Lecture 6 (wk 4 tues)

Question 1

What are social determinants of health?

Answer 1

Non-medical factors that affect health outcomes

Question 2

What are the 5 domains of social determinants of health?

Answer 2

1) Economic stability
2) Neighborhood and built environment
3) Education access and quality
4) Social and community context
5) Healthcare access and quality

Question 3

Economic stability:
1) ____ in 10 live in poverty (US)
2) What is the goal? Why?
3) What is a hurdle towards this?

Answer 3

1) 1
2) Steady employment to reduce # who live in poverty
Less likely to live in poverty, more likely to be healthy
3) Many people have trouble finding and keeping a reliable job.
-Employment programs, career counseling, and high-quality child care opportunities help more people find and keep jobs

Question 4

Neighborhoods and built envt:
1) What is the goal?
2) What can help reduce health and safety risks and promote health?
-Give an example

Answer 4

1) Create neighborhoods and environments that promote health and safety?
2) Interventions and policy changes at all levels (local, state, and federal)
-Providing opportunities for people to walk and bike in their communities (sidewalks, bike lanes) to increase safety and improve quality of life

Question 5

Education Access and Quality:
1) What is the goal?
2) How does education correlate with health? Explain

Answer 5

1) Increase educational opportunities and help children and adolescents do well in school
2) Higher education > healthier, live longer
-Children from low-income families, children with disabilities, and children experiencing bullying and other forms of discrimination struggle in school and are less likely to graduate high school and college
-Leads to less safe, lower-paying jobs

Question 6

Social and Community Context:
1) What is the goal?
2) Why?

Answer 6

1) Increase social and community support
2) Positive interactions and relationships can have a major impact on health and well-being and can reduce the negative impacts from challenges and dangers in the community

Question 7

Health Care Access and Quality:
1) What is the goal?
2) 1 in ____ do not have health insurance
3) What is critical to getting people care?

Answer 7

1) Increase access to comprehensive, high-quality health care services
2) 10
3) Strategies to increase insurance coverage are critical for everyone to get the care they need

Question 8

What is the PERIE approach?

Answer 8

Linking problem, etiology, recommendations, implementation, and evaluation as a cycle

Question 9

What are the “when, who, & how” of public health interventions?

Answer 9

1) When: timing in the course of the disease to implement the intervention
-Primary: before onset of the disease
-Secondary: after development of the disease, but before symptoms
-Tertiary: after initial symptoms, but before irreversible disability
2) Who: at whom should the intervention be directed? Individuals, groups, vulnerable populations, everyone, community wide
3) How: education, motives/incentives, obligation/requirements

Question 10

Describe, and give examples of these types of public health data:
1) Single case or small series
2) Vital statistics and reportable diseases
3) Surveys and sampling

Answer 10

1) Single case or small series
-Case reports from 1 or a small series of cases
-Ex: SARS, anthrax, mad cow disease- Alerts to new diseases, resistant diseases or spreading of diseases.​
2) Vital statistics and reportable diseases
-Ex: vital stats: birth, marriage, divorce, death and some communicable and non-communicable diseases.
-Helps to identify leading causes of deaths, track reportable diseases​
3) Surveys and sampling
Disease registries, cancer registry, National Health and Nutrition Examination Survey (NHANES.) can draw conclusions about populations, but very difficult to capture data from every qualifying patient.

Question 11

Describe, and give uses for these types of public health data:
1) Self-reporting
2) Sentinel monitoring
3) Syndromic Surveillance

Answer 11

1) Self-reporting: monitoring for individual patient side effects can help identify unusual events.
-typically incomplete data and relies on compliance of individual patients.​
2) Sentinal Monitoring: monitoring for the beginning of expected outbreaks to detect the start and changes in virus or disease type.
-Must have in depth knowledge of disease patterns.​
3) Syndromic Surveillance: use of patterns of symptoms in addition to sales data of increase in use of certain OTC drugs.
-Can be used to detect unexpected outbreaks or bioterrorism based on commonly occurring symptoms.
-Does not provide a diagnosis but can be an early warning.

