SocPop Flashcards
1
Q
What are the 3 ways to consider normality?
Hint: SOS
A
Statistical - bell curves, 95% distributions e.g., height
Optimal - what’s the best for a population e.g., BMI
Social - determined by society
2
Q
What is disease?
A
- An objective deviation from the biological norm
- A pathological process confirmed by signs and investigations (objective)
- Definitions of disease change over time as medical knowledge advances
3
Q
What is illness?
A
A subjective experience or feelings, which can be felt in the absence of disease.
4
Q
What is sickness?
A
A social role assigned to or taken on by those perceived to be ill.
5
Q
What is health?
Hint: PMS
A
A state of complete Physical, Mental and Social well-being, and not merely the absence of disease/infirmity.
6
Q
Describe the medical model of health.
A
- Health is seen as the absence of disease
- Disease is caused by biological/pathological changes; based on mono-causal model
- Aim is to treat/cure, focus is on the individual
7
Q
Describe the social model of health.
A
- Social factors and lay beliefs are considered
- It respects autonomy
- Recognises that a person can have a disease/impairment and still feel healthy
8
Q
What are the 4 lay views of health?
A
- Absence of disease
- Functional (healthy if can work/do chores)
- Wellbeing/equilibrium (mind, body and spirit are in sync)
- Physical fitness
9
Q
Define ‘Patient-Centred Care’.
A
‘Treating patients as they want to be treated.’
10
Q
What are the 4 principles of Person-Centred Care?
A
Care is:
PERSONAL (partnership with patient)
ENABLING (recognises strength in self-care)
COORDINATED (over multiple episodes and time)
The patient is treated with DIGNITY, RESPECT and COMPASSION
11
Q
What are the ethical duties of a doctor?
A
Respect - ‘due regard for the feelings, wishes or rights of others’
Autonomy - underpins the legal and professional framework that governs the patient-doctor relationship.
Dignity - ‘a state, quality or manner worthy of esteem or respect; and (by extension) self-respect’
Care - beneficence, best interest, ethics of care (treat the condition, care for the person)
Consequences - better patient outcomes, less litigation, fewer complications, increased trust in the medical profession
12
Q
What are the 5 tasks of the Calgary-Cambridge Model of Consultation?
A
Commence consultation - Supportive environment, build rapport, establish the problem(s), make a plan for the consultation
Gather information - Explore (biomedical and patient perspective) and ensure (accurate, complete and mutually understood information, and patient feels listened to and valued)
Physical examination
Explain and plan- Sharing information, aiding recall, shared understanding and making a plan together (shared decision-making)
Close consultation - Confirm plan, clarify steps, contingency plan, maximise compliance, build rapport, continue to make patient feel like part of the process
13
Q
What are the 2 functions of the Calgary-Cambridge Model of Consultation?
A
Build relationship - Involve patient, build rapport/relationship, encourage sharing, establish trust, counselling as an ends in itself
Provide structure - Make organisation overt, attend to the flow
14
Q
Define demography.
A
Study of the size, structure, dispersement and development of human populations.
It is used to establish reliable statistics on:
• Population size and distribution
• Birth and death rates
• Life expectancy
• Migration
15
Q
How is the quality of health information assessed?
Hint: CARTA
A
Completeness, Accuracy, Representativeness/relevance, Timeliness, [Accessibility]
16
Q
What is a census?
A
Simultaneous recording of demographic data by the government at a particular time pertaining to all the persons who live in a particular territory.
Measures demographic, cultural, material, health and workplace information.
17
Q
How are births registered?
A
Notification by attendant to health authority within 36 hours; notification to health authority; registration by parents within 42 days –> local registrar for births, marriages and deaths –> ONS
18
Q
Describe the measures of fertility.
A
Crude birth rate = live births/1,000 population
General fertility rate = live births/1,000 females aged 15-44
Total fertility rate = number of children that would be born to a female if she were to live to the end of childbearing years and bear children in accordance with current age specific fertility rates
19
Q
How are deaths registered?
A
- Death certificate is issued by the doctor (certifies fact of death, age, place of death and cause of death)
- Death are registered within 5 days, usually by a relative and reported to the registrar for births, marriages and deaths
- The ONS produce mortality statistics (code: ICD10)
20
Q
What are the 3 different categories of causes of death?
A
- Direct cause (e.g., pneumonia)
- Intermediate cause (e.g., malnutrition)
- Underlying cause (e.g., dementia)
21
Q
Why are mortality rates not a reliable picture of mortality?
A
- The underlying cause of death is subject to diagnostic uncertainty, coding issues and variable quality
- Ethnicity is not collected
- Posthumous inflation of status
22
Q
What are population estimates used for?
A
To estimate the size and structure between the census (census baseline + births - deaths +/- migration).
23
Q
What are population projections used for?
A
To forecast for population size and structure (based on assumptions about mortality, fertility and migration).
24
Q
How is morbidity information sourced?
A
- Cancer registration
- Notification of infectious disease
- NHS activity data (HES and QOF)
25
What is HES?
Hospital episode statistics.
• Includes details of all NHS admissions, out-patient and A&E visits
• Clinical information is recorded by ICD-10 (international classification of disease, 10th ed) and OPCS-4 (classification of surgical operations and procedures, 4th ed)
26
What is QOF?
Quality Outcomes Framework.
• Linked to GP contract, based on clinical and public health outcomes
• Almost 100% response from GPs, representative of whole population, updates annually and accessible but excludes non-participating practices, accuracy can be questioned for individual practices and it only provides aggregated data for a practice.
27
How is information regarding determinants of health sourced?
* Socio-economic, deprivation etc (census)
* Lifestyle factors (surveys)
* Health survey for England: Annual since 1991 (1995 for kids). 16,000 adults, 4,000 children, multi-stage randomised sampling (representative), 75-85% response rate, physical and self-reported measures, monitors targets but national data only.
28
What are the downsides of using surveys?
Responder bias (more likely to respond if issue affects you personally) and reporting bias (self reporting can mean lower BMI reported).
29
What are the 4 NICE public health domains?
1. Improving the wider determinants of health
2. Health improvement
3. Health protection
4. Healthcare, public health and preventing premature mortality
30
What is the statistical determinant of normality?
* Normal as the usual or average
* Derived from measurements of populations
* Normal (Gaussian) distribution: 95% of population should be within ±2 standard deviations
* For example, height, weight, blood, waste products
31
What is the optimal determinant of normality?
The 'normal' value is determined by what is required for optimal health.
Examples include: BMI, glomerular filtration rate and vitamin D levels.
32
What is the social determinant of normality?
* What is ‘normal’ is interpreted with reference to social ‘norms’
* Normality is what society finds acceptable or desirable
* It is influenced by cultural and time – ideas about normality vary widely across and within cultures
* Beliefs, attitudes and behaviour considered acceptable in one culture may not be accepted in others, e.g., gender, sexuality (1967), dress and behaviour codes
33
What are the 4 dimensions of health?
- Physical
- Mental and emotional
- Social
- Spiritual
34
What are the limitations to the medical model of health?
- It ignores social factors
- Chronic diseases make it multifactorial/complex
- Power is in the hands of the doctor
35
What data are included in the UK census?
* Demographic data – age and sex
* Cultural characteristics – ethnicity and religion
* Material deprivation – employment, home ownership, overcrowding, car access, lone parents and lone pensioners
* Health – general, long-term illness and unpaid care
* Workplace and journey to work
36
What is a major limitation of measuring fertility using the 'crude birth rate'?
It is a poor indicator of fertility as it includes males, children and post-menopausal women in the denominator.
37
What is a major limitation of measuring fertility using the 'general fertility rate'?
It does not account for variation in fertility with age.
