Module 4: Deciding on Interventions to Improve PopHlth Flashcards
Population/public health goal
Provide max benefit for largest no of people
Why worry about priorities
Health rss are limited
Each prioritisation has an opportunity cost
Rationing involves ethical and evidence-based judgement
Difficult to compare outcome ‘apples and oranges’
Individual (clinical services) vs pop needs (pop health services)
Reasons for Global Burden of Disease (GBD) project
Data on burden of disease and injury from many countries were incomplete
Available data largely focused on deaths; little info on non-fatal outcomes (disability)
Lobby groups can give distorted images of which problems are most important
Unless the same approach is used to estimate burden of diff conditions, it’s difficult to decide which conditions are most important
Aims of GDP project
To use a systematic approach to summarise the burden of diseases and injury at pop level, based on epidemiological principles and best available evidence
- aids in setting health service and research priorities
- aids in identifying disadvantaged groups and targeting of health interventions
To take account of deaths as well as disability when estimating burden of disease
Disability Adjusted Life Years (DALYs)
Specific measure developed to achieve aims of GBD project
A summary measure of pop health combining data on premature mortality and non-fatal health outcomes to represent health of a particular pop as a single number
DALY = ?
YLD + YLL
YLD = years lived with disability
YLL = years of life lost
DALY values
A year in perfect health = 0
A year of life lost due to death = 1
A year with disability = between 0 and 1
YLL (Years of Life Lost)
Represents mortality by counting the years lost due to premature death caused by a disease
i.e. the years lost if a person dies before reaching average life expectancy in their country
YLL = no of 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 years lived with disease
No. of cases with non-fatal outcome with the disease
Average duration of non-fatal outcome until recovery/death
Disability weight (represents severity of impairment)
A DALY represents…
A lost healthy life year
DALYs enable comparisons between…
Diseases by using one measurement unit that compares premature death and disability
Between diseases to:
- prioritise health interventions
- monitor health interventions
- assess changes of disease burden over time
In general, as countries developed economically…
Average life expectancy has increased and fertility rate has decreased
GBD groups
Group 1: Communicable/infectious diseases - includes communicable diseases and perinatal conditions (early life)
Group 2: Non-communicable diseases (NCDs) / chronic diseases
Group 3: Injury
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 mid-income countries (not just rich countries)
DALYs: Challenges - questions to ask
Who should decide what weights should be assigned to various disabilities?
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?
How does physical and social environments influence disability experiences?
2 major challenges in using DALYs to quantify burden of ‘disability’
Disability weights are considered to be the same as the severity of an impairment relating to a disease/health condition, and don’t vary with a person’s social position, where they live, access to healthcare etc.
GBD project criticised for its potential to represent people with disabilities as a ‘burden’
Issues highlight differences in the way ‘disability’ as a concept is sometimes viewed - perceptions
Models of disability
Medical model
Social model
Medical model of disability
Disabled people are defined by their medical condition
Regards disability as an individual problem
Promotes view of a disabled person as dependent and needing to be cured or cared for - excluded from society
Control resides firmly with professionals
Choices for individual are limited to options provided and approved by the ‘helping’ expert
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
A higher burden of deaths at a younger age in low income countries contribute…
A lot of YLLs to the global DALY burden
Diff countries use diff measures to prioritise health issues, which leads to…
Difficulty prioritising on a global scale
High vs low income countries - groups of disease
High income - high amount of group 2 (non-communicable) disease
Low income - high amount of group 1 (communicable) disease
Disability weight - legislation
Can diff countries be given the same disability weight?
Which health model is GDP perceived to focus more on
Medical model of disability
Causes vs risks
Cause - the reason for death/disability (outcome); determinant
Risk - the reason for cause; determinant of determinant
Epidemiological transition
Characteristic shift in common causes of death and disability from perinatal and communicable (infectious) diseases to non-communicable (chronic) diseases
Causes of burden of disease in DALYs overtime
Over time, NCD risks increase and risk for communicable diseases decrease - known as risk transition
Key factors influencing the risk burden
How strong the ‘causal’ association is between risk factors and health conditions (e.g. RR)
How common the exposure to this risk is in the pop of interest (e.g. prevalence of risk factor in pop)
To identify the leading risk factors, GBD examined…
PAR - The amount of ‘extra’ disease burden attributable to a particular risk factor in a pop
This is the amount of disease burden we could theoretically prevent if we removed that risk factor from that pop
Low to high income countries - risks
Low: predominantly communicable and perinatal disease risks
Mid: NCD risks start to predominate
High: predominantly NCD risks
Known as risk transition
Low to high income countries - diseases
Low: slight decrease, but still predominantly communicable diseases
Low-mid: large decrease, but still slightly predominantly communicable disease
Mid: pattern shifted, from more communicable to much more NCDs
High: stable for some time - NCDs predominant
Low to high income countries - risk factors contributing to GBD by SESof country
Increasing SES of country = increasing risks for NCDs and decreasing risks for communicable and perinatal communicable diseases
Risk transition
Changes in risk factor profiles as countries shift from low to higher income countries, where common risks for communicable and perinatal diseases (e.g. unhygienic water) are replaced by risks for non-communicable diseases (e.g. tobacco)
Middle-income countries - risks
In many middle-income countries, previously common risks for communicable diseases co-exist with increasing risks for non-communicable diseases
These countries face a ‘double burden of disease’
Major challenges for health policy
Which countries affect NCDs
> 80% of NCDs contributing to global burden of disease is from low and mid-income countries
NCDs - concentration
Concentrated among poor
Double-burden requires…
Double response
NCDs - affect which age group?
