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Final exam study guide

by: margie Notetaker

Final exam study guide SPHU 1010 (Public Health, Lorelei Dickey-Cropley, Intro to Public Health)

margie Notetaker

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Cell, Individual & The Community
Dickey-Cropley, Lorelei
Study Guide
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This 591 page Study Guide was uploaded by margie Notetaker on Thursday December 3, 2015. The Study Guide belongs to SPHU 1010 (Public Health, Lorelei Dickey-Cropley, Intro to Public Health) at Tulane University taught by Dickey-Cropley, Lorelei in Fall 2014. Since its upload, it has received 238 views. For similar materials see Cell, Individual & The Community in Public Health at Tulane University.

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Date Created: 12/03/15
Epidemics, Revolutions, and Response: An Introduction to Public Health SPHU 1010 Spring,2015 Lorelei Cropley DrPH,CHES ▯Introduction ▯Course over view ▯Review of syllabus ▯Concepts and Definitions of Public Health Practice Contact Information ▯ Course Instructor:Lorelei Dickey Cropley DrPH,CHES, RN. ▯ Contacting me: Phone:(504) 856-5136 Email is preferred method of contact ▯ Office hours:10 to 12Tuesday and 1 to 3Thursday and by appointment.Appointments after five avaiednesday andThursday ▯ Office:105A Catherine Richardson Building. ▯ Class Meeting days/ time MWF 09:00AM - 09:50AM Location: Teaching Assistant: ▯ TA :Olalekan Ogunsakin ▯ « Lekon » . ▯ Office Hours: Overview ▯ Course Description ▯ Participant Learning Objectives Course Requirements Readings ▯ Required: ▯ Riegelman, R. & Kirkwood,B. (2010 )Public Health 101:Healthy People-Healthy Populations (2nd Edition) Jones & Bartlett ▯ Pfizer.(2006) Milestones in Public Health. ▯ Pfizer.(2003)Advancing Healthy Populations:The Pfizer Guide to Careers in Public Health. ▯ Healthy People 2020 ▯Additional Readings ▯ Posted on BB by week,refer to the course scedule ▯Viewings▯ (what you'll be watching) ▯ PowerPoint slides ▯ Videos:some will be in class. ▯ Optional:SUPERCOURSES▯ Online global repository of lectures on public health and prevention. Course Tech Requirements: ▯ AccessTo Black Board,ExitTicket ▯ You can access ExitTicket several ways: ▯ Web : ▯ store ▯ Google chrome free app: Assessment Strategies and Grading Point value % of score Mid-term exam and Finalexams 40%points each Weekly discu1@5npoiestoach 20% Social media posts 5 @2points10ch Participation / attend251 point%or each day x 25 Healthy People 2020 Asi0nment:0Outline due at midterm 50 Points (o)tline 10 points, report 40 Total 250 100% * Extra credit Other Course Information: ▯ Contacting Instructor/TA: only useTulane email address (e.g.,,and specify class in the line. ▯ Instructions ForAccessing Blackboard CourseWebsite: ▯ Professional Conduct ▯ SpecialAccommodation Course Schedule ▯ By week ▯ Topics covered ▯ Required Readings ▯ Assignments due Introduction to service learning component All right- ▯ Let’s get started! Icebreaker activity Partner quiz Introduce yourself Ask how many PH encounters have you had so far today? 5 minutes Let’s think about public health Why study public health? Healthiest Nation in One Generation (2:37 min) ▯ What is public health? First- what is Health? What Is Health? ▯ WHO defines health as“…a complete state of physical, mental,and social well-being and not merely the absence of disease or infirmity.” ▯ Who is healthier? 17 What Is Public Health? Public health is ▯organized attempt to improve ,protect ,promote and restore the health of communities or members of communities. ▯ Many ways public health does this ▯ E.g.Identify factors that influence occurrence of disease,disability,and death,then develop ways to reduce occurrence … ▯concerned with threats to health in the population (a group of people sharing one or more characteristics). 18 Public Health is about populations Population refers to a collection of individuals that share one or more observable personal or observational characteristics from which data may be collected and evaluated. ▯ Social ▯ Economic ▯ Family (marriage and divorce) ▯ W ork and labor force ▯ Geographic factors What population doYOU belong to? Public health At Tulane : 3 key stones ▯ Socio-ecologial model concept that includes all the ways that society as a whole or communities within society are affected by health issues and how they respond to these issues ▯ Determinants of health ▯ Use an evidence-based approach to analyze determinants of health and disease and the options for intervention to preserve and improve health ▯ Is Global Public Health exists to ▯ prevent epidemics and the spread of disease ▯ protect against environmental hazards ▯ prevent injuries ▯ promote and encourage healthy behaviors ▯ respond to disasters and assist communities in recovery ▯ ensure the quality and accessibility of health services. What’s one word missing? …..(hint- what doctors do) Public health is not medicine. ▯ Medicine: focus on individuals ▯ Public Health: focus on populations 22 Assessment ▯ Collection,analysis,and dissemination of information on the health of a population ▯ Examples ▯ Birth and death statistics ▯ “Surveillance” for infectious diseases ▯ Investigation of outbreaks ▯ Evaluation of the effect of prevention programs Policy Development ▯ Establish rules for organizations and individuals to follow that improve health ▯ Examples ▯ Laws,regulations ▯ Organizational policies recommendations ▯ Recommendations for individuals Can you think of examples of policies that impact on health? Assurance ▯ Monitoring and taking actions to assure that policies are followed and that services are provided where needed ▯ Examples: ▯Inspections ▯Enforcement actions ▯Providing services ▯Oversight of organizations providing services ▯Disseminating recommendations ▯Education Other concepts: 3 Levels of Prevention Used in Public Health 3 Levels of Prevention Used in Public Health ▯ Primary :occurs prior to exposure to prevent onset ▯ Immunization ▯ Sanitation ▯ Education/Media campaigns ▯ Warning labels ▯ Active vs passive ▯ Active :Requires behavior change on part of subject o Wearing protective devises:helmet, ▯ Passive:Does not require behavior change ▯ Vitamin fortified foods..Fluoridation ▯ Others ? Prevention ▯ Secondary:minimize ▯ Tertiary :after s/s but progression in individual before irreversible or transmission to others; consequence /reduce detect diseases before s/s limitation of disability from