dph Flashcards
define epidemiology
- study of the distribution of (oral) diseases in a population
why is epidemiology important? (3)
- helps population needs assessment to inform PH policies, planning, resource allocation
- assesses impact of health promotion activities/policies
- identifies changing patterns and population risk factors
define normative need
- professionally defined health needs
- assessed with clinical measures (eg indices for national surveys)
define felt/perceived need
- lay person perception of their need, “wants”
- assessed with self-rated questionnaires
define expressed need
- felt/perceived need translated into action by utilising healthcare services or requesting information
- “demand”
define comparative need
- need is not evenly distributed among similar groups of people
- assessed by comparing oral health needs between groups of people
what is an index? (3)
- method of quantifying disease
- relative numerical value (usually) describing a population on a scale
- allows comparison with other populations
properties of an ideal index (8)
- objectivity
- acceptability
- simplicity
- amenable to statistical analysis and interpretation
- reproducibility
- validity
- reliability
- precision
give some examples of indices in oral health (up to 8)
- DMFS/dmfs
- ICDAS
- gingival index, plaque index
- IOTN
- BEWE
- BPE or CPI
- trauma index
- PUFA
define prevalence (of disease)
amount of disease present at a given point in time (often as a percentage)
define incidence (of disease)
change in disease in a given period of time (rate)
what are the advantages and limitations of using perceived need?
+:
- person-centred, accounts for psychological aspects and QoL
- cheaper, less complicated to assess
-:
- subjective, less reliable than normative need
- influenced by individual’s characteristics
what are the main two types of epidemiological studies?
observational and interventional
list different types of observational studies (4)
- ecological
- cross-sectional
- case-control
- longitudinal
list different types of interventional studies (3)
- randomised controlled trials
- non-randomised controlled trials
- pre-post study
what is a observational study and its general pros/cons?
- researcher collects information without influencing events
- = cost-effective, quick, large samples
- = cannot prove causality
what is a interventional study and its general pros/cons?
- researcher deliberately influences events and investigates the effects of this
- = can establish causality
- = more expensive, dropout rate, ethical considerations, not applicable to all populations
what is an ecological study and its specific pros and cons?
- observational study comparing trends in different populations
- = generate hypothesis, able to compare
- = no individual data, bias/ecological fallacy, difficult to control for confounders
what is a cross-sectional study and its specific pros and cons?
- observational study where the population is assessed randomly at the same time point (eg ADHS)
- = individual data and control of confounders, assess multiple outcomes, hypothesis generation
- = cannot prove temporality or causality
what is a case-control study and its specific pros and cons?
- observational study with pts assigned to case/control groups and matched by potential confounding factors
- = efficient for rare diseases, individual data
- = hard to do retrospectively, recall bias, rarely proves temporality
what is a longitudinal study and its specific pros and cons?
- observational study with collection of data at different time points
- = demonstrates temporality (establish RFs and disease incidence)
- = long if prospective, may miss some confounders
what is a randomised controlled trial and its specific pros and cons?
- interventional study with homogenous randomly assigned intervention/control groups +/- blinding
- = causality
- = may be long, risk of high dropout
what is a non-randomised controlled trial and its main disadvantage?
- weak interventional study with non-random intervention and control groups
- risks bias as it lacks randomisation
what is a pre-post study and its main disadvantage?
- interventional study assessing a group before and after an intervention
- any changes in disease outcome cannot fully be attributed to intervention
describe the reasoning behind a pilot study (3)
- tests organisation of a study - identifies problems and adjustment of survey design
- training and calibration of personnel
- estimates level of disease and guides sample size
how is our population changing in the UK? (2)
- generally increasing
- > 65yo age group increasing faster than the rest of the population = aging population
what is the dominant age group in London?
16-64yo (working age)
what are the 7 domains of deprivation?
