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Public health Flashcards

1
Q

What are the determinants of health

A

o Genes
o Environment – physical and social
o Lifestyle
o Health care

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2
Q

What is the difference between equity and equality?

A

o Equity = About what is fair & just
 Depends on the need

o Equality = Concerned with equal shares

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3
Q

Describe the three domains of Public Health practice

A
  1. Health improvement
    - Concerned with societal interventions (not primarily delivered through health services) aimed at preventing disease, promoting
    health, and reducing inequalities
  2. Health protection
    - Concerned with measures to control infectious disease risks and
    environmental hazards
  3. Improving services (Health care)
    - Concerned with the organisation and delivery of safe, high quality
    services for prevention, treatment, and care
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4
Q

Difference between horizontal equity and vertical equity?

A

Horizontal equity

  • Equal treatment for equal need
    e. g. Individuals with pneumonia (with all other things being equal) should be treated equally

Vertical equity

  • Unequal treatment for unequal need
    e. g. Individuals with common cold vs pneumonia need unequal treatment
    e. g. Areas with poorer health may need higher expenditure on health services
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5
Q

What are different forms of health equity?

A 
Equal expenditure for equal need
Equal access for equal need
Equal utilisation for equal need
Equal health care outcome for equal need
Equal health
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6
Q

What are the dimensions of equity?

A
  1. Spatial - geographical
  2. Social:
    - Age
    - Gender
    - Class
    - Ethnicities
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7
Q

What are the domains in examining health equity?

A
  • Supply of health care
  • Access to health care
  • Utilisation of health care
  • Health care outcomes
  • Health status
  • Resource allocation -health services and other services such as education and housing
  • Wider determinants of heath - diet, smoking, socioeconomic, physical environment
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8
Q

Steps in accessing health inequalities?

A

1) Assess inequality
2) Then decide if inequitable
 Inequalities need to be explained
 But equality (Eg: Equal utilization) may NOT be equitable

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9
Q

Different levels of public health interventions? with example

A

o Individual lvl: Eg: Vaccinations
o Community lvl: Eg: Education in schools
o Ecological (Population) lvl: Laws to make smoking or alcohol harder

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10
Q

Different levels of risks in Domestic abuse?

A

STANDARD – current evidence does NOT indicate likelihood of causing serious harm

MEDIUM – there are identifiable indicators of risk of serious harm. Offender has potential to cause serious harm but unlikely unless change in circumstances

HIGH – there are identifiable indicators of imminent risk of serious harm. Dynamic – could happen at any time and impact would be serious

Use DASH risk checklist

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11
Q

Where do you refer high risk domestic abuse cases to?

A

Multi-Agency Risk Assessment Conference (MARAC)

IDVAS - Independent domestic violence advisor service

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12
Q

What is incidence?

A

New cases/ number of disease free people at
the start of the study

Number of new cases per unit time

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13
Q

What is prevelance?

A

Number of existing cases at a given time

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14
Q

What is absolute risk?

A

Measurement of likelihood of a certain event would happen

gives a feel for actual
numbers involved i.e. has units
e.g. 50 deaths / 1000 population

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15
Q

What is relative risk?

A

Measurement of risk of a certain event happening as compared to other

Tells us about the strength of association between a risk factor and a disease

Absolute risk of expoure / abosulte risk in the unexposed

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16
Q

What is attributable risk?

A

Rate of disease that can be attributed to exposure
o Incidence in exposed – Incidence in unexposed

Is about the size of effect in absolute terms i.e. gives a feel for the public health impact (if causality is assumed)

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17
Q

What is number needed to treat?

A

Number of patients you need to treat to prevent 1 additional bad outcome
o Formula = 1/Absolute risk increase

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18
Q

Two main types of bias?

A
  1. Selection bias - selection of participant (sampling bias), and Allocation of participants into different study groups
  2. Information measurement bias:
    - Observer - Observer bias - (Different observers may assess subjective criteria differently; Eg: Being aware of a subject’s disease status may introduce a bias in how the outcome is assessed)
  • Participant - Recall bias - Due to differences in accuracy or completeness of the recollections retrieved by study participants regarding events or experiences from the past
  • Instrument (wrongly caliberated)
    3. Publication bias - negative results are not published
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19
Q

If association is not causal what else do you need to consider?

