Public Health Pbl

THE WAVES OF PUBLIC HEALTH IMPROVEMENT THERE HAS BEEN 4 HISTORICAL WAVES OF HEALTH IMPROVEMENT IN THE UK The UK has had several phases of public health improvement since the industrial revolution, each of which can be linked to major shifts in the nature of society and the emergence of new threats to population health Each wave rises rapidly reflecting the full impact during this period. Each wave reaches a peak then declines in intensity.

MODERN PUBLIC HEALTH Improvements in modern technology and pushes in public health have reduced age-specific rates of disease in mid-life, but have resulted in a ‘disease burden’ for the ageing population. Therefore modern public health must develop with focus on increasing healthy life expectancy rather than life expectancy itself.(compression of morbidity) Health problems that are of greatest concern tody are of a different nature: they are cultural as much as strictiral or material in origin and character. e.g. the emerging epidemic of obesity, loss of wellbeing, and problematic drug and alcohol use hence, a new push in public health will need to change our world view and social structures

THE 4 WAVES OF PUBLIC HEALTH WAVE ST 1 WAVE (1830-1890)

ND

2

WAVE (1890-1950)

PUBLIC HEALTH SUCCESSES The appliance f science and the development of rational social order  Municipalism – emerging civil and social order – lots of crime ad alcohol  Classic public health interventions; the growth of municipal power and influence  Control of water-borne infection in emerging industrial cities e.g. cholera  Understand-predict-control

A RATIONAL LOOK AT MEDICINE – THE DEVELOPMENT OF GERM THEORY from miasma theory (“dirty air”)

DESCRIPTION 1.

Providing clean water supplies and effective sewerage systems

2.

Sewerage and clean water strictly separated

3.

Purification technologies developed

1.

A wide range of infections can now be prevented with vaccination

1.

Further improvements in living standards

Scientific rationalism; the appliance of science allied to continuing economic development E.g. the development of vaccines – success in eradicating smallpox

RD

3 WAVE (1940-1980) Emergence of post-war consensus; creation of the welfare state

TH

4 WAVE (1960-2000)

2. Concept of government in which state plays key role in promotion of economic and social well-being of its citizens

NHS provision of free health care to all citizens

3.

Social security

MASLOWS HEALTH PYRAMID

4.

Pensions

5.

Social housing

SUPER-SPECIALIZATION IN MEDICINE

Effective health care interventions; focus on risk factors / lifestyle LARGELY INDIVIDUAL Understand-predict-control (emerging evidence from early epidemiological studies – analytical epidemiology Highlighting the harm from smoking) - Tobacco control- smoking has declined due to a large number of synergistic interventions working together

Interventions in the following areas to reduce smoking rates: Price regulation Public education Social marketing - Controls on product promotion, advertising and sponsorship - Introduction of proven treatments - Regulation of package design + labeling - Smoke free policies

What factors were responsible for the UK moving form high birth rates, high death rates, and low life expectancy to what we know today?

1.

Describe the main factors responsible for improved heath between 1830 until today

THE DEMOGRAPHIC TRANSITION The transition of population structure is called the demographic transition and reflects the move from a pre-industrialized society to an industrialized economic system associated with population growth. The demographic transition refers to the transition from high birth and death rates, to low birth and death rates as a country develops from a preindustrial to an industrialized economic system

The demographic transition is set out as an idealized picture showing a generalization of population change in countries over time and summarized in 5 stages:

1.

WHAT IS THE DEMOGRAPHIC TRANSITION?

STAGE 1 Pre-industrialized society, associated with pre-modern times. Characterized by a balance between birth rates and death rates. Birth, fertility, and death rates are very high and their approximate balance results in only a very slow population growth. Birth and death rates were high and unstable de to disease, drought, and other natural events. This produced a relatively young population… Raising a child was relatively inexpensive due to lack of education and entertainment expenses as well as the children contributing to the economy of the household. As for old age dependents, most people did not reach retirement and continued work until their death. High death rates affected birth the elderly and the young meaning the elderly constituted a very small part of society. BIRTH RATES WERE HIGH Children were relatively inexpensive to raise and were able to contribute to household economy so were therefore valued as contribution to household income Lack of family planning – however most people wanted children Religion and tradition at this time encouraged large families Children were regard as an “insurance policy” for their parents who grow depended with aging. Therefore many children provided a means of support in future life Infant mortality rate was high which gave reason for high birth rate

