PAM 3280 Midterm

What is "risk factor epidemiology" (Susser & Susser) and might a "behaviorist" or a "structuralist" (video discussion) be more inclined to approach disease outcomes and disparities from a risk factor perspective?

"Risk factor epidemiology" - Control risk factors by modifying lifestyle, environment, agent. As with the era of Sanitary Statistics, epidemiologists were faced with major mortal diseases of completely unknown origin! Risk factor epidemiology was born to find probable causes and statistical analyses and study designs evolved à sampling, four-fold tables and odds and risk ratios. The specific-cause model of germ theory was replaced with a more multi-level model of disease. Structuralist because he/she focuses on the social (distal) factors that operate both directly to influence health and indirectly (e.g., social determinants, structural determinants, behavior) to .

Describe the cultural/behavioral versus structural explanations for observed disparities in health.

(1)Structuralist view of disease: SES is a "fundamental cause" of disease. Social (distal) factors operate both directly to influence health and indirectly (e.g., by influencing behavior) to affect health. A more distal view of health: the "causes of the causes" -Why are social conditions (SES) "fundamental" causes of disease? Access to resources (money, knowledge, power, prestige, and social connectedness) -- those with the most resources are best able to avoid risks and be less afflicted by disease (2) Cultural/Behavioral (proximal) causes of disease: Easy to focus attention here because behaviors are more proximal to disease in the causal chain. Easier to establish or hypothesize "biological plausibility." Both approaches are plausible. Depending on what stance you take will affect how you develop policy/programs! A population health focus says you need both! (Recall: In Whitehall study, behaviors only account for 25% of the variance of the gradient in health)

In the classic infectious disease transmission model (agent, host, environment), what elements/attributes/characteristics make up each of these points of intervention to "cause" illness?

*Agents* (What): include infectious organisms, physical agents, allergens, chemical agents (agents must be present for disease to occur though presence of that agent may not be sufficient for disease to occur) *Pathogenicity* refers to the ability of an organism to cause disease (ie, harm the host). This ability represents a genetic component of the pathogen and the overt damage done to the host is a property of the host-pathogen interactions. *Virulence*, a term often used interchangeably with pathogenicity, refers to the degree of pathology caused by the organism (severity). The extent of the virulence is usually correlated with the ability of the pathogen to multiply within the host and may be affected by other factors (ie, conditional). In summary, an organism (species or strain) is defined as being pathogenic (or not), and depending upon conditions, may exhibit different levels of virulence. *Host* (Who): The human who can get the disease. Host factors are intrinsic elements influencing the individual's susceptibility to the agent (age, being nutritionally deficient, comorbidities, personal/behavioral choices (e.g., sexual practices; hygiene), genetic endowment, etc) *Environmental factors (Where)*: are extrinsic entities that influence exposure to the agent (water puddles, lack of sewer drainage, pollution, mold, geology and climate, presence of insects (vectors) or sanitation practices (e.g., cleaning of fomites, removal of contamination), and even SES conditions such as crowding and sanitation Note: Factors in each of these categories interact to produce disease. A change in any of the 3 will alter an existing equilibrium to increase or decrease the frequency of disease.

What is the difference between direct and indirect disease transmission?

*Direct*: Person-to-person via direct contact or droplet spread.Routes of spread: exchange of body fluids, skin contract, contact with body lesions, droplet spread over a few feet. *Indirect*: No direct person-to-person contact; requires common vehicle to transmit. Routes of spread: Airborne (droplet nuclei), waterborne, parenteral, vectors, fomites, vehicles Parenteral: injected, infused, or implanted - taken into the body other than through the digestive or respiratory tracts [From Greek para = "beside" and enteron = "intestine", because it bypasses ("goes beside instead of through") the intestines.] - i.e., YOUR HOSPITAL INQUIRED INFECTION VIA IV or dirty needle stick. Fomite: inanimate object that has been contaminated with the pathogen and can convey infection to others (hair brush; stethoscope, bed sheets, exam table, door knobs, neckties) - commonly associated with hospital acquired infections (HAI). Easy to control!

What is the difference between life expectancy and healthy life expectancy?

*LE*: average remaining years of life a person can expect to live on the basis of the current mortality rates for the population *HLE*: Years lived in good health - combines age-specific mortality with morbidity or health status to estimate expected years of life in good health for persons at a given age. - Combine mortality data and morbidity/health/well-being data into one indicator > i.e., healthy life expectancy (HLE)

What are some key differences between the "medical model" of health versus the "population health" model?

*Medical Model * - FFS incentivizes volume - Sickcare system focuses on treatment of individual ill patients - Focus on individual risk - Clinical/reactive (drugs, equipment, dx, maneuvers, contribute to health) - Health care is central to producing health - Focus on disease - Fragmented, silo'd, duplicative *Population Health Model * - VBP rewards quality and incentivizes cost reduction - Healthcare system focuses on coordinated holistic care across continuum - Focus on social structures - Comprehensive/proactive/preventative - Addressing health's determinants and health disparities are central to producing health - Focus on health, wellbeing, HRQoL - Integrated and coordinated

How does neighborhood design impact health: e.g., the impact of proximity and distance on travel behavior?

*Proximity*: A function of both the density of development (compactness) and mix of land uses (spatial distribution of different land use types such as residential, office, retail, industrial, educational, and recreational). Determines how many activities are within a convenient distance (e.g., multiple destination design). *Directness*: A function of street network connectivity. As proximity and directness increase (closer amenities and more direct connectivity), distance between destinations decreases and so does vehicle kilometers travelled (VKT). When distances between destinations are sufficiently short, walking becomes a substitute and health benefits are realized in the form of less air pollution, less noise pollution, greater physical activity, greater social connectedness, etc.

If given the number of life years lived in a given life table age interval, and the percent of the population healthy (or unhealthy) in that age group, could you calculate healthy life years in that age interval?

*Recall*: nLx = Total number of person-years lived for the cohort in age interval x to x+n *New Value*: Assume nπx = proportion in each age group healthy *Therefore*: Proportion of person-years lived in a healthy state: nL'x = (nπx)*nLx

What is the difference between the social and the built environment? Why would your zip code determine your health (e.g., direct and indirect mechanisms)?

