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151 Cards in this Set

  • Front
  • Back
Medicalization
-A process by which non-medical problems become defined and treated as medical problems, using a medical framework or a medical intervention to treat it
-examples: andropause, baldness, erectile dysfunction, ADHD, depression, homosexuality, hypertension, Gulf War Syndrome, chronic fatigue
Cons of Labeling Diseases
-Labels harm people and create artificial disorders; ----labels are a means of social control; many diseases are really on a continuum;
-diagnoses are often made on the basis of things other than symptoms;
-some parties have a financial interest in creating more disease
Pros of Labeling Diseases
Labels get help to those who need it and prevent abuse; labels are the gateway to care; some diseases are categorical
Study of Sanity in Psychiatric Hospital
Eight “pseudopatients” were sent to a psychiatric hospital and the Results showed that the "patients" were not detected, so Psychiatric labels stuck, causing
Powerlessness and depersonalization
-the labels created distress and real psychiatric disorders
Specificity Revolution
-Means that know doctors like to think of disease as distinct entities
-Links knowledge to practice (diagnosis, prognosis, treatment)
Differentiation and typicality
The 2 Competing Conceptions of Mental Illness
-First Argument: it exists on a continuum, meaning it is symptom focused, has "degrees" of depression, has a holistic view of illness that places an emphasis on idiosyncratic views of illness and its atypicality
-Second Argument: it is categorical (Categorical assesment), its specific/ qualitatively distinct (you either have a mental illness or not), and all psychiatrists can reach the same categorical assessment
Benefits of Categorical assesment
-Diagnostic decisions are categorical, even if the illness is not
-research can guide cut-points where a taxon exists (taxon means an underlying discrete entity)
-Provides an estimate of need based on clinically significant criteria, allocating resources towards mental illness & guiding disease management
-allows individuals to feel part of a group, validating the experience of illness and allowing for reliable assesment
-
Costs of Categorical Assesment
-diagnosis as "REIFIED" measurement and use of clinical criteria reinforces their validity
Treatments, also, can reinforce the validity of a diagnosis
Process of Reification
1. Assessing specific symptoms
2. Splitting symptoms among arbitrary cut-off points
3.Promoting the criteria
-treatments can also reinforce validity of diagnosis, and diagnosis reduces information because diagnosis confound the arguments of people such as symptoms, with judgments about those attributes
-it reduces the signal, but not the noise in other words
Negative Ramifications of Diagnoses
-A diagnosis reduces information
-Diagnoses confound the attributes of people, such as symptoms, with judgments about those attributes
-Reduces the signal, but not the noise
-Diagnostic surveys are “valid,” but they are valid only -if you assume professional diagnosis
-Diagnoses allow for professional dominance
-Diagnoses are stigmatized
-Illness is equated with negative characteristics and could make the condition worse (Thinking you have depression causes such anxiety that you actually do become depressed)
-Diagnosis are stigmatized in a way that behaviors are not, once you are classified with a condition you are considered that, whereas if all you do is have that behavior then you’d be considered normal
-
Diagnostic and Statistical Manual
-its theoretically reliable and consistent across psychiatrists
-it is supposed to avoid (or at least there is a desire to avoid) false positives (which means finding an illness when there really isn't one), and false negatives (NOT finding an illness when there IS one)
Criteria for Major Depressive Episode
-should not include symptoms that clearly have to do with another medical disorder (aka should not include side effects)
-if it lasts for less than 2 months then its not a disorder because it could be just a person going through a seasonally bad time in their life (aka, close relative just died, etc)
Results of the DSM in a Survey
-mental illness is so prevalent in the US that the most common (like major depression) affected 17.1% of the surveyed population at least once over their lifetime
-all together, Americans reported a lifetime history of at least 1 disorder and 30.9% of people had at least 1 disorder in the 12 months prior to the interview
-the major societal burden of mental disorders is highly concentrated in the relatively small proportion of the population—in the range of 5-8% of the population in any given year—who have a history of having several co-morbid mental disorders (showed that serious mental illness is associated with an accumulation of emotional difficulties, and later analysis showed that most people with high comorbidity and serious mental illness begin in childhood either with an anxiety disorder or an impulse-control disorder and then accumulate other disorders over the course of adolescence. Very few of these people receive any treatment until adulthood, typically at least a decade after the onset of their first clinically significant disorder.)
-maybe if we belief the results showed the amount of people with disease was too high then actually our threshold is too low
Results of Who World Mental Health Survey
-US has the HIGHEST rate of mental illness compared to any other country (26.4%)
-Also has the highest rate of anxiety (18.2%), mood (9.6%), Impulse control (6-8%),
- Maybe because America Is so competitive that we really are more psychiatrically disabled than other countries
-OR it could be because in some countries there is extremely strong stigma and no one talks about it so that’s why it could be that in US its so high so Americans are more open to admitting it
-comparison among other countries in chart shows that severity is not strongly related to either region or development, but IS correlated with prevalence, countries with the lowest prevalence have the lowest impairment
-
Should we Eliminate Mild Disorders?
