HSPH extra useful stuff Flashcards
Which is the biggest cause of any disability in the UK? 1, Stroke 2, Arthritis 3, Congenital disorders 4, Traumatic accidents 5, Diabetes
2 arthritis
Which is the most common chronic disease in the UK?
1, Diabetes 2, Cardiovascular disease 3, Asthma 4, COPD 5. Arthritis
Asthma
One of the secondary outcomes was death from noncardiac causes; 8 occurred in the preventive PCI group and 6 in the no preventive PCI group; Hazards ratio = 1.10 95%CI: 0.38-3.18. P = 0.86. What does the P value tell us? (2 marks)
a. P = 0.86 tells us that there is an 86% chance that the hazards ratio would be as large as 1.10 or even larger (1 mark) if preventive PCI has no effect on noncardiac deaths. (1 mark)
Or
b. P > 0.05 so the result is not statistically significant (1 mark) and there is no evidence that preventive PCI increases the risk of non-cardiac deaths. (1 mark)
- Why are patients randomised in trials? (2 marks) Why is the randomisation done after the patients are deemed eligible? (1 mark)
To ensure the treatment groups are similar in all aspects (1 mark) apart from the treatment/intervention. (1 mark)
If the patients are randomised first then this may influence the decisions about eligibility (1 mark) or if large numbers of patients are ineligible it might cause unequal numbers to be randomised to each group (1 mark).
- What is the difference between an intention to treat analysis and an on treatment analysis (2 marks) and when will they give the same answer (1 mark).
a. ITT : people are analysed according to the treatment group they are in regardless of whether they receive the treatment or not (1 mark)
b. On Treatment: people are analysed according to the treatment they receive. (1 mark)
c. If everyone receives the treatment they were randomised to then both analyses are identical. (1
mark
why might a trial be stopped early
a. If there is a clear difference in treatment outcomes (1 mark) it is not ethical to continue with the trial (1 mark)
What is a theoretical framework? Name the components of a generic framework (2 marks; 1/5 mark for each component
Any four of the following (1/2 mark each):
Concepts (1/5 mark), definitions (1/2 mark), explanations (1/2 mark), models (1/2 mark) or processes (1/2 mark) that underpin work (1/2 mark).
- One theoretical Framework is the Common Sense Model of Health and Illness (CSM). Name the components of the CSM of health and illness (3 marks; 1⁄2 mark for each component)
A health threat is mediated by cognitive (1/2 mark) and emotional (1/2 mark) representations of that threat (1/2 mark) based on their current experience (1/2 mark), information (1/2 mark) from the external social environment (1/2 mark) and past illness experience (1/2 mark), and general knowledge (1/2 mark)
Provide four ways in which a method of qualitative research can be determined to be valid (2 marks; 1⁄2 mark each)
Theoretical framework links in to method
Inclusion criteria relevant
Exclusion criteria relevant
Ethics approval gained
Informed consent gained
Setting appropriate
Sampling and recruitment strategy appropriate
Include analysis of people involved and their relationship to participants to ensure no bias
Timing was appropriate to population
Diversity or homogeneity of population under study
Method of data collection is appropriate for subject and participants
Data was analysed sufficiently and in-depth description provided
Process of data analysis was
standard and reliable
- What are some common barriers to carrying out self-management (3 marks
higher level of morbidity,
greater financial constraints,
greater number of compound effects of conditions,
persistent depressive symptoms,
mismatch in level of patient-clinician communication,
lower income.
How do Self-management support goes beyond traditional knowledge-based patient education to include (3 Marks)
The following three answers must be provided (3 marks)
processes that develop patient problem-solving skills (1 mark)
improve self-efficacy (1 mark)
support application of knowledge in real-life situations that matter to patients (1 mark)
Self-efficacy relates to an individual’s perception of the degree to which they are capable of performing a given behaviour and has three elements. Name each element and explain what these mean.
