PHM 283L Health Behavior_Health Outcome Exam 2 Study Guide PDF

Lecture 1: Pharmacy in Public Health Learning Objectives: Recognize the definition and concepts in public health ○ Public Health “Public health promotes and protects the health of people and the communities where they live, learn, work and play.” - American Public Health Association Focuses on group...

Lecture 1: Pharmacy in Public Health Learning Objectives: Recognize the definition and concepts in public health ○ Public Health “Public health promotes and protects the health of people and the communities where they live, learn, work and play.” - American Public Health Association Focuses on groups of people (macro level) vs an individual (micro level) Is rooted in the principle of social justice → people have the right to be healthy and to live in conditions that will support their health Spans across a diverse set of issues such as: Infectious diseases, chronic diseases, emergencies, injuries, and environmental health problems ○ A Public Health Approach follows 4 general steps ○ ○ 3 Core Functions of Public Health Assessment: systematically collect, analyze, and make available information on health in communities → [what needs to be done] Policy development: promote the use of a scientific knowledge base in policy and decision making → [being part of the solution to get it done] Assurance: ensure provision of services to those in need → [making sure it gets done] Public health professionals work at the macro- and micro-levels Macro level (planning level) Focus on the well-being of the population as a whole Emphasize the assessment and prioritization of a community’s needs and planning to address those needs Example activities: ○ Educate about health risks (e.g., risks of alcohol and tobacco) ○ Set safety standards to protect workers ○ Develop school nutrition programs to ensure kids have access to healthy food ○ Track disease outbreaks, prevent injuries and shed light on health disparities related to at-risk populations and SDoH ○ Advocate for laws and policy that promote smoke-free indoor air and seatbelts ○ Conduct and disseminate research and give science-based solutions to problems Micro (or provider) level (implementation level) Include activities required to implement public health initiatives Performed on a provider-to-patient or a program-to-population basis Examples: disease screening, immunization, counseling for at-risk populations, & tobacco cessation programs (Pharmacists are involved at Micro levels) ○ Prevention is important to many public health activities Primary prevention: reducing the actual incidence and occurrence of diseases, injuries, and disability Secondary prevention: decreasing the severity or progression of the disease, injury, and disability (usually where pharmacist work) Tertiary prevention: treatment or rehabilitation to return the disease, injury, or disability to the initial or baseline state Describe the evolving role of pharmacists in public health promotion and planning ○ Pharmacists have traditionally been involved in secondary prevention and less involved in primary prevention activities Q: A pharmacist's role is usually involved in secondary prevention. TRUE- don't over think! Secondary prevention Medication therapy management Medication reconciliation - at times of care transitions (e.g., hospital discharge) Education and behavioral counseling Collaborative care models → team-based practice models Primary prevention Immunization Cardiovascular risk reduction clinics Tobacco cessation clinics Disease screenings ○ Pharmacists improve access to care - extension of the health care team to the community, providing patients with the resources and care they need ○ Pharmacist’s role in public health: individualized patient care vs public health efforts By ○ Potential roles for pharmacists in public health promotion Promoting Developing Collaborating Advocating Engaging Summary ○ Pharmacists play a vital role in maintaining and promoting public health ○ Pharmacists should be involved in public health policy decision-making and in the planning, development, and implementation of public health efforts Lecture 2: Pharmaceuticals in the Environment Learning Objectives: Pharmaceuticals are in the environment List where pharmaceuticals have been found in the environment ○ Surface water, groundwater, drinking water, & sediments List the sources of pharmaceuticals contaminating the environment ○ Pharmaceuticals are manufactured, used by humans, administered to animals ○ Difficult to discriminate and quantitate which sources are most significant ○ Excretion is likely the most significant source Explain how pharmaceuticals can move through environmental media ○ By settling from water onto sediments below ○ Onto/into soils By irrigation with recycled water By fertilization with sewage sludge ○ Onto/into plants By irrigation with recycled water By fertilization with sewage sludge ○ From sediments and soils back into water ○ But we have very limited knowledge of this movement. Risks of this exposure Compare how humans and wildlife may be exposed ○ Humans may be exposed to pharmaceuticals contaminating the environment via: Consumption of contaminated drinking water Consumption of fish and seafood from contaminated waters Consumption of crops irrigated with contaminated water or fertilized with sewage sludge or biosolids Bathing in contaminated water Recreation in contaminated water ○ Wildlife may be exposed to pharmaceuticals contaminating the environment via: Consumption of contaminated drinking water Consumption of contaminated food Chronic dermal exposure from living entirely or