Public Health Flashcards
What are the 3 principles that the NHS was founded on?
- It meets the needs of everyone
- It’s free at point of delivery
- It’s based on clinical need and not ability to pay
What does the marmot report 10 years on highlight?
people can expect to spend more of their lives in poor health
improvements to life expectancy have stalled, and declined for the poorest 10% of women
the health gap has grown between wealthy and deprived areas
place matters – living in a deprived area of the North East is worse for your health than living in a similarly deprived area in London, to the extent that life expectancy is nearly five years less.
Name 8 groups considered more vulnerable to health inequalities
Homeless Traveller community Asylum seekers LGBTQ+ Ex prisoners Care leavers Those with learning difficulties Those with mental health problems
How many tiers are there in Maslow’s hierarchy of needs
5
What are the tiers of Maslow’s hierarchy of needs
- Self actualization, mortality, creativity, lack of prejudice
- Esteem - self-esteem, confidence, achievement, respect for and by others
- Love/belonging - friendship, family, intimacy
- Safety - security of body, employment, health
- Physiological - breathing, water, sleep
What are the two main perquisites for homelessness
- Eviction by private landlords
2. Relative/friends no longer offering accommodation
What are the two domains which impact the likelihood of becoming homeless
- Individual circumstances
2. Wider forces
What are some individual circumstances that may lead to homelessness
Poor physical health, drug and alcohol abuse, poor mental health, bereavement, crime
What are some of the wider forces which may lead to homelessness
Poverty, inequality, housing supply and affordability, unemployment, welfare, income policies
What are some barriers for homeless people accessing healthcare
Difficulties registering with a GP, appointment procedures, perceived or actual discrimination, lack of health priority
What is the life expectancy of travellers compared to the general population
10 years less for men
12 years less for women
What is the rate of child death/miscarriage in the traveller community
1 in 5 will lose a child compared to 1 in 100 in general population
What are the rates of traveller suicide compared to the general population
Irish travellers are three times more likely to commit suicide than the general population
What is the prevalence of anxiety and depression in the traveller community compared to the general population
Three times higher anxiety rates, twice as like to have depression
Which diseases are 1.5-4x more prevalent in the traveller community
Chronic bronchitis, asthma, angina, pregnancy complications, smoking
What inequalities are faced by the LGBTQ+ community
Social isolation, homelessness, workplace discrimination, relationship problems, crime and violence
What are the health inequalities for gay and bisexual men
Twice as likely to have anal cancer, higher rates of eating disorders, 21% higher rates of depression and anxiety. 4x lifetime risk of suicide attempt
What are the health inequalities for lesbian and bisexual women
Only half attend cervical screening as thought don’t need to, higher rate of PCOS, higher risk of obesity, poorer mental health, 1.8x suicide risk
What are the health inequalities for trans people
Higher rates of HIV and other STIs, higher rates of substance misuse, globally poorer health and little research
What is an asylum seeker
A person who has made an application for refugee status
What is a refugee
A person granted asylum and refugee status. Have leave to remain for 5 years then reapply
What is indefinite leave to remain
A person granted full refugee status and given permanent residence
What are asylum seekers entitled to
£37.75 a week Housing - no choice Free NHS care NOT allowed to work NOT allowed to claim benefits
When can asylum seekers apply for British citizenship
After five years of refugee status can apply for indefinite leave to remain. After a year of indefinite remain can apply for British citizenship
What are the types of human trafficking
Sexual exploitation, domestic servitude, forced labour, forced criminality, organ harvesting
What are the demographics of slavery
41% forced labour, 34% sexual exploitation, 11% domestic servitude. 2/3 children, mostly from Vietnam and Slovakia
What are some red flags to look for when suspecting human trafficking
Timid, not registered with GP/school, accompanied by controlling person, foreign language, frequent location change, inconsistent history, no control of passport/bank, injuries untreated
What should you do if you suspect human trafficking
Try to talk to them alone, address health needs, ask what they want.
Immediate threat - 999
Under 18 - NSPCC child trafficking advice centre.
If >18 and consent to help inform safeguarding, if not then give leaflet
Name 4 models of behaviour change
Health belief model
Theory of planned behaviour
transtheoretical model
Social norms theory
What are the 4 criteria of the health belief model
- Believe they are susceptible to the disease
- Believe the disease has serious consequences
- Believe taking action reduces susceptibility
- Believe the benefits of taking action outweigh the costs
What are some health motivation/cues to action in the health belief model
Internal cues e.g. heart attack or external cues e.g, advice by GP
Define meta-analysis
Examination of data from a number of independent studies on the same subject, in order to determine overall trends
What are four critiques of the health belief model
- Alternative factors may predict health behaviour, such as outcome expectancy
- It does not consider the influence of emotions on behaviour
- Does not differentiate between first time and repeat behaviours
- Cues of action cannot always be determined in studies
Key points of the health belief model
Longest standing model of behavioural change.
