 Sean, I'm just wondering if you might be able to assign me the or send me the API token or assign me captioning privileges, and then I can just embed it. I see a notation here on my job form that I'm supposed to embed. Okay, I don't know how to do that. No, there's a button down on the bottom right set that says closed captioning. Is there something I should do there or if you. Yeah, try that one. And if not, it might be up at the top somewhere. Your buttons are a little different than mine. The question of control. There's, there's a thing called annotate. No, okay. Well, I guess we'll just leave it, I guess. Okay, I see people are slowly drifting in. Someone's going to have to edit all this early stuff. Welcome everyone. My name is Sean Herman. I'm a member of the Health Law Institute. And I'd like to welcome you all to the third installment of the 2022 23 hli seminar series. This is our first seminar this year that is back online. So hopefully we will avoid any technical difficulties. Please note on your systems that there is a Q&A button at the bottom. So if you have any questions or comments, we'll have we'll have time for questions and comments at the end of the talk. You can post them on the Q&A and and I'm told I will have I will be able to see those and we'll we'll read them out and deal with them in in order. The talk will be about 40 to 50 minutes, we'll have about 20 minutes to have questions and comments. Anyway, I should acknowledge that we are in Mi'kmaqi, the ancestral and unceded territory of the Mi'kmaqi people, and that we endeavor to pay respect to the indigenous knowledge held by the Mi'kmaqi people and to the wisdom of their elders. Mi'kmaqi people signed peace and friendship treaties with the Crown and we are all now treaty people. We are captioning, there should be a button on the bottom of your screen that you can press to initiate this function. I've never tried it so I'm not 100% sure how it works. But we do have closed captioning. So let me introduce our esteemed speaker today we are joined by and I am pleased to introduce Dr. Jennifer Prague. I'm a very impressive CV and I'm just going to hit some of the highlights of her of her biography. She is the Amartya Sen Professor of Health Equity, Economics and Policy, Professor of Medical Ethics and Health Policy at the Center for Global Health and the senior fellow at the Leonard Davis Institute for Health Economics and the Center for Public Health Initiatives, all at the University of Pennsylvania. She is founder and director of the Health Equity and Policy Lab which conducts quantitative and qualitative research on the equity implications of health and social policies. She conducts theoretical and empirical studies of health equity to reduce global and national health inequalities drawing on her training in political economy, health policy, international relations, comparative social research and law. Dr. Prague reexamines the values and principles that underlie health policy and public health and applies these principles empirically, which is something that I've done over the years and so I'm very much especially looking forward to this talk today. As we will hear more about Dr. Prague has created the health capability paradigm and has developed an empirical approach to evaluate public health programs and health policies as they measure up to that paradigm. Dr. Prague has served on several international and US advisory and expert review committees and is the past chair of the Ethics Special Primary Interest Group of the American Public Health Association. Please join me in welcoming Dr. Jennifer Prague. I now turn it over to you. Thank you so much, Sean, and thank you to you and Sheila and Ashley for all your work and inviting me and making this seminar happen. I am just delighted to be here as part of the health law and policy seminar series sponsored by the Health Law Institute at Dalhousie University. The only regret I have is that I'm not there in person. I've heard it's such a beautiful of this world. I am going to talk about the operationalizing the health justice health justice through the health capability profile. And as Sean just mentioned in that very generous introduction. I've been working on the health capability paradigm and the health capability profile which is what I'd like to share with you today and I very much look forward to your feedback. So we'll start with understanding what health capability is health capability is an ability, or it's a kind of power to perform with the potential for achieving desired ends that entails an aptitude. It's a cradle to grave concept that requires lifelong abilities and conditions. And the idea is that that it enables optimal health and flourishing health capabilities are key strengths they result from our societal and individual commitments of human financial physical resources. And that's what the goal of helping to people thrive and flourish. And the health capabilities help us understand for example why personal determination and skills or health beliefs alone are not enough. Why people with even the very best external conditions can still have poor health, and why a narrow biomedical model of disease is insufficient. The health capability model in its sort of conceptual framework we have biology and genetic predisposition. We have intermediate social context. We have public health and healthcare systems. We have the macro social political and economic environment, and sort of at the center all of this is is health capability the confidence and ability to be effective in achieving optimal given ones biological and genetic genetic predisposition and the intermediate and the broader social political and economic environment, as well as access to public health and healthcare system so health capability captures the interactive and dynamic and multi dimensionality of health and flourishing. And so where the circle circles overlap. This figure gives an representation of the way that individual and social factors interact to create health capability and we'll talk more about that later. The ability model is is different from other models and some of the ways it's different are that linear models tend to be limited to one to one associations among variables. And even when we have interactive terms in these linear models. Excuse me, and even when control when one controls for a number of variables, we still see these kinds of limitations, reductionist models examine simple relationships first and then they some the principle sub components. And then we have an aggregated form of something that can be very difficult to interpret or understand the dynamics and interactive nature of something. The health capability model is a more flexible analytical approach. It accounts for both internal and external influences at the