Public Health Flashcards
Name the 3 domains of public health (3)
- Health Improvement
- Health Protection
- Improving Services
What is the “Health Improvement” domain of PH? (+ 5 examples)
“Social interventions aimed at preventing disease, promoting health and reducing inequalities”
- Inequalities
- Education
- Housing
- Employment
- Lifestyles
Define the “Improving Services” domain of PH (+5 examples)
“Organisation and delivery of safe high quality services for prevent, treatment and care”
- Clinical effectiveness
- Efficacy
- Service Planning
- Audit Evaluation
- Clinical Governance
Define “Horizontal Equity” (1)
“Equal treatment for equal need”
To understand this think of taxation - Horizontal equity is saying people who have the same income (equal need) should pay the same taxes (equal treatment). Or that people with the same disease should receive the same treatment quality etc..
This is not mutually exclusive from vertical equity, both can occur together btw
Define “Vertical Equity” (1)
- “Unequal treatment of unequal need”
Basically, like with taxes, if you earn more (unequal need) you should pay more (unequal treatment) than someone who earns less. Note that horizontal equity should really co-exist here. Its not either-or, for example higher earners should pay more than lower earners (Vertical) but within each bracket of pay, identical incomes should pay identical taxes (horizontal)
Outline the Bradford Hill Criteria for Causation (6)
What’s the point? Basically these criteria increase the chance that the causality “seen” in data is actual causality:
1.Temporality - exposure is prior to outcome?
- Dose Response - Increased outcome with increased
exposure - Strength - Strong association between exposure and
outcome - Reversibility - removal/reduction of exposure
mirrored in outcome - Consistency - replicatable results by other studies
- Biological Plausibility - reasonable mechanism
proposed
(+ coherence - agrees with literature, analogy, specificity) - don’t bother here
A paediatric consultant is conducting research to investigate whether the diet of
children in their first year of life is associated with their subsequent risk of food allergy.
Parents of children aged 5-10 years with and without food allergies are asked to
complete a questionnaire about their child’s diet between the ages of 6 months and 1
year (i.e. a case-control study). What Bias may influence this approach? (1)
- Recall Bias - parents asked to remember events years ago
List 5 things associations in data can be due to (other than causality) (5)
- Bias
- Confounding Factors
- Chance
- Reverse Causality
- True Association
List the 3 types of Bias (3)
- Selection Bias
- Information Bias
- Publication Bias
obvs more exist but these are the PH ones needed
Define “Selection Bias” (1)
- A systemic error in the SELECTION of participants or the ALLOCATION of participants to certain study groups
Define “Information Bias” and list 3 causes (4)
- Systemic error in the measurement of classification of exposure or outcome data.
CAUSES:
2. Observer Bias - human error/observer incompetency
- Participant Bias - e.g. Memory or Recall Bias
- Instrument Bias - Poorly calibrated Instrument
Define “Publication Bias” (1)
- Trials with negative results and replication studies are less likely to be published
What is “Lead-Time Bias” (1)
- (Mainly relates to screening) Screening for a disease may pick it up way before it would normally clinically manifest. This extra time where the patient knows they have the Dx without yet having symptoms is known as LEAD TIME. Even though Early detection might not alter prognosis at all, the screening programme APPEARS to improve survival time simply because you knew about the Dx early.
What is “Length Bias” (1)
- (Mainly for screening) Basically, it refers to the fact that Chronic or Slow-progressing illness is more likely to be picked up by screening whereas short-course illness isn’t as the length of illness is so short it may have happened lots in the population but not been picked up at the single time point you investigate with screening - eg many cases have either died or recovered either side of screening. As Chronic disease lasts longer, more will be present at any one time point in the population, appearing to increase its prevalence when compared to an equally prevalent short-term illness.
