1. DETERMINANTS OF HEALTH w Most discussions of determinants of health actually address the determinants of ill health, disease or injury w Disease and injury are the results of complex interactions among people, agents of disease or injury, and their environment w People caught up in what appear to be similar circumstances may be affected differently w Textbook emphasizes multifactorial causation -- I.e., disease, disability and injury are attributable to combinations of biological, behavioral, and environmental conditions

2. DETERMINANTS OF HEALTH (cont/d.) w Must distinguish between necessary and sufficient factors of causation w Remember that public health focuses on health risks associated with groups, or populations w Risk factors may increase the probability of disease or injury, but do not, because of their absence, product health

3. Model Showing Relationship of Health-Field Concept to Health Status Human Biology Life Style Environ- ment Organi- zation Health Status Health Promotion/ Services

4. Preventive Interventions in Lung Cancer Prevention_______ Primary Secondary Tertiary_ Human Biology 0 0 + Environmental ++ + 0 Life-Style ++++ ++ 0 Organizational +++ + 0 0 = Virtually no opportunity + = Least opportunity ++++ = Most opportunity

5. Preventive Interventions in AIDS Prevention_______ Primary Secondary Tertiary_ Human Biology 0 ++ + Environmental ++ 0 0 Life-Style ++++ ++ ++ Organizational +++ 0 + 0 = Virtually no opportunity + = Least opportunity ++++ = Most opportunity

6. Levels of Disease and Injury Prevention w Disease and injury prevention techniques are usually described in one of three categories: Primary Prevention Secondary Prevention Tertiary Prevention

7. Primary Prevention w Includes those activities intended to prevent the onset of disease and injury in the first place w Examples: Immunization against infectious diseases, use of seat belts, avoidance of tobacco use, minimal intake of alcoholic beverages, inspection/licensure of restaurants, inspection of water resources, inspection of work sites... etc.

8. Secondary Prevention w Includes techniques that find health problems early in their course so that action can be taken to minimize the risk of progression of the disease in the individual or the risk that communicable diseases will be communicated to others w Examples: Health screening for disease risk factors, early diagnosis of hypertension with follow-up treatment, early diagnosis of sexually transmitted diseases to minimize transmission potential, glaucoma testing during eye examinations, screening for diabetes mellitus... etc.

9. Tertiary Prevention w Includes techniques focused on rehabilitation to prevent the worsening of an individual’s health in the face of chronic disease or injury w Examples: Physical therapy for an orthopedic injury or cerebrovascular accident (stroke), education on diabetic self-management, other regimens for disease control... etc.

10. The “New” Public Health w What some refer to as the “new public health” focuses on the role of one’s personal behavior in determining health status Life-style interventions (e.g., health promotion programs) have become an important and popular part of public health strategy in the U.S. w Others counter that emphasizing personal behavior ignores/obfuscates the role that organized interests play in perpetuating disease patterns E.g., alcohol and tobacco industry advertising Failure of Medicaid to adequately support prenatal and child health care w Dealing with some public health concerns may involve the work and support of agencies that are far outside the public health domain E.g., attempting to reduce traffic fatalities can involve several different types and levels of intervention

11. Text (p. 36) discusses multifactorial causation -- disease, disability, and injury attributable to combinations of biological, behavioral, and environmental conditions Many public health problems require combinations of multifactorial intervention Public Health Goal: Reduction of Highway Fatalities 1. Driver education 2. Operator license: age limits, testing, revocation 3. Behavioral self-controls -- e.g., drinking and driving; road rage 4. Law enforcement: speed limits; reckless driving 5. Vehicle manufacturing: safety specifications

12. 6. Vehicle inspections 7. Highway/roadway engineering designs for safety 8. Vehicle operator restrictions, based on biological/physical deficiencies 9. Availability of prompt emergency medical services 10. Others... ??

13. Some Ponderable Concerns about Determinants of Health -- Some “On Average” Propositions w People who live alone have higher premature rates of mortality than those who live in a stable relationship with other people w People who are employed live longer than those who are idle w Thin people live longer than fat ones w People who sleep well each night live longer than those who do not w There is ultimately no safe environment; even in the most idyllic setting, wastes are generated, storms and fires occur, and accidents happen

14. Some Ponderable Concerns about Determinants of Health -- Some “On Average” Propositions w Studies of sexual behavior show that (1) large numbers of people either engage in practices they know to be hazardous, or (2) avoid practices they know to be beneficial w In surveys, the great majority of adults indicate that regular exercise is very important; however, only about 40% report that they exercise regularly w Most women (87% or higher) over the age of 18 indicate they know something about breast self- examination; however, just over 1/3 report that they perform BSE at least 12 times a year

15. Some Ponderable Concerns about Determinants of Health -- Some “On Average” Propositions w To date, there has been limited success in altering genetic structure in humans, but this will surely be possible and become widely spread in the future -- but with what ethical and moral implications? w To what extent should human genetic analyses change the meaning of an insurance program; i.e., if risk can be predicted, why insure someone whose fate you already know? w Will gender differences in mortality continue to decline as more women adopt “male” habits, such as tobacco use and enter the workforce in increasing numbers, thus facing new life hazards?

16. LEADING CAUSES OF DEATH (Percentages of All Deaths) Sources: CDC; National Center for Health Statistics 1900 1994 Pneumonia11..7% Heart Disease 32.1% Tuberculosis11.3% Cancer 23.5% Diarrhea & Enteritis 8.3% Stroke 6.8% Heart Diseases 8.0% Bronchitis & Emphysema 4.5% Stroke 6.2% Injuries 3.8% Liver Disease 5.1% Pneumonia & Influenza 3.6% Injuries 4.2% Diabetes 2.4% Cancer 3.7% AIDS 1.8% Senility 2.9% Suicides 1.4% Diphtheria 2.3% Liver Diseases 1.1%

17. Mean Age of Death and Infant Death Rates, England, 1842 Mean Age of Death Infant Deaths per 1000 births Class London England (England)_ Gentry, professional 44 35 100 persons & their families Tradesmen, shopkeepers 23 22 167 & their families Wage classes, artisans, 22 15 250 laborers & their families