Public Health / GP Flashcards
What are 4 determinants of health according to Lalonde Report, 1974
Genes, Environment (physical + socioeconomic), Lifestyle, Health care
What is the difference between equity and equality
Equity = what is fair and just
Equality is concerned with equal shares
Horizontal vs Vertical equity
Horizontal = equal treatment for equal need
Vertical = Unequal treatment for unequal need
What are the 3 domains of public health practice
- Health protection (measures to control infectious disease risks)
- Health improvement (societal interventions)
- Health care (delivery of safe high quality services)
Name a public health intervention at individual level, community level and ecological (population) level
Individual - immunisation
Community - playground for local community
Ecological - Clean Air Act
What is the difference between secondary and tertiary prevention?
Secondary Prevention - trying to detect a disease early and prevent it from getting worse (Screening)
Tertiary Prevention - trying to improve your quality of life and reduce the symptoms of a disease you already have
When we want to improve the health of a population or population subgroup, we start with a heath needs assessment, followed by which other phases of the planning cycle?
(Needs Assessment) > Planning > Implementation > Evaluation
What is the difference between Need, Demand and Supply?
Need - ability to benefit from an intervention
Demand – what people ask for
Supply – what is provided
Give a definition of Health Needs Assessment
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
What’s the difference between a Health Need and a Health Care Need?
- Health need
Need for health
Concerns need in more general terms
e.g. measured using mortality, morbidity, socio-demographic measures - Health care need
Need for health care
Much more specific
Ability to benefit from health care
Depends on the potential of prevention, treatment and care services to remedy health problems
(Bradshaw) - What is the difference between a Felt Need, an Expressed Need, a Normative Need and a Comparative Need
- Felt need - individual perceptions of variation from normal health
- Expressed need - individual seeks help to overcome variation in normal health (demand)
- Normative need - professional defines intervention appropriate for the expressed need
- Comparative need - comparison between severity, range of interventions and cost
(PH Faculty) - What are the 3 different approaches to Health Needs Assessment?
Epidemiological, Comparative, Corporate
What are some problems with the Epidemiological approach to Health Needs Assessment?
- Required data may not be available
- Variable data quality
- Evidence base may be inadequate
- Does not consider felt needs of people affected
What are some problems with the Comparative approach to Health Needs Assessment?
- May not yield what the most appropriate level
e.g. of provision or utilisation should be - Data may not be available
- Data may be of variable quality
- May be difficult to find a comparable population
What are some problems with the Corporate approach to Health Needs Assessment?
- May be difficult to distinguish need from
demand - Groups may have vested interests
- May be influenced by political agendas
- Dominant personalities may have undue influence
How does the Epidemiological approach to Health Needs Assessment work?
- Define problem
- Size of problem
- Services available
- Evidence base
- Models of care
- Existing services
- Recommendations
How does the Comparative approach to Health Needs Assessment work?
Compares the services received by a population (or subgroup) with others (may examine: Health status, Service provision, Service utilisation, Health outcomes)
How does the Corporate approach to Health Needs Assessment work?
Not to do with corporations. It is about obtaining the views a range of stakeholders (Commisioners/Providers/Professionals/Patients/Press/Politicians) (Some may give their views even when not sought or seek to influence health needs assessments)
Give a definition of Evaluation of Health Services
Evaluation is the assessment of whether a service achieves its objectives
(Alternative: Evaluation attempts to determine as systematically and objectively as possible the relevance, effectiveness and impact of activities in the light of their objectives)
A widely used framework for health service evaluation proposed by Donabedian
Structure (what is there - buildings/staff/equipment)
Process (what is done - eg. no of patients seen @ A&E)
Outcome (eg. mortality, morbidity, QoL, satisfaction)
What are some issues with health outcomes?
- Link (cause and effect) between health service provided and health outcome may be difficult to establish as many other factors may be involved
- Time lag between service provided and outcome may be long
Large sample sizes may be needed to detect statistically significant effects - Data may not be available
- There may be issues with data quality
Maxwell’s Dimensions of Quality of Health Care (3Es and 3As)
- Effectiveness, Efficiency, Equity
- Acceptability, Accessibility, Appropriateness
Give a definition of epidemiology
study of the frequency, distribution and determinants of diseases and health-related states in populations in order to prevent and control disease
What is the difference between incidence and prevalence?
Incidence = New cases, Denominator (number of disease free people at the start of the study), Time
Prevalence = Existing cases, Denominator, Point in time (point prevalence)
What is person-time and when is it used?
