Summary of Jerome's Lectures on Health

1.Health **Understanding health concepts** "The Master in Health Sciences at the University of Lucerne offers students from a wide range of disciplines the necessary knowledge and skills towards a **comprehensive understanding of health, functioning and disability**." "The program provides a broa...

1.Health **Understanding health concepts** "The Master in Health Sciences at the University of Lucerne offers students from a wide range of disciplines the necessary knowledge and skills towards a **comprehensive understanding of health, functioning and disability**." "The program provides a broad background in health sciences from a **biopsychosocial perspective**and has a focus on the **interaction of individuals and their environment**within the context of health. Students will also have the opportunity to choose a Major in a specific area to get more in-depth knowledge depending on their professional interest and career direct." We will speak about what health is. In the Uni website they explain that we will develop an approach. There is a story that teachers are telling that explain where we will go and how we will do it. We will have a "comprehensive understanding of health, functioning and disability". **Health** - WHO -- the classical position - Determinant consequence - Descriptive or normative - Definition, Conceptualization or Operationalization? - Health for Science -- measurement These points are clarifying what health as a concept is. We are also looking at health scientifically, so we need to understand how to measure it. If we cannot measure health it has no scientific meaning, because we have no idea what works, and so on. **[WHO -- the classical definition]** **CONSTITUTION OF THE WORLD HEALTH ORGANIZATION** *The States Parties to this Constitution declare, in conformity with the Charter of the United Nations, that the following principles are basic to the happiness, harmonious relations and security of all peoples:* **"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." -- aspirational definition** The classical definition of health is the one WHO gave "Health is a state of complete physical, mental and social well-being and not a merely absence of disease or infirmity." We have to emphatize that health is not just having a problem is something else. There is someone that said health is like a window, when you look at the window you look through the window not the window itself, but you need a clean window for that. That is a very different conceptual way to look at health which make health neutral. But here in the definition we see that health is something that improve. From the definition in bold: You can be physically well-being but not socially well-being or socially but not physically. Complete - so it means we go to one hand of the spectrum to the other: to be health completely 100% or to be unhealth. Is not a very good definition. Health is better a state of *sufficient* physical, mental, and social well-being. **[Three potential confusions to avoid in defining health... ]** *for health science and practice we are interested in what [affects] health and what health [leads to]* - Determinant of health - Consequence of health ***Determinant ≠ health ≠ Consequence*** Health is a phenomenon of a person. We are interested to understand what affect positively and negatively the health. So, we try to achieve its causation: we look that maybe this thing improves it and this not -- it's about determinants. When we understand that something causes health, we need to be aware that maybe this thing is not health. Determinant, health and consequences are different things to be aware. **Social determinants of health** *e.g. health and income inequality* The richer a country is, the better the health of its people. The more equally distributed the wealth of a country, the better the health of its people. A social determinant of health can be for example health and income inequality (unequal distribution of health in the world, population). But we can also look at social phenomenon in general. If we are going to look how health is distribute, we have to look at the income of people. We can see a graphic. But we see association, for causation we need a longer story. Poor housing conditions is a determinant of... depression.... which causes loss of productivity. ***Poor housing ≠ depression ≠ loss of productivity*** Social participation in community life improves... health... which causes increased happiness ***community participation ≠ health ≠ happiness*** We should be really careful that community participation is health. It is an indicator of health. It isn't health. Indicators are things that itself can be measured. So: **Trap 1** However close the association, it is a mistake to confuse what affects health (*causes, risk factors, determinants*) and what health leads to (*consequences or effects*) with health itself. The phenom of health is embodied, is the state of a person. What affects health (determinants) and what health leas to is not health itself. E.g. family relationship is an indicator of health but is not health itself. You don't have to confuse something which is close associate with it as an effect. Health is a good indicator of well-being. If health is well-being, if are the same thing we could even use the two terminology or? But the point of this is that we cannot. Health is something really difficult to define. **The second