Exam Flashcards
Reasons for GBD project
- Data from many countries was incomplete
- Lobbying groups gave distorted images
- Available data largely focused on deaths, little info on non-fatal outcomes
Aim of GBD
Use a systematic approach to summarise the burden of disease and injury at the population-based level
- aid in setting health service and health research priorities
- aid in identifying disadvantaged groups and targeting health interventions
DALY
Summary measure that combines data for both fatal and non-fatal outcomes to represent the health of a population as a single number
DALY Advantages
- Draws attention to previously hidden burden of mental health and injury as a major public health problem
- Recognizes NCDs as a major and increasing problem in LMIC
DALY Challenges
- Criticised for the potential to represent people with disabilities as a burden
- Disabilities are considered to be the same severity as someone living with an impairment relating to disease, and do not change with life circumstances
2 Measures of DALYs and data required to calculate them
YLL - years of life lost
(# of deaths from disease per year, years of life lost per death relative to an ideal age)
YLD - years lived with disability
(# of cases of disease, average duration until recovery/death, disability weight)
Medical model
- Views disability as an individual problem,
- Individuals are defined by their disability
Social model
- Views disability as a social issue
- Focuses on ridding social barriers
Double burden of disease
Top causes of DALYs in a country are both NCDs and CDs (usually occurs when a country transitions from lower to middle income)
Risk transition
Changes in risk factor profiles as countries shift from lower to higher incomes, where common risks for perinatal and CDs are replaced by risks for NCDs
Epidemiological transition
Characteristic shift in common causes of death and disability from perinatal and CDs to NCDs
Perceived ethnicity
The ethnicity others perceive you to be based on skin, dress, accent etc
Foregone healthcare
Inability to access healthcare when needed
Inverse care law
The availability of good medical or social care tends to vary inversely with the need for it in the population served
Snowflake hypothesis
Overprotection and low resilience affecting early development (parental monitoring, parental stress)
Igen hypothesis
Social media, internet access, phones affecting youth mental health (less physical activity, increased bullying, talking to parents less, less sleep, risk taking)
Doomer hypothesis
Impact of job insecurities, housing affordability, climate crisis, political polarisation, disinformation and misinformation on youth mental health
Youth 2000 Limitations
Recruitment: those not at school, those with certain disabilities and language barriers not included
Measurement: Students may not have answered honestly, so can never be certain data is entirely accurate
Reverse causality - difficult to establish temporality as outcome and exposure measurements taken at the same time
Inability to help youth whose responses indicated they were at risk
Youth 2000 strengths
Technology meant better response rates as students are more likely to enjoy experience
Reduced measurement bias due to survey being anonymous
Triple dividend
- Benefits for adolescents now
- Benefits for their future adult lives
- Benifits in outcomes for their future children
Key determinants of ethnic disparities
- Differential access to healthcare
- Differential access in quality of care recieived
- Differential access to exposures/determinants of health
Key indicators of Maori health
- Major causes of death
- Patterns of morbidity and mortality
- Life expectancy
Maori health is exemplified by disparities in:
- Health outcomes
- Health system responsiveness
- Health system representation
- Exposure to determinants of health
Land alienation is associated with:
- Decreased fertility rates and mother:child ratio
- Resentment from Indigenous people
- Breakdown of political power & aliances
- Poverty
- Economic resource depletion
- Overrepresentation of Maori in more deprived areas
Structural intervention
Physical approach/intervention - more lifeboats, no barriers, ensure equal access to safety/healthcare
Social intervention
Rights-based approach - equal rights to lifeboat
R2H: state is obligated to…
Respect (no discrimination)
Protect (no 3rd party interference)
Fulfil (adopt measures to achieve equity)
Instruments relevant to Maori health
- TToW
- Indigenous rights act
- Human Rights Act
- Te Pae Ora act
- Code of patient rights
NZ Living standards frame work captures:
- Resources and aspects of our lives important for wellbeing
- Role of institutions in building and safeguarding our wealth and wellbeing
- How wealthy we are in aggregate as a country
Wealth of Aotearoa
Natural, Human, Financial/physical, Social
Natural
All aspects of the living environment needed to support human life and activity
Human
Peoples skills, knowledge, physical and mental wellbeing
Financial/physical
Things that have a direct role in supporting incomes and material living conditions
Social
Norms and values that underpin society
Commercial determinants of health
