PH Flashcards
What are the GMC Duties of a Doctor?
Protect and promote health of patients and public
Provide good standard of practice and care
Recognise and work within limits of competence
Work with colleagues in way that best serves patient’s interests
Treat patients as individuals and respect dignity
What are the 3 domains of Public health?
Health Improvement - Social Interventions aimed at preventing disease, improving health and reducing inequality
Health Protection - controlling infectious diseases and environmental hazards
Health Care - organising and delivering safe and high quality services
What levels can intervention be considered to improve public health?
Ecological (population) Level:
* Ban smoking in public places
Community Level:
* Delivered at local communities such as playgrounds set up for local areas
Individual Level:
* Childhood immunisations.
What are the determinants of health?
PROGRESS:
Place of residence
Race/Ethnicity
Occupation
Gender
Religion
Education
Socio-economic status
Social Capital/resources
What is the health belief model
Health Belief Model (Becker 1974)
- Individuals must believe they are susceptible to the condition
- Must believe in serious consequences
- Must believe taking action reduces risk
- Must believe benefits of actions outweigh costs
Addition of:
- Health Motivation having the ability to change themselves
- Cues to Action which are the things that actually make someone start to change (eg. hit rock bottom, media)
What are the Strengths and Disadvantages of the Health Belief Model?
Strengths
- Can be applied to wide variety of health behaviours
- Cues to action are unique component
- Longest standing model
Disadvantages
- Doesn’t consider emotional influences
- Doesn’t consider repeated (habitual) behaviour
- Other factors may influence the outcome
What is the Theory of Planned Behaviour?
Proposes the the best predictor of behaviour is intention (eg. I intend to give up smoking)
Also looks at peoples attitudes, subjective societal norms, perceived behavioural control and behavioural intention
What are some determinants of Intention in the Theory of Planned Behaviour Model?
- Persons attitude to the behaviour
- Social pressure to undertake behaviour or the Subjective Norms
- Appraisal of the ability to perform the behaviour or their perceived behavioural control
Give examples of how the Theory of Planned Behaviour can by applied 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 smoking
Perceived Behavioural Control: I believe I have the ability to give up smoking
Behavioural Intention: I intend to give up smoking
What are some Strengths and Disadvantages of the Theory of Planned Behaviour Model?
Strengths
- Can be applied to wide variety of health behaviours
- Useful for predicting intention
- Takes into account importance of social pressures
Disadvantages
- Doesn’t account for emotional influences
- Doesn’t account for hobbies/habits
- No temporal element, direction or causality
- Assumes attitudes can be measured
PC PAM
What is the transtheoretical change model/Stages of Change Model of behavioural change?
- Precontemplation - not ready yet
- Contemplation - thinking about it
- Preparation - getting ready
- Action - Doing it
- Maintenance/relapse - sticking with it
Relapse can occur at any point
How can the Transtheoretical Change model be applied to smoking?
- Precontemplation - no intention of giving up smoking
- Contemplation - beginning to consider giving up
- Preparation - getting ready to quit in the future
- Action - Engaged in giving up smoking now
- Maintenance - Steady non-smoker
What are the Strengths and Disadvantages of the Trans-Theoretical Model of Behavioural Change?
Strengths
- Acknowledges stages
- Accounts for relapse
- Time element
Disadvantages
- Not everyone moves through each stage
- Change may be continuous, not discrete
- Doesn’t account for habits
- Doesn’t account for emotional influences
- Doesn’t consider values e.g., cultural and social factors
What are the structural determinants of illness?
Social Class Material deprivation and poverty unemployment discrimination and racism gender and health
What is the biological Model?
Mind and body are treated separately
The body is like a machine that can be repaired
This privileges the use of technological interventions
It neglects the social and psychological dimensions of disease
Define Morality
Concern with the distinction between good and evil or right and wrong
Define ethics
A system of moral principles and a branch of philosophy which defines what is good for individuals and society
What is utalitarianism/consequentialism?
An act is evaluated solely in terms of its consequences
maximises good and minimises harm
What is Kantianism/Deontology?
Features of the act determine the worthiness of the act
Following natural laws and rights
What is virtue ethics?
Focus is on the individual doing the action.
An action is only virtuous if the person is genuinely intending to do the right thing
What are the 5 focal virtues?
Compassion Discernment Trustworthiness Integrity Conscientiousness
What are the 4 principles of ethics?
Autonomy - The right to make your own informed decisions.
Beneficence - Always do good
Non-maleficence - Do no harm
Justice - Concerns fair distribution of services
What are used to assess the functional limitations in the elderly population?
Katz ADL (Activities of Daily Living)
IADL
Barthel’s ADL
MMSE
What do the Katz and Barthel’s ADL indexes assess?
An individuals ability to carry out activities of daily living such as:
Dressing
Bathing
Going to the toilet - and urinary and bowl continence
Getting in and out of bed
What does the IADL Index assess?
Instrumental activities of daily living: Use a telephone do laundry go shopping handle finances
What does the MMSE assess?
Immediate and orientation memory
Short term memory
language
What are some key challenges that are faced with an ageing population?
Strains on pension and social security - pensions will have a higher payout
Increased demand for health care
Increased demand for longer-term healthcare
Bigger need for trained health workforce
Ageing workforce
Perversive ageism
What is an acute illness?
A disease of short duration that starts quickly
and has severe symptoms (often can be cured)
What is a Chronic Illness?
A persistent or recurring condition, which
may or may not be severe, often starting gradually with slow
changes (can’t be cured but can be treated)
What is Polypharmacy?
The use of multiple medications or
administration of more medications than are clinically indicated
What is the chain of infection?
A susceptible host causative infectious organism Reservoir (somewhere to spread to) Portal of exit Mode of transmission Portal of entry New susceptible host
What are some protective infection control precautions?
Gloves and aprons and hand hygeine
Correct sharps manipulation
Correct clinical waste and linen handling
What are the different types of transmission?
Direct:
- Contact (eg. STIs)
- Faecal oral route
Indirect:
- Vector born (malaria, dengue)
- Vehicle born (Hep B)
- Airborn (TB)
What is stress?
Stress occurs when the demands made upon an individual are greater than their ability to cope
What is good stress?
Eustress - motivational and helpful
What is bad stress?
Distress - Damaging or harmful
What is the bodies stress response?
● Lungs – increased resp rate
● Blood flow – BP increases, HR increases
● Skeletal muscle – tenses
● Spleen – more RBCs discharged
● Skin – blood flow redirected to muscles and heart
● Mouth – mucous and saliva production decreases, dries
● Immune System – redistribution of WBCs
What is the stress illness model?
An individuals susceptibility to disease or illness is increased when an individual is exposed to stressors which cause strain upon the individual leading to psychological and physiological changes
What is Screening?
the process of identifying unrecognized or asymptomatic conditions or diseases in a population by sorting the apparentely well people who may have a disease from those who do not
What is the main purpose of screening?
Prevention of disease
What are the Wilson Jungner Criteria?
