Health Promotion and health policy merged.pdf

Principles and actions of health
promotion
Nóra Kovács, PhD
Based on the lecture slides of Karolina
Kósa MD PhD and Éva Bíró MD PhD

Debreceni Egyetem
Global population growth has been
accelerating in the past 200 years
What can be the reasons for the population
growth?

Debreceni Egyetem
Population growth has been attributable to
a decline in mortality (UK)
Mortality in England and Wales: Average life span, 2010. Office for National Statistics 2012.

Debreceni Egyetem
Population growth has been attributable to
a decline in mortality (USA)
Which leading cause of death can play the
major role in the general decline in
mortality?

The availability, completeness and data source of the total
number of births and deaths for in the period 2009-2013, by
region.
Source: United Nations Statistics Division (UNSD)

The largest decline in mortality was due
to that of infectious diseases
Mean annual mortality rates due to certain
communicable diseases
(standardized to age and sex distribution of 1901 population)
McKeown T., Record RG, Population Studies 1962, 16(2):94-122.
What can be the reasons for the decline in
mortality due to the communicable diseases?

Mortality Rates in England & Wales
Tuberculosis Mortality
Scarlet Fever Mortality
Redrawn from McKeown (1976) by Gherardi (nfs.unipv.it/nfs/minf/dispense/immunology/immun.html).

Mortality decline had occurred before effective medical
treatment for infectious diseases was available

Mortality decline occurred due to
improved sanitary conditions…

Debreceni Egyetem
….and improved nutrition
The Waaler curve
Caballero B. J Nutr 2001, 131(3):866S-870S based on Fogel R.
Vertical lines connecting
weight–height
combinations yielding
identical BMIs, between
16 and 31, are depicted.
Three curves represent
weight–height
combinations with similar
mortality risk are
presented for 0.7, 1.0.
and 1.3 relative risk.

McKeown’s Methods
Offered possible explanations for mortality
decline:
i) Spontaneous change in virulence
ii) Reduced exposure to infection
a) Increased levels & quality of vaccination
b) Improved sanitation
iii) Improved host defence following exposure
a) Improved medical treatments
b) Improved nutritional status

McKeown thesis
Major decline in the mortality of infectious diseases
in the industrialized world was primarily due to the
1) improvements in the overall standards of
living, especially better diet that led to improved
nutritional status for the majority of the
population (contributing greatly to a decreased
mortality of tuberculosis and other respiratory
infections);
2) environmental improvements that occurred as
a result of better sanitation, greatly reducing
mortality due to enteral infections; and
3) a favourable immunological trend for scarlet
fever.

Debreceni Egyetem
With declining mortality, disease
patterns changed
McKinlay JB,
McKinlay S:
Health and
Society 1977,
55(3):405-428.

Source:https://www.nejm.org/doi/ful
l/10.1056/NEJMp1113569
Leading causes of death per 100,000 people in the USA

Debreceni Egyetem
Modern medicine contributed significantly to
the treatment of all diseases…
1846: ether as anesthetic
1884: vaccination against rabies
1899: discovery of aspirin
1903: electrocardiography
1906: first cornea transplantation
1921: first successful treatment of diabetes
1928: discovery of penicillin
1941: discovery of streptomycin
1944: first open-heart surgery
1954: introduction of Salk-vaccine
1954: first successful kidney transplantation
1957: ultrasound for pregnancy
1959: discovery of anti-leukemia treatment
1967: computer tomography introduced
1989: first protocol for gene therapy
Rosen 1993
Ackerknecht 1982

…and led to the rise of modern
health care institutions
Hospital Capacity and the general
population in the US, 1872-1932
Number of doctors of medicine compared
with the population in Finland, 1900-2008
US: Mann Wall, Univ. of Pennsylvania
Finland: SENTE Working Papers 29/2010

Debreceni Egyetem
…as well as to the rise of health expenditure
in other developed countries
The Commonwealth Fund 2007

Rising health care costs
• From a public perspective, the most desirable
strategies to address high and rising health care costs
would involve:
• 1) eliminating duplicative or unnecessary care and
reducing administrative overhead;
• 2) preventing illnesses or complications and
detecting conditions at an early stage;
• 3) avoiding unneeded hospitalizations;
• 4) enhancing productivity and efficiency in the
provision of care.
Source: http://www.commonwealthfund.org/publications/fund-reports/2007/jan/slowing-the-
growth-of-u-s--health-care-expenditures--what-are-the-options

Debreceni Egyetem Lalonde-report:
traditional view of health fields
1974
Health care
organisation
Health
Environment
Lifestyle
Lalonde Report 1974
The Report stated that the traditional or generally-accepted view of the health
field was that medicine has been the fount from which all improvements in
health have flowed, and popular belief equates the level of health with the
quality of medicine.

Debreceni Egyetem Lalonde-report:
the new health fields
1974
Human biology Environment
Health care
organisation
Lifestyle
HEALTH
Lalonde Report 1974
The Report analysed the full impact of environmental and lifestyle factors on
morbidity and mortality and concluded that future improvements in the level of
health can be achieved outside of health care, in other dimensions of the health field.

Modern health care is limited in the
„production” of health
• Conceptual limits: repair/replacement does
not provide equivalent quality compared to
healthy conditions
• Many determinants of health fall outside of
the competence of doctors and healthcare
• Medical and financial possibilities in health
care are in conflict → financial limits to care

Debreceni Egyetem
1978: International conference
on primary health care, Alma-Ata
• Health is a fundamental human right.
• Health → „being a state of complete physical, mental and
social wellbeing, and not merely the absence of disease
or infirmity”
• The attainment of the best of health is a most important
global social goal that requires governmental and
intersectoral action.
• Between- and within-country inequalities in health
should be amended.
• Primary health care is a key element of attaining health
( hospital care!).
• National strategies should be developed to launch and
sustain primary health care.

Debreceni Egyetem
1979: „Health for All” strategy of
the World Health Organization
• Predecessor: Alma-Ata Declaration
• Goal: attainment of acceptable level of health
by all peoples of the world by the year 2000
• Key approach: primary health care
• Policy decision: global and national strategies
• Resources: re-allocation of military spending
Global Strategy for Health for All by the Year 2000
World Health Organization Geneva 1981

Debreceni Egyetem
1986: First international conference
on health promotion: Ottawa Charter
Health:
• to reach a state of complete physical, mental and social
well-being, an individual or group must be able to identify
and to realize aspirations, to satisfy needs, and to change or
cope with the environment
• resource for life NOT the objective of living
• positive concept emphasizing social and personal resources,
as well as physical capacities
Health promotion:
• the process of enabling people to increase control over, and
to improve, their health
Actions: health promotion is not just the responsibility of the
health sector
Ottawa Charter for Health Promotion
World Health Organization 1986

Debreceni Egyetem
Levels and users of health care
Inpatient
specialist
care
Outpatient
specialist
care
Outpatient
general care
Not diagnosed and
not treated
patients
Healthy people
Patient
care
Health
promotion
Source: own figure
Number
and
severity
of
health
risks

Debreceni Egyetem
Prerequisites of health - Ottawa Charter
• peace
• shelter
• education
• food
• income
• a stable eco-system
• sustainable resources
• social justice, and equity

Debreceni Egyetem
Action areas of health promotion
1. Build healthy public policy
2. Create supportive
environments
3. Strenghten community action
4. Develop personal skills
5. Reorient health services

Build healthy public policy
• Healthy public policies are needed in
all sectors and at all levels, directing
them to be aware of the health
consequences of their decisions and
to accept their responsibilities for
health. Health promotion policy
combines legislation, fiscal
measures, taxation and
organizational change in a
coordinated manner that leads to
health, income and social policies
that foster greater equity.

Create supportive environments
• Health promotion generates living
and working conditions that are
safe, stimulating, satisfying and
enjoyable; that is, health promotion
creates environments supportive of
health, among others, by the
protection of the natural and built
environments and the conservation
of natural resources.

Strenghten community action
• Health promotion works through
concrete and effective community action
in setting priorities, making decisions,
planning strategies and implementing
them to achieve better health. At the
heart of this process is the
empowerment of communities, the
strengthening community actions by full
and continuous access to information,
learning opportunities for health, as well
as funding support.

Develop personal skills
• Health promotion supports personal
and social development through
providing information, education for
health, and enhancing life skills
(developing personal skills).

Reorient health services
The role of the health sector must move
increasingly in a health promotion direction,
beyond its responsibility for providing
clinical and curative services. Health
services need to embrace an expanded
mandate that should support the needs of
individuals and communities for a healthier
life, and open channels between the health
sector and broader social, political,
economic and physical environmental
components. Reorienting health services
also requires stronger attention to health
research as well as changes in professional
education and training.

Educate people on the effects of
smoking & how to quit

Make smoking
unfashionable →
reduce peer pressure to
smoke

Make smoking
unfashionable →
smoke
Educate medical
students about treating
tobacco use

Limit smoking in public places
e.g. smoke-free workplaces and
schools
Make smoking
unfashionable →
smoke
Educate medical
students about brief
physician advice

Restrict tobacco sales
Make smoking
unfashionable →
smoke
Educate medical
students about brief
physician advice
Smoke-free
workplaces and
schools

Macro-level
1 Healthy public policy
2 Supportive environment
5 Reoriented health services
Meso-level
3 Community action
Micro-level
4 Personal skills
economic, social,
environmental,
cultural factors
living&working
conditions
social&
community
factors
lifestyle&
behaviour
psychologic
al factors
age,
sex,
genetics
Debreceni Egyetem
Health promotion actions are targeted to
determinants of health at different levels
After Dahlgren and Whitehead, 1993

Debreceni Egyetem
International conferences
on health promotion
• 1986: Ottawa Charter for Health Promotion
• 1988: Adelaide Recommendations on Healthy Public Policy
• 1991: Sundsvall Statement on Supportive Environments
• 1997: Jakarta Declaration on Leading Health Promotion into
the 21st Century
• 2000: Mexico Ministerial Statement for the Promotion of
Health: from ideas to action
• 2005: The Bangkok Charter for Health Promotion in a
Globalized World
• 2009: Nairobi Call to Action
• 2013: Health in All Policies Framework for Country Action –
Helsinki
• 2016: Promoting health, promoting sustainable
development: Health for all, and all for health - Shanghai
World Health Organization

