H&S (Quizlet) Flashcards
What 4 sources are used when making a clinical decision?
- Patient preferences
- Available resources (studies)
- Research evidence (guidelines/systematic reviews)
- Clinical expertise (others)
Why is evidence-based decision making important? (6)
- Deals with uncertainty.
- Medical knowledge is incomplete/shifting.
- Patients will receive most appropriate treatment.
- Constant need for innovation and improvement.
- Improving efficiency of healthcare services.
- Reduces practice variation.
What are the sources of NHS funding? (2)
- Tax finance.
- Some user charges e.g. prescriptions, parking
What is the difference between disease and illness?
- Disease - What is wrong with the body.
- Illness - Looks at the way that the patient experiences the disease.
Why is important to address disease and illness? (2)
- Disease - Means you treat the correct condition, improves biomedical health.
- Illness - Can discover how illness is impacting patients life, patient more satisfied,enhances doctor-patient relationship.
What is epidemiology?
The study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems
What are the 3 types of epidemiology?
- Descriptive - Tell us how things are distributed (who, what where when)
- Analytical - Determining factors for the disease?
- Experimental - Tests a hypothesis to conclude things
What is incidence? + formula
New cases of disease within a period
= total new cases/person years
How to figure out person years for incidence formula?
number of people x follow up period
What is the cumulative incidence formula?
= total new cases/total initially free of disease
What is prevalence? (+ formula)
Proportion of people with a disease at a particular point in time
= total diseased / total population
How can epidemiology be useful in smoking research?(3)
- Identify cause of disease.
- Guides preventative action - Identifies targets for intervention.
- Surveillance of populations and smoking can measure effects of intervention.
What role does descriptive epidemiology play in medicine?
To characterise patterns to ultimately generate hypotheses on risk factors/causes of disease
What is illness behaviour?
The way in which symptoms may be differently perceived, evaluated and acted upon by different kinds of persons.
Define illness?
A feeling of poor health perceived by an individual
What is the symptom iceberg?
- Only a small minority of symptoms are seen by health professionals.
- Most symptoms managed within community
- Patients only report 5-15% of symptoms.
Who is most healthcare word done by?
Lay people - lay referral system. (community)
What is the lay referral system?
People talk to other people (lay people) before seeking help.
Give examples of lay referral systems? (5)
- Friends
- Relatives
- Pharmacists
- Magazines
- Google (80% of people use)
What demographic/social factors influence help seeking and illness behaviour? (5)
- Gender
- Age
- Social class
- Race
- Culture
An example of gender influencing illness behaviour?
Studies suggested men less likely to seek help from health professionals
An example of age influencing illness behaviour?
Studies suggested individuals over 51 more likely to have screening health checks than those younger
Problems with delaying help seeking? (2)
- Reduces opportunity for early diagnosis/intervention
- impacts outcomes for both acute/chronic disease
Barriers to seeking help (13)
- Financial strain
- Lack of childcare
- Lack of awareness
- Negative attitudes
- Availability of services
- Time related issues
- Transportation
- Stigmatisation
- Language barriers
- Fear
- Embarrassment
- Lack of access to services
- Previous experiences
3 examples of complementary and alternative medicine (CAM’s)
- Aromatherapy (aromatic oils)
- Acupuncture (needles)
- Homeopathy (microdoses)
What are Zola’s triggers to help seeking behaviour? (5)
- Interference with work or physical activity
- Interference with social relations.
- Interpersonal crisis e.g. death in family.
- Putting a time limit on symptoms.
- Sanctioning - relative/friends tell them to seek help.
What influences health seeking behaviour? (8)
- Lack of awareness of symptoms e.g indigestion as MI
- Perception and evaluation of symptoms (not severe enough)
- Perceived risk.
- Confirmation from others
- Previous experience.
- Psychological factors - Fear of what it might be.
- Denial.
- Concern about using NHS resources.
What is consequentialism?
Moral based on the consequence of the action
Deontology
Moral based on the actions adherence to the rules/duties
Virtue ethics
Right act is one a virtuous person would do, that express the virtues such as compassion and honesty.
What is the definition of medical professionalism?
A set of values, behaviours and relationships that underpins the trust that the public has in doctors
Describe the regulatory role of the GMC?
To protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.
Outline the role of medical schools and the GMC in ensuring students and doctors fitness to practice? (3)
- GMC sets its guidance for what medical graduates need to accomplish in Tomorrow’s Doctors.
- This is taught by the medical schools.
- This is examined formally in various exams taken throughout the course, reflective essays, learning to give feedback and self-reflection, attendance and punctuality, plagiarism.
Benefits of good communication? (5)
- More accurate diagnosis.
- More accurate data gathering.
- Increased adherence with treatment regime.
- More effective patient-doctor relationship.
- Increased patient-doctor satisfaction.
Consequences of poor communication? (5)
- Inaccurate diagnosis.
- Less recognition of ICE.
- Non-adherence to treatment.
- Decreased satisfaction with doctor.
- More complaints.
What makes science social? (4)
- Decisions about research funding.
- Pharmaceutical industry - profits.
- Ethical issues.
- Nature of scientific work - communication.
What is eugenics? (2)
- Improving a population by controlled breeding.
- Encourages good genetics, discourages bad genetics.
Issues with eugenics? (4)
- Thinking about the future based on genetics.
- Designer babies.
- Genetic screening - health insurance, employment, and civil liberties.
- Many conditions are polygenic.
What is patient centred care?
Care that is responsive to the wants, needs, and preferences of the patient.
6 criteria of patient centred care?
- Explores patients main reasons for visit. +establishes rapport
- Seek integrated understanding of patients world - looks at the whole person.
- Finds common ground on problem and mutually agrees on management.
- Enhances prevention and health promotion.
- Enhances the continuing relationship between the patient and the doctor.
- Is realistic i.e
How does patient centered care enhance heath prevention/promotion?
Allows a doctor to find the methods of health promotion and preventative care which most appropriately match a patient’s world.
What is the sick role?
States the rights and responsibilities for patient and doctors when they have a consultation.
What is the patient expected to do in the sick role? (4)
- Must want to get well as quickly as possible.
- Should seek professional medical advice and cooperate with the doctor.
- Allowed to stop normal activities and responsibilities e.g. work.
- Regarded as being in need of care and unable to get better alone.
What must the doctor do to uphold the sick role? (4)
- Apply a high degree of skill and knowledge.
- Act for welfare of patient, not self interest.
- Be objective and emotionally detached.
- Be guided by rules of professional practice.
Criticisms of the sick role? (4)
- Symptom iceberg - Patients do not necessarily act on symptoms and go see the doctor.
- Chronic illness and MUS - If cause unknown, patients can’t enter sick role due to uncertainty.
- People try to label themselves as sick.
- Conflict between best interests for the patient and cost to society in allocation of resources.
What is health promotion?
The process of enabling people to increase control over, and to improve, their health.
What are WHO’s 5 aspects of health promotion? HARPS
- H - Healthy public policy.
- A - Action in the community.
- R - Re-orientating health services.
- P - Personal skills.
- S - Supportive environment.
What are the 3 different approaches to health promotion?
- Individualistic - encouraging individual responsibility and action
- Collective/societal - educates groups on preventative health
- Governmental - new legalisation to protect/improve health
3 examples of health promotion (success, easy?, hard to solve)
- Success - Cot death (sudden infant death syndrome) was drastically reduced due to health campaigns “back to sleep”
- Easy? - smoking not as easy due to barriers to reduction e.g cool factor, tolerance of society, tax income putting into economy
- Hard - obesity hard to solve due barriers e.g desensitisation/victimisation
What is primary health prevention?
Aims to prevent onset of disease.
* Screening risk factors.
* Health protection.
* Health education.
What is secondary health prevention?
- Detect and cure disease at early stage.
- E.g. cancer screening.
What is tertiary health prevention?
Minimise the effects or reduce the progression of irreversible disease.
What is health persuasion?
- The process of influencing an individual’s attitudes, beliefs, and behaviors related to health
- Includes mass media campaigns, such as sexual health and health eating.
- For example, 5-a-day TV campaign.
How is personal counselling involved in health promotion?
- Opportunistic prevention in consultations.
- For example, working with dietician on food.
What is health protection?
- Legislation to protect public health.
- Includes seat belts, restrictions on smoking in public.
What is prevention paradox?
A preventative measure which brings much benefits to the population but offers little to each participating individual. e.g cigarette tax
What is advocacy for health?
A combination of individual and social actions designed to gain political commitment, policy support, social acceptance and systems support for a particular health goal or programme.
What is empowerment for health?
A process through which people gain greater control over decisions and actions affecting their health.
What is enabling?
Taking action in partnership with individuals or groups to empower them to promote and protect their health.
What is health literacy?
The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health.
What are social inequalities in health?
Differences in people’s health linked to social inequalities in their lives.
What are health inequities?
The unfair and avoidable differences in health status arising from poor governance, corruption or cultural exclusion.
What are the social determinants of health?
The conditions in which people are born, grow, live, work, and age, shaped by the distribution of money, power, and resources at global, national, and local levels
What are the 3 intermediaries between social factors and health outcomes
- Material - stuff you have e.g house, car, food
- Psychosocial - the stressors/emotional wellbeing
- Behavioural - eating, smoking, alcohol consumption
What did the Black Report show? (1980) (3)
- Confirmed social health inequalities are involved in mortality and the extent of this
- Shows health inequalities were widening, despite general improvement
- Recommended increasing child benefit, introducing minimum wages + improving housing
What year was the Black Report?
