GP and PPS

Question 1

What is the Libertarian approach?

Answer 1

each is responsible for their own health, well being and fulfilment of life plan

Question 2

What is the Bolam test and how does it relate to consent?

Answer 2

The Bolam test, which asks whether a doctor’s conduct would be supported by a responsible body of medical opinion, no longer applies to the issue of consent following the case of Montgomery vs. Lanarkshire health board 2015. The law now requires a doctor to take “reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.”

So doctors must now ask themselves three questions:
•Does the patient know about the material risks of the treatment I am proposing?
•Does the patient know about reasonable alternatives to this treatment?
•Have I taken reasonable care to ensure that the patient actually knows this?

Question 3

what is Ethnocentrism?

Answer 3

The tendency to evaluate other groups according to the values and standards of one’s own cultural group, especially with the conviction that one’s own cultural group is superior to the other groups.

Question 4

What is the theory of Epigenetics?

Answer 4

The expression of the genome depends on the environment.
No individual ever has the same experience as another
We are utterly unique and need to be regarded as such
Genetic PREDISPOSITION is key

Question 5

What is the theory of Allostasis and Allostatic load?

Answer 5

Allostasis means:
Stability through Change
Our physiological systems have adapted to react rapidly to environmental stressors,
and are programmed to be turned on and off efficiently, but not too frequently.
The body can ‘rise to a challenge’

Allostatic load is the price we pay for allostasis
Long-term overtaxation of our physiological systems leads to impaired health
THE PATHOPHYSIOLOGY OF STRESS

Example:
Cardiovascular System
Allostasis - works to maintain our erect posture, and enable physical exertion

Allostatic load - Over-activation leads to hypertension, stroke MI

Question 6

What is Salutogenesis?

Answer 6

A new word which means…
Favourable physiological changes
secondary to experiences
which promote healing and health

Question 7

What is Domestic Abuse?

Answer 7

Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to:
psychological
physical
sexual
financial
emotional

Question 8

How does Domestic Abuse impact upon health?

Answer 8

traumatic injuries following an assault:
e.g. fractures, miscarriage, facial injuries, puncture wounds, bruises and haemorrhages

somatic problems or chronic illness consequent on living with abuse:
e.g. headaches, gastrointestinal disorders, chronic pain, low birth weight, premature delivery

psychological or psychosocial problems secondary to the abuse:
e.g. PTSD, attempted suicide, substance misuse, depression, anxiety, eating disorders

Question 9

What is the difference between equity and equality?

Answer 9

Equity is about what is fair and just

Equality is concerned with equal shares

Question 10

What are the 3 domains of public health practice?

Answer 10

Health improvement:
Concerned with societal interventions (not primarily delivered through health services) aimed at preventing disease, promoting health, and reducing inequalities

Inequalities
Education
Housing
Employment
Lifestyles
Family/community

Health protection:
Concerned with measures to control infectious disease risks and environmental hazards

Infectious diseases
Chemicals and poisons
Radiation
Emergency response
Environmental health hazards 

Improving services (Health care):
 Concerned with the organisation and delivery of safe, high quality services for prevention, treatment, and care

Clinical effectiveness
Efficiency
Service planning
Audit and evaluation
Clinical governance
Equity

Question 11

Explain the difference between primary, secondary and tertiary
prevention.

Answer 11

Primary prevention:
Primary prevention targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition.
Examples include childhood vaccination programs, water fluoridation, anti-smoking programs, and education about safe sex

Secondary prevention:
Secondary prevention targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications.
Examples include routine Papanicolaou tests (pap test for cervical screening) and screening for hypertension, diabetes mellitus, or hyperlipidemia.

Tertiary prevention:
Tertiary prevention targets individuals with a known disease, with the goal of limiting or preventing future complications. Examples include screening patients with diabetes for microalbuminuria, rigorous treatment of diabetes mellitus, and post-myocardial infarction prophylaxis with b-blockers and aspirin.

Question 12

Explain the difference between horizontal and vertical equity in relation to health care.

Answer 12

Horizontal equity:
Equal treatment for equal need
e.g. Individuals with pneumonia (with all other things being equal) should be treated equally

Vertical equity:
Unequal treatment for unequal need
e.g. Individuals with common cold vs pneumonia need unequal treatment
e.g. Areas with poorer health may need higher expenditure on health services

Question 13

Explain the difference between public health interventions delivered at the population (ecological) and individual levels, using one example for each to illustrate your answer.