Magnitude describes an individual’s perceived efficacy for their most capable performance
Strength refers to their confidence in their assessment of magnitude
Generality refers to whether this sense of efficacy translates to different situations.
. Name two health models that attempt to explain health behaviour (1 mark) (1/2 mark each)
Health Belief Model (Becker)
Theory of Planned Behaviour (Ajzen)
Transtheoretical Model (Stages of Change) (Prochaska et al.)
Social Cognitive Theory (Bandura)
Leventhal’s Self-Regulatory Theory (Leventhal et al.)
In the case control study of recreational drug use and testis cancer the cases and controls were matched for age – why? (2 marks)
Any four of … Age is a potential confounder (1⁄2 mark). It is associated with testis cancer risk (1⁄2 mark) as younger men more likely to get testis cancer (1⁄2 mark) and it is associated with drug use (1⁄2 mark) younger men more likely to have used certain of the drugs (1⁄2 mark). If the cases and controls were not marched an age difference may cause there to be a difference in drug use totally unrelated to testis cancer. (1⁄2 mark)
The odds ratio of heroin use and testes cancer is 0.92 with a 95% confidence interval of 0.24 to 3.59. What does the confidence interval mean? (2 marks)
The 95% confidence interval tells us that we are 95% confident (1⁄2 mark) that heroin use might decrease the risk of testes cancer by 76% (1-0.24) (1⁄2 mark) or it might increase it by 3.6 times.(1⁄2 mark) There is no evidence that heroin use will reduce the risk of testes cancer (p>0.05). (1⁄2 mark
Give an example of each of the three non-individual focused barriers to engaging with weight loss. (3 marks)
Any example and must include the three types of cultural barriers (3 marks)
Social barriers – bias, stigma, lack of effective knowledge about weight loss, lack of
control over local policies, peer pressure to join in particular eating habits
Political barriers – sugar tax, ideas around how much the state should intervene in
looking after people’s health, tension between health as a human right and fair priority setting; focus on causes championed by relatively wealthy & well-connected which displaces more important activities such as income protection, minimum wage, tax breaks etc
Environmental barriers – widespread availability of fast food that has a high content of salt, fat, and processed carbohydrates
- What does the acronym ACE stand for? (1 mark) Why is this important to know? (1 mark) (2 marks total)
Adverse Childhood Events – includes how early childhood events may affect later health in adults and therefore these need to be attended to in a Trauma Informed Care (TIC).
Outline Michie’s Behaviour Change Wheel. What is it used for (1 mark) and what are the components? (3 marks) How could Lana’s GP use it in his consultation with her about her health? (1 mark) (5 marks in total)
- must be capable (have the knowledge and skills) to engage in the activity. (1 mark)
- be motivated (1 mark)
- have the opportunity i.e. factors outside the individual must allow the behaviour (1 mark)
Lana’s GP could use it as a framework for exploring her initial resistance to taking participating in the cooking lessons.
What is epidemiology
- This is about finding causes of disease and preventing disease
How do you look at protein structure and quantification
Measure using ELISA - often used in clinic to measure the expression of particular protein
Mass spectrometry
X-ray crystallography - gives an idea fo the structure of the protein and how much proteins are available
NMR - structure of the protien
Cryo-EM - Structure of the coronavirus was released using this - get the structure of a protein
How do you look at protein function and expression
Receptors/ion channels/enzymes/transporters e.g. calcium assay (can open the calcium ion channel in the membrane of the cell and allow the entrance of calcium, the more calcium is in the cell the more active the G protein cover receptor is )
Find some way of measuring their activity
Usually measure substrates or products
- Can use ELISA
Common- inflammatory markers, cytokines etc
Products of enzymes can be measured
- Lipids
Determine rates of formation/depletion
- Finds out how badly damaged the enzymes are
What makes up the measure of location
- Median = Middle value when the values are ordered from smallest to largest
- Mode = the most common value
- Mean = average = sum of all of the values divided by the number of values
What makes up the measure of spread
- standard deviation
- interquartile range
What standard deviation correlates to the
- 99% range
- 95% range
- 90% range
99% range (0.5th to 99.5th centile) = mean ± 2.58 SDs
95% range (2.5th to 97.5th centile) = mean ± 1.96 SDs
90% range (5th to 95th centile) = mean ± 1.64 SDs
Define the confidence interval
a range of values so defined that there is a specified probability that the value of a parameter lies within it.
