Public Health Flashcards
What are domains of public health
Health Improvement
Health Protection
Improving Services
What is Health Improvement and give an example
Social interventions aimed at preventing disease, improving health and reducing inequality
eg
Tackling inequalities
Education
Housing
Employment
What is Health Protection and give an example
Controlling infectious diseases and environmental hazards
eg
Chemicals
Notifiable diseases
Radiation
Emergency response
What is improving services and give an example
organising and delivering safe, high quality services
eg
Service planning
Audits
Clinical governance
What are determinants of health
- P- place of residence
- R- race
- O- occupation
- G- gender
- R- religion
- E- education
- S- socio-economic
- S- social capital
what is inverse care law
the availability of medical or social care tends to vary inversely with the need of the population served
what is the most powerful predictor of health experience
Socio-economic model of health
what is primary prevention and give example
Preventing the disease from occurring
eg vaccinations
what is secondary prevention and give example
Early detection of disease in high-risk groups
eg screening programmes
what is tertiary prevention and give example
Preventing complications of disease
eg
Cardiac rehabilitation
Diabetic control
what is the prevention paradox
A preventative measure that brings a lot benefits to population, often offers little to each participating individual (e.g. for each 100 people screened, only 1 suffers from the disease)
what is equity
What is fair and just
what is Horizontal equity
equal treatment for equal need
what is vertical equity
unequal treatment for unequal need
what is felt need
Individual perceptions of deviations from normal health
what is expressed need
Seeking help to overcome variation in normal health
what is normative need
Professional defines intervention/ approach for expressed need
what is comparative need
Needs identified by comparing services received by one group vs another
what is health needs assessment
assess
planning
implement
evaluate
what are types of health needs assessment
epidemiological
comparative
corporate
what is epidemiological health need assessment
Defines problem and size of problem
Looks at current services
Recommends improvements
what is comparative health need assessment
Compares services received by one population to another
what is corporate health need assessment
Takes into account views of any groups that may have an interest eg patients, health professionals, media, politicians
what is Maslows hierarchy of need
- Self Actualization
- Esteem
- Love/Belonging
- Safety
- Physiological
What is Libertarian approach to resource allocation
Taking responsibility for own health, wellbeing and fulfilment of life plan + autonomy
What is maximising principle approach to resource allocation
Concentrating resources on those who stand to gain the most
What is egalitarian principle approach to resource allocation
Equal access, equality and justice in healthcare
What is the quality of a service evaluated
3As and 3Es
- Accessible – will patients actually be able to use it?
- Acceptable – will the service be acceptable?
- Appropriate – is this the right thing to do?
- Equity – Is this fair and just?
- Efficiency – this is concerned with maximizing output e.g., must do X amount of procedures/day for it to be viable
- Effectiveness – Does it do what it’s intended to do?
what is the Donabedian framework of evaluating a health service
- Structure - what is there? E.g. number of hospitals
- Process - what goes on? E.g. how many patients seen
- Outcome - e.g. number of deaths
what are 5 lifestyle factors promoting mortality
smoking
obesity
sedentary life
excess alcohol
poor diet
what is health behaviour
behaviour aimed at preventing disease
E.g., going for a run
Health damaging – Smoking
Health promoting - eating healthy
what is health promotion
the process of enabling people to take control of determinants of health, therefore improving their own health
what is illness behaviour
behaviour aimed at seeking remedy
E.g., going to GP for a symptom
what is sick role behaviour
any behaviour aimed at getting well
E.g., taking antibiotics
what are 3 models of change in behaviour
Health Belief Model
Theory of planned behaviour
Trans-theoretical model
what is trans-theoretical model
Pre-contemplation
Contemplation
Planning
Action
Maintenance/relapse
what are pros of trans-theoretical model
Acknowledges stages
Accounts for relapse
Time element
what are cons of trans-theoretical model
Not everyone moves through each stage
Change may be continuous, not discrete
Doesn’t account for habits
Doesn’t account for emotional influences
Doesn’t consider values e.g., cultural and social factors
what is health belief model
Individuals will change if:
They believe that they are susceptible to the condition
They believe that personal action can reduce susceptibility
They believe that there are serious consequences
They believe that benefits outweigh the costs
what are strengths of health belief model
Widely applicable
Cues to action are unique component
Longest standing model
what are cons of health belief model
Doesn’t consider emotional influences
Doesn’t consider repeated (habitual) behaviour
Other factors may influence the outcome
what is theory of planned behaviour
Intention is predictor of behaviour
Personal attitude about behaviour
Social norms/pressure
Perceived behavioural control
what are strengths of theory of planned behaviour
Can be applied to wide variety of health behaviours
Useful for predicting intention
Takes into account importance of social pressures
what are cons theory of planned behaviour
Doesn’t account for emotional influences
Doesn’t account for hobbies/habits
No temporal element, direction or causality
Assumes attitudes can be measured
what is medical negligence
A legal entity - Outcome of a court case
what are 4 criteria for medical negligence
Was there a duty of care?
