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Phase 3A 'The List' conditions > Public Health > Flashcards

Public Health Flashcards

1
Q

What are the Lalonde Report (1974) determinants of health?

A

Genes, environment (physical, social + economic,) lifestyle and healthcare

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2
Q

More detailed determinants model includes?

A 
Age, sex and constitutional factors 
Individual lifestyle factors
Social + community networks 
Living + working conditions 
General socio-economic, cultural and environmental conditions
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3
Q

Key concerns in public health?

A

Wider determinants of health- not related to healthcare
Prevention- primary, secondary + tertiary
Inequalities in health

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4
Q

What is horizontal equity? Vertical equity?

A

Equal tx for equal need e.g. individuals w/ pneumonia treated equally
Unequal tx for unequal need e.g. common cold vs pneumonia, w/ poorer health may need higher expenditure on health services

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5
Q

Different forms of health equity?

A

Equal expenditure for equal need, equal access, utilisation, healthcare outcome for equal need and equal health

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6
Q

Dimensions of health equity?

A

Spatial i.e. geographical

Social - age, gender, class- socioeconomic, ethnicity

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7
Q

What can health equity be examined in terms of?

A

Supply, access and utilisation of healthcare, healthcare outcomes, health status
Resource allocation, health services and others: education, housing
Wider determinants e.g. diet, smoking etc

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8
Q

How is health equity assessed?

A

Assess inequality, then judge if inequitable- need to be explained, but equality e.g. utilisation may not be equitable
Healthcare systems- in terms of equal access for equal need, measurement= usually of utilisation, health status or supply

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9
Q

3 domains of PH practice?

A

Health improvement- social interventions aimed at prevention, promoting health and reducing inequalities
Protection- control infectious disease risks and environmental hazards
Healthcare- organisation + delivery of safe, high quality services for prevention, tx and care

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10
Q

Improving public health? Delivered at what levels?

A

I.e. interventions, may be: health service/ PH interventions, non-health e.g. improving economy + social conditions

1) Individual e.g. immunisations
2) Community e.g. playground set up
3) Population e.g. Clean Air Act

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11
Q

What is health psychology?

A

It emphasises the role of psychological factors in the cause, progression and consequences of health and illness
Aims to put theory into practice by promoting health behaviours and preventing illness

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12
Q

What are the 3 main categories of health behaviours?

A

Health, illness and sick role behaviours
Health= aimed to prevent disease
Illness= behaviour aiming to seek remedy
Sick role= any activity aimed at getting well

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13
Q

Examples of health damaging/ impairing and promoting behaviours?

A

Smoking, alcohol + substance abuse, risky sexual behaviour, sun exposure, driving without a seatbelt
Taking exercise, healthy eating, attending health checks, medication compliance, vaccinations

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14
Q

What are health interventions at a population level? Individual level?

A

Enabling people to exert control over health determinants (PHE/ Health Promotion Agency)

Patient centred approach, care responsive to individual needs

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15
Q

What are perceptions of risk with health influenced by?

A

Lack of personal experience with problem, belief that preventable by personal action, belief that if not happened by now- not likely to, belief that problem infrequent
Other reasons: health beliefs, culture variability, SE factors, situational rationality, stress, age etc
Promoting behaviour change= only likely once person’s perception of risk is understood

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16
Q

How can doctors help individuals to change their health behaviours?

A

Work with patient’s priorities, aim for easy changes over time, set + record goals, plan explicit coping strategies, review progress regularly, remember public health impact

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17
Q

Phases of the planning cycle?

A

Start with health needs assessment, followed by planning, implementation and evaluation

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18
Q

What is need?

A

The ability to benefit from an intervention

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19
Q

What is health needs assessment?

A

A systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities

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20
Q

Health need vs healthcare need?

A

Health need= need for health, concerns need in more general terms e.g. measured using mortality, morbidity, socio-demographic measures
Need for healthcare, much more specific, ability to benefit from healthcare, depends on potential of prevention, treatment and care services to remedy health problems

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21
Q

Health needs assessment may be carried out for what?

A

A population/ sub-group, a condition, an intervention

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22
Q

What is the felt need? Expressed need? Normative need? Comparative need?

