Populations

Question 1

Define and briefly describe dietary reference values and current dietary intakes in the population

Answer 1

Population-level ‘average’ - required over ‘reasonable’ period of time

Committee on Medical Aspects of Food and Nutrition Policy (COMA) - they give the advice

o Requirement to maintain health in ‘healthy’ individuals.
o Assumes that energy and other nutrient requirements met.
o However, for most nutrients, insufficient data to establish any of the DRVs with confidence

EAR - estimated average requirement:
o The average requirement for a nutrient for a class of individuals 
o By definition, will meet the needs of 50% of the population

• Lower Reference Nutrient Intake (LRNI):
o 2 S.D. less than the EAR
o Will meet the needs of 2.5% of the population

• Reference Nutrient Intake (RNI)

Question 2

Describe the general framework for making recommendations and guidelines on a healthy diet.

Answer 2

GRADE

• balance between desirable and undesirable effects
• quality of evidence - consistent or direct?- publication bias? - magnitude of effect?
• values and preferences
• costs - worth the cost?

Question 3

Describe scientific challenges in nutritional epidemiology

Answer 3

may have issues collecting data - weighed record/food diary?

may have error in dietary assessment:
• Sampling bias
• Response bias
• Estimation of portion size
• Inappropriate coding of foods
• Use of food composition tables

• Cause and effect difficult to disentangle, unless you have repeated measures over time - may be something to do with whole diet rather than single food

Question 4

Discuss barriers to healthy eating, and a life course and food chain approaches to reduce food poverty and obesity

Answer 4

• Low income and debt
• Poor accessibility to affordable healthy foods
• Factors in food production and the food chain - such as the nutrient content of easily available, cheap, processed foods which can be high in fat, sugar or salt.
• Poor literacy and numeracy skills - barriers to information on maintaining a healthy diet, household budget management and employment. Better labelling.

Question 5

List 4 direct health related harms from excessive alcohol intake and 4 social harms.

Answer 5

hypertension
stroke
coronary heart disease
pancreatitis 
liver disease

divorce
isolation from friends
loss of job
isolation from family

Question 6

What strategies could a government employ to reduce the amount of alcohol consumed by the population?

Answer 6

limit advertising
minimum price levels
reduction in licensing hours
prohibit products that appeal to young people
more research

Question 7

Describe some of the influences on social norms associated with drinking among young people

Answer 7

Positive:
previous levels of consumption
entertainment portrayals
alcohol advertising

Negative:
alcohol involved problems
media attention to alcohol-involved problems
concern about alcohol

Question 8

name three common types of medical error

Answer 8

• Medication error – the most common single preventable cause of patient injury
• Missed & delayed diagnosis – e.g. failure to recognise a patient is seriously ill
• Perioperative – e.g. needless infection, wrong site, wrong side, wrong patient, lack of DVT prophylaxis

Question 9

describe the difference between a person approach and system approach in terms go patient safety

Answer 9

• Person approach - focuses on the unsafe act, ‘name and shame’ individuals
• System approach - errors seen as consequence of unsafe systems; aim is to build defences and safeguards- robust systems that protect patients from harm

Question 10

describe some methods of preventing failure in care systems

Answer 10

• Basic standardisation.
• Memory aids - checklists.
• Feedback regarding compliance with
  standards.
• Awareness-raising and training (10-1)

e.g:
• Commonequipment,standardordersheets,and written policies/procedures/protocols
• Personalchecklists
• Feedbackofinformationoncompliance
• EmphasisonAwarenessandTraining

Question 11

describe some mathods of identifying and miticating failure in care systems

Answer 11

• Second tier strategies focus on “catching/identifying” instances when standardised approach is not used;
• Seek to reduce opportunities for humans to make mistakes utilising more sophisticated failure prevention; often referred to as “error-proofing” (10-2)

EG:
• Makingthedesiredactionthedefault
• Reminders,DifferentiationofRoles,Constraints,
Affordances
• Decisionaidsbuiltintothesystem
• Intentionalredundancy
• Schedulingkeytasks

Question 12

what are the three tiers for designing reliable care systems

Answer 12

Prevent Failure T1

Identify and Mitigate Failure T2

System Redesign T3

Question 13

define penetrance

Answer 13

Degree of phenotypic expression/manifestation.