Person-time is a measure of time at risk (i.e. time from entry to a study to (i) disease onset, (ii) loss to
follow-up or (iii) end of study)
It is used to calculate incidence rate which uses person-time as the denominator
No of persons who have become cases in a given time period DIVIDED BY Total person-time at risk during that period
Incidence rate
What are the usual headings used when describing the epidemiology of a disease?
Time, Place, Person
What is the difference between absolute and relative risk?
Absolute risk – gives a feel for actual numbers involved i.e. has units
(e.g. 50 deaths / 1000 population)
Relative risk – risk in one category relative to another i.e. no units
What is the difference between attributable and relative risk?
Attributable risk: The rate of disease in the exposed that may be attributed to the exposure (a type of absolute risk (absolute excess risk)
(i.e. incidence in exposed minus incidence in unexposed)
Relative risk: Ratio of risk of disease in the exposed to the risk in the unexposed
(i.e. incidence in exposed divided by incidence in unexposed)
What is bias?
A systematic deviation from the true estimation of the association between exposure and outcome
What are the 2 main groups of bias?
- Selection bias
A systematic error in: selection of study participants / the allocation of participants to different study groups - Information (measurement) bias
A systematic error in the measurement or classification of: exposure, outcome
What are three sources of information bias?
observer (e.g. observer bias), participant (e.g. recall bias), instrument (e.g. wrongly calibrated instrument)
What is confounding?
The situation where a factor is associated with the exposure of interest and independently influences the outcome (but does not lie on the causal pathway)
6 ‘criteria’ for causality
- Strength of association (magnitude of relative risk)
- Dose-response (the higher the exposure, the higher the risk of disease)
- Consistency (similar results from different researchers using various study designs)
- Temporality (does exposure precede the outcome?)
- Reversibility (removal of exposure reduces risk of disease)
- Biological plausibility (biological mechanisms explaining the link)
Select the term that most accurately describes the type of study:
Investigators find a high level of correlation between levels of socioeconomic deprivation and cardiovascular mortality across electoral wards in the UK
Ecological study
Select the term that most accurately describes the type of study:
Researchers set out to examine the association between alcohol consumption and stroke. They identify all new patients admitted with stroke and compare their alcohol consumption with patients admitted for elective surgery.
Case-control study
Select the term that most accurately describes the type of study:
General practitioners set up a study to estimate the prevalence of depression within their registered population. They decide to start with a random sample of adults aged 45-74 years
Cross-sectional study
Select the term which best describes the measure being used:
In a randomised controlled trial, the time at risk was determined from entry to the study to various end points
Person-time
Select the term which best describes the measure being used:
For patients with meningococcal meningitis, the risk of dying has been estimated to vary from 5-10%
Case fatality rate
Select the term which best describes the measure being used:
In a case-control study of recent alcohol consumption and road traffic accidents, the measure of association was substantially greater than 1 and indicates that there is a positive association between exposure and outcome
Odds ratio
Select the term that is most appropriate to the issue described in relation to causation:
Researchers set out to examine the hypothesis that stress causes hypertension using hypertensive and normotensive individuals in a case- control study. The study design is however criticised because of concerns regarding the temporal sequence of events
Reverse causality
Select the term that is most appropriate to the issue described in relation to causation:
A study reports an association between coffee consumption and cancer. However, subsequent studies find that there is a clear association between smoking and coffee consumption
Confounding
Select the term that is most appropriate to the issue described in relation to causation:
An association between postmenopausal oestrogen use and endometrial cancer was reported in some studies. However, it was subsequently argued that this might be due to increased diagnostic attention received by women with uterine bleeding after oestrogen exposure
Bias
What are population and high risk approaches to prevention?
- The population approach is a preventative measure
delivered on a population wide basis and seeks to
shift the risk factor distribution curve (eg. dietary salt reduction through legislation) - The high risk approach seeks to identify individuals above a chosen cut-off and treat them (e.g. screening for people with high blood pressure and treating them)
(Rose) - What is the prevention paradox?
A preventative measure which brings much benefit to the population often offers little to each participating individual
What is screening?
A process which sorts out apparently well people who probably have a disease (or precursors or susceptibility to a disease) from those who probably do not
(Wilson and Jungner) - What are the 5 criteria for screening
1.) The condition - should be an important health problem
2.) The test - simple, safe, precise, validated, accepted by population
3.) The intervention - effective intervention with evidence of better outcomes
4.) Screening programme - RCT evidence + clinically, socially, ethically acceptable
5.) Implementation criteria - quality standards, adequately trained staff
What is sensitivity?
the proportion of people with the disease who are correctly identified by the screening test
What is specificity?
the proportion of people without the disease who are
correctly excluded by the screening test
What is positive predicted value?
the proportion of people with a positive test
result who actually have the disease
What is negative predicted value?
the proportion of people with a negative
test result who do not have the disease
What is duty of candour?
