Module 1 Overview of Population/Public Health
Sunday, March 12, 2017
1:41 PM
Required Reading
Institute of Medicine (IOM). (1988). A History of the Public Health System. In The Future of Public Health
(pp. 56-72).Retrieved from http://www.nap.edu/openbook.php?record_id?=1091&page=56
Public Health System must play a critical role in
handling threats to public health but currently,
the system is messed up.
2 Factors shaped how modern public health is now:
-Growth of scientific knowledge
-Growth of public scientific acceptance of
how disease control is everyone's responsibility
"The growth of a public system for protecting health
depended both on scientific discovery and social
action."
Before 18th Century: Mostly didn't know anything,
tried to pray it away, sort of got quarantining
18th Century: Got quarantining down pat. Developed
permanent councils in major cities to enforce
quarantining, started thinking less it's inevitable
and more it's controllable. Communities assumed care
for sick and mentally ill but needed thing more
formal
19th Century: Sanitary Awakening- filth seen
as cause of diseas and vehicle of transmission. If
sick, society thought dirty and immoral. Clean is
physical and moral health. Still quarantine but also
now clean to prevent quarantine to begin with.
Sanitation is now public goal.
Sanitary Problem: increased urbanization = dirty
working class. Shit was nasty. 1:10 dies of
smallpox, new york filled with trash, hald the
working class died before age 5.
Isolation impossible in urban society. Makes disease
and then spreads it (not from external source). Rich
and poor now too close together, rish couldn't just
ignore the problem. Thisand mental illness now
societal problem, no just individual prob
Development of Public Activities in Health:
Edwin Chadwick London Lawyer and Secretary of the
Poor Law Commision in 1838 one of the most
recognized ppl in sanitary reform. Conducted studies
NSG 780 Page 1
recognized ppl in sanitary reform. Conducted studies
and documented how bad everything was for the
working class. Average age of death 36 for gentry,
16 for laborers. Proposed network to remove sewage.
Adopted in Public Health Act of 1848.
Shattuck in Massachusesttes did similar studies
published in 1850. Also thought immorality lead to
disease too. Proposed basic public health goals but
initially got no traction (started doing stuff
after the Civil War) Now considered farsighted
and influetial
Griscom in NYC did something similar 1848
During this time people still didn't know exactly
why/how disease was spread.
Dorothea Dix argued for better care for mentally ill
Thought humane treatment could cure them
Public health agencies started on local and state
levels in the US.
Late Nineteenth Century: Enter Bacteriology
Louis Pasteur proved anthrax caused by bacteria
and other labs also found out about bacteria- Germ
theory developed. Immunizations started to be a
more common thing. Public Responsibility for health
came to include bother environmental sanitation and
indiviual health.
Development of State and Local Health Dept Labs:
1890's Start having labs to monitor water sanitation
in major cities. Theobald Smith devloped ways to
identify bacteria in animals and innoculate them
The Success of Bacteriology:
Embraced scientific discoveries and started
employing ideas, saved a lot of lives
Early 20th Century: Move Toward Personal Care
Started figuring out individual people responsible
for sources of disease transmission rather than
things Started having mandatory reporting of
diseases and then started taking responsibility to
treat these things
Public agencies shifted from disease prevention to
promotion of overall health.
Growth of Federal Activities in Health
Marine Hospital Service (initially only cared for
mariners since they had no community) renamed U.S.
NSG 780 Page 2
mariners since they had no community) renamed U.S.
Public Health Service in 1912.
Federal level began taking on more
responsibilities in child, maternal and infant
health.
Mid-Twentieth Century: Further Expansion of Gov Role
in Personal Health
1930-1970s- local state and fed responsibilities
increased.
1930- National Hygienic Lab relocated to DC and
Renamed NIH and expanded research and functions
to include study and investigation of all diseases
WWII CDC established.
Acts passed to expand care/research of mental health
venereal disease, strokes, CA etc. etc.
State and Local Activities:
Many changes on federal level stimulated or supported
growth on state levels.
States Expanded activities in health to accommodate
Medicaid- to participate, states had to designate
a state agency to direct the program. For first time
with Medicaid, funding for institutionalized
mentally ill became available
The Late Twentieth Cent: Crisis in Care and Financing
1970s started feeling financial impact of expansion
in public health activities. People started
criticizing prev social values that led to expansion
Current values also emphasize state responsibility,
federal grant money was cut back in 1980's. More
problems popping up and more financial concern for
cost.
Conclusion:
Science provided foundation for public health but
social values shaped system. Hx of public health
system is identifying health problem, developing
knowledge and expertise to solve problems and then
rallying political and social support around the
solution.
How much gov intervention will be and has always been
controversial
HEALTHY PEOPLE 2020 GOALS:
Overarching Goals
1: Attain high-quality, longer lives free of preventable
disease, disability, injury, and premature death.
NSG 780 Page 3
2: Achieve health equity, eliminate disparities, and
improve the health of all groups.
3: Create social and physical environments that promote
good health for all.
4: Promote quality of life, healthy development, and
healthy behaviors across all life stages.
Modules
INTRODUCTION TO POPULATION HEALTH
Many of the major improvements in the quality of life and longevity of Americans since the late 19th
century have been accomplished through successful public health measures. Examples include:
• Immunization for infectious disease
• Safe food and water
• Population-based screening and follow-up programs for infectious and chronic diseases
Much of this progress is taken for granted, and public health is sometimes referred to in the field as
“what we don’t see”. As a result, funding and critical services may not be sufficient to address public
health crises. Health professionals and the population-at-large need to recognize the importance of
maintaining and, in many cases, enhancing current preventive efforts to meet continuing and
emerging threats to the public’s health.
The IOM Report (The Future of Public Health, 1988) defined public health as “what we as a
society do collectively to assure the conditions in which people can be healthy”. Population-based
health care focuses on reducing morbidity and mortality. It emphasizes the availability and
accessibility of adequate health care resources for the population-at-large, vs. care for a special
few. The organizational mechanism for achieving the best population health, the public health
system, encompasses activities undertaken within the formal structure of government and the
associated efforts of private and voluntary organizations and individuals.
SETTING PRIORITIES FOR THE POPULATION
In most cases, because resources are limited, it is necessary to establish health care priorities for
the population. What becomes a priority is often the result of social policies and politics as well as
science. Priorities are extremely responsive to politics as the majority of public health programs are
funded by public dollars in the form of federal, state, and local taxes.
Given the limited resources we have to spend and the consequences of treating or not treating
certain diseases or reducing risk for certain diseases, it is important to carefully consider how public
health priorities are established. As a society and as health professionals, we need to begin thinking
about which areas should be selected for public intervention, the time it takes to effectively
implement public health programs and the impact of shifting priorities.
From <https://cf.son.umaryland.edu/NRSG780/module1/subtopic1.htm>
MODERN ERA OF PUBLIC HEALTH
Two main factors have shaped our modern public health system:
• Growth of scientific knowledge
• Growth of public acceptance of disease control as both a possibility and a public responsibility
Throughout recorded history, major outbreaks or epidemics such as the plague, cholera and
smallpox evoked sporadic public efforts to isolate or quarantine victims in an attempt to protect
citizens from becoming infected. As scientific knowledge regarding sources of contagion and means
of controlling disease became more refined, public authorities expanded measures for containing
specific diseases beyond quarantine to take on new tasks including sanitation, immunization,
regulation, health education and personal health care.
NSG 780 Page 4
regulation, health education and personal health care.
FIVE PHASES OF MODERN ERA (1850- PRESENT)
A History of the Public Health System summarizes the five phases of the modern era of public
health.
Phase 1 - Miasma (1850 - 1880)
The first phase was based on the Miasma Theory - a theory based on the belief that disease
originated from rotting organic matter. Although the scientific basis of disease was poorly
understood, personal and environmental hygiene gained attention as keys to mitigate spread of
disease and improve health.
Two early proponents of sanitation, Chadwick in England and Shattuck in the U.S., are considered
to be founders of the modern era of public health. They produced landmark data-driven reports and
gained both public and government attention. Their work lead western societies and later
developing countries to recognize the importance of public approaches to solving or preventing
health problems. For more information, view Chadwick’s and Shattuck’s reports.
Phase 2 - Bacteriology (1880 - 1920)
The second phase is identified as the rise of bacteriology. The work of Pasteur, Koch and others in
this rapidly growing field dramatically improved the scientific understanding of the origins of
disease. During the early 20th century, many communicable diseases were checked and science
became a vehicle for desired social change. The average American lifespan was extended from 47
years in 1900 to nearly 70. This shift in mortality is now termed the first public health revolution.
NSG 780 Page 5
years in 1900 to nearly 70. This shift in mortality is now termed the first public health revolution.
Despite improvement in mortality, by the 1920s it became clear that significant disability continued
to exist in the population. With the draft for WWI, 34% of young men were rejected for service due
to physical or mental health disabilities. Physicians and public health experts reviewed the
surprising data from the draft and recognized that while communicable diseases were well under
control, other risk factors were being neglected and these resulted in chronic physical and mental
health problems. Studies of disease registries and mortality and morbidity data also showed higher
than expected rates of death and disability among children and the poor.
Phase 3 - Health Resources (1920 - 1960)
During the third phase, the nation believed disparities could be addressed by improving individual
access to care. From 1920 to 1960 many state and county health departments established TB and
child health clinics to provide medical care. Additional efforts supported health education and mass
immunization programs.
Significant new funding supported hospital construction, healthcare manpower, and biomedical
research and resulted in:
• establishment of the National Institutes of Health (NIH) in 1930
• passage of the Hill-Burton Act in 1947 which provided funding for hospital construction that
was tied to the delivery of a percentage of free care
• increased presence of voluntary organizations like the American Heart Association (AHA)
Despite these initiatives and the proliferation of hospitals, mortality and morbidity rates did not
declined significantly by 1960.
NSG 780 Page 6
Phase 4 - Social Engineering (1960 - 1975)
During the fourth phase, leading health authorities attributed the lack of improvement in morbidity
and mortality rates by 1960 to the fact that medical resources were still inaccessible to many,
particularly the poor, elderly and isolated populations. From 1960 to 1975, the nation targeted social
engineering strategies to provide services to populations identified as high risk.
The Social Security Amendments of 1965, PL 89-97, 79 Stat. 286, enacted July 30, 1965,
resulted in the creation of Medicare and Medicaid. The legislation provided federal health
insurance for the elderly (over 65) and for poor families. Click here to watch President Johnson sign
the bill into law. Additional outreach services were designed to serve groups including immigrants,
Native American, and migrant workers.
As in previous periods, despite strategies to improve resource allocation and access to services,
dramatic changes in morbidity and mortality did not occur. Rates of heart disease, cancer and
stroke, the 3 leading causes of death, followed by accidents, COPD, cirrhosis, suicide and homicide
did not change appreciably. What did change was the per capita cost of health care.
NSG 780 Page 7
Phase 5 - Health Promotion (1975 - Present)
By the mid-1970s, developing new approaches to preventing premature death (before age 75)
became a priority.
NSG 780 Page 8
These landmark reports concluded that health is largely attributable to the four factors in
approximate percentages as noted below.
Percentag
e
Examples
of factors
Environmental
Lifestyle
Human Biology
Health Care System
20%
50%
20%
10%
• age
• gender
• race
• genetics
• access to
• occupational
exposures
• environmental
exposures
• radiation
• poverty
• unhealthy diet
• smoking
• physical
stress
• inactivity
• alcohol
drug misuse
• misuse
• reckless
driving of
• non-use
health care
quality of health
• services
care services
received
seatbelts
Perspecti
ve
Communities can exert
tremendous influence
over these factors
Many of these factors Little can be done to Heavily funded, often
are self-imposed
alter these factors
very late in the disease
risks
process
Based on Healthy People, the Department of Health and Human Services (DHHS) works under the
premise that further improvements in the health of Americans will not be achieved through
greater health expenditures for increasing the number of medical services but through greater
NSG 780 Page 9
greater health expenditures for increasing the number of medical services but through greater
efforts designed to change lifestyles to promote health, reduce risk and prevent disease.
From <https://cf.son.umaryland.edu/NRSG780/module1/subtopic2.htm>
HEALTHY PEOPLE REPORTS
Since the first Healthy People report in 1979, the Surgeon General has issued Objectives for the
Nation every 10 years. These reports identify our health promotion and disease prevention priorities
and outline objectives in focus areas that are to be achieved within the decade. The objectives
serve as a critical component of the health policy agenda for the U.S.
Reassessment of the scientific evidence for each of the Health People reports is a critical
component of the process. In 2011, one outcome of the scientific review lead to a revision of the
weights of the four key determinants of health-- environment, lifestyle, human biology and health
care system-- that contribute to premature mortality, placing an even greater emphasis on lifestyle
(an increase from 50 to 70%).
NSG 780 Page 10
Click here to watch the launch video (3:28) for Healthy People 2020, “Preparing for the Next
Decade: A 2020 Vision for Healthy People.”
From <https://cf.son.umaryland.edu/NRSG780/module1/subtopic3.htm>
NSG 780 Page 11
Module 2 Determinants of Health
Monday, March 13, 2017
10:45 AM
Required Readings
• Bournhonesque, R. & Mosbaek, C. (2002). Upstream public health: An alternate
proactive view. Portland, OR: Upstream Public Health. Retrieved
from &isAllowed=yhttp://libmedia.willamette.edu/xmlui/bitstream/handle/10177/452
3/F2Mosbaek7.pdf?
sequence=1
• National Research Council. (2003). Assuring America's health. In The Future of the
Public's Health in the 21st Century (pp. 19-45). Washington, DC: The National
Academies Press. Retrieved
from http://www.nap.edu/openbook/‌030908704X/‌html/19.html#pagetop
• page=46&National Research Council. (2003). Understanding population health and its
determinants. In The Future of the Public's Health in the 21st Century (pp. 46-95).
Washington, DC: The National Academies Press. Retrieved
from http://www.nap.edu/openbook.php?record_id=10548
• Puska, P. (2009) Fat and heart disease: Yes we can make a change—the case of
North Karelia (Finland).Annals of Nutrition & Metabolism, 54 (suppl1), 33-38. Retrieved
from http://www.theiem.org/library/IEM-2009-_ANM_Puska_fat-a-MC1H.pdf
From <https://cf.son.umaryland.edu/NRSG780/module2/index.htm?globalNavigation=false>
Upstream Public Health: An Alternate Proactive View
Upstream Approach=address problen through prevention
instead of treatment
80% of why people live 30 yrs longer since start of
20th century is b/c of public health
Areas of improvement include: Mandating vaccines,
safe workplace conditions, vehicle safety and
progress in sanitation
Public health tends to focus on educating
individuals but that doesn't guarentee they
will use that education and make healthy
choices. Have to change the environment to
promote health (ie. adding Vit D to milk or
urban design that encourages walking)
HOWEVER, focus stays on education b/c it's
not controversial and it doesn't affect
business.
Record of Public Health shows we can reduce
financial & quality of life cost by changing
social and physical environments.
The Future of Public Health in the 21st Century:
Ch1: Health People 2010 calls for national effort
to improve overall population health and eliminate
possible disparities in Health in the US. This
report provides framework for action, it will:
1.Review US Health Achievement in past century
NSG 780 Page 12
1.Review US Health Achievement in past century
2. Explore Health as public good and need to
partner w/ gov
3. Look at reasons why health nations health
status is crappy
4. Describe system and who can fix it
5. Propose how to fix it
7. Discuss national and world trends that could
affect health in the coming decades.
ACHIEVMENT AND DISAPPOINTMENT:
Everything is better now than beginning of 1900
but US sucks in comparison to other developed nations.
(example: 28th in infant mortality among 39 developed
nations and 1990 report shows everyone is more likely
to get any kind of cancer here than among 30 developed
nations).
Also, focus on national averages doesn't show disparities
in health between ethnic groups, socio-economic status etc.
Vast Majority of health spending (~95%), goes to medical
care and biomedical research, strong evidence shows though
BEHAVIOR and ENVIRONMENT responsible for more than 70%
of avoidable mortality. Additionally, many Americans can't
even access medical care d/t lack of insurance or lack of
access.
HEALTH AS SOCIAL AND POLITICAL UNDERTAKING:
Good health functional to good society (ppl can't do shit
if they're sick). Theories of democracy say pub health is
collective good and pub funds expected to benefit all or
most of population. Pub health needs collective support.
Everyone has to work together to make environment good
so people can be healthy- (ie. clean air, uncontaminated
food and water, safe meds ,etc)
Gov has primary responsibilities for pub health but other
people (ie. private sector) has to do stuff too,
then we all benefit. '
ISSUES THAT MAY SHAPE NATIONS HEALTH STATUS:
SOCIETAL NORMS AND INFLUENCES:
How can you balance individual freedoms (ie. enjoy
eating) with community responsibilities.
Population health is part individual good served
by medicine and part public good secured by health
activities. Money and focus mostly goes to treatment
of individuals though instead of preventative care of
populations. Public perception of how much public health
is needed has decreased since infectious diseases have
declined. But infectious diseases are coming back,
chronic diseases are getting worse- it's getting clearer
we need more equaly distributed population approaches.
"Health" is interplay between
Individual factors (ex: sex, genetics)
NSG 780 Page 13
Individual factors (ex: sex, genetics)
Personal Behavior
Environmental Conditions
Need more commitment to equitable opportunities
which will lead to improved health status of
population. Especially since income disparities
getting worse over past 3 decades.
SYSTEMIC ISSUES:
Government public health agencies are the BACKBONE
of any public health system
Number of systemic probs per Institute of Medicine
(IOM)Survey in 1988 say that Backbone:
Underfunded
Neglected Politically
Excluded from forums where expertise is
needed
Government agencies need to have ability to
perform surveilance of pop. to get evidence
so they know what's going on and then need adequate
resources to do their job. Bad stuff happens when
they don't have this, example: TB resurgence in
1980's happened b/c funding to programs was cut.
Also, funding is poorly distributed.
THE PUBLIC HEALTH SYSTEM AND ITS KEY ACTORS
PUBLIC HEALTH is defined by IOM as "What we as a
society do collectively to assure the conditions
in which people can be healthy."
PUBLIC HEALTH SYSTEM is complex network of
individuals and organizations that have potential
to play critical roles in creating the conditions
for health.
ACTORS IN THE PUBLIC HEALTH SYSTEM
Gov Public Health Infrastructure =
Local and state labs
Healthcare delivery system
Public health and science academia
Other less obvious actors
In addition to Gov health actors, there are:
Employees and Businesses
The Media
Communities (schools, law enforcement, etc.)
1988 IOM report says Public Health System = activities
undertaken within formal structure of Gov AND also
associated efforts of private and voluntary orgs. and
individuals.
SUMMARY (FRAMEWORK) OF REPORT:
NSG 780 Page 14
NSG 780 Page 15
Essential Public Health Services (ES) are:
1 Monitor health status to identify community health
probs
2. Diagnose and investigate health probs and health
hazards in the community
3. Inform, Educate and empower people about health
issues
4. Mobilize community partnerships to identify
and solve health problems
5. Develop policies and plans that support individual
and community health efforts
6. Enforce laws and regulations that protect health
and ensure safety
7. Link people to needed personal health services and
assure the provision of health care when otherwise unavailable
8. Assure a competent public health and personal health
care workforce
9. Evaluate effectiveness, accessibility and quality
of personal and population-based health services
10. Conduct research to attain new insights and
innovative solutions to health problems.
Key players need to interface and communicate with each other.
Health policy should create incentives to make these
partnerships easier. Some things already in place: examples,
health care providers in healthcare delivery provide
surveillance on certain conditions an report to state,
Employees and businesses have opportunity to promote health
and prevent disease in workplace setting
PRESENT AND FUTURE CHANGES NEEDED FOR A HEALTHY NATION
All actors need to work together to:
Adopt POPULATION HEALTH APPROACH
Strengthen BACKBONE (Gov Public health system)
of public health infrastructure
Create and generate PARTNERSHIPS
Develop systems of ACCOUNTABILITY
Assure action is based on EVIDENCE
Acknowledge COMMUNICATION as key to all of this
BROAD TREND INFLUENCING THE NATIONS HEALTH
Several things changing the game of pub health:
Population growth and demographic change
New Technologies
Globalization
POPULATION GROWTH AND DEMOGRAPHIC CHANGE
Bunch of statistics here on how American population is
getting old as fuck percentage wise. Some health probs are
inevitable but community base intervention can encourage
people to be physically active, eat healthy, etc to help
prevent occurrence of additional probs. Aging healthfully
lets people remain functional for as long as possible to
reduce costs.
NSG 780 Page 16
reduce costs.
US also becoming more ethnically and racially diverse d/t
both immigration and natural growth. Expected to be 32%
minority by 2010. Raises questions of cultural competency in
healthcare delivery plus concerns for institutional racism.
As pop. becomes more divers, better knowledge base needed
of way cultural, social and ecological factors shape health
behavior and ultimately, health status.
TECHNOLOGICAL AND SCIENTIFIC ADVANCES
Lots of new knoweldge and abilities, but raises concerns,
for instance genomics- access to it and use of it raises
ethical concerns. Computers are great for spreading info
and also spreading misinfo.
GLOBALIZATION AND HEALTH
Need to collaborate with other countries is increasing
because of need to protect population from flow of
pharmaceuticals, food, people etc coming and going.
World Health Org forum for setting standard for these
things.
Some think health should be included in America's core
foreign policy agenda. Can be matter of national security
(ie. infectious disease, bioterrorism). Nation's health
tied to world health because of these things
CONCLUDING OBSERVATIONS
"Health" shaped by so many factors, only way to do what
is needed is everyone working together. Commitment to work
together needs to be at every level (local, state, national)
and among all players.
Ch2. UNDERSTANDING POPULATION HEALTH AND ITS DETERMINANTS
Need to stop focusing on individual and start focusing on
population a whole for prevention. Also need more political
support to do this.
A POPULATION PERSPECTIVE:
Need upstream approach. Three realities essential to development
of effective pop. based prevention strategies:
1. Start seeing disease risk on continuum instead of
black and white "risk or no risk"
2. Most people in middle distribution of risk for disease,
so need to focus on modifying guidelines for average person
risk instead of only focusing on high risk people
3. People don't live in a vacuum, risk factors change based
on location (ie. more likely to have high cholesterol in US than in
Japan). Need to ask why this happens and try to fix high risk spots
Three kinds of strategies for improving health of population (center
more people around normal levels of something).
1: heavy focus on reducing obese people's BMI's but should be
NSG 780 Page 17
1: heavy focus on reducing obese people's BMI's but should be
focusing on reducing overweight people's BMI's because that would
impact more people and have greater overall effect on bell curve.
2: Shift whole population BMI down, more people underweight
but lots more people WNL now too
3: there is model of redistribution of resources (ie. income),
pulls from the richest and redistributes, mean stay the same but
more people centered around the meant.
FIGURE ON PAGE 52-A guide to thinking about the determinants of
population health. (individual to broad social and environmental
conditions)
THE PHSYICAL ENVIRONMENT AS A DETERMINANT OF HEALTH
Together, global warming, population growth, habitat destruction,
loss of green space, and resource depletion have produced a widely
acknowledged environmental crisis. No quick fix for them, will
require societal engagement.