1980
How do childhood circumstances influence inequalities? (2)
- Childhood is a period of rapid development and heightened sensitivity to environmental
influences. - Father’s occupation at birth is a strong indicator of life expectancy.
Name some government initiatives to help reduce child poverty?(6)
- Raising National minimum wage.
- Increase child benefit.
- Increase income support.
- Teenage pregnancy strategy.
- Supporting families into work and increasing their earnings
- Providing free school meals to all infant school children
Why has child poverty increased? (8)
- Unemployment/part-time work.
- Lower pay.
- Rising prices of food/necessities
- More single parent families.
- Freezing or abolition of some benefits
- government cuts
- More indirect taxation.
- economic inflation
What is in the Marmot Report 2010? (4)
- Shows life expectancy has stalled in UK
- People living in deprived areas spend most of their (shorter) lives in poor health
- Funding cuts have worsened inequalities
- urgent health improvement needed in north
What is the inverse care law?
The availability of good medical care tends to vary inversely with the need of the population served
What is inclusion health?
Services, research or policies that work to redress inequities by supporting specific vulnerable groups e.g homeless, migrants, sex workers
What is culture?
System of knowledge, experience, belief, attitudes, meanings, signs, and symbols shared by a group of people
What is socioeconomic status (SES)?
Defines the economic and social position of a person in terms of income, wealth, education, and occupation
What is enculturation?
Process of learning your own group’s culture.
What is acculturation?
Process of taking on another groups culture
Why do people self care? (2)
- Many people will self treat before seeing a doctor.
- Many cultures have strong non-western medical traditions.
Why are CAMs (complementary and alternative medicine) used? (6)
- Easily accessible, cheap
- own control over treatment.
- Dissatisfaction with health care.
- Poor doctor-patient relationship.
- Desperation.
- Perceived effectiveness and safety.
What is diagnosis?
Determining the nature of a disorder by considering the patient’s signs and symptoms, medical background, and test results.
What is prognosis?
Assessment of future course and outcome of patients disease based on knowledge of similar patients together with the pt’s health, sex and prognostic factors
Why is prognosis important? (3)
- It can help diagnostic and treatment decisions.
- It is important for patients to know the likely course of their disease.
- Helps discussing opinions of patients
3 aspects of prognosis questions
- Qualitative - which outcomes could happen?
- Quantitative - How likely are the outcomes to happen?
- Temporal - over what period will the outcomes happen?
What are the 3 types of theory that evidence based decision-making focuses on?
- Descriptive - What are you doing?
- Normative - What should you be doing?
- Prescriptive - How can we improve what you are doing?
What is the hypothetico-deductive model?
Seeking evidence to disprove your hypothesis
Who uses the hypothetico-deductive model? (2)
- Inexperienced clinicians.
- Experienced clinicians with a problem they don’t recognise.
Two phases of decision making
1) Framing & editing - preliminary analysis of problem
2) Evaluation - framed prospects are evaluated and highest value one is selected
Broad evidence vs narrow evidence
Broad evidence is any factor that can and should influence clinical decision-making, whereas narrow evidence is the results of rigorous clinical trials and observational studies.
What is the hierarchy of evidence?
Lists the types of study design ranked in order of their perceived ability to provide evidence for use in practice.
Evidence Pyramid - the top piece of evidence and why is it used?
Systematic reviews and meta analyses
- most rigorous and least biased
What are the negatives of hierarchy of evidence pyramid? (2)
- Different studies are sometimes suited to certain evidence e.g case studies for smoking relation to cancer
- Doesn’t include qualitative (words) research e.g diaries/blogs can be very useful
What is a meta-analysis?
A procedure for statistically combining the results of many different research studies
Where can good evidence be found? (3)
- Cochrane database.
- Evidence based journals.
- Medline/embase
What is self-medication?
The ability to select and use medication to treat self-recognised illness or symptoms i.e. without medical supervision/ professional healthcare advice.
What is consent?
Voluntary agreement given by a competent patient that has been fully informed.
What are the 3 requirements for valid consent?
- Fully informed
- Voluntary
- Patient with capacity
What are the 4 forms of consent?
- Oral
- Written
- Implied
- Expressed
What information does the patient require as part of the consent process? (3)
- Potential benefits.
- Potential risks.
- Alternative treatment options.
When is consent not needed? (5)
- If patient lacks capacity e.g treated under mental health law
- Under 18, can be refused if in pt best interest
- In an emergency
- Public Health Act 1984/Mental Health 1983, detaining patients
- To prevent serious harm to others
When is consent required? (6)
- Before examination.
- Before treatment or care.
- Disclosure of confidential information.
- Screening.
- Teaching.
- Research.
Why is consent needed? (5)
- Improves trust between patient and doctor.
- Legal requirement.
- Respects pt autonomy.
- Professional duty.
- Avoidance of psychological/physical harm/distress
What is the Bolam principle?
Practitioners are not negligent if they act in accordance with the practice accepted by a responsible body of medical opinion
What is battery?
If a person touches another person without consent.
What is negligence? What needs to be shown to successfully pursue a claim in relation to failure to get informed consent? (2)
- The concept of failure to exercise care.
- Needs to show a causal connection between failure to inform and the resultant harm
What is capacity?
- Determined by a physician, refers to an assessment of the individual’s ability to understand, appreciate, and manipulate information to form rational decisions.
Which act focuses on who has capacity?
Mental Capacity Act 2005
Who does the mental capacity act apply to?
People who are 16 and over.
Which act says a 16 year old has full capacity?
The Family Law Reform Act 1969.
What is Gillick competency?
Child (under 16) can consent to medical treatment if deemed competent by medical professional, without need for parental permission or knowledge.
What is a self-limiting disease?
A disease that does not require treatment to be cured; it will resolve on its own
Name 3 medications/treatments that should NOT be routinely prescribed due to self limiting nature of a disease
- vitamins/minerals
- coughs/colds/nasal congestion
- mild cystitis (bladder infection)
Define POM
Prescription only medicine that is dispensed from a pharmacy/other licensed place
What is a P drug?
You can get it from a pharmacy under the supervision of a pharmacist.
GSL drugs
General sales list - can be purchased from newsagents/ supermarkets, vending machines etc
What are OTC drugs?
Over the counter, can be purchased without prescription.
Why are P drugs used? (3)
- Pharmacists can ask customers questions about who it is for, symptoms, etc.
- Ensures no “red flags” about how long the patient can use it for.
- Duration of a symptom may mean it is not safe to self treat.
Who are the MHRA?
Medicines and Healthcare Regulatory Authority - authorise the marketing of drugs
Why is it important to accurately take medication history when prescribing? (3)
- prevents re-prescribing
- prevents interactions
- OTC medication can be abused (quite prevalent)
When can a POM change to a P?
No danger when used correctly without the supervision of a doctor.
When can a P change to OTC?
Safe to sell without the supervision of a pharmacist.
Why is a prescribed drug prescribed? (4)
- danger to human health, even when used correctly
- frequent incorrect use
- further investigation of side effects required
- product is administered parenterally (injection/infusion)
Name 4 community pharmacy teams?
- Minor ailment schemes.
- Emergency contraception.
- Smoking cessation.
- Health education.
Self-medication scale of analgesics say that the belief of patients can fit into 3 categories?
- People reluctant to take mild analgesics.
- People who “don’t think twice” about taking mild analgesics.
- People who prefer to let pain “run its course”.
2 types of quantitative data?
- Discrete - Only certain values possible.
- Continuous - Any value is possible.
3 types of qualitative data?
- Multinomial - Categories aren’t ordered.
- Ordered - Categories exhibit logical order.
- Dichotomous - Two categories that oppose.
What are descriptive statistics?
Data is collected and summarised and described in terms of means, SDs, etc.
What is ecological fallacy?
Inferences about the nature of individuals are deduced from inference for the group to which they belong.
What are inferential statistics?
Using statistical tests to make generalisations about a population.
What is nominal data?
Categorical e.g. sex.
What is ordinal data?
Categories ordered in value e.g. degree of pain.
What are measures of location? (3)
- Mean - Average of all observations.
- Median - Midpoint of the data set.
- Mode - Most frequent observation.
What is interval data?
Continuous data with equal intervals e.g. height, age, weight.
What are measures of dispersion? (3)
- Standard deviation
- Interquartile range
- Range
What is a hypothesis?
An idea expressed in such a way that it can be tested and refuted.
What is a null hypothesis vs alternative hypothesis? (2)
Null hypothesis H0 - there is no difference between two groups.
Alternative hypothesis H1 - a difference exists between the two groups
4 components of hypothesis testing
- State H0/H1
- Define and evaluate a test statsitic
- Calculate p value
- Interpret the results
What is a P value?
The measure of probability that the null hypothesis was rejected when in fact the null hypothesis is true.
At what point is statistical significance generally accepted? What does it mean with regards to H0? (3)
- P=0.05. (any higher then not statistically signifcant)
- Strong evidence against the null hypothesis, can reject the null hypothesis.
- Statistically significant.
What is standard error? +formula
A measure of the variation of the mean, to asses how much discrepancy is likely in a sample’s mean compared with the population mean.
