2024 POPLHLTH111 Lecture 13 Full Slides PDF

Lecture 13 Framing the Determinants of Population Health: The Dahlgren & Whitehead Model Professor Dan Exeter 2024 https://thespinoff.co.nz/society/the-side-eye/25-03-2021/the-side-eyes-two-new-zealands-the-k-shape/ Population Health in the news … Sources: www.rnz.co.nz, 25 March 2024 Population Hea...

Lecture 13 Framing the Determinants of Population Health: The Dahlgren & Whitehead Model Professor Dan Exeter 2024 https://thespinoff.co.nz/society/the-side-eye/25-03-2021/the-side-eyes-two-new-zealands-the-k-shape/ Population Health in the news … Sources: www.rnz.co.nz, 25 March 2024 Population Health in the news … Sources: Eight people arrested at Auckland protest over felling of native trees in Avondale - NZ Herald (left), Parents' protest saves Campbells Bay School pōhutukawa trees - NZ Herald (right) … sadly, we see this type of story too often! Neighbourhoods considered high risk or “Hazardous” were often “redlined” by lending institutions Denying them access to capital investment which could improve the housing and economic opportunity of residents. Source: Example of the original 1938 HOLC “Residential Security” map of Atlanta with color-coded gradation of neighborhoods by risk level. (Source: Mapping Inequality Project, University of Richmond) available at https://ncrc.org/holc/ Sources: Duck or rabbit? 100-year-old optical illusion could tell you how creative you are | The Independent Lecture Objectives Star = key slide(s) After this lecture you should be able to: 1. Understand the concept of the ‘causes of the causes’ and how these operate at different levels 2. Define the components of the ‘Dahlgren & Whitehead Model’ and use this framework to identify the causes of the causes of dis-eases 3. Define the difference between ‘upstream’ and ‘downstream’ levels of action 4. Briefly describe the 3 high-level components of the Living Standards Framework and ‘The Four Capitals’ used by the NZ Government 5. Define and distinguish between ‘structure’ and ‘agency’ Module 2 readings Today’s reading pages 4-13 ONLY Use the lecture objectives to supplement your understanding The causes of the causes and the GATE Frame… Measuring the Population Understanding the effects of Socio-Economic Position and other determinants Identifying Inequalities & Inequities …And why they should be reduced … and the Public Health Framework MOST of the lectures I teach in 111 relate to phase 2 of the Public Health Framework Assure widespread adoption Develop and test prevention strategies Identify risk and protective factors Define the problem BUT some of the risk factors can also be used in Phase 1 – define the problem – e.g. household overcrowding (http://www.cdc.gov/ViolencePrevention/overview/publichealthapproach.html) The causes of the causes (the determinants of the determinants) Smoking causes lung cancer http://images.clipartpanda.com/cigarette-clipart-cigarette-and-matchbox.jpg https://thumbs.dreamstime.com/b/lung-cancer-5564055.jpg The causes of the causes (the determinants of the determinants) What causes people to smoke? http://images.clipartpanda.com/cigarette-clipart-cigarette-and-matchbox.jpg https://thumbs.dreamstime.com/b/lung-cancer-5564055.jpg http://clipart-library.com/pictures-of-a-question-mark.html The causes of the causes (the determinants of the determinants)   111 test = T+30 days http://images.clipartpanda.com/cigarette-clipart-cigarette-and-matchbox.jpg http://worldartsme.com/images/alcohol-clipart-1.jpg https://thumbs.dreamstime.com/b/lung-cancer-5564055.jpg http://clipart-library.com/pictures-of-a-question-mark.html http://images.clipartpanda.com/stress-clipart-can-stock-photo_csp8319343.jpg https://us.123rf.com/450wm/bbtreesubmission/bbtreesubmission1704/bbtreesubmission170400017/75090790-dad-smoking-around-his-kids.jpg?ver=6 https://openclipart.org/image/2400px/svg_to_png/174022/1357145751.png https://classroomclipart.com/images/gallery/Clipart/Construction/TN_construction-worker-holding-electric-drillclipart.jpg http://images.clipartpanda.com/tax-clipart-income-tax-clip-art-81966.jpg https://www.vectoropenstock.com/media/users/2049/76303/raw/b75d8c151ab57e97562b532170862e52medical-icons.jpg https://62e528761d0685343e1c-f3d1b99a743ffa4142d9d7f1978d9686.ssl.cf2.rackcdn.com/files/22215/article/width668/wdhcvvxx-1365477788.jpg So, what are the causes of the causes ? For individuals: “any event, characteristic or other definable entity, that brings about a change for better or worse in health” Income Employment Education Housing and neighbourhoods Societal characteristics e.g. racism, attitudes to alcohol or violence, value on children