Public health Flashcards
Define public health
the science and art of preventing disease, prolonging life and promoting health through organised efforts of society
Define epigenetic
environment and personal experiences dictates the expression of your genome
Define allostasis
stability through behavioural and physiological change
Define allostatic load
long term overtaxation of the body leading to impaired health and stress (= price we pay for allostasis)
Define salutogenesis
favourable physiological changes secondary to experiences which promote healing and health
Define emotional intelligence
the ability to identify and manages ones own emotions, as well as those of others
what are the 3 domains of public health practice?
- health improvement
= concerned with societal interventions to prevent disease, promote health and reduce inequalities - health protection
= measures to control infectious disease risks and environmental hazards - improving services
= organisation and delivery of safe, high quality services for prevention, treatment and care
What are public healths key concerns?
wider determinants of health
prevention
inequalities in health
What is the difference between equity and equality?
equity = fair and just
equality= equal shares
Define horizontal and vertical equity
horizontal equity = equal treatments for equal need
e.g. patients with pneumonia treated equally
vertical equity = unequal treatment for unequal need
e.g. individuals with common cold or pneumonia need different treatments
How is health equity examined?
supply of health care access to health care utilisation of health care health care outcomes health status resource allocation wider determinants of health
Define health needs assessment
a systematic method of reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities
What is included in the “needs assessment”
- need = ability to benefit from an intervention
- demand= what people ask for
- supply= what is provided
Describe the planning cycle
needs assessment -> planning -> implementation -> evaluation -> needs assessment …
What is the difference between health need and health care need?
health need = need for health, concerns needs more general (measure using mortality, morbidity)
health care need= need for healthcare, more specific and ability to benefit from health care (prevention, treatment, care services)
Who defines need?
individuals family community professionals services
What must a “health needs assessment” be carried out for?
- a condition e.g. COPD
- a population e.g. manor top practice
- an intervention e.g. coronary angioplasty
Outline the social perspective of who defines need
- felt need= individual perceptions of variation from normal health
- expressed need= individual seeks help to overcome variation in normal health
- normative need= professional defines interventions appropriate for expressed need
- comparative need= comparisons between severity, range of interventions and cost
List the 3 approaches the health needs assessment
- epidemiological
- comparative
- corporate
Describe the epidemiological approach to health needs assessment
- define the problem and size of problem
- which services are available
- evidence based
- models of care
- existing services
- recommendations
What are the advantages of the epidemiological approach?
uses existing data
provides data on disease incidence/ mortality/ morbidity
can evaluate services by trends over time
What are the issues with the epidemiological approach?
required data may not be available
variable data quality
does not consider felt needs of people affected
Describe the comparative approach to health needs assessment
compares the services received by a population/ subgroup with others
can examine health status, service provision, service utilisation, health outcomes
What are the advantages of the comparative approach?
quick and cheap if data available
indicates whether service provision is better/ worse than comparable areas
What are the disadvantages of the comparative approach?
may not yield what the most appropriate level is
data might not be available
data of variable quality
difficult to find comparative population
Describe the corporate approach to health needs assessment
elicits the views of the people to decide which services are needed e.g. commissioners, professionals, patients, press, politicians
What are the advantages of the corporate approach?
based on felt and expressed needs of population
wide range of views
what are the disadvantages of the corporate approach?
difficult to distinguish need from demand
groups may have vested interests
influenced by political agenda
dominant personalities have undue influence
How is prevention classified?
- primary = preventing the disease before it has happened
- secondary = catching the disease in the early phase and preventing progression
- tertiary = preventing complications of the disease
What are the 2 approaches to prevention?
