semester 1 Flashcards
what is the biomedical model?
Only looks at Illness in terms of biological and physiological processes therefore treatment is only physical interventions such as drugs and surgery
what are the reasons for improved mortality rates?
due to medical advances:
* vaccinations and new drugs
* social improvements (better housing)
what are the top killers in 20th century?
TB
pneumonia
cancer
stroke
measles
what is the biopsychosocial model?
Psychological - Cognition, emotion, behaviour
Biological - Physiology, genetics, pathogens
Social - Social class, employment, social support
what are health problems associated with obesity?
heart disease
type 2 DM
stroke
what is the whole system approach to decrease obesity?
employment
food preference
social environment
what interventions can be put in place to reduce obesity?
childhood obesity plans (sugar reduction)
schools (improve physical activity sessions)
labelling (mandate calorie labelling)
what are the impacts of weight stigma?
- people dont feel comfortable talking to GP abt obesity
- arent treated with dignity by healthcare workers
- people dont have enough understanding of obesity
what is meant by the term public health?
The art and science of preventing disease, prolonging life and promoting health through the organized efforts of society.
what is meant by the term primary prevention?
(before people get the disease) Campaigns and ads, info before people get the disease, immunisations, safe habits eg protected sex
what is meant by the term secondary prevention?
(people are at risk or starting to get symptoms) needs specific advice for patients such screening, exercise programmes to increase cardiovascular health
what is meant by the term tertiary prevention?
Softening the impact of an ongoing illness or injury. Helping managing symptoms with drugs, support groups rehab etc
what are the 3 domains of public health?
- Health improvement: smoking cessation, public mental health, weight management
- Health protection: From- chemical hazards, infectious diseases, screening, vaccines
- Public health: Service design, needs assessment, prioritisation
what is meant by the term health inequality?
Differences in health between people or groups of people that have been socially constructed and not due to differences in genetics or physiology
what is the relationship between health and socio-economic disadvantage?
the more deprived a person = higher proportion of life spent in ill health so more likely to die young
what are examples of social determinants?
Occupation
Geographical area
Income
what are different explanations for health inequalities?
Black Report (artefact, social selection, behavioral-cultural, materialist)
Psychosocial
Income distribution
what is the artefact explanation of the black report?
Health inequalities evident due to way statistics are measured
* concerns about quality of data and method of measurement
* most discredited explanation
* data problems usually lead to underestimation
what is the social selection explanation of black report?
Direction of causation is from health to social position
* sick people move down social hierarchy, healthy people move up
what is the behavioural cultural explanation of black report?
ill health is due to people’s choices, knowledge and goals; ppl from disadvantaged backgrounds tend to engage in more health-damaging behaviors
* limitations = ‘choices’ difficult to exercise in difficult conditions, ‘choices’ rational due to lack of resources
what is the materialist explanation of black report?
inequalities in health arise from differential access to material resources (low income, unemployment, poor housing conditions)
* lack of choice in exposure to hazard
* most plausible explanation
* limitations = further research needed to determine which material deprivation causes ill health
what is the income distribution explanation of black report?
relative income affects health
* most egalitarian (born equal) societies have the best healths
* higher income inequality = higher stress = lower health
what is the psychological explanation for inequalities of health ?
negative life events, lack of social support and autonomy at work can contribute to social gradient
* direct impact = physiological, immune system
* indirect impact = mental health, health related behaviours
what are utilisation studies?
measure recepit of services
limitation: people who dont have access
(deprived groups are more likely to use GP services but less likely to use preventative or specialist services)
what is deprivation and access theory?
evidence of poorer access for lower socioeconomic groups
* manage health as a series of crises
* normalisation of ill health
* difficulty assembling resources needed for engagement of health services
what is meant by the term lay beliefs?
How people understand and make sense of health and illness. - by people with no specialised knowledge, socially embedded.
(medical info is rejected if incompatible with competing ideas)
what is the negative definition of health?
absence of illness
what is the functional definition of health?
ability to do certain things
what is the positive definition of health?
state of wellbeing and fitness
what is lay epidemiology?