The places in which people work and live have an enormous impact on
their health. 3/4 of Americans live in urban areas, higher risk to
lives there
URBAN HEALTH PENALTY —the “greater prevalence of a large number of
health problems and risk factors in cities than in suburbs and rural
areas” (rural life has issues too- mostly lack of access, but still
not as bad). negative environmental aspects of urban living—toxic
buildings, proximity to industrial parks, and a lack of parks or green
spaces- higher exposure to lead.
Example of how it matters: METHYLMERCURY: A CASE STUDY
Environmental toxins are a specific form of environmental hazard,
caused in most cases by industrial enterprises. Bioaccumulation can
result in very high concentrations of mercury in some fish, which
are the main source of exposure for the population. Prenatal exposures
may interfere with the growth and development of neurons. Can lead to
mental retardation, cerebral palsy, blindness, and deafness. Currently,
40 states have issued fish consumption advisories. EPA and the Food and
Drug Administration (FDA)revised their guidance concerning consumption
of fish species that have been shown to have high levels of mercury.
Ultimately, the threat of mercury can be most effectively reduced through
control of the sources of pollution.
THE SOCIAL DETERMINANTS OF HEALTH
(1) socioeconomic position
(2) race and ethnicity
(3) social networks and social support
(4) work conditions.
(5) Ecological level influences
SOCIOECONOMIC STATUS AND HEALTH
Low Socio-economic status people more likely to die across the board
regardless of other factors. Goes through risk factors why: ex here
NSG 780 Page 18
regardless of other factors. Goes through risk factors why: ex here
is most often, especially in the United States, a striking and consistent
association between SES and risk-related health behaviors such as cigarette
smoking, physical inactivity, a less nutritious diet, and heavy alcohol
consumption. Socioeconomic disparities in health in the United States are
large, are persistent, and appear to be increasing over recent decades,
despite the general improvements in many health outcomes. Huge disparitymost advantaged people in the US have levels of longevity that are beyond
everywhere else in the world and the poorest people experience levels of
health closer to developing nations. Major opportunity to improve health
of US pop is to reduce number of poor people
RACIAL AND ETHNIC DIPARITIES
Numerous studies have shown that minority populations may experience burdens
of disease and health risk at disproportionate rates because of complex and
poorly understood interactions among socioeconomic, psychosocial, behavioral,
and health care-related factors.
Even after controlling for income, African-American men and women have lower
life expectancies than white men and women at every income level. Thought
possibly b/c discrimination is a stressful experience. Also maybe because
they have lower access to healthcare and lower quality. Barriers to care may
include linguistic differences, a lack of insurance or difficulties with payment,
immigration status, social issues such as trust and some pervasive but subtle
forms of racism and discrimination, and even logistical problems related to
distance and transportation.
SOCIAL CONNECTEDNESS AND HEALTH
Powerful epidemiological evidence supports the notion that social support,
especially intimate ties and the emotional support provided by them, is
associated with increased survival and a better prognosis among people with
serious cardiovascular disease
Several studies have recently shown that older men and women with high levels
of social engagement and networks have slower rates of cognitive decline
People who are socially isolated are more likely to engage in such behaviors
as tobacco and alcohol consumption, to be physically inactive, and to be overweight
Because social relationships influence health through such a myriad of pathways,
broad health improvements may be facilitated by considering and enacting policies
that support social connections.
WORK RELATED CONDITIONS AND HEALTH
High stress jobs associated with cardiovascular disease. Loss of job and
threat of job loss also associated with stress and high cholesterol
ECOLOGICAL-LEVEL INFLUENCES
CONCLUDING OBSERVATIONS
Population health improvements will have to focus attention on both overall
improvement in the nation’s health and reduction of the disparities in health.
Many of the determinants of health are part of the broad economic and social
context and, thus, beyond the direct control of administrators in public- and
private-sector health care organizations. Do need resources to support
population based resources.
NSG 780 Page 19
population based resources.
Fat and Heart Disease: Yes We Can
Make a Change –
The Case of North Karelia (Finland)
There was exceptionally high mortality of CVD in Finnish population in
the 1970s. Preventative health initiation started in Province of
North Karelia. Goal was to change pop. diet. - decrease saturated fat
and increase unsaturated fat, increase vege intake and reduce salt.
ing and evaluation, and international collaboration. Results:
The combined efforts of all stakeholders have greatly helped
people to reduce the intake of saturated fat and to replace
this with unsaturated fat. It has led to a 80% reduction in
annual CVD mortality rates among the working aged population, to a major
increasein life expectancy and to major improvements in
functional capacity and health.
Conclusion: The Finnish experience
shows both the feasibility and great potential of
CVD prevention and heart health promotion through general
dietary changes in the population. Did it by educating and
working with food industry
Finnish experience has shown that:
– prevention of CVD is possible and profitable
– population-based prevention is the most cost-effective
and sustainable public health approach to CVD control
– prevention calls for simple changes in some lifestyles
(individual, family, community, national and global
level action)
– influencing diet and especially quality of fat is a key
issue
– many results of prevention occur surprisingly quickly
(CVD/diabetes) and also at relatively late age
– comprehensive action, broad collaboration with dedicated
leadership and strong government policy support.
MODULE NOTES:
Assessing Health Status of the Population
The health status of a population is most commonly measured by indicators that reflect
disease and mortality, rather than health. Despite the inherent problems with using mortality
as a proxy for health, mortality data are often available and used throughout the world to
describe the health status of populations. Data on morbidity are not as readily available but
are also essential when assessing the health status of a population.
Measures of Mortality
Life expectancy is the average number of years people born in a given year are expected
to live based on a set of age-specific death rates. When life expectancy in the U.S. is
compared to other nations in the world, we are not at the top, where we expect to be, but
trailing behind many other countries for both men and women. During the past two decades
life expectancy in the US has fallen to 49th as compared to other nations and is expected to
fall further behind in the next several years.
NSG 780 Page 20
The leading causes of death in the U.S. are heart disease, cancer, chronic lower
respiratory diseases, stroke and accidents (unintentional injuries), followed by Alzheimer’s
disease and diabetes. These are all heavily influenced by lifestyle risk factors.
When assessing mortality, it is also important to consider the leading causes of death by
age group in the U.S.
• From 1 year to the age of 45, accidents are the leading cause of death.
• From 45 to 65, cancer is the leading cause of death.
• After age 65, heart disease is the leading cause of death.
NSG 780 Page 21
From <https://cf.son.umaryland.edu/NRSG780/module2/subtopic1.htm>
We can also measure mortality in the U.S. by examining the leading causes of death by
gender and in comparison with peer countries.
Another way of looking at mortality in the U.S. is to consider the toll of premature
mortality on our society. Death before the age of 75 is generally considered premature.
Families, work, and the society as a whole lose the valuable contributions of each member
NSG 780 Page 22
Families, work, and the society as a whole lose the valuable contributions of each member
who dies prematurely. When we consider premature mortality in relation to the leading
causes of death, we see a different profile of the tolls of the leading causes of death.
Years of potential life lost (YPLL) is a measure of the years of potential life lost due to
premature death. It is an estimate of the average years a person would have lived if he or
she had not died prematurely. Here is an example of a calculation of YPLL before the age of
75 for males & females of ethnic groups in the U.S. Note the differences in years of potential
life lost by category if the calculation is based on the age of 65 as shown in the chart below.
Source: http://webappa.cdc.gov/cgi-bin/broker.exe
NSG 780 Page 23
For more information on how YPLL is calculated, watch this video.
Measures of Morbidity
National Health and Nutrition Examination Surveys
To address the limitations of focusing on mortality data and existing utilization databases
that only include information on those who access services, in 1956 the National Health
Survey Act was passed. This federal legislation authorized a continuing national survey to
provide measures of morbidity in terms of current statistical information on the amount,
distribution and effects of illness and disability in the U.S. Now called the National
Health and Nutrition Examination Surveys or NHANES, the U.S. has a continuous stratified
sampling system in place to gather the data that provides an overview of the health status of
the population. Watch the video, CDC’s Dr. Frieden discusses Public Health Data and the
NHANES Program for a better understanding of public health data and the role of NHANES.
NHANES gathers household and family level information:
1. Demographic background/occupation
2. Food security
3. Health insurance
4. Housing characteristics
5. Income
6. Pesticide use
7. Smoking
8. Tracking and tracing
NHANES includes comprehensive self-reported information on all individuals in the
household:
Acculturation
Medical conditions
Audiometry
Miscellaneous pain
Balance
Physical activity and physical fitness
Blood Pressure
Physical functioning
Cardiovascular Disease
Occupation
Dermatology
Oral health
Diabetes
Osteoporosis
Dietary supplements and prescription medication Respiratory health and disease
Diet behavior and nutrition
Smoking and tobacco use
NSG 780 Page 24
Diet behavior and nutrition
Smoking and tobacco use
Digital symbol substitution exercise
Social support
Early childhood
Tuberculosis
Hospital utilization and access to care
Vision
Immunization
Weight history
Introduction and Verification
Dietary recall
Kidney conditions
Medical conditions
NHANES augments its data with a series of laboratory tests on all individuals in the
household which confirm or question much or the self-reported information:
1. Blood and urine
2. Venipuncture
3. Urine collection
4. Bone markers
5. Diabetes profile
6. Infectious disease profile
7. Markers of immunization status
8. Miscellaneous laboratory assays
9. Kidney disease profile
10. Hormone profile
11. Nutrition biochemistries and hematologies
12. Sexually transmitted disease profile
13. Tobacco use
14. Blood lipids
15. Environmental health profile
NHANES conducts examinations on all members as well.
1. Audiometry
2. Balance and vestibular testing
3. Body composition
4. Body Measurement
5. Cardiovascular Fitness
6. Dermatology
7. Lower extremity disease
8. Muscular strength
9. Oral health
10. Physician’s exam
11. Vision
Using these data, we are able to profile the health status of the nation as a whole.
Behavioral Risk Factor Surveillance System
In the late 1970s and early 1980s, states begin to ask the federal government for data that
were specific to their population rather than the nation as a whole. Resources to replicate
the NHANES laboratory and examination data would have been prohibitive on a state-bystate basis. However, telephone surveys were beginning to show the capacity to gain the
requested data in a cost-effective format.
In the 1980s the Behavioral Risk Factor Surveillance System (BRFSS) was piloted by the
CDC through state health departments and ultimately expanded to provide unique data for
each state. The BRFSS uses telephone surveys which take about a half hour to complete.
The BRFSS is conducted on an annual basis. In most states the samples are designed to
also provide county specific data.
All states gather the same core data including:
1. Health Status
2. Health Care Access
3. Asthma
4. Diabetes
5. Care Giving
NSG 780 Page 25
5. Care Giving
6. Exercise
7. Tobacco Use
8. Fruits and Vegetables
9. Weight Control
10. Demographics
11. Women Health
12. HIV/AIDS
States can add optional modules that include:
Diabetes
Injury Control
Sexual Behavior
Alcohol Consumption
Family Planning
Cardiovascular Disease
Health Care Coverage and Utilization Arthritis
Health Care Satisfaction
Quality of Life and Caregiving
Oral health
Folic Acid
Hypertension Awareness
Skin Cancer
Cholesterol Awareness
Tobacco Use Prevention
Immunization
Smokeless Tobacco
BRFSS data can be analyzed by a variety of demographic variables:
• Age
• Sex
• Education
• Income
• Occupation
• Racial and Ethnic backgrounds
From <https://cf.son.umaryland.edu/NRSG780/module2/subtopic1.htm>
Modifiable Lifestyle Risk Factors
Healthy People emphasizes that improvements in the health of Americans will not be
achieved through increasing the number of medical services but through greater efforts
designed to change lifestyles to promote health, reduce risk and prevent disease. When we
begin to study modifiable lifestyle risk factors for the leading causes of death, it is important
to note that many are risk factors for more than one cause of death. As a result, efforts
aimed at reducing a single risk factor, such as smoking or obesity, will have an impact on
reducing the risk of heart disease, cancer and stroke.
This table shows that many of the major modifiable risk factors for the three leading causes
of death in the U.S. are identical.
The next five subtopics in this module will provide a snapshot of the major modifiable
lifestyle risk factors for the leading causes of death:
• Smoking
• High Blood Pressure
• Elevated Blood Cholesterol
• Diet, Overweight, Obesity and Physical Inactivity
• Impact of Multiple Risk Factors
NSG 780 Page 26
• Impact of Multiple Risk Factors
Scientific evidence will be highlighted that shows reducing these risk factors reduces
premature morbidity and mortality and that we have known this for over fifty years.
From <https://cf.son.umaryland.edu/NRSG780/module2/subtopic3.htm>
One modifiable lifestyle risk factor of the leading causes of death is smoking. This subtopic
will focus on some of the evidence available on the effects of smoking and trends
associated with it.
Ernst Wynder’s landmark studies date as far back as 1950, and described tobacco smoking
as a possible factor in lung cancer. One of the earliest studies of 684 cases describes
smoking as a possible etiologic factor in bronchiogenic carcinoma (1), and another study
describes tobacco as a cause of lung cancer with special reference to the infrequency of
lung cancer among non-smokers (2).
1. Wynder, E.L. & Graham E.A. (1950). Tobacco smoking as a possible etiologic factor in
bronchiogenic carcinoma: A study of 684 proved cases. Journal of the American
Medical Association, 143(4), 329-36.
2. Wynder, E.L. (1954). Tobacco as a cause of lung cancer with special reference to the
infrequency of lung cancer among non-smokers. Pennsylvania Medical Journal,
57, 1073-1083.
The Surgeon General Office has been issuing reports on smoking since 1964. These
reports reaffirm that cigarette smoking is the leading risk factor for premature death in our
country.
Source: http://www.surgeongeneral.gov/priorities/tobacco/
For more information review the executive summary of The Health Consequences of
Smoking—50 Years of Progress: A Report of the Surgeon General, 2014. Available
at http://www.surgeongeneral.gov/library/reports/50-years-of-progress/execNSG 780 Page 27
at http://www.surgeongeneral.gov/library/reports/50-years-of-progress/execsummary.pdf:
Risks of Smoking
Tobacco is responsible for over 20% of deaths in the U.S. and serves as a major contributor
to deaths from cancer, heart disease, stroke, diseases of the lung and numerous other
causes.
Source: 2014 Surgeon General's Report, Table 12.4, page 660
http://www.cdc.gov/tobacco/data_statistics/tables/health/infographics/index.htm
Evidence-based studies implicate smoking as a major risk factor for cancers, including:
• Lung cancer
• Bladder cancer
• Laryngealcancer
• Oral cancer
• Cervical cancer
• Pancreatic cancer
• Esophageal cancer
• Stomach cancer
• Kidney cancer
• Leukemia
Smoking is recognized as a leading risk factor for cardiovascular diseases including
abdominal aortic aneurysm, atherosclerosis, cerebrovascular disease and coronary heart
disease.
Smoking is implicated in a series of respiratory diseases including COPD, pneumonia, and
respiratory effects in utero, childhood, adolescence and adulthood.
Smoking has been identified as a risk factor for reproductive problems including fetal
deaths and stillbirths, impaired fertility, low birthweight and complications of pregnancy.
Other risks of smoking now include cataracts, low bone density and peptic ulcer disease.
Source: The Health Consequences of Smoking: A Report of the Surgeon General, 2004
Trends in Cigarette Smoking
Based on its well-documented negative health effects, information on tobacco use is part of
the Behavioral Risk Factor Surveillance System.
NSG 780 Page 28
the Behavioral Risk Factor Surveillance System.
Current data from the BRFSS indicates that there has been a modest decline in smoking
during the past decade. In 2014, the median smoking rate in the US was 16.8% for all
adults (over 18 years of age).
In 2012, 22% of young adults and 9% of persons over 65 years smoke. Half of all
adolescents that continue to smoke regularly will die eventually from a smoking-related
illness.
In the U.S. smoking rates peak from 25-34 and then begins to declin
NSG 780 Page 29
Source: BRFSS Trend Data 2013
From <https://cf.son.umaryland.edu/NRSG780/module2/subtopic4.htm>
MODIFIABLE LIFESTYLE RISK FACTORS: HIGH BLOOD PRESSURE
Another modifiable lifestyle risk factor for the leading causes of death is high blood pressure.
This subtopic will focus on the effects, risks and trends associated with high blood pressure.
Until the early 1960s blood pressure was thought to rise with age, and essential
hypertension, defined as diastolic blood pressure under 115 mm Hg, was considered a
normal part of aging. The Framingham Heart Study first identified hypertension as a risk
factor in the development of coronary heart disease in 1961(1).
• Kannel, W., Dawber, T.R., Kagan, A., Revotskie, N., & Stokes, J. (1961). Factors of
risk in the development of coronary heart disease—Six year follow-up
experience. Annals of Internal Medicine, 55(1), 33-50.
Research conducted by the Veterans Administration Cooperative Study Group on
Antihypertensive Agents beginning in 1963 also challenged this assumption and showed
that treatment dramatically reduced the risk of a morbid event from over a five year period
and that treatment also reduced the risk of heart failure and stroke. In part two of the study,
NSG 780 Page 30
and that treatment also reduced the risk of heart failure and stroke. In part two of the study,
the differences between the participants in the treated and control (taking placebos) groups
were so dramatic that the trial was terminated early. (2, 3)
• VA Cooperative Study Group. (1967). Effects of treatment on morbidity in
hypertension, Journal of American Medical Association, 202(11), 1028-1034.
• VA Cooperative Study Group, (1970). Effects of treatment on morbidity in hypertension
II. Results in patients with diastolic blood pressure averaging 90 through114 mm
Hg, Journal of the American Medical Association, 213(7), 1143-1152.
The five-year findings of the Hypertension Detection and Follow-up Program (HDFP)
Cooperative Group of nearly 11,000 community-based participants from 30-69 showed that
a program of stepped care as compared to referred care achieved better control of
hypertension and significant reductions in mortality. The study concluded that systematic
effective management of hypertension has a great potential for reducing mortality for the
significant number of people with high blood pressure in the population, including those with
mild hypertension (4).
• HDFP Cooperative Study Group. (1979). Five-year findings of the hypertension
detection and follow-up program I. Reduction of mortality of persons with high blood
pressure, including mild hypertension, Journal of the American Medical Association,
242(23), 2562-2577.
Risks of High Blood Pressure
High blood pressure significantly increases the risk of:
•
•
•
•
•
•
Stroke
Coronary heart disease
Congestive heart failure
Aneurysm
Kidney failure
Vision changes
Trends in High Blood Pressure
In the U.S. trends show that there has been a slight increase in high blood pressure during
the past decade with roughly a third of the population indicating that they have blood
pressure in excess of 140/90.
In the U.S. blood pressure increases with age. Blood pressure is higher in men at younger
ages. It shifts to being higher in women 45 and over, when menopause occurs, and stays
higher than in men for their lifespan.
Nationwide (States and DC) - All available years Adults who have been told they have high
NSG 780 Page 31
Nationwide (States and DC) - All available years Adults who have been told they have high
blood pressure
SaveFile&rdProcessAction=&Source: http://nccd.cdc.gov/brfssprevalence/rdPage.aspx
?rdReport=DPH_BRFSS.ExploreByLocation
islTopic=&islClass=CLASS10&islLocation=99&rdCSRFKey=faceaef3-be9e-4430-b779ac9030349cd4&Generated=1
hidYear=&hidTopicName=High+Blood+Pressure&hidTopic=Topic31
&hidClass=CLASS10&hidLocation=99&islYear=2013&Topic31
hidPreviouslySelected&iclIndicators=_RFHYPE5
&iclIndicators_rdExpandedCollapsedHistory=&irbShowFootnotes=Show&2013
rdRnd=9074&rdScrollY=0&rdScrollX=0
&rdShowElementHistory=&DashboardColumnCount=2&Indicators=
NSG 780 Page 32
As blood pressure increases, the risk of developing blood pressure related diseases
increases. The relative risk of developing CHD is twice as high when systolic blood pressure
is in the 130-139 range as compared to below 110, and 4.5 times as great when systolic
blood pressure exceeds 160 (5).
Relative Risk of Developing CHD vs. Systolic Blood Pressure
Data from the NHANES surveys show that trends in adults in blood pressure awareness,
treatment and control are far from ideal. This is particularly noteworthy given the risk of
preventable disease, the toll of diseases such as stroke, and the well-documented
NSG 780 Page 33
preventable disease, the toll of diseases such as stroke, and the well-documented
effectiveness of anti-hypertensive treatment.
Using 140/90 as the standard of the population that has high blood pressure, 83% are
aware, 76% are being treated and only 52% are under control.
SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey, 2011–2012.
Retrieved fromhttp://www.cdc.gov/nchs/data/databriefs/db133.htm
When we consider the unacceptably low level of control and the fact that by the time
Americans reach age 74, over 60% of the adult population has high blood pressure, it is
clear that uncontrolled hypertension plays a significant role in the health status of the US
population as a whole.
Question:
Dr. Carolyn Clancy, former Director of the Agency for Healthcare Quality and Research
(AHRQ), gave The Dean’s Distinguished Virginia Lee Franklin Lecture at the School of
Nursing in 2011. She identified our inability to control high blood pressure, given our arsenal
of treatment options, as one of the greatest failures of our health care system. Can you
identify possible interventions at the community, provider and policy level that may help to
improve the level of control?
From <https://cf.son.umaryland.edu/NRSG780/module2/subtopic5.htm>
MODIFIABLE LIFESTYLE RISK FACTORS: ELEVATED SERUM CHOLESTEROL
Another modifiable lifestyle risk factor for the leading causes of death is elevated serum
cholesterol. This subtopic will focus on the effects, risks, trends and cultural differences
associated with elevated serum cholesterol.
In 1961, the Framingham Heart Study also identified elevated serum cholesterol for the first
time as a risk factor in the development of coronary heart disease in 1961(1).
1. Kannel, W., Dawber, T.R., Kagan, A., Revotskie, N., & Stokes, J. (1961). Factors of
risk in the development of coronary heart disease—Six year follow-up
experience. Annals of Internal Medicine, 55(1), 33-50.
The Western Electric Study of the relationship between diet, serum cholesterol and mortality
followed nearly 2000 middle-aged men between 1960 and 1980. The study concluded that
the lipid composition of diet affects cholesterol levels and increases the risk of coronary
death (2).
1. Shekelle, R., Shyrock, A., Paul, O., Lepper, M., Stamler, J., Liu, S., & Raynor, W.
(1981). Diet, serum cholesterol and death from coronary heart disease “The Western
Electric Study”, New England Journal of Medicine, 304(2), 65-70.
The Lipid Research Clinics Coronary Primary Prevention Trial studied the efficacy of
cholesterol lowering in reducing risk of coronary heart disease in nearly 4000 middle-aged
men over an average of more than seven years. Results demonstrated that reducing total
cholesterol by lowering LDL-C levels can diminish coronary heart disease morbidity and
mortality. (3)
1. Lipid Research Clinics Program, The Lipid Research Clinics Coronary Primary
Prevention Trial results I. Reduction in incidence of coronary heart disease, Journal of
American Medical Association, 251(3), 351-364.