- population approach = a preventative measure delivered on a population wide basis and seeks to shift the risk factor distribution curve
- high risk approach = seeks to identify individuals above a chosen cut off and treat them
Define prevention paradox
a preventative measure which brings much benefit to the population, often offers little to each participating individual
Define screening
a process of sorting out apparently well people who probably have a disease from this who probably do not
List the types of screening
- population based screening programmes
- opportunistic screening
- screening for communicable diseases
- pre-employment and occupational medicals
- commercially provided screening
Outline the criteria (wilson and junger) needed for a screening programme
THE CONDITION
important health problem
latent/ pre clinical phase
natural history known
THE SCREENING PROCESS
suitable
acceptable
THE TREATMENT
effective
agreed policy on who to treat
THE ORGANISATION
costs and benefits
facilities
ongoing process
What are the disadvantages of screening?
exposure of well individuals to distressing or harmful diagnostic tests
detection and treatment of sub clinical disease that would never have caused any problems
preventative interventions that may cause harm to individual or population
Define sensitivity
the proportion of people who are correctly identified by the screening test
Define specificity
the proportion of people without the disease who are correctly excluded by the screening test
Define positive predictive value
the proportion of people with a positive test result who actually have the disease
Define negative predictive value
the proportion of people with a negative test result who do not have the disease
Define length time bias?
relates to screen detected vs intervals cancer
cancers may be slow or rapid progressive and less aggressive cancers are more likely to be detected on screening rounds
List the types of observational study designs
- descriptive
case reports, ecological studies - descriptive and analytical
cross sectional study - analytical
case control studies, cohort studies
Describe ecological studies
(type of descriptive study design)
use routinely collected data to show trends in data and useful for generating hypothesis
Describe cross sectional studies
divides population into those without the disease and those with the disease
collects data on them once at a defined time to find associations at that point in time
What are the advantages of cross sectional studies?
quick and cheap
provide data on prevalence at a single point in time
large sample size
good surveillance for public health planning
What are the disadvantages of cross sectional studies?
prone to bias
no time reference
cannot measure incidence
risk of reverse causality
Describe case control studies
retrospective studies that take people with a disease and match them to similar people (of age/sex/class) without the disease and study previous exposure
What are the advantages of case control studies?
quick
inexpensive
good for rare outcomes
can investigate multiple exposures
What are the disadvantages of case control studies?
difficulties finding controls to match with cases
prone to selection and information bias
Describe cohort studies
start with a population without the disease and study them over time to see if they are exposed to agent in question and see if they develop the disease or not
What are the advantages of cohort studies?
can follow group with rare exposure
good for common and multiple outcomes
less risk of selection and recall bias
What are the disadvantages of cohort studies?
long time
people drop out of study
need large sample size
List the types of experimental/ intervention studies
- randomised control trials
2. non randomised control trials
Describe randomised control trials
patients randomised into groups, one group given interventions and other given control and outcome measured
What are the advantages of randomised control trials?
low risk of bias and confounding
can infer causality
What are the disadvantages of randomised control trials?
time consuming
expensive
volunteer bias
ethical issues - is it ethical to withhold a treatment if could be effective?
define independent variable
variable that can be altered in the study
Define dependent variable
variable that is dependent on the independent variables - one that cannot be altered
Define odds
ratio of probability of occurrence compared to probability of non occurrence
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 prevalence
existing cases of a condition
Define incidence
number of new cases of a condition
define incidence rate
the number of people who have become cases in a given time period / total person time at risk during that period
Define person time
measure of time at risk
Define absolute risk
actual numbers involved e.g. has UNITs
Define relative risk
risk in one category relative to another e.g. no units
how many times more likely it is that an event will occur in the intervention group relevant to the control group
How is relative risk calculated?
incidence in exposed / incidence in unexposed
Define attributable risk
the rate of disease in the exposed that may be attributed to the exposure (type of absolute risk)
How are relative risk values interrupted?
RR=1 : no difference between the 2 groups
RR<1 : intervention group decreased the risk of the outcome
RR>1 : intervention group increased the risk of the outcome
Define relative risk reduction
the reduction in rate of the outcome in the intervention group relative to the control group
Define absolute risk reduction
the absolute difference in the rates of events between the two groups and gives an indication of the baseline risk and intervention effect
Define number needed to treat
tells us the number of patients we need to treat to prevent one bad outcome
Define bias
a systematic deviation from the true estimation of the association between exposure and outcome
What are the 3 types of bias?
