PUBLIC HEALTH Flashcards
1
Q
PREVENTION + SCREENING
What is primary prevention?
Give some examples.
A
Preventing a disease from occurring in the first place.
E.g. change4life, 5-a-day, vaccines > they eliminate risk factors contributing.
2
Q
PREVENTION + SCREENING
What is secondary prevention?
Give some examples
A
Detecting a disease in its early or pre-clinical phase to alter its course + improve health outcomes.
E.g. all screening programmes (breast, bowel, cervical cancer, heel prick in infants).
3
Q
PREVENTION + SCREENING
What is tertiary prevention?
Give some examples
A
Attempting to slow down disease progression + prevent complications of a disease, helping people manage their illness effectively.
E.g. diabetic foot care, attending rehab after a stroke to prevent immobility.
4
Q
PREVENTION + SCREENING
What are the 2 approaches to prevention?
A
- Population approach.
- High risk approach.
5
Q
PREVENTION + SCREENING
Explain the population approach to prevention.
Give some examples.
A
Preventative measure delivered on a population wide basis + seeks to shift the risk factor distribution curve.
E.g. dietary salt reduction via legislation to reduce BP, adding iodine to salt to prevent iodine deficiency
6
Q
PREVENTION + SCREENING
Explain the high risk approach to prevention.
Give some examples
A
Identifying individuals above a chosen cut-off + treating them.
E.g. screening for HTN + treating them.
7
Q
PREVENTION + SCREENING
What is meant by the prevention paradox?
A
A preventative measure which brings much benefit to the population often offers little to each participating individual.
I.e. it’s about screening a large number of ppl to help a small number of ppl.
8
Q
PREVENTION + SCREENING
What is the concept of screening?
A
A process which identifies seemingly well individuals who may be at risk of a disease, in the hope of catching the disease at its early stage.
- It’s not a diagnostic process, simply a means of assessing risk + catching diseases in their early stage.
9
Q
PREVENTION + SCREENING
In the grid of Disease vs. screening test – what does a, b, c + d stand for?
A
A = true positive.
B = false positive.
C = false negative.
D = true negative.
10
Q
PREVENTION + SCREENING
Define sensitivity.
A
The proportion of people with the disease who are correctly identified by the screening test. a ÷ (a + c)
11
Q
PREVENTION + SCREENING
Define specificity.
A
The proportion of people without the disease who are correctly excluded by the screening test. d ÷ (d + b)
12
Q
PREVENTION + SCREENING
Define positive predictive value (PPV).
A
The proportion with a positive test result who actually have the disease. Dependent on underlying prevalence.
a ÷ (a + b)
13
Q
PREVENTION + SCREENING
Define negative predictive value (NPV).
A
The proportion with a negative test result who do not have the disease. This is lower if the prevalence is higher. d ÷ (c + d)
14
Q
PREVENTION + SCREENING
What are some types of screening available?
A
3 IN PREGNANCY
- infectious diseases in pregnancy (hep B, syphilis, HIV)
- Sickle cell + thalassaemia
- Foetal anomaly screening (downs, edwards, pataus)
3 IN NEWBORNS
- NIPE
- newborn hearing screening
- newborn blood spot screening
5 IN YOUNG PEOPLE + ADULTS
- AAA screening
- Bowel cancer screening
- Breast cancer screening
- Cervical cancer screening
- Diabetic eye screening
15
Q
PREVENTION + SCREENING
What are some of the disadvantages of screening?
A
- Exposure of well individuals to distressing or harmful diagnostic tests.
- Detection + treatment of sub-clinical disease that may have never caused any problems.
- Preventative interventions that may cause harm to the individual or population.
16
Q
PREVENTION + SCREENING
What are the Wilson + Junger criteria for screening?
A
CONDITION
-important
- known natural history
- identifiable latent/pre-clinical phase
THE SCREENING TEST
- suitable (sensitive, specific, inexpensive)
- acceptable
ORGANISATION AND COSTS
- facilities
- costs and benefits
- ongoing process
THE TREATMENT
- effective
- agreed policy on whom to treat
17
Q
PREVENTION + SCREENING
What 2 types of bias may be present in screening?
A
- Lead-time bias.
- Length-time bias.
18
Q
PREVENTION + SCREENING
Explain what lead-time bias is.
A
When screening identifies an outcome earlier than it would otherwise have been identified + results in an apparent increase in survival time, even if screening has no effect on the outcome.
19
Q
PREVENTION + SCREENING
Explain what length-time bias is.
A
Bias resulting from differences in the length of time taken for a condition to progress to severe effects that may affect the apparent efficacy of a screening method.
E.g. less aggressive cancers w/ longer presentations are more likely to be detected by screening. Comparing survival in screen detected + non-screen detected pts may be biased as there’s a tendency to compare less aggressive + more aggressive cancers.
20
Q
STUDY DESIGN
What is the methodology behind an ecological study?
A
- Descriptive/observational study design comprising of case reports or case series studying population/groups rather than individuals. COMPARATIVE
- Uses routinely collected data to show trends in data – often associations between occurrence of disease + exposure to known or suspected causes.
21
Q
STUDY DESIGN
What are the advantages of an ecological study?
A
- Few ethical issues.
- Useful for generating hypotheses.
- Uses routine data so quick + cheap.
- Can show prevalence + association.
22
Q
STUDY DESIGN
What are the disadvantages of an ecological study?
A
- Cannot show causation.
- Bias (variation in diagnostic criteria).
- Inconsistency in data presentation.
23
Q
STUDY DESIGN
What is the methodology behind a cross-sectional study?
A
- retrospective, observational
- collects data from population at a specific point in time
- prevalence of risk factors and disease itself
24
Q
STUDY DESIGN
What are the advantages of a cross-sectional study?
A
- Relatively cheap + quick.
- Provide data on prevalence at a single point in time.
- Good for surveillance + public health planning.
- Large sample size.
25
STUDY DESIGN
What are the disadvantages of a cross-sectional study?
- Risk of reverse causality.
- Cannot measure incidence as no time reference.
- Risk of recall bias + non-response.
26
STUDY DESIGN
What is the methodology behind a case control study?
- retrospective, observational study
- compares similar participant with disease to controls without
27
STUDY DESIGN
What are the advantages of a case control study?
- Quicker than cohort of intervention studies as it's retrospective.
- Inexpensive, good for rare outcomes (e.g. cancer).
- Can investigate multiple exposures.
28
STUDY DESIGN
What are the disadvantages of a case control study?
- Retrospective nature only shows an association (not causation).
- Difficulty finding controls to match with cases.
- Unreliable due to recall bias.
- Prone to selection + information bias.
29
STUDY DESIGN
What is the methodology behind a cohort study?
- prospective longitudinal study
- look at separate cohorts with different treatments or exposures
- wait to see if disease occurs
30
STUDY DESIGN
What are the advantages of a cohort study?
- Can follow-up groups with a rare exposure
- Lower chance of selection + recall bias.
- Good for common + multiple outcomes.
31
STUDY DESIGN
What are the disadvantages of a cohort study?
- People drop out (loss to follow-up)
- Takes a long time,
- need a large sample size, expensive + time consuming.
32
STUDY DESIGN
What is the methodology behind a randomised control trial?
Prospective study
All participants randomly assigned exposure or control intervention
33
STUDY DESIGN
What are the advantages of a randomised control trial?
- Can infer causality (gold standard).
- Low risk of bias and confounding .
34
STUDY DESIGN
What are the disadvantages of a randomised control trial?
- Is it ethical to withhold a treatment that is strongly believed to be effective?
- Time consuming, expensive.
- Volunteer bias – inclusion criteria may exclude some populations.
- drop outs
35
STUDY DESIGN
What is the methodology behind a meta-analysis? How does this differ to a systematic review?