Risk of Elevated Blood Cholesterol
Elevated blood cholesterol significantly increases the risk of coronary heart
disease and stroke.
As cholesterol levels increase, heart disease mortality rates increase.
NSG 780 Page 34
Differences in Cholesterol by Gender and Age
NHANES data indicate that over the last several decades the average serum cholesterol
levels for men and women are declining.
Figure 5. Trends in age-adjusted high total cholesterol and low HDL cholesterol among
adults aged 20 and over: United States, 1999–2000 through 2013–2014.
Source: http://www.cdc.gov/nchs/data/databriefs/db226.htm
NSG 780 Page 35
When you study the population over the age of forty, the differences between men and
women shift. Overall, the toll of this risk factor remains a significant contributor to heart
disease and stroke in the U.S., particularly for women over 60 who have significantly higher
levels than men and are further away from achieving targets.
Cultural Differences in Cholesterol
Cultural differences in serum cholesterol levels are significant. Notice how the average
serum cholesterol in Japan is under 150 and the curve is quite narrow. Compare these data
to Finland, where the mean is 250 and the population levels range from 150 to 350.
NSG 780 Page 36
to Finland, where the mean is 250 and the population levels range from 150 to 350.
Cholesterol levels in different countries vary even in young children ages 5 to 9 years.
Notice the differences between the mean levels in Mexico as compared to the U. S.
Data from the landmark Ni-Hon-San study show that cholesterol levels are not genetically
determined alone. Studies of Japanese natives who migrated to Hawaii showed that their
cholesterol levels eventually matched those of the Hawaiian islanders. Cholesterol levels of
those who migrated to the San Francisco area eventually reflected the levels of the average
American. Studies of each of the migrant populations showed that they adopted the dies of
their new homelands.
NSG 780 Page 37
Data from the Behavioral Risk Factor Surveillance System show that in 2013 over 76.4% of
Americans have had their cholesterol checked. Over 38% were told it was high.
Source: http://nccd.cdc.gov/BRFSSPrevalence/rdPage.aspx?rdReport=DPH_BRFSS.
go=GO&islYear=2014&islTopic=Topic11&islClass=CLASS02&ExploreByTopic
From <https://cf.son.umaryland.edu/NRSG780/module2/subtopic6.htm>
MODIFIABLE LIFESTYLE RISK FACTORS: DIET, OVERWEIGHT, OBESITY AND PHYSICAL
INACTIVITY
Other modifiable lifestyle risk factors for the leading cause of death are diet, overweight,
obesity and physical inactivity. This subtopic will focus on each of these risk factors in
relation to their trends and the risks associated with them.
Research on diet, overweight, obesity and physical inactivity and their relationship to the
leading causes of death has been ongoing since the initiation of the Seven Countries Study
in 1947(1). The Framingham Study first noted the relationship between the risks of physical
inactivity and obesity to increase the risk of heart disease in 1967 (2,3).
1. Keys, A. et al. (1980). Seven countries. A multivariate analysis of death and coronary
heart disease. Cambridge, MA: Harvard University Press.
2. Kannel, W.B. (1967). Habitual level of physical activity and risk of coronary heart
disease: The Framingham Study. Canadian Medical Association Journal, 96(12),
811-812.
3. Thomas, H.E.J., Kannel, W.B., & McNamara, P.M. (1967). Obesity: A hazard to
health. Medical Times, 95, 1099-1106.
NSG 780 Page 38
health. Medical Times, 95, 1099-1106.
Influence of Diet on Cancer
When the influence of diet is studied in relation to cancer, approximately 40% of cancers are
attributable to diet and alcohol.
The evidence now shows that many cancers are associated with low levels of fruit and
vegetable consumption, including:
• lung
• stomach
• breast
• colon
• breast
• prostate
• ovarian
• pharynx
• oral cavity
• esophagus
• larynx
• bladder
• pancreas
• endometrium
• cervix
• ovary
• pancreas
Behavioral Risk Factor Surveillance System data indicate that nearly 75% of Americans are
consuming fewer than 5 fruits and vegetables a day.
NSG 780 Page 39
International studies show that the higher the average dietary fat consumption of the
population, the higher the death rate from breast cancer. Notice how low the rates are in the
Philippines, Thailand and Japan as compared to the Netherlands, New Zealand, Canada
and the U.S. The same relationship is found between high dietary fat consumption and
death rates from intestinal and prostate cancer.
Obesity and Overweight
Excess dietary fat, excess calories and sedentary lifestyles are major causes of the
epidemic of obesity that we are facing in the U.S.
Risks of Obesity
Obesity and overweight increase the risk of a variety of health problems, including
NSG 780 Page 40
Obesity and overweight increase the risk of a variety of health problems, including
•
•
•
•
•
•
•
•
•
•
•
•
•
•
type 2 diabetes
gall bladder disease
stroke
asthma
congestive heart failure
high blood pressure
elevated serum cholesterol
sleep apnea and respiratory disorders
coronary heart disease
angina pectoris
gout
bladder control problems
musculoskeletal disorders
osteoarthritis
Watch this video developed by the CDC on the Obesity Epidemic.
Overweight and obesity increase the risk of poor female reproductive health – pregnancy
complications, menstrual irregularities, irregular ovulation and infertility.
Overweight and obesity also increase the risk of a variety of cancers, including:
• breast
• prostrate
• liver
• colon and rectum
• uterus
• kidney
• pancreas
• esophagus
Trends in Overweight and Obesity
Data from the 2013-2014 NHANES shows that 32.7% of adults age 20 and over are
overweight, 37.9% are obese and 7.7% are extremely obese and the prevalence is similar
across all age groups.
NSG 780 Page 41
across all age groups.
NIH recently found that extreme obesity may shorten life expectancy up to 14 years. Delete
the life expectancy chart and add: For more information, please
review https://www.nih.gov/news-events/news-releases/nih-study-finds-extremeobesity-may-shorten-life-expectancy-14-years.
The Congressional Budget Office indicates that rising obesity rates significantly effects
health care spending.
NSG 780 Page 42
Behavioral Risk Factor Surveillance System data indicate that the percentage of the
population that is neither overweight nor obese is dramatically declining. CDC has used the
BRFSS data to map the changes in obesity prevalence since 1985.
Five years later, at least 10% of the population of the majority of states were obese. By 1999
20% were obese. Now obesity rates are greater than 30% for nearly half of the U.S.
NSG 780 Page 43
Physical Inactivity
Another key to epidemic of obesity is sedentary lifestyle. Numerous studies have shown the
importance of regular physical activity for reducing the risk of chronic disease. Morris’ work
in England on the drivers and conductors of the double-decker busses in the 1960s is a
classic. Drivers and conductors were studied over a ten year period. Both groups were
virtually identical in terms of socioeconomic status, educational level and environmental
exposures. The single difference was that the drivers were sedentary throughout the day
and the conductors ran up and down the bust stairs during the day collecting tickets.
Because the bus company supplied the uniforms, accurate records were available on the
waist sizes of the men throughout the years.
NSG 780 Page 44
Sudden death from ischemic heart disease showed distinct differences between the two
groups – the rate for drivers was substantially higher.
Average waist sizes between the two groups varied significantly over time, with drivers
gaining weight at a much higher rater than the conductors as they aged.
CHD rates in the busmen between the ages of 35 and 64 varied significantly with drivers’
raters far exceeding the conductors.
NSG 780 Page 45
raters far exceeding the conductors.
Data from 2014 indicate that only 22.7% of the population participates in any physical
activities and that only 20.5 % of the population participated in enough aerobic and muscle
strengthening exercises to meet guidelines.
Source: http://nccd.cdc.gov/BRFSSPrevalence/rdPage.aspx?rd
islYear=2014&islTopic=Topic23&islClass=CLASS15
&Report=DPH_BRFSS.ExploreByTopic
From <https://cf.son.umaryland.edu/NRSG780/module2/subtopic7.htm>
NSG 780 Page 46
NSG 780 Page 47
Module 3 Epidemiology
Monday, March 13, 2017
11:50 AM
Required Readings
• CDC Excite. Introduction to Epidemiology. Available
at http://hickmancharterscioly.pbworks.com/f/EXCITE+_+Epidemiology+in+the+
Classroom+_+Intro+Epi.pdf
From <https://cf.son.umaryland.edu/NRSG780/module3/index.htm?globalNavigation=false>
Epidemiology: Basic science of public health
Epidemiology: "the study of the distribution
and determinants of health-related states in
specified populations, and the application of
this study to control health problems.
key epidemiological variables – Person, Place and Time.
Study—Epidemiology is the basic science of
public health. It's a highly quantitative
discipline based on principles of statistics
and research methodologies.
Distribution—Epidemiologists study the
distribution of frequencies and patterns of
health events within groups in a population.
To do this, they use descriptive epidemiology,
which characterizes health events in terms of
time, place, and person.
Determinants—Epidemiologists also attempt to search
for causes or factors that are associated with
increased risk or probability of disease. This type
of epidemiology, where we move from questions of "who,"
"what," "where," and "when" and start trying to answer
"how" and "why," is referred to as ANALYTICAL
EPIDEMIOLOGY
Health-related states—Although infectious diseases
were clearly the focus of much of the early
epidemiological work, this is no longer true.
Epidemiology as it is practiced today is applied to the
whole spectrum of health-related events, which includes
chronic disease, environmental problems, behavioral
problems, and injuries in addition to infectious
disease.
Populations—One of the most important distinguishing
NSG 780 Page 48
Populations—One of the most important distinguishing
characteristics of epidemiology is that it deals with
groups of people rather than with individual patients.
Control—Finally, although epidemiology can be used
simply as an analytical tool for studying diseases and
their determinants, it serves a more active role.
Epidemiological data steers public health decision
making and aids in developing and evaluating
interventions to control and prevent health problems.
This is the primary function of applied, or field,
epidemiology.
Epidemiology looks at population vs individual
way to sum up the task of epidemiologists is to say they
"count things." Basically, epidemiologists count cases
of disease or injury, define the affected population,
and then compute rates of disease or injury in that
population. Then they compare these rates with those
found in other populations and make inferences regarding
the patterns of disease to determine whether a problem
exists
Descriptive study: the epidemiologist collects
information to characterize and summarize the health
event or problem. Descriptive epidemiology is the most
basic of the these categories and is fundamental to the
work of an epidemiologists.
Analytical: epidemiologist relies on comparisons between
groups to determine the role of various risk factors in
causing the problem.
Cross-sectional Study: basically a survey- epidemiologist
defines population and collects info. Like a snapshot
in time, doesn't show cause and effect relationships
Cohort Study: Select population by exposure and see what
happens to them- prospective in nature, take years.
Relative risk- quantified relationship between exposure
and outcome in a cohort study
Advantages: can find multiple outcomes, useful
for looking at rare-exposures, can directly
calculate incidence of disease for each exposure
group, logical time like (starting with exposure
and moving forward.
Disadvantage: costly, if rare disease need a lot
of subjects, can lose subjects.
Case-control Study: work backwards from effect to the
suspected cause, retrospective in nature, participants
chosen based on presence or absence of the disease or
outcome - the "Case" subjects OR chosen based on absence
NSG 780 Page 49
outcome - the "Case" subjects OR chosen based on absence
of (controls). Relationship between exposure and outcome
in case-control study quantified by calculating the ODDS
RATIO.
Advantages: can see multiple exposure for a
single outcome. Good for looking at rare diseases
and those with long latency period. Require
fewer case-subjects and usually quicker and less
expensive to conduct that cohort studies- well
suited for the conditions of an outbreak
investigation
Disadvantages: not good at looking at rare
exposures, subject to bias, don't allow for
direct measurement of disease. timeline not as
clear as cohort studies
Quantifying relationships shows correlation, does not
necessarily show causation. To show cause and effect
relationships, generally need:
Strength of association- relationship must be
clear
Consistency: Observation of the association must
be repeatable in different populations at different
times
Temporality- cause must precede the effect
Plausibility: explanation must make sense
biologically
Biological gradient- must be a dose response
relationship.
Epidemic- occurrence of more cases of disease than would
normally be expected
Outbreak- means basically the same thing but has less
serious connotation to general public, so this term is
used to avoid sensationalism
Cluster: group of cases in a specific time and place
that may or may not be greater than the expected rate.
aim of investigating clusters is to determine baseline
rate of disease for that time and place.
Endemic- high background rate of disease
Pandemic- very widespread, often global disease
Agent- entity necessary to cause disease in a susceptible
host. usually thought to be biological (i.e. parasite,
bacteria, etc) but can be physical force (MVC), chemical
or nutritional imbalance. Characteristics of include:
Infectivity—the capacity to cause infection in a
susceptible host.
Pathogenicity—the capacity to cause disease in a host.
Virulence—the severity of disease that the agent causes
in the host
NSG 780 Page 50
Host: person or organism susceptible to effect of the
agent. Classifiable as susceptible, immune, or infected.
host's response to exposure can vary widely, from
showing no effect to manifesting subclinical disease,
atypical symptoms straightforward illness, or severe
illness.
Environment: conditions or influences that are not part
of either the agent or the host, but that influence their
interaction. Many factors come in to play including:
physical, climatologic, biologic, social, and economic
conditions
These factors alone not enough to have a problem, need to
have adequate chain on transmission. For this need:
Source for the agent
Portal of exit: pathway by which agent leaves source
Mode of transmission: means to carry agent to host
Direct transmission: direct contact
Indirect transmission: airborne, vector born
vehicle born.
Portal of entry: pathway into the host- gives agent
access to tissue where it can multiply or act. often
same as portal of exit but on a new organism
Field epidemiology: practice or application of
epidemiology to control and prevent health problems
Module Notes:
Dr. John Snow = father of epidemiology. Noted pump at
the center of the Broad Street Cholera Epidemic
Edwin Chadwick and Lemuel Shattuck are identified as
the founders of the modern era of public health.
Chadwick wrote “Sanitary Conditions of the Laboring
Classes in Great Britain” in 1842 paid special attention
to the working conditions and mortality of child laborers
as young as five. It was widely distributed and
ultimately shifter public consciousness from thinking
that poverty and disease were individual concerns, to
recognizing that they were critical problems that
affected the well-being of the nation and required
national legislation.
Shattuck’s “Report of the Sanitary Commission of
Massachusetts” written in 1850 was much drier. Although
it was well received by the medical community and
NSG 780 Page 51
it was well received by the medical community and
published in the New England Journal of Medicine, it
wasn’t until 20 years later that it received broad public
acceptance. To this day, many of its 19 recommendations
serve as the foundation of public health practice across
the world. They include:
Establish state and local boards of health
*Collect and analyze vital statistics
Exchange health information
Initiate sanitation programs for towns and buildings
*Maintain a system of sanitary inspections
Study the health of schoolchildren
Conduct research on tuberculosis
Study and supervise health conditions of immigrants
*Supervise mental disease
Control alcoholism
*Control food adulteration
Control exposure to nostrums
Control smoke nuisances
Construct model tenements
Construct standard public bathing and washhouses
Preach health from the pulpit
*Teach the science of sanitation in medical schools
*Introduce prevention in all phases of medical practice
Sponsor routine health examinations
Florence Nightingale
Her careful month-by-month analysis of the causes of
mortality during the Crimean War, and her startling
diagrams referred to as coxcombs, led to the
realization that soldiers were not dying primarily of
war wounds, as expected, but from infection which
resulted from the close living quarters, the unsanitary
conditions and the poor food supply.
In 1948, the Framingham Heart Study was initiated by
the NIH to ascertain whether heart disease was an
inevitable outcome of aging or if certain risk factors
increased the risk for heart disease and stroke. This
cohort study and its next generation studies remain
ongoing, over 60 years later. The Framingham Study has
resulted in over 1000 papers and landmark evidence
regarding the risk for heart disease, stroke and many
other chronic diseases.
By 1950, Ernst Wynder, Bradford Hill and Richard Doll
identified the strong link between cigarette smoking and
lung cancer. Not until 14 years later did the U.S.
Surgeon General issue the first report on Smoking and
Health.
In 1980, WHO declared that smallpox was eradicated.
NSG 780 Page 52
Incidence measures the number of new cases of a disease
over the population at risk during a time frame, usually
a year.
Prevalence measures of all cases that exist within the
population at risk. The onset of the disease is not a
factor. It represents the number of people with a
particular disease or condition in a geographic area.
prevalence = incidence X duration
For infectious diseases, incidence rates are generally
more useful than prevalence. In contrast, for chronic
diseases and conditions, prevalence may be more useful
HISTORY OF EPIDEMIOLOGY
Epidemiology is defined as the study of the distribution and determinants of disease in populations
Source: MacMahon, B. & Trichopoulos, D. (1996). Epidemiology: principles and methods. (2nd
ed.).London: Little, Brown, & Co.
Epidemiology is used to:
1. Determine the distribution and frequency of various diseases and health problems in the
population
2. Identify the cause(s) of various diseases and identify risk factors, which increase the risk of
developing those diseases
3. Understand the natural history and prognosis of various diseases
4. Evaluate the effect(s) on health status of preventive measures, medical therapies and health
care delivery systems
5. Provide a scientific basis for sound decision-making in public health and clinical care
Source: Gordis, L. (2008). Epidemiology, (4th ed.). Philadelphia: W.B. Saunders.
Epidemiological investigations have and continue to help us study a variety of problems that include
questions like:
• What causes coronary heart disease?
• Can diabetes be prevented? If so, how?
• What can individuals do to increase their lifespan?
• Does taking aspirin affect the risk of developing colon cancer?
• Is hypertension more common in Baltimore than the rest of Maryland?
• How many people in Maryland suffer from depression?
• What made Uncle Harry sick after the picnic last Sunday?
The American Public Health Association believes that it is critical to gain an appreciation for the key
figures and events in the development of the field of epidemiology. The following is a brief synopsis
of its history.
Hippocrates – First Epidemiologist
NSG 780 Page 53
Hippocrates is often referred to as the first epidemiologist. In 400 BC he wrote in On Air, Water and
Places, a careful description of what we now refer to as the key epidemiological
variables – Person, Place and Time.
Hippocrates stated,
Whoever wishes to investigate medicine properly, should proceed thus: in the first place to
consider the seasons of the year, and what effects each of them produces for they are not at
all alike, but differ much from themselves in regard to their changes. Then the winds, the hot
and the cold, especially such as are common to all countries, and then such as are peculiar to
each locality. We must also consider the qualities of the waters, for as they differ from one
another in taste and weight, so also do they differ much in their qualities. In the same manner,
when one comes into a city to which he is a stranger, he ought to consider its situation, how it
lies as to the winds and the rising of the sun; for its influence is not the same whether it lies to
the north or the south, to the rising or to the setting sun. These things one ought to consider
most attentively, and concerning the waters which the inhabitants use, whether they be marshy
and soft, or hard, and running from elevated and rocky situations, and then if saltish and unfit
for cooking; and the ground, whether it be naked and deficient in water, or wooded and well
watered, and whether it lies in a hollow, confined situation, or is elevated and cold; and the
mode in which the inhabitants live, and what are their pursuits, whether they are fond of
drinking and eating to excess, and given to indolence, or are fond of exercise and labor, and
not given to excess in eating and drinking
Key Figures and Events
The rise and fall of many civilizations can be understood in terms of their ability to protect the health
of the population. Moving forward 2000 years…
In the mid-1600s, in an era when disease was often attributed to poor moral or spiritual character,
and well before the germ theory was developed,
• Thomas Sydenham distinguished and described numerous infectious disease symptoms.
• William Petty and John Graunt began to carefully analyze mortality data.
• William Farr developed statistical approaches to data analysis and occupational mortality. He
also developed a revolutionary system for the categorization of disease. This became the
foundation for the WHO ICD codes that we still use today. The ICD codes are remarkably only
in their 10th edition since their origin in the mid-1600s.
John Snow 1813-1858
NSG 780 Page 54
In the mid-1800s, John Snow, an anesthetist, often referred to as the father of epidemiology,
conducted his landmark studies of cholera in London.
He reported, The most terrible outbreak of cholera which ever occurred in this kingdom, is
probably that which took place in Broad Street, Golden Square, and the adjoining streets, a few
weeks ago. Within two hundred and fifty yards of the spot where Cambridge Street joins Broad
Street, there were upwards of five hundred fatal attacks of cholera in ten days. The mortality in
this limited area probably equals any that was ever caused in this country, even by the plague;
and it was much more sudden, as the greater number of cases terminated in a few hours.
Polluted Drinking Water from Thames:
Could it be related to Cholera Epidemics?
His investigation began to center on the possible connection between water from the Broad Street
pump and the cholera epidemic. Snow wondered it was about the water:
The sewer passes within a few yards of the well. The water at the time of the cholera contained
impurities of an organic nature, in the form of minute whitish flocculi visible on close inspection
to the naked eye. Dr. Hassall, who was good enough to examine these particles … found a
great number of very minute oval animalcules in the water and deemed the animalcules to be
of no importance at the time….
Despite this conclusion and prompted by John Snow’s inquiry, the local officials decided to disable
the Broad Street pump by removing the handle, which turned out to be a key factor in ending the
epidemic.
NSG 780 Page 55
epidemic.
To learn more about this remarkable scientist, please review the ULCA School of Public
Health website devoted to John Snow.
Edwin Chadwick & Lemuel Shattuck
Edwin Chadwick and Lemuel Shattuck are identified as the founders of the modern era of public
health.
Chadwick’s colorful report on the “Sanitary Conditions of the Labouring Classes in Great
Britain” in 1842 paid special attention to the working conditions and mortality of child laborers as
young as five. It was widely distributed and ultimately shifter public consciousness from thinking that
poverty and disease were individual concerns, to recognizing that they were critical problems that
affected the well-being of the nation and required national legislation.
Shattuck’s “Report of the Sanitary Commission of Massachusetts” written in 1850 was much
drier. Although it was well received by the medical community and published in the New England
Journal of Medicine, it wasn’t until 20 years later that it received broad public acceptance. To this
day, many of its 19 recommendations serve as the foundation of public health practice across the
world. They include:
1. Establish state and local boards of health
2. Collect and analyze vital statistics
3. Exchange health information
4. Initiate sanitation programs for towns and buildings
5. Maintain a system of sanitary inspections
6. Study the health of schoolchildren
NSG 780 Page 56
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Study the health of schoolchildren
Conduct research on tuberculosis
Study and supervise health conditions of immigrants
Supervise mental disease
Control alcoholism
Control food adulteration
Control exposure to nostrums
Control smoke nuisances
Construct model tenements
Construct standard public bathing and washhouses
Preach health from the pulpit
Teach the science of sanitation in medical schools
Introduce prevention in all phases of medical practice
Sponsor routine health examinations
Florence Nightingale
Although not given proper due as an epidemiologist in the nursing literature, Florence Nightingale
was a huge intellect in the field.
Her careful month-by-month analysis of the causes of mortality during the Crimean War, and her
startling diagrams referred to as coxcombs, led to the realization that soldiers were not dying
primarily of war wounds, as expected, but from infection which resulted from the close living
quarters, the unsanitary conditions and the poor food supply.
