Public health Flashcards
Implied consent
Exposing part of the body
(assumptions)
* Blood pressure
* Examination
verbal consent
- Intimate examinations (all
examinations?) - Examination for teaching purposes
- Low risk procedures (local agreement)
- Record in the notes
when is written consent used
- Higher risk procedures
- Local requirements
- Legal requirements
- Research
- Emergencies
- Recording information
- Duration of written consent
Special circumstances with consent
- Mental capacity
– Assessment; involving others - Age
- Advanced care planning
Definition of public health
Developed as a discipline in the mid 19th century in UK, Europe and US.
Concerned more with national issues.
Data and evidence to support action, focus on populations, social justice and equity, emphasis on preventions vs cure.
What is international health?
Developed during past decades, came to be more concerned with
the diseases (e.g. tropical diseases) and
conditions (war, natural disasters) of middle and low income countries.
Tended to denote a one way flow of ‘good ideas’.
What is global health?
More recent in its origin and emphasises a greater scope of health problems and solutions
that transcend national boundaries
requiring greater inter-disciplinary approach
Why do people start smoking?
Usually in teenage years- psychosocial motives
Influence of background- smokers around them, deprived areas ect
Why do people keep smoking?
Nicotine addiction
Habit/cues
Social, economic, personal, and political influences all play an important part in determining patterns of smoking prevalence and cessation
Physical and psychological effects of smoking
Nicotine has pervasive effects on brain chem
Activates nicotinic acetylcholine receptors in the brain and causes dopamine release in the NAcc
Stimulant
Tolerance and withdrawal
Describe the relationship between smoking and social inequality
Smoking has been identified as the single biggest cause of inequality in death rates between rich and poor in the UK
Smoking prevalence among unemployed adults was 35% compared with 19% of adults who were in employment in 2011 (General Lifestyle Survey 2011)
What is the impact of smoking?
Greatest single cause of illness and premature death in the UK
About 100,000 people in the UK die each year due to smoking.
Deaths mainly due to cancer, COPD and heart disease
1/2 of all smokers die from related diseases
What is the economic impact of smoking?
Costs NHS around £2.4bn
Smokers spend around 3.4k per year on cigarettes
Loss of productivity and absenteeism costs £13.17bn and 1.3bn respectively
Describe the 1951 British doctors study
A questionnaire on smoking habits was sent to all British doctors included in the medical register and survivors have been contacted at regular intervals since 1957.
The 40-year study (1994) showed that 80 per cent of non-smokers survived to age 70 and 33 per cent to age 85 whereas only 50 per cent of heavy smokers survived to age 70 and 8 per cent to age 85.
“It now seems that about half of all regular cigarette smokers will eventually be killed by their habit.”
Other smoking studies
American Cancer Society Nine State Study- Concluded that 22% of ischemic heart disease in men and 19% in women was attributed to smoking.
The Canadian Veterans Study-Found those who had ever smoked were 25 times as likely to die from lung cancer than those who had never smoked.
The American Cancer Society Twenty Five State Study-It showed that smokers of cigarettes had a death rate of 9.2 times the rate for those who had never smoked.
Describe some other health problems that can be influenced by smoking
-Cardiovascular problems
-Other cancers
-Stomach ulcer
-Impotence
-Diabetes
-Oral health -Cataracts
Describe smoking cessation practices
Once a person knows they want to stop they can enrol onto a smoking cessation programme
This means receiving support to stop smoking (e.g. NHS Stop Smoking Services)
If they get such support they can also access nicotine replacement therapy (NRT), other medication, or an e-cigarette
What support do stop smoking services provide?
The NHS Stop Smoking Service uses a combination of support, advice, cognitive and behavioural strategies and pharmacological aids (NRT, bupropion, varenicline)
One-to-one or group, online and telephone support
The Stop Smoking Service works on the principle that it is only possible to help people to quit who want to quit
Technically this is the “Stages of change theory/ Transtheoretical Model”
If someone is motivated to stop smoking the Ready, Steady, Stop plan can help
Describe the ready steady stop method
Ready - be prepared and aware, understand the process
Steady - set a quit date, throw away your lighter and ashtrays
Stop - set a plan for the day, avoid triggers, reward yourself
What are some pharmacological interventions?