Was there a breach in the duty of care?
Did the patient come to harm?
Did the breach cause the harm?
what bolam rule
Would a reasonable doctor do the same?
what is bolitho rule
Would that be reasonable?
what information is allowed to be disclosed
- Required by law (notifiable disease, regulatory bodies, ordered by a judge or police)
- Patient consent
- Public interest (serious communicable disease, serious crime, research, education)
what is criteria for disclosure
Anonymous if practicable
Patient’s consent (overrule?)
Kept to a necessary minimum
Meets current law (data protection)
what is an error
An unintended outcome
what is neglect
Falling below the acceptable standard of care
what is error of omisson
Required action delayed/not taken
what is error of commission
Wrong action is taken
what is error of negligence
The actions or omissions do not meet the standard of an ordinary, skilled person professing
what is skill based error
Slips and lapses – when the action made is not what was intended
what is knowledge based error
An incorrect plan or course of action is chosen
what is organisational error
Adverse events are product of many causal factors (Swiss-cheese Model) - the whole system is to blame
what is swiss cheese model
Incidents of patient harm occur as a result of accumulations of multiple failures which align, creating a hazard trajectory
what is 3 bucket
identify potential for something to go wrong.
based on ‘buckets’ of self, context, and task factors
what is a never event
A serious, largely preventable patient safety incident that should not occur if available, preventative measures have been implemented
eg
Medical: wrong route chemo
Surgical: wrong site or retained object
Mental health: escape of transfer patient
What are GMC duties of a doctor
- Knowledge, skills and performance.
- Safety and quality.
- Communication, partnership and teamwork.
- Maintaining trust.
what is screening
Identifying apparently well individuals who have or are at risk of having a particular disease
give 4 examples of screening
Newborn (heel prick)
Breast cancer (mammography)
Cervical cancer (smear)
Bowel cancer (poo in the post)
what are types of screening
- Population-based screening programmes
- Opportunistic screening
- Screening for communicable diseases
- Pre-employment and occupational medicals
- Commercially provided screening
what is Antenatal and newborn screening (6 tests)
foetal anomaly
infectious diseases in pregnancy
newborn and infant physical examination
newborn blood spot
newborn hearing
sickle cell and thalassaemia
what is diabetic eye screening
offered annually to people with diabetes aged 12 or over
what is cervical screening
- offered to women from 25 to 49 every 3 years
- and to women aged 50-64 every 5 years
what is breast screening
- offered to women aged 50 to 70 every 3 years
- women older than 70 can self-refer
what is bowel cancer screening
- offered to men and women aged 60 to 69 every 2 years
- people aged 70 or older can request screening
what is abdominal aneurysm screening
offered to all men aged 65 years, over this age self-refer
negatives to screening programs
- Exposure of well individuals to distressing or harmful diagnostic tests
- Detection and treatment of sub-clinical disease that would never have caused any problems
- Preventive interventions that may cause harm to the individual or population
what is citerai for wilson and jugner screening criteria
I - important problem
A - available Dx/ Facility
T - Treatable
R -Recognisable latent stage
O - Obvious Dx test
G - Gen public accepted
E - Economically viable
N - Natural History of the untreated disease known
I - Issue agreed policy
C - Continuously done
what is a cross-sectional study
Snapshot data of those with and without disease to find associations at a single point in time
what are cons to a cross-sectional study
Established associated at most, not causality
Prone to bias:
Recall bias, Social desirability bias, Researchers bias
No time reference
Group sizes may be unequal
what is a case control study
Retrospective observational study which looks at a certain exposure and compares similar participants with and without the disease
what are pros to case control study
Good for rare diseases
quick
multiple exposures
what are cons to case control study
Can only show association (not causation)
Reliance on recall or records to determine exposure
Confounders
Selection of control groups is difficult
Potential bias: recall, selection
what is a cohort study
Longitudinal prospective study which takes a population of people recording their exposures and conditions they develop
what are pros of cohort study
Can show causation: Establishing timing and directionality of events
Less chance of bias
Ethically safe
Participants can be matched
Eligibility criteria and outcomes can be standardised
what are cons of cohort study
Large amount lost to follow up
Expensive
Controls may be difficult to identify
Exposure may be linked to hidden confounder
For rare disease, larger sample size or longer follow up is needed
What is a RCT
Similar participants randomly controlled to intervention or control groups to study the effect of the intervention
Gold standard
what are pros of RCT
Can infer causality
Less risk of bias/ confounders
Unbiased distribution of confounders
Randomisation facilitates statistical analysis
what are cons of RCT
Expensive: time and money
Volunteer bias
Ethically problematic
bradford hills criteria defintion
Criteria used to support causation
what criteria is used to support causation
DR CBT CASS
Dose-Response
Reversibility
Consistency
Biological Plausibility
Temporality
Coherence
Analogy
Strength
Specificity
what are confounders
Risk factors, other than those being studied, that influence the outcome
what is bias
Systematic error that results in a deviation from the true effect of an exposure on an outcome
what is selection bias
discrepancy of who is involved
what are examples of information bias
- Measurement bias: different equipment
- Observer bias
- Recall bias: past events incorrectly remembered
- Reporting bias: responder doesn’t tell the truth
whats is publication bias
some trials are more likely to be published than others
what is lead time bias
screening merely identifies the disease earlier than before and thus gives the impression that survival is prolonged (but survival time unchanged!)
