HPDP Test 1

Simple Definition of Health Care

"Quality health care means doing the right thing, at the right time, in the right way, for the right person and having the best possible results"

What is Health Literacy?

"The capacity of an individual to obtain, interpret, and understand basic health information and services and the competence to use such information and services in ways that are health enhancing"

Factors Contributing to Tobacco Use

*Individual* - Sociodemographics - Genetic predisposition - Coexisting medical conditions *Pharmacology* - Alleviation of withdrawal symptoms - Weight control - Pleasure, mood modulation *Environment* - Tobacco advertising - Conditioned stimuli - Social interactions Nicotine is a powerful drug capable of inducing a variety of pharmacologic effects, including an alteration in brain chemistry. However, tobacco addiction is more than just a brain disease. It is a complex process involving the interplay of many factors (pharmacologic, environmental, and physiologic) that influence an individual's decision to use tobacco (Benowitz, 2010). As such, treatment of addiction requires a multifaceted approach (Lerman et al., 2005; Leshner, 1999). This slide depicts several important factors that influence tobacco use behavior. Individual factors: Tobacco prevalence differs by various sociodemographic factors (e.g., age, sex), and these factors are also associated with susceptibility to tobacco use (initiation, maintenance). Some individuals exhibit a genetic predisposition for nicotine addiction, and the impact of some coexisting medical conditions (in particular, mental illness) increases an individual's likelihood of using and becoming dependent on tobacco. Pharmacologic factors: As discussed previously, there is a pharmacologic basis for a nicotine-dependent individual's decision to use tobacco. Environmental factors: Tobacco industry advertising: For years, the tobacco industry has engineered major marketing plans to design more addictive cigarettes and to defy the public regarding the hazards of smoking. Their multibillion-dollar marketing effort is an important contributor to tobacco use. Conditioned stimuli: All drug-taking behavior is learned, a result of conditioning. Drug-taking behavior is reinforced by the consequences of the pharmacologic actions of the drug. At the same time, smokers begin to associate specific moods, situations, or environmental factors with nicotine's reward effects. The association between such cues and anticipated drug effects and the resulting urge to smoke is another type of conditioning. For example, people often smoke cigarettes in specific situations, such as after a meal or with coffee or alcoholic beverages. The association between smoking and these other events, repeated many times, causes the environmental situations to become powerful cues for the urge to smoke. A nondrug example of this type of conditioning is the desire to eat popcorn at the movies or hot dogs at baseball games. Other aspects of smoking (e.g., manipulation of smoking materials, taste, smell, feel of smoke in the throat) become associated with the pleasurable effects of smoking. Even unpleasant moods can become conditioned cues for smoking. For example, a smoker may learn that not having a cigarette provokes irritability, a common nicotine withdrawal symptom. Smoking a cigarette relieves withdrawal symptoms. After repeated similar experiences, a smoker may come to regard irritability from any source, such as stress or frustration, as a cue for smoking. Conditioning is a major factor that leads to relapse. As such, it must be addressed as a component of behavioral therapy for nicotine addiction. Social interactions: Having family or peer-group members who smoke increases the likelihood of tobacco use and, therefore, addiction. Among adolescents, peer pressure is often a reason for initiating tobacco use.

What are the advantages of the social norm approach?

- Reflects what students ARE doing, not just what they should be doing - Tailored for each specific campus to maximize opportunities - Community based - Environmental approach

Patients May Seek to Protect Themselves By

- Seeking help only when illness is advanced - Walking out of the waiting room - Making excuses - Pretending they can read - Becoming angry, demanding - Clowning around, using humor - Being quiet, passive - Detour, letting doctor miss the concern

Immunity

Active Immunity: - Artificially acquired (Vaccination) - Natural Acquired (Having had a disease) Passive Immunity - Artificially acquired (antibodies injected) - Naturally acquired (Antibodies passing from mother to baby)

Duke University Example of Workforce Health Programs

Activity: "The Live for Life" program for hourly employees employed for 4 years Results: Participants experienced 3.3 fewer absences in the first year

Health Policy Laws and Regulations

Healthcare system policies - Health services Reimbursement - Licensure of professionals - Funding for research and education - Cost and availability of medications - New medical technologies approval Influence your health behavior - Alcohol use - Seatbelts - Immunizations

What are the best interventions according to HHS?

Include the following: Multiple strategies Targets the community at large Addresses the factors that contribute to health problems Various activities to meet your audiences' levels of readiness

Why is smoking an emergency?

LEADING most preventable cause of death - Tobacco dependence - 1 out of 5 US deaths related to tobacco - 3 million deaths/yr worldwide related to tobacco - 400,000 deaths / yr in U.S. 48 million adult smokers in U.S. 4 million KID smokers in U.S. - Use typically begins by age 16 - 3,000 become addicted every day

The "Language of Health"

The Words, their pronunciation, and the methods of combining them - used and understood by a community The Means of communicating ideas & feelings - use of conventionalized signs, sounds, gestures, or marks having understood meanings

How will HP Objectives be used?

To establish priority areas for funding To provide direction for existing programs To monitor results of current and future programs To provide businesses, healthcare agencies, and communities with an agenda By healthcare providers to encourage their patients to pursue healthier lifestyles

The 5 A's of Smoking

"3 Minute" Tobacco Intervention - 5 A's Ask Advise Assess Assist Arrange As a final review, the 5 A's are as follows (Fiore et al., 2008): Ask about tobacco use; systematically identify all tobacco users at every visit Advise tobacco users to quit Assess readiness, or willingness to make a quit attempt Assist with the quit attempt (provide counseling and medication) Arrange follow-up care

Community Empowerment

"A social action process by which individuals, communities, and organizations gain mastery over their lives in the context of changing their social and political environment to improve equity and quality of life."

1. Ask

"Do you ever smoke or use other types of tobacco or nicotine, such as e-cigarettes?" "I take time to ask all of my patients about tobacco use—because it's important." "Condition X often is caused or worsened by smoking. Do you, or does someone in your household smoke?" "Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?" Ask. Tobacco use can induce early onset of disease and exacerbate existing medical conditions, and tobacco smoke has the potential to interact with many medications, altering both drug levels and efficacy. It is appropriate, if not essential, for clinicians to assess and document each patient's tobacco use status, preferably at each visit. Asking about tobacco use should be considered to be as important as evaluating vital signs during a routine medical screening, and when obtaining a medication history, clinicians should ask about tobacco in the same way that they would ask about any other drug. Clinicians also should consider including a query about tobacco use on the new patient profile form. At a minimum, the form should assess tobacco use status (i.e., current, former, never). Appropriate language for assessing tobacco use status could be: "Do you ever smoke or use other types of tobacco or nicotine, such as e-cigarettes?" This question will capture not only cigarette smoking but all forms of tobacco and inhaled nicotine use. The query also can be linked to the clinician's knowledge of a patient's disease status or medication profile. For example: "Condition X often is caused or worsened by smoking. Do you, or does someone in your household smoke?" or "Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?" When clinicians ask about tobacco use, it is important that they take a genuine and sensitive approach, conveying concern for their patients' well-being. A judgmental tone likely will not result in accurate disclosure of tobacco use. In an effort to promote autonomy with a patient, consider asking for permission to ask questions: "May I ask you a few questions?," before launching a series of inquiries. It could also be helpful to tell patients: "We like to have this information so we can check for any potential adverse interactions with tobacco smoke and your other medicines." "We ask all of our patients, because tobacco smoke can affect how well some medicines work." "We care about your health, and we have resources to help our patients quit smoking."

Why Tobacco Control Efforts are So Important

"Four million unnecessary deaths per year, 11,000 every day. It is rare, if not impossible, to find examples in history that match tobacco's programmed trail of death and destruction. I use the word 'programmed' carefully. A cigarette is the only consumer product which when used as directed kills its consumer." This quote, from the former director of the World Health Organization, summarizes the urgency of tobacco control efforts to counter the tobacco industry.

How can we resolve health disparities?

"Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States." Inequality in Health Care Racial and ethnic minorities experience higher rates of morbidity and mortality than non-minorities. Focusing attention and resources on primary prevention could significantly reduce this huge and unfair inequity. In order to significantly reduce disparities, intervention should occur not only to improve medical care but also as early in the trajectory as possible to ensure that people are not becoming sick or injured in the first place. This is the goal of primary prevention, which aims to remove the conditions in the environment that give rise to poor safety and health. Success of Prevention Tobacco is one example of the success of prevention efforts. A generation ago virtually every public space was smoke filled and, despite the Surgeon General's pronouncement that tobacco smoke was risky for health, the norm was to light up or accept others lighting up in public. Primary prevention efforts has changed this. Behavioral and lifestyle factors account for more than half of premature mortality; environmental exposure to hazards accounts for 20 %, and health care for 10%.

How do we combat college drinking misperceptions?

"Social norms" interventions market true behavior norms A number of studies have documented the success of prevention programs for college students grounded in social norms theory (Perkins, Berkowitz, 1983; Haines, 1996; Johannessen, 1999) Today, approximately 1 in 5 schools have a social norms marketing program

Community Capacity

"The characteristics of communities that affect their ability to identify, mobilize, and address social and public health problem."

What causes Health Disparities

"The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries. The structural roots of health inequities lie within education, taxation, labor and housing markets, urban planning, government regulation, health care systems, all of which are powerful determinants of health, and ones over which individuals have little or no direct personal control but can only be altered through social and economic policies and political processes." Social-Physical-Economic-Services Determinants Income & income inequality Education Race/ethnicity/gender & related discrimination Built Environment Stress Social support Early child experiences Employment Housing Transportation Food Environment Social standing

Disability

*"A condition of the body, mind, or senses of a person of any age that affects ability to work, learn or participate in community life"* - US Surgeon General Call to Action, 2005 22% (54 million) of people in the United States live with at least one disability Some disabilities are visible while some are not One can be born with a disability or can acquire it over a lifetime The unemployment rate for persons with a disability was 13.4 percent in 2012, higher than the rate for persons with no disability (7.9 percent). Disabilities change by age, but many of them are ambulatory and independent living, as well after cognitive, hearing, self-care, and vision

Three Most Common Types of Health Programs

*Awareness Activities*: increase the knowledge base and broaden perception of specific health problems or issues. *Lifestyle Change Programs*: include various behavior change strategies designed to positively modify current activities. *Supportive Environment Programs*: provide encouragement, assistance, and reinforcement for positive health behaviors.

Typical Activities for Health Promotion, Disease Prevention, and Wellness Programs

*Communication*: Raising awareness about healthy behaviors for the general public. Examples of communication strategies include public service announcements, health fairs, mass media campaigns, and newsletters. *Education*: Empowering behavior change and actions through increased knowledge. Examples of health education strategies include courses, trainings, and support groups. *Policy, Systems, and Environment*: Making systematic changes - through improved laws, rules, and regulations (policy), functional organizational components (systems), and economic, social, or physical environment - to encourage, make available, and enable healthy choices.

Community and Interventions (about wording)

*Community interventions* seek small but important changes that relate to the majority of the population within an identified community. *Interventions within a community* focus on producing change in a subpopulation within the community.

Epidemiology Study Types

*Experimental* Observational --> *Descriptive* or *Analytic*

Classification of Diseases and Health problems- 4 Classification Schemes

*Organ or Organ System* *Causative Agent* - Biological Agents : Viruses, Bacteria, Fungi, Protozoa - Chemical agents Pesticides, food additives, pharmacologics, industrial chemicals, air pollutants, cigarette smoke - Physical Agents Heal. Light, radiation, noise, vibration, speeding objects *Communicable vs Non-Communicable* Communicable = infectious (biological agents or their products transmitted from one person to another) Non-Communicable = noninfectious (multicausation diseases) *Acute vs Chronic* Acute = peak symptoms within 3 months or sooner with recovery of survivors usually complete (ex. Influenza) Chronic = longer than 3 months - slow and sometimes

Phases and Steps of a Needs Assessment

*Phase 1: Gather Preliminary Data and Generate Assessment Questions* Steps: 1. Gather basic community information 2. Observe and take notes 3. Talk to people *Phase 2: Collect Community Data* Steps: 4. Assemble secondary data 5. Gather primary data 6. Identify gaps in knowledge *Phase 3: Analyze Data and Interpret Results* Steps: 7. Analyze the data 8. Compare perceived and actual needs 9. Compare your community to others *Phase 4: Prioritize Needs, Identify Assets, and Make Recommendations* 10. Prioritize needs 11. Validate prioritized needs 12. Create an asset map 13. Submit findings and recommendations

Transtheoretical Model: Stages of Change

*Precontemplation* Individuals who have never considered a healthy behavior. *Contemplation* Individuals who have been thinking about the need to change but might be hesitating because of what they'd have to give up. *Preparation* Individuals who have decided to make a change and are planning to do so in the very near future. *Actions and Maintenance* Individuals who have been practicing the desired behavior at different levels of success. Pre contemplation: create awareness; change values and beliefs Contemplation : persuade and motivation Preparation: educate Action: facilitate action Maintenance: reinforce changes, reminder communications - Decisional balance and self-efficacy are core constructs of the transtheoretical model. - Decisional balance is simply the pros and cons of making a behavioral change. - Self-efficacy is one's belief that he/she can perform a task. - The transtheoretical model goes beyond theoretical concepts and offers actual strategies for helping individuals move through the stages of change.

Types of Data to Collect for a Needs Assessment

*Primary Evidence Based Data* - peer reviewed and published findings. Use the original source *Primary Data* - Assessments collected directly from individual or groups - Examples: focus groups, survey responses, photographs *Secondary Data* - data is information that is not from a first-hand source - collecting data from secondary resources can help develop and refine primary data collection methods - examples: county health report, hospital discharge data, national databases

Public Health vs. "Big Tobacco"

*The biggest opponent to tobacco control efforts is the tobacco industry itself" - Nationally, the tobacco industry is outspending our state tobacco control funding - For every $1 spent by the states, the tobacco industry spends $12.40 to market its products Historically, public health efforts to reduce tobacco-related morbidity and mortality have faced strong opposition. The biggest opponent to tobacco control efforts is the tobacco industry itself. Public health opposes the industry Most states fail to spend even the minimum amount recommended by the CDC for expenditures on tobacco control, yet over the past decade the tobacco industry has dramatically increased its promotional. For every $1 spent by the states on tobacco control initiatives, it is estimated that the tobacco industry spends an estimated $12.4 to market its products (Campaign for Tobacco-Free Kids, 2018).

