CoreMeist Public Health Flashcards
GMC duties of a doctor
- make the patient your first concern
- Keep professional knowledge and skills up to date
- Treat your patient politely and considerately
- Respect your patient’s right to confidentiality
- Listen to patients and respond to their concerns and preferences
- Never discriminate unfairly against patients or colleagues
- Work with colleagues in ways that best serve the patient’s interest
- Treat patients as individuals an respect their interest
What are psychosocial factors that increase CHD risk?
- Type A personality (hostile, competitive, impatient)
- Depression/anxiety
- Psychosocial work characteristics (long working hours, stressful job, high demand low control)
- Lack of social support
What does the Bradford Hill criteria aim to provide?
Epidemiological evidence of a causal relationship between an assumed cause and observed effecr
What are the Bradford Hill criteria?
- Temporality: does the cause precede the effect?
- Biological Plausibility: is the association consistent with existing knowledge?
- Consistency: have similar results been shown in other studies
- Strength: what is the strength of association between the cause and effect
- Dose/response: does increased exposure lead to increased effect
- Reversibility: does removal of a cause decrease the risk of the effect?
- Study design: is the evidence based on a robust study design
- Evidence: how many lines of evidence lead to the conclusion?
What are the UK guidelines for daily alcohol limits?
Men: 3-4 units/day
Women: 2-3
Pregnant: avoid altogether/never more than 1-2 units once or twice a week
What can 1 unit of alcohol refer to?
8g/10ml pure alcohol
Half a pint of beer
Small glass of wine
Single measure of spirits = strength of drink (%ABV) x amount of liquid (ml) / 1000
Describe Fetal Alcohol Syndrome?
Pre and post-natal growth retardation
CNS abnormalities: mental retardation, irritability, incoordination, hyperactivity.
Craniofacial abnormalities, congenital defects, increase in incidence of birth marks and hernias
Current strategies for primary prevention of alcoholism
Drinkaware - alcohol labelling. THINK! drink driving campaign 'Know your limits' binge drinking campaign Restriction on alcohol advertising Minimum pricing Legislation - e.g. age limit Opening hours Glass substitution
What strategies aim towards secondary prevention of alcoholism - e.g. screening and intervention
Ask about it routinely using screening questions/tools.
Detect problem drinking - e.g. laboratory tests.
CAGE and Alcohol Use Disorders Identification Test (AUDIT)
Referral to specialists.
Help set goals, agree on plan, provide educational materials.
What does the CAGE questionnaire aim to identigy?
At risk drinking
What are the 4 questions involved in the CAGE questionnair? What result indicates a problem?
- Have you ever felt you should cut down on your drinking?
- Have people annoyed you by criticising your drinking or suggesting you should cut down?
- Do you ever feel bad/guilty about your drinking?
- Have you ever taken a drink first thing in the morning to steady your nerves or get rid of a hangover?
2or> positive responses indicates a problem
What are signs of alcohol dependence?
3 or more in the last 12 months of:
- withdrawal symptoms
- tolerance
- keep drinking despite problems
- Cannot keep within drinking limits
- Spend a lot of time drinking/recovering from drinking
- spend less time on other important matters
definition of health
WHO:
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
key principles/domains of public health
Health promotion/improvement, health protection, improving services.
Wider determinants of health (looking at bigger picture). Population based as opposed to individual.
what are modifiable risk factors that cause disease in poorest vs. developed countries globally?
poorest: underweight, unsafe sex, unsafe water and sanitation
developed: tobacco, HBP, alcohol
why does migrant health have different focusses to UK public health?
cultural practices - e.g. FGM
environments
living conditions
war and conflict –> internal displacement, refugees
What are the social determinants of health?
financial, educational, georgraphical, cultural
What is equality vs equity? why so important in public health?
allocation of ressources based on need - getting everyone to the same end point by levelling the playing field
describe the health determinants model/socio-economic model of health
at centre: age, sex, hereditary factors
- individual lifestyle factors
- social and community influences
- living and working conditions
- general social, cultural and economic conditions
what is the basis of the inverse care law?
perverse relationship between need for healthcare and utilisation of services - those who need medical care most are least likely to access it
barriers to access - e.g. lack of childcare, transport, education
define primary prevention of disease - and examples?
- changes exposure to risk
- prevents disease occuring
e. g. lifestyle changes, fluoridation of drinking water, immunisation in childhood
define secondary prevention of disease - and examples?
- detection of early disease (e.g. breast cancer screening)
- interventions that prevent reoccurrence (e.g. aspirin to prevent further MI)
define tertiary prevention of disease - and examples?
