Public Health

Question 1

Define Public Health

Answer 1

The science and art of preventing disease prolonging life and improving health through organised efforts of society

Question 2

Define equity
Define equality
Define horizontal equity
Define vertical equity

Answer 2

equity - give people what they need to achieve equal outcomes

equality - give everyone the same rights opportunities and resources

horizontal equity - equal treatment for people with equal health care needs

vertical equity - unequal treatment to unequal health care needs

Question 3

define inverse care law

Answer 3

availability of health care tends to vary inversely with its need

Question 4

Determinants of Health

Answer 4

PROGRESS

P-PLACE OF RESIDENCE
R- RACE
O-OCCUPATION
G-GENDER
R-RELIGION
E-EDUCATION
S-SOCIOECONOMIC
S-SOCIAL CAPITAL

Question 5

3 domains of public health practise

Answer 5

health improvement - societal interventions aimed at preventing disease, promoting health and reducing inequalities

health protection - measures to control infectious disease and environmental hazards

improving services - organisation and delivery of safe high quality services

Question 6

in assessing quality of healthcare there is a framework what is it called?

explain it?

then it is important to see structure, process and outcome - what does this mean

Answer 6

maxwells dimensions of quality of healthcare
3 a’s and 3 e’s

acceptability
accessibility
appropriateness

effectiveness
efficiency
equity

structure- what is there? no. of hospitals
process - what goes on? - how many pts seen?
outcome: no. of deaths for ex

Question 7

health needs assessment involves

give examples?

Answer 7

need - ability to benefit from an intervention

demand - what people ask for

supply - whats provided

eg: abx for mild infection is supplied and demanded but not deeded. routine vaccinations are needed and supplied but not demanded.

Question 8

4 types of need

Answer 8

felt need - individual perceptions of variation from normal health -pt feels unwell

normative need - proffesional defines intervention for expressed need - then dr says what they need

expressed need - pt seeks help to overcome variation in normal health - pt goes to dr

comparitive need - comparison between severity, range of interventions and cost

Question 9

when doing a health needs assessment you can look at epidemiological, comparative or corporate perspective.

if i am looking at epidemiological perspective, tell me what it does, where it gets info from and the pros and cons?

Answer 9

look at:;
- size of pop - incidence/prevalence
- services available: prevention/tx/care
- evidence base: effectiveness/cost effectiveness

sources: disease registry, admissions, gp databases

good:
- uses existing data
-provides data on disease incidence/mortality/morbidity

bad:
- quality of data variable
-data collected might not be data required
-doesnt consider felt needs/opinions of pts

Question 10

when doing a health needs assessment you can look at epidemiological, comparative or corporate perspective.

if i am looking at comparitive perspective, tell me what it does, where it gets info from and the pros and cons?

Answer 10

compares services/outcomes recieved by a population with others
- compare diff areas or pt of diff ages

look at:
- health status
-service provision
-outcomes

good:
- quick and cheap if data available
- shows if services are better or worse than compared group

bad:
- can be difficult to find comparable population
-data might not be available/high quality

Question 11

when doing a health needs assessment you can look at epidemiological, comparative or corporate perspective.

if i am looking at corporate perspective, tell me what it does, where it gets info from and the pros and cons?

Answer 11

ask local pop what their health needs are

use focus groups, interviews, public meeting

wide variety of stakeholders

good:
- based on felt and expressed need
- wide range of views takes into account
- recognises detailed knowledge and experience of those working with population

bad:
- can be difficult to distinguish need from demand
- groups might have vested interests
-may have political agendas

Question 12

3 beliefs to resource allocation methods!! and explain
1 good and 1 bad for each

egalitarian
maximising
libertarian

Answer 12

egalitarian: provide all care necessary and required for everyone
good: - equal
bad: too expensive

maximising: - act is evaluated solely in terms of its consequences
good: resources allocated to those who most likely to benefit from it
bad - those who dont make the cut get nothing

libertarian - each are responsible for their own health
- good: promotes positive engagement
bad: most diseases are not self inflicted

