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## Course: Health Across the Life Span: Frameworks, Contexts, and Measurements

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# Assignments

### »Exercise 1: SF-36

After completing this exercise, you will be able to: (1) work with the widely used Short-Form 36 Health Status Questionnaire (SF-36); (2) explain some of the advantages and limitations of standardized health status questionnaires used to obtain subjective assessments of health.

### »Exercise 2: Frameworks and Determinants

After completing this exercise, you will be able to: (1) discuss the range of factors (determinants) that may be related to a variety of disease conditions and levels of health that may be observed in different populations; (2) explain how the multiple determinants associated with any specific condition may be related to each other in a conceptual framework.

Reading: Krieger, N. Epidemiology and the web of causation: has anyone seen the spider? (1994). Social Science and Medicine . 39(7), 887-903.

Look at the matrix. The first column lists a range of determinants that may be associated with the health and disease of certain populations. The first row lists some health problems. Follow the steps below in carrying out this exercise:

1. Select one health problem from the first row that you know something about in terms of its "causes."
2. For each of the determinants listed, consider whether the determinant plays any role in contributing to the health problem in a population. If it does not have any effect on the problem, place a minus sign (-) in the box in the matrix and go to the next determinant.
3. For those determinants that you think will have an effect on the health problem, consider whether they operate as an underlying determinant or a proximate determinant. If underlying, put a "U" in the box; if proximate, put a "P" in the box.
4. Next, for the selected health problem, draw a conceptual diagram showing how these determinants may be (causally) related to each other and to the selected health problem.
5. Based on your diagram, explore two questions: How might you design a study to test whether one or more of these factors might have a "causal" relationship in a particular population? Does your diagram suggest where to intervene and what intervention(s) might be most important in reducing the health problem?

### »Exercise 3: Developmental Origins of Adult Disease: Evolution, Environment, Phenogenetics, and Disease

After completing this exercise, you will be able to: (1) describe a framework for thinking about health and development across the life span; (2) explain what is meant by a life course approach to the study of adult chronic disease; (3) discuss the work of DJP Barker and related research on "fetal origins of adult disease"; (4) describe the mechanisms responsible for associations between fetal/early life factors and adult chronic disease; (5) describe some challenges of researching fetal origins of adult disease; (6) discuss some of the implications of this work for maternal and child health policies and programs around the world.

This exercise is based on Figures 2 and 3 in Gluckman, PD and Hanson , MA . (2004). Living with the past: evolution, development and patterns of disease. Science . 305:1733-1736.

Figure 2 depicts "A general model of how intergenerational, genetic and environmental, and prenatal and postnatal factors interact to create a pathway of altered disease risk in adulthood."

Figure 3 is a depiction of the Predictive Adaptive Response Model (PAR). Also shown on the page with Figure 3 is an alternative depiction of the PAR model developed by Gluckman and his colleagues in a later publication (Gluckman, et al., 2005).

Note that a number of technical concepts and terms related to molecular genetics are introduced in this paper. Please review the Appendix for a general explanation of some basic concepts.

1. What kinds of time periods are involved for the "past history of population" to affect the genotype?
2. What is meant by "epigenetic change," and how do "intergenerational environmental effects" have an influence?
3. Does the link between "prenatal environment" and "epigenetic change" relate to the Barker hypothesis?
4. What is the significance of a "match" between the prenatal and postnatal environment?
5. What is the meaning/significance of the "predictive adaptive response" or "developmental plasticity," and how does this relate to the "birth phenotype"?
6. Why does the model show that the "postnatal environment" has strong a direct effect on the "adult phenotype"?
7. Are the links between "fetal phenotype," the "adult phenotype," and "disease risk" indicative of a life course model of disease?
8. What is the point the authors are trying to make in the last figure? How does this relate to the prospects for an emerging epidemic of chronic disease in less-developed countries as they improve their economic conditions?

### »Exercise 4: Culture, Health and Behavior: Implications for Behavioral Change Strategies

After completing this exercise, you will be able to: (1) explain how culture influences health-seeking behaviors among populations; (2) give some examples of how traditional healers can be incorporated in public health programs and primary health care systems.

This exercise is built around the video, Sangoma: Traditional Healers in Modern Society. After viewing the video, reflect on the following questions.

