Module 3 Flashcards
(103 cards)
1
Q
Epidemiology
A
Epidemiology is the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems.
2
Q
Difference between population and individual health
A
Population health tends to treat everyone within a population while Clinicians only treat individuals that are present with the disease.
3
Q
How can we measure cause?
A
Epidemiology doesn’t determine the cause of disease in an individual. It determines the relationship or association between a given exposure and dis-ease in populations.
4
Q
What is an early experiments that dictates the cause?
A
- James Lind’s experiment with scurvy in sailers. he took 12 scurvy patients and gave them all interventions. The final result was that citrus fruit resulted in prevention of scurvy.
- Observational study in lung cancer deaths vs amount of cigarettes smoked per day. Trend: increasing cigarettes a day results in increasing deaths.
5
Q
Components of Bradford hill criteria
A
Temporality Strength of association Consistency of association Biological gradient Biological plausibility of association Specificity of association Reversibility
6
Q
Bradford hill Criteria (1965) implication
A
Aids to thought, not all criteria have to be fufilled
7
Q
What is Bradford hill Criteria?
A
The Bradford Hill criteria, otherwise known as Hill’s criteria for causation, are a group of minimal conditions necessary to provide adequate evidence of a causal relationship between an incidence and a possible consequence
8
Q
In Bradford hill criteria
-Temporality
A
-The exposure occurs before the outcome with greater likelihood of causality in the absence of bias E.g smoking before lung cancer deaths.
9
Q
In bradford hill criteria
-Strength of association
A
-The stronger an association, the more likely to be causal in absence of know biases (selection,information and confounding) E.g British doctor study had a RR of greater than 10.
10
Q
In bradford hill criteria
-Consistency of association
A
-Replication of the findings by different investigators, at different times, in different places, with different methods. E.g multiple studies show the same results for doctor and lung cancer study.
11
Q
In bradford hill criteria
-Biological gradient (dose-response)
A
-Incremental change in disease rates in conjunction with corresponding changes in exposure. E.g death rate increases as cigarettes per day increases.
12
Q
In bradford hill criteria
-Biological plausibility of association
A
-Does the association make sense biologically?
E.g chemicals in tobacco that are known to promote cancers (carcinogens)
13
Q
In bradford hill criteria
-Specificity of association
A
-A cause leads to a single effect. However, a single cause often leads to multiple effects. Exposure-Outcomes are usually not 1:1. E.g smoking leads to multiple outcomes.
14
Q
In bradford hill criteria
-Reversibility
A
The demonstration that under controlled conditions changing the exposure causes a change in outcome E.g British Dr’s study: reduced risk after quitting
15
Q
A cause of disease….
A
An event, condition, characteristic (or combination of these factors) which play an essential role in producing the disease.
16
Q
KJ Rothmans created the theory of…
A
Causal pies
17
Q
Components of the casual pie
A
- a SUFFICIENT
- a COMPONENT
- a NECESSARY
18
Q
A sufficient cause in a causal pie is…
A
a factor/s that will inevitably produce the specific disease. E.g each entire pie
19
Q
A component cause in a causal pie is…
A
a factor that contributes towards dis-ease causation, but is not sufficient to cause dis-ease on it’s own. E.g A single component of the casual pie.
20
Q
A necessary cause in a causal pie is…
A
a factor (or component cause) that MUST be present if a specific dis-ease is to occur. E.g the component in all of the causal pies.
21
Q
TB reduction resulted as…
A
There was an improvement of living standards… Causes of TB was poverty, poor sanitation, overcrowding, reduced immunity. Slight increase in death rate when chemotherapy was found due to the weakening of immunity this brings. Otherwise, a vaccine further helped reduce deaths from this disease.
22
Q
Intervene in causal pie
A
We can intervene at any number of points in the pie to prevent disease.
23
Q
Preventive measures
A
Knowledge of the complete pathway is not a pre-requisite for introducing preventive measures.
24
Q
Epidemiology can play an essential role in preventing disease/injury by:
A
- unravelling the causal pathway
- directing preventive action
- evaluation of effectiveness
25
Why is the need for disease preventions growing?
- apparent limitations in treating disease
| - cost of medical care is increasing
26
intervention designs in population health are...
trying to improve well being of individuals of populations or identify early stages of disease, reduce number of patient load in order to let those who need the intensive treatment to benefit.
27
What are the three population health actions?
1. health promotion
2. disease prevention
3. health prevention
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Population based (mass) strategy focus
focuses on the whole population in order to reduce the risk factors/ improve the outcome of all individuals in the population.
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Why is population based strategy useful?
-useful for a common disease or widespread cause
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Examples of population based strategy
immunisation, water fluoridation, legislation of seat belts
31
Define high risk strategy
Stratergies that deal with individuals that are at high risks and try to shift those with high risk towards the rest of the population.