- SELECTION BIAS
= error in the selection of study participants or the allocation of participants to different study groups - INFORMATION/MEASUREMENT BIAS
= error in measurement of exposure or outcome (observer bias, recall bias, wrongly calibrated instrument) - PUBLICATION BIAS
Define confounding
a situation where the estimate between an exposure and an outcome is distorted because of the association of the exposure with another factor (confounder) that is also associated with the outcome
Define reverse causality
refers to the situation when an association between an exposure and an outcome could be due to the outcome causing the exposure rather than exposure causing the outcome
List the bradford criteria for causality
strength of association dose response consistency temporality reversibility biological plausibility coherence analogy specificity
Define health psychology
emphasises the role of psychological factors in the cause, progression and consequences of health and illness
What are the 3 health behaviours?
- health behaviour
= a behaviour aimed to prevent disease
e.g. eating healthily, exercise - illness behaviour
= behaviour aimed to seek remedy
e.g. visiting the GP - sick role behaviour
= behaviour aimed at getting well
e.g. taking medication, resting
List health damaging behaviours
alcohol smoking substance abuse sun exposure driving without a seatbelt
List health promoting behaviours
exercise healthy eating wearing sun cream protection attending health checks/screening vaccinations medication compliance
Why do people not comply with taking medications?
bad, intolerable side effects don't understand consequences of not taking medication complex regimes polypharmacy forget don't understand why taking medication
How can we improve compliance of medication?
- explain side effects
- explain what the medication is for and why they need to take it
- reduce number of tablets they are taking
- simplify regime
Define meta analysis
statistical outcome from combining data from multiple studies on a topic
Define systematic review
literature review that collects secondary data, critically appraise research studies and provide a summary of current evidence relevant to a research question
Define regression analysis
statistical process for estimating relationships/ risk factors among variables
List possible interventions at a population level and individual level to improve health behaviours
pOPULATION LEVEL:
- health promotion/ awareness campaigns
e. g. stoptober, change 4 life campaign, 5 fruit/veg a day - promoting screening and immunisations
INDIVIDUAL LEVEL:
- patient centred approach
- care responsive to individual needs
why do we engage in damaging health behaviours? / what is the theory of damaging health behaviour?
UNREALISTIC OPTIMISM *
= individuals continue to practice health damaging behaviour due to inaccurate perceptions of risk and susceptibility
What are perceptions of risk influenced by?
- lack of personal experience with problem
- belief that preventable by personal action
- belief that if not happened by now, it is not likely to
- belief that problem infrequent
Outline the NICE guidelines on behaviour change
- planning interventions
- assessing the social context
- education and training
- individual level interventions
- community level interventions
- population level interventions
- evaluating effectiveness
- assessing cost effectiveness
How as doctors can we help individuals change their health behaviours?
- work with patients priorities
- aim for easy change over time
- set and record goals
- plan explicit coping strategies
- review progress regularly
What is the national centre of smoking cessation and training?
a social enterprise to support the delivery of effective evidence based tobacco control programmes and smoking cessation interventions provided by local stop smoking services
What can the NCSCT provide?
- deliver training and assessment programmes
- provide support services for local and national providers
- conducts research into behavioural support for smoking cessation
- intereventions e.g. behavioural support, group support, text messages, medication, internet support, self help groups
Define health behaviour
any activity undertaken for the purpose of preventing or detecting disease or for improving health and wellbeing
outline the theory of the health belief model
individuals will change fi they…
- believe they are susceptible the condition in question
- believe that it has a serious consequence
- believe that taking action reduces susceptibility
- believe that the benefits of taking action outweigh the cost
What are “cues to action” in the health belief model?
cues to change make the action more likely
can be:
- internal= internally think about health behaviour
- external = being told advice
What are the disadvantages of the health behaviour model?
other factors can predict health e.g. outcome expectancy, self efficacy
does not consider influence of emotions on behaviour
does not differentiate between first time and repeat behaviour
Describe the theory of planned behaviour
proposes the best predictor of behaviour is INTENTION
Attitude + social norm + perceived behavioural control -> intention -> behavioural change
What is intention determined by?