- A statistical technique where you pool all the results of the available evidence + look at effect.
- Systematic review doesn't involve the statistical procedure.
36
EPIDEMIOLOGY
Define bias.
A systematic deviation from the true estimation of the association between exposure + outcome.
I.e. systematic error > distortion of the true underlying association.
37
EPIDEMIOLOGY
What are the 2 main types of bias?
- Selection bias.
- Information (measurement) bias.
38
EPIDEMIOLOGY
What is selection bias?
Give some examples.
- A systematic error either in the selection of study participants or the allocation of participants to different study groups.
- Non-response, loss to follow up.
- Those in the intervention group different in some way from the controls other than the exposure in question.
39
EPIDEMIOLOGY
What is information bias?
Give some examples of sources of information bias.
A systematic error in the measurement or classification of exposure or outcome.
- Observer (observer bias).
- Past event incorrectly remembered (recall bias).
- Responder does not tell the truth (reporting bias).
- Wrongly calibrated instrument (measurement bias).
40
EPIDEMIOLOGY
What type of bias can occur after a study is completed?
Publication bias where some trials are more likely to be published than others.
41
EPIDEMIOLOGY
What is confounding?
What is the effect of confounding on a study?
Where a factor is associated with the exposure of interest + independently influences the outcome but does not lie on the causal pathway.
- May affect the validity of a study.
42
EPIDEMIOLOGY
What is the Bradford-Hill criteria for assessing causality?
- Strength of association (the magnitude of the RR).
- Dose response (the higher the exposure, the higher the risk of disease).
- Consistency (similar results from different researches using various study designs).
- Temporality (does exposure precede outcome?)
- Reversibility (experiment) – removal of exposure reduces risk of disease).
- Biological plausibility (biological mechanisms explaining the link).
- Coherence (logical consistency with other information).
- Analogy (similarly with other established cause-effect relationships).
- Specificity (relationship specific to outcome of interest).
43
EPIDEMIOLOGY
If association is not causal, how could it be explained?
- Bias.
- Chance.
- Confounding.
- Reverse causality.
- A true causal association.
44
EPIDEMIOLOGY
What is meant by reverse causality?
Give an example.
Refers to a situation when an association between an exposure + outcome could be due to the outcome causing exposure rather than the other way.
- E.g. case study showing stress causes HTN but HTN could cause increased stress.
45
HEALTH DETERMINANTS ETC.
Define epigenetics.
The study of how genes interact with the environment.
- Changes in organisms caused by modification of gene expression rather than alteration of the genetic code itself.
46
HEALTH DETERMINANTS ETC.
Define allostasis.
The stability through change, or homeostasis, of our physiological systems to adapt rapidly to change in environment.
47
HEALTH DETERMINANTS ETC.
Define allostatic load.
Long-term over-taxation of our physiological systems leading to impaired health (stress).
- The price we pay for allostasis.
48
HEALTH DETERMINANTS ETC.
Define public health.
Defined as the science + art of preventing disease, prolonging life + promoting health through organised efforts of society.
- Population perspective – thinks in terms of groups, not individuals.
49
HEALTH DETERMINANTS ETC.
What are the key concerns of public health?
- Inequalities in health.
- Wider determinants of health.
- Prevention.
50
HEALTH DETERMINANTS ETC.
What are the determinants of health?
PROGRESS
Place of residence
Race/ethnicity
Occupation
Gender
Religion
Education
Socioeconomic status
Social capital
51
HEALTH DETERMINANTS ETC.
What are the wider/social determinants of health?
- Education, socioeconomic status, unemployment, housing, physical environment etc.
52
HEALTH DETERMINANTS ETC.
What are the 3 domains of public health?
- Health improvement.
- Health protection.
- Improving services.
53
HEALTH DETERMINANTS ETC.
What is meant by health improvement.
What does it encompass?
Societal interventions aimed at preventing disease, promoting health + reducing inequality.
- Inequalities, education, housing, employment, lifestyles, family/community, surveillance + monitoring of some diseases + risk factors (imms, smoking, screening)
54
HEALTH DETERMINANTS ETC.
What is meant by health protection.
What does it encompass?
Measures to control infectious disease risks + environmental hazards.
- Infectious diseases, chemicals + poisons, radiation, emergency response, environmental health hazards.
55
HEALTH DETERMINANTS ETC.
What is meant by improving services.
What does it encompass?
Organisation + delivery of safe, high quality services for prevention, treatment + care.
- Clinical effectiveness, efficiency, service planning, audit + evaluation, clinical governance, equity.
56
HEALTH DETERMINANTS ETC.
What are the 5 levels of Maslow's hierarchy of needs?
- Physiological = breathing, food, water, sleep.
- Safety = security of employment, resources, 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, acceptable of facts.
57
HEALTH DETERMINANTS ETC.
What are health interventions?
Give some examples.
Any tactics that are done to improve public health.
- Health promotion/awareness campaigns (Change4Life, 5-a-day, Stoptober, Movember).
- Promoting screening + immunisations (cervical smear, MMR vaccine).
58
HEALTH DETERMINANTS ETC.
What are the 3 levels of intervention?
- Individual = pt centred approach to care.
- Community = community centred approach to care.
- Population = delivered nationwide, non-specific to individuals.
59
HEALTH DETERMINANTS ETC.
Give some examples of the 3 levels of intervention.
- Individual = immunisations.
- Community = new outdoor play area in a particular village, more cycle paths to make cycling safer.
- Population = iodine in salt to prevent iodine deficiency, PH campaigns (Change4Life), screening, vaccines.
60
HEALTH DETERMINANTS ETC.
Explain how the effects of interventions are rarely restricted to one level.
Brief GP intervention aimed at reducing alcohol consumption.
- Individual = level of alcohol consumption, incidence of domestic violence.
- Community = local alcohol sales, alcohol-related crime.
- Population = national alcohol sale, national stats on alcohol-related crime.
61
HEALTH DETERMINANTS ETC.
Define equality.
giving everyone the same rights, opportunities, and resources
62
HEALTH DETERMINANTS ETC.
Define equity.
giving people what they need to achieve equal outcomes
63
HEALTH DETERMINANTS ETC.
what are the two different types of equity?
vertical
horizontal
64
HEALTH DETERMINANTS ETC.
what is vertical equity?
Unequal treatment for unequal need
(e.g. areas with poorer health may need higher expenditure on health services, common cold + pneumonia require different treatment).
65
HEALTH DETERMINANTS ETC.
what is horizontal equity?
Equal treatment for equal need
(e.g. pts with same disease should be treated equally).
66
HEALTH DETERMINANTS ETC.
What are the different forms of health equity?
- Equal expenditure.
- Equal access.
- Equal utilisation.
- Equal healthcare outcome.
(All for equal need).
67
HEALTH DETERMINANTS ETC.
What are the 2 main factors affecting health equity.
Give an example of each.
- SPATIAL INEQUITY (geographical) – infant mortality rates high in places like Africa but healthcare spending is low in these areas (health inequality + inequity).
- SOCIAL INEQUITY (age, gender, ethnicity, socioeconomic status etc) – socioeconomic inequity as angina Sx higher in more deprived areas but coronary artery revascularisations in those with angina Sx higher in more affluent areas in Sheffield.
68
HEALTH DETERMINANTS ETC.
How is health equity examined?
- Supply/access/utilisation of healthcare.
- Healthcare outcomes.
- Health status.
- Resource allocation (health services or others like education, housing).
- Wider determinants of health.
69
HEALTH PSYCHOLOGY
What is the essence of health psychology?
- Emphasises the role of psychological factors in the cause, progression + consequences of health + illness.
- It aims to put theory into practice by promoting healthy behaviours + preventing illness.
