Session 5 - Health Promotion, Screening and Risk Communication

Question 1

What are meant by determinants of health?

Answer 1

• A range of factors that have a powerful and cumulative effect on the health of populations, communities and individuals:*
• • Physical environment*
• • Social & economic environment*
• • Individual genetics, characteristics and behaviours*
• On this basis therefore, individuals are unlikely to be able to directly control many determinants of health and so blaming them for poor health or crediting them for good health is inappropriate.*

Question 2

What is health promotion?

Answer 2

1. EMPOWERING
2. PARTICIPATORY
3. HOLISTIC
4. INTERSECTORAL
5. EQUITABLE
6. SUSTAINABLE
7. MULTI-STRATEGY

Question 3

What are the 5 approaches to health promotion?

Answer 3

1. Medical or preventative
2. Behaviour change e.g. Smoking = Ask, Advise, Act
3. Educational e.g. Smoking posters
4. Empowerment
5. Social change e.g. banning smoking in public places

Question 4

There are 3 levels of prevention.

What is meant by PRIMARY PREVENTION?

Answer 4

Aiming to prevent the onset of disease or injury. Often has 4 approaches:

1. Immunisation
2. Prevention of contact with environmental risk factors.
3. Taking appropriate precautions re communicable disease.
4. Reducing risk factors from health related behaviours.

Question 5

There are 3 levels of prevention.

What is meant by SECONDARY PREVENTION?

Answer 5

Aiming to detect and treat a disease at an early stage (to prevent progression/potential future complications)

Examples include:

• Screening for cervical cancer
• Monitoring and treating blood pressure
• Screening for glaucoma.

Question 6

There are 3 levels of prevention.

What is meant by TERTIARY PREVENTION?

Answer 6

Aims to minimise the effects of established disease. Examples include:

• Maximising the remaining capabilities and functions of an already disabled patient
• Renal transplants
• Steroids for asthma

Question 7

What are 6 dilemmas around health promotion?

Answer 7

1. Interfering in people’s lives

2. Victim blaming (ignoring determinants of health that cannot be directly controlled)

3. Fallacy of empowerment (having the information doesn’t mean people can act on this because there may be adverse circumstances and wider socio-economic determinants of health limiting this ability).

4. Reinforcing negative stereotypes (e.g leaflets aimed at HIV prevention in drug users can reinforce idea they are only to blame for their situation).

5. Unequal distribution of responsibility (e.g. women are responsible for implementing health behaviours).

6. Prevention Paradox (interventions that make a difference at a population level might not have much effect on the individual [people may not see themselves as a ‘candidate’, and there are also elements of anomalies and randomness of a disease])

Question 8

Define ‘evaluation’, and why it is carried out.

Answer 8

• The rigorous & systematic collection of data to assess the effectiveness of a programme in achieving predetermined objectives.*
• • Needed for evidence-based interventions.*
• • Accountability*
• • Ethical obligation*
• • Programme management & development*

Question 9

There are 3 types of evaluation.

What is meant by PROCESS evaluation?

Answer 9

• Focuses on assessing the process of programme implementation.
• AKA formative or illuminative evaluation.

Question 10

There are 3 types of evaluation.

What is meant by IMPACT evaluation?

Answer 10

Assessing the immediate effects of the intevention.

Question 11

There are 3 types of evaluation.

What is meant by OUTCOME evaluation?

Answer 11

Measuring long-term consequences e.g. improvement in lives, reduction of symptoms.

NB:// The timing of evaluation can influence the outcome - Delay (take time to have effect) and Decay (wear off rapidly)

Question 12

What is meant by the term ‘diagnosis’?

Answer 12

The definitive identification of a suspected disease or defect by application of tests, examinations or other procedures (which can be extensive) to definitely label people as either having a disease or not having a disease.

Question 13

Outline 3 ways in which disease can be detected.

Answer 13

1. Spontaneous Presentation
2. Opportunistic Case Finding
3. Screening

Question 14

What is SCREENING?

Answer 14

A systematic attempt to detect an _unrecognised_ condition by the application of tests, examinations or other procedures, which can be applied _rapidly_ (and cheaply) to distinguish between _apparently well persons_ who _probably_ have a disease (or its precursor) and those who _probably do not_.

Question 15

For what purpose(s) is screening carried out?

Answer 15

• To give a better outcome compared with finding something in the usual way (i.e. having symptoms and self-reporting).
• If treatment can wait until there are symptoms there is no point in screening.

NB:// Finding something earlier is NOT the primary objective.

Question 16

Give examples of some screening programmes.

Answer 16

• AAA screening programme
• Bowel cancer screening programme
• Breast screening programme
• Cervical screening programme
• Fetal anomaly screening programme

Question 17

Give 3 examples of diseases where there is no national screening programme (or a restricted one)…

Answer 17

• Prostate Cancer (PSA test)
• Breast Cancer screening for those women <50 yrs.
• Cervical Cancer screening for women <25 yrs.

Question 18

There are five areas of criteria for screening:

1. Condition

2. Test

3. Intervention

4. Screening programme

5. Implementation.

Describe and explain what is meant by ‘Condition’

Answer 18

• It must be an important health problem (frequency/severity) with epidemiology, incidence and prevalence understood.
• All cost-effective primary prevention interventions should have been implemented as far as practicable.

