Demography and Epidemiology of Ageing and Migration Tutorial PDF

Tutorial Group 1, Demography and Epidemiology of Ageing and Migration Group assignment 1. Alzheimer's disease (Group 3: Emma, Leila, Emilia, Phoebe) 2. Prostate cancer (Group 2: Aminata, Rueben, Annabelle, Martyna) 3. Type 2 diabetes (Group 1: Claudia, Elif, Carla, Carina) Chair Scribe Case 1 Elif Rueben Case 2 Rueben Annabelle Case 3 Carina Emilia Case 4 Emma pre (replaced by Carla Leila, post) Case 5 Carla pre (Aminata post) Martyna Case 6 Leila (pre) Emma Case 7 Aminata Carina (phoebe) Case 8 Emilia (replaced by Elif (replaced by Leila, pre; Annabelle, pre) Emma post) Case 9 Annabelle Claudia Case 10 Martyna Leila Case 11 Claudia Phoebe Case 12 Phoebe Aminata Case 1 Keywords - Demography - Composition - Distribution - Epidemiology - Changes in populations - Differences/similarities between demography and epidemiology. - Statistical study of human populations. - Consequences of demographic changes. - Measures - What can we measure? (fertility, life expectancy, mortality). - Why do we measure these characteristics? The purpose. - What data are used to measure and determine the characteristics? Learning goals 1. What is demography? Look at the different definitions and compare them. a. Why is it important to learn about demography? (In the view of Public Health) b. What is the difference between demography and a population study? c. What are the factors that we study through demography? Think about keywords such as composition and distribution. 2. What is epidemiology? a. What are the differences between demography and epidemiology? 3. How are demographic changes studied or measured? a. What characteristics can we measure? b. What are the effects of ageing and migration on a population? 4. What is being measured in the following graphs? a. How is it being measured and/or calculated? How do you interpret what is in the graph? b. What data is being used to measure the data in the graphs? c. What are the causes for the changes in the graph? d. What are the consequences of population change, including population size and composition, and for public health regarding each graph? Post Discussion 1. What is demography? Look at the different definitions and compare them. Demography: is the scientific study of the human population, including its size, distribution, composition, and the factors that determine its size, distribution, and composition. 2 kinds of demography Demography is the scientific study of population and is concerned both with the measurement, or estimation, of population size and structure and with population dynamics—the interplay between fertility, mortality, and migration which determines population change.hy 1. Basic demography: can be practised from the perspective of formal demography or that of socioeconomic demography. Its problems are internally generated and are defined by theory and the empirical and research traditions of the field itself. 2. Applied Demography: helps business and governments. Addresses tangible problems. conceive of problems from a statistical point of view, investing only the time and resources necessary to produce a good decision or outcome. a. Why is it important to learn about demography? (In the view of Public Health) It is important for describing population changes and crucial for decision-making. Can be used to create clear patterns and can be helpful to meet the health and healthcare needs of a population. Demography has a lot of subfields and there is a lot of overlap. The health of communities and populations depends heavily on the dynamics and relationships within those populations/communities b. What is the difference between demography and a population study? Demography: How do populations change and their measurement? Population Studies: Why do these changes occur and with what consequences? Population studies is more broad, whilst demography focuses more on specific subgroups. Population studies: is the study of the numbers and kinds of people in an area and their changes seeking explanations for the patterns of a variation in a population and causes of changes + projecting future changes and analyzing future consequences. Population study is doing this study, a tool, which can be used in demography to understand these factors in a population change. c. What are the factors that we study through demography? Think about keywords such as composition and distribution. Demography focuses on 5 aspects of human population (a) Size: the number of persons in a given area at a given time. (b) Distribution refers to the way the population is dispersed in a geographic space at a given time. (c) Composition refers to the numbers of persons in sex, age, and other “demographic” categories. (d) population dynamics (e) socioeconomic determinants and consequences of population change. → ascribed characteristics social and economic characteristics including nativity, ethnicity, ancestry, religion, citizenship, marital status, educational level etc. (characteristics can change in the lifetime) → achieved characteristics 2. What is epidemiology? Studies how diseases spread and distribute across populations and the factors that influence this distribution, And it involves the frequencies, patterns, etc across a population. a. What are the differences between demography and epidemiology? Epidemiology: Aims to understand the causes and patterns of health outcomes to prevent disease and improve public health. It’s used to develop health policies, create disease prevention strategies, and implement public health interventions Demography: Aims to describe and analyze the characteristics and changes of human populations for purposes such as policy-making, resource allocation, and understanding societal trends. Epidemiologic transition: high dominance of infectious diseases shifting towards high dominance of non-communicable diseases. Demographic transition: decrease in death rates followed by a period of strong decrease in birth rates. 1. High birth rates and high but fluctuating death rate 2. Declining death rate and continuing high birth rate 3. Declining birth and death rates 4. There is a low death rate and a low but fluctuating birth rate. All of this means an increase in life expectancy and population numbers. 3. How are demographic changes studied or measured? Different types of measures ratios, percentages, rates, and averages. - censuses, - the files of continuous population registers: from which counts of births and deaths can be obtained. Immigration and emigration data can be obtained from immigration registration systems or from continuous population registers - administrative records, - sample surveys: In poorer countries, where other data sources are scarcer, surveys often present the best source of information on basic demographic parameters The most common demographic measures are birth/death rates, marriage, immigration, and emigration. These are the main ones because they are easy to measure. It is also useful information, and these factors also help measure the size of a population because they contribute mainly to a change in population size. Fertility is a characteristic that is most measured. Through the TFR, they estimate the average number of children a woman would have over her lifetime. A TFR of 2.1 means that they would have enough children to replace the couple, but a TFR below 2.1 means that there would not be enough daughters to replace women and thus a decline in population growth. - Crude death rate, the number of deaths of a thousand years. - The use of life-tables shows the probability of dying between specific ages, and helps in regard to life-expectancy. - In rich countries, death reasons are held up to date by the ICD, this is important because for diseases such as Alzheimers, we could get a clear picture of its effect. Fecundity: the potential number of offspring a population could produce under optimal conditions. Fertility is the actual amount. Fecundity could be seen as the potential, whilst fertility is the actual amount. Fertility could thus be different because of social aspects, The fertility rate is influenced by biological, social, cultural, and economic factors, age at first marriage, perceived ideal number of children, literacy status, media exposure, wealth status, and experience of child death. Cohort follows the experiences of an individual over time, period analysis, over a certain amount of time. Period analysis: things change easily. Because it focuses on a specific time, but because women might have kids at an earlier or later stage, the cohort result could be changed. This one could be biased because you are only looking between certain times, and so social events (e.g. wars) or other reasons could affect when a woman has a child, which might be a time that falls outside of the period analysis. - If women have kids earlier, the TFR would increase, even if the total amount of children in a family stays the same. The TFR could think that women will continue to have children, even if this is not the case. This could be seen as a limitation. Cohort analysis: because you look over the whole duration, you can get a clear answer as to how many kids a woman has. a. What characteristics can we measure? Calculate characteristics: fertility rates TFR (crude birth rate, total fertility rate etc), mortality rates (crude deaths rate, Life tables), migration rates (census, balancing equation), Measured characteristics. - Age, race, sex, year of birth, place of birth, ethnicity, sex-ratio, nativity, ethnicity, ancestry, religion, citizenship, marital status, household characteristics, living arrangements, education level, school enrollment, labour force status, income, wealth, childbearing age, and distribution of the population. b. What are the effects of ageing and migration on a population? Older people are more likely to suffer multiple conditions. Migration can change the age distribution and the size of the population and can improve the economy of a population. Age has an effect on the health and healthcare of a system. Things like Alzheimer's, etc would bring with it extra care costs and long-term care services, the working age of society, if increased, would result in fewer workers and more pressure on pension services. This would also affect the economy. Lower birth rates and higher life expectancy lead to an ageing population. High fertility could mean a balance in this ageing population, but without this, you get an ageing population. The divide in age could also create a divide in society. More and more countries are experiencing a population decline. Within countries, there are these smaller populations where only older people live because younger people tend to flock towards bigger cities, which creates a divide between these villages and the cities. 