Nicotine replacement therapy (NRT): available on prescription if you are part of an NHS scheme or available to buy from pharmacies
Patches, gum , nasal spray, microtab, lozenge, inhalator
Non-nicotine pharmacotherapy: bupropion and varenicline, are licensed in the USA and Europe
Varenicline (Champix)
Bupropion (Zyban)
Electronic cigarettes
Describe brief advice that can be given to smokers
Brief advice should be delivered opportunistically during routine consultations – guidelines recommend doing this once a year
1%-3% of patients who receive brief advice (≤5 min) from a GP stop smoking for ≥6 months
Can trigger motivation to quit
What are the 3 A’s of brief advice
Ask – Establish smoking status
Advise – Advise on the most effective way of stopping smoking
Act – Provide options for support and access to medications – e.g. make a referral to the Yorkshire Smokefree Sheffield Service
What is screening?
A process which sorts out apparently well people who probably have a disease (or precursors or susceptibility to a disease) from those who probably do not.
Why?
To make a real difference to health
It is not intended to be diagnostic (diagnostic tests are different).
It is a process, not simply a test
What are the main purposes of screening?
Secondary prevention
and
Primary prevention
What is secondary prevention?
Aim – detect early disease in order to alter the course of the disease
e.g. screening by mammography for breast cancer in order to treat it early
WHat is primary prevention?
Aim - prevent a disease from occurring
screening to identify people with risk factors and reduce risk factor levels
WHy screen?
Reduce the risk of developing disease
Provide treatment
Provide information
E.g. pre-natal screening for genetic disorders
What is sensitivity?
Sensitivity – the proportion of people with the disease who are correctly identified by the screening test
a / a+c
What is specificity?
Specificity – the proportion of people without the disease who are correctly excluded by the screening test
d / b+d
What is PPV?
Positive predictive value – the proportion of people with a positive test result who actually have the disease
a / a+b
What is NPV?
Negative predictive value – the proportion of people with a negative test result who do not have the disease
d / c+d
Why is the positive predictive value so different between high and low prevalence?
Predictive values are dependent on underlying prevalence
(Sensitivity and specificity are not)
What are the Wilson and Junger criteria for the condition?
The condition
The condition sought should be an important health problem
The natural history of the condition should be well understood
There should be a detectable early stage
What does the treatment have to be like to fit the criteria for screening?
There should be an accepted treatment for patients with recognized disease.
Facilities for diagnosis and treatment should be available
Adequate health service provision should be made for the extra clinical workload resulting from screening
What does the test have to be to fit the criteria for screening?
A suitable test should be devised for the early stage
The test should be acceptable
Intervals for repeating the test should be determined (not a one off)
What do the risks and benefits have to be to fit the criteria for screening?
Risks and benefits
There should be an agreed policy on whom to treat
The costs should be balanced against the benefits
Additionally
The risks, both physical and psychological, should be less than the benefits
How should we evaluate screening?
Ideally by RCT
individual
cluster
Could use other methods but potential for bias
Well recognised biases
Selection bias
Lead-time bias
Length-time (or length) bias
What is selection bias?
People who choose to participate in screening programmes may be different from those who do not
May be at higher risk
e.g. women with family history of breast cancer more likely to attend
May be at lower risk
e.g. women in higher socioeconomic groups (lower risk of cervical cancer) more likely to attend
What is lead time bias?
What is length time bias?
What are the types of screening?
Population-based screening programmes (“mass” screening)
-Thailand, national diabetes and hypertension screening
Opportunistic screening
-Prevention and control of substance abuse
Screening for communicable diseases
-Heaf test?
Pre-employment and occupational medicals
-Vision test for commercial drivers?
Commercially provided screening
-Screening is more than a test, it is a
programme
What is the social definition of disability?
It is the loss or limitation of opportunities to take
part in society on an equal level with others due to
social and environmental barriers.
* A disabled person is a person with an impairment
who experiences disability.
* Disability is the result of negative interactions that
take place between a person with an impairment
and her or his social environment.