70
HEALTH PSYCHOLOGY
What are the 3 types of health behaviour?
- Health behaviour
- Illness behaviour
- Sick role behaviour
71
HEALTH PSYCHOLOGY
What is health behaviour role?
- Health behaviour = a behaviour aimed to prevent disease (e.g. healthy eating).
72
HEALTH PSYCHOLOGY
What is the role of illness behaviour?
- Illness behaviour = a behaviour aimed to seek remedy (e.g. going to Dr/pharmacist).
73
HEALTH PSYCHOLOGY
What is sick role behaviour?
- Sick role behaviour = any activity aimed at getting well (e.g. resting, taking prescribed meds).
74
HEALTH PSYCHOLOGY
What are the two broader categories that health behaviours can be split into?
- Health promoting (exercising, vaccinations, attending health checks).
- Health damaging/impairing (smoking, alcohol/substance abuse).
75
HEALTH PSYCHOLOGY
What is the main theory for explaining why people undertake health damaging behaviours?
Unrealistic optimism.
- Individuals continue practicing health damaging behaviours due to inaccurate perceptions of risk + susceptibility.
- They're aware of risks but don't think it would happen to them.
76
HEALTH PSYCHOLOGY
In terms of unrealistic optimism, what are a person's perceptions of risk influenced by mainly?
- Lack of personal experiences with the problem.
- Belief that it's preventable by personal action.
- Belief that it's not happened by now so it's not likely to.
- Belief that the problem is infrequent.
77
HEALTH PSYCHOLOGY
What other factors can influence a person's perceptions of risk?
- Stress.
- Health beliefs.
- Cultural variability.
- Situational rationality.
78
HEALTH PSYCHOLOGY
What needs to be done for patients with unrealistic optimism?
- Work out patient's perception of risk level + address it.
- Promoting behaviour change is only likely once you know this.
79
HEALTH PSYCHOLOGY
What are the issues with health damaging behaviours?
- Health damaging behaviour, mortality + morbidity are related.
- QOL impact, working days lost to sickness, treatment regime adherence issues.
80
HEALTH PSYCHOLOGY
What is meant by medication compliance?
- The extent to which a patient's behaviour coincides with medical advice.
- It's professionally focused + assumes that the doctor knows best.
81
HEALTH PSYCHOLOGY
What is meant by adherence?
- The extent to which the patient's actions match agreed recommendations.
- More patient centred, empowers patients + considers them equal in care decisions.
82
HEALTH PSYCHOLOGY
What factors can affect compliance?
- Side effects of medications.
- Patient perception of risk.
- Socioeconomic status.
- Treatment for an asymptomatic condition (e.g. continuing Abx).
83
HEALTH PSYCHOLOGY
What is the NICE guidance on behaviour change?
- Planning interventions.
- Assessing the social context.
- Education + training.
- Individual, community + population-level interventions.
- Evaluating effectiveness + assessing cost-effectiveness.
84
HEALTH PSYCHOLOGY
What is the impact of smoking?
- Single greatest cause of illness + premature death in the UK.
85
HEALTH PSYCHOLOGY
What conditions cause smoking-related deaths?
- Smoking related deaths are due to COPD, cancers, ischaemic heart disease
86
HEALTH PSYCHOLOGY
When does smoking prevalence peak?
Prevalence peaks in mid 20s.
87
HEALTH PSYCHOLOGY
What is the role of the National Centre for Smoking Cessation and Training (NCSCT)?
- Supports the delivery of effective evidence-based tobacco control programmes + smoking cessation interventions provided by local services.
88
HEALTH BELIEF MODEL
What is the Health Belief Model?
Behaviour change model that states individuals will change if they –
- PERCEIVED SUSCEPTIBILITY - Believe they are susceptible to the condition.
- SEVERITY - Believe that it has serious consequences.
- PERCEIVED BENEFITS - Believe that taking action reduces susceptibility.
- PERCEIVED BARRIERS - Believe that benefits of taking action outweigh costs.
89
HEALTH BELIEF MODEL
Which part of the model is believed to be most important?
Perceived barriers.
- All about the patient having poor self-efficacy (i.e. not being able to stick to a made behaviour change).
90
HEALTH BELIEF MODEL
What can be added to the model to give more information about likelihood of action?
Give examples.
Cues to action.
- They can be internal or external + are not always necessary for behaviour change.
- Internal = increase pain, decrease ADLs.
- External = reminders in post, GP advice.
91
HEALTH BELIEF MODEL
What are the pros of this model?
- Can be applied to a wide variety of health behaviours.
- Cues to action are unique component to the model.
- Long standing model.
92
HEALTH BELIEF MODEL
What are the cons of this model?
- Does not differentiate between first time + repeat behaviour.
- Does not consider the influence of emotions + behaviour.
- Cues to action often missing.
- Alternative factors may predict health behaviour such as self-efficacy or outcome expectancy (whether they feel they will be healthier as a result).
93
THEORY OF PLANNED BEHAVIOUR
What is the Theory of Planned Behaviour?
Proposes that the best predictor of behaviour is intention to change behaviour i.e. I intend to give up smoking.
94
THEORY OF PLANNED BEHAVIOUR
What is intention determined by in this model?
ASP
- ATTITUDE = a person's attitude to the behaviour (I don't think smoking is good).
- SUBJECTIVE NORMS = the perceived social pressure to undertake the behaviour (most people who are important to me want me to give up smoking).
- PERCEIVED BEHAVIOURAL CONTROL = a person's ability to perform the behaviour (I CAN give up smoking).
95
THEORY OF PLANNED BEHAVIOUR
What are the 5 points to bridging the intention-behaviour gap?
PPAIR –
- PERCEIVED CONTROL (something an individual feels they are capable of doing).
- PREPATORY ACTIONS (dividing task into sub-goals increases self-efficacy + satisfaction at the point of completion).
- ANTICIPATED REGRET (reflecting on feelings once failed, related to sustained intentions).
- IMPLEMENTATION OF INTENTIONS (biggest one, "if-then" plans – if I need to take my meds in the morning then I will place them here to remind me).
- RELEVANCE TO SELF (can they relate to the behaviour).
96
THEORY OF PLANNED BEHAVIOUR
What are the pros of this model?
- Can be applied to a wide variety of health behaviours.
- Useful for predicting intention.
- Takes into account importance of social pressures.
97
THEORY OF PLANNED BEHAVIOUR
What are the cons of this model?
- Lack of temporal element + direction or causality, no sense of how long behaviour change may take.
- 'Rational choice model' so doesn't take into account emotions.
- Assumes attitudes, subjective norms + perceived behavioural control can be measured.
- Relies on self-reported behaviour.
98
TRANSTHEORETICAL/STAGES OF CHANGE MODEL
What is the Transtheoretical/Stages of Change Model?
Stage theories see individuals located at discrete ordered stages, rather than on a continuum with each stage denoting a greater inclination to change outcome.
99
TRANSTHEORETICAL/STAGES OF CHANGE MODEL
What are the 5 stages?
PC PAM(R)
- PRECONTEMPLATION = no intention of stopping.
- CONTEMPATION - beginning to consider stopping, probably at some ill-defined time in the future.
- PREPARATION = getting ready to quit in near future, set stop date, go to Dr, throw away items (28d).
- ACTION = engaged in stopping behaviour on stop date (6m).
- MAINTENANCE = continues + engaged with abstinent behaviour (6m).
- RELAPSE can occur at any stage of the model.
100
TRANSTHEORETICAL/STAGES OF CHANGE MODEL
What are the pros of this model?
- Acknowledges individual stages of readiness (tailored interventions).
- Accounts for relapse/allows patient to move backwards in the stages.
- Gives temporal element (idea of timeframe/progression, albeit arbitrary).