Question 13

explain primary secondary and tertiary prevention

Answer 13

primary
- preventing disease from occuring in first place - eg vaccine

secondary:
- early identification of disease to alter disease course eg : screening

tertiary:
- limit consequences of established disease eg: limit consequences of established disease eg: prevent worsening renal function in ckd

Question 14

3 approaches to prevention

population approach

high risk approach

prevention paradox

Answer 14

population - prevention approach delivered to everyone to shift the risk factor distribution curve: dietary salt reductions through legislation

high risk approach: identify individuals above a chosen cut off and treat them eg : screening people for high bp and tx them

prevention paradox: preventative measure which brings much benefit to population often offers little impact to each participating individuals

Question 15

Purpose of screening

disadvantages

Answer 15

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 .

• exposure of well individuals to distressing or harmful diagnostic tests
  -detection and treatment of sub-clinical disease that would never cause any problems
  -preventive interventions that may cause harm to the individual or population
• incorrect results
  -anxiety or false reassurance
  over tx/tx risks

Question 16

benefits of screening

Answer 16

reproductive choice
worthwhile use of resources
informed decision
reassurance
more effective tx
better future health

Question 17

uk 3 screening programme examples in pregnancy

Answer 17

infectious diseases in pregnancy screening programme - hep b, syphillis, hiv

sickle cell and thalaseemia screening

fetal anomaly screening programme - downs, edwards, pataus

Question 18

3 uk screening programmes in newborn babies

Answer 18

newborn and infant physical exam - hearts, eyes, hip, testes

newborn hearing screening programme - permanent childhood hearing impairement

newborn blood spot screening programme - sickle cell, cf, congenital hypothyroidism + 6 inherited metabolic disease

Question 19

define sensitivity and specificity?

Answer 19

sensitivity: proportion of those with disease who are correctly idenitified - does the test pick up the disease

specificity - proportion of people without the disease who are correctly excluded by screening test: does the test identify people who dont have the disease

Question 20

in terms of specificity and sensitivity explain what a positive and negative predictive value would mean?

Answer 20

positive: proportion of people with a positive test result who actually have the disease

negative: proportion of people with negative test result who don’t have the disease

Question 21

What is the wilson and jungner criteria?

4 bits to it

the saying to help understand

Answer 21

knowledge of disease - important. disease understood. recognisable stage.

the screening test: suitable test. accepted by public

treatment: organisation and cost: cost of case findings balance out to possible expenditure. ongoing process

tx: accepted tx. enough facilities. agreed policies on who to tx.

In Exam Season NAP -
- important disease
- effective tx available
- simple and safe
- natural hx of disease known
- acceptable - not too invasive
-policy on who to tx agreed

Question 22

calculations with sensitivity and specificity and positive predictive value and negative predictive value

Answer 22

sensitivity: a/a+c
specificity: d/b+d
positive predictive: a/a+B
negative predictive: d/c+d

(REFER TO PAPER TABLE I HAVE MADE)

Question 23

What is a length time bias?

what is a lead time bias?

Answer 23

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.

lead time bias - early identification by doesnt alter the outcome but appears to increase survival as pt has the disease identified earlier than normal.

Question 24

what is a selection bias?

what is an information bias?

what is an allocation bias?

what is a publication bias?

Answer 24

selection - error in selection of study participants. allocation of participants to different study groups.

information - observes recall and reporting, participants, instrument wrong calibrated

allocation: different participants in different groups - not equally spread

publication - trials with negative results less likely to be published

Question 25

what is confounding?

Answer 25

when a factor is associated with the exposure of interest and independent influences the outcome but doesnt lie on the causal pathway not part of the exposure and the outcome but influences both. almost like air pollution for when the exposure is smoking and the outcome is lung cancer. but doesnt lie on the pathway from exposure to outcome. eg: lack of exercise causes weight gain but there are other confounding variables that also cause it

Question 26

in a study design tell me the hierachy of evidence

Answer 26

systematic reviews and meta analysis randomised control trials cohort studies case-control studies cross-sectional studies case series and case reports editorials and expert opinions

Question 27

what is a case control study? give me the advantages and disadvantages of it?

