Public health Flashcards
what is epigenetics
the study of how genes interact with the environment
- changes in an organism due to changes in gene expression rather than alterations to the genetic code itself
what is allostasis
the stability through change, or homeostasis, of our physiological systems to adapt rapidly to changes in our environment
what is allostatic load
long term over taxation of our physiological systems leading to impaired health - the price of allostasis
What is public health
the science and art of preventing disease, prolonging life and promoting health through organised efforts of societyw
what are the key concerns of public health
inequalities in health
wider determinents of health
prevention
What are the 3 domains of public helath
health improvement
health protection
improving services
what is health improvement (give an example)
societal interventions aimed at preventing disease, promoting health and reducing inequality
e.g. vaccines, education, housing
what is improving services (give an example)
organisation and delivery of safe, high quality sevices for prevention treatment and care
e.g. clincial effectiveness, audits
What are the determinents of health
genes
environment
lifestyle
access to healthcare
what are some wider determinents of health
education
socioeconomic status
uneployment
housing
physical environment
what makes up Marlow’s hierarchy of needs from bottom to top
physiological needs (e.g food, water)
Safety needs (security, housing, job)
Belongingness and love needs (friendship, family)
Esteem needs (self-esteem, confidence)
Self-actualisation (morality, creativity
What are health interventions
tactics to improve public health (e.g. promoting screening, vaccination)
what three levels can health interventions be at
individual level (childhood vaccine)
community level (playground)
population level (public health campaign)
What is the difference between vertical and horizontal equity
horizontal- equal treatment for equal need (e.g. same treatment for the same disease)
vertical- unequal treatment for unequal need (e.g. increased funding in more deprived areas)
How can equity be examined
access to healthcare, healthcare outcomes, health status, resource allocation
what is health psychology
the role of psychological factors in the cause, progression and consequences of health and illness
what are health behaviours
a behaviour aimed at preventing disease (e.g. eating healthier)
what are illness behaviours
a behaviour aimed at seeking remedy (e.g. going to the doctor)
what are sick role behaviours
a behaviour aimed at getting well (e.g. resting, taking medication)
what two types of health behaviours are there?
health promoting and health damaging behaviours
what is the main theory of why people undertake health damaging behaviours
unrealistic optimism - individuals carry on with behaviour as they dont believe that the problem will effect them
Occurs due to
- lack of personal experience with the condition
- belief that its not preventable by the action
- belief that if its not happened by now it wont happen
- belief that the problem is infrequent
What are the components of the health belief model
Individuals will change if they:
- believe that they are susceptible to the condition (perceived susceptibility)
- believe that the condition has serious consequences (perceived seriousness)
- believe that taking action will reduce their susceptibility to the condition (perceived benefits)
- believe that the benefits of taking the action outweigh the costs (perceived barriers)
There may be internal or external cues
What are examples of internal and external cues to behaviour change
internal- pain
external - GP advice
What are some advantages of the health belief model?
it can be applied to a wide range of health behaviours
it included cues to action which is unique\
its a long standing model
what are some criticisms to the health belief model?
it does not differentiate between first time and repeat behaviours,
it does not consider the influence of emotions and behaviour
cues to action often arent present
alternative factors may also influence behavioural change
What is the theories of planned behaviour model
proposes the best predictor of a behaviour is intention to change the behaviour
What determines someones intention in the theories of planned behaviour model?
a persons attitude to the behaviour (e.g. I dont think smoking is good for me)
subjective norm (perceived social pressure to give up the behaviour)
percieved behavioural control (perceived ability to perform the behaviour)
What 5 things bridge the gap between intention and behavioural change in the theories of planned behaviour model?
perceived control- individual feels they are capable
anticipated regret- individual reflects on feelings once failed
Preparatory actions- dividing the task into small sub goals to improve self-efficacy and satisfaction
implementation intentions- most important. The if and then plans.
Relevence to self
advantages of the theory of planned behaviour model
can be applied to a wide range of behaviours
useful in predicting intention
takes into account the importance of social pressure
Criticisms of the theory of planned behaviour model
lack of a temporal element and direction or causality
no sense of how long the behaviour may take
rational choice model so does not take into account emotions
assumes attitudes, subjective norms and percieved control can be measures
relies on self-reported behaviours
what is the transtheoretical model of behaviour change
it is a model that suggests individuals are located at discrete ordered stages rather than on a continuum- each stage indicates an increased likelihood of changing behaviour
What are the stages of the transtheoretical model of behavioural change
precontemplation
contemplation
preparation
action
maintenance
relapse
What are advantages of the transtheoretical model of behavioural change?