38
Why is the 'total fertility rate' a preferable option for measuring fertility?
Accounts for differing fertility rates within age groups.
39
What are the benefits of mortality data?
* Complete coverage in the UK
| * Important information on the health of the population
40
What are the strengths of population estimates?
* More up to date than the census
| * More accurate than projections
41
What are the limitations of population estimates?
- They get less reliable with time from census
- There is poor information available on migration
- Is not reflective of the future
42
What are the strengths of population projections?
- Useful for long-term planning
43
What are the limitations of population projections?
- Accuracy decreases with longer projection and unforeseen events can invalidate results
44
What is the predicted number of people over 85 years of age in 2041?
3.2 million.
45
What are the challenges to assessing a population's health?
* A range of health information is required
* No one source of health data is perfect
* There are many sources of data
46
What are the uses of cancer registration?
* Monitoring cancer rates
* Evaluation and improvement of cancer treatment
* Evaluation of screening programmes
* Aiding cancer research
47
What are the strengths of cancer registration?
* Detailed information is updated over time
| * Record linkage to cancer deaths (ONS)
48
What are the weaknesses of cancer registration?
* It is expensive
| * Access is difficult due to confidentiality
49
What information is included in HES?
* Personal information – age or gender
* Clinical information – diagnoses and operations
* Administrative data – date of admission, discharge
* Geographical information – where treated and lives
50
Who uses HES?
* Commissioning organisations
* Provider organisations
* Researchers
51
What are the uses of HES?
* To assess trends in NHS hospital activity
* To support local service planning
* To assess health trends over time
* To provide fair access to healthcare
52
What is the ICD-10?
International Classification of Diseases.
• Describes conditions treated or investigated, e.g., myocardial infarction and fractured skull
• Also used for coding mortality statistics
53
What is the OPCS-4?
OPCS Classification of Surgical Operations and Procedures.
| • Records details of operations e.g., hip replacement
54
What are the strengths of HES?
* Completeness – as covers all hospital activity
* Accuracy – standard codes used
* Representative – Routine national data
55
What are the weaknesses of HES?
Accessibility to individual data.
56
What are the uses of notification of infectious diseases?
- Surveillance
- Outbreak identification
- Trend monitoring
57
What are the strengths of notification of infectious diseases?
- It is timely (weekly reports by PHE)
- Representative - routine national data
- Accuracy - linked to laboratory reports
58
What are the weaknesses of notification of infectious diseases?
There is poor/variable completeness for some diseases (e.g., food poisoning) and accuracy is questionable as some suspected cases are also reported.
59
How many notifiable diseases are they in England?
31.
60
What should a doctor do if they suspect a notifiable disease?
Notify the Local Health Protection Team (part of PHE).
61
If a laboratory identifies a notifiable organism, what should they do?
Notify Public Health England.
62
How often are trends of notifiable diseases produced by PHE?
Weekly.
63
When was QOF introduced into the GP contract?
2004.
64
What are the maximum number of points available in QOF?
559.
65
What are the 3 domains in QOF?
- Clinical (435 points)
- Public health (97 points)
- Public health additional services (27 points)
66
What percentage of NHS primary care costs are covered by QOF?
15%.
67
What are the strengths of QOF?
- Completeness - almost 100% reponse
- Representative - representative of entire population
- Timeliness - updated annually
68
What are the weaknesses of QOF?
- Completeness - excludes practices who do not respond
| - Representative - only get aggregated data from each practice
69
Define 'prevalence'.
A measure of how common a disease is.
70
How is prevalence presented?
- Percentage
| - Number per n people
71
Name 3 types of prevalence.
- Point prevalence
- Period prevalence
- Lifetime prevalence
72
How is prevalence calculated?
As a proportion:
| number of people with condition/total number of people
73
Why do we calculate prevalence?
To gauge the burden of disease.
74
Why might point prevalence not be an accurate indicator of disease prevalence?
It can be affected by disease duration; acute disease may not occur at that specific time.
75
Define 'incidence rate'.
The rate at which new events occur in a population, over a defined period of time.
76
How is the incidence rate presented?
1. per n people per time period
| 2. per n person-years
77
Define 'person-years'.
A measurement combining the number of people observed and the number of years they were observed for.
person-years = number of people × number of years
78
How is the incidence rate calculated?
number of new cases / (number of people x years observed)
79
What factors increase prevalence?
- Incidence rate
| - Migration rate
80
What factors decrease prevalence?
- Recovery rate
- Death rate
- Migration rate
81
What is the 'point estimate'?
Our best guess based on sample data.
82
What is the 'sampling error'?
The differences between the sample point estimates and the truth.
83
What is the 'standard error'?
A numerical value that represents the sampling error.
84
What is the 'confidence interval'?
A range of plausible values, to represent your level of uncertainty when giving an estimate from a sample.
85
What is a 95% confidence interval?
Includes all values within 1.96 standard errors of the point estimate.
Lower bound = point estimate – (1.96 × S.E.)
Upper bound = point estimate + (1.96 × S.E.)
86
How do you calculate the standard error?
SQUARE ROOT (p(1-p))/n
87
How is the Odds ratio calculated?
OR = (De/He)/(Dn/Hn)
| where D, diseased; H, healthy; e, exposed; n, not exposed
88
Define 'Odds ratio'.
The odds of A in the presence of B and the odds of A in the absence of B.
89
Define 'standardised mortality ratio'.
The ratio of observed deaths in a given group to expected deaths in the general population.
90
Define 'absolute risk'.
The difference of the risk of an outcome in the exposed group and the unexposed group.
91
How is 'absolute risk' calculated?
Ie - Iu
| where Ie, incidence in the exposed group; Iu, incidence in the unexposed group
92
What does personalised care involve?
* Seeing (and getting to know) the patient as a person rather than the person as a patient
* A whole person approach
* Putting the person’s needs and preferences, as they define them, first
* Tailoring therapeutic plans and services to patient’s needs and desires
93
What does enabling care involve?
* Shared decision making – including patients and partners in decision-making
* Recognising the person’s strengths in self-care and management of their condition
* Supporting the person to self-manage: information, knowledge and support
* Patient and public involvement in the design and delivery of services: co-production of health
94
What does coordinated care involve?
Integrated care to address the health, social and emotional needs of patients:
Integration between health services, social services and other care providers; across primary, community, hospital and tertiary care services (vertical integration); through transitions e.g., child to adult services
95
Why do we use 'person-centred care'?
* Evidence of positive outcomes for patients
* Social and political drivers
* Concurs with ethical principles underpinning the duties of a doctor
96
What are the challenges to 'person-centred care'?
* Requires understanding of ethical principles and development of appropriate values
* Requires high level of clinical skill and experience
97
What are the elements of dignity?
Respect, privacy, self esteem, freedom from unnecessary pain and autonomy.
98
Describe the trends in population health in the UK.
* Social and economic development
* Transition in the demographic and disease profile
* Deaths from acute infections and deficiency diseases decline
* Deaths from chronic and non-communicable diseases increase
99
Define 'healthy life expectancy at birth'.
The average number of years in a particular year, one can expect to live in a state of general ‘good’ health.
100
In 2015, were life expectancies and healthy life expectancies higher in males or females?
Females.
101
What were the 5 leading causes of death in England and Wales in 2016?
Lung cancer, chronic lower respiratory diseases, cerebrovascular diseases, ischaemic heart diseases, dementia and Alzheimer's disease.
102
What is 'social epidemiology'?
* Examines differential risks for social groups
* Looks at the attributes (e.g., social conditions, exposure to environmental risk factors etc.) of individuals within these groups to try to explain patterns
103
What social factors may result in systematic differences in health and illness between social groups?