Why we should:
- YES: prevalence is too high,
- there is a bottomless pit of insurance expense,
- treatment should be focused on those with serious disorders,
-categories introduce stigma, high prevalence casts public doubt on psychiatry itself
Should we eliminate mild disorders? Why we shouldn't?
-The definition of a case should not be considered synonymous with need for treatment any more than with clinically significant distress or impairment
-Need empirically grounded decision rules, not ad hoc judgments
-Mild cases might lead to future serious cases
-Shouldn’t reduce statistical power in a young science
What is meant by the "Tyranny" of Diagnosis?
Diagnoses are indispensable because they fills cognitive and emotional needs and are like A “password” to care and a “simulacrum” thriving in the nurturing environment of modern medicine (linkage)
-they have Bureaucratic imperative and The form of creating diagnoses has been around a long time
-diagnosis are neither positive or negative buuuut the form of creating diagnosis is absolutely sovreign
-Disease categories provide meaning (not all of which is alienating) and a way to manage relationships with medical institutions
-Treatments solidify discrete diagnoses
Public/ Formal Curriculum
essential to learning
-public
-basic science facts
-transmitted through texts and lectures
Private/ Hidden Curriculum
-deals with uncertainty, feelings, and attachment.
-Transmitted through allusion, parables, or jokes
-
The Five Areas of Uncertainty in Medical Training
-incomplete mastery of available knowledge
-limitations in current medical knowledge
-Difficulty distinguishing personal ignorance from the limitations of medical knowledge
-client response
-instructor quasi-norms
-
The Four Points of Learning to Cope with Uncertainty
-Knowledge:Master, specialize (claiming ignorance is forgiven), adopt a school (schools develop around uncertainty)
-Diagnosis:Gain experience, experience is self-validating, requires no outside reference
Clinical expertise often overrides scientific evidence
-Treatment: Emphasize technique/process, rather than outcome (in surgeons in particular, the emphasis is on “did you give the right treatment” not “did the patient die or not” so there is a reason doctors emphasize the technique and not the response)
-Client Response: The “crock”: no clear medical problem, threatens the doctors role, because nothing is learned
What are some consequences of Physicians coping mechanisms?
-Over time, physicians become less stressed by uncertainty
-Greater confidence in particular methods, development of practice patterns
-Increased specialization and Decreased focus on the patient
- Friedson argued that above all physicians are self regulated, if physicians become self-validated, there is no reason to expect that you are going to get good self-practice patterns
Medical Errors
-an error is defined as the failure of a planned action to be completed as intended (Error of execution) or the use of a wrong plan to achieve an aim (error of planning)
-other forms of errors are failure of communication, equipment failure, system failure
Preventable Adverse Event
-an adverse event attributable to error
- negligent adverse events represent a subset of preventable adverse events that satisfy legal criteria used in determining negligence (aka whether care provided met the standard of care expected of an average physician qualified to take care of the patient in question)
Diagnostic Errors
-error or delay in diagnosis
- failure to employ indicated tests
-use of outmoded tests or therapy
-failure to act on results of monitoring or testing
Treatment Errors
-error in the performance of an operation, procedure, or test
-error in administering the treatment
-error in dose or method of using a drug
- avoidable delay in treatment or responding to an abnormal test
-inappropriate (not indicated) care
Preventative Errors
-failure to provide prophylactic treatment
-inadequate monitoring or follow-up treatment
IOM (Institute of Medicine) Report on Medical Errors
-there are 44000-98000 deaths a year due to preventable adverse events (adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities, these lead to high error rates with serious consequences and are most likely to occur in intensive care units, operating rooms, and emergency departments)
- these deaths EXCEEDS yearly deaths due to preventable adverse events like car accidents, breast cancer, and AIDS
-Just medication errors cause 7000 deaths
Friedsons Vs Parson's way of Self-Regulation
Friedsons: referrals
Parsons: trust
Different Types of Social Control
Internal: Done by physicians
Informal Internal: everyday control
Formal Internal: review of performance
Technical Errors
-flawed technique
- the two things that must happen is that it must be reported quickly and must not be made twice
- it demonstrates competence apart from failure
-surgeons have to avoid this one specifically
Judgmental Errors
-incorrect strategy
- examples include overly heroic surgery and failure to operate
-conspicuous performance can reinforce the surgeon's orientation
-self-criticism is also controlled: more conspicuous among attending
-even failures among superiors support their authority
-Overly heroic surgery solidifies the surgeons reputation, can reinforces surgeon as trying to do “best” for the patient, but we should not have people performing unnecessary surgeries
Normative Errors
-WORST ERROR A DOCTOR CAN MAKE
-The failure to act in a conscientious manner, the failure to assume a role
-not reporting technical errors, letting personality interfere with care, disrespecting nurses
-While normative errors represented a breach of generally accepted standards of performance, quasi-normative errors are specific to the individual service. These are especially important because attendees are in charger of your career at that point
-a normative error is committing the same mistake TWICE and not respecting other surgeons
How to Deal With Medical Errors?
