SSRD_Stella Flashcards
5 step model of evidence based practice
1 - Ask answerable question 2 - Find best evidence 3 - Appraise critically for validity & clinical performance 4 - Act on evidence; apply to practice 5 - Evaluate your performance
OCEBM Levels of Evidence
Oxford Centre for Evidence based practice
= hierarchy of likely best evidence
1 = Systematic reviews 2 = Randomised trial 3 = Cohort studies 4 = Case analysis 5 = Mechanistic reasoning
- studies can be graded up/down depending on effect size of results, study quality, imprecision, indirectness, inconsistency.
-> rapid appraisal
-> hierarchal approach to finding the best available evidence
-> structure reflects clinical decision making
- can be used by patients & clinicians
-> method of evaluating quality of evidence in a hierarchy system in terms of:
Prevalence
Accuracy of diagnostic tests
Prognosis
Therapeutic effects/Treatment benefits
Common harms
Rare harms
Usefulness of early screening
[Passion And Pride Take CRU]
appraises quality of Types of studies in respect to different considerations to direct you to where to find best evidence
CASP
Critical Appraisal Skills Programme
Initiated under Sir Muir Gray when director of research and development at Oxford regional health authority 1993, in response to need for developing skills in health care staff to meet challenge of evidence based medicine.
For anyone who wants to apply evidence based practice and use research evidence in their professional practice, professional/personal decision making & policy/guideline development
Different checklists for different types of studies e.g. systematic reviews, RCTs
Checklist of 11 Qu’s
First 2 = screening qu’s
Appraises evidence with 3 focuses
1 - Is the study valid
is it unbiased based on evaluation of methodological quality. different validity criteria used for different types of questions on: treatment, diagnosis, prognosis, economics.
2 - What are the results
If decide study valid look at results
- are they clinically important
- analyse certainty of results - are they statistically significant
3 - Are the results useful
once decided valid & important look at how applies to question. is your pt sufficiently similar to those in study?
appraises individual studies that have already been found
Cochrane Collaboration
= International, not-for-profit, independent organisation dedicated to making up-to-date accurate info about effects of healthcare readily available worldwide.
Produces and disseminates systematic reviews of healthcare interventions and promotes search for evidence in the form of clinical trials and other studies of interventions.
Founded in 1993 and named after British epidemiologist Professor Archibald Cochrane
Cochrane library = suite of databases which help you find reliable evidence about effects of health care interventions
Consists of 7 databases
• Cochrane Reviews - Cochrane Database of Systematic Reviews
• Other Reviews - Database of Abstracts of Reviews of Effect
• Clinical Trials - Cochrane Central Register of Controlled Trials
• Methods Studies - Cochrane Methodology Register
• Technology Assessments - Health Technology Assessment Database
• Economic Evaluations - NHS Economic Evaluation Database
• Cochrane Groups - About The Cochrane Collaboration
allow access to highest quality evidence to inform practice
Ensure healthcare decisions throughout world can be informed by high quality, timely research evidence.
Search strategy to find the best available evidence
Select a medical database e.g. Medline, Cochrane
** Key word searching
Split question into key concepts and search for al word variations
Truncation *
- helps find word with variant endings e.g. therapy*
Nesting ()
-use to group words together e.g. (Tooth or teeth) adj3 (whitening or bleaching)
Adjacency adj
- finds words within a given distance of each other e.g. periodontal adj. disease
Wild card ?
- searches for single character/none at all -> combats spelling differences e.g. organic?ation
Combine searches AND/OR
Or - combines all related terms/synonyms within one concept
And - to get final collection references combine 2 concepts’ sets of results
**Subject Heading searching
Map to subject heading
Allows you to find paper about a topic rather than just those that specifically mention it in the text
helps locate more potentially relevant papers than keyword searching alone
**Apply limits Language Date Full text Age group Publication type
(save results + locate full text of articles found)
MODELS OF HEALTH AND WELLBEING
Bio-medical
Health = freedom from disease and abnormalities
Adv
- Helps make relationship clear between disease and treatment
- Useful in healthcare settings i.e. does pt have a disease or not?
Disadv
- Pt’s views about symptoms/medication largely ignored
- Only focuses on pathological change/physical symptoms
- Health status reliant on knowledge & expertise of medical professionals
- Doesn’t address factors leading to development of a particular health condition e.g. mental illness such as depression
- Not all health conditions can be cured, but can be managed via behaviour modification which model doesn’t consider e.g. role functioning
MODELS OF HEALTH AND WELLBEING
WHO
Health = a complete state of physical, mental and social wellbeing, not simply the absence of disease or infirmity
Adv
- Holistic approach; considers all aspects of health, not just pathological view
- Distinguishes between positive and negative aspects of health (true wellbeing/fitness vs injury, disability, deformity, disease etc.)
