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click here for freelancing tutoring sitesPublic health is about those things that make us sick, keep us healthy, and what we do together about it. Health is often perceived as individual health and wellness. Public health focuses on the health of communities and society as a whole. This focus shifts from the individual to the population. It is about examining the impact on individuals and groups at risk as well as the population as a whole.

United States Federal Executive DepartmentsUniformed Services (7 including 5 Armed Services —Army, Navy, Air Force, Marine Corps, Coast Guard; and 2 Noncombatant Services—NOAA, PHS)DOD

• US Army• US Navy• US Air Force• US Marine Corps

DHS• US Coast Guard (USCG)

HHS• US Public Health Service Commissioned Corps (PHS)

DOC• National Oceanic and Atmospheric Administration Commissioned Corps

(NOAA)

Charles-Edward Amory Winslow (4 February 1877 – 8 January 1957) was an American bacteriologist and public health expert who was a seminal figure in public health. In 1920 he wrote:

Public health is “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals.”

In 1988, the Institute of Medicine created a steering committee to describe the future of public health. They described public health as “The substance of public health is the “organized community efforts aimed at the prevention of disease and the promotion of health.”

Riegelman points out that Public health continues to evolve.• Quality of life is more important today.• Protecting health that already exists• Promoting health when it is at risk• How we describe and define communities has had an impact• How we communicate with each other and the population continues to change• Evidence-based public health is required to justify costs associated with

interventions, describing health threats, and raising awareness.• Blurring of public health and clinical care options require new strategies

• Note: IOM—not-for-profit, nongovernmental advisory body established in 1970 to advise on biomedical science, medicine, and health, and its mission to serve as adviser to the nation to improve health

PBH considers environmental, social and economic determinants of health, even those not considered part of what we traditionally consider public health and clinical health. It also would encompass the range of interventions to address health issues including the structure and function of healthcare delivery systems, and how public policies affect health. There are 2 distinct characteristics of public health:1. It deals with preventive rather than curative aspects of health2. It deals with population-level, rather than individual-level health issues

Public health is typically divided into core disciplines including: • Epidemiology• Biostatistics• Environmental health• Health management and policy • Social and behavioral sciences

While this is a good start to describing public health, in 1994, when the country was exploring issues related to health care reform, the public health sector felt that a better definition and description of public health was needed. A “Core Functions of Public Health Steering Committee” was convened to address this need.

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• 1740s James Lind, a British Naval commander demonstrated that lemons and other citrus fruit could prevent and treat scurvy.

• Scurvy due to lack of vitamin C. • Vitamins were unknown in his day• Performed one of the first clinical experiments on record

• Edward Jenner is credited as the pioneer of smallpox vaccine, • Father of Immunology

• On 14 May 1796, Jenner tested his Hypothesis: Infection with cowpox gives immunity to smallpox

• Inoculated James Phipps, (8 year old son of his gardener), with material from the cowpox blisters of the hand of Sarah Nelmes, a milkmaid who had caught cowpox from a cow (Blossom)

• This produced a fever and some uneasiness but no great illness. • Phipps was the 17th case described in Jenner's first paper on vaccination.• Subsequently challenged him with variolous material

• In 1979, the World Health Organization declared smallpox an eradicated disease.

• samples still remain in laboratories in Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia in the United States, and State Research Center of Virology and Biotechnology VECTOR in Koltsovo, Novosibirsk Oblast, Russia.

The importance of his work does not stop there. His vaccine also laid the groundwork for modern-day discoveries in immunology

Ignaz Philipp Semmelweis (July 1, 1818 – August 13, 1865); • physician who worked in Vienna General Hospital's First Obstetrical Clinic • Observed and postulated (1847) that the incidence of puerperal fever (childbed

fever) could be drastically cut by the use of hand disinfection (by means of hand washing with chlorinated lime solution) in obstetrical clinics.

• Puerperal fever (or childbed fever) was common in mid-19th-century hospitals and often fatal, with maternal mortality at 10%–35%.

• Doctors' wards had three times the mortality of midwives' wards. • Despite various publications of results where hand-washing reduced mortality to

below 1%, Semmelweis's practice earned widespread acceptance only years after his death, when Louis Pasteur confirmed the germ theory.

• Died 1865 at age 47.

In mid-19th century in England, the recording of vital statistics (birth and death records) began.