individual level. It allows for contemporaneous multiple relationships among factors. It's overlapping feature offers a nuanced and sequentially interactive, iterative and dynamic and multinational multi dimensional understanding. The model helps reveal heterogeneity in the influence of irreducibly social goods and experiences on an individual and the individuals influence on society. Another of the health capability model we believe our effectiveness in terms of longitudinal over time, intersectoral and multi sectoral policy and institutional analysis and design, allowing for heterogeneous relations among individuals and society level so society level we have income education we have race but we have also racism, sexism gender discrimination heteronormativity and LGBTQ plus rights. In terms of capability capital we have capital that occurs and accrues at the personal and interpersonal level the institutional level and structural so we're trying to understand these different, different levels. And there's something about this that's attempting to address problems of a lack of information in terms of what's going on with respect to the direct impact of external factors by measuring a different kind of construct health capability as opposed to other kinds of constructs. So it incorporates external factors into the individual level and the impacts of individuals on society, rather than trying to draw an inference about an individual and individuals health based on group or macro level characteristics such as demographic information that is measured categorically in different groups. The health capability profiles operationalized into a measurable profile and an index. It is the health capability profile comprises 15 different health capabilities and we're going to go through those though that that that then encompass 49 separate health functionings and agencies. The profile then snapshots and tracks the health capabilities development so the idea here is developing health capabilities. And the goal is for each and every person to reach their highest potential their full health capability. And then this provides a full, a full picture of a person's lived experience and their journey to reach to reaching their health and flourishing potential. So here are the different health capabilities. And this is also information that's available on our website at the health equity and policy lab. Interesting to I said and I mentioned there were 15 different health capabilities the first internal health capability is health status and health functioning. This is your state of health, where you actually are in terms of your health functioning. Internal capability to is health knowledge this is knowing about your health and knowing how to be healthy. Internal capability three is health seeking skills and beliefs and a sense of self efficacy this is your belief in yourself and your health. Internal capability for is health values and goals. This is valuing health. Internal capability five is a sense of self governance and self management and and also your perceived ones perceived self governance and management, and to achieve health outcomes. Internal capability six is effective health decision making making good decisions for health. Internal capability seven is intrinsic motivation. This is being self motivated towards health. Internal capability eight is positive expectations. And so this is having positive expectations about one's health and flourishing. Then we have our external capabilities are external capability is nine is social norms. This is the cultures of health and the expected behaviors in a society. External capability 10 is social networks and social capital for achieving positive health outcomes, connecting to others for help for health. External capability 11 is the group membership influences and these are health norms of your social groups. External capability 12 is material circumstances this is having material circumstances that support health. External capability 13 is economic political and social security general feelings of security and the external capability 14 is utilization and access to health services this is receiving health care when needed and then finally external capability 15 is an enabling public health and health care system. So this is the effectiveness of these health systems so this is a very comprehensive profile in which we have these 15 different internal health capabilities and external health capabilities which to together again as I said interactively work to create our ability to be healthy. I'm just going to this is again is all on our website but I wanted to go through just like a couple of the different capabilities you have a one internal capability external capability so you have a sense of how this, how this works. So here's the internal capability for health values and goals this is valuing health. In overview, this is a kind of valuing our health valuing health related goals valuing life lifestyle choices and behaviors, our ability to recognize encounter damaging or, or, or positive social norms. So what is it health values and goals is the internal capability of value in one's health. So including health related goals and health promoting behaviors. Health related goals refer to two objectives will a person has for one's health, like healthy cholesterol levels or weight or other kinds of goals. An example of the health promoting behavior and lifestyle choice on behavior is a regular exercise a healthy diet active lifestyle. The capability also includes the ability to recognize encounter damaging social norms that undermine the undermine the value of health or, or, or to persist in one's values despite negative social messaging. So what, and then, again we have this on our website this really helps us understand you know why is this important, what does it look like and how do we do how do we do it how do I do it. So why why is it important well health values and goals are important because we live in a world of finite resources including our own resources of attention energy time, and health will not be achieved. If it is not prioritized. So value is something we prioritize. So health values and goals allow us to understand that health is central to a good life and should be treated as such by all of us. So health values and goals ensure that we we see what is truly important in life, and we actually go and pursue it again valuing something is prioritizing. What is truly important. What takes priority. What does it look like someone with a high internal health value and goals capability expresses their values to both their own words and their actions. So how do we positively of health, health related goals, healthy lifestyle choices and behaviors as well as explicitly countering social norms that damage