Public Health Flashcards
What are the 3 domains of public health?
Health improvement, health protection, health care
Examples of health improvement?
Concerned with societal interventions (not primarily delivered through health services) aimed at preventing disease, promoting health, and reducing inequalities
Education, employment, housing
Examples of health protection?
Concerned with measures to control infectious disease risks and environmental hazards
Radiation, immunisation, environment, emergency response
Examples of health care?
Concerned with the organisation and delivery of safe, high quality services for prevention, treatment, and care
Clinical effectiveness, efficiency, audit, clinical guidelines
Determinants of health
PROGRESS
Place of residence
Race
Occupation
Gender
Religion
Education
Socioeconomic status
Social Capital
What are the 3 Health Psychology Behaviours?
Health Behaviour, Illness Behaviour, Sick role Behaviour
What is Health behaviour?
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 medication adherence in developed countries (WHO)?
50%
Intervention at population/ecological level
Health promotion – process of enabling people to exert control over their health
- Awareness campaigns e.g. 5 a day and every mid matters
- Screening and immunisations
- Clean Air Act
Intervention at community level
social and community networks, eg. local sports hubs, improved alcoholic referrals
Intervention at individual level
Patient-centred approach – care responsive to individual needs, eg. vaccinations, lifestyle
What is unrealistic optimism?
“Individuals continue to practice health damaging behaviours due to inacurrate perceptions of RISK and SUSCEPTABILITY.”
What 4 factors affect Perception of Risk?
- Lack of personal experience with the problem
- Belief that the problem is preventable by personal action
- Belief that if its not happened by not, its not likely to
- Believe that the problem is infrequent
Behavioural Change: What is the Health Belief Model?
Perceived barriers have been demonstrated to be the most important factor for addressing behaviour change in patients
Individuals will change if they:
- Believe they are susceptible to the condition in question (e.g. heart disease)
- Believe that it has serious consequences
- Believe that taking action reduces susceptibility
- Believe that the benefits of taking action outweigh the costs
Critique of Health Belief Model
Good:
Can be applied to wide variety of health behaviours
‘Cues to action’ is a unique component of this model
Critique:
▪ Does not consider outcome expectancy or self-efficacy
▪ Does not consider influence of emotions and behaviour
▪ Does not differentiate between first time and repeat behaviour
Behavioural Change: What is Theory of Planned Behaviour?
The best predictor of behaviour change = INTENTION
a. Intention is determined by:
1. Personal attitude to the behaviour
2. Social pressure to change behaviour (social norm)
3. Person’s perceived behavioural control
eg.
1. Attitude – I do not think smoking is a good thing
2. Subjective Norm – most people who are important to me want me to give up smoking
3. Perceived Behavioural Control – I believe I have the ability to give up smoking
4. Behavioural Intention – I intend to give up smoking
Critique of Theory of Planned Behaviour
Good
Takes into account importance of social stressors/influences and perceived control
Critique
▪ Lacks temporal element or lack of direction and causality
▪ Doesn’t take into account emotions
▪ Doesn’t explain the 3 factors interact to determine intention
▪ Doesn’t take into account habits and routines
Behavioural Change: What is the Stages of Change/Trans-theoretical model?
Pre contemplation > Contemplation > Preparation > Action > Maintenance (can be reversed) PC PAM, good because can account for relapse
Examines the process of change, rather than factors that determine behaviour
Allows for interventions to be tailored to the individual according towhat stage they are at
Critique of Stages of Change/Transtheoretical model
Critique
▪ Not all people move through every stage linearly
▪ Change might operate on a continuum rather than discrete stages
▪ Doesn’t take into account habits, culture, social and economics
Other Behavioural Change models
- Social norms theory
- Motivational interviewing
- Social marketing
- Nudging (choice architecture) e.g. fruits and veg near the till
- Financial incentives
Other Behavioural Change things to consider
- Impact of personality traits on health behaviour
- Enjoyment and motivation
- Assessment of risk perception
- Impact of past behaviour/habit
- Automatic influences on health behaviour
- Predictors of maintenance of health behaviours
- Social environment
What are the 4 determinants of health?
Genes, lifestyle, environment, healthcare
Materialist theory
Focuses on the socioeconomic factors, resources, and material conditions that contribute to health disparities.
Lifecourse theory
The Lifecourse theory explains how adverse health events occur more frequently in those individuals who have already had critical periods of ill health in their life.
Psychosocial theory
The psychosocial theory focuses on how individual and social factors, including psychological well-being, social support, and cultural factors, play a significant role in shaping health
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
What is equity and equality?
