PaSS to learn Flashcards
primary prevention example
targets disease free (general poulation)
- poster campaigns
- increasing cost of alcohol
secondary prevention
people at risk of a health problem
- screening of at risk indivciduals, control of risk factors and early intervention
tertiary prevention
people with a health problem
- rehab, preventing complications and improving quality of life
health improvement examples
- Smoking cessation
- Public mental health
- Sexual health services
- Substance misuse services
- NHS health checks
- Weight management
healthcare public health
- Strategic direction and leadership
- Evaluation and research
- Support evidence-based decision making
- Needs assessment
- Service design
- Prioritisation
the biomedical model
- Illness understood in terms of biological and physiological processes
- Treatment involves physical interventions (drugs/surgery)
health definition
health is a state of complete, physical, metnala nd social wellbeing, it is not merely the absence of disease or infirmity’
biopsychosocial model
interdisciplinary model that looks at the interconnection between biology, psychology, and socio-environmental factors
psyco
cognition
emotion
behaviour
Bio
physiology
genetics
pathogens
social
how many definitions of heatlh
3
3 definitions of health
negative
positive
functional
negative definition of health
health equates absence of illness
positive definition of health
health is the state of wellbeing and fitness
functional def of health
health is the ability to do certain things
influence of lay beliefs on behaviour (3)
1) health behaviour
2) illness behaviour
3) sick role behaviour
health behaviour
activity that impacts on health or helps prevent illness
e.g. smoking is more prevalent in lower socioeconomic groups
illness behaviour
activity of ill person to define illness and seek solution
sick role behaviour
formal response to symptoms, inc seeking formal help and acting as a patient
Higher social class more likely to have a
positive definition of health
o Incentive of giving up smoking are more evident for groups who expect to remain health- more able to focus on long term investments e.g. quitting is the rational choice
Lower social class, incentives are less clear
o More of a focus on improving immediate environment
o Smoking used as a coping mechanism
o May be normalised behaviour e.g. smoking is a rational choice
what influences illness hevaiour?
- Culture e.g. stoical attitude
- Visibility or salience of symptom
- Extent too which symptoms disrupt life
- Frequency and persistence of symptoms
- Tolerance threshold
- Info an understanding
- Availability of resource
- Lay referral
Lay referral system
chain of advice-seeking contacts which the sick make with other lay people prior to- or instead of – seeking help from professional
sick role
Sick role described as: ‘a temporary, medically sanctioned form of deviant behaviour’
early presenters to GPs
experienced significant and rapid impact on functional ability
late presents to GPs (delayers)
often developed explanations for symptoms that related to preceding activities
Limitations of the ‘sick role’
- Not all illnesses are temporary
- Does not acknowledge differences between people
- Does not acknowledge individual agency in defining and coping with illness i.e. not involving medical profession
Sick role mechanism
- In order to be excused from normal duties and be considered not responsible for their condition the sick person is expected to seek profession advice and adhere to treatments
- Medical practitioners are empowered to sanction their temporary absence from the work force and family duties as well as to absolve them from blame
deniers and distancers
e.g. half the sample denied either having asthma at all (deniers) or denied having “proper” asthma (distancers)
- Claim symptoms don’t interfere with everyday life
- Use complex or drastic strategies to hide it
- Taking medication relies on accepting asthmatic identity e.g.
o Don’t take the drugs
o Don’t attend asthma clinics
acceptors
Accepted diagnosis and doctors advice completely. Normal life involved having control over symptoms through medication.
Asthma was not a stigmatised identity- happy to use inhalers in public
pragmatists
Did use preventative medication but only when asthma was bad.