health or other other kinds of things that damage one's health health values and goals will have a high priority in their life, including in how they structure their own pursuits their daily schedule, their short term and long term priorities their free time their plans etc. So how do I do it health values and goals can be continuously developed and that's the whole idea behind health capability is a cradle to grave continuously developing questions to ask yourself may include why is my health important to me. How do I practice and honor that in my daily life. What resources am I committing to my health. What are some goals I can set that will help me become healthier. What are some lifestyle saying about what matters to me. How might I change some of my lifestyle habits to have health as a top priority. What are some social norms that detract from my health. How might I respond to them. How might I put myself in a position to benefit from social norms. This is an external capability of social norms. This is the culture of health and the expected behaviors in the society. And here we're looking at the extent to which health norms are scientifically valid and evidence based the extent to which health behaviors and health seeking skills are viewed favorably. The extent to which the behaviors of abstinence from from drugs alcohol, or unfairly cultures of alcohol abuse within a family, other kinds of abuse or violent behavior extent to which health behaviors adopted by a majority or minority the population and the culture. What is discrimination or anti discrimination is the dominant norm in the provision of health care and public health services that influences disparities and access norms about decisional latitude or power in familial and social context. Society's ability to recognize encounter damaging social norms and promote positive ones. What is it what is this external capability social norms are an external capability that encompass a variety of health promoting norms across different social domains. Firstly, a strong social norm capability includes scientifically valid and evidence based health norms. Secondly, health behaviors and health seeking skills are viewed favorably health behaviors are adopted by most of the population. And society is able to recognize encounter damaging social norms and promote positive ones. Anti discrimination is the dot is is the dominant norm in society. Social norms and the provision of health care and public health services ameliorate disparities and access and norms about decisional attitude or power familial and social context are conducive to each person's health agency. That's their ability to achieve health goals they value the culture and expected behavior in society and power each and every person to be healthy. Why is it important social norms are important an important external capability because they shape our beliefs and actions, what we consider acceptable, valuable important normal. What is expected in order to belong to society, living in a society where health is scientifically understood widely regarded as important and supported institutionalized as a priority, and where people are encouraged and sustained in being active agents of their own health. This is a critical capability for one's health. What does it look like a society with positive social norm external capability will demonstrate scientifically accurate health norms, such as social norms of childhood vaccine vaccination, annual influenza immunizations, respectful and anti discriminated discriminatory expectations about behavior and empathy and care towards each other to thrive, seeking and receiving vaccination is immunizations are viewed positively in social circles and professional settings, and all the population is seeking these kinds of vaccinations and immunizations Healthcare and public health providers practice anti discriminatory service provision to ensure underserved populations and communities are properly served and children's health is not put at risk due to power imbalances in the parent child relationship and unscientific beliefs of the parents Public moral norms of justice, equity and fairness are important here, and the goals of public health and health policy are to serve everyone and benefit all. How do we do it. We can develop our health capability of social norms to promoting positive health and public health moral norms through individuals as well as institutions such as the media governmental agencies academia and popular culture. So the health capability profile, as I said it's a flexible and detailed multi dimensional typology. It's a dynamic framework. It focuses on implementation sciences so we want to focus on identifying gaps between reserve health capabilities and optimal level of health capability. It has a normative dimension. The health capability paradigm that was mentioned earlier advances principles that ensure that individuals in society work together towards the health capabilities for all so there is a strong normative dimension to this. How do we apply the health capability profile. Well, first we have to adapt the profile and what we do in this case and we've been we've been doing this in the work conjunction with our collaborators in our lab. We adapt the profile to a particular health condition or particular and or particular setting. The methods that we've been using and it can be used are mixed methods. And this is quantitative and qualitative and social justice at the core in the sense of a normative framework that privileges all individuals ability to be healthy. It's not for certain groups and not others it's for all, and their quantitative and qualitative data collection that occur in adapting the profile. Then there's data integration flow diagrams which I'm going to show you some today, and there's also zero to 100 health capabilities scores so in each of these 15 different health capabilities. We come up with a zero to 100 score and also stages of development of that particular health capability which helps us understand the overall health capability of a person. This can then feed into policy change towards health capability for all. So here are some of the research questions that we've been focusing on. How can the health capability profile be applied to investigate contemporary public health problems and we're working on a three step methodology. What insights can it provide to inform behavioral, programmatic and policy change. And I'm going to show you just a couple of illustrations from the work that we've been doing on a couple public health issues that are pressing for women and the LGBTQ plus community. All right, so in terms of methods, here's how it works. Understanding the profile as a whole. And this involves the 15 separate but interconnected health capabilities