Four key health challenges

- Unfinished epidemic of infectious disease

- Emerging epidemic of chronic conditions
- Unethical epidemic of inequalities
- Unnecessary epidemic of environmental insults

Inverse care law

- The availability of good medical care tends to vary inversely with the need for it in
the population served. This inverse care law operates more completely where
medical care is most exposed to market forces, and less so where such exposure
is reduced

Health discourses: powerful persuaders and used to achieve many professional,

governmental and commercial ends (e.g. ads, food labeling, tobacco packaging)

Key components of health promotion

- Empowerment
- Informed choice
- Creating opportunities (to make informed choice)
- Community development (user defined, user initiated, user benefiting)
- Policies
- Legistlation
- Resources

Goals of health promotion

- Improve choice
- Reduce premature mortality, avoidable morbidity, disability; compress morbidity
 Source of evidence about health effects
- Laboratory and occupational studies show that air pollution could be harmful
- Population (epidemiological) studies are need to show that air pollution is
harmful to public health

Gap in risk communication (e.g. HKAPI maximum limit far above WHO maximum
limit

Risk communication
- Hedley Index for air pollution
 Calculate pain (excess number of adverse health outcomes per yea

Translation of public health research into policy and practice

- Problem  science  advocacy  policy  action  benefits

Loopholes of smoking law in HK

- No penalty for venu manageners for not taking actions to stop smoking in
smokefree places
- SHS goes from outdoor into indoor areas
- Display of cigarettes (a kind of ad)
- Cigarette prices are too low
- Smoking at bus stop or other queuing areas
- Needed:
 Increase tobacco tax
 Expand smoke-free area
 More effective health warnings, plain packaging
 More resources and support on quitting

Doctor’s minimal approach towards smoking

- AWARD: ask, warn, advice, refer, do it again

Illness cognition and behaviour

Illness cognition: A patient’s own common sense beliefs about their illness, serves as
a framework or schema for coping with and understanding their illness, and telling
them what to look out for if they are becoming ill
Five dimensions of illness cognition
- Identity
- Perceived cause of illness
- Timeline
- Consequence
- Curability and controllability

Leventhal’s self-regulatory model of illness cognition (psychological approach)

- Assumption: Given a problem or change in the status quo, the individual will be
motivated to solve the problem and re-establish their state of normality
- Three stages
- Interpretation (making sense of the problem)
 Symptom perception influenced by mood, cognition (anticipated
symptom experience, attention state), social environment
 Social messages (sources: health professionals, lay referral, media)
- Coping
 Response to a threatening situation, the process of managing
demands that are perceived as taxing or exceeding the resources of
the person
 Problem-focus
 Emotion-focus
- Appraisal

Health seeking behaviour (Sociological approach)

- Illness recognition, determined by
 Visibility of recognition of symptoms
 Perceived seriousness
 Life disruption
 Frequency or persistence of symptoms
 Tolerance threshold
 Information, knowledge and cultural assumptions
 Competing priorities
 Competing explanations
 Sanction (pressure from family, friends…)
- Illness danger, determined by
 Relative predictability of outcome
 Amount of threat
- Perception of symptoms  accommodation  breakdown of accommodation 
 Decision to seek help/take action  lay referral/self medication/medical advice

Stages of illness
- Symptom experience
- Assumption of sick role
- Medical care contact
- Dependent-patient role
- Recovery and rehabilitation

Health behaviour

Factors affecting health behaviour

- Cognitive factors
- Vulnerability (perceived susceptibility and severity)
- Benefits and cost
- Cues to action (Internal and external stimuli)
- Health motivation (readiness to be concerned)
- Perceived control (External and internal control)
- Self-efficacy (ability to successfully carry out the behaviour)
- Risk perception and unrealistic optimism
 Belief that problem is rare, one can prevent the problem, won’t
emerge if it hasn’t yet, comparative optimistic bias
- Situational factors
- Subjective norm
 Perception of social norm
 Pressure
 Evaluation whether the individual is motivated to comply
- Situation barriers
- Demographic factors (age, socioeconomic status, gender)

Health behavioral models

Cognition model
Examples Health belief model
Protection motivation theory
Limitations Focus only on individual rather
than the interaction between the
environment and the individual
Social cognition model
Theory of reasoned action
Theory of planned behaviour
Fail to take into account for
habitual beviours
Five stages of change
1. Precontemplation: not intending to make any changes
2. Contemplation: Considering a change
3. Preparation: making small changes
4. Action: actively engaging in a new behaviour
5. Maintenance: sustaining the change over time

Sex, germs and vaccines

Determinants of STI epidemics

- Sexual structure (assertive nature of sexual activities)
- Social determinants: stigma, culture, level of poverty, literacy…
- Interventions

Vaccine effectiveness
Herd immunity: vaccinating an individual indirectly reduces the risk of infection of his
contacts, his contacts’ contacts, and so on, i.e. the whole population

