Disease causation and the diagnostic process in relation to public health, prevention and health promotion. Flashcards
Issues that complicate early years intervention evaluation
- Study designs: Ethics of RCTs on preventative interventions, evaluating national interventions such as fortification of flour to improve pregnancy outcomes.
- Lack of control group/ poorly designed studies over time
- Difficult to measure absence: impossible to project over 20 years what disease prevalence/crime rates might be, how to show the absence of that?
- Lead times: Early years has long term follow up, studies are costly and complex to F/U over this time frame. E.G childhood education to reduce smoking and lifetime risk of lunch ca.
Five key areas of early years evidence
Eduction, Nutrition, Socio-economic benefits, Emotional and social supply, Combined programmes.
Education programmes in early years
Pre school education and parenting education.
Pre school:
Sylvia et al 2004. Cohort study, 3000 children across Europe.
Pre school attenders had higher educational and social attainment.
Quality of schooling did affect attainment
Socioeconomic status did not affect benefit gained by preschool
What parents did with children had more affect than SE status, e.g reading.
Health and nutrition in early years
LBW- increases risk of chronic conditions. Evidence suggests maternal nutrition affected weight, Ca and folate supplements have shown positive outcomes. (Healthy start scheme) Smoking doubles risk of LBW.
Breastfeeding- increased passive immunity, lower SIDs, Reduced obesity, diabetes and atopy, greater bonding, reduced risk of breast and ov cancer in mothers.
Childhood immunisations
Interventions to reduce injuries e.g cycle helmets.
East Sussex childhood injuries picture
- ES 67% of admission due to accidents in under 5s happened within a home.
- High rates in ES compared to England. Particularly bad in deprived areas of Hastings and Rother.
- Higher rates of falls, and accidental poisonings.
- East Sussex fire and rescue service offers home visits for safety checks, education and fitting of safety equipment
Socio- economic benefits in early years
Acheson Report
Families with young children are at increased risk of poverty:
Need affordable childcare
Increase benefits and availability of benefits for pregnant women and families with young children.
Emotional/social support in early years
Evidence for community family support programmes.
Aim to improve parent wellbeing, and children physical, emotional and cognitive development.
European Early Promotion project (2005) found healthcare worker training to support parent infant relationships led to fewer psychological problems in children.
Combined programmes in early years
Programmes that combine multiple aspects.
Sure start (UK)/ Head start (USA)
Pre determinants of health
Factors that indicate/contribute to determinants of health.
Material: Food and water, clean air, Income, housing, Green spaces.
Policy: Minimum wage, Occupational health, Maternal services, Childcare, Benefits and education.
Society: Social cohesion, values and attitudes, ethnic diversity and tolerance, language ability.
Social cohesion
Pre determinant of health.
Society with strong social cohesion- strong interactions, supportive, few inequalities.
Wilkinson (1996) reduced income differentials, greater solidarity, and social cohesion lead to improvements in life expectancy.
Can influence and be influenced by health policy. E.g private insurance could increase inequality.
Motivational interviewing
Motivational interviewing: Rollnick and Miller (1990s) counselling based on the stages of change model. Explores models about why an individual may be ambivalent about behaviour change.
Evidence in drug misuse, smoking cessation, eating disorders.
It utilities: empathy, highlight discrepancies, roll with resistance (respond with understanding not confrontation), build self efficacy.
Individual behaviour change techniques
Motivational interviewing, CBT, incentives
Incentives
Marteau et al 2009
vouchers to encourage smoking cessation, points scheme for healthy school meals (UK)
money towards healthcare costs in improve adherence (USA)
Financial rewards to avoid STIs (Tanzania)
Financial rewards for achieving weight loss targets (Italy)
Incentives- pros and cons
+ effective in short term
+ potential effective long term combines with other activities
- Moral concerns- bribery
- overall paternalistic
poor use of public funds
Define social marketing
Use of techniques of commercial marketing ti sell a health message
Approach to social marketing
- Identify target group: segmentation tactics (define group by lifestyle choice rather than disease state)
- Research target group: survey and focus groups. Assess attitudes, habits, needs.
- Competitive analysis: competition is anything that may encourage the unhealthy behaviour e.g tobacco marketing
- Set objectives
- Develop a message: pretest with target group
- Sell the message
- Evaluate
Four Ps of marketing
Product : It must be clear what is being sold.