NSG 780 Page 57
Florence Nightingale was a leading member and the first woman invited to join the prestigious
London Epidemiological Society begun in 1850.
Pasteur, Koch, Lister & Goldberg
Soon afterwards, the remarkable discovers of Pasteur, Koch and Lister led to the Germ Theory of
Disease. Specific microbiological pathogens were recognized and ways of increasing host
resistance and decreasing disease transmission were identified.
In 1919, Joseph Goldberg demonstrated that Pellagra was due to a nutritional deficiency, not an
infectious agent.
Framingham Heart Study
In 1948, the Framingham Heart Study was initiated by the NIH to ascertain whether heart disease
was an inevitable outcome of aging or if certain risk factors increased the risk for heart
disease and stroke. This cohort study and its next generation studies remain ongoing, over 60
years later. The Framingham Study has resulted in over 1000 papers and landmark evidence
regarding the risk for heart disease, stroke and many other chronic diseases.
Wynder, Hill, & Doll - Smoking and Lung Cancer
By 1950, Ernst Wynder, Bradford Hill and Richard Doll identified the strong link between cigarette
smoking and lung cancer. Not until 14 years later did the U.S. Surgeon General issue the first report
on Smoking and Health.
NSG 780 Page 58
Salk Polio Vaccine
Jonas Salk discovered and developed the first polio vaccine. When asked who owned the patent on
his vaccine, he responded, “The people I would say. There is no patent. Could you patent the
sun? Watch this short video on the impact of the vaccine worldwide.
On the 10th anniversary of President Franklin Roosevelt’s death, Dr. Thomas Francis announced the
results of the Salk Polio Vaccine Field Trials identifying the safety of the vaccine. For more
information on polio, its devastation, treatment strategies, such as the iron lung noted in the photo,
the vaccine and the 50th anniversary announcement, go to this website.
Eradication of Smallpox
In 1980, WHO declared that smallpox was eradicated.
NSG 780 Page 59
With the issuing of the Surgeon Generals’ first report in 1979 on health promotion and disease
prevention, Healthy People, “ a new period in the modern era of public health began. A companion
document entitled, “Objectives for the Nation” was prepared to establish goals and objectives for
achieving a second public health revolution – the control of chronic disease. Now in its 4th
iteration, Healthy People 2020 forms the national promotion agenda for the nation.
From <https://cf.son.umaryland.edu/NRSG780/module3/subtopic1.htm>
DESCRIPTIVE EPIDEMIOLOGY
There are three types of epidemiological studies:
• Descriptive epidemiology
• Analytical epidemiology
• Experimental epidemiology
Descriptive epidemiology focuses on morbidity and mortality data.
Measures of Mortality and Morbidity
In order to critically review the scientific and clinical literature, it is essential to understand the
definitions and be able to distinguish among the various measures of morbidity and mortality:
• numbers of deaths
• crude mortality rates
• age-specific mortality rates
• age-adjusted mortality rates
• years of life lost
• incidence rates
• prevalence
• attack rates
• case fatality rates
Measures of morbidity and mortality are generally expressed as a multiple of 10.
NSG 780 Page 60
Measures of morbidity and mortality are generally expressed as a multiple of 10.
Measures of Mortality
The crude mortality rate expresses the actual observed mortality rate in a population under study.
Crude mortality rates do not take into account the cause of mortality or the age, ethnicity or sex of
the population. Crude mortality rates should always be the starting point for further development of
adjusted rates.
Cause-specific mortality rate identifies the number of deaths from a particular condition during a
calendar year in the population under study.
If we study cause specific mortality from TB, this graph shows the dramatic decline in rates over the
past century.
This graph shows the similar decline in cause-specific mortality from diphtheria
NSG 780 Page 61
Age-specific mortality rates focus on a particular age range, e.g., 20-29 years.
Age-adjusted mortality rates are calculated by applying age specific rates to the age-distribution of
the population at a particular point in time, usually either 1940, 1970 or 2000. These rates allow
comparison of rates among communities, states or countries with populations of different age
distributions, for example Japan and India. They also allow comparisons of morality rates over time
within communities, states or countries as age distribution changes over time.
Knowing that the average longevity of the population at the beginning of the century was 47 and the
current expected life span is near 75, by age-adjusting, it is possible to see the impact of health
problems over time. This chart shows that there has been a tremendous decline in infectious
diseases during the 20th century. The single exception was the effect of the influenza pandemic in
the early part of the century.
Years of life lost are a measure of the impact to society of deaths from various causes. Rather than
looking at the pure number of deaths, the age at which death occurs is the focus. The number of
premature deaths, usually considered as death before age 75, are aggregated and then the toll on
society from specific disease categories is calculated. This measure reflects the years lost to society,
NSG 780 Page 62
society from specific disease categories is calculated. This measure reflects the years lost to society,
in terms of work productivity, family life and contributions to society as a whole.
Years of life lost were initially calculated based on the average of retirement—65, but now they are
more typically calculated based on 75 or 85. The older we get, the more inclined we are to consider
years of life lost as the sum total before 75, 85 or greater.
MEASURES OF MORBIDITY
Incidence measures the number of new cases of a disease over the population at risk during a time
frame, usually a year.
Such a rate is calculated for a specific period of time (usually one year) for a particular geographic
area. The rate is usually presented as the number of cases per 1000, or 100,000, or 1,000,000
population.
For example, there were 500 new cases of cancer per 100,000 population in Maryland in 2010.
Prevalence measures of all cases that exist within the population at risk. The onset of the disease
is not a factor. It represents the number of people with a particular disease or condition in a
geographic area.
Prevalence represents the number of people with a particular disease or condition in a specific area
per 100 or 1000, or 100,000, or 1,000,000 population.Prevalence is generally measured either at a
point in time (“point prevalence”) or over a period of time (“period prevalence”).
For example, there were approximately 2400 people per 100,000 population with coronary heart
disease in the United States in 2010. Note that because prevalence does not measure new cases
developing over time, it does not represent a rate, but rather a proportion.
Relationship between Incidence and Prevalence
There is a relationship between incidence and prevalence.
prevalence = incidence X duration
If you know two of the three parameters, you can calculate the third.
A change in disease prevalence may be due either to an increase in incidence or to an increase in
the average length of time between disease onset and resolution (or death).
For infectious diseases, incidence rates are generally more useful than prevalence. In contrast, for
chronic diseases and conditions, prevalence may be more useful (e.g., for hypertension).
Attack Rates are often calculated for outbreaks of infectious diseases having a very rapid onset.
They are similar to incidence rates, except it does not include the dimension of time.
Attack rates are often calculated for outbreaks of foodborne illness, usually at picnics or special
events: the number of people who ate the food and became sick divided by the number who ate the
food.
Case Fatality Rates usually are calculated for outbreaks of infectious diseases. They reflect the
number of people who died from the disease over the number who contracted the disease. Such
rates were calculated for Legionnaires Disease and for the deaths due to Anthrax following 9/11.
From <https://cf.son.umaryland.edu/NRSG780/module3/subtopic2.htm>
Exercise:
1. 1200 students out of 1500 in the School of Nursing currently are habitually physically
inactive.
○ What is that measure called?
NSG 780 Page 63
2.
3.
4.
5.
6.
○ What is that measure called?
○ Calculate the measure.
Six out of those 1500 students develop meningitis in the next year.
○ What is that measure called?
○ Calculate the measure.
Two of those six students die.
○ What rate would you calculate?
○ Calculate the measure.
You‌wish‌to‌compare‌rates‌of‌death‌for‌UMB’s‌nursing‌and‌social‌work‌students.
○ What rates should you first calculate?
You wish to compare death rates for male and female faculty members at UMB.
○ What rates should you calculate?
You wish to compare rates of death from cancer for two countries.
○ What rates should you calculate?
From <https://cf.son.umaryland.edu/NRSG780/module3/subtopic2.htm>
Exercise Answers 1. 200 students out of 1500 in the School of Nursing currently are habitually physically
inactive. a. What is that measure called? prevalence b. Calculate the measure. 1200/1500 = 800/1000 2. Six
out of those 1500 students develop meningitis in the next year. a. What is that measure called? incidence
rate b. Calculate the measure. 6/1500 = 4/1000 3. Two of those six students die. a. What rate would you
calculate? case fatality rate b. Calculate the measure. 2/6 = 33% 4. You wish to compare rates of death for
UMB’s nursing and social work students. a. What rates should you first calculate? crude mortality rates 5. You
wish to compare death rates for male and female faculty members at UMB. a. What rates should you
calculate? age-specific mortality rates 6. You wish to compare rates of death from cancer for two countries. a.
What rates should you calculate? age-adjusted mortality rates
ANALYTICAL EPIDEMIOLOGY
There are three types of epidemiological studies:
• Descriptive epidemiology
• Analytical epidemiology
• Experimental epidemiology
Analytical Epidemiology focuses on understanding the determinants and origins of disease. Three
major types of studies are used – cross-sectional, case control and cohort.
Cross-sectional Studies
Examples of cross-sectional studies or surveys include NHANES and BRFSS.
As noted earlier, NHANES provides a detailed portrait of the U.S. population as a whole. These data
show the prevalence of HBP in men and women in 1995.
NSG 780 Page 64
Based on the continuing nature of the survey, NHANES data also provide a snapshot of HPB
awareness, treatment and control levels during different periods of time.
NHANES also gives a profile of serum cholesterol levels in the population.
NSG 780 Page 65
Behavioral Risk Factor Surveillance System data provide an annual portrait of a number of health
behaviors, such as seat belt use…
…and the increasing prevalence of obesity during the past decade.
Case-control Studies
Case-control studies are studies of populations that are as similar as possible, except one has the
disease and the other does not. Among the most widely noted case-control studies were those done
in the area of lung cancer.
NSG 780 Page 66
Ernest Wynder’s landmark case-control studies, as far back as 1950, described tobacco smoking as
a possible factor in lung cancer.
1. Wynder, E.L. & Graham, E.A. (1950). Tobacco smoking as a possible etiologic factor in
bronchiogenic carcinoma: A study of 684 proved cases. Journal of American Medical
Association, 143(4), 329-36.
2. Wynder, E.L. (1954). Tobacco as a cause of lung cancer with special reference to the
infrequency of lung cancer among non-smokers. Pennsylvania Medical Journal,
57, 1073-1083.
Cohort Studies
Cohort studies follow populations for years to determine the effect of various factors. These are
much more costly than cross-sectional or case-control studies and require maintaining populations
that are willing to continue to participate and be examined.
The Framingham Study has followed generations for more than 60 years. As a result of these long
term assessments landmark evidence has been obtained beginning in the early 1960s that includes:
1960
Cigarette smoking found to increases risk of heart disease
1961
Cholesterol, blood pressure and EKG abnormalities found to increase risk of heart disease
1967
Physical activity found to reduce the risk of heart disease and obesity to increase the risk of heart
disease
1970
High blood pressure found to increase the risk of a stroke
1976
Menopause found to increase the risk of heart disease
1978
Psychosocial factors found to affect heart disease
1988
High levels of HDL cholesterol found to reduce risk of death
1994
Enlarged left ventricle shown to increase the risk of stroke
1996
Progression from hypertension to heart failure described
2001
High-normal blood pressure is associated with and increased risk of cardiovascular disease,
emphasizing the need to determine whether lowering high-normal blood pressure can reduce the
risk of cardiovascular disease
2002
Lifetime risk of developing high blood pressure in middle-aged adults is 9 in 10
2009
Parental dementia may lead to poor memory in middle-aged adults
NSG 780 Page 67
2009
Parental dementia may lead to poor memory in middle-aged adults
2010
Sleep apnea tied to increased risk of stroke
2010
Occurrence of stroke by age 65 in parent increased risk of stroke in offspring by 3-fold
For more information on the Framingham Heart Study follow this link:
https://www.framinghamheartstudy.org/about-fhs/history.php
Another outstanding cohort study is the National Institute of Aging’s Study of Women Across the
Nation (SWAN).
The SWAN study is a multi-site longitudinal study that looks at the effects of aging on women in
different ethnic groups. It includes cohorts of Japanese, Chinese, Hispanic, African-American and
white women.
This critical study is looking at bone loss, hormonal levels, surgery, pain, menopausal symptoms and
many other factors in aging women.
The cohorts and analysis are well mapped out over the period of time of the study.
From <https://cf.son.umaryland.edu/NRSG780/module3/subtopic3.htm>
EXPERIMENTAL EPIDEMIOLOGY
NSG 780 Page 68
There are three types of epidemiological studies:
• Descriptive epidemiology
• Analytical epidemiology
• Experimental epidemiology
Experimental epidemiology - describes clinical and community trials.
Clinical Trials
Examples:
•
•
•
•
•
VA Cooperative Studies on Antihypertensive Agents
Hypertension Detection and Follow-up Program
Multiple Risk Factor Intervention Trial (MRFIT)
Drug Trials
Hormone Replacement Therapy (HRT) trials
Randomized Controlled Clinical Trials (RCTs) are the gold standard in epidemiology. Evidence
gained from these studies is the forefront for new therapies and risk factor assessments. One
example of a (RCT) is the Hormonal Replacement Therapy After Breast Cancer
(HABITS) investigation.
Before the trial was to have reached its end, the profound increase in repeat breast cancer in the
group that was receiving HRT as compared to the group that was not led the investigators to stop
the trial, citing HRT after breast cancer as an unacceptable risk for women.
Community Trials
Community trials focus on whether evidence from clinical trials can be successfully applied in
community settings.
The North Karalia trial on the community control of cardiovascular diseases is an outstanding
example of such a trial.
North Karalia was the province in Finland that had the highest cardiovascular disease mortality in the
world, despite having a socialized medical system. In the early 1970’s, citizens petitioned the
government requesting that an urgent intervention be initiated to address the problem.
The government agreed, and began an aggressive strategy aimed at reducing high cholesterol, high
blood pressure and smoking. After 20 years of intervention that included dietary strategies aimed at
reducing the fat in the diet, high blood pressure control and smoking cessation, the prevalence of
risk factors in the population dropped dramatically, over 30% for high cholesterol, 15% for
hypertension, and 20% for smoking in men. However, smoking rates in women increased.
Most importantly, mortality changes dropped dramatically as a result of the reduction in risk factors
NSG 780 Page 69
After several years of implementation, the program expanded throughout all of Finland. Now
Finland’s longevity is higher than the U.S. and among the best in the world.
From <https://cf.son.umaryland.edu/NRSG780/module3/subtopic4.htm>
CAUSAL RELATIONSHIPS
One of the leading standards is the Branford-Hill criteria to establish a relationship for causality.
Through the review of the literature of different types of studies, assessments are made regarding:
1. Strength of the association
2. Dose-response relationship – the higher the dose, the more likely the problem
3. Consistency of the association – the relationship holds up regardless of the type of study
4. Specificity of the association
5. Temporal relationship – the factor is present before the onset of the problem
6. Biological plausibility
7. Coherence of the evidence with other studies
8. Experimental evidence reducing exposure lowers risk*
* Not part of original Bradford-Hill criteria
Two key measures which determine the importance of causal associations:
1. Relative risk requires assessing the magnitude of risk in exposed vs. unexposed.
For example: What is the risk of lung cancer in individuals who smoke as compared to those
who do not?
2. Population attributable risk assesses the percent of the diseases due to exposure to a risk
factor.
For example: Approximately 80% of lung cancer is attributable to cigarette smoking.
Quality of Evidence
As we know, much of clinical practice is based on tradition, not evidence. All aspects have not been
studied and we know that scientific knowledge is doubling at least every five years. Evidence-based
practice requires that clinicians and other health care providers know the scientific literature and the
quality of evidence.
When assessing for quality of evidence, ask:
•
•
•
•
What types of studies have been published?
What are their strengths and weaknesses?
Is there strong evidence for causality?
Is there good evidence of effective interventions?
In order to assess the quality of evidence we look at the types of studies that have been done:
•
•
•
•
•
Case series, case reports that may or may not represent the disease pattern in the population
Case-control studies
Cohort studies
Clinical trials – RCTs are highest quality evidence for demonstrating causality
Community trials – Best evidence that RCT results can benefit general community.
NSG 780 Page 70
Quality of evidence is ranked by the U.S. Preventive Health Services Task Force (USPSTF)
according to types of studies that have been conducted:
• Evidence from at least one properly randomized controlled trial.
• Evidence from well-designed controlled trials without randomization.
• Evidence from well-designed cohort or case-control analytic studies, preferably from more than
one center or research group.
• Evidence from multiple time series with or without the intervention. Dramatic results in
uncontrolled experiments (such as the results of the introduction of penicillin treatment in the
1940s) could also be regarded as this type of evidence.
• Opinions of respected authorities, based on clinical experience; descriptive studies and case
reports; or reports of expert committees.
Strength of recommendations is classified by the USPTSF on an A-D and I gradient based on the
extent of the scientific evidence:
• The USPSTF recommends the service. There is high certainty that the net benefit is
substantial.
• The USPSTF recommends the service. There is high certainty that the net benefit is moderate
or there is moderate certainty that the net benefit is moderate to substantial.
• The USPSTF recommends selectively offering or providing this service to individual patients
based on professional judgment and patient preferences. There is at least moderate certainty
that the net benefit is small.
• The USPSTF recommends against the service. There is moderate or high certainty that the
service has no net benefit or that the harms outweigh the benefits.
• The USPSTF concludes that the current evidence is insufficient to assess the balance of
benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the
balance of benefits and harms cannot be determined.
Note: The lack‌of‌evidence‌of‌effectiveness,‌or‌the‌“I”‌recommendation,‌does‌not‌mean‌an‌
intervention is ineffective. It may mean that:
• current studies are inadequate to determine effectiveness,
• high quality studies have produced conflicting results,
• evidence of significant benefits is offset by evidence of important harm from intervention, or
studies of effectiveness have not been conducted.
From <https://cf.son.umaryland.edu/NRSG780/module3/subtopic5.htm>
ESTABLISHING PRIORITIES
Despite the power of epidemiological evidence, public health agencies and organizations do not
always use epidemiology, which is considered the core science of public health, as the basis for
decision-making and priority setting.
Priorities are also based on non-scientific grounds that include:
1. Incremental shifts from previous priorities
2. Personal preferences of new agency decision-maker(s)
3. Executive decisions from outside the agency
4. Legislative demands
5. Epidemiologic evidence
Each of these approaches has advantages and disadvantages
1. Incremental shifts from previous priorities
○ Advantage: few object to these
○ Disadvantage: rarely scientifically grounded
2. Personal preferences of new agency decision-maker(s)
NSG 780 Page 71
2. Personal preferences of new agency decision-maker(s)
○ Advantage: presents opportunities for change
○ Disadvantage: often not scientifically grounded
3. Executive decisions from outside the agency
○ Advantage: presents opportunities for change
○ Disadvantage: usually politically grounded
4. Legislative demands
○ Advantage: thinking outside the “box”
○ Disadvantage: may not be scientifically grounded
5. Epidemiologic evidence
○ Advantage: decisions have a sound scientific foundation
○ Disadvantage: may be politically unpopular
Exercise
Click on the links below to compare the initial news release by the CDC in the wake of Hurricane
Katrina with a report issued by The Lancet on the same day.
Question: How do the reports compare?
Update on CDC's Response to Hurricane Katrina
The CDC’s public health response to Hurricane Katrina continues to be intense. Early disease and
injury assessments have shown no unexpected health concerns. Vigilant disease, environmental
and injury surveillance continues.
Public health professionals remain concerned about mosquito control and health risks posed by
other pests such as rodents in some areas affected by Hurricane Katrina.
Katrina Reveals Fatal Weaknesses in U.S. Public Health
One of the most shocking aspects of the crisis caused by Hurricane Katrina has been the poor
emergency response. But the failure is no real surprise, says Samuel Loewenberg in a World
Report. This week's lead Editorial states: "for the response to have been so sparse and so late that
thousands of people had to endure 6 parched and hungry days in the drowning city, the public-health
authorities must have got things very badly wrong…
Answer: Note how the CDC’s initial reporting of the response to Hurricane Katrina did not raise the
level of concern that was articulated by British health professionals in The Lancet. Start thinking
about how:
• health departments establish priorities,
NSG 780 Page 72
• health departments establish priorities,
• public health is often referred to as what you don’t see, and competing avenues for funding
influence public capacity to address crises.
USING EPIDEMIOLOGY TO ESTABLISH PRIORITIES
Magnitude of the Problem
When priorities are based on epidemiology, a key element is the magnitude of the problem as
measured by:
1. Mortality/morbidity rates
2. Years of life lost
3. Direct and indirect costs
If the focus is the leading causes of death, heavier emphasis is placed on heart disease, cancer,
chronic lower respiratory diseases, and accidents and less on infectious disease.
When we study our public health successes in terms of infectious and chronic diseases, from this
chart, we can see how there truly has been a revolution in the conquering of infectious disease. We
can also see that minimal success has been achieved in the chronic disease arena.
When we consider measuring the magnitude of the problem in terms of years of life lost, the
greatest emphasis would shift to cancer, heart disease and accidents.
NSG 780 Page 73
When we revisit the contributions of various factors to premature mortality, a modifiable cause of
lifestyle interventions become a leading priority.
Population-based Strategies
The most successful large scale interventions that have resulted in significant increases in longevity
and quality of life, like the Finland initiative, have moved beyond high risk
strategies to population-based strategies:
• high risk strategies - focus on identifying the relatively small number of individuals who are at
high risk in order to reduce their risk factor(s) and subsequent development of disease
• population-based strategies - focus on changing behavior in large numbers of people, most
of whom have low or no risk at present, in order to prevent the development of risk factors and
disease
As we look at heart disease mortality in relation to cholesterol levels we see that significant mortality
occurs in the mid-range. Only focusing on those who are highest risk would miss a considerable
part of the population that is at risk as well.
NSG 780 Page 74
This graph shows the distribution of cholesterol levels in the population and again demonstrates that
if prevention strategies are approached from a whole population perspective, the impact on morality
will be much more significant, than if only those at highest risk are targeted.
Epidemiologically-Based Criteria
When health departments or agencies establish priorities based on the epidemiological evidence
they utilize the following criteria:
• Magnitude of the problem
• Mortality/morbidity rates
• Number of people effected
NSG 780 Page 75
• Number of people effected
• Extent to which modifiable causes of the problem had been identified
• Extent to which interventions could reduce these causes and thereby reduce the magnitude of
the problem
• Cost of the program relative to accomplishments
• Whether the program set rigorous goals and objectives and accomplished them
Summary
Putting in All Together
1. The different types of epidemiologic studies each have strengths and weaknesses, but
randomized clinical trials represent the gold standard.
2. Epidemiology provides the scientific tools for acquiring high-quality data and for assessing the
quality of others’ data.
3. Epidemiologic principles should serve as the foundation for priority setting, both in public health
and clinical practice.
4. Data should be the driving forces for scientific policy and decision-making, although often they
are not.
5. Critically reading and keeping up with the literature is crucial to maintaining both clinical and
policy-making skills.