Every healthcare professional must be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress.
What is the cultural expertise model?
Where training focuses on providing information about different groups based on one characteristic
What is culture?
Culture is a socially transmitted pattern of shared meanings by which people communicate, perpetuate and develop their knowledge and attitudes about life
What is ethnocentrism?
tendency to evaluate other groups according to the values and standards of one’s own cultural group, especially with the conviction that one’s own cultural group is superior to the other groups
What is prejudice and what is discrimination?
Prejudice - Attitude towards another person based solely on their membership of a group
Discrimination - Actual positive or negative actions towards the objects of prejudice
What is Peytons’ four step procedure for skills training?
- Trainer demonstrates without commentary
- Trainer demonstrates with commentary
- Learner talks through and trainer does
- Learner talks through and learner does
Name a method of small group teaching
Small group behaviour/dynamics, Snowballing, Rounds, Circular interviewing, Buzz groups, Line ups
Name a question strategy
Evidence, Clarification, Explanation, Linking and extending, Hypothetical, Cause and effect, Summary and synthesis
What is Allodynia?
When a non-painful stimulus is painful
What is opioid-induced hyperanalgesia?
worsening pain sensitivity in patients chronically exposed to opioids
Health improvement vs Health protection vs Improving services
• Health improvement – Concerned with societal interventions (not primarily delivered through health services) aimed at preventing disease, promoting health, and reducing inequalities
o Inequalities
o Education
o Housing
o Employment
o Lifestyles
o Family/community
o Surveillance and monitoring of specific diseases and risk factors
• Health protection -
Concerned with measures to control infectious disease risks and environmental hazards
o Infectious diseases
o Chemicals and poisons
o Radiation
o Emergency response
o Environmental health hazards
• Improving services – Concerned with the organization and delivery of safe, high quality services for prevention, treatment, and care
o Clinical effectiveness
o Efficiency
o Service planning
o Audit and evaluation
o Clinical governance
o Equity
What are the three domains of public health?
Health improvement, health protection, improving services
What is a felt need?
individual perceptions of variation from normal health
What is an expressed need?
individual seeks help to overcome variation in normal health (demand)
What is a normative need?
professional defines intervention appropriate for the expressed need
What is a comparative need?
comparison between severity, range of interventions and cost
Advantages vs disadvantages of epidemiological approach to health needs assessment?
Advantages
- Uses existing data
- Provides data on disease incidence/mortality/morbidity etc
- Can evaluate services by trends over time Quality of data variable
Disadvantages
- Data collected may not be the data required
- Does not consider the felt needs or opinions/experiences of the people affected
Advantages vs disadvantages of comparative approach to health needs assessment?
Compares the services received by a population (or subgroup) with others (may examine: Health status, Service provision, Service utilisation, Health outcomes)
Advantages
- Quick and cheap if data available
- Indicates whether health or services provision is better/worse than comparable areas (gives a measure of relative performance)
Disadvantages
- May be difficult to find comparable population
- Data may not be available/high quality
- May not yield what the most appropriate level (e.g. of provision or utilisation) should be
Advantages vs disadvantages of corporate approach to health needs assessment?
Advantages
- Based on the felt and expressed needs of the population in question
- Recognises the detailed knowledge and experience of those working with the population
- Takes into account wide range of views
Disadvantages
- Difficult to distinguish ‘need’ from ‘demand’
- Groups may have vested interests
- May be influenced by political agendas
What is lead time bias?
When screening identifies an outcome earlier than it would otherwise have been identified this results in an apparent increase in survival time, even if screening has no effect on outcome.
What is length time bias?
Type of bias resulting from differences in the length of time taken for a condition to progress to severe effects, that may affect the apparent efficacy of a screening method
Name a type of observational study and a type of experimental/interventional study?
Observational
- Descriptive (Case report / Ecological study)
- Descriptive and analytical (Cross-sectional)
- Analytical (Case-control / Cohort)
Experimental/Interventional study
- RCT
- Non-act
What is a cross-sectional study + Advantages vs Disadvantages?
Divides population into those without the disease and those with the disease and collects data on them once at a defined time to find associations at that point in time. They are used to generate hypotheses but are prone to bias and have no time reference.
