PUBLIC HEALTH/PPD Flashcards
What is the population perspective?
Think in terms of groups rather than individuals
3 ways of gathering information
Data
Surveys
Studies
What does information relate to in a population?
Demography
Sociology
Epidemiology
Give some determinants of health? (4)
Genes - age, sex
Environment - physical and socioeconomic
Lifestyle
Healthcare - resource allocation
More specific/wider determinants of health? (7)
Agriculture and food production Education Work environment/unemployed Housing Water/sanitation Diet, smoking Healthcare seeking behaviour
Define equity vs equality?
Equity is what is fair and just - give people in more need more help
Equality is concerned with equal shares - give everyone the same
What is horizontal equity?
Equal treatment for equal need - people with pneumonia given same treatment
What is vertical equity?
Unequal treatment for unequal need - areas with poorer health may need more money spending on health
Different forms of health equity? (5)
Equal expenditure/supply Equal access Equal utilisation Equal health care outcomes Equal health
2 dimensions of health equity?
Spatial - geographical
Social - age, gender, class, ethnicity
How is health equity assessed?
Assess inequality
Decide if inequitable
Measure utilisation, health status, supply
3 domains of public health practice?
Health improvement
Health protection
Improving services
What is health improvement?
Concerned with social interventions aimed at preventing disease, promoting health, reducing inequalities
What is health protection?
Concerned with measures to control infectious disease risks and environmental hazards
What is improving services?
Concerned with the organisation and delivery of safe high quality services for care
Examples of health improvement?
Tackling inequalities Education Housing Employment Lifestyle
Examples of health protection?
Infectious disease control
Chemicals/poisons
Emergency response
Environmental hazards
Examples of improving services?
Clinical effectiveness
Efficiency
Audit and evaluation
Clinical governance
Types of health improvement interventions? (2)
Health service or public health interventions
Non health interventions which have an impact on public health
How may interventions be delivered? (3)
Individual level
Community level
Population level
Example of individual, community and population interventions?
Individual - referring individual to smoking cessation nurse
Community - new park or cycle paths to promote exercise, smoking cessation posters in a GP
Population - minimum alcohol pricing, sugar tax
What is the needs assessment and planning cycle?
Needs assessment - planning - implementation - evaluation
2 main ways health of patients can be improved?
Treating individual patients
Influencing the services available to patients
What is need?
Ability to benefit from an intervention
What is demand?
What people ask for
What is supply?
What is provided
What is 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
What is health need?
Need for health - general, measured using morbidity and mortality
What is health care need?
Need for health care - more specific, ability to benefit from health care
Depends on potential of a treatment to remedy problems
For who/what may a health needs assessment be carried out for? (3)
Population or sub group
A condition
An intervention
Who defines need? (5)
Individual, family, community, professionals, society
What are Bradshaw’s 4 types of need?
Felt need
Expressed need
Normative need
Comparative need
What is felt need?
Individual perceptions of variation from normal health
What is expressed need?
Individual seeks help to overcome variation in normal health (demand)
What is normative need?
Professional defines intervention appropriate for the expressed need
What is comparative need?
Comparison between severity, range of interventions and cost
3 types of approaches to health needs assessment?
Epidemiological
Comparative
Corporate
What is the epidemiological approach to health needs assessment? (6)
Define issue, assess the size (incidence/prevalence)
Assess services available for the issue
Assess evidence base - effectiveness, cost effectiveness
Assess models of care, including quality and outcome measures
Assess for any unmet need or un needed services
Make recommendations
Problems with epidemiological approach?
Required data may not be available or of bad quality
Evidence base may be inadequate
Does not consider felt needs of people affected
What is the comparative approach to health needs assessment?
Compares the services received by a population with others
Spatial, social
May examine health status, service provision, service utilisation, health outcomes (mortality, morbidity, QOL)
Problems with comparative approach?
Neither may be giving most appropriate care!
Data may not be available/of variable quality
May be difficult to find comparable population
What is the corporate approach to health needs assessment?
Collect the views of the “stake holders” e.g. The patients/service users, GPs, other health professionals, commissioners, politicians – ask them what they think is needed
Problems with corporate approach?
May be difficult to distinguish need from demand
Groups may have vested interests
May be influenced by political agendas, dominant personalities
Example of an intervention that is supplied, but not needed or demanded?
Routine C section for women with previous C sections
Example of an intervention that is supplied and needed, but not demanded?
Cervical smears/screening
Example of an intervention that is supplied and demanded, but not needed?
Prescription of antibiotics for viral URTIs
Example of an intervention that is needed and demanded, but not supplied?
