factors or clusters of risk

social determinants of health

• the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risk

• education access and quality

• healthcare access and quality

• economic stability

• social and community context

• neighborhood and built environment

• focus on upstream conditions

risk factors

• factors that influence health outcomes with predictable effects

  • behavior or lifestyle

  • biological characteristic

  • health-related condition or environmental exposure

• operate at the individual level

risk factors vs determinants for COVID-19

• risk factors

  • age

  • underlying medical conditions

  • vaccination status

• determinants

  • housing density

  • access to healthcare

  • paid sick leave

stages of prevention

• primary

• secondary

• tertiary

primordial prevention

• aims to completely prevent the expression of a risk factor

• activities take place far upstream

• when successful, lowers disease incidence

primary prevention

• aiming for disease eradication of injury prevention

secondary prevention

• screening

  • do not diagnose disease, but identify people at highest risk for disease who then undergo further evaluation and testing to diagnose disease if it is present

• treatment implemented as early as possible

tertiary prevention

• slowing progression of disease, debility, disability, and death

• rehabilitation is the central theme

rules of thumb for screening usage (according to WHO)

1. should only be done for diseases with serious consequences, so tests have clear benefit to people’s health

2. reliable and not harmful in itself

3. must be effective treatment for the disease when detected at an early age and scientific proof that treatment is more effective when started before symptoms arise

4. unbiased info should be made available to help the public decide for themselves whether or not to have a screening test

sensitivity as a screening performance measure

ability to correctly identify a person with a disease or the percentage of persons with a disease who screen positive

specificity as a screening performance measure

ability to correctly identify a person without disease or the percentage of persons without disease who screen negative

false-positive fraction as a screening performance measure

percentage of people without a disease who screen positive

false-negative fraction as a screening performance measure

percentage of people with disease who screen negative

prevention and COVID

• primary

  • vaccination campaigns

  • transmission prevention strategies (mask wearing, social distancing, good hand hygiene)

• secondary

  • early detection and intervention in people with subclinical forms of COVID

  • regular testing and screening programs

  • contact tracing

• tertiary

  • reduce severity of disease and associated complications in infected people by providing medical care and treatments

plain language

• clear, concise, to the point

• doesn’t rely on public health or scientific jargon

• written for a general audience

• grammatically correct with complete sentence structure and accurate word usage

plain language communicating public health stats

• identify measure and unit, population, place, year, and source of data

• describe statistic in plain language

• describe the significance of the statistic

absolute values (counts)

compare only within the same population

rates and ratios

compare within or between populations

terms to avoid when describing countries

• first or third world

• developed or developing

• global south

key principles to guide communication

• avoid using adjectives

• person-first language

• gender vs sex

population

• requires more than one individual

• individuals have one or more common characteristic

Public Health Act of 1848

• created and operationalized General Board of Health in London

• board then created local health boards