Public Health Flashcards
What is epigenetics?
Expression of a gene depends on the environment
What is allostasis?
Stability through change
Physiology adapts rapidly to environmental stress
What is allostatic load?
long term overtaxing of physiology leads to impaired health
What is salutogenesis?
favourable physiological changes secondary to experiences promoting healing and health
What is primary care for?
Managing illness Finding clinical solutions Prevent illness Promote health Manage clinical uncertainty Best outcomes with available resources Working in health care team Shared decision making with pt
Dangers of overprescribing abx?
Side effects
Medicalise self-limiting conditions
Antibiotic resistance
When to definitely prescribe abx?
B/l otitis media <2yo Acute otitis media + otorrhoea Acute sore throat + >2 centor criteria High risk (co-morbs, immunosuppressed) Complications
Abx in otitis media?
amoxicillin 500mg TDS 5d
Abx in sinusitis?
amoxicillin 500mg TDS 5d
Abx in tonsilitis?
Penicillin V 10d
Abx in LRTI?
Amoxicillin 5d
Abx in UTI?
Trimethoprim 200mg BD 3d
OR
Nitrofurantoin 50mg QDS 3d
Define public health?
The science and art of preventing disease, prolonging life and promoting health through organised efforts of society
3 domains of public health?
Health improvement
Health protection
Improving services
Define health improvement?
Concerned with SOCIETAL interventions aimed at preventing disease, promoting health and reducing inequalities
Define health protection?
Concerned with measures to control infectious disease risks and environmental hazards
Egs of health improvement
education housing employment family surveillance of diseases + RFs
Egs of health protection
Infectious diseases
chemicals
radiation
emergency response
Define improving services?
Concerned with the ORGANISATION and delivery of safe, high quality services for prevention, treatment and care
Egs of improving services?
Clinical effectiveness Efficiency Service planning Audit + evaluation Equity
Key concerns in public health? (3)
Inequalities
Wider determinants of health
Prevention
What is a health needs assessment?
Systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities
Define ‘need’
Ability to benefit from an intervention
Define ‘demand’
what people ask for
Define ‘supply’
what is provided
How is ‘health need’ measured?
need for health eg measured using mortality, morbidity, socio-demographic measures
How is ‘health care need’ measured
the ability to benefit from health care
Depends on potential of prevention, treatment and care services to remedy health problems
Define ‘felt need’
Individual perceptions of variation from normal health
Define ‘expressed need’
individual seeks help to overcome variation in normal health
Define ‘normative need’
professional defines intervention appropriate for the expressed need
Define ‘comparative need’
Comparison between severity - range of interventions and cost
Advantages of epidemiological approach to a health needs assessment?
Uses existing data
Provides data on disease incidence/mortality/morbidity etc
Can evaluate services by trends over time
Disadvantages of epidemiological approach to a health needs assessment?
Relies on quality of data available
Data collected may not be the data required
Does not consider the felt needs/opinions of population
How to do epidemiological approach to health needs assessment?
Define problem Size of problem See what services are available Evidence base for intervention (effective?cost-effective?) Models of care Existing services Recommendations
How to do comparative health needs assessment?
Compares services in one population with others (can be spatial, or social)
Advantages of a comparative health needs assessment?
Quick and cheap if data is available
Relative performance indicator
Disadvantages of a comparative health needs assessment?
May be hard to find a comparable population
Data may not be available/good quality
May not yield what the best intervention should be
Types of health needs assessment?
epidemiological
comparative
corporate
How to do corporate health needs assessment
Ask local population what their health needs are
Use focus groups/interviews/meeting
Wide variety of stakeholders..
Advantages of a corporate health needs assessment?
Based on felt and expressed need of the population
Recognises the experience of those individuals
Takes into account a wide range of views
Disadvantages of a corporate health needs assessment?
Difficult to distinguish need from demand
Groups may have vested interests
May be influenced by agenda
Primary prevention?
preventing disease before it occurs
Secondary prevention?
Catching disease in early phase
Tertiary prevention?
preventing sequelae of disease
Approaches to prevention?
Population
High-risk
Population approach?
Eg?
preventative measures eg dietary salt reduction through legislation to reduce BP of a population
High risk approach?
Eg?
identify individuals above a chosen cut off and treat
eg screening for high BP
Prevention paradox?