● it should be a serious health problem
● the aetiology should be well understood
● should be a detectable early stage
● should be an accepted treatment for the disease
● facilities for diagnosis and treatment should be available
● there can’t be an unmanageable extra clinical workload
● a suitable test should be devised for the early stage
● the test should be acceptable for the patients
● intervals for repeating the test should be determined
● there should be an agreed policy on whom to treat
● the cost should be balanced against the benefits
What is Primary Prevention?
Prevention of the disease occurring
eg. Vaccinations, Couch to 5k
What is Secondary Prevention
Early detection of disease in order to alter the course of the disease and maximise the chances of a complete recovery
Screening Programmes
What is Tertiary Prevention?
Preventing complications of the disease by slowing progression.
eg. Diabetic control/eye screening
Give some examples of Primary, Secondary, and Tertiary Prevention for Type 2 Diabetes
Primary - reduce risk factors by losing weight, having a balanced diet, increasing physical exercise
Secondary - Medications such as metformin, bariatric surgery to treat the condition and prevent progression
Tertiary - Population screening - diabetic eye screening
What is an error?
Any preventable event that may cause or lead to patient harm
What are the possible outcomes of errors?
An Adverse Event
A Near Miss
What are the different types of error?
Errors of Omission
Errors of Commission
Errors of Negligence
What are errors of Omission
When the required action is delayed or not taken
What are errors of Commission?
When the wrong action is taken
What are errors of Negligence?
When the actions, omissions or commissions do not meet the standard of an ordinary skilled person professing leading to harm of a patient
How can errors be managed?
At an individual level or organisational level
What is individual error management?
Errors are the products of wayward mental processes of individual people in the system
What is organisational error management?
What model can be applied to orgaisational error management?
Adverse events are the product of many causal factors (swiss cheese model) and so the whole system is to blame.
Define Prevalence?
The proportion of a population that are found to have the disease at one point in time
Define Incidence?
The number of new cases of a a disease arising within a specified time period
When can you breach confidentiality?
When required by law
When the patient provides consent
When it is in the public interest
What are the criteria for disclosure when breaching confidentiality?
Anonymous Patients consent Kept to a necessary minimum Meets current law After death confidentiality continues
How would you approach a patient about quitting smoking?
3 As
Ask
Advice
Assist
Give 4 examples of UK screening programmes
Antenatal and Newborn screening
Diabetic Eye screening
Cervical Screening (25-49 every 3 years and 50-70 every 5 years)
Breast screening (>50 every 3 years)
Bowel Cancer (>60 every 2 years)
Abdominal Aneurysm Screening (men >65 yrs self refer)
What is Sensitivity?
What is the equation to work it out?
The proportion of people with the disease who are correctly identified by the screening test
(TP / TP + FN)
What is Specificity?
What is the equation to work it out?
The proportion of people without the disease who are correctly excluded by the screening test.
(TN / FP +TN)
What is the Positive Predictive Value?
The proportion of people correctly identified as having the disease
(TP / TP + FP)
What is the Negative Predictive Value?
The proportion of people correctly identified as not having the disease
(TN / FN + TN)
What is the role of the doctor in combating health inequalities?
Changing systems Changing perspectives changing education working hollistically advocating on the social determinants of health
What are the social determinants of health?
Societal factors which influence an individuals health
What are the social determinants of health based on?
Fair society and healthy lives - the marmot report (2010)
Give some examples of social determinants of health
Education housing income access to care occupation
Why are social determinants of health important?
Health problems are worse in more unequal societies
Above a certain level, health ceases to improve in proportional and income disparities within a country affect health
Despite equal access to healthcare in the UK, health outcomes are not equal within society.
What is the Black Report?
what did it investigate
What were the outcomes?
From 1980 comissioned in 1977
Investigates health inequalities, to identify the extent and explore the causes
Stated that health inequalities are affected by:
- Material - environmental causes
- Artifact - there are not inequalities, it is how it is measured
- Cultural/behavioral - poorer people behave in unhealthy ways
- Selection - sick people sink socioeconomically
What is the Marmot Report?
From 2010
Central priniciple is proportionate universalism
Health inequalities are a matter of faireness and social justice
There is a social gradient in health - the lower a persons social position the worse their health
Action should focus on reducing the gradiant in health.
What is proportionate Universalism?
central part of the Marmot report
Only focusing on the most disadvantaged will not reduce health inequalities
Any action taken should be available to anyone but:
This means that universal policies (accessible to everyone) should be implemented, but proportional to the level of disadvantage.
What health inequalties require action on and are thus recommendations from the Marmot Report?
- Give every child the best start in life
- Enable all children, young people and adults to maximise their capabilities and have control over their lives
- Create fair employment and good work for all
- Ensure health standard of living for all
- Create and develop healthy and sustainable places and communities
- Strengthen the role and impact of ill health prevention
What is nudge theory?
Changing the environment to make the healthy option the easiest option
What are the millennium development goals?
- Eradicate Poverty and Hunger
- Universal Primary Education
- Gender equality
- reduce child mortality
- improve maternal Health
- Combat Malaria and HIV and other diseases
- Ensure environmental sustainability.
- Develop global partnerships for development
Define Probability
How likely an event is to happen
Define odds Ratio
The odds ratio compares the odds of an event occurring in one group to the odds of it occurring in another group.
It is most often used in case-control studies, where it’s not possible to directly measure risk because we are looking at odds instead of probabilities.
Define Risk
How is it calculated?
Risk refers to the probability or likelihood that an event will occur over a certain period.
Risk = Number of individuals with event / Total number of people at risk
eg. If 10 out of 100 people develop a disease, the risk is 10/100 = 0.10 or 10%.
Define Absolute Risk
Give an example
Absolute risk is simply the actual risk of developing a disease or outcome in a given population over a specific time period.
It describes the incidence rate of an event in a particular group.
eg. If in a study, 5 out of 100 people who smoke develop lung cancer, the absolute risk of lung cancer for smokers is 5%.
Define Relative Risk
Relative risk compares the risk of an outcome between two groups: one that is exposed to a factor and one that is not.
It tells you how many times more (or less) likely the event is to occur in the exposed group compared to the unexposed group.
What is absolute risk reduction?
ARR is the difference between the risk (probability) of an event occurring in the control group and the risk of the event occurring in the treatment or intervention group.
It helps to show how much the treatment reduces the risk of an outcome compared to not receiving the treatment.
What is number needed to treat
Derived from ARR that indicates how many people need to receive a treatment to prevent one additional adverse event.
NNT = 1 / ARR
Example:
If a new drug reduces the risk of a MI by 4% (ARR=0.04) then the NNT is 1/0.04 = 25
This means that 25 people need to be treated with the new drug to prevent one heart attack.
1/absolute risk reduction
What are confidence intervals?
The range of values that are believed to contain the true parameter value
What are confounding variables?
effects of 2 or more variables on one another
What are some types of screening?
Population-based
Oppotunistic
Screening for Communicable diseases
Pre-employment
opportunistic
What types of bias are screening tests affected by?
Selection bias
Lead time bias
Length time bias
What is Selection Bias?