Health promotion and public health, BSc in Public Health UD
Practical 2: Infrastructure of health promotion
1. Draw the structure of the United Nations! Which programmes and funds within UN deal with
issues related to health?
https://www.un.org/en/about-us/un-system
2. How many offices are there within the WHO? Which regional office does your country
belong?
https://www.who.int/about/structure
3. What is the most reliable source of public health information in Europe?
WHO Regional Office for Europe https://www.who.int/europe/home?v=welcome
4. What is the most reliable source of public health information in the European Union?
http://ec.europa.eu/health/index_en.htm
5. What is the most reliable source of public health–related information in the US?
Centers for Disease Control and Prevention http://www.cdc.gov/
6. Can you find information related to health at the portal of the World Bank?
https://databank.worldbank.org/source/millennium-development-goals
7. Where can you read the Ottawa Charter?
https://www.who.int/teams/health-promotion/enhanced-wellbeing/first-global-conference
Substance use
8. Where can you find data about drug use and smoking habits in Europe?
http://www.emcdda.europa.eu/
www.ensp.org
http://www.espad.org/
9. Where can you find data about drug use and smoking habits in the world?
http://www.who.int/topics/substance_abuse/en/
World Drug Report published by the UN Office on Drugs and Crime
https://www.unodc.org/unodc/en/data-and-analysis/research-on-drugs.html
10. Is coca leaf a drug according to the International Narcotics Control Board?
http://www.incb.org/incb/en/narcotic-drugs/1961_Convention.html
Cancer
11. Where do you find information about cancer epidemiology in Europe?
http://www.iarc.fr/

Health promotion and public health, BSc in Public Health UD
12. Is the substance 3,4,5,3’,4’-pentachlorobiphenyl carcinogenic? Is azobenzene carcinogenic?
http://www.iarc.fr/
Lifestyle
13. Where can you see the list of E numbers?
https://www.eufic.org/en/
https://webgate.ec.europa.eu/foods_system/main/?sector=FAD&auth=SANCAS
The European Food Information Council (EUFIC), US: Federal Food, Drug, and Cosmetic Act;
FD&C
14. From where can you collect data about health behavior in school-aged children?
http://www.hbsc.org/
15. What are the social determinants of health according to the WHO?
http://www.who.int/social_determinants/en/
16. Where can you find the Human Development Reports?
http://hdr.undp.org/en/
17. Search the latest HDI index of your home country.
http://hdr.undp.org/en/data
Infectious diseases
18. Browse the WHO Communicable Disease Global Atlas to know what the current situation in
your country is.
https://apps.who.int/globalatlas/InteractiveMap/HowTo/HowTo.htm

Models of health
Nóra Kovács, PhD
Based on the lecture slides of Éva Bíró MD PhD

World Health Organization (1948)
Health is a state of complete
physical, mental and social wellbeing
and not merely
the absence of disease or infirmity.
• This definition was groundbreaking because of its
breadth and ambition.
•It overcame the negative definition of health as
absence of disease.
•But …

Criticism of the WHO definition
• absoluteness of the word “complete” in relation to wellbeing
The requirement for complete health “would leave most of us
unhealthy most of the time.” - expanding the scope of the
healthcare system
• Demography of populations and the nature of disease have
changed – number of people living with chronic diseases for
decades is increasing worldwide
WHO definition becomes counterproductive as it declares people
with chronic diseases and disabilities definitively ill.
• Operationalisation of the definition: WHO has developed several
systems to classify diseases. Yet because of the reference to a
complete state, the definition remains impracticable, because
‘complete’ is neither operational nor measurable.

Marx (~1850s)
Health is an ability to work.
Parsons (1964)
Health … is the state of optimum
capacity of an individual for the
effective role and tasks for which
(s)he has been socialized.

Illich (1972)
Health is a process of adaptation.
It designates the ability
•to adapt to changing environments,
•to growing up and ageing,
•to healing when damaged,
•to suffering,
•and to the peaceful expectation of death.

Ottawa Charter (1986)
•Health is a resource for everyday life, not the
objective of living.
•Health is a positive
concept emphasizing
social and personal
resources, as well
as physical capacities.

Health
•There is no one, universally accepted definition
•Can be seen as an end or means to an end
•Cannot be understood in isolation from
circumstances of the individual

What is health?
A person’s health is equivalent to
the state of the set of conditions
• which fulfil or enable a person to
work
• to fulfil his/her realistic chosen
• and biological potentials (in a positive
way).
D. Seedhouse: Health promotion: philosophy, prejudice and practice 1997
Nick Vujicic

The most widely used HEALTH
MODELS

What is a health model?
Models of health are „conceptual frameworks” or ways
of thinking about health.
Frequently used models of health:
1. Biomedical
2. Socioeconomic
3. Bio-psycho-social (functional)
4. Spiritual

Biomedical model
•Health = lack of disease
•Focuses on the physical or biological aspects
of disease and illness.
•Health is a commodity ~ can be priced
•Health is quantifiable.
•Human body ~ device, machine
•Treatment of disease: machine dissected to
its component parts
•Medicine ~ engineering

Socio-economic model of health
• WHO state that the social or wider determinants of health are “the
conditions in which people are born, grow, live, work and age. These
conditions or circumstances are shaped by the distribution of money,
power and resources at global, national and local levels”. WHO makes
clear the link between the social determinants of health and health
inequalities, defined as “the unfair and avoidable difference in health
status seen within and between countries.” (WHO, 2012)
• It is not just the physical and environmental conditions in which
people live which affect their health. The psychosocial factors such
as social networks, social status and individual lifestyle work along
side economic and environmental factors in determining health.
• All these factors interact with each other, there is both an inverse and
converse relationship between the determinants of health.

Socio-economic model of health
The classical diagram by Dahlgren and Whitehead (1991)

Bio-psycho-social (functional) model
Social factors
Culture
Social interactions
The sick role
Environmental factors
Participation restriction
(disability)
Psychological factors
Illness behaviour
Belief, coping strategies
Emotions, distress
Activity limitations
Personal factors
Biological factors
Neurophysiology
Physiological dysfunctions
(tissue damage?)
Impairments
Body structure and functions

International Classification of Functioning (ICF)
Source: Harris et al. Health and Quality of Life
Outcomes 2005 3:73

Spiritual models 1.
Animism/magic models: belief in a supernatural
power
All things (animate & inanimate) in the universe are
invested with a life force/soul/mind
•African traditional religions
•Shinto
•Folk Hinduism
•Modern Neopagans

Spiritual models 2.
Religious models
An almighty non-material power or powers created
and control all things including health
•Judaism
•Christianity
•Islam
•Hinduism
•Buddhism
•Shintoism
•New Age religions

• As a first step in helping patients implement lifestyle changes for
weight loss, clinicians should assess the person's lifestyle history and
determine other potential factors that are contributing to weight
gain. Such information can guide the clinician in making the proper
adjustments to a patient's medical regimen that may help with weight-
management efforts and in providing appropriate advice on lifestyle
change. It may also impact treatment recommendations.
• The clinician and the patient who is ready to begin a weight-loss plan
should work together to set appropriate health goals and develop a
comprehensive lifestyle treatment strategy to achieve those goals.
• Data show that the most effective behavioral weight-loss strategy is an
in-person, high-intensity comprehensive weight-loss intervention
provided individually or in group sessions by a trained interventionist.
The principal components of such an intervention include: 1)
prescription of a moderately reduced-calorie diet; 2) a program of
increased physical activity; and 3) the use of behavioral strategies to
facilitate adherence to diet and activity recommendations.

Which health model can be identified?
1. Biomedical
2. Socioeconomic
3. Bio-psycho-social (functional)
4. Spiritual

• In July 2003, at the age of thirteen, Pratik’s eating habits began to
change noticeably over a period of a month. The volume of food that
he consumed dramatically increased and he kept eating throughout
the day. Initially he would eat normally for his age, but now it was
more than double the normal volume.
• Pratik’s grandmother would try to explain to him lovingly and
sometimes sternly about his overeating habit. He would sincerely try
to listen but eventually used to give in to his desire to eat. Once he
said, “I cannot stop my overeating even though I know it is not right.
As soon as I see or think of food I cannot control myself.”
• About a year into his habit of compulsive overeating Pratik’s aunt
came to visit the family. When she saw Pratik’s incessant need for
food she realised something was amiss. She advised Pratik’s mother
that a departed ancestor of their family was causing the problem.

Here’s a roundup of some of the most promising initiatives in Canada’s
fight against fat.
• Sheila Hryniuk will never forget standing on the outskirts and realizing
there was no safe way to walk or bike on a highway. A task force
devised an action plan that included promoting not only active
transportation but economic improvement. The old city centre got a
facelift, storefronts were freshly painted, planters and benches dot
pleasant walking routes and painted footsteps along roads encourage
residents to “Walk a Mile.” The downtown area is safer for pedestrians,
and linked bike paths are being planned, mapped and created.
• Evidence shows that people use the stairs much more often when
stairways are more accessible and visually appealing. In the Stairway to
Health project stairwells were painted welcoming colours, music was
piped in and the works of local artists were hung on walls in the
landings. Posters by the elevators encouraged everyone to take the
stairs. And they did, and still do.

• A 52-year-old woman with obesity and a 9 year history of type 2
diabetes presents with complaints of fatigue, difficulty losing weight,
and no motivation. She states that she has gained an enormnous
amount of weight since being placed on insulin 6 years ago. Her
weight has continued to increase over the past 5 years, and she is
presently at the highest weight she has ever been. She states that
every time she tries to cut down on her eating she has symptoms of
shakiness and increased hunger. She does not follow any specific diet
and has been so fearful of hypoglycemia that she often eats extra
snacks.
• Her health care practitioners have repeatedly advised weight loss and
exercise to improve her health status. She complains that the pain in
her knees and ankles makes it difficult to do any exercise.
• After an explanation that the increasing insulin doses were
contributing to her weight gain and that she would need to decrease
her insulin dose along with her food intake to prevent hypoglycemia,
the patient agreed to follow a restricted-calorie diet and to decrease
her insulin. She was also started metformin.

How can we improve health?
HEALTH PROMOTION

Common element: work for health (health
promotion) to remove or prevent the creation of
•biological,
•environmental,
•societal,
•familial or
•personal obstacles
to the achievement of human potential.