Price: financial na opportunity costs
Place: channel used affects exposure to certain groups
Promotion: medial and advertising, e.g TV, Magazine, partnership with companies.
Strengths and weakness of social marketing
+ Based on understanding of the target group
+ Clear objectives
+ Uses successful commercial techniques
- Assumes behaviour is individual choice
- Danger of portraying partial message e.g “Just say no” catchier than well rounded pos/neg of drugs
- Can reinforce same stereotypes as commercial marketing e.g health = positive physical attributes or = positive moral attributes
Reasons for public involvement
- Improved concordance
- Empowerment
- Democracy
- Acceptability
- Ownership and sustainability
- Integrated approaches: More complex issues are tackled with community members insights as a problem solving tool.
- Better decisions
Absolute vs relative poverty
Absolute: Lacks basic material needs
Relative: lives under 60% of median national income
Factors that reinforce the effects of deprivation
Social exclusion, discrimination, employment, stress, antenatal effects.
Local strategic partnerships
Statutory multi agency bodies
Functioned in areas of LA
Encourage collaborative working and community involvement
Statutory, voluntary, community and private sectors
Why do we set targets in healthcare?
Adaptation of management practices and culture
Improvement of performance and accountability
Consistency
Levels of target setting
Individual e.g personal PDP
Organisational e.g LA target for provision of affordable housing
National e.g Public Service Agreement- Given set minimum target for sectors in return offer investment, schools/health etc
International: WHO’s SDGs, Health for All targets
Criteria for good targets
Specific
Measurable
Achievable
Relevant
Timely
Pros and Cons of targets
+ Provide a focus for performance improvement
+ Explicit priority setting - provides common agenda for a team.
+ Provide accountability
+ Level playing field for organisations under comparison
+ Targets reflect organisations priorities and goals
+ Share good practice
+ Increase interest in particular areas
- Might not be measurable (particularly in health), such may take focus away from some health areas
- Gaming (distortions of practice). e.g reclassifying trolleys in ED as beds to meet 4h targets.
- Distort priorities. Areas where targets are not easily set may be neglected
- Disengagement from staff when targets set top down.
- Costs
Things to consider when setting targets
Closely correlate to clinical outcomes
Select with consensus from team- evidenced, feasibly, acceptable
multiple time frames
Consider which priorities we want the public to know are important/ form of education public on important targets
Targets are practical expression of guidelines
Donabedian’s Framework
(2005)
Framework to evaluate health programmes.
Structure/input, process and outcome measures/targets applied to each to evaluate programmes.
Programming approach
Epidemiological paradigm
Long term effects of environmental exposures during critical periods.
E.g Barker Hypothesis- in utero malnutrition as a risk factor for CHD
Adult risk factor approach
Epidemiological paradigm
Impact of lifestyle and behaviours
Life course approach
Epidemiological paradigm
Combines elements if programming and adult risk factor approach.
Various risk factors across gestation and life affect health and disease.
Limitation:
Little research on very longitudinal cohorts.
Screening: Definition
Aim: Identify people who can be helped in the early stage of disease.
“identify apparently healthy people in the early stages of disease/increased risk. Such that they can be offered information, or further tests and treatment.”
NSC: National Screening Committee
UK Screening programmes
Antenatal:
Early- HIV, Syphilis, hepatitis B, Rubella, Haemolytic diseases, Sickle cell, thalassaemia.
Mid- Downs, Fatal abnormalities.
Neonatal:
Heel prick- PKU, Congenital hypothyroid, sickle cell and thalassaemia, CF, MCADD
Hearing screening
Heart defect, cataract, Malformations, cryptorchidism, hip dislocation.
Childhood:
Growth- turners, growth hormone deficiency
Hearing
Vision
Adult:
AAA- one off USS at 65.
Breast ca- 3 yearly mammogram 50-71
Cervical ca - HPV test, 25-49, 3 yearly
Bowel ca- Feacal occult blood, 60-69, 2 yearly.
DM retinopathy- 12 year + with DM, annually.
Non screening secondary prevention programmes
Health checks
Childhood obesity
Chlamydia
Prostate ca
TB
Reasons for setting high sensitivity for screening tests
Significant disease with definitive treatment
Rick of infectivity to others
Subsequent test cheap/low risk
