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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: At a Glance
- Sprache: Englisch
First Prize in Public health in the 2017 BMA Medical Book Awards
Public Health and Epidemiology at a Glance is a highly visual introduction to the key concepts and major themes of population health. With comprehensive coverage of all the core topics covered at medical school, it helps students understand the determinants of health and their study, from personal lifestyle choices and behaviour, to environmental, social and economic factors.This fully updated new edition features:
• More coverage of audit and quality improvement techniques
• Brand new sections on maternal and child health, and health of older people
• New chapters on social determinants of health and guideline development
• Expanded self-assessment material
This accessible guide is an invaluable resource for medical and healthcare students, junior doctors, and those preparing for a career in epidemiology and public health
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Seitenzahl: 258
Veröffentlichungsjahr: 2016
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Table of Contents
Cover
Title Page
Copyright
Preface to the second edition
Acknowledgements
About the authors
How to use your textbook
Part 1: Introduction
Chapter 1: Introduction to public health
Chapter 2: Public health old and new
Part 2: Epidemiology and evidence-based practice
Chapter 3: Incidence and prevalence
Chapter 4: Risks and odds
Chapter 5: Hierarchy of evidence and investigating causation
Chapter 6: Bias, confounding and chance in epidemiological studies
Chapter 7: Standardisation
Chapter 8: Ecological and cross-sectional studies
Chapter 9: Case–control studies
Chapter 10: Cohort studies
Chapter 11: Trials (experimental studies)
Chapter 12: Systematic reviews and meta-analysis
Chapter 13: Diagnostic tests
Chapter 14: Developing clinical guidelines
Assessing population health
Chapter 15: Health and illness
Chapter 16: Demographic and epidemiological transitions
Chapter 17: Health information
Chapter 18: Measuring population health status
Chapter 19: Determinants of health
Chapter 20: Lifestyle determinants of health
Chapter 21: Social determinants of health
Chapter 22: Environmental determinants of health
Chapter 23: Inequalities in health
Chapter 24: Health needs assessment
Chapter 25: Maternal and infant health
Chapter 26: Health of older people
Part 4: Improving and protecting health
Chapter 27: Disease prevention
Chapter 28: Principles of disease transmission
Chapter 29: Communicable disease control
Chapter 30: Surveillance
Chapter 31: Immunisation
Chapter 32: Screening principles
Chapter 33: Screening programmes
Chapter 34: Health promotion
Chapter 35: Changing behaviour
Part 5: Health economics
Chapter 36: Economic perspectives on health
Chapter 37: Economic evaluation
Chapter 38: Economic perspectives on measuring health-related outcomes
Chapter 39: Economics of public health problems
Part 6: Effective healthcare
Chapter 40: Healthcare systems
Chapter 41: Planning health services
Chapter 42: Improving services
Chapter 43: Healthcare evaluation
Self-assessment questions
Self-assessment answers
Appendix: practical issues in conducting epidemiological studies
Further reading
Index
End User License Agreement
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Guide
Cover
Table of Contents
Preface to the second edition
Part 1: Introduction
Begin Reading
List of Tables
Chapter 38: Economic perspectives on measuring health-related outcomes
Table 38.1 EQ-5D social preference weights
This title is also available as an e-book. For more details, please see www.wiley.com/buy/9781118999325 or scan this QR code
Public Health and Epidemiology at a Glance
Second Edition
Margaret Somerville
MD, MRCP, FFPH
K. Kumaran
DM, FFPHMRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthampton, UK
Rob Anderson
PhD, MSc, MA(Econ.)Institute of Health ResearchUniversity of Exeter Medical SchoolExeter, UK
This edition first published 2016 © 2016 by John Wiley & Sons Ltd
First edition © 2012 by John Wiley & Sons Ltd
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The right of the authors to be identified as the authors of this work have been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
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The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.
Library of Congress Cataloging-in-Publication Data applied for.
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A catalogue record for this book is available from the British Library.
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Cover image: © Mattjeacock/Gettyimages
Preface to the second edition
In this second edition, we are delighted to have been able to expand the content in line with the comments we have had from both students and teachers. That feedback tells us that many of you have found the book useful and we have not wanted to change too much as a result. The basic principles and concepts still stand – and our aim was always to provide that core understanding of public health rather than focus on topics subject to rapid change. Applying this principle has meant that we have still not described the NHS structures, something you told us you wanted – even if we could! We have always taken the view that by the time either this book is published or you graduate, the structures will have changed again. It is also apparent that the NHS structures in the different UK countries are increasingly diverse. Understanding the principal elements of providing a good health and public health system seems, therefore, more relevant.