A

Individual perceptions of variation from normal health
Individual seeks help to overcome variation in normal health(demand)
Professional defines intervention appropriate for the expressed need
Comparison between severity, range of interventions and cost

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23
Q

Epidemiological approach to health needs assessment?

A

Define problem
Size of problem- incidence/ prevalence
Services available- prevention/ tx/ care
Evidence base- effectiveness and cost- effectiveness
Models of care- quality + outcome measures
Existing services- unmet need; those not needed
Recommendations

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24
Q

Issues with epidemiological approach?

A

Required date may not be available, variable data quality, evidence base may be inadequate, does not consider felt needs of people affected

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25
Q

Comparative approach to health needs assessment?

A

Compares services received by a population/ subgroup with others- spatial, social
May examine: health status, service provision, service utilisation, health outcomes

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26
Q

Issues with comparative approach?

A

May not yield what most appropriate level should be, data may not be available, data may be of variable quality, may be difficult to find comparable population

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27
Q

Corporate approach to health needs assessment?

A

Opinion leaders, commissioners, politicians, press, providers, professionals, patients–> corporate view (obtaining the views of a range of stakeholders)

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28
Q

Issues with corporate approach?

A

May be difficult to distinguish need from demand, vested interests, may be influenced by political agendas, dominant personalities may have undue influence

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29
Q

What is domestic abuse?

A

Any incident/ 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/ sexuality
Abuse can encompass, but is not limited to: psychological, physical, sexual, financial or emotional abuse

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30
Q

What is standard risk in relation to domestic abuse?

A

Current evidence does not indicate likelihood of causing serious harm

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31
Q

Medium risk in relation to domestic abuse?

A

There are identifiable indicators of risk of serious harm- offender has potential to cause serious harm, but unlikely unless change in circumstances

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32
Q

High risk in relation to domestic abuse?

A

There are identifiable indicators of imminent risk of serious harm. Dynamic- could happen at any time and impact would be serious

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33
Q

Action for standard/ medium risk domestic abuse?

A

Give contact details for domestic abuse services- keep good records + ensure followup as needed
Out of hours= National Domestic Violence Helpline
National LGBT Domestic Abuse Helpline
GALOP= LGBT support

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34
Q

Action for high risk domestic abuse?

A

Refer to MARAC/ IDVAS in addition to above wherever possible w/ consent- can be done via helpline
You can break confidentiality to do so if you cannot get consent

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35
Q

My role in responding to domestic and sexual abuse?

A

Display Helpline posters and contact cards- environment where people feel able to talk
Focus on patient safety
Ask direct Qs- be non-judgemental + reassuring
Acknowledge and be clear that behaviour is not ok
Give information (Helpline) + refer when appropriate
Be part of their process of recognising + escaping abuse
Be open to working with other agencies and professionals

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36
Q

Should not do with domestic abuse?

A

Assume someone else will take care of things
Ask in front of family members/ informal interpreters
Tell people what to do

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37
Q

Tool used to help identify people who have suffered domestic abuse?

A

HARK:

Humiliation, afraid, rape, kick

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38
Q

What is a MARAC?

A

Multi-agency risk assessment conference- single meeting, links up to date information about victims’ needs & risks directly to provision of appropriate services & responses for those involved: victim, children, perpetrator

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39
Q

Who does the IDVA service work with?

A

Victims who are the highest levels of risk from domestic abuse in Sheffield- helps to increase their safety- advice, safety planning, support through court proceedings, signposting, housing, legal services, refuge provision and home safety services, voice in MARAC process

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40
Q

What is a Domestic Homicide Review?

A

Review of the circumstances in which the death of a person aged 16 or over has, or appears to have resulted from violence, abuse/ neglect by someone related, in intimate relationship with/ member of same household
16-17 age= SCR takes precedence; criteria includes suicides
There are analyses of local DHRs and government national analysis for learning from cases - useful for learning

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41
Q

Some models and theories of behaviour change?

A 
Health belief model (HBM)
Theory of Planned Behaviour (TPB)
Stages of change/ transtheoretical model (TTM)
Social norms theory
Motivational interviewing
Social marketing
Nudging(choice architecture)
Financial incentives
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42
Q

What is the Health Belief Model?

A

Individuals will change if they: believe they are susceptible to the condition in the question, believe it has serious consequences, believe that taking action reduces susceptibility, believe that the benefits of taking action outweigh the costs

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43
Q

2 forms of variables contributing to the HBM? Link to what factors?