Definition of Health Literacy

*The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.* There are many definitions of health literacy. This one, used in Healthy People 2020 reminds us that health literacy is more than just an ability to read; it is action oriented, leading to an improved capacity to be a full participant in one's health care. It is especially important because we live in a highly literate society, and our health care systems require levels of literacy that are often beyond the capacity of care recipients. We expect a great deal from our patients; consider asthmatic patients---a few decades ago,patients took theophylline-period-, now they must learn very complex medication regimes (ie, to use inhalers with spacers and understand the difference between controller meds and rescue meds, tapering doses of prednisone), they must test peak flow rates daily, identify/eliminate allergens at home, advocate with their landlords and schools--and the list goes on. The scope of the problem is significant: more than 90 million Americans cannot understand basic health information These patients, and their families , are greatly disadvantaged in today's health care environment

Vision, Mission, and Overarching Goals of HP 2030

*Vision*: A society in which all people can achieve their full potential for health and well-being across the lifespan. *Mission*: To promote, strengthen and evaluate the Nation's efforts to improve the health and well-being of all people. *Overarching Goals* Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury and premature death. Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all. Create social, physical, and economic environments that promote attaining full potential for health and well-being for all. Promote healthy development, healthy behaviors and well-being across all life stages. Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all.

Wellness, Quality of Life, and Broad Social Issues

*WHEEL DIAGRAM* Immediate factors of Influence: Individual thoughts and behaviors Knowledge, attitudes, beliefs, values Behavioral choices and habits Cultural norms and group dynamics Families, neighbors, friends Local churches, social, or working groups Noncontrollable risk factors Age, gender, genetics Health care and health literacy issues Complex systems, confusing forms Medical jargon, rushed appointments Broad Social Issues Unemployment Poverty Overcrowding High birth rates Crime Bioterrorism Environmental exposures Global Influences Politics and historical events Physical environment Social services and education Economics and community resources

Definition of Health Disparities

*World Health Organization (WHO)* "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." *National Institutes of Health (NIH)* "Health Disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States." My definition: "differences in incidence/prevalence among different groups having different health outcomes"

Tobacco Industry Marketing

- 23.6 million is spent a day A report from the National Cancer Institute (NCI, 2008) delineates a causal association between tobacco advertising and promotion and increased tobacco use. Each year, the tobacco industry spends billions of dollars in promoting its products in the U.S. and abroad. This graph shows the most current data on advertising expenditures in the U.S., along with data for 1970, the first year for which these data are available in the FTC annual reports, to give a basis for comparison (FTC, 2018). Highlights of the report for 2014 are as follows: Annual spending (in the U.S. only) for advertising and promotional expenditures was $8.706 billion. The total number of cigarettes sold by the five major manufacturers to wholesalers and retailers in the U.S. was 240.5 billion in 2016. Significant increases in marketing were witnessed when the Master Settlement Agreement, which introduced new marketing restrictions, went into effect in 1998.

New Topic Areas for 2020

- Adolescent health - Blood disorders and safety - Dementia - Early and Middle Childhood - Genomics - Global Health - Healthcare-Associated Infections - Health-Related Quality of Life and Well-Being - Lesbian, Gay, Bisexual, and Transgender Health - Older Adults - Sleep Health - Social determinants of health

Improvement of Community Conditions

- Community conditions, largely influenced by the root factors, can be improved through a community health approach. - A community health approach builds on strengths and assets within communities and advances community elements that have an impact on health, mental health, and safety.

Health Belief Model

- Comprehensive look at why people make the behavior choices they do - Analyze the probability that a person will make a behavior change - Basic precepts of this model are that person believes they are susceptible to health problems, and those problems have undesirable consequences, and the problems can be prevented, delayed or minimized

Sites for Community Health Promotion

- Hospital/Clinical/Agency Settings: commonly include activities for employees, their families, and even the community at large - Colleges and Universities: opportunities outside the normal classroom instruction for students, staff, and faculty to enhance the quality of their lives through educational and exercise programs - School Health: coordinated school health programs - Worksites: Employee wellness programs - Senior Center or Recreation Centers

American Cigarettes

- Most common, sold in packs of 20 In the U.S., cigarettes are generally sold in packs containing 20 cigarettes, and a carton of cigarettes generally contains 10 packs. In a study analyzing cigarettes sold by the major American manufacturers (Philip Morris; RJ Reynolds; Brown & Williamson; Lorillard Tobacco) from 1997 to 2005 (~200 brands/year), the total nicotine content per cigarette averaged 13.5 mg (range, 11.9 to 14.5 mg/cig) (Connolly, et al., 2007). Notably, this study found a significant increase in the nicotine yield (0.03 mg/cigarette/year, which represents a 1.6% mg/cigarette increase per year) during 1998 to 2005. Modifications in cigarette design, including (a) higher concentrations of nicotine per cigarette and (b) alterations to reduce the "burn rate," which increase the number of puffs/cigarette, are believed to increase the nicotine yield (Connolly, et al., 2007). Cigarette ratings for tar and nicotine are determined by a standardized U.S. Federal Trade Commission machine testing procedure that involves inhalation of 35 mL of smoke over 2 seconds every 60 seconds (NCI, 2001). Under these conditions, in 1998 and 2004 the average machine yield of nicotine among the top-selling brands of American cigarettes (n=116) was 0.9 mg (MDPH, 2006). Full-flavor (regular) brands had higher machine nicotine yields (1.1 mg/cigarette) compared to light (0.8 mg/cigarette) or ultra-light brands (0.4 mg/cigarette). (MDPH, 2006). In contrast, studies with smokers have consistently demonstrated higher nicotine yields (1-2 mg/cigarette) suggesting the FTC machine method underestimates the true nicotine exposure under actual smoking conditions (Benowitz & Jacob, 1984; Jarvis et al., 2001; NCI, 2001). ♪ Note to instructor(s): Researchers from the Massachusetts Department of Public Health have developed a testing method hypothesized to more closely approximate the smoking behavior of a typical smoker (e.g., 45 mL puff volume over 2 seconds every 30 seconds with 50% blockage of filter ventilation holes). Using this approach, the measured nicotine yield was 2-fold higher with the Massachusetts method when compared to the standard FTC method

Health Belief Model Components

- Perceive susceptibility - Perceived seriousness - Perceived threat - Cues to action - Perceived benefit minus perceived barriers - Likelihood the person will take action Modifying Factors - age, personality, culture, experience and many other factors influence other perceptions Perceived benefits and barriers - (pros and cons) to engaging in healthy behavior also increase the likelihood of behavior change if the benefits outweigh the barriers (Nardi & Petr, 2003) Cues to action - Individuals sometime still need a little nudge to help them get started on changing behavior for the better.

Health Belief Model: Self-Efficacy

- The construct of self-efficacy was added to the health belief model (Rosenstock, Strecher, & Becker, 1988) when the model started being used for more complex behaviors. - Self-efficacy is a perception about how well one can perform a specific task. How well you think you can do *The competence to be able to accomplish desired tasks or behaviors. This requires an understanding of an individual's perception about their ability to be successful in accomplishing a task*

Causes and Effects of Disparate Health

- These differences are generally not the result of people experiencing a different set of illnesses than those affecting the general population. - Rather, the same diseases and injuries that affect the population as a whole affect people in low income communities of color more frequently and more severely. - Poor health is not only a burden to those directly affected but also to the entire population whose health status is worsened by the poor health status of its least healthy members. (NAM, 2003) - A population that is not well is more susceptible to and less able to ward off infection, which can be transmitted to others.

Health Care Expenditure in America

- US leads the world in medical research and care - For all we spend on health care, we should be the healthiest people on Earth Here you see total health care expenditures per person for a number of countries in the world, the US far outspends any other country-- If this is true, that health care or clinical care shapes our health, then since America leads the world in medical research and investment in medical care, then Americans should be the healthiest people on Earth Despite tremendous improvements, Americans live shorter lives and suffer more health issues than people in other high-income countries - more americans age 65+ suffer from chronic conditions - our babies are 50% more likely to die before their first birthday - and on average their lives are 3 years shorter People live longer in countries that spend more on *social cafe* than support health programs- shows how important SDoH are The US is the only country that spends more on treating health issues vs social care programs, and prevention programs get only 3% of US health care dollars We all benefit by applying a health lends to decisions in our communities

New Critical Factors of Social Determinants of Health

- shift away from disease specific focus - engages sectors not typically linked to public health- education, jobs, elected officials- all sectors must think about health implications

mapping/capacity building/assessment/empowerment

-mapping resources is part of capacity building and the assessment process -by engaging community members in this process, individuals and the community as a whole are empowered

Research has shown that health promotion activities in the workforce lead to:

1. A healthier workforce 2. Empowered employee morale 3. Lower absenteeism (cost benefit) 4. Retention of quality workers 5. Attraction of prospective employees NON PARTICIPATION AND ATTRITION Adherence and participation are essential elements in the cost-benefit equation. It is important not only to attract and motivate employees but also to maintain participation among those who will benefit most. It is important to consider that individuals who volunteer to join health promotion programs may be healthier than the nonparticipants. Employees with multiple health risks tend to be less productive than their healthier peers. Many studies have indicated that health promotion programs improve health and significantly reduce absenteeism. Increased employee productivity = cost savings for businesses

Lead Health Indicators

1. Access to health services 2. Clinical preventive services 3. Environmental quality 4. Injury and violence 5. Maternal, infant, and child health 6. Mental health 7. Nutrition, physical activity, and obesity 8. Oral health 9. Reproductive and sexual health 10. Social determinants 11. Substance abuse 12. Tobacco Reflect the major health concerns Measure the health of the nation Each of the areas has one or more Healthy People 2020 objectives associated with it Selected to: - Ability to motivate action - Availability of data to measure progress - Importance as public health issues

Summary of Five Steps of Health Literacy

1. Conduct patient-centered visits 2. Explain things clearly in plain language 3. Focus on key messages and repeat 4. Use a "teach back" or "show me" technique to check for understanding 5. Use patient-friendly educational materials to enhance interaction

Steps to Using Plain Language

1. Explain things clearly using plain language - slow down the pace of your speech - use analogies - use plain, non-medical language 2. Focus on key messages and repeat - Limit information by focusing on 1-3 key messages per visit - Review each point and repeat several times - Have other staff members reinforce key messages 3. Use "teach back" or "show me" methods - ask patient to demonstrate understanding instead of just asking "do you understand" 4. Use patient-friendly educational materials to enhance interaction - show or draw simple pictures - focus only on key points - emphasize what the patient should do - minimize information about anatomy and physiology - be sensitive to cultural preferences 5. Conduct patient-centered visits

HRSA Strategic Plan

1. Improve access to quality health care and services 2. Strengthen the health workforce 3. Build healthy communities 4. Improve health equity

2004 Report of the Surgeon General: Health Consequences of Smoking (Four Major Conclusions)

1. Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general. 2. Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general. 3. Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health. 4. The list of diseases caused by smoking has been expanded. *Smoking remains the leading cause of preventable death and has negative impacts on people at all stages of life. It harms unborn babies, infants, children, adolescents, adults, and seniors.*

A Public Health Approach

1. Surveillance: What is the problem? 2. Risk Factor Identification: What is the cause? 3. Intervention Evaluation: What works? 4. Implementation: How do you do it? Kind of like Answer to the question (Answer:question)

Increased Tobacco Excise Taxes Increase Price (how effective are tobacco taxes)

10% increase in cigarette prices 4% drop in adult cigarette consumption Youth much less likely to start smoking when prices are high Adjust taxes to offset inflation and tobacco industry attempts to control retail prices - E.g., promotional discounts for retailers who reduce cigarette prices Tobacco taxes are the single most effective component of a comprehensive tobacco control program

1 Juul Pod

20 CIGARETTES WORTH OF NICOTINE

HP Goals by Year

2000: Increase the length of life 2010: Increase quality and years of healthy life 2020: Attain high-quality, longer lives free of preventable disease, disability, injury and premature death 2030: Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury and premature death. ("thriving" is a new notion) LOOK AT SCREENSHOT (changes in the language of the goals) # of topic areas and objectives have increased

HP Goals by Year

2000: Increase the length of life 2010: Increase quality and years of healthy life 2020: Attain high-quality, longer lives free of preventable disease, disability, injury and premature death 2030: Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury and premature death. and help improve health literacy) ("thriving" is a new notion, as is health literacy) LOOK AT SCREENSHOT (changes in the language of the goals) # of topic areas and objectives have increased

Doctor Appointment Statistics

68% of people experience hearing loss when naked Up to 80% of patients forget what too to them as soon as they leave the healthcare office Nearly 50% of what they do remember is remembered incorrectly

Smoking in movies

70% of adults support assigning an R rating to movies with smoking There is a dose-response, causal relationship between exposure to smoking in movies and youth smoking initiation Cigarette smoking is pervasive in movies Evident in at least ¾ of box-office hits Average, 10.9 smoking incidents per hour

National Prevention Strategy

A Plan for better health and wellness all about PREVENTION *Crucial component of Affordable Care Act* Move from sick care to wellness and prevention Prevention is essential to have healthier lives and keep costs down Strongest predictors of health are outside our healthcare facilities so need to weave prevention into our everyday lives - Housing, transportation, education, workplace, environment,

Americans with Disabilities Act of 1990 (ADA)

A law passed in 1990 that requires employers and public facilities to make "reasonable accommodations" for people with disabilities and prohibits discrimination against these individuals in employment. First civil right law for people with disabilities Ensures equal opportunity in: Employment State and local government service programs Places of accommodation Public and private transportation Telecommunication Prohibits: Denial of the right to participate Unequal or separate treatment Must make "reasonable" modifications to policies, practices, and procedures Must communicate with customers or clients who are deaf, hard of hearing, or have speech or vision impairments For explaining complex procedures, concepts, or treatment options, the facility must make reasonable accommodations for patients using "auxiliary aids and services" - Service providers may: Not deny service to a patient with a disability because the disability may be disturbing other patients Only ask questions that are necessary for treatment and care of the patient Only refer a patient with a disability to another facility for service if the patient seeks or requires treatment outside the referring facility's area of expertise - Public accommodations such as physician's offices and healthcare facilities must make "readily achievable" modifications. *Remove architectural barriers that impede access to patients or clients If removing barriers is not "readily achievable", the facility must take steps for providing "readily achievable alternatives"*

What is a Needs Assessment?

