Public health Flashcards
What are the three domains of pubic health? Give examples of each
1) Health improvement eg education, housing, employment
2) Health protection eg immunisation, emergency response, environment
3) Health care – clinical effectiveness, audit, clinical governance
What is health behaviours?
Behaviour aimed to prevent disease e.g. eating healthy
What is illness behaviour?
Behaviour aimed to seek remedy e.g. going to a doctor
What is sick role behaviour?
Behaviour aimed at getting well e.g. taking tablets and rest
What is the % of medication adherence according to WHO?
50%
Give an intervention at the ecological (population) level with examples
Health promotion - to enable people to exert control over their health:
1) awareness campaigns eg 5 a day
2) screening
3) immunisations
Give an intervention at the individuals level with examples
A patient centred approach eg care responsive to an individuals needs
Define unrealistic optimism
Individuals continue to practice health damaging behaviours due to inacurrate perceptions of RISK and SUSCEPTABILITY.
Define the four factors influencing the perception of risk
1) Lack of personal experience with the problem
2) Belief that the problem is preventable by personal action
3) Belief that if its not happened by now, its not likely to
4) Believe that the problem is infrequent
Describe the three main models/theories of behaviour change
1) Health belief model - barriers to addressing change are important
2) Theory of planned behaviour - the best predictor of change is the intention
3) Trans-theoretical model - uses the stages of change
What are the 4 beliefs behind the change in the health belief model?
1) Believe they are susceptible to the condition
2) Believe that it has serious consequences
3) Believe that taking action reduces susceptibility
4) Believe that the costs of taking action outweigh the benefits
What are three critiques of the health belief model?
Doesn’t consider:
1) outcome expectancy or self-efficacy
2) influence of emotions and behaviour
3) Does not differentiate between first-time and repeat behaviour
What are the 3 factors that determines intention in the theory of planned behaviour?
1) Personal attitude to the behaviour
2) Social pressure to change behaviour (social norm)
3) Person’s perceived behavioural control
What are the 4 critiques of the theory of planned behaviour?
1) Lacks temporal element or lack of direction and causality
2) Doesn’t take into account emotions
3) Doesn’t explain the 3 factors interact to determine the intention
4) Doesn’t take into account habits and routines
What are the 5 stages of the trans-theoretical model?
1) pre-contemplation (not ready yet)
2) contemplating (thinking about it)
3) preparation (getting ready)
4) action (doing it)
5) maintenance (stick to it)
What are the 3 critiques of the trans-theoretical model?
1) Not all patients move through every stage linearly
2) Change might operate on a continuum rather than discrete stages
3) Doesn’t take into account habits, culture, social and economics
Name an advantage of the trans-theoretical model
Accounts for relapse and the temporal element
Name some other models/theories of behaviour change
1) Social norms theory
2) Motivational interviewing
3) Social marketing
4) Nudging (choice architecture) eg fruits near the shop’s till
5) Financial incentives
Name the 4 factors in developing food behaviours
1) Maternal diet
2) Breastfeeding
3) Parenting practices
4) Age of introduction to solids and types of food given
What is NOFED?
Non-organic feeding disorders
- high prevalence in under 6s
- feeding aversions, food refusal, negative mealtime interactions
What are the 4 determinants of health
1) genes
2) environment
3) Lifestyle
4) health care
Define equity
What is fair and just
Define equality
Everyone should have an equal share
What is horizontal equity
Equal treatment for equal need e.g. individuals with pneumonia should all be treated equally
What is vertical equity
Unequal treatment for unequal need e.g. patients with the cold and pneumonia should be treated differently
Give an intervention at the community level with examples
Improving access to green spaces for exercising eg community park/playgrounds
What is a needs assessment?
Systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities.
What is a felt need?
An individual’s perception of variation from normal health
What is expressed need?
A need where an individual seeks helps to overcome variation in normal health (demand)
What is normative need
Professional defines intervention appropriate for the expressed need
What is a comparative need?
