Test 2 Flashcards
(248 cards)
1
Q
What is a determinant?
A
Any event or characteristic that influences health outcomes
2
Q
What is socioeconomic position?
A
The impact of social and economic factors on the individual or group’s standing in social structure
3
Q
What categories does a measure of SEP have to fit?
A
It must be objective, meaningful and measurable
4
Q
What are examples of SEP factors?
A
Income, education, occupation, housing, culture, services nearby, social capital.
5
Q
What do SEP factors do?
A
They: Quantify inequality levels within and between societies
Highlight changes to society
Highlight relationships between health and other factors
6
Q
What needs to be remembered when measuring income?
A
Personal income is often private, therefore it can introduce bias. It can be absolute or categorical
Household income is useful to categorize individuals who may not be the main income earner, but should be equivalized for comparison between populations
7
Q
How does income help measure health status?
A
It has a direct relationship with health, has a cumulative effect and has the greatest potential for change. Therefore it’s a great measure of socioeconomic position
8
Q
How do we measure education levels?
A
It can be continuous (years in education) or categorical (highest qualification). However it can be confusing due to factors such as different education standards for a certain qualification in each population.
9
Q
How does education help measure health?
A
It corresponds with the person’s ability to respond to health messages and is easy to access.
10
Q
How do we measure occupation?
A
Current or longest held job. It is transferrable to the dependents of a head of household.
11
Q
How does occupation help measure health?
A
It’s closely related with income and social standing, and affects stress levels and workplace hazards.
12
Q
What is an odds ratio?
A
Yes / No for each group in the gate frame: a/c and b/d.
13
Q
What is health inequality?
A
Differences in health experience and outcomes of different populations due to factors such as SEP, gender etc (the social gradient).
14
Q
What is health inequity?
A
Inequalities coming from injustices. It involves the distribution of resources being unreflective of health needs. It gives different groups unequal power.
15
Q
What are the four reasons for reducing inequality? (Woodward & Kawachi)
A
- They are unfair
- They affect everyone
- Their reduction could be cost effective
- They are avoidable
16
Q
What is social mobility?
A
People’s ability to move between social strata in a society. It can be intra or inter generational
17
Q
What is equity of opportunity?
A
Everybody having the same chance of moving up the social ladder
18
Q
How do you draw a lorenz curve?
A
Draw a 45 degree line on the axes and plot he cumulative share of wealth by share of population
19
Q
What is the gini coefficient and how does it work?
A
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
Q
What are the three ways life evens can interact to affect our long term health and well-being?
A
- Cumulative (poverty trap)
- Multiplicative (IHD risk factors)
- Programming (foetal stimuli affecting later life)
21
Q
What is the difference between population health and individual determinants?
A
Population determinants also involve the societal context
22
Q
What are downstream interventions?
A
They operate at the micro level, such as treatment of patients and management of individuals.
23
Q
What are upstream interventions?
A
They operate at the macro level: policies and international trade agreements
24
Q
What are the 5 areas of the Dahlgren and Whitehead model?
A
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 focusses 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
What is the ecological fallacy?
Error arising when information about groups is used to infer about individuals- eg. smoker prevalence in neighbourhoods is really ascribed to income
41
What does a healthy environment have?
Physical, social and political settings which prevent disease and promote well-being. This includes clean air & water, good housing, wholesome food, safe spaces, transport and opportunities for exercise.
42
What is the built environment?
All the buildings, spaces and products created or significantly modified by people.
43
What is included in the built environment?
Structures such as homes, schools. Urban design, such as above, below and across-ground structures (like roads).
44
How is the built environment categorized?
Urban density, land-use mix, street connectivity and community resources.
45
How can the street network positively influence health outcomes?
Interconnectivity in a grid pattern encourages active transport.
46
How can traffic calming positively influence health outcomes?
By increasing the street width for cycle lanes, pedestrian crossings etc, it discourages driving and encourages active transport.
47
How can land-use mix positively influence health outcomes in terms of food retail?
Access to supermarkets allows a range of nutritious foods at competitive prices to be provided.
