The Future of the Public's Health in the 21st Century (2003) / Chapter Skim
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2. Understanding Population Health and Its Determinants
2. Understanding Population Health and Its Determinants
Pages 46-95
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From page 46... ...
Approaching health from a population perspective commits the nation to understanding and acting on the full array of factors that affect health. To best address the social, economic, and cultural environments at national, state, and local levels, the nation's efforts must involve more than just the traditional sectors the governmental public health agencies and the health care delivery system.
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From page 47... ...
First, disease risk is currently conceived of as a continuum rather than a dichotomy. There is no clear division between risk for disease and no risk for disease with regard to levels of blood pressure, cholesterol, alcohol consumption, tobacco consumption, physical activity, diet and weight, lead exposure, and other risk factors.
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From page 48... ...
The committee recognizes that achieving the goal of improving population health requires balancing of the strategies aimed at shifting the distribution of risk with other approaches. The committee does, however, endorse a much wider examination, and ultimately the development, of new population-based strategies.
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From page 49... ...
UNDERSTANDING POPULATION HEALTH AND ITS DETERMINANTS 49 2-1a: Hypothetical distribution of overweight and obesity in a population: A high-risk intervention strategy targeting obesity 30 C' 40 30 ~ 20 C' 10 10 o o 40 30 <~' 20 C' 10 o Distribution after intervention Overweight - Cu~'''''''''''''li''''''''''''''''''''''' ~ distribution ~frffr~ Obese _~rffrr~., ~ 15 17 19 21 23 25 27 29 31 33 35 37 39 Body mass index (kg/m2 ) 2-1 b: Distribution of Body Mass Index in the US: Hypothetical shift of the distribution to lower the mean l .
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From page 50... ...
The committee embraces this kind of mode! of disease prevention in the case of policies such as seat belt regulation and the reduction of lead levels in gasoline.
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From page 51... ...
This figure serves as a useful heuristic to help us think about the multiple determinants of population health. It may, for instance, help to illustrate how the health sector, which includes governmental public health agencies and the health care delivery system, must work with other sectors of government such as education, labor, economic development, and agriculture to 2 Upstream refers to determinants of health that are somewhat removed from the more "downstream" biological and behavioral bases for disease.
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From page 52... ...
·The natural and built c environments ·Public health services ·Health care services FIGURE 2-2 A guide to thinking about the determinants of population health. NOTES: Adapted from Dahlgren and Whitehead, 1991.
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From page 53... ...
In the pages that follow, the committee provides a concise discussion of the key determinants that constitute the ecology of health, including environmental and social determinants, and elaborates in more detail on the social influences on health. This decision was made in recognition of a longer history in studying the ways in which environment shapes population health.
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From page 54... ...
A variety of political, socioeconomic, and environmental factors shape the health status of cities and their residents by influencing "health behaviors such as exercise, diet, sexual behavior, alcohol and substance use" (Freudenberg, 2000: 837~. The negative environmental aspects of urban living toxic buildings, proximity to industrial parks, and a lack of parks or green spaces, among others likely affect those who are already at an economic and social disadvantage because of the concentration of such negative aspects in specific pockets of poverty and deprivation (Lawrence, 1999; Maantay, 2001; Williams and Collins, 2001~.
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From page 55... ...
High levels of exposure to certain environmental pollutants are known to cause acute effects including convulsions, paralysis, coma, and death. The effects of lead on health and development have been documented for decades, and policy action regarding leaded gasoline and lead-based paints has been taken, with positive effects on child health.
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From page 56... ...
The influences of many other environmental risk factors on health have not been fully documented, and evidence of the influence of environmental factors for some health conditions like asthma is rapidly accumulating (Trust for America's Health, 2001~. The association between certain chronic diseases and environmental causes is devastatingly clear, yet knowledge about the scope of environmental health risks and their impact on the public's health is limited.
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From page 57... ...
social networks and social support, and (4) work conditions.
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From page 58... ...
Research has documented the relationship between SES and cardiovascular disease (NCHS, 1992; Kaplan and Keil, 1993) , and the British Whitehall longitudinal study of civil servants found that those in the lowest grades of employment were at the highest risk for heart disease (Marmot et al., 1991~.
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From page 59... ...
In either case, however, it is important to note that a "threshold" mode! focused exclusively on the very poorest segments and ignoring others near the bottom and the working poor will not address the relatively poor population health outcomes for the U.S.
