Public Health Flashcards
What is the main determinant of public health?
NOT mean income but the extent of income division
What is the Gini-coefficient
A statistical method of measuring wealth of a nation divided amongst its residents
low co-efficient = greater equality amongst people
High = UK
Low = Scandanavian countries
Name 3 responses to health inequalities…
- The Black Report (1980’s)
- The Acheson Report (1998)
- Proportionate Universalism
What is the Black Report?
Material (environmental causes influenced by behaviour)
Artifact (apparent product of how inequality is measured)
Cultural (poorer people = unhealthy behaviours)
Selection (sick people sink socially and economically)
What is the Acheson Report?
Aim = decrease inequalities in wealth
Healthcare priority to those families with children
What is proportionate universalism?
- just targeting disadvantaged will not reduce inequality
- needs to be a universal approach
- fair distribution of wealth is important
Name 3 theories of causation of inequalities?
- Psychosocial
- Neo-material
- Life-course
What are the 5 structural determinants of illness?
- social class
- poverty
- unemployment
- racism
- gender and health
What is the psychosocial theory of causation of inequalities?
stress»_space; inability to respond efficiently to the bodies demands
- impact on BP, cortisol levels and inflammatory and endocrine responses
What is the neo-material theory of causation of inequalities?
more hierarchical societies are less willing to invest into the provision of public goods
- poorer people has less material goods, quality of which is generally lower
What is the life-course theory of causation of inequalities?
comb of both psychosocial and net-material explanations
critical periods: possess greater impact at certain points in the life course
accumulation- hazards and their impacts add up»_space; hard work leads to injuries»_space; resulting in disabilities that may lead to more injuries
What is the biomedical model?
- mind and body = separate
- body, like a machine, can be repaired
- this privileges the use of technological interventions
- it neglects social and psychological dimensions of disease
When are you allowed to break confidentiality?
- Patient consent
- Public interest e.g. rare disease, research, education
- You are required to do so by law e.g. notifiable disease, ordered by police)
What is the criteria for patient information disclosure?
- anonymous
- patients consent
- kept to a necessary minimum
- data protection
What happens to confidentiality after death?
Duty of confidentiality continues
What are the 3 main notifiable diseases that must be reported to WHO?
cholera, yellow fever and the plague
What is health behaviour?
aimed to prevent disease (e.g. healthy eating, exercising)
What is illness behaviour?
aimed to seek remedy (going to the doctors)
What is sick role behaviour?
aimed at getting well (compliance, resting)
5 factors that promote mortality?
- poor diet
- sedentary lifestyle
- obesity
- smoking
- excess alcohol
What are the 4 domains of public health?
Health protection
Health improvement
Improving services
Addressing the wider determinants of health
What is meta-ethics?
Exploring fundamental questions: right/wrong/defining good or bad
Name the 5 ethical theories…
Virtue Imperative Categorical Utilitarianism 4x principles
What is applied ethics?
a recent emergence of ethical investigation into specific areas (e.g. medical, public health etc)
Name the ethical arguments
DICE Deductive Inducive Considering what we believe in Ethical analogies
What is a deductive ethical argument?
That one ethical theory can be applied to all medical problems
What is an inductive ethical argument?
That settles medical cases generate theory or guidelines for future practice)
What are ethical analogies?
removing limb of a healthy patient vs. plastic breast surgery
What is an ethical fallacy?
The idea that ethical considerations help to solve the problem of free will.
The assumption but some philosophers that free decisions must be restricted to moral decisions
What is Ad hominem?
a claim or argument is rejected on the basis of some irrelevant fact about the persons character rather than focusing on the content of their argument
What is petito principii?
assuming the initial point of the argument (a premise is assumed to be true without warrant)
What is an authority claim?
saying a claim is correct because the authority has said so
What is motherhood with regards to ethical fallacies?
The insertion of a soft statement to disguise the disputable one e.g. all humans are equal (so we shouldn’t stop PVS patient treatment)
What is the Health Belief Model (Becker 1974)
- individuals must believe they are susceptible to the condition
- believe that it has serious consequences
- believe that taking action reduces their risks
- believe that the benefits of taking action outweigh the costs
What is the Transtheoretical model?
Pre-contemplation Contemplation Preparation Action Maintenance Relapse?
What are the key purposes of the NHS press releases?
- reactive- defend the NHS reputation (reporting achievements, improvements, justifications)
- proactive- improving and protecting public health
- social marketing messages (Five-a-day, change4life)
- early recognition and symptom awareness (FAST)
What are the GMC duties of a doctor?
