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Flashcards in Module 2 Deck (170):
1

What is a determinant?

Any event or characteristic that influences health outcomes

2

What is socioeconomic position?

The impact of social and economic factors on the individual or group's standing in social structure

3

What categories does a measure of SEP have to fit?

It must be objective, meaningful and measurable

4

What are examples of SEP factors?

Income, education, occupation, housing, culture, services nearby, social capital. NEET

5

What do SEP factors do?

They: Quantify inequality levels within and between societies
Highlight changes to society
Highlight relationships between health and other factors

6

What needs to be remembered when measuring income?

Personal income
Use absolute (reporting bias) or categorial measures

Household income
Equivalised, standardisation

7

How does income help measure health status?

Dose-response association with health
Cumulative effect
Can change over a short duration e.g. short term contracts

Has the greatest potential for change. Therefore it's a great measure of socioeconomic position

8

How do we measure education levels?

It can be continuous variable (years in education)

Categorical variable (highest qualification).

Parents to person SEP comparisons
Cohort effects problems e.g. more people now study, women study, different countries have different education standards

9

How does education help measure health?

It corresponds with the person's ability to respond to health messages and is easy to access.

10

How do we measure occupation?

Current or longest held job. It is transferable to the dependents of a head of household.

NZSEI groups jobs by potential income i.e. social class

11

How does occupation help measure health?

It's closely related with income and reflects social standing, social mobility and affects stress levels and workplace hazards.

12

What is an odds ratio?


Yes / No for each group in the gate frame: (a/c) / (b/d).

13

What is health inequality?

Differences in health experience and outcomes of different populations due to factors such as SEP, gender etc (the social gradient).

14

What is health inequity?

Inequalities coming from injustices. It involves the distribution of resources being unreflective of health needs. It gives different groups unequal power.

15

What are the four reasons for reducing inequality?(Woodward and Kawachi)

1. They are unfair
2. They affect everyone
3. Their reduction could be cost effective
4. They are avoidable

16

What is social mobility?

People's ability to move between social strata in a society. It can be intra or inter generational

17

What is equity of opportunity?

Everybody having the same chance of moving up the social ladder

18

How do you draw a lorenz curve?

Draw a 45 degree line on the axes and plot he cumulative share of wealth by share of population

19

What is the gini coefficient and how does it work?

It is the ratio between the observed vs. ideal equality. It is A/(A+B) where A = the area between the line and drawn curve, while B = the area under the drawn curve. A coefficient = 0 is perfectly equal, while 1 is perfectly unequal.

20

What are the three ways life events can interact to affect our long-term health and well-being?

1. Cumulative (poverty trap)
2. Multiplicative (IHD risk factors)
3. Programming (foetal stimuli affecting later life)

21

What is the difference between population health and individual determinants?

Population determinants also involve the societal context

22

What are downstream interventions?

They operate at the micro level, such as treatment of patients and management of individuals.

23

What are upstream interventions?

They operate at the macro level: policies and international trade agreements

24

What are the 5 areas of the Dahlgren and Whitehead model?

Age, sex and genes
Individual and lifestyle factors
Social and Community factors
Living/Working Conditions
Socioeconomic, global and cultural factors

25

What are the subgroups of living/working conditions in the Dahlgren & Whitehead model?

Agriculture & food, Education, Work, Development, Sanitation, Healthcare, Housing

26

What are the three levels in the Dahlgren and Whitehead model?

The individual (genetics and lifestyle)
The Community (social and community factors, living/working)
The environment (cultural, global, socioeconomic)

27

What is a habitus?

An individual's lifestyle, values, disposition and expectations

28


What is social capital?

Social networks between individuals which provide an inclusive environment

29


What is structure?

The social and physical environmental conditions and patterns influencing peoples' choices and opportunities. (Operates in areas 3-5 of D-W model)

30

What is agency?

The ability of individuals to make free choices (L2-3 of D-W model).

31

How is maori health exemplified in NZ?

Many disparities in almost all areas of health.

32

What are the two types of intervention?

Structural (providing resources or services)
Social (changing ways of thinking and behavior)

33

How are ethnic disparities determined?

Differential access to health determinants and exposure, leading to differences in incidence
Differential access to care
Differences in care quality

34

What do minority groups tend to report of health care?

Less: feeling listened to
time with the provider
adequate explanations
More: Unanswered questions
dissatisfaction

35

What are the two ways in which minorities are disadvantaged?

Structurally (wealth and power distribution)
Socially (peoples' expectations)

36

What was a result of the ToW?