Gender, ethnicity, geography, socio-economic position, age, sexuality.
104
What is the Registrar General’s socio-economic classification?
* Most commonly used to look at health inequality
* Based on occupation
* Is proxy for status, income, access to material resources and education
105
Which cancer types are less common in more deprived populations?
Prostate, testis, malignant melanoma, ALL (male), brain tumours (female) and breast.
106
Define 'health inequality'.
Systematic differences in health between social groups.
107
What is the belief of the behavioural/cultural model of health inequality?
Health inequalities are the result of variations in health behaviours and lifestyles e.g., smoking, diet and exercise.
108
According to the behavioural/cultural model, health behaviour choices are seen as the result of...
* Individual choices
* Knowledge
* Culture
109
Give 3 examples of health behaviours that are more common in lower socio-economic groups.
- Smoking
- Lack of physical activity
- Poor nutrition
110
What social factors may explain differences in health behaviours between different social groups?
* Socio-economic circumstances
* Education
* Gender
* Culture and ethnicity
111
What is the belief of the 'material explanation' of health inequality?
Health inequality results from the direct effects of poverty and material deprivation (social inequality), due to differences in access to material resources, which is shaped by broader structural factors, including place in society and policies.
112
What evidence is there to support the 'material explanation' of health inequality?
Lower socio-economic status is associated with poorer access to material health resources, including income, food, fuel, heating, housing, transport, healthy environments and exercise facilities.
113
Using food as an example, describe how the 'material explanation' of health inequality explains this.
* Poor diets and nutritional status are associated with an elevated risk of CHD, type 2 diabetes and childhood obesity
* Higher income is associated with a better diet – more fruit and vegetables, higher fibre intake and lower intake of sugars
* Lower income groups spend more of their income on food, leaving less money for other things – higher calorie, low nutritional value foods are cheapest
* Social security benefits are inadequate for a healthy diet
114
Provide an example of poorer access to material resources at the community level.
Underinvestment in physical, social and health infrastructures has greatest effects on lower socio-economic groups.
115
What is the psychosocial explanation of health inequality?
Proposes that health inequality is linked to psychosocial environment (the way people’s environments make them feel).
116
How does psychosocial stress affect health?
* Directly: ‘allostatic load’ theory links psychosocial environment to physical disease through the neuroendocrine pathway
* Indirectly: adoption of ‘unhealthy’ behaviours e.g., smoking
117
What additional stresses may be experienced by people on low incomes?
* Stress associated with low income and poorer material circumstances (e.g., money)
* Stress associated with position in social hierarchy
* Stress associated with less control over life (e.g., in work)
118
What are lifecourse effects?
Material, behavioural and psychosocial (and biological) processes that operate independently, cumulatively and interactively across an individual’s lifecourse, or across generations, to influence the development of disease risk.
119
Define 'health behaviours'.
Behaviours that are related to the health status of the individual.
120
What are the key elements to behaviour change?
* Threat – awareness of a danger or potential threat
* Fear – emotional arousal by perceived relevant threat
* Barriers – preventing response/behaviour
* Benefits – positive reward/consequence
* Subjective norms – the views of others and their relevance
* Attitudes – evaluation/beliefs about the behaviour
* Response efficacy – perception of response in preventing the threat
* Cognitions – awareness of thoughts and perceptions
* Intentions – plans to carry out the response/behaviour
* Cues to action –external and internal factors that influence decision making
121
Why might people be resistant to change?
* Creatures of habit/being told what to do
* Simply just giving information is not effective
* Short term gain vs long term consequences
* Lack of motivation
122
What is 'behaviourism'?
The scientific study of how reward and punishment (stimuli) affect emotion and behaviour (response).
123
Explain the role of operant conditioning (Skinner) in medicine.
Positive reinforcement vs punishment.
124
What are the policy categories of the behaviour change wheel?
- Environmental/social planning
- Communication/marketing
- Legislation
- Service provision
- Regulation
- Fiscal measures
- Guidelines
125
What are the intervention functions of the behaviour change wheel?
- Education
- Persuasion
- Incentivisation
- Coercion
- Training
- Enablement
- Modelling
- Environmental restructuring
- Restrictions
126
What are the 4 components of the COM-B model?
- Capability
- Opportunity
- Motivation
- Behaviour
127
What are the 5 steps of behaviour change in practice?
* Step 1: Define the behavioural problem.
* Step 2: What target behaviour will address the problem?
* Step 3: Develop a clear plan of when and how then patient will perform the target behaviours. What behaviours do they need to change? Who else is involved (healthcare professionals, healthcare systems, family/friends)?
* Step 4: Assess using the COM-B framework. Do they have the capability, motivation and opportunity to engage in the behaviour change?
* Step 5: Reflect, evaluate, monitor and adapt if necessary.
128
Using smoking as an example, explain how the health-belief model (HBM) is used in clinical practice.
•Explore perceived susceptibility and severity:
o How do you think smoking is affecting your health? (current susceptibility)
o How might it effect your health in ten years’ time? (future susceptibility)
o What would it be like if that happened to you/you got the illness? (Severity)
• Educate patient about the risks of smoking, which can increase the perceived susceptibility and severity
• Explore perceived benefits and barriers
o What are the pros and cons of smoking for you? (current benefits and costs)
o Is there anything stopping you from giving up? (current barriers)
• Use education for perceptions of threat, goal setting/action planning and problem solving to help overcome barriers
• Work with the patient to problem solve and overcome barriers and reinforce education about the benefits of giving up
129
Using smoking as an example, explain how the theory of planned behaviour (TPB) is used in clinical practice.
• Explore attitude: What do you think about smoking? Is smoking good or bad for you? In what way? (Educate)
• Explore perceived norms:
o What do your family/friends think about you smoking? (normative beliefs)
o Whose opinion is most important to you? Would you like to quit smoking for them? (motivation to comply)
• Explore intentions:
o Have you ever thought about giving up smoking?
o Do you intend to give up smoking in the next few months?
• Explore perceived behavioural control
o Do you think you can give up smoking?
• If perceived control is low, you can explore further by asking why? Try to normalise the situation and explore ways around the obstacles.
• If perceived control is high, get ready to attempt behaviour change.
130
What are the 5 stages of change in the transtheoretical model?
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance
131
Define 'sex'.
Biological and physiological characteristics that are used to categorise people as male or female.
132
Define 'gender'.
Socially constructed roles, behaviours, activities, and attributes that a given society considers appropriate for males and females.
133
Define 'heteronormativity'.
Society’s assumption that relationships between the opposite binary sex individuals (heterosexuality) are the norm or default.
134
What is meant by 'gender identity'?
Internal sense of one’s own gender.
135
What is meant by the term 'transgender'?
An umbrella term for people whose gender identity differs from the sex/gender they were assigned at birth.
136
What is meant by the term 'sexual orientation'?
A person’s physical, romantic, emotional or other form of attraction to others.
137
Who has a longer life expectancy, males of females?
Females.
138
Who spends a greater proportion of their lives in poor health and with disability, males or females?
Females.
139
Are mental illness rates higher among men or women?
Women.
140
Name some possible biological explanations for sex differences in health.
* Boys are more vulnerable in infancy
* Immune system differences
* Hormone differences
* Cardiovascular reactivity
* Neuroendocrine responses
141
What patterns of health behaviour are observed more commonly in males?
* Higher smoking rates
* Higher alcohol consumption
* Higher rates of hospital admission for alcohol-related problems (65% vs 35%)
* Strong association between heavy drinking, depression and suicide in men
142
In the UK, how might gender roles influence health?
