Part 1 Flashcards
Epigenetics
The expression of the genome depends on the environment
Allostasis
Stability through change, our physiological systems have adapted to react rapidly to the environment
Eg. Cardio, Metabolic, Immune, CNS
Allostatic Load
Long term overtaxation of our physiological systems leads to impaired health (stress)
Salutogenesis
Favourable physiological changes secondary to experiences which promote healing and health
Emotional Intelligence
The ability to identify and manage one’s own emotions, as well as those of others
What is primary care for?
- Managing illness and clinical relationships over time
- Finding the best available clinical solutions to clinical problems
- Preventing illness
- Promoting health
- Managing clinical uncertainty
- Getting the best outcomes with available resources
- Working in a team
- Shared decision making with patients
The dangers of overprescribing antibiotics
- Unnecessary die effects
- Medicalising self limiting conditions
- Antibiotic resistance
Examples of appropriate antibiotic prescription
- Bilateral otitis media <2 years old
- Acute otitis media with otorrhoea
- Acute sore throat with 3 or more censor criteria (exudate, fever, tender cervical lymphadenopathy, absence of cough)
- Systemically very unwell
- High risk eg. comorbidities, immunosuppression, ex premature baby
- Aged >65 and 2 of the following or >80 and one of the following: hospital admission within last 12 months, congestive heart failure, glucocorticoid use
- Complications : pneumonia, mastoiditis, peritonsillar abscess/cellulitis
Public Health definition
The science and art of preventing disease, prolonging life and promoting health through organised efforts of society
Three domains of public health
Health improvement
Health protection
Improving services
What is health improvement?
Concerned with societal interventions (aimed at preventing disease, promoting health and reducing inequalities) Includes... -Inequalities -Education -Housing -Employment -Lifestyles -Family/community -Surveillance and monitoring of specific diseases and risk factors
What is health protection?
Concerned with measures to control infectious disease risks and environmental hazards Includes... -Infectious diseases -Chemicals and poisons -Radiation -Emergency Response -Environmental health hazards
What is service improvement?
Concerned with the organisation and delivery of safe, high quality services for prevention, treatment and care
- Clinical Effectiveness
- Efficiency
- Service Planning
- Audit and evaluation
- Clinical governance
- Equity
Key concerns of public health?
- Inequalities in health
- Wider determinants of health
- Prevention
What are interventions?
Delivered at individual, community or population level. May be health/non-health interventions which have an impact on public health
Before intervening, need to assess health needs
Health Needs Assessment
A systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities
Need- ability to benefit from an intervention
Demand- what people ask for
Supply- what is provided
Health Need
The need for health eg. measured using mortality, morbidity, socio-demographic measures
Health Care Need
The need for health care, ability to benefit from health care. Depends on the potential of prevention, treatment and care
Types of sociological perspective
Felt Need
Expressed Need
Normative Need
Comparative Need
Felt Need
Individual perceptions of variation from normal health
Expressed Need
Individual seeks help to overcome variation in normal health (demand)
Normative Need
Professional defines intervention appropriate for the expressed need
Comparative Need
Comparison between severity, range of interventions and cost
Approaches to a health needs assessment?
Epidemiological, Comparative, Corporate
What does an epidemiological approach consist of?
- Define the problem
- Size of problem (incidence/prevalence)
- Services available- prevention/treatment/care
- Evidence base- effectiveness and cost effectiveness
- Models of care- including quality and outcome measures
- Existing services- unmet need, services not needed
- Recommendations
(Sources of data: disease registry, hospital admissions, GP databases, mortality data, primary data collection)
Advantages and Disadvantages of an Epidemiological approach
Advantages
- Uses existing data
- Provides data on disease incidence/mortality/morbidity etc.
- Can evaluate services by trends over time
Disadvantages
- Quality of data variable
- Data collected may not be the data required
- Does not consider the felt needs or opinions/experiences of the people affected
What does a comparative approach consist of?
Compares the services received by a population (or subgroup) with others
- Spatial
- Social (Age, gender class, ethnicity)
May examine
- Health status
- Service provision
- Service utilisation
- Health outcomes (mortality, morbidity, quality of life, patient satisfaction)
Advantages/Disadvantages of a Comparative approach?
Advantages
- Quick and cheap if data available
- Indicates whether health or service provision is better/worse than comparable areas (gives measure of relative performance)
Disadvantages
- May be difficult to find comparable population
- Data may not be available/high qualaity
- May not yield what the most appropriate level should be (Eg. provision or utilisation)
What does a corporate approach consist of?
- Asks the local population what their health needs are
- Use focus groups, interviews, public meetings
- Wide variety of stakeholders eg. teachers, healthcare professionals, social workers, charity workers, local businesses, council workers, politicians
Advantages/Disadvantages of a corporate approach
Advantages
- Based on the felt and expressed needs of the population in question
- Recognises the detailed knowledge and experience of those working with the population
- Takes into account wide range of views
Disadvantages
- Difficult to distinguish ‘need’ from ‘demand’
- Groups may have vested interests
- May be influenced by political agendas
Consequentialism and types of consequentialism
“The end justifies the means”- the morality of an action is judged solely by the outcome. So the morally right action is the one that gives rise to the best consequences or actions. Eg. lying is okay in some situations if it promotes a better outcome than the truth
Types of consequentialism…
Utilitarianism (the best course is the one that promotes the most happiness/pleasure and absence of pain for all- lesser of two evils)
Egoism (the best course is what’s best for you- which may be positive, negative or neutral for others)
Altruism- the best course is what’s best for others’ wellbeing.
Deontology
“The study of the nature of duty or obligation’ Relates to duty-based theories. There are fundamental rules and duties to follow- some acts are seen as wrong no matter the consequences.
