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Social Behivoral Epidemiology L#1  Public health is the field of medicine concerned with safeguarding and improving the health of a community as a whole. It has a population focus. Efforts to protect and improve the public’s health include assessment, policy development, and assura...

Social Behivoral Epidemiology L#1  Public health is the field of medicine concerned with safeguarding and improving the health of a community as a whole. It has a population focus. Efforts to protect and improve the public’s health include assessment, policy development, and assurance. The primary foundation disciplines of public health are epidemiology, biostatistics, and health services  Epidemiology is the study of the distribution and determinants of health-related states or events and the prevention and control of health problems in human populations. It provides an approach to assess and monitor the health of populations at risk and to identify health problems and priorities, identify risk, identify effective health interventions, and provide a basis for predicting the effects of certain exposures. It provides information that is useful in policy development, individual decision making, and for initiating new research.  Behavioral sciences refer to those disciplines or branches of science (e.g., psychology, sociology, and anthropology) that derive their theories and methods from the study of the behavior of living organisms. The influences on behavior can be broadly characterized as genetics, individual thoughts and feelings, the physical environment, social interaction (with other individuals), social identity (interaction within and between groups), and the macrosocial environment (e.g., state of the economy). Behavioral Sciences In medicine : Behavioral Sciences Behavioral epidemic Behavioral Pathogens Behavioral Psychology Behavioral Disorder Behavioral Modification Behavioral Therapy DO YOU KNOW THE DIFFERENCE BETWEEN EACH ONE? SEE YOUR TEXTBOOK P3-4.  Behavioral epidemiology involves the study of personal behaviors (the manner of conducting oneself), how these behaviors influence health-related states or events in human populations, and how behaviors can be modified to prevent and control health problems.  The study of behavior in epidemiology should involve describing behavior according to person, place, and time factors; determining the link between certain behaviors and health; identifying factors that influence behaviors; and applying and evaluating interventions designed to modify health-related behaviors. Behavioral Epidemiology Behavioral epidemiology is the branch of epidemiology that is related with the psychology. In this we can study about the lifestyle and behaviors of people and how they affect their health conditions.4  Population-based risk factors can be identified by investigating inherent characteristics of people (age, gender, race, ethnicity); acquired characteristics through behavior choices (immunity, marital status, education); behavioral activities (exercise, leisure, medication use); and conditions (access to health care, environmental state). In epidemiology, behavioral variables are treated as risk factors for disease. They are also sometimes treated as outcome variables in which we investigate factors that influence these behaviors  Descriptive Epidemiology of Health Behaviors  Social epidemiology is a branch of epidemiology that focuses particularly on the effects of social structural factors on states of health. Social epidemiology assumes that the distribution of advantages and disadvantages in a society reflects the distribution of health and disease.  ” Social epidemiology focuses particularly on the effects of socio structural factors on states of health (Table 1). History of social epidemiology In the beginning of the 19th century, several investigations were conducted based on the idea that social conditions affect health. In Germany, Virchow reported the relationship between poor social conditions and the typhus epidemic in Upper Silesia. He speculated that unequal access to society’s products was the fundamental cause of unequal distribution of diseases in the society. He highlighted the central role of social conditions in population health In the middle of the 19th century, Chadwick reported that unsanitary soil, air, and water were major causes of diseases and promoted sanitation measures to improve the health of the poor. Clearly, studies in the beginning and middle of the 19th century were conducted with the assumption that societal conditions affect physical health.  