Public Health EV Flashcards
What is the definition of public health?
The science and art of preventing disease, prolonging life and promoting health through organised efforts of society
What are the three domains of PH?
1) Health improvement
2) Health protection
3) Improving services
Define health improvement
Social interventions (not health services) aimed at preventing disease, promoting health and reducing inequalities
Define health protection
Protecting from infectious disease and environment hazards
Define improving services
Organisation and delivery of safe and high quality services (prevention, treatment and care)
Define epigenetics
The phenotype is dependant on the genotype and environment - interaction
Define allostasis
Stability through change
Define allostatic load
Long-term overtaxation of our physiological systems -> impaired health
This is the pathophysiology of stress
e.g. the heart works to maintain physical exertions, but over-use leads to hypertension and MI
Define salutogenesis
Experiences which promote health
Define emotional intelligence
The ability to identify and manage one’s emotions (as well as others)
Define primary prevention and name the two types
PP: Before a disease has occurred - risk reduction!
1) Population approach, e.g. legislation
2) High risk/individual approach, e.g. screening for high risk groups
Define secondary prevention
Catching the disease in its early stage
-> Impact reduction!
Define tertiary prevention
Minimising complications of the disease and long-term management
Define screening
A process which differentiates those who probably do have the a disease (or precursor/susceptibility) from those who probably don’t –> not diagnostic!
Screening criteria?
1) The condition screened for must be IMPORTANT and WELL UNDERSTOOD
2) The screening process should be ACCEPTABLE
3) The diagnostic and treatment facilities should be ACCESSIBLE TO ALL
4) The overall cost should be outweighed by the saving of catching the condition in the early stage
Define sensitivity
The proportion of people WITH the disease who are correctly IDENTIFIED by the screen
Define specificity
The proportion of people WITHOUT the disease who are correctly EXCLUDED by the screen
Define positive predictive value
The proportion of people with a POSTIVE test who DO have the disease
Define negative predictive value
The proportion of people with a NEGATIVE test who DO NOT have the disease
Define lead time bias
When screening identifies an outcome earlier than would have been otherwise and this results in apparently long survival times, which are not true.
Define domestic abuse
Incident of abuse (one off or regular)
Within household, family or partnership
Past or current partners
> 16 years old
Name the different types of domestic abuse
Physical Sexual Psychological Financial Emotional Controlling Coercive Threatening Violent
What are the impacts of domestic abuse on health?
Assault: physical harm, e.g. fracture, miscarriage, bruising
Stress: allostatic load (chronic health problems and medically unexplained symptoms)
Psychological: PTSD, suicide, depression
List the injury red flags (Domestic abuse)
1) Areas that can be hid well (chest, abdo)
2) ‘Unwitnessed’
3) Repeat attendances or delay in seeking help
4) Night/weekend - when abusing partner is not at work
When might you break confidentiality?
If someone is at risk of harm
Alert police if high risk of serious harm or murder
MUST break confidentiality if concerns of child safeguarding
Effects of domestic abuse on children?
Affects physical and psychological wellbeing
Long-term: self-esteem, education, relationships, stress responses
Link between DA and sexual abuses
What support might be offered for domestic abuse?
Counselling
What are the risk levels of domestic abuse?
Standard: Serious harm unlikely or not indicated
Medium: Indicators of risk of serious harm. Potential to happen but not under current circumstances.
High: Indicators of imminent risk of serious harm or murder
What is the doctors role in dealing with domestic abuse?
1) Posters in practice
2) Enquire when suspicious (ensure patient is alone)
3) Focus on safety of children and parents
4) Do not be judgemental
5) Ask direct questions
6) Be clear that DA behaviour is not acceptable and should not be tolerated
7) Give information (Helpline)
8) Escalate to appropriate processes and agencies -> Helpline or DA services or if HIGH risk: MARAC or IDVA
What is MARAC?
Multi-Agency Risk Assessment Conference:
- MDT meeting in all local councils: police, social, IDVA
- .Meet to discuss patients/cases
What is IDVA?
Independent Domestic Violence Advocate:
- Attend MARAC on victims behalf and present all factors which matter to victim and are required
- Focus on housing, legal services, etc.