Question 14

define Allelic heterogeneity

Answer 14

Ability of different mutations in the same gene to give rise to different clinical phenotypes

Question 15

What are the possible categories of explanation for the health inequalities (across socioeconomic groups) that we observe in Northern Ireland.

• According to the Ottawa Charter, what are the four main categories of action that policy makers should aim for to reduce health inequalities. ? Describe the principle of proportionate universalism.
• Describe any three features of a public health intervention that might increase inequalities ?
• What should doctors do to try to reduce health inequalities?
• The Marmot report Fairer Society Healthy Lives urges policy action in a number of areas to reduce health inequalities including (i) giving every child the best start in life and (ii) creating fair employment and good work for all. Give two examples of actions that policy makers might consider in each of these areas.

Answer 15

.

Question 16

describe the difference between inequality and inequity

Answer 16

Inequality:
- Some variations or differences in individual-level health are inevitable – our life is subject to stochastic processes !
o BUT we must ask ourselves WHY should they vary
o according to socioeconomic status, geographical area, age, disability, gender or ethnic group?
o affects of these variations may be more than additive
- Many Inequalities in Health are considered as avoidable and unacceptable variations

Inequity:
• Inequity - “lack of fairness” or injustice
• Equity - ensuring each individual is given the opportunity to attain their full potential for health
• ….The absence of unfair and avoidable or remediable differences in health among social groups.”

Question 17

describe the ‘absolute gap’ in terms of health inequalities

Answer 17

• the absolute difference between the extremes of deprivation
• advantage: intuitive and straightforward to explain
• disadvantage: focuses on extremes - doesn’t take account of patters of inequalities observed across the intermediate groups

Question 18

describe the slope index of inequality (SII) in terms of health inequalities

Answer 18

• the gradient of health observed across the deprivation scale
• measures difference in health outcomes between theoretical most and least deprived individuals
• sensitive to experience of entire population rather than just extremes of deprivation

Question 19

describe the relative index of inequality (RII) in terms of health inequalities

Answer 19

• describes the gradient of health observed across the deprivation scale, relative to the average for the observed population (by dividing the SII by the mean)
• value of RII - tells you magnitude of inequality in relation to the mean - represents proportionate change in the health outcome across the population
• allows inequalities to be compared and contrasted across a number of different health indicators and also to be monitored over time

Question 20

What are the possible categories of explanation for the health inequalities (across socioeconomic groups) that we observe in Northern Ireland.

Answer 20

• Cultural/Behavioural - individual behaviour & lifestyle factors

• Materialistic/structural - economic & associated socio-structural factors
- Inequitable distribution of resources.

• Social Selection - converse view that health determines social position (not other way about)

• eg get sick - lose job - fall down social order
• most people don’t think this is a good explanation

• Artefactual - observation may result from artificial classification of social
class
- the way we classify social class - usually classed due to job 
- Widening in gap isn’t real, it is due to the way class and health are measured.

Question 21

describe some of the difficulties in reducing health inequalities

Answer 21

• Limited evidence-base to guide
policy
• Multi-faceted interventions required
• Many modifiable determinants lie outside direct influence of health service
• Delay between intervention and measurable outcomes - especially for ‘upstream’ interventions

Question 22

According to the Ottawa Charter, what are the four main categories of action that policy makers should aim for to reduce health inequalities.

Answer 22

Strengthening individuals.
• Ensuring people have information and skills to make informed choices.

Strengthening communities.
• Supporting people to make decisions about health issues affecting them.

Improving accesses to facilities and services.
• Mediating between people and service providers to ensure needs are met.

Encouraging a healthy public policy.
• Healthy public policy underpins other areas.

Question 23

Describe the principle of proportionate universalism.

Answer 23

Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage: ~ proportionate universalism.

Question 24

The Marmot report Fairer Society Healthy Lives urges policy action in a number of areas to reduce health inequalities including (i) giving every child the best start in life and (ii) creating fair employment and good work for all. Give two examples of actions that policy makers might consider in each of these areas.

Answer 24

health inequalities lecture slides 33-35

Question 25

What should doctors do to try to reduce health inequalities?

