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NURS 287
Amanda O' Rae

1 NURS 287 September 18, 3013 (Week 2) How do we address inequalities?  Use the Population Health Approach: achieves population health by addressing the influences on health called SEDoH Understanding Health – what do we need to understand the influences on health?  Who, what, when, why?  Health patterns – through a health indicator  Cause of disease and problems  Risk factors for disease and problems  Factors that promote health “protective factors”  Population level data  Across life span, life trajectory  Within and between groups (First Nation, homeless, gender, socioeconomic status) Defining groups:  Marginalized groups: experience fewer privileges, rights, access and power as a result of their position within a political system or a social structure  Vulnerable groups: are more likely than other populations to have adverse health outcomes Epidemiology  “study of the occurrence and distribution of health-related states or events in specified populations”  “to determine the extent of a disease process or health challenge and its final effects on a population we must collect data and analyze and interpret  “study of distribution and determinants of disease frequency in human population in order to control health problems”  Looks at: health states and events  Factors influencing health states and events  The distribution of disease  Looking at the epidemiologic triangle:  Agent: force that prolongs, bacteria, stimulus, determinants that exist in the environment  Environment: factors that promote expose of the agent to the host  Host: that which is impacted by the agent Association Vs. Causation  PH is focused on understanding and addressing the factors that underlie illness or good health  Understanding the ‘how and why’ of disease/health problems  Determining the relationship between a stressor (factors)  Association: reasonable evidence that a connection exists between stressor and a disease  Causation: when relationship has been confirmed beyond doubt  Synergism: the whole is more than the sum of its’ parts o How does ‘synergism’ relate to the PH approach? – Trying to get to the root of the problem Purpose of Epidemiology:  Determine extent of disease in a population  Identify patterns and trends in disease occurrence  Identify causes of disease and risk factors Health Indicators: biological, psychosocial, disease frequency and outcomes, survival, morbidity and mortality  Psychosocial: quality of life, self-perception etc.  Biophysical: blood pressure, exposure 2 Learning Activity: Using Epidemiology -What population does this health indicator relate to? -What does this health indicators infer about this populations health status? Common measure of disease frequency (indicators of health status):  Mortality (death), survival (prognosis), morbidity Mortality Rates – total number of deaths from specific cause/ entire population per year  Infant mortality rate –number of deaths between birth and one year of age/ number of live births during the same time interval  Maternal mortality rates – number of deaths due to pregnancy and childbirth during a certain period/number of live births during the same interval of time Survival Rates “How bas is it?” or “what is the prognosis?” – explained through survival rates  Life expectancy: average age of death of population  Case Fatality: number of deaths from a certain disease/number of cases of that disease within the same period of time Morbidity – describes illness or experiences of health over time. Can be used to describe how susceptible a population is. Two types:  Incidence rate – occurrence of a new disease case o (# of new cases of a disease occurring in a given population during the defined period of time) / (# of persons exposed to risk of developing the disease during that period of time)  Prevalence - measure the existence of a common disease case/ prevalence is the frequency of all current cases of disease, old and new in a specified population o (# of new and old cases/total population) o ** Prevalence is usually presented as proportion of the population even though time is involved o Two types of prevalence: point prevalence and period prevalence o Point prevalence – the frequency of all current cases at a given instant in time, it is a census type of measure. (In contrast to incidence rates, which measure events, point prevalence rates are measures o what exists or prevails) o Period prevalence – expresses the total number of cases of disease known to have existed at some time during specified period of time o Mid-Interval population: (population at the beginning of the time period + population at he end of the time period) /2 Little example: Incidence: the rain arriving Prevalence: the water in the puddle, new and old Period prevalence: during the period Point prevalence: at one point in time Water draining away into the soil or into drains reduces the puddle just as recover or death reduces the number of patients with a problem. Learning Activity: Epidemiology Measures Determine