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Community Health and Wellness Promotion CH06100

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1 Community Health and Wellness Promotion CH06100
Session 1 Concepts, History, Determinates & more May 10, 2011 David Beavers, M.Ed., D.C., M.P.H. Session 1

2 Determinants of Health Major Categories
Concepts, History, & Determinants Determinants of Health Major Categories Physical factors Social & Cultural factors Community organization Individual behaviors Biological factors Session 1: 35, 48, 53, 61, 63-64, 69, 71, 79, 87 Session 1

3 Determinants of Health
Concepts, History, & Determinants Determinants of Health Individual Non-Modifiable Biological host Modifiable Health habits Diet Physical activity Tobacco use Use of health care Environmental Ambient Infectious Crime Stress Family Social Determinants Income Poverty & Inequity Education Race & Ethnicity Community & Social cohesion Session 1: 35, 48, 53, 61, 63-64, 69, 71, 79, 87 Health Care Access Quality Session 1

4 Themes in Public & Community Health History
Concepts, History, & Determinants Themes in Public & Community Health History Plagues & Contagious Diseases War & Conflicts Exploration & Expansion Scientific Progress The Industrial Revolution 19th Century Reforms (beginnings of modern PH) 20th Century Achievements Recurring themes: Science & Social Values Session 1: 35, 48, 53, 61, 63-64, 69, 71, 79, 87 Session 1 4

5 Early Christian Period: 30 - 300 AD
Concepts, History, & Determinants Early Christian Period: AD Order of Deaconesses Organized visiting of the sick Forerunner of community nursing concept Rise of monasteries Tended to be built near reliable water source Fed the hungry Cared for the sick (forerunner of hospitals) Repositories of learning Session 1: 35, 48, 53, 61, 63-64, 69, 71, 79, 87 Session 1

6 Concepts, History, & Determinants
Middle Ages: 500 AD – 1400 AD Ships docking at the Lazzaretto Vecchio, Venice, 14th century Session 1: 35, 48, 53, 61, 63-64, 69, 71, 79, 87 The practice of quarantine began during the 14th century in an effort to protect coastal cities from plague epidemics. Ships arriving in Venice from infected ports were required to sit at anchor for 40 days before landing. This practice, called quarantine, was derived from the Italian words quaranta giorni which mean 40 days. Quarantine: as a control measure, started in Venice, the chief port of entry from the Orient Session 1

7 Renaissance & Enlightenment: 1300 - 1700
Concepts, History, & Determinants Renaissance & Enlightenment: Public Health administration is becoming a city council responsibility Gradual transfer of responsibility for institutional health care from the church to civil authorities By the 1600s towns in Europe had standards for cleanliness and rules for personal responsibility Late 1600s hospitals started became places not only to treat disease but to train doctors Session 1: 35, 48, 53, 61, 63-64, 69, 71, 79, 87 Session 1

8 The Sanitary Movement: 1830-1875
Concepts, History, & Determinants The Sanitary Movement: Growth in scientific knowledge Connection between poverty and disease Importance of water supply & sewage removal Session 1: 35, 48, 53, 61, 63-64, 69, 71, 79, 87 Session 1

9 Concepts, History, & Determinants
British Reformers Sir Edwin Chadwick “Good economics to prevent the evils” Assistant to Bentham 1834 report led to reform of England’s Poor Laws 1842 Report on the Sanitary Conditions of the Labouring Population – “Sanitary Report” first Medical Officer of Health appointed in Liverpool 1848 Public Health Act established the principle that health care should be administered at a local level Session 1: 35, 48, 53, 61, 63-64, 69, 71, 79, 87 Session 1

10 Four Phases of the Development of Modern Public Health
Concepts, History, & Determinants Four Phases of the Development of Modern Public Health Addressing infectious diseases related to “urbanization, poverty and squalor” (1840s to the late 19th century) Added personal preventive medical services related to immunization, family hygiene, health education and family planning which began with the development of vaccines (late 19th century until the 1930s) Focus is on improving population health through the provision of organized medical services deploying effective therapeutic technologies (antibiotics) Recognition that the ‘environment’ is also social, economic and psychological and needs to be considered as part society's health policy Session 1: 35, 48, 53, 61, 63-64, 69, 71, 79, 87 Session 1 Source: Ashton (1990)

11 Part I: Understanding & Improving Health
Concepts, History, & Determinants Part I: Understanding & Improving Health History Determinants of health model How to use a systematic approach Leading Health Indicators (LHI) Session 1: 35, 48, 53, 61, 63-64, 69, 71, 79, 87 Session 1

12 Community Health and Wellness Promotion CH06100
Session 2 Dimensions, Risks, Levels of Prevention, Professional Literature, Related Theories & “Flags” May 17, 2011 David Beavers, M.Ed., D.C., M.P.H. Session 2

13 Wellness Review Wellness is an active process of becoming aware of and making choices toward a more successful existence Wellness is a multidimensional state of being describing the existence of positive health in an individual as exemplified by quality of life and a sense of well-being Session 2: 4, 6-7, 13-14, 21-22, 28, 59 Session 2

