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The Existence of States of Health or Illness in a Population Essay
Read chapters 6 and 7of the class textbook and review the PowerPoints presentations located in the PowerPoint folder. Once done answer the following questions.
1. In your own words defining epidemiology, mention and describe the develop
of the epidemiology as a science.The Existence of States of Health or Illness in a Population Essay
2. Mention and contrast three epidemiologic conceptual models.
3. Mention and describe the primary method used to mention the existence of states of health or illness in a population in a given time period
4. Mention and discuss the use of specific rates when describing characteristics of person, place and time.
800 to 1000 words
APA style (intext citations and reference page)
It is the intention of Community and Public Health Nursing: Evidence for Practice to present the
core content of community and public health nursing in a succinct, logically organized, but
comprehensive manner. The evidence for practice focus not only includes chapters on
epidemiology, biostatistics, and research but also integrates these topics throughout the text.
Concrete examples assist students in interpreting and applying statistical data. Healthy People
goals and measurable objectives serve as an illustration of the use of rates throughout the text.
Additionally, we have added brief learning activities and questions throughout the text to allow
students to apply the Healthy People goals to real-life scenarios. Groups with special needs,
such as refugees and the homeless, have been addressed in several chapters; however, tangential
topics that can be found in adult health and maternal-child health textbooks have been omitted.
A chapter on environmental health concerns has been included, along with a chapter on
community preparedness for emergencies and disasters. Also, a global perspective has been
incorporated into many chapters.The Existence of States of Health or Illness in a Population Essay
Challenges to critical thinking are presented in multiple places throughout each chapter.
Case studies are integrated into the content of each chapter and contain critical thinking
questions imbedded in the case study content. Also, a series of critical thinking questions can be
found at the end of each chapter. (Please see the description of features below.) Considering the
onus presented by Mark Twain: “Be careful about reading health books. You may die of a
misprint,” every attempt has been made to present correct, meaningful, and current evidence for
Part One presents the context within which the community or public health nurse practices.
An overview of the major drivers of healthcare change leads to a discussion of evolving trends,
such as the emphasis on patient/client-centered care, the effects of new technology upon the
delivery of care, and the need for people to assume more responsibility for maintaining their
health. Community and public health nursing as it presently exists is analyzed and reviewed
from a historical base, and issues foreseen for both the present and immediate future are
discussed. The nursing competencies necessary for competent community and public health
practice are also presented.
A more in-depth discussion of the complex structure, function, and outcomes of public
health and healthcare systems follows. National and international perspectives regarding
philosophical and political attitudes, social structures, economics, resources, financing
mechanisms, and historical contexts are presented, highlighting healthcare organizations and
issues in several developed countries. The World Health Organization’s commitment to
improving the public’s health in developing countries follows, with an emphasis on refugees and
disaster relief. With the burden of disease growing disproportionately in the world, largely due
to climate, public policy, socioeconomic conditions, age, and an imbalance in distribution of risk
factors, the countries burdened by disease often have the least capacity to institute change. Part
One concludes with examination of the indicators of health, health and human rights, factors that
affect health globally, and a framework for improving world health.
Part Two provides the frameworks and tools necessary to engage in evidence-based practice
focused on the population’s health. Concepts of health literacy, health promotion, disease
prevention, and risk reduction are explored, and a variety of conceptual frameworks are
presented with a focus on both the epidemiologic and ecologic models. Epidemiology is
presented as the science of prevention, and nurses are shown how epidemiologic principles are
applied in practice, including the use of rates and other statistics as community health indicators.
Specific research designs are also explored, including the application of epidemiologic research
to practice settings.
Part Three is designed to develop the skills necessary to implement nursing practice
effectively in community settings. Since healthcare is in a unique state of transformation,
planning for community change is paramount. The health planning process is described, with
specific attention given to the social and environmental determinants of change. Lewin’s change
theory, force-field analysis, and the effective use of leverage points identified in the force-field
analysis demonstrate the change process in action.
