Block 3 Flashcards
Define health behaviours
Behaviours that are related to the health status of an individual.
3 types:
1. Good health behaviours
Sleeping (7-8 hours), regular exercise, healthy eating
2. Health protective behaviours
Wearing seatbelt, health screening
3. Health imparing habits
Smoking, high fatty diets, alcohol abuse
What are the determinants of health?
Background factors
Factors that define the context in which people live their lives
Stable factors
Individual differences (personality) in psychological activity that are stable over time and context
Social factors
Social connections in the immediate enviroment
Situational factors
Appraisal of personal relevance that shape responses in a specific situation
What drives seeking medical help?
Explanation of symptoms:
How they make sense of it in the context of their lives.
Perception of symptoms:
Frequency, severity etc.
Evaluation of symptoms:
Costs and benefits of seeking help.
What social triggers make us seek help?
Interference with relationships
Sanctioning by others
Interference with job/activities
Interpersonal crisis
Temporising of symptoms.
What are health behaviours?
Behaviours that are related to the health status of an individual
Explain the dual pathway model
There are two main ways that psychology can influence health:
Give examples of emotional dispositions that are important in determining health behaviours
OCEAN!
Openness
Conscientiousness
Extroversion
Agreeableness
Neurotic-ism.
Define locus of control
(Generalised expectancies)
Expectations that future events will be determined by internal (self) factors or external control (others, God etc.)
People with an internal locus of control tend to have better outcomes, as they believe they are in control of their health.
Define self-efficacy
(Generalised expectancies)
Belief in one’s own ability to organise and execute a course of action
And the expectation that the action will result in, or lead to, a desired outcome
What are the 3 broad types of individual differences?
1. Emotional dispositions
(present - psychological processes involved in both the expereince and expression)
2. Generalised expectancies
(future – psychological processes involved in formulating expectations in relation to future outcomes)
3. Explanatory styles
(past – psychological processes involved in explaining the causes of negative events)
Define optimism (Explanatory style)
Expectation of a positive future outcome despite current negative event
Linked to better physical health, illness recovery and health behavours
Define Attributional style
(Explanatory style)
Causal explanations of negative events as internal, permanent and global
What factors need to be considered when designing studies/interpreting results?
- Chance
- Bias
- Confounding factors
Define bias
“Any trend in the collection, analysis, interpretation or publication of data which allows conclusions to be drawn that are systematically different from the truth.”
Define publication bias
Rejection of unflavoured outcomes.
Prefers studies that support favoured theories.
Ie. That a drug works
Define recall bias
Caused by differences in the accuracy/completeness of the recollections obtained from study participants.
This is a type of information bias, as it affects the information received as data.
Define selection bias
Bias in choosing who will take part in the study.
Ie. One might choose patients with less severe symptoms in order to prove that a drug works.
Define confounding factors
An additional, unmeasured variable that is connected to both the dependent and the independent variable.
Eg. Obesity and CHD, smoking may be a confounding factor.
When must bias be considered?
Bias must be considered when interpreting results from a study.
What is the Bradford Hill criterion for causality?
Group of minimal conditions necessary to provide adequate evidence of a causal relationship between an incidence and a consequence.
Critera includes:
- Strength of assciation
- Specificity of association
- Consistency of association
- Temporal sequence
- Dose response
- Reversibility
- Coherence of theory
- Biological plausibility
- Analogy
Describe the hierarchy of evidence
What are the types of bias?
1. Selection
Admission, prevalence/incidence, detection, volunteer, loss to follow up
Error in choosing the individuals or groups to take part in the study leads to the distortion of the analysis.
Needs to be taken into account when making conclusions about the study.
2. Information
Interviewer, questionnaire, recall, diagnostic suspicion and expose.
Bias that arises from measurement error.
3. Confounding
Define reverse causality
Like the chicken or the egg.
Which is the causality and which is the outcome?
Ie. Mental health problems can cause unemployment but unemployment can cause mental health problems.
Define ‘the number needed to treat’
The number of people that would have to receive the treatment in order to prevent one negative outcome.
NNT = 1/AR
What is the difference between observational studies and experimental studies?
Observational studies measure variables of interests in subjects as opposed to actively giving treatments/intervening in any way.
Experimental studies intervene, setting specific variables for differences between groups.