NHS drug rehabilitation
Intervention that is demanded, but not needed or supplied?
Treatment for mild illnesses - cough, pain with no underlying sinister cause
Intervention that is needed but not demanded or supplied?
NHS rehab for drug addicts (may or may not be demanded)
Intervention that is needed, demanded and supplied?
Insulin for diabetes
3 ways of defining health?
Biomedical - ABSENCE OF DISEASE
Psychosocial - STRESS AND FUNCTION
Lay - FELT AND EXPRESSED NEED
Define evaluation?
The assessment of whether a service achieves its objectives
…by systematically and objectively determining the relevance, effectiveness and impact of activities
Examples of health evaluation? (4)
Single intervention - e.g. RCT of a cancer drug
Evaluation of public health interventions - e..g epidemiological studies of health after smoking ban
Health economic evaluation - cost effectiveness of an intervention
Health technology assessment - systematic review, economic evaluation, mathematical modelling
4 things that can be evaluated
Projects
Processes
Programmes
Services
Donabedian framework for health service evaluation?
Structure
Process
(OUTPUT)
Outcome
How is structure evaluated?
What is there - buildings, staff, equipment
i.e. no. of ICU beds or vascular surgeons per 1000 people
How is process/output evaluated?
What is done - number of patients seen in A+E, the process they go through in A+E, number of procedures performed
How is outcome evaluated?
Classification of health outcomes
Mortality, morbidity, quality of life, patient satisfaction
5 Ds classification of outcome?
Death Disease Disability Discomfort Dissatisfaction
What is PROM?
Patient reported outcome measures - questionnaire i.e. oxford hip score
What are some issues with evaluating health outcomes? (4)
Link between service provided and outcome may be influenced by many factors
Time lag between service provided and outcome
Large sample size may be needed
Data may be unavailable/bad quality
How is data quality assessed?
Completeness Accuracy Relevance Timeliness (CART)
What are maxwell’s dimensions of quality of healthcare? (6)
Effectiveness Efficiency Equity Acceptability Accessibility Appropriateness
2 methods of evaluation?
Qualitative
Quantitative
Qualitative methods of evaluation? (4)
Observation - participant and non participant
Interviews
Focus groups
Document review
Quantitative methods of evaluation? (4)
Routinely collected data
Review of records
Surveys
Epidemiological studies
General steps of evaluating health services? (5)
Define what the service is What are the aims of the service FRAMEWORK (structure, process, outcome) Methodology (qual/quant) Results and recommendations
What is epidemiology?
The study of the frequency, distribution, and determinants of diseases and health related states in populations in order to prevent and control disease
What is incidence?
NEW cases in a population during a specific time period
What is prevalence?
EXISTING cases at a specific point in time
How to work out relative risk?
Risk of one group/risk of another i.e. risk of lung cancer in smokers 15%, risk in non smokers 0.7%, 15/0.7 = 21.4
So 21 times more likely to develop lung cancer if a smoker
How to work out attributable risk?
i. e. amount of lung cancer specifically due to smoking so take away naturally occurring cases
0. 15-0.07 = 0.143
How to work out number needed to treat?
Number needed to treat to prevent one death from lung cancer = 1/attributable risk
1/0.143 = 6.99 = 7 people need to stop smoking to prevent one death
What is sensitivity?
% correctly identified WITH DISEASE
100% = correctly identifies everyone with the disease but may cause false positives
What is specificity?
% correctly identified WITHOUT DISEASE
100% = correctly excluded everyone without the disease but may miss people who do have it
What is the positive predictive value?
% of those with a positive test who actually have the disease
true positive / (true positive + false positive)
What is the negative predictive value?
% of those with a negative test who are actually disease free
true negative / (true negative + false negative)
What is absolute, relative and attributable risk?
Absolute - actual numbers involved i.e. how many deaths per 1000
Relative - ratio of risk of disease in the exposed to the risk in the unexposed
Attributable - rate of disease in the exposed that may be attributed to the exposure
What can association be due to? (5)
Bias Chance Confounding Reverse causality True association! (causal)
What is bias?
Systematic deviation from the true estimation of the association between exposure and outcome
Main groups of bias?
Selection bias
Information bias
Publication bias
What is selection bias?
Systematic error in selection of study participants or allocation of participants to different groups
What is information bias?
Systematic error in the measurement or classification of exposure or outcome
Sources of information bias?
Observer
Participant - recall bias, reporting bias
Instrument - wrongly calibrated
What is publication bias?
Trials with negative results less likely to be published
What is confounding?