Edwin Chadwick—diseases/pathological condition should be basis for death record

William Farr—risk factors and social should be basis for death record

The work of Louis Pasteur contributed to the Germ Theory of disease. The germ theory of disease laid the groundwork for modern public health.

Identification of diseases that did not have a “cure.” Worked to prevent those from getting the disease in the first place.

Interestingly, sometimes the cause of a disease was not due to germs as noted with pellagra, which was discovered to be caused by a deficiency of vitamin B-6 (niacin).

Advances in disease causation led to methods to prevent disease before they occurred. The key was still preventing disease. Isolation and quarantine were still used. Sanatoriums for Tb were established.

• Sanitation and Hygiene• The 19th century shift in population from country to city that

accompanied industrialization and immigration • led to overcrowding in poor housing served by inadequate or

nonexistent public water supplies and waste-disposal systems. • These conditions resulted in repeated outbreaks of cholera,

dysentery, TB, typhoid fever, influenza, yellow fever, and malaria.

• By 1900, however, the incidence of many of these diseases had begun to decline because of public health improvements, implementation of which continued into the 20th century. Local, state, and federal efforts to improve sanitation and hygiene reinforced the concept of collective "public health" action (e.g., to prevent infection by providing clean drinking water).

• In 1900, the three leading causes of death were pneumonia, tuberculosis (TB), and diarrhea and enteritis, which (together with diphtheria) caused one third of all deaths.

• Of these deaths, 40% were among children aged less than 5 years.• In 1997, heart disease and cancers accounted for 54.7% of all deaths, with

4.5% attributable to pneumonia, influenza, and human immunodeficiency virus (HIV) infection.

• Expresses an Epidemiologic Transition: Discussed in depth in chapter 6.

In 1945, Fleming was awarded the Nobel Prize in Physiology and Medicine, along with Ernst Chain and Howard Florey, who helped develop penicillin into a widely available medical product.

Ten Great Public Health Achievements —United States, 1900-1999

• Vaccination –eradication of smallpox, poliomyelitis in the Americas, control of measles, rubella, tetanus, diptheria, etc. in US and parts of world

• Motor-vehicle safety • Safer workplaces • Control of infectious diseases • Decline in deaths from coronary heart disease and stroke • Safer and healthier foods

These are three key principles that underlie public health and health care law1. The U.S. Constitution is a fundamental document that governs the issues of public

health and healthcare law.• Constitution does not mention health• Left to the primarily to the states who might delegate to local jurisdictions• Police Power—allows states to pass legislation to take actions to protect

the common good…protect its citizens• Regulate healthcare professionals and facilities• Health and safety standards in retail and occupational settings• Control hazards (car restraints, vaccinations, sale of tobacco)

2. Interstate Commerce Clause of the U.S. Constitution is the major source of federal authority in public health and health care.

• Source of federal authority• Tax, spend and regulate interstate commerce• Offer federal funding incentives to states for them to enact certain

types of legislation• Blood alcohol levels

• Justify national standards that overrule and limit state rules and regulations ranging from quality controls on drugs

• Permissible exposures to toxic substances3. US. Constitution grants individual rights (explicit and inferred)

• Freedom of speech, religion, assembly, bear arms• Right to procreation privacy, bodily integrity, travel• Right to utilize contraception, have an abortion, limit the state and federal

authority to use quarantine and other travel restrictions

• Constitutional law—Includes U.S. Constitution and all 50 State constitutions. Remember responsibilities for health lie with the states unless the federal constitution grants authority to the federal government. They do not usually mandate roles of government in area of health. The commerce clause sand due process clauses of the constitution have the basis for extensions of federal authority in areas of health. State constitutions are easier to amend.

• Legislative statutes—written by legislative bodies at fed, state and local level. Federal statutes typically overrule state and local legislation. We often see that state and local legislation may be more restrictive than federal statutes. Statutes often address directly health issues. May be written in general language.

• Administrative regulations– produced by executive agencies at federal, state, and local governments in order to implement legislative statutes. Think of them as operationalizing the statute…Who is eligible for services, how are the services to be provided, what levels of reimbursement are received?... Examples: requirements for immunization to enroll in public education, regulation of food establishments, medical devises

• Judicial, case, common law– law made by courts when applying constitutional, statutory, or administrative law to specific cases. May fill in holes when statutory law does not provide guidance. Examples: defining “nuisances” excess noise, disposal of garbage. Judge Judy…Judge Wapner…Judges apply previous rulings or precedence to new cases, and they may consider existing traditions and customs of society when applying law to cases.