Define descriptive observational studies
Examines distributions.
Ie. what is the prevalence?
Define analytical observational studies
Examines determinants.
Ie. What exposures increase risk?
What are ecological studies?
Studies that compare an area or population with another.
Ie alcohol consumption of UK to France
What is the ‘ecological fallacy’
The ecological fallacy is thinking that relationships observed for populations hold for individuals:
ie. if populations with more protestants tend to have higher suicide rates, then protestants must be more likely to commit suicide.
What are the pros and cons of ecological studies?
Pros:
Easy to do as information available
Cheap
May raise hypothesis
Cons:
Work on whole population data so cannot be applied to individual persons
Cant establish cauasation only association
Ecological fallacy
Less reliable data collection (disadvantage related to cross-sectional studies)
Confounding
What are cross-sectional studies/surveys?
A study in which information is collected from each subject in the study population at one point in time.
eg. survey
What are the pros and cons of cross-sectional studies/surveys?
Pros:
Cheap and simple
Good for examining exposures that do not change over time (sex)
No exposure to harm or denial of beneficical therapy
May raise hypothesis
Cons:
Cannot establish causation only association
Cannot measure incidence
Confounding
Recall bias
Response rates (dependent on this factor)
Define Case-control studies
Involve comparing subjects with a condition (the cases) to subjects without the condition (the controls).
This involves comparing the exposure of both groups to certain factors.
If the prevalence of an exposure is higher in cases then in controls then it is thought that the exposure may be a risk factor.
What is the odds ratio (equation)?
Odds ratio is the odds in one category over the odds in another category.
Interpret an odds ratio with its 95% confidence interval
(4 point interpretation)
- Odds ratio estimate – best estimate of the odds of the outcome in the population
- 95% CL – 95% confident that the population odds ratio lies between these two limits
- Is the null hypothesis included in the 95% confidence interval
- Is it statistically non-/significant at the 5% level
How many controls per a case is optimum?
The precision of the OR is affected by the number of healthy people (b and d).
Hence is it worth increasing the number of controls; typically up to 4-6 times as many controls as there are cases.
What are the pros of Case-Control studies?
Shorter than cohort studies
Cheaper than cohort studies
Good for studying rare events (which are not studied best via cohort studies as they need a large sample size)
Multiple exposures can be examined
No loss to follow
Suitable when randomisation is unethical (alcohol and pregnancy outcome)
What are the cons of Case-Control studies?
Prone to biases i.e. recall
Problems sorting out sequence of events
Not suited for rare exposures
Cannot measure disease incidence
Multiple outcomes cannot be studied
Define nested case-control study
Nested case-control studies involve collection of data before disease has developed
(from pre-existing records or biological samples)
Whereas conventional case-control studies involve retrospective collection of data
(from recall).
What are the advantages of a nested case control study over a case-control study?
Incidence rates can be calculated
Population for sampling of controls is already defined
Data obtained before disease has developed hence recall bias is eliminated
What are the advantages of a nested case control study over a cohort study?
Can collect more detailed information for a minority of participants
(cost are dramatically reduced)
Cost-effective alternative to a full cohort analysis
Define cohort studies
Study in which a group of people with a common factor are followed up over time
Two groups of people, one group exposed and another unexposed to a potential cause of disease are followed-up over time
The incidence of the disease in one group is compared with the incidence in the other group.
How are cohort studies analysed?
Two ways depending on population used:
- Incidence rate ratio (IRR)
- Standardised mortality/morbidity ratio (SMR)
What are the pros of cohort studies?
Monitor changes over time
Detect (casual) associations and time sequence
Establish population-based incidence
Examine rare exposures
Multiple outcomes can be studied
What are the cons of cohort studies?
Lengthy and expensive
Require very large samples
Not suitable for rare diseases
Not suitable for diseases woth long latency
What is the difference between a cohort study and case-control study?
Case-control study begins with people with the disease (the cases)
Compares them to people without the disease (the controls).
What is the epidemiological transition?
Shift from acute to chronic and degenerative conditions
What are the key features of the epidemiological transition?
Decline in mortality - concentrated on infectious diseases, increase in non-infectious ‘degenerative’ diseases
A shift in burden of illness from younger to older age group
A shift from acute, often fatal illness to chronic conditions
Disease of affluence (CVD, stroke, hypertension, obesity) becoming more common among poorer groups
Table of summary of study designs
How would you calculate the incidence rate ratio?