= SD/ √number in sample
What is a random error?
Random variation that is due to chance
When to reject null hypothesis?
When the p value is less than 0.05 (as strong evidence against it)
When to accept null hypothesis?
When the p value is more than 0.05 (as weak evidence against it. i.e should accept it)
A type I error (false positive) occurs when…
you reject null when it is true
A Type II error (false negative) occurs when…
The null hypothesis is accepted when it should have been rejected (null hypothesis is accepted incorrectly)
What does a larger sample size do to P value?
Lowers p value = more power due to reduced random error
What is the confidence interval?
A range of values so defined that there is a specified probability that the value of a parameter lies within it.
(e.g a range that we think the mean lies within)
What are confidence limits?
The actual upper and lower boundaries that state the boundaries of the confidence interval.
What is the Human Genome Project (HGP)?
An international collaborative effort to map and sequence the DNA of the entire human genome.
What were the HGP key findings? (2)
- All human beings are 99.9% identical at the DNA level = race is a social construct
- Enabled detailed understanding/marketising of human ancestry
What are the 2 HGP testing implications?
- Predictive testing - using genetics to identify risk of disease. However can lead to misinterpretation.
- Diagnostic testing - when a pt has signs/symptoms of genetic disease
How is ethnicity important in medicine? (4)
- Disease prevalence varies with ethnicity.
- Approaches to best treatment may vary with ethnicity.
- Affects behaviour towards others.
- Can look at the patient according to their own values.
what is structural racism?
Refers to organisations and cultures developed through history that maintain racist attitudes, beliefs and practices
what is one example of how race influences social health inequality?
Ethnic minorities have extra psychological stressors due to being treated as ‘other’, leads to increased poor mental health
What is ethnocentricity?
Judging one culture based on the values of another.
What are the primary, secondary, and tertiary management principles associated with sickle cell?
- Primary - Carrier screening.
- Secondary - Postnatal screening.
- Tertiary - Treatment, preventatives, therapeutics.
Why cant we screen everyone for disease? (3)
- Cost - It would cost a lot of money
- Could be seen as racist - Screening certain ethnic groups, impression of ethnic minorities being sicker/bringing in disease.
- How do we determine ethnicity so know who to screen?
What is risk? (2)
- Probability that an event will occur during a specified time.
- Only works if a time period is fixed.
what is relative vs. absolute risk?
- Relative - The ratio of the probability of developing an outcome in those exposed compared to those not exposed (risk ratio).
- Absolute - Risk of developing the disease over a time period.
How to calculate risk ratio? (3)
- Risk in exposed ÷ by risk in non-exposed.
- A RR of 1 - No difference in risk between the two groups.
- A RR of <1 - The event is less likely to occur in the experimental group than is the
control group.
What is absolute risk reduction? +formula
Difference in risk between study and control populations.
= risk in control - risk in experimental
= 0 (risk same in both groups
< 0 (risk reduction)
> 0 (risk increase)
What is confidentiality?
Pledge of agreement to not divulge or disclose information about patients to others.
When can confidentiality be breached? (4)
- Statute (law).
- Consent given by patient.
- When in Publics best interest.
- to prevent harm to others or to self
Name some statutes (laws) that oblige doctors to disclose information? (3)
- Public Health Act 1984.
- Road Traffic Act 1988.
- Prevention of terrorism act 1989.
What is a cross-sectional survey? (3)
- Descriptive study, observational.
- Analyses data from a population at one specific point in time, usually using a survey, to assess frequency/prevalence
- Used to generate hypotheses on risk factors
What is a cohort study? (2)
- Can be prospective (looking to future) or retrospective (looking into past).
- Subjects with certain exposure followed over time for outcome occurrence (start with exposure, compare outcomes)
what are the advantages of cohort studies? (4)
- usually large in size = researchers are able to draw confident conclusions regarding the link between risk factors and disease.
- can investigate multiple outcomes
- allows calculation of useful estimates
- reduces risk of survivor bias
what are the disadvantages of cohort studies? (5)
- complex, time-consuming and expensive.
- Participants may drop out, increasing the risk of attrition bias
- large numbers of confounding variables making it difficult to link cause and effect.
- does not establish causation, only association
- possible selection bias
When collecting past data it may introduce recall bias. What are examples of objective and subjective approaches to gathering this data and which is better at preventing recall bias? (2)
- Objective - gain access to Dr’s notes (BETTER)
- Subjective - surveys/interviews people may not be able to remember
what is attrition bias?
systematic differences between people who drop out or stay in a study
what are the 3 systematic differences in a sample that may occur when recruiting for cohort studies (selection bias)?
- healthy population may not be representative of a real community
- individuals may volunteer purely for monetary gain
- different groups may vary on socioeconomic factors + lifestyle
what are the disadvantages of cross-sectional studies? (4)
- hard to find causal relationships
- cannot estimate incidence
- Limited information on temporal relationships
- potential Bias in sampling
what are the advantages of cross-sectional studies? (6)
- Can be done in a short period of time
- Cheap
- Provides prevalence data
- Provides trend data
- Hypothesis generating
- Easy to conduct a survey
What is a case control study?
An observational style study that looks back retrospectively to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease/outcome.
what are weaknesses of case control studies? (4)
- If frequency of exposure is low, case control studies quickly become inefficient
- difficulty choosing control group
- Particularly prone to bias; especially selection, recall and observer bias.
- The temporal sequence between exposure and disease may be difficult to determine
what is recall bias?
Systematic error due to differences in accuracy or completeness of recall to memory of past events or experiences.
what are the strengths of case control studies? (4)
- can study multiple risk factors/exposures
- effective in the investigation of diseases that have a long developmental time
- allows calculations of multiple useful estimates (incidence rates, relative risk…)
- Useful in the study of rare disease
What is a case report?
Detailed report of symptoms, signs, diagnosis, treatment, and follow-up of individual patient.
What is temporal change? (2)
- People get better or worse irrespective of medical intervention.
- Hard to distinguish whether medical action or temporal change is responsible.
What is regression towards the mean?
If a variable is extreme on its first measurement, it will tend to be closer to average on its second.
What are activities of daily living?
Everyday tasks and functional activities that are an essential part of life.
Can be grouped:
- leisure
- locomotion
- personal
- work/domestic
What is impairment? (2)
- illness, injury or a congenital condition that either causes or is likely to cause a loss of or a difference to function.
- may be functional, physiological or psychological.
What is disability?
Disability is the loss or limitation of opportunities to take part in society on equal a level with others due to either environmental or social barriers.
What is a handicap?
Disadvantage from impairment that limits/prevents the fulfilment of a role that is normal for that individual.
what are allied health professionals?
Healthcare professionals who support the work of physicians pre/during/post treatment to optimise the experience.
INc. nurses, technologists, radiographers, therapists, and others.
What are the major roles of physiotherapists? (2)
- Impairment assessment.
- Management of condition through various therapies e.g acupuncture
What are the major roles of occupational therapists? (5)
- Functional assessment.
- Occupational assessment.
- Goal setting
- QOL assessment
- Advise and arrange adaptations for employment and/or hobbies
Name some measures that assess activities of daily living? (5)
- Measures of disability - Barthel Index
- Observation.
- History taking.
- Clinical examination.
- Validated questionnaires
what are the characteristics of frailty? (5)
- Weight loss
- Fatigue
- Reduced grip strength
- Diminished physical activity
- Slowed gait - often closely associated with an increased risk of falls
What are the requirements of the biopsychosocial model of approach to disability? (2)
- Individuals must be an active participant in their own rehab and recovery, showing effort and approp. behaviour
- Management must relieve pain and prevent disability.
What is the biopsychosocial model?
a model of health that integrates the effects of biological, behavioral, and social factors on health and illness
what are the three components of the biopsychosocial model?
- bio - impairment and loss of function
- psycho - attitudes, illness behaviour, distress
- social - occupational demands, cultural attitudes, economic incentives
what is biomedicine?
understanding disease/illness as a biological cause
What is the medical model of disability? (3)
- Disability due to an underlying disease/disorder
- Exclusion from society.
- looks at what is wrong with the person and that it requires intervention/treatment
what are the historical factors which led to the development of the medical model? (3)
- Industrial revolution - replacing low tech local work
- Advances in technology - something can be done
- Social Darwinism - survival of the fittest
what are the criticism of the medical model disability? (4)
- Looks at disability as a tragedy.
- Doesn’t look at the person as normal in society.
- Sees disability as a medical problem that doctors have to fix.
- Focuses on what they CANT do
What is the social model of disability?
Emphasises the social and environmental constraints on a person, that results in discrimination
What are some examples of the social model of disability being bad? (4)
- Discrimination arises because of the organisation of society.
- Society fails to make activities accessible e.g poorly designed buildings/public transport
- Doesn’t fully appreciate the complexity of different disabled peoples lives.
- segregated education
What is social constructionist theory of disability?
There is no such thing as a disabled individual but that society makes people disabled.
The international classification of functionality, disability and health (ICF) uses what 3 components to measure disability?
1) body function and structures
2) Activities
3) Participation
Which act gives rights to disabled people?
Disability Discrimination Act 1995.
what is an ecological study?