DEATH RATES WERE HIGH High levels of disease and lack of public health and healthcare availability Famine, droughts, and other natural disasters such as plague Lack of clean water and sanitation Malnutrition and poor diet

War

STAGE 2 Imbalance between death rates and birth rates as Britain entered a stage of transition amidst the late th 18 century. INITIATED BY AGRICULTURAL REVOLUTION th

The decline of death rates increased by the late 19 century due to the industrial revolution. Countries in this stage today include Yemen, Afghanistan, Palestine, and much of SubSaharan Africa. Death rates were seen to decrease rapidly for many reasons: 1.

IMPROVEMENTS IN THE FOOD SUPPLY due to improvements in farming technique such as crop rotation, bringing about higher yields, as well as improved technology, storage, and transport.

2.

IMPROVEMENTS IN SANITATION, water supply, sewerage and food handling which reduced the incidence of disease transmission

3.

Provision or improvement of basic health care which reduced mortality rates, particularly the development of vaccinations

4.

Improvements in hygiene from growing scientific knowledge of the causes of disease and improved education

5.

Decreased infant mortality rates

Birth rates at this stage do not change significantly as population culture remains largely the same, thus an imbalance between birth and death rates are established resulting in a large increase in population growth, termed the “population explosion”. THE POPULATION EXPLOSION, IN LARGE PART, IS DUE TO THE IMPROVEMENTS OF THE AGRICULTURAL REVOLUTION AND BETTER SANITAITON WHICH REDUCED DEATH RATES SIGNIFICANTLY LEADING TO AN IMBALANCE BETWEEN RATES OF BIRTH AND DEATH A change in the age structure of the population at this stage is also seen. In stage one most deaths were concentrated in the first 5-10 years of life, but in the second stage a substantial amount of the decrease in death rates are due to the survival of children Thus the age structure of the population becomes increasingly youthful meaning more of these children enter the reproductive stage of their lives whilst still maintaining the high fertility rates of their parents. This causes the base of the population “age pyramid” to widen first, before accelerating population growth.

STAGE 3 THE POPULATION MOVES TOWARD STABILITY THROUGH A DECLINE IN BIRTH RATE SEVERAL FACTORS CONTRIBUTE TO THIS EVENTUAL DECLINE: 1.

Continued decline in childhood death means that at some point parents realize they need not require so many children as to ensure a comfortable old age

2.

Improvements in contraceptive technology results in a decline in fertility

3.

Increase in wages increases the confidence at which parents can enter old age with fewer children to rely on for support

4.

Urbanization changes the traditional values placed upon fertility and raises the cost of child upbringing due to child labor acts increasing dependency

5.

Increasing female literacy and employment lowers the uncritical appetence of childbearing and motherhood as a status of women. Working women have less time to raise children – valuation of women beyond childbearing and motherhood becomes important

The resulting changes in the age structure of the population results in a reduction in the youthdependency ratio and eventually population aging. The population structure becomes less triangular and more like a balloon The change in population structure produces a demographic window for economic growth as a rise in the ratio between the working age and demographic population is observed. The increase in the ratio of the working age to the dependent population is called the demographic dividend STAGE 4 CHARACTERISED BY STABILITY AND OCCURS WHEN BIRTH AND DEATH RATES ARE BOTH LOW Birth rates may even drop below death rates, resulting in slight population shrinkage… The population age structure has become older, the large group born in stage 2 become older than working age and creates an economic burden, as dependent pensioners, on the shrinking work population Death rates may remain low or may increase due to increases in lifestyle diseases associated with low exercise levels, high obesity and age-related diseases. BIRTH RATES REMAIN LOW DUE TO: Children being expensive and parents not being able to afford their upbringing

DEATH RATES REMAIN LOW DUE TO: Ever improving health care

Lower infant mortality rates meaning parents can expect to carry the child to term and be confident of its survival beyond infancy, hence there is less need to bear more children in terms of security in old age

Better standard of living i.e. better housing, sanitation, hygiene, diet

Widely available contraceptives and higher levels of education regarding their use Decreased fertility rates Decreased desire by women to have as many children