(theory of planned behaviour)
- ATTITUDE = persons attitude to the behaviour
- SOCIAL NORM= perceived social pressure to undertake the behaviour
- PERCEIVED BEHAVIOURAL CONTROL= a persons appraisal of the ability to perform the behaviour
Use smoking as an example to explain the theory of planned behaviour
attitude = i do not think smoking is a good thing
social norm= most people who are important to me want me to give up smoking
perceived behavioural control = i believe i have the ability to give up smoking
behavioural intention = i intend to give up smoking
How can you help people to act on their intentions by bridging the intention behaviour gap?
- PERCEIVED CONTROL
= recalled success predicted success in the task - ANTICIPATED REGRET
= increased anticipated regret was related to sustained intention - PREPAPARTORY ACTIONS
= dividing a task into subgoals increases self efficacy and satisfaction at the point of completion - IMPLEMENTATION INTENTIONS
= “if then” plans facilities the translation of intention in to action - RELEVANCE TO SELF
= how is health behaviour relevant to them
What are the disadvantages of the theory of planned behaviour model?
lack of temporal elect of lack of direction
doesn’t take into account emotions
does not explain how attitudes, intentions and perceived behaviours control interact
relies on self reported behaviour
What is the stages of change model also called?
transtheoretical model (TTM)
Describe the stages of change model
stage theories see individuals located at discrete ordered stages and each stage denotes a greater inclination to change their behaviour than the previous one
What are the 5 proposed stages of change?
- pre contemplation
= no intention to give up behaviour - contemplation
= considering changing behaviour - preparation
= getting ready to change - action
= engaged in health behaviour and change - maintenance
= maintaining that health behaviour and sticking with the change for >6 months
What are the advantages of the stages of change model?
acknowledge individual stages of readiness
accounts for relapse
temporal element
What are the disadvantages of the stages of change model?
not all people move through each stage, can move backwards/forwards/skip stages
change could operate on a continuum rather than discrete stages
doesn’t take into account values, habits, social and economic factors
Describe motivational interviewing as a model for behaviour change
a counselling approach for initiating behaviour change by resolving ambivalence
Describe the “nudging” theory of behaviour change
“nudge” the environment to make the best option the easiest
e.g. fruit next to checkouts
List some behaviour change models
- health belief model
- theory of planned behaviour
- stages of change
- motivational interviewing
- nudging
- social norms theory
- social marketing
- financial incentives
Identify the typical transition points whereby interventions are likely to be more effective? (NICE behaviour change guidelines)
leaving school entering workforce becoming a parent unemployment/ losing a job retirement bereavement
What can doctors offer a newly presenting drug user?
health check screening contraception sexual health advice check general immunisation status signpost to additional help e.g. counselling, benefits, housing information for local drug services
What are the aims of treatment for drug users?
reduce harm to user, family and society
improve health
stabilise lifestyle and reduce amount of illicit drug use
reduce crime
Define domestic abuse
any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those >16 y/o and who are/have been intimate partners or family members
What type of abuse can domestic abuse involved?
physical emotional financial sexual psychological
How can domestic abuse impact on health?
- physical injuries as a result of assault
e. g. fractures, miscarriages, bruises, haemorrhages - chronic illness/ somatic problems as a result of living with abuse
e. g. headache, chronic pain, premature delivery, low birth weight - psychological problems secondary to abuse
e. g. PTSD, suicide, substance misuse, depression, anxiety
how can domestic abuse affect children?
- long term impact of self esteem, education, relationship and stress responses
- link between domestic and child abuse
- affect physical and psychological health
What is our role as doctors in responding to domestic/sexual abuse?
- display helpline posters and contact cards
- focus on patients safety
- ask direct, non judgemental questions
- acknowledge and be clear that the behaviour is not ok
- refer when appropriate
- work with other agencies and professionals
Outline the risk levels of domestic abuse
- standard - current evidence does not indicate likelihood of causing serious harm
- medium - there are identifiable indicators of risk of serious harm
- high - imminent risk of serious harm and dynamic (could happen at any time)
Whys should we notify communicable diseases?