-Land alienation -> disruption, power and alliance shifts, resource depletion, resentment
- Policy alienation
- Inferior Citizenship: Entrenched poverty and dependency, barriers to development, acceptance of inequality, resentment, and social breakdown (crime).

37

What does neighbourhood deprivation measure?

The relative position of a neighbourhood in society. It focuses on what a neighbourhood doesn't have.

38

What are variables of deprivation?

Communication, income, employment, qualification, home ownership, support, space and transport.

39

What is NZDep used for and how should its conclusions be phrased?

Planning and allocation, research and advocacy. Should be "people in the most deprived neighbourhoods" NOT "the most deprived people".

40

Where do upstream vs. downstream interventions sit on the Dahlgren and Whitehead model?

Upstream interventions tend to belong on the outermost arch of the DW model- the social, political and physical environment. Downstream tend to target the individual or lifestyle. However, interventions can take place at any level.

41


What are the different measures of inequities?

Relative (no units):
- Relative risk (EGO/CGO)
- External quotient (highest value/lowest value)
Absolute (Units)
- Absolute risk (EGO-CGO)
- Range (Highest value- lowest value)

42

What are the external quotient and range used for?

Measuring the extent of a difference between different populations

43

What is the difference between guidelines and treatment?

Guidelines are more population health- they are upstream interventions.
Treatment is more clinical- they are downstream interventions.

44

Where do the 5 A's fit in the DW model?

They are in the community section (L3)

45

What is the inverse care law?

The availability of good medical care tends to vary inversely with the needs of the population served."

46

What needs to be considered when looking at who uses treatments?

What should the intervention statistics look like, considering who is most at risk for a dis-ease?

47

What can we use as denominators?

Census
HSU (health service utilisation and outcome)
IDI (integrated data infrastructure)

48

What is census?

Everyone who answered the cenus (NZ residents)

49

What is HSU?

Health Services Utilisation, only recorded the people who are using health services in the last 12 months

People who are no sick will not be in it

50

What is IDI?

Integrated data infrastructure:

Large research database containing microdata about people and households. Used to improve the outcomes for NZers'

51

What do we need to consider while using data?

Where we pick participants

Population sample vs the Population

e.g. excluding the people who did not get sick and not use healthcare services

52

What are variables?

Exposure factors

53

What is population structure?

The factors which build your population like sex, age

54

What are some events which determine population structure?

1. Trends of fertility (there is time lag cos it takes a long time until you become adult)

2. Migration (like Chch residents moving to Auck because of the earthquake)

3. Mortality events (death, age, sex)

55

Who are affected in fertility trends?

Females normally aged 20-30 yo, young adults

56

Who are affected in the mortality events?

Old people and the very young children

57

Who are the affected in migration?

varies with sex and stage in life cycle

58

Describe the features of the population pyramid graph

X axis is GENDER
- males on left, females on right

Y axis is AGe
- grouped in 5 year bands
- young to old, bottom to top

Bars wither are % of people in each age-sex group

59

Why is age and sex structure crucial?

Because it is a crucial influence on the rates at which these events occur in the population

e.g. area/country with very youthful population like likely to have less deaths than a elderly population of the same size but may have more fertile and more migrants

60

What are the key measure of fertility?

1. Crude birth rate
2. General fertility rate
3. Age specific fertility rate
4. Total fertility rate

61

What is crude birth rate?

No. birth/no of total population per 1000

62

What is general fertility rate?

an improvement of the CBR

63

What is age specific birth rate?

No. births to mothers in 5 year age band / no. females in 5 year age band

64

What is total fertility rate?

Average measure of fertility in the county

65

What are the types of ageing?

Numerical
Structural

66

What is numerical ageing?

The ABSOLUTE increase in the population that is elderly
- reflects demographic patterns
- shows us improvement in life expectancy

67

What is structural ageing?

the increase in the PROPORTION (%) of the population that is elderly
- fertility rates decreasing
Began occurring in the 1800s

68

Impacts of aging are:

Natural decline
Absolute decline

69

What is natural decline?

More deaths than birth in a population

Combo of absolute and structural ageing

70

What is absolute decline?

occurs when there is insufficient
migration to replace the ‘lost’ births and increased
deaths
– Not expected to happen in NZ for 70+ years
- Happening in some European and Asian countries

71

Dependency ratio:

Child - children/working age x 100

Elderly - elderly/working age x 100

Total (Youth + elderly) / working age x 100

72

What is your acronym to remember NZdep, dimensions of deprivation?

SCLIITSQOE

73

What is the dimension of deprivation the?

Support
Communication
Living space
Income
Income
Qualifications
Owned home
Employment

74

What is support in NZdep?

