HLTB16

Lecture 1
What is Public Health?
● “The activities that ensure conditions in which people can be healthy. These activities
include community-wide efforts to identify, prevent, and combat threats to the health of
the public.” - Institute of Medicine Definition of Public Health
Defining Public Health
● “The science and art of preventing disease, prolonging life, and promoting health
through the organized efforts and informed choices of society, organizations, public and
private communities, and individuals.” -CEA Winslow
Public Health’s Mission
● “Fulfilling society’s interest in assuring conditions in which people can be healthy.”
-Institute of Medicine
● “Public health aims to provide maximum benefit for the largest number of people.” -
World Health Organization
What Public Health Means to Everybody
● Access to fresh clean water
● Puts emphasis on healthier lives
○ Adopting healthy behaviors such as doing activities like riding bikes
○ Provide opportunities so people can engage in activities
● Public health generates evidence to guide policies that can move towards reducing or
shifting population health behaviors to reduce smoking rates
● Reduce infections and such with vaccines
○ Helped save lives
What Public Health Aims to Achieve
● Safer workplaces
● Vaccination
● Motor vehicle safety
● Fluoridation of drinking water
● Control of infectious diseases
● Recognition of tobacco as a health hazard
● Family planning
● Healthier mothers and babies
● Safer and healthier foods
● The decline in deaths from heart disease and stroke
Public Health Core Sciences
● Prevention effectiveness
● Epidemiology
● Laboratory
● Informatics
● Surveillance
The 10 Essential Public Health Services
● Monitor the health status of the community
 ● Investigate and diagnose health problems and hazards
● Inform and educate people regarding health issues
● Mobilize partnerships to solve community problems
● Supports policies and plans to achieve health goals
● Enforce laws and regulations to protect health and safety
● Link people to needed personal health services
● Ensure a skilled, competent public health workforce
● Evaluate effectiveness, accessibility, and quality of health services
● Research and apply innovative solutions
A Public Health Approach
● Public health approach
○ Focus on the broader population
○ Disease prevention & health promotion and protection
○ Population-wide interventions
○ Influence and regulate social, economic, and health policies
● Individual approach
○ Individually-driven interventions
○ Diagnoses and treatment limited within health care settings
○ Opens avenues for privatized care, limited impact on an individuals health
Cholera
● A fatal communicable disease, which spread vastly in the 1800s in Longdon, contributing
to 1000’s of deaths in the area
● Many believed cholera was caused by bad air (miasma theory).
● The major source of contraction is contaminated water
● John Snow
○ Father of modern epidemiology
○ Traced the source of the cholera outbreak
○ A cluster of Cholera Cases, London- 1854
○ Interviewed and asked people where they were getting their water
● Interventions
○ Through continuous research, Snow was able to determine that the cause of the
disease was the contaminated water supply on a larger scale
● Implementation
○ His research convinced the British government that the source of cholera was
water contaminated with sewage and the pump on Broad street was disabled
What is Public Health’s Philosophy
● Healthy equity
● Social justice
● Social determinants of health
5 Essential Pillars of Public Health
● Social determinants of health
● Evidence-informed public health
○ Evaluate the weight of the evidence
 ■ Is it strong enough?
● Primary health care
● Health promotion & prevention
● Holistic care paradigm
○ The interconnectedness between the mind, body, the spirit, the culture, and the
environment
○ They come together to get a view of the world
What Determines the Health of the Population?
● Genes and biology
● Health behaviors
● Medical care
● social/societal characteristics; total ecology
Example: Your Neighborhood From a Public Health Perspective
● Neighborhood features
○ Living close to health food sources e.g. supermarkets
○ Living farther away from unhealthy food sources- e.g. convenience stores, fast
food outlets
○ Zoning of unhealthy food sources
○ Farmers’ markets
○ Community gardens
● Mediating factors
○ Examples:
■ Low prices
■ Convenient store hours
■ Long growing season
■ Food security
● Human response
○ Healthy diets
● Health outcomes
○ Reduced risk for:
■ Premature death
■ Obesity
■ Diabetes
■ Poor mental health
● Other determinants of health
○ Age
○ Genetics
○ Social environment
○ Income
○ Education
○ Culture
○ Health care system
The Bell-Curve Shift in Populations
● Shifting the whole population into a lower risk category benefits more individuals than
shifting high-risk individuals into a lower risk category
Controversies in Public Health
● Economic
○ All goods, services, industries
○ PH initiatives may reduce profits, inflate prices, increase taxes (i.e. tobacco)
● Libertarian
○ Individual freedom vs. community health
○ Promote neoliberalism, paternalism individual autonomy (i.e. market justice)
○ Public health generates evidence - does not create policies
● Moral
○ Differing moral views (i.e. abstinence vs. birth control)
○ Obesity as a cultural norm, e-cigarettes, prescription drug abuse, antibiotic
resistance, gun control, preventing concussions, climate change
The tragedy of the Commons
● The more we exploit our environments, over time it will deplete our resources, and it’s
going to impact lower ses.
Public health and the global burden of infectious disease
○ History of pandemics
○ Many pandemics that took away many lives
○ Headed in the direction such as the Spanish Flu, Hong Kong flu
Breaking News: 2020 is Canceled
● Quarantining
● Social distancing
● Working from home
● Closing schools and other institutions
● Placing hard limits on the size of crowds at events
History of Public Health
● Ancient Greeks (500-323 BC)
○ Personal hygiene and sanitation
○ Physical fitness
■ Olympics (competitive games and source of entertainment)
○ “Humorism” concept
■ Disease caused by an imbalance between the human body and the
surrounding environment
○ Largely influenced by Hippocrates
● Hippocrates (-460 BC)
○ Father of Western Medicine
○ Causal relationships
■ Disease and climate, water, lifestyle, and nutrition… and health
■ 4 humours
● Blood
 ● Phlegm
● Black bile
● Yellow bile
○ Coined the term epidemic
■ Epid (“on” or “akin to”)
■ Demos (“people”)
● Roman Empire (23 BC-476 AD)
○ Adopted Greek health values
○ “A healthy mind in a healthy body” - Juvenal
○ Galen = followed Hippocrates methods (deep breathing)
○ Great engineering plans
■ Sewage systems
■ Aqueducts
■ Army camps
○ Administration
■ Public baths
■ Water supply markets
● Roman Aqueducts
○ Bright in water for public baths, supplied private household, farming, mining, etc
● Middle ages (476 AD-1450 AD)
○ Shift away from Greek and Roman values
■ The physical body less important than the spiritual self
■ The decline of personal and community hygiene and sanitation
○ Beginnings of PH strategies
■ Quarantine of ships
■ Isolation of diseased individuals
○ Leprosy was the worst disease at the time
● The plague
○ 25% to 50% of the population wiped out
● Renaissance and Global Expansion
○ Over time, diseases were vastly spread by merchants, traders, and explorers
○ Resulting in killing nearly 90% of indigenous people in the New World
● Age of Enlightenment (1650- 1800 AD)
○ Giving rise to Modern Medicine (scientific revolution)
○ Separation of the church and the state
○ Rise of empiricism and rational thought
○ William Harvey
■ 1628 theories of circulation
○ Edward Jenner
■ 1796 cowpox experiment
■ Coined the term vaccine (Vacca, Latin for “cow”)
■ Injected a little boy with cowpox and then he never got it again
● Great Sanitary Awakening
○ Adoption and acceptance of scientific inquiry and knowledge
○ Humanitarian approaches to disease and illness
○ The linkage between poverty, living conditions, and disease
○ Investment in improving water and sanitation access (clean sewage, public
awareness)
○ Surveillance and monitoring of individual and community health

● Rise of scientific knowledge

○ Louis Pasteur
■ 1862 germs caused many diseases
■ 1888 first public health lab
■ Eliminated miasma theory, providing evidence to support germ theory
○ Robert Koch
■ 1883 identified the vibrio that causes cholera, 20 years after Snow’s
discovery
■ Discovered the tuberculosis bacterium
● England’s Sanitary Reform
○ 1842 Edwin Chadwick’s report on sanctuary conditions in Great Britain
■ Groundbreaking research
■ Providing detailed and graphic descriptions of filth and disease spread in
urban areas - affecting children, life expectancy, survival rates
○ 1848 Public Health Act
■ Central board of health and placed responsibilities for sanitation in the
hands of boroughs
● PH preparedness and disaster response
○ Biologic warfare
■ Plague used as a weapon of war during the Siege of Kaffa
○ September 2001
■ Public health surveillance conducted after the 9/11 attacks
○ Hurricane Katrina
■ Emergency services, public health surveillance, and disease treatment
provided
● Prevention through policy
○ Health
■ Hygiene, sanitation around food, water, and unsafe conditions
○ Tobacco laws
■ Laws banning smoking in public places
○ Obesity
■ Food labeling and promotion of physical activity
● From pandemics to epidemics to eradication
○ Influenza
■ 500 million infected worldwide in 1918
 ○ HIV
■ 34 million living with HIV worldwide: 20% decline in new infections since
2001
○ Polio
■ Vaccine introduced in 1955; the eradication initiative launched in 1988
Challenges and Disparities in Access and Outcomes Remain
● Tobacco (cigarettes and e-cigarettes)
● diet/ physical activity
● Alcohol consumption
● Infectious agents
● Environmental toxins
● Crime and violence
● STIs
● Injustices, crime
● Substance abuse
● Chronic disease
● Population growth... Aging… climate change… health systems
Lecture 2
Key Public Health Milestones
● Events
○ Outbreaks, gaps in public health action/no action, public outcry led to the
processes of generating evidence, surveillance measures, and shifts in
political-economic and social forces
● People
○ Advocates, researchers, interest groups, community members, and political
leaders contributed to the evolvement of public health in Canada
● Policies
○ Laws acts, or regulations that enforced public health decisions, actions, and
resource allocation
The Early Years
● Staggering health problems
● Unsafe water and sewage disposal systems
● Massive disease spread
● Miasma theory
Pre Confederation: 1600-1866
● People
○ Pre- 1600, prior to French and British colonization, Indigenous inhabited North
America
○ 1723: arm-to-arm inoculation by British scientists
○ 1796: Edwards Jenner’s smallpox vaccine
● Events
○ Explorers brought cholera, typhus, smallpox, measles, tuberculosis
○ Fear of the Black death cautioned for disease prevention strategies
 ○ 1832: cholera spread at Port of Quebec
○ 1847: Irish immigrants arrive, fleeing famine
○ 1854: John Snow- Broad street pump
● Policies
○ Temporary quarantine measure
○ 1721: Quarantine Act
○ 1795: Quarantine Act of Lower Canada
○ But, timings were off!
○ 1816: Health officer of lower Canada for sick immigrants
○ 1823: Quarantine Bill
○ 1830: Health boards!
○ 1860: Canada legislated smallpox vaccination
Immigration Act
● 1869
● Keep contagious disease out
● Quarantine
● Limits to numbers on ships
● Must have a passenger list
Cholera spreads through the colonies, 1832
Confederation and Development: 1867-1913
● The Great Sanitary Reform Movement provided new understanding about personal
hygiene, disease prevention through vaccination and early detection, diagnosis and
treatment
● “Sanitary idea” = individual + community action
● A better understanding of the spread of disease -> data on mortality and morbidity ->
public health activism -> political infrastructure
● British North America Act of 1867
○ Dominion of Canada through Confederation of NS, NB, QB, and ON
○ Corporate and industrial representation at the federal level
○ European immigration for the labor force
○ Health - non-existent, but quarantine remained- why?
○ Community? Local public health?
● Health among the Indigenous population
○ Sharp decline
○ Crowding, isolated, unhygienic living conditions
○ Limited to no access to health care
○ Alarmingly high rates of disease/illness
○ The odds of children dying in residential schools was 1 to 25; 25-35% died with
TB
● 1862, Louis Pasteur developed pasteurization
● 1882, Robert Koch discovered causal agent of tuberculosis
● Sanitary Reformers (after Britain's public Health Act)
○ Demanded data on vital statistics
 ○ Build sewage infrastructure
○ Purify drinking water
● 1874: Dr. Edward Playter; and Ontario for deaths to be reported
● 1874-1892: Canada’s first public health journal (key for disseminating knowledge and
sharing information)
● 1890: Ontario’s first public health lab to test water and milk supplies (i.e. typhoid,
diphtheria)
● 1901: Canadian Association for Prevention of TB among Indigenous populations in BC
● 1910: Canadian Public Health Association
WWI to Great Depression: 1914-1938
● Spanish influenza
○ 50,000 non-Indigenous Canadians died; the mortality rate among Indigenous was
5 times the national rate
● WWI
○ Significant impact on the economy, health care system, resource allocation
● Venereal disease
○ Social hygiene, i.e. normal vs. abnormal sexual activity
Unprecedented Rates of Disease Outbreaks
● Typhoid fever, 1923
○ Sanitary controls of milk supplies
○ 5000 infected and 533 dead
○ Resistance against compulsory pasteurization
● Smallpox
○ 1920, 33 deaths and 200,000 vaccinations followed
○ 1923- 24, 71% mortality rate among unvaccinated
● Poliomyelitis
○ A viral infection that affects the central nervous system
○ “Infantile paralysis”, but did not only affect infants
○ 1910, 1916, 1927, 1930, 1931, 1932, 1937 (most deadly form)
WWI to Great Depression: 1914-1938
● 1919: Social Hygiene Program by Prime Minister Robert Borden
● The program focused on Veneral Disease Control, Child Welfare Division, laboratory of
Hygiene, Dominion Council of Health with reps from labor unions, women’s groups,
social services, agriculture, and academia
● Significant improvement in infant mortality due to education, nurses availability, and
health services
● Canadian Red Cross formed
● But half of Canadians lived in rural areas
● Dr. Peter Bryce
○ 1884: first secretary of ON’s Provincial Board of health
○ 1904: Chief Medical Officer of the Departments of the Interior and Indian Affairs
○ Prioritized infant life, school children, TB, deaths due to industrial causes, and
disease prevention measures
 ○ The blamed federal government for their failure to provide health care for First
Nations
● Progress: Public health education
○ Scientific discoveries led to informing the public about public health disease
control education
○ Increasing use of traveling exhibits to spread lessons learned from bacteriologic
investigations
● Stagnation: Great Depression
○ Put a halt to health services
○ Hindered industrialization
○ Increased disparities
WW2 and Post-war expansion: 1939-1959
● Societal failures:
○ 1939-1944: women’s rate of full-time labor doubled
○ 1940s: 700+ deaths per 100,000 among Indigenous communities (highest ever
reported in Canada)
■ Due to poverty, poor nutrition, overcrowding, comorbidities
○ 1941-1951: Connaught laboratories supplied to treat pneumonia, meningitis,
gonorrhea, and syphilis among civilians and Canadian forces
○ 72% reduction in syphilis rates, and 35% in gonorrhea
○ 1954: Salk vaccine 60-90% protective against poliomyelitis
○ 1942: official policies on food rules
● Social welfare programs
○ 1944: first universal welfare program provided child support
○ 1952: old age security act provided a pension for people more than 70 years
○ 1957: hospital insurance and diagnostic services act federal government covered
50% of provincial/territorial costs for hospital and diagnostic services
Societal transformation and Universal Health Care: 1960-1989
● 1966: Medical Care Act
● 1968: federal task force on the cost of services (drop costs), a shift from hospital to
community
● DDT linked to cancer and other neurological, resp., cardio disorders
● 1970s: Auto emission controls
● 1982: Canada and US join to reduce acid rain
● Pitfalls and failures: synthetic drugs
● Thalidomide for colds, flu, headaches, neuralgia, and asthma
● 1962: ordered off the marker
● 1976: Canada’s first seat belt laws
● 1970s-80s: MADD, Participation
Disease re-emergence:
● 1974,1975: measles outbreaks
● 1960s, smallpox vaccination campaigns
● 1980, smallpox eradication
 ● 1982: 1st AIDS case in Canada
Public Health is Transformed
● 1974
○ Health field concept: an analytic tool for identifying root causes of health issues
● Objectives (focus beyond health care delivery):
○ Identify at-risk populations
○ Reduce mental and physical health hazards
○ Improve access to mental and physical health services
● Data to identify populations at risk:
○ Causes of mortality and kinds of morbidity
○ Underlying reasons for mortality and morbidity
○ Susceptible segments of mortality
A New Perspective on the Health of Canadians by Marc Lalonde
● Five strategy approach:
○ Health promotion
○ Regulation
○ Research
○ Health care efficiency
○ Goal setting
● Impacts
○ Led to a broader public health approach, greater emphasis on health promotion
○ Led to the creation of a new Health Promotion Directorate in 1978 to develop
policies and programs emphasizing individual behavior change
● Criticisms
○ Focus on personal responsibility for lifestyle choices tended to blame the victim
○ Ignored social, economic, and political contexts
Jake Epp
● Report “Achieving Health for All: A Framework for Health Promotion
● 3 major health challenges
○ Disadvantaged groups
○ Preventable diseases and injuries
○ Lack of support live a productive and fulfilling life
1986, Ottawa Charter
● First international conference on health promotion by WHO, CPHA, Health, and Welfare
Canada
● Presented as a result of work done at the First International Conference on Health
Promotion
● Endorsed by 212 participants representing 38 countries
Five Key Action Areas in Health Promotion (focus beyond the individual):
● Build healthy public policy
● Create supportive environments for health
● Strengthen community action for health
● Develop personal skills
 ● Reorient health services
Three Strategies:
● To enable
● Mediate
● Advocate
Health Care Systems
● Are complex organizations comprising regulatory, funding, and service provision bodies
that provide access to health care in accordance with societal goals and values
Health Systems
● Are dynamic and interconnected systems at whose heart are people
● It is the multiple relationships and interactions among the building blocks… that convert
these blocks into a system
How do we understand health systems?
● Need to distinguish the difference between:
○ How we pay for care (financing)
○ How we deliver care (delivery)
● but, also need to consider:
○ The funding mechanism used, and the inherent incentives/disincentives
associated with them (allocation)
Financing and Delivery of Health Care Systems
●
Public financing Private financing

