Public Health Flashcards
1
Q
What is public health?
A
Science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society.
2
Q
What are the different means of intervention in the face of a public health problem?
A
Do nothing/monitor the situation.
Provide information to educate people.
Enable people with choice to change their behaviour.
Guide choice through changing the default.
Guide choice through incentive, financial or otherwise.
Guide choice through disincentives, financial or otherwise.
Restrict choice to regulate the options available.
Eliminate choice to remove options entirely.
3
Q
What are the different types of prevention?
A
Primary prevention: prevent onset of disease
Secondary prevention: preventing progression of disease from a pre-clinical stage.
Tertiary prevention: preventing morbitity and mortality through the treatment of clinical disease.
4
Q
How are the social determinants of health related to health inequalities?
A
Social determinants of health are the conditions in which people are born, grow, live, work and age in They are shaped by the distribution of money, power and resources at global, national and local levels. Health inequalities are the unfair and unavoidable differences in health status within and between countries.
Social determinants of health are mostly responsible for these inequalities.
5
Q
What are the 3 different aspects of public health?
A
Health Improvement: changes in inequalities, education, housing, lifestyles by changing law, environment and culture
Health Protection: control of infections, chemicals, radiation, environmental health
Healthcare Public Health: clinical effectiveness, efficiency, audit to ensure that the NHS is fit for purpose
6
Q
Is lifestyle a free choice?
A
No - our choices are constrained by our physical, social and psychological environments.
e.g. Tobacco - parental/peer pressure, education
Diet - access, availability, affordability, awareness
Substance misuse - homelessness, mental health
Physical activity - built environment, work place
7
Q
Why should we be aware of cultural norms?
A
There are cultural norms regarding breastfeeding, diet, physical activity, tobacco, alcohol, caffeine.
Cultural deviance: any action that is perceived to violate a cultural norm.
When we are telling people to change their lifestyle, we need to be aware that we should not just be telling them to adopt our cultural norms.
8
Q
What factors should we consider when we are asking someone to make a change?
A
Do people know how to make that change?
Do people have the skills to implement that knowledge?
Do people understand the benefits and risks associated?
Are there any social, physical or psychological barriers?
9
Q
What makes someone a susceptible host to infection?
A
Low immunity (low WBCs) Elderly/neonatal/malnourished Antibiotics - normal flora are disrupted Invasive procedures - IV lines/catheters/wound sites/ventilation Inadequate levels of hygiene/cleaning
10
Q
What are some of the major causative microorganisms?
A
Staph Aureus (MRSA) Closteridim difficile Norovirus HIV Tuberculosis Vancomyocin resistant enterococcus.
Increased number in healthcare settings, can develop antibiotic resistance.
11
Q
How can microorganisms enter a host?
A
Repsiratory tract, gastro-intestinal tract, genito-urinary tract, broken skin.
12
Q
How can microorganisms be transmitted?
A
Direct contact, indirect contact, vector spread and airborne spread - EXOGENOUS SPREAD
Self-spread - ENDOGENOUS SPREAD
13
Q
Why do we perform hand decontamination?
A
To remove transient hand flora - staph aureus, streptococci, viruses
To reduce number of resident flora - anaerobic cocci, coagulase negative staphlococci.
All microorganisms found on the hands are capable of colonising susceptible sites.
14
Q
What is the biomedical model of health?
A
Dominant in the West.
Mind and body can be treated separately.
More disease and pain, poorer the health.
The body can be repaired so solutions are found in technologies and treatments.
Diseases are often caused by a specific identifiable agent.
Aims to inspire governments to invest in health services.
Idea that we can always regain something we have lost.
15
Q
What is the social model of health?
A
Medical knowledge itself is a subjective social construct - we are taught how to see the body.
Challenges the mind/body dualism and brings about a more holistic approach.
Health and illness are shaped by a wider socio-economic context.
16
Q
What are the different theories of health?
A
- Health as an ideal state: perfect well-being in every respect (physical, mental and social)
- Health as daily functioning to perform social tasks: means to the end of social functioning
- Health as personal strength/ability: how people respond to the challenges of life (holistic)
17
Q
What’s the difference between illness and disease?
A
Illness: the social lived experience of symptoms and suffering
Disease: the technical malfunction or deviation from the norm which is ‘scientifically’ diagnosed
18
Q
Why are narratives important in patient care?
A
Narrative/stories provide a space for people to show that there is more to illness than medicine can tell.
Important for healthcare professionals because talking and listening can be a form of repair work for people with chronic illness.
Interpreting the narrative of illness is a core task in medicine.
19
Q
What is the sick role?
A
The privileges and obligations which accompany illness.
Legitimate withdrawal from social obligations.
Not blamed for their condition.
Patient must want to get well to take up their social responsibilities.
Patient must seek technically competent help.
Not defined by subjective feelings but by the reactions of others and a pattern of action displayed by the claimant to the role.
20
Q
How does the professional relate to the sick role?
A
The professional must be objective and not judge the patient. Must not act out of self-interest.
Must obey a professional code of practice.
Must be professionally competent.
Have the right to examine a patient.
Only a doctor can sanction entry into the sick role - they ‘legitimize’ illness. They distinguish between normality and ‘deviance’.
21
Q
Why isn’t the sick role black and white?
A
Sick role changes according to social values.
Some illness are not the fault of the patient, some are.
Some illnesses don’t justify claiming the rights of the sick role e.g. cold, minor injuries, stomach upsets
Inappropriate adoption of the sick role is met with a lack of sympathy.
People who don’t comply with treatment plans are criticized.
22
Q
What are some criticisms of the sick role?
A
Doesn’t account for chronic conditions, physical disabilities, unseen disabilities, unexplained symptoms or normal experiences like pregnancy.
Patients are now more active and asymmetrical, patient-doctor relationship needs to be revised.
23
Q
What are some benefits of the sick role?
A
Allows people to receive sympathy, financial allowances, time off work and family responsibilities.
24
Q
What is medicalisation?
A
Explains the problem in medical terms e.g. depression, ADHD, alcoholism
Conceptualises social problems as a problem located in the individual. Paradox is that suggests that they can be treated biologically.
Doctors have been given the right by society to determine what consitutes as sickness, who is or might become sick and what shall be done to them.
25
What are the different levels of medicalisation?
Conceptually: in vocab used to define a problem
Institutionally: adopting a medical approach to treating a problem
Doctor-patient interaction: a problem is defined as medical and medical treatment occurs.
26
What is the process of medicalisation?
Behaviour defined as 'deviant'.
Medical conception of such behaviour is announced in a medical journal.
Claims making from medical and non-medical interest groups.
Legitimatization of a claim.
Medical designation is institutionalized - codified within a medical classification.
Can also have demedicalisation e.g. homosexuality
27
What is Iatrogenesis?
Harm brought forth by a healer or any unitended adverse patient outcome because of a health care intervention.
- Clinical: unintended effects of modern medicine like side-effects/complications.
- Social: leads to the 'medicalisation of life'
- Cultural: removes peoples ability to deal with their weakness and vulnerability
28
What are the benefits and criticisms of medicalisation?
Clinical and symbolic benefits: opportunities to alleviate symptoms, legitimises illness which reduces stigma, counteracts blame.
Criticisms: over simplistic view of medicine, underestimates degree to which disease has been eradicated by modern medicine, addiction of patients to modern medicine is overstated.
29
What is the 90:10 paradox?
Most health activity occurs outside hospitals, but most of our healthcare resources are concentrated inside hospitals.
30
What is the inverse care law?
Those who most need medical care are least likely to receive it. Conversely, those with least need of health care tend to use health services more (and more effectively).
This means that the health system can worsen or even create inequalities.
31
What are the steps involved in looking at a public health problem?
- Gather information through data, studies and surveys
- Relate it to the demography, sociology and epidemiology of a population
- Implement policies and strategic plans
32
What is disability?
- People with a disability as a result of congenital or developmental defects, diseases in early/mid life and accidents.
- Older people with functional limitations which may include physical or cognitive deficits.
Classified based on body function and structure as well as domains of activity and participation.
33
How can functional limitations in older people be categorized through tests?
- Activities of daily living scale. Each capability is graded on the level of dependence. Usually used in GP.