that I just showed you. This is encompassing 49 functionings and agencies. Then we're creating the ability to achieve optimal health now in the future through the process of developing capabilities. Applying the profile of specific cases components of the profile are are the coding matrix and we'll talk about that in a minute. And then quantification of observed capabilities versus the optimal level of capability. And then we have interactions among health capabilities among those 15 capabilities. When we employ the profile to promote health capability. We identify different leverage points. We prioritize in those leverage points in terms of implementation and effectiveness. And then there's a positionality in terms of society and individuals together, working towards the health capability of all people. So the kind of methods that we've been involved with our conductive content analysis. And this is using theory or theoretical frameworks or concept or a conceptual model to analyze data by operationalizing them in a coding matrix. We have couched and developed the health capability profile in the context of our theory of the health capability paradigm and our theory of promoting the ability to be healthy. The three step analysis is you understand a case study through the prism of the health capability profile. You construct the flow diagrams. And this is the quantification of the capabilities level of development observed in relation to the optimal. And then there's a characterization of the detrimental or the enabling interactions among capabilities that overall enable or inhibit somebody from the ability to be healthy. And then there's recommended policy changes that can help promote health capabilities as a result of this analysis. So constructing the flow diagrams is the narrative part of this. And that's dividing this narrative and I'm going to show you the scenarios that we've been working on into meaningful units and these range from a few words to a few sentences. Units are then classified into one of several of the 15 health capabilities units are quantified in terms of their health capability development and placed on a left to right continuum from nil which is not very developed. And is an extreme shortfall in somebody's ability to be healthy. And that particular health capability to realistically are what's possible or to actually the optimal level of development. And this is how we get the detrimental or the positive causal interactions that are depicted. And I'll show you that we put them in red and green arrows respectively but this is to basically understand what the dynamic and interactive nature is among these 15 different health capabilities, external and internal, in terms of the overall ability to be healthy of a person. Okay. So when we're employing the profile, there's positionality. And so this is individuals and society working together to create and foster healthy lives. And the way that we incorporate the positionality in the health capability profile is the internal capabilities and the external capabilities. So this is really neither complete paternalism where we're, you know, really about sort of telling people how they should act and what they should be doing, or unbridled autonomy where it's just people out there doing whatever they want whenever they want. There's a really much more of a nuance and a middle ground there in terms of developing people's agency to make positive choices, and then creating the conditions that make it possible for them to develop these capabilities. So here we're recommending a set of realistic interventions and policies to transition detrimental interactions into positive ones. And this is to ensure an optimal development in the combination of each health capability. We have priority ranking, we have shortfall inequality and effectiveness, and that is when there is a shortfall in the capability and then figuring out the effectiveness in addressing that. All right, so in this application, we've had a sampling strategy, and we've been analyzing explanatory case studies and there are ways to choose what kind of case studies to analyze through the prism of the health capability paradigm. So let's look at the leading causes of death. And here are the leading causes of death. We have heart disease cancer accidents, lower respiratory disease, cerebral vascular disease Alzheimer's kidney intentional self harm suicide, these are leading causes of death. We have pressing public health issues. COVID is at the top of the list. Substance use disorder, structural racism, domestic violence, LGBTQ plus discrimination, gun violence, sexual harassment, structural racism, obesity, anorexia, infertility. So these are the ways to choose different cases to analyze with and apply the health capability profile. And there are other, we have a study going on, where we're looking at chronic hepatitis B and Senegal applying the profile where we've developed a questionnaire and doing our collecting quantitative and qualitative data in a mixed methods capacity. There's other kinds of case studies. So we were I'm just going to present some public health issues focused on women and LGBTQ plus populations to just give you a sense of how to apply the profile in these particular cases. So here we have a particular case study. And this is s s is a 25 year old graduated from a very good university found a job at a prestigious news outlet company. Her boss is very famous he's been in the industry for 30 years has connections with rich and powerful people including elected officials and businessmen. S feels very lucky to join this team. The first week goes well but s is growing uncomfortable with bosses behavior. He has a certain way of looking at her complimenting flattering her whimsically talking with her being near and around her. One day he requests a private meeting at his place after hours. When s tried to reschedule her boss, you know, are you not committed to this job and your career as s's boss behaves increasingly inappropriately during the meeting s feels endangered and she runs away. The next day he threatens to ruin her reputation if she talks. S loses sleep. She has stomach aches. Before she goes to work. She meets with the HR officer and a company doctor, but neither of them report the incident she also tries to approach the topic with her coworkers they tell her that's not the first. She's not the first one to speak up, but nothing changes. She also decides to quit. It takes a few years to regain her mental health because there have been major mental health implications of this experience, and also to put her career back on track. So let's look at what this looks like from a health capability profile perspective. Before the green, we, we, in the green and on the right side of this flow diagram, we