Public Health Flashcards
(248 cards)
1
Q
What is Public Health?
A
The science and art of preventing disease, prolonging life and promoting health through organised efforts of society
2
Q
Define Epidemiology
A
The study of frequency, distribution and determinants of disease and health related states in populations in order to prevent and control disease
3
Q
Define incidence
A
Number of new cases of a disease in a population in a given time frame (new cases per 1000 per year)
- The rate at which new disease occur in a population in a certain time period
4
Q
Define Prevalence
A
Existing cases in a population at a point in time (total number of people with a condition per 100,000 per year)
5
Q
What is Person time?
A
Measure of time at risk = time from entry to a study to
- Disease onset
- Loss to follow up
- End of study
Used as the denominator to calculate incidence rate
6
Q
Define incidence rate
A
Number of person who have become cases in a given period of time / total person time at risk during that period
7
Q
What is meant by absolute risk?
A
Actual numbers involved and has units
e.g. 50 deaths per 1000 people
8
Q
What is meant by relative risk?
A
The ratio of risk in one category relative to another
E.g. risk in exposed compared to the risk in unexposed
Tells us the strength of association between risk factor and disease
9
Q
How is relative risk calculated?
A
Incidence in exposed ÷ incidence in unexposed
10
Q
Define attributable risk
A
Rate of disease in the exposure that may be attributed to the exposure
- Tells us about the size of effect in absolute terms
11
Q
How is attributable risk calculated?
A
Incidence in exposed - incidence in unexposed
12
Q
If the incidence of disease A in smokers is 1/1000 person years and 0.05/1000 person years in non smokers, what is the attributable risk?
A
1-0.05 = 0.95/1000 person years
13
Q
If the incidence of disease A in smokers is 1/1000 person years and 0.05/1000 person years in non smokers, what is the relative risk?
A
1/0.05 = 20 (no units)
14
Q
If the incidence of disease B is 8/1000 person years and incidence of disease B in non-smokers is 4/1000 person years what is the attributable risk?
A
8 - 4 = 4/1000 person years
15
Q
If the incidence of disease B is 8/1000 person years and incidence of disease B in non-smokers is 4/1000 person years what is the relative risk?
A
8/4 = 2 (No units)
16
Q
What is relative risk reduction?
A
Reduction in the rate of the outcome in the intervention group relative to the control group
17
Q
How is relative risk reduction calculate?
A
1 - relative risk
OR
(incidence in non exposed - incidence in exposed) ÷ incidence in non exposed
18
Q
What is absolute risk reduction?
A
Absolute difference in the rate of events between the 2 groups
Gives an indication fo the baseline risk and the intervention effect
19
Q
How is absolute risk reduction calculate?
A
Incidence in non exposed - incidence in exposed
20
Q
Define Number Need to Treat (NNT)
A
Number of patients needed to treat to prevent one bad outcome
21
Q
How is NNT calculated?
A
1 / Absolute risk reduction
OR
1 / (incidence in non exposed - incidence in exposed)
22
Q
What is meant by odds?
A
Odds of an event is the ratio of the probability of an occurrence compared to the probability of non-occurrence
23
Q
How Is Odds calculated?
A
Probability / (1 - Probability)
24
Q
What are the 5 factors that could be responsible if a study finds an association between exposure and an outcome?
A
- Bias
- Chance
- Confounding factors
- Reverse causality
- A true causal association
25
Define bias
A systematic deviation from the true estimation of the association between exposure and outcome
26
What are the 3 main types of bias?
1. Selection bias
2. Information (measurement) bias
3. Publication bias
27
What is selection bias?
A systematic error in
1. Selection of study participants
2. Allocation of participants to different study groups
(those who take part may be different to those who don't)
28
What are some examples of selection bias?
- Non response
- Loss to follow up
- Those in intervention group different in some ways form the controls other than the exposure in question
29
What is information bias?
A systematic error in the measurement or classification of the exposure or outcome
30
What are some potential sources of information bias?
- Observer bias
- Participant --> recall/reporting bias
- Instrument --> wrongly calibrated
31
Define confounding
The situation where a factor is associated with the exposure of interest and independently influences the outcome (but does NOT lie on the causal pathway)
32
Define reverse causality
Refers to the situation when an association between an exposure and an outcome could be due to the outcome causing the exposure rather than the exposure causing the outcome
33
What is the Bradford Hill criteria for causality?
1. Strength of association --> magnitude of relative risk
2. Dose response --> higher the exposure the higher the risk of disease
3. Consistency --> similar results from different researchers using various study designs
4. Temporality --> Does the exposure precede the outcome
5. Reversibility --> Removal of the exposure reduces the risk of disease
6. Biological plausibility --> biological mechanisms explain the link
34
Name 3 types of study design
1. Ecological
2. Cross-sectional
3. Case-control
4. Cohort
5. Randomised control trial (RCT)
35
What does a descriptive study involve?
1. Case reports of case series - study individuals
| 2. Ecological studies - use routinely collected data to show trends in data and thus useful for generating hypotheses
36
Which type of study uses routinely collected population level data to show trends and to generate hypotheses?
Ecological study
37
What is the issue with ecological studies?
Shows prevalence and association but cannot show causation
38
What is a cross sectional study?
Divide the population into those without the disease and those with the disease and collects dat on them at defined times to find associations at that point in time
- Used to generate hypotheses but prone to bias and have no time reference
39
What are the advantages of a cross sectional study?
- Quick and cheap
- Provide data on prevalence at a single point in time
- Large sample sizes
- Good for surveillance and public health planning
40
What are the disadvantages of cross sectional studies?
- Risk of reverse causality (don't know whether outcome or exposure came first)
- Cannot measure incidence
- Risk of recall bias and non response
41
What is a case control study?
