Public health medicine

Question 1

Name some determinants of health.

Answer 1

• economy and environment (living and working conditions).
• family, friends and community.
• smoking, diet, physical activity and alcohol.
• age, sex and genetic factors.

Question 2

What are the levels of prevention of disease?

Answer 2

• primary prevention: intervention occurring before the onset of disease.
• secondary prevention: early detection and early clinical intervention.
• tertiary prevention: rehabilitation.

Question 3

Are the causes of disease in individuals different to the causes of disease in a population? Explain.

Answer 3

• yes they are different.
• e.g. people in Africa are more prone to contracting malaria than people living in the UK. This means that something in the environment is putting people in Africa at a greater risk of malaria. However, not all people in Africa get malaria.
• this is because the individual determinants of disease are different from the population determinants of disease.

Question 4

What are the types of public health interventions?

Answer 4

• social/biological and environmental interventions (e.g. immunisation, provision of safe drinking water, improved living conditions etc).
• behavioural interventions (e.g. health education campaign to promote healthy eating ‘5-a-day’ campaign).
• political interventions (e.g. banning of smoking in public places and increasing tax on alcohol).

Question 5

What are targeted and universal approaches to prevention? How are they different?

Answer 5

• targeted approaches: focus on high risk individuals e.g. provide statins to patients at risk of myocardial infarction (greater capacity to benefit at individual level, greater compliance but low population level impact).
• universal (population) approaches: encourage everyone in the population to eat more healthy diets to prevent obesity and heart disease.

Question 6

What is the prevention paradox?

Answer 6

• population level interventions require many people to change for a few to benefit. May lead to low compliance/incentive to change as low risk people will see little individual benefit for themselves.
• on the other hand, even tiny changes made by everyone will translate into an observable population level health improvement.

Question 7

What are the functions of public health in the UK?

Answer 7

• health improvements: prevention of non-communicable disease, reducing risk factors of disease, promoting healthy behaviours and other determinants of good health.
• health protection: protection from infectious diseases, environmental hazards, chemicals and poisons, radiation.
• improving health services: includes evidence-based clinical management guidelines.

Question 8

Define health inequalities.

Answer 8

• “health inequality is a generic term used to designate differences, variations, and disparities in the health achievements of individuals and groups”.
• Kawachi et al, 2002.

Question 9

Describe variations in health.

Answer 9

• individuals have varying health because of variations in genetics and constitutional factors.
• groups within a larger population also have varying health (e.g. different age-groups, gender, ethnic groups).
• chance can affect an individual’s health (exposure to a certain environmental or infectious hazards).

Question 10

Three distinguishing features, when combined, turn mere variations or differences in health into a social inequality in health, what are they?

Answer 10

• systematic, socially produced (and therefore modifiable) and unfair.
• dahlgren and whitehead, 2006.

Question 11

What is the distinction between health inequality and health inequity?

Answer 11

• “inequalities and equality are dimensional concepts, simply referring to measurable quantities. Inequity and equity, on the other hand, are political concepts, expressing a moral commitment to social justice”.
• Kawachi et al, 2002.

Question 12

Health inequalities are typically observed across certain categories such as …

Answer 12

• socio-economic status.
• gender.
• ethnicity.
• rural/urban settings; geography.

Question 13

Describe some examples of health inequalities.

Answer 13

• prevalence of diabetes is higher among people from lower socio-economic classes.
• woman experience poorer health than men due to social norms, beliefs and practices.
• health inequalities arise in ethnic minority groups e.g. due to limited access to health care services.
• health of the rural population is worse compared to the urban population because of different access to resources and health care provisions.

Question 14

What was the black report and when was it conducted?

Answer 14

• 1980.
• origin: Richard wilkinsons MSc research.
• the black inquiry was set up to investigate alleged worsening of health inequalities in Britain despite the NHS.
• the report concluded that health inequalities were increasing despite the introduction of free health services under the NHS.

Question 15

What was the Acheson report and when was it conducted?

Answer 15

• 1998.
• reviewed the evidence on health inequalities using data from the office of national statistics and department of health.
• conclusions: “inequalities in health exist, whether measured in terms of mortality, life expectancy or health status; whether categorised by socioeconomic measures or by ethnic group or gender.”
• included a range of policy recommendations.

Question 16

What is public health?

Answer 16

• public health deals with the physical health and well-being of all members of society (i.e. preventing disease and promoting health at a population level).

Question 17

What were the Whitehall studies?

Answer 17

• study of British civil servants.
• Whitehall 1 findings: men in the lowest employment grades were much more likely to die prematurely than men in highest grades.
• Whitehall 2: included women.
• implications: social gradient across the social classes.

Question 18

How would you go about identifying health inequalities?

