exam Flashcards
What is the aim of public health?
Reduce disease and promote health?
What are the different golden and dark ages in history? When was NHS established?
1st Dark Age of Public Health = poor hygiene, epidemics = punishment from god
1st Golden Age of Public Health = Hippocrates – “Waters, Airs & Places” – linked disease to environment
2nd Golden Age = Romans – Hygiene Systems – Sewers, Baths, Aquaducts
2nd Dark Age = Tudor/Victoria Times – Plagues & suspicions etc
3rd Dark Age = Industrial Revolution
3rd Golden Age = Health Reforms via. Charles Thackrah
NHS –> 1948
What did Semmelweis do to improve health?
Sanitation techniques such as washing hands reduced mortality
What did Edward Chadwick realise?
There is a relationship between poverty and disease
What is the Kocher’s principles for causing disease?
1)Organism needs to be present at the time of the disease
2) The organism should be isolated and grown in culture
3) The organism should be inoculated into healthy individual and cause same disease
4~) be able to isolated the same organism from the inoculated individual
Marmot review aimed to identify ways to reduce health inequality in England and Europe. What was the outcome findings?
Need to close the gap in financial and resource inequalities
Need to improve living and working conditions
There is a relationship between health and social inequalities
What aims were produced from the marmot review?
All children to have best start to life
All children and young adults to have best possibly opportunities and be able to control there lives
For everyone to have equal employment opportunities
Ensure healthy standards of living
Create and maintain healthy and sustainable communities and places
Strengthen the role and impact of ill health prevention
What are the 3 pathways that affects life course approach?
Behavioural, biological and physical pathways
What are the 5 types of health inequalities?
1) Political : Equal rights to health
2) Life outcomes: Equal quality of health
3) Opportunity: Equal access to healthcare
4) Treatment and responsibility: Equal quality of treatment
5) Participation: Equal consideration in health outcomes
What are the social determinants of health?
The condition in which patients are born, grow, live, work in and age. Also including health systems
The circumstances are shaped by the distribution of money, power and resources
What is the asset approach to health care?
Half glass full approach
Appreciating the skills, knowledge, local expertise of the community
What does community action allow?
Allows people to gain control of there local situation
To be political advocates for the health of there communities
What is a statuary organisation?
Organisation that is set up by law and is publicly funded by tax payers
What is voluntary organisation?
Charity funded and largely independent from government and law
How does WHO define health?
The complete mental, social and physical well being and not merely the absent of disease or infirmity
What is social marketing in health?
To give health advice and address lack of knowledge
What is social norm marketing?
It is addressing and challenging the social norms and misconceptions such as binge drinking.
To bring people ideas and views in line with the actual facts.
What should be the names of intervention?
Educate patients on the actual health norms and do not use negative words/tactics
What is a society?
A group of people living together in a more or less in a community with shared customs, laws and organisations
What is the aim of health promotion?
To increase and promote people taking control of there own health and improving there health.
What are the different prevention levels of disease?
Primary prevention: prevent the onset of the disease
Secondary prevention: identify and treat the disease
Tertiary prevention: minimise the damage of the disease –> chronic
What does behavioural change approach involve and what is the outcome ?
It involves promoting people to make healthy decisions
It relies on the individual person to change attitude and behaviour
Also need to ignore the social determinants of health such as poverty
What does educational approach to health involve and what is the outcome ?
Informing people to make healthy choices
Also allowing people to acquire skills and knowledge to be health such as healthy cooking
Outcome:
Reliant on the individual to change there behaviour and attitude
Also need to reject the social determinants of health such as poverty
What is the aim of the empowerment approach to health?
Allows patients to address/identify there concerns and tackle them
What does empowerment approach to health living involve and what is the outcome?
Patient have to acquire control and skills
Have to change policies and environment to help with the change of life style
Outcome:
To recognise the social determinants of health and tackle them
What is the society change approach to health?
Change society by laws not by individuals
What is the social cognitive theory?
That individual acquisition of knowledge can be directly related to the observation of others in a context of social interactions, experiences and medial influences
For example from role models
What is deprivation?
The damaging lack of basic things that is seen as a necessity
What is deprivation based on? (7)
Employment Income Education, skills and training Health and disability Barriers to housing and services crime Living environment
What are the 3 main causes of child mortality?