STAGE 5 CHARACTERISED BY BIRTH RATES THAT ARE LOWER THAN DEATH RATES LEADING TO A DECLINE IN POPULATION LEVELS KNOWN AS SUB-REPLACEMENT FERTILITY This stage represents countries that have undergone/ are undergoing economic transition to deindustrialization. This is the transition from manufacturing based industries into service and information based industries. Lower birth rates than death rates result in population ageing and population decline may eventually occur presuming that sustained mass immigration does not occur. POPULATION AGEING The decline in death rate and birth rate that occurs during the demographic transition leads to a radical transformation in age structure. As death rates decline in the second stage of the transition, the result is primarily an increase in the child population. The EU however is an ageing community and the percentage of elderly increased modestly in industrial countries despite a small dip in 2010 due to relatively small cohorts born before and during the second world war. There is an expected rise in the elderly population as the “baby boomers” (a very large post-WW2 cohort) ages. This cohort was born between 1945 and 1965and will create a large and significant increase in the elderly population. This has many implications for society and services

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When the death rate is high, the infant mortality is usually very high When the death rate falls, or improves, this, in general, results in significantly lower infant mortality rate, and hence, increased child survival Over time as cohorts increased by higher infant survival rates get older and there will be an increase in the number of older children, adolescents and young adults This implies that there will be an increase in the fertility of the population which will lead to an increase in the number of children born This will further increase the growth of the population The second stage of demographic transition, therefore, implies a rise in child dependency

Socio-cultural changes in this cohort post-war mean there is existing patterns of behavior, which were not present in previous cohorts, which will also impact significantly on future health. ALCOHOL CONSUMPTION IS ONE SUCH BEHAVIOUR Ageing of society has implications for the old age dependency ratio. It is widely recognized that this shift in the balance of old and working aged cohorts in the population will damage the economy and create serious problems for health and social care services.

The old age dependency ratio is the ratio of individuals 65 and over in the population to the size of the economically active segment of the population

THE MAIN CONCERN IS THAT THERE WILL NOT BE A SUFFICIENT NUMBER OF TAX PAYERS TO PAY FOR THE COST OF THE NHS AMONG OTHER SERVICES, AND THERE WILL NOT BE SUFFICIENT NUMBERS OF WORKING AGE INDIVIDUALS TO FILL POSTS IN HEALTH AND SOCIAL CARE PROFESSIONS.

COMPRESSION OF MORBIDITY

The compression of morbidity is a hypothesis that states the burden of lifetime illness may be compressed into a shorter period before the time of death, if the age of onset of the first chronic infirmity can be postponed. As we age the risk of death and disease inevitably increases as ageing leads to progressive generalized impairment of function, resulting in a loss of an adaptive response, the mechanism by which the majority of disorder is corrected in early life. E.g. the ability to withstand infection or trauma depends on the reserve capacity of our physiological system. Pneumonia, for instance, in a young person is much less likely to be fatal due to the large reserve capacity of the young persons lungs, the same infection in an older individual through physiological decline may pose much more of a threat

TWO FACTORS INFLUENCE THIS RISK: 1.

The rate of physiological decline

2.

Risks of external assaults from the environment, including severity and frequency - External assaults include trauma, infection, or any other factor, which impairs physiological function

WIDE RANGE OF EXAMPLES ILLUSTRATING GENERALISED PHYSIOLOGICAL DECLINE:  Efficiency of lung function  Circulation  Muscles  Nerve transmission The rate of decline has largely genetic influence, but is affected by environment, nutrition, and lifestyle in general. Under certain influences, this decline can be accelerated e.g. poor diet and sedentary lifestyle in the case of CHD, but attention to environment and personal behavior can be key to slowing this decline. E.g. those who do not utilize their large muscle groups inevitably lose strength – “use it or lose it” principle

The level of decline is such that we can sometimes define it as pathological, for example, development of ischemia due to coronary stenosis as a result of poor diet or smoking. THERE IS A SLOW DECLINE IN A WIDE RANGE OF PHYSIOLOGICAL FUNCTIONS INEVITABLE WITH AGE, BUT THE RATE OF DECLINE IS AMENDABLE TO A LARGE VARIETY OF BEHAVIOURAL AND ENVIRONMENTAL INTERVENTIONS The chief aim in the compression of morbidity hypothesis is to extend the amount of time for which individuals remain above the symptom threshold of disease before a short period of ill health (morbidity) culminating in death.