1. How is the concept of "health" incorporated into the traditional healers' services?
2. Based on what you saw in the video, describe the primary determinants of health and illness in the population.
3. Why is it that more people go to the traditional healers as opposed to Western biomedical physicians and nurses? What are the factors that influence their health care decision making?
4. How should people's illness beliefs be incorporated into the primary health care system?
5. If you were asked to go to the communities shown in the video to design an STD prevention program, how would you do it?
• How would you incorporate the different illness beliefs about STDs?
• What types of questions would you need to ask the community before you could begin

### »Assignment 1: Multiple Determinants of Health Framework

1. Select a population health problem with which you are familiar and briefly describe the measurable Outcomes and Impacts that are of interest
2. Develop a list of Underlying Determinants and briefly describe how they may relate to the Outcomes.
3. Describe the Proximate Determinants (behavioral and psychophysiological) through which the underlying determinants act to produce the Outcomes.
4. Illustrate your conceptual model with a multiple determinants diagram that shows the connections among your Underlying and Proximate Determinants and the Outcomes and Impacts.

### »Assignment 2: Addressing a Health Inequality

1. Identify a health inequality that exists in a selected location.
2. Document this inequality with any data that may be available.
3. Describe the inequality and some of its key underlying and proximate determinants using the analytical principles presented in the lectures and in the readings on health inequalities.
4. Identify alternative strategies for addressing this inequality (both short- and long-term) and make some specific recommendations for action that are feasible in the location you have selected.

To complete this assignment, you will need to: (1) select a specific geographical area (e.g., city/state, region, or country) with which you are familiar, either in the United States or internationally; (2) select a health inequality that exists within that area

Some suggested health issues include the following: Health care (antenatal care; maternity care; contraceptive services; immunizations; general health care; chronic disease care; etc.); Health behaviors (tobacco; drugs; diet; lifestyle); Health outcomes (unintended pregnancies/abortions; infant/child health; maternal health; injuries; chronic diseases; disabilities; obesity; etc.).

Some suggested inequalities are as follows: gender, race, regional/urban-rural/neighborhood, economic, educational, ethnic/language groups, minority populations, age groups; etc.

A suggested format for the paper is provided:

1. Introduction: the introductory paragraph should contain the purpose of the memo, the specific health inequality you will discuss, and your recommendation(s) for addressing the problem.
2. Background: the background information (a paragraph or two would probably suffice) provides information and data pertaining to the health inequality and helps to provide an understanding of why the inequality exists and why it is important. This information provides the essential context for your proposed recommendations to come later in the paper.
3. Analysis: the analysis, the most important part of the paper, uses the relevant information to build a logical argument that leads to the proposed recommendation. This may be a quantitative argument (based on numeric findings that support a position), if that is the nature of the issue, or it may be a qualitative argument. While the analysis may focus on a single policy or program alternative, the analysis may also be used to compare and contrast different policy/program alternatives.
4. Recommendation(s): the recommendation(s) for action must be based on and logically flow from the analysis. References to the relevant literature should be cited. The literature review should give guidance on feasibility.
5. Conclusion: the conclusion should be clearly stated and based on the analysis and the recommendations.

Because many of these health inequalities are complex, most of the time there is no right or wrong answer in addressing them. They are often controversial, and recommendation(s) and decisions are sometimes based on imperfect information. Therefore, the most important aspect of this assignment is not the final recommendation(s) that may be made, but rather it is the logic and the quality of the argument.

### »Assignment 3: A Life Course Perspective on Chronic Illness

There are two parts to this assignment: (1) Individual Papers and (2) Group Presentations.

Each student will work individually in Part A. This will be used to build the group presentation in Part B. The class is divided into groups of approximately 6-8 students, and each group is assigned a chronic condition that has been linked, in part, to fetal environment. The chronic conditions include the following: coronary artery disease. hypertension, type-2 diabetes, chronic bronchitis, asthma, breast cancer, prostate cancer, obesity, cognition, stroke

Overall Content Objectives: (1) Using the life course perspective, effectively communicate how fetal environment and contemporary risk factors may contribute to the development of the chronic condition; (2) Illustrate how the findings from longitudinal research may result in a different understanding of these conditions than those obtained from cross-sectional research.

Overall Skill Objectives: (1) Perform a critical review of the literature; (2) Develop a professional presentation; (3) Share the knowledge and perspectives gained with the remainder of the class through a professional oral presentation.