appear, disease that has already ▯Cancer screening occurred ▯Availability and response of EMS services Healthy People Since 1979,has served as a national health planning process and established prevention priorities which have been adopted and adapted throughout the country. ▯ Most states and many localities use the Healthy People framework to guide local health policies and programs Healthy People 2010 ▯ 467 objectives in 28 focus areas ▯ “Leading health indicators” ▯ Physical activity ▯ Overweight and obesity ▯ Tobacco use ▯ Substance abuse ▯ Responsible sexual behavior ▯ Mental health ▯ Injury and violence ▯ Environmental quality ▯ Immunizations ▯ Access to health care Were Healthy People 2010 objectives met??? ▯ While much progress has been made with regard to most of the 2010 health objectives,Healthy People assessment found US still comes up short in a number of critical areas,including efforts to reduce health disparities and the obesity rate. ▯ Over past decade,health disparities have not changed for objectives and have increased for an additional13 % . ▯ Report found that obesity rates increased across all age groups. ▯ Among children aged 6-11 years, obesity rates rose by 54.5 percent, and among adolescents aged 12-19 percent.e obesity rate rose 63.6 ▯ In addition,the proportion of adults who are obese rose by 48 percent. What’s New for 2020? Focus on the Determinants of Health ▯A renewed focus on identifying,measuring,tracking,and reducing health disparities through a determinants of health approach. NewTopicAreas ▯Adolescent Health ▯Blood Disorders and Blood Safety ▯Dementias,IncludingAlzheimer’s Disease ▯Early and Middle Childhood ▯Genomics ▯Global Health ▯Healthcare-Associated Infections ▯Health-Related Quality of Life andWell-Being ▯Lesbian,Gay,Bisexual,andTransgender Health ▯OlderAdults ▯Preparedness ▯Sleep Health ▯Social Determinants of Health http://www.healthypeople.go v/2020/about/new2020.aspx EVIDENCE-BASED PUBLIC HEALTH (EBPH)/ EPIDEMIOLOGY Definition for Evidence-based Public Health •“the development, implementation, and evaluation of effective programs and policies in public health through systematic uses of data and information systems, andncluding appropriate use of behavioral science theory and program planning models” * Source: Brownson, R.C. et al, Evidence-based public health, Oxford University Press, 2003. The Need for Evidence-Based Public Health •Avoid being driven by: •Crises -Hot issues -Misinformation -Concerns of organized interest groups (Politics) To Incorporate scientific evidence in: •Making management decisions • Developing policies • Implementing programs Questions- to-Ask •How can we describe a health problem? •Etiology: how do we establish contributory cause? •How can understanding the distribution of disease help us understand cause of disease? •How do epidemiologists investigate changes in the distribution of disease? •Recommendations: what works to reduce the health impact? •Implementation: how do we get the job done? •How do we evaluate the results? Figure 23 - Evidence-based Public Health: The Complete P.E E.RA..proach Adapted from Riegelman R. Evidence Based Public Health and Cigarette Smoking. Available at www.teachpr Accessed August 16, 2013. APIME Planning model Stage Level of evaluation Activities Assess Formative Needs assessment • : Plan Formative Pre-test materials • : Imp•e:ent Process procedures and tasks involved in implementing a program/ program • : launch Mon•t:r Process procedures and tasks involved in implementing a program Evaluate Impact Surveys on Changes in morbidity and mortality, Changes in absenteeism from work Long-term maintenance of desired Outcome behavior Knowledge and attitude changes Expressed intentions of the target Summative audience Short-term or intermediate behavior shifts How Can We Describe a Health Problem? We use epidemiology To describe • The burden of disease •The occurrence of disability (morbidity) and death (mortality) due to a disease • The course of disease •How often the disease occurs, how likely it is to be present currently, and what happens once it occurs • The distribution of disease •Who? When? Where? This infomrtion is used to provide a basis for developing disease control and prevention measures for groups at risk. Epidemiology ▯ ”study of the distribution & dynamics of diseases in populations” (Sartwell) ▯ study of distribution & determinants of disease frequency ▯ distribution: look at populations, not inds. ▯ determinants: factors or events resulting in change in health status; ▯ i.e. biologic, environmental, sociological Epidemiology ▯ Epidemiologist: specialist concerned w/ distribution of diseases, fitting disease occurrence into known scientific & medical knowledge. ▯ Draws on medical, biological Dr. Raoult Ratard, MD, & behavioral sciences as well MPH, TM, MS Louisiana as stats, demographics, state epidemiologist, health care services, the weekly cases of West computer sciences. Nile virus illnesses Advocate photo by Bill Feig Epidemic ▯ occurrence in a community or region of cases of an illness, specific health-related behavior, or other health-related events clearly in excess of normal expectancy. ▯ new cases exceed prevalence of a disease. ▯ e.g., mumps in Epidemiologists investigating the outbreak elementary schools of a mysterious form of pneumonia traced the roots to hotel rooms occupied during the 1976 American Legion convention. Most of the victims had contracted the disease in the hotel's hospitality suites. Terms Endemic ▯ usual prevalence of a disease within a given Hanta virus outbreak in Four Corners population or region The area is home to Navajo Nation & Hanta Virus. In geographic area; Nation, in the Four Corners region of the southwestern constantly present at US, died from a sudden respiratory illness later called Hanta virus (outbreaks of disease in 1918 & 1936) low level. e.g.,colds As part of their investigation, the medical team consulted with Navajo elders & medicine men, who Outbreak five years of drought, an unusually snowy winter &fter rainy spring had produced an abundance of pi–on nuts ▯ occurrence of a large & the mice that eat them. The elders also recalled that outbreaks of disease in 1918 & 1936.d preceded number of cases of a that can be carried by rodents & excreted in their feces disease in a short & urine Pandemic: epidemic over large geographic area (such as the world) e.g., worldwide influenza outbreak in 60s; AIDS. Today, people living with H.I.V., the AIDS virus, are found