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Phase 3a > Public Health > Flashcards

Public Health Flashcards

1
Q

Definition of public health

A

The science and art of preventing disease, prolonging life and promoting health through organised efforts of society

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2
Q

What is population perspective?

A

Thinking in terms of groups rather than individuals

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3
Q

What are the 4 determinants of health (Lolande Report 1974)?

A
  • Genes
  • Environment (physical and social + economic)
  • Lifestyle
  • Health Care
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4
Q

Name 2 classifications for determinants of health

A

Lolande Report 1974 - 4 determinants

Dahlgren and Whitehead 1991 - more detailed classification

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5
Q

What are wider/social determinants of health?

A

Factors not related to healthcare

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6
Q

Describe the3 types of prevention with examples and the targets of each

A

Primary Prevention: prevent the disease from ever occurring
- Examples; childhood immunisations eg MMR
- Healthy individuals who are susceptible (everyone)

Secondary Prevention: emphasises early disease detection and includesmeasures that lead to early diagnosis and prompt treatment of a disease
- Examples; screening (breast ca -> mammograms, cervical ca -> pap smears)
- Target is healthy-appearing individuals with subclinical forms of the disease (consists of pathologic changes, but no overt symptoms that are diagnosable in a doctor’s visit)

Tertiary Prevention - Minimise complications of the disease, reduce the effects of the disease once established in an individual
- Examples; Rehabilitation efforts (stroke and cardiac rehab)
- Implemented in symptomatic patients and aims to reduce the severity of the disease as well as of any associated sequelae

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7
Q

Difference between equality and equity

A

Equality - equal shares

Equity - judgement about what is fair and just

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8
Q

Different types of equity and definitions w/ examples

A

Horizontal Equity - Equal treatment for equal need
- Individuals with pneumonia (with all other things being equal) should be treated equally

Vertical Equity - Unequal treatment for unequal need
- Areas with poorer health may need more expenditure on health services

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9
Q

What are the 5 different forms of health equity?

A
  • Equal expenditure for equal need
  • Equal access for equal need
  • Equal utilisation for equal need
  • Equal health care outcome for equal need
  • Equal health
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10
Q

What are the dimensions of health equity?

A

Spatial - eg geographical

Social - age, gender, class/socioeconomic status and ethnicity

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11
Q

Methods of assessing health equity in health care systems

A

Utilisation
Health Status
Supply

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12
Q

What are the 3 public health domains?

A

Health Improvement - Concerned with societal interventions (not primarily delivered through health services) aimed at preventing disease, promoting health, and reducing inequalities

Health Protection - Concerned with measures to control infectious disease risks and environmental hazard

Healthcare - Concerned with the organisation and delivery of safe, high quality services for prevention, treatment, and care

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13
Q

Give examples of measures used when implementing each domain of public health

A

Health Improvement - education, housing, employment, lifestyles, family/community, addressing inequalities

Health Protection - infectious disease control, chemical and poisons, radiation, emergency response, environmental health hazards

Healthcare - clinical effectiveness, efficiency, service planning, audit and evaluation, clinical governance, equity

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14
Q

What is an intervention + examples

A

Anything done to improve public health
- Health service / public health interventions
- Non-health interventions (e.g. improving the economy and social conditions) which also have an impact on public health

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15
Q

What are the different intervention levels + examples?

A

Individual Level - childhood immunisations

Community Level - interventions delivered to local community eg playground built for community

Ecological/Population Level - general interventions with far-reaching implications eg Clean Air Act (legislation to ban smoking in enclosed public spaces)

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16
Q

What is the purpose of a health needs assessment?

A

Needed when wanting to improve the health of a population sub group carried out for:
- A population subgroup
- A condition (sufferers of COPD)
- Intervention (eg coronary angioplasty)

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17
Q

What is the difference between a health need and a health care need?

