Flashcards in Public Health Deck (367):
Give the 4 domains of public health.
1. Health protection.
2. Improving services.
3. Health improvement.
4. The wider determinants of health - looking at the bigger picture.
Name 5 ethical theories.
5. 4 principles.
Sociology of health medicine: name 5 determinants of illness.
1. Social class.
4. Material deprivation/poverty.
When can confidentiality be broken?
1. When it is required by law.
2. If the patient has given consent.
3. Public interest - research, education, serious crime or disease.
What life style factors promote mortality?
3. Sedentary lifestyle.
4. Bad diet.
5. Excessive drinking.
Describe the Health Belief Model (Becker 1974) of behavioural change.
The individual needs to believe that there are consequences and that they are susceptible to disease. They need to believe that taking action reduces the risks and that the benefits outweigh any costs.
Describe the Transtheoretical model of behavioural change.
1. Pre-contemplation (no intention of giving up smoking).
2. Contemplation (consider quitting).
3. Preparation (get ready to quit in near future).
4. Action (engaged in giving up).
5. Maintenance (steady non-smoker).
A system of moral principles and a branch of philosophy that defines what is good for individuals and society.
What is the Gini coefficient?
A statistical representation of a nation's income distributed among it's residents. It is the most commonly used measure of equality.
Responses to health inequalities: what are the main principles of the Acheson Report (1998)?
1. Reduce income inequality.
2. Give high priority to the health of families with children.
Responses to health inequalities: what are the main principles of Proportionate Universalism?
1. Focusing only on the disadvantaged will not reduce inequalities.
2. Action needs to be universal.
3. A fair distribution of wealth is needed.
Concern with the distinction between good and evil or right and wrong.
What are Utilitarian ethics?
- An act is evaluated solely in terms of its consequences.
- Maximise good and minimise harm.
What are the challenges/criticisms of Utilitarian ethics?
- Treats minorities unfairly to promote happiness of a majority.
- Is it okay to carry out ethically questionable research to maximise the welfare of society?
- What is good/better?
What are the main principles of Virtue ethics?
- Focuses on the person who is acting; are they expressing good character?
- Integrates reason and emotion.
- Virtues are acquired.
- An action is virtuous only if the person is acting with the genuine intention of doing the right thing.
What are the challenges/criticisms of Virtue ethics?
- Virtues are culture-specific.
- Too broad for practical application.
- Kindness and compassion could lead to not telling the harmful truth - lying.
- It is not always clear how to resolve a dilemma with virtue ethics.
What are the 4 principles of ethics?
1. Autonomy (respect the patient's decision).
2. Benevolence (provide benefits to the patient).
3. Non-maleficence (do no harm).
4. Justice (ensure fairness in the distribution of treatment).
What does the GMC say are the 5 main 'duties of a doctor'?
1. Protect and promote health.
2. Provide a good standard of care.
3. Recognise and work within the limits of your competence.
4. Work with colleagues in a way to best serve your patients.
5. Treat patients as individuals and respect their dignity.
Name 4 ways to assess functional limitations among older people?
1. The Katz ADL scale.
3. The Barthel ADL index.
What activities of daily life does the 'Katz ADL Scale' include?
Bathing, dressing, toilet use, eating, urine and bowel continence, transferring in/out of bed.
What activities of daily life does the 'IADL Scale' include?
Use of the telephone, travelling by car or public transport, food/clothes shopping, cooking, housework, medication use, money management.
What activities of daily life does the 'Barthel ADL index' include?
Feeding, grooming, bathing, dressing, walking on a level surface, going up and down stairs, moving from wheelchair to bed, continence, transferring to and from a toilet.
What does the MMSE test?
- Orientation, immediate memory.
- Short-term memory.
- Language functioning.
Define acute illness.
A disease of short duration that starts quickly and has severe symptoms. It often can be cured.
Define chronic illness.
A persistent/recurring condition which may or may not be severe. It starts gradually and can be treated but not cured.
The use of multiple medications (usually >4). Polypharmacy tends to be more common in elderly people.
List 5 challenges of an ageing population.
1. Strains on pension and social security systems.
2. Increasing demand for health care.
3. Bigger need for trained health professionals.
4. Increasing demand for long term care.
5. Pervasive ageism (denying older people rights and opportunities).
What can cause an ageing population?
- Improvements in sanitation, housing, nutrition and medical interventions.
- Rising life expectancy.
- Falls in fertility - people are having fewer children and having them later.
- Decline in premature mortality.
What is intrinsic ageing?
A natural, universal, inevitable process.
What is extrinsic ageing?
Ageing dependent on external factors e.g. UV exposure, smoking etc.
What physical changes happen to the body later in life?
- Loss of skin elasticity and hair colour.
- Decrease in size and weight.
- Loss of joint flexibility.
- Increased risk of illness.
- Decline in learning ability and less efficient memory.
Why do women generally live longer than men?
- 20% biological - premenopausal women are protected from heart disease by hormones.
- 80% environmental - men take more lifestyle risks than women.
Give 3 consequences of people living longer.
1. Pensions will have higher pay outs than currently planned.
2. Chronic and comorbid conditions will prevail.
3. Rising inequalities as more affluent groups will use health services for longer.
List 4 types of dementia.
1. Alzheimer's disease (62%)
2. Vascular dementia (17%)
3. Mixed alzheimer's and vascular (10%)
4. Lewy bodies (6%)
What is medicalisation of death?
Death is seen as a failure. There is a curative endeavour to prolong life at any cost. Death as a natural part of life is challenged.
What is meant by institutionalising death?
60% of people die in hospital but 70% want to die at home.
Glaser and Strauss (1965): What 4 awareness contexts did they identify?
1. Closed awareness.
2. Suspicion awareness.
3. Mutual pretence.
4. Open awareness.
What is closed awareness?
When the patient is unaware of their own impending death but others (staff and family) are aware.
What is suspicion awareness?
The patient suspects that they are dying and tries to seek confirmation of this.
What is mutual pretence?
Everyone knows the patient will die, including the patient, but it is not discussed.
What is open awareness?
