Public health Flashcards
Name some health determinants
Genetics
Environment - physical, social, economic
Lifestyle
Healthcare
What are the key concerns of public health?
Wider determinants of health ie not related to healthcare
Prevention
Inequalities in health
Name a type of primary prevention
Vaccination
What is primary prevention?
Stopping a disease becoming an issue
Name a secondary prevention
Screening/preventing recurrence
What secondary prevention?
Catching and treating disease early
Name a tertiary prevention
Preventing complications of disease/preventing disease worsening/rehabilitation following stroke
What is equity?
What is fair and just
What is equality?
Equal shares
What is horizontal equity?
Equal treatment for equal need
Give an example of horizontal equity
Patients with pneumonia (with all other things being equal) should be treated equally
What is vertical equity?
Unequal treatment for unequal need
Give an example of vertical equity
Patients with common cold vs pneumonia need unequal treatment
Areas with poorer health may need higher expenditure on health services
Name 3 different forms of health equity
Equal expenditure of equal need
Equal access for equal need
Equal utilisation for equal need
Equal healthcare outcomes for equal need
Equal health
What are the two dimensions of health care equity?
Spatial ie geographical
Social
Name 2 social determinants of health equity
Age
Gender
Socioeconomic class
Ethnicity
How do you examine health equity?
Supply of healthcare
Access to healthcare
Utilisation of healthcare
Healthcare outcomes
Health status
Resource allocations - health services and other services (education, housing)
Wider determinants of health - diet, smoking, healthcare seeking behaviour, socioeconomic, physical environment
How do you assess health equity?
Assess inequality then judge if inequitable
Inequalities need to be explained
But equality may not be equitable
How is healthcare system equity assessed?
Equity often defined in terms of equal access for equal need
Measurement of utilisation, health status, or supply
What are the 3 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
Education
Housing
Employment
Lifestyles
Family/community
What is health protection?
Concerned with measures to control infectious disease risks and environmental hazards
Infectious diseases
Chemicals and poisons
Radiation
Emergency response
Environmental health hazards
What is health care?
Concerned with organisation and delivery of safe, high quality services for prevention, treatment, and care
Clinical effectiveness
Efficiency
Service planning
Audit and evaluation
Clinical governance
What are the 3 levels of public health interventions?
Individual
Community
Ecological (population)
Give an example of an individual level public health intervention
Childhood immunisation
Give an example of a community level public health intervention
Playground set up for local community
Give an example of an ecological level of public health intervention
Clean air act - legislation to ban smoking in enclosed public spaces
What is health psychology?
Emphasises the role of psychological factors in the cause, progression, and consequences of health and illness
Aims to put theory into practice by promoting healthy behaviours and preventing illness
What is health behaviour?
Behaviour aimed at preventing disease eg eating healthily
What is illness behaviour?
Behaviour aimed to seek remedy eg going to the doctor
What is sick role behaviour?
Any activity aimed at getting well eg taking prescribed medications, resting
Give 3 examples of health damaging/impairing behaviours
Smoking
Alcohol and substance abuse
Risky sexual behaviour
Sun exposure
Driving without a seat belt
Give 3 examples of health promoting behaviours
Exercise
Healthy eating
Attending health checks
Medication compliance
Vaccination
What is the level of adherence amongst patients suffering from chronic diseases in developed countries?
50%
Name 2 factors that could affect adherence
Polypharmacy - forgetting, getting confused
Lack of understanding why to take medication
Poor medication usage technique
Not able to afford prescriptions
What is the link between lifestyle and mortality?
Poor lifestyle negatively impacts mortality
Poorer lifestyle is, worse mortality eg more health damaging behaviours participated in = worse mortality
What can morbidity affect?
QOL
Working days lost to sickness
Compliance
Name an example of a population level intervention
Health promotion - enabling people to exert control over determinants of health, thereby improving healt
Name 2 health promotion campaigns
Healthier you diabetes prevention
Change 4 life campaign
Every mind matters
Name an example of an individual level intervention
Patient centred approach
Care responsive to individuals needs
What is important to remember about interventions?
Rarely restricted to one level
What is unrealistic optimism?
Individuals continue to practice health damaging behaviour due to inaccurate perceptions of risk and susceptibility
What are perceptions of risk influenced by?