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Examples of high risk stratergies
Intervention targeting obese adults, intravenous drug users (reduce HIV amongst drug users).
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The type of intervention for high risk strategies
the intervention is well defined to the persons needs.
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High risk individual strategy: NZ needle exchange programme
Target: to reduce the amount of HIV within the population of injecting drug users.
Involved exchanging a used needle for a new one.
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advantages and disadvantages of population mass stratergy
advantages: 1. addresses underlying causes
2. large potential benefit for whole population (Vaccine of TB)
3. Behaviourally appropriate (smokers on airplanes)
disadvantages: 1. small benefit to individuals
2. poor motivation of individuals (as may not apply to them)
3. whole population is exposed to downside of strategy (less favourable benefit to risk ratio)
36
Advantages and disadvantages to high-risk individual statergy
advantages: 1. appropriate to individuals
2. individual motivation
3. cost effective use of resources (time and money to group who need it)
4. favourable benefit-to-risk ratio (targeted strategy benefits outrules down sides).
disadvantage: 1. cost of screening, need to identify individuals.
2. Temporary effect (screening is an ongoing process)
3. Limited potential (screenings on women over 40 for down syndrome babies but more is seen in women under 40 who do not receive screening)
4. Behaviourally inappropriate- hard to move away from cultural norms.
37
Health promotion, Acts, focus, enables, involves who?
1. Acts on determinants of wellbeing
2. health/well being focus
3. Enables/empowers people to increase control over, and improve, their health.
4. Involves whole population in everyday context.
38
Examples of health promotion
E.g 5 plus a day and push play
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Types of care and what they are defined as...
Primary care- Patients regular source of health care e.g GP, pharmacist
Secondary care- Referred to by primary care service e.g neurologist
tertiary care- institutional care services e.g hospitals
40
Prerequisite of health according to Alma Ata 1978- the ottawa charter
peace and safety from violence, shelter, education, food, income and economic support, stable ecosystem and sustainable resources, social justice
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Alma Ata 1978 job
1. protect and promote health of all
| 2. advocated a health promotion approach to primary health.
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The ottawa charter for health promotion definition
'Mobilise action for community development'
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The ottawa charter acknowledges that health is:
A fundamental right for everybody
That it requires both individual and collective responsibilities
The opportunity to have good health should be equally available
and the good health is an essential element of social and economic development.
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3 basic strategies of the Ottawa charter
1. ENABLE: to provide opportunities for all individuals to make healthy choices through access of information, like skills and supportive environments. INDIVIDUAL LEVEL OF STRATEGY.
2. ADVOCATE: To create favourable political, economic, social, cultural and physical environments by promoting/advocating for health. SYSTEMS LEVEL STRATEGY
3. MEDIATE: To facilitate/ bring together individuals, groups and/or parties with opposing interests to work together/come to a compromise for the promotion of health. A STRATEGY THAT JOINS UP INDIVIDUALS, GROUPS AND SYSTEMS).
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5 priority action areas of the ottawa charter 1986
1. Develop personal skills- Awareness campaigns, life skills education in schools.
2. Strengthen community action- self help groups and community organisation services, youth health projects.
3. Create supportive environments- air control measures, water and sanitation programmes, building speed bumps, requirement of work place safety.
4. Reorient health services towards primary health care- care process response to needs of patients and families, health care skills, health education services.
5. Build healthy public policy- Taxation on alcohol and cigarettes, mandatory seatbelt use, banning smoking in public areas, mandatory sport in schools.
46
Disease prevention focus and job
The focus is disease.
The job is to look at particular diseases and ways of preventing them. e.g incidence, the prevalence, risk factors, or impacts.
example of disease prevention intervention= immunisation.
47
What is the natural history of disease?
It is where in the example of TB, an individual becomes infected with the bacteria/virus, symptoms worsen and then the person goes to a doctor where they get a clinical diagnosis. From here the outcomes can be death, recovery or disability.
48
Prevention stratergies for disease...
1. primary- limit the incidence of disease by controlling specific causes and risk factors. e.g immunisation
2. secondary- reduce the more serious consequences of disease. e.g breast cancer screening.
3. tertiary- reduce the progress of complications of established disease. E.g treatment to improve quality of life after stroke.
49
Immunisation effects on the population?
High uptake of vaccination results in herd immunity to the general population. E.G those who cannot be immunised are protected by from disease and large amounts of people immunised results in less spread of disease.
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health protection aim
-Environmental hazard focused.
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Health protection actions
- Risk/hazard assessment- including environmental epidemiology and safe air and water, biosecurity.
- Monitoring- biomarkers of exposure to hazardous substances
- Risk communication- relating environmental risk to the public.
