DIS-EASE The absence of death, disability or disease

Population- any cluster of people who share a common factor- geographic, demographic, time period...

Occurrence= # people with disease/ # people in population

Population Exposure group Comparison group Outcomes Time

Exposure Group Occurrence= affected/unaffected in EG Comparison Group Occurrence= affected/unaffected in CG

COHORT STUDY Population allocated into several groups by measuring exposures and the participants are followed over a period of time and relevant disease events are recorded. INCIDENCE

Number of onsets of disease occurring during a period of time Number of people in the study population

Prevalence Counting the number of people with disease at one point of time Number of people in the study group at that point in time

Categorical measures: classifying things, arranging data according to whether or not it fits into your groups

Numerical measures: no categories, all data is recorded and used raw

CROSS SECTIONAL STUDIES Measures disease prevalence in defined groups to investigate associations between exposures and diseases prevalent in groups. It is observational- participants are allocated to EG and CG by measurement

RISK RATIO/ RELATIVE RISK EGO/CGO: no units, 1 is the no effect value for RRs. RRR= (1-RR) x100. RRI= (RR-1)x100

RISK DIFFERENCE EGO-CGO, 0 is the no effect value. ARR if risk is lower in the EG or the ARI if the risk is higher in the EG

RANDOMISED CONTROL TRIALS Cohort studies in which participants are randomly allocated to intervention or control groups .Its the most valid study design for assessing effectiveness of therapeutic or preventive interventions. Its also less prone to confounding because the randomisation produces an EG and CG with similar characteristics...

DOUBLE BLIND RCT- patients and investigators dont know which intervention was given to which participants. Prevents investigators from allocating the treatment to who they believe will benefit (EG will differ). Knowledge of their exposure status can influence their interpretation of signs and symptoms and the assumptions that participants make from this can prevent them from disclosing the true outcome.

Random errors- caused by chance Non- random errors- caused by problems with how the study is designed or constructed. NON RANDOM ERRORS

Recruitment Allocation Maintenance Blind and Objective Measurements ANalysis

RECRUITMENT Occurs when the participants arent representative of the eligible population... Selection bias: 1. Recruiting amongst a small sample of people or specific group that mask the true prevalence 2. When participants in the EG are recruited from a different source than participants in the CG 3. If non responders are different from the responders 4. Response rate less than 70-75% of those invited

ALLOCATION >>>Ideal study- EG=CG, allocation helps make them similar.

1) Allocation via random process- equal chances of being in EG or CG. 2) Allocate via measurement- determines if theyre exposed to the factor being investigated... observational studies as the participants are observed to determine exposure CONFOUNDING The problem of mixing two or more effects that are all related to the disease outcome, so that you dont know which factor caused the result. Concealment of allocation- completely independent person opens the instructions randomly allocated to patients and records it so that any subsequent tampering will be obvious. Unconcealed allocations may exaggerate benefits and harmful effects. Stratified analyses: dividing participants into strata and combining the results ( 2 triangles, 2 studies). E.g. old and young

MAINTENENCE Error occurs is some participants exposure status changes or some are lost to follow up. Will normally occur but if theyre small and similar in both EG and CG, it will cause a conservative error- an underestimate of the true effect of the exposure on the outcome. Preferable to not knowing the effect of the M.E. Double blinding keeps the degree of M.E. similar in EG and CG.

BLIND OBJECTIVE MEASUREMENT Errors occur when participants are classified in the wrong disease outcome category. If the outcome being investigated isnt simple, they are more susceptible to influence from subjective factors unrelated to the effectiveness. BOME can be reduced through double blinding and the use of objective measurements such as blood tests and standardised questionnaires.

ANALYSES Denominators include EG and CG- intention to treatment analyses Those who remained on the treatment are part of the on treatment analyses, but the intention to treat is the preferable approach. Adjustments can be made to possible confounding.

RANDOM SAMPLING ERROR Every representative sample is slightly different than another. True prevalence will be different from the study results. It is inherent in every study as the only way to eliminate this is to investigate the whole group of people rather than use a sample. Smaller the difference between sample and population= smaller the random sampling error.

RANDOM MEASUREMENT ERROR Human ability to measure biological factors in the same way is poor. This could be due to background noise or another factor that influences the operators ability to measure. Multiple measurements taken and averaged will reduce this or the use of an auto instrument.

RANDOM INHERENT IN BIOLOGICAL PHENOMENA Inherent variability in all biological phenomena>>> inherent variability in all measurements of biological phenomena. Reduced by taking multiple measurements and averaging them.

RANDOM ALLOCATION ERROR EG and CG may differ, especially if the trial is small. This can be reduced by undertaking a larger study so numbers are randomised.

CONFIDENCE INTERVALS Used to describe the amount of random sampling error. This describes the range of values o a particular measure that is likely to include the true value. Amount of RE is reflected in the CI- the wider the interval, the more RE in measure. 95% CI is the most commonly used for reporting the amount of RE.

HEALTH The presence or absence of disease and self perceived well being. Absolute inequalities= EGO-CGO Relative inequalities=EGO/CGO INEQUALITIES Measurable differences or variation in health, health experience and outcomes between different population groups, according to socio economic position, geographic areas, age disability, gender or ethnic groups.

