Disease causation and the diagnostic process in relation to public health, prevention and health promotion.

Question 1

Issues that complicate early years intervention evaluation

Answer 1

• Study designs: Ethics of RCTs on preventative interventions, evaluating national interventions such as fortification of flour to improve pregnancy outcomes.
• Lack of control group/ poorly designed studies over time
• Difficult to measure absence: impossible to project over 20 years what disease prevalence/crime rates might be, how to show the absence of that?
• Lead times: Early years has long term follow up, studies are costly and complex to F/U over this time frame. E.G childhood education to reduce smoking and lifetime risk of lunch ca.

Question 2

Five key areas of early years evidence

Answer 2

Eduction, Nutrition, Socio-economic benefits, Emotional and social supply, Combined programmes.

Question 3

Education programmes in early years

Answer 3

Pre school education and parenting education.
Pre school:
Sylvia et al 2004. Cohort study, 3000 children across Europe.
Pre school attenders had higher educational and social attainment.
Quality of schooling did affect attainment
Socioeconomic status did not affect benefit gained by preschool
What parents did with children had more affect than SE status, e.g reading.

Question 4

Health and nutrition in early years

Answer 4

LBW- increases risk of chronic conditions. Evidence suggests maternal nutrition affected weight, Ca and folate supplements have shown positive outcomes. (Healthy start scheme) Smoking doubles risk of LBW.
Breastfeeding- increased passive immunity, lower SIDs, Reduced obesity, diabetes and atopy, greater bonding, reduced risk of breast and ov cancer in mothers.
Childhood immunisations
Interventions to reduce injuries e.g cycle helmets.

Question 5

East Sussex childhood injuries picture

Answer 5

• ES 67% of admission due to accidents in under 5s happened within a home.
• High rates in ES compared to England. Particularly bad in deprived areas of Hastings and Rother.
• Higher rates of falls, and accidental poisonings.
• East Sussex fire and rescue service offers home visits for safety checks, education and fitting of safety equipment

Question 6

Socio- economic benefits in early years

Answer 6

Acheson Report
Families with young children are at increased risk of poverty:
Need affordable childcare
Increase benefits and availability of benefits for pregnant women and families with young children.

Question 7

Emotional/social support in early years

Answer 7

Evidence for community family support programmes.
Aim to improve parent wellbeing, and children physical, emotional and cognitive development.

European Early Promotion project (2005) found healthcare worker training to support parent infant relationships led to fewer psychological problems in children.

Question 8

Combined programmes in early years

Answer 8

Programmes that combine multiple aspects.
Sure start (UK)/ Head start (USA)

Question 9

Pre determinants of health

Answer 9

Factors that indicate/contribute to determinants of health.
Material: Food and water, clean air, Income, housing, Green spaces.
Policy: Minimum wage, Occupational health, Maternal services, Childcare, Benefits and education.
Society: Social cohesion, values and attitudes, ethnic diversity and tolerance, language ability.

Question 10

Social cohesion

Answer 10

Pre determinant of health.
Society with strong social cohesion- strong interactions, supportive, few inequalities.

Wilkinson (1996) reduced income differentials, greater solidarity, and social cohesion lead to improvements in life expectancy.

Can influence and be influenced by health policy. E.g private insurance could increase inequality.

Question 11

Motivational interviewing

Answer 11

Motivational interviewing: Rollnick and Miller (1990s) counselling based on the stages of change model. Explores models about why an individual may be ambivalent about behaviour change.

Evidence in drug misuse, smoking cessation, eating disorders.

It utilities: empathy, highlight discrepancies, roll with resistance (respond with understanding not confrontation), build self efficacy.

Question 12

Individual behaviour change techniques

Answer 12

Motivational interviewing, CBT, incentives

Question 13

Incentives

Answer 13

Marteau et al 2009
vouchers to encourage smoking cessation, points scheme for healthy school meals (UK)
money towards healthcare costs in improve adherence (USA)
Financial rewards to avoid STIs (Tanzania)
Financial rewards for achieving weight loss targets (Italy)

Question 14

Incentives- pros and cons

Answer 14

+ effective in short term
+ potential effective long term combines with other activities
- Moral concerns- bribery
- overall paternalistic
poor use of public funds

Question 15

Define social marketing

Answer 15

Use of techniques of commercial marketing ti sell a health message

Question 16

Approach to social marketing

Answer 16

• Identify target group: segmentation tactics (define group by lifestyle choice rather than disease state)
• Research target group: survey and focus groups. Assess attitudes, habits, needs.
• Competitive analysis: competition is anything that may encourage the unhealthy behaviour e.g tobacco marketing
• Set objectives
• Develop a message: pretest with target group
• Sell the message
• Evaluate

Question 17

Four Ps of marketing

Answer 17

Product : It must be clear what is being sold.
Price: financial na opportunity costs
Place: channel used affects exposure to certain groups
Promotion: medial and advertising, e.g TV, Magazine, partnership with companies.

