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PH6 Public Health and Preventive Medicine Determinants of Health Toronto Notes 2019
Passive Prevention
Measures that operate without the person’s active involvement (e.g. airbags in cars)
are more effective than active prevention, measures that a person must do on their own (e.g. wearing a seatbelt)
Example of Primary Prevention
HPV 9-Valent Vaccine and Its Efficacy in the Prevention of Cervical Cancer
This is a nonavalent HPV vaccine covering strains 6, 11, 16, 18, 31, 33, 45, 52, and 58. The efficacy of this vaccine was studied in 4 randomized, double-blind, placebo-controlled trials on females between 11 and 26 yr of
age and was found to prevent nearly 100% of precancerous cervical changes for up to 4 yr after vaccination
Does Evidence Support Supervised Injection Sites?
Can Fam Physician 2017 Nov;63(11):866 Clinical question: Do supervised injection sites (SISs) reduce mortality, hospitalizations, ambulance calls, or disease transmission? Bottom line: Best evidence from cohort and modeling studies suggests that SISs are associated with lower overdose mortality (88 fewer overdose deaths per 100 000 person-years [PYs]), 67% fewer ambulance calls for treating overdoses, and a decrease in HIV infections. Effects on hospitalizations are unknown.
Young and Growing Populations
• between2006-2016theIndigenouspopulationshaveincreasedby42.5%,4xthatofnon-Indigenous Canadian population growth
• 32.1istheaverageageoftheIndigenouspopulation,about8yearsyoungerthanthenon-Indigenous Canadian population
• buttheagingIndigenouspopulationisalsogrowing,withanticipateddoublingof>65agegroupby 2036
The Impact of Colonialism
• colonialism:subjugationofIndigenouspeoplesbytheEuropeans,leadingtothelossoflands,cultural practices, and self-government
• residentialschools(1870s-1996):placementofchildrenfromIndigenousgroupsinchurch-run, government-funded schools for the purpose of assimilation, resulting in loss of identity, alienation, and abuse, with long-lasting consequences of higher rates of addictions, abusive relationships, and suicide
• TruthandReconciliationCommission(2015):mandateddocumentcreatedbytheCanadian government and residential school survivors that preserves in writing the truth of residential schools and delineates recommendations for reconciliation
• treatiesandlandclaims:inadequateservicesforthoselivingonreservesleadingtopovertyand poor quality infrastructure, reflected in disproportionate burden of infectious diseases (e.g. pertussis, chlamydia, hepatitis, shigellosis)
Traditional Approaches to Healing
• restoringbalanceinthefourrealmsofspiritual,emotional,mental,andphysicalhealthofaperson acting as an individual, as well as a member of a family, community, and nation
■ ideas represented by medicine wheel of First Nations peoples, the Learning Blanket of Inuit peoples, and the Metis tree model of Holistic Lifelong Learning
■ contrast to Western medicine focus of treating illness, leading to challenges for practitioners of Western medicine to meet Indigenous patients’ needs
■ National Indigenous Health Organization (NIHO) offers 8 guidelines on practicing culturally safe health care for Indigenous patients including the need to allow Indigenous patients to access ceremony, song, and prayer; the need for information and for family support; guidelines for the appropriate disposal of body parts and for handling death
Disease Prevention
Natural History of Disease
• courseofadiseasefromonsettoresolution
1. pathological onset
2. presymptomatic stage: from onset to first appearance of symptoms/signs
3. clinical manifestation of disease: may regress spontaneously, be subject to remissions and relapses,
or progress to death
Disease Prevention Strategies
• measuresaimedatpreventingtheoccurrence,interruptingthroughearlydetectionandtreatment,or slowing the progression of disease/mitigating the sequelae
Table 3. Levels of Disease Prevention
Level of Prevention
Primary
Secondary Tertiary
Goal
Protect health and prevent disease onset. Reducing exposure to risk factors.
Early detection of (subclinical) disease to minimize morbidity and mortality
Treatment and rehabilitation of disease to prevent progression, permanent disability, and future disease
Examples
Immunization programs (e.g. measles, diphtheria, pertussis, tetanus, polio, see Pediatrics, P4)
Smoking Cessation.
Seatbelt use
Mammography Routine Pap smears
DM monitoring with HbA1c, eye exams, foot exams
Medication
Basic Concepts in Prevention, Surveillance, and Health Promotion. AFMC Primer on Population Health (http://phprimer.afmc.ca/Part1-TheoryThinkingAboutHealth Chapter4BasicConceptsInPreventionSurveillanceAndHealthPromotion/Thestagesofprevention)
Screening (Secondary Prevention)
• “screeningisastrategyusedinapopulationtoidentifythepossiblepresenceofanas-yet-undiagnosed disease in individuals without signs or symptoms”
■ screening vs. case finding: Screening tests are not diagnostic tests
■ the primary purpose of screening tests is to detect early disease or risk factors for disease in large
numbers of apparently healthy individuals. The purpose of a diagnostic test is to establish the presence (or absence) of disease as a basis for treatment decisions in symptomatic or screen positive individuals (confirmatory test). Both screening and case finding seek to risk stratify for further investigation