throughout the world. Fundamental assumptions Human disease • does not occur at random • is not evenly distributed in populations. • distribution key to understanding causal factors • has causal & preventative factors that can be identified through systematic investigation of different subgroups within a pop. in different places or at different times. Fundamental assumptions •Applicable to all health •Doesn’t just look at conditions disease Morbidity / • Infectious diseases Mortality • Chronic diseases • Hospitalization • Injuries/Trauma • Disability • Mental health • Quality of Life • DALYs Descriptive epi: Person place and Time How can understanding disease distribution help generate hypotheses about disease causation? •Assists epidemiologists in finding group associations or patterns in the frequency of a disease •To gain a greater understanding, examine: • □ Person: Who is getting sick? demographic characteristics, behaviors, exposures • □ Place: Where is the sickness occurring? geographic location, connections between people • □ Time: When is the sickness occurring? 17 CDC Global Disease Detectives: Clues andAnswers ▯ LuYk&list=PLCB110F9550735035 ▯ 6:41 18 Check in •A. Infants getting sick with SARS •B. Bats in caves of Guatemala •C. Seasonal fluctuations of meningitis •Which is an example of the Place? Two Broad Types of Epidemiology studies • Descriptive Epidemiology • Examining the distribution of disease in a population, and observing the basic features of its distribution • Analytic Epidemiology • Testing a hypothesis about the cause of disease by studying how exposures relate to the disease 20 Epi triangle To gain a greater understanding, we examine Distribution of Disease : •Person- demographic characteristics, behaviors, exposures •Place- geographic location, connections between people •Time Case definition ▯ standard set of criteria for determining whether a person has the disease or health outcome of interest ▯CDC/WHO Influenza-like Illness (ILI) ▯temperature of >100.0ºF (>37.8ºC) ▯Cough and/or sore throat ▯in the absence of a known cause other than influenza ▯Listeria outbreak in cantaloupes ▯Fever, muscle aches, GI symtomoms beginning on or after July 31 , 2011 ▯Detection of specific outbreak strain of L. monocytogenes Establishing cause • EBPH approach relies on epi research studies to establish contributory cause • Association Vs Causation • Association simply an identifiable relationship between exposure and disease • Finding an association does not make it casual!! • Causation implies that there is a true mechanism that leads from exposure to disease • Cause often uncertain • Spurious (false) associations /Confounding variables Association versus causation: continuum Spurious (False) Associations p:roxy variables •There is an apparent association between stork's nests & the birth rate in central Europe. •It could be that storks DO bring babies •But a better explanation is that as the birth rate goes up, the number of houses increases, the number of chimneys increases, & the number of nesting sites for storks is increased. •Therefore, association is spurious--not causal. Danish weather vane Spurious (False) Associations: confounding variable • Driving w/out seatbelts increases risk of a fatal auto accident. • But it also known that non-users of seatbelts more likely to speed, & speeding is another cause of auto fatalities. • Thus some of apparent benefits of seatbelts might be related to differing driving speeds of seatbelt users and non-users. • In this case, speeding is a confounding variable. • To be a confounding variable, a risk factor Hills Criteria for causation Strength of association: exposure more common in diseased individuals Consistency : same variable, factors, or events have same repeated association with disease Specificity: 1exposure - 1disease (obviously not always true) Time Sequence: exposure must precede the disease Biologic gradient (dose-response): > dose (or longer exposure to cause) > likelihood of getting the disease. Coherence/Plausibility: proposed cause-effect relationship fits in w/current biological, medical, epi. & scientific knowledge. Inc: experiment, analogy Prevention or Control: methods used to eliminate /modify cause decrease disease incidence Figure 2- Fulfilling Requirements for Establishing Conyuto Cause or Efficacy Fulfilling Requirements for Establishing Contributory Cause or Efficacy • What Can We Do If All 3 Requirements Don’t Definitively Establish Contributory Cause? • Examine supportive or ancillary criteria: •Strength of the relationship •Dose-response relationship •Consistency of the relationship •Biological plausibility 29 Hiil’s exercise •Hills and smoking Implementation: How do we get the job done? • To examine the options for implementation we use “When-Who-How” approach • Deciding when, who, and how to intervene depends in large part upon • Changeability • KAP • Feasibility When Who How Primary=Prevention:eworkIndividuals for Education: ReImplementationg Communicate cause, increase information to promote resistance, or reduce behavior change exposure Secondary At-risk group with Motivation: Rewards to Postexposure common risk factors encourage or intervention, identify & discourage without legal treat risk factors / screen requirement for asymptomatic disease Tertiary: Reverse course General population Obligation: policy, law of disease (cure), includes defined or institutional sanction prevent complications, populations w/ and restore function without risk factor 32 K B Examples“How” Related to Cigarette Smoking Individual Information Motivation Obligation Smoker provided with Health educator Clinician denies Smoker a information explaining encourages Smoker to service unless patient reasons for changing change behavior in order changes behavior behavior to qualify for a service or gain a benefit, e.g., status or financial Example: Health Example: Health educator Example: Clinician educator distributes suggests that the financial implements educational packet to savings from not buying recommendation to refuse a smoker and cigarettes be used to buy birth control pills to women discusses his or her a luxury item over 35 who smoke own smoking habit cigarettes Examples ofHow” Related to Cigarette Smoking : group level (teens) Information Motivation Obligation Info made Those who Those who engage in available to all engage in a a behavior are barred those who behavior are from an activity / engage in a required to pay place/ job behavior a higher price