People aged <65 living in a single parent family

75

What is communication in nzdep?

People aged <65 with no access to internet at home

76

What is in NZdep Income? (1)

People aged 18-64 receiving a means tested benefit

77

What is in NZdep income (2)?

People living in equivalised households with income below an income threshold

78

What is in NZdep living spaces?

People living in equivalised households below a bedroom occupancy threshold

79

What is in NZdep transport?

People with no access to a CAR

80

What is in NZdep qualification?

People aged 18-64 with no qualifications NOT EDUCATION

81

What is in NZdep owned home?

People not living in own home

82

What is in NZdep employment?

People aged 18-64 who are unemployed

83

What are the two population measures?

Area measure
Population measure

84

What is area measure?

falls within the living and working model of the Rainbow model (NZdep) the dimension of deprivation

Deprivation
Access

85

What is population measure?

falls under the GLOBAL DETERMINANTS in Rainbow model

income inequality
literacy rates
GDP per capita

86

Dose effect is?

The wealthier you are the healthier you are linear relationship (straight line +ve graph)

Social gradient

87

Are all inequalities inequities?

No, think breast cancer

88

What is intergenerational social mobility?

Intercity link bus ACROSS GENERATIONS

think about mum your gma did they have education?

89

What is intergenerational mobility?

WITHIN think intercellular (IN THE CELL)

where were you 10 years ago and where are you now? It is your own generation

90

What are the determinants of health life stages?

1. pre birth
2. childhood
3. adolescence
4. adulthood
5. older age

91

PBL stages;

1. define the problem
2. identify risk and protective factors
3. develop and test prevention strategies
4. assure widespread adoption
5. monitor and evaluate

92

What are the main ways of population based and high risk individual strategies?

1. Health promotion
- Alma ata 1978
- Ottawa charter 1986
2. Disease prevention
3. Health protection

93

What are the features of health promotion and what are they?

Focus on wellbeing, "You can change your health" health determinants

Alma ata 1978
Primary Health Care

Ottawa charter 1986
Mobilise action for community development
- enable (provide opportunities for all individuals to make healthy life choices..) INDIVIDUAL LEVEL
- advocate -create favourable political economical social... advocating and focus on achieving EQUITY in health) SYSTEMS LEVEL
- mediate - facilitate individuals with opposing interests to work together to compromise for the promotion is health)JOINS INDI GROUPS AND SYSTEMS

94

What are the different scales of determinants?

Upstream and downstream (proximal and distal)

Micro (individual, lvl 1)
Meso (family, living, work, lvl2)
Macro (environment/national/global, lvl 3)

95

What are the two approaches so describing the determinants of describing health inequalities?

Compositional (characteristics) Who lives here?

Contextual (the social, economic and physical characteristics of the area of matter. What is this place like?

96

What are the global determinants? (lvl3)

Income inequality
National income (GDP)
Literacy rates
Free trade agreements

97

Population based mass strategy?

Focus on whole population

Aims to reduce health risk improve the outcome of individuals in the population

Useful for common disease or widespread cause

E.g. immunisation, seat belt law

98

High risk (individual) strategy?

Focus on individuals

Intervention tlike targeting obese adults

Match high risk individuals and intervention

99

Positive of population based strategy

• Radical - addresses underlying causes
• Large potential benefit for whole
population
• Behaviourally appropriate

100

Negative of population based strategy?

• Small benefit to individuals
• Poor motivation of individuals
• Whole population is exposed to
downside of strategy
(less favourable benefit-to-risk
ratio)

101

positive of high risk strategy?

• Appropriate to individuals
• Individual motivation
• Cost effective use of resources
• Favourable benefit-to-risk ratio

102

negative for high risk strategy?

• Cost of screening, need to
identify individuals
• Temporary effect
• Limited potential
• Behaviourally inappropriate

103

What is disease prevention in population health actions?

Disease focused
Looks are particular diseases or injuries of preventing them

104

Disease prevention chart. Pls DRAW NOW

ok

105

Health protection?

Predominantly environmental hazard focused
RORM
- RIsk/hazard assessment
- Monitoring
- Risk communication
- Occupational health

106

The implications of (income) inequities (6)

Ø An unequal society
Ø Less social cohesion
Ø Less trust between groups
Ø Increased stress
Ø Reduced economic productivity
Ø Poorer health outcomes

107

Draw summary table of disease prevention, health promotion and health protection

ok

108

What are the stages of demographic transition?

1. Pre-transition
2. Mortality declines, birth rate remains high
3. Fertility rate begins to decline
4. Low fertility and low mortality

109

What are the 5 priority action areas of Ottawa Charter of 1986?

