public health Flashcards
(89 cards)
1
Q
3 domains of public health
A
Health improvement
Health protection
Improving services
2
Q
health needs assesment
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.
Need – ability to benefit from an intervention
Demand – what people ask for
Supply – what is provided
3
Q
health needs assessment approaches (3)
A
epidemiological
comparative
corporate
4
Q
screening types
A
- Population-based screening programmes
- Opportunistic screening
- Screening for communicable diseases
5
Q
screening criteria (wilson and jugner)
A
Sensitivity – the proportion of people with the disease who are correctly identified by the screening test (a/a+c)
Specificity – the proportion of people without the disease who are correctly excluded by the screening test (d/b+d)
Positive predictive value – the proportion of people with a positive test result who actually have the disease (a/a+b) - this is higher if the prevalence is higher
Negative predictive value – the proportion of people with a negative test result who do not have the disease (d/c+d) - this is lower if the prevalence is higher
6
Q
lead time bias
A
Lead time bias: When screening identifies an outcome earlier than it would otherwise have been identified this results in an apparent increase in survival time, even if screening has no effect on outcome.
e.g. huntingtons screening
7
Q
length time bias
A
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
e.g. screening for prostate cancer
8
Q
main behaviours related to health (3)
A
health behaviour is a behaviour aimed to prevent disease (e.g. eating healthily)
illness behaviour is a behaviour aimed to seek remedy (e.g. going to the doctor)
sick role behaviour is any activity aimed at getting well (e.g. taking prescribed medications; resting)
9
Q
Stage models of health behaviour
Transtheoretical Model
A
Proposes 5 stages of change:
precontemplation – no intention of giving up
smoking
contemplation – beginning to consider giving up probably at some ill-defined time in the future
preparation – getting ready to quit in the near future
action – engaged in giving up smoking now
maintenance – steady non-smoker
10
Q
Motivational interviewing
A
A counselling approach for initiating behaviour change by resolving ambivalence
11
Q
Nudge theory
A
‘Nudge’ the environment to make the best option the easiest –e.g. opt-out schemes such as pensions, placing fruit next to checkouts
12
Q
maslows hierarchy of needs
A
self actualization - morality, creativity, spontaneity etc
esteem - self esteem, confidence etc
love/belonging - friendship, family etc
safety - security of body, employment, resources etc
physiological - breathing, food, water etc
13
Q
health problems of the homeless
A
- Infectious diseases including TB and hepatitis
- Poor condition of feet and teeth.
- Respiratory problems.
- Injuries following violence, rape
14
Q
barriers to health for the homeless
A
Difficulties with access to health care – due to opening times, appointment procedures location and perceived or actual discrimination.
Lack of integration between mainstream primary care services and other agencies
15
Q
Article 2
A
The right to life (limited)
16
Q
Article 3
A
The right to be free from inhuman and degrading treatment (absolute)
17
Q
Article 8
A
The right to respect for privacy and family life (qualified)
18
Q
Article 12
A
The right to marry and found a family
19
Q
Article 14
A
The enjoyment of the rights and freedoms set forth in this Convention shall be secured without discrimination on any ground such as sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status
20
Q
Utilitarianism
A
maximising good for the maximum number of people
21
Q
autonomy
A
the patient has the right to refuse or choose their treatment.
22
Q
Beneficence
A
a practitioner should act in the best interest of the patient.
23
Q
Non-maleficence (+utility)
A
to not be the cause of harm. Also, “Utility” - to promote more good than harm
24
Q
Justice
A
concerns the distribution of scarce health resources, and the decision of who gets what treatment
25
deontology
Deontological (duty-based) ethics are concerned with what people do, not with the consequences of their actions.
Do the right thing.
Do it because it's the right thing to do.
Don't do wrong things.
Avoid them because they are wrong.
26
deprivation of liberty safeguards
for if the patient needs to be admitted but does not have capacity and doesn’t fit the criteria of the mental health act. Any decisions made must be in their best interests and the least restrictive option must be chosen.