* Pay gap of 10% between men and women (ONS, 2017)
* Slightly higher rates of poverty among women (lone mothers and pensioners)
* Work environments: Improved for men and women, but accidents are higher for men
* Expectations about males and females associated with health and other behaviours
143
How might gender-sanctioned behaviours influence health?
* Men often use ‘masculine-sanctioned’ health-related coping behaviour to relieve stress despite potential damaging consequences
* Accidents: men are at higher risk due to exposure (work, driving and risk-taking)
* Caring is portrayed as women’s work, and is associated with physical + mental illness
144
How might access to health services differ among men and women?
* Certain diseases are often perceived as ‘male’ or ‘female’ and may be handled differently
* There are differences in symptom and symptom perception among women
* Women are more likely to visit the doctor
145
How does CHD differ among men and women?
• 14% male deaths and 9% of female deaths
• 3.4% of all inpatient episodes in men and 1.4% in women
• There are different underlying causes for men and women
• There are different symptoms for men and women:
o Women’s symptoms of MIs are often not those associated with MIs in men. Therefore, women are less likely to recognise their symptoms as those of CHD or MI and wait longer to call an ambulance. As a result, doctors can fail to identify signs/symptoms in women, leading to underdiagnosis and death.
146
Define the term 'race'. [NB: Discredited]
Historical term used to argue for the existence of inherent biological differences between populations.
147
Define the term 'ethnicity'.
* Two common characteristics that separate one ethnic group from another
* A long-shared history of which the group is conscious as distinguishing it from other groups, and the memory of which it keeps alive
* A cultural tradition of its own, including family and social customs and manners, often but not necessarily associated with religious observance
148
Explain the ethnic inequalities associated with type II diabetes.
People of South Asian family origin:
• Are up to 6 times more likely to have type 2 diabetes, and are likely to develop it 10 years earlier, compared with the white population
People of African and African-Caribbean descent:
• Are 3 times more likely to have type 2 diabetes than the white population
149
What are the possible explanations for ethnic inequalities in health?
* Genetic/biological
* Cultural
* Migration
* Social deprivation
* Racism
150
List some limitations to the use of genetic/biological explanations for ethnic inequalities in health.
* Often based on the notion of ‘genetic homogeneity’ – ethnicity and ancestry used as a proxy for genetic risk
* Based on outdated biological concept of ‘race’ – population-specific alleles can only approximate relative genetic contribution for major continents
* Some congenital anomalies and haemoglobinopathies are strongly influenced by genes, but ethnicity is not always helpful in identifying at risk groups
* Epigenetics: Genes are affected by the environment; therefore, genes and biology cannot explain all ethnic inequalities in health
151
Describe the migratory explanation of ethnic inequalities in health, including its limitations.
* Migrants selected by health characteristics usually have better health among their population of origin
* Health of migrants tends to revert to the mean standard of the population of origin – produces a relative decline in health compared to health in the country of destination
* Stressful experience of migration and settling
* The ‘Salmon Bias’ phenomenon – people returning home when ill could artificially reduce the mortality rate of migrant populations
152
How might social deprivation explain ethnic inequalities in health?
* Ethnic inequalities in health reflect the broad patterning of socio-economic inequality among ethnic minority groups
* Socio-economic factors affect access to health resources, including housing, food and exercise
153
Define 'racism'.
Racism consists of conduct, words or practices that disadvantage people because of their skin colour, culture or ethnic origin.
154
What is 'direct racism'?
People are treated less favourably because of their ethnicity or religion.
155
What is 'indirect racism'?
People unaware their actions are undermining the position of people from ethnic minority groups.
156
What is 'institutional racism'?
‘The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethic people’
157
How might racism affect health?
* Direct experiences of racism and racial harassment can result in health inequality
* Indirect experiences of racism also have an effect on health, e.g., a fear of racism creates worry and stress, which can damage health
158
What are the 3 components of very brief advice?
* Ask
* Advise
* Act/refer
159
What are the 5 components of brief advice?
* Assess
* Advise
* Agree
* Assist
* Arrange/refer
160
What does LISTEN stand for?
| Hint: MECC
```
Look interested
Involve yourself by responding
Stay focused on information giving
Test your understanding
Evaluate what is not being said
Neutralise your feelings
```
161
Define '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.’
162
Define 'health promotion'.
“The process of enabling people to increase control over their health and its determinants, and thereby improve their health.”
163
At what stage of disease does primary prevention occur?
Pre-disease.
164
At what stage of disease does secondary prevention occur?
Latent or early stage of disease.
165
At what stage of disease does tertiary prevention occur?
Symptomatic disease.
166
What is the aim of primary prevention?
Avoiding a disease starting in the first place.
167
What are the aims of secondary prevention?
- Early disease detection
| - Early treatment to halt/slow progression
168
What is the aim of tertiary prevention?
Limit damage from disease to:
- reduce progress/severity
- maximise quality of life
169
Name 2 examples of primary prevention.
- Immunisation
| - Health education in schools
170
Name 3 examples of secondary prevention.
- Screening/case detection
- Brief interventions
- Adequate treatment
171
Name 2 examples of tertiary prevention.
- Rehabilitation programmes
| - Pain management
172
Describe the population strategy.
* Directed at the whole population irrespective of individual risk levels
* Directed towards socio-economic, behavioral and lifestyle changes
173
What are the strengths of the individual high-risk approach?
- Extension of clinical approach
| - High doctor and patient motivation
174
What are the weaknesses of the individual high-risk approach?
- A lot of resources required to identify risk
- Medicalises prevention
- Stigmatises individuals
- Does not produce long-lasting change at the population level
175
What are the strengths of the population approach?
- Benefits population as a whole
- Attempts to control root causes/determinants of disease
- Shifts cultural norms
- Can work passively
- Is more permanent
176
What are the weaknesses of the population approach?
- Benefit for each individual is small
| - Low subject motivation
177
What are Ewles and Simnett’s ‘5 approaches’ in health promotion?
- Medical
- Behaviour change
- Educational
- Client-centred
- Societal change
178
What are the 4 quadrants of Beattie's model of health promotion?
```
Health persuasion (TL)
Legislative action (TR)
Personal counselling (BL)
Community development (BR)
```
179
What are the 6 policy objectives of Marmot's review?
1. Give every child the best start in life
2. Enable all people to maximise their capabilities and have control over their lives
3. Create fair employment and good work for all
4. Ensure a healthy standard of living for all
5. Create and develop healthy and sustainable places and communities
6. Strengthen the role and impact of ill health prevention
180
What are the roles of doctors in tackling health inequalities?
• Ensure access to high quality healthcare for vulnerable groups, refer to support services, data on inequality attributable admissions.
• Knowledge and skills:
o Knowledge of social determinants
o Practice-based skills
• 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
181
Where do health beliefs come from?
• Rooted in socio-cultural contexts in which we live
• Shaped by people’s:
o place in society
o culture
o personal experience
o social identity
• Informed by medical and health knowledge
182
Define 'culture'.
Values, norms and traditions that affect how individuals of a particular group perceive, think, interact, behave and make judgments about their world.
183
Why are lay health beliefs important to doctors?
Insights into the needs of your patients:
• Information and support
```
Influence health-seeking behaviour:
• How people respond to symptoms
• Decisions about consulting
• Expectations about treatment
• Concordance with treatment plans
```
184
What are the 3 components of the decision to consult a healthcare professional?
- Perception of symptoms
- Explanation of symptoms
- Evaluation of symptoms
185
List the social triggers to seeking medical help.
* Interference with social and personal relationships
* Interference with vocational or physical activity
* ‘Sanctioning’ by others – influence of lay referral system
* A ‘temporalising’ of symptomology
* Interpersonal crisis
186
Define 'health behaviours'.
“Behaviours that are related to the health status of the individual”.
187
Provide examples of good health behaviours.
