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Associate Professor Jane Turner

GLOBAL AND COMMUNITY MEDICINE LECTURES 1. Introduction 2. Geriatric Giants 3. The Public Health Approach 4. Burden of Disease in Australia 5. Public Health Practice 3: Health, Illness and disease 6. Social Organisation of Health Care 1: Stigma and 7. Assessment & Risk 1: Sources of epidemiological 8. Assessment & Risk 3:Environmental 9. Assessment & Risk 4: Social Determinants of Health 10.Community Interventions 1 11.Public and Clinical Responses to Smoking 12.Community Interventions 2 13.Community Interventions 3 14.Health Services 1 15.Health Services 2 16.Health Services 3 17.Social Organisation of Health Care 3 18.Public Health Practice 4 LEARNING OBJECTIVES 1. Discuss the main elements of a public health approach to addressing community health problems, and their relevance to community medicine 2. Describe and analyse a range of methods for public health assessment and understanding of risk, and apply from a community medicine perspective 3. Describe and analyse the roles and approaches used in community health interventions, the management and control of disease outbreaks, and disaster management 4. Evaluate the healthcare system including the three levels of healthcare, the health financing mechanisms and quality measurements 5. Identify the social organisation of healthcare and outline its effect on patients, their families and other users, and the benefits of multidisciplinary approaches to healthcare in the community CHECKLIST Wk Topic Lecture Compulsary Online Reading Tute 2 The Public Health Approach   NA 3 Burden of Disease in Australia    4 Health, Illness and disease  5 Stigma and Implications  6 A&R1: Sources of Epidemiological Data  7 A&R2: Measures and Causality  8 A&R3: Environmental Exposures  9 A&R4: Social Determinants of Health  10 Community Interventions 1: Public Hlth  11 Community Interventions 2: Outbreaks  12 Community Interventions 3: Disasters  13 Health Services 1: Health Systems  14 Health Services 2  15 Health Services 3  16 Social Organisation of Health Care 2: carers  17 Public Health Practice 4   18 Social Organisation of Health Care 2 – Interdisciplinary Care MODULE 1: PUBLIC HEALTH PRINCIPLES AND PRACTICE MODULE AIMS 1. Key steps of the public health approach used to solve a public health problem 2. Mortality, morbidity and disability in Australia 3. Health, illness and disease 4. The relevance of public health methods and perspectives for community medicine practice INTRODUCTION Community Health: Public health services emphasizing preventative medicine and epidemiology for members of a given community or region Public Health: The science and art of preventing disease, prolonging life and promoting health through the organized efforts of society Population Health: Overall health assessment in populations and design of appropriate interventions Rudolf Virchow “Medicine is a social science, and politics nothing but medicine at a Values of Public Health larger scale”  Emphasis on collective responsibilities  Focus on whole populations  Human health & disease are  Focus on determinants of health and primary the embodiment of the prevention successes and failures of society as a whole, and the  Concern for improvement of the health of one way to improve health disadvantaged groups (equity) and reduce disease is by  Multi-disciplinary approach changing society  The use of scientific evidence as a basis of action THE PUBLIC HEALTH APPROACH TO PROBLEM SOLVING Key steps 1. Assessing the problem  What exactly is the problem? Scoping  What do we know?  Who are knowledgeable?  Views on problem and causes  Controversies?  Why is this on the agenda?  Who do we need to involve?  Epidemiology: what is, what will be, who? 2. Identifying the determinants  Proximal o individual level o tangible, good evidence, but o often small effects and may be resistant to change  Distal / upstream o population/societal level o large effects on many health outcomes, but o more uncertainty and often too big to change  Causal pathways or networks 3. Planning the interventions  Ideally, interventions are o clear and implementable o supported o efficient 4. Implementing the interventions  Process Management  Communication 5. Evaluation  Should have been planned from the start  Types o Process: did all go according to plan, side-effects evident o Output (e.g. number of people reached) o Outcome (e.g. behaviour change BURDEN OF DISEASE IN AUSTRALIA  Burden of disease: size and distribution of health problems  Cost-effectiveness: costs and impacts of health interventions Cost of health services is increasing due to  New expensive technologies  Ageing populations  