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THE WAVES OF PUBLIC HEALTH IMPROVEMENT

THERE HAS BEEN 4 HISTORICAL WAVES OF HEALTH IMPROVEMENT IN THE UK

The UK has had several phases of public health improvement since the industrial revolution, each of

which can be linked to major shifts in the nature of society and the emergence of new threats to

population health

Each wave rises rapidly reflecting the full impact during this period. Each wave reaches a peak then

declines in intensity.

MODERN PUBLIC HEALTH

Improvements in modern technology and pushes in public health have reduced age-specific rates of

disease in mid-life, but have resulted in a disease burden for the ageing population. Therefore

modern public health must develop with focus on increasing healthy life expectancy rather than life

expectancy itself.(compression of

morbidity)

Health problems that are of

greatest concern tody are of a

different nature: they are cultural

as much as strictiral or material in

origin and character.

e.g. the emerging epidemic of

obesity, loss of wellbeing, and

problematic drug and alcohol use

hence, a new push in public health

will need to change our world view

and social structures


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THE 4 WAVES OF PUBLIC HEALTH

WAVE PUBLIC HEALTH SUCCESSES DESCRIPTION

1ST

WAVE (1830-1890) The appliance f science and the

development of rational social order

Municipalism emerging civiland social order lots of crimead alcohol

Classic public healthinterventions; the growth of

municipal power and influence

Control of water-borne infectionin emerging industrial cities e.g.

cholera

Understand-predict-control

1. Providing clean water suppliesand effective sewerage

systems

2. Sewerage and clean waterstrictly separated

3. Purification technologiesdeveloped

2ND

WAVE (1890-1950) A RATIONAL LOOK AT MEDICINE THE

DEVELOPMENT OF GERM THEORY from

miasma theory (dirty air)

Scientific rationalism; the appliance of

science allied to continuing economic

development

E.g. the development of vaccines

success in eradicating smallpox

1. A wide range of infections cannow be prevented with

vaccination

3RD WAVE (1940-1980)

Emergence of post-war consensus;

creation of the welfare state

Concept of government in which state

plays key role in promotion ofeconomic

and social well-being of its citizens

MASLOWS HEALTH PYRAMID

1. Further improvements in livingstandards

2. NHS provision of free healthcare to all citizens

3. Social security4. Pensions5. Social housing

4TH

WAVE (1960-2000)

SUPER-SPECIALIZATION IN MEDICINE

Effective health care interventions; focus

on risk factors / lifestyle

LARGELY INDIVIDUAL

Understand-predict-control (emerging

evidence from early epidemiological

studies analytical epidemiology

Highlighting the harm from smoking)

- Tobacco control- smoking has declined

due to a large number ofsynergistic

interventions working together

Interventions in the following areas to

reduce smoking rates:

- Price regulation- Public education- Social marketing- Controls on product promotion,

advertising and sponsorship

- Introduction of proven treatments- Regulation of package design +

labeling

- Smoke free policies


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What factors were responsible for the UK moving form high birth rates, high death rates, and low life

expectancy to what we know today?

1. Describe the main factors responsible for improved heath between 1830 until todayTHE DEMOGRAPHIC TRANSITION

The transition of population structure is called the demographic transition and reflects the move froma pre-industrialized society to an industrialized economic system associated with population growth.

The demographic transition is set out

as an idealized picture showing ageneralization of population change in

countries over time and summarized in

5 stages:

STAGE 1

Pre-industrialized society, associated

with pre-modern times.

Characterized by a balance between birth rates and death rates. Birth, fertility, and death rates are

very high and their approximate balance results in only a very slow population growth.

Birth and death rates were high and unstable de to disease, drought, and other natural events. This

produced a relatively young population

Raising a child was relatively inexpensive due to lack of education and entertainment expenses as well

as the children contributing to the economy of the household. As for old age dependents, most

people did not reach retirement and continued work until their death. High death rates affected birth

the elderly and the young meaning the elderly constituted a very small part of society.

BIRTH RATES WERE HIGH DEATH RATES WERE HIGH

Children were relatively inexpensive to raise and were able to

contribute to household economy so were therefore valued

as contribution to household income

High levels of disease and lack of public health and healthcare

availability

Lack of family planning however most people wanted

children

Famine, droughts, and other natural disasters such as plague

Religion and tradition at this time encouraged large families Lack of clean water and sanitation

Children were regard as an insurance policy for their

parents who grow depended with aging. Therefore many

children provided a means of support in future life

Malnutrition and poor diet

Infant mortality rate was high which gave reason for high

birth rate

War

The demographic transitionrefers to the transition from

high birth and death rates, tolow birth and death rates as acountry develops from a pre-industrial to an industrializedeconomic system

1. WHAT IS THE DEMOGRAPHIC

TRANSITION?