- understand why and how illness happens
- why is happened to that person at that time?
what are the different influences of lay beliefs on behaviour?
health behaviour
illness behaviour
sick role behaviour
what is meant by the term health behaviour?
activity done to maintain health and prevent illness
what is meant by the term illness behaviour?
activity of ill person to define illness and seek solution.
what is meant by the term sick role behaviour?
Formal response to symptoms, seeking formal help and action of person as a patient
richer people are more likely to have a positive definition of health. what incentives are responsible for this?
Incentives of giving up smoking more evident for people who expect to remain healthy, more able to focus on long term investments
Incentives less clear for disadvantaged groups: normalised behaviour
what is the iceberg of illness?
most symptoms dont get mentioned to a doctor
what are the different factors which influence illness behaviour?
culture
visibility of symptoms
tolerance threshold
lay referral
what is lay referral?
discussing symptoms / seeking advice from lay-people before seeing a doctor
what is the importance of lay referral?
- understand why people delay seeking help
- use of alternative medications
- allows us to understand how, why and when people consult a doctor
what are the 3 types of people when adhering to medication?
deniers and distaners:
* dont accept illness and treatment
accepters
prgmatists:
* accept illness but only use medication when needed
what is the inverse care law?
The availability of good medical care tends to vary inversely with the need for it in the population served e.g those that need it most don’t have access to it
what are the different types of ‘work’ for patients with long term conditions?
illness work
everyday life work
emotional work
biographical work
identity work
what are the 3 components of everyday life work?
coping: cognitive process involved in dealing with illness
strategy: actions done to manage the condition and its impact
normalisation: try to keep pre-illness lifestyle or accept their new life as normal
what is illness work?
getting diagnosis, managing symptoms, self-management
process could be unpleasant and dealing with physical manifestations of illness may be challenging
what is emotional work?
Work that people do to protect the emotional well-being of others
(downplaying pain/symptoms and presenting cheery self, feeling of dependency (useless))
what is identity work?
Some conditions may have stigma, affects how people see them and how they see themselves. Illness could become defining aspect of identity.
what is biographical work?
Loss of self, loss of self-image. Constant struggle to maintain (+) def. of self
Why is biographical disruption associated with LTC?
LTC as major disruptive experience, new consciousness of body & fragility of life, perceiving self as normal to abnormal
what is meant by the term stigma?
negatively defined condition, conferring ‘deviant’ status
what is the differece between discreditable and discredited stigma?
discreditable: not visible but stigma if found out (HIV, mental illness)
discredited: physically visible characteristic or well known stigma sets them apart (physical disability or well known suicide attempt)
what is enacted stigma?
The real experience of prejudice, discrimination and disadvantage as a consequence of a condition
what is felt stigma?
Fear of enacted stigma & a feeling of shame due to the condition (selective concealment- telling only certain people etc)
what are learning theories?
what are the different learning theories?
- behaviours are learnt as a result of unconscious association
- classical conditioning, operant conditioning, social learning theory
what is classical conditioning?
Environmental/emotional cues connected to using drugs/alcohol which can trigger behaviour and lead to relapse
avoid cues/change association
what is operant conditioning?
behaviours reinforced with rewards or punishments
what are the limitations associated with classical and operant conditioning?
Based on simple stimulus-response can’t account of knowledge, beliefs, memory and social context.
what is the social learning theory?
People learn through observation (Bandura and the bobo doll)
Behaviour is goal-directed.
Inclined to perform when valued/ believe they can enact (self-efficacy)
Modelling more effective if people from higher status (celebs)
what are social cognition models?
what are the different social cognition models?
- look at how we decide to behave in a particular way
- cognitive dissonance theory, health belief model, theory of planned behaviour
what is the cognitive dissonance theory?
Discomfort when the beliefs you have had and events don’t match.
to reduce discomfort one may change their beliefs or behaviour
health promotion (create mental discomfort to prompt change in behaviour [smoking kills stickers]
what is the health belief model?