A preventive measure which brings much benefit to the population offers little to each participating individual
Screening?
Process which sorts apparently well people who probably have a disease from those who probably do not.
NOT DIAGNOSTIC
Types of screening?
Population based programmes Opportunistic screening Screening for communicable diseases Occupational medicals Commercial
Disadvantages of screening?
Exposes well individuals to harmful diagnostic tests
Detection and treatment of sub-clinical disease that would never have cause harm
Interventions may cause harm
Wilson+Junger criteria for screening?
The condition [Important health problem, Latent / preclinical phase, Natural history known]
The screening test [Suitable (sensitive, specific, inexpensive), Acceptable]
The treatment [Effective, Agreed policy on whom to treat]
The organisation and costs [Facilities, Costs of screening should be economically balanced in relation to healthcare spending as a whole, Should be an ongoing process]
Sensitivity of a screening test?
The proportion of people with the disease correctly identified by the screening test
Specificity of a screening test?
The proportion of people without the disease who are correctly excluded by the screening test
PPV?
Proportion of people with a positive test result who actually have the disease
NPV?
Proportion of people with a negative test who do not have the disease
Define ‘lead time bias’
Screening identifies an outcome earlier that it would otherwise have been identified resulting in an apparent increase in survival time, even if screening has no effect on outcome
Define ‘length time bias’
Difference in lengths of time taken for a condition to progress to severe effects may affect the apparent efficacy of a screening method
Eg less severe diseases is more likely to be found by screening
Egs of observational studies?
Descriptive [case reports, ecological studies]
Analytical [cross sectional]
Advantages of observational studies?
quick and cheap
provide prevalence data
large sample size
good for surveillance
Disadvantages of observational studies?
Risk of reverse causality
Cannot measure incidence
Risk recall bias/non-response
Egs of analytical studies?
how do they work?
Case control studies (RETROSPECTIVE - people with disease + a matched control without)
Cohort studies (study a population without disease over time)
Advantages of analytical studies?
Good for rare outcomes
Quicker than cohort/intervention
Investigate multiple exposures
Disadvantages of analytical studies?
Difficulty finding control to match with case
Prone to selection and information bias
Egs of experimental/intervention studies?
RCT
Advantages of experimental study
Can follow up a group with rare exposures
Can follow multiple outcomes
Low risk of bias and confounding
Can infer causality
Disadvantages of experimental study
Takes a long time
Lose people to follow up
Needs large sample
Independent variable?
Variable that is altered in a study
Dependent variable?
Depends on the independent variable
Odds?
Ratio of probability of an occurrence compared to the probability of a non-occurrence
Odds= Probability / (1-probability)
Odds ratio?
Ratio of odds for exposed group to the odds for non-exposed group
OR = {Pexposed/(1-Pexposed)} / {Punexposed/(1-Punexposed)}
When to use OR?
OR can be interpreted as RR when an event is rare
Case control studies -> cannot calculate relative risk so OR is used
Cohort studies/cross-sectional studies when it is unclear which variable is IV / DV
Define ‘epidemiology’
The study of the frequency, distribution and determinants of diseases and health related states in populations in order to prevent and control disease
Incidence?
New cases over a period of time
Prevalence?
Existing cases at a point in time
Person time?
Measure of time at risk
i.e. time from entry to a study to outcome (disease onset; loss to follow up; or end of study)
Incidence rate?
incidence / total person-time during the period
Absolute risk?
Has a denominator!
Gives feel for actual numbers i.e. 50 deaths / 1000 population
Attributable risk?
The rate of disease in the exposed that may be attributed to the exposure
i.e. incidence in exposed minus the incidence in unexposed
Relative risk?
Ratio of risk in disease in the exposed to the risk in the unexposed
Tells us about strength of assosciation
EER/CER
How to describe epidemiology of a disease?
TIme
Place
Person [age, gender, class, ethnicity]
Relative Risk Reduction?
RRR=(CER-EER)/CER
Absolute risk reduction?
ARR = CER-EER
Number needed to treat?
NNT = 1 / ARR
What can association between exposure and outcome be due to?
Bias Chance Confounding Reverse Causiality True causal assos
Bias?
Systematic deviation from the true estimation of association between exposure and outcome
Types of bias?