• From 1963 through 1966, studies were carried out at the Willowbrook State School, a New York State institution for “mentally defective persons.”

• These studies were designed to gain an understanding of the natural history of infectious hepatitis and subsequently to test the effects of gamma globulin in preventing or ameliorating the disease.

• The subjects, all children, were deliberately infected with the hepatitis virus; early subjects were fed extracts of stools from infected individuals and later subjects received injections of more purified virus preparations.

The Back to Sleep campaign began in 1994 as a way to educate parents, caregivers, and health care providers about ways to reduce the risk for Sudden Infant Death Syndrome (SIDS). The campaign was named for its recommendation to place healthy babies on their backs to sleep. Placing babies on their backs to sleep reduces the risk for SIDS, also known as "crib death." This campaign has been successful in promoting infant back sleeping and other risk-reduction strategies to parents, family members, child care providers, health professionals, and all other caregivers of infants. Reduced deaths by up to 50% since program was initiated.

• Downstream factors – Focus directly on individuals and individual behaviors

• Mainstream factors – Focus on relationship of individuals with a larger group or population

• Peer pressure • Taxation of cigarettes

• Upstream factors – Focus on social structure and policies

Five Steps individuals go through in changing behavior: Useful in suggesting ways to help individuals change behavior Stages of change In the transtheoretical model as of 1997, change is a "process involving progress through a series of six stages"

• Precontemplation - "people are not intending to take action in the foreseeable future, usually measured as the next 6 months“

• Precontemplators tend to drop out of programs early • Contemplation - "people are intending to change in the next 6 months“

• A personal problem exists • Attempts to understand in order to regain some control over their lives • Perceive a link between overeating and hypertension—seek

dietary/exercise information • Perceive a link between excessive drinking and marital problems— • May take months or years

• Preparation - "people are intending to take action in the immediate future, usually measured as the next month"

• Action - "people have made specific overt modifications in their life styles within the past 6 months“

• May try a healthier diet • May try to increase exercise • May take steps to limit alcohol consumption • Go to a support group • Self esteem seems to rise because they demonstrate self-efficacy through

action • Maintenance - "people are working to prevent relapse," a stage which is

estimated to last "from 6 months to about 5 years“ • Continuance of change rather than an absence of change

• Termination - "individuals have zero temptation and 100% self-efficacy... they are sure they will not return to their old unhealthy habit as a way of coping"

In addition, the researchers conceptualized "relapse" (recycling) which is not a stage in itself but rather the "return from action or maintenance to an earlier stage”

The Health Belief Model is a values expectancy model: people will engage in a healthy behavior if 1) they value the outcome related to the behavior and 2) they think the behavior is likely to result in the outcome.

The Health Belief Model is a health behavior change and psychological model developed by Irwin M. Rosenstock in 1966 for studying and promoting the uptake of health services. The model was furthered by Becker and colleagues in the 1970s and 1980s. Subsequent amendments to the model were made as late as 1988, to accommodate evolving evidence generated within the health community about the role that knowledge and perceptions play in personal responsibility. Originally, the model was designed to predict behavioral response to the treatment received by acutely or chronically ill patients, but in more recent years the model has been used to predict more general health behaviors. Perceived susceptibility (an individual's assessment of their risk of getting the condition) Perceived severity (an individual's assessment of the seriousness of the condition, and its potential consequences)

Perceived barriers (an individual's assessment of the influences that facilitate or discourage adoption of the promoted behavior) Perceived benefits (an individual's assessment of the positive consequences of adopting the behavior).

Self efficacy - A person’s belief in his or her ability to take action.

Social Marketing– the use of marketing theory, skills and practice to achieve social change.

• Product—ID the behavior or innovation being marketed • Price—Identifying the benefits, barriers, final costs • Place—Identify the target audiences and how to reach them • Promotion– Organizing a campaign or program to reach the target

audience(s)

• Early adopters– those who seek to experiment with innovative ideas • Early Majority Adopters—opinion leaders whose social status frequently

influences others to adopt the behavior (John Gummer and daughter Cordelia eating hamburgers in 1990 in Great Britain. It was “safe” to eat.

• Late adopters or laggards—those who need support and encouragement to make adoption possible.