Answer 27

retrospecitve observational study look at cause of disease. compare similar participant with disease to controls without. advantages; - good for rare outcomes - quicker than cohort or intervention studies (outcome already happened) - can ix multiple exposures disadvantages: - difficulties finding controls to match with case - prone to selection and information bias

Question 28

how would the design of a case-control study be?

Answer 28

you have exposed and unexposed for people with the disease exposed and unexposed to ppl without the disease

Question 29

what is a cross-sectional study and what are the advantages and disadvantages for it?

Answer 29

retrospective observational collects data from population at specific point in time "snapshot" prevalence of risk factors and itself. advantages: - relatively quick and cheap - provides data on prevalence at single point in time - good for surveillance and PH planning disadvantages: - risk of reverse causality (did outcome or exposure come firsT) - cannot measure incidence - recall and response bias risk (may miss quick recoveries)

Question 30

what is a cohort study? advantages disadvantages

Answer 30

prospective longitudinal study looking at seperate cohorts with different tx or exposures. wait to see if disease happens. advantages: - can follow-up group with a rare exposure -good for common and multiple outcomes - establish disease risk and confounders -less risk of selection and recall bias disadvantags: - take a long time -people drop out -need large sample size, expensive and time consuming

Question 31

design of a cohort study

Answer 31

you take people without a disease from population. split into exposed and not exposed. then for each split the disease and no disease. (does it happen or not?

Question 32

what is a randomised control trial/ advantage disadvantage

Answer 32

prospective study, all participants randomly assigned exposure or control intervention advantage: - low risk of bias and confounding - can infer causality diadadvantages: -time consuming, expensive -drop outs - inclusion criteria may exclude some populations

Question 33

how would the design of an RCT look like?

Answer 33

study population then select by defined criteria then potential participants - non participants are those who dont meet inclusion criteria then invitation to participate the participants then randomisation then some give treatment and some control

Question 34

what is an ecological study?

Answer 34

look at prevalence of the disease over time - population data rather than individual can show prevalence and association but not causation

Question 35

what does it mean by odds - as a type of probability and how to work out? what is an odds ratio? how to calculate?

Answer 35

for binary outcome - disease occurs or it doesnt divide probability of it happening or not odds = probability events occurs - p / probability events doesnt (1-p) compare odds of an outcome occuring between 2 groups - 1 being exposure/tx and other control group : odds of an events (condition a)/ odds of an events (condition b CONTROL)

Question 36

if odds ratio is =1 it means? if odds ratio is more than 1 it means? if odds ratio is under 1 it means?

Answer 36

1 means that there is no association between the exposure and the outcome. In other words, the odds of the outcome occurring are the same for both the exposed group and the unexposed group. if odd is over 1: - events odds high for group/condition in numerator. risk factor if under 1: - probability of outcome occurring lower than the exposed. - protective factor/tx provided

Question 37

4 types of information bias

Answer 37

measurement - different equipment measuring differently observer - observers expectations influence reporting recall: - past events not recalled correctly reporting: people dont tell truth because of shame/judgement

Question 38

publication bias is?

Answer 38

trials with negative results less likely to be published

Question 39

What is the bradford-hill criteria for causality?

Answer 39

strength - strength of association dose-response - does a higher exposure produce higher incidence? consistency - similar results in different studies and populations temporaility - does exposure precede the outcome? reversibility - removing exposure reduced risk of disease biological plasuibility - does it make sense biologically? coherence - logical consistency with lab info : incidence of lung cancer with increased smoking is consistent with lab evidence that tobacco is carcinogenic analogy - similarity with other established cause-effect relationships in the past like thalidomide in pregnancy, not other teratogenic drugs show similar effects specificity - relationship specific to outcome of interest: introducing helmets reduced head injuries specifically, it wasnt that there has been an overal injury rate.

Question 40

what does it man by reverse causality? - bradford hill criteria?