- income
- employment
- education
- health
- crime
- barriers to housing and services
- living environment
define health inequalities
systematic, unjust differences in health between people/groups that may be considered unfair
list (categories of) social determinants of health (up to 6)
- economic stability
- neighbourhood and surroundings
- education
- food
- community and social context
- healthcare system
describe the social gradient of health (3)
- lower socioeconomic position often leads to worse health
- aggregation of unhealthy behaviours is socially patterned - lower SE classes more likely to engage in health-risk behaviours than health-promoting ones
- often due to factors outside of individual’s control (social determinants) - not everyone has the same opportunities to live a healthy lifestyle
define health promotion (3)
- positive concept
- the process of enabling people to increase control over the determinants of health and thereby improve their health
- making healthier choices easier and unhealthy choices more difficult
what are the basic requisites for health according to the Ottawa Charter? (8)
- peace
- shelter
- education
- food
- income
- stable eco-system
- sustainable resources
- social justice and equity
what is the Ottawa Charter for Health Promotion?
- WHO 1986 consensus statement
- identifies 5 components of health promotion action and basic prerequisites for health
what are the 5 components/action areas for public health? (Ottawa charter)
- build healthy public policy
- create supportive environments for health
- strengthen community action for health (empowerment)
- develop personal skills and social development
- reorient health services
what is meant by “healthy public policy” and give examples (Ottawa Charter)
- putting health on the agency for policy makers in all sectors and at all levels
- investing in public transportation
- tobacco taxation
- age restrictions on certain products
- advertisement and product placement restrictions
give examples of creating supportive environments for health (Ottawa Charter) (4)
- availability of health-promoting resources at work/uni/school - eg gyms, cooking classes
- playground and sport safety
- addressing pollution (eg ULEZ)
- no smoking areas
what are some issues with using health education/information to try and create behaviour change? (5)
- assumes that having knowledge will lead to attitude/behaviour changes
- “top-down” technique
- paternalistic and prescriptive, often using threats and fear arousal
- individualistic and victim blaming - ignoring the broader social context
- assumes homogeneity among receivers - it is most effective on the most educated and economically advantaged
what are some barriers to behaviour change for health promotion? (7)
- media advertisement (false advertising, unhealthy products)
- social norms and peer pressure
- financial factors (affordability)
- availability and accessibility of healthy vs unhealthy choices
- public policy
- financial interest of industries
- science manipulation by industries
is oral health education effective? (4)
- increases knowledge but uncertain effects on behaviour/health
- does not produce long term changes when used alone
- most effective on those who have the resources = may increase health inequality
- little evidence on cost-effectiveness
(But should still be done by HCPs)
what are downstream PH interventions? (what, who, where)
- treatments, prevention, health education for those ALREADY experiencing some disease/disability (small segment of population)
- done in clinic
- consumes most resources
what are midstream PH interventions? (what, who, examples)
- preventive interventions targeting at-risk populations (but not all in the group will be at risk)
- community level
- eg:
– community development
– training other professional groups (carers, teachers)
– media campaigns
– school dental health education, FV, supervised toothbrushing
what are upstream PH interventions? (what, how, examples)
- healthy public policy interventions (governmental, institutional, organisational) directed at ENTIRE populations
- needs adequate support through tax structures, legal constraints and reimbursement mechanisms
- eg:
– sugar, tobacco taxation
– age restrictions
– national policy initiatives
– legislation/regulation
define health advocacy
-informing and educating senior government, community leaders (decision-makers) about specific issues
- setting the agenda to obtain political decisions that improve the health of the population
how can dentists help with upstream and midstream interventions? (4)
(health advocacy)
- inform and educate decision-makers about specific oral health-related issues and how to minimise the root causes
- assess health determinants and community health needs and marshal resources/policy to respond to them (make healthy choices easier)
- supporting skills training of other professionals
- establish an evidence base on cost-effectiveness of interventions to support financing decisions
what kinds of groups may be targeted by community-based programmes? (4)
- prenatal, pregnant
- children, young adults or older people (age)
- culturally/linguistically diverse backgrounds
- special care (homeless, LDs, mental health)
why do we need to understand the local community (eg culture, religion, etc) for implementing community-based programmes? (2)
- to ensure the programmes are culturally sensitive
- improves acceptability and accessibility for community
define evaluation (of oral health promotion intervention)
“the process of determining whether programmes or certain aspects of programmes are appropriate, adequate, effective, efficient for the purpose of the programme”
what are the three different types of evaluation?