Comparison between severity, range of interventions and cost
Give 4 examples of health needs assessments using an epidemiological approach
1) Disease incidence and prevalence
2) Morbidity & mortality
3) Life expectancy
4) Data is from: disease
registry, hospital
admissions, GP
databases, mortality
data, primary data
collection
Give 3 examples of health needs assessments using a corporate approach
Obtaining the views of a range of ‘stakeholders’
1) Asking the local population what their health needs are
2) Use of focus groups, interviews and public meetings
3) Wide variety of stakeholder e.g. teachers, healthcare professionals, social workers, charity works, local businesses, council workers and politicians.
Give 2 examples of health needs assessments using a comparative approach.
1) Compare the needs/provision of healthcare in one population with another
2) Can be spatial (e.g. different towns) or social (e.g. two age groups in the same town)
What are the 5 stages of Maslow’s hierarchy of needs
TOP
Self-actualisation
Esteem
Love/belonging
Safety
Physiological
BOTTOM
Describe the egalitarian resource allocation method
Provides all the care that is necessary and required to everyone
Describe the maximising resource allocation method
Based solely on consequence
Describe the libertarian resource allocation method
Each individual is responsible for their own health
Name the pro and con of an egalitarian resource allocation method
+ Equal for everyone
- Economically restricted
Name the pro and con of a maximising resource allocation method
+ Resources allocated to those likely to receive most benefit
- Those with ‘less need’ receives nothing
Name the pro and con of a libertarian resource allocation method
+ Onus on patient therefore may be more engaged
- Not all diseases are self-inflicted
What is the evaluation of health services
The assessment of whether a service achieves its objectives
Name 2 models of health services evaluation
1) Donabedian’s framework of health service evaluation
2) Maxwell’s dimensions of Quality of health
Describe the structure element of the Donabedian’s framework of health service evaluation
What actually is the service eg staff, equipment, guidelines
Describe the process element of the Donabedian’s framework of health service evaluation
How does the process work eg GP appointment system, interactions, investigations, examinations
Describe the outcome (5Ds) of the Donabedian’s framework of health service evaluation
5 Ds: death, disease, disability, discomfort, dissatisfaction
What are the issues with the outcome (5Ds) of the Donabedian’s framework of health service evaluation
1) Link between health service and health outcomes can be difficult to confirm
2) Time lag between service and outcome may be long
3) Large sample sizes may be needed
4) Data may not be available or have a problem with it (CART = completeness, accuracy, relevance, timeliness)
Name the 3Es and 3As of Maxwell’s dimensions of Quality of health
3Es: effectiveness, efficiency, equity
3As: acceptability, accessibility, appropriateness
What is the definition of epidemiology?
The study of the frequency, distribution and determinants of diseases and health-related states in populations in order to prevent and control disease
Define incidence
Number of new cases in a population in period of time
Define prevalence
Number of existing cases ina population at a point in time
Define absolute risk
Gives a feel for actual numbers involved and has units
Define relative risk
Risk in one category relative to another with no units
Define attributable risk
The rate of disease in the exposed that may be attributed to exposure
Define bias
A systemic deviation from the true estimation of the associated between exposure and outcome (it is an example of a systematic error)
Define selection bias
1) Selection of study participants
2) Allocation of participants to different study groups
Define information bias
Observer’s recall and reporting, participant, instrument wrong calibrated
Define allocation bias
Different participants in different groups (no equal spread)
Define publication bias
Trials with negative results are less likely to be published
Define lead time bias
Early identification by doesn’t alter the outcome but appears to increase survival as the patient has the disease identified earlier than normal
Define length time bias
Disease that progresses more slowly is more likely to be picked up by screening which makes it appear that screening lengthens life eg prostate cancer
Define confounding factors and give an example
Situation where a factor is associated with the exposure of interest and independent influences the outcome but does not lie on the causal pathway
eg lack of exercise causes weight gain but there are many confounding variables that also effect weight gain
Define strength in the Bradford criteria for causality
The strength of association
Define dose-response in the Bradford criteria for causality
Does a higher exposure produce a higher incidence
Define consistency in the Bradford criteria for causality
Are there similar results in different studies and populations
Define temporality in the Bradford criteria for causality
Does the exposure precede the outcome
Define reversibility in the Bradford criteria for causality
Does removing the exposure reduce the risk of the disease
Define biological plausibility in the Bradford criteria for causality
Does it make sense biologically
Define coherence in the Bradford criteria for causality and give an example
Logical consistency with lab information
eg incidence of lung cancer increases with smoking, that is consistent with tobacco being carcinogenic
Define analogy in the Bradford criteria for causality and give an example
Similarity with other established cause-effect relationships in the past
eg thalidomide in pregnancy
Define specificity in the Bradford criteria for causality
Relationship specific to the outcomes of interest
eg introducing helmets reduced head injuries specifically, if that wasn’t there, would there be an overall injury injury rate
Define reverse causality through an example
Stress could have caused HTN rather than HTN causing stress
Define the 3 levels of prevention
Primary prevention – trying to stop yourself getting a disease
Secondary prevention – trying to detect a disease early and prevent it from getting worse
Tertiary prevention – trying to improve your quality of life and reduce the symptoms of a disease you already have
What is a population approach to prevention
Preventative measure delivered on a population wide basis and seeks to shift the risk factor distribution curve.
