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Fielding deterhlth


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  • 1. Determinants of Health Jonathan Fielding Professor of Health Services and Pediatrics, UCLA Director of Public Health and Health Officer, LA County
  • 2. What makes health?
    • Like a book—define the production function
      • Inputs
      • Processes
      • Outputs
    • Unlike a book, need to define what we mean by health
  • 3. What is health?
    • What does it mean to you?
    • What are its major characteristics and dimensions?
    • How do you know when you see it?
  • 4. “ ...a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” World Health Organization, 1948
  • 5. “… an individual’s capacity in relation to aspirations and potential for living fully in the social environment.” Alvin Tarlov, 1996
  • 6. Population Health
    • What is it?
    • Is it best defined by the sum of the health of individuals in the population? Why or why not?
    • What are the different populations of interest?
  • 7. What determines health?
    • Public surveys
      • Medical care
    • Public consumption
      • Alternative medicine
      • Vitamins/ supplements
      • Cosmetic procedures
      • Exercise equipment
      • Diets
      • Viagra
      • HRT
  • 8.  
  • 9. How have health problems changed?
    • Longevity in 1900 vs 2000?
    • Communicable diseases
      • Major killers since before recorded history through early 20 th century
      • Decimated native American populations during early contact with Europeans
      • What are key factors that reduced their toll?
  • 10. How have health problems changed?
    • Chronic diseases—
      • What are they?
      • How quickly do they develop?
  • 11. Health Behaviors and Health Outcomes Multiple Pathways
  • 12.  
  • 13. Family Environment Family Functioning Family Life-Cycle Family’s Characteristics Community, Society & Culture Individual’s Innate Characteristics Individual Health Individual’s Development Individual’s Community Community and Family Pathways to Health Family Functions
  • 14. Family’s Characteristics Health Biological Psychological Health Behaviors Demographic Income Education Occupation Race Ethnicity Housing Residence Employment Religion Language Household Marital Status Composition Relation
  • 15. Family Effects on Physical Aggression by Children Trembly et al., 1996
  • 16. Hostility and Mortality by City Williams et al., 1980 Honolulu Minneapolis Seattle Denver Cleveland Detroit Des Moines New York Philadelphia Chicago
  • 17. Psychological Problems Within Families With at Least One Child with a Psychological Diagnosis Mother (-) Mother (+) Father (-) Father (+) Father (-) Father (+) 36% 47% 68% 72% (-) Individual without diagnosis (+) Individual with diagnosis Child (+)
  • 18. Health of children: a special case
    • What are differences between the relative importance of influences on child and adult health?
      • Role of parents
      • Role of other caregivers
      • Health/ development interactions
      • Long term impact of lifestyles/ attitudes
  • 19. Individual health versus population health
    • Does sum of health of individuals comprise health of the population?
  • 20. Determinants of Individual Health Social Environment Physical Environment Genetic Endowment Individual Response -Behavior -Biology Health & Function Disease Health Care Well-Being Prosperity Source:R.G.Evans & G.L. Stoddard, Why Are Some People Healthy , p. 53
  • 21. Burden of Disease and Injury: Measures
    • Mortality rates
      • the traditional measure of burden
      • counts how many people die of a particular problem
      • does not address disability or premature death
    • Years of life lost (YLL)
      • measures how many years of expected life have been lost due to a particular problem
      • takes into account premature death
    • Disability-adjusted life years (DALYs)
      • the newest measure
      • takes into account both disability and premature death
      • Los Angeles County is the first local jurisdiction to generate DALY’s estimates
    • Frequency of health problems
  • 22. Leading Causes of Death in Los Angeles County, 1997 Number of Deaths in 1999 Los Angeles County Department of Health Services
  • 23. Overall Burden of Disease Among Men in Los Angeles County Based on DALYs, 1997
  • 24. Overall Burden of Disease Among Women in Los Angeles County Based on DALYs, 1997
  • 25. Among Adults (Age 18 years and older), Average Number of Activity Limitation Days by Chronic Health Condition, Los Angeles County, 1999
  • 26. Social Ties and and 9 year Mortality in Alameda County, CA Berkman L et al. Social networks, host resistance, and mortality: A nine year follow up study of Alameda County residents. Am J Epidemiol 109:186-204, 1979. Males
  • 27. Social Ties and and 9 year Mortality in Alameda County, CA Berkman L et al. Social networks, host resistance, and mortality: A nine year follow up study of Alameda County residents. Am J Epidemiol 109:186-204, 1979. Females
  • 28. Income & Health Relative risk of coronary heart disease death by civil service rank- male civil service workers Marmot MG et al. Employment grade and coronary heart disease in British civil servants. J Epidemiol Community Health 3:244-249, 1978
  • 29. Environmental Exposure Haile RW, et al. The Health Effects of Swimming in Ocean Water Contaminated by Storm Drain Runoff. Epidemiology. July 1999 10(4)p 355-363 Selected Attributable numbers/10,000 exposed subjects for total to fecal coliforms HCG- highly credible GI illness with vomiting, diarrhea, and fever or stomach pain and fever
  • 30. Health Disparities
    • Major differences in frequency and severity of major diseases by race and ethnicity
      • All stages of life
      • Both men and women
      • Have not diminished with advances in health care
      • Combination of reasons
      • Elimination a national priroity
  • 31. Prevalence of Asthma Among Children (Age 0 to 17 years) by Race/Ethnicity and Age, Los Angeles County, 1999 - 2000 * Estimate may be unstable due to small sample size
  • 32. Key Health Indicators (LAC)
    • Uninsured adults under 65  31%
    • Overweight and obese adults  52%
    • Cigarette smoking among adults  18%
    • Binge drinking among adults who drink  16%
    • Sedentary adults  41%
    • Kindergarteners IZ up to date at second birthday  64%
    • Low birth weight births  6%
    • Low birth weight black births  12%
    • AIDS incidence rate (males)  34 per 100,000
  • 33. Community Health
    • Population health but includes the characteristics of community that influence determinants over time
      • E.g. safety of parks; housing stock
      • E.g. civic engagement
      • E.g. environmental problems
      • E.g. cohesion to work collectively to improve community
      • E.g. markets selling affordable fresh fruit and vegetables
  • 34. Community Health Report Cards
    • Attempt to:
      • Provide snapshot of community health/ quality of life
      • Improve awareness of problems/ assets
      • Improve community health planning
    • Broad collaborations
      • Often many sectors within community
    • Health determinants often included
  • 36. Thinking ahead
    • Need to consider contribution of different community institutions to health (potential vs actual)
    • Importance of sense of place
    • Need to address underlying health determinants
    • Health care for all important-- but other health determinants at least as important
    • How to develop sense of belonging/ responsibility?
    • Lifecycle perspective –understanding delayed effects
  • 37. Health Department Roles
    • Educate the public about multiple determinants and broad definitions
    • Influence public policies to support health improvement
    • Deliver targeted services to those in need
    • Track changes in health and health risks
    • Reduce disease burden and disparities