Pneumonia: 18%
Pre-ternal (pre-birth) complications: 14%
Diarrhoea: 11%
What is liberation paternalism?
Guided choice by architecture rather than coercion (tax, law etc)
Example is nudge scehem
Define epidemiology?
It is a study of the patterns, causes and effects of health and disease conditions in a defined population
What is the confounding variable?
Adversely effects both the independent and dependent variable which can make the results incorrect
What is error?
The difference between the estimated/measured value and true value
What is bias?
Is a systematic non random deviation from the results and interference from the truth
What is diagnosed bias?
Is diagnosing based on the exposure
What is information bias?
Bias based on measurement error/ distorted evaluation of information.
What leads to misclassification bias and what is it?
Occurs when data is categorised
Surrogate, recall and interview bias all leads to it
What is selection bias?
The selection of people, groups or data for analysis such that proper randomisation has not been achieved or there is not proper representation of the whole population being studied
What is the two types of selection bias?
Participation bias
Self selecting bias
What is causality?
The relationship between cause (1st event) and effect (2nd event)
What does counter factual mean?
Consider the possibility of alternative outcome
What is the intention to treat process in randomised control trials of drugs?
A method of analysis where every patient is randomly assigned to one of the treatment and all are analysed together whether or not they complete or receive the treatment
Why is intention to treat process done?
It reflects the normal practice of people. It is the most realistic observation of people in real time. Reflects real practice
What is randomised trial?
Assigning people in a research study to different groups without taking similarities and differences into account.
Removes selection bias
What is blinding in terms of research?
Keeping study participants, those managing them, those analysing the data unaware of the assigned treatment
What is the effect of doing blinding in research?
Avoid selection bias by the participant
Avoids observer bias by the caregiver
Reduces influence/expectations of the treatment as they don’t know if they have it
Double blinded as both the participant and the caregiver does not know
What is prevalence?
The number of cases of a disease over a given time
What is incidence?
The number of new cases in a given time
What is the aim of case series?
The tracking of subjects with a known exposure such as someone who is receiving a particular treatment or smokes
What are the limitations of case series?
Not scientific: unable to make a hypothesis
Affected by observer bias
Usually in descriptive study
What is ecological Study and What are the pros and cons of the ecological study?
Ecological study is at a group level (community and population) observation with a least one variable measured.
Pros:
Fast and cheap –> Can use already available data
Can create new hypothesis
Very good for very large groups
Cons
May not involve a true representation of the population
Ecological fallacy –> make a generalized statement ( fall assumption) about a individual from something collected from a group.
What is descriptive studies?
Describes cases or population
About a commonly involves case series where the exposure is known,
Affected by observer bias
What is the use of descriptive studies?
To formulate hypothesis about prevalence
To describe prevalence
What is cross sectional study?
It representative of a whole population. The data is taken from a whole population or a representative sub type.
It examines the relationship between disease (or other health related state) and other variables of interest
What is the pros and cons of cross sectional study?
Pros: fast at able to estimate a populations prevelance
Cons
Representative at only a specific point in time
Cannot estimate incidence
What is a cohort study?
Longitudinal study where multiple observations of a cohort group over time is made
What does cohort mean?
A group of people that share a common characteristic or exposure such as smoking, born on a certain date and so forth.
Does a large cohort require a long duration of observation or small duration?
Small duration
What do you measure at the end of a cohort study?
Measure the rate of exposure
Cause of the disease
What are the pros and cons of cohort study?
Pons |t is the best observation study Can follow the participants over time It can test of multiple outcomes Good for rare exposures ( causes) Cons: slow and expensive Can be follow patients for a number of years and see no sign of the disease if its rare --> can be infective for rare disease
What is the aim of the case controlled study?
To test how a drug works
What are the different factors needed in a case controlled study?
Case group –> people with the disease
Control group –> people without the diseae
Both are exposed to the variable
Both are compared to identify the exposure (cause)
Retrospectively disease diagnosis is know
Odds ratio is done between the two group
Outcome is already know
Exposure is what is trying to be figured out
What is the pros and cons of case control study?