Answer 25

• There should be adequate medical input into decisions taken within non-health sectors to ensure that the initiatives do not exacerbate health inequalities and simultaneously maximise potential health gains.
• Healthcare services should be better integrated into the community to reach out to disadvantaged and marginalised groups in society and reduce the many barriers impeding access to advice, prevention, diagnosis and treatment.
• In the course of all doctor–patient consultations there needs to be more scope to discuss the root causes of ill health and signpost patients towards appropriate support and services, inside and outside the health sector.
• More frequent appointments
• Longer consultations
• Educational material adapted appropriately

Question 26

Describe any three features of a public health intervention that might increase inequalities ?

Answer 26

o Educational component
o Voluntary behaviour change
o One size fits all
o Financially regressive (affluent benefiting)

Question 27

Describe any three features of a public health intervention that might decrease inequalities ?

Answer 27

o Compulsory
o Require positive opt-out, rather than opt-in
o Tailored to individual needs and culturally compelling
o Financially progressive (advantage the poorest)

Question 28

what are some of the drivers of service development

Answer 28

• National standards, targets, agencies
and regulatory approaches. (‘must-dos’ )

• Evolving clinical practice, leading to cost pressures and service developments in provider organisation

• Patient-driven
- (choice, voice and competition)

Clinical service inflation rate is much higher than the Treasury inflation rate !

Question 29

• As regards the goal of making the NHS more efficient, economists remind us to be wary of common health economic fallacies. Describe and explain four of the more common ones.

Answer 29

• The government can’t afford the NHS so must make greater use of the private sector and insurance
• Population ageing will dramatically increase health care costs.
• Costs of care will be managed by rationalizing services and closing smaller hospitals - may be true but may also be true that smaller ones are more efficient - have to look at local context
• It is better to invest in health promotion in the young and fit - may be right in terms of added years of life - but never too young or old to adopt a healthier lifestyle - risk is higher in older people - so if they can lower these risks it’ll have a big impact
• Advances in health technology will increase costs - some will but not all
• We should focus resources on areas accounting for the greatest burden of disease - rarely the case

Question 30

describe the Incremental Cost-Effectiveness Ratio (ICER)

Answer 30

resource allocation L - slide 10

The ICER is the ratio of the difference in the mean costs, to the difference in mean QALYs gained.

Question 31

Draw a cost effectiveness plane with labelled axes and explain how it is used to assess whether to invest in a new health care intervention.

Answer 31

resource allocation lectre

slide 10

Question 32

• What are the main reasons the NHS doesn’t spend enough on public health?

Answer 32

• NICE position, based on principals for social value judgement - the needs of such an individual should not outweigh the needs of anonymous present and future NHS patients.
• Therefore, the use of differential QALY weights was previously not recommended.

Question 33

• What are the main reasons the NHS doesn’t spend enough on public health?

Answer 33

• Seemingly mundane and the prime movers are invisible
• The benefits are in the future but costs incurred today
• The beneficiaries are unknown and the personal benefits under- recognized
• Political inertia and vested interests

Challenges:
• How to attribute costs and benefits
• How to incorporate equity considerations
• How to deal with cross-sectoral transfers :
- (eg education, environment)

Question 34

What are the principles underlying the notion of Accountability for Reasonableness with regard to health service rationing

Answer 34

• Publicity - decision processes, outcomes, and rationales should be explicit, transparent and accessible.
• Relevance - rationales should be based on principles, reasons, and evidence that stakeholders can agree are relevant in the decision context
• Appeals - mechanisms to challenge decisions, facilitate resolution of disputes, and revising decisions on the basis of additional evidence.
• Enforcement - there should be regulation mechanism to ensure that the first three conditions are met in the decision-making process.

Equality and Equity:
• Egalitarian approach - requires the distribution of resources to ensure equity of health opportunity - cannot be fully implemented in the context of scarce and fixed resources - should at least aim for this
• A decision may be examined to determine whether any potential differential impact between specified groups is considered fair, reasonable and proportionate.
• Procedural justice relates to the fairness and legitimacy of decision process.

Question 35

• In what ways is climate change expected to affect public health ?