- so HPA can take urgent control measures
- may be the only one who can tell HPA
- duty of registered medical practitioners
Who should be notified for a communicable disease?
the proper officer of the local authority
List some of the notifiable diseases
acute encephalitis acute meningitis acute infectious hepatitis cholera diphtheria food poisoning haemolytic uraemic syndrome legionnaires disease malaria measles meningococcal septicaemia mumps plague rabies rubella tetanus tuberculosis whooping cough yellow fever
what are the modes of transmission for notifiable diseases/
food borne faecal oral route respiratory route direct physical contact acquired from animals
Define inverse care law
those who need medical treatment are least likely to receiver it
Describe maslows hierarchy
gives an idea about the patients priority and needs
if patient not bothered about things at the bottom of the triangle e.g. food, water, sleep then they won’t care about things at the top and won’t progress
What are the stages of maslows hierarchy?
- physiological (bottom of triangle)
breathing, food, water, sleep, sex, excretion - safety
security of body, of employment, of family and of health - love/belonging
friendship, family, sexual partner - esteem
self confidence, achievement, respect of/by others - self actualisation
morality, creativity, problem solving, acceptance of facts
What are the main causes of homelessness?
eviction ** relationship breakdown * mental illness domestic abuse bereavement
List some of the health problems faced by homeless adults
infectious diseases e.g. TB, HIV, hepatitis
poor conditions of teeth, feet
respiratory problems
sexual health
mental health e.g. depression, schizophrenia
poor nutrition
addictions/substance abuse
List the barriers to healthcare with homeless adults
- difficulties with access to health care e.g. not registered at GP, opening times, lack of transport
- lack of integration between primary care services and other agencies
- other things on their mind e.g. other priorities
- may not know where to find help
List the barriers to healthcare with travellers
reluctance of GPs to register travellers poor reading and writing skills communication difficulties mistrust of professionals lack of choice
Define refugee
a person granted asylum and refugee status - leave to remain for 5 years and then reapply
Define humanitarian protection
failed to demonstrate claim for asylum but face serious threat to life if returned - 3 years then reapply
Describe what is meant by a refugee status
indefinite leave to remain (permanent residence in UK)
all the rights of a UK citizen
they are eligible for family reunion
Define asylum seeker
someone who has made an application for refugee status and is waiting for their claim to be decided by the home office
Describe what is meant by an asylum seeker status
entitled to money (£35 a week)
entitled to housing but no choice dispersal
entitled to NHS care
if under 18, have a social services key worker and attend school
BUT not allowed to work or any other form of benefit
List the barriers to healthcare for asylum seekers
lack of knowledge where to get help lack of understanding how the NHS works language barrier health not priority cultural/ religious differences
Outline common physical health problems in asylum seekers
injuries from war/ travelling no previous health checks/ immunisations malnutrition torture and sexual abuse infestations and debilitation blood borne diseases untreated chronic diseases
What are the physical consequences of loneliness
earlier death
take more risks
harder to self regulate / neglect
physical changes which bring on poor health
List some factors which indicate loneliness
body language denial "boredom" lives alone male >50 y/o bereavement mobility sensory impairment close family nearby?
Define social exclusion
the dynamic process of being shut out fully or partially from any of the social, economic, political or cultural systems which determine the social integration of a person in society
Define evaluation of health services
evaluation is a process that attempts to determine as systematically and objectively as possible the relevance, effectiveness and impact of activities in the light of their objectives
Describe the framework for health service evaluation by Donabedian
- Structure - buildings, staff, equipment
- Process- number of patients seen, operations performed…
(3. output) - outcome - mortality, morbidity, quality of life, patient satisfaction
What are the issues with health outcomes?
cause and effect difficult to establish as other factors involved
time lag between service provided and outcome may be long
large sample size may be needed to detect statistically significant effect
data may not be available
issues with data quality
Describes Maxwells dimensions of quality of healthcare
3 E’s and 3 A’S
1. Effectiveness= does the service produce the desired effect
- Efficiency= is the output maximised for a given input
- Equity= are patents treated fairly?