almost entirely in contaminated water Compare the dose humans may receive to the dose wildlife may receive ○ Dose for humans Most exposure is through drinking water Most pharmaceuticals detected at parts per trillion in water Amount consumed in water on a daily basis will likely not exceed daily therapeutic dose However: Presence of pharmaceuticals in drinking water results in long-term exposure Long term exposure may be an issue for medications developed for short term therapeutics uses ○ Dose for Wildlife Exposure is via more than just drinking water Most pharmaceuticals detected at parts per trillion in water Is there an accepted “daily dose” for these animals? These are life-time exposures We don’t know what these drugs will do to various animals Compare the risk to humans and wildlife ○ Risk Quotient (RQ) = exposure dose/adverse response dose RQ is compared to an allowed “level of concern” ○ Exposure dose (often is predicted) ○ Adverse response dose: For humans: we get this data from drug development studies For wildlife: we get this data from observational studies or animal exposure studies Minimizing the problem List how the quantity of pharmaceuticals reaching the environment may be reduced ○ Green Chemistry is “the design of chemical products and processes that reduce or eliminate the use and generation of hazardous substances” ○ The top 10 international pharmaceutical manufacturing companies that embrace environmental stewardship Reduced waste, conserved resources, and decreased hazardous emissions Explain why some medications may be flushed down the toilet ○ Concentrations of pharmaceuticals in influents and effluents of wastewater treatment facility has large variability across geographical regions ○ Conventional drinking-water treatment processes reduce pharmaceuticals, but often don’t eliminate ○ Developing and evaluating methods of removing pharmaceuticals from drinking water continues & effectiveness depends on the process used Select the best drug disposal method and explain why it is the best ○ Drop off the medicine at a drug take back site, location, or program immediately. Decide which mitigation strategies you feel you can most likely impact ○ Limiting prescribing includes prescribing Only when necessary Only the necessary quantity ○ Limit prescribing may impact the environment by reducing Quantity of unused medications that may be improperly disposed of Amount of medication excreted by patients Lecture 3: Access to Care in the US Healthcare System Learning Objectives: Understand the importance access to care plays in overall health and well-being ○ Promoting and maintaining health ○ Preventing and managing disease ○ Reducing unnecessary disability and premature death ○ Achieving health equity for all Americans. Identify the major barriers to healthcare access ○ High cost of care ○ Inadequate or no insurance coverage ○ Lack of availability of services ○ Lack of culturally competent care *Note: Barriers VARY based on race, ethnicity, socioeconomic status, age, sex, disability status, sexual orientation, gender identity, and residential location Access to Health Services Involves 3 Components ○ Coverage, Services, & Timeliness 5 A’s of Access To Care ○ Affordability, Availability, Accessibility, Accommodation, & Acceptability ○ The five As of access form a chain that is no stronger than its weakest link. U.S. spends a lot of money on health care – double that of comparable countries – yet life expectancy is 4 years less than comparable countries There are significant disparities in access to care – all levels of access to care – by gender, age, race, ethnicity, education, family income and geography. Need for a primary care workforce that is better geographically distributed and trained to provide culturally competent care to diverse populations. Accessing and effectively using health care services is multidimensional and complex and thus cannot be effectively addressed with single solutions (e.g., insurance). Lecture 4: Health Equity and Vulnerable Populations Learning Objectives: Describe health disparities and vulnerable populations. ○ Health disparities: differences in the incidence and prevalence of health conditions and health status between groups based on: Race or ethnicity, socioeconomic status, gender or gender identity, sexual orientation age, disability, and geographic location Ex) male babies are generally born at a heavier birth weight than female babies ○ Health inequities: systemic and unjust distribution of social, economic, and environmental conditions needed for health (disparity/inequality + unfair and unjust) Unequal access to quality education, healthcare, housing, transportation, other resources (e.g., grocery stores, car seats) Unequal employment opportunities and pay/income Discrimination based upon social status/other factors Ex) babies born to Black women are more likely to die in their first year of life than babies born to white women ○ Health equity: the opportunity for everyone to attain his or her full health potential No one is disadvantaged from achieving his potential because of his or her social position or other socially determined circumstance Distinct from health equality which works only when everyone starts at the same position Treating everyone the same only works if everyone starts from the same place and needs the same help ○ Equitable care: does not vary in quality because of someone’s race, gender, income, location, etc Does not mean treating every patient exactly the same but means optimal outcomes for all patients, regardless of their background or circumstances ○ Quality improvement can lead to different