*Social environment*: refers to behaviors, connections, norms, social capital, socio-demographic characteristics of people (residents, business owners) in an environment that may impact health *Built environment*: How design, construction, and placement of buildings within a community, as well as the design of the surrounding community (e.g., zoning, sidewalks, parks), impact human health Class Notes: -there are social and physical determinants of health -these relate to physical determinants of health, where we live can impact us b/c of physically how it is designed, and also, based on social norms, relations, connections that can occur in the environment Built and social environments are inextricably linked! Built space and the social environment have a direct impact on residents' health Neighborhood conditions can have an indirect impact on health by making healthy choices easy, difficult, or impossible Public policy choices and private investment decisions shape neighborhood conditions Transportation: Direct: Pollution, MVAs, decreased physical activity Indirect: Routes of demarcation can isolate or exclude

Relative Difference Measures

*Time-based differences (percent change)*: (New value - old value/ Old Value) x 100 *Group-based differences (percent difference)*: (Group of interest - Reference Group/ Reference Group) x 100

Absolute Difference Measures

*Time-based differences*: New value - Old value Can be count, rate, % data *Group differences*: Group of interest - Reference group Can be count, rate, or % data Be sure to express absolute differences consistent with unit of measurement (e.g., 3 visits (count) or 3 deaths per 100,000 (rate) or 6 percentage points (percent))

What is the "social gradient in health" or "health-wealth gradient"?

- Definition: Consistently observed inverse association between SES and poor health outcomes Poor Health Outcomes: Morbidity, mortality, disability, poor mental health, poor/fair self-rated health, low HRQOL, chronic illness, etc. - SES: Income, education, occupation, social status, wealth, equality - Statistical definition there is an inverse association b/w SES and poor health outcomes in study after study, no matter how measure SES (independent variable-income, education levels, employment, type of occupation, wealth, level of quality b/w groups) and no matter how measure health (poor health, morbidity, mortality)à get this graded association

What is the difference between equality, equity, and "upstream" interventions?

- Equality intervention: assumes everyone will benefit from the same supports (treated equally) - Equity intervention: individuals are given different supports to make it possible for them to have equal access to the game - Upstream Intervention: all three can see the game without any supports or accommodations b/c cause of inequity was addressed→ the systemic barrier was removed

According to the video, In Sickness and in Wealth, how does social class "get under your skin" (biological mechanism)? What key stress hormone is involved?

- Idea of control of destiny: ability to influence the events that impinge on your life even if it means not doing anything, but managing those pressures Middle class families: working 2 jobs, not being able to spend time w/ children Unsafe neighborhood, Being relatively poor, having job insecurities will decr control over ppl's lives → likely to increase risk of illness - When we feel threatened or to have no control of our lives, stress response kicks in When brain perceives a threat, it signals the adrenal glands to release potent stress hormones: cortisol Cortisol floods your bloodstream with glucose, increase heart rate, raise BP, put body in alert Helps survive: improve memory, motivate Normal stress response spikes up when needed and then turns off When pressures are relentless and you lack the power and resources to control them Stress response stays turned on for months or years → produce too much cortisol Chronically cortisol can impair immune function, inhibit memory, cause areas of the brain to shrink Prolonged activation then in turn affect ability to handle insulin and glucose which in turn increase risk of diabetes and heart disease Incr stressed reflected in higher rates of disease and accelerated aging - the accumulation of stressors or accumulation of resources to manage them SO much is determined by class Certain economic status brings you control over other parts of your life: places you can live, vacations, food consumption, etc

What was the significance of the Macaque monkey study?

- Monkeys in inferior roles had to submit to more dominant monkeys, experienced higher levels of stress - dominant monkey has control over its life to create an optimal environment around itself However, Subordinate animals: no control over what happens to them, must have high level of vigilance: are in state of chronic stress, higher levels of cortisol in blood When sustained in high levels, has negative effects on cellular function and tissues Stress of social subordination, more advanced atherosclerosis Cross-section of artery: subordinates had greater plaque build-up bc of dominance, power, control, and stress - Only difference between the monkeys was hierarchy (dominance) → stress and psychologically impacted the monkey

Mentally Unhealthy Days

- Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? (UHD) - Pros and cons? - What is the possible range of responses? - Population health indicator: Mean count of days - Population health indicator: Frequent mental distress (FMD) = prevalence 14 or more mentally UHD within the last 30 days -Cons: recall bias (relies on memory), subjectiveness (what is healthy vs another), social desirability (stigmas associated) -Found well validated and correlated with a actual physical poor health, actual probability of dying -however, there is some bias that is some missing variation. (gender-bias: women worse HRQL bc more likely are willing to say it relative to men)

Physically Unhealthy Days

- Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? (UHD) - Pros and cons? - What is the possible range of responses? - Population health indicator: Mean count of day - Population health indicator: Frequent physical distress (FPD) = prevalence 14 or more mentally UHD within the last 30 days Notes: Possible lowest value the response can be: 0, Highest possible response: 30 or 31 days Indicator: mean count of days (in last 30 days, how well where you physically unhealthy? 2.1)

Activity Limitations

- Q4 only asked if responses to Q2 and Q3 are not 0 - During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation? (ALD) Pros and cons? - What is the possible range of responses? - Population health indicator: Mean count of days - Population health indicator: Frequent activity limitation days (ALD) = prevalence 14 or more ALDs within the last 30 days Notes: If 2 and 3 greater than zero, then you are asked question 4 -if you have no bad mental or physical health days, not going to ask this question, not going to ask whether those days impacted your activity of daily living? -gets at the intensity of your discomfort •Did you have a poor mental health day, if you did, did it impact you? Bc you can have 2 or 3 bad physical/mental health days but still go to work and function well

Why are counts of health events (e.g., deaths, births, hospital visits) useful but not the ideal metric to use to describe the health of a population? Why is it important to convert a count to a rate or percent? What is the difference between a crude and an age-standardized rate?

- Simplest measure of disease frequency (count of cases). Useful for describing actual impact of a disease in a pop or actual utilization of care services for planning and understanding resource needs, easy to get this data. Counts does not allow us to compare groups. Counts does not reflect underlying risk in population. - A rate or percent is ideal because it takes into account the size of the sub-group (denominator) which then allows us to compare them. For example, white people have a higher number of visits to the clinic than blacks but we cannot compare the two counts without finding the rate at which they both visit. Pro: Permits comparisons (divides counts (numerator) by population (denominator); Con: Difficulty determining who is in numerator and denominator (denominator ideally reflects population at risk of event in numerator) - Crude rate is the number of events divided by the population. For example, crude death rate is the number of deaths in a specified year over the population of that year. Age-standardized rate, however, adjust this rate for changes in the age composition over time.

HRQOL: Health-Related Quality of Life

- Subjective measure encompassing elements of physical health, mental health, social health, and role functioning (holistic) - Validity: Associated with both self-reported chronic diseases (diabetes, breast cancer, arthritis, and hypertension) and their risk factors (body mass index, physical inactivity, and smoking status) - Used to determine burden of preventable disease, injuries, and disabilities

Self-Rated Health

- Subjective measure of global health - Would you say that in general your health is: Excellent, Very good, Good, Fair, Poor - Validity: SRH is a strong predictor of mortality, morbidity, biological markers and behavioral risk factors across multiple groups and sub-groups What does 'subjective' mean? Think back to the first day of class and how we defined health - are we capturing the full scope of "health" with this question? If not, then why use it? Validated across multiple different groups (age, race-ethnicity, gender, VA, cross-cultural) though performs better in some pops than others. There is definitely an observed cultural bias but it is still predictive (strong criterion validity). -Very well validated, to where can be used as a stand alone question (usually in context of 3 other questions) -well validated question and associated w/health and its risk factors -doesn't have very good content validity (doesn't get to the full scope of the phenomena of health) Does not capture physical, mental, emotional well-being,

What was the significance of the Cold study?