- Acceptability= how acceptable is the service offered to the people needing it
- Accessibility = geographical access, costs to patients, info available
- Appropriateness = is the right treatment given to the right people at the right time?
Describe the 2 methods of evaluation
- qualitative methods - observe, interviews, focus groups, review of documents
- quantitative methods - routinely collected data, review of records, surveys
Define opportunity cost
to spend resources on ONE activity means a sacrifice in terms of lost opportunity cost elsewhere
Define economic efficiency
achieved when resources are allocated between activities in such a way as to maximise benefit
How do we measure benefit?
- natural units e.g. BP, pain score
- Quality of Life Y
- monetary value
Factors that could contribute to promotion of excessive energy intake (over-eating)?
genetics employment e.g. shift work TV adverts reduced physical activity sleep conditions e.g. CF, trader willi characteristics of food e.g. energy density, portion size
Define malnutrition
deficiencies, excess or imbalances in a persons intake of energy +/- nutrients
Name the 2 conditions malnutrition includes
- undernutrition = includes stunting and micronutrient deficiencies
- overweight= obesity and diet related non communicable diseases
Why should doctors understand the psychology of behaviours associated with eating?
understand normal psychological processes related to eating
be able to understand and adequately respond to/advise patients
chronic mental conditions requiring nutritional support e.g. cancer, CF, coeliac disease, IBS, diabetes, failure to thrive, obesity, eating disorders
List the early influences on feeding behaviour
- maternal diet and taste preference development
- role of breastfeeding for taste preference and body weight regulation
- parenting practices
- age of introduction of solid food
- types of food exposed to during the weaning period
describe how maternal diet and taste development influences feeding behaviour
foetus swallow a significant amount of amniotic fluid during gestation
amniotic fluid transmits volatiles from the maternal diet end provide early chemosensory experience
taste and olfactory systems developed prior to birth
Describe the advantages of breastfeeding
- acceptance of novel foods during weaning
- less picky eaters in childhood
- have a richer diet in fruit and veg
- can protect against childhood obesity
- encourages better appetite regulation
How is breastfeeding a public health issue?
prevalence of breast feeding is particularly low among young mothers and disadvantaged socio economic groups
widens existing health inequalities
What does breast milk contain?
- efficient digestion- enzymes (lipase, lysozyme), transfer factors (lactoferrin)
- gut protection- epidermal growth factor, secretory IgA, anti inflammatories
- anti infective- bifidus factor, white cells
- every day health - antibodies, viral fragments, lactoferrin
How can parental practices influence feeding behaviour?
caregivers use tactics such as coercion, percussion and contingencies as a means of encouraging children to try new foods
caregivers need to: model healthy behaviours, recognise hunger and fullness, avoid pressure to eating, not use food as a reward, authoritative parenting
What are non organic feeding disorders?
characterised by:
- feeding aversion
- food refusal
- food selectivity, fussy eaters
- failure to advance to age appropriate food
- negative mealtime interactions
Define eating disorders
clinically meaningful behavioural or psychological pattern to do with eating or weight that is associated with distress, disability or with substantially increased risk of morbidity or mortality
Define disordered eating
inappropriate compensatory behaviours that do not warrant a clinical diagnosis e.g. strict dieting, emotional eating, binge eating, nigh eating
List the 3 basic forms of dieting associated with restriction
- restrict total amount of food eaten
- do not eat certain types of food
- avoid eating for long periods of time
What are the problems with dieting?
risk factors for developing eating disorders
dieting results in loss of lean body mass
dieting slows metabolic rate
chronic dieting may disrupt normal appetite responses
weight cycling leads to overheat and accelerates weight gain
What are the 3 theories of dieting?
- externality theory of obesity
- restraint theory / boundary model
- goal conflict theory