WHAT IS HEALTH? Health comprises both the presence of positive and the absence of negative dimensions. The most important dimensions are physical, mental, and social.

PHYSICAL HEALTH – positive physical function of the body. The resource required for full physical functioning and resilience. PHYSICAL FITNESS – the ability to carry out daily tasks with vigor and alertness, without undue fatigue, and with ample energy to enjoy leisurely pursuits and to meet unforeseen emergencies

MENTAL HEALTH Mental health, in a positive sense, relates to the state in which a person may be able to function in daily life, cope with stressful events (resilience), and contribute towards something larger than themselves. It is not merely the absence of mental illness.

Psychological dimensions of public health are described as positive ‘functionings’ as opposed to positive feelings of subjective wellbeing.

Many of the determinants of mental health are also vitally important for the maintenance of physical health, including genetics, physical activity, and nutrition. Social determinants such as the cultural environment in which the individual lives, and their level f education, have also been found to impact on mental health. Life events also have significant impact. All other aspects of wellbeing including physical and social wellbeing have profound effects on mental health:

SOCIAL HEALTH Individual social heath concerns positive social interactions, behavior, and the ability to form and sustain relationships, in a sense, how one functions in a community. There have been 5 social health dimensions proposed: 1. Integration 2. Acceptance 3. Contribution 4. Actualization 5. Coherence

Social health is dependent on successful adaptation to the social environment, the quantity and quality of relationships, the extent of social networks, and the degree of support one receives from available contacts. Full social health involves feelings of trust and belonging, respect for self and others, and healthy sexual relations. Social health is subject to cultural norms, and may be interpreted differently depending on the society in which the individual lives. The degree to which an individual is health yin a physical and mental sense also impacts on their social health

PHYSICAL DISEASE Physical disease can take many forms from impairments to disabilities, long-term limiting conditions such as obesity, CHD, COPD and DM, infections, and injuries. Every diagnosis of physical disease falls under several categories:

WHAT IS MENTAL ILLNESS? Mental illness is how an individual feels, thinks or behaves, and refers to a wide range of symptoms and disorders, including depression, anxiety, eating disorders, and schizophrenia.

WHAT IS SOCIAL ILL-BEING? Social ill-being can be conceptualized as social dysfunction, an active condition of behavior that is unacceptable to a society in which one lives or visits. Characteristics of social ill-being may include hostility, withdrawal, isolation and insecurity. SUMMARY 1. Health is a construct 2. There are several dimensions to health (physical, social, mental, spiritual) 3. Each dimension has positive and negative poles 4. Subjective and objective measurement scales are required for each dimension

3. The determinants of health over the life course: discuss in some detail what factors at what time in the life course are needed to ensure the population live a long and healthy life

THREE LEVELS OF INFLUENCE 1. THE PERSON a. b. c. d. e. f. g.

Age Sex Genetics Biology Behavior Risk factors Lifestyle

2. THE COMMUNITY a. b. c. d.

Home environment Neighborhood Workplace Wider societal influences e.g. education system or health care system

3. THE ENVIRONMENT a.

Vast

THE LIFE COURSE PERSPECTIVE The life course approach examines the determinants of health at each of the stages of life: pre-birth, childhood, adolescence, working age, and older age. This perspective views health as a product of risk behaviors, perspective factors, and environmental agents that we encounter throughout our entire lives. A mdel is devised to conceptualize how exposure to factors at different life course stages has a cumulative, multiplicative, and even programming influence on long-term health and wellbeing. It allows us to understand the links and timings between exposures and the health outcomes.

There are three ways in which life course events can interact to influence long-term health and wellbeing: 1.

CUMULATIVE Most common mechanism Health damaging influences add to each other throughout the course of life E.g. a mother in poor economic circumstances may be less well nourished, the child then has material disadvantages in childhood and adolescence and tends to grow up to be relatively poor himself. BIOLOGICAL, BEHAVIOURAL, SOCIAL, AND ENVIRONMENTAL DETERMINANTS OF HEALTH CUMULATE

2.

MULTIPLICATIVE Some risk factors do not just add to one another, but have a multiplicative effect

3.