1. Develop personal skills
2. Strengthen community action
3. Create supportive environments
4. Reorient health services towards primary health care
5. Build healthy public policy

DRSBC

110

What is the example of primary prevention in disease prevention?

Immunisation and seat belts (it is preventing the dis-ease from happening)

111

WHat is the example of secondary prevention in disease prevention?

Screening for high risk individuals
Rescue services if a kid had drowned.

These happen AFTER the disease nut BEFORE it has been clincally diagnosed

112

What is the example of tertiary prevention in disease prevention?

"try to get you better" minimise the consequences of the dis-ease like counselling to make secondary better

113

What is an example of health protection?

Think environment, hazards management like the helmets when working outside and also the drug label "keep out of reach of children" statement in bottles of meds.

114

Summary of Maori Health

Two major processes underpinning inequities = structural and societal barriers

Interventions need to address these drivers

For Maori health development we need to:

1. Address the structural barriers to equitable access to the determinants of health

2. Address attitudes in society that stigmatises one group or assigns them a differing value

115

What are the 5 dimensions of Access?

Accessibility
Accommodation
Acceptability
Availability
Affordability

116

What is Access?

Access is the availability of services whenever or wherever the need for such service arose. -

Andersen 1885

117

What is availability?

Existence of services barriers

Relationship of the volume and type of existing services (and resources) to the clients' volume and types of needs.

118

What are some availability questions?

Is there services and if they are, do they fill your need and are there enough services?

i. All things considered, how much confidence do you have in being able to get good medical care for you and your family when you need it?
ii. How satisfied are you with your ability to find one good doctor to treat the whole family?
iii. How satisfied are you with your knowledge of where to get health care?
How satisfied are you with your ability to get medical care in an emergency?

119

What is accessibility?

Geographical barriers

The relationship between the manner in which supply resources are organised and the expectation of clients.

120

Questions on accessibility

When are the opening hours
i. How satisfied are you with how long you have to wait for appointment?
ii. How convenient with the physician's hours?
How long do you have to wait in the waiting room?

121

What is accommodation?

Organisational barriers

Relationship between the location of supply and the location of clients, taking account client transportation resources, and travel time and distance and cost

122

Accommodation questions

i. How far is it? Is it 1 Km or 5km?
How hard was it for you to get there?

123

WHat is affordability?

Financial barriers

The cost of provider services in relation to the clients ability and willingness to pay for these services

124

Questions on affordability

i. How satisfied are you with your health insurance?
ii. How satisfied with doctor's prices?
How satisfied are you with how soon you need to pay the bill

125

What is acceptability

psychological barriers

The relationship between clients' and providers attitudes to what constitutes appropriate care

126

acceptability questions

How satisfied to the appearance of the Doctor's appearance office?

127

Lessons from the Titanic on the 5 A's

Availability: Not enough boats

Accommodation: Lowering the lifeboats and management of passengers

Accessibility: How far the life boats to the passengers, first class close, third class not close

Acceptability: Attitude towards women and children was a value

Affordability: Some people can only get third class tickets which affects the accessibility

128

What is potential and realised access?

POTENTIAL (lack of knowledge about services that you can actually use) AND REALISED (actually using services) ACCESS

129

What is direct vs indirect cost?

If I take off work, how much money do I actually lose?

130

Built environment?

All buildings, spaces, and products that are created or at least significantly modifies by people

131

What is a healthy environment?

Physical, social and political settings which prevent disease and promote well-being. This includes

clean air,
water,
good housing,
wholesome food,
safe spaces,
transport
opportunities for exercise

132

What is included in the built environment?

Above ground: what we see like schools, hotels, parks, buildings

Below ground: subways, pipes, water disposal

Across land: Transport network, motorway

All the buildings, spaces and products created or significantly modified by people.

133

How is the built environment categorised?

Urban density,
land-use mix,
street connectivity community resources.

134

What are the community resource accessibility index? (6)

1. Recreation
2. Public transport
3. Education
4. Health
5. Social
6. Shopping facilities

135

How do you remember the resource accessibility index?

I play squash in the morning and catch the bus to school but hurt my wrist so went to the hospital. After this, I went with friends to go to the mall.

136

Street network characteristics?

Lollipop: not good
Grid: good

137

What is the concept of street network characteristics?

Grid connectivity

138

Key features of street network characteristics what is the health benefit?