A

Health need - need for health, concerns need in more general terms eg measured using mortality, morbidity, socio-demographic measures

Health care need - need for health care, more specific, ability to benefit from healthcare, depends on the potential of prevention, treatment and care services to remedy health problems

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18
Q

Describe the planning cycle

A
  1. Needs Assessment
  2. Planning
  3. Implementation
  4. Evaluation
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19
Q

NICE definition of need

A

Ability to benefit from an intervention

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20
Q

Bradshaw definitions of need

A

(Sociological perspective)

  • Felt need - individual perceptions of variation from normal health
  • Expressed need - individual seeks help to overcome variation in normal health (demand)
  • Normative need - professional defines intervention appropriate for the expressed need
  • Comparative need - comparison between severity, range of interventions and cost
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21
Q

NICE definition of health needs assessment

A

A systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities

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22
Q

What are the 3 methods of carrying out a health needs assessment?

A

Epidemiological -
* Define problem
* Size of problem
* Incidence / prevalence
* Services available
* Prevention / treatment / care
* Evidence base
* Effectiveness and cost-effectiveness
* Models of care
* Including quality and outcome measures
* Existing services
* Unmet need; services not needed
* Recommendations

Comparitive - Compares the services received by a population (or subgroup) with others (Spatial and Social [age, class, gender, ethnicity]). May examine:
* Health status
* Service provision
* Service utilisation
* Health outcomes - mortality, morbidity, quality of life, patient satisfaction

Corporate - obtaining the views of a range of stakeholders (patients, their families, providers, professionals, commissioners etc)

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23
Q

Disadvantages of the epidemiological approach to health needs assessment

A
  • Required data may not be available
  • Variable data quality
  • Evidence base may be inadequate
  • Does not consider felt needs of people affected
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24
Q

Disadvantages of the comparative approach to health needs assessment

A
  • May not yield what the most appropriate level (eg of provision or utilisation) should be; shows difference but doesn’t answer the question as to what’s better
  • Data may not be available
  • Variable data quality
  • May be difficult to find a comparable population
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25
Q

Disadvantages of the corporate approach to health needs assessment

A
  • May be difficult to distinguish need from demand
  • Groups may have vested interests (eg pharma companies, politicians, press)
  • May be influenced by political agendas
  • Dominant personalities may have undue influence
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26
Q

What is health psychology?

A

Emphasises the role of psychological factors in the cause, progression and consequences of health and illness

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27
Q

What are the 2 main aims of health psychology?

A
  • Promoting healthy behaviours
  • Preventing illness
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28
Q

What are the 3 main categories of behaviours related to health + definitions + examples?

A
  • Health behaviour; a behaviour aimed to prevent disease eg eating healthy
  • Illness behaviour; behaviour asimed to seek remedy eg going to the doctor
  • Sick role behaviour; any activity aimed at getting well eg taking prescribed medications, resting
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29
Q

What are the 2 categories of health behaviours?

A

Health Damaging/Impairing - eg smoking, alcohol abuse, sun exposure

Health Promoting - eg taking exercise, healthy eating, medication complicance

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30
Q

What proportion of cancers are potentially preventable by attending to modifiable risk factors/lifestyle?

A

1/3

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31
Q

Domestic Abuse - definition

A

Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to:
○ Psychological
○ Physical
○ Sexual
○ Financial
○ Emotional

*Definition of family members includes people you have lived with but are not related to eg step family members

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32
Q

Domestic Abuse - What model can be used to demonstrate domestic abuse characteristics in a relationship?

A

Duluth Model - Power and Control

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33
Q

Domestic Abuse - best indicators

A

*Injury is reported as unwitnessed by anyone else
*Repeat attendance
*Delay in seeking help
*Multiple minor injuries not requiring treatment
*Presenting between 7pm and 7am
*Majority present with assault injuries

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34
Q

Domestic Abuse - screening questionnaire (brief); questions and examples

A

HARK

  • 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?”
  • Afraid; “In the last year have you been afraid of your partner or ex-partner?” “What does your partner do that scares you?”
  • 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 you have to have sex when you don’t want to?” “Are you ever forced to do anything you are not comfortable with?”
  • Kick; “In the last year have you been physically hurt by your partner?” “Does your partner threaten to hurt you?”
35
Q

Domestic Abuse - what is a MARAC

A

Multi-Agency Risk Assessment Conference (MARAC) - In a single meeting, links up to date information about victims’ needs & risks directly to the provision of appropriate services & responses for all those involved: victim, children, perpetrator.

