Lecture 3 & 4 Determinants of Health PDF

Lecture 3: Determinants of health Day 2, SNGP3011 Checking the temperature How did the first lecture go? Scan the code and let me know! https://www.ment...

Lecture 3: Determinants of health Day 2, SNGP3011 Checking the temperature How did the first lecture go? Scan the code and let me know! https://www.menti.com/al9 8j5qubo5v Learning outcomes Lecture 3/4 LO3 Critically analyse the key concepts of L01 Critically social justice, human analyse the rights and cultural intersection of the safety in relation to individual, health inequalities environmental and between and within social determinants of populations in relation community health to community nursing practice recap so far Community nursing concerned with How does a social equity understanding of health Ill health is linked with social and underpin community environmental & other factors (think nursing? social model of health) Primary Health Care should be Moving beyond basis of health care delivery biomedicine ‘Health in all policy’ areas Understanding there are other factors that Community action and determine health empowerment How we marginalise some population groups (today) Determinants of Health The range of social, ecological, political, commercial and cultural factors that influence health status are known as the determinants of health. These are often complex and interrelating factors that contribute to a person’s current state of health and their chances of maintaining good health or becoming ill or injured. Circumstances are shaped by the distribution of money, power, and resources at the international, domestic and local level. PHAA, 2018  What determines health? Cultural Social Political Commercial Historical Environmental The University of Sydney What determines health…? Political Marketing to An uncomfortable children truth Profit driven Root cause of SDH? Driven by disease Universal health policy/politics care Nursing is never neutral Commercial Social/environmental The University of Sydney Page 7  Upstream and downstream determinants of health: thinking socio ecologically upstream Upstream Major causes that set a pathway in motion leading to health effects that show in the short and long term E.g., education access, town planning and infrastructure decisions Downstream Easily identified factors (attitudes, behaviours, beliefs) that influence health E.g., smoking, diet choices downstream Is society to blame? Structure – agency debate (LO: Define the structure – agency debate) structure agency The University of Sydney Page 9 QUICK THOUGHT BUBBLE 1. What determines health in Singapore/globally? 2. How much control/choice do we really have in shaping our own health? Menti 17058069 The University of Sydney Page 10 A community health approach is underpinned by equity and social justice Inseparable concepts in health: equity and the social determinants of health The University of Sydney Equity and Equality Equity is the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification. World Health Organisation The University of Sydney Equity Access to community health Equity of service: GP; hospitals; community Access services; opportunities for work; housing etc. Resources based on need Patterns of systematic differences between population groups that is unfair and avoidable. Equity in Equity in the health distribution of outcomes resources The University of Sydney  Equity, social justice and human rights Human rights perspective to relieve poverty and ensure equity is enshrined by international law. It is not optional or the responsibility of charity As nurses, this is enshrined in the way we practice and deliver health care governed by code of ethics & scope of practice The University of Sydney What are the (social) determinants of health? The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries WHO. The University of Sydney Historical and contemporary evidence supporting SDoH Government reports Lalonde Report, WHO: Solid 1974 Facts, 2003 Acheson Report, Black Report, 1988 Whitehall 1980 Studies. 1960’s- Dahlgren & 1980’s Whitehead, 1991 Longitudinal studies & Mounting international international collation evidence of evidence, WHO Historical and contemporary evidence The Whitehall studies The lower a person’s economic position the worse their health significant in determining health and well being Social and environment influences disadvantaged groups are typically found at the bottom of the ladder Income and income distribution Wealth = Health  Understand the social gradient and its relationship to health status The social gradient in health is a term used to describe the phenomenon whereby people who are less advantaged in terms of socioeconomic position have worse health (and shorter lives) than those who are more advantaged.. Donkin, 2014 What the Whitehall studies told us..  