Macro-level
Meso-level
Micro-level
economic, social,
environmental,
cultural factors
living&working
conditions
social&
community
factors
lifestyle&
behaviour
psychologic
al factors
age,
sex,
genetics

Macro-level
1 Healthy public policy
2 Supportive environment
5 Reoriented health services
Meso-level
3 Community action
Micro-level
4 Personal skills
economic, social,
environmental,
cultural factors
living&working
conditions
social&
community
factors
lifestyle&
behaviour
psychologic
al factors
age,
sex,
genetics

Health education
Health promotion and health policy
BSc in PH
University of Debrecen
Based on the lecture slides of Éva
Bíró MD PhD

What is health education?
• WHO: constructed opportunities for learning
involving some form of communication
– for communities and individuals
– for positive change of health literacy,
information related to health and attitudes.

Why is health education needed?
• more individuals know about how things
work, how cause and effect are related
the easier for them to take control
• ‘cognitive dissonance’: someone might be
aware of a cause-effect relationship but it
does not necessarily mean that he/she will
try to avoid that cause even if he/she does
not want the effect

Why is health education needed
in health care?
1. Health education → health literacy (ability to
understand health information and use it to
make decisions on health)

Burden of inadequate health literacy
Use of health care services
-increased hospital (re)admissions,
-poorer medication adherence and
increased adverse medication events,
-less effective communication with
healthcare professionals
Health status
-lower functional status,
-poorer self-management of chronic
diseases and poorer disease outcomes,
-poorer overall health status including
increased mortality
Health behaviour
-less participation in prevention activities,
-higher prevalence of risk behaviours
Costs of health care
-increased healthcare costs
Low health
literacy
Own figure based on WHO 2015

Be aware:
• There are problems with general literacy
(ability to read and write) around the world.

Be aware:
• Even those who are literate can be graded
by levels:
– Level 1: very poor literacy skills (eg. cannot
measure fluid medication properly on written
instruction)

Azithromycin 200mg/5ml Powder for Oral Suspension

Be aware:
• Even those who are literate can be graded
by levels:
– Level 1: very poor literacy skills (eg. cannot
measure fluid medication properly on written
instruction)
– Level 2: can comprehend simple, clear material
and perform uncomplicated tasks
– Level 3: required to work in an advanced society
– Level 4/5: can process complex and demanding
information

Be aware:
• Health literacy is related to general literacy
and is limited even in developed countries.
• Improper understanding of health-related
information results in uninformed/bad
decisions made by the patient.

Results of a health literacy (HL) survey in
8 European countries

Why is health education needed?

A woman married at the age of 17 and gave birth to a
hemophiliac son. She was told of the disease and how it is
inherited and she was warned about the certainty of having a
second sick child if it is male.
During her second pregnancy the ultrasound examination
detected a male fetus but for the woman it was inconceivable
that “by pushing a piece of plastic on my tummy back and forth
they could tell the sex of the child” so she declined abortion
and gave birth to a second hemophiliac son.
Both sons became infected by hepatitis C virus by unscreened
factor preparations.
Now the mother tends to her children all the time with great
effort, learned how to inject the factor preparation at home,
and the family has been in extreme poverty because of the
extra costs of raising two sick children and the mother not
being able to work. The woman had her third pregnancy with a
male fetus terminated.

1. If you eat the entire container, how many
calories will you eat?
2. If you are allowed to eat 60 g of
carbohydrates as a snack, how much ice
cream could you have?
3. Your doctor advises you to reduce the
amount of saturated fat in your diet. You
usually have 42 g of saturated fat each
day, which includes 1 serving of ice cream.
If you stop eating ice cream, how many
grams of saturated fat would you be
consuming each day?
4. If you usually eat 2500 calories in a day,
what percentage of your daily value of
calories will you be eating if you eat one
serving?
5. Pretend that you are allergic to penicillin,
peanuts, latex gloves and bee stings. Is it
safe for you to eat this ice cream?
6. Why?
This information below is
on the back of a container
of a pint of ice cream. 1000 calories
half the container
33 g
10%
no
score 4-6 adequate literacy
score 2-3 limited literacy
score 0-1 inadequate literacy it has peanut oil

HLS-EU Consortium: European Health Literacy Survey 2011
Functional health literacy in the EU

The methods of health education
• Who?
• Which form of communication?
– Lectures, seminars
– Videos, computer programs
– Internet
– TV programmes
– Printed materials
– Mobile apps

Internet, videos
Quitting Smoking Timeline

The methods of health education
• Who?
• Which form of communication?
• Where?
• Target population?
any health education information must be
specifically tailored to the target audience

Basic principles of health education
1. Set your presentation to your target
group!
2. Clear and simplify your message!
3. Give concrete advices!
4. Use simplified graphs, pictures in stead
of tables and text!

Nutritional guidelines
Which do you like more?
Which would you recommend for
your grandmother? And for your
40-year-old male neighbour?

swole.me -automatic diet planner

Guidelines for healthy eating
AHA- www.heart.org
• Use up at least as many calories as you take in.
– Start by knowing how many calories you should be eating and drinking to maintain your weight.
Nutrition and calorie information on food labels is typically based on a 2,000 calorie per day diet. You
may need fewer or more calories depending on several factors including age, gender, and level of
physical activity.
– Increase the amount and intensity of your physical activity to burn more calories.
– Aim for at least 150 minutes of moderate physical activity or 75 minutes of vigorous physical activity
(or an equal combination of both) each week.
– Regular physical activity can help you maintain your weight, keep off weight that you lose and reach
physical and cardiovascular fitness. If it’s hard to schedule regular exercise, look for ways to build
short bursts of activity into your daily routine such as parking farther away and taking the stairs instead
of the elevator. Ideally, your activity should be spread throughout the week.
• Eat a variety of nutritious foods from all the food groups.
– a wide variety of fruits and vegetables
– whole grains and products made up mostly of whole grains
– healthy sources of protein (mostly plants such as legumes and nuts; fish and seafood; low-fat or nonfat
dairy; and, if you eat meat and poultry, ensuring it is lean and unprocessed)
– liquid non-tropical vegetable oils
– minimally processed foods
– minimized intake of added sugars
– foods prepared with little or no salt
– limited or preferably no alcohol intake

How to do health education
effectively?

Practical: students
presenting on given topics

Case 1
The Golden Age Club of your neighbourhood
invited you to give a short presentation for them on
medical issues relevant for travellers. The
membership of the club consists of reasonably
healthy retired persons (most of them college-
graduates) who are planning a two-week tour of
India. They are mostly concerned about food and
water safety.

Case 2
The Health Department of the municipal
government to which your practice belongs
asks you to give a brief overview on the
health benefits of physical exercise. Your
target audience is comprised of the officers
of the department, most of them women
with secondary education. They do
sedentary work in the office, some of them
are visibly overweight. Please give some
practical advise as to what forms of
exercise the workers should take up.

Remember
• Literacy is graded
• Health literacy is required for informed
decision making
• Health education should deliver clear,
simple, illustrated messages tailored to the
individual patient from a credible specialist

Health promotion and public health, BSc in Public Health, UD
4. Practical: searching for research-based information on the net
Student handout
1. DE library:
Use: https://lib.unideb.hu/en
• Search for the PhD thesis of Attila Nagy
2. Pubmed:
www.pubmed.gov
Find articles (only systematic reviews!) in the following topic:
• effect of sleep deprivation on cardiovascular diseases (search from 2015-2019)
• effectiveness of workplace intervention to reduce musculoskeletal pain (search from
2013-2019)
3. Cochrane library:
https://www.cochranelibrary.com/
• Can exercise based intervention help for smoking cessation?
• Effectiveness of cervical cancer vaccination (search from 2017)
4. IARC:
http://www.iarc.fr/
Answer the question:
• Can arsenic cause cancer? (Find List of Classifications)
• Can nicotine cause cancer? (Find List of Classifications)
• Can aluminium production cause cancer? (Find List of Classifications)
https://monographs.iarc.who.int/agents-classified-by-the-iarc/
• What are the exposure sources of arsenic for human? (Find Monographs available)
• Which carcinogenic agents show strong association with stomach cancer? (Find List of
Classifications by cancer site)
5. IHME
http://www.healthdata.org/
Global Burden of Disease:
Find data of your Country in the following topics:
• HIV mortality (Use HIV visualization) https://vizhub.healthdata.org/hiv/

Hepatitis mortality rate (use Hepatitis Atlas)
https://hepatitis.ihme.services/impact?age_group_id=22&measure_id=6&metric_id=3
o What country experienced the highest mortality rate caused by hepatitis in 1990,
and how has that changed over the period 1990-2017?
o How does the mortality rate caused by hepatitis B changed in Hungary among
men and women?
6. WHO:
www.who.int
• Find WHO Fact Sheet on Ebola!
o List symptoms of Ebola!
o Who is at higher risk of infection?
• Is red meat carcinogenic? https://www.who.int/news/item/29-10-2015-links-between-
processed-meat-and-colorectal-cancer

Effective communication
Health promotion and health policy
BSc in Public Health

What communication is?
changing information with the help of a
common sign system

What makes the communication
effective?
Reaches its aim.
What is the aim of the
communication?
What communication is?
changing information with the help of a
common sign system

Communication:
Any living’s behaviour, which changes an
another living’s behaviour in order to get better
condition for its survival and reproduction.

• „Impossible not to communicate.”
• Four sided model of communication:
• Sender
• 1: Topic (what do I say)
• 2: Connection (what is our relationship)
• 3: Self-expression (how do I say)
• 4: Purpose (what do I want from he/she?)
Paul Watzlawick et al: Theory of human
communication 1967
1 2
3 4
Receiver
Friedemann Schulz von Thun

Elements of Communication:
• Verbal – the words (what I say)
• Non-verbal (how I say it)
– Vocal
• tone, volume, pitch, intonation, rythm, speed, emphasis
– Body language
• look, eye contact
• facial expressions, gestures
• posture, moving
• proximity: personal space, touch
• appearance, clothing
• attitude: height differences, orientation
Non-verbal communication highligts, modulates,
denies or substitudes the message given by the
words.
nem
verbális

The effect of the different forms of
communication:
Who’s got more
professional
credibility?
10%
55%
35%
words
vocal
other non-
verbal

Communication styles:
http://www.youtube.com/watch?v=o6LcPfnwGec

Styles of communication
• Aggressive („I win”, frightening, threatening,
explosive)
– loud, formulation: strongly worded
• Submissive/Passive (pleasing others,
apologetic and avoiding conflict)
– quiet, formulation: conditional, soft spoken,
uncertain
• Assertive (achiving goal without hurting others,
protect own rights, but respect other’s)
– strong-minded, definite but not wants to override,
pays attention

• If you can manage, it would be good if you
would come….
• Please come.
• Come. You must be there!