Inherent tensions between public and commercial objectives in the consumption, affordability and availability of goods and services
Industry strategies
- Shaping the evidence
- Constituency building
- Employing narratives/framing techniques
- Policy substitution, development & implementation
Shaping the evidence techniques
- Lobbying
- Shaping research and funding priorities
- Financing university chairs and programmes (2012-2018 Fonterra chair in human nutrition UoA)
Constituency building techniques
- Partnerships with charities or health/education related foundations
- Promoting/sponsoring efforts beyond core business (ANZ + cricket)
Employing narratives/framing techniques
- Focusing on youth
- Focusing on individual behaviour problems
- Focusing on corporate social responsibility
- Being apart of the solution
E.g SMASHED - funded by the tmr project which is owned by NZ alcohol producing companies
Policy substitution, development and implementation techniques
- Contributing to health policy consultations
- Partnerships or voluntary agreements with the government (health star rating)
SEP definition
Social and economic factors which influence the position an individual or group holds within the structure of society
Why measure SEP
- Allows us to see changes overtime
- Allows us to see changes in population structure overtime
- Quantify levels of inequalities
- Understand relationships between health outcomes and other variables
Measure of SEP for individuals
- Housing
- Education
- Occupation
- Income
- Assets + wealth
Measures of SEP for populations
Area: Deprivation & access
Population: GDP, literacy rates, income inequalities
Area level deprivation
State of demonstratable or observable disadvantage in relation to local community, wider society or nation to which an individual, group or family belongs - a way of measuring an individuals relative position in society
Global determinants of SEP
GDP, literacy rates, income inequalities, free trade agreements
Preston curve
Life expectancy (y), GDP per capita (x)
Lorenz curve
Measures level of income inequalities in a country (more concave = more unequal)
Gini coefficient
Measures relationship between Lorenz curve and line of perfect equality, A/(A+B), 0 = equal, 1 = unequal
Inequalities
Differences in health experience or outcomes between population groups (according to
SEP, area, age, disability, gender,ethnic group
i.e. ‘the social gradient’)
Inequities
Inequalities deemed unfair or stemming from kind of injustice.
- Health inequities are differences
in the distribution of resources/services across populations that do not reflect health needs
PROGRESS (equity for whom)
Place of residence, race, occupation, gender, religion, education, socioeconomic status, social capital + disability
Why reduce inequalities
- They are unfair
- They are avoidable
- They affect everyone
- They are cost-effective to avoid
Implications of income inequalities
- Unequal society
- Less trust
- Increased stress
- Less social cohesion
- Reduced economic productivity
- Poorer health outcomes
5 As
- Availability
- Accomodation
- Accessibility
- Acceptability
- Affordability
Accessibility
Relationship between location of supply and location of clients, taking into account transportation time, distance and cost
Availability
Volume and type of existing services and resources available in relation to the volume and type of clients needs (e.g knowledge of where to get health care)
Accommodation
Relationship between manner in which services and resources are organised and the expectations of the clients
Affordability
Cost of services in relation to clients’ ability and willingness to pay
Acceptability
Relationship between providers and clients’ attitudes to what constitutes appropriate care
4 Vs
Volume, veracity, velocity, variability
3Vs
Variability, visualisation, value
Events that determine population structure
- Fertility rates
- Death rates
- Birth rates
- Migration
Dependency ratio
(youth+elderly (0-14, 65+)/working age population) x 100
Numerical Ageing
Absolute increase in the population that is elderly
Structural Ageing
Increase in the proportion of the population that is elderly
Natural decline
More deaths than births
Absolute decline
Insufficient migration to replace lost births and increased deaths
Prioritised output advantages
- Ensures ethnic groups are not swamped by NZ European ethnic groups
- Produces data that’s easy to work with, as everyone is only counted once
Prioritised output disadvantages
- Places people in specific ethnic groups which simplifies yet biases the stats as it overrepresents some groups at the expense of others
- Externally applied single ethnicity may be inconsistent with personal identification
Total response output advantages
- Has potential to represent people who do not identify with any given ethnic group
Total response output disadvantages
- Creates complexities in the distribution of funding based on population numbers or in monitoring changes in the ethnic composition of population health
- Creates issues in data interpretation by ethnic grouping where comparisons between groups include overlapping data
What is a healthy environment?