- minimisation of disability and prevent complications - focusses on maximising quality of life
e. g. rehabilitation post-stroke
public health disease prevention paradox?
if something brings a lot of benefit to the population, it is likely to bring little benefit to each individual
screening - classifications
primary: prevent disease occurring (find risk factors, reduce levels)
secondary: detect disease early so alter course of disease (e.g. mammography for breast cancer detection)
what categories can the 12 Wilson-Jungner principles of screening be subdivided into?
criteria relating to:
- the condition
- the test
- the treatment
- risks and benefits
Wilson-Jungner principles of screening: name 5 of the principles
inc. one from each relating to the condition, test, treatment, risks and benefits
condition:
- is it an important health problem
- is the natural history of the health problem well understood
- is there a detectable early stage
test:
- does a suitable test exist for the early stage
- is the test acceptable
- can it be repeated
treatment
- is there an accepted treatment for the disease
- are facilities for diagnosis and treatment available
- is there adequate health service provision for people found positive?
risks and benefits:
- is there an agreed policy on who to treat
- are the costs balances against the benefits
- are the risks, both psychological and physical, balanced against the benefits
what other screening criteria exists apart from Wilson Jungner?
WHO screening criteria - 10 principles based on Wilson-jungner
examples of screening programs
breast cancer, colon cancer, STIs, diabetic retinopathy
what are some restrictions for screening programmes?
age restricted and condition dependent
some can be requested
What are the 2 differing ways of monitoring prevalence of diseases?
Active - seeking out people actively to establish prevalence
Passive - prevalence taken from existing data e.g. at sentinel GP practises/anonymous information
define prevalence
the proportion of a particular population found to be affected by a medical condition
define incidence
the probability of occurrence of a given medical condition in a population within a specified period of time - new cases in a specific period of time
define absolute risk
change in theriskof an outcome of a given treatment or activity in relation to a
comparison treatment or activity
define relative risk
ratio of the probability of an event occurring (for example, developing a disease,
being injured) in an exposed group to the probability of the event occurring in a comparison,
non-exposed group
what is meant by the prevention paradox?
shows that interventions can achieve large overall health gains for whole populations but might offer only small advantages to each individual. This leads to a misperception of the benefits of preventive advice and services by people who are apparently in good health
how is BMI calculated?
weight(kg) over height(m) squared
kg/m^2
prevalence probability
vs
incidence probability
Prevalence probability: probability of disease in the entire population at any point in time
Incidence probability: probability that a patient without disease develops the disease during an interval
what is meant by incidence rate?
the number of new cases per population at risk in a given time period
what is the significance of a rate ratio?
how is it calculated?
compare the incidenceratesof events occurring at any given point in time
95% confidence interval: 95% certain that the true result mean falls within the range of X and Y
what is meant by the odds ratio?
theoddsthat an outcome will occur given a particular exposure, compared to
theoddsof the outcome occurring in the absence of that exposure
what is meant by the doctrine of dual effect in medicine?
The idea that if something morally good has a morally bad side-effect it’s ethically OK to do it providing the bad side-effect wasn’t intended - even if the bad effect was foreseen.
Aiming to do good - e.g. extending life at expense of quality of life
what is meant by nominal variables in data collection?
2 or more categories, but there is no intrinsic ordering to the categories - e.g gender
what are binary variables?
only take 2 values
discrete variables vs continuous
discrete - can only take a finite number of values
continuous - can tae any value between min and max
ordinal variables
order matters but not the difference between values
at what p value is a result said to be statistically significant?
p<0.05 = reject null hypothesis
what is clinical significance compared to statistical significance
Just because a treatment has been shown to lead to statistically significant improvements in symptoms (p value <0.05) does not necessarily mean that these improvements will be clinically significant (i.e. meaningful or relevant to patients)
Relevance of a study’s finding to clinical practice cannot be proved statistically - it is a Question of clinical judgement as to whether the results detected are relevant.
How is the top down deductive argument used in medical ethics?
one specific ethical theory is consistently applied to each problem.
What are the four principles of medical ethics?
Briefly describe each
- Autonomy - the right of competent adults to make informed decisions about their own medical care
- Beneficence - doing the right thing to benefit others
- Non-maleficence - preventing harm, reducing harm and doing no harm
- Justice - being fair in distribution of benefits and risk
What is consequentialism when applied to medical ethics?
Act is valued in terms of its consequences/effect
How does deontology (kantianism) differ to consequentialism and virtue ethics in medical ethics?
Deontology is an approach to Ethics that focuses on the rightness or wrongness of actions themselves, as opposed to the rightness or wrongness of the consequences of those actions (Consequentialism) or to the character and habits of the actor (Virtue Ethics)
What is the idea of virtue ethics in medicine? What characteristics should a doctor have?
Focuses on the character of the person who is doing the act as moral justification. Compassion Discernment Trustworthiness Integrity Conscientiousness
What is the Gini coefficient - social determinants of health inequalities
Statistical representation of a nation’s income distribution amongst its residences - lower coefficient = greater equality. UK has a relatively high inequality coefficient compared with scandinavian countries.
How does social class affect life expectancy?
Decreases as social class decreases. Gaps between lower and upper classes are increasing.
When a country reaches a certain income threshold what pattern is seen in terms of the health of its residents suffer from?
After this shift how do further increases in per capita income affect the health of a nation?
The epidemic diseases of poverty are replaced with degenerative diseases, then further increase in per capita income make little or no difference to the health of a nation
what affects a nations health more - the mean income (above a threshold) or the extent of income division?
The extent of income division within a society determines the population health. More unequal societies have worse health.
What is social class a measure of?