101
TRANSTHEORETICAL/STAGES OF CHANGE MODEL
What are the cons of this model?
- Not all people move through every stage.
- Change might operate on a continuum rather than discreet changes.
- Does not take into account values, habits, culture, social, economic factors.
102
MOTIVATIONAL INTERVIEWING
What is the Motivational Interviewing model?
- A counselling approach to initiating behaviour change by resolving ambivalence (the state of having mixed feelings/contradictory ideas about something).
103
MOTIVATIONAL INTERVIEWING
What is the role of this model?
- Allow someone to change their behaviour by helping them make a decision about the behaviour – helping someone to see whether the behaviour was bad for them or not.
104
MOTIVATIONAL INTERVIEWING
Where has this shown clinical impact?
Problem drinkers.
105
SOCIAL NORMS THEORY
What is the Social Norms Theory?
- Norms are positive protective behaviours.
- Social norms are behaviours + Attitudes that are most common in groups + are one of the most important factors influencing behaviour.
106
SOCIAL NORMS THEORY
How may belief of norms differ to actual norms?
- Typically, people misperceive the peer norms.
- We typically overestimate the risk behaviour + underestimate the protective behaviours but this does not work when the risk behaviour is the social norm (i.e. alcohol, obesity).
- This means that it allows people who want to do high risk behaviours think they're doing what everyone else is but often not the case.
107
NUDGE THEORY
What is the Nudge Theory?
Give an example.
Changing the environment to make the best/healthiest option the easiest.
- E.g. placing fruit next to checkouts instead of sweets, opt-out schemes.
108
HEALTH PSYCHOLOGY
What are some other factors to consider that might influence behaviour change?
- Impact of personality traits on health behaviour (everyone responds differently).
- Assessment of risk perception.
- Impact of past behaviour/habit.
- Automatic influences on health behaviour.
- Predictors of maintenance of health behaviours.
- Social environment.
109
HEALTH PSYCHOLOGY
What do NICE mention about interventions for behaviour change?
- Should work in partnership with individuals, communities, organisations + populations.
- Population-level interventions may affect individuals + communities + vice versa.
110
HEALTH PSYCHOLOGY
NICE mention some typical transition points in life which may influence someone to be more/less receptive to change behaviours dependent on their person + attitude, what are these?
- Leaving school.
- Starting work/new job.
- Becoming a parent.
- Becoming unemployed.
- Retirement.
- Bereavement.
111
HEALTH NEEDS AX
What is a health needs assessment?
“A systematic approach for reviewing health issues affecting a population in order to enable agreed priorities and resource allocation to improve health and reduce inequalities.”
112
HEALTH NEEDS AX
What is the planning cycle in a HNA and how is this relevant to Doctors?
113
HEALTH NEEDS AX
Define need.
ability to benefit from an intervention.
114
HEALTH NEEDS AX
Define demand.
what people ask for.
115
HEALTH NEEDS AX
Define supply.
what is provided.
116
HEALTH NEEDS AX
Define health need
a need for health (concerns need in more general terms).
117
HEALTH NEEDS AX
Define health care need.
a need for health care (more specific + looks at someone's ability to benefit from health care).
118
HEALTH NEEDS AX
How is health need measured?
- Using mortality, morbidity, socio-demographic measures.
119
HEALTH NEEDS AX
What does health care need depend on?
Potential of prevention, treatment + care services to remedy health problems.
120
HEALTH NEEDS AX
What does a health needs assessment usually cover?
- Both a health needs assessment and health care needs assessment.
121
HEALTH NEEDS AX
What are the 4 types of need?
FENC
- Felt need
- Expressed need
- Normative need
- Comparative need
122
HEALTH NEEDS AX
What is felt need?
Felt need = individual perceptions of variation from normal health (patient feels unwell)
123
HEALTH NEEDS AX
What is expressed need?
Expressed need = individual seeks help to overcome variation in normal health
(patient goes to the doctor)
124
HEALTH NEEDS AX
What is normative need?
Normative need = professional defines intervention appropriate for the expressed need.
(the Dr says what they need)
125
HEALTH NEEDS AX
What is comparative need?
Comparative need = comparison between severity, range of interventions + cost.
126
HEALTH NEEDS AX
What are the 3 perspectives of a health needs assessment?
- Epidemiological.
- Comparative.
- Corporate.
127
HEALTH NEEDS AX
Epidemiological HNA: what is the methodology?
Looks at:
- Size of population - incidence/ prevalence
- Services available - prevention/ treatment/ care
- Evidence base - effectiveness/ cost effectiveness
128
HEALTH NEEDS AX
Epidemiological HNA: what are potential sources of data?
- Disease registry.
- Hospital admissions.
- GP databases.
- Mortality data.
- Primary data collection (e.g. postal/patient survey).
129
HEALTH NEEDS AX
Epidemiological HNA: what are the pros?
- Uses existing data.
- Provides data on disease incidence, mortality, morbidity.
- Can evaluate services by trends over time.
130
HEALTH NEEDS AX
Epidemiological HNA: what are the cons?
- Quality of data is variable
- Data collected may not be data required
- Does not consider felt needs/ opinions of patients affected.
131
HEALTH NEEDS AX
Comparative HNA: what is the methodology?
Compares services/ outcomes received by a population with others
Could compare different areas or patients of different ages etc
132
HEALTH NEEDS AX
Comparative HNA: what might it examine?
- Health status.
- Service provision.
- Service utilisation.
- Health outcomes (mortality, morbidity, QOL, pt satisfaction).
133
HEALTH NEEDS AX
Comparative HNA: what are the pros?
- Quick and cheap if data available
- Shows if services are better or worse than compared group
134
HEALTH NEEDS AX
Comparative HNA: what are the cons?
Can be difficult to find comparable population
Data may not be available/ high quality
135
HEALTH NEEDS AX
Corporate HNA: what is the methodology?
Ask local population what their health needs are
Use focus groups, interviews, public meetings
Wide variety of stakeholders
136
HEALTH NEEDS AX
Corporate HNA: what are the pros?
- Based on the felt + expressed needs of the population in question.
- Recognises the detailed knowledge + experience of those working within the population.
- Takes into account a wide range of views.
137
HEALTH NEEDS AX
Corporate HNA: what are the cons?
- Difficult to distinguish need from demand.
- Groups may have vested interests + may be influenced by political agendas.
- Dominant personalities may have undue influence.
138
HEALTH NEEDS AX
Give an example of a service that is demanded but not needed or supplied?
Cosmetic surgery.
139
HEALTH NEEDS AX
Give an example of a service that is supplied + needed but not demanded?
Anti-hypertensives (as usually asymptomatic)
Routine vaccinations
140
HEALTH NEEDS AX
Give an example of a service that is supplied but not needed or demanded?
>75 health check by GP as no benefit seen.
141
EVALUATION OF SERVICES
What is meant by evaluation?
Evaluation is the assessment of whether a service achieves its objectives.
- Process that attempts to determine as systematically + objectively as possible the relevance, effectiveness + impact of activities in the light of their objectives.
142
EVALUATION OF SERVICES
What is the Donabedian framework and what do each headings mean?
- Structure – what is there.
- Process – what is done.
[Output sometimes included or classified under process].
- Outcome – classification of health outcomes.
143
EVALUATION OF SERVICES
Give some structure examples.
- Buildings = locations where screening is provided.
- Staff = number of vascular surgeons/1000 population.
- Equipment = number of ICU beds/1000 population.
144
EVALUATION OF SERVICES
Give some process examples.
- Number of patients seen in A&E.
- Number of operations performed (may be expressed as a rate).
145
EVALUATION OF SERVICES
Give some outcome examples.
5Ds:
- Death, disease, disability, discomfort, dissatisfaction.