potential confusion** **Is health** (compare: money)...a good thing, valuable, something we want...something that leads, or makes possible, good and valuable things, things we want **Is health intrinsically valuable** or **instrumentally valuable** The obligation of society is to improve health because health is a good thing. Alternatively, health is instrumentally valuable, and means that it is good because makes people happy. The entire literature in health is divided in two. If you define health as the absence of disease does it capture its goodness? The normative science say no because doesn't why is a good thing, the other side say that health is just a feature of biology which give a certain status. It's about speaking about what is normal, is not about good or bad but it's about just describe it. **The third potential confusion...** Is health a descriptive or normative notion? [Normative]: health is a normative or evaluative phenomena (i.e. health is a intrinsic human good) [Descriptive]: health is a natural phenomenon best defined factually consistent with biological sciences **[Descriptive: Boorse]** C. BOORSE (1972, 1975) *The Biostatistical Theory of Health* *Health* is the absence of pathology. "A condition of a part or process in an organism is pathological when the ability of the part or process to perform one or more of its **species-typical biological functions** falls below some central range of the statistical distribution for that ability in corresponding parts or processes in members of an appropriate reference class of the species." Ageing definitely limits your capacity of things you can do. Our point is measurement. Here we have huge problem of measurements. **[Normative: Nordenfelt]** L. NORDENFELT, 1987*Action-theoretical account of health* "A person is in health if and only if he or she has the ability, given standard circumstances, to realize culturally-appropriate vital goals, that is, goals necessary and sufficient for **minimal happiness in the long run**." Normative account - From the definition health is about doing things, is what you can do with your health. Health causes happiness therefore health is happiness, no. Nordenfelt rejects Boorse but he does not disagree that health is ultimately a matter of biology. What is statistically considered normal is insufficient to define health. **[Recent attempts: Huber]** **Health is \... "the ability to adapt and to self manage."** - **Physical health:** the maintenance of physiological homoeostasis through changing circumstances. - **Mental health:** "sense of coherence"successful capacity to cope - **Social health: \...**the ability to manage their life with some degree of independence \... and \... to participate in social activities including work. Here we have three definitions **[Recent attempts: Venkatapurum]** **"**Health is a meta-capability for achieving the ten, species-wide, **essential capabilities** that together, given standard circumstances, are necessary and sufficient for minimal happness in the long run.**"** *1.Life 2.Bodily health 3.Bodily integrity 4.Senses, imagination, and thought 5.Emotions 6.Practical reason* *7.Affiliation 8.Other species 9.Play 10.Control over one\'s environment, political and material* These 10 things are the 10 things that constitute a good life **[Recent attempts: Daniels]** **Health and normal functioning.** "Health care is special since it promotes normal functioning, and normal functioning assures opportunity. Thus, health care promotes **opportunity."** the value of health consists in the fact that normal or at least sufficient levels of biological and psychological functioning is a precondition for the opportunity to pursue any meaningful life plan at all. Here we see that health promotes normal functioning, which assures opportunity. This is a challenge because is both, descriptive and normative. **[Pragmatism about defining health]** - Legitimately different definitions: 'fit for purpose' - Aspirational or political purposes may require highly normative conceptualizations - Legal definitions: eligibility for services What do we need for SCIENCE? WE NEED TO MEASURE HEALTH ***[WHY DO WE NEED TO MEASURE HEALTH?]*** - Determining the level of health of a person. - Comparing the health of a person over time. - Comparing the health of more than one person. - Determining whether a health treatment improves health. - Comparing the health of one population with another. - Monitoring changes in the health of a given population. - Identifying health inequalities within populations. - Analysing the benefits of health interventions for use in cost-effectiveness analyses. I.e. doing anything in health sciences! *Definition* *Conceptualization* *Operationalization* We have three steps. It starts with definition, but then we try to find the concepts. What is health? We look for a conceptual definition which tell us what is health and what is not. Then we have operationalization: we have a complex concept, and we want to make it concrete. An indicator is not the conceptualization, but it is associate with it. Operationalization is a move from the abstract to a concretization. E.g. concept walking -- try to define what it is walking. **[Operationalization of health:]** conceptualization classification measurement We can see there are intermediate steps. **[Measureing health: the big challenge]** **What are you measuring?** *Need to operationalize 'the state of health' into **things** you can measure* **How do you measure these things?