A

o Bias
o Chance
o Confounding
o Reverse causality

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20
Q

What is the bradford hill criteria for causality?

A
  1. Temporality: does exposure precede the outcome?
  2. Dose-response: the higher the exposure, the higher the risk of disease
  3. Strength of association: the magnitude of the relative risk
  4. Reversibility (experiment): removal of exposure reduces risk of disease
  5. Consistency- similar results from different researchers using various study designs
  6. Biological plausibility - biological mechanisms explaining the link
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21
Q

What are the different types of prevention?

A
  • Primary = Intervention to prevent onset of disease
  • Secondary = Intervention to pick up asymptomatic individuals with disease & treat
  • Tertiary = Intervention to reduce -ve effects of disease from symptomatic individuals
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22
Q

What is the prevention paradox?

A

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

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23
Q

What is the wilson and jugner criteria?

A
  1. The condition:
    - needs to be an important health problem
    - needs to have a latent phase
    - known disease progression
  2. A screening test:
    - acceptable
    - suitable
  3. Treatment:
    - Effective
    - Agreed policy on whom to treat
  4. organisation and cost:
    - Cost effective
    - Facilities
    - On-going process
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24
Q

What is sensitivity?

A

Proportion of people with the disease to be correctly identified by the test

Memory: How sensitive is the test in picking out those with the disease accurately (True positives)

Formula: true positive / (true positive + false negative)

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25
Q

What is specificity?

A

Proportion of individuals without the disease to be correctly excluded from the results of the test

Memory: How specific is this test in diagnosing those without the condition?

Formula: True negative/ (true negative + false positive)

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26
Q

What is positive predicted value?

A

Proportion of people with a positive test who actually has the disease

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27
Q

What is negative predicted value?

A

Proportion of people with a negative test who don’t have the disease

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28
Q

What is lead-time bias?

A

Overestimation of survival duration due to earlier detection by screening instead of onset of clinical symptoms

AKA you think that screening increases survival, but actually it’s only because you pick up earlier (No change in mortality)

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29
Q

What is length-time bias?

A

Overestimation of survival duration due to relative excess of cases detected that are slowly progression
AKA you think you detect more cases because of screening, but actually it’s because the disease is slow progressing

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30
Q

What is need, demand and supply?

A

o Needs = Ability to benefit from an intervention
o Demand = What people ask for
o Supply = What is provided

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31
Q

What is health needs assessment?

A

Health needs assessment is 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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32
Q

Examples of needed and supplied but not demanded?

A 
• Health promotion 
• GU contact tracing 
• MMR (For some parents)
• Screening (Some)
• CAMS
smoking cessation services
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33
Q

Examples of needed but not demanded and not supplied?

A
  • Treatment of child abusers
  • Palliative care services
  • Contraceptive services
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34
Q

Examples of needed and demanded but not supplied?

A 
• Waiting lists
• Evidence based gaps
• New medications
• Research
Drug rehabilitation
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35
Q

Examples of supplied and demanded but not needed?

A

• Antibiotics for sore throat
• Cosmetic surgery
- Benzodiazepines for insomnia

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36
Q

Examples of needed, supplied and demanded?

A

• Operations of cataracts
• Free contraception
- insulin for DM

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37
Q

What is health needs?

A
  • Need for health
  • Concerns need in more general terms
    e. g. measured using mortality, morbidity, socio-demographic measures
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38
Q

What is health care needs?

A
  • Need for health care
  • Much more specific
  • Ability to benefit from health care
    e. g. Depends on the potential of prevention, treatment and care services to remedy health problems
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39
Q

What are the different needs according to Bradshaw’s sociological perspective?

A
  1. Felt Need - Individual perceptions of variation from normal health
  2. Expressed Need - Individual seeks help to overcome variation in normal health (Demand)
  3. Normative need - Professional defines intervention appropriate for the expressed need
  4. Comparative need - Comparison between severity, range of interventions and costs

FENC

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40
Q

What are the three approaches for a health needs assessment?

A
  1. Epidemiological Approach - Top down view based on statistics
  2. Comparative approach - Compares 2 groups or populations
  3. Corporate approach - includes stakeholders
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41
Q

What are the problems in epidemiological health needs assessment approach?

