public health Flashcards
what are the 3 domains of public health
health improvement (social interventions to promote health & reduce inequalities)
health protection ( disease control measures & environmental hazards)
health care ( health service delivery & quality)
what are the social determinants of health (x8)
PROGRESS
P- place of residence ( rural, urban etc)
R - race/ethnicity
O-occupation
G-gender
R- religion
E- education
S- socioeconomic status
S - social capital or resources
give an example of horizontal equity
every pneumonia pt deserves equal treatment
horizontal equity - equal treatment for equal need
give an example of vertical equity
areas with poorer health care need higher expenditure on health service /// those with pneumonia deserve different treatment to those with a common cold
vertical equity = unequal treatment for unequal need
what are the 9 sections for the Bradford hill criteria for causation
DR B.C. STACS
D- dose -response
R- reversibility
B- biological plausibility
C - consistency
S - strength of association
T - temporality most important
A- analogy (analogous to other similar research)
C- coherence ( coherent to other information)
S- specificity
associations found in research may be due to a variety of reasons, what re the 5 causes of association
bias
confounding fctors
chance
reverse causality
true association
give an example of information bias
information bias - systematic error in measurement / classification of exposure/outcome
e.g. observer - knows controls/cases
participant - recall bis, reporting bias etc
instrument/ measurement - wrongly calibrated/ diff instruments used etc
define lead time bias
early identification appears to increase survival but doesn’t actually alter outcomes they have a lead on the condition
e.g. pt diagnosed earlier, so “lives longer”
define length time bias
slowly progressing diseases are more likely to be picked up by screening, so screening appears to prolong life
Screening tends to detect disease that is less aggressive (slow growing cancers) because they may remain asymptomatic for longer
More aggressive disease becomes symptomatic more quickly, so breast cancer detected because the patient found a lump is more likely to be a more aggressive type of cancer, which is likely to have a poorer outcome.
so length time bias may falsely suggest that those who have been screened have a better prognosis (rather than because they have a less aggressive form of the disease)
give 2 examples of prospective studies
randomised control trial
cohort studies
give 4 types of retrospective studies
case- control
cross-sectional
case series (multiple cases)
case report / anecdote (1 case)
cross-sectional study
advantages (*3)
disadvantages (x3)
cross-sectional - snap shot
adv
- larger sample size
- rapid
- repeated studies = show change over time
disadv
- risk reverse causality
- disease length bias ( excludes people who recover quickly/ conditions with short recovery
- sample size too small for rarer outcomes
case-control studies
advantages (x2)
disadvantages (x2)
adv
- good for rare outcomes
- rapid
disadv
- selection & information bias
- finding well-matched controls is resource consuming
cohort study
advantages (x3)
disadvantages (x4
prospective longitudinal study ( looks at population w/o a disease, splits group into exposed /not-exposed, observes disease/no disease outcome in both groups)
adv
- can establish causal factors ( reverse causality eliminated as disease not happened yet)
- can follow rare exposures
- data on confounders can be collected prospectively
disadv
- difficult in rare outcomes ( conditions may not develop)
- drop outs
- large sample size required (Expensive & time consuming)
RCT disadvantages (x3)
- ethical - is the exposure/ non-exposure ethical?
- drop outs
- expensive & time consuming
how do cross-sectional and ecological studies differ
cross-sectional - prevalence in one area
ecological - compares areas/ time periods / levels of exposure
health needs assessment. when is it needed?