Answer 35

heatwaves
illnesses
floods
insects
cancer from loss of ozone layer

unemployment
violence
displaced populations
unemployment

Question 36

define mitigation and adaption in terms of climate change

Answer 36

Mitigation:
Taking action to reduce greenhouse gas emissions and enhancing natural and artificial processes that remove greenhouse gases from the atmosphere

Adaptation:
Taking action to minimize the expected impacts of climate change

Question 37

describe some mitigation actions for climate change

Answer 37

Reducing demand for emissions-intensive goods and services

o Increased efficiency, which can save both money and emissions

o Action on non-energy emissions, such as avoiding deforestation

o Switching to lower-carbon technologies for power, heat and transport

Question 38

• If we take actions to mitigate the effects of climate change, describe four long term co-benefits on health in Northern Ireland?

Answer 38

A policy or a measure intended to achieve one objective often affects other objectives, either positively or negatively.

When the effects are positive they are called ‘co-benefits’ (also referred to as ‘ancillary benefits’). Negative effects are referred to as ‘adverse side effects’.

Examples of co-benefits for climate change mitigation and improving public health include:
• Emission reduction policies can influence local air quality
• Reducing car use can reduce emissions and increase active travel
• Healthier, sustainable eating relying on local produce can reduce ‘food miles’
• Improved urban planning and design can encourage healthier, more sustainable lifestyles
• Energy efficient homes can reduce emissions and address fuel poverty
• Reduced material consumption can prevent the generation and treatment of waste

see climate change lecture, slide 20

Question 39

• Describe ten things you as a citizen could do to improve the sustainability of your lifestyle.

Answer 39

climate change lecture slide 22 and 23

• cooking and managing a sustainable and healthier diet
• using energy and water wisely
• eco-improving your home (retro-fitting)
• extending the life of things (to minimise waste)
• choosing eco-products and services
• travelling sustainably
• being part of improving the environment
• using and future-proofing outdoor spaces
• setting up and using resources in your community

Question 40

• Describe three things that you as a General Practitioner and three things that the NHS as a whole could do to ensure longer term sustainability of our health service.

Answer 40

NHS:

1. Energy and carbon management
2. Procurement and food
3. Low carbon travel, transport and access
4. Water and Waste
5. Designing the built environment
6. Organisational and workforce development
7. Role of partnership and networks
8. Governance
9. Finance
10. Visions of the future

GP:
• Informourselves.
• Advise our patients. Better diet and more walking and cycling will improve their health and reduce their carbon emissions.
• Uselessenergyourselves(andreducecosts) by more insulation in the roof, walls, and floors; turning off appliances and lights; and, where possible, reducing use of goods and services.
• Drivethecarless;flyless;walkorcyclemore; use public transport; drive an efficient car; share cars; hold meetings by teleconference, videoconference, or webcasting; attend fewer international conferences.
• Influencefoodmenuswhereverwego—ask for local food, less meat, and less processed food; a low carbon diet is a healthy diet. Drink tap water.
• Advocatelocally,especiallyinprimarycare, to maximise home insulation and uptake of relevant grants.
• Advocate for personal carbon entitlements within an equitable, fair shares global framework, such as Contraction and Convergence.
• Advocate to stabilise population—by promoting literacy and promoting women’s access to birth control, through the International Planned Parenthood Federation (www.ippf.org) or Marie Stopes International (www.mariestopes.org.uk).
• Be a champion: put climate change on the agenda of all meetings—clinical teams, committees, professional networks. Doctors can tip opinion with chairs and chief executives.
• Gear up your own influence and that of all health professionals by joining the Climate and Health Council (www.climateandhealth.org) or the Health and Sustainability Network (www.healthandsustainability.net), or both.

Question 41

Explain the concept of herd immunity.

Answer 41

Immunity of a specified population, where a high proportion of immune individuals prevent exposure of susceptible hosts.

Question 42

• On what three parameters does the Basic Reproductive Number of an infectious disease depend?

Answer 42

R0 can be conceptualised as a function of 3 factors:

R0 ≈ c p d

• c = Number of contacts per unit time
• p = Probability of transmission per contact
• d = Duration of communicability period
• R0 assumes that all contacts are with susceptible persons

Question 43

• List the main sources of routine communicable disease information that the PHA regularly collates.

Answer 43

Simplicity; Flexibility; Acceptability; Data quality;

Sensitivity and Positive Predictive Value (PPV); Capture-recapture Representativeness; Timeliness

Question 44

• What can we tell from an epidemic curve in an outbreak?