27
Resource Allocation - just(ice) healthcare:
Egalitarian principles - NHS was founded on a requirement to provide all care that is necessary and appropriate to everyone (equal access)-Aristotelian equality/justice
Maximising principles - Essentially utilitarianism
Libertarian principles - Each is responsible for their own health, well-being and fulfilment of life plan
28
duties of a doctor (6)
Make the care of your patient your first concern
Protect and promote the health of patients and the public
Provide a good standard of practice and care
Treat patients as individuals and respect their dignity
Work in partnership with patients
Be honest and open and act with integrity
29
medical negligence 4 questions
| swiss cheese model
Was there a duty of care
Was there a breach in the duty of care
Would a group of reasonable doctors do the same? (Bolam test)
Would it be reasonable of them to do so? (Bolitho test)
Did the patient come to harm
Did the breach cause the harm
30
types of error
Classification based on intention – failure of planned actions to achieve desired outcome (Skill based errors, Rule-based mistakes, Knowledge-based mistakes)
Classification based on action - Generic factors – eg. omission, intrusion, wrong order, mistiming
Classification based on outcome - Near miss
Classification based on context - Anticipations and perseverations, Interruptions and distractions
31
```
Theory of planned behaviour
what is it
Intention determined by (3)
two things that aid intentions
criticisms
```
Proposes the best predictor of behaviour is ‘intention’ e.g. I intend to give up smoking
Intention determined by:
attitudes
subjective norm
perceived behavioural control
Perceived control
Anticipated regret
Criticisms:
• lack of temporal element
• lack of direction or causality
• relies on self-reported behaviour
32
Meta-Analysis
A way of combining data from many different research studies
33
Systematic Review
A summary of the clinical literature
34
Randomized Controlled Trial
| ad/disad
A controlled clinical trial that randomly (by chance) assigns participants to two or more groups
Low risk of bias and confounding
Time consuming
35
Cohort Study
| ad/disad
A clinical research study in which people who presently have a certain condition or receive a particular treatment are followed over time and compared with another group of people who are not affected by the condition
e.g. follow smokers and compare to non smokers to see if smoking causes cancer
Good for common and multiple outcomes
Takes a long time
36
Case-control studies
| ad/disad
These are retrospective studies that take people with a disease and match them to people without the disease for age/sex/habitat/class etc and study previous exposure to the agent in question.
It is quick and inexpensive
data may not be reliable due to problems with patient’s memories.
37
prevention
primary
secondary
tertiary
Primary prevention - preventing disease before it has happened e.g. immunisation
Secondary prevention – catching disease in the pre-clinical or early phase e.g. screening
Tertiary prevention – preventing complications of disease e.g. fitting a STENT for cardio rehab
38
Domestic abuse impacts on health
traumatic injuries following an assault
somatic problems or chronic illness consequent on living with abuse
psychological or psychosocial problems secondary to the abuse
39
tool used to asses risk for domestic abuse
Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) Risk
40
risk levels of domestic abuse
STANDARD – current evidence does NOT indicate likelihood of causing serious harm
MEDIUM – there are identifiable indicators of risk of serious harm. Offender has potential to cause serious harm but unlikely unless change in circumstances
HIGH – there are identifiable indicators of imminent risk of serious harm.
41
Incidence rate =
No of persons who have become cases in a given time period / Total person-time at risk during that period
42
Incidence
new cases, denominator, time
43
Prevalence
existing cases, denominator, point in time
44
Person time
measure of the amount of time a person is at risk of getting the condition being studied, i.e. time from entry to a study to (i) disease onset, (ii) loss to follow-up or (iii) end of study. Used to calculate incidence rate which uses person time as the denominator.
45
Absolute risk
probability of an event occurring, gives a feel for actual numbers involved i.e. has units (e.g. 50 deaths / 1000 population)
46
Attributable risk
The rate of disease in the exposed that may be attributed to the exposure, i.e. incidence in exposed minus incidence in unexposed. Attributable risk is a type of absolute risk (absolute excess risk). Is about the size of effect in absolute terms i.e. gives a feel for the public health impact (if causality is assumed)
e.g. lung cancer has several causes but 85% is caused by smoking
47
Relative risk
Ratio of risk of disease in the exposed to the risk in the unexposed, i.e. incidence in exposed divided by incidence in unexposed. Tells us about the strength of association between a risk factor and a disease
48
Selection bias
| 2 main types
A systematic error in:
the selection of study participants
the allocation of participants to different study groups
Information (measurement) bias
A systematic error in the measurement or classification of:
exposure
outcome
49
Ecological studies
use routinely collected data to show trends in data and thus is useful for generating hypotheses.