The people who choose to participate in screening programmes may be different from those who don’t; proper randomisation is not achieved.
What is Lead time bias
Screening identifies diseases earlier and therefore gives the impression that survival is prolonged but survival time is actually unchanged.
What is Length time bias?
Diseases with a longer period of presentation are more likely to be detected by screening than ones with a shorter time of presentation.
Give some general examples of Primary, Secondary and Tertiary Prevention
Primary - risk factor awareness, immunisations
Secondary - Screening, reducing impact of early-stage disease
Tertiary - Medications to prevent progression, Rehabilitation
What is the hierarchy of the study designs pyramid?
Top: Systematic reviews + meta-analysis Clinical Trials (RTCs) Observational studies (Cohort, Cross-sectional, Case-control) Case Reports / Case series Anecdotal findings, opinions, or ideas Bottom
What are the types of descriptive observational studies?
Individuals - Case report / Case series
Populations - Ecological study, Cross-sectional study
What are the types of analytical observational studies?
Cross-sectional
Case-Control
Cohort
What is the Bradford-Hill Criteria?
The minimum set of conditions necessary to provide adequate evidence of a causal relationship
What are some methods of collecting qualitative data?
Interviews,
Focus groups
Observation
What is the concept of medicalisation?
When aspects of normal life become the focus of medicine and intervention, medical problems/conditions are thus created.
What are the 3 main behaviours relating to health and what do they mean?
Health behaviour - Behaviour aimed at preventing disease (eg. eating healthily)
Illness behaviour - Behaviour aimed at seeking a remedy (eg. going to the doctor)
Sick role behaviour - Behaviour aimed at getting well (eg. taking prescribed medications)
What can health behaviours be?
Health Damaging - eg. smoking
Health Promoting - eg. exercise
Why is it important to understand health behaviours?
For adequate measures in disease prevention
For assessing where funding should be aimed
For understanding where interventions are best placed (at individual and population-based levels)
Give some examples of health promotion campaigns
Change 4 life Movember Dry January Screening Promotion F.A.S.T
What is unrealistic optimism?
When individuals continue to practice health-damaging behaviours due to inaccurate perception of risk and susceptibility
What are some perceptions of risk influenced by?
- Lack of personal experience with a problem
- Belief that preventable by personal action
- Belief that if not happened by now then it is not likely too
- Belief that the problem is infrequent.
What are some examples of theories of behavioural change?
Health belief model
Theory of planned behaviour
Transtheoretical model
Nudging
What factors are important to consider when promoting behaviour change?
How personality and behaviour interact
Assessment of risk perception
chan ging societal norms
What is the WHO definition of health?
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity
What are some social influences on health?
Life expectancy decreases as social class decreases Gaps between upper and lower class are rising
What determines population health?
The extent of income division within a society. Therefore more unequal societies have worse health
What is Sociology?
The study of social relations (bonds between people or groups of people) and social processes. It is the measure of social interdependencies.
What are the social roles of a sick person?
Exempt from normal social roles
not responsible for their condition
should try to get well
should seek help from and co-operate with the medical profession
What is Iatrogenesis?
The unintended adverse effects of a therapeutic intervention.
They can be clinical, social or cultural
What is the effect of prevalence of a disease on screening results?
A high disease prevalence would mean the incidence of false positives falls. The positive predictive value therefore increases and the negative predictive value would decrease
What are some benefits to screening?
Prevent suffering
early identification is beneficial
early treatment is cheaper and often more effective
Patient satisfaction tends to be high
What are some negatives to screening?
Damage caused by false positives and false negatives
Adverse effects of screening tools on healthy individuals
Personal choice is compromised
What is the prevention paradox?
A preventative measure that brings a lot benefits to population, often offers little to each participating individual
Why does high-risk approach to screening favour those who are more affluent and better educated?
More likely to engage with health services
More likely to comply with treatments
More likely to have the necessary means to change their lifestyle
What percentage of deaths in the UK are attributed to CHD?
Roughly 40%
1 in 5 men
1 in 8 women
What are the unmodifiable risk factors of CHD?
Sex Age Ethnicity Family Hx Early life circumstances
What are the potentially modifiable risk factors of CHD?
Physiological/clinical:
High cholesterol
Hypertension
T2DM
Lifestyle: Smoking Physical Inactivity Overweight Poor nutrition Alcohol
What is the Primary prevention of CHD?
Lifestyle changes (SNAP)
Smoking, Nutrition, Alcohol, Physical Activity
Medical (anti-hypertensives, Statins, Metformin/insulin)
Cardiac Rehabilitation
What is the secondary prevention in CHD?
Primary care CHD registers Medical Management (Apsirin, ACE Inhibitors, Statins) Phase 4 cardiac Rehabilitation
What are some psychosocial influences in CHD?
Personality Depression Anxiety Work Social Support
Give some general facts about smoking
Men smoke more than women
Smoking prevalence is decreasing
Lower Socioeconomic groups smoke more
What government rules have been put in place to reduce smoking?
2005 - Ban smoking in public places
2007 - Minimum age was raised to 18
What are some reasons that people smoke?
Habit
Stress
Nicotine addiction
Socialisation
What are some forms of nicotine replacement therapy?
Patches Gums Nasal Spray lozenges All available on the NHS
What is Influenza?
Flu that is spread via coughing, sneezing and touch.
Incubation period is 1-3 days
Infectious with symptom onset 4-5 days
Which influenza causes pandemics and which influenza is seasonal?
Type A - Pandemics
Type B - Seasonal
What virus family does influenza come from?
Orthomyoxoviridae
What are the surface antigens of influenza?
Haemagglutinin
Neuraminidase
What are the criteria for pandemic spread?
Novel virus Capable of infecting humans Capable of causing illness in humans Large pool of susceptible people Ready and sustainable transmission from people
What are the phases of a pandemic?
Phases of a pandemic:
● Phases 1-3 (mostly animal infections with few human infections)
● Phase 4 (sustained human to human transmission)
● Phases 5-6 ( Widespread human infection)
● Post peak (possibility of recurrent events)
● Post pandemic (disease returns to seasonal levels)
What are some diseases that cause diarrhoea?
Dysentry
Typhoid
Hepatitis
Cholera
What are some Causative organisms of Diarrhoea?
Rotavirus Shigella E.coli Salmonella Typhi Campylobacter Norovirus Clostridium Difficile
What is S.I.G.H.T?
Prevention of C.Diff: Suspect C.diff Isolate the case Gloves Hand wash Test stool for toxin
Treat with Metronidazole or Vancomycin
Why is diarrhoea in children important?
Kills more children than AIDS malaria and measles combined
Prevention is via a package from WHO-UNICEF
Fluid replacement therapy and Zinc treatment
Who are at risk of diarrhoea?
Poor hygiene
children at pre-school/nursery
Those preparing uncooked foods
Health care and social workers
What are the limits for alcohol?
14 units a week for men and women
Pregnant women recommended not to drink
What is a standard unit of alcohol?