Social class is a measure of occupation, stratification, social position and access to power and resources. It can quantified using the Registrar General’s model (occupation focused) or the NS-SEC model.
What are the key challenges of an ageing population?
- Strains on pension and social security systems
- Increasing demand for health care
- Bigger need for trained health workforce
- Increasing demand for long-term care
- Pervasive ageism (denying older people the rights and opportunities available for other adults
What are some reasons cited for smoking?
- nicotine addiction
- coping with stress
- habit
- socialising
- fear of weight gain
Discuss the prevalence of smoking
- men smoke more than women, but this gap is closing
- prevalence is decreasing
- people from lower socioeconomic groups smoke more than those from higher ones
Measures put in place to curb smoking prevalence - e.g.s
- 2005: smoking banned in public places
- 2007: minimum age raised to 18
- nicotine replacement therapy available on the NHS as patches, hum, nasal spray, microtab, lozenges and inhalers
WHat are the 5(or 6) stages of the transtheoretical stages of change model?
- Pre-contemplation
- Contemplation
- Preparation
- Action
- Maintenance
(6. ) Relapse - back to stage 2
Some facts about global health inequalities: % population and diseased population, income vs health spending, distribution of health workers
Developing countries account for 84% of world population and 93% of the world burden of
disease.
They account for only 18% of global income and 11% of global health spending.
There is unequal distribution of nurses and beds to population ratios globally.
As the population ages and increases, what is happening to work fertility?
Decreasing
What are the millennium development goals?
8 goals to be achieved by 2015 that respond to the world’s main development challenges. 3 of them are related to health.
State some of the 8 millennium development goals
- Eradicate Extreme Poverty & Hunger
- Achieve Universal Primary Education
- Promote Gender Equality & Empower Women
- Reduce Child Mortality
- Improve Maternal Health
- Combat HIV/AIDS, Malaria and Other Diseases
- Ensure Environmental Sustainability
- Develop a Global Partnership for Development
What are the leading causes of child death globally?
- Pneumonia
- Diarrhoea
- Malaria
Arguments for screening programs
- prevent suffering
- early identification can be beneficial
- early treatment is cheaper
- patient satisfaction tends to be high
Arguments against screening programs
- psychological and physical damage caused by false positives and negatives
- adverse effects of screening tool on healthy people
- personal choice is compromised
What is sensitivity in relation to a screening test?
People who the test correctly identifies as having the disease out of all individuals with the disease (true positive results divided by total number of people with the disease who are screened). It is a measure of how well a test picks up those with a disease.
What is specificity in relation to screening tests?
Specificity of a test is the probability of a person without the disease testing negative
(true negative results divided by total number of people with the disease who are screened). It is
a measure of how well a test recognises those without the disease.
What is the positive predictive value?
The proportion of people with a positive test result who actually have
the disease
What is the negative predictive value?
of all the negative results, the proportion who actually do not have the disease - excludes the false negatives
People correctly excluded by the test.
Table of truth vs test result: if the test result in on the x axis and truth on the y axis how is sensitivity predicted? true positive = a false positive = b false negative = c true negative = d
Sensitivity = a/a+c
True positive/True positive+False negative
Table of truth vs test result: if the test result in on the x axis and truth on the y axis how is specificity predicted? true positive = a false positive = b false negative = c true negative = d
Specificity = d/b+d
true negative/true negative + false positive
Is it more important that a good screening test has a high negative or positive predictive value?
negative =
people who do not have the disease are correctly identified
It is important that this is high as false negatives are potentially dangerous
Describe the transtheoretical model of change
Describes the stages of behavioural change.
Starts with precontemplation - individual carries out behaviour without thinking of quitting.
Contemplation - individual starts to think about negative effects of behaviour
Preparation - individual prepares to change behavioural patterns and give up behaviour
Action - individual takes steps to stop behaviour
Manitenance - individual attempts to maintain lifestyle change
(can have relapse - maintenance —> contemplation stage)
What are some examples of public health interventions that have attempted to curb smoking?
(2 or 3)
1980s - no smoking on trains
1999 - royal family remove seal from tobacco products
2000s - smoking ban in public places
2007 - change in legal age
Also increases in tax, NHS stop smoking campaign, nicotine replacement therapy available on the NHS
What are some reasons cited as to WHY people smoke?
- addiction to nicotine
- method of coping with stress
- habit/behavioural addiction
- means of socialising
- fear of weight gain during/after cessation
What does Janz&Becker’s Health and Belief model attempt to measure?
The influence of an individual’s perception of their own health - attempts to explain and predict health behaviors. This is done by focusing on the attitudes and beliefs of individuals.
What do Becker and Janz argue contribute to the threat perceived by an individual in regards to their own health?
- own individual perception
- Modifying factors: cues to action such as campaigns, articles, reminder postcards from healthcare professionals, illness/death of a friend)
- modifying factors: demographic and sociopsychological variables
What do Janz and Becker argue determines the likelihood of an individual taking action to change health behaviours in their health and belief model?
perceived benefits - perceived barriers –> likelihood of taking action
Individuals will change if they:
- believe they are susceptible to the condition
- believe it has serious consequences
- believe that taking action reduces susceptibility
- believe that benefits of taking actions outweigh costs
The benefits and barriers are affected by modifying factors such as demographics, sociopsychological variables and cues to action as well as an individuals initial perception of their own health.