The social gradient What are the social Stress determinants of health? Early life conditions (Guyz et al., 2021) Social exclusion Work Unemployment Social support Addiction Food Transport Commission on the Social Determinants of Health Recommendations Improve Daily Living conditions Tackle the inequitable distribution of power, money and resources Measure and understand the problem and Assess the impact of action  WHO Commission - Social Determinants of Health (Chaired by Sir Michael Marmot) The Commission focused on nine broad areas that summarise the major determinants of health and demonstrated that health inequities are the result of a complex system at global, national and local levels. Priority Employment Social public health conditions exclusion conditions Women and Early child gender Globalization development equity Health Measurement Urbanization systems and evidence The University of Sydney Early childhood and health 22% of children starting school developmentally Physical vulnerable on 1 or more Australian Early Development Census One in 6 children (AEDC) domains (16%) were not read to or told stories at all. School success Economic participation, Language Social Social citizenship Cognition Health Emotional The University of Sydney https://www.aihw.gov.au/reports/australias-health/social-determinants-of-health Sustainable Development Goals https://sdgs.un.org/goals https://www.singstat.gov.sg/find-data/sdg/sdg-progress-tracker  Corona virus and the social determinants of health Initially described as a great equaliser Recent evidence shows that social inequalities impact Covid-19 mortality & morbidity Has exposed longstanding structural drivers of health inequities (Paremoer, 2021) https://www.thelancet.com/action/showPdf?pii=S2213-2600%2820%2930234-4 https://www.bmj.com/content/372/bmj.n129 Wider gaps in equality WHO: COVID-19 and the SDOH The University of Sydney expected post pandemic What’s next? The University of Sydney Page 25  So, what does this mean for community nursing? The University of Sydney Translating this to community nursing practice: Recognising the role of social factors in health: devising effective treatment plans to incorporate this into assessment and planning Integrating Code of ethics, standards Advocacy: strength in numbers community and hospital to plan and conduct effective discharge Statement from International Council of Nursing (ICN) Safety and Quality in health Role of nursing CN Leadership in research case management CN are strategically positioned to identify needs for social services  Putting it together: Understanding community Plan interventions Demographic data: who is your community? Pre pathogenesis: Epidemiological data: what are their health Primary: for example, mass vaccinations; experiences? primary engagement with HW in community and cultural/religious leaders; Health service data: what does the data tell us? risk communication Data on knowledge, attitudes and practice (social Secondary: Training, education & behavioural data) management of disease Data on physical characteristics in the environment: Tertiary: ongoing management and is your community safe, clean, have green space? evaluation of programmes Lecture 4: Community Health Literacy Day 2: SNGP3011  Health literacy: Keeping it simple - Today: Focus on health literacy to better understand how best to communicate effectively with clients and patients in community practice. - Learning outcome:competence in communication and interaction with a variety of clients and families as well as agency personnel and other community resources in clinical settings - Define and describe health literacy and its relationship to PHC and Community nursing - Discuss the impact of lower health literacy - Describe the principles to use when communicating with and teaching patients and clients in the community The University of Sydney What do you think health literacy means as a nurse? - Go to Menti: QR code - Respond to the question The University of Sydney  What is health literacy? reading, understanding and acting on preventive health messages completing health forms such as consent forms, insurance forms, Medicare claims finding a healthcare provider or service and making an appointment navigating healthcare systems and services making informed decisions about health and health care The University of Sydney Defining health literacy “…the ability to access, understand, appraise and apply information in order to make judgments and decisions in everyday life concerning healthcare” Sorensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J.M., Slonska, Z., & Brand, H. (2012) "Health literacy and public health: A systematic review and integration of definitions and models", BMC Public Health, vol. 12, no. 1, pp. 80-80. The University of Sydney Image source: https://indigenousx.com.au/  Levels of Health Literacy Nutbeam (2000) Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century, Health Promotion International, 15(3) 259–267 https://doi.org/10.1093/heapro/15.3.259 Basic/functional literacy. Enables the person to function effectively and make informed decisions about personal health and wellbeing. Communicative/interactive literacy. Higher-level