** *Need measurement tools and instruments and **units** of measurement* **How do you compare these things?** *Need **common** measurement units* **How do you measure the overall state of health?** *Need to be able to **'add up'** these units* Vision and mobility -- each of these domains are continuous from 0 to 100. You cannot compare vision and mobility together. **[The Measurement challenge: multidimensionality]** **The 'things' we measure are component or elements of health.** e.g. vision, hearing, mobility, cognition... **Each of these elements can be function well, moderately well, poorly, not at all.** **But these elements are so different, that is hard to find compare them.** e.g. who is healthier, someone who is blind, or someone who is deaf? [WHO's solution:] The 'thing' that all components of the state of health share: F U N C T I O N I N G **[WHO's -- the modern position -- defines health for measurement purposes]** - *health* is a separate concept from well-being, and is of intrinsic value to human beings as well as being instrumental for other components of well-being; adopting a normative position -- health is not well being - *health* is comprised of states or conditions of functioning of the human body and mind, and therefore any attempts to measure health must include measures of body and mind function; and - *health* is an attribute of an individual person, although aggregate measures of health may be used to describe populations. Primarly health is the state of a person, but WHO is looking at population. **Insisting on a clear distinction between health itself and its determinants and consequences.** "To understand how we may act to improve health, we must be able to separate the actual health states in which people live from the factors that influence these health states --only then can we examine the relationships between health and its determinants and intervene in this causal chain." **Understanding health in terms of human functioning** "Efforts to characterize more precisely the relevant attributes of a particular state of health have led to a gradual shift in focus away from diagnostic descriptions alone and towards an understanding of health in terms of functioning and disability expressed in different domains." ***Functioning is the operationalization* of health** 2.Functioning and the ICF **[WHO's -- the modern position]** - [health] is a separate concept from well-being, and is of intrinsic value to human beings as well as being instrumental for other components of well-being; - [health] is comprised of states or conditions of functioning of the human body and mind, and therefore any attempts to measure health must include measures of body and mind function; and - [health] is an attribute of an individual person, although aggregate measures of health may be used to describe populations. These three prepositions are defining principles. In the first they are saying that health is not the same thing as well-being but are connected. Second principle, function of body and mind are things that we can observe. Thirdly, health is primarily a state of a person. **Insisting on a clear distinction between health itself and its determinants and consequences.** "To understand how we may act to improve health, we must be able to separate the actual health states in which people live from the factors that influence these health states --only then can we examine the relationships between health and its determinants and intervene in this causal chain." **Understanding health in terms of human functioning** "Efforts to characterize more precisely the relevant attributes of a particular state of health have led to a gradual shift in focus away from diagnostic descriptions alone and towards an understanding of health in terms of functioning and disability expressed in different domains." *Functioning is the operationalization* of health The feature of complex adaptive system is that the second principle is not really true. Is not correct because instead of adding, the phenomenon is more than the sum. E.g. walking is more than the sum of some parts, there is an integration of them. **[Operationalization]** Conceptualization Classification Measurement **[The Measurement challenge: multidimensionality]** - *The 'things' we measure are component or elements of health.* e.g. vision, hearing, mobility, cognition... - *Each of these elements can be function well, moderately well, poorly, not at all.* - *But these elements are so different, that is hard to find compare them.* e.g. who is healthier, someone who is blind, or someone who is deaf? **[WHO's approach to the problem of multidimensionality]** - **Step 1:** Pick representative 'core set' of ICF domains of health because there are many functions, you cannot measure all them. This measurement thing is another complexity. We have an example -- we have 8 functions which appears the most predictive of health. Statistically we have to find the ones that predicts the most health. That's is all we need to ask before. - **Step 2:** Collect large amount of data about these domains from a general population.