-1) independent variable- Whether parents owned home when growing up; wanted to look at whether this differentially impact whether you get a cold or not (immune system suppressed)? Infected individuals with cold virus, found those with less chronic stress got fewer colds than those with more chronic stress; cold virus could single more serious health problems Higher status (Owned home)→ less stress → better immune function, stress -2) economic security may offer some cumulative health benefits Another cold virus study, now looked at home ownership Asked whether your parents owned a home when you were a kid predict whether you get a cold as an adult Now, take them as adult and expose them to virus Great predictor: graded predictor More years their parents owned their home, less likely to get a cold when expose them to a virus

What is disease? Illness? Morbidity? Comorbidity?

-Acute Disease: Relatively severe, treatable, short duration, outcome of recovery or death -Chronic Disease: Typically less severe diseases of longer duration, frequently recovery not achieved but progressive disability Comorbidity: Two or more diseases/diagnoses. (one or more chronic diseases)

What was the significance of the Whitehall study?

-British civil servants, everyone has health insurance and employed, thus there is NOT an access issue bc all have health insurance and are employed, none of them are poor -the issue-within them, according to their job grade, the social gradient in health was observed -looked at ppl's employment grade, measured health of Britain's civil servants over 30 years -found the lower the grade of employment, the greater the risk of heart disease Not just heart disease but also every other cause of death -in britain everyone has guaranteed healthcare, but still found death rates and illness correlated to status even after controlling for unhealthy behaviors Combination of overweight, sedentary lifestyle, smoking, bp, cholesterol explained no more than ¼ Lower social classes → worse health

Which approach is better from a population health standpoint?

-Focus on "fixing healthcare" has been narrow: on reorganizing care, implementing Health IT, reforming payment system...with less consideration of upstream factors that might keep individuals well (less expensive) and out of the healthcare system in the first place.

What is the general association between age and prevalence of disability?

-basically, there is greater prevalence of disabilities among older individuals -the prevalence of doctor diagnosed arthritis, increases with age and is greater among women than men (also associated with BMI)

What was the significance of the Twin study?

-genetically identical twins, environmentally identical yet these twins overtime got to a point where one had a high-income job and the other didn't → they had different health outcomes Thus, their STATUS impacted their health NOT the family they grew up in or their biology -Among identical twins growing up until age 18, if diverge later in life: one became professional one become working class -> ended up with different health statuses as adults

What would happen to the prevalence and/or extent of health disparities if we eliminated poverty - would disparities be completely eliminated? NO

-if today, we pass a policy that every single individual over age 18 will receive $30,000 per year from the government and therefore, no one is officially poor -not going to get rid of health disparities, will ONLY reduce them → there will still be gradientation in income, some ppl are going to have more than others/difference in resources -ladder scenario: if we remove the poor (bottom of ladder) and make them not poor, we will still have health disparities Ladder still remains, there are still differences in health-they will just be smaller

What are the two main causes of infant mortality in the US (can you define them)?

1. Congenital malformations, deformations and chromosomal abnormalities. 2. Short gestation and low birth weight (preventable)

What is the demographic transition?

A commonly observable pattern of changes in fertility and mortality in populations. Mortality rate falls first, then fertility rates decline → population increases. Stage 1: Pre-industrial society; death and birth rates high and in balance = very slow pop growth Stage 2: Developing countries-improvements in sanitation, food supply, personal hygiene = reduced mortality = population growth Stage 3: Developing countries-access to contraception and increased urbanization, increased educ of women, increased wages = declines in fertility = death and birth rates low and in balance = population growth levels off Stage 4: Populations may begin to decline @ fourth stage if death rates decline as low as possible and fertility declines below replacement

What is a reservoir and can you list common reservoirs you may experience in your future work?

A reservoir is the habitat in which an infectious agent normally lives, grows and multiplies; reservoirs include human reservoirs, animal reservoirs and environmental reservoirs. Reservoirs include humans, animals, and the environment. A reservoir may or may not be the source from which an agent is transferred to a host. As a future health care professional, some of the common reservoirs I may experience are infected patients in hospitals, vectors like mosquitoes, animal models that are used for research or the hospital itself.

What is "population health?"

According to Kindig & Stoddart, it is the health outcomes of a group of individuals, including the distribution of such outcomes within the group.

What is "active commuting?"

Active commuting: Prevalence of walking or biking to work -share of commuters in a country who walk or bike to work (active commuting) corresponding to that country's prevalence of adult obesity less than 5% of US adults bike or walk to workà 33% of adults are obese -countries with lower rates of obesity tend to have higher rates of commuters who walk or bike to work

What are ADLs?

Activities of Daily Living (ADLs): Used to assess basic self-care tasks of everyday life, such as walking, eating, bathing, dressing, toileting, and transferring Significant predictors of: (ppl who score higher on ADL, are more likely to enter nursing home, use paid-care, etc) -Nursing home admissions -Use of paid home care -Use of hospital and physician services -Living arrangements -Insurance coverage (ADLs trigger long-term plan benefits) -Mortality Measure disability using ADLs Activities of daily living include are the "things we normally do" - tasks that are required to get going in the morning, get from place to place using one's body, and then close out the day in the evening. They involve caring for and moving the body. Walking, bathing, dressing, toileting, transferring, eating Assess basic self-care tasks Often times asked of elders You can not be admitted and have insurance pay for your long-term health stay, if you do not have significant impairment or disability (questions used to assess this) → how insurance decides to pays for long-term stay Measuring Disability with ADLs Indicator: Count of "no" responses → % with X or more ADL limitations Higher number of "no's" indicates poorer functional status (less independent)

Median age at death for the population

Age to which half of the cohort survives

Can we say with certainty we currently live in one specific era? Why or why not?

Although one might argue that we live in a Black Box era, we still use preventive measures of sanitation, vaccination, lifestyle modification and other approaches from previous eras. We are also attempting to fully transition to the Eco-epidemiology era. Thus, I would argue that we cannot say with certainty that we currently live in one specific era.

Of the 10 leading causes of death in the US, what percent are preventable?

Answer: 7 of the 10 leading causes of death are preventable

What is avoidable mortality (not ICD10 codes but overall definition)? What two types of deaths make up avoidable mortality?

Answer: A type of cause-specific mortality. Deaths attributed to "lack of preventive healthcare or lack of timely and effective medical care" are considered avoidable. The following two types of deaths make up avoidable mortality: - Preventable: Deaths that could have been prevented due to addressing risk factors - Treatable: Deaths that could have been avoided due to treating the underlying conditions

Which is a measure of risk: incidence or prevalence? Why?