A study that compares groups rather than individuals, snapshot descriptive/observational study
what are the European Convention on Human Rights (ECHR) relevant to clinical practice? (7)
- The right to life (Article 2)
- Freedom from torture (Article 3)
- Right to liberty and security (Article 5)
- The right to respect for family and private life (Article 8)
- Freedom of thought, conscience and religion (Article 9)
- Freedom of expression (Article 10)
- The right not to be discriminated against in respect of these rights (Article 14)
What act defined disability as “a physical or mental impairment that has substantial and long term negative effects on your ability to do normal daily activities”?
Equality Act 2010
What are the measures for assessment of disability? (6)
- Barthel Index.
- SF36.
- Functional assessment measure.
- Health assessment questionnaire (HAQ)
- Nottingham health profile
- EQ5D
What is a informal carer?
A person who, without payment, provides help and support to a partner, child, relative, friend, or neighbour who could not manage without their help.
What is care poverty?
- Cannot work because you are caring.
- so reduced lifetime earnings with wider gender equality implications
What are the effects of caring on health? (3)
- Increased physical health problems e.g lack of time for exercise or to see doctors
- Increased mental health problems e.g loneliness/seeing friends
- Carers often don’t have enough time to look after their own health.
What are the problems with people taking time to identify as carers? (6)
They don’t take advantage of benefits/resources available
e.g
- Carers special grant
- Carers allowance
- Practical and emotional support
- Training in care activities e.g lifting
- Respite and short term breaks
What are some legalisations that supports carers? (4)
- Employment Act.
- Carers and Disabled Children Act.
- Carers Act.
- Equality Act.
What are the rights of carers? (4)
- Assessment of needs in their own right.
- Carers special grants
- Made aware of their entitlement in assessment.
- Assessments must consider carers’ wishes about employment, training, etc.
What is carers’ special grant?
Funding for respite and short breaks for carers.
What financial support is there available for carers? (3)
- Carer’s allowance - For people who regularly spend at least 35 hours a week caring for someone with a severe disability who receives a qualifying disability benefit.
- Disability living allowance - Many carers not only look after someone but are ill
themselves. - Attendance allowance - Benefit for severely disabled people aged 65 or over who need help with personal care.
What employment related policies are there for carers? (2)
- Time off for dependents.
- Flexible working regulations.
( Work and Families Act 2006)
What is distributive justice?
How we distribute finite resources in a fair way.
what is equality vs equity? (2)
- Equality is that people are given the same resources/opportunities e.g hospice nurse spending equal time with pt’s
whereas - Equity is people are given resources/opportunities based on their individual needs/circumstances e.g community free checkups
What are qualified vs limited rights? (2)
- qualified rights can be restricted in order to protect others + in publics best interest (have more exceptions)
- limited rights can be lawfully restricted e.g liberty with arrest (limited to fewer exceptions)
what is an example of qualified right?
right to free speech
what is an example of limited right?
right to own property
How can you decide ways to distribute resources in healthcare? (4)
- QALY (quality adjusted life year) calculation.
- Waiting list (higher = more priority)
- Likelihood of complying with treatment (more compliant = more priority)
- Lifestyle choices of patient (bringing condition upon themself)
what are rights?
Rights are justified claims on others or things to which a person is entitled (and is due them).
what are the importance of rights? (4)
- protective boundaries (limits actions of others)
- conducive to good (dignity, respect, happiness)
- provide minimum standards (represents least we can expect)
- Provide security of expectations - knows where one stands; social environment predictable/secure
what are absolute rights?
no exceptions or limits
e.g prohibition of torture
What is the Libertarian argument?
Some people are poor because they don’t work hard enough, or cause their own needs (e.g. by smoking).
What is a lifestyle-based assessment?
Allocating resources should take into account lifestyle choices patients make.
what are the arguments for lifestyle-based assessment? (3)
- People who contribute to ill health are less deserving of resources for treatment than those who don’t.
- Deterrence - It is more likely to deter people from damaging their health.
- You are also more likely to get more benefits from a treatment in people who don’t behave inappropiately
what are the arguments against lifestyle-based assessment? (5)
- Not everyone purposely engages in high risk behaviour and is not responsible for their actions.
- Unfair to punish people - no less deserving
- Deemed unacceptable by the GMC to use lifestyle-based approach.
- Not the role of doctors to make decisions regarding who is more deserving of treatment
- patient may have no or little control over habits and therefore unfair to say they are less deserving of treatment
What rights does a person have in relation to resource distribution? (3)
- Legal rights e.g to vote
- Natural moral rights e.g to autonomy
- Human rights e.g to life
What are instrumental theories? (2)
- The purpose of rights is to promote a certain state of affairs which is seen as good.
- If we have a system that recognises rights, it will lead to a much happier society.
What are the main 2 aims of the human rights act? (2)
- To make it possible for people to directly raise or claim their human rights within complaints and legal systems in the UK.
- To bring about a new culture of respect for human rights within British Law, not just about public authorities complying with the law.
What is pharmaceuticasation?
Transformation of human condition into opportunities for pharmaceutical intervention.
What is social iatrogenesis?
Harm resulting from the medicalisation of life.
Harm resulting from the medicalisation of life.
The destruction of traditional ways of dealing with and making sense of death, pain and sickness.
What is stigma?
A mark of disgrace associated with a particular circumstance, quality or person that discredits the individual, denying full social acceptance.
What is the process of producing stigma? (5)
- Labelling - Label human difference.
- Stereotyping - Differences link to characteristics.
- Othering - Separating yourself, ‘us and them’.
- Stigmatising - Devaluing people based on ‘undesirable’ attributes.
- Discrimination - Acting differently towards people based on attribute/behaviour.
What is stress?
An imbalance between the demands made on us and our personal resources to deal with these demands.
what is primary vs. secondary appraisal of stress? (2)
- Primary - Appraisal of event.
- Secondary - Appraisal of personal coping skills.
What are the 4 components of the stress response?
- Emotional - Feeling sad, over-reacting.
- Cognitive - Cannot concentrate, sensitive.
- Behavioural - Eating, smoking.
- Physiological - Heart rate, breathing, perspiration.
What is symptoms amplification? (2)
- Misinterpretation and amplification of symptoms due to stress and other psychological factors.
- Occurs due to tendency to worry, mental illness, illness beliefs.
how do medically unexplained symptoms arise during times of stress? (2)
- Misinterpretation and amplification of symptoms due to stress and other psychological factors.
- Occurs due to tendency to worry, mental illness, illness beliefs.
What is illness cognitions?
A patient’s own implicit common sense beliefs about their illness.
What are Leventhal’s 5 dimensions to illness cognition?
- Identity
- Timeline
- Consequences
- Cause
- Control/cure
What are positive coping strategies to illness? (2)
- Problem-solving - Controlling problem and reconstructing it as manageable, seeking
information and support. - Emotion focused - Involves managing emotions and maintaining emotional equilibrium.
What are negative coping strategies to illness? (2)
- Problem focused - Focuses on problem, unlikely to help reduce stress.
- e.g denial, substance abuse, social isolation, avoidance
What are medically unexplained symptoms?
Physical symptoms not explained by organic disease.
What are the main problems with medically unexplained symptoms?
Patient presents with symptoms and doctor tries to treat disease, despite there not being one (iatrogenic harm)
What are the consequences of living with Medically unexplained symptoms? (4)
- Uncertainty - no diagnosis or prognosis.
- Lack of social support.
- Can’t enter the sick role.
- Strained social and family relations.
What are the doctors assumptions about Medically unexplained symptoms? (5)
- Explanation lies with the patient.
- Patients deny a psychological cause.
- They want a cure and diagnosis.
- They get physical intervention because they demand it.
- Doctors should help patients to appreciate psychological factors.
What does the patient want when they present with MUS? (3)
- Alliance with the doctor over problems.
- Wants the doctor to recognise they are suffering and it’s not their fault.
- A convincing explanation that is plausible and credible.
What is a rejective response?
Doctor denies the reality of the disorder and implied it is a stigmatising psychological problem.
What is a collusion response?
Using explanations about blood pressure and serotonin to push antidepressants.
What is an empowering response?
Legitimises patients suffering, exculpation.
what is addiction vs dependence?
- Addiction is mental/behavioural disorder characterised by continued repetition of a behaviour despite adverse consequences,
- Dependence is the presence of the symptoms of tolerance/withdrawal
What are the symptoms of dependence syndromes? (4)
- Salience.
- Compulsion.
- Tolerance/Withdrawal.
- Relief after abstinence.
What factors make a drug addictive? (4)
- Pleasure producing potency.
- Rapid onset of action.
- Short duration of action.
- Tolerance and withdrawal.
What maintains addiction? (3)
- Personality factors.
- Social factors.
- Withdrawal symptoms.
What are the symptoms of end stage addiction? (3)
- Overwhelming desire to take drug.
- Almost automatic habit.
- Can be triggered by cues many years after abstinence.
What is falsifiability?
We can rarely prove things are true, but can easily prove things are false.
What is statistical significance?
Strength of association gained by hypothesis testing.
What is clinical significance?
Practical importance of treatment effect and whether it has a noticeable effect on everyday life.
What is a chronic condition?
Long term illness expected to last 12 months or more.
What are the characteristics of a long term condition? (6)
- Uncertainty - Diagnosis, prognosis, complications, etc.
- Involves high levels of self-management.
- Can have consequences for employment.
- Can be a source of embarrassment or stigma.
- Can have impact on social life.