- Instrumental Activities of Daily living scale
- The Barthel ADL index
- Mini mental state: questions about orientation, registration (immediate memory), short-term memory, language functioning. Commonly used for cognitive function assessment.
Many other scales for different populations and disorders.
34
What's the difference between healthy and unhealthy life expectancy?
Life expectancy is increasing but the proportion of years where people experience a poor quality of life due to illness/disability is also increasing.
Mean life expectancy at birth/any age is relatively easy to determine and is robust.
Mean healthy and unhealthy life expectancy is very difficult to determine and is unreliable.
Big burden on in patient, out patient and social services and the economy as a whole.
35
What are the implications of an increased number of chronic conditions?
Chronic conditions are long term, persistent or recurring conditions.
- Management can be difficult: changes to patient-doctor relationship as they work towards alleviation of symptoms and promoted well being rather than a cure.
- One chronic condition may lead to another
- Management is often poor - failings in communication between specialties, frequent changes in presentation and severity of symptoms, polypharmacy.
36
What is the disability paradox?
People with profound disabilities nevertheless reporting a high quality of life.
Their expectations adjust to their current condition - a 'response shift'.
Challenged health status leads to re-evaluation of what is important to life quality.
Lowered expectations translate into higher sastisfaction.
37
What are intermediate care schemes?
Given after traditional primary care and self-care but before or instead of care that is available in larger acute hospitals.
e.g. medical physics like chairs, artificial limbs or smart homes with automatic features.
38
What is evidence-based medicine?
The conscientious, explicit and judicious use of the best evidence in making decisions about the care of individual.
39
What are the 4 different types of study designs as sources of evidence?
Cross-sectional study: splits population into different categories based on condition.
Case-control study: splits population into cases and controls, each with groups of exposed and not exposed.
Cohort study: splits population into people with condition, then into exposed and not exposed, with and without the condition.
Randomised controlled trial: sample population with both conditions, random allocation to intervention and control groups and outcomes are measured.
Can be done with non-random allocation too but other factors may affect outcome.
40
What are the best kinds of evidence?
```
Systematic review of RCTs
Random Controlled Trials
Cohort study
Case-control study
Cross-sectional survey
Case series
Anecdote/experience/opinion
```
41
What are the steps involved with evidence-based medicine?
Step 0: See if the answer is already out there
Step 1: Ask a focused question using Patient/population, Intervention, Control, Outcome.
Step 2: Find evidence through databases and evidence-based summaries.
Step 3: Critical appraisal to assess and consider validity, reliability and applicability. Using CASP which uses 10 different criteria.
Step 4: Making a decision - to assess internal and external validity and shared decision making.
Step 5: Evaluating performance through ongoing reappraisal and audit.
42
What are the different behaviours related to health?
- Health behaviours: a behaviour aimed to prevent disease
- Illness behaviour: a behaviour aimed to seek remedy
- Sick role behaviour: any activity aimed at getting well
Health damaging
Health promoting
43
What are the different types of risk factor?
Modifiable (smoking, diet, exercise)
| Non-modifiable (sex, age, genetics)
44
What is the combined impact of lifestyle factors on mortality?
Smoking, being overweight, taking little physical exercise, excess alcohol, poor diet can all contribute independently and synergistically to mortality.
Interventions to change behaviour may offer a relatively simple solution to reducing disease and will impact the individual, the local community and the population as a whole.
45
Why do people engage in damaging health behaviours?
Inaccurate perceptions of risk due to:
- Lack of personal experience with the problem
- Belief that it is preventable by personal action
- Belief that if it hasn't happened by now, it's not likely to
- Belief that problem is infrequent
Health beliefs, situational rationality, culture variability, socio-economic factors, stress and age also have an impact.
46
What is the Health Belief Model?
Individuals will change if they believe:
- they are susceptible
- it has serious consequences
- that action reduces susceptibility
- that benefits outweigh the costs
47
What is the best predictor of behaviour in the theory of planned behaviour?
Best predictor of behaviour is 'intention' which is determined by the person's attitude, the subjective norm and the perceived behavioral control.
48
What is the transtheoretical model?
```
Precontemplation
Contremplation
Prepartion
Action
Maintenance
```
49
What are the NICE guidlines for intervention?
```
Planning interventions
Assessing the social context
Education and training
Individual-level interventions
Community-level interventions
Population-level interventions
Evaluating effectiveness
Assessing cost-effectiveness
```
50
What is global health?
More recent in its orgin than public health.
Emphasises a greater scope of health problems and solutions.
Transcends national boundaries and best addressed by cooperative actions and solutions.
Can learn from other countries and share experiences.
51
How have patterns in causes of death changed?
In 1990, pneumonia, influenza and tuberculosis were the biggest killers. In 2010, heart disease and cancer were the biggest killers.
Decrease in communicable diseases due to education and vaccinations. Increase in non-communicable diseases.
52
What health inequities occur between developing and developed countries?
Developing countries account for 84% of the world's population and 93% of worldwide burden of disease.
However, they only account for 18% global income and 11% of global health spending.
Massive digital divide - one of the biggest challenges is access to information.
Richest 20% have 82.7% of income.
Poorest 20% have 1.4% of income.
53
What are health indicators?
Population, life expectancy, total expenditure on health, maternal mortality rate, under 5 mortality rate, infant mortality rate, fertility rate per woman.
54
What goals have been set for global health?
Millennium Development goals: 8 goals to be achieved by 2015 to respond to the world's development challenges.
Sustainable development goals: launched in 2015. 17 goals that include fighting poverty, education, sanitation, climate action, partnership.
55
Why is diabetes a public health issue?
MORTALITY - common underlying cause of death
DISABILITY - blindness, renal failure, amputation
CO-MORBIDITY - other physical and mental health conditions
REDUCED QUALITY OF LIFE - chronic condition, self-management and monitoring
56
Why is there a diabetes epidemic?
Increasing prevalence and affecting younger people
Lack of effective, global, national or local policy that is affecting trends in population obesity and sedentary lifestyles
Major inequalities in prevalence and outcomes with higher prevalence in deprived communities
57
How can we reduce the impact of type 2 diabetes?
Identify people at risk of diabetes
Preventing diabetes (primary)
Diagnosing diabetes earlier (secondary)
Effective management and supporting self-management (tertiary)
58
How to identify who is at risk of diabetes?
Those with:
Sedentary job and sedentary leisure activities
Diet high in calorie dense foods/low in fruit and veg, pulses and wholegrains
'Obesogenic environment'
59
What is an obesogenic environment?
Physical environment - car culture
Economic environment - expensive fruit and veg
Sociocultural environment - family eating patterns
60
What is 'the runaway weight gain train'?
Obesogenic environment - steep slope
Knowledge, prejudice, physiology - ineffective brakes
Vicious cycles of mechanical dysfunction, psychological impact, ineffective dieting, socioeconomic status - accelerators
61
What maintains an overweight state?
```
Physical/physiological = more weight, more difficult to exercise
Psychological = low self-esteem and guilt, comfort eating
Socioeconomic = reduced opportunities in employment and social
```
62
What are the risk factors for diabetes?
- Age, sex, ethnicity, family history
- Weight, BMI, waist circumference
- History of gestational diabetes
- Hypertension or vascular disease
- Impaired glucose tolerance or impaired fasting glucose
63
What are the available screening tests for diabetes?
```
HbA1c
Random capillary blood glucose
Random venous blood glucose
Fasting venous blood glucose
Oral glucose tolerance test (venous blood glucose 2 hrs after oral glucose load)
```
64
What are the diagnostic threshold for diabetes testing?
Impaired glucose tolerance 7.8-11.0 mmol/l
Impaired fasting glucose 6.1-6.9 mmol/l
Diagnostic threshold for diabetes
FBG >7.0 or 2 Glu >11.1 mmol/l
65
How can we prevent diabetes?
Sustained increase in physical activity
Sustained change in diet
Sustained weight loss
Prioritise those who HbA1c = 44-47 mmol/mol or fasting plasma glucose 6.5-6.9mmol/l
66
How can we diagnose diabetes earlier?
Raising awareness of diabetes and possible symptoms in the community and amongst healthcare professionals.
use clinical research to identify these at risk amd/or using blood tests to screen before symptoms develop.
