Module 2 (interventions) Flashcards
Socioeconomic position
The social and economic factors that influence what positions individuals hold in a society; measured to quantify the level of inequality within/between societies and look for patterns associated with social variables and health
Socioeconomic factors
All must be measurable, objective and meaningful
Determinants for individual socioeconomic position
Any event, characteristic or other entity that brings about a change for the better or worse in health; vary at different life stages; income, employment, education, housing and neighbourhoods (conditions), societal characteristics and autonomy and empowerment (social cohesion)
Income determinant
Strongly related to wellbeing and the ability to purchase health-improving goods and services and take time off work for health appointments; modifiable and can change rapidly
Employment determinant
Main factor determining adequate income; enhances social status, improves self-esteem, provides social contact and enhances opportunities for regular activity (important fro physical and mental health)
Education determinant
Critical in determining SEP, as it is a pathway to income opportunities and gives people the ability to stand up for what they believe in health; allows people to have literacy
Literacy
A person’s ability to take on health messages, pick up on signs of illness themselves and understand the health information/services available to them in order to make appropriate health decisions; stems from education
Housing and neighbourhoods (conditions) determinant
Many families now spend a greater proportion of their income on housing costs, leaving less money for other items essential to good health; leads to the sharing of accommodation, causing overcrowding, which impacts physical and mental health
Societal characteristics determinant
Racism, attitudes to alcohol or violence, value on children (how they are treated)
Autonomy and empowerment (social cohesion) determinant
People with strong family/cultural/community ties tend to have a better health than those who are socially isolated; unemployment and high mobility also reduce social connectedness
Determinants for population socioeconomic position
Concepts similar to individuals, but nature of them (how they are measured) are different; not just application of the individual perspective to whole population, but includes characteristics of the population itself; related to the context in which the population exists
Proximal determinants
A determinant of health that is proximal/near to the change in health status; downstream factors
Proximal determinants examples
Lifestyles and behavioural factors related to nutrition, smoking or other factors
Downstream interventions
Operate at the micro (proximal) level; include treatment systems and specific disease management; things we can change easily
Distal determinants
A determinant of health that is either distant in time and/or place from the change in health status; upstream factors
Distal determinants examples
National, political, legal and cultural fcators that indirectly influence health by acting on the proximal factors
Upstream interventions
Operate at the macro (distal) level, such as government policies and international trade agreements; things we can’t change easily
Social gradient
Inequalities in social status due to any determinants related to inequalities in health status; links socioeconomic position and population health; for nearly every health outcome and in nearly every society, there is an association between better health outcomes and tertiary education, good jobs and wealth
Social mobility
The ability of individuals/groups to move within or between social strata or climb the social ladder; lower in more unequal countries; upward, downward, intergenerational and intragenerational
Upward mobility
Moving up the social ladder
Downward mobility
Moving down the social ladder
Intragenerational mobility
Movement on the social laddeer within an individual’s lifetime
Intergenerational mobility
A link in change in SEP or social ladder/position between parent and child
Dahlgren and Whitehead model
Model to show upstream and downstream determninants on health status; three levels of influence; agency and structure
D&W model level 1
The person; includes age, sex and constitutional factors and individual lifestyle factors; individual choices impact the likelihood of good/bad health
Habitus
Level 1 D&W; lifestyle, values and dispositions and expectation of particular social groups ‘learned’ through everyday activities (ability to change behaviour may vary by social groups); learning behaviours may change due to social exposure
D&W model level 2
The community; includes social and community networks and living and working conditions; families/friends have a significant role in developing ‘normative’ behaviour
Social capital
Level 2 D&W; the value of social networks that facilitates bonds between similar groups of people; levels of trust (shown to be higher in countries in more equal countries); provides inclusive environment for people with diverse backgrounds
D&W model level 3
The environment; includes general socioeconomic, cultural and environmental conditions; physical, built, cultural, biological and political environments, and the ecosystem
Agency
The capacity of an individual to act independently and make free choices (empowerment, level of autonomy); level 1 and some level 2 of D&W (downstream)
Structure
Social and environmental conditions (social determinants) that influence choices and opportunities available; level 2 and 3 of D&W (upstream)
The four capitals
Intragenerational wellbeing relies on growth, distribution and sustainability of these four capitals; neural, human, social and financial/physical; make up the patchwork art
Neural capital
All aspects of the natural environment needed to support life and human activity; includes land, water, soil, plants and animals, minerals and energy resources
Human capital
People’s skills, knowledge and physical and mental health; enable people to participate fully in work, study, recreation and society more broadly
Social capital
The norms and values that underpin society; includes trust, the rule of law, the Crown-Māori relationship, cultural identity and people-community connections
Financial/physical capital
Includes things like houses, roads, buildings, hospitals, factories, equipment and vehicles, which make up the country’s physical and financial assets (direct role in supporting incomes and material living conditions)