- Accepted they had asthma but saw it as a mild acute illness
chronic diseases
are diseases which current medical interventions can only control and not cure
life forever altered- no return to normal
what is a long term condition
is a condition that cannot, at present, be cured but is controlled by medication and/or other treatment/therapies
- Increase with ageing population but not only older people who live with LTCS
e.g. rheumatoid arthritis
BIGGEST CHALLENGE FACING NHS
illness work
- getting a diagnosis
- managing the symptoms and self-management and normalisation
3 stages of getting a diagnosis
pre-diagnosis
diagnosis
post diagnosis
everday life work
coping (cognitive processes invovled in dealing with illness) and strategic (mobilising resources) management
emotional work
- Work that people do to protect the emotional well-being of other
- Maintain normal activities becomes deliberately conscious
- People find friendships disrupted and may strategically withdraw
- May involving downplaying pain or other symptoms
- Presenting a ‘cheery self’
biographical work
loss of self
- Former self-image crumbles away without simultaneous development of equally valued new ones
- Constant struggle to lead valued lives and maintain positive definitions of self
- Interaction between body and identity
Burys biographical disruption
Burys biographical disruption
Focuses on people’s experience of the onset of illness as a disruptive event
- Acknowledges differences between individuals
limits of Burys biographical disruption
- Does not deal with conditions from birth
- Some social groups expect illness more than others
- Later work has shown that older people may see chronic illness as ‘biographically normal’
Goffmans stigma outlines
- Distinction between ‘virtual social identity’ (how people are understood by others) and ‘actual social identity” (qualities a person possesses)
THIS SPOILS IDENTITY
stigma is a
a negatively defined condition, attribute, trait or behaviour conferring deviant status
2 TYPES OF STIGMA
- Stigma 1
- stigma 2
Stigma 1
discreditable or discredited
discreditable
Discreditable: nothing seen, but if found..
o Mental illnes/ HIV +ve
discredited
Physically visible characteristic or well known stigma which sets them apart
o Physical disability
o Known suicide attempt
stigma 2
felt vs enacted
felt stigma
real experience of prejudice, discriminated and disadvantage
o As the consequence of a condition
enacted stigma
fear of enacted stigma, also encompasses a feeling of shame (associated with having a condition)
o Selective concealment
Social determinants of health
Are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.
Inverse Care Law:
the availability of good medical care tends to vary inversely with the need of the population served
Deprivation strongly associated with ill health
The more deprived a person is the larger the proportion of their life will be spent in ill health and more likely to die at a younger age
Health and gender
‘Men die quicker, but women get sicker’
Men
- Lower life expectancy
- More CVD e.g. heart attacks
- More suicide
- More violent death
Women
- Higher life expectancy
- Higher reported (poor) mental health
- Higher rates of disability and limiting longstanding illness
Explanations, theories and pathways for health inequalities (6)
- Artefact (discredited)
- Social selection
- Behavioural-cultural
- Materialist (most plausible)
- Psychosocial
- Income distribution
1.Artefact explanation
Health inequalities evident due to the way statistics are collected (re measurement of class)
Social selection explanation
- Sick individuals move down social hierarchy, healthy individuals move up
- Chronically ill and disabled more likely to be disadvantaged
- Plausible explanation
Behaviour-cultural explanation
Ill health due to peoples choices/ decisions, knowledge and goals.
Behaviours are outcomes of social processes, not simply individual choice
Choices may be difficult to exercise in adverse conditions
Choices may be rational for those who lives are constrained by lack of resources
Materialist explanation
Lack of choice in exposure to hazards e.g. radiation
Accumulation of factors across life course
Most plausible
Inequity-
inequity refers to unfair, avoidable differences arising from poor governance, corruption or cultural exclusion
Inequality
inequality simply refers to the uneven distribution of health or health resources as a result of genetic or other factors or the lack of resources
you can have inequality
without inequity
Deprived peoples health is usually managed a
as series of crises (i.e. they don’t go to the doctor until they are very unwell)
Normalisation of ill-health
events based counselling
Event based counselling (i.e. at a food bank or walk in clinic at homeless shelters) may be needed to legitimise consultation
These events are expensive- difficult marshalling resources needed for negotiation and engagement with health services.