Theory of planned behaviour:
States that the best predictor of behaviour is intention - what does the theory claim determines an individual’s intention to change their behaviour?
- Person’s attitude towards act/behaviour
- Perceived social pressure - subjective norm: group beliefs, cultural norm
- Appraisal of their ability to perform behaviour - view of their own behavioural control/self-efficacy
What factors help people to act on their intentions?
- perceived control
- anticipated regret
- preparatory actions
- implementation of intentions
- relevance to self
What is the Nudge Theory?
e.g?
Changing the environment around to help make the best option for health the easiest option.
E.g. not having chocolate bars by the tills in shops.
E.g. cheaper fruit and veg
Discuss some varying beliefs/priorities when it comes to death and dying?
- Different cultural opinions: religious and cultural beliefs and practices
- Place: hospital? home? hospice?
- DNACPR?
- What constitutes a good death: assisted? in hospital following CPR? At home with loved ones?
What do hospices aim to do?
Demedicalise death.
Provide a good death with minimal pain and suffering.
Palliative care: e.g. Liverpool care pathway for end of life care. Aims to treat to relieve pain, control symptoms and improve quality of life.
Support for family of dying person.
Dying is often seen as medical failure but is a fact of life.
Examples of reports looking at the existing health inequalities in Britain
- Black Report - 1980: post introduction of the welfare state, found health inequalities still existed
- Acheson report - 1998: to review the latest information on inequalities in health to identify priority areas for the government’s public health strategy
- Marmot report - 2010: provides strategies to reduce health inequalities in Britain
Why should doctors read medical journals?
- duty to keep up to date with emerging evidence and new protocols/treatment
- constant learning
- engagement with job
- patients (especially those with chronic diseases) do their research and may have specific questions relating to their ailment that require up to date knowledge
What is the difference between morals and ethics?
Morals are personal, self-held beliefs about standards of behaviour
Ethics are based on social frameworks/ethical codes held by a society
Describe utilitarianism as an ethical framework
Describes the idea that actions are right if they benefit the most people and therefore create the greatest overall happiness.
Descrive divine command as an ethical framework
Actions are perceived as ethical or not based on religious text.
E.g. Jehovah’s Witnesses and blood transfusions, abortion
Describe consequentialism as an ethical framework
Actions are perceived as ethical based on the outcome, not the action itself - action justified if the consequences of the action are positive. Ends justify the means.
Describe virtue ethics
Actions are judged based on the character of the individual carrying out the action.
Describe deontology as an ethical framework
Judges actions using rules to distinguish right from wrong. Belief that ethical actions follow universal moral laws which can be used to distinguish between actions that are ethical and unethical.
Describe situation ethics
Whether an action is ethical or not is dependent on the situation/circumstances
Why may health inequalities still exist in Britain?
- Lower income
- Lack of social support
- Limited access to healthcare
- Limited access to educational resources
etc
4 Pillars of Medical Ethics
- Autonomy: patient’s choice
- Beneficience: do good
- Non-maleficence: do no harm
- Justice: fairness of treatment for all, fair distribution of resources.
What 4 broad topics does the new framework (four quadrants of medical ethics) cover? Used in clinical decision making.
- Indications for medical intervention - establish a diagnosis, what are the options for treatment, what are the prognoses for each of the options. Involves beneficence and non-maleficence.
- Preferences of patient - involves respect for patient autonomy
- Quality of life - will the proposed treatment improve the patient’s quality of life? Involves beneficence and non-maleficence
- Contextual features - involves justice, healthcare professionals, family, law.
Modifiable health damaging risk factors vs. non modifiable
Modifiable: Diet/obesity Smoking Alcohol Physical activity Sleep, stress Non-modifiable: Sex Age Genetics/family history
Why is changing health behaviour important?
economics: cost to NHS of damaging health behaviours such as smoking and drinking
What is morbidity vs mortality?
Morbidity: incidence of ill-health
Mortality: incidence of death
3 theories/models of behavioural change (just names)
- Health belief model
- Theory of planned behaviour
- Stages of change/transtheoretical model
(also - nudging, social marketing, financial incentives, social norms theory)
What sources do patients trust most when it comes to information about their health?
Most to least:
- GP (75% trust this)
- Radio documentary
- TV advertising (under 50% trust this)
What is iatrogenesis?
the unintended adverse effects of a therapeutic intervention. Can be clinical, social or cultural.
What is the effect of high prevalence on the incidence of false positives in screening for a disease?
How does this affect pos. and neg. predictive value?
What about a rare disease?
Incidence of false positives will fall.
Pos predictive value therefore increases and negative predictive value falls.
The reverse is true for a rare disease.
What is the high risk approach to prevention of disease in public health?
What are some concerns over this approach?
- Target highest risk individuals
- Aim to reduce risk below set limit
This approach is accepted by society - we treat only those outside normal levels.