* Impairment is thus part of a negative interaction,
but it is not the cause of, nor does it justify,
disability.
What are some disability barriers?
- negative cultural representations;
- inflexible organisational policies, procedures
and practices; - segregated social provision;
- inaccessible information formats;
- inaccessible built environment and product
design.
Describe the negative cultural representations of disabled people
Images and assumptions that medicalise, patronise,
criminalize, and dehumanise people with impairments.
How do inflexible organisational policies,
procedures and practices affect people with disabilities?
- Many deaf people or those with a hearing impairment were
forced to make contact with their GP using a method that was
not the best for them - 90% of GP surgeries in Wales did not offer suitable
alternatives for making appointments.
What is the definition of a learning disability?
- Significant impairment of general cognitive
functioning acquired in childhood that is lifelong. - Leads to difficulty with everyday activities, e.g.
household tasks, socialising or managing money. - People with a learning disability tend to take longer
to learn and may need support to develop new skills,
understand complicated information and interact
with other people.
Describe the epidemiology of learning disabilities
About 4% of population- in 2011 1.2 million ppl in the UK
2.5% of children
Boys more likely than girls
More common in poorer/ less educated households
What are some factors that affect the presence of a learning disability?
-genetic factors
– maternal use of alcohol, drugs and tobacco during
pregnancy
– complications during pregnancy
– and environmental toxins, such as cadmium and lead
What are the differences between the prevalence of physical disorders in disabled and non-disabled people?
Higher prevalence of many disorders such as CHD, respiratory disease, visual impairment, msk impairments and constipation
Lower prevalence of death from cancer
Outline down syndrome
One of the commonest causes of LD
* ~ 40,000 persons with DS in England and Wales (prevalence of
~6 per 10,000)
* More than two thirds are adults.
Average life expectancy for babies with DS born in 2011 was
now 51 years (median of 58 years).
What does having down syndrome increase the risk of?
– dementia,
– thyroid problems,
– visual/hearing impairment
– and other associated long term medical conditions.
What are some social factors of having a learning disability?
- more likely to be economically disadvantaged
– Less than 7% in some form of employment in 2010/11 - have communication, numeracy , literacy and memory
difficulties - have personal health risks and behaviours;
- experience deficiencies in access to and the quality of
healthcare provision. - have increased risk associated with specific genetic and
biological causes of learning disabilities
What are some barriers for disabled people accessing healthcare?
-Failure to provide adjustments
-Discriminatory attitudes
-Failure to provide accessible info
-Diagnostic overshadowing
-Can’t make appointments alone
-Problems with reading appt letters or info leaflets
-Might not trust doctors bc of past trauma
What are some health promotion issues for people with learning disabilities
- Low uptake of health promotion or screening activities among
- Access to health promotion considerably poorer for people
with more severe LD
Describe the annual health check scheme for people with LD
Adults with LD should have annual health checks but the offer
and uptake is poor.
* Health checks are effective in identifying previously
unrecognised health needs, including life threatening conditions
* UK studies report that 88% of persons with LD had specific
health needs identified through a health screening process.
* Annual health checks in primary care for these adults may not
alter overall emergency admissions, but may reduce
preventable emergency admissions by ~18%
Health consequences of mistreatment of people with LD
Premature mortality- due to a failure to diagnose and treat illnesses
Inappropriate use of DNAR orders
Poorer mental health- over prescription of antibiotics
What do we need to do to be good doctors for ppl with learning disabilities?
– Registration with a GP is important in accessing screening
programmes
– Primary care mandated in GP contract to offer people
with learning disabilities an annual holistic health check.
– Easy read formats for patient information leaflets
– Patient champions
– Be aware and mindful of their needs!
WHat is the difference between health inequalities and inequities?
Why is environmental health important?
Individual and population health influenced by
Housing
Sanitation
Food safety
Water quality
Environment quality
Often the poorest groups are most exposed and vulnerable to environmental hazards
What are some traditional environmental health problems?
Water, sanitation and drainage
Garbage collection and waste disposal
Housing structure
e.. ventilation, infestations
Air pollution
Nutrition
House sites
hazards e.g. accidents, floods, illegal occupation
Health services
access
What are some of the vectors of disease?