Sleeping (7-8 hours), regular exercise and healthy eating.
188
Provide examples of health protective behaviours.
Wearing a seat belt, and attending check-ups/screening.
189
What are the 4 types of determinants of health behaviours?
* Background factors: Characteristics that define how people live their lives
* Stable factors: Individual differences in psychological activity that are stable over time and context
* Social factors: Social connections in the immediate environment
* Situational factors: Appraisal of personal relevance that shapes responses in specific situations
190
In what 3 ways do stable factors influence appraisal?
1. Determine if, and to what extent, an event is salient, i.e. sensitivity towards particular types of event
2. Provide a generalised framework for understanding and evaluating the event, e.g. as threat or challenge
3. Make available, or suggest, potential responses, i.e. initial response options
191
What are the 3 broad types of individual differences that affect health?
1. Emotional dispositions: Psychological processes involved in experience and expression (present)
2. Generalised expectancies: Psychological processes involved in formulating expectations in relation to future outcomes (future)
3. Explanatory styles: Psychological processes involved in explaining the causes of negative events (past)
192
What are the 5 personality traits?
| HINT: OCEAN
- Openness to new experiences
- Conscientiousness
- Extroversion
- Agreeableness
- Neuroticism
193
What do people with an internal locus of control believe?
* They are responsible for their own health
* Illness can be avoided by taking care of themselves
* Ill health results in part from not eating correctly or not getting enough exercise
194
Define 'self efficacy'.
Belief in one’s own ability to organise and execute a course of action, and the expectation that the action will result in, or lead to, a desired outcome.
195
Define 'attributional style'.
Causal explanations of negative events as internal (self), permanent (time) and global (situation).
196
Name 3 social cognition theories.
* Health Belief Model
* Theory of Planned Behaviour
* Transtheoretical Model
197
Name 5 key concepts in epidemiology.
- Prevalence
- Incidence
- Mortality
- Bias
- Causality
198
What are the 2 approaches to causality?
Deterministic approach and stochastic approach.
199
What is the principle of the deterministic approach to causality?
'A causes B'.
200
What is the principle of the stochastic approach to causality?
'A increases the likelihood of B'.
201
What is a confounding factor?
Something that is associated with both the exposure and the outcome.
202
What is a mediating variable?
A variable through which an exposure wholly or partially exerts its effect.
203
Name 3 association factors for inferring causality.
- Strength of association
- Specificity of association
- Consistency of association
204
Name 3 exposure/outcome factors for inferring causality.
- Temporal sequence
- Dose response
- Reversibility
205
What 2 study designs would be considered 'optimal'?
- Prospective cohort
| - RCTs
206
What 2 study designs would be considered 'weak'?
- Cross-sectional (prevalence)
| - Case-control
207
Why is reversibility difficult to demonstrate?
* Many diseases have long time lags, e.g., mesothelioma takes 20-40 years to develop following exposure to asbestos
* Ethical issues for an RCT of a prevention programme, e.g. smoking cessation
* A public health programme to remove/prevent exposure often requires action by society
208
What is the relevance of 'coherence of theory' in causality?
A causal link is more likely if the observed association conforms with current knowledge.
209
What is the relevance of biological plausibility in causality?
A causal link is more likely if a biologically plausible mechanism is likely.
210
What is the relevance of analogy in causality?
A causal link is more likely if an analogy exists with other diseases, species or settings. An analogy is easier to infer than a biologically plausible mechanism.
211
What are the 3 types of observational studies?
- Case-control studies
- Cohort studies
- Cross-sectional studies
212
What are cross-sectional studies?
```
May be set up for a specific purpose:
• Prevalence of a specific disease
• Investigate the distribution of a specific disease in population
• Monitoring health over time
• Medium cost
```
213
What are case-control studies?
Almost always set up for specific purpose:
• Investigate suspected determinants e.g., outbreak investigation and determinants of rare conditions
• Quick and cheap
214
What are cohort studies?
May be set up for a specific purpose, more often multipurpose:
• E.g., effects of smoking, asbestos
• Determinants of common conditions
• Relative importance of different factors
215
What are the limitations of uncontrolled studies?
* Selection bias
| * Don’t know what happens without intervention
216
What are the limitations of cohort studies?
* Very slow and very expensive
| * Issues due to confounding with unknown risk factors
217
What are the limitations of case-control studies?
Recall and selection bias.
218
What is the major limitation of natural studies?
Issues due to unknown confounding factors.
219
What is the hierarchy of evidence?
```
• Systematic reviews
• Experimental studies
o Randomised Controlled Trials
o Controlled trials
• Observational studies
o Cohort studies
o Case control studies
• Descriptive studies
o Cross sectional
o (Qualitative studies)
```
220
Define 'bias'.
Any trend in the collection, analysis, interpretation or publication of review of data that can lead to conclusions, that are systematically different from the truth.
221
What are the 3 types of bias in epidemiological studies?
* Selection (design phase, plus execution); admission, prevalence/incidence, detection, volunteer and loss to follow-up
* Information (data collection phase); interviewer, questionnaire, recall, diagnostic suspicion and exposure
* Confounding
222
What are some of the issues with epidemiology?
* Epidemiological studies provide information on average effects
* These averages hide individual level variation
* For some patients, it will be better not to do what is best on average
* If patients have strong preferences for treatments, it is likely to be best to support these
223
Epidemiological studies are best when...
* Single agent causes single disease
| * Or single treatment reverses disease
224
Epidemiological studies are very good when...
A primary factor causes a specific disease with several secondary influences.
225
Epidemiological studies are limited when...
Many different factors interact with each other in complex ways to create the conditions in which multiple diseases are likely to arise e.g., social inequalities and health.
226
What are observational studies?
Observational studies observe distributions and determinants of health, but do not involve interventions.
227
What are the two types of observational study?
- Descriptive
| - Analytical
228
What is a descriptive observational study?
They examine distributions:
| • Example: How much measles is there in different regions of the UK?
229
Name 2 types of observational study.
- Ecological
| - Cross-sectional
230
What are analytical studies?
They examine determinants:
| • Example: Is vaccination related to measles incidence?
231
Name 3 types of analytical study.
Cross-sectional, case-control and cohort.
232
What are the general outcomes of observational studies?
- Measure of effect size
- Confidence interval
- P-value
233
What are ecological studies?
Studies where the “unit” of analysis is not the individual, but a group e.g., school, area, region or country.
• Generally use available administrative or population-level data
• Good for hypothesis generation, but can only establish association, not causation
• Cheap and simple to do, but data may be unreliable
234
What are the potential biases/pitfalls of ecological studies?
* Ecological fallacy
* Confounding variables
* Quality of data (timing)
* Selective reporting
235
What statistical methods are used to analyse data in ecological studies?
Pearson (ND), Spearman (skewed) or Kendall’s tau (ordered).
236
What is R2 used for?
To evaluate the proportion of variance in the outcome (y-axis) explained by variance in the predictor (x-axis).
237
How is Cohen's d calculated?
Cohen’s d = (Mean group 1 – Mean group 2)/Pooled SD
238
What are the methods for statistical testing in cross-sectional studies?
Unpaired t-test (ND) or Mann Whitney U test (skewed).
239
What are the potential biases/pitfalls of cross-sectional studies?
* Sample selection bias
* Response bias
* Recall bias
* Responder/Social desirability bias
* Confounding variables
* Direction of causation
240
What are the pros and cons of ecological studies?
* Good for hypothesis generation, but can only establish association, not causation
* Cheap and simple to do, but data may be unreliable
241
What are the pros and cons of cross-sectional studies?
• Good for hypothesis generation, but can only establish association, not causation.
242
What are the pros of case-control studies?
