You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


[MUSIC PLAYING]
[MUSIC PLAYING]
Welcome to an introduction
to public health.
My name is <PRESIDIO_ANONYMIZED_PERSON>.
As a health education
specialist at the CDC,
I've worked in a variety
of areas of public health,
including children's
health, infectious diseases,
chronic diseases, and most
recently public health
workforce development.
Public health is a dynamic
and multi-disciplinary field
as you'll see from this
introductory course.
This slide shows the
outline for the course.
We will begin by discussing
the purpose of public health
and a few key terms.
We will then look at some events
in history of public health.
Next, we'll go through
the public health approach
and apply it to a
public health problem.
We will then cover
the main functions
and essential services
of public health
to show the broader context and
identify different groups who
have a stake in public health.
Lastly, we'll discuss factors
that determine health,
and I'll present the
health impact pyramid
as a framework for
influencing public health
at different levels.
This introductory
course should enable
you to achieve the
learning objectives
on the slide which align
with the course outline
that I just covered.
So what is public health?
CEA Winslow was a leading
figure in the development
of the modern study
of public health.
Read this definition
of public health
that he developed
almost a century ago
and consider key
words or phrases
in the definition
that speak to you
or tell you what
public health is.
You might notice that as a
combination of science and art,
public health offers many
opportunities to be creative.
Public health is not only
about preventing and treating
disease, but it's also
about promoting good health.
Winslow says this is done
through organized efforts.
So what are some examples
of organized efforts?
You might think about how
national surveillance systems
are set up, how our waste
management infrastructure is
built, or how the latest
vaccination recommendations are
developed and communicated.
From Winslow's
definition, you might
note that public health gives
people and organizations
information to help
them make choices that
inform them and help
them improve their health
or the health of others.
Public health also occurs
at different levels.
Individual, organizational,
and community levels,
and even more broadly
at the city-state,
national, and
international levels.
So here are two statements about
the mission of public health.
The Institute of
Medicine says that there
is a societal interest
in ensuring conditions
in which people can
be healthy, and we'll
come back to the concept of
assurance later in the course.
The World Health
Organization, or WHO,
says public health is about
serving the greater good.
The maximum benefit for the
largest number of people.
From these two
statements, you can
see that public health
focuses on groups of people
rather than only on individuals.
And at the core
of public health,
there is this principle
of social justice.
That people have the
right to be healthy
and to live in conditions
which support their health.
So now that we know
what public health is,
let's review some
common key terms.
Clinical care is the prevention,
treatment, and management
of illness, and the preservation
of mental and physical well
being through health services.
This is all also more commonly
referred to as medical care
or health care.
A determinant, also known
as a health determinant,
is a factor that contributes
to the generation of a trait,
such as one's ethnicity
or genetic makeup.
But more broadly, the
context of people's lives
determines their
health, and we'll
go into more detail about
health determinants also
later in the course.
Epidemic or outbreak, as
you can see on the slide,
is the occurrence in a
community or region of cases
of an illness or a specific
health related behavior
in excess of what
you would normally
expect to see in that area.
An epidemic and outbreak
are used interchangeably.
However, epidemic usually
refers to a larger geographic
distribution of illnesses
or health related events.
It's basically an epidemic
occurs when a disease spreads
rapidly to many people.
You might also hear
the term pandemic,
which is kind of an
epidemic on steroids.
It often has a
global impact, which
means people on
multiple continents
are affected by it, often
crossing borders and going
into different countries.
A health outcome is the result
of a medical condition that
directly affects a person's
life in terms of its quality
or length.
And think about the health
outcomes for somebody
who's living with HIV, for
example, or who has diabetes.
All right.
So now we've come to
a knowledge check,
and I ask you to fill in the
blank with the correct answer.
Does public health
aim to provide
groups of people or
individuals with the right
to be healthy and
live in conditions
that support their health?
The answer is groups of people.
Public health focuses on
populations rather than
individuals.
The next knowledge
check is asking,
what is a disease occurrence
among a population that
is in excess of what's expected
for a given time and place?
Is it pandemic, intervention,
epidemic or outbreak,
or prevention?
And the correct answer
is epidemic or outbreak.
Now we'll take a look at a
few historical highlights
of public health
through the four lenses
of sanitation and environmental
health, pandemics,
disaster response and
preparedness, and prevention
through policy.
So the first lens will
look through encompasses
the control of
disease and promotion
of health through sanitation to
ensure a healthy environment.