48
How can land-use mix positively influence health outcomes in terms of residential:commercial ratio?
Having workplaces near homes increases the chance for active transport.
49
How can public active spaces positively influence health outcomes?
Having activity-encouraging spaces in close proximity increases the opportunity for physical activity.
50
How can housing density positively influence health outcomes?
Increasing the number of residential and commercial sites in an area increases active transport
51
How can site design positively influence health outcomes?
If food is grown in home or community gardens, fresh and nutritious produce is available as well as benefits for mental health and the chance for education.
52
How can street aesthetics positively influence health outcomes?
Increased safety promotes active transport.
53
How can transport positively influence health outcomes?
Public systems like busses, cycle lanes etc. increase active transport.
54
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.
55
What is access?
The relationship between the health service providers and buyers (patients and doctors).
56
What are the 5 A's of access and what barriers do they represent?
```
Availability- Existence of Service Barriers
Accessibility- Geographic Barriers
Accommodation- Organisational Barriers
Affordability- Financial Barriers
Acceptability- Psychosocial Barriers
```
57
What is availability?
The relationship between the volume and type of existing services/resources to the client's volume and type of needs.
58
What were the questions asked to quantify availability?
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?
59
What is accessibility?
The relationship between the location of supply and the location of the clients, taking into account transportation resources, travel time, distance and cost.
60
What were the questions asked to quantify accessibility?
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?
61
What is accommodation?
The relationship between the manner in which supply resources are organised and the expectation of clients- how are they managed to meet clients' needs? This also includes thing such as surcharges for after-hours care, and interpretation services.
62
What were the questions asked to quantify accommodation?
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?
63
What is affordability?
The cost of provider services in relation to the clients' ability and willingness to pay for the services. This also includes opportunity cost of time taken off work etc.`
64
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?
65
What is acceptability?
The relationship between clients' and providers' attitudes to what constitutes appropriate care
66
What were the questions asked to quantify acceptability?
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?
67
What is potential access?
What services could be accessed if needed (applies to everyone)
68
What is realised access?
What is actually accessed or can actually be used (applies to few).
69
Why is there a paradox within access?
It is difficult to remain within treatment guidelines but deliver culturally appropriate services to different groups.
70
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)
```
71
What are the external quotient and range used for?
Measuring the extent of a difference between different populations
72
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.
73
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.
74
Where do the 5 A's fit in the DW model?
They are in the community section (L3)
75
What is the inverse care law?
The availability of good medical care tends to vary inversely with the needs of the population served."
76
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?
77
What is epidemiology?
The study of the distribution and determinants of health related status or events in specified populations, and the application of this study to control health-related issues.
78
What is the aim of population health?
To produce the maximum benefit for the most people while reducing inequities in the distribution of health and well-being.
79
What different studies fit at each levels of the Public Health Framework?
Define = X section
Identify factors = Cohort/Case control
Develop strategies = RCTs, diagnostic test & accuracy studies
80
What is the difference between clinicians and pop healthers?
Clinicians are reactive- they treat patients who are present
Population health is comprehensive and proactive- it is concerned with groups of people in the context of their environment.
81
What do epidemiologists look for?
Relationships between different exposures and outcomes in a population- not necessarily the causes.
82
When can we take preventative action?
As soon as we see a relationship between two factors- we don't need to know the entire disease pathway to put measures in place.
83
What are the 7 bradford hill criteria?
1. Temporality
2. Strength of association
3. Consistency of association
4. Biological gradient
5. Biological plausibility
6. Specificity of association
7. Reversibility
And JUDGEMENT! Remember, we don't need all 7 for causality
84
What is involved with temporality?
Which came first? (Eg does smoking cause cancer or do we smoke because we have cancer?)
This is ESSENTIAL for causality
85
What is involved with strength of association?
The stronger the association, the more likely something is to be causal in the absence of bias.
86
What is involved with consistency of association?
The repetition of findings with different investigators, times, places, and using different measures.
87
What is involved with the biological gradient?
The change in the degree of exposure leads to a change in the degree of outcomes
88
What is involved with biological plausibility?