Answer 40

stress could have caused htn - rather than htn causing stress

Question 41

why would you get results that suggest that the exposure influences the outcome

Answer 41

bias confounding factors chance reverse causality true assocation- meet the bradford-hill criteria

Question 42

define epidemiology define incidence define prevalence define person time

Answer 42

study of frequency, determinants and distribution of diseases and health related states in populations in order to prevent and control disease incidence: no. of new cases over a certain time period prevalence: no. of people with a disease at certain point in time person time: measure of time at risk for all pts in study - eg 1000 pts studied for 2.5 yrs - your study looks at 2,500 person yrs

Question 43

explain the diff between incidence and prevalence

Answer 43

incidence changes with time, new cases prevalence - number at set time of existing cases so eg: 30k student in sheff. 3,600 have asthma. over past 10 yrs they have 1000 new cases diagnosed. incidence: (1000/30,000)*100= 3.3% per 10 yrs prevalence - 3600/30000*100= 12%

Question 44

define health behaviour illness behavior sick role behaviour

Answer 44

aimed to prevent disease - eg regular exercise illness behaviour - aimed to seek remedy- going to the doctor sick role behaviour - aimed at getting well - take meds

Question 45

perceptions of risk influence by? health

Answer 45

1. lack of personal experience with problem 2. belief that it is preventable by personal action 3. belief that if it has not happened by now, its unlikley 4. belief that the problem is infrequent

Question 46

points at with intervention are thought to be more effective - transition points

Answer 46

leaving school entering workforce becoming parents becoming unemployed retirement and bereavement

Question 47

tell me the different models of behaviour change

Answer 47

health belief model theory of planned behaviour stages of change/transtheoretical model (TTM) social norms theory motivational interviewing social marketing nudging (choice architecture) financial incentives

Question 48

what is the health belief model?

Answer 48

individuals will change their behaviour if: 1. believe are susceptible to the condition 2. believe in serious consequences 3. believe taking action reduces susceptibility 4. believe that taking benefits of action outweigh the costs. + a cue to action

Question 49

Stages of change - transtheroretical model

Answer 49

precontemplation - no intention of changing behaviour contemplation - aware of problem but no comitment to action preparation - intent on taking action to adress problem action - active modification of behaviour maintenance - sustained change, new behaviour replaces old relapse - fall back into old patterns

Question 50

what is an addiction?

Answer 50

craving, tolerance, compulse drug seeking behaviour, withdrawal

Question 51

what can you offer a newly presenting drug users?

Answer 51

screening for blood borne virus health check sexual health advice/contraception check immunisation hx signpost to drug services

Question 52

what is positive conditioning in drug users? negative conditioning?

Answer 52

addiction increases desire to use drug. people dont quit due to unpleasant symptoms.

Question 53

principles of treating drug users?

Answer 53

reduce harm to user and family./friends improve health stabilise life reduce crime

Question 54

how does heroin work? sx? side effects

Answer 54

acts on opiate receptors euphoria, miosis, drowsiness dependence, bad withdrawals, nausea, itching, sweating, constipation, resp depression

Question 55

what is an opiate detox benefit of the 1st drug

Answer 55

methadone - helps transition - free no theft not injected naltrexone and buprenorphine used too

Question 56

cocaine crack method of use how it works side effect - leads to what?

Answer 56

oral/snorting/iv smoking blocks reuptake of serotonin - intense pleasurable sensation depletion at secretory neurons - anxiety, panic, adrenaline secretion, wired. leads to depression, panic, paranoia

Question 57

explain maslows hierachy of need

Answer 57

self-actualization - achieving ones full potential esteem needs - prestige and feeling of accomplishement belongingness and love needs: intimate relationships, friends safety needs: security,safety physiological needs: food water warmth rest self-actualisation is self fullfillment esteem and belongingness is psychological and safety and physiological is basic needs

Question 58

screening questionaire for alcohol dependance how to calculate units?

Answer 58

cage questioniare audit - if score over 15 go to specialist units : volume (l) * % of alcohol = units

Question 59

alcohol dependence - level of dependency - factors

Answer 59

withdrawal sx cravings - very strong desire to drink drink despite negative consequences: physical, mental or social/work life tolerance - individual has to drink larger amount to get similar effect primacy - put drinking before other activities - neglect other activities loss of control narrowing of repertoire - start to drink only 1 type of drink in 1 place

Question 60

treating alcohol dependence

Answer 60

disulfiram - promote abstinence - alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase acamprosate: reduces craving, weak antagonist of NMDA receptors, improves abstinence in placebo controlled trials

Question 61

CI of disulfiram

Answer 61

IHD psychosis

Question 62

barriers to health for refugees

Answer 62

reluctance of gps to register them illiteracy communication lack of permanent site mistrust of professionals

Question 63

what is an asylum seeker? what is a refugee? what happens if persons asylum seeker claim refused?