A type of retrospective analytical study that takes people with a disease and compares them to people without the disease for age/sex/habit/class etc
E.g. Researchers set out to examine the association between alcohol consumption and stroke - they identify all new patients admitted with stroke and compare their alcohol consumption with patients admitted for elective surgery
42
Give 2 advantages of a case control study
1. Good for rare outcomes
2. Quicker than cohort or intervention studies (as outcome has already happened)
3. Can investigate multiple exposures
43
Give 2 disadvantages of a case control study
1. Difficulties finding control to match with cases
| 2. Prone to selection and information bias
44
What is a cohort study?
Prospective study that starts with a population without a disease in question and study them over time to see if they are exposed to the agent in questions and if they develop the disease in question or not
45
Give 2 advantages of a cohort study
1. Possible to distinguish preceding causes from concurrent associated factors
2. Lower chance of secretion and recall bias
3. Prospective - so can show causation (where retrospective can't)
4. Good for common and multiple outcomes
5. Absolute, relative and attributable risk can be determined
46
Give 2 disadvantages of a cohort study
1. Takes a long time
2. Loss to follow up
3. Needs a large sample size
4. Requires a control group to establish causation
47
What is a randomised control trial?
A population are randomised into either an interventional or a control group
- Often blind or double blind trials
48
Give 2 advantages of a RCT
1. Low risk of bias and confounding
| 2. Can infer causality (gold standard)
49
Give 2 disadvantages of a RCT
1. Time consuming
2. Expensive
3. Specific inclusion.exclusion criteria may mean the study population is different form typical patients
4. Ethical issues - is it ethical to withhold treatment that is strongly believed to be effective?
50
What are the main issues with controlled trials that are not randomised?
- Very subject to bias
| - Confounding factors are not equally spread across the groups
51
Which type of study is also known as an incidence study?
A cohort study --> follows a population over time to see if they're exposed to the agent in question and if they develop the disease
52
Which type of study is also known as a prevalence study?
A cross-sectional study --> looks at the population at point in time
53
Define Screening
A process which sort out apparently well people who are at risk of disease in hope of caching it in its early stages
- NOT diagnostic
54
What are the Wilson and Junger criteria for screening?
1. Condition must be an important health problem
2. Must have a known detectable latent phase
3. Must have a known natural course/progression
4. Must be a test which is acceptable to the population
5. Must be a treatment for the condition
6. Must be an agreed at risk population of which to screen
7. Must be an agreed policy on who to treat
8. Costs of screening should be economically balanced
9. Facilities for diagnosis and treatment need to be available
10. Screening should be a continuous process, not just a one off
55
What are the different types of screening?
1. Population based screening programmes --> cervical cancer, breast cancer
2. Opportunistic screening --> BP measurements at GP
3. Screening for communicable diseases
4. Preemployment and occupational medicals
5. Commercially provided screening --> pay to get blood sent off and tested for genetic problems
6. Genetic counselling --> genetic testing for people with FHx of genetic diseases
56
What are some disadvantages of screening?
1. Exposure of well individuals to distressing or harmful diagnostic tests
2. Detection and treatment of subclinical disease that would never have caused any problems
3. Preventative interventions that may cause harm to the individuals or population
57
What is sensitivity and how do you calculate it?
Proportion of people with the disease are correctly identified
True positive / (True positive + False negative)
58
What is the specificity of screening and how do you calculate it?
Proportion of people without the disease that are correctly excluded by the screening test
True negative / (True negative + False positive)
59
Define Positive Predictive Value (PPV) and how is it calculated?
Proportion of people with a positive test result who actually have the disease
True positive / (True positive + False positive)
60
Define Negative Predictive Value (NPV) and how is it calculated?
Proportion of people with a negative test result who actually do not have the disease
True negative / (True negative + False negative)
61
What is lead time bias?
When screening identifies an outcome earlier than it would be otherwise have been identifies resulting in an apparent increase in survival time even if screening has no effect on outcome
62
What is length time bias?
Type of bias resulting from differences in the length of time taken for a condition to progress to severe effects, that may affect the apparent efficacy of a screening method
63
Define primary prevention
Preventing disease form occurring int he first place
| - Often eliminating risk factors that contribute to the disease
64
Give an example of primary prevention
1. Immunisations
2. Change4life
3. 5 a day
65
Define secondary prevention
Catching a disease in its early pre clinical phase in order to alter its course and to improve health outcomes
66
Give an example of secondary prevention
Screening --> cervical and Breast
67
Define tertiary prevention
Trying to slow down disease progression, preventing complication fo the disease and helping people manage their illness effectively
68
Give an example of tertiary prevention
1. Diabetes manages --> diet advice, exercise programmes, annual foot check
2. Attending physio/rehab after a stroke to prevent immobility and aspiration pneumonia
69
What is the population approach to prevention?
| Give an example
Preventative measures delivered on a population wide basis
| E.g. Dietary salt reduction
70
What is the high risk approach to prevention?
| Give an example
Approach
Identifying individuals above a chosen cut off and treating them
E.g. Treating those with high cholesterol to avoid heart disease
71
Describe the prevention paradox
A preventative measure that brings much benefit to the population often offers little to each participating individual
72
What are the 4 main determinants of health?
1. Genes --> age, sex, genetic factors
2. Environment --> Physical, socioeconomic
3. Lifestyle --> smoking, exercise, alcohol, diet
4. Healthcare
Wider determinants = inequalities in health, primary, secondary and tertiary prevention
73
What are the structural determinants of health?
Socio-economic connect that someone is born into
- Governance
- Policies
- Social and cultural values communities place on health
74
What factors determine someones socioeconomic position in society?
- Education
- Occupation
- Income
- Gender
- Ethnicity
- Social Class
75
What are the intermediately determinants of health?