What is a P value
a p-value for a result is the probability of observing a result as or more extreme than the sample result if the underlying assumption in the population is true
When can P values be calculated
When there is a comparison
- 2 means – are they different i.e. is their difference different from 0?
- Association – are the observed results different from those expected
- Regression – is the slope different from 0?
describe the phases in developing and evaluating a new drug
• PRECLINICAL – Non-human study
– In vitro and in vivo animal experiments to obtain preliminary efficacy, toxicity and pharmacokinetic information
• PHASE 0 – First in-human trials (not always done)
– Small number of subjects given subtherapeutic dose of drug to determine pharmacodynamics and pharmacokinetics
• PHASE 1 – Screening for safety
– Testing of drug on (usually) healthy volunteers for dose ranging.
– Determine whether the drug is safe to check for efficacy
• PHASE 2 – Assess efficacy and safety
– To determine whether drug can have a therapeutic effect
– May be designed as case series or randomised controlled trial
• PHASE 3 – Assess efficacy and safety
– Randomised controlled trial on large number of patients to determine what the therapeutic effect is
• PHASE 4 – Post-marketing surveillance
– Safety surveillance (pharmacovigilance
What is the relative risk of death in the treatment group compared to the control group
Relative risk of death = risk of death in treatment group/Risk of death in control group
Work out the absolute difference in risk
Absolute risk = risk of treatment group - risk of control group
What are the results of a meta analysis summarized in
• Results of individual studies and a summary estimate often shown in a Forest plot
What are the issues in meta analysis
Heterogeneity
Publication bias
How can you assess publication bias
Funnel plot
How do you work out funnel plots
Funnel plot
- Relative risk of horizontal
- Standard error associated with relative risk of the vertical standard
- If there is no publication bias the points will be scattered either side of the line
What are the biases in a case control study
Recall bias
- Cases may remember more than controls
Reverse causality
- Has disease caused changes in recent exposures
Selection of cases
- Are they representative of all people with the disease
Selection of controls
- Are they representative of all people without the disease
- Are they similar to the cases
What do you you use instead of relative risk in a case control study
odds ratio
- Use odds ratio = odds exposure in cases/ odds exposure in control
What is attributable proportion
The same information allows you to calculate the proportion of disease in the exposed group that can be attributed to the exposure
What are the reasons for associations between an exposure and disease
- Bias
- Reverse causality
- Confounding
- Incorrect analysis
- Chance
- Casual
Name the parts that make up the bradford hill criteria for causation
- Strength of association – how extreme is the relative risk – relative risk of 5 or 0.2 or lower or 0.2 or lower is a strong relative risk
- Dose response - does increasing the dose increase the risk
- Time sequence – exposure preceded the outcome
- Consistency of findings – similar studies on different populations
- Biological plausibility – e.g. tar is known to be carcinogeni
- Coherence of the evidence – cross-sectional, cohort and case-control studies all find the same increased risk
- Reversibility – the relative risk for ex cigarette smokers is between that of current smokers and non-smokers
What is the bias in cohort studies
Loss to follow-up
Exposure usually measured at just one time point
Selection of cohort
What is incidence usually taken to be
INCIDENCE is usually taken to be a measure of RISK
What is the relative risk
Relative risk = incidence of disease in exposed population/ incidence of disease in unexposed population
what are the measures of importance
Absolute excess risk
Attributable proportion
How do you work out absolute excess risk
AER = Risk in Exposed – Risk in Unexposed
What is Self-management
Taking charge of one’s health
Dealing with symptoms and change over time
Working more effectively with healthcare professionals
Improving one’s quality of life
What needs to be managed in self management
Monitoring of symptoms and responding appropriately
Taking Medications
Making Behavioural Changes
Making Role Adjustments
Managing Emotional Impact
Negotiating with Medical Team
Decision Making
Accepting Condition
What is the health belief model
Threat perception and the benefits and costs of the behaviour feed into the idea whether the patient takes action or not, health motivation (do i value health) and cues to action (what triggers to action are there) also feed in to take action and and be the products of taking action