Does it make biological sense?
89
What is involved with specificity of association?
A single cause leading to a single effect. However, this does not often work- eg. obesity, smoking cause multiple issues.
90
What is involved with reversibility?
If a cause is removed, does the outcome disappear/change?
91
What must be remembered when using the bradford hill criteria?
These are not a checklist, but a guide for thought. Causal phenomena are often complex. The exposure-outcome relationship is usually not 1:1.
92
What is the cause of a disease?
An event, condition, characteristic or combination of these which play an essential role in the development of the disease.
93
How do causal pies work?
Each group studied has their own causal pie. This is called a 'sufficient cause'. It is made up of the relative proportion of causes of a dis-ease. The sufficient cause will inevitably produce the specific dis-ease.
94
What is a component cause?
A factor that contributes to the dis-ease, but can't cause it alone. These are the things which make up the 'sufficient cause' of the whole pie.
95
What is a necessary cause?
A component cause which must be present for the disease to occur
96
What are the two ways in which health outcomes can be improved?
Directly via treatment
Indirectly through an improvement in living conditions- levels 2-5 on the DW model. These other determinants can affect the determinants of specific diseases.
97
What are causal pies used for?
To show the association and infer causation to intervene and prevent disease.
98
How does epidemiology help to stop dis-ease?
1. It unravels the causal pathway
2. It allows preventative action to occur
3. It allows us to evaluate the effectiveness of interventions
99
How is the need for upstream intervention (prevention) changing?
It increases as the costs of medicine increase, and limits of treatment become apparent.
100
What are the three different population health actions we can take?
1. Health promotion
2. Disease prevention
3. Health protection
101
What are the two strategies we can use to carry out interventions?
- Population based (mass) strategy
| - High risk individual strategy
102
What is mass strategy?
It involves the whole population
- Reduces risks & improves outcomes of all individuals
- Good for common dis-ease or widespread causes
- Eg. water fluoridation, seatbelts, vaccines.
103
What is high risk individual strategy?
It involves individuals or groups at high risk
- Well matched to individual concerns
- Eg. obese people, IV drug users, people with high BPs.
104
What are the pros of the mass strategy?
- It involves a radical intervention to address underlying causes
- It has a large benefit for the whole population
- It is behaviourally appropriate- eg. modifies social norms to encourage people to do things- convincing them smoking on airplanes is not good, so people won't.
105
What are the cons of the mass strategy?
- It has a small benefit for individuals as most will never need it.
- Individuals are poorly motivated to comply with the intervention as they may feel they know when they're at risk.
The whole population is exposed to any downsides- it has a worse benefit:risk ratio.
106
What are the pros of the individual strategy?
- Appropriate for individuals
- Individuals are motivated to comply as they know the intervention applies to them
- Cost-effective
- Only affects those who need it, so good benefit: risk ratio
107
What are the cons of individual strategy?
- There is a cost to identifying who is at risk
- There can be a temporary effect- as time goes on new people become at risk, so they may not be aware of the intervention. It's an ongoing process
- It has limited potential as there are many other groups which are 'less at risk' but won't get the benefit
- It's behaviourally inappropriate: it's difficult for individuals to go against societal and cultural norms by themselves.
108
What is health promotion?
- It acts on determinants of well-being
- It enables increased control over & improvement of health
- It has an everyday context- eg. 5+ a day, push play.
109
What is the alma ata?
A declaration for primary health care signed in 1978. It calls on governments to protect and promote health for all. It promotes a population health approach to primary health care.
110
What are the prerequisites for health laid out by the alma ata?
- Peace and safety
- Shelter
- Education
- Food
- Income and economic support
- Sustainable resources
- Social justice
111
What is the ottawa charter?
A declaration signed in 1986 to "mobilise action for community development". It outlines that health:
- Is a right for everybody
- Needs individual and collective responsibility
- Must be equally available
- Is essential for economic development
112
What are the 3 strategies of the ottawa charter?
- Enable
- Advocate
- Mediate
113
What is 'enable' from the ottawa charter?