- Can impact self-identity and personal relationships.
What are the positive consequences of being diagnosed? (6)
- Relief.
- Access to sick role.
- May result in employment rights, welfare benefits.
- Accepted as ill by friends and relatives.
- Access to information.
- Access to support groups.
What are the negative consequences of being diagnosed? (7)
- Face new set of uncertainties - prognosis, etc.
- Stigma.
- Possible limitations on paid work.
- Worry about being able to fulfil obligations, e.g. look after children.
- May have to claim benefits.
- Worry about complications.
- Worry about being able to deal with medications.
What uncertainty comes with chronic illness? (4)
- Social - Employment, finance, etc.
- Clinical - Prognosis.
- Diagnosis.
- Psychosocial - Sense of self and identity.
What is biological disruption? (2)
- Sees chronic illness as disruptive event, disrupting structures of everyday life.
- Onset of chronic illness can affect upon a person’s sense of self and their identity.
What is biographical continuity? (3)
- Biographical distribution based on adult-centred model.
- It is a part of themselves since birth.
- Older adults will usually maintain the same activities, behaviours, relationships as they did in their earlier years of life.
What factors affect self-management of a long term illness? (5)
- Relationship with doctor.
- Good experience with doctor in the past.
- Drugs best avoided.
- Experience of symptoms when they don’t take them.
- Gender roles.
What is social cognition theory?
Attitudes are developed and modified based on assessments about beliefs and values.
How do you identify all relevant studies in systematic reviewing? (3)
- Search relevant databases (medline/embase)
- Develop complex search strategy.
- Include unpublished data.
What are the methods of quality assessment? (4)
- Randomisation.
- Allocation concealment.
- Blinding.
- Withdrawals and intention to treat analysis.
What is heterogeneity?
The differences in the results, methodology or study populations used in the included studies.
what are the Kubler-Ross stages of grief? (5)
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
What is publication bias?
Not all clinical studies get included in a systematic review due to:
- not being published
- not written in English
- show non-significant results
What is the margin of error? (2)
- A statistical expression of the amount of random sampling error in the results of a survey.
- The larger the margin of error, the less confident you can be that the results reflect onto the population.
(A way of measuring how effective your survey is)
What are the 5 Principles of the Mental Capacity Act 2005?
- A presumption of Capacity (cant do this), unless proved otherwise
- Individuals being supported to make their own decisions (i.e find ways to communicate)
- There is no Unwise decisions (people have own preferences/beliefs)
- Best Interests
- Less restrictive option
What services are available to assist patients with learning disability? (6)
- Learning disability hotline
- Local groups
- Short breaks and respite services
- Social care support funded by government
- Primary care
- Secondary care
what is social care support for people with LD’s? (2)
- Social care support funded by government - practical, professional support for people who need extra support with everyday life.
- This might be help with cooking, shopping, personal care or support with managing money or getting a job.
what is death by indifference?
Deaths which could’ve been avoided, but occurred due to neglect within the health care system, institutional discrimination, and delay in diagnosis and or treatment
what is a multidisciplinary approach?
A multidisciplinary approach involves drawing appropriately from multiple disciplines to explore problems outside of normal boundaries and reach solutions based on a new understanding of complex situations
What are the 3 core development elements of a multidisciplinary team?
- Continuum - The continuum sets out descriptions of different types of care delivery teams functioning and describes how these change as multidisciplinary team working deepens and extends throughout the team.
- Common Principles - To be effective, every team needs core principles that to adhere their functions, practice and delivery together.
- Commissioning - Focusing on innovative & effective use and distribution of funds to commission services for a multidisciplinary team.
what are the common principles followed in multidisciplinary teams? (6)
- Team approach
- Communication among team members regarding treatment planning
- Access of the full therapeutic range for all patients, regardless of geographical remoteness or size of the institution
- Provision of care in accordance with the nationally agreed standards
- Involvement of patients in decisions about their care
- Shared goals and objectives about providing best care
How does a multidisciplinary team relate to quality of care for patients? (4)
- Pt experience a co-ordinated seamless service that is centred on parental choice and decision.
- promotes independence + QOL
- Improved information sharing
- Health Care Plans based on goals established
what are the 4 stages of drug development?
- drug discovery
- preclinical development/studies e.g non human/animal trials
- clinical development e.g satisfactory human clinical trial + cost effectiveness
- post marketing surveillance stage
what is statistical power? (2)
- the likelihood of finding a statistically significant difference when a true difference exists (True positive result)
- or correctly rejects the null hypothesis when it is false
what is temporal consideration to an RCT?
People being treated may be at different periods of a disease
what is antisocial behaviour?
behaviour that goes beyond the limits (transgresses) of society’s rules, norms and laws and likely causes harm to others
What is the antisocial behaviour prevalence? (2)
- 1/20 five to nineteen year olds
- mainly boys
What is the antisocial behaviour economic impact? (2)
- estimated £70k over lifetime through…
- educational provision (changing schools), criminal justice processes, policing costs, social work
what is Oppositonal Defiant Disorder (ODD)? (2)
- a disorder characterised by age-inappropriate and persistent displays of angry, defiant, and irritable behaviours
- challenging adult authority
what is conduct dissocial disorder? (3)
- repeated rule/law breaking
- disregarding the well being of others
- lacking empathy (with or without prosocial emotions i.e comforting/agreeing with people)
what is dissocial personality disorder? (4)
- repeated disregard to social morals and/or laws
- failure to respond to punishment
- lack empathy
- often manipulative, risk taking and charming
what are developmental issues associated with Conduct dissocial disorder (comorbidities)? (4)
- learning difficulties e.g with school or ADL
- literacy issues e.g dyslexia
- autism
- ADHD (cant concentrate)
Mental health issues associated with Conduct dissocial disorder (comorbidities)? (6)
- depression
- anxiety
- substance misuse
- PTSD
- attachment disorder
- psychosis spectrum illness e.g schizophrenia
How do you assess people with conduct issues? (4)
- NICE guidelines
- developmental history and illnesses
- mental health assessment
- Adverse child experiences (ACE’s)
what is the genetic cause of anti-social behaviour ASB? (2)
- Low activity of the allele of MAOa (breaks down neurotransmitters),
- Leads to aggression and a higher risk of conduct disorders in adult life
What are the types of conduct disorder/antisocial behaviour psychosocial management in under 18’s? (3)
- Parent management training - helps cares deliver good parenting
- Cognitive behaviour therapy - can improve anger management
- Multisystemic therapy - based on family therapy, very expensive but very effective
What is the difference between ICD-10 vs DSM-5? (2)
- ICD is international
- DSM is American and used more in clinical trials
what are 2 forms of depression assessment?
- PHQ-9
- HADS (used in hospital)
what is APMS - Adult psychiatry morbidity survey?
Carried out every 7 years to gauge prevalence of mental disorders
what are the difficulties measuring mental health? (5)
- Hard to categorise and diagnose
- Relapsing and remitting nature of mental health conditions
- A substantial amount of mental health services are delivered outside the health sector
- Huge numbers of people
- Sub-groups in the population
what are the social gradients of health?
the higher a person’s income, education or occupation level (socioeconomic status), the healthier they tend to be and vice versa
what are the impacts of increasing cost of living? (3)
- 3/4 adults having feelings of worry/anxiety
- around 1/2 of patients are cancelling/pausing therapy sessions due to money concerns
- 2/3 of therapists report cost of living is deteriorating mental health of their patients
what are the drivers of the relationship between poor mental health and poverty? (4)
- debt
- food insecurity
- stress
- precarious employment
what are Adverse Childhood Experiences (ACEs)?
Stressful or traumatic life experiences that can lead to poor health in adults. e.g
- abuse
- neglect
- domestic violence
- parental substance abuse
- parental mental disorders
- separation or divorce
what is health psychology?
the subfield of psychology concerned with how psychological factors influence the causes and treatment of physical illness and the maintenance of health
what is health behaviour?
any activity people perform to maintain or improve their health, regardless of their perceived health status or whether the behavior actually achieves that goal
what are 3 common health behaviours?
- Regular exercise
- Eating a balanced diet
- Obtaining necessary vaccinations (inoculation)
what are some examples of health impairing behaviours (negative health behaviour)? (6)
- Smoking
- Poor nutrition
- Lack of exercise
- Alcohol and drug use
- Risky sexual behaviour
- Transmission, misconceptions, and prevention of AIDS
what are some health protective behaviours? (4)
- attending Screenings/health checks
- vaccination
- safe sex
- good exercise/diet
what is the attribution theory of health belief?
How a person perceives causal explanations for events/behaviour
(how people explain causes for their behaviour) e.g internal or external or controllable or uncontrollable
what is the locus of control theory of health belief?
People differ to the degree in which they can control their lives e.g
- internal vs external
- behavioural control (action taken)
- cognitive control (external expect others to help and vice versa)
what is internal vs external locus of control? (2)
- internal - one controls own’s life e.g more likely to manage their own symptoms + use coping strategies
- external - outside forces dictate one’s life e.g belief symptoms are due to luck/chance, more likely to look for others for help
what does Leventhal’s model of illness representation explain?
common sense of self regulation model based on emotional reactions to health
How can Leventhal’s model of illness representation be used in practice? (2)
- provides framework to guide understanding of how patients view their illness
- can correct inaccuracies that may affect management of their condition and decision making
People’s self-efficacy is based on what things? (3)
- previous experience
- outcome expectancy (desirable?)