Pros Fast as no follow up Good for rare disease and exposure Cons Selection and participation bias Also very hard to find a group of people that are exactly the same without having a common disease --> control group
What is the golden standard trial?
Randomized control trial
What is the process of testing a specific intervention in randomised control trials?
Representative of a whole population–> split into treatment and non treatment group
It is done blinded to prevent selection and observation bias
What are the pros of randomised control trails?
Strongest evidence for causality
Randomized so removes selective and observation bias
Blinded so removes selective and observation bias
What are the cons of randomised control trial?
Very expensive and highly unethical
What study allows odds ratio?
Case controlled studies
What is odds ratio measuring?
Measure of association of exposure and outcome between two groups
What is the effect if odds ratio =1?
Exposure has no effect on the outcome
What is the effect if odds ratio is greater than 1?
The exposure increases the risk of outcome
What is the effects if odds ratio is
Then exposure will decrease the risk of the outcome
Define Experimental event rate EER?
The rate in which the outcome occured in the treatment group
Outcome/Number in the group
Define Control event rate CER?
The rate at which outcome occured in the control group
Outcome/Number in the control group
Define the relative risk?
The comparison of risk between two different groups
EER/CER
RR >1 = increase in risk
RR
Define experimental event odds?
The odds that the treatment group will present the outcome
The outcome/no outcome
Define control event odds?
The odds that the control group will display the outcome
The outcome/no outcome
How do you calculate the odds ratio?
Experiment event odds/ Control event odds
If odds ratio for pain releif was 5.7 when taking ibuprofen what would this entail?
That there is a 5.7 times greater chance of getting pain relief if you take ibuprofen
If the confidence interval is 95% what does that mean?
That 95% of the time the values will between two values stated.
What is the confidence interval a messure of?
Indicating the level of uncertainty around the odds ratio
Measure the precisness of the study
What can be the effects of mainstream media?
Can influence peoples views on health and medication
What factors predispose you to disease?
Alcohol, smoking, physical exercise and diet
How much does alcohol misuse cost the NHS?
£3.5 billion a year
8% alcohol related admissions all year
Smoking and alcohol were found in people with low or high exercise rates?
High
Poor diet were found in people with low or high exercise rates?
Low exercise rates
What do commisioning health care services do?
They assess the needs of the population, provide appropiate services and monitor them:
How do commisioning of health care services monitor the service?
Planning:
Planning capacity
Identifying gap and priorities
Procurement: identify a supplier
Acquisition of equipment, staff and services
Contract define
What is qualitive research
It is non numerical and looks at the behavioir, experience and attitude of a target population.
recurrent & distinctive features of participants accounts e.g particular perceptions/experiences .
What data is used in qualitative research?
How is the data collected?
When data is non quantifiable
Sensitive/complex
Explains “Why” & “How?” an individual may perform certain behaviors etc.
Via. Interviews/focus groups/letters/speechs/emails etc
Aim of prenatal testing?
Allows patients to make a informed choice
What things must pre natal testing include?
Be ethical; give autonomy to the parents
Be social: understanding of the illness/disability
Be culture: respect the culture of the patients
Policy an practice: the pre natal testing must be done in a ethical and social acceptable way
Methodology expertise be invovled
What does a person view on termination depend on?
The severity and normality of the condtion and child
What does AnSweR stand for?
Antenatal screening web resource
What percentage of the population is vaccinated?
57%
What is herd immunity?
All members of a population are protected due a proportion already immune
Reduce the spread of disease
What is the “paradox of perental concern” that stops people from getting vaccinations?
Parental concern of the possible effects of the vaccination dwarfs there original concerns they have for the disease
What are the two reasons why patients may not have a vaccine?
The paradoxical of parental concern
Health services
Why might health services be a reason for people not having a vaccine?
Not compulsory
When is hep B, chicken pox and pertussis vaccine given?
Hep B given to sex workers, health works etc
Chicken pox to immunocompromised and pregnant women
Pertussis to a pregnant women
What complication can influenza vaccine cause?
Nacrolepsy
What did the wakefield study try to prove?
That there is a link between MMR vaccine and autism and bowel disease
What was the affects of wakefields study?
Herd immunity was compromised as less people got the vaccination
What is multi morbidity?
When a patient has two medical conditions simultaneously regardless of there casual relationship.