Equity: What is fair and just
Equality: Everyone has equal share
Reasons for the health inequalities established in the Black Report (1980)?
Black Report showed that socioeconomic factors affected health (mortality, life expectancy, chronic illness)
Explanations for the inequalities: (hypothesises why)
Artefact: data inaccuracies
Health or social selection: people in poor health moved down the social hierarchy (less support)
Materialist/structuralist: role of income, housing, education, and working conditions
Cultural/behavioural: lifestyle choices
What is health needs assesssment?
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 are the 4 health care needs?
Need = ability to benefit from an intervention
Demand =what people ask for
Supply = what we actually provide
- Felt need – individual perceptions of variation form normal health
- Expressed need – individual seeks helps to overcome variation in normal health (demand)
- Normative need – professional defines intervention appropriate for the expressed need
- Comparative need – comparison between severity, range of interventions and cost
3 approaches to health needs assessment
Epidemiological, Corporate, Comparative
What is epidemiological approach?
Considers the epidemiology of the condition, current service provision, and the effectiveness and cost-effectiveness of interventions and services
- Disease incidence and prevalence
- Morbidity & mortality
- Life expectancy
- Data is from: disease registry, hospital admissions, GP databases, mortality data, primary data collection
Advantages and Disadvantages of Epidemiology Approach?
Advantages
- Uses existing data
- Provides data on disease incidence/mortality/morbidity etc
- Can evaluate services by trends over time
Disadvantages
- Quality of data variable
- Data collected may not be the data required
- Does not consider the felt needs or opinions/experiences of the people affected
What is corporate approach?
- Asking the local population what their health needs are
- Use of focus groups, interviews and public meetings
- Wide variety of stakeholder e.g. teachers, healthcare professionals, social workers, charity works, local businesses, council workers and politicians
Advantages and Disadvantages of Corporate Approach?
Advantages
- Based on the felt and expressed needs of the population in question
- Recognises the detailed knowledge and experience of those working with the population
- Takes into account wide range of views
Disadvantages
- Difficult to distinguish ‘need’ from ‘demand’
- Groups may have vested interests “stakeholder bias”
- May be influenced by political agendas
What is comparative approach?
- Compare the needs/provision of healthcare in one population with another
- Can be spatial (e.g. different towns) or social (e.g. two age groups in the same town)
Advantages and Disadvantages of Comparative Approach?
Advantages:
- Quick and cheap if data available
- Indicates whether health or services provision is better/worse than comparable areas (gives a measure of relative performance)
Disadvantages:
- May be difficult to find comparable population
- Data may not be available/high quality
- May not yield what the most appropriate level (e.g. of provision or utilisation) should be
What are the Maslow’s Hierarchy of Needs?
(down to up) PSLES
- Physiological: breathe, food, water, sleep, poo
- Safety: employment, health, property
- Love/Belonging: family, friends, sex
- Esteem: self esteem, confidence, respect
- Self-actualisation: (reach full potential) creative, problem solving, morality
What are the resouce allocation methods?
Egalitarian, Maximising, Liberatarian
What is the egalitarian method?
Provide all care that is necessary and required for everyone (A: equal/fair, D: economically restricted)
What is the maximising method?
Based solely on consequences (A: resources allocated to most in need people, D: those with less need get nothing)
What is libertarian method?
Each individual is responsible for their own health (A: patient may be more engaged since its their own responsibility, D: not all diseases are self-inflicted)
Define evaluation of health services
assessment of whether a service achieves its objectives
Donabedian’s framework of health service evaluation:
- Structure - what actually is the service, examine the provision of facilities and staff available e.g. how many heart surgeons there are/number of hospital beds
- Process – how does the process work, what is done for and to a patient or a population, and how well, eg. time taken from diagnosis to treatment
- Outcome – 5 Ds = death, disease, disability, discomfort, dissatisfaction/ QOL, complications, reccurence
Denominator + Numerator
Denominator: The total population eligible for a specific process (e.g., all patients diagnosed with a particular condition).
Numerator: The subset of this population that received the treatment within the recommended time frame.
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)
Maxwell’s Dimensions of Quality of health care:
(3Es and 3As)
- Effectiveness
- Efficiency
- Equity
- Acceptability
- Accessibility
- Appropriateness
Wright’s Matrix
Ties Maxwell’s dimensions and Donbedian approach together
Eg. structure + accessibility = pushchair access
process + effectiveness = only efficient tests included
Define 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
Incidence = (number of new cases) / (number of people x time period)
Define prevalence
Number of existing cases in a population at a point in time
Prevalence = (Incidence) x (disease duration)
Attributable risk
Rate of disease in the exposed that may be attributed to exposure
incidence in exposed minus incidence in unexposed.
