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My DFPH cards > Medical sociology, Social policy, and Health Economics > Flashcards

Medical sociology, Social policy, and Health Economics Flashcards

1
Q

Structural Functionalism

A

Durkheim

Macro approach
Objective reality

Balance within society lies with social structures.
Individuals have limited agency within this model.

This theory validates inequalities as they balance society.

Also validates actions to protect state health, but restrict individuals e.g lockdown.

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2
Q

Social conflict theory

A

Marx

Macro

Society bound by competition for resources and material wealth. Establishing industrialisation and social classes.
Establishing industrial sources of health concerns and inequality.

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3
Q

Interpretivism

A

Micro
Subjective

Individual behaviours and interactions determine how people interpret society

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4
Q

Sick role

A

Parsons
Temporary rights and responsibilities of people who are sick.

Rights:
Exempt from blame for illness
Exempt from normal responsibilities

Responsibilities:
Seek help
Desire to get better

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5
Q

Critically discuss the sick role model

A

+ Applies to all acute illnesses esp infection

  • Some illness can have some level blame attributed e.g risky behaviours
  • Some illness allow for normal duties
  • Some illness mean patient lacks ability to seek care e.g lack of insight due to MH, also cultural definitions of “medical care”
  • Duty to want to get better- definition of better? Defined by toxic societal physical attributes e.g obesity Also not possible for terminal illness.
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6
Q

Definitions of health

A

WHO 1948
“Not nearly absence of disease”

Ottawa Charter 1986
“Resource for everyday life, not object of living”

Canguilhem 1943
“Ability to adapt to environment”

Huber et al 2011
“Ability to adapt and self manage”

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7
Q

Critically discuss WHO/Ottawa definitions

A

+ Simple
+Multicultural appeal
+ Health as human right
+ Influences policy outwit disease

  • Most people “unhealthy”
  • Contributes to medicalisation of society
  • Subjective
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8
Q

Critically discuss Canguilhem/Huber

A

+ More appropriate for current PH burden of chronic illness
+ Individuals can define health needs

  • Individualistic
  • No account for social structures
  • Reactive to health status, not promoting health as human right.
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9
Q

Define deviance

A

Becker 1963
Behaviour seen as unacceptable within society
Audience is important in creating identity

Note different within different cultures.

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10
Q

Labelling theory

A

Becker 1963

Deviance is labelled as being abnormal.
Once recognised as abnormal deviant behaviour may be subject to sanctions, punishment, correction, or treatment.

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11
Q

Deviance in medicine

A

Parsons

Illness as deviant behaviour
Doctors agent of social control, restrict the sick role label by their definition of sickness.

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11
Q

Primary deviance

A

Deviant behaviour prior to labelling.

May only have minor implications for the individual

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12
Q

Secondary deviance

A

Individuals status once labelling of deviant behaviour occurs

Label could become self fulfilling prophesy

Label has greater implications for the individuals social role and self esteem than the behaviour.

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13
Q

Define stigma

A

Goffman 1963

An attribute that is discrediting within a particular social interaction.

Undesirable characteristic within a particular context.

Stigma as a consequence of labelling. Caused by inequalities, fear and misinformation.

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14
Q

Felt vs Enacted stigma

A

Felt stigma is the feeling experienced by those who are stigmatised
e.g Shame, guilt, depression, self stigmatisation, withdrawal from society

Enacted is actions from those with in the “normal’ group to the stigmatised group.
e.g Violence, loss of job opportunities, compulsory testing.

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15
Q

Ways to tackle stigma

A

Education/raising awareness e.g world aids day

Language e.g person with schizophrenia vs schizophrenic

Public acknowledgement of diagnosis by significant figures.

Public acknowledgement of exposure to disease, especially where deviant behaviours involved e.g STI

Treatment, Reducing burden of disease on patient

Legislation e.g Equality act

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16
Q

What is the virtuous cycle?

A

Helps reduce stigma through action.
Positive changes change attitudes and reduce felt stigma, which helps reduce enacted stigma perpetuating positive change.

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17
Q

How is disability assessed?

A

Barthel ADL index.
10 domains
Score out of 20
Bowels, Bladder, Feeding, Grooming, Dressing, Transfer, Toilet use, Walking, Stairs, Bathing.