Everyone knows the patient is likely to die and talks openly about it.
Describe 'death the hospice way'.
- Open awareness, compassion, honesty.
- Emotion and relationships.
- Holistic care.
- Multi-disciplinary teams.
Describe the chain of infection.
1. Susceptible host.
2. Causative micro-organism.
3. Reservoir (patients, visitors etc).
4. Portal of entry/exit.
How can an infection be transmitted?
1. Exogenous spread - direct contact (STI's), airborne (TB), vector spread (malaria).
2. Endogenous spread - self spread.
Give three types of handwashing.
1. Routine handwash.
2. Hygienic hand antisepsis.
3. Surgical handscrub.
Describe the physiological effects of nicotine?
- Activation of nicotinic Ach receptors in the brain. This causes dopamine release.
- Dopamine is a stimulant. Tolerance increases and cessation will result in withdrawal.
List some health problems connected to smoking.
Cardiovascular problems (stroke, MI), cancers, COPD, stomach ulcers, diabetes, oral health problems etc.
What methods can be used in smoking cessation?
1. Nicotine replacement therapy - patches, gums, nasal spray etc.
2. Non-nicotine pharmacotherapy - Varenicline, Bupropion.
3. Transtheoretical model.
What are the 3A's?
1. Ask - ask the patient about smoking.
2. Advice - advice on smoking cessation methods.
3. Assist - refer to local NHS stop smoking services.
What are the 8 millenium development goals?
1. Eradicate poverty and hunger.
2. Universal primary education.
3. Promote gender equality.
4. Reduce child mortality.
5. Improve maternal health.
6. Combat HIV, malaria and other diseases.
7. Ensure environmental sustainability.
8. Develop a global partnership for development.
What are the three leading causes of death in children in the developing world?
Give some examples of migrants.
Asylum seekers, refugees, trafficked people, migrant workers, international students etc.
Where might asylum seekers have originated from?
Pakistan, Iran, Syria etc
Where might migrant workers have originated from?
Poland, Romania, Spain etc
What is the significance of Lampedusa?
Lampedusa is an Italian island that is a primary transit point for immigrants from Africa. It is the closest EU territory to the shores of Libya. It is a deadly migrant route.
What are the 4 main NHS goals in regards to migrant health?
1. Equality of access.
2. Reducing the gap in health inequalities.
3. To provide services for the vulnerable.
4. Ensuring services are appropriate and accessible.
Meeting the needs of today without compromising the ability of future generations to meet the needs of tomorrow.
What are possible consequences of climate change?
Heatwaves, sea levels rise, new diseases, scarcity of resources resulting in migration/war.
What is the Bradford Hill criteria?
A group of minimal conditions necessary to provide adequate evidence of a causal relationship.
What could be done help to slow down the effects of climate change?
- Control world population.
- Reduce energy consumption.
- Invest in renewable energy resources.
A process of identifying seemingly healthy individuals who may be at increased risk of a disease.
What is the main purpose of screening?
Define primary prevention.
Preventing a disease/condition from occurring in the first place. Eliminate exposures/risk factors that contribute to the disease.
Define secondary prevention.
Detecting a disease as soon as possible in order to alter its course and to improve health outcomes.
Define tertiary prevention.
Trying to slow down the progression of a disease and helping people to manage their illness effectively.
The proportion of people with the disease who are correctly identified (a/a+c).
The proportion of people without the disease who are correctly excluded by the screening test (d/b+d). How well a test detects those without a disease.
Define positive predictive value (PPV).
The proportion of people with a positive test result who actually have the disease (a/a+b).
Define negative predictive value (NPV).
The proportion of people with a negative test result who do not have the disease (d/c+d).
The proportion of a population found to have the disease at a point in time.
The rate at which new cases occur in a population in a certain time period.
What is the Wilson and Jungner criteria used for?
To determine whether a condition should be screened for.
What are the 10 Wilson and Jungner criteria for screening?
1. The condition should be a serious health problem.
2. The natural history of the condition should be understood.
3. There should be a detectable early stage.
4. There should be a treatment available.
5. Facilities for diagnosis and treatment need to be available.
6. There should be a suitable test.
7. The test should be acceptable to the population.
8. There should be an agreed policy on whom to treat.
9. The cost should be balanced against the benefits.
10. It should be a continuous process, not just a one off.
Describe selection bias in regards to screening.
The people who choose to participate in screening programmes may be different from those who don't; proper randomisation is not achieved.
Define length-time bias.
Diseases with a longer period of presentation are more likely to be detected by screening than ones with a shorter time of presentation.
Define lead-time bias.
Screening identifies diseases earlier and therefore gives the impression that survival is prolonged but survival time is actually unchanged.
Any preventable event that can cause or lead to patient harm.
What are the 3 types of human error?
1. Errors of omission.
2. Errors of commission.
3. Errors of negligence.
What are errors of omission?
When required action is delayed or not taken.
What are errors of commission?
When the wrong action is taken.
What are errors of negligence?
When actions or omissions do not meet the standard of an ordinary, skilled person professing.
What are the 2 outcomes that medical error can lead to?
1. Adverse event.
2. Near miss.
Define adverse event.
An incident that results in harm to the patient.
Define near miss.
An event which has the potential to cause harm but doesn't develop further, thereby avoiding any harm.
What are violations?
Deliberate deviations from practices, procedures and standards or rules.
Name the 3 types of violation.
1. Routine - cutting corners.
2. Necessary - to get the job done; unavoidable.
3. Optimising - personal gain, selfish.
Describe skill based errors.
When performing a routine, well learnt task you may give little attention. If distracted or interrupted this can result in slips of action or memory lapses.
Describe rule/knowledge based errors.
- When an incorrect plan or course of action is taken. This can happen in an emergency situation or can be due to a lack of experience.
- Mistakes are more likely when tasks are complex. This can be due to inexperience, insufficient information, little support/advice from colleagues etc.
Name 5 factors that can affect performance.
3. Drugs or alcohol.
What are the two main approaches to managing errors?
1. Person approach (individual).
2. System approach (organisation).
Managing errors: describe the person approach.
