Module 4 Flashcards
fundamentals of population/public health
Provide the maximum benefit for the largest number of people
need for priorities
- Health resources are finite (limited)
- Each prioritisation has an opportunity cost
- Rationing involves ethical (what communities want/need) as well as evidence-based judgement
- difficult to compare outcomes
(can only compare mortality and hospitalisation rates but not all who are diseased (reduced QOL compared to those without) die and some are not able to access/afford hospital care and thus not counted) - Tension between: Individual (clinical services) vs population needs (population health services)
reasons for GBD
- Data (measures of calculating or identifying mortality and hospitalisation data) on the burden of disease (and injury) from many countries were incomplete/limited
- Available data largely focused on deaths
=> little information on non-fatal outcomes (disability) - (Tension between) Lobby groups can give a distorted image of which problems are most important
- Unless the same approach is used to estimate the burden of different conditions, it is difficult to decide which conditions are most important and which strategies may be the “best buys”
Lobby groups
form of advocacy with the intention of influencing decisions made by the government by individuals or more usually lobby groups
- whether a condition is prioritised or not often depended on power of the lobby groups to be able to lobby
GBD reason simplified
needed a way to measure/have a comparable measure to look at health conditions across the board from a global context
aims of GBD
- To use a systematic approach to summarise the burden of diseases and injury at the population-level based on epidemiological principles and best available evidence
- To aid in setting health service and health research priorities
- To aid in identifying disadvantaged groups and targeting of health interventions
To take account of deaths (not just counting the number but also when they happen) as well as non-fatal outcomes (i.e., disability) when estimating the burden of disease
in countries where data is not available…
GBP project identifies a comparable country and then use computational methods to estimate the disease burden in those countries
=> trying to get a real global picture rather than just keeping them out
What GBD looks at
- number of deaths but also WHEN a person dies in relation to life expectancy in a particular country
- non-fatal outcomes (disabilities)
Disability adjusted life years (DALYs)
summary measure of population health that combines data on premature mortality (YLL) and non-fatal health outcomes (YLD) to represent the health of a particular population as a single number which can be used in comparisons between diseases
DALYs enable comparisons between diseases to
- prioritise health interventions
- monitor health interventions
- assess changes of disease burden over time
DALY =
YLD + YLL
YLL
years of life lost
- Represents mortality by counting the years lost due to premature death caused by a disease
(Years lost due to dying before reaching the average life expectancy–ideal age–in a particular country)
YLL =
no. deaths from disease in a year x years lost per death relative to an ‘ideal age’
YLD
years lived with disability
- Represents morbidity by counting the years lived with the disease
YLD datapoints
- no. cases with non-fatal outcome (impairment) from disease
- average duration of non-fatal outcome until recovery/death
- disability weight
disability weight
scale between 0 (full health) and 1 (death)
- GDB Project has a huge team of medical experts that look at possible diseases/disabilities and give each a weight
DALY represents a lost healthy life year
- year in perfect health = 0
- year of life lost due to death = 1
- year with disability = between 0 and 1
cause
reason for death/disability (health outcome)
risk
reason for cause
income
- based on world bank definition
- inequities from a global scale
group 1 conditions
- communicable (infectious) diseases
- perinatal conditions
communicable disease example
diarrhoea, TB, measles, HIV/AIDS, malaria
perinatal conditions example
problems in pregnancy, childbirth, early life
group 2 conditions
- non-communicable diseases (NCDs)
- chronic diseases
NCD example
heart disease, strokes, cancer, diabetes
group 3 conditions
injury
global trends in causes of DALYs
- decreasing perinatal and communicable diseases
- increasing non-communicable diseases (NCDs)
major gains of DALY approach in informing priority setting globally
- Drew attention to previously hidden burden of mental health problems and injuries as major public health problems
- Recognises Non-Communicable Diseases as a major and increasing problem in low- and middle-income countries (not just a rich country problem which is how it was previously thought)
SES trends in causes of DALYs
- high income: higher proportion of NCDs
- low income: higher proportion of perinatal and communicable disease
challenges in using DALYs to quantify burden of disabilities
- who should decide disability weights?
- can disability weights be applied universally?