* Fast and cheap, and loss to follow-up is not an issue
| * Good to examine multiple exposures/risk factors
243
What is the main limitation of case-control studies?
Cannot measure incidence (or prevalence).
244
What is the Odds ratio?
Odds of being a case if exposed / odds of being a case if not exposed
245
How is the Odds ratio calculated?
Odds (case if exposed): A/B
Odds (case if not exposed): C/D
OR: A/B / C/D
246
How is the 95% confidence interval?
95% CI = OR/EF to OR*EF
247
What are the potential biases associated with case-control studies?
* Response bias (particularly for controls)
* Recall bias (particularly for controls)
* Confounding bias
248
What are the pros and cons of cohort studies?
* Useful for rare exposures, but not for rare diseases
* Can be lengthy and expensive
* Can establish incidence
* Can estimate dose-response relationships
* Provide evidence of causality when cannot do an RCT
249
What is the difference between case-control studies and cohort studies?
- Case-control is looking back from cases/controls to exposure/unexposure.
- Cohort control is looking forward from exposure/unexposure to disease/absence of disease.
250
What is a chronic condition?
The experience of a long-term condition for which there is currently no cure, and which is managed with drugs and other treatment.
251
Provide examples of chronic conditions.
Diabetes, chronic obstructive pulmonary disease, arthritis, hypertension, some mental health conditions.
252
How many people have chronic conditions?
1 in 3 people living have at least 1 condition
Of these:
24% have 2 LTCs
20% have 3 or more LTCs
253
What percentage of GP appointments are for chronic conditions?
50%.
254
What percentage of outpatient appointments are for chronic conditions?
64%.
255
What percentage of inpatient hospital bed days are for chronic conditions?
70%.
256
Why is it important to look at chronic illness?
- Common experience
- Aetiology and prognoses are very diverse
- Very similar social and psychological sequelae
- Association between social and emotional experiences and coping and managing
- NHS Mandate
257
What areas of every day life are affected by chronic conditions?
- Daily activities (work, hobbies, self-care, caring)
- Social relationships
- Sense of self (biographical disruption)
- Social identity (how others see you)
258
Name 4 common coping strategies for chronic conditions.
- Denial: early stages, helps person take stock, presents difficulty if persists
- Normalisation:
‘Passing’ (Bury 1988), re-designation of ‘normal’ life
- Resignation
- Accommodation
259
What is an expert patient?
Someone who:
- Feels confident and in control of their life
- Aims to manage their condition and its treatment in partnership with healthcare professionals
- Communicates effectively with professionals and is willing to share responsibility for treatment
- Is realistic about how their condition affects them and their family
- Uses their skills and knowledge to lead a full life
260
What is the expert patient programme?
- A peer-led self management programme
- Aims to improve self-management
- Six-week programme suitable for any long-term health condition
- Covers topics such as: healthy eating, exercise, pain management, relaxation, action planning and problem solving
- Are also some disease specific programmes
261
What are the benefits of the expert patient programme?
- Felt more confident that their symptoms would not interfere with their lives
- Felt better prepared for appointments with healthcare professionals
- Fewer visits to GP
- Fewer visits Emergency Department
262
What are the potential problems with the expert patient programme?
- Not attractive to everyone
- Everyone not able to participate
- Extra pressure on patient organisations
263
What are the 5 factors of the self-regulatory model of living with chronic illness?
- Representation of illness (identity, cause, consequences, timeline, cure/control)
- Coping (approach or avoidance coping)
- Appraisal (Was my coping effective?)
- Interpretation (Symptom perception, social messages)
- Emotional response to illness (fear, anxiety, depression)
264
What are illness beliefs?
A patient’s own implicit common-sense understanding of their illness.
265
What are the 5 belief dimensions of 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?
266
What might a patient need to do after being diagnosed with a chronic illness?
- Adjust to symptoms and disability
- Maintain a reasonable emotional balance
- Preserve a satisfactory self-image and sense of competence
- Learn about symptoms and treatment and most importantly self management
- Relationships with friends and family
- Forming and maintaining relationships with health care professionals
- Preparing for an uncertain future
267
What are the benefits of a pain management programme?
- Helps patients manage their pain rather then the pain managing/controlling them.
- Learn to change cognitive perceptions of pain, less catastrophising, challenging unhelpful thoughts
- Management of stress and anxiety as well as low mood, depression.
- Not feeling so isolated with the condition when in a group.
268
What are the challenges of a pain management programme?
- Managing group dynamics
- Stages of change – are they ready to change their behaviours
- Commitment
- Managing fears
269
How can people with chronic conditions maintain meaning in life?
- Enhanced relationships with family and friends
- Finding an inner strength and discovering a new sense of personal resilience.
- Accepting their own vulnerabilities and limitations.
- A greater appreciation of life and living, changed philosophy of life.
270
What is crisis theory?
The way in which people manage and cope with chronic illness:
- They need to find a social and psychological equilibrium
- Challenges, setbacks and social influences (e.g., family) are important and can influence coping responses.
271
What is the purpose of the SRM model?
To develop an appropriate management plan and work with the patient.
272
What are the main factors involved in the management of a long term condition?
- Pain management programmes
- Reinforcing the message of gate control theory – a combination of psychological and physical factors can open and close the gate.
- Involving clinicians, specialist nurses, physiotherapists and psychologists.
- Intensity - residential or spread over 6-8 weeks.
273
What is the definition of 'caring'?
- Displaying kindness and concern for others
| - The work or practice of looking after those unable to care for themselves
274
What are the different types of caring?
- Unpaid or paid
- Non-contractual or contractual
- Private or public
275
How many carers are there in the UK?
6.5 million (10% of adults).
276
What is the gender distribution of carers in the UK?
- Females (58%)
| - Males (42%)
277
What is the peak age of carers in the UK?
50-59 years of age.
278
With regards to caring, what are the variations with ethnicity?
- A smaller proportion of black and minority ethnic population than white population provide unpaid care:
If age controlled for, they more likely to be providing care, but are less likely to identify as carers
- Black and minority ethnic carers:
more likely than white carers to be cared for
- Have less access to financial and practical services
- Report lack of culturally appropriate services
279
How many LGBT people care?
Almost 400,000 (not me).
280
What is the projected increase in the number of carers in the next 30 years?
10 million.
281
What proportion of people will be carers at one point in their life?
3/5.
282
Who are carers caring for?
- 13% for someone with a mental health condition
- 10% for person with dementia
- 58% for someone with a physical disability
- 14% because person is in the older age group and frail
283
What is the economic value of carers?
£57-100 billion per year (comparable to total NHS spending).
284
Who do carers most often care for?
- Parents
- Spouse/partner
- Child
285
What are the 3 main roles of carers?
- Providing practical help
- Keeping an eye on the person cared for
- Keeping person cared for company
286
What are the possible advantages of using the term 'carer'?
- Identify need --> services
- Recognition of work and contribution of carers
- Sense of identity – more likely to attend support groups etc.
287
What are the possible disadvantages of using the term 'carer'?
- Only seen in terms of being a carer
- Lock people into a role they do not want
- May prefer to define themselves as a son, daughter, mother, etc
- Undermines person being cared for
288
What areas of life can be affected by caring?
- Financial
- Work
- Relationships and social exclusion
- Health
- Education (young carers)
289
How might a carer's work be affecting by caring?
- Lower incomes
- Higher costs: laundry, heating bills etc.
Carers UK (2018)
- 1/3 report struggling to make ends meet
- ~1/2 report cutting back on essentials
- 1/3 report having given up a job to care for someone
290
How might a carer's relationships and social exclusion be affecting by caring?
