Block 2 Flashcards
Why is infant mortality used as an indicator of health of population?
- Good proxy for population health
- Correlates well with other proxy measures but easier to measure
- Highly sensitive to social determinants of health and disease epidemics
(Hence good marker for showing what is happening ‘now and here’)
Over the last century there has been a decrease in the infant mortality rate
Define infant mortality rate
The number of babies that die within 1 year of life per 100,000
Define child mortality rate
The number of deaths of children between the age of 1 and 18 per 100,000
What does life expectancy at birth measure?
Life expectancy at birth is a measure for the average number of years that a newborn baby can expect to live
If they pass through life subject to the age specific mortality rates of the time.
What is meant by disability free life years?
Number of years an individual can expect to live without a limiting chronic illness or disability
What does disability free life years indicate?
Gives an indication of how demand on health and social services may increase in future years.
Current results show:
That men and women are living more of their lives disability free
Women live longer but more years with a limiting chronic ill/disability than men
Define health inequality
Is the systematic differences in health and illness across social groups
Factor that influence health inequalities include:
Age
Gender
Ethnicity
Geography
Socio-economical status
As a result of these differences some groups live longer and experience less morbidity than other groups
What is meant by the social gradient in health?
Stepwise (Linear) gradient in health
With each step down the socio-economic ladder, health becomes poorer
Inequalities occur across the whole range of socio-economic groups not only in rich and poor
Evident across almost all indicators
What are the exceptions to the social gradient in health?
1. Breast cancer
(higher in least deprived groups)
2. Malignant melanoma of skin
(higher incidence in least reprived groups)
3. Prostate cancer
(men in least deprived deprivation more likely to have prostate cancer)
What are the general patterns of health inequality of the main causes of death/health indicators?
Infant mortality rate: children in lowest socio-economic households have highest infant mortality rates
Occupation: poorer health in those who are classes in the lowest occupational group
Geography: lowest death rates in those who live in least deprived areas. In UK, higher death rates in north, west and in urban areas
Lung cancer: increased incident of disease as you move down deprivation list
Age: stepwise health inequalities in all ages (birth to old age) but greatest seen in childhood
Gender: less steep health inequalities for women than men. Women live longer
Ethnicity: people from black and minority ethnic groups living in the UK are more likely to be diagnosed with mental health problems and report poorer self-assessed health. Become more pronounced with age
How can socio-economic status be measured?
Occupation
Income
Education
Access to or ownership of assets (house, car)
Index of multiple deprivation
Explain the index of Multiple Deprivation?
Provides relative composite measure of deprivation for small areas
Combines 7 different indicators (social, economic and housing) into a signle deprivation scare for each small area
Areas are ranked from least deprived to most deprived at local authority level
What are the main models of doctor-patient relationships?
- Paternalistic (doctor-led)
- Shared (partnership)
- Informed (patient-led)
What are the key features of the paternalistic model?
1. Information flow largely from doctor to patient
(little information given by patient)
2. Doctor makes the decision about what is best for the patient
(assumes that the doctor is best placed to make the decision regarding the treatment)
3. Expectation that patient will agree as ‘doctor knows best’
When is the paternalistic model appropriate?
- In medical emergencies
- If patient wants this model
What are the key features of the shared model?
- Two way exchange of information between patient and doctor at all stages
- Both participants seen as bringing expertise (medical and personal expertise)
- Patient and doctor reach a decision together about best course of action
- Depends on building a consensus on appropriate treatment
- Challenge for doctor to create an environment in which patient feels able to express treatment preferences
- If disagree, process becomes a negotiation
What are the key features of the informed model?
- Doctor communicates all relevant information and treatment options and the risks/benefits to patient
- Doctor gives patient enough information to make an informed treatment decision
- Patient is active and expects to make the decision
- Decision making is sole perogative of the patient
What are the three main type of explanations of the social gradient in health?
Behavioural/cultural
Material/neo-material and life course
Psychosocial
Outline the Behavioural/cultural explanation of the social gradient in health
Health inequalities due to social variations in health-related behaviors.
Assumed to be the result of individual choice i.e smoking
(linked to lower social groups, people in these groups are more likely to smoke at younger age then those in higher social groups)
Clustering of unhealthy behaviours
(smoking, excessive alcohol use, poor diet and low levels of physical activity has decreased in recent years – greatest reduction seen in those from higher social groups)
Outline the Material/neo-material and lifecourse explanation of the social gradient in health
Health inequalities are due to social differences in material circumstances related to income:
Poor housing (damp, mould growth, excessice heat/cold, asbestos) linked to increased incidence of certain diseases (asthma, infection, RT diseases) and accidents (falls, fires and electrical hazards)
Nutrition – the poorer you are the more likely you are to eat less healthy; poor diet increases the risk of diseases such as CHD, diabetes and cancer
Neo-material approach:
The effect of material circumstances on health reflects a lack of resources.