- protect and promote the health of patients and the public
- provide a good standard of practice and care
- recognise and work within the limits of your competence
- work with colleagues in the ways that best serve patients interests
- treat all patients as individuals and respect their dignity
What is morality?
concerned with the distinction between good and bad or right and wrong
What is ethics?
the attempt to arrive at an understanding of the nature of human values, how we ought to live and what constitutes right conduct
What it consequentialism/utilitarianism?
- act is evaluated solely in terms of its consequences
- maximising good and minimising harm
- the greatest happiness for the greatest number of people
e. g. killing one innocent person to save the lives of 10 others
What are the different types of consequentialism?
- hedonistic
- rule
- act
- preference
What are the 5 virtues of virtue ethics?
- compassion
- discernment
- trustworthiness
- integrity
- conscientiousness
What is the definition of hedonistic utilitarianism?
The theory that the right action is the one that produces the greatest net happiness for ALL concerned
What is the definition of preference utilitarianism?
promotes actions that fulfil the preferences of those involved
What is deontology?
the right/wrong of action themselves (the worthiness of an act)
What are the limitations of virtue ethics?
- assessment of virtue is culture specific
- notion of virtue = too broad and non-specific to allow practical application
- ignores social and communal dimensions
What are some challenges associated with utilitarianism?
- is it okay to treat minorities fairly to promote the happiness of the majority?
- is it okay to carry out ethically questionable research to maximise the welfare of society
What are some rivals of ethics?
- law
- personal conscience
- religious of cultural beliefs
What are the 4 principles of ethics?
- Autonomy
- Beneficience
- Non-maleficence
- Justice
With regards to ethical arguments what is the top down incentive?
That one specific ethical theory is consistently applied to each problem
With regards to ethical arguments what is the bottom-up incentive?
Past problems are used to create guides to future practice
What is the definition of autonomy?
respect the decision of the patient
- the decision is rational and informed
- there are no major controlling influences over the decision
What is non-maleficence?
Do no harm, reduce or prevent harm
What is beneficence?
doing something with the aim to benefit others (providing benefits, balancing the benefits against the risks)
What is justice?
needs vs. benefit, fairness in the distribution of benefit s and risks
What can be used to assess functional limitations amongst older people?
Katz ADL scale
IADL (instrumental Activities of Daily Living)
The Barthel ADL
MMSE
What activities does the Katz ADL assess?
Getting out of bed, bathing, dressing, toilet use, eating
What activities does the Barthel ADL Index assess?
feeding, getting out of bed, walking along the flat, going ups and down stairs
What activities does the IADL assess?
use of telephone, going shopping, cooking food, driving, housework, medication use
What does the MMSE assess?
- orientation, immediate memory
- short term memory
- language functioning
What is an acute illness?
A disease of short duration, that starts suddenly, has severe symptoms (can often be cured)
What is a chronic illness?
a persistent or recurring condition, may or may not be severe, often starts gradually with slow changes (cannot be cured but can be treated.
What is polypharmacy?
the use of 4 or more medications by a patient, generally adults over 65 years
Name 5 key challenges of an ageing population…
- strain on pension and social security systems
- increasing demand for long-term care
- bigger need for trained health workforce
- increasing demand for healthcare
- pervasive ageism
What is pervasive ageism?
denying older people the rights and opportunities available for other adults
What are the causes of an ageing population?
- improvement in sanitation, housing
- decline in premature mortality
- falls in fertility
- life expectancy is increasing around the globe
- more people reaching older age whilst fewer children are born
Name 2 key facts about ageing population…
- In the UK there are as many people +65 as there are under 15
- By 2025 there will be more people aged 65+ than <20
What are the two types of ageing?
Instrinsic: inevitable, natural
Extrinsic: dependent on external factors (air pollution, UV rays, smoking)
What are some examples of physical changes in later life?
- decrease in skin elasticity
- decrease in height»_space; stoop
- hair goes grey
- decreased in weight
- loss of joint flexibility
- increased susceptibility to illness
- decline in learning ability
- less efficient memory
What visual declines does ageing cause?
- need 3x more light
- depth/colour perception
- narrowing of visual field
What hearing declines does ageing cause?
- high frequency loss
- speech comprehension 20%
What loss of taste and smell does ageing cause?
50% loss of taste buds
Why do women live longer than men?
20% biological- pre-menopausal women are protected from heart disease by hormones
80% environmental- men take more lifestyle risks than women)
What are the consequences of a higher life expectancy?
- pensions will have higher payouts than those currently planned
- chronic and comorbid conditions will prevail
- rising inequalities as affluent groups will use health services for longer
What are the different types of dementia?