Here are three examples
from around the globe
of how public health
has been implemented
to contain infectious disease
through environmental measures.
So around 500 BCE, it's
recorded that the ancient Greeks
and Romans actively practiced
sanitation measures.
Fast forward approximately
two millennia
and we see the work
begun long ago in Greece
continuing in the United
Kingdom through the passage
of the Public
Health Act of 1848,
which established a
central board of health
and placed responsibilities
for sanitation
in the hands of burroughs.
In 1970 in the United
States, the administration
of President Nixon established
the Environmental Protection
Agency, which still
today protects
our health by safeguarding
air, water, and land.
So next we'll explore
pandemics, and you'll
recall that these are similar
to epidemics except that they
affect even larger populations,
often across countries
and continents.
So influenza, or the flu, has
caused pandemics many times
during both the distant
past and in recent history.
Almost a century
ago, the Spanish flu
infected 500 million
people across the world,
including in remote Pacific
Islands and the Arctic.
And it's estimated that it
killed between 20 and 50
million people.
More recently, the
influenza pandemic
in 2009 infected people
in 214 countries,
causing almost 19,000
confirmed deaths.
And while 19,000
confirmed deaths is still
many deaths too many,
it's nowhere near
the type of fatality rate that
we saw 100 years or so ago
when the Spanish
flu ran rampant.
So we have made tremendous
strides in public health
in terms of
controlling influenza,
but preparing for
and controlling
the effects of influenza will
likely remain top priorities
for public health.
Historically, polio was a
common and highly feared
disease that caused
severe illness, including
paralysis and even death.
Thousands of people lined up
to receive the polio vaccine
after it was introduced in 1955.
An initiative to
eradicate polio was
launched in 1988
because of outbreaks
in more than 125 countries.
And because of those
efforts, at this time,
polio exists in only
a few countries.
Lastly, with our last
example, during the 1980s,
human immunodeficiency
virus, or HIV,
emerged and spread
rapidly across the globe.
Public health has
responded to this pandemic
by developing new ways
to diagnose and treat
those who are infected.
New infections of HIV are down
20% over the past 10 years,
and that's a sign
that the public health
interventions are successful.
So the third area we'll
explore is public health's role
in preparedness and
disaster response,
both for natural disasters
and human made threats.
The use the biological warfare
to infect people and animals
goes back centuries.
One of the earliest
accounts is the use
of plague as a weapon of war
during the Siege of Caffa
in the 14th century AD.
And Caffa is now an area
where modern day Ukraine is.
So back then,
attacking Tartar forces
likely catapulted
dead bodies filled
with the infection of plague
into the city of their enemy.
This contributed to the
spread of the Black Death
in that area.
During disease
outbreaks that could
be related to
bioterrorism today,
the public health community
is prepared to distribute
lifesaving pharmaceuticals in
antidotes, medical supplies,
and equipment to locations
across the country and even
the world.
In the wake of the terrorist
attacks in the United
States on September 11, 2001,
which I'm sure all of you
remember, public
health workers were
on the ground at the World
Trade Center and at the Pentagon
to conduct surveillance to
identify outbreaks of disease
and health conditions that might
have resulted from the attacks.
Public health workers
monitored occupational health
of first responders
and city residents
as well as
environmental conditions
to detect health threats in
the aftermath of the attacks.
Public health also response
to natural disasters.
After Hurricane
Katrina hit in 2005,
public health workers joined
disaster relief agencies
to provide emergency
services and dispatched teams
to conduct surveillance
for illness and injury
among residents in their
homes and those who
had been relocated to shelters.
So the last lens
we'll look through
as we view public health
history is health policy
as a means of prevention.
We implement a range of policies
across areas of public health
to support efforts
on a societal level.
So as far back as 1500 BCE,
Leviticus, the third book
of the Hebrew Bible, is believed
to be the first written health
code in the world.
The book addresses personal
and community responsibilities
and includes guidance
about bodily cleanliness,
sexual health behaviors, and
protection against contagious
diseases, including
the isolation
of people with leprosy.
You might recall hearing
about leper colonies
back then in history.
So in recent decades, we've
had tremendous movement
in tobacco legislation.
Laws banning smoking in
the workplace, restaurants,
and other public
places have been
passed to encourage
smokers to quit
while also protecting
nonsmokers from the effects
of secondhand smoke.
Also, increases
in cigarette taxes
have been shown to be
a deterrent for buying
cigarettes.
