Intro To Public Health - Exam 2

Front 1

Eight Americas (general)

Back 1

-Chris Murray (Harvard)
-investigating mortality disparities among different "americas"
-"americas" defined by county, race, and race-county
-census and NCHS data

Front 2

What are the Eight Americas

Back 2

-Asian
-North Low-income rural whites
-Middle America (~other)
-Low-income whites in Appalachia/Mississippi valley
-Western Native American
-Black Middle America
-Southern rural low-income blacks
-high risk urban blacks

Front 3

Graphical Data from 8 americas

Back 3

-check ups: show that healthcare access is ~ equal, though actual usage varies (men = less)
-still, large disparities in LE between americas
-disease burden: smoking, alcohol use, obesity highest percentage

Front 4

Eight Americas (conclusions)

Back 4

-21 year gap in LE between 1 and 8
-Since 80s, LE gap for men increased more than 0.5 % per year
-Not enough resources for chronic disease prevention or crime, which account for massive health disparities

Front 5

Bernadette

Back 5

-Paul Farmers patient with HIV
-accompaniment
-She has HIV b/c of gender (relationship dynamics), SES (heath disp.), and biology (women more likely infected)

Front 6

Primary Tobacco prevention

Back 6

-increase taxes on cigs
-regulate ads/packaging
-education programs

Front 7

Tobacco diseases

Back 7

-30% cancer is respiratory/pulmonary
-oral cancer: from tobacco and poor hygiene/diet <-- 50% more likely if black male
-also influences chronic disease: heart disease

Front 8

Heart disease (at risk factors)

Back 8

-male
-black
-uneducated
-**same risk factors apply to strokes
-POOR DIET/OVERWEIGHT

Front 9

structural violence and health behavior

Back 9

-study on education in urban STD clinic suggests that more than education is needed b/c only very slight improvements were found

Front 10

major healthcare disparities

Back 10

• Income inequity increased since 1980
• Disease 300% in low-income
• Men twice as likely to die of accidents and 4 times from guns
• Women have 200% depression
• Premature adult death is 200% in ppl without some higher education
• Infant mortality rate is cut in half for college graduates
• African American IMR is 200%, heart disease is 140%, and all cancers is 130%
• African Americans are 7 times as likely to die of HIV

Front 11

Global response to HIV/AIDS

Back 11

-increase in spending due to global fund, PEPFAR
-disparities in ARV coverage between West and e.g. Africa
-coverage increasing, but not targeting most needy
-pharma claims virus resistance from noncompliance for avoiding universal coverage

Front 12

US response to HIV

Back 12

-stigma, image, assumptions and changes (e.g. Ryan White/Magic Johnson)
-

Front 13

Accompaniment

Back 13

-more humanistic approach to treatment
-DOTS
-# of factors that prevent adherence: housing, stress, mental, substance abuse

Front 14

Pharma/issues

Back 14

-5 meds/American
-expensive to recoup development/marketing
-increases healthcare costs
-issues of adherence

Front 15

PMR

Back 15

-proportional mortality rate: proportion of total mortality

Front 16

Modes of disease transmission

Back 16

-vertical: mother-->child
-direct: STD, blood transfusion, bite injects disease (requires direct contact)
-indirect: air/water resevoir indirectly passes to humans
-vector: mosquito, air, water

Front 17

Major communicable diseases

Back 17

-get a lot of attention even though only represent 1/3 of PMR
-most widespread: flu/pneumonia, clamidyia, gonnorhea
-africa and southeast asia carry 76% of infectious disease burden

Front 18

DALY

Back 18

-Disability adjusted life-years
-measure of years lost due to disability
-DALY= YLL + YLD
-YLL=years life lost=#deaths
xlE
-YLD=incidence x dis.
weight x avg. case duration