Errors are the product of wayward mental processes e.g. inattention, distraction, negligence. It focuses on the unsafe acts of people on the front-line (nurses, doctors).
Managing errors: describe the system approach.
Adverse events are the product of many causal factors, the whole system is to blame (swiss cheese theory).
Briefly describe the Swiss cheese theory of errors.
The idea that the interaction between active failures and latent conditions leads to accidents. There are successive layers of defences and safeguards but the 'holes' can still line up and people can slip through the system.
Name 5 information processing limitations.
2. Cognitive bias.
3. Cognitive interference.
4. Selective attention.
5. Transferring expectations.
What is positive transfer of expectations?
When someone applies a previous experience to a new, similar situation.
What is negative transfer of expectations?
When a previous experience conflicts with the current situation.
Name 5 qualities of an effective team.
1. Optimal size.
2. A common purpose/goal.
3. Good dynamic.
4. An identified leader.
5. Shared knowledge and experiences.
What are the benefits of working in an effective team?
- Improved service delivery.
- Improved decision making.
- Reduces error.
Describe 4 obstacles of working in a team.
1. Organisation - different offices/shifts/rotation posts.
2. Location - ward based/home visits/based elsewhere.
3. Management - different employers/sub-teams.
4. Team members may have other commitments - hard to contact people.
Give 3 examples of NHS systems that promote teamwork.
1. Shared case notes.
2. Multi-disciplinary team meetings.
3. Team offices.
Give 2 examples of checklists used in the NHS.
1. SBAR checklist - for reporting a case.
2. Surgical safety checklist.
What is the SBAR checklist?
It is used for reporting a case.
S - situation.
B - background.
A - assessment.
R - recommendation.
What is the WHO definition of health?
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
What is the WHO definition of mental health.
Mental health is a state of well-being in which the individual realises his or her own
abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community.
Give some examples of common mental health problems (CMHP's).
Depression, anxiety, phobias, social anxiety disorder, OCD, post-traumatic stress disorder (PTSD).
Approximately how many people worldwide have depression at any one time?
Approximately how many people worldwide have a severe mental illness e.g. schizophrenia?
What are the dangers/consequences of CMHP's?
- They have a negative impact on quality of life; effecting employment, ADL's, family.
- They increase the risk of physical illness and they increase the risk of mortality from physical illness.
- Depression is a major risk factor for suicide.
What is depression?
Sustained feelings of sadness that interfere with ones ability to function at school, work and at home.
What symptoms are characteristic of depression?
Loss of interest, decreased energy, feelings of guilt/little self worth, disturbed sleep, appetite loss.
What wider determinants of health may increase your risk of developing a CMHP?
- Lack of qualifications.
- Material disadvantage.
- Living in local authority housing.
What is the relationship between socio-economic background and CMHP's?
A wealthy person with a higher occupational status is less likely to develop of CMHP.
Why do CMHP's have a major impact on society even though they are less disabling than severe mental health disorders?
The prevalence of CMHP's is large. This results in a huge cumulative cost to society.
Name 4 interventions that can help treat CMHP's.
1. Community level interventions.
2. Individual level interventions.
3. Service organisation level.
4. IAPT service model.
Interventions that can help treat CMHP's: describe community level interventions.
Focuses on strengthening protective factors e.g. school based programmes, activities for the elderly etc. Also tries to reduce risk factors e.g. social support after threatening events.
Interventions that can help treat CMHP's: describe individual level interventions.
The patient could take medications to help e.g. anti-depressants. They could also start attending psychological therapies: CBT, counselling etc. as this follows NICE guidelines for depression/anxiety.
Interventions that can help treat CMHP's: describe service organisation level interventions.
Management within primary care; focusing on prevention and early identification. Holistic. Encouraging self-management.
What is IAPT?
- Improving access to psychological therapies.
- The idea is to train more NHS staff in delivering evidence based CBT.
- Provide support for people with CMHP's, help them get back to work and off benefits.
- Psychological services can be paid for by savings made to the benefit bill.
What is the psychological definition of stress?
Stress occurs when the demands made upon an individual are greater than their ability to cope.
What are the two types of stress?
Eustress is a positive stress; it is often beneficial and motivating.
Distress is a negative stress; it can be damaging and harmful.
Name 4 acute stressors.
Name 5 chronic stressors.
What are the 5 signs of stress.
Name 3 external stressors.
3. Social and cultural pressures.
Give examples of physical and psychological internal stressors.
- Physical: inflammation, infection.
- Psychological: attitudes, beliefs, personal expectations, worries.
Responses to stress: what is the fight of flight model?
An automatic response to external acute stressors. The response elicits physiological changes: hypothalamus, adrenal medulla and cortex are stimulated. Activation and inhibition of organs.
Responses to stress: what are the body's responses in the fight of flight model?
- Lungs: take in more O2, rapid breathing.
- Blood flow: increases.
- Skeletal muscles: tense.
- Spleen: more RBC's discharged.
- Skin: blood flow directed away to support skeletal muscles and heart.
- Mouth: drier as saliva dries up.
What is the general adaptation syndrome?
A concept used to describe the body's short term and long term reactions to stress. There are 3 stages.
What are the three stages of general adaptation syndrome (GAS)?
Describe the alarm stage of GAS.
A threat/stressor is identified. There is a sudden burst of energy.
Describe the adaptation/resistance stage of GAS.
The body attempts to adapt or resist the stressor. Defensive countermeasures are engaged.
Describe the exhaustion stage of GAS.
Energy is depleted; the body begins to run out of defences.
What are the 5 signs of stress?
5 signs of stress: what changes occur in the biochemical stage?
Endorphin (peptides that activate opiate receptors) and cortisol (released in response to stress, elevated levels affect learning and memory) levels are altered.
5 signs of stress: what changes occur in the physiological stage?
Shallowing breathing, raised BP, more HCl produced.
5 signs of stress: what changes occur in the behavioural stage?
Over-eating, anorexia, insomnia, more alcohol or smoking or drug use.
5 signs of stress: what changes occur in the cognitive stage?