From <https://cf.son.umaryland.edu/NRSG780/module3/subtopic6.htm>
NSG 780 Page 76
Module 4 Primary, Secondary, and Tertiary Prevention
Monday, March 13, 2017
12:05 PM
OVERVIEW
The purpose of this module is to examine principles of primary, secondary and tertiary
prevention, to introduce clinical practice guidelines, and to showcase a community based health
promotion program that emphasizes primary, secondary and tertiary prevention.
Objectives
At the conclusion of this module, the learner will be able to:
• Differentiate primary, secondary and tertiary prevention
• Identify characteristics of good screening tests
• Explain clinical practice guidelines
• Describe a model population-based primary, secondary and tertiary prevention program
Required Readings
• Butterfield, Patricia G. (1990). Thinking upstream: Nurturing a conceptual
understanding of the societal context of health behavior. Advances in Nursing
Science, 12(2), 1-8.
(This article is a seminal work in the field written when Patricia Butterfield was in her
doctoral program. She is now the Dean at Washington State School of Nursing.)
From <https://cf.son.umaryland.edu/NRSG780/module4/index.htm?globalNavigation=false>
Article:
Thinking upstream: Nurturing a conceptual understanding
of the societal context of health behavior. -Butterfield
Addresses issues of nursing being thought of as a 1:1
interaction- need to realize it's not just talking to
one patient at a time, nurses need to understand social
political and economic influences that shape health of
society. Nursing roles to help all of pop. Also need to
understand client's behaviors in context of their society
Healthcare providers need to look more "upstream" to
figure out what's causing the problem to begin with.
American health system emphasized episodic, individualbased care, doesn't do much for chronic illness which
70% of American pop deals with. Need to alters system
to change the way clients act. People breaking appts
and other issues symptoms of a system issue, not
necisarrily failure of that person or lack of motivation
Three theoretical approaches explored below:
Downstream view: Individuals at the Locus of Change:
Called The Health Belief Model: people make decisions based
on avoiding things they don't like and doing things they
like- individual to blame if they don't recognize a
disease as something they should work to avoid. In
practice- focuses nurse's energies on fixing this
distorted view. Nurse needs to modify the client's
perception of benefits or barriers: ex- if client doesn't
NSG 780 Page 77
perception of benefits or barriers: ex- if client doesn't
have adequate care, need to be counseled on how to see
these barriers in new light. DOES NOT encourage nurse to
promote equal access to those in need. DOES NOT recognize
responsibility for healthcare professionals to reduce
barriers, puts it on the client only. Some proponents of
it aware of this and recognize this limitation, don't
recommend using it except in 1:1 interaction.
Upstream view: Society as the Locus of Change:
Milio's Framework for Prevention: alt view of healthcare
looks at population level. Choices people make
shaped by gov policy decisions by gov and private orgs.
Advocates focusing on national level policy making as
most effective way to affect health of most American.
Proposes health deficits often from mismatch in pop
health needs and health sustaining resources- ie.
affluent societies have diseases from excess (obesity)
and poor from inadequate or unsafe food, shelter and
water. Because of this poor in affluent societies may
have least desirable combo of factors- ie. poor people
living in rich environments always can get cigs, sugar
and pollution.
Most human beings make the easiest choice that's
consistently available to them therefor, need to make
health-promoting choices the easiest thing avaiable.
Suggests that low-income individuals are acting within
the restraints of their limited resources. Additionally,
changes in health pop result in decisions making by a
significant number of people in a pop, not just one
person deciding to change.
Critical Social Theory:
Social inequities prohibit people from reaching their
full potential. Think that power imbalances result in
socially dominant making everyone's life structured a
certain way. If power imbalance doesn't influence policy,
society will be more rational. Way it is now makes
certain groups- ie. women and poor people vulnerable to
being labeled by pseuododiseases ie. hysteria. Way health
system is now doesn't look at fact many sources of
illness in the capitalist industrial environment and only
focuses on individual being to blame for problems.
Proposes each person needs o create social conditions in
which all members can speak freely and nurse should
expose power imbalances
Other Examples of Upstream Thinking
If we're going to say society is part of the root of a cause,
should make fixing society one of the interventions to
fix the problem.
NSG 780 Page 78
fix the problem.
Need to be aware of changing environmental factors and
for example- advocate for people who don't have adequate
housing. Don't just look at how the patient feels about
where they live and try to change their feeling- looks
socio-politically at how it actually is.
Need for Alternative Perspectives:
Need different perspectives to consider things on
microspective and macrospective levels, these
approaches can be complimentary but they can't exist in
a vacuum. If nurses don't understand framework of health
beyond individual level, nurses won't have understanding
of their responsibility to help fix problems on systemic
level.
MODULE NOTES:
LEVELS OF PREVENTION:
PRIMARY PREVENTION
Prevent occurence of disease to begin with, focuse on
population and does NOT have the diease already. Ex:
immunization
SECONDARY PREVENTION:
Aimed at early detection and treatment before signs and
symptoms occur.
Only should screen for IMPORTANT HEALTH PROB (ie. ones
that result in significant morbitiy or mortalits and
those that have high incidence/prevalence).
ALSO need to have evidence that early detection and tx
improves outcomes because other wise what's the point of
knowing.
TERTIARY PREVENTION:
interventions aimed at preventing further morbidity ,
limiting disability and avoiding mortality and those
aimed at rehab from disease.
CLINICAL PRACTICE GUIDELINES
Systematically developed statments used to assist
practitioner and patient decisions about appropriate
health care for specific clinical circumstances
Many synonyms ie. "standards of care"
LEVELS OF PREVENTION
There are three levels of prevention: primary, secondary and tertiary.
Primary Prevention
NSG 780 Page 79
Primary Prevention
Primary prevention describes interventions aimed at preventing occurrences of disease, injury
or disability. Primary prevention strategies focus on a population the does not have a disease
that an initiative is trying to prevent.
Immunizations are a familiar example of primary prevention. As a society, we are very
concerned with vaccine-preventable diseases.
Pediatric and family practitioners and many parents recognize the importance of and follow the
vaccine schedules for children. Proof of immunizations is required by many institutions, such as
day care, schools and health care settings. This requirement further reinforces this primary
prevention measure.
Another example of primary prevention is exercise Let's Move! is an initiative, launched by the
First Lady, that provides parents with helpful information to help children become more
physically active, eat a healthy diet and maintain ideal weight.
Not starting smoking or early smoking cessation are also primary prevention strategies geared
toward preventing heart disease, cancer, stroke and many other diseases.
Secondary Prevention
Secondary prevention describes initiatives aimed at early detection and treatment of disease
before signs and symptoms occur. Secondary prevention focuses on the population that has
disease, but in its earliest stage. With early detection and intervention, secondary prevention
strategies can be effective and significantly enhance health care outcomes.
Secondary prevention is often equated with screening, but it is actually broader than screening
alone and includes early intervention.
Screening is defined in terms of What, Who and Why.
NSG 780 Page 80
Population screening is not appropriate for all diseases. Screenings should focus on important
health problems that result in significant morbidity and mortality for the population as a whole.
This would include:
• diseases with a high incidence or prevalence rates
• disabilities that significantly decrease quality of life
• diseases that have a high mortality rate.
Criteria for screening include:
• an important health problem
• an acceptable form of treatment
• evidence that early detection and treatment improves the outcome
• an understanding of the natural history of the disease
• a recognizable latent stage
• a suitable screening test
• availability of diagnostic/treatment facilities
• an agreed upon policy on whom to treat
• a reasonable cost of screening
If there is not an acceptable form or treatment, or early detection/treatment does not improve
the outcomes, or few of the other criteria are met, then screening may be inappropriate.
Successful screening programs are:
• Valid (accurate)—High probability of correct classification of person tested
• Reliable (precise)—Results consistent from place to place, time to time, person to person
• Capable of large group administration—Fast and inexpensive Innocuous—Minimally
invasive and few side effects
• High yield—Ability to detect enough new cases to warrant the effort and expense
Validity is measured by sensitivity and specificity. Commit the definitions below to memory:
• Sensitivity measures the proportion of persons with the disease correctly identified as
positive (true positives)
NSG 780 Page 81
positive (true positives)
• Specificity measures the proportion of persons the test correctly identifies as negative for
the disease (true negatives)
Screening is appropriate when there is a significant latent phase and detecting the problem
early will lead to improved outcomes and improved survival.
Evaluation of a Screening Program - screening programs are considered effective when
they:
• reduce the burden of disease
• enhance quality of life
• reduce mortality rates.
Examples of Good Screening Tests*
Questions about lifestyle risk factors (e.g., diet, smoking,
physical activity)
Dental exam
Examples of Bad Screening
Tests
Chest X-ray
Resting EKG
Pap smear
Exercise EKG
Blood pressure measurement
Urinalysis
Screening for osteoporosis in the ≥ 60 years of age
PSA
Skin examination
CBC
Blood cholesterol measurement
Thyroid function tests
Stool hemoccult
Sigmoidoscopy/colonoscopy ≥ 50 years of age
Mammography for women ≥ 50 years of age
Blood lead levels (in high-risk populations)
Metabolic diseases of childhood (e.g., PKU hypothyroidism)
*not all of these are appropriate for community screening settings
Tertiary Prevention
Tertiary Prevention includes interventions aimed at preventing further morbidity, limiting
disability and avoiding mortality and interventions aimed at rehabilitation from disease, injury or
disability.
Examples: insulin for diabetes, penicillin for pneumococcal pneumonia, CVD exercise programs,
drug therapy, substance abuse treatment programs.
Summary: This schematic may help in summarizing primary, secondary and tertiary prevention
in relation to disease onset and usual detection.
NSG 780 Page 82
From <https://cf.son.umaryland.edu/NRSG780/module4/subtopic1.htm>
Definition of CPG
CPG's are systematically developed statements used to assist practitioner and patient decisions
about appropriate health care for specific clinical circumstances.
There are numerous synonyms for clinical practice guidelines including:
• practice parameters
• therapeutic guidelines
• practice policies
• management guidelines
• clinical algorithms
• standards of care
Development of CPG
Evidence-based decision making is the best foundation for clinical practice guidelines.
If evidence is not available, they can be based on a formal group consensus-generating
process.
Guidelines come from:
• professional societies (e.g., American Nurses Association)
• federal agencies (e.g., Agency for Healthcare Research & Quality)
• non-profit organizations (e.g., American Hospital Association)
• hospitals
• manage care organizations
Benefits of Clinical Practice Guidelines
Benefits for patients:
•
•
•
•
improve health outcomes
improve consistency of care
empower patients to make informed healthcare decisions
influencing public policy
Benefits for healthcare professionals:
• improve quality of clinical decisions
NSG 780 Page 83
• improve quality of clinical decisions
• support quality improvement activities
• Identify key research questions
On the negative side, clinical practice guidelines may also be seen as self-serving in terms of
reimbursement, turf issues, and medico-legal issues.
Benefits for health care systems
• improve efficiency
• reduce costs
• improved public image
Attributes of Good CPG
•
•
•
•
•
•
•
validity
reliability/reproducibility
clinical applicability
clarity
multidisciplinary process for development
structured review
documentation
U.S. Preventive Services Task Force (USPSTF)
The U.S. Preventive Health Services Task Force is a leader in establishing CPGs under the
auspices of the Agency for Healthcare Research and Quality (AHRQ). The Task Force is an
independent panel of experts in primary care and preventive medicine that systematically
reviews the evidence of effectiveness and develops recommendations for clinical preventive
services.
The federal government has developed a number of clinical and population-based guidelines,
often stemming from the exhaustive work of expert panels. Click here to see the USPSTG A-Z
Topic Guide and the dates when each of the available guidelines was issued.
The Office of the Surgeon General has been a leader in developing guidelines.
National Heart Lung and Blood Institute
One of the earliest sets of guidelines developed by the National Heart Lung and Blood Institute
(NHLBI) was directed to nurses—Guideline on Helping Your Patients Stop Smoking.
NHLBI remains the leader in the field of guidelines for hypertension, issuing the 7th Report of
the Joint National Committee on the Detection, Evaluation and Treatment of
Hypertension(JNC 7 Guidelines). Included in the report is a convenient office reference guide
on treatment guidelines, categories of hypertension, including the prehypertensive category
between 120/80 and 140/90, and guidelines on pharmacological and lifestyle interventions for
treatment.
NHLBI’s Dietary Approaches to Stop Hypertension (DASH) diet is included as a nonpharmocological intervention in the JNC 7 Guidelines.
NHLBI’s Landmark SPRINT study results released September 11, 2015 further reaffirms the
NSG 780 Page 84
NHLBI’s Landmark SPRINT study results released September 11, 2015 further reaffirms the
importance of achieving a target systolic blood pressure of 120 mm Hg. For more information on
the SPRINT study click on http://www.nhlbi.nih.gov/news/press-releases/2015/landmarknih-study-shows-intensive-blood-pressure-management-may-save-lives.
NHLBI’s Adult Treatment Panel has issued its third report on the Detection, Evaluation and
Treatment of High Blood Cholesterol in Adults. The report clearly explains what affects
cholesterol—diet, weight and physical activity, and identifies what patients need to know in
terms of LDL, HDL and triglycerides.
Additional Resources for Guidelines
Numerous guidelines exist in other areas as well. The US Departments of Health and Human
Services and Agriculture recently issues the 2015-2020 Dietary Guidelines to help health
professionals and policy makers improve overall eating patterns of Americans.
The newest guidelines have MyPlate replacing the Food Guide Pyramid.
For more information on the Dietary Guidelines for Americans click here.
Some of the newest guidelines are in the area of obesity. Many guidelines now include
information on the cost/benefit of primary prevention, screening and improved care as a result of
following clinical practice guidelines, all major tenants of the Affordable Care Act.
From <https://cf.son.umaryland.edu/NRSG780/module4/subtopic2.htm>
•
Primary, Secondary and
Tertiary Prevention: Model
NSG 780 Page 85
Tertiary Prevention: Model
Population-based Prevention
Program
•
•
•
At the end of the 1960s, Finnish men,
especially men in North Karelia, had
the highest international rates of
coronary heart disease mortality.
Vartiainen, E., et.al. Thirty-five-year trends in cardiovascular risk
factors in Finland. International Journal of Epidemiology 2010;
39:504-518 citing Thom, T, et. Al., Total mortality and mortality
from heart disease, cancer and stroke from 1950 to 1987 in 27
countries: National Institutes of Health; 1992. Report No.:
92-3088
North Karelian Petition to the
Finnish Government
The petition stated that national
authorities and organizations “should
urgently undertake efficient action to
plan and implement a program which
would organize and finance general
health information to the public,
necessary basic research, and
individual health education to reduce
this greatest public health problem of
NSG 780 Page 86
this greatest public health problem of
the country.”
•
•
•
•
•
•
•
Key Components of the North
Karelia Project
Informing the public
Reorganizing services
Training personnel
Environmental changes
Evaluation services
Prevalence of CHD Risk
Factors in NK,
1972 vs. 1992
1972
High cholesterol
Men
60%
Women
56%
High blood pressure
Men
65%
Women
65%
Smoking
NSG 780 Page 87
1992
27%
17%
49%
39%
Smoking
Men
Women
•
52%
10%
32%
17%
Serum Cholesterol in Men
30-59
1972-2007
Puska, P. (2009) Fat and heart disease: yes we can
make a change—the case of North Karelia (Finland) .
Annals of Nutrition and Metabolism 2009;54 (suppl 1)
33-38.
•
Observed and Predicted Decline in
CHD Mortality in Men 1972-2007
Vartiainen, E., et.al. (2010) Thirty-five-year trends in
cardiovascular risk factors in Finland
•
Finnish Mortality Rate per
100,000
1969-2005
Puska, P. (2009) Fat and heart disease: yes we can make a
change—the case of North Karelia (Finland) . Annals of Nutrition
and Metabolism 2009;54 (suppl 1) 33-38.
•
Theory and Action for
Effective Programs and
Policies
NSG 780 Page 88
Policies
•
•
•
•
•
•
Summary
Think upstream
Recognize the importance of
primary, secondary and tertiary
prevention
Become familiar with clinical
guidelines for clinical and
population-based practice
Apply this in your practice and in
developing population-based
programs
NSG 780 Page 89
NSG 780 Page 90
Module 5 Health Disparities / Cultural Competence
Monday, March 13, 2017
5:22 PM
OVERVIEW
Minority Health Determines the Health of the Nation - The United States has become
increasingly diverse in the last century. According to the 2010 U.S. Census, approximately
36 percent of the population belongs to a racial or ethnic minority group. Though health
indicators such as life expectancy and infant mortality have improved for most Americans,
some minorities experience a disproportionate burden of preventable disease, death, and
disability compared with non-minorities.
https://www.cdc.gov/minorityhealth/ September 8, 2016
The purpose of this module is to introduce the factors that relate to health disparities in the U.S.,
and the role of public health in addressing the disparities. Each of us plays an essential and
individual role in addressing health disparities. In addition, the future of health care in our nation
is in large part determined how health care providers respond to the urgency to address health
disparities as a national health concern.
Although the focus of this discussion is primarily on racial and ethnic groups, health disparities
affect the nation as a whole. Differences in race, ethnicity, sex, geography, sexual identity,
disability and age are some of the factors that contribute to health disparities. Yet, insufficient
attention has been paid to these differences. Your role and the roles of other health care
providers, in addressing health and health services for all segments of the population will
significantly impact the future of health and health care in America. Join in a discussion of
disparities and how you can make a difference!
Objectives
At the conclusion of this module, the learner will be able to:
• Define health disparities and its importance to the nation
• Examine two important frameworks for describing and addressing health disparities
• Explore the evidence supporting health disparities
• Discuss Maryland's Health Disparities Initiatives
• Appreciate cultural group differences and health care beliefs of select priority populations
• Identify public health strategies to address health care disparities
Required Readings
• Centers for Disease Control and Prevention (CDC). (2013).
Fact Sheet. Health Disparities and Inequalities Report – United States. Available
at http://www.cdc.gov/minorityhealth/CHDIReport.html
Recommended Reading
• Strategies for Reducing Health Disparities – Selected CDC Sponsored Interventions,
United States, 2016 available at: http://www.cdc.gov/mmwr/ind2016_su.html
Directions
Read the module and suggested readings within the module.
From <https://cf.son.umaryland.edu/NRSG780/module5/index.htm?globalNavigation=false>
Forward on Health Disparities:
https://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a1.htm?s_cid=su6203a1_w
In the United States, whites have a longer healthy life
expectancy than blacks, and women live longer than men.
There are also marked regional differences, with much
lower life expectancy among both white and black
Americans who live in the Southeast.
NSG 780 Page 91
CDC Health Disparities and Inequalities Report —
United States, 2013 is the second agency report
examining some of the key factors that affect health and
lead to health disparities in the United States. Four
findings bring home the enormous personal tragedy of
health disparities:
1. Cardiovascular disease is the leading cause of
death in the United States. Non-Hispanic black adults
are at least 50% more likely to die of heart disease or
stroke prematurely (i.e., before age 75 years) than
their non-Hispanic white counterparts.
2. The prevalence of adult diabetes is higher among
Hispanics, non-Hispanic blacks, and those of other or
mixed races than among Asians and non-Hispanic whites.
Prevalence is also higher among adults without college
degrees and those with lower household incomes.
3. The infant mortality rate for non-Hispanic
blacks is more than double the rate for non-Hispanic
whites. Rates also vary geographically, with higher
rates in the South and Midwest than in other parts of
the country.
4. Men are far more likely to commit suicide than
women, regardless of age or race/ethnicity, with overall
rates nearly four times those of women. For both men and
women, suicide rates are highest among American
Indians/Alaska Natives and non-Hispanic whites.
CDC Health Dispari es and Inequali es Report—U.S. 2013
Health dispari
es and inequali
es are gaps in health or
health determinants between segments of the popula
on.
Iden
fica
on and awareness of differences among popula
ons
regarding health determinants and health outcomes are
essen
al first steps toward reducing health dispariti
es
During 1999-2002 and 2007-2010, the prevalence of
obesity increased significantly among boys and men but
did not increase significantly among girls and women.
Substan
al dispari
es persisted in theprevalence of
NSG 780 Page 92
es persisted in theprevalence of
obesity by race/ ethnicity, sex, and educa
on.
Preventable hospitaliza on rates were higher for
residents of lower income neighborhoods compared with
higher income neighborhoods and were higher for
non-Hispanic blacks and Hispanics compared with
non-Hispanic whites during 2001-2009.
Binge drinking is more common among persons aged 18-34
years, men, non-Hispanic whites, and persons with higher
household incomes. Binge drinkers aged =65 years report
the highest binge drinking frequency, and those 18-24
years and American Indian/Alaska Na
ves report the
highest binge drinking intensity
Although some progress has been made in reducing
cigare&e smoking among certain racial/ethnic groups in
recent years, li-le progress has been made in reducing
cigare-e smoking among personsof low socioeconomic
status.
Persons living in rural census tracts, or living in
areas with a higher percentage of senior ci
zens, or with
a higher percentage of non-Hispanic whites, more often
lacked at least one healthier food retailer nearby
(within ½-mile of the tract boundary) compared with
persons living in other census tracts.
Strategies for Reducing Health Disparities —
Selected CDC-Sponsored Interventions,
United States, 2016
https://www.cdc.gov/mmwr/volumes/65/su/pdfs/su6501.pdf
Public health programs can be particularly difficult to
manage because of the inability to track program
performance in real time. Moreover, results might not be
apparent for months or even years. As a result, all
programs must include sustainable monitoring systems
that provide simple, accurate information on progress in
program implementation and long-term impact. Even the
best-designed programs might fail without timely, honest
evaluation
NSG 780 Page 93
Asthma can be managed effectively when children and
families receive asthma education, understand
medications, live in healthy housing, and have a system
of coordinated care in place. Multiple social
determinants of health contribute to asthma disparities:
low household income; environmental inequities (e.g.,
outdoor air pollution and substandard housing) and
living in poor communities (18,19); exposure to pests,
mold, air pollution (including secondhand smoke); and
high levels of stress due to community violence.
Racial/ethnic minority youth are at particularly high risk for
morbidity and mortality associated with violence, including
homicide. These youth often live in communities that have
disproportionately high violence rates and community
conditions associated with violence and violent injuries.
Community-level strategies are a critical part of comprehensive
approaches that are necessary to achieve broad reductions in
violence and health disparities
The HoMBReS study provides evidence that strategies
involving lay health advisors can increase condom use and
HIV testing among Hispanic/Latino men. Social networks
among Hispanic/Latino men can be used to promote sexual
health within the community. Because the populations
disproportionately affected by HIV and STDs often lack
needed prevention resources, wide implementation of
interventions that harness community social networks, such
as HoMBReS, HoMBReS Por un Cambio, and HOLA, could
decrease behaviors that increase risk for HIV infection among
Hispanics/Latinos in the United States, including MSM and
transgender persons.
