Block 2 Soc Pop Flashcards
What are the 3 main models of doctor-patient relationship?
1) Paternalistic - doctor led
2) Shared - partnership
3) Informed - patient led
Describe the paternalistic model and it’s pros and cons
- Dr makes a systematic enquiry: asks specific questions
- Patient is passive; answers the doctor’s questions
- Information flow: largely from doctor to patient, often minimal
information given - Doctor makes the decision about what is best for the patient:
underlying assumption is that the doctors is best placed to make it - Expectation that patient will agree as ‘doctor knows best’
Pros
- Supportive – good for when patients are very sick, vulnerable
- Relief for patient – implicitly trust doctor
Cons
1. Very asymmetrical – patient does not have much input – patient values
Describe the Shared doctor-patient relationship model and its pros and cons
- Two way exchange of information between patient and doctor at all stages
- Both participants are seen as bringing expertise
- Patient and doctor reach a decision together about best course of
action/treatment - Depends on building a consensus
- Role of doctor: create an environment in which patient feels able to
express treatment preferences - If disagreement, process becomes one of negotiation.
Pros
Patient has an opportunity to get a good understanding of condition. Dr understands patients values.
Better decision making – collaborative
Cons
Patients capabilities of making decisions?
Describe the informed/patient-led model and its pros and cons
- Doctor communicates all relevant information and treatment options, and the risk and benefits, to patient
- Doctor communicates sufficient information for patient to make an informed treatment
- Patient is active and expects to make the decision
- Decision making is sole prerogative of the patient
Pros
Patient has the power to challenge decision making
Cons
Burden/stress of making decision
What is the current stance on doctor patient relationships?
- Shared model advocated:
a. ‘Partnership’ idea evident in policy and professional discourses
b. Shared decision making is seen key element of person-centred
care - But need a ‘repertoire of doctor-patient relationships’: one shoe
doesn’t fit all, nature of relationship may change within and across
consultations - Need to be guided by patient preferences and clinical condition
Why is infant mortality seen as an indicator of health?
- Easy to measure
- Under 1 year of age
- As conditions change very rapidly see a change in infant mortality
rates. - Important marker for population health.
- Dramatic fall in mortality rates since 1988
- Slight increase in infant mortality rate, don’t know if it’s significant yet
What does life expectancy at birth mean?
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 healthy life expectancy and what it indicates?
Is the average number of years an individual born in a particular year can expect to live in a state of general ‘good’ health
indicates the healthy life expectancy versus life expectancy of the population i.e. number of years a population will not be in good health.
What are the key features of epidemiological transition?
Denotes historical changes in:
- demographic and disease profiles of countries
- as they move through economic and social development
- Deaths from acute infections and deficiency diseases decline
- Deaths from chronic and non-communicable diseases increase
What are the main causes of death in the UK for men?
- Ischaemic heart disease
- Dementia and Alzheimer disease
- Lung cancer
- Chronic lower respiratory diseases
- Cerebrovascular diseases
What are the main causes of death in the UK for women?
- Dementia and Alzheimer disease
- Ischaemic heart disease
- Cerebrovascular diseases
- Chronic lower respiratory diseases
- Lung cancer
What are the main causes of cancer deaths in the UK for men?
- Lung
- Prostate
- Bowel
- Oesophagus
- Pancreas
What are the main causes of cancer deaths in the UK for women?
- Lung
- Breast
- Bowel
- Other sites
- Pancreas
- Ovary
What is the definition of health inequality?
- Health and illness are not randomly distributed across the population
- There are systematic health inequalities across socio-economic groups
- These systematic differences between social groups are called health
inequalities - Groups include:
i. Gender
ii. Ethnicity
iii. Geography
iv. Socio-economic position
v. Age
vi. Sexuality
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 - Evident across many indicators including general health and morbidity
measures
e.g. socio-economic classification: managerial/professional lower mortality and morbidity as opposed to routine/manual occupation
What are the general patterns of health inequality of main causes of death/health indicators?
- Infant mortality rate- Children in lowest socioeconomic status households have highest infant mortality rates
- Cancer mortality – both male and female, most deprived have higher mortality rate compared to least deprived.
- Cancer incidence rates – more cases in many forms of cancer (e.g. larynx, lung) in deprived, male and female except, malignant melanoma, fewer cases in more deprived
- Geography - Morbidity and mortality rates consistently higher in north and west and in urban areas (UK)
- Occupation - poorer health in those who are classes in the lowest occupational group
How can socio-economic status be measured?
