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Question 1

Apply bradford hill framework (7) and rothman causal pie to identify causes of disease

Answer 1

Temporality - establish the cause then the disease

Biological gradient - incremental change in exposure = incremental change in outcome

Biological plausibility of association - does the causal relationship or association between exposure and outcome make sense biologically

Strength of association - stronger in association = more likely to be causal in absence of known bias

Reversibility - under controlled conditions, change in exposure = change in outcome

Consistency of association - replication of findings by different investigators at different times, in different places and with different methods

Specificity of association - single cause leads to single effect and effect has single cause

Question 2

Epidemiological triad

Answer 2

Host, agent and environment
Host = persons in a population
Environment = physical, social and policy - eg easy access to cigs
Agent = biological, nutritional, physical and chemical eg carcinogen in cigs

Question 3

causality

Answer 3

Causal pie = multicausality - event, condition or characteristic or combo which play an essential role in producing the disease

Sufficient causes (a whole pie) = min set of conditions - missing one - disease would not occur - several sufficient causes and several pies can produce same disease

Component cause - factor that contributes to disease causation but not sufficient to cause disease on its own - interact

Necessary cause - must be present for disease to occur

Question 4

Living standards framework

Answer 4

Individual and collective wellbeing - resources and aspects of your life that are important for the wellbeing of individuals and families
Institution and government - the roles that institutions play in safeguarding and growing our wealth to facilitate the wellbeing of individuals and populations
Wealth of NZ - how wealthy we are as a country - not just captures in national accounts

Question 5

4 capitals

Answer 5

Social capital - knowledge, values and beliefs that are shared - the crown relationship and societal norms + trust
Human capital - peoples’ skill, knowledge and health
Natural capital - all aspects of the natural environment around us
financial/physical capital - country’s physical assets and built = roads and buildings and houses

Question 6

sep

Answer 6

SEP - the social and economic factors that influence what position an individual or group holds in the structure of society
Determinants must be measurable, meaningful and objective
You measure SEP to quantify the level of inequality between groups and you can use this to highlight changes in population structure over time and understand the relationship between health outcomes and other variables

Question 7

sep area vs population based

Answer 7

Measures in individuals = education, income, occupation, housing and assets/wealth
Measures in populations - area measures and population measures
Area = deprivation according to decile and access to resources
Population based = income inequality, literacy rates and gdp per capita

Question 8

nzdep

Answer 8

NZDep = area based measure
Income - below threshold or 18-64 with means tested benefit
Communication = 18-64 with no access to internet at home
Employment - 18-64 unemployed
Qualifications - 18-64 no qualifications
Owned home - renting and home unowned - not living in own home
Support - below 65 in a single parent family
Living space - living in households below a bedroom occupancy threshold
Living conditions - people living in houses that are always damp or have mold greater than a4 size

Question 9

preston curve 2000

Answer 9

gdp per capita vs life expectancy

Question 10

Define the terms inequality and inequities in context of pophealth

Answer 10

Inequalities = the measurable differences in outcomes and experiences between groups or individuals based on sep
Inequities = inequalities stemming from injustice - distribution of resources does not reflect health needs - equal and unequal power

Question 11

progress

Answer 11

Place of residence
Race
Occupation
Gender
Religion
Education
Sep
Social capital

Question 12

lorenz curve

Answer 12

Lorenze curve - ratio of area between perfect equality and inequality, reflecting the level of inequality in populations and society - more concave = more disparity
Gini coefficient = A/A+B - closer to 1 = more unequal

Question 13

Implications of income inequity

Answer 13

less social cohesion less trust between groups leading to more stress and therefore lower health outcomes and decreased productivity rates = more unequal society

Question 14

commercial determinants

Answer 14

Structures, rules and practices by which business activities designed to generate wealth and profits influence patterns of health and disease across populations

Question 15

Provide some examples of the strategies that industry actors use to shape public health and protect business interests therefore influencing pop health

