POPULATION HEALTH: Health determinants, Prevention & Health promotion

POPULATION HEALTH: Health determinants, Prevention & Health promotion Ian McDowell Epidemiology & Community Medicinemcdowell@uottawa.ca Other resources available on SIM web site Toronto Notes

MCC Objectives: Population health 78-1 Concepts of health and its determinants As defined by Health Canada and the World Health Organization: • Discuss alternative definitions of health, wellness, illness, disease and sickness; • Describe the determinants of health (Health Canada list) • Explain how the differential distribution of health determinants influences health status, and • Explain the possible mechanisms by which determinants influence health status. • Discuss the concept of life course, natural history of disease, particularly with respect to possible public health and clinical interventions. • Describe the concept of illness behaviour and the way this affects access to health care and adherence to therapeutic recommendations. • Discuss how culture and spirituality influence health and health practices, and how they are related to other determinants of health.

Objective 1: Definitions of Health

Definitions of Disability, etc WHO (1980): International Classification of Impairments, Disabilities & Handicaps (ICIDH) • Impairment = loss or abnormality of psychological, physiological, or anatomical structure or function (e.g., loss of visual acuity) • Disability = resulting loss of ability to function, perform normal activities (can’t see well) • Handicap = resulting disadvantage due to inability to perform social roles (loses driving license, so perhaps job) WHO (2001): Critique of negativity of above leads to International Classification of Function (ICF). Similar concepts, renamed impairments, activities & functions. Emphasizes ‘participation’ & importance of environment in which person lives.

Disease Discussion over margins of what constitutes ‘disease’ • Pathological process? Abnormal condition? Illness causing discomfort? • Nosologiesevolve over time: • what we have a treatment for (impotence) = a disease? • Syndrome & ill-defined conditions evolve into disease • “Each civilization defines its own diseases…” (Illich) • “Non-diseases” (Richard Smith): burnout, senility, baldness, jet lag, etc. • Illness = what the patient complains of; sickness = society’s definition (what is allowable: ‘sick days’; the ‘sick role’)

Assembling these concepts Handicap;Participation Socialfunction (WHO terms in red) (disadvantage; loss of involvement) (Susser’s terms in green) Disability;Activity Sickness (restriction in performing a function) (socially defined status of peoplewho are ill) Illness (the patient’sexperience of beingunwell) Level of impact Disease (something the doctordiagnoses and treats) Impairment (loss or abnormalityof structure or function) Cellular Disease onset signs &symptoms consequences Diagnosis Time line

Objective 2: Determinants • Determinants seen as underlying social forces that affect large groups of people • ‘Causes of the causes’ of disease • E.g. poverty levels; policies; pricing of commodities • Risk factors largely relevant at individual level (age, genetics, health behaviours, etc) • They often mediate the influence of determinants • Clarify determinants versus confounding factors

Health Canada’s list of determinants Income and Social Status Social Support Networks Education and Literacy Employment / Working Conditions Social Environments Physical Environments Personal Health Practices and Coping Skills Healthy Child Development Biology and Genetic Endowment Health Services Gender Culture Note that this list blendsindividual and societalfactors. But it may be the basis for the exam!

Causes, Determinants & Risk Factors Betterhealth Risk factorscause individualvariability around mean Averagehealth insociety Determinants Level of a risk factor

Objectives 3 & 4: Differential socioeconomic impact of health determinants • Individual Poverty associated with increased incidence of virtually all health problems, often working through known risk factors (smoking, obesity, etc). • On a population level, Income inequality is a factor in many nations: the broader the spread, or disparity, in income the worse the average health. • Seems to operate through decreased social cohesion, greater conservatism, less community investment, less concern over supportive legislation, less caring society, etc. (Few Turnbulls!)