67
How can we effectively support self-care for diabetes?
Self-monitoring - helpful for some, but not all
Diet - support for changing eating patterns
Exercise - support for increasing physical activity
Drugs - support for taking medication
Education - professionals/expert patients
Peer support - health champions/health trainers
68
What is the BMI? And the issues?
A crude population measure of obesity
A person's weight divided by the square of his and her height
Issues: ethnicity and children mean that it isn't that accurate
69
What is normal and abnormal waist circumference and when is it used?
Waist circumference is used for people with a BMI of 35kg/m
Men: low (<94), high (94-102), very high (>102)
Women: low (<84), high (80-88), very high (>88)
70
How do obesity and overweight patterns follow a social gradient?
Geographic distribution - more prevalent in the North
Higher levels of obesity are found in areas with higher levels of social deprivation
Other patterns related to ethnicity, disability and qualifications
71
What are the health and social implications of obesity?
Health implications: type 2 diabetes, hypertension, some cancers, heart disease, stroke, liver disease
Reduction in life expectancy by 3 years
Social: less likely to be in employment, discrimination, stigmatisation, increased risk of hospitalisation
72
What effects does poor nutrition in childhood have?
Emotional and behavioural - stigma, bullying, self-esteem
Education - school absence
Physical health - heart, lungs, pancreas, liver, joints
Long term - risk into adulthood, morbidity and mortality
73
What are some of the influences which affect somebody's weight?
School, employment, food preference, culture and attitudes, workplace, housing, social environment, planning, time and skills, marketing, built environment, local and national policy
Accessibility, availability, acceptability and affordability.
74
What do we know about weight loss diets?
No wonder diet
Large scope in guidelines for a variety of approaches
Weight loss requires focus on diet in the short-term but maintenance requires exercise/movement
Variation in weight loss outcomes
Dietician contact linked to a better outcome
Calorie counting linked a marginally better outcome
Comparison of behaviour linked to a marginally better outcome
75
What foods are classed as beneficial/harmful?
Benefit: fruits, nuts, fish, vegetable oils, wholegrains, beans and yoghurts
Harm: red meat, processed meat, sugar sweetened beverages, high sodium foods, refined grains
76
What national action seeks to fight the obesity epidemic?
Sugar reduction - taxation, bans on energy drinks for children
Local communities - strengthen government buying standards for food and catering services
Marketing - 9pm watershed for advertising
Retail - ban price promotion and location of certain foods and drinks
Labelling - mandate calorie labelling
77
What does impairment mean?
Any loss or abnormality of psychological, physiological or anatomical structure or function.
78
What does disability mean?
Any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.
79
What does handicap mean?
A disadvantage for a given individual that limits or prevents the fulfilment of a role that is normal
80
What is the legal definition of a disability?
A person has a ‘disability’ if ‘he or she has a physical or mental impairment which has a substantial and long-term adverse effect on her or his ability to carry out normal day-to-day activities.’
81
What is the social definition of a disability?
Loss or limitation of opportunities to take part in society on an equal level with others.
A person with an impairment who experiences disability.
The result of negative interactions that take place between a person with an impairment and her or his social environment.
82
What are some of the disability barriers?
Negative cultural representations
Inflexible organisational policies, procedures and practices
Segregated social provision
Inaccessible information formats
Inaccessible built environment and product design
83
What is a learning disability?
Significant impairment of general cognitive functioning acquired in childhood that is lifelong
Leads to difficulty with everyday activities, e.g. household tasks, socialising or managing money
Take longer to learn and may need support to develop new skills, understand complicated information and interact with other people.
84
What is the epidemiology of learning disabilities?
Boys more likely than girls
1.5million people in UK
2.5% of children
Parents who went to uni are less likely to have children with a LD
85
What causes learning disabilities?
Unclear
Genetic factors
Maternal use of alcohol, drugs and tobacco during pregnancy
Complications during pregnancy
Environmental toxins, such as cadmium and lead
86
What is Down's syndrome?
One of the commonest causes of LD
Increase in survival of babies born with DS
Average life expectancy is 51 years
More than a third are in their 40s
Increased risk of developing dementia, thyroid problems, visual/hearing impairment, other associated long term problems
Significant health and social implications
87
What are health inequalities?
Health inequalities are differences in health status between different population groups that are attributable to the external environment and conditions mainly outside the control of the individuals concerned, unnecessary, avoidable, unjust and unfair.
88
What are the health inequalities experienced by people with LDs?
More likely to be economically disadvantaged
Have communication, numeracy , literacy and memory difficulties
Have personal health risks and behaviours
Experience deficiencies in access to and the quality of healthcare provision
Have increased risk associated with specific genetic and biological causes of learning disabilities
89
What are some of the health risks associated with poverty?
Poor nutrition, poor housing conditions, environmental toxins, family, peer and community violence, poor parenting, family instability
90
What are the barriers to accessing healthcare for people with an LD?
- Failure to identify people with LD in health systems so that reasonable adjustments can be made in advance - -- Discriminatory attitudes and a lack of expertise on the part of healthcare staff
- Failure to make reasonable adjustments in light of the literacy and communication difficulties
- ‘Diagnostic overshadowing’ (symptoms of physical ill health being mistakenly attributed to a behavioural problem or seen as being inherent in the person's LD)
- Unable to phone to make appointments unaided
- Unable to read appointment letters and other correspondence,
- Have difficulties with patient call systems
- Unable to read or understand standard advice leaflets
- Not trust doctors or other clinicians they have not met before
91
What screening activities do people with LD find it difficult to get to?
```
Assessment for vision or hearing impairments
Routine dental care
Cervical smear tests
Breast self-examinations and mammography
Bowel and prostate screening
Annual health check-ups
```
92
What are the health consequences of low uptake of screening activities for people with LD?
```
More risky health behaviours
More sensory & physical impairments
Poorer physical health
Shorter life expectancy and premature mortality (due to delays/problems with diagnosis or treatment, problems with identifying needs, problems with providing appropriate care)
Poorer mental health
```
93
How can HCP seek to provide for the needs of patients with LDs?
Identify information or communication needs
Record these needs clearly in a set way
Highlight or flag the person’s file or notes
Share information about needs with other providers of NHS and adult social care
Take appropriate steps to address needs
94
What is an asylum seeker?
Person who has departed their country of origin and officially applied for asylum in another country but is awaiting a decision on their request for refugee status
95
What is a refugee?
A person who 'owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of their nationality, and is unable to, unwilling to avail himself to the protection of that country.
96
What is and undocumented migrant?
Foreign born nationals who don't have the right to remain in the UK
97
What is the pre-migration context like?
Fled war, conflict, persecution or natural disasters
From countries with poor healthcare systems
Long and dangerous journeys
Stayed in refugee camps
Limited access to food, water and proper sanitation
98
What is the post-migration context like?
```
Long and complex legal immigration process
Detention
New culture and language
Unable to work
Delayed access to education
Loss of identity and status
Lack of family and community support
Integration challenges
Poverty and poor housing
Racism and discrimination
```
99
What are some examples of 'hostile environment' policies put in place by the British government?
ID checks and upfront charging of undocumented migrants for hospital
Treatment and NHS-funded community health services
No recourse to public funds for asylum seekers and undocumented migrants
Banks and building societies prohibited from opening accounts for undocumented migrants
Criminalisation of letting to undocumented migrants and asylum-seekers awaiting a decision on their case as they are disqualified from renting
Criminalisation of employing undocumented migrants for whom it is illegal to work
Data sharing for immigration enforcement purposes between the Home Office and public services
100
What are the major health needs of migrants?
```
Communicable diseases
Incomplete immunisation history
Non-communicable diseases
Malnutrition and micronutrient deficiencies
Obesity
Anaemia
Musculoskeletal complaints
Oral disease
Sexually transmitted infections
Pregnancy
Female genital mutilation
Psychological disturbance
```
101
What UK policies mean that migrants/refugees are often in poverty?
Asylum seekers and undocumented migrants
• No recourse to public funds
• Not allowed to work
• Housing and £37.75 pp/pw
Refugees
• Asylum support axed after 28 days
• Need NI number to claim welfare benefits – can
take 28 weeks!