\* you collect data. We take different dimensions like pain, vision, and so on and all them are about the same phenomenon. Then there are a lot of additional steps. - **Step 3:** Use item response theory --Rasch modelling --to create a 'latent trait' --in this case functioning --and a metric scale of functioning. - **Step 4:** Map survey scale (0 problem, mild, moderate, severe, total problem) for each domain onto a 'position' on the functioning scale. - **Step 5:** Add up 'scores' on functioning scale for each response, per domain for a summary score for each person. **[Models of Disability: a short history]** - "Medical" Model - Social Models (US and UK versions, c. 1975-1980) - Interactive Models (Environmental/ecological, Nordic, WHO ICIDH, c. 1980-1995) - Interactive Model of functioning and disability: WHO's International Classification of Functioning, Disability and Health (ICF) 2001- **The rehabilitation insight** *"We do not know which disability a war injury causes until we know the veteran's trade or employment." -- R. Fontesque Fox, 1917* ***General Features of Interactive Models:*** ***I.Interaction:*** Disability is an outcome of the interaction between [Intrinsic features of a person] (i.e. their health state)...and [features of the external context] in which the person lives and acts (environmental factors) ***II.Continuous*** *Disability and the determinants of disability are matters of 'more or less', not 'yes or no'* **The development of the ICF (1995-2001)**: - Rejection of ICIDH (1980) --not truly interactive - WHO's data collection requirements \*ICF = International Classification of Functioning. **[ICF - *the language of human functioning*]** - A model of functioning and disability - A classification of functioning and disability **WHO's Rationale for ICF** For WHO reliable and timely information about the health of populations is critical input into world public health. *"People will not count until we can count people"* For WHO reliable and timely information about the health of populations is critical input into public policy. Mortality statistics have long been collected in terms of WHO's *International Statistical Classification of Diseases and Related Health Problems* (ICD-10). Though useful for measuring life expectancy, these data did not capture the overall health status of living populations. Missing was information about levels of functioning and disability across all areas of life *"the lived experience"* *...the impact of health conditions on life and living* *[Why do we need functioning and disability data?]* - Medical diagnosis alone does not predict health service needs, length of hospitalization, or level of care required. - Presence of a disease is not an accurate predictor of receipt of disability benefits, work performance, return to work potential, or likelihood of social integration. **WHO's Requirements** **ICF** - ***International [common conception]*** ***of functioning and disability*** - Comparable application of 'disability' - Facilitating international health and disability data - Clinical applications - Health systems applications (e-health) - Research **ICF -- International [common language] of functioning and disability** - International standard for comparable world disability statistics - Exhaustive and consistent: STANDARD - Comparable language across sectors **WHO's OBJECTIVES** A true *epidemiology* of disability **A *science* of human functioning** **Principles of theICF** ***...the theoretical principles underlying the ICF...*** 1. [Universalism] - Disability is a common, normal and natural feature of the human condition, not a mark of a social minority group (or a label of a specific individual) all of us have a disability, is not something that mark a social minority. 2. [Interactive Model of Disability] - Disability is a multi-dimensional phenomena -- the outcome of an interaction between intrinsic features of the person and extrinsic features of the person's physical, human-built, social and attitudinal environment is everything outside a person that also counts. E.g. can happen that our life is affected by a functioning problem which is mostly because of the environment. Is not part of our biology but is part of our performance. 3. [Continuous] - Functional status and disability are not 'yes' or no' or dichotomous issues, but rather a matter of degree 4. [Etiological Neutrality] - Status of a person's functional or disability is not determined by etiology or background health condition you don't have to go down. You may have a problem for various reasons These are the principles of the ICF model of functioning and disability **Bio**psycho**social** model **[What is *Functioning* in the ICF sense? ]** ICF Functioning is "The set of all functions and structures of the human body and all of the behaviors, actions, tasks --simple to complex --that person does or performs" Functioning is the last area that go from blood pressure to religious How do you know when is something that the body does and when something the person do. E.g. people walk, not legs walk, because to walk has a mental component -- is you that decide if you want to walk. It's intentional because there is a mental component. ICF Functioning -- see definition 2 schemes below:  **ICF Principles -- consequences** - *Everyone can be disabled, and over the lifecourse, likely everyone will be disabled to some degree* - *Disability is a matter of degree* - *There is no single threshold or cutoff, it depends on one's purposes* - *Two people with the same health problem can have different disabilities* - *Two people with different health problems can have the same disability* Distribution -- people up there are rare individual. **ICF Interactive model of functioning and disability** **Functioning** is a product of an interaction between intrinsic features of the person body and the person's environment or context: the world in which she or he performs actions and behaviours. We are interest in how **health problems** play out in people's lives --so the interaction is between health problems and the external world or **environment** You have a health problem and then you live with it. You have a health condition, then you have the three levels - body functions & structures, activity, participation. That's the ICF model.   