14 Six Major Dimensions of Health & Wellness
Emotional – continuum of feelings, managing stress, transitioning major changes, work-life balance Intellectual – stimulating mind & mental capacity, reasoning & creatively, continuing education Occupational – contributing, using vocational skills/abilities, hobbies 4. Physical – taking action to maintain health, exercise, nutrition, ADLs, self-care Session 2: 4, 6-7, 13-14, 21-22, 28, 59 Session 2

15 Six Major Dimensions of Health & Wellness
5. Social – connecting & interacting with family, friends, co-workers & others 6. Spiritual – life purpose, seeking spiritual centered beliefs, nature, religion Session 2: 4, 6-7, 13-14, 21-22, 28, 59 Session 2

16 Health Problems & Intro to Risk Factors
a condition that can be represented in terms of measurable health status, or quality of life indicators To intervene in a health problem requires ability to identify risk factors pathways of causation Risk factors in general: Causative factors that increase likelihood of a condition or disease Direct Contributing Factors - affect the level of the condition Indirect Contributing Factors - likely to be controllable and basis for intervention Session 2: 4, 6-7, 13-14, 21-22, 28, 59 Session 2

17 Analyzing Health Problems for Risk Factors
Source: Definitions adapted from Centers for Disease Control and Prevention Public Health Practice Program Office Determinant - scientifically established factor that relates directly (most proximal) to the level of the health problem. A health problem may have any number of determinants identified for it. Example: Low birth-weight is a prime determinant for the health problem of neonatal mortality Direct Contributing Factor - scientifically established factor that directly affects the level of the determinant. Example: Use of prenatal care is one factor that affects the low birth weight rate Indirect Contributing Factor – individual or community-specific factor that affects the level of a direct contributing factor. Such factors can vary considerably from one individual or community to another. Example: Availability of day care or transportation services within the community may affect the use of prenatal care services NOTE: Work sheet example on later slide (#21) Session 2: 4, 6-7, 13-14, 21-22, 28, 59 Session 2

18 Health Problem Analysis Worksheet Example
Session 2: 4, 6-7, 13-14, 21-22, 28, 59 Session 2

19 Ten Leading Causes of Death
Depends on age group Observable patterns Overall age group ranking #1 = heart disease #2 = malignant neoplasms #3 = cardio-vascular Session 2: 4, 6-7, 13-14, 21-22, 28, 59 Session 2

20 Three Levels of Prevention
Primary Stop or delay onset Secondary Early diagnosis & prompt treatment Tertiary Retrain, re-education & rehabilitate Session 2: 4, 6-7, 13-14, 21-22, 28, 59 Session 2

21 Health “Flag” System Flags help explain risk factors
Guidelines to help make clinical decision(s) Evaluation, triage & augmentation of treatment Five types of flags Session 2: 4, 6-7, 13-14, 21-22, 28, 59 Session 2

22 Community Health and Wellness Promotion CH06100
Session 3 Behavioral Health May 24, 2011 David Beavers, M.Ed., D.C., M.P.H. Session 3

23 Importance & Responsibilities of Health & Wellness Promotion
For prevention or reduction of morbidity, mortality, injury & disability Lifestyle causes nearly 80% of health issues Musculoskeletal conditions are a leading cause of disability (Chiropractors are uniquely qualified) Need competency in use of evidenced-base theories, models, knowledge & skills Wellness concepts to promote patient self-efficacy Session 3

24 Definition of Terms Counseling Coaching
The act of giving advice about issues, challenges or health problems Attempts to clarify patient’s own thinking about a health problem rather than solve the health problem Coaching The act of directing, instructing and training with the aim to achieve a specific health goal Such as addressing health and adjusting lifestyle for wellness Session 3

25 Theory vs. Model Theories comprise principles devised to explain a group of facts or phenomena; used to make predictions Health behavior theories provide broader understanding of behavior & its links to the general human condition Models comprise representations of structures or processes & the interactions among these; logically links phenomena together Health models provides a framework for targeting system, structural & process changes Session 3

26 Ecological Framework Brief Introduction
Ecology (“environment”) is the space outside the person Five levels of concentric influence: Intrapersonal (“self/individual”) factors Interpersonal (“primary groups”) processes Institutional factors Community Factors Public policy Session 3

27 Models of Intrapersonal or Individual Health Behavior
Health Belief Model Theory of Reasoned Action & Planned Behavior Transtheoretical Model With Stages of Change Session 3

28 Models of Individual Health Behavior
Health Belief Constructs Perceived susceptibility, severity, benefits & barriers Self-efficacy – confidence Cues to Action – strategies, reminders, push to take action, phone a friend, postcard Session 3

29 Models of Individual Health Behavior
Theory of Reasoned Action & Planned Behavior (two separate theories work together) Foundation Individual motivational factors Motivation Internal state activates & directs behavior Desire energizes & directs goal orientation Needs influence intensity & direction Session 3