Example:
- Incidence of cancer in smokers, 1/1000 person-years
- Incidence of cancer in non-smokers, 0.05/1000 person-years
– Attributable risk = 0.95/1000 person-years (difference)
– Relative risk = 20 (ratio, no units)
Relative risk
Ratio of risk of disease in the exposed relative to the risk in the unexposed, has no units (is a ratio)
RR = (incidence in exposed/ incidence in unexposed)
Relative Risk Reduction = (1 - Relative Risk)
Absolute risk
Absolute risk aka incidence (eg. 4 per 1000 people per year): Likelihood of a particular event occurring in a specific population over a defined period, has units
Absolute Risk Reduction (ARR) = (Incidence in Placebo - Incidence in Treatment)
Numbers needed to treat = (1/ARR)
Standard Deviations
68.3% of values lie within 1 SD of the mean
95.4% of values lie within 2 SD of the mean
99.7% of values lie within 3 SD of the mean
Define bias
a systemic deviation from the true estimation of the associated between exposure and outcome (it is an example of a systematic error)
Selection
Information: Report/Recall/Measurement/Observer
Attrition
Allocation
Publication
Lead time
Length time
What is selection bias
error in selection and allocation of participants
What is information bias (MORR)
- Measurement (e.g. different equipment used to measure the outcome in the different groups)
- Observer (e.g. the researcher knows which participants are cases and which are controls and subconsciously reports/measures the exposure or outcome differently depending on which group they are in)- expectation bias/Pygmalion effect
- Recall (e.g. events that happened in the past are not
remembered and reported accurately) - Reporting (e.g. respondents report inaccurate information because they are embarrassed or feel judged)
What is attrition bias
participants are removed from the study after withdrawing from it or becoming uncontactable.
What is allocation bias
different participants in different groups (no equal spread)
What is publication bias
Trials with negative results are less likely to be published
What is lead time bias
When screening identifies an outcome earlier than it would otherwise have been identified this results in an apparent increase in survival time, even if screening has no effect on outcome
What is length time bias
Type of bias resulting from differences in the length of time taken for a condition to progress to severe effects, that may affect the apparent efficacy of a screening method
Define confounding
Situation where a factor is associated with the exposure of interest and independently influences the outcome but does not lie on the causal pathway e.g. lack of exercise causes weight gain but there are many confounding variables that also effect weight gain
Stratification can reduce this (analysing data after separating participants into subgroups according to confounders of interest)
Bradford Hill Criteria for causality
SDCTRBCAS
- Strength - The strength of the association
- Dose-response – does a higher exposure produce higher incidence?
- Consistency – similar results in different studies and populations
- Temporality – does the exposure precede the outcome
- Reversibility – removing exposure reduced risk of disease
- Biological plausibility – does it make sense biologically
- Coherence – logical consistency with lab information e.g. 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 e.g.
thalidomide in pregnancy, not other teratogenic drugs show similar effects - Specificity – Relationship is specific to the outcome of interest e.g. introducing
helmets reduced head injuries specifically, it wasn’t that there has been an overall lower injury rate
What is reverse causality?
This refers to the situation when an association between an exposure and an outcome could be due to the outcome causing the exposure rather than the exposure causing the outcome.
Reverse causality – Stress could have caused HTN rather than HTN causing stress
What is person-time and when is it
used?
Person-time is a measure of time at risk
– i.e. time from entry to a study to (i) disease onset, (ii) loss to follow-up or (iii) end of study.
Types of prevention
Primordial prevention -prevent risk developing
Primary prevention – Prevent problem when risks exist, 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
Quaternary prevention - prevent over treatment
What is population approach?
are a preventative measure delivered on a population wide basis and seeks to shift the risk factor distribution curve
What is high risk approach?
seeks to identify individuals that are above a chosen cut off and treat them.
What is the prevention paradox?
“A preventative measure which brings much benefit to the population but offers little to each participating individual”
E.g. 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.
What are the types of screening?
- Communicable diseases
- Commercially provided screening
- Population-based
- Opportunistic
- Pre-employment and occupational medicals
Examples: cervical/breast/bowel cancer, AAA, diabetic eye
Criteria for screening
Wilson & Jungner
Purpose of screening: 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
Wilson Jungner
The Condition
* Important condition
* Natural history, risk factors and disease markers understood.
* The disease should have a latent, detectable stage.
Screening Programme
* Screening should be ongoing and not just performed on a ‘one-off’ basis.
* Cost-effective
The Test
*Simple, safe, precise & validated screening test.
* The distribution of test values in the target population should be known and a suitable cut-off level defined and agreed.