Alzheimers = 62%
Vascular = 17%
Mixed dementia = 10%
Lewy bodies= 6%
What are the alternatives to hospital admission for older people?
- supporting discharge from inpatient hospital care
- providing alternatives in acute care within the community
- supporting chronic disease management within the community
What is institutionalising death?
60% of people die in hospital (but 70% want to die at home)
What is medicalisation of death?
Death is seen as a failure, prolonging life at any cost, death as natural part of our life challenged
What did Glaser and Strauss (1965) observe?
observational study of interactions between dying people, relatives and staff in USA hospitals
What 4 types of awareness contexts did Glaser and Strauss identify?
closed awareness
suspicion awareness
mutual pretence
open awareness
What is social death?
When people die in social and interpersonal terms before their actual biological death- lonely impersonal death
What is a good death?
palliative care became a speciality, aiming to demedicalise death- a reaction against the impersonal medical city
What is death the hospice way?
- open awareness, compassion, honesty
- MDT’s
- emotion and relationships- modelled on a family approach
- holistic care
Who is Kate Granger and what has she introduced?
- A campaign by a terminally ill doctor .
- Introduced the #hellomyname is campaign to encourage healthcare staff to introduce themselves to patients - to improve the patient experience in a hospital
What is the chain of infection?
Susceptive host»_space; causative microorganism»_space; reservoir»_space; portal of entry/exit»_space; transmission
Name two modes of transmission
Exogenous spread (direct/indirect contact, vector, airborne) Endogenous spread (self-spread)
Give some examples of susceptible hosts…
those with low immunity, low WBC count, imbalance in normal flora, invasive procedures
Give some examples of portal of exit/entry?
respiratory tract, GI tract, broken skin
What are the 3 different types of handwashing?
- routine handwashing
- surgical scrub
- hygienic hand antisepsis
Name two types of resident flora?
- anaerobic cocci
2. staphylococcus epidermis
How can you prevent infection?
By breaking the chain!!
Give some examples of how you can break the chain?
Handwashing, disposal of clinical waster, standard infection control precautions
Name some standard infection control precautions…
gloves and aprons, hand hygiene, correct sharps manipulation, correct clinical waste and linen handling
What are the physiological effects of nicotine?
- activation of nicotinic Ash receptors in the brain
- causing dopamine release in the NAcc (nucleus accumbent)
- stimulant, tolerance and withdrawal
What is the impact of smoking?
- greatest single cause of illness and premature death in the UK
- 100,000 deaths per year due to smoking
- cancers, COPD, CHD
a great economic impact of smoking
What are the health problems connected to smoking?
- cardiovascular problems (stokes, heart attacks, DVT’s)
- cancers
- stomach ulcers
- impotence
- diabetes
- oral health (gum disease)
- cataracts
Methods for smoking cessation…
- nicotine replacement therapy (patches, gum, inhalator)
- non- nicotine pharmacotherapy (varenicline, bupropion)
- trans-theoretical model (change in behaviour)
What are the 3A’s
The patient approach to smoking
ASK- your patient about smoking
ADVICE- your patient on cessation methods
ASSIST- your patient and refer to local NHS stop smoking service
The Law and smoking- key dates
1908- Children Act- sale of tobacco to under 16s prohibited
1965- parliament bans cigarette advertising on TV
2007- smoking in public banned + legal age raised to 18 in the UK
2015- smoking in car with children banned
What is the ‘digital divide’?
difference in access to information
What are the millennium developmental goals?
- eradicate extreme poverty and hunger
- achieve universal primary education
- promote gender equality
- reduce child mortality
- improve maternal health
- combat HIV/AIDS and other diseases
- ensure environmental sustainability
- develop a global partnership for development
What are the 3 leading causes of death in children in the developing world?
Diarrhoea, pneumonia and malaria
Name the UN agencies involved in global health?
UNICEF
WHO
Name the foundations involved in global health?
The Rockefeller Foundation
The Bill and Melinda Gates Foundation
Name the NGO’s involved in global health?
Doctors without borders (MSF)
Save the children
Name the multilateral development banks involved in global health?
The World Bank
Asian Developmental Bank
Name some current global environmental changes
CFC's and stratospheric ozone depletion loss of biodiversity within ecosystems freshwater decline and land degradation loss of natural fisheries increasing desertification
Give some examples of migrants…
international students, asylum seekers, refugees, trafficked people, migrant workers, family joiners
How do you define a migrant?
- country of birth
- country of nationality
- duration of stay
What is the origin of asylum seekers?
Iran, Pakistan,Sri Lanka, Syria
What is the origin of economic migrants?
