Public Health: What It Is and How It Works, Fourth Edition

1. Public Health:What It Is and How It Works, Fourth Edition Chapter-by-Chapter Power Point Slides Links to Internet-based resources

2. Chapter 2Understanding andMeasuring Health

3. Chapter 2 Will Help You To: • articulate several different definitions of health • identify 4 or more categories of factors that influence health and, for each of the these categories, specify 3 or more factors that influence health • identify several categories of commonly used measures of health status and, for each of these categories, identify 3 or more commonly used measures • describe major health status trends over the past 100 years • access and utilize comprehensive and current national data on health status and factors influencing health in the U.S. • utilize information on factors that influence health and measures of health to develop community health priorities and effective interventions for improving community health status

4. Health in the U.S. • Health status improving • Life expectancy at birth • Birth outcomes better • Years of healthy life increasing • Disease trends changing • Shift from infectious to chronic diseases • Disparities increasing • Ethnic and racial groups

5. U.S. Infant Mortality Rates by Race Deaths under 1 year per 1,000 live births Black All races White 1940 2001 1950 1960 1970 1980 1990 NOTE: Infant deaths are classified by race of decedent.

6. American Life Expectancy White women Black women Years White men Black men 2001 1970 1975 1980 1985 1990 1995

7. Leading Causes of Death Among U.S. Children Deaths per 100,000 children Ages 1-4 year, 2000 Homicide Heart Disease Pneumonia/Influenza Unintentional Injury Birth Defects Cancer

8. Health, Illness and Disease • Definitions of health also changing • From absence of disease • To a state of complete physical, mental, and social well-being (WHO) • Health and disease not opposites • Definition drives measures used • Shift from mortality based measures to indicators of functionality and healthy lifespan

9. Americans’ Views of Health Problems, 2001 “Issue is 1 of 2 or 3 most important health problems” (%) “Issue is 1 of 2 or 3 most urgent health problems” (%) Bioterrorism/Anthrax/Smallpox Cancer 22% 50% Healthcare costs/Insurance Heart Disease 19% 24% Cancer HIV/AIDS 19% 23% Other Diabetes 17% 11% AIDS 7% Obesity Heart Disease 7% 6% Smoking 7% Alcohol/Drug abuse 1% Health problems from terrorist attacks Smoking 6% 1% 0 10 20 30 40 50 0 10 20 30 40 50 Note: Sums up to more than 100% because each respondent was asked to give up to three different answers. HSPH/RWJF/ICR poll, November/December 2001 Gallup poll, November 8–11, 2001

10. Heart Disease Cancer Stroke Chronic lower respiratory disease Unintentional injuries Diabetes Pneumonia/influenza Alzheimer’s disease Kidney disease 0 5 10 15 20 25 30 35 Percentage (of all deaths) Health Problems in the U.S. Leading Causes of Death* United States, 2000 Actual Causes of Death† United States, 2000 Tobacco Poor diet/physical inactivity Alcohol consumption Microbial agents (e.g., influenza, pneumonia) Toxic agents (e.g., pollutants, asbestos) Motor vehicles Firearms Sexual behavior Illicit drug use 0 5 10 15 20 Percentage (of all deaths) *Minino AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: final data for 2000. National Vital Statistics Reports 2002; 50(15):1-20. †Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291 (10): 1238-1246.

11. Discussion • Based on data in the article Actual Causes of Death in the United States, 2000 (this is an update of 1990 information provided in Table 2-4 on page 60 of the text), identify three causes of death that you believe are given more media attention and coverage than they deserve based on their importance as an indicator of health status (and then three causes that you believe receive less attention than they deserve). • What are the implications of such over- or under-coverage on public policy and on public opinion?

12. Measuring Health • Mortality based measures • Crude, adjusted, and specific mortality rates • Composite measures: life expectancy and years of life lost • Morbidity, disability and quality measures • Disease prevalence • Days lost from work or school • Self reported health status

13. Life Expectancy at Birth by Gender and Ranked, Selected Countries, 2001*

14. Crude and Age-Adjusted Mortality Rates,U.S., 1950-2003

15. Total Life Expectancy and Years Healthy Life be Race and Hispanic Origin, U.S., 1998

16. Influences on Health • Ecological perspective • Multiple factors and pathways • Risk factors • Increase likelihood of condition or disease • Social and cultural determinants • Social status and standing • Global health influences • Population, pollution, poverty and more

17. HIPPOCRATES • Observed that the health of a people could be understood in terms of: • THE WINDS AND THE CHARACTER OF THE AIR • THE WATER THAT THEY DRINK • THE LAY OF THE LAND • THE HABITS OF THE PEOPLE c 600 BCE

18. Determinants of Disease

20. Discussion • Population, poverty, and pollution are sometimes cited as the 3 most important factors influencing global health status today. After examining the World Health Organization (WHO) web site, briefly cite your reasons for agreeing or disagreeing with this assertion using a specific country or region of the world as an example.

