Flashcards in Module 2 Deck (170):
What is a determinant?
Any event or characteristic that influences health outcomes
What is socioeconomic position?
The impact of social and economic factors on the individual or group's standing in social structure
What categories does a measure of SEP have to fit?
It must be objective, meaningful and measurable
What are examples of SEP factors?
Income, education, occupation, housing, culture, services nearby, social capital. NEET
What do SEP factors do?
They: Quantify inequality levels within and between societies
Highlight changes to society
Highlight relationships between health and other factors
What needs to be remembered when measuring income?
Use absolute (reporting bias) or categorial measures
How does income help measure health status?
Dose-response association with health
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
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
How does education help measure health?
It corresponds with the person's ability to respond to health messages and is easy to access.
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
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.
What is an odds ratio?
Yes / No for each group in the gate frame: (a/c) / (b/d).
What is health inequality?
Differences in health experience and outcomes of different populations due to factors such as SEP, gender etc (the social gradient).
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.
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
What is social mobility?
People's ability to move between social strata in a society. It can be intra or inter generational
What is equity of opportunity?
Everybody having the same chance of moving up the social ladder
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
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.
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)
What is the difference between population health and individual determinants?
Population determinants also involve the societal context
What are downstream interventions?
They operate at the micro level, such as treatment of patients and management of individuals.
What are upstream interventions?
They operate at the macro level: policies and international trade agreements
What are the 5 areas of the Dahlgren and Whitehead model?
Age, sex and genes
Individual and lifestyle factors
Social and Community factors
Socioeconomic, global and cultural factors
What are the subgroups of living/working conditions in the Dahlgren & Whitehead model?
Agriculture & food, Education, Work, Development, Sanitation, Healthcare, Housing
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)
What is a habitus?
An individual's lifestyle, values, disposition and expectations
What is social capital?
Social networks between individuals which provide an inclusive environment
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)
What is agency?
The ability of individuals to make free choices (L2-3 of D-W model).
How is maori health exemplified in NZ?
Many disparities in almost all areas of health.
What are the two types of intervention?
Structural (providing resources or services)
Social (changing ways of thinking and behavior)
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
What do minority groups tend to report of health care?
Less: feeling listened to
time with the provider
More: Unanswered questions
What are the two ways in which minorities are disadvantaged?
Structurally (wealth and power distribution)
Socially (peoples' expectations)
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).
What does neighbourhood deprivation measure?
The relative position of a neighbourhood in society. It focuses on what a neighbourhood doesn't have.
What are variables of deprivation?
Communication, income, employment, qualification, home ownership, support, space and transport.
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".
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.
What are the different measures of inequities?
Relative (no units):
- Relative risk (EGO/CGO)
- External quotient (highest value/lowest value)
- Absolute risk (EGO-CGO)
- Range (Highest value- lowest value)
What are the external quotient and range used for?
Measuring the extent of a difference between different populations
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.
Where do the 5 A's fit in the DW model?
They are in the community section (L3)
What is the inverse care law?
The availability of good medical care tends to vary inversely with the needs of the population served."
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?
What can we use as denominators?
HSU (health service utilisation and outcome)
IDI (integrated data infrastructure)
What is census?
Everyone who answered the cenus (NZ residents)
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
What is IDI?
Integrated data infrastructure:
Large research database containing microdata about people and households. Used to improve the outcomes for NZers'
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
What are variables?
What is population structure?
The factors which build your population like sex, age
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)
Who are affected in fertility trends?
Females normally aged 20-30 yo, young adults
Who are affected in the mortality events?
Old people and the very young children
Who are the affected in migration?
varies with sex and stage in life cycle
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
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
What are the key measure of fertility?
1. Crude birth rate
2. General fertility rate
3. Age specific fertility rate
4. Total fertility rate
What is crude birth rate?
No. birth/no of total population per 1000
What is general fertility rate?
an improvement of the CBR
What is age specific birth rate?
No. births to mothers in 5 year age band / no. females in 5 year age band
What is total fertility rate?
Average measure of fertility in the county
What are the types of ageing?
What is numerical ageing?
The ABSOLUTE increase in the population that is elderly
- reflects demographic patterns
- shows us improvement in life expectancy
What is structural ageing?
the increase in the PROPORTION (%) of the population that is elderly
- fertility rates decreasing
Began occurring in the 1800s
Impacts of aging are:
What is natural decline?
More deaths than birth in a population
Combo of absolute and structural ageing
What is absolute decline?
occurs when there is insufficient
migration to replace the ‘lost’ births and increased
– Not expected to happen in NZ for 70+ years
- Happening in some European and Asian countries
Child - children/working age x 100
Elderly - elderly/working age x 100
Total (Youth + elderly) / working age x 100
What is your acronym to remember NZdep, dimensions of deprivation?
What is the dimension of deprivation the?
What is support in NZdep?
People aged <65 living in a single parent family
What is communication in nzdep?
People aged <65 with no access to internet at home
What is in NZdep Income? (1)
People aged 18-64 receiving a means tested benefit
What is in NZdep income (2)?