- acknowledges individual stages of readiness
- accounts for relapse and allows backwards movement between the stages
- gives a time frame
what are criticisms of the transtheoretical model of behavioural change
- not all people move through every stage
- change might operate on a continuum rather than discrete stages
- does not take into account values, habits, culture, social or economic factors.
What is motivational interviewing
a councelling approach to initiate behaviour change by resolving ambivolence - helping someone to see smoking is bad
What is the social norms theory?
suggests that social norms (which are the behaviours and attitudes most common in groups) are one of the most important factors in influencing behaviour
What are some problems with the social norms theory
sometimes the perceived social norms of the group are not the actual social norms
does not work when the risk behaviour is the norm
people often overestimate risk taking behaviour and understimate protective behaviours
what is the nudge theory
the idea that changing the environment to make the best option easier can influence behaviour change- e.g. putting fruit by checkouts
How doe transition points influence behaviour
there are transition points in life which may make a person more or less likely to change their behaviours- e.g. getting a job, unemployment, having children
List some theories of behavioural change
health belief model
theory of planned behaviour
transtheoretical model of behavioural change
motivational interviewing
social norms theory
nudge theory
what is a health needs assessment?
a systematic method of reviewing the health issues faced by a population leading to agreed priorities and resource allocation that will improve health and reduce inequality
define need
the ability to benefit from an intervention
define demand
what people ask for
demand supply
what is provided
what is a health need
a need for health in general
what is a health care need
a need for health care
What are Bradshaws 4 types of social need
felt need
expressed need
normative need
comparative need
what is felt need-
an individuals perception of variations from normal health
what is expressed need
when an individual seeks help to overcome variation in normal health
what is normative need
Give an example
when a professional defines interventions appropriate for the expressed need
Vaccinations
what is comparative need, give an example
comparsion between severity, range of interventions and cost
A village may identify a need for a school if a neighbouring village has one
what are three types of health needs assessments?
epidemiological health needs assessment
comparative health needs assessment
corporate health needs assessment
what is an epidemiological health needs assessment
defines a problem, the size of a problem, the services available for a problem, models of care, cost effectiveness and recommendations
what sources may be used for an epidemiological health needs assessment
GP registry, hospital admissions, mortality data
advantages of an epidemiological health needs assessment
uses existing data
provides data on current incidence, mortality and morbidity
can evaluate services by trends in time
criticism of epidemiological health needs assessment
the required data may not be available or may vary in quality
evidence bases may be inadequate
does not consider felt needs
what is a comparative health needs assessment?
compares the services received by a population with others- may vary spatially or socially (by age, gendeR)
advantages of a comparative health needs assessment
quick and cheap
indicates whether health or service provision is better or worse than comparable areas (gives a relative indication of performance)
what are some limitations of a comparative health needs assessment?
data may not be available or may differ in quality
may be hard to find a comparable population
may not yield what the most appropriate level of provision should be
what is a corporate health needs assessment?
it asks what the local populations health needs are- uses focus groups, interviews.
Includes a wide range of stakeholders (e.g. teachers, HCP, support works)
advantages of coporative health needs assessments?
bases on felt and expressed needs of the popualtion
recognises the detailed knowledge and experience of those working within the population
takes into account a wide range of views
what are some disadvantages of a corporative health needs assessment
difficult to distinguish between need and demand
groups may have vested interests and may be influenced by political agents
dominant personalities may have undue influence
what is an example of something that is demanded but not needed?
cosmetic surgery
what is an example of something that is needed but not demanded
anti hypertensives
what is an example of something that is not needed or demanded
> 75 health checks with GP
what is an evaluation of a health service?