1. Material circumstances --> housing, clothing, food
2. Psychosocial factors --> living circumstances, relationships, support
3. Behavioural and biological factors
76
Define Equality and Equity
```
Equality = equal shares
Equity = What is fair and just
```
77
Define horizontal equity
Equal treatment for equal need
| - Individuals with same disease should all be treated equally
78
Define Vertical equity
Unequal treatment for unequal need
- Individuals with common cold need different treatment to those with pneumonia
- Areas with poorer health may need higher expenditure on health services
79
How can vertical equity be justified?
```
On morally relevant factors
- Need
- Ability to benefit
- Deservingness
NOT morally irrelevant factors
- Age/sex
- Ethnicity
- Income, class
- Disability, genetics
```
80
How can health equity be classified?
1. Spatial --> geographical
| 2. Social --> age, gender, class, ethnicity
81
How can we examine health equity?
1. Supply of healthcare
2. Access to healthcare
3. Utilisation of healthcare
4. Health care outcomes
5. Health status
6. Resource allocation --> health services, education, housing
7. Wider determinants of health --> diet, smoking, healthcare seeking behaviours, socioeconomic and physical environment
82
What are the 3 domains of public health practice?
1. Health Improvement
2. Health Protection
3. Healthcare (Improving services)
83
What is meant by health improvement domain?
Concerned with societal intervention aimed at preventing disease, promoting health and reduction inequalities
84
Give 2 examples of the health improvement domain
1. Addressing inequalities
2. Education
3. Housing
4. Employment
5. Lifestyle
6. Family/community
85
What is meant by health protection domain?
Concerned with measures to control infectious disease risks and environmental hazards
86
Give 2 examples of the health protection domain
1. Infectious disease
2. Chemical and poisons
3. Radiation
4. Emergency response
5. Environmental health
6. Hazards
87
What is meant by health care domain?
Organised and delivery of safe, high quality services for prevention, treatment and care
88
Give 2 examples of the health care domain
1. Clinical effectiveness
2. Efficiency
3. Service planning
4. Audit and evaluation
5. Clinical governance
6. Equity
89
What are the 3 levels that a public health intervention can occur at?
1. Individual level
2. Community level
3. Ecological (population level)
90
Give an example of an individual level public health intervention
Childhood immunisations --> where injection are delivered to each individual child to stop them getting ill
91
Give an example of a community level public health intervention
Similar to ecological level intervention but delivered at the local or community level
E.g. Playground set up for local community, more cycle paths, outdoor gym
92
Give an example of an ecological level public health intervention
- Clean air act --> legislation to ban smoking in enclosed public places
- Sugar tax
- Putting iodine in salt --> prevent iodine deficiency
- Screening programmes
- PH campaigns --> change4life, Movember
93
Define health psychology
Emphasises the role of psychological factors in the cause, progression and consequences of health and illness and promotes healthy behaviours and prevents illness
94
What are the 3 behaviours related to health?
1. Health behaviour
2. Illness behaviour
3. Sick role behaviour
95
Define health behaviour
A behaviour aimed at preventing a disease
| - Can be health damaging or health promoting
96
What are health damaging behaviours?
Often related to mortality
- Smoking
- Alcohol
- Substance misuse
- Sun exposure
- Driving with no seatbelt
97
Give 2 reasons why people engage in health damaging behaviours
1. Unrealistic optimism
2. Health beliefs
3. Situational rationality
4. Culture variability
5. Socio-economic factors
6. Stress
98
What are health promoting behaviours?
Behaviours that seek and maintain health
- Exercise
- Health eating
- Attending health check
- Medication compliance
- Vaccinations
99
Define Illness behaviour
A behaviour aimed to seek remedy
| - Going to the doctor
100
Define Sick role behaviour
Any activity aimed at getting well
| - Taking prescribed medications, resting
101
Define unrealistic optimism
When individuals continue to practice health damaging behaviour due to inaccurate perception of risk and susceptibility
102
Give 3 factors that contribute to unrealistic optimism (e.g. influence an individuals perception of risk)?
1. Lack of personal experience with the problem
2. belief that the risk is preventable by personal action
3. Belief that if something hasn't happened by now then its not likely to happen
4. Belief that the problem is infrequent
103
Why is it important to understand a patients perception of risk?
A patients perception of risk can impact on medication adherence and keeping appointments etc
104
What is health psychology?
Emphasises the role of psychological factors in the cause, progression and consequences of health and illness
105
Name 4 models/theories of behaviour change
1. Health Belief Model
2. Theory of Planned Behaviour
3. Transtheoretical model (stages of change)
4. Social norms theory
5. Nudging
6. Motivational interviewing
106
What is the Health Belief Model (Becker 1974)?
Individuals with change if they
- Believe they are susceptible to the condition in question
- Believe that it has serious consequences
- Believe that taking action reduces susceptibility
- Believe that the benefits of taking action outweigh the costs
107
What are the 4 key aspects to the Health Belief Model?
1. Perceived Susceptibility
2. Perceived Severity
3. Perceived Benefits
4. Perceived Barrier
108
"Cues to action" are another important aspect of the Health Belief Model - What is meant by this>
- Internal cues --> e.g. worsening pain/SOB may trigger someone to want to change their behaviour
- External cues --> e.g. Reminder letters or phone calls from GP
109
Give 3 disadvantages of the Health Belief Model
1. Alternative factors may predict health behaviour, such as outcome expectancy (Whether the person feels they will be healthier as a result of their behaviour) and self-efficacy (the person belief in their ability to carry out preventative behaviour)
2. Does not consider the influence of emotions on behaviour
3. Does not differentiate between first time and repeat behaviour
4. Cues to action are often missing
110
What is the Theory of Planed Behaviour?
