Principles of Population Health Sciences
Principles of Population Health Sciences POP HLTH 795
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This 9 page Class Notes was uploaded by Mrs. Mortimer Weissnat on Thursday September 17, 2015. The Class Notes belongs to POP HLTH 795 at University of Wisconsin - Madison taught by Whitney Witt in Fall. Since its upload, it has received 34 views. For similar materials see /class/205109/pop-hlth-795-university-of-wisconsin-madison in Health Sciences at University of Wisconsin - Madison.
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Date Created: 09/17/15
Four models for defining health 1 Medical absence of disease or disability not sick Then healthyIDoesn t take into account the role of mood beliefs or social factors 2 WHO definition more holistic a state of complete physical mental and social wellbeing notjust the absence of disease or infirmity 3 Wellness holistic model focus on promoting health and preventing disease integration of mindbodyspirit 4 Environmental model focus on conditions outside of individual affecting health air quality socioeconomic conditions social relationships health care system Population Health 1 health of a population and study of determinants of health conceptual framework forthinking about why some people are healthier than others policy development research agenda and resource allocation that comes out of this 2 health outcomes of a group of individuals and the distribution of these outcomes within the group 3 patterns of health determinants outcomes and interventions Public health doesservice deliveryapplication a spectrum of programs and services protect promote restore health what should we do to keep people healthy Pop health studies determinants outcomes interventions Objectives describe explain predict offer solutions increases our understanding of the determinants of health need for public health professionals to examine and critique policy 1Addresses the entire range of factors that determine health rather than focusing on the risks and the clinical factors related to particular diseases2Affects the entire population rather than only in or high risk individuals Pophealthquestion what is the optimal balance of investments time policies in the multiple determinants of health behavior culture social economics environment SES medical care genetics over the life course that will maximize overall health outcomes and minimize health inequities at the population level DHrr39rrrirrnnls of Population Imrllh Social Physical Generic Equot quot39 Equot EquotVi39 quotquot39equot Endiwm mj Traditional Measures of health mortality Mm WWW mummy and morbidity 7 NontraditionalTypes of Health Care L I I Indicators disability qual of life 1Health WellBeing status indicators2 Indicators of health determinants3Healthcare indicators Summary measures HALYs uses determine burden identify subgroups guide interventions monitor objectives Consfail to give priority to worst off discriminate against ppl w limited tx potential fail to account for quantitative differences Health disparitydifference in the incidence prevalence mortality and burden of diseases and other adverse health conditions that exist among specific population groups Determined by 1naturabio variation 2behavior freely chosen 3transient health advantage health damaging behavior exposure to unhealthy livingworking conditions access to healthcare health related social mobility Healthcare Disparities Sources healthcare system cultureling barriers fragmentation cost incentives location amp clinical encounter pt comm provider biasclinical uncertaintystereotypes pt reaction to prov behave racism ethnocentrism acculturation access to health promoting environments Targeted advertisingmarketing segregation social capital collective efficacy enviro factors access to healthcare Points of intervention socioenvironmental comm Redevel individual increase healthy eating improve edu system inc avail of svc univ access to H0 Steps to eliminating disparities data collection fundamental determinants recognition comm Involvement test interventions sustainability health equitysoc Equity imp Enviro equal access understand effects of racism eval policies lnequality disparitydifference lnequityunnecessaryavoidableunfairunjust Friedman Stressor an events that challenges the organism critical attributespredictability controllability intensity Stress feeling psych that the challenge exceeds available resources Stress response how the body reacts physio cortisol levels to stress Allostatic loadhow much stress you can take CortisoISteroid hormone Product of hypothalamicpituitaryadrenaI HPA axis I iregulated by the brain Released from adrenal glands Normal physiological function Peakjust after waking Trough at bedtime Stress hormone External demand perceived as threatening Need to marshal resources to adapt Increase blood sugar Increase heart rate and blood pressure Inhibit nonessential functions Digestion protein synthesis reproductive functions The stress modeIAdaptive processes Physiological wear and tear through repeated activationPhysiologicaI abnormalities often show up only in response to challenge Loss of regulation Transactional ModeIImpact of stressor defined by transaction between individual and environment Lazarus and Folkman 1984 Primary Is this stressor bad How bad is it and Secondary appraisal Can I deal with it Challenges to Behavior Change Delayed effects Probabilistic multicausal association Behavior change requires