30 Models of Individual Health Behavior
Theory of Reasoned Action & Planned Behavior (two separate theories work together) Foundation (continued) Behavior is result of one’s intention Intent is result of beliefs & attitudes Suggests that attitude is better predictor of behavior Assumes people are rational Session 3

31 Models of Individual Health Behavior
Theory of Reasoned Action & Planned Behavior (two separate theories work together) Constructs Behavioral intention Attitude toward behavior Positive - strong beliefs that positively valued outcomes will result Negative - strong beliefs that negatively valued outcomes will result Session 3

32 Models of Individual Health Behavior
Theory of Reasoned Action & Planned Behavior (two separate theories work together) Constructs Subjective norms Normative beliefs Referent others Approval-Disapproval Sum & Neutral Think – “Intention & Individual Intention” Session 3

33 Models of Individual Health Behavior
Theory of Reasoned Action & Planned Behavior (two separate theories work together) Foundation – similar to TRA Constructs Volitional control – large degree of control Perceived behavioral control Influences of outside factors Assumes person will exert more effort when perception of control is high Session 3

34 Theory of Reasoned Action (grey) & Planned Behavior (white)
Session 3

35 Models of Individual Health Behavior
Transtheoretical Model & Stages of Change Foundation People are generally in 1 of 5 stages of change (total of 6 stages) Used often with addictive behaviors Session 3

36 Models of Individual Health Behavior
Transtheoretical Model & Stages of Change Six stages (only 5 are “active”) Pre-contemplation – not intending Contemplation – intending within 6 months Preparation – intending/planning within 30 days Action – currently & within last 6 months Maintenance – actively doing/preventing relapse Termination – no temptation, integrated into lifestyle, “non-active” Session 3

37 Models of Interpersonal Health Behavior
Social Cognitive theory Foundation Principles of reinforcement & punishment Learn by watching others = observational learning/modeling Cognitive process mediates social learning R & P affect motivation, not behavior itself Assumptions Learning internal process – may/may not affect behavior Behavior is directed toward particular goals Behavior becomes self-regulated Session 3

38 Models of Interpersonal Health Behavior
Social Cognitive theory Constructs Reciprocal determinism Personal factors (P) Behavior (B) Environmental (E) Environment Physical-Social-Cognitive Observational learning Attention-Retention-Motor Reproduction-Motivation Session 3

39 Models of Interpersonal Health Behavior
Social Cognitive theory Constructs (continued) Behavioral capacity Must have knowledge/skill of a behavior before one can perform behavior Reinforcement Positive = reward Removal of reward -> behavior reverts Reduce barriers Session 3

40 Models of Interpersonal Health Behavior
Social Cognitive theory Constructs (continued) Outcome expectations Belief will lead to certain outcome Maximize positive and minimize negative Learned four ways Previous experience in similar situations From observing others Hearing about situations From emotional/physical responses Session 3

41 Models of Interpersonal Health Behavior
Social Cognitive theory Constructs (continued) Self-efficacy = self-confidence that one can do the behavior Confidence in performing Enhancing – similar to four ways of learning Verbal persuasion for incremental changes Physiological state Session 3

42 Models of Interpersonal Health Behavior
Social Cognitive theory Constructs (continued) Self-control Evaluation of internal standards & external perceptions (“reality”) Emotional Coping Responses Have control over emotions Psychological defenses of repression, denial Cognitive techniques – restructuring, CBT Treatment of symptoms – relaxation, stress Session 3

43 Models of Interpersonal Health Behavior
Social Networks & Social Support Social Support (continued) Important function of social relationships Categories of supportive behaviors Emotional – empathy, love, trust, caring Instrumental – tangible aid, service Informational – advice, suggestions, information Appraisal – information for self-evaluation Session 3

44 Models of Community & Group Behavior
Diffusion of Innovations Adoption process – follows bell curve Innovators Early adopters Early majority Late majority Think – iPad Session 3

45 Models of Community & Group Behavior
Communication Theory & Health Behavior Change “To make common to many” on many levels: Individual – persuasion theories, social cognitive theory Organization – news gate-keeping Communities & Social systems – diffusion of innovations, knowledge gap Mass society & culture/Cross-level analysis – framing problems, agenda setting, risk communication Session 3

46 Application of Models & Theories for Patient Health & Wellness
PRECEDE-PROCEED Planning Model – how to apply theories PRECEDE part Predisposing, Reinforcing & Enabling constructs in educational/environmental diagnosis & Evaluation Just as a diagnosis precedes a treatment plan, so should educational diagnosis precede an intervention plan Session 3

47 Application of Models & Theories for Patient Health & Wellness
PRECEDE-PROCEED Planning Model – how to apply theories PROCEED part Policy, Regulatory & Organizational constructs in Educational & Environmental Development Adds determinants of health & health behaviors/lifestyle factors Session 3

48 Application of Models & Theories for Patient Health & Wellness
Stages of Change 1. Pre-contemplation – usually uninformed or under-informed; tried change but demoralized; provide facts and general information 2. Contemplation – acutely aware of cons, so ambivalent, chronic contemplation; provide information about pros 3. Preparation – have a plan of action; recruit for action-oriented programs, such as weight loss clinic Session 3