Objective 5: Concept of Life Course Two hypotheses in understanding genesis of chronic disease • Biological programming: long term, cumulative health effects of early exposures at critical periods (during gestation, childhood, adolescence). • Learned lifestyle patterns (e.g., via culture, religion, SES, parenting). “Embodiment”: extrinsic factors inscribed into body functions or structures. Life course approach blends these 2 conceptions: both are important. Descriptive perspective: • 0 – 45 = age of misadventure (morbidity from injuries) • 45 – 75 = age of premature degenerative diseases • 75+ = age of senescence Analytic perspective: • Health is determined by cumulative impact of insults at critical developmental times + lifetime behaviors, exposures & compensating coping mechanisms (these are also determined by early experiences). “Accumulation of risk model” • Child rearing & patterning of behaviours that become risk factors. Links to SES. • Bowlby: early child attachment determines susceptibility to later psychiatric disorders • Eepigenetic influences on neural development that establish set points for a range of physiological parameters • Barker hypothesis: under-nutrition in utero ‘programs’ the structure & function of body systems and affect later risk of CVD & diabetes

Therapy Impairment Disability Handicap Objective 5: Natural history & interventions Etiological Phase Social &EnvironmentalDeterminants Risk & ProtectiveFactors Preclinical Phase Clinical Phase Post-clinical Phase Initialoutcome Longer-termoutcome: Impact on familywork;economic impact, etc. Living environment ↑ Communitycircumstances(services available, etc.) ↑ Conditions in society (economic stability, etc.) Personalfactors: Lifestyle; Genetics; Education; Occupation; Socialsupports,etc. Symptoms Biological onset of disease Diagnosis

Objective 6: Illness Behavior Person’s response to illness. Several ingredients: • Behaviour in seeking care: may seek care promptly or may delay (fear, denial, $ cost) • Coping mechanisms; changes activities? • Factors affecting adherence to therapy (knowledge, attitudes, personality, $) Describe one or more models of behaviour change, including predisposing, enabling and re-enforcing factors • Health Belief Model • ‘Stages of change model’ (aka trans-theoretical model)

Health Belief Model Modifying Factors Perceived Susceptibility to Disease · Demographics · Personality, SES, peer pressures, etc.· Knowledge, prior experience, etc.) Perceived Severity of Disease Perceived benefits of taking action, minusPerceived barriers to action Perceived Threat of the Disease Cues to Action · Raised awareness (e.g., mass media campaign)· Personal advice (e.g., reminder from health professional)· Personal symptoms· Illness of family member or friend Likelihood of TakingRecommended Health Action

StableLifestyle Action Preparation Maintenance Contemplation Relapse Precontemplation Stages of Change “Transtheoretical” model

Objective 7: Culture & Spirituality • Culture = shared knowledge, beliefs, and values that characterize a social group. Learned through socialization. • Cultural sensitivity = understanding the values and perceptions of your culture and how this may shape your approach to patients from other cultures. • Cultural competence = attitudes, knowledge, and skills of practitioners necessary to become effective health care providers for patients from diverse backgrounds. • Cultural safety goes a step beyond accepting differences, to appreciating the power imbalances and possible discrimination that exist, & treating people with respect

Cultural influences on health (Close connection to religion, morals, spirituality) • Perceptions of disease (‘sickness’ = social perceptions of what is considered disease) • May affect styles of treatment & care • Alternative therapies • Health behaviours (diet, use of alcohol, etc) • Decision-making (individual vs. collective) • End of life care, life support, etc. • Ethics & morality • Social bonds & mutual obligations

Self-test questions SIM web questions on concepts of health, etc: http://www.medicine.uottawa.ca/sim/data/Self-test_Qs_Pop_Health_e.htm

MCC Objectives: Population health 78-3 Interventions at the population level • Define the concept of levels of prevention at individual (clinical) and population levels • Name and describe the common methods of health protection (such as agent-host-environment approach for communicable diseases, and source-path-receiver approach for occupational/environmental health). • Apply the principles of screening… discuss the potential for lead-time bias and length-prevalence bias. • Understand the importance of disease surveillance in maintaining population health and be aware of approaches to surveillance. • Identify ethical issues with the restricting of individual freedoms and rights for the benefit of the population as a whole..

78-3 (continued) • Describe the advantages and disadvantages of identifying and treating individuals versus implementing population-level approaches to prevention. • Describe the five strategies of health promotion as defined in the Ottawa Charter and apply them to relevant situations. • Describe one or more models of behaviour change, including predisposing, enabling and re-enforcing factors (covered above). • Identify community factors that might promote healthy behaviours & ways to assist communities in addressing these factors.