What is DHR?
Domestic homicide review
- Review all deaths which may be due to domestic violence
- Present points to learn from
List the determinants of health
1) Genetics
2) Environmental: physical, social or economic
3) Lifestyle
4) Access to healthcare
Define equity
What is the difference between horizontal and vertical equity?
Equity:
- Treating individuals fairly based on their DIFFERENT NEEDS and requirement
- Resources should be distributed based on need, not in equal measures
- Fair and just, judgement-based, not measurable
Horizontal: Equal treatment for equal need (pneumonia vs pneumonia)
Vertical: unequal treatment for unequal need (cold vs pneumonia)
Define equality
- Treating each and every individual the same, irrespective of needs and requirements
- Equal shares, measurable
How might we examine health equity?
- Supply, access and utilsation of health care
- Health outcomes
- Resource allocation (health, education, housing)
- Wider determinants of health
Define health psychology
The role of psychological factors which affect cause, progression and consequences of disease
List and describe the five health behaviours
1) Health behaviour - aimed at preventing disease - healthy eating
2) Illness behaviour - seeking remedy - going to the doctor
3) Sick role behaviour - getting well - rest, exercise, taking medication
4) Health impairing/damaging - smoking, risky sexual activities
5) Health promoting - e.g. exercise
What is a risk of burnout in students or doctor?
Depersonalisation –> student or doctor may not see patients as individuals with unique experiences
Define systematic review
Pools conclusions together from many different studies
Define meta-analysis
Pools statistical findings together from many different studies
Define cohort study
Follow a group of people (free from disease at start) over a defined period of time, measuring a defined outcome, e.g. affect of sleep on cardiovascular health over 15 years
- Can be useful for ascertaining whether exposures cause outcomes (e.g. smoking causes lung cancer)
- Non-experimental
Define regression analysis
Enables statistical analysis of multiple contirbuting factors on a single outcome
Give examples of a population-level intervention
5-a-day
Stoptober
Give examples of a local-level intervention
Alcohol cost
Local campaigns
Give examples of an individual-level intervention
Vaccinations
Cervical screening
What is self-serving bias
Justifying engaging in health damaging bejaviours, despite castrating others/patients for doing so
What is unrealistic optimism
An inaccurate perception of risk, e.g. high risk when they believe they are low risk
What affects perceptions of risk?
Perceptions of risk are affected by:
- Lack of personal experience
- Belief that preventable by personal action (“I’ll stop in a years time”)
- Belief that if not happened now, it never will
- Belief that the problem is infrequent
List other reasons for health-damaging behaviour
- Situational reality (feels like a good idea at the time)
- Cultural variability
- Socioeconomic factors
- Stress
- Age
NICE guidance of behaviour change
- Work with patients priorities
- Aim for easy changes over time
- Set and record goals
- Plan explicit coping strategies
- Review progress regularly (this really matters)
- Remember public health impact of lots of you making small differences to individuals `
Why is behavioural change so important?
- Changing behaviour can have the biggest impact on mortality and morbidity
- Simple solution to reducing disease
- Genetic predisposition -> difficult to change
- Socio-economic circumstances -> difficult to change
- Interventions –> expensive
- People’s behaviour (collectively) may be easier to change
Why is a health needs assessment important?