Question 12

1) List some bioethics
2) List some public health ethics
3) What is the overlap b/t the two?

Answer 12

1) Autonomy, liberty, privacy, individuals
2) Common good, paternalism, protection, society
3) Critical ethics, human rights, societal goals involving individual input

Question 13

Nuremberg Trials:
1) What did it establish?
2) What was it?

Answer 13

1) Established 10 principles: The Nuremberg Code
2) Ethics and Research reviewed
-crimes from the Nazi concentration camps

Question 14

Tuskegee Syphilis Study (1932):
1) What was this study? Who were the participants?
2) What was the payment?
3) What happened in 1940?

Answer 14

1) Tuskegee Study of Untreated Syphilis in the Negro Male”
-600 black men. 399 with syphilis.
2) Received free medical exams, free meals and burial insurance
3) 1940: penicillin available but not given

Question 15

1) Belmont Report established what?
2) What 3 things did this establish?
3) What are 3 ways these principles are applied?

Answer 15

1) Institutional Review Boards (IRBs) developed
2) Respect for persons, Beneficence, Justice
3) Risk/Benefits Assessment
-Selection of Participants
-Informed Consent

Question 16

_________________ aims to measure the potential impact of known hazards (inherent danger of an exposure) through the quantity, route, and timing of the exposure.

Answer 16

Risk assessment

Question 17

Give 4 examples of occupational investigations relevant to risk assessment

Answer 17

1) Chimney sweeps and increased incidence of testicular cancer in the 1700s due to high-dose carbon residue exposure
2) Radiation exposure in workers who painted watches with radiation-containing paint and increased levels of cancer
3) Ship workers in WW2 who were exposed to high levels of asbestos and were later diagnosed with cancer
4) Chemical workers who were exposed to benzene and an increased incidence of leukemia

Question 18

Occupational Safety and Health Administration (OSHA) established in __________

Answer 18

1971

Question 19

What are the 4 steps of risk assessment?

Answer 19

1) Hazard identification: What health effects are caused by the pollutant?
2) Dose-Response Relationship: What are the health problems at different exposures?
3) Exposure Assessment: How much of the hazard are people exposed to during a specific time period?
How many people are exposed?
4) Risk characterization: What is the extra risk of health problems in the exposed population?

Question 20

1) Public Health Assessment includes data on what?

Answer 20

-Actual exposure in a community.
–Not just the risks in a specific location, but also the risks to large numbers of individuals and often to the population as a whole.
-Can take years/decades to complete

Question 21

In 2015, over ____________ people in Flint, MI were exposed to high levels of lead in drinking water including a number of children

Answer 21

100,000

Question 22

Ecological risk assessment examines what?

Answer 22

The impacts of contaminants on ecological systems ranging from chemicals, to radiation, to genetically altered crops

Question 23

Mercury from industry contaminated the Great Lakes in the 1800s and 1900s. It has been filtered by fish who absorbed the mercury in their fat.
Certain species absorb more mercury than others.

Assessing this issue is an example of what?

Answer 23

Ecological risk assessment

Question 24

Mercury from industry contaminated the Great Lakes in the 1800s and 1900s. Why is this an issue?

Answer 24

1) Birds eat the fish… so birds are in danger.
2) There is no feasible method of removing mercury from bodies of water.
3) Low levels pose risks to fetuses (neurological damage) so recommendations for limiting fish consumption during pregnancy are a mainstay
- Avoid shark, swordfish, marlin, king mackerel, and tilefish
-Limit salmon, pollock, catfish, and canned light tuna

Question 25

Multiplicative Interaction: 1) Define it 2) Give an example and explain it

Answer 25

1) Interactions between exposures that lead to an impact much greater than the estimate 2) The multiplicative interactions between radon and cigarette smoking -Radon is a naturally occurring colorless, odorless gas that emits ionizing radiation during its radioactive decay and is found all over the country -The second leading cause of lung cancer (after cigarettes) and most common cause in nonsmokers -According to the EPA <2pCi/L is attainable and 4pCi/L is the maximum recommended level.

