My Public Health Flashcards
What are the 4 domains of public health?
Health protection (infectious diseases, chemicals and poisons, pollution, radiation, emergency response)
Improving services (clinical effectiveness, efficiency, service planning, equity)
Health improvement (lifestyles, family & community, education, employment, housing, surveillance and monitoring)
Addressing the wider determinants of health (seeing the big picture - making sense
of data)
Define Demography
the study of statistics such as births, deaths, income, or the incidence of disease, which illustrate the changing structure of human populations, or the study of the compostion of a particular population
Define Prevalence
Proportion of of a population affected, overall burden , affected by incidence and rate of cure/death
Define Incidence
How many new cases of something in a year
Define Burden of Disease
how something/to what extent does a disease affect your life
What is said to be the main determinant of population health?
Income division - the wider the gap, the worse the health of the population is
What is the Gini Coeffeient?
a Statistical representation of a nation’s income distribution
The lower the coefficient, the greater the equality
UK has high inequality coefficient compared to Scandinavian countries
What things does social class measure?
Occupation
Stratification (ones hierarchical rank in society
Social position
Access to power and resources
What are the 3 main notifiable diseases?
(Diseases you need to report to public health doctors/WHO upon suspicion or diagnosis?
Plague
Cholera
Yellow fever
what happens when a country reaches a certain income threshold?
When a country reaches a certain income threshold;
Disease stops being due to poverty
Become degenerative disease
Then income has no effect on the health of a nation
Define Disease.
technical malfunction or deviation from the norm which is scientifically diagnosed
Define illness
the social, lived experience of symptoms and suffering
What is the prevention paradox?
That a large number of people with a small risk of a disease may contribute to more cases of a disease than a small group with an individually larger risk
Give an example of a health promotion campaign
Change 4 Life Stoptober Promoting screening and immunisations Cervical smear screening MMR vaccine Smoking ban – population approach to secondary prevention
What is primary prevention
Prevention of disease who have not been diagnosed as having the disease, includes promoting health
Intent is to reduce/eliminate causative risk factors
What is secondary prevention?
An intervention implemented after a disease has begun, but before it is symptomatic.
Intent is to identify early and minimise risks
What is tertiary prevention?
Intervention implemented after a disease is established
Intent is to stop bad things getting worse
What is the stages in the Nuffield Ladder of intervention?
Do nothing (just monitor)
Provide information (so people are informed and educated)
Enable choice (Enable people to change their behaviours)
Guide choice through changing the default
Guide choice through incentives
Guiding choice through disincentives
Restrict choice ( Regulate options available)
eliminate choice
Give an example of an intervnetial method
Motivational interviewing Social marketing Nudge theory – changing the environment to make the healthy option the easiest Mindspace Financial incentives
List some reasons why people may be resisitant to change
Health beliefs Situational rationality Culture variability Socioeconomic factors Stress Age
unrealistic optimism -
Individuals continue to practice health damaging behaviour due to inaccurate perceptions of risk and susceptibility, eg nothings bad has happened with me smoking so far
What is the transtheoretical model of change?
Not thinking (pre-contemplation)
Thinking about changing (contemplation)
Preparing to change
Action
Maintenance
Stable changed
lifestyle/relapse
Outline the health belief model of change, by Becker 1974
Individuals must believe; They are susceptible to the condition It has serious consequences That taking action reduces their risks That the benefits of taking action outweigh the costs
name some of the key actors in global health
United Nations and their agencies (UNICEF/UNAIDS/WHO) Multilateral Developmental Banks (The World Bank/Asian Development Bank) Bilateral agencies (USAID/CIDA/DFID) Private foundations (Rockefeller Foundation/Bill and Melinda Gates Foundation) Non-governmental organisations (Doctors Without Borders/Save The Children
What are the 3 leading causes of death of children in developing countries?
Pneumonia
Diarrhoea
Malaria
List some global population trends over the last 80 years.
World’s population is increasing
Births per woman; decreasing in less developed countries, remains stable in developed countries
World’s fertility is generally decreasing
Population is aging, especially in middle class
High population of under 15’s
Name some Global health issues that can arise as a consequence of climate change
Heatwaves – bacteria friendly environment
Sea levels rise
New diseases
Scarcity of resources
What are some health challenges commonly faced in the poorest countries in the world?
Underweight/malnutrition Unsafe Sex Unsafe water and sanitation Zinc deficiency Iron deficiency Vitamin A deficiency
What are some health challenges commonly faced in the richest countries in the world?
