Public Health Flashcards
What is primary prevention and examples?
Preventing a disease from developing by modification of risk factors.
e.g. immunisations, smoking cessation
What is secondary prevention and examples?
Early detection of disease to slow progression/reduce impact of already diagnosed disease
e.g. Screening, statins post MI
What is tertiary prevention and examples?
Reducing complications or severity once a disease in established and symptomatic
e.g. Chronic disease management programmes
Examples of study design?
Cohort study
Cross-sectional study
Case control study
Randomised control trial
Ecological
What is a cohort study?
Look at a group with a certain exposure and look for outcomes
What is a cross-sectional study?
Assess a cross section of people with a certain exposure or outcome at fixed point in time
What is case control study?
Select cases with particular outcome already, and look back for exposure/factors in common
What is a randomised control trial?
2 groups, one exposed and one unexposed (control), look at response over time
What is an ecological study?
Use routinely collected population level data to show trends and generate hypotheses
What is sensitivity?
Proportion of people with the disease correctly identified by screening test
a/a+c
What is specificity?
Number of people without the disease correctly excluded by the screening test
d/d+b
What is positive predictive value?
Proportion with positive test who actually have the disease
What is negative predictive value?
Proportion with negative test who do not have the disease
What is screening?
Identifying people at risk of developing a particular disease
Why do we do screening?
So interventions can be implemented earlier
Cons of screening?
Test may be distressing or harmful to healthy ppl with no benefit
Preventative measures may carry greater risk for gen pop
What is lead time bias?
Earlier detection gives impression of longer survival but does not alter prognosis
What is length time bias?
Screening more likely to pick up slow growing illness with better prognosis
Name of criteria for screening programmes?
Wilson and Junger
Wilson and Junger key principles?
Knowledge of the disease
Knowledge of the test
Treatment for the disease
Cost considerations
4 different types of screening?
Population based e.g. breast
Opportunistic e.g. BMI at appt
Screening for communicable disease e.g. in pregnancy
Pre-employment/occupational
What is incidence?
Number of new cases in population during specific time period
What is prevalence?
Number of existing cases in population during specific time period
PREvalence = PRE-existing
What is relative risk?
How much more likely an individual is to get the disease with A compared to B
Risk in one category relative to another (strength of association between RF and disease)
Relative risk calculation?
Risk in exposed / risk in unexposed
Absolute risk?
Probability of event occurring in a group
Absolute risk calculation?
Number of events / absolute population
What is number needed to treat?
Number needed to treat for 1 person to benefit
NNT calculation?
1 / absolute risk
Risk calculation?
Number of cases / total population size per year
Odds calculation?
Number of cases / number of non cases per year
Rate calculation?
Number of cases / person-time at risk of developing disease
What is person time?
The amount of time each person is at risk of developing the disease
4 main questions in negligence?
Was there a duty of care?
Was there a breach in duty of care?
Was the patient harmed?
Was the patient harmed due to breach in care?
What are the tests for negligence?
Bolam and Bolitho test
What is the Bolam test?
Would a group of reasonable doctors do the same?
What is the Bolitho test?
Was it a logical/reasonable way to act?
Examples of types of bias?
Selection bias, measurement bias, attrition bias
What is selection bias?
Sample chosen is not representative of the population e.g. healthy user bias, volunteer bias
What are examples of measurement bias?
Observer = knowledge of the hypothesis influences observations and measurements
Recall bias
Social desirability bias
What is attrition bias?
Differences between those who finish trial vs. those who do not
What are Maxwell’s dimensions used for?
Assessing quality of healthcare
What are Maxwell’s 6 dimensions?
Effectiveness
Acceptability
Efficiency
Access
Equity
Relevance
What is the Bradford Hill criteria?
9 principles for establishing evidence of a causal relationship
What are the 9 Bradford Hill criteria?
Strength - strong association between the 2
Consistency - observed multiple times/studies
Specificity - Exposure associated with specific outcome and vise versa
Temporality - exposure must precede outcome
Biological gradient - dose-repsonse relationship
Plausibility - association in plausable
Coherence - cosistent with other knowledge
Experiment - confirmed by experimental studies
Analogy - similar to other know causal relationships
What is the prevention paradox?
A preventative measure that brings a lot benefits to population, often offers little to each participating individual
e.g. for each 100 people screened, only 1 suffers from the disease
What are the 4 main domains of determinants of health?
Genetic - age, gender, ethnicity
Environment - housing, education
Lifestyle - smoking, employment
Healthcare - access and quality
What is Maslow’s hierarchy of needs?
Physiological - food, water, sleep
Safety - employment, home
Love/belonging - friendship, intimacy
Esteem - confidence, respect of others
Self-actualisation - morality, creativity etc.
What is health needs assessment?