What is high risk approach to prevention
Seeks to identify individuals that are above a chosen cut off and treat them.
What is a prevention paradox and give an example
A preventative measure which brings much benefit to the population but offers little to each participating individual
eg If all male British doctors wore their car seat belts on every journey throughout their working lives, then for one life saved there would be 400 who never benefit from it.
Name 5 types of screening
1) Population-based
2) Opportunistic
3) Screening for communicable diseases
4) Pre-employment and occupational medicals
5) Commercially provided screening
Name the criteria for screening
Wilson and Junger
What needs to be considered regarding the condition in screening
1) Important condition
2) Natural history, latent and declared staged, risk factors and disease markers understood.
3) The disease should have a latent, detectable stage.
What needs to be considered regarding a screening programme
1) Screening should be ongoing and not just performed on a ‘one-off’ basis.
2) Cost-effective
What needs to be considered regarding the test in screening
1) the screening test should be simple, safe, precise and validated
2) The distribution of test values in the target population should be known and a suitable cut-off level defined and agreed.
3) The test should be acceptable to the population.
4) There should be an agreed policy on the further diagnostic investigation of individuals with a positive test result and on the choices available to those individuals.
What needs to be considered regarding the treatment in screening
1) There should be an effective treatment or intervention for patients identified through early detection, with evidence of early treatment leading to better outcomes than late treatment
2) Agreed policy on who to treat
3) Facilities should be available
Define sensitivity
Proportion of people with the disease
who are correctly identified by screening test
Define specificity
Proportion of people without the disease
who are correctly excluded by the screening test
Define positive predictive value (true positive)
The proportion of people with a positive test result who actually have the disease
Define negative predictive value (true negative)
Proportion of people with a negative result who actually do not have the disease
What is a cohort study
1) Sample is taken from study population and split into two groups, one exposed and one not.
2) The incidence of the disease amongst the two groups is compared.
3) Prospective
Identify 4 pros and 4 cons with cohort studies
+ identifies risk factors, can prove cause-effect, multiple exposures and outcomes can be measured, follow up rare exposure
- needs large sample sizes, expensive, high attrition rate over a long time period, impractical for diseases with a long latent period
What is a case control study
1) Groups with and without a disease are selected and past exposures are identified
2) Retrospective
Name 3 pros and 3 cons of a case control study
+ quick, good for diseases with long latency periods, multiple exposures can be studies
- selection and information bias, hard to establish sequence of events, difficult to identify confounding factors
What is a cross-sectional study
Exposure and outcome are measured simultaneous in a population at one particular time ‘snapshot’
Name 3 pros and 3 cons of a cross-sectional study
+ Can assess a large sample size, quick, repeating the study over time can show changes
- Risk of reverse causality, not useful for rare disease, unclear timeline
What is a randomised control trial
Two groups – one control and one treatment which allows for comparison in order to assess the effectiveness of an intervention
Name 3 pros and 4 cons of a randomised control trial
+ Low risk of bias and confounding factors, comparative, good evidence of cause and effect
- High attrition rate, ethical issues, time consuming and expensive, generalisation is poor due to strict entry criteria
What is an ecological study and give an example
Investigation finds a certain correlation between two things in a population e.g. there is a high level of CHD in deprived areas.