Almost half in 30-69 year olds
Prevention of chronic diseases
They can be prevented; significant proportions of premature heart disease, strokes, cancer and diabetes can be prevented
Population groups most affected by NCDs
Low income groups
Those living in LMICs
Determinants and determinants of determinants of NCDs
Underlying socioeconomic, cultural, political and environmental determinants –>
Common modifiable and non-modifiable risk factors –>
Intermediate risk factors –>
Main chronic diseases
Unequal NCD epidemic - commercial sector
Commercial sector (distal/upstream determinant) drives the NCD epidemic Creates uneven distribution of risks --> unequal distribution of disease and health inequities
How have commercially driven epidemics come to be - smoking
Social norms changed as smoking became popular among other social groups - smoking in 1960s was seen as a status symbol, promoted by the rich
Commercial sector drives NCD inequities by…
Marketing to vulnerable targets, shaping preferences and changing social norms
Changing physical and social environments
- influence public policy development
- concentrate outlets in low SES areas
Actively exploit difficulties with behaviour change
- frame education as the most effective solution (social responsibility)
- offer choice and pleasure
- emphasises moderation
Density of outlets
Not randomly distributed - more gaming machines, liquor outlets and takeaways for populations per unit in most deprived areas
Industrial epidemics
Diseases arising from over-consumption of unhealthy commercial products
Addressing commercial determinants NCDs and health inequalities
Shift focus from individual behaviours to broader environment and upstream drivers of unhealthy product consumption
Tackle broader determinants of health (upstream/distal determinants)
Develop effective health policy recognising tension between commercial and health objectives
Tobacco control strategies (WHO)
MPOWER
Monitor tobacco use and prevention policies
Protect people from tobacco use (smoke-free legislations)
Offer help to quit tobacco use (downstream) - targeted programmes
Warn about dangers of tobacco
Enforce bans on tobacco advertising and sponsorship
Raise taxes on tobacco
Right to Help concept
Respect - to be free from discrimination
Protect - protect pop from 3rd party interference
Fulfill - fulfill right to health and address inequalities
Uses of epidemiology in obesity
Descriptive - current trends and burden
Predictive - future burden
Explanatory - changes over time, differences between pops
Evaluative - effectiveness of interventions
Global trend of obesity
Over time, all age groups increased simultaneously and equivalently
Increasing obesity at diff rates in diff regions of the world
NZ - obesity rank
Adults - third fattest in OECD
Children - third fattest on OECD
Increasing trend
NZ obesity - SES quintile
Increasing trends by lower SES
Gradient much steeper for children than adults
Most overweights and obesity in least disadvantaged group is overweight (less obesity) –> less severe
More severe obesity in most deprived
NZ obesity - ethnicity
> 60% of Pacific children overweight/obese and half of those are obese
2 main factors/causes of obesity (by DALYs)
Diet (poor nutrition) - biggest problem in many countries
High BMI
Consequences of obesity
Metabolic diseases (type 2 diabetes, CVD, most cancers) Mechanical disorders (arthritis, back pain, skin disorders) Psychological problems (low self esteem, reduced quality of life) Social consequences (weight bias and discrimination)
Type 2 diabetes vs BMI
Increasing risk of getting diabetes for increasing BMI
To get rid of diabetes, must get rid of obesity
Causes of obesity
Individual questions - why am I getting fatter?
Pop questions - why is this pop’s obesity prevalence going up?
Answers depend on the question - genetic, metabolic, behavioural, environmental
Obesogenic environments
The sum of influences the surroundings, opportunities or conditions of life have on promoting obesity in individuals or pops
Environment type: Physical, economic, policy, socio-cultural
Micro-environment (settings): Food, physical activity
Macro-environment (sectors): Food, physical activity
Obesogenic environments - environment type
Physical - what is or isn’t available?
