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DETERMINANTS Powered By Docstoc

   Most discussions of determinants of health actually
    address the determinants of ill health, disease or
   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

   Must distinguish between necessary and sufficient
    factors of causation
   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
  Model Showing Relationship of Health-Field
          Concept to Health Status

Human         Life             Environ-   Organi-
Biology       Style             ment      zation


   Preventive Interventions in Lung Cancer
                               Primary   Secondary Tertiary_
Human Biology                      0          0         +
Environmental                     ++          +         0
Life-Style                     ++++          ++         0
Organizational                  +++           +         0
0 = Virtually no opportunity
+ = Least opportunity
++++ = Most opportunity
           Preventive Interventions in AIDS
                               Primary   Secondary Tertiary_
Human Biology                      0         ++         +
Environmental                     ++          0         0
Life-Style                     ++++          ++       ++
Organizational                  +++           0         +
0 = Virtually no opportunity
+ = Least opportunity
++++ = Most opportunity
Levels of Disease and Injury Prevention

   Disease and injury prevention techniques are
    usually described in one of three categories:

    • Primary Prevention

    • Secondary Prevention

    • Tertiary Prevention
                  Primary Prevention

   Includes those activities intended to prevent the onset of
    disease and injury in the first place

   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 . . .
                Secondary Prevention

   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

   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

   Includes techniques focused on rehabilitation to prevent
    the worsening of an individual’s health in the face of
    chronic disease or injury

   Examples: Physical therapy for an orthopedic injury or
    cerebrovascular accident (stroke), education on diabetic
    self-management, other regimens for disease control . . .
The “New” Public Health
   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
     • 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
9. Availability of prompt emergency medical services
10. Others . . . ??
Some Ponderable Concerns about Determinants of
Health -- Some “On Average” Propositions

 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

   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 self-
    examination; 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

   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
Class                       London England       (England)_

Gentry, professional           44       35          100
persons & their families

Tradesmen, shopkeepers         23       22          167
& their families

Wage classes, artisans,        22       15         250
laborers & their families

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