IRR is a ratio of the incidence of the outcome in the exposed group over the incidence of the outcome in the unexposed group.
What is the standardised mortality ratio?
Used when you have to compare the population in your cohort study to an external population.
Ie. “If my cohort had the same composition (age, sex, ethnicity) as a reference population, would we expect more or less deaths then expected?”
How would you calculate the standardised mortality ratio?
Define attributable risk
The incidence of disease in the exposed that can be attributed to the exposure
Ie the risk difference:
AR = I exposed – I unexposed
Define chronic illness
The experience of living with a long tem condition for which there is no other cure
Which may be managed with drugs and other treatment
1 in 3 live with chronic illness.
Explore some illness narratives
Search for meaning – Why me?
Uncertainty/Unpredictability
Resilience and coping.
What are the main biopsychosocial areas affected by chronic illness?
ADLs
Sense of self
Social relationships
Social identity (How others see you.)
Outline some common coping strategies used by people affected by chronic illness
Denial
Ignoring
Normalisation
“Passing off” as normal
Resignation
Embrace illness
Accommodation
Deal with the illness
Becoming the expert patient.
What is meant by ‘passing off’ in relation to chronic illness
To cover up the presence of symptoms and act as if everything is normal.
The cost of passing off normal can come at a cost
i.e. increase the risk of symptoms becoming evident
Usually the presentation of normal requires the support and co-operation of partners and other relatives
What is meant by biographical disruption?
Biographical disruption with respect to chronic illness means that chronic illness may disturb the trajectory of people’s lives.
Everything changes for them and it gets hard!
What is the expert patient programme?
Recognises the knowledge and expertise held by patients living with chronic illness
Encourages patients to become ‘key decision makers in their treatment process’
Provides training opportunities for people with chronic conditions to develop skills to ‘self-manage’ their condition more effectively
Is open to all people living and coping with a long-term health condition
Led by people with chronic health conditions
What are the potential pros of the expert patient programme?
Patients will see their condition improve or stay stable
Patients will have more confidence in seeking the right health and social care services for them
Patients will contribute towards improving health services
Patients will need fewer visits to GPs and outpatient clinics thus saving NHS resources
Patients and health professionals will work together to find better solutions to care and treatment issues
What are the potential cons of the expert patient programme?
How is the participation of all social groups to be achieved
May intensity the exclusion and marginalisation of the most disadvantaged groups
Extra pressure placed on patient organisations
No corresponding strategy to challenge professional attitudes
Thought just to be a method to save resources
What are the impacts of chronic illness?
Biopsychosocial impact
It’s a shock and as a result there are huge changes in life – reduces quality of life
The patient needs to make many changes to deal with the chronic illness
Examples:
Adjust to symptoms and disability
Maintain an emotional balance
Preserve a self-image and sense of competence
Learn about symptoms, treatment and self-management
Maintain relationships with friends and family
Forming and maintaining relationships with health care professionals
Preparing for an uncertain future
Explain pain management using psychological and social factors via the crisis theory
Crisis theory – tries to explain how people manage and cope with chronic illness
They need to find a social and psychological balance.
Certain challenges, setbacks and social influences can impact the coping responses of patients.
For example:
When in a crisis, patients are more likely to listen to those close to them (family).
What are the features of a pain management programme?
Endorsed by NICE
Reinforces the message of gate control theory (a combination of psychological and physical factors can open and close the gate)
Involves clinicians, specialist nurses, physiotherapists, and psychologists
Can come in different formats
i.e. intense and residential or spread over a few weeks (6-8) and not residential
What are the pros of the pain management programme?
Helps patients manage their pain rather than the pain managing/controlling them
Learn to change cognitive perceptions of pain, less catastrophizing, challenging unhelpful thoughts
Management of stress and anxiety as well as low mood and depression
Not feeling so isolated with the condition when in a group
What are the cons of the pain management programme?
Managing group dynamics
Stages of change – are patients ready to change their behaviours?
Commitment
Managing fears
What is the difference between social carers (paid carers) and unpaid carers?
Paid carer:
Include staff who work with people in residential care homes, in day centres and who provide care in someone’s home.