Classification Body functions: there is not a separation between body and mind, mental function is also body function as we can see in the slide. / Then we have together activity and participation (the other two levels)  This is the official ICF model diagram, with also personal factors. But as we can see in the second slide, since now there are no classification about that... **[Why is the interactive approach to understanding functioning and disability important?]** **Return to work tragectory** Why is important? We are looking here at injury. We have the capacity of people to do their job (blue line) and then they have an injury and the capacity go down, and after goes up (red line)... You can change the workplace, or the workplace can change because of you. If you cannot reach the blue line, then you may search another job, or the work is adapting to you -- performance with work adaptation (green line). Then we can see the range of environmental modification and we need to ask how much does this cost. **[Linking Functioning and Disability with Health]** **Health operationized as functioning** When health is conceptualized as an intrinsic state of the human body... - understood in purely biological terms - distinct from determinants and consequences - operationalized for scientific description and measurement in terms of domains of functioning [Health is a matter of Body Functions and Structures] We might call this ‟**BIOLOGICAL HEALTH**" For many health professionals this is too **abstract** and distant from the day-to-day experience of patients. Isn't there more to the experience of health than the biological functions and structures? We might call this ‟**LIVED HEALTH"** In some sense health is under the skin, so we might call this biological health. But seems to abstract so Lived health **Functioning 'Perspectives'** - [CAPACITY]: "...the biological state of the person's health, operationalized in terms of impairments of body function and structure and the intrinsic health capacity of a person to perform activities." - [PERFORMANCE]: "a person's actual performance of an activity, taking into account the interaction of capacity with the person's environment." **Perspectives of Performance and Capacity** - **Capacity** - Describes an individual's intrinsic ability to execute a task or an action BIOLOGICAL HEALTH Body Function and Structure domains - **Performance** - Describes what an individual does in his environment --that is, taking into account all aspects of the physical, social and attitudinal world LIVED HEALTH Activity and Participation domains Capacity is the metric for biological function, but what we measure is performance and performance is what we do. Let's see an example: the professor can see 80% without glasses and 100% with glasses have he improved his health by wearing the glasses? His health is exactly the same, but his lived health is improved. The notion of performance or lived health is about living with the health problem. 3.Health-related notions Why health does matter to you? Because it makes possible for you to do things you want to do or impossible to do. In the context of functioning, we have to look in the environment of our life... Biological health is captured [primarily] by body function and structures and lived health [primarily] by activity and participation. **[Application of Capacity/Performance]** This document is called "model disability survey" because was requested by the member states in US. This is designed with 2 characteristics: it's self-report (and this makes it subjective). Alternative of self-report is the one about clinicians that do observe people, but the self-report one is really cheaper. Then there is household survey: If you have household survey is about to go to each house and ask if there is someone in house with health problem and ask after if we can speak with them. We have a fairly collection of responses. This is the first survey of any size that was built on\... The Model Disability Survey asks people -- not previously identified in terms of the health conditions -- what they do, or do not do, in their lives. These kinds of questions concern how people actually function in multiple domains given the environmental barriers and facilitators that constitute their real life situation. [Sections] there are different tables with questions divided in these three following way: environmental factors, functioning, health condition How difficult is to you to run based on your health problem? The environment can make something more difficult to you, but there are also system devices which can help something be better for you. E.g. a wheelchair but even glasses are facilitator. The environment typically alter performance positively or negatively -- so you do more or less than your capacity is able. But most changes are intrinsic change in the body (see surgeries). What about vaccine? Is about capacity to be immune, but some people are doing it for performance -- to go again to restaurants, and so on\... In the last assignment the different in the two towns is probably in the environment. The purpose of putting environment factors questions first, was to make people think about it, because generally people start to think directly what it's inside them when the topic is health. **[Health and related notions: disease, illness, sickness, "subjective health"]** (Biological) **Health**: an intrinsic, fully biological state of the individual, operational by domains of body functions and structure (capacity). **MENTAL HEALTH?