A planned process that identifies the reported needs of an individual or a group First step in health promotion planning The process of collecting and analyzing information to develop an understanding of the issues, resources, and constraints of populations A *process* which is perhaps the most critical part of program planning

Theory of Planned Behavior

ATTITUDES TOWARD BEHAVIOR Behavioral Beliefs, Evaluation of Behavioral Outcomes and Attitude Toward Behaviors - An individual's belief about a behavior (what will happen if a behavior is performed) plus his/her judgment about that outcome (positive or negative) make up the attitude toward the behavior which, in turn, impacts the intention to perform a behavior. The behavioral *intention*, then, influences the actual behavior. SUBJECTIVE NORM AND PERCIEVED BEHAVIORAL CONTROL *Subjective Norm* perceptions about whether others approve or disapprove of the behavior (normative belief) plus the degree to which he or she values their opinions (motivation to comply). *Perceived Behavioral Control* made up of control beliefs and perceived power perception that there are things that help or prevent a behavior are control beliefs weight that an individual gives those things determines negative or positive perception of behavioral control influences both the behavioral intention and the actual behavior

NALS Level 2 Marginal Literacy (27%)

Able to: Find intersection on street map Locate information in newspaper article Determine difference in price on tickets Cannot consistently: Use a bus schedule Identify information from a bar graph Write a brief letter of complaint Purpose: To provide specific information about Level 2. Individuals reading at level 2 can read simple materials, but have difficulty with words and numbers. Thus they struggle to decipher bus schedules or make sense of bar graphs. Level 2 includes tasks such as getting the information from the newspaper article, finding the intersection on the map. Concepts with words and numbers such as figuring out the bus schedule or the bar graph or even writing a simple letter explaining an error on a bill. All health care directions are words and numbers. Take one of our oldest directions "Take one teaspoon four times a day". How do you divide 24 by 4? Do you count night as day? Is this every 6 hours or every 31/2 hours while awake? Does it need to be equally divided? Could it be two in the morning and two at night? Or all 4 at once? Another example: "Take 2/3 of your insulin dosage before surgery." We should be translating this into the exact amount....e.g. if they normally take 15 units, they should take only 10 units before surgery.

Epidemiology of Tobacco Use: Summary

About one in five adults are current smokers; smoking prevalence varies by sociodemographic characteristics. Nearly half a million U.S. deaths are attributable to smoking annually. Smoking costs the U.S. $193 billion per year. Lifetime financial costs of smoking approaches one million US dollars for a heavy smoker. At any age, there are benefits to quitting smoking. The biggest opponent to tobacco control efforts is the tobacco industry. *Thus, it is clear that tobacco use is a significant public health problem. The morbidity and mortality associated with tobacco use can be curbed through effective tobacco prevention and cessation efforts.*

Addressing Health Literacy Improves

Access to information Access to care Ability to navigate institutions Ability to complete forms Ability to provide informed consent Ability to communicate with Professionals Provide information for diagnosis and assessment Make sure that directions and treatments are understood

Martin Marietta Example of Workforce Health Programs

Activity: Program to impact the 1 million dollars a year in low-back injuries. Began a back program that included back classes, fitness, stretching, flexibility, sports injuries, posture, etc. Results: net savings of a lot

General Electric Example of Workforce Health Programs

Activity: implemented employee fitness center Results: members of the fitness center reduced their medical costs by about 150 dollars

Actual vs Perceived Needs

Actual needs: needs reported and documented based on incidence and prevalence data. Perceived needs: needs reported by community members based on their subjective views. The more that is understood about *both* actual and perceived needs the more equipped health professionals will be to prioritize program goals.

2. Advise

Advise tobacco users to quit (clear, strong, personalized) "It's important that you quit as soon as possible, and I can help you." "Cutting down while you are ill is not enough." "Occasional or light smoking is still harmful." "I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan." It is the clinician's responsibility to assist patients in improving their health. Patients who use tobacco should be strongly advised to quit. At the very least, these patients should be advised to consider quitting. The message should be clear and strong, yet personalized and sensitive. The message must be delivered without judgment—or the clinician will likely waste that "teachable moment" and potentially alienate his or her patient. Tone and manner should convey a concern for the patient's well-being as well as a commitment to help him or her quit—when the patient is ready.

What do we know about health disparities?

African Americans have higher death rates than Whites for 12 of the 15 leading causes of death. African Americans and American Indians have higher age-specific death rates than Whites from birth through the retirement years. Hispanics have higher death rates than whites for diabetes, hypertension, liver cirrhosis and homicide. People of color get sick younger, have more severe illness and die sooner than whites.

Specific NA Steps: Step 11- Validate Prioritized Needs

After completing the "community puzzle," it is important to determine if the picture is accurate. It may be necessary to conduct more primary and secondary data collection to aid in validation. Develop networking opportunities with community and professional leaders.

Infectious Disease: Agent, Host, Environment (Epidemiological Triangle)

Agent most common agents in infectious disease are viruses, bacteria, fungi, and worms Host can be thought of as a person's internal environment Environment physical aspects (such as terrain, precipitation, and temperature) as well as social aspects (such as cultural characteristics)

Cancer

All cancers account for the second leading cause of death in the United States. Lung cancer is the most common cancer in the U.S.; 213,380 new cases were diagnosed in 2007 (ACS, 2007). Lung cancer, while not always easy to treat, is the most preventable.

Hookah

Also known as - Shisha, Narghile, Goza, Hubble bubble Tobacco flavored with fruit pulp, honey, and molasses Increasingly popular among young adults in coffee houses, bars, and lounges - In 2012, 18.3% of 12th graders and 25.7% of U.S. college students had smoked hookah in the past year Nicotine, tar and carbon monoxide levels comparable to or higher than those in cigarette smoke

Clove Cigarettes/Kreteks

Also known as Kreteks Mixture of tobacco and cloves Imported from Indonesia In 2012, an estimated 3.0% of 12th graders in the U.S. reported smoking kreteks in the past year Two times the tar and nicotine content of standard cigarettes

Compounds in Tobacco Smoke

An estimated 4,800 compounds in tobacco smoke, including 11 proven human carcinogens: Gases: - Carbon monoxide - Hydrogen cyanide - Ammonia - Benzene - Formaldehyde Particles: - Nicotine - Nitrosamines - Lead - Cadmium - Polonium-210 Note: nicotine itself does not cause cancer, it is the fact that tobacco is combustable that causes byproducts that are carcinogens. Nicotine is the addictive component of tobacco products, but it does not cause the ill health effects of tobacco use Tobacco smoke, which is inhaled either directly or as second-hand smoke, contains an estimated 4,800 compounds. The majority of the compounds are present in the particulate phase, suspended in tobacco smoke. Based on a classification system by the International Agency for Research on Cancer, cigarette smoke contains 11 known human carcinogens (Group I), 7 probable human carcinogens (Group 2A), and 49 animal carcinogens that possibly also are carcinogens in humans (Group 2B) (NCI, 2001). Examples of detrimental compounds (some of which are carcinogens) in tobacco smoke include the following: Carbon monoxide: automobile exhaust; binds to hemoglobin, inhibits respiration Hydrogen cyanide: gas chamber poison; highly ciliotoxic, inhibits lung clearance Ammonia: floor/toilet cleaning agent; irritation of respiratory tract Nicotine : addictive substance; toxic alkaloid Benzene: solvent, banned substance in organic chemistry labs; Group I carcinogen Nitrosamines: carcinogenic in animals and probably in humans; Group 2A and 2B carcinogens Lead: heavy metal, toxic to central nervous system; Group 2B carcinogen Cadmium: heavy metal found in rechargeable batteries; Group I carcinogen Hexavalent chromium: highlighted in the movie Erin Brockovich; Group I carcinogen Arsenic: pesticide; Group I carcinogen Polonium-210: radioactive agent; Group I carcinogen Formaldehyde: embalming fluid; Group 2B carcinogen Other substances in tobacco smoke (not listed above) with sufficient evidence to be classified as Group I carcinogens in humans include 2-naphthylamine, 4-aminobiphenyl, vinyl chloride, ethylene oxide, beryllium, and nickel.

What is an intervention strategy?

An intervention strategy is a plan of action for affecting a health-related problem. It is quite common to use multiple behavioral strategies in order to produce successful change. Applying theory: Different theories work in different situations Combinations of theories are often most effective

Definition of a Norm

An unspoken social rule or code about how people are supposed to behave or what they are supposed to believe

CDC's Target Areas for Immunity

Antimicrobial resistance Foodborne and waterborne diseases Vectorborne and zoonotic diseases Diseases transmitted through blood transfusions or blood products Chronic diseases caused by infectious agents Vaccine development and use Diseases of persons with impaired host defenses Diseases of pregnant women and newborns Diseases of travelers, immigrants, and refugees To accomplish these goals, objectives, and activities, CDC's "Preventing Emerging Infectious Diseases: A Strategy for the 21st Century" targets nine categories of problems that cause human suffering and place a burden on society: Antimicrobial resistance. The emergence of drug resistance in bacteria, parasites, viruses, and fungi is reversing advances of the previous 50 years. As the 21st century approaches, many important drug choices for the treatment of common infections are becoming increasingly limited, expensive, and, in some cases, nonexistent. Foodborne and waterborne diseases. Changes in the ways that food is processed and distributed are causing more multistate outbreaks of foodborne infections. In addition, a new group of waterborne pathogens has emerged that is unaffected by routine disinfection methods. Vectorborne and zoonotic diseases. Many emerging or reemerging diseases are acquired from animals or are transmitted by arthropods. Environmental changes can affect the incidence of these diseases by altering the habitats of disease vectors. Diseases transmitted through blood transfusions or blood products. Improvements in blood donor screening, serologic testing, and transfusion practices have made the U.S. blood supply one of the safest in the world, despite its size and complexity. However, because blood is a human tissue, it is a natural vehicle for transmitting infectious agents. Therefore, continued vigilance is needed to ensure the safety of the U.S. blood supply. Chronic diseases caused by infectious agents. Several chronic diseases once attributed to lifestyle or environmental factors (e.g., some forms of cancer, heart disease, and ulcers) might be caused or intensified by infectious agents. This new knowledge raises the possibility that certain chronic diseases might someday be treated with antimicrobial drugs or prevented by vaccines.

The Responsibility of Health Professionals and Smoking

As a final note, it is important to emphasize that it is inconsistent, and perhaps unethical, to provide health care and—at the same time—remain silent (or inactive) about a major health risk. Addressing tobacco use is an essential component of clinical care. Promoting tobacco cessation is, in itself, an important component of therapy—it has immediate payoff in terms of both health improvements and cost savings (Lightwood & Glantz, 1997). The primary goal of the Rx for Change: Clinician-Assisted Tobacco Cessation program is to provide current and future health professionals with the knowledge and skills necessary to make an impact on the incidence of tobacco-related disease in the U.S. and abroad. Clinicians can make a difference (Fiore et al., 2008).

Social History

Ask about education, reading, learning styles- be non-judgmental Use this discussion to open a space for the patient to talk about literacy issues Using the social history is a safe, nonjudgmental approach because it is one of many questions asked. We saw a good example in the video. After asking about occupation and education, the clinician added a question that would help the patient "open up" and discuss the issue if they so desired. She asked: "How happy are you with the way you read?"

3. Assess

Assess readiness to make a quit attempt After the clinician advises the patient to quit, the next step is to assess the patient's readiness, or willingness, to try to quit. Is the patient considering quitting in the next month? Or did he or she quit recently?

Phases of a Social Norms Campaign

Assessment or collection of data to inform the message Actual behavior Perceived behavior Selection of the normative message that will be distributed Testing the message with the target group to ensure it is well-received Selection of the mode in which the message will be delivered Amount, or dosage, of the message that will be delivered Evaluation of the effectiveness of the message

4. Assist

Assist with the quit attempt Not ready to quit: enhance motivation (the 5 R's) Ready to quit: design a treatment plan Recently quit: relapse prevention The patient's readiness to try to quit will define the next course of action, which is delivering an intervention tailored to his or her needs. By being a good listener and gathering appropriate information, the clinician can tailor the interventions effectively. A patient who is not ready to quit will receive a very different type of intervention than will one who is ready to quit in the upcoming weeks. For the patient who is not ready to quit, clinicians should apply the 5 R's (to be discussed later). If the patient is ready to quit (i.e., in the next 30 days), a treatment plan should be designed. Ideally, this should include including counseling and pharmacotherapy (if appropriate). The clinician could suggest that the patient enroll in a structured tobacco cessation program to increase the likelihood of quitting—this is particularly important for persons who are at high risk of relapse or for patients who are highly dependent, refractory smokers (i.e., having made multiple serious quit attempts). Other patient populations that might be particularly well suited for structured programs include adolescent smokers, pregnant smokers, and patients with coexisting psychiatric conditions. A patient who recently quit (i.e., in the past 6 months) will need continued support and encouragement, and reminders regarding the need to abstain from all tobacco use—even a puff. A patient who has been off of tobacco for more than 6 months typically is relatively stable but often needs to be reminded to remain vigilant for potential triggers for relapse.

What are the Social Determinants of Health?

Availability of resources to meet daily needs Social norms and attitudes, such as discrimination Exposure to crime, violence and social disorder Social support and social interactions Exposure to mass media and emerging technologies Socioeconomic conditions such as concentrated poverty Quality schools Transportation Public safety Residential segregation *Poor health outcomes are often made worse by the interaction between individuals and their social and physical environments*

What does shame-free communication look like?

Be curious, listen Ask before you advise Give the patient time to respond Take the patient's concern seriously Discuss how you can best help the patient care for themselves Ask patients how they want information communicated to them Be positive, hopeful, empowering Take a minute to look over these points....(give them about 10 seconds to look at the slide). These points sound very basic but it is not always easy to follow them. For example, taking the time to listen to the patient's concerns is something that can easily be overlooked in the rush of day-to-day appointments. The average patient actually talks for 90 seconds or less, when asked. Reference: Langewitz W, Benz M, Keller A, Kiss A, Ruttimanns, Wossmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002; 325: 682-3. Slowing down and giving the patient enough time to respond is very important to creating shame-free communication. It is also important to ask patients how they want information communicated.....Example: "How would you like to learn about mammograms?"

Results of HP 2010

Best: - Tobacco (taxes and restriction in public places) - mammogram rates - Helmet laws - Colorectal cancer screening Worst - Obesity - binge drinking - safe sex - mental health

Tobacco Dependence: a Two Part Problem

Between Physiological and Behavioral Treatment should address BOTH Smoking is both an addiction and a habit Tobacco dependence is a chronic condition that requires a two-prong approach for maximal treatment effectiveness (Fiore et al., 2008). Prolonged tobacco use of tobacco results in tobacco dependence, which is characterized as a physiological dependence (addiction to nicotine) and behavioral habit of using tobacco. Addiction can be treated with FDA-approved medications for smoking cessation, and the behavioral habit can be treated through behavior change programs, such as individualized counseling and group or online cessation programs. The Clinical Practice Guideline for treating tobacco use and dependence (Fiore et al., 2008), which summarizes more than 8,700 published articles, advocates the combination of behavioral counseling with pharmacotherapy in treating patients who smoke.

Epidemiology

Branch of medical science concerned with the incidence, distribution, and control of diseases that affect large numbers of people. *Study of the distribution and determinants of health-related states among specified populations and the application of that study to the control of health problems* Science and Core of Public Health

Why do we use theories and models?

Builds clarity in understanding targeted health behavior and environmental context. Directs program planning - why, what and how? Directs evaluation as integral part

Assessing Needs leads to more Effective Community Programs!

By assessing community needs, you will have: Learned more about your community and its most pressing health issues. Included community members and important stakeholders in the process. Mapped important resources and barriers. Created a list of priorities. Thought about health behavior and what influences people's decisions. Identified gaps between what exists and what ought to exist so that you can design a program to reduce those gaps. Become ready to begin the planning process!