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From page 60... ...
People in lower socioeconomic positions are not only more materially disadvantaged, but also have higher levels of job and financial insecurity; experience more unemployment, work injuries, lack of control, and other social and environmental stressors; report fewer social supports; and more frequently, have a cynically hostile or fatalistic outlook (Berkman and Syme, 1979; Karasek and Theorell, 1990; Adler et al., 1994; Heaney et al., 1994; Bosma et al., 1997~. There is most often, especially in the United States, a striking and consistent association between SES and risk-related health behaviors such as cigarette smoking, physical inactivity, a less nutritious diet, and heavy alcohol consumption.
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From page 61... ...
Racial and Ethnic Disparities in Health A substantial body of research documents the relationship between racial and ethnic disparities and differences in health status. Numerous studies have shown that minority populations may experience burdens of disease and health risk at disproportionate rates because of complex and poorly understood interactions among socioeconomic, psychosocial, behavioral, and health care-related factors (NCHS, 1998; DHHS, 2000; IOM, 2002~.
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From page 62... ...
Rates of illness such as asthma are much higher among African Americans than among whites, as are levels of obesity, diabetes, and other cardiovascular risk factors that are often established in adolescence and young adulthood. For example, the prevalence of obesity among African Americans is 29.3 percent and that among Hispanics is 21.5 percent, whereas it is 18.5 percent among whites (CDC, 2002~.
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From page 63... ...
Among other disparities in health care, African Americans have been shown to be less likely to receive certain diagnostic testing; adequate pain medication; early-stage diagnoses of cancer; dialysis as initial treatment for end-stage renal disease, placement on a kidney transplant waiting list, or a kidney transplant; and preventive rather than acute asthma control measures (IOM, 2002~. Hispanics are also likely to experience similarly unequal access to health care services (IOM, 2002~.
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From page 64... ...
and better survival independent of physical activity (Glass et al., 2000~. The pathways by which social networks might influence health are multiple and include
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From page 65... ...
Although much of the research in this area examines the effects of close relationships and social support, there is also evidence that weak social ties may also have indirect positive effects on health and well-being. For instance, a classic investigation of how people find jobs suggests that weak ties to others may be more helpful in enabling people to find jobs, providing access to one of the most critical life opportunities.
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From page 66... ...
Much of the experimental work cited here supports the concept that social isolation increases the risk for poor health. However, a recent clinical trial, Enhancing Recovery in Coronary Heart Disease, aimed at improving social support to reduce mortality and reinfarction among subjects after myocardial infarction, found no effect (NIH, 2001~.
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From page 67... ...
However, other U.S. epidemiological findings associate unemployment or risk of job loss with health conditions such as depression and engagement in negative health behaviors such as substance abuse, poor diet, and inactivity (Dooley et al., 1996~.
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From page 68... ...
In this section, the committee reviews evidence related to two aspects of places economic inequality and social capitalthat are assessed at an ecological level to examine their effects on health. These findings are relatively new and undoubtedly will be refined with further research.
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From page 69... ...
and Kennedy and colleagues (1996) independently found that the degree of household income inequality in the 50 states was associated with the state-level variation in total mortality, as well as with the state-level variations in infant mortality and rates of death from coronary heart disease, cancer, and homicide.
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From page 70... ...
analyzed social capital indicators across the United States in relation to state-level death rates. The per capita density of membership in voluntary groups was inversely correlated with age-adjusted mortality from all causes.
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From page 71... ...
Finally, neighborhood social capital could influence health through direct psychosocial pathways by providing social support and acting as the source of self-esteem and mutual respect. Although there has been a great deal of interest in these area-level studies of social capital, there has also been a fair amount of skepticism regarding their validity.
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From page 72... ...
For example, a universal preventive measure for heart disease could include the provision of general advice to consume a diet low in fat accompanied by a regulatory policy requiring food labeling. A selective intervention could include a program focusing on diet and behavioral changes for overweight individuals who do not exercise regularly, and an indicated preventive measure might include antihypertensive medication for those diagnosed as hypertensive.
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From page 73... ...
It is now time to determine their social equivalents elements of the social environment that influence health status and take action to shape them in support of population health. Such action may focus not only on education, decent housing, and a living wage but also on the political choices that move the broad (social and other)
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From page 74... ...