Proposes that the best predictor of behaviour is INTENTION
111
What are the 3 factors that determine intention in Theory of Planned Behaviour ?
1. Persons Attitude (e.g. I do not think smoking is a good thing)
2. Subjective Norms --> perceived social pressure to undertake a behaviour (e.g. people who are important to me want me to give up smoking)
3. Perceived behaviour control --> A persons appraisal of their ability to perform the behaviour (e.g. I CAN give up smoking)
112
How do we bridge the intention to behaviour gap in the Theory of Planned Behaviour?
Only 50% of intentions transfer to behaviours
1. Perceived control = ask them to reflect on how they felt when something went well (e.g. saying no to a cigarette)
2. Anticipated regret = reflect on how they felt when they didn't do something (e.g. When they weren't able to say no to a cigarette)
3. Preparatory actions = remind people to prepare for their change of behaviour (e.g. Throw cigarettes away)
4. Implemented intentions = help them help themselves incorporate the behaviour change into their routine (e.g. Putting tablets next to the kettle)
5. Relevance to self
113
Give 3 disadvantages of the Theory of Planned Behaviour
1. Lack of temporal elements (no timescale)
2. Lack of direction or causality
3. Doesn't taken into account emotions
4. Relies on self reported behaviour
5. Doesn't explain how attitudes, intentions and perceived behavioural control interact
6. Habits and routine bypass cognitive deliberation and undermine a key assumption of the model
114
Describe the Transtheoretical model
| - And give an example of each
1. Pre-contemplation = haven't thought about stopping smoking
2. Contemplation = thinking about stopping
3. Preparation = goes to doctor, gets prescription of champix, sets stop date, throws away cigarettes
4. Action = stops smoking on quit date and uses medications to help
5. Maintenance = Continues to abstain from smoking by going for regular reviews and picking up more medication
6. Relapse = potential relapse after trigger type event
115
Give 2 advantages of the Transtheoretical Model
1. Acknowledges individual stages of readiness
2. Accounts for relapses and allows patients to move backward in stages
3. Give an idea of time frame
116
Give 2 disadvantages of the Transtheoretical Model
1. Not all people move through every stage
2. Change might operate on a continuum, not discreet stages
3. Doesn't taken into account habits, culture, social and economic factors
117
What is the role of motivational interviewing (Miller, 1996)?
A counselling approach for initiating behaviour change by resolving ambivalence
- Role is to allow someone to change their behaviour by helping them to make a decision about the behaviour
118
What is the Nudge Theory?
Change the environment to make the best/healthiest option the easiest
- E.g. Place fruit next to checkout rather than sweets, Opt out pension schemes
119
What are the typical transition points in life which may influence how someone changes their behaviour?
1. Leaving school
2. Entering workforce
3. Becoming a parent
4. Becoming unemployed
5. Retirement
6. Bereavement
120
What are some other factors to consider when if comes to behaviour change?
- Impact of personality traits on health behaviours
- Assessment of risk perception
- Impact of past behaviour/habit
- Automatic influences on health behaviour
- Predictors of maintenance of health behaviours - does it stay changed 6 months down the line
- Social environment
121
What impact does Social Norms have on health behaviours?
Social Norms = behaviours and attitude common in a. group of people
- Providing truth about social norms cold decrease high risk behaviour
- Doesn't work when risky behaviour is the social norm
122
What do NCIE advise we do about behaviour change?
1. Planning interventions
2. Assessing social context
3. Education and training
4. Individual level interventuons
5. Community level interventions
6. Population level interventions
7. Evaluating cost effectiveness
8. Assessing cost effectiveness
123
What is "Health Need Assessment"?
Systematic method for reviewing the health issues facing a population and resource allocation that will improve health and reduce inequalities
124
In terms of Health Need Assessment, define Need
Ability to benefit from an intervention
| - Minimum unit pricing for alcohol
125
In terms of Health Need Assessment, define Demand
What people ask for
| - Cosmetic surgery
126
In terms of Health Need Assessment, define Supply
What is provided
| - Tamiflu stockpiles for influenza
127
Briefly desire the planning cycle of Health Needs Assessment
Needs assessment --> Planning --> Implementation --> Evaluation --> Needs assessment --> etc
128
Define Health need
Need for health
| - Concerns measures of morality, morbidity and sociodemographic measures
129
Define Healthcare need
Need for healthcare and the ability to benefit from healthcare
- Potential for prevention, treatment and care services to remedy health problems
130
Give 2 reasons why a health needs assessment may be carried out for
1. Population or subgroup
2. A condition
3. An intervention
131
What are the 4 Sociological Perspectives of need (Bradshaw)?
1. Felt need
2. Expressed need
3. Normative need
4. Comparative need
132
Define felt need
Individual perceptions of variation from normal health
133
Define expressed need
Individuals seek help to overcome variation in normal health (demand)
134
Define Normative need
Professional defines intervention appropriate for the expressed need
135
Define comparative need
Comparison between severity, range of interventions and cost
136
Name the 3 different approaches to Health Needs Assessments
1. Epidemiological
2. Comparative
3. Corporate
137
Describe the epidemiological approach to Health Needs Assessment
1. Define the problem
2. Size of the problem --> prevalence and incidence
3. Services available --> prevention, treatment, care
4. Evidence base --> cost effectiveness and efficacy
5. Models of care --> quality, outcome measures
6. Existing services --> unmet need, services not needed
7. Recommendations
138
Give 3 potential sources of data for an epidemiological Health Needs Assessment
1. Disease registry
2. Hospital admissions
3. GP databases
4. Mortality data
5. Primary care data - postal/patient survey
139
Give 2 advantages of an epidemiological health needs assessment
1. Uses existing data
2. Provides Dara on disease incidence/mortality/morbidity etc
3. Can evaluate services by trends over time
140
Give 2 disadvantages of an epidemiological health needs assessment
1. Require data not available
2. Variable data quality
3. Evidence based may be inadequate
4. Does not consider felt needs of people affected
141
Describe a Comparative approach to a Health Needs Assessment
Compares the service received by a population (or subgroup) with others
- Spatial (different towns)
- Social (age, gender, class, ethnicity)
ie. compares the services for a particular health issue in 2 different areas
142
What factors might a comparative health needs assessment examine?