Objective 1: Levels of Prevention Interventions to arrest disease development 1°, 2°, 3° categories are not black and white Primary prevention: Strategies applied BEFORE disease starts. E.g., Immunization Secondary prevention: Early identification of disease in order to intervene to prevent its progression E.g., Cancer screening Some people suggest secondary prevention relates to reducing the severity of disease. Tertiary prevention: Treatment and rehabilitation of disease March 2012 21

Etiological Phase Social &environmentaldeterminants Risk & protectivefactors Preclinical phase Clinical phase Post-clinical phase Secondaryprevention: Detect &treat pathologicalprocessat an earlierstage whentreatmentcan be moreeffective Tertiaryprevention: Preventrelapses & furtherdeteriorationviafollow-up care& rehabilitation Primordialprevention: Alter societalstructures& therebyunderlyingdeterminants Primaryprevention: Alter exposuresthat leadto disease

Linking Health Promotion and Disease Prevention Prevention strategy Health Promotion 1° Prevention 2° Prevention 3° Prevention Healthy population Those withrisk factors Limited disease Symptomatic or advanced disease Populationaddressed Prevent developmentof risk factors; reduce average population risk Prevent development of disease: reduce incidence Reduce recurrence, complications or disability Prevent disease progression Goals

Objective 2: Health Protection Activities undertaken by public health departments & government agencies such as the Public Health Agency of Canada (PHAC) to: • Reduce threats to the health of the population (environmental & occupational health; terrorism) • Includes primordial and primary prevention: • ensuring safe food and water supplies; restaurant inspections; • protecting people from environmental threats; • regulatory framework for controlling infectious disease. • smoke-free bylaws . • Legislation covers identified threats, often detected via surveillance systems • Public health policies & healthy public policies.

The ‘epidemiologic triad’: Disease arises when a susceptible host encounters an agent in a supportive environment (virulence; infectivity;addictive qualities, etc.) Agent Host Environment (genetic susceptibility;resiliency; nutritional status; motivation, etc.) (rural/urban; sanitation; social environment; access to health care, etc) The idea can also be represented more dynamically, suggesting that disease results from imbalance between agent virulenceand host resistance, mediated by the environment in which they interact: Host Agent Oleckno WA: Essential epidemiology. Waveland Press, Long Grove, IL, 2002 Environment

Source-Path-Receiver model for Occupational / Environmental health protection Receiver Path(s) Source Potential approaches to risk control Modify Redesign Substitute Relocate Enclose Absorb Block Dilute Ventilate Enclose Protect Relocate

Objective 3: Screening • Can either: • Detect pre-disease states (e.g. dysplasia) • Detect the disease at an early stage • Criteria for when screening is useful • Disease criteria • Serious: Disease causes significant morbidity, mortality • Early detection can lead to an intervention that will arrest or slow the course of the disease • Criteria related to the screening test • Valid test: high sensitivity (and specificity if possible) • Safe, rapid, cheap, acceptable • Health care System criteria • Adequate capacity for follow-up & providing treatment

Evaluating a screening program: the hazard of Lead Time bias Disease onset Detectable by screening Appearance of 1st symptoms Death Time No screening Survival after diagnosis Screening Survival after screening Apparent increase in life expectancy or lead time

Legend Disease onset Slowly progressive disease death Rapidly progressive disease Lengthbias Screening identifies 2 cases of rapidly progressive disease and 5 cases of slowly progressive disease Note: The incidence of rapidly progressive disease is equal to that of slowly progressive disease Screening

Objective 4: Surveillance • = the systematic collection, analysis and timely dissemination of information on population health… • Can be: • Passive: system for collecting information sent in by MDs (e.g. notifiable disease reports). Long term. • Active: hunt for cases of a disease of concern. Short term. • Sources: • Notifiabledisease reports • Vital statistics • Hospital data & OHIP billing reports

Objective 5: Public health ethics • Underlying principles of • Respect for autonomy (dignity & making one’s own choices) • Beneficence (do good) • Nonmaleficence (do more good than harm) • Justice (distribute benefits fairly & impartially) • Four virtues: Prudence, Compassion, Trustworthiness, Integrity • Conflicts: • Beneficence for majority may conflict with autonomy • Justice in funding prevention vs. high-tech cure • Between values in different cultures (e.g. reproduction)