Principilism
The four principles
- Autonomy (Freedom for the patient to choose and advocate for their own health)
- Beneficence (what is considered the patient’s best interests)
- Non-maleficence (“do no harm”- balance the benefits against the harm)
- Justice (equity and avoiding discrimination at both an individual and societal level)
Dynamism
Situations are almost always dynamic and a decision taken at one time may not be appropriate at a later stage.
The 6 principles of good safeguarding practice
Relevant to protecting and promoting the health of individual patients including vulnerable groups
Empowerment (person-led decisions/informed consent)
Protection (support and representation for those in greatest need)
Prevention (it is better to take action before harm occurs)
Proportionality (proportionate and least intrusive response appropriate to the risk presented)
Partnership (local solutions through services working with their communities)
Accountability (accountability and transparency in delivering safeguarding)
The Care Act 2014
Sets out a legal framework for how local authorities and other parts of the health and care system should protect adults at risk of abuse or neglect
Primary Prevention
Preventing disease before it has happened
Secondary Prevention
Catching disease in the pre-clinical or early phase
Tertiary Prevention
Preventing complications of disease
Approaches to prevention
Population Approach (preventative measure eg. dietary salt reduction to reduce bp)
High risk approach (identify individuals above a chosen cut off and treat eg. screening for high bp)
Prevention paradox
A preventative measure which brings much benefit to the population often offers little to each participating individual
Screening
A process which sorts out apparently well people who probably have a disease (or precursors or susceptibility to a disease) from those who probably do not
Types of Screening
- Population-based screening programmes
- Opportunistic screening
- Screening for communicable diseases
- Pre-employment and occupational medicals
- Commercially provided screening
Disadvantages of screening
- Exposure of well individuals to distressing or harmful diagnostic tests
- Detection and treatment of sub-clinical disease that would never have caused any problems
- Preventative interventions that may cause harm to the individual or population
Wilson and Junger Criteria
The condition (important health problem, with a latent/preclinical phase, natural history unknown)
The screening test (suitable- specific, sensitive, inexpensive), acceptable
The treatment (Effective, agreed policy on whom to treat)
The organisation and costs (Facilities, costs of screening should be economically balanced in relation to healthcare spending as a whole, should be an ongoing process)
Sensitivity and Specificity
Sensitivity
The proportion of people with the disease who are correctly identified by the screening test (true positive/false neg + true pos)
Specificity
The proportion of people without the disease who are correctly excluded by the screening test (true negative/false pos + true neg)
Positive and negative predictive values
Positive predictive value
The proportion of people with a positive test result who actually have the disease (true pos/true pos +false pos)
Negative predictive value (the proportion of people with a negative test result who do not have the disease (true neg/true neg+false neg)
Lead time bias and length time bias
Lead time bias
When screening identifies an outcome earlier than it would otherwise have been identified, this results in an increase in survival time, even if screening has no effect on outcome
Length time bias
Type of bias resulting from differences in the length of time taken for a condition to progress to severe effects, that may affect the apparent efficacy of a screening method
Social Determinants of Health
Environment Economics Food Social Health Care Education
Social Capital
The networks of relationships among people who live and work in a particular society, enabling that society to function effectively
Types of Study design
Can be observational or experimental/interventional
Case Reports
Study individuals
Ecological Studies
Use routinely collected data to show trends in data and thus is useful for generating hypothesis.
Shows prevalence and association, not causation
Cross sectional study/survey
Divides the population into those without the disease and those with the disease and collects data on them once at a defined time to find associations at that point in time.
Advantages
Quick/cheap, provide data on a single point in time, large sample size, good for surveillance and public health planning
Disadvantages Risk of reverse causality (did exposure or outcome come first) Cannot measure incidence Risk recall bias and non-response Prone to bias, no time reference
Case-control studies
Retrospective, analytical studies that take people with a disease and match them to people without the disease for age/sex/habitat/class etc and study previous exposure to the agent in question.
Advantages
Good for rare outcomes
Quicker than cohort or intervention studies
Can investigate multiple exposures
Disadvantages
Difficulties finding controls to match with cases
Prone to selection and information bias
Cohort Studies
Start with a population without the disease in question and study them over time to see if they are exposed to the agent and develop the disease or not.
Advantages
Can follow-up a group with a rare exposure
Good for common and multiple outcomes
Less risk of selection and recall bias
Can distinguish preceding causes from concurrent associated factors
Disadvantages
Takes a long time
Loss to follow up- people drop out
Need a large sample size
Randomised Control Trial
Patients are randomised into two groups, one group is given an intervention, the other is given a control and the outcome is measured.
Advantages
Low risk of bias and confounding
Can infer causality (gold standard)
Disadvantages
Time consuming
Expensive
Specific exclusion/inclusion criteria may mean the study population is different from typical patients (eg. very elderly people)
Ethical issues- ethical to withhold a treatment
Non-randomised control trial
Same as RCT but no randomisation. Very subject to bias
Independent/Dependent variable
Independent variable- can be altered in a study
Dependent variable- cannot be altered, dependent on the independent variable
Odds
The odds of an event is the ratio of the probability of an occurrence compared to the probability of a non-occurance
Odds = probability/(1-probability)
Odds Ratio
The ratio of odds for exposued group to the odds for the not exposed group
OR = (Pexposed/1-Pexposed) over (Punexposed/1-Punexposed)
Can be interpreted as a relative risk when the event is rare.
Epidemiology
The study of the frequency, distribution and determinants of diseases and health related states in populations in order to prevent and control disease.
The epidemiology of a disease is described by time, place, person- age gender class ethnicity
Incidence v Prevalence
Incidence= new cases, denominator, time Prevalence = existing cases, denominator, point in time