Example: Examples: Example: Smokers Warning labels Taxes on banned from campus on cigarette cigarettes packages Examples of “How” Related to Cigarette Smoking at Population level Information Motivation Obligation Information is made Incentives are An activity is required available to the entire provided for those or prohibited for those population, including not at risk to at risk and also for those who do not discourage the those not at risk of the engage in the behavior in those condition behavior at risk Example: Media Example: Lower Example: Cigarette information on the health care costs sales banned for dangers of smoking for everyone those under 18 results from reduced % of smokers How do we know a program is working/ worked ? •Critical to measure how much of the problem has been eliminated by the intervention(s) and what is the nature of the problem that remains •How do we define success? •Different types of evaluation 37 Look at •Effectiveness. •Efficacy. •Cost analysis How Do We Evaluate the Results? •A new framework, called the RE-AIM framework, is increasingly being used to evaluate how well specific interventions work and are accepted in practice • RE-AIM stands for reach, effectiveness, adoption, implementation, and maintenance 39 Costs •Program costs •Costs to participants •Cost to others affected by the intervention 40 Cost Analysis •The systematic collection, categorization, and analysis of intervention (or program) costs • Opportunity cost • Intervention cost • Management, operation, and implementation • Cost of side effects • Cost of illness • Direct, indirect, or intangible 41 Cost-Benefit Analysis •Useful for comparing a wide range of public programs with disparate outcomes. •Assesses alternative interventions in terms of incremental cost-effectiveness ratio (ICER). •Most suitable when comparing interventions with similar health outcomes. 3 Recommendations —What works to reduce the health impacts? •What is the quality of the evidence for the intervention? •What is the impact of the intervention in terms of benefits and harms? •What grade should be given to indicate the strength of the recommendation? Table 2-7 Adapted from Riegelman R. Evidence Based Public Health and Cigarette Smoking. Available at Accessed August 16, 2013. Implementations —How can we get the job done? •When should the implementation occur? •At whom should the implementation be directed? •How should the intervention(s) be implemented? Table 2-7 4. Adapted from Riegelman R. Evidence Based Public Health and Cigarette Smoking. Available at Accessed August 16, 2013. Evaluation—How well does the intervention work in practice? • How well does the intervention work in practice •on the intended or target population •as actually used? • How well is the intervention accepted in practice? • Table 2-7 5. Steps of EBPH • Develop an initial statement of the issue • Search the scientific literature and organize information • Quantify the issue using sources of existing data • Develop and prioritize program options; implement interventions • Evaluate the program or policy A sequential Framework for enhancing EBPH (B )rownson Develop an initial Problem Statement of Disseminate widely issue Or Tools: rates & Discontinue program Risks, surveillance data or policy Quantify the issue Tools: systematic reviews, Risk assessment, economic Search the data Evaluate the Scientific literature Program or & organize information policy Re-tool Develop & Prioritize Develop an action Program options Plan & implement interventions Scenario analysis • Each group will receive a scenario in which it makes sense to do an evaluation. • Each group will 1. identify costs associated with the program, • Program costs • Costs to participants • Cost to others affected by the intervention 2. whether the program is worth continuing as it is. If not, how would you use the evaluation information in the decision making process regarding the program?: SCENARIO 1: AFTER-SCHOOL HUMAN RIGHTS EDUCATION FOR YOUTH •A local non-profit organization that is active in human rights initiated an after-school human rights education program for junior high school students run in a church facility near the local junior high school. It started very successfully but, over the years, enrollments began to dwindle. The decline was especially marked during the last school year. The board of the non-profit decided they needed an evaluation to help them figure out: (a) whether to continue the program; and (b) if they were to continue the program, what needed to be done to reinvigorate it. SCENARIO 2: A SOCIAL MARKETING CAMPAIGN T O INCREASE INFLUENCZA VACCINATIONS TO AT RISK INDIVIDUALS • Kendra worked for a public health agency. The agency anticipated a particularly severe flu epidemic that posed a threat to the elderly and otherwise infirm. Kendra conducted a well-funded, well-organized and well- implemented social media campaign to encourage those at risk to become immunized. A very high percentage of the target group responded; however the epidemic was actually mild posing little threat. In addition, several of those receiving flu shots experienced some side effects. Kendra heard from sources that many vaccine recipients complained and said they’d been deceived about the flu epidemic and that wouldn’t ever get another shot. The public health agency decided they needed an evaluation to help them figure out: (a) whether the information campaign was a success; and (b) if they were to run a campaign for next year’s flu season, what needed to be done to differently. SCENARIO 3: A PROGRAM TO HELP COMMUNITIES COPE WITH DOMESTIC VIOLENCE •The Governor's task force on domestic violence introduced a program for assisting communities and victims to understand the dimensions of domestic violence and help them take action to address domestic violence. The task force identified a program being used overseas with the elements they were looking for and adapted the program to their needs. They conducted a pilot of the program in several communities in their state, with the idea that, if the program was successful, the task force would like to expand it for use throughout the state. The task force commissioned an evaluation to find out if (a) if the program was effective in achieving its objectives; (b) how it was received in the pilot communities Videos •PBS: Virus Hunter Tracks New and Deadly Pathogens Around the Globe Responsibilities Authorities Burdens 1 ▯ Thetypesof healthpoliciesfavoreddepend greatlyon one’sphilosophiesabout