- lack of consideration of environment
who decides disability weights
GBD uses expert panel: been a contentious issue due to the way they assign weights for different questions
but should the person living with the disability? Their parent or carer? Healthcare provider? Government providing support services? decide?
application of disability weights
Disability weights are considered to be the same as the severity of an impairment relating to a disease/health condition, and do not vary with a person’s social position, where they live, their access to healthcare or any other life circumstance
- Is it reasonable to apply one set of disability weights globally? Do all people with a particular level of ‘disability’ have similar opportunities to be part of society?
(diff. Countries have diff. Govt. support services)
consideration of environment
GBD does not consider social context
- How does the physical and social environment influence disability experiences?
Models of disability
1) medical model
2) social model
medical model of disability
- disabled person is the problem, not society
- disabled people are defined by their illness/medical condition
- Promotes the view of a disabled person as dependent and needing to be cured or cared for (and justifies the way in which disabled people have been systematically excluded from society)
- Control resides firmly with professionals and choice limited to these
social model of disability
- “Disability” is no longer seen as an individual problem but as a social issue caused by policies, practices, attitudes and/or the environment
- focuses on ridding society of barriers, rather than relying on ‘curing’ people who have impairments.
perspective of social model example
e.g person using a wheelchair who cannot access a building => disabled due to absence of ramp NOT their own impairment
climate change => severe weather events =>
- floods
- infection
- hurricanes
indirect effects of climate change
- spread of disease vectors
- agriculture and food supply
- migration
actions against climate change
- planetary diet
- bikes for transport
- better heating
epidemiologic transition
Characteristic shift in common causes of death and disability from perinatal and communicable (infectious) diseases to non-communicable (chronic) diseases
- common causes of death: perinatal/communicable to NCDs
double burden of disease
- experienced by middle income countries
- due to previously common risks for perinatal and communicable diseases co-existing with increasing risks for non-communicable diseases
- major challenges for health policy
factors influencing risk burden
1) strength of causal association between the risk factor and health condition(s)
- e.g relative risk
2) commonness of exposure to risk in the population of interest
- e.g prevalence of risk factor in pop.
PAR (population attributable risk) using DALYs
The amount of “extra” disease or DALYs attributable to a particular risk factor in a particular population
- If the association is causal, this is the amount of the disease burden that we could theoretically prevent if we removed that risk factor from the population.
- DALYs enable comparisons between risk factor
risk transition
changes in risk factor profiles as countries shift from low- to higher income countries, where common risks for perinatal and communicable diseases are replaced by risks for non-communicable diseases
NCD myth: affect mostly high-income countries
reality: >80% of NCDs in LMICs
NCD myth: Affect mostly rich people
reality: Concentrated among poor
NCD myth: LMICs should control infectious diseases first
reality: “Double-burden” requires double-response
NCD myth: Primarily affect old people
reality: Almost half in <70 years (30–69-year-olds)
NCD myth: Chronic diseases can’t be prevented
reality: Significant proportions of premature heart disease, strokes, cancer and diabetes can be prevented
most affected pop. groups
- pop. living in POVERTY
- those living in LMICs
commercial sector (upstream determinant) drives NCD inequities by:
1) shaping preferences and changing social norms
2) actively exploiting difficulties with behaviour change when public health measures place greater emphasis on downstream strategies
1) shaping preferences and changing social norms
Marketing to vulnerable targets
E.g Socioeconomically deprived, women, children (addiction more likely and earlier => lifelong customer)
2) actively exploiting difficulties with behaviour change when public health measures place greater emphasis on downstream strategies
- Frame education as the most effective solution
- Offer choice and pleasure
- Emphasis on moderation
=> puts equity in public health at risk
commercial sector =>
promote unhealthy consumption among vulnerable groups
=> create uneven distribution of risks