Economic - what are the financial factors
Policy - what are the rules?
Socio-cultural - what are the attitudes, beliefs, perceptions and values?
Escalating obesity pandemic - factors
The food system - the most plausible explanation for the simultaneous, global increase in obesity is that it has been driven by changes in global food supply (4Ps), creating pop ‘passive overconsumption’ of total energy
Other changes have contributed - e.g. reduced occupational activity
Underlying political and economic drivers
Obesity through a pop - who is affected first?
Women –> Men
Middle age –> Children
High SES –> Low SES
Urban –> Rural
Local environments shaping obesity prevalence
Economic environments - income (disparities)
Physical environments - food, physical activity
Socio-cultural environments - food, physical activity, body size
Policy environments - market regulations
Population differences in obesity prevalence
Obesity prevalence is driven up by global drivers but diff local environments determine the trajectories of diff pops
Moderators attenuate or accentuate rise in obesity
Determinants of obesity
Drivers (changes over time drive changes in outcomes over time) –>
Mediators (factors through which the drivers operate) –>
Outcomes (changes in obesity prevalence)
Moderators (factors which accentuate or attenuate trends) –>
Mediators
Obesity - now
Youngest and well-off children starting to turn the corner
For NZ - may be starting to go down
Policy inertia on implementing food policies
Food industry opposition:
- direct opposition (Coca Cola on SSB taxes)
- self-regularly pledges
Government reluctance to regulate/tax:
- weak governance systems, conflicts of interest
- belief in education approaches and market solutions
- unwilling to battle food industry (chill effect)
Lack of sufficient public demand for policies:
- usually supportive of policy actions
- not translated into pressure for change
Obesity prevention action in NZ
Major policies:
- junk food marketing to children; no regulations
- tax on sugary drinks; none
- healthy food policies in schools; voluntary
- healthy food policies in early childhood settings; poorly implemented
- front of pack labelling; only 20% implemented
- restrictions on health claims on foods; yes
Community action:
- Healthy Families NZ
Obesity - history to now
1980s - scientists identifying epidemic
1990s - advocacy to get obesity on public and political agenda
2000s - increased awareness and some action; largely program-based
2010s - evidence of effectiveness of interventions strengthening, and declines in some pops, ongoing battles over food policies
HIV - DALYs
Ranked 11th in both 1990 and 2016
HIV - demand from public health epidemiologists
Human rights (Varying perspectives) and fears (local situation)
Screening (in absence of a known agent and test)
Request for ‘definitive’ evidence
Costs for screening vs numbers to save
HIV: What was known at the time?
Transmission form:
Infected blood (transfusions)
Homosexual men
No specific test but Hepatitis test was an indicator (proxy) Virus was not isolated at the time Vaccine not available Treatment options minimal Prevention - best hope
HIV: What we know now
Several modes of transmission identified - facilitate prevention
Cheap, reliable and HIV-specific screening tests available
Caused by a virus (human immunodeficiency virus)
Better treatment options - improved life-expectancy
Vaccine still not available
Global summary of HIV/AIDS epidemic (2016)
No of people living with HIV: 36.9 million
People newly infected: 1.8 million
No of HIV-related deaths: 1 million
> 70% of infected people live in Sub-Saharan Africa
Global summary of HIV/AIDS epidemic - no of people accessing antiretroviral therapy (ARV)
20.9 million (June 2017)
AIDs epidemic: low access to treatment
Especially marked in low and middle-income countries
78% treated in Western and central Europe and North America
36% treated in Western and central Africa
Changes in life-expectancy at birth in selected countries in Africa 1985-2015
Dramatic decrease in life-expectancy in 1990s e.g. Zimbabwe
Dramatic increase in life-expectancy in 2000s due to increased availability and accessibility of treatment
Communicable disease effect on life-expectancy
Communicable diseases can have a profound effect on life-expectancy, particularly in low and middle-income countries
No of people living with HIV
Increases, due to life-prolonging treatment
Decreased no of people newly infected - preventative measures
Decreased no of deaths –> increased prevalence pool
AIDs epidemic - global factors shaping the epidemic
AIDs related deaths are decreasing and people are living longer with HIV due to improved treatment and access to treatment/care
Nearly 50% of people with HIV don’t know their HIV status
Most people living with or at risk for HIV don’t have access to HIV prevention, treatment and care
AIDS epidemic - different regions / populations
Affected differently
Sub-Saharan Africa has ~1.2 million new infections per year
Young people account for a significant and rapidly growing % of pop and are reaching age of highest risk for sexual transmission
To reduce burden of HIV/AIDS, it is essential to…
Tailor the response and interventions to local circumstances and prevalent risk factors
HIV - high risk groups
Homosexuals (men)
Heterosexuals
Sex workers
Injecting drug users
Those receiving injections with un-sterilised needles
Infants born to or breast fed by untreated HIV+ mothers