Answer: Because incidence is a measure of the rate at which new cases of disease/injury/condition are occurring, it is a measure of risk.

Why is age adjusting so important when comparing the mortality of two populations or examining the mortality of a population over time?

Answer: Because some population might have a greater proportion of older or younger people than others who might be vulnerable to death because of certain diseases. Hence, it is crucial to adjust for age when comparing the mortality of two populations or examining the mortality of a population over time. (Note: Developed countries/areas usually have a greater proportion of older population compared to developing countries/ areas.)

Which group of mothers (race) has the highest infant mortality? (Tying to 9/22 lecture, why might we see this stark difference even after controlling for mother's age, behavior, marital status, education, geography, etc.?)

Answer: Black mothers have the highest infant mortality rate. Even after controlling other variables we will see this stark difference because of health care disparities, lack of access to health care and other social determinants of health.

T/F: The US spends more on healthcare than any other nation because the US leads the world on key population health indicators.

Answer: FALSE, US sucks.

What is the relationship between incidence and screening?

Answer: Improving early detection (screening) of a given disease leads to increase in incidence of that disease.

Why are crude rates "crude?" How do you calculate crude death rates?

Answer: It is crude because it is not age adjusted. Everyone is in the denominator not just the risk population. CDR= Deaths in a year/ Midyear population from census * K (100,000)

What is the difference between life expectancy and lifespan?

Answer: Life expectancy at birth is how long, on average, a newborn in a given year is expected to live based on the age-specific mortality data provided in the specified year whereas life span is the oldest possible age to which an organism or species may live under optimal conditions. Life expectancy is a mean. Life span is a max.

What is the general shape of a mortality curve (plot of age-specific mortality rates) in a developed (developing) country? (i.e., J shaped versus U shaped) What does this shape reflect?

Answer: More developed countries tend to have a J-shaped mortality curve (hockey stick) whereas developing countries, with higher mortality at younger and older ages as well as lower life expectancy, have more U-shaped mortality curves.

What percent of the US population has at least one chronic disease?

Answer: Nearly 50% of Americans have at least one chronic disease (WOW!)

If incidence increases, must prevalence necessarily increase?

Answer: No. BUT if both incidence and duration increase, prevalence increases. If both incidence and duration decrease, prevalence decreases.

What are the general race and gender trends in life expectancy at birth?

Answer: On average females have a higher life expectancy at birth than men; White females have the highest life expectancy at birth while black males have the lowest; Black females gave a higher life expectancy at birth than white males. Life expectancy at birth trend: White female > Black female > White male > Black male

What is premature mortality and its key measure (e.g., YPLL)?

Answer: Premature mortality is years of potential life lost due to premature death. Its key measure is Years of Potential Life Lost (YPLL).

When examining mortality rates over time (or any other health trend), why is it important to be able to distinguish between real versus artifactual difference (examples of each)?

Answer: Real changes are changes in age structure of population, changes in survival, changes in incidence while artifactual changes are changes in disease recognition, definition, classification, changes in reporting accuracy or population identification. Sometimes a disease might be existing in a population but we might not have the scientific expertise or technological advancement to discover it. When we do discover the disease, it will show a sharp rise in mortality curve. For instance, if we look at the graph of cause specific mortality, we will see that deaths from Alzheimer's disease rise sharply around the 1980's. This is artifactual change as Alzheimer's disease was present in the population but was not discovered before that time period. An example of real change will be the decrease in mortality from heart diseases.

Why is proportionate mortality not a measure of risk?

Answer: Risk is measured by the number of new cases in the population. Proportionate mortality is the ratio of deaths by a certain cause by total deaths *100 which has nothing to do with new cases of diseases. Therefore, it is not a measure of risk. Only Incidence is the measure of risk.

What is the general difference in cause of death contributing to neonatal mortality versus postneonatal? How might this impact health services and prevention strategies?

Answer: The cause of death contributing to neonatal mortality is medical care and post-neonatal mortality is SES. Once we know which among the two has the highest mortality rate, we can implement health services and prevention strategies based on that cause. For instance, in areas where neonatal mortality rate is higher, medical care should be improved while in areas where post- neonatal mortality rate is higher, the policies should focus on minimizing health care disparities and other social determinants of health.

Which column of a life table is used to generate a 'survival curve'? What can graphing a survival curve tell us about the health of a population? What is meant by the term "rectangularization of mortality?

Answer: The column showing the number of persons surviving at the beginning of each given age interval (lx) can be used to create survival curves. The developed countries survival curves will look rectangular while developing countries will look triangular. More rectangular shape of the survival curve means higher survival which in turn means healthier population. Rectangularization of mortality means compression of mortality in a survival curve.

What is the general trend of infant mortality in the US and how does the US compare to other developed countries in terms of infant mortality?

Answer: The general trend is that the US infant mortality rate over time is decreasing. Infant mortality declined by approx. 88% between 1940 and 2014. The US has one of the highest infant mortality rates among the developed nations of the world.

What are the main components of a life table? What is the key output statistic of a life table? Why is life expectancy considered a "hypothetical" measure and what is a life table radix?

Answer: The main components of a life table are Set of tabulations describing probability of dying, number dying, and number of survivors for each age or age group. The key output statistic of a life table is life expectancy at birth (e0). Life expectancy is considered a "hypothetical" measure because the actual age-specific death rate of any particular birth cohort cannot be known in advance. If [death] rates are falling, actual life spans will be higher than life expectancy calculated using current death rates. (Please check) The starting number of newborns in the life table usually set at 100,000 newborn babies is called the life table radix.

What is the effect on your incidence rate (e.g., overstated or understated) if your population denominator failed to be specific to those people at risk of the event in the numerator or if your numerator included repeated (or duplicated) cases?

Answer:If your population denominator failed to be specific to those people at risk of the event in the numerator, incidence rate will be understated. If your numerator included repeated (or duplicated) cases, incidence rate will be overstated.

Life expectancy at age x (ex)

Average number of years of life remaining to be lived for persons who have achieved given age x Formula: ex = Tx / lx Tx = Total number of person-years lived at and above the indicated age Number of persons from the original synthetic cohort of 100,000 live births, who survive to the beginning of each age interval (lx)

Crude death rate

CDR = D/P x 100,000 Num: Number of death in specified year Denom: Midyear population in that year

What are some of the ways we define a 'case' (e.g., numerator) in healthcare (i.e., nosology, case definition, ICD-10)?

Case (human) is defined by time, place, person (including symptoms, diagnostics, risk factors) Case definition: Set of uniform criteria used by public health agencies in the surveillance, or monitoring, of disease syndromes Nosology: the classification, arrangement, and cataloging of diseases ICD-10: The international classification of disease. Alphanumeric designations given to every diagnosis, description of symptoms, cause of death attributed to human beings

What are "complete streets?"