It is related to the underinvestment in physical, health and social infrastructure
Life-course approach:
Exposure to one form of material deprivation increases the risk of exposure to others
i.e parental disadvantage is transmitted in utero, early years of life influence later health outcomes.
Outline the Psychosocial explanation of the social gradient in health
Based on the impact of psychosocial effects of stressful conditions at work/home or of low self esteem
Affects health in two ways:
Indirectly (i.e smoking)
Directly (increased vulnerability to mental and physical illness via neurological pathways)
People lower down the social structure tend to face negative circumstances more frequently
Define absolute poverty
The minimum standards of food, shelter and clothing necessary to sustain life
Define relative poverty
Below acceptable standards of living, which prevents people participating in community life
What is social capital?
Defined in terms of both social networks (high levels of participation in community groups) and norms (high levels of trust and reciprocity amongst community memebers) that faclitate co-ordination and co-operation
Two types:
- Bonding (feel others are there)
- Bridging (communities feel isolated, not part of wider communities)
What is the importance of social capital for health?
Evidence suggests that social capital can have benefical effects on health
Psychococial interpretation: income inequalities can lead to reduced community involvement (people percevies their position in social hierarchy is low down)
Neo-materialist interpretation: lack of health enhancing resources at an individual level, deprived social resources and neglected infrastructure at the community level leads to a decline of social capital and health
Why should doctors be concerned of health inequalities?
Health inequalities have a profound effect on peoples lives
Health is a human right (all systematic differences in health between social groups is unfair)
To reduced the costs assocaited with premature deaths and illness
Good medicial practice can make a difference
Key theme in government health policies (royal colleges see it as a role of doctors)
What is the aim of tackling health inequality?
To yield a more equal distribution of health across social groups
i.e reduce the gradient
What are the main recommendations of the Marmot Review on health inequalities?
- Reduce the social gradient
- Action across all social determinants (i.e low education, unemployment, low pay, poor material environments, pollution and assess to services)
- Six key policy objectives
- Action across all sectors (i.e health, education, social services, housing, employment and environment)
- Participatory decision making at local level
What are the 6 key policy objectives outlined in the marmot review?
Six key policy objectives
i. Give every child the best start in life
ii. Enable all children, young people and adults to maximise their capabilities and have control over their lives
iii. Create fair employment and good work for all
iv. Ensure healthy standard of living for all
v. Create, develop healthy and sustainable places and communities
vi. Strengthen the role and impact of ill health prevention
What is meant by tackling the social gradient?
Progressive Universalism - good way!
Improvement for all social groups not only those worst off.
Adopting a population wide strategy that seeks to obtain highest health standard for all
What is meant by tackling social disadvantage?
Improvement of health for those who are worst off.
Adopts a group specific approach.
The bad way to tackle health inequalities
What is meant by upstream and downstream approaches to tackling health inequalities?
Upstream Approaches:
Approaches that tackle wider influences on health through public policy approaches
(reducing poverty, taxation, reducing price barriers, reducing unemployment via national policies)
Downstream Approaches:
Approaches that tackle individuals
(health behaviours, lifestyle factors – smoking, diet, assess to care)
What is the role of doctors in reducing health inequalities?
As clincians: access to high quality health care for vulnerable groups
As advocates for development of services/programs for better health outcomes
As managers and clincial leads: model employer ·
As educates: placements in disadvantaged areas, investigate social determinants, local projects
Give examples of interventions that have been shown to reduce health inequalities
Upstream approaches:
housing interventations
improve standard of living
increased choice
water fluoridation
free folic acid supplements
tobacco price increase
improvement in education for children and young people
Give examples of interventions that have been shown to increase inequalities
Downstream approaches: ·
Mass media campaigns on stop smoking and folic acid
Work place smoking bans
What is the difference between health promotion and disease prevention?
Health Promotion:
Process of enabling people to increase control over their health and its determinants and thus improving their health.
It offers a positive and inclusive concept of health as a determinant of the QoL and encompassing mental and spiritual wellbeing
Disease Preventation:
Actions aimed at eradicating, eliminating or minimising the impact of disease and disability
What are the three levels of prevention?
