Lecture 2 Upstream determinants of lifestyle behaviours and chronic risk

Question 1

What are upstream determinants? Give an example for obesity.

Answer 1

• Determinants that suggest entry points for population level action to prevent or reduce a disease.
• They can take the form of tangible characteristic in the built or natural environment surrounding us.
• They can also manifest and interact with less tangible features as economic, political, and socio-cultural environments.
• Downstream to upstream: obesity, overweight, obesogenic behaviours, obesogenic environments

Question 2

How can upstream determinants be structured? Give an example in case of obesity.

Answer 2

• With the use of frameworks
• In case of obesity, this can be done by the ANGELO framework

                          Micro              Meso            Macro

Socio-cultural

Physical

Economic

Political

Question 3

What are the key challenges in upstream research? Explain these.

Answer 3

• Study design  There are not a lot of RCT of longitudinal studies.
• Self-selection  someone can be influenced by their neighbourhood, but they can also have chosen the neighbourhood because it fits their lifestyle.
• Area of exposure  The area of exposure to a certain determinant can in actuality be different than the one you theorized. This leads to different outcomes.
• Defining exposure: many ways to operationalise exposure
• Mismatch between how to measure data  it can be measures subjective or objective, the difference is staggering.
• Interactions: how do downstream determinants interact with upstream determinants

Question 4

What are complex adaptive systems and why are they now in fashion?

Answer 4

• It’s a model with a lot of arrows relating actors and factors and how they are connected. There are feedback loops.
• It acknowledges complexity of the problem.
• They are about understanding and changing the system, maybe even implementing an intervention within the system.
• Are about evaluating the impact.

Question 5

What are downward causations

Answer 5

Cases in which upstream determinants at social and physical environmental levels influence and regulate lower-level factors as individual behaviour, psychology, and physiology.

Question 6

What are the needs of upstream research?

Answer 6

• Objective exposure measures
• Longitudinal studies
• Variance in exposures, behaviours, and outcomes
• Power to pick up subtle associations
• Power to enable subgroup analyses
• Ways to cope with complexity of relations and the amount of data.