Negative thoughts, no concentration, worse memory, tension headaches.
5 signs of stress: what changes occur in the emotional stage?
Mood swings, irritability, aggression, boredom, apathy (lack of interest), tearfulness.
Define the stress-illness model.
An individuals susceptibility to disease or illness is increased because the individual is exposed to stressors which cause strain upon them, leading to psychological and physiological changes.
What is the diagnostic criteria for PTSD?
1. The person experienced an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
2. The person's response involved intense fear, helplessness, or horror.
Give 3 symptoms of PTSD.
1. Recurrent and distressing recollections of the event(s) e.g. in dreams.
2. Persistent avoidance of stimuli associated with the event.
3. Persistent symptoms of increased arousal (when the brain remains 'on-edge', wary and watchful of further threats) e.g. insomnia, irritability etc.
Give some examples of traumatic events that may result in PTSD.
1. Childhood physical/emotional/sexual abuse.
2. Violent attacks/war.
3. Natural disaster.
What physical illnesses can be related to stress?
Cancer, CHD, chronic fatigue, infertility/miscarriage, peptic ulcers, IBS.
Name 4 stress management techniques.
Medicine in the media: what are the key purposes of NHS press releases?
1. Reactive - defending the NHS' reputation e.g. reporting achievements, improvements, justifications.
2. Pro-active - improving and protecting population health via social marketing messages (five-a-day, change for life etc) and early recognition and symptom awareness campaigns (act FAST).
List some diseases that are linked to obesity.
Type 2 diabetes, hypertension, infertility, CHD and stroke, osteoarthritis, cancer (among non-smokers), angina, high blood cholesterol.
What has happened to the epidemiological pattern of obesity?
In the past obesity affected the rich, nowadays obesity is a condition associated with poverty and lower socio-economic groups.
What are the 3 main components of the aetiology of obesity?
What is the WHO definition of obesity?
Abnormal or excessive fat accumulation resulting from a chronic imbalance between energy intake and energy expenditure that presents a risk to health.
Give 6 causes of obesity.
1. 'Americanisation' of diet and society.
2. Increased car culture, less walking.
3. More commuting.
4. Longer working hours.
5. Greater availability of energy dense food, cheaper and better promoted.
6. Replacing water with sugary drinks.
What diagnostic tools can be used in obesity?
- Waist circumference.
- WHR (waist to hip ratio).
- Skinfold thickness.
How is BMI calculated?
Weight (KG) / Height^2 (m)
What is the range for a normal BMI?
18.5 - 24.9
Describe Prader Willi Syndrome.
- Paternal chromosome 15 deletion.
- The individual will have learning difficulties, growth abnormalities and obsessive eating.
What genetic conditions can be linked to obesity?
1. Prader Willi Syndrome.
2. Mutations of the leptin and melanocortin receptors.
3. Congenital leptin deficiency. (leptin: appetite inhibitor).
What aspects of behaviour can be associated with weight gain?
1. Employment: shift work, lack of sleep, reduced physical activity, 'hunger' hormones (cortisol, leptin, ghrelin) affected.
2. Dietary patterns.
3. Reduced physical activity.
What developmental factors can affect a child's risk of being obese later in life?
1. Rapid infant weight gain increases the risk of obesity.
2. Breast feeding is shown to decrease the risk of obesity.
3. Premature introduction of solid foods can increase the risk of obesity.
4. Childhood obesity is a large predictor of adult obesity.
What is meant by 'direct controls of meal size'?
Direct - all the factors relating to the direct contact of the food with the GI mucosa receptors.
What is meant by 'indirect controls of meal size'?
Indirect - metabolic, endocrine, cognitive, social and environmental factors. Indirect can override the direct controls.
What brings an eating episode to an end.
The inter-meal period.
What is the satiety cascade?
Sensory -> cognitive -> post-ingestive -> post-absorptive.
What is the theory behind reducing the energy density of foods?
- People to tend to keep portion sizes the same regardless of the energy density of the food.
- By reducing energy density we can keep the same portion sizes but consume fewer kcal and so keep satiety.
What 4 mechanisms can be used to reduce energy density?
1. Incorporation of water or air.
2. Fruits and vegetables.
3. Reducing fat (industry).
4. Method of cooking (no frying).
Define energy compensation.
The adjustment of energy intake following the ingestion of a particular food. The energy compensation is lower with liquids than it is with solids (except soups).
What is the role of alcohol in over-eating.
- Alcohol stimulates the intake of food, gives almost no satiety.
- It is efficiently oxidised.
- It adds to the total daily energy intake.
- Alcohol is associated with poor food choices.
Name 3 broad factors that can promote over-eating.
1. Environmental factors.
2. Psychological factors.
3. Food-characteristic factors.
Factors that can promote over-eating: what are examples of environmental factors?
1. Variety - greater variety can lead to overeating.
2. Portion sizes have increased significantly over the last century.
3. Distractions like watching TV promote food intake.
4. Social facilitation - going out for food with friends etc.
Factors that can promote over-eating: what are examples of psychological factors?
1. Stress often promotes over-eating.
2. Lack of sleep.
3. Dietary disinhibition.
4. Reward sensitivity.
Factors that can promote over-eating: what are examples of food-characteristics factors?
1. Macronutrient composition.
2. Energy density.
3. Liquids v solids.
What can cause an STI and how are they transmitted?
- STI's are caused by >30 different bacteria, viruses and parasites.
- They are transmitted predominantly by sexual contact.
Name the 4 main STI's.
What is the 'ABC' list of HIV safety?
A - abstain.
B - be faithful.
C - condom use.
What is it important to achieve in sexual health education?
1. Involving young people effectively - they are the key decision makers.
2. Provide comprehensive and accurate information.
3. Address barriers to accessing health services.
4. Empower young people to make the life choices that are best for them.
What is the definition of complementary and alternative medicine (CAM)?
A broad domain of healing resources that encompasses all health systems, modalities and practices and their accompanying theories and beliefs. Healing resources other than those intrinsic to the dominant health system of a society.
Name some different types of CAM.