1. Health status
2. Service provision
3. Service utilisation
4. Health outcomes --> mortality, morbidity, QOL, patient satisfaction
143
Give 2 advantages of a comparative health needs assessment
1. Quick and cheap data is available
2. Indicates whether health or services provision is better/worse than comparable areas (gives measure of relative performance)
144
Give 2 disadvantages of a comparative health needs assessment
1. May be difficult to find comparable population
2. Data may not be available
3. Data may not yield what the most appropriate levels of provision of utilisation should be
4. Data may be of variable quality
145
What does the Corporate approach to a Health Needs Assessment involve?
- Asks the local population what their health needs are
- Used focuses groups, interviews, public meetings
- Involves wide variety of stakeholders --> teachers, healthcare professionals, social workers, charity workers, local businesses, council workers, politicians
146
Give 2 advantages of a corporate health needs assessment
1. Based in the felt and expressed needs of the population in question
2. Recognises the detailed knowledge and experience of those working with the population
3. Takes into account a wide range of views
147
Give 2 disadvantages of a corporate health needs assessment
1. May be difficult to distinguish need from demand
2. Groups may have invested interests
3. May be influenced bu political agenda
4. Dominant personalities may have undue influence
148
What is the definition of an Evaluation of Health Services?
Assessment of whether a service achieves its objects --> a process that attempts to determine as systematically and objectively as possible the relevance, effectiveness and impact of activities in the light of their objectives
149
What can an Evaluation of Health Services include?
- Single intervention (e.g. RCT evaluating effectiveness of new cancer drug)
- Public health intervention (e.g. impact of smoking ban on health using epidemiological studies)
- Health economic evaluation (e.g. evaluating cost effectiveness of a medical intervention)
- Health technology assessment (e.g. incorporate systematic review, economic evaluation and mathematical modelling)
150
A health service evaluation is based upon which framework?
DONABEDIAN
| - Structure, process, output and outcome
151
What are the 3 things that make up the framework for a health service evaluation?
1. Structure
2. Process (+output)
3. Outcome
152
What sort of things would be evaluated for the Structure part of a health service evaluation?
- Buildings (e.g. number of ICU beds per 1000 population)
- Staff (e.g. number of vascular surgeons per 1000 population) m
- Equipment (locations where screening is provided)
153
What sort of things would be evaluated for the Process part of a health service evaluation?
What is done
- Number of patients seen in A&E --> process which patients fo into A&E (where and when patient is first seen, who carries out triage, how priority is assessed)
- Number of operations performed
154
What sort of things would be evaluated for the Outcome part of a health service evaluation?
Classification fo health outcomes
- Mortality --> 30 day mortality rate
- Morbidity --> complication rates
- QOL/Patient reported outcomes measures (PROMs)
- Patient satisfaction
155
What is another way to assess Outcomes in a health service evaluation?
The 5Ds
1. Death
2. Disease
3. Disability
4. Discomfort
5. Dissatisfaction
156
What are some examples of Patient reported outcome measures (PROMS) questionnaires used in primary care?
- Oxford hip score
- Oxford knee score
- EQ-5D
- Aberdeen varicose vein questionnaire
157
Give 3 possible issues with health outcomes in an evaluation
1. Link between health service provided and health outcome may be difficult to establish as many other factors involved (severity, confounding factors)
2. Time lag between service provided and outcome may be long (e.g. healthy eating intervention in childhood and incidence of T2DM in middle age) m
3. Large sample sized needed to detect statistically significant effects
4. Data may not be available
5. Issues with data quality
158
When assessing the quality of health services, what are the 6 dimensions of Maxwell's classification?
3Es and 3As
1. Effectiveness --> does the intervention produce the desired effect
2. Efficiency --> is the output maximised fo r given output
3. Equity --> are the patients being treated fairly
4. Acceptability --> how acceptable is the service offered to the people needing it
5. Accessibility --> geographical access, cost for patients, information available, waiting times
6. Appropriateness --> is the right treatment being given to the right people at the right time
159
What are the 2 different methods which can be used for a health needs assessment?
1. Qualitative
- Consult relevant stakeholders (staff, patients, relatives, carers, policy makers)
- Methodology = observation, interviews, focus groups, review documents
2. Quantitative
- Routinely collected data (hospital admissions, mortality)
- Review of records (medial, administrative)
- Surveys
- Other special studies using epidemiological methods
160
Give 3 factors that contribute to the promotion of excessive energy intake
1. Genetics
2. Employment --> shift work
3. Early developmental factors
4. TV viewing and advertising
5. Characteristics of food --> energy density, macronutrient composition, satire and satiation, portion size
6. Sleep
7. Reduced physical activity
8. Environmental cues
9. Psychological factors
161
Define malnutrition
Deficiencies, excesses or imbalances in a persons intake of energy and/or nutrients
162
What are the 2 different types of malnutrition?