Public delivery National Health Service User fees for public

(e.g., UK) services (e.g., public health
labs?)

Private delivery Public Insurance (e.g., Private Insurance (e.g.,

Canada) US)
History of Canada’s Health System
● 1867: Constitution Act (h/c under provinces jurisdiction)
● 1947: Tommy Douglas introduces Saskatchewan’s Hospital Insurance Plan
● 1957: hospital Insurance and Diagnostic Services Act (feds reimburse provinces &
territories)
● 1966: Medical Care Act (feds reimburse doctors outside of hospitals)
● 1977: Established Programs Financing (Trudeau offers transfer payments, cash, and tax
points)
● 1984: Canada Health Act (all services medically necessary)
● 1996: Canada health and Social Transfer
The Great Reform: Hospital Insurance to Medical Insurance
● July 1, 1962, doctors strike!
● Strike widely condemned:
○ Bad press globally
 ○ Unpopular with the public
● Negotiations: docs autonomy and control over medical decision-making preserved
● July 24, doctor strike ends
● CMA continues to lobby feds
1984, Health Canada Act
● Medically necessary hospital and physician services
● No extra-billing and user fees for insured services
● “To protect, promote, and restore the physical and mental well-being of residents of
Canada and to facilitate reasonable access to health services without financial or other
barriers.”
Five Principals of the Canadian Health Care System
● Comprehensive
● Publicly administered
● Universal
● Portable
● Accessible
How is our system financed?
● 15.4% is out of pocket costs
● 64.2% of government covered
● 12.4% being private insurance
● 3.2% rated as “other”
● 4.8% from other public sources
Financing our health care system: Public Sector
● Primary source: Provincial/territorial governments
○ Canadians participate through general taxation and health premiums
○ Mandatory, universal health insurance plans to cover medically necessary
services
○ Special plans for low-income residents and seniors (e.g. out of hospital drug
benefits, ambulance costs)
● Secondary source: the federal government
○ Annual fiscal transfers to provinces and territories for health care
○ Directly funds care for First Nations, Inuit and Metis communities, RCMP,
Veterans, federal penitentiaries, refugee claimants, public health programs
● Tertiary source: municipal government
○ For enhanced responsiveness to community needs
○ Boards oversee hospital serviProvince decentralize obligations to regional boards
ces, nursing homes, home care, public health services
How is Ontario’s Healthcare system funded?
● Income (salary) -> Ontario Government (taxes) -> Ministry of Health & Long Term Care
(38.7%)
Remuneration of Physicians
● Insert pic
Major causes for increasing costs
● Increased access to care
○ Increases in supply and demand
● Technological advances
○ New treatment more expensive
○ Broader use of new technologies/drugs
● Limited incentives to control cost
○ Health care is a large sector of the economy
Strategies to save costs
● Reduce of services
○ Apply financial incentives to patients through the use of co-payments
○ Limit resources (e.g. hospital beds)
○ Use gate-keepers
● Improve the efficiency of services
○ Use professional skills appropriately
○ Educate patients in self-management
● Improve support services
○ Use information systems
○ Improve administrative systems
2006, Public Health Agency of Canada Act
● The public health agency of Canada to promote and protect the health
● Concentrate and focus federal resources
● Enhance collaboration between different levels of government
● Allow faster, flexible response to emergencies
● Improve and focus communication
● Achieve greater success in attracting and retaining public health professionals
Public Health today..
● Biostatistics
● Community health
● Environmental health
● Epidemiology
● Health care
● Health economics
● Occupational safety and health
● Population health
● Preventive healthcare
● Public health
● Social work
Who, cpa, cdc,
Lecture 3
Ontario's Health Care and public Health System Structure
Ontario’s Health Care Sector
● Provincial level
○ The ministry of health and long term care
○ Office of chief medical officer of health
○ Provincial agencies (e.g. PHO, HQO)
● Regional Level
○ Regional public health entity
○ LHIN
● Local level
○ Local public health service delivery areas
○ LHIN Sub-Regions
Graph
Ontario’s Local Health Integration Networks (LHINs)
Ontario’s Population Health Approach
● What is public health?
○ Public health work is grounded in a population health approach- focused on
upstream efforts to promote health and prevent diseases to improve the health of
populations and the differences in health among and between groups
○ Health risks and priorities change as people grow and age and public health
works to address health across the life course

○ Graph
Focus Areas
● 13 provincial standards:
○ These include “foundational” standards (for monitoring population health data,
decreasing health inequities, and implementing effective public health practice
and emergency management)
○ Programmatic ones (food safety, health environments, health growth and
development, immunization, infectious and communicable diseases prevention
and control, safe water, school health, substance use and injury prevention, and
chronic disease prevention and well being)

○
 ● Chronic disease prevention and well being
○ To reduce the burden of chronic diseases of public health importance and
improve well being
● Food safety
○ To prevent or reduce the burden of food borne illnesses
● Healthy environments
○ To reduce exposure to health hazards and promote the development of healthy
built and natural environments that support health and mitigate existing and
emerging risks, including the impacts of a changing climate
● Healthy growth and development
○ To achieve optimal preconception, pregnancy, newborn, child, youth, parental,
and family health
● Immunization
○ To reduce or eliminate the burden of vaccine preventable diseases through
immunization
● Infectious and communicable disease prevention and control
○ To reduce the burden of communicable diseases and other infectious diseases of
public health significance
● Safe water
○ To prevent or reduce the burden of waterborne illnesses related to drinking water
and recreational water use
● School health
○ To achieve optimal health of school aged children and youth through partnership
and collaboration with school boards and schools
● Substance use and injury prevention
○ To reduce the burden of preventable injuries and substance use
Epidemiology and Surveillance
How did Taiwan handle COVID-19?
● Total cases: 503, deaths = 7
● How?
● Travel and quarantine (early)
● Clear plan and good leadership
● Ahead of mask shortages
● Regular communication
● Digital healthcare system
● Community mindedness and solidarity
● Missing
○ More education around prevention
○ Masks for foreigners
○ Privacy policy- loose?
○ Flexibility around work from home
Epidemiology
● Study of the distribution and determinants of disease frequency in human populations
● Epidemiology aims to:
○ Discover the agent, host, and environmental factors
○ Determine the relative importance of causes of illness, disability, and death
○ Identify segments of the population with greatest risk
○ Evaluate the effectiveness of health programs and services

Epidemiology Key Terms

● Epidemic or outbreak
○ Disease occurrence among a population that is in excess of what is expected in a
given time and place
● Cluster
○ Group of cases in a specific time and place that might be more than expected
● Endemic
○ Disease or condition present among a population at all times
● Pandemic
○ A disease or condition that spreads across regions
● Rate
○ Number of cases occurring during a specific period; always dependent on the
size of the population during that period
Two Broad Types of Epidemiology
● Descriptive epidemiology
○ Examining the distribution of a disease in a population, and observing the basic
features of its distribution in terms of time, place, and person
○ Typical study design:
■ Community health survey (approximate synonyms- cross-sectional study,
descriptive study)
● Analytic epidemiology
○ Testing a specific hypothesis about the relationship of a disease to putative
cause, by conducting an epidemiologic study that relates the exposure of interest
to the disease of interest.
○ Typical study designs:
 ■ Cohort, case-control

●
Three essential characteristics of epidemiology
● Person
○ Age, gender, ethnic group
○ Genetic predisposition
○ Concurrent disease
○ Diet, physical activity, smoking
○ Risk taking behavior
○ SES, education, occupation
● Place
○ Presence of agents or vectors
○ Climate
○ Geology
○ Population density
 ○ Economic development
○ Nutritional practices
○ Medical practices
● Time
○ Calendar time
○ Time since an event
○ Physiologic cycles
○ Age (time since birth)
○ Seasonality
○ Temporal trends
Case study: COVID-19
● Time
○ When?
○ Trends over time
● Place
○ Where is it affected?
○ Geographical variations
● Person
○ Who is affected?
○ Age, gender, and other characteristics
Epidemics/Pandemics occur when…
● Host , agent, and environmental factors are not in balance due to new agent
● Due to change in existing agent (infectivity, pathogenicity, virulence)
● Due to change in number of susceptible in the population
● Due to environmental changes that affect transmission of the agent of growth of the
agent

●
Example: Food-borne illnesses (FBI) in Canada

Epidemiology in Action -FBI in Toronto

● Toronto: largest city in Canada, multicultural
● 17000 food establishments
○ 43,700 cases of foodborne illnesses annually
○ $476-587 million
● Numerous special events
● Canadian national exhibition (CNE)- 1.5 million visitors
● Event: call from CNE manager at 10:30 pm- August 20
● What occurred: several persons reported being ill shortly after consuming food at a
specific outlet
○ Toronto public health (TPH) 24/7 on call system
○ CNE advised to ensure premise is kept closed
 ○ Secured any left over food product
● Response: control of communicable disease (CDC) manager informed
● Public announcement: outbreak included in news
● Response: PH inspectors and CDC staff onsite by 8:30am
○ Modified food safety audit and inspection
● Investigation: food and environmental samples collected for lab analysis
○ RTE burgers, bacon jam
● Inspection: production site of major ingredient inspected and sample taken
○ Bacon jam sample
● Incubation period
○ Short incubation period
■ Mean 4.7 hours
■ Median 4.0 hours
■ Range 0.5-22.0 hours
● Symptoms
○ Watery diarrhea (83%)
○ Vomiting (81%)
○ Nausea (76%)
○ Abdominal pain (74%)
○ Loss of appetite (62%)
○ Headache (43%)
○ Chills (42%)
○ Bloody diarrhea (6%)
● Investigation: CDC staff interviewed 257 persons
○ Standard outbreak investigation questionnaire
○ Fluid survey data entry tool
○ iPHIS (integrated Public health information system- at provincial and national
level)
○ At risk population exposure August 16-20
○ Kits provided for specimen collection
○ Victims reported
■ Treated onsite by EMS personnel
■ Taken to hospital
■ Family physician
○ Food handling staff interviewed
● Partnership and collaboration
○ Liaise with other affected health units based on where cases reside
○ Notify to ministry of health and long term care
■ Responsibility for healthcare system
■ Chairs outbreak investigation coordinating committee
○ Inform public health ontario
■ Public health laboratory
■ Technical support
 ● Outbreak management
○ News release
○ Implicated premises closed voluntarily
○ Section 13 order contemplated
■ No health hazard identified
■ Epi Evidence
■ No new cases
○ Follow-up visit to establishment where bacon jam produced
■ Teaching school
■ Bakery
○ Modified food safety audit and additional sampling