Disadv
- Vague, not detailed .’. hard to classify health status of a pt in a health care setting.
- Time consuming & difficult to implement as hard to ‘measure’ each aspect of wellbeing.
MODELS OF HEALTH AND WELLBEING
Sociological
Health = a state of optimum capacity (physical & mental fitness) of an individual for the effective performance of roles and tasks for which they have been socialised i.e. role functioning
Adv
- Considers ‘feeling state’ of individual + biological functioning
- Expectations may vary by sex & age so health classification specific to each individual. (different expectation of 18yr boy to 80 yr woman)
- Easy to be implemented by the individual
Disadv
- Difficult to implement in certain healthcare settings by medical professionals
- Very subjective to individual and what expect from themselves, and what society expects from them
- Health and illness ‘normatively’ defined .’. expectations may be different in different communities .’. difficult to standardise, not a universal level
MODELS OF HEALTH AND WELLBEING
Biopsychosocial
Captures all three aspects of health; biological, psychological and social wellbeing and shows interaction between them.
Adv
- Holistic view; takes into account more than one aspect of health and shows interaction between different aspects
- Can be applied to wide range of diseases
Diadv
- Too complex .’. time consuming & difficult to apply
- Some areas are subjective .’. difficult to standardise
Locus of control
= a psychological construct
→ extent to which people feel they have control over their lives, what happens to them and aspects that control them
Measured by questionnaire
Internal/External locus of control
May contribute to some health behaviours
Related to frequency of dental visiting, oral hygiene and dental health status
Dental self-efficacy = belief in one’s ability to succeed in a specific task e.g. maintain oral hygiene
- Has been shown to be associated with caries levels
Disease
= pathological condition recognised by indications agreed among biomedical practitioners – indicated by signs and symptoms
Illness
= subjective state experienced by an individual – feeling of being ill and its impacts
Sickness
= the social state that results as a consequence of feeling ill or being diseased. Sickness is reflected in a changed lifestyle (sick role) = Psychological construct & Social construct
Sick Role
= Social construct
→ Temporary release from ordinary obligation & duties e.g. Work
→ Addition to ordinary privileges
→ Obligation to co-operate and seek help in treatment
Must be sanctioned by the medical profession – diagnosis + treatment
(Parsons, 1951) – being sick not simply state of fact or condition, it is a specifically patterned social role. In western societies sick role implies major expectations.
Rights of sick role
Temporarily exempt from normal duties/social roles
More severe sickness → greater exemption
Sick person not held responsible for their condition (absence of blame). Illness considered beyond individual’s control .’. not simply curable by will power – incorporates internal/external loci of control
To be taken care of
Duties/Obligations of sick role
Expected to see being sick as undesirable → have obligation to try to get well
Exemption from normal duties temporary and conditional upon wanting and trying to get better
To seek technically competent help from a suitably qualified professional and to co-operate in the process of trying to get better.
If sick person doesn’t fulfil obligations/duties immunity from blame withheld and may lose ‘rights’
Criticisms of sick role
Resistance/rejection of sick role – does person accept sick role, may not want to be branded as sick and thus not perform sick role i.e. continue to work, do daily activities .’. don’t enter sick role contract
Roles of doctor/patient – now out-dated, different types, changing (JC lecture)
Disease ‘stigma’ and victim blaming – exists for some diseases more than others e.g. STIs, lung cancer in smokers
Acute vs chronic health condition - harder to apply chronic health conditions to sick role
– “Parsons (1975) countered this objection…the sick role obligation of the chronically ill is to minimise deterioration of their condition”, rather than get well - which may not be possible.
Health belief
Based on decision making theory
Cue to action -> Perceived susceptibility to disease -> Perceived seriousness of disease
consequences -> Belief effective measures available -> Benefits outweigh barriers -> Health action taken
Health action
[Belief + Normative + motivational system] + Educational + Policy input -> Facilitating & Inhibiting factors -> Health choice -> Health action
Theory of reasoned action
external variables lead to beliefs, outcome evaluation, normative beliefs, motivation to comply. these combine to form attitude towards behaviour and subjective norm + relative importance of attidudinal and normative components –> Intention -> Behaviour
Good intention doesn’t always lead to behaviour, however it is a good indicator that behaviour will occur
External variables -> Beliefs + Outcome evaluation + Normative beliefs + motivation to comply -» Intention -> Behaviour
Transtheoretical model of behaviour change
Pre-contemplation -> contemplation -> preparation -> action -> maintenance -> Exit (can relapse at any point)
Help patient make the decision themselves and take ownership over their health
Can only exit model if sustained over long period of time. Can relapse at any point, any stage of process, not allowing them to exit model.