4. What is being measured in the following graphs? Total fertility, life expectancy, and International migrant stock a. How is it being measured and/or calculated? How do you interpret what is in the graph? For graph 1, how many babies are women having on average over a lifetime. The world wars caused a decline, but after the world wars you can see an increase (baby boom). Beginning of 1900’s: due to the demographic transition, people are actively deciding to have fewer children, there is more development because people are choosing the have fewer children. Contraceptives also played a role then. People are making a conscious decision to have fewer children. This dip is less affected by the epidemiological transition, through for example diseases etc. Graph 2: Life expectancy, the two dips being due to the world wars. The deaths here are not just due to combat, but also due to diseases. The increase is mainly due to epidemiological transitions. Nonetheless, there is an overlap with demographical, but the main reason is due to a decrease in diseases and thus it is more of an epidemiological reason. Things like antibiotics, vaccines, decrease in smoking, better diets (improved nutrition), less famine, sanitation, decreased infections diseases, more education and awareness. Graph 3: Increasing migrants. Because of the decrease in the younger population (work force), there is a market demand for workers (immigrants), and also because Germany is in the EU allows for free moving, which allows for a lot of new people moving in. Stock meaning people born outside of Germany but who are now migrants there. Education, wars, and asylum-seeking are all reasons for this increase in migrants. b. What data is being used to measure the data in the graphs? c. What are the causes for the changes in the graph? d. What are the consequences of population change, including population size and composition, and for public health regarding each graph? Case 2 How to classify/label different types of migration Keywords - ‘asylum seekers’ - ‘Refugees’ - ‘Expats’ - ‘internally displaced people’ - ‘Migrants’ - ‘legal’ and ‘illegal’ migrants. - Push and pull factors: - security - environment - stability - economics - services - EU policies - Citizenship - Impacts on public health Learning goals 1. What is migration? What makes someone a migrant? Migration - the movement of persons away from their place of usual residence, either across international borders or within a state/ change in residence and crossing of an administrative border. Internal migration: moving within the country External migration: crossing borders Migratory mobility: Change of residence across administrative borders Non-migratory mobility: All forms of mobility that don’t qualify as migration (Shopping, tourism…) Short term / temporary migrants: 1 year or longer Long term / permanent migration: 3 to 12 months naturalisation - legal process by which a non-citizen of a country voluntarily acquires citizenship or nationality of that country. Based on several requirements: residency, language proficiency, cultural integration, good character, oath of allegiance. Grants individuals full citizenship rights - Different definitions/types of migration and compare them. (‘Asylum seekers’, ‘Refugees’, ‘Expats’, ‘internally displaced people’, ‘Migrants’, ‘legal’ and ‘illegal’ migrants, citizenship) Analytical categories: by researchers and policy makers Administrative categories: governments and states Discursive categories: politicians and media Asylum seekers: first step before becoming a refugee; every refugee is an asylum seeker first, mostly forced to flew Refugee: someone who is unable or unwilling to return to their country of origin wing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion Expats: usually remain closely tied to their home country; often only temporarily and because of work Internally Displaced country: people who are forced to move but within the country (as a result of /or in order to avoid the effects of armed conflict, situations of generalised violence, violations of human rights or natural or human-made disasters) Legal migrants: people who move to another country following the legal immigration processes (visas,…) Illegal migrants: people who stay in a country without proper legal authorisation, visa… ○ A person cannot be illegal, acts can. There are alternatives for ‘ilegal’ like irregular, undocumented or unauthorised migration. Citizenship: Legal status granted to individuals by a country, giving them rights within that country, such as the right to vote, work, and reside permanently. Can be obtained by birth, descent, naturalisation, or marriage Globalisation: the widening, deepening and speeding up of worldwide interconnectedness in all aspects of contemporary social life. It is often portrayed primarily as an economic process. It has led to the idea that globalisation is both new and inevitable. - It rules out human agency by depicting immigrants as victims of global capitalism who have no choice but to migrate in order to survive. Receiving country bias: the tendency of migration studies to focus on the consequences of immigration in wealthy, migrant-receiving studies, and to ignore the causes and consequences of migration in origin countries. Two ‘kinds’ of theories. 2. Functionalist: sees society as a system, a collection of interdependent parts somehow analogous to the functioning of an organism, in which an inherent tendency towards equilibrium exists. Migration is a positive phenomenon. 3. Historical-structural: social, economic, cultural, and political structures constrain and direct the behaviour of individuals in ways that generally do not lead to greater equilibrium, but rather reinforce such disequilibrium. Economic and political power is unequally distributed, and their cultural beliefs and social practices tend to reproduce such structural inequalities. Migration provides cheap, exploitable labour which mainly serves the interests of the wealthy in receiving areas, causes a ‘brain drain’ in origin areas, and therefore reinforces social and geographical inequalities. Pendular migration - refers to regular movement of people between two places(residence and workplace). Seen in cross-border movements where individuals live in one country/region work in another Circular migration - repetitive movement of a person between two or more locations(home and host country) for employment or other purposes with the intention to eventually return home, maintaining ties with home country Transit migration - temporary stay of migrants in a country en route to their final destination 4. What are the Push and Pull factors for migration? - Push and pull models identify economic, environmental, and demographic factors which are assumed to push people out of places of origin and pull them into destination places - Push factors: include population growth and population density, lack of economic opportunities and political repression - Pull factors: include demand for labour, availability of land, economic opportunities and political freedoms Push factors: - Economic hardship - unemployment, poverty - Economic instability after the fall of communism in EE countries - Political instability - conflict or war, persecution - Syrian civil war - asylum in Germany, Sweden and NL - Natural disaster/environmental factors - climate change, natural disasters - Sub-Saharan and North Africa fleeing to Mediterranean countries - Social factors - poor healthcare or education, overpopulation - Limited access to quality healthcare, education and infrastructure in post Soviet countries - Lack of security - crime and violence - High levels of organised crime and political corruption in Albania and Kosovo Pull factors: - Economic opportunities - employment and higher living standards - Higher wages in countries like the UK, Germany and France - Political stability - peace and security, democratic rights - Turkish, Kurdish Iraqi and Irani migrants in Germany due to political instability and lack of democratic freedoms - Better social services - healthcare, education - Germany and Sweden are known for their strong welfare systems - Family reunification - Moroccan and Turkish communities in Belgium, France and NL - Primary family reunion: migrant is joined by spouse and children - Secondary family reunion: migration follows new unions between migrant’s offspring and spouse - - Environmental factors - favourable climate - Quality of life - social mobility and opportunities for personal/professional growth - Ireland, Germany and Sweden have policies designed to attract highly skilled migrants, particularly in fields like technology, engineering, and healthcare Combined Push and Pull factors: - Brexit - reverse migration of British citizens into Eu countries(Spain, France and Germany). Push: uncertainty over job security and residency rights in the post-Brexit UK, pull: access to the EU’s single market and continued freedom of movement Factors that Pushes people out of places and pull them into another place for better life conditions Critiques: negative: the model assumes that these factors “cause” migration, without taking into account of the role of other factors it’s a list of major factors, where all of them can contribute to migration; but it is not clear how the various factors can be combined Negative aspects: It can be misleading. It is a purely descriptive model in which factors assumed to play a role in migration are enumerated in a relatively arbitrary manner, without specifying their role and interactions. ‘It is never entirely clear how the various factors combine together to cause population movement. We are just left with a list of factors’. It is also deterministic (not taking into account the role of other factors). Environmental or demographic factors should not be isolated from other social, economic, political, or institutional factors affecting people’s living standards. - Do they influence each other? And how? Distinguishing between push and pull factors is nearly impossible, they interconnect and influence each other 5. How does migration influence demography in the EU? Places of immigration may change/ they have changed for years. Nowadays the “heart” of immigration is Europe but it may change to China for example in the future - The political significance of migration has also increased in Europe, which is reflected in the rise of far-right, anti-immigrant and anti-refugee parties and a huge shift to the right across the political spectrum on migration and diversity issues 1989 fall of the Iron Curtain “Lotus land” - germany, uk, france Break-up of Yugoslavia - Bosnian War, Croatian War of Independence, Kosovo War - ethnic violence(ethnic cleansing of Bosnian Muslims), war crimes, genocide(Srebrenica Massacre 1995) - biggest humanitarian crisis since WWII Co-nationals returning to their “motherland” - populations displaced in communist times, in the former