Public Health

Question 1

Equity vs Equality

Answer 1

Equity - Giving people what they need to achieve equal outcomes

Equality - Giving everyone the same rights, opportunities and resources

Question 2

Horizontal vs vertical equity

Answer 2

Horizontal - Providing equal treatment for people with the same health needs. E.g. 2 towns with similar rates of asthma getting equal access to treatment and resources

Vertical - Different levels of care based on different needs. E.g. patients with more critical needs prioritised over minor illnesses

Question 3

What are some determinants of health

Answer 3

PROGRESS
Place of residence
Race
Occupation
Gender
Religion
Education
Socio-economic
Social capital

Question 4

What are 2 methods used to assess quality of healthcare

Answer 4

Maxwells dimensions of the quality of healthcare (3As, 3Es)

Donabedian’s framework of health service evaluation (structure, process, outcome)

Question 5

Explain Maxwells dimensions of the quality of healthcare

Answer 5

(3As, 3Es)
- Acceptability
- Accessibility
- Appropriateness

• Effectiveness
• Efficiency
• Equity

Question 6

Donabedian’s framework of health service evaluation

Answer 6

(structure, process, outcome)
S - What is the service? (e.g. number of hospitals)
P - How does the service work/what goes on? (e.g. how many patients seen)
O - Outcome (e.g. Number of deaths)

Outcomes (5 Ds):
- Death
- Disease
- Disability
- Discomfort
- Dissatisfaction

Question 7

What are some issues with assessing health outcomes

Answer 7

• Link between service and outcome can be difficult to confirm
• Time lag between service and outcome may be long
• Large sample sizes needed
• Data problems (CART - Completeness, Accuracy, Relevance, Timeliness)

Question 8

What is a Health Needs Assessment

Answer 8

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

Question 9

What are the types of health care need

Answer 9

Felt Need - Individual perception of variation from normal health (patient feels ill)

Expressed need - Individual seeks help to overcome variation (patient goes to doc)

Normative need - Professional defines intervention for expressed need (doctor says what they need)

Comparative need - Comparison between severity, range of interventions and cost

Question 10

What are 3 perspectives of a health needs assessment

Answer 10

Epidemiological - Looks at evidence base (incidence/prevalence, availability of services, cost effectiveness etc)

Comparative - Compares services and outcomes received by a population with others (can be spacial or social - areas or ages for example)

Corporate - Asking local population what their needs are (focus groups, public meetings, interviews etc)

Question 11

Give a pro and con for each type of health needs assessment perspective

Answer 11

Epidemiological
- Pro: Uses existing data and provides evidence of incidence/morbidity/mortality
- Con: Quality of data variable, Data collected may not be data required, Does not consider felt needs/opinions

Comparative
- Pro: Quick and cheap if data available. Allows comparison for service effectiveness
- Con: Difficult to find comparable populations, may not be available or high quality

Corporate
- Pro: Based on felt and expressed needs of population. Recognises knowledge and experience of those within the population
- Con: Difficult establishing need from demand. Groups may have vested interests or political agendas

Question 12

What are 3 resource allocation methods

Answer 12

Egalitarian - Provide ALL necessary and required care to everyone. (Equal, but expensive)

Maximising - Act solely evaluated by its consequence (Resources allocated to those most likely to benefit, those who dont make cut get nothing)

Libertarian - Each individual responsible for their own health (Promotes engagement in own healthcare, most diseases not self inflicted)

Question 13

What are the 3 types of prevention

Answer 13

Primary - Prevention of condition before it occurs (e.g. vaccine)
Secondary - Early identification to alter disease course (e.g. screening)
Tertiary - Limit consequences of established disease (e.g. preventing worsening of renal function in CKD)

Question 14

What are 2 approaches to disease prevention and what is a prevention paradox

Answer 14

Population - Prevention approach delivered to everyone to shift risk factor distribution curve (e.g. dietary salt reduction through legislation)

High risk - Identify individuals above a chosen cut off and treat (e.g. Blood pressure screening)

A preventative measure which brings benefit to the population often offers little impact to each participating individual (E.g. if everyone wore seat belt, for every life saved, 400 would never benefit from it)

Question 15

What is Need, Demand and Supply

Answer 15

Need - Ability to benefit from intervention
Demand - What people ask for
Supply - What is provided

Question 16

What is the purpose of screening

Answer 16

The purpose of screening is to identify apparently well individuals who have (or are at risk of developing) a particular disease so that you can have a real impact on the outcome.