outcomes Neutral: more of the same Narrowing: shows improvement Widening: gap worsens ○ General approaches to changing inequities: Focusing on the most disadvantaged Narrowing health gaps Reducing the social gradient ○ Policies to remedy health disadvantages, to close health gaps and to reduce health gradients need to be pursued in tandem Describe the root causes of disparities in health outcomes and health care systems use. ○ Income and income distribution ○ Education ○ Unemployment and job security ○ Employment and working conditions ○ Early childhood development ○ Food insecurity ○ Housing ○ Social exclusion ○ Social safety network ○ Health services ○ Aboriginal status ○ Gender ○ Race ○ Disability Identify strategies to reduce health inequities ○ Engage the community ○ Delivering education and training ○ Restructuring the care team ○ Providing financial incentives ○ Providing reminders and feedback ○ Enhancing language and literacy services ○ Increasing access to testing and screening ○ Providing psychological support BARBER Study ○ Engage the community + restructuring the care team + increasing access to screening = target vulnerable population ○ Black men have the highest rate of hypertension-related death compared to any other racial, ethnic, or sex group in the US ○ Purpose: test the effectiveness of pharmacist led interventions in barber shops ○ Outcomes of hypertension control: pharmacists led intervention vs standard primary care practice ○ Hypothesis: reduction in systolic blood pressure would be greater among participants at barbershops with the pharmacist-led intervention than those in the control group ○ Results: Intervention was effective and sustained Lecture 5: Disability Awareness & Inclusive Practices Learning Objectives: Understand disability rights ○ Knowing the Law: Americans with Disabilities Act (ADA) Historically, people with disabilities were persecuted and institutionalized without protected civil rights or access to many facets of civic engagement in daily life ADA became law in 1990 A civil rights law that prohibits discrimination against individuals with disabilities in all areas of public life including jobs, schools, and transportation. This law is intended to ensure that individuals with disabilities have the same rights and opportunities as everyone else. It guarantees equal opportunity in public accommodations, employment, transportation, and state/local services. In 2008 the ADA Amendments Act extended the definition of disability and extended protections to include post-secondary/ higher education. ○ Why do Pharmacists need to know this? Pharmacists must be able to support and understand diverse populations Individuals with disabilities have diverse needs Pharmacists must be able to effectively/sensitively communicate with and serve the diverse needs of individuals with disabilities Deconstruct the social construction of disability, dispel common stereotypes and myths associated with individuals with disabilities, and reconstruct perceptions through engagement ○ Invisible disabilities An invisible disability may not be visible or noticeable on the individual Do not overlook accommodations or limitations associated with invisible disabilities Honor the challenges that these individuals may be facing Develop disability etiquette/ considerations when interacting with individuals with disabilities for better advocacy/ allyship ○ Physical & Mobility Disability Do not push a person’s wheelchair, or grab the arm of someone walking with difficulty, without asking if you can be of assistance Personal space includes a person’s wheelchair, crutches, or other mobility aid When speaking with someone using a wheelchair for more than a few minutes, try to find a seat for yourself so that the two of you are at eye level ○ Blind or Visual Impairment Identify yourself when you approach/leave a person who is blind Face the person and speak directly to him or her using a normal tone of voice Never pet or distract a guide dog unless the owner has given permission If offering directions, be as specific as possible Get descriptive. For example, instead of, “It’s just over there,” say, “The door is about four feet to your left.” ○ Deaf/Hard of Hearing/ Hearing Impaired Tap them on the shoulder or wave to get their attention Ask the individual how he or she prefers to communicate (writing notes, lip reading, interpreter) Talk directly to the individual who is deaf or hard of hearing Speak in a normal tone, do not raise your voice unless asked to If you do not understand something, ask the individual to repeat it or write it down ○ Service Animals Regulated under the Americans with Disabilities Act (ADA) Visual Impaired, Hearing Impaired, Physical and Mental health issues Must provide independence, safety, or dignity to a person with a disability Must do work or perform tasks; they are not pets Federal Regulations Only TWO questions are permitted to verify that an animal is in fact, a service animal, and those are: Is the dog a Service Animal that is required because of a disability? What work or tasks has the dog been trained to perform? Become Allies by increasing advocacy on both personal and community levels, including understanding the roles of privilege and marginalization ○ Some individuals have more than one disability ○ Individuals can be affected differently by the same diagnosis ○ Some disabilities can fluctuate and change from day to day and overtime ○ A disability is only one aspect of a person’s identity ○ Disability does not always mean inability Lecture 6: Research in Multicultural Populations Learning Objectives: Describe health outcomes