A

Demographic variables, psychological characteristics
Perceived susceptibility, perceived severity, health motivation, perceived benefits, perceived barriers–> likelihood of action (along with cues to action)

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44
Q

Cues to action in HBM?

A

Unique component of the model, can be internal or external cues, not always necessary for behaviour change

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45
Q

Critique of the HBM?

A

Alternative factors may predict health behaviour e.g. outcome expectancy + self-efficacy, if doesn’t consider the influence of emotions on behaviour, does not diff between 1st time + repeat behaviour, cues to action= often missing in HBM research

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46
Q

What is the theory of planned behaviour?

A

Expansion of Theory of Reasoned Action- proposes best predictor of behaviour= intention, is determined by: persons attitude to behaviour, perceived social pressure to undertake the behaviour/ subjective norm, persons appraisal of their ability to perform the behaviour/ perceived behavioural control

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47
Q

Things bridging gap between intention + behaviour?

A

Perceived control, anticipated regret, preparatory actions, implementation intentions, relevance to self

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48
Q

Critique of theory of planned behaviour?

A

Lack of temporal element, direction/ causality
Doesn’t take into account emotions, does not explain how attitudes, intentions + perceived behavioural control interact, habits + routines bypass cognitive deliberation, assumes attitudes, subjective norms + PBC can be measured, relies on self-reported behaviour

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49
Q

What is the Stages of change model?

A

Sees individuals located at discrete ordered stages, rather than on a continuum
Each stage denotes a greater inclination to change outcome, typically behaviour, than the previous one

50
Q

5 stages of transtheoretical model?

A

Precontemplation, contemplation, preparation, action, maintenance

51
Q

Pros + cons of transtheoretical model?

A

Acknowledges individual stages of readiness, accounts for relapse, temporal element
Not all move through each stages- some move back/ forwards/ miss some stages out, change might operate on continuum rather than in discrete stages, doesn’t take into account habits, culture, social + economic factors

52
Q

What is motivational interviewing?

A

A counselling approach for initiating behaviour change by resolving ambivalence

53
Q

What is Nudge theory in behaviour change?

A

‘Nudge’ the environment to make the best option the easiest e.g. opt-out schemes

54
Q

Other factors to consider for behaviour changes models?

A

Impact of personality traits on health behaviour, assessment of risk perception, impact of past behaviour/ habit, automatic influences on health behaviour, predictors of maintenance of health behaviours, social environment

55
Q

Typical transition points to include?

A

Leaving school, entering the workforce, becoming a parent, becoming unemployed, retirement + bereavement

56
Q

What is a health, illness and a sick role behaviour?

A

Behaviour aimed to prevent disease, aimed to seek remedy, aimed at getting well

57
Q

What are the NICE guidelines on behaviour change?

A

Interventions should work in partnership with individuals, communities, organisations and populations
Population- level may affect individuals, and community + family-level may affect whole populations

58
Q

Definitions of ‘evaluation’ of health services?

A

The assessment of whether a service achieves its objectives
A process that attempts to determine as systematically + objectively as possible the relevance, effectiveness and impact of activities in the light of their objectives

59
Q

Widely used framework proposed by Donabedian for evaluation of health services?

A

Structure, process, output, outcome–> usually not output

classified under process

60
Q

‘Structure’ of evaluation health services?

A

Buildings, staff, equipment

61
Q

‘Process’ of evaluation services?

A

What is done

62
Q

‘Outcome’ of evaluation health services?

A

Classification of health outcomes: mortality, morbidity, QOL/ PROMs, patient satisfaction
5 Ds: death, disease, disability, discomfort, dissatisfaction

63
Q

Issues with health outcomes?

A

Link between health service and health outcome may be difficulty to establish as many other factors may be involved
Time lag between service provided and outcome may be too long
Large sample sizes may be needed to detect statistically significant effects
Data may not be available
May be issues with data quality (completeness, accuracy, relevance, timeliness)

64
Q

Maxwell’s dimensions of quality of healthcare?

A

Effectiveness, efficiency, equity, acceptability, accessibility, appropriateness

65
Q

Qualitative methods of evaluation of services?

