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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.

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Presentation on theme: "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."— Presentation transcript:

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 2 Determinants of Health Major Categories Physical factors Social & Cultural factors Community organization Individual behaviors Biological factors Session 1

3 3 Determinants of Health Environmental Ambient Infectious Crime Stress Family Individual Non-Modifiable Biological host Modifiable Health habits Diet Physical activity Tobacco use Use of health care Health Care Access Quality Social Determinants Income Poverty & Inequity Education Race & Ethnicity Community & Social cohesion Session 1

4 4 Themes in Public & Community Health History Plagues & Contagious Diseases War & Conflicts Exploration & Expansion Scientific Progress The Industrial Revolution 19 th Century Reforms (beginnings of modern PH) 20 th Century Achievements Recurring themes: Science & Social Values Session 1

5 5 Early Christian Period: 30 - 300 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

6 6 Middle Ages: 500 AD – 1400 AD Quarantine: as a control measure, started in Venice, the chief port of entry from the Orient Ships docking at the Lazzaretto Vecchio, Venice, 14th century Session 1

7 7 Renaissance & Enlightenment: 1300 - 1700 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

8 8 The Sanitary Movement: 1830-1875 Growth in scientific knowledge Connection between poverty and disease Importance of water supply & sewage removal Session 1

9 9 British Reformers Sir Edwin Chadwick 1800-1890 Good economics to prevent the evils Assistant to Bentham 1834 report led to reform of Englands Poor Laws 1842 Report on the Sanitary Conditions of the Labouring Population – Sanitary Report 1847 - 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

10 10 Four Phases of the Development of Modern Public Health 1.Addressing infectious diseases related to urbanization, poverty and squalor (1840s to the late 19th century) 2.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) 3.Focus is on improving population health through the provision of organized medical services deploying effective therapeutic technologies (antibiotics) 4.Recognition that the environment is also social, economic and psychological and needs to be considered as part society's health policy Source: Ashton (1990) Session 1

11 11 Part I: Understanding & Improving Health History Determinants of health model How to use a systematic approach Leading Health Indicators (LHI) 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 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

14 14 Six Major Dimensions of Health & Wellness 1.Emotional – continuum of feelings, managing stress, transitioning major changes, work-life balance 2.Intellectual – stimulating mind & mental capacity, reasoning & creatively, continuing education 3.Occupational – contributing, using vocational skills/abilities, hobbies 4. Physical – taking action to maintain health, exercise, nutrition, ADLs, self-care Session 2

15 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

16 16 Health Problems & Intro to Risk Factors Health problem – 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

17 17 Analyzing Health Problems for Risk Factors 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) Source: Definitions adapted from Centers for Disease Control and Prevention Public Health Practice Program Office Session 2

18 18 Health Problem Analysis Worksheet Example Session 2

19 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

20 20 Three Levels of Prevention Primary – Stop or delay onset Secondary – Early diagnosis & prompt treatment Tertiary – Retrain, re-education & rehabilitate Session 2

21 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

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 23Session 3

24 Definition of Terms Counseling – The act of giving advice about issues, challenges or health problems – Attempts to clarify patients 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 24Session 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 25Session 3

26 Ecological Framework Brief Introduction Ecology (environment) is the space outside the person Five levels of concentric influence: 1.Intrapersonal (self/individual) factors 2.Interpersonal (primary groups) processes 3.Institutional factors 4.Community Factors 5.Public policy 26Session 3

27 Models of Intrapersonal or Individual Health Behavior Health Belief Model Theory of Reasoned Action & Planned Behavior Transtheoretical Model – With Stages of Change 27Session 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 28Session 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 29Session 3

30 Models of Individual Health Behavior Theory of Reasoned Action & Planned Behavior (two separate theories work together) – Foundation (continued) Behavior is result of ones intention Intent is result of beliefs & attitudes Suggests that attitude is better predictor of behavior Assumes people are rational 30Session 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 31Session 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 32Session 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 33Session 3

34 Theory of Reasoned Action (grey) & Planned Behavior (white) 34Session 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 35Session 3

36 Models of Individual Health Behavior Transtheoretical Model & Stages of Change Six stages (only 5 are active) 1.Pre-contemplation – not intending 2.Contemplation – intending within 6 months 3.Preparation – intending/planning within 30 days 4.Action – currently & within last 6 months 5.Maintenance – actively doing/preventing relapse 6.Termination – no temptation, integrated into lifestyle, non-active 36Session 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 37Session 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 38Session 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 39Session 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 40Session 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 41Session 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 42Session 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 43Session 3