Acupuncture, Chinese medicine, chiropractic, osteopathy, herbal medicine, hypnotherapy, reflexology, homeopathy, aromatherapy etc.
What groups can CAM be divided into based on therapeutic similarity?
- Manual therapies.
- Ethnic medical systems.
- Mind-body/energy medicine.
- Non-allopathic systems.
Give examples of manual CAM therapies.
Chiropractic, osteopathy, massage, reflexology.
Give examples of ethnic medical CAM therapies.
Chinese medicine, acupuncture, herbal medicine, yoga.
Give examples of mind-body/energy CAM therapies.
Give examples of non-allopathic CAM therapies.
Homeopathy, iridology, naturopathy.
House of lords report CAM classification: what is group 1?
There is some scientific evidence of efficacy e.g. acupuncture, chiropractic, homeopathy, osteopathy, herbal medicine.
House of lords report CAM classification: what is group 2?
Modalities working in a supportive capacity alongside conventional medicine, not offering independent diagnosis e.g. hypnotherapy, aromatherapy, reflexology, massage.
House of lords report CAM classification: what is group 3?
Traditional systems of medicine backed by historical practice only/with little evidence e.g. Chinese medicine, iridology etc.
Who uses CAM?
- 35-60 age group, mainly women.
- Higher income and higher educational levels.
- 60% have a chronic disease.
- Geographical variation; mainly people in the South.
What are the most common problems that people use CAM for?
Depression, eczema, chronic pain, IBS.
Give the 3 main expected outcomes of using CAM.
1. Reduction of symptoms.
2. Avoidance of medication.
3. Gaining control and improving coping skills.
What are 5 'push' factors for new CAM patients?
1. Lack of effective conventional treatment for their problem.
2. Concern about medication side-effects; want to avoid medication.
3. Bad past experiences, rejection of science.
4. Gullibility and naivety.
5. High (60-80%) patient satisfaction rates for CAM.
Give the 3 main major concerns of using CAM.
1. Unrealistic expectations.
2. Using CAM may delay conventional care.
3. General safety - unregulated practitioners and treatments.
What does the NHS describe as the 'Big 5' CAM?
2. Chiropractic therapy.
4. Herbal medicine.
What is the basic economic problem with regards to health services?
1. Resources are finite (scarcity).
2. The desire for services is infinite (insatiable).
3. No country can treat all treatable ill health; they don't have the capacity to do so.
4. Choice cannot be avoided (decision making).
What is economic efficiency with regards to health economics?
Economic efficiency is achieved when resources are allocated between activities in such a way as to maximise benefit.
What is economic evaluation with regards to health economics?
It is the method used to assess whether benefit is maximised - the assessment of efficiency. Are the incremental benefits of a new treatment worth the incremental costs?
What are the 3 types of economic evaluation?
1. Cost-effectiveness analysis.
2. Cost-utility analysis.
3. Cost-benefit analysis.
What is cost-effectiveness analysis?
Outcomes measured in natural units: incremental cost per year of life gained.
What is cost-utility analysis?
Outcomes measured in quality adjusted life years: incremental cost per QALY gained.
What is cost-benefit analysis?
Outcomes are measured in monetary units: net monetary benefit.
Health economics: what is equity?
Equity is concerned with the fairness or justice of the distribution of costs and benefits.
What is the problem with equity in health economics?
There are opposing views about what is fair; it is difficult to quantify and very subjective.
What has had the most significant effect in the reduction of TB?
Improvements in social conditions.
What is social class a measure of?
Occupation, stratification, social position, access to power and resources.
What is the inverse care law?
The availability of good medical care tends to vary inversely with the need for it within a population.
How can you reduce incidence rates of a disease?
Decrease risk factors e.g. primary preventions.
What may increase incidence rates?
Screening for a disease and identifying new cases and increasing risk factors.
What can decrease prevalence?
Cures and decreasing risk factors.
What can increase prevalence?
Screening and identifying new cases and increased life expectancy.
An unintended, adverse effect of a medical intervention.
If the prevalence of a disease is high, what effect would this have on the incidence of false positives?
- Incidence of false positives would fall.
- PPV would increase and NPV would fall.
Give 3 reasons for screening.
1. It can prevent suffering.
2. Early identification of the disease is beneficial.
3. Early treatment may be cheaper short and long term and improve health outcomes.
Why do prevention approaches favour those who are more affluent and better educated?
- These people are more likely to engage with health services.
- They are more likely to comply with treatments.
- They are more likely to have the necessary means to change their lifestyle.
What lifestyle changes can prevent CHD?
1. Smoking cessation.
2. Healthy eating.
3. Reduced alcohol intake.
4. Increased physical activity.
What has been done to help with smoking cessation?
2. Ban on smoking in public places.
3. Cessation services.
4. Public health campaigns/health warnings.
What has been done to help people eat healthily?
1. Public health campaigns e.g. 5-a-day.
2. Improved labelling of food.
3. Improvements in food in schools.
What has been done to help people reduce alcohol intake?
1. Public health campaigns - know your limits.
3. Alcohol pricing and regulation.
What are unmodifiable risk factors?
Things we have no control over: sex, age, ethnicity, family history, early life circumstances.
What are modifiable risk factors?
Things we can change:
- high blood pressure, high cholesterol, type 2 diabetes, smoking, physical inactivity, overweight, poor diet, alcohol intake.
What control measures can help stop the spread of diarrhoea?
- Hand washing.
- Safe drinking water.
- Safe processing and handling of food.
- Safe disposal of human waste.
How many units of alcohol can men have a day and in a week?
- 3-4 units a day.
- 28 units a week.
How many units of alcohol can women have a day and in a week?
- 2-3 units a day.
- 21 units a week.
What equation can be used to work out how many units of alcohol there are in a drink?
(%ABV x volume of drink (ml))/1,000.
What are the CAGE questions for alcohol dependency?
1. Have you ever fault that you should Cut down?
2. Have you ever felt Annoyed by people telling you to cut down?
3. Do you feel Guilty about how much you drink?
4. Eye opener: ever had a drink first thing in the morning?
What are the social implications of alcohol?