Changes directed at decreasing health disparities must be culturally sensitive, clientcentered, and community-oriented. A chapter on cultural diversity and values fosters the
development of culturally competent practitioners, and the process of cultural health assessment
is highlighted. Frameworks of community assessment are presented and various approaches are
explored. Management of care and the case management process follows. The role and scope of
home care nursing practice and the provision of services is presented along with the challenges
inherent with interdisciplinary roles, advances in telehealth, and other home care services.
Although content on family assessment can be found in other texts, it is an integral
component of community and public health practice. Therefore, theoretical perspectives of
family, and contemporary family configurations and life cycles are explored. Family Systems
Nursing and the Calgary Family Assessment and Intervention Model are provided as guides to
implementing family nursing practice in the community. Evidence-based maternal-child health
home visiting programs and prominent issues related to family caregiving are also highlighted.
Part Four presents the common challenges in community and public health nursing. The
chapter addressing the risk of infectious and communicable diseases explores outbreak
investigation with analysis of data experience provided by the case studies. Public health
surveillance, the risk of common foodborne and waterborne illnesses, and sexually transmitted
diseases are followed by a discussion of factors that influence the emergence/reemergence of
infectious diseases, examples of recent outbreaks, and means of prevention and control.
The challenge presented by violence in the community is presented with an emphasis on
intimate partner violence and the role of the healthcare provider. Because of the cultural
variations in substance use disorder, multifaceted approaches to the problem are discussed with
the recommendation that evidence-based prevention and treatment protocols for substance use
disorder are incorporated by community health nurses in all practice settings. Meeting the
healthcare needs of vulnerable and underserved populations is another challenge. Health
priorities for people who live in rural areas; are gay, lesbian, bisexual, or transgender; are
homeless; or live in correctional institutions are reviewed.
The issues of access to quality care, chronic disease management, interaction with health
personnel, and health promotion in hard-to-reach populations among these populations are also
presented.The Existence of States of Health or Illness in a Population Essay
The environmental chapter demonstrates how to assess contaminants in the community by
creation of an exposure pathway. The health effects of the exposure pathway can then be
ascertained. Individual assessment of contaminant exposures, interventions, and evaluations are
also explored, ending with a focus on maintaining healthy communities. The final chapter in
Part Four presents the issue of community preparedness. The types of disasters along with
classification of agents are described, disaster management outlined, and the public health
response explained. The role and responsibility of nurses in disasters and characteristics of the
field response complete the content.
Part Five describes five common specialty practices within community and public health
nursing. All have frameworks that define practice and reflect the competencies necessary for
competent practice in a variety of community settings. These include application of the
principles of practice to community mental health, school health, faith-oriented communities,
palliative care, and occupational health nursing The Existence of States of Health or Illness in a Population Essay
The distribution of health is determined by a wide variety of individual, community, and national factors (See Figure 1). There is a growing body of evidence documenting inequalities in both the distribution of health (i.e. health outcomes) and access to health care both internationally and in the UK. Access to health care is a supply side issue indicating the level of service which the health care system offers the individual.
Figure 1: Determinants of health
Inequalities in the distribution of health
Researchers have documented inequalities in the distribution of health by social class, gender, and ethnicity. Inequalities in health have been measured using many different outcomes including infant deaths, mortality rates, morbidity, disability, and life expectancy.
Social class (including income, wealth and education)
Research on socio-economic inequalities in health in the UK has a long history. For over 150 years, inequality in health outcomes have been a concern since the early Medical Officer of Health reports (Wellcome Trust). Health outcomes generally worsened with greater socioeconomic disadvantage. In the early part of the 20th century the British government introduced questions on occupation in the decennial census. This allowed researchers to examine health outcomes by social class. The five-class scheme Registrar General’s Social Class (RGSC) was created in 1911 and a variation of this scheme was still used until 2001. The National Statistics Socio-Economic Classification (NS-SEC) has now replaced the RGSC. For a description of the current scheme see:
http://www.ons.gov.uk/methodology/classificationsandstandards/otherclassifications/thenationalstatisticssocioeconomicclassificationnssecrebasedonsoc2010 The Existence of States of Health or Illness in a Population Essay
Table 1: Classifications of Social Classes.