Define Confounding (1)
- When an apparent association between two factors is actually the result of a separate factor affecting both variables
Is a Randomised Control Trial Prospective or Retrospective? (1)
- Prospective
Is a Cohort study Prospective or Retrospective? (1)
- Prospective
Is a Case-Control study Prospective or Retrospective? (1)
- Retrospective
Is a Cross-Sectional study Prospective or Retrospective? (1)
- Retrospective
Is a Case Series study Prospective or Retrospective? (1)
- Retrospective
Is a Case Report study Prospective or Retrospective? (1)
- Retrospective
Outline the Structure of a Cross Sectional Study (3)
- Retrospective OBSERVATIONAL study
- Collects data from a population at a SEPCIFIC time
- Produces data on PREVELANCE of RISK FACTORS and DISEASE
List 3 advantages of a Cross-Sectional Study Design (3)
- Large Sample Size possible
- Rapid
- Repeated Studies can show changes over time (eg by taking repeated “cross sections”)
List 3 disadvantages of Cross Sectional Studies (3)
- Risk of Reverse Causality (which came first??)
- Disease Length Bias - (won’t include rapid recoveries)
- Sample size too small for rarer outcomes / diseases
Outline the Structure of a Case-Control Study (2)
- Retrospective study looking back at a Cohort WITH a disease and a cohort WITHOUT/control population
- Looks for the CAUSE of a disease by trying to identify differences between the two cohorts
List 2 Advantages of a Case Control Study (2)
- Good for rare outcomes
- Rapid
List 2 Disadvantages of a Case Control study (2)
- Prone to Selection Bias and Information Bias
- Resource consuming to find well matched populations
Outline the Structure of a Cohort Study (2)
- Prospective longitudinal study looking at separate cohorts with different treatments or exposures applied
- Basically waiting to see what will happen, u basically follow two different cohorts up to see if a treatment of exposure changes anything but you haven’t literally given the intervention
List 3 Advantages of a Cohort Study (3)
- Can establish disease Risk Factors without risk of reverse causality (as disease hasn’t happened yet)
- Can follow rare exposures
- Data on confounders can be collected prospectively
List 3 Disadvantages of a Cohort Study design (3)
- Difficult to assess rare diseases as they may not develop
- Drop outs are common as it is prospective
- Large Sample Size required - expensive and time consuming
Outline Structure of an RCT (2)
- Prospective Interventional Study
- U randomly give populations an intervention and see what happens
List 3 Disadvantages of RCTs (3)
- Ethical issues - eg is it ethical to give a population treatment you don’t think will work? may cancel trial if one group see incredible improvements or side effects for example
- Drop Outs
- Expensive and time consuming + lots of regulation and hoops to jump through
Outline the structure of an Ecological Study
- Comparative, Population Based data (instead of individual)
It is comparative in two main ways:
2. Geography: Outcomes at GP practice A vs B
- Time trends: Covid cases/time
What type of study design was used? (1)
“Investigators found a high level of correlation between socioeconomic deprivation and IHD mortality across electoral wards in the UK”
- Ecological
Compares population level data across geographical regions
What type of study design was used? (1)
“Researchers set out to examine the association between alcohol consumption and stroke. They identify all new patients admitted with stroke and compare alcohol consumption with patients admitted for any elective surgery”
- Case-Control Study
Because they’re looking at patients ALREADY WITH disease and looking BACKWARDS to identify the risk factors for it. I originally though Cohort study, but that’s because i forgot this is retrospective. The Stroke has ALREADY HAPPENED. Cohort would be looking forward after alcohol consumption to see who then got a stroke later.
What type of study design was used? (1)
GPs set up a study to assess prevalence of Depression in their community. They start with a random sample of adults aged 40 - 65
- Cross-sectional
They’re assessing PREVALENCE at a SPECIFC POINT IN TIME
List the 4 types of Health Needs outlined in Bradshaw’s Needs (4)
- Felt needs
- Expressed Needs
- Normative Needs
- Comparative Needs
“FENC”
Define “Felt Needs” from Bradshaw’s Needs (1)
- Individual perceptions of variation from normal health
eg a perceived illness or upset by the patient
Define “Expressed Needs” from Bradshaw’s Needs (1)
- The seeking of help - Individual seeks help to overcome the variation in normal health
(the “Demand” bit from the “Need, Demand, Supply” triad)
Define “Normative Needs” from Bradshaw’s Needs (1)
- Professional Defines the Intervention appropriate for the expressed need
Define “Comparative Needs” from Bradshaw’s Needs (1)
- Comparison between severity, range of interventions and cost.