Situation where a factor is associated with the exposure of interest and independently influences the outcome
When an apparent association between an exposure and an outcome is actually the result of another factor e.g. grey hair associated with back pain, confounder is age
What are the Bradford hill criteria for causation? (evidence for a causal relationship) (6)
Strength of association Dose response Consistency between studies Temporality (exposure preceding outcome) Reversibility (removal of exposure reduces risk) Biological plausibility
What is a cohort study?
Longitudinal study in similar groups but with different risk factors/treatments i.e. exposed and not exposed, follows up over time
Pros/cons of a cohort study?
Pros: Can follow up rare exposure, can identify risk factors, is prospective
Cons: large sample needed, impractical if rare, expensive, people drop out
What is a case control study?
Observational study looking at the cause of a disease, compares similar participants with the disease to controls without, looks retrospectively for a cause
Pros/cons of a case control study?
Pros: Quick, good for rare outcomes
Cons: difficult to find appropriately matched controls, prone to selection and information bias
What is a cross sectional study?
Observational study collecting data from a population at a specific point in time, snapshot of a group
Pros/cons of a cross sectional study?
Pros: large sample size, provides prevalence data, quick, repeat studies can show changes over time
Cons: risk of reverse causality (which came first), less likely to include quick recoveries
What is a randomised control trial?
Similar participants (selection criteria) are randomly assigned to an intervention or control group to study effect of intervention
Pros/cons of randomised control trial?
Pros: low risk of bias and confounding, comparative
Cons: high drop out rate, little incentive for controls (ethical?), time consuming and expensive
What is an ecological study?
Looking at disease prevalence correlation with geographical location or over time
What is odds ratio?
Measure of association between exposure and outcome
= (Odds of exposure in cases) / (Odds of exposure in controls)
What is the population approach to prevention?
Preventative measure delivered on a population wide/subgroup (i.e. all over 60s) basis and seeks to shift the risk factor distribution curve
i.e. dietary salt restriction through legislation and advice to public should shift blood pressure curve
What is the high risk approach to prevention?
Seeks to identify individuals above a chosen cut off and treat them
i.e. screening for people with high BP
What is the prevention paradox?
A preventive measure which brings much benefit to the population often offers little to each individual
How can prevention be classified?
Primary
Secondary
Tertiary
Criteria a screening programme must fulfil? (6)
Important disease
Natural history of the disease must be understood e.g. detectable risk factors, disease marker
Simple, safe, precise and validated test
Acceptable to the population
Effective treatment from early detection with better outcomes than late detection
Agreed policy of who should receive treatment
Achievable with facilities, inexpensive
What is primary prevention?
Aims to prevent disease before it occurs, for example education about healthy living/not smoking
What is secondary prevention?
Aims to reduce the impact of a disease that has already begun to occur, by detecting and treating as soon as possible
i.e. screening to detect early cancer, daily aspirin/clopidogrel after MI
What is tertiary prevention?
Aims to soften the impact of an established, ongoing illness to improve QOL
i.e. stroke rehabilitation, support groups
What is screening?
A process which sorts out well people who probably have a disease/disease precursor/disease susceptibility from those who probably do not
NOT DIAGNOSTIC
5 types of screening?
Population based screening Opportunistic screening Screening for communicable diseases Pre employment medicals Commercial screening
What is lead time bias?
Early identification does not alter outcome but appears to increase time of survival e.g person knows they have the disease for longer
(e.g. diagnosed earlier)
What is length time bias?
Disease that progresses more slowly is more likely to be picked up by screening as the person is around for longer, making it seem like screening prolongs life
What is health psychology?
Emphasises the role of psychological factors in the cause, progression and consequences of health and illness
Puts theory into practice by promoting healthy behaviours and preventing illness
3 main categories of health behaviours?
Behaviours related to health…
Health behaviour
Illness behaviour
Sick role behaviour
What is health behaviour?
A behaviour aimed to prevent disease i.e. eating healthy
What is illness behaviour?
A behaviour aimed to seek remedy i.e. going to the doctor
What is sick role behaviour?
Any activity aimed at getting well i.e. taking medication
What are health damaging behaviours?
Smoking, alcohol or drug abuse, sun exposure, risky sex, risky driving
What are health promoting behaviours?
Exercise, healthy eating, vaccinations, compliance with medication
What fraction of cancers can be potentially prevented by modifiable risk factors/lifestyle? What are the others due to?