Greater demands from ‘consumers’ The goals of our health system is to  Overall, improve the health of the population  Prevent early death  Better quality of life  More equal distribution of health Measuring health outcomes  In order to calculate the burden of disease and cost-effectiveness of health interventions, there must be quantitative measures  Mortality, incidence and prevalence can not be compared  Disability-adjusted Life year (DALY) quantifies health loss o 1 DALY = 1 year lost of healthy life o DALY = YLL + YLD o Years of Life Lost (YLL) = Future stream of life lost due to premature mortality base of life expectancy o Years Lived with Disability (YLD) = future loss of ‘healthy’ life arising from new cases of disabling conditions  Life expectancy o Determined from the registration of deaths in Why does Australia have a Australia o Australia 3 best life expectancy in the world good LE and HALE?  Low smoking prevalence Males Females  ‘Public Health obedient’ population Non-indigenous 80 84  Universal access to health care (2009) Indigenous (2005-07) 68.5 (11.5 gap) 74.3 (9.7 gap)  Health immigrant effect  Health adjusted life expectancy: estimates of the number of healthy years (free from disability or disease) that a person born in a particular year can expect to live based on current trends in deaths and disease patterns. o The average number of years spent in unhealthy states is subtracted from the overall life expectancy, taking into account the relative severity of such states. o At birth in 2003 Males: 70.6, Females: 75.2 Leading causes of mortality (YLL) Leading causes of disability (YLD) Cause % of all YLL Cause % of all YLL 1. Ischaemic heart disease 16.8 1. Anxiety & Depression 14.1 2. Stroke 6.6 2. Type 2 Diabetes 7.8 3. Lung Cancer 6.5 3. Dementia 5.2 4. Colorectal cancer 4.0 4. Adult onset hearing loss 4.8 5. Suicide 3.9 5. Asthma 4.4 6. COPD 3.7 6. Ischaemic Heart Disease 3.3 7. Breast Cancer 3.1 7. COPD 2.9 8. Road traffic accidents 2.8 8. Osteoarthritis 2.5 9. Diabetes 2.0 9. Stroke 2.5 10. Kidney Failure 1.9 10. Personality Disorders 2.4 Leading causes of mortality & Disability (DALYs) Major reductions in mortality and disability from Cause % of total  Tobacco-related disease 1. Ischaemic heart disease 10.0  Cardiovascular disease  Injuries 2. Anxiety & Depression 7.3 3. Diabetes 5.0 4. Stroke 4.5 5. Dementia 3.6 6. Lung Cancer 3.4 7. COPD 3.3 8. Hearing Loss 2.5 9. Colorectal Cancer 2.4 10. Asthma 2.4 HEALTH, SICKNESS AND HEALING Biopsychosocial model  Given prominence by George Engel in the late 1970s.  Engel argued that the medical profession needed to broaden its focus beyond the doctor- patient dyad as he believed the patient’s social context influenced his/her health and illness trajectories. Society and Disease  Ackerknecht (1947) a physician and pioneer in the field of medical anthropology wrote, ‘Disease and its treatment are only in the abstract biological processes. Actually such facts as whether a person gets sick at all, what kind of disease he acquires and what kind of treatment he receives depend largely on social factors’ (in Scotch 1963:30). Society  A system of social life such as a political state supported by national institutions, common cultural practices and values, and economic organization.  Society is constructed from social groupings of individuals who engage in social relationships and collective action. Cultures  System of beliefs, values and behavioural norms found in every society Illness  Illness is the social and cultural construction of sickness  Illness is a subjective interpretation of sickness  Ideas about illness and what to do when ill vary with culture  Biomedicine often disregards illness problems because disease is considered to be the disorder. Illness problems are the difficulties in living resulting from sickness which are usually view for the patient as the entire disorder Disease  Key concept within Western scientific biomedicine  Defined as: pathological process with the development of increasingly sophisticated taxonomies of both body and mind based on pathophysiology and psychological disorder or psychiatric dysfunction  Clinical practitioners learn to translate the individual’s experience of feeling sick and believing they are ill, into signs and symptoms that are evidence of disease o Objective testing (laboratory based) o Diagnosis of named disease is a ‘burden of proof’ process  Biomedicine o Has notion of ‘cure’ o Provides explanantory theories for disease causation e.g. germ theory, gene expression o Has philosophical separation of body and mind (body-mind dualism) Health  Interpretations o Absence of disease o Not ill o Not sick o The ability to function normally o