Prochaska & Norcross 2007 = revised version
Social determinants of health and oral health
- Fixed factors
o Gender, race, age… - Lifestyle and behavioural factors
o Extreme sporting activities
o Smoking
o Drinking - Social positions
- Environments
o Living
o Working - Food and transport policies
- Early childhood experience / life course influences
- Poverty
- Unemployment
o Psychological impacts; stress, anxiety
o Lack of money – can’t afford nutritious foods, malnutrition - Social and psychological circumstances, cultural factors
- Social and economic circumstances
- Access to services – leisure, health, /education/food/transport etc.
- International security
o War breeds poverty
o Feeling of insecurity affects life choices
o Psychological and physical impacts on health
Policy Rainbow (1991)
Shows social determinants of health
fixed factors
lifestyle factors
social and community networks
living and working conditions - housing health care services water and sanitation unemployment work environment education agriculture and food production
general socio-economic, cultural and environmental conditions
Upstream – outside of your control
Downstream – within your control
Social Class (SC)
The Registrar-General’s Social Classes were introduced in 1913 and were renamed in 1990 as Social Class based on Occupation.
The classes are described as follows: I Professional occupations II Managerial and technical occupations IIIN Skilled non-manual occupations IIIM Skilled manual occupations IV Partly-skilled occupations V Unskilled occupations
[Please May Someone Sell Party Umbrellas]
Health gaps by socio-economic position of occupations in England & Wales:
- North-south divide; north have generally higher rates of poor health for all socioeconomic classes
- Men & women in least advantages ‘routine’ occupation have highest rates of poor health
- Regional health gap between classes generally larger for women
- Local authorities with largest health gaps generally found in large population centres e.g. inner London
Ethnic variations in general health and unpaid care provision:
- In 2011 African ethnic group had lowest proportion of poor general health, gypsy/Irish traveller has highest proportion of poor health
- Greater levels of poor health associated with providing 50hr+ unpaid care/week within same ethnic group
Oral health inequalities
Differences between developed & developing countries:
Developed access more refined carbohydrates -> more caries in children
Developing countries getting more & more resources to maintain oral health so improving, also less access to refined sugar so have better oral health than in industrialised developed countries.
In UK:
Higher % caries free children in social classes I-IIINM
Regional differences – North-South divide
Gradient persists even within high F and low F areas
Social class gradient at childhood associates with oral health problems in adulthood
Clear socio-economic gradient, those from more advantaged backgrounds have less decay, more teeth, less bleeding gums, less deep pocketing etc and patterns persist over time
Theoretical explanations for health inequalities
Artefact Health selection Cultural or behavioural explanations Materialist or structuralist explanations Psychosocial Life course
Race =
a biological concept based on genetic expression of physical features that distinguish mankind
Culture =
a dynamic concept (can change over time) – defined as a system of shared ideas, concepts, custom and meaning that underlie and are expressed through the ways that humans live
Ethnicity =
self-defined social construct - what you identify yourself as based on a shared sense of belonging. Based on characteristics such as common religion, language, ancestry, national and geographic origin and/or other cultural attribute.
Racism =
actions which disadvantage individuals or groups based on racial prejudice
Differing patterns of disease between different ethnic groups
Pakistani, Chinese and Black African males had the highest prevalence of ischaemic heart disease.
Black Caribbean have highest prevalence of stroke among men. Bangladeshi and Pakistani highest prevalence among women.
Bangladeshi and Chinese men had lowest obesity rates.
High BP higher among men than women and increased with age in both sexes. Men : Highest Black Caribbean, lowest Bangladeshi. Women : highest Black Caribbean, lowest Chinese.
Chinese lowest % self-reported illness. Chinese also most likely to have used CAM (complementary and alternative medicine).
CAM – different ethnic groups e.g. Chinese more likely to use complementary and alternative medicines. May be due to lack of trust/faith in Western medicine.