36
Q

Domestic Abuse - what is the IDVA service?

A

Independent Domestic Violence Advisor Service (IDVAS) - works primarily with victimswho are at the highest levels ofrisk from domestic abuse in Sheffield, andhelps them to increase their safetyby providing: advocacy and advice around domestic abuse, safety planning, support through court proceedings, signposting to specialist services: housing, legal services, refuge provision and home safety services, a voice in the MARAC process.

37
Q

Domestic Abuse - what is a Domestic Homicide Review (DHR)?

A

A review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by: (a) a person to whom (s)he was related or with whom (s)he was or had been in an intimate personal relationship, or (b) a member of the same household as himself. Held with a view to identifying the lessons to be learnt from the death. Age 16-17: SCR takes precedence; criteria include suicides.

38
Q

Domestic Abuse - referral for standard, medium and high risk?

A

Standard/Medium Risk - Give contact details for Domestic Abuse services, keep good records, ensure follow up as needed.

High Risk - Refer to MARAC/IDVAS (local authority meeting - police, social care, GP, housing, probation etc, IDVAS is the independent advocate) in addition to the above, wherever possible with consent, can be done via helpline as well
*However, for HIGH risk cases, you can break confidentiality to do so if you cannot get consent.

39
Q

Domestic Abuse - 3 red flag risk factors from dynamic risk assessment

A

Strangling/Choking/Drowning - less likely to admit to these compared to other forms of harm like hitting

Access to weapons - eg abuser works in police, w/ pesticides, soldier

Suicidal intent in perpetrator - doesn’t care about consequences when abusing as isn’t planning to be around

40
Q

Domestic Abuse - 2 important considerations during consultation

A

When told about domestic abuse by patient - always acknowledge that that behaviour is wrong; doing nothing is perceived to be tacet acceptance

Never tell them what to do (behaviourally) - they are treading a fine line and stepping outside of that may trigger a response from abuser, empower them instead to make safe and informed choices

41
Q

Opioids - which opioid is safe to prescribe in renal failure?

A

Fentanyl - mainly metabolised by the liver so won’t accumulate in the blood during renal failure

(Buprenorphine will accumulate but to a lesser extent than the other opioids)

42
Q

Opioids - examples of naturally occurring compounds, semi-synthetic compounds and synthetic compounds

A

Naturally Occurring Compounds
* Morphine
* Codeine
* Thebaine
* Papaverine

Semi-Synthetic Compounds
* Diamorphine (heroin)
* Dihydromorphone
* Buprenorphine
* Oxycodone

Synthetic Compounds
* Pethidine
* Fntanyl
* Methadone
* Alfentanil
* Remifentanil
* Tapentadol

43
Q

Pain prescribing in primary care - numbers needed to treat or amitriptyline and pregabalin (for chronic non-malignant pain management)

A

Amitriptyline - NNT = 5

Pregabalin - NNT = 7

44
Q

Opioids - time frame for efficacy of opioids in management of chronic non-malignant pain

A

No evidence that opioids help for chronic non-malignant pain beyond 3 months

So review after 3 months and if no effect, stop it

45
Q

Opioids - strategy for preventing opioid dependence when first prescribing?

A

Manage expectations when prescribing - say this will work for a short period of time but isn’t a long term fix

46
Q

Opioids - S/E

A
  • Constipation
  • Addiction
  • N+V
  • Endocrine (dampening down) - anterior pituitary hormone suppression
  • Immune suppression (dampening down not suppression)
  • Drowsiness
  • Respiratory depression + sleep disordered breathing - especially in combination with benzos, pregabalin etc, risk increased with obesity (OSA) and alcohol use
    ○ Patient may likely say that they are tired all the time (think anti-cholinergic burden)
    *Itch
47
Q

Opioids - what type of laxative should be used to treat opioid-induced constipation

A

Stimulant laxatives like senna and bisacodyl

48
Q

Opioids - withdrawal symptoms

A
  • Sweating
  • Anxiety
  • Vomiting
  • Hallucinations
  • Jittering
    *Sneezing
    *Insomnia
49
Q