-the IOM recommends creating a center for patient safety and learning from errors by a nationwide mandatory reporting system organized by the national forum of health care quality measurement and reporting, IOM also encourages VOLUNTARILY reporting errors
Bosk's idea of errors
-Bosk suggests that errors are essentially contested
-qualities of errors that are contested are: what one is,
who is culpable, and what needs to be done to prevent their occurrence
Affective Neutrality and Patient Death
-Parsons thinks that surgeons have to be rational and under control and can't think too much about their well-being because they have to concentrate on the task at hand
-physicians ARE TAUGHT affective neutrality
Fox's idea of the emotional responses of physicians
-there is a detached concern
Smith and Kleinman's Opinion on Death
-coping is key because it minimizes emotions
-doctors want separate the body from the person, and see the body as a puzzle and personality of the parts
-sometimes to cope they'll transform the body into something non-human or accentuate the positive aspect of what they are doing (take pride in learning)
Effect of Primary Education on Sexual Rates
Near-universal primary education has the potential to further impact timing
Sexual Initiation and Marriage in Latin America
-50% of women get married before age 20
-Between 77% and 95% of sexually active women 15-24 are in a union
-very common to not have sex until marriage so if women are waiting till they are married to have sex and they wait for a while till they get married there will be a decline in fertility rates
What Affects the Age of First Birth
-marriage (traditional sequence is get married, have sex, have your first birth, BUT hypothesize that Urbanization, secularization, increased access to contraceptives has led to separation over time AND difference in order of events)

-
Relationship Between Schooling and First Birth/ Marriage
-The more school you have the later you are going to experience these events
-the relationship between schooling and sexual initiation is more complicated
Objectives of Vala. Hayne's Studies
-Examine patterns and correlates of ages at leaving school, sexual initiation, marriage and first birth
-survey given to women to fill out asks amount of years of schooling and more sensitive questions like how many children have you been PREGNANT with, not necessarily survived, also asks if your partner has ever been violent to you (but this question is asked in private)
Regression Models of "Events"
-show how events vary by birth cohort, region, wealth, sex education, school enrollment, religious devotion, experience of abuse, and empowerment
Average Ages of Leaving School in Central America
-El Salvador: 17
-Honduras & Guatemala: 14-16
-Nicaragua: 15-17
Average Ages of Sexual Initiation in Central America
-El Salvador and Guatemala: 18-19
-Honduras and Nicaragua: 18
Average Ages of First Marriage
El Salvador: 20,
Guatemala and Honduras: 18-19
Nicaragua: 18
Age at First Birth
-El Salvador and Guatemala: 20
-Honduras and Nicaragua: 19-20
Results of Measurement of Traditional Order
-overall, for central America, the order of events is still: quit school, sexual initiation, first marriage, first birth
-however, regression models show that events vary by birth cohort, region, wealth, sex education, school enrollment, religious devotion, experience of abuse, and empowerment
Desirability Bias
young women are more likely to report a later age than men even if thats not true
Dependent Variables
-What the study is trying to explain: We want to know who delays these events and who experiences them at earlier ages.
-Age at which they quit school, Age at sexual initiation
Age at first marriage, Age at first birth
Independent Variables
-Birth cohort
-Region
-Wealth quintile
-Indigenous identity (Guatemala, Nicaragua)
-Sex education
-In school
-Religious devotion (El Salvador, Nicaragua): None, Devout/non-Devout Catholic, Devout/non-Devout, Protestant
-Experienced emotional or physical abuse
-Empowerment
Association Between School and Events
-Being in school is very strongly associated with delaying sexual initiation, first marriage and first birth
-Being in school makes the BIGGEST difference compared to all other variables
Association Between Religious Devotion and Events
-compared to Catholics, everyone experiences quitting school, sexual initiation, marriage, and first birth earlier.
-People are all more likely to experience at earlier ages if you are not religious, religion usually means social conservatism
Correlation between emotional/physical abuse and events
people ever abused were more likely to have sex, get married, have a first birth at an early age.