assessment should be conducted before health intervention is done - systematic method to review health issues facing population
what are the 3 sections of a health needs assessment
Need - ability to benefit from an intervention
demand
supply
give the 4 Bradshaw’s needs
FENC
Felt need (individual perceptions of variation from normal health e.g. can’t walk as far)
Expressed need ( individual seeks help to overcome variation form normal health)
Normative need ( professional defines appropriate intervention for expressed need)
Comparative need (comparison between severity, range of interventions & cost (e.g. pt with worse sx are prioritised for oversubscribed service)
what are the 4 stages of the planning cycle of health needs assessments
needs assessment ( assessing pt)
planning( make plan to improve)
implementation (implement new service )
evaluation (evaluate effect on wellbeing)
health needs assessment - advantages ( x3) and disadvantages (x4) to the epidemiological approach
epidemiological approach = top down
adv
- uses existing data
- provides data (incidence, mortality, morbidity etc)
- can evaluate services by trends over time
disadv
- data quality variable
- data collected may not be that required
- does not consider felt needs/ opinions/experiences of those affected
- reinforces purely biomedical approach
health needs assessment - advantages ( x2) and disadvantages (x4) to the comparative approach
(compares services between sub-groups) - e.g. spacial ( MS pts in north vs south yorkshire) vs social ( MS pts >30 vs <30)
adv
- quick & cheap ( if data available)
- gives measure of relative performance
disadv
- may be difficult to find comparable population
- data may not be available/ high quality
- may not yield what the most appropriate level (e.g. of provision/ utilisation) should be
- may be comparing 2 poor quality services
health needs assessment - advantages ( x3) and disadvantages (x4) to the corporate approach
incorporates views from pts, politicians, press, professionals, commissioners etc (e.g. service may be requested but politicians lower its priority due to costs)
adv
- based on felt & expressed needs of population
- recognises detailed knowledge & experience of those working with the popultion
- wide range of views considered
disadv
- difficult to distinguish need from demand
- groups considered may have vested interests
- may be influenced by political agendas
what are the 3 categories in Donabedian approach to evaluating clinical services
structure (What there is)
process ( what is done)
outcome - the 5 Ds ( death, disease, disability, discomfort, dissatisfaction)
what are the 6 categories to Maxwell’s Dimensions for evaluating clinical services
3Es and 3As
Effectiveness
Efficiency
Equity
Acceptability (e.g. OPs happen@ accetable time of day)
Accessibility
Appropriateness ( given to those who need it )
what is Wrights matrix
the combination of Donabedian’s approach and Maxwell’s dimensions for evaluating clinical services
define incidence
number of new cases during a specific time period divided by the size of the population
(Number of new cases during time period/ Population size) x 100%
define prevalence
number of existing cases in a population at a specific point in time
(Number of existing cases/Population size x 100% )
define relative risk
- Risk in one category relative to another
define relative risk
risk in one category relative to another
relative risk = absolute risk in exposed group/ absolute risk in unexposed group
define absolute risk
proportion of a disease which is specifically due to the exposure
In Crookes (population of 1000), 300 people smoke. 45 of the smokers developed lung cancer. 5 of the non-smokers developed lung cancer
* What is the absolute risk of lung cancer in smokers?
* 45 in 300 = 0.15 = 15% = 15 per 100
define absolute risk difference
aka attributable risk
to find the risk specifically attributable to an outcome: difference between the “naturally occurring” cases and cases in exposed group.
- Risk of lung cancer in smokers = 45/300 = 15%
- Risk of lung cancer in non-smokers = 5/700 = 0.7%
- Attributable risk (risk difference) = (15/100) – (0.7/100) = 14.3/100 = 14.3%
how to calculate NTT
1/attributable risk
- always round up NNT, as a fraction of a person cant be treated
300 people smoke. 45 of the smokers developed lung cancer. 5 of the non-smokers developed lung cancer
* Attributable risk = 14.3%
* NNT = 1/attributable risk = 1/0.143 = 6.99
* So, if 7 people gave up smoking in this population, you would prevent one person getting lung cancer
define point prevalence
no. cases @one time/ total population @same time
period prevalence = no. cases in a period / total no. people in population @same time
cumulative incidence calculation
no. new events or cases of disease/ total no. individuals in the population at risk for a specific time interval.
e.g. proportion of patients who develop postoperative complications within one month of surgery
define cumulative incidence
aka incidence proportion
estimate of the risk that an individual will experience an event or develop a disease during a specified period of time.