INEQUITIES Those inequalities deemed unfair or stemming from injustice. Inequities in health are the differences in the distribution of resources and services across populations that dont reflect health needs.

Why reduce inequalities?????? 1. Theyre largely avoidable so theyre preventable or treatable 2. Theyre unfair when they are the result of underlying structural factors (inequities) 3. They affect everyone: a more healthy society means theres a greater productivity which will improve the wealth of country and make more $ in the economy RAINBOW MODEL

1. Global, Financial, Ecological 2. National socio-economical, cultural and environmental 3. Rural and urban living and working conditions 4. Family and community influences 5. Personal behaviour 6. Age, sex, hereditary factors

LEVELS OF ACTION Downstream: intervention operate at the micro level (treatment systems, disease management) Upstream: operates at the macro levels (government policies and international trade agreements)... more efficient economically and more successful than focusing on individuals.

MEASURING SEP 1. Area measures: deprivation, access 2. Population measures: income inequality, literacy rates

MEASURING AREA LEVEL DEPRIVATION Deprivation- a state of observable and demonstratable disadvantage relative to the local community or the wider society or nation to which an individual, family or group belongs. Measures focus on material deprivation and peoples relative position in society.

ACCESS 1. Availability 2. Accessibility 3. Accommodation 4. Affordability 5. Acceptability

AVAILABILITY >Existence, supply, personnel, equipment; the extent to which the provider has the resources to meet clients needs. Provision of resources NOT organisation of them. ACCESSIBILITY >Geographic, location, transport, distance, remoteness, travel time; the location of services in relation to the population ACCOMMODATION >Organisation, design delivery; increasing the efficiency of existing services through reorganising the service deliver so that a greater output is achieved for each unit of input...efficiency.

AFFORDABILITY >Economic, socio-economic, cost, poverty, ability to pay; the cost of provider services in relation to the clients ability and willingness to pay for these services... the financial barrier to access

ACCEPTABILITY >Psychosocial, health beliefs, cultural, racial, minority, status; relationship between clients and providers attitudes to what constitutes appropriate care

THE PUBLIC HEALTH MODEL 1. Define the problem 2. Identify risk and protective factors 3. Develop and test prevention strategies 4. Assure widespread adoption

CAUSALITY Cause of disease= an event/s, condition/s, characteristic/s which play an essential role in producing the disease. Sufficient cause= inevitably produce the specific disease. Component cause= contributes towards disease causation but isnt sufficient to cause it on its own Necessary cause=must be present if a disease is to occur but doesnt have to cause it directly

BRADFORD HILL INFERRING CAUSALITY 1. Temporality 2. Strength of association 3. Consistency of association

4. Biological gradient (dose-response) 5. Biological plausibility of association 6. Reversibility 7. Specificity of association

Primary intervention- patients regular source of medical care (GP) Secondary intervention- medical care provided by a specialist usually resulting from a referral from primary care doctors Tertiary intervention- hospital based care and rehabilitation

ASSESSMENT OF THE IMPORTANCE OF A POPULATION HEALTH PROBLEM 1. Size of the problem- how common 2. Severity of problem- consequences 3. Groups affected age/gender 4. Treatment/ preventive measures available

POPULATION ATTRIBUTABLE RISK (PAR) >The amount of extra disease attributable to a particular risk factor in a population. If causal, the disease could be prevented if we removed that particular risk factor

DISEASE PREVENTION >Looks at certain diseases and ways of preventing them. Levels of disease prevention: 1. Primary- limits the incidence of disease by controlling specific causes and risk factors (before disease occurs) 2. Secondary- reduce the more serious consequences of disease (after disease occurs, disease control) 3. Tertiary- reduce the progress of complications of established disease (after disease)

ALMA ATA PRE-REQUISITES FOR HEALTH -Peace and safety from violence -Shelter -Education -Food -Income and economic support -Stable ecosystem and sustainable resources -Social justice

OTTAWA CHARTER 1. Build healthy public health policy 2. Create supportive environments 3. Strengthen community action 4. Develop personal skills

5. Reorient health services towards primary health care

HEALTH PROTECTION >Environmental hazard focused, risk assessment, monitoring, risk communication to public and occupational health (safety regulations) HEALTH PROMOTION >Health and well being focus; enables people to increase control over and improve their health. Action on determinants of well being.... whole population in everyday contexts.

SCREENING >Identifying unrecognised disease or risk factors for disease by applying tests on a large scale to a population. SCREENING PROGRAMME CRITERIA 1. Suitable disease- important health problem, detectable at an early stage 2. Suitable test- simple, safe and precise. Validated and acceptable to the population. 3. Suitable treatment- effective with evidence to prove this 4. Suitable screening programme- RCT evidence that screening programme will result in reduced mortality or morbidity... benefits must outweigh harms...cost effective

VALIDITY Sensitivity= the % of people test correctly identifies as positives). Calculated using tested negative but have the with the disease that the having the disease (true true positive/people that disease

Specificity= the % of people without the disease that the test correctly identifies as not having the disease (true negatives). Calculated using the true negative/ people who tested positive but dont have the disease.