The lab results

● Seven food samples positive for Staph aureus
○ 4 burgers with bacon jam
○ 2 bacon jam
○ Smoked bacon
● All samples, except the bacon jam, were safe
How do epidemiologists guide public health decisions?
● Evidence: make decisions based on best available scientific evidence
● Data: using data and information system systematically to identify sources and respond
immediately and efficiently
● Apply the evidence: applying program planning frameworks, policies, and standards
● Engage: engaging the community and media in decision making
● Partnerships: establishing partnerships and collaborations throughout the process
● Disseminate: and disseminating what is learned- keeping the public informed and
reassured throughout the investigation period
● Communicate
In Epidemiology
● we measure disease burden and risk

●
● We determine associations
 ● Association does not equal causation
○ Country’s average number of hours watching T.V per day as y-axis
○ Mortality rate from cardiovascular disease as x-axis
What's the denominator?
● Total population vs. population at risk
● The denominator must only include persons who are susceptible to (at risk for) the
outcome
● E.g. lung cancer

Rates
● Help us compare compare health problems among different populations that include two
or more groups who differ by a selected characteristic
● To calculate a rate, we first need to determine the frequency of disease, which includes:
○ The number of cases of the illness or condition
○ The size of the population at risk
○ The period during which we are calculating the rate
Risk
● A proportion or probability
● Cumulative incidence, incidence proportion
● Specific to certain time period
● Assumes patients followed entire time (sometimes problematic due to date of entry,
underlying conditions, loss of follow up, ineligibility)
● Number of patients developing disease over a specific period
---------------------------------------------------------------------------------
Number of subjects followed during that period
Incidence and Prevalence
● Incidence and prevalence measure different aspects of disease occurrence

Prevalence Incidence

Numerator All cases, no matter how long Only NEW cases

diseased

Denominator All persons in population Only persons at risk of

disease

Measures Presence of disease Risk of disease

Most useful Resource allocation Risk, etiology

Incidence
● Rate of occurrence of new cases of disease in a population at risk during a specified
period of time
● Measures risk
● Calculations

Measures of Incidence
● Person-time incidence rate
○ Numerator: # of new cases
○ Denominator: person-time at risk
○ Used when not all people are followed for entire period
○ Observation time from study onset to development of health outcome, to death,
to loss to follow-up, or to study end
○ Must include a unit of time
● Cumulative incidence
○ Numerator: # new cases
○ Denominator: # people at risk at beginning of study period
 ○ Used when all people are followed for entire period (or it is not possible to
determine person-time at risk)
○ Probability that individuals in the population get the disease during the specified
time period
○ Usually expressed as cases per 1000 population

Person-time Incidence rate

● Rate of occurrence of new cases of disease in a population at risk during a specified
period of time
● Takes into account variable time periods at risk
Example: person time and cumulative incidence
● Unlike for risk, denominator includes a measure of time
● Ex. for person time incidence rate: the incidence of hip fractures among women is 2.5
per 100 person-years, compared to 1,5 per 100 person years for their male counterparts
● Ex. for cumulative incidence: the cumulative incidence of hip fractures among women is
20% at 5 years, compared to 10% for their male counterparts

Prevalence
● Disease burden can be measured in terms of costs, life expectancy, morbidity, quality of
life, or other indicators
● Knowledge of the burden of disease can help determine where investment in health
should be targeted
● Example: monitoring canada's obesity weights in children
● Prevalence proportion or point-prevalence
○ Number of subjects having disease at a particular point in time
-----------------------------------------------------------------------------------
 Total number of subjects in the population
● Prevalence period
○ Existing cases at the start of the period plus the new cases that develop over the
study period
-----------------------------------------------------------------------------------------------------------
Total number of subjects in the population
How do we conduct epidemiological studies?
Qualitative Research Studies
● “A holistic and subjective process used to describe and to promote a better
understanding of human experiences and phenomena via the collection of narrative
data, and to develop conceptual models and theories that seek to describe these
experiences and phenomena”
● Study designs to understand needs, perceptions, experiences, and connectedness of
humans, their behaviours:
○ Action research or inquiry
○ Discourse analysis
○ Ecology psychology
○ Ethnographic research
○ Ethnomethodology
○ Ethology
○ Grounded theory
○ Hermeneutics
○ Historical research
○ Phenomenology
Quantitative Research Studies
● “A formal, precise, systematic and objective process in which numerical data are used to
obtain information on a variety of health-related phenomenon of interest or concern”
● Study designs to understand disease burdens, risk and distribution of
determinants/causal factors and their impact on health:
○ Case-control studies
○ Case studies
○ Clinical trials
○ Cohort studies
○ Correlational studies
○ Cross-sectional studies
○ Descriptive studies
○ Experimental studies
○ time-series/time trends studies
Types of Epidemiological (quantitative) studies

-
Experimental studies

Randomization
● Step 3 is the difference between randomized controlled experiments and
non-randomized experiments
● quasi - experiments: non-random approach to divide participants (e.g. where or when
recruited, by sequence of study entry)
 ● Randomized controlled trials: random approach to divide participants; usually patient and
researcher are blinded to participants’ group status (i.e. double-blinding removes
allocation bias)
Efficacy vs. Effectiveness
● Efficacy
○ Refers to potential impact of treatment under optimal controlled conditions
● Effectiveness
○ Refers to potential impact of treatment under normal, real-world conditions of
routine practice
Example:
● The New England journal of medicine
● Methods: we randomly assigned 3234 non-diabetic persons with elevated fasting and
post load plasma glucose concentrations to placebo, metformin (850 mg twice daily), or
a lifestyle modification program with the goals of at least a 7% weight loss and at least
150 minutes of physical activity per week
● Results: lifestyle changes and treatments with metformin both reduced the incidence of
diabetes in persons at high risk
● Study population: non-diabetic individuals with elevated glucose values (n=3234)
● Randomization: random assignment according ot clinic centre
● Intervention: 1. Lifestyle change; 2. Metformin
● Control : placebo
● Outcome: diabetes
Ethical Issues
● It is unethical to deny a patient access to an effective treatment, but it is also unethical to
adopt a new treatment without conducting rigorous testing to prove efficacy
● It is also unethical to continue a trial if the treatment is found to be obviously effective or
obviously dangerous
● Most epidemiological studies are observational, little potential for harm
● Several critical checks to ensure the potential is negligible, for example:
○ Study must be approved by an institutional research ethics board
○ Participants must be informed about the study purpose, risks and benefits, and
must freely consent to participate
Observational studies: Cohort Studies
● A cohort is a sample of people who share a defining characteristics and can be followed
over time (e.g. birth cohorts share the same year of birth)
● Example
○ Framingham heart study: investigates risk factors for cardiovascular disease
(CVD)
○ In 1948, began following 5,209 adults who did not have CVD
○ Every 2 years, collected data on diet, exercise, medication use etc.
○ Measured new CVD cases
○ Determined effect measures for levels of exercise, cigarette smoking, blood
pressure, and blood cholesterol
Measure of Disease- Relative Risk
● Relative risk: compares risk of health outcome among two groups
● Typically defined by exposure to (primary group) and lack of exposure to (comparator)
suspected causative factor
● Risk ratio = 1.0, identical risk
● Risk ratio > 1.0, increased risk in exposed
● Risk ratio < 1.0, decreased risk in exposed

Example of Cohort studies

Case-control studies
● Method: controls are matched with cases for several characteristics so that the two
groups are as similar as possible, except for exposure.
● Starts with disease status
Example
● Lung cancer and smoking
● Important epidemiological study
● Doll and Hill’s study began in 1950
 ● Identified lung cancer patients in 20 london hospitals and identified comparator group of
patients without lung cancer
● Cases and controls matched by sex, age, hospital
● Surveyed each group about smoking habits (exposure)
● Cases comprised of greater proportion of smokers, and of heavy smokers
Measures disease -Odds ratio
● Exposure-odds ratio for data on cases and controls is the ratio of the odds in favor of
exposure among the cases to the odds in favor of exposure among non-cases
● Reduces to…
● Determines the odds of a disease given the exposure to the risk factor

Descriptive studies
● Unlike analytic and experimental studies, do not aim to test hypotheses
● Focus on ecological units (e.g. subgroups, whole population at different time points)
● Survey-based data collection on risk factors related to disease occurrence
● Generates overall, summary measures (e.g. counts, prevalence)
● Example: cross-sectional study
Cross-sectional studies
● Examines relationship between diseases and risk factors in a defined population
at one time point
● Presence of disease and risk factors determined in each study participant at a given time
point
● Relationship between risk factor and disease allows estimation of:
○ Prevalence of the disease in different subgroups
○ presence/absence of risk factors in individuals with and without the disease
● The time order of cause and effect (temporality) cannot be determined
Challenges with Epidemiological Studies/Science
● Misleading conclusions
○ Chance, random error
○ Bias, systematic error
○ Confounding
Random Error
● There is a natural variability to all uncertain outcomes
● Consider average height in samples of men who are identical in every measurable way
● Average does not change, spread does
● Cannot reduce random error
Systematic Error
● Error in the conception, design or reporting of a study that leads to results or conclusions
that are systematically (as opposed to randomly) different from truth
● Selection bias and recall bias are common forms
Selection bias
● How individuals are selected in the study can produce erroneous estimated associations
or effects on an exposure on an outcome
○ For example, estimated effect of cigarette smoking on heart disease biased if
participants are volunteers and the decision to volunteer is affected by smoking
status or by having a family history of heart disease
● Sampling frame different from target population
● Sampling procedure does not mirror sampling frame
● Solution: rigorous sample selection and recruitment procedures
Recall bias (more relevant for case-control studies)
● Systematic error due to differences in accuracy or completeness of recall to memory of
past events or experiences
● For example, women who have had a baby with malformation will remember better any
events during pregnancy than mothers of infants with no malformations
● Tend to overestimate association between exposure and outcome
● Can reduce through cross-verification of participant responses with medical records
Confounder
● Must be associated with both the risk factor of interest and the outcome
● Must be distributed unequally among the groups being compared
 ● Cannot be an intermediary step in the causal pathways from the exposure of interest to
the outcome of interest.
● Usually introduced by the investigator or participants
● Solution: controlled for in the analysis through stratification and multivariate regression
methods
● Study on the association between birth order and the risk of down syndrome
● Increasing prevalence of down syndrome with increasing birth order
● Order in which children are born is linked to a woman's age at the time of her child's birth
● Correlation between maternal age and child having down syndrome much stronger
● Relationship between birth order and prevalence of down syndrome is confounded by
age
Challenges with Epidemiological Studies/Science
● Example of false data reporting
● Challenges in pharmaceutical research
● Paid off SickKids hospitals top pediatrician understated the risks of a powerful
antipsychotic used to treat kids with behavioural problem
● Article concluded no correlation between long term use of Risperdal and an increased
risk of growth of breasts in boys
Lecture 4
Public health in the context of infectious disease
Significant public health achievements
● Water purification
● Effective sewage disposal
● Milk pasteurization
● Immunization
● Improved nutrition and personal hygiene
● Chemotherapy
● Antibiotics
What are some contributing factors to global spread of infectious diseases?
● Surveillance: “systematic collection, analysis and timely dissemination of information on
population health to those who need to know, so that action can be taken”
● Surveillance provides information of health and disease and guide planning and
interventions
○ Prevention and control efforts
○ Planning health services
○ Evaluating their (planning) impact
Data sources for Health surveillance
● Vital statistics
○ Births and deaths
● Environmental data
○ Air and water quality
● Health services indicators
○ Hospitalizations, discharge, same day surgery, screening, diagnoses, etc.
● Census data
○ Population data (i.e. income, language, and ethnic group)
Types of Surveillance
● Passive surveillance
○ Reporting mandated or requested from laboratories, care providers, and others in
the community (ongoing)
■ Most common approach to surveillance
■ Less expensive, less complete than other approaches
● Ex: a doctor’s office reports 2 cases of measles
● A nursing home reports an unusual number of older patients with
unexplained rashes
● Monitoring cigarette sales; goes down as years pass
● Active surveillance
○ Active case finding and record review by public health authorities
■ Often initiated as a component of outbreak investigations or when there is
an indication that something unusual is occurring
■ Resource intensive
■ Ex. youth risk behavior surveillance surveys
■ Ex. monitoring covid-19 cases
● Sentinel surveillance
 ○ Repeated testing or monitoring of groups of people or animals, or environmental
samples
■ Resource intensive
■ Ex. emerging infectious diseases (e.g., west nile virus) and
non-reportable diseases of public health importance (e.g., influenza)
■ emerging/re-emerging infectious diseases wit
● Syndromic surveillance
○ Detect cases before a clinical diagnosis is made, based on behaviours or
symptoms that can be tracked through a variety of data sources
■ Attempt to enhance timeliness and completeness of surveillance for
diseases where cases may not present for medical care and/or receive
laboratory testing
■ Ex. monitoring school or work absenteeism, purchase of over the counter
medications, calls to Telehealth, hospital admission records, google
searches
How do we detect and report outbreaks?
Notifiable diseases
● Globally: obligation under international health regulations to report to the WHO any even
that may constitute a public health emergency of international concern
● In Canada: each province and territory has own legal requirements for reporting certain
infectious and noninfectious diseases considered important for public health monitoring
○ Reporting is mandated by legislation
● Nationally, PHAC collects information from jurisdictions on diseases considered
important for national surveillance
○ Reporting is voluntary, via agreements with provinces and territories
● Provincially: health protection and promotion act requires that each public health unit
collect information about people with reportable diseases in their jurisdiction and report it
to the ministry of health and long term care
○ Integrated public health information system (iPHIS)- database used by all public
health units to report cases
How does surveillance inform decision making?
● An integrated early warning system to transform diverse big data into actionable insights
that help mobilize precise, efficient, timely and coordinated responses across sectors
How could we have prevented SARS?
● Challenge during SARS: Timing! Since the, digital disease detection has emerged as
important tool for outbreak detection
Digital Disease Detection
● The use of media sources and other digital technologies to detect disease outbreaks and
track their spread
Traditional indicator-based surveillance systems
Henle-Koch’s Postulates
● Organism must be present in every case of the disease
● Organism must be able to isolated and grown in pure culture
● Organism must cause specific disease when inoculated into susceptible individual
● Organism must then be removed from such individual and identified
Classification of infectious agents
● Micro-parasites: bacteria
○ Fatty membrane contains DNA and cellular machinery
○ Obtain energy from sugars, proteins, fats
○ Live and multiply outside host
○ Examples: mycobacterium tuberculosis (TB), salmonella typhi (typhoid), vibrio
cholerae
● Bacilli
○ Escherichia coli (intestinal infection, vibrio cholerae (cholera)
● Cocci
○ Streptococci (pharyngitis), staphylococci (skin infections)
● Spirochete
○ Treponema pallidum bacterium (syphilis), borrelia burgdorferi (lyme disease)
● Viruses
○ Smallest infectious disease agent
○ Thin protein coating around genetic material
○ Requires energy from host cells
○ Cannot replicate outside host cell
○ Examples: human immunodeficiency virus, hepatitis C virus
● Parasites
○ Protozoa, helminths, or arthropod
○ Defined nucleus
○ Single or multi celled
○ May or may not need host to replicate
○ Examples: plasmodium falciparum (malaria), lice (head lice)
6 modes of transmission
● Contact
○ Direct physical contact between infected individual and susceptible host (body
surface to body surface)
○ Examples: chlamydia, influenza, infectious mononucleosis
○ Precaution: use condoms, hand hygiene, masks
● Indirect
○ Infectious agent is deposited on surface (fomite) and survives to be transmitted to
susceptible host who touched surface
○ Example: rhinovirus, norwalk, respiratory syncytial virus
○ Precaution: sterilizing instruments, disinfect surfaces and toys, masks
● Dropet
○ Contact
 ○ By coughing and sneezing large droplets can be projected up to 1 meter
○ Example: meningococcus, respiratory viruses
○ Precaution: surgical mask, cover mouth physical distance
● Airborne
○ Non-contact
○ Transmitted by aerosols (suspended solid particles or liquid droplets) that contain
the organism
○ Example: measles, chickenpox
○ Precaution: masks, use negative pressure rooms
● Vehicle
○ Non-contact
○ Single contaminated source spreads infection (common source or point source)
○ Example: expired restaurant food, listeriosis in 2008
○ Precaution: follow safety standards
● Vector-borne
○ Non-contact
○ Transmitted by animal or insect vectors
○ Example: mosquitos (malaria), ticks (lyme disease)
○ Precaution: protective barriers, window screens, bed nets, insect spray
Characteristics of infectious disease