Answer 13

population intervention aimed at improving the health of an entire population. examples include public smoking bans, minimum unit pricing, change 4 life campaigns

individual intervention aims at improving the health of an individual. examples include, smoking cessation support, weight loss classes,

Question 14

What are the types of health behaviour?

Answer 14

Health Behaviour: a behaviour aimed to
prevent disease (e.g. eating healthily)

Illness Behaviour: a behaviour aimed to seek
remedy (e.g. going to the doctor)

Sick role Behaviour: any activity aimed at
getting well (e.g. taking prescribed
medications; resting)

Question 15

Explain what is meant by the comparative approach

to health needs assessment.

Answer 15

Compares the services received by a
population (or subgroup) with others
Spatial
Social (age, gender, class, ethnicity)

May examine:
 Health status
 Service provision
 Service utilisation
 Health outcomes
 (mortality, morbidity, quality of life, patient satisfaction)

Problems with this approach:
May not yield what the most appropriate level
e.g. of provision or utilisation should be
Data may not be available
Data may be of variable quality
May be difficult to find a comparable
population

Question 16

Give three potential limitations of the epidemiological

approach to health needs assessment.

Answer 16

Data may not be available
Data may be innaccurate or of variable quality
Evidence base may be inadequate
Does not consider felt needs of people affected

Question 17

Give one health related example of something that
you consider is demanded but not needed or
supplied, clearly explaining the reasoning for your
example.

Answer 17

Cosmetic surgery. This is demanded by some people but it is not strictly needed for health reasons or supplied on the NHS.

Question 18

Explain what is meant by the epidemiological approach

to health needs assessment.

Answer 18

Define problem
Size of problem
 incidence / prevalence
Services available
 prevention / treatment / care
Evidence base
 effectiveness and cost-effectiveness
Models of care
 including quality and outcome measures
Existing services
 unmet need; services not needed
Recommendations

Problems with this approach:
Required data may not be available
Variable data quality
Evidence base may be inadequate
Does not consider felt needs of people affected

Question 19

Explain what is meant by the corporate approach

to health needs assessment.

Answer 19

Various groups e.g. commisioners, providers, proffessionals, patients, press, politicians, opinion leaders all influence what the health needs are.

problems with this approach:
 May be difficult to distinguish need from
demand
 Groups may have vested interests
 May be influenced by political agendas
 Dominant personalities may have undue
influence

Question 20

What is Maslow’s Hierarchy of Needs?

Answer 20

from base to top:

Phsiological needs (breathing,sleep, food, water, sex etc…)
Safety (security, employment, family safety etc…)
Love/belonging (friendship, family, partner)
Esteem (self esteem, confidence, achievement, respect etc…)
Self actualisation (morality, creativity, spontaneity etc…)

you cant progress to the next level without fulfilling the needs in the levels below

Question 21

What is the difference between an asylum seeker, a refugee and humanitarian protection?

Answer 21

An asylum seeker is someone who is temporarily resident in the UK whilst a decision is made by the home office upon whether they can remain in the country or not.

a refugee has been granted asylum and allowed to stay due to fear of harm/death upon returning to home country.

Humanitarian Protection: Failed to demonstrate claim for asylum but face serious threat to life if returned. Usually 3years then reapply

Question 22

What does refugee status grant an individual?

Answer 22

Indefinite leave to remain (ILR) :when a person is granted full refugee status and Given permanent residence in the UK.
They have all the rights of a UK citizen.
They are eligible for family reunion- one spouse, and any child of that marriage under the age of 18

Question 23

What rights does an asylum seeker have?

Answer 23

Are entitled to money- currently £35 pounds per week
Are entitled to housing- no choice dispersal
Are entitled to NHS care
If under 18, have the services of a social services key worker and can go to school

               Are NOT allowed to work
     and are not entitled to any other form of    
     benefit.
              FAILED Asylum Seekers 
Are NOT entitled to any money 
Are NOT housed
Are NOT entitled to full NHS care

Question 24

What is social exclusion?

Answer 24

the dynamic process of being shut out, fully or partially, from any of the social, economic, political or cultural systems which determine the social integration of a person in society.”

  5 Domains: 
Material Resources,
Civic Activities,
Basic Services
Neighbourhood, 
Social Relationships

Question 25

Name 4 causes of social exclusion?

