(5)公共健康方法-Public Health Approaches-公开课-关爱惟士
(5)公共健康方法-Public Health Approaches

课程视频http://player.youku.com/embed/XMzYwNDQ4MDEwOA


Prof. Carol Brayne

Carol Brayne 教授


Public health defines prevention in several ways. There's primary prevention, secondary prevention and tertiary prevention.

公共健康对疾病预防有着不同定义。这里主要指一级预防,二级预防和三级预防。


Primary prevention is removing a cause of a disease, so the classic example is smoking and lung cancer. You remove the smoking, you remove the lung cancer that is attributed to smoking. There will be other lung cancers but they are not lung cancers caused by smoking.

第一级预防目的是消除病因,最典型的例子就是吸烟跟肺癌。如果你戒了烟或不吸烟,就等于消除了吸烟导致你患肺癌这一因素,当然会有其他原因导致肺癌,但是不会包括吸烟导致的肺癌.


Secondary prevention is early detection of a disorder at the point where you can change its natural history in a way that means the survival of the person with the early disease, or the quality of life of that person, is enhanced.

第二级预防对疾病症状进行早期检测,并在某种程度上改变这个病的自然发展,这就意味着可以提高一些早期患者的生存率,或者病人的生活质量。


Tertiary prevention is when a disorder is fully manifest, is fully there, and it's about the treatment and the interventions, the care that we can provide that will improve the quality of life of that person in the presence of the disorder, and that includes palliative care, so that includes dying as well as we can.

第三级预防是当疾病症状已经相当明显,需要对症治疗和干预,这时第三级预防重点在于提供照护并改善病人该疾病阶段的生活质量,这也包括安息护理,就是我们所说的临终关怀。


Put those all together and you have the balance of care and activity required for a society to do the best it can with the resources that it has.

总而言之,这就要求我们尽可能利用所拥有的资源为整个社会营造最佳的医疗照护环境。


Secondary prevention is effectively screening. That can be done in an intensive case identification method or it can be done at a population level. To implement screening and/or early detection, we need really rigorous evidence and that is - in the UK and many countries such as the US, there are whole commissions looking at screening evidence.

二级预防是对疾病的有效筛选。它可能是一个严重病例的确诊过程,也可能是对一个群体水平进行筛查。实施筛选或早期诊断,我们都需要严格细致的证据,这就是-在英国及其他很多国家,比如美国,都有这样的委员会在研究寻找筛查实证。


At the moment, dementia is not one of the conditions that is recommended for screening, for systematic screening in the population. At present, our research investments across the world are focused on early detection and diagnostics. The implications of this kind of research is that there will be, in the future, some sort of screening program, whether it's applied at population level or within clinic settings. So we need an evidence base that is robust enough to meet the requirements of a screening program. At present, despite massive investment, the evidence is not sufficient for that and the implications in terms of cost are enormous for societies of implementing that kind of approach. It doesn't mean it won't be possible in the future but it needs to be thought about very, very carefully.

目前,认知症不属于被推荐的人口系统性筛查疾病中。现在全世界的研究资金都致力于早期诊察和诊断研究。这类研究的意义在于未来会得到一些运用在无论是人口筛查还是临床中的检测项目。那么我们需要满足这个项目筛选的要求的一些强有力的实证。但是现在,尽管有大量的资金投入,得到的证据仍然不足以解决这个问题,而且对这个社会来说投入的费用已经很大了。但这并不意味着这种筛查技术在将来不可能出现,只是需要我们更加周全考虑。


Primary prevention; we have evidence already about the approaches that we can take to reduce the conditions that are themselves risk factors for dementia. We have evidence of reduction in the prevalence, that is the proportion of people with dementia, in many countries and the incidence, that is the new occurrence of disease in populations. So we have that evidence from the US, from the UK, from some European countries. So we have good evidence that we can change the course of people's ageing and brain ageing.

第一级预防;我们有通过可以降低一些风险因素来减少认知症发病几率的实证。我们也有证据显示认知症流行率的下降及同时许多国家中认知症新发病例的减少。我们从英国,美国及一些欧洲国家得到的证据证实了这一点,因此我们拥有能通过降低人类衰老以及大脑老化速度来改变病程的非常乐观的证据。


We also have evidence on how to support people when they have dementia - that's the tertiary prevention side - increasing evidence about improvements in provision of care in care homes and the nature of the interventions that we can make to support people with dementia. So at present we have an imbalance of investment into what effectively would lead to a screening program for dementia and less investment into the primary and the tertiary, and it is clear from a public health point of view that we need to rebalance that.

我们同样也有大量的证据来支持患有认知症的人群-这就是我们第三级预防-收集更多证据来帮助完善养老院疗护制度及开发非药物干预,为患有认知症的人群提供更有力的支持。但是目前我们的研究资金的不平衡影响了我们去开展认知症的筛查项目,只有少量的资金投入到一级和三级疾病预防,从公共健康的角度来说我们需要平衡这种资金投入,这一点非常毋庸置疑。


Thinking about primary prevention of dementia, we need to take into account the context in which that prevention needs to occur. We have a constellation of different risk factors which relate to early, mid and later life, and we have very many different populations across the world that are experiencing ageing, so that the kinds of primary prevention activities that we might want to undertake in Australia might be very different in different groups within the population.