21. Determining Causative Factors • Determinants • Proven to influence level of health problem • Direct contributing factors • Affect the level of a determinant • Indirect contributing factors • Affect the level of direct contributing factors; more likely to be controllable and basis for intervention • Health problem analysis model

22. Discussion • After reviewing the Tobacco Use achievement from the Century of Progress in Public Health case study site, select a specific health outcome (other than lung cancer) related to tobacco use and analyze that health problem for its determinants and contributing factors, using the method described in the text. Identify at least two major determinants for that problem. For each determinant, identify at least two direct contributing factors, and for each direct contributing factor, identify at least two indirect contributing factors.

23. Annual Adult Per Capita Cigarette Consumption and Major Smoking and Health Events—United States, 1900-1998

24. Economic Dimensions of Health • Cost benefit analysis • Assesses ratio of costs to benefits • Cost effectiveness analysis • Cost to achieve a specific outcome • Cost utility analysis • Cost to achieve a quality adjusted outcome

25. Healthy People 2010 • Healthy People 1990 and 2000 • Earlier national efforts to promote health and prevent disease • Healthy People 2010 Goals • Increase quality and years of healthy life • Eliminate health disparities • 28 focus areas • Leading Health Indicators • Use in community health improvement

26. Discussion • Review the list of leading health indicators for Healthy People 2010 (Exhibit 2-2 on page 76 of the text) and the list of proposed indicators for community health profiles (Exhibit 2-3 on page 77 of the text). Your governor has directed you to use these panels of health indicators to guide a new statewide health improvement initiative in your state, but to modify or tailor the final list of indicators to reflect the special needs or circumstances in your state. Identify three changes (modifications, additions, deletions) that you would make and provide a brief rationale for your decisions.

27. Discussion • Your agency administrator is speaking to a community group on bioterrorism preparedness. She asks you for information on the number of cases of anthrax and smallpox that occur each year, and on complications related to smallpox vaccinations, that occur nationally and in your state. What information source(s) would you use to compile this information?

28. Discussion • Compare the Public Health Achievements in Twentieth-Century America presented in Chapter 1 (Control of Infectious Diseases, including Advances in Childhood Immunizations) and Chapter 2 (Tobacco Use). Both are available at the Century of Progress in Public Health case study site. • Which of these achievements (infectious disease reduction or tobacco use reduction), in your opinion, has had the greater impact on the heath status and quality of life of Americans living in the year 2000? Identify three specific criteria you used to compare these accomplishments and provide data for each criteria for both accomplishments.

29. Discussion • The state legislature recently passed a law that would reduce the information related to the cause of death that has been collected on the death certificate. Only one item, to be determined by the State Board of Health,  will now be reported as the official cause of death. The State Board of Health is considering two options as to the type of information that will be collected and you have been asked to offer brief testimony in support of one of these two options: • Position A: only disease entities can be listed as the cause of death. • Position B: only underlying risk and contributing factors can be listed as the cause of death.

30. Internet Resources • Healthfinder a DHHS-sponsored gateway site that provides links to hundreds of other useful sites, as well as links to frequently asked questions on health issues, and links to databases and web search engines by topic and agency • Fedstats a gateway to a variety of federal agency data and information, including health statistics • National Center for Health Statistics, an invaluable resource for data and information. Visit its Health United States 2005 Web Site where you can find and download the very useful publication, Health United States 2005 with Trends in the Health of Americans Chart Book. • CDC Mortality and Morbidity Weekly Reports and MMWR morbidity and mortality data by time and place • CDC WONDER system • IPLAN data set for Illinois counties and communities (IPLAN = Illinois Project for Local Assessment of Needs) • US census data---the best general denominator data anywhere

31. Additional Resources • Actual Causes of Death in the United States, 2000. (also available as PDF document) Mokdad AH, Marks JS, Stroup DF, Gerberding JL. JAMA 2004;291(10)1238-1245. • Community Indicators of Health-Related Quality of Life--United States, 1993-1997. MMWR 2000;49(13):281-285 • Consuming Research, Producing Health. Evans RG and Stoddart DL. AJPH 2003;93(3):371-379 • Health United States 2005 Web Site. National Center for Health Statistics. Washington DC; DHHS-PHS-CDC-NCHS; 2005. Includes access to Health United States 2005 (with Trends in the Health of Americans Chart Book) • Healthy People 2000 web site for information on both Healthy People 2000 and Healthy People 2010. Office of Disease Prevention and Health Promotion, USDHHS; 2001 • Healthy People 2010: Understanding and Improving Health. US Department of Health and Human Services. Washington DC; DHHS-PHS; 2000 • Healthy People 2010; Leading Health Indicators. US Department of Health and Human Services. Washington DC; DHHS-PHS; 2000 • Leading Health Indicators for Healthy People 2010, Final Report. Institute of Medicine. Washington DC; National Academy Press; 1999 • State Health Facts. Kaiser Family Foundation • What Are Public Health Data? Public Health Data Standards Consortium