Systematic process to identify health and healthcare needs of a population
= agreed priorities and resource allocation, improve health and decrease inequalities
Stages of health needs assessment?
Needs assessment
Planning
Implementation
Evaluation
Needs vs. supply vs. demand?
Need = health issues requiring intervention
Supply = what is provided
Demand = what people ask for
What is felt need?
Individuals/communities perceptions about health needs
What is expressed need?
Demands for services explicitly stated or observed
What is normative need?
Need defined by proffesionals
What is comparative need?
Need defined by comparing health status of one population to another
Three different approaches to health needs assessment?
Epidemiological
Comparative
Corporate
Epidemiological approach to HNA?
Defines burden and size by looking at current data (e.g. incidence, prevalence, mortality)
Looks at current services and recommends improvements
Cons of epidemiological approach?
Database may be poor/inadequate
Doesn’t consider felt need
Comparative approach to HNA?
Compares services received by one population to another
Cons of comparative approach?
Data may vary in quality
May be hard to find comparable populations
Corporate approach to HNA?
Takes into account views of anyone with an interest e.g. patients, professionals, media, politicians
Cons of corporate approach?
Hard to distinguish needs for demand
Groups have vested interest
Dominant individuals may have undue influence
Name three theories for behaviour change
Health belief model
Theory of planned behaviour
Trans-theoretical model
Stages of trans-theoretical model?
Pre-contemplation - not considering change
Contemplation - aware of problem
Planning - ready to change, plans/steps
Action - taking necessary steps
Maintenance/Relapse - continue/revert
Pros and cons of trans-theoretical model?
Pros:
Flexibility - allows for setbacks/relapse
Recognise ppl change at difference paces
Covers entire process from unaware to maintenance
Cons:
Subjectivity in determining current stage
Potential for stagnation
Doesn’t account for emotional influences
What does the health belief model rely on?
Person believes:
They are susceptible to the condition
Personal action can reduce susceptibility
That there are serious consequences to the condition
The benefits of action outweigh the cons
Pros and cons of health belief model?
Pros:
Can be applied to wide variety of behaviours
Cues to action are a unique component
Longest standing model
Cons:
Doesn’t consider emotional influence
Doesn’t consider habitual behaviour
Other factors may influence outcome
What is the theory of planned behaviour?
Human behaviour is a result of behaviour, normative, and control beliefs
What are the predictors in the theory of planned behaviour?
Intention is predictor of behaviour:
Personal attitude about behaviour (perceived consequences)
Perceived social pressure/norms
Perceived behaviour control (have skills/resources)
Pros and cons of theory of planned behaviour?
Pros:
Can be applied to wide variety of behaviours
Useful for predicting intention
Takes into account importance of social pressures
Cons:
No temporal element, direction, or causality
Doesn’t consider emotional influence
Doesn’t account for hobbies/habits
Assumes attitudes can be measured
What are some other models of change that could be mentioned?
Social norms theory = behaviour is influenced by misperceptions of how our peers think and act
Motivational interview = counselling approach for initiation of behavioural changes
Nudging = more effective to encourage positive choices rather than restricting unwanted behaviour with sanctions
What is an error?
Any preventable event which may cause/lead to patient harm
What is neglect?
Falling below an acceptable standard of care
4 main domains of error?
Error of omission = action delayed/not taken
Error of commission = wrong action
Error of negligence = not meeting standard
Skill based errors = slips/lapses
Medical error types?
Sloth
Poor team working
Fixation/loss of perspective
Communication breakdown
System error
Lack of skill
Ignorance
Bravado
Playing the odds
What is the Swiss cheese model?
Incidents occur due to accumulations of multiple failures in defence = align, creating hazard trajectory
What are latent errors (Swiss cheese model)?
Weakness in the system which are hidden/dormant. Existed for a long time without training
What are active errors (Swiss cheese model)?
Unsafe acts/mistakes made by individuals
What is the three bucket model?
Error due to interaction between personal, environmental, and physical (task) factors
Examples for the three bucket models?
Personal: poor knowledge, fatigue, little experience
Environmental: distraction, poor handover, equipment failure
Physical: unfamiliar equipment, variation from ‘normal’
What are never events?
Serious, largely preventable events resulting in harm or death to patients which should not occur (preventable measures in place)
Examples of never events?
Med - wrong chemo route
Surg - wrong site/retained object
MH - escape of transfer patient
What are confounders?
Risk factors, other than those being studied, that influence the outcome
Who should notifiable diseases be reported to?
Local health protection officer
What is a disease outbreak?
Number of cases exceeds that of what would be expected
Epidemic defintion?
Cases occurring in the same geographical region
Pandemic definition?
Disease has spread over countries/continents affecting large numbers of people
Definition of an asylum seeker and NHS access?