10mL/8g of ethanol
(% alcohol by Volume X amount of liquid in mL) / 1000
What are some social implications of Alcohol?
Violence rape depression anxiety driving offences
What are the CAGE Questions for alcohol dependency?
Ever felt like you should CUT down?
Been ANNOYED by people telling you to cut down?
Do you feel GUILTY about the amount you drink?
EYE OPENER - Ever had a drink first thing in the morning?
What is concordance?
Concordance refers to the process of shared decision-making between a patient and a healthcare provider, focusing on mutual agreement about the treatment plan.
It emphasizes dialogue and respect for the patient’s values, beliefs, and preferences.
A mutual agreement on a treatment plan after shared decision-making
What are some reasons for non-compliance?
Disagree with doctor
Cost
Side-effects
Forgetful (psych/neuro/chronic diseases)
Lack of understanding of importance/need for taking
Barriers to healthcare
Intentional - the patient has their own beliefs about their condition or treatment
What is adherence?
Adherence refers to the degree to which a patient follows through with an agreed treatment plan that they have actively participated in creating.
Sticking to a treatment plan that the patient has agreed to
What is Compliance?
Compliance refers to the extent to which a patient follows a prescribed treatment or healthcare regimen as directed by a healthcare provider
Following medical advice as prescribed by a healthcare provider
Paternalism means the patient must follow the doctor’s orders, not taking into account their views
What is Palliative Care?
Palliative care improves the quality of life of patients and families who face life-threatening illness by
providing pain and symptom relief, spiritual and psychosocial support from diagnosis to the end of life
and bereavement.
What is the difference between Specialist palliative care and generalist palliative care?
Specialist:
HCPs who specialise in palliative care within an MDT. often used for patients with cancer.
Generalist:
Available to anyone with advanced progressive disease likely to end in death. Provided by GPs. district nurses, hospital doctors, social workers etc.
What is ethics?
The attempt to arrive at an understanding of the nature of human values of how we ought to live and of what constitutes right conduct
What is Top Down Deductive?
Where one specific ethical theory is consistently applied to each problem
What is Bottom Up Inductive?
Using past medical problems to create guidelines to practice
What is the doctrine of dual effect?
If you carry out an action knowing that X is a likely consequence of that action. Then in the eyes of the law you are regarded as intending to cause X
What is validity?
How close to the truth something is
What is Reliability?
How consistent the results are
What is Applicability?
How relevant a study is to clinical medicine
What is positive Skew?
Tail to the right
Mean > Median > Mode
eg. household income
What is negative skew?
Tail to the left
The mode is greater than the median which is greater than the mean
(age of death)
What are Glaser and Strauss (1965) 4 awareness contexts?
Closed awareness
Suspicion awareness
Mutual pretense
Open Awareness
What is closed awareness?
When the patient is unaware of their own impending death but others (staff and family) are aware
What is suspicion awareness?
The patient suspects that they are dying and tries to seek confirmation of this
What is Mutual pretense?
Everyone knows the patient will die including the patient but it is not discussed
What is Open awareness?
Everyone knows the patient is likely to die and talks openly about it
What is the sequence of the stress response?
Alarm
adaptation
exhaustion
What is cost utility analysis?
give an example?
describes outcomes measured in quality/disability adjusted life years e.g. incremental cost per QALY gained.
Example:
Imagine a public health program offering a new diabetes treatment.
Cost: $100,000 for 100 patients.
Outcome: 50 QALYs gained.
Result: Cost per QALY = $100,000 / 50 = $2,000 per QALY.
What is economic efficiency?
when resources are allocated between activities in such a way as to maximise profit and is NOT a type of economic evaluation.
what is cost effective analysis?
give an example
Outcomes are measured in natural units, such as life years gained, cases averted, or deaths prevented
Example:
A public health program costs $200,000 and prevents 100 cases of heart disease.
Cost per case prevented = $200,000 / 100 = $2,000.
what is cost benefit analysis?
Give an example
describes outcomes measured in monetary units allowing for a direct comparison of the financial return on investment.
Example:
A vaccination program costs $1 million and is projected to save $3 million by reducing healthcare costs and productivity losses.
Benefit-Cost Ratio = $3 million / $1 million = 3:1.
This means every $1 spent generates $3 in benefits.
what is minimilisation analysis?
Give an example?
CMA is only applicable when the outcomes of the compared interventions are known to be the same. For example, two different brands of the same vaccine with identical efficacy.
Example:
Scenario: A government wants to procure vaccines for a public health program. Two vaccines, A and B, are equally effective at preventing disease X.
Vaccine A: Costs $10 per dose.
Vaccine B: Costs $8 per dose.
Analysis: Since both vaccines provide the same health benefit, CMA recommends Vaccine B, as it is cheaper.
> Application: This analysis can also include indirect costs like transportation, storage, or administration fees to determine the total cost of each option
how do you work out the incremental cost effectiveness ratio for a new drug?
ICER = difference in costs/difference in benefits.
eg. Difference in costs would be £25,000-£10,000 = £15,000. Difference in benefits is 6 QALY – 5 QALY = 1 QALY. £15,000/1 = £15,000 per QALY gained.
What are the big 5 CAM (complementary and alternative medicine)
Acupuncture, chiropractic herbal medicine homeopathy osteopathy
What is the Inverse care Law?
the availability of medical or social caretends to vary inversely with the need of the population served
Define:
Equity
Horizontal Equity
Vertical Equity
Equity: What is fair and just
Horizontal equity: equal treatment for equal need
- Same access/prioritisation to healthcare despite age, sex race etc.
Vertical equity: unequal treatment for unequal need
- Greater access/prioritisation to healthcare to those who have a greater need. Less access/prioritisation to those who have lower needs
(Essentially the opposite of inverse care law.)
What are some different types of need?
Felt Need - individuals perceptions
Expressed Need - Seeking help to overcome something
Normative Need - professional defines the intervention
Comparative Need - Comparison between severity, range of interventions and cost
What are the steps of the health needs assessment?
A systematic approach for reviewing the health issues affecting a population which leads to agreed priorities and resource allocation that will improve health and decrease inequalities
- Needs assessment
- Planning
- implementation
- Evaluation
What are some different types of health needs assessments?
what do they consider?
Epidemiological:
- Defines problem and size of problem.
- Looks at current services.
- Recommends improvements
Comparative:
- Compares services received by one population to another
Corporate
- Takes into account views of any groups that may have an interest eg patients, health professionals, media, politicians
What are the Limitations of some health needs assessment models?
Epidemiological:
- Data available may be poor
- May be inadequate evidence base
- Doesn’t consider felt need
Comparative:
- Data available may vary in quality
- May be hard to find comparable population
- Comparison may not be perfect
Corporate:
- May be hard to distinguish need from demand
- Groups have vested interest – leads to bias
- Dominant individuals may have undue influence
How can you assess the quality of a Service?
Maxwells dimensions of quality (3As and 3Es):
- Accessible – will patients actually be able to use it?
- Acceptable – will the service be acceptable?
- Appropriate – is this the right thing to do?