USSR 1990s - increasing integration of central and eastern Europe 2015 Syrian refugee crisis - mass displacement of millions of Syrians due to the civil war - conflict between syrian government, rebel groups, ISIS 6. How does migration affect public health in the EU? - Lack of access to proper housing, education, legal protection, healthcare system may lead to the exacerbation (worsening of breathing symptoms in COPD - lung infection) and creation of health risks - TB, SARS-CoV-2. - Understanding the demographic processes as well as political context of migration is crucial for understanding and addressing public health concerns of both migrants and local populations. - Access to healthcare differs between migrants - Different people moving to different places brings a huge range of different diseases - Migrants and refugees are part of the Universal declaration of human rights - but you need a state that would ensure those rights - Human rights = healthcare and person rights Case 3: Ageing Europe - Part A: Diseases that are associated with older age e.g. dementia and stroke - Part B: Comparing different study designs Keywords: - Dementia - Stroke - Ageing population - Observational and experimental research - Depression Learning goals: Part A: 1. Define depression, ageing, stroke, dementia. a. Look at dementia: causes, symptoms, types, (trends and epidemiology), risk factors, how is age related to this. - Broad term for cognitive function decline - Memory, thinking, language, problem solving, behaviour - Related to ageing because affects elderly - Greatest global challenge - ⅓ cases could be prevented - Risk factors: Education, inactivity, hearing loss, less social contacts, genetics, family history, diabetes, hypertension, obesity, smoking, depression, traumatic brain injury, visual impairment, sleep disorders. - Modifiable and unmodifiable (age, genetics) factors - Types: Alzheimer, vascular dementia, Lewy’s body dementia, frontotemporal - Biological and environmental causes - Trends: - 4 most common types: 1. Alzheimer 60-80% of cases 2. Vascular - 3. Lewy 4. Frontotemporal - Dementia can develop after stroke or injuries in the brain. - 15 million people globally, 10 million cases every year. - It affects more women than men. - Decrease in Sweden, NL and Canada. - Symptoms: memory loss, difficulty communicating, poor judgement, mood changes, personality changes, difficulty performing daily tasks. Mild cognitive declinement. Symptoms get worse over time. - Important factor is cognitive reserve, which refers to the brain's ability to resist damage and delay the onset of dementia. Some people have a stronger cognitive reserve (due to factors like education, intellectual and physical activity. - Randomized control study, interventions on dementia progression, cohort studies for longterm studies. Cross-sectional to identify risk factors. Case-control to find protective factors. - Relation to age: Age is less of a risk factor, but still important because life expectancy is increasing. Cognitive decline because of changes in the brain. - Young-onset dementia is anyone before 65years 9%. - Cognitive reserve: education, activity. - Symptoms and development are not linear. Dementia can also get worse very quickly/slowly. b. Look at depression: causes, symptoms, types, (trends/epidemiology), risk factors, how is age related to this. - Mental disorder, involves a depressed or mood or loss of pleasure or interest in activities for long periods of time; Can affect all aspects of life, including relationship with family, friends and community - Symptoms: fatigue, changes in appetite, sleep issues, loss of concentration, guilt, suicidal thought, these emotions are persistent. - Symptoms for 2 weeks to be able to be diagnosed. - Anxiety symptoms can appear before major depression. - Types: - Major depressive disorder (MDD) - Persistent depressive disorder - Bipolar disorder - Postpartum depression - Depressive episodes - More common in women than men. Common in the elderly. - 40% experience first episode before age 20. - Men commit more suicide. - Germany highest number of depression in EU 9,2% of German male and female, Luxembourg and Sweden also had high numbers - Lifetime prevalence 10-15% - Prevalence increased after Covid-19 pandemic. - Relation to age: Risk increases with chronic illness, social isolation, disability - Undiagnosed because can be mistaken as dementia symptoms. - Elderly are more lonely and get less diagnosis that can affect the prevalence/incidence. - Elderly may not have as much access to information as younger people (social media) - Resilience has built up during life. - Risk factors: Family history, stress and life events, medical conditions, substance abuse, hormonal changes, social isolation, identity struggles, social media pressure, genetics c. Look at stroke: causes, symptoms, types, (trends/epidemiology), risk factors, how is age related to this. - Blood supply to brain is interrupted. - neurological deficit attributed to an acute focal injurt of the brain, retina or spinal cord by a vascular cause. - Leads to death of brain cells and causes sudden brain dysfunction - High blood pressure risk factor - ¼ people affected, 2nd leading causes of death. - Symptoms: nausea, vomiting, decreased level of consciousness, weakness, difficulty speaking, loss of balance, confusion, vision problems, numbness in one side of the body only - sudden onset of symptoms - Risk factors: high blood pressure, smoking, diabetes, hyperlipidemia, physical inactivity; Atrial fibrillation (irregular and often very rapid heart rhythm) - Types: - Ischemic stroke: caused by blocked artery, usually due to a blood clot(thrombosis or embolism), accounts for 85% of all strokes - Hemorrhagic stroke: caused by a ruptured blood vessel in the brain, leading to bleeding. Often due to high blood pressure or aneurysms - Transient ischemic stroke(TIA): temporary blockage of blood flow to the brain, often called a mini-stroke, which can be a warning sign of a future stroke - Trends: - more people living with a stroke is increasing because of population ageing. - Incidence: 600 000 death annually in the EU, 1.3 million cases of long term disability annually in the EU. 2. How do they impact public health and the EU? Dementia: - EU has highest proportion of elderly. 10 million people are living with dementia and its estimated to double by 2050. - 250 billion euros costs annually to EU. - Stigmatization - Poorer countries have lack of management to dementia because of higher costs and lack of understanding dementia - Family members end up caring for the patients that create economic costs - People in Nursing homes and hospitals are increasing. Depression: - 40 million adults in the EU. - Loss of productivity. - 75% of people in low and middle income countries receive no care, lack of care and care providers, social stigma associated to mental disorders. Stroke: - 2nd leading cause of death in the EU. - 45 billion euros annually (hospitalitation, rehabilitation, long-term care…) - Loss of productivity connected to disability. 3. Trend of ageing in the EU? How does it impact public health? What impacts the life expectancy/what causes the ageing (fertility, demography) 4. How can we measure and monitor these trends? - Self-reported data from questionnaires - Health insurance companies, GP, hospitals - Registries - Prevalence, incidence, demographic studies Part B: 1. What are the different study designs? (observational and experimental) Observational: - Observing and analyzing variables without manipulation, natural environment - Case reports - Ecological studies - Cross-sectional - Cohort study - Case-control study Observational study: The main objective of case reports and case series is to document a comprehensive and detailed description of the case(s) under observation. - Case reports and case series are key hypohtesis-generating tools. Howeve,r without a comparison group, not much can be done. This is where ecologic studies come in. Cross-sectional study: examines the relationship between diseases (or other health-related characterstics) and other variables of interest as they exist in a defined population at a partciular point in time. They could be defined as studies taking a snapshot of a soceity. They provide information on the prevelance of disease. Used in initially investigating the association between a specific exposure and a disease of interest Case-Control Study: to examine the possible relation of an exposure to a certain disease, we identify a group of individuals with that disease and, for purposes of comparison, a group of people without that disease. Limitations: temporal bias. Where you cannot establish if the exposure is a consequence of the disease —-> reverse causality. This can, however, be solved through a questionnaire. Survival bias: where the number of prevalence of an exposure is lower than that of incidence. If a risk factor leading to a diseases is particularly deadly there would be less registered diseases caused by that specific risk factor Any risk factors we may identify in a study using prevalent cases may be related more to survival with the disease than to the development of the disease (incidence), which introduces selection bias. Cohort Studies: the investigator slect a group of exposed individuals and a group of unexposed individuals and follows both groups over time to compate the incidence of disease (or rate of death from disease) in the two groups. - Longtituinal/ prospective cohort study: it is concurrent (happening or done at the same time) because the investigator identifies the original population at the beginning of the stuy and, in effect, follows the subjects concurrently through the calder time until the point at which the disease develops or does not develop Experimental: - Active manipulation of the independent variable to see the impact on the dependent variable. - Randomized Controlled Trials (RCTs) - Participants are randomly placed in either a treatment or control group to test an intervention, like a new drug. Randomization helps reduce bias, making RCTs the best for proving cause and effect. - Quasi-Experimental Studies - Similar to RCTs but without random assignment. a. Advantages and disadvantages of them Observational: advantage: - Useful to generate hypotheses - Causal relationship Case-control: - Only measures prevalence Cohort: - Longitudinal, expensive Case-control - Short-term, cheaper than cohort - Selection bias Cross-sectional: - Limitations: temporal bias, reverse causality, survival bias, RCT: - Cause and effect can be determinant - Investigate the effectiveness of intervention - Randomization - Disadvantage: a complex study, expensive, ethical concerns 2. How do you approach and investigate them? 3. Prepare a 5-10 minutes presentation (5 slides) with your group. Research questions from the case - Why you chose