Elsewhere, we have expanded our discussion of health inequalities – an issue that is likely to be with us for some time to come, the determinants of health and epidemiological studies, added chapters on older people, maternal and infant health, improving services and the development of the subject and practice of public health. We have revised and updated existing chapters and also added new self-assessment questions.
Just as with the first edition, we hope that the book will continue to promote interest in public health as well as be useful. Again, we would urge anyone wanting to find out more to contact their local public health team and spend time with them to find out what working as a public health physician is like on a day-to-day basis: it can be very diverse given the variety of work that public health professionals are involved with.
Margaret SomervilleK. KumaranRob AndersonSandwood, March 2015
Acknowledgements
We had the support and guidance of many people in developing the Peninsula Medical School course, and we have used much of the material as the basis for the chapters in this book, but we would particularly thank Stuart Paynter, Graham Crocker, Rod Taylor, Stuart Logan and Ken Stein for their help with parts of the curriculum relating to epidemiology, evidence-based practice and statistics. Any misrepresentation of their original contributions to the teaching material is entirely our responsibility. We are also very grateful for the help and guidance from Wiley-Blackwell, particularly Laura Murphy and Elizabeth Johnston, in getting this book from ideas to finished product.
About the authors
Margaret Somerville has recently retired as Director of Public Health and Health Policy for NHS Highland, a post she held from 2010 to 2014. Before that, she was Director of Public Health Learning at the Peninsula Medical School, where she led the development of the public health aspects of the undergraduate curriculum from its inception in 2002. As a public health consultant in Devon, she was also involved with screening programmes, developing and implementing evidence-based practice and undertaking research into housing interventions and health.
Rob Anderson is an applied health researcher and economic evaluator with over 20 years' experience in the United Kingdom and Australian healthcare systems. He teaches on the University of Exeter Medical School's course for medical undergraduates and is an editor of the Cochrane Public Health Group. His public health research has included evaluations and systematic reviews of screening programmes, oral health promotion, injury prevention, obesity prevention and the implementation of health promotion programmes in schools. He is based in the Institute of Health Research, University of Exeter Medical School, Exeter.
After completing his undergraduate medical degree in India, Kumaran underwent public health training in the United Kingdom. During this period, he obtained an MSc in Public Health, a postgraduate certificate in clinical education and the membership of the Faculty of Public Health, UK. He then worked at consultant level in the United Kingdom for the Health Protection Agency and NHS Somerset where he was involved in service public health. He also held an academic post at the Peninsula Medical School where he was closely involved in the development and delivery of undergraduate and postgraduate public health teaching. He is now based in India working across the MRC and various Indian teams on collaborative projects relating to the developmental origins of health and disease. His role is to contribute to the development of future research strategy, acquisition of funding and translation of research evidence into public health practice and policy. His long-term interests include the application of multi-faceted, evidence-based population level interventions to improve foetal growth and long-term cardiometabolic health using a lifecourse approach, and teaching and training initiatives. He is currently Associate Professor, MRC Lifecourse Epidemiology Unit, University of Southampton, UK and Senior Scientist Public Health, Diabetes Unit, KEM Hospital Research Centre, Pune, India.
How to use your textbook
Features contained within your textbook
Each topicis presented in a double-page spread with clear, easy-to-follow diagrams supported by succinct explanatory text.
Your textbook is full of photographs, illustrations and tables.
Part 1Introduction
1 Introduction to public health 2
2 Public health old and new 4
Chapter 1Introduction to public health
What is public health? Why do I need to study it? We hear this question a lot from medical students just starting out on their medical careers. There is, of course, the standard definition:
Public health is the science and art of preventing disease, promoting health and well-being and prolonging life through the organised efforts of society (Faculty of Public Health)
…but what does this really mean?
The difference between the clinical and public health roles of doctors (and health services) is often illustrated by the image of people pulling others out of a river (Figure 1a). So busy are these people with saving those who are drowning that nobody has thought to go back upstream to find out why people are falling in to begin with. Public health aims to go upstream to find out why people are drowning. Besides understanding the problem, public health also tries to prevent it or reduce the harm resulting from it. Such action may involve persuading decision-makers to put up effective barriers to stop people falling into the river, repairing damaged river banks or controlling flooding, as well as providing information in the right way to prevent risky behaviour near the river. It may also be appropriate to make sure that the people saving those who are drowning are well trained and at the right place on the river bank to save as many lives as possible effectively and efficiently.