Answer 15

Shaping the evidence by lobbying, shaping research and funding priorities, financing university programmes and chairs
Employing narratives and framing techniques eg working with yough and having corporate social responsibilities to make it seem like they are part of the solution
Constituency building - promoting or sponsoring as well as charity partnerships or health and wellbeing partnerships
Policy substitution, development and implementation - partnerships or voluntary agreements with government to contribute to health policy consultations

Question 16

Access

Answer 16

Availability - relationship between the volume and type of service being provided and the clients’ volume and types of need - are there enough and - knowledge and ability to get it - how much confidence do you have in being able to get medical care when needed?
Accessibility - Considers the geographical barriers - the relationship between the location of the supply and the location of the client, taking into account, cost, distance for travel and transportation - convenience and difficulty - how satisfied are you with how convenient your physician’s offices are to your home?

Affordability - The relationship between the cost of the service being provided and the ability and willingness of the client to pay - how satisfied are you with your health insurance and how satisfied are you with your doctors prices or how soon you have to pay bills?

Acceptability - The relationship between clients’ and providers’ attitudes to what is thought of as appropriate care - how satisfied are you with the appearance of the waiting room or other patients or the neighbourhood?
Accommodation - the relationship between the way that the resources are organised and the expectations of clients - how satisfied are you with how long you have to wait to get an appointment or office hours?

Question 17

Exemplified by systematic disparities (differences)

Answer 17

in health outcomes, healthcare responsiveness, health care work force representation and exposure to the determinants of health - dalhgren and whitehead model
Step wise gradient - NZDep - neighbourhood deprivation = maori in most deprived areas - more mortality due to deprivation

Question 18

ethnicity

Answer 18

internally - is it being measured because of how I am inside my body or is it because of externally with how society is treating me

Question 19

Ethnic inequities - disparities

Answer 19

Differential access to health care - asthma and immunisation
Differential access to quality of care recieved - asthma
Different exposure to health determinants, leading to differences in disease incidence
Maori have different health outcomes - deprived neighbourhood - access to different foods, access to less clean air and environment - lower quality food and transport quality

Question 20

IDI

Answer 20

IDI - routinely collected measured from government and other agencies - this is deidentified and strict rules re in place for confidentiality - computer in a room and only some researchers can look at it
Data from many sources linked to be population based
Data safe haven
Longitudinal - watch data over years and evaluate effectiveness of interventions -insight analysis
Resident population - compare with census
Age structure of idi based population vs census - defined population who uses services - education or acc or who goes to winz - older gen and criminal vs general pop - younger or maori and pacifica - addictions - overrepresentation = different to census
Denominator of gold standard - census or IDI
Idi- refreshed and routinely collected whereas census is not as frequent
Population base increasing or decreasing based on different data sources - numerator remains the same - show difference by changing denominator
Changing denominator - dont count accuraetley may not show proper interventions for maintain equity eg measure deprivation

Question 21

ethnic coding

Answer 21

prioritised output - in terms of need and equity - actual pop, total response - more than actual population and sole/combination - more than actual
Prioritised - ethnic groups not swamped by nz european data - easy to work with and same as population number - specific ethnic groups - over represents some and is externally applied ethnicity - inconsistent with self identification
Total response - potential to represent those who do not identify with any depending on level of detail - create complexities in distribution of funding based on population numbers or monitoring changes in ethnic composition of population - create issues in interpretation of data - comparisons = overlapping data

Question 22

dependency ratio

Answer 22

Dependency ratios - child 0-14/working age x 100 elderly = over 65/working age x 100

Question 23

imd

Answer 23

Employment - degree at which working age people are excluded from employment
Income - measure state financial assistance to capture extent of income deprivation
Crime - risk of personal and material victimisations and damages to persons property
Housing - proportion living in rented accommodations and overcrowded homes
Health - high level of ill health or mortality
Education - working age population without formal qualification - youth disengagement
Access - cost and inconvenience of travelling to access basic services eg hospital, grocery store and gas station