In a number of ways:
1. occupation,
2. income,
3. education,
4. access to or ownership of assets (housing, car)
5. index of multiple deprivation
Registrar General’s socio-economic classification
Based on occupation
Proxy for status, income, access to material resources, education
Name the three theories for inequalities (social gradient)
- Behavioural/cultural
- Material/neomaterial
- Psychosocial
Describe the behavioural and cultural model for social inequality
- Proposes: Health inequalities are as result of variations in health behaviours and lifestyles e.g. smoking, diet, exercise etc.
- Health behaviour choices is seen as result of:
Individual choices or
Knowledge or Culture
Evidence: Most important health behaviours follow the social gradient: smoking, lack of physical activity, poor nutrition are higher in lower socio-economic groups
Describe the material/neomaterial model for social inequality
Proposes:
1. Health inequalities are the result of differences between socio-
economic groups in access to material resources (social inequality) –
2. direct effects of poverty and material deprivation
3. Access to material health resources is shapes by broader structural
factors: place in society, policies etc
Evidence:
• Lower socio-economic status is associated with poorer access to material health resources (Marmot Review, 2010)
• E.g. Income, food, fuel, heating, housing, transport, healthy environments, exercise facilities
Describe the psychosocial model of social inequality
psychosocial environment = the way people’s environments make them feel
1) Psychosocial stress affects health:
I. Directly: ‘allostatic load’ theory links psychosocial environment to physical disease through neuroendocrine pathway
II. Indirectly: adoption of ‘unhealthy’ behaviours e.g. smoking
2) Psychosocial stress associated with social inequality leads to social gradient of health outcomes:
I. Money and other worries associated with low income and poorer material circumstances
II. Stress associated with position in social hierarchy
e.g. poor health outcomes associated with lower social control over life
What is the life course explanation for health inequalities?
- health impacted by behavioural, material and psychosocial pathways
- interact across people’s lives in a complex way: known as lifecourse
effects - Material, behavioural, and psychosocial (and biological) processes
operate independently, cumulatively and interactively across an individual’s life course, or across generations, to influence the development of disease risk
Which explanations are most likely to account for inequalities between socio-economic groups?
- All likely to operate to some extent
- material circumstances and psychosocial explanations appear to have
explained more of health inequality than behaviour explanations
Define health promotion
- Health promotion is “the process of enabling people to increase control over their health and its determinants, and thereby improve their health.”
- Health promotion “offers a positive and inclusive concept of health as a determinant of the quality of life and encompassing mental and spiritual well-being.”
Define disease prevention
Actions aimed at eradicating, eliminating, or minimising the impact of disease and disability, or if none of these is feasible, retarding the progress of disease and disability.
What is the difference between health promotion and disease prevention?
Health promotion aims to improve health state – targeting health.
Disease prevention: the disease or disability is present, aim to eradicate, eliminate or minimise its impact or retards its progress – targeting the disease/disability.
Explain the three levels in the prevention framework by Leavell and Clark
Primary = avoid a disease starting in the first place
Secondary = Early detection of the disease or early treatment to halt/slow progression
Tertiary = limit damage from disease to reduce progress/severity and maximise quality of life
What are the strengths and weaknesses of targeting health promotion in high risk individuals
Strengths:
- Extension of clinical approach
- High patient motivation
- High doctor motivation
Weaknesses:
- High resources on identifying high risk
- Medicalise prevention
- Stigmatise individuals
- Does not produce lasting change at population level
What are the strengths and weaknesses of targeting health promotion in the whole population?
Strengths:
- Benefit for population as a whole
- Attempts to control root causes/determinants of disease
- Can work passively
- More permanent
Weaknesses:
- Benefit is small for each individual
- Low subject motivation
What is Rose’s prevention paradox?