Improve health literacy for individuals, and provide them with information and resources to make their own health decisions and make healthy choices (Individual level)
114
What is 'advocate' from the ottawa charter?
Create favourable conditions for health system by advocating for better social, political and physical environments and promoting health. (Systems level)
115
What is 'mediate' from the ottawa charter?
To bring together individuals and groups who hold opposing views to create a compromise for health promotion (joins individuals/groups and systems)
116
What are the 5 priority action areas from the ottawa charter?
- Develop personal skills
- Strengthen community action
- Create supportive environments
- Reorient health services towards primary health care
- Build healthy public policy
117
What are some examples of developing personal skills from the ottawa charter?
Life skills in schools, ICT for health, awareness campaigns
118
What are some examples of strengthening community action from the ottawa charter?
Self-help groups and community based initiatives/programs
119
What are some examples of create supportive environments from the ottawa charter?
Implementing air control measures, water sanitation, workplace safety measures
120
What are some examples of reorienting services to primary health care?
Having a care process responsive to needs of patients and families, enhancing hospital experiences, providing health education services
121
What are some examples of building public health policy from the ottawa charter?
Taxes on alcohol/cigarettes, mandatory seatbelt use
122
What is disease prevention?
Looking at particular diseases and ways of preventing them
123
What is the timeline of a disease?
1. Exposure
2. Biological onset (cells change, you actually catch the disease)
3. Time (symptoms begin developing)
4. Clinical diagnosis- identified by doctor
5. Outcome- recovery, death or disability
124
What is primary disease intervention?
Limits the incidence of disease by controlling specific causes and risk factors
125
What are some examples of primary disease intervention?
Immunisation
| Wearing of seatbelts.
126
What is secondary disease intervention?
Reducing the more serious consequences of disease
127
What are some examples of secondary disease intervention?
Cancer Screening
| Coastguard services
128
What is tertiary intervention?
Reduce the progress of complications of established diseases
129
What are some examples of tertiary disease intervention?
Counselling for those with PTSD
| Rehabilitation for a stroke
130
When does primary intervention take place?
Between exposure and biological onset
131
When does secondary intervention take place?
During the time between onset of the disease and diagnosis of the disease
132
When does tertiary intervention take place?
Between the diagnosis and outcome
133
What is herd immunity?
If many people are immunised, the spread of contagious disease is very slow, so the non-immunised may not be affected by flow-on contagion. It is a primary prevention strategy
134
What is health protection?
Focussed on the environment and how to protect people from its adverse effects
135
What are the categories in health protection?
Risk/hazard assessment
Monitoring
Communication
Occupational health
136
What is involved with risk/hazard assessment?
Epidemiology, water and air cleanliness
137
What is involved with monitoring?
Biomarkers for hazardous substance exposure
138
What is involved with communication?
Relating environmental risks to the public
139
What is involved with occupational hazards?
Safety regulations etc.
140
What are the three different types of ethnicity classification?
Prioritised, Total output, and Solo/combination
141
What is prioritised output?
Each respondent is allocated to a single ethnicity. Those who put more than one ethnicity have their 'overall' ethnicity decided by which one is given more precedence
142
What is the precedence for prioritised output?
Maori>Pacific>Asian>Others
143
What are the pros of the prioritised output?
Easy to work with data
The sum of all ethnic groups = NZ population
Good for collecting data on groups of policy importance, especially minorities as they are not swamped with NZEuro
144
What are the cons of prioritised output?
Might cause bias in the statistics
Over-represent some groups at the expense of others
Doesn't take into account self-identification
145
What is total output?
Individuals are counted in every ethnic group they mark- some may have more than one.
146
What are the pros of total output?
Represents all people who identify with any ethnic group
| Doesn't change peoples' choices
147
What are the cons of total output?
Sum of ethnic group counts exceeds total population
Difficulties in distributing funding based on population numbers
Difficult in monitoring changes in ethnic composition
148
What is sole/combination output?
Participants choose from 9 different ethnicities
149
What are the pros of the sole/combination output?