- Perceived susceptibility (How likely am i to face a problem) and perceived severity (how serious is the problem) leads into threat perception
Describe the theory of planned behaviour
there are attitudes (overall evaluation of an action) and subjective norm (beliefs about others approval of the action) and this leads to the intention which is how hard i intend to try and change my behaviour
- this can lead to a change in behaviour
- there is also the perceived behavioural control (persons assessment of their ability to undertake action) which leads to intention and behaviour changed
Describe how the transtheoretical model of change works
- Pre-comtemplation - this is when you have no intention of changing behaviour
- Contemplation - aware of a problem exists, no commitment to action
- preparation - intent upon taking action
- action - active modification of behaviour
- maintenance - sustained change - new behaviour replaces the old
- relapse - this is when you fall back into the old patterns of behaviour
- then pre-contemplation again
Describe what behaviour change wheel is made up of
Sources of behaviour
- opportunity
- capability
- motivation
Intervention functions
- Environmental restricting – if you want people to walk give people a place to walk in
- Restrictions – put smoking cigarettes behind the counter
- Education
- Persuasion
- Incentivisation
- Coercion
- Training
- Enablement
- Modelling
Policy Categories
- fiscal measures
- guidlines
- environmental social planning
- communication
- legislation
- service provision
- regulation
what is the expert patient programme based on
Based on theory – Social Cognition and Social Learning Theory (Bandura 1977)
What are heuristics
Cognitive shortcuts /decisional shortcuts
What makes up cognitive biases
Availability Representativeness Anchoring Diagnosis Momentum Fundamental Attribution Error Commissioning bias
what are health inequalities
WHO = Health inequalities can be defined as differences in health status or in the distribution of health determinants between different population groups.
What are health inequities
Health inequities are avoidable inequalities in health between groups of people within countries and between countries. These inequities arise from inequalities within and between societies.
What are the open working group sustainable development goals
Achieve universal health coverage
Maternal deaths: Target MMR of 50/100,000 live births
Access to family planning
Child/Infant mortality: below 20/1,000 IMR all countries
End epidemics: HIV/AIDS, TB, malaria, neglected tropical diseases
Noncommunicable diseases mortality: 30% reduction
Include mental health
define risk factors
Risk factors are variables associated or correlated with an increased incidence of disease or infection
What is a food desert
this is a lack of nutritional food in the area
What is food insecurity
Food insecurity - this is when you cannot afford the food therefore you go without food or buy cheap food such as fast food
define healthy life expectancy
the number of years lived in self-assessed good health)
What are 3 reasons why people do not disclose
intrapersonal:
- Self-doubt and pre-verbal abuse, neglect hard to articulate, shame and self-blame, fear of feeling worse
Interpersonal:
- Fear of others’ reaction, rejection, exposure, previous bad experience of disclosure, not being asked, expectation of narrative
- Negative attitudes and perceived social disapproval is related to PTSD severity (Mueller et al, 2008)
Social and cultural:
- Stigma, misunderstanding, disbelief
What are the three ways in which AEDs can heal and recover
Establishing safety:
- Environment, home, health, (Maslow’s hierarchy of needs,) safety from future abuse, gaining autonomy, reconstructing self-care, arts and music therapies
Remembrance and mourning
- Trauma specific therapies (not what everyone wants), integrating fragmented memories
Reconnection with ordinary life
- Re-establishing trust, awareness of boundaries
name what healthcare professionals can do
Primary preventions:
- prevent the occurence of adverse childhood events so that fewer children experience them
e. g. = programmes preventing child cause and neglect, increase family and community stability
Secondary prevention
- reduce the severity and acute consequences of the ACES
- e.g. trauma informed care to identify and intervene on ACEs, psychological first aid that reduces psychological impact of trauma
tertiary
- treat and reduce the lung term consequences of ACEs
- e.g.= Programs that identify and reduce risky health behaviours associated with ACES, social marketing campaigns that build empathy with ACE consequences
What are the challenges for implementing NICE guidelines