Relationship Between Female Empowerment and Events
In Guatemala and Nicaragua, “empowered” women delayed each event significantly
-however, its very difficult to measure
Conclusion of Events Study
-there has been little to no change in experiencing events in the past two decades despite expanding education systems
Rural Regions and Events
More likely to leave school at younger ages, but LESS likely to experience other events
Relationship Between Sex Ed and First Birth
-Looking at a study in US, sex education is linked to higher contraceptive use in US
- Abstinence only education also delays these events
-therefore the actual content of sex education isn't as important as the fact that you’re talking about it
Paternalistic Model
-The values are objective.
-The doctor must promote the patient’s well-being independent of the patients wishes.
-The physician identifies the problem and treats it with his knowledge.
-The physician informs the patient and shares with the patient his superior knowledge of the patient’s experiences and symptoms.
Present select information to encourage patient consent.
Assumes shared criteria for evaluation.
 -There exist shared objective criteria in which to evaluate an illness.
 -Patient autonomy is actually patient assent (approval).
-The physician is a guardian.
-But patients have values, patients may be more likely to comply when their values match the physician’s
Informative Model of Doctor-Patient Relationship
-The patient’s values are known to the patient.
 -The patient’s autonomy comes in having choices over medical care and ultimate control over it.
 -The physician is there to provide information to the patient about his or her condition, treatments, and the likelihood of recovery.
 -The patient may retain his or her own values, but what they are missing is the facts of the matter.
 -Critiques: the informative physician lacks a carding approach that requires an understanding of the patient’s values. Indeed, patients often expect this from their doctors.
 -This model assumes that the patient has known and fixed values.
Interpretive Model
-The focus is on the patient’s values, in trying to elucidate those values, and to help the patient select the treatments that will allow the patient to reach these values.
 -Here, it is assumed that the patient’s values may be conflicted, and that it is the job of the physician to find out what they really are.
 -Autonomy is equated with the patient’s self-understanding.
 -The physician is a counselor or advisor.
-The goal of the relationship, therefore, becomes a joint process of understanding.
 -Criticisms: physicians are not given training to do this and, in the face of countervailing
-Patient autonomy = patient self-understanding
Deliberative Model
-The doctor and the patient deliberate over treatments and how those treatments represent different kinds of values.
 -In this model, the physician acts as a teacher or friend: the patient is allowed to consider other possibilities.
-Patient autonomy = moral self-understanding
But recommendations should not depend on the idiosyncrasies of the physician
-Author's favor deliberative model because it attempts to persuade, not impose 
-Fundamental objection
-balance choice and objective information
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Fundamental Objection
-it is not appropriate for physicians to promote a particular value.
-These are, after all, values. Recommendations should not depend on the idiosyncrasies of the physician.
Instrumental Model
-The patient’s values are irrelevant.
-The physician aims for the good of the society, irrespective of the individual patient.
-Here the Tuskegee experiment is the outcome.
-Example: Nazi doctors
New Trends in Doctor-Patient Relationship
-move toward patient sovereignty/"right to die" movement in medicine, embodied in the informative model.
 -physician must do more than simply provide arid information. The patient makes the decision, yes, but the simple reporting of facts makes little allowance for the patients values, which must be considered in these matters.
Common Diagnostic Errors in Internal Medicine
-74% involved cognitive errors, 7% were no fault
-46% were both system-related and cognitive factors
-19% system only, 28% cognitive error only
Anchoring Bias
the tendency to be unduly persuaded by features encountered early in the presentation of illness, thereby committing to a premature diagnosis
Confirmation Bias
where attention is directed disproportionately toward observations that appear to confirm a hypothesis instead of seeking evidence that might disprove it
Search Satisficing
-a physician calls off the search for further abnormalities, having achieved satisfaction from finding the first.
- Example: Second or additional fractures or significant soft-tissue injuries are commonly missed; missing a ruptured spleen thinking it’s only musculoskeletal pain.