Give the stage of disease and the aim of treatment .
Primary Prevention:
Pre-disease
Preventing disease in the first place.
Secondary Prevention:
Early stage of disease
Find and treat disease early in order to halt or slow the progression of disease
Tertiary prevention:
Symptomatic disease (irreversible disease of disability)
Manage associated health problems of the disease to: Prevent further deterioration, Achieve high a level of functioning as possible, Maximise quality of life
Give and example of the prevention and the service that would provide it for the 3 levels of prevention
Primary prevention
Immunisation, alcohol education in schools
Public Health, GP
Secondary prevention
Screening/case detection programmes, Brief interventions, Adequate treatment
GP, Hospitals
Tertiary prevention
Rehabilitation programmes, Pain management
Rehab and palliative services, Hospitals
Who can be targeted for primary and secondary prevention?
- Individuals at high-risk of disease
(aim: bring preventitive care to those at high risk; requirements: detection of high risk individuals) - Whole population
(aim: direct at everyone irrespective of individual risk levels)
Give pros and cons for targeting individuals at high risk for disease for primary and secondary prevention
Pros:
Appropriate to indivdual
High patient motivation
High doctor motivation
Cost-effective?
Cons:
Hard to idenify high risk
Medicalise prevention
Stigmatise individuals
Limited effects on population level
Give pros and cons for targeting the whole population for primary and secondary prevention
Pros:
High benefit for population as whole
Attacks root cause
Shifts cultural norms
Can work passively
Cons:
Benefit is small for each person
Low subject motivation
Costly?
What are Ewles & Simnett’s five approaches in health promotion?
Medical
Screening/immunisation
Early detection of smoking related disorder eg. spirometry
Behavioural change
Encourages healthier behaviours
Smoking cessation support
Educational
Provide information/informed choices
Giving information on health effects of smoking in schools
Client centred
Health issues identified by client/community
Client identifies what they want to know/do about smoking
Societal change
Change in physical, social and economic environment (making healthier choices)
No smoking policies/taxation
What is Beattie’s model of health promotion?
What are Ottawa Charter’s action areas?
- Build healthy public policy
- Create supportive environments
- Reinforce community actions
- Develop perosnal skills
- Reorient health services
What are Bangkok Charter’s action areas?
- Advocate for health based on human rights and solidarity
- Invest in sustainable policies, actions and infrastructure to address the determinants of health
- Build capacity for policy development, leadership, health promotion practice, knowladge transfer and research and health literacy
- Regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people
- Partner and build alliances with non-governmental public, private and international organisations and civil society to create sustainable actions
Define Sex
Refers to those characteristics between males and females that are biologically determined
Define Gender
Refers to the social and cultural meanings assigned to being male or female
How does sex differ from gender?
Biological features whereas gender is socially constructed
Explain the main health outcomes for men and women regarding life expectancy at birth
Men more likely to die at all stages of lifecourse
(differences pronounced in youth and early adulthood)
MEN – lower than women - 76 years
WOMEN – higher than Men - 81 years
Explain the main health outcomes for men and women regarding mortality rates for cancer and CHD
Cancer
Men more likely to die from cancer but it is also gender specific
i.e prostate cancer kills men and breast cancer kills women
CHD
Men more likely to die from CHD at all stages of lifecourse expect after 75 years of age (biological reasons)
Women have lower cardiovascular reactivity to stress
Oestrogen protects women before menopause
Men have greater sensitivity to certain damaging metabolities
Men’s susceptibility due in part to central obesity
Explain the main health outcomes for men and women regarding accidental death
Younger men (16 to 34 years old) at higher risk of death from accidents
(involved in car crashes – speed and alcohol)
Rates of accidental death among men exceeds those in woman at all ages except towards the end of the lifecourse
Explain the main health outcomes for men and women regarding suicide
Men more likely (4 times) to commit suicide than women
Men tend to use more violent and lethal methods of suicide
Explain the main health outcomes for men and women regarding self-harm
Women 3/4 times more likely to self-harm than men
Outline the gendered patterns of smoking
Men smoke more than women
Outline the gendered patterns of alcohol consumption
Men nearly twice as likely as women to exceed the recommened daily limits of alcohol comsumption
Men more likely to binge drink
Strong assocaition between heavy drinking, depression and suicide in men
Outline the gendered patterns of overweight and obesity
Overweight
More men than women are overweight in all age groups
Obesity
Similar proportions of men and women are obese but women become obese 10 years later than that for men
Outline the main gendered patterns in health service use regarding women
More likely to consult their GP
High attendance of well person checks
More likely to seek help early
Less likely to be diagnosed with CHD
Less likely to be hospitalised
Less likely to receive invasive treatment
More likely to be prescribed psychotropic drugs
Outline the main gendered patterns in health service use regarding men
More likely to use locums and A&E services
Low well person checks
More likely to leave health problems late
Men more likely to die from skin cancers despite a lower incidence rate of the disease among men
Structural and institutional barriers inhibit men from assessing health services
Why are women prescribed more psychotropic drugs than men?