Autonomy and empowerment – social cohesion... These determinants may vary at different life-stages Determinants of health for populations (AKA Causes of the Causes for populations) Concepts are similar as for individuals, but nature of determinants is often different – Not just application of the individual perspective to whole population, but includes characteristics of the population itself. Determinants of health in populations are also related to the context in which the population exists. Systolic BP in middle-aged males % 30 25 20 15 10 5 0 60 70 80 90 100 110 120 130 140 150 160 170 180 Systolic B.P. (mm. Hg) London Civil Servants Kenyan nomads Adapted by author from: Rose, G (1985) Sick individuals and sick populations, International Journal of Epidemiology, 14(1) pp.32-38 190 200 Source: https://en.wikipedia.org/wiki/Braided_river#/media/File:Waimakariri01_gobeirne.jpg. Photograph by Greg O'Beirne, Permissions: GFDL / Creative Commons Approaches to reducing high BP in the population Often, determinants and actions/interventions designed to improve population health are discussed the analogy of a river: – Downstream interventions operate at the micro (proximal) level, including treatment systems, and disease management – Upstream interventions operate at the macro (distal) level, such as government policies and international trade agreements Proximal and Distal determinants (causes of causes) Distal Determinants: A determinant of health that is either distant in time and/or place from the change in health status. Distal determinants of health are also referred to as ‘upstream factors’. E.g. national, political, legal and cultural factors that indirectly influence health by acting on the proximal factors. Proximal Determinants: A determinant of health that is proximate or near to the change in health status; ‘near’ generally refers to any determinant that is readily and directly associated with the change in health status. E.g. lifestyles and behavioural factors related to nutrition or smoking or other exposures. Source: Understanding health (3rd edition). Edited by Helen Keleher and Colin MacDougall. Chapter 3 Percentage of adults who are obese, by area deprivation quintiles (NZDep2018) 50 45 Obese adults (%) 40 The social gradient 35 30 25 20 15 10 5 0 Quintile 1 (least deprived) Quintile 2 Quintile 3 Quintile 4 Source data: https://minhealthnz.shinyapps.io/nz-health-survey-2019-20-annual-data-explorer/_w_f830a717/#!/explore-indicators Quintile 5 (most deprived) Using the Dahlgren and Whitehead Model Dahlgren, G & Whitehead M. (1991) "Policies and Strategies to Promote Social 9." Equity in Health. Stockholm: Institute for Future StudiesC Why are adults in the most deprived areas more likely to be obese? Dahlgren, G & Whitehead M. (1991) "Policies and Strategies to Promote Social 9." Equity in Health. Stockholm: Institute for Future StudiesC Why are adults in the most deprived areas more likely to be obese? Work / pay choices Fast food access Housing quality/affor dability Dahlgren, G & Whitehead M. (1991) "Policies and Strategies to Promote Social 9." Equity in Health. Stockholm: Institute for Future StudiesC Why are adults in the most deprived areas more likely to be obese? Fast food access Dahlgren, G & Whitehead M. (1991) "Policies and Strategies to Promote Social 9." Equity in Health. Stockholm: Institute for Future StudiesC Level 1 – the individual Age, sex, constitutional factors & individual lifestyle factors At the core of the Dahlgren & Whitehead model are factors that are sometimes referred to as ‘nonmodifiable’ determinants: genes and biology There are important distinctions between the impact on individuals and populations – Single gene disorders = rare among the population – Polygenic inheritance = influences likelihood of offspring developing a disease Genes are important, but so too is the influence of the environment Prevalence of CHD among Japanese immigrants to USA: it’s not just genes Source: Marmot, MG, Syme SL. Acculturation and Coronary Heart Disease in Japanese-Americans. American Journal of Epidemiology 1976;104:225-47. Level 1 – the individual There is a wealth of evidence demonstrating the importance of food, exercise, and risky behaviours in relation to health outcomes. – Remember the social gradient The choices you make as an individual impact on the likelihood that you will have good(or bad) health Habitus: lifestyle, values, dispositions and expectation of particular social groups ‘learned’ through everyday activities – Ability to change behavior(s) may vary by social group Level 2 – the community Dahlgren, G & Whitehead M. (1991) "Policies and Strategies