Breeding of vectors of disease e.g.
Mosquitoes
Transmit diseases such as malaria, dengue fever, Japanese Encephalitis B, yellow fever, Chikunguya
Flies
Transmit foodborne disease such as Typhoid fever, dysentery and cholera
Rats
What is risk transition?
Move from traditional hazards to modern hazards
What are traditional hazards?
Related to poverty & insufficient development:
- Lack of safe drinking water,
Inadequate sanitation,
Indoor air pollution,
Inadequate waste disposal
What are modern hazards?
Related to development that lacks health & environmental safeguards, & to unsustainable consumption of natural resources:
- Environmental contamination
Urban air pollution
Climate change
Describe water pollution
Microbiologically contaminated drinking water can transmit diseases such as diarrhoea, cholera, dysentery, typhoid, hepatitis A, and polio
Causes ~505,000 diarrhoeal deaths each year.
Also risks from chemical pollutants in drinking water e.g. arsenic
What is cryptosporidium?
Intracellular parasite
Commonest non-viral cause of diarrhoea worldwide
Prevalence ~ 1% - 4.5% of population in North America/Europe. (3% - 20% in developing countries)
80% of the population has had cryptosporidiosis.
Peak age of incidence 1-5 years, marked reduction over 35 years.
Describe transmission and the risk groups
Faeco-oral transmission
Person-to-person spread
Nurseries
Food handlers
Animal contact
MSM
risk groups for cryptosporidium
Occupational risk groups
Vets
Animal handlers
Farm workers
Waterborne transmission of cryptosporidium
Transmitted in surface run-off water contaminated by calf faeces.
Incidence seasonal and related to rainfall.
Manure fertilizers
Waterborne
Oocysts are resistant to standard chlorination or many disinfectants.
Unboiled tap water
Swimming pools
What is the clinical manifestation of cryptosporidium?
Self-limiting in most healthy individuals
Low infectious dose
Symptoms: watery diarrhoea lasting 2-4 days, abdominal cramps, fever, vomiting, anorexia.
Likelihood of recurrence in cases (auto-infection).
Can lead to malnutrition from malabsorption, gall bladder infection
Can get chronic cryptosporidiosis in patients who are immunodeficient (e.g. AIDS)
Difficult to treat.
Describe prevention of cryptosporidium
In general, good hygiene & handwashing is essential, especially after handling animals.
Avoid ingesting water if swimming in lakes, rivers or swimming pools.
You should not swim in a swimming pool for 14 days after your symptoms have cleared. This is because cryptosporidium can still be present in your stools during this time.
Food handlers should stay away from work until 48 hours after the last episode of diarrhoea or vomiting.
Water companies routinely test for it
Drink only treated water
Immunocompromised persons should drink boiled water.
Describe sources of arsenic in the water
naturally present at high levels in the groundwater of a number of countries, e.g. Argentina, Bangladesh, Cambodia, Chile, China, India, Mexico, Pakistan, USA.
industrial processes: e.g. as an alloying agent, processing of glass, pigments, textiles, paper, metal adhesives, wood preservatives, hide tanning, pesticides, and pharmaceuticals.
tobacco
What can long-term exposure to arsenic cause
Long-term exposure to arsenic can cause
Skin lesions
Cancers of the bladder, lungs and skin,
Arsenic-induced myocardial infarction
Diabetes
Adverse outcomes in pregnancy
Also affects cognitive development
Describe lead poisoning
Exposure to lead can affect multiple body systems and is distributed to the brain, liver, kidney and bones.
No level of exposure to lead that is known to be without harmful effects.
Young children are very vulnerable and can suffer profound and permanent adverse health impacts, particularly on brain and central nervous system, and can lead to acute encephalopathy, coma, convulsions and even death.
Causes long-term harm in adults, including increased risk of high blood pressure, cardiovascular problems and kidney damage.
Exposure of pregnant women can cause miscarriage, stillbirth, premature birth and low birth weight.
How do people get lead poisoning?