Because, as doctors, we will be in a position to decide what services are provided and implemented, not just treating individuals
Define ‘need’ and the different types
Need = ability to benefit from an intervention
- Anyone can define a need
- FELT need: individual perceptions
- EXPRESSED need: individuals seek help
- NORMATIVE need: professional defines the intervention appropriate for the need
- COMPARATIVE need: comparison between severity, range of interventions and cost
Define demand
What people ask for
Define supply
What is provided
Define health needs assessment (HNA)
A systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities
Who can a HNA be carried out for
- Population (or sub-group)
- A condition
- An intervention
Define the epidemiological approach to HNA
Uses data and evidence available to quantitate the need of a population
Pros of epidemiological approach to HNA
- Uses existing data
- Can evaluate trends over time
Cons of epidemiological approach to HNA
- Data may not be available
- Does not consider the FELT need
Define the comparative approach to HNA
Compares X between sub groups
X could be:
- Health status or outcome
- Service provision or utilisation
Pros of comparative approach to HNA
- Quick and cheap and no need for data
- Gives a measure of relative performance
Cons of comparative approach to HNA
- Difficult to find directly comparable populations
Define the corporate approach to HNA
Opinions of all stakeholders in that populations
Pros of the corporate approach to HNA
- Recognises the detailed and experienced knowledge of those in the population
Cons of the corporate approach to HNA
- Difficult to distinguish need from demand, especially with dominant personalities
- Vested interests and external (political) agendas
What are the three core principles of the NHS
1) Meets the needs of all
2) Free at the point of delivery
3) Based on clinical need, not the ability to care
Definition of health inequalities
Preventable, unfair and unjust differences in health status between individuals/groups/populations
What is the inverse care law?
Julian Tudor Hart 1971
- Availability of good medical/social care tends to vary inversely with the needs of the population served
- Those who access health care the least tend to be those who need it the most
Who are vunerable groups with relation to the inverse care law?
- Homeless
- Travellers
- Refugees/Asylum Seekers
- LGBT
- Ex-prisoners
- Disabilities
- Health problems
- Frail
What is Maslow’s hierachy of need?
- Those in the bottom will probably not be concerned with their long term health
- Those in the top will most likely take good care of their medical condition
- Location in the hierarchy will determine a person’s medical/social requirements
Define a gypsy/traveller and the types
- Traditional travelling community, normally Roma background
- Romani, Irish
What are the barriers that gypsies/travellers face?
- Language and communication
- Mistrust of outsiders
- Constantly moving –> no address:
- big problem for antenatal and baby care/checks
- childhood immunizations cannot be arranged
- continuity of care for chronic disease is difficult - Discrimination
- Illiteracy
Services in Sheffield for gypsies/travellers?
- Traveller’s Team - liase between all facilities
- Only one Roma translator - NOT ENOUGH!
Define homelessness
Having no home
List some causes of homelessness
- Relationship breakdown
- Mental illness
- Domestic abuse
- Drug / alcohol abus
- Bereavements/disputes - no family to ask for help
What are the msot common causes of death amongst the homeless?
- Accidents and suicide
- Assault
- Alcohol and drugs
- CHD
- Pneumonia
47 yrs = average age of death
What barriers to healthcare do the homesless face?
- Access: opening times, location, finding out about appointments, no address
- Integration with other agencies: housing, social, crime
- Maslow’s hierarchy: do not prioritise their long term survival when they need to focus more on immediate survival
- Do not know where to find help
What is HASS?
Homeless Assessment and Support Services
- 3 core MDTs
Define a refugee
- Cannot return to their own country due to fear of persection
- Due to race, nationality, religion, political alliance, etc
Define an asylum seeker
- Submitted an application to the Home Office to be recognised as a refugee and is waiting for the decision
- Entitled to money (£35 a week) , NHS care and housing (< 18 - social service and schooling)
- Not allowed to work
What is the Geneva Convention of 1951?
- Anyone has the right to apply for asylum and can remain in the country until the decision is made
- Granted status -> ILR (indefinite leave to remain) -> all the rights of a citizen
- Family reunion: one spouse and all children < 18 yrs
What are the barriers to healthcare faced by asylum seekers?
- Lack of knowledge and understanding of the NHS
- Language and culture
- Maslow’s Hierachy - health needs are not their priority
What health problems do asylum seekrs face?
- Infectious disease
- Malnutrition
- Violence and torture
- Sexual abuse
- Psychological trauma -> PTSD
- All the conditions we can get in the UK!
List some asylum seeker health services
- Rapid access
- Screening
- Immnunsation catch up
- Education, especially about the asylum seeker process
Health belief model: individuals will only change if they what?
- Believe they are susceptible
- Believe there are serious consequences
- Believe that taking action will reduce their susceptibility
- Believe that the benefits of taking action will outweigh the costs
What are the cues to action in the health belief model?