Answer 18

• compare disease incidence and mortality rates across various population groups (e.g. across gender, ethnicity, socioeconomic status, rural/urban areas, geographic areas etc).
• if you find any differences, are these real or simply statistical artefacts?
• if the differences are real, can they be attributed to biological/genetic variation or are they socially mediated?

Question 19

What are the possible explanations for health inequalities?

Answer 19

• black report (1980) suggested:
• artefacts: artificial effect due to how variables representing ‘social class’ and ‘health’ were defined/measured.
• natural and social selection: health influences social class and not vice versa.
• materialist and structural explanations: access to money and essential services.
• cultural and behavioural explanations: association of unhealthy behaviours with poor education and cultural identity.

Question 20

What is the life course theory?

Answer 20

• an individual is particularly vulnerable at certain points in their life course.
• early years experiences are critical in determining life-long health.

Question 21

What is the inverse care law?

Answer 21

• “the availability of good medical care tends to vary inversely with the need for the population served. The inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”
• Julian Tudor Hart (1971).

Question 22

How would you carry out a health equity audit?

Answer 22

• pick a ‘dimension’ of measurement e.g. socioeconomic status.
• identify areas of ‘health need’ (e.g. Mortality, disease rates).
• map ‘provision of treatment’ or ‘access to health services’ for that particular ‘health need’ for each socioeconomic group and see if there is a difference.
• e.g. If you found that people belonging to lower socioeconomic groups were less likely to be on preventive treatment for heart disease but had higher cardiovascular mortality, you could infer that there was a health inequity.

Question 23

How would you measure socioeconomic status (SES)?

Answer 23

• individual level measures (income, education, occupation).
• composite area-based measures: bring together a number of different dimensions to build a more complex picture of socioeconomic status.
• e.g. Townsend score and index of multiple deprivation 2007 (IMD 2007).

Question 24

Name some specific actions to reduce health inequalities.

Answer 24

• the marmont review ‘fair society, healthy lives’ (2010):
• children: maternity services, parenting programmes, early years childcare and education.
• “skills for life” teaching; training and employment opportunities.
• fair employment.
• minimum income for healthy living; progressive taxation.
• create healthy spaces and communities (good public transport links, green spaces, improving food availability i.e. Healthy, low cost options, energy efficient housing).
• strengthen disease prevention: reduction of risk factors.

Question 25

How can a reduction in health inequalities be achieved?

Answer 25

• holistic approach to health that addresses social and economic determinants of health.
• multi-sectoral action: partnerships with local authorities, transport, housing, environment departments.

Question 26

What is health protection?

Answer 26

• one of the domains of public health practice.

- protection of population health from infectious and environmental hazards.

Question 27

What are the health protection functions of public health England (PHE)?

Answer 27

• an executive agency of the UK DH established on 1 April 2013.
• the former health protection agency (HPA) functions moved to the PHE health protection division.
• purpose: protection from infectious diseases and environmental hazards.
• advisory body providing advice and information to health professionals and the general public.
  Specific functions: disease surveillance, infectious disease outbreak investigation and control, guidelines, emergency planning, microbiology.

Question 28

What is surveillance?

Answer 28

• “public health surveillance is the ongoing, systematic collection, analysis, interpretation and dissemination of data about a health-related event for use in public health action to reduce morbidity and mortality and to improve health”.
• centres for disease control and prevention (2001).

Question 29

Why conduct surveillance?

Answer 29

• case management.
• early warnings of epidemics and outbreak investigation.
• understand the natural history of the disease (incubation period, disease progression, duration of illness).
• estimate the magnitude of disease in the population.
• identify risk factors for a given disease.

Question 30

Name the types of surveillance systems.

Answer 30

• surveillance systems are broadly designed for the following purposes:
• disease management.
• outbreak detection and investigation.
• programme planning and evaluation.

Question 31

What are the characteristics of a good surveillance system?

Answer 31

• depends on the purpose of the surveillance system but generally:
• timeliness.
• data quality (completeness, consistency of coding).
• representativeness.

Question 32

What are the data sources for each surveillance system type?

Answer 32

• disease management: case reports from clinicians, health care facilities, school laboratories.
• outbreak detection: case reports, electronic health records (GP patient record systems), lab data, sales of over-the-counter drugs.
• programme planning and evaluation: population-based surveys, census data, programme monitoring data, disease registries, GP data.

Question 33

Describe infectious disease surveillance in the UK.

Answer 33

• statutory requirement to notify the PHE HP division of certain diseases.
• about 30 notifiable diseases including meningitis, tuberculosis, mumps, measles.
• the prime purpose of the notifications system is speed in detecting possible outbreaks and epidemics. Accuracy of diagnosis is secondary, and since 1968 clinical suspicion of a notifiable infection is all that is required.