Doctors and other healthcare professionals spend their time dealing with people with health problems – those drowning people – and in treating individuals as effectively as possible. But many individuals' ability to obtain and follow medical advice is limited by circumstances outside their control. They may not be able to get to a clinic or hospital or afford the tests, drugs or other treatment once there; they may not understand the advice or treatment because of educational, language or cultural barriers, or may find it impossible to follow because of their domestic or social circumstances. Understanding these ‘upstream’ determinants of health is vital to providing health services that are sensitive to people's needs and effective in improving health. Methods of addressing them include legislation (e.g. wearing seat belts or motorcycle helmets), fiscal policy (e.g. taxing alcohol and tobacco), local and national social initiatives (e.g. literacy programmes, housing improvements and cycle paths) as well as more specific disease prevention programmes (e.g. immunisation). Taking such action requires a very different approach from that of the traditional healer, one that recognises that doctors and healthcare professionals may not be able to act directly themselves, but can work with and influence others to take action to improve health. It involves working with many different people, professionals, organisations and communities both within and outside the health sector.
There can be tensions between the traditional clinical approach to individuals' health problems and this population approach: what leads to improvement in the health of a population as a whole may not mean health improvement for every individual within it. Conversely, doing what is clinically best for the individual patient may mean others are excluded from getting appropriate, or even any, healthcare. Getting this balance as right as possible is a public health concern.
So public health is not just about acquiring a detailed knowledge base or a specific set of skills, it is also about an approach to health and health problems that is population-based, rational, transparent and fair. The public health approach seeks to identify and quantify health problems at a population or community level and then develop, introduce and evaluate interventions to improve health, monitoring progress to see whether the actions have made a difference. Epidemiology, the study of disease patterns, is the key discipline that helps us to understand population health, but in order to fulfil the role set out in the previous sentence, public health needs to draw on a wide range of other disciplines and knowledge. Statistics, sociology, psychology, health economics, health promotion, management and leadership, health systems and policy all contribute to the public health approach. This book attempts to give you an introduction to this complex and fascinating subject, which is fundamental to the good practice of medicine.
Domains of public health
The scope of public health, as described earlier, is very wide ranging, but is generally recognised as falling into three domains (Figure 1b). All three domains draw on the academic disciplines listed here and all collect or make use of information relevant to health, such as population data from the census, data on health service use (e.g. prescribed drugs, hospital admissions or consultations with health professionals), registrations of births and deaths, and disease and risk factor prevalence levels (e.g. alcohol consumption or diabetes).
Health protection
covers communicable diseases and environmental hazards, such as exposure to toxic chemicals and poisons. Exposure to hazardous substances at work is covered by the separate discipline of occupational medicine.
Health improvement
includes understanding the wider determinants of health, such as housing, education, poverty and lifestyle risk factors and seeks to improve health through health promotion and disease prevention.
Improving services
is concerned with how the quality of health services can be improved through evidence-based planning, the provision of effective and cost-effective treatment and ensuring that services are available to everyone who can benefit from them.
In the first section of this book (Chapters 3–14), we cover the main epidemiological concepts and methods that underpin evidence-based practice, whether public health or clinically focussed. The second section (Chapters 15–26) covers the types and sources of information used to assess population health status and need for healthcare. The third section (Chapters 27–35) covers health improvement and the final two sections health economics (Chapters 36–39) and health services (Chapters 40–43).
Chapter 2Public health old and new
The last chapter described the scope of public health practice today, and how actions to improve public health include societal interventions such as legislation, taxation and infrastructure as well as providing healthcare and behavioural modification. Many of these actions are not new: ancient civilisations, such as the Romans, provided water and sanitation as part of the civic state and the Venetians and others instituted quarantine measures to prevent the spread of infectious diseases, particularly plague (Figure 2a).
In the United Kingdom, the Poor Law had provided for the poor and sick since medieval times. However, by the early nineteenth century, the urban poor, whose numbers had grown during the Industrial Revolution, were living in appalling conditions. Their plight was well described and quantified by Edwin Chadwick, whose report in 1842 (The Sanitary Condition of the Labouring Population) attributed their poor health and low life expectancy to their insanitary living conditions. These findings led to the 1848 Public Health Act, which set up a General Board of Health and local sanitary authorities with powers to provide pure water, effective sewage disposal and improve housing. The first Medical Officer of Health was appointed in Liverpool in 1847 and other cities soon followed.
Major epidemics of communicable disease were a feature of urban life in the nineteenth century. John Snow mapped cases of cholera in Soho in London in 1854 and showed that the people who lived closest to a particular water pump in Broad Street were the ones most likely to get the disease (Figure 2b). Legend has it that, when he failed to persuade the authorities to stop the pump being used, he removed the pump handle himself to prevent its use. John Snow's work, alongside that of William Farr, led to the development of epidemiology, the science that investigates disease patterns. Despite a growing acceptance that drinking water contaminated with raw sewage was the likely cause of cholera outbreaks, it took the ‘great stink’ of 1858 to make legislators agree to providing an adequate sewer system for London. Bazalgette's scheme was not completed until the 1870s and is still functioning today.