Front 19

DALYs

Back 19

-measure of years lost due to morbidity and mortality
-calculated for specific disease
-DALY=YLL+YLD
-YLL=years life lost
-YLD=years lost to disability
-YLL=N x L
-N=# of deaths
-L=life expectancy
-YLD=I x DW x L
-I=incidence
-DW=disability weight (0-1)
-L=avg. duration of case
-also: (YLD[LE-age])*i

Front 20

Major causes of DALYs

Back 20

-Heart Disease
-Infectious disease
-Mental/neurological
-Cancer

Front 21

TB

Back 21

-global incidence has been generally increasing since 1980
-54% of cases are XD/MDRTB
-MD=resistant to 1st line drugs
-XD=resistant to 1st+2nd line drugs
-drug resistant cases are very difficult to treat; XD has 50% mortality even w/DOTS
-incomplete adherence=key driver of drug resistance
-95% or resistant cases are in poor countries
-often co-morbid w/HIV

Front 22

PEPFAR

Back 22

-GWBush legislation
-voice for HIV/related causes
-helps pay for anti-viral treatments
-largest global initiative
-global legislation

Front 23

HIV in Uganda

Back 23

-prevalence decreasing (now 5%)
-high-risk sexual activity, commercial sex work
-discordant monogamy
-vertical

Front 24

HIV-TB Nexus

Back 24

-40% co-occurrence TB/HIV
-lack of primary contributes
-STD co-morbid as well--> weakens immune system
-stigma/discrim: exacerbates disease, less help-seeking, e.g. anti-gay
-leads to shun, avoidance -->
non-adherence-->drug resist

Front 25

Integrating HIV/TB care

Back 25

-district-level planning: coordinate NGOs and international org.
-94% funding is international
-2x as much spent on treat vs. prevent

Front 26

Malaria

Back 26

-515 million cases; 20% mort.
-endemic in tropical regions
-mosquito: anopheles stephensi
-drugs are overRx and poorly adhered-->high drug resist
-prevention: DDT spraying
-prevention: mosquito nets

Front 27

Mosquito net case study

Back 27

-Tanzania
-tech used at night in villages
-anthro needed to help understand cultural interpretation of tech
-dawa=word that means poison
-applied to many western items --> nets labeled dawa, thus people lay them outside
-anthro recommend more culturally sensitive approach
-confusion about efficacy of nets b/c mosq. don't always die
-alcoholism
-intermittent NGOs

Front 28

Yellow Fever

Back 28

-mosquito vector
-vaccine
-"sylvatic"(jungle), savannah, urban
-issues of disease resist/genetic drift

Front 29

Jungle yellow fever

Back 29

-multiple mosquitos
-Africa/S. America
-obstacle to eradication

Front 30

savannah yellow fever

Back 30

-aedes mosquito
-most common human transmit
-Africa only

Front 31

urban yellow fever

Back 31

-aegyptis mosquito
-transmits dengue & Chikungunya
-Africa only

Front 32

Typhoid fever

Back 32

-common natural course/flue-like
-contaminated water and mechanical infection (<--insects)
-5% asymptomatic-->Typhoid Mary
-10-30% mort w/out treat
-treat/prevent: clean water, vaccine
-high burden: S. Am, Africa, SE Asia in ages 5-19

Front 33

Hep B

Back 33

-burden: S.Am, Africa, Asia
-30% prevalence; only 2-8% symptomatic
-bloodborne viral liver disease

Front 34

Hep C

Back 34

-similar burden to Hep B
-injecting drug use (60% in US)
-30% mort.
-causes liver cancer/transplants
-35% co-infect w/HIV

Front 35

Public health & crime/prisons

Back 35

-increasing prison populations
-no public mental, drug laws, privatization
-HVC & TB both show especially high rates among prisoners

Front 36

HAIs

Back 36

-hospital-acquired infections
-10% of all patients
-2x Europe
-raises healthcare costs

Front 37

Ebola virus

Back 37

-outbreak in Zaire, 1976
-Yambuku mission hospital
-quarantine on region
-67% mort.; unknown cause
-person-to-person; bodily fluids