which epidemiological measure you selected. Which type is it? 6 Functions of Public Health  Health Protection  Disease and Injury Prevention  Health Promotion  Emergency Preparedness and Response 3  Health Surveillance  Population Health Assessment A daycare has 15 children. During the first week of April there were 3 new cases of Varicella followed by 4 new cases in the second week of April. Calculate the Incidence rate of Varicella in the first week of April. Answer: 3/15 =0.2 cases in the first week by April = 0.2 x 1000 = 200 cases of Varicella (per 1000 per first week of April) Using the Epidemiological Process  The problem solving process  The diagnostic process  The scientific process  Quality improvement cycle  Surveillance Case Series: Counts of selected variables within a specific population  Often look at variable of interest in which is a hypotheses for a risk factor/cause for disease Cross-sectional: snapshots of the present (prevalence studies)  Often used to collect a baseline  Could be collected several times over a period of time to determine effectiveness of an interventional (measure change) Case-control: individuals with disease are matched with individuals with similar characteristics but who do not have the disease  To compare common factors/differences between two populations with the potential to identify a risk factor for the disease Cohort Studies: an examination of individual histories of a group of people with a particular disease to determine common factor shared and differences  Retrospective and prospective Randomized Control Study )RCT): individuals are randomly assigned to the group that receives the treatment or to the group that does not Learning Activity: According to your data source, can you tell how your health indicator was obtained? Hint: what type of research was performed? Surveillance: the constant watching or monitoring of diseases to assess patterns and quickly identify events that do not fit the pattern.  Process: data collection, analysis and interpretation, communication of findings  Types of surveillance data:  Mandatory reporting of communicable diseases  Biological risk factors  Occurrence of health events; accidents, injury  Incidence and prevalence of diseases  Determining population and subpopulation impacts by disease  An Example: “Screening”- the presumptive identification of an unrecognized disease or defeat by the application of tests or other procedures Types: Mass (whole population) & Selective (high risk groups)  Screening is NOT diagnostic  These tests must be valid, sensitivity, reliable, yield results Knowledge Translation – to fill in the gaps between basic science research, clinical research and clinical practice and make sure this translation of knowledge is being made. These gaps lead to practice variation. 4 Mental Illness – “characterized by alterations in thinking, mood, or behavior associated with significant distress and impaired functioning” Mood disorders  Major depression – one or more depressive episode which includes a depressed mood or loss of interest or pleasure in nearly all activities for at least 2 weeks. Four of the seven additional symptoms must also be present. o What might you observe? o Reduced intensity of emotional expression o Absent or nearly absent affective expression o Inappropriate expression of mood o Varied, rapid, and abrupt shifts is affective expression o Mild reduction in range or intensity of emotional expression  Bipolar disorders – distinguished from depressive disorder by the occurrence of manic episodes o Decreased inhibition, participation in risky activities or new endeavors o Impulsivity and distractibility, lack of concentration o Lack of restraint in expression of feelings o Irritable mood o Increased energy, decreased need for sleep o Manic Episodes – euphoria  Anxiety disorders – a collection of disorders but all have anxiety symptoms o Edgy, impatient, nervous, dazed, self-conscious, hyper vigilant, inhibited, avoidance, restlessness Causes: a complex interplay of genetic, biological, personality and environmental factors causes mental illnesses. Risk Factors include: substance abuse, chronic diseases, stress, family history of mental illness o Depression in seniors is prevalent but harder to diagnose o Suicide account for 24% of all deaths among 15-24 year olds and 16% among 25-44 year olds o Suicide rates among the aboriginal population are 3 to 6 times the rate of the national average o Approximately 10-20% of Canadian youth are affected by a mental illness or disorder – the single most disabling group of disorders worldwide Health Canada Recommendations: o Early identification and treatment programs that address the predisposing factors o Crisis intervention that addresses the precipitating factors o Treatment programs that address the contributing factors o Mental health promotion programs that address the protective factors 5 September 25, 2013 (Week 3) Communicable Disease – kills more than 14 million people each year, mainly in the developing world  Our environment has allowed infectious disease to evolve and infect us ‘differently’  Outbreak: when the new cases of a disease exceed the normal occurrence during a given period of time eg. Seasonal Epidemic (Influenza)  Endemic: the steady presence of a disease in a defined geographic area or population  Pandemic: when a disease spread affects a large number of populations worldwide  Most significant achievement in North America for preventative medicine?  