Barriers to oral health among the BME groups and ways of overcoming them:
Poor uptake of service due to:
Inequalities in access – promote services to BME groups
Higher levels of dissatisfaction within NHS services among some Minority Ethnic groups
Pakistani, Indian and Bangladeshi groups reported significantly poorer experiences (as hospital inpatients) particularly on questions of prompt access – take actions to eradicate institutional racism
Their experience of involvement and choice – education of medical profession to eliminate misconceptions and prejudices
Failure to respond to most basic of needs have resulted in fatalities in some cases
Genetic disposition
Cultural norms, beliefs,
attitudes and practices
Deprivation
Environment
Social exclusion
Racism
Cultural shock
Cultural and language barriers in assessments
Barriers to Oral Health care
Patient’s perspectives
- Language difficulties
- Cultural differences
- Unfamiliar with the system
- Perception of needs
- Attitudes & beliefs
- Anxiety & fear
- Faith in dentist
- Cost
- Availability including opening hours
- Physical barriers
Barriers to Oral Health care
Professionals’ perspectives
- Communication problems
- Varying naming systems
- Appointment system
- Lack of cultural sensitivity & empathy
- Attitudes
- Obtaining consent
- Symptomatic approach
- ‘Dentist shopping’
- Occupational stress
- Obtaining medical history
- Training & education
Barriers to Oral Health care
Overcoming barriers
- What, How, Why • Improved information • Health promotion • Education and training • Multi-disciplinary approach • Role of SDS / GDS / HDS • Prevention and treatment strategies • Service provision • Healthcare system & manpower planning • Crèche in practice • Ramp • Geographical location – accessible by public transport
How measure health
Health difficult to measure directly, inferences about health of population made by reference to measure of:
- Death rates
- Life expectancy
- Neonatal/infant mortality/Maternal mortality
- Morbidity rates
- Other measures e.g. QoL, Trust and Community Life
describe patterns of disease
Decreased infant mortality rates Longer life expectancy Women live longer than men Rich – poor divide Infant mortality and maternal rates higher in poorer countries
In developed countries leading causes of death = NCDs (non-communicable diseases) & injuries
In developing countries leading causes of death = infectious diseases, maternal, neonatal, nutritional causes
changing pattern of diseases over time
In past decade almost every country in the world experienced a major shift away from premature deaths due to infectious diseases and towards NCDs and injuries.
Top 3 causes of premature death =
1. CHD
2. Lower respiratory infections (such as pneumonia)
3. Stroke
Obesity on the rise; including childhood obesity → wide range of associated serious health complications and increased risk of premature illness.
Total number of tobacco attributable deaths projected to rise.
role of health care systems
Between 1995 -2012 56 million people were successfully treated for tuberculosis and 22 million lives were saved.
Good health care system = Accessible, Universal coverage, Efficient (time, cost).
Components of health care systems
• Structure: how is the system organised? Is it centrally organised? Primary, secondary, tertiary care
• Personnel: who works in the system? Who provides the services?
• Function: what does the system aim to achieve?
• Location: In what locations e.g. government facilities, schools, hospitals, health clinics, general community facilities, etc.
• Funding: how is the system funded? e.g. taxation, insurance, direct payment from individuals, etc.
• Remuneration: how are the health professionals paid? e.g. fee-per-service, capitation, contract, salary.
• Target population: who does the system provide care for? What are their demographics?
• Outcomes: e.g. reduce tooth loss, improve OH & QoL
Oral health systems
Good Oral health systems respond to:
o Changes in population demographics;
o Changes in patterns of oral diseases;
o Impact of oral diseases in relation to other systemic diseases;
o Social, political or economic structure and societal norms as reflected in national policies, legislation, regulations and payment systems.
• Influence oral health status, behaviours and service utilisation (Chen et al, 1997 International comparison of oral health systems).
importance of social context on health
People generally living longer, not due to medicine, due to better nutrition and sanitation.
3 E’s of more developed countries that result in better health .’. conditions may not kill people but may result in significant disabilities
Environment
Emergency services
Engineering
Health powerfully influenced by social and physical environments in which we live. Risk conditions integral to those environments damage health directly and through physiological, behavioural and psychosocial risk factors they engender
Improving health requires political action to modify these environments
Upstream vs downstream factors
Common risk factors
prevalence and range of chronic illnesses in the population
NCDs – also include neurological and musculoskeletal diseases. * not every chronic disease is non-communicable and some non-communicable disease may have a communicable origin e.g. Hep B & liver cancer
Long duration
Generally slow progression
Increasing prevalence worldwide
4 main types – CHD, diabetes, cancer, respiratory diseases
4 main risk factors – tobacco, alcohol, obesity, lack of physical activity
No clear relationship between ethnic background and chronic illness
Association with lower socioeconomic classes (Barnett et al., 2012)
o ↑ Early disease development (10-15 years)
o ↑ Early disability
o ↑ Prevalence of chronic illnesses
o ↑ Severity of chronic illnesses
o ↑ Comorbidities (including depression)
o ↓ Life expectancy