- process evaluation
- outcome evaluation
- economic evaluation
describe process evaluation (what, when, why)
- assesses how well the programme is working:
– extent to which it is being implemented
– accessible and acceptable to target population? - starts as soon as programme is implemented and throughout operation
- = gives early warning for any issues
describe outcome evaluation (what, when, why)
- measures effect of programme on target population:
– progress in outcomes the programme addresses
– target population behaviours - starts after programme has made contact with at least one person/group in target pop
- = shows if programme is meeting objectives
describe economic evaluation (what, when)
- assesses value gained from vs costs of implementing an intervention (cost analysis)
– resources used and costs
– outcomes - at beginning and during programme operation
give some examples of quantitative evaluation methods (3)
- surveys and questionnaires
- secondary data analysis
- economic evaluation
give some examples of qualitative evaluation methods (3)
- interviews
- focus groups
- scenarios
what does ROI mean?
return on investment - measure of cost-effectiveness of interventions
what are the main principles of the NHS? (7)
- comprehensive service available to all
- access based on clinical need (not ability to pay)
- high standards of excellence and professionalism
- reflect needs and preferences of pt/family/carer
- partnership working with other organisations/communities for pt interests
- cost-effective and fair use of resources
- accountable to public communities and pts
what are the different types of dental services in England? (7)
- general dental services
- community dental services
- out of hours, urgent care dental services
- hospital dental services
- domiciliary care
- prison dentistry
- private dental care
where does most of the funding of dental services come from?
- taxation mainly
- NHS pt charges
what is the dental quality and outcomes framework (DQOF)?
- measures quality of care provided
- 3 domains = clinical effectiveness, pt experience, safety
- part of NHS contract value with a practice
according to studies, why should we improve access to dental care? (2)
- at any age, routine attenders have better-than-average oral health and lower DMFS scores
- the longer routine attendance was maintained, the stronger the effect
define access (to dental care)
- timely use of personal health services to achieve the best outcomes
- the “fit” between the patient and healthcare system
what are the 5As affecting access to care?
- available (geographical)
- accessible (travel and physical)
- acceptable (welcoming, quality, language, etc)
- affordable (direct and indirect costs)
- accommodating (flexible opening hours)
briefly describe the access model (3)
- environmental factors (availability, SE, etc) determine population characteristics (knowledge, resources and needs)
- population characteristics affect utilisation of health services, affecting health outcomes and satisfaction
- positive feedback loop - if pts are satisfied, they’ll return for further care
what is the inverse care law?
those who most need care are less likely to utilise care services
give some barriers to accessing dental care in the UK (9)
- difficulty getting an NHS appointment
- cost (varies by country)
- anxiety
- lack of perceived need
- surgery/visit features and dentist characteristics (= satisfaction)
- availability
- knowledge of NHS services
- MH - LDs, mobility limitations
- others (transport, etc)
how can we minimise barriers to access of dental care? (5)
- address broader social determinants of health (reduce poverty, income inequalities)
- improve education = increased average income and awareness
- exempt status (financial)
- improve information available with incentives to attend
- outreach dental care - mobile caravans, domiciliary services, community initiatives
what are health systems? (2)
- all organisations/people/actions whose primary intent is to promote, restore or maintain health
- efforts influencing determinants of health and direct health-improving activities
what are the universal laws of healthcare systems (Cheng)? (3)
- no matter how good the healthcare in a particular country, people will complain about it
- no matter how much is spent on healthcare, doctors and hospitals will argue that it is not enough
- the last reform always failed (always need a new reform)
(no such thing as a perfect healthcare system)
what is universal health coverage?
everyone, everywhere, able to access an essential package of quality health services without facing financial hardship as a result
what are the 3 main dimensions of universal health coverage?
- population = who is covered?
- services = which interventions are included?
- financial protection = what proportion of costs are covered by pooled funds?
what are 3 challenges to universal health coverage?
- availability of resources (not all technologies and interventions are available nationally and internationally) - what counts as essential?
- over-reliance on direct payments at the time people need care (can lead to financial hardship) - when should payments be made?
- inefficient and inequitable use of resources (20-40% wasted)
what is the HRH: Workforce Strategy 2030?
