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An Introduction to Public Health and Epidemiology an Introduction to Public Health and Epidemiology SECOND EDITION SECOND EDITION An Introduction to Public Health and Epidemiology An Introduction to Public Health and Epidemiology SECOND EDITION “The contents are not specifically nursing orientated but very neatly balanced to be of relevance to all working in the public An Introduction to health arena… the book is well written, the language is clear, and the concepts clearly and simply explained and easily understood” Journal of Biosocial Science Public Health • What are epidemiology and public health? • What is the nature of public health evidence and knowledge? and Epidemiology • What strategies can be used to protect and improve health? The second edition of this bestselling book provides a multi-professional introduction to the key concepts in public health and epidemiology. It presents a broad, interactive account of contemporary public health, placing an emphasis on developing public health skills and stimulating the reader to think through the issues for themselves. The new edition features additional material on: • Historical perspectives • Public health skills for practice • Evaluation of public health interventions SECOND EDITION • The nature of evidence and public health knowledge • Translating policy and evidence into practice An Introduction to Public Health and Epidemiology is key reading for students of public health and healthcare professionals, including: nurses, doctors, community development workers and public health workers. Carr Susan Carr is Reader in the Health Improvement Research Programme, Community Health & Education Studies Research Centre, Northumbria University, UK where she • researches and teaches public health and primary care issues. Unwin Nigel Unwin is Professor of Epidemiology in Advancing Research in Chronic Disease Epidemiology (archEpi) and lead of the WHO Collaborating Centre for Diabetes in • the Institute of Health and Society at Newcastle University, UK. Pless-Mulloli Tanja Pless-Mulloli is Professor of Environmental Epidemiology and lead of the Environment and Health team in the Institute of Health and Society at Newcastle University, UK. Susan Carr • Nigel Unwin • Tanja Pless-Mulloli Cover design Kate Prentice www.openup.co.uk Page 1 An Introduction to Public Health and Epidemiology 10:11:29:06:07 Page 1 Page 2 10:11:29:06:07 Page 2 Page 3 An Introduction to Public Health and Epidemiology Second Edition Susan Carr, Nigel Unwin and Tanja Pless-Mulloli 10:11:29:06:07 Page 3 Page 4 Open University Press McGraw-Hill Education McGraw-Hill House Shoppenhangers Road Maidenhead Berkshire England SL6 2QL email: [email protected] world wide web: www.openup.co.uk and Two Penn Plaza New York, NY 10121–2289, USA First edition published 1997 First published 2007 Copyright © Susan Carr, Nigel Unwin and Tanja Pless-Mulloli All rights reserved. Except for the quotation of short passages for the purposes of criticism and review, 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, without the prior written permission of the publisher or a licence from the Copyright Licensing Agency Limited. Details of such licences (for reprographic reproduction) may be obtained from the Copyright Licensing Agency Ltd of Saffron House, 6–10 Kirby Street, London, EC1N 8TS. A catalogue record of this book is available from the British Library ISBN10: 0 335 21624 2 (pb) ISBN13: 978 0 335 21624 6 (pb) Library of Congress Cataloging-in-Publication Data CIP data has been applied for Typeset by RefineCatch Limited, Bungay, Suffolk Printed in Poland EU by OZGraf S.A. www.polskabook.pl 15:42:26:07:07 Page 4 Page 5 To our families. 10:11:29:06:07 Page 5 Page 6 10:11:29:06:07 Page 6 Page 7 Contents Preface ix Introduction 1 1 Lessons from the history of public health and epidemiology for the twenty-first century 5 2 Sources and critical use of health information 17 3 Measuring the frequency of health problems 35 4 Measures of risk 49 5 Epidemiological study designs 57 6 Weighing up the evidence from epidemiological studies 72 7 The determinants of health and disease 83 8 Health promotion 97 9 Health needs analysis 111 10 Principles of screening 131 11 Changing public health: what impacts on public health practice? 