processing and analysis capacity, enables the person to apply the knowledge to different situations Critical literacy. Cognitive capacity, where the person can critically analyse information. Can use knowledge and the capacity building to influence change in community, social situations and events for collective action addressing underlying determinants of health. The University of Sydney Health literacy and public health Sørensen, K. et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 12, 80 (2012). https://doi.org/10.1186/1471-2458-12-80 The University of Sydney What is health promotion? Health promotion is any combination of educational, organisational, economic and environmental supports for actions conducive to health” (Green & Kreuter, 1991) The University of Sydney  1986 ~ Ottawa Charter for Health Promotion 5 KEY ACTION AREAS 01 02 03 04 05 Building Creating Strengthening Developing Reorientating healthy public environments community personal health care policy which support action skills healthy living The University of Sydney  Promoting health - Sustainable Development Goals 1.Transformative policy orientations 2.Creating the political will to act 3.Enabling transformative governance capacities at country level A strong focus on people – the centrality of health literacy in improving community health Leaving no one behind Health-in-all-policies approaches Strengthen legislation, regulation, and taxation of unhealthy commodities Strong public health systems and health promotion organizations The University of Sydney  Health Literacy and Health Promotion Health promotion is “the process of enabling people to increase control over, and to improve, their health” Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. Health literacy is the basis of health promotion There is no health without health literacy The University of Sydney  Effective health promotion strategies focus on prevention 3 broad categories of health promotion Primary Prevention aims to Health prevent the disease before it Education occurs. E.g., behaviour modification Secondary Prevention aims to reduce the impact of a disease or injury that has already occurred. Disease Health prevention Protection E.g., seat belt E.g., Tertiary prevention aims to soften legislation legislation the impact of an ongoing illness or injury that has lasting effects. The University of Sydney What is health education? ‘consciously constructed opportunities for learning involving some form of communication designed to improve health literacy, including improving knowledge, and developing life skills which are conducive to individual and community health Health education and health literacy to develop knowledge and skills for health and wellbeing action in Talbot, L., & Verrinder, G. (2018). Promoting health : the primary health care approach (7th edition.). Elsevier Australia. The University of Sydney  Health education Provision of both verbal and written health education: Patient is health literate health knowledge Infrastructure is available to Information is satisfaction scores make healthy choices accurate confidence level recovery time ASSUMPTI adherence to treatment ONS Educator and patient are Education is a readmission rates operating under the same belief system motivator for better health complication rates costs of health care Education is culturally stress and anxiety appropriate The University of Sydney  Health education is the tool - health literacy is the outcome Health Education: Is more then just giving good advice Is well planned Targets a person who is likely/ready to listen (the recovering patient) Ethically respects the right of clients to ignore your message Includes using appropriate body language Confirms understanding of information provided Provides options relevant to the person’s Having a patient listen to you is situation about planning, not shouting Includes following up about actions to be taken by health consumers The University of Sydney  Addressing the health literacy challenge Health literacy – describes a range of outcomes to health education and communication activities Health education intends to improve health literacy Education is an essential component of action to promote health / prevent disease Health education remains a fundamental tool in promotion of health and prevention of disease The University of Sydney  Health literacy influences safety and quality of health care Three areas of action: 1. Embedding health literacy into systems 2. Ensuring effective communication 3. Integrating health literacy into education The goal: People can access, understand and act on health-related information https://www.safetyandquality.gov.au/sites/default/files/migrated/Health-Literacy-National- The University of Sydney Statement.pdf https://www.youtube.com/watch?v=iCobR-JmhVw&ab_channel=ABCNews%28Australia%29  Primary Health Care and health literacy? Recap: A philosophy or framework with a broad vision for health that incorporates all sectors working collaboratively in