Health Equity is when everyone has the opportunity to be as healthy as possible. (CDC, 2016)
Health disparities are differences in health outcomes and their determinants between
segments of the population as defined by social, demographic, environmental and geographic
attributes. (CDC, 2011)
Health disparities are often referred to as gaps in health between segments of the population.
Often they are between groups that reflect social inequities. The CDC has been monitoring and
responding to these challenges since 1946.
Health inequalities is a term used more in the scientific and economic literature to refer to
summary measures of population health associated with individual- or group-specific attributes
(e.g., income, education or race/ethnicity). (CDC, 2011)
Health inequities are a subset of health inequalities that are modifiable, associated with social
disadvantages, and considered ethically unfair.
Often the terms health disparities and health inequalities are used interchangeably. It is
important to know the context of the discussion to distinguish their meaning.
NSG 780 Page 94
Source: http://www.cdc.gov/minorityhealth/strategies2016/index.html
Framework for Action on Social Determinants of Health
In 2007 Solar and Irwin developed a conceptual framework for action on the social determinants
of health. The framework was updated in 2010. This framework was created to help policymakers develop interventions to counter health inequities. The model includes three core
components:
• socioeconomic and political context
• structural determinants of health inequities
• intermediary determinants of health
The structural determinants cause and operate through intermediate determinants to shape
health outcomes.
Education and Income
NSG 780 Page 95
Education and Income
Source: United Way Live United. Available at http://www.unitedwaycassclay.org/how-wehelp
The socioeconomic circumstances of individuals and the places where they live and work
strongly influence their health.
The risk for mortality, morbidity, unhealthy behaviors, reduced access to health care and poor
quality of care increases with decreasing social circumstances. The association is continuous
and graded across a population and cumulative over the life course. This is an example of
health disparity that is also a health inequity. (Beckles & Truman, 2013)
From <https://cf.son.umaryland.edu/NRSG780/module5/subtopic1.htm>
Disability Measures
Basic actions difficulty and complex activity limitation are ways of measuring disability
status:
• Basic actions difficulty measures limitations in movement, and emotional, sensory, or
cognitive functioning associated with a health problem.
• Complex activity limitation is the inability to function successfully in certain social roles,
such as working, maintaining a household, living independently, or participating in
community activities.
As shown in the image below from 2000 to 2010, the prevalence of each disability was higher
for women than men in the same age group, with the exception of complex activity limitation
among those aged 18–64, where the prevalence was the same for men and women.
NSG 780 Page 96
Differences between men and women, young and old are disparities, but they are not inequities.
Obesity in Children
Some health disparities appear to be increasing over time in the United States. For example,
from 1988 to 1994 higher levels of education among the head of household resulted in lower
rates of obesity among boys and girls 2-19 years of age. This trend continued in surveys from
2007-2010 but the rates of obesity increased in all groups. In households where the head of
household had less than a high school education, 24% of boys and 22% of girls were obese. In
households where the head had a bachelor’s degree or higher, obesity prevalence was 11% for
males and 7% for females aged 2-19.
Life Expectancy
Another example of a health disparity is the widening of the gap in life expectancy at age 25
between 1996 and 2006 for both men and women. Between 1996 and 2006, life expectancy
increased for men and women with a Bachelor’s degree or higher, while remaining unchanged
for those with less than a Bachelor’s degree. The high school graduation rate in the U.S. is 75%.
Consider the impact of increasing the rate on the health status of the US.
NSG 780 Page 97
Consider the impact of increasing the rate on the health status of the US.
Delay or Nonreceipt of Medical Care or Prescription Drugs Due to Cost
Health disparity is also noted in the delay or nonreceipt of medical care or prescription drugs.
These kinds of delays may result in more serious illness, increased complications, and longer
hospital stays. From 2004–2014, uninsured adults were 4–5 times more likely than those with
private coverage and 1½ – 3 times more likely than those with Medicaid to identify medical care
and prescription access problems. For adults with Medicaid, medical care access problems
were stable until 2008 and then decreased through 2014. For adults with private insurance,
medical care access problems increased until 2009 and then decreased through 2014. For the
uninsured, medical care and prescription access problems increased (until 2010 and 2009,
respectively) and then were stable for medical care and decreased through 2014 for access to
drugs. Drug access problems were stable in 2004–2014 for those with private insurance and
decreased for adults with Medicaid.
SOURCE: CDC/NCHS, Health,UnitedStates,2015,Table 63.Data from the National Health
Interview Survey (NHIS).
NSG 780 Page 98
Vaccinations
One area in which there has been great success in reducing health disparities is in vaccinations
among adolescents. Vaccinations recommended for the preteen to the teenage years include
tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap), meningococcal conjugate
vaccine (MenACWY), and three doses of human papillomavirus vaccine (HPV). MenACWY was
recommended for use in 2011 and HPV for females in 2007. Although adolescents living in
poverty were less likely to have recommended vaccinations compared with adolescents living in
families with income at 400% or more of the poverty level, the differences were relatively low.
Vaccinations may be expensive but are often covered by health insurance. Uninsured children
may receive vaccinations at little or no cost. In addition, many schools, daycare, camps and
other facilities require proof of vaccination before children can participate. We need to
recognize these programs as a model on how to counter health disparities.
NSG 780 Page 99
Vaccine coverage has further improved over the last five years and differences based on
poverty level have been eliminated as noted in the table below.
From <https://cf.son.umaryland.edu/NRSG780/module5/subtopic2.htm>
COMMUNITY HEALTH INDICATORS
Health disparities, inequalities and inequities are important indicators of community health.
The guiding premise for Healthy People 2020 reinforces the foundational statement from the
Healthy People 2010 report. “The health of the individual is almost inseparable from the health
of the larger community and the health of every community in every state and territory
determines the overall health status of the nation.” (Healthy People 2010)
This analysis of healthy days across states indicates that states that have lower average health
also have higher health inequality. At each level of the U.S. income distribution (low, medium,
high), higher health inequality is associated with lower average number of healthy days.
From <https://cf.son.umaryland.edu/NRSG780/module5/subtopic3.htm>
NSG 780 Page 100
IOM Report on Unequal Treatment
LEADING REPORTS ON HEALTH DISPARITIES
From <https://cf.son.umaryland.edu/NRSG780/module5/subtopic4.htm>
A landmark report on health disparities is the Institute of Medicine (IOM) report published in
2002 titled: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.
“Disparities in the health care delivered to racial and ethnic minorities are real and are
associated with worse outcomes in many cases, which is unacceptable.”
- Alan Nelson, retired physician, former president of the American Medical Association and chair
of the committee that wrote the IOM report. Martha Hill, former dean of the Johns Hopkins
NSG 780 Page 101
of the committee that wrote the IOM report. Martha Hill, former dean of the Johns Hopkins
School of Nursing, co-chaired the committee.
The report described evidence of racial and ethnic disparities in healthcare:
• Found consistently across a wide range of disease areas and clinical services
• Present even when clinical factors, such as stage of disease presentation, co-morbidities,
age, and severity of disease are taken into account
• Found across a range of clinical settings, including public and private hospitals, teaching
and non-teaching hospitals, etc.
• Associated with higher mortality among minorities
The report identified potential sources of disparities in care:
• Health systems-level factors – financing (e.g., lack of insurance), structure of care; cultural
and linguistic barriers
• Patient-level factors – including patient preferences, refusal of treatment, poor adherence,
biological differences
• Disparities arising from the clinical encounter
AHRQ Report on National Healthcare Disparities
http://www.ahrq.gov/research/findings/nhqrdr/nhqdr15/index.html
Since 2003, the Agency for Healthcare Research and Quality has produced the National
Healthcare Quality Report and the National Healthcare Disparities Report. These reports to
Congress are mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129).
Beginning with the 2014 reports, findings on health care quality and health care disparities are
integrated into a single document that provides a comprehensive overview of the quality of
health care received by the general U.S. population and disparities in care experienced by
different racial, ethnic and socioeconomic groups. The 215 report includes an update on the
National Quality Strategy and identifies six priorities that target quality concerns that affect most
Americans:
• Patient Safety: Making care safer by reducing harm caused in the delivery of care
• Person- and Family-Centered Care: Ensuring that each person and family is engaged as
partners in their care
• Care Coordination: Promoting effective communication and coordination of care
• Effective Prevention and Treatment: Promoting the most effective prevention and
treatment practices for the leading causes of mortality starting with cardiovascular disease
• Healthy Living: Working with communities to promote wide use of best practices to enable
healthy living
•
NSG 780 Page 102
• Care Affordability: Making quality care more affordable for individuals, families, employers
and governments bv developing and spreading new health care delivery models
If you are interested in further information, review the priorities available
at: http://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/nhqdr15/201
5nhqdr.pdf
CDC Health Disparities & Inequities Report
Report Inequities & CDC published the 2nd CDC Health Disparities in 2013. The report
focuses on health disparities and inequalities for a broad range diseases, behavioral risk
factors, environmental exposures, social determinants, and healthcare access by sex, race and
ethnicity, income, education, disability status and other social characteristics.
Report addresses:
• National level data are included with some state-specific results
• Findings are to be used as baseline estimates for monitoring and reporting changes in
health disparities and inequities
• Major topics:
○ Mortality and morbidity
○ Behavioral risk factors
○ Health care access and preventive health services
○ Environmental hazards
○ Social determinants of health
Four findings in the report highlight significant health disparities:
1. The leading cause of death in the U.S. is cardiovascular disease. Non-Hispanic black
adults are at least 50% more likely to die of heart disease than non-Hispanic white adults.
2. Hispanics, non-Hispanic black and other mixed races have a higher prevalence of adult
diabetes as compared to Asians and non-Hispanic whites. The prevalence is also higher in
those with lower incomes and without college degrees.
3. Non-Hispanic blacks have the highest infant mortality rate - double the rate for nonHispanic whites.
4. Suicide rates are highest in men – four times greater than in women. They are the highest
among American Indians/Alaska Natives and non-Hispanic whites.
The 22 topics included in the report were chosen because they met one or more of the following
criteria:
• leading causes of premature death
• social, demographic or other disparities in health outcomes
• effective and feasible interventions exist to improve outcomes
• high quality data available for national monitoring sources
For more information on each of these 22 topics, consults one of the CDC Fact Sheets noted
below. These are excellent resources for course assignments.
From <https://cf.son.umaryland.edu/NRSG780/module5/subtopic4.htm>
NSG 780 Page 103
From <https://cf.son.umaryland.edu/NRSG780/module5/subtopic4.htm>
Exercise
Inequities Report Fact Sheet & Take a few minutes to review the findings in the 2013 CDC
Health Disparitiesand see if you can find the answers to the following questions:
1. What minority ethnic group had the highest infant mortality rate in both 2005 and 2008?
2. What minority ethnic group had the highest motor vehicle-related death rate?
3. What are 3 behavioral risk factors that are more common in low income minority ethnic
groups?
4. Which environmental hazards are minorities at a greater risk?
5. Identify 3 social determinants of health that are monitored by the CDC for health
disparities.
From <https://cf.son.umaryland.edu/NRSG780/module5/subtopic4.htm>
Answers to questions based on 2013 CDC Health Disparities & Inequities Report Fact Sheet: 1) NonHispanic Black women 2) American Indiean/Alaska Natives – 2.5 times higher than other
races/ethnicities 3) Binge drinking, adolescent births, and cigarette smoking 4) Living near major
highways, high risk occupations, and work-related deaths 5) Unemployment, completion of high school,
having at least one healthier food retailer nearby
FEDERAL & STATE INITIATIVES TO REDUCE DISPARITIES
HHS Action Plan to Reduce Racial and Ethnic Health Disparities
In 2011, the U.S. Department of Health and Human Services (HHS) developed a report on
disparities in health care, titled the HHS Action Plan to Reduce Racial and Ethnic
Disparities: A Nation Free of Disparities in Health and Health Care.
This report describes the goals and actions HHS plans to take to reduce health disparities. It
details evidence-based programs and initiatives to reduce racial and ethnic disparities (e.g.,
Healthy People 2020, the First Lady's Let's Move initiative and the President's National
HIV/AIDS Strategy).
The vision of the HHS Disparities Action Plan is:
“A‌nation‌free‌of‌disparities‌in‌health‌and‌health‌care.”
The HHS Disparities Action Plan proposes a set of Secretarial priorities, pragmatic strategies,
and high-impact actions to achieve strategic goals for the Department. The five goals from the
HHS Strategic Plan for Fiscal Years (FY) 2010-2015 provide the framework for the HHS
Disparities Action Plan. They are:
1. Transform health care
NSG 780 Page 104
1. Transform health care
- insure the uninsured, make coverage more secure for those who have it and improve the
quality of care.
2. Strengthen‌the‌nation’s‌Health‌and‌Human‌Services‌infrastructure‌and‌workforce;
- increase the capacity of providers and systems to address disparities
- support cultural competence
- prepare a workforce that reflects the diversity of the population (e.g., Hispanics are 16%
of the population but less than 6% are physicians)
3. Advance the health, safety, and well-being of the American people
- Increase availability of community-based programs and policies
4. Advance scientific knowledge and innovation
5. Increase the efficiency, transparency, and accountability of HHS programs.
Source: HHS Action Plan to Reduce Racial and Ethnic Disparities: A Nation Free of
Disparities in Health and Health Care, 2011.
Key Disparity Measures – calculated by race, ethnicity and income
I. Transform health care
% of the U.S. nonelderly population (0-64) with health coverage
% of people who have a specific source of ongoing medical care
% people who did not receive or delayed getting medical care due to cost in the past 12 months
% people who report difficulty seeing a specialist
% people who reported that they experienced good communication with their health care provider
rate of hospitalization for ambulatory care-sensitive conditions
% adults who receive colorectal cancer screening as appropriate
II.‌Strengthen‌the‌nation’s‌Health‌and‌Human‌Services‌infrastructure‌and‌workforce
% clinicians receiving National Health Service Corps scholarships and loan repayment services
% degrees awarded in the health professionals, allied and associated health professionals fields
% practicing physicians, nurses, and dentists
III. Advance the health, safety, and well-being of the American people
% infants born at low birth weight
% people receiving seasonal influenza vaccination in the last 12 months
% adults and adolescents who smoke cigarettes
% adults and children with healthy weight
National Partnership for Action
The National Partnership for Action (NPA) was “established to mobilize a nationwide,
comprehensive, community-driven, and sustained approach to combating health disparities and
to move the nation toward achieving health equity.” (NPA, 2011)
The focus of the NPA is on social, behavioral, environmental, and biological determinants of
health through community engagement, leadership and partnerships.
The Mission
NSG 780 Page 105
The Mission
“The mission of the NPA is to increase the effectiveness of programs that target the elimination
of health disparities through the coordination of partners, leaders, and stakeholders committed
to action.” (NPA, 2011)
The Goals
“The goals of the NPA and its National Stakeholder Strategy for Achieving Health Equity are:
• Awareness - Increase awareness of the significance of health disparities, their impact on
the nation, and the actions necessary to improve health outcomes for racial, ethnic, and
underserved populations.
• Leadership - Strengthen and broaden leadership for addressing health disparities at all
levels.
• Health System and Life Experience - Improve health and healthcare outcomes for racial,
ethnic, and underserved populations.
• Cultural and Linguistic Competency - Improve cultural and linguistic competency and
the diversity of the health-related workforce.
• Data, Research, and Evaluation - Improve data availability and coordination, utilization,
and diffusion of research and evaluation outcomes.” (NPA, 2011).
Disparities in Maryland
Health disparities in Maryland have decreased over the past decade and mortality rates have
declined for all leading causes of death with a black-white mortality excess.
Source: http://dhmh.maryland.gov/mhhd/Documents/Maryland-Black-or-AfricanAmerican-Data-Report-December-2013.pdf
NSG 780 Page 106
However, significant mortality disparities between black and white Marylanders occur for 11 of
the leading 15 causes of death.
NSG 780 Page 107
Source: http://dhmh.maryland.gov/mhhd/Documents/Maryland%20Chartbook%20of%
20Minority%20Health%20
and%20Minority%20Health%20Disparities%20Data,%20Third%20Edition%20(December%
202012).pdf
Costs of Health Disparities in Maryland
In 2004 Johns Hopkins University and the University of Maryland carried out a study in on The
Economic Burdens of Health Inequalities in the United States, where they analyzed Medical
Expenditure Panel Survey data for the years 2002-2006 to determine the cost burden of health
inequities.
At that time, they determined that the combined costs of health inequalities and premature
deaths in the United States were $1.24 trillion. Subsequent review of Maryland hospital
discharge data identified higher rates of hospital admissions for blacks than whites for all ages
and higher costs for blacks than whites because on average blacks are sicker than whites on
admission resulting in longer and more expensive hospital stays.
NSG 780 Page 108
Source: http://dhmh.maryland.gov/mhhd/Documents/Maryland%20Chartbook%20of%
20Minority%20 Health%20and
%20Minority%20Health%20Disparities%20Data,%20Third%20Edition%20(December%
202012).pdf
It was this kind of data that 1) lead to legislation in 2004 (HB 86) that officially established
Maryland’s Office of Minority Health and Health Disparities in the state’s Department of Health
and Mental Hygiene and 2) supported the Maryland Health Improvement and Disparities
Reduction Act of 2012 (SB 234)which provided $4 million toward a pilot program to decrease
health disparities throughout the state. The funding supports improving health care access and
outcomes and lowering health costs and hospital readmissions.
The Office of Minority Health and Health Disparities focuses on improving the health of all
Marylanders by promoting health equity among African-Americans, Asian-Americans,
Hispanic/Latino Americans and Native Americans. Its goal is to eliminate health disparities,
build partnerships to develop health policies, implement programs and track and report progress
to the public.
For more information, check out the website
at http://dhmh.maryland.gov/mhhd/Pages/home.aspx
For additional information on disparities in the Hispanic, Non-Hispanic Asian, Asian & Pacific
Islander, American Indian and Alaskan Native populations in Maryland review the health equity
data in the state at http://dhmh.maryland.gov/mhhd/Pages/Health-Equity-Data.aspx.
From <https://cf.son.umaryland.edu/NRSG780/module5/subtopic5.htm>
NSG 780 Page 109
From <https://cf.son.umaryland.edu/NRSG780/module5/subtopic5.htm>
CULTURAL COMPETENCE
Health Inequity and Language
One strategy to eliminate health inequities is Culturally and Linguistically Appropriate
Services (CLAS).
“By tailoring services to an individual's culture and language preference, health
professionals can help bring about positive health outcomes for diverse populations. The
provision of health care services that are respectful of and responsive to the health beliefs,
practices and needs of diverse patients can help close the gap in health care outcomes.
The pursuit of health equity must remain at the forefront of our efforts; we must always
remember that dignity and quality of care are rights of all and not the privileges of a few.”
(Office of Minority Health, DHHS, 2014)
What are the CLAS Standards?
"The National Standards for Culturally and Linguistically Appropriate Services in Health
and Health Care (the National CLAS Standards) aim to improve health care quality and
advance health equity by establishing a framework for organizations to serve the nation's
increasingly diverse communities.(Office of Minority Health, DHHS, 2015)
NSG 780 Page 110
Take a few moments to watch this video (3:48 min) on the importance of implementing
culturally and linguistically appropriate services.
CLAS Legislation Map
State agencies have supported cultural and linguistic competency since the CLAS Standards
were developed. Several states have passed legislation on cultural competency training for
some health professionals. Others have mandated cultural and linguistic competency for the
majority of health care providers. See the map below on the status of CLAS legislation. What is
the status of your state?
NSG 780 Page 111
Source: https://www.thinkculturalhealth.hhs.gov/clas/clas-tracking-map
For more information on the status of CLAS in different states check out the website
at: https://www.thinkculturalhealth.hhs.gov/clas/clas-tracking-map
From <https://cf.son.umaryland.edu/NRSG780/module5/subtopic6.htm>
NSG 780 Page 112
Module 6 Social Justice and the Social Determinants of
Health
Monday, March 13, 2017
5:35 PM
NRSG 780 - HEALTH PROMOTION AND POPULATION HEALTH
Module 6: Social Justice and the Social Determinants of Health
OVERVIEW
“The do-no-harm approach to responsibility alone will do wonders if we stop shaping
and re-enforcing the social conditions that, foreseeably and avoidably, cause the
monumental suffering of the poor.”
Wendy Austin, RN, MEd, PhD, “On being ethical in a global community: what is a nurse to do?”
(2008)
The purpose of this module is to provide an overview of the concepts of social justice, health
equity and human rights. The module will emphasize the Framework for Action on the Social
Determinants of Health (SDH)-- the circumstances in which people are born, grow up, live, work
and age, and the systems put in place to deal with illness. These circumstances are further
shaped by a wider set of forces: economics, social policies, and politics – at both local and
global levels. Understanding the multidimensional social conditions of individual clients, families,
households, and communities, will enhance the capacity to develop effective, innovative and
meaningful health interventions for populations in most need. Health professionals can mobilize
and address how current resources are being distributed and advocate for policies supporting
social justice and health.
Objectives
At the conclusion of this module, the learner will be able to:
• Explain the relationship between professional ethics, social justice and health equity
• Discuss the Framework for Action on the Social Determinants of Health and its importance
in addressing health disparities and working towards health equity
• Assess how social injustices related to class, race and gender and how social injustices
have an impact on population health outcomes
• Identify ways to integrate a social justice approach into advanced practice and to become
advocates for communities and populations with critical health needs
Required Readings
• Braveman, P., S. Egerter, and D. Williams. (2011). The social determinants of health:
Coming of age. Annual Review of Public Health, 32, 381-98. Retrieved
from: http://scholar.harvard.edu/files/davidrwilliams/files/2011the_social_determinants-williams.pdf
The Social Determinants of Health: Coming of Age
Few governments have explicit policies for tackling
socially determined health inequalities.
This article’s doi:
10.1146/annurev-publhealth-031210-101218
A large body of evidence from observational
research strongly and repeatedly links multiple
upstream social (including economic) factors
with a wide array of health outcomes, and
understanding—albeit incomplete—of underlying
pathways and biological mechanisms
has been growing. With notable exceptions,
however, we know little about effective ways
to address social factors to improve health and
NSG 780 Page 113
to address social factors to improve health and
reduce health disparities—about when, where,
and how to intervene.
The gaps in knowledge reflect several challenges.
More often than not, the relationships
between upstream social factors and health are
complex and play out over long periods of time,
involving multiple intermediate outcomes subject
to effect modification by characteristics of
people and settings along the causal chain. This
complexity makes it difficult to learn about the
specific pathways through which upstream social
factors shape health and to identify priorities
for intervention. Addressing the knowledge
gaps is also complicated by our limited ability
to measure upstream social factors. Current
measures do not fully capture—or tease out the
distinct effects of—relevant aspects of income,
wealth, education, or occupational rank. For
example, the observed effects of race/ethnicity
on adult health after adjustment for available
socioeconomic measures suggest a potential
role for unmeasured social influences.
FACT THAT WE CAN'T ACCOUNT FOR WHY PEOPLE OF DIFFERNT
RACE HAVE DIFFERENT HEALTH STATUSES, EVEN WHEN ADJUSTED
FOR SOCIOECONOMIC MEASURES, MEANS THERE'S UNKNOWN
VARIABLES.