Also:
- Mortality (e.g. 30-day mortality rate).
- Morbidity (e.g. complication rate).
- QOL/patient reported outcome measures (PROMS).
- Patient satisfaction.
146
EVALUATION OF SERVICES
Give some examples of PROMs used in outcome.
- Oxford hip score.
- Oxford knee score.
- Aberdeen varicose vein questionnaire.
- EQ-5D.
147
EVALUATION OF SERVICES
What are some issues with health outcome?
- Link (cause + effect) between health service provided + health outcome may be difficult to establish as many other factors may be involved (e.g. case-mix, severity, other confounding factors).
- Time lag between service provided + outcome may be long (e.g. healthy eating intervention in children + T2DM incidence in adults).
- Large sample sizes may be needed to detect statistically significant effects.
- Data may not be available or may be issues with data quality.
148
EVALUATION OF SERVICES
When considering data quality what should be considered?
CART
- Completeness.
- Accuracy.
- Relevance.
- Timeliness.
149
EVALUATION OF SERVICES
One aspect of evaluation is the quality of health services. What can be used when assessing this?
Maxwell's Dimensions of Quality
150
EVALUATION OF SERVICES
what are the different parts of Maxwell's dimensions of quality?
(3As + 3Es) –
- ACCEPTABILITY (how acceptable is the service to the people needing it?)
- ACCESSABILITY (is the service provided?)
- APPROPRIATENESS (right treatment given to right people at right time?)
- EFFECTIVENESS (does the intervention/service produce the desired effect?)
- EFFICIENCY (is the output maximised for a given input or is the input minimised for a given level of output?)
- EQUITY (are patients being treated fairly?)
151
EVALUATION OF SERVICES
Give some examples of things to consider under...
i) accessibility.
ii) appropriateness.
i) Geographical access, cost to patients, waiting times.
ii) Overuse? Underuse? Misuse?
152
EVALUATION OF SERVICES
What are the 2 types of evaluation methods?
- Qualitative.
- Quantitative.
153
EVALUATION OF SERVICES
Describe qualitative evaluation methods.
- Consult relevant stakeholders as appropriate (e.g. staff, patients, relatives, carers, policy makers).
- Methodology = observation (participant vs. non-participant), interviews (unstructured, semi-structured or structured), focus groups, review of documents.
154
EVALUATION OF SERVICES
Describe quantitative evaluation methods.
- Routinely collected data (e.g. hospital admissions, mortality).
- Review of records (e.g. medical, administrative).
- Surveys, other special studies (using epidemiological methods).
155
EVALUATION OF SERVICES
When evaluating health services what is the overall framework?
General framework depends on service being evaluated + can be prospective or retrospective –
- Define what the service is i.e. what it includes.
- What are the aims + objectives of the service? Are they stated + appropriate.
- Donabedian framework ± dimensions of quality.
- Methodology i.e. qualitative, quantitative, mixed methods.
- Results, conclusions + recommendations.
156
FOOD + BEHAVIOUR
What are some factors promoting excessive energy intake?
- Employment (shift work).
- Characertistics of food (energy density, portion size).
- Social aspect (people usually go out for food).
- Genetics.
- Advertisements.
157
FOOD + BEHAVIOUR
Define malnutrition.
Refers to deficiencies, excesses or imbalances in a person's intake of energy and/or nutrients.
158
FOOD + BEHAVIOUR
What does malnutrition cover?
Undernutrition:
- Stunting (low height for age).
- Wasting (low weight for height).
- Underweight (low weight for age).
- Micronutrient deficiencies + insufficiencies.
Over nutrition/weight:
- Obesity + diet-related diseases (CVD, stroke, T2DM).
159
FOOD + BEHAVIOUR
What are some chronic medical conditions that require nutritional support?
- T2DM.
- Coeliac disease.
- IBD.
- Eating disorders.
- Obesity.
160
FOOD + BEHAVIOUR
What period is sensitive for the development of food preferences?
What 4 topics has an influence on feeding behaviours
- First 2 years of life.
- Maternal diet, breastfeeding, parenting practices, age of weaning + types of food exposed to.
161
FOOD + BEHAVIOUR
Explain how maternal diet influences feeding behaviour.
- Human foetuses swallow significant amount of amniotic fluid during gestation + amniotic fluid is influenced by maternal diet.
162
FOOD + BEHAVIOUR
What role does breastfeeding play?
Taste preference + bodyweight regulation.
163
FOOD + BEHAVIOUR
What are the pros of breastfeeding?
- Less picky eaters in childhood.
- More likely to accept novel foods in weaning.
- More likely to have a diet rich in fruit + vegetables if >3m.
- Bodyweight regulation (babies stop feeding when full if breastfeeding whereas bottle-fed infants usually encouraged to finish bottle).
164
FOOD + BEHAVIOUR
Explain the difference in parenting practices relative to feeding behaviours.
Maladaptive tactics:
- Coercion, persuading + contingencies.
- Risk of non-organic feeding disorders (food aversion/refusal).
Positive practices:
- Avoid pressure, don't use food as a reward, provide variety of foods.
165
FOOD + BEHAVIOUR
What are the 3 distinct eating disorder illnesses recognised in DSM-V?
- Anorexia nervosa.
- Bulimia nervosa.
- Binge eating disorder.
166
FOOD + BEHAVIOUR
Explain what is meant by disordered eating.
- Restraint.
- Strict dieting.
- Disinhibition.
- Emotional/night eating.
- Weight + shape concerns.
- Inappropriate compensatory behaviours.
167
FOOD + BEHAVIOUR
What are the three basic forms of dieting?
All associated with restriction of food intake:
- Restrict the total amount of food eaten.
- Restrict the types of food eaten.
- Restrict the time-window for eating (intermittent fasting.
168
FOOD + BEHAVIOUR
What are some problems with dieting?
- Risk factor for development of EDs.
- Results in loss of lean body mass, not just fat mass.
- Slows metabolic rate.
- Chronic dieting may disrupt normal appetite responses + increase sensations of hunger.
- Long-term weight loss is challenging, usually plateau + then regain weight.
169
FOOD + BEHAVIOUR
What is the portion size effect?
Consumption of large portion sizes of energy dense food facilitates over consumption.
- Without compensatory effects > increased obesity.
170
FOOD + BEHAVIOUR
What is dietary restraint?
Restrained eating is the deliberate attempt to inhibit food intake in order to maintain or lose weight:
- Effortful, cognitively demanding where you ignore feelings of hunger.
- Certain circumstances > disinhibition > overeating.
171
SOCIAL EXCLUSION
What are the 3 core principles of the NHS?
- Universal = it meets the needs of everyone.
- Comprehensive = it's based on clinical need, not ability to pay.
- Free = at the point of delivery.
172
SOCIAL EXCLUSION
What is health inequality?
The unjust + avoidable differences in people's health across the population + between specific population groups.
- They go against the principles of social justice as they are avoidable.
173
SOCIAL EXCLUSION
What is the inverse care law?
The availability of medical care tends to vary inversely with the need of the population served.
- I.e. those who need it most, don't access it as much + vice versa.
174
SOCIAL EXCLUSION
What are some vulnerable groups of patients in the NHS?
- Asylum seekers.
- LGBTQ+.
- Homeless.
- Ex-prisoners.
- MH sufferers.
- LD patients.
175
SOCIAL EXCLUSION
What is meant by social exclusion?
The process of being shut out from any of the social, economic, political or cultural systems which determine the social integration of a person in society.
176
SOCIAL EXCLUSION
Define homelessness.
A person without a home, typically living on the streets.
- Also includes people living with family, in B+Bs etc.
177
SOCIAL EXCLUSION
What are some causes of homelessness?
- Relationship breakdown (#1 stated cause).