Identify the communication style:
• Oh, really, I don’t know…we can do whatever you want.
• Don’t you dare to interrupt me!
• You never understand, what I mean. I’ll try to simplify it
for you!
• I see it is important for you and I would also like to solve
the problem, so we should calm down and talk about
this, we can certainly find some kind of solution.
• You never do anything properly!
• I don’t mind….
• Please do not talk to me this way, beacuse it hurts me!
• When you come in, close the door please, I don’t want to
get cold in this weather.

Practice
• One Saturday afternoon you just want to go out
with your friends. Your parents asks you to do
some task for them. The task seems important
for them, but you consider it surely can wait till
tomorrow.
• How do you argue?
• Would you use different terms, if your
girl/boyfriend asks your help?
• And your boss?

Professional Communication:
• Colleague
• Health promotion’s target population
• 1. Speak
• 2. Listen
• 3. Ask
• 4. Where can it go wrong?

Professional Communication:
• Colleagues:
– Same position: Be friendly, open and honest!
• Your goal: partnership
– Higher position: Respect
– Lower position: Accept
• Handling disagreements:
Conflict solving styles:
• Avoid conflict
• Submit
• Win/Loose
• Consensus
• Problem solving

”Good” Communication:
• Clear, precise and two-way, constructive
changing of information; where the
message is undamaged.
• Accept vs. Judge
• Autonomy vs. Dependence
• Partnership vs. One-direct
• Positive vs. Negative feelings generated
(reward vs. punishment)

Self-evaluation, self-respect (self-confidence),
emotional intelligence,
and effective communication:
Emotional intelligence
is the ability to
understand, use, and
manage your own
emotions in positive
ways, communicate
effectively, empathize
with others, overcome
challenges and defuse
conflict → to make
optimal decisions.

Self-Confidence in Communication:
• Who dares to say all what he/she wants to
and asks everything he/she is interested
in, open, comprehensible and honest way.
• NO aggression.
• NO hiding of real feelings.
• NO speaking of unimportant things.
• NO manipulation of others in order to get
what he/she wants.

• Creates Win-Win situation:
– Consensus. The situation may not be ideal,
but good enough for both parties to support
the case.
– Both of us compromised.
– We can manage successful negotiations in
the future.

is needed for:
• Moral communication and partnership.
• Respect myself AND the other people.
• Being sensitive for other’s need and
beliefs.
These qualities are abilities. Learnable
and improvable.
Eg. role model

Observe:
Handling emotional situations:
• 1. Recognition: What do you feel?
• 2. Accept: It’s OK, that you feel that way.
• 3. Say: „I know, how you feel.”
• 4. Give ideas for solution.

Emotional intelligence and effective
communication:
Say it effectively:
• I’m totally fed up with that
idiot from HR!
• I’m a big misfortune!
• Mum said I must accept that
good job.
• You just not able to help me!
• Everybody is stupid, who
smokes inside!
• I think I need to go swimming
now to calm down!
• I dont feel very fortunate
today…
• I think I don’t perform well in
an office.
• I see you are too tired to help
me now.
• The smoke makes me cough.
Please don’t smoke inside!

Active listening:
• Aim: Understanding.
• Let the other talk without hesitation and
interruption about his/her situation, help
expressing his/her feelings, beliefs and
opinions, help reveal his/her knowledge,
values and attitudes.
• Result:
• Strengthen the speaker’s responsibility for
his/herself. Motivates health-related
decisions.

Active listening:
• How to do it?
• 1. pay attention– eye contact
• 2. encourage– gestures
• 3. paraphrases
• 4. mirror feelings
• 5. mirror meanings
• 6. summarise– Am I thinking correctly based
on what you mention that….

Asking:
• Closed questions
• Open questions
• Question with prejudice
• Multiple question
• Feedback: Always ask with open question!
It is the informer’s responsibility that people
get and understand the message.

Failure Situations:
• 1. Social and cultural differences:
– Ethnics
– Social class
– Values
– Gender
• Will result different beliefs about health
• Clothing
• Language using
• Hygiene
• Eating.

Failure Situations:
• 1. Social and cultural differences.
• 2. Reduced receptivity:
– Difficulty in learning.
– Sick, tired, in pain.
– Emotional distress (apathic).
– Too busy / distracted / absent minded.
– Incorrect self-evaluation, health is not important.

Failure Situations:
• 2. Reduced receptivity.
• 3. Negativ attitude toward the health
promoter (HP):
– Previous negative experience.
– Lack of trust toward „authority”.
– HP is disrespected.
– HP deemed dangereous (criticises).
– „I know all these stuff”.
– „I can’t afford this lifestyle…”
– Don’t bear facing bad news.

Failure Situations:
promoter (HP).
• 4. Understanding Problems:
– Language differences.
– Under-educated.
– Don’t understand the professional expressions.
– Unable to remember the given information.

Failure Situations:
promoter (HP).
• 4. Understanding Problems.
• 5. HP doesn’t stress the important
information:
– Contacting in not prioritised.
– Lack of confidence or abilities.
– Over-occupied, or the leadership not supportive.
– Don’t want to share the information.

Failure Situations:
promoter (HP).
• 4. Understanding Problems.
• 5. HP doesn’t stress the important
information.
• 6. Contradictory informations:
– Other HP tells otherwise.
– Family / friends tell otherwise.
– Up-to-date information differs from previous.

1. The spirit contains methanol.
2. Back dated chocolate Santa from the last year.
3. Sugar syrup sold in stead of honey.
4. Sausage from skin, fat , chemicals and additives.
5. Chicken covered with curcuma.
6. Soy oil with colouring in stead of extra fine olive oil.
7. Not bio product in stead of bio product.
8. Chili coloured with minium.
Go back to the shop and complain!

Talk with your boss!
1. The rating system is too rigid, recognize only
knowledge and working term.
2. Bonuses are not nor resorted for everyone.
3. Compulsory physical activity programmes
thought up by the management.
4. Tasks that your boss charged you are illegal
or are not contained in the scope.

Tactful Communication:
• T Think before you speak
• A Apologise
• C Converse
• T Time your comments
• F Focus on behaviour
• U Uncover feelings
• L Listen for feedback

DOs: DON’Ts:
Do be direct, courteous and
calm. Don’t be rude or pushy.
Do spare others your
unasked advice.
Don’t be patronising, superior or
sarcastic.
Do acknowledge that what
works for you may not
work for others.
Don’t make personal attacks or
insinuations.
Do say main points first,
then offer more details if
necessary.
Don’t expect others to follow your
advice or always agree with you.
Do listen for hidden
feelings.
Don’t suggest changes that a
person cannot easily make.

Literature:
L. Ewles, I. Simnett:
Promoting Health
A Practical Guide

3. Practical in groups: Finding Background materials in the following health
topics:
• nutritional guidelines: US (health.gov)
• guidelines on physical activity: CDC (US), WHO, EHIS
• psychoactive drugs: most frequently consumed substances below 18 ys, problem drug use;
universal, selective, indicated prevention (according to EMCDDA, ESPAD)
• CDC on quitting smoking
• cardiovascular risk assessment: SCORE risk based on case description (heartscore.org)
Questions:
1. Search for the current American nutritional guideline for healthy adults (age 19-59)! (a)
Write down the recommendations for grains, fruits, vegetables and dairy products. (b)
Check the recommendation of added sugar consumption. What is the major source of
intake of added sugar?
http://www.choosemyplate.gov/
http://health.gov/dietaryguidelines/
https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials
2. (a) Compare the American and World Health Organization (WHO) guidelines on
physical activity. Summarize the most important recommendations (for adults) and add
the publication dates of the guidelines. (b) Check the Hungarian data of the European
Health Interview Survey 2009! Do Hungarians get enough physical activity on average?
EHIS (ELEF) 2009- http://www.ksh.hu/docs/eng/xftp/stattukor/eelef09.pdf
CDC: http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html
https://health.gov/our-work/nutrition-physical-activity/physical-activity-guidelines/current-
guidelines (2018)
WHO: https://www.who.int/publications/i/item/9789240015128 (2020)
3. Find the most frequently used subtances in the Netherlands, Czech Republic and Ireland
between 15-16 years! (b) What does lifetime prevalence mean and (c) what is the lifetime
prevalence of the use of cannabis among aged 15-16 years in Netherlands, Czech
Republic and Hungary in 2019? Add the sources of your data!
EMDCCA: http://www.emcdda.europa.eu/countries
https://www.emcdda.europa.eu/publications-seriestype/country-drug-report_en
ESPAD: http://www.espad.org/espad-report-2019

4. What does it mean:
a. problem drug use
b. universal prevention
c. selective prevention
d. indicated prevention
In which field of public health can we use these definitions?
http://www.emcdda.europa.eu/topics/prevention
https://www.emcdda.europa.eu/publications/manuals/european-prevention-curriculum
Topics: prevention, problem drug use
5. Find the American recommendation for quit smoking! Add the link of the website where
you could find it! Which methods are used for quit smoking?
http://www.cdc.gov/tobacco/quit_smoking/
6. A 50-year-old man from the United Kingdom ask you as a public health professional to
evaluate his risk to cardiovascular disease:
a) Smoking for 15 years, smokes 10-15 cigarettes daily.
b) His blood pressure was not less than 145/135 Hgmm.
c) He doesn’t have diabetes mellitus, but his cholesterol level was high in the last 2 years
(8,6 mmol/L), HDL level was 1.1 mmol/L.
d) Weight: 95 kg, Height: 165 cm, waist circumference: 106 cm
European score: https://www.heartscore.org/en_GB
http://www.escardio.org/static_file/Escardio/Subspecialty/EACPR/Documents/score-
charts.pdf

How to make a good
presentation
Based on the lecture slides
of Éva Bíró MD PhD

What makes a good presentation?