Successful range of health behaviours
Perceived barriers have been shown to be the most important factor for addressing behaviour change
What are the three components of the theory of planned behaviour
Attitudes
Subjective norms/Social norms
Perceived behaviour control
What are attitudes
The degree to which a person has a favourable or unfavourable opinion on the behaviour of interest. e.g. do they like running
What is behavioural intention
The motivational factors that influence a given behaviour where the stronger the intention to perform the behaviour, the more likely it will be performed. e.g. the behavioural intention behind running is that its good for my health
What are subjective norms
The belief about whether most people approve or disapprove of the behaviour. If people important to you will approve of the behaviour
What are social norms
The codes of behaviour acceptable in a group of people or a larger cultural context.
What is perceived power
The perceived presence of factors that will facilitate or impede performance of a behaviour. The factors which contribute to perceived behavioural control
What is perceived behavioural control
The persons perception of the ease or difficulty of performing the behaviour. Are they able to do it?
Limitations of the theory of planned behaviour
Lacks time scale (how long from intent to action), doesn’t consider emotions, doesn’t consider habit/routine, assumes that attitudes/subjective/social norms can be measured, relies on self-reported behaviour, doesn’t consider economic or environmental factors
Key concepts of the theory of planned behaviour
Rational choice model
Attitudes, subjective norms and perceived behavioural control are the major determinants of intentions
can predict intentions for a wide range of health behaviours
Takes into account social pressures and perceived control
Useful for predicting intentions but not actual behaviours
What is the stages of change model/transtheoretical model
Descrete, ordered stages with each stage denoting a greater inclination than the last
What are the five stages of transtheoretical model
Precontemplation Contemplation Preparation Action Maintenance
What stage would buying nicotine patches be in the transtheoretical model
Preparation
What stage would being a steady non-smoker be in the transtheoretical model be
Maintenance
What stage would thinking about giving up smoking be in the transtheoretical model
Contemplation
What stage would stopping smoking be in the transtheoretical model be
Action
What stage would no intention of giving up smoking be in the transtheoretical model be
Precontemplation
What are the advantages of the transtheoretical model
Acknowledges individual stages of readiness
accounts for relapse
temporal (time) element
What are the disadvantages of the transtheoretical model
Not everyone progresses in a linear fashion - may skip a step or go back
Change can operate on a continuum and does not always have an end
Doesn’t consider values, habits, culture, social and economic factors
Key concepts of the transtheoretical model
Precontemplation, contemplation, preparation, action, maintenance
Examines process of change rather than factors determining behaviour
Allows for interventions to be tailored for individuals
What are the ideas surrounding social norms theory
Scare tactics don’t work
Humans are group orientated so common beliefs and attitudes are the most influential factors influencing behaviours
What is a critique of social norms theory
Perceived social norms may be different from actual norms but still influence behaviour.
Social norms aims to find real norms via statistics.
Information does not equal behaviour change.
Population data may not reflect an individual’s social environment
Name three behaviours to health
Sick role
Illness
Health behaviours
What is the sick role
Behaviour aimed at getting well. Rules and obligations such as they are not responsible for their condition, and they should receive help/medical treatment. (engaging in treatment)
What is illness behaviour
Behaviour aimed at seeking a remedy. (finding treatment)
What is health behaviour
An activity undertaken by an individual who believes themself to be healthy, for the purpose of preventing illness.
What are some physical consequences of loneliness
Early death, more risks, smoking
What are some signs of loneliness
Talkative, clinging, denial, boredom, living alone, males >50, bereavement, poor mobility, sensory impairment.
What are the five domains of social exclusion
Material resources Civic activities Basic services Neighbourhood Social relationships
Define relative risk
One intervention’s risk of an event occurring compared to another’s
Give an example of relative risk
Relative risk of smoking on developing lung cancer is 3. You are 3x more likely to get lung cancer if you smoke than if you don’t
Define hazard ratio
The risk of an event occurring over a set amount of time
Give an example of hazard ratio
Hazard ratio of smoking and lung cancer over 10 years is 2. Over a 10-year period, twice as many people who smoked developed lung cancer than those who didn’t
Give an example of reverse causation
People who are already ill don’t drink coffee. Coffee does not make you healthy!
What is the aim of a population approach to prevention
Delivered on a population wide basis and seeks to shift the risk factor distribution curse. e.g. salt restrictions in the food industry.
