LITERATURE Health Promotion & Disease
Prevention
Lecture 2 – Upstream Determinants of Lifestyle Behaviors and
Chronic Disease Risk
The Upstream Determinants of Adult Obesity
Jeroen Lakerveld, Joreintje Mackenbach; The Upstream Determinants of Adult Obesity. Obes Facts 13 July 2017; 10 (3): 216–222. https://doi.org/10.1159/000471489
Fundamental cause of obesity is an imbalance between calories consumed and calories expended.
Overconsumption of high-energy foods, lack of physical activity, lack of sleep, high stress levels and
sedentary behavior play a role; these are obesogenic behaviors. These are in turn influenced by a
range of individual factors, including
biological, genetic and psychological
factors, which are nested within
contexts that contain influencing
characteristics further upstream.
Attention for upstream determinants of
obesity is important for population-level
action to prevent obesity and reduce its
prevalence and burden.
In history, we have adapted the context we live in. High availability of calorie-dense foods, and
avoidance of physical activity at any time.
Upstream determinants of health: overarching factors that are largely beyond the control of the
individual and which have significant spill-over effects on other more proximal/downstream
determinants of health. An upstream determinant of obesity is defined as any contextual
characteristic that influences obesogenic behaviors.
Upstream determinants are multiple, none operates in isolation, and they interact at different levels.
Research is challenging due to the complexity of causal pathways and the long time periods during
which effects manifest themselves. Mostly studied in cross-sectional observational studies.
Types of environments in which upstream determinants of obesity appear can be divided into
physical, socio-cultural, economic and political.
- Physical: little evidence of single physical environmental factors being strongly related to obesity.
However, urban sprawl and land-use mix are consistently correlated with weigh status.
o Urban sprawl: residents may be less inclined to opt for active modes of travel, have
decreased access to facilities and engage less in social interaction.
o Land-use mix: better mix is associated with less obesity, likely due to levels of active modes
of travel and more amenities available.
- Socio-cultural: socio-economic status and inequality
o Lower SEP, and more inequality in general, is associated with higher obesity in adults. May
be due to lack of psycho-social and material resources.
o Social networks also have an important impact, via social contagion (network influences
behavior via modelling), social capital (sense of belonging and social support influences
behaviors), and social selection (individual’s network is function of their weight).
o However, in general, few social environmental factors are consistently related to adult
obesity.
,- Economic: sparse research.
o Effect of cost of a healthy diet influences behavior.
- Political: many determinants of obesity require political action. However, there is general lack of
insight into the political upstream determinants of obesity.
o Quality of governance is associated with obesity as increased stability and greater
effectiveness of government provide more opportunities for policy makers to focus on key
public health problems.
o No government has implemented a comprehensive or effective set of policy approaches.
Obesity is caused by a complex system of both downstream and upstream factors that interact with
one another recognition of the need to consider the multifaceted and complex nature of
upstream influences on obesogenic behaviors.
In contrast, efforts to prevent obesity and/or reduce prevalence do not necessarily have to be
complex. By refraining from making political decisions about prevention, responsibility of the
problem is shifted downstream to medical doctors. Individual-level approaches remain important,
but priority should be given to political actions that address the obesogenic environment.
, Lecture 3 – Hearing Problems
Effectiveness of an online SUpport PRogramme (SUPR) for older hearing aid users: study
protocol for a cluster randomized controlled trial
Meijerink, J. F., Pronk, M., Paulissen, B., Witte, B. I., Van Der Wouden, B., Jansen, V., & Kramer, S. E. (2017). Effectiveness of an online SUpport PRogramme (SUPR) for older hearing aid
users: study protocol for a cluster randomised controlled trial. BMJ open, 7(5), e015012.
Hearing impairments is one of the most prevalent chronic health conditions affecting older adults. It
leads to inability to communicate effectively, in turn may lead to poor psychosocial outcomes. It is
also associated with accelerated cognitive decline and falls. Also partners/spouses can be negatively
affected.