A

Consult relevant stakeholders- observation, interviews, focus groups, review of documents

66
Q

Quantitative methods of evaluation of services?

A

Routinely collected data, review of records- medical, administrative, surveys, other special studies: epidemiological methods

67
Q

General framework of evaluating health services?

A

1) Define what the service is
2) What are the aims/ objectives of the service?
3) Structure, process, outcome +/- dimensions of quality
4) Methodology used- quantitative/ qualitative
5) Results, conclusions and recommendations

68
Q

3 opioid receptors? Where are they distributed? What is their major effect in the NS?

A

MOR (alpha,) KOR (K,) DOR
Throughout- to lesser extent in periphery + within vas deferens, knee joint, GI tract, heart + immune system
Presynaptic action inhibiting neurotransmitter release

69
Q

GI effects of opiates? Resp system? CVS effects? CNS? MSK? Endocrine? Immune system?

A

Constipation, nausea
Sleep-disordered breathing
CVS events
Dizziness + sedation–> falls, fractures, and resp depression, hyperalgesia
Risk of fractures/ falls
Affects hormone release from anterior pituitary
Affect micro-opioid receptor on all immune cells, increase in pneumonia
Increased addiction risk

70
Q

Non-pharm tx for chronic pain?

A

Weight loss, smoking cessation, exercise, physio, yoga, pilates, psychological, complementary therapy, occupational

71
Q

Guidance on tx chronic pain?

A

Non-opioid: NSAIDs, COX-2 inhibitors, paracetamol
Opioid= intermittent usage/ slow + low
Anti-convulsants, antidepressants, lidocaine patches
Opioids= more common in areas of higher social deprivation, tramadol= most prescribed, high rates of buprenorphine

72
Q

Signs of abuse and dependency of opioids?

A

Use of meds other than for pain tx, impaired control, compulsive use, continued use despite harm, craving/ escalation of use, selling/ altering prescriptions, stealing/ diverting meds, calls for early refills/ losing prescriptions, reluctance to try non-pharm interventions

73
Q

Key associations with opioid dependency?

A

High in younger- decreases with age increase, highest in cohabiting not married, highest in unemployed, non-white population, bad health, smokers + never smoked, buying on internet + dependency

74
Q

What are health inequalities?

A

The preventable, unfair and unjust differences in health status between groups, populations/ individuals that arise from the unequal distribution of social, environmental and economic conditions within societies, which determine the risk of people getting ill, their ability to prevent sickness, or opportunities to take action and access treatment when ill health occurs

75
Q

E.g. of vulnerable groups?

A

Homeless, gypsies and travellers, asylum seekers, LGBTQ, ex-prisoners, care leavers, those with learning disabilities, those with mental health issues

76
Q

Levels of Maslow’s Hierarchy of Needs?

A

Physiological, safety, love/ belonging, esteem, self-actualisation

77
Q

Definition of social exclusion?

A

Dynamic process of being shut out, fully/ partially, from any of the social, economic, political or cultural systems which determine the social integration of a person in society

78
Q

5 domains of social exclusion?

A

Material resources, civic activities, basic services, neighbourhood, social relationships

79
Q

Causes of social exclusion?

A

Poor health, sensory impairment, poverty, housing issues, fear of crime, transport, problems on roads, discrimination, sexuality, gender, ethnicity, belief, insufficient + fragmentation of services, lack of imagination, bureaucracy, poor coordination, lack of information, fragility of networks

80
Q

Emotional needs of humans (human givens)?

A

Security, attention, autonomy + control, intimacy, part of wider community, privacy, status, competence, achievement, meaning + purpose

81
Q

What is an asylum seeker? Refugee? What is indefinite leave to remain(ILR)?

A

A person who has made an application for refugee status
Person granted asylum and refugee status- usually means leave to remain for 5 years then reapply
When a person is granted full refugee status and given permanent residence in the UK

82
Q

Asylum seekers are entitled to what? Not what?

A

Money- £37.75 per week, housing(no choice dispersal,) free NHS care
<18 y/o= services of a social services key worker and can go to school
Work, any other form of benefit

83
Q

After year of ILR, asylum seekers can apply for what?

A

British citizenship

84
Q

What is human trafficking?