1/3
2/3 due to total number of cell renewals in normal cells as part of homeostasis
Modifiable risk factors for cancer? (12)
Stop smoking Healthy BMI Eat fruit and veg Less alcohol Less sun exposure Eat less processed/red meat High fibre diet Exercise/less sedentary Eat less salt Minimise chemical/radiation exposure Minimise certain infections Breastfeed
Most common causes of death in UK? (5)
Cancer Cardiovascular disease Cerebrovascular disease Dementia Respiratory disease - flu, pneumonia
What % of patients with chronic illnesses are non compliant with medication?
50%
May be higher in females, non white groups
What is health promotion?
The process of enabling people to exert control over the determinants of health, thereby improving health
How are interventions carried out at the individual level?
Patient centred approach, care responsive to individual needs
Name 3 health promotion campaigns
Change 4 life (eat well move more)
Stoptober (stop smoking)
Act FAST (stroke)
How can preventing individual alcohol consumption affect other levels of intervention?
Individual - level of consumption, individual health outcomes, incidence of domestic violence
Community - local alcohol sales, alcohol crime, A+E visits
National - national alcohol statistics, demographic patterns of liver disease
Why do people engage in health damaging behaviours?
Smoking - stress relief
Alcohol/drugs - social, escapism
Unhealthy food - convenience, social
What is unrealistic optimism of health?
Individuals continue to practice health damaging behaviour due to inaccurate perceptions of risk and susceptibility
What is perception of risk influenced by? (4)
Lack of personal experience with the problem
Belief that it is preventable by personal action
Belief that if it hasn’t already happened it won’t
Belief that the problem is rare
Also stress, age, socioeconomic and cultural factors
What does perception of risk impact on?
Adherence - lower risk perception associated with reduced attendance to cardiac rehab, reduced medication compliance
NICE guidance on behaviour change? (8)
- Planning interventions
- Assessing the social context
- Education and training
- Individual-level interventions
- Community-level interventions
- Population-level interventions
- Evaluating effectiveness
- Assessing cost-effectiveness
5 steps to helping individuals to change their health behaviours?
Work with your patient’s priorities Aim for easy changes over time Set and record goals Plan explicit coping strategies Review progress regularly
Why is behaviour change important?
Both individually for mortality and morbidity
Population perspective
Relatively simple way to reduce disease!
What is the biggest cause of illness and premature death in the UK?
Smoking
kills 100,000 a year in the UK
Due to cancer, COPD, heart disease
What is smoking linked to?
Poverty
Unemployment
Being single
Male
What is QOF?
Quality and outcome framework indicators
8 models/theories of behaviour change?
- Health belief model (HBM)
- Theory of Planned Behaviour (TPB)
- Stages of change /transtheoretical model (TTM)
- Social norms theory
- Motivational interviewing
- Social marketing
- Nudging (choice architecture)
- Financial incentives
What is the health belief model? (4)
Individuals will change if they:
Believe they are susceptible to condition
Believe it has serious consequences
Believe taking action reduces susceptibility
Believe benefits outweigh costs- perceived barriers
This motivates them and cues them to action
What are cues to action in the health belief model?
Can be internal or external
i.e. advice from GP
Critique of health behaviour model? (3)
Alternative factors may predict health behaviour - self efficacy, outcome expectancy
Does not consider emotions
Does not differentiate between first time or repeat behaviour
Most important factor of the health behaviour model for addressing behaviour change?
Perceived barriers
What is the theory of planned behaviour model?
Best predictor of behaviour is intention
Attitudes, subjective norm and perceived behavioural control lead to intentions which lead to behaviour
What is intention determined by? (3)
A persons attitude to behaviour
Perceived social pressure to undertake behaviour
Persons thoughts that they are able to perform the behaviour
5 ways to help people act on their intentions?
Perceived control Anticipated regret Preparatory actions Implementation intentions Relevance to self
Critique of planned behaviour model?
Lack of temporal element, direction or causality
Doesn’t take into account emotions
Relies on self reported behaviour
What are the 5 stages in the stages of change model (transtheoretical)?
Precontemplation Contemplation Preparation Action Maintenance
Pros and cons of stages of change model?
Pros: acknowledges individual stages of readiness, accounts for relapse, temporal
Cons: people might not move through every stage, doesnt take into account external factors
What is motivational interviewing?
Counselling approach - initiating behaviour by resolving ambivalence
What is nudge theory?
Change environment to make the best option the easiest - opt out schemes, fruit next to checkouts
Typical transition points to initiate behaviour change? (5)
Leaving school Entering workforce Becoming a parent Retirement Bereavement
Common implication of all models?
Need to explore a persons beliefs and reasons why they engage in behaviours before developing a plan for change
Features of a communicable disease that would make it a public health concern? (5)
High mortality High morbidity Highly contagious Expensive to treat Effective interventions
Who must report notifiable diseases?