Lack of personal experience with problems
Belief that preventable by personal action
Belief that is not happened by now, not likely to
Belief that problem infrequent
Health beliefs
Situational rationality
Culture variability
Socioeconomic factors
Stress
Age
What is important to remember about risk taking behaviours?
Risk perception and risk taking behaviours embedded in social contexts
Promoting behaviour change only likely once have understood perception of risk
How can you help individuals to change health behaviours?
Work with patients priorities
Aim for easy changes over time
Set and record goals
Plan explicit coping strategies
Review progress regularly
Remember public health impact of lots of small differences to individuals
Why is behaviour change important?
Can have impact on some of largest causes of mortality and morbidity
What is tobacco dependence?
Chronic, relapsing clinical condition that prematurely kills at least half of people who smoke, seen as a medical condition that can be treated rather than lifestyle choice
What is the impact of smoking of health?
One of the greatest causes of illness and premature death
77,900 deaths attributable to smoking
Smoking related deaths mainly due to cancer, COPD, and heart disease
Describe the epidemiology of tobacco smoking
Men > women
14.9% adults in England current smokers
Black, Asian, Chinese less likely to be smokers than Mixed, White, or other
Highest in younger age groups
Poverty and tobacco use linked
Costs NHS 2.6bn
What is a population approach preventative measure?
Delivered on a population wide basis and seeks to shift the risk factor distribution curve
Doesn’t have to be the entire population, could just be the relevant subgroup eg infants
What is a high risk approach preventative measure?
Identify individuals above a chose cut-off and treat them
What is the prevention paradox?
Preventative measure that brings much benefit to the population often offers little benefit to each participating individual
What is domestic abuse?
Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or who have been intimate partners or family members regardless of gender or sexuality
Name 3 types of abuse
Psychological
Physical
Sexual
Financial
Emotional
How common is domestic abuse?
20-30% injuries that send women to A&E departments are caused by physical abuse from partners
Majority present with assault injuries (55%), trauma (8%), or abdominal complaints (7%)
What are the most common injuries in domestic abuse?
Bruising
Fractures
Cuts
Usually to head or chest
What indicators suggest domestic abuse?
Unwitnessed by anyone else
Repeat attendance
Delay in seeking help
Multiple minor injuries not requiring treatment
What should you ask about with domestic abuse?
Children - safeguarding
How can domestic abuse affect children?
Physical and psychological health and well-being
Self-esteem
Education
Relationships
Stress responses
Clear link between child abuse and domestic abuse - often starting/escalating during pregnancy
What questions should you discuss with the victim in domestic abuse?
Pregnancy/new baby
Children/step children
Isolated
Own fears/perceptions
Depressed/suicidal
Child contact conflict
Separation
Stalking
Death threats
Sexual abuse
Escalation - frequency/severity
Financial issues
Strangling/choking/drowning
What should you consider when asking about the perpetrator in domestic abuse?
Violence towards others criminal history
Drugs/alcohol/mental health
Animal abuse
Weapon
Accomplices
Controlling/jealous
Perpetrator suicidal
What can you do for someone experiencing domestic abuse?
Standard/medium risk - give contact details for DA services, keep good records, ensure FU as required
High risk - refer to MARAC/IDVAS in addition to services, wherever possible with consent, can be done via helplines, can break confidentiality
What is important to do when taking a DA history?
Focus on patient safety and children
Ask direct questions, be non-judgemental and reassuring
Acknowledge and be clear behaviour not ok
What should you not do when taking a DA history?
Assume someone else will take care of things
Ask about DA in front of family members or use informal interpreters
Tell people what to do - they are experts in their own situations
What are the HARK questions?
4 questions developed as a framework for helping to identify people who have suffered domestic abuse
What is the H of the HARK questionnaire?
Humiliation
- In the last year have you been humiliated or emotionally abused in other ways by your partner?
- Does your partner make you feel bad about yourself?
- Do you feel you can do nothing right?
What is the A of the HARK questionnaire?
Afraid
- In the last year have you been afraid of your partner of ex-partner?
- What do they do that scares you?
What is the R of the HARK questionnaire?
Rape
- In the last year have you been raped by your partner or forced to have any kind of sexual activity?
