Slide 1 Orientation to Violence Prevention The Public Health Approach 1 Slide 2 Slide 3 Lesson Objectives Describe common misconceptions about public health Describe key concepts of public health Lesson Objectives (cont.) Describe the public health approach Describe examples of the core functions in action 2 The Public Health Approach. This is Part 2 of an Orientation to Violence Prevention. After completing this lesson, you will be able to: -Describe common misconceptions about public health -Describe key concepts of public health -Describe the public health approach. -Describe examples of the core functions in action. 3 Slide 4 What is Public Health? 4 What is Public Health? The most common response to this question by the general public is, Health care for poor people. While public health departments do play a role in providing a health safety net, that is just one of its many functions. The field of public health is broad, diverse and now more important than ever. 1
Slide 5 What is Public Health? 5 When was the last time you looked at a newspaper that did not have at least one article on a public health related subject, such as the flu, obesity, terrorism, AIDS, high lead and mercury levels, school violence, violent hazing cases and high profile family violence cases? Slide 6 Population Health 6 Public health takes a population approach to interventions to increase the likelihood of people living healthy and safe lives. In short, public health is population health, focusing on the whole population, rather than one individual at a time. Slide 7 World Health Organization a state of physical and mental wellbeing, not simply the absence of disease. The World Health Organization defines health as a state of physical and mental wellbeing, not simply the absence of disease. 7 Slide 8 Definition of Public Health Activities that society undertakes to assure the conditions in which people can be healthy, including organized efforts to prevent, identify and counter threats to the health and safety of the public. 8 Public health can be defined as activities that society undertakes to assure the conditions in which people can be healthy, including organized efforts to prevent, identify and counter threats to the health and safety of the public. Public Health: What it is and how it Works, Bernard J. Turnock 1997. 2
Slide 9 Slide 10 The Public Health System Health departments Community-based organizations Law Enforcement Health Care system Schools Social Services Media Policy-making bodies Workplaces Evidence-Based Where, When, Who, Why and How Determine the extent of the problem 9 10 Another common misconception is that public health is just a profession or the health department. While there certainly are people who are public health workers by profession, public health takes place through the work of a wide variety of actions taken by many different professions working in many settings such as: -State and local health departments -Community-based organizations -Law Enforcement -Health Care system -Schools -Social Services -Media -Policy-making bodies -Workplaces Public health is science-based, meaning it relies on solid evidence. Evidence is a critical piece of public health. Data tell us where, when, who, why and how. Data about the nature of the problem is one type of evidence that is used to guide program or policy development. This type of evidence makes it possible to identify the extent of a problem and particular behavioral and environmental factors that need to be addressed to reduce the occurrence or severity of the problem. 3
Slide 11 Evidence Based (cont.) 11 Evidence also allows one to monitor trends over time to see if a problem is changing in response to a given program or policy or in relation to other changes in the environment. Having a system in place to keep track of a problem in the population also enables new problem areas to be discovered and interventions to be developed more quickly and responsively. Slide 12 Evidence-Based (cont.) Supports policy development Evaluation Allocation of resources 12 Data are also necessary to make the case for policy development necessary to make change. And, data are also critical for evaluating how well a program or policy is working, so that it may be replaced, modified or replicated. This, in turn, helps decision makers plan how to allocate scarce resources. Slide 13 Data Sources Hospital and health care visits Death records Law enforcement Insurance records Surveys 13 Data comes from many different sources. For example, violence information comes from sources such as from hospitals, death records or law enforcement. Other information comes from surveys so as to learn about events that don t come into contact with health care or law enforcement systems and don t result in death. 4
Slide 14 Slide 15 Public Health Approach Assess Problem Disseminate and Implement Promising Interventions Identify Risk and Protective Factors Develop, Implement and Evaluate Preventive Approaches Assess Problem and Risk Factors High rates of teen suicide Risk Factors Alcohol use Access to firearms 14 The public health approach is a science-based approach which relies on evidence to: -Assess the problem -Identify risk and protective factors -Develop, implement and evaluate preventive approaches -Disseminate promising approaches Here is an example of the model applied. Your community has an increase in teen suicide. Hospital and police data indicate that many of the deaths were firearm related and occurred under the influence of alcohol. 15 Slide 16 Develop Program Strengthen or enforce laws Public awareness campaign about the problem and local resources Publicize increased enforcement 16 You create a coalition including community-based organizations, businesses, churches, schools, the health department and the police department to develop and implement an initiative to actively enforce alcohol and gun laws that restrict teen access. If those laws do not exist, you might have to work together to create them. At the same time you launch a community-wide campaign to educate people about the risks for teen suicide and about local resources. You also publicize your campaign to crack down on illegal sale of alcohol and guns to minors, so as to act as a deterrent to those breaking the laws. 5