Answer 25

Poor Health, Sensory Impairment, Poverty, housing issues, fear of crime Transport, problems on the roads, Discrimination (Internalised), sexuality, gender, ethnicity, belief. Services: insufficient range. Fragmentation. Lack of imagination. Bureaucracy Poor coordination, Lack of information, Fragility of networks

Question 26

Name the local and national initiatives to reduce social exclusion

Answer 26

``` Sheffield: Age Better- £6m Lottery Funding Age UK 50+ Club (IT etc) Active Sheffield Darnall Dementia Care Dementia Cafes ``` ``` National: Age UK Silverline Dementia Friends Men in Sheds U3A ``` ``` Housing: Intergenerational - Housing/Activities Co-Housing Flexible Care Planning for Older People ``` ``` Self Help (books): A Compass for Old Age Mindful Ageing ‘Sod 70’ ‘Retirement with Attitude’ ```

Question 27

What is the health belief model?

Answer 27

Individuals will change if they: Believe they are susceptible to the condition in question (e.g. heart disease) Believe that it has serious consequences Believe that taking action reduces susceptibility Believe that the benefits of taking action outweigh the costs

Question 28

What is the theory of planned behaviour?

Answer 28

Proposes the best predictor of behaviour is ‘intention’ e.g. I intend to give up smoking Intention determined by: A persons attitude to the behaviour The perceived social pressure to undertake the behaviour, or subjective norm A persons appraisal of their ability to perform the behaviour, or their perceived behavioural control Example with regard to smoking: Attitude – I do not think smoking is a good thing Subjective Norm – most people who are important to me want me to give up smoking Perceived Behavioural Control – I believe I have the ability to give up smoking Behavioural Intention – I intend to give up smoking

Question 29

What is the stage model theory of behaviour?

Answer 29

Stage theories see individuals located at discrete ordered stages, rather than on a continuum. Each stage denotes a greater inclination to change outcome, typically behaviour, than the previous one. Transtheoretical model, or stages of change model (Prochaska & DiClemente, 1984) Proposes 5 stages of change: precontemplation, contemplation, preparation, action, maintenance According to the theory, individuals are most likely to experience success in changing behaviour when they engage in strategies that are appropriate to their stage of readiness to make the change.

Question 30

Describe the transtheoretical model of change with regards to smoking cessation

Answer 30

Precontemplation – no intention of giving up smoking Contemplation – beginning to consider giving up, probably at some ill-defined time in the future Preparation – getting ready to quit in the near future Action – engaged in giving up smoking now Maintenance – steady non-smoker, i.e. state of change reached the 6th stage could be relapse if the intervention was not effective

Question 31

Donabedian’s “structure, process, outcome” is a useful | framework to use when carrying out evaluation of health services. Explain what is meant by “structure”

Answer 31

``` Structure: What is there Buildings, staff, equipment Examples: Number of ICU beds per 1000 population Number of vascular surgeons per 1000 population Locations where screening is provided ``` Process: What is done Examples: Number of patients seen in A&E The process through which patients go in A&E e.g. where and when is patient first seen; who carries out triage; how is priority assessed Number of operations performed (may be expressed as a rate) [Some would classify procedures performed as “outputs”] ``` Outcome: Classification of health outcomes 1) Mortality e.g. 30 day mortality rate 2) Morbidity e.g. complication rates 3) Quality of life / PROMs 4) Patient satisfaction ``` Another classification is using five Ds Death, Disease, Disability, Discomfort, Dissatisfaction

Question 32

When assessing the quality of health services, Maxwell’s classification lists six dimensions. List the six dimensions

Answer 32

Maxwell’s Dimensions of Quality (3Es and 3As): Effectiveness Does the intervention / service produce the desired effect? Efficiency Is the output maximised for a given input (or is the input minimised for a given level of output)? Equity Are patients being treated fairly? Acceptability How acceptable is the service offered to the people needing it? Accessibility Is the service provided? Geographical access; Costs for patients; Information available; Waiting times Appropriateness Is the right treatment being given to the right people at the right time? [Overuse? Underuse? Misuse?]