Selection
Information (measurement)
Publication
Selection bias?
Systematic error in: selection of study participants / allocation of participants to study groups
Information bias?
Systematic error in measurement
Sources of info bias?
Observer
Participant (recall / reporting)
Instrument (badly calibrated)
Publication bias?
More likely to publish positive studies
Confounding?
A situation when estimate between exposure and outcome is distorted because the association of exposure with another CONFOUNDING factor that is independently associated with the outcome
Reverse causality?
Outcome causes exposure not the other way round
Bradford-Hill criteria for causality
Strength of assos Dose-response Consistency Temporality Reversibility Biological plausibility Coherence Analogy Specificity
Features of drug-addiction
Craving
Tolerance
Compulsive drug-seeking behaviour
Physiological withdrawal
Effects of dependent drug use?
Physical - injection complications, OD, SEs, BBVs, poverty
Social - criminality, imprisonment, exclusion
Psychological - fear of withdrawal, craving, guilt
Principles of treating drug-addiction?
Harm reduction
Detoxification
Maintenance
Detoxification of heroin?
Buprenorphine
Maintenance of heroin abstinence?
Methadone
Buprenorphine
What to offer newly presenting drug user?
Health check Screening for BBVs Contraception Sexual health advice Immunisations Signposting Local drug services info
Health behaviour?
Behaviour to prevent disease
Illness behaviour?
Behaviour to seek remedy
Sick role behaviour?
Aimed at getting well
Theory of planned behaviour?
Best predictor of behaviour is ‘INTENTION’
What is intention determined by? [in TPB]
Attitude
Subjective norms (social pressure)
Perceived control
Criticisms of TPB?
lack of temporal element
lack of direction/causality
5 stage model of health behaviour?
Pre-contemplation Contemplation Preparation Action Maintenance
Motivational interviewing?
Counselling to resolve ambivalence and initiate behaviour change
Nudge theory?
eg?
‘nudge’ the environment to make the best option the easiest
eg opt-out schemes
fruit next to checkout
Factors in health psychology/behaviour change?
Personality traits
Perception of risk
Past behaviours/habit
Social norms
Transition points for behavioural change
leaving school starting work becoming a parent unemployment retirement bereavement
What is NCSCT?
National Centre of Smoking Cessation + Training
social enterprise supporting tobacco control programmes and smoking cessation interventions
Actions of NCSCT?
deliver training and assessment programmes
provides support services
conducts research
Why notify PHE of communicable disease?
So PHE can take urgent control measures
You may be the only one who can tell PHE
Duties in communicable disease control?
Duty to notify suspected disease, infection or contamination in patients and dead people
Duty to notify causative agents found in human samples (orally ASAP; in writing in 7d)
Notifiable diseases
encephalitis meningitis poliomyelitis hepatitis anthrax botulism brucellosis cholera diphtheria enteric fever HUS infectious bloody disarrhoea group A strep Legionnaires' leprosy malaria measles meningococcal septicaemia mumps plague rabies rubella SARS smallpox tetanus TB typhus VHF whooping cough yellow fever
Role of consultant in communicable disease control?
Surveillance
Prevention
Managing outbreaks?
Clarify problem Decide if it is an outbreak (>2 of a communicable disease) Get help! Call outbreak meeting Identify cause Initiate control measures
Modes of transmission?
Foodborne Faecal-oral Resp Physical contact Zoonoses
Maslow’s hierachy of needs
Self-actualisation Esteem Love/belonging Safety Physiological
Causes of homelessness?
RELATIONSHIP BREAKDOWN mental illness DA disputes bereavement 'no family ties'
Health problems for homeless?
Infectious diseases (TB, hepatitis) Feet, teeth Resp Violence Sexual health Mental illness Poor nutrition Substance misuse
Barriers to healthcare for travellers?
Reluctance of GPs Poor reading/writing Communication difficult Too few permanent sites Mistrust of professionals
Barriers to healthcare for homeless?
Access
Lack of integration
Don’t prioritise health
May not know where to find hlep
Asylum seeker?
Person who has made an application for refugee status
Refugee?
A person granted asylum and refugee status
Can stay for 5y then must reapply
Humanitarian protection?