therole thatpublicandprivateinstitutionsshould playinpublichealthandhealthcare ▯ Theappropriateroleof governmentis often controversial ▯ Socialjustice vs. marketjustice ▯ In 1948, a right to health care was incorporated into theUniversal Declaration of Human Rights and the Constitution of theWorld HealthOrganization (WHO) ▯ A right to health care in theUnitedStates has not be generally established ▯ It can be created within a state via its constitution or throughout the country by legislative action ▯ This issue has not been definitively settled ▯ Focus of responsibility differs by the type of risk ▯ Self-imposed risk- risk an individual knowingly and willingly takes on through his or her own actions ▪ Wearing a helmet on a motorcycle ▯ Imposed risk- risk to individuals and populations that is out of their direct control ▪ Exposure to environmental toxins from a factory ▯ Medical ethics:concernedwith patient and provider, not patient and otherpeople. ▯ Public healthethics:addressespopulations andrisks that each personmay presentto otherspopulation ▯ applied ethics deals w/ actions orpolicies inethical situations commonto aparticular profession. ▯ involves interactions ofmany-on-many,suchasahealth department with the population ofthose they serve. ▯ Sometimes autonomyofan individual whomaypresenta riskto others needs to be constrained forthe benefit of the population. Figure 7.1. Sign Used in Quarantine 5 ▯ A codeof ethicshasbeenpreparedthrough thePublicHealthLeadershipSocietyto guide publichealthpractitionerswhenmaking decisionsandtakingaction ▯ Table5-5 Principlesof theEthicalPracticeof PublicHealth ▯ Assessmentofuntreatedsyphilis. ▯ Participantsnot informedof studypurpose. ▯ TX not true txof condition ▯ Use of penicillinwithheldfollowing emergenceof its availability. ▯ Study participants mainly low-income, uneducated minorities from ruralAlabama. ▯ Research Allocating Resources ▯ Datacollectedw/intentof Processesshould applyingknowledge to populations>thanthose ▯Be fair usedin samplepopulation. ▯Promote humandignity ▯ Informedconsentensures voluntaryparticipation. ▯Be partofour democracy ▯Be a▯just▯ wayto proceed ▯ Decision making:Arrival at a morally defensible decision: ▯Help gainthe support of ▯ Transparency suspiciouspopulations ▯ Inclusiveness ▯ Reasonableness ▯ Responsiveness . ▯ Accountability 8 ▯ Setforth 3 basic ethical principlesunderlying acceptableconduct of researchinvolving human subjects ▯ Respectfor personsinvolves arecognitionof personal dignity andautonomy of individuals, and special protectionof thosepersonswith diminished autonomy. ▯ Beneficenceentails an obligationto protectpersons fromharm by maximizing anticipatedbenefitsand minimizingpossiblerisksof harm. ▯ Justicerequiresthatbenefitsand burdens of research 9 • Institutionalreviewboards (IRBs) must approvemost humanresearchbeforeitcan begin • Created to ensure ethical conduct of research • Uses the framework set forth by the Belmont Report to review research proposals ▯ Utilitarianismcan be thought of as ▯the greatest good for the greatest number.▯ ▯ Correct choice is one that creates greatest good for largest # of people ▯ Demands a high degree of self-sacrifice ▯ Individual treatment or concern may be lost in focusing on the ▯greatest good.▯ ▯ Ex: vaccines.Any others? ▯ Justice ▯ What is fair for one should be fair for all. ▯ Distributive justice: both rewards and burdens should be shared by everyone 11 ▯Natural law: individual should have thedecision- making power. ▯Paternalism: gov’t can interveneinaffairs of peopleif overall societybenefits. ▯Nonmalificence: do no harm,prevent harm, removeharm ▯Beneficence:(public good):contributeto health and welfareof people;notharming not enough ▯Autonomy: peoplefreetochooseas long as they do no harm Seethe conflict above ? ▯ Humans havearight toresources necessary forhealth. ▯ Humans are inherentlysocialandinterdependent, with a senseofcommunity. ▯ Effectiveness ofinstitutionsdepends on public’strust. ▯ Collaborationamongallwithinthe community is required. ▯ Peopleandtheir physicalenvironmentare interdependent. 13 ▯ Each personin a community should have an opportunitytocontributeto public discourse. ▯ Identifying and promoting fundamental requirementsfor health in a community are a primary concern to public health ▯ Scienceis thebasis formuch ofour public health knowledge. ▯ People are responsibleto act on the basis of what they know. ▯ Actionis not based on information alone. ▪ Why doesn’t K not equal B? ▯ Adopted in 2002 ▯ Balancing individual and public rights ▯ Guide for tough decisions ▯ Restriction is ▪ provided forandcarriedoutin accordancewith thelaw. ▪ in the interest ofalegitimate objective ofgeneral interest. ▪ strictly necessaryin a democraticsociety toachieve the objective. 16 Must be shown to be ▯ Effective ▯ Necessary ▯ Theleast restrictivemeans ▯ Proportional ▯ Impartial Duty, Restraint. University of California Press, Berkeley. 2001. SCENARIOS ILLUSTRA TING NEED FOR ETHICAL PRINCIPLES Implementation ofsocial distancing (isolation or quarantine) with potential closureof business, schools, churches, recreation, social events, and mass gatherings. preparedness: an ethical framework to guide decision-making. BMC Medical Ethics. 2006. 7:12. Implementingredistributionofscarceresources (e.g.vaccines) to protectthepublic’shealthin thefaceof aserious infectiousdiseaseepidemic (SARS). SARS Commission Executive Summary: Volume One © Spring of Fear Introduction. The Campbell SARS Commission Report. ▯ Setprioritiesandjustify theorder ofHIV- infectedindividualsto receiveantiretroviral (ARV) therapyforHIV treatmentwhennot all canbeprovidedwithtreatmentasthedrug supply is madeavailable.Mark1 nextto the person/group whowouldbe1 to receive 1 ▯ TheDepartmentof HealthandHuman Services(HHS) is thecentralpublichealth agencyofthefederalgovernment ▯Table12-2 outlineseachagency,theirroles andauthority,andtheirbasicpublichealth structure andactivities ▯CDC andATDSR,NIH,FDA, HRSA,SAMHSA ▯ CDC andATDSR ▯ NIH ▯ FDA ▯ HRSA ▯ AHRQ ▯ SAMHSA ▯ IHS ▯ Taxing authority: powertolevy and collect taxes on specifiedactivities. ▯ Ex:Taxes can beusedto discourageharmful activities such as federaltobaccoexcisetaxes to reduce consumption of tobaccoproducts. ▯ Spending authority: powerto allocate federal government revenues for specified health programsand policies. ▯ Ex:, fed.governmentadministersgrants to state& localpublic healthagenciesfor use in supporting cancerpreventionand control activities. 