What should we know
about our audience?
• Age
• Gender
• Level of education, occupation
• Knowledge about the topic
• Literacy level
• Number of people
• Interest
• Attitude towards the topic & lecturer
• Other important feautures (e.g. religion)

time
attention
span
G. Reynolds
Length of human attention span

Structure of the presentation
• Introduction
– Captatio benevolentiae (reach the audience)
– Aim of the presentation
– Importance of the topic
• Content
– What is the message?
– How can I confirm?
– How can it be more expressive?
• Discussion
– What is the conclusion? („take home message”)
• Questions

HOW DO WE PRESENT OUR
TOPIC?
• In a scientific way
• Dreadfully
• Interestingly
• Humorous

What would you say about the topic if
the target group is teenagers?
• Smoking
• Alcohol consumption

What would you say about the
topic if the target group is
elderly people?
• Physical activity
• Nutrition

Communication with lay
public
• Use simple language.
• Use plenty of illustrations.
• Give specific advice.
• Tell stories.
• Pay attention to the feedback.

Health communication =
persuasion
logic emotion

Physical activity
30 min every day
- a specific age group should
always be given examples from
their own age group

What are the circumstances like?
• How large is the audience?
• How large is the room?
• What kind of tools can we use during the
presentation?
Is it available? We have to bring it?
• How long is the presentation?
• 1 powerpoint slide ~ 1 min
• 1 page ~ 1-3 min
• Visual illustrations

Tips for an effective presentation
• Prezentáció készítése
• A prezentáció (bemutató) készítésének célja lehet egy előadás anyagának érthetőbbé,
figyelemfelkeltőbbé tétele. A távoktatásban is használhatjuk, hiszen weblap (.htm) formátumban
elmenthető, így feltehető az internetre. Használhatjuk marketing eszközként, reklámokat
készíthetünk, üzleti beszámolók, tudományos konferenciák segédeszköze lehet.
• A prezentáció az oktatásban is jelentősen segítheti a tanulási-tanítási folyamatot.
• Egy bemutató helyettesítheti az eddigiekben használt audio-vizuális eszközök jó részét.
(Írásvetítő, diavetítő, epidiaszkóp, audio,-videomagnó)
• Megjegyzés:
• Sajnos eszközei költségesebbek, mint egy diavetítőé vagy egy írásvetítőé. Számítógép, (asztali,
vagy hordozható) természetesen a legális software és egy kivetítő (projektor) általában kell.
• A prezentációt alkotó „diakockák” (slide) tartalmazhatnak szöveget, képet, ábrát, diagramot,
táblázatot, de hangot, mozgóképet (clip) is. Ilyen tekintetben mindenképpen a multimédiás
alkalmazások kategóriájába sorolható.(lsd.: Multimédia segédanyag)
• Ilyen programok pl. a Lotus Freelance, Harvard Graphics, Corel Presentation, OpenOffice, MS
PowerPoint.
• A PowerPoint program (XP verzió)
• A bemutató tartalmi és formai elkészítése
• A prezentációkészítő programok közül a Microsoft Office XP programcsomagban lévő PowerPoint
programmal fogunk közelebbről megismerkedni.
• A program indító felületén kiválaszthatjuk, hogy létező bemutatót nyitunk meg, vagy új bemutatót
készítünk. Ha új bemutató készül, rendelkezésünkre áll a bemutatás tervező varázsló (wizard),
amely a kezdő felhasználót végigvezeti a készítés lépésein.
1.Don’t put too much information on one
slide.
2.Use notes instead of full sentences.
3.Use a font size of at least 20.

Light letters on a dark background
Fonts and legibility

Dark letters on a light background

Table 2: Binary logistic regression estimates (OR [95%CI]), full model
OR and CI values were rounded to two decimals. a Reference category = Boys; b Reference group; c Dichotomous variable; d Numeric variable
* p<0,05; ** p<0,01; *** p<0,001
CDI Cantril ladder Somatic symptoms
Psychological
symptoms
Family support Peer support
Gendera 2.63 (1.82-3.80)*** 0.56 (0.36-0.88)* 3.63 (2.08-6.36)*** 2.23 (1.39-3.57)** 0.48 (0.30-0.77)**
2.66 (1.66-
4.26)***
Age 1.04 (0.91-1.18) 1.02 (0.87-1.18) 0.89 (0.73-1.08) 0.91 (0.77-1.06) 1.10 (0.94-1.29) 1.01 (0.86-1.19)
Type of school 0.77 (0.56-1.07) 1.32 (0.90-1.93) 1.09 (0.66-1.81) 0.69 (0.46-1.05) 1.67 (1.12-2.51)* 1.07 (0.73-1.58)
Father’s education
elementary school or belowb 1 1 1 1 1 1
vocational training 0.66 (0.31-1.43) 2.21 (1.04-4.71)* 0.73 (0.26-2.26) 0.81 (0.34-1.95) 1.58 (0.71-3.54) 1.15 (0.49-2.72)
high school 0.69 (0.31-1.54) 3.19 (1.44-7.07)** 1.21 (0.38-3.79) 0.49 (0.20-1.24) 1.86 (0.80-4.32) 1.31 (0.54-3.19)
graduated 0.89 (0.39-2.05) 4.70 (1.97-11.23)*** 0.76 (0.23-2.54) 0.88 (0.34-2.30) 1.47 (0.58-3.58) 1.36 (0.53-3.49)
Mother’s education
vocational training 1.03 (0.42-2.49) 1.01 (0.42-2.45) 2.39 (0.59-9.64) 2.34 (0.74-7.39) 0.85 (0.34-2.12) 1.67 (0.62-4.47)
high school 0.81 (0.35-1.90) 1.13 (0.49-2.56) 1.46 (0.38-5.71) 2.05 (0.67-6.28) 1.14 (0.47-2.75) 1.18 (0.47-2.95)
graduated 1.03 (0.43-2.49) 0.68 (0.28-1.63) 2.20 (0.55-8.85) 2.82 (0.89-8.92) 0.98 (0.39-2.49) 1.07 (0.41-2.80)
FAS
lowb 1 1 1 1 1 1
middle 0.60 (0.34-1.08) 1.33 (0.89-1.98) 0.99 (0.60-1.64) 0.79 (0.51-1.23) 1.45 (0.95-2.21) 1.10 (0.73-1.65)
high 0.83 (0.59-1.16) 1.55 (0.69-3.48) 0.68 (0.28-1.64) 0.88 (0.43-1.80) 1.47 (0.66-3.28) 1.80 (0.82-3.94)
Subjective SES
lowb 1 1 1 1 1 1
medium 0.39 (0.18-0.85)* 1.62 (0.74-3.53) 0.44 (0.17-1.15) 0.43 (0.19-0.97)* 2.10 (0.95-4.61) 2.43 (1.12-5.27)*
high 0.49 (0.21-0.94)* 3.36 (1.41-8.01)** 0.46 (0.16-1.29) 0.35 (0.15-0.84)* 3.43 (1.43-8.24)** 2.51 (1.09-5.78)*
Regular smokingc
1.40 (0.88-2.21) 0.60 (0.36-1.01) 1.41 (0.76-2.61) 1.91 (1.16-3.26)* 0.78 (0.46-1.33) 2.02 (1.01-4.03)*
Regular drinkingc 0.89 (0.59-1.34) 0.64 (0.40-1.03) 1.53 (0.85-2.74) 0.94 (0.56-1.58) 0.90 (0.55-1.49) 1.73 (0.99-3.00)
Alcohol intoxicationc 0.97 (0.67-1.40) 1.20 (0.77-1.88) 0.80 (0.47-1.36) 0.91 (0.57-1.45) 0.76 (0.48-1.20) 1.34 (0.84-2.13)
Physical activityc 0.87 (0.56-1.36) 1.08 (0.63-1.85) 1.27 (0.66-2.44) 1.16 (0.66-2.00) 1.05 (0.59-1.85) 1.34 (0.78-2.30)
Breakfast (weekdays)d 0.80 (0.62-1.03) 1.38 (1.05-1.81)* 0.78 (0.57-1.08) 0.68 (0.51-0.89)** 1.59 (1.21-2.09)** 1.20 (0.88-1.62)
Breakfast (weekends)d 0.96 (0.80-1.15) 1.11 (0.89-1.38) 0.78 (0.60-1.02) 1.04 (0.83-1.32) 1.13 (0.90-1.42) 1.03 (0.82-1.29)
Healthy eatingd 0.97 (0.93-1.01) 1.07 (1.02-1.12)** 1.00 (0.95-1.06) 0.99 (0.94-1.04) 1.05 (1.00-1.10)* 1.02 (0.97-1.07)
Watching TV on weekdaysc 1.28 (0.93-1.76) 0.76 (0.52-1.11) 1.55 (0.97-2.47) 1.51 (1.00-2.26)* 0.86 (0.57-1.28) 0.84 (0.57-1.24)
Playing on computer on
weekdaysc 1.08 (0.75-1.57) 1.18 (0.76-1.82) 0.98 (0.55-1.72) 1.42 (0.90-2.23) 0.73 (0.46-1.14) 0.98 (0.64-1.50)
Using computer on weekdaysc 1.13 (0.82-1.56) 1.40 (0.96-2.05) 1.46 (0.89-2.39) 1.16 (0.77-1.75) 1.29 (0.86-1.92) 0.99 (0.68-1.45)