represent positive development in terms of the health capabilities so on the positive side s is motivated. She's resourceful and proactive in terms of strong beliefs and skills self governance and management decision making motivation values and goals. On the red side or the deficit side, there's a culture of domination and power structures those are the social norms that that that this experiences is all about. The company is protecting toxic behaviors that's a group membership, kind of a capability, and these are linked and related, they are interacting in this particular scenario. There's a inertia of HR and healthcare professionals in in this scenario. And so that's not enabling in terms of the healthcare system and the and the sense of security in this particular scenario. These are related to the social norms, because the social norms create the context for this kind of inertia on the part of these parts of the institution. She's her functioning is very debilitated because she's losing sleep and she has anxiety and stress she's having major mental health ramifications as a result of this experience. She has to quit her job and does not feel like she can continue in this situation because she loses hope. And so her expectations are negatively impacted, and this is impacted by the social norms is impacted by the group membership that she's a part of. So this is how these interactions are occurring. It affects her career, and her losing hope and quitting her job affects her career, and these kinds of experiences are all interconnected. So what does it look like to change things. What it looks like is to, to change from the experience where we had a culture of male domination and power structures to a culture of equality and respect. So instead of being over here in the red, where we're having this cascade of interactions and dynamic flow of negative interactions and experiences which is creating this, these detriments and her ability to be healthy. We're switching now, and we're transforming and developing a culture of equality and respect. And that shifts things in the direction of a positive external capability of social norms that the interconnectedness that we saw in the prior experience so now these are shifting from from red to gray because they're transitioning, transforming as a result of the link with the norms and the cultural change towards equality and respect. We see differences in terms of how people are treated protected, promoting equality, promoting respect companies promoting a healthy work environment. And now we see relationships between a culture of equality and respect, a promoting healthy work environment, protecting and promoting equality and respect among staff. There's a general sense of optimism and wellness that is related to other capabilities functioning and expectations. These are internal capabilities so this is how external capabilities and internal capabilities are interacting in a positive shift to move things in a positive direction. We see good career and living conditions for people and an overall better experience. Here's another example. This is you. You is 35. She went to her doctor for a checkup she was worried because she's been trying to get pregnant for over two years you was very connected to her body, and she's able to identify her She has been monitoring her diet and doing regular physical exercises during her visit she mentioned that she experiences very painful periods. And she always has her doctor replied that all women are in pain during their menstruation, and that she just needs to be patient and relax in order to get pregnant. She searches period pain and infertility on the internet and she finds information on endometriosis, realizing that she exhibits most of these symptoms she asked her doctor for an MRI. He says she would wait at she should wait another year before suspecting endometriosis 12 months later when you finally does the MRI it confirms that she does indeed have endometriosis, and that the disease has progressed to the point that there is nothing that can be done to to prevent her from infertility. The specialist further tells her that if her condition have been diagnosed earlier. She probably would have been able to freeze her eggs and attempt in in vitro fertilization. So let's look at what this looks like in terms of the of the flow diagram. She said that you is motivated she values health and learn skills. This is high values and skills and motivation health capabilities. And these are related to beliefs and skills. Then we see decision making and self governance and management. She's seeking information and controlling and controlling her behavior. These are all positive things that she's doing. These are positive developments in her in these internal health capabilities. We also see her using health care and accessing it and accessing it. But you isn't but she's not getting pregnant. Her functioning has been compromised. That's not working. It is related to her being utilizing and accessing health care. But we have the physician physicians belief that women's periods are to be painful. This is the social norm that's embedded in the institution in which she is operating and she is engaging. That's a negative part that is compromising the health care system to be enabling for her in the situation. It's also compromising and detrimental to her access and utilization. It's also been detrimental to her knowledge. She ignores her condition. And then that in in turn affects her ability to get pregnant and to function, which is not not happening. This this health care utilization and access is having a negative impact on her functioning and her in fertility. Sadly, is it irreversible. And so her expectations are negatively impacted. But that is a way in which we see this interaction of internal health capabilities and external health capabilities and, and in that particular situation. There wasn't any, any further thing that can be done. Another example here we have P who has been married for 10 years. She met her husband in college and they married upon graduation. Over the years, her husband and grown very controlling. He started with making remarks about her high school friends, which he didn't like very much and asked that she spend more time with him at night. He then refused to celebrate holidays with peace family. She became a mother he told P it would be better she quit her job as an office clerk to look after their child, and that he could provide for the family. P never pictured herself as a stay at home mother but she's doing her best to adjust. Often her husband becomes home angry and gets mad at her for small things such as the such as the food not being to his liking he regularly talks her down. Sometimes even insults her he said he has threatened to be violent