PROGRAMMING Exposure to some risks at any stage of the life course can programme increased risk of adverse health outcomes much later in life

THE SOCIOECONOMIC GRADIENT Position on the socioeconomic hierarchy has a profound impact on health for individuals – poverty causes ill-health. Socioeconomic gradient is considered at all aspects of the life course

LEVEL 1: THE PERSON Huge impact of genetics on individual health, otherwise considered uncommon in wider community or population. Genetic-type conditions such as chromosomal abnormalities including Down syndrome are relatively less common and have a small population health impact; however they can have a profound effect on every aspect of the individual’s life At an individual level, polygenetic inheritance influences the chance of an individual developing a chronic disease or cancer. For chronic diseases, the genes are found to interact with the environment and behavioral factors to affect outcomes; such is the case of epigenetic theory. Biological markers are also implicated e.g. high levels of cortisol are seen in those of low socioeconomic status. Cortisol is termed the “stress hormone” and is an important par of the body’s response to stress, however prolonged elevation in cortisol levels can result in a state of chronic stress, higher blood pressure and increased risk of heart attacks and strokes. GENDER AND ETHNICITY Sex is an important discriminant of health – females are protected from early development of heart disease due to the cardio-protective properties of the sex hormone estrogen, therefore gender influences the susceptibility to disease This mechanism is however the combination and interaction between genetic, behavioral, cultural and structural factors EMPLOYMENT AND OCCUPATION Good work is good for health. Employment that brings satisfaction, provides income, creates daily structure, promotes social interaction, and provides purpose and meaning in life is seen as beneficial to health outcome of the individual. Disease and mortality rates for different occupations vary markedly PERSONAL CHARACTERISTICS Personal skills necessary for success in life (e.g. assertiveness and delaying gratification) are also attributed with a wide range of health outcomes. People who are driven to do so can often derive their own health benefits from inner qualities they possess. i.e. take up initiative to live a life that promotes healthier outcome Another useful concept is the ‘sense of coherence’ – the ability of the individual to make sense of the world around them in a manner that allows them to act purposefully. This could correlate with the attainment of self-actualization as modeled in Maslow’s hierarchy of individual needs and describes the very summit of ‘health’ attainment. HEALTH RELATED BEHAVIOURS Importance of smoking, alcohol, food, exercise, sexual behavior, ad drug taking to health outcomes. HABITUS Class-dependent. Oversimplifying, an individual is brought up to consider a certain way of eating, talking, walking, and seeking entertainment (among others) as ‘natural’. It is ‘natural’ as it is part of their habitus – their environment. People have the capacity to change their lifestyles so long as they have the motivation to do so, however, changes that do occur will tend to be in accordance with their underlying habitus. Bluntly, healthy eating, exercise, learning to relax, and a while range of similar behaviors are less likely to be part of the habitus or disposition of less advantageous groups; in general,

groups of high cultural or educational capital are able to practice a key form of social distinction in contemporary society. LEVEL 2: THE COMMUNITY FAMILY FRIENDS AND ACQUAINTANCES The family context is important for health. In the early years, security and consistency are vital. Findings show that children who are subject to adverse experiences in childhood are much more vulnerable during adolescence and adulthood. These adverse effects include sexual, physical, and verbal abuse, drugs and alcohol misuse, and a lack of love and encouragement. Being loved unconditionally and supported by parents and others builds resilience in young people. The family is also important in that it creates behavior. Good parenting is seen as a vital foundation for good health – health damaging behaviors usually replicate themselves: a child brought up in a household in which either parent is a smoker and whose friendship group also smoke is much more likely to smoke themselves – therefore a key target is to CHANGE THE INFLUENCE OF FAMILY AND FRIENDS THE LOCAL COMMUNITY People in the local community beyond family and friends also have an influence on the development of personal traits and health related behaviors. The local community creates a sense of what is normal and expected. Support in schools, the workplace, and local organization’s is health enhancing; its absence can damage health. A community has financial capital (money) and physical capital (buildings and facilities) that are of value to everyone in the community. Social capital concerns the value of social networks that bind similar people together and bridge between more diverse people. Thus, a community where people help each other out and there are high levels of trust between people is generally a healthier place to live – because it has higher social capital. A community with higher social capital has good will and trust between individuals, which serves as a resource that enhances life and therefore makes health and wellbeing more likely to follow – illustrated as a level of ‘need’ in Maslow’s need hierarchy.