- global strategy aiming to progress towards universal health coverage and the UN sustainable development goals
- by ensuring equitable access to health workers within strengthened health systems
what is meant by “making every contact count”?
- every time a HCP contacts a patient, it is an opportunity for health promotion and prevention, lifestyle improvement and reduction in health inequalities
what are the steps of the rational planning model? (6)
1 identification of need
2 options
3 decisions of policy
4 identification of resources
5 implementation
6 evaluation
(and repeat)
what information is needed for planning health services? (4)
- population profile/demographics
- disease levels (epidemiological data)
- public concerns (priorities, demand)
- existing service provision/use
what are some barriers to providing fluoridated water nationally? (3)
- safety concerns, risks of toxicity (although only 0.7ppm)
- anti-fluoride associations
- political will
define proportionate universalism
resourcing and delivering of universal services at a scale and intensity proportionate to the degree of need
pros and cons of upstream intervention
+ = addresses social determinants of health, higher ROI
- = influenced by political will, can enhance health inequalities
pros and cons of midstream intervention
+ = more cost-effective than upstream, better uptake/targeted, fewer political issues
- = difficult to set target population, evidence base needed
pros and cons of downstream intervention
+ = individualised
- = very few targeted, low ROI, patient cost
describe trends in service utilisation by age and gender (4)
- ADHS 2009 = 3/4 report attending every 2 years, increases with age then decreases
- CDHS = 1/3 attend before 2yo (constant)
- females more likely to be regular attenders and attend for preventative care
- males more symptomatic
describe trends in service utilisation by ethnicity (3)
- inequality in use and for specific procedures (tend to favour extractions)
- BAME visits more likely to be symptomatic
- ADHS 2009 = all ethnic minorities less likely to visit regularly
describe trends in service utilisation by SE class (2)
- routine and manual occupation households less likely to be regular attenders, more likely to be symptomatic
- middle classes visit earlier and more frequently for preventative tx
describe general trends in caries epidemiology (and DBOH-specific) (up to 9)
- decline in prevalence and severity over past 30-40years in all ages
- most have low/no carious cavities, small percentage have higher levels
- progression of early lesions is less frequent and slower
- lesions are generally smaller and cavitation tends to occur at a later age
- more common among the least affluent and least educated
- more common in Asian children in England (diet?)
- most lesions are pit and fissure lesions rather than smooth surfaces
- most caries occurs in adults now instead of children
DBOH = root caries increases with age
upstream interventions for caries (4)
- water fluoridation (also salt fluoridation in Europe, milk fluoridation in Blackpool)
- public health policies - sugar tax
- nutritional guidelines emphasising low sugar intake, balanced diet
- education and awareness campaigns on OH and dental checkups
midstream interventions for caries (4)
- school-based programmes - FV, toothbrushing lessons, OHI
- affordable dental care - subsidised preventive and restorative tx for low-income families
- community oral health promotion programmes - free dental checkups, workshops
- targeted health communication
downstream interventions for caries (5)
- OHI
- FV
- fissure sealants
- regular dental check ups
- diet advice and risk factor discussion
what conditions is excess sugar a risk factor for? (5)
- obesity
- diabetes
- CVD
- cancers
- caries
describe epidemiological trends relating to sugar (and DBOH-specific) (5)
- 1/8 of adults achieve 5% sugar of dietary energy recommendation
- highest sugar intake in children (4-18yo)
- sugar-sweetened drinks providing 30% of free sugars in 11-18yo
DBOH:
- intake of free sugars decreasing over time in children but still above recommendations
- fewer children and young people report drinking sugar-sweetened beverages, and those drinking them are consuming less
upstream interventions for diet and sugar intake (5)
- food policies and legislation - decrease fat/sugar/salt in processed food, mandatory food labelling
- agricultural subsidies towards fruits and vegetables - more affordable and accessible than unhealthy food options
- urban planning - easy access to supermarkets, farmers’ markets
- taxation and pricing policies - sugar, salt, subsidise healthier options
- labelling and menu board information in restaurants and on food
midstream interventions for diet and sugar intake (5)
- food banks
- free school meals for 20% most deprived individuals
- community-led gardens and cooking classes
- health promotion campaigns for healthy eating
