Module 1: Determinants of Health
- 1. Developed through the APTR Initiative to Enhance Prevention and Population Health Education in collaboration with the Brody School of Medicine at East Carolina University with funding from the Centers for Disease Control and Prevention
- 2. APTR wishes to acknowledge the individuals and institution that developed this module: ¡ Lloyd F. Novick, MD, MPH Department of Public Health Brody School of Medicine at East Carolina University ¡ Julie C. Daugherty, BS Department of Public Health Brody School of Medicine at East Carolina University This education module is made possible through the Centers for Disease Control and Prevention (CDC) and the Association for Prevention Teaching and Research (APTR) Cooperative Agreement, No. 5U50CD300860. The module represents the opinions of the author(s) and does not necessarily represent the views of the Centers for Disease Control and Prevention or the Association for Prevention Teaching and Research.
- 3. 1. Discuss the role of population-level determinants on the health status and health care of individuals and populations 2. Identify the leading causes of death, leading underlying causes of death, and health disparities in the United States 3. Describe the distribution of morbidity and mortality by age, gender, race, socioeconomic status, and geography in the United States 4. Describe the use of Healthy People objectives in public health program planning
- 4. ¡ “Common diseases have roots in lifestyle, social factors and environment, and successful health promotion depends upon a population-based strategy of prevention.” Rose 1992
- 5. Life Expectancy in Years by Country at Birth (2009 est.) Japan 82.12 Norway 79.95 Singapore 81.98 Greece 79.66 Australia 81.63 Austria 79.50 Canada 81.23 Netherlands 79.40 France 80.98 Germany 79.26 Sweden 80.86 Belgium 79.22 Switzerland 80.85 United Kingdom 79.01 Israel 80.73 Finland 78.97 New Zealand 80.36 Denmark 78.30 Italy 80.20 Ireland 78.24 Spain 80.05 United States 78.11
- 6. Adapted from McGinnis JM, Williams-Russo P, Knichman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21(2):78-93. 30% 15% 5% 10% 40% Impacts of Various Domains on Early Deaths in the United States Genetic Predisposition (30%) Social Circumstances (15%) Environmental Exposure (5%) Shortfalls in Medical Care (10%) Behavioral Patterns (40%)
- 8. ¡ As health professionals, training and reimbursement systems emphasize diagnostic and treatment services to individuals. ¡ We need to focus on those factors (DETERMINANTS) which have the most influence on the health of the population. Rose 1992
- 9. ¡ Focus on those determinants which have the most influence on the health of the population. § Environment § Social § Biology ¡ Current attempts at health reform will not be successful at improving health unless the population health determinants are addressed.
- 10. 0 100 200 300 Diptheria Senility Cancer Accidents Nephritis Stroke Heart Disease Diarrheal Diseases Tuberculosis Pneumonia 0 50 100 150 200 250 Septicemia Nephritis Influenza and Pneumonia Diabetes Alzheimer's Disease Accidents CLRD Stroke Cancer Heart Disease 1900: Ten Leading Causes of Death per 100,000 persons 2007: Ten Leading Causes of Death per 100,000 persons Adapted from the MMWR Vol. 48, no. 29, 1999 Centers for Disease Control and Prevention and 2007 data from the National Center for Health Statistics
- 11. Novick, LF. Used with permission.
- 12. ¡ Health has multiple determinants. ¡ Factors important to health, illness, and injury are social, economic, genetic, perinatal, nutritional, behavioral, infectious, and environmental. Omenn 1998
- 13. ¡ Biologic or host factors include: § genetics § behaviors that determine the susceptibility of the individual to disease § other factors related to susceptibility
- 14. ¡ Environment includes: § physical environment § conditions of living § toxic agents § infectious agents
- 15. ¡ Social factors of importance include: § poverty § education § cultural environments (including isolation)
- 16. ¡ A contemporary example of the agent-host- environment model can be seen with the transmission of HIV in a community, which is determined by: § infectious agent § host individuals § environment ¡ The agent-host-environment model facilitates public health intervention because disease can be interdicted by addressing any one of these factors
- 17. Environment Individual Agent Agent Occurrence Prevention Partner notification/ Needle exchange/ Safe sex/ Condoms Information Education Peer norms Drug use Condom availability Sexual behaviors Condom utilization Multiple partners Intravenous drug use Individual Environment Used with permission.