research and its application to diverse populations in pharmacy practice. ○ Importance of Diversity in Clinical Trials Clinical trial are voluntary human research studies designed to answer specific questions about the safety and effectiveness of drugs, vaccines, devices, and other therapies Few people actually participate in trials - but participation is especially low fro certain populations: adults aged 75 or older, racial and ethnic minority groups & women Societal Imperative for equity: Excludes minorities from the benefits of clinical trial participation → systematically lower access to innovation products for some populations Scientific Imperative for generalizability: Biased medical evidence → patients enrolled in a trial should be representative of the types of patients who are likely to use the medical product if it is approved or cleared by the FDA. Research shows there can be important difference in how people of diverse groups respond to medical products Understand the implications of diverse research populations and generalizable results. ○ Tuskegee Study of Untreated Syphilis Involved 600 African American men Participants were unaware of syphilis and thought they were being treated for “bad blood” Incentives for participation/treatment (Coercion to impoverished land workers) ○ Between 1945-1966 the NIH funded 2,000 research projects, and none of them used informed consent Thalidomide being developed to prevent miscarriages - 200,000 American women were given the drug without knowing that it had not been approved and were not warned of the risks HeLa cells (Henrietta Lacks) - most commonly used cell in research which was cultivated from a patient named Henrietta Lacks (removed healthy and cancerous sections of her cervix) without her knowledge ○ The Beecher Report of 1966: exposed many government funded, clinical research trials that were very highly unethical. Cited many clinical trials done on marginal members of society such as the poor, developing mentally disabled and senile who couldn't decide to participate in these trials. ○ Legislative milestones in the creation of Informed Consent The Nuremberg Code, The Declaration of Helsinki, The Common Rule (U.S. Federal Policy for the Protection of Human Subjects) and 1979 Belmont Report – detailed the basic ethical principles in human subject research (respect for person, beneficence, and justice) through which oversight processes for research on human subjects would be developed. Researchers required to get voluntary informed consent from all study participants Human subjects research reviewed by Institutional Review Boards (review and approve study protocols that meet ethical standards) ○ 1993: NIH Revitalization Act: required that all federally funded clinical research: Prioritize the inclusion of women and minorities Participant characteristics be disclosed in all documentation Barriers to Research Participation: ○ Trust in medical providers and the health care establishment ○ Social and Economic Factors are consistent barriers to participation ○ Access/Knowledge limit many patients’ willingness and eligibility Distrust is present but does not predict willingness of minorities to participate in biomedical research ○ Published enrollment rates of minorities into biomedical research studies have found that minorities enroll, proportionally, in clinical research at expected and targeted rates when a reasonable effort is made. Framingham Heart Study ○ Concluded that the associations of the Framingham risk factors with atherosclerosis and CVD had similar directions across race/ethnic groups. However, the magnitude of associations between risk factors and the presence of atherosclerotic disease differ between race/ethnic groups A growing proportion of Americans are not fully benefiting from clinical and biomedical advances. Racial and ethnic minorities make up ~40% of the United States population but much smaller percentages of clinical trial participants – even in studies of treatments of diseases that disproportionately affect them The proportion of taxpayers who have not gained optimal benefit from scientific discoveries they are funding continues to grow. Barriers to diversifying research participation need concerted attention. Ensuring that diverse populations are adequately included in scientific research is imperative. ○ Scientific integrity ○ Fiduciary responsibility ○ Matter of social justice Lecture 7: People Experiencing Homelessness Learning Objectives Describe health issues in persons experiencing homelessness and how their circumstances present challenges in health care. ○ ↑ Mortality ↑ Morbidity ○ ↑ Injuries ↑ Trauma ○ ↑ Skin and foot problems ○ ↑ Infectious diseases ○ ↑ Food insufficiency ○ ↑ Mental health problems ↑ Substance abuse ○ ○ ○ ○ ○ ○ ○ ↓ Dental health ↓ Management of chronic conditions High number of ED visits and unplanned hospitalizations Frequent use of social services and have high incarceration rates Fragmented communication Competing priorities Follow-up Transportation Transient nature of population Understand how health inequities in the homeless population can be addressed. ○ Remember, everybody has a story. ○ Team-based care ○ Inclusion of people with lived experience ○ Keep in mind context when counseling, developing solutions ○ Know your community resources Medical access program Housing assessment Benefits eligibility ○ Housing Focus on permanent housing vs. shelters ○ Rapid re-housing ○ Permanent supportive housing ○ Increasing employment and income ○ Enhanced communication across systems ○ Future Social determinants of health (i.e., housing) integration with health care