the study design? - What population you would use? - Which measurements you would perform (dependent and independent variables)? - Which measure of association? - Practical aspects of the study. Case 3 - Research question 1 - Presentaciones de Google https://docs.google.com/presentation/d/1-CMqRsJBEYcj8TjEmxChHgLhDNRz_-yYuIzWq0u AOWM/edit?usp=sharing Group 3 - https://docs.google.com/presentation/d/1XiYgNwraYD04-XbuDYCzUQ1PRPR6E8WntKPB-p e33xY/edit?usp=sharing Case 4 Keywords - Socioeconomic status → impact on health inequalities - Mortality, morbidity - Mental health - Interactions → interconnectedness of all the indicators - Inequalities throughout the EU - Education level - SES indicators - Differentiation between parental SES and children’s perceived SES - Dependent on individual perception, surroundings - Analysis of the graph - what does the graph depict? Learning goals - What is socioeconomic status? = position of an individual within a society, often based on income, occupation or education - Also includes subjective perceptions of SES (American psychological Association) Socioeconomic status (SES) encompasses not only income but also educational attainment, occupational prestige, and subjective perceptions of social status and social class. SES reflects quality-of-life attributes and opportunities afforded to people within society and is a consistent predictor of a vast array of psychological outcomes. - What is a low, medium, high SES? - People with a lower SES have less access to financial, educational, social, and health resources than those with a higher socioeconomic status - Lower education levels associated with higher levels of CVDs - Food, shelter and safety are priority in a low SES, education less important - How individuals see themselves - Income, education, and occupation are 3 main ways to define SES - Low SES individuals live near or below the poverty line - Difference between high and medium SES: both have their basic needs met, but high SES individuals can afford luxuries - Difficulties in drawing the line (subjective perception, different ways to measure SES - all of which are flawed) - What are the indicators of SES? (focus on prestige-based, resource based indicators) Prestige based SES indicators: individuals ́s social standing and perceived status in society related to occupation and education - Occupation: often used to reflect social standing or prestige, high status professions are considered prestigious, while lower-status jobs may indicate lower prestige o SE index classifies occupations into hierarchical categories - Parental education level: number of years of formal education or highest degree obtained Resource-based: income, education, wealth - Material, social resources and assets Individual measures: education, income, employment Contextual Measures: zip-codes, average house-value, % single parent families - What is the impact of SES on mental health, loneliness, access to health, and quality of life? Mental health - Lower SES groups exposed to stress, low control, negative life events - Low SES affects ability to manage stress - Bad mental health can lead to addiction - Health inequalities resulting from SES - Worse in men in most countries (more prone to substance use etc.) Loneliness - Chance of loneliness increase with low SES - Loneliness: unpleasant experience occurring when the quality or quantity of an individual’s social relationships are insufficient - Lack of coping mechanisms or sources in individuals with low SES - Also related to geographic area, living conditions Access to healthcare - Low SES: limited access to healthcare services, often due to lack of health insurance, inability to afford care, or living in areas with fewer healthcare facilities → not an issue in high-income countries anymore (healthcare financing systems) - Disparities between and within EU countries regarding SES - Direct link between money and healthcare - Certain groups may have higher exposure to stressors (e.g. migrants) - exclusion due to ethnicities or race - Bias leads to dismissal of health concerns in certain racial, ethnic groups → worse health concerns - Language barriers or ability to understand healthcare providers Quality of life - Quality of life decreases with lower SES → higher income, knowledge, education increases possibilities - Lower SES not only live shorter lives but also have higher rates of disability - Quality of life also perceived as lacking among people with a low SES - Childhood in higher SES households leads to better physical and mental health outcomes later in life - Substandard housing greatly impact health outcomes → exposure to pollutants - Neighbourhood characteristics - Availability of alcohol and exposure to violence - Working conditions impacts health outcomes Disability Adjusted Life Expectancy (DALE): - The concept of Disability Adjusted Life Expectancy (DALE) is introduced, which combines both the quantity (life expectancy) and quality of life (years lived with disability). Lower socio-economic groups not only live shorter lives but also spend more years in disability, resulting in a significant disparity in DALE. - In some European countries, people from lower socio-economic groups can expect to live up to 10 fewer years in good health compared to their wealthier counterparts. - Is there a distinction between parental SES and children’s SES (parental SES, adolescent subjective SES, adolescent educational level) Parental SES - Occupation, wealth and income of the parents → long-term effects on their children - Occupation has less impact in terms of social standing, but important in terms of the income and opportunities that can then be provided → but varies depending on context one is in *no difference between ‘normal’ SES and parental SES → same indicators, but look at how this impacts the child Adolescent subjective SES - Personal perception of one SES - How they see themselves in comparison to their peers → surroundings can impact this subjective view Children’s SES - Limited indicators → education level, familial composition (income distribution, household number), neighbourhood composition - zip-codes (type of school, physical activity opportunities, safety, social environment) - If you come from a lower SES the chance of you being in a low SES as an adult increases (vicious cycle) - Low SES: higher fertility, but less healthy children → premature mortality - Level income: also dependent on cost of living in different countries, different currencies - What are the differences between SES groups with regard to the age related groups (mortality, morbidity, disability) Mortality - Extreme differences in mortality within countries between high and low SES (e.g. differences in probability in male death between Zimbabwe and Sweden - 20% vs, 82%) - East-west differences within the EU - Life expectancy also greatly varies between countries in Europe - Differences in life expectancy within the same city (‘goes down with each tram stop’) - Child mortality highest among the poorest households - Most chronic diseases have higher prevalence among lower SES (exception: cancer) Morbidity = The condition of suffering from a disease or medical condition - Subjective health: people with lower SES usually reported low health, face higher exposure to health risks - Individuals with lower education levels more likely to report poor health - Higher rates of chronic conditions in individuals with low SES - However, over the past decades, inequalities in morbidity by SES have been stable in the EU (however still high inequalities) - Bulgaria is the poorest and has the highest burden for disability - Sweden, Finland, France have the best rates - Interpret the graph - Mortality higher among men than in women → has been changed over the past years - Gap has widened between men in middle and low level of education - Slight increase among women as well - Gap between men and women decreasing - What is interaction? Effect of an independent variable on a dependent variable Occurs when the effect of one variable depends on the value of another variable - RCTs to find a causality - How the relationship between SES and health outcomes changes based on the presence of other various - E.g. you have low SES and you smoke → effect of those two things is more that what you would expect from them separately - Effect modification: third variable which modifies the effect Case 5 Keywords: - Epidemiological Study designs - Three types of systematic errors - Cause-and-effect research questions - Research quality Learning Goals: 1. What are the different study designs (short recap)? - Case-control studies, cohort studies, cross-sectional → observational - Randomised control trials → experimental 2. What exactly is meant by research quality when considering cause and effect type of research questions? - High quality research is the one that is designed, conducted and analysed in the right way to minimise potential errors. Flawed research leads to wrong answers to causal questions. a. How is it linked to the different study designs? 3. What is bias and what is meant by internal and external validity? Bias: a systematic deviation from the truth. The study findings deviate from the truth due to systematic errors, giving an incorrect picture of hte target population. // Bias: “any systematic error in the design, conduct or analysis of a study that results in a mistaken estimate of an exposure’s effect on the risk of disease.” - Internal validity: Internal validity examines whether the study design, conduct, and analysis answer the research questions without bias. - External validity: External validity examines whether the study findings can be generalized to other contexts. - Quantitative Bias: the quanittiy of observed assocation deviated from the truth. Can either be an oversestimation or underestimation, meaning that hte observed assoaiton appears stronger or waeker than the true associaton in the population Overestimation (bias towards the null) Underestimation (bias towards teh null) - Qualitative bias: the observed association is opposite of the truth (bias acorss the null). - 4. What are the three types of systematic errors (selection, information and confounding bias)? Selection bias - Selection bias: systematic errors during selection and/or follow-up of study population - Happens when you select a study population that misrepresent the target population - Due to systematic selection errors into or out of a study - Can be caused by: o The researcher (unclear definition of study variables; unclear definition of population; influences treatment allocation) o The participants (willingness to participate; dropout or loss to follow up) - Depending on specific mechanism and timing of systematic errors when selecting and following up study - Susceptibility for selection bias depends on study design o Case control & cross-sectional