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18
Q

Define impairment

A

Loss or abnormality of a body function.

e.g amputations

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19
Q

Define disability

A

Inability or restricted ability to perform an activity

e.g unable to walk due to impairment. wheelchair use

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20
Q

Define handicap

A

Disadvantage due to an impairment/disability that limits role in society

e.g difficulties accessing workplace

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21
Q

Iatrogenesis

A

Disease caused by medicine

Clinical - side effects/complications

Social- Widespread health service provision leading to people feeling “ill/abnormal” when previously would be well. e.g on demand C section/ cosmetic surgery

Structural - Reliance on medical care rather than use of previously used coping mechanisms or support networks.

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22
Q

Health seeking behaviour

A

Zola 1973

Triggers- concomitant crisis, sanctioning by others, interference with normal activity (work/social), temporising deadlines.

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23
Q

Black report

A

1980
Found social class gradient across all ages, major diseases, increasing over time.

Possible explanations for health inequalities

Artefact

Social selection- Health determine social class “drift”

Behavioural/cultural - social class determines health through promoting or damaging behaviours

Materialistic- social class determines health through material circumstances

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24
Q

Social epidemiology

A

The study of the social determinants of the distribution of disease within a population.

Micro/meso/macro level assessment

Surveillance of HI, Investigation of social determinants, evaluating interventions.

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25
Q

Implications of the clinical iceberg

A

Underestimate of burden of ill health if only interactions with healthcare are the measure

Value of healthcare enhanced by understanding informal care systems

Self care is the commonest form of care- e.g with chronic illness. DM on average 3h of healthcare interaction annually.

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26
Q

Kaiser pyramid

A

Depicts proportion of selfceare in relation to the complexity of long term conditions.

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27
Q

How do hospitals influence society

A

+ Employer
+ Purchases
+ Community resource
+ Research facility
+ Education and training

  • Polluter
  • Isolation/exclusion
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28
Q

Aspects of medical profession (Parsons)

A
  • Defined knowledge base
  • Patients expected to defer to authority
  • Self governing
  • Potential to exploit power
  • Commitment to public service
  • Protection for patients
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29
Q

Factors that balance clinical autonomy

A

Management, Costs, Guidelines, revalidation, competition.

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30
Q

Illness behaviours

A

Mechanic 1968

Disability
Perceived seriousness
Disruption
Frequency/persistence of symptoms
Tolerance
Knowledge
Denial
Competition of needs with illness
interpretations of symptoms
Availability of treatment

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31
Q

Definitions of need

A

Doyal and Gough - physical health as a basic objective need, but healthcare doesn’t automatically follow on from this need for health.

Culyer and Wagstaff Need is equal to a persons capacity to benefit from healthcare.

Bradshaw - Felt, expressed, normative and comparative needs.

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32
Q

Bradshaw categories of need

A

Felt- Subjective experience of being unwell, doesn’t necessarily correlate to service use.
Measured by surveys and census.

Expressed- Seeking of healthcare. Measured with waiting lists

Normative- Professional judgement of an individuals/groups health status. Measured through HNA

Comparative- comparing services in areas with similar prevalence.

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33
Q

Distributive justice

A

The fair distribution of the burdens and benefits of social cooperation among diverse persons

Interpretations:
Utilitarianism - greatest good for the greatest number.
Can marginalise groups.

Justice as fairness-
basic liberties for all, difference principle (resources distributed equally but social and economic inequalities should benefit the most)

Maximising individual capabilities-

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34
Q

Define and criteria of procedural justice

A

Fairness in the process rather than the outcome.

  • Consistent
  • Neutral
  • Evidenced based
  • Potential to be corrected
  • Takes account of all parties
  • Ethical
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35
Q

Types of social justice (5)

A

Distributive- fair distribution of goods
Procedural- Fair process/decisions
Interactional- treating people fairly
Retributive- fair punishment of injustice
Restorative- restore justice after harm

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36
Q

Macro level rationing

A

Government level

+ Save duplication of work at local level

  • No scope for local decision making
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37
Q

Meso level rationing

A

Organisation level

+ respond locally

  • Can’t dress individual needs
  • risk of duplication if similar issues in near by areas
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38
Q

Micro level rationing

A

Individual clinical decision making

+ Individualised response
- Vulnerable to inconsistencies
- Lack of accountability

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39
Q

Rationing criteria

A

Need- Individual/societal
Cost effectiveness
Fairness- equal access to care

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40
Q

Pareto optimal

A

Efficiency has reached a point where no further improvement can be made to one part of a system without disadvantaging another part.

41
Q

Efficiency vs Equity

A

Conflict:
Efficiency = greatest good, but this may marginalise or increase inequality.

