DETERMINANTS OF HEALTH

Most discussions of determinants of health actually address the determinants of ill health, disease or injury

Disease and injury are the results of complex interactions among people, agents of disease or injury, and their environment

People caught up in what appear to be similar circumstances may be affected differently

Textbook emphasizes multifactorial causation -- I.e., disease, disability and injury are attributable to combinations of biological, behavioral, and environmental conditions

DETERMINANTS OF HEALTH (cont/d.)

Must distinguish between necessary and sufficient factors of causation

Remember that public health focuses on health risks associated with groups, or populations

Risk factors may increase the probability of disease or injury, but do not, because of their absence, product health

Model Showing Relationship of Health-FieldConcept to Health Status

HumanBiology

LifeStyle

Environ-ment

Organi-zation

HealthStatus

HealthPromotion/

Services

Preventive Interventions in Lung Cancer

Prevention_______

Primary Secondary Tertiary_

Human Biology 0 0 +

Environmental ++ + 0

Life-Style ++++ ++ 0

Organizational +++ + 00 = Virtually no opportunity

+ = Least opportunity

++++ = Most opportunity

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

Levels of Disease and Injury Prevention

Disease and injury prevention techniques are usually described in one of three categories:

• Primary Prevention

• Secondary Prevention

• Tertiary Prevention

Primary Prevention

Includes those activities intended to prevent the onset of disease and injury in the first place

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.

Secondary Prevention

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

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.

Tertiary Prevention

Includes techniques focused on rehabilitation to prevent the worsening of an individual’s health in the face of chronic disease or injury

Examples: Physical therapy for an orthopedic injury or cerebrovascular accident (stroke), education on diabetic self-management, other regimens for disease control . . . etc.

The “New” Public Health 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.

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 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

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

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 . . . ??

Some Ponderable Concerns about Determinants of Health -- Some “On Average” Propositions

People who live alone have higher premature rates of mortality than those who live in a stable relationship with other people

People who are employed live longer than those who are idle

Thin people live longer than fat ones People who sleep well each night live longer than

those who do not There is ultimately no safe environment; even in

the most idyllic setting, wastes are generated, storms and fires occur, and accidents happen

Some Ponderable Concerns about Determinants of Health -- Some “On Average” Propositions

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

In surveys, the great majority of adults indicate that regular exercise is very important; however, only about 40% report that they exercise regularly

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

Some Ponderable Concerns about Determinants of Health -- Some “On Average” Propositions

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?

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?

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?

LEADING CAUSES OF DEATH(Percentages of All Deaths)Sources: CDC; National Center for Health Statistics

1900 1994

Pneumonia 11..7% Heart Disease 32.1%

Tuberculosis 11.3% 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%

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