the pursuit of health as defined by the WHO. The University of Sydney Break The University of Sydney The impact of lower health literacy  Australians & Singaporeans are encouraged to actively participate in maintaining their heath https://www.aihw.gov.au/reports-data/australias-health The University of Sydney https://hpb.gov.sg/newsroom/article/health-promotion-board-raises-an-army-of-10-000-health-ambassadors  Types and levels of literacy Levels of literacy Health literacy Basic/functional literacy: sufficient, basic skills in reading and writing to be able to function effectively Cultural literacy in everyday situations Communicative/interactive literacy: more advanced cognitive and literacy skills which, together Scientific literacy with social skills, can be used to actively participate in everyday activities Financial literacy Critical literacy: skills, can be applied to critically analyse information and to use this information to Informational literacy exert greater control over life events and situations Media/print literacy Procedural knowledge: knowing what to do and when Visual literacy Judgement skills: able to apply knowledge/skills to The University of Sydney a new situation Factors that can impact health literacy Age Education Disability Culture and Gender language The University of Sydney  Health literacy and health outcomes Studies have shown correlations between lower levels of health literacy and: increased hospital admissions and readmissions poorer medication adherence and increased adverse medication events less participation in prevention activities higher prevalence of health risk factors poorer self-management of chronic diseases and poorer disease outcomes less effective communication with healthcare professionals increased healthcare costs poorer overall health status including increased mortality The University of Sydney Berkman, N., Sheridan, S., Donahue, K., Halpern, D., Crotty, K., & Berkman, N. ( 2011). Low health literacy and health outcomes: an updated systematic review. Annals of Internal Medicine, 155(2), 97–107.  Causal pathways between Health Literacy and Improved Health Outcomes 1. Access & utilisation of healthcare Occupation services PATIENT FACTORS SYSTEMS FACTORS Employment Navigation skills of HC Complexity Income system Acute Care Social Self-Efficacy Orientation Support Perceived barriers Tiered Delivery Model Culture Language 2. Provider-Patient Interaction Race/Ethnicity PATIENT FACTORS PROVIDER FACTORS Health Status Knowledge, attitudes Communication Skills Education    Beliefs, social norms  Teaching Ability Health  Participation in Decision  Time Outcome Age Making Vision  Patient-Centered Hearing Care Speaking 3. Self-Efficacy ability Memory PATIENT FACTORS EXTRINSIC FACTORS Recall  Motivation  Support technologies Reasoning  Problems solving  Mass Media  Knowledge  Health education  Skills  Resources The University of Sydney Page 53 Impact of lower health literacy and poor communication in community Practitioners ask patients to monitor their disease We expect patients to acquire necessary disease knowledge and complex self-management skills Many patients have limited health vocabulary Providers should not routinely assume that patients correctly understand their diagnoses and treatment plans. Poor communication may result in: misinformation, misunderstandings, mistakes The University of Sydney Page 54  Real patients, real stories A health literacy problem is a crisis in understanding medical information rather than one of access to information Understanding health information is everyone’s right Improving clear health communication is everyone’s responsibility The University of Sydney Page 55 The University of Sydney Page 56  Lower health literacy affects people’s ability to: Understand instructions on prescription drug bottles and nutrition labels Act on health-related news and announcements (e.g., severe weather alerts) Share personal and health information with providers Manage chronic health conditions Understand and act on concepts like preparedness and risks associated with unhealthy behaviors and environmental issues (e.g., vote on an environmental issue like smoking bans) Understand how to locate and access affordable health care for themselves and their families or children. Recognise bias in health information reported by the media (e.g., pharmaceutical sponsors) CDC National Center for Health Marketing, 2009 The University of Sydney Page 57  Shame and social stigma Consider the relationship of shame and health literacy Social stigma associated with illiteracy creates feelings of inadequacy and poor self- esteem Patients with lower literacy might hide their problem by saying: I'd like to discuss this I don't need to I forgot my with my family first; read this through reading may I take the now; I'll read it glasses instructions home? when I get home Several assessment of patients' reading ability are available The University of Sydney Page 58  Red flags for lower literacy Frequently missed appointments