Determinants (inputs) of the four capitals
Institutional equality; social and collaborative skills; education; family/whanau wellbeing; reconcilliation of injustices and historical damage to trust; population density; built environment; home ownership and residential stability; material wellbeing; income inequality
Social capital (outputs)
The more of these put in, the more positive wellbeing outcomes (safer communities and more demographic function); pro-social behaviour, pro-social norms, sense of equity, social connections, institutional trust
Wellbeing outcomes
Better physical health; better mental health; better educational outcomes; better labour market outcomes; better housing outcomes
Societal outcomes
Stronger economic performance; better democratic functioning; safer communities; more inclusive society
Inequality
Measurable differences or variations in health experiences/outcomes between different population groups
Measures of association for inequality
Absolute inequality = risk difference; relative inequality = relative risk
Why health inequalities should be reduced
Equitable thing to do; they are avoidable; they affect everyone; has economic benefits
Population health
Concerned with the health of groups of individuals in the context of their social and physical environment
Causal relationships
Causality cannot be proved in human studies (for practical and ethical reasons)
Bradford hill criteria
Framework where not all criteria need to be fulfilled and judgement should be used due to the usually complex causal phenomena; temporality, strength of association, consistency of association, biological gradient, biological plausibility of association, specificity of association and reversibility
BHC temporality
First the cause and then the dis-ease; essential to distinguish a causal relation
BHC strength of association
The stronger an association, the more likely to be causal in absence of known biases (selection, information and confounding)
BHC consistency of association
Replication of the findings by different investigators at different times in different places with different methods (multiple studies show similar results)
BHC biological gradient
Incremental change in dis-ease rates in conjunction with corresponding changes in exposure; as exposure rates increase, disease rate increases
BHC biological plausibility of association
Does the association make sense biologically?; biologically makes sense
BHC specificity of association
A cause leads to a single effect or an effect has a single cause; however, health issues have multiple, interacting causes and many outcomes shares causes
BHC reversibility
The demonstration that under controlled conditions, changing the exposure causes a change in outcome
Causal pies
Several causal components act together to produce an effect; a given disease can be caused by more than one causal mechanism; blocking/removing any component (sufficient, necessary, component) cause would prevent some cases of disease
Sufficient cause
The whole pie; a minimum set of conditions without any of which the disease would not occur; not usually a single factor, often several; a disease may have several sufficient causes
Component cause
A factor that contributes towards dis-ease causation, but it is not sufficient to cause the dis-ease on its own; interact to produce a disease
Necessary cause
A factor or component cause that must be present if a specific dis-ease is to occur
Population based strategy
Mass strategy; attempts to shift distribution of health outcomes to a more favourable position in the whole population
Population based strategy advantages
Radical and addresses underlying causes; large population benefit for whole population; behaviourally appropriate
Population based strategy disadvantages
Small benefit to individuals; poor motivation of individuals; whole population is exposed to downside of strategy (less favourable benefit-to-risk ratio)
High risk strategy
Individual strategy; tries to move outcome for high risk group toward normal distribution
High risk strategy advantages
Appropriate to individuals; individual motivation; cost effective use of resources; favourable benefit-to-risk ratio
High risk strategy disadvantages
Cost of screening needed to identify individuals; temporary effect; limited potential; behaviourally inappropriate
Population health actions
Come under both population based and/or high-risk strategies; health promotion, health protection and disease prevention
Health promotion
Health/wellbeing focus; acts on determinants of wellbeing; enables/empowers people to increase control over and improve their health; involves whole population in everyday contexts
Disease prevention
Disease focus; looks at particular diseases (or injuries) and ways of preventing them
Health protection
Predominantly environmental hazard focussed; risk/hazard assessment; occupational health and monitoring; risk communication
Healthcare services
Primary care (patients’ regular source of healthcare); secondary care (specialist care) and tertiary care (hospital-based care; rehabilitation)
Alma Ata 1978
Declaration for primary healthcare; first time that social determinants of health (and primary healthcare) was recognised as key to achieving good health for individuals within a population
Ottawa charter
First international conference on health promotion and asked that governments consider health in all its polices (not just health); has three basic strategies and five strands/priority action areas
Basic strategies of ottawa charter
Enable, advocate and mediate
Enable OC
Provide opportunities for all individuals to make health choices through access to information, life skills and supportive environments (individual level strategy)
Advocate OC
Create favourable political, economic, social, cultural and physical environments by promoting/advocating for health and focusing on achieving equity in health (systems level strategy)
Mediate OC
Facilitate/bring together individuals, groups and parties with opposing interests to work together/compromise for the promotion of health (strategy that joins up individuals, groups and systems)
Priority action areas of ottawa charter
Develop personal skills; strengthen community action; create supportive environments; reorient health services toward primary healthcare; build healthy public policy
- Develop personal skills; examples
Priority action of OC; life skills, education in schools, awareness campaigns
- Strengthen community action