* The test should be acceptable (willing to do it) to the population.
* 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.
The Treatment
* 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
* Agreed policy on who to treat
* Facilities should be available
Disadvantages of Screening?
- Exposure of well individuals to distressing or harmful diagnostic tests E.g. colonoscopies for those with positive faecal occult blood tests
- Detection and treatment of sub-clinical disease that would never have caused any problems E.g. non-aggressive prostate cancer in elderly men
- Preventive interventions that may cause harm to the individual or population E.g. the potential for increased antibiotic resistance if all mothers were screened for group B streptococcus in pregnancy (this is not currently carried out in the UK, in contrast to the USA:
Sensitivity vs specificity?
Sensitivity – proportion of people with the disease who are correctly idenitified by screening test (a/a+c)- true positive divide by everyone who actually has the disease (true positive + false negative)
Specificity – proportion of people without the disease who are correctly excluded by the screening test (d/b+d) - true negative divide by everyone who actually does not have the disease (true negative + false positive)
The likelihood ratio for a negative test result is defined by how much the odds of the disease decrease when a test is negative. This is calculated by:
(1-Sensitivity)/Specificity
The likelihood ratio of a positive test result/how much the odds of disease increase when the test is positive:
Sensitivity/(1-Specificity)
0.95/1-0.2 = 1.1875
Positive predictive value vs Negative predictive value
Positive predictive value - the proportion of people with a positive test result who actually have the disease (a/a+b) - true positive divide by true positive + false positive
Negative predictive value – proportion of people with a negative result who actually do not have the disease (d/c+d) - true negative divide by true negative + false negative
IF LOWER DISEASE PREVALENCE:
- PPV decreases because there are more false positives relative to true positives
- NPV increases because there are more true negatives relative to false negatives. This affects counseling - in lower-risk populations, positive results need more careful interpretation while negative results are more reassuring.
Odds Ratio
Odds of exposure in cases = 75/25
Odds of exposure in controls = 80/20
Odds ratio:
(Odds of exposure in cases) / (Odds of exposure in controls) = (75/25) / (80/20) = 0.75
Statistical Significance = CI does not contain 1
Odds ratio >1 = could be risk factor
<1=protective factor
=1 =no association
Type 1 + 2 Error
type II error= when an investigator finds no difference, even though a difference exists, ie. incorrectly accepting the null hypothesis.
A type I error is when the null hypothesis is true and was wrongly rejected. The greater the p-value, the greater the chance that the null hypothesis will be rejected. With a large p-value of 0.2, there is a greater chance the null hypothesis will be rejected and a significant difference will be found. Therefore, the risk of a type I error is high.
The power of the study is the ability of a study to detect a difference if a difference exists. Therefore, the power is 1 minus the probability of making a type 2 error, so is calculated as 1 – p (type 2 error).
The power of a study is the ability of a study to reject the null hypothesis when it is false. It is dependent on sample size.
Qualitative methods of research for evaluating healthcare
observation (ethnography)
in depth interviews
focus groups
document review
Quantitative methods of research for evaluating healthcare
Routinely collected data: e.g. hospital admissions; mortality
Review of records
Surveys
Other special studies: e.g. epidemiological methods
Professionalism
- Human error: communication errors, judgement errors, omissions, violations
- Misconduct: Deliberate harm, lack of candour, fraud/theft, inappropriate relationships
- Poor performance: poor attitude, rudeness, failure to learn from mistakes
- Neglect: care falls below acceptable standard
PDSA - MODEL FOR IMPROVEMENT
WHAT IS IT?
- A framework for developing, testing and implementing changes leading to improvement.
WHEN TO USE IT?
- it is safer and more effective to test out improvements on a small scale before wholesale implementation.
KEY QUESTIONS:
- What are we trying to accomplish? (The aims statement).
- How will we know if the change is an improvement? What measures of success will we use?
-What changes can we make that will result in improvement? (The change concepts to be tested).
Cohort Study
- Sample is taken from study population and split into two groups, one exposed and one not. Incidence of the disease amongst the two groups is compared.