a couple of times. When P went to the police, the officer asked her if she realized that her husband would realize that her husband would be arrested and sent to jail, and therefore won't be able to provide for her family anymore. Her husband beg for forgiveness and threatened to kill himself if she ever considered leaving him. She also mentioned issues with the husband to her GP, her provider, but the physician did not inquire further. She has no one to talk to she is not a member of any association or club and she hasn't seen her relatives in over two years. So what does this look like. He is cut off from friends and family by her abusive husband. This is a detriment to her social capital and networks. He is emotionally abused this is a detriment to her functioning. And these two are interacting with each other. Gender inequality and male domination is a social norm that is, is, is the context for this situation. That's impacting her social capital and networks, which is impacting her functioning. The institutions and the police are not protecting her so there's not a sense there's a detriment in terms of a sense of overall security for P. And this is impacted by the gender inequality and male domination that is the social norm in this context. P is feeling hope helpless and loses hope, which is impacting her internal capabilities, her beliefs and skills for self governance and management her expectations. And these are all impacted by the the detriment in her social capital and our networks on the positive side she is seeking help. She is seeking access to the healthcare system and utilizes it for her annual checkups, but she did not get the response that she needed from the GP that was not an enabling healthcare system in this setting and that was affected by the gender inequality and the male domination the social norms. She has a nice house. She has very good housing, but this depends on her husband's job. So her material circumstances are somewhat in the middle. They are, she has a nice house but there's a contingency and there's a dependency there that's compromising her ability. That's impacted by the social capital and the networks that are compromised in this system. So these are the kinds of ways in which this is interacting. Here's another example. This is Q. Q is a 30 year old who broke his wrist. Social baseball game. HIV is undetectable for now his partner takes him to the nearest hospital for emergency surgery. The check in proc process goes smoothly Q has a very good has very good health insurance provided by a stable job. And he has to stay overnight to be operated on first thing in the morning past visiting hours Q's partner returns the hospital and gives a few pills to the nurse and duty explain that Q needs to take his daily HIV medication, which he had forgotten at home. The next day Q sets get surgery and is kept for observation Q repeatedly asked for his HIV prescription, but his reference nurse ignores him after mumbling, one gets what one deserves. He gets extremely anxious. He knows that disruption is medication might compromise the control of his HIV viral load and destroy his efforts to ensuring that his HIV remains undetectable, and therefore untransmitable his main goal, since he found out he had HIV. He has a good job and insurance, a supportive partner. So economic social political security material circumstances social capital are all positive health care access and utilization is somewhat positive, because he is accessing care. There's a sense of homophobia and LGBT TQ plus discrimination that is related to the social norms in this context. There's staff discrimination because of sexual orientation that compromises the health care system. And this is related to the social norm of discrimination and homophobia. And this relates to health care access and Q get surgery but discontinues the HIV medication. He was worried about about the the management of his own HIV, and this, but he does have the resources and that does possibly impact his health care utilization. He's knowledgeable motivated and skilled as he monitors his HIV. So his knowledge and motivation and values and skills are high. And so this is this is all positive, his self governance and management and beliefs are high. And these are all related to each other. So self governance motivation helps beliefs and skills and values and goals is also related to knowledge affects self governance motivation affects self governance and values and goals felt affect beliefs and skills so these are how these are all interacting. And then the his wrist is fixed. And so the functioning of that part is is good and the HIV is undetectable for now. But the health care utilization is also negatively impacting that. Let's look at some of the cross cutting and as like I said we these were just a couple these are scenarios and these are hypothetical scenarios these are not these are just hypothetical scenarios that were presented to show and demonstrate the impact of looking at these particular kinds of public health issues from a health capability profile perspective. So they're pressing public health issues for women and LGBTQ plus. And this is a highlight of the role, particularly of detrimental social norms of domination discrimination, the significant shortfalls and social norms though however our leverage point. So detrimental social norms can unbalance even the strongest profiles, where we have very strong internal health capabilities, but when we have the strong external social norms. They can be very imbalancing the overflows, they overflow into the health care and public health system as well as institutions. This prevents positive influences from the internal care of capabilities, and it affects health care accessing utilization which in turn damages health outcomes. So these shortfalls and in health functioning then can further weaken the profile. This jeopardizes also expectations and material circumstances so this is a, again, and just these are hypothetical case studies demonstrating through the prism of the health capability profile, how these internal health capabilities and external capabilities interact to positively influence or negatively influences one's overall health capability and then identify the leverage points and the ways in which there are linkages and interactions to intervene to ameliorate or better the situation. We're talking about promoting health capability we're talking about leverage points and shortfall and equality so the shortfall and qualities are the places where there are the these detriments and shortfalls in the social norms as a lever leverage point changing detrimental social norms of domination bias and discrimination into norms of equality and respect for all, and promotion of wellness and flourishing for all. So, so