calculation for Rate ratio
incidence rate in exposed group/ incidence rate in unexposed group
odds ratio
odds of disease in exposed group/ odds disease in unexposed group
with odds being: probability of getting disease / probability of not getting disease
give 3 disadvantages of screening
- distress/ harm in well individuals
- Detection and treatment of sub-clinical disease
- Preventative interventions that may cause harm to the individual or population
- e.g Increased antibiotic resistance if all moms screened for GBS during pregnancy
define tertiary prevention
trying to slow down the progression of the disease
define the prevention paradox
seatbelts
preventative measure which brings much benefit to the population but offers little to the individual
define sensitivity
proportion of people with the disease who are correctly identified
(true positive)/(true positive +false negative)
aka true positive/ total diseased
sensitivity - correct selection (inclusion)
define specificity
proportion without the disease who are correctly excluded
(true negative)/ (true negative/false positive)
aka true negative / total disease free
specificity - correct exclusion
positive predictive value
proportion of +ve results who actually have disease
(true positive)/ (true positive +false positive)
aka (those who actually have disease)/ (all who received positive result)
negative predictive value
proportion with -ve result who don’t have the disease
(true negative)/(true negative +false negative)
(people w/o disease)/ (people told they don’t have disease)
what are the 4 components of Wilson and Junger’s criteria for a screening programme
the condition (serious, well understood, detectable at early stage)
the treatment (accepted tx, facilities for dx &tx vailable, w/ extreme extra workload)
the test ( suitable, acceptable for pts, establish intervals to repeat it)
the benefits ( policy on who to tx, benefit > cost)
health psychology - define health behaviour
preventing disease ( e.g. going for run)
health psychology - define illness behaviour
seeking remedy - e.g going to GP for Sx
health psychology - define sick role behaviour
aim: to get well - taking antibiotics
how are risk behaviours & protective behaviours seen in social norms theory
often overestimate the risk behaviour and underestimate the protective behaviours
social norms theory:
* Social norms are behaviours and attitudes that are most common in groups
* belief of norms is different to actual norms and people often misperceive the peer norms
* Often overestimate the risk behaviour and underestimate the protective behaviours
* Does not work when the risk behaviour is the social norm
define nudge theory
Changing the environment to make the best option the easiest
give an example of transition points in life which can influence behaviour change
any of:
- Leaving school
- Starting work/new job
- Becoming a parent
- Becoming unemployed
- Retirement
- Bereavement
Health intervention can be conducted at an: individual, community and population level.
Give an example of health intervention at an individual level (alcohol)
reducing level of alcohol consumption
Health intervention can be conducted at an: individual, community and population level.
Give an example of health intervention at a community level (alcohol)
improved alcohol referrals/ support in A&E
Health intervention can be conducted at an: individual, community and population level.
Give an example of health intervention at a population level (alcohol)
nationally increased tax on alcohol sales
what are the 4 aspects of the health belief model?
that individuals will change their health behaviour if
- belief of susceptibility
- belief consequences are serious
- belief action reduces susceptibility
- belief benefits of action outweigh cost
what are the advantages ( x3) and disadvantages (x3) of the Health belief model (A model of behaviour change)
adv
- applicable to variety of health behaviours
- cues to action are unique component
- longest standing model
disadv
- other factors may influence the outcome
- doesnt consider emotions
- doesnt differentiate between first time & repeated behaviours
what are the 5 stages of the transtheoretical model
precontemplation, contemplating, preparation, action, maintenance ( with relapse possible at each stage)
what are the advantages ( x3) and disadvantages (x3) of the transtheoretical model (A model of behaviour change)
adv
- acknowledges individual stages of readiness
- accounts for relapse
- gives temporal element
disadv
- not everyone goes through it stage
- change may be a continuum, not discrete phases
- doesn’t incorporate values/habits/ cultes/ SEC factors
what are facets of the Theory of planned behaviour
attitudes/subjective norm/ perceived behavioural control –> intentions –> behaviours
- Attitude – smoking is bad
- Subjective norm – most people around me want me to give up smoking
- Perceived behavioural control – I believe I have the ability to give up smoking