- Do you ever feel that you have to have sex when you don’t want to?
- Are you ever forced to do anything you are not comfortable with?
What is the K of the HARK questionnaire?
In the last year have you been physically hurt by your partner?
Does your partner threaten to hurt you?
What do we need to know to change patient behaviour?
An overview of the theories and models of behaviour change
An understanding of what works in practice
Name 4 models/theories of behaviour change
Health belief model
Theory of planned behaviour
Stages of change/transtheoretical model
Social norms theory
Motivational interviewing
Social marketing
Nudging
Financial incentives
What is the health belief model
Individuals will change if they
- Believe they are susceptible to the condition in question
- Believe that it has serious consequences
- Believe that taking action reduced susceptibility
- Believe that the benefits of taking action outweigh the costs
What is the theory of planned behaviour?
Proposes the best predictor of behaviour is intention
Intention determined by
- Attitude to behaviour
- Perceived social pressure to undertake behaviour or subjective norm
- Persons appraisal of ability to perform behaviour, or perceived behavioural control
What can help to bridge the intention behaviour gap?
Perceived control
Anticipated regret
Preparatory action - dividing task into sub-goals
Implementation intentions
Relevance to self
What is the stages of change/transtheoretical model?
Precontemplation -> contemplation -> preparation -> action -> maintenance
What is motivational interviewing?
Counselling approach for initiating behaviour change by resolving ambivalence
What is nudging?
Nudge the environment to make the best option the easiest
What is the cues to action section of the health belief model?
Internal/external cues
Not always necessary for behaviour change
What are the critiques of the health belief model?
Alternative factors may predict health behaviour outcome expectancy, self-efficacy
Doesn’t consider influence of emotions on behaviour
Doesn’t differentiate between first time and repeat behaviour
Cues to action often missing in research
What are the critiques of the theory of planned behaviour model?
Rational choice model - doesn’t take into account emotions such as fear, threat, positive affect
Doesn’t explain how attitudes, intentions, and perceived behavioural control interact
Assumes attitudes, subjective norms, and PBC can be measured
Relies on self-reported behaviour
What are the advantages of the stages of change model?
Acknowledges individual stages of readiness
Accounts for relapse
Temporal element
What are the critiques of the stages of change model?
Not all people move through every stage
Change might operate on continuum rather than discrete changes
Doesn’t take into account values, habits, emotions, culture, social, and economic factors
Often change behaviour in absence of planning/intentions can change over short period
What other factors should you consider when changing health behaviour?
Growing interest in development of interventions to change health behaviour, mixed pattern of results reported
Single unifying theory yet to be developed
Impact of personality traits on behaviour
Assessment of risk perception
Impact of past behaviour/habit
Automatic influences on health behaviour
Predictors of maintenance of health behaviour
Social environment
What is the NICE guidance for interventions in health?
Interventions to change health related behaviour should work in partnership with individuals, communities, organisations, and populations
Population-level interventions may affect individuals and community and family-level interventions may affect whole populations
What are the typical transition points?
Leaving school
Entering the workforce
Becoming parents
Becoming unemployed
Retirement and bereavement
What is malnutrition?
Deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients
What is undernutrition?
Low height for age, micronutrient deficiencies, or insufficiencies
What is overweight?
Obesity, diet-related non-communicable diseases
Name 5 medical conditions that require nutritional support
Cancer
CF
Coeliac
IBD
T1DM, T2DM
Failure to thrive
Eating disorders
Overweight/obesity
Management of sarcopenic obesity in elderly patients
What are the early influences on taste preferences?
Maternal diet - taste and olfactory systems capable of detecting flavour information prior to birth, foetuses swallow a lot of amniotic fluid during gestation
Parenting practices
Age of introduction of solid foods
Types of food exposed to during weaning
How does the in utero experience affect feeding behaviour?
Amniotic fluid influenced by maternal diet
Influences taste exposure
Potential role of maternal diet on taste preference development
What are the benefits of breast feeding?
Efficient digestion
Gut protection
Anti-infective
Everyday health - antibodies, lactoferrin (dental hygiene), viral fragments
How does breastfeeding influence feeding behaviour?