Due to lack of cultural alignment between health and service and lower socio-economic groups
name some social determinants of health and illness
x
name some social determinants of health and illness
Social class, ethnicity, gender and deprivation
health related behaviours
x
‘Anything that can promote good health or lead to illlness’
• Drinking
• Smoking
• Drug use
• Taking exercise
• Safe sex behaviour
• Taking up screening activities
integrative model
COM-B
classical conditioning (learning theory)
- Environmental cues- sights, smells, location, people e.g. signal expectation of drug/ alcohol
- Cues may be emotional (e.g. anxiety)
- Cues with connection to using drug/alcohol can trigger behaviour and lead to relapse when quitting (e.g. drinking with friends could trigger smoking or drug use)
classical conditioning and changing behaviour
Involves avoiding cues/change association with cues
• E.g. Aversive techniques in alcohol misuse= pair behaviour with unpleasant response
• Alcohol + medication to induce nausea (nausea is result of medication and loopholes but comes to be associated with alcohol)
- Behaviour decrease if
o Punished
o Reward taken away
E.g. Skinners Rat experiment- lever pressing
operant conditioning and healthy related behaviours
- Explains why we do things and for our health- immediately rewarding e
- The problem is… Unhealthy behaviour is rewarding .g. nicotine rush
- Driven by short term rewards and avoiding short term negative consequences (withdrawal)
- E.g. using financial incentive for smoking cessation
limitation of classical and operant (reward/punishment)conditioning
- Based on simple-stimulus response associations
- No account of cognitive processes, knowledge, belief, memory, attitudes etc
- No account of social context
social learning theory (learning theory)
- Built on operant theory
- People can learn vicariously (observation/modeeling)
- Behaviour is goal-directed
People are motivated to perform behaviours:
o That are valued e..g if you see celeb being praised for doing it
o That they believe they can enact (self-efficacy)
health promotion and cognitive dissonance theory
Providing health info (usually uncomfortable) creates mental discomfort and can prompt change in behaviour
COM-B demonstrates the barriers to behaviour change
- Lack capability (inadequate knowledge and/or skills)
- Insufficient opportunity
- Motivation (desire) at key movements to engage in healthy behaviour is lacking
- Because healthy behaviours are usually different, boring or unpleasant while unhealthy are enjoyable or meet immediate needs
types of capability
• Physical and psychological capability: knowledge, skill, strength, stamina
types of motivation
• Reflective and automatic motivation: plans, evaluations, desires and impulses
types of opportunity
time, resources, cues/prompts
nudge theory
Based on the idea that 80% of human behaviour is automatic
Nudge involves making simple changes to the choice architecture to steer decision in the right direction
e.g.
placing a fruit bowl on the front counter in a school canteen to encourage children to buy more fruit
dependence can be
physical - physical or pscychological
pscychological- impaired control
risk factors for drug use
- family life (neglects, drug use and abuse)
- mental health
- employment and educational attainment
- social group
- previous drug use
- biology
correlation between addiction and
adverse childhood experiences (ACE)
maltreatment
1) verbal abuse
2) physical abuse
unconditional stimulus
stimulus such as falling blood alcohol levels leads to an unconditional response such as having withdrawal symptoms
conditional stimulus
- e.g. sight of a needle or the smell of fav drinks- paired with an unconditional stimulus like falling blood alcohol levels
different addiction treatment models
- Medical model
- Disease model
- Behavioural model
- Medical model
- Detoxification regimes
- Substitute prescribing
- Disease model
- Step facilitation
- AA/NA – ‘12 step programme’
- Behavioural model
- CBT
- Motivational interviewing
disease model (Minnesota)
x
combines in-patient with therapy and groups
- Addiction is an illness
- Loss of control the primary symptom
- Addiction is genetic and therefore predetermined
- Abstinence/avoidance is the only viable treatment
harm reduction (most important) and alcohol
o Vitamin B
o Safety advice
harm reduction (most important) and opiates
o Naloxone
o Overdose awareness
harm reduction (most important) and injecting
o Needle exchange
o Injecting advice
o BBV screening
o Sexual health
relapse prevent for alcohol
- Disulfiram (Antabuse)- Alcohol Deterrent (24h after last drink)
obese BMI
>30
underweight BMI
<18.5
(overweight is >25)
levels of prevention
1) Primordial
2) Primary prevention
3) Secondary prevention
4) Tertiary prevention
primordial
- Concerned with avoiding the emergence and establishment of the social, economic and cultural patterns of living that are known to contribute to an elevated risk of disease
- It involves intervention that are applied at population level to influence or affect individuals