Question 24

imd vs nzdep

Answer 24

Imd allows you to look at disadvantage in overall terms as well as in 7 domains

Use nzdep for - planning and resource allocation, research and advocacy - imd and nzdep are both area based measured

Question 25

ecological fallacy

Answer 25

Ecological fallacy - error that arises when information about groups of people is used to make inferences about individuals - area in which they live eg income is not representative of individual households or people

Question 26

Urban planning and how these influence making healthy choices with respect to travel

Answer 26

Street connectivity - grid like pattern - reduces distance between destination, encouraging use of active transport Traffic calming - street width and more cycle lanes and pedestrian crossings - facilities that encourage walking and cycling and discourage driving Land use mix - residential, commercial and business use - different uses of land in zone - increase opportunity for active transport Parks and recreational public open spaces and physical activity spaces - open spaces in close proximity to residents eg pools and parks and playgrounds - increase physical activity

Question 27

Discuss how different aspects of built environment can promote or restrict healthy behaviours

Answer 27

Built = all buildings, spaces and products that were significantly produced or altered by people Measured by - urban density, street connectivity, land use mix and community resources

Question 28

sdg

Answer 28

end poverty, protect planet and improve lives for everyone everywhere - all member states address inequities in own location in hopes for global reduction in inequities 3 layers - environment at bottom which supports next layer of society and this supports next layer of economy Each goal has targets and indicators - use publicly available data to compare to see how others are being meeting targets

Question 29

gender inequalities and reduced inequalities mapped onto living standards and 4 capitals

Answer 29

12 different wellbeing domains in living standards framework and 17 sdg - not all map onto sdg Gender inequalities and reduced inequalities - everything would map onto that - reduce inequalities across the board - goals trying to match - dont map onto living standards frameworks - goals for all govt policies - imbedded in all wellbeings Four capitals go onto gender equality and reduced inequalities - expected policies - committed to te tiriti

Question 30

4 V and big data

Answer 30

Big data - large and complex datasets - large amounts of information at a population, regional or local level or span different geographical regions Combining data from multiple sources to explore pop health outcomes Volume - computing capacity required to store and analyse large data Velocity - the speed at which data are created and analysed Variety - types of data sources available Veracity - accuracy and credibility of big data Variability - internal consistency of data - reproduce information provides variability but also maintains veracity of the data - accuracy to be maintained Value - the costs required to undertake big data analyses - how much money you can make Visualisation - use of novel techniques to communicate patterns that would otherwise be lost in large data sets

Question 31

population based strategy vs high risk strategy

Answer 31

Population based (mass) strategy - whole population - move distribution of health outcomes in the more favourable direction and reduce the health risks to improve the outcome of all individuals in the population - useful for a common disease or widespread cause eg immunisation programmes or legislated use of seatbelts and low salt foods Advantage - radical measure - addresses underlying cause - has large potential benefit for whole population eg smallpox vaccine eradicated small pox - behaviorally appropriate as it changes social norms - easier to adhere to messages eg smoking section in aeroplanes but now no smoking as social norms changed Disadvantage - small benefit to individuals - eg seatbelts have saved many lives but many people will not experience a severe car crash but as population it has large benefit - and poor motivation of individuals - wont think something will affect us so we wont listen - whole population is exposed to the downside of the strategy High risk (individual) strategy - high risk strategy targeted towards high risk groups - intervention is well matched to individuals and their concerns eg targeting obese adults - move outcomes of the high risk groups or intravenous drug users - eg needle