High blood pressure Alcohol High cholesterol High BMI Low fruit and vegetable intake Physical inactivity
What 3 things make up the definition of a migrant?
Country of Birth
Country of nationality
Duration of stay
What are some causes of vulnerability that would cause migrants to come to the UK?
Persecution, war, political and social unrest
Exploitation, torture, rape, bereavement
Burden of disease and socioeconomic status
Where/what is Lampedusa? what is its significance?
Italian island
Closest European territory to the shores of Libya
Primary transit point for immigrants from Africa
Deadliest migrant route in the world
Give examples of different groups of people that could be defined as migrants
Asylum seekers Refugees Economic migrants Trafficked people Migrant workers Family workers Family joiners international students
Theories of Causation:
What is the Psychosocial theory
Stress results in inability to respond efficiently to body’s demands
Impact on BP, cortisol levels, and inflammatory and neuroendocrine markers
Theories of Causation: What is the Neo- material theory
More hierarchical societies are less willing to invest in provision of public goods
Poorer people have less material goods and of less quality
Theories of Causation: What is the life course theory
Combination of both psychosocial and neo-material explanations
Critical periods – possess greater impact at certain points in the life course e.g. childhood
Accumulation – hazards and their impacts add up
Interactions and pathways – sexual abuse in childhood leads to poor partner choice in adulthood
Theories of Causation: what is the Proportional Universalism theory
Focusing on the disadvantaged only will not help to reduce inequality
Action must be universal
Scaled to be intensity proportional to the disadvantaged
Fair distribution of wealth
Response to health inequalities - outline the work of Ignacz Semmelweis in 1847
Campaigned for hand washing
Found correlation between puerperal fever and dissection
Response to health inequalities - outline the work of the Black report in 1980
Material (environmental causes, might be mediated by behaviour)
i Artefact (an apparent product of how the inequality is measured)
ii Cultural/behavioural (poorer people behave in unhealthy ways)
iii Selection (sick people sink socially and economically)
Response to health inequalities - outline the work of The Acheson Report (1998)
Income inequality should be reduced
Give high priority to the health of families with children
Define opportunity cost
The cost of any decision measured in terms of the next best alternative that had to be sacrificed/forgone in the making of the decision
E.g. balancing time and money
Opportunity cost; what is the Loewy approach?
Select a few from all treatment options
Opportunity cost; what is the Efficiency approach?
; More from the cheapest areas, ignores expensive treatments
What is QUALYs? What is it used for?
QUALTIY ADJUSTED LIFE YEARS
Used in some economic evaluations to measure health
Combines length of life and quality of life
Allows one to compare interventions that have different types of effects
It makes funding decisions easier
Define equity
Equity is concerned with the fairness or justice of the distribution of costs and benefits
The sick role: what are the 4 components to the sick role?
Pt. exempt from normal social roles
Is not responsible for their condition
Should try to get well
Should seek help and cooperate with medical professionals
What makes up the beliefs of the biomedical model of health?
Down to physical and biological factors, so can be repaired
Only health professionals can practise it
Mind/body Dualism, suggests that they can be treated separately#
This privileges use of technological interventions
It neglects social and psychological dimensions of disease
What makes up the beliefs of the social model of health?
Gives thought to a wide range of factors
Focus on prevention
Wide range of people can practice it
Challenges mind/body dualism
What are the 3 theories of health?
Health as an Ideal State
Health as a state of social functioning
Health as a personal strength or ability
Theories of health: Outline the Health as an Ideal State theory.
What are its problems?
Goal of perfect well-being (WHO definition)
Disease, illness, and forms of handicap, along with social problems must be absent in order for health to be present
Problems; Is anyone ever healthy? What is complete well-being? Can we ever attain this ideal state? Misleading?
Theories of health: Outline the Health as a state of social functioning
theory.
What are its problems
Health is a means towards social functioning
All forms of disease and social handicap need to be removed
Can still be healthy (function socially) even when suffering with a chronic illness/disease
Problems;
Very narrow definition seeing health as the opposite of disease
Patients normal state may be unhealthy
Refusal of treatment might be seen as healthy
Theories of health: Outline the Health as a
personal strength or ability
theory.
What are its problems?
focus on how people respond to challenges
Health is a means to a greater end – responding positively to problems
Attempts to recover holistic ideas about health
Problems;
Vague
How can we intervene?
\
What are some structural determinants of health?
Structural Determinants Genetic Constitutional (age/sex) Culture Lifestyle Social/community networks Living and working conditions
Determinants of health, what are some lifestyle barriers promoting mortality?