Unpaid carer:
Carers who provide unpaid care by looking after an ill, frail or disabled family member, friend or partner
What are the main kinds of support that unpaid carers provide?
Practical help
(preparing meals, housework)
Personal care
(bathing, washing, dressing and toileting)
Physical help
(with getting in and out of bed, walking and getting up and down stairs)
Finances
Administering medication
Why do some people not use the term ‘carer’?
May not consider themselves to be a ‘carer’
They may not describe or see themselves as carers:
Instead they continue to be husbands, wives, partners, parents, sons, daughters
Believe they are caring out of love for the other person
Outline the pros and cons of using the term carer
Pros:
May identify need and open up the way to providing services
May give recognition of the demands made upon carers and the contribution they make
May offer some carers a sense of identity – more likely to attend support groups
Cons:
May lead to others to see that person only in terms of that definition and the responsibilities linked to it
May lock some people into a role they do not want
Some may dislike or reject carer tag preferring to define them in terms of their relationship to the patient
Person being cared for may feel undermined if someone close is defined as their carer
Define caring
“Caring for somebody that is unable to look after themselves.”
What are the main impacts of caring, on carers?
Financial
Social exclusion
Health
Work
Being a young carer (education)
What are the main impacts of caring on carers regarding finances?
Carers usually on lower income as reduced ability to work
Usually have higher costs: additional laundry, higher bills
What are the main impacts of caring on carers regarding social exclusion?
Hard to access holidays, leisure pursuits and other social activities
Most get few or no breaks from caring duties
Most look after people who do not get any regular visits from health or welfare professionals
Those people who care carer by relatives are less likely to receive help
Greatest lack of support in black and minority ethnic groups
What are the main impacts of caring on carers regarding health?
Carers usually have poorer mental and physical health than non-carers
Injuries due to the manual handling responsibilities of the role
High prevalence of stress and depression among carers
Unable to find time for own health check-ups or do things to improve own health
Reluctant to accept certain treatments if it interferes with caring duties
May want to be discharged from hospital earlier
Outline the potential impacts on a young carer
Lots of younger carers around who provide care for a parent, sibling or other relative
There can be a lack of awareness of their existence
Usually have double responsibilities which can impact them
- Absence from education
- Behavioural problems
- Social exclusion/isolation
- Emotional problems
- Physical health problems
- Traumatic life changes
- Poverty
- Lack of support and benefits
What support is available for carers?
Financial support:
Carer’s allowance – if you care >35 hours a week for someone who qualifies for disability benefit and not earning more than £100 a week
Health services support:
Consideration of carer when planning care for patient · Consideration for carers health
Signposting carers services (carers assessment, carers allowance, other services)
Carer’s assessment:
Have right to assessment of their needs
Allows carer support even if who they care for does not want help from social services
Provides information about support available to carers
Young carers project
What is the young carers project?
Aims to provide opportunities for young carers to take break from their caring duties and spend time with other young carers
Can provide guidance on other support available for them
What are the key ways of improving health and wellbeing of carers?
Give information about rights and entitlements
Provision of equipment quickly can help
Doctors play important role in signposting support for carers
Regular health checks for carers
Should consider the impact of timing and nature of health decisions on the carer
Carers should be consulted about decisions where possible
What is the difference between experimental and observational studies?
Experimental studies:
The effect of clinical intervention is assessed
The patients receive treatments in a designed experiment.
i.e. clinical trial
Observational studies:
Patients receive normal medical care
The outcomes are observed and the relationship to risk factors is assessed.
i.e. cohort study, case-control study
Define clinical trial
Any form of planned experiment, which involves patients
Is designed to find to most appropriate method of treatment of future patients with a given medical condition.
What is the purpose of a clinical trial?
To evaluate a new treatment:
Scientifically
Unbiased evaluation
Controlled comparison
Ethical considerations
What are the features of randomised controlled trials?
- Concurrent controls
- Random allocation
- Process of randomisation (computer generates random numbers)
- Blinding
- Placebo effect
Why is random allocation important in RCT’s?
Aims to have the groups differ only in treatment they receive
Random allocation allows:
Gives equal chance of receiving each treatment
Long run leads to groups that are likely to be similar in characteristics by chance
Reduces the selection bias
Used in other experimental settings
Why is blinding important in RCT’s?