Vaccines!! Vaccines:  Purpose: Respond to foreign proteins (antigens) in the body with intention to resist infection  Acquired Immunity: o Active: host produces antibodies in response to an antigen (Natural or Artificial) o Passive: host receives antibodies produces by another source (Natural or Artificial)  Benefits: o Prevention of morbidity and mortality in those vaccinated/ in those around them (herd immunity) o Benefit to health and savings in direct medical care costs Influenza  RNA virus  Types: Influenza A, B, and C  Type A has multiple subtypes – typing is based on types of surface protein o Eg. H3N2, H1N1 (seasonal), H1N1 (pandemic)  Influenza B and C do not have subtypes  Influenza B can be classified in two antigenically distinct lineages: Yamagata and Victoria  Influenza A and B are seasonal epidemics – these two are included in seasonal vaccines  Transmission – spread via droplets or contact with respiratory secretions of infected individuals  Symptoms – fever, respiratory illness, headache, myalgia, and malaise  Infectivity – 1 day before symptoms develop and 5 days after becoming  Contagious – depends on age and health of person  Complications of Influenza: pneumonia, ear & sinus infections, dehydration, worsening of chronic medical conditions  High Risk Group o Adults > 56 & anyone living in long term care facilities o Children <2 o Persons with chronic illness o Immunosuppressed individuals o Women who are pregnant or postpartum (within 2 weeks of delivery) o First Nations o Obese Individuals  Influenza causes about 20,000 hospitalizations and 4,000 deaths in Canada each year  Alberta – about 1500 cases of influenza/year with up to 500 hospitalizations and 30 deaths  Effectiveness depends on the similarity between vaccine strains and the strains in circulation during influenza season o With a good “match,” influenza immunization prevents disease in 70 to 90% of healthy individuals  Alberta Health funds a Universal Influenza Immunization Program  All people 6 months of age and older who live, work or go to school in Alberta are eligible for vaccine at no charge 6  WHO provides a recommendation on the strains to be included in the influenza vaccine for the northern hemisphere. They select 2 – A and 1 – B.  Flu Season: October to early Spring  Included in this year: o A/California/7/2009 (H1N1)pdm09 – like virus o A/Victoria/361/2011 (H3N2) – like virus o B/Massachusetts/2/2012 – like virus (B Yamagata lineage) Population Health Approach: Influenza  Measure and Analyze health status and SEDoH?  Multiple Strategies – policy, health promotion  Inter-sectoral Collaboration? Multi levels? – Community action  Create supportive Environments? Develop personal skills? – Upstream, Reduce inequalities Pneumococcal disease – acute and serious illness caused by the bacterium Streptococcus pneumonia  Leads to bacteremia, meningitis, bacterial pneumonia  Spread through droplets from the nose or mouth by sneezing, coughing, talking  Infants and children – pneumococcal 13 at 2,4, and 12 months and 4-6 years of age  Adults – pneumococcal 23 Every communicable disease has unique characteristics that modify how we manage the disease Diphtheria  2 forms: Respiratory, Systemic  Presents itself like a lot of other illnesses (the common cold)  Transmitted though respiratory droplets mostly during dry cold months associated also with crowded conditions  If left untreated, leads to multi-organ toxicity: heart, nerve, and renal failure Tetanus Toxin  Caused by release of the tetanus toxin, found commonly in soil and environment  Tetanus toxin prevents release of inhibitory neurotransmitters. Leads to muscle contractions, lock jaw.  In the developing world, tetanus continues to be endemic  Boosters are required every 10 years Pertussis (whooping cough)  Characterized by 3 stages: 1. Catarrhal stage: Lasts 7-10 days; clinically indistinguishable from a viral upper respiratory tract infection 2. Paroxysmal stage: 1-6-10 weeks; bursts of coughing fits followed by long inspiratory “whoop” - Paroxysmal stage continued… in bad cases there may be up to 30-40 episodes/24h 3. Convalescent phase (after 2-3 months) – coughing gradually improves  Serious complications: most often in infants. There are serious side effects that lead to hospitalization and death.  Spread through droplets in the air from an infected person’s coughs or sneezes.  Symptoms may appear between 7-10 days after exposure to an infected person, symptoms may be delayed for up to 20 days. Pertussis is most contagious during the first 2 weeks when symptoms resemble those of a common cold. Why are the 3 stages of Pertussis infection significant to the management of the disease? 