CDI Cantril ladder Somatic symptoms
Psychological
symptoms
Family support Peer support
Gendera 2.63 (1.82-3.80)*** 0.56 (0.36-0.88)* 3.63 (2.08-6.36)*** 2.23 (1.39-3.57)** 0.48 (0.30-0.77)**
2.66 (1.66-
4.26)***
Age 1.04 (0.91-1.18) 1.02 (0.87-1.18) 0.89 (0.73-1.08) 0.91 (0.77-1.06) 1.10 (0.94-1.29) 1.01 (0.86-1.19)
Type of school 0.77 (0.56-1.07) 1.32 (0.90-1.93) 1.09 (0.66-1.81) 0.69 (0.46-1.05) 1.67 (1.12-2.51)* 1.07 (0.73-1.58)
Father’s education
vocational training 0.66 (0.31-1.43) 2.21 (1.04-4.71)* 0.73 (0.26-2.26) 0.81 (0.34-1.95) 1.58 (0.71-3.54) 1.15 (0.49-2.72)
high school 0.69 (0.31-1.54) 3.19 (1.44-7.07)** 1.21 (0.38-3.79) 0.49 (0.20-1.24) 1.86 (0.80-4.32) 1.31 (0.54-3.19)
graduated 0.89 (0.39-2.05) 4.70 (1.97-11.23)*** 0.76 (0.23-2.54) 0.88 (0.34-2.30) 1.47 (0.58-3.58) 1.36 (0.53-3.49)
Mother’s education
vocational training 1.03 (0.42-2.49) 1.01 (0.42-2.45) 2.39 (0.59-9.64) 2.34 (0.74-7.39) 0.85 (0.34-2.12) 1.67 (0.62-4.47)
high school 0.81 (0.35-1.90) 1.13 (0.49-2.56) 1.46 (0.38-5.71) 2.05 (0.67-6.28) 1.14 (0.47-2.75) 1.18 (0.47-2.95)
graduated 1.03 (0.43-2.49) 0.68 (0.28-1.63) 2.20 (0.55-8.85) 2.82 (0.89-8.92) 0.98 (0.39-2.49) 1.07 (0.41-2.80)
FAS
lowb 1 1 1 1 1 1
middle 0.60 (0.34-1.08) 1.33 (0.89-1.98) 0.99 (0.60-1.64) 0.79 (0.51-1.23) 1.45 (0.95-2.21) 1.10 (0.73-1.65)
high 0.83 (0.59-1.16) 1.55 (0.69-3.48) 0.68 (0.28-1.64) 0.88 (0.43-1.80) 1.47 (0.66-3.28) 1.80 (0.82-3.94)
Subjective SES
lowb 1 1 1 1 1 1
medium 0.39 (0.18-0.85)* 1.62 (0.74-3.53) 0.44 (0.17-1.15) 0.43 (0.19-0.97)* 2.10 (0.95-4.61) 2.43 (1.12-5.27)*
high 0.49 (0.21-0.94)* 3.36 (1.41-8.01)** 0.46 (0.16-1.29) 0.35 (0.15-0.84)* 3.43 (1.43-8.24)** 2.51 (1.09-5.78)*
Regular smokingc
1.40 (0.88-2.21) 0.60 (0.36-1.01) 1.41 (0.76-2.61) 1.91 (1.16-3.26)* 0.78 (0.46-1.33) 2.02 (1.01-4.03)*
Regular drinkingc 0.89 (0.59-1.34) 0.64 (0.40-1.03) 1.53 (0.85-2.74) 0.94 (0.56-1.58) 0.90 (0.55-1.49) 1.73 (0.99-3.00)
Alcohol intoxicationc 0.97 (0.67-1.40) 1.20 (0.77-1.88) 0.80 (0.47-1.36) 0.91 (0.57-1.45) 0.76 (0.48-1.20) 1.34 (0.84-2.13)
Physical activityc 0.87 (0.56-1.36) 1.08 (0.63-1.85) 1.27 (0.66-2.44) 1.16 (0.66-2.00) 1.05 (0.59-1.85) 1.34 (0.78-2.30)
Breakfast (weekdays)d 0.80 (0.62-1.03) 1.38 (1.05-1.81)* 0.78 (0.57-1.08) 0.68 (0.51-0.89)** 1.59 (1.21-2.09)** 1.20 (0.88-1.62)
Breakfast (weekends)d 0.96 (0.80-1.15) 1.11 (0.89-1.38) 0.78 (0.60-1.02) 1.04 (0.83-1.32) 1.13 (0.90-1.42) 1.03 (0.82-1.29)
Healthy eatingd 0.97 (0.93-1.01) 1.07 (1.02-1.12)** 1.00 (0.95-1.06) 0.99 (0.94-1.04) 1.05 (1.00-1.10)* 1.02 (0.97-1.07)
Watching TV on weekdaysc 1.28 (0.93-1.76) 0.76 (0.52-1.11) 1.55 (0.97-2.47) 1.51 (1.00-2.26)* 0.86 (0.57-1.28) 0.84 (0.57-1.24)
Playing on computer on
weekdaysc 1.08 (0.75-1.57) 1.18 (0.76-1.82) 0.98 (0.55-1.72) 1.42 (0.90-2.23) 0.73 (0.46-1.14) 0.98 (0.64-1.50)
Using computer on weekdaysc 1.13 (0.82-1.56) 1.40 (0.96-2.05) 1.46 (0.89-2.39) 1.16 (0.77-1.75) 1.29 (0.86-1.92) 0.99 (0.68-1.45)
Table 2: Binary logistic regression estimates (OR [95%CI]), full model
OR and CI values were rounded to two decimals. a Reference category = Boys; b Reference group; c Dichotomous variable; d Numeric variable
* p<0,05; ** p<0,01; *** p<0,001

How can we be credible?
• The information is:
– trusted & valid
– without personal/vested interests
• The presenter:
– knows the topic
– is congruent
– is able to communicate
– is enthusiastic

Priority setting
Dr. Nóra Kovács
Department of Public Health and Epidemiology
Based on the lecture slide of Eva
Biro MD, PhD

Public health cycle
priority setting
objectives
action programs
(interventions)
evaluation
measuring health
of the population
(health monitoring)

How should health needs be
prioritized?

How should health needs be
prioritized?
• Type 2 diabetes mellitus
• Colon cancer
• Acne vulgaris
• PCOS
• Hypertension
• Hashimoto’s thyroiditis

Basic methods used for priority
setting in public health
• based on disease burden
• based on intervention/prevention

Basic methods used for priority
setting in public health
• based on disease burden
Indices used to measure disease burden in
the society
– mortality figures
– measures of morbidity
– composite measures
(mortality + reduction in quality of life)
– economic burden

Burden of disease
–mortality figures
–measures of morbidity
–composite measures
(mortality + reduction in quality of
life)
–economic burden

Measured by: incidence (death as a new event)
Mortality
Cause-specific
Cancer mortality
Cardiovascular
mortality
AIDS mortality
Age-specific
Infant mortality
(IM)
Under five
mortality
(U5M)
Premature
mortality
(under 65 years)
Sex-specific
Male mortality
Female mortality

Which world region has the highest / lowest mortality rate?

Comparison of
leading causes of
deaths, global,
2000 and 2019

Compare the leading causes of death by sex.
What are the main differences?
The 10 Leading Causes of Death by Sex, Global, 2019
Males, all ages, deaths/100.000 Females, all ages, deaths/100.000

External causes
Non-communicable
diseases

Avoidable mortality
Causes of death substantially influenced by the quality of health care before the
age of 75 years
Avoidable deaths which could have been prevented with adequate disease
prevention and therapy
• Preventable mortality: Causes of death that can be mainly avoided
through effective public health and primary prevention interventions (i.e.
before the onset of diseases/injuries, to reduce incidence).
• Treatable mortality: Causes of death that can be mainly avoided through
timely and effective health care interventions, including secondary
prevention and treatment (i.e. after the onset of diseases, to reduce case-
fatality).
Indicators of avoidable mortality can provide a general “starting point” to assess
the effectiveness of public health and health care systems in reducing deaths
before 75 years of age from various diseases and injuries.

Avoidable mortality
List several causes of death that likely to
belong to this category!
– skin cancer
– trachea, bronchus and lung cancer
– IHD, hypertension and cerebrovascular diseases
– chronic liver diseases and liver cirrhosis
– motor vehicle accidents
– cervical cancer
– diabetes
– appendicitis

What was the consideration behind for
listing these conditions as avoidable?
Causes of death Preventable/treatable
mortality
Rationale for inclusion
Measles preventable
Most of these infections can be prevented
through vaccination.
Viral Hepatitis preventable
This condition is preventable and will not
require treatment if prevented.
Colorectal cancer treatable
Case-fatality rates have been reduced
through earlier detection and treatment.
Epilepsy treatable
Case-fatality rates can be reduced through
early detection and appropriate treatment.
Hypertensive
disease
preventable (50%) and
treatable (50%)
This condition is both preventable through
prevention measures (e.g. reduce smoking,
improve nutrition and physical activity) and
treatable.
Appendicitis treatable
Case-fatality rates can be reduced through
early detection and appropriate treatment.
https://www.oecd-ilibrary.org/sites/6cf53429-en/index.html?itemId=/content/component/6cf53429-en

Main causes of avoidable mortality
in the European Union
Note: Data are based on the 2019 OECD/Eurostat revised definitions and lists of preventable and treatable causes of mortality. The new lists attribute half of all
deaths for some diseases (e.g. ischaemic heart diseases, stroke, diabetes and hypertension) to the preventable mortality list and the other half to treatable
causes, so there is no double-counting of the same death.
Source: Eurostat Database (data refer to 2017, except for France 2016).

Potential Years of Life Lost
(PYLL)
• PYLL represents the total number of years NOT
lived by an individual who died before the average
life expectancy.
• The calculation of Potential Years of Life Lost
(PYLL) involves summing up deaths occurring at
each age and multiplying this with the number of
remaining years to live up to a selected age limit
(age 75 is used in OECD Health Statistics)

Potential years of life lost
Total, Per 100 000 inhabitants aged 0-69, 2020 or latest available
Source: OECD Data

Causes of death Causes of YLL
Compare the leading causes of death and YLL.
The 10 leading causes of death and YLL, global, 2019

Burden of disease
–mortality figures
–measures of morbidity
–composite measures
(mortality + reduction in quality
of life)
–economic burden

Measured by: incidence & prevalence
Morbidity
Cause-
specific
Age-
specific
Sex-
specific

Estimated age-standardized incidence and mortality rates (World)
in 2020, WHO Africa (AFRO), both sexes, all ages

Measuring Population Health Outcomes
Parrish RG. Measuring population health outcomes. Prev Chronic Dis 2010;7(4):A71.