- Equity – Is this fair and just
- Efficiency – this is concerned with maximizing output e.g., must do X amount of procedures/day for it to be viable
- Effectiveness – Does it do what it’s intended to do?
Define Evaluation
The assessment of whether a service achieves its objectives and the relevance and impact of the activities on the objective
Give some examples of Evaluation
Single Intervention - RCT evaluating the effectiveness of a new cancer drug
Evaluation of public health interventions - evaluating the impact of a smoking ban on health with epidemiological studies
Health economic evaluation - cost-effectiveness of a medical intervention
Health technology assessment - systematic reviews and meta-analysis
How can we Evaluate Health Services?
Donabedian Framework
Structure – What is there
- Services, Buildings, Number of beds, staff, equipment
Process – What is done/How is it done
- Screening, Vaccinations, Number of patients seen, counselling, prescribing
Outcome – The results afterwards
- Morbidity, Mortality, QOL, Patient satisfaction,
What are some challenges attributing health outcomes to services
- Link (Cause and Effect) case-mix, severity
- Time lag between services provided and outcome
- Large sample sizes may be needed for statistically significant results
- Data may not be available
- Issues with data quality (CART)
Completeness, Accuracy, Relevance, Timelessness.
What are some different approaches to resource allocation?
Lick My Ear
Libertarian approach: Taking responsibility for own health, wellbeing and fulfilment of life plan + autonomy
Maximising principle: Concentrating resources on those who stand to gain the most
Egalitarian principle: Equal access, equality and justice in healthcare
What is Maslow’s Heirachy of Need?
- Self-Actualisation
- Self-Esteem
- Social (Love/Belonging)
- Safety
- Physiological
What are some models of Change?
Health Belief Model
Theory of Planned Behaviour
Trans-theoretical Model
What are the criteria for medical negligence?
What two rules help determine an outcome?
4 Criteria:
- Was there a duty of care?
- Was there a breach in the duty of care?
- Did the patient come to harm?
- Did the breach cause the harm?
Bolam rule: A doctor is not negligent if their actions align with a responsible body of medical opinion.
Bolitho rule: Courts can reject a body of opinion if it is not logical, reasonable, or defensible.
What is Neglect?
Falling below the acceptable standard of care
What are violations?
Deliberate deviations from practices, procedures and standards or rules
What are some examples of errors of negligence?
Skill based Errors
Slips and lapses – when the action made is not what was intended
Rule/Knowledge Based Errors
An incorrect plan or course of action is chosen
What is a sample?
A selection from a population which aims to represent the whole population.
Name some types of bias and explain
Sampling bias, some people are more likely to be included in your sample than others. (omission, inclusive bias)
Recall bias, people cannot remember information correctly
Social- desirability bias, change answers to more acceptable ones
Information bias, errors in your measurements.
What is a confounding factor?
Risk factors other than those being studied that influence the outcome
What are the categories of studies?
– Experimental vs. Observational
– Retrospective vs. Prospective
– Individual vs. Population level
What is an experimental research method?
One where the researcher has made some kind of intervention eg crossover trial or RCT
What is an observational study?
There is no intervention data is just collected about what happens, E.g. case-control, cross-sectional,cohort,ecological studies
What is a retrospective study?
One which looks back at what has already happened case-control
What is a prospective study?
Collect information then follow up over time Cohort study
What is an individual study?
Collect information about individuals all studies except ecological.
What is a population study?
Talk about a whole population
What is the ecological fallacy
when inferences about individual-level behavior or characteristics are drawn from aggregate data at the group or population level
Describe case-control studies
Find individuals with the outcome and a similar group without and take a random sample of each and see who had the eposure compared to others.
What are the strengths and weaknesses of case-control studies?
Strengths: Quick and inexpensive suitable for rare diseases multiple exposures can be measured suitable for measuring outbreaks
Weaknesses:
Only a single disease can be measured
not suitable for rare exposures
need data before the study (retrospective study)
affected by selection bias and confounding variables
Describe a cross-sectional study
Investigates what is happening at the current time.
Outcomes and exposures are measured simultaneously
What are the strengths and weaknesses of a cross-sectional study?
Strengths:
fast and inexpensive
rapid feedback on current events
multiple outcomes and exposures can be studied
Weaknesses
not suitable for rare diseases
limited potential to establish disease aiteology
affected by selection bias and confounding variables
Describe a cohort study
Collect information on a sample and follow- up over time to explore who gets the outcome
What are the strengths and weaknesses of a cohort study?
Strengths:
useful for demonstrating casual affects
multiple diseases can be studied
multiple exposures can be studied
Weaknesses:
expensive and time-consuming
not suitable for rare diseases
need to deal with confounding factors
Describe a RCT?
Have multitple groups with different exposures compare the outcomes to get a causal relationship.
What are the strengths and weaknesses of an RCT?
Strengths:
most convincing evidence for cause and effect
The gold standard for evaluating interventions
weaknesses: expensive not always practical for showing long term effects can be affected by non-compliance not always ethical
What is a crossover trial?
an extension to an RCT. everyone does all the arms of the study. which reduces confounding even more as each person can be compared across the arms. thre can be carry-over effects and more technical analyses
What steps should be taken in an RCT to minimise bias?
Blinding, randomisation, placebos, matching
What are the two main groupings for variables?
Categoric and numeric
What are the types of categoric variables?
Binary, ordinal, nominal
what are the numeric variables?
Discrete and continuous
What is the odds?
number with the outcome/ number without the outcome
How can you quantify differences?
Risk differences, risk ratios, absolute risk, and relative risk.
What is risk difference?
the difference between the two risks you have calculated
What is a risk ratio?
divide one risk by the other. the top group is the focus group compared to the other one.
How do you interpret a risk ratio?
RR> 1 the focus risk is higher
RR=1 the two groups are the same
RR<1 the focus risk is lower than the other
1 is no difference
How can you swap the focus of the risk ratio is?
inverse 1 divide by it
What is odds ratio?
Odds divided by odds
How do you interpret odds ratio?
> 1 – Greater odds of associated with exposure and outcome
=1 – No association
<1 – Lower odds of association between exposure and outcome
Eg. Odds ratio of 0.8 = 20% decrease in odds
Why might you use risk ratio?
It puts it in context more
Why do we use Odds ratios?
they are useful for some statistical methods
If something is very rare how does OR and RR compare?
RRroughly= to OR for rare outcoumes
If something is more prevalent what happens to RR and OR?
it makes the OR a poor approximation of the RR
What is the median
middle value in sequential order
What is positive skew?
where the peak is to the left
the mean is greater than the median which is greater than the mode
What is negative skew?
most of the values are to the right,
the mean is less than the median which is less than the mode
How to decide which measure of spread to use?
if it is symmetric and normally distributed (with the median and mean close together) then use mean and SD
Otherwise use median and IQR as they are less affected by skew
What is the use of the normal distribution?
The sd can tell you about percentage certainty
What are the limits of correlation coeffiecient?
-1 = perfect negative correlation 0 = no linear relationship \+1 = perfect positive correlation
What is standard error?