- THEN intention – I intend to give up smoking
- THEN Behaviour – Giving up smoking
what are the advantages ( x3) and disadvantages (x3) of the theory of planned behaviour (A model of behaviour change)
adv
- applicable to variety of health behaviours
- useful for predicting intentions
- considers importance of social pressures
disadv
- no temporal element, direction, or causality
- doesn’t consider emotions
- assumes attitudes, subjective norms & percieved behaviour control can be measured
- relies on self-reported behaviour
what are the 5 aspects of the Bridging the intention-behaviour gap model
- Perceived control - individual’s felt capability
- Preparatory actions = sub-goals increases self-efficacy and satisfaction
- Anticipated regret = reflection on feelings if they fail
- Implementation intentions = “if-then” plans and is the biggest one
- Relevance to self = can they relate to the behaviour
how many grams of alcohol are in 1 unit
8g
calculation for units of alcohol
BV% x vol (mls) / 1000
7 factors that lead to error
sloth (lazy = e.g. inadequate documetntion)
system error ( e.g. inadequate built in safeguards)
lack of skill
fixation (focussed on one dx)
bravado - working beyong compltency
playing odds - deciding its a common disease but its actually rare
poor team working
what 2 outcomes may result from an error
adverse even
near miss
what are the 3 aspects in the 3bucket model ( situations leading to error)
self
- poor knowledge, fatigue, inexpereinced, feeling ill
context
- distraction, inadequate handover, production pressure, equipment failure
task
- variation from normal, omission errors, unfamiliar equipment
in managing error in never events, what does the anticipation of blame promote?
it promotes cover ups
what are the 4 spects of the PDSA model of quality improvement
PDSA
plan , Do, study (analyse the data collected from running the test in “do” stage, act (action plan to change and start new cycle)
how does unrealistic optimism lead to health damaging behaviours
innaccurate perceptions of risk & susceptibility –> continue practicing health damaging behaviour
perceptions of risk is influenced by…
- lack of personal experience with problem
- Belief that its preventable by personal action
- belief that if it hasn’t happened by now, it’s unlikely to happen
- belief that problem is infrequent
what are the notifiable diseases
- Acute encephalitis
- Acute meningitis/ Meningococcal septicaemia
- Cholera
- COVID-19
- Diphtheria, Tetanus, Pertussis
- Food poisoning
- Haemolytic uraemic syndrome (HUS)
- Invasive group A streptococcal disease
- Legionnaires’ disease
- Malaria
- MMR
- Rabies
- Scarlet fever
- Tuberculosis
2 base aspects of capacity
assume person has capacity unless proven otherwise
if a pt does not have capacity, decisions must be made in their best interest and in the least restrictive way possible
4 aspects of assessing capacity
1, can they understand
2. retain -long enough to make a decision
3. weigh up
4. communicate
what is gillick competency
assessment of capacity in <16 yo. if deemed competent, parents do not need to be notified of decision making
BUT
<13 cannot legally consent to sexual intercourse
children cannot refuse life saving treatment
what is the fraser guidelines
assessing <16 for contraceptives ( fraser = contraceptives alone)
what are the 5 facets if fraser guidelines which allow advice to be given for contraceptives
- can understand the nature & implications of proposed tx
- cannot be persuaded to inform parents
- very likely to begin/ continue sexual intercourse
- physical/mental health is likely to suffer w/o tx
- advice/ tx is in the young person’s best interest
what is stigma
negative response to a label
biological reductionism = dx is a social label w/ -ve social, moral, financial consequences
who understood stigma and normal to be opposites of a continuum of identity which exist relative to one another
Goffman
(stigma is spoiled identity)
what is a potential political consequence of stigma
citizenship & (lack of ) entitlement
where does Goffman argue that stigma resides
in the r/ship between the attribute & audience
Give 3 types of stigma, according to Goffman
abominations of the body ( bemish/deformities)
character defects ( mentally ill, criminal)
tribal stigma (social collective)
what is the difference between Felt and Enacted stigma
felt stigma - people feel stigma by comparing themselves to ‘normal’ attributes, doesn’t actually mean they’re being discriminated against
enacted stigma - overt discrimination
what does Scrambler (2004s) hidden distress model of epilepsy in Britten show
felt stigma is more disruptive than enacted stigma
what is the difference between discredited and discreditable people
discreditable - vulnerable to being discredited but can hide the characteristic ( mastectomy, alcoholic)
discredited - unable to conceal discreditable characteristic (Eg. amputee in a wheelchair)
how does using people first language avoid stigma?