Registered medical practitioners
Labs - if results
When must you report notifiable diseases?
Any case of a notifiable disease, on clinical suspicion don’t need lab confirmation
Any other infection/contamination that could risk human health
What must you report about notifiable diseases?
Case details - NHS no, DOB, contact
Details of disease
Details of contamination
How do you report notifiable diseases?
Contact local health protection/public health england
Written, telephone if urgent
Name some notifiable diseases (8)
Yellow fever Whooping cough TB Scarlet fever Measles, Mumps, Rubella Meningococcal septicaemia Acute encephalitis/meningitis Food poisoning
What is an epidemic? Pandemic?
Epidemic - occurrence of disease in excess of what is expected for a given time period
Pandemic - epidemic widespread over several countries
What different factors can contribute to excessive energy intake?
Genetics, early development Employment - shift work Media Fatty food, big portions Reduced activity Psychological
What is malnutrition?
Deficiencies, excesses or imbalances in a persons intake of energy/nutrients
Can be undernutrition or overnutrition
Name some chronic conditions requiring nutritional support? (5)
Type 2 diabetes Coeliac disease Eating disorders IBD Cancer
Early influences on feeding behaviour?
Maternal diet/taste preference (can detect flavour before birth through amniotic fluid)
Breastfeeding
Parenting practices - age of solid food, types of food
What is breastmilk composed of?
Colostrum 3 days after birth - protein, protective factors
Mature milk is calorie dense, fatty
Enzymes for digestion, gut protection IgA, white cells and bifidus factor for infection, lactoferrin
Impact of breastfeeding on later eating habits? (4)
Acceptance of new foods during weaning
Less picky eaters
Eat more fruit and veg
Preferences to flavours they have been exposed to in amniotic fluid/milk
Bad parental feeding practices?
Tactics such as coercion, persuasion
Using food as an incentive to eat increases liking for the reward and decreases liking for the other food
Good parental feeding practices?
Modelling healthy eating
Variety of food
Avoid pressure to eat
Not using food as reward
What is non organic feeding disorder?
High in children before 6
Food aversion, refusal, selectivity, failure to advance to age appropriate food
Often parents use bad feeding practices
What is chemical continuity?
Transmission of certain flavours from maternal diet via amniotic fluid and breast milk
What are the 3 basic forms of dieting?
Restriction of total amount
Avoidance of certain types of food
Fasting
4 problems with dieting?
Risk factor to develop eating disorders
Loss of lean mass
Slows metabolic rate
Disrupt notmal appetite responses - increased feelings of hunger
Why is dieting difficult for some people?
Unresponsive to internal cues that signal satiety and hunger
Vulnerable to external cues that signal availability of food
What is the externality theory of obesity?
Normal weight individuals responsive to internal homeostatic cues
Overweight eat according to external cues, time of day, sensory food cues
What is restrained eating and disinhibition?
Restrained - inhibit food intake, ignore hunger
Disinhibition - inability to maintain control
What regulates food consumption?
Hunger to increase food intake, satiety to keep it below a max level
Determined by body weight set point
Regulated by social, environmental, psychological factors
What is the boundary model of dieting?
Self imposed desired intake of food
If exceed this, continue to eat until feel full (more than that of normal eater)
Leads to overeating repeatedly
Disinhibitors of diet?
High energy preload
Alcohol
Stress, emotion
Large portions
What is the goal conflict theory?
Dieters experience conflict between enjoying eating and controlling weight
What is the portion size effect
Consumption of large portion sizes of energy dense food facilitates over consumption
Common eye conditions leading to sight loss? (6)
Cataracts Age related macular degeneration Glaucoma Retinitis pigmentosa Hemianopia Diabetic retinopathy
What are cataracts?
Lens inside the eye becomes less transparent, cloudy
Vision appears misty
What is age related macular degeneration?
Damage to the macular (central part of retina), affects central vision
May be able to be slowed/halted by lasers/drugs
What is glaucoma?
Group of eye conditions that affect the optic nerve, may be caused by raised pressure or nerve weakness
Damage cannot be reversed
Affects peripheral vision, often leads to blindness
What is retinitis pigmentosa?
Group of inherited conditions of the retina that lead to gradual progressive vision reduction
Difficulties with peripheral vision, night vision
What is hemianopia?
Loss of right or left half of visual field in both eyes, following stroke
Damage to right posterior brain causes loss of left field of view in both eyes
What is diabetic retinopathy?