Smoking Obesity Sedentary lifestyle Excess alcohol Poor diet
Smoking: What are the physiological effects of smoking?
How many people die a year
Activation of nicotinic ACh receptors in the brain
Dopamine release in the nucleus accumbens
Stimulant, tolerance, withdrawal
100,000 deaths a year
name some diseases associated with smoking
Associated health problems; Cancers, COPD, CHD, stomach ulcers, impotence, oral health, cataracts
Give some reasons for smoking
Addiction Coping with stress Habit Socialising Fear of weight gain after cessation Pleasure Choice Advertising Peer group/family Signifier of cultural status
Apple the planned behaviour theory to smoking
Attitude - I do not think smoking is a good thing
Subjective norm – most people who are important to me want me to give up
Perceived behavioural control - I believe I have the ability to give up
Behavioural intention - I intend to give up
what was the law passed in 1908 in regards to smoking?
Children Act – Sale prohibited in U16s
what was the law passed in 1965 in regards to smoking?
– parliament bans cigarette advertisement on TV
what was the law passed in 2007 in regards to smoking?
smoking banned in public places and legal minimum raised to 18
What government intervention did the government do in 2016?
Standardised packaging required as of 2016 – ‘plain packaging protects’
Give some reasons as why someone would be reclutant to change a habit like smoking
Type A behaviour – hostility, competitiveness, impatience
Uncle Norman behaviour – smoked/drank and was obese all his life and died when he was 90, so I can do the same…
The last person behaviour – well he was fit and well and died suddenly, what benefit is this to me if he died…
Unrealistic optimism – tendency to perceive oneself of being at less risk of disease than other people of same age/sex
List some of the social implications of drinking
Violence
Rape
Depression/anxiety
Driving offences
How much alcohol is one unit?
A standard unit is 10 mL/8 g of ethanol
(% alcohol by volume x amount of liquid in mL)/
1000
What are the limits of alcohol consumption for men, women and weekly
Men = 3-4 units a day, 28 units a week (old recommendation)
Women = 2-3 units a day, 21 units a week (old recommendation)
NEW GUIDELINES SAY 14 UNITS/WEEK FOR MEN AND WOMEN
Name a sign of alcohol wihtdrawal
Tremors Activation syndrome (agitation, shakes, rapid heart rate, high blood pressure) Seizures Hallucinations Delirium tremens
How much energy in 1g of of alcohol?
7kcal
name one of the 4 questions in the CAGE questionaire for alcohol dependancy.
Ever felt that you should cut down?
Been annoyed by people telling you to cut down?
Do you feel guilty about how much you drink?
Eye opener: ever had a drink first thing in the morning?
What is an associated disease with diarrhoea?
Dysentery
Typhoid
Hepatitis
Cholera
What would be a risk factor for infection?
- low immunity, low white cell count, imbalance in normal flora, invasive
procedures (64% of blood stream infections are directly related to IV devices in situ
)
Define reservoir in the context of infection control
where the spread originates, patients, visitors, stuff, fomites
What are the 3 types of handwashing?
i Level 1: Routine handwash
ii Level 2: Hygienic hand antisepsis
iii Level 3: Surgical handscrub
Name one of the standard IPC precautions in hospitals
gloves and aprons, hand hygiene
• correct sharps manipulation
• correct clinical waste and linen handling
What does Alcohol gel destroy? What about antimicrobial liquid soap?
Alcohol gel - destroys most transient organisms (MRSA) but does not kill Norovirus or
Clostridium difficile
ii Antimicrobial Liquid Soap - removes all transient organisms
What are some of the challenges of having an increasingly aging population?
Strains on pensions and social security
Increasing demands for health care
Bigger need for trained health workforce
Increasing demand for long term care
Pervasive ageism that denies older people the rights and opportunities for other adults
What are the causes of an increase in the age of the population?
Improvement in sanitation, housing, nutrition, and medical interventions
Life expectancy is rising
Substantial falls in fertility
Decline in premature mortality
More people reaching old age whilst fewer children are born
What are the two reasons women tend to live longer than men?
Biological (20%) – premenopausal women are protected from heart disease by hormones
Environmental (80%) – men take more lifestyle risks
Give an example of extrinsic aging
Extrinsic – dependent on external factors, UV rays, smoking, air pollution
List some of the physical changes seen in aging
Loss of skin elasticity Loss of hair and hair colouring Decrease in size and weight Loss of joint flexibility Increased susceptibility to illness Decline in learning ability Less efficient memory Affects sight, hearing, taste, smell Visual – need x3 more light, narrowing visual field, worse colour/depth perception Hearing – high frequency loss, poor speech comprehension Taste and smell – 50% loss of taste buds
What is intrinsic ageing?