146 Further reading, references and resources 160 Index 168 10:11:29:06:07 Page 7 Page 8 10:11:29:06:07 Page 8 Page 9 Preface People who practise public health come from many walks of life: • nurses and doctors running screening programmes; • local residents campaigning for better housing; • engineers drilling bore holes to provide clean water for villagers in a developing country; • politicians introducing legislation to ban cigarette smoking in public places; • ‘pop stars’ who speak to school children on the dangers of drug misuse. These are a few examples. Many people will not identify their activities as ‘public health’. What links these and similar activities together is improving the health of populations or communities. Such a broad range of activities illustrates that the factors which influence health are complex and wide-ranging. Any attempt to under- stand and change them must involve many disciplines, and the study of public health draws on the expertise of people from a variety of backgrounds. Statistics, psych- ology, sociology, microbiology, politics and management are some of the specialities which contribute to the study of public health. Epidemiology has a central role. It can be defined as the study of the distribution and determinants of health-related states and the application of this study to the control of health problems. Knowing the extent of health problems, who suffers from them and what causes them within a population is the information needed for organized public health groups to address them, as well as the measure of whether the efforts were successful. The focus of public health is on populations and communities. This is a very different perspective from the day-to-day focus of most health professionals on the health problems of individuals. We hope in this book to introduce students and practi- tioners of nursing and other health and social care workers to the ‘public health perspective’, to provide a framework for examining public health issues and to allow the reader to start to place her or his practice within the wider context of health, and determinants of health, of the community in which they work. This book is a study guide. Our goal is to encourage you to think through, and be 10:11:29:06:07 Page 9 Page 10 x PREFACE critical about, key issues to do with the measurement and improvement of public health and the role in this played by organized health care. The chapters cover topics which we hope will enable this goal to be achieved. There may be other areas you feel we should have covered. We would very much welcome your feedback on the content and any other aspect of this book. How to use this book Each chapter has a standard format and is presented in the following way: • Questions: some examples of the kinds of questions the chapter will help you to answer. • Outcomes: what you should be able to do after working through the chapter and the exercises provided. • Exercises: these are presented throughout the chapter. They are there to help you understand key issues. It is therefore important to work through them. You’ll be pleased to hear that most of them are very short. There are a few exercises that will involve going away and seeking out other information, but these are identified in the text and are optional. They are there if you wish to develop further your understanding of a particular issue. • Summary: key issues, ideas or concepts from the chapter are identified in sum- mary questions. Spaces are left for your responses for two main reasons: (1) by completing this section you can revise the issues of the chapter and assess for yourself how well you have met the outcomes; (2) you can make your own summary specific to your particular health interests and your branch of health or social care. • Public health standards: at the end of each chapter a table is provided which lists ten public health standards. You are invited to consider which are pertinent to the chapter content, to reflect on your current skills and knowledge, and to develop action plans to address any learning needs. At the end of the book we have identified some useful references and resources relating to each chapter for further exploration of the chapter subject. Chapter 1, ‘Lessons from the history of public health and epidemiology for the twenty-first century’, defines concepts underpinning the evolution of epidemiology and public health thinking. It then places public health successes within a historical context and highlights remaining challenges. Chapter 2, ‘Sources and critical use of health information’, provides an overview of the different types of information that are relevant to public health practice. Criteria are suggested by which to assess critically the quality of routinely available health information. The application of these criteria is illustrated by consideration of routinely available information on population size and cause of death. Next, the types of information routinely available on morbidity (episodes of illness) are considered and the concept of the health care iceberg is introduced. Finally, consideration is given to the potential pitfalls when making comparisons between the health of 10:11:29:06:07 Page 10 Page 11 PREFACE xi populations in different places or at different times when using routinely collected information. Chapter 3, ‘Measuring the frequency of health problems’, starts by illustrating the need for rates to measure the frequency of health problems. Two rates of special importance in epidemiology, incidence and prevalence, are defined and their relation- ship is discussed.
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