• Home Office delay in issuing identity documents
• Employers, banks etc not recognising Biometric
Residence Permits as form of ID
102
How can school education improve health?
Stable social support
Encourage resilience
Develop personal capabilities and self belief
Facilitate integration
Empower to communicate in English
Recognise children-in-need
Access to school nursing service
Provision of skills and qualifications for future employability and financial security
Lack of access: deterioration in mental health
103
How can poor accommodation affect health?
```
Respiratory illness
Accidental injury
Poor mental health
Vulnerable household relationships
Poor early childhood development
```
104
What is the health contact for a newly arrived migrant?
Unaccompanied asylum seeking children: Initial Health
Assessment within 28 days of registration with the local
authority
No official health pathway for other refugees, asylum seekers and undocumented migrants
GP new patient checks
Acute situations: be opportunistic and holistic!
105
Why shouldn't healthcare be a hostile environment for migrants and refugees?
Healthcare workers have a primary duty of care to patients
Access to healthcare is a human right
There are ramifications for public health
No economic argument for it!
106
What are the difficulties in providing good healthcare for migrants in the UK?
Financial constraints
Staff shortages
Language barriers andcomplex health needs : GP practice unwillingness to register
Health professionals clinically and emotionally unprepared
Over-stretched services
Lack of specialist services
Referral challenges
107
How can you remove healthcare barriers for migrants?
Identify the patient’s entitlements.
Be familiar with RCPCH, Government and BMA
guidance on assessment and management of refugees
and asylum seekers.
Understand their life experiences and health needs
and the correct technical and cultural approach to
address them non-discriminately.
Always use an interpreter when necessary and allow
additional time for appointments.
Support migrants and their families in navigating the
healthcare system and encourage engagement with
service-providers.
108
What are the risk factors for coronary heart disease?
Unmodifiable risk factors - genetics, male sex, age, ethnicity
Lifestyle risk factors - diet, exercise, smoking
Clinical risk factors - diabetes, hypertension, lipids (cholesterol)
Psychosocial risk factors - behaviour patterns/trait, depression/anxiety, work, social support (may be modifiable?)
109
What are Psychosocial Factors?
Factors influencing psychosocial responses to the social environment and pathophysiological changes
E.g. Stress has a significant impact on our immune system
Psychological aspect involves cognition, behaviours and emotional responses.
110
What is the Coronary Prone Behaviour Pattern?
Type A behaviour - a particular behavioural pattern
Traditionally someone who is competitive, hostile and impatient. Research indicated that individuals who have these types of behaviours are at greater risk of coronary heart disease and coronary events.
Behaviour assessed through questionnaires and structural clinical interviews.
The behaviour pattern can change, and the risk can change. Interventions like cardiac counselling and Type A Behaviour Modification may have served to reduce their risk. It is not enduring, it is modifiable.
111
How can anger and hostility affect your risk of CHD?
More recent research identifies the ‘Hostility’ dimension of as a key risk factor
- Feelings of anger
- Annoyance and resentment
- Verbal or physical aggression
The current review suggests that anger and hostility are associated with CHD outcomes both in healthy and CHD populations. Besides conventional physical and pharmacological interventions, this supports the use of psychological management focusing on anger and hostility in the prevention and treatment of CHD.
112
What's the link between depression/anxiety and CHD?
Patients are more likely to have depression following a coronary event, even if they didn’t have it before. Both depression and anxiety share common antecedents (e.g. social deprivation) so difficult to separate out what is specifically depression-related and specifically anxiety-related. More research and stronger evidence related to depression.
113
What's the link between Psychosocial work characteristics and CHD?
Significant associations between psychosocial job characteristics and myocardial infarction.
Particularly high-risk are those who are in a high-demand job with very little control or those with jobs that have high effort and low reward.
Long working hours or shift work may also have an impact.
If there are good support networks in place - supportive colleagues/supervisors can help to reduce this risk.
114
What's the link between social support and risk of CHD?
Loneliness, social isolation and deficiencies in social relationships are associated with an increased risk of developing coronary heart disease.
Both quantity and quality of social relationships have been found to be related to morbidity and mortality:
Helps coping with life events
Motivation to engage in healthy behaviours
115
What is substance misuse?
Relates to the harmful use of any substance for non-medical purposes or effect.
Typically psychoactive substances that produce CNS effects (alteration to the normal activity within the brain for positive reasons).
Associated with both illicit and legal substances.
116
What are some of the major classes of drugs of misuse?
Opiates - heroin, codeine, tramadol. Effects of euphoria, analgesia.
Depressants - alcohol, benzodiazepines, gabapentinoids. Effects of sedation, anxiolytic.
Stimulants - amphetamines, khat, cocaine, crack, caffeine, ecstasy/MDMA. Effects of increase alertness, alter mood.
Cannabinoids - cannabis. Effects of relaxation, mild, euphoria.
Hallucinogens - LSD, magic mushrooms. Effects of altered sensory perceptions and thinking.
Anaesthetic - Ketamine, GHB, nitrous oxide. Effects of anaesthesia and sedative.
117
What are New psychoactive substances?
Previously termed ‘legal highs’ or club drugs
Designed to mimic other substances of abuse but less predictable effects.
Depressant - Etizolam Pyrazolam
Stimulant - Mephadrone, BZP
Cannabinoids - Spice, Clockwork Orange, Black Mamba
Hallucinogens - Bromo-dragonfly
118
What are the current trends in drug use?
2017/18
Most common: cannabis, cocaine, ecstasy. Reducing trend for opiate use but recent increase in crack presentations.
Trends in drug use driven by history patterns, poverty, supply and demand.
119
Which people groups are most likely to use drugs?
Disproportion in use of substances between males and females (far more males) and between ethnicities (more black people) and employment status (more in those who are unemployed/economically inactive).
120
What are some of the harms associated with substance misuse?
Mortality
Morbidity (physical and psychological impact on quality of life)
Social (criminal justice involvement, crime, violence, acceptability)
Economic (productivity, tax)
Personal (identity, stigma, relationships)
121
What are some of the common theories of why people misuse drugs?
Disease model: Addiction is a disease
Moral model: Addiction is a lack of values
Socio-cultural model: Addiction only exists due to social injustice
Behavioural model: Addiction will be eliminated if we increase punishments
Volitional model: Addiction is due to a failure of will
Disease model: Addiction is due to genetic factors
122
What is severe substance use disorder?
Also known as Addiction.
Involves compulsive use of a substance despite harmful consequences.
Often involves structural and biochemical changes to parts of the the brain linked to reward, self-control and stress.
123
What is psychological dependence (drugs)?
Feeling that life is impossible without the drug. Emotional effect: feelings of fear, pain, shame, guilt, loneliness if not on drug
124
What is physical dependence (drugs)?
Body needs more and more of a drug for same effect (tolerance) Depending on substance: withdrawal symptoms, eg runny nose, stomach cramps, muscle aches
125
What are some of the preventative factors against substance misuse?
```
Self-control
Parental monitoring and support
Positive relationships
Neighborhood resources
Academic achievement
School anti-drug policies
```
126
What are some of the risk factors for substance misuse?
```
Aggressive childhood behaviour
Lack of parental support
Community deprivation/poverty
Drug experimentation
Poor social skills
Availability of drugs at school
```
127
What are the weekly alcohol guidelines?
Not advised to drink more than 14 units a week
| Spread the drinking over 3 ore more days if you are consuming 14 units a week
128
What is a unit of alcohol?
A UK unit is 8 grams or 10ml of pure alcohol
| The number of units in a drink depends on what you're drinking; how strong it is; and how much there is.
129
How to calculate the number of units of alcohol in a drink?
```
Strength of the drink (% ABV)
x
Amount of liquid in millilitres (one pint is 568ml; a small glass of wine 125ml).
÷
1,000
```
130
Which age group is likely to be drinking over 14 units of alcohol a week?
Men and women aged 55 - 64 (36% and 20% respectively)
Young people are now less likely to drink and, if they do drink, they start doing so later, drink less often and consume smaller amounts.
131
When does drinking become too much?
Causes or elevates the risk for alcohol-related problems, or
| Complicates the management of other health problems
132
What are the symptoms of alcohol withdrawal?