A

The movement of people, by means such as force, fraud, coercion or deception, with the aim of exploiting them (modern-day slavery)

85
Q

Types of exploitation?

A

Sexual, organ harvesting, domestic servitude, forced labour, forced criminality

86
Q

Common presentation of forced prostitution?

A

Late booking/ requesting a late abortion- may have rape injuries, higher STI risk, injuries from physical abuse, back/ joint/ muscle pain, unsafe conditions–> injuries, malnourished, RTI/ dental pain + cavities

87
Q

Red flags for human trafficking?

A

Timed/terrified/tense, not registered with GP/nursery/ school, accompanied by controlling person, foreign language, frequently moving location, inconsistent history, no control of passport/ bank account, keep alert, evidence injuries left untreated, DNA future appointments

88
Q

What is incidence? What is prevalence?

A

New cases, denominator, time

Existing cases, denominator, point in time (point prevalence)

89
Q

What is person-time and when is it used? Used to calculate what? Used as the what? Incidence rate is useful when what?

A

Person-time= measure of time at risk i.e. time from entry to a study to i) disease onset, ii) loss of follow-up iii) end of study
Incidence rate- uses person-time: denominator
Cumulative incidence uses the number of disease- free people at the start of the study as the denominator
Study participants are followed up for varying lengths of time

90
Q

Calculation for incidence rate?

A

No of persons who have become cases in a given time period/ total person-time at risk during that period

91
Q

Difference between absolute and relative risk?

A 
Absolute= feel for actual numbers involved i.e. has units
Relative= risk in one category relative to another i.e. no units
92
Q

Attributable vs relative risk?

A

Rate of disease in exposed may be attributed to the exposure - incidence in exposed- in unexposed (type of absolute risk)
Ratio of risk of disease in exposed to risk in unexposed i.e. incidence in exposed/ incidence in unexposed

93
Q

What does attributable and relative risks tell us?

A

About the strength of association between a risk factor and disease
About the size of effect in absolute terms

94
Q

What is bias?

A

Systematic deviation from the true estimation of the association between exposure and outcome

95
Q

2 main groups of bias?

A

Selection bias= systematic error in selection of participants, allocation to groups
Information bias: in measurement/ classification of exposure, outcome, sources= observer, participant, instrument

96
Q

What is confounding?

A

The situation where a factor is associated with the exposure of interest and independently influences the outcome(does not lie on causal pathway)

97
Q

When considering association and causation, what needs to be considered?

A

Bias, chance, confounding, criteria

98
Q

Factors to consider when assessing causality?

A

Strength of association, dose-response, consistency from different researchers, temporality, reversibility, biological plausibility

99
Q

If association not causal, how could it be explained?

A

Bias, chance, confounding, reverse causality

100
Q

What is the population approach to prevention? High risk approach?

A

A preventative measure delivered on a population wide basis and seeks to shift the risk factor distribution curve
Seeks to identify individuals above a chosen cut-off and treat them

101
Q

What is screening?

A

Process which sorts out apparently well people who probably have a disease from those who probably do not

102
Q

Types of screening?

A

Population-based screening, opportunistic screening, screening for communicable diseases, pre-employment and occupational medicals, commercially provided screening

103
Q

Criteria considered for screening?

A

The condition: important health problem, latent/ preclinical phase, natural history known
Screening test: suitable(sensitive, specific, inexpensive,) acceptable
Treatment: effective, agreed policy on whom to treat
Organisation + costs: facilities, costs and benefits, ongoing process

104
Q

What is sensitivity? Specificity? Positive predictive value? Negative predictive value?

A

Proportion of people with the disease who are correctly identified
Proportion without disease who are correctly excluded
Proportion with +ve test who actually have disease
Proportion with -ve result who do not have disease

105
Q

Why are positive predictive value so different?

A

They are dependent on underlying prevalence- sensitivity and specificity are not

106
Q

What is the prevention paradox?

A

A preventative measure which brings much benefit to the population often offers little to each participating individual

107
Q

What is domestic abuse?

A

Any incident/ 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
Abuse= can encompass but is not linked to: psychological, physical, sexual, financial, emotional

108
Q

Risk levels for domestic abuse?