A person who has made an application for refugee status
Free access to GP and secondary care if they have an active application
Definition of a refugee?
A person granted asylum and refugee status
Definition of indefinite leave to remain and access to NHS?
A person is given full refugee status and permanent residence in the UK
Free full access to NHS
Definition of an unaccompanied child and NHS access?
Someone that has crossed international borders in seek of refuge <18 years old
Free full NHS access
What is equity?
Providing resources and opportunities based on individual need
Horizontal = equal treatment for equal need
Vertical = unequal treatment for unequal need
What is equality?
Everyone treated the same
What is inverse care law?
The availability of medical or social care tends to vary inversely with the need of the population served
3 resource allocation principles?
Libertarian approach
Egalitarian approach
Maximalism approach
Libertarian approach to resource allocation?
Taking responsibility for own health
+ Onus on pt, may be more engage
- Not all diseases are self-inflicted
Types of observational studies?
Case control
Cohort
Cross-sectional
Maximalism approach to resource allocation?
Concentrating resources on those who stand to gain the most
+ Resources allocated to those likely to receive most benefit
- Those with ‘less need’ receive nothing
What is odds?
The ratio of the probability of an event occurring to the probability of it not occuring
What is odds ratio?
Measure of an association between exposure and outcome
Odds ratio calculation?
Incidence in exposed / incidence in unexposed
Egalitarian approach to resource allocation?
Provide all care that is needed and required to everyone
+ Equal for everyone
- Economically restricted
What NHS access do refused asylum seekers have?
Free GP access
Can refused asylum seekers access secondary care?
NI, Scotland, Wales - yes
England - depends if care is immediately necessary/urgent or non-urgent + other exemptions
When can confidential information be disclosed?
Required by law - notifiable disease, ordered by judge
With patient consent
Public interest - serious crime, communicable disease
GMC Duties of a doctor?
Protect and promote health
Provide good standard of care
Recognise + work within limits on competence
Work with colleagues to best serve patient interests
Treat patients as individuals and respect their diginity
What is domestic abuse?
Any incident or pattern of behaviour showing controlling, threatening, violent or abusive actions between >16 years olds and their partners/family members
Types of domestic abuse?
Psychological
Physical
Sexual
Emotional
Financial
Who to report domestic violence to if imminent risk of serious harm?
MARAC/IDVAS
MARAC - Multiagency risk assessment conference
IDVAS - Independent domestic violence advice services
Examples of motivations for unhealthy behaviour?
Short term benefits > long term risks
Challenge of affluence to self control
Social networks
Backwards looking vs forward looking
What are some of the early influences of feeding behaviours?
Parental preferences/practices
Breast feeding
Maternal diet and taste preference
Examples of ‘dieting’?
Restricting amount of food
Not eating certain types of food
Avoiding eating foods for long periods of time
What is the external theory of obesity?
Suggests obese individuals are more responsive to external food cues and less sensitive to internal hunger and satiety signals compared to lean individuals e.g. the sight or smell of food
Less responsive to internal signals of hunger/satiety
What is the restraint theory?
Suggests deliberate attempts to restrict food intake can paradoxically lead to increased eating and weight gain
Restrained eaters = cognitive strategies to control intake
Cognitive controls broken = overeating
Common triggers = stress, emotions, exposure to tempting foods
List some examples of social determinants of health which can influence substance misuse?
Physical/mental health
Trauma
Access to substances
Access to peer support
Fhx of substance abuse
Harm reduction programmes
Access to healthcare services
Attitude/opinion towards substance
Barriers homeless people face when accessing healthcare?
Unable to coordinate - no watch/clock
Transport issues
Unable to afford indirect costs (meds, transport)
Judgement/maltreatment from HCPs
Concurrent mental illness
Which report investigated inequalities in health?
The Black report 1980
What were the main findings of the Black report?
Health inequalities due to social and economic factors, including:
Income inequality
Education
Employment
Working conditions
Housing
Diet
WIDENING HEALTH GAP
Recommendations from the black report?
Reduce income inequality
Improve education
Create more jobs
Improve working conditions
Improve housing
Promoting healthy lifestyles
What is deontologism?
Concerned with moral duty
Patient-centred
What is utalitarianism?
Advocates actions that promote happiness or pleasure and oppose actions that cause unhappiness or harm
Society-centred
What is consequentialism?
Ends justify the means
What is an advance decision?
Legally binding document specifying a refusal of treatment in the future
What is an advance statement?
Not legally binding - express preference for care/treatment and broader range of topics
What is beneficence?
Duty to act in patients best interest and promote good
What is non-maleficence?
Duty to avoid causing harm to others - do no harm
What is autonomy
Right of the patient to make their own decisions and act under self-chosen plan
What is justice?
Treating all people fairly and equitably