- self efficacy expectancy (that one can perform the behaviour properly)
what are the steps of the Transtheoretical Model of Change? (6)
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance
- Relapse
what is the health belief model?
model for explaining and predicting how beliefs may influence behaviours
In the health belief model patients are more likely to adhere when….? (5)
- Perceived severity - view problem as severe
- Perceived benefits - consider likelihood of effective treatment as high
- Perceived susceptibility - Perceived threat to sickness or disease
- Self efficacy - believe they can change
- Perceived barriers - identify few barriers to adherence
what is Protection Motivation Theory (PMT)? (2)
- A psychological theory that explains how individuals respond to threats and engage in protective behaviours.
- Influenced by two key factors:
threat appraisal and coping appraisal.
What needs to happen for protection motivation theory to occur?
the perceptions of vulnerability and severity (threat appraisal) should outweigh the awards associated with the response
What are the theories of predictors of health behaviours? (4)
- The Transtheoretical Model/Stages of Change
- the Health Belief Model
- the Theory of Planned Behavior.
- protection motivation theory
what is the theory of planned behaviour?
assumes that individuals act rationally, according to their attitudes, subjective norms, and perceived behavioural control
what are some life events that may contribute to stress? (6)
- work problems
- money problems
- debts
- relationships
- moving house
- diagnosis of physical illness
what are some reasons for MUS? (3)
- Reduces stigmatisation of mental illness
- Allows people to assume the sick role
- Physical expression of distress, thus reduces internal emotional conflict.
what is primary vs secondary appraisal of stress?
- primary = appraisal of the event
- secondary = appraisal of personal coping abilities or resources available
what are the 4 main domains of the stress response?
- Emotional responses - feeling on edge, sad, irritable, tearful, overreacts (emotional dysregulation)
- Cognitive responses - difficulty concentrating and switching off, sensitive to criticism, self critical, difficulty making decisions (cerebral processes)
- Behavioural responses - comfort eating/loss of appetite, drinking/smoking, hyperactivity/underactivity, disturbed sleep
- Physiological response - physical symptoms e.g activation of SNS
what are the impacts of stress on existing physical illness (3)
- relapses
- poor control of chronic illness
- increased morbidity
What the impacts on health of stress? (4)
- poor compliance with medication
- increased alcohol intake
- increased smoking
- reduced exercise
what are the2 types of coping strategies for stress?
- problem solving e.g seeking information/support, developing action plan
- emotion focused coping e.g managing emotions, supportive friendships, resigned acceptance
what are the causes of MUS? (4)
- small genetic effects
- Cognitive processes e.g over worriers/thinkers
- childhood factors e.g physical illness used (unconsciously) as a method of obtaining support (insecure attachment)
- Previous neglect/abuse re wiring the brain
what is illness denial?
Behaviours to avoid the ‘stigma’ or inability to accept physical/mental disease
what is the prevalence of MUS?
- General population - 20%
- Primary - 10 to 33% presenting complaint diagnosed as MUS
what are the factors associated with poorer outcomes in addiction recovery? (2)
- social instability/support, alcohol free network, family history of dependence
- severity and chronicity of addiction
What are the social attitudes towards addiction?
stigma association
Motivational interviewing (within CBT) is a technique used to promote change, what are the 5 main principles?
- Expressing empathy through reflective learning
- Develop discrepancy through client’s goals and their current behaviour
- Avoid argument and direct confrontation
- Adjust to client resistance rather than opposing it directly
- Support self-efficacy and optimism
what is grief?
Physical, psychological, cognitive and spiritual responses to a loss
What are the types of grief responses (5)
- Affective - e.g depression, anxiety, anhedonia. anger
- Cognitive - e.g preoccupation of thoughts of deceased, helplessness
- Behavioural e.g agitation, crying, social withdrawal
- Psychological somatic - e.g appetite loss, energy loss, sleep disturbance
- Immunological/endocrine - e.g susceptibility, disease, mortality
what are the misunderstandings of kubler ross stages of grief? (4)
- grief is not linear and doesnt follow a specific pattern
- you can feel each state more than once
- theres no over/end date or point
- people may feel more than these 5 stages
What does a grieving child need during grief? (4)
- to know that they are going to be cared for
- to know that they didnt cause the death
- to feel important and involved
- someone to listen to feelings + questions
what are the cultural differences in grief/mourning? (3)
- the way grief is expressed
- treatment/disposal of body
- time allotted to mourning
what is complicated grief?
A cluster of symptoms such as anxious and depressive thoughts, painful memories, dreams of and preoccupation with the deceased.
What is the Equality Act 2010’s definition of disability?
A physical or mental impairment that has a substantial and long term negative effect on your ability to do normal daily activities
learning disability includes the presence of…? (4)
- a significantly reduced ability to understand new or complex information
- a significantly reduced ability to cope independently
- significant impairment in intelligence
- which started before adulthood, with a lasting effect on development
what are the problems facing people with learning disabilities? (5)
- discrimination
- social exclusion
- poverty
- insufficient support for carers
- premature mortality
What is the definition of PMLD and what does it stand for? (3)
- Profound and multiple learning disability
- Have more than one disability, the most significant of which is a profound intellectual disability.
- These individuals all have great difficulty communicating, often requiring those who know them well to interpret their responses and intent.
What are the 5 Reasonable adjustments for people with learning difficulties? (acronym)
T - Time - offering double appointments, early morning quieter app.
E - Environment - visiting a home/operating nurses meeting in normal clothes
A - Attitude - treating everyone with dignity and respect
C - Communication - using accessible information that they can understand
H - Help - Listening to others e.g family/staff/supporters advice
what are the examples of extra management/support given to people with PMLD? (4)
- reasonable adjustments
- hospital passports
- annual health checks
- intensive interaction/sensory stories
what are the five most prevalent comorbidities present in learning disabilities?
- visual impairment
- obesity
- epilepsy
- constipation
- ataxic/gait disorders
what is the 2 stage process to assess capacity of people with learning disabilities?
- Is there impairment/disturbance of functioning of brain?
- If so, is it sufficient to effect their capacity to make a normal decision?
A person is unable to make their own decisions if they cannot do one or more of… (4)
U - Understand info given to them
R - Retain info long enough to make a decision
W - Weigh up the info
C - communicate their decision
Why are annual health checks important for people with learning disabilities? (3)
- improve care for people with LD
- reduce health inequalities
- prevents early deaths
what are the things included in a LD annual health check? (8)
- physical check up including height, weight, BP, HR
- Urine/blood tests
- discuss how to keep healthy
- ask about common problems e.g constipation, dysphagia, eyesight etc
- medication review to prevent over medicalisation
- vaccinations
- ask about feelings
- create health action plan
What is the social cognitive model of stigmatisation? (3)
- Cognitive - Problems of knowledge: faulty info
- Emotional - Problems of attitude: stereotypes lead to fear/anxiety
- Behavioural - Problems of discrimination
what is self-stigma vs felt stigma?
- self stigma is - the disgrace people assign themselves because of public stigma, impacts their self esteem.
- felt stigma - the shame and expectation of discrimination that prevents people from talking about their experiences and stops them seeking help.
what is enacted stigma?
refers to the experience of unfair treatment by others
what is stigma by association (courtesy stigma)?
people being impacted by being associated with a stigmatised person
what are the 3 levels of stigma + examples?
- Individual Stigma e.g self stigma
- Public/social Stigma e.g media representations
- Structural Stigma e.g black lives matter (more likely to enter MH services through police/criminal justice system)
what is personality?
an individual’s characteristic style of behaving, thinking, and feeling
what are the 4 theories of personality?
- Psychoanalytic - unconscious motives + childhood experiences
- Humanistic - Subjective human experience + perspective (focuses on optimism)
- Trait - extroversion/introversion, 3 factor theory, 16 personality factors
- Social-cognitive - influenced by social learning theory, environment and conditioning, internal/external locus of control
what is Self-actualisation (Maslow)?
realisation of personal potential, becoming everything one is capable of
what are Freud’s 3 levels of consciousness?
- Conscious - contact with outside world
- Preconscious - things just below that you can bring to consciousness
- Unconscious
what is Eysenck’s 3 factor Theory?
Suggests that personality can be described and understood based on three fundamental dimensions or factors:
- extraversion > introversion
- neuroticism > emotional stability
- psychoticism > impulse control
what are the big 5 personality factors (CANOE)?
C - conscientiousness
A - agreeableness
N - neuroticism (poor emotional stability)
O - openness to new experience
E- extraversion
what are the criticisms of the big 5 personality factors (2)
- does not comment on personality development (changing)
- poor predictor of future behaviour
what are 3 objective personality tests?
- MMPI - Minnesota Multiphasic Personality Inventory
- 16PF Questionnaire
- NEO personality inventory - measures the “Big Five” personality traits
what is a personality disorder?
A diverse category of psychiatric disorders characterised by long term behaviour that deviates markedly from the expectations of cultural norms.
what is the WHO’s definition of mental health?
A state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community
what is mental illness?
a disorder that affects a person’s thoughts (cognition), emotions, and social behaviours
what are the differences in how classifying/treating mental illness has changed (4)
- emergence of medical sciences (traditionally seen as religion/witchcraft)
- rise of psychiatry + neurology (who started to treat + use talking therapies)
- new pharmacology
- psychoanalysis
what is the definition of ethnicity?