- Internal: symptoms
- External: poster, GP advice
Critiques of the health belief model?
There are other factors which affect behaviour change:
- Self-effiacy: someone’s belief that they can carry out
- Emotions
Useful for:
- Breast examination
- Vaccinations
- Adherence to medication
Explain the theory of planned behaviour
Also known as rational choice model
Theorises that the best predictor of behaviour is INTENTION, which is determined by:
- Individual’s attitude (Smoking is bad)
- Percieved social pressure from the SUBJECTIVE NORM (family want me to stop)
- Individuals perceived ABILITY to stop (I believe that I can stop)
What are the critiques of the theory of planned behaviour
- Assumes that all choices are rational - doesn’t consider influence or irrational (e.g. fear)
- Assumes that all 3 factors are measurable and not linked
- Useful in predicting intentions, but not for actual behaviours - need to use other techniques to bridge the gap between intentions and behaviours
What is the transtheoretical model
Examines the process of change, not the factors that influence it
What are the stages of the transtheoretical model?
- Pre-contemplation
- Contemplation
- Preparation
- Action
- Maintenance
- Relapse (can occur throughout)
What are the critiques of the transtheoretical model?
- Arbitrary time frame allocated to each section - varies for every person and action
- Some people move through the stages differently, maybe skip a stage or go backwards
- Change could operate on a continual basis, rather than a discrete one
What does it mean to evaluate health care?
Assessment of whether a service achieves it’s objectives
Which four assessments can be done to evaluate health care?
- Single intervention, e.g. RCT
- PH intervention, e.g. impact of a smoking ban
- Health economic evaluation, e.g. cost-effectiveness of an intervention
- Health technology assessment, e.g. systematic review , economic evaluation and mathematical modelling
Describe the framework for health service evaluation:
Structure
Assessed by: Donabedian Structure
Structure:
- What is physically there - buildings, staff, equipment
- e.g. number of ITU beds and consultant anaesthetists per 1000 population
Describe the framework for health service evaluation:
Process
Process:
- What is done
- e.g. number of people seen in A&E
Describe the framework for health service evaluation:
Outcome
Outcome:
- Classificaiton of health outcome
- Mortality, e.g. 30 day mortality rate
- Morbidity, e.g. complication rate
- QOL or PROM (Patient Recorded Outcome Measurement, e.g. Oxford Hip Score)
- Patient satisfaction
What are the problems with assessing outcome in health service evaluation?
- Direct cause and effect could be difficult to assess
- Time lag between implementation and outcome
- May require very large sample size to detect statistically significant events
Describe Maxwell’s dimensions of quality
3Es and 3As:
- Effectiveness: does the intervention produced desired effect
- Efficiency: is output maximised for any given input?
- Equity: are patients being treated fairly?
- Acceptability: how acceptable is the service?
- Accessibility: costs, geographical access, waiting times, etc
- Appropriateness: is right treatment given to right people at right time?
Describe qualitative healthcare evaluation methods
- Observation
- Focus groups
- Interviews
Describe quantitative healthcare evaluation methods
- Data, e.g. audit
- Review records
- Surveys
- Studies, e.g. epidemiological
Summarise the framework for health service evaluation
- Define the service and what it includes
- Aims and objectives of service - are they appropriate?
- Donabedian’s Structure, Process, Outcome
- Methodology to be used
- Results, conclusion and recommendations
Define malnutrition
Under / over / imbalances in consumption of macro or micro-nutrients
Explain taste preference development
- Preference for certain food types begins in-utero, e.g. garlic
- Taste and olfactory systems are capable fo
detecting flavour prior to birth - Foetuses swallow around 1 litre of amniotic fluid per
day, which contain volatiles (garlic/anise/chilli)
- Taste and olfactory systems are capable fo
- Breastfeeding
- Parenting practises
- Age of intro of solids
- Sensitive years = < 2yrs (not critical)
- Greater variation of food exposed to during this
time -> more variable the diet in older years
Discuss breastfeeding and diet
- PH issue: low prevalence in young and low SES
- 46% in most deprived areas vs 65% in least deprived
- Taste of breastmilk varies throughout day and depends on mothers diet. Early exposure to variation of tastes -> less picky if breastfed
- Lower rates of obesity: formula has a ‘timetable’ which leads to excessive intake and BM includes natural satiety hormones
Discuss influence of parents on diet
- Tactics - coercion, persuasion, bribery
- Has a paradoxical effect: evidence shows if you let children eat whatever they want, removes anxiety related to meal times, then introduce novel foods
What are non-organic eating disorders
NOFEDs
- Feeding aversion, food refusal, picky/fussy etc
- Parents tend to adopt maladaptive mealtime interactions -> worsens the problem
What are eating disorders
Complex, and not one size fits all
- Anorexia nervosa
- Bulimia nervosa
- Binge eating disorders
What are the RFs for eating disorders?