studies susceptible upon participant inclusion o Experimental & cohort studies mainly susceptible during longitudinal follow-up - Selection bias to non-response is problem in case-control (and cross sectional) studies when selecting study subjects but NOT in experimental (and cohort) studies - How to deal with it: o Needs to be controlled during design and conduct of study o Cannot be corrected anymore in data analysis but signs of possible bias need to be recognized; and effects of bias need to be estimated - Options for preventing or decreasing risk of selection bias: o Clear eligibility criteria (should properly reflect characteristics of target population) o Random selection (selection should be independent from exposure and outcome) o Maximize participation and minimize loss to follow up (try to get high response and keep participants in study) o Randomization and blinding in an RCT (removes predictability and knowledge of treatment assignment) - Information bias: Systematic errors during measurement of study variables - Information bias is caused by measurement errors when gathering information about exposure and/or outcome from study participants (-> almost always occur) - Measurement errors can be caused by … - The researcher: wrong execution of study measurements - the participant: provides wrong information, willingly or unwillingly - the measurement instrument: suboptimal validity and reliability for study population - Differential classification - bias towards, away from the null. the degree of misclassification is not the same for all study participants (called systeamtic miscalsification), usually results in a bias towards, way from, or across the null. - Non-differential classification: the degree of miscalsssifciation is the same for all study pariticpants, which resulats in a bias towards null. - Compensating bias: The idea is that when the bias in selecting cases and controls is of the same magnitude. A hypothetical example of compensating bias is a case-control study in which both cases and controls are identified through a screening program - Confounding: not accounting to outside variables influencing the study. Can be caused by mixing of effects of two (or more) exposures - Effect modification - IS NOT CONFOUNDING bias - these are the differences that naturally occur in every study - Factor X is a known risk factor for disease B. Factor X is associated with exposure A, but is not a result of exposure A. - confounder is NOT an intermediate in the relation between determinant and outcome - because an intermediate we would not adjust,as it is a part of the path in the study (cause and effect), but the confounder we would want to adjust. - - Triangle; Outcome (e.g. disease) are usually caused by multiple, interrelated factors - Confounder is a cause of the outcome - Confounder is associated with the determinant - Confounder is NOT an intermediate in the relation between determinant and outcome Stratified analysis is used to detect and account for confounding 1. Calculate the associations of the determinants with the outcomes in the total study population (crude association) 2. Calculate the associations of the determinants with the outcome in the subgroups (strata) based on the confounder (stratified association) 3. Compare the crude associations with the stratified associations, three options: a. No confounding, the crude association is equal to the stratified association b. Confounding, the stratified associations are equal to each other, but not to the crude association c. Effect modification, the stratified associations are not equal How do we deal with them?: - Identify potential confounders and measure them - adjust, for example randomisation. - Design strategies to prevent or reduce risk of confounding, for example randomization, restriction and matching - Analysis strategies aim to eliminate biassing influence confounders, for example stratified analysis 5. What can go wrong in epidemiological studies? Random errors - Threaten the precision of study findings - Random errors cause imprecise findings - Precision is dependent on sample size (the larger the study, the more precise your findings will be) - Lack of precision = sampling error Systematic errors - Threaten the accuracy of study findings - Systematic errors lead to incorrect findings - Accuracy is independent of sample size - Lack of accuracy = bias Following up study participants - Loss of participants - selection bias - in follow-up studies - it is especially bad when it happens in only one group leading to bias Measuring important study variables as part of the data collection - Risk of information bias - providing wrong information or wrong measurements are used (validity - the extent to which the answer is a reflection of real population// reliability - when you are not getting consistent answer - if its precise and consistent) Disregarding important extraneous variables in data analyses - Quality of measurement instrument criteria reliability: the consistency of measurement (its ability to produce similar results when repeated measurements are made under identical conditions) validity: the extent to which a measure really measures what it intends to measure Random error Systematic error 6. Which analytic strategies would you use to handle potential systematic errors? - For selection bias - randomisation, minimise loss of follow up, understanding why the loss of participants occurred and addressing it, focus on target population (clear selection criteria) - For information bias - using standardised instruments for data collection, minimise errors during the study as correction is not possible later, - For Confounding - trying to anticipate the confounders before the study, stratified analysis, matching, 7. Additionally, answer 3 questions in the 3rd paragraph - everyone presents the answers based on the given articles Article 1 - Effects of a randomized, culturally adapted, lifestyle intervention on mental health among Middle-Eastern immigrants Potential sources of systematic error: - The participation rate is 15.1%. This low rate may result in selection bias, which may not represent the whole population - Selection bias - Small group - Information bias - Short time to follow-up - Recall bias - Confounding Study design and analytic strategies to handle errors: - RCT - other strategies or designs the authors could perhaps have used to improve the quality of their research: Article 2 - Common mental disorders among young refugees in Sweden: The role of education and duration of residency.(Emma) Potential sources of systematic error: - Information bias - misclassification - Self report / subjective - Did not account for pre migration mental health Study design and analytic strategies to handle errors: - Cohort study → relationship and the impact of the role of education and duration of residency in mental health other strategies or designs the authors could perhaps have used to improve the quality of their research: - Instead of self report use data from registers Article 3 - Migration history and risk of psychosis: results from the multinational EU-GEI study. Potential sources of systematic error: - Selection bias - Non representative group - Only focussed on first generation migrants Study design and analytic strategies to handle errors: other strategies or designs the authors could perhaps have used to improve the quality of their research: - Maybe a prospective cohort study would have been better Case 6 Keywords: - Migration and infectious diseases - Screening - Refugees and asylum seekers - Why are migrants more susceptible to TB - Hep B and C, TB, HIV - Identifying types of bias - Risk factors - Health of migrants, health of locals or both? - Stigma - Healthcare access - Endemic places of TB - Why they couldn't get treatment before the arrival to denmark - Why do we associate migrants with infectious diseases and screening programmes Learning goals: 1. Short recap of TB, Hep B and C, HIV(epidemiology, general info) TB - Bacteria that affects the lungs - caused by a type of bacteria. It spreads through the air when infected people cough, sneeze or spit. - 10.6 million were ill with TB in 2022 - Prevention: - Vaccine Hep B: - is a viral infection transmitted through blood, sexual contact, and from mother to child at birth. It's endemic in parts of Asia and Africa, where migrants may come from. - General Info: Chronic HBV infection can lead to liver disease or cancer. Vaccination exists, but access may be limited for some migrant populations. HIV - Human immunodeficiency virus - Weakens the body's capability to fight infections - Transmission: direct contact with certain body fluids (blood, semen, vaginal fluids, rectal fluids, and breast milk) from a person with HIV unprotected sex, sharing needles, mother-child transmission (pregnancy, childbirth, breastfeeding), blood transfusion/organ transplants - 2. How can healthcare be accessed by migrants? a. How is it defined; - How access is defined - Optimal access is providing the optimal services at the right time - Utilisation of preventative services, GPs, ERs, Hospitalisation - Equal vs equitable - Barriers to access - Formal: Legal, FInancial - Informal: Language, Communication, sociocultural factors - Access has been defined as the fit between patients and the health systems - Access is considered equitable if it does not depend on education, income, migrant status, ethnicity or geographical distance. what healthcare problems are important to address in the context of migration? - Chronic diseases; maternal and child health; health care access in general b. What are some risk factors (for TB and other infectious diseases) migrants are exposed to? - Poor living condition - Barriers to access care in home country - Poor hygiene - Health literacy - Little access to preventative measures - Legal barriers -> undocumented migrants (fear of consequences) - In most European countries only emergency services are available for undocumented migrants 3. What are challenges migrants face in accessing health care a. What is the role of socioeconomic inequalities in migrants' access to healthcare? - Communication between health professionals and patients - Language barriers - Marginalisation, racism - Poor living conditions - Lower income and no stable employment - Social exclusion -> harder to interact with healthcare - Migrants not feeling a part of society and that they don’t have a right to use health services - Inadequate information on healthcare systems 4. What is the role of health screening in this context? a. Who should be screened, why, and where? - Screening is defined as ‘any intervention that involves providing information about the chances that an asymptomatic individual will develop a particular disease’ - TB: strengthen screening in high TB prevalence countries - Early detection of disease - To study social determinants