A
  • Required data may not be available
  • Variable data quality
  • Evidence may may be inadequate
  • Does NOT consider felt needs of people
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42
Q

What are the problems in comparative health needs assessment approach?

A
  • May be difficult to find a comparable population
  • Variable quality of data
  • Data may NOT be available
  • May NOT yield what the most appropriate level of Provision or utilisation should be
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43
Q

What are the problems in corporate health needs assessment approach?

A
  • Difficult to distinguish need from demand
  • Groups may have vested interests
  • May be influenced by political agendas
  • Dominant personalities may have undue influence
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44
Q

What is the epidemiological health needs assessment approach?

A
  1. Define problem
  2. Size of problem - incidence / prevalence
  3. Services available - prevention / treatment / care
  4. Evidence base - effectiveness and cost-effectiveness
  5. Models of care - including quality and outcome measures
  6. Existing services - unmet need; services not needed
  7. Recommendations
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45
Q

What is the egalitarian principle?

A

Equal access to provide all care that is necessary and approrpaite to everyone
o Limitations = Finite resources

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46
Q

What is the maximising principle?

A

Criteria that maximises public utility

o Limitations = Who should decide this?

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47
Q

What is the Libertarian approach?

A

Each person is responsible for their own health, welling being & fulfillment of life plan

o Eg: The German health incentive – Bonuses given for participation in screening / health promotion and check-ups
o Limitation = Socio-economic inequality & divide

48
Q

What is the rule of rescue (Johnsen) definition?

A

An ethical imperative to save individual lives even when the money might be more efficiency spent to prevent deaths in the larger population

Human proclivity to rescue a single identified endangered life regardless of cost, at the expense of any nameless face who will therefore be denied healthcare

49
Q

What is health psychology?

A

Health psychology emphasises the role of
psychological factors in the cause, progression
and consequences of health and illness

50
Q

What are health behaviours?

A
  1. Health behaviour - Behaviour to prevent disease - eating healthy
  2. illness behaviour - Behaviour to seek remedy - going to the doctor
  3. Sick role behaviour - Activity aimed at getting well - taking prescribed medications; resting
51
Q

Why might knowledge of risk factors not

influence a patients behaviour?

A

o Unrealistic optimism = Due to inaccurate perceptions of risk & susceptibility
Perceptions of risk influenced by:
1. Lack of personal experience with problem
2. Belief that preventable by personal action
3. Belief that if not happened by now, its not likely to
4. Belief that problem infrequent

o Health beliefs
o Socioeconomic factors
o Stress
o Age

52
Q

What are some of the models for behaviour change?

A
  1. Health belief model (HBM)
  2. Theory of Planned Behaviour (TPB)
  3. Stages of change /transtheoretical model (TTM)
  4. Social norms theory
  5. Motivational interviewing
  6. Social marketing
  7. Nudging (choice architecture)
  8. Financial incentives
53
Q

What is the health belief model for behaviour change?

A

• Believe they are susceptible to the condition in
question (e.g. heart disease)

  • Believe that it has serious consequences
  • Believe that taking action reduces susceptibility

• Believe that the benefits of taking action outweigh
the costs

54
Q

What does the likehood of action depend on in health belief model?

A

o Health motivation

o Cues to action - simple advice from a GP can make a patient stop smoking for up to 12 months

55
Q

What are the limitations of the health behaviour model?

A

o Other factors may predict healthy behaviour (Eg: Outcome expectancy & Self-efficacy)
o Does NOT consider influences of emotions on behaviour
o Does NOT differentiate btwn 1st time & repeat behaviour
o Cues to actions often missing in health belief model research

56
Q

What should you not do in domestic abuse cases?

A

Do not ask about domestic abuse in front of family members
Do not tell them what to do - empower them
Do not assume someone will take care of things

57
Q

What is the best predictor of behaviour in theory of planned behaviour? And how is it determined?

A

Intention - – I intend to give up smoking

o A person’s attitude to the behaviour - I do not think smoking is a good thing

o The perceived social pressure to undertake the behaviour (Subjective norms) - most people who are important to me want me to give up smoking

o A person’s appraisal of their ability to perform the behaviour (Perceived behavioural control) - I believe I have the ability to give up smoking

58
Q

How can you assist people with acting on their intentions according to the theory of planned behaviour?