Tremulousness - "the shakes"
Activation syndrome - characterized by tremulousness, agitation, rapid heart beat and high blood pressure
Seizures - acute grand mal seizures can occur in alcohol withdrawal in patients who have no history of seizure or any structural brain disease
Hallucinations - usually visual or tactile in alcoholics
Delirium tremens - can be severe/fata. Tremors, agitation, confusion, disorientation, hallucinations, sensitivity to light and sound, and seizures
133
What are the consequences of foetal alcohol syndrome?
Pre and post-natal growth retardation
CNS abnormalities including mental retardation, irritability, incoordination, hyperactivity
Craniofacial abnormalities
Associated abnormalities including congenital defects of eyes, ears, mouth, cardiovascular system, genitourinary tract and skeleton and an increase in the incidence of birthmarks and hernias
134
What are the psycho-social effects of excessive alcohol consumption?
```
Interpersonal Relationships
Violence
Rape
Depression or anxiety
Problems at Work
Criminality
Social Disintegration
Poverty
Driving incidents/offences
```
135
What is Minimum Unit Pricing (MUP)?
Every drink containing alcohol has a minimum price based on the amount of pure alcohol it contains. The minimum price for alcohol in Scotland is currently set at 50 pence per unit (ppu).
↓ alcohol related deaths ; ↓ hospital admission
↓ crime volumes ↑ financial saving (health, employment, crime…)
136
What are some of the excessive drinking screening tools?
A Clinical Interview – a single question about heavy drinking days
FAST - Fast Alcohol Screening Test
AUDIT - Alcohol Use Disorders Identification Test
CAGE Questions
137
When would you screen a patient for excessive drinking?
As part of routine examination
Before prescribing medication
In the emergency department
In patients who are…
- Pregnant or trying to conceive
- Likely to binge drink heavily (e.g. smokers, adolescents, young adults)
- Having health problems that might be alcohol induced
- Experiencing chronic illness not responding to treatment
138
What are the different levels of alcohol consumption/dependence?
At Risk Drinking (Hazardous)
A pattern of drinking which brings about the risk of physical or psychological harm – Screening tools
```
Alcohol Abuse (Harmful drinking)
a pattern of drinking which is likely to cause physical or psychological harm.
```
Alcohol Dependence
Substance dependence is defined as a set of behavioural, cognitive and physiological responses that can develop after repeated substance use.
139
What causes good or bad health?
Age, sex and constiutional factors
Individual lifestyle factors
Social and community networks
Living and working conditions - agriculture and food production, education, work environment, unemployment, water and sanitation, healthcare services, housing
General socio-economic, cultural and environmental conditions e.g. war zones, flooding etc
140
What are some of the causes of the causes of mortality?
```
Loneliness
Unemployment
Poor housing
Fear of crime
No access of green space
Food poverty
Pollution
Social inequality
```
141
How can the natural environment improve health?
- Improved relaxation and restoration
- Improved social capital
- Improved functioning of the immune system
- Enhanced physical activity
- Anthropogenic noise buffering
- Reduced exposure to air pollution
- Reduction of the urban heat island effect
- Enhanced pro-environmental behaviour
- Optimised exposure to sunlight and improved sleep (Vit D)
- Beneficial to microbiome
142
What can healthcare professionals do to improve health of patients using greenspaces?
- Improve the quality of healthcare environments
- Harness the benefits of nature connection in therapeutic interventions
- Identify a range of nature-based interventions that work for a diversity of people
- Encourage patients to consider to effective alternatives to medical treatments
- Signpost patients to natural spaces
143
How does the 'cause' of mental health issues affect the treatment?
If biological - drugs
If social - change social structures
If psychological - give therapy
For many, medicine is seen as a “quick fix” although, one could argue, it doesn’t address underlying issue which may be psychological and/or social.
144
What are the common mental health disorders?
```
– Depression
– Generalised anxiety disorder (GAD)
– Panic disorder
– Phobias
– Social anxiety disorder
– Obsessive-compulsive disorder (OCD)
– Post-traumatic stress disorder (PTSD)
```
145
How do mental health disorders have a physical effect?
```
CMDs are a factor in e.g.
– Functional syndromes
– Psychosomatic disorders
– Medically unexplained symptoms
– Anxiety complications of asthma
– Depression co-occurring with a wide range of long-term conditions
– Role in ‘accidents’
```
146
Why are mental health issues a public health concern?
```
CMDs have a negative impact on:
– quality of life
– employment
– personal finances
– activities of daily living
Impact on wider society as well as individual
```
147
How do social determinants play into incidence of mental health disorders?
You are much more likely to experience a mental health disorder if you are unemployed, lack formal qualifications, live in local authority or housing association accommodation, move home frequently, live in urban areas.
Childhood experience and family history are also predictors, along with personality factors.
148
How can inventions for mental health disorders be brought about on a service organisation level?
Management within primary care
Integrating specialist services through collaborative and stepped care
Focussing on prevention and early identification
Promoting self-management
Holistic approach
Outcomes focussed
149
How can inventions for mental health disorders be brought about on a community level?
Strengthening protective factors, e.g. school-based programmes, social & problem-solving skills for young people, physical activity for the elderly
Reducing risk factors, e.g. parental depressive symptoms, social support after severely threatening life events
150
What is the difference between low and high intensity Psychological Therapies?
Low intensity - Facilitated by Psychological Well-being Practitioner. May be pure self-help (e.g. computerized CBT), or guided self-help (e.g. psychoeducational groups). 1-6 sessions.
High intensity - Mainly CBT, counselling for depression, interpersonal therapy, or couples therapy. Qualified therapists/ counsellors. Up to 16 sessions.
151
What are the diseases associated with ageing?
Osteoporosis and the consequences - falls, fractures, reduced mobility, social isolation and pain
Dementia, delirium and cognitive impairment
Stroke and cardiovascular/cerebrovascular disease
Parkinson’s disease
Osteoarthritis and immobility
152
Who are the multidisciplinary team?
Involves all those who care for the patient providing information and insight into different areas of the patient’s progress.
153
What is Erythema ab igne and onychogryphosis?
Erythema ab igne: change in skin due to chronic thermal injury - may be an indication that the patient is particularly poor or cold.
Onychogryphosis: overgrowth of toe nails which can affect mobility.
154
What is fraility?
When a patient is already close to the line between independence and dependence, and an event occurs, it may mean that they lose a bit of function.
As these events/incidents happen (fall, heart attack, pneumonia, bereavement), recovery takes a long time and the patient doesn’t reach the same level of independence that they once had, meaning that they are closer to the line, more at risk of dependence and vulnerability.
155
What are the Department of Health Guidelines on lower-risk limits?
To keep your risk of alcohol-related harm low, the NHS recommends:
not regularly drinking more than 14 units of alcohol a week
if you drink as much as 14 units a week, it's best to spread this evenly over three or more days
if you're trying to reduce the amount of alcohol you drink, it's a good idea to have several alcohol-free days each week
156
What is substance misuse?
Recurrent substance use resulting in a failure to fulfill major role obligations such as work, school or home life.
Recurrent substance misuse in situations in which it is physically hazardous, e.g. Driving or operating machinery.
Continued substance misuse despite persistent or recurrent social or interpersonal problems caused by its effects, e.g. Friction with family members.
157
How to screen alcohol-misuse disorders?
Screening with evidence based clinical tools e.g.:
| Alcohol Use Disorders Identification Test (AUDIT) which uses questions to gather a score.
158
How to calculate the units of alcohol?
% (ABV) x Volume (ml) = Units)
| /1000
159
What are the options of extended brief interventions
Behavioural change – based on CBT
Motivational – Enhancement Therapy.
Motivational Interviewing (talking therapy)
Structured 20 – 30min sessions with a follow up.
Can be delivered by GP or by specialist service EG NHS specialist provider or third sector e.g. Turning Point
160
Who is alcohol-misuse disorder brief intervention for?
AUDIT 0-7 Lower risk - positive reinforcement
AUDIT 8-15 Increasing risk - Brief intervention Level 1
AUDIT 16-19 Higher risk - Brief intervention Level 2
AUDIT 20-40 Possible dependence Further Assessment
161
What is the Severity of Dependence questionnaire (SADQ)?
```
A measure of the severity of dependence.