Shared origins, culture and traditions that are maintained between generations, ultimately leading to a sense of identity and group
what is the definition of race?
A group of human beings distinguished by physical traits, blood types, genetic code patterns or genetically inherited characteristics.
what are the ethnic minority variations in health? (Black and african caribbean)
Black and african caribbean more likely:
- to be diagnosed schizophrenia/psychosis
- to be regarded as violent
- to be hospitalised via police
- were more affected by pandemic
what is the Minority Stress Model?
A model that explains how individuals of marginalised groups experience discrimination (environment not genetic) and how it can produce both negative and positive physical and mental health outcomes for stigmatized group members
what are the 5 reasons for differences in mental health numbers between races/genders?
- constructions of masculinity/feminity (internal/external)
- cultural and social causation
- environment
- minority stress model
- medical systems (racism, lack of diversity, disparity in treatment)
what is intersectionality?
the complex, cumulative way in which the effects of multiple forms of discrimination (such as racism, sexism, and classism) combine, overlap, or intersect especially in the experiences of marginalized individuals or groups
what is attachment?
the tendency to make strong emotional bonds to particular individuals, usually seen in children seeking protection/care
what is the smoking culture in mental health services? (3)
- way to pass boredom
- staff offer cigs
- elevated smoking rates amongst staff
what is therapeutic nihilism?
belief that rehabilitation doesn’t work
what are the problems facing SMI patients who want to quit smoking? (2)
- dont have access to conventional cessation services
- not encouraged to do so by MH workers
what are some consultation issues regarding sex? (6)
- Embarrassment depending on approach
- Lack of language to describe emotions/sensations/body parts
- Assumptions of gender
-What is “normal”? - Assumptions of another’s experience
- easy to be distracted by own experiences
what are the considerations of consultations regarding sex? (5)
- LGBTQ+
- type of penetration?
- be aware of cultural norms
- be open and comfortable
- is there violence/payment involved? (be non judgemental)
what is the definition of medicalisation?
Process by which some natural aspects of human life come to be considered/treated as medical problems, whereas before they weren’t considered pathological.
e.g pregnancy, childbirth, death, ageing, sexual desire and sadness, menopause, menstruation, sleep, stress
what is Conrads theory of medicalisation of hyperkinesis? (2)
- Hyperkinesis (ADHD)
- Happened because children were not conforming to social expectations, but also because of pharmaceutical developments in psychoactive drugs
Ivan Illich argued medical care caused iatrogenic harm at what 3 levels?
- Clinical - unnecessary/harmful medical treatments e.g side effects from drugs
- Social - people becoming over reliant on health care
- Cultural/structural - medicine undermines peoples capacity to cope with life, such as pain suffering and death
What is the medicalisation of childbirth? (4)
- In the past, childbirth was a domestic event, attended by mainly females + 1 midwife at home, now less private
- Recently the credibility and traditional knowledge of midwives were reduced + Homebirth is considered more hazardous
- healthy and normal physiological phenomena
- Active management of labour
What is the active management of labour as an example of the medicalisation of childbirth?
Women subjected to hourly internal examinations and progress in labour measured by cervical dilatation
What is the medicalisation of ageing? (3)
- process of gradual physical decline, used to be managed by families/communities
- medicalisation of conditions such as pre-diabetes, prehypertension, overactive bladder, sarcopenia (low muscle mass) and borderline-high risk cholesterol
- gives the idea that ageing is wrong, fearful and requires treatment. There is a huge budget for this.
what is Focault’s deployment of sexuality? (2)
- Sexuality is not a fixed, natural category but rather a socially constructed concept that has been used to regulate and control individuals and groups.
- biological basis of sexuality = anything that deviated from “normal” was underpinned with a biologically driven pathology, which could be rooted out, diagnosed and “cured” or contained.
what is an example of a manifestation of heteronormativity described by Focault?
conversion therapies
what is a heternormative society?
a condition in society where it is assumed that everyone is heterosexual
what is heteronormativity?
An ideology that indirectly promotes heterosexuality as the preferred sexual orientation
what is heterosexism?
discrimination or bias against persons because they are not heterosexual
what is trans inclusive care?
ensuring trans people feel safe to access healthcare regardless of setting
what was the 2018 LGBT action plan?
everyone regardless of their sexual orientation, gender or sex characteristics to be able to live safe, happy and healthy lives where they can be themselves without fear of discrimination
what are the advantages of medicalisation? (4)
- More humane treatment (palliative care)
- Gives the patient the feel of validation of their felt state (e.g associating low mood with MH disorders)
- life changing treatments
- release someone from social obligations (sick role)
what are the disadvantages of medicalisation? (3)
- overuse of unnecessary medical technologies
- Experts tend to dominate health care
- Dislocation of responsibility (i.e. with cases of PTSD rising)
what is a systematic review?
A systematic review is an appraisal and synthesis of primary research papers using a rigorous and clearly documented methodology in both the search strategy and the selection of studies in order to minimise bias in results.
what is the method for carrying out systematic review (7)
1 - review question
2 - define eligibility criteria + method
3 - search for studies
4 - apply eligibility criteria
5 - collect data + appraise quality
6 - analysis + synthesis
7 - Conclusions
what is the PICOS tool? (3)
- focuses on the Population, Intervention, Comparison, Outcomes and Study design of a (usually quantitative) article.
- used to identify components of clinical evidence for systematic reviews in evidence based medicine
- endorsed by the Cochrane Collaboration
What questions does PICOS ask? (5)
P – Population: Problem interested in, population/person characteristics
I – Intervention: Treat/diagnose/observe/…
C – Comparator(s): Placebo/no treatment/alternative
O – Outcomes: Morbidity/death/complications/…
S – Study design: RCT/cohort studies/historical cohort studies/…
When selecting studies for a systematic review what is important? (3)
- identify all relevant studies using pre specified selection/eligibility criteria
- check for unpublished data
- does it meet all of PICOS
What happens during the synthesis stage of developing a systematic review?
- collate, combine + summarise findings of individual studies found in all the systematic reviews.
*can be narrative or quantitative (meta-analysis)
what is a forest plot?
A graphical display to present the results of a meta-analysis
what do the horizontal line on a forest plot represent?
- illustrate the length of the confidence interval.
- The longer the line, the wider the confidence interval and hence, the less reliable the study results
what does the vertical line on a forest plot represent? (2)
- The vertical line is the line of no effect. -
- The position at which there is no clear difference between the intervention and control groups
what is a pooled estimate on a forest plot (diamond)?
Pooled estimate is the probability of an event occurring in the treatment group vs. it occurring in a control group across ALL studies.
- a narrower diamond = more precise estimate
What is the significant of lying left or right of the vertical line on a forest plot? (2)
- If the outcome of interest is adverse (i.e. mortality), the results to the left of the vertical line favour the intervention over the control.
- If the outcome of interest is desirable (i.e. remission), the results to the right of the vertical line favour the intervention over the control.
If the diamond (pooled estimate) touches the vertical line in a forest plot what does this mean?
- The overall (combined) result is not statistically significant.
- The overall outcome rate in the intervention group is the same as in the control group
what does % weight indicate on forest plots?
- indicates the influence an individual study has on the pooled result.
- In general, the bigger the sample size and narrower the CI, the higher the % weight, larger the box and greater the influence the study has on the pooled result
what is odds ratio? (2)
- the number of participants in the group who achieve a stated end-point divided by the number of patients who do not.
- measure of strength of association between a risk factor and outcome in a case control study
what is risk ratio? (2)
- number of participants in the group who achieved the end stated end-point, divided by the total number of patients in the group
- a measure of the strength of association. It is usually used in cohort studies
what is the confidence level for odds ratio? (3)
- the probability that the confidence interval also contains the true odds ratio. - If the study was repeated and the range calculated each time, the true values are expected to lie within these ranges on 95% of occasions.
- The higher the confidence level, the more certain that the interval contains the true odds ratio
what are clinical guidelines? (2)
- statements that include recommendations intended to optimise patient care.
- informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options
what are some examples of clinical guidelines? (4)
- WHO
- Royal college of physicians
- NICE
- SIGN
what are the key aims of clinical guidelines? (2)
- Reduce post-code lottery - allow for equity. NICE guidelines were founded to reduce variation in the quality and availability of NHS care and treatments
- To make sure practice is evidence based
what are the problems with compliance to guidelines? (4)
- Lack of knowledge of the guideline
- Out of date guideline in rapidly developing area of therapy
- Conflicting guidelines (i.e. for patients with multi-morbidities)
- Failure to understand/agree on responsibility for using the guidelines
Making of good guidelines required it to be what 4 things?
- Systematic
- Formal and transparent. Open for scrutiny
- Relevant clinical questions are addressed
- Best evidence available is used to answer the each question
what are the issues with non systematic traditional reviews? (3)
- not comprehensive
- not reliable
- not objective
Where do guidelines get their information from? (2)
- many systematic reviews
- expert opinion
what are some other factors guidelines have to consider? (2)
- value for money e.g cost effectiveness
- social value e.g equality + pt preferences
what are the purpose of clinical protocols? (2)
- sets out a precise/logical sequence of activities to be adhered to in the management of a specific clinical condition.
