HST209 - 26 09 22

HST209H1F
Introduction to Health:
Determinants of Health and
Health Care
Fall 2022
Health Studies Program
University College
University of Toronto
Instructor: Anthony Lombardo, PhD 1

September 26, 2022
● Recap
○ Public health; health promotion; & population health
○ Tutorial article analyses
● Writing & Academic Integrity Workshop
● Paradigms of Health
○ Epidemiology
● Tutorial Activity
2
Recap 3
Recap
4
Recap
● Public health; health promotion; & population health

● Tutorial article analyses
5
Research &
Writing Tips 6
7
Researching/Finding Articles
● Check library help section

○ http://onesearch.library.utoronto.ca/research?source=research
● Use e-resources at UT Library

○ “Article databases and indexes”
■ Scopus:
● https://onesearch.library.utoronto.ca/popular-databases
8
Peer-Reviewed Articles
● aka “refereed” journals
● Check “Ulrich’s Web” from UT library:
○ http://guides.library.utoronto.ca/peer-review
9
Writing Resources
● Writing Centre at University of Toronto
● Writing Centre Appointments

○ http://www.writing.utoronto.ca/writing-centres
● PDF Advice Sheets

○ http://advice.writing.utoronto.ca/student-pdfs/
10
Writing Resources
● Writing Centre at University of Toronto: PDF Advice Sheets:
○ Organizing an essay
○ Introductions and conclusions
○ Using thesis statements
○ Developing coherent paragraphs
○ Revising and editing
○ General advice on academic essays
○ Hit parade of common errors
11
Writing Tips
● Develop and use an outline
● Make your ideas/arguments explicit

○ “SEE” your argument
● Revise and edit first drafts
● Follow instructions
12
Writing Tips
S tatement
E xample
E xplanation
13
APA Format
● https://owl.purdue.edu/owl/research_and_citation/apa_style/apa_style_intro
duction.html
14
Assignment #1 Tips
● Cite every fact you use, even if it comes from course materials.
● Follow assignment requirements.
● Follow formatting instructions in syllabus.
● Do not start papers with broad, sweeping generalizations (such as "in today's
society," "throughout all of history" etc).
● Write in clear, simple language. Ask yourself, "what am I trying to say here?"
This should be easily apparent for the reader.
● Do not use a thesaurus to make your paper sound more intellectual - use
appropriate words.
● Do not be afraid of paragraph breaks, they are your friend.
Academic
Integrity Tutorial
15
Is this plagiarism?
● Original text from Smith (2009), page 99:
○ Lorem ipsum dolor sit amet, ex alii inani reformidans nec, no vero ancillae offendit
mei. Health promotion is centrally concerned with understanding how people’s
environments influence their health behaviour. Sea agam malis malorum ut.
Propriae partiendo usu ne, altera cetero animal et sed. Impedit officiis electram
no vim, cum eu tation putent. Enim imperdiet neglegentur eos cu.
● Your paper:
○ Lorem ipsum dolor sit amet, per ex scaevola temporibus. Nullam accusamus ea
sit. Eu mel rebum explicari, no vis utinam possit. Eam vitae albucius ut, bonorum
corrumpit usu ut. Health promotion is centrally concerned with understanding how
people’s environments influence their health behaviour. Alia quot contentiones per
et, sint deterruisset at has, sonet omnium mentitum et mel. Stet summo meliore
at vim, nec ad virtute utroque nonumes. At quo inermis deterruisset, duo iisque
vituperata an.
● YES! This is plagiarism.

○ You have not provided a citation for the text and you have copied text
word-for-word from the original source.
16
Is this plagiarism?
● Your paper:
people’s environments influence their health behaviour (Smith, 2009). Alia quot
contentiones per et, sint deterruisset at has, sonet omnium mentitum et mel. Stet
summo meliore at vim, nec ad virtute utroque nonumes. At quo inermis
deterruisset, duo iisque vituperata an.