Front 38

Ecological model of Health behavior

Back 38

-describes factors that influence people's health-related behaviors
-intra-personal, interpersonal, institutional, community, public policy

Front 39

Social Cognitive Theory

Back 39

-psych model of health behavior
-knowledge, benefits, self-efficacy, expectations, barriers

Front 40

Transtheoretical Model

Back 40

-psych model of health behavior
-stages of behavior change
-pre-contemplation--> contemplation-->preparation--> action-->maintenance

Front 41

MARCH

Back 41

-Modeling And Reinforcement to Combat HIV/AIDS
-Ethiopia, Botswana, Zambia
-result of theories of behavior change

Front 42

Avahan

Back 42

-aims to improve environmental level factors through community mobilization
-combats AIDS in India

Front 43

Smallpox

Back 43

-Major killer in 1700s
-30% mortality rate, 80% for at risk groups
-Trend of at-risk populations
-Low-tech bifurcated needle
-No refrigeration
-Targeted Vaccination campaign
-Only needed to vaccinate 80% of people for herd immunity
-eradicated

Front 44

Ringworm

Back 44

-fungal infection
-higher rates in Af. Am and lower SES
-outbreaks in urban elementary schools
-prevent: hygiene, screen, antifungal
-impacts: self-esteem, cost

Front 45

intervention study

Back 45

-experimental v. control group
-groups=similar as possible
-e.g. Polio trials (Salk)

Front 46

Cohort study

Back 46

-tracking large # of ppl over time
-gather health data; no intervention
-inform about temporal & dose-response relations
-expensive, confounders, difficult to manage/administer

Front 47

Famous Cohort studies

Back 47

-Framingham, MA = health behavior of ppl in city
-Nurses Health Study (breast cancer)
-Doll & Hill studies (smoking & cancer)

Front 48

Case-Control studies

Back 48

-compare group w/disease to healthy group
-max similarities across groups
-easy and efficient but lots of bias

Front 49

Randomized clinical trial

Back 49

-test drugs vs. placebos
-"gold standard"
-ethical, recruitment, managerial issues

Front 50

Confounding factors

Back 50

-relationships btwn variables distort links btwn risk and disease
-controlled through design/statistical manipulation: stratification, distribution across groups, exclusion, matching

Front 51

Simpson's Paradox

Back 51

-breaking down data is usually more revealing than large groups
-e.g. Jeter vs. Justice batting avg
-e.g. treatment A vs. B on kidney stones

Front 52

Framingham Study

Back 52

-Heart disease risk by NIH
-4 generations
-genetic biomarkers via DNA samples
-relationship btwn cholesterol and heart disease
-BMI and mortality relation
-risk factors (cholesterol, smoking, high BP) --> relative risk for males=3

Front 53

Helsinki declaration

Back 53

-set of ethical principles dealing with human experimentation
-intended to guide regulations established by countries

Front 54

Whitehall Study I,II

Back 54

-1967: 18,000 men
-1985: 10,000 men and women
-access does not ensure health equality
-lower pay grades=higher mortality
-dispelled myths e.g. "CEO heart attack"
-complex interaction btwn social enviro, physiology, and psych

Front 55

social determinants of health & disease

Back 55

-why zebra's don't get ulcers
-low-level chronic stress as major contributor to poor health
-Robin-Hood index: steeper inequality-->more distrust--> higher mortality
-thus, social conditions shape/predict life expectancy

Front 56

vector transmission

Back 56

-any agent (person, animal, insect, microorganism) that carries and transmits infectious disease
-mechanical or biological

Front 57

mechanical transmission

Back 57

-type of vector transmission
-passive transfer of infectious agent; never enters vectors body
-e.g. housefly lands on feces which it carries and lands on food before it is consumed

Front 58

biological transmission

Back 58

-vector transmission
-vector harbors pathogen inside its body
-often mosquitos, lice, fleas, ticks

Front 59

Suicide (general)

Back 59

-used as measure of overall mental health
-increased in developed countries
-8th leading cause of death in the US
-1/10 attempts succeed