Complete Streets Definition: •Designed and operated to enable safe access for all users (pedestrians, bicyclists, motorists, transit riders) of all ages and abilities •Make it easy/safe to cross the street, walk to shops, and bicycle to work; allow buses to run on time and make it safe for people to walk to and from train stations Class Notes: There is no singular design prescription for Complete Streets; each one is unique and responds to its community context. A complete street may include: sidewalks, bike lanes (or wide paved shoulders), special bus lanes, comfortable and accessible public transportation stops, frequent and safe crossing opportunities, median islands, accessible pedestrian signals, curb extensions, narrower travel lanes, roundabouts, and more. Why need complete street policies? Incomplete streets - those designed with only cars in mind - limit transportation choices by making walking, bicycling, and taking public transportation inconvenient, unattractive, and, too often, dangerous.

What are key population mortality indicators (and what data make up their numerators and denominators)?

Crude Death Rate Pros: Quick and easy measure of overall mortality Cons: Not age adjusted; everyone is in the denominator not just risk population. Age specific mortality rate: Pros: can make mortality curves (J shaped or U shaped) Race specific mortality rate: Pros: denominator is group at risk Cons: Still "crude" if not age-adjusted

Post-neonatal mortality rate (SES)

D 28 days < 1 year / B x 1,000

Neonatal mortality rate (medical care)

D < 27 days /B x 1,000

Proportionate mortality ratio

Dc/D x 100 (where c = specific cause)

Cause-specific mortality rate

Dc/P x 100,000 (where c = specific cause)

Case fatality ratio

Dc/Pc x 100 (where c = specific cause and Pc is the population diagnosed with the specific disease)

What is meant by the term "compression of morbidity"?

Definition: "is to squeeze or compress the time horizon between the onset of chronic illness or disability and the time in which a person dies." "if the age at the onset of the first chronic infirmity can be postponed more rapidly than the age of death, then the lifetime illness burden may be compressed into a shorter period of time nearer to the age of death."

Specific rate

Di/Pi x 100,000 (where i = specific group such as age, race, gender, etc.) E=event D=deaths B=births P=population

Maternal mortality ratio

Dp/B x 100,000 (where p = puerperium (i.e., related to pregnancy & childbirth)

What are some modern examples of preventive strategies proposed by each era?

Era I: Sanitation, drainage, and sewage department Era II: Quarantine for Ebola Outbreak, vaccination at airports Era III: Modifying lifestyle (e.g. healthy eating, quit smoking) Era IV: Holistic care? Looking diseases at multiple levels (biological, behavioral, environmental, social, molecular); preventative measures rely heavily on biomedical technologies.

What are common measures of frequency and intensity and when would you most likely use them? Examples?

Example: Frequency (prevalence) and intensity of binge drinking among women. Prevalence of binge drinking: In the last 30 days, in one occasion, if you had four or more drinks. Frequency of binge drinking: If you said Yes to binge drinking, how many episodes of binge drinking? Intensity of binge drinking: If you had one or more episodes, average largest number of drinks in the last 30 days.

True or False: Education explains most of the difference in black-white infant mortality rates.

False: According to Sir Michael Marmot, behaviors explain about half of social gradient in mortality. No more than 25% of the social gradient in mortality was accounted for by behaviors Invite patients to quit smoking, etc

What are the 5 leading causes of death in the US in 2014?

Heart Disease Cancer Chronic Lower Respiratory Diseases Accidents Stroke

Why might avoidable and premature mortality be an indicator of population health or quality of care?

Higher avoidable and premature mortality is an indicator of poor population health or quality of care and vice versa. People shouldn't be dying of the causes that are either avoidable or preventable. Ideally, avoidable and premature mortality shouldn't exist. Premature mortality: Focuses on potentially unnecessary deaths and weights deaths at younger ages more, can calculate separately for specific causes of death

How do power, control, and stress interplay to impact health? (Monkey Study!)

How do power, control, and stress interplay to impact health? (Monkey Study!) -Social class most important determinant of health, above any other risk factor How do we carry social class in our bodies? How does it under our skin? Idea of control of destiny: ability to influence the events that impinge on your life even if it means not doing anything, but managing those pressures Middle class families: working 2 jobs, not being able to spend time w/ children Unsafe neighborhood, Being relatively poor, having job insecurities will decr control over ppl's lives → likely to increase risk of illness When we feel threatened or to have no control of our lives, stress response kicks in When brain perceives a threat, it signals the adrenal glands to release potent stress hormones: cortisol, etc -the accumulation of stressors or accumulation of resources to manage them SO much is determined by class Certain economic status brings you control over other parts of your life: places you can live, vacations, food consumption, etc In small doses, stress is good! A normal stress response spikes up when needed, then turns off! But what happens when pressures are relentless, and you lack the power and resources to control them? What happens when the stress response stays turned on for months? Years?

Why is understanding the distribution of health outcomes in a population important?

If you just focus on the mean health outcome in a population (e.g., mean life expectancy at birth) and you don't calculate any differences in life expectancy for different groups (e.g., how life expectancy is distributed across groups in the pop) then you will miss important variation that signals disparities in health and where you should target your resources.

Why is it important to measure quality of life and well-being (and not just morbidity/mortality)?

Importance of measuring QOL and Well-being: Quality of life: subjective well-being, *removes diagnostic case definition *(you get to say how YOU rate your health) •Non-fatal health outcomes from diseases/injuries are a crucial consideration in the promotion and monitoring of individual and population health •*Life expectancy increasing...disability more prevalent* -Health systems must address needs of rising numbers of individuals with a range of disorders that largely cause disability but not mortality •*Reflects increased appreciation for not only how long one lives, but also how well one lives* •*Provides individual's perspective* on health and wellbeing - Although the World Health Organization (WHO) defined health very broadly as long as a half century ago, health in the United States has traditionally been measured narrowly and from a deficit perspective, often using measures of morbidity or mortality. But, health is seen by the public health community as a multidimensional construct that includes physical, mental, and social domains. - As medical and public health advances have led to cures and better treatments of existing diseases and delayed mortality, it was logical that those who measure health outcomes would begin to assess the population's health not only on the basis of saving lives, but also in terms of improving the quality of them. - There is no consensus around a single definition of well-being, but there is general agreement that at minimum, well-being includes the presence of positive emotions and moods (e.g., contentment, happiness), the absence of negative emotions (e.g., depression, anxiety), satisfaction with life, fulfillment and positive functioning. In simple terms, well-being can be described as judging life positively and feeling good. For public health purposes, physical well-being (e.g., feeling very healthy and full of energy) is also viewed as critical to overall well-being. - allows you to be subjective, nice to allow an individual perspective (although there are some bias issues) - allows us to see how well we live, just not whether we live in a diseased state - whole idea: we are living older → we are going to see a greater prevalence of chronic diseases due to age → may want to start measuring and track overtime well-being, esp with incr life expectancy

Why is measuring healthy life expectancy an important population health goal? (i.e., what may be wrong with focusing solely on increasing life expectancy as a public or population health goal?)