This is a need felt by the service provider not the patient. For example a patient needs treatment X, but there are other patients more severely ill needing treatment X and the service is oversubscribed and costly, therefore the patients needs are COMPARATIVELY no longer as severe in the system context
Outline the 4 (Minh) Bradshaw’s Needs (4)
- Two cheeky Tinnies - the amount considered by multiple RCTs on west street to be sufficient in meeting needs.
- An outrageously large lasagne pot - essential for the frequent expressed need of gorgeous group cooking
- A sexy surfboard - The Normative intervention suggested for maintenance of mental and physical health in you Minh’s throughout the population
- Any new bumper for a Ford Polo - COMPARITIVELY the most pressing need for all Minh’s worldwide ;) x
List the 4 stages of the “Planning Cycle” for Health Services in the Health Needs Assessment (4)
- Needs Assessment
- Planning
- Implementation
- Evaluation
Name the 3 types of approaches used to Health Needs Assessments (3)
- Epidemiological
- Comparative
- Corporate
Outline the “Epidemiological” approach to a Health Needs Assessment (4)
“Top Down Approach”
- Define Issue/Disease: e.g: Multiple Sclerosis
- Assess Size (Incidence/Prevalence): e.g: In Yorkshire
- Assess Services available and match against current evidence base for optimal cost effectiveness and quality of care: e.g: Access to physio - the compare to evidence on benefits and access
- Look at existing services compared to theoretical ideal quality from literature and suggest improvements
List 3 Problems with the “Epidemiological” approach to a Health Needs Assessment (3)
- Doesn’t consider FELT NEEDS of people its catering for
- Reinforces a purely biomedical approach
- Requires existing data to compare/define high quality by
Outline the “Comparative” approach to a Health Needs Assessment (1)
- Compare services received by one cohort with those received by another
eg compare MS Physio services in South and North Yorkshire
List 3 Problems with the “Comparative” approach to a Health Needs Assessment (3)
- Difficult to find comparable groups (due to confounders in different areas/age gorups)
- May be comparing 2 poor quality services
- Requires existing data to define high-quality
Outline the “Corporate” approach to a Health Needs Assessment (1)
- Takes into account views from patients, politicians, press, professionals, commissioners, stakeholders etc.
List 3 Problems with the “Corporate” approach to a Health Needs Assessment (2)
- May be difficult to distinguish Need from Demand
- Certain Groups may have vested interests and undue influences with money, investments, personalities that sway rooms etc..
Give the 2 main types of health needs assessment EVALUATIONS (2)
- Donabedian Approach
- Maxwell’s Dimensions
Outline the Donabedian approach to Health Needs Assessment Evaluation (3)
- Structure - What there is: eg buildings, staff, equipement
- Process - What is done: eg. the path the patient goes through from phoning reception to the surgery
- Outcome - Mortality, Morbidity, PROMS (Patient Reported Outcome Measures) , Satisfaction, the “5 Ds”
What are the “5 Ds” in outcome analysis (Donebedian Approach to HNA Evaluation) (5)
- Death
- Disease
- Disability
- Discomfort
- Dissatisfaction
Outline the “Maxwell’s Dimensions” approach to Health Needs Assessment EVALUSATION (6)
The “3Es + 3As”
- Effectiveness - Does it do what its meant to
- Efficiency - Is output maximum? minimal waste?
- Equality - Equal access?
- Acceptability - Operations at a good time of day?
- Accessibility - Can far away patients access it easily?