The case of seat belt legislation demonstrates that such upstream or population-level measures aiming to prevent disease and disability may be effective in transforming social norms and ultimately changing behavior. The Case of Tobacco Tobacco prevention and cessation efforts have offered many lessons about the links between behavior and disease and how to intervene effectively to improve population health.
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From page 75... ...
Also, as noted earlier in the context of generic population health improvement, upstream approaches, including action at the community or population level, may be more cost-effective than downstream approaches directed at specific individuals (Corbett, 2001~. Such measures, it seems, make use of the characteristics of social networks and relationships that may be used as elements to further protect health.
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From page 76... ...
Such data support recent efforts to control tobacco advertising, adding this to the arsenal of taxation and limits on smoking in public places. THE PUBLIC HEALTH SYSTEM IN ACTION: A SCENARIO In this section, the committee uses the specific scenario of a risk to population health namely, obesity to present and discuss the contributions that communities, the health care delivery system, employers and business, the media, academia, and the governmental public health infrastructure can make to improve health.
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From page 77... ...
. Obesity is a growing concern because it poses a higher risk and results In a higher incidence of health conditions such as diabetes, cardiovascular disease, stroke hypertension, osteoarthritis, and certain cancers than other risk factors (NIH, 1998; Allison et al., 1999; Must et al., 1999; Williamson, 1999; Tataranni and Bogardus, 2001; Tuomilehto et al., 2001~.
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From page 78... ...
(2000~. associated with poor diet and inadequate physical activity (McGinnis and Foege, 1993~.
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From page 79... ...
At the same time, the number of physical education programs in schools is declining, and people in some communities lack access to affordable and nutritional food options and safe areas in which to exercise (Hill and Peters, 1998; CDC, 1999a; Crespo et al., 2001; Dietz, 2001; French et al., 2001~. The association between obesity and socioeconomic factors illustrates the value of a population perspective and the need to consider the multiple determinants of health in addressing population health improvement.
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From page 80... ...
In partnership with local media, health officials, large and small businesses, and others, community groups can spearhead public awareness campaigns and emphasize the importance of physical activity and the opportunities available, as well as the need to make healthy food choices, within a context of enhanced access, affordability, and cultural appropriateness.
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From page 81... ...
By taking part in tackling this major population health concern, the media can better fulfill its accountability to the public to provide accurate and timely information. The academic setting can make many contributions to addressing obesity and its impact on overall population health, especially to the evidence base.
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From page 82... ...
The role of the federal government in addressing obesity is essential, as it sets the pace for the nation and underscores this as a critical issue in assuring population health. In June 2002, in the wake of the 2001 Surgeon General's report on obesity, President George W
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From page 83... ...
Population-based interventions, such as tobacco control policies, show that it is possible to implement cost-effective strategies that benefit society as a whole and improve the health of many segments of the population. Population health improvements will have to focus attention on both overall improvement in the nation's health and reduction of the disparities in health, as recommended by Healthy People 2010.
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From page 84... ...
The chapters that follow discuss several partners within a redefined public health system that has as its backbone the governmental public health infrastructure but that includes the resources, perspectives, and actions of other stakeholders who are partners in the public health system. Each of these partners can increase the relevance of its contributions to population health by considering the multiple determinants of health, especially those that contribute to unequal opportunities for good health.
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From page 85... ...
study. British Medical Journal 314:558-565.
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From page 86... ...
Reduce television viewing and promote playing. British Medical Journal 322(7282)
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From page 87... ...
British Medical Journal 311: 1264-1269. Ferric J
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From page 88... ...
British Medical Journal 312:999-1003. Karasek R
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From page 89... ...
1997. Social capital, income inequality and mortality.
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From page 90... ...
British Medical Journal 301:461-465. McGinnis JM, Foege WH.
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From page 91... ...
2001. Study finds no reduction in deaths or heart attacks in heart disease patients treated for depression and low social support.
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From page 92... ...
British Medical Journal 282:1847-1851.
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From page 93... ...
1994. Social networks social support and mortality among older people in Japan.
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From page 94... ...
1992. Social networks as predictors of ischemic heart disease, cancer, stroke, and hypertension: incidence survival and mortality.
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From page 95... ...
British Medical Journal 304:165-168. Wilkinson RG.
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