Doesn't change peoples' responses
Reflects the diversity of the population
Ethnicity responses = population size
Most flexible- both other outputs can be derived from this one
150
What are the cons of the sole/combination output?
New form of output, relatively untried
Fails to include some ethnicity combinations
Maori may be misidentified as they are the most likely group to have multiple ethnicities
Can be problematic practically- tables created will be quite large.
151
Why do we need prioritisation in health care?
We don't have enough money to fund everything- therefore we must make decisions.
152
What are the three factors for prioritising health care?
Descriptive, Explanatory, Evaluative
153
What are the questions behind desscriptive?
Where are we now, Where have we come from, Where are we going?
Who is most/least affected?
154
What are the questions behind Explanatory?
What are the determinants/risks?
Why are we getting worse/better?
Why are populations different?
155
What are the questions behind Evaluative?
What can improve health outcomes (and in whom)?
156
What can we use to illustrate our 'descriptive'?
We can use our population group of interest to define the problem, and compare them with others- this tells us who is most affected.
We can then look at mortality/incidence/prevalence data over time to look at trends and evaluate where the issue is headed.
157
What happens if we find that rates for our disease when prioritising are falling?
There will be no extra funding given as this shows that the current intervention is working.
158
What can we use to illustrate 'explanatory' when prioritising?
List of ranked risk factors to determine where to target interventions.
Also, we must consider equity in terms of both the Treaty of Waitangi and whether (and why) different groups in the population are exposed to/affected by risk factors differently.
159
What are the measures used when prioritising?
Years of Life Lost (YLL)- Describes age at death and premature mortality
Disability Adjusted Life Years (DALYs)- Describes time living with a disability
Population Attributable Risk (PAR)
160
What is attributable risk?
The same as risk difference (EGO -CGO)
161
What does attributable risk mean?
It shows the amount of extra dis-ease in the exposed population due to a particular risk factor
162
What does PAR mean?
It is the amount of extra dis-ease in a particular population due to a particular risk factor
163
How can we use PAR to improve health outcomes?
If the relationship is causal, by removing this risk factor from the population this is the amount of disease we could prevent.
This helps us to decide which risk factor to target.
164
How do we calculate PAR?
It is the Total Population Outcomes minus the Outcomes of the unexposed population. (Population Outcomes- CGO = PGO-CGO)
165
What happens if RR and RD give different indications about which treatment should be prioritised?
It is more important to look at how many per given number can be improved- absolute prevention is more important than relative risk.
166
What is the second way of calculating PAR?
Risk Difference multiplied by the prevalence of exposure in the population.
167
What must be considered when comparing how well an intervention works (evaluative)?
Who is the target population?
Who do we expect will be reached?
What evidence is there (from literature) about how effective this intervention is?
What is the cost?
Also: Economic Feasibility and Opportunity cost.
168
What is involved with economic feasibility?
Does it make sense to address the problem?
| Is there an economic consequence if no intervention is carried out?
169
What is involved with opportunity cost?
What are the health benefits which could be achieved if we decided to spend money on the next best alternative?
170
What other aspect must be considered when determining if an intervention is effective?
Community expectations and values, acceptability, public attitudes and human rights
171
What is involved with acceptability?
Whether the community will accept it (is it appropriate?) and Whether there are competing interests between the intervention and the community.
172
What do patients want (Important for evaluation)?
```
Access to necessary care
Confidence in the health system
Fair treatment
Culturally appropriate services
Good information about their options
```
173
Specific to obesity: What is the 'descriptive' part of the epidemiological process?
- Describing obesity trends, consequences and burdens, as well as which population groups are most affected, to get it on the agenda for action
174
Specific to obesity: What is the 'predictive' part of the epidemiological process?
Predicting future trends in obesity.
175
Specific to obesity: What is the 'explanatory' part of the epidemiological process?
- Understanding the determinants of obesity by asking the right questions. For aCn individual, it could be 'Why am I getting fatter' or 'Why am I fatter than others?'. For a population, it could be 'Why is the population getting fatter?' 'Why are some populations fatter than others?'