A preventive measure that brings large benefits to the community, offers little to each participating individual
Name the two charters that encompass health promotion
Ottawa Charter (WHO, 1986) Bangkok charter (WHO, 2005)
Describe the Ottawa Charter (WHO, 1986)
Health promotion action areas:
- Build healthy public policy
- Create supportive environments
- Reinforce community actions
- Develop personal skills
- Reorient health services from treatment to prevention
Describe the Bangkok Charter (WHO, 2005)
Health promotion action areas:
1. advocate for health based on human rights and solidarity
2. invest in sustainable policies, actions and infrastructure to address
the determinants of health
3. build capacity for policy development, leadership, health promotion
practice, knowledge transfer and health literacy
4. regulate and legislate to ensure a high level of protection from
harm and enable equal opportunity for health and well-being for all
5. partner and build alliances with nongovernmental, public, private
and international organizations to create sustainable
Describe Ewles and Simnett’s five approaches
Medical - screening, immunisation
Behaviour change - Encourages healthier behaviours
Educational - provide. information, informed choice
Client centred - health issues identified by client/community
Societal change - change physical, social and economic environment
Describe Beattie’s model
4 quadrants with axes being: authoritative at the top, negotiated at the bottom, collective at the right and individual at the left.
Legislative action is in top right quadrant, community development is in bottom right quadrant, personal counselling is in bottom left quadrant, health persuasion is in top left quadrant
Why should health inequalities be a concern for doctors?
- Health inequalities have a profound effect on people’s lives:
- Health as a human rights: all systematic differences in health
- To reduce the costs associated with premature deaths and illness: to
individuals and the state - Good medical practice can make a difference
- Key theme in government health policy (Public Health White Paper
Health Lives, Healthy People )
a. helping people live longer, healthier and more fulfilling lives;
b. and improving the health of the poorest, fastest.
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 determinants of health inequalities?
Structural determinants and conditions of daily living
- material factors
- psychosocial factors
Describe the Marmot review on health inequalities
Main recommendations:
- Reduce the social gradient - Progressive universalism
- Action across all social determinants
- Action across all sectors
- Participatory decision making at local level
Policy objectives:
1. Give every child the best start in life
2. Enable all children, young people and adults to maximise their
capabilities and have control over their lives
3. Create fair employment and good work for all
4. Ensure healthy standard of living for all
5. Create and develop healthy and sustainable places and
communities
6. Strengthen the role and impact of ill health prevention
What is meant by upstream and downstream approaches to tackling health inequalities and examples of each
Upstream: Tackle wider influences on health through public policy approaches e.g. reducing poverty, taxation, reducing unemployment via national policies
Downstream: tackling individual g health behaviours, lifestyles e.g. smoking, diet, access to care
What is tackling social gradient and what are some strengths and weaknesses of it?
- Population wide approach
- Aim = a more equal distribution of health chances across socio-
economic groups i.e. reduce the gradient - Need absolute improvements for all groups but a rate of improvement
which increases at each step downwards on the socio-economic ladder - Provide resources and services at a progressively greater level as needs
increase
Strength:
1. Tackles every group
Weakness:
1. Progressive, over time. May take longer than tackling socially disadvantaged straight away.
What is tackling social disadvantage and what are its strengths and weaknesses?
Tackling social disadvantage aims to improve health of worst off only
Strength:
1. Moral arguments support steering interventions at those in poorest health
Weakness:
- not a population wide strategy therefore won’t tackle the social gradient in health
- What about those just above the line – where do we even draw the line?
How does tackling social gradient differ from tackling social disadvantage?
Social gradient aims at the whole population regardless of which social group they belong to whereas social disadvantage aimed only at the disadvantaged group.
What is progressive/proportionate universalism?
- Reducing social gradient in health by tackling the gradient
- Population wide approach
- Aim = a more equal distribution of health chances across socio-
economic groups i.e. reduce the gradient - Need absolute improvements for all groups but a rate of improvement
which increases at each step downwards on the socio-economic ladder - Provide resources and services at a progressively greater level as needs
increase
Give some examples of interventions that have been shown to reduce health inequalities
- Workplace interventions that increase employee control over work environment have positive impact
- Housing interventions to improve standard of housing, more choice for low income families
- Water fluoridation
- Free folic acid supplements
- Tobacco price increases
- Improving educational level for children and young people
- High quality parenting programmes and smoothing transition form home to school
- Incentivised prescribing e.g. preventive medication for IHD
Give some examples of interventions that have been shown to increase health inequalities
- Mass media campaigns on stop smoking and folic acid: increase inequality
- Work place smoking bans: increased inequality
What is the role of doctors in reducing health inequalities?