State of fitness  WHO 1974: Health is not merely the absence of disease, but a state of complete physical, mental, spiritual and social well-being  WHO 1984: The extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs and on the other hand, to change or cope with the environment. Health is therefore seen as a resource for everyday life, not the objective of living: it is a positive concept emphasizing social and personal resources as well as physical capabilities  Ottawa Charter 1986: Health is a resource for everyday life, not the object of living  Dominant popular culture o Health as the absence of disease ( shaped by the dominant biomedical paradigm within Western societies) o Well-being interpreted as repeated dieting, running marathons, abstaining from particular foods, etc Indigenous Australian Concepts of health  Holistic including land, community and spirit  Deeply dependent on harmonious social relationships  Impact of colonization on community  Impact of the struggle to define post-colonial Aboriginality These views influenced Aboriginal help-seeking in the 1980s  Late presentation of severe symptoms  Presentation of more complicated illness and/or injury, sometimes exacerbated by alcoholic behavior  Interpreted as careless attitude to treatment and health maintenance  Exacerbated by communication difficulties and problems with physical examination Significant factors in achieving individual health  Autonomy  Opportunities for social engagement and participation  Social exclusion – prevents people from participation in society and accessing standards of living  Access to medical services Medical pluralism  Ethno-medical system o Historically: indigenous system of medicine including etiology of sickness and illness, practices and treatment practitioners i.e. the health care systems of non-Western, non- scientific others RESEARCH METHODS AND COMMUNITY MEDICINE PRACTICE Learning Objectives  Understand the contribution of public health research methods to population health  To Consider and reflect on case studies and research questions in their applicability to community medicine practice Qualitative Methods  Largely focused on textual analysis  Often local or small studies/populations  Usually provides ideographic rather than nomothetic explanations highlighting aspects of an individual phenomenon rather than proposing law like or universal explanations  Can consist of interviews, observations, ethnography or analysis of textual data  Often accompany qualitative methods to determine meaning behind patterns MODULE 1 SUMMARY Key steps of the public health approach used to solve a public health problem 1. Assessing the problem 2. Identifying the determinants 3. Planning the interventions 4. Implementing the interventions 5. Evaluation Mortality, morbidity and disability in Australia  DALY (quantitative measure of health loss) = YLL + YLD  Most DALY’s attributed to (1) Ishcaemic Heart Disease (2) Anxiety and depression (3) Diabetes  Australia has good LE and HALE due to low smoking prevalence, ‘Public Health’ obedience, universal access to healthcare and the ‘immigrant effect’ Health, sickness and disease  Illness: difficulties in living arising from being sick, subjective interpretation of sickness. MODULE 2: PUBLIC HEALTH ASSESSMENT AND UNDERSTANDING RISK MODULE AIMS  Epidemiological data sources  Disease frequency and risk  The epidemiological triad  Environmental hazards  Social determinants  Individuals and populations; ‘mass’ and ‘high risk’ prevention strategies. SOURCES OF EPIDEMIOLOGICAL DATA Learning Objectives 1. Define routine data, give example, name some potential uses and explain their strengths and weaknesses for research 2. Describe how routine mortality data in Australia are collected and identify the underlying cause of mortality in case story 3. Interpret incidence and mortality rates and explain the effect of direct age-standardisation 4. Critique, at a basic level, the usefulness of sources of data for specified research purposes and apply the concepts of selection bias and reporting bias Routine Data  Definition: data that are recorded without any specific research question in mind  Examples o Health outcomes data e.g deaths, hospital admission and primary care consultations or prescriptions, levels of well being from national surveys o Exposures and health determinant data e.g. smoking, air pollution, crime statistics o Disease prevention data e.g. screening uptake o Demographic data e.g. Census population counts o Geographical data e.g. health authority boundaries, location of GP practices  Uses o Monitor disease frequency over geography and time o Identify problems and give clues to their causes o Determine health care