• Promote ease of use and widespread acceptance

Problem: What is the health Problem? • What is the burden of disease and has it changed over time? • Are there differences in the distribution of disease? Can we use the differences to

generate hypotheses about their etiology? • Are the differences or changes used to suggest group associations artifactual or

real? Etiology: What is/are the contributory cause(s)?

• Has the association been established at the individual level? • Does the cause precede the effect? • Has altering the cause been shown to alter the effect? (if not use ancillary/Hill

Criteria to determine association) Recommendations: What works to reduce the health impacts?

• What is the quality of the evidence for the intervention? • What is the impact of the intervention in terms of benefits and harms? • What grade should be given indicating the strength of the recommendation?

Implementation: How can we get the job done? • When should the implementation occur? • At who should the implementation be directed? • How should the intervention(s) be implemented? • This is an ongoing process that describe the framework for defining, analyzing

and addressing public health issues • We will break this process down to its elements.

• Burden of Disease: Impact it is having on the community; the occurrence of disability and death in the population.

• Morbidity: Sickness • Mortality: Death • Etiology: Cause

Using at-risk populations for calculations are often more precise and should be used where possible. Example: prostate cancer can not occur among women so only men are at risk for developing prostate cancer; cervical cancer would only include women. Incidence: measures the chances of individuals to develop a disease during a particular time period Prevalence: measures the proportion of individuals who have the disease at a point of time (or during a time period).

Incidence rate# of new cases of a disease over a period of time # of people in the at-risk population

Prevalence Rate # living with a particular disease # in the at-risk population

• Usually describes a point in time • Can use a period of time (period prevalence) • Good for describing the total burden or impact of the health problem in the

population at a given time

prevalence = incidence x duration of disease

Artifactual changes in rates• Changes in the interest in identifying the disease • Changes in the ability to identify the disease • Changes in the definition of the disease

Group Level Associations and all differences identified at the group level need to be assessed.

• Determined using Ecologic studies or Population comparisons; (correlation statistics)

• Associations at a group level may not hold true at the individual level • May lead to hypothesis generation and further study to determine the existence

of associations at the individual level

Study Designs • Cross-Sectional Studies assesess a snapshot in time of risk factor and case status • Case Control studies begin with knowledge of disease status and seeks

associations with a risk factor

• Cohort studies begin with assessing those with/without the risk factor and follow them forward in time to see if they develop the disease.

• Randomized Clinical Trials start with individuals who are assigned to the exposure (cause) to see if they develop the effect. May lead to ethical concerns…Can be used to determine efficacy (did the intervention work?)

Hills criteria for determining casual association1. Strength 2. Consistency 3. Specificity 4. Temporal relationship (Temporality) 5. Biological gradient (Dose-response relationship) 6. Plausibility (Biological plausibility) 7. Coherence 8. Experiment 9. Analogy (Consideration of alternate explanations)

Strength: how closely related the risk factor is to the disease; Relative Risk and Odds Ratios are measures of strength of relationship. (Optional: if time permits, cover the 2x2 table; calculate a relative risk and odds ratio) Consistency: seen across studies, preponderance of evidence across time, geographic areas, groups Biologic Gradient: Dose-response relationship: amount of exposure affects development of the outcome Biological Plausibility: can accept based on accepted/known biologic mechanisms

Criteria 1: Quality of evidence

Good: fulfills requirements for quality Fair Poor: fatal flaws in evidence…insufficient evidence (under powered

studies) Criteria 2 Magnitude of the impact – How much of the disability and/or death due to the disease be potentially removed by the intervention? (Net Benefit = benefits of interventions minus potential harms)

• Substantial • Moderate • Small • Zero/Negative

Combined overall Score (Agency for Healthcare Research and Quality) A—Must B—Should C—May D—Don’t I—Indeterminant, insufficient, don’t know

Implementation When: timing of the intervention Primary Secondary tertiary Who: individuals targeted for the intervention Vulnerable groups Entire population How: process of implementing interventions Information (Education)—individual encounters, mass media, group interactions Motivation (incentives)—it implies a tangible reward for changing behavior, Obligation (requirements)

Primary: • before the onset of disease • prevent smoking

Secondary: • after the development of a disease or risk factor, but before symptoms appear • screening programs to detect disease; smoking cessation programs

Tertiary: • after occurrence of symptoms, but before irreversible disability • diagnose and treat disease, prevent permanent disability or death (maintenance of

disability)