=> unequal distribution of NCDs (deprived communities > wealthier communities)
density of outlets that promote unhealthy habits (e.g takeaways, liquor outlets, gaming machines
NOT randomly distributed
- purposely distributed so that there are more in most deprived areas as they bring in greater income
commercial sector is a…
structural driver of NCD inequalities
industrial epidemics
diseases arising from overconsumption of unhealthy commercial products
e.g tobacco, alcohol, processed food, sugar-sweetened beverages
in order to address commercial determinants of NCDs/health inequities
- Shift focus from individual behaviours to broader environment and upstream drivers of unhealthy product consumption
- Tackle the broader determinants of health (i.e. upstream determinants)
- Develop effective health policy recognising the tension between commercial and health objectives
HIV/AIDS was associated with…
a lot of discrimination and stigma
current knowledge of HIV/AIDS
- several modes of transmission
- cheap, reliable, specific screening tests
- caused by virus
- better treatment
not available for HIV/AIDS
- vaccine
- cure
AIDS related deaths are…
decreasing and people are living longer with HIV due to improved treatment and access to treatment/care
Globally, most people living with or at risk for HIV…
do not have access to HIV prevention, treatment and care
high risk groups for unprotected sexual intercourse
- homosexual men sex with HIV+ men
- heterosexual relationships
- sex workers
high risk groups for sharing unsterilized needles
- injecting drug users
- those receiving injections with unsterilised needles (generally in low-resource settings)
high risk groups for mother to child transmission
infants born to or breast fed by untreated HIV+ mothers
high risk groups for blood-borne
- anyone receiving un-screened blood products, organs (generally in countries with inadequate screening)
primary prevention - child
treating HIV+ pregnant women with anti-retroviral drugs reduces mother-to-child transmission
secondary prevention - mother
reduces disease progression in HIV+ mother to AIDS
dominant mode of transmission HIV/AIDS
heterosexual transmission at global level
HIV SEP trends
95% were in low and middle income countries
HIV age and sex trends
- majority are female and in Sub-Saharan Africa (60% of those in Africa are women too)
- young people
feminisation of HIV
observation that increasing proportions of new infections are among women primarily due to heterosexual transmission of the infection
HIV and violence
violence = 3 fold increase
women are more likely to:
- face barriers in accessing HIV prevention, treatment and care services
- face barriers to education
- experience poverty
HIV and gender inequity
driven by AND entrenches gender inequity leaving women more vulnerable to its impact
upstream/social determinants of HIV infection
- gender inequities
- poverty and low social status
- social norms, stigma and discrimination
HIV gender inequities
- Rules governing sexual relationships, negotiating condom use
- Sexual abuse/violence
- Problems with disclosure of HIV status. Partner notification and confidentiality (This can prevent getting necessary prevention options, testing for HIV and treatment)
- Men prevent women from being tested for HIV as it means they’re also associated which they don’t want to face
HIV poverty and low social status
consequent, limited access to education and reproductive health services
HIV Social norms, stigma and discrimination
prevent access to prevention efforts and treatment
HIV determinants =>
inequitable distribution of risks => … infection
HIV human rights
women’s right to safe sexuality and to autonomy in decisions relating to sexuality: intimately related to economic independence
- need basic social and economic arrangement to not exchange sex for survival
HIV prevention and control
- safer sex
- safer products and related practices
- increase access to healthcare
safer sex
- Media campaigns and wider policy strategies to reduce stigma and discrimination
- Educational approaches re risks: teachers, peers, workplaces, mass media campaigns
- Condoms: promote use (social marketing campaigns), increase availability, reduce cost
safer products
- Screen blood products for HIV
- Needle and syringe exchange programs for IV drug users
- Protect against needle-stick injuries (health professionals)
increase access to healthcare
- Voluntary testing & counseling to reduce risk of sexual transmission
- Treatment, care and support for HIV+ people
- Treatment of sexually transmitted infections, and provision of family planning services
- Antenatal screening and treatment for HIV to prevent Mother-To-Child-Transmission of HIV
HIV control in NZ
need to encourage condom use to reduce risk of HIV transmission, and HIV testing to detect infection early.