关于一级认知症预防,我们需要仔细斟酌预防所需的背景。我们知道有一系列与认知症早期,中期及晚期密切相关的不同风险因素,与此同时在每个国家都有大量的不同老龄化人口,我们如想要在澳大利亚进行一级预防活动,那针对不同的群体可能方式都不一样。


So for example, those in the clusters where, say, smoking and drinking excessively or to harmful levels is more prevalent, we might want to have a different approach to one where people are already doing physical activity and already having very good diets. That might relate to increasing the educational levels or one might think about groups in the population who are socially isolated. So these are all the different types of risk factors that one needs to take into account.

举个例子,那些吸烟,饮酒过量或风险水平较高的群体中,我们可能想要采用不同的方法来帮助他们,方法会不同于那些已经在锻炼身体及有良好的饮食习惯。可能需要提升受教水平或者要考虑到是不是有群体处于社会孤立中。这些都是需要我们考虑的风险因素的不同类型。


When we think about low and middle income countries or even a country like Japan, the profile of risk factors across the life course will have been very different for the people who are entering old age now. So it is absolutely not one size fits all, but a sense of needing to understand the risk factors that are operating for different age groups in different cultures and what is the evidence base for approaching those risk factors in those cultures.

一些低收入或者中等收入国家,或者像日本这样的国家,同样的社会老龄化,因为人们的生活状态截然不同,那么对认知症风险因素的侧写就会明显不同。所以可以肯定一个适用于所有状况的万能法则是不存在的,也因此我们要更加去了解处于不同年龄人群在不同文化下所面对的种种风险因素,并且针对于这些文化差异下所产生的风险因素进行收集统计,以作为今后的证据基础。


If I was in the happy position of being in charge of the public health program in Australia, I would first want to map very carefully our knowledge of dementia in the population and different sectors of the population in different regions and different groups. I would then want to map our knowledge of the risk factor and protection factor profiles - so education is a key one there and social integration is another key one - to understand that across the population. Then I would want to bring to bear the evidence base that we have about how to change those factors and what works best, what our understanding is about what works best, at the individual level and at the population level and at the community level.

如果我在澳大利亚的公共健康项目中能够身居高位,我会首先把认知症的科普规划进来,包括不同地区、不同群体。然后我会把风险因素和保护性因素也规划进来-所以说教育是一个非常关键的内容-而另一个关键是社会融合-理解范围包括整个大众群体。最后我会给出我们当前的支持性证据,包括如何改变这些风险因素,如何做才能达到最佳效果。我们所认识到的是如何在个体水平,群体水平及社区水平上做的更好。


Then I'd want to create a community-based program which integrated that knowledge for a community and work with the community on the concerns of the community. And then, with embedded evaluation, look to see or basically implement combined interventions going from individual to population in those communities and then follow up the impact over time. So that would be integrating community and individual.

之后我想创建一个整合了社区相关知识以及基于对社区关心的相关工作的基础社区项目。然后,我们运用嵌入式的评估,观察或实施对这些社区中不同个体和群体的综合干预措施,并进行效果随访,这就是对社区和个体的整合。


What I would also do, though, is look at the life course risk factors that we know we need national action on, and with that it would need to be a very careful discussion with the commercial sector. So sugar, alcohol and tobacco would probably need national activity.

我同时还想做的是,探讨一些需要全民行动来应对的的生命周期风险因素,而这些都需要基于与相关企业部门之间所做的谨慎决策,比如关于糖,烟和酒的合理性就需要全民行动来控制。


Thinking from a whole population perspective and from the public health evidence, individually based interventions are pretty ineffective if one thinks about the resources required for individual interventions. So, for example, smoking cessation programs, although they're effective, they're nothing like as effective as doing things at community and population level, at national level. So when we think about the barriers, we need to think very carefully about each individual risk factor and what influences people's behaviours and what approaches we need to use. So a good example of the exultation to eat well is that, in socioeconomically-deprived areas of the UK, so my own nation's experience, fast food companies target opening in socioeconomically deprived areas. So the populations within those areas are at a particular disadvantage because what's available to them in their environment is an obesogenic environment. So it's very difficult to behave in a healthy way if you live in a place which has no areas for physical activity and also you don't have much money and low cost fast food outlets.

从大众群体的角度与从公共健康方面得来的统计数据来考虑,如果考量到个体干预所需的资源,进行个体基本干预效果会很不理想。举例,个体的戒烟项目,尽管它有效果,但是却不如社区,群体及整个国家层面来得有效果。由于这些不利因素,我们需要非常周全地考虑到每个不同个体的风险因素,影响个人行为的因素和其相应的对处方法。举一个恰当的例子,是饮食喜好的定位,在英国本土,快餐业把目标人群定位在这些低收入的经济底层地区。那结果就是生活在这些地区的人群被置于了一种不利的环境 — 一种容易引起肥胖的生活环境里。所以如果你生活在这样一个缺乏运动、低收入以及低成本不健康食物的地区,你很难拥有一个健康的生活方式。


So we have to work with communities and with businesses to shift the way that these things are operating within communities, because in the end businesses don't want to kill people and don't want to make their dementia risk higher. But they do need to make a profit, so we do need to think about what are the huge barriers that exist in terms of vested interests in our own ill health, and even in dementia occurrence. So we need to try to work to turn that around.

这就是为什么我们必须要和社区以及很多企业去合作,并改变他们的运营模式,因为企业经营的最终目的不是去伤害人们或者增大他们的认知症风险。但是企业需要盈利,所以我们需要能获得利益的角度去考虑关乎我们健康、甚至是认知症发生的那些巨大的障碍,所以我们需要努力改变这一切。


翻译:关爱惟士-未经允许不得转载,违者必追究法律责任

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