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Phase 3a > Public Health > Flashcards

Public Health Flashcards

1
Q

What are the three domains of public health?

A

Health improvement

Health protection

Improving services

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2
Q

What is health improvement?

A

Social interventions aimed at preventing disease, promoting health and reducing inequalities

Inequalities
Education
Housing
Employment
Lifestyles

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3
Q

What is health protection?

A

Measures to control infectious disease risks and environmental hazards

Infectious disease
Chemicals and poisons
Radiation
Environmental health hazards

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4
Q

What is improving services?

A

Organisation and delivery of safe, high quality services for prevention, treatment and care.

Clinical effectiveness
Efficiency
Service planning
Audit evaluation
Clinical governance

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5
Q

What is equality?

A

Treating everyone the same

Giving equal shares

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6
Q

What is equity?

A

Being fair

Giving everyone what they need to be successful

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7
Q

What is horizontal equity?

A

Equal treatment for equal need

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8
Q

What is vertical equity?

A

Unequal treatment for unequal need

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9
Q

What are the Bradford Hill criteria for causation?

A
  1. Temporality
  2. Dose-response
  3. Strength
  4. Reversibility
  5. Consistency
  6. Plausibility (biological)
  7. Coherence
  8. Analogy
  9. Specificity
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10
Q

What is temporality (most important)?

A

Exposure occurs prior to outcome

(People smoke before getting lung cancer)

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11
Q

What is dose-response?

A

Increased risk of outcome with increased exposure

(The more you smoke the more likely to get lung cancer)

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12
Q

What is strength?

A

The stronger the association between the exposure and the outcome, the less likely that the relationship is due to another factor

Very high relative risk

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13
Q

What is reversibility?

A

Intervention to reduce exposure reduces the outcome

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14
Q

What is consistency?

A

Same result observed from various studies in different geographical settings

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15
Q

What is plausibility?

A

Reasonable biological mechanism

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16
Q

What is coherence?

A

Logical consistency with other information

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17
Q

What is analogy?

A

Similarity with other established cause-effect relationships

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18
Q

What is specificity?

A

Relationship specific to outcome of interest

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19
Q

What can association be due to?

A
  1. Chance
  2. Bias
  3. Confounding
  4. Reverse causality
  5. A true causal assocaition
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20
Q

What is bias?

A

A systematic error that results in a deviation from the true effect of an exposure on an outcome

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21
Q

What are the three types of bias?

A
  1. Selection bias
  2. Information bias
  3. Publication bias
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22
Q

What is selection bias?

A

A systematic error in the selection of study participants or the allocation of participants to different study groups

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23
Q

What is information bias?

A

A systematic error in the measurement or classification of exposure or outcome. Sources of information bias: observer (observer bias), participant (e.g. recall bias) or instrument (e.g. wrongly calibrated).

Report inaccurate information because feel judged

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24
Q

What is publication bias?

A

Trials with negative results less likely to be published

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25
Q

What is lead time bias?

A

Early identification doesn’t alter outcome but appears to increase survival
e.g. patient knows they have the disease for longer

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26
Q

What is length time bias?

A

Disease that progress more slowly is more likely to be picked up by screening (i.e. symptom free and around for longer), which makes it appear that screening prolongs life.

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27
Q

What is confounding?

A

When an apparent association between an exposure and an outcome is actually the result of another factor

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28
Q

Study design?

A

Think retrospective vs prospective

Most useful are- systematic review/meta analysis then randomised control trial then cohort

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29
Q

What is a cross-sectional study?

A

Retrospective observational study collecting data from a population and a specific point in time

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30
Q

What are the advantages of a cross-sectional study?

A

Larger sample size

Rapid

Repeated studies show changes over time

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31
Q

What are the disadvantages of a cross-sectional study?

A

Risk of reverse causality- which came first?

Cannot measure incidence

Risk recall bias and non response

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32
Q

What is a case control study?

A

Retrospective observational study looking at population with disease and control population

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33
Q

What are the advantages of case control studies?

A

Good for rare outcomes

Rapid

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34
Q

What are the disadvantages of case control studies?

A

Prone to selection bias and information bias

Resource consuming to find well matched controls

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35
Q

What is a cohort study?

A

Prospective longitudinal study looking at separate cohorts with different treatments/exposures applied – await to see if disease occurs

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36
Q

What are the advantages of a cohort study?