1. Undernutrition
- Stunting
- Wasting
- Underweight
- Macronutrient deficiencies or insufficiencies
2. Overweight
- Obesity
- Diet related non communicable disease (heart disease, stroke)
163
Name 3 chronic medical conditions that require nutritional support
1. Cancer
2. Cystic Fibrosis
3. Coeliac disease
4. IBD
5. Type 1 and 2 DM
6. Failure to thrive
7. eating disorders
8. Overweight/obesity
164
Name 2 early influences on feeding behaviour
1. Maternal diet --> amniotic fluid is influences by maternal diet and in utero environment influences taste exposure
2. Breast feeding --> taste preference, bodyweight regulation
3. Parental practices
165
Give 3 ways in which parents can encourage eating/tackle fussy eating
1. Model health eating behaviours
2. Responsive feeding --> recognising hunger and fullness cues
3. Providing a variety of foods
4. Avoid pressure to eat
5. Restriction
6. Authoritative parenting
7. Not using food as a reward
166
Define non-organic feeding disorder
High prevalence in children <6
Characterised by feeding aversion, food refusal, food selectivity, fussy eaters, failure to advance to age appropriate foods, negative meal time interactions
167
Define eating disorder
Clinical meaningful behaviour or psychological pattern having to do with eating or weight that is associated with distress, disability or with substantially increased risk of morbidity or mortality
168
Name 3 eating disorders
1. Anorexia Nervosa
2. Bulimia Nervosa
3. Binge eating disorder
169
Define disordered eating
Restraint and strict dieting, disinhibition, emotional eating, binge eating, night eating, weight and shape concerns, inappropriate compensatory behaviours that do not warrant clinical diagnosis
170
What are the 3 forms of dieting?
1. Restrict the total amount of food eaten
2. Do not eat certain types of food
3. Avoid eating for long periods of time
171
Give 3 potential problems with dieting
1. Risk factor for development of eating disorders
2. Dieting results in loss of lean body mass not just fat mass
3. Dieting slows metabolic rate and energy expenditure
4. Chronic dieting may disrupt normal appetite responses and increase subjective sensations of hunger
5. Long term weight loss is challenging, people of often regain weight
6. Weight cycling (from related diet relapse) often leads to overshoot and may accelerate weight gain
172
Define Health inequalities
The preventable, unfair and unjust differences in health status between groups, populations or individuals that arise from the unequal distribution of social, environmental and economic conditions within societies, which determine the risk of people getting ill, their ability to prevent sickness, or opportunities to take action and access treatment when ill health occurs
173
What is the inverse care law?
Principle that the availability of good medical or social care tends to vary inversely with the need of the population serves
- The more you need health care, the less there is available
174
Name 3 vulnerable groups to health inequalities
1. Homeless
2. Gypsies and Travellers
3. Asylum seekers
4. LGBTQ+
5. Ex-prisoners
6. Those with learning difficulties
7. Those with mental health problems
175
What are the 5 Levels of Maslow's hierarchy of needs?
1. Physiological needs --> breathing, food, water, sleep, homeostasis
2. Safety --> security of body, employment, resources, mortality, daily, health and property
3. Love and belonging --> friends, family
4. Esteem --> self esteem, confidence, achievement, respect of and by others
5. Self-actualisation --> morality, creativity, spontaneity, problem solving, lack prejudice
176
Define homelessness
Someone who doesn't have a permanent home
177
Give 3 causes of homelessness
1. Eviction by private landlords
2. Relative/friends no longer able to offer accommodation
3. Loss of job
4. Mental health problems
178
Name 3 health problems often faced by homeless adults
1. Physical health condition
2. Serious mental illness
3. Addictions/substance misuse
4. Infectious disease --> TB, hepatitis
5. STIs
6. Injuries following violence and rape
7. Poor condition of feet and teeth
8. Poor nutrition
179
What barriers to care do homeless people face?
1. Difficulty accessing health care
2. Lack of integration between primary care services and other agencies
3. People may not prioritise health when there are other more immediate health problems
4. May not know where to find help
5. Communication difficulties
180
Define refugee
A person granted asylum and refugee status in the UK
| - They have the rights of a UK citizen
181
Define Asylum Seeker
A person applying for refugee status
| They are entitled to £35 a week, housing and NHS care
182
What barriers to care do asylum seekers and refugees face?
1. Language/cultural/communication problems
2. Money/other priorities
3. Different perceptions of care
4. Racism, prejudice, discrimination, stigma
5. May not understand how the NHS works
6. Lack of knowledge about where to get help
183
What health problems do refugees and asylum seekers face?
1. Injuries from war/travelling
2. No previous health surveillance/immunisations
3. Malnutrition
4. Injuries from torture and sexual abuse
5. Blood borne and infectious disease
6. Intreated chronic disease
7. PTSD, depression, psychosis
184
What barriers to care do gypsies and travellers face?
1. Registering and accessing GP services
2. Discrimination
3. Difficulties navigating the NHS
4. No permanent address
5. Frequent movement/transient sites
6. Communication difficulties
7. Mistrust of professionals
185
Give 3 examples of gypsy/traveller health beliefs
1. Cultural pride in self resilience
2. Stoicism and tolerance of chronic ill health
3. Illness is inevitable and medical treatment is unlikely to make a difference
4. Deep-rooted fear of cancer or other diagnoses perceived as terminal and hence avoidance of screening
5. More trust in family carers than professional care
6. Gender differences
186
What health problems are LGBTQ+ members more likely to suffer from?
1. Depression, suicide, self harm
2. Drugs and addiction problems
3. STIs
4. Social isolation and homelessness
187
What are the barriers to healthcare LGBTQ+ members face?
1. Stigma/prejudice
2. Discomfort/fear of disclosing LGBTQ+ status due to real or perceived homophobia
3. Previous negative experiences
188
Define Human Trafficking
Movement of people, by means such as force fraud, coercion or deception, with the aim of exploiting them
189
Give 3 type of exploitation
1. Sexual
2. Domestic servitude
3. Forced labour
4. Forced criminality
5. Organ harvesting
190
What are the barriers to healthcare human trafficked individuals face?