labelling people by their disease –> reinforced stigma
people first langue (people with obesity) ,rather than “obese people” avoids discrimination
give examples of people most at risk of malnutrition in the aging population (>60s)
Poor dental health/lacking own teeth, living in institutions, 85+yo, low SEC environments.
what are the current nutritional requirements for older adults
0.75g/Kg body/day
but complex because:
Lower lean mass in older adults = ?lower requirements
Argued: that increased protein intake = ?renal damage / more needed to replace what is lost
“anorexia of aging” reduced appetite & earlier satiety ( reduced hunger hormones and slowed gastric emptying)
what are common causes of Fe deficiency in older age
GI bleed (chronic disease e.g. colorectal cancer, NSAIDs)
regular bloods taken
reduction in global food intake
describe malnutrition
state of nutritional deficiency or excess which causes measurable adverse effects on tissue/body function and clinical outcome.
what GI changes in elderly affect nutritional intake
taste
hormone - CCK/Ghrelin
Gut motility
atrophic gastritis
what are the direct implications of malnourishment on healthcare (X3)
- More likely to be admitted.
- Require lengthier stays
- Higher morbidity/mortality risks
what screening tools are used to assess nutritional status in older adults
MUST ( Malnutrition universal screening too)
MNA ( mini nutritional assessment
give examples of anthropometric measures in assessing nutritional status in older adults
- BMI (inaccuracies: if pt unable to stand, oedema etc)
- Demi span- Distance between the midpoint of the sternal notch to the finger tips – with arms outstretched laterally)
- Waist circumference
- Skinfold thickness
- Bioelectrical impedance analysis ( for bodyfat %)
give 3 tests which can be used to assess frailty
- Handgrip strength
- Timed ‘up and go ( Time taken to stand up from a chair, walk 3 metres, turn and sit back down)
- 30 second chair stand test
(Leg and strength endurance - Postural hypotension ( falls risk) , How many times someone can stand and sit down in a chair )
what are the 2 types of harm in medication abuse
physiological harm
social harm
what are the harms in abuse of
benzos/ opiates
alcohol/illicit drugs
laxatives
SSRIs
Chlorphenamine antihistamines
benzos/ opiates - addiction, gateway effects
alcohol/illicit drugs - gateway effects
laxatives - electrolyte imbalances
SSRIs - withdrawal syndromes
Chlorphenamine antihistamines - convulsions, acidosis
ibuprofen - indigestion, bleed, hypokalaemia, acidosis
paracetamol - hepatotoxicity, rebound headache
what are the 3 social harms of medication abuse
economic consts
accidents
effects on jobs & r/ships
give risk factors for abuse of OTC meds/opiates
older female
genetic
(F)Hx addiction/psych disorders
high pain level
self-reported craving
concurrent use of tobacco/alcohol/benzos
what are the competing identities in OTC misuse
perceived stereotypical addict identity
addict identity
professional idenitiy
what are the 3 types of OTC medicine addiction
1: never exceeded a max dose
2: slightly exceeded a max dose
3: grossly exceeded a max dose
changes made to reduce medication abuse
- pharmacy (x3)
- training
- tx (x2)
- support groups
o Pharmacy
Large packs of analgesics (e.g., 100 packs of co-codamol) now given as prescription only
Changed the indications – e.g., only for pain, not cold or flu
Pack warning: ‘can cause addiction. For 3 days use only’
o Increased training for professionals; information given to patients
o Treatments
Substitution treatments, tapering off
Regular reviews
o Internet support groups
in patient safety, there are hard and soft defences in system design to minimise risk. what is a Hard defence
what is a soft defence
hard defence - engineering safety features
soft defence - people & systems
Give 7 system defences intended to minimise risk
- System design ( hard & soft defences)
- Patient safety alerts
- Simplification and standardisation of clinical processes (e.g. SBAR)
- Checklists and aide memoires
(E.g. Standardised observations through NEWS) - Information technology (reduces adverse effects & medication errors esp. in elderly & polypharmacy )
- Tools to improve uptake of evidence based treatment ( e.g. C. diff care bundle)
- Supporting better team working (training, simulations, safety huddles)
in system defences to minimise risk, what is the benefit of checklists and aide memoires?