Opioids - signs of addiction

A
  • Use of pain medications other than for pain treatment
  • Impaired control (of self or of medication use)
  • Compulsive use of medication
  • Continued use of medication despite harm (or lack of benefit)
  • Craving or escalation of medication use
  • Selling or altering prescriptions
  • Stealing or diverting medications
  • Calls for early refills / losing prescriptions
    *Reluctance to try nonpharmacologic interventions.
50
Q

Opioids - key associations with dependency

A
  • Age: High in younger and then decreases with age increases.
  • Marital Status: Highest in those cohabiting but not married.
  • Employment: Highest dependency in the unemployed.
  • Ethnicity: Highest rates in non white population.
  • General Health : Very bad health has a strong association.
  • Smoking : Association with smokers compared to non-smokers
  • Internet Pharmacy: High association between buying on the internet and dependency

*No statistically significant association with opioid dependency and gender, education and alcohol use

51
Q

Pain - 3 components that make up pain

A
  • Physical Component
    ○ Eg injury
    ○ Brain tries to manage it itself
  • Psychological Component
    ○ Depression from being in pain all the time
    ○ Because it hurt yesterday it will hurt again today thought pattern
  • Environmental Component
    ○ Stress factors - eg anti-social environment
    (Shit life syndrome)
52
Q

Pain - definitions of allodynia and hyperalgesia

A

Allodynia - pain due to a stimulus that does not normally provoke pain

Hyperalgesia - an increased sensitivity to feeling pain and an extreme response to pain

53
Q

Opioids - MOA

A
  • There are three opioid receptors, MOR (µ), KOR(κ) and DOR(δ)
  • Opioid receptors are distributed throughout the central nervous system, to a lesser extent in the periphery, and also occupying sites within the vas deferens, knee joint, gastrointestinal tract, heart and immune system

*The presynaptic action of opioids inhibiting neurotransmitter release is considered to be their major effect in the nervous system.

54
Q

Opioids - positive effects

A

Analgesia for short term pain relief eg post operative pain

55
Q

Opioids - guidance on treating chronic non-malignant pain

A
  • It is crucial that the potential benefits and potential risks are discussed with the patient.
  • Side effects resulting from continuing use of opioids may include tolerance, withdrawal, weight gain, reduced fertility and irregular periods, erectile dysfunction, hyperalgesia, depression, dependence, addiction, reduced immunity, osteoporosis and constipation.
    *There is a variety of evidence regarding misuse of these medicines and this should be considered particularly when prescribing to at risk patients.

Consider non pharmacological measures:
*Physical - eg weight loss, smoking cessation, exercise/physio
*Psychological - counselling, CBT, meditation etc
*CT - massage reflexology
*Occupational - work place based review

Consider pharmacological interventions:
* Non-opioid analgesics - NSAIDs, COX-2 inhibitors, paracetamol
* Opioid analgesics - intermittent usage/slow and low
* Adjuvant analgesics - anti-convulsants, antidepressants, lidocaine patches

56
Q

Pain - which anti-depressant is licensed for use in pain management?

A

Duloxetine

57
Q

Models of Behaviour Change - name 6 models of behaviour change

A

Health Belief Model (HBM)

Theory of Planned Behaviour (TPB)

Stages of Change/Transtheoretical Model (TTM)

Social Norms Theory

Motivational Interviewing

Nudging (Choice Architecture)

58
Q

Models of Behaviour Change - factors to consider when using these models

A

Despite growing interest in their use, mixed patterns of results reported

Single unifying theory has yet to be developed

Other factors need to be considered eg impact of past behaviour/habit, automartic influences on health behaviour

59
Q

Health Belief Model (HBM) - individuals will change if they…

A
  • Believe they are susceptible to the condition in question (e.g. heart disease)
  • Believe that it has serious consequences
  • Believe that taking action reduces susceptibility
  • Believe that the benefits of taking action outweigh the costs
60
Q