Question 18

Strengths and weakness of social marketing

Answer 18

+ Based on understanding of the target group
+ Clear objectives
+ Uses successful commercial techniques

• Assumes behaviour is individual choice
• Danger of portraying partial message e.g “Just say no” catchier than well rounded pos/neg of drugs
• Can reinforce same stereotypes as commercial marketing e.g health = positive physical attributes or = positive moral attributes

Question 19

Reasons for public involvement

Answer 19

• Improved concordance
• Empowerment
• Democracy
• Acceptability
• Ownership and sustainability
• Integrated approaches: More complex issues are tackled with community members insights as a problem solving tool.
• Better decisions

Question 20

Absolute vs relative poverty

Answer 20

Absolute: Lacks basic material needs
Relative: lives under 60% of median national income

Question 21

Factors that reinforce the effects of deprivation

Answer 21

Social exclusion, discrimination, employment, stress, antenatal effects.

Question 22

Local strategic partnerships

Answer 22

Statutory multi agency bodies

Functioned in areas of LA

Encourage collaborative working and community involvement

Statutory, voluntary, community and private sectors

Question 23

Why do we set targets in healthcare?

Answer 23

Adaptation of management practices and culture
Improvement of performance and accountability
Consistency

Question 24

Levels of target setting

Answer 24

Individual e.g personal PDP

Organisational e.g LA target for provision of affordable housing

National e.g Public Service Agreement- Given set minimum target for sectors in return offer investment, schools/health etc

International: WHO’s SDGs, Health for All targets

Question 25

Criteria for good targets

Answer 25

Specific Measurable Achievable Relevant Timely

Question 26

Pros and Cons of targets

Answer 26

+ Provide a focus for performance improvement + Explicit priority setting - provides common agenda for a team. + Provide accountability + Level playing field for organisations under comparison + Targets reflect organisations priorities and goals + Share good practice + Increase interest in particular areas - Might not be measurable (particularly in health), such may take focus away from some health areas - Gaming (distortions of practice). e.g reclassifying trolleys in ED as beds to meet 4h targets. - Distort priorities. Areas where targets are not easily set may be neglected - Disengagement from staff when targets set top down. - Costs

Question 27

Things to consider when setting targets

Answer 27

Closely correlate to clinical outcomes Select with consensus from team- evidenced, feasibly, acceptable multiple time frames Consider which priorities we want the public to know are important/ form of education public on important targets Targets are practical expression of guidelines

Question 28

Donabedian's Framework

Answer 28

(2005) Framework to evaluate health programmes. Structure/input, process and outcome measures/targets applied to each to evaluate programmes.

Question 29

Programming approach

Answer 29

Epidemiological paradigm Long term effects of environmental exposures during critical periods. E.g Barker Hypothesis- in utero malnutrition as a risk factor for CHD

Question 30

Adult risk factor approach

Answer 30

Epidemiological paradigm Impact of lifestyle and behaviours

Question 31

Life course approach

Answer 31

Epidemiological paradigm Combines elements if programming and adult risk factor approach. Various risk factors across gestation and life affect health and disease. Limitation: Little research on very longitudinal cohorts.

Question 32

Screening: Definition

Answer 32

Aim: Identify people who can be helped in the early stage of disease. "identify apparently healthy people in the early stages of disease/increased risk. Such that they can be offered information, or further tests and treatment." NSC: National Screening Committee

Question 33

UK Screening programmes

Answer 33

Antenatal: Early- HIV, Syphilis, hepatitis B, Rubella, Haemolytic diseases, Sickle cell, thalassaemia. Mid- Downs, Fatal abnormalities. Neonatal: Heel prick- PKU, Congenital hypothyroid, sickle cell and thalassaemia, CF, MCADD Hearing screening Heart defect, cataract, Malformations, cryptorchidism, hip dislocation. Childhood: Growth- turners, growth hormone deficiency Hearing Vision Adult: AAA- one off USS at 65. Breast ca- 3 yearly mammogram 50-71 Cervical ca - HPV test, 25-49, 3 yearly Bowel ca- Feacal occult blood, 60-69, 2 yearly. DM retinopathy- 12 year + with DM, annually.