6 ▯ Authority to regulate interstate commerce: ▯ Ex: federal government’s role in enforcing regulations concerning safety and efficacy pharmaceutical products ▯ Convening power and persuasion: ▯ Ex federal government’s role in establishing voluntary quality and safety reporting programs for hospitals and physicians 7 ▯ Constitutional provisions limit federal government’s authority over health issues relative to that ofstate governments. ▯ ▯Policepowers▯usedin regulatingprivatebehavior for health, safety,and welfarereservedfor state governmentsor localcounterparts. ▯ Influence of interest groups and political parties on thefederal policy-making process limits political feasibility offederal action on health issues ▯ E.g. sexed 8 ▯ heightenedpublicandpolicyawarenessof healthrisks posed by naturalandhuman- madeemergenciessuch as ▯ emerging infectious diseases ▯ bioterrorism, ▯ catastrophic natural events. 9 10 Have lead responsibility for 3 core functions of PH : assessment, policy development, and assurance in that state best meets needs of state based on values, preferences, & health status of population as indicated by desires of citizens expressed through elected representatives, community leaders, andadvocacy groups ▯responsible for developing & advocating for policies that protect healthof state’s population(s). ▯most states also have agencies that address ▯environmental quality, ▯ health services for the aging, ▯food safety ▯substance abuse. 11 ▯ Collectingvitalstatistics ▯ Runningapublichealthlaboratory ▯ Licensinghealthprofessionals ▯ Administeringnutritionprogram ▯ Regulatinghealthfacilities ▯ Drinkingwaterregulation ▯ Administrationof thestateMedicaid program ▯ Officeof themedicalexaminer 13 ▯ Admin. or service unit of local or state government concerned w/ health and carrying some responsibilities for health of a jurisdiction smaller than a state. ▯ 3 core functions of public health▯: (1) assessment, (2) policy development, and (3) assurance. ▯ In 2006, nearly 3000 local governmental agencies fulfilled public health responsibilities. 14 ▯ Immunizations for thosenot covered bythe privatesystem ▯ Communicable disease surveillance and initial investigation ofoutbreaks ▯ Communicable diseasecontrol ▯ Inspection and licensing ofrestaurants ▯ Environmental health surveillance ▯ Coordinating public health screeningprograms ▯ Tobacco controlprograms ▯ Public health preparednessand responseto disasters ▯ Governancestructure ▯ SpecificauthorityvestedinLHDs bystate statute ▯ Specificneedsofthecommunity ▯ Differentsize populations served ▯ Differentamounts offunding ▯ Presence(or absence)of other organizations incommunity providingPH services. 17 ▯ Effectivelocal public health will becharacterizedby accountability, heightenedvisibility,andrapid responsetoemerging public healththreatsand emergencies ▯ Health inequalitiesbestaddressedthrough social justice principles. ▯ Obesity riskfactorforotherconditions(diabetes, cardiovascular disease,stroke)& likelyotherchronic diseaseepidemicswillemerge. ▯ Global climate changewillcontinuewithheatwaves, flooding, droughts,airpollution, andintensestorms. ▯ Unforeseenevents. 18 ▯ Collaborationneedsto beaneverydayeffort ▯ Not just a requirement for emergencies or epidemics ▯ Must coordinatelocal,state,federal,and globalpublichealthagenciesintoone unified effort ▯ As evidencedby the public health response to SARS by theWHO,CDC, national agencies, and local agencies ▯ EnvironmentalProtectionAgency(EPA) ▯ Examines environmental health issues and makes recommendations ▯ OccupationalSafetyandHealth Administration(OSHA) ▯ Aims to reduce injuries and hazardous exposures in the workplace ▯ Departmentof HomelandSecurity ▯ Preparation and response to disasters and terrorism ▯ DepartmentofAgriculture&theFDA ▯ Protects the nation’s food supply ▯ Departmentof Housing andUrban Development ▯ Influences the built environment and its impacts on health ▯ Departmentof Energy ▯ Sets radiation safety standards for nuclear power plants and other sources of energy ▯ TheAmerican RedCross ▯ Collects blooddonations ▯ Obtains donations, mobilizes volunteers, andpublicizes the need fordisaster assistance ▯ Advocacy groups ▯ Advocate forpublic health interventions andaimto influence policy decisions ▯ PrivateOrganizations :AmericanCancerSociety,The American HeartAssociation,andtheMarch ofDimes ▯ Provide public health education, supportresearch, develop evidence-based recommendations,andother services Clinicians and public health professionals share a common commitment to: • Evidence-based thinking • Cost-effective delivery of services • Providing quality services to the entire population and eliminating health disparities • Computerized and confidential data systems • Community-oriented primary care (COPC) model • Expand the delivery of health services from a focus on the individual to also include an additional focus on the needs of communities • To connect the common commitments of public health and medicine ▯ From thereadings: ▯ Delay in Dallas EbolaCleanup asWorkersBalk at Task ▯ ContactTracingIsCalled Pivotal in Fighting Ebola ▯ Discussion: ▯ identifypublic health agenciesinvolvedwith Ebola case ▯ what type /level(fed/state/ local/NGO)are each agency ▯ Evidenceof collaborationsuccess/ failure? ▯ Lessonslearned - 1 ▯ Definition: prolonged illnesses that are rarely completed cured. ▯ Wide range of diseases: Cardiovascular disease, cancers,Alzheimer’s ▯ Represent majority of causes of death and disability in most developed countries ▯ Chronic disabilities, largely due to noncommunicable diseases, now most rapidly growing component of morbidity in most developing as well as developed countries 2 ▯ mG0 ▯ 6 min Table 19.1. Years of Potential Life Lost Before Age 75 for Selected Causes of Death, United States, Selected Years 1990 and 2003* Table 19.2. Actual Causes of Death in the United States in 1990 and 2000 4 Surveillance ApproachesSurvey-Based Chronic Disease ▯ Public health surveillance : monitors diseasetrends and rates,behavior, and social factors in various populations over time. ▯ Mortality surveillance: Datacollection on individual causesof death. ▯ Surveillance of behaviors: Physiological riskfactorsand disease outcomes. 5 ▯ Ownershipand partnershipindata collectionfor chronic diseases ▪ Data collection from large states often not reflective of real differences w/in state. ▯ Quality surveillance data ▪ Questionnaire content and data collection methods. 