A natural, universal, inevitable process.
Give 3 consequences of people living longer.
- Pensions will have higher pay outs than currently planned.
- Chronic and comorbid conditions will prevail.
- Rising inequalities as more affluent groups will use health services for longer.
List 4 types of dementia.
- Alzheimer’s disease (62%)
- Vascular dementia (17%)
- Mixed alzheimer’s and vascular (10%)
- Lewy bodies (6%)
What is medicalisation of death?
Death is seen as a failure. There is a curative endeavour to prolong life at any cost. Death as a natural part of life is challenged.
What is meant by institutionalising death?
60% of people die in hospital but 70% want to die at home.
Glaser & Srauss (1965) did an observational study of interactions between dying people, family and staff – what were the 4 Awareness
contexts they identified?
Closed awareness
Suspicion awareness
Mutual pretence
Open awareness
Define social death
– when people die in social and interpersonal terms before their biological death; lonely, impersonal death
Outline a “good”death
palliative care became a speciality, aiming to de-medicalise death; reaction against impersonal medical deaths
outline “death the hospice way”
Open awareness, compassion, honesty
Multi-disciplinary teams
Emotion and relationships – modelled on a family approach
Holistic care
What does the Katz ADL scale measure?
Bathing Dressing Toilet use Transferring (in/out of beds and chairs) Urine and bowel continence Eating
Standard ADLS
What does the IADL (instrumental activities of daily living) measure?
Use of the telephone Travelling by car or using public transport Food/clothes shopping Meal preparation Housework Medication use Management of money
General daily living
What does MMSE - Mini Mental state Examination Measure?
Orientation, immediate memory
Short term memory
Language functioning
What does the Barthel ADL index measure
Feeding Moving from wheelchair to bed Grooming Transferring to and from toilet Bathing Walking on level surface Stairs Dressing Continence of bowels Continence of bladder
(10 items that measure daily functioning)
Give the psychological definition of stress
Occurs when demands made upon an individual are greater than their ability to cope
state the 2 kinds of stress.
Distress – Negative stress, damaging and harmful
Eustress – Positive stress, beneficial and motivating
List the causes of Chronic stress
– health, home, finances, work, family, friends etc.
List the causes of acute stress
noise, danger, infections, injuries, hunger etc
Give some reasons for workplace stress
Pressure
Lack of managerial support
Work related violence and bullying
What are some of the physiological signs of stress?
the body’s response to the fight or flight model
Lungs - increase O2 uptake
Blood flow - increases to muscles, up to 400%
Skeletal muscles - tense
Spleen - More erythrocytes released
Skin – loses blood flow
Mouth – drier as saliva and mucus dry up
Immune cells – redistributed to where injury might occur
Name 3 external stressors.
- Environment.
- Work.
- Social and cultural pressures.
What are the 5 signs of stress.
- Biochemical.
- Physiological.
- Behavioural.
- Cognitive.
- Emotional.
What is the fight of flight model?
An automatic response to external acute stressors. The response elicits physiological changes: hypothalamus, adrenal medulla and cortex are stimulated. Activation and inhibition of organs.
Give examples of physical and psychological internal stressors.
- Physical: inflammation, infection.
- Psychological: attitudes, beliefs, personal expectations, worries.
What is the general adaptation syndrome?
A concept used to describe the body’s short term and long term reactions to stress. There are 3 stages.
What are the three stages of general adaptation syndrome (GAS)?
- Alarm.
- Adaptation/resistance.
- Exhaustion.
Describe the alarm stage of GAS.
A threat/stressor is identified. There is a sudden burst of energy.
Describe the adaptation/resistance stage of GAS.
The body attempts to adapt or resist the stressor. Defensive countermeasures are engaged.
Describe the exhaustion stage of GAS.
Energy is depleted; the body begins to run out of defences.
Describe the biochemical signs of stress
– endorphin levels altered, increase in cortisol
Describe the Physiological signs of stress
– shallow breathing, raised BP, increased acid production in stomach (and see fight/flight response)
Describe the behavioural signs of stress
– increase in absenteeism, smoking, alcohol, changes in eating patterns, sleep disturbances
Describe the cognitive signs of stress
negative thoughts, loss of concentration, tension headaches
Describe the emotional signs of stress
tearful, mood swings, irritable, aggressive, bored, apathetic
What is the diagnostic criteria for PTSD?