Importance: overall, on average LE is increasing. In 1900's, lived to about 40 years old. Average length of life was 40 years, now average length of life is 78.8 years old -LE almost doubled since then 1900's ; is this a great health objective? Should we just keep implementing or should we improve health tech/aspects to healthcare that keep us alive as long as possible? Is this a great goal. -all agree: NO it depends, it might be a good goal if we are also increasing the proportion of life spent in good health; we don't want everyone to live longer, if we are just going to have extended low quality of life → We want to measure healthy life expectancy

What is the epidemiological transition? How do these transitions contribute to the burden of illness patterns observed in the US today?

In the 1900's, the leading causes of death were infectious disease. Now in the 2000's, the leading causes of death are chronic conditions associated with lifestyles of individuals. Epidemiological transition + demographic transition = rapid increases in and aging of the US population, as reflected by an increasing proportion of persons aged 65 and older. Pop aging did not account for all of rise in chronic disease mortality (lifestyle factors) In the 1900's, Pneumonia and TB were the major causes of deaths. In the 2000's, the burden has shifted because of the epidemiological transition, and heart diseases and cancer are the major causes of death.

What is the difference between incidence and prevalence? What is the mathematical association between incidence, prevalence, and duration?

Incidence is a measure of risk of a disease or event (based on count of new cases) in a given time period while prevalence is a measure of how much of a disease or condition there is in a pop at a given point in time or time period. Mathematical association: Prevalence ≈ Incidence x duration •Incidence rate provides a measure of the risk of developing a disease or condition within a given population in a specified time period -Can make between-group comparisons (e.g., by person, place, time) to identify risk factors for the disease or condition (etiology) and to predict utilization/new cases -New cases of disease/condition are called incident cases •Prevalence is not a measure of risk b/c it ignores duration of disease and/or death -High prevalence of a disease within a population might reflect high incidence or prolonged survival without cure or both -Low prevalence might indicate low incidence, a rapidly fatal process, or rapid recovery

What is the typical population health indicator derived from the question of self-rated health? What are the pros and cons of this widely-used measure?

Indicator: Percent of population reporting fair or poor health (prevalence) Pros: easy, short, cheap, well-validated Cons: lacks content validity

What are IADLs?

Instrumental Activities of Daily Living (IADLs): Used to assess independent living ability - Target: Older non-institutionalized adults in community or hospital setting 8 areas of function: Historically, women evaluated on 8; men evaluated on 5 Scoring: Highest level in each category; range 0 (low function, dependent) to 8 (high function, independent) - Instrumental activities of daily living are the activities that people do once they are up, dressed, put together. These tasks support an independent life style. Many people can still live independently even though they need help with one or two of these IADL's. They include: cooking, driving, using the telephone or computer, shopping, keeping track of finances, managing medication - Basically asks the question, can you go out and function? range from 0 (low fxn, very dependent) to 8 (high fxn, very independent) historically, women were evaluated on all 8 questions and men just 5 questions, now everyone gets asked all 8 questions Men excluded from Laundry, housekeeping, food preparation Men in traditional households bc if responded to no, simply impaired and unable to complete or just never had to do? Men would look like had greater IADL limitations when really did not

Who is the "Father of Modern Epidemiology" and why?

John Snow: First to suspect a waterborne transmission of cholera (1854 cholera epidemic in Soho) and used map and water-source-specific mortality rates to test theory. Disproved miasma theory using one of first-recorded natural experiments -A "natural experiment". 1854 cholera epidemic in Soho, central London. Snow used statistics to show that water from Southwark & Vauxhall Co (lower Thames; more polluted) was associated with more deaths to cholera than water from the Lambeth Co (upper Thames; cleaner) and relative to cholera deaths in London overall. This is "within-group" analysis that is common to population health!!!

Life expectancy at birth (e0)

Life expectancy at birth is defined as how long, on average, a newborn can expect to live, if current death rates do not change

On average, who reports greater morbidity and lower HRQOL, men or women?

MUJERES

What are McKeown's and LaLonde's theses and why were they important to the evolution of population health? Can you tie them to the "behaviorist/structuralist" and "upstream/downstream" concepts in 9/22 lecture?

McKeown Thesis (1950s+): Improved economic and social conditions (not medical therapies) reduced mortality from infectious diseases in 1700s. Physician and demographic historian proposed that the growth in population in the industrialized world from the 1700s to the present was due to a decline in mortality (the "demographic transition") that was not attributed to life-saving advancements in the field of medicine or public health but, instead to improvements in overall standards of living especially diet and nutritional status resulting from better economic conditions. Became a huge controversy and much of his work has since been largely contested LaLonde Report (AKA "white paper" 1974): Changes in lifestyles or social and physical environments would likely lead to more improvements in health than would be achieved by spending more money on existing health care delivery systems. "Health field concept": Environment, Lifestyle, Biology, Health Care, Delivery System. Importance: McKeown work was controversial but the importance thesis remains today and laid the foundation trying to understand what are the most important determinants of society's patterns of morbidity and mortality and how should public health practitioners focus their efforts? Key contributing question he posed: Are public health ends better served by narrow interventions focused at the individual or community level or by broad measures to redistribute the social, political, and economic resources that exert such a profound influence on health status at the population level? The Lalonde Report gave rise to a number of highly successful, proactive health promotion programs which increased awareness of the health risks associated with certain personal behaviours and lifestyles (e.g., smoking, alcohol, nutrition, fitness). Proposed the concept of "health field" saying the current field that equates health with the quality of medicine is wrong and that the new concept of health field can be broken up into four broad elements (that exist outside the healthcare system): human biology, environment, lifestyle, and health care organization. Tieing it together: Both take on the structuralist approach because they focus on the structural and social determinants, and behaviors (e.g. smoking, nutrition) that affect health. Both look at the upstream causes of mortality and morbidity. Lalonde leans toward a more behaviorist approach but she takes into account the role of the environment.

Which is a more distal health factor, smoking or neighborhood poverty?

Neighborhood poverty

lx

Number of persons from the original synthetic cohort of 100,000 live births, who survive to the beginning of each age interval (lx)

What are some of the challenges of defining a metric's numerator and denominator? If one or the other were over- or under-counted, what impact would that have on the validity of the metric (e.g., over or underestimated)?

Numerators - Accurately defining who is a case or who experienced the event of interest - In measuring health and disease in populations, a decision is necessary to distinguish what is "normal" and what is "abnormal" Diagnostic cut offs Case definitions ICD-10 Denominator - Often difficult to assess who is truly "at risk" of the event in question (ideally, individuals in denominator are at risk of event in numerator) Fertility rate? Incidence of 30-day readmission? - Lack of adequate collection in EHR - Population health researcher and managers deal with large "open" populations (communities) - Selective undercounting of vulnerable populations Impact: Over/under estimation

How is cause of death determined on a death certificate?