By the 1980s, however, several epidemiologists developed social epidemiology, underscoring the importance of sociostructural factors on health as well as in a population perspective. In a backlash against the strong individualism of modern epidemiology, social epidemiologists argued for the need to return to the traditional epidemiological theme: how do social conditions produce patterns of health and disease? The central question of social epidemiology—what are the effects of social factors such as social structure, culture, and environment on both individual and population health—has existed since the beginning of epidemiological history. Significant concepts of social epidemiology In this section, will present several significant concepts of the field of social epidemiology: First, the bio-psychosocial paradigm. The biological paradigm assumes that all diseases are biological phenomena and can be described fully in biological terms. It guides the views that a population is merely the sum of its individuals, and that the population pattern of diseases is simply a reflection of individual risk factors. Consequently, social level factors cannot be considered “real” causes of diseases, if the biological paradigm is used.  In other words, diseases are assumed to be products of mutual interaction among social factors, individual factors, and biological factors. The bio-psychosocial paradigm assumes that population is not merely the sum of its individuals; rather, every population has its own history and culture, which determine how and why people are exposed to specific individual risk factors. In social epidemiology, social factors can be risk factors of health by adding to or interacting with individual and biological factor.  Population perspective is another significant concept in the field of social epidemiology. Geoffrey Rose pointed out that an individual’s risk of disease cannot be isolated from the disease risks of the population to which s/he belongs. Figure 1 shows the distributions of serum cholesterol in Country A and Country B. Judging from the figure, we can predict that a person living in Country B is more likely to die prematurely of a heart attack compared to someone living in Country A. This prediction is reasonable not only because any given person in Country B may have a high cholesterol level, but also because the population distribution of cholesterol level in Country B as a whole is higher than that of Country A. Why is the distribution of cholesterol in Country B at a higher level than in Country A? What caused the difference between these distributions? In order to answer these questions, it is crucial to consider society as a whole. Asking why a population has a particular distribution of risk is different from the etiological question of why a particular individual got sick.Social epidemiology is particularly interested in the first question, that of distribution. Researchers in social epidemiology look for socio structural factors that affect distributions of diseases and risk factors, and they propose measures to shift these distributions in the desired direction, as a “population strategy.” Population perspective and population strategy are essential to social epidemiology.  A third important concept in the field of social epidemiology is the use of new statistical approaches, such as multilevel analysis. To determine the effects of sociostructural factors on health. Multilevel analysis allows several levels of analysis to be accounted for simultaneously and more effectively than in conventional multivariate analysis.  Lastly, the use of theory is another significant concept in social epidemiology. Social epidemiology requires the use of theory to build hypotheses and interpret results. Social epidemiologists select variables in statistical models based upon a conceptual framework that indicates hierarchical relationships among factors. This conceptual framework is built upon theory. Behavior and the Epidemiologic Transition The epidemiologic transition describes changing patterns in age distribution, fertility, life expectancy, disease, and death. McKeown (2009) classified the transition as changes in the population composition and growth trajectories, particularly movement toward an older age distribution, and changes in patterns of mortality, related life expectancy, and causes of death. The epidemiologic transition is a way of looking at and understanding the relationship among population dynamics, disease, and death.  Improvements in life expectancy over the past few centuries, throughout many places in the world, have been attributed to cultural adaptations, Eco biologic and socioeconomic factors and, more recently, advances in public health (e.g., hygiene and nutrition, housing conditions, sanitation, water supply, antibiotics, and immunization programs). Consequently, the causes of death have shifted from primarily infectious diseases (e.g., pneumonia, tuberculosis, and diarrhea) and conditions (e.g., maternal mortality) to chronic diseases such as heart disease and cancer. Degenerative diseases that are often associated with the aging process (e.g., arteriosclerosis, gout, and mental decline) have also increased. References Behavioral Epidemiology - Principles and Applications Merrill, Cara L. Frankenfeld, Michael Mink, Nancy Freeborne Jones & Bartlett Publishers 2015,ISBN ISBN 9781449648275. Honjo, K. (2004). Social epidemiology: Definition, history, and research examples. Environmental health and preventive