- Occupational health- safety regulations on work sites.
52
Why do we need to prioritise in health?
Due to only 6% of money being included in public health.
53
Requirements for prioritisation?
Evidence based process + community expectations and values
54
Evidence-based process includes?
Descriptive
Explanatory
Evaluation
55
What does the descriptive part of evidence based process include?
Where are we now?
What is the problem according to statistics and who is it including?
Where is it going e.g trends over time.
Prioritise the health issue causing the most problem amongst group effected.
- Breast cancer- common diagnosed invasion cancer in NZ women and 2nd leading cause of cancer death.
56
What does the explanatory part of evidence based process mean?
What are the main risk factors? Why are we getting worse/better? Does the problem effect different subgroups differently?
-Breast cancer- modifiable risks factors of breast cancer identified for Nz women identified in RR,PAR and risk difference.
57
Major risk factors of disease in NZ
1. Tobacco use
2. High body mass index
3. High blood pressure
4. High blood glucose
5. Physical inactivity
6. Alcohol
58
Epidemiological measures used in prioritisation
1. Age at death and premature mortality
2. Time lived with disabilities
3. Population attributable risk (PAR)
59
How can population attributable risk (PAR) be measured?
RISK DIFFERENCE= ATTRIBUTABLE RISK= EGO-CGO risk difference is better than using RR
60
What is the attributable risk?
The amount of 'extra' disease attributable to a particular risk factor in the exposed group.
61
What is population attributable risk (PAR)?
The amount of the 'extra' disease attributable to a particular risk factor in a particular population.
-EG association is causal- the amount of disease we could prevent if we removed that particular risk factor from the population
62
How to calculate PAR?
Incidence of disease in a population (a+b/P) - CGO or RD x Prevalence of exposure in the population (EG/P).
63
What is the benefit of using PAR?
Better way of measuring the amount of disease caused by a risk factor (presuming no bias).
64
Evaluative in terms of the evidence-based process?
How can the problem be solved?
- target population
- expected number in population who will be reached.
- evidence of effectiveness
- cost
- Breast cancer- Healthy life style proven to reduce risk of breast
65
Economic feasibility?
- does it make sense to address the problem?
| - are there economic consequences if not carried out?
66
Opportunity cost definition
The health benefits that could have been achieved had the money been spent on the next best alternative intervention or health care programme
67
Acceptability can be related to prioritisation. How?
Will the community/population accept the intervention or the problem being accessed?
68
Prioritisation- what do patients want?
- access to necessary care
- confidence in the health system
- Fair treatment
- Culturally appropriate
- Good information about their option
69
Rationale for maori health promotion
1. Maori health status/ inequalities
2. Rights as indigenous peoples and Treaty of partners
3. 'Mainstream' health promotion interventions have generally been less effective for Maori than for non maori.
4. Maori health is everyones responsibility
70
Systematic inequalities (maori worse health than non-maori)
- In health outcomes
- In exposure to the determinants of health
- In health system responsiveness
- In representation in the health workforce
71
The state of maori health
- Ethnic inequalities in health can be reduced, eliminated and prevented.
72
Trend of life expectancy, deprivation in maori vs non maori
Maori life expectancy is lower than non Maori despite the fact that all of the life expectancies are increasing.
In most deprived areas there are more maori then non maori where as in non maori the number of non maori is decreasing from least deprived to most deprived.
73
What causes health inequalities?
The unequal distribution of the social determinants of health
- education, employment and income
- housing, place, area
- poverty, deprivation
- health care
74
conventional health promotion properties
- Based on western models
- Universal formula
- Often simply adapted for Maori
- Doesn't incorporate Maori values and realities
- Superficial vs structural approach
- Has tended to benefit non-maori to a greater extent than Maori
75
Campaigns such as 5+ a day, clean your teeth etc are??
- These are superficial, downstream interventions targeted to individuals where some benefit from the strategy where others don't. More health education rather than health promotion.
76
Maori health promotion
Te Pae Mahutonga
77
What is Te Pae Mahutonga based on?
The southern cross as a navigation aid
78
What does Te Pae Mahutonga consist of?
4 central stars (key tasks) and 2 pointers (prerequisites)
79
The 4 central stars of Te Pae Mahutonga?
Mauriora
Toiora
Waiora
Te Oranga
80
What is Mauriora
- Access to Te Ao Maori (the maori world)
This acknowledges that as maori to be healthy need access to maori world e.g language, connections to land, whanau and cultural resources.
81
What is Waiora?
- Environment protection
| Health promotion is not just individual choices as the environment may create an unhealthy environment.
82
What is Toiora?
-Healthy lifestyles
| For example, eating, drinking, physical exercise avoid smoking etc
83
What is Te Oranga?