Anyone receiving unscreened blood products / organs
HIV - transmission modes
Unprotected sexual intercourse with HIV+ person
Sharing unsterilised injections and needles
Mother-to-child transmission
Blood-borne
Of the NEW infections in 2016…
~95% were in low and mid-income countries
Among aged 15 and older:
- ~39% among people aged 15-24 years
- new infections among women aged 15-24 were 44% higher than men their age
- at a global level, heterosexual transmission has become the dominant mode of transmission
Feminisation of HIV epidemic
Refers to the observation that increasing proportions of new infections are among women, primarily due to heterosexual transmission of the infection
In Sub-Saharan Africa, ~60% of people living with HIV are women
Feminisation of epidemic: Proportion of HIV+ people who are women
Steadily increased over time
Leading cause of death for women of reproductive age (15-49) worldwide
Experience of violence is associated with a 3x increased risk of HIV
Feminisation of epidemic: Women are more likely to…
Face barriers in accessing HIV prevention, treatment and care services
Face barriers to education
Experience poverty
HIV is not only driven but gender inequity, but also…
Entrenches gender inequity, leaving women more vulnerable to its impact
Distal (upstream) social determinants of HIV infection: Gender inequities
Rules governing sexual relationships, negotiating condom use
Sexual abuse/violence
Problems with disclosure of HIV status - partner notification and confidentiality (can prevent getting necessary prevention options, testing for HIV and treatment)
Distal (upstream) social determinants of HIV infection: Poverty and low social status
Consequently, limited access to education and reproductive health services
Distal (upstream) social determinants of HIV infection: Social norms, stigma and discrimination
Prevents access to prevention effects and treatment –>
Inequitable distribution in risks of HIV infection –>
Inequitable distribution of HIV infection among the poor, women and young people
Human rights, women and HIV/AIDS
Women’s rights to safe sexuality and to autonomy in all decisions relating to sexuality is intimately related to economic independence
- most violated in places where women exchange sex for survival as a way of life
Not about prostitution, but a basic social and economic arrangement between sexes, which results from:
- poverty affecting men and women
- male control over women’s lives in a context of poverty
Human rights, women and HIV/AIDS: Economic security
The right not to live in abject poverty in a world of immense riches
Unless and until the scope of human rights is fully extended to economic security, women’s right to safe sexuality is not going to be achieved
HIV prevention and control
Safer sex:
- media campaigns and wider policy strategies to reduce stigma and discrimination
- educational approaches re risks
- condoms: promote use, increase availability, reduce cost
Safer products (and related practices):
- screen blood products for HIV
- needle exchange programs for IV drug users
- protect against needle-stick injuries (health professionals)
Increases access to healthcare:
- voluntary testing and counselling
- treatment, care and support for HIV+ people
- treatment of sexually transmitted infections and provision of family planning services
- antenatal screening and Rx for HIV to prevent mother-to-child transmission
HIV/AIDS: Mother-to-child transmission
Without treatment, ~1/3 children born to HIV+ women become infected while in the womb, at birth or through breast-feeding
Risk greatly reduced by screening pregnant mothers and treating those who are HIV+ with anti-retroviral drugs
Sub-Saharan Africa is home to 91% of pregnant mothers needing treatment
HIV/AIDS in Pacific Islands
90% of burden is in Papua New Guinea
Largely heterosexual transmission
Relatively high prevalence of other STDs increases risk of also acquiring HIV
Other Pacific Island nations currently have relatively low prevalence, but high prevalence of other STDs makes HIV a potentially major problem
HIV/AIDS in NZ
Low prevalence, but no room for complacence
Routine Antenatal screening - no cases of mother-to-child transmission since 2007
Among people currently living with HIV in NZ…
75% are men who acquired infection via sex with men
15% are men and women who acquired infection through heterosexual transmission
HIV/AIDS: 2008 Auckland survey
6.5% of men who have sex with men were infected; 20% unaware of HIV status
Need to encourage condom use to reduce risk of HIV transmission, and HIV testing to detect infection early
HIV/AIDS: Southeastern Indiana Outbreak
160 cases in 4 months, when usually < 5 cases/year
Community with long history of umemployment, poverty and generational addiction
Consistently lowest health status in state; slow roll-out of Affordable Care Act
HIV/AIDS: Southeastern Indiana Outbreak - why this happened
County was without an HIV testing centre from early 2013 when the sole provider - a Planned Parenthood clinic - closed
HIV/AIDS: Southeastern Indiana Outbreak - US/CDC Response
Public health emergency
- outbreak investigation - needle-sharing among injection-drug users
- ‘one-stop shop’ clinic for prevention advice, testing, treament
- needle and syringe exchange program (temporary)
- public education
HIV - what was crucial in establishing prevention efforts before the virus was discovered?