A

Standard: current evidence does NOT indicate likelihood of causing serious harm
Medium: identifiable indicators of risk of serious harm- offender= potential to cause serious harm- unlikely unless change in circumstances
High: are identifiable indicators of imminent risk of serious harm, dynamic- could happen at any time and impact would be serious

109
Q

Management for medium/ high risk domestic abuse?

A

Contact details for domestic abuse services, keep good records, ensure follow-up as needed
Refer to MARAC/ IDVAS in addition to above with consent- via helpline as well
Can break confidentiality in high risk cases if no consent

110
Q

You should not do what in domestic abuse?

A

Assume someone else will take care of things, ask about DA in front of family members/ use informal interpreters, tell them what to do- aim to empower them to make safe + informed choices

111
Q

4 HARK Qs for identifying domestic abuse?

A

Humiliation
Afraid
Rape
Kick

112
Q

Who are the IDVA service?

A

Works primarily with victims who are at the highest levels of risk from domestic abuse in Sheffield- helps to increase their safety by providing: advocacy + advice around DA, safety planning, support through court proceedings, signposting to services, housing, legal services, refuge provision and home safety services- voice in MARAC process

113
Q

What is a Domestic Homicide Review?

A

Review of the circumstances in which the death of a person aged 16 or over has/ appears to have resulted from violence, abuse or neglect by: someone related / had been in intimate relationship/ same household, age 16-17: SCR takes precedence; criteria= suicides

114
Q

DASH risk assessment Qs?

A

Has the current incident resulted in injury?
Are you frightened?
What are you afraid of?
Do you feel isolated from family/ friends?
Within last 3 months: are you feeling depressed, had suicidal thoughts, made a suicide attempt?
Separated/ tried to separate from abuser within past year?
Is there conflict over child contact?
Does…. constantly text, call, contact/ follow/ stalk/ harass you?

115
Q

Factors contributing to promotion of excessive energy intake?

A

Genetics, employment, early developmental factors, TV viewing, characteristics of food: macronutrient composition, satiety and satiation, portion size/ reduced physical activity, sleep, environmental cues, psychological factors

116
Q

What is malnutrition? Undernutrition? Stunting? Wasting? Underweight? Micronutrient deficiencies?

A

Deficiencies, excesses/ imbalances in a person’s intake of energy and/ or nutrients
Includes stunting, wasting, underweight, micronutrient deficiencies/ insufficiencies
Low height for age
Low weight for height
Low weight for age
Lack of important vitamins + minerals

117
Q

Early influences on feeding behaviour?

A

Maternal diet + taste preference chronic conditions
Role of breastfeeding for taste preference and bodyweight regulation
Parenting practices
Other: age of intro of solid food, types of food exposed to during the weaning period and beyond

118
Q

What is influenced by maternal diet? What influences taste exposure?

A

Amniotic fluid

In-utero environment

119
Q

Composition of breastmilk?

A

Colostrum- 3 days after birth
Foremilk= beginning of feed (watery)
Hindmilk= end of feed> energy dense
Efficient digestion: enzymes, transfer factors- lactoferrin
Gut protection- epidermal growth factor, secretory IgA, anti-inflammatories
Anti-infective- bifidus factor, white cells, oligosaccharides
Everyday health: antibodies, entero/ broncho- mammary pathways, viral fragments, lactoferrin- dental hygiene

120
Q

Vision in cataracts? Macular degeneration? Glaucoma? Retinitis pigmentosa? Hemianopia? Diabetic retinopathy?

A

Cloudy, misty- in many cases= can be corrected by timely surgery- full vision restored

Loss of central vision, usually age-related, is a hereditary version: Stargardt’s macular- affects younger people

Tunnel vision, no peripheral vision

Tunnel vision–> blindness

Split vision, losing half of visual field in one/ both eyes

Patchy vision, poor/ non-existent night vision

121
Q

Charles Bonnet syndrome vision? Phantom visions?

A

Affects up to 50% of people who lose sight- especially in early stages
Brain creates visual hallucinations, always silent e.g. simple images, grids, patterns, elaborate, complex images of objects

Not sign of dementia- normal response–> sudden loss of vision

122
Q

5 things to help visually impaired?

A

Make it bigger, make it brighter, bolder, make it speak, make it tactile- bump-ons, tactile dominoes, braille(only used by 5% + decreasing due to improved technology)

Phase 3A 'The List' conditions (8 decks)

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