SocPop Flashcards
What is an epidemiological transition?
As countries move through economic and social development, change in disease profile and demographic
Life expectancy increases
Deaths from acute infections and deficiencies reduce
Deaths from chronic, non communicable diseases increase
Why do we need a population perspective?
Produces a different view
Factors affecting health of population equate to more than adding up of individual determinants
What is a good proxy marker for population health?
Infant mortality rate
Why is infant mortality rate a good marker for population health?
Correlates well with other markers
Simple to measure
Highly sensitive to social determinants of health and disease epidemics
What is the trend in child mortality rates in the UK?
Reducing over the years although still higher than countries like Sweden
What is the trend in life expectancy from birth? And what gender differences exist?
Life expectancy at birth rising. Women consistently higher life expectancy than men although the gap between the genders is closing
What factor can affect the life expectancy rates in some less well developed countries?
High rates of child mortality
What is disability free life expectancy?
Number of years an individual can expect to live without a limiting chronic illness or disability
What does the difference between life expectancy and disability free life expectancy show?
The number of years an individual can expect to live with a limiting chronic illness or disability
Which gender will live more of their life with a limiting chronic illness or disability?
Females
What is the main cause of death in the UK?
Cancer
What is the main site of cancer that causes death?
Lung in both males and females
What is social epidemiology?
Social patterning of population health - systematic
Examines differential risks for social groups
Looks at personal and social attributes of individuals to explain patterns
Not all individuals within a group have all the attributes or experience same outcomes
What are health inequalities?
Systematic differences in health and illness across social groups
What attributes may contribute to health inequalities?
Socio economic position Gender Ethnicity Geography Age
How can socio economic status be measured?
Index of multiple deprivation Occupation (registrar Generals socio economic classification) Access to or ownership of assets Income Education
What is National statistics socio economic classification?
Divides into 7 categories based on occupation
From unclassified through to higher professional and managerial
Which SES group in the UK has highest rates of infant mortality?
Lower SES groups eg those in routine, manual jobs
What is the trend in mortality rates and how is this affected by SES?
Mortality rates decreasing over time in all social groups
However, still same divide between highest and lowest SES groups with 3x less deaths in those in highest SES groups
What are indices of multiple deprivation?
Relative composite measure of deprivation for small areas
Combines 7 indicators
Areas ranked from least deprived to most deprived
What is the trend in coronary artery disease death rates and how does SES affect this?
Decrease in mortality over time in all groups
However, widening inequality between those in highest and lowest SES groups
Incidence of lung cancer in most deprived areas is the same as in least deprived areas, true or false?
False
2.5 x higher incidence rate in most deprived areas
What is the social pattern evident across many indicators?
Clear social gradient, stepwise decline in health from highest to lowest SES groups
What are the exceptions to the stepwise gradient of social health?
Breast and prostate cancer higher incidence in least deprived groups
Malignant melanoma higher incidence too, could be as can afford more holidays so spend more time in sun, skin damage
Socio-economic inequality in health status are found across all age groups, from birth to old age. Where are the steepest stepwise gradients in inequality found?
Childhood
Geographically, where in UK are mortality and morbidity rates highest?
North, west and urban areas
What factors can explain health inequalities?
Age, sex and constitutional factors Individual lifestyle factors Social and community networks Living and working conditions Socio economic, cultural and environmental conditions
What 3 models can be used to describe health inequalities?
Behavioural/cultural
Material/life course
Psycho social
How does the behavioural model explain health inequalities?
Health related behaviours are result of individual choices
Policy responses focus on promoting change at individual level - promote quit smoking and harms of drinking
However, potentially widens inequalities because most affluent people are most likely to access the services
How does the materialist model explain health inequalities?
Direct effects of poverty and material deprivation such as poor housing, income, working environments, cultural/ behavioural factors on health inequalities
Over-crowding & poor housing associated with higher rates of some infectious diseases, including tuberculosis and higher rates of respiratory conditions
Childhood accidents and injury, including injuries in the home higher in deprived areas
Poor diets associated with elevated risk of CHD, childhood obesity, type 2 diabetes
Food poverty - Limited access to affordable, healthy food, Low level of cooking skills/ access to equipment, Easy availability of high calorie, low nutritional value fast food
How is life course linked to health inequalities?
Accumulation of positive and negative effects throughout life on health and wellbeing
There is a multiplication of risk through people’s lives
Post natal depression, child being read to regularly, regular bed times etc all affect the child’s future health but are different between social classes
Correlation between education level as an adult and prevalence of illness
How does the psycholosocial model explain health inequalities?
Relative position in social hierarchy is important, not just absolute deprivation
Social isolation and sense of control over life influences health outcomes: repeated activation of ‘fight-or-flight’ response
How can the fight or flight response influence health outcomes?