Health Belief Model (HBM) - cues to action

A

Unique to HBM

Can be internal or external cues

Not always necessary for behaviour change

61
Q

Health Belief Model - critiques

A
  • Alternative factors may predict health behaviour, such as:
    ○ Outcome expectancy (whether the person feels they will be healthier as a result of their behaviour)
    ○ Self-efficacy (the person’s belief in their ability to carry out preventative behaviour)
  • As a cognitively based model, HBM does not consider the influence of emotions on behaviour
  • HBM does not differentiate between first time and repeat behaviour
  • Cues to action are often missing in HBM research
62
Q

Theory of Planned Behaviour (TPB) Model - overview

A

Proposes the best predictor of behaviour is ‘intention’ e.g. I intend to give up smoking

Intention determined by:
○ A persons attitude to the behaviour
○ The perceived social pressure to undertake the behaviour, or subjective norm
*A persons appraisal of their ability to perceived behavioural control

Rational choice model - attitude, subjective norms, percieved behavioural control

63
Q

Theory of Planned Behaviour (TPB) Model - between intention and behaviour how can you help people to act on their intentions?

A
  • Perceived control – Fisher & Johnson (1996) patients with chronic back pain took part in a lifting task. Recalled success predicted success in the task
  • Anticipated regret – Abraham & Sheeran (2003) increased anticipated regret was related to sustained intentions
  • Preparatory actions – Stock & Cervone (1990) dividing a task in to sub-goals increases self-efficacy and satisfaction at the point of completion
  • Implementation intentions – Gollwitzer (1999) “if-then” plans facilitates the translation of intention in to action (specify a time and a context)
  • Relevance to self
64
Q

Theory of Planned Behaviour (TPB) Model - critique

A
  • Criticisms include the lack of a temporal element, and the lack of direction or causality (Schwarzer, 1982)
  • TPB is a “rational choice model”. Doesn’t take in to account emotions such as fear, threat, positive affect, all of which might disrupt “rational” decision making
  • Model does not explain how attitudes, intentions and perceived behavioural control interact
  • Habits and routines - which Simon (1957) referred to as “procedural rationality” - bypass cognitive deliberation and undermine a key assumption of the model
  • Assumes that attitudes, subjective norms and PBC can be measured
  • Relies on self-reported behaviour
65
Q

Stages of Change/Transtheoretical Model (TTM) - overview

A
  • Stage theories see individuals located at discrete ordered stages, rather than on a continuum
  • Each stage denotes a greater inclination to change outcome, typically behaviour, than the previous one
  • Examines the process of change, rather than factors that determine behaviour
  • Allows for interventions to be tailored to the individual according to what stage they are at

Transtheoretical model, or stages of change model (Prochaska & DiClemente, 1984)

66
Q

Stages of Change/Transtheoretical Model (TTM) - what are the stages

A

Proposes 5 stages of change (with smoking cessation example):

1) Precontemplation - No intention of giving up smoking

2) Contemplation - Beginning to consider giving up, probably at some ill-defined time in the future

3) Preparation - Getting ready to quit in the near future

4) Action - Engaged in giving up smoking now

5) Maintenance - Steady non-smoker, i.e. state of change reached

*Progress = travelling up from 1 onwards
**Relapse = travelling down

67
Q

Stages of Change/Transtheoretical Model (TTM) - advantages and critiques

A

Advantages
* Acknowledges individual stages of readiness (tailored interventions)
* Accounts for relapse
* Temporal element (although arbitrary)

Critiques
* Not all people move thorough every stage, some people move backwards and forwards or miss some stages out completely
* Change might operate on a continuum rather than in discrete stages
* Doesn’t take in to account values, habits, emotions, culture, social and economic factors
* People often change their behaviour in the absence of planning/ intentions can change over a very short time period

68
Q

Motivational Interviewing - what is it?