6 ▯ Screening for disease can result in detection at an early stage under assumption that early detection will allow for treatment that will improve outcomes ▯ Successful for colon cancer, vision, hearing, etc ▯ Successful screening programs will reduce disability and/or death due to these diseases 1. The disease producessubstantial death and/or disability 2. Early detectionis possible and improves outcome 3. Thereis a feasible testingstrategyforscreening 4. Screeningis acceptablein termsofharms, costs, and patient acceptance ▯ Program interventions: ▯ Counseling, skill building, and medical and community services delivered at and through various media and settings. ▯ Appliedresearch: ▯ Examines efficacy and efficiency of programs. 9 Substantial Early detection is Screening is Screening is acceptable in mortality/ possible and feasible terms of harms, costs, morbidity alters outcome and patient acceptance Hyper- Contributory Highblood Test Screeningitselfisfree of tension causeof pressureprecedes everyone— harms, low cost, and strokes, bad outcomes desirable acceptable to patients myocardial often by decades range has Treatments, however, may infarctions, and effective been be complicatedand have kidney treatment is established harms, costs,and side disease available effects LDL Contributory Precedesthe Test Screeningitselfisfree cholesterol cause of development of everyone— of harm, low cost, and strokes, disease by desirable acceptable to patients myocardial decades and range has Treatment has rare side infarctions, treatment is been effects,which can be other vascular effective in established detected by symptoms diseases alteringoutcome and low-costbloodtests Substantial Early Screening is Screening is acceptable in mortality/ detection feasible terms of harms, costs, and morbidity possible/alter patient acceptance s outcome Breast 2nd most Early For those 50 Harmmay occur due to false cancer common detection and over, positives,low riskof harm from fatal cancer improves combination of radiation, patient acceptance among outcome mammography good, but test can be somewhat women + and follow-up painful most biopsyshown Screeningyounger women commonfor to be feasible increasescostsand false women <70 positives Cervica If Early Pap smear and Pap results in substantial l cancer undetected treatment follow-up number of false positives and dramatically testinghave New DNA testingmay be untreated — reduces the been extremely used to separate true and may befatal riskofdeath successful false positives Substantial Early detection Screening is feasible Screening is mortality/ possible/alters acceptable morbidity outcome Colon Secondmost Early detection Men and women 50 and Patient cancer commonfatal ofpolyps older,plusthose with acceptance has cancer inmen reduces high-risktypesof colon been major and thirdin developmentof disease barrier, small women cancer, and Optionsfor screening probabilityof early detection include:fecal occultblood harm from ofcancer testing,plusflexible procedure, improves sigmoidoscopy, substantial cost chances of colonoscopy,and virtual for colonoscopy survival colonoscopy and virtual colonoscopy ▯ Multiple risk factor reduction is a strategy to intervene simultaneously on a series of risk factors, all of which contribute to a particular outcome ▯ Mosteffective whenthere are constellations,or groupsofriskfactors that cluster indefinablegroups of people ▯ Useful strategy when the presence of two or more risk factors increases the risk more than would be expected by addingtogether the impact of each risk factor ▯ Multiple interventions combining health care, traditional public health approaches,andsocialinterventions areoften needed ▯ population health approachrequires combinedand integrated useofmultiple interventions ▯ Lookat ▪ Riskfactors ▪ Behaviors ▪ Settings ▪ Populations Supportive physical andsocial environments ▯ Physical ▯ Sidewalkavailability,walkingtrails, safeplayareas. ▯ Foodchoicesandpricingwithinan area. ▯ Fluorinationofthe city’s watersupply. ▯ Alsophysicalactivity asapart ofdaily life by makingattractiveand accessiblestairwells,safe neighborhoods,andfacilitiesfor leisureexercise. ▯ Social ▯ Walkinggroups. ▯ Tobaccocessationcounselor 15 ▯ Tobacco use ▯ increasedexcisetaxes oncigarettes, risingpublicintoleranceof environmentalsmokeasa healthhazard,andstate legislationto restrict indoorsmoking. ▯ Poor nutrition ▯ nationalfruitandvegetableprogram(formerly 5A Day program)and LeadingtheWaytowardHealthierYouth.Standards for Foods inSchools: ▯ Alcohol use: ▯ Controllingexcess use focuses ontheindividual;reduce availabilityto minors. ▯ Obesity: ▯ ▯ACalltoActionto Prevent and DecreaseOverweight andObesity▯: communicationinitiatives,interventionsandactivities,research and evaluationin partnershipwithfamilies,communities, schools,work sites, healthcare settings,andthe media 16 ▯ Heart diseaseandstroke: ▯ Highbloodpressureand highcholesterol control,e.g.APublicHealthActionPlan to Prevent Heart Disease andStroke. ▯ Cancer: ▯ Promotion and adoption of health practicessuch as HPVvaccination, avoiding tobacco use, increasingphysical activity,improvingnutrition, and achievingand maintaining normal weight. ▯ Diabetes: ▯ Controllingbloodsugar,foot care and retinalscreening,moderate weightloss, and physicalactivity. ▯ Arthritis: ▯ Self-managementinterventions (education and exercise) can improve pain,function, and mental health among adults with arthritis ▯ Families: ▯ Establishand reinforcehouseholdbehaviorsand decisionsrelatedto nutrition, physicalactivity, health carescreenings,and alcoholand substanceabuse. ▯ Schools: ▯ Idealfor environmentalinterventions (nonsmoking, schoollunch, physicalactivity). ▯ Workplaces: ▯ Idealto promotehealth anddiseaseprevention (influencesocialnorms,healthpolicies,behaviors, and screenings). 18 ▯ Communities: ▯ Geographic or social linkages provide clinical practitioners access to specific populations and multiple ethnicities. ▯ Health care settings: ▯ Detection and treatment of disease, delivery of primary and secondary preventive services, and promotion of healthy lifestyles. ▯ Media and technology: ▯ Drives consumer spending and can also serve to promote healthy behaviors. 19 ▯ Racial and ethnic groups: ▯ African-Americans, Native Americans,Alaskan Natives,Asian Americans, Hispanics, and Pacific Islanders experience higher rates of chronic diseases. ▯ Young people: ▯ Best to target prevention activities before late childhood. ▯ Seniors: ▯ It is never too late to encourage healthy behaviors. ▯ Maintaining good cognitive skills (social, physical, andintellectual pursuits). 