Question 34

Non screening secondary prevention programmes

Answer 34

Health checks Childhood obesity Chlamydia Prostate ca TB

Question 35

Reasons for setting high sensitivity for screening tests

Answer 35

Significant disease with definitive treatment Rick of infectivity to others Subsequent test cheap/low risk

Question 36

Reasons for setting high specificity for screening tests

Answer 36

Unpalatable treatment Costly/ high risk subsequent test

Question 37

ROC curves

Answer 37

Receiver operated characteristic curves Plots the trade off between sensitivity and specificity (TP/FP) - Aids threshold setting for tests - Helps compare different possible screening tests Should be high and left

Question 38

Active case finding

Answer 38

Systematically searching for high risk people. E.g GP identification of high risk CHD, Genetic testing of family, case finding in disease outbreaks. + Cheap + Low personal demand + Improves PPV of a test + Targets prevention + Cost effective for familial conditions - Potential to widen inequalities for hard to reach groups

Question 39

Likelihood ratios

Answer 39

How many more times people with the disease are likely to have a positive test result LR > 1 test result is associated with presence of disease. > 10 high likelihood LR < 1 Result indicates absence of disease The further from one indicates stronger association. Positive LR = Sensitivity/ (1- specificity)

Question 40

Pre test probability

Answer 40

“the probability of the screened person having the disease” = prevalence Pre test odds = Pre-test probability/ [1 – Pre-test probability] Using routine data, practice data, and clinical judgement

Question 41

Post test probability

Answer 41

“is the probability of the patient having a disease after obtaining the test results” Can be extrapolated from PPV - but this is based on prevalence Can also be estimated from pre test probability and LR - (using Bayesian statistics) Fagans nomogram can be used.

Question 42

Factors that affect screening participation

Answer 42

+ Perception of severity + Perception of susceptibility + Perception of benefit + Knowledge of disease + Knowledge of treatment - Phobia - Disease severity (low) - High residential mobility - Low acceptance of test - Stigma - Inaccessibility

Question 43

Informed choice in screening

Answer 43

GMC Patients need to know - Purpose of the test - Risks of test - Likelihood of positive findings - Possibility of false results - Implications of screening - Follow up

Question 44

Screening : Evaluation

Answer 44

1. Relative burden of disease 2. Feasibility Organising attendance, acceptability, post screen care, costs 3. Effectiveness - Extent to which the programme affects outcomes - Consider bias (selection, lead time, length time) - Issues with understanding over diagnosis, takes time/ long follow up.

Question 45

Screening : Planning

Answer 45

Consider: Who is eligible How often to screen Invitations Quality assurance Wilson and Jungner criteria- Disease is : Important, pre clinical stage/natural history known. latent period. Test is: Valid, simple/cheap, acceptable, reliable Follow up: Agreed policy in place, facilities to diagnose/treat, Treatment available Overall: Evidenced, Acceptable, Opportunity cost balanced, adequate staffing/facilities, Clear management, patient able to make an informed choice.

Question 46

Screening : Case study’s (bowel, breast, prostate)

Answer 46

Bowel ca- England uptake 69.6% 21/22 Less in deprived areas compared to affluent areas. Breast ca- DH and Ca research review found that for 10 000 screen cases 43 deaths prevented, 129 over diagnosed. Suggested new information should be given to reflect this. Prostate ca- Not recommended. Test low sens/spec, unclear which treatment option is the best. Cervical cancer England uptake- 69%

Question 47

Control of genetic disease

Answer 47

testing of embryos Ante/neonatal testing Screening for genetic conditions Treatment to reduce risk (familial hypercholesterialaemia) Genetic counselling

Question 48

National nutrition surveillance

Answer 48

Food supply data- imports/exports, agricultural data, food mapping exercises. ONS Living cost and food survey- annual, self reported diaries, 5,000 homes across the UK. Diet and nutrition surveys- (Self reported, biased and unreliable ) DH and food standards agency: National diet and nutrition survey. 1000 adults. Breast feeding survey, every 5 years School meals - from LA catering services. Self reported surveys- children,

Question 49

Nutritional interventions

Answer 49

Flouridation of water Fortification of food- folic acid in flour. School and workplace campaign- canteen meals TV Collaboration with food industry Free fruit in schools Sugar tax

Question 50

Social determinants of diet

Answer 50

Poverty Ethnicity/culture - BAME- Higher fruit and veg, less fat, higher salt intake Education