medicine, 9, 193-199. Social standards and health equity L3  Health equity found in the history of social medicine, since the mid-nineteenth century. Rudolf Virchow, Friedrich Engels recognized that social and class inequalities lead to inequities in health. poses questions and leads to idea into practice. (WHO, 1946) “the highest standards of health should be within reach of all, without distinction of race, religion, political belief, economic or social condition” IN1948 UN, states that “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family control.” IN1978 (WHO) Conference on Primary Health Care in Alma-Ata. The launch of “Health for All” campaign (HFA), implicitly made health equity a priority for all countries. IN 1991“The Concepts and Principles of Equity and Health,” published Health Promotion International. IN 2015 SDG/ Global Goals, to end poverty, protect the planet and ensure that all people enjoy peace and prosperity by 2030.  overview Terminology Differences between equity/equality and examples Governance of health equity Advance health equity Health equity index Health equity monitoring Universal health coverage Difficulties facing to attain health equity Public health approach to achieve health equity Summary References  TERMINOLOGY HEALTH : physical and mental health status and well-being, EQUITY : Fair opportunity to everyone. EQUALITY : the state of being equal, especially in status, rights, or opportunities HEALTH EQUITY : Attain highest level of health for all people as a process (valuing everyone equally reducing disparities in health and its determinants) and as an outcome (the elimination of social disparities in health and its determinants). HEALTH DISPARITIES: differences in health outcomes and their determinants as social, demographic, environmental, and geographic attributes. HEALTH INEQUALITIES: differences in health status or in the distribution of health determinants between different population groups. HEALTH INEQUITIES: subset of health inequities that are modifiable, associated with social disadvantage and considered ethically unfair. SOCIAL DETERMINANTS OF HEALTH: conditions in the environments in which people are born, live ,learn ,work, play, and age that effects a wide range of health DIFFERENCES Equality means giving everyone the same thing, whereas Equity means giving people what they need to reach their best health. Example: three people of different heights are trying to reach the fruit on the tree. In this case, the fruit symbolizes good health. The different heights of the people represents the unequal distribution of the social determinants of health in society. If we treat these people equally, we would give everyone the same box to stand on, so only the tallest person could reach the fruit. If we treat them equitably, we would give them as many boxes as they need to reach the fruit. GOVERNANCE OF HEALTH EQUITY Governing for health equity through action on social determinants Characteristics of smart governance: Collaboration Citizen engagement Through a mix of regulation and persuasion Through independent bodies and expert bodies Through adaptive policies, resilient structures and foresight By these strategic approach to addressing health challenges, including Reducing health inequalities as whole of government and as whole of society approaches PRINCIPLES TO ACHIEVING EQUITY IN HEALTH CARE Embrace equity as foundational Capacity building for health systems and health equity research Deliberative process of achieving equity in healthcare The challenge of how to prioritize and implement pro-equity health policies Engage communities and mobilize partners Investing in public health and primary care: cornerstones for equity in health Address structural and social determinants of health. Apply equitable evaluation approaches. Actions to achieve HEALTH EQUITY LEITZELL, B. (2019). Achieving a Culture of Health: Steps for Engaging State Government. The American Journal of Accountable Care, 7(3), 4-11. http://ajmc.s3.amazonaws.com/_media/_p df/AJAC_09_2019_Scanlon%20final.pdf  OUTCOMES FROM PRINCIPLES Good health flourishes across geographic, demographic, and social sectors Attaining the best health possible is valued by our entire society Individuals and families have the means and the opportunity to make choices that lead to the healthiest lives possible Business, government, individuals, and organizations work together to build healthy communities and lifestyles No one is excluded. Everyone has access to affordable, quality health care because it is essential to maintain, or reclaim, health Health care is efficient and equitable The economy is less burdened by excessive and unwarranted health care spending Keeping everyone as healthy as possible guides public and private decision-making Explaining the Key Steps to Advancing Health Equity 1. Identify important disparities in health and social inequities in access to the resources and opportunities needed to be healthy 2. Change and implement policies, laws, systems, environments, and practices to reduce inequities in access to the opportunities and resources needed to be healthy. 