an assessment of whether a service achieves its objectives - it attempts to systematically and objectively determine the relevance, effectiveness and impact of activities in the light of their objectives
what are the three components of the Donebedian framework for evaluating services and give an example for each
structure- what is there (e.g. number of vascular surgeons per 1000 patients)
Process- what is done (number of operations performed, number of patients need in a and e)
Outcome- the 5D’s (death, disease, disability, discomfort, dissatisfaction)
what are the steps of the general framework of service evaluation
- define what the service is
- what are the objectives of the service - are they stated and appropriate
- Framework (structure, process, outcome)
- methodology of evaluation- qualitative or quantitative
- results, conclusions and recommendations
What factors may promote excessive energy intake
employment- shift work
characteristics of food (energy density, portion size)
social aspect- going out for food
genetics
advertisements
What is malnutrtion
deficiences, excesses and imbalances in a persons intake of energy and/or nutrients
Includes both undernutrtion (stunting, wasting, underweight, micronutrient deficiencies)
and overnutrtion
What are some examples of medical conditions that require special nutritional support
coeliac, T2DM, eating disorders
What factors can influence early eating behaviours
- maternal diet during pregnancy
- breast feeding
- parenting practices (maladaptive or positive)
How can breast feeding influence eating behaviours
breast fed infants are more likely to:
- be less picky eaters
- accept more novel foods during weaning
- have a diet full of fruit and veg by 3 months
How can breast feeding affect bodyweight regulation
breast fed infants usually stop feeding when full whereas bottle fed are often encouraged to finish the bottle
How can parenting practices influence early eating behaviours
maladaptive tactics like coercion and percuading is more likely to cause non-organic feeding disorders such as aversion)
positive practices include - no pressure, not using food as a reward, providing a wide range of choices
what are some examples of factors associated with disordered eating
restraint
strict dieting
disinhibition
emotional eating
night eating
weight and shape concern
inappropriate compensatory behaviours
what 3 factors may make up dieting
restricting the amount of food eaten
restricting the type of food eaten
restricting the time window of eating
what are some problems with dieting
increased risk of eating disorder
loss of lean body mass not just fat
slows metabolic rate
disruption of normal appetite response and increases hunger
long term weight loss is challenging- often plateaus then regains
what are the core priniciples of the NHS
it is universal (meets the need of everyone), comprehensive (based on clinical need not ability to pay) and free at the point of delivery
what are health inequalities?
unjust and avoidable differences in people health across a population or subgroup of the population
- they go against the principle of social injustice as they are avoidable
what is the inverse care law
the availability of medical care tends to vary inversely with the need of the population served- those who need it most dont access it
what is social exclusion
the process of being shut out from a social, economic, political or cultural system which determine the social integration of a person in society
causes of homelessness
relationship breakdowns
mental illness
domestic abuse
disputes with parents
bereavement
drugs and alcohol
no money or job
populations who are vulnerable to homelessenss
LGBTQ+
ex service men and women
subtance misusers
asylum seekers
health problems faced by the homeless
infectious diseases (TB, hepatitis)
poor feet and teeth
resp problems
injuries from violence and rape
serious mental illness
poor nutrtion
addictions and substance misuse
barriers travellers may experience on accessing healthcare
reluctance of GP’s to register travellers or visit traveller sites
poor reading and writing skills
communication difficulties
too few permanent sites
mistrust of professionals
barriers homeless might experience in accessing healthcare
difficulty accessing care (opening times, location)
perceived or actual discrimmination
lack of integration between primary care services and other agencies such as housing, social care, criminal justice)
other priorities
not knowing where to go or how to get there
barriers migrants might experience when accessing health care
language, cultural and communication barriers
racism, prejudice, discrimmination and stigma
different perceptions of care
not understanding how the NHS works
What is domestic abuse?
any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged > 16 who are or have been intimate partners or family members, regardless of their gender and sexuality.
What are types of domestic abuse?
physical
sexual
psychological
Financial
Emotional
How might domestic abuse present?
injuries following assault (miscarriages, facial issues, bruises, haemorrhage, puncture wounds)
Somatic problems or chronic illness from living with abuse (headaches, GI issues, chronic pain)
psychological or psychosocial problems (PTSD, substance misuse, depression and anxiety)
What indications are there that someone might be experiencing domestic abuse
repeat attendances to GP and A&E - often at antisocial times
delay in seeking help for minor injuries
What assessment tool might be used for domestic abuse
the DASH- Domestic abuse and sexual harassment tool
works by encouraging you to gain information about everything going on - no one score indicates a high risk but instead it might make someone say something suggestive of high risk
if someone is moderate risk of domestic abuse what should be done
it is their choice- give information about services and allow them to decide
if someone is high risk for domestic abuse what should be done
referal to MARAC/IDVAS with or without their concent
what is MARAC
the domestic abuse Multi-Agency Risk Assessment Conference
What are IDVAS
independent domestic abuse advisors
What is the role of IDVAS
adovcate for patients and give them advice surrounding domestic abuse
support them through court proceedings
signpost to specialist services
act as a voice at MARAC
What is the role of doctors in domestic abuse
ask women about abuse - in a direct, non-judgemental way
display posters and contact cards
only report to police if safe to do sso
give information and refer to appropriate services
do not ask in front of family members or tell patient what to do
How can domestic abuse effect children
physical and psychological health problems - self-esteem, education, relationships
can be linked with child abuse
What is equity?
giving people what they need to achieve equal outcomes
what is equality
giving everyone the same amount of rights opportunities and resources
What is horizontal equity?