Concerns that this approach misses the large number of people at small risk of a disease who may contribute to more cases. It also favours people who are more affluent and better educated (more likely to engage with health service, have means to change their lifestyle)
What is the population approach to prevention of disease in public health?
what are some concerns over this approach?
- targets all individuals
- aims to reduce the risk for each individual
- recognises that the low risk majority may contribute most cases
Concerns over treating the well and creation of a ‘nanny state’
utilitarianism in ethics
the best action is the one that creates maximum overall happiness
Define health
WHO:
“A state of complete physical, mental, and social well-being and not merely the absence of disease of infirmity”
What are the key differences between public health/the role of public health doctors and general medicine?
- About improving and protecting the health of groups of people, rather than treating individual patients
- Looking at the bigger picture - taking action to promote healthy lifestyles, prevent disease, protect and improve general health and improve healthcare services
NHS start date - who created it and under the basis of what report?
July 5th, 1948.
Aneurin Beavan.
The Beveridge report
What are some reasons that those with the greatest need for healthcare access it the least, according to the inverse care law?
Geography - no car/long journey/no buses
Education - lack of understanding
Finance - missed days at work/cost of transport
Barriers - multiple children/work hours/single parents
Apply the transtheoretical model for stages of change to an individual attempting to give up smoking.
What support can a healthcare professional (HP) give at each stage?
- Precontemplation: not thinking about quitting, possibly defensive about smoking behaviour. HP can encourage them to start thinking about quitting.
- Contemplation: begins thinking about quitting, provide more info - leaflets, advice etc
- Preparation: getting ready to quit, help them to plan an attempt - refer to NHS Stop Smoking Services
- Action: actively quits. Encourage them to maintain, reward for quitting.
- Maintenance: encourage and reward, provide NHS free helpline and website.
(6) relapse - advise that this doesn’t mean the end of their attempt, help them think a bout cause of their lapse and plan to prevent further lapse. Leave door open for further support. On average smokers attempt to quit 7-8 times before quitting for good
What are some factors that affect health inequality in the UK?
- socioeconomic background
- ethnicity: minority ethnic groups generally have poorer health
- age: older people more likely to become unwell
- gender: gender norms, roles and relations can influence health outcomes
Describe the burden of chronic disease in the healthcare system
- 70% of primary and acute healthcare budget used for management of chronic conditions
- linked to modifieable risk factors
Give some examples of change making a difference in the past in terms of population health
- Control of work-related health problems, such as coal workers’ pneumoconiosis (black lung) and silicosis;
- Decline in deaths from coronary heart disease and stroke;
- Development of and access to safer and healthier foods;
- Fluoridation of drinking water to prevent tooth decay;§
- Recognition of tobacco use as a health hazard and subsequent public health anti-smoking campaigns
What is a common misconception when it comes to end of life care pathways?
Not the WITHDRAWAL of ALL medical care. Medications to put the patients at ease: Remove pain Control symptoms Aims to improve quality of life Supports families Designated health care professionals involved Supportive
Key challenges of an ageing population
- Strains on pension and social security systems
- Increasing demand for health care
- Greater need for trained health workforce
- Increasing demand for long-term care
- Pervasive ageism (denying older people the rights and opportunities available for other adults
Arguments for and against screening
FOR: Prevent suffering Benefits of early detection Early treatment is cheaper Patient satisfaction tends to be high AGAINST: Damage caused by false positives and false negatives Adverse effects of screening tool on healthy people. Personal choice compromised
types of human error
Errors of omission - required action delayed/not taken
Errors of commission - wrong action is taken
Errors of negligence - the actions or omissions do not meet the standard of an ordinary, skilled person professing
Define obesity
Abnormal or excessive fat accumulation resulting from chronic imbalance between
energy intake and energy expenditure that presents a risk to health. It is a state of positive
energy balance.
What BMI range indicates obesity?
30 and above
what BMI indicates someone is underweight?
below 18.5
What is the ‘normal’ BMI range?
20-25
What are some suggested lifestyle changes for primary prevention of CHD?
‘SNAP’
Smoking (taxation, cessation, health warnings etc.)
Nutrition (recommendations, standards, regulation)
Alcohol (taxation, regulation, campaigns)
Physical activity (promotion, PE in schools)
Describe the epidemiology of CHD in the UK
Accounts for 40% of deaths.
More deaths in men.
Rates are decreasing due to effective treatments and lifestyle changes.
What does secondary prevention in CHD involve?
- primary care CHD registers
- medical management: aspirin, B-blockers, ACE inhibitors, statins
- phase 4 cardiac rehabilitation
How have risk factors and treatments for CHD changes over time?
- factors increasing the risk, factors decreasing the risk, improvements
- obesity and diabetes have risen, physical activity fallen - increase risk of CHD
- smoking, cholesterol, BP levels, deprivation have fallen, decreasing risk.
- treatments are improving
Describe examples of some unmodifiable risk factors for CHD?
- sex
- age
- ethnicity
- family history
- early life circumstances
what are some potentially modifiable risk factors for CHD?
Clinical: - high blood cholesterol, hypertension, type 2 diabetes Lifestyle: - smoking - physical inactivity - overweight - poor nutrition - alcohol intake
What are some psychosocial risk factors for CHD?