- Participation in society
Socioeconomic resources, participating in incomes, participate education, political participation.
Shape community and environment.
84
Pre requisites of Te Pae Mahutonga?
```
Nga Manukura (leadership)
Te Mana Whakahaere (autonomy)
```
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What is the prerequisite of Nga Manukura?
-Health promotion and community leadership.
| Enables empowerment of community helping determine what to do.
86
What is the prerequisite of Te Mana Whakahaere?
- Capacity for self governance
- Community control and enabling political environment.
- Choices not enforced by political government
87
The maori SIDS (sudden infant death syndrome)
- Travelled the country listening to the realities of each community
- Attended to their concerns and priorities
- Assisted communities to develop their own interventions
- Used maori collectives, networks, values and approaches.
88
New Zealand had the highest rate of a disease in 1970's what was this disease?
SIDS (sudden infant death syndrome)
89
Rates of SIDS initially within NZ
Maori had 2 times the rate of non maori.
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Risk factors of SIDS?
- Not being breast feed
- Smoking
- Lying baby on front or back
- Bed sharing
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mid trend in SIDS
Maori had a steady rate while non maori and others were on the decrease.
92
When did the rate of disease decrease in maori in terms of SIDS
After maori SIDS prevention programme
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How the Maori SIDS prevention programme connected with the Te Pae Mahutonga frame work?
Mauriora- Access to Te Ao Maori
- worked with communities to incorporate/revitalise traditional practises.
For example; Cultural flax beds due to the fact that bed sharing is a huge cultural event in maori culture.
Waiora- Environmental protection
-smokefree, safe bed sharing.
Toiora- Healthy life styles
-smoking cessation, breastfeeding promotion
E.g traditional breastfeeding programs were discrete when maori moved to urban living
Te Oranga- Participation in society
- Improving education, income support
E.g made sure that everyone was receiving an income to address determinants of health.
94
Prerequisites of the maori SIDS prevention programme
Nga Manukura- Leadership
- Maori professional and academic leadership
- Collaboration with leaders in communities
Te Mana Whakahaere- Autonomy
- communities enabled to identify their own aspirations and priorities, and to share in the design of their own solution.
95
Principles of maori health promotion
- By maori for maori (for everyone)
- Self determination and control
- Valid models, frameworks, concepts- important to apply a model that related to where group of interest are at.
- Maori people, values, collectives
- Contemporary tools and methods
- Allows for diverse realities e.g not everyone goes to the marae
- Focus on determinants of health E.g maori must move out of the most deprived region model in order for interventions to work.
- Evidence based e.g Monitoring of SIDS in NZ results to identify if there are areas in which things are not working and thereby, the intervention may need to be adapted.
96
What may addressing the underlying social determinants of health result in?
Maori health improved and a reduced ago between the two- less inequality, which ultimately effects everyone. E.g breast screening in pacific women
97
3 Types of ethnicity coding
1. Prioritised output
2. Total response output
3. Sole/combination output
98
Prioritised output
Each person is allocated to one ethnicity good using the prioritisation system. This allows people to be allocated to a single ethnicity group which helps assign people to small groups, ethnicity groups of policy importance and single ethnicity groups that are not swamped with NZ European ethnic group.
This type is used in the Ministry of health and the health and disabilities sector for funding calculations, monitoring changes in resource use by ethnic groups and so on.
99
Total response outputs
Individuals who indicate more than one ethnic group are counted more than once. The sum of the ethnic group population will exceed the total population in NZ. This strategy is used by census.
100
Sole/combination outputs
- Recommended by SNZ
- 9 groups
- Relatively new
101
Pros and cons of prioritsed outputs
pros-
Produces data that is easy to work with
Sum of the ethnicity group population is the total of NZ population
Helps to collect data on policy importances
cons-
- Places people into ethnicity groups on terms of prioritisation may oversimplify and result in bias in the statistics
- Over-represents some groups at expenses of others
- goes against the principle of self-identification
102
Total response output pros and cons
Pros-
- Represents all of the people who identify themselves with any given ethnic group
- Does not change the responses that people give.
Cons-
- The sum of ethnic group population "counts" will exceed the total population number
- Create difficulties in distribution of funding based on population numbers
- Creates difficulties in monitoring changes in the ethnic composition of a population.
103
Sole/combination outputs pros and cons
Pros-
- Does not change the response of individuals and reflects diversity of the population
- Actual population size
- Most flexible approach as both of the other two output forms can be derived from it.
Cons-
- This form of output is new and relatively untried
- Will fail to include some combinations of ethnicities
- Maori population may be misidentified as they are the most likely (ethnic group) to record multiple ethnicities.
- A table or any other means of presenting the data for the whole population can be quite large. Managing such data presentation can be problematic in practical terms.