On a death certificate, the cause of death is determined solely by the underlying cause. The underlying cause as defined by WHO: the disease or injury which initiated the train of events leading directly to death or the circumstances of the accident or violence which produced the fatal injury. Thus, underlying cause: disease or injury that initiated the events resulting in death. Died of pneumonia, but had AIDS

Infant mortality rate

One of the most important indicators of the health of a nation; Associated with factors such as maternal health, quality and access to medical care, SES, and public health practices . Number of infants deaths (under 1 year of age) in a specified time period per 1,000 live births (B) in the same period D < 1 yr/ B x 1,000

Epidemiology

Paradigm: Black Box: "Exposure related to outcome without necessity to interpolate intervening factors or pathogenesis: (we know there's a statistical association regardless of whether there is a physiological mechanism) Analytic Approach: Risk ratio of exposure to outcome at individual level in population (no need to identify complex mechanism) Preventative Approach: Control risk factors by modifying lifestyle, environment, agent (AKA: "risk factor epidemiology") After WWII - dramatic rise in chronic diseases, especially among middle age men. Efforts to understand chronic disease epidemiology created changes in study design: observational cohort and case-control studies. Key studies at the time were understanding the link between smoking and lung cancer and serum cholesterol and coronary heart disease. As with the era of Sanitary Statistics, epidemiologists were faced with major mortal diseases of completely unknown origin! Risk factor epidemiology was born to find probable causes and statistical analyses and study designs evolved à sampling, four-fold tables and odds and risk ratios. The specific-cause model of germ theory was replaced with a more multi-level model of disease. Black box paradigm remains the prevailing paradigm (though we certainly still apply techniques learned during sanitary and infectious disease epi) Black Box Era: metaphor of "web of causation": multi-causal nature of pub health problems, particularly of chronic diseases, replaced the single causative agent model of disease; leads to new statistical multivariate models using new research methods (e.g., case control and cohort studies) to try to model causes of chronic disease. Classic "four fold table" still in use today to produce risk and odds ratios as measures of disease risk.

Eco-epidemiology?

Paradigm: Chinese boxes: relations within and between localized structures organized in a hierarchy of levels Analytic Approach: Analysis of multiple determinants of health, at multiple levels of analysis; within and across contexts Preventative Approach: Use multi-level, multi-contextual information to develop efficacious prevention programs Era IV: Argues that an exclusive focus on individual risk factors no longer will provide the largest gains in population health. Re-emergence of infectious diseases and increasing technology to understand disease at the molecular level argues we should look at diseases at multiple levels (biological, behavioral, environmental, social, molecular, access). Relies heavily on new biomedical technologies! No longer sufficient to construct risk estimates.

Infectious Disease

Paradigm: Germ Theory: Organisms cause disease ("single agents relate one-to-one to specific diseases"); Vector epidemiology identified Analytic Approach: Laboratory isolation and culture from disease sites; experimental transmission; reproduction of lesions Preventative Approach: Interrupt transmission (vaccination, quarantine, antibiotics)

Sanitary Statistics

Paradigm: Miasma: Disease is caused by "foul emanations from soil, air, and water" (malaria = bad air) Analytic Approach: Demonstrate morbidity and mortality clustering Preventative Approach: Sanitation, drainage, sewage Sanitary statistics: (extra notes) Early 19th century. Diseases are caused by "miasma" noxious forms of bad air - poisonous vapor or mist identifiable by its foul smell. Theory: cholera was transmitted by air and there was a deadly connection between smell and disease. Miasma explained why cholera and other diseases were epidemic in places where water was undrained and very foul-smelling. The theory led to improvements in sanitation systems and public health reforms which incidentally led to decreased episodes of cholera - thus, helping support the theory! Remember Edwin Chadwick: Sanitary Reform movement

What is the "poverty tax?"

Poverty tax: in poorer areas, everything costs more (ex. Cars-paying premiums, etc) -basically, everything costs more in poor areas -incidence of higher prices for goods and services paid by those with low incomes, particularly those living in poverty-stricken areas.

nqx

Probability of dying between ages x and x+n

Prevalence (period and point)

Proportion (%) of all cases of disease in specific population in a specified time period *Point prevalence* Prevalence of the disease at a single point in time Numerator: Count of existing cases at point of observation Denominator: Count of population at point of observation *Period prevalence* Prevalence of disease at any time during specified period Numerator: Count of existing cases at any time during period of observation Denominator: Usually "mid-period population"

Incidence

Rate at which new cases of disease occur in a specified population in a specified time period Rate (or %) = E/P x k -Where E is some event of interest -P is the population at risk of the event -k is some constant used to make the rate more easily interpretable (100 for percent; 1,000, 10,000, 100,000 for rates) Label: e.g., "# office visits per 1,000 males"

What was the significance of removing the handle off of the Broad Street pump?

Removal of the handle prevented additional cholera deaths, supporting Snow's theory that cholera was a waterborne, contagious disease.

What four epidemiological or health eras did Susser and Susser (1996) describe?

Sanitary Statistics Infectious Disease Epidemiology Eco-epidemiology

Population pyramids

See study guide

What four questions make up the CDC's "Healthy Days" measure of HRQOL?

Self-Rated Health Physically Unhealthy Days Mentally Unhealthy Days Activity Limitations

Why is it so hard to work "upstream"?

Social issues lack a quick and easy solution. Politics and the need to look "fiscally prudent."

What are the "social determinants of health" (SDH), specific examples, and how might they directly or indirectly impact health (mechanisms)?

The social determinants of health are the social and economic factors, and physical conditions in the environment that impact health and the distribution of health Social determinants •Economic conditions, social factors, and the physical conditions in the environment in which people are born, live, learn, play, work, and age which, in turn, are shaped by the global distribution of money, power, and resources (WHO; HP 2020) •Prerequisites of health such as peace, shelter, education, food, income, sustainable resources, equity (Ottawa Charter for Health Promotion) •"Upstream" factors that impact health and the distribution of health Examples: •Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods •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, such as the Internet or cell phones •Socioeconomic conditions, such as concentrated poverty •Quality schools •Transportation options •Public safety •Residential segregation

What are the two main hypotheses that explain the observed statistical correlation between social status and health?

Two main hypotheses: 1) Social causation hypothesis -•SES causally affects health (SES à Health) (your SES affects your health) •Mechanistic process: Lower SES may be associated with less access to health care, higher stress, lower ability to process health information, unhealthy behaviors, reduced access to health-producing environments and products, etc. 2) Health selection hypothesis •Health affects SES (Health à SES) •"Social drift" hypothesis: Unhealthy persons "drift down" to poverty •Mechanistic process: Childhood health affects adult SES indirectly via its affect on the individual's ability to achieve higher SES status (e.g., via educational attainment) or to rise out of low SES status

How do food deserts evolve?