20 questions about:
physical withdrawal symptoms
affective withdrawal symptoms
relief drinking
frequency of alcohol consumption
speed of onset of withdrawal symptoms.
```
162
What do the scores from a SADQ mean?
A score of 31 or higher indicates "severe alcohol dependence".
A score of 16 -30 indicates "moderate dependence"
A score of below 16 usually indicates only a mild physical dependency.
A chlordiazepoxide detoxification regime is usually indicated for someone who scores 16 or over.
163
What is dependence?
A state in which an organism functions normally only in the presence of a drug.
Manifested as a physical disturbance when the drug is withdrawn.
164
What is tolerance?
A state in which an organism no longer responds to a drug.
| A higher dose is required to achieve the same effect.
165
What are the possible treatments for patients who are dependent on alcohol?
Community based assisted withdrawal (clinical risk permitting).
In – patient based assisted withdrawal.
Treatment with benzodiazepines
Preferred choice chlordiazepoxide (relatively long t1/2).
166
What dosage of chlordiazepoxide should be used in alcohol dependence?
Insomnia associated with anxiety disorders: 10 – 30mg at bedtime.
Muscle spasm: 10 – 30mg daily in divided doses.
Symptomatic relief of alcohol withdrawal in adults: 25 – 100mg repeated if necessary in 2 – 4 hrs.
167
What are the therapeutic indications of chlordiazepoxide?
Symptomatic relief of anxiety
Muscle spasm (varied aetiology)
Symptomatic relief of acute alcohol withdrawal.
Not recommended for long term use (4 weeks max including 2 week tapering off period).
168
What is the pathophysiology of alcohol dependency?
Alcohol = depressant
Effects resemble those of general anaesthetics
Inhibits presynaptic Ca2+ entry and transmitter release.
Potentiates GABA mediated inhibition.
Not fully understood but research indicates presynaptic Ca2+ (ionized calcium) channels may increase (Tolerance).
169
What are the effects of chronic alcohol use on the CNS?
Number of calcium channels multiply
Chloride ion flow is reduced
Electrical impulse in nerve increases
Excitability of nerve enhanced
170
How does Chlordiazepoxide work?
Precise sites & mechanism of actions not known, however it is proposed that:
Chlordiazepoxide acts by enhancing the actions of a natural brain chemical, GABA (gamma-aminobutyric acid).
171
What are the Pharmacokinetic properties of Chlordiazepoxide?
Well absorbed at small intestine
Absorption is age related and can be delayed in the elderly
Half life 6 – 30 hrs.
Highly protein bound
Extensively metabolised by the liver.
Active metabolites inc:
desmethyl-chlordiazepoxide
Crosses BBB – needs to get into the CNS
Particularly active in CNS ‘grey matter’ (high blood flow)
Excreted in the urine mainly in the form of it’s metabolites.
Excreted as conjugates (glucuronide or sulphate).
172
What are the contraindications of Chlordiazepoxide?
```
Hypersensitivity to benzodiazepines
Severe pulmonary insufficiency
Phobic & obsessional states
Chronic psychosis
Severe hepatic insufficiency (may precipitate encephalopathy)
Pregnancy
Myasthenia gravis
May precipitate suicidal tendencies if used as a stand alone treatment for anxiety and depression
```
173
Is there a risk of dependency on Chlordiazepoxide?
Short term use = low chance of dependence
Risk of physical & psychological dependence increases with increased dose, particularly over long periods of time.
Risk of dependence also increased in patients with alcohol dependency (monitor).
174
What are the withdrawal effects of Chlordiazepoxide?
```
Can occur when treatment stops abruptly (if physically dependent).
Headache
Muscular pain
Anxiety
Hallucinations
Epileptic seizures
```
175
What are the drug interactions of Chlordiazepoxide?
Alcohol: Enhanced sedative effect.
Centrally acting drugs. Antipsychotics, analgesics & sedative anti- histamines. Enhanced central depressive effects.
Anti – epileptic drugs. Side effects & toxicity more evident when used concurrently.
Compounds affecting hepatic enzymes (cytochrome P450). Reduced clearance rate of the benzodiazapine e.g. Disulfiram.
176
What are the side-effects of Chlordiazepoxide and how can they be managed?
Drowsiness - don't drive or operate machinery
Ataxia - discuss with keyworker, dose may need to be reduced
Aggression/disinhibition - discuss with keyworker, dose may need to be reduced
Headache - mild painkiller
Amnesia - discuss with keyworker
Respiratory depression - stop taking, see a doctor
Impaired liver function - stop taking, see a doctor
177
What do liver function tests tell you?
Elevated ALT & AST levels indicate a degree of inflamation.
Present in Hepatocytes & leak out when these cells are damaged.
ALT more specific to liver as AST is present elsewhere.
Alkaline phosphatase (ALP)/GGT
178
When would you give Lorazepam for alcohol dependence?
For people with hepatic impairment
Much easier to metabolise than chlordiazepoxide
But half life is not as good
179
What is Wernicke’s encephalopathy?
Caused by deficiency of Thiamine
Common in severely dependent drinkers
Poor diet
Poor intake of vitamins
Poor gastro – intestinal absorption (Gastritis)
High demand as metabolism of alcohol depends on Thiamine as a co – enzyme.
Treatment by Pabrinex and ongoing with VitB/Thiamine
180
How to prevent relapse in patients who are alcohol dependent with Acamprosate?
Acamprosate (Campral) 333mg tablets
Mechanism of action not fully understood, but believed to act on the neural pathways (VOCC)(compromised by alcohol use (GABA/NMDA).
Safe, no interaction with alcohol, Diazepam, SSRI
10% of patients experience gastrointestinal symptoms
More effective when offered as a combined therapy with talking therapy
181
How to prevent relapse in patients who are alcohol dependent with Disulfiram?
```
Disulfiram (Antabuse) 200mg tablets.
Disrupts the oxidative metabolism of alcohol.
Alcohol
Acetaldehyde
Acetic acid
Results in a build up of acetaldehyde.
```
182
What are the side effects of Disulfiram?
```
Acetaldehyde levels are 5 – 10 times higher.
Symptoms = hangover x 10 x 20hrs
Flushing of the skin
Tachycardia
SOB
Nausea
Vomiting
```
183
How to prevent relapse in patients who are alcohol dependent with Nalmefine?
```
Nalmefine (Selnicro)
An opioid receptor antagonist
Modifies activity at receptor sites linked to reward mechanisms (Dopamine).
Effects of alcohol are still present.
Reduced feeling of reward/pleasure.
Can be taken PRN (as required)
```
184
What is sexual and reproductive health?
Complete physical, mental and social well-being and not merely the absence of disease, dysfunction or infirmity, in all matters related to the reproductive system and to its functions and processes.
Responsible, sastifying and safe sex life
Capacity to reproduce and the freedom to decide when and how often
185
What are the current government priorities for sexual and reproductive health?
Fall in unwanted pregnancies
More HIV testing in high-risk groups
Access to free condoms and knowledge of STIs
Protecting children from sexual abuse and exploitation
Eradicate prejudice based on sexual orientation
Build confidence in ability to say No
Build knowledge and resilience in young people
Improve service access
186
What are the characteristics of STIs?
Caused by more than 30 different bacteria, viruses and parasites
Spread predominantly through sexual contact (including vaginally, anal and oral)
Majority are asymptomatic
Some increase the risk of HIV
Consequences include infertility, mother-to-baby transmission and chronic diseases
Drug resistance
187
What are the consequences of maternal morbidity and mortality?
99% of maternal deaths occur in developing countries
Causes: post-partnum bleeding, unsafe abortion, hypertension, obstructed labour, post-partum infection.
Long-term morbidities and disabilities
188
What is female genital mutilation?
Sometimes referred to as female circumcision
Procedures that intentionally alter or cause injury to the female genital organs for non-medical reasons.
Practice is illegal in the UK.
189
Why is FGM done?
Cultural, religious and social reasons
Often considered a necessary part of raising a girl properly, to prepare her for adulthood and marriage.
Belief to benefit the girl and reduce libido and discourage sex before marriage.
Prevalent in Africa, Middle East and Asia.
Prevalent in areas of the UK with first-generation asylum seekers.
190
What are the long-term effects of FGM?