How well your sample representing the population.
How can standard error be reduced?
Enlarging the sample size the more similar the people are.
What is the formula for the standard error of a mean?
SD/root(n)
What is the difference between standard error and standard deviation?
- Measures the precision of the sample mean as an estimate of the true population mean.
- Measures the spread or dispersion of individual data points around the mean of a dataset.
What is the use of confidence interval?
It is often used as a comparative value between data sets. can be used for inferential statistics
What are confidence intervals?
The true value is quite certain to lie between those two points.
What are confidence interval calculated from?
Standard error and SD values
What is the null hypothesis?
There is no link between the two variables
What is a p value?
A p-value measures the probability of obtaining the observed results, assuming that the null hypothesis is true
The probability that the mean could be from the standard deviation.
If mean is close to the null what will the p value be?
Close to one
How should you phrase rejecting the null hypothesis?
The evidence suggests to reject the null hypothesis
What is the generally accepted significant p value?
p=0.05 for statistical significance
What is another significance test?
One sample t test, two sample t test, chisquare tests, ANOVA test, Pearson correlation coefficient
What is regression?
Plotting the correlation between variables using y=a+bx
What is the effect of using multivariable method?
It accounts for the effect of confounding factors
How can you appraise the study design?
Who is studied? are there missing groups over sampling? is it clear what the aim is
What can you appraise the descriptive statistics?
Summariesed data appropriately, Normal distribution, SD
What can you appraise the inferential statistics?
p values CI did they look at normality test
A 25-year-old woman presents to a general practitioner reporting
that she is suffering from stress and has recently been having increased
negative thoughts and poor concentration. What type of stress response is
this patient experiencing?
Cognitive: Cognitive signs of stress - Negative thoughts; Loss of
concentration)
An elderly man presents to his general practitioner reporting that he is suffering from stress. On examination the GP notices that the patients’ blood pressure is raised and his breathing is shallow. What type of stress response is this patient likely to be experiencing?
Physiological: Physiological signs of stress - shallow breathing;
Raised blood pressure; Increase in acid production in the stomach)
A 42-year-old woman has attended her general practitioner reporting that she is suffering from stress. She says that she very tearful, has been increasingly irritable with her partner and has had mood swings. What type of stress response is this patient experiencing?
Emotional: Emotional signs of stress - Mood swings;
Tearful; Irritable; Aggressive; Apathetic
Which term would best describe: The total number of UK adults with a BMI greater than 30 (i.e. obese) at a given time?
Prevalence: Proportion of a population with a
disease/condition at a point in time
Which term would best describe: The detection of early
disease in order to alter its course, for example cancer screening and
the early identification of heart disease?
Secondary prevention: Early detection of disease, followed
by appropriate intervention
Which term would best describe: The number of
diagnosed cases of alcohol related liver disease per
100,000 in England during 2009.
Incidence: Rate at which new cases occur in a
population in a certain time period
Which type of study design below would be best to investigate
the following; to identify patients who have had heart attacks and
compare their diet, smoking habits and exercise activity with people
that are similar to them except that they have not had heart attacks?
Case control: Observational study of persons with the
disease of interest and a suitable control group (without disease).
Analysis of events that occurred before onset of disease
(retrospective
A new drug has been developed to reduce blood pressure and the drug manufacturer wants to measure its clinical effectiveness in the very elderly. A professor in care of the elderly agrees to run a research study. In order to have enough power he will need to recruit patients from the clinics of other hospitals as well his own patients. Which type of study design would be most appropriate?
RCT: Investigation involving intentional change in some aspect of
the status of the subjects; randomisation of subjects to intervention and
control conditions)
What aspect of the relationship between occupation and
asthma could only be examined through prospective studies?
(Causation: The existence of a causal relationship between
variables; the cause must precede the effect
If these figures came from an analysis of time to
infection (mean= 2.5, median= 1.2, SD=2, IQR= 0.6 to
2.8); which would you expect to see published in the
article:
There is a big difference between mean and
median, so not normally distributed. That leads to median,
and IQR goes with the median
In a small randomised trial of a new treatment in type 2
diabetes, the mortality in the treated group was half that in the
control group, but the difference was not significant. We can
conclude that:
The treatment shows promise (half the mortality) but
we need a larger size to make sure the difference is not by chance
The Odds Ratio (OR) of death for a new treatment
compared to placebo is 0.51 (95% 0.30, 0.83). This
means:
There is a 49% reduction in the odds of death for
treatment vs. placebo
Which of the following is true about linear regression:
A. The predictor variables can be only numeric
B. The outcome variable is binary (yes/no)
C. Can only explore the joint associations between two variables
D. Can remove background associations to reveal a clearer picture of
the relationship between the main exposure of interest and outcome
E. Cannot produce confidence intervals for the coefficients
Can remove background associations to reveal a clearer picture of
the relationship between the main exposure of interest and outcome
What is prevalence probability?
The probability of having a disease at a given point in time
What is incidence probability?
The probability of getting a disease during a specified point in time
What is the incidence rate?
The average rate of change over time
What is the hazard rate?
Instantaneous rate of change.
What is conditional probability?
The probability that something will happen given that an event has already happened
What are odds?
The probability that an event will occur.
Range between 0 and 1
What is length time bias?
Conditions with a longer duration are more likely to be captured in prevalence.
Drug A has a risk of 0.6
Drug B has a risk of 0.2. of causing heart attacks
What is the risk difference
What is the risk Ratio
What is the absolute risk difference
What is the relative risk difference
Risk difference = 0.4 (0.6-0.2) and therefore is 40%
Risk Ratio = 3 (3x the risk of drug A than B)
Absolute risk = 0.4 (A-B)
Relative risk difference = (A-B)/B *100 = 200%
What information does risk difference provide?
An absolute measure of the association of exposure on disease occurrence
Gives a clear sense of public health impact
What information does risk ratio give?
Gives a relative measure
Gives a clear sense of the strength of the effect
What is an association?
A statistical link between exposure and disease.
may not reflect a cause and effect relationship
What is a Causation?
A statistical link where a disease is directly caused by exposure.
How can sample variability be measured both within a sample and between a sample?
Within a sample - use the SD
Between a sample - Use the SE
What do 95% confidence intervals mean?
That 95% of the data falls within 2 SDs of the mean and this contains the true mean value.
What is an application of regression?
Develop a model for risk prediction of a clinical outcome
What is the difference between crude and adjusted effects?
Crude effects do not take confounding variables into account whereas adjusted does.
What form are regression lines written in?
Y= a + bx Y= Continuous outcome a = intercept b = coefficient (slope) x = explanatory (predictor value) variable
What is the bradford hills criteria?