People can become exposed to lead through occupational and environmental sources:
inhaling lead particles generated by burning materials containing lead (e.g. during smelting, recycling, stripping leaded paint and plastic cables containing lead) and leaded fuel
ingesting lead-contaminated dust, water (from leaded pipes) and food (from lead containers) and from hand-to-mouth behaviour (e.g. pica) due to lead paint.
What is used to manage, treat and prevent lead poisoning?
Key management action is to removing the source of exposure!
Some patients may require chelation therapy
Prevention: phasing out of lead-containing fuel, lead in paint
What are some health concerns about slum areas?
Diseases like hypertension, diabetes, intentional and unintentional injuries, tuberculosis, rheumatic heart disease, leptospirosis and HIV infection exist in slums
Late complications of these diseases seen
Issues of poverty and disadvantage, that affect access to healthcare and good health
Also limited access to key services e.g. clean water, sanitation etc…
What are some concerns with food hygiene and safety?
Almost 1 in 10 people in the world fall ill after eating contaminated food and 420,000 die every year.
Foodborne illnesses usually infectious or toxic in nature and caused by ingestion of food contaminated with bacteria, viruses, parasites or chemical substances.
Food hygiene refers to the practices used to minimize the risks of foodborne illnesses caused by bacterial contamination.
Involves proper food handling, transport, storage, processing/preparation of food
What is autonomy?
Emmanuel Kant’s Categorical
Imperative, that you should treat others
as ends in themselves and not merely
as a means to an end.
* Subsumes informed consent before
treatment, confidentiality, honesty (lack
of deceit) and good communication
What is beneficence?
Doing the right thing for patients
* A Subset of respect for autonomy in
many ways
* Also incorporates empowerment;
helping the patient to make appropriate
decisions for themselves
What is non-maleficence?
Not doing the wrong thing to patients
* Not harming patients intentionally or
inadvertently where ever possible.
* Means evidence based practice
* And keeping up to date
* Again, it is a subset of respect for
autonomy
What is justice?
The moral obligation to act on the
basis of fair adjudication between
competing claims
* Distributive justice - Fair distribution of
scarce resources
* Rights based justice - Respect for
people’s rights.
* Legal Justice - Respect for the Law
What are some behaviours related to health?
Sleep
Smoking
Eating
Exercise
Ways to categorise health behaviours?
Health damaging/impairing
Health promoting
What are soem damag9ing health behaviours
Smoking, alcohol and substance abuse, risky sexual behaviours, sun exposure, driving without a seatbelt
Health promoting
Exercise, healthy eating, attending health checks, medication compliance, vaccinations
What are some modifiable risk factors?
(things we can potentially change)
Diet/ Excessive weight, Smoking, Alcohol, Physical activity, Sleep, Stress
What are some non-modifiable risk factors?
(things that we cannot change)
Sex, Age, Genetics/ Family history
Why is it important to know about behaviour change?
➢Important from both an individual and population perspective
➢ Overwhelming evidence that changing people’s health behaviour can have
an impact on some of the largest causes of mortality and morbidity
What is population level intervention?
➢Health promotion
*The process of enabling people to exert control over the
determinants of health, thereby improving health
What is individual level intervention?
➢Patient centred approach
*Care responsive to individual needs
Effects of intervention (using the example of alcohol)
*Individual’s behaviour (level of alcohol consumption, individual health
outcomes, or incidence of domestic violence)
*Local community (local alcohol sales, alcohol-related crime or accident and
emergency [A&E] events)
*Population level (for example, national alcohol sales and consumption,
national statistics on alcohol-related crime and A&E events, or demographic
patterns of liver cirrhosis)
What is unrealistic optimism when it comes to risky health behaviours?
Individuals continue to practice health damaging behaviour
due to inaccurate perceptions of risk and susceptibility
What are perceptions of risk influenced by?
- Lack of personal experience with problem
- Belief that preventable by personal action
- Belief that if not happened by now, it’s not likely to
- Belief that problem infrequent
What are some models and theories of behaviour change?
- Health belief model (HBM)
- Theory of Planned Behaviour
- Stages of change (transtheoretical) model
What is the health belief model?
Individuals will change if they:
➢ 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