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STAGE 2

Imbalance between death rates and birth rates as Britain entered a stage of transition amidst the late

18th

century. INITIATED BY AGRICULTURAL REVOLUTION

The decline of death rates increased by the late 19th

century

due to the industrial revolution. Countries in this stage today

include Yemen, Afghanistan, Palestine, and much of Sub-

Saharan Africa. Death rates were seen to decrease rapidly for

many reasons:

1. IMPROVEMENTS IN THE FOOD SUPPLY due toimprovements in farming technique such as crop rotation, bringing about higher yields, as well as

improved technology, storage, and transport.

2. IMPROVEMENTS IN SANITATION, water supply, sewerage and food handling which reduced theincidence of disease transmission

3. Provision or improvement of basic health care which reduced mortality rates, particularly thedevelopment of vaccinations

4. Improvements in hygiene from growing scientific knowledge of the causes of disease andimproved education

5. Decreased infant mortality ratesBirth rates at this stage do not change significantly as population culture remains largely the same,

thus an imbalance between birth and death rates are established resulting in a large increase in

population growth, termed the population explosion.

THE POPULATION EXPLOSION, IN LARGE PART, IS DUE TO THE IMPROVEMENTS OF THEAGRICULTURAL REVOLUTION AND BETTER SANITAITON WHICH REDUCED DEATH RATES

SIGNIFICANTLY LEADING TO AN IMBALANCE BETWEEN RATES OF BIRTH AND DEATH

A change in the age structure of the population at this stage is also seen. In stage one most deaths

were concentrated in the first 5-10 years of life, but in the second stage a substantial amount of the

decrease in death rates are due to the survival of children

Thus the age structure of the population becomes increasingly youthful meaning more of these

children enter the reproductive stage of their lives whilst still maintaining the high fertility rates of

their parents.

This causes the base of the population age pyramid to widen first, before accelerating populationgrowth.


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STAGE 3

THE POPULATION MOVES TOWARD STABILITY THROUGH A DECLINE IN BIRTH RATE

SEVERAL FACTORS CONTRIBUTE TO THIS EVENTUAL DECLINE:

1. Continued decline in childhood death means that at some point parents realize they need notrequire so many children as to ensure a comfortable old age

2. Improvements in contraceptive technology results in a decline in fertility3. Increase in wages increases the confidence at which parents can enter old age with fewer

children to rely on for support

4. Urbanization changes the traditional values placed upon fertility and raises the cost of childupbringing due to child labor acts increasing dependency

5. Increasing female literacy and employment lowers the uncritical appetence of childbearing andmotherhood as a status of women. Working women have less time to raise children

valuation

of women beyond childbearing and motherhood becomes important

The resulting changes in the age structure of the population results in a reduction in the youth-

dependency ratio and eventually population aging. The population structure becomes less

triangular and more like a balloon

The change in population structure produces a demographic window for economic growth as a rise in

the ratio between the working age and demographic population is observed. The increase in the ratio

of the working age to the dependent population is called the demographic dividend

STAGE 4

CHARACTERISED BY STABILITY AND OCCURS WHEN BIRTH AND DEATH RATES ARE BOTH LOW

Birth rates may even drop below death rates, resulting in slight population shrinkage

The population age structure has become older, the large group born in stage 2 become older than

working age and creates an economic burden, as dependent pensioners, on the shrinking work

population

Death rates may remain low or may increase due to increases in lifestyle diseases associated with low

exercise levels, high obesity and age-related diseases.

BIRTH RATES REMAIN LOW DUE TO: DEATH RATES REMAIN LOW DUE TO:Children being expensive and parents not being able to afford

their upbringing

Ever improving health care

Lower infant mortality rates meaning parents can expect to

carry the child to term and be confident of its survival beyond

infancy, hence there is less need to bear more children in

terms of security in old age

Better standard of living i.e. better housing, sanitation,

hygiene, diet

Widely available contraceptives and higher levels of

education regarding their use

Decreased fertility rates

Decreased desire by women to have as many children


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STAGE 5

CHARACTERISED BY BIRTH RATES THAT ARE LOWER THAN DEATH RATES LEADING TO A

DECLINE IN POPULATION LEVELS

KNOWN AS SUB-REPLACEMENT FERTILITY

This stage represents countries that have undergone/ are undergoing economic transition to

deindustrialization. This is the transition from manufacturing based industries into service and

information based industries.