- Appropriateness - Given to Pts who actually need it?
What is the tool used to combine Maxwell’s Dimensions with the Donebedian Approach to HNA Evaluation? (1)
- Wright’s Matrix
basically a table with the 3Es and 3As down left side and Structure, Process and Outcome across the top
Define Incidence (1)
- The number of NEW CASES in a population during a set time frame
Unit: Cases/population size (usually /1000)/timeframe
Define Prevalence (1)
- Number of ACTIVE CASES at a specific time point in a population
Unit: Percentage of population
Define Relative Risk (1)
- Ratio in one category relative to another (risk of cancer in smokers divided by/versus risk of cancer in non-smokers)
Tells us about the strength of an association between a risk factor and a disease.
RR >1 is an increased risk
Eg. Population 1000. 300 smoke. Cancer in 45 smokers. Cancer in 5 nin-smokers.
Risk of cancer in smokers: 45/300 = 15%
Risk of cancer in Non-smokers: 5/700 = 0.7%
Relative Risk (Ratio) 15/0.7 = 21.4
so 21 times MORE likely to develop cancer as a smoker than non-smoker
Define Attributable Risk/ Absolute Risk (1)
- Numerical/Absolute difference between two populations’ risks of a disease
eg.
in x population:
Risk of cancer in smokers - 15%
Risk of cancer in non-smokers - 0.7%
Attributable Risk = 15-0.7 = 14.3%
Define Number Needed to Treat
- The number of patients who need to receive a treatment in order to prevent ONE bad outcome.
A small NNtT is really good - as it basically reflects the chance that giving that med to any one patient with actually heal them so a small NNtT means a higher proportion of patients u treat will receive benefit
eg. Smoking Cessation NNT
population 1000, 300 smoke. Cancer in 45 smokers. Cancer in 5 non-smokers. Attributable risk is 14.3% (15% (risk of cancer in smokers from 45/300) minus 0.7% (risk of cancer in non-smokers from 5/700) = 14.3%)
NNT = 1/Attributable risk
= 1/0.143 = 6.99 - basically 7 people
This means for every 7 people that stop smoking, 1 will stop cancer
Outline Wilson and Jungner Criteria for Screening (4)
- The Condition
- Important
- Known Aetiology
- Identifiable Latent Phase
- Organisation and costs:
- Facilities
- Costs and benefits
- Ongoing process / review
- The Screening Test:
- Suitable (Sensitive, Specific, Inexpensive)
- Acceptable to patients
- The Treatment:
- Effective - why check for shit we can’t fix
- Agreed policy on who to treat
Define “Sensitivity” (1)
- Does the test pick up the disease?
Define “Specificity” (1)
- Does the test identify people without the disease?
Define “Positive Predictive Value” (1)
- The probability that subjects with a Positive Test Result ACTUALLY HAVE THE DISEASE
Define “Negative Predictive Value” (1)
- The probability that a person with a negative result DOES NOT INFACT HAVE THE DISEASE.
How to think about Sensitivity, specificity PPV and NPV
So, confusing I know. Start with the population size and Test Results and your basic definitions.
EXAMPLE: Breast Cancer Screening
Results:
20 people got a +ve result. 13 of which ACTUALY HAD cancer
8 people got a -ve result. 7 of which DIDN’T have cancer
Initial thoughts: quite a few false positives there aren’t there? only 13 people got a true positive. Also it seems really good at excluding cancer as 7/8 people were successfully negative.
Calculate:
- Total Population: 20 positives and 8 negs = 28 people.
- Disease burden: 7 people were false positives and 7 people were true negatives, so 14 people Don’t have it, 14 do.
- Sensitivity: How good is the test at true positives?
- 13 true positives in a population with 14 cases
so: 13/14 = 93% sensitive - Specificity: How good is it at True Negatives?