3. Evaluate and monitor efforts using short-, intermediate-,and long-term measures. 4. Reassess strategies to plan next steps. Advance Health Equity Practice Inside strategies: 1. Focus on addressing the “causes of the causes of health inequities” – oppression and power 2. Prioritize improving the social determinants of health through policy change 3. Build understanding of and capacity to address equity across the organization 4. Support leadership, innovation, and strategic risk-taking to advance equity 5. Change the narrative of what leads to health 6. Commit the organization and its resources to advance equity 7. Use data, research, and evaluation to make the case 8. Change internal practices such as hiring and contracting Outside strategies: Externally focused practices to advance health equity 1. Build partnerships with communities experiencing health inequities in ways that intentionally share power and decision making and allow for meaningful participation 2. Build alliances and networks with community partners to protect against risk and build power 3. Build alliances with other public agencies 4. Engage strategically in social justice campaigns and movements 5. Change the administrative and regulatory scope of public health practice 6. Join broader public health movements to advance equity HEALTH EQUITY INDEX What is the Heath Equity Index? The Health Equity Index is a community-based assessment that can be used to identify social, political, economic, and environmental conditions that are most strongly correlated with specific health outcomes. The Health Equity Index is implemented in conjunction with public health workforce development and community engagement strategies as an overall approach to address health inequities. Why was the Health Equity Index Developed? Unlike approaches that describe differences in health status among certain populations, the Health Equity Index was developed to focus on the root causes of differences in health status. What can the Health Equity Index Do? Illuminate conditions in neighborhoods and communities that are the root cause of poorer health.​ Encourage collaboration between public health personnel, community leaders, municipal department heads, neighborhood residents, and community-based organizations to address health inequities.​ Provide an opportunity to focus policymakers’ efforts and investments in prevention, improving conditions that promote good health rather than waiting for people to become sick. How does the Health Equity Index Work? The Health Equity Index is based on a seven social factors (determinants) that are linked to health status: Political Access Community Safety and Security Economic Security Education Employment Environmental Quality Housing HEALTH EQUITY MONITORING “Identifying health inequalities and their drivers is essential for achieving health equity” The Health Equity Monitor database, a large database of disaggregated data, which currently includes data for more than 30 reproductive, maternal, newborn and child health indicators, disaggregated by six dimensions of inequality, from over 360 international household health surveys conducted in 112 countries in 1991-2017. Interactive data visualizations, that present data from the Health Equity Monitor database in an interactive way. The Health Equity Assessment Toolkit, a software application for assessing health inequalities in countries.  UNIVERSAL HEALTH COVERAGE UHC means that all people have access to the health services they need, when and where they need them, without financial hardship. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care. Currently, at least half of the people in the world do not receive the health services they need. Examples Service Delivery and Safety (SDS) Health financing Essential medicines and health products Health system governance Health workforce Health statistics and information systems Universal Health Coverage - What does it mean? Video Universal Health Coverage - What does it mean? CHALLENGES/ Difficulties facing to attain health equity The epidemiological transition. Low investment. Lack of accessing opportunities. Low quality of health services at primary care level. Financial crisis of some countries. Less participation of innovation and implementation to find solutions of health problems. Long way in achieving better health outcomes. Some countries including Saudi Arabia have low density of health work force. Poor connection with remote areas.  