Prevalence bias
-the tendency to misjudge the true base rate of a disease
-Implicit assumption that patients presenting to the ED have more serious conditions than those who attend a clinic (Emergency room doctors see more dramatic experiences than normal doctors, so they may misjudge the commonality of it)
-Examples: one study showed a fourfold overestimation of the probability of breast cancer in a woman with a positive mammogram by not taking into account the base rate of the disease and the correct detection rate of the imaging technique
Availability Heuristic
-tendency to overestimate the prevalence of a disease if we have recently seen a case, or read about one, because what is readily available to our consciousness is more easily recalled and, therefore, overrepresented
-ex: Flu pandemic shapes perception of symptoms; doctors see bacteria more frequently after identifying a positive case, what you see first in the day sets your mind at what you are going to see later in the day
Representativeness Heuristic
-the assumption that something that appears similar to other things in a category is a member of that category
Outcome bias
-the tendency to judge the quality of a decision in terms of its outcome
-bias reflects organization of medicine, reflection of what a physician in that situation is required to do
Countefactual
what happened with the patient had you not taken out prostate? Lots of men will have prostate cancer and not die so maybe it wasn’t necessary for it to be removed
McKeown Thesis
Eliminating potential explanations
Decline in organism virulence
Immunization
Urban hygiene improvements
Treating symptoms
Nutritional improvements
Negative finding: 1 through 4 don’t work
Positive finding: 5 does, but it’s hard to prove
Why Does Life Expectancy Keep Increasing and What has Caused it to Increase in the Past
-First decline is from flu pandemic, , second is WWII, we know its WWII because its sharper for male than women bc there were primarily male combaters
-there is decrease in variability of countries over time
The Standard of Living Debate
Debate vs standard living and purposeful action as causal engines
The Standard of Living as the Causal Engine
Incomes improved, which lead to an improved diet
Specific medical intervention mattered little
The market is beneficent
Purposeful action as the Causal Engine
-The market is not beneficent: we must intervene
-Health-focused interventions matter a great deal
-Technology and knowledge are important
- if you want to improve life expectancy, you should actively try to improve life expectancy, vaccinations, public health, environment
McKeown Thesis
-McKeown concluded that “the rise of population was due primarily to the decline of mortality and the most important reason for the decline was an improvement in economic and social conditions.”3(p121) Among these conditions, the most significant was improved diet.
-Medicine, McKeown stated, placed far too much emphasis on “cure” and not enough on “care,” in part because of a misunderstanding of history: “[M]isinterpretation of the major influences, particularly personal medical care, on past and future improvements in health has led to misuse of resources and distortion of the role of medicine. He concluded with a plea for a more humanistic, less technocratic role for the medical profession.

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What was the decline in mortality in 19th century England due to?
it was attributable almost entirely to infectious disease
Critiques of the McKeown Thesis
- Why diet when height is responsive to nutritional improvements, but is only weakly correlated with life expectancy.
-We don’t have good info about diet but we do have info of how much people weigh, this is indicative of how much people eat
-we know as a fact that when your diet improves you get taller
-If its really diet that matters, you should see both increasing, but only life expectancy actually increases
The trends don’t quite line up, diet is not super clear lifestyle wise
Social Intervention
-the importance of health-specific action
-over time the entire Preston curve should move up due to a change in the entire function, countries jump ahead, inconsistent with standard living debate because ITS NOT ONLY GDP THAT INCREASES LIFE EXPECTANCY, its all the other interventions they are borrowing form other countries could also lead to increase in gdp, argument is that all countries borrow innovations form other countries, all those things cause entire function to shift up
Preston Curve
it shows the improvement in life expectancy as due to either two components:
1) that arising from a movement along what economists call an aggregate 'health production function', relating life expectancy to real GDP.
2) due to an upward shift in the function caused by 'technological change', the ability to use given resources more productively to control disease and lengthen life
over time the entire Preston curve should move up due to a change in the entire function, countries jump ahead, inconsistent with standard living debate because ITS NOT ONLY GDP THAT INCREASES LIFE EXPECTANCY, its all the other interventions they are borrowing form other countries could also lead to increase in gdp, argument is that all countries borrow innovations form other countries, all those things cause entire function to shift up
Urban-Rural Differences in Life Expectancy
- can be up to 10 years different
-As income improves, mortality improvements are offset by movement to urban areas because urban aras tend to have more infectious disease, only when infectious diseases are cured then do urban areas start showing improved mortality rates as compared to rural areas
-Only with purposeful interventions can this be stopped
Epidemiological Transition
-In progressing from high to low mortality, all populations experience a shift in the major causes of illness.
- These changes are associated with socioeconomic improvements—as total mortality declines and income rises, communicable disease mortality declines
-the main diseases shift from:
Infectious disease, Nutritional health, Reproductive Health to Chronic Disease, Degenerative Disease,
“Man-Made” Disease
The Four Epidemiological Transitions
-External Injuries to Infectious disease: (Larger populations, higher density, longer periods in the same location)
-Infectious to degenerative disease: Reductions in crisis mortality (e.g., 1918 pandemic), Gradual decline in infectious disease, Population ages
-Cardiovascular to Cancer: Accelerated in the 1970s
Factors: better preservation and less salt, anti-hypertensives, better detection
-Cancer to ??
In the 1990s some countries witnessed a decline in total cancer mortality
Trends in Sweden's Mortality Rates
-Crisis mortality is diminished (as indicated by declining volatility)
-Population grows exponentially
The Epidemiological Transition of Women and Children
-most profound changes occur among women and children
- their susceptibility to infection is high
-Females’ risk of dying is less than that for males in the post-reproductive period AT ALL life expectancy levels, but females have a higher probability of death during the adolescent and reproductive age intervals at low life expectancy levels.