Question 51

Dietary reference values

Answer 51

Used by professionals Values set by healthy people in different age brackets Estimated average requirement Reference nutrient intake - amount needed by 97% Lower reference nutrient intake - amount needed by 2.5% Safe intake

Question 52

Challenges in evidence for nutrition

Answer 52

Hard to obtain undisputed evidence Ensuring risks are accepted Implementing evidence to change consumption Long term outcomes of CHD hard to research Ethical issues of RCTs Seven countries study- shows a link between animal fats and CHD, compared to med diets

Question 53

Environmental determinants of health

Answer 53

Global warming/climate change Sustainable development Housing Built environment Transport occupation Water and sanitation Agriculture and food Air quality Temperature, noise, radiation Chemical agents Biological agents

Question 54

Environmental injustice

Answer 54

Exposure to environmental risk factors is greater amount more deprived people, but wealthier people are responsible for more pollution. E.g Weather people won care- pollute- affects people living in urban areas/poor housing global carbon dioxide is produced by weather countries but effects of climate change felt most in developing areas

Question 55

Environmental risk vs hazard

Answer 55

Hazard- potential to harm health (pollution, radiation, extreme temps) Risk- probability of an unfavourable event occurring x consequences of that event

Question 56

Effects of climate change on health

Answer 56

Direct: Heatwaves, extreme weather Indirect: Changing epi of IDs Floods- water borne disease, changing vectors Resp diseases & pollution Droughts- food insecurity Rising sea levels- displacement reduced farming activity Pressure on resources - war Increased skin cancer

Question 57

Responding to climate change

Answer 57

Mitigation- reduce greenhouse gasses Adaptation- flood defences, increased vaccine programmes, sun protection advice

Question 58

Define and principles of sustainable development

Answer 58

Definition: “meeting our needs today without compromising the ability of those to meet their needs tomorrow” Respecting the environment, resources, biodiversity Health and justice- meeting needs of all communities Governance Evidence based - precautionary principle Sustainable economy - Polluter pays principle

Question 59

Water pollutants

Answer 59

Fertilisers - nitrates, phosphates Metals- Aluminium, lead, Heavy metals Slurry- organic waste Sewage

Question 60

Radiation

Answer 60

Ionising - 84% produced by naturally occurring radon gas, need to improve ventilation in homes where this occurs (due to geology). 15% healthcare <1% due to industry. Acute radiation sickness, or long term exposure e.g cancer Non ionising- sun/ power lines/ phones. cancer, cataracts, sunburn. Measured - Gray (GY) Energy deposited in each gram of tissue. Single exposure of 5Gy across body- fatal

Question 61

Principle air pollutants

Answer 61

CO Ozone Nitrogen dioxide (cars)/ sulphur dioxide (coal) - resp illness, acid rain Lead- Particulates- car emissions, resp and Cv disease Organic compounds- traffic emissions, industrial processes- carcinogenic, smog Radon

Question 62

2 principles of EU environment legislation

Answer 62

Polluter pays: Party responsible for creating pollution pays for recovery/clean up/ recycling/ disposal. Or tax on business that use non friendly products/processes Precautionary principle: Credible but unproved hazards should be treated as real threats. err on side of caution.

Question 63

Compliance with environmental legislation

Answer 63

Business not aware of legislation Monitoring variable across EU Penalties weak compliance not previewed as key to business survival

Question 64

UK agencies involved in occupational health

Answer 64

Health and safety executive Trade unions LA Employers occupational health

Question 65

Collectivism

Answer 65

That the state has a responsibility for the population. Drink driving laws Health and safety regulation Fluoridation of water Tax

Question 66

Individualism

Answer 66

Political/moral philosophy that emphasises the individual. Safe drinking limits advertised Alcohol licences to allow purchase 24H a day private healthcare providers

Question 67

Policy Rainbow

Answer 67

Dahlgren and Whitehead 1991 Determinants exist and interconnected layers. Age, sex non modifiable but others are modifiable, and interact with health in different ways. Used in London Health Commission report

Question 68

Health Belief model

Answer 68

Hochbaum 1958 Person will take health related action if: Perceived susceptible Perceived severity Course of action available Benefits outweigh risks Perceived ability to carry out action +Useful for simple preventative behaviours + Evidenced to predict behaviour/improve interventions - Complex long term behaviours (alcohol dependance) doesn't work as well - Doesn't account for factors outside personal beliefs, e.g culture, provision of healthcare.