Injuries trend projection
projected to make an increasingly greater contribution to the GBD over the next decades
males dying at young age of injury contribution
contributing many YLLs
serious injuries contribution
contributing many YLDs
risk factors of RTI
- speed
- alcohol
- seatbelts and child restraints
- helmets
- visibility
vulnerable road users
- motorised 2-3 wheelers
- pedestrians
- cyclists
most policies until recently…
were around safety of cars
- <33% protect vulnerable road users
RTI and SES
demonstrate steep socio-economic differentials within and between rich and poor neighbourhoods and countries
RTI and SES risk in LMIC and HIC
in both LMIC and HIC, disadvantage socioeconomic groups (those living poorer areas) are at greatest risk of being killed/injured in RTcrash
RTI inequities age
children > adults
RTI inequities sex
men > women
RTI inequities road user
pedestrian > car occupants
RTI inequities fatality
fatal > non-fatal crashes
RTI upstream determinants - distribution of resources and opportunities
- choice of transport
- choice of residential area (hazardous environ)
- along highways => conflict over space between road users and local pop
- poor road design
- less speed restrictions
- no safe and accessible playgrounds
- unaccompanied children
- limited access to health services
RTI upstream determinants - legal and policy framework
- vulnerable road users less protected
- poorly funded and regulated public transport
- more poor road designs in poor neighbourhoods
poor road design
- less marked crossing
- less traffic calming measures
- less sidewalks
- higher posted speeds
RTI upstream determinants =>
disproportionally affect SE deprived groups => increased vulnerability to road traffic injury and mortality
addressing RTI
- inequity lens to help identify upstream determinants
- environmental prevention strategies => major decreases in pedestrian mortality
- social dimension: epidemiological approach beyond proximal causes
RTI epidemiological approach
- determine exposure within social context
- determine what shapes risk for injury
- examine relationship between injury and social status
framework for road safety strategy - global framework (pillars)
1) road safety management (adherence/implementation of legal instruments)
2) safer roads and mobility (infrastructure)
3) safer vehicles
4) safer road users (behaviour)
5) post crash response (emergency/health systems for treatment/rehab)
overarching recommendations - social determinants of health
- improve daily living conditions
- tackle inequitable distribution of power, money and resources
- measure and understand the problem and assess impact of action
RTI remaining challenges
- increase political will
- ensure accountability
- strengthen data collection
- build capacity in low resources countries
- improve vehicle safety measures
consequences of obesity
- metabolic diseases
- mechanical disorders
- psychological problems
- social consequences
metabolic diseases
type 2 diabetes, cardiovascular diseases, almost all cancers, gallbladder disease
mechanical disorder
arthritis, back pain, obstructive sleep apnoea, skin disorders
psychological problems
low self esteem, reduced quality of life, depression
social consequences
weight bias and discrimination, reduced life opportunities
causes of obesity
- genetic (indiv.)
- metabolic (indiv.)
- behavioural (indiv. but influenced by environ)
- environmental (population)
obesogenic environ
sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations
environment type (e.g food environments)
- physical
- economic
- policy
- socio-cultural
environment size
micro and macro
what influences food environments?
- food industry
- government
- society
how to food environ influence people
individual factors => food environ => diets
explanation for escalating obesity pandemic
- food system: food supply creating pop passive overconsumption
- other changes: reduced occupational activity
- underlying political and economic drivers
food system is supplying…
hyper-palatable, heavily-promoted, readily-available, cheaply-priced, highly-profitable ultraprocessed foods
economic environments
- income
- income disparities
physical environments
- food
- physical activity
socio-cultural environ
food, physical activity, body size
policy environ
marketing regulations (how tightly?)