primary
- Concerned with preventing the onset of pathological changes
- It involves interventions that are applied before there is pathology
- E.g. vaccination, smoking cessation, physical fitness, road safety
secondary
• Concerned with detecting a disease in its earliest stages, before symptoms appear, an intervening top slow or stop its progression i.e. catch it early
• The assumption is that earlier intervention will be more effective, and that this disease can be slowed or revered
o e.g. screening and risk prediction’’
tertiary
(we want to avoid due to cost to NHS and patient)
• Concerned with arresting the progress of an established disease and to control its negative consequences
o To lessen impairment (inc recurrence)
o To reduce disability and handicap
o To minimise suffering caused by existing departures from good health
o To promote the patient adjustment to irremediably conditions i.e. minimise the consequences
universal approach to health promotion
aim to reduce risk across the whole population e.g. sugar tax
targeted approach to health promotion
aim to identify those most at risk and then tailor messages and approaches to that group or groups e.g. breast feeding initiatives in young mums
models for health promotion
health persuasion e.g. a doctor advising a pregnant women to stop smoking
legislative action e.g. ban on smoking in public places
personal counselling e.g. counselling for someone with alcohol problems
community development e.g. times to change campaign developed by local champions
definition of screening
“The presumptive identification of unrecognised disease or defect by the application of tests, examinations or other procedures that can be applied rapidly to sort out apparently well persons who probably have a disease from those who probably do not”
all screening tests require confirmation by a
diagnostic test after
cost-effecitveness dictates that only
only high-risk screening test results are confirmed by a diagnostic test or procedure
ethical and consent implications for screening
great responsibility for care required in screening than in clinical care:
‘Screening will inevitably turn some people who test ‘positive’ into patients – a transformation not to be undertaken lightly. If a patient asks a medical practitioner for help, the doctor does the best possible. The doctor is not responsible for defects in medical knowledge. If, however, the practitioner initiates screening procedures the doctor is in a very different situation. The doctor should, in our view, have conclusive evidence that screening can alter the natural history of the disease in a significant proportion of those screened.’
five criteria for screening
- The condition
- The test
- The intervention
- The screening programme
- Implementation
the condition
- An important health problem with understood epidemiology, incidence, prevalence and natural history
- All cost effective primary prevention interventions should have been implemented as far as practicable
- If the carriers of a mutation are identified as a result of screening, the natural history of people with this status should be understood, including the psychological implications
the test
- Simple, safe, precise and validated screening test
- Agreed cut off level must be defined and agreed
- Acceptable to target population
- Diagnostic test available for those who test positive
the intervention
- Effective interventions for patients identified through screening, with evidence that intervention at a pre-symptomatic phase leads to better outcomes for the screened individual compared with usual care
- Treatment at early stage should be of more benefit than at a later stage
the screening programme
- Proven effectiveness in reducing mortality or morbidity
- Evidence that the complete screening programme is clinically, socially and ethically acceptable to health professionals and the public
- Benefit gained by individual should outweigh any possible harms e.g. over treatment, false reassurance etc
sensitivity
is the proportion of cases which the test correctly detects
a/a+c
specificity
x
positive predictive valie
is the proportion of positive tests who are cases
A/A+B
NPV
is the proportion of negative tests who are not cases
D/C+D
Screening programs are hard to evaluate due to
o Lead to time bias
o Length time bias
o Selection bias
lead time bias
- Early diagnosis falsely appears to prolong survival
- Screened patients appear to survive longer, but only because they were diagnosed earlier
- Patients actually live the same length of time, but longer knowing they have the disease
length time bias
- Screening programmes better at picking up slowly growing, unthreatening cases than aggressive, fast growing ones
- Diseases that are detectable through screening are more likely to have a favourable prognosis, may indeed never have caused a problem
- Could lead to a false conclusion that screening is beneficial in lengthening lives of those found positive- curing people that didn’t need curing?