Surveillance, investigation of risk factors and health promotion
HIV: Subsequent biomedical and pharmaceutical innovations provided…
Rapid tests for HIV and treatment options that improve quantity (YLL) and quality (YLD) of life
Treatment and prevention of diseases
Treatment does not replace importance of prevention
As long as most HIV-infected persons are unaware of their infection status, prevention and treatment efforts will be hampered
HIV/AIDS: 3 major challenges for the future
Global rss for prevention and care of HIV fall well short of needs
Successful efforts for prevention nee to combat stigma and discrimination
Inequities in rss and access health care, make it essential to address social determinants of health and human rights
Is providing subsidised anti-retroviral drugs to pregnant mothers infected with HIV an example of primary or secondary prevention?
Reduces mother-to-child transmission = primary prevention with regard to the child
Reduces disease progression in HIV+ mother = secondary prevention with regard to the mother
Every _____ someone in the world dies as a result of an injury
Six seconds
How many women experience physical and/or sexual violence?
One in three women
____ of causes of death due to injuries are road traffic injuries (RTI)
~1/4 (24%)
Age group that is the largest contributor to road traffic injuries (RTI)
15-29 year olds
Most people dying of road injuries are young people –> greatest contributor to YLL in NZ –> burden of disease increase (DALY = YLL + YLD)
Deaths on NZ roads by user type (2011-2017)
- Vehicle drivers
- Vehicle passengers
- Motorcyclist
- Pedestrian
Road toll in NZ
Decreased from 2000 until 2013, then started increasing
% change in fatalities and serious injuries NZ
Much higher in Auckland (77.8%) than rest of NZ (22.9%)
Global rankings of injury-related mortality and burden of disease (DALYs)
Increased in ranking over time - particularly road traffic injuries
Injuries are projected to make an increasingly greater contribution to the global burden of disease over the next decades
Projected to increase from 9th (2004) to 5th (2030)
How many people die from RTIs - statistics
1.25 million die a year
500 children die everyday due to RTI
20-50 million more are injured each year
Burden of RTI in LMICs
Increasing
>90% of burden of RTI in LMICs
RTI: GDP
1-2% of GDP exceeds international aid provided to many low-income countries
RTI: LMICs vs high-income countries - vehicles vs injuries
Although low and mid-income countries have only half of the world’s vehicles, they have 90% of the world’s road traffic deaths
RTI: younger age groups (globally) - SES
Within younger age groups, predominantly low-income people dying from RTI
RTI in NZ - gender
Predominantly young males dying –> contributes to YLL –> burden of disease (DALY)
RTI: rich vs poor countries
Rich countries reduce road traffic deaths
Poorer countries are worst affected by road traffic deaths (increasing)
Road traffic fatalities predicted to increase by _____ by 2020
66%
WHO: Key risk factors to target for road safety efforts in LMICs
Speed Alcohol Seat-belts and child restraints Helmets Visibility
Reported deaths by type of road user by region and income group
In LMICs: mostly vulnerable road users
In HICs: less proportion of vulnerable road users; more occupants of four-wheeled motorised vehicles
Vulnerable road users
Pedestrians, cyclists and motorcyclists
Road user distribution of road injury (DALY) - statistics
On average, >50% of road traffic deaths in LICs are among vulnerable road users
<33% have policies to protect these road users
Most policies, until recently, were around safety of cars
RTIs demonstrate…
Steep socio-economic differentials within and between rich and poor neigbourhoods and countries
RTIs - socioeconomic groups
In both LMICs and HICs, disadvantaged socioeconomic groups (or those living in poorer areas) are at greatest risk of being killed/injured in a road traffic crash
Why does RTI disproportionately affect less privileged children living in LMICs?