Question 33

Although using measures of health outcomes is desirable in evaluation of health services, there are potential limitations. Explain why it may be difficult to attribute a health outcome to the service provided

Answer 33

Link (cause and effect) between health service provided and health outcome may be difficult to establish as many other factors may be involved e.g. case-mix, severity, other confounding factors Time lag between service provided and outcome may be long e.g. between healthy eating intervention in childhood and incidence of Type 2 diabetes in middle age Large sample sizes may be needed to detect statistically significant effects Data may not be available There may be issues with data quality consider CART – Completeness, Accuracy, Relevance, Timeliness

Question 34

Name 3 qualitative and 3 quantitative methods of service evaluation

Answer 34

``` Qualitative methodology: Observation Participant observation Non-participant observation Interviews Focus groups Review of documents ``` ``` Quantatitive methodology: Routinely collected data e.g. hospital admissions; mortality Review of records medical; administrative Surveys Other special studies e.g. using epidemiological methods ```

Question 35

What is alcohol dependence syndrome?

Answer 35

Cluster of 3 of below symptoms in a 12 month period: Tolerance-increasing amount of alcohol to achieve the same effect Characteristic physiological withdrawal Difficulty controlling onset, amount and termination of use Neglect of social and other areas of life Spending more time obtaining and using alcohol Continued use despite negative physical and psychological effects

Question 36

What is the classical triad of signs for Wernickes encephalopathy and what is it caused by?

Answer 36

Triad of symptoms- acute mental confusion, ataxia and opthalmoplegia Serious disorder caused by vitamin b1 deficiency, often occurs on withdrawal of alcohol. It is reversible - treat with IV/IM thiamine (pabrinex) Can lead to Korsakofs syndrome if untreated

Question 37

What are the population and high risk approaches to prevention?

Answer 37

The population approach is a preventative measure delivered on a population wide basis and seeks to shift the risk factor distribution curve e.g. dietary salt reduction through legislation, working with the food industry and advice to the general public should shift the blood pressure distribution curve to the left The high risk approach seeks to identify individuals above a chosen cut-off and treat them e.g. screening for people with high blood pressure and treating them

Question 38

What is the prevention paradox?

Answer 38

A preventive measure which brings much benefit to the population often offers little to each participating individual.

Question 39

What is screening?

Answer 39

A process which sorts out apparently well people who probably have a disease (or precursors or susceptibility to a disease) from those who probably do not. It is not intended to be diagnostic.

Question 40

Name 3 types of screening

Answer 40

``` Population-based screening programmes Opportunistic screening Screening for communicable diseases Pre-employment and occupational medicals Commercially provided screening ```

Question 41

What are the criteria for a screening program?

Answer 41

The Wilson and Junger criteria: The condition Important health problem Latent / preclinical phase Natural history known The screening test Suitable (sensitive, specific, inexpensive) Acceptable The treatment Effective Agreed policy on whom to treat The organisation and costs Facilities Costs and benefits Ongoing process

Question 42

Define Sensitivity, Specificity, Positive Predictive value and Negative Predictive value

Answer 42

Sensitivity – the proportion of people with the disease who are correctly identified by the screening test a / a+c Specificity – the proportion of people without the disease who are correctly excluded by the screening test d / b+d Positive predictive value – the proportion of people with a positive test result who actually have the disease a / a+b Negative predictive value – the proportion of people with a negative test result who do not have the disease d / c+d

Question 43

Why can the positive/negative predictive value of a screening test vary so much between tests whereas the sensitivity and specificity do not?

Answer 43

Predictive values are dependent on underlying prevalence (Sensitivity and specificity are not)

Question 44

What is lead time bias?

Answer 44

Lead time is the length of time between the detection of a disease and its usual diagnosis. Early diagnosis by screening may not prolong the life of someone. Lead time bias can affect interpretation of the five-year survival rate. Diagnosing a disease earlier does not automatically make patients live longer — they merely live for a longer time with the disease ‘label'. Put another way, survival appears longer because the ‘disease clock' starts earlier. This is an example of another sort of bias known as ‘lead-time bias' — and it can be overcome by analysing the results by date of birth instead of age at diagnosis

Question 45

What is length (length-time) bias?

Answer 45

Cancers may be slowly or rapidly progressive (length of arrows denote onset to death). Less aggressive cancers are more likely to be detected by screening rounds. A comparison of survival in screen detected patients with non-screen detected patients may be biased as there will be a tendency to compare less aggressive with more aggressive cancers.

Question 46

What is a Cohort study?

Answer 46

one or more cohorts from a population are studied PROSPECTIVELY. Individuals in the cohort are then identified as either having been exposed to or not exposed to a "suspected causative agent" and then evaluated as to whether they developed or did not develop a disease.

Question 47

What is a Case-control study?