- Difficulty accessing holidays, leisure pursuits and other social activities
- May be harder to maintain relationships and social networks
- May get few or no breaks from caring responsibilities
- - Individuals cared for by relatives less likely to receive services
- - Black and minority ethnic carers less likely to receive practical support
291
How might a carer's relationships and social exclusion be affecting by caring?
- 72% reported they had had mental ill health and 61% physical ill-health as result of (Carers UK 2018)
- Evidence that caring for a child with LLTI/disability increases risk of parent developing LLTI/disability (Blackburn et al, 2011, Kelly et al, 2007)
- Injuries due to manual handling
- Lack of time to care for own health
292
What financial support is available for carers?
- Carer’s Allowance (£64) if caring for at least 35 hours a week for someone on a qualifying disability benefit and not earning more than £120 per week
- Carer Premium payable with means-tested benefits
293
What is the role of the Carer’s Assessment: Care Bill (2014)?
Gives local authorities a responsibility to assess a adult carer’s own needs for support.
294
How many young carers are there in the UK?
166,000 young people between the age of 5 and 18 (average age is 12 years).
295
How much more likely are Black and minority ethnic children to become carers?
1.5 times.
296
Who are young people most likely to provide care to?
A parent, sibling or other relative.
297
How many young people provide 50+ hours of care per week?
13,000.
298
What is the impact of caring on young people?
- Absence from school
- Lower educational attainment
- Behavioural problems/bullying
- Social exclusion/isolation
- Stress
- Physical health problems
- Traumatic life changes
- Poverty
- Lack support and benefits
299
What support is available for young carers?
- Social services: legal entitlements. Since April 2015 a social worker from the local authority must visit to carry out a “young carer’s needs assessment”
- Schools
- Young carers projects
300
What are young carers projects?
- Opportunities for young carers to take a break from their caring responsibilities, spend time with other young carers and share experiences
- Support young carers to use local services such as sports clubs, support groups, and health centres.
- Provide advice and emotional support through counselling and drop-in sessions
- Liaising with schools so that teachers can better support their students
- Providing opportunities for young carers to learn more about their parent’s illness or disability
- Help the family to find the support they need, and are entitled to, from local services, so that a child’s caring responsibilities can be reduced.
301
How can doctors help carers?
- Identify whether someone has caring responsibilities when discussing their health
- Provide responsive health care for carer and person they care for
- Consider carer when planning care of patient and discharge planning
- Involve carer in all stages of discharge planning (NHS guidance: Ready to Go (2010)
- Carer, as well as patient, can have an assessment prior to discharge
- Families and friends have a choice whether to take on caring
- Use Carer’s Passport if available
- Give early information about rights and entitlements
- Signposting carers to services
302
What wider support is available to carers?
- Better access to social care
- Better social security benefits for carer and person cared for
- Carer-friendly employment policies
- Increased awareness of and services for:
Black and minority groups
Child carers
303
What are the 4 common features of the medical model of disability?
Disability: intrinsic to the individual
Restrictions: attributed to physical or cognitive impairments
Interventions/services: changing or curing the disabled person
Medical/health care profession’s role: treatment and central
304
What are some criticisms of the medical model of disability?
- Individualises the issue of disability
- Negative /disempowered image
- ‘Personal tragedy’
- Medicine defines and controls disabled people e.g. Zachary/Lorber conflict
305
What are 3 common features of the social model of disability?
- Disability is extrinsic to individual: Social, attitudinal and physical barriers prevent disabled people from participating in society to the same extent as other people
- Problem is primarily caused by by the way society is organised
- Public issue: Needs socio-political responses
306
Define 'impairment'.
Bodily, mental or intellectual limitation or condition.
307
Define 'disability'.
Loss of or limitation of opportunities to take part in society on an equal basis.
308
Name 3 advantages of the social model of disability.
- Disability is not seen as an inevitable consequence of living with impairment
- Emphasises the need to remove physical, attitudinal and social barriers to full social participation
- Calls for social and political change rather individual adaptation
309
What is the main disadvantage of the social model of disability?
It can fail to acknowledge the significance of impairments for individuals.
310
What are the aims of the International Classification of Disability?
Aims to address some of the difficulties with the previous classification system:
- Addresses difference of emphasis implicit in the medical and social models of disability
- Establishes a common language for describing health and health-related states to improve communication between different users
- Provides an international coding system for classifying coding and functioning
311
What is the main principle of the interactional model of disability?
The role of polices and services is to enable disabled people to lead ordinary lives and to participate in society to the same extent as non-disabled people .
312
What tools are in place to promote rights and equality for disabled people?
- International: UN Convention on Rights of Persons with Disabilities (UNCRPD) and other human rights conventions
- National: e.g. UK Equalities Act (2010)
313
Describe the human rights approach to disability (UNCRPD).
- Establishes that disabled people are not ‘other’ i.e. have the same rights and as others
- Established a universal standard or benchmark which can be applied
- If a disabled person’s experiences fall short of this universal standard, it is understood as a human rights violation
314
With regards to disability, why is human rights and equality legislation needed?
Disabled people experience social, economic and health inequality; as a group, they have lower levels of participation in all aspects life.
315
Name some areas of inequality for disabled individuals.
- Employment (increased unemployment and discrimination)
- Education (3 times less likely to have qualifications)
- Poverty (more likely to experience poverty)
- Access to goods and services (including health services)
- More likely to experience poor health outcomes
316
What is a systematic review?
- A review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyse data from the studies that are included in the review.
- Statistical methods (meta-analysis) may or may not be used to analyse and summarise the results
- Increasingly diverse approaches, e.g. realist review; meta-synthesis
317
A systematic review is...
- Summary of (all available) evidence on a particular topic
- Based on a clearly defined search of the literature, using explicit criteria to appraise quality
- Stringent study inclusion & exclusion criteria
- Findings analysed using validated methods
318
What types of bias are there in a systematic review?
Selection bias: Systematic bias in the way participants are selected
Performance bias: Systematic differences in the care provided to the participants in the comparison groups other than the intervention under investigation
Detection bias: Systematic differences between the comparison groups in outcome assessment
Attrition bias: Systematic differences between the comparison groups in the loss of participants from the study
Reporting bias: Selective reporting of study outcomes
Other bias: Funding, error is results
319
What are the overall contents of a high quality systematic review?
- Search strategy - inclusive, reproducible
- Flow of all studies/papers -PRISMA
- How inclusion and exclusion criteria are applied (PICOS/SPICE)
- Table of characteristics of studies (included and excluded - reasons)
- Quality assessment Cohesive synthesis / analysis (+/-meta-analysis)
- Practical application (context) of findings
- Strengths and limitations of the systematic review
320
What are the 3 functions of a systematic review?
- Synthesise the evidence
- Understand heterogeneity in treatment effect
- Set the research and practice agenda
321
Before you start a systematic review, what do you need to know?
- Purpose of review
- Nature of research question
- Population
- Team factors
- Search strategy
- Type of studies / data included
- Outcomes
- Methods of analysis / evaluation of outcome
- Conclusions and added value
322
What are the steps involved in a systematic review?
Before: Rationale
- Has a similar review been done before? If so, what is the justification for this review?