Answer 32

exchange programme - decriminalised needles and syringes sale to intravenous drug users if they exchange - reduce needle sharing = decreased hiv Advantages - appropriate to individuals and provides individual motivation - cost effective use of resources as only high risk targeted and favourable benefit to risk ratio Disadvantages - cost of screening eg mammogram - repetitive, need to identify individuals - temporary effect - screening - identify high risk group so effect is temporary - and limited potential (eg targeted towards women who get pregnant over 45 is very limited so any strategies will be limited in potential) and behaviourally inappropriate - constricted by social norms as it can make high risk people to make decisions that go against social norms exchange programme - decriminalised needles and syringes sale to intravenous drug users if they exchange - reduce needle sharing = decreased hiv Advantages - appropriate to individuals and provides individual motivation - cost effective use of resources as only high risk targeted and favourable benefit to risk ratio Disadvantages - cost of screening eg mammogram - repetitive, need to identify individuals - temporary effect - screening - identify high risk group so effect is temporary - and limited potential (eg targeted towards women who get pregnant over 45 is very limited so any strategies will be limited in potential) and behaviourally inappropriate - constricted by social norms as it can make high risk people to make decisions that go against social norms

Question 33

alma mata vs ottawa charter

Answer 33

Alma Ata - declaration for primary care - protect and promote health of all - advocate for health promotion approach to primary care Prerequisites for health - peace and safety from violence, shelter, education, food, income and economic support, stable ecosystem and sustainable resources and social justice and equity Ottawa charter - mobilise action for community development - recognises that health is a fundamental right for all and requires both individual and collective responsibility - the opportunity for good health should be equally available - good health is an essential element of social and economic development Equity lens

Question 34

3 strategies ottawa charter

Answer 34

Enable - to provide opportunities for all individuals to make healthy choices through access to info, life skills. And supportive environments - individual level strategy Advocate - to 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 - to facilitate/bring together individuals and groups with opposing interests to work together and compromise for the promotion of health (strategy joins individuals, groups and systems)

Question 35

5 priority actions ottawa charter

Answer 35

Develop personal skills (capacity, capability and health literacy), strengthen community action (groups of people minorities - make decisions about own health and set priorities = empower) (changing community aspirations over time not just stagnant), create supportive environments (protecting natural environments eg parks and outdoors to encourage physical activity and economic support), reorient health services towards primary care (provide support to populations and being mindful of wellbeing), build healthy public policy (health in all sectors and policies not just curative care)

Question 36

health protection

Answer 36

Health protection - Environmental hazard focus - safe water and air and biohazard management and monitoring - risk communication to public and occupational health eg safety regulations at work

Question 37

Te Pae Mahutonga (health promotion) central stars

Answer 37

Mauriora - access to Te Ao Maori and everything that is in maori society and culture Waiora - a healthy environment Taiora - healthy lifestyle Te Oranga - participation in society - can be linked to Mauriora - education, housing and community

Question 38

te pae mahutonga pre requisites

Answer 38

Te Mana Whakahaere - Autonomy - enables Maori self governance and community control to help create more effective interventions Nga Manakura - Leadership - partnership with health professionals rather than health professionals assuming control - work alongside to better address risk factors and cater to the community for an effective intervention

Question 39

what is te pae mahutonga for

Answer 39

Addresses determinants of health Made by maori for maori - Te Mana Whakahaere and Nga Manakura - autonomy and leadership - making it more effective in addressing various risk factors for various communities Channels and messages are more effective for each community Reduces disparities and inequities Can be applied to all communities but mainstream interventions cannot be applied to maori Removes barriers - equity establishment

Question 40

good screening test must be

Answer 40

Reliable Affordable Simple Acceptable Accurate - sensitivity and specificity

Question 41

Screening criteria

Answer 41

know causes of the disease, has to be suitable disease - common or uncommon - uncommon = screen early for early intervention, suitable screening, suitable treatment and suitable screening programme Benefits must outweigh harm and must reduce mortality and morbidity to be successful - screening causes early intervention to reduce mortality and morbidity

Question 42

sensitivity specificity ppv and npv

Answer 42

Sensitivity = true pos/all with disease Specificity = true neg/all without disease Positive predictive value - depends on prevalence of a disease - true positive/all who test positive (predictive) Negative predictive value - depends on prevalence - true negative/all who test negative (predictive) - they are not fixed characteristics - reflect test accuracy and prevalence of disease If prevalence is high = higher false neg If prevalence is low = higher false pos