20 ▯ Immigration and border health: ▯ Migration back and forth across borders limits interventions. ▯ Global connections: ▯ Chronic diseases are the leading causes of death and disability-adjusted life years, worldwide. ▯ Mental health: ▯ Interrelationship between New Orleans homeless under Claiborne mental health and chronic overpass behavior.with an emphasis on 21 1 ▯ At beginningof 20th centuryinU.S., maternalandinfantmortalitywerefearsome. 1900 . . for every 1,000 live births: 2000 – 6-9 women died of for every1,000 live births: pregnancy-related ▯ 0.1 maternal deaths complications –100 infants diedbefore ▯ 7.2 infants died before age 1 year age1year 2 ▯ Improvements in medical care and public health interventions both played important roles: ▯ Environmentalinterventions ▯ Nutritionimprovements ▯ Advances inclinicalmedicine including ▪ Entryinto male-dominatedmedical professions ▪ Formalization of femaledominatedhealth professions suchas nursingand midwifery ▯ Improvements inaccesstohealth care,surveillanceandmonitoringof disease ▯ Higher education levels ▯ However, significant health disparities still exist Remarkable advances in women’s health throughout the 20th century: Average life-span increased by mo3e ▯Coalition of public health providers, physicians, and advocacy groups such as March of Dimes lobbied for regional perinatal centers. ▯Family planning services: ▯WIC ▯Schoollunch programs ▯Title Ieducationalassistance ▯ Maternalchildhealth affectedby fertilitylevels. ▯ Early 1930s—Some public health departments began offering family planning services. ▯ 1960—First oral contraceptive and intrauterine device used. 6 On anAverage Day in theU.S. 11,266 babiesare born 1,393 babiesare bornpreterm (lessthan 37completed weeksgestation) 909 babiesare bornlow birth weight (lessthan 2,500 grams,or 5½ pounds) 329 babiesare born with abirth defect 224 babiesare bornvery preterm (lessthan 32 completed weeksgestation) 166 babiesare born very lowbirth weight (lessthan 1,500 grams,or3½ pounds) 76 babiesdie before reaching their firstbirthday -AA infantsmore than 2 x aslikely as whiteinfants to die before their 1stbirthday 7 Amaternal death : onethat occursduring pregnancyorwithin 42 days ofthe end of a pregnancy,irrespectiveofthe duration and site ofthe pregnancy,from any causerelated to or aggravated by a woman’s pregnancyorits management, but not from accidental or incidental causes ▯ # of deathsfrom childbirth causes ▯ Total # oflivebirths for same time period ▯ x 100,000 live births during one year. March of Dimes (2008) 8 Maternal Mortality U.S. maternaldeath rate hasnot substantially improved since 1980s Increase inrecentyearsin # of women dyingduring pg& birth inUS. 13.1maternaldeaths per 100,000 live births in2004(actual rate estimated to be 1.3 to3times higher) Upfrom 1990 :7.6per100,000 livebirths ranks 21stamong developed countries. U.S.among countriessuch asSlovenia and Portugal. 29countrieshave achieved lower maternalmortality levels than theUnitedStates (WHO) Upto halfofall maternaldeaths in this countrycouldbe prevented throughavariety ofinterventions Upto 30% ofwomenhave apregnancy-related complication March of Dimes (2008) InCalifornia maternal deaths tripledin the last decade! Uses in Epidemiology:Similar to IMR Reflects: ▯ health status of a population ▯ complications of pregnancy& birth ▯ prenatal care, medical management of birth process ▯ public health measures ▯ demographic factors ▯ Maternal mortality ratio is measured per 100 000live births. ▯ TheU.S. maternal mortality rate doubled in past 25 years ▯ US MMR about 12.7 in 2012 ; ▯ maternal deaths per 100,000 live births ▯ US spends $98 billion annually on hospitalization for pregnancy and childbirth, but theUS maternal mortality rate has doubled in past 25 years. ▯ U.S. ranks 50th in world for maternal mortality, meaning 49 countries were better at keeping new mothers alive. ▯ Poverty ▯ Lack of education ▯ Lack of prenatal care ▯ Residencein urban areas & in southern states ▯ Ethnicity ▯ Blackwomen: 4x morelikely to die than white women ▯ Hispanic women:1.6 xmorelikely to die ▯ Age ▯ Teens & women over age 35 ▪ Not in prime childbearing years (20-35 yrs). ▪ Unmarried women & women childrenady have many ▪ Older moms increased risk for developing complications during pg & having babiesw/ weight.efects or low birth ▯ But # of babies born to older women still relatively small, so this cannot fully explain the increase 12 ▯ Cesarean birth ▯ Although immediate cause ofdeath frequently given as "hemorrhage," in manycases the hemorrhage is assoc. w/ cesarean section ▯ MMR forcesarean birth 4x higher than forvaginal birth; even when cesarean section is routine or"elective“ (not an ER procedure)MMR 2x as high as forvaginal birth ▯ ~ 90% maternal deaths assoc. w/general anesthesia take place during cesarean section ▯ Obesity ▯ Increaseduse of epiduralblocksfor labor pain. ▯ doubles risk that woman will die ▯ Drugsto induce labor: e.gCytotec; Misoprostol ▯ in past 10 years, # of women given powerful & dangerous drugs to induce labor has gone from 10 % of births to 20 % (CDC) ▯ Cytotec has become single most popular labor-inducing drug; inducing labor w/ it increases risk of uterine rupture ▯ Increasein fertility treatments, e.g. invitro fertilization& fertility drugs ▯Increased#oftwins,triplets& quintuplets;babies who tend to be born earlier,smaller& tomothers who hx of pgcomplications 15 Infant Mortality For more than 20 years, birth defects have been leading cause of infant mortality By contrast, prematurity/low birth weight is most common cause of neonatal mortality (death in the first month of life) Birth defects and prematurity/low birth weight together responsible for about 37% of all infant deaths and nearly 46% of all neonatal deaths in 2004 March of Dimes (2008) ▯ Upto ½ofall maternal deaths in this country could be preventedthrougha variety of interventions, ▯ earlydiagnosis ▯ appropriatemedicalcare of pregnancycomplications. ▯ At least 30% of women have a pregnancy- related complication before, during, or after delivery. ▯ Thesemay causelong-termhealth problemsevenif they do not causedeath. 17 Healthy People 2010: Maternal, Infant and Child Health A number of Healthy People 2010 objectives concern maternal, infant, and child health: Reduce rates of infant and maternal mortality, preterm and low birth weight births, and birth defects Increase the proportion of women receiving ea


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