Roads are commonly shared places for playing, working, walking, cycling and driving
RTI - Sweden
Risk of injury for pedestrians and cyclists was 20-30% higher for children of manual workers than those higher-salaried
Inequities in RTIs and death: groups most at risk
Children > Adults
Men > Women
Pedestrian > Car Occupants
Fatal > Non-fatal crashes
Inequities in RTIs and death: Due to income disparities…
The socioeconomic gradient amounts to violation of rights to safety, participation, education and health
Inequities in RTIs and death: What forces determine risk for injuries
Distal determinants;
Forces that determine distribution of rss and participation in society also determine risks for injury
Key driver of socioeconomic differences in RTIs and death leads to…
Variations in exposure to distal/upstream social determinants, i.e. deficiencies in legal and policy frameworks
Related to education and income
Related to road environments
RTI legal and policy frameworks: Disproportionate effects on the poor
Influences choice of transport available –> vulnerable road users
Limit choice of where they can live –> live in more hazardous environments, e.g. along highways, poor road design, less speed restrictions, no safe and accessible playgrounds
Compel children to be unaccompanied by parent when walking
Limits access to health services consequence to accidents
RTI legal and policy frameworks: Disproportionate effects on the poor lead to…
Increased vulnerability to road traffic injury and mortality
RTI: Poor countries/areas - public transport
Poorly funded and regulated
RTI: Poor countries/areas - vulnerable road users
Less protected
RTI: Poor countries/areas - poor road designs
Less marked crossing
Less traffic calming measures
Less sidewalks
Higher posted speeds
–> Increased vulnerability to RTI and mortality
Addressing RTI and death globally
Inequities lens helps identify social determinants of road crashes
Addressing RTI and death globally - prevention strategies
Major decreases in pedestrian mortality found in countries where environmental prevention strategies were implemented, rather than pedestrian education - unless roads are safer, educational interventions won’t make a big difference
Addressing RTI and death globally - social dimension - epidemiological approach
Social dimension of road injury calls for adoption of an epidemiological approach that goes beyond proximal causal factors to address road injuries globally
Determine exposure within social context
Determine what shapes the risk for injury
Examine relationship between injury and social status
Framework for road safety strategy: Global framework - Decade of action for road safety 2011-2020
Pillar 1: Road safety management - adherence to full and implementation of relevant UN legal instruments
Pillar 2: Safer roads and mobility - infrastructure - safety and protective quality of road networks for benefit of all road users
Pillar 3: Safer vehicles - enhance safety of vehicles
Pillar 4: Safer road users - road user behaviour
Pillar 5: Post-crash response - increase responsiveness of post-crash emergency systems and improve ability of health systems to provide appropriate acute treatment and long-term rehabilitation for crash victims
WHO commission on social determinants of health - Overarching recommendations
Improving daily living conditions
Tackle inequitable distribution of power, money and rss
Measure and understand the problem and assess impact of action
RTI: Travel experiences of older people and people living with disabilities in Sri Lanka
Community aspirations and values, public attitudes, human rights –>
Government targets, monitoring indicators and performance measures
Who is a Maori
What do we mean by Maori? Ancestry, whakapapa, descent (‘blood’ genes)
Classification of ethnicity - census questions
Census = denominator, vitals and hospital data = numerator
Maori health is exemplified by systematic disparities in…
Health outcomes
Exposure to determinants of health
Health system responsiveness
Representation in health workforce
% of Maori in deciles
> 50% of Maori in the 3 most deprived deciles –> worse health outcomes
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
Maori health - who has the duty to act
[Individuals], professionals, families, communities, nations, gtovernments
Maori health - what leverage can be used to invoke action?
The Right to Health - evolution, actualisation
Human Rights Instruments: Universal Declaration of Human Rights (1948)
UN General Assembly
Article 25
Right to a “standard of living adequate for the health and well-being of himself and his family including … medical care and … right to security”
Didn’t define parameters of right to health, but noted they both include and transcend medical care
Determinants of health contextualised
Human Rights Instruments: International Covenant on Economic, Social and Cultural Rights (ICESCR 1966)
UN, Article 12
Explicit “right to health” and steps states should take to “realise porgressively” “the max available rss” to the “highest attainable standard of health”
Gives examples of inclusions, able ot evolve, ‘reasonableness’ for diff states and expectation of international co-operation
Human Rights Instruments: International Covenant on Economic, Social and Cultural Rights (ICESCR 1966) - 2000
UN Committee issued General Comment #14 clarified:
- R2H is not the same as R2be Healthy
- related to other human rights and health equity
- itemises some ‘freedoms from’ and ‘entitlements to’