Answer 44

Data (date and time) of onset of symptoms (x axis) against number of cases (y axis)

Can help establish:

• type of outbreak
• probable time of exposure
• incubation period

Question 45

• List the steps of an outbreak investigation.

Answer 45

1. Establishinvestigativeteam
2. Background (Lit review)
3. Establish the existence of an outbreak
4. Identify additional cases
5. Collectpreliminarydata
6. Characterise the outbreak in terms of time, person, place
7. Formulate hypothesis as to the source/mode of transmission
8. Test the hypothesis, reformulate and retest
9. Recommendinterventions
10. Communicate findings

Question 46

describe the use of the reproductive number

Answer 46

• R = 1, each case will produce one infective secondary case.
o The infectious disease incidence and prevalence in the population
remains stable over time.

• R > 1, each case produce more than one infective secondary case; incidence will increase over time.
• R < 1, the generation of secondary cases is insufficient to sustain transmission of the infection within the specified population. Incidence of disease will decrease.

Question 47

describe the use of the reproductive number

Answer 47

• R = 1, each case will produce one infective secondary case.
o The infectious disease incidence and prevalence in the population
remains stable over time.

• R > 1, each case produce more than one infective secondary case;
- incidence will increase over time.

• R < 1, the generation of secondary cases is insufficient to sustain transmission of the infection within the specified population.
- Incidence of disease will decrease.

Question 48

what are the assumptions of R0 and R

Answer 48

• Assumption of average transmissibility
- Should not always assume that transmissibility is constant for all individuals – have super-spreaders

• Assumption of homogenous mixing
- Assumes random mixing; people tend to mix in groups

Question 49

1. Understand the theory behind any population screening programme
2. Understand how the performance of screening tests is assessed
3. Be able to outline the principles of screening programme evaluation
4. Know of the major types of population screening programme in the NHS and who is responsible for commissioning them

Answer 49

-

Question 50

• Why do interval cancers appear more aggressive on average?
• What are some of the negative effects of screening programmes?
• At a population level, how might we reduce the mortality from abdominal aortic aneurysm ? Of 1000 men screened for AAA, how many will be put under surveillance and how many will need immediate referral to a vascular surgeon
• Outline ways by which we may quality assure any screening programme.
• What are the ways screening for familial hyperlipidaemia differs from most of the other screening prgrammes in Northern Ireland?
• Outline the how the colorectal cancer screening programme operates, including how many of every 1000 persons screened will have colonoscopy and how many will have cancer detected.

Answer 50

.

Question 51

What are the requirements for screening programmes - Wilson hunger criteria

Answer 51

• Disease important health problem.
• Recognisable latent/early symptomatic stage.
• Cheap, quick, acceptable test.
• Reliable (same result if repeated).
• Validity (how good is test at discriminating who has the disease from those who do not).
• Does treatment confer benefit?
• Facilities for diagnosis and treatment.
• Agreed policy on whom to treat as patients
• Cost considered in context other demand for resources

Question 52

• Explain lead time and length time bias.

Answer 52

Lead Time Bias - Screening detects the disease earlier but there is no difference to outcome.

Length bias - The screening test increases detection of low risk tumours which may never cause symptoms, be detected otherwise, or cause harm to health.

Question 53

• What are some of the negative effects of screening programmes?

Answer 53

• Hazards from screening test, e.g. Radiation.
• Reliance on false negatives so ignoring symptoms.
• Anxiety and additional tests for false positives.
• Opportunity Costs.
• Over-diagnosis - detection of cases that would never have come to clinical attention without screening
• Over Treatment (especially of dysplasia – changes never would have progressed)
• Risk from interventions
• Creating ‘patients’ from well people.
• Anxiety and interventions in those whom disease will never kill.

• Anxiety in those who choose to ignore invitation

Question 54

• Outline ways by which we may quality assure any screening programme.

Answer 54

• Plan for managing and monitoring the screening programme with an agreed set of quality assurance standards. (eg uptake rates and uptake rates by area deprivation; reporting intervals; false positive appointment; stage of tumour; waiting times for confirmatory tests; outcomes of treatment)
• Adequate staffing levels and facilities - should be available prior to the commencement of the screening programme.
• All other options for managing the condition should have been considered - improving treatment or providing other services.
• Opportunity costs - should be economically balanced in relation to expenditure on medical care as a whole.