Multifaceted
- Life events and trauma
- Mental health
What is disordered eating?
- Differs from eating disorders, which are clinically diagnosed
- Examples: restraint, dieting, disinhibition, emotional eating, night eating
What are the basic forms of dieting?
Basic forms:
- Restrict total intake
- Omit certain foods
- Avoid eating for long periods of time
What are the problems with dieting?
- RF for eating disorders
- Loss of lean body mass, not just fat
- Slows metabolic rate and energy expenditure - body becomes accustomed to less intake
- Chronic dieting disrupts normal satiety responses
- Long-term is challenging: fluctuation in weight
The bottom line = those who diet are heavier (on average) than those who don’t
What makes someone susceptible to obesity?
- Unresponsive to internal cues, e.g. satiety hormones
- Dietary restraint
- Vulnerable to external cues, e.g. more food on offer
What is absolute risk and how do you calculate it?
AR = Using the actual numbers involved, e.g. 50 death per 1000 population
Number of events within the treated/control group DIVIDED BY total number of people in that group
What are ARC and ART?
The absolute risks within the control group (ARC) and the treatment group (ART)
What is the absolute risk reduction and how do you calculate it?
ARR (Absolute risk reduction): Difference in risk between intervention and control groups
= ARC - ART
How do you calculate the relative risk?
ART / ARC
How do you calculate the relative risk reduction?
RRR = (ARC - ART) / ARC or = 1 - RR
How do you calculate the number needed to treat?
1 / ARR
What is the incidence and how do you calculate it?
The number of new cases over time
New cases / time
What is the prevalence?
The number of existing cases at a single point in time
What is the odds ratio and how do you calculate it?
Odds of an event in the intervention group DIVIDED BY odds of an event in the control group
(a/b) / (c/d)
ad / cb
= 1 (1 - probability)
Describe three elements of association and causation
- Bias: studies findings association are more likely to be published
- Chance: could all be due to chance
- Confounding: other influencing factors (the measured factor could be incidental)
- Reverse causation: the link is the other way round, e.g. people who are ill do not drink coffee
What is the prevention paradox?
- A preventative measure which brings much benefit to the population often offers little to each individual
- e.g. NNTT of statins is 40. Therefore, every one person prevented from having an ACS, 39 people take statins for life
- Way to improve this: more effective treatment or more effective/sensitive ways to identify those who are needed to treat
Describe negligence
- Duty of care
- Breech in that duty of care
- Patients come to harm
- Breech directly led to the patient coming to harm
Define never events
Serious and preventable mistakes which should never happen
Give some examples of never events
- Operated on wrong limb or wrong spinal level
- Medication administered via wrong route
Who do you need to inform in the case of a never event?
- National Reporting and Learning System (NRLS)
- Strategic Executive Information System (StEIS)
Investigating a never event?
- Personal approach: looking for an individual who causes the error
- Systems approach: what in the system caused the error to occur
List the 10 types of errors, with examples, and their corresponding skills/behaviours/attributes with examples
See page 17 of PPS document
Why have rationing needs changed for resource allocation?
- More chronic illness than before, rather than acute
- Normal physiological events have been medicalised - pregnancy and labour, death, etc.