Answer 47

2 groups of patients are identified - those with and those without a disease. The groups are then investigated RETROSPECTIVELY to identify those that were and those that weren't exposed "suspected causative agent"

Question 48

What is a Randomised Controlled Trial?

Answer 48

A study population is identified. Patients are selected by defined criteria, those who do not meet the criteria are excluded. Remaining patients are invited to participate. Patients that agree are randomised into a control and an intervention group. This is the most robust study design

Question 49

What is a Cross-sectional study?

Answer 49

A population is identified at a specific point in time and analysed according to those with and without a disease against those with or without exposure (this forms a 2x2 table for analysis) Prevalence = People with disease / Population (sample) surveyed

Question 50

What is a Geographical Ecological study?

Answer 50

An ecological correlation of disease prevalence against exposure level

Question 51

What is a Time-trends Ecological study?

Answer 51

An ecological correlation of disease prevalence against time

Question 52

How would you calculate the Odds of developing a disease and the Odds Ratio?

Answer 52

To calculate the Odds for either Cases (those with disease) or a control (those without disease) you would divide the cases with high exposure by those with low/no exposure for each group. E.g: Odds for Cases - 75 with high exposure and 25 with low/no exposure. you divide 75 by 25 to get the odds of 3 (75/25=3) Odds for Control- 80 with high exposure and 20 with low/no exposure. you divide 80 by 20 to get the odds of 4 (80/20=4) The Odds ratio = (Odds of exposure in cases) / (Odds of exposure in controls) E.g: = (75/25) / (80/20) = 0.75

Question 53

What is epidemiology?

Answer 53

The study of the frequency, distribution and determinants of diseases and healthrelated states in populations in order to prevent and control disease

Question 54

What is the difference between Incidence and Prevalence?

Answer 54

``` Incidence (cumulative incidence): New cases Denominator (number of disease free people at the start of the study) Time ``` Prevalence: Existing cases Denominator Point in time (point prevalence)

Question 55

What is person-time and when is it used?

Answer 55

Person-time is a measure of time at risk – i.e. time from entry to a study to (i) disease onset, (ii) loss to follow-up or (iii) end of study. It is used to calculate incidence rate which uses person-time as the denominator. Cumulative incidence uses the number of disease free people at the start of the study as the denominator. Incidence rate is useful when study participants are followed up for varying lengths of time.

Question 56

What is the difference between absolute and relative risk?

Answer 56

Absolute risk – gives a feel for actual numbers involved i.e. has units (e.g. 50 deaths / 1000 population) Relative risk – risk in one category relative to another i.e. no units

Question 57

What is the difference between Attributable and Realative risk?

Answer 57

Attributable risk: The rate of disease in the exposed that may be attributed to the exposure – i.e. incidence in exposed minus incidence in unexposed. – Attributable risk is a type of absolute risk (absolute excess risk). Attributable risk – is about the size of effect in absolute terms i.e. gives a feel for the public health impact (if causality is assumed) Relative risk: Ratio of risk of disease in the exposed to the risk in the unexposed – i.e. incidence in exposed divided by incidence in unexposed. Relative risk – tells us about the strength of association between a risk factor and a disease

Question 58

Calculate the following using the given information. Cumulative incidence of Disease X in people given a new treatment is 6/1000 Cumulative incidence of Disease X in people on placebo is 10/1000 Absolute risk reduction = Relative risk = Number needed to treat = Relative risk reduction =

Answer 58

Cumulative incidence of Disease X in people given a new treatment is 6/1000 Cumulative incidence of Disease X in people on placebo is 10/1000 Absolute risk reduction = 4/1000 (over 5 years) i.e. 1000 people treated and four cases if disease avoided Relative risk = 0.6 i.e. Incidence in treatment group / Incidence in placebo group Number needed to treat (to avoid one case of Disease X) = 250 Relative risk reduction = 40% (or 0.4) i.e. relative risk reduced by 0.4 (1-0.6)

Question 59

Define Bias?

Answer 59

A systematic deviation from the true estimation of the association between exposure and outcome i.e. a systematic error which leads to a distortion of the true underlying association

Question 60

What are the 2 main groups of Bias?

Answer 60

1. Selection bias - A systematic error in: the selection of study participants the allocation of participants to different study groups 2. Information (measurement) bias - A systematic error in the measurement or classification of: exposure outcome Sources of information bias observer (e.g. observer bias) participant (e.g. recall bias) instrument (e.g. wrongly calibrated instrument)

Question 61

What is Confounding?

Answer 61

The situation where a factor is associated with the exposure of interest and independently influences the outcome (but does not lie on the causal pathway)

Question 62

What are the “Criteria” for assessing causality (or factors to consider when assessing causality)?

Answer 62

Strength of association the magnitude of the relative risk Dose-response the higher the exposure, the higher the risk of disease Consistency similar results from different researchers using various study designs Temporality does exposure precede the outcome? Reversibility (experiment) removal of exposure reduces risk of disease Biological plausibility biological mechanisms explaining the link

Question 63