○ Although you have provided a reference, you have still copied text word-for-word
from the original source.
17
Is this plagiarism?
● Your paper:
people’s environments influence their health behaviour (Smith, 2009, p. 99). Alia quot

○ Although you have provided a reference and a page number, you have still copied
text word-for-word from the original source.
18
Is this plagiarism?
● Your paper:
corrumpit usu ut. Health promotion is really concerned with understanding how
people’s environments influence their health (Smith, 2009). Alia quot contentiones
per et, sint deterruisset at has, sonet omnium mentitum et mel. Stet summo
meliore at vim, nec ad virtute utroque nonumes. At quo inermis deterruisset, duo
iisque vituperata an.

○ Although you have provided a reference and changed a few words from the
original source, the wording is still very similar to the original.
19
Is this plagiarism?
● Your paper:
corrumpit usu ut. “Health promotion is centrally concerned with understanding how
people’s environments influence their health behaviour” (Smith, 2009, p. 99). Alia quot
● No – this is not plagiarism.

○ You have used a direct quotation and provided a correct citation, including the
author, year and page number. However, direct quotations should be used
sparingly and only when absolutely necessary.
20
Is this plagiarism?
○ Lorem ipsum dolor sit amet, ex alii inani reformidans nec, no vero ancillae offendit mei. Health
promotion is centrally concerned with understanding how people’s environments influence their
health behaviour. Sea agam malis malorum ut. Propriae partiendo usu ne, altera cetero animal
et sed. Impedit officiis electram no vim, cum eu tation putent. Enim imperdiet neglegentur eos
cu.
● Your paper:
○ Lorem ipsum dolor sit amet, per ex scaevola temporibus. Nullam accusamus ea sit. Eu mel
rebum explicari, no vis utinam possit. Eam vitae albucius ut, bonorum corrumpit usu ut. As
numerous authors have explained, health promotion focuses on people’s environments and how
those environments may shape individuals’ health choices and behaviours (Doe, 2011; Jones, 2007;
Smith, 2009). Alia quot contentiones per et, sint deterruisset at has, sonet omnium mentitum
et mel. Stet summo meliore at vim, nec ad virtute utroque nonumes.
● No – this is not plagiarism.
○ You have paraphrased the author’s original wording and you have provided a reference. Even
better, you have synthesized findings from different sources. Paraphrasing from original
sources is the preferred method of citation/writing, because it demonstrates that you
understand what the author is saying.
21
Paradigms of
Health 22
Epidemiology
23
What is Epidemiology?
● Epidemic
24
● Epidemiology
● Focus on…
○ Health
○ Determinants
○ Improving health
Stephen Bezruchka, “Epidemiological approaches to population health,” in Toba Bryant, Dennis Raphael and Marcia Rioux, Eds., Staying Alive: Critical Perspectives
on Health, Illness, and Health Care, 2nd edition, Toronto, Canadian Scholars’ Press, 2010, pp. 13-39. 25
● Study of…
○ Distribution of health-related states/events
○ Determinants of health-related states/events
○ Application to prevention of health problems
○ Application to control of health problems
● Focus on certain group
○ Specific population/area
○ Specific time
R. Bonita et al., Basic epidemiology, Geneva: World Health Organization, 2006. Chapter 1: What is epidemiology?
26
27
Term Explanation
Study Surveillance, observation, testing hypotheses,

analytic/experimental
Distribution Times, persons, places, classes of people affected
Health-related states/events Diseases, causes of death, health behaviours,

responses to prevention, provision/use of health
services
Specified populations Identifiable characteristics
Prevention & control Promoting, protecting and restoring health (ie,

public health)
Adapted from R. Bonita et al., Basic epidemiology, Geneva: World Health Organization, 2006, p. 4, Box 1.2.
The Epidemiological Triangle
Host
Vector
Agent Environment
28
The Epidemiological Triangle
www.menti.com | 1191 8140
29
Early Epidemiology
● 19th C England – cholera