Cysts and formation of scar tissue
Complications of pregnancy and newborn deaths
Pain during sex and lack of pleasurable sensation
Psychological damage - low libido, depression and anxiety, flashbacks during pregnancy and childbirth
Need for corrective surgery to lower vagina for sexual intercourse and childbirth
191
What is the narrow approach to address SRH?
Narrow approach - providing information, distributing condoms. Often fails to address embedded obstacles.
192
What is the combined approach to address SRH?
Combined approach - a range of coordinated actions tailored to the local setting and HIV epidemic characteristics.
Behavioural interventions - sex education, counselling, stigman and discrimination reduction
Biomedical interventions - needle exchange programmes, voluntary male circumcision
Structural interventions - decriminalisation of sex work, homosexuality, micro-finance schemes
193
What is primary prevention of HIV?
Primary prevention of HIV/AIDS focuses on:
Protecting uninfected persons from acquiring HIV
Education and outreach programmes to encourage the adoption of abstinence or protective measures such as condom use
194
What are the challenges in SRH?
Deep seated hierarchies and inequalities
Religious and moral understandings - religious leaders, teachers, healthcare providers, public opinion
Stigma, discrimination, confidentialy concerns, compounded by legal issues
Wide-range of disjointed providers
Data gaps
195
What's the problem with BMI?
BMI does not measure adiposity, visceral body fat
| But we continue to rely on it in clinical practice
196
How has obesity increased in the UK?
UK – rates of obesity have more than doubled in 25 years
Waist circumference shows same trend.
Significant shift in proportion of those obese or morbidly obese.
Increase in overweight and obesity seen in almost all age groups (inc. pre-school & primary school children).
197
What's the link between obesity, overweight & mortality?
Relative to normal weight, both obesity (all grades) and grades 2 and 3 obesity were associated with significantly higher all-cause mortality. Grade 1 obesity overall was not associated with higher mortality, and overweight was associated with significantly lower all-cause mortality.
198
How is exercise a a mediator of relationship between obesity/overweight and mortality?
1) regular PA activity attenuates many of the health risks associated with overweight or obesity;
2) active obese individuals actually have lower morbidity and mortality than normal weight individuals who are sedentary;
3) inactivity and low cardio-respiratory fitness are as important as overweight and obesity as mortality predictors.
199
What's the link between obesity and socio-economic status?
Clear association between SES and obesity (for both men & women).
Health consciousness, time available for healthy food preparation, and demands of work whilst caring for family – were reported as barriers to healthy eating by w/c women.
W/c families spend least amount of time preparing food, most likely to rely on pre-packaged meals, more likely to have to juggle a volume of competing demands.
200
What's the link between lack of physical activity and socio-economic status?
Education, household income & local area deprivation are all independently & strongly associated with inactivity, controlling for availability of physical recreation facilities, weather & geography.
More financially costly forms of physical activity are associated with larger socioeconomic position differences - financial and cultural barriers need to be overcome.
201
Why wasn't obesity a problem 20 years ago?
Smaller portion sizes, children walked to school, had more ‘play’ time and less teaching, cost-conscious purchasing habits, less car dominated, less consumerist, less unequal
202
What are the causes of the obesity epidemic?
‘Americanization’ of diet & society;
Increasing dominance of car culture; less walking to school / work
Numerous technical advances marginalizing daily activity;
More commuting / longer distances / hieghtened fear of crime;
Longer working hours;
Over-consumption of food;
Greater availability of energy dense food;
More, cleverer advertising of food /
More food ‘on the move’;
‘Grazing’ replacing meal times;
Replacement of water by sugary drinks; promotion of sugary drinks
Dominance of companies framing what we should buy, what sells;
Rise of a culture of consumption / food ‘prized’ as cultural capital;
Greater income inequality & social inequality…
203
How have food choices changed? How does that affect obesity?
Demographic distribution of obesity is likely to be influenced by food cost.
Cheapest way to ‘buy’ 100 calories of food is via fats, processed starches & sugars.
204
What are the diseases of high-income countries?
Cardiovascular diseases
Malignant neoplasms
Respiratory disorders
205
What are the major risk factors of high-income countries?
High blood pressure
Smoking
High cholesterol
Obesity
206
What are the diseases of high-income countries?
Lower respiratory infections
HIV/AIDS
Diarrhoeal diseases
207
What are the major causes of child mortality?
```
Diarrhoeal disease
Acute Respiratory Infections
Malnutrition
Vaccine Preventable Diseases: Measles
Neonatal causes
```
208
What are the major causes of maternal mortality?
```
Medical causes:
Haemorrhage
Obstructed labour
Puerperal sepsis
Eclampsia
```
```
Other factors:
Too young
Too soon … after the last child
Too late … to access healthcare
Too many
```
209
Why are infectious diseases so prevalent in deveoping countries?
```
Close contact
Overcrowding
Smoking
Indoor air pollution
Delayed health seeking
No access to care
```
210
What determines patients' care outcome?
```
Ease of access to care
Affordability of care
Reliability of care
Stigma/taboo
Lack awareness & understanding
Mental wellbeing
Gender
Socio-economic deprivation
Migrant status
```
211
What is global health?
Health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions.
212
Why is Global Health important?
Massive disease burden in the world‘s poorest nations poses a huge threat to global wealth and security.
Millions around the world die of preventable and treatable infectious diseases because they lack access to basic medical care and sanitation.
Potential to save millions of lives each year, but only if wealthy nations provide the poorer ones with the requisite services and support.
213
What is the brain drain?
The emigration of highly trained or qualified people from a particular country.
214
What is an 'error'?
An ‘error’ is any preventable event that may cause or lead to patient harm (‘failure’).
Prevalence - data consistently show that medical errors and health-care related adverse events occur in 8% to 12% of hospitalizations
215
What is an adverse event?
Adverse event - incident resulting in harm to a patient, which is not a direct result of their illness or other chance event
Human error contributes to many adverse events. But not all adverse events result from human error
216
What is a near miss?
Near miss - ‘an event which arises during care and has the potential to cause harm but fails to develop further thereby avoiding harm’
217
What are the two types of error?
Errors of omission (e.g. when required action is delayed or not taken)
Errors of commission (where wrong action is taken)
218
How can you classify errors?
SKILL BASED
When performing a routine task that is well learnt. You give little attention and often perform it together with other tasks. But, if distracted or interrupted it is possible that you will miss a step. Skill-based errors can be slips of action or memory lapses.
RULE/KNOWLEDGE BASED
An incorrect plan or course of action [protocols & guidelines] e.g. novel situation, a number of options, an emergency, or situation that occurs frequently but the individual is inexperienced
Mistakes more likely when tasks are complex (e.g. diagnosis), people are inexperienced, insufficient information or communication of information is poor, and little support/advice from colleagues.
219
What are some of our information-processing limitations?
Automaticity: necessary for skills, makes us prone to actions-not-as-planned (slips)
Cognitive Interference: More complex task make greater processing demands
Selective attention: Limited attentional resources, necessary for coherent action, leave us prey to inattention and information overload
Cognitive biases: A long-term memory containing ‘mini-theories’ (heuristics) rather than facts leaves us liable to confirmation bias
220
Why might expectations contribute to human error?
Expectations - Tendency to see what you expect to see
Identified as a cause of checking errors even where there are several independent checking processes in place.
People transfer their expectations from familiar objects/situations to similar new ones
- Positive transfer: previous experience applies to new situation
- Negative transfer: previous experience conflicts with new situation
221
What effects our performance?
```
Fatigue/Lack of Sleep
Illness
Drugs or alcohol
Boredom/Frustration
Stress
Reliance on memory
Reliance on vigilance
Distractions
Noise
Clutter
Too many handovers
Complexity
Poor procedures
Poor device design
```
222
How to mentally prepare for human error?
Accept that errors can and will occur.
Assess the local “bad stuff” before embarking upon a task.
Have contingencies ready to deal with anticipated problems.
Be prepared to seek more qualified assistance.
Do not let professional courtesy get in the way of checking your colleagues’ knowledge and experience, particularly when they are strangers.
Appreciate that the path to adverse incidents is paved with false assumptions.
223
Why are neurological disorders unique in their presentation?