Advantages
- Relatively quick and cheap
- Provide data on prevalence at a single point in time
- Large sample size
- Good for surveillance and public health planning
Disdvantages
- Risk of reverse causality (don’t know whether outcome or exposure came first)
- Cannot measure incidence
- Risk recall bias and non-response
What is a case-control study + Advantages vs Disadvantages?
These are retrospective studies that take people with a disease and match them to people without the disease for age/sex/habitat/class etc and study previous exposure to the agent in question. It is quick and inexpensive, but the retrospective nature shows only an association and data may not be reliable due to problems with patient’s memories.
Advantages
- Good for rare outcomes (e.g. cancer)
- Quicker than cohort or intervention studies (as the outcome has already happened)
- Can investigate multiple exposures
Disadvantages
- Difficulties finding controls to match with cases
- Prone to selection and information bias
What is a cohort study + Advantages vs Disadvantages?
These studies start with a population without the disease in question and study them over time to see if they are exposed to the agent in question and if they develop the disease in question or not. The advantage is that it is possible to distinguish preceding causes from concurrent associated factors. There is a lower chance of bias and absolute, relative and attributable risks can be determined. Requires controls to establish causation. It is prospective which can show causation where retrospective studies cannot.
Advantages
- Can follow-up a group with a rare exposure (e.g. a natural disaster)
- Good for common and multiple outcomes
- Less risk of selection and recall bias
Disadvantages
- Takes a long time
- Loss to follow up (people drop out)
- Need a large sample size
What is an RCT + Advantages vs Disadvantages?
patients are randomised into groups, one group is given an intervention, the other is given a control and the outcome is measured. Randomisation allows confounding features to be equally distributed. Confounding and biases are minimalized. They tend to be large and expensive and show volunteer bias. Ethical issues – is it ethical to withhold a treatment that is strongly suspected to be effective?
Advantages
- Low risk of bias and confounding
- Can infer causality (gold standard)
Disadvantages
- Time consuming
- Expensive
- Specific inclusion/exclusion criteria may mean the study population is different from typical patients (e.g. excluding very elderly people)
What is odds vs odds ratio + how to calculate?
Odds = ratio of the 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 the not exposed groups.
OR = {Pexposed/ (1 – Pexposed)}
{Punexposed/ (1 – Punexposed)}
OR can be interpreted as a relative risk when the event is rare
Incidence vs Prevalence vs Person time
Incidence – new cases, denominator, time
Prevalence – existing cases, denominator, point in time
Person time - measure of time at risk, i.e. time from entry to a study to (i) disease onset, (ii) loss to follow-up or (iii) end of study. Used to calculate incidence rate which uses person time as the denominator
What is incidence rate?
(No.of persons who have become cases in a given time period)/(Total person-time at risk during that period)
What is absolute risk?
gives a feel for actual numbers involved i.e. has units (e.g. 50 deaths / 1000 population)
What is attributable risk?
The rate of disease in the exposed that may be attributed to the exposure, i.e. incidence in exposed minus incidence in unexposed. Attributable risk is a type of absolute risk (absolute excess risk)
What is relative risk?
Ratio of risk of disease in the exposed to the risk in the unexposed, i.e. incidence in exposed divided by incidence in unexposed. Tells us about the strength of association between a risk factor and a disease
(ie RR is how many times more likely it is that an event will occur in the intervention group relevant to the control group)
Types of bias
Selection bias: a systematic error in:
- the selection of study participants
- the allocation of participants to different study groups eg. Non-response, loss to follow up, those in the intervention group (or cases) different in some way from the controls other than the exposure in question?
Information (measurement) bias: a systematic error in the measurement of classification of exposure or outcome
Sources of information bias:
- Observer (eg. observer bias)
- Participant (eg. recall bias, reporting bias)
- Instrument (eg. wrongly calibrated instrument)
Publication bias
What is reverse causality?
This refers to the situation when an association between an exposure and an outcome could be due to the outcome causing the exposure rather than the exposure causing the outcome
Criteria for causality (Bradford-Hill criteria)
• Analogy – similarity with other established cause-effect relationships
• Biological plausibility - biological mechanisms explaining the link.
• Coherence – logical consistency with other information
• Consistency – similar results from difference researchers using various study designs
• Dose-response - the higher the exposure, the higher the risk of disease
• Reversibility (experiment) – removal of exposure reduces risk of disease
• Specificity – relationship specific to outcome of interest
• Strength of association – the magnitude of the relative risk
• Temporality – does exposure precede the outcome
What is a health behaviour?