Shows prevalence and association, cannot show causation.
50
Cross sectional study/survey
| ad/disad
Divides population into those without the disease and those with the disease and collect data on them once at a defined time to find associations at that point in time. They are used to generate hypotheses but are prone to bias and have no time reference.
Relatively quick and cheap
Risk of reverse causality
51
criteria for screening (4)
Disease - Important health problem, Latent / preclinical phase, Natural history known,
Test - Suitable (sensitive, specific, inexpensive), Acceptable
The treatment - Effective, Agreed policy on whom to treat,
The organisation and costs - Facilities, Costs and benefits Ongoing process
52
Horizontal equity
Equal treatment for equal need
| e.g. Individuals with pneumonia (with all other things being equal) should be treated equally
53
Vertical equity
Unequal treatment for unequal need
e. g. Individuals with common cold vs pneumonia need unequal treatment
e. g. Areas with poorer health may need higher expenditure on health services
54
Health behaviour & Medicine
| Intervention - Population level
Health promotion
| The process of enabling people to exert control over the determinants of health, thereby improving health
55
Health behaviour & Medicine
| Intervention – Individual level
Patient centred approach
| Care responsive to individual needs
56
social exclusion causes
Poor Health, Sensory Impairment,
Poverty, housing issues, fear of crime
Transport
Discrimination
57
social exclusion initiatives
Age UK
Co-Housing
Silverline
58
health belief model
| Individuals will change if they:
• Believe they are susceptible to the condition in
question (e.g. heart disease)
• Believe that it has serious consequences
• Believe that taking action reduces susceptibility
• Believe that the benefits of taking action outweigh
the costs
59
health belief model disad
```
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’s belief in their ability to carry out preventative behaviour)
```
does not consider the influence of emotions on behaviour
does not differentiate between first time and repeat behaviour
60
Transtheoretical model
| ad/disad
Acknowledges individual stages of readiness (tailored interventions) Accounts for relapse
Not all people move thorough every stage, some people move backwards and forwards or miss some stages out completely
61
Assessing quality of health care
Maxwell’s Dimensions of Quality
(3Es and 3As)
```
Effectiveness
Efficiency
Equity
Acceptability
Accessibility
Appropriateness (Relevance)
```
62
Framework for health service evaluation - donabedians model
Structure - what is there i.e. hospital
Process - what is done
Outcome - Classification of health outcomes
1) Mortality e.g. 30 day mortality rate
2) Morbidity e.g. complication rates
3) Quality of life / PROMs
4) Patient satisfaction
(can also be the 5Ds Death, Disease, Disability, Discomfort, Dissatisfaction)
63
Confounding
A situation in which the estimate between an exposure and an outcome is distorted because of the association of the exposure with another factor (confounder) that is also independently associated with the outcome.
64
Reverse causality
This 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.
65
information bias
what is it
causes
a systematic error in the measurement of classification of: exposure, outcome
Sources of information bias:
Observer (eg. observer bias)
Participant (eg. recall bias, reporting bias)
Instrument (eg. wrongly calibrated instrument)
66
prevention paradox
| example of
A preventive measure which brings much
benefit to the population often offers little to
each participating individual
use of statins to combat CVD - may stop it in a few however many will be taking them for no reason
67
addiction is
craving, tolerance, compulsive drug-seeking behaviour, physiological withdrawal state
68
Health determinants:
- genes
- environment (physical, social, economic)
- lifestyle (diet and exercise)
- healthcare (access and quality)
Equity: what is in line with fairness and justice (process) —> giving everyone what they need
Equality: (outcome) treating everyone the same
69
factors affecting health equity
```
supply of healthcare
access
utilisation
outcomes
health status
```
70
principles of treatment for substance abuse (3)
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• Harm reduction:
– advice on risky behaviour
– safe sex advice
– blood borne virus advice
– Hep B/C testing & vaccination
– contraceptive advice
```
```
• Brief intervention:
– explanation of effects
– explanation of risks
– advice on controlled use
– setting limits
– cognitive based approaches
```
• Team working:
– referral to sexual health/infectious diseases etc
– referral to voluntary agency if appropriate
– referral for specialist advice if necessary
71
alcohol dependence syndrome
tolerance-increasing amount of alcohol to achieve the same effect
characteristic physiological withdrawal
difficulty controlling onset, amount and termination of use
neglect of social and other areas of life
spending more time obtaining and using alcohol
continued use despite negative physical and psychological effects
72
an example of one of the 10 types of error - sloth
Not bothering to check results/information for accuracy. Incomplete evaluation. Inadequate documentation.