- obligations of states (R, P, F)
Right to Health
Enshrined in International Law
Extends beyond healthcare to pre-conditions
Includes freedoms and entitlements
States obliged to respect, protect and fulfil
Social epidemiology links health with social justice and good government
Right to Health - RPF
Respect - no discrimination
Protect - no interference from third parties
Fulfil - adopt measures to achieve equity
Right to Health - in Human Rights framework
Health inequities are evidence of laws, policies and practices that distribute rss and opportunities in a discriminatory manner and limit full participation
Health is acknowledged as political (power, social, politics) and health policy decisions have a legal dimension rather than being purely political discretion
Right to Health - strategies
Will need a number of strategies incl leadership, advocacy, policy and political bravery against multi-national interference
e.g. Tobacco control, SSB, climate change
R2H is specifically mentioned in…
Art 5 of International Convention on the Elimination of all forms of Racial Discrimination (1965)
Also noted in other ‘Elimination of Discrimination’ conventions
Scope and range broadened and made more explicit
Right to Health - discrimination
Discrimination travels on various axes of identity –> impacts on multiple layers of determinants
Acts on access to and through (quality of) care
Even if not intentional, if discrimination causes impairment of enjoyment of rights = violation
Right to Health - State
Has moral and legal obligation to prohibit and eliminate, including acting affirmatively
e.g. disability car parks
R2H - accountability
R2H framework goes beyond medical, ethical and quality issues to focus on accountability
R2H - nations
Implementation and enforcement dependent on political, legislative and judicial action at a national level (~70 nations)
Critically important relationship with domestic law, regulations and polices
R2H in NZ: The Code of Health & Disability Service Consumer’s Rights
Outlines 10 rights including freedom from discrimination and services of an appropriate standard
Aligns with Human Rights Act, NZ Public Health and Disability Act
R2H not explicit
In part a response to ethical issues in health services research
R2H in NZ: NZ Public Health & Disability Act
One purpose is to reduce inequalities
No explicit mention of R2H but main purpose a DHB-based health system to foster community participation
Has a ToW clause, and clause that notes that no-one will have special privileges on basis of ‘race’
Reducing inequalities focus reiterated in overarching policy documents - NZ Health Strategy, NZ Disability Strategy, He Korowai Oranga
R2H in NZ: Te Tiri o Waitangi
Affirms indigenous rights as does 1835 Declaration of Independence
Various ways of using ToW as a framework with diff strengths and liminations
Art 1: Good governance
Art 2: Active protection of taonga - Te Reo Claim
Napier Hospital Claim - health as a taonga
Ngati Porou Claim - inequities as a breach
Currently hearing Kaupapa Claims incl health
R2H in NZ: UN Declaration on Rights of Indigenous Peoples
Adopted by UN after 25 years of negotiations in 2007, NZ signed on 20th April 2010
Introduction/preamble and 46 articles
Preamble states:
- everyone has human rights
- indigenous peoples have not rights fully realised
- seeks to facilitate full realisation of rights and stronger relationships between Indigenous Peoples and States
R2H in NZ: R2H Instruments
Universal Declaration of Human Rights ICESCR Other international rights conventions Indigenous Rights: - ToW - UN Declaration on Rights of Indigenous Peoples NZ legislation and policies: - Human Rights - NZPHDS - Code of Patient Rights
Youth age group
10-24 years
Adolescent age group
10-19 years
% of people in youth age group
Most countries consist of at least 20% of people in the youth age group
Large proportion of youth age group in NZ compared to whole pop
All cause mortality rates in adolescents in NZ
NZ has high rates
Adolescent - world pop
1/6 of world pop
Larger cohort of adolescents and young people today (just under 2B) than ever before
Adolescent - LMICs
86% live in low and mid-income countries
Adolescent disease and injury burdens
Many are preventable / treatable, but are often neglected
2030 Agenda for Sustainable Development: Investment in adolescent health
Brings a triple dividend:
- Benefits for adolescents now
- Benefits for their future adult lives
- Benefits for their children
2030 Agenda for Sustainable Development and SDGs
Adopted in 2015 at a special UN summit
Commitment to eradicate poverty and achieve sustainable development by 2030 worldwide, ensuring no one is left behind
A landmark achievement, providing for a shared global vision towards sustainable development for all
2030 Agenda for Sustainable Development can’t be achieved without investment in adolescent health and well-being including fulfilment of its goals related to…
Poverty Education Water and sanitation Human settlement Peaceful and inclusive societies Hunger Gender equality Economic growth Climate change
Leading causes of DALYs lost among 10-24 year olds - global
Mental health & substance use and other NCDs
Also affected by injuries (transport and unintentional)
Leading causes of death among 10-24 year olds - global
Mainly injuries (transport, self-harm and violence, unintentional) Also communicable diseases (diarrhoea/lower respiratory infections and HIV/AIDS and tuberculosis)
Adolescent deaths - where?