to Promote Social 9." Equity in Health. Stockholm: Institute for Future StudiesC Level 2 – the community Social and community networks & Living and working conditions Families and friends play a significant role in developing ‘normative’ behaviours Attitudes and behaviours of people living and working in the local community influences the sense of what is normal and acceptable Social capital - the value of social networks that facilitates bonds between similar groups of people – provides an inclusive environment for people from diverse backgrounds – Civic participation, volunteerism, supportive communities “it’s not what you know, but who you know”! Level 3 - the environment Dahlgren, G & Whitehead M. (1991) "Policies and Strategies to Promote Social 9." Equity in Health. Stockholm: Institute for Future StudiesC Level 3 – the environment General socioeconomic, cultural and environmental conditions Physical environments – Water quality, clean air, all living things Built environments – Design of communities: buildings, roads, light rail Cultural environments – Knowledge, beliefs, and values that are accepted by a group of people Biological environments – Emerging or re-emerging toxins affecting populations The ecosystem – Biodiversity, climate change, the ecological footprint Political environments – Approaches to improving population health The Current Living Standards Framework Captures those resources and aspects of our lives that are important for the wellbeing of individuals, families, whānau and communities Captures the role our institutions play in safeguarding and building our wealth, as well as facilitating the wellbeing of individuals and collectives. Captures how wealthy we are in aggregate as a country, including sources of wealth not fully captured in the system of national accounts: human capability and the natural environment. The Wealth of Aotearoa: The Four Capitals Source: Figure 1 in http://www.treasury.govt.nz/publications/research-policy/dp/2018/18-04/dp18-04.pdf Structure and agency in population health Structure- social and physical environmental conditions/patterns (social determinants) that influence choices and opportunities available Agency – the capacity of an individual to act independently and make free choices Structure = social determinants Agency = empowerment Dahlgren, G & Whitehead M. (1991) "Policies and Strategies to Promote Social 9." Equity in Health. Stockholm: Institute for Future StudiesC The causes of the causes (the determinants of the determinants)   http://images.clipartpanda.com/cigarette-clipart-cigarette-and-matchbox.jpg http://worldartsme.com/images/alcohol-clipart-1.jpg https://thumbs.dreamstime.com/b/lung-cancer-5564055.jpg http://clipart-library.com/pictures-of-a-question-mark.html http://images.clipartpanda.com/stress-clipart-can-stock-photo_csp8319343.jpg https://us.123rf.com/450wm/bbtreesubmission/bbtreesubmission1704/bbtreesubmission170400017/75090790-dad-smoking-around-his-kids.jpg?ver=6 https://openclipart.org/image/2400px/svg_to_png/174022/1357145751.png https://classroomclipart.com/images/gallery/Clipart/Construction/TN_construction-worker-holding-electric-drill-clipart.jpg http://images.clipartpanda.com/tax-clipart-income-tax-clip-art-81966.jpg Source: Left = Fig 1.13, in Bambra C (2015) Health Divides: Where you live can kill you. Policy Press, Bristol UK. Right: Dahlgren, G & Whitehead M. (1991) "Policies and Strategies to Promote Social 9." Equity in Health. Stockholm: Institute for Future StudiesC The Dahlgren & Whitehead Framework: Is a framework to help you identify the ‘causes of the causes’, determine whether these are risk or protective factors, and prompt you to consider levels of intervention Age, sex & hereditary factors are non-modifiable, other determinants are modifiable There is permeability between factors – No arch operates in isolation from the others – Events at one level may impact on factors at another (higher or lower) level Recognises that determinants operate at different scales – Upstream (distal) or downstream (proximal) – Micro (individual), meso (family, living, work), macro (national/global) Are you able to: 1. Understand the concept of the ‘causes of the causes’ and how these operate at different levels 2. Define the components of the ‘Dahlgren & Whitehead Model’ and use this framework to identify the determinants of dis-eases 3. Define the difference between ‘upstream’ and ‘downstream’ levels of action 4. Briefly describe the 3 high-level components of the Living Standards Framework and ‘The Four Capitals’ used by the NZ Government 5. Define and distinguish between ‘structure’ and ‘agency’ ?