Composition/taste varies between woman, across the day - constitutes repeated exposure to different tastes
Acceptance of novel foods during weaning
Less picky eaters in childhood
Diet richer in fruit and veg if BF > 3m
How can early taste exposure affect later preferences?
Greater preferences for flavours to which they have been exposed through amniotic fluid, breast milk, or formula
Effect shown to last until at least 10 years
How can parents affect feeding behaviour?
Tactics such as coercion, persuasion, and contingencies as a means of encouraging children to consume new foods - often has opposite affect - increases liking for reward and reduces liking for novel food
Modelling health eating behaviour
Responsive feeding - recognising hunger and fullness cues
Providing variety of foods
Avoiding pressure to eat
Restriction
Authoritative parenting
Not using food as a reward
Indulgent/neglectful feeding practices
What is a NOFED?
Non-organic Feeding Disorder
High prevalence in children younger than 6
Characterised by feeding aversion, food refusal, food selectivity, fussy eaters, failure to advance to age-appropriate foods, negative mealtime interactions
Parents often use maladaptive feeding practices
What are the 4 different types of eating disorders?
Anorexia Nervosa
Bulimia Nervosa
Binge eating disorder
OSFED - other specified feeding or eating disorder
Complex - patients rarely fit into one single diagnostic category
What are the NHS 3 core principles?
Meets needs for everyone
Free at the point of delivery
Based on clinical need, not ability to pay
What are health inequalities?
Preventable, unfair, and unjust differences in health status between groups, populations, or individuals
Arise from unequal distribution of social, environmental, and economic conditions within societies
Determine the risk of people getting ill, their ability to prevent sickness, or opportunities to take action and access treatment when ill health occurs
What is the inverse care law?
Principle that the availability of good medical or social care tends to vary inversely with the need of the population served
Name 3 health inequities in England
More deprived the area, the shorter life expectancy, social gradient has become steeper
Marked regional differences in life expectancy, particularly among people living in more deprived areas
Mortality rates are increasing for men and women aged 45-49 - perhaps suicide, drugs, alcohol abuse
Child poverty has increased - children’s and youth centres have closed, funding for education down
Housing crisis, rise in homelessness, insufficient money to lead a healthy life, more ignored communities with poor conditions and little reason for hope
What are the 10 vulnerable groups?
Homeless
Gypsies and travellers
Asylum seekers
LGBTQ
Ex-prisoners
Care leavers
Learning disabilities
Mental health problems
Physical disabilities
Elderly/care home residents
Why might people have difficulty in accessing care?
No specific address
Moving around a lot
Physical disability
Not being able to read/write
Language barrier
What is the order of Maslow’s hierarchy of needs?
Physiological - breathing, food, water, sex, sleep, homeostasis, excretion
Safety - security of body, employment, resources, morality, family, health, property
Love/belonging - friendship, family, sexual intimacy
Esteem - self-esteem, confidence, achievement, respect
Self-actualisation - morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
What is homelessness?
State of having no home - hostels, squatting, not necessarily on the street
How many people are homeless in England?
320,000 homeless in England
What individual circumstances cause people to become homeless?
Poor physical health
Drug and alcohol issues
Mental health problems
Bereavement
Care leavers
Prisoners
What wider forces contribute to homelessness?
Poverty
Inequality
Housing supply and affordability
Unemployment
Welfare
Income policies
What health issues might homeless people experience?
Mental health - schizophrenia, depression, personality disorders
Alcohol abuse
Drug use
Injuries following violence and rape
STI
78% physical health conditions
Infection - TB, hepatitis, HIV
Poor condition of feet/teeth
Poor nutrition
DVT/PE
Name 3 common causes of death amongst homeless people
Drug poisoning
Alcohol
Suicide
Injury and violence
Transportation related illness
Homicide
Infection - influenza and pneumonia
Cancer
Coronary heart disease
Liver disease
What is the average age of death of homeless people?
45.9 men
41.6 women
What are the barriers to access of care for homeless people?
Difficulty registering with GP
Appointment procedures
Perceived or actual discrimination
Lack of integration with other agencies - housing, social services, criminal justice system, voluntary sector
Don’t prioritise health when more immediate survival issues
What is the physical health of travellers like compared to general population?