Front 60

suicide prevention

Back 60

-clinical care/meds
-social support/stability
-gun control
-school/workplace surveillance

Front 61

suicide at-risk/causes

Back 61

-adolescents/young-adults
-data about attempts
-decreased social trust
-increased urbanization
-blame of failure individualized
-more job impermanence

Front 62

Barriers to public mental health

Back 62

-preoccupation w/infectious disease, sanitation, and infrastructure
-mental health difficult to define/measure
-diagnoses: high sensitivity, low specificity

Front 63

4 filters for mental health treatment/issues

Back 63

-primary care (physician)-limited Rx
-specialized mental health-limited access
-hospitalization-$$, harm
-psychiatric in-patient-$$, limited acces, alienation/segregation

Front 64

community-based psychiatry

Back 64

-focus of psychiatric phealth response
-workplace/unemployment--> stigma, stress
-discrimination/stigma--> lead to mental disorders
-housing stability
-school/comm institutions frontline for screening
-access to meds/clinical care

Front 65

mental illness (general)

Back 65

-high DALYs/morbidity
-high rates of comorbidity
-increased healthcare costs
-global prevalence:
-anxiety/phobia
-mood (depression, bipolar)
-personality
-substance abuse
-organic - alzheimers/
dementia

Front 66

mental health prevalence in US

Back 66

-20-30% in a given year
-50% at least one
-14% have comorbid conditions
-<14% of affected receive no treatment

Front 67

depression

Back 67

-DSM-IV=definitions of all disorders and criteria for diagnosis
-provides definition of depression
-depression: must have 5 of 9 symptoms & 2 of 3 for at least 2 months

Front 68

dose-response relationship

Back 68

-change in effect on organism based on level of exposure to dose/stressor
-linear=any dose toxic, increasing dose is worse
-non-linear=threshold past which exposure is toxic (e.g. Radon or Tobacco smoke)

Front 69

Global Disease Burden (5 highest mortality rates)

Back 69

1. Heart Disease
2. Infectious disease
3. Cancer
4. Respiratory illness
5. Unintentional injuries/accidents

Front 70

Lead

Back 70

-absorbed in body:
-inhalation (industry)
-ingestion (child, soil, pottery)
-water (pipes)
-in-utero
-prevention:
-remove lead from paint,
toys, gas
-monitor soil
-chelation=treatment that
reduces lead in blood
-causes decreased mental fxn

Front 71

Risk/Hazard Assessment

Back 71

-Hazard ID
-Dose-Response
-Exposure Assessment (who? how much?
-Risk-characterization

Front 72

Lung Cancer

Back 72

-leading causes: Radon & 2nd hand smoke
-15% of homes > 4p/L(EPA limit)
-risk multiplies with both present

Front 73

Motor Vehicle Accidents

Back 73

-most common injury death
-50% brain/spinal injury
-leading cause of death in ages 1-24 in US and world

Front 74

Accident prevention

Back 74

-seat belts/helmets
-speed limits
-alcohol control
-age req. and licensing
-road construction/safety

Front 75

Secondhand Smoke

Back 75

-Ralph Nader/airline --> sued for clean air as right
-clean indoor legislation
-began as workers rights issue

Front 76

Federal PHealth Agency (roles)

Back 76

-"Federalist system"
-focus on science, natl security, commerce, & health care
-set goals for research
-dispersed; lacks uniform structure

Front 77

Government health spending

Back 77

-25% of healthcare spending
-mostly medicare and medicaid
-largest purchaser in world
-federal phealth spending has halved

Front 78

DHHS

Back 78

-Dept. of Health and Human Services
-65,000 employed
-largest grantmaker in world
-CDC, FDA, NIH, ATSDR (Agency for Toxic Substances & Disease Registry), IHS (Indian Health Service - Native Americans)
-NIH does most of funding and has much larger budget