7  Adults are not up to date on their at Pertussis vaccines and so, they are the ones who are spreading it to children because some babies are too young to be vaccinated. Neisseria Meningitidis  Colonizes in the oropharynx  Transmitted via direct contact with nasal secretions  If recognized, can be treated with antibiotics to prevent complications Measles  Can cause blindness, swelling of the brain  Spread through close contact with an infected person. Affects all age groups.  Measles, Mumps, Rubella, Varicella (MMRV) – given all together to prevent the Varicella from causing Shingles in adults Hepatitis B (HBV)  Transmitted via blood and body fluids  Pullback because people paired it with sex and drugs HPV  Causes cervical cancer  70% of people carry this virus Public Perceptions – review scenarios in week 3 slides Health Belief Model  Perceived susceptibility and severity (threat)  Perceived benefits  Perceived barriers or costs perceived self-efficiency Roles of Public Health in Management  Collect, analyze, and communicate cases of reported CD  CD support, advice by physicians  Identification of potential contacts  Provision of preventative vaccine  Outbreak control 8 October 2, 2013 (Week 4)  Today, we will be talking about SEDoH Socio-Ecological: an individual’s interaction with their social circumstances and external environment Determinants of health: factors that influence the health status of individuals, communities and society as a whole Income: Socioeconomic Status (SES) – income, education, occupation How do we measure income?  LICO – the low-income cut-offs (LICOs) are income thresholds below which a family is expected to spend 20 percent points more than the average family on food, shelter and clothing. Is LICO Permanent?  People are likely to only live in that category for one year, it fluctuates.  Generally, it is lone parent families, children, seniors etc.  Prevalence of low income among immigrants to Canada decreases over time spend in Canada. What is core housing?  Affordable, Adequate, Suitable  In Northern Canada impact of low income is exacerbated – causing health implications  Higher cost of living  Crowded dwellings  In-Need of repair What is poverty?  Social disparities created by income and opportunity  Material poverty vs. Social Poverty ($ vs. belonging)  3 pathways of poverty:  Materialist factors  Neomaterialist factors  Processes of social comparisons and social distance The Poverty Experience (Ruetter, Stewart et al. (2009))  Social Hierarchy – based on income, economic and political power  Control Power – the more in control you feel the less stress you experience  Society’s Perceptions – societies perceptions and the hierarchy of perception and ‘not in my backyard’ weakened social cohesion  Poverty Stigma o Social Exclusion  Decreased opportunities to participate in life  Weakened social cohesion and self concept  Isolate Review: Population Health Approach  Goal: Reduce Inequalities  Focus: on the Inter-related conditions and factors that influence health  Strategy: All levels, all sectors (not just health care) Human capital vs. Social capital Human capital: cognitive and verbal ability may predict someone’s potential to participate in workforce Social capital: Healthy citizens that are engaged in their communities, creating social cohesion are more productive and have better overall wellbeing  How do you measure social cohesion? Participation in events, ask peoples’ perceptions of their community? How supported do you feel? How do we measure education? 9  Level of educational attainment  Literacy  “Literacy means more than knowing how to red, write or calculate. It involves understanding and being able to use the information required to function effectively.”  Literacy Levels – Level 1,2,3,4,5 - 1=illiterate 5=complexly literate  Health Literacy  “Ability to access, understand, evaluate and communicate information as a way to promote, maintain, and improve health in a variety of settings across the life-course.”  Directly affects  Incorrect medication use  Failure to comply with medical instructions  “Basic literacy has not declined, but the demands on people to understand health information has increased” (Eg. Change of health abbreviation)  Seniors literacy matters because of chronic disease & multiple medications  Immigrants score lower literacy levels  Rural populations – unique subgroups including religious groups & aboriginal groups  Measuring literacy skills on an individual level  Frequently missed appointment  Bringing family members along etc. New scales to measure Health Literacy  Health Promotion: the ability to enhance and maintain health  Health Protection: the ability to safeguard individual or community health  Disease Prevention: the ability to take prevention measures and engage in early detection  Health-Care Maintenance: the ability to seek and form partnership with health-care providers  System navigation: the ability to understand and the access needed health services How do the
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