Incomplete registration forms Mistakes taking or not taking prescribed medication Unable to name medications, explain purpose or dose Identifies pills by looking at them, not reading label Unable to give coherent, sequential history Asking fewer questions Making excuses Lack of follow-up on tests or referrals The University of Sydney Page 59  The Ophelia approach - Optimising health literacy to improve health and equity https://sdgs.org.au/project/optimising-health-literacy-and-access-ophelia-to-leave-no-one-behind/ Feel understood and supported by healthcare providers Have sufficient information to manage my health Actively managing health Have social support for health Appraise health information Ability to actively engage with healthcare providers Ability to navigate the healthcare system Ability to find good health information Ability to understand health information well enough to know what to do The University of Sydney Page 60 Supporting effective communication: health literacy is a safety & quality issue Identify situations within the community where identification, procedure matching, structured handover and communication of critical information are required Review policies and processes to see if they support and enable effective communication at these times If there are gaps, or improvements can be made, revise or develop policies and processes to reduce these gaps Provide resources and tools to encourage effective communication processes at these times. Everyone can play a part in addressing health literacy. The University of Sydney  Principles, skills and tools to use when communicating with and teaching patients  Guiding principle: Adult Learning Principles Adults are internally motivated and self- directed Adults bring life experiences and knowledge to learning experiences Adults are goal oriented Adults are relevancy oriented Adults are practical Adult learners like to be respected Consider the educational setting The University of Sydney Page 63 How do you communicate as a (community) nurse? Turn to the person beside you - 2s or 3s You are going to communicate complex health information to your patient who has low health literacy Provide the following information in ‘lay’ language Rate your partner on i) simplicity of information ii) ability to engage iii) retention of information Post on menti- ‘how do we communicate?’ The University of Sydney  Teach-back in practice Watch this video to see an example of teach-back in practice What proportion of the population has ‘inadequate’ health literacy in Australia? The University of Sydney Page 65  Guiding principle: The right to understand & universal precautions approach Clear information about my condition, the possible benefits and risks of different tests and treatments, so I can give my informed consent Receive information about services, waiting times and costs Be given assistance, when I need it, to help me to understand and use health information Request access to my health “…involves structuring healthcare services information and health communication in such a way to minimise risk for everyone when it is unclear Be told if something has gone wrong during my health care, how it which patients may have difficulty.” happened, how it may affect me and what is being done to make care safe The University of Sydney Page 66  The role of culture in communication Health literacy is affected by: belief systems, communication styles, and understanding and response to health information (often web based) Promoting health literacy: Creating helpful supporting environment Helping patients navigate system Preparing to interact with health provider National Network of Libraries of Medicine. 2013. http://nnlm.gov/outreach/consumer/hlthlit.html#A6 Shaw, S.J. et al. The Role of Culture in Health Literacy and Chronic Disease Screening and Management. J Immigrant Minority Health 11, 460–467 (2009). The University of Sydney https://doi.org/10.1007/s10903-008-9135-5 Page 67  Principles to inform the way nurses communicate with patients and their families Person-centred care: what are patient perspectives? Shared decision-making: patients are experts in their own lives Supporting health literacy: using tools and strategies to include patients in decisions The University of Sydney Page 68  Clinical skills for shared decision making Simplifying language - Keep it Simple, Stupid (KISS) Good Listening communication Summarising information skills Ask patients to tell you what you they have understood (Teach-back) Support patients List options and their families Explain known risks, benefits and harms to be involved in Individualise risks, benefits and harms Ensure you actively allow opportunity to ask questions decisions The University of Sydney Page 69  Tools to support communication and SDM Decision aids Supporting question asking Question prompt lists Patient coaching Consultation audio recording Summaries The University of Sydney  Ask Share Know – communicating evidence A set of questions which represent the minimum