PUBLIC HEALTH APPROACH Access to high quality health care Provide equal and social economic opportunities Invest in and revitalize in low income neighborhoods https://www.aafp.org/about/policies/all/integration-primary-care.html Case study Castro, A., Sáenz, R., Avellaneda, X., Cáceres, C., Galvão, L., Mas, P.,... & Fuentes, M. U. (2021). The Health Equity Network of the Americas: inclusion, commitment, and action. Revista Panamericana de Salud Pública, 45, e79. https://iris.paho.org/bitstream/handle/10665.2/54418/v45e792021.pdf?sequence=1&isAllowed=y Summary Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family control  REFERENCES Hosseinpoor, A. R., Bergen, N., & Schlotheuber, A. (2015). Promoting health equity: WHO health inequality monitoring at global and national levels. Global health action, 8(1), 29034. https://www.who.int/health-topics/health-equity#tab=tab_1 World Health Organization. (2024). Working for a brighter, healthier future: how WHO improves health and promotes well- being for the world’s adolescents. World Health Organization. https://www.who.int/campaigns/world-health- day/2021/health-equity-monitoring World Health Organization. (2023). Universal health coverage partnership annual report 2021: health systems strengthening and health emergencies beyond COVID-19. World Health Organization. https://www.who.int/news-room/fact- sheets/detail/universal-health-coverage-(uhc) Rechel, B. (2020). How to enhance the integration of primary care and public health. Approaches, Facilitating Factors and Policy Options. Copenhagen, Denmark. https://www.aafp.org/about/policies/all/integration-primary-care.html LEITZELL, B. (2019). Achieving a Culture of Health: Steps for Engaging State Government. The American Journal of Accountable Care, 7(3), 4-11. http://ajmc.s3.amazonaws.com/_media/_pdf/AJAC_09_2019_Scanlon%20final.pdf Castro, A., Sáenz, R., Avellaneda, X., Cáceres, C., Galvão, L., Mas, P.,... & Fuentes, M. U. (2021). The Health Equity Network of the Americas: inclusion, commitment, and action. Revista Panamericana de Salud Pública, 45, e79. https://iris.paho.org/bitstream/handle/10665.2/54418/v45e792021.pdf?sequence=1&isAllowed=y Thanks Questions Sociocultural context of health L2  “Sociocultural” refers to a wide array of societal and cultural influences that impact thoughts, feelings, behaviors, and ultimately health outcomes. Sociocultural determinants of health and illness encompass socioeconomic status (SES) factors (traditionally assessed by income, education, occupation) and cultural factors. There are several dimensions encompassed by the term, which can include race, ethnicity, ethnic identity, sex, acculturation, language, beliefs and value systems, attitudes, and religion. Objectives Develop an understanding of cultural competency issues related to race, gender, class and other difference and explore the interconnectedness of identities across differences, critical consciousness and relationship to cultural competence. Students will be able to develop a framework for cultural competency within the context of one’s environment. Cultural Competency What is cultural competency? What is Cultural Competence? “The state of being capable of functioning effectively in the context of cultural differences.” “A set of congruent behaviors, attitudes, and policies which come together in a system, agency, or amongst professionals to work effectively in cross-cultural situations.” Towards a Culturally Competent System of Care. Cross et. al., 1989, Georgetown University Child Development Center Cultural Competence in Healthcare Cultural forces are powerful determinants of health-related behavior A lack of knowledge about or sensitivity to health beliefs and practices of different cultures can limit one’s ability to provide quality healthcare Culture What is cultural? What Is Culture? “The body of learned beliefs, traditions, principles, and guides for behavior that are commonly shared among members of a particular group. Culture serves as a roadmap for both perceiving and interacting with the world.” Increasing Multicultural Understanding: A Comprehensive Model. Don Locke, SAGE Publications, 1992 What is Ethnicity? Refers to particular social groups in complex societies, groups differentiated not only on the basis on a range of shared cultural content, but also on the bases of social attitudes and economic and political considerations. Working with Latino Youth: Culture, Development and Context. Joan D. Koss-Chioino and Luis A. Vargas What Shapes Culture? Political values Experience with oppression or discrimination Socioeconomic factors Rituals Family roles and structure Degree of opposition to acculturation Response of majority culture Examples of Cultural Health Beliefs Illness or disease is caused by stress or working too hard or as a punishment for something Eating protein (meat or eggs) will counteract the effects of x-rays Everyone has dormant diseases in body, whether or not they develop depends on how well you take care of yourself Importance of balancing Yin and Yang, e.g. hot/cold theory  Cultural Competence What is cultural competence in a healthcare setting? Influence of Cultural and Social Factors Health-seeking behavior Perceived causes of illness Understanding of disease process Treatment decisions Health Seeking Behavior ▪Is the symptom serious? ▪How long has the symptom lasted? ▪Is there a cause for the symptom? ▪Anyone else with similar symptoms? ▪Who should I seek help from? Perceived Causes of Illness Some people believe that the cause of their disease is the result of some “other” force