Discussion questions 1

Definitions

1. What is the risk factor model of health and disease?

• General:

  • Takes an individual-level perspective

  • Identifies specific factors that increase likelihood of having a disease (genes, personality, health behaviours, environmental factors…)

• Suggested social policies:

  • Policies focused on changing individual-health behaviours using education, persuasion and treatment regimes

  • Public health intervention such as clean air and water regulations or measures like quarantine of infection people

2. What is the Lalonde Report?

• Arguments:

  • There are 4 health fields: human biology, the social and physical environment, lifestyle, and healthcare organization

  • Public health interventions should be focused on populations at risk

3 + 4. Differences between individual-level and population-level analyses?

5. Focusing on some individual-level factors (such as age, sex, and genetic disposition), evaluate the capacity of individual characteristics in predicting health outcomes.

• General:

  • Indidvidual-level factors are not good predictors of health outcomes

    • These factors can mediate the relationship (ex: increase risks) through many mechanisms but are not direct predictors

      • Age

        • Variations at all ages

        • We live longer and healthier lives

        • Differences in health and life expectancy at different ages in different populations

      • Sex

        • Treated as a binary variable but is on a spectrum due to variances in hormones → dichotomizes people

        • Confounded with gender and related social expectations

      • Genes

        • No one gene

6. What was the MR FIT study about?

• General:

  • The goal was to evaluate the problems associated with individual-risk factor modification initiatives

  • Even with intense education, group support, and a range of incentives, health-related behaviours and the health outcomes associated with them fail to shift significantly

• Conclusions:

  • It is very difficult to change people’s habits in a lasting way

  • The risk factors the trial focused on account collectively for only a minority of heart attacks

• Main implication: health operates at a multifactorial level

  → Lots of different pathways that lead to incidences of disease

7. Define reductionism and provide examples of reductionism in health and illness studies.

• Reductionism: taking a complex phenomenon and reducing it to a single cause

  • You make the phenomenon very simple + present it in its most basic form

• Examples:

  • Health problems are caused by aging

  • Certain health problems are caused by being male or female

  • Health problems are caused by certain genes

8. What were Thomas McKeown’s arguments about the role of health interventions in the improvements in health evident in western European populations?

• Arguments:

  • Medical advancement wasn’t the cause of health improvements since 1700

  • The sharp decline in mortality after 1850 was entirely due to changing social and environmental factors (ex: the availability and affordability of more diverse and nutritionally rich foods)

  • We should consider the social determinants of health (ex: social and economic factors)

• Implications:

  • Advocates more for a population-level

  • Focus on social determinants of health because factors other than healthcare have far more impacts

  • Prioritizing preventative measures

9. What are the demographic and the epidemiologic transitions?

• Demographic transition:

  • Place becomes more affluent → death rates drop and birth rates remain high causing the population to grow very rapidly → birth rates begin to fall and decline to match or even end up lower than death rates

• Epidemiologic transition:

  • The change from infectious and parasitic diseases in poorer places to chronic diseases in richer ones

10. Explain Rose’s population approach. How does it compare/contrast with the arguments advanced by the Lalonde Report?

• Rose’s population approach:

  • The distribution of risk exposure in a population is shaped by contextual conditions

  • Most cases in a population are represented by individuals with an average level of risk exposure

  • Look at population as a whole

11. What do population approaches to intervention based on Rose’s ideas involve?

• Interventions:

  • Broad scale interventions targeting the whole population

    • Examples: mass environmental control methods and interventions aimed at changing behavioral norms

12. What is a population at risk and how does it differ from a vulnerable population?

13. Define fundamental cause and explain the pathways through which the fundamental cause mechanism works.

• Fundamental cause: a cause that links risk factors and their accumulation to one’s position in the social structure

• Mechanisms

  • Life course: a person’s health is the result of all previous experiences, including those that may not be directly related to health

    • Latent effects → the early life environment affects adult health independent of intervening experience

    • Pathway effects: the early life environment sets individuals onto life trajectories that in turn affect health status over time

    • Cumulative effects: the intensity and duration of exposure to unfavourable environments adversely affects health

  • Concentration of risk: exposure to multiple risk factors and a greater number of comorbidities are more frequent in some vulnerable populations

14. What is the difference between health inequality and health inequity?

15. Explain the differences between the two distinct approaches for evaluating health inequalities:

16. Beckfield et al. identify 3 main institutional theories that are used to study how the welfare state affects health inequality, what are they?

• Limitations:

  • Don’t explain why some of these individual-level determinants vary in their frequency or in their effects across institutional contexts

  • Try to pinpoint one specific aetiological cause of health inequalities but it is the entire approach to accumulation, legitimation and reproduction taken by a particular welfare state, over a long period of time or life course that matters

  • Overlook institutional effects that span national boundaries

17. What is the socioeconomic gradient in health? Do you think poverty is the sole aetiological cause for these health differences?

• Socioeconomic gradient in health: people who are at the highest socioeconomic position (income, occupational grade, educational attainment) are healthier and live longer disability-free lives than poorer people

  • BUT poverty is not the only aetiological cause for these health differences due to the collinearity problem

    → Several predictive variables are highly correlated with each other, making it difficult to ascertain the relative contribution of each to the outcome

    • Examples of variables associated with being rich: higher education levels, improved living conditions, improved housing, better diet, and safer, more rewarding work…

Critical thinking questions

1. Why do governments and public health authorities continue to rely almost exclusively on individual-level measures intended to change personal behaviour?

2. In class we noted that a number of carefully run trials and interventions have tried to induce health-relevant behavioural changes. However, the expected differences in behaviour and health outcomes has failed to ensue. Why might experiments/ health interventions intended to support healthier behaviour fail?

3. In what ways does life for the average person living in Montreal differ today from 100 years ago? How might differences affect infant mortality? Life expectancy? The patterns of disease and disability?

4. As we saw in class, at lower stages of economic development, infectious, parasitic, and nutritional diseases afflict predominantly the less well-off while the rarer chronic diseases such as coronary heart disease afflict mostly the rich. In other words, as social and economic change advance, infectious, parasitic, and nutritional diseases became rarer, but chronic diseases became more common, amongst the less well-off, not the rich. What lies behind these important changes? What features of our modern society are driving coronary heart disease, diabetes, and renal failure, particularly amongst the less well-off members of our society?

5. Preventive medicine—screening, early diagnosis, and putting people on medication to modify risk factors like blood pressure—is not making much progress in creating a healthier public. Why?

6. Why might the distribution of resources within a society have a decisive impact on its health?