Alignment:
Externalities- beneficial by products
E.g vaccination, resources spent on reaching hard to reach groups benefit the whole of society through herd immunity.

42
Q

Prioritisation frameworks

A

Programme budgeting and marginal analysis

Save to invest

Multi criteria decision analysis

43
Q

Programme budgeting and marginal analysis

A

Priority setting approach
Plan and allocate expenditure across health programmes/primary, secondary and tertiary.
Aim is to balance spending across disease areas.

+ manages finite resources/ resources in competing demands
+ assumes rational behaviour
+ can address both technical and allocative efficiency

  • variable coding of healthcare data to work with
  • changes in year on year budget info so hard to compare yearly trends
44
Q

Bartleys explanations of inequalities

A

Individual: risky behaviours

Materialist: living in deprived conditions

Psychosocial: effects of social circumstances on psychology and physiology

Life course: cumulative effect of social circumstances through life

45
Q

Solutions to inequalities: Acheson inquiry 1998

A

Focus on evaluating gov policies affecting family and children
Reduce income inequalities, Improve housing standards

46
Q

Solutions to inequalities: Marmot 2010

A

Best start in life,
Take control of lives
Fair employment
Healthy standard of living
Healthy and sustainable places and communities
Strengthen prevention

47
Q

Factors that affect migrant health

A

Reason for migration, rights of the migrant, Geography/understanding systems and rights, genetics, culture, language

48
Q

Health risks for forced migrants

A

Communicable disease- poor sanitation/living conditions in camps
Sexual violence
PTSD
Transit risks
Hostility on arrival
Dental
Screening

49
Q

Direct and indirect impacts of trade on health

A

Direct :
Availability of medical technologies
Infection risks
Food safety

Indirect:
economic and environmental determinants

50
Q

Issues with economic evaluation of health promotion interventions

A
  • Multiple objectives
  • Clients heather so benefits are broader
  • QUALY doesn’t capture the full benefits
  • RCTs are useful to confirm observed benefits but don’t suit the time frame of health promotion
51
Q

Health economics

A

Healthcare always in a position of scarcity, resources spent could be infinite. Such decisions must be made.
Health economic is the science of making these decisions.

52
Q

Scarcity

A

More resource is wanted than available

53
Q

Opportunity cost

A

Benefits that are forgone by making a choice.
Important in finite resource setting for evaluation.

Calculated via CEA/CUA

54
Q

Microeconomics

A

Elements within the economy e.g People, households, buyers, sellers, markets

55
Q

Macroeconomics

A

Entire economy e.g unemployment, inflation, economic growth, policy

56
Q

Economics definition of need

A

A capacity to benefit from healthcare

E.g Bradshaws needs

57
Q

Economics definition of demand

A

A request for healthcare. the amount of good/services that consumers are willing and ale to purchase.

E.g attending a service, waiting for a service, paying for a service.

58
Q

Determinants of demand

A
  • Price elasticity of demand
  • Income
  • Preferences
  • Price/availability of alternatives
59
Q

Define substitutes

A

Products where increased price of one item increases the demand for an alternative item.

E.g vaccine brands

60
Q

Define Complements

A

Increase in price of one, causes decreased demand in another.

e.g needles and syringes - increase cost of leur lock may decrease demand for complimentary needles

61
Q

Define and explain price elasticity of demand

A

Measure of how much swing in demand there is based on changes in price.

PED = % change in demand / % change in price

PED > 1 Large response in demand on changes of price

PED= 1 proportionate demand response

PED < 1 Small response in demand

PED = 0 No response in demand to price change

62
Q

Changes to the demand curve : Rise and fall in price

A

Rise in price : less product demanded, move left along curve

Fall in Price : More product demanded, move right along curve

63
Q

Changes to demand curve : Left shift

A

Due to decreased income

64
Q

Changes to demand curve : Right shift

A

Due to increased income, population size or change in preference in favour of the item

65
Q

Define and explain Income elasticity of demand

A

Measure of how much swing in demand there is with changes in income

IED = % change in demand / % change in income

IED>1 Large demand for luxury goods as income rise

IED > 0 Proportionate changes, normal good demanded alongside income

IED<0 Goods demanded are inferior as income has fallen

66
Q

Define supply in healthcare context

A

Supply is how much of a good/service can be supplied at a given price and depends on cost of material, cost of production etc

For health care services it is the capacity of services to meet need. Defined by costs of staff, beds, equipment etc.

67
Q

Changes to the supply curve : Rise and fall in price

A

Rise in price : More product is supplied, move right along curve

Fall in price: Less product is supplied, move left along the curve.