49 Application of Models & Theories for Patient Health & Wellness
Stages of Change (continued) 4. Action – have taken some action, still have not obtained sufficient level to reduce risks; encourage continued progress 5. Maintenance – for example 12 months of not smoking has 43% relapse, 5 years has only 7%; strive to prevent relapse 6. Termination – total self-efficacy; less than 20% reach this stage; encourage life-time of “maintenance” with continued check-ups Session 3

50 Community Health and Wellness Promotion CH06100
Session 4 Epidemiology May 31, 2011 David Beavers, M.Ed., D.C., M.P.H. Session 4

51 Why even bother to count
Measuring: how many people get ill, have a dysfunction or die each year; who, when, why & where do they live is one of the most important means of, . . along with gauging how various “diseases” and injuries are affecting the living, … at assessing the effectiveness of a country’s health system Session 4

52 Epidemiology Definition (WHO)
The study of the distribution & determinants of health-related states or events (including disease & dysfunction), and the application of such study to the control of diseases and other health related problems Disease in not randomly distributed Has patterns (risk factors) so can predict & control Two chief methods are used to carry out epidemiological investigations Descriptive (& surveillance) studies are used to study distribution patterns; organized by time, place & person Analytical studies are used to study determinants; concerned with cause & effects Session 4

53 Epidemiology overview “Population Medicine”
All epidemiological studies involve sampling of population at risk Subject to sampling (random) error P-values & confidence intervals (CI) used to express degree of uncertainly or statistical variability in estimates This does not consider systematic (non-random) error or bias Session 4

54 Major goal of Epidemiology
Obtain an unbiased & precise estimate of the true effect of an exposure or intervention on outcome in the population at risk Use findings to prolong the number of years of healthy life of the population, community and individuals (prevent disease & avoid human suffering) Session 4

55 Epidemiology Terms & Descriptions
Variable Anything that can be measured & observed to vary A single value is a constant; therefore, not a variable Data characterization Quantitative Measured on a numeric scale Discrete integer – number of moles, shoe size Continuous scale – blood pressure, speed of driving Qualitative No natural sense of ordering, aka “categorical” Can be coded as numeric (but have no meaning) Hair color, race; male = 1 & female = 2; names Discrete values equal to an integer Session 4

56 Epidemiology Variables
Two types of variables Dependent variable - outcome of interest, variable being affected, “depends on what we did”; example - spinal ROM Independent variable - the “hypothesized” cause or influence on dependent variable, “what or how much we did”; spinal manipulation Controllable factor – treatment/intervention; example - chiropractic manipulation Non-controllable factor – exposure, risk factor, demographic; example - slip, trip or fall type of injury Session 4

57 Relationship between independent & dependent variables
An example from a mathematical formula to convert temperature If: F = 1.8 x C + 32 (F is unknown) C is independent F is dependent (changes in F depend on changes in C) Constants = 1.8 and 32 Now if: C = (F – 32)/1.8 C is now dependent F is now independent Session 4

58 Epidemiology Types of Data
Continuous Any value within a defined range Ratio – numbers can be compared as multiples of one another Interval - along a scale in which each position is equidistant from one another, an “integer” Categorical (Discrete) Only whole numbers Nominal – Latin for “name”, can count but not order Ordinal – ranked in order, can count but not measure Dichotomous categorical Only two options Yes/No; Pass/Fail; Pregnant/Not Pregnant Session 4

59 Data Measurement Variable type determines subsequent statistical analysis performed
Commonly used scales of measurement Nominal Group qualitative into arbitrary categories 1 = white, 2 = Hispanic, 3 = American Indian Ordinal Rank “categorical” data Likert scale: 1 = strongly agree, 2 = agree, etc. Interval Similar to ordinal, but has meaningful difference between successive values; 70 to 80 same as 30 to 40 Session 4

60 Data Measurement continued
Commonly used scales of measurement Ratio Similar to interval, with a meaningful zero Zero is absence of weight/matter, while zero degrees F is totally arbitrary Significance of “meaningful” zero Means ratio of two values is also meaningful 10 lbs. is twice as heavy as 5 lbs. But, an object with 10 degrees F is not twice as warm as that object at 5 degrees F since the zero value point on the F scale is arbitrary Session 4

61 Epidemiology Major Concepts
Measures of Disease Frequency Measures of Association Disease Rates Bias, Confounding & Effect Modification Adjusted disease rates by standardization Surveillance Study designs Hypothesis Testing Session 4

62 Measures of Disease Frequency Primarily used for descriptive purposes to explore trends & patterns
Prevalence Number of existing cases any given time Calculated by (# existing cases/total population) Answer ranges from 0 to 1 No temporality – no info on when disease developed Key word = proportion Point prevalence – one point in time Period Prevalence – beginning date to ending date Session 4