Define high risk approach to prevention
Identifies individuals above a chosen cut-off and treats them e.g. high blood pressure
What is the prevention paradox
A preventative measure which brings much benefit to the population, often offers little to each participating individual. e.g. statins for CVD prevention
What is relative risk reduction
How much the risk of an event is reduced in an experiment compared to a CONTROL group
What is absolute risk
The odds of an event happening over a stated time period. e.g. women have an absolute risk of 12% of developing breast cancer in her life. Out of every 100 women, 12 will develop breast cancer in their life.
What is number needed to treat
Number of people needed to treat for event to be prevented in 1 person
How to calculate NNT
Ratio between number treated and number successful. e.g. give 10 million people statins and prevent 250,000 CVD, NNT = 40
Define bias
A systematic deviation from the true estimation of the association between exposure and outcome
What are the two main types of bias
Selection bias (selection of participants or allocation into groups) Information (error in measurement - observer, participant or instrument)
What are some criteria for causality
Strength of association Dose-response Consistency Temporality Reversibility Biological plausability
What study is this: Investigators find a high level of correlation between levels of socioeconomic
deprivation and cardiovascular mortality across electoral wards in the UK
Ecological study
What study is this: Researchers set out to examine the association between alcohol consumption
and stroke. They identify all new patients admitted with stroke and compare
their alcohol consumption with patients admitted for elective surgery.
Case-control study
What study is this: General practitioners set up a study to estimate the prevalence of depression
within their registered population. They decide to start with a random sample
of adults aged 45-74 years.
Cross-sectional study
What is Person-years
the number of people in the study and the amount of time each person spends in the study. For example, a study that followed 1000 people for 1 year would contain 1000 person years of data.
What best describes the measure being used: For patients with meningococcal meningitis, the risk of dying has been
estimated to vary from 5-10%.
Case-fatality rate
What best describes the measure being used: In a case-control study of recent alcohol consumption and road traffic
accidents, the measure of association was substantially greater than 1 and
indicates that there is a positive association between exposure and outcome.
Odds ratio
What best describes the issue best: Researchers set out to examine the hypothesis that stress causes
hypertension using hypertensive and normotensive individuals in a casecontrol study. The study design is however criticised because of concerns
regarding the temporal sequence of events.
Reverse causality
What describes the issue best: A study reports an association between coffee consumption and cancer.
However, subsequent studies find that there is a clear association between
smoking and coffee consumption.
Confounding
What describes the issue best: An association between postmenopausal oestrogen use and endometrial
cancer was reported in some studies. However, it was subsequently argued
that this might be due to increased diagnostic attention received by women
with uterine bleeding after oestrogen exposure.
Bias
Define randomised control trial
Participants are allocated to intervention and control groups using random sorting.
Give some advantages of RCT
Unbiased distribution of confounders
blinding more likely
randomisation facilitates statistical analysis
Give some disadvantages of RCT
Expensive
Volnteer bias
takes time
ethical to not treat?
What is a cohort study
Can be prospective or retrospective. When retrospective the outcomes have already occurred. USUALLY prospective - follows a cohort
What is a case control study
Always retrospective, two groups one who has disease, one who doesn’t. Look at rates of exposure of a defined risk factor.
Advantages of case control study
Cheap
Easy
Assess multiple exposure
Disadvantages of case control
Prone to bias (recall)
only assess one outcome
cannot establish risk
Cohort study advantages
Usually prospective
Can establish risk
Can assess multiple outcomes
Cohort studies disadvantages
More expensive
Longer
What is an ecological study
Observes rates of disease in populations. Mostly geographical, can compare ecological studies to each other to look for trends. Can also use prevalence over time.
What is a cross sectional study
Examines relationship between disease and risk in defined population at a single point or over a short period of time.
What are the advantages of a cross sectional study
May be used to show prevalence.
Quick and easy
Multiple outcomes and exposures studied.
What are the three domains of public health practice
Health improvement
Health protection
Health care
What is health improvement
Concerned with societal interventions aimed at preventing disease, promoting health, and reducing inequalities
What is health protection
Concerned with measures to control infectious disease risks and environmental hazards
What is health care
The organisation and delivery of safe, high quality services for prevention, treatment, and care
What is horizontal equity
Equal treatment for equal need. e.g. those with pneumonia should be treated equally
What is vertical equity
Unequal treatment for unequal need. e.g. those with cold vs pneumonia need unequal treatment. Areas with poorer health need higher expenditure
What is a health needs assessment
A systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities
What are three approaches to the health needs assessment
Epidemiological
Comparative
Corporate
What is the epidemiological approach to health needs assessment
Define problem and size of problem. Consider services available, look at evidence, cost-effectiveness, review existing services (are they needed) and make recommendations.