Affects blood vessels supplying the retina, leading cause of blindness in adults under 65
Can be treated with laser if early to stop progression
How can communication be improved for blind people?
Large print
Audio
Braille
Speech packages
What is a disability?
A disability is related to anyone who has a physical, sensory or mental impairment which seriously affects their daily activities
How would you recognise a visually impaired person?
White walking stick White symbol cane, guiding cane Reading braille Dark glasses Being guided/guide dog Feeling the way Peering closely at something
What are some emotional needs (human givens)?
Security Attention Intimacy Status Part of a wider community Privacy Control/autonomy Meaning and purpose
What is the prevalence of loneliness?
Half of over 75s live alone
1 in 6 over 65 depressed, 1 in 5 alone for more than 12 hours a day
50% of men over 50
Physical consequences of loneliness?
Earlier death Take more risks Harder to self regulate Physical changes = poor health Cigarette smoking
How to recognise loneliness?
If pt is clingy, talkative Says they're bored Lives alone, esp. male >50 Recent bereavement or transition Lack of mobility Sensory impairment No family nearby
Define social exclusion
Dynamic process of being shut out, fully or partially, from any of the social, economic, political or cultural systems which determine the social integration of a person in society
5 domains of society?
Material resources civic activities basic services neighbourhood social relationships
Causes of social exclusion?
Poor health Poverty Housing issues Fear of crime Transport problems Disrcimination Lack of information Lack of social networks
Initiatives to help with social exclusion?
Age UK
Silverline
Regional clubs - dementia cafes
What is domestic abuse?
Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality
Forms of abuse?
Psychological Physical Sexual Financial Emotional
How does domestic abuse impact on health?
Traumatic injuries, inc. miscarriage
Chronic illness - headache, pain
Psychological problems - PTSD, depression, substance misuse
Indicators of domestic abuse in a presentation?
Injury unwitnessed by anyone else
Repeat attendance
Delay in attendance
Multiple minor injuries
How does domestic abuse impact children?
Affects self esteem, education, relationships, stress response
Predispose to conditions i.e. mental health
How to respond to domestic abuse?
Display helplines, contacts
Focus on safety
Ask direct qs
Be non judgemental, reassuring
Acknowledge behaviour is not OK
Be open to working with other organisations
DONT discuss it in front of family members
What are the risk levels in domestic abuse?
Standard - no indication of causing serious harm
Medium - some indicators of serious harm, but unlikely unless change in circumstances
High - indicators of imminent risk of serious harm, could happen at any time
Things that increase risk?
Victim - new baby/pregnant, isolated
Perpetrator - history of violence, drug use, weapons, accomplices, controlling
Other - sexual abuse, financial issues, death threats, stalking
What to do if standard/medium/high risk?
Standard/medium - give domestic abuse services contact
High - refer, if very serious don’t need consent and can break confidentiality
What is MARAC?
Multi agency risk assessment conference for domestic abuse
What is the DHR?
Domestic homicide review for deaths that appear to have resulted from abuse
What is the IDVA?
Independent domestic violence advocate - works with high risk women to increase safety
What is Maslows hierarchy of needs?
TOP: self actualisation (morality, creativity) Esteem (confidence, achievement) Love/belonging (family, sex) Safety (employment, property) BOTTOM: Physiological (food, water)
Implications of rough sleeping?
30 years less life expectancy
4 x more likely to die from unnatural causes
Nearly half have mental health problems - 35x more likely to commit suicide
Half have alcohol/drug issues
Causes of homelessness?
Relationship breakdown - mental illness, abuse, disputes, bereavement
Some health conditions faced by homeless people?
Infection - TB, hepatitis Poor dental and foot care Resp problems Injury - violence, rape Poor sexual health, no contraception Serious mental illness Substance addiction Malnutrition
Needs of homeless children?
Stability and emotional security Safety Immunisations Education Play
Barriers to healthcare faced by homeless? (4)
Access - opening times, appointment times, discrimination
Lack of integration of health with housing/social services
Health not a priority
May not know where to access
Healthcare issues faced by travellers?
Children 2x more likely to die in first year
2.5x higher miscarriage rate
More smoking, asthma, angina, anxiety
Barriers to healthcare faced by travellers?
Reluctance ot GPs to visit communities Illiteracy Communication difficulties Transient lifestyle Mistrust of professionals
Interventions to increase healthcare in homeless/travellers?
Homeless - homeless assessment and support service with specialists
Travellers - specialist health visitor since 1985, caused gradual acceptance of health care
What is a refugee?
owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion is outside the country of his nationality, and is unable, or owing to such fear, unwilling to avail himself of the protection of that country
What is an asylum seeker?