Don’t have to be linked just exist together
What is the treatment of multi morbidity?
Polypharmcy
The use of 4 or more medications simultaneously to treat multi morbidity and seen in the elderly.
How can polypharmcy imporve patient medication system?
Cost effective
Reduce errors by medication review and patinet medication education
What does the quality and outcome framwork identify?
40 different morbidities
What is the cause of multi morbidity?
Multiple health behvaiours: Smoking Drinking Unhealthy diet Physical inactivity
More common in deprived areas
Fragmentation of care is one of the ways to treat multi morbiditiy. What is it?
There is specialist care for each type of disease
Such as heart clinic, diabeties clinic and so forth
What is the king funds commissioning priorities?
It is a organisation served to improve the treatment for patients with multiple conditions
What is primary prevention?
Reducing the incidence and life style risk
For example motivational support and education
What is secondary prevention?
Detect early signs and symptoms. Reduce the severity
Screening
Managing
Specialist care
What group of people are more likely to develop mental health conditions?
People with chronic conditions
What is the 4 themes for treating multi morbidity?
Systematic and proactive management of chronic disease
Empowerment of patients –> knowlege and skills
Integrated model of care, all specialties working and communicating together
Population base aproach to commisioning
What is the primary prevention?
Prevent a healthy person from getting a disease
• Behaviour & Environment
What is a secondary prevention?
Halt progression once started
• Early diagnosis e.g Screening
What is tertiary prevention?
Limit disability and complications in established disease
• Rehabilitation
What is the high risk aproach to treatment?
For example hypertension you just treat people wh is identified as being high risk.
What is the population wide approach?
Preventive
Shift the mean distribution to the left –> lower incidence
What is Social Capital ?
The networks of relationships among people who live and work in a particular society, enabling that society to function effectively.
What is the individual based aproach to detecting peopel who are a at high risk of disease?
High Risk Approach:More personal
Identify individuals at high risk:screenng
Intervene only in individuals at high risk
Risk benefit balance indivdually assessed
What is the population based aproach to detecting peopel who are a at high risk of disease?
Population Wide Approach
More general
Identify important risk factors for the cumminity (prevelence)
Policy to reduce risk factor irrespective of individuals risk
Risk benefit balance for whole community
What are the aims of NICE?
Independent organisation
Advice on safe, effective and cost effective practice in health and social care in a resource constrained organisation
What are the NICE core principles?
- Comprehensive evidence base – not just RCTS - other studies
- Expert input - from clinicians, economists etc
- Patient and public involvement
- Independent advisory committees
- Genuine consultation with all stakeholders
- Regular review and updating
- Open and transparent process – meetings held in public.
What is clinical guidelines for the NHS based on interventional procedures?
safety and efficacy (the ability to produce a desired result)
• Invasive procedures (surgery/catherisation etc.)
• Use of electromagnetic radiation
What are the clinical guidelines for nhs based on?
Based on evidence of clinical/cost effectiveness
What is the diet pathway?
- Combat Obesity
• Weight management before/during/after pregnancy
• Prevention of Cardiovascular Disease
• Maternal & Child nutrition
What are the Sentinel markers used by the NICE?
A prioritised set of concise, measureable statements designed to drive quality improvements across a pathway of care.
What is qualative research?
- Values
- Practical considerations (resources, experience etc)
- Interests of specific groups
What are the Guideline for development?
- Topical Referral – point brought to concern
- Scoping – assessment & investigation
- Developing
- Consulting – expert advice given
- Validation – applicability
- Publication -
What is Citizens Council ?
30 people represent social make-up of population of England & Wales
Consider selected questions – with expert opinion input
What are the single indicator used in cost effectiveness analyses
- Life years saved
- Weight lost (kg)
- Deaths averted
What is cost utility analyses
How it is used in the real world Combined Index (multifactorial).
The cost of the medical intervention compared to the benefits it produces in terms of thenumber of healthy years the patient has
What is the defintion of quality adjusted life years (QALY)
Maintained quality of life for as many life years as possible with the drug intervention
Initially the quality of life could be reduced due tot he intervention for example because of the side effects but generally people live a longer and healthier life.
What is Patient Access Scheme?
How can NICE use this scheme?