- 18. ¡ What is the cause of TB? ¡ What explains the decrease in TB from 1900 to the present? ¡ The answer to both of these questions is related to the multiple factors that cause TB.
- 19. Used with Permission, Lienhardt 2001
- 20. Used with permission, Lienhardt 2001
- 21. Novick, LF. Used with permission.
- 22. ¡ 2003 Institute of Medicine report concludes Americans today “are healthier, live longer, and enjoy lives that are less likely marked by injuries, ill health, or premature death” ¡ Gains are not shared fairly by all members of society § Widening gap between upper and lower class IOM 2003
- 23. ¡ Elevated death rates for the poor are evident in almost all of the major causes of death and in each major group of diseases, including infectious, nutritional, cardiovascular, injury, metabolic, and cancers. Wilkinson, 1997
- 25. ¡ Heart disease is the leading cause of death in the United States and is one of the areas in which disparities are most evident.
- 26. Adapted from Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2008, Series 10, Volume 242, December 2009 0 20 40 60 80 100 120 140 160 180 L e s s t h a n $ 3 5 , 0 0 0 $ 3 5 , 0 0 0 - - $ 4 9 , 0 0 0 $ 5 0 , 0 0 0 - - $ 7 4 , 9 9 9 $ 7 5 , 0 0 0 - - $ 9 9 , 9 9 9 $ 1 0 0 , 0 0 0 o r m o r e
- 27. ¡ The Whitehall I Study, a long-term follow-up study of male civil servants, was set up in 1967 to investigate the causes of heart disease and other chronic illnesses. ¡ Researchers expected to find the highest risk of heart disease among men in the highest status jobs; instead, they found a strong inverse association between position in the civil service hierarchy and death rates. Wilkinson 2009
- 28. ¡ Men in the lowest grade (messengers, doorkeepers, etc.) had a death rate three times higher than that of men in the highest grade (administrators). ¡ Further studies in Whitehall I, and a later study of civil servants, Whitehall II, which included women, have shown that low job status is not only related to a higher risk of heart disease: it is also related to some cancers, chronic lung disease, gastrointestinal disease, depression, suicide, sickness absence from work, back pain and self-reported health. Wilkinson 2009
- 29. 0 0.5 1 1.5 2 2.5 A dm inistrative Professional/Executive C lerical O ther Re lati ve Ra te (% ) Relative Rates of Death from Cardiovascular Disease among British Civil Servants according to the Classification of Employment
- 30. Regional Convergence of Social Issues 8.3% - 13.2% 13.3% - 16.2% 16.3% - 20.2% 20.3% - 32.0% Percent Poverty 20051 13.4% - 17.0% 17.1% - 18.6% 18.7% - 20.6% 20.7% - 27.5% Percent Uninsured 20052 553 - 797 797 - 878 878 - 977 977 - 1250 Low High Premature Mortality3 2002-2006 Notes: 1. US Census estimates on poverty for 2005 with 90% CIs. Interpret with caution. Accessed http://www.census.gov on 5-16-08. 2. Sheps Center (UNC) estimates of those without health insurance for 2005. Accessed http://www.shepscenter.unc.edu on 5-16-08. 3. Based on calculations from ECU’s CHSRD (using data from The Odum Institute, UNC). Years of life lost before the age of 75. James Wilson, PhD Center for Health Services Research and Development East Carolina University Greenville, NC.
- 31. ¡ In the United States, individuals without a high- school diploma as compared with college graduates are 3X as likely to smoke and nearly 3X as likely not to engage in leisure-time physical exercise Pratt et al. 1999
- 32. ¡ As a result of a sedentary life-style and unhealthy eating habits (often as a result of conditions in which wholesome food is unavailable or exorbitantly priced, public recreation is non-existent, and exercising outdoors is dangerous), obesity and the diseases it fosters now characterize lower-class life.