- Increase in patient choice and expensive drugs
Name and describe the theories of resource allocation
- Egalitarian: Provide all care that is necessary and appropriate. This can be difficult due to finite resources
- Maximising: Public utility should be maximised (cost-benefit analysis). Some treatment is highly effective, but inefficient use of money. Similar to utilitarianism.
- Libertarian: individuals are responsible for their own health, well being and fulfilment of their life plan. However, many people do not have the resources to do so.
What is the rule of rescue?
- Ethical principle whereby if someone presents in a life threatening situation then measures will be taken to save their life
- Even if the money/resources would be better used somewhere else
- ‘A perceived duty’
What is addiction per the ICD10
- Craving
- Intolerance
- Withdrawal
- Compulsive seeking behaviour - differentiate from dependence
What are the physical effects of drug use
Acute: - Injecting - DVT/Abscess - OD and respiratory depression - Poor pregnancy outcomes - Opiates SEs: constipation etc. Chronic: - Blood-borne viruses, e.g. Hep C in 50%
What are the social effects of drug use?
- Families
- Crime
- Poverty and homelessness
What are the psychological effects of drugs use?
- Fear of withdrawal
- Craving
- Guilt
All temporarily alleviated by drug use
Discuss heroin
Routes: any Lasts 6 - 8 hours Effects: - Escape from real world - Euphoria - Intense relaxation - Mitosis - Drowsiness Adverse effects: - Dependence - Physical - nausea, itching, sweating, constipation - OD - Above
Discuss cocain/crack
Routes: oral, smoking, snorting, IV Action: Blocks re-uptake of serotonin and dopamine neurotransmitters Effects: - Intense pleasure, anxiety, panic - Adrenaline secretion: confidence, euphoria, energy, alertness, impaired judgement Chronic use: - Paranoia - Psychosis - Damaged nasal septum - Respiratory (crack lung)
What are the aims of treatment for drug users?
- Reduce harm to the user, family and society
- Improve health
- Stabilise lifestyle - reduce amount of drug use
- Reduce crime - benefits for wider society
What help can be offered to drug users?
- Health check
- Screening for blood-borne viruses
- Contraception
- Smear
- Sexual health
- Immunisations, especially Hep C
- Signposting (benefits, counselling, housing, local drug programmes, needle exchange)
What drugs are used for detoxification of opioids?
- Lofexidine: not an opioid, reduces withdrawl symptoms
- Buprenorphin: weak opioid, reduces withdrawal symptoms, used for first two days
What drug is used for the maintainence of drug detox?
- Methadone: weak opioid, don’t prescribe in those who take lots of heroin
What can be used for relapse prevention?
- Naltrexone: tablet, feel unwell if take heroin aswell. Need regular urinlaysis to ensure taking the drug
- Naloxone: beginning to distribute into the community to prevent death from OD
What psychological interventions can be used to help drug addiction?
In or out patients
- AA
- Motivational enhancement therapy
- ‘12 step programmes’
- Family therapy
How might you conduct a rapid assessment of someone with a drug addiction?
- What drug?
- Route?
- How long addicted?
- Patient goals?
- Referrals needed for medical problems/complications?
- Interagency involvement?
Discuss methadone for inpatients
- Confirm dose on admission
- Do not give benzodiazepines
- Be careful with methadone and analygesia (continue with normal pain ladder)
- Must have a prescription when discharged
Discuss spice
- Legal high, but illegal
- Potent cannabinoid - high concentration of THC (made - not grown)
- ‘Zombie state’ - no control over potency so dosingvaries massively between doses
- Many accidental ODs
- Smoked in a spliff
What is pregablin?
It’s used for neuropathic pain or epilepsy
What does the GMC state about drug addiction?
- Drug users have the same right to the NHS as all the patients
- All patients have a right to ‘high quality care, irrespective of their medical condition’
What is the recommended weekly intake of alcohol?
14 units
What is the dangerous intake for
a) women
b) men
a) women - 35
b) men - 50
Discuss acceptable alcohol intake in pregnancy
0 in first trimester
2 onwards
How do you calculate the number of units in alcohol?
% X mls
e.g. 12% bottle of wine = 750 X 12 = 9000 = 9 units
What is the time taken to metablolise alcoholic units?