Lower birth rates than death rates result in population ageing and population decline may

eventually occur presuming that sustained mass immigration does not occur.

POPULATION AGEING

The decline in death rate and birth rate that occurs during the demographic transition leads to a

radical transformation in age structure. As death rates decline in the second stage of the transition,

the result is primarily an increase in the child population.

The EU however is an ageing community and the

percentage of elderly increased modestly in industrial

countries despite a small dip in 2010 due to relatively

small cohorts born before and during the second world

war. There is an expected rise in the elderly population

as the baby boomers (a very large post -WW2 cohort)

ages. This cohort was born between 1945 and 1965and

will create a large and significant increase in the elderly

population.

This has many implications for society and services

Socio-cultural changes in this cohort post-war mean

there is existing patterns of behavior, which were not

present in previous cohorts, which will also impact significantly on future health.

ALCOHOL CONSUMPTION IS ONE SUCH BEHAVIOUR

Ageing of society has implications for the old age dependency ratio. It

is widely recognized that this shift in the balance of old and working

aged cohorts in the population will damage the economy and create

serious problems for health and social care services.

THE MAIN CONCERN IS THAT THERE WILL NOT BE A SUFFICIENT NUMBER OF TAX PAYERS TO PAY

FOR THE COST OF THE NHS AMONG OTHER SERVICES, AND THERE WILL NOT BE SUFFICIENT

NUMBERS OF WORKING AGE INDIVIDUALS TO FILL POSTS IN HEALTH AND SOCIAL CARE

PROFESSIONS.

When the death rate is high, the infant mortality is

usually very high

When the death rate falls, or improves, this, in general,

results in significantly lower infant mortality rate, and

hence, increased child survival

Over time as cohorts increased by higher infant survival

rates get older and there will be an increase in the

number of older children, adolescents and young adults

This implies that there will be an increase in the fertility

of the population which will lead to an increase in the

number of children born

This will further increase the growth of the population

The second stage of demographic transition, therefore,implies a rise in child dependency

The old age dependency ratio is the ratio of

individuals 65 and over in the population to

the size of the economically active segment of

the population


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COMPRESSION OF MORBIDITY

The compression of morbidity is a hypothesis that states the burden of lifetime

illness may be compressed into a shorter period before the time of death, if the age

of onset of the first chronic infirmity can be postponed.

As we age the risk of death and disease inevitably increases as ageing leads to progressive generalized

impairment of function, resulting in a loss of an adaptive response, the mechanism by which the

majority of disorder is corrected in early life.

E.g. the ability to withstand infection or trauma depends on the reserve capacity of our physiological

system. Pneumonia, for instance, in a young person is much less likely to be fatal due to the large

reserve capacity of the young persons lungs, the same infection in an older individual through

physiological decline may pose much more of a threat

TWO FACTORS INFLUENCE THIS RISK:

1. The rate of physiological decline2. Risks of external assaults from the environment, including severity and frequency

- External assaults include trauma, infection, or any other factor, which impairs physiological

function

WIDE RANGE OF EXAMPLES ILLUSTRATING GENERALISED PHYSIOLOGICAL DECLINE:

Efficiency of lung function Circulation Muscles Nerve transmission

The rate of decline has largely genetic influence, but is affected by environment, nutrition, and

lifestyle in general. Under certain influences, this decline can be accelerated e.g. poor diet and

sedentary lifestyle in the case of CHD, but attention to environment and personal behavior can be key

to slowing this decline.

E.g. those who do not utilize their large muscle groups inevitably lose strengthuse it or lose it

principle


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The level of decline is such that we can sometimes define it as pathological, for example,

development of ischemia due to coronary stenosis as a result of poor diet or smoking.

THERE IS A SLOW DECLINE IN A WIDE RANGE OF PHYSIOLOGICAL FUNCTIONS INEVITABLE WITH

AGE, BUT THE RATE OF DECLINE IS AMENDABLE TO A LARGE VARIETY OF BEHAVIOURAL AND

ENVIRONMENTAL INTERVENTIONS

The chief aim in the compression of morbidity hypothesis is to extend the amount of time for which

individuals remain above the symptom threshold of disease before a short period of ill health

(morbidity) culminating in death.