Shifting of Causes of Death in a Gradual and Fast Transition in England and Wales and Japan from 1860 to 1960
-increased occurrence of heart disease, cancer, vascular of Central Nervous System
-decrease occurrence in TB, infectious disease, and diarrhea
-japan had a dramatic increase in vascular of CNS while England had dramatic increase in heart disease
Deviations in Pace of Epidemiological Transition
-Japan went through the stages quickly
-Some developing countries have yet to fully move through them
Counter Transitions
-age-specific mortality rates rise, rather than fall, which results in a deviance from linear and unidirectional change
Age-Specific Transitions
-the epidemiological transition occurs at all ages, but is more pronounced among the young
Trends in Infectious Diseases
-In the U.S. age-adjusted mortality from infectious diseases increased 39% between 1980 to 1992.
-from 1980 to 1992 HIV increased from 0 to 15% death rates per 100000 population
-from 1980 to 1992 Respiratory tract infections increased from 25-30%
-29 new pathogens have been discovered since 1973
-the increased incidence and prevalence could be due to antimicrobial resistance
Compression of Morbidity Trends
-Frie's Theory is that the burden of lifetime illness may be compressed into a shorted period of time of death, if the age of onset of the first chronic infirmity can be postponed.
-occurs if the age at first appearance of chronic disease increases more rapidly than life expectancy.
Failure of Success
-Gruenberg's Theory
-Medicine puts emphasis on causes of death rather than on causes of non-fatal chronic diseases.
- We are living longer only to live for longer periods of time with disease and disability
The Process of Population Health Change
Risk factors ---> diseases, conditions, impairments ---> functioning loss ---> disability ----> death
-trends in one box don't necessarily need to be related to trends in another box
Fries vs Gruenberg's Theory
Neither Fries nor Gruenberg is entirely correct.
Trends in Mortality from 1981 to 1997
-Men's mortality improved faster than women, in large part because of smoking (they found out smoking was bad and stopped doing it)
-in 1980's decline of mortality started slowing down
Late-Life Disability
Declining in prevalence from '83 to '05
-there has been the largest increase (out of white men, white women, black men, and black women) in limitation-free years later in life in white men, then black men, then black women, then white women
Prevalence of Heart Disease and other Chronic Conditions
-decline in cardiovascular mortality
-increase from 1984 to 1994 in men's mortal diseases like HD, Hypertension, stroke, cancer, diabetes, morbid conditions like arthritis and glaucoma, and impairments like cataracts
-increase in same time pd of these diseases for girls too except girls had a slight decrease in hypertension
Trends in Biological Risk Factors from 1988-2000
- Smoking, diastolic bp, and cholesterol went down
-obesity went up
Self-Reported Health Trends from 1982 to 1999 for Ages 65+
-percent of people reporting good health has improved from 34% to 38%
-percent of people reporting fair/poor health has decreased from 35% to 26%
Health Trends in the 1970's
Longer lives but worsening health
-disease and disability are linked
Health Trends in the 1990's
-higher disease prevalence overall, but better health
-disease is no longer linked with disability
Optimistic View of Future Health Trends
-life expectancy will continue to go up
Pessimistic View of Future Health Trends
-we’ve exhausted everything at our disposal
Juvenile Mortality (LEj)
-mortality under 25
-from 1850 to 2000 this caused the largest increase in Life expectancy (35 years for women and 33.2 years for men)
Background Mortality (LEb)
-risks of mortality that do not change with age
-from 1850 to 2000 decreased from -1.8 to -8.1 in females and from -.09 to -6.7 in males
-
Senescent Mortality (LEs)
-level of mortality that increases with age, due to deterioration
-Assume that a new born survives to 25 and is not subject to background mortality
-from 1850 to 2000 senescent life expectancy increased from 1.0 to 9.4 in women and 1.7 to 8.0 in men
-Once you remove the effects of smoking, improvements in senescent life expectancy are linear
Overall Trends in Life Expectancy from 1850 to 2000
-Over time we’ve caught up with senescent life expectancy
-Life expectancy was propelled by improvements in juvenile mortality especially
-adjusted from juvenile mortality effect increases in life expectancy drop from 35 to 17.5 in women and 33.2 to 14.8 in men
US Disadvantage in Life Expectancy
-varied from a decade in 1900 to less than a year in 1950 and increased again to 5 years in 2000
Associations between STD Mortality Ratio, Annual Death Rate, Chronic Disease, Infant Mortality and SES
-There is a dramatic increase in these incidences in lowest socioeconomic statuses
Schooling and Mortality
-according to studies among men by Grossman, schooling is the most important correlate to good health
-Continuous decline in mortality in education, not a diminishing returns with education
Credentialing Effect
-with every credential you obtain your life expectancy goes up correspondingly
-right as you enter college the line for US goes down a bit, if there is a straight credentialing effect, you should find drops at specific areas, meaning decreased mortality per each credential you get ( high school diploma/ BA/ MD/ Ph.d) So is it seems as if it is not the credential itself but the years of actual education
- so besides particularly large decline at each milestone your are going to get little declines in mortality per year because you actually gain something for each year of education
Income and Mortality
-more educated people make more money than less educated income
-however, income matters less for well educated people so if you graduate but don’t make much money you’ll still have a better mortality rate than uneducated people
-therefore, regardless of income, years of education completed is the most correlate factor to good health
Michael Marmot's Whitehall Study of Civil Servants
-led to psychosocial revolution
-shows that there is a significant relationship between your job position and your mortality because all whitehall servants got equal benefits and health insurance and were all well-paid
- results show that people in high positions like administrative and professional/ executive positions have lower mortality than the relative rate while people in clerical and other lower positions have higher mortality than relative rate
-This could be because if you are at the top of the Whitehall ladder, you command more status, etc, so its not material deprivation but psychosocial position and psychosocial benefits: you’re at top of ladder relative to bottom ladder
Trends in Education and Mortality from 1960 to 1983
- in both uneducated and educated men and women mortality has declined but its the well educated that have mortality going down the fastest
- Among men the relationship between mortality and education is the strongest
-trends show that education is more strongly related to mortality than it was in the past
Why are people unemployed?