KnowledgeMotivation Skills A supportive environment including accessHampered by structural and cultural factors Individual spa a Health Dlsease Care mummy Mmralrw Adjusting for SES does not eliminate differences in health outcomes Debate on Culture vs SES how much of cultural difference is accounted for by SES Social and economic determinants are more important predictors than culture in understanding health care disparities Cultural explanations divert attention from structural and contextual factors Hispanic paradox Complex not uniform not fully understood phenomenon Overall negative effect of acculturation on health behaviors Diet smoking substance use birth outcomes Gender differences Effects attenuated when enabling and predisposing factors are controlled Positive effect on access to care and use of preventive services What mechanisms account for these associations Study MeasuresSmoking bans SHS Smoking status History of tobaccorelated diseases Theoretical mediators of tobacco control Determinants of tobacco use and bans Individual Family social cultural environment Theoretical Mediators Social norms Perceived criticism for smoking in public places Normative intolerance toward smoking Density of smokefree public places Perceived smokefree legislation Support for smokefree legislation Participation in tobacco prevention Awareness of cessation services Access to tobacco selling points lndividual Determinants Demographics Smoking status Attitudes on tobacco and SHS Acculturation Familiy Social cultural determinants Children in the home Other smokers in the home Social pressure from normative group Smoking ban in the workplace City of residence Conclusions The prevalence of home smoking bans is influenced by cultural and policy factors country of residence and level of exposure to the CTCP Smoking bans are effective to reduce SHS but more effective when supported by tobacco control programs The likelihood of having a smoking ban is associated with individual behavioral social and cultural factors Evidence of a doseeffect relationship between CA Tobacco Control Program and Smoking SHS smoking bans Tobaccorelated diseases amp theoretical correlates Evidence of spill over effects of CA Tobacco Control Program on Tijuana Similar programs would be effective in Mexico and other middleincome countries I I39nlwllu 39illlurul l u39lon l lllllllquotl I wt Rr lll39lul in Ilw I llrl39ulllrc I Ilrrul L 39nul Ill lln Dummy H RixL Prevention Health f xluuauun um mum Secondary 1 Praventlan RISk Factors mm Tm Hullquot Prevention DiseaseInjury Ilmim iuulmmtum tul yum wml um um Death um wu n1 immuuui m unulmc rmM uu um m l indhhl VlHu Measuing Class SESEducation IncomeAssets Occupation How Does SES affect Healthlncome What it Buys Education Shapes Cognitive Resources Medicare Prescription Drug Helps in Interaction with Medical System Occupation Determines OccupationWhy does occupation affect health Position of individual in occupational structure Repetitive work Limited Decision AuthorityLow Autonomy Physical demands Workload Work Pace and Conflicting Requests Role Ambiguity Education and Income Bad Behaviors SmokingDrinking Obesity Lack of Exercise Education Occupation and Income PsychosocialCoping Skills Social supports Stress Sense of Control Fundamental Cause Across time across countries across the life course Shapes the emergence of new risk factors andor reduction in risk factors RACE there is a difference in early mid and late lifeWhat Explains the Difference BiologyGenetics SES Discrimination Gender Sources of Sex Differences in Health Biology Behaviors Violence Risky Behaviors Smoking Obesity Exercise Social Factors Marriage Reproductive HealthMixing biological and social Neighborhoods How do neighborhoods affect health Where people congregate helpful for targeting interventions condition human behaviors and psychosocial experiences access to food safe areas transportation advertising have independent effects on health Contemporary researchBetween group differences in health of neighborhoods How does structure impact individuals lmplies resource allocation Pros addresses upstream determinants Cons politically unpopular difficult doesn t have much of a role for individual agency Within group differences in health of neighborhoods Agency of individuals resilience how do people thrive in the face of risk factors lmplies bolstering protective factors Pros more politically realistic shortterm solutions viable involves communities groundup model Cons doesn t address root causes of poor health can end up blaming the victim expects communities to improve from within despite resource issues Structure versus agency Indeendem Effects of Service environment health care social services education police Neiohborhood on Health sanitation food liquor Social and economic environment economic b opportunity social capital bondingemotional and tangible bridginginks to resources outside of neighborhood social norms sexual activity smoking eatingdrinkingexerciseweight High social capital is protective of health How segregation can affect health Quality of education and employment available Pathogenic neighborhood and housing conditions Conditions linked to segregation can constrain practice of health behaviors and encourage unhealthy ones Access to medical care social services and other services Can have positive effects ethnic enclaves Behavioral norms diet alcohol drugs Social capital bonding but not bridgingOther neighborhood research lncome inequality crime r tes social