6 link chain of infection

● Pathogens
○ Virus, bacterium, or parasite that causes disease in humans
○ Public health approach: kill agent
○ Example: antibiotics
● Reservoir
○ Location which pathogen lives and reproduces
○ Public health approach: eliminate reservoir
○ Example: remove garbage
● Portal of exit
○ Route pathogen takes to leave the infected host
 ○ Public health approach: knowledge important for understanding transmission and
control measures
● Transmission
○ Method of traveling from reservoir/infected host to susceptible host
○ Public health approach: block movement of pathogens
○ Example: quarantine infected individuals
● Portal of entry
○ Route pathogen enters host
○ Public health approach: block point of entry
○ Example: wear long sleeves
● Susceptible host
○ Entry into host that is not immune
○ Public health approach: improve resistance against infection post-invasion
○ Example: vaccination
Herd Immunity
● 83%-94% is protected
Steps for outbreak detection & control
● Establish existence of outbreak
● Define cases and identify as they occur
● Develop hypotheses about causes/controls
● Test hypotheses through data analysis
● Draw conclusions and adjust controls
● Plan long-term control and prevention
Case study: Ontario’s SARS experience
● What is Severe Acute Respiratory Syndrome (SARS)?
○ Viral respiratory illness caused by a coronavirus, called SARS-associated
coronavirus
○ Presents with malaise, myalgia, fever, and respiratory symptoms
○ Transmitted from person to person by close contact or direct contact with
respiratory secretions or body fluids of a suspect or probable case of SARS
○ Transmitted most readily through respiratory droplets produced when an infected
individual coughs or sneezes and possible through fomites
○ The incubation period is between 3 to 10 days
○ Adoption of masks during SARS outbreak- fast!
● The SARS epidemic
○ February 2003, hotel guests in hong Kong contacted ill physician who had been
treating patients with an atypical form of pneumonia in Guangdong, China
○ Guests developed similar symptoms and transmitted the disease via international
travel to contacts in China, Singapore, Vietnam, and Canada
○ By March 15, 2003, WHO received reports of >150 cases
○ SARS affected 29 countries
○ 8,096 probable cases identified, of whom 774 died
 ○ First introduced to Canada upon the return of one of the hotel guests to Toronto,
Ontario in February 2003
● Pressures on Ontario’s health care and public health systems
○ Many patients required intensive care
○ Hospitals were shut down
○ Elective procedures were cancelled
○ Collecting adequate types and quantities of supplies to combat the disease was
difficult
○ Challenged regional capacity for outbreak containment, surveillance, information
management, and infection control
● Outcomes:
○ 3% increase in funding for public health services
○ Recruitment of a new chief medical officer of health, dr. theresa tam
○ Advocate for effective disease prevention and health promotion initiatives
○ Provide science based health policy analysis and advice to federal health
minister
○ Improve the quality of public health practice
○ Creation of the public health agency of canada
○ Concentrate and focus federal resources
○ Enhance collaboration between different levels of government
○ Allow faster, flexible response to emergencies
○ Improve and focus communication
○ Allow for longer-range plans than the usual annual planning cycle of
governments
○ Achieve greater success in attracting and retaining public health professionals
● The SARS outbreak went on for 3 months before being identified as a distinct disease.
Then, search of a pathogen went on for another 2 months: the identification and
genomic sequencing of the virus itself largely came from researchers outside China
● By contrast, 3 weeks after the first COVID-19 case, China notified the WHO of a spike in
cases of a pneumonia-like disease
● 2 weeks later, the COVID-19 was isolated, genetically sequenced, and a diagnostic test
developed, giving China the tools it needed to launch one of the greatest infectious
disease containment efforts the world has ever seen
Lecture 5
Public Health Risk Communication
Crisis Risk communication
● Accurate and effective communication to diverse audiences in emergency situations
● Risk communication
○ Information exchange about health risks caused by environmental, industrial, or
agricultural, processes, policies, or products among individuals, groups, and
institutions
■ It is focused on dialogue with those affected and concerned and strives to
ensure communication strategies are evidence based
Objectives of Risk communication
● Inform or educate people about risk
● Build, strengthen or repair trust
● Encourage people to take appropriate action
● Inform people about policies and response plans
● Provide timely information and instructions to reduce potential injuries, illnesses,
economic losses and social disruption
● Preventing stigmatization (neighbourhoods, people)
● Getting people to help you identify issues of concern
● Increase social cohesion and resilience
● Increase confidence in risk management authorities
Types of Risk Communication
● Precaution advocacy (public relations: high hazard, low outrage)
○ Audience: apathetic, aren’t interested, getting their attention is quite difficult
○ Task: messages that reinforce appeals to move the audience towards your goals,
provoke more outrage -action
○ Medium: monologue via the mass media
○ Barriers: audience inattention, size, resistance
● Stakeholder relations: (moderate hazard, moderate outrage)
○ Audience: stakeholders- interested and attentive audience, neither too apathetic
or too upset to listen
○ Task: to discuss, explain, respond to the audience/stakeholder
○ Medium: dialogue, supplemented by specializes media
○ Barriers: inefficiency of one on one dialogue
● Outrage management (low hazard, high outrage)
○ Audience: outraged- anger, largely at you, ‘fanatics’, (justified or not) you have
their attention
○ Task: to reduce audience outrage- listening, acknowledging, apologizing, sharing
control and credit
○ Medium: in person dialogue, audience does most of the talking
○ Barriers: outrage
● Outrage communication (high hazard, high outrage)
○ Audience: very upset, outraged- more fear and misery than anger
○ Task: to help the audience bear its dear and misery
○ Medium: monologue via the mass media, dialogue- one on one where possible
○ Barriers: stress of the crisis, missing the difference between crisis communication
and routine public relation tasks
Theories in Risk Communication
● Mental noise theory
○ Elevated stress leads to more attention to internal “mental noise”, and less
attention to externally generated information
● Negative dominance theory
 ○ When people are upset more likely to listen to negative rather than positive
reports and information
● Protection motivation theory
○ Ideational constructs of threat appraisal and coping appraisal are keys to shaping
an individual's intention to protect themselves
● Social learning theory
○ People learning directly from others through their actions or examples
● Precaution adoption process
○ Passing through stages of increasing engagement, from ignorance to compliance
Risk perception
● Risk is the probability of an event occurring
● Perceived risk from a particular threat and the actual probability of that threat occurring
often bare little relation to each other
● Based on:
○ Facts
○ Feelings
○ Fear
● Treat with:
○ Trust
○ Transparency
○ Early response
○ Listening
○ Planning
Important Risk Perception Factors
● Safe:
○ Voluntary, Natural, Familiar, Not memorable, Not dreaded, Isolated events,
Knowable, Individually controlled, Fair, morally irrelevant, trustworthy source,
responsive process
● Risky:
○ Coerced, industrial, exotic, memorable,dreaded, catastrophic, unknowable,
controlled by others, unfair, morally relevant, untrustworthy sources,
unresponsive process
 ○ Perception in Risk Communication

Planning for Risk communication

Risk communication cycle

● Challenges with a generic risk communication cycle:
○ What is the hazard? How much risk does it pose to the public?
○ Do we have the right tools to assess risk:?
○ How long until policies are developed? Lag time?
○ Can policies be implemented? Approval? Emergency act?
○ Were the policies effective? How do we know?
○ Are all outbreaks the same?
Essay Question: Outline the risk communication cycle with the COVID-19 pandemic
● Respond with each category: risk assessment, policy development (what safety
measures were put into place - i.e. close schools and non-essential businesses), policy
implementation (how did we put these measures into place - i.e. how did we close
schools, mandatory to wear masks in stores), policy evaluation (was the policy effective?
-i.e. It was at the beginning when people were following the rules but as stores and
schools began to open up again, cases began to rise.
Role of Risk Communication in public health emergencies
● Help at risk populations make informed decisions
● Encourage protective behaviours
● Complement existing surveillance systems
● Coordinate health and non-health partners
● Minimize social and economic disruption
● Builds the trust required to prepare for, respond to and recover from serious public health
threats
Trust
● The single most important factor in perception of risk
● If there is no trust, unlikely there will be effective risk communication
● Trust typically built over long period of time
 ● Easily lost, once lost, difficult to regain
● In part created by a proven track record
● Enhanced by endorsements from highly trusted sources
● Implications for risk communication? Are you and your organization trusted?
Factors that Impact Public health messaging
● Environmental factors
● Social and cultural characteristics
● Language preferences
● Difficulty of attitudes towards PH interventions
● Effective risk communication = achieve positive outcomes
● Ineffective risk communication = create problems or make them worse
Trust Factors in High Stress Situations
● Sender - perceived trust and credibility critical
● Receiver- reduced ability to process complex information
● Message- needs to be simplified
● Feedback- what is receiver hearing, feeling?
● Mental noise- harder to hear, understand, remember
● Ex. COVID-19 outbreak among senior/older populations; those with underlying
conditions
● How do we communicate in this “high stress” situation?
Special Challenges in Crisis Communications

Crisis Questions
● How many people were harmed or injured?
● Are those who were harmed getting help?
● How are people who were harmed getting help?
● Who is in charge?
● What are you advising people to do>
 ● Who else is involved in the response?
● Why did this happen?
● When did your response to this begin?
● What was the cause?
How do we do risk communication?
● Best practices in public health risk and crisis communication:
○ Accept and involve stakeholders as legitimate partners
○ Listen to people
○ Be truthful, honest, frank, and open
○ Coordinate, collaborate, and partner with other credible sources
○ Meet the needs of the media
○ Communicate clearly and with compassion
○ Plan thoroughly and carefully
Case Study: West Nile Virus in NYC 1999
● NYC risk communication effort related to the WNV epidemic was far-reaching, resource
intensive, competently handled, and effective
● But there were issues:
○ Little effort was made to collect, analyze, and evaluate empirical information
○ Full range of communication channels not used
○ Official spokespersons were not informed about stakeholder perceptions or about
expected levels of concern, fear, hostility, or outrage
○ Public concern over the city’s decision to use pesticides
○ Lack of attention to the unequal weights given to negative and positive
information in high- concern situations
○ Trust issues and lots of mental noise
Risk communication - in an Infodemic
● Promoting fake products and services (e.g. fake COVID-19 tests and vaccines)
● Promoting a false sense of security (e.g. misleading information about treatments)
● Promoting suspicion of the official guidelines and sources
Quiz 1
● The provincial and territorial governments are responsible for funding provision to:
○ None of the above
○ Not first nations, inuit, metis communities on reserve
○ Not refugee claimants
○ Not individuals in federal corrections
● The Bell-Curve Shift posits that shifting the whole population into a lower risk category
benefits more individuals than shifting high-risk individuals into a lower risk category
○ True
● Which of the following is NOT characteristic of a public health approach?
○ Influence and regulate social, economic, and health policies
○ Diagnoses and treatments limited within health care settings
○ Disease prevention and health promotion
○ Population-wide interventions
● A ___ level of prevention involves actions and measures to eradicate, eliminate, and/or
minimize the pact of disease
○ Primordial
○ Primary
○ Secondary
○ Tertiary
○ Quaternary

