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MODULE 3 Strategies for Improving Population Health Flashcards

L1* Describe the place of individual health care in an overall framework of determinants and distribution of health of the population * Understand and apply guidelines/frameworks for assessing causation: Bradford Hill Criteria Rothman’s Causal Pies

1
Q

Individual vs Population Health Care

A

Clinicians: individuals. treat disease to restore health. Reactive. Treating patients who are present

Population Health: health of groups of individuals, in the context of their environment. Proactive and comprehensive approach to clinical practice. Identifying and treating all appropriate patients in a population

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2
Q

The Public/Population Health Model

A

Provide maximum benefit for the largest number of people, at the same time reducing inequities in the distribution of health and wellbeing.

Epidemiology:

  1. Define the problem

(CSS)

  1. Identify the risk and protective factors

(Cohort S, Case-C S)

  1. Develop and test prevention strategies

(RCTs; Diagnostic Test Accuracy Studies)

  1. Assure widespread adoption
  2. Monitor and evaluate
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3
Q

Role of Epidemiology

A

To seek the cause of dis-ease, so appropriate preventative measures can be introduced.

NOT determine the cause of a dis-ease in a given individual.

Determines the relationship/association between a given exposure and dis-ease populations

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4
Q

James Lind’s Experiment

A

RCT

Prevention of Scurvy before the cause was identified

Study Participants:

12 British Sailors with Scurvy

Learned that citrus helped with treating Scurvy

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5
Q

Bradford Hill Criteria (1965)

“Aids to thought”

(means that not all have to be present. Judgement necessary!)

A
  1. Temporality
  2. Strength of Association
  3. Consistency of association
  4. Biological Gradient (dose-response)
  5. Biological Plausibility of association
  6. Specificity of association
  7. Reversibility
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6
Q

Temporality

A

First the cause, then the dis-ease

essential to establish a causal relation

e.g. Smoking as a cause of lung cancer: British Doctors’ Study

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7
Q

Strength of Association

A

the stronger an association, the more likely to be causal in absence of known biases (selection, information, and confounding)

BDS: RR>10

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8
Q

Consistency of Association

A

Replication of the findings by different investigators, at different times, in different places, with different methods

e.g. Multiple studies have shown similar results

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9
Q

Biological Gradient (dose-response)

A

Incremental change in disease rates in conjunction with corresponding changes in exposure

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10
Q

Biological plausibility of association

A

does this association make sense biologically?

e.g. Carcinogens in tobacco

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11
Q

Specificity of association

A

A cause leads to a single effect

However, a single cause often leads to multiple effect

e.g. Smoking –> Multiple outcomes

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12
Q

Reversibility

A

The demonstration that under controlled conditions that changing the exposure causes a change in the outcome

e.g Reduced risk after quitting in BDS

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13
Q

Notes on Bradford Hill Criteria

A

USE YOUR JUDGEMENT

Causal phenomena are usually complex- and exposure -outcome relationships are not usually 1:1.

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14
Q

Causal Pies Framework:

JK Rothman

A cause of disease:

A

An event, condition, characteristic (or combination of these factors) which play an essential role in producing the disease.

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15
Q

Causal Pies

A
  • sufficient cause
  • component cause
  • necessary cause
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16
Q

Sufficient cause

A

Factor/s that will inevitably produce the specific dis-ease

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17
Q

Component cause

A

Factor that contributes towards disease causation, but is not sufficient to cause disease on its own

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18
Q

Necessary Cause

A

Factor (or component cause) that must be present if a specific dis-ease is to occur

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19
Q

Difference between Sufficient and Component Cause

A

Component Causes are all the possible causes. Sufficient Causes are the causes that are enough to cause an event

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20
Q

A CAUSAL PIE FOR TB (example)

What are the Component Cause?

What is/are the Necessary Cause?