Slide 17 Evaluation Decrease in teen suicide Decrease in teen homicide and unintentional injuries Decrease in sexual assault, intimate partner violence 17 After a time, your coalition reviews hospital and police data and finds that the rate of teen suicide from firearms has decreased. Though your primary goal is to reduce suicide, you might also find a drop in alcohol and firearm related homicide or unintentional injuries among teens, since the risk factors are the same. Alcohol abuse is a risk factor for intimate partner violence and sexual assault as well, so reducing access may also impact the rates of these crimes. This is primary prevention. Slide 18 Disseminate Your Results Share results with other communities Write articles Make presentations Post results on websites. 18 You have been able to demonstrate success and now you should share the information. You could: -Share results with other communities -Write articles -Make presentations -Post results on websites Slide 19 Key Factors in the Public Health Approach Concerned with the health of populations Datadriven/evidencebased Primary Prevention is key 19 There are four key elements that characterize the public health approach: -It focuses on the health of populations -It is evidence-based -Primary prevention is the key focus 6
Slide 20 Slide 21 Culturally-Appropriate Core Functions of Public Health Assessment Policy development Assurance 20 21 Another factor emphasized within public health is cultural appropriateness. Cultural appropriateness is emphasized in the way data are collected and the how programs are developed and disseminated. Simply translating a questionnaire or educational materials into another language is not enough. Cultural appropriateness must be taken into account in all aspects of prevention, especially in replication. A program that works with one group may not work with another because of cultural practices and beliefs. Another way to look at the public health approach is to think about the three core functions of public health. They are: -Assessment -Policy development -Assurance Slide 22 Assessment Data on the health status of the population Threats to health and wellbeing of the population Access to health resources 22 The first core function is Assessment. By assessment we mean examining: -the health status of the population -threats to health that focus on - physical and social factors, and -health resources such as the type and distribution of services or professionals. 7
Slide 23 Slide 24 Policy Development Mobilize community partnerships to reduce threats or assure appropriate responses. Assurance Enforcement of laws and regulations Linking people to needed care and assuring care when otherwise unavailable Evaluating effectiveness, accessibility and quality of programs and services 23 24 The next core function is Policy Development. Once information about health status is known, an informed public, community groups and health professionals mobilize to reduce threats or assure appropriate responses. Public health professionals rely on partnerships and community action in achieving many public health policy developments. An example of this might be community organizing around an increase in illegal sales of alcohol to minors. The last core function is Assurance. Assurance is the process of making sure that programs and policies that are developed are, in fact, implemented and evaluated. This may be accomplished through the: -Enforcement of laws and regulations -Linking people to needed care and assuring care when otherwise unavailable -Evaluating effectiveness, accessibility and quality of programs and services 8
Slide 25 Slide 26 Slide 27 Tobacco: Assessment Overwhelming scientific evidence of the link between smoking and cancer led to the Surgeon General s report on smoking and health. Tobacco: Policy Development Warning labels Ban on cigarette advertising Age restrictions on sales to minors Smoking bans on airplanes and restaurants Tobacco: Assurance Enforcement of laws relating to tobacco sales Evaluation of anti-smoking policy 25 26 To further explain the core functions of public health, let s look how the core functions are played out in a classic example of a public health issue: Tobacco. While it is not a violence example, it is something that everyone knows about and about which we have seen many changes over time. In the early 1960s scientific evidence of the link between smoking and cancer led to the Surgeon General s Report on Smoking and Health. This was an example of assessing the problem for the purpose of providing evidence for change. Among many policy developments stemming from tobacco and health research, warning labels were put on cigarettes, cigarette advertising was banned on television and later there were restrictions on tobacco sales to minors. Many of these came about not simply to impact individual behavior, but also to protect the health of the general population, especially as the body of evidence grew to demonstrate the impact of second hand smoke. Enforcement of tobacco laws and the evaluation of antismoking policy and programs are examples of assurance. 27 9
Slide 28 Slide 29 Youth Suicide: Assessment Youth suicide rates have tripled between 1952 and 1996. Youth Suicide: Assessment Males are more likely to commit suicide than females. Firearm related suicide accounted for 63% of the increase in youth suicide between 1980 and 1996. 28 Now let s look at youth suicide through the three core public health functions. Data compiled by the U.S. Department of Health and Human Services found that between 1952 and 1996 youth suicide rates tripled in the United States. Among the key issues, emerging from youth suicide data are: -Males are more likely to commit suicide than females, although females are more likely to attempt suicide using less lethal means. Slide 30 Youth Suicide: Policy Development 1999 Surgeon General s Call to Action to Prevent Suicide Improved training Improved access to mental health services Improved methods for coding violent deaths, such as the National Violent Death Reporting System 29 30 -Firearm related suicide accounted for 63% in the increase in youth suicide between 1980 and 1996. The 1999 Surgeon General s Call to Action to Prevent Suicide was released. This report signaled a commitment on the part of the Department of Health and Human Services (DHHS) to increase funding for efforts to raise awareness, develop preventive interventions and enhance research to study suicide prevention. Among the prevention recommendations were: -Improved training for clinicians, teachers, clergy, social workers and others in the community to recognize suicide risk and make appropriate referrals -Improved access to mental health services -Improved methods for coding violent deaths 10