Poland, Spain, Italy, Romania
Why are migrants vulnerable in their own countries?
- persecution, war, political and social unrest
- exploitation, torture, rape, bereavement
- burden of disease and socio-economic status
What is the significance of Lapedusa?
Island off the coast of italy
Primary transit point for immigrants from Africa
EU territory closest to the shores of Libya
THE DEADLIEST MIGRANT ROUTE IN THE WORLD
January to April 2015 about 1600 died
What are the NHS goals with regards to migrant health?
- equity of access
- reducing gap in health inequalities
- providing services for the vulnerable
- ensuring the services are appropriate and accessible
What is the definition of sustainability?
Being able to meet the needs of today without compromising the ability of future generations to meet the needs of tomorrow
What is climate change leading to?
the greenhouse effect»_space; irreversible heating of the planet
What are the Bradford Hill Criteria?
a group of minimal conditions necessary to provide adequate evidence of a causal relationship
Name the Bradford Hill criteria…
strength consistency specificity coherence temporality analogy
What are the possible consequences of global warming?
heatwaves
sea levels rising
new diseases
scarcity of resources»_space; migration»_space; war?
What are the solutions to climate change?
- control world population
- reduce energy consumption
- get our energy from renewable resources
How do you define an effective team?
- optimal team size
- good team dynamic
- a common purpose
- an identified team leader
- shared knowledge and experiences
What are the benefits of team working?
- improving the service delivery
- improving decision-making
- reducing the error
What are the obstacles when it comes to team work?
- organisational (different offices, shifts, rotations)
- location (ward based/visiting/based elsewhere)
- management (different employers/sub-teams)
- other commitments of team members
When handing off a patient from one clinician to another what checklist is used?
SBAR checklist- to improve patient safety S = situation B = background A = assessment R = recommendation
What is the WHO definition of mental health?
a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community.
What are the CMHP’s (Common Mental Health Problems)
- depression
- general anxiety disorder
- panic disorder
- probes
- social anxiety disorder
- OCD
- PTSD
Why are CMHP’s dangerous?
- have a -ve impact on QoL (employment, family, ADLs)
- increase risk of physical illness (chronic conditions)
- increase mortality from physical illness (e.g. heart disease)
- depression = major risk for suicide
Men are how many times more likely to suffer from CMHP?
men are 3x more likely
What are the interventions for public health?
- community level
- service organisation level
- individual level
- IAPT service (Improving Access to Psychological Therapies)
What does IAPT service model include?
- high intensity care
- low intensity care
How many people worldwide have depression at any one time?
350 million people
How many people have a sever mental illness such as schizophrenia?
24 million people
How many people commit suicide
1 million
How many children have a mental disorder
10-20%
How many doctors have some kind of mental disorder ?
1/3
Do doctors or the general population have a higher suicide risk?
Doctors
What diseases are linked to obesity?
- type 2 diabetes
- hypertension
- cancer deaths amongst non-smokers
- CHD and stroke
- reproductive function
- osteoarthritis
- angina
- high cholesterol
- bladder control problems
- psychological disorders: depression, eating disorders, low self-esteem
What is the difference in epidemiological patterns in the the past and nowadays?
In the past obesity affected the rich first
Nowadays obesity is a condition affected with poverty
What social gradient is reflective of obesity?
18% professionals/managers are obese
28% unskilled/manual workers are obese
What words describe the causes of obesity?
complex, multi-factorial, rooted in society, economic and cultural factors
What are the causes of obesity?
- ‘Americanisation’ of diet and society
- increasing dominance of car culture
- technological advances minimising physical work
- more commuting
- longer working hours
- greater availability of energy dense food, cheaper, better promoted
- replacing water with sugary drinks
What is the main question with regards to the causes of obesity?
Is the more about the increased energy intake or the reduced energy expenditure??
What is the WHO definition of obesity?
abnormal or excessive fat accumulation resulting from chronic imbalance between energy intake and energy expenditure that presents a risk to health. It is a state of positive energy balance.
What diagnostic measures can be used in obesity?
MRI Waist circumference WHR (waist to hip ratio) Skinfold thickness BMI
How do you calculate BMI?
Weight (kg) / height squared (m)
What are the BMI categories?
<18.4 = underweight 18.5-24.9 = normal range 25-29.9 = over-weight 30-34.9 = Obese Class I 35-39.9 = Obese Class II > 40 = Obese Class III
What are the 7 key domains of energy balance?
- food environment (energy intake - population level)
- food consumption (energy intake - individual level)
- individual activity (energy expenditure)
- activity of the environment (EE-PL)
- societal influences (I & E)
- individual psychology (I & E)
- individual biology (I & E)
What is the aetiology of obesity?