Poorer than general population
Life expectancy 10 years less for men, 12 years less for women
42% long term condition
1/5 experience loss of child (1/100 non-traveller)
3x increase suicide
3x anxiety
2x depression
What are the barriers to accessing healthcare for travellers?
Registering and accessing GPs
- Discrimination
- Navigating NHS
- No permanent address
- Frequent movement/transient sites
- Communication difficulties
- Mistrust
Cultural - not wanting to seek medical attention, self-reliance, women see only women, men see only men, fatalistic attitude, more trust in family carers, men often unwilling to seek help, mental health not spoken about
Nomadic
Poor education achievement
Lowest income rate of any ethnic group
What is an asylum seeker?
Person who has made an application for refugee status
What is a refugee?
Person granted asylum and refugee status usually means leave to remain for 5 years then reapply
What does indefinite leave to remain mean?
When a person is granted full refugee status and given permanent residence in the UK
What is an unaccompanied asylum seeking child?
Someone who has crossed international border in search of safety and refugee status, under the age or 18 or appears to be, without adult family members or guardians
Name 5 countries of origin for asylum seekers
Iran
Iraq
Pakistan
Sudan
Bangladesh
What can asylum seekers claim?
Money - just under £40
Housing
Free NHS care
Under 18 - social services key worker, schooling
English lessions
What can asylum seekers not claim?
Not allowed to work
Not entitled to any other form of benefit
What are refugees entitled to?
5 years to remain
Right to work and claim benefits
Access to mainstream housing
Apply for family reunion
Apply for travel document
Apply for ILR after 5 years
How can the physical health of asylum seekers be affected?
Common illness
Injuries from war and travelling
Torture and sexual abuse
Illness specific to country of origin
Infectious diseases
Malnutrition
Untreated chronic disease
No previous health surveillance/immunisations
What impact on mental health can asylum seekers have?
PTSD
Depression
Sleep disturbance
Psychosis
Self-harm
What impact of social situation can asylum seekers have?
Separation from family
Hostility
Racism
Poverty
Poor housing
Unemployment
Detention
What previous experiences might asylum seekers have gone through?
Massacres/torture
Sexual assault/rape
Witnessing torture of others
Disappearance of family
Forced conscription
Political repression/detention
Being held under siege or being taken hostage
What barriers to healthcare might asylum seekers have?
Lack of knowledge of where to get help
Lack of understanding on how NHS works
Language barriers
Culture differences
Perception of discrimination relating to race, religion, and immigration status
Difficulty meeting costs
Transport to appointments
Dispersal by home office
Not homogenous group
What is human trafficking?
Movement of people with the aim of exploiting them
Modern day slavery
Distinct from migrant smuggling, unaccompanied child asylum seekers, child sexual exploitation
Name 4 types of abuse victims of human traffickers may experience
Sexual
Organ harvesting
Forced labour
Domestic servitude
Forced criminality
How does human trafficking occur?
Spiritual manipulation
Poverty
Lack of education
Debt bondage
Vulnerability
Lied to
Violence
Threats
Sold into slavery
How does trafficking impact health?
Abuse
Skin issues
Infections
Injuries
Pregnancy
Malnutrition
Dental ill health
How can trafficking affect access to care?
Often have no access
Illness can reduce ability to work
Accompanied by trafficker?
Lacking official documents
No fixed address
Language barriers
Unaware of entitlement to care
What are the red flags of human trafficking?
TRAFICKED
-Timid/terrified/tense
-Registered with GP/nursery/school
-Accompanied by controlling person
-Foreign language
-Inconsistent history
-Control of passport/bank account
-Keep alert
-Evidence of injuries left untreated
-DNA future appointments
What do we use a health needs assessment for?
Improving the health of a population or population subgroup
Treating individual patients
Influencing the service available to patients
What is the difference between need demand and supply?
Need - ability to benefit from an intervention
Demand - what people ask for
Supply - what is provided
What is a health needs assessment?
Systematic method of reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities
What is the difference between health need and health care need?
Health need - need for health, concerns need in more general terms, measured using mortality, morbidity, socio-demographic measures
Health care need - need for health care, much more specific, ability to benefit from health care, depends on the potential prevention, treatment, and care
In practice health needs assessment covers both
What might a health needs assessment be carried out for?