Two types of blinding:
Single blind
One of the patient, clinician or assessor does not know the treatment allocation
(usually patient)
Double blind
Two or more of patient, clinician or assessor does not know the treatment allocation
(usually patient +clinician/assessor)
Examples
Make treatments appear identical (taste, appearance, texture or dosage)
Compare active drug to placebo
Use a designated pharmacy to label identical containers with code numbers
Why is concurrent controls important in RCT’s?
All patients undergo the two types of treatments at the same time
Prevents historical controls process and thus eliminates bias and makes the trial fairer
Why is a placebo effect important in RCT’s?
Even if the therapy is irrelevant to the patient’s condition, the patient’s attitude to her or his illness and the illness itself can be improved by a feeling that something is being done about it
What does non-compliance mean?
Not every patient remains in the trial due to several reasons.
- The clinical condition may mean they have to be removed from the trial
- They may choose to withdraw from the trial.
Not every participant complies with his or her allocated treatment.
- They may have misunderstood the instructions
- May not like taking their treatment
- May think the treatment is not working
What is the difference between ‘As-Treated’ and ‘Intention to treat’ analysis?
Explanatory trials – “As-treated approach.”
Realises issues with non-compliance.
Follows up only the subjects that took to treatment and complied with their treatment.
BUT loses some of the randomisation, as compliers are likely to be fundamentally different from non-compliers, selection bias and confounding.
Pragmatic Trials – “Intention to treat approach.”
Takes everybody into account, disregarding the problems associated with non-compliance.
Is the ‘As treated approach’ or the ‘Intention to treat approach’ more relevant to clinical practice?
The intention to treat approach ( Pragmatic trails) is more relevant to clinical practice!
This is the approach used in clinical trials.
They give smaller effect sizes.
What are the ethical issues involved in a clinical trial?
- Doctors should provide best treatment for each individual patient*
- Scientific integrity requires treatment chosen randomly*
Clinical equipoise
Reasonable uncertainty about which treatment is better
Randomisation does not deny any patient the best treatment
Informed consent
It should be explained that patient is invited into a trial, what the alternative treatments are, that the treatment is allocated at random, that the patient may withdraw at any time.
The information should be given verbally and in writing with some time to decide and by a knowledgeable informant
Outline the ethical and governance research requirements
Ethical requirements:
The type of ethical review required depends on the type of study carried out
If the study type is an audit or service evaluation then the approving ethical requirements include:
- Course director/Supervisor
- Head of NHS department.
Governance Requirements:
Compliance with the principles of GCP
NHS Research Governance Framework 2005
What are the guiding principles in research ethics (Declaration of Helsinki)?
Regarded as the cornerstone document of human research ethics but not legally binding
(4 key points):
- Respect for the individual
- Informed consent
- Risks and benefits
- Ethics review
What are the 13 principles of good clinical practice?
- Clinical trials should be conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki, are consistent with GCP and applicable regulatory requirements
- Before trial, potential risks should be weighed against the anticipated benefit for the individual trial subject and society.
- The rights, safety and well-being of the trial subjects are the most important considerations and should prevail over interests of science and society
- The available non-clinical and clinical information on an investigational product should be adequate to support the proposed clinical trial
- Clinical trials should be scientifically sound and described in a clear, detailed protocol.
- A trial should be conducted in compliance with the protocol that has received prior institutional review board (IRB) / independent ethics committee (IEC) approval / favourable opinion
- The medical care given to, and medical decisions made on behalf of, subjects should always be the responsibility of a qualified physician
- Each individual involved in conducting a trial should be qualified by education, training and experience to perform his or her respective task(s).
- Freely given informed consent should be obtained from every subject prior to clinical trial participation.
- All clinical trial information should be recorded, handled and stored in a way that allows its accurate reporting, interpretation and verification
- The confidentiality of records that could identify subjects should be protected by privacy and confidentiality rules in accordance with the applicable regulatory requirement(s).
- Investigational products should be manufactured, handled and stored in accordance with applicable good manufacturing practice (GMP).
- Systems with procedures that assure the quality of every aspect of the trial should be implemented
What is reflexivity and why is important in qualitative research?
Considers influences on data sources (social desirability) and analysis (preconceptions)