Trade off between benefits & harms of treatment
Trade off between economic consideration & resource use
Quality of the evidence, use of indirect evidence & availability/lack of evidence to support implementation
Size of effect & impact on population
Wider basis for making decisions – ethics, inequities, social value judgments - ethical, practical & scientific
Conceptual framework or logical model
Name the types of syndemic interaction among diseases
- Enhanced contagiousness
- Accelerated virulence
- Alterations of the physical body
- Alterations of the emotions
- Gene reassortment
- Iatrogenic factors
Describe the syndemic model
- There are disparity of conditions that promote disease clustering
- then there are two diseases that have adverse interactions with each other
- this leads to enhanced disease transmission, progression and more negative health outcomes
Why do syndemics emerge
- Changing political and economic conditions
- Shifting ecological and environmental conditions
- Altering demographics and changing social behaviours
- Rapidly developing technology
- Expanding patterns of globalisations
- Ongoing microbial adaptation
- Breakdown of public health protective measures
What are the arguements that Mendenhall have
The arguments are that
1. diabetes must be understood as a disease of poverty without obscuring this fact and concomitant health inequities;
- diabetes is always syndemic;
- A diagnosis transforms how people perceive and experience their physical condition;
- The social life of diabetes is significant across contexts and
- Interventions should employ syndemic thinking for both upstream and downstream locations.
What is the definition of domestic violence
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.
What is the definition of controlling behaviour
: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.
What is the definition of coercive behaviour
an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.
This definition includes so called ‘honour’ based violence, female genital mutilation (FGM) and forced marriage
Describe the E frailty index
-embedded on common GP computer systems.
- Searches for 36 variables from the last year such as what age they are, admission to hospital, what medication they are on
= Mild - 0.12-0.24
= Moderate = 0.24-0.36
= Severe >0.36
Name factors that can be a predictor of suspicions of frailty
- Falls (e.g. ‘collapse’, ‘legs gave way’, ‘found lying on floor)’
- Immobility (e.g. sudden change in mobility, ‘gone off legs’ ‘stuck on toilet’)
- Delirium (e.g. acute confusion, worsening of pre-existing confusion/short term memory loss)
- Incontinence (e.g. new onset or worsening of urinary or faecal incontinence)
- Susceptibility to medication side effects (e.g. confusion with codeine, hypotension with antidepressants).
What are the principles of trauma informed care
Patient empowerment: using individuals’ strengths to empower them in the development of their treatment
Choice: informing patients regarding treatment options so they can choose the options they prefer
Collaboration: maximizing collaboration among health care staff, patients and their families in organizational and treatment planning
Safety: developing healthcare settings and activities that ensure patients’ physical and emotional safety, NB: physical examination and investigations
Trustworthiness: creating clear expectations with patients about what proposed treatments will entail, who will provide services and how it will be provided
What does the SAMHSA GUIDE to TRAUMA-INFORMED CARE include
Realises
Realises the widespread impact of trauma and understands potential paths for recovery
Recognises
Recognises signs and symptoms of trauma in patients, families, staff, and others involved in the system
Responds
Responds by fully integrating knowledge about trauma into policies, procedures and practices
Resists
Seeks to actively resist re-traumatization
Why do you not need documentation for registration with a GP practise
“there is no regulatory requirement to prove identity, address, immigration status or the provision of an NHS number in order to register”
Lack of proof of address/ID “would not be considered reasonable grounds to refuse to register a patient” or withhold appointments
“Where necessary, (e.g. homeless patients), the practice may use the practice address to register them if they wish”
What are the groups of undocumented migrants that are exempt from charges
- Refugees and asylum seekers
Refused asylum seekers receiving “section 4” support - those destitute and prevented from returning to country of origin
Survivors of trafficking
Children looked after by a local authority
People treated under the Mental Health Act
People in immigration
detention.