• A health behaviour is a behaviour aimed to prevent disease (e.g. eating healthily)
What is an illness behaviour?
• An illness behaviour is a behaviour aimed to seek remedy (e.g. going to the doctor)
What is a sick role behaviour?
• A sick role behaviour is any activity aimed at getting well (e.g. taking prescribed medications; resting)
Transtheoretical model of health behaviour (smoking) (5 stages)
- Precontemplation - Not aware a change needs to be made
- Contemplation - Begins to think about changing
- Preparation - Intends to take action
- Action - Changed behaviour is initiated
- Maintenance - Keeping up the desired behaviour
Notifiable diseases
Acute encephalitis
Acute meningitis *
Acute poliomyelitis *
Acute infectious hepatitis *
Anthrax *
Botulism *
Brucellosis
Cholera *
Diphtheria *
Enteric fever (typhoid or paratyphoid) Food poisoning
Haemolytic uraemic syndrome (HUS) *
Infectious bloody diarrhoea
Invasive group A strep disease and scarlet fever
Legionnaires’ disease *
Leprosy
Malaria
Measles *
Meningococcal septicaemia *
Mumps
Plague *
Rabies *
Rubella
SARS *
Smallpox
Tetanus
Tuberculosis
Typhus
Viral Haemorrhagic fever (VHF) *
Whooping cough
Yellow fever
Maslow’s hierarchy of needs (5 tiers)
Physiological - food, water, sex, sleep
Safety - security of job, health, resources, property
Love/Belonging - friendship, family, sexual intimacy
Esteem - confidence, respect by others, self-esteem
Self-actualisation - morality, creativity, problem-solving
Refugee vs Asylum seeker
- Asylum seeker: a person who has made an application for refugee status
- Refugee: a person granted asylum and refugee status. Usually means leave to remain for 5 years and then reapply
What is a never event + give an example?
Never events - serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented
eg:
• Surgery – wrong site/implant, retained item
• Medication – wrong preparation/route
• Mental health – suicide
4 main leadership styles?
• Inspirational
• Transactional
• Laissez-faire
• Transformational
Neglect vs Misconduct
• Neglect
- Not showing sufficient care
- Falling below expected standard
- Often a chain of minor failures
- May be multidisciplinary – communication and assumptions
- May or may not lead to harm
• Misconduct
- Deliberate harm
- Covering up errors
- Fraud/theft/abuse – falsely claiming sickness or expenses, drug or alcohol misuse
- Improper relationships
When asking ‘was there a breach in duty of care?’, which two questions/tests should be used?
- Would a group of reasonable doctors do the same? (Bolam test)
- Would it be reasonable of them to do so? (Bolitho test)
(Also - Are your actions supported by others?)
4 main types of learners?
- Theorist – complex situations, can question ideas, offered challenges
- Activist – new experiences, extrovert, likes deep end, leads
- Pragmatist – wants feedback, purpose, may like to copy
- Reflector – watches others, reviews work, analyses, collects data
Rights that are frequently engaged in healthcare and their relevance to clinical practice? (4 Articles)
• Article 2 – the right to life (limited)
• Article 3– the right to be free from inhuman and degrading treatment (absolute)
• Article 8– the right to respect for privacy and family life. (qualified)
• Article 12 – right to marry and found a family
What are the 6 key GMC duties of a doctor?
1.) Make the care of your patient your first concern
2.) Protect and promote the health of patients and the public
3.) Provide a good standard of practice and care
(Keep your professional knowledge and skills up to date)
(Recognise/work within the limits of your competence)
(Work with colleagues in the ways that best serve patients’ interests)
4.) Treat patients as individuals and respect their dignity
. Treat patients politely and considerately
. Respect patients’ right to confidentiality
5.) Work in partnership with patients
. Listen to patients and respond to their concerns and preferences
. Give patients the information they want or need in a way they can understand
. Respect patients’ right to reach decisions with you about their treatment and care
. Support patients in caring for themselves to improve and maintain their health
6.) Be honest and open and act with integrity
- Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk
- Never discriminate unfairly against patients or colleagues
- Never abuse your patients’ trust in you or the public’s trust in the profession.
What are the four layers of Seedhouse’s ethical grid?
- Central conditions (Core rationale)
- Key principles (Deontological layer)
- Consequences (Consequential layer)
- External considerations
What are the 4 quadrants in the 4 quadrants ethical approach?
- Medical indications (Beneficence + Non-maleficence)
- Patient preferences (respect for autonomy)
- Quality of life (Beneficence + Non-maleficence)
- Contextual features (loyalty and fairness)