- 7 true negatives in a population with 14 Non-cases So: 7/14 = 50% Specific - PPV: How many Positive Results were TRUE POSITIVE:
- 13 people had it, but 20 got told they did
So: 13/20 = 65% PPV
NPV: How many Negative Results were TURE NEGS?
- 8 people got Negs but only 7 didn’t have it
So: 7/8 = 88%
Fat I know but really sit with this one it should make sense, Find a table example, this is from the PPT
Define a “Health Behaviour” + example (2)
- Behaviour aimed at PREVENTING DISEASE
Example:
2. Going for a run
Define a “Illness Behaviour” + example (2)
- Seeking Remedy
Example:
2. Going to GP
Define a “Sick Role Behaviour” + example (2)
- Activity aimed at GETTING BETTER
Example:
2. Taking your meds
Define a Health Intervention at the “Individual Level” + example (2)
- Intervention aimed at specific patient
Example:
2. Getting them to reduce alcohol intake
Define a Health Intervention at the “Community Level” + example (2)
- Intervention aimed at improving health outcome for entire community
Example:
2. Improving local referral pathways for alcohol support
Define a Health Intervention at the “Population Level” + example (2)
- Intervention aimed at improving health outcome at national/systemic level
Example:
2. Nationally increasing Alcohol Tax
List the 3 main models of Behaviour Change (3) (additional ones listed too)
- Health Belief Model
- Theory of Planned Behaviour
- Stage of Change/Transtheoretical Model
Additional:
( Social Norms Theory, Motivational Interviewing, Social Marketing, Nudging, Financial Incentives)
Outline the 4 key points of the Health Belief Model of Behavioural Change (4)
- Believe they are SUSCEPTIBLE to condition
- Believe in SERIOUS CONSEQUENCES of condition
- Believe TAKING ACTION IS EFFECTIVE in reducing risk
- Believe that BENEFITAS of action OUTWIEGH COSTS
+ a CUE TO ACTION - internal or external ( a wake-up-call symptom or near miss - internal, or a family member or doctors advice - external)
List 4 Critiques of the Health Belief Model of Behavioural Change (4)
- Doesn’t account for Social Cues in change of behaviour
- Alternative Factors may explain Health Behaviour such as the persons belief in their ability to carry out preventative behaviour
- HBM doesn’t consider influence of emotions on behaviour
- Doesn’t differentiate between first-time and repeat attempts/behaviour
Outline the 5 key Steps of the Transtheoretical/ Stages of Change Model of Behavioural Change (5)
- Pre-contemplation - not yet ready
- Contemplation - Thinking bout it
- Preparation - Getting ready, setting quit date, throwing away cigarettes etc..
- Action - Doing it - Quit day
- Maintenance - Sticking to it
ALLOWS FOR RELAPSE - Huge advantage, just hop back on at any stage
List 2 limitations of Transtheoretical Model of Behaviour Change (2)
- Isn’t accurate for all behaviour changes as people skip steps
- Doesn’t account for social factors like values, culture and socioeconomic factors
Outline the 5 key points of the Theory of Planned Behaviour of Behavioural Change (5)
3 factors THEN intention THEN behaviour
3 factors:
1. Attitudes - “smoking is bad”
2. Subjective Norm - “Most people in my life want to stop smoking”
3. Perceived behavioural control - “I reckon I could stop”
THEN
- Intention: “I intend to quit”
THEN
- Behaviour - “I have stopped”
Good because it accounts for social factors
List 4 Disadvantages with the Theory of Planned Behaviour Model of behavioural change (4)
- Lacks Causality
- Not Temporal
- Doesn’t account for emotions
- Relies on self reported behaviour
Define “Social Norms” theory for behaviour change (1)
- By telling someone accurately what the social norm is (vs what they over-assume it to be) you can use social pressure to change behaviour
- Most people overestimate harmful/risky behaviours undertaken by peers, classic example is people over estimating how many students regularly do drugs on nights out - overestimated compared to real numbers
Define “Nudge Theory” Behavioural Change Model
- Suggestive tactics/Making behaviours easier
eg - placing fruit by checkouts at supermarkets
Calculation of Alcohol Units (1)
- Units = %ABV x VOlume (mls) ALL over 1000
eg
Pt drinks 2 cans of 500ml 8% cider per DAY - what is weekly units?