* We use the association and several other factors to infer causation and intervene to prevent disease

* we can intervene at any number of points in the pie

* knowledge of the complete pathway is not a pre-requisite for introducing preventive measures

A

Component Cause:

poverty

reduced immunity

poor sanitation

overcrowding

TB Bug

Necessary Cause:

TB Bug

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21
Q

Why do we need to prioritise in health?

A
  1. currently not enough money to fund all health problems
  2. new technologies being developed everyday, incr in medical cost
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22
Q

Where NZ’s health dollar goes (2008)

A

Total budget for 2013/2014

6% public health

4% administration

26% inpatient curative and rehab care

26% outpatient/home curative and rehab

20% long term nursing

12% medical goods

6% ancillary services

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23
Q

Estabilishing Public Health Priorities

A

Problem

Solution

Decision Criteria

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24
Q

The problem

A

who is affected?

how common is it?

size, groups, seriousness

(death rates: cancer (high priority area as first but may not be this list, depending on who you are/where you are looking at))

consider death rates in diff population groups

trends over time of major risk factors in NZ

how serious is it?

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The problem--how serious is it?
* age at death and premature mortality (years of potential life lost to death (YLL)) * time lived with disability (disability adjusted life years (DALY)) * **population attributable risk (PAR)**
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risk difference= attributable reisk (AR)
= EGO-CGO i.e. The amount of “extra” disease attributable to a particular risk factor in the exposed group ~ incidence in exposed population (EGO)
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Population Attributable Risk (PAR)
The amount of “extra” disease attributable to a particular risk factor in a particular population • _If the association is causal_ – this is the amount of disease (theoretically) we could prevent if we removed that particular risk factor from the population (WHOLE POPULATION, NOT JUST THE WHOLE GROUP)
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Population Attributable Risk (PAR)
= Incidence in the total population – Incidence in unexposed pop (CGO) (PGO-CGO) (total who got disease/total population - comparison group who got the disease/ comparison group total)
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Population Attributable Risk (PAR)
= RD x Prevalence of exposure in the population = risk difference (EG-CG) x (exposure group/ population)
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Population Attributable Risk (PAR)
The amount of "extra" disease attributable to a particular risk factor in a **_particular population_**
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Solution- effectiveness | (Second stage, after Problem)
Estimated effectiveness of the solution How well can the problem be solved?
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How well can the problem be solved? | (in terms of a particular intervention)
1. target population 1. expected number in population who will be reached 2. evidence of effectiveness (based on known success rates in literature) 3. cost
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Possible ways to intervene to solve the problem (e.g. obesity)
Brief GP intervention National mass media campaign school-based intervention
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Decision Criteria | (after Problem and Solution)
Economic feasibility Acceptability Equity Others
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Economic feasibility
does it make economic sense to address the problem? are there economic consequences if not carried out?
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Opportunity cost
the health benefits that could have been achieved had the money been spent on the next best alternative invervention or healthcare programme (Tobacco use versus Obesity)
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Acceptability
Will the community and/or target population accept the problem being addressed? competing interests
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Equity
does the problem disproportionately affect population sub groups? treaty of waitangi
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Legality
do current laws allow the problem to be addressed?
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After Problem, Solution, Decision Criteria have been addressed...
DESICION MAKING!
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Opportunity cost
foregone benefit to other patients if the same resources were invested in the best alternative way
42
Promotion, Prevention, Protection: Approaches to Taking Action
1. Discuss the advantages and disadvantages of the high risk and population approaches to prevention 2. Gain familiarity with the strands of the Ottawa Charter - a framework for health promotion 3. Describe and differentiate the three different levels of disease prevention 4. Understand and be able to discuss the differences in approaches and the overlaps between: health promotion, disease prevention and health protection 5. Describe the main components of the tobacco control programme in relation to health promotion, disease prevention and health protection
43
Importance of preventing disease
Epidemiology can play a central role in preventing diseases by: **unravelling the causal pathway** **directing preventive action** **evaluation of effectiveness** the need for prevention is growing as the limitations in curing disease become apparent and as the cost of medical care escalate