Share cost of expensive drugs between NHS & Pharmaceutical Company
PAS for each drug must be approved by Department of Health before being used by NICE
What is the NICe implementation strategy?
- Raise Awareness of issue
- Motivate & Encourage Change - in practice
- Provide practical support – to allow change in practice
- Evaluate Impact & Uptake of guidelines
When can there be deviation from the NICE guideleines be given?
- Patient is fully informed & understands (using CRIB)
- Patient has Capacity
- There is clear documentation (in patients notes) of NICE deviation
- The doctor is acting in good faith
What is the CRIB checklist?
Choice, Risk, Impracticality, and Benefits
• Explores all issues with patient > fully informed
Health Prevention & Screening:
What is the positive predictive value?
Is the probability that a person with a positive test result actually HAS the disease
Actual number positive results/ Total number of positive results (+ False Positive
What is PPV equation?
Number of true psoitives/ number of positive calls
What is the negative predictive value and the equation?
Is the probability that a person with a negative test result actually HASN’T got the disease
Actual number negative results / (Total Number of negative results + False negatives)
What is sensitivity?
The proportion of people with disease who are identified as having it by a positive test result
What are the pros and cons of high sensitvity testing?
PROS = good for disease where missed diagnosises would have significant adverse affect e.g Cancer CONS = unnecessary investigations or treatments for others & gives lots of falase positives
What is specificity ?
The proportion of people without the disease who are correctly re-assured by a negative test result
What is “lead time”?
Time between detection of the disease & presentation of disease
What is the aim of national screening committee?
Aim to reduce False Positives (scare patient) & reduce False Negatives (miss disease > worse prognosis)
“There should be evidence from high quality Randomised Controlled Trials that the screening programme is effective in reducing mortality or morbidity.”
Give examples of lead time bias?
- Early diagnosis falsely appears to prolong survival
* Early screening has no effect on outcome of disease – unchanged
What is “length time bias”?
Screening over-represents less aggressive disease:
Symptoms present at different times.
What determines global health?
Health is determined by problems, issues and concerns that transcend national boundaries
What is International health policies?
Health practices, policies and systems in countries other than one’s own and focuses more on the differences between countries
what are communicable diseae and give examples?
Disease able to be transmitted from animal/human to human
• SARS (Server Acute Respiratory Syndrome
• Swine/Bird Flu
• Ebola
Give example of vector, vehicles, epidemic and pandemics?
Vector – Transmission by an Animal e.g Malaria/yellow Fever
Vehicle – Transmission by Fomite (object) e.g Plate or Bowl
Epidemic = serious outbreak in a single community, population or region
Pandemic (more wide spread) = epidemic spreading around the world affecting hundreds of thousands of people, across many countries
What are the objectives of health system?
How much would low income countries have to pay to meet the international standard goal?
- Improving Health of population
- Responding to peoples expectations
- Providing financial protection against the costs of health
Low income countries have to spend 12% of there GDP to meet the international standard goal
What were the Millennium Development goals? (idealistic goals)
A worldwide agreement of 8 goals to be achieved by 2015 that respond to the world's main development challenges • End Poverty & Hunger • Maternal & Child Health • Gender Equality • Combat HIV/Aids • Universal Education etc
What is equity?
an ethical concept in health – even distribution of wealth & resources amongst rich & poor countires
What is the Laisez-faire/Hands-off approach ?
Increased commercialization & privatization of Health Care e.g USA
What is theaims of the Health protection policy?
- Protecting people from infectious disease
- Reducing the adverse effects of chemical, microbiological and radiological hazards
- Preparing for potential/emerging outbreaks
What increases the susceptibility to infection?
Both hum and physical causes?
- Human – poverty & emotion stress
* Physical - Ventilation, Sanitation, Over-crowding
What are the direct and indirect transmission of infection?
Direct – Sexual/Faecal-Oral/Conact e.g STI’s , Scabies
Indirect -
• Vector (animal) e.g Malaria
• Vehicle (Fomite/object) e.g Hep B, Viral GE
What ar ehte different infectious disease periods?
Latent Period = not infectious
Infectious Period = infectious > secondary case (infection of another person)
(can be before symptoms present)
Incubation Period = time of acquisition > time of symptom presentation (includes latent and most of infectious periods)
Resolution = disease treated/person dies
What is the function of neuraminidase ?