Criteria used to support a causal association
- Biological Plausibility: reasonable pathway to link exposure to outcome
- Consistency: same results if repeated at different times with different people/geographical location
- Temporality: exposure precedes outcome
- Strength of association: with or without a dose response relationship
- Specificity: causal factor relates only to outcome in question
- Dose response
- Reversibility
- Coherence
- Analogy
Define Outbreak
Define Epidemic
Define Pandemic
Outbreak: a number of cases that exceeds what would be expected
Epidemic: Cases occurring in the same geographical location
Pandemic: disease that has spread over countries or continents affecting large numbers of people
Give some notifiable diseases
Acute encephalitis
Acute meningitis
Anthrax
Cholera
HUS
Malaria
Meningococcal Septicaemia
Rabies
Scarlet Fever
Tetanus
Whooping Cough
Acute Infectious Hepatitis
Poliomyelitis
Botulism
Diphtheria
Leprosy
Measles
Mumps
Rubella
Smallpox
Tuberculosis
Yellow Fever
Define Domestic Abuse
Any incident or pattern of incidents of:
- controlling,
- coercive,
- threatening behaviour,
- violence or abuse
between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality
What are some types of domestic abuse?
- psychological
- physical
- sexual
- financial
- emotional
What risk assessment tool is used to assess domestic abuse?
DASH - Domestic Abuse Stalking and Harassment Risk Assessment
What are the different risk assessment levels following the DASH score?
Standard: Current evidence does not indicate likelihood of causing significant harm
Medium: Identifiable indicators of risk of serious harm. Perpetrator has the ability to cause harm but unlikely unless there is a change in circumstances
High: Identifiable indicators of imminent risk of serious harm that could happen at any time.
What should be done if you have a patient who is being domestically abused?
Use the DASH criteria to assess the patients risk
Standard/Medium:
- Give contact details for Domestic Abuse Services
- Keep good records
- if there are children then ensure they are protected
- Ensure follow up as needed
High risk:
- Refer to MARAC/IDVA in addition to the above
- You can break confidentiality if consent is not gained in high risk cases
What is MARAC?
Multi-Agency Risk Assessment Conference:
In a single meeting, links up to date information about victims’ needs & risks directly to the provision of propriate services & responses for all those involved: victim, child/ren, perpetrator
What is the IDVA?
Independent Domestic Violence Advisor:
Works primarily with victims who are at
the highest levels of risk from domestic abuse in Sheffield, and helps them to increase their safety by providing: advocacy and advice around domestic abuse, safety planning, support through court proceedings, signposting to specialist services: housing, legal services, refuge provision and home safety services, a voice in the MARAC process.
What are some risk factors for Victims of Domestic Abuse?
- Previous abuse against them
- Pregnancy/New babies
- Children/Step-children
- Isolated
- Victims own fears/perceptions
- Depression/suicidal thoughts
What questions should be asked if you are suspecting domestic abuse?
HARK
Humiliation:
- “In the last year, have you been humiliated or emotionally abused in other ways by your partner?”
- “Does your partner make you feel bad about yourself?”
- “Do you feel you can do nothing right?”
Afraid:
- “In the last year have you been afraid of your partner or ex-partner?”
- “What does your partner do that scares you?”
Rape:
- “In the last year have you been raped by your partner or forced to have any kind of sexual activity?”
- “Do you ever feel you have to have sex when you don’t want to?”
- “Are you ever forced to do anything you are not comfortable with?”
Kick:
- “In the last year have you been physically hurt by your partner?”
- “Does your partner threaten to hurt you?
What are some risk factors for Perpetrators of Domestic Abuse?
- Violence towards others/criminal history
- Drugs/Alcohol/Mental Health
- Animal Abuse
- Weapons
- Accomplices
- Controlling/jealousy
- Perpetrator suicidal (means they may not have much concern of consequences)
What should you make sure you do not do when suspecting Domestic Abuse?
- Assume someone else will take care of things, you may be her/his/their only contact.
- Ask about domestic abuse in front of family members or use informal interpreters.
- Tell people what to do – they are the expert in their own situation – aim to empower them to make safe and informed choices
What are Odds?
How likely an event is to happen compared to not happening
Number of people with an event / Number of people without an event.
eg. If 30 smokers develop lung cancer and 70 do not, while 10 non-smokers develop lung cancer and 90 do not:
Odds in smokers = 30/70 = 0.43
Odds in non-smokers = 10/90 = 0.11
How is an Odds Ratio calculated, interpreted and what does it mean?
OR = Odds of event in exposed group / Odds of event in unexposed group
where
Odds = No. of people with event / No. of people without event.
Interpretation:
- OR > 1: The event is more likely in the exposed group.
- OR = 1: The odds of the event are the same in both groups (no association).
- OR < 1: The event is less likely in the exposed group.
Example:
If 30 smokers develop lung cancer and 70 do not, while 10 non-smokers develop lung cancer and 90 do not:
- Odds in smokers = 30/70 = 0.43
- Odds in non-smokers = 10/90 = 0.11
- OR = 0.43/0.11 ≈ 4
This means that the odds of developing lung cancer are 4 times higher in smokers compared to non-smokers.
How do you calculate relative risk, how is it interpreted and what does it mean?
Relative Risk (RR) = Risk in exposed group / risk in unexposed group
Interpretation:
- RR > 1: The event is more likely in the exposed group.
- RR = 1: The event is equally likely in both groups (no association).
- RR < 1: The event is less likely in the exposed group.
Example:
If the risk of developing lung cancer is 10% for smokers and 2% for non-smokers, then:
RR = 0.10 / 0.02 = 5
This means that smokers are 5 times more likely to develop lung cancer compared to non-smokers.
When would you use:
- Relative risk
- Odds ratio
- Absolute Risk
- Risk
Relative Risk is typically used in cohort studies where the incidence of an outcome in both exposed and unexposed groups can be directly measured.
Odds Ratio is most often used in case-control studies where direct measurement of incidence is not possible, but odds can be calculated.
Absolute Risk is useful for providing real-world context of how common a condition is in a population.
Risk gives a general understanding of the likelihood of an event in a population and is a fundamental concept in calculating absolute risk.
What is the calculation of absolute risk reduction, and give an example?
ARR = Risk in control group - Risk in treatment Group
Where risk in both control and treatment group is the percentage of individuals who experience outcome respectively.
Example:
Imagine a clinical trial testing a new drug to prevent heart attacks:
- Risk of heart attack in the control group (without drug): 10% (0.10)
- Risk of heart attack in the treatment group (with drug): 6% (0.06)
- ARR = 0.10 - 0.06 = 0.04 or 4%.
This means that the new drug reduces the absolute risk of having a heart attack by 4 percentage points compared to not taking the drug.
Therefore: for every 100 people taking the new drug, 4 fewer people would have a heart attack compared to those not taking the drug.
What does the health belief model and Theory of Planned Behaviour say the most important factor in addressing behaviour change is?
Health Belief: Perceived Barriers
Theory of Planned Behaviour: Intention
What are the key determinants of health?
- Genes
- Environment
- Lifestyle
- Health care
What are some developing food behaviours?
- Maternal Diet
- Breastfeeding
- Parenting Practices
- Age of introduction to solids and types of food given
What is a health need assessment for?
Systematic method for reviewing the health issues facing a population
Therefore to determine resource allocation
What aspects of public health are involved in Health Needs Assessments and resource allocation?