Priority action of OC; self-help groups and community-organised services, community initiatives that promote healthy schools, healthy cities, youth health projects
- Create supportive environments
Priority action of OC; implementing air control measures, water and sanitation programmes, building speed bumps, requirement of workplace safety measures
- Reorient health services toward primary healthcare
Priority action of OC; care process responsive to needs of patients and families, health education services, amenities to enhance hospital experience
- Build healthy public policy
Priority action of OC; taxation on alcohol and cigarettes, mandatory seat belt use; banning of smoking in public places, food and drug control, mandatory sports in schools
Primary disease and prevention strategies
Between the exposure and the biological onset; limit the occurrence of disease (focus on preventing onset) by controlling certain risk factors
Secondary disease and prevention strategies
Between the biological onset and clinical diagnosis; reduce the more serious consequences of the disease by identifying the disease early so simple measures can help patient before it is too late
Tertiary disease and prevention strategies
Between the clinical diagnosis and outcome; reduce the progress of complications of established disease (improve outcome)
Challenges for health promotion in Māori health
Pakeha population usually benefits; sometimes widened the health inequalities between the two ethnicities; due to the models being Western and universal
Te Pae Mahutonga
4 central stars/key stars (Mauriora, Waiora, Toiora, Te Oranga) and 2 pointers/pre-requisites (Ngā Manukura, Te Mana Whakahaere)
Mauriora
Access to the Māori world; cultural identity; e.g. working with communities to incorporate/revitalise traditional practices for SIDS)
Waiora
Physical environments are a key determinant to health; e.g. smokefree, safe bed-sharing for SIDS
Toiora
Diet, smoking, exercise, safe sex, alcohol; e.g. smoking cessation and breastfeeding promotion for SIDS
Te Oranga
Social determinants of health, ensuring we have resources to put other key tasks into practice; education, income, employment, housing, political participation, decision-making in society at all levels; e.g. improving education and income support
Ngā Manukura
Leadership; partnering and enabling community leadership (health professional and community); e.g. Māori professional and academic leadership, collaboration with leaders in communities
Te Mana Whakahaere
Autonomy; communities need to be enabled to do stuff for themselves; enabling control and having structures in place to be able to make decisions; e.g. communities enabled to identify their own aspirations and priorities and to share in the design of their own solutions
Screening in health
Involves identifying risk factors for a disease or unrecognised disease by applying the test on a large scale to a population; screening test less expensive diagnostic test, people who test positive subject to a diagnostic test;
Screening criteria
Suitable disease, suitable test, suitable treatment and suitable screening programme
Suitable disease
Needs to be an important public health problem; need to have knowledge of the natural history of the disease (or relationship of risk factors to the condition)
Suitable test
Reliable, safe, simple, affordable, acceptable and accurate
Suitable treatment
Evidence of early treatment leading to better outcomes; effective, acceptable and accessible treatment; evidence-based policies covering who should be offered treatment and the appropriate treatment to be offered
Suitable screening programme
Benefits must outweigh cost; RCT evidence that screening programme will result in reduced mortality and/or increased survival time; adequate resourcing and agreed policy for testing, diagnostic, treatment and programme management; cost affective; able to reach people who need it
Lead time bias
Survival time from clinical diagnosis to outcome/death; screening before clinical diagnosis may show an apparent increase in life expectancy; may give a false impression of success
Length time bias
Some diseases will have shorter/longer progress times, patients may have a longer/shorter period between disease onset and death/outcome; likely to pick up more people with slow progressing disease; gives impression of longer average survival
GATE frame for study findings in screening
Triangle: whole population
Circle: cases diagnosed with (EG)/without (CG) using gold standard
Square: cases diagnosed with/without new test; a (true +) and c (false -) in EG, b (false +) and d (true -) in CG
Specificity
Likelihood of a negative test in those without the disease; high if the proportion of true negatives is high
= true negatives / all without disease
Sensitivity
Likelihood of a positive test in those with the disease; high if the proportion of true positives is high
= true positives / all with disease
PPV
Positive predictive value; proportion who really have the disease of who people who test positive (probability of having the disease if test is positive)
= true positives / all who test positive
NPV
Negative predictive value; proportion who are actually free of the disease of all people who test negative (probability of not having the disease if test is negative)
= true negatives / all who test negative
Population health priorities
Evidence-based measures, community expectations and values, human rights and social justice
Evidence-based measures (health priority)
Finding what conditions are most important in a population; descriptive evidence (square in GATE; trends, most/least affected); explanatory (circle in GATE; determinants, why?); evaluative (how can in be solved, economic feasibility and opportunity cost)
Community expectations and values (health priority)
Acceptability (will the community/target population accept the problem being addressed?); what do communities want? (culturally appropriate, good information, fair treatment, access)
Human rights and social justice (health priority)
Obligation to Treaty of Waitangi
YLL
Years of Life Lost (due to death); age at death and premature mortality
YLD
Years Lived with a Disability ; time lived with disability
PAR formula
Population attributable risk = PGO (incidence in total population) - CGO (incidence in unexposed population)
Population attributable risk
Amount of ‘extra’ disease attributable to a particular risk factor in a particular population; if the association is causal, PAR is the amount of disease we could prevent if we removed that particular risk factor from the population