44 Models of Community & Group Behavior Diffusion of Innovations – Adoption process – follows bell curve Innovators Early adopters Early majority Late majority – Think – iPad 44Session 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 45Session 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 46Session 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 47Session 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 48Session 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 49Session 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 countrys health system 51Session 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 52Session 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 53Session 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) 54Session 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 55Session 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 56Session 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 57Session 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 58Session 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 59Session 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 60Session 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 61Session 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 62Session 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 63Session 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%) 64Session 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? 65Session 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% 66Session 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) 67Session 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 68 Disease or risk factors (cases) No Disease or no risk factors (controls) Totals Exposedaba + b Not Exposedcdc + d Totalsa + cb + da + 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 69Session 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 70Session 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 71Session 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 72Session 4

73 Surveillance Passive – 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 73Session 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 74Session 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 75Session 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 76Session 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 77Session 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 78Session 4

79 Case-Control 79Session 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 80Session 4

81 Cohort study 81 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 82Session 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 83Session 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 84Session 4

85 Levels of Inference First 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) 85Session 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 Ss (1) Survey – Method of monitoring: 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 87Session 5

88 The three Ss (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 88Session 5

89 The three Ss (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 89Session 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 90Session 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 10 th, 20 th, etc. Random variation is a random error (attributed to chance); therefore, not controllable 91Session 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 92Session 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 93Session 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 1.Range 2.Interquartile range 3.Variance 4.Standard deviation 94Session 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 25 th to 75 th percentiles 95Session 5

96 Measures of Dispersion (3) Common measures 3. Variance (s 2 ) – 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 96Session 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 97Session 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 98Session 5

99 Null Hypothesis (H 0 ) 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 99Session 5

100 Alternative hypothesis (H A ) 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 100Session 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 101Session 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 102Session 5

103 Statistical testing (2) Descriptive statistics – Continuous Parametric tests – t-tests, analysis of variance (ANOVA), Regression – Categorical/Discrete Non-Parametric tests – Chi-square, Fishers exact test 103Session 5

104 Statistical testing chart If you want toUseResearch Question Examples Compare individual score to a group mean z-scoresHow does my test score compare to class average Compare mean of single group to a population or hypothesized mean One sample t-testIs the average height of Logan students 64 Compare means of 2 related measure on the same group Paired samples t-testDo 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-testDo men & women have same number of years of education Compare means of a measure for more than 2 groups One-way ANOVADoes income vary among those with HS diplomas, college degrees, & graduate degrees Determine how 2 continuous variables are related Correlation CoefficientIs years of education related to income Predict value of one continuous variable from another Simple linear regressionCan income be predicted if years of education is known Compare proportions for 2 categorical variables Chi-squaredIs proportion of men who have college degrees different from the proportion of women who have college degrees 104Session 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. 106Session 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. 107Session 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 108Session 6

109 109 Public Sector Funding Federal 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 110Session 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 111Session 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 112Session 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, doctors directions & consent forms – Ability to negotiate the health care systems 113Session 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 115Session 7

116 Public Health Organizations: Governmental – WHO guided by 2 documents Millennium Summit (2003) - 6 health goals 1.Eradicate extreme poverty & hunger 2.Reduce child mortality 3.Improve maternal health 4.Combat HIV/AIDS, Malaria & other diseases such as TB 5.Ensure environmental sustainability 6.Develop a global partnership for development, especially for essential drugs 116Session 7

117 Public Health Organizations: Governmental – WHO guided by 2 documents 11 th General Programme of Work - 5 areas for work priorities (2006 – 2015) 1.Provide support to countries in moving to universal coverage with effective PH interventions 2.Strengthening global health security 3.Generating & sustaining action across sectors to modify behavioral, social, economic & environmental determinants of health 4.Increasing institutional capacities to deliver core public health functions under the strengthened governance of ministries of health 5.Strengthening WHOs leadership at global & regional levels & by supporting work of governments at country level 117Session 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) 118Session 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 119Session 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 1.Assessment 2.Policy Development 3.Assurance 120Session 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 122Session 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 123Session 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 124Session 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 125Session 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) 126Session 7

127 Public Health Organizations Non-Governmental Four basic objectives of voluntary agencies 1.Raise money to fund their programs, with majority going to research 2.Provide education both to professionals & to the public 3.Provide service to those individuals & families that are afflicted with a disease or health problem 4.Advocate for beneficial policies, laws & regulations that affect the work of the agency and in turn the people they are trying to help 127Session 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 128Session 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 audiences point of view 129Session 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 130Session 7

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

132 Claims on Label Nutrient content claims – Free 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 132Session 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 133Session 7

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