Treatment caused by sexual or domestic violence, FGM, or torture
What does the GMC make a good doctor
Make the care of your patient your first concern
Be confidence and keep your professional knowledge and skills up to date
Take prompt action if you think patient safety is being compromised
Establish and maintain good partnerships with your patients and colleagues
Maintain trust in you and the profession by being open, honest and acting with integrity
What is the triad of perfectionism
chronic doubt, chronic shame and exaggerated sense of responsibility
What is shame
powerful emotion which occurs in response to negative evens such as making mistakes or experiencing mistreatment
What is guilt
feel unhappy because you think that you have done something wrong or have failed to do something which you should have done.
What is obesity fuelled by
- economic growth,
- industrialization
- mechanized transport,
- urbanization,
- an increasingly sedentary lifestyle
- a nutritional transition to processed foods and high calorie diets over the last 30 years
What is the residual conversion model
the social and the individual are linked
- individual factors impinge on social factors and social factors impinge on individual factors
- also the cycles we go on for blaming the individual and social thing that the individual is in
what are health inequalities due to
age
sex
ethnicity - Indian 3x higher chance of getting diabetes
Deprivation
What factors lead to mental health inequalities
Material inequality - poverty, poor housing, lack of employment opportunities.
Social inequality and injury - stigma and discrimination or experiences related to:
- living in care
- immigration status
- ethnicity
- sexual orientation
- disability
- experience of violence or abuse.
Health inequality - including having long-term physical health conditions
what are the types of inequalities are there in tower hamlets
Lack of access to high quality medical care
Food deserts in poor neighbourhoods
Exposure to environmental toxins
High rates of incarceration
Experiencing the stress of racial discrimination
What are the forms of structural racism
- social segregation
- disproportionate criminalization
- unequal resources
- inequalities in access to high quality personalised HIV care which are overlapping and mutually reinforcing
What is synergi collaborative
an independent centre of excellence on ethnic inequalities, severe mental illness and multiple disadvantage.
What does synergi do
Invest in infrastructure
Invest in relational roots
Devolving decisions
Access through clear roads, bolt on/off bridges, and tunnels
Who’s got power?
Enable safe spaces for dialogue & negotiation, or creative spaces for relational & network actions on health systems
What is the offer we make to this community?
What is gender fluidity
- more flexible range of gender expressions with interests and behaviours that can change from day to day
- not confined to boundaries of sterotypical expectations of men and women
What is non binary
An umbrella term for people whose gender identity doesn’t sit comfortably with ‘man’ or ‘woman’. Non-binary identities are varied and can include people who identify with some aspects of binary identities, while others reject them entirely.
what is genderqueer
Genderqueer people embrace a fluidity of gender expression that is not limiting.
May not identify as male or female, but as both, neither, or as a blend.
What is the ecological model of IPV
Societal factors
- unequal position of women
- poverty
- normative use of violence
Community factors
- acceptance of traditional gender roles
- normative use violence
- weak community sanctions
Relationship/family factors
- man has multiple sexual partners
- martial dissatisfaction
- low or different level of education
Individual factors
- affecting women risk of being abused = young age, low level of education, maltreatment as a child, depression
- affecting mens risk of abusing = low income, low level of education, being sexually abused or witnessing violence as a child
What is a multi agency risk assessment conference (MARAC)
Multi Agency Risk Assessment Conference (MARAC)is a victim focused information sharing and risk management meeting attended by all key agencies, where high risk cases are discussed