Question 69

Stages of change model

Answer 69

Prochaska and DiClemente 1984 Behaviour change as a process. Predicts who will change behaviour and who will fail to progress through. Pre contemplation, contemplation, determination, action, maintenance, termination. + Useful for complex long term behaviour changes + Can tailor counselling to the stages the patient is at + useful for programme planning to plan interventions sequentially - Less useful for whole communities.

Question 70

Spheres of health promotion

Answer 70

Tannahil 1985 Three overlapping spheres of activity- health education, protection against harm, prevention of disease. + simple + Widely adopted + encompasses wellbeing - Difference between prevention and protection is arbitrary

Question 71

Beattie Model

Answer 71

1991 Considers activities for health promotion and how they are delivered. Useful tool for critically evaluation of promotion programmes. 2 axis- authoritative- negotiated, individual - collective. 4 approaches - health persuasion, Personal counselling, Legislative action, Community development.

Question 72

Health messages

Answer 72

McGuire Source - ?credibility/trust Message Channel - medium and setting Receiver - primed? targeted destination- outcome of message

Question 73

Requirements for successful communication

Answer 73

Be seen/heard by target Attract attention Be understood Be accepted Change behaviour

Question 74

Mass communication

Answer 74

+simple +many recipients + Useful for reinforcing ideas + same message reaches all - Low flexibility - No feedback - Don't know its been seen/heard - Expensive

Question 75

Individualised communication

Answer 75

+ Can challenge current attitudes + Complex messages + Can also use counselling techniques (support self efficacy) + flexible + feedback - Small numbers - Variability in dissemination of message

Question 76

Community development: Activities

Answer 76

Formal participation, community action (priority setting), Facilitation (by health service), Interface (work closely with community), Strategy (support)

Question 77

Community development: +/-

Answer 77

+ Projects are based in community proprieties + Focus on root cause of ill health + positive process of involvement, confidence, control + Can reach excluded groups - Resource intensive - time consuming - hard to secure funding - Long timescale - results often intangible - Conflict of accountability for community workers

Question 78

Partnership working

Answer 78

Types: within organisation, across local areas, outreach to community Methods: Statutory committee, Shared targets, Joint projects, Specific initiatives, joint post, shared budget + avoids duplication + Pools resources + Political imperatives - Shared outcomes? - different processes - requires commitment - power dynamic - influence

Question 79

Surveillance

Answer 79

Detects trends, Evaluate prevention/control measures, alert for threats, monitor known IDs, research Passive, active, enhances, sentinel, syndromic. Evaluation: Importance of condition under surveillance Clear case definition? System/process - objectives, process Analysis- methods Usefulness Recommendations for improvement

Question 80

Evaluation of vaccine programmes

Answer 80

Disease surveillance Sero-epidemiological surveillance Market testing Monitor adverse events

Question 81

Developing and immunisation strategy: General considerations

Answer 81

Mass vs selective Live vs attenuated Age Dose interval Outbreak response Surveillance Containment Investment in research

Question 82

Developing and immunisation strategy: Mass vs selective

Answer 82

Mass- herd immunity. E.g Rubella Selective - high risk groups, less costly, less adverse events e.g hep B

Question 83

Outbreak investigation: concurrent tasks

Answer 83

Epidemiology Control measures Collect environmental samples Outbreak control group Communication

Question 84

Outbreak investigation:

Answer 84

Epidemiology Case definition Confirm cases Define background rate Assess if outbreak has occurred Active case finding Time/place/ person characteristics Epi curve Generate hypothesis Test hypothesis Conclude

Question 85

Outbreak investigation: Control measures

Answer 85

Control source, spread. Protect at risk persons Continue surveillance Declare outbreak over when back to background levels Consider future control

Question 86

Outbreak investigation: outbreak control group

Answer 86

HP cons Micro/ viro/toxo Admin Food/vets Epidemiologist DPH GP Other involved orgs - Environmental health, food standards, water standards etc

Question 87

WHO disaster management cycle

Answer 87

Prevention Preparedness Detection and alert Response Recovery

Question 88

Routine micro techniques

Answer 88

Microscopy, culture, id, drug sense testing +low cost + definitive diagnosis - Take time - Low sensitivity - can't always isolate organism - may not be able to provide strain with limited techniques

Question 89

Reference lab techniques

Answer 89

Nucleic acid probes/ amplification systems + Incase sens/spec + ID orgs that don't grow on culture + Genes that result in resistance + Epi tracking + New infections + Control of Abx resistance - Specialist equipment - Some techniques have longer turnaround times