And you've probably heard
the term obesity in the news.
Approximately 60 million
Americans-- nearly one third
of all adults-- and about one
in five children are obese.
And doctors usually
define obesity
as a condition in which a
person's weight is 20% or more
above normal weight or
as a body mass index
measurement of 30 or more.
Policies and laws
related to food labeling,
minutes of physical
education and resource
for children in
schools, and even access
to healthy foods and safe
places to be physically
active in communities.
These are all examples of
prevention through policy
that can impact obesity
in a positive way.
So to summarize this
section of the course,
we work in public health
to prevent epidemics
and the spread of
disease and injuries,
protect against
environmental hazards,
promote and encourage
healthy behaviors,
and respond to
disasters and outbreaks.
All right.
It's time for another
knowledge check.
Which of the following events
in public health history
have been pandemics?
And just a hint.
There's more than one answer.
Also remember, pandemics are
not the same as epidemics.
So the correct
answers are B and C.
Both influenza and
polio are examples
of pandemic in the
history of public health.
So now let's talk about public
health in the broader context.
As we've seen, public
health problems are diverse.
They include infectious
diseases, chronic diseases,
emergencies, injuries,
environmental health problems,
as well as a multitude
of other health threats.
Regardless of the
topic though, we
take the same approach to
a public health problem
by following four general steps.
First we ask, what
is the problem?
In public health, we
identify the problem
by using surveillance
systems to survey and monitor
health events and behaviors
among a population.
And then after we've identified
the problem, the next question
is, what is the
cause of the problem?
For example, are
there risk factors
that certain populations
may have that make them
more susceptible to disease?
Maybe it's something
in the environment
or it's certain behaviors
that people are practicing.
Once we've identified the risk
factors related to the problem
we ask, well, what intervention
works to address the problem?
We look at what's
worked in the past.
Maybe in addressing
the same problem
with different
populations we look
to see if something might
work with our population,
and we look to see if a proposed
intervention would make sense
with our affected population.
In the last step we ask, how can
we implement the intervention?
Given the resources
we have and what
we know about the
affected population,
will this intervention work?
And this is a very
simplified approach.
Each of these steps
can be spliced
into more specific activities,
but these are really
just the general
questions that must
be answered to identify a
response to a public health
problem.
Surveillance, risk factor
identification, intervention
evaluation, and implementation.
Now to implement the
public health approach,
practitioners use and
apply scientific methods
that come from a
series of core courses.
These sciences include
public health surveillance,
which we use to monitor a
public health situation,
and epidemiology
enables us to determine
where diseases originate,
how or why they
move through populations,
how they spread,
and how we can prevent them.
Public health laboratories
have a very important role
in supporting public
health by performing tests
to confirm disease diagnoses.
And laboratories also
support public health
by conducting research
and training that's
valuable to the field.
As far as informatics
goes, as we continue
to move from the use
of paper documents
more to electronic
health records,
public health
informatics continues
to increase in importance.
Informatics deals
with the methods
for collecting, compiling, and
presenting health information,
and it enables us to use
electronic data effectively
when addressing a
public health problem.
And lastly, prevention
effectiveness.
This is closely linked
to public health policy.
Prevention effectiveness
studies provide
important economic
information to decision makers
to help them compare
interventions and then choose
one to implement.
So together, these
five core sciences
can help us protect and
promote the public's health
by giving public health
practitioners the answers
that they need.
Public health is
better able to respond
to a given situation or
problem by using contributions
from each of these sciences.
So let's take a look at
the public health approach
and how can it can be applied
to a historical example
of an infectious disease.
During the 1800s in London,
cholera, an often fatal
intestinal disease,
was rampant, causing
deaths of thousands
of people within hours
sometimes of first symptoms.
So at that time, and this was
before bacteria and viruses
were recognized as the cause
for many illnesses and diseases,
popular opinion
held that cholera
was caused by bad air coming
from rotting organic matter.
This was known as the
miasma or miasma theory.
John Snow, a British
physician during that time,
he had a different
opinion of cholera.
He believed that the
illness was spreading
by way of a contaminated
water supply
because sewage was
being routinely dumped
into the Thames River and in
cesspools near town wells.
Because of his work tracing the
route of the cholera outbreak,
Dr. Snow's often considered the
father of modern epidemiology,
and his research changed the
way we look at disease today.
So let's apply the public health
approach to Dr. Snow's research
of cholera outbreak.
So this is a slide of a
neighborhood in London,
and you'll recall that
first we need to identify
the public health problem.