Question 17

What are some downsides to screening

Answer 17

Exposure of well individuals to harmful or distressing diagnostic tests

Detection and treatment of sub-clinical disease that would never cause problems

Preventative interventions that may cause harm to individual or population

Anxiety or false assurances

Question 18

What screening programmes exist in pregnancy

Answer 18

• Infectious diseases in Pregnancy Screening Programme (hep B, syphilis, HIV)
• Sickle Cell and Thalassaemia Screening
• Fetal Anomaly Screening Programme (Down’s syndrome, Edwards’ syndrome and
  Patau’s syndrome)

Question 19

What screening programmes exist in newborns

Answer 19

• Newborn and Infant Physical Examination (hearts, eyes, hips, testes)
• Newborn Hearing Screening Programme (permenant childhood hearing impairment - Done via Otoacoustic Emissions testing and Auditory Brainstem Response as follow up if failed.)
• Newborn Blood Spot Screening Programme (sickle cell disease, CF, congenital
  hypothyroidism + 6 inherited metabolic disease)

Question 20

What is the criteria for disease screening

Answer 20

Wilson and Jungner

Condition
- Important, natural history understood, disease should have a latent, detectable stage

Program
- Ongoing, cost effective

Test
- Simple, safe, precise, validated
- Distribution of values must be known with clear cut off
- Acceptable to population (not too invasive)
- Agreed policy on further investigation of individuals with positive result and on choices available to them

Treatment
- Effective treatment or intervention for patients identified through early detection, with evidence of better outcomes compared to late treatment
- Agreed policy on who to treat

“In Exam Season, NAP”
- Important disease
- Effective treatmtent available
- Simple and Safe to test for
- Natural history known
- Acceptable to population (not invasive)
- Policy on who/how to treat agreed

Question 21

What is sensitivity, specificity, positive predictive value and negative predictive value

Answer 21

Sensitivity - Proportion of those with condition that are correctly identified with positive test

PPV - Those with positive test, who actually had the condition

Specificity - Proportion of those without disease correctly excluded

NPV - Those with negative test, who actually dont have the disease

Question 22

Lead time vs length time bias

Answer 22

Lead time: Early identification doesnt alter outcome, but appears to increase survival as disease was identified earlier than normal.

Length time: Disease that progresses slowly is more likely to be picked up in screening, making it appear that screening lengthens life, even though slow progressing disease always wouldve killed that late, as opposed to rapid progressing.

E.g. Lead time: Diagnosed earlier but person still dies same time from symptoms onset

Length time: E.g. Slow-growing disease, or disease with long latent period. Screening more likely to detect less severe disease, falsely suggesting improved outcome

Question 23

Define these biases:
- Selection
- Information
- Allocation
- Publication

Answer 23

Selection is an error in
- Selection of study participants, allocation of participants to different study groups, causing sample to not be representative of general population
- Including/excluding groups e.g. more health conscious people, or selectively choosing based on sex,age,etc no longer reflecting broader population.

Information bias is
- Error in observer’s recall and reporting. Paricipant, instrument wrongly calibrated. Error in data collection/measurement

Allocation bias is
- Non random assignment of participants to different treatment groups in a study. Can lead to differences between groups confounding the results
- E.g. younger healthier people in one and older and sicker people in another. Younger/healthier always gonna look better

Publication
- When positive or significant results are more likely to be published than not.
- Can lead to overestimations of safety/efficacy of interventions

Question 24

What is a case control study with pros and cons

Answer 24

Retrospective, observational study looking at cause of disease. Compares similar participants with disease to controls without

Pros: Good for rare outcomes, quicker than cohort or intervention studies, investigate multiple exposures

Cons: Difficulties finding controls to match with case, prone to selection and information bias

Question 25

What is a cross sectional study

Answer 25

Retrospective, observational Collects data form population at a specific point in time ("snapshot"). Prevalence of risk factors and disease itself Pro: - Relatively quick and cheap - Provide data on prevalence at point in time - Good for surveillance and PH planning Cons: - Risk of reverse causality (Did exposure or outcome come first?) - Cannot measure incidence - Recall and response bias risk (may miss quick recoveries)

Question 26

What is a cohort study

Answer 26

Prospective longitudinal study looking at separate cohorts with different treatments or exposures Pros: - Can follow up a group with rare exposure - Good for common and multiple outcomes - Less risk of selection and recall bias Cons - Takes a long time - Large sample size, expensive, time consuming - People drop out

Question 27

What is a RCT

Answer 27

Prospective study, all participants assigned a random exposure or control intervention Pros - Low risk of bias and confounding - Can infer causality Cons: - Time consuming, expensive - Drop outs - Inclusion criteria may exclude populations

Question 28

What is an ecological study

Answer 28

A study that looks at the prevalence of a disease over time in a population rather than individuals

Question 29

What are odds

Answer 29

Odds are used to look at binary outcomes e.g. if a disease occurs, or if it doesn't. To work out divide the probability of it occurring by the probability of it not occurring. [Probability the event occurs (p)] / [Probability it doesn't (1-p)]