LEVEL 3: THE ENVIRONMENT PHYSICAL ENVIRONMENT Clean water, clean air, and other aspects of a good physical environment are fundamental to health; in their absence, life expectancy will fall dramatically. Evidence exists to suggest vehicle and industrial emissions cause substantial premature death, but is primarily through effects on those who already have respiratory disease. THE BUILT ENVIRONMENT Refers to buildings, roads, and infrastructure. Housing has an impact on health: hosing of very poor quality negatively impacts on health, psychologically, and in terms of disease through effects of damp or rot, perhaps. The standard of housing has been raised so high that further investment in housing improvement will give little benefit towards health improvement. The ill-health associated with poor housing does not always arise directly from the building itself, but is a function of the interaction of all the determinants of health acting together in areas of deprivation. The building is only part of the ecology of poor health.

THE BIOLOGICAL ENVIRONMENT Emergence of new disease and infection including HIV, hepatitis C, and E. Coli. Infections remain a relatively minor source of increased mortality on a population basis, however they pose a risk to population health. THE CULTURAL ENVIRONMENT Culture helps to create a total way of life for people and provides a way of thinking, feeling, and believing. Culture defines a map that orientates the way we live and is an important determinant of health. Culture can influence health related behaviors such as smoking, drinking, exercise, and sexual activity. Our culture helps o condition what is normative in almost all health related behaviors. Media also serves as an important determinant of health and is critical in influencing the forming of ideas, values, and societal norms. THE ECOSYSTEM Effects of global warming and the influence it has on human populations. Climate change is arguable the worlds most important environmental health issue as its progression determines activity such as droughts and floods. There is also huge economic cost and prosperity damage and impact on agriculture and food supply Climate change will also include the geographical range of some vector-borne infectious diseases such as malaria. THE ECONOMIC ENVIRONMENT Analysis of gross national product shows that poor countries often have poor levels of health; bur that a modest improvement of GNP of a poor country often brings quite a marked health improvements. However once a country becomes sufficiently wealthy, additional improvements in GNP are not associated with equivalent improvements in life expectancy. Additional wealth given to those who are already wealthy has minimal impact on health status, while the same amount of health, if given to those who are poorer, results in greater health gain.

THE LIFE COURSE PRE-BIRTH Antenatal care is a key determinant of material health, but by extension, has a profound impact on the subsequent health of the baby. Pre-birth maternal nutrition can play and important role and observations have been made that demonstrate babies subjected to certain factors in-utero resulting in low birth weight seemed to be ‘programmed’ to develop hypertension and diabetes in adult life (BARKER HYPOTHESIS) Smoking during pregnancy is a significant risk factor, the main impact of which is through lower birth weight. Smoking also compromises the childs neurological development during pregnancy. Alcohol also presents risks (FAS) due to its ability to cross the placenta. EARLY YEARS Attachment theory – suggests that early attachment of the child to a principal carer is crucial to correct neurological, social, and emotional development. Failure of attachment can have far reaching effects on behaviors such as violence and the development of emotional intelligence – necessitates the need for good parenting and the provision of a home environment that is safe and promotes all aspects of the child’s development. Nutrition is also a key component – beginning with breast feeding and then evolving into a healthy age-specific diet. Critical periods are a phase in the life span during which an organism has heightened sensitivity to exogenous stimuli that are compulsory for the development of a particular skill. If an individual does not receive a stimulus during the time of this critical period, it may be difficult, ultimately unsuccessful, or impossible, to develop some functions in later life. Critical windows are seen for the acquisition of language, and the development of vision and auditory processing. – E.g. seen in feral children ADOLESCENCE Many health related behaviors are influenced by risk-taking patterns during this phase of development. Adolescence is a bio-psycho-social phenomenon ADULT LIFE All determinants of health and socioeconomic gradient by this time interact with the factors from earlier in the life course to create and destroy health. Working aged adults are influenced by their social position and relationship status. Late middle life sees the emergence of chronic disease and the need to develop and/ or maintain functional capacity in the face of continuing disease. Health status is therefore influenced by the interaction and accumulation of determinants of health over the life course.