capital accessexposure to resources and hazards Methodological problems causation and selection Culture articles Prevention PopulationBased Health a I ronotio1 120ch m Zellner sexual identity and sexual behavior at risk for HIV Latino men dap39e lquotquotquot quot rquot m with hetero identifying but bipractices are at a greater risk for HIV which is true for other groups as well so there is no disparity among ethnicities w ml c nellwlrlipznmnriuli z Indivilnnl So if there is an intervention it should be for the hetero identifyingbi 39 quot quot quot quotquot quot quot 2quotquotequot quot quot practicing Part of a larger study so questions weren t designed for this I t m mi focus Men in northern san diego county so not representative m hamlwm va Underreported practices because of cultural beliefs Only asked about anal intercourse not oral DUbard language spoken and difference in health status access pursuit of hc Behavioral risk factors survey look at differences among mm 0Wquot 3993 primary spoken language Demographic factors less than HS more likely quot to have incomes less than 15000 Chronic conditions sp showed less than English speaking Similar rates of diabetes and High BP SP favorable health behave smoking and drinking SP less likelyto have exercise Language was sig assoc with indicators ACCESS sp had less access preventative services etc SP more likely to rate their health as fairpoor but this may be due to BRFS Healthy migrant event subgroup more likely to have protective health factors carried from previous life Language is a measure of immigrant acculturation Employment status did not differ So access might be affected by ability to apply for medicaid mmm wrlucmg Epidemiology Child mortality and hospitalization has decreased Mortality in very low birth weights has increased Asthma Obesity and Poor health rated top problems in 2007 Determinants Poverty lncome inequality maternal health and well being education and genes Population health interventions Special education Differences seen by states Gini coefficient area under curve and gives measure of income and inequality Easier parents had access to health care systems less unmet need less caregiver burden Poor kids experience far more unmet need Strengths and challenges Limited resources IT and database separated silos changing face of child health Individuals with Disabilities Education Act mandates that states provide early intervention services for infants and toddlers with or at risk for developmental difficulties Comparative effectiveness research is the conduct and synthesis of research comparing the benefits and harms of different interventions and strategies to prevent diagnose treat and monitor health conditions in real world settings The purpose of this research is to improve health outcomes by developing and disseminating evidencebased information to patients clinicians and other decisionmakers responding to their expressed needs about which interventions are most effective for which patients under specific circumstances CER lS IMPORTANT 4 DsDevelopment dependency demographics differential epidemiology Change in diseases from actue to chronic Early intervention helps Home visiting programs Bolstering parental education and support will translate to a more developmentally supportive home environment improved neurodevelopment and less abuse and neglect Lecture 27Planning Interventions 9 need to go over 2quotd half Health Intervention Action that reduces the frequency duration or severity of disease and promotes the health and wellbeing of the individual family or community Health Education used as promotion in US but not int Any combination of learning experiences designed to facilitate voluntary adaptations of behavior conducive to health Health Promotion used as intervention Process of enabling people to increase control over and to improve their health Health promotion emphasizes broader social context of health behavior amp environmental supports and is notjust about individuals Health Physical mental and social wellbeing notjust absence of disease or infirmity Behavior change is a major focus of population health interventions across the healthdisease continuum The behavior of interest people whose health is in question who control resources or rewards such as community leaders parents employers peers teachers and health professionals Individual behavior change efforts will be far more successful ifthey target individuals andtheir environment 1 prevention take place before a disease or injury is present to prevent it from occurring 2 Prevention Activities that take place after disease has occurred but before the person experiences symptoms 3 Prevention Tertiary prevention targets the person who already has symptoms of the disease ry across disease eg decrease distribution of BP 2 mmHg vs those at of Change theory suggests how individuals can change 5 As behavioral counseling framework Ask screen for unhealthy behaviors Assess what is their readiness to change Advise to alter the behavior Assist provide practical support to make the change Arrange for followup to provide support as barriers arise Patient centered partnership model patient plays major role in setting goals for change Explanatory people acquire behaviors by watching the behaviors and outcomes of others Change Offer credible role models to perform desired behavior Interventions and associated research should be conducted in partnership with communities Precede Predisposing reinforcing and enabling