People living in equivalised households with income below an income threshold
What is in NZdep living spaces?
People living in equivalised households below a bedroom occupancy threshold
What is in NZdep transport?
People with no access to a CAR
What is in NZdep qualification?
People aged 18-64 with no qualifications NOT EDUCATION
What is in NZdep owned home?
People not living in own home
What is in NZdep employment?
People aged 18-64 who are unemployed
What are the two population measures?
What is area measure?
falls within the living and working model of the Rainbow model (NZdep) the dimension of deprivation
What is population measure?
falls under the GLOBAL DETERMINANTS in Rainbow model
GDP per capita
Dose effect is?
The wealthier you are the healthier you are linear relationship (straight line +ve graph)
Are all inequalities inequities?
No, think breast cancer
What is intergenerational social mobility?
Intercity link bus ACROSS GENERATIONS
think about mum your gma did they have education?
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
What are the determinants of health life stages?
1. pre birth
5. older age
1. define the problem
2. identify risk and protective factors
3. develop and test prevention strategies
4. assure widespread adoption
5. monitor and evaluate
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
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
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)
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?
What are the global determinants? (lvl3)
National income (GDP)
Free trade agreements
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
High risk (individual) strategy?
Focus on individuals
Intervention tlike targeting obese adults
Match high risk individuals and intervention
Positive of population based strategy
• Radical - addresses underlying causes
• Large potential benefit for whole
• Behaviourally appropriate
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
positive of high risk strategy?
• Appropriate to individuals
• Individual motivation
• Cost effective use of resources
• Favourable benefit-to-risk ratio
negative for high risk strategy?
• Cost of screening, need to
• Temporary effect
• Limited potential
• Behaviourally inappropriate
What is disease prevention in population health actions?
Looks are particular diseases or injuries of preventing them
Disease prevention chart. Pls DRAW NOW
Predominantly environmental hazard focused
- RIsk/hazard assessment
- Risk communication
- Occupational health
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
Draw summary table of disease prevention, health promotion and health protection
What are the stages of demographic transition?
2. Mortality declines, birth rate remains high
3. Fertility rate begins to decline
4. Low fertility and low mortality
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
What is the example of primary prevention in disease prevention?
Immunisation and seat belts (it is preventing the dis-ease from happening)
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
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
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.
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
What are the 5 dimensions of Access?
What is Access?
Access is the availability of services whenever or wherever the need for such service arose. -
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.
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?
What is accessibility?
The relationship between the manner in which supply resources are organised and the expectation of clients.
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?
What is accommodation?
Relationship between the location of supply and the location of clients, taking account client transportation resources, and travel time and distance and cost
i. How far is it? Is it 1 Km or 5km?
How hard was it for you to get there?
WHat is affordability?
The cost of provider services in relation to the clients ability and willingness to pay for these services
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
What is acceptability
The relationship between clients' and providers attitudes to what constitutes appropriate care
How satisfied to the appearance of the Doctor's appearance office?
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
What is potential and realised access?
POTENTIAL (lack of knowledge about services that you can actually use) AND REALISED (actually using services) ACCESS
What is direct vs indirect cost?
If I take off work, how much money do I actually lose?
All buildings, spaces, and products that are created or at least significantly modifies by people
What is a healthy environment?
Physical, social and political settings which prevent disease and promote well-being. This includes
opportunities for exercise
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.
How is the built environment categorised?
street connectivity community resources.
What are the community resource accessibility index? (6)
2. Public transport
6. Shopping facilities
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.
Street network characteristics?
Lollipop: not good
What is the concept of street network characteristics?
Key features of street network characteristics what is the health benefit?
Grid like feature
Reduces distances between destinations
INCREASE ACTIVE TRANSPORT
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
Traffic :Concept, Key features, Health benefits
discourage driving encourage ACTIVE TRANSPORT
Active spaces :Concept, Key features, Health benefits
Having activity-encouraging spaces in close proximity increases the opportunity for physical activity.
increase number of residential areas
Increasing the number of residential and commercial sites in an area increases active transport
Good lighting, opens spaces, not afraid to walk around
Cheap fresh, education and mental benefits
Public systems like busses, cycle lanes etc. increase active transport.
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?
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?
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?
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?
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?
What is potential access?
What services could be accessed if needed (applies to everyone)
What is actually accessed or can actually be used (applies to few).
Why is there a paradox within access?
It is difficult to remain within treatment guidelines but deliver culturally appropriate services to different groups.
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.
What is driving the deprivation differences of Manurewa and the North Shore?
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”
What is NZ IMD
Index of Multiple Deprivation
WHat does NZ IMD include, 7 domains?
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.
- Fluoridating water at source
- Taxation schemes
Upstream interventions: LVL3
Interventions can target the individual family, and community or the environment.
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
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.
How do you measure inequities?
WHat is relative measures
RR = EGO/CGO
Extreme quotient = Highest rate/ Lowest rate
What is absolute measures?
RD = EGO - CGO
Range - Highest - lowest
UNITS!!! inclu. Time and denominator
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
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
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.
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