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Population Health Actions
1. Health promotion 2. Disease prevention 3. Health protection
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Strategies for Prevention
Population based (mass) strategy High risk individual strategy
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Population based (mass) strategy
focuses on the whole population aims to reduce health risks of the entire population useful for a common disease or widespread cause e.g. immunisation, programmes, water fluoridation, legislated use of seatbelts
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High Risk Strategy
Focuses on individuals perceived to be a high risk e.g. intravenous drug users, those with systolic BP \> 160mmHg intervention is well matched to individuals and their concerns e.g. screening for elevated BP then treating (e.g. intervention targeting obese adults) (e.g. needle exchange programme--successful at preventing spread of HIV amongst IDUs)
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Advantages of Population (Mass) Strategy
1. radical- addressses underlying causes 2. large potential benefit for whole population 3. behaviourally appropriate
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Disadvantages of Population (mass) strategy
1. Small benefit to individuals 2. poor motivation of individuals 3. whole population is exposed to downside of strategy (less favourable benefit-to-risk ratio)
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Advantages of High-risk individual strategy
1. Appropriate to individuals 2. individual motivation 3. cost effective use of resources 4. favourable benefit-to-risk raito
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Disadvantages of high-risk individual strategy
1. cost of screening, need to identify individuals 2. temporary effect 3. limited potential 4. behaviourally inappropriate
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Health Promotion
acts on determinants of wellbeing health/wellbeing focus enables/empowers people to increase control over, and improve their health involves whole population in every day contexts
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Alma Ata 1978
Declaration for primary health care (international conference on primary health care in Kazakhstan)
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Aims of Alma Ata
protect and promote health of all advocated a health promotion approach to primary care
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prerequisites for health
1. peace and safety from violence 2. shelter 3. education 4. food 5. income and economic support 6. stable ecosystem and sutainable resources 7. social justice
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Ottawa Charter for Health promotion "Mobilise action for community development"
Charter acknowledges that health is: * a fundamental right for everybody * requires both individual and collective responsibility * opportunity to have a good health should be equally available * good health is an essential element of social and economic development
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Ottawa Charter 1986 Three basic strategies
Enable Moderate Advocate
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Ottawa Charter 5 priority action areas
develop personal skills strengthen community action create supportive environments reorient health services towards primary health care build healthy public policy
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Enable
to enable all people to achieve their fullest health potential through supportive environments, access to info, life skills, opportunities for healthy choices etc
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Moderate
to bring together all parties with opposing/other interests to work towards the promotion of health
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Advocate
to encourage/speak for positive changes by explaining the benefits of change
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Care Pyramid
Tertiary Secondary Tertiary
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Ottawa charter hung in the Rainbow Frame
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Ottawa Charter examples
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Disease prevention
disease focus looks at particular diseases (or injuries) and ways of preventing them e.g. the incidence, the prevalence, risk factors, or impacts
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Natural history of diesease prevention and strategies
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Primary
limit the incidence of disease by controlling specific causes and factors Examples : - Immunisation - Slip, slop, slap - Seat belt regulations
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Secondary
Reduce the more serious consequences of disease Examples : - Screening people 65+ for risk of hip fractures - Rescue services for prevention of drowning
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Tertiary
Reduce the progress of complications of established disease Examples : - Counselling services for people with post traumatic stress disorder(PTSD) - Rehab services for stroke patients
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Health Protection
predominantly environmental hazard focus risk/hazard assessment (environmental epidemiology; safe water and air, bioscecurity) monitoring (biomarkers of exposure hazardous substances) risk communication (relating environmental risks to the public ) occupational health (safety regulations on work sites)
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Summary for disease prevention, health promotion and disease protection
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Public Health Actions for Prevention

Population Health 111 (4 decks)

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