I Professional occupations
1 Higher managerial, administrative and professional occupations
II Managerial and technical occupations
2 Lower managerial, administrative and professional occupations
III Skilled occupations
3 Intermediate occupations
manual (M) and non-manual (N)
4 Small employers and own account workers
IV Partly-skilled occupations
5 Lower supervisory and technical occupations
V Unskilled occupations
6 Semi-routine occupations
7 Routine occupations
8 Never worked and long-term unemployed
The 1970-1972 Decennial Supplement of occupational Mortality (OCPS) showed that men in social class V (unskilled) were 2.5 times as likely to die before the age of 65 than those in social class I (professional). Children in social class V families were twice as likely to die as those in social class I.
Table 2 shows the relationship between social class and death.
Bartley and Blane (2008).
Table 2: Social class and health, 1991-1993 and 1993-1995
Infant mortality rate
(1-15 years) The Existence of States of Health or Illness in a Population Essay
Standardised mortality ratio (men 20-64 years)
Still birth rate = number of deaths per 1000 live and death births, 1993-5
Infant mortality rate = number of deaths in the first year of life per 1000 live births, 1993-5
Mortality rate (1-15 years) = number of deaths per 100,000 population aged 1-15 years, 1991-3
Standardised mortality ratio (men 20-64 years) = The ratio of the observed mortality rate in a social class to its expected rate from the total population, multiplied by 100, 1991-3
Source: Bartley and Blane, 2008
Social class inequalities in the UK persist at every age and for all the major diseases. An analysis of health outcomes in England for the Global Burden of Disease study showed that males living in the most deprived region of England in 2013 had a life expectancy 8.2 years shorter than those living in the least deprived region, which was as large a difference as seen in 1990. Life expectancy for women living in the most deprived region in 2013 was 6.9 years shorter than for those in the least deprived region, an improvement since 1990 when the difference was 7.2 years. (Newton JN et al., 2015)
The inverse relationship between deprivation and health outcomes though well established as shown above (Table 2 and recently in Newton JN et al 2015) is also slightly more complex as shown below. (Tables 2b, 3b and 4b).The Existence of States of Health or Illness in a Population Essay
The table of Life Expectancy (LE) and Healthy Life Expectancy (HLE) at birth for both genders and by national deciles of area deprivation in England over a 3 year period (2009-2011) shows there is a difference in life expectancy by gender and level of deprivation throughout.
Of importance was the largest differences in healthy life expectancy between neighbouring deciles were found between the most deprived area groupings.
Table 2b: Life Expectancy (LE) and Healthy Life Expectancy (HLE) at birth for males and females by national deciles of area deprivation in England, 2009-2011
Proportion of life in ‘Good’ health (%)-MALES
Proportion of life in ‘Good’ health
These are the first intercensal estimates of inequality in healthy life expectancy by deciles of deprivation to be produced by ONS using clusters of Lower Super Output Areas (LSOAs) by the English Index of Multiple Deprivation (IMD).The Existence of States of Health or Illness in a Population Essay
Above add to the debate of the complex relationship between health outcomes, gender and social class. Previous studies have shown that causes of death differ in their relationship to social class.
Erikson and Torssander (2008) in the European Journal of Public Health describe this relationship as a ‘variation lacking in detail’. They found in their European study using data from a decade (1990-2003) a clear mortality gradient among employees for the majority of causes; from low relative risk of death among higher managerial and professional occupations to relatively high risks for the unskilled working class.
The authors noted exceptions to the general pattern and discovered causes of death in which higher social classes were at a greater risk, or in which there was a very small or no mortality gradient.