A

Can establish disease risk factors (no chance or reverse causality as disease not happened yet)

Can follow rare exposure

Data on confounders can be collected prospectively

Less risk of selection and recall bias

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37
Q

What are the disadvantages of cohort studies?

A

Takes a long time

People may drop out

Large sample size required, expensive, time consuming

Difficult to assess rare diseases as may not develop

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38
Q

What is a randomised control trial?

A

Prospective study where all participants are randomly assigned an exposure or control intervention

39
Q

What are the advantage of randomised control trials?

A

Two groups can be compared accurately

Low risk of bias and confounding as it is prospective and randomised

Can infer causality

40
Q

What are the disadvantages of randomised control trials?

A

Expensive

Time consuming

Ethical issues

Drop outs

Specific inclusion/exclusion criteria may mean study population different from typical patients

41
Q

What is an ecological study?

A

Population based data rather than individual data – comparative

2 key comparisons:

Geographical (e.g all pts in a GP practice vs all patients in another GP practice)

Time trends (e.g 1950-2000)

42
Q

Difference between cross sectional and ecological study?

A

Ecological different to a cross sectional because COMPARES two areas/two years whereas a cross sectional would just look for prevalence for example in England at one point in time with no comparison

43
Q

What is the definition of need, demand and supply?

A

Need- ability to benefit from an intervention

Demand- what people ask for

Supply- What is provided

44
Q

What is the NICE definition of health needs?

A

A health needs assessment is a systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities

45
Q

What are Bradshaw’s needs?

A

Felt need- individual perceptions of variation from normal health

Expressed need- individual seeks help to overcome variation in normal health (demand)

Normative need- professional defines intervention appropriate for the expressed need

Comparative need- comparison between severity, range of interventions and cost

46
Q

What is an example of applied Bradshaw’s needs?

A

FENC

Felt – Can’t walk as far.

Expressed – Seeks help from doctor.

Normative – doctor says should go to cardiopulmonary rehab.

Comparative = Pt improves and then service is oversubscribed – there are worse pts than them so in comparison they no longer get priority for the rehab.

47
Q

What are the stages of the needs assessment cycle?

A
  1. Needs assessment
  2. Planning
  3. Implementation
  4. Evaluation
48
Q

What are the health needs assessment approaches?

A

Epidemiological

Comparative

Corporate

49
Q

What is the epidemiological approach (health needs assessment)?

A

A top down approach

Define issue/disease →
Assess size (incidence/prevalence)→
Assess services available and match against existing evidence base for cost effectiveness and quality of care.
Look at services already available and recommend how to improve.

50
Q

What are the advantages of the epidemiological approach?

A

Uses existing data

Provides data on disease incidence/mortality/morbidity

Can evaluate services by trends over time

51
Q

What are the disadvantages of the epidemiological approach?

A

Does not consider the felt needs of the people it is catering for

Quality of data variable

Data collected my not be the data required

52
Q

What is the comparative approach (health needs assessment)?

A

Compares the services received by a sub-group with services received by a different subgroup

53
Q

What are the advantages of the comparative approach?

A

Quick and cheap if data available

Indicates whether health or service provision is better or worse than comparable areas

54
Q

What are the disadvantages of the comparative approach?

A

Difficulty in finding comparable groups

Data may not yet be available/of high quality

May not yield what most appropriate level should be

55
Q

What is the corporate approach (health needs assessments)?

A

Takes into account views from patients, politicians, press, professionals, commissioners, etc

56
Q

What are the advantages of the corporate approach?

A

Based on the felt and expressed needs of the population in question

Recognises the detailed knowledge and experience of those working in the population

Takes into account wide range of views

57
Q

What are the disadvantages of the corporate approach?

A

May be difficult to distinguish need from demand

Certain groups may have vested interest

May be influenced by political agenda

58
Q

What is health needs evaluation?

A

Process that attempts to systematically assess whether service meets its objectives

59
Q

Give the two main types of health needs assessment valuation?

A

Donabedian approach

Maxwell’s dimensions

Can tie them together- do structure, process, outcome for each of the 3 Es and 3 As

Called Wright’s matrix

60
Q

What are the components of the Donabedian approach?

A
  1. Structure- what there is
  2. Process- what is done
  3. Outcome- Mortality, morbidity, PROMS (patient reported outcome measures) (quantitative score), patient satisfaction focus groups (qualitative) OR “the 5 Ds” (death, disease, disability, discomfort, dissatisfaction)
61
Q

What are the components of Maxwell’s dimensions?