● September 1854 – 600 deaths in one week in those close to Broad Street Pump
● John Snow vs. William Farr
○ Farr – miasmatic theory of disease
■ Low clouds contained disease; those at higher altitudes were safer
● Snow visited houses to ask about how many deaths and water sources
○ Southwark & Vauxhall Co – 315 deaths/10,000 houses
○ Lambeth Co – 38 deaths/10,000 houses
Leon Gordis, Epidemiology (2nd ed.), New York: Saunders, 2000. Chapter 1: Introduction.
30
Early Epidemiology
31
Early Epidemiology
● What did he do to solve the problem?

○ Remove the pump
32
Uses of Epidemiology
● Disease causation
○ How is disease transmitted?
○ What are the risk factors?
● Natural history of disease
○ Understand disease baseline to measure changes
● Population health status
○ Identifying the burden of disease
R. Bonita et al., Basic epidemiology, Geneva: World Health Organization, 2006. Chapter 1: What is epidemiology?; Leon Gordis, Epidemiology (2nd
ed.), New York: Saunders, 2000. Chapter 1: Introduction. 33
Uses of Epidemiology
● Intervention evaluation
○ Effectiveness of health services
○ Efficiency of health services
● Policy implications
○ Using epidemiological data to shape public policy
R. Bonita et al., Basic epidemiology, Geneva: World Health Organization, 2006. Chapter 1: What is epidemiology?; Leon Gordis, Epidemiology (2nd
ed.), New York: Saunders, 2000. Chapter 1: Introduction. 34
Epidemiology & Clinical Practice
● Diagnosis
○ Population-based data for understanding what disease “looks like”
● Prognosis
○ Decided on basis of how disease has progressed in population-level data
● Therapy
○ Decisions based on effectiveness of treatment data (e.g., RCTs)
35
Epidemiology at its best…
The Japanese eat very little fat and suffer fewer heart attacks
than the British or Americans.
On the other hand, the French eat a lot of fat and also suffer
fewer heart attacks than the British or Americans.
The Japanese drink very little red wine and suffer fewer heart
attacks than the British or Americans.
The Italians drink excessive amounts of red wine and also

suffer fewer heart attacks than the British or Americans.
Eat and drink whatever you like.