Snow conducted public
health surveillance
looking at where those people
with cholera lived in London,
and he saw that large
clusters of cases
were occurring in
specific areas.
So you'll note the
red circle, and you'll
see more black dots
are in that circle
and those represent
cholera cases.
So the concentration of
cholera cases, you'll note,
are surrounding
the area of Broad.
Street and the black
dots represent the deaths
from cholera.
Notice the higher density of
deaths around Broad Street.
Snow was assisted back
then by a local clergyman
by the name of Reverend
Henry Whitehead.
He was very, very familiar
with the neighborhood
and people who lived there.
So together-- kind of
working separately but then
their efforts combined
together later on-- they
were able to track down and
interview surviving cholera
victims and their families
and geographically map
the outbreak.
And their efforts
highlight the benefit
of linking scientific
inquiry with engagement
of community
stakeholders to build
the shared ownership of health.
So next, Dr. Snow
examined the data
and tried to identify
risk factors.
So that is he tried to
determine the cause of deaths
by using the pattern of
where cases were occurring.
So this slide illustrates
the location of the water
pumps in the neighborhood.
These are the black boxes.
So on the basis of
his previous work,
Snow believed that water was
a potential source of cholera.
So the map reveals that
the larger number of cases
occurred in areas
near water pumps,
and this observation prompted
Dr. Snow to further research
the distribution of
water pumps in London.
And he identified where
people who had cholera
were drawing their water.
His findings showed that
clusters of cholera cases
were more commonly located
around certain pumps,
particularly the pump on
Broad Street, smack dab
in the center of that graph.
So through this
research, Dr. Snow
concluded that drawing water
from the Broad Street pump
was a primary risk factor for
becoming ill with cholera.
So after identifying
the likely risk factors,
the next step in the
public health approach
is to evaluate
potential interventions.
With the water supply from the
Broad Street pump identified
as the risk factor,
Snow then worked
to identify interventions
to address the problem.
He did a lot of
continuous research,
and from that
research he understood
that the interventions required
to control the cholera outbreak
were basically two
different interventions.
One was to stop exposure
to the contaminated water
supply in the neighborhood,
and then on a larger scale,
to stop exposure to the entire
supply of contaminated water
in the area.
So using the final step of
the public health approach,
Snow implemented
the intervention
by getting the handle removed
from the Broad Street pump.
And that prevented people
from drawing their water
from that pump
because, again, he
believed that the
supply of water
was the source of
the contamination.
That was a pretty
simple but brilliant way
of effectively
stopping their exposure
to the contaminated
water supply.
And then, after a very long
battle with the politicians
and the water
companies in the area,
Dr. Snow finally convinced
the British government
that water contaminated with
sewage, and not smell or bad
air coming from
the waste itself,
that it was the water that
was the source of cholera
and as well as other diseases.
So this resulted in the
implementation of policies
and laws for water sanitation,
and that was an intervention
on a much larger scale than
just eliminating the threat
from any one single water pump.
But both interventions
had their importance.
All right.
It's time for another
knowledge check.
So this knowledge
check just asks
you to fill in the blanks
with the correct answers.
Each public health
core science helps us
to blank and blank
the public's health
by providing public health
practitioners with the answers
they need.
So I'll give you a hint.
The answers both start with P's.
Public health core sciences
help us protect and promote
the public's health.
But if you had anything remotely
close to protect and promote
we'll count that as correct.
So with this knowledge check--
this is a matching one.
And just match each component
of the public health
approach with the
questions that they answer.
So again, when we ask
what is the problem,
we're basically talking
about surveillance.
When we ask what
is the cause, we're
looking at risk
factor determination.
And then we want to know,
well, what's going to work?
What's going to help to solve
this public health problem?
That's when we're looking
at intervention evaluations.
Possible interventions
that we might
be able to implement with
our particular population.
And then lastly, by process of
elimination, how do you do it?
And that's where you
basically decide what
are you going to implement.
So this section of the course
introduces the core functions
and essential services
of public health.
In 1988, the
Institute of Medicine
defined three core functions
of public health agencies
that must be carried out
at all levels of government
for the overall public health
system to work effectively.
The three core functions are
assessment, policy development,
and assurance.
So assessment is knowing
what needs to be done,
and it's based on the
collection and analysis of data.
You have to have data before
you can do anything else.
Policy development
is much broader
than legislation for one.