Question 30

What is an odds ratio, and how should they be interpreted

Answer 30

Comparing the odds of an outcome occurring between 2 groups. E.g. a group with a treatment, and a control group. Odds ratio = Odds of an event (Group/Condition A) / Odds of an event (Group/Condition B - (Tends to be control)) Ratio = 1 - No change in odds of outcome in either group. Change in condition did not affect odds. Ratio > 1 - Numerator>denominator. Odds of event happening are higher in numerator than denominator. Often denotes a risk factor. Ratio < 1 - Denominator>numerator. Odds lower for condition in the numerator. Often protective factor or treatment

Question 31

Explain these types of information biases: - Measurement - Observer - Recall - Reporting

Answer 31

Measurement - Different equipment measuring differently Observer - Observers expectations influencing reporting Recall - Past events not recalled correctly Reporting - Not telling truth due to shame/judgement

Question 32

What is confounding

Answer 32

A situation where a factor is associated with the exposure of interest and independently influences outcome, but does not lie on causal pathway. E.g. Lack of exercise causes weight gain, but many confounding variables also affect weight gain.

Question 33

What is the criteria for causality

Answer 33

Bradford Hill - 9 criteria - Strength - of association - Dose-response - higher exposure=higher incidence? - Consistency - Similar results in other studies/populations - Temporality - Does exposure precede outcome? - Reversibility - Does reducing exposure reduce risk? - Biological plausability - Coherence - Logical consistency with other info - Analogy - Similarity with other cause-effect relationships - Specificity - Relationship specific to the outcome of interest. E.g. helmets reduced head injuries, as opposed to accidents going down in general.

Question 34

What is reverse causality

Answer 34

E.g. Did stress increase HTN or did increased HTN cause stress.

Question 35

Define epidemiology, incidence, prevalence and person time

Answer 35

● Epidemiology: The study of the frequency, determinants and distribution of diseases and health related states in populations in order to prevent and control disease ● Incidence: Number of new cases over a certain time period ● Prevalence: The number of people with a disease at a certain point in time ● Person time: Measure of time at risk for all the patients in the study- therefore if 1,000 patients were studied for 2.5 years, the study would have looked at 2,500 person years

Question 36

Define relative risk, absolute risk, and number needed to treat

Answer 36

Relative risk - Risk among exposed group divided by risk in unexposed group - doesn't take into account baseline risk (e.g. new drug reduces incidence by 50%, may only be from 2 to 1) Absolute (or attributable) risk - Subtract risk from control group from the exposed group, giving you the excess risk caused by the exposure (e.g. new drug reduces incidence 2 in 1000, down to 1 in 1000, so AR is 1 in 1000) Number needed to treat - Number of patients to treat for one to benefit. 1/absolute risk. (E.g. AR is 1 in 1000, 1/(1/1000) = 1000 treated to save 1)

Question 37

What are health behaviours

Answer 37

Health behaviour - Behaviour aimed at preventing disease e.g. eating healthy Illness behaviour - Behaviour aiming to seek remedy e.g. going doctors Sick role behaviour - Behaviour aimed at getting well e.g. taking tablets and resting

Question 38

What 4 factors are perceptions of risk influenced by

Answer 38

1. Lack of personal experience with problem 2. Belief that it is preventable by personal action 3. Belief that if it hasn't happened by now, its not likely to 4. Belief that the problem is infrequent

Question 39

What are transition points

Answer 39

Points at which interventions are thought to be more effective - Leaving school - Entering workforce - Becoming a parent - Becoming unemployed - Retirement and bereavement

Question 40

What are some models of behaviour change

Answer 40

1. Health belief model (HBM) 2. Theory of Planned Behaviour (TPB) 3. Stages of change /transtheoretical model (TTM) 4. Social norms theory 5. Motivational interviewing 6. Social marketing 7. Nudging (choice architecture) 8. Financial incentives

Question 41

What is the Health Belief Model

Answer 41

Individuals likely to change behaviour if they: 1. Believe they are susceptible to condition 2. Believe in serious consequences 3. Believe action reduces susceptibility 4. Believe benefits of taking action outweigh the costs

Question 42

According to the Theory of Planned Behaviour, what 3 factors determine an individual's health behaviour?

Answer 42

1. Their attitude to the behaviour 2. The subjective/social norm 3. Their own perceived behavioural control

Question 43

What are the 6 steps of the States of Change (Transtheoretical) Model?