Physical, social or political settings that prevent disease while enhancing human health and wellbeing
Elements of a healthy environment
- Access to wholesome food
- Safe community spaces
- Appropriate housing
- Clean air and water
- Opportunities to incorporate exercise as part of daily life
Measures or built environment
- Urban density
- Land use mix
- Street connectivity
- Community resources (e.g. facilities and healthy food)
4 Urban design concepts that improve active travel (including features and benefits)
- Street connectivity - grid-like design - reduces the distance between destinations increasing use of active travel
- Land use mix - mix of commercial, residential and business uses of land within a given area - increase active travel
- Traffic calming - crossings, cycle lanes, footpaths, street width - encourages active travel and discourages driving
- Public open spaces - open spaces close to residents e.g. pools, parks, playgrounds - increases physical activity
Ecological fallacy
Bias that arises when information about a group of people is used to make inferences about an individual
SDGs goal
A global call to action to end poverty, protect the planet and improve the lives and prospects of everyone everywhere.
SDGs Economy acronyms
DIRR
SDGs environment acronym
CCLL
What 2 SDGs do not map onto NZ LSF
- Gender equality
- Reduced inequalities
What NZ LSF do not map onto SDGs
- Cultural identity
- Recreation and leisure
- Subjective wellbeing
- Social connectiveness
Population health actions
- Health promotion
- Health protection
- Disease prevention
Population-based (mass) strategy aim
Improve health outcomes for all individuals in a population
Population-based (mass) strategy advantages
- Behaviourally appropriate
- Large potential benefit
- Addresses underlying causes
Population-based (mass) strategy disadvantages
- Small individual benefit
- Poor motivation of individuals
- Whole population exposed to downside
High-risk (individual) strategy:
Focuses on individuals perceived to be at high risk
High-risk (individual) strategy advantages
- Cost-effective
- Favourable benefit-to-risk ratio
- Individual motivation
- Appropriate to individuals
High-risk (individual) strategy disadvantages
- Cost of screening/need to identify individuals
- Behaviourally inappropriate
- Temporary effect
- Limited potential
Primary prevention
Aims to reduce occurrence of disease by addressing known risk factors
Secondary prevention
Early detection of disease to reduce more serious consequences
Tertiary prevention
Reduce complications of already established disease
Prerequisites for health
Peace, income and economic support, education, social justice and equity, shelter, safety, stable ecosystem, sustainable resources, food
Te Pae Mahutoga tasks and pre-requisites
Te oranga - participation in society
Mauriora - cultural identity
Toiora - healthy lifestyle
Waiora - healthy environment
Te mana whakahaere - autonomy
Nga manukura - leadership
Reasons for Maori health promotion
- Mainstream health promotions are often less effective in Maori
- Maori health outcomes/inequities
- Rights as Indigenous people and treaty partners
Ottowa Charter basic strategies and action areas
Enable, advocate, mediate
- Develop personal skills
- Strengthen community action
- Create supportive communities
- Build healthy public policy
- Reorientate health services towards primary care
Screening criteria
- Suitable disease
- Screening test
- Screening programe
A suitable screening test is:
- Reliable
- Safe
- Simple
- Affordable
- Acceptable
- Accurate
Sensitivity
Likelihood of a positive test in those with disease (true positive/all with disease) x 100
Specificity
Likelihood of negative test in those without disease (true negatives/all without disease) x 100
PPV
Positive predictive value, (true positives/all who test positive) x 100, increases with increase in prevalence
NPV
Negative predictive value, (true negatives/all who test negative) x 100, decreases with increase in prevalence
Lead time bias
An apparent increase in life expectancy due to the time of diagnosis
Length time bias
Mean survival time from screened patients gives impression of longer average survival time due to different rates of disease progression in each patient
PAR
Population attributable risk, PGO-PGO, occurrence in total population - occurrence in unexposed population
3 point panther platform
- Peaceful resistance against racism
- Create mana Pasifika (own ethnic identity)
- Educate to liberate
Actions of PPP
- T.A.B
- P.I.G
- Homework centres
- Legal aid booklet and human rights
- Protests (dawn raids, 1986 springbok tour)
Racism
Any individual action or institutionalized practice backed by institutionalized power than negatively affects people because of their ethnicity
Institutionalised racism
Differential access to good, services and opportunities of society by race
Material conditions influenced by institutionalized racism
- Clean environment
- Sound housing
- Gainful employment
- Quality education
- Appropriate medical facilities
Access to power influenced by instituionalized racism
- Less Maori in government
- Differential access to information, resources, voice
Personally mediated racism
Prejudice and discrimination towards someone because of their race - where prejudice means differential assumptions about the abilities, intentions and motive of someone and discrimination means differential action towards them.