of migration and their access to care - Health Belief Model (HBM) and the Theory of Planned Behaviour (TPB) - HBM:HBM: Health Beliefs Model, effective in predicting the uptake of screening, and the model has been used to inform interventions for NCDs. - TPB: Theory of Planned Behavior: (TPB) used to inform screening interventions targeting communicable as well as stigmatising diseases. - Cost-effectiveness increases if these models were used 5. What are the potential consequences of defining migrants as a risk group for infectious diseases? - Stigamtisaton - Reinforcement of healthcare inequalities - Fear of marginalisation -> migrants not feeling included and scared to make use of preventative measures - Community networks: between migrants can strengthen their use of healthcare / needed for good health -> but are often weak 6. Why are screening programmes predominantly focused on infectious diseases(in context of migration)? - Migrants might arrive from countries with high prevalence of infectious disease - Chance of migrants having TB was seen to be higher than in non-migrants 7. Read Kristensen et al (2019) and try to identify different types of bias - Selection bias - Undocumented migrants were excluded -> different results if they were included. Underestimation of TB in undocumented migration - Only after the age of 18 -> no information on children - Information bias - Only migrants with residency were included -> miscalculation / no information on the time span after arriving in the EU (did they have TB before?) - Confounding - Socioeconomic status - Survivorship bias - Death before diagnosis or residency Case 7: Quality of screening tests for cystic fibrosis in newborns - Epidemiology - Statistics - Diagnostic testing, different types. Keywords: - Sensitivity - Specificity - Predictive values - Reliability-validity - False positive/negative results - ROC curves - Diagnostic testing - Properties ( validity-reliability) - Basic principles of screening tests Learning goals: 1. What is diagnostic research? The method of measurement to determine diagnosis of care for disease. Used to identify the causes of the problem, used in business, healthcare to find the root cause of the problem and find appropriate solutions. Diagnosis is when you classify problems( you have symptoms), screening you're identifying high risk persons. Diagnostic research is focused on identifying whether individuals have a particular disease or condition, usually by developing and evaluating the performance of diagnostic tests. The goal is to determine the accuracy and effectiveness of these tests in distinguishing between individuals with and without the disease. Diagnostic and prognostic testing includes: - Clinical investigation - Identify the symptoms observed by the patients through history-taking (interviewing the patient) - Physical examination - Using imaging techniques such as X-rays, computed tomography (CT), magnetic resonance imaging (MRI) or ultrasound, and lab tests, to supplement the observations a. What are the different types? Clinical investigation- Physical examination ( xrays) b. What are the basic principles of screening tests? (don't go into depth) Implies a use of a simple test for disease for a healthy asymptomatic population, separating people who are more likely to have the disease from those who are less likely. Reduce mortality and disability with the benefits of decrease in costs, less exposure and benefits the health of those being screened. The test should be cheap and simple. 2. What is reliability and validity? The validity of a test is defined as its ability to correctly distinguish between who has a disease and who does not. Validity has two components: sensitivity and specificity. The reliability of a test can be repeated and there are several factors, - intrasubject variation (variation within individual subjects), intraobserver variation (variation in the reading of test results by the same reader), and interobserver variation (variation between those reading the test results). a. What are the properties ( different types of validity)? Content validity- more subjective- Construct validity- if the instrument is constructed in accordance with theoretical.- Internal validity - degree to which study design represent truth in target population External validity: extent in which the results can be generalised to other populations and settings. Criterion validity: It evaluates how well the measurements predicts and correlates with an outcome or another. How well your tests relates to that gold standard. https://www.simplypsychology.org/criterion-validity-definition-examples.html Concurrent and predictive validity are components of criterion validity. → most important one when it comes to screening 3. What is sensitivity/ specificity/predictive values of screening tests( focus on definition but also how to interpret ) ? Sensitivity: the chance of positive test in people with health condition, or the ability of a test to identify patients who have the disease. It is not related to the prevalence of disease. - High sensitivity means that the proportion of true positive is high and false positive is low. Sensitivity, or true positive rate, quantifies how well a test identifies true positives Specificity: the ability of the test to correctly identify the people who do not have the disease. The sensitivity of the test is defined as the ability of the test to correctly identify those who have the disease. The specificity of the test is defined as the ability of the test to correctly identify those who do not have the disease. Values of screening tests: a different question may be important for the clinician: “If the test results are positive in this patient, what is the probability that this patient has the disease?” This is called the positive predictive value (PPV) of the test. In other words, what proportion of patients who test positive actually have the disease in question? To calculate the PPV, we divide the number of true positives by the total number who tested positive (true positives + false positives A parallel question can be asked about negative test results: “If the test result is negative, what is the probability that this patient does not have the disease?” This is called the negative predictive value (NPV) of the test. It is calculated by dividing the number of true negatives by all those who tested negative (true negatives + false negatives). 𝑎 𝑡𝑟𝑢𝑒 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒𝑠 Positive Predictive Value (PPV) = 𝑎+𝑏 = 𝑡𝑟𝑢𝑒 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒𝑠 + 𝑓𝑎𝑙𝑠𝑒 𝑝𝑜𝑠𝑖𝑡𝑖𝑣𝑒𝑠 → chance that health condition is present in case of positive test 𝑑 𝑡𝑟𝑢𝑒 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒𝑠 Negative Predictive Value (NPV) = 𝑐+𝑑 = 𝑓𝑎𝑙𝑠𝑒 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒𝑠 𝑡𝑟𝑢𝑒 𝑛𝑒𝑔𝑎𝑡𝑖𝑣𝑒𝑠 → chance that health condition is absent in case of negative test In practice you don't always have the results of the gold standard Thus, there is a trade-off between sensitivity and specificity: if we increase the sensitivity by lowering the cutoff level, we decrease the specificity; if we increase the specificity by raising the cutoff level, we decrease the sensitivity. the higher the prevalence, the higher the predictive value. Therefore, a screening program is most productive and more cost-effective if it is directed to a high-risk target population. Prevalence indicates likelihood of diagnosis before the test is applied (pre-test or prior probability). a. False positive/negative test results and their meaning? False positives: those who do not have the disease but test positive and vise versa. Some people who do not have the disease are erroneously called “positive” by the test (false positives) , and some people with the disease are erroneously called “negative” (false negatives). The issue of false positives is important because all people who screened positive are brought back for more sophisticated and more expensive tests or perhaps undergo an invasive procedure that is not necessary. False positives are associated with costs—emotional and financial—as well as with the difficulty of “delabeling” a person who tests positive and is later found not to have the disease. Those with false-negative results, on the other hand, will be told they do not have the disease and will not be followed, so a serious disease might possibly be missed at an early treatable stage. Thus the choice of cutoff level relates to the relative importance of false positivity and false negativity for the disease in question. b. What are ROC curves? ROC (Receiver Operating Characteristic) curve represents the combinations of sensitivity and specificity for different cut-off points. It is used to evaluate the diagnostic performance of a test by showing the trade off between sensitivity (true positive) and 1-specificity (false positive) at different threshold levels. Helps us to understand how well the test can distinguish between two groups. The area under the curve indicates the overall accuracy of the test You have a screening test, how do you choose the cutoff point Cutoff point depends on what disease were screening Number Prevalen Numbe Number Positive Negativ s ce of CF r of true of true predictiv e predictiv screene positive negativ e value e value d s es (%) (%) Germany 1,000,0 0,04% 388 999,600 79.5% 99.99% 00 Denmark 1,000,0 0,02% 194 999700 65.99% 99.99% 00 Netherlan 1,000,0 0,02% 196 999 500 39.5% 99.99% ds 00 Germany Disease (Sensitivity) No disease Total (Specificity) Positive True positive False Positive (Denmark) 200 Negative False Negative True negative 400 999,600 1,000,000 Denmark 999,800 1,000,000 Positive 194 100 294 Negative 6 999,700 999,706 200 999,800 1,000,000 4. Fill out the table and interpret it. [The same screening test is apparently used in Germany and Denmark (sensitivity 97.00%, specificity 99.99%), while another test is used in The Netherlands (sensitivity 98.00%, specificity 99.97%).] Case 8 Crossing borders: child health challenges in the EU Keywords: - Differences between different EU member states when it comes to healthcare access - In particular children's health, in regards to migration - Strategies for approaching this issue - Universal health coverage - Vaccination, mental health - Child prematurity - What effects migration has on childhood and maternal health Learning goals: 1. What is child health? - Children's health is the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical and social environments. - Child health refers to the physical, mental, emotional, and social well-being of children from infancy through adolescence. It encompasses various aspects such as growth, development, nutrition, disease prevention, and access to healthcare services. - Children must also be given a stable environment in which to thrive, including good health and