Sickness as form of social deviance

Sick role
- Rights
- Exempt from usual responsibilities
- Not responsible for his/her illness
- Responsibility
- Should want to get well
- Should seek and accept professional help

- Label: defines an individual as a particular kind of person

- Labeling: the process whereby individual characteristics are identified by others
and given a negative label
- Deviance: violation of social norms
- Primary deviance: before the deviant is labeled as such
- Secondary deviance: any action that takes place after primary deviance as a
reaction to social identification of the person as a deviant
- Stigma: a label that changes the way an individual is viewed in society, typically in
a negative manner

Friedson’s classification of deviance

- Imputation of responsibility
- Illegitimate (stigmatized)
- Conditionally legitimate
- Unconditionally legitimate
- Seriousness
- Major or minor deviance

Medicalisation of devision
- The process of defining an increasing number of life’s problems (non-medical) as
medical problems

Experiencing chronic illness and disability

Characteristicsllness of chronic illness

- Ongoing, last longer than 3-6 months, non-reversible, involve disability,
uncertain, requires training and motivation on the part of the patient to care for
himself/herself, imply loss and change in life

- Impairment: loss or abnormality of psychological, physiological or anatomical

 structure or funciton
- Disability: any restriction or lack of ability to perform an activity in the manner or
within the range considered normal for a human being
- Handicap: a disadvantage for a given individual, resulting from an impairment or
disability, that limits or prevents the fulfillment of a role that is normal for that
individual
- Alternative definition: defined as disadvantage and deprivation, stems from
the environment in which an individual lives, consists of missed
opportunities because of barriers in the environment
-
The meaning of being chronically ill
- Managing medical regimens
- Managing symptoms and manifestations
- Coping with medical technology
- Acquiring new skill and useful information
- Compliance (being overwhelmed by the realization that treatment
adherence is life-long, interference with job and other activities)
- Prevent and managing potential medical crisis
- Always on the lookout for signs that indicate an impending medical crisis
- Biographical disruption
- Loss of personal independence
- Change of body image
- Impact on sense of self
- Disruption of family and social life
- Uncertainty
- Control over course of disease
- Prediagnostic uncertainty
- Trajectory uncertainty (predict outcome)
- Symptomatic uncertainty (day-to-day fluctuation in symptoms)

Causality
- Derministic causality: necessary cause, sufficient cause, sufficient-component
cause (no one cause is sufficient)
- Probabilistic causation
- Prediposing factors: prepare, sensitize, condition or otherwise create a situation
that the host tends to react in a specific fashion to a disease agent.
- Precipitating factors: associated with definitive onset, usually necessary
- Enabling factors: facilitate the manifestation
- Reinforcing factors: perpetuate or aggravate the presence
- Counterfactual definition

Henle-Koch’s postulates
- Agent present in every case of the disease
- Agetn must not be found in cases of other disease
- Once isolated, agent must be capable of reproducing the disease in experimental
animals
- Agent must be recoverd form the experimental disease produced

Mill’s Canon
- Method of agreement
- Method of disagreemtn
- Joint method
- Method of concomitant variation
- Method of residues

Factors for continued overuse of imaging

- Doctor’s perspective
- Defensive medicine
- Time constraint
- Clinician’s incentive

Health economics

Cost-effectively analysis
- Cost: medical cost, productivity loss
- Outcome:
- QALY: measures equivalent healthy years lived (0=comparable to death)
- DALY: measure loss of health (1=death)
- Mortality rate: the number of deaths in a population per 1000 individuals
per year
- Crude death rate: the number of deaths per year per 1000 population at
risk of dying in the middle of the year
- Standardized rates (age/sex standardized)
-
- Incremental cost-effectiveness ratio (ICER): difference in cost/difference in
outcome
Measurement of morbidity
- Health care utilization data
- Surveillance data
- Registration of disease
- Population-based health information
- Trade-off between coverage, specificity and timeliness
- CART: completeness, accuracy, Relevance, timeliness

Factors leading to an increase in observed prevalence

- In-migration of diseased
- Out-migration of healthy
- Better diagnostic technique
- Less stringent diagnostic criteria
- Life-prolonging treatment (without cure but not dead yet)

The gut microbiome in complex chronic disease

Gut microbiota
- manipulated by probiotics, prebiotics, antibiotics, fecal transplant, weight loss
- Types and location
- Upper GI: acidic, oropharynx,
- Small intestines: short transit time, bile, facultative anaerobes
- Large intestines: slow flow rate, neutral to mildly acidic pH, low oxygen,
obligatea anaerobes
- Function
- Help digest
- Produce nutrients (biotin, vit K)
- Trains immune system
- Stops growth of pathogenic bacteria (competition, fermentation makes
colon more acidic)
- Modifies drugs
- Potential chronic disease relevant: obesity, diabetes, mental health, hormone
levels, colorectal cancer, infections, malnutrition