- 33. ¡ Poor neighborhoods § often dangerous § high crime rates § substandard housing § few or no decent medical services nearby § low-quality schools § little recreation § almost no stores selling wholesome food ¡ Offer residents, no matter what their race, income or education, little chance to improve their lives and engage in health-promoting behaviors. Diez et al. 2001
- 34. ¡ People of lower socioeconomic status are more likely to die prematurely than are people of higher socioeconomic status, even when behavior is held as constant as possible.
- 35. ¡ Inequitable distribution of income and wealth may itself cause poor health. Daniels et al. 2000
- 36. ¡ Life expectancy appears to be more related to income inequalities than to average income or wealth. ¡ In a study of the relationship between total and cause-specific mortality with income distribution for households of the United States, a Robin Hood index measuring inequality was calculated and found to be strongly associated with infant mortality, coronary heart disease, malignant neoplasms, and homicide. Wilkinson 1989, Kennedy et al. 1996
- 37. ¡ Despite decreases in mortality, widening disparities by education and income level are occurring in mortality rates. Mortality rates for children and adults are related both to poverty and to the distribution of income inequality. ¡ Growing inequalities in income and wealth will likely continue to be a significant determinant of disparities of health in the near future. US Department of Health and Human Services, 1998
- 38. Used with permission, Wilkinson 2009
- 39. Used with permission, Wilkinson 2009
- 40. ¡ The problems in rich countries are not caused by the society not being rich enough (or even by being too rich) but by the scale of material differences between people within each society being too big. ¡ What matters is where we stand in relation to others in our own society. Wilkinson 2009
- 41. ¡ In and around Washington DC, the gap is bigger still—a 20 year gap between poor Blacks in downtown Washington and well-off Whites in Montgomery County, Maryland, a short metro ride away. Marmot 2006
- 42. Used with permission, Wilkinson 2009
- 43. ¡ Above a level where material deprivation is no longer the main issue, absolute income is less important than how much one has relative to others. ¡ Relative income is important because, it translates into capabilities. ¡ What is important is not so much what you have but what you can do with what you have. Hence control and social engagement. Marmot 2006
- 44. Novick, LF. Used with permission.
- 45. ¡ Hazardous Wastes ¡ Air Pollution ¡ Water Pollution ¡ Ambient Noise ¡ Residential Crowding ¡ Housing Quality ¡ Educational Facilities ¡ Work Environments ¡ Neighborhood Quality Lee, et. al 2003
- 46. Novick, LF. Used with permission.
- 47. ¡ Modifiable behavioral risk factors are leading causes of mortality in the United States. Mokdad et al. 2004
- 48. ¡ Microbial Agents ¡ Toxic Agents ¡ Motor Vehicles ¡ Firearms ¡ Sexual Behavior ¡ Illicit Use of Drugs Mokdad et al. 2004
- 49. Actual Causes of Death in the United States in 2000 Actual Cause No. (%) in 2000 Tobacco 435 000 (18.10) Poor diet and physical inactivity 365 000 (15.20) Alcohol consumption** 85 000 (3.50) Microbial agents 75 000 (3.10) Toxic agents 55 000 (2.30) Motor vehicle 43 000 (1.80) Firearms 29 000 (1.20) Sexual behavior 20 000 (0.80) Illicit drug use 17 000 (0.70) Total 1 159 000 (48.20) *Data are from McGinnis and Foege. The percentages are for all deaths. **In 2000 data, 16,653 deaths from alcohol-related crashes are included in both alcohol Consumption and motor vehicle death categories. Used with permission, Mokdad et al. 2004
- 50. ¡ The burden of chronic diseases is compounded by the aging effects of the baby boomer generation and the concomitant increased cost of illness at a time when health care spending continues to outstrip growth in the gross domestic product of the United States. Mokdad et al. 2004