- Prospective
Advantages of Cohort Study
- Can follow-up a group with a rare exposure (e.g. a natural disaster)
- Good for common and multiple outcomes
- Less risk of selection and recall bias
Disadvantages of Cohort Study
- Takes a long time
- Loss to follow up (people drop out)
- Need a large sample size
Case Control Study
- Groups with and without a disease are selected and past exposures are identified
- Retrospective
Advantages of Case Control Study
- Quick
- Good at looking at rare diseases and long latency diseases
- Multiple exposures
Disadvantages of Case Control
- Selection and information bias
- Impractical for rare exposures (difficult to find controls)
Cross sectional study
Exposure and outcome are measured simultaneous in a population at one particular time ‘snapshot’
Advantages of Cross sectional study
- Relatively quick and cheap
- Provide data on prevalence at a single point in time
- Large sample size
- Good for surveillance and public health planning
Disadvantages of Cross sectional study
- Risk of reverse causality
- Cannot measure incidence
- Risk recall bias and non-response
Randomised Controlled Trial
Two groups – one control and one treatment which allows for comparison in order to assess the effectiveness of an intervention
Advantages of RCT
- Low risk of bias and confounding factors
- Causality (gold standard)
Disadvantages of RCT
- High drop out rate
- Ethical issues
- Time consuming + expensive
- Specific inclusion/exclusion criteria may mean the study population is different from typical patients (e.g. excluding very elderly people)
Ecological study
Investigation finds a certain correlation between two things in a population e.g. there is a high level of CHD in deprived areas.
Meta Analysis
Qualitative method of combining the results of independent studies which are drawn from the published literature, and synthesizing summaries and conclusions
Systematic review
Review which endeavours to consider all published and unpublished evidence of a specific question
THE BEST ONE!
Childhood Consent 2 things?
- Never inform their parents for them
- Children under 13 can never consent to sex
Fraser Guidelines
- Does she understand the advice?
- Has the doctor encouraged her telling the parents?
- Will she have sex anyway?
- Is the mental/physical health going to be effected if you don’t give it
- Best interests
Gillick’s competence
- Does a child under 16 have capacity to make own medical decisions?
- Clinical judgement made by the doctor; age, capacity, maturity
Features of a disease that make it a public health concern:
- High mortality
- High morbidity
- Highly contagious
- Expensive to treat
- Effective interventions
Cluster
a group of cases that might be linked e.g. scabies in a care home
What do Epidemic, Pandemic, Endemic and Hyper-edemic mean?
Epidemic = more than expected incidence in a country
Pandemic = more than one country
Endemic = persistent level of disease occurrence
Hyper-endemic = persistently high level of disease occurrence
4 aspects of negligence
- Was there a duty of care?
- Was there a breach of that duty?
- Was the patient harmed?
- Was the harm due to the breach of care?
How do things go wrong?
Poor performance:
- below acceptable standard
- communication, accessibility, taking responsibility
Neglect
- culture in an organisation
- accepting low standards
Misconduct
- deliberate act, eg. theft. inappropriate relationships, deliberate harm
Martha’s Rule
- All staff in NHS trusts must have 24/7 access to a rapid review from a critical care outreach team, who they can contact should they have concerns about a patient.
- All patients, their families, carers, and advocates must also have access to the same 24/7 rapid review from a critical care outreach team, which they can contact via mechanisms advertised around the hospital, and more widely if they are worried about the patient’s condition.
- The NHS must implement a structured approach to obtain information relating to a patient’s condition directly from patients and their families at least daily. In the first instance, this will cover all inpatients in acute and specialist trusts.
Bolam Rule
Would a reasonable doctor do the same?
Bolitho Rule
Would that be reasonable?
Swiss Cheese Model
Falling through the holes because there are failed or absent defenses against error happening.
These are called LATENT FAILURES.
For catastrophic error to occur, holes need to align in each step in the process allowing all defences to be defeated and resulting in an error
If layers are set up with all the holes lined up, it is an inherently flawed system that allows a problem at the beginning to progress all the way through to adversely affect the outcome
The bucket model of error
SELF = Poor knowledge, fatigue, little experience/skill, feeling unwell
CONTEXT = distraction, poor handover, lack of team support, equipment
TASK = errors, task complexity, new task, process
Types of Error
SFCPPBIMLS
- Sloth = inaccurate documenting/not checking results for accuracy
- Fixation/loss of perspective = focus on one diagnosis – confirmation bias
- Communication breakdown = unclear plan/not listening and explaining well
- Poor team working = some individuals out of depth and others underutilised
- Playing the odds = choosing the common and dismissing the rare
- Bravado/timidity = working beyond competence/not having confidence to object
- Ignorance = lack of knowledge (can be conscious or unconscious incompetence)
- Mistriage = over or under-estimating the severity of the situation
- Lack of skill = not having appropriate skills/training/practice
- System error = environmental/technological/equipment failure
Never Events
- A serious, largely preventable patient safety incident that should not occur if available, preventative measures have been implemented
- Examples: wrong site for surgery, wrong drug given, escape of psychiatry patient
- Report to: Care Quality Commission and NHS Improvement
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 is inverse care law?