Common ethical issues in public health Social beneficence versus individual autonomy: • Isolation & quarantine restrict freedom but are acceptable in communicable disease control. However, maintain confidentiality & avoid stigma. • Authority to search for contagious cases is acceptable. • Mass medication (beneficence vs. nonmaleficence): • Harm : benefit ratios for immunizations have to accept some individual harm (should we stop immunization against measles after it is eradicated, thereby risking returning epidemics?) Risks of not immunizing usually greater; everyone must be informed. • Opposition to fluoridation: political or evidence-based? • Privacy & health statistics (individual autonomy vs. social beneficence) • Surveillance systems can use anonymous, unlinked data (e.g. from blood test results) • Subsequent analyses of medical records for research purposes • Computerized record linkage • Issue of research discoveries that damage commercial interests (e.g. industrial pollution; cigarette companies & lawsuits) • Informed consent is required for testing (e.g. HIV) (autonomy) • Debate, however, over anonymity vs. linking to allow for counseling.

Common ethical issues in public health • Occupational health code of ethics guides balance between protecting company which employs you and worker. • Put the health of the worker first; must inform workers of health threats • MD to remain fully informed of the working conditions • Advise management of health threats; workers can inform unions • Apply precautions • Must not reveal commercial secrets, but must protect workers’ health • Only inform management of worker’s fitness to work, not the diagnosis • “Crimes against the environment” (pollution, etc) conflict with economic interests & jobs (which harm health also) • Legally subpoenaing research records in order to discredit the data or pursue legal action (e.g. toxic shock case; breast implant study) not allowed, but variations in ruling.

Objective 6: Strategies for Prevention:High Risk Approach • Identify individuals at high risk and attempt to reduce their risk, by changing behaviour, etc. • Logical: high risk people should be motivated to change • But it may require testing larger population (costs, false positives) • Asks targeted people to act differently from their peers • It may also miss many cases depending on how you define ‘high risk.’ (Mostcases typically occur in medium-risk people:see next slide)

BMI distribution in the Canadian population (2007) Population burden: new cases of diabetes2007–2017 Individual risk of diabetes over 10 years X = BMI ≥ 35 X 32 % = 129,280 cases 12 % of total 30 to 34.9 13 % X 21 % = 274,700 cases 26 % 25 to 29.9 41 % X 10 % = 418,500 cases 40 % 23 to 24.9 22 % X 7 % = 157,800 cases 15 % < 23 20 % X 3 % = 61,400 cases 6 % of total Data source: ICES report, June 2010: How many Canadians will be diagnosed with diabetes between 2007 and 2017?

Strategies for Prevention: Population Approach • Attempts to shift distribution of risk factor in whole population • Gets to root of the problem • Shades into health promotion • Benefits everyone

Objective 7: Health Promotion Distinguishable from prevention: • Non-specific: Focuses on enhancing health (e.g., resiliency, coping skills) rather than preventing specific pathology. • Tackle ‘upstream’ factors. • Uses a participatory approach: active community involvement; often grass roots groups. • Partnerships withcommunity agencies: community mobilization. • Public health physician roles = advocacy, support.

HP Goals: “Squaring the survival curve” Health, Quality of life Disability-free survival Birth Time Death The red line represents a survival curve for a population. The blue lines represent varying levels of disability among survivors. Squaring the curve implies shifting these lines up and to the right, towards the green line, which represents the hypothetical population health limit.

HEALTH PROMOTION • Ottawa Charter for Health Promotion (1987) • Five key pillars to action: • Build healthy public policy • Smoking-free areas; mandatory bike helmets, etc • Re-orient health services • Alter physician fees to encourage prevention • Create supportive environments • Needle drop-off locations; safe jogging trails • Strengthen community action • Neighbourhood Watch; increase walkability • Develop personal skills • CHC community cooking skills program Policy  services  env’tcommunity  individual

Objective 9: Social marketing 2. Select materials& channels • Applies commercial marketing approaches to the analysis, planning, execution and evaluation of programmes to influence voluntary behaviour in order to improve their personal welfare and that of society • Draws on many other models • Studies what consumer thinks & tailors approach to that • Uses marketing approaches • Can apply to changing behaviour of professionals 1. Planoverallstrategy 3. Developinterventionand pretest 4. Implementthe program 6. Use resultsto refineprogram 5. Assesseffectiveness(process &outcomes)