- type A personality traits (competitive, hostile, impatient)
- depression/anxiety
- work factors - high demand and low control jobs are linked to MI
- lack of social support
How do types A and B influenza differ?
A in the strain which causes pandemics. B is seasonal.
What are some population changes since previous pandemics that could alter the risk of a new disease pandemic?
- increased international travel
- increased crowding
- large population
- interdependence between countries
- animal husbandry
- overall population health has improved
What are some public health interventions that could prevent the spread of pandemics such as influenza?
- hand washing
- respiratory hygiene
- reduce social contact
- travel restrictions
- restricting mass gatherings
- school closures
- voluntary home isolation of cases
- screening people entering the UK
Describe the chain of infection in infectious disease (e.g. infectious causes of diarrhoea)
(6)
infectious agent –> susceptible host (reservoir) –> portal of exit for the agent –> mode of tranmission (e.g. faeco-oral) –> portal of entry into the susceptible host –> susceptible host
Describe direct vs indirect vs airborne transmission of disease
e.g.
Direct:
- STIs
- faecal oral route e.g. viral gastroenteritis
Indirect
- vector-borne e.g. malaria/dengue
- vehicle-borne e.g. hep B
airborne
- respiratory route e.g. TB
What is the SIGHT protocol when it comes to treating unexplained cases of diarrhoea?
Suspect c.diff as a cause Isolate the case Gloves and aprons must be worn Hand washing with soap and water Test stool for toxin
What are control measures to prevent diarrhoea?
- hand washing with soap
- safe drinking water
- safe disposal of human waste
- breastfeeding of infants and young children
- safe handling and processing of food
- control of flies/vectors
- vaccination
What is a standard unit in ml/grams of ethanol?
How is this calculated?
10ml/8g ethanol
(%alcohol by volume x amount of liquid in millimetres)/1,000
what shift does patient-centred medicine aim to involve?
a shift in focus from treatment to care
What is compliance?
some flaws with the concept
the extent to which a patient’s behaviour coincides with medical/health advice/ Professionally rather than patient focused. Assumes doctors know best. Does not look at problems patients have in managing their health/illness
What could be some reasons for non-compliance in patients?
Can be unintentional - forgetting/non understanding instructions
Can be intentional - patient beliefs about their condition/treatment and personal preferences.
e.g. not taking prescribed medication/taking different amounts, continuing with behaviours against medical advice.
What is adherence as opposed to compliance?
What about concordance?
Compliance - following doctor’s recommendations for medication dosing. Implies a paternalistic role for the physician and a passive role for the patient.
Adherence - Healthcare professional is expert conveying their knowledge, but patient is empowered to take matters into their own hands and is adhering to the proper dosing schedule themself.
Concordance thinks of patients as equals on care, so medical consultation is a negotiation between equals. It is expected that patients will take part in treatment decisions.
What are some ethical considerations that must be considered when assessing compliance/adherance/concordance in patients
- mental capacity
- decisions detrimental to patient’s wellbeing
- potential threat to the health of others
- child must give permission if of sufficient understanding, or parent/guardian must consent.
What is the consequence of the discrepancy between healthy life expectancy vs life expectancy?
More people living with disability.
Can be older people with functional limitations.
The prevalence of chronic conditions rises exponentially through mid and later life.
What scales can be used to assess limitations of an individual?
The Katz, Barthel and Intrumental activities of daily living scales.
name some activities that are scored (as either dependent or independent) in Katz’s index of Independence in Activities of Daily Living
- bathing
- dressing
- toiletting
- transfering
- continence
- feeding
Describe specialist palliative care in the UK?
Involves health professionals who specialise in palliative care within an MDT.
It is delivered in hospitals, care homes, hospices or at home and is provided mainly to those with cancer.
Describe generalist palliative care in the UK
Available to anyone with advanced progressive disease likely to end in death, by practitioners who are not exclusively concerned with specialist palliative care.
Provided by GPs and hospital doctors, district
nurses, nursing home staff, social workers etc.
Which groups of people have higher incidences of chronic illness?
- older age - correlates with increasing comorbidities
- people with lower socioeconomic status
How do gerontology and geriatrics differ?
gerontology - concerned with studying the changes in the body and mind that accompany ageing
geriatrics - concerned with the diagnosis and treatment of disorders that occur in old age
compare the issues faced by patients suffering from COPD and those with lung cancer
COPD patients report a worse quality of life and have more cases of depression. COPD patients receive fewer visits from district nurses and are less likely to be aware of their prognosis.
Lung cancer patients receive support from specialist palliative care.
what are notifiable diseases?
Registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases.
examples of notifiable diseases
Acute infectious hepatitis Acute meningitis Anthrax Cholera Diphtheria Enteric fever (typhoid or paratyphoid fever) Food poisoning Infectious bloody diarrhoea Leprosy Malaria Measles Meningococcal septicaemia Mumps Plague Rabies Rubella Scarlet fever Smallpox Tetanus Tuberculosis Typhus Whooping cough Yellow fever
what is stress?
Occurs when the demands made upon an individual are greater than their ability to
cope
what are the 2 types of stress?
distress - negative stress: damaging and harmful
eustress - positive stress: beneficial and motivating
What causes stress?