- The person experienced an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
- The person’s response involved intense fear, helplessness, or horror.
Give 3 symptoms of PTSD.
- Recurrent and distressing recollections of the event(s) e.g. in dreams.
- Persistent avoidance of stimuli associated with the event.
- Persistent symptoms of increased arousal (when the brain remains ‘on-edge’, wary and watchful of further threats) e.g. insomnia, irritability etc.
What physical illnesses can be related to stress?
Cancer, CHD, chronic fatigue, infertility/miscarriage, peptic ulcers, IBS.
Name some stress mediating factors
social support, beliefs and attitudes,perception, personality, coping strategies, lifestyle, gender
Name some Stress management techniques
– CBT,T’aiChi, yoga, exercise, self help andsupport
What is the WHO Definition of Obesity
Abnormal/excessive fat accumulation
Resulting from chronic imbalance between energy intake and expenditure which presents a risk to health
State of positive energy balance
State some diagnostic measures for obesity
MRI Dual-energy X-ray Absorptiometry Waist circumference Waist to hip ratio Skinfold thickness Body Mass Index (BMI)
What is a criticism of BMI?
BMI does not measure adiposity or visceral body fat
How do you work out BMI?
Weight (KG) / Height^2 (m)
What is the range for a normal BMI?
18.5 - 24.9
What genetic conditions can be linked to obesity?
- Prader Willi Syndrome.
- Mutations of the leptin and melanocortin receptors.
- Congenital leptin deficiency. (leptin: appetite inhibitor).
What aspects of behaviour can be associated with weight gain?
- Employment: shift work, lack of sleep, reduced physical activity, ‘hunger’ hormones (cortisol, leptin, ghrelin) affected.
- Dietary patterns.
- Reduced physical activity.
What developmental factors can affect a child’s risk of being obese later in life?
- Rapid infant weight gain increases the risk of obesity.
- Breast feeding is shown to decrease the risk of obesity.
- Premature introduction of solid foods can increase the risk of obesity.
- Childhood obesity is a large predictor of adult obesity.
What is the role of alcohol in over-eating.
- Alcohol stimulates the intake of food, gives almost no satiety.
- It is efficiently oxidised.
- It adds to the total daily energy intake.
- Alcohol is associated with poor food choices.
What are the Ranges for BMI
<18.4 = underweight 18.5-24.9 = normal 25-29.9 = overweight 30-34.9 = obese class I 35-39.9 = obese class II >40 = obese class III
State some of the causes of the rise in obesity
Built and obesogenic environment - “Americanisation” of diet and society
car culture and commuting = less walking
technical advances that minimise physical work
Longer working hours
Over consumption (& increasing portion sizes), greater availability of energy dense food
Grazing & snacking replaces meal times
Replacement of water by sugary drinks
What is the energy density of... Protein Carbs Fat Alcohol
Protein 4.7 kCal/g
Carbohydrates 3.6 kCal/g
Fat 9.5kCal/g
Alcohol 7.0 kCal/g
What macronutrient has the best satiety?
Satiating efficiency = proteins > carbs > fats > alcohol
So proteins the best, Alcohol is the worst
define satiety
a state of noneating, characterized by the absence of hunger, which follows at the end of a meal and arises from the consequences of food ingestion.
What is the theory behind reducing the energy density of foods?
- People to tend to keep portion sizes the same regardless of the energy density of the food.
- By reducing energy density we can keep the same portion sizes but consume fewer kcal and so keep satiety.
What 4 mechanisms can be used to reduce energy density?
- Incorporation of water or air.
- Fruits and vegetables.
- Reducing fat (industry).
- Method of cooking (no frying).
Factors that can promote over-eating: what are examples of environmental factors?
- Variety - greater variety can lead to overeating.
- Portion sizes have increased significantly over the last century.
- Distractions like watching TV promote food intake.
- Social facilitation - going out for food with friends etc.
Name 3 broad factors that can promote over-eating.
- Environmental factors.
- Psychological factors.
- Food-characteristic factors.
Factors that can promote over-eating: what are examples of psychological factors?
- Stress often promotes over-eating.
- Lack of sleep.
- Dietary disinhibition.
- Reward sensitivity.
Factors that can promote over-eating: what are examples of food-characteristics factors?
- Macronutrient composition.
- Energy density.
- Liquids v solids.
Name 5 qualities of an effective team.
- Optimal size.
- A common purpose/goal.
- Good dynamic.
- An identified leader.
- Shared knowledge and experiences.
What are the benefits of working in an effective team?
- Improved service delivery.