Internalized racism
Acceptance by members of stigmatized races of the negative messages said about their own intrinsic worth and abilities.
HIV Social determinants
- Harmful social norms that promote harmful power dynamics (rules governing sexual relationships: negotiating condom use, gender-based violence/sexual abuse - associated with 3x risk of HIV, problems with disclosure of HIV status, stigma & discrimination
- Early school dropout (lack of education leads to lack of safe/well paid jobs, lack of resources)
- Lower access to health services
Prevention for HIV
- Address social determinants (empower women & educate men, enable opportunities for education & financial independence, change social norms around power dynamics, gender-based violence, stigma and discrimination, improve health literacy, improve access to sexual health services
- Safer sex (media campaigns, education, condoms)
- Safer products (screen blood products, needle exchanges)
- Increase access to health care (voluntary testing, treatment, care and support for HIV+, antenatal screening & treatment)
Control
Reduce to an acceptable endemic level using feasible means
Elimination
Reduce to zero in a country for prolonged periods
Eradication
Reduce to zero globally, permanently
Mitigation
Reduce to avoid overwhelming the health care system
Suppresion
Reduce to minimise negative health impacts
R.eff
Mean number of additional infections from an initial infection at one point in time
Herd immunity
When enough of a population has been immunised against a disease to stop its spread and further infections
Message
Appropriate, co-designed, tested, clear and simple
Messenger
Trustworthy, credible
Channel
Relevant, accessible, trustworthy
Who influences food environments?
- Food industry
- Government
- Society
Local environments that shape obesity
- Physical
- Economic
- Policy
- Socio-cultural
Drivers of obesity
Underlying global impacts e.g. national wealth
Mediator definition
Factors through which drivers operate, lies on the causal pathway between a risk factor and the associated outcome.
Mediators of obesity
Food availability, food composition, prices, e-bikes, PA, screen environments
Moderators definition
Factors which accentuate the trends (e.g. sociocultural and built environment)
Moderators of obesity
Culture, built environment, food culture, local climate, religion
Policy inertia is caused by:
- Food industry opposition
- Government reluctance to tax/fund
- Lack of public demand
Industry influence in NZ
- Big money behind harmful products
- Dirty PR operator
- Attack blogger
- Character assassination of public health advocates
Industrial epidemic
Diseases arising from over consumption of unhealthy commercial products
To address commercial determinants:
- Shift focus from individual behaviours to the broader environment and upstream drivers of unhealthy product consumption
- Tackle upstream determinants
- Develop effective health policy recognising the tension between commercial and health objectives
How commercially driven epidemics came to be:
- Social norms changed
- Market to vulnerable targets
- Changing physical and social environments (concentrated outlets and influence policy)
Passive overconsumption of energy is due to
Hyperpalatable, heavily promoted, readily available, cheaply priced, highly profitable ultraprocessed foods
Cost
The cost associated with implementing the policy to people, and the overall cost of the prevention strategy
Stigmatization
Concept that a program or policy should not stigmatize people wherever possible
Freedom
Extent to which the freedom of a particular group is compromised
Vertical equity
Refers to unequal treatment of unequally situated individuals to make them more equal in regard to a particular attribute
Horizontal equity
Involves treating everyone equally, applied universally
Appropriate uses of NZDep & IMD
- Resource allocation and planning
- Research
- Community advocacy
- Policy development
NZDep 2018
- Area based measure which has variables that determine area deprivation
- Divides small census areas into deciles/quintiles based on deprivation
- Based on data from census
NZDep 2018 Domains
- Income
- Income
- Qualifications
- Support
- Communication
- Owned home
- Living space
- Living conditions
- Unemployment
IMD
- Looks at overall deprivation to understand the drivers
- Based on data from IDI
IMD domains
- Employment
- Income
- Crime
- Health
- Access
- Education
- Housing
IMD strengths
- Measures data more comprehensively than existing area based measures
- 7 domains can be used individually or together
- Weights different domains differently, resulting in different identified areas of deprivation
- Uses data from multiple data sources
- Data is more recent as it is continuously updated
- Includes health and crime, which are good indicators of area deprivation
Data sources other than census
- ERP (estimated resident population)
- Vital events
- HSU (health service utilisation)
- IDI (integrated data infrastructure)
- Nationally representative survey
- Ad Hoc survey
IDI benefits
- De-identified
- Can compare different denominators
IDI disadvantages
- Resource is only as good as the data it contains
- Cannot follow or identify individuals
- Deficit approach - describes population in relation to what they don’t have.