- As clinicians – Ensure access to high quality health care for vulnerable groups, refer to support services (e.g. housing, debt advice), data on inequality attributable admissions
- As advocates - Development of services/programmes for better health outcomes
- As managers and clinical leads – model employer
- As educators - Provide placements in disadvantaged areas, investigate
social determinants, local projects
Define sex
biological and physiological characteristics that are used to categorise people as male or female
Define gender
Socially constructed roles, behaviours, activities, and attributes that a given society considers appropriate for males and females
Define heteronormativity
society’s assumption that relationships between the opposite binary sex individuals (heterosexuality) are the norm or default
Define gender identity
internal sense of one’s own gender
Define transgender
umbrella term for people whose gender identify differs from the sex/gender they were assigned at birth
What is the difference between gender and sex?
Sex is biological whereas gender is a social construct
What are the main differences in health outcomes for men and women?
- 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 - Morbidity:
Women – greater proportion of life in poor health with diability - Mental health:
Mental illness rates higher in women for common mental disorders
e.g. depression, phobias, OCD, generalised anxiety disorder - Breast cancer – higher mortality rates in men
- CHD - women more likely to remain undiagnosed and undertreated
What are the key explanations for gender differences in health?
- Biological
- Boys more vulnerable in infancy
- Immune system differences
- Some hormone differences
- Cardiovascular reactivity
- Neuroendocrine responses - Health behaviour
- Female: lower smoking rates, more difficulty quitting
- Male: higher smoking rates, alcohol consumption and rate pf
hospital admission in relation to alcohol problems - Gendered roles/exposures
- 10% pay gap
- Higher rate of poverty among women
- Work environment – men at higher risk of accidents due to
exposure
- Health seeking behaviours – men less likely – demonstrate
masculinity - Health service access and provision
- Conditions perceived as men’s e.g. CVD or women’s e.g. anxiety and depression
What is the difference between gender difference in health and gender inequality in health?
- Prostate cancer: men only – difference rather than inequality 2. Breast cancer:
a. higher rates in women – difference not inequality
b. Lower survival rates in men: gender inequality
What does the term race refer to and what are reasons for not using the term?
Historically term used to argue for the existence of inherent biological differences between populations
Reasons for not using the term:
Observed differences used to support argument that some populations were superior to others and used to justify subjugation of some populations
Populations are physically and genetically more similar than different
What is the meaning of the terms ethnicity and culture?
- Two common characteristics that separate one ethnic group from another (UK Commission for Racial Equality, 2006)
- A long shared history, of which the group is conscious as distinguishing it from other groups, and the memory of which it keeps alive
- A cultural tradition of its own, including family and social customs and manners, often but not necessarily associated with religious observance.
What are the key ethnic inequalities in health?
- Ethnic minority groups generally have poorer health than white majority population
- Poorer health outcomes and experience is not uniform within the ethnic minorities
- Infant mortality rates
Higher in Pakistani, African and Caribbean compare to White British Pakistani is higher than African and Caribbean - Type 2 diabetes
South Asian family origin:
up to six times more likely to have type 2 diabetes than the white population
Likely to develop type 2 diabetes 10 years earlier
African and African-Caribbean descent:
three times more likely to have type 2 diabetes than the white population
What are some key explanations for ethnic inequalities in health?
- Genetic/biological
- ‘genetic homogeneity’- ethnicity and ancestry used as a proxy for genetic risk
- Some congenital anomalies and haemoglobinopathies strongly influenced by genes but ethnicity not always helpful in helping to identify at risk groups
- Epigenetics: genes are affected by the environment
- Genes and biology cannot explain all ethnic inequalities in health
- Cultural – health behaviour
- 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
- Often focus is on health beliefs and behaviours of ethnic minority groups e.g.
- ‘Asian rickets’ caused by deficient South Asian diet
- High ghee content of some Asian diets - Diverse range of health behaviours and lifestyles among minority
groups:
- Smoking
- Exercise - Migratory
- Migrants selected by health characteristics – usually have better health among population of origin
- Health of migrants tends to revert to the mean standard of the population of origin – produces a relative decline in health compared to health in country of destination
- Stressful experience of migration and settling in new country
- The ‘Salmon Bias’ phenomenon – people returning home when ill could
artificially reduce the mortality rate of migrant populations - Social deprivation
- Ethnic inequalities in health reflect the broad patterning of socio- economic inequality among ethnic minority groups (Nazroo,)
- Socio-economic factors make a major contribution to ethnic differences in health - more important than other factors
- Affects access to health resources: housing, food, exercise etc.
- More likely to live in deprived areas
- Higher unemployment rate
- Racism
- Racism is a daily experience for many ethnic minority groups
- Direct experiences of racism and racial harassment can result in health
inequality - Indirect experiences of racism also have an effect on health, e.g. a fear
of racism creates worry and stress which can damage health - Lack of responsive service provision for some ethnic minority groups:
services need to be sensitive to cultural and religion
Most likely: social deprivation
What is racism and its different forms?