The availability of good medical care tends to vary inversely with the need for it within a population.
What are some rivals/barriers to ethics?
● Law
● Codes of ethics
● Religious or cultural beliefs
● Personal conscience
Ethical Arguments
● Top down deductive, where one specific ethical theory is consistently applied to each problem
● Bottom up inductive, using past medical problems to create guides to practice
Autonomy
a patient should be provided with enough information and support to make their own informed decision about their healthcare, and this decision should be respected
Beneficence
The duty of acting in the patient’s best interest to benefit their health
Non-Maleficence
the duty to prevent, reduce and do no harm
Justice
This principle relates to the fair and equal distribution and access to healthcare resources.
Utilitarianism
An act is evaluated solely in terms of its consequences. It acts to maximise good e.g. killing one to save many.
Deontology
Focuses on adherence to duty, rules, and moral principles rather than on the consequences of actions
Virtue ethics
These focus on the character of the person, integrating reason and emotion. An action can be virtuous only if it is performed by a person in the right state of mind (i.e. genuinely intending to do the right thing).
The five focal virtues are: CDTIC
● Compassion
● Discernment
● Trustworthiness
● Integrity
● Conscientiousness
The Mill’s harm principle
individual liberty can be justifiably restricted if one’s actions harm others
Doctrine of double effect
an ethical principle that states that an action can be morally acceptable if it has both good and bad consequences, as long as the bad outcome was not intended
Deprivation of Liberty Safeguards (DoLS)
A procedure in law where it is necessary to deprive a patient of their liberty as they lack capacity to consent to treatment or care to keep them safe from harm, lasts 12 months
Conditions for DoLS
CONDITIONS TO BE MET (ALL)
- >18
- suffering from mental disorder
- in hospital or care home
- lacks capacity to decide for themselves
- whether the person should be instead considered for detention under MHA
- restriction would deprive the person of their liberty
- restriction would be in the person’s best interests
- they do not have a valid advance decision made that would be overriden
- if the LPA agrees
Mental Capacity Act 2005
MAIN PRINCIPLES (5)
- Every adult is assumed to have capacity unless proven otherwise
- Don’t treat someone as lacking capacity unless all practicable steps to help him to do so have been taken without success
- Don’t treat someone as lacking capacity cuz of an unwise decision
- All acts/ decisions/ Tx done under the act must be done in their best interests
- Ensure all acts/ decisions made for them are effectively achieved in the least restrictive way possible
Mental Capacity Act: Assessment of Capacity
ASSESSMENT OF CAPACITY
- Is decision and time specific
An adult is lacking capacity if:
1. They have an impairment of or disturbance in the functioning of the mind or brain whether permanent or temporary AND
2. They are unable to do any of the following
- Understand info for the decision
- Retain the info
- Use the info to make the decision
- Communicate the decision they made
Mental Capacity Act: Best Interests
CONSIDER:
- Whether the person is likely to regain capacity and the decision can wait
- How to encourage and optimise the participation of the person in the decision
- The past and present wishes, feelings, beliefs and values of the person and any other relevant factors
- Views of other relevant people
Lasting Power of Attorney
- Legal document that lets ppl appoint one or more ppl to help make decisions on their behalf
- For when ppl get into accidents or illness (lack mental capacity)
- Health and welfare/ property and financial affairs
Advanced Care
Advance care planning offers people the opportunity to plan their future care and support, including medical treatment, while they have the capacity to do so.
Advanced Directives
- Medical decision made by pt with capacity regarding their future wishes for treatment
- Only comes into force if the pt subsequently lacks capacity
- Can be used to refuse treatment eg. CPR, abx, ventilation, blood transfusion, etc.
- Legally binding document as long as it complies with Mental Capacity Act, applies to situation and is valid
Advanced care plan VS Advanced directives?
ACP: eg. respect form, a process that guarantees the respect of the patient’s values and priorities about future care at the end of life. Not legally binding
AD: a set of legal documents helpful to clinicians and family members for making critical decisions on behalf of the patient in case they become incapable to do so. Legally binding.
Polypharmacy
the concurrent use of multiple medications, taking or prescribing more medicines than are clinically required
Systems Approach
A method of addressing patient safety, quality improvement, and healthcare delivery through an understanding that the healthcare system is complex and involves multiple interacting components.
The system approach seeks to identify and address underlying factors contributing to incidents or inefficiencies, with the aim of improving the overall system for better outcomes.
Persons Approach
Focuses on addressing errors, incidents, or issues by looking at individual actions or behaviors and attributing responsibility for mistakes to people involved
Mental Capacity Act and Mental Health Act
The Mental Capacity Act allows patients to be treated for physical disorders which affect their brain function if they refuse treatment.