1 unit per hour
What is Delirium tremens and how do you treat it?
- Peaks at 72 hrs
- Acute confusion, seizures, hallucinations (visual and tactile)
- Supportive fluids, chlordiazapoxide, prevent/treat seizures
What is Wernicke’s encephalopathy and how do you treat it?
- Confusion, ataxia
- Opthalmoplegia - paralysis of eye muscles
- Requires thiamine (B1/pabrinex)
What is Korsakoff’s syndrome and how do you treat it?
- Amnesia - retrograde and anterograde
- Confabulation
- Personality changes
- Irreversible
List some physical problems from alcohol
- Pancreatitis -> diabetes -> amputation
- Erectile dysfunction
- Liver damage
- Dilated cardiomyopathy
- Anaemia
- Cancer - mouth/oesophagus/liver/breast/bowel
What are the screening questions for alcohol?
- CAGE
- AUDIT
What medications can be used in alcohol-dependency?
- Antabuse - disulfiram
- Acamprostate - GABA blocker
- Naltrexone - specialised centres only
What is AUDIT?
See page 25 of PH notes
What is CAGE?
C: ever felt you need to Cut down on drinking?
A: do you get Annoyed at people criticizing your drinking?
G: have you every felt Guilty about drinking?
E: first thing drink to steady nerves or hangover? (Eye-opener)
Define health
Health = the state of complete physical, mental and social wellbeing and not merely the absence of disease or deformity…the highest attainable level of health is the fundamental right of every human being
What is the Human Rights Act 1998?
- Forms part of the decision making processes when making decisions about people’s rights
- Is part of all policy making
What are the underlying assumptions of human rights?
- The irreducible moral status of individuals demands that people are treated in ways that are compatible with that moral status
- These claims can be made against a duty bearer such as the state and are universal
What are the problems with human rights?
- Are they universal? E.g. FGM
- Which interests are significant enough to justify ennobling a human right?
- All basic rights are claim rights
- Can absolute claims conflict? All rights are interdependent and inter-related
List the rights frequently used in healthcare?
- Article 2: The right to life (limited)
- Article 3: The right to be free from inhuman and degrading treatment
- Article 8: The right to respect for privacy and family life (qualified)
- Article 12: The right to marry and found a family
- Article 14: The enjoyment of the rights and freedoms set forth in this Convention shall be secured without discrimination on any ground such as sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status
What are the absolute rights?
Never acceptable
- Right to protection - from torture, inhuman and degrading treatment and punishment (Article 3)
- The prohibition - on slavery and enforced labour (Article 4)
- Protection from retrospective criminal penalties (Article 7)
What is a limited/qualified right?
Limited under explicit and finite circumstances, e.g. the right to liberty (Article 5)
What is utalitarianism?
Maximising good for the maximum number of people
What is a judical review?
The opportunity for an individual to challenge the exercise of power by a public body
What is the ‘deprivation of liberty safeguard?’
If the patient needs to be admitted but does not have capacity and doesn’t fit the criteria of the mental health act.
Any decisions made must be in their best interests and the least restrictive option must be chosen.
What is a doctor?
One who has ultimate responsibility for difficult decisions, using knowledgement and judgement
What are Aristotle’s virtues?
Moral virtues: - Courage - Integrity Intellectual virtues: - Epsteme - knowledge - Techne - skill - Phronesis - judgement
Define a case control study?
- Examines a group of people who have experienced an event and a group of people that haven’t and looks at how exposure to suspected agents differed between the 2 groups.
What are the advantages of a case control study?
Advantages:
- Most useful trying to ascertain the cause of rare events (rare cancers)
- Quick – event already happened
- Multiple factors can be investigated.
What are the disadvantages of a case control study?
Disadvantages:
- Only generate OR not RR
- Difficult to find controls to match cases
- Prone to bias
What is a case series?
Analysis a group of people with a disease (no comparison)
What is cluster randomisation?
Group of participants randomised to do same intervention together (by village, hospital, school), results are analysed as a group not on an individual level.
What are the advantages of cohort study?
- Can follow up rare exposure
- Good for common and multiple outcomes
- Less risk of selection and recall bias
What are the disadvantages of cohort study?