- Racism in general terms consists of conduct or words or practices which disadvantage people because of their colour, culture, or ethnic origin. In its more subtle form it is as damaging as in its overt form (The Macpherson Report 1999
- Direct racism: people are treated less favourably because of their ethnicity or religion.
- Indirect racism: people unaware their actions are undermining the position of people from ethnic minority groups.
- ‘Institutional racism’: ‘the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethic people’
How can racism affect health?
- Direct experiences of racism and racial harassment can result in health inequality
- Indirect experiences of racism also have an effect on health, e.g. a fear of racism creates worry and stress which can damage health
- Lack of responsive service provision for some ethnic minority groups: services need to be sensitive to cultural and religion
What are the benefits of MECC?
Benefits of brief advice/interventions to patients
1. Most serious illnesses are caused or perpetuated by unhealthy lifestyles
2. Adopting healthier lifestyles can have a huge positive effect of people’s health
3. Delivering Brief Advice/Interventions can be the trigger to change
4. Most people want to be healthy and even to improve their own health
(70% of smokers want to quit)
5. Research has found that patients welcome the opportunity to talk to
staff about lifestyle issues, but don’t start this conversation themselves
or think that staff are too busy to talk
6. MECC makes it easier for people to make those changes
Benefits of brief advice/interventions medical professionals
- You should see improved and quicker outcomes from treatments (e.g. wound healing)
- The satisfaction of knowing you are making a difference to patients’ lifestyles
- Increased confidence in contacts with patients
- Improving your own lifestyle
- Enhancing your skill set.
Duty of care
As an NHS organisation we have a responsibility to protect and improve the overall health and wellbeing of our staff and service users
Finance
e.g. estimates that £10,000 invested in brief advice could save £43,000 health care costs
What is MECC?
brief advice / intervention
1. It is a brief intervention about lifestyle issues e.g. smoking, alcohol
2. Encouraging people to make healthier choices for better health
3. Systematically promoting the benefits of healthy living - ask advise,
act/refer
Encouraging people to make healthier choices for better health:
Systematically promoting the benefits of healthy living
Asking individuals about their lifestyle
Responding appropriately
Taking the appropriate action - give information, signpost or refer to support service
How many units of alcohol are in different types of drinks?
Recommended: 14 units men and women
Wine:
Bottle (750 ml): 10 units Small glass: 1.5 Standard glass: 2.1 Large glass: 3
Lager/beer/cider
1 pint low strength: 2 1 pint high strength: 3
Bottle (330 ml): 1.7
Can (440 ml): 2
Other
Alcopop (275 ml): 1.5
Small shot: 1
What are the 5 ways to wellbeing?
- Be active – walking, running etc
- Take notice – reflect on surroundings
- Connect – help a friend, join a group
- Give - volunteer
- Keep learning – try something new
What are the 3 A’s or 5A’s for MECC?
Very brief advice (3A’s)
- Ask
- Advise
- Act/refer
Brief advice (5As)
- Assess
- Advise
- Agree
- Assist
- Arrange/refer
What are the key elements to behaviour change?
Health Behaviours: behaviours that are related to the health status of the individual
1. Threat – awareness of a danger or potential threat
2. Fear – emotional arousal by perceived relevant threat
3. Barriers – preventing response/behaviour
4. Benefits – positive reward/consequence
5. Subjective Norms – the view of others and how relevant
6. Attitudes – evaluation/beliefs about the behaviour
7. Response efficacy – perception of response in preventing the threat
8. Cognitions – awareness of thoughts and perceptions
9. Intentions – plans to carry out the response/behaviour
10. Cues to Action –external and internal factors that influence decision
making
What are the patients reasons for resistance to changing their behaviour
- Creatures of Habit
- Simply just giving information is not effective
- Short term vs long term
- Being told what to do
- Motivation
What are the 3 key models for helping patients change their behaviour?
- Health Belief Model
- Theory of planned behaviour
- Transtheoretical model
What are the 6 stages of the transtheoretical model for behaviour change?
- Precontemplation – never thought about changing factor
- Contemplating – thought about what to change
- Preparation – preparing to change the factor
- Action – putting into action their preparation
- Maintance – maintaining the change
- Relapse – going back to old habit