Failed to demonstrate claim for asylum but face serious threat to life if returned
Stay for 3y then must reapply
Rights of asylum seekers?
no choice dispersal vouchers/70% of income support sum NASS support package NHS access Not allowed to work
Health problems of asylum seekers?
Physical - common illness, injuries, no previous screening/vaccines, malnutrition, infestations, communicable disease, chronic/congenital problems
Mental - PTSD, depression, psychosis, DSH
Define error?
an unintended outcome
Why is safety compromised so often in healthcare?
Complex High risk environment Resource intensive Shared responsibility Unknowing risk taking
Common issues in healthcare resulting in error?
Wrong diagnosis -> wrong plan
Medication reconciliation
High conc medication solutions
Error classification based on….?
Intention [skill- ; rule- ; knowledge- based mistakes]
Action [generic, task specific]
Outcome [near miss, death, litigation]
Context [
Perspectives on error?
Person approach -> blame the individual
System approach -> focus on working conditions
Strategies to reduce error
Simplify and standardise clinical processes Checklists - SBAR Information technology Team training Risk management Mechanisms
Never event?
Serious, largely preventable patient safety incidents that should not occur if available preventative measures have been implemented
Egs of never event?
Surgery - wrong site, retained item
Medication - wrong preparation/route
Mental health - suicide
Leadership styles?
Inspirational
Transactional
Laissez-faire
Transformational
Why do things go wrong in health care?
System failure Human factors Judgement failure Neglect Poor performance Misconduct
Qs to ask when possible negligence?
- Is there a duty of care?
- Was there a breach in that duty?
- Did patient come to harm?
- Did the breach cause the harm?
Bolam test
Would a group of reasonable doctors do the same
Bolitho test
Would it be reasonable for them to do so?
them being the group of reasonable doctors in the Bolam test
Approaches to learning?
Tripartite model
- Surface (fear of failure)
- Strategic (desire for success)
- Deep approach (intrinsic desire for understanding)
Kolb’s learning cycle
Types of learner
Theorist
Activist
Pragmatist
Reflector
Key responsibilities of small group tutors
Manage the group, activities and learning
How to facilitate learning?
Lead discussions
Open-ended Qs
Guide process
Enable active participation
Why teach diversity?
Better health outcomes for patients
More satisfying doctor-patient encounters
Define ‘culture’
what is it based on?
socially transmitted pattern of shared meanings.
Based on heritage as well as individual circumstances and personal choice.
Define ‘ethnocentrism’
the tendency to evaluate other groups according to the values and standards of one’s own cultural group.
Conviction that one’s own cultural group is superior
Define ‘stereotype’
generalisations about ‘typical’ characteristics of members of a group
Define ‘prejudice’
Attitude towards another person based solely on their membership of a group
Define ‘discrimination’
positive/negative actions towards the objects of prejudice
Why has the need for rationing resources increased?
Shift from acute illness to chronic long term
Normal physiological events medicalised
Increase in choice and cost of drugs
Define ‘rationing’
resource is refused due to lack of affordability
Theories of resource allocation?
Egalitarian - provide all care that is necessary and appropriate to everyone.
Maximising - criteria maximising public utility
Libertarian - each is responsible for their own health
Rights in health care?
Right to life
Right to be free from inhuman and degrading treatment
Right to respect for privacy
Right to marry and found a family
Benefits of social media
Wide and diverse social/professional networks
Engage in debates
Facilitates public access to health information
Improve patient access to services
Risks of social media
Loss of privacy
Confidentiality breach
Online behaviour seen a unprofessional
Risk of being reported
GMC duties of a doctor
Care of patient is 1st concern
Protect + promote health of patients and public
Provide a good standard of practice and care
Treat patients as individuals + respect their dignity
Work in partnership with patients
Be honest, open and act with integrity
3 features of health economic evaluation?
Cost of service(s)
Benefit of service(s)
Comparison of cost and benefit of the service and any alternate service
2 features compromising a QALY?
Number of years
Quality of life - i.e. utility
What system do health economists use to evaluate disability?
DALYS - disability adjusted life years
Define health care economic ‘efficiency’
Getting the maximum cost/health benefit outcomes from a service
What is the term when treatment is given elsewhere and benefit foregone other patients?
Opportunity cost - i.e. money is spent elsewhere because it gives better benefit on another opportunity