Answer 63

someone applying for refugee status someone grafted asylum status for 5 yrs only access emergency nhs services- get charged after.

Question 64

what healthcare benefits do refugees get ?

Answer 64

vouchers to live off- sometimes restricted where they can spend NASS support package access to nhs not allowed to work initially, no control over location

Question 65

what kind of health problems for refugees?

Answer 65

injury/illness from war/travelling communicable disease lack of health screening and immunisation malnutrition untreated chronic disease mental illness

Question 66

explain malnutrition

Answer 66

deficiencies, excesses or imbalances in persons intake of energy and/or nutrients. covers 2 conditions: undernutrition - stunting - low height for age, wasting - low weight for height, underweight - low weight for age, and micronutrient - deficiencies or insuffieincyes - lack of important vits and minerals overweight, obesity and diet related noncommunicable diseases - heart disease, stroke, diabetes, cancer what is triple burden= micronutrient deficiencies - hidden hunger

Question 67

tell me the 4 dimensions of food insecurity

Answer 67

availability (affordability) of food access - economic and physical utilisation - opportunity to prepare food stability of 3 dimensions over time

Question 68

tell me all the different ways there can be error in practise by the doctor

Answer 68

sloth error: being lazy, not checking results/info for accuracy lack of skill: lack of appropriate skills or teaching in practise communication breakdown: unclear instructions or plans and not listening to others system failure: machine/equipment stopped working human factors: bravado, timidity fixation/loss of perspective = focus on 1 diagnosis = confirmation bias judgement failure neglect poor performance misconduct mistriage = over/under estimating the severity of the situation.

Question 69

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

Answer 69

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 70

what is the bolam rule? what is the bolitho rule?

Answer 70

bolam - would a reasonable doctor do the same? bolitho - would that be reasonable?

Question 71

4 aspects of negligence and error

Answer 71

was there a duty of care? was there a breach of that duty? was the pt harmed? was the harm due to the breach of care?

Question 72

explain the swiss cheese model of error

Answer 72

falling through the holes because there is failed or absent defences against error happening. - called latent failures. organisational influence (to) unsafe supervision (to) preconditions for unsafe acts (to) unsafe acts

Question 73

what is the bucket model of error

Answer 73

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

Question 74

what is never event?

Answer 74

serious largely preventable pt safety incident that shouldnt occur if available, preventative measures have been implemented. eg: wrong site for surgery wrong drug given escape of psychiatry pt

Question 75

what is a duty of candour

Answer 75

every healthcare professional must be open and honest with pts when something goes wrong with their tx causes, or has the potential to cause, harm or distress

Question 76

define epidemic, pandemic, endemic, hyper-endemic

Answer 76

epidemic - more than expected incidence in a country pandemic - more than 1 country endemic - persistent level of disease occurence hyper-endemic - persistently high level of disease occurence

Question 77

features of a disease that make it a public health concern

Answer 77

high mortality high morbidity highly contagious expensive to treat effective interventions

Question 78

tell me about childhood consent - fraser and gillick

Answer 78

never inform parents - encourage them to inform under 13s can never consent to sex - inform social services. fraser guidlines - does she understand the advice? - has the dr encouraged her telling the parents? - will she have sex anyway? - is the mental/physical health going to be effected if you dont give it - best interests gillick's competence - does a child under 16 have capacity to make own medical decisions? -clinical judgement made by the dr: age capacity, maturity

Question 79

what is the donabedian framework of health service evaluation? issues with health outcomes?

Answer 79

structure - what actually is the service eg: how many heart surgeons there are process - how does the process work outcome - 5 Ds = death, disease, disability, discomfort, dissatisfaction issues with health outcomes: - link between health service and health outcome can be difficult to confirm - time lag between service and outcome may be long -large sample sizes may be needed -data may not be available or have a problem with it (CART= completeness, accuracy, relevance, timeliness)