63 Measures of Disease Frequency
Incidence Number of new cases during a defined period Cumulative Incidence (Incidence Risk/Attack Rate) Measures individuals who develop the disease Calculated by (# new cases / total population at risk) Answer ranges from 0 (no new cases) to 1 (everyone infected) Average risk (probability) of developing the disease Incidence Density (Incidence Rate/Person-Time Incidence/Event rate) Measures rate that new cases occur in population Calculated by (# new cases / total person-time) Answer ranges from 0 to infinity & integrates time into denominator of formula Average hazard rate of expected number of “events” per unit of time Session 4

64 Measures of Disease Frequency
Relationship between Prevalence & Incidence P/(1-P) = I x D P = prevalence I = incidence (density or rate) D = duration P = I x D When prevalence is low (<10%) Session 4

65 Calculation Chiropractic example
In a population of 1,000, an initial exam reveals 100 individuals with scoliosis. Over next 10 years, 40 more subjects develop scoliosis. What is prevalence of scoliosis? What is 10-year risk (cumulative incidence) of developing scoliosis? Session 4

66 Calculation In a population of 1,000, an initial exam reveals 100
individuals with scoliosis. Over next 10 years, 40 more subjects develop scoliosis. What is prevalence of scoliosis? 100 initial cases / 1,000 people at risk = 10% What is 10-year risk (cumulative incidence) of developing scoliosis? 40 new cases/900 people at risk = 4.4% Session 4

67 Measures of Association Estimates relationship between possible risk factors & disease occurrence to make inferences about effects of exposure Uses a “2 x 2” contingency table Ratio measures Risk Ratio Odds Ratio Difference measures Attributable Risk (Risk Difference) % Population Attributable Risk (Risk Difference) Session 4

68 2 x 2 Contingency Table aka “Cross Tabulation”
Record & analyze the relationship between two or more categorical variables Displays the multivariate or frequency distribution of variables in a matrix format Used also with case-control & cohort studies Disease or risk factors (cases) No Disease or no risk factors (controls) Totals Exposed a b a + b Not Exposed c d c + d a + c b + d a + b + c + d Session 4

69 Measures of Association
Risk Ratio (RR) Equation RR = [a / (a+b)] / [c/(c+d)] Measures (compares) risk for disease between two groups: exposed & unexposed Those with exposure have a RR-% increase in risk of developing condition Does not explain absolute risk to population Use with Cohort study Session 4

70 Measures of Association
Odds Ratio (OR) Equation OR = ad / bc The odds of exposure among the cases (with disease) are OR-times greater as compared to controls (subjects without disease) When exposure-specific risk or rates cannot be calculated since no true denominator If disease is rare then OR approximates RR Use with Case-Control study Session 4

71 Measures of Association “Non-independence”: Measures for impact of exposure or intervention
Attributable Risk (Risk Difference) Estimates excess risk of disease in exposed that is attributable to exposure % Population Attributable Risk (Risk Difference) Estimates the proportion of disease in the total population that is attributable to the exposure and that can be eliminated if the exposure is eliminated Session 4

72 Standardization US Census is an example
Adjusted or standardized rates are computed to remove the effect of other “factors” from crude (overall/total population) rates Crude has “differences” mixed in – age, sex, etc. Need age-specific rates of sample population & age-structure of standard population Special formula to calculate Session 4

73 Surveillance Passive Active Voluntary reporting of disease cases
Provider initiated Example – Anthrax, Brucellosis, Rabies & various animal diseases State reportable infectious diseases Active Mandated reporting of disease cases Health department initiated Extensive outreach Example – HIV, TB Easier to spread & more life-threating Session 4

74 Study Design Types Two major types
Performed when disease or death occurs in unexpected or unacceptable numbers Observational Exposure status not influenced by investigator “Natural experiment” – John Snow Experimental Involve manipulation of exposure or intervention Randomization is common Session 4

75 Study Design Types Observational (aka “Descriptive”)
Observational - data at individual or group level & organized by time, place & person Case Report/Case Study Ecological Study Cross-sectional Case-Control Cohort Session 4

76 Study Design Types Experimental (aka Analytic)
Experimental - concerned with causes & effects of an event; tests hypotheses about relationships between health problems & risks Quasi-Experimental (non-random) Cross-over (intervention order random) Clinical Hypothesis testing Randomized Controlled Trial (RCT) Blinded & Double Blinded Session 4

77 Major Observational Studies Cross-sectional (includes cases & non-cases)
Exposure & disease are measured simultaneously Snapshot of health experience for population at a specified time, but no temporality Example - Behavioral Risk Factor Surveillance System (BRFSS) Strengths Prevalence of exposure & disease can be estimated for study population Can be completed quickly Generally used to generate a hypothesis Limitations Temporality cannot be established Study participants are not randomly allocated to exposure group Does not provide concrete answers; no follow-up Session 4

78 Major Observational Studies Case-Control
Starts with disease status Compares frequency of prior exposure to a specific risk factor between individuals with a specific disease (cases) & those without the same disease (controls) Assessed retrospectively Strengths Multiple exposures of a single disease can be studied More cost effective with long induction-latency disease More cost effective with rare “diseases” Limitations Temporality may be difficult to establish Only prevalence rates can be calculated, not incidence rates Susceptible to bias Session 4