Question 19

There are five areas of criteria for screening:

1. Condition

2. Test

3. Intervention

4. Screening programme

5. Implementation.

Describe and explain what is meant by the ‘Test’

Answer 19

• Has to be simple, safe, precise and validated.
• It must be acceptable to the target population.
• The distribution of test values in the population must be known with an agreed cut-off-level.
• There must be an agreed policy on further diagnostic investigation for those who have a +ve result.

Question 20

There are five areas of criteria for screening:

1. Condition

2. Test

3. Intervention

4. Screening programme

5. Implementation.

Describe and explain what is meant by the ‘Intervention’

Answer 20

• Evidence is required that intervention at a pre-symptomatic phase leads to better outcomes for the screened individual compared with usual care.

Question 21

There are five areas of criteria for screening:

1. Condition

2. Test

3. Intervention

4. Screening programme

5. Implementation.

Describe and explain what is meant by the ‘Screening programme’

Answer 21

• There needs to be a proven effectiveness in reducing mortality or mobidity (high quality RCT data).
• The complete screening programme must be clinically, socially and ethically acceptable to health professionals and the public.
• The benefit gained by individuals should outweigh any harms (e.g. from overdiagnosis, overtreatment).
• The opportunity cost of the screening programme should be economically balanced in relation to expenditure on medical care as a whole.

Question 22

There are five areas of criteria for screening:

1. Condition

2. Test

3. Intervention

4. Screening programme

5. Implementation.

Describe and explain what is meant by the ‘Implementation’

Answer 22

• That clinical management and patient outcomes should be optimised in all healthcare providers.
• All other options for managing the condition should have been considered.
• There should be adequate staffing and facilities for the programme.
• Evidence-based information should be available to potential participants (informed choice).
• Public pressure should be anticipated.

Question 23

Discuss some of the difficulties (3) in evaluating screening programmes.

Answer 23

1. Lead time bias => early diagnosis falsely appears to prolong survival i.e patients live the same length of time, but simply know about the disease for longer.

2. Length time bias => Screening programmes are better at picking up slow growing, unthreatening cases rather than aggressive, fast-growing cases.

3. Selection bias => studies often skewed by ‘healthy volunteer effect’ i.e. those who have regular screening are likely to do other things to protect them from disease.

Question 24

What are the 2 types of error that any screening test is going to make?

Answer 24

1. It is going to refer well people for further investigation i.e FALSE POSITIVES.
   * (stress, anxiety, direct & opportunity costs)*
2. It is going to fail to refer people who do actually have an early form of the disease i.e. FALSE NEGATIVES.
   * (inappropriate reassurance and delay)*

Question 25

There are 4 features of test validity:

(i) SENSITIVITY

(ii) SPECIFICITY

(iii) POSITIVE PREDICTIVE VALUE

(iv) NEGATIVE PREDICTIVE VALUE

What is meant by the term ‘Sensitivity’?

Answer 25

• The proportion of people with the disease whose result is positive.
• It is also known as the detection rate.
• If the sensitivity is high then the test is very good at correctly identifying people with the disease that is being screened for.

Question 26

There are 4 features of test validity:

(i) SENSITIVITY

(ii) SPECIFICITY

(iii) POSITIVE PREDICTIVE VALUE

(iv) NEGATIVE PREDICTIVE VALUE

What is meant by the term ‘Specificity’?

Answer 26

• This is the proportion of people without the disease whose result is negative.
• If the specificity is high then the test is very good at correctly identifying people without the disease as not having the disease.

Question 27

There are 4 features of test validity:

(i) SENSITIVITY

(ii) SPECIFICITY

(iii) POSITIVE PREDICTIVE VALUE

(iv) NEGATIVE PREDICTIVE VALUE

What is meant by the term ‘Positive Predictive Value’?

Answer 27

• If a person tests positive, what is the risk of them actually having the disease.

Question 28

There are 4 features of test validity:

(i) SENSITIVITY

(ii) SPECIFICITY

(iii) POSITIVE PREDICTIVE VALUE

(iv) NEGATIVE PREDICTIVE VALUE

What is meant by the term ‘Negative Predictive Value’?

Answer 28

• It is the proportion of people who have a negative result who actually do not have the disease.

Question 29

What are some of the implications of a FALSE POSITIVE result?

Answer 29

• Patients will be offered diagnostic testing (often invasive) with all its anxieties and risks, for a condition they do not actually have.
• May lead to lower uptake of screening in future.

Question 30

What are some of the implications of a FALSE NEGATIVE result?

Answer 30

• Patients will not be offered (invasive) diagnostic testing when in fact they may have benefited from it.
• They will be falsely reassured and may present late with symptoms as a consequence.

Question 31

What is meant by PROPORTIONATE UNIVERSALISM?

Answer 31

The idea that focusing solely on the most disadvantaged will not reduce health inequalities suffiiently.

In essence, to the reduce the steepness of the social gradient in health, actions must be universal.

Question 32

What is the INVERSE CARE LAW?

Answer 32

The availability of good medical care tends to vary inversely with the need of the population served.