The Mental Health Act allows patients to be treated for established mental health disorders if they refuse treatment.
What is the Common Law
Used to treat patients in emergency scenarios
Define Malnutrition
“Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/ or nutrients.
Early influences on feeding/ eating behaviour
- Maternal diet and taste preference development
- Role of breastfeeding for taste preference and body weight regulation
- Parenting practices
- Other important influences: Age of introduction of solid food, types of food exposed to during the weaning period
Non-Organic Feeding Disorders (NOFEDs) :
- High prevalence in children younger than 6 years old
- Characterized by feeding aversion, food refusal, food selectivity, fussy eaters, failure to advance to age-appropriate foods, negative mealtime
interactions
“Chemical continuity”
transmission of certain flavours from the maternal
diet via amniotic fluid and then breast milk
What are the 4 dimensions of food insecurity?
- Availability (affordability) of food
- Access – economic and physical
- Utilisation – opportunity to prepare food
- Stability of the three dimensions over time
Challenges of Weight Loss
➢ Long-term weight loss is challenging – interventions typically demonstrate weight loss, plateau then weight regain
➢ Weight cycling (from repeated diet-relapse) often leads to ‘overshoot’ and may accelerate weight gain – metabolic set point/ defended fat mass
➢ Dieting results in a loss of lean body mass, not just fat mass – implications for metabolic rate and energy expenditure
➢ Chronic dieting may disrupt ‘normal’ appetite responses and increase subjective sensations of hunger
➢ Risk factor for the development of eating disorders in some individuals
Smoking Cessation drugs
nicotine replacement therapy (NRT):
- SE nausea & vomiting, headaches and flu-like
- combination of patches better
varenicline
- a nicotinic receptor partial agonist
- should be started 1 week before target date to stop
- SE nausea, headache, suicidal link?
- CI pregnancy and breastfeeding
bupropion
- a norepinephrine-dopamine reuptake inhibitor and nicotinic antagonist (unlike many antidepressants it has a minimal effect on serotonin)
- SE: seizures,
- CI: pregnancy and breastfeeding
pregnant:
- first line = CBT
Features of childhood sexual abuse can include:
- pregnancy
- sexually transmitted infections, recurrent UTIs
- sexually precocious behaviour
- anal fissure, bruising
- reflex anal dilatation
- enuresis and encopresis
- behavioural problems, self-harm
- recurrent symptoms e.g. headaches, abdominal pain
Geriatric Comprehensive Approach
Physical Health, Psychological Assessment, Functional Assessment, Social Assessment, Home environment
GCA Physical Health Assessment
medical assessment (history, exam, nutrition, RESPECT forms)
medication review: START/STOPP, compliance, SE, drug interactions
START: may provide benefits eg ppi for bleed risk
STOPP: risk>benefits
DOCTOR/GERIATRICIAN
GCA Psychological Assessment
cognition
capacity
mood
MENTAL HEALTH NURSE
GCA Functional Assessment
mobility
frailty
ADLs
hearing/vision/swallow
SALT + PHYSIO
GCA Social Assessment
carers/legal/financial (community team)
SOCIAL WORKER
GCA Home Environment Assessment
Occupational Health/Physiotherapy
housing
safety
equipment
transport
OCCU THERAPY
MDT Geriatrics
Doctors: medical, psychiatric, functional
Nurses: medical, psychiatric, functional
Physiotherapy: functional (activity limitations)
Occupational Therapy: functional, environmental (house, social support)
Social workers: environmental
SALT: swallowing
Malnutrition in elderly
One of:
- BMI <18.5
- Unintentional weigt loss >10% in 3-6m
- BMI <20 + unintentional weight loss >5% in 3-6 m
MDT: “food first” approach, then supplement
The 4 Geriatric Giants
Instability
Immobility
Incontinence
Impaired Cognition/Intellect
Physiology of Ageing
Cardiac: calcified, stenosed, ischaemic
Resp: poor muco-ciliary escalator
Immunity: reduced
Neuro: poor hearing, vision, memory
Gastro: reduced motility
MSK: muscle weakness, atrophy, arthritis
GU: incontinence, prolapse
Renal: excretion problems
Define Frailty
- diminished strength + endurance
- reduced physiological function
- increased vulnerability to develop dependency or death
Pressure sores
- localised damage to skin +- underlying tissue
- as a result of pressure/shear
- lack mobility, incontinence, pain, malnourishment
- managed with moist + hydrocolloid, NO SOAP!