It can be guidelines, standard
operating procedures, laws,
rules, regulations-- all
of that is encompassed
by policy development.
And policy development is
based on the information that
comes from the
assessment function,
and it provides the
use of such information
in policy and decision making.
Assurance is making sure that
policies and programs get
implemented by providing
public health services to those
who need them.
So if you'll briefly reflect
on the mission statement
that we discussed earlier of
the Institute of Medicine,
that public health is assuring
conditions in which people
can be healthy, this is
what this core function
is talking about.
In this graphic, the
three core functions
are on the outside
of the circle.
You'll see assessment
on the top right leads
to policy development
underneath and then assurance
on the other side.
The 10 essential
public health services
are grieved underneath
these three core functions.
These services are
not a prescription
for what public health
agencies should do,
but rather they're
really intended
to capture the field
of public health
and communicate
what it provides.
The strength of a
public health system
rests on its capacity
to effectively deliver
the 10 essential services
of public health.
So using the issue of
tobacco use prevention,
let's explore how the essential
services can be implemented.
Under the function
of assessment,
what are examples of number one,
monitoring health for tobacco
use prevention?
So one example is to monitor
health among segments
of the population.
For example, youth.
Another example could be
monitoring global tobacco use
prevention by country.
For number two, public health
investigates risk factors
associated with tobacco use,
such as the risk of developing
a certain kind of cancer.
Assessing the problem
provides more data
to inform policy
development, and that's
the second core function,
you'll recall, of public health.
And that's, again, on
the outside of the circle
at the bottom right side.
The third essential
service, which
is under policy development, is
to inform, educate, and empower
people about health concerns.
So think of different
ways that you
hear about the danger
of using tobacco.
Do you hear it from
your physician?
So you see public
service announcements
maybe in magazines?
So all of those are examples.
People must be
informed and educated
before they become
empowered to make changes,
such as quitting tobacco use
or never starting at all.
On a larger scale,
empowerment leads
to community mobilization,
which is number four.
This might include the
work of advocacy groups
to rally support around
banning smoking in restaurants.
And that leads to number
five, where policymakers then
develop policies to do that
work, to accomplish that work.
So what other policies
regarding tobacco use prevention
can you think of?
Often, people might say,
well, raising tobacco taxes
or not selling tobacco products
to people under a certain age.
Having a minimum age
requirement and enforcing
that in retail establishments.
And those are all great
examples of policies.
After policies are
enacted, they must
be enforced to have an impact.
If they're not enforced,
they don't do any good.
So enforcement is number six
of the essential services
of public health.
And using our example, this
might be fining someone
for smoking on an airplane
because smoking is not
permitted on airplanes
per federal legislation.
Number seven is to link
people to needed public health
services.
So an example is to refer
smokers to tobacco quit lines
or for counseling so that
they can stop smoking.
For number eight,
we need to ensure
that a competent public
health workforce is in place
to help people quit smoking.
And for all of the
interventions we develop,
it is critical to evaluate
them for their effectiveness,
both during and at their end.
And this is number nine.
So we ask, did the
anti-smoking campaign
do what it was supposed to do?
Did the tobacco
cessation program
achieve its intended objectives?
How successful was the
policy that we implemented
to raise taxes on tobacco?
Did it deter people
from buying cigarettes
and thus, help
people stop smoking?
So evaluation is critical
throughout the entire process.
The essential services of
enforcing laws, linking
to care, assuring a competent
workforce, and evaluation, they
fall under that core
function of assurance
on the left side of the circle.
And you'll recall
that assurance is
ensuring provision of services
to those who need them.
Now you'll note in the middle
of this graph there's research.
So research is in
the middle of all
of these core functions
and essential services
because it's continually
informing everything.
So think about as new tobacco
products are developed
and there are new things
coming out all of the time,
CDC's laboratories
are continuously
conducting research
on these new products
to help us discover their
potential negative health
effects and help us to look
at new products that are being
marketed or sold and how we
might combat those and battle
the tobacco industry.
One important point about
these essential services
is that while they're
shown in a very nice graph
and that they occur
in a sequential order,
they actually don't always
occur that way in reality.
You might have it
where you are you
doing a couple of the
essential services
and then you might
skip around or you
might skip a couple
of essential services
and move to a different one.
Sometimes things just
aren't neatly packaged.
Sometimes you might do a few
services and then actually loop
back and do them over again.
And again, with new
research continually
informing everything,
that again prevents
a nice chronological,
sequential flow.