Priorities for Further Research:
*Descriptive studies and monitoring
*Longitudinal research. We need more
life-course research, including longitudinal
studies to build public-use databases with comprehensive
information on both social factors
and health, collected over time frames long
enough—ideally multiple generations—for
health consequences of early childhood experiences
to manifest. A more reasonable balance is
needed between investments in studying adult
disease and examining children’s trajectories
of health and social advantage across the life
course.
*Connecting the dots: linking knowledge
to elucidate pathways and assess interventions.
Even robust longitudinal data are unlikely
to provide sufficient information for tracing
the effects of an upstream determinant (A)
through relevant pathways to its ultimate health
outcomes (Z), particularly if exposure to A occurs
in childhood and outcome Z occurs much
later. Attempting to document and quantify the
effects of A on Z in a single study represents an
important obstacle to understanding how social
factors influence health—and how to intervene
Once the links in the causal chain are documented, a
NSG 780 Page 114
Once the links in the causal chain are documented, a
similar incremental approach could be applied
to study the effectiveness of interventions, e.g.,
testing the effects of an upstream intervention
on an intermediate outcome with established
links to health.
*Testing multidimensional interventions
versus seeking a magic bullet. We need
research to inform translation of existing
knowledge about the SDOH into effective and
efficient policies. Often, the rate-limiting step
may not be insufficient knowledge of pathways
but rather lack of solid evidence about what,
specifically and concretely, works best in
different settings to reduce social inequalities
in health. For example, although we have convincing
evidence that educational quality and
attainment powerfully influence health through
multiple pathways, lack of consensus about interventions
is often invoked to justify inaction.
Knowledge of pathways can point to promising
or at least plausible approaches but generally
cannot indicate which actions will be effective
and efficient under different conditions; that
knowledge can come only from well-designed
intervention research, including both randomized
experiments (when possible and
appropriate) and nonrandomized studies with
rigorous attention to comparability and bias.
the complex pathways
linking social disadvantage to health
suggest that seeking a single magic bullet is
unrealistic. Interventions with individuals may
require simultaneous efforts with families and
communities. Recognizing the expense and
methodologic challenges, we need multifaceted
approaches that operate simultaneously across
domains to interrupt damaging (and activate
favorable) pathways at multiple points at which
the underlying differences in social advantage
and the consequent health inequalities are
produced, exacerbated, and perpetuated.
*Political barriers to translating knowledge
to action.
Lack of evidence is not always
the major barrier to action. Often, the chief
obstacle is lack of political will; particularly in
the United States, our deeply embedded culture
of individualism can impede actions that
require a sense of social solidarity.
Descriptive, explanatory, and interventional
research can play a supportive role in building
consensus about the need for action by increasing
public and policy-maker awareness of unacceptable
NSG 780 Page 115
public and policy-maker awareness of unacceptable
conditions such as racial and socioeconomic
disparities in health; by making the links
between social factors and health meaningful
and plausible to the public and policy makers;
and by suggesting, testing, and helping to estimate
the costs of promising science-based approaches.
Information about the pathways and
mechanisms through which social advantage influences health can provide an important counterweight
to victim-blaming, which too often
impedes policies focused on upstream social
and economic factors.
• Commission on Social Determinants of Health. (2008).Closing the gap in a generation:
Health equity through action. Executive Summary of the CSDH. Geneva: WHO. Retrieved
from:
http://www.who.int/social_determinants/final_report/csdh_finalreport_2008
_execsumm.pdf
Commission on Social Determinants of Health. (2008).
Closing the gap in a generation: Health equity through
action. Executive Summary of the CSDH. Geneva: WHO.
http://www.who.int/social_determinants/final_report/csdh_finalreport_2008_execsumm.pdf
Commission's Overarching Recommendations:
1. Improve Daily Living Conditions Improve the well-being of
girls and women and the circumstances in which their
children are born, put major emphasis on early child
development and education for girls and boys, improve
living and working conditions and create social
protection policy supportive of all, and create
conditions for a flourishing older life. Policies to
achieve these goals will involve civil society,
governments, and global institutions.
2.Tackle the Inequitable Distribution of Power, Money,
and Resources In order to address health inequities, and
inequitable conditions of daily living, it is necessary
to address inequities – such as those between men and
women – in the way society is organized. This requires a
strong public sector that is committed, capable, and
adequately financed. To achieve that requires more than
strengthened government – it requires strengthened
governance: legitimacy, space, and support for civil
society, for an accountable private sector, and for
people across society to agree public interests and
reinvest in the value of collective action. In a
globalized world, the need for governance dedicated to
equity applies equally from the community level to global
institutions.
3. Measure and Understand the Problem and Assess the
Impact of Action
Acknowledging that there is a problem, and ensuring that
health inequity is measured – within countries and
NSG 780 Page 116
health inequity is measured – within countries and
globally – is a vital platform for action. National
governments and international organizations, supported by
WHO, should set up national and global health equity
surveillance systems for routine monitoring of health
inequity and the social determinants of health and should
evaluate the health equity impact of policy and action.
Creating the organizational space and capacity to act
effectively on health inequity requires investment in
training of policy-makers and health practitioners and
public understanding of social determinants of health.
It also requires a stronger focus on social determinants
in public health research.
From <https://cf.son.umaryland.edu/NRSG780/module6/index.htm?globalNavigation=false>
Inequities v Inequalities v. Disparities in Health
Disparity: Is there a difference in health status rates
between population groups---> Is that difference too
large?
Inequity: Is the disparity d/t differences in social,
economic, environmental or healthcare resources?-->
When thinking about policy, is the distribution of
resources fair?
Inequality How do rates vary with the amount of the
resource and how is the population distributed among
resource groups? --> Can the distribution of the pop
among the resource groups and the rates within the groups
be influenced?
Burden: How many people are affected in the specific
groups and in the total population?---> How many people
would benefit from intervention?
Health equity is the absence of systematic disparities
in health (or in the major social determinants of health)
between groups with different levels of social advantage
or disadvantage (e.g. wealth, power, privilege –
different positions in a social hierarchy) (Braveman &
Gruskin, 2003). Equity implies social justice and
fairness. It is an ethical concept, grounded in
principles of distributive justice.
Health Inequity the presence of differences in the social
determinants of health that place groups of people who
are already socially disadvantaged (for example, by
virtue of being poor, female, and/or members of a
disenfranchised racial, ethnic or religious group) at
further disadvantage with respect to their health.
SO Health Inequalities is equivalent to disparities, the
NSG 780 Page 117
SO Health Inequalities is equivalent to disparities, the
question is are these inequalities/disparities
specifically INEQUITIES- where it's unfair
John Rawls Theory of Justice:
Justice is fairness- fair distribution of burdens and
resources. Focus on where people start out- (ie. gender,
race, socioeconomic status) institutions of society
favors certain starting positions more than others (ex:
education is way better is richer areas).
Course of ones life is influenced by one's birth
Goal of social justice is to make sure that social,
economic and political institutions work in a fair,
nonexclusive way.
Social patterns are unjust is they hinge on victimizing
or exploiting one group for the benefit of the otherclassic example- factory workers get exploited by the
owners of the factories, making a profit off their
suffering
Rawl's Theory led to the social policy interventionsSocial protections and redistribution efforts reduce the
structural bias of poverty- ex: poverty among elderly
dramatically reduced after the passage of medicare in
the 1960's.
These policy interventions differ dramatically between
economically developed countries.
American Nursing Association - Code of Ethics
The following statements of the American Nursing
Association (ANA) integrated into the language of Ethics
Standards and Code of Ethics for nurses specifically
address aspects of social justice:
“The nursing profession is committed to promoting the
health, welfare, and safety of all people.”
“Nurses act to change those aspects of social structures
that detract from health and well-being.”
“The nurse has a responsibility to be aware not only of
specific health needs of individual patients, but also
the broader health concerns such as world hunger,
environmental pollution, lack of access to health care,
violations of human rights and inequitable distribution
of nursing and health care resources.”
Video: Sir Michael Marmot: How Social, Political &
Economic Policies Affect Health
No biological reason for different life expectancies-has
to do with environmental issues and access to healthcare
Possible with many points of intervention- grassroots
NSG 780 Page 118
Possible with many points of intervention- grassroots
efforts helpful and pushes policies
Educating young women is a good upstream way to help
their future kids and make sure they get good care.
Government should creat conditions in which people can
lead flourishing lives. His goal: to close the gap in a
generation
Social Determinants of Health (SDH) are the circumstances in which
people are born, grow up, live, work and age, and the
systems put in place to deal with illness. These
circumstances are shaped by a wider set of forces:
economics, social policies, and politics – at both local
and global levels (WHO, 2008).
Three Principles for Action on the Social Determinants of
Health (WHO, 2008)
1. Improve the conditions of daily life – the
circumstances in which people are born, grow, live, work
and age
2. Tackle the inequitable distribution of power, money
and resources – the structural drivers of those
conditions of daily life – globally, nationally and
locally
3. Measure the problem, evaluate action, expand the
knowledge base, develop a workforce trained in the social
determinants of health and raise public awareness about
the social determinants of health
The Framework for Action on the Social Determinants of
Health offers a holistic view of the social challenges to
health and the evidence for action to ensure improved
health outcomes across the globe.
“A key aim of the framework is to highlight the
difference between levels of causation, distinguishing
between the mechanisms by which social hierarchies are
created, and the conditions of daily life which then
result”
SOCIAL CONTEXTS create social stratification and assign
individuals to different social positions (ie. "you are
born poor").
Social stratification in turn engenders DIFFERENTIAL
EXPOSURE to health damaging conditions and DIFFERENTIAL
VULNERABILITY in terms of health conditions and material
resource availability.
Social stratification likewise determines DIFFERENTIAL
CONSEQUENCES of ill health for more and less advantaged
groups (including economic and social consequences, as
well differential health outcomes per se)
So someone's social contexts assigns them to their place
NSG 780 Page 119
So someone's social contexts assigns them to their place
in the social stratification (poor person born, bottom
of the rung). Poor person then has DIFFERENTIAL EXPOSURE
to let's say, factory smoke, gets cancers from it and
that's their DIFFERENTIAL CONSEQUENCE.
Downstream Social Determinants of Health are factors that
are temporarily and spatially close to health effects and
outcomes, which are relatively apparent (e.g. health
related knowledge, attitudes, beliefs or behaviors
related to smoking), but are influenced by upstream
factors in the causal pathways influencing health. These
downstream factors are also referred to as INTERMEDIARY
DETERMINANTS in the Social Determinants of Health (SDH)
framework. They include:
Material Circumstances
Behavioral and Biological Factors
Psychosocial Factors
Health Systems
Upstream Social Determinants of Health are fundamental,
structural causes that set in motion causal pathways
leading to (often temporally and spatially distant)
health effects and outcomes though downstream factors.
These upstream factors, which are outside of the control
of the individual, are also referred to as the Structural
Determinants in the SDH framework, which include:
Socioeconomic Position
Governance/Political Context
Macroeconomic Policies
Socio-Cultural Values
2008 WHO Social Determinants of Health Report: Closing
the Gap in a Generation:
Social Injustice is Killing People on a Grand Scale
Poor health of the poor
Social Gradient in health within countries
The inequities between countries
Caused by : Unequal global and national distribution of
power, income, goods and services
These cause an unequal distribution of "health damaging
experiences" in people's immediate lives:
access to health care, schools, education
Their conditions of work and leisure
Their homes, communities, towns or cities
What are "Social Determinants"?
Income and what income brings (basic material needs for
food, clothing, shelter and sustainable livelihood,
physical environments and health systems
Report emphasized human development as essential to
health and hence the need for education, supportive
communities and participatory political structures
NSG 780 Page 120
MYTHS ABOUT HEALTH INEQUITIES:
Some people talk about health disparities. Others talk
about health inequities. What’s the difference?
Health disparities is an empty term, basically means
difference, measurable difference in health status and
health outcomes. And health inequities represent a
stronger view that these differences are unjust and
unfair and could be avoided if the will were there.
How can health inequities be framed in economic terms
so as to broaden interest in the issue? Is there a way to
quantify this cost in terms of its impact on economic
development or our ability to compete in a global market?
We estimate that closing education-related disparities in
health and mortality would increase the level of “health
capital” in this country by over one trillion dollars
each year. Quantifying disparities in this manner may
help the public and policymakers better understand the
magnitude of disparities in comparison with other policy
issues competing for attention. The findings from the
OECD analysis are consistent with others indicating that
no incompatibility exists between high labor market
performance and a policy environment supportive of both
the social determinants of health and population health
itself. Indeed, for those concerned with producing
employment policies that support health, the conclusions
are clear: employment policies can, in fact, support
economic growth, encourage labor participation, and
reduce unemployment while also supporting health. Such
policies are more typical of North European nations,
especially the Nordic ones. While the employment policies
of English-speaking liberal political economics may also
produce high labor market performance, such outcomes
clearly come at a high social and health cost.
Organization for Economic Cooperation and Development
(OECD) 2006 Report OECD economic outlook: Boosting jobs
and income.
Are Black Americans (especially women) more likely to be
obese because of stress or lack of health/medical
options?
What we’ve found suggests that low-income communities,
particularly African American and Latino communities, are
really canaries in a coalmine in America. They are a
harbinger of things to come for all of us, in that they
are more susceptible to the environmental determinants of
obesity than are people who have greater access to
resources, so consequently they will demonstrate the
consequences of these environmental factors before other
NSG 780 Page 121
consequences of these environmental factors before other
populations will. But inevitably, if we don’t start to
address the environmental determinants of obesity, we will
all be facing a much more obese future.
New Hispanic immigrants who don't speak English are among
the most excluded and isolated groups in society, so
wouldn't they suffer worse health outcomes as a result?
It’s amazing, but among immigrants, Latinos who represent
the poorest subpopulations of our communities in Alameda
County and elsewhere in California have overall the best
health of anybody in these communities, including welloff whites. We have seen lower rates of hospitalization,
lower rates of death, and lower rates of disease in
immigrant Latino and Asian populations that are socially—
by all the social measures—very poor and living in
communities where one would expect high rates of chronic
disease and other morbidity.
One of the things I find interesting about this question
is the distinction between the social isolation of
individuals and social isolation of communities. It’s
false to assume that immigrant Latino populations are
socially isolated at the individual level. They do
immigrate typically to reunite themselves with family
members or community members, and they form very tight
social networks that have a health protective quality to
them. They’re extremely hopeful people; they’re looking
forward to the future. They’re much less likely to engage
in smoking and drug use and the kinds of risk behaviors
that we associate with poor health outcomes
Do other immigrant groups to the U.S. have a health
advantage similar to Latinos? And does it erode for them
as well? Is the health advantage true across Latino
populations? Which groups are exceptions?
We see something similar in all immigrant groups. The
data is sometimes tricky to find because of the nature of
how it’s collected and how we describe people, but you
see it most prominently in birth outcomes. For example,
African immigrants to the United States have better birth
outcomes than African Americans, even though you would
expect probably the opposite. Certainly every other
immigrant group, including white immigrant groups, has
better birth outcomes than their American counterparts in
the United States. So just looking at that phenomenon
tells you something about how America may not be good for
your health. And ultimately understanding why that might
be the case is critical to ascertaining the factors that
are health protective among immigrants.
We’ve just completed national research on mental health
in the United States for Black Caribbean immigrants,
Latino immigrants and Asian immigrants. Again, we see the
NSG 780 Page 122
Latino immigrants and Asian immigrants. Again, we see the
same pattern for all groups: the immigrants do better
initially, but with increasing length of time and stay in
the United States, the health of Asian immigrants, Latino
immigrants, and Black Caribbean immigrants declines. So
it seems to be a pretty robust phenomenon across multiple
population groups.
If U.S. health inequalities are so bad, why do people
from other countries, socialist and communist, choose to
come to America for better care?
In the United States, we ration healthcare by ability to
pay. In Canada, healthcare is rationed according to need.
Everywhere in the world, healthcare is rationed. It is an
expensive resource and a critical social resource. In
most countries, it is determined to be a right and not a
privilege. But in the United States, healthcare is not a
right; it is a privilege of wealth. That is why people
who have wealth can come here to purchase the newest
level of technology and the highest and greatest
technological marvel to diagnose or treat their difficult
to treat or cure disease. Of course that’s a good thing,
but the cost of that is, unfortunately, in the American
system, many people who have need but don’t have the
ability to pay are denied healthcare, and they suffer the
physical and psychological consequences of essentially
being excluded from this system.
To what extent can the high costs of medical care in the
U.S. be attributed to the fact that Americans tend to be
sicker than people in other countries?
Numerous analyses indicate that it is clearly the market
-driven, for-profit nature of the U.S. health care
system that is responsible for its high health care costs
The U.S. is a capitalist society, not a socialist one.
So, two questions: is it possible to remedy health
inequities with market-driven solutions, and aren’t
differences in health simply an unfortunate but
inevitable part of the way we live?
Sweden, Norway, Denmark, and every other European nation
are also capitalist, yet each of them takes better care
of their citizens than does the U.S. The issue is not
capitalism per se, but whether capitalists are allowed
to call all the public policy shots without taking into
account the needs of citizens. In no nation on Earth have
solely market-driven solutions been successful in
reducing poverty, providing accessible health care and
NSG 780 Page 123
reducing poverty, providing accessible health care and
providing for the security needs of the majority of its
citizens.
Good capitalists understand the value of making
investments that will have high returns for society in
the future. Policies that improve health can lead to
future social returns such as via a healthier and hence
more productive labor force. Too often we fail to take
into account such factors when considering the pros and
cons of social policies. While it is likely true that
many of the most aggressive policies for reducing health
disparities are justified primarily on the basis of moral
values for how we should treat the disadvantaged in our
society, it is important to recognize that there is a
subset of powerful policy recommendations that could
receive broad political support even on the basis of
economic efficiency grounds alone.
Is it your sense that overt, and covert, negative
expectations of Black men contributes to an increase in
underlying resentment and, therefore, potential increase
in disease susceptibility and decreased life expectancy?
There is some interesting research that suggests that
larger societal stereotypes and negative expectations
affect both the academic performance and the health of
not just African Americans, but other persons who are
negatively stigmatized by society. One example of this
would be the work by Stanford researcher Claude Steele on
what he calls “stereotype threat.” He showed that if you
give African Americans a test and you tell some of them
this is a test in which Blacks tend to do poorly, those
who are told that Blacks tend to do poorly will do worse
than those who were just told to take a test. And he’s
shown that it’s not just African Americans who are
susceptible to this, but also white women— if white women
are given a test and told that women do more poorly than
men—and white men, if they are told that whites do more
poorly than Asians on a test. So it’s a pretty robust
phenomenon. When you tap into a societal stereotype of a
group, even when those members are aware of it, just
highlighting that negative characterization seems to
affect their performance. There is research by Jerome
Taylor at the University of Pittsburgh and others that
shows that when African Americans buy into society’s
negative stereotypes about their group—that Blacks are
lazy and inferior, for example—they do more poorly on
measures of mental health and are at a higher risk of
substance abuse. This work goes under the rubric of
internalized racism. But another important consequence of
those larger negative societal expectations is how they
get translated into actual health outcomes, and there is
a growing body of scientific research that shows how,
among stigmatized racial/ethnic populations, experiences
NSG 780 Page 124
among stigmatized racial/ethnic populations, experiences
of discrimination are a source of stress that actually
leads to premature onset of disease and other negative
health effects. So there are multiple ways in which the
larger racism within society adversely affects both the
socioeconomic opportunities and the health of
disadvantaged racial/ethnic populations.
It’s not just internalized racism; it’s also a
stigmatization associated with class status and
disability. We see this also among kids who have major
disabilities. Knowing about this gives us an opportunity
to intervene, to create opportunity structures, as we
call them, in communities to both extend the hopefulness
that is inherent in young people and protect them against
the deleterious social forces that devalue them
systematically as they age.
To be healthy requires discipline and making smart
choices. These are the same elements that bring a person
wealth. It’s no secret that Americans are fat and in poor
health because they eat a high-fat, high-sodium, highly
processed diet. Aren’t we just letting people off the
hook by blaming society?
There is a role for individual responsibility, there is
also a role for social responsibility, too. Social
context is what can create barriers for individuals to
make choices, and social responsibility and social policy
can create opportunities that facilitate individuals
making healthy choices. So the social component must be
paired with the individual component.
Paula Lantz, Ana Diez-Roux, and other American
researchers point out that when
you try to predict who’s going to live or die, or who’s
going to be sick or die, behavioral factors certainly
contribute, but the amount the so-called “risk behaviors”
contribute pales in magnitude to the living conditions
which people are exposed to, not only in their
contemporaneous situation as adults, but the life
experiences they’ve had as children. The best predictors
of cardiovascular disease and Type 2 diabetes are
adverse living conditions that people experience as
children—in fact, frequently, as has been pointed out,
prior to their being born. So even from a statistical
predictability, the best predictors are adverse living
conditions, and the United States is unique in subjecting
a larger proportion of its people to adverse living
conditions than most other developed countries.
If lack of control increases risk of illness, how can
government programs be the answer? Welfare programs don’t
NSG 780 Page 125
government programs be the answer? Welfare programs don’t
offer recipients more control. If the government is
responsible for our wellbeing, doesn’t that disempower
us?
There are two kinds of government programs. The ones that
are typical throughout most of the developed world say,
“We’re all in this together, so what can we do to
facilitate human development?” Certainly Abraham Maslow
recognized in the 1960s that in order for people to be
creative and productive, they have to have their basic
needs met. So, in most developed countries, there’s
extensive effort to make sure that every child has a
decent education, has food, has decent housing, and if
they’re capable and able, can go on to university whether
they have the financial resources to pay for it or not.
Compared to many European nations, the United States, and
to some extent in Canada and the United Kingdom, those
commitments are not as strong. What you see instead is
that governments step in, not to provide universal
general financial income and educational support for the
population, but only to respond to people that are the
most in need, whether you want to call them homeless or
call them hungry. The nature of these programs are such
that, since they are targeted to the least well off and
are combined with the belief that people have somehow
gotten themselves into these situations, these programs
are frequently stigmatizing. So the questioner is
actually right; they usually don’t do very much to
promote autonomy and self-control.
Your program asserts that other countries have better
health because they are more equal and have better social
supports. But many of those countries have homogeneous
populations. Doesn’t the incredible diversity of the U.S.
mean that social, economic and health equity are harder
to achieve?
To directly address the question, if we were to look just
at the white population of the United States, as a
country we would still be doing poorly, and we would
still be at the bottom of the industrialized countries.
Other countries in fact have a lot more diversity than
the average American thinks exists out there. But also,
diversity is not the problem, since even the largest
group in the U.S., the white population, is doing poorly
compared to these other countries. So we really have to
look at how we are using resources, and how we are
investing in the quality of life of all people in terms
of making changes so that we can improve the health of
all.
The point is that it may very well be more difficult to
have a shared commonality of views in more heterogeneous
societies, but that’s not a biological thing. It’s just
that historically, diversity has been used as a weapon to
split people and to make it more difficult to come to
NSG 780 Page 126
split people and to make it more difficult to come to
communal agreement.