Stressors:
acute vs chronic
internal stressors - physical, psychological
external stressors - environmental factors, work, social and cultural factors
describe general adaptation syndrome in response to stress
- alarm: when threat/stressor identified
- adaptation/resistance: body engages in defensive countermeasures
- exhaustion - body begins to run out of defences
How does the interaction model explain stress and how we cope with it?
- explains stress as an interaction between the individual and environment
- introduces the concept of appraisal
- impact of stressors influenced by coping methods adopted and past experiences with stressors
Biochemical signs of stress:
endorphin levels altered, increase in cortisool
Physiological signs of stress
shallow breathing, raised bp, increased acid production in stomach
behavioural signs of stress:
- increase in absenteeism, smoking and alcohol
- eating altered: changes patterns of food intake/stress-eating
- sleep disturbances
Cognitive signs of stress
- negative thought
- loss of concentration
- tension headaches
Emotional signs of stress
- tearful
- mood swings
- irritable
- agressive
- bored
- apathetic
What is the stress-illness model?
An individual’s susceptibility to disease or illness is seen as increased because an individual is exposed to stressors, which cause strain upon the individual and lead to psychological and physiological changes
what are some physical illnesses that are associated with stress?
- cancer
- heart disease: usually from type A personalities
- chronic fatigue syndrome
- peptic ulcers
- IBS
Causes of ageing population
- 1940s baby boom
- improved sanitation, housing, nutrition and medical interventions
- life expectancy rising
- falling fertility
- decline in premature mortality
= more people reaching older age while fewer children are born
what are the 2 distinctive types of ageing?
Intrinsic: natural, universal, inevitable
Extrinsic: dependent on external factors, e.g. smoking, air pollution, UV rays
Physical changes associated with ageing
Loss of skin elasticity. Loss of hair and hair colouring. Decrease in size and weight.
Loss of joint flexibility. Increased susceptibility to illness. Decline in learning ability. Less efficient memory. Affects sight, hearing and taste & smell.
Back pain red flags
- Age below 20 or above 55
- Thoracic pain
- Persistent night pain
- Night sweats
- Recent unexplained weight loss
- Saddle anaethesia/Sphincter disturbance
- Trauma
- Significant PMHx (Past Medical History)
In poorer countries, where does unsafe sex come in the list of risk factors leading to disease/disability/death?
What about in developed countries?
2nd
9th in developed countries
Primary prevention STIs
Reducing risk of acquiring STI
- Raising awareness of STIs
- Vaccinations (Hep B and HPV)
- One-to-One risk reduction discussions
Secondary prevention of STIs
Case finding: - Easy access to STI/HIV tests/treatment - Partner notification - Targeted screening o Antenatal screening for HIV and syphilis o National Chlamydia Screening program
Tertiary prevention of STIs
Reducing morbidity/mortality:
- anti-retrovirals for HIV
- prophylactic antibiotic for PCP
- Acyclovir for suppression of genital herpes
Causes of obesity
- Americanisation of diet & society
- Increasing dominance of car culture
- Longer working hours
- Over-consumption of food
- Grazing replacing meal times
- Replacement of water by sugary drinks
Why is diabetes a public health issue?
Mortality – Common underlying cause of death. Under-reported on death certificates.
Disability – Blindness. Renal failure. Amputation. (Neuropathy and peripheral vascular disease)
Co-Morbidity – Other physical and mental health conditions (e.g. obesity, depression)
Reduced quality of life – Chronic condition. Long-term self-management and monitoring.
Increasing in prevalence – Affecting younger age groups
Preventable – Evidence from RCTs that onset of diabetes postponed by diet/exercise/drugs
Inequalities in prevalence and outcomes
Links to bigger picture of obesity trends and climate change policies
Primary prevention of diabetes
- sustained increase in physical activity, change in diet, weigh loss
- focus on ethnic minorities and socio-economically deprived communities
- focus on culturally appropriate interventions
Secondary prevention of diabetes
- Raising awareness of diabetes and possible symptoms in the community
- Raising awareness of diabetes and possible symptoms in health professionals
- Using clinical records to identify who is at risk
- Blood tests to screen before symptoms develop – Done as part of CHD primary & secondary
prevention. Also at review of hypertension management.
Tertiary prevention of diabetes
Effective management of diabetes, supporting self-management
- self-monitoring
- diet: support for changing eating patterns
- exercise: support for increasing physical activvity
- drugs - support for taking medication
- education
- peer support
- foot clinics to monitor diabetic’s feet
factors that maintain overweightness
- Physical/Physiological – More weight = More difficult to exercise (arthritis, stress incontinence)
and diet - Psychological = Low self-esteem and guilt. Comfort eating. Being too scared to go to the gym
- Socioeconomic – Employment. Relationships. Social mobility. Price of healthy food
Describe the runaway weight gain train model
Runnaway weight gain train:
Rides on the downhill slope of obesogenic environments. Twin tracks are energy in and energy out. Default direction is downhill towards positive energy balance.