- Mental illness, domestic abuse.
- Disputes with parents.
- Bereavement (≥50% say they have no family ties).
- Drugs, alcohol.
- No money or job.
178
SOCIAL EXCLUSION
What populations are vulnerable to homelessness?
- LGBTQ+.
- Ex-service men + women.
- Substance misusers.
- Failed asylum seekers.
179
SOCIAL EXCLUSION
What are some health problems faced by the homeless?
- Infectious diseases (TB, Hepatitis).
- Resp problems.
- Poor condition of feet + teeth.
- Sexual health issues.
- Injuries following violence, rape.
- Serious mental illnesses (e.g. schizophrenia).
- Poor nutrition.
- Addictions/substance misuse.
180
SOCIAL EXCLUSION
What are the common causes of death amongst the homeless?
- Accidents.
- Suicide.
- Liver problems.
181
SOCIAL EXCLUSION
What are some general barriers to accessing medical care?
- Language + communication barriers.
- Education levels (not knowing when to access care).
182
SOCIAL EXCLUSION
What are some barriers to healthcare for travellers?
- Reluctance of GPs to register travellers + visit traveller sites.
- Poor reading + writing skills (many are illiterate).
- Communication difficulties.
- Too few permanent sites.
- Mistrust of professionals.
183
SOCIAL EXCLUSION
What are some barriers to healthcare for the homeless?
- Difficulties with access to healthcare (opening times, appointment + procedures location, perceived ± actual discrimination).
- Lack of integration between primary care services + other agencies (housing, social services, criminal justice system).
- Other things on their mind (people do not prioritise health when there are more immediate survival issues).
- May not know where to go or may be unable to get there.
184
SOCIAL EXCLUSION
What are some barriers to healthcare for immigrants?
- Language, cultural + communication barriers.
- Racism, prejudice, discrimination + stigma.
- Different perceptions of care.
- May not know how the NHS works.
185
SOCIAL EXCLUSION
Define asylum seeker.
a person who has made an application for refugee status.
186
SOCIAL EXCLUSION
Define refugee
a person granted asylum + refugee status, usually means leave to remain for 5 years then reapply.
187
SOCIAL EXCLUSION
Define humanitarian protection.
failed to demonstrate claim for asylum but face serious threat to life if returned. Usually 3 years then reapply.
188
SOCIAL EXCLUSION
What are some asylum seekers entitlements?
- Housing but no choice of where.
- Cash support amounting £37pp in the household (or £35 if refused).
- Full access to NHS (free prescriptions, eyesight tests, dental care).
- Education for children 5–17.
189
SOCIAL EXCLUSION
What health problems affect asylum seekers?
- Common illness + illnesses specific to country of origin.
- Injuries from war + travelling.
- No previous health surveillance, neonatal screening, immunisations.
- Malnutrition, torture + sexual abuse (including FGM).
- Communicable + blood borne diseases.
- PTSD, depression, psychosis, self-harm, sleep disturbance.
190
DOMESTIC ABUSE
Define domestic abuse.
Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged ≥16 who are or have been, intimate partners or family members regardless of gender or sexuality.
- Includes – psychological, physical, sexual, financial + emotional.
191
DOMESTIC ABUSE
How might domestic abuse present?
Traumatic injuries following an assault:
- #s, miscarriage, facial injuries, bruises, haemorrhages, puncture wounds.
Somatic problems or chronic illness consequent on living with abuse:
- Headaches, GI issues, chronic pain, premature delivery, low birth weight.
Psychological/psychosocial problems secondary to abuse:
- PTSD, parasuicide, substance misuse, depression, anxiety, eating disorders.
192
DOMESTIC ABUSE
What are some indications of domestic abuse?
- Unwitnessed by others.
- Repeat attendances to GP or A+E (especially during unsociable hours).
- Delay in seeking help + multiple minor injuries?
193
DOMESTIC ABUSE
What assessment tool can be used in domestic abuse?
Domestic Abuse + Sexual Harassment (DASH) tool.
- Encourages you to gather information about everything that is going on in the situation.
- No score that = high risk but may say something that suddenly makes you think they're high risk + need intervention.
194
DOMESTIC ABUSE
What does a standard/medium DASH risk mean and how do you manage this?
Lower likelihood of serious harm:
- It's their choice what to do.
- Give them contact details for domestic abuse services + let them decide.
- CANNOT break confidentiality.
195
DOMESTIC ABUSE
What does a high DASH risk mean and how do you manage this?
Risk of imminent or serious harm:
- Refer to MARAC/IDVAS (wherever possible with consent).
- CAN break confidentiality.
196
DOMESTIC ABUSE
What is MARAC?
Multi-Agency Risk Assessment Conference:
- Meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, IDVAS, probation + other specialists.
197
DOMESTIC ABUSE
What will happen in the MARAC?
- Representatives discuss options for increasing safety of victim + turn these into a coordinated action plan with primary focus of safeguarding victim.
- MARAC will also make links to safeguard any children + manage the behaviour of the perpetrator so it considers all those involved.
198
DOMESTIC ABUSE
What is IDVAS?
What do they do?
- Independent Domestic Abuse Advisers.
- Help victims to navigate the domestic abuse services.
199
DOMESTIC ABUSE
How do IDVAS help victims navigate the domestic abuse services?
- Advocacy + advice around domestic abuse, safety planning.
- Support through court proceedings.
- Signposting to specialist services (housing, legal services).
- A voice in the MARAC process + a single point of contact.
200
DOMESTIC ABUSE
What do individuals want a doctor to do in terms of domestic abuse?
- Take initiative + ask.
- Try + speak to them alone.
- Document everything they say + any injuries.
- Display helpline posters + contact cards to create comfortable environment.
- Ask direct questions being non-judgemental + reassuring.
- Only report to police if safe to do so – focus on patient's + children's safety.
- Give info + refer where appropriate (work with other agencies).
201
DOMESTIC ABUSE
In terms of domestic abuse, what should doctors not do?
- Assume someone else will take care of things (they may be their only contact).
- Ask about domestic abuse in front of family/informal interpreters.
- Tell them what to do, they are the expert in their own situation.
202
DOMESTIC ABUSE
What is the impact of children living with domestic abuse?
- Affects their physical + psychological health, has long-term impacts on self-esteem, relationships, education + stress.
- Link between child abuse + domestic abuse so always consider safeguarding duty.
203
UNDERAGE SEX
What are some issues related to teenage pregnancy?
Negative outcomes for both mothers + child:
- Poor health.
- Lower academic achievement, socioeconomic status + self-esteem.
- Under achievement at work.
204
UNDERAGE SEX
What are some compliance issues with contraception?
- SEs like acne, weight gain.
- Mood changes.
- Fertility concerns.
- Bleeding patterns.
205
UNDERAGE SEX
What does the law regarding underage sex state?
- Child <13 CANNOT consent to sex so it is rape in ANY circumstance.
- Child 13–15 is underage for sex but can legally consent (if mutually agreed + not abusive or exploitative).
- Confidentiality can be broken in a case of safeguarding or child welfare.
206
UNDERAGE SEX
What is meant by Gillick Competence + Fraser guidelines?
- Refers to Gillick court case about underage contraception.
- Fraser guidelines are criteria that judges the competence of a young person to make decisions about contraception without parental consent.
- If they satisfy the criteria, they are Gillick competent.
207
UNDERAGE SEX
What are the Fraser guidelines?
- Patient understands the advice given.
- It's likely that the patient will continue to have sexual intercourse ± contraception.
- The patient's physical or mental health may suffer as a result of withholding contraceptive advice or treatment.
- It's in the best interests of the patient + the doctor to provide contraceptive advice + treatment without parental consent.
- Patient cannot be persuaded to inform their parents.