Someone who has submitted an application to be recognised as a refugee and is waiting for their claim to be decided by the home office
What is refugee status?
Indefinite leave to remain (ILR) :when a person is granted full refugee status and given permanent residence in the UK.
They have all the rights of a UK citizen.
They are eligible for family reunion- one spouse, and any child of that marriage under the age of 18
Usually reapply in 5 years
Rights of asylum seekers?
£35 a week, housing, NHS care
If under 18 - social services, school
NOT allowed to work or other benefits
FAILED asylum seekers - no money, housing etc
Barriers to healthcare in asylum seekers? (4)
Lack of knowledge where to go/how NHS works
Communication/language/culture barriers
Move around a lot
Health not a priority
Health problems faced by asylum seekers?
Mental from previous experiences - separation, poverty, war/threat, detention
Physical health - malnutrition, abuse, infestations, blood borne diseases, untreated chronic disease or congenital, no immunisations etc
What does asylum seeker health care service provide? (7)
Rapid access Screening Catch up imms programmes Appropriate referrals Education Mental health expertise Supporting evidence for hearings
What is humanitarian protection?
Failed to demonstrate claim for asylum but face serious threat to life if returned. Usually 3years then reapply
Example of sloth? Opposite?
Not bothering to check results/information for accuracy, incomplete evaluation or documentation
Conscientiousness
Example of fixation and loss of perspective? Opposite?
Unshakeable focus on a diagnosis, overlooking other signs, can’t see bigger picture
Open minded, situational awareness
Example of communication breakdown? Opposite?
Unclear instructions or plans, not listening to others
Effective communication
Example of poor team working? Opposite?
Team members working independently, poor direction, not using people’s skills
Good team working
Example of playing the odds? Opposite?
Choosing the common, dismissing the rare condition
Probability assessment
Example of bravado? Opposite?
Working beyond your competence, show of confidence to hide deficiency
Humility
Example of ignorance? Opposite?
Lack of knowledge, unconscious incompetence
Self awareness
Example of mis-triage? Opposite?
Over/underestimating the seriousness of a situation
Prioritisation
Example of lack of skill? Opposite?
Lack of appropriate skills, teaching, or practice
Effective technical skills
Example of system error? Opposite?
Environmental, technology, equipment or organisation mistake, inadequate safeguards
Good system design
Define culture?
Socially transmitted pattern of shared meanings by which people communicate, perpetuate and develop knowledge and attitudes about life
Distinguishes between groups of people
What is ethnocentrism?
Tendency to evaluate other groups according to the values and standards of one’s own group, especially thinking you are superior
What are the goals of diversity education?
- understand how culture influences our thoughts, perceptions, values, bias
- understand the nature of individual cultural identity as dynamic
- respectful curiosity attitude
What is individual culture based on?
Heritage - country, language
Individual circumstances - gender, age
Personal choice - lifestyle
What is a stereotype?
Generalisations about the typical characteristics of members of a group
What is prejudice?
Attitudes towards another person solely on their membership of a group
What is discrimination?
Actual positive or negative actions towards the objects of prejudice
Challenges of cultural distance?
Takes effort Assumptions more likely to be wrong Lack of rapport Language barrier Different expectations
How to overcome challenges of cultural distance?
Flexibility - capacity to adapt, accommodate, modify
Inquisitive - eager to learn
Intellectual integrity - examining own thoughts
Be open minded
Reflect
What are never events?
Adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability
Why are never events a problem? (5)
Cause harm/death to patients Show gaps in provision of care Affect NHS reputation Financial penalties Prompt visits by CQC etc
Examples of never events? (5)
Surgery - wrong site, retained object
Medication - wrong preparation, route or overdose
Maternity - PPH death
Suicide in mental health care
General - falls from window, entrapment in bed rails, misidentification
What is the biggest cause of medical errors?
Miscommunication - ignoring team members, no clear leader
What is the swiss cheese model?
Accident/injury occurs errors in from organisational factors (i.e. cost cutting), unsafe supervision (deficient training), preconditions for unsafe acts (mental fatigue) and unsafe acts (wrong surgical site) all lining up in some patients
Interventions for patient safety?
Checklists
SBAR (situation background assessment recommendation)
What is the conformity problem?
People migrate to working in ways that they know to be wrong if there is great beneftit (eg saving time) and unlikely consequences
Become normalised, and if someone takes longer to be safe they are criticised
What is transformational leadership?
Concerned with values, ethics, standards and long term goals
Inspires with possibilities and raises confidence to work together for a common purpose
What is transactional leadership?