Give and example
equal treatment for people with equal healthcare needs
e.g. giving the same pneumonia treatment to people with the same severity of pneumonia
What is vertical equity?
Give and example
unequal treatment for unequal health care needs
Giving different treatments for less severe and mores severe diseases
What is the inverse care law?
the availability of health care tends to vary inversely with its need
how can you remember the determinents of health ?
PROGRESS
P- place of residence
R- race
O- occupation
G- gender
R- religion
E- education
S- socioeconomic
S- social capital
What two frameworks are there to assess the quality of health care?
Maxwell’s dimensions of the quality of health care
Structure, process, outcome measures
What makes up Maxwells dimensions of the quality of healthcare
3A’s and 3E’s
Acceptability
Accessability
Appropriateness
Effectiveness
Efficiency
Equity
Give three different approaches to resource allocation
Egalitarian
Maximising
Libertarian
Explain egalitarian approach to resource allocation
provides all the care that is necessary and required for everyone
What is primary prevention?
preventing the disease from occuring in the first place -e.g. vaccines
what is secondary prevention?
early identification of the disease to alter disease course (e.g. screening)
What is tertiary prevention?
limiting the consequences of the established disease- prevent worsening renal function in CKD
What is the prevention paradox
a preventative measure which brings much benefit to the population often brings little impact to the individual participating
e.g. the covid vaccine
What is the purpose of screening?
to identify patients who have or are at risk of a particular disease so that you can have a real impact on outcome
disadvantages of screening (4 )
exposure of well individuals to distressing or harmful diagnostic tests
detection and treatment of subclinical disease that would never cause problems
prevention interventions that may cause harm to the individual
Difficult decisions- e.g. a mother finding out her foetus will likely have downs syndrome
Advantages of screening
- reproductive choices about risks
- more effective treatment
- reassurance
- worthwhile use of resources
What three screening programmes are there in pregnancy?
infectious disease pregnancy screening programme (HepB, syphilis, HIV)
sickle cell and thalassaemia screening
Fetal anomaly screening programme (Downs, edwards and pataus)
what three screening programmes are there in newborns?
newborn and infant physical examination (heart, eyes, hips, testes)
newborn hearing screening programme
newborn blood spot screening programme
what diseases for are included in the newborn blood spot test?
sickle cell
CF
congenital hypothyroidism
+ 6 inherited metabolic diseases
what 5 screening programmes are done in adults?
AAA screening
bowel cancer screening
breast cancer screening
cervical cancer screening
diabetic eye screening
What makes up the WIlson and Jungner criteria for a screening programme
remember as ‘In Exam Season NAP’ or INASEP
-Important disease
- Natural history of the disease is understood
- Acceptable: the screening test needs to be acceptable to the population
- Simple safe test
- Effective treatment needs to be available
-Policy agreed on who to treat
Define sensitivity?
the proportion of those with a disease who are correctly identified
Define specificity
the proportion of people without the disease who are correctly identified as non having the disease
Define positive predictive value
the proportion of those with a positive test result who actually have the disease
define negative predictive value
the proportion of those with a negative test result who do not have the disease
What is length time bias?
occurs when screening is more likely to detect slow growing disease that has a long phase without symptoms
This may mean that evaluation suggests that those screened had a better prognosis
What is lead time bias?