A

o Perceived control = Think about last successful attempt
o Anticipated regret = Think about consequences of behaviour
o Preparatory actions = Dividing a task into small goals
o Implementation of intentions = Translate intention into action
o Relevance to self = Relate to oneself

59
Q

What are the limitations of theory of planned behaviour?

A

o Relies on self-reported behaviour

o Assume attitudes, subjective norms & perceived behavioural control can be measured

o It does NOT explain how attitudes, intentions & perceived behavioural control interact

o Lack of causality

o Does NOT take into account emotions (Eg: Fear, Threat, Positive effect)

o Does NOT take habits & routines into account

o Intention behaviour gap (Only 50% translate into behaviour)

60
Q

What are the steps in the trans-theoritical model?

A

1) Precontemplation
2) Contemplation
3) Preparation
4) Action (6 mths)
5) Maintenance
6) (Relapse)

61
Q

What are the advantages and limitations of the theoretical model?

A

Advantages:
o Acknowledges individual stages of readiness
o Accounts for relapse
o Temporal element

Limitations:
o Not all people move thru every stage systematically
o Changes might operate in continuum rather than discrete stages
o Does NOT take into account values, habits, culture & economic factors

62
Q

What is motivation interviewing?

A

o Counselling approach for initiating behaviour

o Limitation: Clinical impact shown in problem drinkers only (Not for smoking / HIV)

63
Q

What is nudge theory?

A

o Change the environment to make changing the best option ( such as optout schemes schemes in pensions, placing fruits next to checkout)
o Limitation: Little evidence that it works

64
Q

What is social norms theory?

A

o People are peer-orientated & likely to engage in behaviours that is most common
Limitations - Some norms are undesirable

65
Q

Typical transition points in life when interventions would be more effective?

A
  • Leaving school
  • Entering workforce
  • Becoming a parent
  • Becoming unemployed
  • Retirement & bereavement
66
Q

What is the most common eye condition in the UK?

A

Age-related macular degeneration

Treatment:

  • No cure
  • Can be slowed / halted in some cases with medical Rx
67
Q

Give 4 examples of common eye conditions that lead to blindness

A

o Diabetic retinopathy - Most common cause of blindness in adults >65yo

o Age-related macular degeneration
o Retinitis Pigmentosa - initially night and peripheral vision --> reading and colour vision
o Glaucoma
o Hemianopia
o Cataracts
68
Q

Describe pattern of vision loss for age-related macular degeneration

A

Blurred/Distorted or dim vision

Loss of central vision

69
Q

According to the health belief model, what is the most important factor for addressing behaviour change in patients?

A

Perceived barriers

70
Q

How often do you need to have eyes checked?

A

o At least every 2 yrs

o Every year if a condition is dx or if elderly

71
Q

What is the planning cycle in assessing things?

A

Needs assessment –> planning –> implementation –> evaluation –> needs assessment

72
Q

What are the approaches of health service evaluation?

A

o Qualitative = Consult stakeholders (Observation, Interviews, Focus groups, Review of documents)

o Quantitative = Routinely collected data, Review of records / surveys / other special studies

73
Q

What is the donebedian framework of health service evaluation?

A
  1. Structure - Building, staff and equipment
  2. Process - what is done + Output - combined with process usually
  3. Outcome - different from output; focused on long term impact such as mortality, morbidity, QoL and patient satisfaction

Mnemonic: SPO

74
Q

Give an example of donebedian framework of health service at work

A

SPO

Structure - Number of surgeons per 1000 population

process - Number of surgeries in a day

Outcome - Mortality and Morbidity

75
Q

What are the 2 ways of classfiying outcome in the donebedian framework of health service evaluation?

A

1) Mortality e.g. 30 day mortality rate
2) Morbidity e.g. complication rates
3) Quality of life / PROMs (patient reported outcome measures)
4) Patient satisfaction

1) Death
2) Disease
3) Disability
4) Discomfort
5) Dissatisfaction

76
Q

What are the issues with the health outcomes?

