Public Health Flashcards
What is public health?
Science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society.
What are the different means of intervention in the face of a public health problem?
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.
What are the different types of prevention?
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.
How are the social determinants of health related to health inequalities?
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.
What are the 3 different aspects of public health?
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
Is lifestyle a free choice?
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
Why should we be aware of cultural norms?
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.
What factors should we consider when we are asking someone to make a change?
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?
What makes someone a susceptible host to infection?
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
What are some of the major causative microorganisms?
Staph Aureus (MRSA) Closteridim difficile Norovirus HIV Tuberculosis Vancomyocin resistant enterococcus.
Increased number in healthcare settings, can develop antibiotic resistance.
How can microorganisms enter a host?
Repsiratory tract, gastro-intestinal tract, genito-urinary tract, broken skin.
How can microorganisms be transmitted?
Direct contact, indirect contact, vector spread and airborne spread - EXOGENOUS SPREAD
Self-spread - ENDOGENOUS SPREAD
Why do we perform hand decontamination?
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.
What is the biomedical model of health?
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.
What is the social model of health?
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.
What are the different theories of health?
- 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)
What’s the difference between illness and disease?
Illness: the social lived experience of symptoms and suffering
Disease: the technical malfunction or deviation from the norm which is ‘scientifically’ diagnosed
Why are narratives important in patient care?
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.
What is the sick role?
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.
How does the professional relate to the sick role?
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’.
Why isn’t the sick role black and white?
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.
What are some criticisms of the sick role?
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.
What are some benefits of the sick role?
Allows people to receive sympathy, financial allowances, time off work and family responsibilities.
What is medicalisation?
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.
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.
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
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
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.
What is the 90:10 paradox?
Most health activity occurs outside hospitals, but most of our healthcare resources are concentrated inside hospitals.
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.
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
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.
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.
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.
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.
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.
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.
What is evidence-based medicine?
The conscientious, explicit and judicious use of the best evidence in making decisions about the care of individual.
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.
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
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.
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
What are the different types of risk factor?
Modifiable (smoking, diet, exercise)
Non-modifiable (sex, age, genetics)
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.
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.
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
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.
What is the transtheoretical model?
Precontemplation Contremplation Prepartion Action Maintenance
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
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.
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.
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.
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.
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.
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
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
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)
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’
What is an obesogenic environment?
Physical environment - car culture
Economic environment - expensive fruit and veg
Sociocultural environment - family eating patterns
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
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
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
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)
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
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
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.
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
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
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)
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
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
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
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.
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
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
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
What does impairment mean?
Any loss or abnormality of psychological, physiological or anatomical structure or function.
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.
What does handicap mean?
A disadvantage for a given individual that limits or prevents the fulfilment of a role that is normal
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.’
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.
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
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.
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
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
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
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.
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
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
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
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
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
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
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
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.
What is and undocumented migrant?
Foreign born nationals who don’t have the right to remain in the UK
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
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
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
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
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
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
How can poor accommodation affect health?
Respiratory illness Accidental injury Poor mental health Vulnerable household relationships Poor early childhood development
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!
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!
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