outside the individual (supernatural or spiritual forces such as punishment for behaviors, etc.) Understanding the Disease Process Perception of messages from different healthcare providers Stigma/fear Social networks Contacts Treatment Decisions ▪What is necessary for healing to occur ▪Risk assessment (cost-benefit analysis) ▪Lifestyle factors ▪Healthcare worker/patient interactions Cultural Competence Frameworks and models Purnell Model for Cultural Competence https://files.midwestclin icians.org/sharedchcpolici es/Policies_Forms/Cultura l%20Competency/PURNE LL'S%20MODEL.pdf This article will be in exams plz study the model well from this paper. Domains of Model Global Society Communication Spirituality Community Family Organization Healthcare Practices Family Workforce Issues Healthcare Practitioners Person Biocultural Ecology Heritage High-Risk Health Behaviors Nutrition Pregnancy & Childbearing Death and Dying Dominant Cultural Characteristics Beliefs, values, and practices Standard for the entire group of people Dominant socially, politically, economically Variant Cultural Characteristics Determines the degree which the dominant culture varies History of the culture Ethnicity Caste/status Race Gender Sexual orientation Age Language or dialect Spirituality/religion Military Experience Socioeconomic Status Educational Status Political Beliefs Marital Status Urban/Rural Residence Sexual Orientation Immigration Status, Time and Reasons Cultural Competent Care Examples of cultural competence in healthcare settings Components of Culturally Competence Care Exercising Cultural Sensitivity Knowledge of patient population Acceptable social behaviors Cultural health beliefs Conveying respect Working with interpreters Cultural sensitivity Characteristics of the Patient Population ▪What cultures are predominantly represented in your program? ▪What are the values, beliefs, traditional concepts particular to these groups? ▪Who are the “gatekeepers” of health within these groups? ▪What is the group’s perception of health and illness? Know the Patient Population Non-KSA born Migrant workers Persons with international travel histories Racial and ethnic minorities Elderly Refugees Know Acceptable Social Behaviors In some cultures, the following behaviors can be seen as offensive or may not be reciprocated: ▪Handshake ▪Staring, direct questioning, or direct eye contact ▪Getting “down to business” immediately - asking “how are you?” in passing without truly listening for response  Examples of Cultural Competence Convey respect, working with interpreters, cultural sensitivity Conveying Respect Build rapport and trust Explain why you must ask personal or sensitive questions (suspicion of HIV status); may require an expression of sympathy for doing so Watch for patient’s verbal and non-verbal cues; allow patient to ask questions at frequent intervals Acknowledge non-traditional living situations (e.g., joint or extended families, homeless shelter) Acknowledge the stigma attached to a diagnosis of HIV Do not ask about immigration status Provide appropriate health education Working with Interpreters In medical setting, use of a trained, medical interpreter is necessary Avoid use of family or non-medically trained staff to interpret Keep a list of available interpreters and schedule patients accordingly Introduce yourself to the interpreter and patient; explain ground rules of interpretation and confidentiality Address patient directly, in the first person and make eye contact Check that interpreter is engaged in working with the patient; make sure pace is appropriate and direct Avoid local jargon and phrases Exercising Cultural Sensitivity Do you have posters on the wall that depict people of different racial/ethnic groups? Do you have books and pamphlets addressed to people of different genders? Is staff trained to take calls from a call relay operator for hearing-impaired patients Do you have an appointment line with a TTY line? How do you make people of different ethnicities, gender, age, etc. comfortable in your setting? Are the front-line office or clinic staff (e.g. receptionists and intake workers) trained in cultural competency? Summary Develop an understanding of cultural competency issues related to race, gender, class and other difference and explore the interconnectedness of identities across differences, critical consciousness and relationship to cultural competence. Students will be able to develop a framework for cultural competency within the context of one’s environment. Conclusion Culture is not defined This system of values, exclusively by ethnicity, beliefs, and behaviors but rather a shared may also be influenced by system of values, beliefs, variables such as: history, and learned ▪ Gender patterns of behaviors ▪ Language ▪ Disability ▪ Sexuality ▪ Age References The Purnell Model for Cultural Competence Liu, J., Gill, E., & Li, S. (2021). Revisiting cultural competence. The clinical teacher, 18(2), 191-197. Centers for Disease Control https://npin.cdc.gov/pages/cultural-competence Thank You! Questions?