-Disabilities
-poor health
Importance of Heart Disease
-Widening differentials by heart disease mortality, in 1960 there was not much difference between heart disease mortality and education but that drastically changed in 1971-1984 when an increase in education began to cause a great decline in HD Mortality
-actual interpretation in 1960 there was no association between education and heart disease and this might be the case because well-educated people in 1960’s did a lot of things that were bad for them (Not a strong proof yet of relationship between smoking, rich diets, and heart disease)
-it can't be just due to health insurance because there are similar increases in mortality differentials found in England and Wales, so it’s not entirely health insurance
- also in 1960 to 1984 we learned a lot more about heart disease
- Mortality dropped from 30.3 to 13 in people that had 13+ years of education (huge decrease) so during this time period there was a growing understanding HD, and well educated people’s health improved
-This same effect does not apply to cancer because when it comes to preventing cancer we don’t know what to do whereas we do know what to do with HD
Benefits of a Degree (Cumulative Advantage)
-growing significance of risk factors as you age
-Returns of your degree grows,
- wealth accumulates faster,
-you find yourself in better social groups, but distance between you and less well-educated people grows, so therefore the association between education and mortality grows as you age, increasing disparity
Age-As-Leveler Theory
-declining significance of risk factors
- Everyone is going to be healthy at 25, yet when your older even rich people are going to have worse health
-actual evidence shows that its between age-as-leveler theory and cumulative advantage theory
-at younger ages there is not much association between mortality and education but then it increase when you get older, so argument that age is a leveler but it is actually much later than you think so key point is that when you get the biggest benefit of education is at middle age
-age matters but the point in which age eliminates social factors is very advanced
Selection/ Drift Explanation
social position and health are not related, the apparent association is spurious and attributable to genetic/ biological factors
-genes/ biological factors lead to social position and health
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Social Causation Explanation
-social position causes health
-you’re poor so you have worse health because you have fewer resources so you have less incentive to use those few resources for health
- PEOPLE with higher incomes and higher education levels are more likely to have a normal weight and less likely to have smoked
Economists Explanations of SES and Health
the fewer resources you have, the less incentive there is to preserve health
Psychologists’ explanations of SES and Health
Psychosocial stress/culture leads to bad health
-Hierarchy (people in higher class are healthier than those in lower class)
Statisticians’ explanations
-Childhood conditions/ income/etc turn into adult SES
-Contamination explanation: Personal characteristics underlie both health and SES
-Reverse Causation: Adult health determines adult SES
Health Causes Social Position Theory
-Health causes social position
-ex: you get lots of headaches so you end up with a bad social status
Percentage of Health Behavior Explained by Education, Income, and Health Beliefs
-no more than 14%
Dominance of Situational Factors in Health
-situational factors dominate health behaviors (smoking, drinking, being overweight) more than education, income, and health beliefs
Detection and Disparities
-Education may shape the detection of conditions, as well as successful management
-therefore it may seem like well-educated people have more disease but what it could actually be is that they are more likely to detect it
Innovation and Disparities
-Innovation often increases disparities, even as it decreases mortality overall.