obesity prevalence is driven…
up by global drivers but diff local environ determin trajectories of diff pop
- moderators attenuate or accentuate rise in obesity
implementation of recommendations is…
very patchy
policy inertia on implementing food policies
- food industry opposition
- government reluctance to regulate/tax
- lack of sufficient public demand for policies
food industry opposition
- direct opposition
- self-regulatory pledges/codes
government reluctance to regulate/tax
- weak governance systems, conflicts of interest
- belief in education approaches and market solutions
- unwilling to battle food industry
lack of sufficient public demand for policies
- usually supportive of policy actions
- not translated into pressure for change
heavy industry influence in NZ
big money behind harmful products => dirty PR operator => attack blogger => character assassination of public health advocates
top obesity prevention policies for NZ
- junk food marketing to children
- tax on sugary drinks
- health food policies in schools / early childhood settings
- front of pack labelling
investment in adolescent health brings a triple dividend
- benefits for adolescents now
- benefits for their future adult lives
- benefits for their children
people who experienced difficulties in accessing healthcare
- Māori, Pasifika and Asian students
- Students from more deprived neighbourhoods
- Students living with disability or chronic health conditions
- Students who were worried about drinking or had tried to cut down (concerned about drinking)
inverse care law
availability of good medical or social care tends to vary inversely with the need for it in the population served
emotional wellbeing
- most students have good
- declines especially among female
symptoms of depression
- most don’t have significant symptoms
- sharp increases in proportions of students
symptoms of depression inequity
- Significant ethnic disparity for rangatahi (young people)
* Gap is widening particularly for females
Symptoms of Depression: Rainbow youth
- Decline in wellbeing for Rainbow Young People
* High and increasing symptoms of depression since 2012
Inequities in mental health: intersectional identities
Rainbow young people with disability/ chronic health conditions:
• High symptoms of depression
• Low wellbeing
Self-reported Suicide Attempts (Past year)
- Increase in suicide attempts - especially for males
* Highest in communities exposed to socioeconomic deprivation
drivers of decline in mental health
- aspects affecting early development (2000-2005)
- contemporary 2012 current aspects
- aspects affecting future
aspects affecting early development
younger experience
- overprotection and low resilience
- snowflake hypothesis
current aspects
increased use of social media, internet access, smart phones => poor mental health mediated by other factors including decreased exercise and risk taking
- iGen hypothesis
- increasing perfectionism, exceptionalism, indiv achievement
aspects affecting future
- less hopeful
Impact of job insecurities, housing affordability, climate crisis, political polarisation - ‘Doomer’ hypothesis
youth2000 survey limitations
- recruitment bias
- causal relationships
- measurement bias
youth2000 recruitment bias
young peep not at school - dropped out
at higher risk of:
• adverse health outcomes
• unmet health needs
• socio-economical disadvantage
fewer positive connections with supportive networks
youth2000 causal relationships
cross-sectional => reverse causality
- bradford hill aspect of temporality unlikely to be fulfilled
youth2000 measurement bias
- can never be certain
- anonymous and confidential => increase likelihood of honesty
- self-reported info
=> still doesn’t eliminate likelihood of socially desirable answers
strengths of collecting data using tech
• More likely to provide honest answers - Less measurement
bias
• More likely to complete the survey as they enjoyed the
experience and felt engaged - Better response rates
limitations of collecting data using tech
• Students with some disabilities or language difficulties may
not complete the survey - Recruitment bias
• Can’t get back to youth whose responses may indicate they
are vulnerable or at risk (because the survey is anonymous)
strength-based approaches promote…
sources of resilience and focus on strategies for positive youth development
resilience
ability to spring back despite adversity
- peep with various protective factors may be less vulnerable to harm despite risk exposure
- presence of resiliency factors is associated with a reduction in health risk behaviours
relationship between neighbourhood characteristics and student wellbeing
- family connections
- school connections
- community connections
high => better wellbeing
Maori Health Is exemplified by systematic disparities in:
- health outcomes
- exposure to the determinants of health
- health system responsiveness, and
- representation in health workforce.
Determinants of Ethnic Inequities in Health
- Differential access to health determinants or exposures leading to differences in disease incidence
- Differential access to health care
- Differences in quality of care received
Right to Health
- Enshrined in International Law
- Extends beyond health care to pre-conditions
- Includes freedoms and entitlements
- States obliged to: respect (e.g. no discrimination), protect (e.g. no interference from 3rd parties), fulfil (e.g. adopt measures to achieve equity)
- Social epidemiology links health with social justice & thus links to good government
Health inequities are evidence of …
laws, policies & practices that distribute resources & opportunities in a discriminatory manner & limit full participation.
Health is acknowledged as…
political (power, social context & politics) and health policy decisions have a legal dimension rather than being purely political discretion
right to health instruments
- Universal Declaration of Human Rights
- International Covenant on Economic, Social & Cultural Rights (ICESCR)
- Other international rights conventions
- Indigenous Rights
- NZ legislation & policies
Other international rights conventions
a. International Convention on the Elimination of all forms of Racial Discrimination
b. ‘Elimination of Discrimination’ Conventions
Indigenous Rights
a. Te Tiriti o Waitangi
b. UN Declaration on Rights of Indigenous Peoples
NZ legislation & policies
a. Human Rights
b. NZ Public Health & Disability Act (NZPHDS)
c. Pae Ora Bill
d. Code of Health & Disability Service Consumer’s Rights (Patient Rights)