again, as I said, detrimental social norms can unbalance even the strongest profiles, they can be embedded in health care and public health systems as well as institutions, they can prevent positive influences from internal capabilities, and they can affect health care access and utilization which in turn damages health outcomes. So the profile enables a transformational shift. It describes the step by step process of moving from these negative discrimination bias abuse experiences to equality and flourishing. It illuminates what the promotion of health capability looks like in a specific case study, and it highlights what it takes to make it happen. So, and then I'm going to finish fairly fairly soon. The profile is very flexible. It can be applied to a wide variety of individual situations and broader settings. It's unique to each individual at one point in time. External capabilities are assessed at the individual level and different social norms experienced by individuals living in the same community. It offers a multi level analysis that shows strength versus vulnerability at the glance as well as a detailed granular information at the health capability level. What does it do reveals multiple causes accurately describes people's complex experiences of intersectionality. It identifies cumulative and heterogeneous effects allows incorporation of equity concerns. It showcases underlying vulnerabilities that need to be addressed. It provides the roadmap to build individual and collective capabilities. It highlights strengths and positive examples illustrates how to achieve optimal health capability. The limitations, of course, it is prior understanding an in-depth review of the profile. It's very labor intensive. There are might their drybacks and light it. We think the drawbacks in light of the in light of what what it allows is that it provides a detailed and accurate understanding of people's complex individual experiences. It's really very important. It's comprehensive and impracticable in terms of a template to achieve collective well being. It's proactive and prevention oriented, and it's a collaborative effort. It's, it can be a valuable tool for clinicians and health professionals, policymakers and people themselves. And lastly, let me end with health capability and justice. It's oops. The health capability profile is embedded in achieving justice and achieving justice requires providing people with the conditions to be healthy and flourish and oops. Why? Because we have a societal obligation to transform the conditions where everyone has the ability to be healthy and how the profile shows how to transform the conditions that are detrimental to health and detrimental to flourishing and detrimental to wellness situations that promote and ensure equality and respect, enable health, enable well being and enable flourishing. And I'll stop there. Thank you so much. Thank you very much, Dr. Prott. We now have about 15 minutes for some questions. So if people who anyone who has a question or comment can put it in the Q&A, and that should then appear in my chat panel and I can, and I can read it out so there are one or two questions now. But I would encourage people to think about some more and I'll let me ask you this then Dr. Prott. So I think you've demonstrated quite well how the tool can help one organize information and then therefore assess where issues are exerting negative impacts and need to be altered. But there might be, this might show that there's a lot that needs to be done beyond the reach of say the physician or the public health official who wants to take decisions or so on. So how do we marshal the resources to make the changes, including some of the cultural changes that some of your scenarios identified in order to improve outcomes in these scenarios. Thank you for that question. Like I said, these are hypothetical scenarios to demonstrate what can happen and what can be done. We envision with the profile is using it to collect real data. And we are doing that in, so I mentioned the Senegal project. We've developed a survey at the individual level and an interview guide at the individual and the local level. And so we are collecting data from individuals and from the key stakeholders. And so the idea there is to aggregate data across individuals, and at these different levels in which this any particular application of the survey and interview guide can happen to create the information, both across individuals and at the community, local, state, provincial, whatever level. So, and then that information data is then advanced for policy purposes, so input to policy. Okay, and then with the scenarios we can show that's the real data that what I just showed you are, like I said, hypothetical case studies. Okay, so what I showed you was how then with the data that we gather across individuals, it can be used to demonstrate because we will see patterns of transformation to demonstrate how you move from one part of the profile to the other to the you know, I just I'm, I'm now also the director of the Ortenor Center on violence and abuse, and our mission is safe, safe daughters confident women strong society. And so the idea is, you know, what are the conditions of abuse and violence and discrimination and negative influences to toxicity to health unhealthy to healthy well being and flourishing. And what is that transformation look like. And the health capability profile can can help us see that and can aggregate across individuals to provide the information for policymakers. Okay, thank you. I questions are coming in now this one's from Josh Shaw. How do cultural differences in the interpretation of health factor into the model, and he's thinking of differences and understandings of body weight or the help of smoking with managing stress and so on. Thank you. Thank you for that question I appreciate that the way that the cult cultural as I understand the question how does cultural that our cultural values incorporated in the model. But by asking people. And again, the, the idea is that we're going to be asking, you know, many people or whoever's using the, the instrument, applying the profile is asking many people and that across people. We will understand and learn what what the cultural values are and the cultural norms are in those particular societies and those particular contexts. And if I could just follow up on that then so do you see this then as identifying areas where there might need to be value change. And how do you, how do you, how would I know this particular tool may not sort of speak to to that but how do you see the encouraging the value changes that might need to be made based on the evidence that you're generating. Excellent. Thank you so much that's that's so great. Yes, it is possible that value change may