●
● As the concept of health evolved from prehistoric times to current times, which
population was the first to implement a prototype of a health maintenance organization?
○ Roman civilizations in Ancient Rome
● ____ refers to an increase, often sudden, in the number of cases of a disease above
what is usually expected in that population in a given region
○ Epidemic , outbreak
● A decline occurred in mortality and morbidity rates in the Canadian population after The
Great Depression due to limited participation in risk behaviours such as drinking and
smoking
○ True
● The critical determinants of health, described by the first evidence-informed report by a
developed nation challenged the mechanistic medical model of health, which include:
○ Human biology, environment, lifestyle, and healthcare organization
● What are the three critical values and principles for delivering public health to residents
in Canada?
○ Equity, social justice, and sustainable development
 ● Since the onset of the pandemic, the daily new COVID-19 cases across health regions in
Ontario demonstrate that:
○ The trend in new cases appears to be inconsistent across the province with
varying volume of cases over months
Quiz 2
● The total number of cases of a disease existing in a defined population at a specific point
in time (i.e. given year) is called:
○ Point prevalence
● A type of bias that can be corrected through rigorous recruitment procedures
○ Selection bias
● In the province of Ontario, Local Health Integration Networks do not oversee which of the
following?
○ Ontario Health Insurance Program
● A confounder in a research study:
○ Must be associated with both the risk factor of interest and the outcome
● During the SARS epidemic, which of the following exposure settings were linked to the
highest proportion of infections?
○ Healthcare
● Descriptive epidemiology is useful for all of the following purposes except:
○ Testing hypotheses
● Women who have had a baby with a congenital malformation will remember better any
events during pregnancy than mothers of infants with no malformations. This is an
example of:
○ Recall bias
● How does the incubation period differ from the latency period when referring to the
natural history of disease?
○ The incubation period is the time from exposure to pathological changes before
the onset of overt clinical symptoms
● Which of the following is an example of an analytic study design?
○ Case-control study
● What are some challenges with conducting epidemiological studies?
○ Random error
○ Confounding
○ Systematic error
○ All of the above
Lecture 6
Chronic diseases in the context of public health
Mental Health in Canada
● “The capacity of each and all of us to feel, think, and act in ways that enhance out ability
to enjoy life and deal with the challenges we face, and a positive sense of emotional and
spiritual well-being that respects the importance of culture, equity, social justice,
interconnections and personal dignity”
● Allostatic load: wear and tear on the body (eustress, distress)
 ● Coping and coping mechanisms: who is responsible to take action?
Key facts
● 6.7 million people in Canada are living with a mental health condition or illness today
● By age 40, about 50% of the population will have or have had a mental illness
● Suicide is one of the leading causes of death in both men and women from adolescence
to middle age
Mental illness in Canada
● “Alterations in thinking, mood or behaviour- or some combination thereof- associated
with significant distress and impaired functioning”
● Chemical imbalance theory-
● Three general theories related to the aetiology of mental illness and disorders:
○ supernatural , (attributed to possession and/or punishment by evil or demonic
spirits, displeasure of gods or deities, etc)
○ Psychogenic, (traumatic or stressful experiences, distorted perception, treatment
via psychotherapy and psychoanalysis)
○ Somatogenic (disturbances in physical functioning resulting in either illness,
genetic inheritance, brain damage or chemical or force of nature imbalances)
● Burden of mental illness in canada
● Who is at risk?
○ Those who are homeless, don't have access to health care, no income
● How do we provide access to mental health services?
● What are the challenges in our system?
● An estimated 1 in 5 canadians experience a mental health problem or disorder in any
given year
● 7.5 million canadians live with a mental health problem or illness twice the number of
people with heart disease or type 2 diabetes
Mental Health in Canada
● 1 in 5 canadians experiences a mental health or addiction problem
● 2.3 million adults with mood disorders in canada, ⅔ of them were females
● 6.7 million adults who reported that their perceived life stress was “quite a lot”. More than
half were females
● Only one in three people who experience a mental health problem or illness report that
they have sought and received services and treatment
● Cost to the economy of well in excess of $50 billion
Is Bell let’s talk about the solution?
● “You want to have a real talk about mental health, Bell Canada? Then, with all due
respect for the genuine good of the “let's talk” day, please shut up. Turn down the
volume on your logo and focus in on using the substantial financial resources and
massive communications infrastructure to raise up voices that are usually silenced”
● “(but) the campaign is just the tip of the iceberg...using the hashtag or posting a picture
online one day a year does not dive into the underlying issues our society is facing”
Priority Strategic directions from a population health perspective- by the CMHC
● “Promote mental health across the lifespan in homes, schools, and workplaces, and
prevent mental illness and suicide wherever possible
● Foster recovery and well-being for people of all ages living with mental health problems
and illnesses, and uphold their rights
● Provide access to the right combination of services, treatments, and supports, when and
where people need them
● Reduce disparities in risk factors and access to mental health services, and strengthen
the response to the needs of diverse communities and Northerners.
● Work with first nations, inuit, and metis to address their mental health needs,
acknowledging their distinct circumstances, rights and cultures
● Mobilize leadership, improve knowledge, and foster collaboration at all levels”
Genetic Diseases
Congenital anomalies
● Structural or functional anomalies (for example, metabolic disorders) that occur during
intrauterine life
● Can develop at conception (e.g. down syndrome, achondroplasia), embryonic period (0
to 7 gestation)(e.g.spina bifida), or early fetal period (8 to 16 gestation)
● Significant source of disability, health system costs)
● Between 1998 and 2009, the national congenital anomalies prevalence rate decreased
from 451 to 385 per 10,000 total births
● Approximately 1 in 25 canadian babies is diagnosed with 1 or more congenital
anomalies every year
● 2nd leading cause of infant death (23%)
Are chromosomal abnormalities inherited?
● Most chromosomal disorders are not passed from one generation to the next
● Examples: down syndrome, turner syndrome
● Such chromosomal abnormalities caused by
○ Changed in the number of chromosomes
○ Changes in the structure of chromosomes
Environmental Factors
Teratogens:
● Infectious agents (e.g., rubella, syphilis, toxoplasma)
● Physical agents (e.g., ionizing agents, hyperthermia)
● Maternal health factors (e.g. diabetes)
● Environmental chemicals (e.g. mercury, herbicides)
● Drugs (e.g. Prescription, recreational)
● Low birth weight babies face risk of vertebral palsy, mental health disorders
● Birth defects associated with prenatal exposure to alcohol can occur in the first three to
eight weeks of pregnancy
The burden of Chronic diseases
● 3 of 5 people 20+ years hace a chronic disease
● 4 of 5 people 20+ years are at risk for chronic disease
 ● In 2012, 219,500 deaths due to chronic disease; 27% such death premature (i.e. <70
years old)
● Chronic disease in Ontario accounts for 79% deaths
Chronic disease
● Complex causality, with multiple factors leading to their onset
● A long development period, for which there may be no symptoms
● A prolonged course of illness, perhaps leading to other health complications
● Associated functional impairment or disability
Top 4 Chronic disease worldwide
● Cardiovascular disease
● Diabetes
● Cancer
● Chronic respiratory
Cardiovascular disease
● Disease burden
○ Accounts for 22% of deaths in females, 26% in males
○ $21 B in mortality costs, physician/hospital services, lost productivity
○ 80% of canadians, have at least one risk factor for cardiovascular disease
● Physiological mechanisms
○ Atherosclerosis contributes to CVD
○ Plaque narrows arteries, restricts blood flow, forms clots
○ Causes heart attacks and strokes
○ Risk factors: high cholesterol, diabetes, smoking excess alcohol use, etc
Diabetes
● Disease burden
○ Contribute to 41,500 candian deaths each year
○ Prevalence will reach 3.5B by 2018/19
○ $11.78 for treatment in 2010
● Physiological mechanisms
○ Body either cannot produce insulin or properly use the insulin it produces
○ Insulin hormone controls blood sugar by causing cells to absorb sugar as energy
or as fat
○ High blood sugar damages organs, blood vessels, nerves
● Type 1 diabetes
○ Immune system attacks and kills the beta cells of the pancreas that creates
insulin
○ Sugat builds up in the blood instead of being used as energy
○ Generally develops in childhood or adolescence, but can develop in adulthood
○ Treatment includes insulin, meal planning
● Type 2 diabetes
○ Accounts for nearly 90% of diabetes cases
○ Body cannot effectively use insulin or does not create sufficient insulin
○ Generally develops in adulthood, but can affect children
 ○ Treatment can include drugs, insulin, meal planning, physical activity
Challenge: undiagnosed diabetes
● “Canadian study (2015) found that 1.13% of the canadian adult population (20+) had
undiagnosed diabetes based on fasting plasma glucose levels
○ The hemoglobin A1c test demonstrates average level of blood sugar
○ Canadian guidelines diagnosis criteria: hemoglobin A1C level of greater or equal
to 6.5%
Cancer
● Disease burden
○ 2 in 5 canadians will develop cancer in their lifetime (40% of women and 45% of
men)
○ 206, 200 new cases of cancer and 80,000 deaths from cancer in canada in 2017
○ Half of all new cases will be lung, colorectal, breast, and prostate cancer
● Physiological mechanisms
○ Body either cannot produce insulin or properly use the insulin it produces
○ Insulin hormone controls blood sugar by causing cells to absorb sugar as energy
or as fat
○ High blood sugar damages organs
Chronic disease research
● Randomized controlled trials
○ Ethical concerns
● Observational epidemiologic studies
○ on y observe natural phenomena
● Animal model studies
○ Controlled conditions; study effects across lifespan; biological processes differ;
may not be susceptible
● Laboratory culture studies
○ Oversimplified conditions
The pipeline of evidence informing practice

●
Common risk behaviors as causes for chronic diseases
● Unhealthy diets (ie., processed foods, concentrated fats, inadequate fruit and vegetable
consumption)
 ● Physically inactive (increase sedentary behaviors, cost 6.8B)
● Tobacco (responsible for 85% if lung cancer; 7.2 billion direct and indirect costs in
Ontario)
● Alcohol use (high consumption, responsible for 3.3M deaths worldwide)
Social determinants of health as causes for chronic diseases

Obesity prevalence in canada

Populations at greater risk of obesity- ontario
● Females from neighbourhoods with the highest material deprivation (28%), compared to
the lowest (19.9%)
● People born in canada (28.7%), compared to people that immigrated in the past 5 years
(13.2%)
● People who have not completed high school (33.9%), compared to people with post
secondary education or more (25.7%)
● People who identify as Aboriginal (38.2%) compared to people who do not (28.4%)
Causes and RIsk Factors
● But in reality, one is at risk of obesity across the life course, beginning before birth and
extending into adulthood
● Biology
○ Genetics
○ Prenatal environment
● Individual behaviours
○ Physical activity
○ Food consumption
○ Sleep
○ Sedentary behaviour
● physical , social, and policy environment
○ Activity environment
○ Food environment
○ Economic environment
○ Societal influences
Ontario’s Strategy
3 Part Strategy
● Start all kids on the path to health
○ Supports young women and babies health pre- and post conception
● Change the food environment
○ Addresses difficulties in making health food decisions in out current environment
(marketing to kids, point of sale promos, fast food availability)
● Create healthy communities
○ Focuses on the need to develop coordinated programs and broad community
approaches to kids' health (e.g., schools as hubs, advancing poverty reduction
strategies etc.)
● Jan 2012: ontario government set a target of reducing childhood obesity by 20% in 5
years
(Un)intended consequences of how we define obesity: weight bias and stigma
What is weight bias?
● Refers to negative attitudes toward others because of their weight
● Stereotypes leading to:
 ○ Stigma
○ Rejection
○ Prejudice
○ Discrimination
● Verbal, physical, relational, cuber
● Subtle and overt
● Weight bias
○ Negative personal attitudes and views about obesity and people with obesity
● Weight stigma
○ Social stereotypes
○ Damaged identities
○ Deeply rooted in society
● Weight-based discrimination
○ Actions
○ Verbal, physical, relation
○ Subtle and overt actions/expressions
Stereotypes and negative attitudes towards people with obesity
● Lazy
● Awkward
● Sloppy
● Non-compliant
● Unintelligent
● Unsuccessful
● Lacking the self-discipline and self-control necessary to manage their weight
The Public Health War on Obesity
● Heavy focus on individual based approaches and lack of scaled-up socio-environmental
policies and programs
● Modest effects of interventions in reducing and preventing obesity at the population level
● Inappropriate focus on weight rather than health
● Excessive weight preoccupation among the population (changing body size ideals)
Critical analysis of canadian obesity prevention policies
● Childhood obesity is problematized (prevention not treatment)
● Eat less and move more narrative prevails (not evidence based; weight bias driver)
● Obesity framed as a social problem but strategies targeted at individuals (individual
responsibility)
● Healthy body weight narrative labels and moralizes weight and health behaviors (weight
bias)
● Obesity if framed as a risk factor (not a chronic disease)
● People with obesity are not engaged
● Weight bias and obesity stigma are not addressed
Weight bias among health care professionals
● Dietitians and nurses view patients with obesity as:
 ○ Overeaters, lacking self control and willpower, unattractive, insecure, slow, non
compliant, overindulgent, lazy, unsuccessful
● Nurses:
○ Would prefer not to care for patients with obesity, feel repulsed by them, and
would prefer not to touch them
● Psychologist
○ Ascribe more pathology, sever symptoms, negative attributes, and worse
prognosis
Recommendations for public health
● Recognize that weight bias and stigma impact individual and population health outcomes
● Monitor the impact of weight bias and obesity stigma at the population level
● Develop interventions to address weight bias and obesity stigma at the population level
Two policies approaches for addressing chronic development
● Messaging environment
● Taxation
Messaging environment
● Various forms of nutrition and physical activity information and messaging that influence
behaviours
● Intervention examples
○ Nutrition labelling on food packages, menu boards
○ Advertising and marketing- especially to children
■ E.g., packaging, TV, internet
○ Product placement
○ Public service, mass media campaigns (e.g., participACTION)
Menu Labelling
● Implemented jan 1st, 2017
● All food service providers with 20+ locations in ON required to post calories for each
food and beverage
Chile’s Proposed warning labels
● Labels that have stop signs that show what the food is high i.e., high in sat. fat
Fiscal Environment
● Subsidies
○ Subsidies to food procedures -e.g., corn syrup
○ Trade agreements
○ Reorient food and agriculture subsidies to support healthier foods
○ Financial incentives (e.g., children's fitness tax credit)
● Taxation
○ Taxation of unhealthy foods (e.g., sugar sweetened beverages)
○ Sugar taxes around the world
Example from Mexico- Sugar sweetened beverage tax
● Mexico implemented a 1 peso per liter excise tax (about 5.5 US cents) on sugar
sweetened beverages (excluding beverages with artificial sweeteners and 100% juices)
on january 1, 2014
 ● Purchases of taxed beverages decreased 5.5% in 2014 and 9.7% in 2015
● Households at the lowest socioeconomic level had the largest decreases in purchases of
taxed beverages
Should we tax sugar sweetened beverages?
● The average canadian consumes and average of 73.2 litres of soft drinks per year
● New york plans to ban sale of big sizes of sugary drinks
○ Aban sale of large sodas/sugary drinks at restaurants, movie the\eatres, sport
arenas, and street carts
■ Prohibit the sale of cup.bottle of sweetened drink larger than 16 ounces
■ Not applied to diet soda, fruit juices, milk shakes, or alcohol
Population health promotion model