resource use o Allocate health care resources o Explore impact of health care services Advantages of Routine Data Disadvantages of Routine Data  Cheaper and quicker than collecting your  Availability own data  Varying reliability and quality  Potentially more accurate than self-  Completeness (selective recording, reported data (i.e. specific medial data) missing data, undefined population)  Population-based  Ecological fallacy  Longitudinal vs cross-sectional Routine Mortality Data  The identification of individual death events in a defined population,  Widely available and commonly used for priority setting in health and health program, monitoring and evaluation  Unambiguous and are generally easier to obtain and more reliable than morbidity data  Sources o Vital registration systems (complete or sample)  gold standard o Household surveys o Censuses o Surveillance systems Vital Registration Systems  Legislative requirement in most countries including Australia that o Vital events, such as births and deaths, are registered o A medical practioner completes a death certificate whenever anybody dies  Death certificate contains immediate cause of death, intermediate or underlying conditions (antecedent causes) and other significant conditions Morbidity Types of Data A. Disease registers o issues with completeness, cost, data quality and population representation? B. Population surveys o tend to be representative (selection bias) o can have measurement bias due to self-reporting (e.g. drug use, weight, height) C. Hospital or medical practice records o good for conditions that lead to admission o More about service than about disease frequency and severity o Barriers are ethical approvals, legal, privacy, confidentiality and jurisdictional differences D. Epidemiological studies o Longitudinal studies: natural history of disease o Studies of chronic disabilities o Studies of particular population groups o Issues with generalization of studies to populations E. Medicare: consultations and drugs F. Industrial, school, armed forces, insurance, etc. CAUSALITY, ENVIRONMENT AND MEASURES OF DISEASE FREQUENCY Learning Objectives  Appreciation of the effects of the wider environment on disease incidence  Identification of necessary, component and sufficient causes of disease  The difference between measures of incidence and prevalence  The difference between relative and absolute measures of incidence  The important of standardizing incidence measures in comparisons Causality  An event, condition or characteristic (or combination of these factors) that plays an essential role in producing disease in a person  A cause must proceed a disease  Rarely a single event or exposure would cases a disease, usually a set of component causes.  Sufficient Cause: a factor or combination of factor that will inevitably cause disease  Necessary Cause: any sufficient cause or component of a sufficient cause required for development of disease  Component Cause: any component of a sufficient cause that is not an absolute requirement for the development of disease Evaluating Causation  Is an association due to chance? – statistical tests, p values and 95% confidence intervals  Is an association due to bias in study design or the sample? – selection bias, measurement bias  Is the association due to uncontrolled confounding? – other causal factors no considered Measurements Measurement Meaning Formula Prevalence Number of cases in population at a given time Number of people in the population Cumulative Number of new cases over a period Incidence/Risk Number of people at risk at start of the period Incidence Rate Number of new cases Number of person years at risk Relative Risk (RR) Rate Ratio – Using the Incidence in exposed group Incidence Rate Incidence in unexposed group Risk Ratio – Using the cumulative incidence Odds Ratio (OR) Attributable Risk/Risk The excess risk due to the Incidence exposed – Incidence in unexposed Difference (AR) exposure Age Standardized Rate Controls for differences in population age structure ENVIRONMENTAL EXPOSURES AND HEALTH CONSEQUENCES Health: The state of being free from illness of injury Environment:  The surrounding or conditions in which a person, animal or plant lives or operates  The setting or conditions in which a particular activity is carried on Greatest Environmental Health Threats  Population  Climate Change  Resource depletion/Loss of biodiversity  Environmental Health impacts Exposures Airborne Waterborne Foodborne Biometric Interaction  Particulates  Turbidity  Chemical  Venomous  Foamites  Bacteria compounds creatures  Chemical  Viruses  Bacteria  Radiation compounds  Chemical  Virus  Traffic injuries  Spores compounds  Prions  Drowning  