68
Q

Changes to the supply curve : Left shift

A

Less product supplied for same price point

Due to less land/resource
Reasons for increased price- war, cross, climate change etc

69
Q

Changes to the supply curve : Right shift

A

More product supplied for same price point

Due to - Better technology, more land/labour

70
Q

Market equilibrium

A

The price reaches equilibrium at the intersection of the supply and demand curve.

71
Q

Characteristics of a free market

A

Atomicity- Many buyers and sellers

Homogeneity- identical products

Free entry/exit - sellers are free to come and go

Equal access- production technology is available to all sellers

Perfect information- All buyers/sellers know price and product info for all products

No externalities- benefit or disbenefit to someone other than the buyer.

72
Q

Causes of market failure

A

Failure to meet characteristics of a free market.

Externality- benefits/dis-benefits to others e.g in health herd immunity

Public goods- publicly available good e.g health promotion posters.

Market control - Monopoly (single seller), monopsony (single buyer)

Imperfect information-
Agency: relying on doctors for information
Uncertainty
Moral hazard: no price to consumer at time of use
Adverse selection: people opting out of paying health insurance.

Merit goods- belief that certain goods are special in someway

73
Q

Characteristics of perfect agency

A

Balance between Patient health status, patient preference and utility to society.

74
Q

Imperfect agents

A

Supplier induced demand- recommendations for treatment where in a perfect scenario treatment isn’t necessary

Supplier reduced demand- not recommending a treatment, especially where resources are scarce. Making it look like demand is lower.
Policy can counter this by linking payment to quality indicators.

75
Q

Define margin

A

incremental variation in inputs that is required to have corresponding outputs.

Marginal cost- cost of producing one extra unit of service.

Marginal benefit- benefit gained from increased unit of service.

76
Q

Marginal analysis

A

Process of examining the effect of small changes in expenditure.

  • Help to identify-
    where resources should be targeted
  • Where reductions should be made if expenditure must be cut.
  • How resources can be reallocated to achieve an overall gain.
77
Q

Efficiency

A

Measure of how much good is achieved with available resources

Technical- max output to input

Economic- Max output to expenditure

Allocative - level of production that marginal benefit is greater than marginal cost.

78
Q

Discounting

A

Discounting is used to deal with positive time preference.

Where the preference is for the benefit to come early and the cost later.

But in PH cost often comes first with benefits later. As such discounting is applied.

“Adjusting the value of costs/benifits that occur in the future such that they can be compared as if they occurred in the short term”

79
Q

Distinguishing features of healthcare in economics

A

Supply and demand: not truly independent

Imperfect markets

Immediacy: short time scales in urgent health situations

Agency

Uncertainty

Necessity

80
Q

WHO dimensions for assessing a healthcare system

A

Social goals
Resource use
Efficiency
Review - How the system influences outcomes and efficiency
Feedback- improve outcomes and monitoring the effect

81
Q

Healthcare funding systems: Private insurance

A

Private purchase of insurance by individuals/ workplaces

+ Competitive insurance/ patient choice
+ incentivise providers to increase quality/ decrease cost

  • Adverse selection: low risk people don’t want to pay in, doesn’t subsidies higher risk people.
  • providers compete on perceived rather than actual quality
  • generally inefficient
  • exacerbate inequalities
  • Moral hazard
82
Q

Healthcare funding systems: Social insurance

A

Contributions made by employees, employers, and government to provide healthcare

+ generally lower cost than private insurance
+ Government is a strong partner
+ fewer inequalities due to better coverage

  • Only provides insurance for employed, another government scheme is required for others
  • consumer and provider moral hazard
83
Q

Healthcare funding systems: Public funding

A

+ lower cost/ efficient
+ Government strong partner can influence costs
+ fewer inequalities due to high coverage

  • Less competitive pressure
    -consumer and provider moral hazard
84
Q

Incentives used in healthcare

A

Quality and outcome frameworks (QOFs) - incentives for improved quality to target
Payment by results/ activity- payment of average cost nationally, incentive to reduce cost and increase coverage
Delayed discharge - hospitals crane social care the cost of IP care, incentivising provision of care upon discharge.
Re admissions - Trusts are accountable for readmissions
Vaccinations - Fee for service e.g flu vaccines
Case mix - payment based on average costs so mix of complex and non complex balances out

85
Q

Types of economic evaluation : CBA

A

Cost benefit analysis

Calc costs and benefits in monetary terms and the difference - Result - net benefit