dataset required to make an informed choice under conditions of uncertainty: The University of Sydney www.askshareknow.org.au Page 71  Question prompt lists  Tools to encourage patients to ask questions  To increase information exchange  To engage and involve patients in their own healthcare https://www.cancer.nsw.gov.au/about-cancer/document- library/medical-radiation-oncologist-question-list 72 The University of Sydney Page 72  Written information Calculating readability Grade 8 readability level (general population) Grade 5 readability level (lower literacy populations) http://www.hemingwayapp.com/ The University of Sydney Page 73  Written information Testing written resources with patients prior to publication and dissemination Author registers the resource and drafts materials Step 1 in line with plain English guidelines and using standardised templates and images. Author tests for readability using Readability Step 2 Calculator - a score of Grade 8 or lower is required. Author tests the resource with patients (n>5) and Step 3 logs feedback using standardised feedback tools. Author uses the feedback to make changes to the Step 4 resource and retest readability to reach required score (see Step 2). Mastroianni, F., Chen, Y., Vellar, L., Cvejic, E., Smith, J., McCaffery, K., & Muscat, D. (2019). Implementation of an organisation-wide health literacy approach to improve the understandability and actionability of patient information and education materials: A pre-post effectiveness study. Patient Education and Counseling, 102(9), 1656–1661. https://doi.org/10.1016/j.pec.2019.03.022 The University of Sydney Page 74  Written information Patient Education Materials Assessment Tool (PEMAT) https://www.ahrq.gov/sites/default/files/publications/files/pemat_guide.pd f The University of Sydney Page 75  Communicating complex information Challenges Communicating risk  Language Descriptive terms may convey a totally different order  Medical jargon of magnitude to different people.  English?  Literacy and numeracy ‘Low risk’ ‘Likely’  Patient understanding  Patient anxiety  Time Avoid explaining risks in purely descriptive terms.  To ask questions  Review and consider The University of Sydney Page 76  Teach-back: a method to evaluate comprehension Creates an opportunity for dialogue in which the provider gives information, then asks the patient to respond and confirm understanding before adding any new information. Iteratively asking the patient to summarise or restate the important points in a consultation using their own words The University of Sydney Page 77  Teach-back: Closing the loop Schillinger D, Piette J, et al.2003. Closing the Loop Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med. 63(1):83-90. The University of Sydney Page 78  Finding your own words What will you tell your parents about how to We’ve talked a lot about how give the medicine to you can increase your physical your baby? activity. Please go over what we talked about in your own words. Just to make sure I So I can be sure I haven’t missed any have covered important points, could everything, could you explain back to you just run through me how you are going what you will do to manage …? when you …? The University of Sydney Page 79  An asset approach across whole community Schools Education programs Digital platforms Image source: https://unsplash.com/ The University of Sydney Page 80  An asset approach to engaging patients Patient training prior to consultations Videos in waiting rooms Referral to Chronic Disease Self- Management Programs. ‘Prescribing’ evidence-based apps which support skill development. Image source: https://www.wslhd.health.nsw.gov.au/Quality-Patient-Safety/WSLHD-Quality-Awards-in-Healthcare/2017-Quality-Awards The University of Sydney Page 81  Building health literacy skills An asset approach Three-level hierarchy of health literacy skill development (Nutbeam, 2000) Critical health literacy Refers to the cognitive and Communicative social skills needed to health literacy critically assess the Skills which can be used to applicability of health participate actively in information to personal everyday situations, extract situations or its reliability. health information and Functional derive meaning from health Refers literacy to the basic different forms of health skills for obtaining communication and apply health information. this to changing circumstances. The University of Sydney Page 82 Summary Health literacy refers to “…the ability to access, understand, appraise and apply information in order to make judgments and decisions in everyday life concerning healthcare”. Many factors impact health literacy – age, gender, culture and language, education Nurses and other HPs can use strategies such as clear and effective communication, patient centred communications and tools to support patients, e.g., QPLs, Teach-back strategies Health care organisations need to review their communication resources to check they meet needs of their populations and safety and quality standards