79 Case-Control Session 4

80 Major Observational Studies Cohort (Example - Framingham studies)
Start with exposure Naturally occurring exposure followed to determine frequency of disease Prospective or retrospective All study participants free of disease of interest in beginning Need to match exposure and comparison groups as much alike as possible to avoid bias Strengths Temporality can be delineated Incidence rates can be calculated Cost effective with rare “exposures” Limitations Primary exposure cannot be controlled Participants can be lost to follow-up over time which causes bias Not cost effective for studying rare “diseases” Session 4

81 Cohort study Retrospective looks backward from “future”/current to “present”/past) Session 4

82 Major Experimental Studies Randomized Control Trial (RCT)
Randomly allocates study participants to two or more groups Considered “gold standard” in research Strengths Strongest evidence for cause & effect relationship Random assignment eliminate selection & confounding bias Limitations Requires larger sample sizes to detect statistically significant differences in outcomes between intervention & control groups Generalizability of results to population my be limited due to restrictive eligibility criteria Study design may not be appropriate or ethical to test efficacy of some interventions Session 4

83 Epidemiology Bias, Confounding & Modification
Bias – systematic error in design, conduct or analysis Selection & information/observation Lack of internal validity Confounding – third variable distorts measure of association Must be associated with exposure in source population, be a risk factor, not be in causal pathway Try to eliminate Modification – third variable changes relationship between independent & dependent variables Strata RR differ by level of third variable Try to explain Session 4

84 Quality Assurance & Control Data collection & processing
Validity Accuracy – distinguish between who has a disease and does not Absence of bias As related to classification of individuals Sensitivity – ability to identify correctly those who do have the disease of interest Specificity – ability to identify correctly those who do not have the disease of interest Reliability Precision – extent to which results obtained are replicated if test is repeated Reproducibility or repeatability Session 4

85 Levels of Inference First level Second level Third level Fourth level
Association between exposure & disease only requires accurate measurements Second level Plus no confounding Third level Plus generalizability Fourth level Plus ability to modify exposure Fifth level Plus large attributable ratio (fraction) Session 4

86 Community Health and Wellness Promotion CH06100
Session 5 Biostatistics June 7, 2011 David Beavers, M.Ed., D.C., M.P.H. Session 5

87 The three “S”s (1) Survey Method of monitoring: Relatively inexpensive
Behaviors associated with a disease, disorder or dysfunction Attributes that affect disease risk Knowledge or attitudes that influence health behaviors Use of health services Self-reported disease occurrence Relatively inexpensive Provide reliable & reproducible method for getting information from individuals Examples – cross-section survey, census, poll Session 5

88 The three “S”s (2) Surveillance
Systematic collection, analysis & dissemination of disease data From groups of people Designed to detect early signs of disease Cornerstone of preventive health care Prevent disease & injury to improve quality of life Active & Passive studies Example – Framingham Heart Cohort Study, Nurses’ Health Study Session 5

89 The three “S”s (3) Sampling
Cost & logistics are constraints in collecting measurements on entire target population Use smaller segment of population for extrapolation back to larger target population Variety of sampling types Must understand inherent limitations of sampling when making generalizations to target population Therefore, need to use biostatistics Session 5

90 Sampling Error (1) Two types
Difference between measurement in sample & target population (target comes from “whole”) Main causes of error in sampling Selection bias Using sample population with measurement characteristics not representative of target population Random variation Measurement error attributable simple to chance Session 5

91 Sampling Error (2) Methods to reduce
Selection bias can be minimized by using a randomized selection process Simple random - each individual is chosen entirely by chance, such that each individual has the same probability of being chosen Stratified random – from each group after homogeneous division Clustered random – of groups after homogeneous division Systematic random – every 10th, 20th, etc. Random variation is a random error (attributed to chance); therefore, not controllable Systematic random is the most uded Session 5

92 Why randomize In sample selection
Ensure sample is representative of overall target population Sampling process (not the sample itself) determines randomness Helps eliminate bias, thus leaving random variation as the only possible source of error Magnitude of that error determined by the size of sample & heterogeneity of population Session 5

93 Biostatistics What are all these formulas & numbers
Framework for analysis & interpretation of data Application of statistic principles to the biologic sciences Methodically distinguish between true differences among observations & random variations caused by chance alone Knowledge of biostatistics & epidemiology allows valid conclusions from data sets about associations between risk factors & disease Session 5

94 Measures of Dispersion (1)
Describes distribution or “spread” of data Used in conjunction with measures of central tendency Provide a more complete description of data Four common measures Range Interquartile range Variance Standard deviation Session 5

95 Measures of Dispersion (2) Common measures
1. Range Difference between largest & smallest value in data distribution 2. Interquartile range Describes the middle 50% of observations Data that fall in the 25th to 75th percentiles Session 5

96 Measures of Dispersion (3) Common measures
3. Variance (s2) Describes amount of overall variability around the mean (in all directions) Measured as the average of the squared distances between each variable & the mean (accounts for negative & positive values) Formula Session 5