be, may be necessary. And, and that's because of, I mean, you may have familiar with the ideas like adaptive preferences that people may not have enough information or know what could be possible, or what, you know, what is possible for them, because they've got access to it, they didn't, they wouldn't know that. And so the counterfactual or the positive deviants what you know what's possible. And what's the potential is something that we hope to illuminate and share with people through gathering information through the profile, then sharing that information with others where there may need to be value change. In terms of, again, sharing the information, showing how this particular set of values may be more conducive to health well being and flourishing for all people in particular society. And how that how that is, it's not a black, hopefully, it's not as much of a black box anymore. It's trying to see actually how that works and why, and showing, you know, the proof of why certain kinds of values are more conducive, like equality and respect are more conducive to more flourishing and healthy environments. Yes, thank you. Okay, thank you. I've got a question here from Ali medicine and society have conceptualized of a number of kinds of people as problematic in achieving optimal health overweight people people who use drugs HIV positive non deterrent people for example. How does your framework address medicines own creation of oppression. Thank you. That's excellent by by trying to collect data on it, and people's experiencing experiences with it. And that's where, when I showed you the enabling or not enabling health care system and the norms that are embedded in the health care system. The social norms and the arrows between, and by asking people and having them tell us what their experience is with those kinds of interactions can illuminate why the system may or may not be serving all people because the goal is to serve all people. Regardless of your addiction status, your weight, you know, that's not those are just that's just information to help a person help them understand whether those factors are enabling them or not to be healthy and to flourish. It's not to judge. There's the health capability profile is for every person on the planet. And it's a belief that every person has the ability to be healthy, regardless of their and that's why the predisposition of biological factors is part of the profile. No matter what a person's born with. No matter what their circumstances. Are the conditions in place that are developing their internal capabilities and their external capabilities to enable them to be healthy and enable them to flourish. And also to support because equity and justice is the foundation for the profile and also to ensure that other people have the ability to be healthy and the ability to flourish. That's the project. And this hopefully will help us understand what's what whether whether that's occurring or not. Okay, thank you. There's another question here it's a two part question I guess from Andrea. One, she's wondering which factors might facilitate or hinder buy in by people or groups who could be using the tool. And then sort of a more, I guess a practical question of where might one go to follow up and learn more about where and how the tool is being applied and or used in the future. Thank you. That's a great question buy in is is is all about trying to understand whether it's useful and whether it provides information that can be helpful. So by by being as detailed and granular as the health capability profile seeks to be to really be comprehensive to be rigorous to show the dynamic and interactive nature of the complex systematic experiences that people having it's a system health capability profile as a system, then it, it, it, it will help us better understand people's experiences we know the statistics are ready the epidemiology has been has been very helpful. We know disparities in health outcomes exist. We know rates of mental illness are very, very high. We know rates of substance abuse disorders are very high we know that cancer we know that all sorts of kinds of disease disease are very high and are very problematic. What we have been focused less on is, how do we create environments of wellness and health and flourishing and the health capability profile is based on the based on the night, the notion that we are agentive. We health agency, our ability to achieve health values that we health goals that we value our, our responsibility and our project in the context of societies, responsibility and societies project so it does not dichotomize between individuals and society is a collaborative cooperative and endeavor. So the buy in comes from understanding that we're really trying to get the complex experience gathered through data, understood, recognize the leverage points and change for the better. It's for the better. It's for health and well being and wellness and flourishing, and we're on this end of the spectrum, and we've got wonderful scientific research on diseases and the brain and the body system. And we've learned a lot. We have a cove a vaccine because we did a lot of great research. What are the conditions to prevent disease to prevent the onset of ill experiences among people to promote health and wellness and the good life flourishing in terms of tools, the health equity and policy lab. We have on our research themes health capability is one of our research themes and so you can go there and then if you just keep going through the that research tab. You'll find more information and we're putting more up as we as we go. Thank you. I don't see any other questions coming in which is, I suppose, timely because we're out of time as far as I can tell. So I would like to thank our speaker once again for a very interesting talk and a very interesting, I think, policy tool. And if we could, I don't know, it's hard to do when we're online but thank you very much for for speaking with us today. In closing, I would like also to thank everyone who participated. And I would also note that the next talk from the HLI seminar is on November 25, but please stay tuned, because I've been given a note here that there has been a schedule change so there's not a change of date but a change of speaker. So next, next seminar will be lawyer Alyssa Lombard will be speaking on the topic of coerced sterilization of indigenous women. So thank you all and thank you, Dr. Praugh. And please everyone have a good and safe weekend. Thank you. Thank you for having me. And thank you for all your comments. It's really, I think it's, it's really interesting. Maybe before I let you go, I had, I had one sort of question that arose from your last comment if you had a moment. Are we on, are we, are we, let me, let me stop recording.