SURVEILLANCE >On-going, systematic collection, analysis and interpretation of data regarding health related vents for use in public health action to reduce morbidity and mortality. Passive surveillance- depends on data generated from healthcare providers without solicitation, intervention or contact by the health agency carrying out the surveillance. Inexpensive but may be incomplete. Active surveillance- the organisation conducting surveillance actively seeks relevant information from healthcare providers Sentinel surveillance- reports are obtained from certain facilities or populations.

CASE DEFINITION

>Clinical and laboratory characteristics that a patient must have to be counted as a case for surveillance purposes.

EPIDEMIOLOGIC TRIAD Agent- disease causing organism characteristics: infectivity, pathogenicity, virulence, immunogenicity, antigenic stability, survival Environment- ecological conditions that favour the interaction of host and agent: weather housing, geography, occupational setting, air quality Host- biological makeup of individuals that make them vulnerable: age, sex, genotype, behaviour, nutritional status, health status

LEVELS OF INFECTIOUS DISEASE OCCURRENCE Outbreak: occurrence of cases of disease in excess of what would normally be expected in a defined community Endemic: transmission occurs, # of cases constant, disease that exists permanently in a particular region. Epidemic: infectious disease spreads rapidly to many people, # of cases increases in excess of the expected level Pandemic: When epidemics occur at several continents

OUTBREAK INVESTIGATIONS 1. Prepare for field work 2. Establish the existence of an outbreak 3. Verify diagnosis 4. Number of cases, count them using line listing 5. Perform descriptive epidemiology (incidence...) 6. Develop the hypothesis (source of problem) 7. Evaluate the hypotheses (look for risk factors) 8. Refine hypothesis and perform additional studies 9. Implement control and prevention measures 10. Communicate findings

MAORI HEALTH PROMOTION >>> inequalities, determinants of health, rights as indigenous peoples, mainstream health promotion interventions are less effective DETERMINANTS OF ETHNIC INEQUALITIES IN HEALTH 1. Differential access to health determinants or exposures: differences in disease incidence 2. Different access to health care 3. Differences in quality of care received

TE PAE MAHUTONGA- MAORI MODEL OF HEALTH 4 key tasks 1. Maurirora- access to tea o maori 2. Waiora- environmental protection 3. Toiora- healthy lifestyles

4. Te Oranga- participation in society (access to education, employment...etc) 2 Pre-requisites 1. Nga Manukura- leadership 2. Te Mana Whakahaere- autonomy; community control

CASE CONTROL STUDY DESIGN -Used to investigate the association of putative risk factors with the incidence of rare disease. Separate samples are taken of cases and controls from a defined population. Information on the exposure and other risk factors is collected but recall bias is a big issue.

POPULATION BASED CONTROLS -Cases and controls sourced from the same study base; ensuring the control exposure experience is representative of the individuals who compose the study base. E.g. hospital, neighbourhood, random digit dial, population based registry

DALYs=Disability Adjusted Life Years >Summary measure that combines data on mortality and non fatal health outcomes to represent the health of a particular population as a single number. YLL= years of life lost (mortality) = # of deaths multiplied by years lost per death

YLD= years lived with disability = incidence of their outcomes x average duration x disability weight

Demographic transition- decline in fertility and mortality rates Epidemiologic transition- characteristic shift in the composition of causes of death and disability from infectious and parasitic to non communicable diseases Risk transition- common risks for communicable diseases now co-exist with increasing risks for non communicable diseases= double burden of risks and consequences

CHALLENGES WITH DALY APPROACH TO DISABILITY - Disability weights for a specific health condition are assumed to be the same, regardless of life circumstances. - Viewed as seeing people with disabilities as a burden.

SOCIAL DETERMINANTS OF HEALTH 1. General socio-economic, cultural and environmental conditions 2. Living and working conditions: work environment, education, agriculture and food production, unemployment, water and sanitation, health care services, housing... 3. Social and community networks 4. Individual lifestyle factors

5. Age, sex and hereditary factors

THE RIGHT TO HEALTH The Right to Health is conceptualised at a population (usually nation) level and as such populations should be able to attain similar health outcomes if risks to population health and wellbeing were similarly resourced and protected. This R2H supports governments to reduce systematic differences between groups within nations (inequities) and ideally also support cooperation between nations to reduce differences between nations. Health policies and practices that support the R2H within a nation eg smoke free policies, immunisation schedules and road transport rules will also help individuals and families to optimize their health. A government cannot guarantee an individual the right to be healthy (the individual may come from a family with Huntingtons or very significant breast cancer risk) but a government ought to ensure all individuals have safe living and working environments, equitable access to the determinants of health and health services etc

THE RIGHT TO BE HEALTHY The right to be healthy is usually thought of at an individual level and cannot be guaranteed as it is a function of an individual's family history and other risks. We know that in a population some people will have accidents, get asthma, and childhood cancer etc so there will be differences in individual health outcomes.

CHRONIC DISEASES - 80% in low and middle income countries; concentrated among the poor. - Double burden=> double response: low income countries need to deal with infectious diseases and chronic diseases as the severity