- Understanding, therefore, what and whom to target
176
Specific to obesity: What is the 'evaluative' part of the epidemiological process?
- Measuring the different impacts of interventions (from a program, clinical and policy point of view)
- To find out what works for who, why and at what cost
177
On the obesity trends graph: What is involved at the latest data point for the current trend?
Descriptive: Current burden and trend
178
On the obesity trends graph: What is involved with the different sets of 'future' lines?
Predictive: Future burden
179
On the obesity trends graph: What is involved with the gradient and gradients of different lines?
Explanatory: Shows trends over time as well as occurrence in different populations
180
On the obesity trends graph: What is involved with the arrow leading from the highest to lowest predicted values?
Evaluation: effectiveness of different interventions.
181
What are the trends with obesity?
It is increasing in all areas- childhood and adult, men and women. It is especially prevalent in low and high income countries. HICs got it first, but had a slower increase. LICs have gotten it later, but had a sharp increase.
182
How does obesity progress through a population?
Women --> Men
Middle Age --> Children
High SES --> Low SES (This flips as a country becomes high income- the low income get it first).
Urban --> Rural
183
What is the paradox with LICs and obesity?
LICs often have malnutrition in addition to obesity.
184
What are the relationships between men, women, children and obesity in high income countries?
Women: Strong negative
| Men and Children: Mainly negative
185
What are the relationships between men, women, children and obesity in low income countries?
Women: Strong positive
| Men and Children: positive
186
What are the consequences of obesity?
- Metabolic diseases such as type 2 diabetes, cancers, CV disorders
- Mechanical disorders such as back pain, arthritis, skin disorders
- Psychological problems such as depression, low self esteem.
- Social consequences such as weight discrimination, reduced life opportunities
187
What can happen when health messages are promoted to turn around an epidemic (such as obesity)?
An increase in inequalities is likely, as the more 'well off' people are in a better position to respond to these messages. The overall epidemic may go down, but low SES groups will still be rising.
188
What is used to make predictions in epidemiology?
Historical data for more confident explanations.
| Current data can also be used if the trend changes, but these will be less confident.
189
What predictions can be made about obesity?
The overall world rate is rising, but may be able to be slowed.
190
How do predictions help to develop interventions?
We can identify 'hot spots' and high vs exemplary action areas. It allows us to apply things working in certain areas to other areas.
191
What determines the answers to our 'explanatory' questions?
-Genetic, Behavioral, Metabolic, Cultural and Environmental factors
192
What are some environmental conditions which affect our explanatory answers for obesity?
Can be environment on the micro or macro scale- in a house or country. Also can be categorized into physical, economic, policy and socio-cultural environments.
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How do we know that the drivers affecting the obesity epidemic are global?
There has been a concerted rise in global obesity levels, suggesting this factor affects everybody worldwide. Also, all age ranges show almost identical curves in obesity prevalence.
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What is the main driver behind obesity?
Globalized food systems
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How do globalized food systems cause the obesity epidemic?
- It leads to a great deal of processed, affordable, available, promoted and tasty foods.
- This has a push effect from the environment- we feel we should eat it because it's there
- This is called passive consumption- not eating because we need to but because we have the option
- A rise in food energy is more than enough evidence to explain the obesity epidemic
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How can obesity be shaped by the local environment?
- Economic environments contribute to low income families, and income disparities
- Physical environments affect our food consumption and physical activity
- Our sociocultural environments have an effect on the food we eat, activity and body size
- The policy environment affects market regulations
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How can we explain population differences in obesity?
Obesity prevalence is driven up by global drivers, but different local environments determine the trends of different populations.
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What is the relationship between evidence uncertainty and the difficulty/importance of interventions and the further 'back' you go in terms of preventing obesity?
Interventions which take place further back (Systemic drivers-->Environmental drivers --> Environmental moderators) are more uncertain and difficult/important than those which are more person focussed (Behavioral drivers --> Treatment)
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What are the actions we can take for different determinants of obesity (Environment, Behavior, Physiology)
Policy interventions target the environment
Health promotion programmes and marketing target the environment and behavior
Drugs and treatment target physiology
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What is the problem with intervening to stop obesity?