- Maslow’s Heirarchy of Needs
- Types of health care need: Felt, Expressed, Normative, Comparative
- Health needs assessment (Resource allocation)
- Approach to Health Needs Assessments: Epidemiological, Comparative, Corporate
- Resource allocation Methods: Libertarian, Maximising, Egalitarian
What aspects of Public Health are involved with evaluation of health services and assessing the quality of health care?
- Evaluation: Assessment of whether a service achieves its objectives
- Donabedian Framework: Structure, Process, Outcome
- Maxwell’s Dimensions of Quality of Health Care: 3A’s and 3E’s
What is bias?
A systemic deviation from the true estimation of the association between exposure and outcome
What are some types of bias?
Selection bias: selection of participants
Information Bias: observers recall and reporting, instruments wrong
Allocation bias: Different participants in different groups
Publication Bias: Trials with negative results are les likely to be published
Lead time bias: Earlier screening does change survival outcome
Length time bias: diseases with slower progression more likely to be identified by screening
Explain what these features mean on the Bradford Hills Criteria:
- Strength
- Dose response
- Consistency
- Temporality
- Reversibility
- Biological Plausibility
- Coherence
- Analogy
- Specificity
- Strength - The strength of the association
- Dose-response – does a higher exposure produce higher incidence?
- Consistency – similar results in different studies and populations
- Temporality – does the exposure precede the outcome
- Reversibility – removing exposure reduced risk of disease
- Biological plausibility – does it make sense biologically
- Coherence – logical consistency with lab information e.g. incidence of lung cancer with increased smoking is consistent with lab evidence that tobacco is carcinogenic
- Analogy – similarity with other established cause-effect relationships in the past e.g. thalidomide in pregnancy, not other teratogenic drugs show similar effects
- Specificity – Relationship is specific to the outcome of interest e.g. introducing helmets reduced head injuries specifically, it wasn’t that there has been an overall lower injury rate
Should you ever inform parents about a childs actions?
No but encourage them to inform
What should you do if an Under 13 year old presents saying they have had sex?
Refer to social services
What are the Fraser Guidelines?
- Does she understand the advice?
- Has the doctor encouraged her telling the parents?
- Will she have sex anyway?
- Is the mental/physical health going to be effected if you don’t give it
- Best interests
What is Gillick’s Competency?
Does a child under 16 have capacity to make own medical decisions?
Clinical judgement made by the doctor; age, capacity, maturity
What are some different types of error and what do they mean?
- Sloth = inaccurate documenting/not checking results for accuracy
- Fixation/loss of perspective = focus on one diagnosis – confirmation bias
- Communication breakdown = unclear plan/not listening and explaining well - - - - - -
- Poor team working = some individuals out of depth and others underutilised
- Playing the odds = choosing the common and dismissing the rare
- Bravado/timidity = working beyond competence/not having confidence to object
- Ignorance = lack of knowledge (can be conscious or unconscious incompetence)
- Mistriage = over or under-estimating the severity of the situation
- Lack of skill = not having appropriate skills/training/practice
- System error = environmental/technological/equipment failure\
Define Public Health
The science and art of preventing disease, prolonging life and improving health through organised efforts of society
What should be considered in a health needs assessment?
Need: ability to benefit from an intervention
Demand: What people ask for
Supply: What is provided
What does the epidemiological perspective look at?
Size of population
Services available
Evidence base
What are the different approaches for disease prevention?
Primary Secondary and Tertiary Prevention
- Population approach: Prevention approach delivered to everyone to shift risk factor distribution curve
- High Risk Approach: Identify individuals above a cut off and treat them
- Prevention Paradox: Preventative measures which benefits the population has little impact to individual participants
How many UK Screening programs are there?
11 total:
3 in Pregnancy:
- Pregnancy infectious disease (HIV, Syphilis, Hep B)
- Thalassaemia and Sickle Cell
- Fetal Anomaly Screening (Downs, Edwards, Pataus)
3 In Newborns:
- NIPE
- Newborn Hearing screening program
- Heelprick blood spot
5 in Adults
- Cervical Cancer
- Breast Cancer
- Bowel Cancer
- AAA screening
- Diabetic Retinopathy
What are the 4 dimensions of Food insecurity?
- Availability of food
- Access - Economic and physical
- Utilisation: Opportunity to prepare food
- Stability of 3 dimensions over time
What is malnutrition in public health?
Deficiency’s, Excess or imbalances in a persons intake of energy and/or nutrients
Includes: Undernutrition, Overweight/obesity and Triple burden
Define Undernutrition and what it includes:
Define Overweight and obesity?
Undernutrition:
- Stunting: Low height for age
- Wasting: Low weight for height
- Underweight: Low weight for age
- Micronutrient Deficiencies: Lack of important vitamins and minerals
Overweight Excess diet
What is an Asylum Seeker?
Someone who is applying for refugee status
What is a refugee?
Someone who has been granted asylum status for 5 years
What healthcare can an asylum seeker access if their claim is refused?
Emergency NHS Services
Get charged for anything after that
What are common health problems for refugees?
- Injury and illness from war and travelling
- Communicable disease
- Lack of health screening and immunisations
- Malnutrition
- Untreated chronic disease
- Untreated Mental Illness
What are some barriers against Refugees/Asylum seekers?
- Reluctance of GPs to register them
- Illiteracy
- Communication barriers
- Lack of permanent site
- Mistrust of Professionals
What support do Asylum Seekers Receive?
- Vouchers to live off (may or may not be restricted)
- NASS support package
- Access to Emergency NHS services
- Not allowed to work initially and no control over location
What is a Never Event?
Serious largely preventable patient safety incidents that should not occur
What are some levels of Alcohol Dependency?
- Withdrawal Symptoms
- Cravings - strong desire to drink
- Drinking despite negative consequences
- Tolerance - drinking larger amounts to achieve the same effect
- Primacy - Neglecting basic physical needs such as food and water
- Loss of control
- Narrowing of repertoire - Start to drink only one type of drink in one place
What is the purpose of Disulfiram?
Promotes abstinence - Alcohol intake causes severe nausea and vomiting reaction due to inhibition of acetaldehyde dehydrogenase
What is the purpose of Acomprosate?
Reduces craving by acting as a weak NMDA antagonist - improves abstinence in placebo controlled trials
What components make up drug addiction?
Craving, tolerance, compulsive drug seeking behaviour and withdrawal
What can you offer a newly presenting drug user?
- Screening for blood borne viruses
- Health check
- Sexual health and contraception advice
- Check immunisation Hx
- Signpost to drug services
What is positive and negative conditioning in relation to drug use?
Positive Conditioning: Addiction increases desire to use drug
Negative Conditioning: People don’t quit due to unpleasant symptoms
What can an association between an exposure and outcome be due to?
- Chance
- Bias
- Confounding
- Reverse Causality
- True Causal Association
What are some types of information bias?
- Measurement
- Observer
- Recall
- Reporting
What is reverse causality?
When an association between an exposure and outcome are due to the outcome causing the exposure