** "Mental health" differs from physical health 1. *in terms of the body functions and structure that typically characterize mental health states --*mental health is also an intrinsic, fully biological state of the individual; 2. *the impairments typically affect behaviors and other dispositions* Mental health more often than physical health attracts stigmatization\... they attract this kind of social reaction. The other important distinction is that mental health problem concern behaviours. **[Health notions]** **DISEASE?** *A theoretical description of a cause of a decrement in health* - usually defined by diagnostic criteria (signs and symptoms) - usually characterized by nature of originating cause: genetic or congenital, infection, parasite, poison, injury.... - acute, episodic, or chronic Disease is not a thing, is a theory, is a theoretical construction. The difference between diseases is a matter of agreement. Human created pain attacks because a pharmaceutical company found a medicine to help this disease, so they actually "created a disease". There was not a disease before. Disease come in three type: acute, episodic or chronic. **INJURY?** *Another kind of cause of a decrement in health* - Not usually thought of as a disease, but the borderline is hazy Injury is not always clear when something is injury and when not. **Other causes of health problems?** - [Ageing?] Aging is a process of accumulation of functional problem - [Pregnancy?] - [Social determinants] (association or causation?) - Social cohesion - Social isolation - Income level - Employment status - Discrimination and social injustice **Sickness? Illness?** Sickness is not a disease because sickness is a feeling, and disease is a theory. **Subjective Health?** **[Objective and subjective]** Fallacies: I. Objective is true, subjective false (untrue?) II. Objective is scientific, factual and reasonable, subjective is irrational, emotional opinion III. Objective is valid and reliable, subjective invalid and unreliable IV. Objective is impossible...it's all subjective? *and so on...* ***Different perspectives on information...*** **Objective perspective**: - Information about the external world, that is true or false (probable to some degree) - Testable - ‟Intersubjectively verifiable" - Debateable **Subjective perspective**: - Information about someone's experience stated by that person - Accessible only by that person, as a fact - ‟Incorrigable" E.g. of objective is if I say "I have a foot" -- it is something external, testable. And intersubjectively is like "can you see if I have a foot?". On the other hand, subjective perspective is typically about an experience. If I say that I have a foot is not an experience is a fact. In principle if we talk about our experience we are the only one who can experience our experience. And by that you cannot be wrong. If say that I see something strange, it's not false is what I'm seeing. ***Self-report questions (e.g. in a health survey)***  Discriminate -- you can be wrong, but you are saying what happen as a fact, is not an experience. With pain in a day there is the problem with "frequently" -- maybe one says twice is frequently, and another four, so this is a bad survey question. Overall health: this is the most reliable of any question. How satisfied means your reading, reaction to something in this case your health status. Depressed: is in the middle because now it is considered as a disease, but on the other part is subjective because you can say that you are depressed just because you feel bad, not happy. Happy: is in the middle, because it can be the name of a feeling or a psychological disposition. ***Lessons learned...*** - The fact that a person is reporting on something, on its own does not make the answer subjective. - Self-reported health claims are either objective or subjective, and both are essential for diagnosis and treatment; but they may not be descriptive of a person's state of health. - There is an important difference between **description** and **evaluation** (*they are not orthogonal variables*) **[Health notions]** **Sickness?** Generally thought to be a subjective assertion about how one's feels at the moment, or felt earlier. *Hence: not a statement about the person's health, but incorrigible* **Illness?** Either a synonym for disease, or for sickness. *Hence: use carefully* **Subjective health?** Like sickness. *Hence: not a statement about the person's health, but incorrigible.