> 2/3 of adolescent deaths occurred in LMICs (2015)
Africa 45%, SE Asia 26%
HICs - main contributors to DALYs lost
Mental health and some road injuries
African LMICs - main contributors to DALYs lost
Communicable diseases and some mental health
SE Asia LMICs - main contributors to DALYs lost
Mental health, NCD and some injury causes
HICs, MICs and LICs - health profile for adolescents
HICs - NCD predominant
(L)MICs - injury excess
Africa and SE Asia - multi-burden
Leading global risk factors for deaths 15-19 year olds
Alcohol use Unsafe sex Unsafe water Unsafe sanitation Handwashing Occupational injury Intimate partner violence Drug use Low glomerular filtration Childhood sexual abuse
Leading causes of DALYs lost among 10-24 year olds - NZ
Mainly NCDs (mental health & substance use, other NCDs, musculoskeletal disorders, neurological disorders) Also self-harm and violence
Leading causes of death among 10-24 year olds - NZ
Mainly injuries (self-harm and violence, transport, unintentional) Also NCDs - neoplasms and neurological disorders
National secondary school surveys
Cross-sectional surveys using random samples of secondary school students in 2001, 2007, 2012 and 2018
Profile of health, health risks and sources of resilience among adolescents in NZ
Anonymous, confidential, self-report
National secondary school surveys - M-CASI
Multimedia-Computer Assisted Survey Interviews
Using internet tablets
Youth survey - topics covered
Ethnicity and culture Family relationships School Injuries and violence Health and healthcare Emotional health Food and eating Leisure activities Sexual health Alcohol, smoking and other drug use Community involvement
Youth survey - prevalence of good to excellent health
92%
A result that hasn’t changed since 2001
Youth survey - who was recruited
Each student in secondary schools had an equal probability of being invited to complete the survey if they were at school
Reasonably representative of young people IN secondary schools in NZ
Youth survey - survey response rate
About 70%
Youth survey - how reliable might this information be? (measurement bias)
Can never be entirely certain
Survey was anonymous and confidential, which would increase likelihood of honesty
Self-reported info - directly entered into internet tablet rather than responding to an interviewer
Reduces, but does not eliminate likeliness that respondents are providing socially desirable rather than honest answers
Youth survey - who had diffiulties accessing healthcare
Students who were worried or had tried to cut down (concerned about drinking)
Maori and Pacific students
Students from more deprived neighbourhoods
Students living with disability or chronic health conditions
Inverse care law
The availability of good medical (or social) care tends to vary inversely with the need for it in the population served
i.e. those who need the care the most find it the most difficult to use it
Youth2000 surveys - Limitation: examining ‘causal relationships’
Reverse causality - did having a disability increase risk of injury or did having an injury increase risk of having a disability?
Difficult to know which came first in cross-sectional surveys
Bradford Hill criterion of ‘temporality’ unlikely to be filfilled
Youth 2000 surveys - Limitation: Who is not represented?
Recruitment bias
Young people not at school (e.g. dropped out, truanting) - these youth likely to be at higher risk of adverse health outcomes etc.
Young people with significant disability who can’t complete survey or aren’t in mainstream schools - could also be at higher risk of adverse outcomes and have unmet health needs
Youth20000 surveys - major strengths of M-CASI technology
More likely to provide honest answers (privacy and confidentiality) - less measurement bias
Students more likely to respond and complete survey because they enjoyed the experience and felt engaged - better response rates
Youth2000 surveys - major limitations of M-CASI approach
Can’t get back to youth whose responses may indicate they are vulnerable/at risk (survey is anonymous)
Students with some disabilities or language difficulties may not complete the survey - recruitment bias
Implications of NZ youth surveys
Valuable role in determining health and well-being of NZ’s young people in schools
Continue to track prevalence of key youth health indicators
Basis for significant policy and practice - reports used by governements etc
Explore outcomes of social, education and economic policies and changes on aspects of young people’s well-being
Changes in adolescent risk-taking behaviours in NZ 2001-2012
Overall decrease in risk-taking behaviours in NZ
Smoking, alcohol use and risky driving:
- policy and legislative environment
- public health and social marketing campaigns
- school-based health services are curricula
Sexual health:
- school-based health services and curricula
Socioeconomic deprivation and students’ health
80% of students had low levels of household poverty
5% experienced high levels of poverty
Depressive symptoms and cigarette smoking were 2-3 times higher in poverty groups
Resilience
Refers to ability to spring back despite adversity
People with various protective/resiliency factors may be less vulnerable to harm despite exposure to risk
Presence of resiliency factors is associated with a reduction in health risk behaviours
Strength-based approaches promote sources of resilience
Youth2000 surveys - family connections
Family member/s care
Time with family
Meals with family
Youth2000 surveys - school connections
Adults at school care
Teachers fair
Feel part of school
Feel safe at school
Youth2000 surveys - community connections
Friendships Caring neighbours Caring workmates Volunteer roles Community groups
Strength-based approaches promoting sources of resilience on youth development - strategies
Promote bonding and +ve connections to family, school, community Promote social, emotional and moral competence Foster spirituality Foster self-efficacy Foster clear and +ve identity Foster belief in the future Provide recognition for +ve behaviour Foster healthy standards for behaviour