constructs in educational and environmental diagnosis and evaluation Proceed Policy regulatory organizational constructs in educational and environmental development 4 assessment phases of precedeproceed 1 Social 2 Epidemiological 3 Behavioral amp Environmental 4Educational amp Ecological 5Administrative amp Polic Quality of life goal work backward to figure out the health behavioral amp environmental determinants and their determinants Predisposing knowledge attitudes beliefs values perceptions that facilitate or hinder motivation for change readiness for change Enabling skills resources barriers that can help or hinder desired behavioral and environmental changes Reinforcing Feedback positivenegative after adoption of the behavior that encouragesdiscourages continuation Lecture 26 Health policy Aim to help people in their quest for health Impacts health by impacting Physical environment Behavioral choices Social determinants Health services Politics vs Analysis When we say that policies are decided by analysis we mean that an investigation of the merits of various possible actions has disclosed reasons for choosing one policy over others When we say that politics rather than analysis determines policy we mean that policy is set by the various ways in which people exert control influence or power over each other Alternatives to Medicare cost Begin means testing in Part A Increase the age of eligibility Increase premiums for beneficiaries or increase revenue from nonbeneficiary taxes Encourage further use of managed care Restrict benefits home health care technology prevention Reduce payments to providers and health plans Use Medicare s purchasing power to negotiate better prices on drugs and other services Risk adjust payments to providers Pay for performance may or may not reduce expenditures Sources of Innovation in Policy Making Critical junctures in policy development Political opportunities and leadership Policy entrepreneurs and investors Linkage of multiple venues in reform Strategies for Public Health Entrepreneurs Defining benefits avoidance of negative external costs Documenting and publicizing benefits attract new support or strengthen existing support Selecting interventions consistent with distribution of benefits and costs Limitations of Litigation Comprehensiveness of policy and target populations Compensation rather than prevention Resources needed to litigate not commensurate with injuries Durability of the solution Political Analysis of Value Seeing conflict and power as intrinsic elements of policy making and as determinants of governmental action and inaction Understanding the origins and goals of policies and programs Anticipating and diagnosing problems in policy implementation and performance Considering how programs should be evaluated and refined over time Lecture 25 Multilevel Analysis Analysis of Clustering Responses from the same group tend to be similar predictor variables from multiple levels fixed effects correlation among responses from the same clusters random effects Idea is to figure how interaction between different levels affects responses and outcomes same cluster 9Var Total Var Between VarWithin ICC Var Between Var Total No clustering ICC 0 Perfect clustering ICC 1 Importance of multilevel Learning about effects that vary Using all the data to perform inferences for small groups borrowing strength Prediction Analysis of structured data More efficient inference for regression parameters Including predictors at multiple levels Getting the right standard error Lecture 24 SHOW goals Established in 2008 as a stateof the art infrastructure for population health research in Wisconsin NHANES Cannot provide state specific data Data at statecounty level Mortality Hospital discharge data BRFSS Family Health Survey Risk factor epidemiology Underlies traditional clinical preventive medicine logic and approaches screening and treatment Lecture 23 Community Intervention Research History of community trials 1960s Confronting cardiovascular disease eg 7 Country Study Characteristics Integrated and comprehensive Not limited to medical care settings Systematically involve community leaders social networks and media Involve Tattle 2 Factors in uencing a chotce between longitudinul and repeated crossrscctional snrnnles strategies to create policy and enVIronmental Factor Longitudinal Cmss smm changes V I V Program Objecnve Dtrcctly measures change tn inni Directly measures change Issues vldual health characteristics in community prev Low statistical power elem 9f health char Community as the unit of analysis Between and withincommunity variance Selection bias at recruitment May be worse because participation Participation may be ts not anonymous anonymous Attrition Losses lo followup may be related to Nut a problem Koepsell et al behavior being evalua ed Study designs Testing Repealed questioning may be a 00 Not a problem intervention Lac k of ra ndom lzatlo n Maturation Panel gets older while community at Not a problem Int t ma not Va d39ty threats History Panel consists of more long Icrm Less a problcm oDifferential selection communit residents with expo sure to local historyquot oHistory Crosscontamination Not a pmlslern Movement between inter vention and control Contamlnatlon communities may Cohort versus crosssectional designs mlmemw Longitudinal studies measure at individual Statistical power Higher for xed sample size and Lower level and cross sectional is at community level Emmi 9 CBPR Community based research where