1. Lacking official documents
2. No fixed address
3. Language barriers
4. Unaware of entitlement to care
5. Controlled movement and accompanied by trafficker/boss?
6. Lack of trust in authorities
7. Self-blame
8. Stigma
9. Stockholm syndrome’
191
What are the red flags for suspecting human trafficking?
TRAFFICKED
- Timid/terrified/tense
- (Not) registered with GP/nursery/school
- Accompanied by a controlling person
- Foreign Language
- Frequently moving location
- Inconsistent history
- (No) Control of passport/bank account
- Keep alert
- Evidence of injuries left untreated
- DNA future appointments
192
Define Multimorbidity
People with multiple health conditions
| - Often long term health conditions which require complex and ongoing care
193
Give 3 impacts of Multimorbidity
1. Polypharmacy
2. Accumulation of side effects
3. Issues with compliance of medications
4. Management --> conflicting view on how to manage
5. Decreased QOL
6. Burden of appointments --> hospital and GP
194
Define Polypharmacy
Concurrent use of multiple medicated
| - Often >5 medications
195
What is appropriate polypharmacy?
Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence
- Optimisation of medication regimes has the potential to improve quality of life, longevity and minimise the harm from medications.
196
What is problematic polypharmacy?
Prescribing of multiple medications inappropriately, or where the intended benefit of the medication is not realised
197
Give 3 potential problems associated with polypharmacy
1. Drug interactions
2. Can affect compliance and lead to decreased patient satisfaction
3. Pill burden
- More common in problematic polypharmacy
198
Define domestic abuse
Any incidence or pattern of incidents on controlling, coercive, threatening behaviour, violence or abuse between the age of 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality
199
Give 3 explains of types of domestic abuse
1. Emotional
2. Physical
3. Sexual
4. Financial
200
What are 3 main ways in which domestic abuse presents to healthcare?
1. Traumatic injuries following assault --> fractures, bleeding, bruising
2. Somatic problems or chronic illness --> chronic pain, headaches, GI disorder, premature delivery
3. Psychological or psychosocial problems --> PTSG, depression, anxiety, attempted suicide
201
Give 3 potential indication of domestic abuse
1. Unwitnessed by anyone else
2. Repeat attendances to GP or A&E
3. Delay in seeking help
4. Multiple minor injuries
202
What is the role of a doctor if they suspect a case fo domestic abuse?
- Try and speak to them alone (i.e. away from their partner and away from their children)
- Document EVERYTHING THEY SAY
- Document what their injuries look like
- Only report to the police if it’s safe to do so - focus on safety
- Tell them you can help them and point them in the right direction for proper support
- Display posters about helplines etc. in your GP surgery
- Ask direct questions --> be non-judgement and reassuring
203
What assessment tool can be used to determine someones risk of domestic abuse?
DASH (domestic abuse and sexual harassment) tool
204
What do you do if you think someone is a standard/medium risk of domestic abuse?
It's their choice what they do
| - give them contact details for domestic abuse service and let them decide what to do
205
What do you do if you think someone is a high risk of domestic abuse?
Refer to MARAC or IDVAS (with consent wherever possible)
| - You can break confidentiality if needed
206
What is the role of domestic homicide review?
Circumstances in which the death of a person aged 16 or over has or appears to have resulted from violence, abuse or neglect
207
What are the gastrointestinal effects of opioids?
- Constipation
- Nausea
Due to stimulation of k and Mu receptors in GIT
208
What are the respiratory effects of opioids?
- Sleep apnoea
- Ataxic breathing
- Hyperaemia
- CO2 retention
- Respiratory depression
209
What are the cardiac effects of opioids?
- Increased incidence of Cardiovascular events --> MI, Stroke
210
What are the CNS effects of opioids?
- Dizziness and sedation leading to falls, fractures and respiratory depression
- Hyperalgesia associated with excessive sensitivity to pain
211
What are the MSK effects of opioids?
- Risk of fractures
212
What are the Endocrine effects of opioids?
- Interact with pituitary adrenal axis affected release of anterior pituitary hormones --> GH, Prolactin, TSH, ACTH, LH
- Decreased gonadotrophin in Males = sexual dysfunction, infertility, fatigue, decreased testosterone --> metabolic syndrome
- Decreased gonadotrophin in Females = low oestrogen, osteoporosis, oligomenorrhoea, galactorrhoea
213
What are the immune system effects of opioids?
Affect the U receptors on all immune cells
214
What behaviours may suggest someone has an addiction or is misusing opioids?
1. Increasing dose without prescription
2. Obtaining additional opioids from other doctors
3. Purposeful sedation
4. Uses for purpose other than pain relief
5. Hoarding pain medications
215
What are the signs of abuse and dependancy of opioids?
- Use of pain medications other than for pain
- Impaired control
- Compulsive use of medication
- Continued use of mediation despite harm or lack of benefit
- Craving or escalation of medication use
- Selling or altering prescriptions
- Stealing or diverting medications
- Calls for early refills or losing medication
- Reluctance to try non-pharmacologic interventions
216
Give 3 possible side effects resulting from continued opioid use
1. Tolerance
2. Withdrawal
3. Weight gain
4. Reduced fertility
5. Irregular periods
6. ED
7. Hyperalgesia
8. Depression
9. Dependence
10. Addiction
11. Reduced immunity
12. Osteoporosis
13. Constipation
217
What are the non-pharmacological options for treatment chronic pain?
- Physical --> weight loss, smoking cessation, exercise, yoga, pilates, joint injections
- Psychological --> counselling, CBT, meditation
- Complementary therapy --> massage, reflexology
- Occupational --> work place based review
218
What are the pharmacological options for treatment of chronic pain?