To Improve the Health and Wellness of Persons with Disabilities: The Surgeon General's Call to Action 2005

Calls for: - Public knowledge and understanding about disability - Provider training and capacity to see and treat the whole person and not just a person's disability - Health and wellness promotion for persons with disabilities - Access to needed healthcare services for persons with disabilities

What can long-term unemployment lead to?

Can lead to: Poorer physical health Poorer mental health Greater usage of medical services Poorer social integration Loss of worth and self-confidence Less monetary resources Trans-generational effects Re-employment can reverse these changes Being out of work is not good for you. We know that about 10% claiming incapacity benefit have a mental health condition which developed whilst they were out of work. The knock on impact of this is on us all thorough the cost to the NHS and the economy. Getting people who can work, back to work as soon as possible benefits us all.

What do most Americans think make us healthy?

Can't talk about health equity without first talking about drivers of health When asked what drives our health, or what makes us healthy, two of the top 3 responses from Americans are health care/medical related Not entirely true

Joe Camel

Cartoon character logo for Camel cigarettes; teen smoking Camels rose sharply Analysis of tobacco-industry marketing campaigns has revealed that tobacco company advertising efforts intentionally targeted the youth market (Cummings et al., 2002; Ling & Glantz, 2002). As depicted in this slide, the widely popular R. J. Reynolds "Joe Camel" ad campaign, which ran between 1988 and 1997, was specifically developed to appeal to children and adolescents. During the first three years of the Joe Camel campaign, Camel's share of the under-18 cigarette market jumped from 0.5% to 32.8%, representing a $470 million increase in annual sales for RJR Nabisco (DiFranza et al., 1991). In a study of young children, more than 90% of 6 year olds were able to correctly matched Joe Camel with a picture of a cigarette, making him as well-known as Mickey Mouse; in comparison, only 67% of adults recognized Joe Camel (Fischer et al., 1991). A Cochrane Database Systematic Review concluded that exposure to tobacco advertising and promotion is associated with an increased likelihood that adolescents will start to smoke. This conclusion was based on the strength of this association, the consistency of findings across observational studies, temporality of the exposure versus smoking behavior, and a theoretical plausibility for the impact of advertising on smoking behavior (Lovato et al., 2003).

Smokeless Tobacco

Chewing tobacco - Looseleaf - Plug - Twist Snuff - Moist - Dry Smokeless tobacco is classified as either chewing tobacco or snuff (Hatsukami et al, 2007; USDHHS, 1986). Chewing tobacco is chewed or held in the cheek or lower lip. The following types of chewing tobacco are marketed in the U.S.: Looseleaf: consists of stripped and processed tobacco leaves that are stemmed, cut, and loosely packed to form small strips of shredded tobacco (depicted in slide). Most brands are sweetened and flavored with licorice. Generally available in a 3-ounce pouch. Users tuck a piece of tobacco ¾ to 1 inch in diameter in the back of the mouth between the gum and jaw and chew intermittently. Plug: made from tobacco leaves or fragments wrapped in fine tobacco and pressed into bricks (depicted in slide). Most plug tobacco is sweetened and flavored with licorice. Generally available in compressed bricks or blocks. Users chew or hold a piece inside cheek or lower lip. Twist: handmade from leaf tobacco treated with a tar-like tobacco leaf extract and twisted into strands (depicted in slide) that are dried. Usually contains no sweeteners or flavoring agents. Generally sold by the piece. Used in a manner similar to plug tobacco. Snuff has a much finer consistency than chewing tobacco and is held in place in the mouth without chewing. The following types of snuff are marketed in the U.S.: Moist snuff: consists of tobacco stems and leaves that are processed into fine particles, strips, or mini-sachets resembling tea bags (depicted in slide). Some products are flavored. Has moisture content of up to 50%. Available in cans and plastic containers. Users place a small amount (a "pinch") between the lip or cheek and gum (also known as dipping) and suck on the moist mass of tobacco for 30 minutes or longer. Because of increased surface area, finer cuts of tobacco result in more rapid absorption of nicotine. Dry snuff: consists of tobacco that is fermented and processed into a dry powdered form. Generally has a moisture content of less than 10%. Available in cans and glass containers. Used in a manner similar to moist snuff but also may be sniffed. Estimated 8.8 million users in the U.S. in 2013 (3.4%) - Adult males (6.5%) more likely than adult females (0.4%) to be current users - Prevalence highest among -- Young adults aged 18-25 years -- Residents of the Midwest and Southern U.S. -- Residents of nonmetropolitan areas Significant health risks - Numerous carcinogens - Nicotine exposure comparable to that of smokers, leading to -- Physical dependence -- Withdrawal symptoms after abstinence According to the U.S. Department of Health and Human Services (2014), in 2013 an estimated 9.0 million Americans aged 12 years or older (3.5%) had used smokeless tobacco in the past month. Males (6.7%) were more likely than females (0.3%) to be current users. The prevalence of smokeless tobacco use is highest among individuals aged 18-25 years, residents of the Midwest and Southern U.S. and nonmetropolitan areas. Users of smokeless tobacco products often believe this is a safe alternative to smoking cigarettes, because it is not inhaled. This is not true. Smokeless tobacco has high concentrations of numerous carcinogens, including nitrosamines, polycyclic aromatic hydrocarbons, and radioactive polonium-210, which are in direct contact with mucosal tissues for prolonged periods (Boffetta et al., 2008; USDHHS, 1986). Furthermore, regular smokeless tobacco users experience comparable exposure to nicotine and are as likely to develop physical dependence as are regular smokers (Ebbert, 2004).

Trends in Teen Smoking

Cigarette smoking among adolescents is a public health concern of utmost importance. In the U.S., experimentation with cigarettes and the development of regular smoking typically occur during adolescence. It is estimated that 5,753 persons became new smokers each day in 2013, with 50.5% of these persons being under the age of 18 years (the legal age for smoking) when they smoked their first cigarette (SAMSA, 2014). The average age at first cigarette use is 17.8 years (SAMSA, 2014). Because most youth who smoke at least monthly continue to smoke in adulthood, tobacco use trends among youth are a key indicator of the overall health trends for the U.S. During 1991-1997, the smoking prevalence (defined as one or more cigarettes in the 30 days before survey completion) among high school seniors increased to 36.5%. At that time, the prevalence was highest among whites (40.7%) and lowest among blacks (14.3%). This worrisome increasing trend highlighted a need for tobacco prevention and cessation programs focused on this age group. In 2013, an estimated 10.5% of 12th graders (12.7% of males and 8.1% of females) had smoked one or more cigarettes in the past 30 days (Johnston et al., 2016). Among 8th- and 10th-grade students in 2014, the overall 30-day point prevalence for cigarette smoking was 2.6% and 4.9%, respectively (Johnston et al., 2016). As can be seen in the graph, smoking among adolescents varies substantially by racial/ethnic groups.

Annual US Death Attributable to Smoking

Cigarette smoking is the primary known preventable cause of premature death in the U.S., with nearly one of every five deaths being smoking related (Danaei et al., 2009). This number surpasses the combined death toll due to alcohol, car accidents, suicides, homicides, HIV disease, and illicit drug use. Between 2005 and 200, more than 480,000 deaths annually were attributable to smoking. This slide delineates the percentage of smoking-attributable deaths, by disease 70% of smokers see a provider but only 37% get advice about smoking

Health Education Campaigns

Cliff Notes Version? - Minimal information -- "This is your brain on drugs" -- Just Say No! Scare Tactics & Manipulation -- "Red Pavement" -- Totaled car on high school lawn (MADD) -- Body bags for tobacco control ad (truth campaign) More health ed. history: - Peer education -- Drug abuse, HIV/AIDS, safe sex - "Health terrorism" -- Exercise campaigns -- Anti-smoking ads

Difference Between a Clinician and an Epidemiologist

Clinician: Patient diagnostician Investigations Diagnosis Therapy Cure Epidemiologist: Community diagnostician Investigations Predict trend Control Prevention

E-Cigs vs. Cigarettes

Clinicians want their patients who smoke (at last count, around 38 million in total[23]) to quit. The adverse effects of conventional cigarettes are well known, but little is known about electronic cigarettes (e-cigarettes). Early opinions about e-cigarettes were negative, because they contain nicotine as well cancer-causing chemicals in the aerosol emitted.[24] Outside of the United States, this view has evolved, and e-cigarettes are now marketed in some countries as smoking cessation aids. Recently, the United States appears to have reached a similar view on e-cigarettes.[25] As Dr Lin points out, "although the research into e-cigarettes still is fairly sparse and we are still trying to figure out the long-term effects, the consensus now is that if you are going to use one of them, choose e-cigarettes." Recognizing that the evidence supporting e-cigarettes as aids to help adults quit smoking is inconclusive,[25,26] Dr Lin believes that smokers who have tried to quit numerous other ways should try e-cigarettes. "Usually, you end up saying that they couldn't be any worse for you than what you are doing now," he admits. The main concern about e-cigarettes is whether nonsmokers who try them, particular young people, will move on to conventional cigarettes. Many studies have indicated that the use of e-cigarettes by young people increases the odds of smoking conventional cigarettes[25] (by double, according to recent data[27]). "Most adolescents I talk to have tried e-cigarettes, and many believe that they are less harmful than conventional cigarettes," Dr Lin notes. "If it becomes a widespread trend, we could end up with a whole generation of teenagers hooked on cigarettes, and that might not have happened if they hadn't had the e-cigarette option," he warns. "When we counsel adolescents, we must take the position that they shouldn't start smoking at all," he stresses.

Specific NA Steps: Step 12- Community Asset Inventory of Map

Community Asset Mapping: Identify local resources, organizations, or services that can help address the determined need.

Specific NA Steps: Step 9- Compare your Community to Others

Compare your data to data reported from other communities. For example, if you are collecting state data, compare the findings to national averages.

Important Screenshots

Comparison of Definitions Comparison of Health Inequities and Disparities Healthy People Definitions

Specific NA Steps: Step 13- Report Finding and Make Recommendations

Compile a final report and provide suggestions to address needs When writing the formal report be sure to include: - Introduction and community description - Methods of data collection - Data analysis - Findings - Implications/suggestions - Conclusion

Mortality Rates and Ratios

Crude mortality = Number of deaths in a selected year x 100,000 Number of people in population Infant mortality* = Number of infant deaths during a year x 1,000 Number of live births during a year Disease-specific mortality = Number of deaths due to a specific disease x 100,000 Number in population Age-specific mortality = Number of deaths in a selected specific age group x 100,000 Number of people in same age group *Infant deaths are defined as deaths among babies from 0 to 365 days old.

Understanding Cultural Norms

Culture is the shared values, beliefs, norms, and assumptions that guide (often unconsciously) the behavior of the members of the community The way things get done The way things are explained What is important to the community How decisions are made Develop insight into what members value Considers informal channels of communication Considers unplanned activities of members of the community

FDA Regulation of Tobacco Products

Currently, the FDA Center for Tobacco Control Products is responsible for regulation of: - Cigarettes - Cigarette tobacco - Roll-your-own tobacco - Smokeless tobacco - E-cigarettes * (ENDS: electronic nicotine delivery systems) The Family Smoking Prevention and Tobacco Control Act, also referred to as the Tobacco Control Act, gives the U.S. Food and Drug Administration (FDA) authority to regulate the manufacture, distribution, and marketing of tobacco products to protect public health. This Act, which was signed into law on June 22, 2009, aims to curb the trend of new users becoming addicted to tobacco before they are old enough to understand the associated risks. Specifically, the Tobacco Control Act (FDA, 2013a): Recognizes that virtually all new users of tobacco products are under 18 - the minimum legal age to purchase these products. Many new users will become addicted before they are old enough to understand the risks and ultimately will die too young of tobacco-related diseases. The Tobacco Control Act seeks to, among other things, prevent and reduce tobacco use by these young people. Recognizes that tobacco products are legal products available for adult use, prohibits false or misleading labeling and advertising for tobacco products and provides the tobacco industry with several mechanisms to submit an application to FDA for new products or tobacco products with modified risk claims. Gives FDA enforcement authority as well as a broad set of sanctions for violations of the law, and directs FDA to contract with states to assist FDA with retailer inspections. The list of products regulated by the FDA Center for Tobacco Products is shown on this slide. E-cigarettes that are marketed for therapeutic purposes are currently (as of April 2013) regulated by the FDA Center for Drug Evaluation Research. It is anticipated that the FDA Center for Tobacco Control Products will regulate other nicotine-containing products, including electronic cigarette products that do not make a therapeutic claim, in the future (FDA, 2013b).

What is Health Information?

Data related to a person's medical history, including symptoms, diagnoses, procedures, and outcomes

Mortality and Morbidity as Indicators of Health Status of a Population

Death is a unique and universal event, and as a final event, clearly defined Age at death and cause provide an instant depiction of health status In high mortality settings, information on trends of death (by causes) substantiate the progress of health programs As survival improves with modernization and populations age, mortality measures do not give an adequate picture of a population's health status Indicators of morbidity such as the prevalence of chronic diseases and disabilities become more important

Experimental Study Type

Deliberate manipulation of the cause is predictably followed by an alteration in the effect not due to chance

What is the purpose of a Needs Assessment?

Develop a level of awareness to accurately anticipate program strategies and how these activities will be received by the intended audience Identify resource availability Indicate the gaps and set goals Provide an opportunity to learn about any hidden agendas that may be present

Health Disparities (different from inequity)

Differences in the incidence and prevalence of health conditions and health status between groups, based on: - Race/ethnicity - Socioeconomic status - Sexual orientation - Gender - Disability status - Geographic location - Combination of these *Health disparities are the RESULT of health inequity*

Common Secondary Sources in Epi

Disease Registries—databases that list numbers of new cases of diseases Population Surveys—health-related data are collected systematically in the United States through: - U.S. Census -- occurs every 10 years in order to determine seats in the U.S. House of Representatives and funding of some health and social services programs - Vital Statistics -- vital life event are recorded and then counted

Things that need to be improved to help health literacy

Dosage charts Prescription labels

What are tobacco control strategies?

Efforts to curb the availability of tobacco products Efforts to curb the use of tobacco products Efforts to educate about the harms of tobacco products and the tobacco industry Efforts to reduce exposure to tobacco smoke in public places Monitoring of tobacco distribution and use Examination of tobacco industry practices Tobacco control involves efforts to curb the availability and use of tobacco products. It also involves efforts to prevent tobacco use, through such means as media campaigns, adoption of smoking prohibition restrictions in public places, and school- or community-based educational/cessation programs. Tobacco control also encompasses research into such approaches and programs. Types of activities that fall within the overall category of tobacco control include such diverse activities as: School- and community-based educational and prevention programs Counter-tobacco advertising campaigns Legal actions to obtain tobacco industry documents Publication and discussion of tobacco industry practices and tactics Examination and reporting of tobacco distribution, usage patterns, and youth access Development of community and government coalitions and initiatives to regulate tobacco products Publication and dissemination of scientific and technical information about tobacco Study and reporting of the economics of tobacco Enactment of worksite and community smoke-free tobacco regulation Enforcement of tobacco regulations, e.g., "sting" operations to identify retailers that sell to underage consumers Increasing the retail price of tobacco products Community-based, public treatment interventions such as smokers' helplines, quit-and-win contests Many other techniques that could be used to educate the population about the harms of tobacco

Risk Factors for Low Health Literacy

Elderly individuals 65 and older - Cognitive impairment may play a role Lower education level - 49% of people who never attended or did not complete high school had below basic HL Individuals who do not speak English. - 11 million adults in the United States are non-literate in English - Immigrants are at particular risk Lower socioeconomic status - Minorities and those living under the poverty line have decreased health literacy

A Tool to Reduce Disparities?