208
DEFINITIONS
Define salutogenesis.
Favourable physiological changes secondary to experience which promote healing + health.
209
DEFINITIONS
Define emotional intelligence.
Ability to identify + manage one's own emotions as well as those of others.
210
MODELS OF BEHAVIOURAL CHANGE
Give 4 models of behavioural change?
Health Belief Model
Theory of Planned Behaviour
Transtheoretical model
motivational interviewing
211
MODELS OF BEHAVIOURAL CHANGE
Aside from the recognised models, what factors might influence a person’s ability to change their behaviour(s) eg. smoking cessation
Impact of personality traits on health behaviour
Assessment of risk perception
Impact of past behaviour / habit
Automatic influences on health behaviour
Predictors of maintenance of health behaviours
Social environments
212
MODELS OF BEHAVIOURAL CHANGE
What are the transition points in life for behaviour change?
Typical transition points include:
> leaving school
> entering the workforce
> becoming a parent
> becoming unemployed
> retirement + bereavement
213
SUBSTANCE MISUSE
The ICD-10 can be used to assess addiction. What behaviours might a person who is addicted to drugs / alcohol exhibit?
Craving
Tolerance
Compulsive drug-seeking behaviour
Physiological withdrawal state
214
SUBSTANCE MISUSE
List some acute physical effects of dependent drug use.
Complications of injecting -> DVT, Abscesses
Overdose -> respiratory depression
Poor pregnancy outcomes
Side effects of opiate: constipation, low salivary flow
215
SUBSTANCE MISUSE
List some chronic physical effects of dependent drug use.
Blood-borne virus transmission e.g. Hep C
Effects of poverty
SE of cocaine: vasoconstriction, local anaesthesia
216
SUBSTANCE MISUSE
List some social effects of dependent drug use.
Effects on families / relationships
Social exclusion
Driven to criminality
Imprisonment
217
SUBSTANCE MISUSE
List some psychological effects of dependent drug use.
Fear of withdrawal
Craving
Guilt
all are temporarily alleviated by drug use.
218
SUBSTANCE MISUSE
How does Heroin act?
How is it used?
Acts at opiate receptors; used 8 hourly
Routes of administration:
> smoking / snorting
> oral / rectal
> sub cut / IV / IM
219
SUBSTANCE MISUSE
What are the effects of Heroin?
Euphoria
Intense relaxation
Miosis (excessive pupil constriction)
Drowsiness
220
SUBSTANCE MISUSE
What are the adverse effects of heroin?
dependance + withdrawal symptoms
physical complications -> nausea, itching, sweating, constipation
over dose :(
221
SUBSTANCE MISUSE
How does Cocaine / Crack act?
Blocks re-uptake of mood-enhancing neurotransmitters at the synapse (serotonin, dopamine)
Intense, pleasurable sensation
Reinforcement -> leads to further use
Depletion at sensory neurone
222
SUBSTANCE MISUSE
What are the effects of Cocaine / Crack?
Confidence, well-being, euphoria, impulsivity, increased energy, alertness
impaired judgement, decreased need for sleep
223
SUBSTANCE MISUSE
What are the ‘negative’ effects of Cocaine / Crack?
May produce anxiety, hypertension, arrhythmias
subsequent ‘crash’ -> dysphoria
Chronic effects:
depression, panic, paranoia, psychosis
damaged nasal septum
cerebrovascular accidents
respiratory problems
224
SUBSTANCE MISUSE
What are the aims of treatment for drug users?
To reduce harm to user, family + society
To improve health
To stabilise lifestyle, and decrease the amount of illicit drug use
Reduce crime
225
SUBSTANCE MISUSE
What are the modalities of treatment for drug users?
Harm reduction
Detoxification
Maintenance
> Methadone = full agonist
> buprenorphine = partial agonist
Relapse prevention -> Naltrexone
Psychological interventions
Referral for allied problems (Hep C, STIs, etc.)
226
SUBSTANCE MISUSE
What can I offer a newly presenting drug user?
Health check
Screening for blood borne viruses
Contraception, smear
Sexual Health Advice
Check general immunisation status
Sign post to additional help
Information on local drugs services, including needle exchange
227
SUBSTANCE MISUSE
You are an F1 + you need to do a quick assessment of a newly presenting drug user.
What 6 questions should you ask?
1. Which drug?
2. Route of administration?
3. How long have they been addicted?
4. What is the patient’s goal?
- quick detox -> good outcomes in new users
- slow reduction / maintenance
5. Does the patient need a referral?
- eg. pregnancy, severe psychiatric co-morbidity, Hep C positive
6. Does the patient require interagency working / specialised support?
- child protection issues
- housing problems etc.
228
SUBSTANCE MISUSE
What are the 3 levels of Basic Harm Reduction (as applied to drug users).
Action to prevent deaths
Action to prevent blood borne virus transmission
Referral where appropriate.
229
SUBSTANCE MISUSE
Who might be suitable for quick detoxification (as applied to drug use)?
Young user
Less time addicted
Often not injecting
Lower level of drug use
230
SUBSTANCE MISUSE
What medication(s) might you use for quick detoxification (of drug use)?
Buprenorphine is 1st line
> Lofexidine in very young / very low level use
Other symptomatic medication
Support from other agencies + teams
231
SUBSTANCE MISUSE
Following drug use, who might be suitable for ‘Stabilisation + Maintenance’?
Opiate user
Longer time addicted, usually injecting
May be high levels of drug use
232
SUBSTANCE MISUSE
What is the aim of ‘Stabilisation + Maintenance’ following drug use?
How is the medication used?
Harm minimisation
Use methadone or buprenorphine
Titrate from a low starting dose to a maintenance dose.
Keep people alive until they are ready to become abstinent
233
What is the aim of treating a person who is using crack cocaine?
1. Harm reduction is key -> no substitute meds are available
- advice on safe sex / contraception / blood borne virus advice
2. Brief Intervention
- explanation of effects / risks
- setting limits
- cognitive based approaches
3. Team working
- Refer to Sexual Health / Infectious Diseases
- Referral for specialist advice, if appropriate
234
SUBSTANCE MISUSE
What is involved in drug relapse prevention?
Naltrexone tablets are licensed
> check LFTs, Urinalysis
> warnings regarding concomitant heroin use
MDT approach = essential
Constantly relapsing patients may need stabilisation + maintenance to avoid ‘revolving door’
235
SUBSTANCE MISUSE
What considerations should you have when a drug user comes into hospital?
may be very ill
may be craving drugs, esp. opiates
may fear a negative response from staff
may already be prescribed maintenance medication (needs to be continued)
may be untreated and will need to start treatment if they are to stay in hospital
liaison between community + hospital prescribers on admission + discharge
236
ALCOHOLISM
What are the recommended alcohol intake levels for men and women?
14 units / week
237
ALCOHOLISM
What is the guidance for alcohol consumption during pregnancy?
Abstain for 1st trimester
- No more than 2 units / week in the 2nd and 3rd trimesters
238
ALCOHOLISM
What is ‘hazardous drinking’?
Pattern of alcohol use which increases someone’s risk of harm
239
ALCOHOLISM
What is ‘higher risk drinking’?
Men: 50+ units / week
Women: 35+ units / week
240
ALCOHOLISM
What is ‘increasing risk drinking’?
Men: 22-50 units / week
Women 15 - 35 units / week
241
ALCOHOLISM
What is a ‘unit’ of alcohol?
A standard measurement of the alcohol content of a drink. Takes into account the strength (%ABV) and the volume.
242
ALCOHOLISM
Give an equation used to calculate the number of units in a drink.
[ % ABV x volume (mls) ] / 1000 = units
243
ALCOHOLISM
Why do men metabolise alcohol faster?
Due to their %age body fat.