- Improved decision making.
- Reduces error.
Describe 4 obstacles of working in a team.
- Organisation - different offices/shifts/rotation posts.
- Location - ward based/home visits/based elsewhere.
- Management - different employers/sub-teams.
- Team members may have other commitments - hard to contact people.
Give 3 examples of NHS systems that promote teamwork.
- Shared case notes.
- Multi-disciplinary team meetings.
- Team offices.
Give 2 examples of checklists used in the NHS.
- SBAR checklist - for reporting a case.
2. Surgical safety checklist.
Define error.
Any preventable event that can cause or lead to patient harm.
What are the 3 types of human error?
- Errors of omission.
- Errors of commission.
- Errors of negligence.
What are errors of omission?
When required action is delayed or not taken.
What are errors of commission?
When the wrong action is taken.
What are errors of negligence?
When actions or omissions do not meet the standard of an ordinary, skilled person professing.
What are the 2 outcomes that medical error can lead to?
- Adverse event.
2. Near miss.
Define adverse event.
An incident that results in harm to the patient.
Define near miss.
An event which has the potential to cause harm but doesn’t develop further, thereby avoiding any harm.
What are violations?
Deliberate deviations from practices, procedures and standards or rules.
Name the 3 types of violation.
- Routine - cutting corners.
- Necessary - to get the job done; unavoidable.
- Optimising - personal gain, selfish.
Describe skill based errors.
When performing a routine, well learnt task you may give little attention. If distracted or interrupted this can result in slips of action or memory lapses.
Describe rule/knowledge based errors.
- When an incorrect plan or course of action is taken. This can happen in an emergency situation or can be due to a lack of experience.
- Mistakes are more likely when tasks are complex. This can be due to inexperience, insufficient information, little support/advice from colleagues etc.
Name 5 factors that can affect performance.
- Fatigue.
- Illness.
- Drugs or alcohol.
- Stress.
- Distraction.
What are the two main approaches to managing errors?
- Person approach (individual).
2. System approach (organisation).
Managing errors: describe the person approach.
Errors are the product of wayward mental processes e.g. inattention, distraction, negligence. It focuses on the unsafe acts of people on the front-line (nurses, doctors).
Managing errors: describe the system approach.
Adverse events are the product of many causal factors, the whole system is to blame (swiss cheese theory)
Briefly describe the Swiss cheese theory of errors.
The idea that the interaction between active failures and latent conditions leads to accidents. There are successive layers of defences and safeguards but the ‘holes’ can still line up and people can slip through the system.
Name 5 information processing limitations.
- Automaticity.
- Cognitive bias.
- Cognitive interference.
- Selective attention.
- Transferring expectations.
What is negative transfer of expectations?
When a previous experience conflicts with the current situation.
Define Automaticity
Doing a task without thinking
Define selective attention
Limited attentional resources, information overload
Define ethics
A system of moral principles and a branch of philosophy that defines what is good for individuals and society.
Define morality
concern with distinction between good and evil, right and wrong (universal)
Outline top down deductive ethical arguments
Top down deductive; where one specific ethical theory is consistently applied to each problem
Outline bottom up deductive ethical arguments
; using past medical problems to create guides to practice
An approach where theories are considered which best fit one’s own beliefs before applying
What are the 3 times confidentiality may be broken?
Required by law
patient consent
Public interest
outline the basic GMC “duties of a doctor”
Protect and promote the health of patients and the public
Provide a good standard of practice and care
Recognise and work within the limits of your competence
Work with colleagues in the ways that best serve patients’ interests
Treat patients as individuals and respect their dignity
GMC (2009) – Tomorrow’s Doctors; graduates will be able to behave according to ethical and legal principles
What are the four principles of ethics?
Autonomy
Beneficence
Non - Maleficence
Justice
Define autonomy
Allowing a patient to make a rational and informed decision if they have capacity, with obligation to respect their decisions
The autonomous individual freely acts in concordance with a self chosen plan
Decision made intentionally, with understanding, and without controlling influences that determine an individuals actions
Define Beneficence
Doing the right thing to benefit the other
Balancing risks against benefits
Define non - maleficence
Preventing harm, reducing harm, and doing no harm
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Define justice
Being fair in the distribution of risks and benefits
Need vs. Benefit
What are Utilitarian ethics?
- An act is evaluated solely in terms of its consequences.
- Maximise good and minimise harm.
What are the main principles of Virtue ethics?
Focuses on the person who is acting; are they expressing good character?
- Integrates reason and emotion.
- Virtues are acquired.