* **Health-related notions** - Quality of life - Well-being **[Quality of Life]** *History:* - a common sense notion - Pharmaceutical outcome measure: patient report outcomes (PROs) - QoL and HRQoL - The economic QoL: QALYs The QoL Industry The "Disability Paradox" QoL was invented in the 50s. It was invented because in that time a pharmaceutical company was developing something for depression. They used to say that their medicament improves quality of life. Quality of life mean what a quality of life measure measures. When QoL became an outcome there was then an industry and this industry produce a lot of instruments (in the slide 27 there was a very long list of them). **The QoL Industry** "Since the 1970s, the measurement of quality of life has grown from a small cottage industry to a large academic enterprise. In addition, the development of new instruments to measure quality of life has become increasingly complex\..." "\...An extensive literature has been developed regarding instruments that express quality of life \..." "Consequently, while professing to measure quality of life, many researchers are really measuring various aspects of health status. " "The instruments may be satisfactory for indicating health status, but quality of life is something that is perceived by each patient individually." WHOQoL QoL of WHO In the slides is possible to see a short version of its instrument... **The "Disability Paradox"** A substantial body of evidence shows that people with serious and persistent disabilities report that they experience a good or excellent quality of life when to most external observers these people seem to live an undesirable daily existence. Indeed: inverse relationship! *Brickman et al. 1978: "the happiness of people who had recently developed paraplegia or quadriplegia following a motor vehicle accident did not differ substantially from that of recent* *lottery winners."* Says something about misperceptions about how bad living with a disability is... (perspectives of performance and capacity) Also says something about how tricky it is to interpret quality of life assessments... **What is Quality of Life good for?** **Amartya Sen's concern** (see diagram) -- Here we can see the difference between US and India.The woman in India has very low expectation: life is short and painful. In other countries you think where you could be and that you are only there, at a lower level. see for more info: [Sen\_A Health Perception Versus Observation BMJ 2002 - \[PDF Document\] (vdocuments.mx)](https://vdocuments.mx/sena-health-perception-versus-observation-bmj-2002.html) **[Well-being]** ***History*:** - Long history, viewed both as an objective and subjective notion (‟what makes life go well"). - Overlapping with quality of life - Objective well-being = the good things in life - Resources - Experiences - Opportunities - Subjective well-being traditionally = happiness - Recently, SWB has *become extremely popular*... **Subjective Well-being** "[Subjective well-being] refers to all of the various types of evaluations, both positive and negative, that people make of their lives. It includes reflective [cognitive evaluations], such as life satisfaction and work satisfaction, interest and engagement, and [affective reactions] to life events, such as joy and sadness. Thus, subjective well-being is an umbrella term for the different valuations people make regarding their lives, the events happening to them, their bodies and minds, and the circumstances in which they live." Subjective well-being? This is about evaluation that people make of their lives. We have an affective emotional side of happiness, but there is also something more cognitively: it's about how we evaluate our life. It's relevant but not stable. **Using SWB as Policy indicator** "\...unifying theme of the report, is that the time is ripe for our measurement system to shift emphasis from measuring economic production to measuring people's well-being." - Stigliz et al., 2009 "Governments around the world are now beginning to seriously consider the use of measures of subjective wellbeing (SWB) --ratings of thoughts and feelings about life --for monitoring progress and for informing and appraising public policy. - Stigliz et al., 2009 UK Office for National Statistics 2011 [Annual Population Survey] (n=4000) 1. Overall, how satisfied are you with your life nowadays? 2. Overall, to what extent do you feel the things you do in your life are worthwhile? 3. Overall, how happy did you feel yesterday? 4. Overall, how anxious did you feel yesterday? **[Two interesting results in SWB research]** 1.'Hedonic treadmill 2.Health and Well-being **Hedonic Treadmill** Other two phenomena are hedonic treadmill, health and well-being. The first is something that affects happiness studies. In the diagram we can see that the happiness level goes down. This could be depression. It can be done on happiness, depression, etc. Professor says that if you have generally a lower point in the graphic, you can even won at the lottery but in no time you will be down again... **Health and Well-being** [Determinants of happiness:] HEALTH - Material living standards (income, consumption and wealth); - Education - Personal activities including work - Political voice and governance - Social connections and relationships - Environment (present and future conditions) - Insecurity, economic and physical WHO 1949 - "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." **???