97 Measures of Dispersion (4) Common measures
4. Standard Deviation (s) Calculated as the positive square root of the variance Describes variability of data only in one direction Has same units of measurement as the mean; therefore, used more frequently than variance to describe the breath of data Formula Session 5

98 Hypothesis Testing Oh no not again
How to perform statistical inference Allows the drawing of conclusions & make statements based upon the information obtained from the sample being analyzed Assumes mean of sample is same as mean of population from which sample is drawn Attempt to prove or disprove above statement Example: A new intervention (therapy) is superior to the current standard of care for a specific condition Session 5

99 Null Hypothesis (H0) There is no difference in among groups being compared Any observed difference is random variation in data rather than a result of actual disparity By convention, assumed that null hypothesis is true at outset of study Investigators attempt to refute or reject this with statistical analysis of data gathered Session 5

100 Alternative hypothesis (HA)
Opposing option to the null hypothesis Contradicts null stating that there is “in fact” a true difference beyond the probable by random chance alone among groups being compared Session 5

101 Screening vs. Predictive
Sensitivity & specificity of screening are properties inherent to the test & do not vary with disease prevalence Predictive values vary directly with the prevalence of the disease within the tested group Session 5

102 Statistical testing (1)
z-Statistic inference procedure “z” used when normal curve & SD of population is known Sample size of 30 or more t-Statistic inference procedure “t” used when SD is unknown as in health research Sample size of less than 30 important Session 5

103 Statistical testing (2)
Descriptive statistics Continuous Parametric tests t-tests, analysis of variance (ANOVA), Regression Categorical/Discrete Non-Parametric tests Chi-square, Fisher’s exact test important Session 5

104 Statistical testing chart
If you want to Use Research Question Examples Compare individual score to a group mean z-scores How does my test score compare to class average Compare mean of single group to a population or hypothesized mean One sample t-test Is the average height of Logan students 64” Compare means of 2 related measure on the same group Paired samples t-test Do brothers & sisters living in same household watch the same hours of TV on average Compare mean for one measure for 2 independent groups Independent samples t-test Do men & women have same number of years of education Compare means of a measure for more than 2 groups One-way ANOVA Does income vary among those with HS diplomas, college degrees, & graduate degrees Determine how 2 continuous variables are related Correlation Coefficient Is years of education related to income Predict value of one continuous variable from another Simple linear regression Can income be predicted if years of education is known Compare proportions for 2 categorical variables Chi-squared Is proportion of men who have college degrees different from the proportion of women who have college degrees Session 5

105 Community Health and Wellness Promotion CH06100
Session 6 Federalism, Public Good, Collaboration, Health Care System June 14, 2011 David Beavers, M.Ed., D.C., M.P.H. Session 6

106 Government Levels of Public Health
Federal Provide leadership & guidance Develop national health policies Establish national standards Conduct basic research Offer technical assistance Provide funding DHHS, US Public Health Service, CDC, FDA, EPA, OSHA, etc. Session 6

107 Government Levels of Public Health
State Primary responsibility is health of the population Assess health needs on statewide data Enact necessary state laws Establish state health priorities & policies Assure appropriate services are available Support local service capacity Common functions Vital stats, PH education, environmental sanitation, prevention & control communicable disease, etc. Session 6

108 Government Levels of Public Health
Local Assess & monitor local health issues & solutions Provide leadership for local involvement Assure access to quality services within context of community Can be county or city level Sometimes a special district Independent tax base Own elected Board of Trustees Session 6

109 Public Sector Funding Federal Funding Source State Funding Source
Federal income tax State Funding Source Sales tax & income tax Local Funding Source Property tax Session 6

110 Public Good Public health has characteristics of public, social & collective goods Free market place will not voluntary provide all necessary public health services Some public health interventions are required to address “bystander” well-being Collective action by government is required to assure the availability of such goods & services Session 6

111 Health Care System Overview 3
U.S. Health Care System Structure No central governing agency Focuses on acute care Technology driven Involves multiple players Based on Market Justice NOT on Social Justice Imperfect market condition Driven by profit motive Government serves as subsidiary to the private sector question Session 6

112 School Health Program Coordinated School Health Program (CSHP)
Vast potential to affect health of school children, their families & community Organized set of policies, procedures & activities designed to: Protect, promote & improve health & well-being Includes: Health education & Health services Counseling with psychological & social services Physical education & Nutritional services Session 6

113 Health Literacy The degree to which individuals have the capacity to obtain, process & understand basic health information and services needed to make appropriate health decisions (Healthy People 2010) Health literacy includes the ability to understand: Instructions on prescription drug bottles & appointment slips Medical education brochures, doctor’s directions & consent forms Ability to negotiate the health care systems Session 6

114 Community Health and Wellness Promotion CH06100
Session 7 Public Health Organizations: Global to Local June 21, 2011 David Beavers, M.Ed., D.C., M.P.H. Session 7

115 Public Health Organizations: Global to Local
Governmental International to Local Quasi-Governmental American Red Cross to National Science Foundation Non-Governmental Voluntary to Corporate Session 7