Eliminating persistent and growing health disparities requires a public health strategy that not only includes, but also goes beyond treating afflicted individuals. Attention must be paid to the three trajectory elements: Environment, Exposures and Behaviors, and Medical Care.

Strategies to Enhance Health Literarcy

Enhance assessment techniques Create a shame-free environment Improve interpersonal communication with patients Create and use patient-friendly written materials

Health Disparities Trajectory

Environment --> Exposures and Behaviors --> Medical Care --> Health Disparities Explanation: Root Factors, Compromised Social and Physical Environments --> Absorption of Toxins and Stressors, Risky Unhealthy Behaviors --> Unequal Access and Treatment --> Disparities in Health, Safety, and Mental Health

Why does Epi matter?

Epidemiological studies provide much valuable information to health educators. As a health professional you will need to know how to use a vast amount of epidemiological data. Epidemiology skills will be important in your (any) position in health care.

Cigars

Estimated 12.4 million cigar smokers in the U.S. in 2013 Tobacco content of cigars varies greatly One cigar can deliver enough nicotine to establish and maintain dependence Cigar smoking is not a safe alternative to cigarette smoking Very prone to leaving behind thirdhand smoke colleagues concluded that it is possible for one large cigar to contain as much tobacco as an entire pack of cigarettes and deliver enough nicotine to establish and maintain dependence (Henningfield et al., 1999).

What about just Intermittent smoking?

Even intermittent use has almost as bad health consequences *Smoking 1 cigarette/day: 40-50% of the additional risk associated with smoking 20 a day Smokers should aim to quit completely Compared to never smokers, men who smoke approximately one cigarette/day exhibit 48% higher risk of heart disease and a 25% higher risk of stroke (74% and 30%, respectively, when not adjusting for confounders). These estimates are higher among women, with a 57% increased risk for heart disease and 31% increased risk for stroke (119% and 46%, respectively, when not adjusting for confounders. Individuals who smoke approximately one cigarette/day exhibit an estimated 40-50% of the additional risk associated with smoking 20 cigarettes/day (coronary heart disease and stroke). Although reduced smoking can yield some benefits for cardiovascular health, the risk is not linear -- even low levels of smoking are significantly more harmful than one might expect (e.g., as much as half the risk of smoking 20 per day). We There is no safe level of smoking when it comes to cardiovascular disease. Patients who smoke should be encouraged to quit completely.

Evolving HP Foci

Every decade, HHS leverages scientific evidence and lessons learned from the past decade as well as up-to-date data, trends and innovation. Major risks to health and wellness Changing public health priorities Emerging issues related to health preparedness and prevention - US Communicable Disease Center -- Became CDC (by 1970) -- Then CDC (and Prevention) Healthy People 1990, 2000, 2010, 2020 - Increase life span - Eliminate disparities - Improve quality of life (2010) --> don't want people to live long, unhealthy lives

Foundational Principles of HP 2030

Explain the thinking that guides decisions about HP 2030 - Health and well-being of all people and communities are essential to a thriving, equitable society. - Promoting health and well-being and preventing disease are linked efforts that encompass physical, mental and social health dimensions. - Investing to achieve the full potential for health and well-being for all provides valuable benefits to society. - Achieving health and well-being requires eliminating health disparities, achieving health equity, and attaining health literacy. - Healthy physical, social, and economic environments strengthen the potential to achieve health and well-being. - Promoting and achieving the Nation's health and well-being is a shared responsibility that is distributed across the national, state, tribal, and community levels, including the public, private, and not-for-profit sectors. - Working to attain the full potential for health and well-being of the population is a component of decision-making and policy formulation across all sectors.

From Medical Care to Exposure and Behaviors (what are they I guess)

Exposures and behaviors are those characteristics which capture the risks of poor health, safety, and mental health outcomes such as exposure to environmental toxins risky or unhealthy behaviors, and experiencing chronic stressors associated with racism, poverty, or witnessing violence.

What is Health Risk?

Factors that raise the probability of adverse health outcomes HP 2020 will address risks not previously addressed as health risks - poverty, crime, employment, community planning. HP2030 - What will be added?

Socio-Ecological Model

Five Levels Individual Interpersonal Organizational Community Public Policy

The history of the tobacco industry

For decades, the tobacco industry publicly denied the addictive nature of nicotine and the negative health effects of tobacco. *April 14, 1994: Seven top executives of major tobacco companies state, under oath, that they believe nicotine is not addictive: http://www.jeffreywigand.com/7ceos.php* - Tobacco industry documents indicate otherwise - Documents available at http://legacy.library.ucsf.edu The cigarette is a heavily engineered product. Designed and marketed to maximize bioavailability of nicotine and addictive potential Profits over people For decades, the tobacco industry has publicly denied the addictive nature of nicotine and the negative health effects of tobacco. On April 14, 1994, the top executives of all the major tobacco companies stated, under oath, that they believe nicotine is not addictive. Yet tobacco industry documents, which are now available publicly on the Internet (http://legacy.library.ucsf.edu), suggest otherwise. The cigarette is a heavily-engineered product that was designed and marketed to maximize the bioavailability of nicotine and hence maximize its addictive potential. The tobacco industry is financially vested in selling its product and has taken affirmative steps to maximize profits and minimize anti-tobacco public health efforts. At times the industry has actively sought to disrupt particular public health programs and legislation, and other times it is simply trying to promote its own interests above the interests of the public health. An example of this is the development and marketing of "light" cigarettes.

The Shame of Low Literacy

From that video Mrs. Walker: "It paralyzes your every thought." Mr. Bowman: "This is your greatest fear." Mrs. Grigar: "I hide it....it drains you." Mr. Bell: "I blame them, they don't respect me." Fearful Anxious Angry Stupid Embarrassed Ashamed Suspicious, on guard Other emotions?

Shifts in Cause of Death

From: 1904 Pneumonia Tuberculosis Heart Disease Now: 2015 Heart Disease Cancer Lower Respiratory Disease Differ by age group too

Analytic Study Type

Further studies to determine the validity of a hypothesis concerning the occurrence of disease. To identify the cause of an event and to test their developing hypothesis Helpful to determine prevention strategies How was the population affected? Why was the population affected? Used when insight about various aspects of disease is available Rely on development of new data Why Evaluates the causality of associations

What is an E-Cig?

Generally similar in appearance to cigarettes, cigars, pipes, or pens Battery-operated devices that create a vapor for inhalation -vSimulates smoking but does not involve combustion of tobacco Also known as - E-cigarette - E-hookah, Hookah pen - Vapes, Vape pen, Vape pipe - Electronic nicotine delivery system (ENDS) Advertised as an alternative to cigarettes - Very little data showing that the use of E-Cigarettes help smokers quit or decrease use (Callahan-Lyon, 2014) "e-cigarettes" are battery-operated devices that generally contain cartridges filled with nicotine, flavor, and other chemicals. The electronic cigarette turns nicotine and other chemicals into a vapor that is inhaled by the user. These products, which are readily available online and in shopping malls, do not contain health warnings that are comparable to conventional cigarettes or FDA-approved nicotine replacement therapy products. They are also available in different flavors, such as chocolate and mint, which may appeal to youth. Public health experts are concerned that electronic cigarettes could increase nicotine addiction and tobacco use in young people (US FDA, 2009a). FDA laboratory analysis (US FDA, 2009b) has identified toxic chemicals such as diethylene glycol (used in antifreeze) and carcinogens (including nitrosamines). Cartridges labeled as containing "no nicotine" had low levels of nicotine in all cartridges tested, except one. Manufacturing quality control measures are virtually non-existent. On September 9, 2010, the FDA announced that it had taken enforcement action against five electronic cigarette companies for violations of the Federal Food, Drug, and Cosmetic Act, including unsubstantiated claims and poor manufacturing practices (US FDA, 2010). However, on April 25, 2011, FDA announced in a letter to stakeholders that it will not appeal the recent decision by the U.S. Court of Appeals for the D.C. Circuit in Sottera, Inc. v. Food & Drug Administration, stating that e-cigarettes and other products are not drugs/devices unless they are marketed for therapeutic purposes, but that products "made or derived from tobacco" can be regulated as "tobacco products" under the FD&C Act (US FDA, 2011). FDA is aware that certain products made or derived from tobacco, such as electronic cigarettes, are not currently subject to pre-market review requirements of the Family Smoking Prevention and Tobacco Control Act. On September 24, 2013, a letter from the National Association of Attorneys General was addressed to the commissioner of FDA urging the FDA to regulate e-cigarettes, especially the advertising of the products to youth. In the letter, attorneys general argued that FDA has the authority to regulate electronic cigarettes as "tobacco products" under the Tobacco Control Act since they are products "made or derived from tobacco" that are not a "drug," "device," or combination product. Writers of the letter cited Sottera, Inc. v. Food & Drug Administration, 627 F.3d 891 (D.C. Cir. 2010) as support to further the contention that e-cigarettes are "made or derived from tobacco" and can be regulated as "tobacco products" under the Tobacco Control Act. The letter concluded with a message to FDA urging the agency to ensure all tobacco products are tested and regulated to ensure that companies do not continue to advertise to youth.

HP 2020 Misconceptions about Disability

HP 2020 Misconceptions Four key misconceptions about disability status: Disability is associated with poor health status Public health should focus solely on preventing disabling conditions No standard definition of disability is needed for public health purposes The genesis of disability is not impacted by the environment

What does HRSA run?

Health Centers Ryan White HIV/AIDS Program National Health Services Corps Workforce Training Maternal and Child Health Rural Health Programs Federal organ procurement system Poison Control Centers Low drug cost program

HRSA and its Mission

Health Resources and Services Administration Mission: to improve health and achieve health equity through access to quality services, a skilled health workforce and innovative programs All about workforce and healthcare accessibility (would be in charge of community clinics)

Definition of Health Behavior

Health behavior is the activity (actions) undertaken by individuals for the purpose of maintaining or enhancing their health, preventing health problems, or achieving a positive body image. It is not limited to healthy people trying to stay healthy, but also includes the physically handicapped and persons with chronic diseases who seek to control, minimize, or contain their affliction through positive forms of health behavior, such as diet, exercise, and avoiding smoking.

Definition of Health Education

Health education is any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes.

Definition of Health

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or immunity

Definition of Health Policy

Health policy refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. An explicit health policy can achieve several things: it defines a vision for the future which in turn helps to establish targets and points of reference for the short and medium term. It outlines priorities and the expected roles of different groups; and it builds consensus and informs people.

Health Promotion vs. Disease Prevention

Health promotion and disease prevention programs focus on keeping people healthy. Health promotion programs aim to engage and empower individuals and communities to choose healthy behaviors, and make changes that reduce the risk of developing chronic diseases and other morbidities. Disease prevention differs from health promotion because it focuses on specific efforts aimed at reducing the development and severity of chronic diseases and other morbidities.

What is Health Promotion?

Health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behavior towards a wide range of social and environmental interventions

Health Assumptions (But Good I guess?)

Health status can be changed Strategies can be developed for problems Health is affected by a variety of factors Genetics, environment, health care system Changing behavior and altering lifestyle can positively (or negatively) affect health status Individuals can be taught to assume responsibility for their health Public health is multidisciplinary aimed at reducing preventable morbidity and premature mortality, and promoting higher QoL.

History of Healthy People

Healthy People 2030 is the fifth edition of Healthy People. It aims at new challenges and builds on lessons learned from its first 4 decades. The initiative began in 1979, when Surgeon General Julius Richmond issued a landmark report entitled, Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. This report focused on reducing preventable death and injury. It included ambitious, quantifiable objectives to achieve national health promotion and disease prevention goals for the United States within a 10-year period (by 1990). The report was followed in later decades by the release of updated, 10-year Healthy People goals and objectives (Healthy People 2000, Healthy People 2010, and Healthy People 2020

Examples of Health Centers

Healthy Start Ryan White HIV/AIDS Program Core Services Outpatient ambulatory/medical Early intervention (Part A & B) Home health care Home/community-based services Medical case management Substance abuse: outpatient Support Services Case management (nonmedical) Pediatric Assessment/ early intervention Emergency financial assistance Food bank/home delivered meals Health education/risk reduction Housing services Legal services Medical transportation services Outreach services Permanency planning The Everyone Project American Academy of Family Physicians (AAFP) aims to transform health care to achieve optimal health for everyone. The EveryONE Project focuses on providing family physicians and their practice teams with education and resources, advocating for health equity, promoting workforce diversity, and collaborating with other disciplines and organizations to advance health equity. *"The health of the individual is almost inseparable from the health of the larger community. And the health of each community and territory determines the overall health status of the Nation" *

Community Focused Assessment

Identifies capacities, skills, assets, or contributions that can be provided by individuals, associations, organizations, or institutions.

Low Health Literacy Statistics

Impacts 1:3 people living in the U.S.? Does not discriminate? Costs $58 billion a year? Can't be diagnosed or observed? Only 12% are considered to be proficient

Heart Disease

Impacts as a chronic noninfectious disease. Most is preventable. The category "heart disease" encompasses over 20 different conditions that make it difficult for the heart to function (CDC, 2007).

Bidis

Imported from India Resemble marijuana joints Available in candy flavors In 2010, an estimated 1.4% of 12th graders in the U.S. reported smoking bidis in the past year Deliver 3-fold higher levels of carbon monoxide and nicotine and 5-fold higher levels of tar when compared to standard cigarettes

National Academies Report States that:

Improving health literacy is essential for effective self-management and collaborative care Health literacy strategies important at micro and macro level - Micro= where patients and professionals interact - Macro= where population health is the target

Smoking Prevalence by Education

In 2017, the prevalence of current smoking1 in the U.S. was highest among adults (aged 25 years or older) who had received a General Educational Development (GED) diploma (36.8%). Persons with a graduate degree (masters, professional, or doctorate) had the lowest prevalence (4.1%) (CDC, 2018). Also notable is the fact that the prevalence of adult smoking is inversely associated with annual income. The persons who smoke the most tend to be the ones who can least afford to smoke. The smoking prevalence is 10.4% for persons aged 18-24; 16.1% for persons aged 25-44; 16.5% for persons aged 45-64; and 8.2% for persons at least 65 years of age (CDC, 2018). Persons with a self-reported sexual orientation of lesbian/gay/bisexual exhibit a smoking prevalence of 20.3%, compared to 13.7% among heterosexual persons (CDC, 2018). 1Current smokers: persons who reported having smoked 100 or more cigarettes during their lifetime and who smoked every day or some days at the time of the interview.