(Eur J Public Health (2008) 18 (5): 473-478. doi: 10.1093/eurpub/ckn053)
Efforts have been made to reduce health inequalities through policies and interventions dating back to the 1980 Black Report. Although notable improvements across society in indicators such as life expectancy (ONS, 2013) have occurred, a large, persistent health gap remains.The Existence of States of Health or Illness in a Population Essay
The Health and Social Care Act 2012 introduced legal duties on health organisations to have regard to the need to reduce health inequalities. Reducing differences in health between populations is a key policy objective for NHS England (NHS England, 2014) and Public Health England (PHE).
There are four major models used to explain social class inequalities in health (Bartley and Blane, 2008; Bartley, 2004).
Behavioural model: There are social class differences in health damaging or health promoting behaviours such as dietary choices, consumption of drugs, alcohol and tobacco, active leisure time pursuits, and use of immunisation, contraception and antenatal services. However, long-term studies (like the Whitehall study described below) have found that differences in health behaviour explain only one-third of social class differences in mortality. Furthermore, evaluations of interventions that seek to change health behaviours have rarely found clear cut improvements in health that would be predicted by the behavioural model.The Existence of States of Health or Illness in a Population Essay
Materialist model: Poverty exposes people to health hazards. Disadvantaged people are more likely to live in areas where they are exposed to harm such as air-pollution and damp housing. The Black Report (see below) found materialist explanations to be the most important in explaining social class differences in health. There is some specific evidence for materialist explanations. For example, many studies have associated higher rates of childhood respiratory disease with damp housing. The full impact of living standards, however, can only be understood over the course of the life term. While most experts in public health agree that materialist explanations play a role in explaining health inequalities, many find a simple materialist model to be insufficient. In the UK, relatively disadvantaged people receive various kinds of state help (rent, school meals etc) which, some argue, makes diet or poor housing unlikely to account for all inequalities health outcomes. Furthermore, in the UK and internationally, inequalities in health tend to follow a steady gradient, rather than there being poor outcomes for the most disadvantaged and equally good outcomes for the rest of society.The Existence of States of Health or Illness in a Population Essay
Psycho-social model: Social inequality may affect how people feel which in turn can affect body chemistry. For example, stressful social circumstances produce emotional responses which bring about biological changes that increase risk of heart disease. Psycho-social risk factors include social support, control and autonomy at work, the balance between home and work, and the balance between efforts and rewards. There has been a plethora of research exploring associations between psycho-social factors and health. Evidence shows that people who have good relationships with family and friends, and who participate in the community, have longer life expectancies than those who are relatively isolated. Evidence of an association between stress at work and health is less clear, but most well designed studies show a higher risk of heart disease among individuals who work in jobs where demands are high and control is low. Furthermore, a number of studies have shown that an imbalance between effort and reward at work tends to be linked to high blood pressure, fibrinogen and a more adverse blood fat profile.The Existence of States of Health or Illness in a Population Essay
Life-course model: Health reflects the patterns of social, psycho-social and biological advantages and disadvantages experienced by an individual over time. The chances of good or poor health are influenced by what happened to a child in-utero and in early childhood and disadvantages are likely to accumulate through childhood and adulthood. For example, individuals who experienced poor home conditions in childhood are more likely to experience occupational disadvantage. The life-course model was developed relatively recently and studies investigating life-course explanations require detailed longitudinal data. Regardless, several studies have shown that health disadvantage accumulates over time.