what is length time bias
diseases with longer period of presentation are more likely to be detected by screening than the ones with shorter time of presentation
what is an outbreak
a number of cases that exceeds what would be expected
what is an epidemic
Cases occurring in the same geographical location
what is a pandemic
disease that has spread over countries or continents affecting large numbers of people
what are examples of notifiable diseases
Acute Encephalitis
Acute infectious hepatitis
Acute meningitis
Acute poliomyelitis
Anthrax
Botulism
Cholera
Diptheria
HUS
Leprosy
Malaria
Measles
Meningococcal septicaemia
Mumps
Rabies
Rubella
Scarlet fever
Smallpox
Tetanus
Tuberculosis
Whooping cough
Yellow Fever
what are vulnerable groups
Homeless people
Gypsies and travellers
LGBTQ+
Asylum seekers and refugees
what are asylum seekers
A person who has made an application for refugee status - Access to GP and A&E
what is a refugee
A person granted asylum and refugee status
what is indefinite leave to remain
A person is given full refugee status and permanent residence in the UK with Full access to NHS
what is an unaccompanied child
Someone that has crossed international borders in seek of refuge <18 years old
what article concerns human rights
article 14
The right to not be discriminated against on the groups of sex, race, colour, language, religion, political or other opinion, national origin, property, birth or other status.
what is domestic abuse
Any incident or pattern of behaviour showing controlling, threatening, violent or abusive actions between >16 year olds and their partners/family member
what are types of domestic abuse
Psychological
Financial
Sexual
Physical
Emotional
what is standard risk domestic abuse
Does not suggest imminent serious harm – signpost
what is moderate risk domestic abuse
Potential for serious harm but unlikely unless there is a change in circumstances – signpost
what is high risk domestic abuse
Imminent risk of serious harm –
MARAC/IDVAS
MARAC: Multiagency risk assessment conference
IDVAS: Independent domestic violence advice services
what is adherence
the extent to which patient actions match AGREED recommendations
Still recognises the doctor as the expert but acknowledges importance of patient beliefs
what is compliance
the extent to which the patient’s behavior coincides with medical or health ADVICE, a paternalistic relationship
Paternalism means the patient must follow the doctor’s orders, not taking into account their views
what are reasons for non adherence
Disagree with doctor
Cost
Side-effects
Forgetful (psych/neuro/chronic diseases)
Lack of understanding of importance
Barriers to healthcare
what is unrealistic optimism
Individuals continue health damaging behaviour due to inaccurate perception of risk and susceptibility
what is sustainability
Meeting the needs of the present without compromising the needs of future generations
what is morality
concern with the distinction between good and evil, or right and wrong
what is ethics
A system of moral principles and a branch of philosophy which defines what is good for individuals and society
what is utilitarianism
An act is evaluated solely in terms of its consequences
Maximizes good and minimizes harm
what is criticism of utilitarianism
Assumes consequences can be predicted
Ignores rights of minorities
Happiness can’t be quantified
what is Kantianism (deontology)
Features of the act determine the worthiness of the act
actions are good or bad according to a clear set of rules
what is criticism Kantianism
Doesn’t consider consequences
Conflicting duties
Only considers absolutes, doesn’t allow for ‘grey areas’
Conflicting moral duties, rules might not be best for everyone, lack of emotion when applying ethics
what is virtue ethics
Focus is on the individual doing the action
Is the person in action expressing good character or not?