- An action is virtuous only if the person is acting with the genuine intention of doing the right thing.
What are the challenges/criticisms of Utilitarian ethics?
- Treats minorities unfairly to promote happiness of a majority.
- Is it okay to carry out ethically questionable research to maximise the welfare of society?
- What is good/better?
What are the challenges/criticisms of Virtue ethics?
Virtues are culture-specific.
- Too broad for practical application.
- Kindness and compassion could lead to not telling the harmful truth - lying.
- It is not always clear how to resolve a dilemma with virtue ethics.
What are Deontology ethics?
Inherent morality determines worthiness of actions, without concern for potential consequences
“Do unto others as you would be done by”
Deon = duty (in Greek)
What is Kantianism ethics?
Judges the morality of an action based on the actions adherence to rules
Obligatory duty
Following natural laws and rights
Categorical imperatives – set of universal moral premises from which duties are derived (do not lie, do not kill…)
define screening
Process that sorts out apparently well people who have a disease (or disease precursor) from those who don’t
Screening the population is to detect individuals who are more likely to have the disease (in most cases) –aim is preventing disease or early detection to alter course of disease
Types of screening - define population based screening
Population based - Testing entire population
Types of screening - define opportunistic screening
– patient seeks help for something else and doctor takes a sample
Types of screening - define communicable disease screening
screening for analysing/controlling epidemics/pandemics
Types of screening - define Pre-employment/commercial
screening for occupational health
Briefly outline the Wilson and Junger criteria for screening test.
The condition must;
Be important
Recognised latent phase (early catching improves prognosis)
Recognised natural history (know how disease progresses)
The test must;
Be suitable, sensitive, specific, inexpensive
Be acceptable
The post-screening treatment options must;
Be effective
Follow agreed policy
The organisation and cost must;
Include adequate facilities
Not be overly expensive to achieve benefit
Have ongoing processes for improvements
Screening: define True positive
patient does have the disease, and screening test was positive
Screening: define False positive
patient does not have the disease, but screening test was positive
Screening: define True negative;
patient does not have the disease and screening test was negative
Screening: define False negative
patient does have the disease and screening test was negative
Outline some reasons for screening
Prevent suffering
Early identification is beneficial
Early treatment is cheaper
Patient satisfaction tends to be higher
Outline some reasons against screening
Damage caused by wrong results
Adverse effects on healthy people
Personal choice is compromised
Define sensitivity
A test of the probability of a person with the disease obtaining a positive test result
Probability of a true positive
= Number of true positive results / total number screened
= true positives / (true positives + false negatives)
A measure of how well a test picks up those with a disease
Same logic but opposite to Specificity!
Define Specificity
Probability of a true negative in screening
= Number of true negatives / total number screened
= True negatives / (false positives + true negatives)
A measure of how well a test recognises those without the disease
Same logic but opposite to Sensitivity!
Define Incidence
Number of new cases per unit time
Expressed as % or per population size (e.g. per 100,000)
What would increase incidence in a population?
Increased by screening, identifying new cases, and increasing risk factors
What would decrease incidence in a population?
Decreased by reducing risk factors e.g. primary preventions
Define prevalence.
Number of existing cases at a particular point in time
Expressed as a percentage or per population size (e.g. 100,000)
People enter prevalence pool when diagnosed with a condition
Only leave the pool if they are cured or die
Define positive predictive value
The proportion of people with a positive test result who actually have the disease
= True positives / (true positives + false positives)
Define negative predictive value
The proportion of people without the disease who are correctly excluded by the screening test
= True negatives / (false negatives + true negatives)
how would you work out positive predictive vale?
= True positives / (true positives + false positives)
how would you work out negative predictive vale?
= True positives / (false negatives + true negatives)
Define selection bias
– people who chose to participate in screening programmes may be different from those who do not
Define lead time bias
– screening identifies the disease earlier than before and thus gives the impression that survival is prolonged (survival time is unchanged)
Define length time bias
diseases with longer period of presentation are more likely to be detected by screening than those which are more aggressive
Define ecological study
a study that uses routinely collected data to show trends and to generate hypotheses
Define Cross sectional study
divides a population into those with the disease and those without and collects data at a single point in time
Define Case-control study - retrospective.
matches people with a disease to those without for age, sex, habits, class etc
Define Cohort study
Observe a larger number of people, over a long period of time and compare incidence between groups that differ in terms of exposure
Define an analytical study
Observational (vs intervention) analytical of relationships rather than simply descriptive
Give 3 advantages of an ecological study.
- Uses routine date and so is quick and cheap.