116 Public Health Organizations: Governmental – WHO guided by 2 documents
Millennium Summit (2003) - 6 health goals Eradicate extreme poverty & hunger Reduce child mortality Improve maternal health Combat HIV/AIDS, Malaria & other diseases such as TB Ensure environmental sustainability Develop a global partnership for development, especially for essential drugs Session 7

117 Public Health Organizations: Governmental – WHO guided by 2 documents
11th General Programme of Work - 5 areas for work priorities (2006 – 2015) Provide support to countries in moving to universal coverage with effective PH interventions Strengthening global health security Generating & sustaining action across sectors to modify behavioral, social, economic & environmental determinants of health Increasing institutional capacities to deliver core public health functions under the strengthened governance of ministries of health Strengthening WHO’s leadership at global & regional levels & by supporting work of governments at country level Session 7

118 Public Health Organizations: Governmental
National Agencies Each national government has agency with primary responsibility for protection of health & welfare of its citizens In US the primary agency is Department of Health & Human Services (HHS) Has 11 divisions & 10 regional offices AHRQ, CDC, FDA, IHS, NIH, SAMHSA, etc. Other agencies include WIC, EPA, OSHA Public Health Service (PHS) Session 7

119 Public Health Organizations: Governmental
US Department of Health & Human Services Primary national health agency for US Protects the health of all Americans Provides essential human services, especially for those who are least able to help themselves Session 7

120 Public Health Organizations: Governmental
Concepts flow from top down Develop guidelines IOM through state to local agencies Three Core Functions of US Public Health agencies Assessment Policy Development Assurance Session 7

121 Public Health 10 Essential Services Basis for Public Health Practice
Link to the 3 core functions Sets a continuous processes Manages at a systems level Enhances through active research Provides an organizing framework for individual & collective practice Session 7

122 Public Health Organizations: Governmental
State Agencies All 50 states have public health agency Guided by the 3 Core Functions Direct the 10 Essential Services Overall purpose Next slide Session 7

123 Public Health Organizations: Governmental
Overall purpose of state agencies Promote, protect and maintain the health & welfare of their citizens Represented in 3 core functions & the 10 essential services Sets health priorities Promulgate health regulations Laboratory services & technical support Environmental health (generally crosses boundaries) Link between federal & local agencies For expertise For funding Session 7

124 Public Health Organizations: Governmental
Local Agencies - continued Through LHDs public health services are provided to community Major actors for 3 core functions Major provider of 10 essential services Mandated services include Inspection of food services Detect & report required diseases Collection of vital records Health education & promotion Some provide clinical services Session 7

125 Public Health Organizations: Quasi-Governmental
Some responsibilities assigned by government Function under a charter or contract Funded by combination of Tax dollars Grants Private sources Operate relatively independent of government supervision Session 7

126 Public Health Organizations: Quasi-Governmental
Best known at international level International Red Cross In various parts of world as known as Red Crescent Red Crystal On US national level: American Red Cross War & disaster relief Blood drives CPR classes Others on US national level National Science Foundation National Academy of Sciences (chartered 1863) Session 7

127 Public Health Organizations Non-Governmental
Four basic objectives of voluntary agencies Raise money to fund their programs, with majority going to research Provide education both to professionals & to the public Provide service to those individuals & families that are afflicted with a disease or health problem Advocate for beneficial policies, laws & regulations that affect the work of the agency and in turn the people they are trying to help Session 7

128 Health Communication Strategies
Identify the health problem & determine whether communication should be part of the intervention Identify the audience for the program & determine the best ways to reach audience Culturally & Linguistically Competent Develop & test communication concepts, messages & materials with representatives of the target (sample) audience Session 7

129 Media Literacy Teaches target audience (often youth) to analyze media messages to identify the sponsors motives Teaches communicators how to create messages geared to the intended audience’s point of view Session 7

130 Food Labeling Guidance & Regulatory control by U.S. Food & Drug Administration (FDA) FDA responsible for assuring that food sold in the U.S. are safe, wholesome & properly labeled Applies to all foods sold in U.S. Produced domestically Produced in foreign countries & imported Session 7

131 Food Labeling Defines certain food stuffs Net quantity of contents
Juices vs. cocktails Net quantity of contents Ingredients list Colors & Allergens Nutrition labeling General & nutrient declaration Separately packaged & assortments Session 7

132 Claims on Label Nutrient content claims Free Low Reduced/less Comments
Zero, no, without, trivial source Low Little, small amount, low source of Reduced/less Lower, fewer, modified; 100 gram basis Comments Free, very low, low must indicate if food meets definition without benefit of special processing Session 7

133 Structure & Function Claims
Names such as "CarpalHealth" or "CircuCure" are disease claims because these are implied disease claims for carpal tunnel syndrome and circulatory disorders, respectively; context very important Example: "Soothing Sleep" could be considered a claim to treat insomnia, a disease, unless other context in the labeling makes clear that the claim relates to a non-disease condition, such as occasional sleeplessness Session 7

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