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At the core of epidemiology is the use of quantitative methods to study health, and how it may be improved, in populations. It is important to note that epidemiology concerns not only the study of diseases but also of all health-related events. Rational health-promoting public policies require a sound understanding of causation. The epidemiological analysis of a disease or activity from a population perspective is vital in order to be able to organize and monitor effective preventive, curative and rehabilitative services. All health professionals and health-service managers need an awareness of the principles of epidemiology. They need to go beyond questions relating to individuals to challenging fundamentals such as ‘Why did this person get this disease at this time?’, ‘Is the occurrence of the disease increasing and, if so, why?’ and ‘What are the causes or risk factors for this disease?’
Public health cannot be understood or fully appreciated without some knowledge of its history, which this Introduction provides. Conventionally, this begins with the large body of work associated with Hippocrates (c. 460–370 BC). In these writings, health was viewed as resulting from a sound balance of the humours. Therapy included diet, exercise and other interventions tailored to the individual – akin to today’s emphasis on healthy living and lifestyle. The Hippocratics were, in addition, early exponents of environmentalism. In Airs, Waters, Places, the occurrence of disease was linked to such factors as climate, soil and water quality. Proposals for disease prevention were related to specific social and economic circumstances.
Health-care systems within most countries are resource-limited – budgets are finite and not every service one would like to provide can be funded. In publicly funded health systems, those responsible for procuring health-care need to be able to explain how taxpayers’ money has been spent. Decisions are made at both individual patient and population levels. At an individual level, the decision might be: which statin should this patient get a prescription for to lower her blood cholesterol? At a population level, the decision might be: will a health and social care commissioning organization purchase a heart-failure specialist nurse or an additional sexual health clinic?
This chapter focuses on how such decisions are made and considers a framework for priority setting, a discussion of what factors should be taken into account when comparing options, a consideration of basic health economic concepts, and an overview of ethical principles which influence decisions.
Effective health-care makes a large and increasing contribution to preventing disease and prolonging life by reducing the population burden of disease. However, only the right kind of health-care delivered in the right way, at the right time, to the right person can improve health. Health-care interventions that are powerful enough to improve population health are also powerful enough to cause harm if incorrectly used. How can public health specialists know whether their interventions are having the desired effect? Clinicians can monitor the impact of their treatments on an individual patient basis, but how do we examine the impact of a new service? This chapter looks at what we mean by quality of health-care and considers some frameworks for its evaluation.
The first element of understanding how to improve the health and well-being of a population relies on a thorough assessment of the needs of the specified population, be it a local population defined by geography, a specific age group or those with certain characteristics. This chapter begins by considering how ‘health need’ can be conceptualized; the distinction between need, demand and supply; and the difference between health needs and the need for health-care. Secondly, the wider determinants of health are introduced and their relation to health needs discussed. Finally, the steps involved in a systematic assessment of the health needs of a defined population are explained, including tools and resources used to achieve this. Practical challenges are considered.
How much of what health and other professionals do is based soundly in science? Answers to the question, ‘Is our practice evidence based?’ depend on what we mean by practice and evidence.
The expansion of evidence-based medicne (EBM) has been a major influence on medical practice over the past 25 years. In this chapter, we examine the nature of what is nowadays more broadly referred to as evidence-based health-care (EBHC) and discuss its limitations. It is worth noting that in the UK this field continues to expand, particularly into the arena of social care, which often goes hand in hand with the provision of health-care. Increasingly, the term ‘evidence-based practice’ (EBP) is used as a catch-all. While this chapter focuses on health-care, the principles of EBP we describe apply equally to other disciplines, including public health and policy.
As we discussed with regard to leadership in Part 1, the context in which the public health tools are used has a bearing on the choice of tool and how it is implemented. In the second part of Essential Public Health: Theory and Practice, we consider a range of contemporary contexts in which public health is practised and illustrate how the tools we have described are applied.
How can society most effectively prevent disease and promote health and wellbeing? That is the challenge addressed by this textbook. This new edition equips readers with a toolkit of key public health skills and approaches to improve health and wellbeing for different populations. It considers how to tackle perennial public health challenges, effectively address the wider determinants of health, navigate health systems and engage in partnership working. Fully updated with contemporary examples, this new edition includes new content on sustainability and climate change, global health, leadership and management, mechanisms for measuring health and healthcare, addressing inequalities and promoting inclusivity. Essential reading for all those training and working in healthcare, social care and related disciplines, this book also shines a light on the work undertaken during the COVID-19 pandemic by those working in public health. Online material includes supplementary information and interactive, self-assessment questions to test understanding and aid learning.
Planning for the preterm birth of a fetus with known anomalies can raise complex ethical issues. This is particularly true of multiple pregnancies, where the interests of each fetus and of the expectant parent(s) can conflict. In these complex situations, parental wishes and values can also conflict with the recommendations of treating clinicians. In this article, we consider the case of a dichorionic twin pregnancy complicated by the diagnosis of vein of Galen aneurysmal malformation (VGAM) in one of the twins at 28 weeks’ gestation. Subsequent deterioration of the affected twin prompted the parents to request preterm delivery to prevent the imminent in-utero demise of the affected twin. However, given the associated risks of prematurity, complying with the parents’ request may have disadvantaged the health and wellbeing of the unaffected twin. This article canvases the complex ethical issues raised when parents request preterm delivery of a multiple pregnancy complicated by a fetal anomaly in one twin, and the various ethical tools and frameworks that clinicians can draw on to guide their decision-making in such cases.
This paper reports the findings of a scoping review on the organisation and delivery of health improvement activities in general practice and the primary healthcare team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices and how individual practices and the primary healthcare team organise such public health activities and how these contribute to health improvement. Our focus was on health promotion and prevention activities and aimed to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary healthcare team. Many of the research studies reviewed had some details about the type, process, location or who provided the intervention. Little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches with practices engaging in both primary and secondary prevention. Although many GPs do not take a population approach and focus on individual patients some do see health promotion as an integral part of practice – whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Based on our analysis we conclude that there is insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care.