A life course approach underpins the recommendations made in the Marmot Review on reducing health inequalities in England. The review states that ‘action to reduce health inequalities must begin before birth and continue through the life of the child. Only then can the close links between early disadvantage and poor outcomes throughout life be broken’. (Marmot review, 2010). Similarly, the Welsh Adverse Childhood Experiences (ACE) Study, 2015) highlights the impact of adverse childhood experiences on individuals’ risks of developing health harming behaviours in adult life. ACEs are stressful experiences occurring during childhood that directly harm a child (e.g. sexual or physical abuse) or affect the environment in which they live (e.g. growing up in a house with domestic violence).The Existence of States of Health or Illness in a Population Essay
Landmark studies in social class inequalities in health in the UK include:
The Black Report
The Black Report, published in 1980 confirmed social class health inequalities in overall mortality (and for most causes of death) and showed that health inequalities were widening. The report set out four possible mechanisms to explain widening socio-economic health inequalities:
Artefact: Population information came from the decennial census while death and cause of death information came from death certificates. An individual may have been described in different ways in the two data sources leading to numerator-denominator bias. The report also noted widening inequalities may be explained by the shrinking of social class V. With fewer people who were completely unskilled, the average health of social class V moved further from social class I. Furthermore, the report noted that the meaning of social class may have changed over time as some jobs disappear and others emerge.
Social selection: Health determines social position. Somewhat similar to Darwin’s ‘natural selection’, i.e. healthy people are more likely to get promoted while unhealthy people are more likely to lose their jobs.
Behaviour: individuals in the lower social classes indulge in comparatively more health damaging behaviour (see behavioural model above).
Material circumstances: poverty causes poor health (see materialist model above).The Existence of States of Health or Illness in a Population Essay
Whitehall Study of British Civil Servants
The ongoing Whitehall Study of British Civil Servants http://www.ucl.ac.uk/whitehallII/ is a cohort study following British civil servants over a long period of time. It collects detailed information on risk factors such as weight, cholesterol, smoking, and blood pressure. The study found inequalities in health and mortality between employment grades and found that risk factors could only explain one-third of the observed variation in health by employment grade.
The Acheson Report
The Acheson Report published in 1988 found that mortality had decreased in the last 50 years but that inequalities in health remained, and in some instances health inequalities had widened. The report recommended:
evaluating all policies likely to affect health in terms of their impact on inequalities
giving high priority to the health of families with children
the government should take steps to reduce income inequalities and improve living conditions in poor households.The Existence of States of Health or Illness in a Population Essay
The Marmot Review
The Marmot Review was commissioned in 2008 to provide evidence-based recommendations for a strategy to reduce health inequalities in England. The review found that:
Health inequalities must be addressed in the interests of fairness and social justice.
There exists a social gradient in health: health improves as social status goes up.
Social inequalities result in health inequalities; therefore to reduce health inequalities we must consider all the social determinants of health.
Health inequalities cannot be properly addressed by only targeting those worst off. Reducing the steepness of the social gradient in health requires universal actions, concentrated according to levels of deprivation (‘proportionate universalism’).
Taking action to reduce health inequalities will have a positive effect on society in many ways, such as bringing economic benefits by reducing population illness and increasing productivity.
A country’s success is measured by more than economic growth: fair distribution of health, wellbeing and sustainability are also important. Climate change and social inequalities in health should be addressed simultaneously.
Policy to reduce health inequalities must cover all of the following objectives:
– Give every child the best start in life
– Enable all children young people and adults to maximise their capabilities and have control over their lives
– Create fair employment and good work for all
– Ensure healthy standard of living for all
– Create and develop healthy and sustainable places and communities The Existence of States of Health or Illness in a Population Essay
– Strengthen the role and impact of ill health prevention
These policy objectives can only be delivered through effective involvement of central and local government, the NHS, third and private sectors, individuals and communities.
Much research has shown that in industrialised countries women live longer than men (tables 3 and 3B) but appear to experience more ill health. While men have higher mortality from the most common single causes of death (ischemic heart disease and lung cancer), more women than men suffer from somatic complaints such as tiredness, headache, muscular aches and pains. However, some researchers have raised questions about the validity of studies that show higher illness rates in women, as many different health outcome variables have been used and not all show gender differences. There is more consistency in studies that examine minor psychological illness, anxiety, sickness absence from work, functional limitation, and depression (Bartley, 2004).The Existence of States of Health or Illness in a Population Essay