- Long time
- People drop out
- Need large sample size
Define a controlled clinical trial?
Participants assigned to two or more treatment groups by a method other than random allocation
Define a crossover randomised trial
- Trial where participants receive one treatment and have outcomes measured, then received an alternative treatment and have outcomes measured again.
- Order of treatment randomly assigned.
Define a cross-sectional study? WHat are advantages and disadvantages?
- Surveying population about an exposure/condition/both at a point in time.
- To assess prevalence, NOT causality of treatment
Advantages: - Quick and cheap
- Large sample
- Good for PH planning and surveillance
Disadvantages - Risk of reverse causality (don’t know if outcome or exposure came first)
Define an experimental study
Studying the effect of intentionally altered factors under otherwise controlled conditions
Define observational studies
- Individuals observed or certain outcomes measured (no intervention/treatment given).
- Most appropriate for providing evidence on prognosis, aetiology, incidence/prevalence.
- Cannot prove causality
- Examples: Cross-sectional, Case-control, Cohort
What is a pragmatic study?
- RCT designed to provide results that are directly applicable to normal practice.
- Recruit populations representative of those normally treated
Define an RCT
- Participants randomly assigned to 2 or more groups
- At least one receiving an intervention being tested and the other receiving an alternative treatment or placebo
What are the advantages of an RCT?
- Low risk of bias
- Can infer causality
What are the disadvantages of an RCT?
- Time consuming
- Expensive
- Sample may not be representative of typical patients
Define selection bias and reasons
Systematic error in:
- Selection of study participants
- Allocation of participants to study groups
Reasons:
1. Non-response (from elderly, low SE background, ill?)
2. Loss to follow up
3. Difference between participants in intervention and exposure group other than exposure in question.
What is information bias?
- Measurement – different equipment used to measure outcomes between groups
- Observer – researcher knows which groups individuals are in causing them to report outcomes differently
- Recall – remembered events are not reported accurately
- Reporting – inaccurate info reported due to embarrassment or feeling judged.
What is publication bias?
- Trials with unfavourable results are less likely to be published
- Especially if trials are paid for by pharmaceutical companies
What is confounding?
- Estimate (relationship) between exposure and outcome is distorted because of the association of the exposure with another factor (confounder) independently related to outcome.
- E.g. High dietary fibre intake is associated with lower risk of CVD, high dietary fibre intake also associated with lower BMI and effects outcome – low BMI is a confounder
What is reverse causality?
Unclear whether ‘exposure’ caused ‘outcome’ or ‘outcome’ caused ‘exposure’
What is the Bradford-Hill criteria of causality?
- Strength: strong association between exposure and outcome
- Consistency: same results observed in various studies, in different geographical settings
- Dose-response: increased exposure = increased risk of outcome
- Temporality: exposure occurs prior to outcome
- Plausibility: reasonable biological mechanism, depends on knowledge in area
- Reversibility: Intervention to reduce/remove exposure eliminates/reduces outcome
- Coherence: logical consistency with other information
- Analogy: similarity with other established cause-effect relationships (previous research shows similar effects)
- Specificity: relationship specific to outcome of interest (e.g. head injury reduction following introduction of bike helmets greater than reduction in cycling injuries in general)
What is length time bias?
The differences in the length of time taken for a condition to progress to a severe stage, may make screening methods appear to detect only certain types of conditions (e.g. less aggressive cancers might be picked up by a screening tool whereas an aggressive cancer may develop during the period between screening)
Wilson and Jungner criteria
- Condition should be IMPORTANT
- Should be ACCEPTED TREATMENT for disease
- Facilities for diagnosis/Tx should be AVAILABLE
- Recognised LATENT or EARLY SYMP stage
- Suitable test or examination
- Test should be ACCEPTABLE
- Natural history fo condition, including development from latent to declared disease, should be UNDERSTOOD
- Should be an agreed POLICY on WHO TO TREAT
- Cost should outweigh expenditure on healthcare if found later
- Case-finding should be a CONTINUOUS process and not a ‘once and for all’ project