A

A counselling approach for initiating behaviour change by resolving ambivalence (having mixed feelings/contradictory ideas about something)

A meta-analysis did not support efficacy for smoking or HIV-risk behaviour, however clinical impact shown in problem drinkers

69
Q

Nudge Theory - overview

A
  • ‘Nudge’ the environment to make the best option the easiest –e.g. opt-out schemes such as pensions, placing fruit next to checkouts
  • To date, few nudging interventions have been evaluated for their effectiveness in changing behaviour in general populations and none has been evaluated for its ability to achieve sustained behaviour change.
  • At present, the evidence to support the view that nudging alone can improve population health is weak (Marteau, 2011)
70
Q

Social Norms Theory -

A

Perceptions of norms
○ Is the perception of peer norms the same as the actual peer norms - people misperceive the norms among their peers
○ Norm is positive protective behaviours
○ We typically overestimate the risk behaviour activity and underestimate the protective factors

*Eg university students thinking that the majority of students use cocaine when in reality its 5% (exact figures not relevant)

  • “If I think everyone else is doing it, even if I think it is wrong, I will do it to be like everyone else”
  • Let people know and promote what the majority are doing and that it is a healthy behaviour that is the social norm
71
Q

What are the 3 core principles of the NHS?

A
  • That it meets the needs of everyone
  • That it is free at the point of delivery
  • That it is based on clinical need, not ability to pay
72
Q

Definition of Health Inequalities

A
  • The preventable, unfair and unjust differences in health status between groups, populations or individuals
  • Arise from the 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.
73
Q

Inverse Care Law

A

The principle that the availability of good medical or social care tends to vary inversely with the need of the population served (Julian Tudor Hart 1971)

74
Q

Examples of vulnerable patient groups

A
  • Homeless
  • Gypsies and Travellers
  • Asylum Seekers
  • LGBTQ
  • Ex prisoners
  • Care leavers
  • Those with learning disabilities
  • Those with mental health problems
75
Q

Definitions of asylum seeker, refugee and indefinite leave to remain

A

Asylum Seeker - A person who has made an application for refugee status

Refugee - A person granted asylum and refugee status. Usually means leave to remain for 5 years then reapply

Indefinite Leave to Remain (ILR) - When a person is granted full refugee status and Given permanent residence in the UK

76
Q

What is an unaccompanied asylum seeking child

A
  • Is someone who has crossed an international border in search of safety and refugee status
  • Is applying for asylum in his/her own right
  • Is under the age of 18, or in the absence of documentary evidence appears to be under that age
  • Is without adult family members or guardians in this country
77
Q

Asylum seeker rights

A

Entitled to:
○ Money- currently £37.75 per week
○ Housing- no choice dispersal
○ Free NHS care

If under 18, have the services of a social services key worker and can go to school
○ NOT allowed to work
*NOT entitled to any other form of benefit

78
Q

What can an asylum seeker do once their asylum claim is approved by the home office?

A
  • Have five years leave to remain in the UK
  • Have the right to work and claim benefits
  • Access to mainstream housing
  • Can apply for family reunion
  • Can apply for a travel document

After five years of refugee status:
* Can apply for Indefinite Leave to Remain (ILR), and after a year of ILR can apply for British citizenship

79
Q

What happens to failed asylum seekers?

A
  • NOT entitled to any money
  • NOT housed
  • NOT entitled to full NHS care (only emergency care)
  • Reliant on charities
  • Maybe able to appeal the decision
  • Maybe detained in an immigration removal centre
80
Q

Definition of human trafficking

A

The movement of people, by means such as force, fraud, coercion or deception, with the aim of exploiting them
* It is modern day slavery

81
Q

What are the different types of exploitation faced by victims of human trafficking?

A
  • Sexual exploitation - prostitution
  • Domestic servitude - cleaning, cooking, looking after children
  • Forced labour - agriculture, construction, kitchens, car wash, nail bars, factories
  • Forced criminality - forced begging, illegal drugs, benefit frauds
82
Q

Red flags for trafficking

A

TRAFFICKING

  • Timid/terrified/tense
  • (not) Registered with GP/nursery/school
  • Accompanied by a controlling person
  • Foreign language
  • Frequently moving location
  • Inconsistent history
  • (No) Control of passport/bank account
  • Keep alert!
  • Evidence of injuries left untreated
  • DNA future appointments
83
Q

If human trafficking/modern slavery is suspected by who do you refer to?

A

National Referral Mechanism

Phase 3a (7 decks)

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