The usual care is often restricted to assessment of hearing loss and fitting of hearing aids. Hearing aid
use has positive effects on quality of life, wellbeing and may reduce depressive complaints and
cognitive decline. However, the uptake and use of hearing aids is low. Reasons include low
perceived need, limited acceptance of hearing loss, low expectations, limited gain in noisy situations
and low overall sound quality. Other barriers include stigma, high costs and need for regular hearing
aid care and maintenance. Also lack of social support or social pressure to get hearing aid.
Therefore, it is argued that hearing healthcare should not be restricted to provision of hearing aids
only. Because experienced hearing disability is the outcome of a complex interaction between an
individual and his/her contextual factors.
Various interventions, including aimed to improve speech perception and/or communication
management. These have shown improvement in communication. However, these are rarely offered
in hearing healthcare. Also there are barriers, such as lack of time or no easy access. But these can be
overcome with e-health and technology. Some studies have evaluated online communication
programs and these show benefits. However, there is no study evaluating the effectiveness of an
online communication training program on a large scale this article.
Aim: determine effectiveness of SUPR as part of standard hearing aid dispensing care among older
hearing aid users and their communication partners.
Clustered randomized controlled trial – 18-month follow-up
- Intervention: hearing aid fitting + SUPR
- Control: hearing aid fitting only
Outcomes:
- Primary outcome: use of communication strategies, measured with questionnaire.
- Secondary outcomes include: personal adjustment to hearing impairment, self-efficacy, hearing
aid use, self-reported intervention outcomes, satisfaction with service, self-reported activity
limitations and participation restrictions, readiness to do something about hearing problems,
emotional response.
Process evaluation includes seven parameters: recruitment, reach, fidelity, dose delivered, dose
received and implemented, satisfaction and perceived benefit.
SUPR’s primary aims: to improve older hearing aid owners’ communication strategies and personal
adjustment and decrease disability of communication partners.
Prevention
Lecture 2 – Upstream Determinants of Lifestyle Behaviors and
Chronic Disease Risk
The Upstream Determinants of Adult Obesity
Jeroen Lakerveld, Joreintje Mackenbach; The Upstream Determinants of Adult Obesity. Obes Facts 13 July 2017; 10 (3): 216–222. https://doi.org/10.1159/000471489
Fundamental cause of obesity is an imbalance between calories consumed and calories expended.
Overconsumption of high-energy foods, lack of physical activity, lack of sleep, high stress levels and
sedentary behavior play a role; these are obesogenic behaviors. These are in turn influenced by a
range of individual factors, including
biological, genetic and psychological
factors, which are nested within
contexts that contain influencing
characteristics further upstream.
Attention for upstream determinants of
obesity is important for population-level
action to prevent obesity and reduce its
prevalence and burden.
In history, we have adapted the context we live in. High availability of calorie-dense foods, and
avoidance of physical activity at any time.
Upstream determinants of health: overarching factors that are largely beyond the control of the
individual and which have significant spill-over effects on other more proximal/downstream
determinants of health. An upstream determinant of obesity is defined as any contextual
characteristic that influences obesogenic behaviors.
Upstream determinants are multiple, none operates in isolation, and they interact at different levels.
Research is challenging due to the complexity of causal pathways and the long time periods during
which effects manifest themselves. Mostly studied in cross-sectional observational studies.
Types of environments in which upstream determinants of obesity appear can be divided into
physical, socio-cultural, economic and political.
- Physical: little evidence of single physical environmental factors being strongly related to obesity.
However, urban sprawl and land-use mix are consistently correlated with weigh status.
o Urban sprawl: residents may be less inclined to opt for active modes of travel, have
decreased access to facilities and engage less in social interaction.
o Land-use mix: better mix is associated with less obesity, likely due to levels of active modes
of travel and more amenities available.