But if you were to look at
this in a sequential order,
it does make sense
that you'd start
with monitoring
health and then moving
all the way through to insuring
competent workforce to actually
carry out whatever the
interventions are that you've
decided to implement
to achieve better
health of the population.
So the core functions of
assessment, policy development,
and assurance, they
must be carried out
at all levels of the government
for the public health system
to function effectively.
And this slide shows the
core functions at the top
and the three different levels
of government at the left.
So I'll just go through
each level of government
and give you the example of
assessment, policy development,
and assurance.
So at the federal level,
an example of assessment
would be conducting
national public health
surveillance about tobacco.
And then a policy, as
we've already discussed,
is that they've banned smoking
on commercial airline flights.
And then assurance is that
the federal government,
such as CDC, provides
federal grants
for anti-smoking
research and tobacco
use prevention
cessation and control.
At the state level, states
also monitor tobacco use.
States have autonomy for
increasing tobacco taxes.
If you look across
all states, there
are a whole bunch of different
types of tobacco taxes.
They're not all the same amount.
That's completely up to the
states to regulate that.
And then lastly, assurance.
An example of that
may be a estate
that has a proposition, such
as Proposition 99-- I believe
that was in California--
funding for campaigns to prevent
smoking.
At a local level,
local communities
also report on tobacco use.
So that is a way that
they conduct assessment
to gather data and diagnose.
Then that moves, again,
to policy development.
So you have county laws
that prohibit smoking
in bars and restaurants.
Maybe in your county
those are good things.
And then assurance,
at the last level,
an example of that
at the local level
are resources that county
or a local health department
might develop to help
people quit smoking.
And they might put
those resources
in different languages
that are representative
of the populations of people
who live in those communities.
So again, very different
levels, but each level
has to have a role for all of
these functions and services
to work together
and be successful.
All right.
So this brings us to
a knowledge check.
Which of the following is not a
core function of public health?
And hopefully you
all got this right.
The correct answer is authority.
So assurance assessment
and policy development
are all functions
of public health.
So here's a second
knowledge check.
The essential health
services of monitoring health
and diagnosing and
investigating disease
relate to which core
public health function?
Is it assurance, assessment,
or policy development?
And remember, it's learning
more about the health problem,
and so you do that
through assessment.
And you have to do that
before you can do anything
else in a meaningful way.
So the next section
of this course
is about the roles
of different groups
who have a stake
in public health.
The field of public health
requires stakeholders
with skills and intervention
programs, policies, research,
education, et cetera.
Partners include governments,
community groups, clinical care
providers, employers and
businesses, the media,
academia.
I could go on and
on but those are
the main groups, at least
that this slide shows,
in addition to the
infrastructure provided
by the government at all
levels as we just covered.
So what other sectors
and fields can you
think of that have a
stake in public health?
When I talk this over
with other groups,
some of the answers
that they provide
are transportation, housing,
schools, city planning,
law enforcement, faith
based institutions.
I mean, all of those
are great examples
of just other partners who
have a stake in public health.
And some of those are considered
nontraditional partners,
but our hope is that they
will become more traditional
and people won't think about
only providing with health care
providers, for example.
Or that basically, we
realize that there's
a health and all
policies approach,
which I'll get to in a moment.
Nongovernmental organizations,
often referred to as NGOs,
play a key role
in public health,
especially at the
community level.
NGOs serve many
different purposes,
from advocacy or education
to emergency relief
and economic development.
[INAUDIBLE] types of NGOs
include professional membership
organizations, groups that
focus on a specific health
problem, citizen
groups, advocacy groups,
and foundations that
support health projects
and work at the policy level.
So the column at
the right just shows
an example of each one of
these types of organizations.
Along with public
health, health care
plays a vital role in
protecting and promoting
the health of people.
So while the roles of public
health and health care
are complementary,
there are differences
that are shown on this slide.
Public health, as we've
talked about before,
focuses on populations
while health care
focuses on the
individual patient, which
is reflected in
different guiding
ethics for both those areas.
Public health focuses
on prevention.
And while health care is
concerned with prevention
to some extent,
its main focus is
more on diagnosing and
treating the problem.
Each type of laboratory
works jointly,
yet public health
interacts with the field
on behalf of groups of people.
And clinical laboratories work
with health care providers
on behalf of
individual patients.
And the last row
of the table shows
that while clinical sciences
are of peripheral importance
to public health, they are
essential to the training
of health care providers
on the clinical side.
So here are some of the
other primary partners
in public health.