- Few ethical issues.
- Useful for generating hypotheses.
Give 3 disadvantages of an ecological study.
- Cannot show causation.
- Inconsistency in data presentation.
- Bias - variation in diagnostic criteria.
Give 4 advantages of a cross-sectional study.
- Can give rapid insight into events within a population.
- Few ethical issues.
- Good for generating hypotheses.
- Quick and cheap.
Give 3 disadvantages of a cross-sectional study?
- Prone to bias.
- No time reference.
- Could be reporting medical oddities.
Give 3 advantages of a case-control study?
- Quick - results can be obtained quickly (retrospective).
- Cheap.
- Usually a small number of people required to produce statistically significant results.
Give 3 disadvantages of a case-control study?
- Retrospective date may be unreliable - selective memory.
- Shows association but not causation.
- Prone to selection and information bias.
- Cannot calculate incidence.
Give 3 advantages of a cohort study?
- Can calculate incidence and so can find relative and absolute risk.
- Reduced chance of bias - exposure measured before disease develops.
- Can distinguish causes from associated factors.
Give 3 disadvantages of a cohort study?
Collect information on a sample (some have exposure, some do not). None should have outcome
- Expensive - long time and large population.
- Causation cannot be calculated - control study is needed for this.
not suitbale for rare diseases
3. Often difficulties with follow-up.
Outline/define an RCT
Patients are randomised into groups
One group is given an intervention and the other is a control
The outcome is measured
Randomisation allows confounding features to be equally distributed
Confounding biases are minimalised
They do show causation
What are some of the disadvantages of an RCT?
Tend to be large and expensive and show volunteer bias
Outline what a systemic review is
a review of clearly formulated questions that uses symptomatic and explicit methods to identify, select, and critically appraise relevant research
Collect and analyse data from studies that are included inthereview
Outline what a meta analysis is
Statistical methods used to analyse and summarise resultsofincluded studies
Can be graphically represented in a forest plot
Define what a type 1 error is
rejecting a null hypothesis when it is true
`Define what a type 2 error is
– failure to reject a null hypothesis when it is false
Give examples of some alternative medicine
Acupuncture – inserting needles at specific points, pain relief mostly
Osteopathy – emphasises the physical manipulation of body tissue and bones
Herbal medicine – plants for medical purposes
Chiropractic – manipulation of spine, joints, and soft tissue
Homeopathy – simila smimmilibus curentur, homeopathic dilutions in alcohol or distilled water
Traditional Chinese medicine – vital energy “qi” circulates through channels “meridians” that have branches connected to organs. No histological or physiological evidence for the concept. Based on pre-scientific culture
What are the 4 main STIs
Chlamydia – fallopian tube occlusion
Gonorrhoea (drug resistant)
Syphilis
Trichomoniasis
Give an example of primary prevention of STIs
prevention – reducing risk of acquiring Raising awareness Vaccinations (Hep B and HPV) One to one risk reduction discussions Condom use
Give an example of secondary prevention of STIs
Easy access to STI/HIV tests and treatments Partner notification Targeted screening Antenatal screening for HIV and syphilis National chlamydia screening programme
Give an example of tertiary prevention of STIs
– reducing morbidity and mortality
Anti-retrovirals for HIV
Prophylactic antibiotic for PCP
Acyclovir for suppression of genital herpes
Define compliance
Extent to which behaviour coincides with medical/health advice
Professional focused rather than patient focused - assumes doctor knows best
Does not look at problems patient’s have in managing their health/illness
Essential for treatment, but may still be poor
Outline some reasons for non - compliance
Unintentional :
Mis-understanding
Problems with treatment
Payment
Memory
Intentional
Patient beliefs about their
condition or treatment
Personal preferences
Outline what concordance means in medical practise
Negotiation between equals - an agreement to differ and respect for either’s agenda
Thinks of patients as equals in care
Expected that they will take part in treatment decisions
Consultation is now a negotiation between equals
Outline inverse care law
People who need the most care are least likely to access it and vice versa
Define association
a statistical link between exposure and disease
Many not reflect a cause and effect relationship
define causation
a statistical link where a disease is directly caused by the exposure
What are the two main types of bias?
Selection bias => problem with study population
Information bias => problem with information provided
Define observer bias
when variables are reported differently between assessors
Define procedure bias
subjects in different arms of the study are treated differently (other than the exposure or intervention)
if the median is greater than the mean of the data, what is the data described as
negatively skewed
if the median of the data is less than the mean, the distribution is said to be what?
is said to be positively skewed.