- Socio-cultural: socio-economic status and inequality
o Lower SEP, and more inequality in general, is associated with higher obesity in adults. May
be due to lack of psycho-social and material resources.
o Social networks also have an important impact, via social contagion (network influences
behavior via modelling), social capital (sense of belonging and social support influences
behaviors), and social selection (individual’s network is function of their weight).
o However, in general, few social environmental factors are consistently related to adult
obesity.
,- Economic: sparse research.
o Effect of cost of a healthy diet influences behavior.
- Political: many determinants of obesity require political action. However, there is general lack of
insight into the political upstream determinants of obesity.
o Quality of governance is associated with obesity as increased stability and greater
effectiveness of government provide more opportunities for policy makers to focus on key
public health problems.
o No government has implemented a comprehensive or effective set of policy approaches.
Obesity is caused by a complex system of both downstream and upstream factors that interact with
one another recognition of the need to consider the multifaceted and complex nature of
upstream influences on obesogenic behaviors.
In contrast, efforts to prevent obesity and/or reduce prevalence do not necessarily have to be
complex. By refraining from making political decisions about prevention, responsibility of the
problem is shifted downstream to medical doctors. Individual-level approaches remain important,
but priority should be given to political actions that address the obesogenic environment.
, Lecture 3 – Hearing Problems
Effectiveness of an online SUpport PRogramme (SUPR) for older hearing aid users: study
protocol for a cluster randomized controlled trial
Meijerink, J. F., Pronk, M., Paulissen, B., Witte, B. I., Van Der Wouden, B., Jansen, V., & Kramer, S. E. (2017). Effectiveness of an online SUpport PRogramme (SUPR) for older hearing aid
users: study protocol for a cluster randomised controlled trial. BMJ open, 7(5), e015012.
Hearing impairments is one of the most prevalent chronic health conditions affecting older adults. It
leads to inability to communicate effectively, in turn may lead to poor psychosocial outcomes. It is
also associated with accelerated cognitive decline and falls. Also partners/spouses can be negatively
affected.
The usual care is often restricted to assessment of hearing loss and fitting of hearing aids. Hearing aid
use has positive effects on quality of life, wellbeing and may reduce depressive complaints and
cognitive decline. However, the uptake and use of hearing aids is low. Reasons include low
perceived need, limited acceptance of hearing loss, low expectations, limited gain in noisy situations
and low overall sound quality. Other barriers include stigma, high costs and need for regular hearing
aid care and maintenance. Also lack of social support or social pressure to get hearing aid.
Therefore, it is argued that hearing healthcare should not be restricted to provision of hearing aids
only. Because experienced hearing disability is the outcome of a complex interaction between an
individual and his/her contextual factors.
Various interventions, including aimed to improve speech perception and/or communication
management. These have shown improvement in communication. However, these are rarely offered
in hearing healthcare. Also there are barriers, such as lack of time or no easy access. But these can be
overcome with e-health and technology. Some studies have evaluated online communication
programs and these show benefits. However, there is no study evaluating the effectiveness of an
online communication training program on a large scale this article.
Aim: determine effectiveness of SUPR as part of standard hearing aid dispensing care among older
hearing aid users and their communication partners.
Clustered randomized controlled trial – 18-month follow-up
- Intervention: hearing aid fitting + SUPR
- Control: hearing aid fitting only
Outcomes:
- Primary outcome: use of communication strategies, measured with questionnaire.
- Secondary outcomes include: personal adjustment to hearing impairment, self-efficacy, hearing
aid use, self-reported intervention outcomes, satisfaction with service, self-reported activity
limitations and participation restrictions, readiness to do something about hearing problems,
emotional response.
Process evaluation includes seven parameters: recruitment, reach, fidelity, dose delivered, dose
received and implemented, satisfaction and perceived benefit.
SUPR’s primary aims: to improve older hearing aid owners’ communication strategies and personal
adjustment and decrease disability of communication partners.