** 4.Functioning and Rehabilitation **The 'strategies of healthcare'** CURATIVE PROMOTIVE PREVENTIVE REHABILITATION (PALLIATION) In healthcare there are strategies. In the 19 century there was the curative one: the first thing is to fix a problem and you have to stop a process that is leading to more and more problem. And you can do it by having a cure that eliminate the problem. Then came the preventive - e.g. in Covid what we can do with it? Now the best thing that we can do is to prevent rather than cure after. In this case we move from prevention smoking program to nutrition program, and so on. If you prevent things to not happen is cheaper and better. The functional primary care is to identify problem. So, the health care system is in general a social phenomenon. Health promotion is essentially the same thing, but it increases the existing independence of the body. Health promotion and prevention go hand to hand. Then we have rehabilitation, and we will see soon. And last, palliation: professor said that palliative care is not curing because are done when cure is not an option, are no more effective. Are done when people are dying, and palliation is just a service that can be available for them to improve their quality of life. But suicide is not one of this, is not improving life. **The origins of rehabilitation** [European:] the 'spa' tradition (*Kurortmedizin*) and 'cripple care' (orthoses, prosthesis, AT); chronic medicine; professionalization (1940-50), development of PT, OT, Speech [North American:] returning soldiers (1917-19); extended to all people with disability; professionalization (1940's) physiatry, orthopaedics, development of PT, OT, Speech Low level of public recognition or appreciation --viewed as highly specialized, 'add-on' service (sports medicine or substance abuse recovery) --a high income country luxury service.. **.** Rehabilitation before was about helping soldiers to come back to work, and after goes to a service that anyone can use. **[The changing health situation]** DEMOGRAPHY EPIDEMIOLOGY Professors thinks that world is changing, and it is changing in a very dramatic way. ‟For the first time in history, more people die today from eating too much than from eating too little,...more people die from old age than from infectious diseases...\" Yuval Noah Harari, *Home Deus* **1.Demography: Population ageing** In the graphic we can se that the rate of people with 60 years and over is dramatically increasing in the time, especially in developed world. In the 2° and 3° graphics we can see what the future will probably be: "More old...fewer young" So, there will be probably less people being young and many people being older, but that is a big problem because in this way you no longer have the tax pays and economic resources of young people to help old people. More people using the economic resources than there are. The fact is that there are more people living longer and less woman having babies... *[Distinctive health phenomena of ageing:]* MULTIMORBIDITY FRAILTY And ageing is becoming more a disease **2.Epidemiology: NCD prevalence shift** **But COVID 19 you say...** - Mortality of any infectious disease is lower (these days) than top NCDs (Cardiovascular, cancers, respiratory diseases, diabetes) - Infectious diseases are more controllable than NCDs - Infectious diseases have both acute and chronic phases (so, in effect raise the epidemiological shift to chronic conditions) We killed more people now with covid than with Spanish flu. **As a population we are living longer, but with more problems with functioning (disability)** **DEMOGRAPHY + EPIDEMIOLOGY =** Ever-increasing proportion of world's population living with one or more limitation in functioning **[Future health healthcare needs?]** CURATIVE - chronic conditions are not curable PROMOTIVE -- sure, but ageing is unavoidable PREVENTIVE - likewise REHABILITATION - ? **What is the aim of rehabilitation?** Rehabilitation physicans and therapists always knew that their job was not to cure people... *most of their patients had chronic conditions*... or to design population-based health promotion or disease prevention programmes... *although they did do secondary/tertiary prevention for their clients*... but their primary focus and aim was to optimize what their patients could do in their lives, to live independently and pursue life plans. The ICF provided the concept for expressing the aim of rehabilitation. *Rehabilitation aims to optimize functioning* The irony and also the frustration is that were resources should go now is in rehabilitation. The point of rehabilitation is to optimize functioning. **What does rehabilitation do? Optimizing functioning** **Intrinsic capacity**: what your body can do (declining over your life span). **Functional ability**: what you can do with your capacity in your environment. Rehabilitation increases capacity. Rehabilitation improves your environment (AT, modifications to your home, etc.) to improve your functional ability. The intrinsic capacity is body health, is biological, under the skin, and is going to decline over time. But the concern of many researchers is what we can do, which is better that the one that our capacity is about we could do. Whatever it is that the society provide for us, we can improve the red line of intrinsic capacity: we can have environmental modification that increase the functioning and performances of people. Rehabilitation intervention can improve capacities and even performances. In the health context people who should make this possible are probably rehabilitation professionals. But some how the gap increases when getting old, so it is unrealistic. Professor thinks that at the end of the life span it is unrealistic (end of the Life span -- ageing and health).