Early diagnosis may be difficult, patients presents with non-specific symptoms
Many neurological conditions progressive
May be absence of effective regeneration after damage or injury
Lack of curative treatment means priorities include
1) prevention
2) rehabilitation
224
What is epidemiology?
The study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to control of health problems
225
What is Clinical epidemiology?
Clinical epidemiology uses information about distribution and determinants in a clinical setting, especially in diagnosis
226
What are the aspects of epidemiology in neurology?
Case definition and case ascertainment
Incidence, prevalence, trends
Risk factors
Scope for earlier diagnosis & prevention
227
What are the common neurological disorders of public health importance?
```
Migraine headache
Stroke
Dementia
Epilepsy
Parkinson’s disease
Multiple Sclerosis
Cerebral palsy
```
228
What is the triad of migraine symptoms?
Unilateral pain distribution
Premonitory visual disturbance
Presence of nausea or vomiting
229
What are the risk factors for migraines?
Age and sex (more common in women, and middle age)
Sex hormones (oral contraceptive)
Family history
Education, income and socio-economic status
230
What is the definition of a stroke?
'Rapidly developing clinical signs of focal (at times global) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than vascular origin.’
231
How to classify the aetiology of a stroke?
Thombotic
Embolic
Haemorrhagic
232
What are the risk factors for a stroke?
```
Age
Sex - male
Hypertension
Smoking
Alcohol consumption
Cardiac disease
Diabetes mellitus and lipids
```
233
Why is screening for dementia controversial?
Screening controversial due to lack of evidence that benefits outweigh harms.
Current policy includes awareness raising and opportunistic screening for memory loss (eg as part of NHS Health Checks).
234
What is epilepsy?
A condition characterised by recurrent epileptic seizures unprovoked by any immediate identified cause.
235
What is the aetiology of epilepsy?
```
Genetic factors
Febrile seizures
Head injuries
Bacterial/parasitic infections
Viral meningo-encephalitides
Toxic agents
```
236
What is the epidemiology of Parkinson's disease?
Incidence: increases with age
Prevalence: 1 in 200 over 70 years
Variable progression, mean survival 10 to 15 years
risk factors: notably less common in smokers
237
What is Parkinsonism?
Any condition that causes a combination of the movement abnormalities seen in Parkinson's disease — such as tremor, slow movement, impaired speech or muscle stiffness.
Parkinsonism - drug induced movement
disorder
- non-progressive
Post-encephalitic parkinsonism
- rare, seen in epidemics
238
What is the epidemiology of MS?
Onset commonest 20 to 35 years (earlier diagnosis in countries where MRI scanning is available)
Prevalence directly proportional to distance from the equator (link to Vit D)
Uncommon in fishing communities (something in the diet that is protective?)
Positive association with some HLA antigens
239
What are the characteristics of cerebral palsy?
Definition: based on time of onset
Apparent at birth or in childhood
Non-progressive brain damage before or during neo-natal period
Wide spectrum of physical and/or mental impairment
Risk factors
- anoxia
- low birth-weight
240
What is Creutzfeldt-Jakob Disease (CJD)?
Neuro-degenerative disease (dementia)
Average age of onset 55 to 75 years
Rapidly progressive dementia, abnormal EEG, cerebellar signs, myoclonus
0.5 -1 case per million per year world wide
85% of cases no identifiable cause
14% of cases associated with gene mutation
<1% iatrogenic (via tissue or instruments)
241
What is variant Creutzfeldt-Jakob Disease (CJD)?
Neuro-degenerative disease similar to CJD
Peak incidence at 27 years (much younger than CJD), genetic susceptibility
Different brain appearance at post-mortem
242
What are the factors that contribute to overweight/obesity?
General overeating
Poor diet - high fats, salts
Sedentary lifestyle
Deprivation
243
Why is overweight/obesity an issue?
Widespread - across the board in children and adults
Prevalence in rising
Consequences are costly (socioeconomic impacts)
244
What health problems are associated with obesity?
```
Coronary artery disease
Reproductive function
Respiratory diseases
Gout, gallstones and cholecystitis
Cancer
Diabetes
Osteoarthritis
Psychological disorders
```
245
How do we define obesity?
Abnormal or excessive fat accumulation resulting from chronic imbalance between energy intake and energy expenditure that presents a risk to health.
246
How do we measure obesity?
```
BMI, waist circumference, waist to hip ratio.
Dual-energy X-ray absorptiometry
MRI
Bodpod
Can be mapped to their risk
```
247
What is the energy equation?
Energy in - carbohydrate, protein, fat, alcohol
| Energy out - basic metabolic rate, dietary induced thermogenesis, physical activity
248
What determines your appetite?
Peripheral signals that head to the hypothalamus to determine appetite
Tonic - long term signals determined by body composition which is determined by fat-free mass (resting metabolic rate) and fat mass (levels of leptin)
Episodic - arise from the gut, determined by appetite-stimulating hormones (Ghelin) and appetite-inhibiting hormones (CKK, PYY, GLP-1)
249
What is Prader Willi syndrome?
PWS caused by deletion of a critical portion of one of the paternal chromosomes (15) or the whole chromosome is missing and two maternal chromosomes are present.
Characterised by short stature, almond shaped eyes, mis-shaped hands and feet, intellectual impairment, reduced life span, hyperphagia, and obesity.
250
What is propriomelanocortin deficiency?
POMC deficiency results in hyperphagia and early-onset obesity due to loss of melanocortin signalling at the melanocortin 4 receptor (MC4R).
251
What is congenital leptin deficiency?
Children with a congenital leptin deficiency show extreme adiposity and excessive/uncontrollable appetite.
Restoration of normal body weight in these children requires recombinant leptin administration.
252
What is Polygenic ‘common’ obesity?
GWAS have identified common genetic variants robustly associated with anthropometric indicators of adiposity.
FTO (Fat mass and obesity-associated) is the most relevant polygenic identified to date.
253
What is the obesogenic environment?
The sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations.
254
What are the increased risks of shift-working?
```
Fair/poor health
Limiting long-standing illness
More than one long-standing illness
Obesity
Diabetes
Poor diet
```
255
Why is there an increased risk of obesity in people who are shift-working?
Lack of sleep
Food preferences, temporal element of food consumption
Reduced physical activity
Lower leptin and increased ghrelin levels
256
What are the developmental factors associated with obesity?
Birth weight and early infancy
Rapid infant weight gain
Breastfeeding - protective of childhood obesity?
Early introduction to solid foods (before 6 months)
257
Why is the aetiology of obesity complex?
The influences of these factors are likely to vary between populations, groups (ethnic groups or neighbourhoods/communities) within a population and even individuals within that group.
An interaction between biology, behaviour, culture and the environment.
258
Why do people start smoking?
Experimenting with smoking usually occurs in teenage years driven by psychosocial motives.
Influence of background (parents, siblings, peers, deprived neighbourhoods).
259
What encourages the sustained habit of smoking?
Social, economic, personal and political influences.
Behaviour and habit e.g. familiar cues
People's sense of identity
260
What are the psychological effects of smoking?
Nicotine crosses the BBB within 10 seconds.
Activated nictotinic acetylcholine receptors in the brain and causes dopamine release.
Stimulates CNS and increases HR.
261
Who typically smokes?
```
20% of adults
Slightly more men
Married people less likely to smoke
Those in poverty
Those who are unemployed
```
262
What are the impacts of smoking?
Greatest single cause of illness and premature death
Economic burden to the NHS
Cleaning cigarette butts
House fires
Unable to work because of smoking-related illness
Reduced life expectancy
263
What are some of the major health problems caused by smoking?
```
Lung cancer
Cardiovascular problems
Other cancers
Stomach ulcers
Impotence
Diabetes
Oral health e.g. gum disease
Cataracts
```
264
What services are available for smoking cessation?
Uses a combination of support, advice, cognitive and behavioural strategies and pharmacological aids (NRT, bupropion, varenicline).
One-to-one or group, online and telephone support.
Priniciple: Only possible to help people to quit who want to quit
(linked to the stages of change theory)
265
What are the pharamcological interventions for smoking cessation?
NRT: patches, gum, nasal spray, microtabs, lozenge, inhalator. Available to buy or on prescription.
Non-nicotine pharmacology: bupropion and varenicline
