Transcript DETERMINANTS - courses.psu.edu

DETERMINANTS OF HEALTH
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Most discussions of determinants of health actually
address the determinants of ill health, disease or
injury
Disease and injury are the results of complex
interactions among people, agents of disease or
injury, and their environment
People caught up in what appear to be similar
circumstances may be affected differently
Textbook emphasizes multifactorial causation -- I.e.,
disease, disability and injury are attributable to
combinations of biological, behavioral, and
environmental conditions
DETERMINANTS OF HEALTH (cont/d.)
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Must distinguish between necessary and sufficient
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Remember that public health focuses on health risks
associated with groups, or populations
Risk factors may increase the probability of disease
or injury, but do not, because of their absence,
product health
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factors of causation
Model Showing Relationship of Health-Field
Concept to Health Status
Human
Biology
Life
Style
Environment
Health
Status
Health
Promotion/
Services
Organization
Preventive Interventions in Lung Cancer
Prevention_______
Primary
Secondary Tertiary_
Human Biology
0
0
+
Environmental
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+
0
++++
++
0
+++
+
0
Life-Style
Organizational
0 = Virtually no opportunity
+ = Least opportunity
++++ = Most opportunity
Preventive Interventions in AIDS
Prevention_______
Primary
Secondary Tertiary_
Human Biology
0
++
+
Environmental
++
0
0
++++
++
++
+++
0
+
Life-Style
Organizational
0 = Virtually no opportunity
+ = Least opportunity
++++ = Most opportunity
Levels of Disease and Injury Prevention
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Disease and injury prevention techniques are
usually described in one of three categories:
• Primary Prevention
• Secondary Prevention
• Tertiary Prevention
Primary Prevention
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Includes those activities intended to prevent the onset of
disease and injury in the first place
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Examples: Immunization against infectious diseases, use
of seat belts, avoidance of tobacco use, minimal intake of
alcoholic beverages, inspection/licensure of restaurants,
inspection of water resources, inspection of work sites . . .
etc.
Secondary Prevention
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Includes techniques that find health problems early in their
course so that action can be taken to minimize the risk of
progression of the disease in the individual or the risk that
communicable diseases will be communicated to others
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Examples: Health screening for disease risk factors, early
diagnosis of hypertension with follow-up treatment, early
diagnosis of sexually transmitted diseases to minimize
transmission potential, glaucoma testing during eye
examinations, screening for diabetes mellitus . . . etc.
Tertiary Prevention
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Includes techniques focused on rehabilitation to prevent
the worsening of an individual’s health in the face of
chronic disease or injury
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Examples: Physical therapy for an orthopedic injury or
cerebrovascular accident (stroke), education on diabetic
self-management, other regimens for disease control . . .
etc.
The “New” Public Health
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What some refer to as the “new public health” focuses on the
role of one’s personal behavior in determining health status
• Life-style interventions (e.g., health promotion programs)
have become an important and popular part of public health
strategy in the U.S.
Others counter that emphasizing personal behavior
ignores/obfuscates the role that organized interests play in
perpetuating disease patterns
• E.g., alcohol and tobacco industry advertising
• Failure of Medicaid to adequately support prenatal and child
health care
Dealing with some public health concerns may involve the work
and support of agencies that are far outside the public health
domain
• E.g., attempting to reduce traffic fatalities can involve
several different types and levels of intervention
Text (p. 36) discusses multifactorial causation -- disease,
disability, and injury attributable to combinations of biological,
behavioral, and environmental conditions
Many public health problems require combinations of
multifactorial intervention
Public Health Goal: Reduction of Highway Fatalities
1. Driver education
2. Operator license: age limits, testing, revocation
3. Behavioral self-controls -- e.g., drinking and driving;
road rage
4. Law enforcement: speed limits; reckless driving
5. Vehicle manufacturing: safety specifications
6. Vehicle inspections
7. Highway/roadway engineering designs for safety
8. Vehicle operator restrictions, based on biological/physical
deficiencies
9. Availability of prompt emergency medical services
10. Others . . . ??
Some Ponderable Concerns about Determinants of
Health -- Some “On Average” Propositions
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People who live alone have higher premature rates of
mortality than those who live in a stable relationship
with other people
People who are employed live longer than those who
are idle
Thin people live longer than fat ones
People who sleep well each night live longer than
those who do not
There is ultimately no safe environment; even in the
most idyllic setting, wastes are generated, storms
and fires occur, and accidents happen
Some Ponderable Concerns about Determinants of
Health -- Some “On Average” Propositions
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Studies of sexual behavior show that (1) large
numbers of people either engage in practices they
know to be hazardous, or (2) avoid practices they
know to be beneficial
In surveys, the great majority of adults indicate that
regular exercise is very important; however, only
about 40% report that they exercise regularly
Most women (87% or higher) over the age of 18
indicate they know something about breast selfexamination; however, just over 1/3 report that they
perform BSE at least 12 times a year
Some Ponderable Concerns about Determinants of
Health -- Some “On Average” Propositions
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To date, there has been limited success in altering
genetic structure in humans, but this will surely be
possible and become widely spread in the future -but with what ethical and moral implications?
To what extent should human genetic analyses
change the meaning of an insurance program; i.e., if
risk can be predicted, why insure someone whose
fate you already know?
Will gender differences in mortality continue to
decline as more women adopt “male” habits, such as
tobacco use and enter the workforce in increasing
numbers, thus facing new life hazards?
LEADING CAUSES OF DEATH
(Percentages of All Deaths)
Sources: CDC; National Center for Health Statistics
1900
1994
Pneumonia
11..7%
Heart Disease
32.1%
Tuberculosis
11.3%
Cancer
23.5%
Diarrhea & Enteritis
8.3%
Stroke
6.8%
Heart Diseases
8.0%
Bronchitis & Emphysema
4.5%
Stroke
6.2%
Injuries
3.8%
Liver Disease
5.1%
Pneumonia & Influenza
3.6%
Injuries
4.2%
Diabetes
2.4%
Cancer
3.7%
AIDS
1.8%
Senility
2.9%
Suicides
1.4%
Diphtheria
2.3%
Liver Diseases
1.1%
Mean Age of Death and Infant Death
Rates, England, 1842
Mean Age of Death
Infant Deaths
per 1000
births
Class
Gentry, professional
London England
(England)_
44
35
100
23
22
167
22
15
250
persons & their families
Tradesmen, shopkeepers
& their families
Wage classes, artisans,
laborers & their families