- 51. ¡ Although there is still much to do in tobacco control, it is nevertheless touted as a model for combating obesity, the other major, potentially preventable cause of death and disability in the United States. ¡ Smoking and obesity share many characteristics. Schroeder 2007
- 52. ¡ are highly prevalent ¡ start in childhood or adolescence ¡ were relatively uncommon until the first (smoking) or second (obesity) half of the 20th century ¡ are major risk factors for chronic disease ¡ involve intensively marketed products ¡ are more common in low socioeconomic classes ¡ exhibit major regional variations (with higher rates in southern and poorer states) ¡ carry a stigma ¡ are difficult to treat ¡ are less enthusiastically embraced by clinicians than other risk factors for medical conditions Schroeder 2007
- 53. ¡ Personal behaviors play critical roles in the development of many serious diseases and injuries. ¡ Behavioral factors largely determine the patterns of disease and mortality of the twentieth-century populations of the United States. US Department of health, Education and Welfare, Breslow 1998
- 54. ¡ The Age of Obesity and Inactivity Gaziano 2010
- 55. ¡ The steady gains made in both quality of life and longevity by addressing risk factors such as smoking, hypertension, and dyslipidemia are threatened by the obesity epidemic. ¡ The latest prevalence and trends in obesity data from the National Health and Nutrition Examination Survey (NHANES), reported by Flegal and colleagues, show that in 2007-2008, 68.0% of US adults were overweight, of whom 33.8% were obese. Gaziano 2010
- 56. ¡ Early obesity strongly predicts later cardiovascular disease, and excess weight may explain the dramatic increase in type 2 diabetes, a major risk factor for cardiovascular disease. ¡ The longer the delay in taking aggressive action, the higher the likelihood that the significant progress achieved in decreasing chronic disease rates during the last 40 years will be negated, possibly even with a decrease in life expectancy. Gaziano 2010
- 57. ¡ More men than women were overweight or obese, 72.3% compared with 64.1%. ¡ If left unchecked, overweight and obesity have the potential to rival smoking as a public health problem, potentially reversing the net benefit that declining smoking rates have had on the US population over the last 50 years. Gaziano 2010
- 58. ¡ Inadequate health care may account for 10% of premature death ¡ Health care receives by far the greatest share of our resources and attention.
- 62. ¡ Missing routine or preventive medical care can lead to the need for emergency care or even to preventable hospitalizations. ¡ Lack of access to transportation due to not owning a vehicle, not having a vehicle available via a friend or family member, or not having access to public transportation can lead to difficulty in seeking medical care. National Center for Health Statistics Health, United States, 2008 With Chartbook Hyattsville, MD: 2009
- 63. ¡ Preventable chronic illnesses ¡ Obesity epidemic ¡ Unsustainable health care delivery system Maeshiro 2008
- 64. ¡ The fundamental principle is that health of the community is dependent on many factors affecting an entire population. ¡ Thus the target for public health interventions should be a geographic or otherwise defined population.
- 65. ¡ Because of the broad distribution of most diseases and health determinants, using a population as an organizing principle for preventive action has the potential to have a great impact on the entire population’s health. ¡ It takes partnering at all levels to fully realize the impact of any health intervention.
- 66. ¡ Population-based and individual-targeted preventive strategies must be considered to be complementary, not exclusive. ¡ Comprehensive population-based prevention strategies may involve screening programs for individuals, for example, newborn screening for metabolic diseases, childhood lead testing, colorectal cancer screening, mammography, and pap smears.