A

3Es + 3As

Effectiveness

Efficiency

Equity

Acceptability

Accessibility

Appropriateness

62
Q

What is the incidence?

A

The number of new cases in a population during a specific time period

63
Q

What is the prevelence?

A

The number of existing cases at a specific point in time

64
Q

What is relative risk?

A

Risk in one catagory compared to another e.g. comparison of disease in the exposed and unexposed

Tells us about the association between risk factor and disease

RR >1 indicates risks increased due to factor exposure

Relative risk = Absolute risk or incidence in an exposed group/ Absolute risk or incidence in non-exposed group

65
Q

What is the attributable risk?

A

The amount of the disease that is specifically due to the exposure

The difference in the disease rates in exposed and unexposed individuals

What is the risk of lung cancer that is attributable to smoking?
Risk of lung cancer in smokers = 45/300 = 15%
Risk of lung cancer in non-smokers = 5/700 = 0.7%

Attributable risk = 15% - 0.7% = 14.3%

66
Q

What is the number needed to treat?

A

The number of patients who need a specific treatment to prevent one bad outcome

NNT= 1/attributable risk

Always round up NNT as can’t treat a fraction of a person

67
Q

What are the Wilson and Junger criteria (screening)?

A
  1. The condition- important, known natural history, identifiable latent/preclinical phase
  2. Organisation and cost- facilities, costs and benefits, ongoing process
  3. The screening test- Suitable (sensitive, specific, inexpensive)
  4. The treatment (effective, agreed policy on whom to treat)
68
Q

Screening calculations?

A

Sensitivity – does the test pick up the disease?

Specificity – does the test identify people who do not have the disease?

Positive predictive value is the probability that subjects with a positive screening test truly have the disease

Negative predictive value is the probability that subjects with a negative screening test do not have the disease.

69
Q

Screening calculations MedSchool?

A

Check slide 17 med school 53 presentation

Sensitivity: a/(a+c) Proportion of those with the disease who are correctly
identified by the screening test (if this is too low, you will miss too many
cases)

Specificity: d/(b+d) Proportion of people without the disease who are
correctly excluded by the screening test (if this is too low you will have many
people who undergo unnecessary diagnostic interventions because they
don’t have the disease)

Positive predictive value: a/(a+b) Proportion of people with a positive test
result who actually have the disease (this is higher if the prevalence is higher)

Negative predictive value: d/(c+d) Proportion of people with a negative test
result who do not have the disease (this is lower if the prevalence is higher)

70
Q

Do question on GP slides and look at MedSchool powerpoint/ do MedSchool mock questions

A

auifiuSJ

70
Q

Screening summary?

A

Sensitivity – does the test pick up the disease?
% correctly identified with the disease

Specificity – does the test identify people who do not have the disease?
% correctly excluded as disease free

Positive predictive value is the proportion of people with a positive test result who actually have the disease

Negative predictive value is the proportion of people with a negative test who do not have the disease

71
Q

What is health behaviour?

A

Aimed at preventing disease

Doing exercise

72
Q

What is illness behaviour?

A

Seeking remedy

Going to GP for a symptom

73
Q

What is sick role behaviour?

A

Activity aimed at getting well

Taking antibiotics

74
Q

What are the models of behaviour change?

A
  1. Health belief model
  2. Theory of planned behaviour
  3. Stages of change/transtheoretical model
  4. Social norms theory
  5. Motivational interviewing
  6. Social marketing
  7. Nudging
  8. Financial incentives
75
Q

What are the components of the health belief model?

A

Individuals will change their behaviour if-

  1. Believe are susceptible to the condition
  2. Believe in serious consequences
  3. Believe taking action reduces susceptibility
  4. Believe that benefits of action outweigh the costs

+ cue to action

76
Q

What are the features of the transtheoretical model?

A

Pre-contemplation (not ready yet)

Contemplation (thinking about it)

Preparation (getting ready)

Action (doing it)

Maintenance (sticking with it)

Can make progress or relapse between steps

Advantages: Account for relapse (6th stage) and is the only model to do this, acknowledges a variation of mindsets in the individual (e.g each specific stage)

Disadvantages: Isn’t accurate for all forms of health behaviour – some people move backwards through or skip stages, doesn’t take into account social factors such as values, habits, culture and socioeconomic factors

77
Q

What are the features of theory of planned behaviour?