Beliefs about health threat (perceived susceptibility & severity) and beliefs about health related behaviour (perceived benefits and barriers) affects cues to action.
what is the theory of planned behaviour?
Attitude toward behaviour, subjective norm, perceived control impact INTENTION which impact behaviour
Good predictor of intentions but bad predictor of behaviour (prob. In translating intention to behaviour)
Implementation of intentions (concrete plan of action)
why do people not promote health?
Lack of capability
Insufficient opportunity
Lack of motivation
what is the COM-B model?
capability, motivation, oppurtunity all impact behaviours
what do the different parts of the COM-B model stand for?
capability: physical and psychological capability to do something: knowledge, skill, strength and stamina
motivation: reflective and automatic motivation (plans, desires, impulses)
oppurtunity: physical and social opportunity (time, resources)
what are the impacts of applying the COM-B model?
- apply rules to reduce oppurtunity to engage in behaviour
- increase knowledge
- create expectation/reward or punishment/cost
what is the nudge theory?
Focuses on unconscious influences on behaviour (change enviro. Using (+) reinforcement/ messages/ indirect suggestions)
when is a nudge successful?
- decrease effort required to make desired choice
- improve motivation to opt for choice (in Switzerland, train station stairs look like keyboard, encourage ppl stairs>lift)
what are the possibile negative implications with focusing on individual behaviour?
- Determinants of health are complex, outside of individual’s control
- Risk of victim blaming
- Single interventions target specific behavioural risk could have little impact
what are the implications of health promotion?
requires comprehensive strategy with 3 components:
1. a behaviour change approach
2. strong policy framework that creates a supportive environment
3. empowerment of people to gain control over healthy decisions
what is the definition of substance misuse?
Harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs.
what are the different types of substance?
- Stimulants: Feel more alert, energetic and confidence (Tobacco, cocaine, speed)
- Hallucinogens: Mind altering, changes perception/mood/senses (LSD, magic mushrooms, ecstasy)
- Volatile substances
- Depressants: Feel relaxed (alcohol, heroin, cannabis (suppresses CNS))
what are the risk factors associated with drug use?
Lack of parental supervision, substance abuse (peer pressure), drug availability (peers), poverty
what are the effects of drug use?
- Physical: Poverty, blood-borne virus transmission, constipation
- Social: Imprisonment, poor work/academic performance, social exclusion
- Psychological: Craving, guilt
- Mental health: Depression, anxiety, ⬆️ aggression, paranoia
what is the definition of dependence?
physical (relates to withdrawal symptoms) or psychological (impaired control, desire to repeat action)
what are the tools to assess alcohol dependence?
screening, Audit-C (test for at risk/increasing risk/high risk individuals)
what are the different theories of dependence?
learning theories
imitation theories
rational choice theories
what is the learning theory of dependence?
- classical conditioning
- drug dependence arises from environment
- effects paired with drug use
- conditioned to want substance when exposed to stimulus
what is the imitation theory of dependence?
learn behaviours through observation + has 3 components:
1. modelling (see others do it)
2. expectation (reward)
3. self-efficacy (own ability to enact)
what is the rational choice theory of dependence?
making rational choice that favour benefits of dependence > cost of dependence
motivated by own goals
what are the key elements of dependence treatment?
Reduce harm to user/fam/community, improve lifestyle, reduce crime, reduce amount of illicit drug use
what advice/checks are done for newly presenting drug users?
- health check
- screening for blood borne virus
- signposting
- sexual health advice
what are common health regimens for substance abusers?
- substitue drugs
- counselling (support groups)
- detoxification of substances
- recovery capital
these tests are proven to reduce mortality, crime + risk of blood-borne virus
what are common health regimens for substance abusers?
- substitue drugs
- counselling (support groups)
- detoxification of substances
- recovery capital
these tests are proven to reduce mortality, crime + risk of blood-borne virus
what are the different lessons for medical professionals when dealing with substance abusers?
- No single treatment appt. for all individuals
- Treatment needs to be readily available
- Effective treatment attends multiple needs, X just sub. Abuse
what is adherence?