What is the comparative approach to health needs assessment
Compares the services received by one group to another. May examine: health status, service use, patient satisfaction
What is the corporate approach to health needs assessment
Obtains views from stakeholders to make adjustments e.g. politicians, press, patients, comissioners
What is Donabedian’s framework for health service evaluation
Structure e.g. staff
Process e.g. no. of patients seen
Outcome e.g. 30 day mortality rate
What are Maxwell’s dimensions of quality (health needs assessment)
3Es and 3As Effectiveness Efficiency Equity Acceptability Accessibility Appropriateness
What are some examples of the Wilson and Junger criteria for screening
Important health problem Latent/preclinical phase Natural history known Screening test is suitable (sensitive, specific) Screening test is acceptable Effective treatment is available Facilities are available Cost-effective
What is sensitivity
The proportion of people with the disease who are identified by the screening test
What is specificity
The proportion of people without the disease who are correctly excluded by the screening test
What is positive predictive value
The proportion of people with a positive test result who actually have the disease
What is negative predictive value
The proportion of people with a negative test result who do not have the disease
What is lead time bias
Phenomenon where early diagnosis/detection of a disease makes it look like people are surviving longer
What is length-time bias
Fast progression diseases have a smaller time period for which they can be detected. This means that screening picks up more cases of the slow progressing disease than the aggressive ones.
What are the Bradford-hill criteria for causality
Strength - stronger the association
Consistency - various studies get same result
Dose-response - Increased risk of outcome with increased exposure
Temporality - Exposure prior to outcome
Plausibility - reasonable biological mechanism
Reversibility - removal of risk decreased outcome
Coherence - logical consistency with other information
Analogy - similar to other cause-effect relationships
Specificity - Relationship specific to outcome of interest
Name some types of error
System error - equipment Lack of skill Ignorance - not knowing what you don't know Poor team working Bravado - working beyond competence Sloth error of inherent thinking
What are the four components of medical negligence
- Was there duty of care
- Was there a breach in that duty
- Was the patient harmed
- Was the harm due to the breach in care
What is a never event
A serious, largely preventable patient safety incident that should not occur. If available preventative measures should have been implemented
What is opportunity cost
To spend resources on one activity e.g. a heart transplant, means sacrificing an opportunity elsewhere e.g. hip replacements
What is economic efficiency
Achieved when resources are allocated between activities in a way that maximises benefit
What is meant by an equity-efficiency trade-off?
Improving equity often leads to loss in efficiency. e.g. funding treatment of rare disease with expensive drugs
How can health benefits be measured
Natural units (blood pressure/pain score/number of cases)
Quality adjusted life years
Monetary value
What is horizontal equity
equal treatment for equal need
What is vertical equity
unequal treatment for unequal need
what are the Bradford Hill criteria for causation
temporality dose-response strength of association reversibility consistency biological plausibility
what can association be due to
bias confounding factors chance reverse causality true association
give an example of publication bias
trials with negative results are less likely to be published
lead-time bias
ealry identification doesnt alter outcome but appears to increase survival
Length-time bias
disease that progresses more slowly is more likely to be picked up by screening
pros of corss sectional study
larger sample size
rapid
repeated studies show changes over time
cons of cross sectional study
risk of reverse causality
disease length bias so wont include those who recover quickly
sample size too small for rarer disease
pros of case control study
good for rare outcomes
rapid
cons of case control study
prone to selection bias and information bias
resource consuming
pros of cohort study
can establish disease risk factors - no reverse causality
can follow rare exposure
data on confounders can be collected
cons of cohort study
difficult to assess rare disease
drop outs
large sample size required
pros of randomised control trial
two groups compared accurately
risok of bias and confoudners low
cons of RCT
ethical issues
drop outs
expensive and time consuming
basics of ecological study
population based data rather than indicidual date
geographical or time comparisons
what are Bradshaw’s needs
felt need
expressed need
normative need
comparative need
what is felt need
indicidual perceptions of variation from normal health
what is expressed need
individual seeks help to overcome variation in normal health
what is normative need
professional defines intervention appropriate for the expressed need
what is comparative need
comparison between severity range of interventions and cost
e.g we need this because they have it
two main types of health needs assessment evaluation
Donabedian approach
Maxwell’s dimensions
What is the Donabedian approach to health needs assessment
structure - what there is
process - what is done
outcome - mortalilty etc
what are Maxwells dimensions
effectiveness equity efficiency acceptability appropriateness accessibility
how to calculate ABSOLUTE RISK REDUCTION (attributable risk)
take the risk of two interventions and subtract one from the other
how to calculate NNT
1/absolute risk reduction (as a decimal not its percentage (how ARR is usually expressed))
what is the recommended alcohol a week for women and men
BOTH 14 units per week
what would count as a binge drinking episode for women and men
men 8 units
women 6
how to calculate units of alcohol
%ABV*volume(ml)/1000
two screening questionnaires for alcohol
CAGE
AUDIT