A

3 factors-
1. Attitudes
2. Subjective norm
3. Percieved behvioural control

These lead to

Intentions

then

Behaviour

Advantages = Takes into account social factors, works with a wide range of health behaviours e.g smoking to abortion
Disadvantages = Lack of causality, not temporal, doesn’t take into account emotions, relies on self reported behaviour

78
Q

Overview other behavioural theories?

A

Social norms = Evidence to show if inform other of what the majority do they will follow that. (This fails if the sick behaviour e.g alcohol, obesity is the norm)

Motivational interviewing = Counselling technique

Nudge theory = Placing healthy food (fruit) next to checkout

Financial Incentives

79
Q

Alcohol over view?

A

Units = %ABV x volume (mls)/1000

Recommended limit = 14 units per week for men AND women. Binge = 6 women, 8 men in a single session

Higher risk drinking = 50+ units in men. 35+ units in women.

Men metabolise quicker due to difference in body fat percentage.

Screening: CAGE or AUDIT

80
Q

Unit calcualtion?

A

“Pt describes drinking 2 cans of 500ml 8% cider a day, what is their units of intake per week?”

((8 x 500)/1000) x2 x7 = 56 units a week.

81
Q

What are the error types?

A

Sloth = Lazy = inadequate documentation

System error = Inadequate built in safeguards, lack of surgical equipment due to failure of rota for someone to check stock

Lack of skill = Not having appropriate training – unable to do ABG

Fixation = Focus on one diagnosis only – patient comes in with photophobia, you decide is meningitis actually turns out to be SAH

Bravado = Working beyond competence, deciding to treat complex patient alone without requesting senior opinion

Playing the odds = Deciding it is a common disease and then turns out to be a rare one

Poor team working = Communication breakdown

82
Q

What else to cover?

A

DO EPIDEMIOLOGY REVISION POWERPOINT QUESTIONS AT END

Ethics/PPS e.g: Negligence, types of leadership, ethics of resource allocation

83
Q

Purpose of screening?

A

The purpose of screening is to identify apparently
well individuals who have (or are at risk of
developing) a particular disease so that you can have
a real impact on the outcome

84
Q

Disadvantages of screening?

A

Exposure of well individuals to distressing or harmful
diagnostic tests

Detection and treatment of sub-clinical disease that
would never have caused any problems

Preventive interventions that may cause harm to the
individual or population

85
Q

Four dimensions of food instability?

A
  1. Availability (affordability)
    of food
  2. Access – economic and
    physical
  3. Utilisation – opportunity to
    prepare food
  4. Stability of the three
    dimensions over time
86
Q

What are the types of prevention?

A

Primary Prevention—intervening before health effects occur, through.
Secondary Prevention—screening to identify diseases in the earliest.
Tertiary Prevention—managing disease post diagnosis to slow or stop

Primary- before disease or symptoms

Secondary- Before symtpoms but not disease- screening

Tertiary- reduce symptoms and effects of the disease

Quaternary- reduce the negative effects of treatments

In primary prevention, the intervention aims to remove or reduce a risk factor or introduce a
protective factor (in this case folic acid) to prevent a disease before it has developed (in this
case neural tube defects). Secondary prevention aims to intervene to prevent progression of a
disease whilst it is asymptomatic or in the early stages (e.g. screening) or to prevent
recurrence (e.g. after a myocardial infarction), whereas in tertiary prevention the disease is
already established and the aim is to minimise disability and other negative effects of the
disease and reduce complications

87
Q

Definition of a never event?

A

A serious, largely preventable patient safety incident that should not occur if available preventive measures have been implemented

88
Q

Transition points?

A

Where interventions are more likely to be effective

Leaving school
Entering the workforce
Becoming a parent
Becoming unemployed
Retirement and bereavement

89
Q

Maslow’s hierarchy of needs?

A

Self actualisation

Esteem needs

Love and belonging

Safety

Physiological needs

90
Q

Medical negligence?

A

What four principles make up medical negligence?
Duty of care?
Breech of the duty of care?
- Bolam – would 2 doctors do the same thing?
- Bolitho – would it be reasonable for them to do so?
Did the patient come to any harm?
Did the breech cause the harm?

91
Q

What is public health?

A

The science and art of preventing disease,
prolonging life and improving health through
organised efforts of society

92
Q

What is the inverse care law?

A

Availability of health care tends to vary
inversely with its need

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