73
transition points where health interventions are more effective
```
leaving school
entering the workforce
becoming a parent
becoming unemployed
retirement and bereavement
```
74
unrealistic optimism definition
| Perceptions of risk influenced by (4)
Individuals continue to practice health damaging behaviour due to inaccurate perceptions of risk and susceptibility
1. Lack of personal experience with problem
2. Belief that the problem is preventable by personal action
3. Belief that if not happened by now, its not likely to
4. Belief that problem infrequent
75
Health Promotion examples
Health promotion/ awareness campaigns - Everyone enjoys a drink, no one enjoys a drunk.’ Change 4 Life Campaign, “5 a day”
Promoting screening and immunisations - Cervical smear screening, MMR vaccine
76
ways of changing health behaviours
* Work with your patient’s priorities
* Aim for easy changes over time
* Set and record goals
* Plan explicit coping strategies
* Review progress regularl
77
negligence factors
```
System failure
Human factors
Judgement failure
Neglect
Poor performance
Misconduct
```
78
health needs assessment - corporate
method
ad/disad
Ask the local population what their health needs are
Use focus groups, interviews, public meetings etc
Wide variety of stakeholders: e.g. teachers, healthcare professionals, social workers, charity workers
Based on the felt and expressed needs of the population in question
Takes into account wide range of views
Difficult to distinguish ‘need’ from ‘demand’
Groups may have vested interests
79
health needs assessment - Comparative
method
ad/disad
```
Compares the services received by a population (or subgroup) with others
May examine:
. Health status
. Service provision
. Service utilisation
```
Quick and cheap if data available
Indicates whether health or services provision is better/worse than comparable areas (gives a measure of relative performance)
May be difficult to find comparable population
Data may not be available/high quality
80
health needs assessment - Epidemiological
method
ad/disad
Defines problem and size of problem
Looks at current services
Recommends improvements
Uses existing data
Provides data on disease incidence/mortality/morbidity etc
Quality of data variable
Does not consider the felt needs or opinions/experiences of the people affected
81
Red flags: the symptoms and sign of evolving error chains
Ambiguities/anomalies/conflicting information/surprises.
Broken communication or inconclusive discussions
Confusion/loss of awareness/uncertainties
Missing information/incomplete briefing
Departures from standard procedures/normal practices
Fixation/pre occupation
Time distortion/event runaway
Unease/fear; Denial/stress/action
Alarm bells in your mind or warning from equipment
82
sustainable medical practice definition
a sustainable process is one that “meets the needs of the present without compromising the ability of future generations to meet their own needs.”
83
decision making
novices decide ...
experts decide ...
analytically
| intuition
84
intuitive decision making
advantages
disadvantages
ability to understand something instantly without consciousness reasoning
recognition is primed and heuristic
irresistible - cant stop it
fast and frugal
prone to bias
85
bias in intuitive thinking
error of over attachment
error due to failure to consider an alternative
error due to inherited thinking
errors in prevalence, perception or over thinking
86
analytical decision making
advantages
disadvantages
accurate and reliable
| slow and cognitively demanding
87
reducing risk in intuition
decision environment
personal debiasing techniques - affective debiasing (acknowledgement of bias) also cognitive debiasing (slowing and stopping techniques)
structural debiasing - group decision strategies (MDT), checklists
88
dual process theory
intuitive thinking with its irresistible combination of heuristics and biases, together with analytical thinking using evidence based medicine
89
Never events
examples
consequences
A serious, largely preventable patient safety incident that should not occur if available, preventative measures have been implemented
Examples:
Medical – wrong route chemotherapy
Surgical – wrong site or retained object
Mental health – escape of a transfer patient
Consequences:
Financial penalties
CQC visit
Reputation loss