Take Action
● Society
○ Public policy and governmental interventions should be aimed at modifying
policies and creating environment to promote healthy behaviours in individuals
○ Population based tobacco control strategies require few sources to
■ To increase taxes on tobacco products
■ Ban cigarette advertising
■ Restrict spaces to smoke
● Community
○ Collective engagement in ensuring access exercise facilities, team sports,
healthy food, support groups to quit smoking and tackle obesity
● Individual
○ Empowerment of individuals to help manage conditions through lifestyle changes
and adherence to treatment regimens
Lecture 7
The determinants of health and health behaviour
Epidemiology
● Focuses principally on variations between people that are systematic, meaning that
identifiable groups of people experience different levels of health”
● The interacting triad of causal factors

○
○ Agent, environment, host
Clinical course of a disease: pre- and post-disease stages

Risk factors
 ● Suspected causes of disease at the individual level
● Characteristics of the person, their behaviour or environment
● ‘Risk’ or probabilistic language fitting since very few exposures inevitably cause disease
Determinants of health (Dahlgren & whitehead)
● General term describing proximal and distal factors that impact health -micro (genetics,
heredity, biology), meso (family, neighbourhood, community), and macro (national and
international conditions)
Social Determinants of health
● Income and social status
● Social support networks
● Education and literacy
● employment/working conditions
● Social environments
● Physical environments
● Personal health practices and coping skills
● Healthy child development
● Biology and genetic endowment
● Health services
● Gender
● Culture
The Lalonde Report, 1974
Brunner and Marmot’s model

● Intermediary factors:
○ Material factors
■ housing , work conditions
○ Psychosocial factors
■ Stressful living conditions and life events, lack of social supports
○ Behavioural and/or biological factors
■ smoking , eating habits
Upstream vs. Downstream determinants
● “Refer to underlying characteristics of society that ultimately shape the health of
individuals and communities”
● Upstream factors
○ Broader social, economic, and political forces that influence chain of intermediate
processes and lead to specific diseases among individuals, whereas downstream
factors, include micro level determinants
● Non specific factors
○ Poverty reduction policies, education policies, food insecurity, climate change
policies or policies that focus on creating supportive environments
● Post pic
Health inequalities
● “Systematic differences in health status between groups of people, including both those
that arise naturally,, and those whose origins lie in social disadvantage… may result from
biological differences or from personal choices, social conditions..”
Health Inequities
● Systemic
● Avoidable
● Unfair and unjust
Social production of disease
● Do we not always find the diseases of the populace traceable to defects in society? - Dr.
Rudolf Virchow (father of social medicine)
Is COVID-19 a social and economic production?

-
Social conditions and health status
● “The result [of the social situation] is the same as if 20 or 30,000 of these people were
annually taken out of their wretched dwelling and put to death… and we know the
economic, financial, and political forces responsible for this” - Edwin Chadwick
Capitalist production and working class
● Among the british working class, there is an incompatibility between the capitalist
economic system and the health and working conditions of working people
Production of inequalities
 ● “A girl born in Sweden will live 43 years longer than a girl born in Sierra leone”
● “In Glasgow, an unskilled, working class person will have a lifespan 28 years shoert than
a businessman in the top income bracket in scotland - Vincent Navarro
Socio economic status across the lifespan
● As a general rule:
○ The wealthier the population the better their health status, the poorer the
population the worst their health outcomes. Measured using three components
○ Income increases the opportunities for nad education, and occupation increases
one's income, and an education increases one's job opportunities and therefore
income

Socio-economic status and health during a pandemic

● Low ses (higher risk of infections)
○ Live in poorer areas with lack of physical resources
○ Poorer quality of housing
○ More likely to smoke, have poor nutrition and lack of physical activity
○ More likely to work in precarious jobs that increase risk of infection
○ Lack of access to testing, health care, treatment
○ Limited ability to understand public health messages
○ More likely to experience adverse outcomes - death
● High ses (lower risk of infections)
○ Income increases ability to purchase healthy foods and resources
○ Better quality of housing, access to community resources
○ More likely to hold jobs that provide security, protection, etc
○ Access to healthcare, treatment, testing
○ Ability to understand public health messages around prevention
○ Better social support and network systems
○ Less likely to experience adverse outcomes
Social determinants of health: SES and literacy
● Education and literacy: a person's social position in childhood influences their access to
educational opportunities
● Education -> employment -> income
 ● ‘Health literacy’ refers to the patient’s ability to understand health information and to
follow guidelines for their treatment

SDOH: work and employment

● Employment , working conditions, and occupational health
○ Are unemployment rates and job insecurity a coincidence today?
○ Work stress affects many Canadians, especially women
○ Interacts with other determinants, such as income, in that the lowest income
households report high rates of work stress due to job insecurity and
dissatisfaction
○ Workers who perceive work insecurity experience significant adverse effects on
their physical and mental
SDOH: Food insecurity
● The aquality, access, availability and affordability of the food supply all affect what
people eat
● A shortage of food or lack of variety can lead to deficiency and malnutrition
● Excess intake of unhealthy foods can contribute to diet related diseases, such as
diabetes and cardiovascular disease
● Inability access or afford healthy foods lead to buying cheaper processed foods, which
are often made from poorer quality produce and have added fat, salt and/or sugar
SDOH: Early childhood development
● Early childhood development: the life course perspective emphasizes that early
experiences have a profound formative impact on an adult
● Early nutrition, physical development and fitness are important, as is emotional
development which, if positive, builds resilience, and if negative, enhances vulnerability
● Timing of exposures and experiences can be critical
SDOH: Social Capital
● People's willingness to collaborate in groups and engage in collective action, which in
turn reinforces trust and confidence within the networks (i.e., neighbourhood watch
programmes)
● Low social capital is characterized by unwillingness to collaborate with others who are
perceived as different and typically occurs where there are wide disparities in income
and a perception of social inequalities
SDOH: Physical Environments
● Environmental influences on health can be positive or negative, adn cover a wide range
of factors, from global (climate change) to national and regional issues (economic
recessions, strife, air and water pollution) to issues in the local built environment (indoor
air quality) to the social environment
Case Study 1: Health of Indigenous Populations
● Indigenous people in canada refers to aboriginal people, first nations, metis, and/or inuit
(4% of canada's population)
● Colonization
 ○ Defined as the process of establishing a colony or group of settlers in a new land
or territory
● Residential schools
○ Funded by the canadian governments department of indian affairs; first nations
children were stripped off their heritage, beliefs, value systems and society.
Mandatory from 1884 to 1948, last school closed in 1996
● Indian act 1867
○ Discriminatory against status (i.e., woman)
● Bill C-31
○ A status Indian woman “permitted” to marry a non-indigenous man, who can now
also apply to become registered also
● Alterations to environments
○ Mining, forestry, the exploration of oil and natural gas, the polluting of rivers and
lakes with various contaminants including pesticides, herbicides, mercury, lead
and PCBS, and hydroelectric dam construction
● Life expectancy of Indigenous peoples is ~10 years less in comparison to non
indigenous canadians
● Other major health issues
○ Self-inflicted injusties, suicide, injuries, trauma, infectious diseases such as TB,
chronic diseases such as T2 diabetes, CVDm STIs
● Other determinants
○ Unsafe drinking water, inadequate housing quality, lack of access to sustainable
jobs, access to health care, ressources, and other community services
Community types and access to services according to first nations and inuit branch of
health canada

●
Case study 2: Health of immigrant populations
● “Overall, immigrants appear to be healthier than the Canadian-born population, by virtue
of being capable, both physically and mentally, of successfully moving themselves, and
often their families, from one country to another. However, over time, this healthy
immigrant effect is lost”
● Why is this the case?
○ Healthy migrant effect?
● “The health of migrants is a product of environmental, economic, genetic, and
socio-cultural factors related to when people migrated to Canada, where and how they
lived in their original home country, and how and why they migrated”
● Why is this the case?
○ Premigration, migration, and post migration resettlement, as well as social
determinants of health
How can public health behaviour change?
Health behaviours
● Illness behaviour
○ Refers to the actions people take in response to their illness, including whether or
not they seek healthcare and whether or not they follow the doctor’s
recommendations
● Smoking and drinking
● Physical activity
● Diet
● Sleep
● Safe sex
Models of health behaviour change
Trans-theoretical change
 -

Theory of planned behaviour

 -

The health belief model

Limitations of behaviour change models
● assumptions on availability of resources
● Do not account for underlying individual factors (i.e., self esteem)
● Assumes behaviour is a linear decision making process
● Do not account the social, environmental and political contexts
● Time frame?
● Assumes individuals are rational decision makers, activated and informed at each stage
Population level vs. individual level impact
Factors that impact health

Framework 3: toward health equity: a framework for action

WHO- Commission on the SDOH: 5 action areas

 ● Improve living and learning conditions in early childhood
● Strengthen social programs to provide fair employment conditions and access to labour
markets
● Emphasize policies and interventions to protect people in informal employment
● Promote intersectoral policies to improve living conditions in urban slums
● Implement programs to address the major determinants of women’s health
Tobacco control: an example of cross-sector collaboration

Lecture 8
Health Promotion & Disease Prevention
Ethological phase

Health Promotion
 ● “Aims to help people increase control over and improve their health”
● Who?
○ Individual, family, community, sector/system, society
● What?
○ Income, social status, education, healthy child development, work and
environment, social support, personal skills, biology, health services
● How?
○ Community action, public policy, supportive environment, personal skills, health
services
● Evidence based decisions
○ Research, experience, evaluation
○ Values and assumptions:
■ Evidence forms the bases of agreements between program and policy
decision makes, health promoters analyze all possibilities and act within
their jurisdiction, there is a need for overall coordination of activity, society
as whole must take care of all its members, interaction between people
and their physical and social surroundings affects health and health
behaviors, social justice, equity, mutual respect and caring are necessary
for health, health care, health protection and disease prevention
complement health promotion
Key Health Promotion Values
● Equity and social justice
● Holistic definition of health (well-being)
● Enhances health, not just preventing disease
● Encompass full range of determinants of health
● Recognizes role of environments (settings) in shaping human behaviour
● Empowerment
● Meaningful social participation (not just tokenistic)
Models of Health Promotion
● Tannahill 1985
○ Health protection
■ Includes public policies that address fair access to housing, employment,
education, and health care
○ Health promotion
■ “Sustainable fostering of positive health and prevention of ill health
through policies, strategies, and activities in the overlapping action areas
of:
● social ,economic, physical, environmental and cultural factors;
● Equity and diversity
● Education and learning
● Services, amenities, and products
● Community led and community based activity
● Caplan and Holland 1990
○ What is it?
■ More complex and theoretically driven
■ Attempts to unpick what determines health and ill health and therefore
what activities can be used to address health issues
■ One axis refers to a theory of knowledge and how knowledge is
generated in relation to health
■ The other axis refers to how society is constructed and how this impacts
on health
○ An objective perspective
■ One that is not influenced by emotions, opinions, or personal feelings
-based on quantifiable and measurable facts
○ A subjective perspective
■ Open to greater interpretation based on personal feeling, emotion,
aesthetics
○ Radical humanist paradigm
■ Concerned with releasing social constraints that limit human potential
○ Humanism
■ An approach in study, philosophy, or practice that focuses on human
values and concerns
○ Radical structuralist
■ Contemporary society is characterized by fundamental conflicts which
generate radical change through political and economic crises
○ Traditional
■ Embedded in behavioural understandings of disease and illness
● Beattie 1991
○ Examines 2 axis
 ■ Type of approach used top-down (authoritarian) or bottom up (negotiated
or owned by the clients)
■ Size of approach categories 4 types of activities
● Personal counseling: working with dietician on food and physical
individual person plans and goals
● Health persuasion: campaign for eating 5 fruits and vegetables a
day on TV
● Legislative action: laws that subsidize the price of healthy food
stuff
● Community development: communities producing and distributing
food themselves

● Tones and Tilford

○ States interaction between 2 main sets of processes for health improvement:
■ Development and implementation of healthy public policy
■ Health education in which people are empowered to take control of their
life
○ Only when these two approaches work in parallel can the conditions for living and
individuals behavioural aspects of health be addressed
● Naidoo and Wills 2000
 ○ Medical
○ Education
○ Behaviour
○ Empowerment
○ Social change

Lalonde’s Report, 1974

● Identify populations at risk:
○ Causes of mortality and kinds of morbidity
○ Underlying reasons for mortality and morbidity
○ Susceptible segments of mortality
● Impacts
○ Led to a broader public health approach, greater emphasis on health promotion
○ Led to the creation of a new health promotion directorate in 1978 to develop
policies and programs emphasizing individual behaviour change
Epp Report- 1986: Achieving Health for All
● Challenges
○ Reducing inequities, increasing prevention, enhancing coping
● Mechanisms
○ Self care, mutual aids, and healthy environments
● Strategies
○ Public participation, strengthening services, coordinating healthy public policy
The Ottawa Charter for Health Promotion- WHO, 1986
 ● First international conference on health promotion by WHO, CPHA, Health and Welfare
Canada
● Presented as a result of work done at First International Conference on Health
Promotion
● Endorsed by 212 participants representing 38 countries
● Five key action areas in health promotion (focus beyond the individual)
○ Build healthy public policy
○ Create supportive environments for health
○ Strengthen community action for health
○ Develop personal skills
○ Reorient health services
● Three strategies: to enable, mediate, and advocate

Hancocks Recommendations to Revamping Canada’s health promotion strategy

● To put sustainable and equitable human development, rather than the economy, at the
heart of governance and decision-making at all levels
● A commitment to a ‘whole government’ approach in the shape of the structures and
processes recommended by the senate sub-committee
● Meaningful national and provincial anti-poverty strategies
● To change the physical and social structures and governance processes of our
communities to create more environmentally sustainable, socially engaging communities
that always make the healthy choice the easy choice in the settings where we lead our
lives
 ● To strengthen the community and NGO sectors so that citizens can play a meaningful
role in creating the conditions for healthy living
● A serious national health literacy strategy that will enable and support people in making
healthy choices and keeping themselves and their families healthy
● A profound reorientation of our content illness care system to be truly a health system
one that invests heavily in prevention, that supports people in appropriate self care, that
emphasizes quality primary care and that not only sees quality of care and the
prevention of the adverse effects of health care as a priority, but also creates healing
environments for patients and a healthy workplace for staff while being environmentally
responsible
Causes of the causes