what are 5 focal virtues
Compassion
Discernment
Trustworthiness
Integrity
Conscientiousness
what are the four principles
Autonomy
benevolence
Non-maleficence
Justice
what is opportunity cost
health benefits for patients that will be foregone if a new treatment is funded
what is QALY
Quality adjusted life year
Used as an outcome measurement, allowing for comparisons
what is incremental cost
effectiveness ratio
Used to guide NHS on whether they should purchase a treatment
what is economic evaluation
Comparative evaluation of cost and benefit, used to allocate finite resources
what factors are needed for economic evaluation
- Patient population: condition and severity, review of previous treatments
- Intervention: drug (dose, frequency) and who can deliver the intervention
- Currently used treatments
- Outcomes
what is cost effectiveness analysis
Measured in natural units
E.g., Cost per life year gained
New treatment adds 10 years to life. Cost of treatment is £10,000
£10,000 / 10 = £1000 per life year gained
what is Cost-utility analysis
outcome measured in QALYs
what is cost benefit analysis
outcomes measured in monetary units
what is cost minimisation analysis
outcome is the same in both treatments, aim to minimise cost
how is QALY calculated
QALY = length of life (years to life after a treatment) x Quality of life (0-1)
0 = dead
(eg can be 0.8)
1 = alive
what is incidence
The number of individuals newly diagnosed with a condition over a set period of time
what is prevalence
Number of individuals with a condition at one point in time
what is absolute risk
An absolute measure of association between exposure and risk
what is relative risk
How much more likely an individual is to get the disease with A compared to B
what is odds
the probability that one thing is so or will happen rather than anothe
p = probability of disease = number of cases / total population
odds = p / 1-p
what is odds ratio
a/c : b/d
what does odds ratio >1 mean
Greater odds of associated with exposure and outcome
what does odds ratio of 1 mean
No association
what does odds ratio <1 mean
lower odds of association between exposure and outcome
Odds ratio of 0.8 = 20% decrease in odds
what is the difference between odds ratio and relative ratio
OR- very simple, does not need incidence, binary outcome, Usually used in retrospective studies. Disadvantage- can overestimate risk in rare disease
RR- need incidence, good for prospective and RCTs, able to examine and model a variable over time
what is prevalence proportion
number of cases at the time / total population at the time
what are pros of prevalence proportion
- Useful in causation research where follow-up data is not attainable and onset is hard to define
- Useful for measuring disease burden
what are cons of prevalence proportion
- Hard to make meaningful comparisons of risk
- Length-time bias: disease with longer duration is more likely to be captures in prevalence
what is incidence proportion
number of new cases in time period / size of population at start of time period
by cohort study
what are pros of incidence proportion
Used in range of circumstances
Attack rate in outbreaks
Case fatality rate
Risk of death from acute disease
what are cons of incidence proportion
Required fixed and complete follow up
In long risk periods there are competing risks (e.g., death by other cause)
what is incidence rate
number of diagnosed / time period x 100
what is risk difference
Measure of association between exposure and disease occurrence
what is absolute risk difference
the difference in the average risk of an event between two groups
Risk of A – Risk of B
what is relative risk difference
(Risk of A – Risk of B) / Risk of B
what does a risk difference >0 mean
positive association (risk factor)
what does a risk difference <0 mean
negative association (protective factor)
what is Attributable risk
The proportion of disease rate that is attributable to the exposure
incidence in exposed – incidence in unexposed
what is risk ratio
A relative measure of association between exposure and disease occurrence
Risk ratio = risk of A / risk of B
what is number needed to treat
A measure of the potential benefit of a clinical intervention
Number of people needed to be treated in order to prevent one outcome
NNT = 1 / Absolute risk difference
what is confidence intervals a measure of
Estimate of range of plausible values for 95% of the population parameter
measure of certainty
what is p value
p-value <0.05 – statistically significant
assess the credibility of a null hypothesis by calculating the p-value
what are categorical/qualitative data
Nominal - mutually exclusive and unordered eg sex M/F
Ordinal - mutually exclusive and ordered eg pain 0-10
what are numerical/quantitative numbers
discrete - whole numbers eg children in family
continuous - any value eg Height in cm
what is sensitivity
correct ID disease
what is specificity
correct excluding
what is Positive predictive value
Proportion of people with a positive test
result who actually have the disease
what is Negative predictive value
Proportion of people with a negative test
result who do not have the disease
what is a T1 error
false positive
what is a T2 error
false negative
what is PICO
population
Intervention
Control
Outcome
what are 3 levels for intervention
individual
community
population
what are early food influences
maternal diet
breastfeeding
age of solid food
what is restraint theory
paradoxical increased subjective hunger after dieting
unbalanced leptin and ghrelin levels
what are 3 forms of dieting
decrease calories
decrease types of food
decrease window to eat
what is sex <13 yrs
always rape, esclate
what is sex 13-15yr
gillick-fraser guidence
what is fraser
Contraception <16 specific guidance
give Contraception if
- if understands/competent
- likely to have UPSI anyway
- Cannot be persuaded to tell parents
- in best interest
- mental/physical health will suffer
what is Gillick
assess a child’s ability to consent to medical treatment w/o parental permission
competence; if capacity (understands retains, weighs up, communicates)
what are Dr duties
knowledge
skills
performance
safety
quality
maintain trust
name 4 leadership styles
authoritarian
participation
delegative
transformational
transactional