- 67. ¡ In 1979, Healthy People marked a turning point in the approach and strategy for public health in the United States. ¡ The key to Healthy People was the premise that the personal habits and behaviors of individuals determined “whether a person will be healthy or sick, live a long life or die prematurely.” US Department of Health, Education and Welfare 1979
- 68. Cover of 1979 edition of Healthy People
- 69. Letter from Jimmy Carter from 1979 Healthy People
- 70. ¡ National agenda that communicates a vision and overarching goals, supported by topic areas and specific objectives for improving the population’s health and achieving health equity. Slade-Sawyer, P, HHS Office of Disease Prevention and Health Promotion
- 71. ¡ The report urged Americans to adopt simple measures to enhance health including: § elimination of cigarette smoking § reduction of alcohol misuse § moderate dietary changes to reduce the intake of excess calories, fat, salt, and sugar § moderate exercise § periodic screening (at intervals to be determined by age and sex) for major disorders such as high blood pressure and certain cancers § adherence to speed laws and the use of seat belts US Department of Health, Education and Welfare 1979
- 72. ¡ A major thrust of the report was a focus on age- related risk. ¡ The health problems that affect children change in adolescence and early adulthood and again in old age. At each stage in life, there are different problems and different preventive actions. US Department of Health, Education and Welfare 1979
- 73. ¡ Accidents and violence predominate in adolescence; chronic disease is the major problem in later adulthood and old age. Public health program planning must be attuned to the age-specific diversity of health problems. ¡ Healthy People set out five age-specific goals in 1977. US Department of Health, Education and Welfare 1979
- 74. ¡ These goals with specific objectives were reformulated by a second report issued by the surgeon general in the fall of 1980. ¡ Promoting Health/Preventing Disease: Objectives for the Nation established quantifiable objectives to reach the broad goals of Healthy People. ¡ This objective-based population preventive strategy continues today with the Healthy People 2020 objectives US Department of health and Human Services 1980
- 75. Target Year 1990 2000 2010 2020 Overarching Goals Decrease mortality: infants-adults Increase independence among older adults Increase span of healthy life Reduce health disparities Achieve access to preventive services for all Increase quality and years of healthy life Eliminate health disparities Attain high quality, longer lives free of preventable disease… Achieve health equity, eliminate disparities… Create social and physical environments that promote good health… Promote quality of life, healthy development, healthy behaviors across life stages… Topic Areas 15 22 28 42* # Objectives 226 312 467 > 580 Slade-Sawyer, P, HHS Office of Disease Prevention and Health Promotion *39 Topic areas with objectives
- 76. Slade-Sawyer, P, HHS Office of Disease Prevention and Health Promotion
- 77. ¡ Mission—Healthy People 2020 strives to: § Identify nationwide health improvement priorities § Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress § Provide measurable objectives and goals that are applicable at the national, state, and local levels § Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge § Identify critical research, evaluation, and data collection needs. Slade-Sawyer, P, HHS Office of Disease Prevention and Health Promotion
- 78. ¡ Successful health promotion depends on a population- based strategy of prevention ¡ Common diseases have roots in lifestyle, social factors, and environmental determinants ¡ Determinants which have the most influence on health: environment, social factors, biology ¡ Americans live longer with less ill health or premature death but gains are not shared equally by all members of society
- 79. ¡ Elevated death rates for the poor are evident in almost all causes of death ¡ Modifiable behavioral risk factors are leading causes of mortality in the US ¡ Because of the broad distribution of determinant impacts on health, addressing populations will have great impact
- 80. ¡ Center for Public Health Continuing Education University at Albany School of Public Health ¡ Department of Community & Family Medicine Duke University School of Medicine
- 81. Mike Barry, CAE Lorrie Basnight, MD Nancy Bennett, MD, MS Ruth Gaare Bernheim, JD, MPH Amber Berrian, MPH James Cawley, MPH, PA-C Jack Dillenberg, DDS, MPH Kristine Gebbie, RN, DrPH Asim Jani, MD, MPH, FACP Denise Koo, MD, MPH Suzanne Lazorick, MD, MPH Rika Maeshiro, MD, MPH Dan Mareck, MD Steve McCurdy, MD, MPH Susan M. Meyer, PhD Sallie Rixey, MD, MEd Nawraz Shawir, MBBS
- 82. ¡ Sharon Hull, MD, MPH President ¡ Allison L. Lewis Executive Director ¡ O. Kent Nordvig, MEd Project Representative