``` Which of the following study design terms best describes the study described below: A. Cohort study B. Case-control study C. Case series D. Case report E. Meta-analysis F. Randomised controlled trial G. Cross-sectional study H. Ecological study I. Systematic review J. Migration study ``` Investigators find a high level of correlation between levels of socioeconomic deprivation and cardiovascular mortality across electoral wards in the UK.

Answer 63

H. Ecological study

Question 64

``` Which of the following study design terms best describes the study described below: A. Cohort study B. Case-control study C. Case series D. Case report E. Meta-analysis F. Randomised controlled trial G. Cross-sectional study H. Ecological study I. Systematic review J. Migration study ``` Researchers set out to examine the association between alcohol consumption and stroke. They identify all new patients admitted with stroke and compare their alcohol consumption with patients admitted for elective surgery.

Answer 64

B. Case-control study

Question 65

``` Which of the following study design terms best describes the study described below: A. Cohort study B. Case-control study C. Case series D. Case report E. Meta-analysis F. Randomised controlled trial G. Cross-sectional study H. Ecological study I. Systematic review J. Migration study ``` General practitioners set up a study to estimate the prevalence of depression within their registered population. They decide to start with a random sample of adults aged 45-74 years.

Answer 65

G. Cross-sectional study

Question 66

``` In the situation described, select the term which best describes the measure being used: A. Attributable risk B. Case-fatality rate C. Cumulative incidence D. Incidence rate E. Odds ratio F. Person-years G. Prevalence H. Absolute risk reduction I. Relative risk J. Number needed to treat ``` In a randomised controlled trial, the time at risk was determined from entry to the study to various end points.

Answer 66

F. Person-years

Question 67

``` In the situation described, select the term which best describes the measure being used: A. Attributable risk B. Case-fatality rate C. Cumulative incidence D. Incidence rate E. Odds ratio F. Person-years G. Prevalence H. Absolute risk reduction I. Relative risk J. Number needed to treat ``` For patients with meningococcal meningitis, the risk of dying has been estimated to vary from 5-10%

Answer 67

B. Case-fatality rate

Question 68

``` In the situation described, select the term which best describes the measure being used: A. Attributable risk B. Case-fatality rate C. Cumulative incidence D. Incidence rate E. Odds ratio F. Person-years G. Prevalence H. Absolute risk reduction I. Relative risk J. Number needed to treat ``` In a case-control study of recent alcohol consumption and road traffic accidents, the measure of association was substantially greater than 1 and indicates that there is a positive association between exposure and outcome.

Answer 68

E. Odds ratio

Question 69

``` For the situation described, select the term that is most appropriate to the issue described in relation to causation: A. Bias B. Chance C. Confounding D. Specificity E. Reverse causality F. Dose-response G. Strength of association H. Reversibility I. Biological plausibility J. Consistency ``` Researchers set out to examine the hypothesis that stress causes hypertension using hypertensive and normotensive individuals in a case-control study. The study design is however criticised because of concerns regarding the temporal sequence of events .

Answer 69

E. Reverse causality

Question 70

``` For the situation described, select the term that is most appropriate to the issue described in relation to causation: A. Bias B. Chance C. Confounding D. Specificity E. Reverse causality F. Dose-response G. Strength of association H. Reversibility I. Biological plausibility J. Consistency ``` A study reports an association between coffee consumption and cancer. However, subsequent studies find that there is a clear association between smoking and coffee consumption.

Answer 70

C. Confounding

Question 71

``` For the situation described, select the term that is most appropriate to the issue described in relation to causation: A. Bias B. Chance C. Confounding D. Specificity E. Reverse causality F. Dose-response G. Strength of association H. Reversibility I. Biological plausibility J. Consistency ``` An association between postmenopausal oestrogen use and endometrial cancer was reported in some studies. However, it was subsequently argued that this might be due to increased diagnostic attention received by women with uterine bleeding after oestrogen exposure.

Answer 71

A. Bias