Composite measures
Mortality + reduction in quality of life
• Healthy life expectancy
• Disability adjusted life years (DALY)

Healthy life expectancy
• Similar to the life expectancy at birth with
the difference that it reflects the average
number of expected healthy (activity and
participation restriction free) life years.
• need information/data on the age-specific
mortality figures and the proportion of
healthy individuals

Life expectancy vs. Healthy life
expectancy

General model of health-expectancies
Life expectancy
Disability-free life expectancy
Healthy life expectancy
Life with disability

WORLD HEALTH STATISTICS 2019
Life expectancy and HALE by sex, WHO region and World Bank
income group, 2016

Disability adjusted life years
(DALY)
• DALY
– extends the concept of potential years of life
lost due to premature death to include
equivalent years of healthy life lost by virtue of
individuals being in states of poor health or
disability
– combines mortality and morbidity into a
common metric
• DALY = YLL + YLD

Years of life lost (YLL)
• YLL is the number of years of life lost due to mortality.
• Years of life lost (YLL) is a measure of premature
mortality that takes into account both the frequency of
deaths and the age at which it occurs.
Years lost due to disability (YLD)
• YLD is the number of years lived with a disability,
weighted with a factor between 0 and 1 for the
severity of the disability.

Disability: severity weights
The burden of infectious diseases in Europe: a pilot study
Eurosurveillance, Volume 12, Issue 12, 01 December 2007

Causes of death Causes of YLD
Compare the leading causes of death and YLD.
The 10 leading causes of death and YLD, global, 2019

Which world region has the highest
burden of disease?

Which are the major risk factors of DALYs?
WaSH: unsafe water, sanitation and hand washing
NTDs: neglected tropical diseases

forrás: Health on course? The 2002 Dutch Public Health Status and Forecast Report, RIJVM, Bilthoven, 2003

Economic burden
• Direct costs: value of goods and
services for which payment was
made and resources used in
treatment, care, and rehabilitation
related to illness or injury
– Hospital Care Expenditures
– Drug Expenditures
– Physician Care Expenditures
– Expenditures for Care in Other
Institutions
– Additional Direct Health
Expenditures
– Costs borne by patients or
other payers (such as costs for
transportation to health
providers, special diets and
clothing)
• Indirect Costs: value of
economic output lost because
of illness, injury-related work
disability, or premature death
– Mortality Costs
– Morbidity Costs due to
Long-term Disability
– Morbidity Costs due to
Short-term Disability
– the value of time lost from
work and leisure activities
by family members or
friends who care for the
patient

SOURCE: Measuring the Public’s Health. Public Health Rep. 2006 Jan-Feb; 121(1): 14–22.

Examples of primary, secondary and tertiary prevention
interventions targeting individuals and populations

Source: Baltussen and Niessen Cost Effectiveness and Resource Allocation 2006 4:14

You are asked to give advice to
your Minister of Health:
For which diseases should a
surveillance system be set up in
your country?
First step:
• Identify the major communicable and non-
communicable diseases of importance in
your country and record on the worksheet
(first column).

What are the leading causes of
burden of disease in your
country?
• Search in Google for ‚GBD’ (Global burden of disease)
http://www.healthdata.org/gbd
• Click on Results option on main menu.
• Choose Data Visualizations
• Scroll down to GBD compare
• On the left side you can switch between the different
types of charts.
• Use advanced settings:
chart: patterns; display: cause; metric: DALYs; location:
select your country; sex: both; unit: %

How high is the burden of
disease in your country?
• http://www.healthdata.org/gbd
• Click on Results option on menu
• Choose Country profiles

Second step: Hanlon method to prioritize
https://www.naccho.org/uploads/downloadable-
resources/Gudie-to-Prioritization-Techniques.pdf

Second step: Hanlon method to prioritize

Reliable data sources
• HFA
• Global Burden of Disease Study
• WHO: Global Health Observatory
• WHO Disease Outbreak News
• WHO Europe: CISID
• ECDC: Surveillance Atlas of Infectious Diseases
• CDC: Centers for Disease Control and Prevention
• Cancer incidence, prevalence and mortality worldwide
• WHO: Health topics
• U.S. Preventive Services Task Force
• Cochrane Reviews
• The Guide to Community Preventive Services

Practical: Critical reading
A. Points to consider for critical reading
Fact ↔ Opinion
Fact is a statement that can be considered certain because it does not change according to who
states it, where or when (eg. The heart is responsible for maintaining blood circulation). Opinion is a
statement that varies greatly from one person to another. Opinion is a belief that may or may not be
shared by other people. (Eg. The heart is our most important organ.)
What is critical reading?1
Texts provide facts to the non-critical reader who is content with what the texts state and gains
knowledge by memorizing these statements.
The critical reader considers any text as one particular lay-out of facts, one individual’s (the author’s)
interpretation of the subject matter. The critical reader pays attention not only to what a text says, but
also how that text portrays the subject matter. The critical reader recognizes the uniqueness of a given
text by noticing how a particular selection of facts creates one possible interpretation of the subject.
What is critical thinking?
Critical reading is a technique for discovering information and ideas within a text.
Critical thinking is a technique for evaluating information and ideas in order to decide what to accept
and believe out of the presented information and ideas.
Points to consider in critical reading
Regardless of the topic, the following points must be addressed in any text:
• a specific topic/issue must be presented (what is the text about)
• terms must be clearly defined
• evidence must be presented to support statements of the author
• well-known facts (common knowledge) must be taken into account
• exceptions must be explained
• the inference is causal or not (cause must be shown to precede effects and to be capable of
the effect)
• conclusions must be shown to follow logically from earlier arguments and evidence.
Critical reading is careful, active and interpretive reading. Critical thinking focuses on the evaluation of
the validity of what we have read using our previous knowledge. It follows that the two are strongly
related and complement each other.
Reading original scientific publications
Reading to see what a textbook or handouts to a lecture say and restating the key remarks may
suffice when we want to learn specific information or to understand someone else's ideas. But when
we read original scientific publications (research papers), we usually read with other purposes. We
need to solve problems and make decisions. Therefore we must evaluate what we have read and
integrate that understanding with our prior knowledge of medicine. In order to evaluate the
conclusion(s) of a paper, we must evaluate the evidence upon which conclusion is based. We do not
want just any information; we want reliable information.
1
Note: This text relates to non-fictional texts.

B. Critical reading of original research papers
Original papers reporting biomedical research are usually divided into the following chapters:
Summary / Abstract, Introduction, Materials and Methods, Results, Discussion/Conclusion,
References / Bibliography. Additional parts such as Figures, Tables, Appendix, Conflict of Interest, and
Acknowledgements can also be included. The following list gives a summary of points to consider for
the critical reading of chapters.
Introduction: presentation of the topic/issue/research question, justification of the study
Critical questions:
✓ Is the question important?
✓ Is the problem really unknown?
✓ Are all existing evidence related to the topic taken into account?
Materials and Methods: description of the process by which results were produced
Critical questions:
✓ Is description of the methodology sufficiently detailed?
✓ Is the methodology appropriate for answering the research problem?
Results: description of the results/outcomes
Critical questions:
✓ Is evidence for the research problem valid and reliable?
✓ Is description of the evidence appropriate?
Discussion/Conclusion: presentation of the conclusions/inferences; limitations of the study,
comparison with other studies on the same or similar research problem
Critical questions:
✓ Are the conclusions justified by the results and relevant to the research question?
✓ Are the conclusions similar to those found by others?
✓ Can exceptions be explained?
✓ Can the inference be causal?
Abstract/Summary: a short summary of the paper
Critical questions:
✓ Is the abstract in concert with the main text, especially regarding the conclusions?
Additional critical questions:
✓ Are technical terms appropriately used and unequivocal?
✓ Is the list of references relevant?

BMJ 1995;311:1668 (23 December) Handout for students
Why do old men have big ears?
James A Heathcote, general practitioner, South View Lodge, Bromley, Kent BR1 3DR
In July 1993, 19 members of the south east Thames faculty of the Royal College of General
Practitioners gathered at Bore Place, in Kent, to consider how best to encourage ordinary general
practitioners to carry out research. Some members favoured highly structured research projects;
others were fired by serendipity and the observations of everyday practice. Someone said, "Why do old
men have big ears? Some members thought that this was obviously true--indeed some old men have
very big ears--but others doubted it, and so we set out to answer the question "As you get older do
your ears get bigger?"
Methods and results
Four ordinary general practitioners agreed to ask patients attending for routine surgery consultations
for permission to measure the size of their ears, with an explanation of the idea behind the project. The
aim was to ask consecutive patients aged 30 or over, of either sex, and of any racial group. Inevitably it
was sometimes not appropriate--for example, after a bereavement or important diagnosis--to make
what could have seemed so frivolous a request, and sometimes (such as when a surgery was running
late) patients were not recruited. The length of the left external ear was measured from the top to the
lowest part with a transparent ruler; the result (in millimetres), together with the patient's age, was
recorded. No patients refused to participate, and all the researchers were surprised by how interested
(if amused) patients were by the project. The data were then entered on to a computer and analysed
with Epi-Info; the relation between length of ear and the patient's age was examined by calculating a
regression equation.
Scatter plot of length of ear against age
In all, 206 patients were studied (mean age 53.75 (range 30-93; median age 53) years). The mean ear
length was 675 mm (range 520-840 mm), and the linear regression equation was: ear
length=55.9+(0.22 x patient's age) (95% confidence intervals for B co-efficient 0.17 to 0.27). The figure
shows a scatter plot of the relation between length of ear and age.
It seems therefore that as we get older our ears get bigger (on average by 0.22 mm a year).
Comment
A literature search on Medline by the library at the Royal College of General Practitioners that looked
for combinations of "ears, external," "size and growth," "males," and "aging" produced no references.
A chance observation--that older people have bigger ears--was at first controversial but has been
shown to be true. For the researchers the experience of involving patients in business beyond their
presenting symptoms proved to be a positive one, and it was rewarding to find a clear result. Why ears
should get bigger when the rest of the body stops growing is not answered by this research. Nor did
we consider whether this change in a particular part of the anatomy is a marker of something less
easily measurable elsewhere or throughout the body.
I acknowledge the generous help of Drs Colin Smith and David Armstrong and Ms Sandra Johnston
with the data analysis; the work of my fellow data collectors, Drs Ian Brooman, Keren Hull, and David
Roche; and the support of all members of the Bore Place group.