- > grade 3 = surgeon
Delirium supportive things to do
- clocks
- familiar objects eg. photos
- control noise level
- lighting + temperature (bright in morning, dark at night)
- involve family
- consistent medical team
- access to aids
medication: haloperidol (lorazepam if parkinsons/lwbd)
Conditions which all pregnant women should be offered screening
- Anaemia
- Bacteriuria
- Blood group, Rhesus status and anti-red cell antibodies
- Down’s syndrome
- Fetal anomalies
- Hepatitis B
- HIV
- Neural tube defects
- Risk factors for pre-eclampsia
- Syphilis
The following should be offered depending on the history:
- Placenta praevia
- Psychiatric illness
- Sickle cell disease
- Tay-Sachs disease
- Thalassaemia
Biological basis of depression
- Low levels of blood tryptophan (source of serotonin)
- Low serotonin levels in brain and low receptor
- HPA dysregulation & elevated blood cortisol levels
- Low serotonin and 5HIAA (serotonin metabolite) in the CSF of suicide victims
Management Any young person is not discharged until there is a:
- Risk assessment (active suicidal plans, access to lethal methods, psychotic, agrees to plan)
- Safety plan/ Crisis plan derived
- Methods for maintaining safety, and ensuring no access to lethal suicidal methods
- Hospitalization is recommended when safety is unpredictable and provides removal from a stressful environment.
- If it is not safe to be discharged – advice admission
Marshmallow Experiment
a study that measures a child’s ability to delay gratification in order to receive a larger reward in the future
Strange Situation Experiment
a psychological experiment that assesses how infants bond with their primary caregiver
Variable penetrance
Age related penetrance
Variable expressivity
Variable penetrance: % of individuals carrying a genetic variant who manifest a disease
Age related penetrance: % of individuals who develop a given genetic disease at different ages
Variable expressivity: different phenotypes expressed by different people with the same genetic disease
Palliative Care
“an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
Leadership
- To set a path, goal, or vision for the people who are being led.
- To motivate people to pursue and eventually achieve the goal
Models:
Laissez Faire
Transactional
Transformational
Others:
- Bureucratic (like military, rules)
- Autocratic (like dictatoroship)
- Coaching (recognising s+w in members)
Importance of effective leadership
- representative of subordinates
- guides + inspires
- appropriate counselor
- creates vision + initiative
- creates work environment
- resolves conflict
- strives for effectiveness
Laissez Faire aka Democratic + Facilitative
- Collaboration + everyone can participate in decision-making, ideas and discussion
- more autonomy and freedom
- The democratic leader still has the power of control
Critique of Laissez Faire
PROS
- can evaluate own performance
- establish goals
- encourages growth and promotion
- recognises and encourages achievements
CONS
- some employees prefer not to be involved
- quiet team members may not share ideas unless prompted
- assigning blame for failure/scapegoating
- not effective if working with underqualified or underskilled worders
Transactional Leadership aka managerial leadership
Leader rely on rewards and punishments to achieve optimal job performance from their subordinates
Critique of Transactional Leadership
PROS
- performance is rewarded so good behaviour is encouraged
- high productivity in repetitive processes
- order + structure is clear
CONS
- limited creativity: very rigid system
- punishment can result in low engagement
- no longer term motivation + rewards don’t work on everyone
Transformational Leadership
- Focuses on inspiring and motivating employees
- Leaders act as role models
- Idealised influence + inspirational motivation + individualised consideration + intellectual stimulation
Critique of Transformation Leadership
PROS
- strong motivation factor
- encourage personal growth
CONS
- team dynamics differ
- might not be realistic, blindly follow leader
- employee favouritism (focusing on those contributing more and neglecting the rest)
** best one for NHS
- Empowerment + motivation needed in high pressure environments
- Innovation + adaptability encouraged
- common long term vision/goal
Doctors problems with leadership
- Used to working individually
- Value autonomy highly
- Power imbalance fear
- Think its presumptuous to set a vision for an organisation
- Science driven, behave tactically rather than strategically
Types of people in a team
- Implementor: rule follower, conservative
- Coordinator: confident, chairperson
- Shaper: challenging, likes pressure
- Plant: creative
- Resource Investigator: over optimistic
- Monitor Evaluator: strategic
- Team worker: diplomatic
- Completer Finisher: anxious
Dual Process Theory
a theory that explains how doctors make decisions and think when diagnosing patients
System 1: Fast, intuitive, automatic, and requires minimal effort
System 2: Slow, deliberate, conceptual, and systematic
eg. if youre deciding between doing an invasive biopsy or blood test and you go ask ask supervisor what to do
Ethnocentrism
evaluation of other cultures according to preconceptions originating in the standards and customs of one’s own culture.