Question 26

A ___________ is an interacting group of items forming a unified whole that maintains its existence and functions as whole based on the interaction of its parts

Answer 26

system

Question 27

Give some characteristics of systems

Answer 27

1) A series of interconnected parts which function as a whole 2) A system changes if you take away or add pieces 3) Parts are connected to each other and work together, and the arrangement is crucial 4) Behavior of a system depends on its overall structure

Question 28

1) What is system analysis? 2) Explain

Answer 28

1) The investigation of systems 2) Implementing systems thinking requires tools for analyzing the pieces and understanding how they fit together Often relies on diagrams or graphics visuals to display the relationships between the parts

Question 29

What is systems thinking?

Answer 29

It’s an approach that examines multiple influences on the development of an outcome or outcomes and attempts to bring them together in a coherent whole. *From this, we can understand how societies organize themselves to achieve collective health goals and how members contribute to policy outcomes.

Question 30

What is reductionist thinking?

Answer 30

Traditional thinking in public health (and medicine) which looks at 1 factor or 1 variable at a time (think of this one as more linear unlike systems)

Question 31

1) What does reductionist thinking imply? 2) What is reductionist thinking useful for? 3) Give examples

Answer 31

1) We are searching for the single etiology (cause) and the one-and-only answer (effect) to what should be done to improve the outcome. 2) Establishing specific factors as contributory causes of disease 3) Cigarettes and lung cancer; Aspirin and Reye’s syndrome

Question 32

1) What relate to both the cause and effect and may confound or confuse the investigation of the relationship between a single cause and a single effect? 2) Give examples

Answer 32

1) Confounding variables 2) Differences between groups in age, severity, or disease that affect the chances of developing disease or experiencing a poor outcome

Question 33

1) What is systems thinking? 2) What does it look at? Explain

Answer 33

1) Data derived from reductionist thinking but goes beyond reductionist thinking to look at multiple factors that cause disease and disease outcomes 2) Impact of multiple factors and see how they work together -Instead of one cause and effect, there may be many etiologies and outcomes based on what goes on between the two

Question 34

1) How can we use systems diagrams to display the workings of a system? 2) Explain

Answer 34

1) Systems diagrams begin with identifying the key factors that will be included in the systems. 2) For each factor, we need to: a) Indicate the direction in which it operates; the thicker the arrow, the greater the impact b) Indicate whether the factor operates to reinforce/increase another factor or dampen/decrease (+ or -)

Question 35

What can help us identify bottlenecks?

Answer 35

Negative feedback loop

Question 36

What are the initial steps of system analysis? Define and give examples

Answer 36

First couple steps built on data from reductionist thinking 1) Step 1: Identify the most important influences on the outcome(s) of interest -Ex: influences on smoking cessation; what are they? -Effective interventions include smoking cessation programs- prohibitions on smoking in public places, social marketing, and cigarette taxes 2) Step 2: Indicate the relative strength of the impact of each of the influences or interventions -Linear relationship (reductionist)= increased levels of an intervention (ie. Greatly increasing the taxes on cigarettes would produce a straight line substantial decrease in cigarette use)

Question 37

What is step 3 of systems analysis?

Answer 37

1) Identify how these influences or interventions interact -How do they work together? Or interfere with each other? -Instead of looking at one factor or intervention at a time (reductionist), systems thinking asks about the best combination of interactions + how they can be used together

Question 38

Give an example of step 3 of systems analysis

Answer 38

-Example looking at interactions of interventions: The four most important interventions (or influences) on the rate of cigarette smoking- smoking cessation programs, prohibition on smoking in public, social marketing, and higher taxes -The question is then, how can they be most effectively combined? -Ie. how can cigarette taxes be utilized most effectively when combined with other approaches such as using increased cigarette taxes to support tobacco education programs?