Question 43

lead vs length time bias

Answer 43

Lead time bias - apparent increase in life expectancy - not actually=if screening programme is evaluated in terms of survival time they may get a false impression of success - early detection may make it seem longer but time after clinical diagnosis is the same Length time bias - if rapidly progression and slow progression is averaged out via mean - may give the impression that there is longer average survival years but the time of screening = death for rapid

Question 44

evidence based measures

Answer 44

Descriptive - what is the health problem and the extent of it - who is most affected and where are we now - trends over time Explanatory - what are the risk factors and determinants - why are we getting better or worse and why are populations different - equity and sep - te tiriti Evaluative - develop and test - analyse and widespread - monitor and evaluate - what can be improved and how - is the intervention improving health conditions - economic feasibility

Question 45

State the epidemiological measures used to prioritise population health issues

Answer 45

Epidemiological measures in prioritisation - YLL and YLD - compare between and within countries YLL - years of potential life lost to death YLD = years lived with disability

Question 46

Describe how population attributable risk (PAR) is used for prioritisation - calculate PAR and interpret findings

Answer 46

PAR = population attrituble risk = PGO - CGO PAR = determine if causal - amount we could decrease if risk factor was removed - amount of extra disease attributable to a certain risk factor in a population - amount that you could decrease because PGO - CGO = rest left to exposure so reducing risk factor would reduce the PAR increase in CGO or decrease in PGO = decrease in PAR PGO = occurrence in total population = all positive divided by total population

Question 47

Describe the reasons, the aims and major impacts of the global burden of disease project

Answer 47

GBD = global burden of disease Reasons for the project - very little data on non fatal outcomes - lobby groups = distorted image - same approach needs to be used to decide prioritisation - data for burden of disease = incomplete Aims = systematic approach to summarise burden of disease at population level based on epi principles - aid in health research priorities Take account of death as well as non fatal when estimating the burden of disease Disability adjusted life years was the specific measure developed to achieve these aims

Question 48

Define disability adjusted life year and the data elements required to complete DALY

Answer 48

DALY - measure of population health that combines data of premature mortality and non fatal health outcomes to represent the health of a particular population in a single number DALY = YLL + YLD So years of potential life lost to death + years of life lived with disability = Disability adjusted life years YLL = years lost if a person dies before reaching the average life expectancy in a particular country - years of life lost relative to ideal age x number of deaths YLD = morbidity - years life lived with disease - disability weight, average duration of non fatal outcome until recovery or death and number of non fatal outcomes with the disease DALY - represents a lost healthy life year Year in perfect health = 0 Year of life lost due to health condition = 1 Year lived with disability = between 0 and 1 - therefore CD and injury and NCD = lots of dalys Daly - enables comparisons between diseases by using a summary measure that considers fatal and non fatal outcomes Assess changes of disease burden over time and prioritise health issues and monitor health interventions

Question 49

Understand the leading causes and risk factors contributing to deaths and disability in NZ and globally

Answer 49

NCD greater than CD now globally but CD is higher in LMIC NCD more common in NZ Therefore LMIC contribute more life lost and years lost to daly = higher daly Lower CD in high income countries but more NCD NCD is increasing in low income

Question 50

gains and limitations of daly

Answer 50

Gains - drew attention to mental health and injuries as major public health problems and addressed the fact that NCD are becoming more common and increasing in frequency in low income countries and middle income therefore not just a rich country problem Challenges - disability weights are considered to be the same as the severity of an impairment relating to a disease - do not vary with person’s sep or any other life circumstance, eg access to health care or where they live Views people with disability as a burden in the global burden of disease project

Question 51

Recognise the implied distinctions between the medical and social models of disability

Answer 51

GBD takes this view of medical - defined by their illness - viewed as an individual problem - disabled person needs to be cured - justifies systematic exclusion Disabled person is the problem not society Control is given to professionals and choices given to the individual is limited to options provided Social model Disability seen as a social issue caused by policies, practices, attitudes and or the environment Rid society of barriers, rather than relying on curing people who have impairments