Urban areas: supermarkets move to suburbs; leave behind fast-food and convenience stores In an urban area, food desserts might evolve bc supermarkets move out to the suburbs, part of that-this is business-making (making a rational decision) If the ppl who can afford to move, do move → businesses logically follow, leaving behind disinvested areas Suburban areas: Increase in supermarkets; out of walking distance also have a suburban food desert: increase in supermarkets, businesses moving out to the suburbs but are still greater than a mile distance

What are distal (upstream) versus proximal (downstream) causes of health and health disparities?

WHO definition: The chain of events leading to an adverse health outcome includes both proximal and distal causes -- proximal factors act directly or almost directly to cause disease, and distal causes are further back in the causal chain and act via a number of intermediary causes Distal: Structural (racism, policies, political climate) and social determinants (employment status, social support, food, stress,) Proximal: behaviors (smoking, nutrition)

In small doses, stress is good! A normal stress response spikes up when needed, then turns off! But what happens when pressures are relentless, and you lack the power and resources to control them? What happens when the stress response stays turned on for months? Years?

When stress response systems work on overtime, we produce too much cortisol (and other hormones) which floods our bloodstream with glucose, increase heart rate, raise blood pressure, and put body on alert! Over time, increased cortisol impairs immune function, can inhibit memory, and can even cause areas of the brain to shrink! This also leads to increased altherosclerotic plaque, heart disease, heart attack and death! Stress hormones released: Adrenaline, noradrenaline, cortisol! Allostatic load describes the effects of the chronic wear and tear that repeated exposure to stress has on the body. Allostatic load is higher among lower SES individuals. Differential exposure to acute and chronic stress further exacerbate the health-wealth gradient.

Is all policy health policy?

YES

Does access to green spaces follow the health-wealth gradient?

YES! -The inequitable distribution of power, money and resources in society has direct impact on the green environment and ultimately on health. -There is a social gradient on the ways people have access to green space: the lower the economic status, the lower the environmental quality -The access to green space improves mental health and reduces the social gradient in cardio-vascular mortality How might social connections

Can you infer/determine effective modes of disease transmission interruption based on a given disease description and vice versa? (e.g., when are saniwipes appropriate versus condoms?)

You should know enough about modes of disease transmission (e.g., direct (e.g., blood/fluids), indirect (e.g., fomite) to know apply the information to a mode of transmission interruption (e.g., condom versus wiping a cell phone with a saniwipe) versus covering a cough versus docs wearing a face mask etc).

Healthy life expectancy equation

e'x = T'x/lx l'x = Number surviving to age x in good health

Number dying in a given age interval (ndx)

ndx = nqx * lx

What is a food desert?

• *Neighborhood with poor access to healthful foods such as fresh and affordable fruits and vegetables, whole grains, low-fat milk, and other foods that make up the full range of a healthy diet* •USDA definition: A low-income census tract (20% of pop in poverty) with 33% or more of population residing at least 1 mile (10 miles if rural) from a supermarket or large grocery store (Census tract: Small, relatively permanent statistical subdivisions of a county; usually have between 2,500 and 8,000 persons and, when first delineated, are designed to be homogeneous with respect to population characteristics, economic status, and living conditions. Census tracts do not cross county boundaries.) Class Notes: Food desert: inability to access fresh and affordable healthy fruits and vegetables, etc -you can have a store down the street with healthy food BUT maybe you can't afford -access and affordability go hand in hand, healthy choices and affordability

What is the leading cause of disability in the US (2010) ? (shown in order)

•Arthritis and musculoskeletal problems •Heart disease •Stroke •Cancer •Mental health problems •Diabetes •Nervous system disorders •Pregnancy •Accidents

According to the WHO, what is the difference between impairment and disability?

•Impairment: Loss or abnormality of function or structure at the organ level (e.g., loss of eyesight; paraplegia; amputation) •Disability: Restriction in participation that results from a lack of fit between the individual's functional limitations and the characteristics of the physical and social environment Notes: Normalizing impairment- if we report good health it is only a temporary state, all of us at any given time can experience impairment and/or disability -an impairment is some functional lost, but it is only a disability if there is a lack of fit b/w what you need in your environment

If given examples of health statistics or survey questions, could you determine whether the statistic/question was asking about incidence, point prevalence, or period prevalence?

•Incidence rate provides a measure of the risk of developing a disease or condition within a given population in a specified time period •Prevalence is not a measure of risk b/c it ignores duration of disease and/or death Hospital 30-day readmission rate (Incidence) Did you experience a stroke last year? (Incidence) Percent of population with BMI >=30.0 in given year (Prevalence) Do you currently smoke cigarettes? (Point Prevalence) Percent pop age 25+ with HS diploma in given year (Prevalence) Have you ever been diagnosed with hypertension? (Lifetime Prevalence)

What is the "Bronx paradox?"

•Most severe hunger-related problems in the nation exist in the South Bronx - one of US's most obese areas Bronx: paradigm/paradox, concept that this is one of the poorest counties in the US, with one of the highest obesity rates in the US, poverty is associated with obesity (high energy dense, less nutrient rich foods are least expensive meanwhile healthy foods are the most expensive) Extra notes: related to this (so she may ask) •Food insecurity: Limited ability to secure adequate food; often associated with obesity -Rational choice: Chose most energy-dense foods which tend to be the cheapest •3-point solution: -Income supports (Health Bucks) -Increasing healthy options (fruit and veggie carts; tax credits to draw in healthy grocers; FRESH program) -Encouraging nutritious behavior

What is a health disparity?

•Observed population-specific differences in morbidity, mortality, well-being, HRQOL, access to care, and healthcare quality -Even after controlling for behavior! •Cost to US: $309B (KFF 2012) - very simplified view of how disparities in health form: Differences in structural determinants of health create differences in access to social determinants of health which create differences in health behavior which leads to differences (disparities) in health outcomes. There is so much more to investigate beyond social and biological determinants. Issues like culture, discrimination, all play a role in observed health disparities.

What is "red lining" and how do redlining practices contribute to segregation? (major upstream social determinant of health)

•Red lining: Discriminatory practices adopted by FHA and HUD -Exclusionary zoning and Section 8 steering -Discriminatory mortgage funding •Fed used interstate highway and urban renewal programs to segregate Blacks in more racially diverse areas •Results in segregation, concentrated poverty, and cycle of disinvestment -Federal Housing Admin, Housing and Urban Development How the policy of Racial Redlining created wealthy white suburbs and Black Ghettos. Housing policy is rooted in racism and controlling the access that black families have to land and wealth. -United States of Africa

If given a table of age-specific mortality rates and the number of deaths per age group, could you calculate YPLL?

•Years of potential life lost due to premature death = Sum [65 - i] x di