What is a meta-analysis
Qualitative method of combining the results of independent studies which are drawn from the published literature, and synthesizing summaries and conclusions
What is a systemic review
Review which endeavours to consider all published and unpublished evidence of a specific question
What are the 5 elements of the Fraser guidelines
1) Understands advice
2) Can’t be encouraged to tell parents
3) Will have sex regardless of contraception
4) Is their mental health/physical health going to be effected if you don’t give contraception
5) In their best interest
When is the Fraser guidelines utilised?
Specifically to advice and treatment about contraception and sexual health in under 16 year olds
When is Gillick competence utilised and what is it based on
Used to judge whether a child under 16 years old has capacity to consent to medical treatment
Based on age, capacity and maturity
What are the 5 feature of a disease that could make in a public health concern and therefore a notifiable disease
1) High mortality
2) High morbidity
3) Highly contagious
4) Expensive to treat
5) Effective interventions
What are the details required in a notifiable disease report
Case details, NHS number, DOB, contact details
Who is a notifiable diease reported and within what timeframe
Public Health England
Report by writing within 3 days or by telephone within 24 hours if urgent.
Give 7 examples of notifiable diseases
Rabies, whooping cough, scarlet fever, smallpox, acute meningitis, cholera, acute infections hepatitis
Give 3 examples of communicable disease control
Surveillance, prevention, control
Define epidemic
More than expected incidence in a country
Define pandemic
More than one country
Define endemic
Persistent level of disease occurrence
What are the 4 aspects of negligence and error?
1) Was there a duty of care?
2) Was there a breach of that duty?
3) Was the patient harmed?
4) Was the harm due to the breach of care?
Define hyper-endemic
Persistently high level of disease occurrence
What is Bolam’s rule?
Would a reasonable doctor do the same
What is Bolitho rule?
Would that be reasonable?
Describe the Swiss Cheese model of Error
Falling through the holes because there is failed or absent defences against error happening.
These are called LATENT FAILURES.
Organisational influence leads to Unsafe supervision, leads to preconditions for
unsafe acts = unsafe acts
Describe the bucket model of error via self, context and task
SELF = Poor knowledge, fatigue, little experience/skill, feeling unwell
CONTEXT = distraction, poor handover, lack of team support, equipment
TASK = errors, take complexity, new task, process
What is a sloth type of error?
Inaccurate documenting/not checking results for accuracy
What is a fixation/loss of perception type of error?
Focus on one diagnosis – confirmation bias
What is a communication type of error
Unclear plan/not listening and explaining wel
What is a poor team working type of error?
Some individuals out of depth and others underutilised
What is a Playing the Odds type of error
Choosing the common and dismissing the rare
What is a bravado/timidity type of error?
Working beyond competence/not having confidence to object
What is ignorance type of error?
Lack of knowledge (can be conscious or unconscious incompetence)
What is a mis-triage type of error?
Over or under-estimating the severity of the situation
What is a lack of skill type of error?
Not having appropriate skills/training/practice
What is a system error?
Environmental/technological/equipment failure
Describe a never-event and give examples
A serious, largely preventable patient safety incident that should not occur if available, preventative measures have been implemented
eg wrong site for surgery, wrong drug given, escape of psychiatry patient
Describe the duty of candour
Every healthcare professional must be open and honest with patients when something that goes wrong with their treatment causes, or has the potential to cause, harm or distress.
What age is a infant’s first vaccine and what does it entail?
8 weeks: 6 in 1, rotavirus, menB
What vaccines are given at 12 weeks old?
1) 6 in 1 (2nd dose)
2) pneumococcal
3) rotavirus (2nd dose)
What vaccines does a child get at 1yr old?
1) Hib/MenC
2) MMR
3) pneumococcal
4) meningococcal
What is included in the 6 in 1 vaccine?