- The case of cholesterol (graph shows that people with higher poverty rates are more likely to have higher blood cholesterol rates)
Gottfredson Conjecture
-Intelligence is associated with health in a monotonic fashion
-the association between intelligence and health is increasing as the complexity of care for chronic conditions increases
- the importance of accidents
-intelligence explains a great deal of the SES-health association
elusive fundamental cause
the epidemiologists' elusive of social class inequalities in health
Relative Status Ladder
-at the top of this ladder are all the people who are best off
-a the bottom are people who are worst off
-Some have argued that standing in the social order affects health directly
- Some evidence links position on the ladder to self-rated health
Survival Among Academy Award Winners Study
-nominees and non-nominated people have the same rate of mortality, showing that being nominated has no difference
-what really makes the difference is the actual WINNING
-actors/actresses with more success have a higher survival rate
Psychosocial Effects on Health
-Psychosocial stressors engender feelings of lack of control and predictability, and a sense of lacking outlets for frustration
- Higher psychosocial stressors are associated with higher health while lower rank is associated with lower health
-primate studies show that primates highest in the primate hierarchy have lower cortisol rates
Perceived Control and Health
-a well-balanced job encourages people to take control over successes and failures, those individuals tend to do better
-gradient relationship is less steep than when you don’t allow for those things
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Reverse Casualty
Is health a cause or an effect? The answer, depending on the context, can be either or both. 'Reverse' causality refers either to a direction of cause-and-effect contrary to a common presumption or to a two-way causal relationship in, as it were, a loop. Thus, higher incomes are associated with better health. But which causes which? Higher incomes are expected on balance to lead to better health but better health may enhance productivity growth and hence lead to higher incomes.
Health Shocks
-New unexpected health problem
-out-of-pocket health expenses, immediately after major health shock, causes household gdp to decline on annual basis by about 4000 dollars
-there is the expense of the condition itself, decline in personal work probability even for surrounding family member because families often have to stop working in order to help
Role of Insurance in Health
-Insurance is not a complete safeguard against expense
-The number of medical bankruptcies increased 23-fold between 1981 and 2001
-income having a causal effect on health argument:its reassuring to have 200k on the bank vs 2k in the bank
Most IMPORTANT probits predicting the major and minor onset of childhood conditions
-education and childhood SES virtually ALWAYS is related to health
Trends in Marriage and Health
-lines start to come together between health of working married me and non-working married men around age of retirement
-some people retire independently of their health but prior to that married men that would be expected to marry are in more stress bc they know that they SHOULD be working
Childhood Origins of Health and SES Disparity
-if you calculate income gradient among kids, you see it gets larger and it doesn’t disappear with time, in fact correlation between income and child's health gets bigger as child gets older
- There is very strong evidence for effect of SES on child health
-James is a skeptic on relationship of SES on adulthood, but he is NOT skeptical of relationship between this and childhood
-a true skeptic would say its not income cause health but health causes income, but this is suggesting that these kids are hurt early in life by their poor health, which is in part caused by their income
Why Are Tall People Better off than Short People?
-tall people make more money, its not your height at any one time, its your height in high school, because tall people play sports and it may be they develop really good friendships that pay off later on
- Taller people tend to have slightly better childhood environments and nutrition
Poverty and Health Trends Among Children
-More severe conditions are more common among poor children
-They are also of more consequence, like Asthma, diabetes, epilepsy
-its not clear why: Insurance is only part of the issue,
Maternal health literacy is another small part
- -kids aren't getting heart disease and cancer, they are getting chronic conditions like asthma and these conditions are especially important because a lot of school absences result from these things and people that cant be absence cant pay attention as much in school, thus resulting in doing bad in school
-if you take a wealthy kid with asthma, they have a very different relationship with it so it has less of a relationship with GPA and graduating from high school/ college than a poorer kid
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Macroeconomic Conditions and Health
- in the US, State-level income inequality increases overall mortality irrespective of individual level income
-what happens if you control for race in states of large inequality? south states have low life expectancy because black have low life expectancy. Once you control for race in those states that the association between ses and health either gets reversed or mortality even gets LOWER, its also the case that education plays a bigger role than people realize
-In places where there is higher overall mistrust there is higher mortality (the leasting trusting state is North Dakota and the most trusting state is LA)
The Ecology of Discrimination and Trends in Mortality
-disrespect of black culture affects white mortality as well
-mortality is higher in states where larger fraction of pop endorses discrimination than no discrimination
Women Empowerment and Mortality
-Higher Respect of women reduces male mortality as well
-in states where larger fraction of things are owned by women and more women are registered to vote and in more positions of power there is reduced mortality
-relative to men, women are more likely to add to programs that are beneficial to health, in particular in health to kids
Empirical Critiques of Gini Coefficient
-trends show that for the top 9 developed countries, the more money going to the least well off in each country, the higher the life expectancy (aka the less inequality, the higher the life expectancy)
-criticisms:
-if you expand countries to larger set and not just high income countries, the relationship gets closer to zero
-you get even weaker evidence at lower levels of aggregation. This is sort of the opposite of what you might expect