Extent to which a person’s behaviour corresponds with agreed recommendations from a healthcare provider
- More patient centred than “compliance” (patient has the right to choose and its more holistic)
what is non-adherence?
failing to complete prescription or pick it up, taking more or less, missing doses.
how can you improve adherence?
educating patient on med
simplify regimen
use of physical aids and reminders
what are the limitations with adeherence?
doesn’t address intentional non-adherence
what are factors that affect adherence?
- Patient beliefs: Lay beliefs about illness/about medication (side effects, stigma, conflict w. activities) à patient may reject/modify regimen based on beliefs & priorities
- Social support results in higher adherence
- Quality of interaction/trust in healthcare provider
what is the multi-dimensional model of adherence?
- Patient factor: beliefs, understanding
- Psychosocial factors: social support, psychological health
- Healthcare factors: Dr-Pt interaction, communication
- Treatment factors: side effects, stigma, complexity
- Illness factors: symptoms, severity
what are the approaches to providing good healthcare for homeless patients?
- Disease prevention
- Pharmacological
- Psychosocial
what are the burden of disease / health needs of homeless people?
- Alcoholism
- Drug abuse
- Poor mental health
what is health promotion?
process of enabling ppl. To increase control over/improve their health. Goes beyond healthy lifestyles to wellbeing
what is the definition of health?
Extent to which an individual/group able to realise aspirations/fulfil needs to cope w environment
what are the different levels of prevention?
- Primary: (reduce exposure to risk factors) immunisation, diet, exercise
- Secondary: (early diagnosis/treat risk factors) screening for cervical cancer, monitoring
- Tertiary: (minimise effects) transplants, steroids for asthma
what are the different prevention measures of heart disease?
Smoking ban in public places
raising taxes on tobacco & alcohol
warning about dangers of tobacco
bans on alcohol advertising
what are the different prevention measures of type 2 diabetes?
Primary (exercise)
Secondary (screening for gestational diabetes)
Tertiary (screening for retinopathy)
what are the principles of “making every contact count (MECC)”?
Use brief opportunistic advice (BOA) to encourage patients to change lifestyle:
* Signposting to further help/additional support
* Increasing awareness of risks/provide encouragement for change
* Allows people to: promote mental/emotional wellbeing, ⬇️alcohol, X smoke, ⬆️physical activity
how is health promotion evaluated?
- Produce evidence-based interventions
- Accountability (for political support)
- Ethical obligation (ensure no direct/indirect harm)
- Programme management/development
what is the purpose of screening programmes?
give a better outcome compared with finding something the usual way
if treatment can wait till symptoms start then no point in screening
findining out the cause earlier is the main aim so prognosis is better
what diseases are there no screening programmes for?
alzheimers
protstate cancer
what are the different criteria of screening?
Condition: Must be an impt. Health prob. Where epidemiology(distribution), natural history is understood & all other cost-effective primary preventions dy implemented
Test: Simple, safe, precise and validated
Intervention: Evidence that intervention at pre-symptomatic phase leads to better outcomes
Screening Programme: Proven effectiveness in ⬇️mortality & benefit gained by individuals outweigh harms (e.g overdiagnosis, overtreatment), cost-effective
Implementation: Optimised in all healthcare providers & management/monitoring programme (quality assurance)
what is the difficulty in evaluating screening programmes?
lead time bias:
* early diagnosis falsely appears to prolong survival, known about illness earlier, treatment doesnt actually prolong life
Length time bias:
* screening picks up slow progressing illness rather than fast aggressive tumours, fast growing ones arent detected so arent involved in statistics
selection bias:
* screening skewed by healthy volunteers (need random controlled trial)
what is sensitivity of study?
Proportion of the people with the disease who test positive. High sensitivity = good at picking up the disease
a / a+c
what is specificity of study?
proportion of people who dont have disease who test negative
high specificity = good at ruling out people who dont have disease
d / b+d
what is positive predictive value?
probability that someone who tested positive actually has disease
a / a+c
what is negative predictive value?
probability of people who test negative who do not actually have disease
d / c+d
what factors affect screening uptake?