1) Diphtheria
2) Hep B
3) Haemophilus influenza type b
4) Polio
5) Tetanus
6) Whooping cough
What is included in the MMR vaccine?
Mumps, measles and rubella
What type of vaccine is the MMR? What are some adverse reactions to look out for?
Live attenuated vaccine
Anaphylaxis, seizures (febrile convulsions), immune thrombocytopenic purpura
How do vaccine schedule work in pre-term babies
Stick to chronological order eg 8 weeks at their 8 weeks
What are some side effects to vaccines
tenderness, systemically unwell, anaphylaxis
What vaccine should you advice parents to give their child liquid paracetamol just prior and why?
Menb (8 & 16 weeks, 1yr)
Decreased risk of fever, crying irritability etc
Which vaccine increases the risk of intussusception?
Rotavirus
What 2 vaccines are contraindicated in people with egg allergies?
1) Yellow fever
2) Influenza
What vaccine can’t people that are immunosuppressed have?
Live attenuated vaccine eg MMR
Describe anaphylaxis and what would you seen on blood tests
- type 1 hypersensitivity reaction
- controlled by basophils + mast cells
- increased serous tryptase
What three drugs are involved in the management of a child with anaphylaxis
Adrenaline (rebound bi-phasic response)
Chlorphenamine
Hydrocortisone
Name 9 red flags in a child with a higher fever
cyanotic, no responding to social cues, ill to healthcare professional, weak high pitch continuous cry, tachypnoea, grunting, chest depressions, reduced skin turgor, bulging fontanelles
Describe diabetic eye screening
Diabetics aged over 12 yrs, every 2 years, identify diabetic retinopathy
Describe cervical screening
smear test
25 to 64 yrs old
every 3 years up to 49
every 5 years until 64
no need if total hysterectomy
Describe breast screening
Mammograms every 5 years between 50 and 71
Describe bowel cancer screening
home test kit: Faecal Immunochemical Test (FIT)
60 to 74 years old every 2 years
Describe abdominal aortic aneurysm screening
Offered to men the year they turn 65
abdominal USS
What percentage is needed for heard immunity
95%
What HPV vaccines are now offered to boys and girls aged 11-12
HPV 16 & 18 = cervical cancers
HPV 6 & 11 = genital warts
What are the 4 determinants of health
genes, environment, lifestyle, healthcare
Define domestic abuse
Any incident or pattern of incidents of controlling, coercive, threating 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.
What are the 5 forms of domestic abuse?
Phycological
Physical
Sexual
Financial
Emotional
What is MARAC?
multi-agency risk assessment conference
where information is shared on high risk domestic abuse cases between local police, probation, health and child protection
What are health inequalities?
Preventable, unfair and unjust differences in health status between groups, populations or individuals
What is the inverse care law?
The principle that the availability of good medical or social care varies inversely with the needs of the population served
What is human trafficking
The movement of people by means such as force, fraud, coercion or deception with the aim of exploiting them
what are 9 red flags to suspect a patient is a victim of human trafficking
Timid
Not registered to GP/school
Accompanied by a controlling person
Foreign language
Frequency in moving locations
Inconsistent history
No control over passport/bank account
Evidence of untreated injuries
DNA future appointments
What is the national referral mechanism
Framework to identify trafficked people and ensure they receive the appropriate protection and support
Allows Home Office to collect data
What are some non-pharmacological ways to treat chronic pain?
Physical - weight loss, smoking cessation, exercise-stretching, physiotherapy, yoga Pilates, joint injection
Psychological - counselling, CBT, mediation, relaxation
Complementary therapy - massage, reflexology
Occupational - work place review
What are some pharmacological ways to treat chronic pain?
Non opioid - NSAIDs, Cox-2 inhibitors, paracetamol
Opioid - intermittent usage/slow and low
Adjuvant analgesia - anti-convulsant, antidepressants, lidocaine patches
What is malnutrition?
Deficiencies, excess or imbalance in a person’s intake of energy and/or nutrients
Name some chronic conditions that require additional nutritional support
1) Cancer
2) CF
3) Coeliac
4) IBD
5) DM