A

1) Link (cause and effect) between health service provided and health outcome may be difficult to establish i.e due to confounding
2) Time lag between service provided and outcome may be long
3) Need large sample sizes to detect statistical differences
4) Data may not be available
5) There may be issues with data quality
–> consider CART – Completeness, Accuracy,
Relevance, Timeliness

77
Q

While assessing quality of healthcare, Maxwell’s dimensions of quality are useful. What are they?

A

AAAEEE

  • Acceptability - How acceptable is the service offered to the people needing it?
  • Accessibility - Is the service provided? Geographical access; Costs for patients; Information available; Waiting times
  • Appropriateness - Is the right treatment being given to the right people at the right time? [Overuse? Underuse? Misuse?]
  • Effectiveness - Does the intervention / service produce the desired effect?
  • Equity- Are patients being treated fairly?
  • Efficiency - Is the output maximised for a given input
78
Q

What is malnutrition and what are its two forms?

A

Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients.

Undernutrition - wasting, underweight, micronutrient deficiencies
Overweight - obesity, diet-related non communicable diseases i.e heart disease, stroke

79
Q

Some early influences on eating behaviour/ taste

preference development?

A

Maternal diet and taste preference development –> amniotic fluid influenced by maternal diet

Role of breastfeeding

Parenting practices

Other practices: age of introduction of solid food, types of food exposed to during weaning period and beyond

80
Q

why dieting for weight loss is a challenge for patients

A

i. Risk factor for the development of eating disorders in some individuals
ii. Dieting results in a loss of lean body mass, not just fat mass
iii. Dieting slows metabolic rate and energy expenditure
iv. Chronic dieting may disrupt ‘normal’ appetite responses and increase subjective sensations of hunger

81
Q

Advatanges of breast feeding?

A

➢ Acceptance of novel foods during weaning (Mennella 2015)
➢Evidence to suggest that children who were breastfed are less picky eaters in childhood
➢Have a diet richer in fruit and vegetables if BF > 3m

82
Q

What are some parental feeding practices?

A
  • Modeling “healthful” eating behaviours
  • Responsive feeding: Recognizing hunger and fullness cues
  • Providing a variety of foods
  • Avoiding pressure to eat
  • Restriction
  • Authoritative parenting/ Authoritarian parenting
  • Not using food as a reward
  • Indulgent/ neglectful feeding practices
83
Q

What is article 14?

A

Enjoyment of the rights and freedoms set forth in this Convention shall be secured without discrimination on any ground such as sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status

84
Q

What is article 2?

A

Right to life (Denied treatment)

85
Q

What is article 3?

A

Right to be free from inhumane and degrading treatment (MCA)

86
Q

What is article 5?

A

Right to liberty (DOLS)

87
Q

What is article 8?

A

Right to respect privacy and family life (Eg: Confidentiality)

88
Q

What is article 12?

A

Right to marry and found a family (Eg: IVF)

89
Q

What are the list of notifiable diseases to be informed to CDC?

A 
o	Acute meningitis
o	Acute poliomyelitis
o	Malaria
o	Measles
o	Mumps 
o	Rubella 
o	Scarlet fever
o	TB
o	Whopping cough
90
Q

How to assess a persons mental capacity?

A

o Are they able to understand the information given to them?
o Are they able to retain that information long enough to make a decision?
o Are they able to reason and weigh up the information available to make a decision?
o Are they able to communicate their decision?

91
Q

What are the principles of best interest?

A

o Assume a person has the capacity to make a decision themselves unless proved otherwise

o Wherever possible, help people to make their own decision

o Don’t treat a person as lacking the capacity to make a decision just because they make an unwise decision

o If you make a decision for someone who doesn’t have capacity; must be in their best interests

o Treatment & care provided to someone who lacks capacity should be the least restrictive of their basic rights and freedoms

COP3 - form to formally assess and report someone’s capacity

92
Q

What is the 2 stage test of capacity?

A

1) Does the person have an impairment of their mind / brain, whether as a result of an illness / external factors such as alcohol or drug use?
2) Does the impairment mean the person is unable to make a specific decision when they need to?

93
Q

What should the best interest take into account?

A

o Past & present wishes and feelings
o Beliefs and values that may have influenced the decision being made, had the person had capacity
o Other factors that the patient would be likely to consider if they had capacity
o Encouraging the person lacking capacity to take part in the discussion

94
Q

How long does DoLs last?