Violence, rape, driving offences, depression, anxiety etc.
What are some reasons for why people smoke?
Nicotine addiction, coping with stress, habit, socialising etc.
Smoking laws: what law was introduced in 2005?
Smoking was banned in public places.
Smoking laws: what law was introduced in 2007?
The minimum age to buy tobacco products was increased to 18.
What is patient compliance?
The extent to which a patients behaviour coincides with medical advice. It is professionally focused and assumes that the 'doctor knows best'.
What are some reasons for non-compliance?
- Unintentional: forgetting or not understanding.
- Intentional: the patient has their own beliefs about their condition or treatment and doesn't agree with medical advice.
What is non-compliance?
- Not taking medications.
- Taking medications incorrectly; wrong time, wrong dosage etc.
- Continuing behaviours against medical advice.
What is the doctrine of double effect?
If you administer a drug to relieve pain in doses you know may be fatal, provided your intention is to relieve pain and not to shorten life the administration is ethically okay.
What are the 5 focal virtues?
What is evidence based medicine about?
1. Asking focused questions.
2. Finding evidence.
3. Critical appraisal.
4. Making a decision.
What is the gold standard of evidence based medicine?
Systematic reviews of RCT.
What are confounding factors?
Factors that can affect the validity of a study. They may be responsible for the results seen.
What is critical appraisal and why is it important?
Critical appraisal is about assessing validity, reliability and applicability. It is important because it means you can provide your patients with the best possible evidence and information.
What should a good study have?
- Randomisation of participants to interventions (reduces bias/confounding).
- Show causation rather than association.
- Have outcome measures (results) for at least 80% of the population.
Define systematic review.
Systematic methods are used to identify, select and analyse relevant research in order to answer a specific question.
Give 2 examples of non-random sampling?
1. Convenience sampling.
2. Purposive sampling.
What is NNT (number needed to treat)?
The number of patients that need to be treated in order to have an impact on one person.
Is a test significant if the 95% confidence interval contains zero?
No it is not significant.
Why is a good doctor-patient relationship important?
- Better health outcomes for the patient.
- Improved patient compliance.
- Improved patient satisfaction.
- Reduced risk of malpractice.
Is there a relationship between stress and illness?
Yes - the stress-illness model. When an individual is stressed they are more susceptible to disease due to psychological and physiological changes.
Rapidly developing focal neurologic signs of cerebral function. Lasting >24 hours. There is no apparent cause other than vascular origin. Can be hemorrhagic or ischemic.
Give 5 risk factors for stroke.
3. Drinking alcohol.
What are the problems with sending patients home early from hospital?
Patients go home with a higher dependency. They may need carers and social support and if this fails you often get readmission.
How can we prevent recurrent hospital admission?
1. Support discharged patients.
2. Support chronic disease management.
3. Community care services.
What type of study uses routinely collected data to show trends and to generate hypotheses?
What type of study divides a population into those with the disease and those without and collects data at a single point in time?
What type of study matches people with a disease to those without for age, sex, habits, class etc?
Case-control study - retrospective.
What type of study studies a population to see if they're exposed to the agent in question and if they develop the disease?
Cohort study - prospective.
Give 3 advantages of an ecological study.
1. Uses routine date and so is quick and cheap.
2. Few ethical issues.
3. Useful for generating hypotheses.
Give 3 disadvantages of an ecological study.
1. Cannot show causation.
2. Inconsistency in data presentation.
3. Bias - variation in diagnostic criteria.
Give 4 advantages of a cross-sectional study.
1. Can give rapid insight into events within a population.
2. Few ethical issues.
3. Good for generating hypotheses.
4. Quick and cheap.
Give 3 disadvantages of a cross-sectional study?
1. Prone to bias.
2. No time reference.
3. Could be reporting medical oddities.
Give 3 advantages of a case-control study?
1. Quick - results can be obtained quickly (retrospective).
3. Usually a small number of people required to produce statistically significant results.
Give 3 disadvantages of a case-control study?
1. Retrospective date may be unreliable - selective memory.
2. Shows association but not causation.
3. Prone to selection and information bias.
4. Cannot calculate incidence.
Give 3 advantages of a cohort study?
1. Can calculate incidence and so can find relative and absolute risk.
2. Reduced chance of bias - exposure measured before disease develops.
3. Can distinguish causes from associated factors.
Give 3 disadvantages of a cohort study?
1. Expensive - long time and large population.
2. Causation cannot be calculated - control study is needed for this.
3. Often difficulties with follow-up.
Give 3 advantages of a RCT?
1. Confounders are equally balanced.
2. Blinding minimises bias.
3. Statistical tests are easier when confounders are minimised.
Give 4 disadvantages of a RCT?
1. Expensive - large populations.
2. Poor compliance can mean statistical tests lose their power.
3. Volunteer bias.
4. Ethical difficulties in withholding treatment from control groups.
What does the presence of bias in a set of results imply?
The results of the study are not accurate.
True or False: if the confidence interval contains 1 the results are statistically significant.
False - the results are not statistically significant if the CI contains 1 at the p
Will the standard error in a set of results be big or small if the precision is good?
There will be a small standard error.
Give an example of a primary prevention.
Vaccination e.g. MMR vaccine.
Give an example of a secondary prevention.
Screening programmes e.g. Breast cancer screening.
Give an example of a tertiary prevention?
Reducing risk factors and changing lifestyle e.g. In copd pulmonary rehabilitation and smoking cessation are types of tertiary prevention.
How can you calculate the NNT?
What is nominal data?
A qualitative classification of data - a naming system.
What is ordinal data?
When data has numerical scores existing in order.
What is binary data?
Data that can only take one of 2 possible states. E.g. alive or dead.
What is discrete data?
Data with a finite number of values e.g. Number of people living in a house.
What is continuous data?
Data that can take any value e.g. height.
What is linear regression used for?
Estimating mean differences between groups.
What is logistic regression used for?
Binary outcomes. It models an odds ratio.
What is poisson regression used for?
It models rate ratios.
What is cox regression used for?
It models hazard ratios.
Suffering from a disease.
The number of deaths per year for a specified disease.