- multifaceted and complex
- causes = interaction between biology and behaviour
What links does obesity have with genetics?
Prada-Willi Syndrome
Mutations of the leptin and melanocortin receptors
congenital leptin deficiency
polygenic obesity
What is Prada-Willi Syndrome (PWS)?
- short, stature, almond shape eyes, small hands and feet
- intellectual impairment
- hyperplasia (overeating)
- chromosome 15 partial deletion (paternal)
What does congenital leptin deficiency lead to?
extreme adiposity and uncontrollable apetite
What is leptin?
Leptin, the “satiety hormone”, is a hormone made by adipose cells that helps to regulate energy balance by inhibiting hunger.
What obesity studies have been carried out on agouti mice?
agouti mice produce excess Agouti; a natural antagonist of melanocortin receptor, thus decreasing the melanocortin systems response to leptin (leptin insensitive)
What is melanocortin gene?
A gene responsible for appetite and satiety regulation. Appetite is the desire to eat while satiety refers to the sensation of fullness after eating.
What is melanocortin receptor?
MC4R codes for a protein called melanocortin 4 receptor, which is mainly found in the hypothalamus of the brain, an area responsible for controlling appetite and satiety.
What happened to the Pima Indians when they were exposed to the western environment ?
a dramatic increase in obesity
What aspects of behaviour are associated with weight gain?
- employment
- dietary patterns
- leisure and activities
Why is employment associated with weight gain?
- shift work, lack of sleep, upset circadian rhythm
- reduced physical activity
- cortisol, leptin, ghrelin
How are cortisol, leptin and ghrelin linked to obesity?
sleep loss has been shown to result in metabolic and endocrine alterations, including increased evening concentrations of cortisol, increased levels of ghrelin, decreased levels of leptin, and increased hunger and appetite.
What effect do cortisol, leptin and ghrelin have on the body?
Cortisol exhibits circadian rhythmicity
Ghrelin and leptin promote and suppress food intake, respectively
What are the developmental factors associated with obesity?
- rapid infant weight gain (in first 2 years of life = increased risk)
- breast feeding (associated with protective mechanisms from obesity)
- early intro of solid foods (<4 months increases risk)
- childhood obesity (big predictor of adult obesity)
What are the direct and indirect controls of meal size?
direct = all the factors relating to the direct contact of the food with the GI mucosal receptors indirect = metabolic, endocrine, cognitive individual differences >> indirect controls can override direct
What is satiation?
what brings an eating episode to an end
What is satiety?
inter-meal period
Describe the satiety cascade…
sensory»_space; cognitive»_space; post-ingestive»_space; post-absorptive
- fat has a relatively weak effect on satiation and satiety
- high fat foods often improve the sensory properties (palatable)
How many calories does protein contain?
5 kCal/g
How many calories does carbohydrate contain?
4 kCal/g
How many calories does fat contain?
9.5 kCal/g
How many calories does alcohol contain?
7 kCal/g
What is the satiating efficiency of macronutrients…
Protein > CHO > Fat > Alcohol
What is the macronutrient utilisation by the body?
Alcohol > Protein + CHO > Fat
How can we reduce the energy density of our foods?
- incorporation of water or air
- fruits and vegetables
- reducing fat (industry)
- methods of cooking (no frying)
By reducing the density of our foods what happens..
we consume fewer kCal and keep satiety
Energy consumption of which foods is lower than solids?
liquids with exception of soup
What is the role of alcohol in over-eating?
- stimulates intake, gives almost no satiety
- efficiently oxidised
- adds to the total daily energy intake
What food environment characteristics lead to obesity?
- variety of foods available
- portion size (increased over the last century)
- distraction e.g. watching TV and social facilitation- eating with others
What psychological factors are associated with under/over eating?
- dietary restrain (disinhibited eating behaviour)
- stress (often promotes eating)
- sleep (short sleep linked to over eating)
- reward sensitivity (neural response)
How are sexually transmitted diseases spread?
sexual contact
How are STI’s caused?
by over 30 different bacteria, viruses and parasites
What are the 4 main STI’s?
- chlamydia
- gonorrhoea (DRUG RESISTANT)
- syphilis
- trichomoniasis
What is the ABC list with regards to HIV safety?
A- abstain
B- be faithful
C- condom use
What are the 4 things that sexual and reproductive health education must do…
- involve young people as they are key decision makers
- provide comprehensive, accurate information
- address barriers to accessing health services
- empower adolescents to make life choices best for them