Each member of the group should carefully read the following assigned reading material. These readings provide a background on the life course perspective.

Ben-Shlomo, Y and Kuh, D (2002). A life course approach to chronic disease epidemiology: conceptual models, empirical challenges and interdisciplinary perspectives. Int J Epidem 31: 285ï¿½93.

Halfon, N and Hochstein, M (2002). Life course health development: and integrated framework for developing health, policy and research. Milbank Quarterly 80: 433-479.

Lynch, J. and Smith, GD (2005). A life course approach to chronic disease epidemiology. Annual Reviews of Public Health 26: 1ï¿½35.

Next, the group should begin this assignment by searching for publications that are based on longitudinal, retrospective, or cross-sectional studies designed to show how the fetal environment and/or contemporary risk factors may contribute to the development of the chronic condition.

The group should identify a representative sample of longitudinal and cross-sectional studies that allow you to effectively communicate how both the fetal environment and contemporary risk factors may contribute to the development of the chronic condition, using the life course perspective. If there are developing-country studies available for the condition, be sure to include them.

After conducting a thorough review of the literature, the group should select the key publications, which will be used for the individual paper assignments in Part A and for building the group PowerPoint presentation in Part B.

Grading Framework: Each member of the group will receive the same grade for Part B. Evaluation of the PowerPoint presentation will serve as the remaining 10% of each student's total grade for the course. Elements in grading are given below:

• Abstract: clearly highlights major points of the presentation
• Introduction/Background and Objective : quality and completeness of presentation of natural history and magnitude; clearly stated objective
• Methods: thoughtful review of the literature that demonstrates a representative sample of longitudinal and cross-sectional studies
• Results: discussion of strengths and weaknesses of key publications
• Conclusions and Discussion: logical flow of conclusions and discussion from results
• Organization and Presentation of Slides: clarity of ideas, visual layout (easy to read/understand)
• Oral Presentation: main idea of slides clearly conveyed within given timeframe

Part A: Individual Papers

Each person in the group will submit an individual paper pertaining to the final PowerPoint presentation. The papers are described below:

Natural history: one group member will be responsible for producing an individual paper discussing the prevailing view of the life course of the condition. (This is often called the "natural history" of the disease process and can be found in standard medical textbooks.) The discussion should evaluate whether this standard or prevailing view of the natural history of the condition derives from longitudinal or cross-sectional studies. This may be used to build the Introduction/Background section of the PowerPoint presentation.

Magnitude of the health problem: one group member will be responsible for producing an individual paper discussing the magnitude of the health problem in the United States (or other country) and its consequencesï¿½e.g., disability caused by the chronic disease, health care costs, etc. This, too, may be used to build the Introduction/Background section of the PowerPoint presentation.

Review of a key publication: each of the remaining group members will be responsible for producing an individual paper that reviews one of the key publications selected by the group. Each review paper should summarize a publication, including the following:

• Rationale for the study
• The study question
• Study methodology/design
• Results

Finally, there should be a discussion of how this paper adds to the body of knowledge on how life course events contribute to the burden of the chronic disease. Relevant citations of the publication under review by later papers should be incorporated in the discussion, if these are available. You can usually find these citations using PUBMED or other databases. You should use these individual review papers as the basis for the Results and Conclusions sections of the group PowerPoint presentation.

Part B: Group PowerPoint Presentation

The group will work together to produce a PowerPoint presentation on the life course perspective of its assigned chronic disease. Please include the following in the PowerPoint presentation:

• Abstract: give a brief summary of the project. highlighting the major focus of the PowerPoint presentation.
• Background: provide a brief background of the natural history of the condition and describe the magnitude of the health problem in the United States (or other country).
• Objective: clearly state the objective of the presentation.
• Methods: describe the methodology used to search for and select the key publications.
• Results: show evidence for how the risks for the condition occur over the entire life span, using the reviews of the key publications selected by the group. Draw inferences about the relative contribution of early influences and contemporary risk factors.
• Conclusions: based on the literature reviews, the group is to develop its own understanding of the life course of the condition. Come to some conclusions about the strengths and weaknesses of the longitudinal versus the cross-sectional approaches.
• Discussion: briefly discuss the implication of your results and also the limitation of the conclusions reached.
• References: provide a list of references used to research and create the PowerPoint. (References should be on separate slides but must not be included in the oral PowerPoint presentation). Please remember to use appropriate and consistent citation style.