A

12 mths but renewable

95
Q

What happens while a DoLs is in place?

A

To ensure:
o Arrangements are in the patient’s best interest
o The person has appointed someone to represent them
o The person has given legal right of appeal over the arrangements
o The arrangements are reviewed & continue for no longer than necessary

96
Q

When does deprivation of liberty occur?

A

o A person is under continuous supervision & control
o Is NOT free to leave
o The person lacks capacity to consent to these arrangements

97
Q

What are the assessments to perform for DoLs?

A 
o Age assessment 
o No refusals assessment 
o Mental capacity assessment 
o Mental health assessment 
o Eligibility assessment 
o Best interests’ assessment
98
Q

What are the risks when the needs of the elderly are not met?

A 
o	Isolation 
o	Loneliness 
o	Purposelessness
o	Depression 
o	Despair
o	Self-neglect
o	Self-harm
o	Earlier mortality
99
Q

What’s the definition of social exclusion?

A

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

100
Q

What is social theory?

A

Disengagement = Ageing is an inevitable, mutual withdrawal of disengagement

101
Q

What are the 5 domains of social exclusion?

A 
o	Material resources 
o	Basic services 
o	Civic activities
o	Neighbourhood 
o	Social relationships
102
Q

Initiatives for combating loneliness in older people?

A

Age UK
Silverline
Dementia Friends

103
Q

What are the consequences of loneliness?

A
  • Earlier death
  • Increased risk taking
  • Physical changes which can bring on poor health
  • Health risk - smoking more i.e 15 cigarettes a day
104
Q

What are the 3 core principles of the NHS?

A
  • Meets the needs of everyone
  • Based on clinical need, not on ability to pay
  • Free
105
Q

What are health inequalities?

A

Preventable, unfair and unjust differences in health status between groups, populations or individuals that arise from the unequal distribution of social, environmental and economic conditions.

106
Q

What is the inverse care law?

A

The inverse care law is the principle that the availability of good medical or social care tends to vary inversely with the need of the population served.

107
Q

Who are the vulnerable groups in the NHS?

A 
Homeless
Gypsies and Travellers
Asylum Seekers
LGBTQ
Those with learning disabilities
Those with mental health problems
Ex prisoners and care leavers
108
Q

Common causes of homelessness

A 
o	Eviction (Since 2017)
o	Relationship breakdown
o	Domestic abuse
o	Mental illness / Breakdown
o	Berevement
109
Q

What are the barriers to healthcare faced by the homeless?

A

o Prioritizing other immediate survival issues over health
o May not know where to find help
o Poor reading / writing skills
o Communication difficulties
o Mistrust of professionals
o Difficulties accessing healthcare (Eg: Discrimination, Physical difficulties)
o Lack of integration btwn primary care & other agencies (Eg: Housing, Social services, Voluntary sector, Criminal system)

110
Q

What is the definition of a refugee?

A

Someone who is forced to flee his/her country due to persecution, war, violence and has a well founded fearof persecution due to race, religion, nationality, political opinion, membership in a particular group

111
Q

What is the definition of an asylum seeker?

A

o Some who has left their country of origin and formally applied for asylum in another country but whose application has not yet been approved
o They have applied to be a refugee in UK

112
Q

What benefits do asylum seekers get?

A

o Entitled to £35/wk (Not entitled if failed asylum seeker)
o Entitled to housing (Not entitled if failed asylum seeker)
o Entitled to NHS care (Not entitled if failed asylum seeker)
o Social services key worker & school if <18 yo
o NOT allowed to work
o NOT entitled to any other form of benefit

113
Q

What are the barriers to health for asylum seekers?

A 
o Lack of knowledge of where to get help
o Lack of understanding how NHS work 
o Communication difficulties
o Hyper-mobility 
o Health is NOT the priority 
o Not homogenous group
114
Q

What are the health problems dealt with by asylum seekers?

A

o Injuries from war & travelling
o Malnutrition
o Illness specific to country of origin
o No previous health surveillance / neonatal screening / immunization
o Torture & sexual abuse
o Communicable disease / Blood born disease
o Untreated chronic disease / congenital problems
o Mental health problems

115
Q

Whats the difference between ecological and cross sectional study?

A

Ecological studies compare smokers and smokers within a ward. Whereas the

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