What is the medicalisation hypothesis?
Professionals tend to see problems in terms of their own profession. Doctors therefore look at problems medically. Some conditions that seem medical can be a product of social forces e.g. mental illness can be seen medically when the route of the problem may be socially related.
Unintended side effects caused by therapeutic intervention e.g. making someone more ill when trying to treat them.
Explain the concept of concordance in healthcare.
Patients are viewed as equals in care. They are involved in decision making about their treatment.
Behavioural change: what is the nudge theory?
Changing the environment to make healthy option an easier choice. E.g. making healthy food cheaper and more accessible.
If the prevalence of a disease is low, what affect does this have on false negatives?
- The number of false negatives will decrease.
- NPV will increase and PPV will decrease.
When would a screening service look at improving the sensitivity of a test?
When the effect of missing someone with the disease and not treating them is worse than the trauma a false result will cause. The number of false negatives is minimised.
What is the 'prevention paradox'?
The idea that a large number of people at small risk of a disease may contribute more cases than a small number of people who are at greater risk.
What is the population approach to prevention?
Targeting all individuals with the aim of reducing the risk for everyone. It recognises that the low risk majority may contribute a lot of cases and it reduces social inequalities.
What is the high risk approach to prevention?
Targeting only the individuals who are a high risk. It is accepted by society - treating those outside 'normal levels' and it is cheaper than the population approach.
What are the disadvantages of the high risk prevention approach?
- It favours those who are better educated: more likely to engage with NHS services and comply with treatments.
- It can be difficult to identify those who are at high risk.
What are the disadvantages of the population approach?
- Public concerns over treating well people unnecessarily.
What is a p value?
It tells us the probability of the results being due to chance.
Define clinical significance.
The results are significant enough to be worthwhile clinically. They will have a genuine effect on day to day life.
Define statistical significance.
The results are used to accept or reject the null hypothesis. They are not necessarily clinically significant.
What are some reasons for why people start smoking?
Influence from parents/siblings/neighbourhood they grow up. Peer pressure, wanting to fit in. 'Solution' to stress.
What law was introduced in 1965 to encourage people to stop smoking?
Smoking advertisements on television were banned.
Describe the epidemiology of smoking.
- Married people are less likely to smoke.
- Unemployed people are more likely to smoke.
- There is a link between poverty and smoking; people from lower socio-economic backgrounds are more likely to smoke.
State two potential psychosocial implications of infertility?
2. Relationship breakdown.
State a reason why infertility might be increasing in the general population?
People are delaying having a family until they are older. There is a higher incidence of STI's too which can lead to infertility.
What are the outcomes of IAPT?
Lower socio-economic groups are now more likely to access talking treatments than before. But the well-off are still paying disproportionately more for private therapy.
What can doctors do to help people with CMHP's?
1. Provide user-friendly, accessible, information and advice to disadvantaged groups.
2. Signpost patients to appropriate advice and support services.
What type of stressors would elicit the fight of flight response?
External acute stressors.
How is the fight or flight response activated?
The hypothalamus activates the sympathetic nervous system and also the adrenal medulla (Na, Ad) and adrenal cortex (cortisol). There is activation of some organs and inhibition of others.
Give 3 reasons why obesity is such a big issue.
1. Its widespread.
2. Its prevalence is increasing.
3. Its consequences are costly.
What can twin-studies tell us about the aetiology of obesity?
Twin and family studies suggest a high degree of genetic contribution to body mass.
What are the 7 key domains for energy balance?
1. Food environment.
2. Food consumption.
3. Individual activity.
4. Societal influences.
5. Individual biology.
6. Individual psychology.
7. Activity environment.
What are the 2 main ways in which STI's can be prevented?
1. Counselling and behavioural methods e.g. sex education, safer-sex counselling, interventions targeted at vulnerable populations.
2. Barrier methods e.g. condom use.
Give 3 barriers to improving sexual health services.
1. Lack of funding and resources.
2. Influences of religion.
3. Personal attitudes of staff.
What is consequentialism (utilitarian) ethics?
An act is evaluated in terms of its consequences. Acts to maximise good.
What are the challenges of consequentialism?
1. Minorities may be treated unfairly to promote the happiness of the majority.
2. Determining whether a consequence is good could be subjective.
3. Is it okay to carry out ethically questionable research to maximise the welfare of society?
What is deontology?
Features of the act determines worthiness. Deontology teaches that acts are right or wrong, people have a duty to act accordingly. Do unto others as you would be done by.
Categorical imperatives are a version of deontology. What are they?
A categorical imperative is a rule that is true in all circumstances. You should act in such a way that you would be willing for it to become universal law that everyone follows in the same situation.
What are the challenges of deontology?
Consequences aren't looked at. Duties can conflict.
What are virtue ethics?
Focuses on the character of the person, integrating reason and emotion. An action is only virtuous if the person has the right mind set. Virtues are acquired.
What are the 5 focal virtues?
5 focal virtues: define discernment.
The ability to judge well.
5 focal virtues: define integrity.
Being honest and having good moral principles.
5 focal virtues: define compassion.
Showing concern for others.
5 focal virtues: define conscientiousness.
Being thorough, careful and vigilant. Wanting to complete a job as well as you can.
5 focal virtues: define trustworthiness.
The ability to be relied on and trusted.
What are the challenges of virtue ethics?
Virtue ethics don't focus on consequences. Virtues are culture specific and too broad for practical application. It is not always clear how to solve a moral dilemma using virtue ethics.
What is capacity?
The patient's ability to make a decision.
What are the 4 questions that should be asked when assessing capacity?
1. Does the patient understand?
2. Can the patient retain the information?
3. Can they use the information to weigh up options and make a decision?
4. Can they communicate their decision?
What is the age of consent for medical treatment?
What is Gillick/Fraser competence?
If a child under 16 is assessed as Gillick/Fraser competent they can make their own decisions about their care without parental permission.
A 14 year old girl having sex without a condom, has contracted an STI and refuses to use condoms even though she’s on the contraceptive pill. What needs to be considered when making decisions?