We're seeing the role
these days of social media
as a vehicle for
public discourse
on all matter of issues,
including public health
concerns.
Whereas historically, it was
more public health agencies
and other partners that
have educated the public
and promoted healthy behaviors
through news and entertainment
media.
But now, there is more
of a self promotion
as well as social media
continues to take off.
Employers and
businesses, obviously.
They contribute to
the public's health
by providing health insurance.
Workplaces also have
wellness initiatives,
such as gym subsidies or
workout facilities on site,
and these can promote the
health of their employees.
Government agencies,
such as the CDC--
they work in partnership with
state, local, and tribal health
departments.
However, important
contributions are
made by other governmental
agencies at all levels.
City planning departments can
include sidewalks and bike
paths to promote and support
safe places for people
to be physically active.
Education departments can ensure
healthy food options in schools
and in vending machines.
Similarly, many other
government agencies
work as partners
in public health
by including health
considerations in their policy
development, and this is known
as a health and all policies
approach.
There's just this
concept that regardless
of what you do as
you're planning,
think about how can
impact public health.
And so that's what I
referred to earlier.
It says health and all policies.
And really, that opens up the
opportunity for public health
to partner with a
variety-- there's really
an endless number of different
types of organizations.
And lastly, but not
leastly, academia
educates and trains the
public health workforce
and conducts research
that informs public health
and provides a great
service to the field.
So we have another
matching exercise
for this knowledge check.
You need to match
each stakeholder
to its role in public health.
So for a vehicle for
public health discourse,
the correct answer is media.
Newspapers, opinion editorials,
social media, all media.
Health in all
policies, as I said,
is something that the
government definitely
can have an active
role in doing,
as well as other organizations.
But for the purposes of
this knowledge check,
the correct answer
is C, government.
Education and training
are things that academia
contribute to public health.
And the stakeholder that
provides wellness initiatives
and employee benefits is
employers and businesses.
So the last section
of this course
covers determinants
of health and explains
how they affect public health.
As we discussed
earlier, certain factors
determine a person's
state of health.
Scientists typically recognize
the same general categories
of health determinants
for any population,
and these are genes and
biology, health behaviors,
social or societal
characteristics, and health
services or medical care.
So I would like you to think
of some examples of each
of these broad categories.
What are some examples
of genes and biology?
You might think of a person's
sex or age or immunity levels.
For health behaviors it
could be whether or not
a person is a smoker.
What are that person's
eating habits?
Whether or not a person
takes medications
that are prescribed
for a chronic condition
that person has.
Social or societal
characteristics.
They can include
one's ability to work,
the quality of schools,
where a person lives.
What's the quality of
air, water, and sanitation
in that person's
immediate neighborhood?
And then, examples
of medical care
are insurance coverage and
even one's proximity to getting
quality health care.
This chart is an estimate of
how these four major categories
of health determinants influence
health at the population level.
The chart shows that
health care is not
the major factor
determining our health,
yet it represents a substantial
portion of the United States
budget.
Most of what determines
our health you'll
see at the population level
are the social and societal
characteristics, whereas
genes in and biology,
they have the least
amount of influence.
And then health
behaviors, again,
a pretty substantial amount.
But it's really the social
and societal characteristics
and the ecology, including
the person's environment, that
has the greatest impact.
To address the health
determinants on this slide
that we just discussed, we
have to have a plan of attack.
A means to effect change.
The health impact pyramid
describes such a plan.
It shows the impact of
different types of public health
interventions.
So as we move down the pyramid,
the public health impact
grows greater, and as
we move up the pyramid,
the amount of individual effort
to achieve impact increases.
So let's start at the top.
When we start at
the top and go down,
we can provide
counseling and education.
We can provide ongoing
direct clinical care.
Next, we can provide
clinical interventions
that require a more
limited contact
but confer long term protection.
That's kind of what
preventive medicine does.
We can change the context
to make individuals default
decisions be easy decisions but
ones that are the healthiest.
And at the bottom
of the pyramid,
that addresses the socioeconomic
determinants of health.
Interventions focusing on the
lower level of the pyramid
tend to be more effective
because they reach
broader segments
of society and they
require less individual effort.
This isn't to say that what's
at the top of the pyramid
is not important because it is,
but implementing interventions
at all levels of
the pyramid, that's
what's going to achieve
the maximum possible
sustained public health benefit.
And a point to
emphasize here too
is that there are trade offs.