Planning phase What can be achieved? What needs to be changed to achieve it? Start Identify the administrative & financial policies needed Identify education, skills & ecology required Identify desirable outcomes: Behavioural, Environmental, Epidemiological, Social Policies Resources Organisation Service or programme components Predisposing factors Enabling factors Reinforcing factors Lifestyle Health status Quality of life Environment Implementation: What is the programme intended to be? What is delivered in reality? What are the gaps between what was planned and what is occurring? Process: Why are there gaps between what was planned and what is occurring? What are the relations between the components of the programme? Impact: What are the programme’s intended and unintended consequences? What are its positive and negative effects? Outcome: Did the programme achieve its targets? What can be learned? What can be adjusted? Evaluation phase Finish Adapted from: Green L. http://www.lgreen.net/precede.htm

Population health 78-7 Health of Special Populations Enabling objectives Aboriginal health • Describe the diversity amongst First Nations, Inuit, and/or Métis communities • Describe the connection between historical and current government practices towards FNIM… and the intergenerational health outcomes that have resulted. • Describe medical, social and spiritual determinants of health and well-being for First Nations, Inuit, Métis peoples • Describe the health care services that are delivered to FNIM peoples Global health and immigration. • Identify the travel histories and exposures in different parts of the world as risk factors for illness and disease. • Appreciate the challenges faced by new immigrants in accessing health and social services in Canada. • Appreciate the unique cultural perspective of immigrants with respect to health and their frequent reliance on alternative health practices. • Discuss the impact of globalization on health and how changes in one part of the world (e.g. increased rates of drug-resistant Tuberculosis in one country) can affect the provision of health services in Canada.

(Objectives, continued) • Persons with disabilities. • Identify the challenges of persons with disabilities in accessing health and social services in Canada. • Discuss the issues of stigma and social challenges of persons with disabilities in functioning as members of society • Discuss the unique health and social services available to some persons with disabilities (e.g. persons with Down’s syndrome) and how these supports can work collaboratively with practicing physicians. • Homeless persons. • Identify the challenges of providing preventive and curative services to homeless persons. • Discuss the major health risks associated with homelessness as well as the associated conditions such as mental illness. • Challenges at the extremes of the age continuum • Identify the challenges of providing preventive and curative services to isolated seniors and children living in poverty. • Discuss the major health risks associated with isolated seniors and children living in poverty. • Discuss potential solutions to these concerns.

Aboriginal groups • Historical threats: colonization; Indian Act; residential schools; move to urban living; disruption of traditional economies; poverty, inadequate housing & facilities; • Elevated rates of • Trauma, poisoning, SIDS, suicide, substance use • Circulatory diseases (incl rheumatic fever) • Neoplasms • Respiratory diseases (TB…) • Infection (gastroenteritis, otitis media, infectious hepatitis) • Diabetes • Life expectancy rising, but still 9 years lower than ROC; high birth rate; IMR has fallen dramatically;

Special populations: Seniors • Risk of • Musculoskeletal injuries • includes falls & injuries • Hypertension/heart diseases • Respiratory diseases • Dementia • Polypharmacy

Special populations: Children in Poverty • Note life course approach (above) • Low birth weight • Trauma/poisoning • Oral problems (abnormalities in teeth and jaws) • Fever/infectious diseases • Psychiatric problems

Special populations: People with Disabilities • Increased risk of • Emotional & psychological problems • Job insecurity (hence low income & poverty)

Some MCQs.

28) In describing the leading causes of death in Canada, two very different lists emerge, depending on whether proportional mortality rates or person-years of life lost (PYLL) are used. This is because: a) one measure uses a calendar year and the other a fiscal year to calculate annual experience b) one measure includes morbidity as well as mortality experience c) both rates exclude deaths occurring over the age of 70 d) different definitions of “cause of death” are used e) one measure gives greater weight to deaths occurring in younger age groups

Which of the following statements concerning cross-cultural care is true? • a) It has proven very hard to change physicians’ attitudes and make them more culturally aware. • b) There still is no formal accreditation requirement to train physicians in cross-cultural skills. • c) There is considerable literature comparing the effectiveness of different techniques of cross-cultural communication • d) Lower quality care results when clinicians fail to acknowledge cultural differences. • e) The CMA and Royal College have collaborated to produce clear guidelines on developing cultural competency.

POPULATION HEALTH: Health determinants, Prevention & Health promotion