Doctors more likely to perceive a physical illness as a psychological one when it’s a woman
Women are more likely to seek help - due to social stigma
Medical advertising reinforces this perception
This type of medication more socially acceptable for women than for men
What are they key explanations for gender differences/inequalities in health in men?
Increased risk of dying from accidents due to increased exposure to occupational accidents and diseases
Health behaviours seen as a way to express ‘masculinity’ – a way to gain status as men
They use ‘masculine-sanctioned’ coping behaviour to relieve stress despite potential damaging consequences – turn to drink and drugs
Men taught to be ‘self-sufficent’, not to complain and to be strong minded – prevents them comsulting when health problem arise
Perceive themelves as less vulnerable or susceptible to illness than women
Normalise their symptoms and fear wasting doctors time
Less likely to accept emotional pain as valid
What are they key explanations for gender differences/inequalities in health in women?
More vulnerable to poverty and bear the burden of low income within households
Maintaing the material and psychosocial environment of the house increases social isolation and denial of self
(Linked to higher rates of depression and anxiety)
Define race
Concept that concentrates on assumed biological or genetic differences between groups of people
Why should the term ‘race’ not be used?
Was used to support racist views towards ethnic miniority groups.
No scientific basis for the notion that different ‘races’ share biological or genetic features significant for health
Define Ethnicity
Defined by two main common characteristics that separate one ethnic group from another:
- Long shared history – the group is conscious of it and the memory of which it keeps alive
- A cultural tradition of its own including family, social customs and manners
Define Culture
Concentrates on shared experiences, beliefs and values
Outline the key ethnic inequalities in health
Ethnic minority groups generally have poorer health than majority white population but within the ethnic minority groups the distribution of health inequalities is not uniform
CHD: people born in Bangladesh and Pakistan have highest rates of death from CHDs and stroke
Circulatory disease: people born in India, East Africa and Ireland have higher than average mortality rates from circulatory diseases ·
Hypertension/Strokes: highest amongest people born in the Caribbean and West/South Africa
Diabetes: high but variable ratees of diabetes across all non-white groups
What are the key genetic/biological explanations for ethnic inequalities in health?
Based on the notion of ‘genetic homogeneity’
Some disease strongly linked to gentic factors but cannot be used to explain ethnic health inequalities
Concentrating on the genetic factors ignores wider causes of ill health that affect more people in these groups
What are the key cultural explanations for ethnic inequalities in health
Seek to locate the poorer health of ethnic minority groups in the nature of what it is to be a member of that particular group
Concentrate on health beliefs and behaviours of ethnic minority groups
Assumes other features of particular cultures also harmful or that harmful factor is somewhat inherent in those people ‘cultural blaming’
Neglect the fact that the major health problems in these ethnic groups are the same as for the general population
What are the key migratory explanations for ethnic inequalities in health?
Migrants selected by the health characteristics – usually have better health among population of origin
Health of these migrants tends to revert back to mean standard of the population of origin hence lead to a relative decline in health compared to health in country of destination
Salon Bias phenomenon – people returning home when ill could also reduce the mortality rate of the migrant populations
What are the key social deprivation explanations for ethnic inequalities in health?
Ethnic patterns of health mirror the broad patterning of socio-economic inequality among minority groups
These factors make a major contribution to ethnic differences in health and these factors are more important than other factors (cultural/genetic)
What are the key racial explanations for ethnic inequalities in health
Conducts/words/practices that disadvantage people based on their colour, culture or ethnic origin.
Daily occurrence for many people of ethnic minority groups, and whether overt or subtle, it is just as damaging.
Which is the most likely explanations for key ethnic inequalities in health?
Social deprivation
What is racism?
In general terms consists of conduct, words, practices which disadvantage people because of their colour, culture or ethnic origin.
What are the different forms of racism?