Answer 43

1. Precontemplation - No intention of changing the behaviour 2. Contemplation - Aware of the problem but no commitment to action 3. Preparation - Intent on taking action to address problem 4. Action - Active modification of behaviour 5. Maintenance - Sustained change, new behaviour starts to replace old 6. Relapse - Fall back into old patterns

Question 44

What does heroine act on and what does it do to the patient. What are some side effects

Answer 44

Acts on opiate receptors Causes euphoria, miosis, drowsiness Dpeendance, bad withdrawals, nausea, itching, sweating, constipation, respiratory depression

Question 45

What drug is used for an opiate detox

Answer 45

Methadone Naltrexone or buprenorphine are also used

Question 46

What is crack cocaine and how does withdrawal present

Answer 46

Oral/snorting/IV/smoking Blocks reuptake of serotonin - intense pleasurable sensation Depletion at secretory neurons - anxiety, panic, adrenaline, wired. Leads to depression, panic, paranoia

Question 47

What is Maslows hierarchy of needs

Answer 47

Self fulfilment: - Self actualisation: Achieving full potential, including creative activities Psychological - Esteem: prestige/ accomplishment - Belongingness/love: Intimate relationships, friends Basic needs: - Safety/security - Physiological: food, water, warmth, rest Works from bottom up. In order to fulfil self actualisation, basic necessities need to be fulfilled

Question 48

What is used for Alcohol overuse assessment

Answer 48

CAGE questions AUDIT - If score >15, refer for specialist support Units: Volume (L) x %ABV = Units

Question 49

How can alcohol dependency be gauged

Answer 49

- Withdrawals - Cravings - Drinking despite negative consequences on physical, mental, social/work life - Tolerance - This is said to occur when the individual has to drink larger amount of alcohol to obtain similar effect - Primacy (put drinking before other activities) - Loss of control

Question 50

Asylum seeker vs refugee

Answer 50

AS if seeking refugee status R once granted, usually for 5 years

Question 51

What do asylum seekers receive

Answer 51

- Vouchers to live off (restricted) - NASS support package - Access to NHS - Not allowed to work, no control over location

Question 52

What are some barriers to life for refugees

Answer 52

- Reluctance of GPs to register them - Illiteracy - Communication - Lack of permanent site - Mistrust of professionals

Question 53

Health problems for refugees

Answer 53

Health problems for refugees: Injury/illness from war/ travelling Communicable disease Lack of health screening and immunisation Malnutrition Untreated chronic disease Mental illness

Question 54

Define malnutrition

Answer 54

Deficiencies, excesses, imbalances in a person's intake of energy and/or nutrients. 2 broad groups: - Undernutrition - Stunting (low height for age), wasting (low weight for height), micronutrient deficiencies (vitamins, minerals) - Overweight, obesity and diet related non communicable diseases (heart disease, stroke, diabetes, cancer)

Question 55

Four dimensions of food insecurity

Answer 55

1. Availability 2. Access - economic/physical 3. Utilisation - Opportunity to prepare food 4. Stability of 3 dimensions over time.

Question 56

Types of error:

Answer 56

● Sloth error: being lazy, not bothering to check results/information for accuracy. ● Lack of skill: lack of appropriate skills or teaching in practice ● Communication breakdown: unclear instructions or plans and not listening to others ● System failure: machine/equipment stopped working ● Human factors: bravado (working beyond means), timidity (not working to competence) ● Judgement failure ● Neglect ● Poor performance ● Misconduct

Question 57

What should be taken into account when classifying the severity of an error

Answer 57

- Intention - Action - Outcome - Context

Question 58

What are the 4 components to consider in regards to a negligence error

Answer 58

1. Was there a duty of care? 2. Was there a breach in that duty? 3. Was the patient harmed? 4. Was the harm due to the breach in care?

Question 59

What rules are questioned in the case of negligence

Answer 59

Bolam rule: Would a reasonable doctor do the same Bolitho rule: Would that be reasonable?

Question 60

What is a never event

Answer 60

Never event: Serious, largely preventable patient safety incidents, should not occur if the available preventative measures have been implemented

Question 61

Why is a systems approach preferred to a person approach

Answer 61

Person approach - hold one person accountable Systems approach - Identify there are latent errors in the system Why is this good: systems approach eliminates blame culture.

Question 62

What is the swiss cheese model of error

Answer 62

When an error occurs due to a multiple failed or absence defences against errors Holes line up, allowing the error to occur

Question 63

What is the bucket model of error

Answer 63

The bucket model of error in healthcare categorizes mistakes into three "buckets": Knowledge Errors: - Gaps in clinical knowledge or expertise. Rules Errors: - Failures to follow established protocols or guidelines. Action Errors: - Mistakes in performing tasks correctly, even when knowledge and rules are clear. This model helps identify and address multiple sources of error, emphasizing a systems-based approach to improve patient safety by reducing individual blame and focusing on comprehensive safety measures.

Question 64

What is duty of candour

Answer 64

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.