These interventions led to improvements in the health of the population, particularly reducing infant mortality, before the microbiological cause of cholera and other epidemics was known: Robert Koch identified the organism that causes cholera (Vibrio cholerae) in 1882. His work on micro-organisms, particularly the tubercle bacillus, led to the germ theory of disease replacing the earlier miasmic theory, which attributed disease to bad air. From providing social interventions to prevent disease, public health action now also focussed on individuals and interrupting the chain of disease transmission with immunisation and other measures (host–agent–environment model, see Chapter 33).
In the early twentieth century, concerns about the health and poor nutritional status of working class recruits to the British army for the Boer wars led to the development of community nursing services to improve maternal and child health, supported by a growing understanding of the role of vitamins in preventing diseases such as rickets. The rise of the welfare state, providing benefits such as pensions, free school meals and milk, eventually resulted in the provision of universal access to healthcare, free at the point of use. The National Health Service started in 1948, following the creation of the Emergency Medical Service during the Second World War. With the development of antibiotics and other drugs, a new era of effective therapeutics began.
Finally, in the second half of the twentieth century, a rational, evidence-based approach to health and healthcare has emerged. Establishing and assessing evidence of the effectiveness of healthcare and health improvement interventions is now routine (Figure 2c; for explanation of the plot see Chapter 12 on meta-analysis), leading to the development of evidence-based clinical guidelines and services. As the costs of healthcare systems increase, evidence of cost-effectiveness and affordability of interventions is also in demand, leading to the development and application of health economic expertise.
Future public health challenges
If communicable disease, poor living conditions and lack of accessible healthcare for all stimulated public health action in the past, what should public health practitioners in the twenty-first century be concerned about? Are current concepts of health and configurations of services adequate to meet future challenges?
Undoubtedly, providing services for the ageing population is one concern. Health services are generally geared towards providing episodes of acute care with an emphasis on hospital and specialist provision. Working with patients and their families to manage multiple chronic conditions over decades requires a different approach. Redirecting the super-tanker of the NHS to develop community-based services in partnership with other agencies and the voluntary sector has to be the focus for future health and social care provision.
While all long-term conditions are increasing in prevalence as the population ages, and have overtaken communicable diseases as the leading global cause of death, two conditions give cause for particular concern and present challenges for all agencies, not just health. The obesity epidemic is proving resistant to action at an individual level and requires far more concerted societal action to address the obesogenic environment. Increases in mental health problems, particularly anxiety and depression, also require concerted actions to promote mental well-being as well as reduce the stigma of mental illness and provide effective early intervention.
Climate change is already happening; actions to mitigate its effects and adapt to those that are inevitable may be beneficial to health in some countries, but substantial health harms are also predicted. As the impact will be felt far more in poor countries, with resulting population displacement, the global impact will be to widen health inequalities. Providing sustainable services to maintain and improve health and reduce health inequalities present public health with its major challenge for the future.
As health improves and life expectancy increases, health is increasingly seen as more than the absence of disease: understanding, measuring and promoting positive well-being in individuals and populations is of growing importance.
Part 2
Epidemiology and evidence-based practice
Chapters
3 Incidence and prevalence 8
4 Risks and odds 10
5 Hierarchy of evidence and investigating causation 12
6 Bias, confounding and chance in epidemiological studies 14
7 Standardisation 16
8 Ecological and cross-sectional studies 18
9 Case-control studies 20
10 Cohort studies 22
11 Trials (experimental studies) 24
12 Systematic reviews and meta-analysis 26
13 Diagnostic tests 28
14 Developing clinical guidelines 30
Chapter 3Incidence and prevalence
Definitions
Epidemiology: the study of the occurrence and distribution of health-related states or events in specified populations, including the study of the determinants influencing such states, and the application of this knowledge to control the health problems.
Incidence (I): the number of instances of illness commencing, or of persons falling ill, during a given period in a specified population; more generally, the number of new health-related events in a defined population within a specified period of time. It may be measured as a frequency count, a rate or a proportion.
Prevalence (P): the total number of individuals who have an attribute or disease divided by the population at risk of having that attribute or disease either (a) at a specified time (point prevalence), or (b) over a specified period (annual, lifetime, one year; period prevalence).
(All these definitions come from M. Porta and J.M. Last, Dictionary of Epidemiology, 5th edition, OUP, 2008).
The relationship between incidence and prevalence is modified by the duration of the disease:
High prevalence may result from a high incidence or a long disease duration or both. For example, assume that in a population of 100 people, 5 new cases of disease occur during the first year of observation (Figure 3a). Assuming that no one in the population had the disease at the start of our observation period, both the prevalence of the disease in the first year and the annual incidence is 5 per 100 people or 5%. If the disease lasts 10 years or more, but no more new cases arise during our second year of observation, then the incidence in the second year is zero, but the prevalence at the end of that time is still 5%.