1. Direct racism:
People are treated less favourably due to their ethnicity or religion
2. Indirect racism:
People unaware their actions are undermining the position of people from ethnic minority groups
3. Institutional racism:
The collective failure of an organisation to provide an appropriate and professional service to people based of their colour, culture or ethnic origin.
How can racism affect health?
Direct racism and racial harassment and indirect experiences = health differences
- A fear of racism creates worry and stress = damaging to health
What is the link between physical and mental health?
Physical illness caused by lifestyle factors.
Ill health is very preventable and susceptible to health promotion, and how a patient views their health
Helping people develop well being, decreases diseases
What are the key features of the health belief model?
Used to explore patients perceived susceptibility, severity, benefits and barriers.
Model helps educate for perceptions of threat and goal setting/action planning and problem solving to help overcome barrier.
This model does not take into account social behaviour
What are the steps in the health belief model?
- Explore perceived susceptibility and severity
- Educate patient about risk which can increase susceptibility and severity
- Explain pros and cons
- Any barriers to stopping
- Work with patient to problem solved and overcome barriers
- Reinforce education of benefits
What are the key features and steps of the theory of planned behaviour?
Used to explore intentions.
- Explore intentions
- Explore perceived behavioural control
- If control low, further explore by asking why
- If percieved control high, ready to attempt behaviour change
- Work with patient and plan
What are the key features and steps of the self-regulatory model?
Applied to a range of illnesses to help understand adaption and coping.
Helps develop appropriate management plan while working with the patient
Define DALS
DALS = sum of YLL + YLD for a particular condition
What are the stages of change (transtheoretical model)
Key features of stages to change (transtheoretical model)
1. Precontemplation
Never thought about changing factor
2. Contemplating
Thought about what to change
3. Preparation
Preparing to change the factor
4. Action
Putting into action their preparation
5. Maintenance
Maintaining the change
6. Relapse
Going back to old habbit
What are the differences between the models for change?
Health belief model can be used to educate a person of certain factors ie smoking
Theory of planned behaviour can be used to assess patients current intentions
Transtheoretical model can be used to help assess the patient current stage with respect to the factor in question
Define Structure.
Define Agency.
What are their relevance to health?
Structure
Focuses on the way in which society is constituted which influences or limits the choices and opportunities available
Agency
Focuses on the capacity of individuals to act independently and to make their own free choices
Relevance
Underpinned by certain philosophical assumptions, ontological, epistemological and methodological – both effect health
Define lay beliefs/knowledge
Peoples common-sense understanding and knowledge about health and illness
Generally rooted in peoples own experiences
(it is not always different from medical understandings)
Where do lay beliefs originate from?
- Personal knowledge and experience
- Previous medical encounters
- Folk knowledge
- The media and internet
- Spiritual beliefs
- Alternative and complementary medicine
Why are lay beliefs important to doctors?
Help doctors to better understand peoples illness related behaviour
Helps gain insight into the needs of patients and their expectations of doctors
Taking lay beliefs into account = more satisfied patients and doctors
What are lay referral/triggers to seeking medical help?
People usually seek advice from others before consulting a doctor – called the lay system
Triggers include:
Interpersonal crisis
Interference with social or personal relations
Sanctioning (being told to go)
Interference with vocational or physical activity
A temporalising of symptomatology (when it doesn’t get better by a certain data)
Define symptom iceberg
Only the tip of the iceberg actually come to the GP, the rest of population do nothing/self-medicate/see somebody else.
The decisions to consult are influenced by perception, explanation and evaluation.
What is MECC?
Encouraging people to make healthier choices for better health by:
Systematically promoting the benefits of healthy living
Asking individuals about their lifestyles, responding appropriately and taking appropriate action.
It’s a “chat for change.”
What does MECC typically address?
Tackles lifestyle factors such as:
Maintaining a healthy weight and diet
Stopping smoking
Drinking in moderation
Mental health
Sexual health.
What are the recommendations for:
Smoking:
Drinking:
Weight/healthy eating:
Physical activity:
Smoking
Do not do it
Drinking
14 units weekly for male and female. Binge drinking is 6 units or more in women and 8 units of more in men. 2 days detox per week.
Weight/healthy eating
0.5-1kg per week = healthy weight loss. Normal BMI is 18.5-25.
Physical activity
30mins x 5days per week. Lower risk of many chronic diseases, depression, dementia, stress.
What are the key elements to behavioural change?
Threat
Fear
Barriers
Benefits
Subjective norms
Response efficacy
Attitudes
Intentions
Cues to action.