(8 x 500)/1000 = one can = 4 Units
x 2 for daily intake, then x7 for WEEKLY units = 56 units/week
Define a BINGE for 1. Men and 2. Women in UNITS (2)
- MEN: 8 Units in a Session
- WOMEN: 6 Units in a Session
Average time taken to process 1 unit of alcohol (1)
- 1 Hour
Screening tools for Assessing Alcohol Use (2)
- AUDIT
- CAGE
How many Grams of Alcohol are in a Unit? (1)
- 8g
Define “Sloth” Error (1)
- Lazy error - forgetting to document something basic
Define “System Error” (1)
- Inadequate built in safeguards
eq - lack of surgical equipment due to lack of rotad staff to check stocks
Define “Lack of Skill” Error (1)
- Inadequate Training or Competency for task
Define “Fixation” Error (1)
- Focus on one Diagnosis only “Tunnel Vision” on one Dx ignoring other signs and possibilities - Very easy to do if you’re not self aware
Define “Bravado” Error (1)
- Working beyond known competencies - assuming higher competency, arrogance basically, treating complex patient without calling for senior help
Define “Playing the Odds” Error (1)
- Deciding its a common condition, because “common is commons” when in fact its a rare one you miss
Define “Error of Inherent Thinking” (1)
- Assuming another clinician’s advice to you/suggested Dx is correct. Basically assuming just because your Reg tells you its appendicitis, it must be appendicitis and failing to do due diligence in considering your own DDxs
What is the “Swiss Cheese” Model of Error (1)
- A patient is unlucky to fall through many “Holes” or errors in a system that usually wouldn’t result in death or adverse outcomes as each individual error may be small. Run the numbers enough though and someone will experience ALL errors in a single admission, which added up may lead to death, near miss or adverse outcomes. Occur because each error individually is small and hard to detect and normally leads to no harm as is picked up and fixed by another aprt of the system usually
Outline the “Three Bucket” Model of Error
- Self - fatigued, long on call shift, stressed personal life
- Context: Busy ward, Emergency situation
- Task: new equipment not used before
If all buckets are “full” then error is likely
similar to swiss cheese model
Its trying to help you visualise the main areas procedural error arises from
List the 4 layers of Seedhouse’s Ethical Grid (4)
- Core Rationale (top of pyramid)
- Deontological Layer
- Consequential Layer
- External Considerations (Bottom of pyramid)
Outline Maslow’s Hierarchy of Needs
- Self Actualisation (Top)
- Esteem
- Love/Belonging
- Safety
- Physiological (Bottom)
Define primary, secondary and tertiary prevention (3)
- Primary - PREVENT disease in first place
- Secondary - TREAT acute disease state
- Tertiary - Prevent FURTHER COMPLICATIONS of disease - Educate DM patients on good BM control to prevent Cx of DM
Outline the 4 key principles of “Peyton’s Four Step Procedure for Skills Training” (4)
- Trainer demonstrates WIHTOUT COMMENTARY
Then - Trainer Demonstrates WITH commentary
Then - Learner talks through the process and TRAINER does it
Then - Learner talks through the process and LEARNER does it
Outline the 9 steps of “Gangne’s Nine Events of Instruction” - teaching model from PPS (9)
- Gain Attention of Students
- Inform of Objectives
- Stimulate RECALL of prior learning
- Demonstrate the skill
- Re-demonstrate WITH COMMMNETARY
- Student Practice under supervision
- Provide Feedback
- Assessment
9 Enhance Retention and transfer to Job
DONT MEMORISE THIS just read it a few times, it looks like a normal lesson u got at school or uni, teachers probably bum this. It’s all quite self explanatory