Leader offers something in return for something i.e. increased pay for more work
Mechanisms underlying inhumane behaviour? (3)
Conformity - unwillingness to rebel against common view
Pressing situational factors - emergency
Bystander effect - ambiguity
Why have healthcare resource needs increased?
Shift from acute illness to chronic
Normal physiological events medicalised
Increase in number and cost of drugs
What are allocation theories based on?
Egalitarian principles
Maximising principles
Libertarian principles
What is the egalitarian principle of allocation?
NHS was founded on the requirement to provide all care that is necessary and appropriate to everyone - equal access
But now finite resources
What is the maximising principle of allocation?
Criteria that maximise public utility
What is the libertarian principle to allocation? Example?
Each is responsible for their own health, well being and life fulfilment
i.e. german incentive schemes for participation in screening etc
What about those unable to pay healthcare!
What is the solidarity principle of health allocation?
Contribution according to level of income, benefits according to need
What is sustainable medical practice?
a sustainable process is one that “meets the needs of the present without compromising the ability of future generations to meet their own needs.”
What is health?
Health is the state of complete physical, mental and social wellbeing and not merely the absence of disease or informity
4 rights (from human rights act) that are frequently engaged in healthcare?
Art 2 – the right to life (limited)
Art 3 – the right to be free from inhuman and degrading treatment (absolute)
Art 8 – the right to respect for privacy and family life. (qualified)
Article 12 – right to marry and found a family
What are absolute rights in the human rights act?
Art 3 - protection from inhuman treatment
Art 4 - prohibition of slavery
Art 7 - protection from retrospective criminal penalties
What are qualified/limited rights?
Rights are limited under explicit and finite circumstances i.e. respect to privacy qualified to protect health
Is there a right to medical treatment?
Article 2 - There is a positive obligation upon the State; to take appropriate steps to safeguard life
But cannot impose an impossible or disproportionate burden on the authorities.
Difference between novice and expert decision making?
Novices use analysis
Experts use intuition
Hinges on pattern recognition
What is intuitive decision making?
Ability to understand something instantly without conscious reasoning
Fast and strong but prone to bias
Biases in intuitive thinking?
Error of over attachment
Error due to failure to consider alternative
Error due to diagnosis momentum
Errors in prevalence estimation
Use debiasing techniques - acknowledge it, rethink, checklists, group decision making
What is analytical decision making?
Not good at estimating odds or values but good at measuring or calculating things - evidence based medicine
Accurate but slow, resource intensive
What is the dual process theory?
Intuitive thinking with analytical thinking - may come up with different diagnoses from both
GMC duties of a doctor?
Knowledge, skills and performance
Safety and quality
Maintaining trust
Examples of human error?
Communication
Judgment
Omissions/lapses
Examples of misconduct?
Deliberate harm
Lack of honesty
Fraud/theft
Improper relationships
Bolam test for breach in duty?
Would a group of reasonable doctors do the same?
Bolitho test for breach in duty?
Would it be reaosnable of them to do the same?
How to determine medical negligence?
1) Was there a duty of care
2) Was there a breach in the duty of care?
3) Did the patient come to harm?
4) Did the breach cause the harm?
What is the 3 buckets model?
Each bucket contains diffrent sources of risk - the more full each one is the greater the risk
Self/Context/Task
Self - fatigue, lack of skill
Context - distraction, equipment failure
Task - complex, long
What is Peyton’s 4 step procedure for skills teaching?
Trainer runs through without commentary
Trainer talks through and does
Learner talks through and trainer does
Learner talks through and does
2 types of small group dynamics?
Group taught by teacher
Teacher facilitates communication
4 distinct learning styles?
Activist
Theorist
Pragmatist
Reflector
4 teaching styles?
Facilitator
Conductor
Enabler
Dominator
What is consequentialism?
The end justifies the means - the right action is the one that gives the best outcome
Types of consequentialism?
Utilitarianism
Egoism
Altruism
What is utilitarianism?
Best course is the one that promotes most happiness/absence of pain for all - lesser of two evils
What is egoism?
Best course is what’s best for you (may not be best for others)
What is altruism?
The best course is what is best for others (may not be best for you)
What is deontology?
Duty based - there are fundamental duties and rules to be followed, and acts are seen as wrong if they violate these no matter what the consequence
What are the 4 principles of ethics?
Autonomy - patient choice
Beneficence - patients best interest
Non maleficence - do no harm
Justice - equity, avoid discrimination
What is dynamism?
situations are always dynamic/changing and what is best at one time may not be appropriate at a later stage