Costs £
Outcomes £

+ Can compare the value across different sectors
+ Also examines allocative efficiency

  • Requires a monetary value to be places on life/health
86
Q

Types of economic evaluation : CEA

A

Cost effectiveness analysis

Compares costs of different interventions that produce the same outcome
Result- Incremental cost effectiveness ratio (ICER)

Cost £
Outcome - clinical

+ Useful to compare difference interventions that produce the same outcome

  • Can’t compare across areas/diseases
87
Q

Types of economic evaluation : CUA

A

Cost utility analysis
Measures outcomes in terms of DALYs/QUALYs to compare across disease areas.
Result - ICER

Costs £
Outcome DALY/QUALY

+ Can compare interventions for different medical conditions
+ some assessment of allocative efficiency

  • Can’t be used to compare interventions across sectors
88
Q

Types of economic evaluation : CMA

A

Cost minimisation analysis
Compares interventions who produce the same outcome (e.g clinical)
just compares which is cheaper for the same outcome.

89
Q

Types of economic evaluation : CCA

A

Cost consequence analysis
Consequence are listed but not aggregated into same units
Disaggregated approach

90
Q

Types of costs used in economic evaluation

A

Direct: Exclusive for that output

Indirect: Shared costs across several outputs, productivity, community costs

Overhead: Shared across the organisation

Tangible: easily measured in £

Intangible : Difficult to measure in £

Fixed: don’t change with volume of activity

Variable: Vary with activity/proportion produced.

91
Q

Monetary and non monetary valuation on health

A

Monetary-
Easy to compare across sectors e.g education and non health outcomes e.g income

Use : Human capital, Revealed preference, and stated preference to calculate

Non monetary-
Difficult to give accurate monetary value for health. QUALY/DALY

92
Q

QUALY

A

Commonly used unit of utility
Combines quality and duration of life

QUALY= Utility value in health state x Years in that state.

Utility value is 0- death –> 1 perfect health.

+ Combine QoL and mortality
Compare outcomes across specialities
+ can be specific to the population of interest

  • Not necessarily equal/ comparable as depends on creation of utility value
  • Not weighted
  • may not be generalisable
93
Q

Methods to calculate utility for QUALY

A

Rating scales-
patient rates health state
* poor interval properties

Time trade off - patients state how many years os diseased life they would trade for 1 year of health
* time preference

Standard gamble -
respondents imagine they have a disease and decide on a treatment that can cure/cause death at set probabilities
* biased by participants attitude to risk.

Person trade off -
comparing treatments that cure many/few until stand off is reached.
* respondents may consider more than the health question e.g moral/personal

94
Q

DALY

A

DALY = YLL + YLD (age weighting and discounting of 3%)

YLL- Years life lost = (75- av age of death) x Number of deaths

YLD- Years lived with disability=
No of cases x Disability weight x average years lived in that state

+ Combine morbidity and mortality
+ international comparisons
+ Good for MH
+ Discounting applied

  • Based on expert opinions
  • Age weighting could be discriminatory
  • requires good morbidity and mortality data
95
Q

Approaches to valuing life in monetary terms: Human capital

A

Expected value of individuals productivity is calc, and adjusted for life expectancy.

Productivity - market and household, e.g via wages

+ Objective

  • Hard to identify changes in productivity
  • the value of children, older ages appears lower than working age
  • Doesn’t reflect what we are willing to pay for treatment
  • Improvements in health are only valued for their improvement in productivity
96
Q

Approaches to valuing life in monetary terms: Revealed preference

A

Individual preference of risk/benefit are traded against income

+ Based on actual choices
+ Provides insight into individuals valuation on their life

  • Focus on immediate accidental death rather than through chronic exposures
  • Biased toward working age males
  • Ignores imperfect labour markets
  • Limited generalisability
97
Q

Approaches to valuing life in monetary terms: Stated preferences

A

Individuals state what they would choose in hypothetical situations. Two types:

Contingent valuation
Understand max willingness to pay to avoid a risk or improve health

Discrete choice
choose between different interventions based on cost.

98
Q

Decision analysis

A

Economic decision process the involved breaking down components into decision trees, attaching probabilities.

99
Q

Sensitivity analysis

A

Testing assumptions made during an economic evaluation.

Deterministic: model different parameter values (where assumptions have been made) to see the effect on ICER. One way or multi way.

Probabilistic: Uses parameter distributions rather than distinct parameters.
Displayed as cost effectiveness acceptability curve.

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