Rapid activation of sympatho-adrenal pathway (psychological arousal/ energy mobilisation/inhibitions of functions not essential to immediate survival)
Second (slower) activation of hypothalamic-pituitary-adrenal axis leading to release of cortisol. Cortisol acts as antagonist of insulin, leading to mobilisation of energy reserves by raising blood glucose
Repeated activation - acute and chronic stress
What is the allostatic load theory?
Links psychosocial environment to physical disease via Neuroendocrine pathway - lack of control in life
Relevant to CV disease, cancer, infection, cognitive decline
From the Marmot review, what 6 actions were suggested to tackle health inequalities?
Give every child the best start in life
Enable all children, young people and adults to maximise capabilities and have control over their lives
Create fair employment and good work for all
Ensure healthy standard of living for all
Create and develop healthy and sustainable places and communities
Strengthen the role and impact of ill-health prevention
What 3 theories/studies are used to describe human behaviour?
Behaviourism
Social psychology
Cognitive psychology
What is behaviourism?
Study of how reward and punishment affect emotion and behaviour
Behaviour is a conditioned response occurring in the presence of a stimuli
Can be learned or unlearned through conditioning
Name 3 studies which looked at conditioning
Operant conditioning - Skinner. Learning through reward in rats
Classical conditioning - Pavlov. Learning through association
Classical conditioning - Watson. Baby
How does operant conditioning apply to medicine?
Positive reinforcement much stronger than punishment so can use it to encourage adaptive behaviours
Chronic pain behaviours can be reinforced when families are over controlling and encourage patient to lie down and rest
What is social psychology?
Study of way people’s thoughts feelings and actions are influence by social environment
What study was a classic example of how social psychology can affect people’s behaviour?
Milgrams obedience study - authority figure facilitates obedience
How does obedience fit in with healthcare?
Nurses instructed wrongly by doctor will 21/22 times administer the drug, knowing that it is wrong
Perceived authority facilitates obedience
What are the social cognition theories?
Health belief model
Theory of planned behaviour
Transtheoretical model
What are the 4 strands of the health belief model?
Perceived: Benefits - efficacy Barriers - efficacy Susceptibility - threat Severity - threat
What is the health belief model largely used to predict?
Screening, whether people will engage with this behaviour
What is a limitation of the health belief model?
Doesn’t take into account influence of people around us or environment
What are the 3 strands of the theory of planned behaviour?
Behavioural attitude - beliefs and outcome evaluation
Subjective norm - normative beliefs and motivation to comply
Perceived behavioural control - control beliefs and self efficacy
What are the stages of the transtheorectical model/ stages of change?
Pre contemplation Contemplation Preparation Action Maintenance Relapse
In what clinical situation can the stages of change model be applied?
Rehabilitation programs
What are the 5 belief dimensions that patients may have for a particular illness?
Identity - what is it Cause - what caused it Time - how long will it last Consequence - how will it impact my life Control-cure - can it be treated, controlled, managed etc
What factors feed into the self regulatory model?
Illness representations
Interpretations - symptom perception, social messages
Coping - approach or avoid
Appraisal - was coping effective
Emotional response - fear, anxiety, depression
What clinical tool can be used to evaluate a patients self regulatory model?
Illness perception questionnaire
Why should health inequalities be an issue to doctors?
Human rights
Reduce costs associated with premature deaths and illness
Helping people live longer, healthier and more fulfilling lives
What have major reports concluded about health inequalities?
Major determinants of health inequalities are structural determinants and conditions of daily life
What were recommendations from Marmot review about reducing health inequalities?
Reduce social gradient - progressive universalism
Action across all social determinants
Action across all sectors
Participatory decision making at local level
Action across 6 policy areas
What is proportionate universalism?
Population wide approach that seeks to obtain highest health
standard for all
Aim for a more equal distribution of health chances across socio-economic groups
Need absolute improvements for all groups but a rate of improvement
which increases at each step downwards on the socio-economic
ladder
What are some social determinants that contribute to health inequalities?
Low education, lack of employment, low pay, poor material environments, pollution, poor access to services
What sectors should be tackled in order to tackle health inequalities?
Health, education, social services, housing, income maintenance, employment, environment
What might be some up stream approaches to tackling health inequalities?
Public policy approaches - reducing poverty, taxation, reducing price barriers, reducing unemployment through national policies
What might be some down stream approaches to tackling health inequalities?