Population or sub-group eg practice population
Condition
Intervention
What is the sociological perspective?
Felt need
Expressed need
Normative need
Comparative need
What is felt need?
Individual perceptions of variation from normal health
What is expressed need?
Individual seeks help to overcome variation in normal health (demand)
What is normative need?
Professional defined intervention appropriate for the expressed need
What is comparative need?
Comparison between severity, range of interventions and cost
What is the epidemiological approach of a health needs assessment?
Define issue
Size of issue - incidence/prevalence
Services available - prevention/treatment/care
Evidence base - effectiveness and cost-effectiveness
Models of care - quality and outcome measures
Existing services - unmet need, services not needed
Recommendations
What are the issues with the epidemiological approach to health needs assessment?
Required data may not be available
Variable data quality
Evidence base may be inadequate
Does not consider felt needs of people affected
What is the comparitive approach of a health needs assessment?
Compare the services received by a population with others - spatial, social (age, gender, class, ethnicity)
May examine - health status, service provision, service utilisation, health outcomes (mortality, morbidity, QOL, patient satisfaction)
What are the problems with the comparative approach of a health needs assessment?
May not yield what the most appropriate level eg provision of utilisation should be
Data may not be available
Data may be of variable quality
May be difficult to find a comparable population
What is the corporate approach of a health needs assessment?
Obtaining views of a range of stakeholders
Who might be involved in the corporate approach of a health needs assessment?
Commissioners
Providers
Professionals
Patients
Relatives and carers
Voluntary organisations
Opinion leaders
Politicians
Press
Pharmaceutical companies
What are the problems with the corporate approach of a health needs assessment?
May be difficult to distinguish need from demand
Groups may have vested interests
May be influenced by political agendas
Dominant personalities may have undue influence
What is anxiety?
Excessive anxiety and worry for more than 6 months and difficulty controlling these feelings of anxiety or worry
What can be differential diagnoses of anxiety?
Hyperthyroidism
Tachycardia
Temporal lobe epilepsy
Phaeochromocytoma
Hypoglycaemia
Cushing’s
Hypoparathyroidism
Caffeine and other drugs
What are the features of GAD?
Excessive anxiety and worry
Difficulty controlling the worry
Symptoms present for 6 months or more
Restlessness, on edge
Easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbances - difficulty falling asleep, staying asleep
What are the features of panic disorder?
Frequent and unexpected panic attacks
Sudden periods of intense fear, discomfort, sense of losing control even when there is no clear danger or trigger
What are the symptoms of a panic attack?
Pounding or racing heart
Hyperventilation
Sweating
Trembling/tingling
Chest pain
Feelings of impending doom
Feelings of being out of control
What is social anxiety disorder?
Overwhelming fear of humiliation
Social situations cause high stress
Fear, anxiety may trigger avoidance
What is a phobia?
Intense fear of or aversion to specific objects or situations
Fear out of proportion to actual situation
What conditions can be co-morbid with anxiety?
Depression
Other anxiety disorders
Physical health conditions
OCD
Alcohol usage
Avoidant personality disorder
PTSD
Eating disorders
ADHD
Autism
How can you treat anxiety?
Psychotherapy - CBT, acceptance or commitment therapy
Medication - antidepressants (SSRIs), benzos (short term), beta-blockers
Support groups
Stress management techniques
What lifestyle changes can be made for managing anxiety?
Limit sugar intake
Restrict caffeine
Avoid alcohol
Exercise
Quit smoking
Take medication as prescribed
What screening questionnaires can be used for anxiety and depression?
GAD-7
PHQ-9
HAD scale
What questionnaires can you use for alcohol usage?
AUDIT-C
CAGE
What are the 5 points of good medical practice?
Make the care of your patient your first concern
Competent and keep professional knowledge up to date
Take prompt action if you think patient safety is being compromised
Establish and maintain good partnerships with your patients and colleagues
Maintain trust in you and profession by being open, honest, and acting in integrity
What is the mnemonic for the MSE and what does it stand for?
ASEPTIC
A - appearance/behaviour
S - speech
E - emotion (mood and affect)
P - perception (visual/auditory hallucinations)
T - thought content (suicidal/homicidal ideation) and process
I - insight and judgement
C - cognition