244
ALCOHOLISM
Describe the aetiology of problem drinking.
Individual
> genes / personality / physique
> occupation
> advertising / availability / peer group
Family
> Religion / tradition / culture
245
ALCOHOLISM
Why are women now drinking more than ever?
more socially acceptable
more disposable income
more drinks marketed at women
more drinking places aimed at women customers
246
ALCOHOLISM
Give 5 social + psychological risk factors for problem drinking
Drinking within the family
Childhood problem behaviour relating to impulse control
Early use of alcohol, nicotine + drugs
Poor coping responses to life events
Depression as a cause (not a result) of problem drinking
247
ALCOHOLISM
How might Alcohol + Deprivation be linked?
Adverse effects of alcohol exacerbated amongst lower SE groups
more likely to experience negative effects directly and indirectly
lack of money means they are less likely to protect themselves against negative health + social consequences
more likely to die of causes influenced by - or attributable to - alcohol
248
ALCOHOLISM
What are the 4 most common causes of death due to alcohol?
Accidents + violence
Malignancies
Cerebrovascular disease
Coronary Heart Disease
249
ALCOHOLISM
Alcohol causes multi system disease, and has physical, psychological + social implications. What might be some of the physical manifestations of alcohol disease?
Liver disease
Birth defects -> fetal alcohol syndrome
Respiratory
Neurological
Haematological
Rheumatological
250
ALCOHOLISM
Describe the possible progression of liver disease in an alcoholic.
Fatty liver -> Cirrhosis
No significant risk of liver damage at less than 30g alcohol / day
Fatty liver reversible on withdrawing alcohol
251
ALCOHOLISM
Give some symptoms of mild - moderate alcoholic hepatitis.
Anorexia
Nausea
Abdominal pain
Weight loss
patients are more susceptible to infection
252
ALCOHOLISM
What are the signs of severe alcoholic hepatitis?
Ascites
Bleeding
Encephalopathy
severe alcoholic hepatitis is a medical emergency
253
ALCOHOLISM
What is the relationship between alcohol + heart disease?
Moderate alcohol intact can protect against interstitial heart disease
Heavy alcohol use increases risk -> hyperlipidaemia, hypertension
> alcohol can precipitate arrhythmias eg. Atrial Fibrillation
254
ALCOHOLISM
What is the relationship between alcohol + cancer?
25-50% head and neck cancers due to alcohol
- Other alcohol-related cancers: breast, liver, stomach, colon, rectum, pancreatic
255
ALCOHOLISM
What is the recommended alcohol intake during pregnancy?
NO ALCOHOL IS SAFE IN PREGNANCY
None in the 1st trimester
- 2-3 units / week in 2nd + 3rd trimesters
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How does excess alcohol intake affect a pregnancy?
Increased rate of miscarriage
- Low birthweight babies
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What does persistent drinking throughout pregnancy lead to?
Foetal Alcohol Syndrome
small, underweight babies; slack muscle tone
mental retardation; behavioural + speech problems
characteristic facial appearance
cardiac, renal + ocular abnormalities
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What percentage of Child Protection cases involve parental alcohol use?
30 - 60%
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What can be done to curb alcohol usage?
Increase price + decrease supply
Screening + brief interventions from healthcare workers
Develop a more ‘joined up’ approach from services
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What Public Health measures might be used to reduce alcohol usage?
Minimum price per unit of alcohol
Change licensing laws in areas where cirrhosis is the biggest problem
Reduce ‘passive drinking’ effects
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What is the recommended management for people requesting help with an alcohol problem.
Perform physical + mental assessment
Offer appropriate investigation(s) + follow up
Offer referral / treatment as appropriate
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What should you consider under ‘general support + care’ for a person requesting help with an alcohol problem?
Address other health issues, as well
Consider vitamin supplementation
Assess interstitial heart disease risk
Consider osteoporosis risk
Tailor health assessment to an individual
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When should blood tests be used with regards to a person who is known to drink alcohol in excess?
Should NOT be used in screening
- use in established alcohol-related disorder to assess severity + progress in primary care / hospital
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What screening questionnaires can be conducted if a person is suspected of excessive alcohol consumption?
Who are these questionnaires recommended for?
AUDIT or CAGE
- Recommended for ‘at risk’ groups, including children
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When should you consider using the AUDIT or CAGE questionnaires?
Consider in all adults presenting with health problems commonly linked to alcohol problem drinking
not blood tests
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What does the AUDIT questionnaire (alcohol use) comprise?
10 point questionnaire; 5 mins to carry out
Hazardous drinking: Score 8 +
Alcohol dependence: Women = 13; Men = 15
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What are the 4 questions which make up the CAGE questionnaire?
Have you ever thought you needed to CUT DOWN on your drinking?
Have you ever become ANGRY/ANNOYED at people criticising your drinking?
Do you ever feel GUILTY about your drinking?
Have you ever had an EYE-OPENER in the morning to ease your hangover?
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What is the sensitivity + specificity of the CAGE questionnaire for alcohol usage?
Sensitivity = 87%
Specificity = 65%
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Brief structured advice (Motivational interviewing) has been shown to reduce alcohol intake. What might this discussion cover?
Potential harm caused
Reasons for changing
> health + wellbeing benefits
> obstacles to change
> strategies to combat
> goals
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What medications might be used to prevent an alcoholic person from relapsing?
Disulfiram -> sensitise against alcohol
Acamprosate -> GABA blocker
Naltrexone -> used in specialist centres
none of these agents are particularly effective
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How does acamprosate help with stopping alcohol relapse?
reduces cravings
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How does disulfram help with stopping alcohol relapse?
Promotes abstinence - even a small amount of alcohol can induce bad symptoms such as nausea and vomiting
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How is Alcohol Dependence Syndrome classified?
Cluster of 3 of the below symptoms in a 12 month period:
Tolerance: increasing the amount of alcohol to achieve the same effect
Characteristic physiological withdrawal
Difficulty controlling onset, amount + termination of use
Neglect of social + other areas of life
Spending more time obtaining + using alcohol
Continued use, despite negative physical and psychological effects
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What is Wernicke’s Encephalopathy?
Vitamin B1 deficiency, often occurring on withdrawal of alcohol.
Reversible.
Not treating can lead to Korsakoff’s.
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Wernicke’s Encephalopathy is characterised by a triad of symptoms. Name these symptoms.
Acute mental confusion
Ataxia
Ophthalmoplegia
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How should Wernicke’s Encephalopathy be treated?
Timely injections of Thiamine (Vitamin B1)
Poorly absorbed orally
Small risk of anaphylaxis when given IV.
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What is Korsakoff’s syndrome?
Amnestic disorder due to enduring B1 malnutrition
not reversible
short term memory loss
lose spontaneity, initiative
confabulation -> disturbance in memory, defined as the production of fabricated, distorted or misinterpreted memories about oneself or the world.
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How is diagnosis of Korsakoff’s syndrome made?
CT scan
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What is Delirium Tremens?
A short-lived (3-5 days) toxic confusional state which usually occurs as a result of reduced alcohol intake in alcohol dependent individuals with a long history of use.
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What symptoms might a person experiencing delirium tremens present with?
Clouding of consciousness / confusion / seizures
Hallucinations in any sensory modality
Marked tremor
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What is the treatment for Delirium Tremens?
Supportive:
> Fluids
> Benzodiazepines
Detoxification in acute situation -> use Benzodiazepines
Need support: effective in short term in hospitals
Don’t forget about Pabrinex!!! (Vitamin B1)
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When do symptoms of withdrawal appear?
6-12 hours after last drink
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When do seizures occur in withdrawal?
Peak incidence is 36 hours after last drink
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When does delirium tremens occur in withdrawal?
Peak incidence is 48-72 hours after last drink