- Awareness of possible nature and volume of evidence / implications for timeline and resource
1. Familiarise yourself with the process
- Start preparing your protocol
- Consult standard reference books
2. What is your question?
- Translate search question into review
3. Protocol
- Informed by and refined from research question(s)
Include all relevant items (follow PRISMA and module guidelines), in particular:
- Search strategy: sources, terms, limits
- Inclusion/exclusion criteria: linked to research question and aims
- Data extraction: linked to research question and aims
- Risk of bias assessment: suitable tool; inform analysis and interpretation
- Analysis/synthesis plan: quantitative, qualitative, both
- Presentation and interpretation (GRADE)
4. Literature searching and study retrieval
5. Screening
- De-duplicates
- Number of records screened (included vs. excluded)
6. Eligibility
- Number of records assessed for eligibility (in/out)
- Number of records excluded with reasons
7. Data abstraction
- Pre-defined data abstraction form
- Linked to research question and aims
8. Quality assessment
- Suitable tool; inform analysis and interpretation
- GRADE
9. Analysis (meta-analysis is the combination of results of the individual studies)
- Quantitative (optimal)
- Qualitative
10. Summary and write-up
- Presentation and interpretation of the findings
323
What 2 frameworks can be used for translating search questions into systematic reviews?
[Hint: PICOS and SPICE]
P (Population): patients with stable angina
I (Intervention): exercise-based cardiac rehabilitation
C (Comparator): usual care / no exercise
O (Outcomes): all cause mortality, myocardial infarction, quality of life
S (Study design): randomised controlled trials
S (Setting): UK
P (Population or perspective): young people aged 12–18 years
I (Intervention): not applicable
C (Comparison): not applicable
E (Evaluation): perception/views (attitudes, opinions, beliefs, feelings, understandings or experiences) about obesity
324
What questions need to be asked in a meta-analysis?
What is the outcome being examined?
What is the timeframe for the outcome?
What is the summary effect size being used?
What is the number of trials included?
What is the heterogeneity in the comparison?
325
What is heterogeneity and how is it determined?
- We use I2 to understand heterogeneity
- The percentage of variation between studies in a meta-analysis is due to differences between studies and not just sampling error
0% → no heterogeneity,
25% → low,
50% → moderate,
75% → high*
(It is important because it shapes our understanding of the pooled effect: is this the true effect, or the average effect in a distribution?)
326
List some of the effects of 'worklessness'.
- poorer physical health - more likely to die sooner
- poorer mental health
- more medical care
- poorer social integration
- loss of self-confidence
- fewer monetary resources
- effect on next generation
327
What percentage of employed, compared to unemployed, people have a long-term health condition or disability?
29% vs. 26%
| 48% of inactive persons
328
List 3 factors that encourage 'ill role'.
Culture, beliefs and attitudes
- Misconceptions about health and work – e.g. “need to be 100% fit”
- Poor retention in work of those with disabilities or chronic disease
Inadequate systems
- No pathways of rapid intervention to keep you in work or return you to it
Lack of Primary Care involvement
- Rehabilitation to work is not a performance measure for healthcare
- Lack of occupational health advice
329
Define 'occupational health.'
“A discipline concerned with the effects of work on health and the influence of pre-existent health problems on the capacity to work.”
330
What is the aim of occupational health?
- Promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations;
- Prevention among workers of departures from health caused by their working conditions;
- Placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities;
- “the adaptation of work to man and of each man to his job"
331
Describe the changes in work-related ill-health.
```
Industrial revolution
- Accidents
- Poisoning
- Musculoskeletal
Current
- Mental Health – depression, anxiety
- Musculoskeletal
- Skin
- Respiratory
- Infection
```
332
Define 'hazard'.
Something that might cause harm.
333
Define 'risk'.
The likelihood of harm actually occurring.
334
What are the 3 components of risk assessment?
- Identify the hazard
- Assess the risks (to health)
- Manage/control the risks
335
What are the 5 categories of hazards?
- Physical
- Chemical
- Mechanical (ergonomic)
- Biological
- Psycho-social/organisational
336
What are the risks of inoculation injury from source-positive patients?
Hep B - 1 in 3
Hep C - 1 in 30
HIV - 1 in 300
337
What are the 4 types of hazards a junior doctor could be exposed to?
Patients
Investigations
Therapeutic agents
Environment
338
Provide examples of biological, chemical, physical and psychosocial hazards that a junior doctor might be exposed to.
```
Biological: Infectious agents
Chemical:
- Aldehydes
- Anaesthetic agents
- Antineoplastic drugs
- Latex
Physical:
- Ionising radiation
- Manual Handling
Psychosocial:
- Working hours/shift systems
- Bullying
- Workload
- Commuting
- Home-work interface
- Stress
```
339
How should work-related neck and upper limb disorders be addressed?
- Establish the anatomical diagnosis.
- Consider work-related risk factors by asking the patient what they do at work in functional terms.
- Exclude recreational risk factors.
340
What are the 5 most common work-related neck and upper limb disorders?
```
Shoulder pain
Epicondylitis
Tenosynovitis
Non-specific diffuse forearm pain
Carpal Tunnel Syndrome
- prolonged and extreme wrist flexion
- forceful and repetitive wrist movement
- direct pressure on the carpal tunnel
- the use of hand-held vibrating tools.
```
341
How can the risk of upper limb disorders be reduced?
- improved ergonomics of tool design, equipment and work layout to improve posture, reduce forces and repetition
- job rotation to reduce time at a repetitive task
- new employee to work at a slower rate initially
- rest breaks to allow recovery time
- redeployment if the above measures aren’t effective.
- rehabilitation of affected workers
- - Reduce hours
- - Reduce work-rate
342
Which occupations are associated with occupational asthma?
```
Carpenters - wood dust
Electronic soldering - Rosin
Bakers - flour and enzymes
Paint sprayers
Polyurethane foam
Glues and laminates
- isocyanates
```
343
What questions are relevant to an occupational history?
```
What is your job?
What do you do in your job?
What tasks do you do?
What do you work with?
Chemicals, vapours, gases, dusts, fumes, tools etc
How long have you been doing this job?
Do you have any other jobs?
Long latency conditions:
Have you done any different kinds of work in the past?
What were you exposed to?
```
Have you been told that anything you use at work may make you ill?
Has anyone at work had the same symptoms? Domestic exposures to work agents
Do you have hobbies e.g. DIY or gardening, that may bring you into contact with chemicals?
344
Name 2 occupational causes of mesothelioma.
Gas masks and asbestos.
345
What is involved in the process of assessing fitness for work and promoting return to work?
- Assessing fitness for work
- Medical certification
- Sickness absence and rehabilitation
346
Who assesses fitness to work?
- A GP is rarely involved with determining fitness to start work.
- Normally the Employer’s responsibility (with advice from their Occupational Health Adviser).
347
What should be considered in assessing ability to return to work?
- Return to work should be one of the key clinical outcomes by which the success of treatment is measured.
- It needs to be an integral part of the case management plan.
- “after only six weeks’ sickness absence, almost one in five people will eventually leave paid employment”
348
How can sickness absence be certified?
Sickness absence self-certification
- Up to 7 days.
Beyond 7 days
- Medical Certificate (now called “fit note”; Med 3)
349
What is a fit note?
Provide certification for statutory sick pay.
Advises patient about period of sickness absence
Advises employer about suitable adjustments.
Facilitate return to work through communication with doctors, patients and employers.
350
What may included in a fit note - may be fit for work?
What can they not do?
Amended duties; activities to be avoided?
Altered hours: changes to the times or duration of work
rest breaks
A phased return to work: a gradual increase in work duties or hours
Workplace adaptations: changing aspects of the workplace
Redeployment
351
What is the role of the OH team?
- Providing independent and impartial advice to both the employer and the employee
- Investigating and diagnosing those who are sick or injured due to their work
- Assisting the return of the sick and injured to work at the earliest opportunity
- Matching people with jobs appropriate to their health, fitness and susceptibility status
352
What is the role of the health and safety executive?
- Shaping and reviewing regulations
- Producing research and statistics
- Enforcing the law
353
What type of help is provided by Access to Work?
- special aids and equipment
- adaptations to equipment
- travel to work
- travel in work
- Mental Health Support Service