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WHAT IS HEALTH?

Health comprises both the presence of positive and the absence of negative dimensions. The most

important dimensions are physical, mental, and social.

PHYSICAL HEALTH positive physical function of the body. The resource required for full physical

functioning and resilience.

PHYSICAL FITNESS the ability to carry out daily tasks with vigor and alertness, without undue

fatigue, and with ample energy to enjoy leisurely pursuits and to meet unforeseen emergencies


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MENTAL HEALTH

Mental health, in a positive sense, relates to the state in which a person may be able to function in

daily life, cope with stressful events (resilience), and contribute towards something larger than

themselves. It is not merely the absence of mental illness.

Psychological dimensions of public health are described as positive functionings as opposed to

positive feelings of subjective wellbeing.

Many of the determinants of mental health are also vitally important for the maintenance of physical

health, including genetics, physical activity, and nutrition. Social determinants such as the cultural

environment in which the individual lives, and their level f education, have also been found to impact

on mental health. Life events also have significant impact. All other aspects of wellbeing including

physical and social wellbeing have profound effects on mental health:


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SOCIAL HEALTH

Individual social heath concerns positive social interactions, behavior, and the ability to form and

sustain relationships, in a sense, how one functions in a community.

There have been 5 social health dimensions proposed:

1. Integration2. Acceptance3. Contribution4. Actualization5. Coherence

Social health is dependent on successful adaptation to the social environment, the quantity and

quality of relationships, the extent of social networks, and the degree of support one receives from

available contacts.

Full social health involves feelings of trust and belonging, respect for self and others, and healthy

sexual relations. Social health is subject to cultural norms, and may be interpreted differently

depending on the society in which the individual lives. The degree to which an individual is health yin

a physical and mental sense also impacts on their social health


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PHYSICAL DISEASE

Physical disease can take many forms from impairments to disabilities, long-term limiting conditions

such as obesity, CHD, COPD and DM, infections, and injuries. Every diagnosis of physical disease falls

under several categories:

WHAT IS MENTAL ILLNESS?

Mental illness is how an individual feels, thinks or behaves, and refers to a wide range of symptoms

and disorders, including depression, anxiety, eating disorders, and schizophrenia.

WHAT IS SOCIAL ILL-BEING?

Social ill-being can be conceptualized as social dysfunction, an active condition of behavior that is

unacceptable to a society in which one lives or visits. Characteristics of social ill-being may include

hostility, withdrawal, isolation and insecurity.

SUMMARY

1. Health is a construct2. There are several dimensions to health (physical, social, mental, spiritual)3. Each dimension has positive and negative poles4. Subjective and objective measurement scales are required for each dimension


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3. The determinants of health over the life course: discuss in some detail what factors at what time in the life

course are needed to ensure the population live a long and healthy life

THREE LEVELS OF INFLUENCE

1. THE PERSONa. Ageb. Sexc. Geneticsd. Biologye. Behaviorf. Risk factorsg. Lifestyle

2. THE COMMUNITYa. Home environmentb. Neighborhoodc. Workplaced. Wider societal influences e.g. education system or health care system

3. THE ENVIRONMENTa. Vast

THE LIFE COURSE PERSPECTIVEThe life course approach examines the determinants of health at each of the stages of life: pre-birth,

childhood, adolescence, working age, and older age. This perspective views health as a product of risk

behaviors, perspective factors, and environmental agents that we encounter throughout our entire

lives.

A mdel is devised to conceptualize how exposure to factors at different life course stages has a

cumulative, multiplicative, and even programming influence on long-term health and wellbeing. It

allows us to understand the links and timings between exposures and the health outcomes.


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There are three ways in which life course events can interact to influence long-term health and

wellbeing:

1. CUMULATIVEMost common mechanism

Health damaging influences add to each other throughout the course of life

E.g. a mother in poor economic circumstances may be less well nourished, the child then has

material disadvantages in childhood and adolescence and tends to grow up to be relatively

poor himself.