- Acceptability of the test: non-invasive/invasive
- Awareness of benefits of screening: risks of morbidity/mortality
- Convenience
- Accessibility (ppl. W disabilities)
- Reminders & endorsements
what is the importance of informed choice?
- More holistic approach to evaluation
- Respect for consumer autonomy in decision making
- Lead to more benefit>harm
- Assess effectiveness of particular screening programme
what are the difficulty in informed choice?
communicating benefits/risks of preventive interventions can be challenging
what factors increase demand of NHS resources?
increased ageing population
inchreased chronic disease
what is opportunity cost?
Once you have used a resource in one way, no longer want to use it another way
* Cost is viewed as sacrifice rather than financial expenditure
* opportunity cost is measured in Benefits Given Up
what are the 2 forms of rationing?
explicit rationing
implicit rationing
- what is explicit rationing?
- what are the advantages of explicit rationing?
- what are the disadvantages of explicit rationing?
- Based on defined rules of entitlement. The use of institutional procedures for the systemic allocation of resources.
- Transparent and accountable, evidence based, open for debate.
- Complex, there is individuality in each patient and illness, impact on clinical freedom
- what is implicit rationing?
- what is the disadvantage of implicit rationing?
- Allocation of resources through individual clinical decisions without those decisions being explicit.
- Can lead to discrimination, open to abuse, decisions could be based on social deservingness
- what is scarcity?
- what is efficiency?
- what is equity?
- what is effectiveness?
- what is utility?
- needs > resources, prioritisation occurs
- getting the most from limited resources
- fair distribution of resources
- extent to which an intervention produces a desired outcome
- value an individual labels on a health state
what is cost minimisation analysis?
Focus on costsnot relevant as outcomes rarely equivalent (E.g. All prostheses for hip replacement improve mobility equally, choose cheapest one)
what is cost effectiveness analysis?
Used to compare interventions which have common health outcome
compared in terms of cost per unit outcome (Qs. Is extra benefit worth the cost?)
what is cost benefit analysis?
Value everything in monetary terms, allows comparison w. external (not healthcare) interventions, methodological difficulties (diff. labelling non-monetary benefits, lives saved)
what is cost utility analysis?
Type of cost effectiveness analysis, focuses on quality of health outcomes produced/negated, measured as QALY
what are QALY’s?
measure survivala and quality of life
1 QALY= 1 year of perfect health. Assumes that 1 year in perfect health = 10 years with 0.1 perfect health.
1 QALY= 2 years of 50% QOL for 1 person
1 QALY= 6 months of healthy life for 2 people
how can you calculate QALY’s?
QoL x num of years
- what are the advantages of QALYs?
- what are the disadvantages of QALY’s?
- Prevents large implicit rationing, Explicit rationing (more transparent and centralised)
- dont distribute resources according to need but benefits gained per cost, disadvantages common conditions, dont assess impact on carers or family.
what are some alternatives to QALYs?
Health year equivalents
Saved young-life equivalents
Disability Adjusted Life Years
what is health related quality of life?
Impact of treatments & disease as perceived by patient
what are PROMs?
(Patient Reported Outcome Measures)
Instruments used to measure PROs
turn subjective experiences into numerical scores that can be used to measure HRQoL (Covers hip/knee replacements)
PROM’s are valid and reliable
what are the 2 types of PROMs?
Generic - Used in any patient popn
Specific - disease specific
- what are the advantages of generic PROMs?
- what are the disadvantages of genertic PROMs?
- Used for a range of health-probs, enable comparison across treatment/conditions, used to assess health of pop.
- Less detailed, ⬇️relevance, less sensitive to changes that occur
- what are the advantages of specific PROMs?
- what are the disadvantages of specific PROMs?
- Relevant context, sensitive to change, acceptable to patients
- Limited comparison, dont detect unexpected change
what are the key points in selecting PROMs?
Sensitivity to change
Easy to administer/analyse
Acceptable to patients