occurs when patients diagnosed earlier appear to live longer because they know they have the disease for longer
Describe a case control study
a retrospective observational study that looks at the cause of a disease by comparing similar patients with a disease to controls without
Looks for exposures in both cases
Advantages of care control studies (3)
good for rare outcomes
quicker than cohort or intervention studies (the outcome has already happened)
can assess multiple different exposures
Disadvantages of case control studies (2)
difficulty finding control to match with a case
prone to selection bias and information bias
Describe a cross-sectional study
a retrospective observational study that collects data from a population at a specific point in time- a snapshot
Examines the presence of risk factors and the disease itself
advantages of cross-sectional studies (3)
- relatively quick and cheap
-provide data on prevalence at a single point in time
-good for surveillance and public health planning
Give some disadvantages of cross-sectional studies (3)
can cause reverse causality - dont know if the exposure or the outcome came first)
cannot measure incidence
recall and response bias may occur
describe a cohort study
a prospective longitudinal study looking at separate cohorts with different treatments or exposures - waits to see if the disease occurs
advantages of cohort studies (3)
- can follow up a group with a rare exposure
- good for common outcomes and multiple outcomes
- less risk of selection and recall bias
disadvantages of cohort studies (3)
takes a long time
people drop out
needs a large sample size- is expensive and time consuming
Advantages of randomised control trials
low risk of bias and confounding
can infer causality
disadvantages of randomised control trials (3)
time consuming and expensive
drop outs
inclusion criteria may exclude certain populations
What is an ecological study
one that looks at the prevalence of a disease overt time- uses population data rather than individual data
How do you work out odds?
divide the probability of an even happening by the probability of an event not happening
How do you work out an odds ratio?
you divide the odds of an event happening by the odds of an event not happening
how do you calculate the absolute risk of an event ?
the p( event happening in an exposed/ control)/ the total number of people in that group
How do you work out absolute risk reduction
the absolute risk of the event happening in the control group- the absolute risk of the event in the treatment group
how do you work out relative risk
absolute risk in treatment group/ absolute risk in control group
how do you calculate relative risk reduction
1- relative risk (absolute risk in treatment/relative risk in control)
How do you calculate number needed to treat?
1/ absolute risk reduction (ARR)
ARR= absolute risk in control group- absolute risk in treatment group
What are 4 types of information bias
measurement bias
observer bias
recall bias
reporting bias
describe measurement bias?
different measurement equipment may measure differently
explain observer bias
observer expectations may influence reporting
explain recall bias
past events may not be recalled correctly
explain reporting bias
people may not tell the truth because of fear of judgement or shame
explain selection bias
bias in the recruitment or allocation to a group within a study, some may also be loss to follow up
explain publication bias
trials with negative results are less likely to be published
What components make up the Bradford hill criteria for causality
- strength
- temporality : exposure is prior to outcome
- coherence: logical consistency with other info
- consistency : same result from various studies
- plausability: reasonable biological mechanism
- analgoy: similarity with other established cause - effect relationships
- dose responsive: increased risk of outcome with increased exposre
- reversibility: intervention to reduce outcome
- specificity: specific to the outcome of interest
Why might you get a result that suggests an exposure influences an outcome?
- true association (proven by Bradford hill)
- bias
- confounding factors
- chance
- reverse causality (the outcome actually results in the exposure_
what criteria is used to prove causality
bradford hill criteria
define incidence
the number of new cases of a disease over a certain time frame
define prevalence
the number of people with a disease at a certain point in time
alcohol dependence symptoms
withdrawal symptoms
cravings
drinking despite negative consequences
tolerance
primacy
loss of control
narrowing of repertoire
What two medications can be used to treat alcohol dependence
disulfram and acamprosate
How does disulfram work?
it promotes abstinence by causing a severe reaction to occur when alcohol is taken - due to inhibition of acetaldehyde dehydrogenase
Contraindications to disulfram
ischaemic heart disease and psychoiss
how does acamprosate work?
reduces cravings to alcohol
thought to be due to it being a weak agonist of NMDA receptors
What is an asylum seeker?
someone who is applying for refugee status
What are the four dimensions of food insecurity
availability of food
access to food- economic and physical
utilisation- opportunity to prepare food
stability of the three dimensions over time
what is egalitarian resource allocation
provide all care needed for everyone - everything is equal.
problem- not financiable possible
what is libertarian resource allocation
everyone is responsible for their own health
problem- not ethical, some conditions hard to reach out for help
what is maximizing resource allocations
thinking about the consequences, using resources ….
what three features make up an epidemiological health needs assessment
descriptive epidemiology- identify the problems by analyzing patterns
analytical epidemiology- determining risk factors and causes of problems
evaluative epidemiology- assess the effectiveness of interventions
what are the three key stages of a corporate health needs assessment
consultation - engage stakehlders to gather insights
collaboration- work together to align goals and resources
prioritization