Different treatments work differently in different populations- they have to be culturally appropriate as well as evidence-based for them to work. Therefore it is difficult to intervene as many different interventions will need to be created.
201
What is the relationship between obesity and wealth distribution?
The countries with greater wealth distribution inequalities tend to have higher rates of obesity
202
What is a 'natural experiment' when testing the effectiveness of an intervention?
Look at data for a country which has already been through an intervention without the direction of scientists. Then see the effect on the characteristic of interest.
Eg. Cuba with its economic collapse- we can see now that less energy intake and more physical exercise does lead to a decrease in obesity and associated dis-eases such as diabetes, followed later by a drop in mortality.
203
Why is maori health promotion important?
- Rights as treaty partners
- Currently they have worse health outcomes
- Mainstream health promotion is less effective for them
- It's everyone's responsibility
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What causes health inequalities?
Disparities in the determinants of health
- Income, employment and education
- Housing, community and environment
- Poverty and deprivation
- Access to health care
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What are the hallmarks of 'conventional' health promotion?
- Based on western ideals
- One size fits all
- Often just adapted for maori
- Doesn't incorporate maori values and realities
- Superficial approach- doesn't change the way people do things
- Benefits non-maori more than maori
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Why does a model such as the ottawa charter often fail to aid maori?
It only works given that the prerequisites (PFISSES) are in place- for maori this is often not the case
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What makes up Te Pae Mahutonga?
Four key tasks and two prerequisites
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What are the names of the four key tasks of Te Pae Mahutonga?
Mauriora
Waiora
Toiora
Te Oranga
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What is mauriora?
Access to the maori world
210
What is waiora?
Environmental protection
211
What is toiora?
Healthy behaviors/lifestyles
212
What is te oranga?
Participation/contribution to society
213
What are the two prerequisites?
Nga Manukura
| Te Mana Whakahaere
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What is Nga Manukura?
Health, professional and community leadership
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What is te mana whakahaere?
Capacity for self governance (autonomy)
| Community control and an enabling political environment
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What are the hallmarks of maori health promotion?
- By maori for maori
- Self determination and control
- Valid models, frameworks and concepts
- Involves maori people, values and collectives
- Uses contemporary tools and methods
- Allows for diverse realities
- Focussed on the determinants of health
- Evidence based.
217
What is screening?
It involves identifying unrecognized diseases or risk factors for a disease by applying tests on a large scale to a population.
218
Where does screening fit on the disease prevention timeframe?
It is primary when screening for a risk factor for a disease as it happens between exposure and onset.
It is secondary when screening for a disease as it happens between onset and diagnosis
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What is the mechanism for screening?
The whole population is screened. The negatives come back for screening at intervals. The positive get sent for a gold standard diagnostic test. Negatives come back at intervals. Positives have intervention/treatment
220
What are the criteria for screening?
```
Must have a suitable:
Disease
Test
Treatment
Screening programme
```
221
What is a suitable disease for screening characterised by?
1. Relatively common
2. If uncommon, early detection and intervention must give a better outcome
3. The disease history is known
4. The time between onset and diagnosis must be long enough for screening and intervention to take place. If the symptoms are obvious people will just go to the doctor (this is known as a long pre-clinical phase)
222
What is a suitable test for screening characterised by?
```
Reliable results (consisten)
Safe
Acceptable
Simple
Cheap
Accurate (sensitivity/specificity)
```
223
What is the difference between gold standard and screening tests and why?
Gold standard is expensive and very accurate, as it is only used by a few people. Screening is cheap as it is used by many.
224
What is sensitivity?
The ability of the test to determine if someone has a disease- the likelihood of a + test in those who are +
(True +/ are +) (a/EG)
225
What is specificity?
The ability of the test to determine if someone doesn't have the disease- the likelihood of a - test in those who are -
(True -/Are -) (d/CG)
226
What are the fixed characteristics of a test?
Sensitivity and specificity
227
What is PPV?