It's speaking English that kills you.
36
37
Evolution of Epidemiology
Era Paradigm Analytic Preventive
Approach Approach
Sanitary Statistics Miasma: Clustering of Drainage, sewage,
(first half of 19th C) poisoning by foul morbidity and sanitation
emanations from mortality
soil, air, water
Infectious Disease Germ theory: Laboratory Interrupt
Epidemiology Single agents isolation; transmission
(late 19th C relate one-to-one experimental (vaccines,
through first half to specific diseases transmission quarantine,
of 20th C) antibiotics)
Chronic Disease Black box: Risk ratio of Control risk
Epidemiology Exposure related exposure to factors – lifestyle,
to outcome – outcome agent,
intervening environment
factors?
Adapted from Mervyn Susser and Ezra Susser, “Choosing a Future for Epidemiology: I. Eras and Paradigms,” American Journal of Public Health, vol. 86,
no. 5 (1996): 668-673.
Epidemiological Achievements:
Smallpox
● Epidemiology crucial in eradication
○ WHO declared eradicated in 1980
○ Renewed interest due to biological warfare/terrorism
● Epidemiological inquiry found…
○ No non-human hosts
○ Recovered patients become immune, cannot spread
infection
○ Transmission typically through sustained face-to-face
contact
■ 2 metres
○ Transmission not usually until later, when patients are
bed-ridden
■ Helps limit transmission
R. Bonita et al., Basic epidemiology, Geneva: World Health Organization, 2006. Chapter 1: What is epidemiology?; Zack S. Moore et al., “Smallpox,”
Lancet, vol. 367 (2006):430. 38
Epidemiological Achievements:
“Minamata” Disease
● Methyl mercury poisoning
● 1950s – release of methyl mercury into small bay in
Minamata, Japan
○ Accumulation of mercury in fish → severe poisoning
● Epidemiology played role in identification and control
○ First thought to be infectious meningitis
○ 121 patients resided close to Minamata Bay
○ Survey showed affected were members of families where
fishing was main occupation and diet was fish
■ Visitors did not get as sick
R. Bonita et al., Basic epidemiology, Geneva: World Health Organization, 2006. Chapter 1: What is epidemiology?
39
New Advances in Epidemiology
Wastewater Epidemiology
● National Wastewater Surveillance System (CDC)
● Description
○ Sewage from households/buildings
○ Can be tested for covid-19
● Advantages
○ Unobtrusive, early detection of disease
○ Captures symptomatic and asymptomatic infections
○ Indicator of covid-19 burden in a community
○ Independent of healthcare system
● Complements “usual” covid-19 testing
○ Pooled samples
○ “Bridge the gap” where routine testing is not available
See also:
● World Health Organization. (2020, August 7). Status of environmental surveillance for SARS-CoV-2 virus. Available at:
https://www.who.int/news-room/commentaries/detail/status-of-environmental-surveillance-for-sars-cov-2-virus
● Crawley, M. (2020, September 9). Testing sewage for COVID-19 could be ‘early warning’ system, Ontario researchers hope. CBC News. Available at
https://www.cbc.ca/news/canada/toronto/covid-19-wastewater-testing-ontario-1.5715972
Centers for Disease Control and Prevention. (2020, August 17). National Wastewater Surveillance System: A new public health tool to understand 40
COVID-19 spread in a community. Available at: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/wastewater-surveillance.html
Reproduced from Ontario Covid-19 Science Advisory Table. 41

Social Media Outbreak Monitoring
● Tracking social media feeds to identify outbreaks based on reports of
symptoms, illnesses
● “December 30, ProMED, another digital disease detection group, became
aware of online chatter about a pneumonia of unknown origin on China’s
micro-blogging website, Weibo. As researchers later reported, newly popular
keywords on the social media platform WeChat included “SARS,” “shortness of
breath” and “diarrhea.”” (Ellison, 2020)
● Challenges
○ “Noise”
■ Cholera
■ Flu
○ Digital divide
○ Privacy
See also:
● Aiello, A.E., Renson, A. & Zivich, P.N. (2020). Social media- and Internet-based disease surveillance for public health. Annual Review of Public
Health, 41, 101-118. https://doi.org/10.1146/annurev-publhealth-040119-094402
Ellison, K. (2020, March 30). Social media posts and online searches hold vital clues about pandemic spread. Knowable Magazine. Available at: 42
https://www.scientificamerican.com/article/social-media-posts-and-online-searches-hold-vital-clues-about-pandemic-spread/
Tutorial Activity 43
Health in the Media
● How is health portrayed in this

media source?
○ What messages about “health” are given in
this source?
■ What do you think of those messages?
● What critiques might we level

against this media portrayal from a
determinants of health perspective?
● What implications would these

portrayals have for how we might
design health promotion programs?
44
Media Sources
● Oprah
○ https://youtu.be/9qwZMVe2WVY
45
Oprah & Vaccine
● McCarthy: First thing I did—Google. I put in autism. And I
started my research.
● Winfrey: Thank God for Google.
● McCarthy: I’m telling you. Winfrey: Thank God for
Google.
● McCarthy: The University of Google is where I got my
degree from. . . . And I put in autism and something came
up that changed my life, that led me on this road to
recovery, which said autism—it was in the corner of the
screen—is reversible and treatable. And I said, What?!
That has to be an ad for a hocus pocus thing, because if
autism is reversible and treatable, well, then it would be
on Oprah.
46
Adapted from:
http://blogs.plos.org/thepanicvirus/2013/07/15/a-jenny-mccarthy-reader-pt-2-jenny-brings-her-anti-vaccine-views-to-oprah/
Oprah & Vaccine
● McCarthy: Mommy instinct.