Question 39

What is the 4th step of systems analysis? Explain

Answer 39

1) Identify the dynamic changes that may occur in a system by identifying the feedback loops that occur in the system. -Systems thinking requires a dynamic approach -How do factors change over time due to changes in one or more of the factors or influences? -We know, therefore, that the impact of interventions is not static. -These changes provide feedback into the process producing feedback loops, which can have a positive or negative impact on the outcome

Question 40

Give a Positive (or increasing) Feedback Loop Example:

Answer 40

Do the higher taxes on cigarettes that have reduced the number of people smoking lead to changes over time in social attitudes, which themselves may set the stage for greater enforcement of public smoking regulations?

Question 41

Give a Negative (or decreasing) Feedback Loop Example

Answer 41

Raising cigarette taxes might reduce the money available to low-income individuals to pay for smoking cessation programs if these services are not paid for by health insurance

Question 42

Systems analyses encourage identification of feedback loops, including what?

Answer 42

1) Positive feedback loops that reinforce or accentuate the process 2) Negative feedback loops that slow down the process

Question 43

1) What is step 5 of systems analysis? 2) Explain

Answer 43

1) Identify bottlenecks 2) By studying the dynamic nature of systems over time, we can identify bottlenecks that limit the effectiveness of systems and in step 6, leverage points that provide opportunities to greatly improve outcomes

Question 44

1) What is step 6 of systems analysis? 2) Give an example

Answer 44

1) Identify leverage points: Leverage points provide opportunities to greatly improve outcomes 2) Example: a bottleneck could be the need to train large numbers of clinicians in smoking cessation methods so that they can address the demand for smoking cessation services created by the influences we previously mentioned -Addiction could be looked at as another bottleneck that needs to be addressed for other intervention to be effective

Question 45

Give a second example of step 6 of systems analysis

Answer 45

A leverage point could be identifying pregnant women who smoke and are highly motivated to quit due to the issues associated with smoking during pregnancy

Question 46

How can we use a systems analysis to better understand a problem such as CAD? (first 2 steps)

Answer 46

Step 1) Identify Influences; what are some influences? HTN, high LDL, low HDL, abdominal obesity, DM, cigarette smoking, physical inactivity, FH Step 2) Estimate the relative strength of the influences -Estimate the relative risk for each factor OR classify their impacts as weak, moderate, or strong -In CAD, each factor is generally considered moderate strength with relative risks in the range of 2-4

Question 47

How can we use a systems analysis to better understand a problem such as CAD? (steps 3 and 4)

Answer 47

Step 3) Examine the Interactions Between Factors Additive vs multiplicative (generally thought to be additive in the case of CAD) -Ex: HTN + high LDL + low HDL -Ex metabolic syndrome (increased waist circumference, low HDL, elevated triglycerides, HTN, elevated fasting BS) is multiplicative based on how many risk factors occur together -Some factors may be protective (ex: physical activity) Step 4) Identify feedback loops that lead to dynamic changes in the functioning of the system

Question 48

How can we use a systems analysis to better understand a problem such as CAD? (steps 5 & 6)

Answer 48

Step 5) Identify Bottlenecks -Points in the system that need to be addressed for the other factors or influences to have their potential impacts -Example: if these bottlenecks that are listed can be addressed, the other risk factors may have a greater impact. Step 6) Identify Leverage Points -What is an example in this situation with CAD? > post op exercise when tolerated and patients are motivated

Question 49

1) Define One Health 2) What is its focus? 3) What 3 things have accelerated the speed of the spread of existing diseases?

Answer 49

1) Human health is dependent on animal health and the health of the ecosystem 2) Developing a systems thinking approach regarding the connections between human, animal, and ecosystem health 3) Environmental change, population growth, and economic disparities

Question 50

Give examples of One Health applications

Answer 50

1) Better control of zoonotic diseases + more treatment for infectious diseases in the 1960s and 1970s 2) 1980s - HIV emerged (likely originally from African tropical forests) 3) Mosquito-born diseases such as malaria, dengue fever, west nile virus, zika spreading 4) COVID-19