It determines the probability of having the disease if the test is +. It's True + / Test + (a/a+b)
228
What is NPV?
Determines the probability of not having the disease if the test is -. It's True - / Test -. (d/c+d)
229
What do PPV and NPV reflect?
The accuracy of the test and the prevalence in the population
230
What happens to NPV and PPV as population prevalence increases?
In more prevalent populations, PPV increases and NPV decreases
231
What must a suitable treatment have?
Evidence that early treatment improves outcomes
Effective, acceptable, accessible
Evidence based policies stating who to offer what treatment to
232
What must a suitable screening programme have?
Benefits outweigh harm
RCT evidence of reduced mortality and increased survival
Adequate resources, policy agreements for testing, diagnosis, treatment and management
Cost effective
The system must be able to support all stages of the screening pathway
Needs to reach those likely to benefit from it
233
What are the two biases that can emerge from a screening programme's evidence of reduced mortality/increased survival?
Lead and length time bias
234
What is lead bias?
Occurs when death occurs at the same time regardless of screened or not. However, they know about the disease for longer if they're screened, so it seems like survival time is increased
235
What is length time bias?
Those with faster versions of a disease may have less time to be screened, so only those with slower disease versions are screened. Therefore it looks like the screening prolongs survival, where it doesn't.
236
Why is breast cancer screening an example of an appropriate screening programme?
Disease: Common, incidence increases with age, rates differ in different groups
Test: Mammogram detects lumps before symptoms arise. Sens: 75-90%, Spec: 90-95%
Treatment: With surgery etc: 5 yr survival is 95-100%
Programme (Breast screen aotearoa):
- Those +ve are offered diagnostic testing and treatment
- Reduction in mortality by 20-45%
- Goal of improving maori/PI women
- Impacts 10 yr survival rates
237
What is involved with mauriora?
- Access to language, knowledge, culture & cultural institutions
- Access to economic resources such as land, forests and fisheries
- Access to social resources (whanau, networks) and social domains where being maori if facilitated
238
What is involved with waiora?
- Combining the external world with the spiritual
- Water and air free from pollutants
- Plentiful vegetation
- Noise levels are natural
- Opportunities for people to experience the environment
239
What is involved with toiora?
- Nutrition
- Alcohol and drugs
- Roadway practices
- sex
- tobacco use
- others' safety
- sedentary lifestyles
- spending
- use of unsafe machinery
240
What is needed to improve toiora?
- Harm minimisation
- targeted interventions
- risk management
- cultural relevance
- positive development
241
What is involved with te oranga?
Participation in
- economy
- education
- employment
- knowledge society
- decision making
242
What is involved with Nga Manukura?
- community leadership
- health leadership
- tribal leadership
- communication
- alliances between leaders and groups
243
What is involved with te mana whakahaere?
- control
- recognition of group aspirations
- relevant processed
- sensible measures and indicators
- the capacity for self-governance
244
What is the argument for reducing health inequalities because they are unfair?
- Although it is tempting to want to improve the health status of those who did not perpetuate it themselves, we must consider whether the choices people make are truly free- eg. tobacco
245
What is the argument for reducing health inequalities because they affect everyone?
- Poor health increases the chance of spreading infections
- Increases (violent) crime, including domestic violence
- Leads to lower literacy and higher drop-out rates
246
What is the argument for reducing health inequalities because they are avoidable?
- They can be fixed by decisions made by society- tax policy, home ownership, business regulation, welfare and health care funding.
- The extent to which we can reduce disparities depends on the nature of the intervention we choose.
- High risk vs. mass strategies
247
What is the argument for reducing health inequities because they're cost effective?
- If health inequities are reduced, it is likely that complex conditions will be caught earlier on, preventing them from becoming even more problematic
- Reduces the number of complex conditions needed to treat, so reduces expenditure.
- This also reduces the spillover effects of poor health
248
What is the unexpected position regarding immigrants and their disease rates?
Whatever their genes, migrants tend to take on the disease rates of their adopted country, showing that it is the environment which is having a larger effect than genes.