● Winfrey: Mommy instinct.
● McCarthy: Mommy instinct. . . . I went, okay—I know my kid. . . . I know what’s
going on in his body, so this is what makes sense to me. . . .
● Winfrey: Okay—so this is what Jenny says really worked for her. It doesn’t mean it
will work for all children. . . . It worked for her. This is her book. She wrote the
book. So she knows what she’s talking about.
47
Adapted from:
Oprah & Vaccine
● Winfrey: So what do you think triggered the autism? I know you have a
theory.
● McCarthy: I do have a theory.
● Winfrey: Mom instinct.
● McCarthy: Mommy instinct. You know, everyone knows the stats, which
being one in one hundred and fifty children have autism.
● Winfrey: It used to be one in ten thousand.
● McCarthy: And, you know, what I have to say is this: What number does it
have to be? What number will it take for people just to start listening to
what the mothers of children who have autism have been saying for years?
Which is that we vaccinated our baby and something happened. . . . Right
before his MMR shot, I said to the doctor, I have a very bad feeling about
this shot. This is the autism shot, isn’t it? And he said, “No, that is
ridiculous. It is a mother’s desperate attempt to blame something on
autism.” And he swore at me. . . . And not soon thereafter, I noticed that
change in the pictures: Boom! Soul, gone from his eyes.
48
Adapted from:
Oprah & Vaccine
● Oprah cites CDC:
○ We simply don’t know what causes most cases of autism, but we’re
doing everything we can to find out. The vast majority of science to
date does not support an association between thimerosal in
vaccines and autism. . . . It is important to remember, vaccines
protect and save lives.
● When Winfrey appeared back on screen, she turned to
McCarthy, who was ready with a response: “My science is
named Evan, and he’s at home. That’s my science.”
● There was little question that Winfrey’s sympathies lay with
the “mother warrior” who’d written a “beautiful new book”
about how she’d cured her son of a supposedly incurable
disease as opposed to the faceless bureaucracy that couldn’t
provide any answers.
49
Adapted from:
Oprah & Vaccine
● Before the end of the show, Winfrey told viewers that
McCarthy would be available to answer questions for
anyone who logged on to a “special [online] message
board just for this show so you can share your stories.”
One fan asked McCarthy what she would do if she could
do it all over again. “The universe didn’t mean for me to
do anything else besides what I did,” McCarthy
answered, “but if I had another child, I would not
vaccinate.”
● A mother wrote in to say that she had decided not to
give her child the MMR vaccine “due to the autism link.”
McCarthy was delighted. “I’m so proud you followed
your mommy instinct,” she wrote.
50
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HST209H1F

Instructor: Anthony Lombardo, PhD 1

● Public health; health promotion; & population health

● Check library help section

● Use e-resources at UT Library

● aka “refereed” journals

● Check “Ulrich’s Web” from UT library:

● Writing Centre at University of Toronto

● Writing Centre Appointments

● PDF Advice Sheets

● Develop and use an outline

● Make your ideas/arguments explicit

● Revise and edit ﬁrst drafts

● YES! This is plagiarism.

● YES! This is plagiarism.

● YES! This is plagiarism.

● YES! This is plagiarism.

● No – this is not plagiarism.

Study Surveillance, observation, testing hypotheses,

Distribution Times, persons, places, classes of people aﬀected

Health-related states/events Diseases, causes of death, health behaviours,

Speciﬁed populations Identiﬁable characteristics

Prevention & control Promoting, protecting and restoring health (ie,

● 19th C England – cholera

● What did he do to solve the problem?

The Italians drink excessive amounts of red wine and also

Eat and drink whatever you like.

Reproduced from Ontario Covid-19 Science Advisory Table. 41

● How is health portrayed in this

● What critiques might we level

● What implications would these

● McCarthy: Mommy instinct.

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