- Non opioid --> NSAIDs, COX-2 inhibitor, paracetamol
- Opioid --> intermittent use at slow and low dose
- Adjuvant analgesics --> anticonvulsants, antidepressants, lidocaine patches
219
What is the single greatest cause of illness and premature death in the UK?
Smoking
220
What 3 disease are smoking related deaths normally due to?
1. Cancers
2. COPD
3. CHD
221
What is the role of NCSCT?
NCSCT supports the delivery of effective evidence-based tobacco control programmes and smoking cessation interventions provided by local services
222
Give 3 symptoms of smoking withdrawal
1. Difficulty concentrating
2. Increased appetite
3. Irritability
223
What are the 6 aims of High Quality Care?
1. Safe
2. Effective
3. Patient-centred
4. Timely
5. Efficient
6. Equitable
224
What is the general structure of quality improvement?
1. Assessment --> patient feedback, process, data, staff feedback
2. Diagnosis --> change ideas
3. Treatment = PDSA
4. SDSA = standardise
225
What is PDSA role in quality improvement?
```
Plan --> objective, questions, plan
Do --> do plan, document problems/observations
Study --> analyse the data
Act --> what changes made now
REPEAT
```
226
Briefly describe the Model for improvement
1. Specific aim --> what are we trying to accomplish?
2. Measurement over time = measurement plan--> how will we know if a change is an improvement
3. Change idea --> what changes can we make that will result in improvement
227
Give 3 of Langleys Change Concepts (change ideas)
1. Eliminate waste – are all processes essential?
2. Eliminate multiple entry – can this be combined?
3. Move steps closer together
4. Find and remove bottlenecks
5. Do tasks in parallel
6. Use pull systems
7. Give people access to information
8. Use proper measurement
9. Smooth workflow, reduce variation
10. Minimise handoffs – passing work between depts or individuals
11. Reduce waiting times
12. Standardise – use exactly same system
13. Listen to customers
228
Give the 4 elements that need to be met to make change selection criteria
1. Ideas that can be started fast
2. The change is reasonably low cost
3. The effort is small compared to the impact
4. The idea can be tested without getting permission from others
229
How do things go wrong the it comes to the duties of a doctor?
1. Human error
2. Neglect
3. Poor performance
4. Misconduct
230
Briefly describe human error
- System rather than individual
- Included omissions, lapses and violations
- Rarely due to insufficiency knowledge or skill
- Jim Reason's Swiss cheese Model
231
What is neglect?
Falling below accepted standard and accepting this
- Repeated minor mistakes
- Open necessary care is withheld, safeguarding doesn't occur
232
What is poor performance?
An individual with conduct below acceptable standard
- A problem of attitude, failure to learn from mistakes or listen to advice
- Usually evident from student days
233
What is misconduct?
1. Deliberate harm
2. Lack of candour --> hiding/ignoring own/others mistakes, altering medical records
3. Fraud and theft
4. Improper relationships
234
What is medical negligence?
A legal entity = court ruling on standard of care on the balance of probabilities
- A civil claim for damages --> remedy is compensation for patient, not punishment for Dr
- You are found liable NOT guilty
235
Give the 4 criteria for medical negligence
1. There was a duty of are
2. There was a breech in the duty of care
3. The patient came to harm
4. The patient was harmed due to the breech in duty of care
All 4 have to be met to be considered medically negligent
236
What is an NHS near event?
A serious, largely preventable patient safety incident that should never happen if the available preventable measures have been implemented
237
Give an examples of an NHS near event
1. Patient misidentification
| 2. Misplacement of an NG tube
238
Clinical errors can be managed using a systems approach and a persons approach. Describe the persons approach
- Errors are due to wayward mental processes e.g. negligence, inattention, distraction
- Focuses on unsafe acts of staff on the front-line e.g. nurses, doctors
239
Clinical errors can be managed using a systems approach and a persons approach. Describe the systems approach
- Adverse events are the product of many causal factors --> a whole system is to blame (swiss cheese)
- Implementation of standardised working and developing error free processes
240
What are the 2 distinct but intersecting systems of decision described by Kahneman and Tversky?
1. Intuitive thinking
| 2. Analytical thinking
241
What is intuitive thinking?
- Ability to understand something instantly without conscious reasoning
- Recognition primed and heuristic, pattern recognition
242
What are Heuristics?
Cognitive shortcuts
- Availability = more likely to diagnoses the thing in the news
- Anchoring and adjustment = hard to move far from an anchor
- Representativeness = a patient in one category represents that category
243
Give an advantage and disadvantage of intuitive thinking
```
Advantage = fast and frugal
Disadvantage = prone to biases, strong cognitively predisposed to recognise
```
244
Give 3 biases in intuitive thinking
1. Error of over attachment --> confirmation bias, premature closure
2. Error due to failure to consider alternative --> reach satisfaction
3. Error due to inserting thinking --> diagnosis momentum
4. Errors in prevalence perception or estimation
245
Give 2 ways we can reduce the risk of intuitive thinking
1. Decision environment and process
2. Personal debiasing techniques --> acknowledge bias, personal accountability, slowing and stopping techniques
3. Structural debasing --> training in dual process theory, checklists, group decision strategies
246
What is analytical thinking?
- Not good at estimating odds or values but very good at measuring and calculating them
- Premise of medical research and evidence based medicine
247
Give an advantages and disadvantage of analytical thinking
```
Advantage = accurate and reliable
Disadvantage = slow, resource intensive (expensive), cognitively demanding
```
248
What is the dual process theory?
Intuitive thinking with its irresistible combination of heuristics and biases
AND
Analytical thinking
Not always just either/or, often BOTH in unison