people in the community have their saw Secular Trends major threat to national studies Magnitude of Effect smaller effect compared to clinical trials Limited Ecologic approach since community targeted Conclusions Trade off between cost and reach Easy to show effects with high cost interventions in limited populations Challenging to demonstrate effects with lowcost interventions in large populations olncreasing focus on ecologic approach for interventions with a focus on media and policy interventions Evaluation of outcomes has shifted from mortalityhealth behaviors to health policies The most significant potential of public health programs to improve the quality of community life may perhaps emerge from the engagement with communities in an ongoing process of social change Merzel Lecture 22 Research Development and Design in Population Health Two major types of study design Experimental Investigator introduces a factor or intervenes in the environment of the study subjects amp Observational Investigator does not directly Intervene Develops methods for describing events that occur naturally Qualitative research Research methods used to provide a detailed descriptions and analyses of issues of interest in terms of how and why things happen the way that they do Purpose Exploratory Preliminary data Complement largescale research Validation or further explanation Method of choice for certain types of research Alternative approach Types Direct observation Interviews Document analysis Sources of caregiver stress lifestyle alterations change in PD patients status communication issues lack of social support Lecture 21 Quantitative Research Types Analytical DescriptiveExperimental Action Steps DescribeExplainPredictControl Types of Causal Direct Indirect Joint Experimental Design types Pre case series no control or randomization Quasi no randomization but control present True randomization but control present The preexperimental designs are the weakest of the experimental designs Because oftheir absence of control Might be helpful for pilot data Threats to external validity setting places people time Types of observational studies descriptive or analytic Internal Validity is Necessary for External Validity Types of Research study design depends on Directionality Timing Sample selection Purpose and Investigator ontrol rl Quasi limitations Control exerted by investigator how controls are selected Single Group Time Series Design NR E 01 02 03 X04 05 06 Multiple Group Time Series Design NR E 01 02 03 X04 05 06 NR 00102 03 04 05 06 Multiple baseline studies when everyone gets the drug at some point but diff times NR 01X 02 03 04 05 06 NR 0102 X03 04 05 06 NR 0102 03 X04 05 06 True experiment R E 0 X 0 RCO O Rm 39 I quot iPI OS Rm 39 I quot iCOI iS Increases the likelihood that the only difference In real world subjectssites not willing to between intervention group and nonintervention participate group is the intervention itself Ethical concern about withholding treatment Important when effect is likely to be small Expensive to carry out Internal Validity External Validity History Testingtreatment Maturation interaction Testing Selectiontreatment Instrumentation interaction Statistical regression Reactivesituational Selection bias effects Attrition Multiple treatment effects Cr ss sectional at one point of time Not good for rare or acite disease Advantages of Case control Disadvantages of Case control Quick and inexpensive Inefficient for studying rare exposures Optimal for studying rare diseases or diseases with a Difficult to establish temporal sequence long latent Prone to certain biases eriod Recall Versatile used to study interventions health Inadequate medical records services an safety measures Advantages of Cohort Disadvantages of Cohort Observe the natural history of disease Inefficient for studying rare diseases Valuable if exposure is rare ie occupational exposures Allows for one or a few exposures to be examined Can examine multiple outcomes Expensive and timeconsumin Temporal sequence can be established Often difficult to maintain the cohort and reduce loss to followup Lecture 20 Economic Determinants Opportunity Cost forego opportunities to do or accomplish certain things when I choose to do or accomplish others Health care interventions that have temporal patterns of costs should be evaluated based on temporally discounted cost magnitudes Root is Scarcity of resources Risk Aversion risk aversion is a feature of individuals39 preferences wherein one would prefer the actuarial mean expected value of an uncertain monetary situation to the uncertain situation itself Moral hazard implies that the use of healthcare will depend on the level of insurance coverage In uncertain situations that is individuals may be resolution preferring or resolution averse Lecture 19 Health Technology Health Technology Assessment form of policy research that examines short and longterm consequences of the application of a healthcare technology Properties assessed include evidence of safety efficacy patientreported outcomes realworld effectiveness cost and costeffectiveness as well as social legal ethical and political impacts Costeffectiveness analysis is a set of tools used to assess the relative value of health technologies A technology is costeffective relative to another technology if and only if reallocating resources away from the best available alternative technology to the new technology results in an increase in average population wellbeing Health related