- often developed for specific local situations.
what are the advantages of clinical protocols? (5)
- Clear framework
- Increased autonomy
- Ensures consensus
- Accountability
- Identify training needs
what are the disadvantages of clinical protocols? (5)
- May stifle individual care management
- May reduce need for qualified staff
- Requires regular review
- Compliance
- May resist clinical discretion
what are features of good guidelines? (5)
- Based on systematic reviews
- Developed by competent multi-disciplinary panel of experts and representatives from key affected groups
- Considers important patient subgroups and patient preferences
- Is based on an explicit and transparent process
- Provides ratings of quality of evidence used and the strength of the recommendations
what are the advantages of case-control studies? (5)
- Cost effective relative to other analytical studies such as cohort studies.
- Case-control studies are retrospective, and cases are identified at the beginning of the study; therefore there is no long follow up period (as compared to cohort studies).
- Efficient for the study of diseases with long latency periods.
- Efficient for the study of rare diseases.
- Good for examining multiple exposures.
what is berkesonian bias?
A bias introduced in hospital based control studies due to the varying rates of hospital admission
what is ordinal variable?
a qualitative variable e.g mild, moderate, Severe
what is gender?
the socially constructed roles and characteristics by which a culture defines male and female
what is intersex?
a condition present at birth due to unusual combinations of male and female chromosomes, hormones, and anatomy; possessing biological sexual characteristics of both sexes
what is sexuality?
sexual preference
What does the GMC say about the ethics of children’s rights in medicine? (4)
The GMC highlights the principle of acting in a child’s best interests, even if it conflicts with parental preferences.
Also…
- Effective communication
- confidentiality
- safeguarding child welfare
What is rationing? + example
a means to ensure the fair distribution of resources that are scarce.
e.g COVID:
- Ventilators
- PPE
- Dialysis
- Testing resources
- Vaccines
what are the causes of scarcity/rationing in health care (4)
- Considerable advances in medical technology (Often very expensive + poor cost:benefit ratio)
- Demographic trends (ageing/greying population)
- Budgetary restrictions on the NHS
- Public expectations (expect more)
what are non-monetary scarcities in healthcare? (2)
- Time of health professionals
- Availability of operating theatres, dialysis machines, ICU beds…
who rations healthcare in the UK? (2)
- 42 Integrated care boards are the main commissioning organisations
- doctors are the primary rationing agents
what is the hippocratic basis vs economic basis for rationing?
- Hippocratic looks at maximising the benefits of care for the individual patient in your care
- Economic (societal perspective) considers both costs and benefits of treatment choices (including doing nothing) and also comparing the competing needs of other patients
what are the principles of rationing healthcare (3)
- Rationing by ability to pay
- Rationing by “need” or ability to benefit
- Rationing by social values
what is rationing by ability to pay? (2)
- Demand exceeding supply leads to price increases. Goods and services are distributed according to ability to pay.
- Causes exclusion of the poorest and discourages others from using healthcare
e.g healthcare in USA
what is rationing by need?
Resources are targeted at cost effective interventions e.g healthcare in UK where access to services is based on clinical need, not an individual ability to pay
what is rationing by social values?
Rather than rationing on the basis of need as defined by cost per quality adjusted life year (QALY) (NICE approach), use a basis of cost per QALY by social values (i.e. age)
when is there a need for care?
if an individual is able to benefit from an intervention
How does NICE related to rationing? (2)
- They are the explicit device for rationing healthcare.
- They aim to maximise benefits from constrained healthcare budgets, using QALY.
what is demand vs utilisation of care?
- Demand of care exists when an individual considers that he has a need and wishes to receive care
- utilization occurs when an individual actually received care
what is the past vs present difference + reason for rationing in the NHS? (2)
- Before the NHS, healthcare was simply rationed by price.
- Since then, care is constrained by non-price rationing, mostly waiting time, due to constraints in:
- Staffing levels
- Equipment
- Training
- Perceived appropriate care
what are QALYs?
A measure of how many years of high-quality life a person lives. Used by medical economists in justification of healthcare decisions (typically rationing) where 1 QALY = 1 year of perfect health.
What are the principles to guide rationing (Williams 1998)? (3)
- To treat equally and with dignity
- To meet people’s needs for healthcare as efficiently as possible (imposing the least sacrifice on others)
- To minimise inequalities in the lifetime health of the population
what are the features of a health promoting environment? (5)
one that supports and encourages healthy behaviors and choices through
- physical environment (clean, safe, encourages activity)
- social environment (supportive and inclusive)
- policy environment (healthy gov. policies)
- access to healthcare
- Availability of healthy resources
what are potential synergies between policies and practices that promote environmental sustainability and those that promote health? (4)
- Active transportation e.g walking/cycling
- Access to healthy/sustainable food
- creation and preservation of green space (improves air quality, good for MH)
- renewable energy ( improves air quality)
what is a bimodal distribution curve? (2)
- 2 modal curves
- used when there are 2 DIFFERENT population
what are the properties that summarise the shape of a normal distribution? (3)
- mean and standard deviation
- mean, median and mode are exactly the same
- distribution is symmetrical about the mean
what is reference interval?
the range of test values expected for healthy individuals.
what is a positive skew distribution?
- Asymmetrical distribution where the long tail is on the positive (right) side of the peak and the distribution is concentrated on the negative (left) side.
- mean > median > mode
what is a negative skewed distribution? (3)
- Asymmetrical distribution where the long tail is on the negative (left) side of the peak and the distribution is concentrated on the positive (right) side.
- mean < median < mode
What criteria is used to determine if an observed association between an exposure and outcome is likely to be causal?
Bradford Hill Criteria
what is the Bradford Hill Criteria for Causation? (9)
- Strength of association - Stronger the association between a risk factor and outcome, more likelier the relationship to be causal
- Consistency of findings - Same findings being observed among different populations, in different study designs or different times (over and over and over)
- Specificity of association - 1:1 relationship between cause and outcome
- Temporal sequence of association - Exposure must precede outcome
- Biological gradient/dose response relationship - Change in disease rates should follow from corresponding changes in exposure (dose-response) i.e greater exposure = greater effect
- Biological plausibility - Presence of a potential biological mechanism that helps ascertain causality
- Coherence - Does the relationship agree with the current knowledge of the natural history/biology of the disease?
(i.e match between epidemiology and laboratory) - Experimental evidence - Does removal of the exposure alter frequency of the outcome
- Analogy - use of similarities between observed association and any other associations i.e when one causal agent is known, the standards of evidence are lowered for a second causal agent that is similar in some way
What are 3 factors that affect investigations of cause and effect?
- Chance (random error)
- Bias (systematic error)
- Confounding (when both factors are not directly associated but linked by a 3rd factor)
what is a market in the NHS? (2)
- a group of buyers and sellers of a particular good or service
- in the NHS , Buyers (commissioning groups - ICB’s) and sellers (providers of care)
what are the arguments against a market for blood? (6)
- stops altruism (generosity)
- erodes the sense of community
- sanctions profits in services
- subjects services to market rules/regulations
- commercialisation may increase infection risks
- increases blood supply from poor, unskilled, unemployed
what are the arguments for a market for blood? (3)
- no different from any other tradeable product
- supply can be increased by removing obstacles to donors
- offering financial rewards of gifts
what are the 2 methods the UK has implemented to increase the supply of organs for transplant? (2)
- From 2020 in England, replaced opt in donor cards with opt out scheme (assumed consent)
- intervention/adverts on DVLA website to encourage people to join
What is the case for a market for organs (3)
- would increase supply
- illegal ‘transplant tourism’ occurs and is risky for donor + recipient
- illegal black markets of organs is dangerous
what is comorbidity vs multimorbidity?
- Comorbidity is the co-existence of other conditions with an index condition that is the specific focus of attention,
whereas - Multimorbidity is the co existence of several conditions where none are considered an index condition that is the specific focus of attention
what is the Academy of medical sciences definition of multimorbidity?
The co existence of two or more chronic conditions, each one of which is either:
- a physical non communicable disease thats chronic
- a mental health condition thats chronic
- an infectious disease thats chronic
what is the prevalence of multimorbidity (3)
- Estimates are between 23-27%
- higher prevalence in women (30& compared to 24% in males)
- people living in most deprived areas develop MM 10 years earlier that those in least deprived
what are the burdens of living with multiple long term conditions? (4)
- more unscheduled hospital appointments
- reduced functional ability and QOL
- Polypharmacy (multiple meds)
- Fragmented care (multiple specialists)
what are the 4 themes of chronic illness (Charmaz)?
- leading restricted lives
- experiencing social isolation
- being discredited
- burdening others
what is the impact of chronic illness in terms of loss? (6)
- Loss of control and personal power – Self-esteem
- Loss of independence
- Loss or change of Role – family, work
- Loss of financial security
- Loss or change of hopes and dreams
- Loss of identity
what is the purposes of risk calculations? (3)
- informed shared decision making
- help with health promotion activities
- informs clinical practice
what are general factors that you should take into account in making treatment decisions about random online drugs? (4)
- Research evidence of effectiveness and safety
- Your clinical expertise
- Availability (e.g. is the drug licensed? Is it affordable by the NHS?)
- Patient preferences
what are standard health outcome measures that could be used to assess the effectiveness drugs? (4)
- Mortality rate
- Weight change
- BMI change
- Quality of life measures (e.g. SF-36, QALY)