"The Cost of a Long Life" in US

In a recent report the US 32nd in the world in life expectancy and ranked third in total expenditures ho health care as a percentage of GDP (HIA Report 2011) BUT- even though the US spends the most, the US is outranked by many other countries which spend less , as you can see here Explain legend Chart shows top 30 countries in the world in terms of life expectancy Highlight bubbles Despite the wide gaps, higher spending on health care does not necessarily prolong lives. In 2000, the United States spent more on health care than any other country in the world: an average of $ 4,500 per person. Switzerland was second highest, at $3,300 or 71% of the US. Nevertheless, average US life expectancy ranks 27th in the world, at 77 years. Many countries achieve higher life expectancy rates with significantly lower spending. The chart below shows the top 30 countries in the world ranked by life expectancy. The red line indicates per-capita health expenditure (right axis), and shows that many countries outperform the US with approximately half the spending. The chart (right) also highlights the sharp contrast between the US and Cuba. With a life expectancy of 76.9 years, Cuba ranks 28th in the world, just behind the US. However, its spending per person on health care is one of the lowest in the world, at $186, or about 1/25 the spending of the United States. There are other cases where high life expectancies are achieved with low spending on health care. The scattergraph (below) shows the relation between per-capita health care expenditure and average life expectancy for 2000. Countries with higher spending generally have longer life expectancy rates, but there are also many countries that perform nearly as well with much lower spending. One reason for the discrepancy between spending and longevity is that these numbers are average life expectancies and per-capita spending rates, which mask inequalities. For example, the US Health and Human Services department found that people with lower incomes and less education tended to die younger. Life expectancy also varied by ethnicity. In 1998 life expectancy among white Americans was 76.8 years, while African Americans lived an average of 70.2 years. (See Intracountry Inequality). Another reason some countries achieve high life expectancy with low health spending is that clean drinking water and preventive health care can be provided with little spending. If there is near universal clean water and preventive care, life expectancy rates can be high. In the US, however, nearly 40 million Americans lack basic health insurance, and are therefore less likely to receive preventive care. In contrast, Cuba has universal health care and one of the highest doctor-to-patient ratios in the world (See Physicians). Although Cuba has limited resources and many economic problems, it has made health care a priority. It is not alone. Sri Lanka, China and the Indian State of Kerala are considered "low-income, high well-being" countries, which have adopted policies that not only reduce inequality but also increase overall health and well-being. The results of these policy priorities are significant, and can be measured in survival indicators, such as average life expectancy.

Financial Impact of Smoking per person

In addition to the many health benefits of quitting, there are financial benefits associated with quitting. The financial costs of tobacco use can be substantial to a smoker, particularly when costs are accrued over a lifetime. What three levels of smokers who buy cigarettes every day for 50 years at $6.16 pack (average national cost; Campaign for Tobacco-Free Kids, 2014) will have if they instead bank their cigarette money each month:1 1 pack a day: $112,785 2 packs a day: $225,570 3 packs a day: $338,355 *The cost of smoking is $2,248 per year for a pack-a-day smoker*.

Obesity

In an increasingly competitive global economy, only the healthiest businesses will prosper. Companies that invest to support employees' health will be fitter to survive. USA has highest rate of obesity It is likely that by 2025 40% of adults will be obese, and the number of people living and working with chronic conditions will rise steadily, affecting morale, competitiveness, and profitability.

Indoor Air Pollution caused by E-Cigs

In many localities, smoking bans have been expanded to include smoke emitted from electronic nicotine delivery devices. The long-term safety of second-hand exposure to e-cigarette aerosols is not known E-cigarettes are not emission-free During vaping sessions, compounds and particles emitted into the indoor air Levels of most substances lower than conventional cigarettes Long-term safety of second-hand exposure to e-cigarette aerosols is unknown

Why should we care about health equity?

Inequities decrease opportunities for people to be healthy on the basis of social factors (Moral) Inequities affect everyone - Spillover effects: infectious diseases, consequences of alcohol and drug misuse, occurrence of violence and crime, etc. Inequities are avoidable/preventable Interventions to reduce inequities are promising and likely cost effective "the health of the individual is almost inseparable from the health of the larger community and... the health of every community in every State and territory determines the overall health status of the Nation" How can a neighborhood affect health? Safe places to exercise Access to healthy food Exposure to targeted advertising of harmful substances Social networks & support Norms, role models, peer pressure Fear, anxiety, stress, despair Violence and fear Quality of schools

Cigarette Prices and Sales

It is well established that increases in the retail price of cigarettes leads to reduced initiation among adolescents, prompts quit attempts among current smokers, and reduces the average cigarette consumption among individuals who continue to smoke (Institute of Medicine, 2007). This slide demonstrates the inverse relationship between cigarette pricing and sales of tobacco products (Chaloupka, 2015; CDC, 2010). According a national Task Force commissioned by the Centers for Disease Control and Prevention, a 20% increase in the tobacco unit price would yield a 3.6% reduction in the prevalence of tobacco use, a 10.4% reduction in tobacco product consumption, and an 8.6% reduction in initiation of tobacco use among youth (Task Force on Community Preventive Services, 2014).

CDC Priorities for Immunity

Leading causes of death Years of potential life lost Economic costs to society Quality of life impacts

Social Determinants of Health Definition

Life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education and health care, whose distribution across populations effectively determines length and quality of life.

An Effective Marketing Strategy: "Light Cigarettes

Like Marlboro and Marlboro lights --> the difference is an extra row of ventilation holes But basically there is a way around it that smokers do sub-consciously As smokers became more concerned about the negative health consequences of smoking, the tobacco industry created "mild," "light," and "ultra-light" cigarettes. These products incorporate ventilation holes on the cigarette filters in order to "reduce" the nicotine and tar yields as measured by the FTC machine-test method. During inhalation, room air is drawn through the ventilation holes into the smoke stream, diluting the amount of smoke in each puff. When "light" or "ultra-light" cigarettes are tested using a smoking machine, the yields of tar, nicotine, and carbon monoxide are significantly reduced. However, smokers do not smoke cigarettes in the same manner that the machine does. Smokers easily obstruct the ventilation holes with their lips or fingers, thereby inhaling higher amounts of tar and nicotine than might be expected based on the reported product-yield rating (machine-test yields). The actual yield of tar and nicotine for the smoker, however, might be similar or greater—depending on the smoking technique. The tobacco industry knows this but continues to market the products as if they are safer alternatives. These products often appeal to smokers who are health conscious or are thinking about quitting. However, data suggest smokers tend to compensate for reduced nicotine delivery by smoking more cigarettes per day or by smoking 'light' cigarettes more intensely. As a result, these products do not significantly reduce exposure to nicotine or toxins in tobacco smoke including carbon monoxide and carcinogens (Benowitz et al., 2005). The 2004 Surgeon General Report on the Health Consequences of Smoking concluded that "smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health" (USDHHS, 2004). This image, courtesy of Dr. Richard D. Hurt, director of the Mayo Clinic Nicotine Dependence Center - Research Program, illustrates the difference between Marlboro and Marlboro Lights. As can be appreciated from the photo, the products have cosmetic differences (white vs. brown filter-tip paper color) and an extra row of ventilation holes is found in the light version. When tested by the smoking machine, the tar and nicotine yields for Marlboro are 15 mg and 1.1 mg per cigarette, respectively. The corresponding tar and nicotine yields for Marlboro Lights are 10 mg and 0.8 mg per cigarette, respectively (FTC, 2000).

Health Communication Impacts Health Literacy

Literacy demands of most printed health materials exceed the reading abilities of the average American adult. Up to 25% of the American population has difficulty with everyday reading tasks. It's essential to develop materials for those with less than a 6th grade reading level.

Health Center Model

Located in or serve a high need community Governed by a community board Provide comprehensive primary care services Provide enabling services: case management referrals translation/interpretation transportation eligibility assistance health education health literacy outreach Provide services available to all Meet other performance and accountability requirements

Economic Impact of Low Health Literacy

Low health literacy costs the United States an estimated $106 billion to $238 billion annually Likely due to: • Higher usage of emergency services • More hospitalizations as a result of preventable illnesses • Patients seeking care after their disease has worsened rather than early on, which may be more expensive THE COST = $50 BILLION or more PER YEAR (based on 1998 dollars), attributable to low literacy alone. Primary source of higher health care expenditures for persons with low health literacy is longer hospital stays. Other factors include medication errors, excess hospitalizations, more use of the emergency department and higher level of illness. Who pays for all this? We all do.

Herd Immunity

Low- low immunization levels fall short of protecting individuals within a group High- a high level of immunization within the group affords a good level of protection to most of the individuals within the group think about diagram with blue yellow and red people, it makes sense Like Colds would have no herd immunity, but influenza would

Forms of Tobacco

Many forms of tobacco are available in the U.S.: Cigarettes Smokeless tobacco (also called "spit tobacco"; includes chewing tobacco and oral snuff) Pipes Cigars Clove cigarettes Bidis Hookah (waterpipe smoking), also called shisha, narghile, goza, hubble bubble Electronic cigarettes ("e-cigarettes") - these are devices that deliver nicotine and are not a form of tobacco. Also referred to as "electronic nicotine delivery systems, or ENDS.

Example of Psoriasis and Health Literacy

Many patients don't even fill their prescription because they think it is a condition they can just live with Highly motivated patients - In a clinical trial - Being paid to put on the product - Who are told they are being monitored - And who are filling out logs - They do not use the medication and they lie about it Imagine how much less compliant are patients are with their topicals

Limitations on Tobacco Control

Many tobacco users believe they have a legal and ethical right to use tobacco if they choose to do so. Even the most effective strategies do not reach all tobacco users: - The least dependent tobacco users are typically the first to reduce or quit tobacco use in response to tobacco control efforts. - The most dependent users might never quit. Some members of the tobacco control movement view tobacco as if it were the equivalent of the smallpox virus: something to be eliminated from the face of the earth. Others take a more reasoned approach to tobacco control and recognize that even the most effective combinations of tobacco control strategies will not curtail all tobacco use. Many tobacco users believe that they have a legal and ethical right to use tobacco if they choose to do so. However, in the U.S. there is no constitutional right to smoke. Although legal, smoking—like other behaviors such as making noise, owning pets, and driving a car—can be highly regulated. So far, few countries in the contemporary world have made tobacco completely illegal. Most developed countries are coming to adopt a strategy of controlling tobacco (with the possibility of reducing its harmfulness), rather than attempting to eliminate it completely. It appears likely that widespread bans on tobacco will be implemented slowly worldwide. Research has shown that those who are least addicted and who use smaller amounts of tobacco respond first to tobacco control and treatment availability, while those who use more tobacco and are more dependent on tobacco tend to continue to use. Thus the hard-core tobacco users may be largely unaffected by even the most vigorous tobacco control efforts (Fagerström et al., 1996). This situation also necessitates the availability of intensive treatment environments for those who are unable to quit using tobacco without extensive help.

Specific NA Steps: Step 10- Prioritize Needs

McKenzie, Neiger, and Smeltzer suggest asking these four questions: 1. What is the most pressing need? 2. Are resources adequate to deal with the problem? 3. Can the problem best be solved by a health promotion intervention, or could it be handled better through administration, Policy change, politics, or changes in the economy? 4. Can the problem be solved in a reasonable amount of time?

Mortality

Means death Crude mortality rate is computed by dividing the number of deaths in a selected year by the number of people in the population and multiplying by 100,000. Creates a perspective on the impact of an epidemic in a community. Leading Causes of Mortality - Tobacco - Physical inactivity - Poor diet

Morbidity

Means illness Causes of morbidity have shifted over time Infectious diseases such as tuberculosis (TB), pneumonia, and gastroenteritis were more common causes of death in the early 1900s than were noninfectious diseases (Friis & Sellers, 1999) Today, noninfectious diseases, like heart disease, cancer and stroke, are the most common causes of death (National Center for Health Statistics, 2007)

If you have low health literacy, you will likely have problems with:

Medications Appointment Slips Informed consent Discharge instructions Health education materials Insurance applications Purpose: To identify problems that result from inadequate health literacy. As you can imagine, a constellation of reading and numerical skills are required to function in the health care environment. This includes: Reading prescription bottles Figuring out appointment slips (one study found that 26% of patients could not read their appointment slips). Understanding informed consents (Informed consent language is usually at the 12th-17th grade level. The average American reads at an 8th grade level.) Understanding discharge instructions Following diagnostic test instructions Reading health education materials (Most are written at 12th grade or above. It is very difficult to simplify complex ideas. See the manual for more information.) Completing health insurance applications Transition: And these problems are compounded in a health care system that has changed dramatically over the last 35 years.......

Tertiary Prevention

Minimizing the effects of disease and disability by surveillance and maintenance activities aimed at preventing complications and deterioration Focus on rehabilitation to help people attain and retain an optimal level of functioning regardless of the disabling condition

5. Arrange

More sessions with doctor, higher estimated quit rate The clinician should make certain to arrange for follow-up care and patient monitoring. With each contact, it is important to document the counseling session. These records can provide a starting point for subsequent discussions. Follow-up visits can be arranged in several ways. For example, the clinician can do the following: "Check in" with the patient when he or she next returns. Schedule specific follow-up visits to discuss tobacco cessation. Invite the patient to enroll in a tobacco cessation group with which the clinician is affiliated, or provide a referral to the tobacco quitline (1-800-QUIT NOW). With prior approval, call the patient at home to see how he or she is progressing. (If a message is left, the clinician should not indicate that he or she is calling regarding a quit attempt—this might be private information that the patient does not want others to hear. Be sure to comply with HIPAA regulations.) Document key dates (e.g., quit dates, tobacco-free anniversaries); acknowledge important milestones. The best approach for spacing the counseling sessions (i.e., the number of days or weeks over which treatment is spread) is not known (Fiore et al., 2008), but in general follow-up contact should be scheduled within the first week after the quit date. The next follow-up is recommended within the first month. Further follow-up contact should be scheduled as needed or indicated. During the follow-up contacts, the patient should be congratulated for success. If tobacco use has occurred, the circumstances should be reviewed and a commitment sought to return to total abstinence. The patient should be reminded that lapses (slips) occur as part of the normal learning process and should be viewed as such. Pharmacotherapy use should be assessed, including adherence with the regimen and side effects experienced. When appropriate, referral to more intensive treatment should be considered. According to the Clinical Practice Guideline, multiple patient contacts are associated with higher quit rates (Fiore et al., 2008; p. 86). The estimated abstinence rates, based on number of treatment sessions (i.e., counseling contact sessions) are presented in this slide. Even brief interventions (1-3 minutes) can increase patients' odds of quitting (odds ratio, 1.4; 95% CI, 1.1-1.8), increasing abstinence rates from 11.0% with no counseling to 14.4% with counseling. More intensive interventions (greater length of session, greater total amount of contact time, and greater number of sessions), however, are clearly associated with a higher odds of quitting (Fiore et al., 2008; pp. 83-86). Yet in the absence of time or expertise, clinicians should, at a minimum ask patients about tobacco use, advise them to quit, and provide information about other resources for quitting, such as the tobacco quitline (1-800-QUIT NOW) or local programs.