Component cause
Individual factor that contributes to disease causation but is not sufficient to cause disease on its own
Sufficient cause
Minimum set of conditions for disease to occur
Necessary cause
A factor (or component cause) that must be present for disease to occur
Temporality
First the cause, then the disease (e.g. cohort studies have shown an association between maternal Zika virus in early pregnancy and microcephaly in new-born babies)
Strength of association
The stronger the association, the more likely to be causal in the absence of known biases
Specificity of association
A cause leads to a single effect, an effect has a single cause
Consistency of association
Replication of the findings by different investigators, at different times, in different places, with similar methods (similar studies have shown similar results)
Biological plausibility of association
Does the association make sense biologically? (e.g. virus infections are known to affect brain growth in new-born babies)
Biological gradient
Incremental change in disease rates in conjunction with corresponding changes in exposure
Reversibility
The demonstration that under controlled conditions, a change in exposure results in a change in outcome
Level 1 of rainbow model
The individual: age, sex, constitutional and life-style factors - non modifiable
Level 2 of rainbow model
The community: social & community networks and living & working conditions
Level 3 of rainbow model
The environment: general socioeconomic, cultural and environmental conditions
Living and working conditions
- Ag & food production
- Housing
- Unemployment
- Working conditions
- Water and sanitation
- Access to health services
- Education
Built environment
Design of communities/all the buildings, spaces and products that are created or significantly modified by people
Causes of causes for individuals
- Income
- Education
- Employment
- Housing
- Neighbourhood
- Societal characteristics
- Autonomy and empowerment
Downstream/proximal
Health determinant that is near the change in health status
Upstream/distal
Health determinant that is distant in time and/or place from change in health status
Structure
Social and physical environmental conditions that influence the choices and opportunities available
Agency
The capacity of an individual to act independently and make free choices
RCT main design features
- Longitudinal
- Experimental
- Random allocation
- Measured over follow up
RCT strengths
- Random allocation minimises confounding
- Can measure incidence and prevalence
RCT weaknesses
- Ethical limitations
- Difficult to recruit representative populations
- Maintenance error
- Expensive
- Small
Cohort main design features
- Longitudinal
- Observational
- Participants allocated by measurement and followed up
Cohort strengths
- Easier to recruit
- Ethical to study harmful exposures
- Cheaper than RCT
- Often large
Cohort weaknesses
- Confounding common
- Maintenance error
Cross-sectional main design features
- Observational
- Participants allocated by measurement and outcomes measured at same time
Cross-sectional strengths
- Easier to recruit people
- Ethical to study harmful exposures
- Maintenance error not an issue
- Cheap
- Fast to undertake
- Large
Cross-sectional weaknesses
- Confounding common
- Reverse causality
- Can only measure prevalence
- Crucial for sample to be representative
Ecological main design features
- Groups/countries
- Can be RCT, cohort or cross-sectional
Ecological strengths
- Large, so low random error
- Cheap
- Quick
Ecological weaknesses
- Confounding common
- Measurement error very common
Equity
Equity recognises different people with different
levels of advantage require different approaches
and resources to get equitable health outcomes
4 steps in preventing disease
- Define the problem
- Identify risk and protective factors
- Develop and test prevention strategies
- Assure widespread adoption
Commercial determinants 2
Structures, rules, norms and practices by which business activities designed to generate profit influence patterns of health and disease across populations