1. Does this patient have capacity?
2. Are there any child protection issues?
A 14 year old girl having sex without a condom, has contracted an STI and refuses to use condoms even though she’s on the contraceptive pill. What are 2 ethical problems in this case?
1. Underage sex.
2. Under 16, are they gillick competent?
A gentleman has made some nonspecific arrangements about his end-of-life management. His health deteriorates and the managing team consult family in making care-related decisions. According to the mental capacity act, why should family be consulted?
Family may be able to help the managing team better aware of the patient’s values and preferences when they have capacity. It can help with care-related decisions.
You are a medical student on a ward and you are concerned about the way one of the doctors is treating a patient. He tells you to examine the patient’s abdomen, but fails to ask for her consent. Which of the 4 ethical principles is being compromised here?
Autonomy is being compromised - the doctor is not respecting the patients decision. In this situation you would ask the patient for consent before carrying out the examination.
One of your fellow medical students turns up to ward rounds smelling of alcohol and you are concerned about their fitness to practice. Explain your course of action using the principle of deontology.
The duties of a doctor is a deontological document. Deontology is about the worthiness of the act. Turning up to work drunk is putting patients at risk; you are not protecting the health of patients and won't be able to provide a good standard of care.
You are walking home one day and a lady recognises that you are a doctor. She comes over to you and says you’ve recently been treating one of her neighbours and she wants to know how he is. She asks if you can tell her anything about his condition as she is really worried. What is your course of action?
You listen to the lady and understand her concern. However you can not tell her anything and you can not even reassure her as this would be breaking confidentiality. You could advise the lady to contact her neighbour herself and you apologise that there isn't anything you are able to say.
Can you think of reasons why you may not mind if the test is not particularly sensitive?
This may be acceptable where the consequences of missing the disease are minimal e.g. a disease with slow progression where delayed diagnosis was of no concern. Often screening tests with regular rounds e.g. when people are screened every 3 years have low sensitivity.
Why would a screening service look at improving the specificity of a test?
When the follow up diagnostic test is expensive or carries some risk so you want to minimise the number of disease free people having unnecessary procedures. Minimising False Positives may also be desirable where significant anxiety may be caused by a positive test result, or where there is significant stigma associated with the disease for which you are screening.
Can you think of reasons why you may not mind if the test is not particularly specific?
This may be acceptable where the condition creates little anxiety, and the follow on diagnostic testing is quick, cheap and safe.
What are deductive ethical arguments?
Using one general ethical theory and applying it to all medical problems.
What are inductive ethical arguments?
Using settled medical cases to generate theories or guides to medical practice.
What is the BMI range of someone who is overweight?
Give 2 factors in the economic environment that can lead to being overweight.
1. Unhealthy food tends to be cheaper.
2. There is more advertising for unhealthy food because it is produced by large manufacturers.
Give 2 factors in the cultural environment for being overweight.
1. Social - eating out more.
2. Family influences - if your family eat unhealthily you're likely to as well.
What is the first line of treatment for obesity?
Encourage people to improve their diet and to do more exercise to lose weight.
Give 2 social consequences of being overweight.
1. Depression and isolation.
2. Unable to work, especially if the job is very demanding.
Give 2 advantages of a systematic review?
1. Can prove causation.
2. Compares similar studies.
Give 2 disadvantages of a systematic review?
1. Time consuming.
Define opportunity cost.
The benefits forgone from investing and allocating resources in one thing but not in something else.
How do you calculate incremental cost?
New cost - old cost
How do you calculate the effectiveness ratio?
Incremental cost (new-old) / difference QALY (new-old).
What is an obesogenic environment?
An environment that encourages people to eat unhealthily and not do enough exercise.
Give 3 physical characteristics of an obesogenic environment.
1. Increased car culture.
3. TV remotes.
Give an economic characteristic of an obesogenic environment.
Expensive fruit and vegetables.
Give a socio-cultural characteristic of an obesogenic environment.
Family eating patterns.
Describe the ready, steady, stop process for quitting smoking.
- Ready: be prepared and aware, understand the process.
- Steady: set a quit date, throw away ashtrays and lighters etc.
- Stop: set a plan for the day, avoid triggers and reward yourself.
Give 5 signs of foetal alcohol syndrome.
1. Growth abnormalities.
2. CNS abnormalities.
3. Learning difficulties.
4. Poor socialisation skills.
5. Low birth weight and small head circumference.
Give 2 reasons for an increase in childhood obesity.
1. Technological advances - video game culture. Children exercise less.
2. Cheaper unhealthy food and increased promotion aimed at children.
Give 2 reasons for screening.
1. Identifying a disease early can improve prognosis.
2. Treatment at an early stage may be cheaper and so save money long term.
3. Reduces mortality and morbidity.
4. Reassurance for those with a negative test result.
What is the most important statistical information you would need to give a patient who has a positive screening test result.
The PPV, the proportion of people with a positive result who do actually have the disease.
How much alcohol is there in one unit?
8g or 10ml.
Give an example of a one unit alcoholic drink.
Small glass of wine, half a pint of beer.
Name 3 liver conditions associated with chronic alcoholism.
Cirrhosis, fatty liver disease, alcoholic hepatitis.
Name 4 methods of reflecting on medical practice.
4. 'Would you recommend to a friend?'
What 3 things may be considered in bio-ethics?
2. Organ donation.
What does PICO stand for?
P - patient problem or population.
I - intervention.
C - comparison.
O - outcome.
What is the analysis of data in a systematic review called?
What can the government do to encourage healthy behaviour?
Make healthy food cheaper and more appealing. Promote exercise - subsidise gym costs etc.
What can the government do to discourage unhealthy behaviour?
Bring in taxes e.g. the sugar tax. Reduce advertising for unhealthy products.
Give 6 of the Bradford Hill criteria that provide evidence for causation.
3. Biological plausibility.
4. Strength of association.
5. Temporality - cause before disease.
What is health behaviour?
Behaviour aimed at preventing disease e.g. eating healthily, exercising etc.
What is illness behaviour?
Behaviour aimed at seeking remedy e.g. going to see a doctor.