Health behaviours, lifestyles eg smoking, diet, access to care
Reduce teenage pregnancy
Improve parenting skills, early access to education
Give examples of evidence based upstream interventions which have been shown to reduce health inequalities
Increased employee control over their work environment
Improved standard of housing, more choice for low income families
Water fluoridation
Free folic acid supplements
Tobacco price increase
Improving education levels
Give examples of downstream interventions which have actually increased health inequalities
Mass media campaigns on smoking cessation and folic acid
Work place smoking bans
What are key messages from “working for health equity”?
Knowledge of social determinants
Practice-based skills: taking a social history, referring patients to non-medical services, placements in disadvantaged areas
Working with individuals and communities
Tackling health inequalities among NHS staff
Working in partnership with other agencies
Working as advocates for individuals, communities and general population
What are the key messages from Royal college of physicians on the role of health professionals in tackling health inequalities?
As clinicians: access to high quality health care for vulnerable groups,
bilateral referral pathways, refer to support services (e.g. housing, debt advice), data on inequality attributable admissions
As advocates for development of services/programmes for better
health outcomes
As managers and clinical leads: model employer
As educators: placements in disadvantaged areas, investigate social
determinants, local projects
What is disease prevention?
Actions aimed at eradicating, eliminating or minimising the impact of disease and disability, or if none of these is feasible, retarding the progress of disease and disability
What is health promotion?
Process of enabling people to increase control over their health and its
determinants, and thereby improve their health
Offers a positive and inclusive concept of health as a determinant of the quality of life and encompassing mental and spiritual well-being
What is primary, secondary and tertiary disease prevention?
Primary - pre disease, avoid disease in first place eg immunisation and health education
Secondary - latent or early stage, find and treat early eg screening, brief interventions, adequate treatment
Tertiary - symptomatic disease, limit damage eg rehabilitation, pain management
What are the 2 options for choosing who to target for disease prevention?
Individuals at high risk - preventative care. Requires detection of risk
Whole population - Small reduction in average blood pressure or cholesterol of a population would produce a large reduction in incidence of cardiovascular disease. The population approach is directed towards socio-economic, behavioural and lifestyle changes
What are strengths and weaknesses of the individual high risk strategy for disease prevention?
Strengths - appropriate for individual, high patient and doctor motivation
Weaknesses - high resources to identify risk, medicalise prevention, stigmatise individuals, limited effect at population level
What are the strengths and weaknesses of the population approach to disease prevention?
Strengths - high benefit for population as a whole, attacks root causes, shifts cultural norms, can work passively
Weaknesses - benefit small for each individual, low subject motivation
What is Roses prevention paradox?
A preventive measure that brings large benefits to the community offers little to each participating individual
What are the action areas of the Ottawa charter on health promotion?
Build healthy public policy Create supportive environments Reinforce community actions Develop personal skills Reorient health services
What are action areas of the Bangkok charter on health promotion?
Advocate for health based on human rights and solidarity
Invest in sustainable policies, actions and infrastructure to
address the determinants of health
Build capacity for policy development, leadership, health
promotion practice, knowledge transfer and research, and health
literacy
Regulate and legislate to ensure a high level of protection from
harm and enable equal opportunity for health and well-being for all people
Partner and build alliances with nongovernmental, public,
private, and international organizations and civil society to create
sustainable actions
What are Ewles & Simnett’s 5 Approaches in Health Promotion?
Medical - screening, immunisation eg early detection of smoking related disorders
Behaviour change - eg smoking cessation support
Educational - information of effects of smoking
Client centred - what do clients want to know about smoking
Societal change - make healthy choices easier eg no smoking policies, taxation, bans
What is Beatties model of health promotion?
Aspects of authoritative and negotiated, individual and collective interventions
Social and political aspects
Health persuasion, legislation, personal counselling, community development
When are differences in men and women’s death rates most pronounced?
In youth and early adulthood
What particular disorders do women report more of than men?
Anxiety and depression
In coronary artery disease, there is only one age group in which the death rates for women are higher than men, which group is this?
75+
Why are patterns of coronary heart disease so different between men and women?
Women have lower neuro-endocrine and cardiovascular reactivity to stressors
Men have a life-long sensitivity to certain damaging metabolities
Oestrogen protects women prior to the menopause
Men’s greater tendency to accumulate fat around the abdomen (central obesity), women accumulate fat around the hips and thighs (peripheral obesity), increased risk of metabolic syndrome
Describe gender differences in cigarette smoking and alcohol consumption
Historically men have smoked more cigarettes than women
Men are almost twice as likely as women to exceed the recommended daily limits for alcohol consumption
Men are also more likely to ‘binge drink’; 21% of men compared to
9% of women
Estimated that 38% of men and 16% of women have an alcohol use disorder
Strong association between heavy drinking, depression and suicide in men
When are obesity rates highest for men and women?
Older age groups but peak for women about 10 years later than men
Who is most at risk of accidental death?