●
Approaches that act on the SDOH inequalities
● Political economy
○ Assumptions and ideologies that underlie political and state structures and the
effects that these have on populations
○ Focus on power and wealth distribution
● Macrosocial policies
○ Broad social policies that provide the conditions concomitant with the underlying
ideological structures of governance of the state (universal health care, in liveral
democracies, for example, or provisions for daycare in social democracies)
● Intersectionality
○ Understanding that discrimination and disadvantage operate isn distinct easy
across social categories to produce intersections that are more or less salient in
some places and times
● Life course approach
○ Calls for intervention aimed at reducing health inequalities by considering the
multiple dimensions of lives as they are actually lived
The settings approach
● Reduce inequalities
 ● Equitable distribution of physical and social resources
● Supportive environments

Successes and Failures of Health Promotion

● Successes
○ Tobacco control
○ Municipal leadership in enacting healthy public policy
○ Uptake of healthy promotion in sectors outside public health infrastructure (e.g.,
by hospitals, within the school system, but business/workplaces)
○ Need for environmental supports for behavior change (going beyond health
education to address community barriers to behaviour change)
○ Increased recognition of the need for, and competence in, the design and
delivery of more culturally appropriate programs and services for increasingly
diverse populations
○ Greater integration of health promotion into the healthcare system (what the
Ottawa Charter referred to as “reorienting healthcare”)
○ Training of health promotion practitioners
● Failures
○ A growing gap between rich and poor
○ Too many children (and families and individuals) still live in poverty
○ Dreadful living conditions on many aboriginal reserves (lack of fresh water,
adequate housing, affordable nutritious foods, meaningful paid employment) and
the social consequences and health status consequences
○ Homeless and underhoused (there is no federal housing strategy in Canada, or
meaningful, sustained funding from any level of government for social housing
○ An epidemic of early onset diabetes and childhood obesity, particularly amongst
the less advantaged and aborigional populations (attributable to a combination of
‘fast food’ promotion, lack of affordable fresh food in northern locations,
sedentary lifestyles, inadequate physical activity programs in schools, inequitable
access to public recreation facilities)
○ Erosion of the social safety net (funding for social programs) by successive
provincial and federal governments, in keeping with a ‘neoliberal’ turn in North
American politics
Targeted vs. population approaches
● Targeted (high-risk) approach:
○ Identify individual person or group of people at high risk, offer advice and
treatment
● Universal (population) approach: lower the average level of risk in the population
Two approaches to implementing care
● Individual level
● Population level
Prevention paradox
 ● A large number of people exposed to a small risk may generate many more cases than a
small number exposed to high risk
● A preventive measure that brings large benefits to the community offers little to each
participating individual
Individual based, high risk strategies example
● Counselling
○ Counselling on breastfeeding for pregnant women
● Screening
○ Chlamydial infection in sexually active women under 25
● Vaccination
○ Protect against risk while travelling
Population based, high risk strategies examples
● Regulation
○ Income redistribution policies
● Infrastructure
○ Services within walking distance
● Education
○ Advertising
Advantages of individual and population based approaches
● Individual based, high risk
○ Patients motivated to change behaviour to reduce their risk
○ High risk patients likely to benefit more from intervention than low risk individuals
○ Arguably cost effective as resources are directed to individuals most in need
● Population based, average risk
○ Lessens the possibility of creating prejudice against high risk groups
○ Small reduction in risk factor in a population can improve health for large number
of people
○ Can engage self-sustaining social change
Disadvantages of individual and population based approaches
● Individual based, high risk
○ Difficult to identify high risk individuals
○ Dividing line between average and high risk is often arbitrary
○ Reaches those most at risk but has little impact on the disease burden in society
● Population based, average risk
○ Most individuals derive minimal benefit that is not outweighed by the risk of the
intervention
○ Imposes change on a large number of people who would not have developed the
disease at all
○ Little intrinsic motivation for low risk individuals to change behaviour
Harm Reduction
● Reducing the negative consequences of risk behaviours, rather than trying to eliminate
the behaviours themselves (e.g., smoking only outdoors rather than not smoking)
 ● Ex. insite, supervised drug consumption site accessible to street drug users in toronto,
november 2017
○ Reducing the number of drug overdose and deaths
○ Reducing risk factors leading to infectious diseases such as HIV and hepatitis
○ Increasing the use of detox and drug treatment services
○ Connecting people with other health and social services
○ Reducing the amount of publicly discarded needles
○ Cost effectiveness
○ Not contributing to crime or increased drug use in the local community
Insite
● Since its conception, insite has met the following objectives
○ Increasing referrals to health and social programs
○ Reducing overdose fatalities
○ Reducing the transmission of blood-borne infections like HIV and
Hepatitis C
○ Reducing injection related infections
○ Improving public order
Lecture 9
Program Planning and Evaluation in the context of Public Health
Evidence informed public health (EIPH)
● “The process of distilling and disseminating the best available evidence from research,
practice, and experience and using that evidence to inform and improve public health
policy and practice”
● Evidence use cycle
○ Identify a problem, gap in practice, or demonstrate need for interventions
○ Identify appropriate interventions to address the problems (program, practice or
policy)
○ Determine continuation or modifications of intervention
● Examples of EIPH interventions
○ Case 1
■ Effective interventions to prevent alcohol exposed pregnancies: a rapid
review of the literature
○ Case 2
■ Local public health practices to reduce social inequities in health
○ Case 3
■ Rural healthesteps: exercise Rx
○ Case 4
■ Cancer screening awareness in PEI
○ Case 5
■ Cook it up! Community-based cooking program for at risk youth
Case 2: Local Public Health Practices to Reduce Social Inequities in Health
● About case 2:
 ○ Public health utilizes a population health approach to improve the health of the
entire population and to reduce health inequities among population groups.
Health inequities (a.k.a. Social inequities in health) are differences in health
status that are systematic, socially produced, and unfair and unjust. There are
many actions that should be taken at the national and provincial levels to address
inequities. Actions to be taken at the local level are less clear and evidence was
not readily available
● Approach
○ The team at the Sudbury & District Health Unit wanted to contribute to the
knowledge base for local public health action on social inequities by identifying
practices that would be relevant for front line public health practice settings. They
have identified 10 promising practices, because they are found to be “promising”
in their potential to “level-up” and reduce health inequities
Programming planning evaluation in public health
● Program planning
○ “An organized and structured systemic decision making process which attempts
to meet specific primary healthcare aims or objectives through the application of
currently available, and competing or needed resources in the future based on
identified priorities or projected needs.”
● Program planning can be:
○ Situational (e.g., aging population & increased incidence of NCDs)
○ Reactive in nature (e.g., SARS, Zika Virus, Ebola outbreak, Avian flu, Scarlet
fever
● Strategic planning pandemic preparedness
○ Canadian Pandemic Influenza Plan: to minimize serious illness, overall deaths
and social disruption
The 6 steps for planning a health promotion program by Public health ontario
● Step 1
○ Manage the planning process
■ Develop a plan to manage stakeholder participation, timelines, resources,
and determine methods for data-gathering, interpretation, and decision
making
● Step 2
○ Conduct a situation assessment
■ Learn more about the population of interest, trends, and issues that may
affect implementation, including the wants, needs, and assets of the
community
● Step 3
○ Identify goals, population of interest, outcomes, and outcome objectives
■ Use situational assessment results to determine goals, populations of
interest, outcomes and outcome objectives
● Step 4
○ Identify strategies, activities, outputs, process objectives, and resources
 ■ Use the results of the situational assessment ot select strategies and
activities, feasible with available resources, that will contribute to your
goals and outcome objectives
● Step 5
○ Develop indicators
■ Develop a list of variables that can be tracked to assess the extent to
which outcome and process objectives have been met
● Step 6
○ Review the program plan
■ Clarify the contribution of each component of the plan to its objectives,
identify gaps, ensure adequate resources, and ensure consistency with
the situational assessment findings
Evaluation
● “Process ultimately intended to determine the worth of something new, presumably in
comparison with some current norm or standard of “goodness”
● Example 1
○ School-based health promotion program: to encourage youth aged 12 to 17 to
become more physically active in nature to help prevent the development of NCD
as adults, based on Canadian Society for Exercise Physiology (2012)
recommendations
■ 94.4% of youth not meeting physical activity guidelines
● Example 2
○ Wait times for surgical procedures in Ontario (how long are people waiting? What
are the unintended consequences of being placed on a waitlist? Impact on
worsened health outcomes?)
Program Evaluation
● “A formalized ongoing and dynamic process to monitor, assess, and refine public health
program activities and interventions and to identify gaps or actual or potential flaws in the
original program design and implementation”
Types of Program Evaluation
● Formative
○ Focus on public health programs that are being planned and developed to ensure
that the stakeholders needs are being addressed
■ E.g., nuclear accident in Durham Ontario
● Process
○ Focus on programs that have gone through the formal planning stages and have
been implemented or are already underway
■ E.g. what health services are being delivered and to whom?
● Summative
○ Are carried out for programs that are well underway or have been completed and
can be used to assess short-, med or long-term aims, goals, or desired outcomes
of the program, both intended and unintended
■ E.g. Telehealth Ontario
Key Concepts
● Outcome measure
○ Evaluates what specifically occurred as the result of the health programme being
implemented in reference to its noted aims or goals
● Impact measure
○ Evaluates the effect of the implemented health program on the users,
stakeholders, and implementers and specifically measures what changes (+,- or
neutral) occurred as a result of the program
● Health indicators
○ Public safety, behavioural changes, health quality measures, health-related
policies, participation in community-based physical activities, individual healths
status, population health status, use of resources and the like
8 steps in the programme planning, implementation and evaluation process
● Step 1: Conduct needs assessment
○ Helps to formulate a clear understanding by all stakeholders and implementers
as to what the actual or potential needs, problems or health related issues are
that need to be addressed to positively influence health and well being in a
defined community or region
○ Common question to ask
■ What is the problem/health issue?
■ What is the burden of the issue?
■ What services/resources are available at the moment?
■ What are the gaps in current services/resources?
■ What is missing? Knowledge? Resources? Networks?
○ Identify your stakeholders
■ “Individuals or groups (both internal and external) who have an interest in
the program or those who may be affected by the program either directly
or indirectly; including community volunteers, potential program
participants, policymakers, governmental agencies, non-governmental
agencies, or (private) industry”
● Step 2: articulate program aims and goals
○ Program aims or goals should be clearly measurable in nature and those that are
not specific should be clarified before preceding
○ Things to consider:
■ What impact is being planned for achievement? (i.e., achiever improved
overall health and wellbeing)
■ What are the goals of the program/intervention? (i.e., decrease the
incidence of type 2 diabetes)
■ Who will be impacted by the outcome? (i.e, reduce the burden of type 2
diabetes among high risk populations)
■ Is the impact or outcome short or long term? (i.e., achieve lower incidence
of type 2 diabetes within 1 year, 5 years, 10 years)
 ■ Who will implement the program? (i.e., local public health unit, community
health center, provincial government, hospital, NGO)
● Step 3: develop a draft program plan
○ Based on a critical review of the best available evidence and the current state of
knowledge related to the actual or potential problem(s) or issue(s) identified
○ Questions to consider:
■ What is the current state of knowledge related to cosmetic pesticides and
the development of skin rashes, neurological disorders and cancer in our
community?
■ What are the current effects of water fluoridation on prevention of dental
decay in our community?
■ What are the current trends in impaired driving and related injuries and
death posts?
■ Legalization of marijuana in ontario?
● Step 4: seek feedback and suggestions
○ Communities and groups work from their own values, experiences, and
definitions of situations, and public health care professionals and workers need to
be supportive of these
○ Effective communication emphasizes the need to find a common language and
ground which recognizes the interdependence between stakeholders and public
health care professionals and workers
● Step 5: refine action plan, model, or design based on feedback
○ This information may be utilized to help clarify program aims or goals, target
populations or users, resources available or needs, definitions of actual or
potential health related issues or concerns, action plans, and timelines, and/or
evaluation tools or methods
● Step 6: implementation
○ Once the program is implemented, it is critical to carefully monitor and assess the
program on an ongoing basis for unforeseen events or circumstances that may
negatively impact on the overall success of the program
● Step 7: evaluation
○ This step involves the formal evaluation of the program aims or goals
○ Evaluation is based on the documented outcomes achieved and an analysis of
the qualitative and/or quantitative data collected
● Step 8: dissemination and communication of findings
○ Recognized as a “vehicle for providing feedback related to the program findings
and outcomes achieved to all stakeholders and implementers in reference to the
program aims or goals”
○ Knowledge translation = synthesis, exchange, application, dissemination
 ○

Example: Vibrant Communities Saint John

● A national initiative in which a learning agenda is central to the program
● A community that uses evaluation processes to stimulate collaboration on local
strategies
● An intermediary organization that supports a network of community partners in gathering
and sharing data to enhance learning and improvement
What are logic models?
● Represents the theory of how an intervention produces its outcomes. It represents, in a
simplified way, a hypothesis or ‘theory change’ about how an intervention works
Key components of a logic model