BIOLOGICAL, BEHAVIOURAL, SOCIAL, AND ENVIRONMENTAL DETERMINANTS OF HEALTH

CUMULATE

2. MULTIPLICATIVESome risk factors do not just add to one another, but have a multiplicative effect

3. PROGRAMMINGExposure to some risks at any stage of the life course can programme increased risk of

adverse health outcomes much later in life

THE SOCIOECONOMIC GRADIENT

Position on the socioeconomic hierarchy has a profound impact on health for individuals poverty

causes ill-health. Socioeconomic gradient is considered at all aspects of the life course


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LEVEL 1: THE PERSON

Huge impact of genetics on individual health, otherwise considered uncommon in wider community

or population. Genetic-type conditions such as chromosomal abnormalities including Down syndrome

are relatively less common and have a small population health impact; however they can have a

profound effect on every aspect of the individuals life

At an individual level, polygenetic inheritance influences the chance of an individual developing a

chronic disease or cancer. For chronic diseases, the genes are found to interact with the environment

and behavioral factors to affect outcomes; such is the case of epigenetic theory.

Biological markers are also implicated e.g. high levels of cortisol are seen in those of low socio-

economic status. Cortisol is termed the stress hormone and is an important par of the bodys

response to stress, however prolonged elevation in cortisol levels can result in a state of chronic

stress, higher blood pressure and increased risk of heart attacks and strokes.

GENDER AND ETHNICITY

Sex is an important discriminant of health females are protected from early development

of heart disease due to the cardio-protective properties of the sex hormone estrogen,therefore gender influences the susceptibility to disease

This mechanism is however the combination and interaction between genetic, behavioral,

cultural and structural factors

EMPLOYMENT AND OCCUPATION

Good work is good for health. Employment that brings satisfaction, provides income, creates

daily structure, promotes social interaction, and provides purpose and meaning in life is seen

as beneficial to health outcome of the individual.

Disease and mortality rates for different occupations vary markedly

PERSONAL CHARACTERISTICS

Personal skills necessary for success in life (e.g. assertiveness and delaying gratification) are

also attributed with a wide range of health outcomes. People who are driven to do so can

often derive their own health benefits from inner qualities they possess. i.e. take up initiative

to live a life that promotes healthier outcome

Another useful concept is the sense of coherence the ability of the individual to make

sense of the world around them in a manner that allows them to act purposefully. This could

correlate with the attainment of self-actualization as modeled in Maslows hierarchy of

individual needs and describes the very summit of health attainment.

HEALTH RELATED BEHAVIOURSImportance of smoking, alcohol, food, exercise, sexual behavior, ad drug taking to health

outcomes.

HABITUS

Class-dependent. Oversimplifying, an individual is brought up to consider a certain way of

eating, talking, walking, and seeking entertainment (among others) as natural. It is natural

as it is part of their habitus their environment.

People have the capacity to change their lifestyles so long as they have the motivation to do

so, however, changes that do occur will tend to be in accordance with their underlying

habitus.

Bluntly, healthy eating, exercise, learning to relax, and a while range of similar behaviors are

less likely to be part of the habitus or disposition of less advantageous groups; in general,


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groups of high cultural or educational capital are able to practice a key form of social

distinction in contemporary society.

LEVEL 2: THE COMMUNITY

FAMILY FRIENDS AND ACQUAINTANCES

The family context is important for health. In the early years, security and consistency are

vital. Findings show that children who are subject to adverse experiences in childhood are

much more vulnerable during adolescence and adulthood. These adverse effects include

sexual, physical, and verbal abuse, drugs and alcohol misuse, and a lack of love and

encouragement.

Being loved unconditionally and supported by parents and others builds resilience in young

people. The family is also important in that it creates behavior.

Good parenting is seen as a vital foundation for good health health damaging behaviors

usually replicate themselves: a child brought up in a household in which either parent is a

smoker and whose friendship group also smoke is much more likely to smoke themselves

therefore a key target is to CHANGE THE INFLUENCE OF FAMILY AND FRIENDS

THE LOCAL COMMUNITY

People in the local community beyond family and friends also have an influence on the

development of personal traits and health related behaviors. The local community creates a

sense of what is normaland expected.

Support in schools, the workplace, and local organizations is health enhancing; its absence

can damage health.

A community has financial capital (money) and physical capital (buildings and facilities) that

are of value to everyone in the community. Social capital concerns the value of social

networks that bind similar people together and bridge between more diverse people.

Thus, a community where people help each other out and there are high levels of trust

between people is generally a healthier place to live because it has higher social capital. A

community with higher social capital has good will and trust between individuals, which

serves as a resource that enhances life and therefore makes health and wellbeing more likely

to followillustrated as a level of need in Maslows need hierarchy.