Young men aged 16-34
Car crashes with speed and alcohol involved
When might accidental death rates in women exceed those in men?
In older age groups, 75+
Possibly due to increased falls
Describe gendered patterns of suicide and self harm
Men are nearly four times more likely to commit suicide than women
Deliberate self-harm is three/four times more common in women
Men tend to use more violent and lethal methods compared to women
Describe gendered patterns of access to health care
Women are more likely to then men to consult their GP
Men are more willing to use locums and to use A+E services as an alternative to GPs
Well-person checks in GP surgeries are less well attended by men than women
Men are 50% more likely than women to die from skin cancers despite a 50% lower incidence of the disease among men
Describe gendered explanations for patterns of men’s health
Male mortality partly reflects men’s exposure to occupational accidents and diseases
Men’s health-related behaviours now viewed as a means by which men demonstrate their masculinity; how men gain status as men - take more risks
Men often use ‘masculine-sanctioned’ coping behaviour to relieve stress despite potential damaging consequences - less likely to seek help and therefore more likely to reach crisis point
Changing men’s health-related behaviour may demand a
corresponding rejection of masculine ideals
Describe why men’s engagement with health services is less than women’s
Men are taught to be self-sufficient, not to complain and to be strong in mind and body; this may prevent men consulting when health problems arise
Men perceive themselves to be less vulnerable or susceptible to illness than women
Men tend to ‘normalise’ their symptoms and fear wasting doctors time
Men are less likely to accept emotional pain as valid
Structural and institutional barriers also inhibit men from
accessing health services
Describe gendered explanations for patterns of women’s health
Women tend to be characterised by different duties and responsibilities; most notably within the home
Women are more vulnerable to poverty and bear the brunt of low income within households
Maintaining the material and psychosocial environment of the
home increases social isolation and denial of self
Linked to women’s higher rates of anxiety and depression
CHD is perceived to be a mans disease, how does this influence women’s treatment?
Women less likely to receive a preliminary diagnosis of CHD; reduces likelihood of further investigation
Fewer women prescribed aspirin and lipid lowering drugs
Women less likely to be hospitalised and receive less invasive
treatment
Twice as many men with CHD had had surgery for their condition
Mental health is perceived to be a womens disease, how does this influence men’s treatment?
Women are prescribed more psychotropic drugs than men
Three main reasons put forward:
Doctors are more likely to perceive a physical illness as a psychological one when the patient is a woman
Medical advertising reinforces this perception
This type of medication more socially acceptable for women than for men
What can explain patterns of settlement?
Needs of the local economy and patronage of family and friends Fortunes of certain minority communities inextricably tied to certain industries and regions; decline in these industries disproportionately impacted on these groups
What factors of ethnic groups may affect health patterns?
Younger age distribution and larger household size
Why can mortality data for ethnic groups be inconsistent?
Ethnic group not recorded on death certificate. Only place of birth which may not reflect ethnicity
Which ethnic groups have the highest risk of circulatory disease?
Bangladesh and Pakistan
Which ethnic groups have high mortality rates for hypertension and stroke?
Caribbean and west/South African
Give 5 reasons for health inequalities in ethnic groups
Genetic/biological - eg sickle cell anaemia
Cultural - health beliefs and behaviours
Migratory - salmon bias phenomenon
Social deprivation - socio economic factors big influence
Racism - direct, indirect and institutional
What is MECC?
Making every contact count - brief intervention
Encouraging people to make healthier choices for better health:
Systematically promoting the benefits of healthy living
Asking individuals about their lifestyle and responding appropriately
Taking the appropriate action - give information, signpost or refer to support service
What lifestyle issues should be covered by MECC?
Healthy eating/maintaining healthy weight
Taking regular physical activity
Stopping smoking
Drinking alcohol within recommended limits
Mental health and wellbeing
Sexual health
What are benefits of brief interventions?
Most serious illnesses are caused or perpetuated by unhealthy lifestyles
Adopting healthier lifestyles can have a huge positive effect of people’s health
Delivering Brief Advice/Interventions can be the trigger to change
Ideal for most settings
Skills needed are generic
Quick and cost effective
Evidence based
Estimated that £10,000 invested in brief advice could save £43,000 health care costs
The effects persist for periods up to two years after intervention and perhaps as long as four years
Improved and quicker outcomes from treatments (e.g. wound
healing)
The satisfaction of knowing you are making a difference to patients’ lifestyles
Increased confidence in contacts with patients
Improving your own lifestyle
Enhancing your skill set
What percentage contribution to premature death are behavioural patterns?
40%
What are things to remember when discussing MECC?
LISTEN Look interested Involve yourself by responding Stay focused on information giving Test your understanding Evaluate what is not being said Neutralise your feelings