nutrition, protection from threats and access to opportunities to learn and grow - a. Risk factors; prevention measures; factors that could hinder child health (public health concerns) b. - Substance abuse during pregnancy - Lack of vaccines - Lack of nutrition - Premigration: children can be vulnerable to vaccine preventable diseases, chronic diseases, mental and physical abuse, poverty - During the journey: (by boat) drowning, hypothermia, pneumonia, malnutrition, dermatological conditions due to poor hygiene, dehydration, infants born during the journey and breastfeeding - Country of destination: asylum seekers live in bad conditions, often relocated, low access to resources - Economic inequality - Climate change - food insecurity - Pandemics - Physical and mental abuse - Children living in DV homes have a greater risk for worse health outcomes due to stress, inclination to risky behaviours, hypertension - Multiple influences co-occur and interact over time. - 2. What is the concept of universal health coverage? = all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of the services does not expose the user to financial hardship - Embodies 3 objectives: o Equity in access to health services: everyone who needs services should get them, not only those who can pay for them o Quality of services: should be good enough to improve the health of those receiving them o Protection from financial risk: ensuring that the cost of using services does not put people at risk of financial harm - Sexual Reproductive Maternal Newborn Adolescent Health - core of the UHC Sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) is at the core of the UHC agenda, which cannot be achieved without a strong focus on these services. On this basis, an assessment was undertaken in six countries (Albania, Azerbaijan, Kazakhstan, Kyrgyzstan, the Republic of Moldova and Romania) in the WHO European Region to: - delineate which SRMNCAH services are included in policies concerning UHC; - assess the extent to which they are available to the people for whom they are intended and at what cost; - identify potential health system barriers to the provision of SRMNCAH services, using a tracer methodolo- gy and equity lens; - identify priority areas for action and develop policy recommendations - Main points: prioritise family planning, health seeking behaviour, delivery care, full child immunisation, eliminating all forms for violence against women and girls; eliminating all harmfull practices such as child, early and forced marriage and female genital mutilation a. How is it related to child health? - Access to Vaccination: UHC helps ensure that children are immunised against common and life-threatening diseases. - Maternal and Child Care: UHC promotes prenatal and postnatal services, essential for reducing infant and child mortality rates. - Nutrition Programs: With UHC, programs for malnutrition and growth monitoring become more accessible. - Management of Diseases: Access to diagnosis and treatment of chronic and infectious diseases is essential for child survival. - Financial Protection: UHC prevents families from facing catastrophic health expenditures, enabling them to seek timely care for their children 3. What is the effect of migration on child health? - Effect of violence on mothers and children - often are vulnerable to exploitation, violence and abuse - Mental health - migration causes a lot of PTSD, anxiety and depression caused by stress - Infectious diseases,multi-drug resistant bacteria, dental problems, mental health issues,... affect migrants children more 4. What are the approaches, principles, and suggested strategies to deal with child health? - Mandatory sexuality education - reduce teenage pregnancies and increase sexual safety and disease prevention - European Laws make record linkage possible →Exacting inequities and identifying their causes. a better focus on systematic rights-based maternal, child, and adolescent law, policy counries better monitoring and accountability for child and adolescent health - Integrated Management of Childhood Illness (IMCI): A strategy by WHO and UNICEF focusing on the holistic care of children, covering prevention, treatment, and healthcare education Key policies to promote good health and well-being: - EU : European Child and Adolescent Health Strategy 2015–2020 -> enable children and adolescents in the WHO European Region to realise their full potential for health, development and well-being; -> be visible to policy-makers, decision-makers and carers; - Children have the right to be seen and heard; all births are registered so they can access the healthcare system Guiding approaches(source 2): Life course approach - Based on the recognition and adult health is rooted in previous stages of the life course - Childhood affects you later on - Health should be kept up to date throughout life Evidence information approach - Based on available evidence for the development of policy responses and prioritization of population groups and actions Adopting a rights-based approach ( universal health coverage) - Human rights become better respected leading to more effectiveness in helping more effectiveness in helping the government to strengthen its health system,deliver healthcare for all, and improve health. - Participation of children and adolescents is very important for the successful development and implementation of strategies, policies and services. Partnership approach - Promoting strong partnerships and intersectoral collaboration - Health is determined by factors that go beyond the ministry of health Priorities: - achieving a tobacco-free millennial generation (increasing the price of tobacco, pictures on labels, smoke-free zones) - promoting healthy nutrition and physical activity throughout the life course tackling depression and other mental health problems in adolescence - protecting children and adolescents from environmental risks: air quality, housing, safe drinking water, hygiene, etc - Transforming the governance of child and adolescent health supporting early childhood development (include all children and use all sectors) - Addressing the preventable deaths and infectious diseases, introducing new vaccines - EU laws and legal backing and support the use of these data for health promotion and protection. Case 9: Understanding causality - a cause or the cause of TB? Keywords: - Basic concepts of causality - Causality vs causes - Cause and effect relationships - Disease causality - Effective interventions - Sufficient causes and Necessary causes - Guidelines ‘’Sir Austin Bradford Hill’’ - Interpreting evidence - Complexities inferring causes and effects LEARNING GOALS 1) What is causality? Causality is the relation of cause to effect. In epidemiology it means that an exposure causes a disease, for example smoking causes cancer. Causality: the relationship between something that happens and the reason for it happening. It’s about cause-and-effect relationships. The major goal of epidemiological research is to answer causal questions. a) Is there a difference between causality/causation and cause? - Causality = the relationship between something that happens and the reasons for it happening - Causation = the process of one event causing or producing another event (causation typically reflects an underlying mechanism or process: how does a cause lead to an effect?) context-dependent (depends on time, population, situation…) - Different definitions of “cause”: A cause is an event, condition, or characteristic that.. o.. plays an essential role in producing an effect o.. precedes the occurrence of the effect o.. without which the effect would not have occurred (at that time) b) Do you distinguish between a cause and the cause? - A cause is not necessary for the outcome to occur - The cause is necessary for the outcome to occur - You need the necessary outcome also c) What is the sufficient and necessary cause? (focus on TB and examples) Sufficient cause - Combination of factors that together form cause of an outcome = unique multi-factorial causal mechanism - The outcome can be produced for sufficient causes - For each disease you can have multiple causes and factors - TB → Weaken immune system (e.g. HIV), poor sanitation, smoking - MULTICAUSALITY = Consider all the different combination that can cause the disease - Without A the pie will not be completed, an complete pie means that you are getting the disease - Each causal pie is sufficient for producing outcome (outcome can be produced by different causal mechanism) - Causal pies can be formed by different combinations of component causes (components of sufficient cause act in concert to produce outcome) - There are multiple ways that you can get a disease - Each combination can be different Necessary cause - a factor that is indispensable for producing the outcome - Without the presence of the factor the disease will never develop - Component cause that is part of every sufficient cause - Example: HIV exposure is necessary for AIDS to occur - Focusing on reducing necessary cause(s) can reduce the risk of getting the disease (e.g. reducing smoking intake can reduce the chances of getting lung cancer) 2) How do you establish causality in research? Frequent sequence of studies in human population: 1. Clinical observations at the bedside (e.g. when surgeon observed that every patient on whom he operated for lung cancer gave a history of cigarette smoking) 2. Identify available data Then do studies specifically designed to determine whether there is an association between an exposure and a disease, and whether a causal relationship exists, namely: 3. Case control studies (e.g. compare smoking histories of a group of patients with lung cancer with those of a group without) – but only hypothesis generating, one shouldn’t infer causality from any single observational study 4. Cohort studies – used if a case-control study yields evidence that a certain exposure is suspect (e.g., comparing smokers and nonsmokers and determining the risk of lung cancer in each group) or do: 5. RCT (but generally only used for studying potential beneficial agents) a) How do you use evidence from observational studies? (To infer cause and effect) → next learning goal 3) What are the Guidelines? (‘’Sir Austin Bradford Hill’’)(Original and modified guidelines from source gordins) ORIGINAL GUIDELINE 1. Strength - How strong is the association? - RR or RR 2. Consistency - Is the association consistent? - Replication of study findings increases confidence 3. Specificity - Is the association specific? - It's about specific exposures & specific outcomes 4. Temporality - Did the cause occur before the effect? - Correct time frame is absolute requirement for causation 5. Biological gradient - Is there a dose-response relation? - When different amount or dose of cause has different effect 6. Plausibility - Is the association (biologically) plausible? - Plausible explanation increases possibility of causation - Is not a necessary 7. Coherence - Is the association coherent with current knowledge? - What do we know? Is it in line? Does it make sense? Biological mechanism that can explain these effects? (e.g. explanations that can explain why smoking cause lung cancer) 8. Experiment - Does experimental evidence confirm the association? - Experiments provide (strongest) evidence for causation - Look for evidence on benefits of (preventive) interventions 9. Analogies - Is association similar for analogous exposures? - Is not a strong factor for causation - E.g. lung cancer → Is not just cigarettes, is other things that are connected Coherence vs plausibility 1. Distinction between plausibility and coherence is not always clear-cut 2. Plausibility worded positively (biological mechanism to explain it), coherence worded negatively (is a contradict or is in line?) a. You are looking at the current and past knowledge 3. Cessation of Exposure: a. If a factor is a cause of a disease, we would expest the risk of tehe disease to decline when exposure to the factor is reduced or eliminated. MODIFIED GUIDELINES - Process of elimination → What can actually explain it? Case 10: time for reflection… Prepare a presentation in subgroups 1. First part: Summary of what we learned so far, including main messages and relation to each other 2. Second part: Focus on one topic which we found difficult (look at the teaching activities and literature) 3. Third part: include two critical questions or statement for the end discussion 4. Each group has to submit one question for the Q&A discussion board → 12 slides, approx. 10 min per subgroup for the presentation, 10 min discussion Three Groups: 1) Focus on Case 7 Emilia, Leila, Aminata, Phoebe https://www.canva.com/design/DAGSvBSIYis/SPdP21uHGfB4JRUQYKq6MQ/edit?ut m_content=DAGSvBSIYis&utm_campaign=designshare&utm_medium=link2&utm_s ource=sharebutton 2) Focus on Case 5 Carina, Annabelle, Claudia, Rueben Case 5 Recap - Presentaciones de Google 3) Focus on Case 9 Elif, Martyna, Carla, Emma - https://docs.google.com/presentation/d/1fZIVV9lKpubjpxcMl8py4oeUxSZCzA6C5DJ QQhY8SKk/edit#slide=id.g308a19a2947_0_116 Case 11: To screen or not to screen, that’s the question… Key words: - Screening - Certainty of a test - Purpose of participating in a screening program - Criteria for judging when to put a screening test in place - How do we judge if a screening test is successful - Criteria by Wilson and Jungner - Importance of screening - Advanced polyps - Cancer screening programs - breast/lung/colorectal cancer Learning goals: 1. What is screening? population-based research using diagnostic aimed at detecting precursers of a disease, with the aim of reducing mortality and/or morbidity with early treatment. - early detection and early treatment of increased risk of chronic disease with the ultimate goal of improving the health of the screened. Types of screening - Mass screening: unslect population - Universal screening: each individuals in a certain category is screening, (e.g. all children in a certain age category, or all women for breat cancer). - Target screening: select population with risk factors - Opportunistic screening: testing of patients during a consultation for diseases that are not related to the health complaintes of these patients (e.g. a GP mearsuing blood pressure of patients over 50 years of age with backache). Screening can be multifaceted, and can be targeted towards multiple diseases. The success depends on the characteristics of the disease, testing, and treatments of early diagnosed patients. Screening can be made more cost-effective by screening high-risk people, choosing a relatively high specificity, screening less frequently, and having high management standards. a. What are the basic principles and major sources of bias? - Basic principles - No disease: equal to primary prevention. You are looking at trying to prevent - Asymptomatic: secondary prevention. Reducing mortality and morbidity with early treatment - Illness: Tertiarty disease: you are looking to stop the disease from worsening. Major Sources of Bias - Selection bias: If you have volunteer,s they could be more healthy than other people - Length bias sampling: screening programs are more likely to detect… - Length biased sampling/prognostic selections: - does screening identify cases which have a better prognosis? - screening programmes are more likely to detect slow-progressing cases of a disease. - Lead time bias: occurs when the early detection of the disease makes it seem like the survival period seems way longer than it really is. - Overdiagnosis bias: sometimes you detect things that would never have caused an issue if the patient never knew it existed. You diagnose something where there was no need. (e.g. if the patient dies before the disease becomes relevant). - Confounding disease: to avoid, you can compare people who are screening with those not screened, to check if those have the disease. - GORDIS CHAPTER 18 TABLE 2. What is the purpose of participating in a screening program? Overall purpose is to lower mortality/morbidity rates. The purpose is to detect diseases early, especially diseases like cancer that benefit from starting treatment early a. Look at data and interpret how effective screening programs are Breast cancer, cervical cancer, and colorectal cancer have all benefited from screening programmes to lower mortality. - Less extensive treatment needed ( fewer complications). Treatment is less aggressive when screening programmes are used. Assessing the Effectiveness of Screening Programs Using Operational Measures 1. Number of people screened 2. The proportion of target populations screened and number of times screened 3. Detected prevalence of preclinical disease 4. Total costs of the program 5. Costs per case found 6. Costs per previously unknown case found 7. Proportion of positive screenees brought to final diagnosis and treatment 8. Predictive value of a positive test in population screened Assessing the Effectiveness of Screening Programs Using Outcome Measures 1. Reduction of mortality in the population screened 2. Reduction of case-fatality in screened individuals 3. Increase in percent of cases detected at earlier stages 4. Reduction in complications 5. Prevention of or reduction in recurrences or metastases 6. Improvement of quality of life in screened individuals b. What are the advantages/limitations of participating? Advantages: less mortality and less extensive treatment needed - Prevention of disease progression - Improved quality of life. Disadvantages - False positive diagnosis - Detection of cases that are not lethal - Pressure on healthcare system. - Can be very painful/ hazardous - False negative results - Financial costs. - If you're detected to have cancer, you just live longer with the disease, and has nothing to do with change in the chance of you surviving the disease. QUALY. You have to make sure that prognosis improves quality of life/ how long someone lives. c. Screening in the netherlands(focus on what screening programs exist/ population level) Screening programmes need to have a permission of the government if they use - Ion radiation - Aimed at cancer - Aimed at a disease or cure is not possible. - The decision has to be taken by the Minister after an advice by the Health Council Breast Screening: they use a mamograph. Cervical :Screening every 5 years for women aged 30–60 using a Pap test or HPV test Collorectal cancer: fecal immunichemical test (age 50-75). After a positive test you go to get a colonoscopy. Prenatal screening for infectious diseases. Screening for down’s, edwards, patau’s syndrome. They can do bloodtrip and ultrasound. They can also do a nip-test (between 9-14th week of pregnancy) Neonatal blood spot screening (heel prik test) (done in the first week, usually at the same time as the hearing screening) Neonatal hearing screening https://www.rivm.nl/en/about-rivm/organisation/centre-for-population-screening - 8 screening programmes in the netherlands. - Structural ultrasound scan - 13 and 20- week (of pregnancy) scan - Perinatal screening | RIVM - Physical abnormality (13 week) to check if there is something severy wrong with the baby. 3. Look into the Criteria by Wilson and Jungner 3 Criteria Related to the disease 1. The condition sought should be an important health problem; 2. There should be a recognizable latent or early symptomatic stage 3. The natural history of the condition, including development from latent to declared disease, should be adequately understood Related to the screening test - There should be a suitable test or examination. - The test should be acceptable to the population. Criteria related to the diagnostic test and treatment of the disease. - There should be an accepted treatment for patients with recognised disease. (otherwise it is not ethical). - There shold be an agreed policy on whom to treat as patients - Facilities for daignostic and treament should be availabe. (Preparations are needed in advance) Criteria realted to the overall screening programme - The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole. - Case finding should be a continuous process and not a “once and for all” project. Modified criteria (in 2008), because they thought it was too vague and theoretical. - The screening programme should respond to a recognized need - The objectives of screening should be defined at the outset - There should be a defined target population - There should be a scientific evidence of screening pogramme effectiveness - The programme should integrate education, testing, clinical services and programme management. - There should be quality assurance, with mechanisms to minimize potential risks of screening. - The programme should ensure informed choice, confidentiality and respect for autonomy - The programme should promote equity and access to screening for the entire target population - Programme evaluation should be planned from the outset - The overall benefits of screening should outweigh the harm. 4. Look into colorectal/lung cancer screening programs Colorectal: Incidence in Europe: - almost 520,000 new cases - 241,000 deaths - Almost 1,500,000 survivors (5-year prevalence) - Number 2 on the list of most frequent cancers in Europe - Risk factors include: Age, male sex, family history, inflammatroy bowel disease, smoking, excessive alcohol consumption, high consumption of red and processed meat, obesity, and diabetes. - Infectious bacteria can cause a risk factors for colorectal cancer. - Diagnosis: After a positive FIT(fecal immunal-chemical test) test, a colonoscopy is performed, Magnetic resonance imaging (MRI) of the colon. - Biopsy is how you do a final diagnosis of cancer. (this is for all cancers). - Treatment:

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