BMJ 1999;318:367-367 (6 February) Handout for students
Laterality of lower limb amputation in diabetic patients: retrospective audit
Jonathan P Coxon, house officer, Ian W Gallen, consultant physician.
Chiltern Diabetes Centre, Wycombe Hospital, High Wycombe HP11 2TT
Complications associated with diabetic patients' feet remain common and major problems for
clinicians and patients. We conducted an audit after observing that lower limb amputations in
diabetic patients who attended hospital seemed to occur more on the right side than on the left.
Subjects, methods, and results
We obtained information from the database of the Chiltern Diabetes Centre, which records the details
of around 2000 diabetic patients attending hospital clinics in South Buckinghamshire. Patients' details
are recorded on the computer system at each clinic visit.
For our audit, we extracted details from the database by setting up structured queries in the Microsoft
Access program. Raw data consisted of one entry per patient. If a patient had more than one
amputation, the level of the last amputation only was recorded. We excluded patients with bilateral
amputations (0.5%).
We performed 2 tests (without continuity correction) to investigate any difference in laterality of
amputation.
The table shows data for 1876 diabetic patients, 219 (11.7%) of whom had had unilateral amputation.
When we used 2 tests to compare the sites of amputation between the left and right side, the
differences between the two sides were highly significant for all levels.
Comment
We found a higher prevalence of right lower limb amputations in diabetic patients, regardless of the
site of amputation. Estimates of the prevalence of amputation among diabetic patients vary
considerably, with studies – usually population based – quoting between 1% and 7%.1-3 In our study it
was higher (11.7%); there are two likely reasons. Firstly, our audit included amputations that were
minor. Secondly, a higher prevalence of disease is to be expected as those patients who attend
hospital usually have advanced disease. These reasons limit extrapolation of our results to all diabetic
patients.
Our audit confirms a significant propensity for amputations of the right rather than the left lower limb in
our cohort of diabetic patients. This applied to both types of diabetes.
An explanation for this finding must consider those factors that predispose to diabetic foot disease.
The traditional triad of peripheral vascular disease, peripheral neuropathy, and infection is not entirely
responsible as pressure loading on the sole of the foot, particularly callus formation, is believed to be
important in diabetic foot disease. 4 5 Callus is thought to arise from a combination of dry skin (through
autonomic neuropathy) and increased mechanical stresses.
Only physical stresses can account for the difference in laterality of amputation. If most people
favoured their right foot during movement, especially in starting and stopping, more pressure would be
applied cumulatively to that foot.
The clinical importance of this finding may be limited, but an awareness of the importance of
mechanical strains on the foot may help to educate diabetic patients.

Table: Differences in laterality of amputation in diabetic patients attending hospital clinics.
Values are number (percentage) of patients unless stated otherwise.
Site of
amputation
All patients
(n=1876) Patients with type 1 diabetes (n=1021)
Patients with type 2 diabetes
(n=855)
Right Left P value χ2* Right Left P value χ2* Right Left P value χ2*
Toe 80 (4.3) 19 (1.0) <0.0001 >25 36 (3.5) 12 (1.2) 0.0005 12 44 (5.1) 7 (0.8) <0.0001 >25
Partial foot 48 (2.6) 10 (0.5) <0.0001 >25 27 (2.6) 6 (0.6) 0.0003 13.3 21 (2.5) 4 (0.5) 0.0007 11.6
Below
kneed† 51 (2.7) 11 (0.6) <0.0001 >25 26 (2.5) 3 (0.3) <0.0001 18.2 >25 (2.9) 8 (0.9) <0.003 8.8
All sites 179 (9.5) 40 (2.1) <0.0001 >25 89 (8.5) 21 (2.1) <0.0001 >25 90 (2.2) 19 (2.2) <0.0001 >25
Acknowledgements
Contributors: JPC analysed the data, reviewed the literature, and wrote the paper. IWG set up the database and reviewed the final draft of the paper; he will
act as guarantor for the paper.
Funding: None.
Competing interests: None declared.
References
1. Moss S, Klein R, Klein B. The prevalence and incidence of a lower extremity amputation in a diabetic population. Arch Intern Med 1992; 152: 610-616.
2. Lehto S, Romemaa T, Pyorala K, Laakso M. The risk factors predicting lower extremity amputation in patient with NIDDM. Diabetes Care 1996; 19:
607-612.
3. Reiber GE. The epidemiology of diabetic foot problems. Diabet Med 1996; 13: 6-11S.
4. Ctercteko GC, Dhonendran M, Hutton WC, LeQuesne LP. Vertical forces acting on the feet of diabetic patients with neuropathic ulceration. Br J Surg
1981; 68: 608-614.
5. Veves A, Murray HJ, Young MJ, Boulton AJM. The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. Diabetologia
1992; 35: 660-663.

C. Critical reading of random news
The students should read the news below and evaluate the validity of their claim.
1. Squalene
“Instead of mass murdering quickly and compassionately, putting squalene in today’s swine flu
vaccines assures populations will suffer chronically and painfully for life, assuming people survive
the viral recombinants in the vaccine.” Leonard G. Horowitz, DMD, MA, MPH. DNM, DMM – Award
winning author and public health expert
Miracle Mineral Supplement (MMS)
Magical or not it’s sometimes called Miracle Mineral Supplement or the master mineral
supplement. No matter what it’s called one does have to be careful when using a substance like
MMS. And whether its main proponent Jim Humble is going out of his mind or not we have to be
clear about what this substance can do safely and what it cannot. I say out of his mind for now he
has invented, out of the pocket of his imagination, the new profession titled “Doctor of MMS”,
which anyone can become. “Americans can afford the training of less than two weeks, or buy the
new book, “The Master Mineral of the Third Millennium”. In an email he recently said, “We
thought you might like to see the difference in a MMS doctor and a Medical doctor.” As Jim has
become increasingly embarrassing to the health field I have personally eaten some of my words
on the value of this chlorine-type of substance as I have been carefully experimenting with it on
myself. In fact, if the truth be known, I am finding out there may be some possible benefits to it
(…) I am using it transdermally, mixed with malic acid and DMSO to try to control a fungus infection
between my toes.
2. 'THE DRUG THAT EATS JUNKIES'
Krokodil originated in Russia but has spread across the world at an alarming rate.
It has become so popular because it is three times cheaper to produce and buy than heroin and
the intense high lasts for an hour and a half.
Dubbed 'the drug that eats junkies', it rots from the inside, causing such severe damage to tissue
that users suffer from gangrenous sores which open all the way to the bone.
Continual use of Krokodil causes blood vessels to burst, leaving skin green and scaly among addicts
eventually causing gangrene and their flesh to begin to rot.
Rabid use in Russia has caused up to 2.5 million people to register and seek treatment as addicts
and the average life span for a user is only two to three years.
The condition can lead to limbs being amputated, but life expectancy for addicts is at the most two
to three years, with the majority dying within a year.
The drug, whose name means 'crocodile' - reportedly a reference to the way it turns users' skin
scaly - also rots their brains.
Krokodil is a sickening cocktail of over the counter painkillers, paint thinner, acid and phosphorus.
In some cases, petrol is also added.
The resulting mixture is called desomorphine - a derivative of morphine - and is extremely
addictive.
Source: http://www.dailymail.co.uk/news/article-2460854/Krokodil-Two-sisters-claim-proof-
Russian-flesh-eating-drug-used-U-S.html#ixzz3JVYx8dLs

3. https://www.davidwolfe.com/8-foods-medications-never-mix/
8 Common Foods & Medications You Should NEVER Mix!
Most of us have taken medication at some point. Whether it’s for a headache, back pain, an infection
or an illness. While medication is designed to help with your symptoms, it also comes along with a list
of risks and unwanted side effects that may occur. If you’ve ever had a prescription filled, you know
that most medications come with a list of do’s and don’t’s. You might be warned not to take the
medication on an empty stomach, or not to drink alcohol with the medicine in your system. Something
that most doctors or pharmacists don’t tell you, is that everyday foods can also have an effect on your
medication and your body.
Certain foods can have unwanted effects when they interact with certain medications inside your
body. Even food that is good for you might not pair well with your prescription. It’s best to talk with
your doctor before making any major changes to your diet, but if you’re taking medication, the
following list might help!
1. If you take cholesterol medication…
Skip grapefruit and grapefruit juice! Grapefruit juice can increase the levels of cholesterol medication
in your bloodstream. This can leave you more susceptible to unwanted side effects of your medicine.
2. If you take anticoagulants…
Ditch the cranberry juice! According to some studies, patients who drank cranberry juice while taking
anticoagulants experienced blood thinning. Dramatic thinning of the blood can lead to health
complications.
3. If you take blood pressure medication…
Avoid bananas! Blood pressure medications can increase the levels of potassium in your body. Bananas
are filled with potassium, and too much can cause problems. If your potassium levels are too high, you
may experience irregular heartbeat or heart palpitations.
4. If you take heart failure medication…
Put down the black licorice! Black licorice contains glycyrrhizin, a chemical that can cause irregular
heartbeat when combined with digoxin. Licorice may also inhibit the effectiveness of your medication,
causing further complications.
5. If you take blood thinners…
Skip the spinach! Spinach, along with other leafy greens, contain Vitamin K. This vitamin can interfere
with blood thinners and anticoagulants. It may cause your medication to be less effective. Kale,
broccoli and other dark green veggies should be avoided as well.
6. If you take tetracycline antibiotics…
Avoid dairy! The high calcium content in dairy can prevent your body from correctly absorbing the
antibiotics. The antibiotics may becomes less effective and unable to work properly.
7. If you take thyroid medication…
Ditch the walnuts! Walnuts are high in fiber, which can prevent your body from properly absorbing
thyroid medication. Be sure not to overindulge in high fiber foods.
8. If you take medication for bacterial infections…
Skip cured meats! Eating food containing tyramine while taking medication for a bacterial infection
can cause harmful spikes in blood pressure. Tyramine is an amino acid that is found in food that is
smoked, cured or fermented. Avoid salami, dry sausage and processed cheeses. Taking medication
comes with a risk of unwanted side effects. While some medication may be necessary, exploring
natural healing may allow you get a better handle on your condition, without risking harm to your
body. It’s worth a shot! Check out the video below to learn about some of the amazing effects of
two natural foods: cinnamon and honey.

Health Promotion and health policy merged.pdf

Health Promotion and health policy merged.pdf

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