Slide 31 Slide 32 Youth Suicide: Assurance Child Fatality Review Teams Improve interagency case management Identify breakdowns in child protections systems Develop data information systems CFRTs and Youth Suicide More suicides were attributed to firearms than any other method. Firearm suicides were more likely to be associated with positive alcohol levels. Those who committed suicide with a firearm rarely had a history of depression or a recent life crisis. 31 32 An example of an assurance mechanism is Child Fatality Review Teams (CFRTs). CFRTs are multi agency, multi disciplinary teams that review child deaths from various causes for the purpose of preventing child fatalities. In addition to evaluating the systems, CFRT data provides evidence to support or challenge traditional prevention efforts. CFRTs are designed to: -Improve interagency case management -Identify breakdowns in child protections systems -Develop data information systems. CFRT data have been used to look at youth suicide. Recently a number of researchers examined five years of data from the Arizona CFRTs and made these observations: -More suicides were attributed to firearms than any other method. -Firearm suicides were more likely to be associated with positive alcohol levels -Those who committed suicide with a firearm rarely had a history of depression or a recent life crisis. Azrael, Deborah, et al., Youth Suicide: Insights from 5 Years of Arizona Child Fatality Review Team Data, Suicide and Life Threatening Behavior 34(1) Spring 2004, 36-43. 11
Slide 33 Slide 34 CFRTs and Youth Suicide (cont.) Restricting youth access to lethal weapons Broadening youth suicide prevention to include raising awareness of the link between firearm-related suicide and alcohol use Social Change as Primary Prevention From this To this 33 These findings question some assumptions surrounding youth suicide prevention efforts that focus only on those who exhibit traditional risk factors such as depression, recent trauma and suicidal ideation. The researchers assert that youth suicide prevention needs to focus heightened attention on restricting youth access to lethal weapons and focusing more on broadening public awareness efforts to include the link between alcohol and suicide. The public health approach also often seeks to change public perception of a hazard, so as to change behavior. 34 Let s look again at the example of smoking. Smoking was once a sign of sophistication and played a major role in American cultural identity. Now decades later, the tobacco industry has been sued and laws are making it harder for people to light up publicly. Thus there were not only policy changes but cultural changes as well with regards to tolerance of negative behavior. 12
Slide 35 Social Change - Tobacco Youth smoking has decreased: 13% since 2001 40% since 1997 35 Do people still smoke? Yes. It is addictive and a difficult habit for many to break. One can look around and see many people smoking, including young people. Yet when one looks at data from the National Cancer Institute, the number of young people who start smoking has decreased 13% since 2001 and 40% since 1997. Thus, it appears there has been significant behavior change. National Cancer Institute. Changing Adolescent Smoking Prevalence: Where It Is and Why. Smoking and Tobacco Control Monograph No. 13. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute, April 2002. Slide 36 Social Change Bullying 36 Bullying is another example of how public perception has changed over time due to the efforts of violence prevention professionals. When confronted by bullies as children, many of us were told to turn the other cheek or boys, in particular, were told to stand up and fight like a man. How many girls were told, He only does it because he likes you, when confronted with physical or verbal abuse on the playground? What kind of message did that send? 13
Slide 37 Bullying (cont.) 37 Now bullying is viewed as a symptom of a much larger problem, so much so that the US Department of Health and Human Services launched a national anti-bullying campaign in 2004. Bullying has also been linked to suicide. Because of this, many schools are taking a hard line against both verbal and physical bullying rather than shrugging it off as a rite of passage. This is a change in social norms. Graphic: SAMHSA Slide 38 In summary Key Points Concerned with the health of populations Data-driven/evidence-based Primary Prevention is key 38 Public health is: -Concerned with the health of populations -Data-driven/evidence-based -Primary Prevention is key Slide 39 Key Points (cont.) The public health approach requires cooperation between a wide array of groups including: community groups, schools, law enforcement, policymakers and the health care system. 39 Violence prevention requires cooperation between a wide array of groups including: community groups, schools, law enforcement, policymakers and the health care system. Slide 40 Key Points (cont.) The public health approach utilizes data to assess the extent of a problem and develop, implement and evaluate culturally appropriate preventive strategies and policies. The public health approach is science-based utilizing data to assess the extent of a problem and develop, implement and evaluate culturally-appropriate preventive strategies and policies. 40 14
Slide 41 Conclusion 41 15