- community support group for those making dietary changes
downstream interventions for diet and sugar intake (4)
- diet advice and pt education
- behaviour change programmes
- mobile health applications (trackers, recipes, tips)
- pt education materials (brochures, flyers, online resources)
describe epidemiological trends relating to oral cancer (and DBOH-specific) (5)
- risk increases with age
- RFs = low SE background, alcohol, poor diet, pollution, genetics, (chewing) tobacco
DBOH:
- Scotland - lower SE groups 3x greater risk
- SE Asian groups in London have higher risk
- oropharyngeal cancer >3x higher in men
upstream interventions for oral cancer (5)
- tobacco control policies - taxation, advertising bans, smoke-free areas, age restrictions
- alcohol regulation - taxation, minimum legal age restrictions, limits on hours of sale
- HPV vaccination to vaccinate everyone (not current)
- PH campaigns to raise awareness on risk factors
- nutritional policies - promoting good balanced diet, 5/day
midstream interventions for oral cancer (4)
- screening programmes - at risk populations
- HPV vaccinations currently in schools
- community outreach programmes - education on RFs, importance of early detection
- workplace health initiatives, esp where workers are exposed to carcinogens
downstream interventions for oral cancer (3)
- smoking cessation advice/referral (VBA)
- advising alcohol reduction
- discuss risk factors, pt education
what conditions is tobacco use a risk factor for? (4)
- lung cancer and other cancers
- respiratory disease
- heart disease
- periodontal disease and peri-implantitis
describe epidemiological trends relating to tobacco use (and DBOH-specific) (3)
- most take up smoking in teens or early twenties
- decreasing in the UK but still high, more men than women
- DBOH - 2.5x higher prevalence in routine and manual occupations
upstream interventions for tobacco specifically (3)
- tobacco control policies - taxation, advertising bans, smoke-free areas, age restrictions
- plain packaging +/or health warnings on packaging
- agricultural subsidies for alternative crops and farmer education
midstream interventions for tobacco specifically (4)
- campaigns - educating on risk, Stoptober
- school-based programmes
- workplace smoking cessation programmes - counselling, medications
- community-led initiatives and support groups
downstream interventions for tobacco specifically (4)
- smoking/paan cessation advice/referral (VBA)
- pt education, discussing RFs
- GP referrals
- digital health interventions (apps, texts, online resources)
what conditions is alcohol consumption a risk factor for? (4)
- hypertension
- liver cirrhosis
- CVD
- cancers
(social problems - family violence, crime, trauma)
describe epidemiological trends relating to alcohol consumption (and DBOH-specific) (3)
- 2x males than females drank >14u/wk
- managerial and professional occupations most likely to drink alcohol
- DBOH = adults living in least deprived areas more likely to drink >14 units in a normal week
upstream interventions for alcohol specifically (4)
- pricing policies - minimum unit pricing, taxation
- regulation of availability - restricting to certain hours
- marketing restrictions - advertising, sponsorships, promotions
- legal drinking age law
midstream interventions for alcohol specifically (5)
- education and awareness campaigns, dry January
- school and workplace programmes for prevention and support
- community-led initiatives
- offer screening and brief interventions for risky alcohol use in primary care settings
- training other HCPs on recognising alcohol misuse
downstream interventions for alcohol specifically (4)
- referral to rehabilitation services
- behaviour change methods with patients
- mental health support referral if appropriate
- pt education, discussing RFs
describe epidemiological trends relating to the aging population (and DBOH-specific) (3)
- the number of >65yo is increasing faster than the rest of the population
- people are retaining more of their natural teeth and for longer
- DBOH - root caries increases with age and amongst independently-living older adults
upstream interventions relating to health of older and elderly people (3)
- public health policies - access to dental care, inc those in long-term care facilities (insurance coverage expansion, funding)
- community water fluoridation to help reduce caries incidence
- free dental check ups (legislation)
midstream interventions relating to health of older and elderly people (4)
- regular oral health assessments in community settings - eg care homes, disabilities or severe illness
- mobile dental services
- interprofessional collaboration - dental and general health
- education for caregivers and families
downstream interventions relating to health of older and elderly people (2)
- regular dental check up - xerostomia, root caries, periodontal
- pt education and discussing RFs