Why is health literacy a multidimensional issue?

More than just a reading problem There is a numeric component Cultural relevance is a large component Involves understanding so an individual can take an active role in managing their own health

Contributing Factors to a Health Problem

Motivators—factors motivating a person to take action Enablers—factors enabling a person to take action Rewards—factors rewarding a person's behavior

What is Healthy People

National effort that sets goals and objectives to improve the health and well-being of people in the US National Preventive initiative that focuses on improving the health of Americans by providing a comprehensive set of diseases prevention and health promotion goals and objectives with target dates

Physical Determinants of Health

Natural environments Built environments Worksites, schools and recreational settings Housing, homes and neighborhoods Exposure to toxic substances Physical barriers Aesthetic elements: lighting, trees, benches *Poor health outcomes are often made worse by the interaction between individuals and their social and physical environments*

E-Cig Research

Not proven superior to placebo in helping smokers quit. Propellants may break down in aerosols to form carcinogens (Chang & Barry, 2015) May produce vapors (secondhand vapors) Young adolescents that use e-cigs more likely to use combustible tobacco during the ensuing year (Leventhal, 2015) Healthcare needs to impress teens of potential dangers (Rigotti, 2015)

Tobacco Industry Tactics Target Kids

One of the tobacco industry's new tactics in targeting kids is the introduction of candy-flavored cigarettes and smokeless tobacco.

Public Health Core Sciences

PUBLIC HEALTH - Epidemiology - Laboratory - Informatics - Surveillance - Prevention Effectiveness

How to Relate to and Communicate With and About People with Disabilities

People first language (not say retarded, or suffers from, etc) Recognize the individuality, equality, and dignity of people - no group designations such as "the blind", "the retarded", or "the disabled" Show respect and courtesy If you offer assistance, wait until the offer is accepted Treat adults as adults Relax When unsure of what to do, don't be afraid to ask questions

Cycle of Misperceived Norms

People have to infer what the norms are in each environment BUT: people often misperceive the true norms of an environment AND: misperceived norms are as powerful as actual norms in influencing behavior ex: advertising examples (the "bad girl" and the alcohol) Lots of misperceptions in the media about college drinking games More people think others are drinking on college campuses

Health Consequences of Smokeless Tobacco

Periodontal effects - Gingival recession - Bone attachment loss - Dental caries Oral leukoplakia Cancer - Oral cancer - Pharyngeal cancer

Five Types of Wellness

Physical Intellectual Emotional Spiritual Social

Planning Needs Assessment

Pick your target population, also called target audience or intended audience/population Based on needs of a particular city/neighborhood/community/campus/organization Programs not interchangeable between organizations Must consider culture What might you need to do? Quantitative data -many sources Interviews Surveys - focused Focus groups Policies Review of literature Scope of problem Impacts of problem Best practices Requires you to put meaning to data and importance of data

Determinants of Health

Policymakers Social factors Health Services Individual Behavior biology and genetics

E-Cig Components

Power source - Rechargeable or disposable battery Cartridge containing liquid solution - Propylene glycol - Glycerin - Flavorings (tobacco, fruit, chocolate, mint, cola, candy, etc.) - Nicotine (0-36 mg/mL) Electronic atomizer/vaporizer Heating element vaporizes liquid at temperatures 65-120 °C

Primary Prevention

Precedes disease or dysfunction Purpose is to decrease the vulnerability of the individual or population to disease or dysfunction Health promotion activities Includes health education about risk factors Advocating for health policies that promote health Strategies - Education - Behaviors to avoid disease - Immunization - Policies

E-Cigs- Current Trends and Evidence

Predominantly used by smokers and smokers who are considering quitting Used as an alternative to cigarette smoking and as an aid for cessation - Perceived as less harmful than conventional cigarettes Use is increasing among adolescents and young adults Currently, e-cigarettes are used by smokers as well as smokers who are considering quitting. For some, it is an alternative to cigarette smoking and/or as an aid for cessation. E-cigarettes are often perceived as less harmful than smoking conventional cigarettes. It is of particular concern, among the public health community, that its use is increasing among adolescents and young adults. Can reduce the desire (craving) to smoke cigarettes and alleviate nicotine withdrawal symptoms Some smokers reduce the number of cigarettes smoked or quit smoking as a result of using e-cigarettes Have not been proven effective as an aid or sustained smoking cessation Long-term safety and efficacy data are lacking

Epidemiology Terms Summary

Prevalence - number of persons with disease (either raw number or a percentage of population at risk) Incidence - number of new cases during a defined period of time (usually one year) Lifetime prevalence - percentage of population with disease over the course of their lifetime

Pipe Tobacco

Prevalence of pipe smoking in the U.S. is less than 1% Pipe smokers have an increased risk of death due to: - Cancer (lung, oral cavity, esophagus, larynx) - Chronic obstructive pulmonary disease Risk of smoking tobacco-related death: cigarettes > pipes ≈ cigars In 2013, 0.9% of Americans aged 12 or older were current (past month) pipe smokers (USDHHS, 2014). Compared to never-smokers, pipe smokers have an increased risk of death from lung, oral, esophageal, and laryngeal cancer and chronic obstructive pulmonary disease (Henley et al., 2004). The risk of tobacco-related mortality among pipe smokers is lower than that observed in cigarette smokers and comparable to that found among cigar smokers (Henley et al., 2004). These differences might result from the tendency of pipe and cigar smokers to smoke less and generally to inhale less deeply than do cigarette smokers.

How do smoke-free policies save lives

Prevent heart attacks - Up to 17% average reduction in heart attack hospitalizations in places that enact smoke-free laws Help motivate smokers to quit Worker safety issue - not "personal nuisance" - All workers deserve equal protection - Only way to protect non-smokers from secondhand smoke Smoke-free workplace laws don't hurt business No trade-off between health and economics

Types of Data to Collect

Primary data is information from its original source - Data-collection methods include individual or group assessments - Examples: focus groups, photographs, survey responses Secondary data is information that is not from a first-hand source - Collecting data from secondary resources can help develop and refine primary data collection methods - Examples: county health report, hospital discharge data, national databases

Prevention Continuum (Review of Levels)

Primary prevention is a systematic process that promotes safe and healthy environments and behaviors, reducing the likelihood or frequency of an incident, injury, or condition occurring. Primary prevention is distinguished from secondary prevention because it explicitly focuses on action before there are symptoms. Secondary prevention relies on symptoms to determine action, focusing on the more immediate responses after symptoms. Tertiary prevention focuses on longer term responses to ameliorate future negative consequences.

Populations and Program Recipients

Program recipients (intended audience or target population) are those for whom a health promotion program is designed. Target audiences may be all or part of a population

Potential Health Risks of Electronic Cigarettes

Propylene glycol may cause respiratory irritation and increase the risk for asthma Glycerin may cause lipoid pneumonia on inhalation Nicotine is highly addictive and can be harmful - Refill cartridges with high concentrations of nicotine are a poisoning risk, especially in children Carcinogenic substances are found in some aerosols Use of e-cigarettes leads to emission of propylene glycol, particles, nicotine, and carcinogens into indoor air - Long-term safety of second hand exposure to e-cigarette aerosols is unknown

Guiding Principles for Health Literacy

Provide easy-to-understand information for ALL patients. Ensure the environment is patient-friendly and shame-free for ALL patients. All patients, not just those with low health literacy, will benefit from these guidelines.

ACA Community Requirement

Provisions of the Patient Protection and Affordable Care Act require each non-profit health care facility in the United States to conduct a community health needs assessment (CHNA) and adopt an implementation strategy to meet identified community health needs, In conducting the CHNA, non-profit hospitals are required to take into account input from persons who represent the broad interests of the community served, including those with special knowledge of or expertise in public health."

What is Public Health?

Public health is the science and art of protecting and improving the health of communities through education, promotion of healthy lifestyles, and research for disease and injury prevention. Public health helps improve the health and well-being of people in local communities and across our nation. Public health helps people who are less fortunate to achieve a healthier lifestyle. Public health works to prevent health problems before they occur. Public health professionals achieve true job satisfaction by knowing they are making the world a better place. Improving health is a crossing boundary issue- meaning all disciplines must come together Public health protects and improves the health of families, communities, and populations, locally and globally Pays attention to aggregate people!

NALS Level 1 (National Assessment of Adult Literacy) Inadequate Literacy 21%

Purpose: To provide more specific information about Level 1. This level person would have inadequate literacy to function in society. Individuals reading at level 1 cannot read well enough to read an article on the front page of a newspaper. They can sound out each word and tell you that this is an article about, say, Germany, or President Bush, but not what is being said about them. They could not give you the "gist" of the content of the article. They usually (with 80% reliability) can sign their name and total a bank deposit entry They usually (with 80% reliability) cannot use a bus schedule, enter information on a social security application or total costs on an order form.

Specific Prevalence of Smoking

Ranges from 9.7% in Utah to 27% in West Virginia Much higher prevalence in American Indian/Alaskan Native, and least prevalent in Asians

Comparing Population Characteristics

Rates help us compare health problems among different populations that include two or more groups who differ by a selected characteristic Help us narrow down the issue

Significance

Refers to the level of priority assigned to the disease as a public health concern Often determined by the quantity and quality of life affected by the disease - The greater the physical and/or psychological harm to the community the more significant the disease becomes

Statistics about People with Limited Literacy Skills

Report poorer overall health Are less likely to make use of screening Present in later stages of disease Are more likely to be hospitalized Have poorer understanding of treatment Have lower adherence to medical regimens Seek emergency care more frequently

What drives our health outcomes in America?

SO- we can see, just because we spend a great deal on health care, does not mean that we are the healthiest If not health care/clinical care, then what drives our health outcomes?? Its now WHAT you spend, its HOW you spend it This is the County Health Rankings models, which has conducted studies on the factors that impact health You can see here that... Health is dependent on so much more than dollars invested in medical care in our country, the United States and in Wisconsin In fact medical care only accounts for 20% of health outcomes -we've seen poorer outcomes, large disparities -so if not medical care, then where does health start? People often think health behaviors -discuss breakdown of percentages -address the myth of individual behavior Programs and Policies --> Health Factors --> Health Outcomes

Components of Quality Health Care

Safe Effective PATIENT-CENTERED Timely Efficient Equitable

Secondary Prevention

Screening, early treatment, limiting disability by averting or delaying the consequences of disease. Throat culture CBC Flu culture CXR

2006 Report of the Surgeon General: Involuntary Exposure to Tobacco Smoke

Second-hand smoke causes premature death and disease in nonsmokers (children and adults) Children: Increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma Respiratory symptoms and slowed lung growth if parents smoke Adults: Immediate adverse effects on cardiovascular system Increased risk for coronary heart disease and lung cancer Millions of Americans are exposed to smoke in their homes/workplaces Indoor spaces: eliminating smoking fully protects nonsmokers Separating smoking areas, cleaning the air, and ventilation are ineffective Ei Major conclusions: 1. Second-hand smoke causes premature death and disease in children and in adults who do not smoke. 2. Children exposed to second-hand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children. 3. Exposure of adults to second-hand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer. 4. The scientific evidence indicates that there is no risk-free level of exposure to second-hand smoke. 5. Many millions of Americans, both children and adults, are still exposed to second-hand smoke in their homes and workplaces despite substantial progress in tobacco control. 6. Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to second-hand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to second-hand smoke.

How do you select the right theory?

Selecting the right theory takes some time and effort on your part. The first thing to consider is the specific use for the theory. The selection of a theory will depend on three aspects, the behavior being changed, the characteristics of the participants, and the environment. - Behaviors are not all equal. Some are deeply rooted in culture while others have a biological foundation and still others result as a reaction to another behavior. And, of course, cognition plays a powerful role in most behaviors. Talk to other practitioners; practice using the theories and read the literature.

Guidelines for Creating Patient Friendly Written Materials

Simple words (1-2 syllables) Short sentences (4-6 words) Short paragraphs (2-3 sentences) No medical jargon Headings and bullets Lots of white space. Written at a 5th to 6th grade reading level

Risk Factors for Disability

Smoking Physical Inactivity Obesity

How do Health Policies Make a Difference?

Smoking restrictions Environmental policies Immunization mandates Affordable Care Act Standard of Care Recommendations (screening) Housing policies Minimum age requirements - alcohol, tobacco Policies that impact you??

Annual Smoking-Attributable Economic Costs

Societal cost: $19.16 per pack of cigarettes The economic costs to society associated with smoking are enormous. Grand total annual smoking-attributable economic costs in the United States is approximately $288.9 billion, of which an estimated $132.5 billion are due to health care expenditures and $156.4 billion are associated with lost productivity costs due to premature mortality. This latter number includes premature deaths due to second-hand smoke exposure but does not include lost productivity costs due to smoking morbidity; as such, this estimate significantly understates the full impact of lost productivity. Smoking-related health care expenditures account for approximately 8% (USDHHS, 2014) of total annual spending on health care in the U.S. For each pack of cigarettes sold, the societal costs due to smoking-related health care costs and lost productivity are estimated at $19.16 per pack, nearly 3 times the cost of the cigarettes ($6.18/pack; Campaign for Tobacco-Free Kids, 2014). Strong tobacco control programs can reduce the prevalence of smoking, save lives, and also substantially impact health-care expenditures. In California, the tobacco control program was associated with an estimated $86 billion reduction in total health costs between 1989 and 2004—a strong return on investment (Lightwood et al., 2008).

Detailed Steps of Social Norm Campaign

Step 1: Data Collection - Data shows that most students make responsible decisions about alcohol, however perception of what "everyone else" is doing gets skewed - Many students feel like they are more conservative than their peers Step 2: Select the message - like stall seat journal, that is multifaceted and student driven - could be about eating food before drinking alcohol Step 3: Test the Message - How have students responded? -- Focus groups have yielded mostly positive responses from undergrads -- most believe this to be a publication by their peers -- Demystifies the subject of alcohol -- Reinforces the concept that not everyone drinks Step 4: Determine a Delivery Strategy -- How will we get our message to the target audience? -- Multifaceted approach -- could be peer education, marketing, newsletter, websites, NSO Step 5: Choose a dosage - how often will be change ads - where else do we want to catch the audience? (radio, tv, etc) Step 6: Evaluation - this is essential for several reasons -- To measure awareness/saturation levels -- to understand how the audience is perceived to your message -- to see if your program has made an impact

What are medication reviews? (also called brown bag assessment)

Steps: Ask patients to bring in all their medications Ask them to name and explain the purpose of each one Discuss exactly how and when they take each one Use this discussion to identify areas of confusion and to answer questions At the time the appointment is made, ask the patient to bring in all medications (prescription and over-the-counter medications, nutritional and herbal supplements, etc.). When the patient comes to the office, the physician, nurse or medical assistant can conduct the medication review by asking the patient to name each medication and explain its purpose and how it is taken. Here are some things to look for: Does the patient identify the medication by reading the label or by opening the bottle and looking at or pouring the pills into their hand? (If they look at the pills it may be a sign of low literacy skills.) How easily can the patient answer specific questions about how they take the medication? Example: "When was the last time you took this medicine and when was the time before that?" Do they become confused when asked questions about the medication? Use this discussion about the medications to address any areas of confusion.