Heavy metals  Metals  Heat Stroke  Minerals  Foreign Objects  Animal injuries  Asphyxiation  Electrocution  Burns and scalds  Falls and trips Cause Action/Intervention Routes of exposure Driving Forces: Population Environment and health as a  Ingestion growth mainstream activity in economic  development  Inhalation Pressure: Consumption and Achieve sustainability and  Dermal intake 1’  Injury waste release equitable patterns of consumption  and waste minimizing Environments State: Degraded ecosystems, Manage wastes and resources – less resources, pollution implement remediation activities,  Domestic  vector control  Travel  Occupation Exposure: infections, Substitute, engineer, educate, 2’  Institution toxification injury protect  Rehab   Recreation Effect: Well-being, morbidity, Prevent disability and death mortality through immunization, early diagnosis, treatment and 3’ rehabilitation Prevention 1. Primary Prevention:  Modify driving forces, pressures and state of the environment  Two categories o Health Promotion: e.g. education, information dissemination o Specific Protection: e.g. technology 2. Secondary Prevention  Prevent/limit exposure  Before the onset of disease 3. Tertiary Prevention  Dealing with the effects of disease  Preventing disability and death SOCIAL DETERMINANTS OF HEALTH Learning Objectives  Identify key social determinants (social, cultural, religious, economic and political) of health and demonstrate their link to health outcomes (health status, health-related activities and access to health care)  Recap on the social determinants and the role disadvantage plays in health  Explore the contributions of health care to the health of the disadvantaged  Consider ways to enhance health care access to reduced the risks experienced by disadvantaged groups Social Determinants of Health  SES Socio-economical Status  Early life  Poor men are 1.8 times more likely to die a premature death  Work and women 1.5 times  Food  Children are most vulnerable to cumulative risks of poor  Transport conditions; e.g. substandard housing, poor food, bad schools,  Social Support unsafe streets and chronic stress  Social exclusion and isolation  Unemployment  Nutrition  Drug use  Stress  The impacts are cumulative, leading to a pile-up of risk that influences adult health and can even affect the next generation WHO: Medical care can prolong survival after some serious disease, but the social and economic conditions that affect whether people become ill are more important for health gains in the population as a whole. Barriers to Preventative Care Patient Factors Practice/GP Factors System/Other Factors  Less participatory in  Availability – less GPs in low  Access to referral programs consultations, ask fewer SEs areas e.g. cost of transport, questions  Workload: demand of GPs location, availability,  Language, culture and and their time waiting time, delay in entry literacy  GP attitude to effectiveness into programs, coordination  Openness of patients to of referral services of entry and referral disclosure of risk factors  Access to the GP and bulk  Waiting time for public and barriers billing services  Knowledge and attitudes to  Funding for nurses to do  Workforce availability of health prevention GP based nurses  Priority given to health vs funding other priorities  Social factors, family stress, unemployment  Co-morbidities – e.g. depression, mobility  Study results have found that: o The ratio of GPs and specialists per head of population in disadvantaged areas is lower than in advantaged areas o GPs spend less time in consultations with patients from low SES areas o Drug treatment are systemically poorer for disadvantaged groups o Referral to specialists, psych services, etc are systemically poorer for disadvantaged groups o Pathology tests and immunisations lower o Lower SEs have fewer health checks o Lower levels of preventative care and education o GP perceptions of patients and consequences for maintaining equity o GP’s Medicalising social problems e.g. using psychotropic meds Strategies to reduce Risk  Longer consults to support complex chronic conditions  Relaying information and using strategies to increase patients’ health literacy to increase adherence  Identify and collect information on individual SES – done sensitively to avoid assumptions  Social prescribing – formal process of referring patients to relevant community supports and services MODULE 2 SUMMARY Measures of disease frequency  Prevalence = # cases in pop at given time ÷ # of people in population  Cumulative Incidence = # of new cases over a period ÷ # people at risk at start of period  RR = Incidence in exposed ÷ Incidence in unexposed Sources of Data  Routine Data: data that are recorded without any specific research question in mind  Types of Morbidity Data: 1. Disease Registers – issues with completeness, cost, quality and representation 2. Population surveys – subjective to selection and measurement biases 3. Hospital/medical practice records 4. Epidemiological studies 5. Medicare 6. Industrial, school, armed forces, insurance, etc Social Determinants of Health  SES  Early life  Work  Food  Transport  Social Support  Social exclusion and isolation  Unemployment  Nutrition  Drug use  Stress MODULE 3: COMMUNITY INTERVENTIONS MODULE AIMS 1. Primary, secondary and tertiary prevention 2. Health communication strategies 3. Managing disease outbreaks 4. Disaster prevention and management. 5. Vulnerable populations and health disparities PUBLIC HEALTH APPROACH TO INTERVENTIONS Learning Objectives  Describe the three levels of disease prevention  Understand the role of health promotion in reducing illness and improving the health status of individuals and populations through primary, secondary and tertiary prevention  Define health promotion and its component parts Health Promotion  Focus on prevention the causes and determinants of illness  Principles of attainment of population health 1. Focus on prevention 2. An understanding of the causes and determinants of illness 3. Evidence based practice 4. Community participation in decisions which affect health  Health promotion is performed by health promotion officers, child health nurses, teachers, town planners, governments, GPs, dentists, sport and recreation officers psychologists and the media Population Health Principles  Maintain or improve health of entire groups/populations  Reduced inequalities in health status between group  Good for the greatest numbers  Reach most at need groups, not just the well educated  Not concerned with individual cases  Consider wide range of determinants of health  Often involves small changes for many people Prevention Type Definition State of Health Effects on Examples targetted Health Primary To prevent the initial occurrence Healthy  Incidence of  Immunisation of an illness and to promote health Disease  Safe drinking water by  Wearing seat belt 1. Protect against disease  Sun protection and disability  Regular exercise 2. Health Promotion  Good nutrition Secondary To stop or slow an existing illness Asymptomatic  Prevalence of  BP screening to by early detection and appropriatebut at high riskDisease identify HTN treatment by  Glucose intolerance 1. Identify and detect disease screening to identify in early stages pre-diabetes 2. Prevent the spread of  Treatment of people communicable diseases with STIs  Policies keeping children with chicken pox away from school Tertiary To reduce the re-occurrence of Symptomatic  Complications chronic illness and improve and Disability quality of life for the sick by  Limit complications and disabilities  Reduce severity, progress of disease  Provide rehabilitation  Provide psychological support/coping strategies *Incidence: number of new cases in a specific period of time Prevalence: total number of cases at one point in time Example of Prevention strategies – Drug Use Type Primary Secondary Tertiary Aim Prevent use or drugs or Aimed at high risk groups to Aimed at people already delay the uptake intervene early to prevent suffering from a drug use the problem from occurring dependency and seeks to reduce harm to the individual and community Actions  School drug education  Responsible service of  Needle and syringe programs alcohol programs  Laws against illicit drug  Advertisements in pubs  Treatment/Rehab use interventions Example of Prevention Strategies – Cigarette Smoking Intervention Framework 1. Build Healthy public policy  Tax increases on the price of cigareetes (Ottawa Charter) 1. Build Healthy public policy  Illegal to sell tobacco to people < 18 years 2. Create supportive  Plain paper packaging environments  Limited shop frontage for displays 3. Strengthen community 2. Create supportive environments action  Restrictions on smoking in pulic places – public 4. Develop personal skills transport, workplaces, shopping centres, restaurants, 5. Reorient health services pubs/clubs  Changing social norms in young adults 3. Strengthen Community Action  Community support groups  Anti-smoking and non-smoker rights’ organisations 4. Develop personal skills  Social marketing campaigns  Quitline and smoking cessation advice 5. Reorient health services  Health-promoting hospitals  Screening for smoking in healthcare contacts  Smoking cessation programs in health service settings MANAGING DISEASE OUTBREAKS Definitions  Endemic: the disease
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