Controls release of new viruses from host cell
What is the most common STI in the UK?
Genital Chlamydia trachomatis
What can Genital Chlamydia trachomatis lead to?
- Can lead to Arthritis (both M/F)
* Rectum, throat, eyes
What are the effectes of Chalmydia on females?
% women = asymptomatic > Pelvic Inflammatory Disease
• Vaginal discharge - white
• Urethritis – pain when weeing
• Bleeding after sex/not on period
What are the affects of Chalmydia on males?
% men = asymptomatic
• Penile Discharge – watery/cloudy
• Urethritis
Which type of HSV caues oral herpes and which causes genital?
HSV 1 = Oral Herpes
HSV 2 = Genital
Which type of HPV caues cervical cancer?
Types 16 & 18 = worst > Cervical Cancer
What caues Syphillis and what are the symptoms?
via. Treponema pallidum (spirochaete bacterium)
• Chancre – highly infectious sore around mouth/genitals
• Secondary symptom = bad rash
• Tertiary stage – paralysis & heart defects
Who does Neisseria gonorrhoea affect?
2nd most common
Most commonly affected =
• homosexual/bisexual men
• black and ethnic minority populations
What are the symptoms of Neisseria gonorrhoea?
- Testicular Pain
- Pain after sex
- Also affects rectum, throat & eyes
How is Neisseria gonorrhoea resistant?
Plasmid mediated – penicillin & tetracycline
Chromosomally mediated - penicillin, tetracycline & fluoroquinolones
If an infectious disease could suddenly be cured what would happen to the incidence of that disease?
Decrease – infected people cured = less transmission to other people > decrease in incidence
If an non-infectious disease could suddenly be cured what would happen to the incidence of that disease?
Stay the same – non-infectious therefore not affected by cures
e.g Diabetes – curing people would not affected incidence as cause is environmental/genetic not via. Infection
What type of prevention is giving aspirin to a person to prevent coronary heart disease
Primary Prevention – preventing actual disease
What is the aim of Chemoprophylaxis ?
often protects the wider community
What is the odd ratio?
can only be calculated in Case Control group
Measures risk of disease in exposed group/ risk of disease in control group
What is meta anlysis?
take a number of studies & combine results
Are the causes of population incidence and cause of individual cases the same?
No they are not
What does population mean predict?
The number of new cases
What is the aim of cost benefit analyses?
The monetary value of benefit
The willingness to pay vs the social value of life.
Comparing all the benefits to all the costs.
What is lead time bias?
When detection/testing of a disease increases the perceived survival time but does not actually have a affect on the actual course of a disease
What two ways can lead time bias preent it self?
- Early diagnosis falsely appears to prolong survival
- Early screening has no effect on outcome of disease – unchanged
Identify the diseae at a earlier stage before the symptoms are present
Why do you get a lot of false positives in prostate cancer?
Due to elevated levels of prostate specific antigens
What is the biggest risk factor for prostate cancer?
Age
Common in males over 70
Below this it is rare
What is the effect of HIV and malaria on the GDP of African countries?
It has stunted there GDP due to the affect of many of its work force
What is the chain infection?
The reservoir of pathogen The mode of exit from the agent The mode of transmission The mode of entry into the host Then person to person spread Then start all over again
What is avain influenza?
Bird flue
What is H1N1 flu?
Swine flu
What is the role of pigs in the creation of new influenza virus?
The pig can act as a “mixing vessel” where is mixes influenza from different viruses –> genetic reassortment and creates a new/resistant influenza virus.
What is the use of Oseltamivir (tamiflu)?
To prevent the spread of influenza type A and B.
Was used in bird flue pandemic
What is the alert phase in influenza pandemic?
The identification of a influenza caused by a new subtype of a influenza in a human
How long does it take for a vaccine to be produce when a flu pandemic has occured?
Takes 6 months to develop a vaccine
Give examples of ecological stduies?
- Rate of cancer incidence per local authority
- The mean level of hypertension
- The average sunlight exposure at specific geographic location
Scientific Evidence used by NICE must be:
Explicit – codified &propositional
Systematic – transparent &; explicit methods for codifying
Replicable – same methods > same results