Grid like feature

Reduces distances between destinations

INCREASE ACTIVE TRANSPORT

139

Land use mix: Concept, Key features, Health benefits

Food retail range of nutritious foods in competitive prices

Mix of residential commercial use

INCREASE ACTIVE TRANSPORT

140

Traffic :Concept, Key features, Health benefits

Cycling paths

discourage driving encourage ACTIVE TRANSPORT

141

Active spaces :Concept, Key features, Health benefits

Having activity-encouraging spaces in close proximity increases the opportunity for physical activity.

142

House density

increase number of residential areas

Increasing the number of residential and commercial sites in an area increases active transport

143

Site design

Street aesthetics

Good lighting, opens spaces, not afraid to walk around

ACTIVE TRANSPORT

144

Food production

Homegrown vege
Cheap fresh, education and mental benefits

145

Transport

Public systems like busses, cycle lanes etc. increase active transport.

146

How satisfied are you with how long you have to wait for an appointment?
How convenient are the doctors' office hours?
How satisfied are you with the length of time you wait in the waiting room?
How easy is it for you to get in touch with your doctor?

Accommodation

147

How satisfied are you with how convenient the doctors' office is from your home?
How difficult is it to get to your physician's office?

Accessibilty

148

Do you feel you can get good medical care when you need it?
Are you satisfied with your ability to find one good doctor for your whole family?
How satisfied are you with your knowledge of where to get healthcare?
Are you satisfied with your ability to get health care in an emergency?

Availibilty

149

What were the questions asked to quantify affordability?
How satisfied are you with your health insurance?
How satisfied are you with your doctor's prices?
How satisfied are you with how soon the bill must be paid?

Affordabiltiy

150

How satisfied are you with the appearance of the doctors' offices?
How satisfied are you with the neighbourhoods the offices are in?
How satisfied are you with the other patients you see at the doctors offices?

Acceptability

151

What is potential access?

What services could be accessed if needed (applies to everyone)

152

What is actually accessed or can actually be used (applies to few).

Realised access

153

Why is there a paradox within access?

It is difficult to remain within treatment guidelines but deliver culturally appropriate services to different groups.

154

What is important about carrying out interventions in certain groups?

Different strategies can be used based on INDIVIDUAL patient risk factors- you can test them the same way and have the same disease outcome, but different interventions can be enacted.

155

What is driving the deprivation differences of Manurewa and the North Shore?

ACCESS

156

What is deprivation?

Townsend 1987 - “Deprivation is a state of observable and demonstrable disadvantage relative to the local community or the wider society or nation to which an individual, family or group belongs”

157

What is NZ IMD

Index of Multiple Deprivation

158

WHat does NZ IMD include, 7 domains?

Employment
Income
Crime
Housing
Health
Education
Access

159

What are the domains for?

7 Domains can be used separately instead of the overall area we can target and can tackle the path of dep that we are interested in.

160

- Fluoridating water at source
- Taxation schemes
Green prescription

Upstream interventions: LVL3
Interventions can target the individual family, and community or the environment.

161

What is a healthy environment? Elements of healthy environments include:

- Clean air and water
- Appropriate housing
- Access to wholesome food
- Safe community spaces
- Access to transport
Opps to incorporate as part of daily life

162

How could the built environment be measured?

2. Urban density
a. Population and/or employment density
3. Land use mix
a. Residential commercial industrial wasteland
4. Street connectivity
a. Lollipop vs well connected streets
5. Community resources
Access to recreational facilities or healthy foods.

163

How do you measure inequities?

Relative measures
Absolute measures

164

WHat is relative measures

RR = EGO/CGO
Extreme quotient = Highest rate/ Lowest rate

NO UNITS

165

What is absolute measures?

RD = EGO - CGO
Range - Highest - lowest

UNITS!!! inclu. Time and denominator

166

How do you reduce inequities>

Redistribution of resources (more resources in South Auckland than the North SHore)

Use of example of best practice. Improve what they do in the beginning, Compare with caucasian people

167

Rationale for Maori Health promotion:

1. Maori health status / inequalities
2. Right as indigenous peoples and Treaty partners?
3. Mainstream health promotions interventions have generally been less effective for Maori than for non - Maori
Maori health is everyone's responsibility

168

4 systematic Maori Health disparities

a. In health outcomes (and quality of care)
b. In exposure to the determinants of health
c. In health system responsiveness
In representation in the health workforce.

169

3 determinants of ethnic inequalities in health

1. Differential access to health determinants and exposures lead to disease incidence

2. Differential access to healthcare

3. Different quality of healthcare received

170

What are the interventions for Maori Health?

Structural interventions: "more lifeboats" reduce barriers. To fix we need to target..


Social interventions: people and the values. Targets people values more, Like the children vs the men in Titanic