quality of life scale 1 perfect health to 0 dead Optimal Resource allocationmaximizes notjust the utility on the health condition ICER 7 being considered health production function but also the utility from other activities EItnwr opportunity cost Simple economic rule of optimality marginal benefit marginal opportunity cost Health as a component of well being cannot be purchased Instead of purchasing health individuals produce health by investing in health capital Production function set of inputoutput relationships amenable to empirical analysis q lq2 qm f x1x2 xk Marginal productivity determine how many inputs to use the value of additional output changing one input and keeping others constant will be weighed against mm calm M the cost of the additional inputs 1 Economic determinants central considerations Substitution and complementarin among compone ts of health outputs 2 Substitutability among different lifestyles eg diet and exercise among different forms of medical care eg pharmacotherapy surgery counseling and be ween lifestyles and medical care 3 Lifestyles and medical care are chosen in contex 3 of social natural and build environs 4 Both monetary time constraints bind on choices of lifestyles and medical care use their interplay determines the full price of quotXquot Measures of Utility Mortality QOL Clinical measure Translational research 17 years for 40 of research to put to practice Americans receive 55 of needed health care 40 billion medicare spending is waste Type 2 translational research helps put research from efficacy trials into practice Good policies necessary but not sufficient 3 types of policy public federal state local initiatives organizational quot quotquot practices clinics clinicalclinicians amp patients mmmllyllnuikymmul l m IIIH Type 1 Tmnslational earch I I I F0115 on the complete h39an tional ButMn um summum run A null mquot m pathway NIH Type 2 Translational Raeardt Bedside to curbside39 Lecture 16 Medical Care access Obliged to give care 9 acute care hospitals receiving Medicare reimbursement Voltage Drops from Potential to Delivered Quality Consistent mmce Enmned in gag Pgmw Samoa 3 Uninsured rates are highest Ava able Insurance CW3 Available amongst African Americans and Hispanics Adults w high deductibles are more likely to get less health care because of costs Uninsured adults are less likely to have regular source of care Minority care patients have less referral Potential Quality Delivered Quality Lecture 15 Cells to Society Cells to Society lmplies a common research thread from basic science and clinical science to implementation and policy ww wn 3 potential life course models critical period accumulation of risk pathway effects Critical period model Developmental phase effects may last through life course Accumulation of risksCumulative effects Accumulation of advantage or disadvantage Intensity and duration of exposure throughout the life course affects health l w m m a status Doseresponse relationship W quot Pathways model Focus on trajectories Early life environment sets individuals onto life trajectories pathways Trajectory in turn affects health status over time Weathering Blacks have higher allostatic load than whites and this does not change with age or SES Thrifty phenotype Fetus adapts to a world in which food is scarce Barker s Hypothesis Mismatch leads to increased risk for poor outcomes shocks The gap in health between poor and nonpoor children widens as children a e omolex 39 39 39 39 D39 quot39 W quot Interactions Feedback loops Lecture 17 Medical care as determinants ofhealth am or mum MillINan mm mum Lecture 13 WMi quot quot39 m quot quot Children most affected by environmental chan es mW c quot quotquotquot quotquotquotquot Extrinsic incubation periodquot or EIP shortens at higher temps so mosquitoes lmm m min i M infectious sooner mi mm m m m ammimn mummm Lecture 12 Environmental Health Wm Defni 39 J J r L r 539 quotLNquot mmmmm d hazards which exist or could exist In the biological chemical 39 W n or physical environment I I I aw m Environmental health concerns Drinking Water Food Land Built quotmm quotmm MIMI Environment Indoor Air Emergencies in quotIIIInimme M m Risk assessment is s n bass of scientlfi 39W quotWquot quotquot quot quotquot research as define the pronamuey of some ham coming when IIImi u an individual or a population a a result at expasun uraniummu to a substance or situation iusk manausmenz in menu is the public process if decisian uh Ii do when risk has dllnmined ED axisz t in hides integrating risk assessment with onsxdsratians of Inglneering teasibilit ligusing out how to Eleni 39 par Ve to reduce r k in we light a sacill Ecolmink and political factors Q Determ nants vention Primar lncome uasi 7 Farmers market 3 block rad Martial Status experimental r Coalition AvailiablityProximity Measures 7 Grocery store develop onset of chronic Household site of lunches c 7 Kids lun h diseases 39 obesity measure use 7 Insurance incentives Accordingto Cutler rise in spending snouid be baianced by attention to neaitn benerits gained He supports nistneoiy by noting tnat it cost 121000LYin198071990and145000LYW19902000 t u iiai iiiiai a preventable Out or MS ion as couid be avoided by better access to neaitn care rn di al car Prof care contributes between 10 and 50for a given outcome wnere at ieast nair cornes trorn otner determinants in resource iirnited World we have to be carerui about now we are spending our doiiars
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