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LEVEL 3: THE ENVIRONMENT

PHYSICAL ENVIRONMENT

Clean water, clean air, and other aspects of a good physical environment are fundamental to

health; in their absence, life expectancy will fall dramatically.

Evidence exists to suggest vehicle and industrial emissions cause substantial premature

death, but is primarily through effects on those who already have respiratory disease.

THE BUILT ENVIRONMENT

Refers to buildings, roads, and infrastructure.

Housing has an impact on health: hosing of very poor quality negatively impacts on health,

psychologically, and in terms of disease through effects of damp or rot, perhaps.

The standard of housing has been raised so high that further investment in housing

improvement will give little benefit towards health improvement.

The ill-health associated with poor housing does not always arise directly from the building

itself, but is a function of the interaction of all the determinants of health acting together in

areas of deprivation. The building is only part of the ecology of poor health.

THE BIOLOGICAL ENVIRONMENT

Emergence of new disease and infection including HIV, hepatitis C, and E. Coli. Infections

remain a relatively minor source of increased mortality on a population basis, however they

pose a risk to population health.

THE CULTURAL ENVIRONMENT

Culture helps to create a total way of life for people and provides a way of thinking, feeling,

and believing. Culture defines a map that orientates the way we live and is an important

determinant of health.

Culture can influence health related behaviors such as smoking, drinking, exercise, and

sexual activity. Our culture helps o condition what is normative in almost all health related

behaviors.

Media also serves as an important determinant of health and is critical in influencing the

forming of ideas, values, and societal norms.

THE ECOSYSTEM

Effects of global warming and the influence it has on human populations. Climate change is

arguable the worlds most important environmental health issue as its progression

determines activity such as droughts and floods. There is also huge economic cost and

prosperity damage and impact on agriculture and food supply

Climate change will also include the geographical range of some vector-borne infectious

diseases such as malaria.

THE ECONOMIC ENVIRONMENT

Analysis of gross national product shows that poor countries often have poor levels of

health; bur that a modest improvement of GNP of a poor country often brings quite a

marked health improvements. However once a country becomes sufficiently wealthy,

additional improvements in GNP are not associated with equivalent improvements in life

expectancy.

Additional wealth given to those who are already wealthy has minimal impact on health

status, while the same amount of health, if given to those who are poorer, results in greater

health gain.


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THE LIFE COURSE

PRE-BIRTH

Antenatal care is a key determinant of material health, but by extension, has a profound

impact on the subsequent health of the baby.

Pre-birth maternal nutrition can play and important role and observations have been made

that demonstrate babies subjected to certain factors in-utero resulting in low birth weight

seemed to be programmed to develop hypertension and diabetes in adult life (BARKER

HYPOTHESIS)

Smoking during pregnancy is a significant risk factor, the main impact of which is through

lower birth weight. Smoking also compromises the childs neurological development during

pregnancy. Alcohol also presents risks (FAS) due to its ability to cross the placenta.

EARLY YEARS

Attachment theory suggests that early attachment of the child to a principal carer is crucial

to correct neurological, social, and emotional development. Failure of attachment can havefar reaching effects on behaviors such as violence and the development of emotional

intelligencenecessitates the need for good parenting and the provision of a home

environment that is safe and promotes all aspects of the childs development.

Nutrition is also a key componentbeginning with breast feeding and then evolving into a

healthy age-specific diet.

Critical periods are a phase in the life span during which an organism has heightened

sensitivity to exogenous stimuli that are compulsory for the development of a particular skill.

If an individual does not receive a stimulus during the time of this critical period, it may be

difficult, ultimately unsuccessful, or impossible, to develop some functions in later life.

Critical windows are seen for the acquisition of language, and the development of vision and

auditory processing. E.g. seen in feral children

ADOLESCENCE

Many health related behaviors are influenced by risk-taking patterns during this phase of

development. Adolescence is a bio-psycho-social phenomenon

ADULT LIFE

All determinants of health and socioeconomic gradient by this time interact with the factors

from earlier in the life course to create and destroy health. Working aged adults are

influenced by their social position and relationship status.

Late middle life sees the emergence of chronic disease and the need to develop and/ or

maintain functional capacity in the face of continuing disease. Health status is therefore

influenced by the interaction and accumulation of determinants of health over the life

course.

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