selection bias
- Studies of screening are often skewed by healthy volunteer effect
- Those who have regular screening likely to also do other things that protect them from disease
- Randomised control trials help with this bias
negatives of screening
-psychological impact of false negatives
example of screening programs
cervical cancer
bowel cancer
explicit rationing
specific rules for allocations
administrative authority as to the amounts and types of resources to be made available, eligible populations
implicit rationing
is the allocation of resources through individual clinical decisions without the criteria for those decisions being explicit
opportunity cost
once you have used a resource in one way, you no longer have it to use in another way
opportunity cost of the new treatment is the . value of the
next best alternative sue of those resoruces
QALY incorporates
quality and quantity of life gained by a treatment
1 year of perfect health
1 QALY
2 years of 50% QOL
1 QALY
NICE and cost per QALY
x
NICE and cost per QALY
below £20k per QALy will normally be approved
above £30k
need an increasingly stronger case
health related quality of life HRQoL
mobility
self-care
usual activities
pain
anxiety/depression
PROMS
patient reported outcomes measures
“The tools or instruments used to measure PROs: turn subjective experiences into numerical scores that can easily be utilized “
EQ-5D is an example of a PROM
definition of mindfulness from secular perspective
“the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to the unfolding experience moment by moment”
in meditative terms mindfulness means
awareness
aim of mindfulness to reduce suffering
pillars of mindfulness
acceptance
patients
non-judgement
beginners mind
letting go
trust
non striving
burnout
a state of mental and physical exhaustion related to work or care-giving activities - emotional exhaustion - depersonalisation - reduced sense of personal achievement
ruminators
prolong low mood AND have reduced problem solving ability
allostatic load
Prolonged stress leads to wear-and-tear on the body
allostatic load causes
Impaired immunity, atherosclerosis, metabolic syndrome, bone demineralization
define flow
“…a psychological state that can occur when challenges and skills in a situation are both high.”
HEP is based on the
ESSENCE model- based on 7 pillars of health
Education
Stress management
Spirituality
Exercise
Nutrition
Connectedness
Environment
Prochaska and DiClemente cycle of change
PLEASE CAN PEOPLE ACT MORE RESPECTFULLY
- Pre-contemplation
- Contemplation
- Preparation
- Action
- Maintenace
- Relapse
In the contemplation stage
the person has identified that there is a problem but not yet decided to make any effort to change. Here there may be a mental “turning point” where you recognise the problem, but nothing changes yet.
In the preparation stage
the person resolves to change their behaviour and decides on a plan of action. This requires the person to see that their behaviour was unhelpful and believe in their ability to change.
In the action stage
they begin to use the tools at their disposal to make gradual changes to their behaviour. Step by step, day by day, new habits are formed and old ways are replaced
During the maintenance stage
the person keep up the progress they have made, and new behaviours start to permanently replace the old way of acting.
maintenance stage can last for a long time, even months or years, but at some point the person may enter the relapse stage by temporarily falling back into their old habits. From there the cycle repeats.
motivational interviewing
“Motivational interviewing is a directive, client- centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence.”
Express empathy through reflective listening.
Develop discrepancy between clients’ goals or values and their current behavior.
Avoid argument and direct confrontation.
Adjust to client resistance rather than opposing it directly.
Support self-efficacy and optimism.
SMART GOALS
Specific
measurable
attainable
realistic
timely
tool for reflective practice
Gibbs
whast?so what? now what?
stages of Gubbs reflective cycle
davina felt every ache cus aerobics
- description
- feelings
- evaluation
- analysis
- conclusion
- action plan
sleep pressure
the pressure to go to sleep
Build up while awake of adenosine, higher levels greater sleep pressure
Breakdown when asleep
Caffeine temporarily blocks the receptors
sleep occurs in
90 min cycles with periods of waking
stages of sleep
Non-REM (NREM) sleep (Stages 1, 2 & 3) and REM sleep.