What is the effect of college drinking misperceptions?

Students overestimate the prevalence of negative (often dangerous) behavior among their peers. Students believe they are more conservative than their peers. Students feel pressure to conform to misperceived, false behavior norms, often resulting in significant cognitive dissonance.

Conducting Studies

Studies are conducted in an attempt to discover associations between an exposure or risk factor and a health outcome After data are collected, hypotheses are tested, trends are evaluated, and factors between groups are compared. By conducting studies, epidemiologists are attempting to discover if a causal association exists between an exposure or risk factor and a health outcome by making comparisons of factors between groups. For example, epidemiologists frequently compare data regarding ill persons with those of well persons. Or, the epidemiologist might compare data for a group of persons exposed to a risk factor with those who were not exposed to see if the outcomes are different for each group.

Descriptive Study Type

Study of the occurrence and distribution of disease. That part of epidemiology that involves the description of health events in terms of time, place, and person. When/where was the population affected? Who was affected? Used when little is known about the disease Rely on preexisting data Who, where, when Illustrates potential associations

More about HRSA goal 4: Improve Health Equity

Subgoals a. Reduce disparities in quality of care across populations and communities b. Monitor, identify and advance evidence-based and promising practices to achieve health equity c. Leverage our programs and policies to further integrate services and address the social determinants of health d. Partner with diverse communities to create, develop, and disseminate innovative community-based health equity solutions, with a particular focus on populations with the greatest health disparities

Health Inequity (different from disparity/inequality)

Systematic and unjust distribution of social, economic, and environmental conditions needed for health - Unequal access to quality education, healthcare, housing, transportation, other resources (e.g., grocery stores, car seats) - Unequal employment opportunities and pay/income - Discrimination based upon social status/other factors

Life Expectancy

The average number of years groups of people are expected to live Life expectancy rates have changed over time Advances in available treatments, prevention methods, and healthier lifestyles have contributed to the change In the 1900s the U.S. life expectancy was 49.24 years Between 2013 and 2014, life expectancy at birth for the total U.S. population (78.8 years), males (76.4), or females (81.2) did not change.

Why Health Promotion Programs at the Worksite?

The basic goal of worksite health promotion is to provide opportunities for participants to engage in screenings/assessments, self-help activities, and educational programs with the goal of improving their quality of life as well as their life span. Health promotion efforts at the worksite have demonstrated success at reducing health care costs.

What is the role of the environment in SDoH

The environment represents both the root factors of illness and injury (racism, discrimination, poverty, economic disparity, and other forms of oppression) and the community conditions (physical, economic, social, and cultural) which reflect how the root factors play out at the community level.

Anti-Tobacco Media Messages

The media have been used to promote policy changes that shape the environment in which tobacco companies sell their products. Advertisements such as those shown in this slide increased the public's awareness of the increased health risks associated with smoking.

Health Equity

The opportunity for everyone to attain his or her full health potential No one is disadvantaged from achieving this potential because of his or her social position or other socially determined circumstance. Distinct from health equality: every has the same health outcome

How does health literacy increase its age?

The prevalence of inadequate health literacy steadily increases with age. Of note, patients were screened for dementia in this study and those with any signs of dementia excluded. We do not know why this happens. There are many theories. Many adults in America over 80 grew up in the Depression years and never completed 8th grade and may not have ever had these sophisticated literacy skills. Or this may be a "use it or lose it" phenomenon. Older individuals may read less as they age and spend more time in passive activities such as watching TV. While we do not know why this happens, we do know that those with the greatest need to read and understand health care information (those taking multiple medications for multiple conditions) have the poorest skills and the greatest burden of low health literacy.

Program requirements of theories and models

The process of developing health promotion programs that have a chance of achieving their goals and objectives is a time consuming process that requires a large knowledge base of behavioral theory and information about best practices.

What prevents us from working?

The two most common reasons given are: Common mental health problems Musculo-skeletal problems - High prevalence across population - Little or no objective disease or impairment - Most episodes settle rapidly, though symptoms often persist or recur - Essentially whole people, with what should be manageable health conditions - Psychosocial factors important - especially in chronic disability. Plus other factors: Chronic diseases - mental and physical Obesity-related diseases Domestic violence, addiction Lack of education and/or skills Deprivation, poverty, lack of jobs. Relative importance of these factors will vary with gender, type of work, and country.

Ring Immunity

The vaccination of all susceptible individuals in a prescribed area around an outbreak of an infectious disease. Ring vaccination controls an outbreak by vaccinating and monitoring a ring of people around each infected individual. The idea is to form a buffer of immune individuals to prevent the spread of the disease. used to control smallpox until the last naturally occurring case in 1977. When an infection was diagnosed, all people who were or may have been exposed were identified and vaccinated. Then, a second "ring" of people who may have been exposed to the first ring were also identified and vaccinated.

Health Benefits of Quitting

There is a great advantage to QUITTING ANY TIME You can quit at age 65 (obviously wouldn't be the same but you still would have some benefits) The 1990 Surgeon General's Report on the health benefits of smoking cessation outlines the numerous and substantial health benefits incurred when patients quit smoking (USDHHS, 1990): Health benefits realized 2 weeks to 3 months after quitting include the following: circulation improves, walking becomes easier, and lung function increases up to 30%. One to nine months later, lung ciliary function is restored. This improved mucociliary clearance greatly decreases the chance of infection because the lung environment is no longer as conducive to bacterial growth. Consequently, coughing, sinus congestion, fatigue, and shortness of breath decrease. In some patients, coughing might actually increase shortly after quitting. This is because the cilia in pulmonary epithelial cells are functioning "normally" and are more effectively clearing the residual tars and other accumulated components of tobacco smoke. One year later, excess risk of coronary heart disease (CHD) is decreased to half that of a smoker. After 5 to 15 years, stroke risk is reduced to a rate similar to that of people who have never smoked. Ten years after quitting, an individual's chance of dying of lung cancer is approximately half that of continuing smokers. Additionally, the chance of getting mouth, throat, esophagus, bladder, kidney, or pancreatic cancer is decreased. Finally, 15 years after quitting, an individual's risk of CHD is reduced to a rate similar to that of people who have never smoked. Thus the benefits of quitting are significant. It is never too late to quit to incur many of the benefits of quitting

What are emerging infectious diseases?

These are human illnesses caused by microorganisms or their poisonous byproducts and having the potential for occurring in epidemic numbers. Emerging infectious diseases can be defined as infections that have newly appeared in a population or have existed but are rapidly increasing in incidence or geographic range. Globalization

Intersection between Health, Place, and Equity

These are just notes from the slides Outline the Issues May be helpful to support with examples from recent news or statistics from catchment area (local, state, national area or foundation's targeted populations). Some points for elaboration: Schools - both youth education and higher education Safety - on many levels, starting with youth safety in the home and at school; safe places for everyone to work, live and play; traffic safety; etc. Transportation - safe and affordable options for commuting; ability to access needed resources Pollution - the water we drink, the air we breathe, our food sources Climate change - critical issue internationally Access to resources - access to healthy foods, clothing, necessities for living "These issues are complex and interrelated." [click] Obvious links between climate change, pollution, and sustainability [click] Jobs, education and available resources are factors of the economy [click] Health impacted by pollution, safety, ability to transport to get the resources, to get the exercise, to get to the doctor, etc. Point out links between Environment, Economy & Health as well This diagram does not reflect all of the linkages or all of the factors

Smoking Advertisements

This image depicts the marketing strategy of the tobacco industry for an ultra-light cigarette targeted toward women, a population with a lower smoking prevalence and concerns about the effect of cessation on weight gain. Physicians also were central to tobacco advertising in the early to mid-1900s. It wasn't until the 1950s that the link between smoking and cancer became public knowledge. As part of massive marketing campaigns, the tobacco industry promoted its products through trusted health professionals, including nurses.

Social Conditions

To work towards health equity we need to address the root causes, social determinants of health, social and economic facts Social conditions drive resource distribution and social disadvantage Health equity and therefore overall health is shaped by social conditions Increasingly, research in public health, medicine, sociology, population health and psychology suggest that traditional health care plays only a small role in overall population health particularly in developed countries like the United States Social Determinants of Health - Circumstances shaped by distribution of money, power, and resources at all levels (local, state, national, global) which drive health inequities

Health Consequences of Smoking

Tobacco use damages virtually every part of the body (both smoking and secondhand smoke) - Cancers Acute myeloid leukemia Bladder and kidney Cervical Esophageal Gastric Laryngeal Lung Oral cavity and pharyngeal Pancreatic - Pulmonary diseases Acute (e.g., pneumonia) Chronic (e.g., COPD) - Cardiovascular diseases Abdominal aortic aneurysm Coronary heart disease Cerebrovascular disease Peripheral arterial disease - Reproductive effects Reduced fertility in women Poor pregnancy outcomes (e.g., low birth weight, preterm delivery) Infant mortality - Other effects: cataract, osteoporosis, periodontitis, poor surgical outcomes

Challenges People with Disabilities Face when trying to access health care

Transportation problems Inaccessibility of facilities or services Lack of provider knowledge about disability Untimely appointments

What do all medical staff need to be involved in?

Understanding the scope of the problem Identifying patient barriers to care Creating strategies to address the barriers Implementing and assessing the effectiveness of these strategies Conducting on-going follow-up and evaluation

Worldwide Prevalence of smoking

Varies a LOT by country (highest in china, Europe) Also varies a lot by men and women, especially in china Smoking is mostly on the decline, but almost 38 million American still smoke

Life Expectancy In US

Varies by decades in different counties

What about Individual Behavior?

Very important to health (30%) HOWEVER, Everyone does not begin in the same place or has the same tools and environments (OPPORTUNITIES) to support individual choices that maximize their health potential Racial and ethnic health inequities exist at every income level, not just among the poorest Americans (IOM, 2003) Land of the free- but not everyone has the same opportunity to be healthy

Place Matters?

We know that place and health are inextricably linked. That WHERE you live impacts HOW you life. Improving health cannot be addressed disease by disease but must be informed by a comprehensive understanding of the wide range of factors that shape health status. That people thrive when parents earn living wages, when children can get a quality education and have easy access to safe parks, grocery stores selling F&V. Families cannot thrive in unhealthy environments People living in communities with walking paths, parks are more active than those who not have access to these. When people have access to healthier foods, they make healthier choices- and that securing new or improved local grocery stores can also improve local economies and create jobs All community environments are not created equal when it comes to opportunities for healthy living. Low-income and communities of color are more likely to lack health-promoting infrastructure and resources . At the same time, a national health movement is growing More and more people are recognizing the impacts that chronic diseases such as diabetes and obesity are having on their communities, which are often preventable, and wanting to do something about it to change the health of their families, communities and constituency. This movement recognizes that healthy people and healthy places go together. The growing movement for healthy communities—with its push for changes in the physical, economic, social, and service environments -holds great promise

The Tobacco Master Settlement Agreement (MSA)

What was it? One of the most successful tobacco restriction cases in history November 23, 1998 Attorney Generals from 46 states, the District of Columbia and five U.S. territories signed an agreement with the tobacco industry to settle ALL the state lawsuits seeking to recover Medicare costs of treating smokers. Settlement Included: Approx $206 Billion paid to participating states through 2025 Requires $12 billion "up-front" money to the states over 5yrs Payment to states over $9 billion/yr to begin 2008 Payment to states do not include settlements already reached with Miss, Florida, Texas, and Minnesota Requirements? 14,000 tobacco billboards to be torn down & replaced with anti-smoking messages Outdoor advertising on all public transit systems & arenas, stadiums, shopping malls, and video arcades to be removed forever Joe Camel to be gone forever www.tobaccoresolution.com to contain the "secret" tobacco documents and make available for public viewing American Legacy Foundation (www.americanlegacy.org ) to oversee a sustained $1.45 billion national public education campaign A national tobacco farmers settlement trust fund to compensate farmers and quota holders for anticipated financial losses. (Does not address restrictions on print advertising, marketing & advertising inside retail stores, and internet advertising Does not include provisions to limit youth access to tobacco products Vending machines Self-service displays Mail order sales)

How are health education approaches limited?

While these approaches aren't "wrong," they do have limitations: -- Not "inclusive" -- Tend to focus on the negative -- Often miss some core issues (e.g., environmental and personal influences)

SDoH: Work and its Value

Work is a social determinant of health Work is generally good for health - the two are inextricably linked Enabling people to be in productive work is a health issue Work provides income: material well-being and participation in today's society Work meets important psychosocial needs in societies where employment is the norm Employment and socio-economic status are the main drivers of social gradients in health Work needs to be 'good work'

Does teach back really work?

Yes, very effective! "Asking that patients recall and restate what they have been told" is one of 11 top patient safety practices based on strength of scientific evidence. Physicians' application of interactive communication to assess recall or comprehension was associated with better glycemic control for diabetic patients.

Illness-Wellness Continuum

a model that illustrates the full range of health between the extremes of illness and wellness You can have a chronic disease and still be well

SMOG readability formula

can be used to adapt anyone's written materials to a specific audience reading level

Epidemiology Purposes in Public Health Practice

discover the agent, host, and environmental factors that affect health; determine the relative importance of causes of illness, disability, and death; identify those segments of the population that have the greatest risk from specific causes of ill health; and evaluate the effectiveness of health programs and services in improving population health.

HP 2030 Goals

don't memorize these, but think about how they are different from 2030 Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury and premature death. Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all. Create social, physical, and economic environments that promote attaining full potential for health and well-being for all. Promote healthy development, healthy behaviors and well-being across all life stages. Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all.

Cigarette smoking... (quote from Surgeon General)

is the chief, single, avoidable cause of death in our society and the most important public health issue of our time

Three Levels of Prevention

primary, secondary, tertiary

Adult Per-Capita Consumption of Tobacco Over the Past Century

shifts in per-capita consumption for the various tobacco products in the U.S. between 1880 and 2005 (Thun et al., 2002; updates from the U.S. Department of Agriculture). During the late 19th and early 20th centuries, tobacco use was predominantly in the form of chewing tobacco, cigars, pipes, and snuff. Now, the cigarette is the leading form of tobacco use in the United States.