Ineffective brakes:
Several brakes act against increasing weight gain, such as social discrimination, personal discomfort, the body’s physiological responses attempting to combat weight gain, knowledge of risks of obesity. However the brakes are not strong enough to halt increasing momentum of the weight gain train.
Accelerators:
Vicious cycles in which weight gain becomes self-perpetuating, e.g. movement inertia - disincentive for movement. Mechanical dysfunction cycle - problems such as arthritis make exercise difficult. Physiological dysfunction cycle - low self esteem, lack of motivation to exercise. Dieting cycle - cravings for forbidden foods.Low socioeconomic status - obesity leads to reduced opportunities for jobs, education, marriage, social inclusion, as well as reduing the range of healthy choices/expensive physical activities.
Summary:
- obesogenic environment is driving the obesity epidemic…
- … despite the existing brakes against weight gain - (social, personal, cognitive, physiological)…
- …. which are outweighed by further accelerators in the form of a series of vicious cycles such as movement inertia, mechanical dysfunction, psychological dysfunction, cyclical dieting, and socioeconomic disadvantage - all associated with obesity and making weight loss difficult.
Describe the key concept of opportunity cost in the economic evaluation of health care?
- To spend resources on one activity means a sacrifice elsewhere
- the loss of other alternatives when one alternative is chosen
Health benefits that could have been achieved had the money been spend on the next best alternative intervention or healthcare programme
Describe the key concept of economic efficiency in the economic evaluation of health care?
- resources allocated between activities in such a way as to maximise benefit
What is meant by the acronym ‘QALYs”
- when is it used?/why is it useful?
Quality Adjusted Life Years
Used in some economic evaluations to measure health.
Combines length and quality of life.
Allows comparison of interventions that have different types of effects
What are some principles used by healthcare officials to allocate scarce resources?
Age, social status, prognosis, causation
4 types of economic evaluation of healthcare
- Cost minimisation analysis
- Cost effectiveness analysis
- Cost utility analysis
- Cost benefit analysis
How does cost utility analysis measure outcomes compared to cost benefit analysis?
Cost utility measures outcomes in QALY, benefit measures in monetary units
what is incremental cost?
This increment tells us how much our budget will increase by if we accept the new therapy,
and the anticipated health effects.
Calculation:
new treatment cost - old treatment cost
How is the effectiveness ratio of new treatments calculated?
incremental cost/old treatment cost
what is an adverse event in healthcare?
An incident which results in harm to a patient, which is not a direct result of their illness or some other event
What is a near miss in healthcare?
An event which arises during care and has the potential to cause harm but fails to develop further thereby avoiding harm
What are 3 reasons why an individual may deliberately deviaye from practices, procedures, standards or rules?
- Routine: cut corners
- Necessary to get the job done
- Optimising - for personal gain
What are some examples of strategies used in healthcare to reduce errors and harm?
- simplification and standardisation of clinical processes
- checklists and aide memoires
- information technology
- team training
- risk management programmes
- mechanisms to improve uptake of evidence based treatment patterns
Types of stress (6)
- Eustress vs distress
- Behavioural - alcohol, poor sleep, absenteeism
- Cognitive - poor concentration, negative thoughts
- Physiological - headaches
- Emotional - mood swings, tearful, irritable
- Biochemical - altered endorphin/cortisol levels
First Aid
D - danger: check area is safe
R - response: shout name, squeeze shoulders
S - shout for help (call 999)
A - airway: open it by tilting head back and lifting chub with 2 fingers
B - breathing: feel/listen for breath
C - CPR
Discuss sustainable healthcare
Global warming will lead to a change in the diseases we treat, and a change to the way we deliver care.
Care that reduces waste, recycling, thinking of environmental consequences.
Effect of meat/dairy industry on the environment and on health.
NHS carbon footprint = 25% of public CO2
Steps taken to end malnutrition in hospitals
- Older people must be assessed for the signs or danger of
malnourishment on admission and at regular intervals
during their stay - Introduce ‘protected mealtimes’
- Implement a ‘red tray’ system and ensure that it works
in practice - Use volunteers where appropriate
- Nutrition nurses/specialists and dieticians assess, monitor and support malnourished patients
Some limitations of virtue ethics?
Assessment of virtue is dependent on culture, non specific.
Notion of virtue it too broad to allow for practical application.
Possible conflicting virtues - e.g. honesty vs. kindness.
An emphasis on the moral character of individuals ignores
social and communal dimensions
What is the disability paradox?
People with profound disability report a high QOL:
- expectations adjust to current condition – there is a response shift, challenged health status leads to re-evaluation of what is important to life quality, lowered expectations translates to higher satisfaction
What is the iceberg concept of disease?
Suggests that the number of cases of disease ascertained is outweighed by those not discovered - assessment of the true burden of disease and need for services is often not easily done. Due to:
- pre-symptomatic disease
- undiagnosed/wrongly diagnosed
- diagnosed but uncontrolled
- diagnosed but controlled
ecological studies
population based data rather than individual data
cross sectional study
analyses data from a population at a specific point in time
RAAMbo in critical appraisal
Representative?
Allocated/Adjusted?
Accounted for?
Mbo - measurement blind or objective?