We have to sometimes give
up resources in one area
in order to have a
larger impact in another.
But let's take a
look at some examples
of each level of intervention.
So the pyramid
illustrates the impact
of different types of
public health interventions.
And again, working our way
from the top to the bottom.
Counseling and education
in clinical settings,
public health
settings-- they are
regarded by some as the essence
of public health action.
I went to school and I actually
majored in health education
and promotion when I
got my master's degree
in public health.
But being at CDC, I've
learned a lot about how
all of those other
areas, including
the area at the bottom, really
make a substantial impact
in interventions.
But that's, again, not--
counseling and education--
they're not as effective
as we would like.
But that being said,
there are times
when counseling
and education are
the only forms of
intervention that
are available or appropriate.
And when they're applied
consistently and repeatedly,
they can have a positive impact.
So moving to clinical
interventions,
ongoing medical care for a
health condition is an example.
For example, in the case
of cardiovascular disease,
these interventions can
have a considerable effect.
But we're also limited
by a lack of access
to certain patients who
need that type of care
and a lack of adherence
to medical instructions
and taking prescriptions as
prescribed in the real world.
So again, that medical
care has its limitations.
So in the very
middle of the pyramid
looking at the intervention
level of preventive medicine,
let's talk about
vaccinations as an example.
Vaccinations prevent 2.5
million deaths among children
around the world every year.
So in this case, a single dose
or instance of an intervention
can have a lifelong effect.
So this is an example of a long
lasting preventive medicine
intervention.
The next level
down on the pyramid
is where we make
decisions the default
by changing the context
in which behaviors occur.
And it makes it more difficult
to avoid the intervention.
So for example, changing laws
to require seat belt use.
Making it easier for
people to wear their seat
belts because if you don't
put your seat belt on,
you get this really annoying
beeping noise until you put it
on, so you want to put it on
and just make the noise go way.
But it's much easier than it
used to be to wear your seat
belt. Banning smoking
in certain public places
is another example.
Both of these examples
and accomplishments
in public health have
had a tremendous impact
and saved many,
many, many lives.
In another basic example,
some of the buildings
at CDC-- the newer buildings
for example-- when you first
walk in, the stairs
are what you see
before you see the elevator.
And the stairs have
windows and maybe
have some plants or some music.
So that makes it much more
enjoyable and very easy
for people to decide to
take the stairs instead
of going all the way around the
corner to find the elevator.
So that's a real basic example
of making the healthy decisions
the default.
At the base of the pyramid are
the public health interventions
that affect
socioeconomic factors.
If we can improve
the quality of life
by helping people
out of poverty,
providing basic sanitation,
improving access to education,
helping them get jobs, providing
healthy food, medical care,
we can greatly improve
a population's health.
So it's time for
another knowledge check,
and I'd like you to just list
four determinants of health.
Now remember, it can be genes
and biology, health behaviors,
social societal characteristics,
and health services
or medical care.
In our last knowledge
check of the course,
just fill in the blanks
using the two choices.
For number one, as we move
down the health impact pyramid,
the public health
impact grows greater.
Remember, the base
of the pyramid
is the socioeconomic factors.
As we move up the
pyramid, the health impact
becomes greater in terms of
the amount of individual effort
that's required.
Again, all levels of the
pyramid are important,
but it's just a nice
framework for thinking
about how interventions
can be implemented
at different levels.
Within each of the topics
we've covered in this course,
underlying all of our
actions and decisions
is the application of the
public health core sciences.
I encourage you to build on this
introduction to public health
by learning more about
these core sciences
and how they contribute to
the field of public health.
Let's review the learning
objectives for this session.
The course provided
content to help
you describe the purpose
of public health,
define some key terms
used in public health.
You'll recall we talked about
epidemics, health determinants.
The course helped you
identify prominent events
in the history of public health.
That's where we looked at
a few historical highlights
of public health
through sanitation
and environmental
health, pandemics,
disaster preparedness and
response, and prevention
through policy.
The course helped you recognize
the core public health
functions-- those three
functions-- and 10
essential services.
You should be able
to describe the role
of different stakeholders in
the field of public health,
as well as to list some of
the determinants of health.
And lastly, you
should recognize how
individual
determinants of health
affect population health.
Thank you for your attention
today for the introduction
to public health.
To receive continuing
education units,
CEU credits, for
today's webinar,
please complete the webinar
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please visit
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Again, thank you
for participating
in today's webinar.
Have a positive and
healthy afternoon.
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