Does equality make us well? Are there examples worldwide
where racial and economic equality is enjoyed and health
status a benefit?
A lot of work has looked at the factors supporting
health in developed wealthy countries. It seems there are
three clusters of countries. The first includes the
United States, Canada, the United Kingdom, Australia, and
New Zealand. These countries are sometimes called
“liberal political economies”; sometimes they’re called
“Anglo-Saxon economies”. These countries have evolved in
such a manner that the communal programs of supports are
minimal. As a result, or correlated with it, health
tends to be not as good as it is in other countries. The
second cluster of countries are called the “continental” or
“conservative countries”; for example, France, Germany,
Belgium or Holland. These conservative countries actually
provide fairly good security for people. Life expectancy
tends to be longer and crime rates are lower than in
these so-called liberal countries. But the countries that
have really put it all together in terms of providing
people with security, and as a result people live longer
and have lower obesity rates,are the Scandinavian
countries.
What Americans don’t realize, though, is that 40-50 years
ago, the United States was more equal than even these
Scandinavian countries. Over time, there’s been a shift
away from equity, a shift away from equitable
distribution of income in the United States, such that
the United States has gone from being one of the
healthiest and most equal countries to the opposite pole.
If that can happen over 50 years, then there’s certainly
no reason why it can’t begin to reverse itself.
So the brief answer is, yes, most countries, whether
they’re the conservative countries of continental Europe
or the northern social democratic countries, are more
egalitarian and they show the benefits of it:
people are more secure; people live longer; and, for the
most part, they have less illness than Americans do. But
America has a history of having done that as well; it’s
just that right now we’re not in a period where these
kinds of approaches are in fashion
It’s obvious why the poor have worse health than the rich.
But why would the middle class? They don’t suffer from
material want.
There’s a tremendous amount of insecurity in the United
States. So if you’re making $60,000 a year versus $80,000
a year, the difference isn’t just about material
possessions; it’s also a reflection of how secure you are.
NSG 780 Page 127
possessions; it’s also a reflection of how secure you are.
The reality is that middle class people do not have
everything they need to be healthy. They still—and this
is uniquely so in the United States—can have medical
emergencies, they can have medical bankruptcies, and if
they lose their jobs, as factories close, they are
left on their own. So the gradient is more a reflection
of the tremendous amount of insecurity that runs through
the entire gradient, but is especially focused on the
people at the bottom. Frequently, some of the people who
talk about the social gradient have very little
understanding of the actual insecurities that even
middle class people experience.
If you could pick one thing to change in order to
improve health outcomes, what would it be?
Well, in Canada, when I’m asked that question, I say a
universal childcare system, because it would provide the
most concrete benefits, especially for the most
disadvantaged children, and it would also enable women,
especially disadvantaged women, to gain employment and
become more a part of society. The second thing I would
argue for is to make it easier for people to organize
their workplaces and form unions.
This is, of course, an expensive, long-run strategy. But
many of the root causes of health disparities have
developed over generations, and it will likely take
generations to undo them. My best guess based on the
research literature is that improving education for the
current generation of kids is the most promising path for
reducing disparities by the next generation.
Health Inequities and the Social Class Gradient Video
Whitehall Study longitudinal study, followed 10,000
British civil servants to see if/when they died. Found
that the poorer you are, the more likely you are to die
of all causes sooner, Gradient of life expectancy
consistent across all countries, where the gradient
starts and ends varies by country and even within the
country when looking at different populations.
Global Inequities in Health- Video
Correlation between countries with least amount of wealth
and how healthy the people are. More resources= more
health.
Almost 1/3rd of people in developing nations live in
poverty.
Developing world carries 90% of the disease burden yet
poorer countries have access to only 10% of the resources
that go to health.
Inverse Care Law: Availability of good medical care tends
NSG 780 Page 128
Inverse Care Law: Availability of good medical care tends
to vary inversely with the need for it in the pop served.
People who have it the most are the ones who need it the
least and visa versa.
Paul Farmer- mobilized a lot of people to try to help a
lot of people globally- Haiti and Rowanda
Per Paul Farmer- in Haiti suffering is structuredpolitical and economic forces have structured risk for
AIDS, tuberculosis and indeed most other infectious and
parasitic diseases.. the social forces at work there
have also structure risk for most forms of extreme
suffering from hunger to torture and rape.
Government not representative of needs of the pop.
Global inequities example: Violence against women
Violence is widespread and growing in nearly all
societies. It occurs in all settings: work, home, and in
the community. It affects men and women of all ages but,
most violence is perpetrated by men whatever the sex of
the victim. Women are disproportionately the victims of
violence.
Violence against women is defined as any act of genderbased violence that results in, or is likely to result
in, physical, sexual or mental harm or suffering to
women, including threats of such acts, coercion or
arbitrary deprivation of liberty whether occurring in
public or in private life” (WHO, 2013) Approximately 35%
of women worldwide report physical or sexual violence
in their lifetimes. Violence is associated with shortand long-term physical and mental health problems for
survivors and their children.
Factors associated with increased risk of perpetration of
violence include low education, child maltreatment or
exposure to violence in the family, harmful use of
alcohol, attitudes accepting of violence and gender
inequality.
Factors associated with increased risk of experiencing
intimate partner and sexual violence include low
education, exposure to violence between parents, abuse
during childhood, attitudes accepting violence and gender
inequality.
There is evidence from high-income settings that school
-based programs may be effective in preventing
relationship violence (or dating violence) among young
people.
In low-income settings, strategies to increase women’s
economic and social empowerment, such as microfinance
combined with gender equality training and communitybased initiatives that address gender inequality and
relationship skills, have shown some effectiveness in
reducing intimate partner violence.
Situations of conflict, post conflict and displacement
NSG 780 Page 129
Situations of conflict, post conflict and displacement
may exacerbate existing violence, such as by intimate
partners, and present additional forms of violence
against women.
ANA Position Statement on Nurse’s Role in Ethics and
Human Rights In January 2017 The American Nurses
Association issued its Ethics and Human Rights Statement:
“Nursing is committed to both the welfare of the sick,
injured, and vulnerable in society and to social justice.” -
Inequities vs. Inequalities vs. Disparities In Health
Health Disparities are “population-specific differences in the presence of disease, health
outcomes, or access to health care” (HRSA, 2001). The key is that there are differences
between populations in measures of health (e.g. rates of disease incidence, prevalence,
morbidity, mortality, or survival rates).
Health Inequalities are equivalent to health disparities. Again, the issue is that there is a
difference between the health status of one population compared to another population
Health Equity is the “attainment of the highest level of health for all people. Achieving health
equity requires valuing everyone equally with focused and ongoing societal efforts to address
avoidable inequalities, historical and contemporary injustices, and the elimination of health and
health care disparities” (Healthy People, 2020).
Health equity is the absence of systematic disparities in health (or in the major social
determinants of health) between groups with different levels of social advantage or
NSG 780 Page 130
determinants of health) between groups with different levels of social advantage or
disadvantage (e.g. wealth, power, priviledge – different positions in a social hierarchy)
(Braveman & Gruskin, 2003). Equity implies social justice and fairness. It is an ethical
concept, grounded in principles of distributive justice.
Health Inequity is the presence of differences in the social determinants of health that place
groups of people who are already socially disadvantaged (for example, by virtue of being poor,
female, and/or members of a disenfranchised racial, ethnic or religious group) at further
disadvantage with respect to their health.
In the article “Health disparities and health equity: The issue is justice,” Braveman et al (2011)
describes health inequities as:
• Systemic, avoidable, unfair and unjust differences in health status and mortality rates, as
well as in the distribution of disease and illness across population groups according to
race, ethnicity, socioeconomic position, gender, sexual orientation, or other characteristics
that reflect social advantage or disadvantage.
• Sustained over time and generations and beyond the control of individuals.
• Resulting from an unequal structuring of life chances and circumstances.
• Arising from some form of social injustice such as racism, sexism, economic inequity, or
political marginalization.
Health Equity Is Social Justice In Health
Think About the Following…
Imagine we are about to be born into the world, but we don’t know who we will be –
nothing about our biology, sex, race, social class position or nationality. What rational,
ethical rules would we agree to live by?
The concept of social justice refers to the overall fairness of a society in its divisions of rewards
and burdens among the population. Most variations on the concept hold that as governments
are instituted among populations for the benefit of members of those populations, those
governments which fail to address the welfare of their citizens are failing to uphold their part in
the social contract and are, therefore, unjust. The concept of social justice usually includes, but
is not limited to, upholding human rights and promoting more equitable distributions of wealth
and resources.
Have you ever thought of how social justice carries over into health and health
care? Studying social justice helps health professionals (re)frame “the why of the why” to
examine the upstream factors (or root causes) of both individual and population level health
issues.
John Rawls, the most influential 20th century American political philosopher whose contribution
to the idea of a just society, resulted in the well known book, "A Theory of Justice", will be
discussed in the first mini-lecture of this module.
Click here to watch and listen to Dr. Jeffrey V. Johnson, professor and former director of the
Office of Global Health discuss: “Social Justice as Fairness – Ethics of Johns Rawls”
Click here for a copy of the powerpoint that accompanies the presentation.
Ethics Of Social Justice
What are the Ethics of Social Justice?
• Emphasis on equality
• Emphasis on fairness
NSG 780 Page 131
•
•
•
•
•
Emphasis on fairness
Emphasis on freedom
Emphasis on human rights
Emphasis on collective action to protect those that are vulnerable in society
Emphasis on action to transform structure of society that causes oppression and
exploitation
Why study ethics?
•
•
•
•
•
•
How should I act towards others?
What are my most fundamental values?
How do I want and expect to be treated by others?
What do I consider “just” or “fair”?
What are my “rights”?
How do I work with “dignity & integrity”?
Key Moral Principles that Guide Actions of Health Professionals
•
•
•
•
Respect for Autonomy of Individuals
Non-malfeasance requires that we minimize harm and act with due care
Beneficence requires that we maintain and enhance human dignity and life
Distributive Justice requires that we seek a fair distribution of society’s benefits and
burdens
Public Health Code of Ethics
These three components of the American Public Health Association (APHA) Ethical Framework
specifically address aspects of social justice:
• Public health should advocate and work for the empowerment of disenfranchised
community members, aiming to ensure that the basic resources and conditions necessary
for health are accessible to all.
• Public health should address principally the fundamental causes of disease and
requirements for health, aiming to prevent adverse health outcomes
• Public health programs and policies should incorporate a variety of approaches that
anticipate and respect diverse values, beliefs, and cultures in the community
Source: http://www.apha.org/codeofethics/ethics.htm
American Nursing Association - Code of Ethics
The following statements of the American Nursing Association (ANA) integrated into the
language of Ethics Standards and Code of Ethics for nurses specifically address aspects of
social justice:
• “The nursing profession is committed to promoting the health, welfare, and safety of all
people.”
• “Nurses act to change those aspects of social structures that detract from health and wellbeing.”
• “The nurse has a responsibility to be aware not only of specific health needs of individual
patients, but also the broader health concerns such as world hunger, environmental
pollution, lack of access to health care, violations of human rights and inequitable
distribution of nursing and health care resources.”
Source: http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthic
sforNurses/ Code-of-Ethics.pdf
In summary, while it may seem easier to have discussions about the morality and ethics of
certain specialized treatments and targeted practices than to truly consider the morality of the
impact of certain types of health care institutions, policies, and the privatization of care on
different communities, it is a critically important to foster dialogue among healthcare
professionals. As the processes of globalization impact more and more communities and the
healthcare landscape evolves, re-examining professional ethics and integrating the concept of
social justice into practice is an excellent way to expand clinicians and researchers focus
beyond the bedside, offering them a more global lens and a way to reflect and act on issues of
health equity, distributive justice, and the “proper allocation” of resources to those populations in
most need. Healthcare providers are in a strong position to become advocates not only for
NSG 780 Page 132
most need. Healthcare providers are in a strong position to become advocates not only for
individual clients and families, but they can also empower clients to advocate for themselves
and align themselves with clients’ priorities by supporting policies that may change their social
determinants of health and ultimately improve health outcomes for all.
From <https://cf.son.umaryland.edu/NRSG780/module6/subtopic1.htm>
SOCIAL DETERMINANTS OF HEALTH
Watch the following video (6:23) titled How Social, Political Economic Policies Affect
Health. This is part of a World Health Organization report in which Sir Michael Marmot, Chair of
the Commission on Social Determinants of Health, explains why social, political and economic
policies affect health.
Social Determinants of Health (SDH) are the circumstances in which people are born, grow
up, live, work and age, and the systems put in place to deal with illness. These circumstances
are shaped by a wider set of forces: economics, social policies, and politics – at both local and
global levels (WHO, 2008).
Three Principles for Action on the Social Determinants of Health (WHO, 2008)
1. Improve the conditions of daily life – the circumstances in which people are born, grow,
live, work and age
2. Tackle the inequitable distribution of power, money and resources – the structural drivers
of those conditions of daily life – globally, nationallyand locally
3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce
trained in the social determinants of health and raise public awareness about the social
determinants of health
By following the vision outlined in the Closing the Gap in a Generation report, and through the
cooperation of many groups and institutions at local, national and nternational levels, the
Framework for Action on the Social Determinants of Health offers a holistic view of the social
challenges to health and the evidence for action to ensure improved health outcomes across the
NSG 780 Page 133
challenges to health and the evidence for action to ensure improved health outcomes across the
globe.
Levels of Causation & Pathways from Context to Health Outcomes
“A key aim of the framework is to highlight the difference between levels of causation,
distinguishing between the mechanisms by which social hierarchies are created, and the
conditions of daily life which then result” (WHO, 2010, page 4).
Downstream Social Determinants of Health are factors that are temporarily and spatially
close to health effects and outcomes, which are relatively apparent (e.g. health related
knowledge, attitudes, beliefs or behaviors related to smoking), but are influenced by upstream
factors in the causal pathways influencing health. These downstream factors are also referred to
as Intermediary Determinants in the Social Determinants of Health (SDH) framework. They
include:
• Material Circumstances
• Behavioral and Biological Factors
• Psychosocial Factors
• Health Systems
Upstream Social Determinants of Health are fundamental, structural causes that set in
motion causal pathways leading to (often temporally and spatially distant) health effects and
outcomes though downstream factors. These upstream factors, which are outside of the control
of the individual, are also referred to as the Structural Determinants in the SDH framework,
which include:
• Socioeconomic Position
• Governance/Political Context
• Macroeconomic Policies
• SocioCultural Values
The structural determinants cause and operate through intermediate determinants to shape
health outcomes.
NSG 780 Page 134
Click here to watch and listen to Dr. Jeffrey V. Johnson, professor and former director of the
Office of Global Health discuss “Social Justice and the Social Determinants of Health”.
Click here for a copy of the powerpoint that accompanies the presentation.
Review this video (7:31) that profiles two Kansas City area women whose health outcomes are
significantly influenced by education, poverty, transportation, crime and neighborhood
conditions.
Source: Health Care Foundation of Greater Kansas City (2009). Social Determinants of Health
Exercise
Take a few minutes to read and review the Q&A “Forum # 3: Myths about Health
Inequalities.” This is an interview with William Dow, Tony Iton, Dennis Raphael and David
Williams. They discuss diet, universal health care, the economic costs of poor health, the
“healthy immigrant effect,” and the difference between health disparities and health inequities.
From <https://cf.son.umaryland.edu/NRSG780/module6/subtopic2.htm>
HEALTH INEQUITIES AND RACIAL INJUSTICE
Understanding Social Factors And Social Context In Shaping Health
Social determinants of health are factors that play a fundamental causal role and represent
important opportunities for improving health and reducing health disparities.
The following figure is a conceptual framework on the social factors that shape health. It shows
that health related personal behaviors and receipt of recommended medical care (i.e.,
key downstream determinants of an individual’s health) do not occur in a vacuum. These
factors are shaped by key upstream determinants related to the living and working conditions,
and even more by economic and social opportunities and resources. Key upstream
determinants include:
•
•
•
•
•
Neighborhood conditions and health
Working conditions and health
Education and health
Income, wealth and health (social position)
Race, racism and health (social position)
NSG 780 Page 135
• Race, racism and health (social position)
• Gender and health (social position)
Social Advantage or Disadvantage refers to the relatively favorable or unfavorable social,
economic, or political conditions that some groups systematically experience based on their
relative position in social hierarchies. (Braverman et.al., 2011).
Social Gradients in Health refers to stepwise patterns in income, education, or occupational
grade that reflect relatively direct health outcomes (Braverman et.al., 2011). For example, more
economic resources and income relate to healthier nutrition, housing, and less stress due to
more resources and assets to cope with daily challenge.
Economic Inequality Affects Health in Three Main Ways
1. Economically unequal societies have greater levels of poverty
2. Economically unequal societies provide fewer social safety nets
3. Economically unequal societies have weaker social cohesion
Click here to watch and listen to Dr. Jeffrey V. Johnson, discuss “Health Inequities and the
Social Class Gradient”
Click here for a copy of the powerpoint that accompanies the presentation.
Exercise
After watching the following brief video (2:31) on the Social Determinants of Health, take a
moment to reflect on the questions listed below.
1. How did this brief video convey the key concepts related to the Social Determinants of
Health? Describe their social advantages and disadvantages.
2. Based on the information provided, describe what you imagine the health status of each
character (Chad and Jeff) to be? How would they compare to each other? Why? What
types of health issues might Chad and Jeff have encountered as boys? What types of
NSG 780 Page 136
types of health issues might Chad and Jeff have encountered as boys? What types of
health issues might be expected to develop for Chad and Jeff as they age?
3. How different would the health outcomes of Chad and Jeff be if they were a different race?
A different gender? From a different geographic location than what you may have
imagined?
4. How could being aware of the social factors and conditions of Chad and Jeff change or
influence the way you would interact with them in a healthcare setting?
A Closer Look at One Upstream Determinant: Racial Injustice and Health Inequities
“Contextualizing‌Risk‌Factors”
• How do people come to be exposed to individually-based risk factors (diet, cholesterol,
lack of exercise, high blood pressure, smoking, etc…)?
• What is it about people’s lives that shape their exposure to individual risk factors?
• What is the social process that leads to exposure?
Social Determinants are linked to health through complex causal chains
• “Recognizing the causal chains is crucial to recognizing the injustice in the current
state of health and longevity of human beings in modern societies.” ~Sridhar
Venkatapuram,
Racial disparities in health exist.
Some social policies within the United States have served to discriminate against minorities by
limiting educational and occupational advancement, denying access to community and social
services, and segregating communities. These long-term structural determinants of health have
impacted the health outcomes of generations of the population. African-Americans suffer a
much greater burden of disease compared to whites. The relative risk of mortality for AfricanAmericans is higher than that for whites for all ages under 85. Causes of excess death include:
•
•
•
•
•
•
•
Heart disease and stroke
Homicide and injuries
Cancer
Infant mortality
Cirrhosis
Diabetes
HIV/AIDS
Racism is one of the primary structural determinants behind racial disparities in health because
it changes the “Risk Profile” of groups and leads to differences in exposure to:
• Stress
NSG 780 Page 137
•
•
•
•
Stress
Hazardous environments
Restriction of opportunities
Adverse health behaviors
The gap in life expectancy between black and white Americans is narrowing for a variety of
reasons and is now 3.4 years. The rates of homicide, cancer and infant mortality are declining at
a faster rate in blacks than whites. Life expectancy is also decreasing faster for whites than
blacks as a result of the opioid crisis.
Source http://www.nytimes.com/2016/05/09/health/blacks-see-gains-in-lifeexpectancy.html?_r=0
For more information read the New York Times article entitled, “Black Americans See Gains in
Life Expectancy” (May 8, 2016) Available
at http://www.nytimes.com/2016/05/09/health/blacks-see-gains-in-life-expectancy.html?
_r=0.
From <https://cf.son.umaryland.edu/NRSG780/module6/subtopic3.htm>
GLOBAL INEQUALITY
Click here to learn 8 facts about global social determinants of health as reported by the World
Health Organization (WHO).
WHO Social determinants of health Facts
Poverty, social exclusion, poor housing and poor health
systems are among the main social causes of ill health.
Differences in the quality of life within and between
countries affect how long people live.
The probability of a man dying between the ages of 15 and
60 is 8.2% in Sweden, 48.5% in the Russian Federation,
NSG 780 Page 138
60 is 8.2% in Sweden, 48.5% in the Russian Federation,
and 84.5% in Lesotho.
In Australia, there is a 20-year gap in life expectancy
between Australian Aboriginal and Torres Strait Islander
peoples, and the Australian average.
Low- and middle-income countries account for 85% of the
world’s road deaths.
In 2002, nearly 11 million children died before reaching
their fifth birthday – 98% of these deaths were in
developing countries.
Inequality in income is increasing in countries that
account for more than 80% of the world’s population.
Review the WHO summary of key concepts for the social determinants of health available
at http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/
Health inequities are avoidable inequalities in health between groups of people within countries
and between countries. These inequities arise from inequalities within and between societies.
Social and economic conditions and their effects on people’s lives determine their risk of illness
and the actions taken to prevent them becoming ill or treat illness when it occurs.
Click here to watch and listen to Dr. Jeffrey V. Johnson, professor and former director of the
Office of Global Health discuss “Global Inequities in Health.”
Click here for a copy of the powerpoint that accompanies the presentation.
Global Inequities Example: Violence Against Women
Violence is widespread and growing in nearly all societies. It occurs in all settings: work, home,
and in the community. It affects men and women of all ages but, most violence is perpetrated by
men whatever the sex of the victim. Women are disproportionately the victims of violence.
Violence Against Women Defined
“Any act of gender-based violence that results in, or is likely to result in, physical, sexual or
mental harm or suffering to women, including threats of such acts, coercion or arbitrary
deprivation of liberty whether occurring in public or in private life” (WHO, 2013) Approximately
35% of women worldwide report physical or sexual violence in their lifetimes. Violence is
associated with short- and long-term physical and mental health problems for survivors and their
children.
Review the WHO fact sheet on Violence Against Women available
at http://www.who.int/mediacentre/factsheets/fs239/en/
ANA‌Position‌Statement‌on‌Nurse’s‌Role‌in‌Ethics‌and‌Human‌Rights
to social justice and the welfare of the sick, injured, and vulnerable in society both In January
2017 The American Nurses Association issued its Ethics and Human Rights
Statement: “Nursing‌is‌committed‌to.” - This statement supports its 2016 revised position
on The Nurse’s Role in Ethics and Human Rights: Protecting and Promoting Individual
Worth, Dignity, and Human Rights in Practice Settings. This statement is based on the
Universal Declaration of Human Rights adopted by the United Nations General Assembly in
1948 but goes beyond to address attention to duty, social justice and interdependence. It
provides nurses with specific actions to protect and promote human rights in every practice
setting. It describes the relationship between nurses’ ethical obligations, the concept of human
rights and professional nursing practice.
NSG 780 Page 139
From <https://cf.son.umaryland.edu/NRSG780/module6/subtopic4.htm>
NSG 780 Page 140