●
● Process:
○ Inputs: “resources that go into a program or intervention- what we invest. They
include financial, personnel, and in-kind resources from any source”
○ Activities: “events undertaken by the program or partners to produce desired
outcomes - what we do. You could include a clear identification of “early”
activities and “later” activities”
○ Outputs: “direct, tangible results of activities- what we get. These early work
products often serve as documentation of progress”
○ Outcomes: “the desired results of the program- what we achieve. Describing
outcomes as short, intermediate, or long term depends on the objective, the
length of the program, and expectations of the program or intervention”
 ● Outcome:
○ Short term outcomes: immediate effects of the program or intervention activities,
they often focus on the knowledge and attitudes of the intended audience
○ Intermediate outcomes: behavior, normative, and policy changes
○ Long-term outcomes: the desired results of the program and can take years to
accomplish
○ Impacts: the ultimate impacts of the program. They could be achieved in a year
or take 10 or more years to achieve. May not be reflected in the model,
depending on length and scope of the program
Community engaged practice interventions (CEPI) for type 2 diabetes
● Interdisciplinary and evidence based community interventions put into practice
● Scientific professionals, practitioners and community change agents (engaged
stakeholders) have shared circumstances and work together as equal partners in the
development of an action oriented agenda
● Clinical care outcomes and chronic disease management align with community based
public health practice
● Evidence based implementation and diffusion of actionable innovation v, results-based
outcomes are relevant, sustainable and replicable
Lecture 10
Global Public Health
Global health and public health share common features:
● Population based and prevention focused
● Marginalized populations
● Multidisciplinary approaches
● Consider health as a public good and values health infrastructure
● Comprise of several stakeholders
Unique features of global health:
● International health
● Global health
● Global public health
Defining global health, international health, and public health
 -
Geographical reach
● Global health
○ Focuses on health issues affected by transnational determinants
○ E.g. climate change, large-scale outbreaks, polio eradication
○ ‘Global’ refers to scope of issue, not simply location
● Public health
○ Focuses on health issues that affect the health of the population of a particular
community or country
Level of Cooperation
● Global health
○ Development and implementation of solutions requires global cooperation
○ High-resource settings do not have monopoly on good ideas, cross-cultural
disease prevention, efficient food production
○ Emphasizes mutuality, pooling knowledge, exchange between high and low
resource settings
● Public health
○ Development and implementation of solutions does not usually require global
cooperation
● International health cooperation projects
○ 36% support to the healths systems
○ 44% maternal and child health
○ 12% non communicable diseases
○ 8% infectious diseases
Individuals or populations
● Global health
○ Embraces both prevention in populations and clinical care of individuals
● Public health
○ Mainly focused on prevention programs for populations
Access to Health
 ● Global health
○ Health equity among nations and for all people is a major objective
● Public health
○ Health equity within a nation or community is a major objective
Range of disciplines
● Global health
○ Highly interdisciplinary and multidisciplinary within and beyond health sciences
■ E.g. law, economics, history, engineering, biomedical and environmental
sciences, and public policy
● Public health
○ Encourages multidisciplinary approaches, particularly within health sciences and
with social sciences
Global Health 2035: WDR 1993 @20 years
● the world bank's world development report 1993
○ Evidence based health expenditures are an investment not only in health, but in
economic prosperity
○ Additional resources should be spent on cost-effective interventions to address
high-burden diseases
● The lancet commision on investing in health
○ Reexamines the case for investing in health
○ Proposes a health investment framework for low and middle income countries
○ Provides a roadmap to achieving gains in global health through a ‘grand
convergence’
1993- 2013: Extraordinary health & economic progress
 -
2015-2035: Three domains of health challenges
● Unfinished agenda
○ High rates of avertable infectious, child, and maternal deaths
● Emerging agenda
○ Demographic change and shift in GBD towards NCDs and injuries
● Cost agenda
○ Impoverishing medical expenses, unproductive cost increases
Global Health 2035: 4 Key Messages
● A grand convergence in health is achievable within our lifetime
● Fiscal policies are a powerful, underused lever for curbing noncommunicable diseases
and injuries
● The returns from investing in health are extremely impressive
● Progressive pathways to universal health coverage are an efficient way to achieve health
and financial protection
Population dynamics model
 ● S-shaped pattern:
○ Temporary exponential growth rate is followed by plateau
● J-shaped
○ Population growth rate (no. of organisms per generation) increases as the
population gets larger
Determinants of carrying capacity
● Availability of freshwater
● Amount of arable land
● Availability of fuel, resources
● Amount of technological and biological waste
● 1700s, death rates declined remarkably due to :
○ New technologies in agriculture, treatment, and health
○ Greater survival beyond adolescence
○ Increase in population average life expectancy
○ Adoption of health lifestyles
○ Health promotion and public health efforts
Demographic Transition Model
● Helps to explain and make sense of population demographics within a country
● Each stage characterized by relationship between birth and death rates
● Relationship changes as country acquires resources
● Country’s total population growth rate cycles through stages
 ● Stage 1:
○ Most of the world before the Industrial Revolution; N is stable
● Stage 2
○ Least developed countries modern medicine decrease DR in children; high BR
● Stage 3
○ Developing countries; BR gradually decreases due to improved economics,
women's health, access to contraception; N growth constant
● Stage 4
○ Most developed countries; high SES, working women, 2 child per woman; N
growth slows down
● Stage 5
○ Countries where fertility rate below 2 child per woman; elderly population greater
than reproducing population; N declines
Crowding and Urbanization
● 1950-2019: people living in cities increased from 33% to over 80%
● Conditions threaten to reverse public healths progress
○ Increasing volumes of uncollected waste
○ Concentrated automobile exhaust pollutes air
○ Disruption of traditional lifestyles
● Example: cholera in Dar ES Salaam, Tanzania
○ Example of major informal settlement expansion
○ Along coastline and roads
○ N= 76,000 in 1950 to 3.31 million in 2008
○ 65% live informal areas
○ Study demonstrated cholera incidence associated with
■ Informal housing
■ Population density
■ Income level
Climate Change
● Population growth changing composition of Earth
● Combustion of wood, coal, oil, and gas
● Increased concentration of atmospheric carbon dioxide
● Causing global warming and greenhouse effect
● Impact on public health
● Extreme temperatures, weather events, wildfires
● Degraded outdoor air quality
● Water and food shortage
● Increased insect related infections
Emergency preparedness and response to outbreaks and disasters
● Example: spread of vector-borne diseases
○ Weather patterns can alter:
■ Vectors population size and density
■ Vectors survival rates
 ■ Relative abundance of disease carrying animals
■ Pathogen reproduction rates
○ Vector borne disease transmission depend on
■ Pathogens adapt and change
■ Availability of vectors, zoonotic hosts
■ Changing ecosystems and land use
■ Human demographics, behaviour, and adaptive capacity
COVID-19 Seroprevalence in Ontario
● Public Health Ontario (PHO) has initiated a COVID-19 Serosurveillance program
● To estimate the proportion of the Ontario population that has been infected by and
developed antibodies against SARS-CoV-2
● Serology testing: a lab test that measures antibodies specific to COVID-19 (f someone
has been previously infected not current infections)
● Findings: from June 5 tp 30, the study found 1.1% of the samples were positive for
COVID-19 antibodies- meaning: 160,000 of 15 million Ontarians could have been
infected in June alone
● Toronto: known- 15,000 cases, but actual rates could be 4X higher
● Therefore “we must all continue our public health measures to prevent the ongoing
spread of COVID-19, and we must keep our vulnerable populations protected”
Natural Events and Disasters
● May be predictable (e.g., hurricanes, forest fires, blizzards) or unpredictable (e.g.,
earthquake)
● Usually occur in predictable geographic regions
● Communities can develop and implement disaster plans such as floods, earthquakes,
fires and highly dangerous infectious diseases
● May include industrial explosions, building and bridge collapses, terrorist events
● Not predictable but potential can be sometimes be identified
● Impact can be minimized through government regulation and community planning
Impact and the role of public health
● Disasters yield health consequences for immediate victims, emergency response
personnel, volunteers, general public
● Public health’s role
● Planning preparedness in advance of the emergency
● Coordinating activities of the responders
● Being knowledgeable about community resources

Case Study: Haiti Earthquake 2010

● Earthquake in 2010, magnitude of 7.0
● Lack of building codes, inadequate infrastructure
● Poverty
● Lack of preparedness
● Lack of sufficient resources and health care services
Emergency Preparedness Tasks
● Improve epidemiologic capacity to detect and respond to threats
● Ensure local public health agencies have necessary diagnostic and treatment supplies
(e.g., vaccines, drugs)
● Establish communication programs to make sure information is accurately relayed
● Prepare educational materials for incoming the public
● Encourage research on vaccines, diagnostic, tests, and drugs
Canada's center for emergency preparedness and response
● Creates and maintains national emergency response plans for PHAC and Health
Canada
● Monitors local outbreaks and global disease events
● Assesses risk to public health during emergencies
● Collaborates with federal and international health and security agencies
● Develops and implements federal rules around security and quarantine
● Responds to bioterrorism and other emergencies
● Scenario:
○ Flooding in rural area destroys 50 homes and 10 businesses (Port Bruce,
Ontario, 2008)
● Response:
○ Sends 2 emergency field hospitals, cots and bedding for emergency shelters,
and medical supplies
● Scenario
○ Suspicious package with powder arrives at an office, 2019
● Response
○ Check for other substances; test for microorganisms quarantine exposed and
notify local health authorities
● Scenario
○ 2003 SARS outbreak
● Response
○ Protectively clear data-sharing protocols across levels of government to avoid
delays in process of establishing the risk or presence of an outbreak
○ Development of response capacity in hospitals
○ More timely access to laboratory results and vaccinations
○ Better communication between public health and health care
● Scenario
○ Influenza A/H1N1 appeared in 2009; 17,000 deaths in 74 countries worldwide
● Response
○ PHAC helped identify and monitor H1N1 virus
○ Financial framework was already established
○ Antivirals were stockpiled, and vaccines tested quickly
○ Chief Public Health Officer was visible throughout pandemic
What is working against global health?
● The price of inequality
Lecture 11
The future of public health
Top ten public health achievements of the 20th century
● Routine use of vaccination
● Improvements in motor vehicle safety (i.e., seatbelt, speeding and impaired driving
policies)
● Safer workplaces
● Control of infectious diseases (i.e., prevention and management)
● Decline in deaths from health disease and stroke
● Safer and healthier foods
● Healthier mothers and babies
● Access to family planning and contraceptive services
● Fluoridation of drinking water
● Recognition of tobacco use as a health hazard (and perhaps e-cigarettes one day)
The future of public health - USA concerns
Major public health threats - 2005 and beyond
● Potential threat of biological, chemical, and radiological terrorism
● Natural disaster response- assisting the injured and containing disease as a result of
natural disasters, such as hurricanes, tornadoes, floods, fires, chemical spills, and
accidents
● Infectious diseases- west nile virus and norovirus outbreaks, mad cow disease,
foodborne pathogens, asian flu pandemic, flu vaccine shortage, decreased rate of
immunizations (20% of preschoolers do not receive all recommended vaccinations)
● Growing prevalence of cancer, heart disease, diabetes, asthma, and the chronic
diseases across all age groups
● Sixty percent of americans are now considered overweight or obese
● Twenty percent of Americans experience mental illness in a given year. More than 9
percent has a substance abuse problem
● Environmental threats
● Increasing public violence
The future of public health - global concerns
● Aging population
● Chronic conditions, across the lifecourse
● Urbanization & populations growth
● Climate change and natural disasters
● Migration and conflict (extreme poverty
● Emerging and reemerging infectious diseases
Aging Populations
● Our population has increased exponentially but looking at aging populations by 2050 2.1
billion is going to double
● Living long with chronic illnesses and disability, this challenges public and health care
systems that we are well equipped and prepared
 ○ And there needs to be government funding available to protect the aging
population
● Issues for the aging population
○ Average age of adults is increasing globally
○ Older adults are living longer with chronic conditions
○ According to life course perspective, early childhood development and healths
status across one's life impacts quality of life and lifestyle in older age
○ Challenge for public health
■ Improve health of older people by prevention of disease and disability
■ Funding for primary prevention strategies
Chronic Conditions are driven by:
● Smoking, drinking, substance abuse
○ Linked with cardiovascular diseases, cancer, lung disease, osteoporosis, mental
illness
● Stress, strongly linked with poverty and disparities
● Inequalities and inequities in SES, all other SDOHs
● Level of diet and physical activity
○ Obesity causes cardiovascular disease, cancer, diabetes, arthritis
Urbanization & Population growth
● What does an increase in the size of our population mean for public health?
● Our future is urban!
○ From only 751 million in 1950, the population of the world cities has rocketed to
4.2 billion
● Urbanization around the world
○ The americas are the most urbanized regions in the world today
● Will growth cost the earth?
○ The economic rebound could impact climate change
○ The acceleration in economic growth creates an increasing necessity to consider
its links to the environment, as global CO2 emissions start to rise again
● How concerned are Canadians about climate change?
○ Less concerned than they are about unemployment, poverty, health care and
many other issues
○ Percentage of times each issue appeared in the top three worries for
respondents
○ Health care- 40%
○ Unemployment jobs - 39%
○ Taxes - 32%
○ Poverty and social inequality - 26%
○ Corruption - 25%
○ Immigration control 23%
○ Education 16%
○ Crime and violence 14%
○ Climate change 13%
Climate Change and natural disasters
● Medical and physical health
○ Changes in fitness and activity level
○ Health related illness
○ Allergies
○ Increased exposure to waterborne and vector borne illness
● Mental health
○ Stress, anxiety, depression, gried, sense of loss
○ Strains on social relationships
○ Substance abuse
○ Post traumatic stress disorder
● Community health
○ Increased interpersonal aggression
○ Increased violence and crime
○ Increased social instability
○ Decreased community cohesion
Migration and Conflict
● Deaths of migrants along migratory routes across the glob
● Around the world, over 46,000* migrants have lost their lives along migratory routes
across the globe since 2000. In 2014 and 2015 alone the global count was over 10,4000
and many more are unaccounted for
● This year, in the first 4 months of 2016, already 1638 migrants have died in shipwrecks
in the Mediterrean, at the horn of africa, in south east asia, in central america, or the
sahel and other places
● Around the world, 5400 migrants lost their lives in 2015.
● Many more are unaccounted for. Right now europe is in the world's most dangerous
destination for “irregular” migrants, with the mediterranean costing the lives of 2700 in
2015 almost 70% of the total figure
● Think prompt: what do migration patterns mean for public health?
● Over time, the # of refugees and displaced populations have increased globally, placing
greater responsibility on societies to provide access to health and social services,
employment, security, safety, and other population needs
Emerging & reemerging infectious diseases
● Diagnostics
● Microbial pathogenesis
● Advances in molecular biology
● Drug development
● Immunology
● New approaches to vaccines
Directions for Public health policy - Bloom (1999)
● Develop epidemiological approaches that can identify the many additional risk factors of
smaller effect
● More epidemiological surveillance is needed not only to trace emerging infections but,
more generally, systematically to ascertain the burden of disease (years of healthy life
lost due to disease, disability)
● A growing role is in understanding the burdens and costs of interventions and improving
the quality and efficiency of the health service
● Develop a public health approach that will protect populations and establish prevention
strategies for groups, not just for individuals