allow for immediate structured action in a situation where there is little time to think
e.g. surgical safety checklists / NEWS
n system defences to minimise risk, Care bundles are an example of tools to improve uptake of evidence based Tx. Define && gve examples of care bundles
Care bundles – contain 3-5 evidence informed practices which need to be delviered collectively and consistently
E.g., C. diff care bundle, sepsis care
how is foresight important in pt safety
watchfulness and foresight –> preventing &recovering incidents
.
how can the 3 bucket model be used for assessing risky situations
self, context, task
the fuller the bucket, the more likely something will go wrong
An academic core trainee in rheumatology wants to investigate whether there is any
association between the use of antihypertensive drugs and gout. What would be the
most appropriate study design, given that she has relatively little time in which to
conduct the research?
Cohort study
Retrospective case-control study
Audit of anti-hypertensive prescribing
Randomised controlled trial
Population-based cross-sectional study
Retrospective case-control study
cohort & RCT - long duration of study ( e.g. cohort, have to develop disease etc etc, and gout very uncommon compared to no. people on anti-HTN, so large group needed)
case-control. starts w/ group w/ and w/o condition, and info on anti-HTN intake can be taken
- Case-control study – split into “case” and “control” and looks at exposures in each
A GP practice sets up a diabetes clinic to try to improve the glucose control of its
patients with diabetes. Patients are provided with education and support, along with
lifestyle advice and regular screening of their eyes, kidneys and feet. What type of
prevention is this?
tertiary prevention
the disease (in this case diabetes) is already present and the patient
may be symptomatic. The aim is to reduce complications or the impact of complications on the
patient.
secondary preventions are screening programmes: * Secondary prevention – detection of early disease in order to alter the course of the disease and maximise the chances of a complete recovery e.g. screening programmes
An elderly man asks his GP why all men do not get screened for prostate cancer
using PSA tests. The GP replies that few patients with high PSA turn out to have
prostate cancer. What does this suggest about PSA as a screening test for prostate
cancer?
The sensitivity is high
There is a low disease prevalence
The specificity is high
The positive predictive value is low
The positive predictive value is high
A: PPV is low
The GP has explained that many people with a high PSA (a positive screening test) do not
have prostate cancer. This means the positive predictive value (the proportion of those with a
positive screening test result who truly have the disease) is low.
what is the epidemiological approach to health needs assessment
essentially epidemiological data collection
- disease incidence & prevalence
- morbidity & mortality
- life expectancy
- services available ( location, cost, utilisation, effectiveness)
sources of data: disease registry, hospital admissions, GP databases, mortality data, primary data collection (
postal/patient survey)
what is the comparative approach to health needs assessment
- compares health/healthcare provision of 1 sub-group tgo another
- spatial ( e.g. different towns) / social ( e.g. age, social class etc)
- can compare health, service provision/ utilisation, health outcomes
- means of evaluating variation in performace/ cost of service
what is the comparative approach to health needs assessment
- asks the local pop what their health needs are
- use of focus groups, interviews, public meetings etc
- wide variety of stakeholders: e.g. teachers, healthcare professionals, social workers, charity workers, local businesses, council workers, politicians etc
According to the theory of planned behaviour, what is the greatest predictor oh health behaviours?
intention
which is determined by their attitude to the behaviour, subjective norms, and perceived behavioural control over the behaviour