Front 79

State Health Agencies

Back 79

-Food safety
-collecting vital stats
-tobacco prevention
-inspecting and monitoring hospitals
-professional licensing
-environmental health
o DISPARITY: # of employees that work in state health agencies
• 26 SHAs have <1501 employees
• 9 SHAs have >4500 employees

Front 80

Local Public Health Agencies

Back 80

-similar to state agencies
-food safe, enviro, tobacco, immunizations, bp screening, infectious disease surveillance
-disparities:
-small LPHAs don’t have
physicians, nutritionists or
health educators
-small pop. have high % of
LPHAs that serve low % of
pop. vs. large pop. opposite

Front 81

Tobacco Prevention

Back 81

-1=stop new smokers
-1964 surgeon general
-2009 Obama family
-Truth campaign
-Fairness Doctrine
-Masters Settlement (no
youth)
-2=address ppl w/symptoms
-public smoke bans
-high taxes
-masters:co. donate $ to treat

Front 82

Ainsworth article

Back 82

-global AIDS
-affects poorer countries
-lack of govt. action
-too broad is ineffective, narrow focus will have greater impact

Front 83

Cohen article

Back 83

-global health org. "soul-searching"
-HIV highly funded
-PEPFAR limiting
-GAVI=gates

Front 84

Piot article

Back 84

-Global impact of HIV/AIDS
-HIV rising in affluent nations b/c increased survival rates
-stigma=barrier
-effective control=unified national planning, access to care, social inclusion of high-risk & HIV+

Front 85

Bedford/Elliman article

Back 85

-Vaccine concerns
-some parents against vaccines
-believe unnecessary/alternate methods, & cause other illnesses

Front 86

Baker article

Back 86

-childhood vaccine prob. greatest impact on mort. reduction
-british vs. us immunization methods
-british: formal clinical methodology (more resistant)
-US: lab tech/research --> widespread application
-diptheria, pertussis, polio, measles

Front 87

Gleissberg article

Back 87

-Drug resistant TB
-conditions can make it very difficult to treat TB
-WHO Global TB: implementing DOTS
-MDRTB has only 56% recovery
-full course meds needed to treat/prevent

Front 88

Medicare vs. Medicaid

Back 88

-medicare=fed. program covering elderly health
-medicaid=inteded to cover poor; also as "medi-gap" covering extra elderly expenses

Front 89

dartmouth study

Back 89

-more aggressive care at end of life not better
-medicare costs reduced if more humane end of life care

Front 90

Kastrup article

Back 90

-global mental health
-major psych disorder/prevalence
-calls for more prevent/treat
-developed: depression, alcohol

Front 91

Ommeron article

Back 91

-mental/social health during emergencies
-planning, access, long term, monitoring, training, collaboration
-acute emergency then post emergency both important
-stress best handled w/out meds

Front 92

Costello article

Back 92

-poverty & psychopath
-social causation=gene-enviro interaction
-"great smokey mountain study"
-flaws but saw social causation for oppos/deviant behavior but not depress/anxiety

Front 93

Disasters & Public Health

Back 93

-predictable and some unpredictable
-phealth has job of preparing, collaboration/coordination, protection of survivors
-9/11 & Katrina reveal weaknesses in govt response

Front 94

Mann article

Back 94

-ethics relates to public health
-officials must protect public health rights and human rights
-public health should spend more time thinking about ethics/human suffering and rights

Front 95

Henderson article

Back 95

-bioterrorism is now more likely than ever
-we are ill-prepared
-must be able to detect, diagnose, understand epidem, and respond to bioweapon

Front 96

Tilson & Berkowitz article

Back 96

-public health & policy challenges
-US needs competent & prepared phealth infrastructure
-policy advocates must align with broader system to create cohesive whole

Front 97

Broadhead article

Back 97

-needle exchange closed after controversy blames it for drugs
-interviewed clients of exchange
-showed increase in unreliable syringes, reusing, and sharing syringes
-closing the exchange didnt decrease drug use, just increased high risk HIV behavior